Dysphonia is a common presenting symptom to the outpatient ear, nose and throat team and the need to have a systematic approach to its investigation and management is imperative. Red flag features combined with clinical examination including flexible nasoendoscopy will help to identify laryngeal causes of dysphonia. Vocal cord palsy can have both laryngeal and extralaryngeal aetiologies including Ortner’s syndrome. We present a case where a woman in her 70s was referred with persistent hoarseness, found to have an isolated vocal cord palsy with CT scan revealing a very large hiatus hernia producing mass effect at the aortopulmonary window with no other pathology identified. To our knowledge, this is the second case in the literature of a hiatus hernia causing a vocal cord palsy. This case underpins the need for prompt assessment by flexible laryngoscopy, and consideration of extralaryngeal causes of vocal cord palsy during a dysphonia assessment.

Necrotising fasciitis (NF) is a life-threatening infection which can affect the skin, subcutaneous tissue, superficial and deep fascia with muscular extension. 1 Predisposing factors include chronic immunocompromised states, such as prolonged corticosteroid use, diabetes mellitus and intra-venous drug use. 1 NF affecting the head and neck region is rare. 1 NF has been documented in patients with dental infections, traumatic neck wounds and deep space neck infections. 1 Periocular NF is very rare, with a rate of 0.24 cases per million per annum. 2 Mortality rates of NF can exceed 50%, with periocular NF mortality ranging from 3% to 10%. 2,3 The pathophysiological mechanism behind NF includes the seeding and proliferation of a bacterial pathogen in the subcutaneous tissue, triggering the release of inflammatory mediators, including toxins and cytokines. 2 This inflammatory cascade results in microthrombi formation heralding ischaemic necrosis of tissue. Severe pain, erythema, bullae formation, and surgical emphysema with systemic sepsis are hallmark features, which should raise suspicion.Four types of NF have been described in the medical literature, with types 1 and 2 the most prevalent. 3 Type 1 NF is a polymicrobial infection usually consisting of mixed anaerobes, and can account for up to 80% of all NF cases. 3 Type 2 usually has a monomicrobial aetiology, with Group A beta-haemolytic Streptococcus (GAS) as the most prevalent pathogen. 3 Type 2 NF accounts for 20%-30% of cases, and can present as aggressive and rapidly progressing. GAS can induce a large inflammatory response with type 2 NF more likely to produce bacteraemia, with streptococcal shock syndrome. 4

Otitis externa is a common condition encountered in primary care, with 10% of the population being affected during their lifetime. It can cause many patient issues including pain, sleep disturbance, hearing loss and temporary loss of income. It can have a significant burden on patients’ mental health and psychosocial wellbeing.

Multiple haemangiomas of the head and neck area have been reported sporadically in the literature. Concurrent subglottic and carotid sheath haemangiomas have not been reported before in the paediatric population. The authors present the case of a 13-week-old child admitted under the paediatric ENT team with stridor. Diagnostic micro-laryngoscopy identified a subglottic haemangioma as the cause of stridor and subsequent magnetic resonance imaging demonstrated an incidental 7 cm carotid sheath lesion extending from the skull base to the superior mediastinum. Subsequent biopsy confirmed a benign infantile haemangioma. To our knowledge, this is the first reported case of concurrent subglottic and carotid sheath infantile haemangiomas in a paediatric patient. Here we discuss the clinical features and management of infantile haemangioma.

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