Volume 10 Issue 1 - 2017

Welcome to the first issue of 2017. We are very grateful to you for continuing to send in high quality papers; we accept original research, reviews, case reports, audits and teaching viva articles, so please do keep them coming!

As always please do let Francis Vaz or I know if you have any suggestions for the journal. If any of you would like to join the panel of reviewers please contact either Francis or myself. The on line access for the CPD part of the journal continues to be an important part of the journal and I encourage you to try it out.

With best wishes,

Sanjai Sood

Editor in Chief


Different surgical techniques have been developed in order to dilate the cartilaginous portion of the Eustachian tube (ET), the site of most pathology, including laser tuboplasty, tissue ablation using the microdebrider and more recently balloon dilation. The osseous segment of the ET, sharing an intimate party wall with the internal carotid artery, should be treated carefully as injury to the artery is possible and dilation with a noncompressible balloon is not recommended. Balloon dilation of the cartilaginous segment of ET through a transnasal endoscopic approach has gained popularity among the other surgical techniques such as laser or microdebrider for treatment of resistant ET dilatory dysfunction (ETD). There is accumulating evidence that transnasal endoscopic balloon dilation of the cartilaginous portion is becoming the main approach for ETD. Numerous studies have shown improvement in multiple assessments of ET function after balloon dilation including: ability to perform a Valsalva, improvements in tympanograms, atelectasis, tubomanometry, mucosal inflammation scores, mean ETDQ-7 symptom scores, and other ET measurements. Likewise, there is mounting evidence that outcomes after balloon dilation are durable to at least 2.5 years in regards to being able to perform a Valsalva manoeuvre, improvement in tympanograms and by the mucosal inflammation score.


Introduction: Novel oral anti-coagulants (NOACs) are set to become increasingly common in ENT patients. January 2015 NICE guidelines recommend rivaroxaban for up to 1 year after a myocardial infarction. This review sets out a guide to managing the new anticoagulants in acute and elective ENT patients.

Methods: Medline/ EMBASE searches and reviews of specialist society guidelines and expert recommendations were conducted.

Results: Limited RCT evidence exists to date on peri-operative management and emergency reversal. We have therefore condensed society guidelines and expert recommendations to create a succinct, practical guide to the peri-operative and emergency management of these patients.

Conclusion: Novel anticoagulants are poised to take over from warfarin (at least 1% of the UK adult population) for most indications. Yet in practice most surgeons have had limited experience with them. This review and ‘surgeon’s guide’ aims to set out a best-evidence foundation from which to respond to the emerging challenge.


Purpose: Successful endonasal DCR relies on the identification and modification of local anatomical variations. Preoperative imaging allows for thorough evaluation of nasal and paranasal sinus anatomy.

Methods: A retrospective review of 66 consecutive CTDCG examinations were reviewed in preoperative patients undergoing endonasal DCR. Anatomical details pertaining to the nasal septum, middle turbinate, ethmoid complexes, presence of mucosal disease and site of nasolacrimal obstruction were documented. A review of each operative note was conducted to compare the preoperative surgical plan with the subsequent intervention.

Results: 33 percent of patients undergoing endonasal DCR are likely to require or benefit from adjuvant septal corrective surgery for surgical access. 74 percent of patients had middle turbinates anterior or parallel to the nasolacrimal duct and a further 37 percent had anatomical variations of the middle turbinate that narrowed the middle meatus. A discrete area of nasolacrimal obstruction was not identified in 36 percent of cases suggesting high rates of functional obstruction.

Conclusions: Preoperative imaging facilitates accurate surgical planning, precludes intraoperative surprises and enables effective communication with patients relating to adjuvant surgical procedures.


Introduction: Peritonsillar abscess is a common ENT emergency condition, usually requiring drainage along with antibiotic therapy. The treating doctor should be aware that a number of important structures are close to the peritonsillar space, including the External Carotid Artery (ECA), which may be injured during abscess drainage.

Patients and Methods: Axial head CT scans with intravenous contrast were assessed to measure depth of the ECA from the mucosal surface of the anterior tonsillar pillar.

Results: Mean depth of the ECA was found to be 16-17mm from the anterior tonsillar pillar in an adult population.

Conclusion: The depth of the ECA is smaller than previously thought and should be borne in mind when abscess drainage occurs.


Both the external and the internal nasal valve are areas of naturally occurring narrowing in the cross sectional area of the nose. Nasal valves are crucial zones of airstream regulation especially the internal nasal valve area, which represents the narrowest part of the nasal airway and is instrumental in accelerating and circulating the inspired air. Static or dynamic collapse in these areas of the nose may contribute to decreased inspiratory airflow in patients.


Introduction: Stapes fixation resulting in a conductive hearing loss is a condition that can be successfully treated surgically, although other common management options include observation and hearing aid(s).

Most otologists perform stapedotomy by creating a small fenestra in the stapes footplate to allow insertion of a solid piston prosthesis.

We present our outcomes following stapes surgery, in particular looking at the effect of surgery on closure of the air-bone gap, tinnitus and taste disturbance.

Methods: A retrospective case notes review of 137 consecutive stapedotomies performed by a single consultant ENT surgeon, using the Fisch Teflon-platinum piston prosthesis, was analysed over a five year period.

Results: 137 operative cases from 109 patients were identified and included into this study. The average age at operation was 46 years. Incudo-stapedotomy was performed in 88% of cases and malleo-stapedotomy in 12% of cases. The average pre-operative air-bone gap was 31.5 db HL (SD=10.70) and the average post-operative air-bone gap at 1 year was 13.8 dB HL (SD=10.45). Subjective hearing improvement was reported by 94% of patients at 1 month follow-up and 83% at 1 year. Taste disturbance was reported by 3% patients at 1 year follow up. Pre-operative tinnitus was present in 50% of patients, and this reduced to 16% at 1 year.

Conclusion: Our study has shown a statistically significant reduction in the air-bone gap and improvement in hearing in all patients who had stapedotomy performed for otosclerosis. In this series, there was an improvement in post-operative tinnitus with minimal complication rates overall.

A 46-year-old patient presents with a history of hoarseness of voice. They are a smoker of 30 years.


This viva provides two different cases of vascular anomaly. It focuses on initial management of these children in a District General Hospital. It is aimed as a tool for preparation for the Intercollegiate exam.


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