Cerumen is the product of the secretion of the sebaceous, ceruminous or apocrine glands together with cells exfoliated from the cornified stratum of the epithelium of the external auditory canal (EAC).

In the present study we identified and quantified common flora of human cerumen. The mean count obtained was 106 microorganisms per ml of cerumen suspension.

In 24 pools of cerumen (33.3 per cent) the isolates were monomicrobial, Staphylococcus epidermidis (12), Corynebacterium spp (10), Staphylococcus aureus (1) and Streptococcus saprophyticum (1). In 48 pools (66.6 per cent) we found polymicrobial isolates.

The most commonly isolated bacteria in these polymicrobial isolates were S. epidermidis (35) and Corynebacterium spp. (43). It is noteworthy that there were isolates of Candida albicans in three cases; in one case of Pseudomonas stutzeri, in one case of Pseudomonas aeruginosa, and, on seven occasions, of S. aureus.

The organisms isolated as common bacterial components of human cerumen in our experience were similar to those found by other authors. However, the mean count was much higher. This could be related t o climatic conditions and to the length of time the cerumen had remained in the external auditory canal.

The management of epistaxis is reviewed from ancient times onwards. Many curious methods have been employed and indeed epistaxis has been encouraged at times. Although current management is based on sound principles folklore remedies still predominate amongst some of our patients. The basis of contemporary treatments was known and practised by our ancient forebears.

Neuroendocrine neoplasms of the larynx have been divided into those of epithelial or neural origin. The latter consist of paragangliomas while the epithelial origin group can be divided into the typical and atypical carcinoids and small cell neuroendocrine carcinomata, the latter consisting of the oat cell type, the intermediate cell type and the combined cell type. There are now over 500 cases of neuroendocrine neoplasms of the larynx in the literature.

The diagnosis is primarily based on light microscopy, and, in some instances, it may be supported by special histochemical studies. It should be confirmed by immunocytochemical and/or ultrastructural investigation. The different biological behaviour of neuroendocrine neoplasms of the larynx makes a specific diagnosis of paramount importance, since treatment depends on diagnostic accuracy.

Typical carcinoid is an extremely rare lesion. It is treated preferably by conservative surgery; elective neck dissection is not necessary because of the lack of lymph node metastases at diagnosis. Chemotherapy and/or radiotherapy have not been effective in the limited number of patients treated thus far. Prognosis is excellent with cure following surgery.

Atypical carcinoid is the most frequent non-squamous carcinoma of the larynx. The mainstay of treatment is surgery. Elective neck dissection should be performed because of the high likelihood of cervical lymph node metastases. Primary radiation therapy with adjuvant chemotherapy is not indicated. The survival rate is 48 per cent at five years and 30 per cent at 10 years.

Although the larynx is one of its most common extrapulmonary sites, small cell neuroendocrine carcinoma is still a rare tumour. Surgical results for this tumour have been disappointing and is reserved for cases of local relapse with no evidence of metastasis. Chemotherapy and radiotherapy currently appear to offer the least disabling and most effective forms of therapy. The two- and five-year survival rates are 16 per cent and five per cent, respectively.

Paraneoplastic syndromes have occasionally been reported in association with carcinoid tumours (typical and atypical) and small cell neuroendocrine carcinoma. There have been also rare reports of an elevated neuropeptide serum level.

Paraganglioma is the only laryngeal neuroendocrine neoplasm with a female preponderance (3:1). Confusion with atypical carcinoid has led to incorrect diagnosis and inappropriate classification schemes, erroneously suggesting that laryngeal paraganglioma has the potential for aggressive behaviour. Conservative surgery represents the treatment of choice; elective neck dissection is not necessary, and the prognosis is excellent.

The profoundly deaf, who gain little or no benefit from conventional hearing aids and meet various criteria are potential candidates for cochlear implantation. The last two decades have witnessed remarkable progress in this field, and it is now a routine clinical procedure. A few adult patients who are potential candidates for cochlear implantation have an unacceptably high risk for hypotensive general anaesthesia due to other systemic conditions. This group has been successfully implanted under local anaesthesia in our centre. The post-implantation progress of these patients was comparable to those carried out under hypotensive general anaesthesia. Data regarding patient selection criteria, examination, anaesthesia, surgery and the outcome are discussed. It was concluded that cochlear implantation under local anaesthesia is a safe and effective procedure for those patients who otherwise may be denied an implant.

At present there are no topical otological preparations on the World Health Organisation's essential drug list, largely due to the ototoxic potential of preparations containing aminoglycoside antibiotics. Acetic acid and Burow's solution have long been used in the treatment of the discharging ear. The aim of this study was to ascertain the antibacterial activity of these two preparations against the most commonly occurring bacteria isolated from discharging ears in our department. Twenty fresh isolates of each of the following organisms – Pseudomonas aeruginosa, Staphylococcus aureus, Proteus mirabilis and Streptococcus pyogenes – were plated onto blood agar and tested against one per cent, two per cent and three per cent acetic acid and Burow's solution (13 per cent aluminium acetate). The activity of each agent was ascertained by the size of the zone of inhibition of bacterial growth. Burow's solution showed significantly larger average zones of inhibition than acetic acid (p < 0.001). The two per cent and three per cent acetic acid as well as the Burow's solution were active against all the organisms tested.

A review of the structure-function relationships in normal, diseased and reconstructed middle ears is presented. Variables used to describe the system are sound pressure, volume velocity and acoustic impedance. We discuss the following

(1) Sound can be transmitted from the ear canal to the cochlea via two mechanisms: the tympanoossicular system (ossicular coupling) and direct acoustic stimulation of the oval and round windows (acoustic coupling). In the normal ear, middle-ear pressure gain, which is the result of ossicular coupling, is frequency-dependent and smaller than generally believed. Acoustic coupling is negligibly small in normal ears, but can play a significant role in some diseased and reconstructed ears.

(2) The severity of conductive hearing loss due to middle-ear disease or after tympanoplasty surgery can be predicted by the degree to which ossicular coupling, acoustic coupling, and stapes-cochlear input impedance are compromised. Such analyses are used to explain the air-bone gaps associated with lesions such as ossicular interruption, ossicular fixation and tympanic membrane perforation.

(3) With type IV and V tympanoplasty, hearing is determined solely by acoustic coupling. A quantitative analysis of structure-function relationships can both explain the wide range of observed postoperative hearing results and suggest surgical guidelines in order to optimize the post-operative results.

(4) In tympanoplasty types I, II and III, the hearing result depends on the efficacy of the reconstructed tympanic membrane, the efficacy of the reconstructed ossicular chain and adequacy of middle-ear aeration. Currently, our knowledge of the mechanics of these three factors is incomplete. The mechanics of mastoidectomy and stapedectomy are also discussed.

The literature on verrucous carcinoma of the head and neck was reviewed to analyse the use of primary radiation therapy in the treatment of this lesion. The results emphasize an overall local control rate of 43.2 per cent, and 6.7 per cent of true anaplastic transformation following irradiation. Diagnosis remains the fundamental problem: without a correct diagnosis of verrucous carcinoma, no correct treatment can be applied.

Despite good evidence to the contrary, the Spanish singing teacher Manuel Garcia is still credited by many to have been the discoverer of the mirror for inspecting the larynx. Although the adoption of this technique into clinical practice, and thus the beginning of laryngology as a specific discipline, is rightly credited to others Manuel Garcia achieved unwarranted fame…if not fortune. Careful examination of the published literature has substantiated the claim that 26 years prior to the paper presented on Garcia's behalf to the Royal Society of London, Babington had described to the Hunterian Society a similar device which later evidence indicated had been used clinically on at least one laryngologist. This claim was also supported by no less than Morell Mackenzie in a published lecture in 1864, nine years after Garcia's lecture. Possible explanations for this aberration of justice are considered.

The case notes of 185 patients who had bismuth-iodoform-paraffin paste (BIPP) impregnated ribbon gauze used for packing following ear surgery were analysed retrospectively. The incidence of hypersensitive allergic reactions to BIPP was 5.9 per cent and a five-fold increase risk of developing allergic reactions was found in those with previous exposure to BIPP. Where temporalis fascia was used to repair tympanic membrane defects, the incidence of tympanic membrane graft perforations was higher when allergic reactions to BIPP developed post-operatively, compared to non-allergic cases.

The aetiology of idiopathic facial nerve palsy (Bell's palsy) and sudden deafness are not known, although viruses have been suspected as a cause of them. We investigated the relationship between Bell's palsy or sudden deafness, and reactivation of cytomegalovirus, human herpesvirus 6 (HHV-6) and 7 (HHV-7).

Paired sera were collected from 22 patients with Bell's palsy and 24 patients with sudden deafness. IgG antibody titres to HHV-7 were increased in one patient with Bell's palsy. IgG antibody titres to HHV-6 were increased in one patient with Bell's palsy and two with sudden deafness. IgG antibody titres to cytomegalovirus were increased in one patient with sudden deafness. Titres of the three viral antibodies were not increased simultaneously in any patients. These viruses may contribute to the development of Bell's palsy or sudden deafness in some cases. It is, however, unlikely that these viruses are the main cause of Bell's palsy and sudden deafness in the majority of patients.

This article describes the anatomy of the visual pathways and how they should be assessed under anaesthesia. The differential diagnosis of asymmetrical pupils is illustrated with clinical examples and a strategy as to how they should be examined.