The arrangement and number of intralaryngeal ganglia and their neurons in five mammals (dog, rat, guinea pig, rabbit and cat) were examined morphologically. Intralaryngeal ganglions were situated mainly in branches of the internal branch of superior laryngeal nerve (Int-SLN), dorsal and/or dorsolateral to the posterior cricoarytenoid muscle, and around the inferior laryngeal nerve in dogs, rats, guinea pigs and cats, but they were identified at the branching out point ofthe Int-SLN exclusively in rabbits. The ganglion of each animal was spindle-shaped, with a surrounding fibrous capsule, and it contained many ganglionic neurons, vessels and connective tissue cells. The ganglionic neuron was oval-shaped and had a round nucleus: the diameter was smaller (20–25 μm) in the rat than in the other mammals (25–30 μm). More than 80 percent of ganglionic neurons occurred in the supraglottis of all the animals except the rat. In the rat, this value was approximately 40 percent.

The Provox™ voice prosthesis has been used in our department since September 1992 for postlaryngectomy voice rehabilitation. This prosthesis is an indwelling low-resistance tracheoesophageal valve. The cohort consisted of 28 laryngectomees with a mean follow-up time of 352 days. The average valve life before failure was 148 days. Speech intelligibility of 85 per cent was achieved for complete sentences. No major surgical problems were associated with the valve insertion or its use. Replacement of the prosthesis as an outpatient procedure was accomplished without difficulty.

We report the results of a prospective pilot study of 54 adult patients undergoing tonsillectomy using the KTP-532 laser, designed to assess whether the technique would facilitate day-case adult tonsillectomy. Subjective and objective assessment at six hours post-operatively showed that only 43 per cent could, in our judgement, have been discharged at this interval. Furthermore, the overall complication rate was 31 per cent with a secondary haemorrhage rate of 19 per cent. We conclude that KTP-532 laser tonsillectomy as performed in this pilot study compares unfavourably with dissection tonsillectomy and we discuss possible reasons for this.

Three hundred and seventeen patients with hypopharyngeal tumours presented at Assuit University Hospital and were studied retrospectively with regard to sex and age incidence. Postericoid tumours form the majority (50.1 per cent) followed by pyriform fossa tumours (26.5 per cent) and finally posterior pharyngeal wall tumours (23.4 per cent). Men form the majority (211 out of 317, i.e. 69.7 per cent). The age incidence shows two peaks at 31–35 years and 56–60 years. The first peak is formed mainly of women while the second peak is formed mainly of men.

The excellent visualization and minimally invasive surgical technique of endoscopic sinus surgery was applied to the management of 40 patients with sellar lesions. Endoscopic management of sellar lesions offers, not only the advantage of improved visualization, but also magnification, and a panoramic perspective of the important relationships of the sella turcica. In the past year, we have managed 40 subjects with sellar lesions, endoscopically: 38 patients had pituitary adenomas and two a craniopharyngioma.

At our hospital, the endoscope has replaced the operating microscope for surgery for pituitary adenomas and other sellar lesions. The endoscopic approach to the sphenoid sinus and the sella is performed by an ENT surgeon and the ablative surgery performed by a neurosurgeon.

Our experiences, using the endoscope to perform surgery on sellar and parasellar lesions, are reported and the advantages, over the operating microscope, which is traditionally used are discussed. The technique for endoscopic management of sellar lesions is described.

Pharyngeal perforation is an uncommon injury in children. Most reported cases to date have been secondary to instrumentation or penetrating wounds. Laceration to the pharyngeal wall may introduce air, secretions and bacteria into the parapharyngeal space and mediastinum and consequently has potentially life-threatening sequelae. The management of these injuries is controversial. We present a series of four children who suffered pharyngeal trauma, accidentally and otherwise, and discuss their management.

We recommend a high index of suspicion of pharyngeal injury in all cases of oropharyngeal trauma and overnight admission to hospital for observation until an accurate diagnosis has been established. Non- accidental injury of the child must be seriously considered in all cases.

Larynges from 24 victims of Sudden Infant Death Syndrome (.S.I.D.S.) and 10 controls, with ages ranging from two days to 24 weeks in the controls and from two toN 16 weeks in theS.1.D.S. victims, were transversely, step-serially sectioned and then stained to show acid, neutral and mixed mucus glycoproteins

The proportion of sulphated mucus glycoprotein and sialylated mucus glycoprotein to total acid mucus glycoprotein was determined by the use of various staining techniques and a comparison was made for each type between S.I.D.S. and controls. The differences were significant with a mean of 27 per cent in the controls compared to 59 per cent in the S.I.D.S. for sulphomucin (difference 32 per cent; standard error of difference 6 per cent; p<0.01) and 73 per cent in the controls compared to 41 per cent in the S.I.D.S. larynges (difference 32 per cent; standard error of difference six per cent; p<0.01) for sialomucin. The results suggest that sulphated mucus glycoprotein is secreted in excess in some victims of Sudden Infant Death Syndrome.

To demonstrate morphologically the neurons participating in the4aryngeal reflex, Fos-expression, activated with tactile stimulation of the laryngeal vestibulum, was mapped in the cat's lower brain stem utilizing immunohistochemistry. In the stimulation group, many Fos-immunoreactive (ir) neurons were recognized in the nucleus tractus solitarii (NTS) from the level of the most rostral portion of the dorsal motor nucleus of the vagus to the level of the most caudal portion of the inferior olivary nucleus (IO), and in the nucleus ambiguus (NA) from the level of the rostral end of the hypoglossal nucleus to the level of the caudal end of the IO, bilaterally. While some Fos-ir cells were found in the spinal nucleus of the trigeminus, they were also found in the reticular nuclei bilaterally. In the control group, Fos-ir cells were distinctly fewer in number than those in the stimulation group. The results suggested that in the brain stem, the laryngeal reflex pathways have more than two synaptic relays through the interneurons in between the NTS and the NA.

A study to investigate the value and reliability of clinical photographs as teaching aids was undertaken. Twenty colour photographs were taken using the StarMed video-otoscopic system. The pictures, which were a mixture of normal and abnormal ears, were shown to 21 experienced otolaryngologists from the UK and Canada. These clinicians were asked to identify the abnormality if any.

The median score for correctly identified pictures was 15 (range 12–18). This score was identical for both the UK and Canadian subgroups. Although the abnormalities were consistently well recognized with an average correct identification rate of 90 per cent (range 67–100 per cent), the ‘normals’ were recognized significantly less well at only 41 per cent (range 5–71 per cent) (chi-squared = 110.6; 1 df; p<0.001).

This result is probably due to failure of the camera to capture the huge variation and subtleties in the range of normal, and the clinicians' natural inclination to identify pathology, when in doubt. We would conclude that as long as this failing is recognized, clinical photographs, and specifically those from the video-otoscope, represent a useful and reliable teaching tool.

Polysomnography is currently used for diagnosis, evaluation and selection of therapy in patients with obstructive sleep apnoea (OSA), but clinically successful uvulopalatopharyngoplasty (UPPP) is not necessarily reflected by post-operative improvement of polysomnographic recordings. Post-operative polysomnography may suggest deterioration of pre-existing OSA or, in snorers, de-novo precipitation of OSA. Thus, if polysomnography is a reliable indicator of OSA, then OSA may be a post-operative risk of UPPP. The aims of our study were: (i) to assess the possible deleterious effect of UPPP on sleep patterns; (ii) to further define the role of cardioisotope scanning in the evaluation of OSA; (iii) to assess the reliability of polysomnography given the clinical and cardioisotope scan findings. Symptoms, polysomnography and radionuclide ventriculography were prospectively compared pre- and post-operatively in 41 patients undergoing UPPP. In 12 patients (29 per cent), there were disparate results between pre- or post-operative polysomnography and the clinical and/or radionuclide ventriculography, as follows: In four of 16 patients with abnormal pre-operative ventricular performance, there was pre-operative symptomatology of severe OSA and a bedmate's reports of apnoeic episodes. This was in contrast to normal or near normal sleep apnoea recordings. In eight patients, post-operative improvement of symptoms was reported, despite deterioration of post-operative polysomnographic recordings. In these patients the post-operative improvement of symptoms was also reflected by improved ventricular performance. Worsening of ventricular performance was not demonstrated in any patient. In conclusion, UPPP does not induce OSA. Polysomnography may underestimate or even misdiagnose cases of OSA. The diagnostic importance of patient symptomatology should be stressed particularly in those patients with only mildly abnormal or even completely normal sleep studies. A combination of polysomnographic and cardiovascular evaluation in patients with symptomatology consistent with OSA is recommended.

The evolution of voice and speech parameters following supracricoid partial laryngectomy (SCPL) has been evaluated in a prospective fashion over an 18-month period of time in three patients using the Computerized Speech Lab (from Kay Elemetrics). Preliminary results demonstrate the post-operative instability of voice parameters. Speech parameters remain stable with time. Our data stresses that voice is attained post-operatively even if one arytenoid cartilage is disarticulated at time of resection.

Forty-one adults were entered into a prospective study to investigate the pattern of pain over 10 days after elective dissection tonsillectomy. The severity of pain was scored by the patient on a visual analogue scale. The results confirm that tonsillectomy is a very painful experience and the provision of adequate analgesia is of paramount importance, especially if day-case tonsillectomy is performed.

The management of acute otitis externa is variable, despite the fact that it is one of the commonest otological emergencies. We formed the impression that many patients attending our ENT casualty clinic with otitis externa were being treated and followed up inappropriately. To test this hypothesis we performed a retrospective pilot study on our practice which revealed a lack of uniformity in the management and follow-up of these patients. And as a result of this, guidelines were developed to improve our management of otitis externa and decrease the number of unnecessary review visits. Our practice was then audited prospectively over a six-month period with the guidelines in place. An improvement in the overall management and a rationalization of follow-up for otitis externa was seen by applying basic audit principles to this common clinical problem.

The incidence, severity and pattern of post-intubation laryngotracheal sequelae in a 12 bed multidisciplinary intensive care unit (ICU) were assessed in this prospective study. One-hundred and fifty consecutive patients requiring intubation for more than 24 hours for various indications were studied. Evaluation of the larynx and trachea was done using a fibreoptic bronchoscope introduced through the endotracheal tube prior to elective extubation. Rigid bronchoscopy and direct laryngoscopy were performed in very small children and adults requiring tracheostomy. One-hundred and thirty-one (87.6 per cent) patients had visible laryngeal pathology in the immediate post-extubation period. Thirteen (8.6 per cent) had long term sequelae. A high incidence of long term sequelae was noted in patients with seizures (25 per cent) followed by patients with head injury (19 per cent). Steroid therapy failed to offer any significant protection but resulted in doubling of pulmonary sepsis. A grading system was adopted to classify acute laryngotracheal injury and a significant correlation was found between the presence of slough in the immediate post-extubation period and subsequent development of long term sequelae. There was also a significant correlation between a deeper insertion of the endotracheal tube and development subsequently of long term sequelae. The significance of these findings is discussed.

We reviewed 21 patients who underwent salvage treatment after a biopsy of proven locally recurrent carcinoma of the oropharynx. Two of these patients underwent a second salvage treatment after failure of the first. Treatment was performed with Ir192 interstitial implant in 17 cases (13 rT1 and 4 rT2); by surgery in five cases (3 rT1, 1 rT2, 1 rTx), including two patients who had relapsed after salvage treatment with Ir192 implant; and by hyperfractionated external beam irradiation plus concomitant Tegafur chemotherapy in one case (rT3).

The primary tumour was controlled in four of the 17 cases (23 percent) treated with Ir192 implant. Of these four patients, two remained disease-free 42 and 59 months after treatment, one died of nodal metastases eight months after treatment and another of distant metastases 19 months after treatment. Four of the five cases (80 per cent) treated with surgery, including two patients who relapsed after salvage brachytherapy, remained free from local, regional and distant relapse 21, 25, 31 and 56 months after treatment.

Photodynamic therapy (PDT) is a new and promising treatment modality for the treatment of malignant disease. This paper reports the preliminary experience of our group in the use of this therapy for the treatment of tumours arising in the head and neck. The majority of treatments in these cases have used a second generation systemic photosensitizer, meta-tetrahydroxyphenylchlorin (m-THPC). Two other cases were treated with either Photofrin 2 (a first generation systemic sensitizer) or with the topical photosensitizer, delta-aminolaevulinic acid (δ-ALA).

The initial results have been encouraging with good clinical responses evident in patients presenting with a variety of differing tumour types. We feel there is now sufficient evidence of the efficacy of this treatment to warrant a multicentre prospective study into the treatment of early head and neck cancer with PDT.

The expression of EGF/EGFR in 47 laryngeal surgical specimens from 44 patients was examined. PCNA analysis as an index of proliferating cells was also performed in 32 cases of laryngeal cancer, six cases of pre-cancerous lesions and nine cases of normal laryngeal mucosa. EGFR failed to show a significant correlation with tumour behaviour, but EGF expression was statistically significantly higher in malignant (SCC) than in non-malignant tissues (pre-cancerous and normal tissues) (p<0.006), and PCNA also showed a statistically significant difference (p<0.016) between the two. In malignant tissues when EGF/EGFR in ‘double-positive’ and ‘double-negative’ cases was compared, a statistically significant difference in PCNA was found (p<0.029); but this was not seen in non-malignant tissues. Our results support the hypothesis that an autocrine mechanism exists in laryngeal cancer and in this mechanism EGF may play an important role in tumour progression, especially when EGFR is overexpressed.

The usefulness of fine-needle aspiration cytology (FNAC) in the diagnosis and treatment of submandibular gland lesions is not well known. The 210 FNACs taken from submandibular gland lesions at Turku University Central Hospital between 1984 and 1991 were reviewed. Of these FNACs, 78 samples from primary lesions were confirmed histologically. Within this subset 10 FNACs were taken from benign neoplasms, all of which were correctly classified (sensitivity 100 per cent; specificity 88 percent). Only four of the 14 FNACs from malignant lesions were cytologically considered malignant (sensitivity 29 per cent). On the other hand, four FNACs raised a false suspicion of malignancy (specificity 6 per cent). Out of 54 FNACs from non-neoplastic lesions 43 were correct (sensitivity 80 per cent; specificity 63 per cent). There were 104 patients (123 FNACs), who had not been operated on: the follow-up of these patients shows that in this subset of FNACs there were no false malignant but probably one false benign finding (1 per cent). We conclude that FNAC can offer valuable information about the type of the submandibular gland lesion, but the decision of operative and other treatment should not be based solely on the result of FNAC.

Two patients presenting to the Central Military Hospital of Beirut with symptomatic lingual thyroid are reported. I131 thyroid scanning revealed the lingual thyroid to be the only functional thyroid tissue present in each patient. Subsequent CT scanning demonstrated the large size of these ectopic thyroids causing significant mechanical obstruction. These were excised transorally using a posterior midline tonguesplitting incision and reimplanted in the rectus abdominis muscles.

Details of this modified tongue-splitting surgical approach are described. A brief review of the literature concerning lingual thyroid and its surgical treatment is also presented as well as three patients operated on for lingual thyroid at the American University of Beirut Medical Centre between 1975 and 1994 using an external neck incision.

The risk for post-operative exposure of the carotid artery due to skin flap necrosis after major head and neck surgery is increased after previous radiation and in severely malnourished patients. Eight patients are described who presented with an (imminent) carotid exposure one to eight weeks after surgery. Pectoralis major myofascial flap transfer with split thickness skin graft coverage was used for protection of the carotid artery. All cases were managed successfully and healed primarily in two to four weeks with acceptable cosmesis. We advocate immediate treatment in the event of an exposed carotid (or imminent exposure) by a pectoralis major myofascial flap with split-thickness skin grafting.