The midfacial degloving approach was first described by Casson et al. in 1974 but despite a number of papers in the American literature advocating its use, it has not gained popularity in Europe. The advantages and application of the technique are presented in 36 patients, ranging from 7–78 years of age. The approach is ideally suited for extensive benign lesions in the nasal cavity, ethmoid and sphenoid sinuses and enables access to the nasopharynx and infratemporal fossa whilst avoiding an external incision. These lesions have included angiofibroma (13 cases), inverted papilloma (five cases), a variety of cysts (three cases) and six miscellaneous cases of benign pathology. Malignant lesions which have not breached the anterior cranial fossa may also be removed, up to and including bilateral maxillectomy (nine cases) and this can be combined with orbital clearance. The approach may be repeated if necessary and is associated with few significant complications though vestibular stenosis, oro-antral fistula, nasolacrimal damage and upward rotation of the nasal tip may occur. Strategies to avoid these problems can be undertaken and long-term cosmetic results are excellent.

Whilst it is generally accepted that the standard management for anterior or benign epistaxis is either cautery or anterior nasal packing, that of posterior or intractable epistaxis remains controversial. Various modalities of treatment, ranging from posterior nasal packing to arterial ligation and embolization, have been advocated but none have been unanimously accepted as the treatment of choice.

The purpose of this paper was to determine the efficacy of internal maxillary arterial ligation versus combined internal maxillary arterial ligation and anterior ethmoid arterial coagulation in intractable epistaxis.

Over a six year period, from 1985 to 1990,454 patients were admitted and treated for epistaxis. Forty-seven patients were diagnosed as having intractable epistaxis on the basis that the epistaxis failed to settle on anterior nasal packing. They were moved to the next step in management, which was combined anterior and posterior nasal packing. There were 30 failures, one was found to have choriocarcinoma of the maxilla, and was treated wtih cytotoxics, and the other 29 were moved to the next step, which was arterial ligation. Fifteen patients had internal maxillary arterial ligation, and 14 combined internal maxillary arterial ligation and anterior ethmoidal arterial coagulation.

Large windows were created in both the anterior and posterior walls of the maxillary sinuses and all identifiable branches of the internal maxillary artery were dissected out carefully and two medium size ligating clips were placed over the main trunk, the sphenopalatine and the descending palatine branches. Single clips were placed on all other identifiable branches. Coagulation of the anterior ethmoidal artery was performed with a bipolar cautery. There were three (20 per cent) failures in the internal maxillary arterial ligation group and none in the combined internal maxillary arterial ligation and anterior ethmoidal arterial coagulation group. Furthermore, the three failures were successfully treated with anterior ethmoidal arterial coagulation. The conclusion is that combined internal maxillary and anterior ethmoidal arterial occlusion is the treatment of choice in intractable epistaxis.

One hundred and thirteen children with bilateral otitis media with effusion (OME) underwent myringotomy and insertion of Shah grommets. They were classified into three groups according to the presence or absence of ‘glue under pressure’ unilaterally or bilaterally. The follow up period ranging between 18 and 32 months determined the comparative rate of recurrence of OME and the number of grommet reinsertions. This study shows a significantly higher incidence of recurrent OME, requiring grommet reinsertion, in ears with glue under pressure (60 per cent) compared to those with glue not under pressure (7.4 per cent). Thus it was possible to identify a subset of children with OME who have a poorer prognosis for recurrence and who should be treated with long-stay grommets in the first instance.

This study was set up, prospectively, to determine factors affecting the long-term hearing results of patients undergoing incus transposition as a second stage in ossicular reconstruction, following a successful drumhead repair in non-cholesteatoma ears. Seventy-one patients were entered into the study over five years from 1980–1985, 66 were available to be studied throughout the five year follow-up period.

Nine weeks post-operatively, 74 per cent of all patients has an air-bone gap of less than 15 dB (48/66). The type of first stage procedure had a significant effect on the hearing levels in the final five year assessment. The most successful sub-group were those patients who had a cortical mastoidectomy and silastic sheeting inserted in the first staging procedure. The air-bone gap, of less than 15 dB, was maintained in 71 per cent of this group (17/24). The sub-group who had a simple myringoplasty as the primary procedure had a good initial hearing level. By five years, however, only 30 per cent of the patients had maintained the air-bone gap of less than 30 dB (3/11).

The use of the rigid endoscope has been investigated in the management of 63 cases with posterior nasal obstruction. It was found to be a true advance in rhinology, since it visualizes and localizes the site of the obstruction which is classified into pre-choanal, and post-choanal. Moreover, the nasal endoscope allowed complete and safe removal of most of the obstructing lesions under direct endoscopic vision.

We report our experience of using the laryngeal mask airway (LMA) over a period of 18 months in 217 patients undergoing a variety of otorhinolaryngological operations. Advantages over conventional intubation for both patient and surgeon are suggested in both safety, speed and economy. An inadequate airway, necessitating replacement of the LMA, only occurred on two occasions whilst two known cases of difficult intubation easily had their airways secured by use of the LMA. Protection of the lower airways from secretions, fluid or blood, arising above the LMA, would appear to be confirmed

Spontaneous pain was one of many complaints on initial examination of 845 patients with maxillary sinus carcinoma. The pain was analysed; cheek, teeth, head and eye pain were compared with the T-classification and the anterior-posterior direction of invasion. The incidence of the cheek, teeth, head and eye pain was 48,39,29 and 23 per cent respectively. The incidence of both the cheek and teeth pain was increased according to the advancement of T-classification and invasion towards the posterior. Head and eye pain was often referred. In the localized posterior group which tend to be diagnosed late, spontaneous pain occurred in 15 to 48 per cent of the patients. Maxillary sinus carcinoma should always be a differential diagnosis in patients with unclear cheek, teeth, head ana eye pain. A careful investigation should be performed in order to diagnose malignant diseases as early as possible

The maxillary sinuses of 40 patients suffering from primary atrophic rhinitis (ozaena) were studied radiologically, antroscopically and histopathologically. Sixty percent of the patients showed thick bony walls and a small cavity of the maxillary sinus on X-ray and on antroscopy. On the other hand, 25 percent of the cases revealed signs of infection including mucopurulent secretion on antroscopy associated with corresponding histopathological changes. It is concluded that poor pneumatization of the antrum plays a more important role in the pathogenesis of ozaena than infection.

The study reviewed the case histories of 14 young aphonies. A questionnaire was completed by the five speech therapists involved with these cases. The patients were all initially examined by E.N.T. specialists and then treated by speech therapy. All the patients were ‘cured’ by speech therapy, that is the voice returned to its premorbid state. This study looks at common characteristics of presentation, different approaches to management, and the patterns of voice return.

This paper reports a new procedure used successfully in the reconstruction of 12 radical mastoid cavities in King Fahd Hospital of the University, Al-Khobar, Saudi Arabia. A composite pedicled flap composed of temporalis muscle and its fascia attached along one border, based posteriorly, is rotated in to the radical cavity. The muscle is used to obliterate the cavity and the fascia is hinged forward as a tympanic membrane graft.

We prospectively studied 190 patients undergoing tonsillectomy or nasal surgery to assess the value of two structured interview techniques. There were four groups: Group A did not have a consent interview during the study period. Group B had an informal interview. Group C had a structured interview and Group D had a structured interview and were given an information sheet. Anxiety assessments were made and patients' recall of the operation name, details of the operation and its complications was assessed.

Patients had higher than normal anxiety levels when admitted, but several hours after the interview anxiety was normal for Groups B, C and D. Group A maintained a higher anxiety level.

Only 37 per cent correctly recalled the operation name, where as 87 per cent of all groups recalled the explanation of the operation. However, Groups C and D recalled a higher mean number of complications per patient.

A structured interview when obtaining informed consent increases the number of complications recalled without increasing pre-operative anxiety.

We treated 114 patients with advanced inoperable head and neck cancer with a combined-modality protocol that included two cycles of chemotherapy followed by radiotherapy or three cycles of chemotherapy and in 18 patients with a radiosensitizing agent. At the beginning of the treatment all but one patient presented with a stage IV cancer. With a follow-up of 42–58 months, four patients are alive (three from the radiosensitizing group and one of the chemotherapy group). Complete response after the radiosensitizing agent correlated with superior prolonged disease-free survival in comparison to complete responses after chemotherapy at the level of p<0.009.

Devitalized homologous costal cartilage is widely employed as an implant in the management of the saddle nose. The tissue response induced by the implant is a combination of enveloping fibrosis and implant resorption, which will probably, ultimately, be complete. We have studied the balance between resorption and fibrosis, following different modes of cartilage preparation, in the mouse. Homologous costal cartilage was devitalized by four common methods—irradiation, formalin, glutaraldehyde and alochol. Segments of this cartilage were inserted at separate sites in the subcutaneous plain of the tail. These implants were harvested after one year for histology. Variations in the mode of cartilage devitalization, while inducing variations in the degree of the tissue response, did not influence the balance between fibrosis and resorption. Thus the long term maintenance of tissue bulk following homologous cartilage implantation is not influenced by the mode of preparation. Evidence suggests that the ultimate cosmetic results of autologous and homologous costal cartilage implantation would be much the same, and the use of homologous cartilage must be justified on other grounds.

We present a validated method of determining in vivo pressure, flow and voice parameters from patients using tracheo-oesophageal voice prostheses post laryngectomy.

This apparatus was constructed simply using equipment which should be available in most large Otolaryngology Departments. There was good agreement between measurements made over two separate sessions of in vivo opening pressure, maximum flow through the device and maximum voice amplitude and these were significant. These measurements may be useful in monitoring patient progress and also in elucidating the mechanics of prosthesis failure.

The results of pre-operative radical radiotherapy and subsequent maxillary resection are reported in 54 consecutive patients with carcinoma of the maxillary antrum treated at The Royal London Hospital from 1965 to 1989. The actuarial two and five year survivals were 50.3 per cent and 38.5 per cent respectively. Patients with adenocarcinomas fared better when compared with squamous and undifferentiated carcinomas (log rank p = <0.01). Undifferentiated carcinoma and involved regional lymph nodes were both very poor prognostic factors. In those patients who were either unfit for or refused maxillary resection, radical radiotherapy alone was still an effective treatment, with only a slight disadvantage in terms of local control and survival.

A series of 129 patients who had undergone translabyrinthine removal of a unilateral acoustic schwannoma completed a postal questionnaire about pre- and post-operative tinnitus. A simple grading system was devised from which it was possible to determine the likely outcome of translabyrinthine acoustic schwannoma surgery upon tinnitus. The results have been analyzed in detail, and as a result it is possible to advise a patient undergoing this form of surgery that if they have no tinnitus pre-operatively they are unlikely to develop it, and if they do it will not besevere enough to significantly affect their quality of life. If they have mild or moderate tinnitus it is most likely to stay the same, or become less intense. If a patient has severe tinnitus it is very likely to improve and not affect their future quality of life.

This prospective study included 30 patients with glottic carcinoma of the larynx who were treated primarily by vertical partial laryngectomy. The pyriform sinus mucosa was used to reconstruct the new laryngeal wall and to form a pseudo-vocal fold at the side of resection. Our results showed that 90 per cent of patients were decannulated, 80 per cent were able to eat a normal diet, 70 per cent developed excellent voice quality after surgery and a 97 per cent three-year survival was achieved. The pyriform sinus mucosa proved to be a reliable material for reconstruction after vertical partial laryngectomy.

Most patients have no response to injectable collagen or silicone, but some cases may have positive or ‘undersea’(= clinically negative but immunologically positive) response to collagen. From the results of the Macrophage migration inhibition test, the relative immunogenicity was augmented most when we used implants with the following combination. The firstimmunization was collagen and the second one was collagen with silicone.

The augmented antigenicity might be enough to cause an allergic reaction to the patients who had no response to each implant alone. The purpose of this article is to warn of the potential hazard of injection.

The result of a study conducted on 30 patients of lepromatous leprosy regarding laryngeal involvement is presented. The incidence of leprous laryngitis is 36.6 per cent in this part of India in lepromatous leprosy patients. Leprosy is long standing disease so laryngeal lesions developed gradually and may be asymptomatic in some cases while others have been found to have variety of clinical manifestation in form of congestion, infiltration, nodulation, thickening and fibrosis. Anti-leprosy chemotherapy is equally effective on these lesions. A screening survey of laryngeal pathology in such cases should be done periodically.

A prospective study was undertaken to compare the efficacy of calcium sodium alginate fibre (Kaltostat®) to petrolatum gauze impregnated with bismuth tribromophenate (Xeroform®) for the control of epistaxes that require hospital admission.

Forty patients presenting with severe epistaxis requiring hospital admission were treated with either Kaltostat®r Xeroform® nasal packs. Allocation to either treatment group was made randomly. The composition of each group in terms of age, sex distribution, aetiology of epistaxis and severity of bleed was not significantly different.

There was no significant difference in the efficacy or patient acceptability of either therapeutic agent. It is concluded that calcium sodium alginate fibre should be considered as an acceptable alternative to traditional gauze packing.