High jugular bulbs in the middle ear have been reported many times. To our knowledge, there has only been one previous report of a high jugular bulb in the external ear. These cases illustrate the importance of full, accurate assessment of high resolution computed tomography images, and of appropriate, immediate management of bleeding.

The simulated-ward learning activity received positive feedback, although the mix of patient simulators and high-fidelity manikins proved a challenge to some students. Medical school assessments appear to be inadequate in the assessment of teamworking ability, with change needed in future to ensure that this and other non-technical skills are assessed.

SummaryWe present an unusual case of a 54-year-old Chinese lady presenting to the ears, nose and throat clinic after family members noticed that her hearing had progressively deteriorated over the preceding weeks. She also complained of tinnitus. Examination of the ears, nose and throat was unremarkable. Flexible nasoendoscopy demonstrated swelling in the postnasal space, which, following biopsy, was shown to be pathognomonic of tuberculosis. This was successfully treated with multidisciplinary input and the patient made a complete recovery. BACKGROUND

Children with syndromic craniosynostosis may present with airway anomalies. We reviewed a cohort of such individuals who underwent tracheostomy at the Great Ormond Street Hospital for Children (London, UK) between 1999 and 2012 from a prospectively collated database. A case note review was undertaken in 11 patients. We evaluated the indication for tracheostomy in these children and the presence of laryngotracheal anomalies. The most common indication for tracheostomy was upper airway obstruction refractory to medical and first-line surgical management. Laryngotracheal anomalies were detected both at diagnostic microlaryngoscopy and bronchoscopy and at the time of tracheostomy. The commonest anomaly was a tracheal cartilaginous sleeve, but we also describe the figure-of-eight trachea that, to the best of our knowledge, has not been described before in this group of patients. A mutation of a fibroblast growth factor gene was found in 71% of our patients with a laryngotracheal anomaly. We present the largest cohort of children with syndromic craniosynostosis and confirmed anatomical anomalies of the airway and uniquely describe the figure-of-eight appearance of the trachea. These findings highlight the importance of thorough airway evaluation and the special care needed in airway management for children with syndromic craniosynostosis.

ObjectiveA variety of paediatric tracheostomy tubes are available. This article reviews the tubes in current use at Great Ormond Street Hospital for Children and Evelina London Children's Hospital.MethodsThis paper outlines our current preferences, and the particular indications for different tracheostomy tubes, speaking valves and other attachments.ResultsOur preferred types of tubes have undergone significant design changes. This paper also reports further experience with certain tubes that may be useful in particular circumstances. An updated sizing chart is included for reference purposes.ConclusionThe choice of a paediatric tracheostomy tube remains largely determined by individual clinical requirements. Although we still favour a small range of tubes for use in the majority of our patients, there are circumstances in which other varieties are indicated.