The results of intraoperative monitoring of the electrocochleogram in patients undergoing surgery for poorly controlled Menières Disease are presented with particular reference to the masking effect of drill-generated noise. The results obtained using a direct, in vivo, electrophysiological method of assessment of drill-generated noise levels are compared with previous postmortem and intraoperative studies and the implications with respect to the likelihood of drill-generated noise induced acoustic trauma are discussed.

In the period from 1976 to 1988, 417 patients with supraglottic carcinoma of the larynx were treated by primary surgery.

Infiltration of the pre-epiglottic space was found in 11.99 per cent (50/417) of the patients. Carcinomas of the infrahyoid epiglottis spread to this space more frequently—14.24 per cent (44/309), than those of suprahyoid localization—5.55 per cent (6/108). Tumour invasion of the pre-epiglottic space is a relative contraindication for reconstructive surgery. Partial conservation operations were performed on 32 per cent (16/50) of patients with invasion of the pre-epiglottic space. The remaining patients had a total laryngectomy.

Infiltration of the paraglottic space intra-operatively was found in 2.4 per cent (10/417) of patients and all of these tumours were from the infrahyoid localization. Spread of tumours to this site is an indication for radical surgery and laryngectomy was performed on 80 per cent (8/10) of patients.

Considerable clinical success has been claimed for functional endoscopic sinus surgery but objective assessment of prospective series is lacking in the literature. Twenty-four patients with chronic rhino-sinusitis underwent assessment of symptoms by visual analogue scoring, nasomucociliary function by ciliary beat frequency, olfaction by qualitative olfactometry and nasal airway resistance by anterior rhinomanometry pre- and post-operatively. This demonstrated a significant improvement in all symptoms examined and in ciliary beat frequency. Quantitative olfaction and anterior rhinomanometry were not improved despite diminished symptoms. These results offer quantitative evidence of clinical improvement following functional endoscopic sinus surgery which supports the pathophysiological concepts on which the technique is based.

Four cases with Obstructive Sleep Apnoea Syndrome (OSAS) are presented. They consisted of two cases with TMJ ankylosis with micrognathia, one case with Treacher Collins Syndrome, and one case with the Long Face Syndrome.

Standard and specific cephalometric parameters were obtained to detect the site of the obstruction. Polysomnographic studies yielded information regarding the patient's sleep-wake state, respiratory and cardiac functioning, pre- and post-operatively. A temporary tracheostomy corrected the symptoms in one patient but the syndrome recurred when it was closed. Surgical correction of the maxillofacial anomalies will reestablish normal sleep patterns preventing OSAS.

Five cases of a rare malignant sinonasal tumour of neurofibromatous nature are described. The term neurogenic sarcoma (or malignant peripheral nerve sheath tumour) is advocated instead of malignant schwannoma.

The clinicopathological features of this tumour are described, and the differential diagnosis are discussed. The necessity of using immunohistochemistry in the diagnosis of sinonasal tumours of fibromatous nature is emphasized. The clinical management consists of radical surgery and adjuvant radiotherapy. Clinically there seems to be a high-grade and a low-grade type of sinonasal neurogenic sarcoma, however, this could not be distinguished histologically in the present series.

Benign paroxysman positinal vertigo (BPPV) is a common condition which is usually self-limiting. Surgical treatment is rarely required and for many years the mainstay of such treatment has been singular neurectomy (posterior ampullary nerve section).

A new operation has recently been described for the treatment of BPPV involving occlusion of the posterior semicircular canal. We have performed this operation on five patients with intractable BPPV and report our result with follow up of between 12 and 36 months from operation.

The excellent results of posterior semicircular canal occlusion which have been previously reposted in the literature are confirmed by our experience. In our opinion the operation is a safe and effective alternative to singular neurectomy.

Posterior epistaxis is usually treated by repeated nasal packing and in failed situations by ligation of feeding arteries with considerable morbidity and mortality. The most logical approach should be location of the bleeding site and arrest of haemorrhage by local treatment. The exact location of the bleeding area can be identified in actively bleeding noses with the fibreoptic naso-laryngoscope and the bleeding arrested by chemical, or thermal cautery and in failed situations by using small nasal packs confined to the bleeding site. This approach to the management of posterior epistaxis is effective and reduces the duration of hospital stay. It significantly reduces the discomfort to the patient. The current practice of indiscriminate blind nasal packing in the hope of arresting nasal haemorrhage by incidental pressure on the bleeding site should be re-evaluated.

Despite the fact that around 12 per cent of adult patients attending an audiology department will be severely hearing impaired (pure tone averages of 0.5, 1, 2 and 4 kHz of 70 dB HL or worse in the better hearing ear), their clinical and audiometric characteristics have not been well documented.

These characteristics were collected prospectively in 132 adult patients attending a Severe Impairment Clinic, set up to manage their specific problems. The inability to provide sufficient masking makes audiometric assessment of the severity of the impairment uncertain in the poorer hearing ear in 52 per cent of these patients. In addition, the limited bone conduction output makes it almost invariably impossible to assess the masked bone conduction thresholds and hence the air-bone gap in the poorer ear. Hence, accurate characterization is only practical of the better hearing ear in such patients.

In 67 per cent of the better hearing ears, there was a mixed hearing impairment, the air-bone gap being 20 dB or greater. The aetiology of the conductive component was almost equally otosclerosis and chronic otitis media. In only 19 per cent was the impairment of a pure sensorineural type, broken down as 6 per cent congenitally acquired, 5 per cent due to meningitis and 9 per cent being adult in onset. In the remaining 14 per cent of patients the type of impairment could not be classified as the bone conductive thresholds were off scale.

Having had experience of managing these patients at a special clinic and knowing the workload involved, it is argued that consideration be given to setting up such clinics in most departments.

Results are reported of a study to evaluate possible associations between nasal septal deformity and palatal symmetry in neonates.

Five hundred babies, born consecutively, were examined within three days of birth. Prenatal and delivery data were recorded for each baby and the nose was examined to determine airway patency and possible septal deformity. When a deviation of the septum was discovered an alginate impression of the palate was taken along with photographs of the nostrils. A matched control was then selected for each study group baby and similar records were obtained.

Only 14 cases of septal deformity were found, an incidence of 2.8 per cent. No evidence of palatal asymmetry was found. The theory that moulding pressures during delivery may be a major cause of nasal septal deformity was not supported.

A retrospective series is presented of 51 cases operated on for suspected perilymph fistula. In 26 ears a fistula was identified at surgery. A positive fistula test was found to strongly indicate a perilymph fistula but was more often negative than positive in surgically demonstrated fistula ears. Other vestibular tests were found to be of little value in the pre-operative diagnosis. Ears with a surgically demonstrated fistula and sensorineural hearing loss had either flat or downward-sloping audiograms. Difficulties in diagnosing a perilymph fistula at tympanotomy are discussed. At follow-up, vestibular symptoms were found to be eliminated or improved in 96 per cent of cases with surgically demonstrated fistulae and in 68 per cent of cases in which no fistula was detected at tympanotomy but hearing improved significantly in only one ear (4 per cent) of the former group and in five ears (20 per cent) of the latter group.

A study was undertaken on a 3.2 kilogram fresh stillborn neonate, to determine ways and means of preventing damage to the skull base.

Gruber and Rosen aural specula were inserted separately into the right nostril, to determine the degree of exposure of the choana with each. The position of the surgeon was varied (septoplasty versus tonsillectomy position), to determine on which anatomical site of the choana the surgeon's field of vision was focused.

The Gruber aural speculum, gave a completely, uninterrupted view of the choana.

In the tonsillectomy position, the entire field of vision was focused on the choana itself, whilst in the septoplasty position, one half was focused on the choana and the other half on the roof. Since the roof is part of the skill base, damage to this area can result in serious intracranial complications, such as CSF leak and meningitis.

These complications can be avoided if the surgeon uses the Gruber aural speculum for exposure and operates from a tonsillectomy position.

A new imaging technique is described, in which photographic subtraction as practised in angiography, is combined with Gadolinium enhanced Magnetic Resonance (GdMR)imaging and applied to the investigation of the paranasal sinuses and skull base. The densities on the subtraction image are dependent upon the blood supply of the tissues examined, thus producing a record of their vascularity: in effect a vasculogram. The method has proved to be technically feasible, and is advantageousin certain situations, particularly those in which the anatomy is complex as in theskull base or where normal structures havebeen distorted by previous surgery. The technique provides a more accurate record of tumour extent than that shown on unsubstracted GdMR scans.

Patients undergoing 204 endoscopic laryngeal operations were studied prospectively to determine the incidence of complications. Twelve patients were considered to be at high risk of postoperative airway obstruction. Two of these patients had an elective tracheostomy. One required temporary reintubation in the recovery room. No case of respiratory obstruction occurred in a patient not considered to be in the high risk group. Mucosal haemorrhage or oedema was seen on postoperative indirect laryngoscopy in 31 per cent of patients. The commonest abnormality found was mucosal haemorrhage in the oropharynx.

A radiological study of skull base anatomy was performed in patients presenting with primary spontaneous CSF rhinorrhoea. Radiology correctly identified the fistula site in 90 per cent of cases. Contrast CT imaging was found to be the most suitable technique for identifying the presence and site of CSF fistulae. However, pre-contrast bony dehiscences were identified in all patients leaking from the cribriform plate region. More significantly, all of these patients showed deviation of their crista galli, a radiological sign hitherto unreported. These findings support the theory that congenital bony dehiscence is the aetiological basis for this condition. The importance of radiology in the management of this condition is emphasized.

Sixty-three patients undergoing surgery to the nasal septum followed by bilateral packing had pre- and post-operative tympanometry in order to determine the effect on eustachian tube function. Fifty-five of the 126 ears tested (46 per cent) developed a reduction in middle ear pressure of at least 50 daPa; 76 per cent became normal within 24 hours of removing the nasal packs. All ears were asymptomatic and no patient had evidence of middle ear effusion. Nasal packing following septal surgery is a frequent cause of shortlasting eustachian tube dysfunction but rarely severe enough to cause symptoms or middle ear effusion. Tubal dysfunction is most likely due to a combination of surgical oedema and a direct effect of the nasal packing.

Computerized tomographic (CT) imaging provides detailed information on the paranasal sinuses and is now well established as an alternative to standard radiographs. The planning and safety of surgery to the paranasal sinuses is greatly improved by CT imaging. We describe a new CT protocol comprising a limited coronal and axial scan series, based on ourexperience with the previously described ‘CT Mini-series’.

One hundred and thirty two patients who had undergone tonsillectomy for recurrent sore throats were evaluated by a questionnaire regarding the effectiveness of their operation. There were 98 respondents of whom 88.8 per cent were satisfied with the benefit gained. Smoking habit did not affect the post-operative satisfaction rate. Dissatisfied patients were more likely to have changed their General Practitioner recently and more likely to have had multiple hospital referrals in the past. Improved patient satisfaction rates may be achieved by more careful assessment of patients with the latter characteristics.

The number of mast cells in the inferior turbinate from patients with perennial allergy due to house dust mite were compared with ten normal controls. Ten random high powered fields were counted in the epithelium and the submucosa in samples which had been divided into two and fixed either in aqueous formaim or Carnoy's fixative. The sections from each block were stained with either Azure A or Chloroacetate esterase technique. No statistical differences were found. The lack of increase in mast cell numbers was attributed to degranulation since numbers have been shown to be increased in perennial allergy when sections are examined ultrastructurally.

The ultrastructure of mast cells from the nine normal inferior turbinates were compared with those found in eight patients with perennial allergic rhinitis due to house dust mite allergy. Forty-six mast cells from normal patients were found in forty blocks and eighty cells were found in thirty-three blocks in patients with perennial allergy suggesting an increase of mast cell numbers in perennial allergy. There were no basophils outside the blood vessels and whole mast cells were found only in the submucosa. There was no difference in the morphology of cells of different sizes. Mast cells were more degranulated in the allergic mucosa. Degranulation, irrespective of cell size was found at all depths of the mucosa. A review of the literature covered the in vivo and in vitro descriptions of the ultrastructural morphology of human mast cells in the respiratory tract.

The significance of the beta adrenergic system in the nasal mucosa isunclear. The authors have used the technique of autoradiography to localize and classify beta adrenoceptors in human nasal mucosa. The receptors have been found to beexclusively of thebeta-2 subtype and the highest density is found in the glandularducts. It is suggested that the beta-adrenergic system may have a physiologically important role in controlling the electrolyte composition of nasal secretions.