Symptomatic dyspnoea addressed by excision of ossified anterior longitudinal ligament

Ossification of the anterior longitudinal ligament (OALL) in cervical spine is known to cause dysphagia. However, dyspnoea and obstructive sleep apnoea (OSA) due to OALL is a rare entity. A 50-year-old man presented to our clinic 2 years after anterior cervical discectomy and fusion (ACDF) with complaints of dysphagia, dyspnoea and difficulty in sleeping supine. The clinico-neurological examination of patient was normal without any long tract signs. The diagnosis of OALL was made on plain lateral radiographs. Ultrasonic bone cutter was used to convert sessile osteophyte mass into a pedunculated mass. It was then disconnected from the anterior aspect of vertebral bodies with a chisel. The patient showed immediate relief from dysphagia and OSA. Dyspnoea improved over a week and the postoperative change in voice responded well to speech therapy. To the best of our knowledge, this is the first report of dyspnoea due to OALL after ACDF.

Cogan's syndrome with pyoderma gangrenosum: management of two uncommon disorders with aggressive presentation in a patient

Pyoderma gangrenosum (PG) coexisting with Cogan's syndrome (CS) is uncommon, although cutaneous manifestations are known to develop in CS. A middle-aged white female patient had chronic relapsing PG requiring ciclosporin and prednisolone. Despite receiving optimal doses of ciclosporin and prednisolone, she developed acute vestibulo-auditory symptoms as a result of CS. Ciclosporin was switched to methotrexate and prednisolone was increased. However, she continued to develop acute scleritis, requiring methylprednisolone pulses, and still had further flares of PG. Her methotrexate was held off when she developed severe pneumonia and she then received a trial of intravenous immunoglobulins (IVIG) for her recurrent leg ulcers. Unfortunately, she failed to respond to IVIG. Her ulcers eventually responded to six doses of monthly intravenous cyclophosphamide induction. Although CS is not an antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis, we used pulse cyclophosphamide, based on the experience of cyclophosphamide efficacy in severe ANCA-associated vasculitis (AAV). Following induction, both diseases currently remain under control with azathioprine as maintenance treatment.

Subcutaneous emphysema to the head and neck: an unlikely traumatic origin

Subcutaneous emphysema to the neck represents a rare entity mainly derived from iatrogenic and traumatic origin. We report a case of a subcutaneous emphysema resulted from an intraoral injury aiming to emphasise the significance of precise medical history to identify an unlikely mechanism. A 40-year-old female patient was presented with subcutaneous emphysema extending from the region underneath the left eye up to the submandibular area of the neck. The patient complained of painful, swollen neck. The patient mentioned that the symptoms began after an intraoral injury accidentally caused by the use of a high-pressure water jet device meant for car wash. The patient was managed conservatively and was discharged after 2 days. This case highlights the urgency for clinical suspicion for unlikely mechanisms. Moreover, the manufacturer companies should alert and give official warning for the contingency of injury due to incorrect or careless usage.

Maxillary sinus schwannoma

Schwannoma (neurilemmoma) is a benign tumour that arises from the Schwann cells which cover the nerve sheaths of the peripheral or autonomic nervous system especially the sympathetic system. Reported cases of schwannoma arising from the sinonasal tract are rare. We report a case of a 28-year-old man who presented to otolaryngology-head and neck surgery clinic with left cheek swelling and left-sided nasal obstruction for 1-year period. Endoscopic examination and high-resolution CT scan revealed a homogenous expansile mass occupying the left maxillary antrum extending to the left orbit and left ethmoidal air cells. The mass was excised through endoscopic endonasal approach followed by Caldwell-Luc approach for the residual tumour. Postoperative histopathological examination revealed benign type Antoni A schwannoma.

Neisseria meningitidis sepsis in a patient with acute epiglottitis and respiratory failure

A 78-year-old female patient presented to our emergency department with a 5-day history of throat pain, hoarseness and a progressive and dolorous submandibular swelling. Due to non-conclusive clinical examination and the stable but visibly affected patient, we performed a neck CT scan with intravenous contrast, which showed the thumbprint sign typical for acute epiglottitis. Within minutes, the patient’s condition deteriorated and the patient was close to respiratory exhaustion. As intubation was severely complicated by massive swelling of the supraglottic soft tissue, the patient went into hypoxaemia and eventually cardiac arrest. After initiating reanimation protocol, eventually the airway was secured and Return of spontaneous circulation (ROSC) achieved after around 5 min. The initially sampled blood cultures revealed Neisseria meningitidis bactera emia and the patient was successfully treated accordingly. In patients with swelling of the upper airway, rapid clinical deterioration is possible. Diagnostics should not delay therapy, including administration of empiric antibiotics, steroids and intubation.

Numb chin syndrome: an ominous sign of mandibular metastasis

A 51-year-old woman a known case of stage 2 breast carcinoma in 2006 and underwent left mastectomy performed in the same year presented with bilateral lower limb pain suggestive of spinal pathology, and left chin numbness, both of 2 weeks' duration. Examination revealed left mandibular hypoesthesia without any other sign or symptoms. Orthopantomogram was unremarkable apart from mild alveolar bone expansion at tooth 36 area, which was extracted 3 months earlier. Subsequently, a full-body positron emission tomography contrast enhanced computer tomography revealed hypermetabolic lesions of her axial (excluding skull) and appendicular skeleton. In the head and neck region, left mandibular foramen and oropharynx bilaterally showed increased metabolism suggestive of tumour metastasis. The diagnosis was numb chin syndrome secondary to mandibular metastasis. Apart from supportive treatment, she was started on palliative chemotherapy and radiotherapy. At the time of discharge, there were no active complaints other than the aforementioned hypoesthesia.

Spontaneous closure of branchial sinus of the pyriform fossa

Management of third and fourth branchial cleft anomalies are similar. These anomalies should be suspected in a child with recurrent low-anterior neck abscess. Investigations in the form of cross-sectional studies and examination of the pharynx under anaesthesia will facilitate diagnosis and resolution of abscess. Spontaneous closure of the pyriform sinus can occur following conservative management with antibiotic treatment and abscess drainage. This emphasise the role of second-look prior to implementing endoscopic cauterisation or surgery.

Lateral semicircular canal osteoma presenting as chronic postaural fistula

Temporal bone osteoma is an unusual pathology which can occur by birth or can be acquired and mostly involves the tympanomastoid segment of the temporal bone. Osteomas arising from the otic capsule are extremely rare, and there has been only one other report of a lateral semicircular canal osteoma in the literature. We report a similar case of an acquired lateral canal osteoma which presented as a chronic postaural fistula in an ear previously operated for paediatric cholesteatoma.

Immunoglobulin G4-related disease of the paranasal sinuses

Immunoglobulin G4-related disease (IgG4-RD) is becoming increasingly documented. It was first described in relation to autoimmune pancreatitis. Features of the disease include tissue infiltration by IgG4 plasma cells with associated fibrosis and the growth of pseudotumours. A 71-year-old woman presented with increasing right cheek swelling and mild proptosis. Ten years earlier, she had a similar presentation and was diagnosed with an inflammatory pseudotumour. Examination revealed a lesion in the right nasal cavity. CT and MRI confirmed a mass within the right maxillary antrum extending into the nasal cavity. Endoscopic biopsies showed florid plasma cell infiltrate with marked increase in IgG+ plasma cells. Immunostaining expressed IgG4 (70%). She was started on a course of prednisolone and her symptoms resolved. IgG4-RD is becoming an emerging disease entity. Its involvement in the paranasal sinuses can mimic nasal tumours. Major surgical resection should be avoided as patients can often be treated medically.

A severe deep neck odontogenic infection not prioritised by the emergency department triage system and National Early Warning Score

A 62-year-old man with a background of type 2 diabetes mellitus presented to the emergency department (ED) with a 5-day history of dental pain, progressive right facial swelling, trismus, dysphagia and voice changes. The oropharynx could not be directly examined completely due to trismus. The patient had a National Early Warning Score of 0 and so was triaged into the ‘minors’ section of ED. Following assessment by the on-call oral and maxillofacial surgeon, an urgent contrast-enhanced CT demonstrated a large parapharyngeal collection, which required urgent anaesthetic and surgical intervention. The patient developed pulmonary complications postoperatively, but eventually made a full recovery.

Not quite Pott's puffy tumour

Pott's puffy tumour (PPT) is characterised by a subperiosteal abscess associated with osteomyelitis of the frontal bone-a rare complication of frontal sinusitis, more common in the paediatric population. We describe a case mimicking PPT, where abscess extension was facilitated by previous surgery. Usually patients with PPT would be systemically unwell, but our patient, a 63-year-old Caucasian man, was systemically well with a large swelling of his forehead. A CT was performed to evaluate possible intracranial and intracerebral complications such as epidural, subdural and brain abscesses. Emergent surgical drainage was performed with prolonged administration of antibiotic therapy. 12 weeks later, he had recollection in the frontal sinus requiring incision and drainage. 6 weeks afterwards, he underwent planned Lothrop procedure and endoscopic sinus surgery. Although clinically the patient presented with overwhelming features of PPT, we emphasise that PPT involves osteomyelitis of frontal bone, which is absent in our case.

High-riding brachiocephalic (innominate) artery during surgical tracheostomy

Two cases of a high-riding innominate artery, which were found during routine surgical tracheostomy. A cartilage flap was applied to cover the significant vessel to prevent the life-threatening complications. These two cases were followed up for 2 months without any adverse events. We discussed the related vascular anatomy, imaging studies and brief literature review.

Accidental and potentially life-threatening finding: pulsatile mass of the hypopharynx

Anatomical variations of the cervical part of the internal carotid artery (ICA) are not rare in the general population. They are usually asymptomatic and more common in the elderly. We report the case of a 70-year-old Caucasian woman who was referred to our department due to chronic cough. We performed a flexible nasofibrolaryngoscopy that demonstrated the presence of a pulsatile mass in the hypopharynx. After performing a cervical contrast-enhanced CT, the mass turned out to be an aberrant variation of the cervical part of the ICA. This case is intended to alert otolaryngologists, anaesthesiologists, radiologists and surgeons for this accidental finding and the possible consequences for the patient if not diagnosed and properly oriented.

Nasal septal schwannoma: a rare sinonasal tumour with certain peculiarities

Sinonasal schwannomas constitute 4% of head and neck nerve sheath tumours; however, schwannomas involving the nasal septum are quite rare. We present a 57-year-old male patient with nasal septal schwannoma who was managed successfully by endoscopic excision. 32 cases of septal schwannoma have been reported so far in the literature. This report discusses certain peculiar features exhibited by schwannomas of the nasal septum. Septal schwannoma does not show any age, sex or side predilection. However, they tend to involve posterior part of the septum and presumed to arise from the nasopalatine branch of the trigeminal nerve. Imaging findings of the sinonasal schwannoma are non-specific, but the histopathological characteristics are diagnostic, with seldom need for immunohistochemistry. Endoscopic excision is the safe and effective treatment option for the septal schwannoma of any size and location. Recurrence has not been reported in the literature following endoscopic excision.

Eye for an eye: near-fatal outcome of fungal infection in a young, diabetic girl

In this report, we describe the case of a young, diabetic girl with ketoacidosis who suffered sudden loss of vision of the right eye. The loss of vision was caused by an invasive rhino-orbital-cerebral fungal infection (mucormycosis) with extensive periorbital thrombosis. Despite maximal antifungal and surgical treatment (including exenteration of the right orbit), the clinical situation deteriorated. It was only after overcoming the difficulties of managing her hyperglycaemia that the patient's condition stabilised and her life was saved. Another factor contributing to this girls' survival was the swift diagnosis of mucormycosis, which was made soon after the onset of symptoms. Because of this, treatment could be started almost immediately.

A huge pleomorphic adenoma of the submandibular salivary gland

The most common tumour of salivary gland is pleomorphic adenoma (PA). They are benign, painless, can grow into big tumours but usually do not affect nerves or lymph nodes. PA most commonly occurs in the parotid gland but it may involve submandibular, lingual and minor salivary glands also. They can attain giant proportions and weigh several kilograms. We report a giant PA arising in the submandibular gland and treated by complete surgical excision without any complication. A female patient presented with a tumour in the submandibular region and front of neck with a history of more than 18 years. The weight of the resected mass was 4.35 kg. Patient's fear of surgery and lack of awareness were the main reasons for her long-standing swelling. Such giant PAs of the submandibular gland are very rare in medical literature.

An unusual manifestation of olfactory neuroblastoma

A 62-year-old woman presented with an 11-month history of worsening nasal symptoms of rhinorrhoea, anosmia, nasal congestion and intermittent epistaxis. MRI revealed a large mass in the upper nasal vault. Biopsy of the mass revealed an olfactory neuroblastoma. While waiting resection, she acutely developed severe proximal muscle weakness, lethargy and lower extremity oedema. Blood glucose was elevated, and hypokalaemic metabolic alkalosis was noted. Elevated serum cortisol level of 95.7 µg/dL (8.7-22.4 µg/dL) and markedly elevated 24-hour urinary cortisol level of 6962.3 µg/24 hours (4.0-50.0 µg/24 hours) with concurrent adrenocorticotropic hormone (ACTH) level of 171 pg/mL (6-58 pg/mL) were suggestive of an ACTH-dependent source of hypercortisolism. A subsequent positive high-dose dexamethasone suppression test was consistent with ectopic ACTH production. She underwent near-total resection of the right nasal mass followed by radiotherapy, resulting in complete resolution of signs and symptoms of cortisol excess.

Nasal oncocytoma causing unilateral epiphora in an elderly patient: the vital role of nasendoscopy

Oncocytomas are rare glandular tumours, typically found in salivary glands and kidneys. A 76-year-old man presented to an ophthalmology department after 3 months of persistent right-sided epiphora. Lacrimal syringing and a fluorescein dye test demonstrated an obstruction at the level of the nasolacrimal duct (NLD). Owing to the patient's history of dacryocystitis, endoscopic dacryocystorhinostomy was organised. When in theatre however, nasendoscopy identified a polypoid mass at the lateral aspect of the inferior turbinate, obstructing the right NLD opening. Histopathology confirmed an oncocytoma. There was no local destruction or distant metastases. The mass was resected, a Monoka stent inserted and symptomatic relief achieved. In this case, the cause of epiphora was initially missed because no direct nasal examination was performed. It is vital that patients with unilateral epiphora undergo an endoscopic nasal examination before arranging treatment. This could prevent delayed diagnoses, ensure prompt and appropriate management, and reduce morbidity and mortality.

Meningococcal serogroup W135 epiglottitis in an adolescent patient

Acute epiglottitis is a severe and potentially life-threatening condition. Since the implementation of Haemophilus influenzae vaccination, the number of cases of epiglottitis has decreased and the proportion of other infectious causes has increased. We report a case of acute epiglottitis in a teenager caused by Neisseria meningitidis, an unusual pathogen.

Painful torticollis following adenotonsillectomy: a cardinal sign of atlantoaxial subluxation

An 11-year-old boy with a history of autism spectrum disorder attended the emergency department with his mother 8 days after an adenotonsillectomy reporting postoperative bleeding. Detailed physical examination revealed no active bleeding, but a rigid neck posture was noted. A head and neck CT scan demonstrated unilateral rotatory atlantoaxial subluxation and possible damage to the anterior spinal ligament. He was reviewed by neurosurgeons who performed manipulation under anaesthetic and successfully realigned the occipital cervical tract. Non-traumatic atlantoaxial subluxation (Grisel's syndrome) is a rare but serious complication of routine ear, nose and throat (ENT) procedures. An awareness of this complication among paediatricians, otolaryngologists and emergency physicians, and a high index of suspicion in any patient presenting with torticollis following ENT surgery is essential in preventing significant neurological morbidity.

The man that lost (part of) his mind

An 84-year-old man presented to the emergency department following recurrent falls over several weeks and onset of new left-sided weakness. CT of the brain revealed a large air cavity (pneumatocoele) in the right frontal lobe thought to be secondary to an ethmoidal osteoma communicating through the cribriform plate allowing air to be forced into the skull under pressure. Subsequent MRI confirmed these findings and also revealed a small focal area of acute infarction in the adjacent corpus callosum. The patient had a prolonged hospital stay, declined neurosurgical intervention and was discharged home on secondary stroke prevention.

Recurrent epistaxis leading to diagnosis of primary sinonasal melanoma

A 48-year-old man presented to urgent care with recurrent epistaxis over 6 months. Initially, nosebleeds were controlled with packing or cautery. Ultimately, he was referred to ear, nose and throat department and underwent nasal endoscopy which revealed polypoid tissue. A biopsy of the polyp showed non-specific inflammation with no evidence of malignancy. Follow-up maxillofacial CT revealed a large mass lesion in the right maxillary sinus, right nasal fossa, much of the ethmoids and right sphenoid, with destruction of adjacent bony structures. MRI revealed a mass in the right nasal cavity with extension into the ethmoid and anterior sphenoid sinus, anterior cranial fossa and medial orbits. Staging CT discovered metastatic disease in the adrenal glands and lymphadenopathy in the neck. The patient underwent endoscopic sinus surgery with debulking and tissue diagnosis of malignant melanoma. He completed radiation therapy to sinus and was subsequently enrolled in a clinical trial. Most recent imaging revealed complete metabolic response on positron emission tomography.

Localised nasopharyngeal amyloidosis: the importance of postoperative follow-up

Localised nasopharyngeal amyloidosis is rare. Findings on physical examination and invasive pattern on CT scan can be misleading as it can resemble nasopharyngeal carcinoma. A 64-year-old man presented with left aural fullness for 6 months. The physical examination showed straw-coloured fluid in the left middle ear and irregular reddish mass at the left side of the nasopharynx. The CT scan showed a lobulated heterogeneous mass at the left side of the nasopharynx involving the left Eustachian tube opening. Pathology report was amyloidosis, thus, surgery was done. After a year, there were new foci of amyloidosis at the right side of the nasopharynx, and a repeat surgery was performed. Two years later, the systemic amyloidosis with underlying IgG4-related disease was suspected due to multiple organ involvement. Surgery is the treatment for localised amyloidosis with compressive symptoms. Close follow-up is important after surgical excision due to its recurrence and progression to systemic amyloidosis.

Spontaneous pneumomediastinum

Spontaneous pneumomediastinum is the presence of free air within the mediastinum that is not associated with trauma. It is a rare, self-limiting condition that can cause widespread subcutaneous surgical emphysema. We present the case of a 12-year-old boy who presented with widespread spontaneous surgical emphysema and pneumomediastinum, with no history of trauma or respiratory tract disease. We discuss our assessment of him and management with our multidisciplinary team (MDT), and whether radiological investigations including CT are helpful in such cases. In conclusion, we hypothesised that the child's coughing was the most likely cause of the tracheal rupture leading to the spontaneous surgical emphysema. Spontaneous pneumomediastinum in the paediatric patient is extremely rare. This case highlights how spontaneous pneumomediastinum can be successfully managed conservatively, and how MDT input can be helpful in guiding management in such unusual cases.

Successful management of benign paroxysmal positional vertigo (BPPV) in a patient who was ventilated with a C3 complete spinal injury on a regional spinal unit intensive care

Benign paroxysmal positional vertigo (BPPV) occurs in 14.5% of patients with spinal cord injury (SCI) and may require intervention on intensive care unit (ICU). A 61-year-old man was admitted to a spinal injury ICU with a traumatic C3 complete SCI following a mountain bike accident. Ventilated but stable he complained of severe dizziness on rolling, during personal cares, which lasted for 40 s. Clinical examination was limited due to the injury and ventilation. Subjective questioning, visio-ocular control and a modified Dix-Hallpike and roll tests confirmed a right posterior canalithiasis BPPV. A modified right Epley was performed with assistance of four people, medical supervision, monitoring of tracheal ventilation and vital signs. No adverse reaction was observed. Resolution of dizziness on rolling was achieved with no recurrence at 1 year. BPPV can be successfully and safely managed on ICU.

Nasopharyngeal angiofibroma in a 32-year-old man

Nasopharyngeal angiofibroma (NA) is a benign, highly vascularised tumour of the nasopharynx, which typically occurs in young males aged 14-25 years. We report an interesting case of an NA arising de novo in a 32-year-old male. He was referred to our facility for severe nasal haemorrhage after biopsy of a left nasopharyngeal mass. In the operating room, extensive bleeding was noted, and an endoscopic medial maxillectomy was performed, and the left internal maxillary artery was ligated allowing for near total resection of the lesion. The pathological specimen confirmed the diagnosis of NA. To our knowledge, this is one of the oldest patients presenting with a de novo NA, in his fourth decade of life, confirming that this diagnosis must be considered in all those with large nasopharyngeal masses.

Vertebro-vertebral fistula presenting as a pulsatile tinnitus

Tinnitus is the perception of sound in the absence of a corresponding external acoustic stimulus, resulting in an estimated prevalence of 10% to 15% in adults. Tinnitus may be classified as pulsatile (PT) or continuous (non-PT), and may be subjective (heard only by the patient) or objective (also audible to the examiner). PT is usually related to vascular causes and is pulse synchronous (coinciding with the patient's heartbeat). PT is much less common affecting approximately 4% of patients with tinnitus, but unlike non-PT, usually has a specific identifiable cause. We present a case of a man without previous otological disease or head trauma, with a left-ear subjective PT. MR angiography detected a left vertebro-vertebral arteriovenous fistula, which was treated by endovascular embolisation with important symptomatic relief.

Recurrence of Graves' disease in ectopic thyroid tissue

A 40-year-old woman with a history of Graves' disease status postorbital decompression for severe ophthalmopathy underwent total thyroidectomy by a high volume thyroid surgeon in July 2013 with a benign final pathology. Eight months later, she presented with a mass on the right anterior neck that showed minimal growth over time. Her thyroid stimulating immunoglobulin and thyroid-stimulating hormone receptor antibody levels were consistently elevated and increasing. She underwent removal of the neck mass in September 2016. Final pathology showed benign thyroid tissue with diffuse hyperplasia and lymphoid follicles, consistent with Graves' disease. We present an unusual recurrence of Graves' disease post-total thyroidectomy that recurred secondary to ectopic thyroid tissue in the right upper anterior neck deep to the strap muscles.

Unusual 'feathery' cause of a parapharyngeal abscess in an infant

A 7-month-old boy presented to the emergency department with reduced oral intake, neck swelling and fever. Clinical examination revealed a 3 cm left parotid and left level I neck swelling with left medialised tonsil but no trismus. Computed imaging confirmed the presence of an abscess in the peritonsillar area with extension into the parapharyngeal space and deep lobe of the parotid gland. The abscess was incised and drained transorally. Following drainage of the abscess, a small 3 mm suspicious foreign body was seen. After extraction, this was revealed to be a 60 mm feather. We would like to highlight this unusual case in an infant and to ensure that foreign body is considered as aetiology. There are only a handful of cases in the literature involving feathers causing neck abscesses and, to our knowledge, this is the first case where the patient presented with a pharyngeal abscess, which was drained transorally.

Laryngeal tuberculosis: a rare cause of critical airway obstruction

Laryngeal tuberculosis (TB) is a rare condition, occurring in less than 1% of patients infected with pulmonary TB. We present a case of a 57-year-old male patient, who presented in extremis with audible stridor, increased work of breathing and cyanosis. In addition, the patient had a complex medical history, including a recent diagnosis of congenital malformation of the epiglottis. Emergency intervention was required to secure the airway, and after initial attempts at intubation were unsuccessful, an emergency tracheostomy was performed. Four days after initial presentation, his sputum tested positive for acid-fast bacilli, and a subsequent CT chest revealed pulmonary as well as laryngeal TB, which was confirmed on biopsy of the larynx. The patient was commenced on a 24-week course of anti-tuberculous treatment and was successfully decannulated 6 months after the emergency airway was established.

Recurrent hiccups may signal brainstem pathology and should be investigated

While occasional hiccups are normal, their persistent recurrence is distressing and may have an underlying aetiology. Patients with recurrent hiccups may undergo a long journey and see many physicians before the diagnosis is finally made. The purpose of this report is to increase awareness of central nervous system lesions as a possible cause for recurrent hiccups and provide an illustrative case of an otherwise fit man presenting with ongoing hiccups caused by a medullary haemangioblastoma.

Lemierre's syndrome: a pain in the neck with far-reaching consequences

Lemierre's syndrome is a potentially life-threatening consequence of oropharyngeal and ear infections and often results in critical care admission and even intubation. Due to the multisystem manifestation, multiple teams may initially be involved in the care, some of which may be unfamiliar with the features and usual clinical course. This report describes a case in a 36-year-old woman with the classic features of internal jugular vein thrombosis and septic emboli to the lungs secondary to an oropharyngeal infection. Treatment comprised antibiotic therapy, anticoagulation and fluid resuscitation, and was carried out in a high dependency unit setting. At follow-up 3 months after discharge, the patient was well with no residual symptoms off all treatment. During the events of this case, it became apparent that while ear, nose and throat and infectious diseases team members were relatively familiar with the condition, other departments including the critical care team were less so.

Variant of Lemierre's syndrome with internal jugular vein aneurysm

Internal jugular vein (IJV) aneurysm is a rare entity, and a thrombosed aneurysm poses diagnostic and management challenges. We came across a 53-year-old woman who presented with fever, vomiting and right neck swelling for a week. Laboratory investigations showed neutrophilic leucocytosis, raised acute phase reactant and blood culture yielded Klebsiella pneumoniae Ultrasound and contrast-enhanced CT neck revealed a large fusiform aneurysm of the right IJV with filling defect extending from the aneurysm into the right transverse sinus. There was a cavity at the right lower third molar tooth. MRI confirmed the findings with additional enhancing focus at right lower periodontal region. The swelling reduced after 2 weeks of medical therapy, and follow-up imaging 4 months later showed complete resolution of the aneurysm with residual thrombosis. After extensive workup, dental infection remains the only identifiable primary source leading to thrombophlebitis of the right IJV and subsequent sequelae.

Uvular necrosis following diagnostic gastroscopy

Uvular necrosis is an extremely rare complication of gastroscopy. We describe the fifth published case of uvular necrosis following an uncomplicated diagnostic gastroscopy in a young man. Presentation with severe sore throat and inability to swallow saliva occurred within 24 hours of gastroscopy and resolved with conservative treatment.

Emergency salpingectomy for ruptured ectopic pregnancy in patient with Melnick-Needles syndrome: a rare otopalatodigital syndrome

Melnick-Needles syndrome (M-NS) is a rare genetic disorder which primarily affects skeletal developments. M-NS may also affect the cardiorespiratory and renal systems. A 35 kg patient presented complaining of abdominal pain. Following a positive pregnancy test and ultrasound examination, she was diagnosed with a ruptured ectopic pregnancy. She had a significant background history of M-NS, obstructive sleep apnoea (with narrow gauge tracheostomy in situ), obstructive lung disease and scoliosis. She received fluid resuscitation, and the case was managed using an open salpingectomy and clot evacuation under combined spinal/epidural anaesthesia. Anticipated difficulty in securing a definitive airway was pivotal to choosing a regional anaesthetic technique. The operation was successful and the patient recovered well. This was a unique surgical and anaesthetic challenge due to abnormal facial, spinal and abdominal morphology compounded by the time-critical emergency nature of the case. Individually tailored perioperative management is frequently required for patients with rare syndromes.

Preoperative simulation unveiled undetected surgical difficulties in a case of cochlear implantation

We herein report a case in which extensive preparation changed a difficult-to-treat patient into an easy one. We performed a revision cochlear implantation on a patient whose first procedure had been aborted due to unidentified difficulties. During a series of thorough three-dimensional simulations, we found that the patient in question had a normal cochlea but the cochlea was placed in an unusual position and orientation. This condition is difficult to detect on standard preoperative radiographic images. Through this simulation, we were able to propose a surgical plan to avoid making the same mistakes as the first surgeon. We present this case not as a rare difficult case of an unfortunate patient but instead emphasise the importance of performing surgical simulation and looking for non-obvious difficulties. This case is an example of the success that can be achieved with such extensive preparation.

Lyric hearing aid: a rare cause of benign necrotising otitis externa/external ear canal cholesteatoma

An 80-year-old Caucasian man presented with an incidental and asymptomatic lesion in his right ear thought to be secondary to his use of hearing aids for presbycusis. He used Lyric hearing aids, designed for 24 hours-a-day use for 4 months at a time and had no other previous otological problems. He underwent a bony meatoplasty and vascular flap reconstruction via a retroauricular approach to remove the lesion for histological analysis and regrafting of the area. The lesion was confirmed on histopathology as an ear canal cholesteatoma.

Cervical oesophageal perforation secondary to food consumption in a well-appearing patient

A 71-year-old woman presented to the emergency department 8 days after ingesting fish with mild neck pain but otherwise demonstrated no signs of infection. X-rays were negative but CT imaging demonstrated a curvilinear radiodense object extending from the posterior cervical oesophagus through the right thyroid lobe terminating in the neck just a few millimetres from the external carotid artery. Rigid oesophagoscopy and direct laryngoscopy were negative and the neck was explored for the foreign body, which ultimately was encountered after a painstaking dissection of the right neck that included skeletonisation of the recurrent laryngeal nerve. Her postoperative recovery was uneventful and after a 3-day course of intravenous antibiotics she was discharged on oral antibiotics, in good condition and tolerating a soft diet.