We have reviewed our experience of tracheostomy in children over the past 20 years at Sheffield Children's Hospital. One hundred and forty-eight tracheostomies were performed in 143 children aged one day to 13 years old (average 27 months). Sixty-five per cent of patients were < one year old. The indications for tracheostomy were upper airways' obstruction in 72 per cent, and assisted ventilation/ bronchopulmonary toilet in 28 per cent. The commonest single reason was acquired subglottic stenosis (SGS) in infants, accounting for 25 per cent of tracheostomies (36/143). The complication rate of tracheostomy was 46 per cent, most commonly granulation tissue formation. There were four deaths directly due to the tracheostomy: two accidental decannulations and two obstructions. Eighty-nine children were decannulated under our care. The average time until decannulation was 25 months.

To evaluate outcomes of intractable epistaxis managed with arterial embolisation. Fourteen sequential cases of intractable epistaxis that underwent embolisation in our centre were evaluated retrospectively and interviewed over the phone. All patients had several failed treatment modalities prior to embolisation. Patients' follow up ranged from 1 to 57 months with median of 26 months. All 14 cases underwent a single embolisation procedure with successful arrest of epistaxis. Four cases (29%) developed recurrent epistaxis at a later date. One (7%) required re-embolisation 19 months after his first procedure. One bled 17 days after embolisation, but this settled with hospital admission and Bismuth Iodoform Paraffin Paste packing. The other two developed minor episodes of epistaxis, which did not require hospital admission. Two patients developed local ischaemic complications following arterial embolisation. Of those, one developed necrosis of the left alar skin and cartilage that healed reasonably well after 5 months. The other case developed mucosal necrosis of the right side of the hard palate; this patient was the one who bled 17 days post-embolisation. The palatal necrosis healed in a satisfactory manner without causing any functional impairment of the oral cavity. Embolisation is a successful intervention in management of persistent epistaxis, when other interventions fail. The risks of major complications such as stroke are well known, and discussed with patients prior to the procedure. It is also important to discuss the risks of ischaemic damage to the face and oral cavity. In our experience, these complications have been minor and the benefits still outweigh the complications.

midwinter k.i., ahmed a. &willatt d. (2001) Clin. Otolaryngol.26, 281–283 A randomised trial of flexible versus rigid nasendoscopy in outpatient sinonasal examination Nasendoscopy is used extensively in ENT clinics both as a diagnostic tool and for local postoperative care. Both flexible and rigid fibreoptic scopes are available for the purpose of sinonasal examination. A prospective study of a flexible versus rigid endoscope was carried out, randomly assigning one type of scope to each nostril of 56 patients presenting to clinic with sinonasal symptomatology. Patients awarded each type of scope a pain score on an analogue scale, according to the level of discomfort experienced, and the operator noted the number of structures seen. Significantly more structures were visualized with the rigid scope than the flexible scope (P = 0.05). The pain scores were similarly in favour of the rigid scope, showing a trend to less discomfort. The rigid nasendoscope is the scope of choice for sinonasal examinations in the outpatient clinic based on these data.

Iatrogenic injury to the spinal accessory nerve following surgical procdures in the neck is well recognized in causing significant morbidity to patients, with shoulder pain and loss of function being particularly problematic. We have used a Magstim Neurosign 100 peripheral nerve monitor, that is most often used in our practice to monitor the facial nerve during middle ear and parotid surgery, to monitor the accessory nerve during neck surgery. Ten patients undergoing accessory nerve-sparing neck dissection, or excision biopsy of neck mass had their accessory nerve monitored during the procedure. No patient suffered injury of the nerve. In several cases the nerve closely adhered to the tissue being resected, and in two cases, the nerve bifurcated or gave off branches. We found that the monitor aided identification and preservation of the nerve.

Malignant (invasive) otitis externa is an infection involving the external ear canal, often in elderly diabetic patients, which carries a high morbidity and mortality. It may involve widespread areas of soft tissue around the skull base, and in more advanced cases, may give rise to osteomyelitis and cranial neuropathy. We describe two patients who were treated for malignant otitis externa complicated by destructive osteomyelitis of the temporomandibular joint (TMJ). For both patients, diagnosis was made using magnetic resonance imaging (MRI), and repeat scans were employed during follow-up. Improved scan appearances mirrored improvements in clinical condition in both cases.