Clinical tests of hearing are regularly used in adults but their role, now that pure-tone audiometry is almost universally available, has not been evaluated by modern methods of analysis including sensitivity and specificity.

Free-field voice testing was carried out in 101 patients and the Rinne tuning-fork test in a different group of 127 patients prior to clinical or audiometric evaluation. The results were subsequently compared to air and bone conduction pure-tone thresholds assessed using rigorous standards.

Depending on the audiometric definition as to what constitutes a hearing impairment, the sensitivity of free-field voice testing to identify such an impairment because of an inability to hear a whispered voice at two feet (60 cm.) was 86 per cent or better with the specificity being in the region of 90 per cent.

In the Rinne test the 256 Hz fork was superior to the 512 Hz fork (p<0.05) and the loudness comparison method superior to the threshold decay method (p<0.01) in detecting an air-bone gap. Combining the responses to the two forks did not improve the results. The Rinne test with the 256 Hz fork will identify correctly 48 per cent of individuals with a 15 dB, 69 per cent with a 20 dB, 87 per cent with a 25 dB, and 95 per cent with a 30 dB conductive impairment. In all instances the specificity is greater than 90 per cent.

An investigation into the causes of sensorineural hearing loss in young children has been used as a basis for determining risk factors for parents of children with a hearing loss of unknown origin having a further affected child and for the defect to be passed on to a subsequent generation. The degree of hearing loss likely to be found if further children are affected, is examined.

Through an ultrastructural study of the endolymphatic duct (ED) and sac (ES) system, the effects of an impaired body fluid metabolism on the inner ear fluid environment in the mongolian gerbil has been evaluated. A dehydrative state has been determined depriving of water for both five and twelve days this desert animal, which is known to withstand long periods of water abstinence. The morphological changes of the ED and ES under these circumstances have been compared with those induced by ethacrynic acid intoxication. Although the cochlear partition did not show signs of damage, the ED and ES system seems to be negatively influenced by the dehydrative state and displays a marked imbibition of the subepithelial tissue, which at places shows accumulation of an organic matrix.

A regulating role for the antidiuretic hormone on the inner ear fluids of the mongolian gerbil is also proposed and discussed.

Otomycosis (fungal infection of the ear) is a not uncommon clinical problem encountered in our ENT practice. It makes up to 6 per cent of all patients with symptoms of ear disease seen in the Outpatient Clinic. Of the 193 patients with a clinical diagnosis of otomycosis, 171 cases produced positive fungal isolates. In this study Aspergillus species (niger and fumigatus) have been the most common fungal pathogens. Various aetiopathological factors have been examined in detail, and the available literature reviewed. The results of the treatment by nine antifungal agents currently available in Bahrain have been analysed.

The otoadmittence or impedance measurements are common procedures in the diagnosis of middle ear pathologies. The present study was undertaken for the purpose of studying the clinical validity of static admittance values in 42 confirmed otosclerotic ears. For both 220 Hz and 660 Hz probe tones only one third of the otosclerotic ears had low admittance values, as expected. The remainder showed admittance values in the normal or high ranges. No significant correlation was found between air bone gap (ABG) and the admittance values.

Fifteen dry, small or medium-sized tympanic membrane perforations were treated by local application of 1 per cent hyaluronic acid after excision of the perforation rim. The duration of the perforations ranged from two months to ten years. Fourteen of the perforations were covered within 15±7.4 (S. D.) days and 5 ± 2.4 (S.D.) applications were needed to achieve closure. Hyaluronic acid treatment of dry tympanic membrane perforations not exceeding one quadrant seems to be an alternative to surgical myringoplasty.

The authors report on a series of 25 patients who, in the process of undergoing tympanoplasty, were noted to have erosion of the long process of the incus. This was rapaired with bone pâté in an attempt to restore ossicular continuity. The methods and results are presented and the prospects for the future are discussed.

The sensorineural hearing loss in 150 patients with chronic otitis media who were treated in the Haifa Medical Center (Rothschild) during a ten year period was studied. There were 124 patients treated with a mixture containing neomycin, polymyxin B and dexamethasone and a control group of 26 patients with dexamethasone only.

All patients were followed up for a period of 1–2 years. Patients with hearing loss due to factors such as previous ear surgery, family history, exposure to noise etc., have been excluded.

The conclusions reached were that there is a relationship between the period of disease and the sensorineural hearing loss and that the local treatment with a mixture containing neomycin + polymyxin B appears to contribute to the worsening of the sensorineural hearing loss in patients with chronic otitis media.

Our numbers are small and further studies must be done, but the fact that currently used ear drops may produce a sensorineural hearing loss should not be ignored.

Advances in audiological, radiological and microsurgical techniques have enabled otologists to diagnose and excise very small acoustic tumours with a low morbidity and mortality. Is this cost effective?

In an attempt to answer this question, an analysis of 66 cases of surgically treated acoustic neuromas is presented. This represents part of a series of skull base procedures carried out at Addenbrooke's Hospital over the last five years. As a result of this work an investigative protocol is suggested. By studying the relative morbidity of early and late surgical intervention in these cases, and by costing the exercise, the justification for early diagnosis and treatment is presented both in financial and human terms.

Complete clinical facial paralysis immediately after acoustic neuroma removal occurs in between 40 to 90 per cent of patients despite the fact that the facial nerve has been preserved anatomically. Some of these patients improve rapidly with adequate cosmetic and functional recovery. Others however, have incomplete or no return of useful function.

A pilot study to assess the prognostic value of electroneuronography (ENOG) in 14 patients following acoustic neuroma removal was performed. The results suggest that post operative ENOG is of value in dividing those patients with anatomically intact facial nerves yet complete clinical paralysis post-operatively into groups: one with rapid improvement to an acceptable functional and cosmetic result and one with prolonged paralysis with incomplete or no recovery. Electroneuronography may thus be used to predict the initial recovery profile in patients with complete facial paralysis after surgery.

This evaluation of recent experience of hypoglossal-facial nerve anastomosis in ten patients who had undergone acoustic neuroma resection, indicates that this procedure may have a role to play in the treatment of this disfiguring condition. Facial symmetry at rest is satisfactory in the majority of patients, who suffered little long term deficit from the loss of their hypoglossal nerve. This procedure is ideally suited to otolaryngological practice.

Adenoidectomy performed for ‘glue ear’ accounts for many of the admissions for surgery in childhood. In spite of this there are no objective guidelines to enable the clinician to select those cases in whom a definite benefit is likely, or in whom such procedures might best be avoided. A total of 147 children with established bilateral glue ear randomized to adenoidectomy (A) or no pharyngeal surgery (NS) treatment groups were examined for clearance of effusion in an unoperated ear after one year. Outcome was analysed with respect to the pre-operative Radiographic Palatal Airway size in three groups in relation to mean measurements obtained from matched populations of normal children and those with established disease. Those with small airways had significantly increased clearance following A when compared with NS between the ages of 3–7 years. Adenoidectomy should probably not be performed in those children with large airway measurements, although the outcome may ultimately be related to the age at which surgery is performed.

Clinical assessment of adenoidal enlargement in children is difficult and so the lateral nasopharyngeal radiograph is frequently used to assess both adenoid size and the appearance of the adjacent airways. Various measurements of the soft tissues and airways can be made to assess normality or otherwise. Little previously has been mentioned about the physiological conditions, particularly the mode of respiration, under which these radiographs should be obtained and how changes in these conditions affect their appearance. The marked effect in the appearances of nasopharyngeal soft tissues and palatal airway on simply changing from mouth to nose breathing is presented, and an alternative method of examination, for use under certain circumstances is described.

Congenital hemifacial hypertrophy is an extremely rare condition. At the time of writing this article, there have been 37 cases reported in the literature. Of these, only two have appeared in the otolaryngologic literature. Cholesteatoma of the external auditory canal (EAC) in hemifacial hypertrophy has not been reported before. This article reports one such case, and discusses the classification of hemihypertrophies. A review of the literature is included in the discussion. Management of cholesteatomas of the external auditory canal is also touched upon. A new theory for the peculiar site selection of cholesteatomas of the external auditory canal is postulated.

A columellaform stapes found in male patient 18 years old with a conductive hearing loss, has been examined by SEM and light microscopy. The ossicle was smaller than a normal stapes. The head was linked to the base by a crural plate, probably formed by the fusion of the material of the two crura. Microscopy showed a slightly less interwoven structure of the fibrillar bone present mainly at the cranial aspect of the crural plate. Honeycomb-like bone was confined to the caudal part of the crural plate. Microscopy revealed a cavity in the centre of the stapes at the transition between the base and the plate. During surgery, a bony structure was found linking the posterior side of the head of the stapes to the pyramidal eminence. Post-operative audiograms revealed improved hearing with some residual conductive loss of about 10 dB. This case illustrates that a columellaform stapes may occur without forming part of a syndrome.

Three cases of acute, non-suppurative otitis media in adults are described. They are unusual in that the effusion was confined to the upper middle ear, whilst the lower middle ear was aerated. The aetiology of such localized effusions, is probably related to the anatomy of the middle ear compartments, the mucosal folds forming them and the apertures allowing communication between them. The compartments are relatively constant and are a result of the embryological development of the middle ear. The localization of these effusions, demonstrates the segmental anatomy of the middle ear.

Carcinoid tumours belong to the rarer neoplasms of the middle ear. In 1980, Murphy et al. described the first case of a carcinoid tumour of the middle ear. Only five cases could be traced in the literature. The light and electron microscope features of a primary atypical carcinoid tumour of the middle ear are presented and compared with those described in the literature. Primary carcinoid of the middle ear appears to be derived from the epithelial lining of the middle ear. Distant metastases have not been reported. The duration and nature of the symptoms are of little diagnostic value. An atypical carcinoid tumour in the left ear of a 33-year-old woman is described.