This study retrospectively investigated the microbiology and management of 40 children who suffered from chronic sinusitis.

The sinuses infected were the maxillary (15 cases), ethmoid (13), and frontal (seven). Pansinusitis was present in five patients. All aspirates were cultured for aerobic and anaerobic bacteria. A total of 121 isolates (97 anaerobic and 24 aerobic) were recovered. Anaerobes were recovered from all 37 culture- positive specimens, and in 14 cases (38 per cent) they were mixed with aerobes. Twenty-three 3- lactamase-producing bacteria were isolated from 16 (43 per cent) patients. The 15 patients who received clindamycin had the most rapid response to therapy and a change of therapy and surgical drainage was required in one case. Of the 16 patients who received amoxycillin or ampicillin, 16 responded to therapy, six needed a change of therapy, including four who also had surgical drainage. Of the six who were treated with erythromycin, three needed antibiotic change, two with surgical drainage. Of the three that received cefaclor, two were cured, and one had an antibiotic change. Resistant organisms were recovered in all the cases that required therapeutic change.

These findings support the important role of anaerobic bacteria in the polymicrobial cause of chronic sinusitis in children, and the superiority of therapy effective against these organisms.

A prospective study was carried out on 25 consecutive patients referred to an outpatient clinic at The Royal National Throat, Nose and Ear Hospital, with a medical letter suggestive of sinusitis, to test the hypothesis that the diagnosis of inflammatory sinus disease could be made simply and accurately by employing systematic nasal endoscopy and a series of plain sinus X-rays.

The study compared the diagnostic yields of the history, rigid nasal endoscopy and plain sinus films with computed tomography. All the investigations were performed on the same day. The interobserver variability between consultant ENT surgeon, senior registrar and registrar were compared.

With heightened concern over the radiation exposure patients are receiving for medical investigations, the radiation exposure was determined for a selected group of patients. This study demonstrated that in the diagnosis of inflammatory sinonasal disease the clinical assessment correlated with the CT findings in over 90 per cent of cases. This accuracy was dependent on the experience of the clinician in using rigid nasal endoscopy. Interobserver variability ranged from 71 to 90.4 per cent in the correct diagnosis of underlying sinus disease. Close agreement was seen with the interpretation of CT scans. The concordance rate between plain films and CT scans was 87 per cent when reported by a consultant radiologist. This is in close agreement with previously reported studies. The average radiation exposure of coronal CT scanning was 218 times the dose for plain sinus X-rays.

Eighty-seven patients who were treated by laser mucotomy (L-mucotomy) of the inferior turbinates were followed-up for one year. Patients presented for laser surgery because of one of the three following symptoms: sneezing, rhinorrhoea, or nasal obstruction. All of them had had prior conservative or surgical treatments for their symptoms without improvement in their complaints and/or quality of life. L-mucotomy is a simple procedure performed under local anaesthesia on an ambulatory basis. A controlled amount of tissue from the inferior turbinates is ablated with improvement in the symptoms, as reported by the patients one year after laser surgery.

The procedure is easy to perform, there is no bleeding, it is painless and without complications, but it requires rather expensive surgical equipment.

There is a paucity of studies investigating middle ear pressures (MEPs) in patients with nasopharyngeal carcinoma (NPC). This paper prospectively examines MEPs in patients with nasopharyngeal carcinoma before and after radiotherapy and discusses their clinical significance. Newly diagnosed patients with nasopharyngeal carcinoma were studied before and at three to 12 months (mean 7.5 months) after radiotherapy. MEPs were measured by tympanometry. Thirty-three patients completed the study. The mean MEP before and after radiotherapy was −55.2 mm water(range −250 to 45 mm water) and −73.1 mm water (range −215 to 35 mm water) respectively. About two-thirds of assessable ears had an increase in negative MEPs after irradiation and the rest had less negative MEPs after irradiation. Those ears which developed post-irradiation middle ear effusions were found to have pre-irradiation negative middle ear pressures of at least −45 mm water. These findings provide possible explanations for some unexplained audiometric observations previously made in patients with nasopharyngeal carcinoma after radiotherapy. Tympanometry before radiotherapy may prove to be useful in identifying ears with a high risk of developing post-irradiation middle ear effusion.

The position of the jugular bulb (JB) is of great clinical significance to the otologist. A high and laterally situated jugular bulb may pose difficulties when dealing with the middle ear while a high and medially sited jugular bulb can create problems in neuro-otological surgery. This paper aims to study possible racial differences in the position of the jugular bulb.

Fine-cut computed tomogram (CT) scans of temporal bones (in the axial plane) of 34 Caucasians and 34 Chinese were studied. The position of the jugular bulb was determined with reference to the midpoint of the lumen at the inferior limit of the cochlea (mpC).

Of the 60 Caucasian and 58 Chinese temporal bones with identifiable jugular bulbs, 33 jugular bulbs of the Caucasian (55 percent) and 34 jugular bulbs of the Chinese (58.6 percent) were at the same height or higher than the mpC (p = 0.2; chi-squared test). The midpoint of the jugular bulb was 8.67 ± 1.73 and 8.61 ± 2.49 mm posterior to the mpC for the Caucasian and Chinese respectively (p = 0.2; t-test). However, the midpoint of the jugular bulb of eight Caucasian (24.2 percent) and 22 Chinese (64.7 percent) were medial to the mpC (p<0.001; chi-squared test).

Race does not influence the height of the jugular bulb nor its position in the sagittal plane but can influence whether a high jugular bulb is medially or laterally situated.

A retrospective study was undertaken to assess the outcome of 19 consecutive patients, who underwent endolaryngeal resection with a CO2-laser for laryngeal carcinomas. Sixteen of these patients had recurrences after primary curative radiotherapy. Seventeen of the patients had a curative operation carried out. So far, four CO2-laser treatment failures have been observed (median observation time 35 months). None of the patients needed tracheostomy in connection with the operation. Voice quality was in all cases acceptable.

It is recommended, that small recurrences (after radiotherapy of laryngeal squamous cell carcinomas)should be considered for a partial laryngectomy with the aid of a laser.

The aetiology of Menière's disease (MD) remains obscure, but is likely to be multifactorial, one of the factors being a genetic predisposition. Forty-one families with more than one living member with MD were ascertained and affected and normal relations examined. Blood was collected and DNA extracted and stored. In these families the mode of inheritance is autosomal dominant, the penetrance of the mutation being about 60 per cent. Some of the family members exhibit a partial syndrome, vestibular symptoms predominating. Sporadic and familial cases exhibit the same clinical features. The striking finding is the phenomenon of anticipation, whereby with successive generations there is an earlier age of onset and a tendency to more severe manifestation. The inference, considering that the cells which regulate endolymph are of neuroectodermal origin, is that, like other neurodegenerative disorders which show anticipation, MD manifestation is likely to be related to trinucloetide expansion within a gene.

The Charing Cross computerized tomography protocol for imaging the paranasal sinuses uses 2 mm thick slices with table increments of 8 mm: 10 to 12 coronal and two axial images are produced. These provide the necessary information for diagnosis of chronic rhinosinusitis and safe endoscopic sinus surgery. The technique is quicker and cheaper than previously described protocols and exposes the lens of the eye to less radiation

Following a lesion in the vestibylar system visual, proprioceptive and residual vestibular information is integrated by the brain, to enable a patient ot attain equilibrium. The basis of vestibular rehabilitation is to encourage these adaptive and compensatory mechanisms. Another form of rehabilitation is to provide some form of mechanical aid, and walking sticks are often used for this purpose in patients with balance disorders.

There are no reported studies objectively assessing the use of walking sticks in patients with balance disorders. In this study we used the Sway Weigh balance patform (Raymar) to determine the efficacy of a walking stick in 25 patients with peripheral vistibular balance disorders. Patience were tested with their eyes opened and eyes closed whilst they were standing on a flat surface and on an air-filled bed (to alter limb proprioeption) on the Sway Weigh balance platform. All the tests were carried out with, and without, a walking stick. The results demonstrate that a walking stick significantly reduces lateral body sway in patients with peripheral vestibular balance disorders.

Numerous studies have postulated the possible benefit of corticosteroids on olfaction in patients with nasal/sinus disease. Twenty-nine patients with bilateral nasal polyps were included in our study using strict selection criteria to reduce other aetiologies of olfactory dysfunction. The University of Pennsylvania Smell Identification Test (UPSIT) was performed pre-operatively on the right and left nostrils separately. Following intranasal polypectomy the patients received a six-week course of beclomethasone nasal spray (Beconase) to one nostril only, with the other acting as a control. The UPSIT scores were again obtained for each nostril separately. Wilcoxon Signed Rank test revealed no statistically significant difference in UPSIT scores between treated and untreated nostrils (p = 0.31; power 70 per cent; ES = 0.47). We conclude that topical beclomethasone does not improve olfaction following nasal polypectomy.

Between 1991 and 1993, 13 children (25 hearing ears) underwent recordings of the auditory brain stem response (ABR) under a general anaesthetic. The anaesthetic technique was similar for each child. Fourteen of these ears had fluid aspirated after myringotomy with insertion of grommets prior to the auditory brain stem response investigation. On subsequent hearing assessment six of these 14 ears (43 per cent) showed clear evidence of a threshold shift of 15 dB or greater. Eleven ears had either dry myringotomies or did not have a myringotomy prior to ABR and none of these showed evidence of a temporary threshold shift. Using Fisher's Exact probability test this difference is significant (p = 0.034). We feel it is important to report these observations so that unexpected high ABR thresholds following aspiration of glue are interpreted with caution.

A total of 687 school children, aged six to 15 years, were examined clinically, radiologically and audiometrically. Lateral radiological examination of paranasal sinuses was carried out in 663 (96.5 per cent) children for evaluation of the size of adenoids. The size of the soft tissue shadow (adenoids) was assessed as normal or large. It was large in 133 (25 per cent) children, three times more frequently in seven-year-old than in 14-year-old children. The occurrence of adenoidal symptoms (blocked nose, mouth breathing, snoring, snuffling or rhinitis) varied from 14.3 to 30.1 per cent in children with large adenoids compared to 7 to 9.8 per cent in children with normal adenoids. Logistic regression analysis revealed that only recurrent snoring and the child's age were significantly associated with radiologically large adenoids. The hearing thresholds were 1.1 to 4.2 dB poorer and mean middle ear pressure values were 60 to 70 mmH2O lower in children with large adenoids compared to those with normal size adenoids. Large adenoids have an influence on the hearing level of a child, but probably via the negative middle ear pressure.

It has been proposed that sleep nasendoscopy (SN) will improve the success rate of the uvulopalatopharyngoplasty operation by identifying those patients with palatal snoring. The aim of this study was to test the efficacy of SN in the management of snorers who do not have obstructive sleep apnoea. This study compared a group of 26 snorers managed without SN (group A) to a group of 27 snorers managed with SN (group B). The post-operative results of group A were 61 per cent cured, 27 per cent better and 8 per cent unchanged. Group B results were 76 per cent cured, 19 per cent better and 5 per cent unchanged. However, if patients with only palatal snoring had surgery, the results for group B would have been 94 per cent cured, 6 per cent better and 0 per cent unchanged (95 per cent C.I. of difference +0.14,+0.54, p = 0.017). The results confirm the predictive power of SN in identifying success following uvulopalatopharyngoplasty. A simple grading system is suggested to aid in treatment planning. Patients are divided into three categories on SN: palatal snorers, mixed snorers and non-palatal (tongue base) snorers. It is proposed that uvulopalatopharyngoplasty may cure palatal snorers but mixed snorers will need additional therapies to eliminate their snoring although uvulopalatopharyngoplasty may improve the symptoms.

Cryotherapy is an established method of treating hypertrophic obstructive inferior turbinates. The long-term effectiveness of the technique is assessed in this study, using the need for alternative nasal surgery as an objective way of distinguishing success from failure. Over 50 per cent of patients with obstructive symptoms, including those with minor septal deviation or allergy derived lasting benefit from the technique. Cryotherapy is an effective means of treating nasal obstruction due to mucosal hypertrophy of the turbinates and may replace the need for more radical surgery.

The place of conservative treatment in sinogenic orbital complications has not been fully explained in the literature. The question that remains unresolved is – at which stage of the disease is surgery indicated?

A study was undertaken in 240 patients with sinogenic orbital complications, to determine this. The patients were divided into three groups according to the stage of the disease as determined clinically: Group 1 (52 patients) with early stage disease, as detected by cellulitis only; Group 2 (76 patients) with intermediate stage, as detected by periorbital cellulitis and proptosis, but with full range of eye movement and unaltered vision: Group 3 (122 patients) with late stage disease, as detected by periorbital cellulitis and gross proptosis. with limitation of eye movement and altered vision.

Group I and Group 2 patients were treated conservatively, with intravenous antibiotics and antral lavage. Group 3 patients were treated with intravenous antibiotics and surgery. External frontoethmoidectomy was performed in 31 (bilateral in two), ethmoidectomy in 91 (bilateral in five), sphenoidectomy in 15 and bilateral antral washout in all (122 patients). There was 100 per cent success with conservative treatment in Group 1 patients, whilst in Group 2 there was 98.6 per cent failure. The 75 patients in whom conservative treatment failed were successfully treated with surgery: frontoethmoidectomy was performed in 66 and ethmoidectomy in nine. In Group 3 patients, 100 per cent success was achieved with intravenous antibiotics and surgery.

Sinogenic orbital complications can be treated conservatively and surgically, depending on the stage of the disease on presentation. Conservative treatment is only suitable for early complications, i.e. patients with periorbital cellulitis only. For disease beyond this stage i.e. intermediate and late stage disease, surgery is the treatment of choice.

This study includes 155 patients with T1–4N0 carcinoma of the postcricoid region seen between 1963 and 1993. Sixty-seven were treated by primary surgery, 50 by primary irradiation therapy, 36 were unsuitable for curative treatment and two patients were lost to follow-up. Reasons for deciding against curative therapy were: advanced age, poor general condition and advanced disease at the primary site. This study included only those patients who had no neck node metastases at presentation.

Patients receiving surgery tended to be in better general physical condition and tended to have more advanced disease than those treated by irradiation in this series. The tumour-specific five-year survival rate for those treated by surgery was 43 per cent (95 per cent confidence interval (CI) 23–60 per cent). For those patients treated by irradiation the five-year survival rate was 48 per cent (95 per cent CI 27–66 per cent) and for those receiving no treatment the median survival rate was three months (95 per cent CI two-six months). The observed survival for the surgery group was only 18 per cent and for the radiotherapy group 25 per cent at five years.

Multiple logistic regression showed no significant difference in proportions of host and tumour factors between the group receiving radiotherapy and the group receiving surgery. Recurrence at the primary site and the appearance of neck node metastases were not predicted by any host or tumour factor.

Twenty-one patients out of 67 receiving primary surgery had recurrence at the primary site compared with 26 patients out of 50 receiving primary irradiation. Neck node metastases occurred in 16 out of 67 patients receiving surgery and in eight out of 50 receiving radiotherapy. The difference was statistically significant for recurrence at the primary site (X21 = 4.261; p = 0.039) but not significant for neck node metastases (X 21= 0.661;p = 0.416). The data were further analysed using Cox's proportional hazards model for survival and no host or tumour factors were found to be predictive of eventual outcome apart from poorly differentiated histology. This adversely affected survival (X21 = 6.4444; p = 0.011). If patients not treated were included in the model, treatment became a significant factor in improving the survival (X21 = 4.4197; p = 0.034).

Radiotherapy appears to be at least as good as surgery for treating patients with an early carcinoma of the postcricoid region. We would recommend radiotherapy is used in patients with no detectable neck node metastases and in tumours <5 cm long. The complication rate from radiotherapy was reduced when compared with that of surgery.

Septal surgery (submucous resection and septoplasty) has been performed as a day-case procedure routinely under general anaesthesia and local anaesthesia with sedation at the Ipswich Hospitalsince 1992. The outcome of the day-case septal surgery over a period of 18 months has been audited. A total of 95 cases were operated on of which 48 were under general anaesthesia (GA) and 47 under local anaesthesia (LA) with sedation using midazolam intravenously. The bleeding rate and overnight admission rate were 10.5 and 11.4 percent respectively. The bleeding rate was the same in both GA and LA groups. The combination of local anaesthesia and sedation has been foundto be safe, effective and acceptable to patients. It is concluded that septal surgery is suitable as a day procedure and that local anaesthesia combined with sedation has a definite place ifcarried out properly.

There have been many attempts at identifying substances and describing methods that would assist the surgeon and be of benefit to the patient undergoing a tonsillectomy. The use of bismuth subgallate as a haemostatic adjunct during tonsillectomy has only been described previously in retrospective studies. A controlled prospective randomized trial of 100 paediatric patients, in which 50 patients had a tonsillectomy performed using bismuth subgallate as a haemostatic agent and in which the remainder did not have any associated haemostatic substance, is presented here.

Data on 72 patients was analysed, 39 patients belonging to the bismuth subgallate group and the remaining 33 to the control group. The time for haemostasis was three to 18 (mean 7.8) minutes in the bismuth group. It was four to 16 (mean 9.9) minutes in the non-bismuth group. These figures are statistically significant.

The range of ties used in the bismuth group was none to three (mean 1.5) ties and one to seven (mean 3.4) ties in the non-bismuth group. These figures are also statistically significant. The remainder of the recorded parameters did not differ significantly.

It was found that bismuth subgallate/adrenaline paste decreases operating time by significantly reducing the haemostasis time and the number of ties required but does not decrease post-operative morbidity.

The introduction of a topically active H1-antihistamine nasal spray Azelastine, has given an extra dimension in the management of allergic rhinits. The drug acts rapidly and avoids the sustemic adverse effects of antihistimines. An objective prospective study was performed to detect the effect of Azelastine nasal spray on nasal airway resistance. Twelve healthy adult volunteers with no rhinological problems were included in the study. Nasal cavites were sprayed with 280 μg (two puffs) of Azelastine nasal spray and the nasal airway resistance was measured with anterior rhinomanometry at intervals of 30 minutes for up to two hours. Our study has shown statistically significant increase in the total nasal airway resistance following the use orf Azelastine nasal spray in the absence of a subjective change in nasal airway resistance. There are substances when inhaled which can cause subjective improvement in nasal airway patency without changing the measured nasal airway resistance. However this medication gives no subjective change in nasal airway patency in spite of increasing nasal airway resistance.

Sinus-induced intracranial sepsis can represent a genuine medical and surgical emergency. We review 12 cases presenting to our hospitals over a five-year period. Nine were male and three were female with an age range of 16 to 74 years (mean 35.5 years). Four patients had their sinusitis diagnosed prior to admission and eight did not. Nine patients had bilateral sinus disease, the most common sinus involved was the frontal followed by the ethmoid, maxillary and sphenoid. Neurosurgical drainage was via a craniotomy in seven cases and burr hole in three. Nine patients underwent sinus surgery and three did not. Of the nine who had sinus surgery three had frontal drainage, four fronto-ethmoidal and two transsphenoidal drainage. The most common organism was Streptococcus milleri. Our series confirms that sinus-induced intracranial sepsis is a serious problem needing early diagnosis and aggressive treatment. We would recommend a high index of suspicion of sinusitis in patients with intracranial infection.