The diagnosis of a patulous Eustachian tube relies mainly upon the history, examination and a clinical awareness of the condition. More recently, objective tests such as tympanometry and sonotubometry have been shown to be useful in confirming the diagnosis. This paper describes how computed tomographic imaging may also be useful in aiding the diagnosis. Supporting this, clinical cases of patulous tubes are demonstrated radiologically associated with congenital hemifacial microsomia and following radiotherapy for a nasopharyngeal carcinoma. The role of computed tomographic imaging in the diagnosis, research and monitoring of treatment for his condition is discussed.

Facial nerve specimens obtained during reinnervation surgery from 31 patients with facial palsy of varying aetiology were studied. In patients who had a facial palsy after attenuation during acoustic schwannoma removal the facial nerve had normal populations of myelinated nerve fibres in the sensory zone but their numbers and sizes were severely reduced and fibrosis was increased in the motor zone. The latter also had large numbers of endoneurial tubes with thin unmyelinated axons.

When the facial nerve had been severed in tumour removal, it had practically no remaining nerve fibres. In three out of four patients with middle ear cholesteatoma, the distal facial nerve stump showed severe fibrosis. In patients with iatrogenic trauma and skull fracture, the distal stump usually showed few myelinated nerve fibres, endoneurial tubes with thin unmyelinated fibres and increased fibrosis.

The pathological changes observed indicate that in all cases the motor fibres distal to the lesion have undergone Wallerian degeneration and demyelination and in most a subsequent partial regeneration. However, the regeneration remained incomplete. The distal stump of the facial nerve with numerous endoneurial tubes in most cases of the material presented appear to provide favourable structural preconditions for reinnervation surgery.

The manifestations of Lyme disease as they may present to the ENT surgeon are discussed. The most important ENT symptom is facial palsy. Particularly when combined with other cranial palsies, systemic illness or signs of meningeal irritation, the diagnosis must be considered. Three case reports are used to illustrate the presentation and diagnosis and treatment of Lyme disease. The characteristics of the disease are reviewed and the limitations of serological testing outlined. The literature has concentrated on bilateral or relapsing facial palsy. A review of palsies in Zurich that presented to the ENT clinic found only unilateral and partial palsies. The diagnosis should be considered in every case of facial palsy of unknown aetiology especially in children.

One hundred and four cases of osteoradionecrosis (ORN) of the mandible following irradiation of head and neck cancer are reported.

Conservative management for ORN failed in all cases. Indications of hemimandibulectomy included intractable pain, severe trismus, pathological fracture, oro-cutaneous fistula and persistent exposure of bone.

Surgical approach was intra-oral in 100 cases and extra-oral in four. Immediate soft tissue reconstructions were carried out in 20 per cent cases. Post-operative complications included minor sepsis (8.6 per cent), major sepsis (2.9 per cent), haemorrhage (2.9 per cent) and fistula (3.8 per cent). Major complications occurred only in patients treated exclusively by external irradiation at doses equal to or higher than 65 Gy.

Relief from pain and trismus was obtained and normal swallowing was established following radical surgery.

One hundred and seven consecutive patients with acute and chronic epistaxis were examined to identify the site and nature of the source. Aetiological factors in the history, nasal anatomy or pathology were noted, along with the blood pressure and laboratory results.

In most presentations an anterior bleeding point was isolated. Cautery usually sufficed in both anterior and posterior sources. No source was hidden behind a septal spur or deflection. Hypertension was associated with bleeding from the middle meatus, but not with the severity of bleeding. Patients on antihypertensive medication were more likely to be admitted.

Point sources of bleeding were from prominent vessels or haemorrhagic nodules; the latter are not well recognized and are easily overlooked.

Routine blood tests did not reveal unsuspected abnormalities or change management; neither did sinus X-rays.

Initial examination of the nose in the acute phase by experienced personnel is suggested, to reduce admissions and avoid nasal packing.

One-hundred-and-fifty patients with Zenker's diverticulum were reviewed; twelve patients received no treatment; 26 patients were treated endoscopically by dilatation, five of these had a diverticulectomy performed at a later stage.

One-hundred-and-ten patients had a diverticulectomy performed (a total of 115 primary operations were performed). Eighteen of the patients operated upon had a recurrence and six underwent re-operation.

Local complications occurred in 24 patients. Seven patients had a fistula and two had mediastinitis. Ten patients had recurrent nerve palsy, of which five were permanent. Thirteen patients had other complications, usually infection. One death occurred.

Post-operative prophylactic treatment with antibiotics was found to significantly reduce the number of local infectious complications and a correlation was found between the occurrence of local, infectious complications and later recurrence of the pouch.

The use of the sternocleidomastoid muscle and musculocutaneous flaps in the reconstruction of defects arising after surgery for cancer of the head and neck has been a subject of some discussion.

Experience with these flaps over a ten year period from 1980 until 1989 is presented. Attention is drawn to the various types of flaps in vogue, their indications to date, benefits and drawbacks. A new reliable compound musculocutaneous flap developed by the author for use in defects of the skull base after total temporal bone excision is presented.

The complication rate after emergency tracheostomy is two to five times greater than after elective procedures. One of the main causes of the high risk of complications in emergency tracheostomy appears to be the amount of time required to open the trachea. Therefore, simple and fast procedures are mandatory. We have developed a new procedure as follows: A horizontal skin incision is performed. Strap muscles are dissected and retracted laterally. A transverse cut between tracheal rings below the thyroid isthmus is performed up to membranous portion of the trachea. The cut ends of the trachea remain open naturally because of the elasticity of the trachea. Skin and tracheal cut-ends are then joined by interrupted sutures.

We have used this procedure during the past three years and have not experienced any major complications. This demonstrates the clear advantage and the more physiological nature of the procedure over various other incisions of the tracheal wall.

The near field monitoring of an auditory evoked response from the cochlear (electrocochleography) is a tried and trusted clinical tool. Conventional techniques for performing electrocochleography are cumbersome to use and frequently uncomfortable for the patient. We present a simple, modified technique which provides more flexibility with regard to where and when electrocochleography may be performed and also improves patient comfort during the test.

Heterotopic brain tissue is a rare cause of symptoms in neonates in whom it may present with respiratory obstruction. In infants it may produce unilateral nasal obstruction due to a nasal ‘polyp’ or cerebrospinal fluid rhinorrhoea with an associated risk of meningitis. It is exceedingly rare in adults but may nevertheless be a cause of significant morbidity as this case demonstrates.

A case of lymphogranuloma venereum of the tonsillar lymph tissue is presented. The similarities of tonsils to cervical lymph nodes are discussed and the importance of histological examination of abnormal tonsil tissue is reiterated.

The case of an osteosarcoma arising in the mandible of a six-year-old child is presented. It was originally misdiagnosed as a desmoplastic fibroma, and after initial curettage continued to grow for twelve years. The differential diagnosis is presented and details of the surgical access and difficulties encountered in the surgical removal of this very large tumour are described.

The relationship between pre-existing disease and osteosarcoma of the mandible is discussed, and the difficulties experienced in distinguishing between the fibro-osseous lesions and osteosarcoma of the mandible are highlighted.

The case is presented as a well-differentiated, intra-osseous osteosarcoma with subsequent transformation into a high-grade, conventional osteosarcoma.

A 44-year-old man presented with acute airway obstruction. A pedunculated lesion was found arising from the right vallecula. This was confirmed to be an angioleiomyoma, a type of hamartoma rarely found in the oropharynx.

A case of valvular obstruction of the oesphagus following inversion of a pharyngeal pouch is described. This complication has not been described before.

A case of oncocytoma of the larynx is presented. These lesions are rarely found in the larynx, and have been more commonly described in the salivary and thyroid glands. The histopathological diagnosis is often difficult and the light microscopy can be unreliable for oncocytic lesions. For a more accurate definition of these tumours, the use of histochemical stains together with electron microscopy are advocated. With adequate surgery, the prognosis is excellent, and tumours are unlikely to recur. This paper discusses the management of a patient with a benign oncocytoma of the true vocal cord, and presents a review of the world literature.

Parotid metastases from a cutaneous malignant melanoma are uncommon. Although the long-term prognosis is poor, loco-regional palliation is important. In a group of eight patients with parotid metastases, local control was obtained by superficial parotidectomy. Occult cervical lymph node metastases were identified in five cases in whom radical neck dissection provided regional control. Superficial parotidectomy with elective neck dissection is advocated for patients with parotid metastases from cutaneous melanoma to ensure optimal loco-regional palliation.

Metastatic tumours in major salivary glands are uncommon with a higher incidence of primary sites from the head and neck. The lungs and breast are the common primary sites, while metastases from the kidney are very rarely found. The authors describe a case of renal clear-cell carcinoma with metastastis to the parotid gland. The incidence of a metastasis in the parotid gland from a primary renal carcinoma, even if rare, should not be overlooked in making a correct differential diagnosis with acinic cell carcinoma and monomorphic clear cell adenoma.

A case of cervical thorotrast granuloma and its surgical complications is presented. The properties and usage of thorotrast and its later complications are described, and the management of the complications is discussed. It is emphasized that there is usually a long latent period between thorotrast exposure and the advent of complications and perhaps more cases of similar difficulty may be anticipated in the future.

The former view of infectious mononucleosis as an invariably benign disease has been modified in recent years by reports of life-threatening complications. A case is presented of a deep cervical abscess complicating infectious mononucleosis which came close to a fatal conclusion. The implications for the management of the illness are discussed in the light of this rare event, no exactly similar instance of which has been recorded.