A modification of the CO2 laser hand-piece is presented which utilizes a simple finger controlled mechanical shutter. This instrument safeguards against accidental direction of the laser beam.

Encounters with the jugular bulb in ear surgery are uncommon. This communication relates three cases where the author was confronted with the bulb in middle ear surgery – one in relation to the external auditory canal when raising a tympanomeatal flap and two in the hypotympanum when entering the middle ear. The anatomy of the jugular bulb is considered, particularly in regard to its quite variable placement within the temporal bone. The manner of clinical presentation of the high jugular bulb and previous cases in the literature where the jugular bulb has been discovered in juxtaposition to the surgical approach are discussed. Implications of surgical management are considered.

Abstract: Primary extramedullary plasmacytoma (PEP) is an uncommon neoplasm of plasma cell origin which afflicts the head and neck mainly. In this study we report a rare case of a 34-year-old man who presented with left ear tinnitus, hearing loss, blocked feeling and headache. Exploratory tympanotomy revealed a mass extending into the attic and the mastoid antrum. Following canal wall-up mastoidectomy, the tumour was carefully removed. Histological examination (including immunoperoxidase staining) and thorough clinical, laboratory and radiological evaluation revealed an exclusively cytoplasmic monoclonal IgG immunoglobulin PEP. The combination of surgery (including a second-look procedure) and radiotherapy used in this case may be an over-treatment. However, the patient is still disease-free seven years after his first admission to hospital.

A case of spontaneous rupture of the tympanic membrane during anaesthesia is reported and its possible aetiology discussed.

The first isolated case of agenesis of the mastoid antrum, previously only described in association with the congenital syndromes trisomy 13 and mandibulofacial dysostosis, is reported. The loss of this important surgical landmark may result in disorientation and iatrogenic trauma. The surgeon must be aware of its existence, and where it is suspected the middle fossa dura should be exposed and followed posteriorly until the lateral sinus is encountered.

The nonrecurrent laryngeal nerve is vulnerable during thyroid surgery. Pre-operative recognition of this nerve allows surgeons to avoid injuring the nerve. This anomaly depends upon the aortic arch anomaly and, therefore, in some cases, surgeons are able to predict the presence of this nerve pre-operatively by chest X-ray or barium swallow. Two patients with nonrecurrent laryngeal nerve are reported, one of whom, a 48-year-old man, had an abnormal shadow of the aortic arch, which led to confirmation of a right aberrant subclavian artery. Barium swallow plays a decisive role in the diagnosis of nonrecurrent laryngeal nerve, and this test is mandatory in patients who complain of difficulty in swallowing.

The treatment of double strictures in the airway and the oesophagus has always been time-consuming and causes additional suffering. A new technique using an open approach with the placement of two Montgomery silicone T-tubes to support and dilate the two strictures was successfully performed on a patient after caustic substance ingestion. Scar tissue was incised before two T-tubes were positioned into the larynx and oesophagus through a laryngo-fissure approach. The tubes remained in position for one year and no complications occurred. No foreign body sensation or prosthesis migration was observed and the patient had nearly normal peroral alimentation. After removal of the tubes, follow-up for an additional two years revealed no recurrence of the stenoses and normal alimentation without stridor. This technique permits simultaneous stenting of strictures of the larynx and oesophagus by using a connecting suture between the superior parts of two stents.

A multivariant analysis of the value of the use of a pre-operative topical antiseptic mouthwash to reduce the incidence of post-operative wound complications in 106 consecutive patients undergoing head and neck surgery involving the oral cavity or oropharynx was carried out at the University of Iowa, Department of Otolaryngology-Head and Neck Surgery. An oral presentation employing povidone–iodine solution was used for 43 patients. The remaining 63 patients studied received no oral presentation. Unfavourable wound outcome was not associated with age, sex, presence and condition of teeth, or serious pre-existing medical illnesses. A significant correlation was found between post-operative wound breakdown and type of closure, stage of disease, and previous operation or radiotherapy. The use of an oral preparation correlated significantly with favourable wound outcome independent of all other variables (p<0.01).

Our data support the use of a topical antiseptic mouthwash to reduce the incidence of post-operative wound complications in surgery of the oral cavity and oropharynx.

Myxomas of the paranasal sinuses are rare but well described in the literature. They may be related to dental malformations or missing teeth, but may also occur without any such abnormalities. Their local aggressiveness and ability to erode bone should not be underestimated, and they should be totally removed whenever possible. A case of myxoma of the sinuses is described, in which recurrence followed several local removals. The patient was only cured by radical maxillectomy. The operation is described, and the literature on the subject reviewed.

A retrospective review was conducted of 64 patients with deep neck abscesses. Based on clinical and operative findings, these abscesses were categorized as retropharyngeal abscess (29 patients), parapharyngeal abscess (10 patients), Ludwig's angina (19 patients), or necrotizing cervical fasciitis (six patients). Regional trauma from an ingested foreign body was the cause for 59 per cent of the patients with a retropharyngeal abscess. In 90 per cent of subjects with Ludwig's angina, an odontogenic cause was established; however, in the majority of cases of parapharyngeal abscess (80 per cent) and necrotizing fasciitis of the neck (85 per cent), aetiology was unknown.

Fifty-five patients (86 per cent) required open neck drainage. In the remaining nine (14 per cent) endoscopic drainage of the abscess was possible. Eight patients (12 per cent) needed a tracheotomy for airway control. The overall mortality was eight per cent despite aggressive anti-microbial therapy and early surgical intervention. Thirty-four cultures grew aerobic organisms. Seventy-six per cent of these were gram-negative microorganisms. The bacteriological pattern of deep neck abscesses is changing and may be responsible for the considerable mortality rate with which the abscesses are still associated despite anti-microbial therapy.

In order to evaluate the vocal quality of tracheo-oesophageal and oesophageal speech, several objective acoustic parameters were measured in the acoustic waveform (fundamental frequency, waveform perturbation) and in the frequency spectrum (harmonic prominence, spectral slope). Twelve patients using tracheo-oesophageal speech (with the Provox® valve) and 12 patients using oesophageal speech for at least two months, participated.

The main results were that tracheo-oesophageal voices more often showed a detectable fundamental frequency, and that this fundamental frequency was fairly stable; there was also a tendency to more clearly defined harmonics in tracheo-oesophageal speech. This suggests a more regular vibratory pattern in the pharyngo-oesophageal segment, due to the more efficient respiratory drive in tracheo-oesophageal speech. So, a better quality of the voice can be expected, in addition to the longer phonation time and higher maximal intensity.

For overseas doctors, looking for higher training posts, the chance of being employed in the developed countries is becoming bleaker. This article considers the need for an increase in the number of local postgraduate training programmes in the Arab world in keeping with other developing countries. The model used for this study was an internal audit, of the postgraduate programme in ENT offered by King Faisal University in Dammam, Saudi Arabia. A dropout rate of more than 30 per cent among those who joined the programme reflected either the tougher standard of the course, or an inappropriate selection process. A major reason was the frustrating inability of the trainees to cope with the basic sciences course. This point was also addressed in the audit with a view to rationalizing the course to meet specific objectives.

Wegener's granulomatosis is a systemic vasculitis characterized by necrotizing granulomata and without treatment is associated with a poor prognosis. Antineutrophil cytoplasmic antibodies (ANCA) have proved to be a useful serological marker allowing for early diagnosis and treatment of this condition. We report two cases of patients who were ANCA-negative on presentation despite clinical suspicion of Wegener's granulomatosis. In both cases the patients developed a positive ANCA titre as the disease progressed.

Tracheostomy has, in the past, been performed in the majority of children under one year with bilateral vocal fold paralysis. We present our experience of 11 cases over a ten-year period during which tracheostomy was avoided whenever possible. Ten cases were managed conservatively but in the youngest a tracheostomy was required. Full bilateral vocal fold mobility developed in all cases at a mean age of 11.5 months (range 5–26 months). Our experience suggests that the airway can commonly be managed expectantly without a tracheostomy.

Neonates with symptoms of stridor from birth, present a difficult diagnostic problem. We have demonstrated that by the use of a laryngeal mask airway in an anaesthetized baby breathing spontaneously, we are able to reach a diagnosis. This is accomplished by the introduction of a rigid fibre-optic endoscope through a Portex swivel connector and visualizing the glottis and larynx.

We report the case of a female patient who presented with sudden deafness as the first symptom of a cerebellar tumour which was not localized strictly in the cerebellopontine angle and did not show direct compression on the extrabulbar portion of the Vlllth cranial nerve. The clinical picture contained a number of signs and symptoms typical of cerebellar involvement.

Surgical intervention restored the hearing and caused the symptoms to disappear.

We also review the association between tumours and sudden deafness in the literature.

A 47-year-old man presented, in 1990, with a short history of left-sided cerebellar ataxia. In 1986 he had undergone excision of a glomus jugulare tumour. A magnetic resonance (MRI) scan demonstrated cerebellar herniation through a defect in his skull base. Surgical repair was undertaken with resolution of his symptoms.

Various techniques for performing a secondary tracheo-oesophageal puncture to enable insertion of a speech prosthesis in laryngectomized patients have been described. We describe a modification that allows a safe secondary tracheooesophageal puncture under local anaesthesia using standard equipment available in an ENT department.

We present two rare, but similar, cases of button batteries in the nose in male children of Caucasian origin. The importance of early diagnosis, treatment and the long-term morbidity of such a foreign body in the nose are discussed.

Three cases of Wegener's granulomatosis are described in which the common presenting symptoms were those of aural discomfort and discharge. The otological manifestations of this disease process are discussed and a review of the literature is presented.