As yet, there is no totally satisfactory means for treating hypertrophied turbinates and the proper management of turbinate dysfunction remains in question. In the present series, four of the widely practiced surgical procedures for the reduction of the size of the inferior turbinates were evaluated and compared. In all cases turbinectomy was performed as an isolated procedure. Eighty patients with chronic non-allergic rhinitis and hypertrophied inferior turbinates were selected, randomly divided into four groups, and followed up post-operatively for one year. Study of the results indicated that the beneficial effect of the operation is mainly mechanical by reduction of the resistance to nasal airflow. The post-operative improvement in smell acuity correlated positively with the increased patency of the nasal airway. None of the procedures had a deleterious effect on olfactory acuity. In contrast, the operation failed to enhance the mucociliary clearance rate or significantly decrease nasal drainage. Partial inferior turbinectomy and laser turbinectomy improved nasal breathing in 77 per cent of patients, and enhanced olfactory acuity in 78 per cent of patients who had pre-operative hyposmia. The results of turbinoplasty and cryoturbinectomy were less favourable. The surgical technique, advantages, and drawbacks of each of these procedures are discussed.

Tympanic neurectomy was first described 44 years ago. Although its indications have subsequently increased, it has not become a popular procedure. This paper concentrates on its use in treating otalgia. The history of tympanic neurectomy, the anatomy of the tympanic plexus and the aetiology of otalgia with specific reference to the tympanic plexus are discussed and a case of bilateral otalgia due to glossopharyngeal neuralgia successfully treated by staged, bilateral tympanic neurectomy reported. It is suggested tympanotomy performed under local anaesthesia with selective stimulation of the intra-tympanic nerves may lead to accurate diagnosis and treatment of the various forms of neuralgic otalgia.

The use of the sternocleidomastoid muscle and musculocutaneous flaps in the reconstruction of defects arising after surgery for cancer of the head and neck has been a subject of some discussion.

Experience with these flaps over a ten year period from 1980 until 1989 is presented. Attention is drawn to the various types of flaps in vogue, their indications to date, benefits and drawbacks. A new reliable compound musculocutaneous flap developed by the author for use in defects of the skull base after total temporal bone excision is presented.

Technetium-99m (Tc99m)(v) Dimercaptosuccinic Acid (DMSA) is animaging agent which has been proposed as a scintigraphic marker for head and neck squamous cell carcinoma. Fifty-four patients were studied of whom 51 had a head and neck tumour. All patients were examined and then imaged using Tc99m(v) DMSA scintigraphy and computerized tomography.

Scintigraphy was less sensitive than clinical examination in the detection of patients with cancer, patients with primary tumours and patients with metastatic neck disease. CT was as sensitive and as accurate as clinical examination but more senstive than Tc99m(v) DMSA in detecting patients with cancer and with primary tumours. CT was more sensitive and more accurate than both clinical examination and Tc99m(v) DMSA scintigraphy in predicting which patients had metastatic neck disease.

Although Tc99m(v) DMSA is accumulated by squamous cell carcinoma, its inability to detect low volume disease and apparent low specificity means it has no role to play in the management of patients with head and neck squamous cell carcinoma.

Fifteen acinic cell carcinomas from an equal number of patients were analysed for their DNA content and proliferative (S-phase) index by flow cytometry from archival tissues. Seven of the carcinomas manifested a diploid DNA content. None of the patients with diploid acinic cell carcinomas died of their carcinomas and none developed metastases in follow-up periods extending for 10 or more years. Four of eight patients with aneuploid acinic cell carcinomas have died because of their malignancies within a 10 year period after the first surgical removal of the carcinoma. Five of the eight patients exhibited metastases. Although the number of cases does not permit strong correlations between histopathological features, abnormalities in DNA content and outcome of patients, it was noted that carcinomas with prominent necrosis, tubulo ductal differentiation and ‘dedifferentiated’ areas displayed more aggressive biological courses.

There is current concern about the possible adverse affects of blood transfusion on patient survival after cancer surgery. In addition, blood transfusion is associated with a low incidence of morbidity and mortality in any patient. 100 patient records have been examined retrospectively to outline the problems with blood transfusion policy in head and neck surgery. The current situation lacks standardization on a scientific basis and represents an area of resource over-utilization. A new approach to this subject in head and neck surgery is proposed and a recommended ‘new policy’ suggested.

This paper reviews a 20 year experience of radiation treatment of 286 laryngeal cancers and presents results with a minimum five year follow-up. All cases presented had glottic or supraglottic squamous cell carcinomas with no clinical evidence of nodal metastasis. A policy of primary radiotherapy, with surgery for salvage of treatment failures, produced control of primary disease and prevention of metastases superior to most other regimes documented in the literature.

A 30-year-old female presented with a ten-year history of bilateral conductive deafness. A pre-operative diagnosis of otosclerosis was made but at tympanotomy, the stapes crura in each ear was found to be disconnected from the foot- plate, the ossicular chain being otherwise normal. A Teflon-wire prosthesis was used to join incus and footplate, with good results. In the absence of a history of trauma or sepsis this may be a late presentation of a congenital stapedial anomaly which has not previously been reported.

One hundred and seventy cases of nasal and/or sinus polyps diagnosed in the Pathology Service of the Hospital Militar Central GOMEZ/ULLA of Madrid (Spain) between 1.9.79 and 1.9.88 are reviewed. In two cases areas of ‘carcinoma in situ’ in the epithelium covering the polyps were demonstrated. The literature is reviewed for reports of malignant transformation and dysplastic changes in nasal and sinusal polyps. We suggest that precancerous changes may ocassionally be noted in inflammatory lesions, a fact that pathologists should keep in mind.

The intranasal approach is generally accepted as the route of choice in the correction of bilateral choanal atresia but unfortunately it is associated with a significant incidence of stenosis.

Over a five-year period, we have diagnosed bilateral choanal atresia in 30 neonates. Trans-nasal surgery was performed on 27 of them. All belonged to the Black race group. The incidence was 1:8,300 live births. There was a female predominance of 5:1. Four (13 per cent) had other associated anomalies. One was a twin.

Various factors were analysed to determine the cause of the stenosis. These were:

1. Drilling compared with curettage of the bony atretic plate. 2. Stenting versus non-stenting. 3. Soft versus hard Portex tube stenting. 4. Variation of stenting period—six, eight and twelve weeks. 5. The use of prophylactic broad spectrum antibiotic for the whole of the stenting period.

The conclusion derived from this study is that curettage of bony atresia, stenting with soft Portex tube for a period of six weeks and the use of broad spectrum antibiotic for the entire stenting period eliminates the problem of stenosis associated with the trans-nasal approach for the correction of bilateral choanal atresia.

Two male siblings presented in infancy with hyponatremia. The levels of plasma renin activity and aldosterone were elevated. Sodium supplement was necessary to maintain normal sodium balance. The salivary sodium concentrations were markedly elevated, with sweat sodium levels being in the upper normal range. Urinary sodium concentration and renal epithelial exchange between sodium and potassium were normal. This was felt to be due to an autosomal recessive disorder.

Both siblings were later diagnosed as having a bilateral moderate to severe sensorineural hearing loss with intermittent conductive overlay due to middle ear fluid. The sensorineural loss was also felt to be autosomal recessive in origin, but the possibility of a disturbance of sodium balance in the inner ear has been questioned.

The author proposes the term ‘vertical partial laryngectomy on demand’ for all modifications of vertical laryngectomics (frontal, frontolateral, vertical and hemilaryngectomy). This term includes two conditions: the first is complete oncological removal of the tumour (proven by histological examination and with the use of magnification or the operating microscope during the operation); secondly, reconstruction of the laryngeal defect by various procedures. The author uses the sternohyoid fascia in vertical and frontolateral partial laryngectomies. From 120 operated cases, a five-year survival rate of 81 per cent was achieved. The fascia showed resistance to post-operative complications and irradiation.

The complication rate after emergency tracheostomy is two to five times greater than after elective procedures. One of the main causes of the high risk of complications in emergency tracheostomy appears to be the amount of time required to open the trachea. Therefore, simple and fast procedures are mandatory. We have developed a new procedure as follows: A horizontal skin incision is performed. Strap muscles are dissected and retracted laterally. A transverse cut between tracheal rings below the thyroid isthmus is performed up to membranous portion of the trachea. The cut ends of the trachea remain open naturally because of the elasticity of the trachea. Skin and tracheal cut-ends are then joined by interrupted sutures.

We have used this procedure during the past three years and have not experienced any major complications. This demonstrates the clear advantage and the more physiological nature of the procedure over various other incisions of the tracheal wall.

We report 44 cases of monomorphic adenoma (MA) of the major salivary glands observed during the years 1979–1989. All of these tumours were reviewed and classified on the basis of the World Health Organisation (WHO) criteria. Histological type, site, sex and age were considered. 34 cases of adenolymphoma were observed, all of them located in the parotid glands; 10 MA without lymphoid stroma were located in both parotid and submandibular glands. Distinctive histological and clinico-pathological features of the latter group of tumours are discussed, as well as the diagnostic criteria in distinguishing these tumours from pleomorphic adenoma and adenoid-cystic carcinoma.

The UCLA experience with subdural empyema (SDE) of otorhinological origin was reviewed. All cases of SDE with additional intracranial complications were excluded. Thirteen cases of SDE were identified with the prediposing factors being sinusitis (ten), mastoiditis (two), and otitis media (one). Based on data obtained from this review and from studies previously published in the literature, the keys to optimal outcome are rapid diagnosis, craniotomy with complete evacuation of the purulent collection followed by immediate surgical management of the otorhinological source of the SDE, and appropriate antibiotic therapy. Computed tomography is nearly always diagnostic but can be equivocal and magnetic resonance imaging may become the diagnostic study of choice. Of the five patients initially treated with craniotomy, 100 per cent improved as compared to 50 per cent of the eight patients initially treated with burr holes. None of the patients initially managed with craniotomy were worse or died, whereas of the four patients initially managed with burr holes, two were worse (25 per cent) and two died (25 per cent). Antibiotic therapy is guided by the organisms found in the empyema and the site of origin of the infection. The otolaryngologist must remain aware of the clinical features and management of SDE and work closely with his neurosurgical colleagues to provide early, decisive surgical treatment.

Although pseudocyst of the auricle is a common disease in China, its cause and mechanism are still not clear. Several methods of treatment have been advocated: repeated aspirations combined with physiotherapy, and incision and drainage with contour pressure dressing, magnetotherapy etc. In recent years, a new technique with a drainage tube inserted into the pseudocyst using a guide needle has been used in our hospital in the treatment of this condition. We report 45 cases treated by this method, none of whom had the condition previously.

Acute orbital infection is an uncommon condition which is often secondary to acute sinusitis. Although it can present in any age group it is most prevalent in children and may cause impaired vision, blindness, intracranial complications and death. This paper documents the experience at the Royal Liverpool Childrens Hospital, Alder Hey, from 1973 to 1989. Clinical details were recorded retrospectively from the hospital case notes. Sixty-eight children had orbital sepsis of whom 30 had associated acute sinusitis. Of these 30 children, orbital sepsis was always unilateral with a preference for the left side; ten had diplopia of whom four had a sub-periosteal abscess which was subsequently drained. There were no serious complications although two children had diplopia for two to three months.

A retrospective study is presented of 31 patients who required ventilatory support via a tracheostomy for periods of one month to 27 years whilst in a tertiary referral centre for the care of patients with restrictive respiratory insufficiency. All patients underwent closure of a long-standing tracheostomy. Post-operative follow-up periods of up to 16 years are documented. The indications for and the complications of tracheostomy closure in patients with severe chronic restrictive respiratory insufficiency requiring long-term respiratory support are discussed. It is concluded that the benefits of operative tracheostomy closure outweigh the disadvantages in this unusual type of patient.

DNA content was measured by flow-cytometric analysis in 30 paraffin embedded sections from patients with laryngeal squamous cell carcinoma. The morphological characteristics and N staging of the tumours as registered in their clinical charts were correlated with their DNA content. Eighty per cent of the tumours were found to have a predominantly aneuploid distribution of DNA values. There was no correlation between the N stage of the tumour or degree of cell differentiation and DNA content. A multiploid pattern correlates with non-metastatic laryngeal tumours and we suggest that this pattern may be a good indicator for biological activity.