High definition CT has been advocated for the evaluation of chronic suppurative otitis media (CSOM) either generally or in selected cases. It is said to be capable of producing the fine detail needed to detect lateral canal fistulae, exposed dura and facial canal dehiscences, and to demonstrate the ossicular chain. At present there is no agreement on either the indications for CT scanning in CSOM or the most appropriate scanning plane. To determine the value of high definition CT in CSOM and to decide a unit policy for its application, 36 cases of CSOM underwent pre-operative CT scanning and their scans were compared with the operative findings.

Our results show CT to be highly sensitive to the presence of soft tissue disease and bone erosion, moderately sensitive to the presence of lateral canal fistulae but less sensitive to the presence of small areas of exposed dura, ossicular continuity and facial canal dehiscence. Axial scans were better able to demonstrate the lateral canal but otherwise coronal scans were superior; ideally patients should be scanned in both planes. The principle value of CT in CSOM is its ability to demonstrate disease which is not clinically apparent.

Haphazardly treated active otitis media was investigated bacteriologically in 214 children. Analysis showed that Pseudomonas aeruginosa was more prevalent than other micro-organisms. Candida was also found in appreciable quantity. The author contends that this was due to inadequate self treatment before these children reported in his hospital. He advocates that decision regarding the chemotherapeutic agent to be used should be based on culture and in vitro sensitivity.

Bismuth subnitrate, one of the constituents of BIPP is known to cause methaemoglobinaemia. Ten patients had blood estimations for methaemoglobin levels before and after nasal packing with BIPP impregnated gauze. Only one patient exhibited abnormal levels of methaemoglobin and this was most probably the result of the large quantity of BIPP used. It is unlikely that significant methaemoglobinaemia occurs during the routine use of BIPP in the nose.

The efficacy of a biocompatible, surgically implantable, antimicrobial release system (IARS) as the exclusive antimicrobial therapy of necrotizing external otitis (NEO) was evaluated in six NEO patients. Gentamicin incorporated polymethyl-methacrylate beads were implanted, following surgical debridement and were removed two months later. Post-implantation alleviation of clinical symptoms: pain, periauricular tissue swelling, otorrhoea, eradication of pseudomonal infection (100 per cent) and substantially shortened hospitalization (4–15 days) were the salient results of this therapeutic modality. Three patients recovered. Two patients who died, one of sudden cardiac arrest and the other of paralytic ileus, 15 and 60 days postoperatively while the beads were still implanted, were symptomless. Recurrence was seen in one patient with early bead extrusion. Ipsilateral sensorineural hearing loss (one patient) and external meatal stenosis were the main complications. IARS appears to offer an effective alternative to long-term systemic antibiotic administration for the eradication of NEO-pseudomonal infection in patients who are sensitive, develop resistance, or when quinolone medical treatment has failed or is contra-indicated.

This incidence of blast trauma to the ears in significant numbers is relatively rare in peace time. This paper outlines the results and management of twenty patients injured as a result of the outside explosion of 800 kg of high explosives in Peterborough on 22 March 1989.

Cholesteatoma in children presents characteristics that differentiate it from the adult condition. Surgery has been performed in 55 ears. The main reason for referral was otorrhoea (83 per cent), either alone (29 per cent) or with hearing loss (54 per cent). Apart from three cases with an intact eardrum, a perforation was always present mostly posterior-superior (50 per cent). Open techniques were performed in 27.3 per cent of the ears and the closed technique in 72.7 percent. Only in 18 per cent of cases was the ossicular chain normal and mobile. The attic was occupied by cholesteatoma in 79 per cent. Recurrence took place in 37 per cent and 13 per cent of the closed and open techniques respectively. Open techniques tend to be employed in the presence of extensive disease, whereas the closed technique is reserved for those with a more localized problem.

Fifty members of a family with a unique autosomal dominant bone disease were investigated. Nineteen of the family members were either known to have, or were strongly suspected of having the disease. All but one of these had a hearing loss which was conductive in the younger age group and mixed in the older members. The common finding in those who had middle ear surgery was replacement of the long process of incus by a fibrous band. The histological features were similar to those found in Paget's disease. The age of onset, distribution of lesions and radiographic findings, however, were not typical of this disorder.

The following hypothesis is presented: that the susceptibility of an individual patient to hearing loss as a result of cis-platinum administration can be predicted on the basis of eye colour. The rationale is that the melanin content of the inner ears is related to that of the eyes; dark eyes contain more melanin than lightcoloured eyes; and melanin causes the accumulation of the ototoxic drug within the inner ear. Hence those with dark eyes will suffer greater damage to the hearing than those with pale eyes. An investigation that confirmed this hypothesis is reported. In addition to cochlear damage there is a significant likelihood of damage to the auditory nerve as a result of the treatment.

In patients with peripheral vertigo the presence of an asymmetrical hearingloss is an important lateralizing sign, having both diagnostic and prognostic significance. In a consecutive series of 83 patients undergoing retro-labyrinthine vestibular nerve section for uncontrolled vertigo, asymmetrical hearing loss was associated with an 83 percent incidence of complete control of vertigo and a 49 per cent incidence of complete relief from dysequilibrium. In the absence of a lateralizing hearing loss, the figures were 50 per cent and 24 per cent respectively (p<0.01 and p<0.05). The explanation for this finding may be that the presence of a hearing loss is more often associated with an exclusively peripheral disorder (controllable by peripheral surgical ablation), whereas inpatients with symmetrical hearing there may be an unrecognized central or contralateral pathology resulting in lesseffective results from a unilateral peripheral surgical approach. The bithermal caloric test did not give such useful diagnostic or prognostic information.

We report a retrospective study of 54 children with 57 involved ears who underwent surgery for cholesteatoma before their sixteenth birthdays. The majority of these underwent open cavity operations (modified radical mastoidectomy, radical mastoidectomy or atticotomy). The incidence of residual disease was only 6 per cent and overall 70 per cent of ears have been free of chronic discharge. The post-operative hearing thresholds were disappointingly low, though overall no worse than those recorded before surgery. The mean post-operative hearing level for the group was 39 dB and the mean air-bone gap was 29 dB. Open cavity surgery is the method of choice for childhood cholesteatoma, mainly because of the low incidence of residual disease.

Twenty-five patients who had undergone a closed-cavity tympanomastoidectomy in our Unit and wore a hearing aid in the operated ear were reviewed, and information was recorded on the use of the aid, and the patients’ impression about it. The information obtained was analysed and compared with similar data from 39 hearing aid users of similar age with no history of ear surgery. Eighty per cent of the patients with a closed mastoid cavity were satisfied with the aid, and no significant difference was found between the two groups regarding the impression about the aid (chi square 3.06, p = 0.08), or the problems with it, which, in most of the cases, were related to several changes of mould (chi square 2.19, p = 0.13). The various recorded parameters are discussed, and it is concluded that the patients with a closed mastoid cavity can tolerate a hearing aid in the operated ear at least as well as the control subjects with no ear surgery.

We present a British series of eleven patients with primary cholesteatoma, including one patient with bilateral disease. Eight children presented with a history of hearing loss, while one child had had recurrent otitis media and another had had carache. Operative findings were: in five ears, cholesteatoma confined to the antero-superior segment with intact ossicles, in a further four, cholesteatomas extending throughout the mesotympanum with ossicular erosion in one, and in two ears posterior disease throughout the middle ear and mastoid, which had eroded the ossicles in both cases. The five cases of antero-superior cholesteatoma lend most support to Michaels' concept of epidermoid formation as a possible source of congenital cholesteatoma. With a greater awareness of the problem and careful examination of the antero-superior quadrant of the tympanic membrane, earlier diagnosis may be possible enabling removal of small intact cholesteatoma sacs and preserving the structures of the middle ear and therefore the hearing.

A screening programme for infants included as part of their routine examination which would be undertaken by examiners who are trained to be more aware of the problem and skilled at otoscopy, would help in the earlier detection of such cases as is shown by reports from the U.S.A.

New Zealand Maoris are one of five ethnic groups in developed countries known to have a high rate of ear disease, including perforation of the eardrum (CSOM). It is a strongly held belief by otolaryngologists whose practice dates back to the 1960's that the prevalence of CSOM in Maori children is gradually falling. Despite the obvious practical implications this change has not yet been documented.

The aim of the study was to compare the prevalence of CSOM in two surveys conducted in 1978 and 1987 of children living in a North Island Maori community. A second aim was to examine the natural history of CSOM in these children.

The raw data from the 1978 study were reviewed. Of 134 children aged 4–13,12 had CSOM. In 1987 the same age group yielded 12 children out of 250 with CSOM. The prevalence of CSOM fell from 9 per cent to 4 per cent. The incidence of new perforations in 1987 was 1.3 per cent per child per year. It is concluded there has been a fall in the rate of CSOM, although otitis media remains a significant problem for these children.

The probability of a perforation healing was influenced by whether or not the perforation had been observed before: at least 35 per cent of perforations seen for the first time healed, but none of the perforations seen on two occsaions healed spontaneously. It was concluded that perforation of the eardrum can be managed conservatively at first.

This article presents the results of an analysis of the variable and surgically important relationship between the oval window, the fossular walls and the related posterior tympanic recesses in 50 temporal bones. The visual impressions of superficial and deep oval windows seem to correspond fairly closely to the depth of the inferior wall of the fossula fenestra vestibuli (FFV). The depth of the superior and anterior walls of the FFV by themselves, did not appear to have such a dominating relationship in determining the deep oval window. There does not appear to be a well defined posterior wall in the vast majority of the specimens (86 percent). In the event of scar tissue forming between the superior, inferior and anterior walls, the gap between the postero-superior part of the promontory and the posterior tympanic wall (posterior communication) could allow aeration of the region of the deep oval window in such an instance. Closure of this gap by a solid shelf of ponticulus or scar tissue could cause a localized malaeration of the fossula in most cases of deep oval windows. This is an entirely new concept of the likely problems of malaeration of a deep oval window which could arise due to anatomical variations and of the possible safety valve mechanism which could prevent such malaeration and its consequences.

The anatomy of the different layers of the temporalis fascia is reviewed. The superficial and deep layers of the temporalis fascia have been studied by light microscopy to assess any histological difference between the two. We have also assessed the physical characteristics of the different layers by measuring their Young's modulus in the wet and dry states.

Anatomically the superficial layer is part of the epicranial aponeurosis and thus covers nearly the entire lateral aspect of the skull. The deep temporal fascial layer covers exactly the temporalis muscle and measures 10 × 12 cm. The fascial layers have a separate arterial and venous supply enabling them to be used as a homograft, a rotation flap or free microvascular flap. Histologically there is no difference between the two layers. A study of the physical characteristics of the two fascial layers using Young's modulus revealed no significant difference in elasticity between the two. The most significant factor affecting the elasticity was the state of hydration of the fascia.

Autologous cultured epithelial layers were established from biopsies from the mucosa of the cheek, a nonkeratinizing region of the oral cavity. These were grafted to the unepithelialized mastoid cavities of nine patients with chronic mastoiditis and severe otorrhoea varying from two to 30 years' duration. All procedures were performed on an out-patient basis, with no anaesthesia except for topical anaesthesia for the mucosal biopsy. In seven of the patients the grafts took well, with complete resolution of the otorrhoea for a minimum follow-up period of eight months. In one patient there was a partial take of the graft with substantial improvement in the rate of discharge. The mastoid cavities of two patients were biopsied five months after grafting, and demonstrated a stratified squamous epithelium, with keratinization of the epithelium clearly evident.

Obliteration of persistently discharging open mastoid cavities is one surgical option to achieve a dry ear. All the currently described techniques involve the use of random pattern local tissue flaps or free grafts. Ten patients have undergone obliteration procedures using the vascularized temporoparietal fascia flap. This resulted in rapid epithelialization by six weeks in seven out of 10 cases. The remaining three patients have persistent non healed areas over the medial attic wall, but are not troubled by otorrhoea. The indications, technique and complications of mastoid obliteration by this axial pattern flap are described.

This study was designed to confirm the longer in situ life of the Sheehy collar button compared with the Shepard tube and to assess the complication rate associated with the two tubes. Cases of bilateral otitis media with effusion had a Shepard tube inserted in one ear and a Sheehy contralaterally. The insertion position was allocated randomly. The patients were then assessed at three-monthly intervals for two years. In 71 percent of those in whom at least on tube had extruded, the Sheehy remained in situ longer. The antero-inferior tube remained longer than the postero-inferior whichever type was used. There was no significant difference between complication rates, or recurrence rates of middle ear effusion after tube extrusion, for the two types. We conclude that use of a Sheehy rather than a Shepard tube carries no increased risk of complications and the patient may require further surgery less often in total.

A histopathological study of acquired cholesteatoma in four temporal bones from two adults and one child is presented. The findings suggest that the cholesteatoma originated from the retraction pockets of the tympanic membrane and there was active growth of the squamous epithelium of the retraction pockets, which may be enhanced in the presence of otitis media.

A prospective study was designed in which General Practitioners were issued with a standard referral letter for hearing aid provision. Unknown to the General Practitioner an independent otolaryngologist assessment was obtained at the time of first attendance. Three hundred consecutive patients selected by General Practitioners applying these guidelines were seen in a designated hearing aid clinic staffed by audiological technicians of senior grade or above. Referral pro formata were incomplete in 75 patients who were not assessed. Ninety-four patients (31 per cent) (95 per cent confidence interval 29–36 per cent) were accepted by the audiologist. Obstructing wax was the most common criterion failed. Clinical agreement between audiologist and otolaryngologist was 57 per cent greater than chance. None of the cases of clinical disagreement altered treatment. A direct referral system as proposed could have processed only 31 per cent of 300 referrals. However, experienced technical staff reliably detected otological pathology and with aural toilet facilities 91 per cent of 225 patients (confidence interval 88–94 per cent) were aided.