Ten patients with chronic non-allergic rhinitis and presenting mainly with nasal obstruction due to hypertrophied inferior turbinates were subjected to laser turbinectomy using CO2. Tiny biopsies were taken, at the time of surgery as well as one monthlater, and were processed for transmission electron microscopy. The ultrastructural observations included: early epithelial loss which wasfollowed by prompt regeneration of healthy epithelium, decreased number and activity of the seromucinous glands, fibrosis of the connective tissue stroma, as well as diminished number and congestion of the cavernous blood spaces. These observations were discussed in view of the excellent clinical response of the patients.

The complications of sinusitis have been well described. The most common classifications used for orbital complications have been that of Chandler et al. (1970) and Moloney et al. (1987). With the ready availability of high-resolution computed tomography (CT) scanners, limitations of these classifications have become apparent. The aims of this study were to determine the relative frequency of the various complications associated with acute sinusitis, to determine which groups of sinuses were most frequently involved and to correlate the orbital signs with a new proposed classification of orbital complications. Over a five-year period, 87 consecutive patients were admitted with acute sinusitis. Sixty-three patients (72.4 per cent) had one or more complications. When orbital complications were classified under the proposed classification, all patients with proptosis and/or decreased eye movement had post-septal infection. Visual impairment occurred only in the post-septal group. Most complications had a combination of sinus involvement with the maxillary/ethmoid/frontal combination being the most common. The authors propose a modification of Moloney's classification for orbital complications of acute sinusitis that allows a clear differentiation between pre- and post-septal infection and a radiological differentiation to be made between cellulitis/phlegmon and abscess formation. The latter is of importance when a decision is made on whether surgical intervention is appropriate or not.

Sixty consecutive patients (48 males, 12 females; age range 16 to 57, mean age 35 years) underwent nasal septal surgery at our out-patient department for symptoms of nasal obstruction. The operations were performed under local anaesthesia supplemented with 2.5–5 mg intravenous midazolam. Only one surgeon and one nurse were needed for the procedure. The total time spent at the hospital averaged three hours. The preliminary short-term results of surgery are comparable to those at our day-care unit. The complication rate was negligible. Ninety-five per cent of these patients regarded the arrangements for their operation as safe. Our results show that nasal septal surgery can be performed with good costeffectiveness, satisfactory quality and with good safety and patient satisfaction as an out-patient procedure.

From a cohort of 35 patients with hereditary haemorrhagic telangiectasia (HHT), 12 patients have undergone closure of the one or both nasal cavities during the last three years for refractory epistaxis. All had failed other forms of treatment including hormone therapy, laser coagulation and septodermoplasty. All patients were available for follow-up at six months or longer. In all patients where complete closure was achieved (11 out of 12) bleeding ceased completely from the operated side.

A questionnaire was sent to consultant Otolaryngologists (483) throughout the UK to identify any mortality associated with uvulopalatoplasty and other forms of palatoplasties for snoring and/or obstructive sleep apnoea. The response rate was 76.8 per cent (371). Six intra- and post-operative deaths were reported and four were known to have obstructive sleep apnoea. Life-threatening morbidity occurred in at least seven patients (three known apnoeic), two required immediate tracheostomy and two were managed in the intensive care unit. This suggests that the apnoeic patients undergoing palatoplasties experienced significant mortality and morbidity. Pre-operative sleep study should be performed in all snoring patients to identify the apnoeic subgroup. Continuous positive airway pressure, management of excessive obesity, elective tracheostomy and other strategies should be first considered before palatoplasties in these patients.

Forty patients above the age of 40 years with oral submucous fibrosis were studied to determine the frequency and severity of snoring. The results were compared with a controlled group of similar sex and age for presence of snoring. The present study indicates that patients with oral submucous fibrosis having a short and fixed uvula and scarred soft palate are less likely to develop snoring. Thus it is suggested that in laser surgery or in classical uvulopalatopharyngeal surgery, the uvula and soft palate should be reduced in size and volume to the extent of that found in oral submucous fibrosis.

The ultrastructure of the nasal mucosa following theuse of intranasal levocabastine was studied in 20 patients suffering from perennial allergic rhinitis. The patients received twice daily 0.05 per cent levocabastine spray with a treatment duration of four weeks. At the end of the treatment period regression of the allergic process was evidenced by progressive reappearance of normal cilia and microvilli on the columnar cells, decrease of intercellular oedema andcytoplasmic vacuoles, increased number of mucous acinar cells, gradualdecrease of vascular congestion, as well as diminished oedema fluid formation. The drug, however, had no effect on mast cell degranulationnor on eosinophilic infiltration. Normalization of the ultrastructural features correlated well with clinical improvement.

Considering the results of the present study, levocabastine nasal spray appears to be an effective treatment for perennial allergic rhinitis and can be used with, or as an alternative to, other anti-allergic medications.

In spite of previously favourable reports on day-case adenoidectomy, thereare still worries amongst otolaryngologists that such practice is unsafe, especially in arural environment. A national survey was therefore carried out which shows that only 41 per cent of respondents perform adenoidectomy routinely as day-case, and even fewer in rural areas. A regional audit on day-case adenoidectomy, covering five hospitals, was conducted in East Anglia. Between 1994 to 1995, 73 day-case adenoidectomies were performed and the outcome was compared to those of 183 in-patient adenoidectomies during the same period. The children in the day-case group recovered post-operatively even better than the in-patient group. None of them stayed overnight or required re-admission. There was no increased in post-operative consultation to the general practitioner. The parents in the day-case group were mostly in favour of the day-case arrangement (88 per cent). The results suggest that day-case adenoidectomy is safe and popular with parents even in a rural environment.

Cochlear implantation in the paediatric population is now an accepted method of rehabilitating profoundly or totally deaf children. The problems of cochlear implantation in children with other significant medical problems are examined. A retrospective review of the records of the first 45 children implanted at our centre was carried out. The review focused on surgical factors and outcome in addition to variations in technique which have occurred since the programme began. Congenital hearing loss was the most common indication for implantation. Fifteen children (33 per cent) had other medical problems. Three cases of flap breakdown (two occurring after direct trauma to the package bed) and one case of a misplaced electrode requiring re-implantation accounted for the only major complications to date. Minor complications included hypertrophic scar formation and post-operativewound infection. All children were using their implants at the time of this review, but two have subsequently been explanted. Cochlear implantation of children with multiple medical problems requires acceptance of a slightly higher risk of complications.

Three hundred and sixty children who had a head and neck mass excised during 1987 to 1992 at the Royal Hospital for Sick Children, Glasgow were studied. There were 210 males and 150 females with a mean age of 60.7 months (0.5 to 198 months). Pilomatrixomata/sebaceous cysts (34 per cent), thyroglossal cysts (13 per cent), branchial remnants (nine per cent) and dermoids (nine per cent) accounted for almost twothirds of the 264 non-lymphadenomatous benign lesions excised. Ninety-three lymphadenopathy masses consisted of 60 with reactive hyperplasia, 21 with Mycobacterium infection and 12 lymphomas. There were three solid malignant tumours, two were rhabdomyosarcomata and one disseminated round cell tumour. The correlation between clinical diagnosis and histopathology of benign non-lymph node masses and solid tumours was 90 per cent and 100 per cent respectively, in benign lymph nodes, 66 per cent, but was poor in differentiating lymph node content. The mean time from presentation of a swelling to its excision was almost a year and the mean in-patient stay for excision of a mass was almost five days. The role of fine needle aspiration cytology (FNAC) in arriving at a diagnosis and reducing patient morbidity is discussed.

A surgical cure for adult obstructive sleep apnoea syndrome (OSAS) is an attractive alternative to nasal continuous positive airway pressure, but current research suggests that uvulopalatopharyngoplasty is not effective in all patients. No subgroup of these patients, who might benefit from surgery to the oropharynx, has as yet been identified. In this study we examined the results of tonsillectomy either as an isolated procedure or as part of uvulopalatopharyngoplasty in seven patients, who had tonsillomegaly. In all seven there was a short-term improvement between the pre-operative and post-operative apnoea/hypoapnoea (A/H) index (100-65 per cent), which could not be accounted for by change in the body mass index (BMI). In one patient a diagnosis of Non-Hodgkin's lymphoma was made from histological examination of the tonsils. The results suggest that adult patients with tonsillomegaly may represent a subgroup of patients with OSAS, who would benefit from surgery aimed at the oropharynx.

Nasopharyngeal carcinoma (NPC) is one of the most difficult diseases to diagnose at an early stage. The clinical presentation of 122 patients with confirmed NPC is described and the findings analysed. The common modes of presentation and cases where detailed nasopharyngeal examination need to be performed are highlighted. We emphasize the importance of health education and training for primary care physicians for early detection of these cases.

The expression of cyclin D1 gene was investigated in 74 laryngeal squamous cell carcinomas (LSCCs) in order to determine its clinical and prognostic value. Overexpression of cyclin Dl was detected immunohistochemically using DCS6 monoclonal antibody on formalin-fixed, paraffin-embedded tissue sections. Cyclin D1 expression was detected in 22 of the 74 cases investigated (30 per cent), thirteen of which presented nodal metastases (59 per cent); of the patients without any detectable cyclin D1 protein expression, six presented nodal metastases (12 per cent). Cyclin D1 protein expression was found in five per cent of the specimens of normal mucosa, eight per cent of thosewith low-grade dysplasia and 20 per cent of those with high-grade dysplasia. A statistically significant association was found between cyclin D1 expression and the supraglottic site (p<0.05), tumour extension (p<0.001), the presence of lymph node metastases (p<0.001), and advanced clinical stage (p<0.001). Cyclin D2 expression analysis is an important tool in the selection of LSCC patients with an aggressive clinical course.

A prospective study was carried out to examine the degree to which a standard voice assessment could discriminate between the potential benefits of two different voice therapy programmes for individual patients. The study encompassed 200 dysphonia subjects who were referred for voice therapy and had completed treatment within a prescribed two-year period. A standard assessment procedure was carried out on first attendance for each patient and guidelines were used to assign patients to different treatment programmes on the basis of the assessment results. The assessment discriminated well between patients requiring voice therapy to change physiological parameters of voice usage and patients able to self adjust voice usage, and provided an objective means of measuring outcomes.

Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu syndrome, Osier's disease) is an inherited abnormality of the vasculature characterized by abnormal subepithelial vessels. Treatment has included repeated intranasal cautery, intra-arterial embolization and arterial ligation.

Treatment has included repeated intranasal cautery, intra-arterial embolization and arterial ligation. Historically, the operation of septodermoplasty and the use of systemic/topical oestrogens have been the most effective and lasting treatments, but over time the telangiectasias recur. There is increasing interest in the use of a variety of lasers for intranasal photocoagulation.

A report of nine patients suffering from hereditary haemorrhagic telangiectasia who have undergone laser treatment with the Chromos pulsed dye laser is presented. This laser produces light energy at a wavelength of 585 nm and causes localized thermal damage to the blood vessel wall.

Initially, no patient saw an improvement in their symptoms, but following an average of approximately three courses of treatment, all have reported a measurable reduction in the number of epistaxes suffered.

Although no treatment completely resolves the epistaxis associated with this condition, we have found the pulsed dye laser to be effective at treating telangiectasias within the anterior nasal cavity.

Retropharyngeal abscesses are uncommon but potentially lethal infections, especially in the paediatric population under the age of five years. Abscesses in this group are classically secondary to upper respiratory infections especially oropharyngeal infections, while in the adult group they are usually secondary to trauma, foreign bodies, or as a complication of dental infections. Early diagnosis and the wide spread use of antibiotics have made these infections less common today. Between the years 1985–1996,19 cases of retropharyngeal abscesses were treated in our department. Factors such as age, sex, aetiology, presenting signs, symptoms, methods of diagnosis, treatment and complications were reviewed. Thirty-two per cent of the cases were secondary trauma. A lateral neck film showing widening of the prevertebral space was the most important diagnostic tool, computed tomography (CT) scan was used in 63 per cent of cases to verify the signs of an abscess and to provide more accurate anatomical localization.

Thirteen cases required surgical drainage. The single most commonly isolated pathogen was Streptococcus pyogenes. There were no deaths and only one recurrence requiring repeated surgical drainage. One case was complicated by a spinal canal abscess. We also report two cases of retropharyngeal abscess in children caused by swallowing of unusual foreign bodies.

In the past cerebrospinal fluid (CSF) leaks were managed via a craniotomy with intradural repair. With the advent of endoscopic sinus surgery, transnasal repair has become more popular. The comparatively low morbidity and high success rate of endoscopic repair has made it the treatment of choice for CSF leak repair. As more surgeons practice endoscopic sinus surgery, the incidence of iatrogenic CSF leaks has increased. It is important that endoscopic sinus surgeons be aware of the techniques for closing such leaks. The aim of this study is to present a new technique for the endoscopic repair of CSF leaks. Since the technique was devised the authors have used the technique on six patients. All patients had lumbar drains inserted and five patients had intra-thecal fluorescein inserted for location of the leak. All repairs have been successful with an average follow-up of 13 months. The technique consists of introducing a fat plug with a specifically secured vicryl suture into the intradural space and placing traction on the suture to seal the defect much as a bath plug seals a bath. There were no complications in any of the patients either intra- or post-operatively. The difficulties and possible complications of the technique as well as the use of a lumbar drain and intra-thecal fluorescein are discussed.

Although the role of high resolution ultrasound (US) in evaluating cervical nodes is well established, it is often combined with fine needle aspiration cytology (FNAC). As a result, US appearances that help in distinguishing the various causes of cervical adenopathy are often overlooked and not emphasized. The aim of this study is to re-emphasize to the sonologist the US clues that may help in differentiating the aetiology of abnormal cervical nodes.

We, therefore, present the spectrum of US appearances of lymph nodes. One hundred and forty patients (702 abnormal nodes) with known pathology were compared with 100 normal subjects (1211 nodes).

After identifying an abnormal node, US features that further help in distinguishing between the various pathologies are the distribution of lymphadenopathy, echogenicity, calcification, distal enhancement, intranodal cystic necrosis, matting and soft tissue oedema.

Tracheoesophageal puncture is an established procedure for voice restoration following laryngectomy. A method using a flexible gastroscope and a percutaneous endoscopic gastrostomy (PEG) set is described. This overcomes a number of problems and complications which may be encountered when using a rigid endoscope.