The Science Citation Index (SCI) was introduced primarily as a method of information retrieval but has also been used an objective measure of the quality of an article. Citation classics have been described as papers that have been cited 100 times or more. The aim of this study was to identify the articles published during the 20th century in otolaryngology-head and neck surgery journals that have achieved classic citation status and to present an analysis of this data. Using a database provided by the Institute of Scientific Information (Philadelphia, PA), an assessment was performed of all articles cited 100 or more times in one of the 28 clinical otolaryngology-head and neck journals indexed by the annual Journal Citation Reports. The data were based on citation counts using the 1900 through 1999 Science Citation Index. Institutions located in 10 different countries produced 80 noteworthy articles. The most-cited paper achieved a citation score of 406 and there were 11 articles cited on more than 200 occasions. All of the articles were published in eight journals. The earliest identified publication was in 1933 and the most recent was published in 1993. Twenty authors were involved in two articles and four authors were associated with three classic citations. This paper confirms that analysing citation classics reveals a partial insight into advances and historical developments in the specialty during the last century.

The presence of Streptococcus pneumoniae in chronic otitis media was determined with a new antigen detection kit, the NOW test. The NOW test was originally designed as a urinary antigen test but was adapted to middle-ear effusions for the present study. Middle-ear effusions from 52 children were studied. Streptococcus pneumoniae was cultured from 10 per cent of the effusions. The NOW test was positive in 23 per cent of the effusions, 80 per cent of culture positive and 17 per cent of culture negative effusions. The NOW test proved to be rapid, simple, reliable and relatively inexpensive for the detection of pneumococcal antigen in the middle-ear effusions. This test may prove valuable for the management of children with acute otitis media who undergo tympanocentesis.

The present study is intended to explore the effects of the KTP laser on various types of implant, used in middle-ear surgery. A laboratory study was undertaken to evaluate the interaction between the KTP laser (KTP-532 Orion Laser, Laserscope, UK) and individual middle-ear implants. A variety of middle-ear implants were used: a silicone sheet, Teflon® , hydroxylapatite, ionomeric cement, gold and titanium prostheses as well as gelfoam. Following exposure to the laser, these implants were studied by direct inspection using an operating microscope.

The KTP laser induced no detectable alteration in any of the implants when they were clean and dry. However, in the presence of fresh blood, under the influence of the energy of the absorbed laser, the silicone burnt and melted and the Teflon® piston was vaporized. Likewise, a few tiny holes appeared on the surface of the ionomeric implant and then the prosthesis deformed. The hydroxylapatite implant broke into two pieces. However, no detectable alteration could be observed on gold or titanium pistons, even in the presence of blood.

The authors conclude, that in the presence of blood, interaction between the KTP laser and both silicone and hydroxylapatite implants needs to be avoided. Teflon® prostheses can be cautiously vaporized. Gold and titanium prostheses were unaffected by laser even in the presence of blood.

The purpose of this study was to evaluate whether use of a positioner for situating the Clarion 1.2® standard electrode array in close proximity to the modiolus, causes damage to fine intra-cochlear structures, and to provide a comparison with results obtained for insertions of the array performed without a positioner. The study was performed in seven freshly frozen human temporal bones. Electrode location and intra-cochlear trauma was analysed using cross-sectional imaging and histological analysis. Insertion of the Clarion® array did not reveal major trauma. The devices inserted with the positioner showed a consistently closer location of the electron array towards the modiolus, however, insertion resulted in significant displacement of both the electrode array and the positioner resulting in severe destruction of the basilar membrane and osseous spiral lamina along the length of the basal and middle turns. The devices inserted with the positioner resulted in major trauma to the basilar membrane and osseous spiral lamina. Therefore, systematic safety studies in larger samples of human temporal bones should be performed and the results carefully evaluated before implantation can be recommended unreservedly.

Spontaneous dehiscence of the superior semicircular canal (SSC) in the middle cranial fossa is rare and may cause clinical problems. This dehiscence was investigated in cadaveric and dried temporal bone specimens. One cadaveric specimen showed a spontaneous defect: the dehiscence was a symmetrical, elongated ellipse with smooth margins. Four of 244 dry bone specimens showed bony defects in the roof of the SSC, however, only one specimen was thought to have a spontaneous defect. Based on computer-simulation models, we hypothesized that spontaneous defects of the SSC may arise during the fetal period. Although rare, this defect may cause problems in middle cranial fossa surgery and may relate to certain vertiginous disorders.

The aim of this prospective study was to examine skin reactivity to four vasomotor agents and to determine whether non-eosinophilic rhinitis patients differ from patients with eosinophilic rhinitis. Nasal cytology enabled us to classify 74 rhinitis patients into a non-eosinophilic (n = 63) and an eosinophilic group (n = 11). Skin reactivity to intradermal tests with papaverine, metacholine, histamine and compound 48/80 was measured. No significant difference for papaverine, metacholine, histamine and compound 48/80, singly, was found between the non-eosinophilic and eosinophilic group. The frequency of the total pathological skin reactivity to vasomotor agents, singly and in combinations, was greater in the eosinophilic (91 per cent) then in the non-eosinophilic group (78 per cent) but intergroup difference was not significant. These findings suggest that pathologic skin reactivity to vasomotor agents is a feature of non-eosinophilic as well as eosinophilic non-allergic rhinitis patients and indicate that no difference is noticed in the skin reactivity between these groups.

The aim of this study was to determine risk factors for pharyngeal cancer and to propose 10 result-based preventive measures. It was a case-control study conducted in Madrid, Spain, with 232 consecutive patients diagnosed between January 1 1990 and December 31, 1995, sex- and age-matched with 232 control individuals with no oncological disease or history. By means of an interviewer-administered questionnaire, seven different epidemiological areas were surveyed, namely: (1) sociodemographic variables, (2) familial all-site cancer history, (3) medical history, (4) lifestyle (habits), (5) diet, (6) occupational exposure, and (7) non-occupational exposure. Of the great number of factors within each epidemiological area, the following were found to be risk factors after adjustment for tobacco smoking and alcoholic beverage drinking: (1) tobacco smoking, (2) alcoholic beverage drinking, (3) low and low-middle socioeconomic background, (4) low educational level, (5) rural milieu, (6) working, or having worked, as a manual worker in agriculture, (7) working, or having worked as a manual worker in building industry, (8) having an upper aerodigestive tract cancer familial history, (9) having a medical history of alcholism, low weight/malnutrition, gastroesophageal reflux or chronic obstructive bronchopneumonia, (10) low dietary intake of fruit, fruit juice, uncooked vegetables, dietary fibre-containing foods, fish and milk and dairy products, (11) high dietary intake of meat and fried foods, (12) deficient oral and dental hygiene, (13) abuse of black coffee, (14) abuse of ’carajillo’ (a typical Spanish drink composed of black coffee and flambéed brandy), (15) occupational exposure to pesticides, solvents and dust of different origins.

On the basis of our results and those reported by other authors, we put forward 10 measures for the prevention of pharyngeal cancer. However, due to the small size of the nasopharyngeal cancer subsample (n = 35, 15.08 per cent), our results as well as the preventive measures are to considered as referring uniquely to oropharyngeal and hypopharyngeal cancers. In addition, from descriptive statistical data inspection one can conclude that nasopharyngeal cancer is likely to bear risk factors different from those for oropharyngeal and hypopharyngeal cancers, thus nasopharyngeal cancer warrants specific epidemiological investigation with a sufficiently large patient sample.

We have reviewed our experience of tracheostomy in children over the past 20 years at Sheffield Children’s Hospital. One hundred and forty-eight tracheostomies were performed in 143 children aged one day to 13 years old (average 27 months). Sixty-five per cent of patients were <one year old. The indications for tracheostomy were upper airways’ obstruction in 72 per cent, and assisted ventilation/bronchopulmonary toilet in 28 per cent. The commonest single reason was acquired subglottic stenosis (SGS) in infants, accounting for 25 per cent of tracheostomies (36/143). The complication rate of tracheostomy was 46 per cent, most commonly granulation tissue formation. There were four deaths directly due to the tracheostomy: two accidental decannulations and two obstructions. Eighty-nine children were decannulated under our care. The average time until decannulation was 25 months.

Isotonic saline solution is frequently used in nasal and tracheal lavage. In a previous clinical study, it was found that Ringer-Lactate solution, as a nasal lavage, was better for mucociliary clearance function than isotonic saline solution after nasal septal surgery. In this experimental study, the effects of Ringer-Lactate and isotonic saline solutions on mucociliary clearance of healthy rat tracheal epithelium were investigated by measuring the transport of carbon particles. We found that tracheal segments that were irrigated with Ringer-Lactate had better mucociliary transport than those irrigated with isotonic saline (p = 0.035).

We report the use of a nasal septal clip. We believe that this instrument is more easily inserted and removed when compared with the classical nasal packs.

Group A streptococcal meningitis is rarely encountered today, although group A streptococcal severe infections are on the increase. We present here a case of an adult male with bacterial meningitis as a complication of otitis media induced by Group A Streptococcus. The approach to diagnosis and treatment considerations are discussed.

Nasal septal abscess complicating acute sinusitis is rare. There have been very few reports in the literature of this condition. We present a 12-year old-male with a nasal septal abscess complicating acute pansinusitis.

Multiple congenital dehiscence of the skull base is rare and can give rise to spontaneous CSF rhinorrhoea. A search of the world literature revealed only five reports of CSF leak with more than one concomitant skull base defect. When treating a patient with spontaneous CSF rhinorrhoea the possibility of its originating from the middle ear and eustachian tube should be considered. An intrathecal injection of fluorescein is useful in establishing the site of a CSF leak especially when a computed tomography scan (CT) or magnetic resonance image (MRI) has not localized the site. We discuss a case of a 72-year-old lady presenting with CSF rhinorrhoea, who had an anterior skull base defect localized with the help of intrathecal fluorescein and repaired surgically. Subsequent to this she had a further episode of CSF rhinorrhoea that originated from a middle-ear meningocele that was then repaired.

We report a case of a very unusual penetrating injury of the middle third of the face. The patient was involved in a road traffic accident, and the indicator control lever became impaled in his right cheek. There was contralateral orbital damage resulting in loss of sight. The cribriform plate was breached and a pneumoencephalocele ensued.

We discuss the modern management of such injuries including injury assessment. We emphasize the importance of crash scene information gathering and analysis of injury mechanisms. Facial injury zonal classification and imaging are reviewed in the context of the case. We discuss the reasons that led us to treat this patient via the subcranial approach.

A case of multiple cervical schwannomas in a five-year-old boy, without other evidence of neurofibromatosis type 2, is described. Schwannomatosis is a disorder characterized by the presence of multiple schwannomas in the absence of neurofibromatosis type 2 that has only been recognized in the last 15 years. The clinical and genetic features of neurofibromatosis types 1 and 2 and schwannomatosis are compared and contrasted. This patient with possible schwannomatosis is presented to illustrate the potential pitfalls of making this diagnosis in the paediatric age group and to increase awareness of the debate on whether this is a distinct entity or a form fruste of neurofibromatosis type 2.

Skull base osteomyelitis classically presents as a complication of severe external otitis, middle ear, mastoid or sinus infection and can lead to multiple lower cranial nerve palsies when the jugular foramen is involved as a consequence of widespread involvement of the skull base. Bilateral skull base osteomyelitis is a recognized phenomenon, but has not previously been reported secondary to pseudomonal infection in the absence of a clinically obvious focus of infection. We report the case of a 77-year-old diabetic patient who presented with dysphonia and dysphagia and had a bilateral Xth cranial nerve palsy. No focus of infection was evident on presentation. Subsequent radiological investigation confirmed the diagnosis of bilateral skull base osteomyelitis.

In phonosurgery, in cases where it is not possible to use a rigid laryngoscope, a flexible fibrescope with laryngeal-mask ventilation may be used. In flexible fibreoptic surgery, the forceps are normally inserted through a small channel in the fibrescope. Since only a small forceps tip can pass through this channel, a limited range of forceps has been available for use in fibrescope procedures. We have developed a new type of forceps for flexible fibre-optic surgery that allows this size limitation to be overcome. The new forceps is made up of two parts: (i) the forceps tip and its control wire assembly, and (ii) a detachable handle. A wide range of forceps can be used, including those with tips larger than the biopsy channel. We report a case that was treated with this new technique.

A tracheo-innominate artery fistula is an uncommon but frequently fatal complication of tracheostomy. Rarely, it can also occur in laryngectomized patients. We report a post-laryngectomy, post-radiotherapy patient using a metal tracheostomy tube, who developed a tracheo-innominate artery fistula about two months after radiotherapy. To our knowledge this is only the second reported case in a laryngectomized patient. The computed tomography (CT) angiography findings helped confirm the diagnosis and the patient was successfully managed by surgical exploration and ligation of the innominate artery. Coagulase negative Staphylococcus aureus was cultured from a tracheal swab. The clinical features, CT angiography findings, management protocols and possible aetiological factors are discussed.