Besides the use of conventional techniques such as light and polarization microscopy, the present paper proposes the combined use of transmission electron microscopy, secondary and backscattered electron imaging, energy dispersive X-ray analysis and computed tomography for the diagnostic evaluation of ear pathology in the human fetus. These methods were used to revisit the primary calcification front of the fetal otic capsule between 16 and 23 weeks gestational age. Ultramicroscopic evaluation demonstrates similar fetal bone formation to that found in other bones of the human fetus. The formation of the endosteal and periosteal layers is a typical example of early intra-membranous ossification. The enchondral layer is made up of fibrillar bone, laid down around the calcified cartilage remnants. Microchemical analysis indicates a significantly higher Ca/P ratio in the endochondral layer with respect to the endosteum and periosteum. The consequences of a lower Ca/P ratio in the endosteal layer are discussed in view of calcium homeostasis and inner ear function.

Recent studies have shown neuroendocrine-type cells in human spiral prominence epithelium. A light microscopic and ultrastructural study was made on the guinea pig spiral prominence epithelium to try and identify neuroendocrine cells. The study showed that such cells were not present in the guinea pig spiral prominence epithelium. The spiral prominence epithelium was characterized by uniformity of cellular staining with Toluidine blue and the ultrastructural appearance. The morphology of the spiral prominence epithelium was similar to that previously described. The absence of neuroendocrine cells in spiral prominence epithelium in the guinea pig is discussed in relation to species differences.

Changes in ciliary interconnections in the organ of Corti are described after acoustic overstimulation using a special high resolution scanning electron microscope and tannic acid-osmium staining technique, giving an almost three dimensional view. Guinea pigs were exposed to a 3.85 kHz pure tone at an intensity of 120 dB for 22.5 minutes. The first detectable change was a disarrangement of the cilia with a loosening of the interconnections. The ciliary plasma membrane presented with an abnormally smooth appearance. The tip links connecting the tips of the stereocilia to their taller neighbours were also affected showing elongation or even disappearance. The fine granules which cover the tips of the tallest stereocilia of the outer hair cells were decreased. These findings suggest that acoustic overstimulation may affect the carbohydrate metabolism exceding to degeneration of ciliary interconnections resulting in a disarrangement and detachment of cilia. The tip links, which may participate in sensory cell transduction, seem also to be affected by acoustic overstimulation.

A group of 33 patients with the autosomal dominant form of Waardenburg Type II syndrome underwent hearing and vestibular examination. A bilateral, symmetrical, sensorineural hearing loss was found in 51 per cent of the tested subjects. The severity of hearing loss varied from mild to severe. Strong evidence indicated the possible progressive nature of the hearing loss. Concerning the frequency of vestibular findings, the study highlights the frequent divergence between cochlear and vestibular involvement.

The degree of inter-observer variability in the results of pneumatic otoscopy, used to predict the presence or absence of middle ear effusion was assessed. A group of 114 patients with 209 suitable ears had pneumatic otoscopy using a Seigle's speculum performed independently by two observers. The results were compared to the findings at myringotomy, on the basis that mobility of the tympanic membrane was indicative of a dry middle ear. The observers agreed in 187 ears, a concordance rate of 91 per cent, and in 174 of these (93 per cent) the observers' prediction of middle ear state was correct. The overall predictive accuracy of observer A was 89 per cent and of observer B 84 per cent, this difference is not statistically significant, p> 0.05.

A new objective test of endolymphatic hydrops has been described previously. The test uses auditory brainstem response (ABR) techniques to estimate the basilar membrane travelling wave velocity (TWV). The underlying hypothesis is that raised pressure in the scala media will lead to an increase in the stiffness of the basilar membrane and that this will give rise to a travelling wave velocity that is greater than normal.

It was considered that verification of the technique could be obtained by carrying out the new test before and during a glycerol dehydration procedure. Patients who required this procedure for verification of the diagnosis or as a prognostic indicator for sacculotomy, underwent the following tests. Prior to dehydration an audiogram, the ABR TWV test and a blood sample (for plasma osmolality) were taken. The patient was then given the appropriate amount of glycerol mixed with lemon juice and laid on a bed in a test room. The audiogram and a blood sample were repeated every hour and the ABR TWV test was repeatedly carried out every twenty minutes between the other tests.

Six of these procedures have been carried out. In five of them the 0.5 and 1kHz average threshold improved by at least 10dB and in all those cases the ABR TWV test showed an abnormal pre-dehydration result which moved towards the normal value following dehydration. One patient gave ABR TWV results that were within normal limits before and during the procedure and gave an audiometric change of only 5dB.

These data indicate that the ABR TWV test does detect endolymphatic hydrops. The additional hardware to carry out this test has been constructed and parallel clinical trials at IHR Southampton, Addenbrooke's Hospital, Cambridge, and Queen's Medical Centre, Nottingham, are in hand.

The noise levels produced by a variety of do-it-yourself power tools were measured in a real-life situation. Most of the devices tested produced noise of 100 dB(A) or greater at the user's ear. A questionnaire was issued to 100 males who used these devices. The vast majority used the devices infrequently and therefore are unlikely to be directly at risk of hearing damage. A group of users who may be more at risk from using power tools in the home are those who are, or have been exposed to occupational noise.

There is scant literature relating to tinnitus in children. This may be due in part to the inability of the child to differentiate normal from abnormal, and also adults failing to communicate adequately with children to allow them to describe their observed symptoms.

One hundred and two children with severe to profound hearing loss between six to seventeen years of age were questioned as to the presence of tinnitus. The 24 children (23 per cent) who reported tinnitus, also completed a questionnaire, and were interviewed about their symptoms and then were compared to the non-tinnitus children regarding hearing level, age, sex and aetiology of the deafness.

No significant difference was found between the two groups. This study documents that tinnitus does exist in a significant number of children with severe to profound deafness and addresses the problem involved in its description and assessment.

A modification of existing techniques for the treatment of auricular haematoma is described. This method employs incision, drainage and the application of silicone rubber splints (SilasticR). Existing methods of treatment are reviewed and discussed. A retrospective review of 16 cases using this technique showed a satisfactory cosmetic result in all cases.

The study was undertaken to define the characteristics of spontaneous eardrum perforation in acute otitis media. Eighty (29.5 per cent) out of 271 children with acute otitis media had eardrums which perforated. An increased incidence of perforation was associated with a previous history of otitis media.

All perforations were small and limited exclusively to the pars tensa. In 85 per cent of the patients, the perforation was located in the anterior-inferior quadrant. It had smooth margins enabling free drainage of pus and was associated with a favourable clinical course. In the remaining 15 per cent of the cases, the perforation was located in the posterior-superior quandrant. It had a nipple-like shape with a tiny opening that did not allow pus to drain sufficiently from the middle ear.

The perforation closed in 94 per cent of the patients within one month. The healing process was gradual and following perforation closure, there was evidence of middle ear effusion for some time before normal aeration was regained.

The middle ear cavity is exposed and vulnerable to waterborne infection in patients with grommets, perforated tympanic membranes and after radical mastoidectomy. Patients suffering from chronic otitis externa and those receiving radiotherapy to the head and neck also have an increased susceptibility to such infections. Many advocate the use of waterproof ear protectors in such patients when swimming. The choice of a suitable ear protector is complicated as many are now available commercially.

This study was therefore designed to evaluate the degree of protection afforded by seven different ear protectors in a group of six swimmers. A very sensitive, original method of water detection was devised incorporating a pH indicator strip.

The results showed conclusively that cotton wool coated in paraffin jelly BPC was the most effective method of ear protection and was found to be comfortable and easy to use. Other methods, including custom-made silicone rubber plugs, were not adequate in sealing the external auditory canal and are considerably more expensive.

The diagnosis ‘acute;’ mastoiditis is not an unambiguous entity. It contains both ‘classical’ and ‘latent’ mastoiditis. ‘Classical’ mastoiditis was often seen before the antibiotic era, had serious complications and was cured by mastoidectomy. After the introduction of antibiotics, the number of cases of ‘classical’ mastoiditis decreased and was replaced by a more prolonged condition called ‘latent’ mastoiditis. Lately in Oslo, we have seen an increase in numbers of ‘classical’ mastoiditis and at the same time a decrease in the incidence of ‘latent’ mastoiditis. A four year study of patients with ‘classical’ mastoiditis is described.

It is almost impossible to establish the natural history of Menière's disease and, by the same token, it is difficult to confirm the efficacy of endolymphatic sac surgery. The authors doubt the logic of sac operations. Only two controlled trials of sac surgery have been found and both cast doubt upon its value. There do not appear to be any controlled trials indicating that it works.

In 14 cases of incapacitating Menière's disease, where vestibular nerve section was indicated, cortical mastoidectomy was offered and accepted in the expectation that two-thirds might be spared the more major procedure. In the event, the vertigo was controlled in eight out of 14 (57 per cent), the remaining six (43 per cent) requiring more major surgery.

A surgical model illustrates that, of themselves, these results are essentially meaningless in assessing the efficacy of cortical mastoidectomy in Menière's disease. Until all cases in a community are considered and followed-up, we shall be in doubt about the value of sac surgery and most other treatments of Menière's disease.

Surgery may have to be considered in the management of large glomus tumours since other modalities of treatment are not curative. The judicious use of surgical intervention is imperative since a neurological deficit involving the last four cranial nerves may ensue and consideration of the quality of life of the patient in the post-operative period is of paramount importance. A brief description of the historical aspects and pathology of these tumours is followed by an analysis of the clinical presentation, investigation and assessment of a series of 10 patients. Six patients underwent surgery and their tumours were removed by the infra-and trans-temporal approach. This is described and illustrated in detail and the surgical results presented.

Aspergillus infection of the nose and sinuses has been recognized for nearly 100 years but a variant, allergic aspergillus sinusitis, has recently been recognized. This non-invasive form causes chronic sinusitis characterized by thick green inspissated mucus in which eosinophils and Charcot-Leyden crystals are found. Fungal hyphae are scanty and are indentified with special stains. Consequently the diagnosis may frequently be overlooked. It has many similarities with allergic broncho-pulmonary aspergillosis and is treated by surgical debridement and aeration with or without cortico steroids, either topical or systemic.

Antroscopy has been shown to have a role in the diagnosis and treatment of antral disease. Four cases of ‘non-secreting’ benign antral cysts, each presenting with facial pain, were successfully treated using antroscopic techniques. The aetiology and management of these lesions is reviewed with the recommendation that antroscopic removal is the treatment of choice for all symptomatic cases, and for asymptomatic cases in which the diagnosis is in doubt.

Wegener's granulomatosis is difficult to diagnose, especially when the presentation is unusual, restricted to an isolated region. We report four cases of recurrent subglottic stenosis posing difficulty in diagnosis. In each case the finding of anti-neutrophil cytoplasm antibodies (ANCA) strongly suggested an underlying vasculitic pathology, Wegener's granulomatosis. We discuss reasons for the difficulty in diagnosis in the past, the possible role of the ANCA assay in such patients, and suggest it should be more widely used in the future.

This report adds 16 myoepitheliomas of salivary glands to the 47 already recorded in the literature. It includes, for the first time, a flow cytometric analysis of their ploidy (DNA content) and proliferative capacity (S-phase fraction). Thirteen myoepitheliomas were diploid; three were aneuploid in their DNA content. A high proliferative capacity was always associated with an abnormal DNA content. Only one diploid myoepithelioma had a high S-phase fraction. Both flow-cytometric parameters are good predictors of an aggressive biological behaviour. Recurrences, however, were all the outcome of incomplete primary removal of the myoepitheliomas. Four of the twelve (33 per cent) diploid myoepitheliomas recurred and one, with high S-phase fraction, led to the death of the patient. Two of the three (67 per cent) aneuploid myoepitheliomas recurred. Extensive loco-regional invasion by one killed the patient. The other has clinical evidence of distant metastasis.

The thick oily and pigmented skin present in majority of tropical patients makes rhinoplasty challenging surgery. Rhinoplasty by the external approach though gaining increasing acceptance all over the world is yet to gain popularity in this country. Hypertrophied scars are not uncommon in coloured skin and the reluctance to give an external incision for a cosmetic procedure is natural. We started the external rhinoplasty approach with some reservations, however in a series of over seventy cases, no significant problem has been encountered, with the columellar scar. Accurate approximation of the columellar wound is probably a more important factor in wound healing than the skin colour. Our experience of external rhinoplasty is presented.

A case is presented of a 3-year-old girl with no previous history of ear disease or developmental defects who bled profusely upon (right) myringotomy. The haemorrhage could only be stopped with the aid of an ear insert and a nasopharyngeal balloon catheter. The balloon catheter was removed the following day but the girl had to use an ear insert for a total of 76 days following myringotomy because of repeated haemorrhage from the ear. The subsequent investigation using CT and angiography revealed an aberrant internal carotid artery in the middle ear.

It is concluded that the one most important factor in the handling of these cases is to be aware of the existence of aberrant internal carotid arteries and to have a high degree of suspicion when encountering any abnormal clinical or radiological findings which might point in the direction of vascular abnormalities. The failure to detect this condition before any surgical intervention on the affected ear can have disastrous consequences.

The method of choice in handling these cases is one of avoidance of middle ear manipulation in order not to cause haemorrhage from the aberrant artery.