It is an honour for an otological surgeon to be asked to deliver the second Sir Morell MacKenzie address. Thank you for the invitation and for that honour. Exactly 100 years ago MacKenzie, with Norris Wolfenden, founded ‘The Journal of Laryngology and Rhinology’. ‘Otology’ was not added to the title until 1892, the year MacKenzie died. I shall return to this theme later. It is also exactly 100 years since, in 1887, MacKenzie was asked by Queen Victoria to examine her son-in-law, Frederick, Crown Prince of Germany. The controversy and subsequent recrimination which flowed from the management of Frederick's laryngeal lesion I shall leave to future lecturers to assess. It is as the founder of British laryngology that he should be remembered. As early as 1863 he had started the Metropolitan Free Dispensary for Diseases of the Throat and Loss of Voice, the first institution of its kind in the world. He wrote authoritatively on diseases of the throat and invented many instruments for the difficult art of indirect laryngeal and pharyngeal surgery. He received his Knighthood, also in 1887.

One hundred and thirty patients with acute-on-chronic mastoiditis were managed by the ENT Department of Groote Schuur Hospital between 1980 and 1984 inclusive. Seventy-four patients had cholesteatomas, of whom 78.4 per cent had intracranial extension and 44.6 per cent had intradural extension of the infection. In contrast, of the 56 patients without cholesteatomas, only 23.2 per cent had intracranial extension of the infection. These may be rare conditions in some privileged parts of the world but their lethal potential requires all ENT surgeons to be competent in their management.

Three hundred and ten patients were examined by otoscopy. Age, sex, social class and use of cotton buds for-aural toilet were recorded. The incidence of visually occlusive wax plugs in the external auditory canals was not significantly different between users and non-users of cotton buds, either in children or in adults.

The operation of inferior meatal antrostomy has emerged as the most popular surgical technique in the management of maxillary sinusitis though the surgical anatomy and natural history of the procedure are poorly understood. The anatomy of the inferior meatus determines surgical limitations and a retrospective study of 108 patients who have undergone antrostomy provides a oasis for a prospective study in which the size of the antrostomy has been assessed in 65 patients pre- and post-operatively using direct measurement and serial photography. After initial circumferential healing within the first few weeks, the majority remain unchanged unless infection supervenes when complete closure may result. The closure is a combination of fibrous tissue and bone in the majority of cases. A critical size is apparent below which complete closure can be anticipated whereas if too large an antrostomy is fashioned, related anatomy is jeopardised and therefore the dimensions must be carefully judged if long-term patency is desired.

The effect of patency on the mucus-secreting elements of sinus mucosa is examined in a second prospective group of 19 patients. Assessment of subjective clinical success determines overall benefit from the operation in most patients though mucous discharge is least improved and this is directly related to the level of increase in goblet cells.

The role of the inferior meatal antrostomy is dependent upon an understanding of the pathophysiology of sinusitis and thereby determining those patients who have potentially reversible mucosal damage and are therefore most likely to benefit from the procedure.

A survey of 67 patients with 74 mastoid cavities has been carried out. During the study period they made a total of 126 cavity/outpatient visits. Thirty-five patients (56 per cent) had discharge from at least one cavity on at least one outpatient visit. At only 5 per cent of visits was the discharge classified as profuse. A retrospective study of 54 mastoid revision operations on 51 patients has been made. Overall 59 per cent of operations resulted in a dry ear. The best results were achieved by carrying out cavity revision combined with a meatoplasty (83 per cent dry ears). Cavity revision alone produced a dry ear in only 57 per cent of cases. The worst results were produced by soft tissue obliteration (33 per cent dry ears). This supplement also presents the early results of a prospective investigation of bone pate obliteration of mastoid cavities. Of the eight cases studied so far, five (63 per cent) have dry ears following surgery. Three of the patients in this group had undergone previous unsuccessful revision surgery using other techniques. Cavity revision with meatoplasty is the technique of choice for most patients, but mastoid obliteration offers potential advantages for younger patients, particularly those wishing to swim.

ABR were recorded in 68 cases suffering from severe acute closed head injuries. Abnormal recordings were observed in 60 per cent of patients, and the abnormalities ranged from prolongation of the interpeak latency intervals to complete absence of auditory brain stem activity. Based on the results obtained, a grading system was developed and correlated with the neurological outcome. It was concluded that ABR is a useful diagnostic and prognostic tool which can provide valuable information about the function of the brain stem in these patients. Inclusion of ABR studies in the head injury management protocol is strongly recommended.

This paper applies the technique of finite element analysis to the tympanic membrane. A Two-dimensional cross-sectional model of the tympanic membrane and malleus is described. A variety of experiments have been performed on this model, and displacements under a uniform load are analysed. The shape of the displaced membrane and the movement of the umbo were found tobe sensitive to a number of factors. These include the elastic modulus of the membrane, the presence and position of the axis or rotation of the malleus, and the size of the pars flaccida. Some implications of these results are discussed.

Patch testing of ten patients who had been treated with gentamicin-hydrocortisone ear drops for active chronic suppurative otitis media showed evidence of contact sensitivity in five. Positive skin tests correlated with failure to respond to treatment.

One hundred and thirty patients with acute and acute on chronic mastoiditis were managed at Groote Schuur Hospital between 1980 and 1984. Twenty-two (16.9 percent) had pathology of the lateral (sigmoid) sinus and 19 of these patients had cholesteatomas. Nine patients (40.9 per cent) had concomitant intradural sepsis and there were two deaths.

The modern literature is reviewed and the pathology, presentation and management of lateral sinus pathology is discussed. This condition is rare and clinical features may range from subtle signs to gross toxaemia, torticollis and evidence of septic embolization. The otolaryngologist must be competent in diagnosing and treating this condition in all forms of its wide spectrum of presentation.

Spontaneous cerebrospinal otorrhoea is a rare complication of a cholesteatoma. The histological findings in a temporal bone from such a case are reported. The cholesteatoma had eroded deeply through the vestibule into the internal auditory meatus.