This paper describes the results of a comparative audit of the costs of using artificial prostheses and cortical bone. The costs of using a bone graft have been calculated by estimating the expenses incurred as a result of the additional time required for preparation of the grafts. The mean cost of preparing a graft was £29.10, while the mean cost of using a prosthesis was £65.01.

Recurrent or persistent carcinoma of the nasopharynx or naso-ethmoid region occurs even after combined surgery and radical external irradiation. The confined bony access and proximity of vital structures may compromise resection margins. Brachytherapy using implantable radioactive gold or iodine seeds is a useful adjunct to the skull base surgeon in eliminating residual microscopic disease. We report nine cases with recurrent or persistent disease of the nasopharynx or naso-ethmoid regions treated with brachytherapy with encouraging results.

Ninety-five patients undergoing routine nasal surgery were enrolled into a randomized, prospective trial to investigate the efficacy and morbidity of nasal packing. The patients were randomized to receive a bismuth iodoform paraffin paste (BIPP) pack, a Telfa pack or no pack. Patients for septal surgery were randomized between the BIPP and Telfa groups only. They were independently randomized to receive or not receive, a silastic nasal splint for the first post-operative week.

Post-operative pain levels were analysed using a visual analogue scale. Mean pain scores were increased 50 per cent by the use of nasal packs and pack removal, particularly BIPP which, was a most painful event (p<0.001).

Reactionary haemorrhage occurred in only two patients (2.1 per cent), both of whom had packs in situ. Vestibulitis was unique to the patients with a silastic splint, who were packed with BIPP, occurring in 21 per cent of them. Similarly septal perforation was unique to this group. There was no significant difference in the incidence of adhesions between the groups which received packs and those who did not.

Routine nasal packing, especially with BIPP, would seem difficult to justify in view of the increased pain levels and increased complications which occur without any demonstrable benefit in the majority of patients. Therefore packing should be reserved for cases where there is concern about persistent haemorrhage. In these cases Telfa would be preferable to BIPP.

The results of stapedectomy were compared between 162 otosclerotic ears operated on using the posterior crus technique and 182 otosclerotic ears undergoing Teflon piston stapedectomy. The large fenestra technique with fascia seal to the oval window was used in all cases. Mean follow-up period was 9.6 years. Neither short- nor long-term hearing results showed any significant differences between the two surgical technique groups. Complications of surgery were more common in patients undergoing Teflon piston stapedectomy. On the other hand, a re-operation for recurring conductive deafness was performed significantly more often in patients undergoing posterior crus stapedectomy.

Standard recommended treatment for patients with intracranial complications from otitis media, has been radical mastoidectomy, whether cholesteatoma is present or not. This was established in the pre-antibiotic era to improve survival. Over a six-year period, from January 1985 to December 1990, 268 patients were admitted with intracranial and extracranial complications of otitis media. The prospective treatment consisted of antibiotics and surgery. Surgery entailed mastoidectomy and drainage of intracranial collections of pus in all patients.

However, prospectively in these patients the ear pathology and not the complication dictated the type of mastoidectomy performed. Cortical mastoidectomy was performed in non-cholesteatomatous ears and radical mastoidectomy in cholesteatomatous ears.

Recurrence of intracranial complications occurred in only four patients (two per cent), a temporal lobe cerebritis in the non-cholesteatomatous ear group, and, a temporal lobe abscess, posterior fossa abscess and subdural empyema in the cholesteatomatous ear group. The temporal lobe cerebritis settled on intravenous antibiotics whilst the temporal lobe abscess, posterior fossa abscess and subdural empyema required redrainage. In none of these was the ear surgery revised.

There were 15 deaths (eight per cent), all occurring in patients with intracranial complications, 12 associated with brain abscess, two with subdural empyema and one with meningitis. Eight were from the non-cholesteatomatous group and seven from the cholesteatomatous group. The mortality was directly related to the patients consciousness level on admission and not to the type of ear pathology.

It can therefore be concluded that radical mastoidectomy is unwarranted in the non-cholesteatomatous ear, even with an otogenic intracranial complication.

The effect that variation of nasal airflow has on the mucociliary clearance was studied in healthy volunteers.

The nasal saccharin particle clearance time was found to have an inverse relationship with the nasal airflow.

Nasal sprays, which work on the Venturi principle, have the disadvantage of suck-back which makes them unhygienic for use in more than one patient. In Wrexham we have developed a disposable nasal spray system, which is safe and would be of benefit to other ENT departments.

Over a four-year period 72 children with ear abnormalities have been referred for assessment by the extraoral osseointegrated implant team at The Queen Elizabeth Hospital, Birmingham. Thirty-two children have been judged suitable for rehabilitation. Twelve children have completed rehabilitation using bone-anchored hearing aids and/or auricular prostheses. Two fixtures (seven per cent of those loaded) have dislodged and required replacement. Audiological assessment of the bone-anchored hearing aid users shows only small improvements in their aided thresholds, compared to thresholds obtained with their previous aid. However all now have thresholds of 30 dB(A) or better and report a marked improvement in sound quality. When surveyed, hearing aid and prosthesis users report high levels of satisfaction with this form of rehabilitation. The technique adds a new dimension to the management of children with aural anomalies. The approach and results of a multidisciplinary programme are reported.

The distribution and abundance of mast cells in nasal polyps, the maxillary sinus mucosa of patients with sinusitis and the turbinate mucosa of allergic rhinitis was microscopically examined using different methods of fixation. In the epithelium of the surface and the ducts of nasal polyps (n = 8), the mean number of mast cells was over 20,000 per mm3 using Mota's fixation and the increase was correlated with the epithelial thickness (P<0.05). On the other hand those of the maxillary sinus mucosa (n = 6) and the nasal turbinate mucosa (n = 7) were less than 6,000 per mm3. In the subepithelial layer or areas deeper than the area with the glands, however, mast cell counts were less than 3,200 per mm3 in all diseases. More than 70–90 per cent of all mast cells in the epithelium of the mucosal surface and the ducts of the polyp, the maxillary sinus mucosa and nasal turbinates were formalin sensitive. Most of the mast cells in the subepithelial and deeper areas were formalin resistant in all diseases.

These results suggest that conditions for mast cell growth differ between polyps and the other diseases, and that the conditions which affect mast cells may contribute to polyp development.

Thirteen patients suffering from primary hypogammaglobulinaemia receiving intravenous immunoglobulin replacement therapy underwent computerized tomography of the paranasal sinuses. The CT scans were evaluated and related to clinical data from the patients, who were selected for study on the basis of having symptoms of rhinosinusitis. The scans varied from normal to demonstrating widespread sinus abnormality. Th.ere was no relationship between the scan findings and duration of ENT symptoms, range of current symptoms, or the interval between the onset of ENT symptoms and the start of intravenous immunoglobulin replacement therapy. It is nevertheless possible that prompt institution of replacement therapy, after correct diagnosis early in the course of the disease, may prevent the development of sinus disease refractory to such treatment.

Inflatable balloon catheters are widely used in the treatment of severe epistaxis and are designed to be filled either with air or liquid. A postal survery revealed that 87 per cent of respondents used an inflantant which was deemed inappropriate by the manufacaturer. When ballons designed for water or saline were filled with air, they defalted rapidly, in some cases beings virtually empty after 24 hours. Better and more accessible instruction leaflets are required if the balloons are to be used as intended.

Foley catheters are frwquently used as nasopharyngeal packs, in conjunction with anterior nasal packs. Paraffin in the commonly used anterior packs damages the rubber of the catheter, resulting in the balolon bursting. This should be recognized by clinicans as a possible cause of rebleeding.

The magnitude and origin of audiometric air-bone gaps in the range 3 kHz to 8 kHz was investigated in 20 normal subjects. The average gap ranged from a minimum of about 3 dB at 3 kHz to a maximum of about 19 dB at 6 kHz. Approximately 5 dB of the gap at high frequencies is caused by excess air-radiated sound from the bone vibrator. A larger error appears to result from discrepancies between the air and bone conduction standards to which audiometers are calibrated. These errors may influence diagnosis and we recommend that bone conduction tests at frequencies greater than 4 kHz are avoided. These findings have implications for medico-legal work where small air-bone gaps have diagnostic significance.

Some patients complain of altered sensation in the mouth following nasal surgery. A prospective study of 60 consecutive patients who underwent a total of 83 intranasal procedures revealed that this was a common complication, particularly following submucous resection (SMR) or intranasal antrostomies.

The area affected by painlparasthesia appears to be anatomically related to the surgical procedure(s) performed.

Juvenile respiratory papillomatosis involving the tracheo-bronchial tree imposes a significant management problem and is sometimes life threatening. The mainstay of treatment is repeated vapourization with a CO2 laser. To date, adjunctive medical treatments have been of limited value. A tracheostomized child with extensive laryngo-tracheo-bronchial papillomatosis who has required bronchoscopic lasering at two-weekly intervals for three years was treated with ribavirin, a broad spectrum anti-viral agent. The drug was administered in nebulized form using a small particle aerosol generator (S.P. A.G.) to the lower respiratory tract (6 gm/150 ml over nine hours) on three consecutive nights every two weeks over seven weeks and also administered orally (15 mg/kg/day). Endoscopic assessments were made every two weeks. At 14 days the papillomata were regressing and far less lasering was required. No further lasering was required up to 56 days. One month after stopping the ribavirin, however, a few sessile papillomata in the tracheo-bronchial tree had recurred and were treated with the laser. No adverse reactions were encountered. During the treatment period there was a significant reduction in the frequency of therapeutic endoscopies. This promising response requires further evaluation to define the role of ribavirin in the treatment of juvenile respiratory papillomatosis.

In the treatment of group A streptococcal tonsillitis, as the bacteria are located on the epithelial surface, an important determinant of outcome is the concentration of penicillin in extracellular tonsillar surface fluid. Accordingly, we investigated the concentration of penicillin in serum, and penetration to tonsillar surface fluid and saliva in nine patients with acute group A streptococcal tonsillitis and in nine healthy controls.

Among the healthy subjects, despite high serum penicillin concentrations (mean, 2.04) (ig/ml), there was no penetration to tonsillar surface fluid or to saliva, whereas erythromycin penetrated to tonsillar surface fluid in 3/6 cases.

Of the nine patients with acute tonsillitis, on the first day of treatment eight manifested high concentrations of penicillin in tonsillar surface fluid (mean, 0.34 (ig/ml—i.e. well above the minimal inhibitory concentration (MIC) for group A streptococci), but penetration to saliva was found in only two patients. On the tenth day of treatment, penicillin was not present in the saliva of any of the patients and was present in the tonsillar surface fluid of only one. The results suggest that measurable concentrations of penicillin in tonsillar surface fluid can only be obtained in the presence of inflammation with fluid exudation through the tonsillar epithelium.

A random prospective study of 180 patients with chronic nasal obstruction who underwent inferior turbinate resection as a part of a multinasal surgical procedure is presented. The aim of our study was to examine the influence of nasal pack on the incidence of post-operative haemorrhage following inferior turbinate resection.

The haemorrhage rate in Group 1 (no nasal pack), Group 2 (nasal pack retained for 24 hours) and Group 3 (nasal pack retained for 48 hours) was 11.7, 8.3 and 0 per cent respectively.

We recommend that a nasal pack should be retained for 48 hours following inferior turbinate resection.

This investigation was performed in order to evaluate the observer variations in facial nerve function after surgery for an acoustic neuroma. From 1976–90, 507 patients were operated on by the same surgical team (M.T. and J.T.) using a translabyrinthine approach. One hundred and forty-four patients living in Copenhagen City and County were invited for interview and objective examination. Only 128 patients attended the interview and examination which were carried out by the same ENT physician. Data concerning observation of the facial nerve function only is presented. Its function was clinically evaluated (using the House and Brackmann (1985) grading scale) by two different observers i.e the ENT physician and one of the surgeons. The patients were asked face-to-face with the ENT physician to estimate the degree of facial nerve function according to a 0–100 per cent scale. Comparing normal and abolished facial nerve function the judgments of the ENT physician and the surgeon agreed with the patient‘s own evaluation.

Aspiration frequently occurs in patients with a competent glottis. Analysis using a modified barium swallow (MBS) can reveal an extraglottic mechanism of aspiration in these patients. The MBS examination guided the design of two surgical procedures in patients with severe aspiration. The surgery corrected the underlying extraglottic cause of aspiration while preserving glottic function. In one case the epiglottoplasty controlled aspiration due to spillage over the epiglottis into the airway. In the other case translaryngeal resection of the cricoid lamina combined with cricopharyngeal myotomy controlled aspiration of residue in the hypopharynx. After surgery, both patients had their gastrostomy and cuffed tracheostomy tubes removed and were discharged home on a normal oral diet. Detailed analysis of deglutition by a modified barium swallow canprovide a scientific basis to guide the surgical management of patients with severe dysphagia.

This paper offers an account of the contemporary surgical approach to advanced tumours of the external ear based on a series of 11 patients. There were eight squamous, two basal cell carcinomas and one mucoepidermoid tumour. The traditional method of excision was slightly modified by performing microsurgical dissection of the lateral part of the temporal bone rather than chisel osteotomies, and then including it en bloc with the involved soft tissues. The defect was then closed using a scalp or myocutaneous flap and this combination of otological and reconstructive expertise has proved satisfactory. Four patients are alive with no evidence of disease a mean of 4.2 (range 1.0–7.0) years from surgery: two patients who remained free of disease have subsequently died of unrelated conditions 12 and 24 months post-operatively, and in three cases death from recurrent disease occurred a mean of 1.4 (range 0.9–2.1) years after our surgery. There were two postoperative deaths. Based on the actuarial survival of 36 per cent and a successful disease clearance rate of 54 per cent, our conclusion is that the outlook of this condition has not dramatically improved since the original descriptions of the management of this problem first appeared, although intervention remains justifiable because of the potential curability and relief of symptoms.

This paper reports on 16 cases of primary malignant melanoma of the external ear and the patients were followed up for two to 116 months. Fourteen patients had surgical excision with wide margins as initial treatment, whilst two had an amputation performed. Eleven patients had no recurrences, two died of other diseases, and four died of malignant melanoma. The five patients who developed recurrences received further surgery and two also radiotherapy.

Seven of the cases were histologically of the nodular type, six were superficial spreading, two were in situ melanoma, and one was a lentigo maligna. The thickness ranged from 0.15 to 11.5 mm. Classification according to Clark et al. (1969) revaled that as many as nine cases were Clark level IV or more. Immunostaining with PCNA yielded strong positivity in all cases, however, statistical analysis did not reveal any differences that could be correlated to the prognosis. Estimation of the vascularization at the base of the tumours by means of immunostaining with CD31 did not reveal any significant differences either.

We concluded that in our material the thickness of the tumour is of greater prognostic value than the estimation of proliferation by PCNA and vascularization by CD31. The value of PCNA and CD31 as possible prognostic parameters needs to be evaluated in a larger series. It is emphasized that malignant melanoma of the external ear is a highly malignant tumour, and that four of our 16 patients died of their disease, three of them within a year after diagnosis. Malignant melanoma of the external ear is readily inspected and thereby an early diagnosis should be possible.