Following radiation treatment for carcinoma of the larynx it may be very difficult to differentiate between persistent or recurrent tumour and severe radiation effects particularly chondroradionecrosis. Despite repeated negative biopsy it may be necessary to perform total laryngectomy where the concern about persistent cancer remains and the larynx is non-functioning. We report nine cases presenting as chondroradionecrosis over a five-year period. Two patients settled on medical treatment. Of seven patients treated with laryngectomy the histology on two revealed residual or recurrent carcinoma.

We outline the dilemmas in diagnosis and propose management strategies to deal with this condition including recommendations for prevention and treatment.

The relationship between upper and lower respiratory tract infections has been demonstrated previously, although the effect of chronic infection of One tract on the other has not been well studied. This work analyses the broncho-alveolar lavage fluid of patients with chronic purulent rhino-sinusitis and reveals and increase in the neutrophil nitro-blue tetrazolium dye reduction test positivity provides evidence for increased phagocutosis to compensate for the increased contamination of the lower respiratory tract.

We present four cases where a brow incision was indicated for access to the anterior skull base and paranasal sinuses. We discuss the indications for this incision and present a modification of the incision, to improve cosmesis over the nasion.

The alpha-amylase activity in tracheobronchial secretions of 16 consecutive patients with a total laryngectomy was studied. None of these patients had a tracheopharyngeal fistula or pulmonary disorder which might affect the amylase activity. This study proves the presence of amylase in tracheobronchial secretions of laryngectomized patients with a normal lung at a level between x and y and the quantitative analysis of the amylase activity is discussed. The relevance of investigating laryngectomy patients is because of the nature of the surgery the lower respiratory tract is permanently and physically isolated from any other source of salivary amylase. No similar study of the analysis of amylase in normal lung tissue had been reported before.

This information may be of value in order to detect salivary aspiration in patients with a tracheostomy or endotracheal intubation if the level in the aspirate is in the order of a-b times greater than that found in normal tracheobronchial secretions, (x = 35 and y = 1125 i.u./l; a = 31.8 and b = 628.6 i.u./l).

Non-tuberculous mycobacterial (NTM) infections in children commonly present as cervicofacial masses. The importance of early diagnosis is in the exclusion of infection requiring treatment, particularly tuberculosis and the rare case of malignancy. Five children with NTM presenting with salivary gland masses illustrate the value of skin testing with new tuberculins and the place of fine-needle aspiration cytology in the investigation of these infections.

Four children who were skin tested reacted specifically to one of the new tuberculins, two indicating infection with Mycobacterium malmoense, confirmed by culture, the others responding to tuberculins from M. scrofulaceum and M. avium-intracellulare, neither having a positive culture. The one case not skin tested produced M. avium-intracellulare on culture.

All five patients were managed conservatively. The place for conservative management when the facial nerve is at risk and extensive skin excision is indicated are discussed.

A prospective study of all foreign body complaints presenting through our Accident and Emergency Department was conducted in a population where the condition is endemic. All patients were managed by otolaryngologists. Six hundred and eight patients were attended to yielding 179 foreign bodies. Making use of modern equipment and a practical approach, the requirement for examination under general anaesthesia was 6.3 per cent. In this series there was a complication rate of 0.5 per cent.

A reproducible method for the estimation of volumes of small tissue samples was needed to allow comparison of the biological activity of tissue explants and to relate symptom improvement to procedures such as adenoidectomy or polypectomy. Holdens apparatus, which utilizes fluid displacement between two chambers, was compared to displacement in a 20 ml syringe. Two observers made four readings each on 20 tissue samples (range 0.37 to 4.70 ml) using both methods for comparison.

A two-way analysis of variance for replicated data gave an F ratio of 0.6885 (df 19; p>0.8) for Holden's apparatus, and an F ratio of 1.4307 (df 19; p>0.1) for the 20 ml syringe. The standard error of the mean for repeated readings on the same sample by an observer was 0.001 ml for Holden's apparatus and 0.014 ml for the syringe method. For accurate estimation of small tissue volumes within 0.01 ml we recommend Holden's apparatus.

Blom—Singer valve prosthesis is an increasingly popular technique for voice rehabilitation in alaryngeal patients. Although primary voice puncture is being practised, the creation of the tracheo-oesophageal fistula is performed in the majority of patients as a secondary procedure.

We describe a technique of secondary tracheo-oesophageal puncture using the flexible endoscope which can be performed under local anaesthetic and sedation. The technique overcomes the difficulty of passing a rigid oesophagoscope or forceps to the level of the tracheostome in a scarred and irradiated neck. The new technique also obviates the need for general anaesthesia.

We have successfully used the technique in three patients.

Fifty-one patients who presented with anterior cervical or throat pain, without apparent cause, were selected for study at the ENT outpatient department from January 1987 to January 1992. Their clinical symptoms, probable aetiologies and treatment were studied. The most common diagnosis was hyoid syndrome, followed by thyroid cartilage syndrome and cricoid cartilage syndrome. These last two syndromes have not been previously reported because they were coined in Ramathibodi Hospital for patients who had similar clinical patterns localized to the thyroid and cricoid cartilages respectively. Treatment using intralesional triamcinolone acetonide injection was effective in all cases. There was no recurrence after one-five years follow-up.

This paper presents the results of a national confidential comparative audit of stapedectomy: 185 operations by 28 consultants over a two-year period were retrospectively analysed. This included 10 revision procedures. Small fenestra stapedectomies accounted for 63 per cent of the total. Thirty-nine per cent of consultants operated on the second ear. Of the 168 stapedectomies in which the hearing change was known at six months, 87 per cent achieved improved hearing, eight per cent had no change and five per cent were worse. The overall complication rate was 30 per cent with a ‘dead ear’ rate of two per cent.

A new multi-transducer probe system for measuring pharyngeal pressures was compared with an established open catheter system. Pharyngeal pressure measurements were made at the same time, and site, in subjects awake, at unmodified and with artificially increased nasal airway resistances, and during sleep documented by polysomnography. The two systems yielded almostidentical results. It is anticipated that the multi-transducer probe system will prove of clinical value.

WR 2721 (ethiofos) protects against the toxic effects of the heavy metal compound cisplatin. which is used in the treatment of solid tumours. In a Phase I protocol designed to determine the maximum dose of WR 2721 which could be tolerated when administered in combination with cisplatin and radiation therapy to patients with cervical carcinoma. 11 patients were evaluated by audiologic testing before and after cisplatin WR 2721 administration in an attempt to identify the degree of ototoxicity. Forty-five per cent were noted to have significant hearing threshold changes. predominantly in the high frequencies. There were no significant changes in the speech frequencies in this series. This contrasts with the greater degrees of ototoxicity observed in controls treated in the same way who received cisplatin without WR 2721 protection.

A simply manufactured whistle for the use of laryngectomees is described. It is useful for attracting attention in an emergency.

Fifty-six total laryngectomy cases are presented with special reference to post-operative fistula formation. All these patients were operated upon at the Department of Otorhinolaryngology at the Bnai Zion Medical Centre by one surgeon over a 16-year period, from 1976–1992. The incidence of fistula was 12.5 percent. This paper could not verify reports that any specific factors were significantly related to fistula formation, although there was a preponderance of fistulas in patients presenting with late stage tumours. No relationship was found with rate of infection, age, or between previous neck irradiation (ranging from 5500 to 7000 cGy) and fistula formation in the patient population.

If a fistula occurs, the administration of oral solid food keeping the nasogastric tube in place for administration of fluids may lead to spontaneous closure of the fistula, with no need for secondary surgical repair.

Since its introduction in the 1960's the injection of Teflon into a paralysed vocal fold has become a standard treatment in laryngology. Although in recent years alternative treatments have been suggested, such as the injection of collagen or autogenous fat (Mikaelian et al., 1991), re-innervation procedures and thyroplasty (Crumley, 1990), the use of Teflon is still widespread (Rontal and Rontal, 1991; Dedo, 1992). Various instruments have been developed for the application of Teflon paste and these take the form of a gun-like syringe with a ratchet mechanism. For a number of years we have injected Teflon using a needle marketed for internal jugular vein cannulation along with a plastic 1 ml syringe thus making substantial savings to our department in terms of both time and cost.

A simple, safe and effective procedure of improving the diagnostic accuracy of nasopharyngoscopy is described. It is most useful for the exposure of the hypopharynx, especially in the elderly patient.

A report of the first 100 patients treated in the multidisciplinary Dysphagia Clinic in Salisbury District Hospital is presented. It was established in January 1992 and involves the Departments of ENT Surgery, Clinical Radiology and Speech and Language Therapy. In the first 18 months, 100 patients have been assessed and treated. These included 46 males and 54 females, between the ages of four and 93 years. Neurological problems accounted for 39 cases. The management comprised the assessment clinic, videofluoroscopy in 83 patients, and finally the appropriate treatment. Forty-four patients were treated primarily by swallowing therapy. Seventy-three patients showed complete recovery, resolution of their symptoms or did not require treatment. Two patients were still under treatment at the time of writing this paper.

Teflon injection has been widely used for the treatment of unilateral vocal fold paralysis. Complications are few and infrequent. Overinjection and Teflon granuloma are the two commonest problems encountered. Treating such complications and restoring vocal quality is widely regarded as difficult. Endoscopic transmucosal excision of the excess Teflon and/or granuloma has not been successful in improving phonatory quality. Cordectomy is proposed as an alternative surgical approach for managing both the convex vocal fold and Teflon granuloma after injection.

We describe a simple and objective practical method for the detection of recovery from facial paralysis by multiple photographic assessments. The photographs are printed as life-size transparencies representing maximal effort. Each time the patient attends for review the new transparency is overlapped on the previous one and the difference can be detected easily. The prints are filed with the patient's notes for future reference. To achieve this system a specific photographic protocol is mandatory in order to avoid technical artefacts. We believe that this system avoids many of the complexities of other grading systems and is very suitable for use at outpatient follow-up.

This study was undertaken to assess any salivary aspiration in seriously ill patients with tracheostomies in an Intensive Care Unit setting. The alpha-amylase activity in the tracheostomies in an Intensive Care Unit setting. The alpha-amylase activity in the tracheobronchial secretions of 15 such patients were analysed to evaluate the incidence of salivary aspiration. None of the patients had clinical or radiological evidence of lung disorder at the time of the commencement of the study. Six out of 15 patients showed very high levels of alpha-amylase activity in their tracheobronchial secretions on Day 3 and all six subsequently developed severe chest infections. The other nine patients showed a low level of amylase activity in their secretions. Two patients in the latter group developed severe pulmonary disease. This study demonstrates that a high level of alpha-amylase activity in the tracheobronchial secretions of tracheotomized, ventilated patients indicates that salivary aspiration may be taking place, and further suggests that progressively increasing levels may indicate the likelihood of a major pulmonary complication developing.