In 1908 Sluder described a symptom complex consisting of neuralgic, motor, sensory and gustatory manifestations that he attributed to the sphenopalatine ganglion. He stated that treatment directed at the ganglion successfully alleviated these symptoms. Over the last 90 years several reports have described patients as having sphenopalatine neuralgia and have directed treatment at the ganglion. The symptoms described and the criteria for patient selection in these studies has often been varied and deviated from Sluder’s description. In reports claiming cures with treatment directed at the ganglion the duration of post-treatment follow-up has been short. This article discusses Sluder’s description and attempts to analyse its features in the light of current understanding of the different mechanisms and categories of facial pain. It is proposed that the condition described by Sluder is a neurovascular headache that most closely resembles cluster headache in its aetiology and clinical manifestations. Wepropose that the term Sluder’s neuralgia should be discarded as there are serious flaws in its original description and many authors have misused the term leading to persistent confusion about it.

Myringoplasty is an established procedure. However, the quest is on to improve the results further by studying the different influencing factors, that could possibly affect the outcome. In the present randomized prospective study of one year’s duration, 60 patients having dry, large and subtotal perforations of the tympanic membrane were subjected to myringoplasty, 30 by the overlay technique and 30 by the underlay technique keeping all other influencing factors constant. The graft take-up rate was found to be the same (93.3 per cent) in both techniques but the underlay technique was judged to be better because of its technical ease, better assessment of ossicular chain integrity and mobility, less time consumption (55 minutes vs 90 minutes), earlier healing of graft (four to six weeks vs six to eight weeks), hearing gain in more patients (92.8 per cent vs 57.1 per cent) and fewer minor complications (6.6 per cent vs 33.3 per cent).

Previous studies concerning the microbiology of otitis media with effusion (OME) did not correlate the past use of antimicrobial agents with the recovered organism’s antimicrobial susceptibility. A retrospective analysis of cultures obtained from aspirates of 129 children with OME was performed. The study identified the isolated organisms and determined their susceptibility to the most recently administered antimicrobials. Bacterial growth was noted in 58 (45 per cent) patients. Aerobic organisms only were recovered in 37 aspirates (63 per cent of the culture-positive aspirates); anaerobic bacteria in seven (12 per cent); and mixedaerobic and anaerobic bacteria in 14 (24 per cent). A total of 92 bacterial isolates were recovered, accounting for 1.6 isolates per specimen (1.1 aerobes and 0.5 anaerobes). There were a total of 66 aerobic isolates, including Haemophilus influenzae non type-b (20 isolates), Streptococcus pneumoniae (17), and Staphylococcus spp. (seven). Twenty-six anaerobes were recovered, including Peptostreptococcus spp. and Prevotella spp.(eight each) and Propionibacterium acnes (four). Resistance to the antimicrobial used was found in 60 (65 per cent) isolates, recovered from 41 (71 per cent) of the patients. Of the41 patients in whom resistance was detected, 37 (90 per cent) had been treated within three months of culture and four (10 per cent) had completed treatment more than three months before thecultures were taken (p < 0.01). The highest rate of recovery of resistant organismswas following trimethoprim-sulfamethoxazole (96 per cent), amoxycillin (71 per cent), and azithromycin (56 per cent). Of the patients treated with amoxycillin, H influenzae predominated. S pneumoniae was recovered from four of the seven (57 per cent) after trimethoprim-sulfamethoxazole, four of 14 (29 per cent) following amoxycillin, and three of 11 (27 per cent) after azithromycin. The data illustrate the relationship between resistance to the antimicrobials given to children and their recovery from the middle ear of patients with OME.

The value of high resolution computerized tomography (CT) prior to routine mastoid surgery for cholesteatoma remains controversial. Doubts about sensitivity and specificity, in detecting the extent of underlying pathology and in predicting asymptomatic complications, prevent widespread adoption.

This retrospective study looks at the influence of pre-operative scanning on the surgical management of chronic suppurative otitis media over an 18-month period. The radiological findings determined the choice of surgical approach, but contributed less to the decision to operate and the prediction of potential hazards. CT is of most value when the otologist can be flexible in surgical technique, tailoring it to imaging findings.

Intratympanic gentamicin is increasingly used in the treatment of Ménière’s disease. Many protocols have been published for its use, but there is little difference in outcome between them. The goal of the study was therefore to assess current UK practice in the use of intratympanic gentamicin.

A postal and e-mail survey of consultant ENT surgeons in the UK was conducted. Of 34 consultants who regularly used intratympanic gentamicin, 21 used a protocol based upon a single intratympanic dose of gentamicin via a needle through the tympanic membrane and repeated after at least a week. The remaining 13 used either a regime of more frequent administration or attempted a more complicated route of delivery in an effort to improve reliability and selectivity of action.

In the absence of evidence demonstrating benefit from regimens of increased complexity the majority of consultants are using the simplest possible protocol.

Glomus tympanicum tumour is one of the commonest neoplasms of the middle ear. It is more common in females. The most common presenting symptom is pulsatile tinnitus. A retrotympanic mass is found in the middle ear in all the cases. Computed tomography (CT) scan is the investigation of choice, however in difficult cases magnetic resonance imaging (MRI) can be helpful. Surgery is regarded as the gold standard of treatment in spite of the fact that radiation therapy has also been advocated in the literature. In this series 17 cases of glomus tympanicum treated at Gruppo Otologico Piacenza – Rome (Italy) were analysed retrospectively. A simple and safe technique has been described. All the cases were female and treated by surgery. The tumour was removed completely in all the cases and the ossicular chain kept intact. Recurrence was encountered in only one case after nine years. Surgical removal of the tumour is recommended as the treatment of choice with the following advantages: complete removal, a low complication rate, a low recurrence rate, acceptable hearing level and minimum morbidity.

The aetiopathogenesis of acute unilateral peripheral vestibular dysfunction (APV), also known as vestibular neuritis, is still debated: the principal cause is viral infection with vascular factors second in importance.

Plasmatic D-dimer, considered a plasmatic index of hypercoagulation, was measured in a group of 45 APV patients and in a group of 25 patients suffering from Ménière’s disease. Measurements were taken both during the acute stage and after a four to six week period of pharmacological washout. The mean D-dimer levels were significantly higher than those measured in the controls both during the acute phase (301 SD161 vs 202 SD113 ng/mL) and after follow up (304 SD211 vs 192 SD111 ng/mL) (p = 0.008). Moreover, during the acute stage 23 of the APV patients (51.1 per cent) had plasmatic D-dimer levels above the upper normal limit (i.e.: <300 ng/mL), compared to four of those with Ménière’s disease (16 per cent).

Our results lead us to postulate an involvement of the haemostatic system in APV.

The study presents a comprehensive statistical analysis of a series of 500 consecutive rhinoplasties of which 380 (76 per cent) were primary and 120 (24 per cent) were secondary cases. All cases were operated upon using the external rhinoplasty technique; simultaneous septal surgery was performed in 350 (70 per cent) of the cases. Deformities of the upper two-thirds of the nose that occurred significantly more in the secondary cases included; dorsal saddling, dorsal irregularities, valve collapse, open roof and pollybeak deformities. In the lower third of the nose; secondary cases showed significantly higher incidences of depressed tip, tip over-rotation, tip asymmetry, retracted columella, and alar notching. Suturing techniques were used significantly more in primary cases, while in secondary cases grafting techniques wereused significantly more. The complications encountered intra-operatively included; septal flap tears (2.8 per cent) and alar cartilage injury (1.8 per cent), while post-operative complications included; nasal trauma (one per cent), epistaxis (two per cent), infection (2.4 per cent), prolonged oedema (17 per cent), and nasal obstruction (0.8 per cent). The overall patient satisfaction rate was 95.6 per cent and the transcolumellar scar was found to be unacceptable in only 0.8 per cent of the patients.

Voice disorders can cause problems for patients emotionally, physically, economically and functionally. Neither subjective nor objective voice examinations are able to evaluate such factors adequately. For this study, a retrospective analysis of 79 dysphonic cases was conducted using the voice handicap index (VHI) to gather comprehensive data across a variety of voice disorders. Of the 79 cases, 41 involved glottic insufficiency, 26 involved vocal polyps or mass, and 12 involved functional voice disorders. Cases were assessed with the VHI using physical (P), functional (F), emotional (E) parameters and a total (T) of the three. P, F, E and T variables were entered into a statistical programme and analysed using one-way analysis of variance (ANOVA). Mean ±SE values for P, F, E and T, respectively, in glottic insufficiency cases were 31.61 ± 1.10, 26.49 ± 1.43, 26.06 ± 1.54, and 84.20 ± 4.21. Mean ±SE values for P, F, E and T, respectively, in vocal mass cases were 30.69 ± 1.73, 25.23 ± 1.90, 23.96 ± 1.82, and 79.88 ± 5.08. The mean ±SE values of P, F, E and T,respectively, in functional voice disorders were 20.92 ± 2.06, 18.33 ± 1.82, 16.83 ± 1.86, and 56.08 ± 5.23. We found the mean glottic insufficiency was significantly greater than functional voice disorders for each measure. There were significant differences between vocal mass and functional voice disorders means for P and T. Glottic insufficiency and vocal mass means were not significantly different for any measure. Problems in the physical realm were identified as the most severe amongst all patients. Glottic insufficiency patients were found to suffer the most in every VHI value. Although VHI is a relatively new method by which to measure discomfort in voice-disordered patients, it provides a mechanism for patients to define their discomfort and for therapists to better target recovery programmes to patient’s needs.

Successful results of genioglossus advancement and hyoid myotomy with suspension (GAHM) in the treatment of obstructive sleep apnoea (OSA) have been reported. However, there have been few studies of long-term results. Forty-six patients with hypopharyngeal obstruction underwent GAHM. Patients had a mean age of 40.1 ± 4.2 years and a mean body mass index (BMI) of 28.9 ± 2.1 kg/m2. The mean follow-up was 39.4 ± 5.7 monthswith a range of 37 to 46 months. The mean pre-operative RDI, short-term RDI, and long-term RDI were 47.9 ± 8.4, 14.2 ± 3.9, 18.6 ± 4.1, respectively. The mean post-operative LSAT, short-term LSAT, and long-term LSAT were 81.2 per cent ± 2.9 per cent, 88.8 per cent ± 2.7 per cent and 87.2 per cent ± 3.1 per cent, respectively. The changein BMI was significantly different in the patients with, and without, recurrence (2.1 ± 0.3 vs 0.4 ± 0.2.kg/m2, <0.05). Thirty (65.2 per cent) patientshad long-term clinical success, and six (16.7 per cent) patients with short-term success failedlong-term. GAHM appears to be an effective procedure and results in long-term success. However,patients with weight gain are at risk of recurrence.

Helical rim defects are noticeable and may well need reconstruction, especially in men. A method for reconstructing this type of defect together with primary donor site closure by Z-plasty is described.

To close partial helical rim defects, a retroauricular caudally based rotational skin flap is performed to cover a conchal cartilage graft from the same ear that is harvested first and sutured into place to remodel the helical rim. To primarily close the donor site defect a retroauricular Z-plasty was developed which easily allowed primary closure of the donor site.

The technique described here is straightforward, safe and reproducible. The Z-plasty approach for closing the donor site is useful, since the slight disturbance of the hairline is well hidden retroauricularly. This technique can be considered as a single-stage repair modality for the reconstruction of helical rim defects within primary donor site closure.

Complications following stapedectomy are the most common cause of litigation involving otological cases in the USA. Manipulation and placement of the prosthesis during a stapedectomy may have a profound effect on the final hearing results. Concerns have been raised over the reduced number of cases, training of residents, and the maintenance of the necessary skills to achieve consistently good results.

Temporal bone dissection is an important adjunct to developing the required skills to perform stapedectomies. However the reduced availability of specimens limits their use for teaching or practising the procedure.

In order to circumvent these problems an inexpensive and easily constructed middle-ear simulator has been developed based on materials readily available in any ENT ward. It is believed that this might help trainees develop the necessary skills to master the procedure.

Fine needle aspiration test is a useful tool in the investigation of head and neck masses, be they of salivary gland, lymphoid, thyroid or other (branchial cyst) origin. Some practical aspects of this procedure are presented.

Foreign body reactions and myospherulosis are rare complications of using oil-based ointments in otological surgery. A case of persistent otorrhoea following mastoid surgery is presented. Histology showed a foreign body reaction, with some features of myospherulosis.

The investigation of a complaint of unilateral right sensorineural hearing loss led to the identification of a right 3 mm vestibular schwannoma arising from the inferior division of the right vestibular nerve. On investigation the patient was found to have normal caloric function, this being mediated by the superior vestibular nerve. Both transient and distortion product otoacoustic emissions were absent in the right ear, and ABR was abnormal on this side. These findings are of interest as they indicate that this small lesion produced a hearingloss that was both cochlear and retrocochlear. The anatomical finding that the medial auditory efferents run within the inferior vestibular nerve is considered. This patient did not experience tinnitus or hyperacusis despite the site of the lesion arising from the inferior vestibular nerve.

A case of idiopathic intracranial hypertension (IIH) with visual field loss was decompressed in the intracanalicular segment of the optic nerve transnasally under endoscopic control. Visual functions improved after surgery.

The histopathological and imaging findings of a rhabdomyoma of the base of the tongue were studied. An immunohistochemical examination of the tumour cells showed positiveimmunostaining for myoglobin, desmin, and striated muscle actin, but negative immunostaining for smooth muscle actin. Electron microscopy showed many glycogen granules and mitochondria in the tumour cells. The T2-weighted and contrast-enhanced magnetic resonance images (MRI) clearly delineated morphological features of this tumour, but T1-weighted MRI and computed tomography (CT) images showed no important features. These findings are typical for an adult extracardiac rhabdomyoma located in the head and neck region, and they will be useful for diagnosis of this tumour.

A variant of a type 2 first branchial cleft anomaly, in which accessory ossicles were found, is described. There follows a discussion of the classification of first branchial cleft abnormalities and how this particular case falls outside the standard classification. CT scanning is mentioned as the investigation that is most useful for defining these abnormalities.