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.

The endoscopic approach is a simple and cost-effective option in the treatment of hypopharyngeal diverticula. Whereas almost a third of all endoscopic myotomies performed by UK otolaryngologists are carried out with the stapling technique, CO2 laser diverticulotomy has not been given as much consideration (Koay et al., in press).

We report on the first British series of 15 patients treated between 1985 and 1993 with microscopic laser diverticulotomy. The follow-up period was four to 11 years. Complications occurred in three patients, two patients required a repeat myotomy and 11 patients have been satisfied with their swallow since the operation.

Our results are similar to those of larger studies. The laser technique is more established than the stapling gun myotomy and it has the advantage of superior visualization. It may also be used in small pouches which do not admit the insertion of a stapling gun.

To investigate the relation between the clinicopathological findings, and the survival of patients with malignant tumours of the maxillary sinus, and the tumour's biological parameters, we examined the expression of p53 and bcl-2 and the number of silver-stainable nucleolar organizer regions (AgNORs) in 23 paraffin-embedded specimens from primary tumours. Fifteen of 23 (65 per cent) maxillary tumours expressed p53 and two of 23 (nine per cent) tumours expressed the bcl-2 gene product. The mean number of AgNORs per nucleus was 5.2 ± 2.4. There was no relationship between the expression of p53 or bcl-2 and the patient's clinical course. In contrast, there was a statistically significant difference in the survival of patients with a high (>6) number of AgNORs and patients with a low (<6) number of AgNORs. These data suggest that the number of AgNORs may be useful in evaluating the prognosis of patients with malignant maxillary sinus tumours.

Between October 1987 and October 1993, 92 patients with squamous cell carcinoma of the supraglottis were treated by supraglottic laryngectomy and neck dissection in our department. There were 33 T1, 46 T2, six T3 and seven T4 cases. All patients with N+ necks and T3 or T4 tumours received post-operative radiotherapy (5,000–6,500 cGy). The patients were followed for a minimum of 36 months or until death. The incidence of local recurrence was 7.6 per cent. Neck recurrence was observed in 13 per cent of patients. Decannulation was achieved in 93.4 per cent of the cases with three patients undergoing gastrostomy because of aspiration. The average hospital stay was 26 days. The overall three-year survival was 83.6 per cent, with eight patients dying of unrelated causes. There was a significant difference in recurrence rate between patients in the N0 and the N+ stage.

Endoscopy of the upper airways in neonates and infants has traditionally been accomplished using rigid laryngoscopes and bronchoscopes. The laryngeal mask may be used both to control the airway for anaesthetic ventilation and to guide a fibre-optic endoscope to the laryngeal inlet and beyond.

We report our experience with five neonatal and paediatric cases where fibre-optic laryngoscopy and bronchoscopy were performed through the laryngeal mask airway. All were cases in which standard rigid endoscopy had proved difficult with only a poor and restricted view of the laryngeal inlet being obtained due to the age of the infants, or abnormal anatomy of the upper airways.

No problems have been encountered with maintenance of the airway or with the endoscopic view obtained. In fact in neonatal patients, this technique has been found to be preferable with regard to safety and ease of use when compared to the ventilating bronchoscope. With the size 1 laryngeal mask airway it is not possible to simultaneously ventilate and endoscope the patient. Cases included, a vascular ring, Goldenhar's syndrome, laryngomalacia, supraglottis and vocal fold paresis.

This technique provides a secure method of maintaining anaesthetic ventilation during airway endoscopy, and also a means of easily locating the glottis.

Laryngeal papillomatosis is one of the first diseases where interferon (IFN) was found to be effective. In 1983, a programme for the treatment of all such cases started in Cuba. Up to December 1991, 125 patients (92 children, 33 adults) have been treated: 102 with leucocyte IFN-α, 12 with recombinant IFN-α-2b, and 11 have received both preparations. Case management consisted of surgical removal of the lesions followed by an IFN schedule starting with 105 IU/kg of weight in children or 6 × 106 IU in adults, i.m. daily. The dose was progressively reduced, as long as no relapses occurred. At the end of the one-year schedule the doses were reduced to 5 × 104 IU/kg in children or 3 × 106 IU in adults, weekly. If there was a relapse, it was removed surgically and the patient returned to a higher dose level. Most cases (89; 71 per cent) have not relapsed after the treatment; 60 of them have been followed for more than three years. In those with relapses, the frequency of recurrence decreased in all but four patients. The treatment seemed to be more effective if initiated less than three months after the disease onset. The tracheostomy could be removed in five out of seven patients who needed it before the IFN treatment and was necessary in only three new cases during IFN treatment. In two of these, decannulation was possible later on. In a total of 14 patients relapses persisted after several cycles of IFN treatment. They were considered resistant to such treatment. No severe side effects were reported. The most frequent ones were fever, drowsiness, increased bronchial secretion, chills and headache. The establishment of this programme has maintained the disease under control in Cuba.

The authors report on their experience with 25 cases of horizontal glottectomy and discuss the functional and oncological results of this operation. Indications for this procedure are Tia and Tib glottic carcinomas. The overall three-year and five-year survival was respectively 94 and 88 per cent. Distant metastasis appears to be the major long-term failure, three patients dying of lung carcinoma. Short functional rehabilitation was observed in all cases. Decannulation was achieved in 100 per cent of the cases and none of our patients had laryngeal stenosis. The average time of removal of the nasogastric tube was 11.8 days. Because of its high local control and reduced functional after effects, horizontal glottectomy appears to be a reliable and safe procedure for limited glottic carcinomas and must be included in their therapeutic management.

Eighty children who had myringotomy performed for otitis media with effusion in 1984 were reviewed in 1994. This had involved surgery on 158 ears. Three aspects of ear condition were studied: hearing loss, tympanic membrane perforation, and tympanosclerosis. Hearing losses were present in 13 ears (8.2 per cent), involving 10 children (12.5 per cent), although losses were under 20 dB in seven of these ears (five patients).

Of the six ears with losses more than 20 dB (3.8 per cent), in five patients bilateral losses of 30 dB were due to a recurrence of effusions, a large dry posterior perforation was the cause of a 30 dB loss, an infected anterior perforation had caused a 30 dB loss, an ear which had a cholesteatoma, and had a mastoidectomy and ossiculoplasty in 1987, had a 30–40 dB loss, and one ear which had a Type I tympanoplasty in 1994 had a 50 dB loss. Therefore in only three ears (1.9 per cent) could hearing loss be associated directly with myringotomy and ventilation tube insertion.

Perforations had persisted unilaterally in seven patients, three having had tympanoplasties. Of the remaining perforated tympanic membranes, two were free of symptoms, one had only a slight hearing loss, and one had a more significant loss with recurrent infection.

Tympanosclerosis was only found in those ears which had ventilation tubes inserted (and not those which had myringotomy only), occurring in 48 ears (31 per cent, or 39 per cent of those which had a ventilation tube inserted).

There was no link between tympanosclerosis and hearing loss. The site of tympanosclerosis was not restricted to the site of myringotomy, and in many cases was present only in other areas of the tympanic membrane. There was a tendency for more extensive tympanosclerosis to occur in those ears which had more ventilation tube insertions. The risk of perforation in particular lends support to a policy of ‘watchful waiting’.

The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) canhave multiple causes. Surgical neck dissections may have an association with this syndrome and represent the basis for this study. A retrospective review of 50 patients undergoing neck dissections was performed to evaluate for the development of hyponatraemia as a consequence of SIADH. Based on the results of this review, a prospective study of 20 consecutive patients undergoing 22 neck dissections was performed to determine the incidence ofSIADH. A control group of 25 consecutive patients undergoing major non-neck dissection surgery was also studied. SIADH developed in nine of 50 patients (18 per cent) of our retrospective group with a high incidence of development in those who had jugular vein ligation (JVL) (22 per cent), pre-operative radiation therapy (25 per cent) or squamous cell cancers (32 per cent). SIADH developed in six patients undergoing 22 neck dissections (27 per cent) in our prospective group. A high incidence was also noted for those with JVL (42 per cent), pre-operative radiation therapy (67 per cent) or squamous cell cancer (40 per cent). No patients developed symptomatic hyponatraemia. No patients in the prospective control group developed SIADH. Neck dissection surgery is associated with a significant risk for the development of SIADH. Factors such as jugular vein ligation (JVL), pre-operative radiotherapy and squamous cell cancer appear to increase this risk.

Frey's syndrome, i.e. gustatory sweating on the cheek, is a fairly common embarrassment after parotid gland surgery. New surgical techniques have been proposed to avoid this complication, but are not widely in use. Hence, there is need for treatment of Frey's syndrome. All surgical and topical treatments have drawbacks. This study was set up in order to evaluate a recently described treatment. One hundred and two patients were interviewed after parotidectomy. Thirty-one of them had noticed gustatory sweating and 15 patients underwent Minor's starch iodine test before, and after, treatment with intracutaneous injections of botulinum toxin A (Botox®, Allergan Inc., USA). Thirteen of the patients did not experience any gustatory sweating at follow-up (one to 13 months). Minor's starch test showed total disappearance of gustatory sweating in 12 of the 15 treated patients. The only side effect was a discreet, transitory affection of the orbicularis oris muscle in one patient. As this treatment is minimally invasive it could be an attractive treatment for Frey's syndrome if the effect is maintained. Complaints of local hypoaesthesia and pain were also common after parotid surgery.

Tonsillectomy is frequently associated with a considerable post-operative morbidity. In some cases reactionary or secondary haemorrhage occurs and all patients suffer a degree of post-operative pain. The use of bipolar diathermy excision has become popular because it reduces intra-operative blood loss, but all diathermy inevitably produces a degree of damage to adjacent normal soft tissues. In turn this inadvertent injury must act to increase the post-operative pain.

Monopolar dissection using a fine tungsten diathermy needle (the Colorado needle) allows sharp dissection at low power levels and in previous studies has been shown to produce a reduction in collateral tissue damage. In this prospective study the morbidity associated with tonsillectomy using this needle was compared to that following a standard bipolar dissection.

Using the monopolar needle produced no enhanced risk of reactionary or secondary haemorrhage while causing significantly less post-operative pain and a reduction in eschar. We believe that excision using this needle preserves the advantages associated with bipolar dissection while reducing local soft tissue damage.

Ploidy status using flow cytometry of head and neck cancers may be of prognostic value. We describe the use of image cytometry in ploidy measurement of squamous cell carcinomas of the head and neck (SCCHN). This technique allows only tumour cells to be measured, thereby rejecting debris, artefact and benign cells. Tissue sections were cut from tumours and then Feulgen stained. A total of 60 patients were included in this study, 23 females and 37 males. The data reveals a relationship between ploidy status and the histological differentiation. However, the ploidy status and histological differentiation do not appear to correlate to the clinical stage of the disease. This method of measuring ploidy may be more accurate than flow cytometry and may have a prognostic role in head and neck cancer patients. A study comparing both methods may demonstrate this and we aim to evaluate this in the future.

Conventional methods of arterial ligation in persistent epistaxis often involve significant surgical morbidity, as well as failure due to arterial anastomosis.

We have performed endoscopic intranasal end ligation or diathermy of 11 sphenopalatine arteries in 10 patients with no complications and with no further episodes of epistaxis, with an average follow-up period of nine months.

In order to assess its discriminating and prognostic value, we studied the immunoreactivity for proliferating cell nuclear antigen (PCNA) in tissue from 52 human salivary gland tumours using the murine monoclonal antibody PC10.

The PCNA percentage count, namely, the average number of positive nuclei counted per 100 randomly selected tumour cells was recorded for each tumour. Anaplastic carcinoma was used as a positive control and histologically ‘normal’ salivary gland and tonsil served as a negative control.

A PCNA count of 30 per cent was postulated to predict malignancy within a given salivary gland tumour i.e. a PCNA count of 30 per cent or above would indicate malignant potential. This gave a sensitivity of 96.9 per cent and a specificity of 95.2 per cent and a positive predictive value of determining malignancy of 96.8 per cent.

We conclude that PCNA immunoreactivity is useful in discriminating between benign and malignant salivary gland tumours and that it may have prognostic value in this diverse group of neoplasms.

Morphometric measurements of nuclei may be of prognostic value in some cancers. In this present study we have evaluated the mean nuclear area (MNA) of 50 squamous cell carcinomas of the oral cavity (SCCOC) using computerized image analysis. Since chromosomal DNA content is a reflection of the DNA content in the nucleus, we have evaluated the relationship between MNA and chromosomal DNA. Thirteen tumours had a MNA greater than 49.9 μm2 and 37 had a MNA less than this. Six tumours were classified as hypodiploid, 29 as diploid and 15 as aneuploid. There were 44 node-negative patients and six node-positive. When comparing MNA in these groups, 50 per cent of node-positive patients had a larger MNA whilst only 20 per cent of the node-negative group had a large MNA. The correlation coefficient between MNA and DNA indices was r = 0.75. The greater nuclear size is possibly a reflection of a more aggressive tumour biology in the node-positive patients. We conclude that a large MNA may be a marker of aggressive tumour biology in this group. In the future, we aim to evaluate the prognostic significance of MNA in patients with SCCOC.

Airway management is one of the main dictums in anaesthesia, emergency medicine and critical care. Endotracheal intubation, tracheostomy and cricothyroidotomy are all approved methods to secure a patient's airway. Cricothyroidotomy is performed in the space between the anterior inferior border of the thyroid cartilage and the anterior superior border of the cricoid cartilage. We studied 107 autopsies with special interest in the anatomy of the cricothyroid space.

A seven-day course of cephazolin and metronidazole chemoprophylaxis for clean-contaminated head and neck oncological procedures is compared to results with previously published antibiotic regimens. Aetiological factors associated with increased rates of wound complications are analyzed. Retrospective analysis of procedures over asix-year period was performed. The overall wound complication rate was 28.1 per cent, comparing favourably with previously published results. A major fistula was the most common complication with a rate of 9.2 per cent. Factors statistically associated with increased rates of wound complications included: radical neck dissection, extended surgical procedures requiring flap reconstruction, previous tracheotomy, and race. This is the largest single institutional study to show thata seven-day course of cephazolin and metronidazole is an effective chemoprophylactic regimen in head and neck surgery.

Orbital decompression for dysthyroid eye disease is traditionally performed either through an external approach or transantrally. The introduction of endoscopic sinus surgery over the last decade has led to a better understanding of the intranasal surgical landmarks of orbital walls and the development of endoscopic orbital decompression. We have adopted the endoscopic technique as the treatment of choice for orbital decompression in dysthyroid eye disease for the last two years. The surgical technique is described and illustrated, and the results of our first series of 15 patients (30 orbits) are presented.

A prospective study into the aetiology of acute food bolus obstruction (AFBO) was carried out on 17 consecutive patients who presented with this complaint. There were nine males and eight females. Twelve patients (71 per cent) had symptoms of oesophageal disease and 10 patients (59 per cent) had prior food bolus obstruction. Investigations included endoscopy, barium swallow, oesophageal pH and manometry studies. Evidence of oesophageal pathology was found in 12/14 (86 per cent) of patients investigated. No patients had malignancy and the most common abnormality, gastroesophageal reflux (GOR) was found in eight out of 14 (57 per cent) of cases. Oesophageal dysmotility was seen in five out of 12 (42 per cent) patients who had manometric studies.

With such a high incidence of recurrence of AFBO, we suggest that patients with this condition be investigated to exclude malignancy and to identify benign oesophageal pathology using techniques such as oesophageal pH and manometry. Appropriate treatment of oesophageal disease may help prevent recurrence of this distressing condition.