PROBLEM Syphilis is a sexually-transmitted disease caused by the spirochete Treponema pallidum, and is transmitted either through sexual contact or vertically across the placenta. Rates of infection were at a low point in the early 1990s. Since then, increasing numbers of new cases of infections have been observed in all Western countries. AIM Presentation of three patients with syphilis who presented within a short period of time in an ENT outpatient clinic. CONCLUSIONS One must be aware of the increasing incidence of syphilis, even in head and neck disciplines. Typical symptoms of an early infection are an ulcerous lesion in the mouth, with or without cervical lymphadenopathy. The main therapy is high doses of penicillin G administered intramuscularly. Other simultaneous sexually-transmitted diseases, especially HIV infection, must be excluded. Unnoticed and untreated patients may develop late and life-threatening complications.

Carotid blowout syndrome (CBS) is an emergency complication in patients undergoing treatment for head and neck cancers. The classical management of CBS is the ligation of the common carotid artery, because suturing is not be possible due to infection and necrosis of the field. In this case report, we present a patient with CBS, in whom we applied a self-expandable polytetrafluoroethylene (PTFE) stent and observed no morbidity. Endovascular stent is a life-saving technique with minimum morbidity that preserves blood flow to the brain. We believe that this method is preferable to ligation of the artery in CBS.

OBJECTIVE To present the management of a rare case of progressive bilateral sensorineural hearing loss in a patient with superficial siderosis secondary to a cavernoma. METHOD A case report and a review of the literature concerning superficial siderosis. RESULTS The patient benefited significantly from a cochlear implantation. CONCLUSIONS Careful assessment and adequate counselling is necessary to determine the best approach to hearing rehabilitation in patients with superficial siderosis of the central nervous system. Cochlear implantation in patients with superficial siderosis is controversial due to the retrocochlear origin of the hearing loss and, although the case presented had a successful outcome, the results might deteriorate with time.

Congenital cholesteatoma may arise in various locations within the temporal bone. The rarest site of origin is the mastoid process. We report an unusual case of a 52-year-old man with mastoid congenital cholesteatoma that manifested as a persistent ear discharge. The preoperative suspicion was based on the imaging findings and the patient's history. A simple mastoidectomy was conducted and the cholesteatoma was completely removed while using facial nerve monitoring. Although rare, mastoid congenital cholesteatoma can be considered as an alternative in the differential diagnosis of persistent otorrhea.

INTRODUCTION AND AIM Sinonasal malignant neoplasms are uncommon, with an annual incidence of less than 1/100,000. About 80% of these are squamous cell carcinoma. Adenocarcinoma and adenoid cystic carcinoma are next in frequency. Lymphoma of the nasal cavity, paranasal sinuses and nasopharynx are rare, constituting less than 5% of all extranodal lymphomas. CASE REPORT A 47-year-old man was referred to our hospital because of severe headache and progressive facial pain. He also complained of right-sided visual acuity. He had a manifest exopthalmia with disturbed eye movements. Nasoscopy showed a large mass with atypical appearance. CT and MRI showed a bilateral ethmoid mass invading the frontal sinuses, the right orbit, the lamina cribrosa and the right frontal cerebral region, and growing posteriorly through the choana. The first biopsies were inconclusive, showing only necrotic cells and purulent inflammation with epithelial elements. A larger biopsy demonstrated a high-grade malignant tumour with necrosis. The differential diagnosis of undifferentiated sinonasal carcinoma, undifferentiated neuro-endocrine tumour or T-cell lymphoma was suggested. In the meantime our patient developed high fever and sudden-onset pancytopenia. Bone marrow punction showed 65% blasts, leading to the diagnosis of AML type M2. He was immediately referred for chemotherapy, but died in intensive care before his first session. The biopsy of the sinonasal mass was diagnosed surprisingly as a natural killer cell lymphoma stage IVB. CONCLUSIONS Natural killer cell lymphoma is rare in Europe. The simultaneous appearance of a NK-cell lymphoma and acute myelogenous leukemia has, as far as we know, never been described in the English literature before.

We describe the rare simultaneous appearance of an atypical adenolymphoma with a glomus caroticum tumour on the same side of the neck in a middle-aged man. This case report is the first to describe this coexistence. Due to the atypical, cyst-like presentation of the Warthin's tumour, a final diagnosis was made only after surgical resection and histopathological examination. Both the adenolymphoma and glomus caroticum tumour were successfully removed surgically.

OBJECTIVE We present a case report of a patient with a putative diagnosis of complex regional pain syndrome of the nose. We would like to bring this disorder to the attention of rhinologists. CASE REPORT A 53-year-old man presented with a history of extreme, constant, debilitating pain in his nose that started after he underwent several extensive nasal surgeries. Examination revealed atrophic nasal mucous membranes at the nasal septum. No other abnormalities were found. The pain did not diminish despite administration of analgesics and neuropathic pain medications. We propose a diagnosis of complex regional pain syndrome of the nose. CONCLUSION The large number of nasal surgeries performed worldwide and the far reaching consequences of this debilitating syndrome indicate that it merits further investigation to determine whether it is a distinct disorder that should be recognized as such.

INTRODUCTION Outpatient clinic letters are a widely used and effective means of communication between hospital staff and general practitioners. This study audited the letter format used by consultants and specialist registrars (SpRs) at an otolaryngology clinic to assess the readability of different formats. MATERIALS AND METHODS The two-cycle audit was performed at the Otolaryngology Clinic at Guy's and St Thomas' NHS Foundation Trust in London, England. A readability score (0-4) was assigned to the letters as an indication of how easy it was to extract information from structured or unstructured (paragraph) format letters. RESULTS In the first cycle, 71.91% of the SpR letters followed a structured format and had an overall mean readability score of 2.87/4; 46.58% of the consultant letters followed a structured format and had an overall mean readability score of 1.25/4. In the second cycle, after the results of the first audit were presented to the participating physicians, 84.72% of the SpR letters followed a structured format and had an overall mean readability score of 3.41/4. Consultants followed a structured format in 52.56% of the letters, which had an overall mean readability score of 2.04/4. CONCLUSIONS We found that a structured format for outpatient letters was better than unstructured format. This audit helped change the structure and consequently the readability scores of the clinic letters.

OBJECTIVES Although polyps seem to be a manifestation of the chronic inflammation of nasal/paranasal sinuses mucosa in both allergic and non-allergic subjects, the pathogenesis of nasal polyposis remains unknown. The aim of this prospective study was to compare the clinical characteristics of nasal polyposis in non-allergic and allergic patients, to compare the cytokine levels in nasal secretions in atopic and non-atopic nasal polyp patients and to correlate these levels with eosinophil counts in nasal polyp tissue specimens. METHODS This study included thirty patients with nasal polyposis (13 atopic and 17 non-atopic) requiring surgical treatment. Nasal secretion samples were collected from the nasal cavities of all 30 subjects a few days before the surgical treatment. The levels of tumour necrosis factor-alpha (TNF-alpha), tumour necrosis factor-beta (TNF-beta), interleukin (IL)-1beta, IL-2, IL-12, interferon-gamma (IFN-gamma), IL-4, IL-5, IL-6, IL-10, and IL-8 were measured using the flow cytometric method. Each of the 30 patients was staged clinically according to nasal symptom score, endoscopic score and Lund-Mackay computed tomography (CT) score. All these patients had undergone sinus surgery. Eosinophils were counted in hematoxylin- and eosin-stained sections of all nasal polyp samples. RESULTS Our results showed that allergy does not modify the symptoms, or the endoscopic and CT findings, of nasal polyposis. We found significantly higher concentrations of IL-4 (p < 0.01), IL-5 (p < 0.05), IL-6 (p < 0.05) and TNF-beta (p < 0.05) in nasal secretions of allergic nasal polyp patients than in non-allergic ones. Eosinophil counts were significantly higher in tissues of atopic patients' polyps than in non-atopic subjects (p < 0.01). No correlation was observed between cytokine levels and eosinophil counts. CONCLUSION Non-atopic and atopic patients' polyps have different immunological patterns. Our results showed that the presence of Th2 cytokines was a more significant feature in allergic patients with nasal polyposis than in non-allergic patients.

BACKGROUND Nasal packing (NP) after septoplasty has some negative aspects. The nasal septal suture (NSS) is therefore becoming increasingly preferred. OBJECTIVE The aim of this study was to analyze the effects of NSS and NP on pulmonary function tests. METHODS Sixty patients who suffered from nasal blockage resulting from nasal septal deviation and who were otherwise healthy were included. Patients were randomized into two groups, NP or NSS. Pre-operative spirometry was performed for all patients. The NP group received a finger glove packing for two days after septoplasty, whereas no additional dressing was used for the NSS group. Narcotic analgesics were not used for pain relief after septoplasty in either group. Spirometry was performed post-operatively on the third day for all patients and before removal of the NP for the NP group. RESULTS We observed statistically significant differences between pre-operative and post-operative values of forced vital capacity (FVC; p = 0.008), forced expiratory volume in the first second (FEV1; p = 0.006), and forced expiratory flow ((FEF)25-75%; p = 0.011) in the NP group. In comparison, pre-operative and post-operative values did not differ for FVC, FEV1, FEV1/FVC%, and FEF25-75% in the NSS group. CONCLUSION NP negatively influenced pulmonary function based on spirometric parameters, while NSS did not.

OBJECTIVES Septoplasty is one of the most commonly performed procedures in otolaryngology practice. Prophylactic use of antibiotics is controversial. Disruption of nasal flora may predispose individuals to infection. We investigated the effect of antibiotic prophylaxis and septoplasty on nasal flora. METHODOLOGY We included 115 consecutive patients who underwent septoplasty because of symptomatic nasal septal deviation. Patients were divided into study and control groups. Study patients received prophylactic parenteral sodium cefazoline twice a day beginning intra-operatively and while the nasal packing remained in the nose for 48 h, and expandable polyvinyl acetate (Merocel) packing covered with antibiotic ointment containing 0.2% nitrofurazone was inserted into each nostril at the end of the operation. Control patients received neither parenteral antibiotic prophylaxis nor antibiotic ointment around the Merocel packs. Both groups received oral prophylactic cefuroxime axetil for 5 d after nasal packing was removed. Nasal flora was determined pre-operatively, post-operatively when nasal packing was removed, and 3 mo after surgery. RESULTS Study patients were compared to control patients at pack removal and 1 mo after surgery The effect of antibiotic use in septoplasty on nasal flora was as follows: Increased isolation rate of gram-positive rods (p = 0.007), decreased methicillin-sensitive coagulase-negative staphylococci (p = 0.002). Pre-operative and post-operative culture results at 3 mo were compared. The effect of septoplasty on nasal flora was as follows: Decreased coagulase-negative staphylococci (p = 0.05), decreased Klebsiella (p < 0.001), decreased gram-positive rods (p < 0.001), increased methicillin-sensitive Staphylococcus aureus (p < 0.001). CONCLUSIONS Septoplasty increases S. aureus colonization and decreases normal flora. Antibiotics do not protect against S. aureus colonization and contribute to a decrease in normal flora. Antibiotics do not seem to confer benefit in terms of flora changes. Studies investigating flora changes with a longer follow-up should be conducted.

INTRODUCTION The present study was performed to evaluate the efficacy of Ericksonian hypnosis in reducing the impact of tinnitus on patients' quality of life. PATIENTS AND METHODS A controlled prospective longitudinal study was designed. The severity of tinnitus was assessed with Tinnitus Handicap Inventory (THI) before hypnotherapy and then 1 week, 1 month, 3 months, and 6 months after therapy. Health Survey SF-36 was used to assess health-related quality of life before and after hypnotherapy. Thirty-nine patients with severe idiopathic subjective tinnitus were enrolled in the study. RESULTS The mean SD age of the patients was 44.5 +/- 12.5 years, ranging from 21 to 65 years; 48% were female. Mean THI scores assessed at the beginning and 4 times after commencement of therapy were evaluated. The changes in THI scores were significant. Health Survey SF-36 was assessed separately. The greatest increases were seen in physical role followed by emotional role difficulty. CONCLUSION The preliminary results of our study demonstrated the effectiveness of Ericksonian hypnosis in the study group.

OBJECTIVES The aim of this study was to determine the prevalence and significance of traditional risk factors associated with sensorineural hearing loss (SNHL) in a population of 615 neonates who attended the neonatal intensive care unit (NICU) of the University Hospital in Leuven, Belgium between January 2005 and December 2007. METHODOLOGY Auditory brainstem response (ABR) audiometry using 40 dB stimuli was performed in all 615 neonates. A retrospective medical database analysis was performed to evaluate the influence of 14 predetermined risk factors. The evaluated risk factors were ototoxic medication, hyperbilirubinemia, in utero infections (including CMV, rubella, syphilis, herpes, and toxoplasmosis), craniofacial anomalies, syndromes associated with SNHL, low birth weight (< 1,500 g), low Apgar score, mechanical ventilation lasting for 5 days or longer, bacterial meningitis, family history of hereditary childhood SNHL, endocranial hemorrhage, hypoxic ischemic encephalopathy, convulsions, and sepsis RESULTS Uni- or bilateral hearing impairment was diagnosed in 25 out of 615 neonates (4.1%). In utero infections (especially CMV), craniofacial anomalies, and syndromes known to include SNHL were significant risk factors. For the remaining risk factors, no significant correlation with SNHL was found. CONCLUSIONS In this study, only in utero infections (especially CMV), craniofacial anomalies, and syndromes known to include SNHL were significant risk factors associated with SNHL. Adequate management of hyperbilirubinemia and ototoxic drug administration may eliminate some of the major historical risk factors associated with SNHL in NICU neonates.

INTRODUCTION Leksel Gamma Knife (LGK) radiosurgery is a safe and efficient therapeutic approach for vestibular schwannoma (VS) with low side effects. The goal of radiosurgery is not necessarily to cause significant tumour necrosis or to obtain a complete radiographic response, but to halt the tumour's growth permanently through its biological elimination. The 2 major aims of radiosurgery for VS are long-term tumour control and functional hearing preservation. The purpose of this study is to report our experience with LGK radiosurgery in the management of VS and to evaluate the hearing preservation rate after a minimum one-year follow-up. MATERIAL AND METHODS Between January 2000 and January 2011, 415 patients with unilateral VS underwent LGK radiosurgery at the University Erasmus Hospital of Brussels. There were 349 patients with previously untreated VS (86 grade I, 96 grade II, 141 grade III, 9 grade IVa, 17 unknown grades, according to Koos) and 66 patients with post-operative residual tumour. All patients in our series underwent evaluation with high resolution neurodiagnostic imaging including computed tomography and magnetic resonance imaging, and clinical evaluation as well as audiological tests that included tonal and speech audiometries. The Gardner Robertson (GR) classification is used to report the results of this study. We identified 276 patients treated for VS with LGK, tested and retested with speech and tonal audiometries by the same team, and followed for a minimum of one year. RESULTS Before LGK, 144 patients had serviceable (85 GR class I and 59 GR class II) hearing; 95 (65.97%) of these patients had preservation of serviceable hearing (Pure tone average < or = 50 db and Speech discrimination > or = 50%) at minimum one-year audiological follow-up. It was observed that 44 of the 85 GR class I patients (51.76%) maintained their level of audition and 66 of these (74.64%) preserved serviceable hearing. In the 34 patients with preradiosurgery non-serviceable hearing (GR class III-IV) 25 of these patients (73.52%) maintained their hearing. The tumour was stable or declining in size in 90.44% of cases. CONCLUSION LGK radiosurgery provides excellent tumour control in vestibular schwannomas and has low toxicity even after long-term follow-up.

The management of hypervascular skull base tumours is complex and requires a multidisciplinary approach. Skull base surgery may be challenging because of the risk of serious intra-operative bleeding and of potential injuries to lower cranial nerves and/or large cervical vessels. Over the last four decades, advances in neuro-interventional procedures have produced a range of adjunctive endovascular techniques in addition to conventional surgery. Digital subtraction angiography (DSA) allows for a better understanding of tumour vascularisation and its relationship with Surrounding vessels. Tumoural devascularisation and the occlusion of feeding arteries is a useful adjunct to surgery because it allows for the reduction of intra-operative blood loss and induces ischaemic necrosis of the tumour. Finally, surgery-related iatrogenic vascular lesions may be successfully treated with endovascular techniques. Nevertheless, endovascular procedures in the head and neck region are associated with infrequent but potentially serious complications. An extensive and comprehensive knowledge of head and neck vascular anatomy is therefore necessary. This article provides a review of the indications for, and results of, diagnostic, pre-operative and therapeutic endovascular procedures for the management of skull base tumours and related surgical complications.

Over the past two decades, Cerebrospinal Fluid (CSF) leak repair has advanced from open invasive intracranial approaches to transnasal endoscopic ones that avoid the traditional morbidities of frontal craniotomy approaches--such as anosmia, intracranial haemorrhage or oedema, seizures, memory deficiencies, and behaviour disorders--reducing morbidity, reducing hospitalisation times and accelerating return to work, and therefore cutting indirect costs. The diagnosis of CSF rhinorrhoea is both clinical and radiological. The presence of CSF in clear nasal drainage should be established by analysis for CSF markers. Localisation of the leak site involves radiological investigation, mainly Computerised Tomography (CT) and Magnetic Resonance Imaging (MRI). In addition to suppressing symptoms, the main goal of the closure of CSF rhinorrhoea is to prevent ascending meningitis. The operative management of cerebrospinal fluid leak is advised in the following circumstances: persistent, posttraumatic CSF leaks after 4 to 6 weeks of conservative treatment; all cases of spontaneous CSF fistulae; cases with intermittent leaks; delayed posttraumatic leaks; cases of CSF leak with a history of meningitis; false CSF rhinorrhoea coming from the petrous bone via the Eustachian tube. The graft material used depends mainly on the authors' experience and did not significantly influence the success rate. The main steps in the surgical procedures do not differ as much from one author to the other: accurate localisation of the defect; creation of a raw surface around the defect to accept the graft and to help in the formation of synechiae to support the seal later; plugging of the defect with fat covered with fascia lata supported by absorbable gelatin and Merocel. The differences between the authors relate to the use of fluorescein to locate the defect, the importance of prophylactic antibiotherapy, the plugging materials, the technique of underlay or overlay grafting, the use of fibrin glue and the need for lumbar drainage. The success rate for endoscopic repair of CSF rhinorrhoea is high: approximately 90% at the first attempt. Recent reports in the literature highlight the group of patients with spontaneous idiopathic CSF leak as a group with specific attributes and treatment challenges.

Recent advances in technology and techniques in neurosurgery and otolaryngology have revolutionised skull base surgery with the introduction of endoscopic endonasal approaches. One of the greatest limitations of endoscopic endonasal skull base surgery is the repair of osteodural defects. Numerous reconstructive techniques have been developed that maximise endoscopic endonasal approach efficacy and minimise complications. The choice of technique for closure depends on different factors and is based on an individual approach in each patient. In particular, size, the localisation of the defect and the presence of a high-flow CSF leak are major determinants of the reconstructive options. Free tissue transfer remains the mainstay for the reconstruction of smaller defects. However, local vascularised flaps and the nasoseptal flap in particular now play a pivotal role in the reconstruction of larger defects. These flaps have significantly reduced the morbidity and risk of post-operative CSF leaks after endoscopic endonasal approaches.

Lesions in the clivus and suprasellar region are rare but challenging pathologies for physicians. The most common tumours are chordomas and chondrosarcomas, but a wide variety of histopathological tumours can be found in these areas. Their deep location in the midline and their close relationship to important neurovascular structures frequently make total removal difficult. Neurosurgeons are often required to perform aggressive external-approach surgical therapy, which is usually associated with high levels of morbidity and a discouraging tendency for recurrence during long-term follow-up. Fortunately, over the past few years, close collaboration between otorhinolaryngologists and neurosurgeons has led to the development of minimally invasive surgery along the entire neuraxis, with endoscopy being used as the primary visualisation tool. This has been further augmented by the concept of team surgery: ENT surgeons and neurosurgeons working simultaneously throughout all phases of the surgery (approach, resection, and reconstruction). This concept has also changed the surgical approach as a whole, making the endonasal route the main approach for treating these types of lesions in carefully selected patients and external approaches the second-place option. The endonasal approach has revolutionised skull base surgery as it enables less aggressive surgery (reaching deep-seated structures without the need for craniotomy and brain retraction). It is therefore associated with lower morbidity and an absence of visible scars, with encouraging initial oncological prognosis. The aims of this paper are to describe the anatomical landmarks for this approach, to relate our experiences and to provide a literature review.