The aetiology of chronic rhinitis and nasal obstruction is often elusive and obscure. Many different causes have been documented including allergens, cigarette smoke, cold dry air, viruses, sulphur dioxide and industrial pollutants. This is the first case we have been able to identify of rhinitis associated with exposure to high levels of lead through indoor pistol shooting.

It is now widely accepted that snoring causes significant social dysfunction. In the absence of obstructive sleep apnoea syndrome, palatal surgery offers a very good chance of eliminating or reducing snoring. The traditional operation of uvulopalatopharyngoplasty remains the ‘gold standard’, but may be complicated by velopharyngeal incompetence, severe post-operative pain and even nasopharyngeal stenosis. A newer technique to reduce snoring caused by palatal flutter by using a neodymnium: yttrium aluminium garnet laser to stiffen the soft palate has been introduced recently by another unit. We show that this procedure can be carried out using a CO2 laser, and present the initial results of the first 29 patients operated on at The Royal National Throat, Nose and Ear Hospital.

Infra-red tympanic thermometry is a relatively new technique for measuring body temperature which requires the minimum of co-operation and is quick and easy to use. It is therefore ideal for use in children. Its use is becoming more widespread and as it is theoretically possible that minor ear surgery may interfere with function its reliability in these patients may be in question.

Twenty-two children (mean age 5.3 years) who underwent myringotomy ± grommet insertion had the tympanic temperature of each ear measured immediately before, and 15 minutes after, surgery on the recovery ward. No difference was found between the pre- and post-operative temperatures (mean difference – 0.1°C, p>0.1, paired t-test, hypothesized difference of 0).

This thermometer appears to be a reliable way of monitoring body temperature on a paediatric ENT recovery ward in patients who have undergone minor ear surgery.

The authores report a case of patient with pachyonychia syndrome, a rare genedermatosis inherited as an autosomal dominant trait, who also had otological lesions beyond the other classic signs and symptoms of the syndrome. Many kinds of treatment have already been proposed, but all failed to show satisfactory results. A new, cheap and easy-to-use treatment was developed in this study, using keratoplastics interpolated with humectant lotion for 90 days. The results after three years of follow-up are still thoroughly satisfactory.

In order to better define the anatomical and clinical importance of the deep parotid lymph nodes, the surgical specimens obtained from a series of 18 total parotidectomies were evaluated. In 10 cases primary parotid pathology was found, whereas in the remaining eight cases metastases to glandular lymph nodes were present.

One hundred and forty-nine lymph nodes, in all, were identified (range 3–14, average 8.2, mean 8), 118 located in the superficial parotid lobe (range 3–11, average 6.5, mean 7), and 31 in the deep lobe (range 0–5, average 1.7, mean 2).

In the group of patients with oncological pathology, of the total 64 lymph nodes examined, 21 were found to be sites of metastasis, 11 in the superficial lobe, and 10 in the deep lobe.

The above findings confirm the anatomical and oncological importance of the deep parotid lymph nodes, and highlight the necessity of a total parotidectomy in all cases in which intraglandular spread of lymph node metastases is certain or suspect.

The process of clerking routine pre-operative admissions involves the house officer taking a full medical history and performing a full physical examination. The diagnostic yield is thought to be low, and the educational value to the house officer is also small. This study addresses the question as to whether routine physical examination is always indicated.

One hundred and nine children admitted for routine Otolaryngology procedures were prospectively studied to identify the importance of examination in the pre-operative assessment of patients.

The results showed that 51 per cent of the children admitted had risk factors. The medical history was sufficient to identify these risk factors in all patients with the exception of one cardiac condition.

This study concludes that a suitable alternative to the current process of clerking such as a standardized nurse history could be safely and efficiently undertaken. Eliminating the tiny percentage of previously unrecognized disease would be a prerequisite for such a change.

A prospective audit study was undertaken to assess the effect of two different management policies following tonsillectomy in children in this hospital, one of which requires a prophylactic five-day course of oral antibiotics and the other does not. A total of 95 children were entered into the trial: 54 received post-operative antibiotics and 41 did not. The post-operative recovery was assessed by completion of a parent questionnaire which included the following parameters: degree of patient distress, nausea and vomiting, otalgia, halitosis, pharyngeal bleeding, analgesic requirement, day of return to a regular diet and General Practitioner consultation. There was no significant reduction in any of the morbidity measures in patients treated with antibiotics. In fact, the analgesic requirement and the incidence of otalgia and irritability on Days 6 and 7 and secondary haemorrhage were significantly higher in the antibiotic-treated patients. Although the number of patients included in this study are small, the results suggest that post-operative antibiotics do not improve the outcome of uncomplicated tonsillectomy. Our previous practice of routinely administering antibiotics to post-tonsillectomy children has been discontinued as the consequence of this audit.

A simple, safe and effective procedure for improving the bacterial isolation in chronic suppurative otitis media (CSOM) is described. It is most useful for the isolation of aerobes as well as anaerobes from the middle ear.

This study was performed to assess the survival times of the Provox™ valve in the Manchester area. Thirty-nine patients from four hospitals, representing 81 valve failures, were studied. The effects of the timing of the tracheo-oesophageal puncture, previous radiotherapy, and the presence and timing of cricopharyngeal myotomy on valve life were analysed. Regression analysis using an extension of the Cox model to allow strata showed that the lifetime of the first valve only is adversely affected by previous radiotherapy. The other covariates do not have a statistically significant effect on valve survival. The median valve survival is 4.5 months, (range one to 12 months). A small percentage of valve users with particularly frequent valve failures may require additional support and prolonged anti-fungal therapy.

A restrospective study was performed on 61 eligible patients with stage III and IV (AJC/UICC Staging System) squamous carcinomas of the head and neck region who were treated with definitive radiotherapy with, or without, surgery. DNA contents were measured by flow cytometric analysis of archival paraffin blocks and were correlated with clinicopathological findings, tumour response and patient survival. Comparison of variables including treatment modality was performed for identification of significant prognostic factors. There were 28 diploid, 27 aneuploid tumours and the remaining six were questionable. All patients were followed-up for at least two years or until death.

Aneuploid tumours had a significantly higher S-phase fraction (percentage S-phase) (p<0.001). Neither ploidy nor percentage S-phase were found to have predictive value in tumour response or patient survival within the power of a sample size of 61. Twenty of the 27 (74 per cent) aneuploid tumours had a complete response (CR) whereas 19 out of 28 (68 per cent) diploid tumours achieved CR. Five-year survival by the Kaplan-Meier method was 33 per cent for both aneuploid and diploid tumours. However, nodal stage (N stage) was found to have significant predictive value in both tumour response and patient survival. The complete response for stage N0 patients was 96 per cent, N1 patients 61 per cent, N2 patients 60 per cent and 43 per cent for N3 patients (p<0.002). Similarly, the five year survival for the N0 and N3 groups of patients was 53 per cent and 29 per cent respectively (p<0.05).

The correction of prominent ears requires a logical approach to address each of the anatomical defects present while bearing in mind the overall shape of the ear. The two most common problems encountered are the lack of an antihelix and a deep conchal bowl.

We describe a method of reducing the depth of the conchal bowl which avoids some of the problems previously encountered such as occlusion of the external auditory meatus and visible irregularity on the external surface of the pinna. Resection of the inferomedial part of the conchal bowl and thinning of the ponticulus allow realignment of the ear and prevent prominence of the antitragus. The ear is then secured with concha-mastoid sutures and the scapha-conchal angle can then be corrected to form an antihelix if necessary.

Caustic ingestion can lead to oesophageal stenosis. We studied 251 patients, 205 of whom were children, in a sixteen-year period. Seventeen patients, of whom one was an adult, acquired deep burns in the oesophagus which had to be treated, to prevent the development of oesophageal strictures. These patients were treated with long-term stenting of the oesophagus with specially designed, silicone rubber stents, impregnated with silicone oil 20 cS, designed by one of us (R.N.P.B.) as the only treatment. Of all models, the twin-tube dilatator was the most satisfactory. No corticosteroids were administered. Only one patient developed a mild stenosis. It is therefore our opinion that, when life-saving operations are not indicated, twin-tube stenting of the oesophagus is helpful in treating caustic lesions of the oesophagus and will prevent stricture formation. Corticosteroids were not given in this series, and should be abandoned in the treatment of caustic lesions.

We report a case of mucoepidermoid carcinoma of the middle ear, a site which does not appear to have been previously described. A discussion of four possible theories of pathogenesis are presented.

We present a case of Hodgkin's disease of the mastoid associated with upper cervical lymph node involvement without disseminated disease. This patient was treated with chemotherapy alone and lesions responded rapidly. At present the patient is well, with no evidence of recurrence or extension of this disease. Hodgkin's disease of the middle ear and mastoid is an extremely rare disease. After a wide search in the literature no cases of Hodgkin's disease arising in the middle ear and mastoid have been found.

Marfan syndrome (MS) is a rare connective tissue disorder, uncommon in otological practice. Ear surgery in MS has not been previously reported. An identical complication of meatoplasty developed in two patients with MS after modified radical mastoidectomy and meatoplasty for chronic otitis media. Both cases presented postoperatively with an external auditory canal narrowing when the walls of the initial meatoplasty in both cases collapsed. It is proposed that this occurred because of the inherent structural abnormality of the cartilage in Marfan syndrome. A simple technique of revision meatoplasty is described that resulted in successful management of these cases.

Foreign bodies in the noses of children may often be expelled by simple nose blowing. Success of this manoeuvre depends on how firmly the object is lodged, and on the co-operation and skill of the child. Attempts at direct removal using instruments frequently result in the patient becoming distressed and resort to general anaesthesia is sometimes required. This short communication describes a series of cases in which nebulized adrenaline helped loosen firmly impacted foreign bodies, thereby facilitating removal, minimizing upset for the child, and avoiding anaesthetic risk.

The genetic aspects of choanal atresia have not been clearly defined though it is probably a multifactorial trait as in cleft lip and cleft palate. The appearance of the condition in both single and successive generations supports this contention.

Choanal atresia can occur as an isolated anomaly, but is more commonly associated with one or more concomitant congenital anomalies. In this report two sisters both in their teens presented with unilateral choanal atresia as an isolated anomaly. Endoscopic trans-nasal repair of choanal atresia was performed in both of them as this offers excellent visualisation and access.

The adult cochlear implant programme in Manchester was established in 1988 and the evaluation of the cochlear implant service involved the first 58 implants users (mean age = 51.65 years, range 19–75 years). Questionnaires were sent to implant users and their partners to evaluate the service with regard to provision of information, clinical care during in-patient assessments, waiting times, operation for cochlear implant and postoperative rehabilitation. The results show that the majority of patients (78 per cent) felt that the implant gave them as much or more benefit than expected. Areas identified for improvements include provision of more written information about cochlear implants; reduction in waiting times for first appointments; more information about the surgical risks and more instruction about home auditory training exercises for family and friends.

As a consequence of the audit results the clinical practice and service provision for cochlear implantation in Manchester has been modified.

Surgical therapy for early lesions of the tongue should have the potential to be both oncologically sound and easy to rehabilitate. Obviously, the amount of tongue left behind after surgery is proportional to the post-operative function. Hence accurate mapping of the diseased tongue is of paramount importance in order to limit or extend the resection margins. We have evaluated the use of ultrasound in carcinoma of the tongue, and also compared its relative accuracy with physical examination for determining the extent of growth, keeping the histopathological size as a gold standard. We found that ultrasound is more accurate in detecting T2 and T3 tumours than T1 lesions. Intraoral sonographic mappng may be the answer for such small lesions. In addition, ultrasonography is beneficial in showing spread to contiguous areas of the tongue. However, post-radiation fibrosis and frank residual disease were not differentiated accurately by ultrasound. Thus ultrasonography can be an effective investigative tool and together with physical examination it can increase diagnostic accuracy leading to precise surgery for carcinoma of the tongue.