Simple rhinohygrometry and passive rhinomanometry studies have suggested that the ‘nasal cycle’ in children is often different in pattern of that of adults and experimental animals. We aimed to establish whether this assertion was correct, using a reliable and sensitive method, acoustic rhinometry (AR), and to compare results with those of simple rhinohygrometry (RH). Healthy children with no evidence of nasal disease were examined (n = 15; age range three to 10 years; mean age six years). Simultaneous recordings using AR and RH were made on each child every 10–15 minutes over two to four hour periods. Six children underwent nine additional AR studies on separate occasions. ‘Classical’ reciprocal alternating patterns were evident in 80 per cent (12/15) AR and 53 per cent (8/15) RH studies, ‘in concert’ patterns in seven per cent (1/15) AR and 20 per cent (3/15) RH studies and ‘irregular’ patterns in 13 per cent (2/15) AR and 27 per cent (4/15) RH studies. The agreement between the two methods was 47 per cent, with a kappa (K) value of −0.17 (poor agreement compared to chance). Agreements between the acoustic rhinometry parameters were ‘fair’ for all data (K = 0.34) and excellent (K = 1.0) if irregular patterns were ignored. Repeated studies showed that the pattern of fluctuation varies within any particular individual. The nasal cycle is similar in pattern in children and adults, and acoustic rhinometry is currently the method of choice to further investigate and clarify this phenomenon.

We report two cases of unilateral choanal atresia and one of choanal stenosis treated successfully by endoscopic fenestration, with no recurrence at a mean follow-up of 18 months. Rigid endoscopy and axial CT scanning confirm the clinical diagnosis and this technique avoids the need for stenting or prolonged postoperative stay.

Facial motor function was assessed in 61 patients 18 months after surgical resection, by the translabyrinthine approach, of vestibular schwannoma involving both the cerebellopontine angle (CPA) and the auditory canal.

Pre-operative magnetic resonance imaging (MRI) was performed to measure the maximum extracanalicular diameter of the tumour between the porus and the farthest extension in the CPA on tranverse slices and to calculate extracanalicular tumour volume. Post-operative facial motor function was graded according to the House and Brackmann system.

There was a statistically significant relationship between late facial motor function and extracanalicular diameter. The best cut-off point for good and poor results was 20mm. There was no relationship between the tumour volume and the late post-operative facial motor function grade.

In this study the best pre-operative radiological predictor of the late facial motor function in patients operated on by the translabyrinthine approach was the maximum diameter measured byMRI.

Two hundred and nineteen patients, with intracranial complications of sinusitis, are presented. Sinusitis is still a life-threatening condition and if neglected, or mismanaged, can lead to intracranial complications that result in a high mortality and morbidity.

Twenty-two patients had meningitis, 127 subdural empyema, 38 brain abscess, 15 combined brain abscess and subdural empyema and 17 extradural empyema. The diagnosis of intracranial abscess and sinusitis was made with the aid of a CT scan, and that of meningitis on cerebrospinal fluid microscopy, chemistry and culture. The most frequent presenting signs were fever (68 per cent) and headache (54 per cent). The most common localizing neurological sign was hemiparesis (35.5 per cent). Orbital inflammation was present in 41.5 per cent of patients.

Treatment entailed immediate, appropriate, intravenous antibiotic therapy and prompt surgery, performed within 12 hours of admission. In patients with meningitis, the surgery entailed surgery of the sinus disease only. In patients with subdural empyema, brain abscess and extradural empyema, evacuation of the primary source of infection by the radical frontoethmoidectomy approach, immediately after drainage of the intracranial collection of pus, was carried out.

There were 35 deaths (16 per cent). The highest mortality rate was recorded in patients with meningitis (45 per cent) followed by brain abscess (19 per cent) and subdural empyema (11 per cent). Despite advances in medicine, i.e. antibiotics and CT scan for early and accurate diagnosis, the mortality from sinogenic intracranial complications has remained significant. This can only be eliminated through education. This paper emphasizes to younger generations of otolaryngologists and primary care physicians that sinusitis is a serious disease and there is no place for delay or complacency when managing such patients.

Tuberculosis of the thyroid gland is an extremely rare condition. Amongst 1565 cases of thyroid lesions subjected to fine needle aspiration cytology (FNAC) over a period of nine years, 18 cases (1.15 per cent) were found to have cytological features consistent with tuberculosis thyroiditis. Acid-fast bacilli were isolated in all cases. The ages of the patients ranged from 36 to 52 years with a median age of 46 years: there were 12 females and 6 males. All the patients presented with painless solitary nodules of the thyroid. Three patients had concomitant cervical lympadenopathy and four patients were known to have tuberculosis of the lungs which was being treated. Solitary nodules of the thyroid were confirmed by a thyroid scan with radioactive iodine. Fine needle aspirates from thyroid swellings showed epithelioid granulomas with necrosis in all cases. There were no false reports or complications.

It is evident from this study that FNAC is an efficient way with which to detect tuberculosis of the thyroid gland.

An endoscopic study of the sphenoid sinus was carried out, on 30 cadavers, to understand the important anatomical relationships of the sphenoid sinus, and the sella turcica. The aim was to study the endoscopic anatomy and the variants, and to determine if endoscopic instrumentation and techniques, could play a beneficial role in endoscopic management of sellar lesions.

The results of this study are discussed, with particular reference to the important surgical anatomical features of the sphenoid sinus. A surgical technique for the endoscopic transsphenoid approach to the sella turcica was developed.

Anatomical variants can be identified endoscopically, and endoscopic techniques have the advantages of improved visualization, magnification, angled vision, and a panoramic perspective of the intrasphenoid anatomy, compared to currently employed methods of pituitary/sellar surgery, using the operating microscope/.

Post-operative nasal medications are commonly used following routine septal or turbinate surgery but their efficacy in removing blood clots, improving the sensation of a patent airway and promoting healing are unknown. This prospective randomized trial of patients undergoing septal and/or turbinate surgery assessed the efficacy of three commonly used nasal medicines, 0.5 per cent ephedrine hydrochloride nasal drops, betamethasone sodium phosphate (Betnosol®) nose drops and alkaline nasal douches, in producing the sensation of a patent airway in the 14 days following surgery. Ninety-seven patients were randomized into the three treatment groups and a control group who received no nasal medication. Patients assessed their nasal patency by means of a visual analogue scale (VAS) and any complications of treatment were recorded. Statistical analysis of the 76 complete sets of results using the Mann-Whitney U-test showed that there was a significant difference in the distribution of all of the treatments for each of the time intervals (p<0.05). Glass rank biserial correlation coefficients were all small (rg<0.085) but the most significant differences were between ephedrine and the control group at two hours, two, seven and 10 days (0.02, 0.054, 0.057, 0.085 respectively), alkaline nasal douches being most significant at four and 14 days (0.06 and 0.0722 respectively).

Tonsillectomy is a common operation in children performed by a variety of techniques. Recently we have introduced a modified form of electrodissection tonsillectomy using bipolar diathermy. A prospective study was designed to evaluate this technique against the conventional dissection/snare technique. Sixty children were entered into each section of the study (total 120 children). There is a statistically significant shorter operating time (mean 11.2 minutes) and lower intraoperative blood loss (mean 5 ml) using the bipolar diathermy technique. Post-operatively, the children who had bipolar diathermy tonsillectomy were found to be able to drink and eat significantly earlier than the cold dissection group. There was no measurable difference in analgesia requirements before discharge and the time of discharge between the two methods. Post-operative haemorrhage occurred in two out of 60 (3.4 per cent) and one out of 60 (1.7 per cent children) in the conventional and bipolar diathermy dissection, respectively, but this was not statistically significant.

To study the efficacy of peak nasal inspiration flow (PNIF) as a means of recording change in nasal patency 20 subjects were given increasing doses of intranasal 5tometazo1ine. Nasal resistance (NR) and peak nasal inspiratory flow (PNIF) were measured in the resting stateand after each xylometazoline administration. Successive increases in dose caused a progressive decrease in nasal resistance and an increase in PNIF but the change in peak nasal inspiratory flow (PNIF) was much less. Peak nasal inspiratory flow shows a plateau effect as nasal resistance decreases. The reasons for this plateau are discussed in terms of respiratory flow mechanics

Day-case surgery is increasing to improve health care efficiency. Adult tonsillectomy is performed on an inpatient basis in the UK because of safety concerns regarding primary haemorrhage. This study aims to investigate the likely safety of day-case tonsillectomy in adults, by defining the incidence and timing of primary haemorrhage and therefore to establish a safe time period for same-day discharge.

Prospectively recorded data on 2 157 adult tonsillectomies over a five-year period were reviewed. Serious primary haemorrhage was uncommon (0.8 per cent). The 95 per cent reference range of time to primary haemorrhage was within 0 to 6.8 hours of surgery and the 95 per cent confidence interval (C.I.) of its upper limit was 5.2 to 8.4 hours. The results compare favourably with the UK inpatient and US adult day-case literature.

We conclude that day-case tonsillectomy would probably be safe in adults if the patients are discharged after 8.4 hours.

Acute and chronic infections cause morphological changes in the respiratory mucosa. The ultrastructure of human respiratory mucosa was studied by scanning electron microscopy from the maxillary sinuses of 28 patients, with chronic sinusitis, from middle turbinates of 60 patients, with recurrent respiratory infections, and from healthy sphenoidal sinuses of 31 patients. A loss of ciliated cells and an increasing number of nonciliated columnar cells with microvilli were seen in 62 per cent of the maxillary sinus mucosa. Ciliary disorientation was seen in 81 per cent of the chronically infected sinus mucosa and eight per cent in the healthy sphenoidal sinuses. Also metaplasia and extrusion of epithelial cells were prominent in chronic infections. Compound cilia were seen in 52 per cent of the samples from patients with chronic sinusitis and in 31 per cent of the healthy sphenoidal sinuses. Short cilia were often seen in infected mucosa indicating ciliogenesis.

The pattern of recurrences after surgical treatment of 276 patients with stage T3 and T4 laryngeal carcinoma was reviewed. Nodal recurrence was the commonest site and occurred mainly in patients with supraglottic and transglottic carcinoma. Distant metastasis was the second commonest site of recurrence, and the most distant metastases developed without locoregional recurrence. Local recurrence alone was uncommon in patients treated with primary surgery.

A retrospective analysis of 34 cases of sino-nasal squamous cell or undifferentiated carcinoma in patients admitted between 1984 and 1992 was undertaken. Multimodality therapy incorporated radiation, surgery and chemotherapy. The five-year survival rate was 53 per cent. The local control rate was 82 per cent. Patients died of local failure (six), distant metastases (six), lymph node metastases (one) and other causes (three). Twenty-eight patients with local control were separated into groups: G1–2 (well and moderately differentiated) and G3–4 (poorly differentiated and undifferentiated) and evaluated to find the association between differentiation and metastasis. Lymph node metastasis was not related to the degree of differentiation. Distant metastasis was significantly related to the degree of differentiation (Fisher's exact test: p = 0.007). The result of the combination therapy is poor for patients with poorly differentiated or undifferentiated carcinoma because of distant metastases. Adjuvant chemotherapy may be necessary for them to prevent distant metastasis.

The aims of this study were to demonstrate the effect of bismuth subgallate and adrenaline paste application to the tonsillar fossae on operating time and peroperative blood loss during tonsillectomy. Ninety-eight patients were included in a prospective randomized trial.

Bismuth subgallate powder is mixed with 10 ml of normal saline and 0.03 ml of 1:1000 adrenaline to make a paste. This paste is used as a topical haemostatic agent during tonsillectomy. Bismuth subgallate activates Factor XII and therefore accelerates the coagulation cascade. Adrenaline causes vasoconstriction and promotes platelet aggregation. The application of bismuth subgallate and adrenaline paste to the tonsillar fossae during tonsillectomy reduces operating time by 23 per cent for Consultant staff (p<0.05) and 32 per cent for Junior staff (p<0.05). Blood loss is reduced by 21 per cent (p>0.05), for the average paediatric tonsillectomy.

The differential diagnosis of stridor in an infant depends on a careful history and examination, followed by radiological and endoscopic investigations. Currently a chest, lateral neck and antero-posterior, high kilovolt (Cincinnatti) view radiographs in association with a diagnostic barium swallow are performed prior to the definitive diagnostic procedure of microlaryngobronchoscopy.

Our impression was that some of the routinely ordered radiological investigations were of limited value in the differential diagnosis. We undertook a retrospective audit study to determine the value of radiological investigations in the pre-endoscopic assessment of infants with stridor. The radiological and endoscopic information of 100 infants presenting over the three-year period 1991–1993 at Great Ormond Street Hospital, London (a tertiary referral centre) was collected.

It was found that only five out of 65 barium swallow investigations performed had consistent positive findings at diagnostic microlaryngobronchoscopy. The lateral neck and Cincinnatti views identified many of the more gross pathologies of the larynx and trachea e.g. the space occupying lesions, which occur infrequently. The more common diseases e.g. laryngomalacia or subglottic stenosis are rarely identified radiologically.

Our results confirmed that radiology had a limited screening role and that in a child presenting with stridor the initial radiological assessment should be a chest radiograph with further imaging and a barium swallow only if an abnormality is found at microlaryngobronchoscopy.

Squamous cell carcinoma of the posterior oro-and hypopharyngeal wall (SCCPPW) is a relatively rare tumour. A retrospective investigation of 63 patients with SCCPPW and 449 patients with carcinoma of the lateral oro- and hypopharyngeal wall, treated between 1964and 1992, has been carried out. Most SCCPPW were asymptomatic, macroscopically superficial and at early stages. They were usually detected by chance during an examination for a different type of malignancy. Fifty-seven per cent of SCCPPW patients had multiple tumours; however this occurrence did not alter the survival rate. The crude five-year survival rate for SCCPPW was 22 per cent and was not significantly different from that of patients with lateral wall tumours. Moreover, both local control and recurrences also were not statistically different.

We present our experience in the surgical management of 21 snorers, utilizing a new approach designed to stiffen the palatal musculature, without compromising its function. This was achieved by using a punctate patterna of intrapalatal diathermy to achieve fibrosis within the palate and hence the requisite stiffening. The initial results of this procedure are encouraging showing a subjective improvement in snoring in 85.7 per cent of patients and an increase in sleeping in the same room as their partner every night, from 14.3 per cent pre-operatively to 57.1 per cent post-operatively.

A prospective randomized study was carried out to assess the post-tonsillectomy morbidity of the electrodissection technique as opposed to the blunt dissection and ligation technique. One hundred and four patients, each serving as his or her own control, were randomized to have either the right or left tonsil removed by electrodissection. There was significantly less pharyngeal pain on the electrodissection side in the first postoperative day in adult patients. This, however, was transient as there was increased pharyngeal discomfort and otalgia, both in severity and duration, on the electrodissection side by the end of first week. There was no difference in the incidence of haemorrhage between the two techniques.

For a long time uvulopalatopharyngoplasty (UPPP) has been used to treat the obstructive sleep apnoea syndrome (OSAS). The diverse surgical effects, the inadequate understanding of operation effect consistency, the possibility of disease progression, and the few reported papers for long-term evaluation after UPPP aroused our interest in designing this study. Fifteen OSAS patients who had undergone UPPP with pre-operative, initial post-operative and long-term post-operative polysomnographic studies were included in this study. Long-term post-operative polysomnography was undertaken more than five years after surgery. The polysomnographic evaluations included respiratory disturbance index (RD I), duration of saturation SaO2 <85 per cent (DOS), and the lowest O2 saturation (LOS). Amongst them, 10 patients with initial post-operative RDI reduction > 50 per cent were considered responders. In these responders, the long-term follow-up results of all three parameters showed improvement compared to the preoperative data. In a comparison between the initial and long-term post-operative sleep study results, LOS and DOS showed no significant difference. However, the long-term post-operative RDI result became significantly worse. More than 80 per cent of all cases had subjective symptomatic improvement in the long-term post-operative evaluation. The subjective improvement after operation is not adequately correlated to the polysomnographic result. We suggest that long-term follow-up for patients after UPPP is necessary.

Soft tissue sarcomas in the head and neck are rare. Aetiological factors relating to these tumours have not yet been identified. The association with von Recklinghausen's disease andwith irradiation is however well recognized. In the literature it has been speculated that trauma may also play a role in the development of soft tissue sarcomas. In this article we present five patients with a history of surgical trauma at the site where a sarcoma later developed. Although we cannot prove a causal relationship, the relatively high incidence of possibly trauma-related soft tissue sarcomas in a series of 60 patients we have seen over a 30-year period, suggests that such a relationship could exist.