Dominic Bray

Over the last decade, injectable soft tissue fillers have become an integral part of facial plastic surgery practice. The vast choice of new products being brought to the market, improved safety profile, lower costs in the current economic climate and high street availability mean that demand for nonsurgical rejuvenation treatments are increasing at an exponential rate and are no longer the preserve of the affluent. Recent published work has focused on the addition of local anaesthetic into fillers, widening their indications, reporting longer term results, avoidance of complications, regulation and future directions. The refinement of techniques to restore facial volume with dermal fillers, and widely available botulinum (BTX) injections to treat dynamic facial rhytids, fuelled by widespread mainstream advertising, has led to a surge in demand for nonsurgical rejuvenation procedures. An increasingly well informed and discerning patient population now seek better value procedures that require minimal downtime and have instant results. A thorough knowledge of the dermal fillers available for soft tissue facial augmentation is therefore essential to any clinician involved in facial plastic surgery.

Objective: Airway compromise due to paediatric intubation injuries is well documented; however, intubation injuries may also cause severe voice disorders. We report our experience and review the world literature on the voice effects of traumatic paediatric intubation.Case series: We report five cases of children referred to Great Ormond Street Hospital for Children who suffered traumatic avulsion of the vocal fold at the time of, or secondary to, endotracheal intubation. All children had significant dysphonia and underwent specialist voice therapy.Conclusions: The mechanisms of injury, risk factors and management of the condition are discussed. Children suffering traumatic intubation require follow up throughout childhood and beyond puberty as their vocal needs and abilities change. At the time of writing, none of the reported patients had yet undergone reconstructive or medialisation surgery. However, regular specialist voice therapy evaluation is recommended for such patients, with consideration of phonosurgical techniques including injection laryngoplasty or thyroplasty.

Objectives and hypothesis: Isshiki type one medialisation thyroplasty is an accepted treatment for a unilateral immobile vocal fold. It can also be performed simultaneously as a bilateral procedure in patients with severe bowing of the vocal folds (e.g. presbyphonia). The objectives of this study were to assess the incidence and timing of post-operative complications, and to evaluate whether patients undergoing this operation could, in future, be treated as day cases.Study design and methods: A retrospective analysis was undertaken of 57 consecutive patients who had undergone a type one thyroplasty (52 unilateral and five bilateral) at a tertiary referral centre between April 2003 and April 2006. Post-operative improvement in the voice (measured subjectively, perceptually and quantitatively) was considered to constitute a successful outcome. Any complications were documented.Results: Fifty-seven patients who had undergone laryngeal framework surgery were recruited from the study database. All of these patients had undergone either unilateral or bilateral type one medialisation thyroplasty but no arytenoid surgery. Thirty-seven were male (65 per cent) and 20 female (35 per cent), and there was left-sided predominance (74 per cent). All patients were discharged the morning following afternoon surgery (i.e. within 24 hours). Complications occurred in four patients (7 per cent). One patient, who was taking warfarin, developed a post-operative haematoma which resolved with conservative treatment. Two patients (both of whom had undergone revision thyroplasty) developed a wound infection three days post-operatively, which resolved with antibiotics. One patient returned with hoarseness five months post-operatively, after an initially successful result. This patient had previously received radiotherapy for early glottic carcinoma, and the Silastic^® implant was eroding through the mucosa. This was subsequently removed under general anaesthesia. No patients developed complications leading to airway compromise.Conclusion: The only complications in this series were in patients taking anticoagulation medication, undergoing revision surgery, or in whom the laryngeal tissue was atrophic or absent. Careful patient selection to exclude any of the above should reduce the risk of complications. The authors would therefore advocate type one thyroplasty for unilateral or bilateral vocal fold paralysis as a suitable procedure for day-case surgery within our department.

Ameloblastoma is an odontogenic neoplasm of enamel organ type tissue which does not undergo transformation to the point of enamel formation. We present the second case in the English literature of maxillary ameloblastoma that presented with nasal obstruction and rhinorrhoea, and the first to be excised using a combined maxillotomy and endoscopic ethmoidectomy. The patient had no previous dental history. The unusual presenting symptoms, as well as the highly destructive nature of these lesions when arising in the maxilla, make them worthy of consideration in the differential diagnosis of nasal and maxillary masses. We discuss the clinical features, pathology and management of these lesions and review the literature.

. Grommet insertion is one of the most common procedures performed under general anaesthesia. . The authors describe an innovative grommet that, through an anatomically contoured and user friendly design has been designed to minimize anaesthetic time by facilitating and expediting its placement and/or removal.

Objective: To investigate the previously documented inverse association between ambient temperature and presentation rates for patients with epistaxis and seasonal variation of emergency presentation rates for patients with epistaxis.Study design: A retrospective analysis of all consecutive emergency patients with epistaxis presenting to hospital from the community over a five-year period, 1997–2002 (1830 days), including those who required admission to hospital with epistaxis over the same period. Patients in whom there was a clear aetiology for the epistaxis (traumatic, recurrent, iatrogenic, coagulopathic and hypertensive) were excluded.Setting: A tertiary referral centre in south-west London serving a population in excess of 2.8 million.Method: A retrospective analysis of all patients presenting or admitted to St George’s Hospital with epistaxis over a five-year period. Daily ambient temperature readings from London Heathrow airport were recorded for the same period. Presentations were correlated with monthly temperature variations and the month itself. Statistical analysis with Pearson’s correlation coefficient was performed.Results: 1373 patients with epistaxis presented to our department, of whom 386 (28.1 per cent) were admitted to hospital. No correlation is seen between ambient temperature and presentation rate for patients with epistaxis. No seasonal preponderance is noted for presentation rate (Pearson r = 0.160, p = 0.221) in this series.Conclusion: To our knowledge, this is the largest study to date examining ambient temperature association and epistaxis, and the first to investigate presentation rate in place of admission rate. We feel that the exclusion of all patients with epistaxis not admitted to hospital introduces a bias. In this series, there is no correlation between ambient temperature, seasonal preponderance, presentation rate or admission rate for patients with epistaxis. This is contrary to previously reported findings. We do not support the view that there is a relationship between epistaxis and temperature or seasonal variation. This contradicts the current belief that incidence of epistaxis displays seasonality, and has implications for the allocation of resources for healthcare provision within ENT departments.