Inverted nasal papilloma is a unique neoplasm characterised by a tendency to recur following excision, an association with malignancy and an ability to destroy bone. The coexistence with nasal polyps (not always sent for histology), the lack of a universally accepted staging system and the fact that most data on Inverted papilloma come from tertiary centres (selected cases probably the most aggressive) account for the difficulty in determining its true incidence. Treatment is surgical. The gold standard approach was an open radical procedure. The introduction of endoscopic surgery for primary or recurrent lesions has shown potential advantages. Lack of complications of open surgery together with improved access to specific nasal areas suggests that the endoscopic techniques in experienced hands and for selected lesions may be a good alternative. The aim of this review was to assess the effectiveness of the endoscopic versus open techniques for management of inverted papilloma. There is not enough evidence in the literature to support one or the other treatment option for management of inverted papilloma. There is a trend though towards endoscopic approach. Ideal management should aim at complete removal of all diseased mucosa with creation of wide cavities and long term follow-up to detect subsequent recurrence or malignant transformation.

Beta-2-transferrin is a protein produced by neuraminidase activity in the brain which is uniquely found in the cerebrospinal fluid (CSF) and perilymph. Its absence in other body secretions makes its detection invaluable in diagnosing a CSF leak. In this series samples were analysed from 25 patients with suspected CSF rhinorrhoea. The presence of beta-2-transferrin was determined by immuno-fixation electrophoresis. Out of 25 patients 16 were positive for beta-2-transferrin. A dural defect and CSF leak were confirmed during surgery in 13 of the 16 patients. In three patients the rhinorrhoea stopped spontaneously. Out of nine patients who were negative for beta-2-transferrin in the nasal fluids, two underwent a craniotomy and neither had evidence of CSF leak or dural effect. Two of the eight patients had a normal computerized coronal tomography (CT) despite a CSF leak. Seventeen patients underwent CT cisternography (six in the beta-2-transferrin negative group and 11 in the positive group). A leak was shown by CT cisternography in seven patients in the positive beta-2-transferrin group, but a leak could not be confirmed in the other four patients. No leak was demonstrated in the six patients in the negative beta-2-transferrin group. Beta-2-transferrin is a valuable and sensitive means of confirming the diagnosis of CSF leaks. Patients with a suspected CSF leak but no beta-2-transferrin in their nasal discharge can avoid unnecessary invasive investigations.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. With only limited high-level evidence for management of nasal and paranasal sinus cancers owing to low incidence and diverse histology, this paper provides recommendations on the work up and management based on the existing evidence base.Recommendations• Sinonasal tumours are best treated de novo and unusual polyps should be imaged and biopsied prior to definitive surgery. (G)• Treatment of sinonasal malignancy should be carefully planned and discussed at a specialist skull base multidisciplinary team meeting with all relevant expertise. (G)• Complete surgical resection is the mainstay of treatment for inverted papilloma and juvenile angiofibroma. (R)• Essential equipment is necessary and must be available prior to commencing endonasal resection of skull base malignancy. (G)• Endoscopic skull base surgery may be facilitated by two surgeons working simultaneously, utilising both sides of the nose. (G)• To ensure the optimum oncological results, the primary tumour must be completely removed and margins checked by frozen section if necessary. (G)• The most common management approach is surgery followed by post-operative radiotherapy, ideally within six weeks. (R)• Radiation is given first if a response to radiation may lead to organ preservation. (G)• Radiotherapy should be delivered within an accredited department using megavoltage photons from a linear accelerator (typical energies 4–6 MV) as an unbroken course. (R)

INTRODUCTION Sore throats and tonsillitis represent a considerable health burden as well as a significant source of expenditure for the National Health Service (NHS). As part of the recent NHS savings drive, the introduction of 'procedures of low clinical effectiveness' (PoLCE) lists has reinforced a large reduction in the number of tonsillectomies performed. We carried out a crosssectional study of trends in emergency sore throat admissions in the context of the number of tonsillectomies performed. METHODS Hospital Episode Statistics (HES) data were extracted. Office for National Statistics data were also used. RESULTS Between 1991 and 2011, the overall tonsillectomy rate fell by 44%. In the same time, the admission rate for tonsillitis rose by 310% (Pearson's r=-0.67, p=0.01). The peritonsillar abscess admission rate rose by 31% (r=-0.79, p<0.01). Between 1996 and 2011, the overall tonsillectomy rate fell by 41% and the retro and parapharyngeal abscess admission rate rose by 39% (r=-0.55, p=0.026). There was a 14% overall increase in tonsillectomy and sore throat associated bed days. This was despite the large fall in tonsillectomy numbers and the reduction in length of hospital stay. CONCLUSIONS Efforts to reduce the tonsillectomy rate are correlated with a significant rise in emergency admissions. The rise in the retro and parapharyngeal abscess rate is perhaps most alarming given the very high mortality of these conditions. Bed day data suggest that no net saving has been made despite the new measures.

OBJECTIVE The management of CSF rhinorrhoea following dopamine agonist (DA) treatment for invasive prolactinomas is difficult and there is no clear consensus for its treatment. Our objective was therefore to investigate the different treatments for this condition. DESIGN AND PATIENTS We examined the case notes of five patients with invasive prolactinomas and CSF rhinorrhoea following DA treatment. The different ways in which this complication had been managed is detailed along with a review of the literature. RESULTS Five patients aged 24–67 years (3 male) with massive invasive prolactinomas (serum prolactin 95000–500000 mU/l) eroding the skull base were treated with dopamine agonists (3 bromocriptine, 1 cabergoline and 1 both). CSF rhinorrhoea developed in all patients between 1 week and 4 months after commencing dopamine agonist treatment. In two patients (cases 1 and 4), CSF rhinorrhoea ceased within a few days of stopping bromocriptine but restarted when treatment was resumed. One of these (case 4), a 67‐year‐old woman had no further treatment and CSF leakage stopped completely. She died of unrelated medical problems 3 years later. In one patient staphylococcus aureus meningitis and pneumocephalus developed as a complication of CSF rhinorrhoea. Three patients had endoscopic nasal surgery to repair the fistula using muscle grafts, and to decompress the pituitary tumour, with success in two. One patient had intracranial surgery and dural repair, which was successful in sealing the leak. CONCLUSIONS We suggest that surgery as soon as is feasible is the treatment of choice for the repair of a CSF leak following dopamine agonist treatment. An additional strategy is the withdrawal of dopamine agonist to allow tumour re‐growth to stop the leak.