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.

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.

The ultrastructure of the guinea pig endolymphatic sac was studied, using the ruthenium red staining technique. The dye stained the apical cell surface coat and the homogeneous substance in the luminal space of the endolymphatic sac, when introduced from the luminal side of the epithelium. It is suggested that the surface coat and homogeneous substance may play an important part in the endolymph regulatory mechanism in the endolymphatic sac. When ruthenium red was introduced from the subepithelial side, the basolateral surface of the epithelial cells usually became brightly stained in the absence of staining of the apical cell surface, due to the presence of the tight junctions. In some instances, however, the dye penetrated beyond the level of the tight junctions. Pinocytotic vesicles and larger vacuoles in the epithelial cells were also sometimes stained, both apically and near the lateral cell surface. These findings suggest that endolymph efflux mechanisms in the endolymphatic sac may involve the combined actions of a paracellular and transepithelial flow as well as a transcellular, vacuolar bulk flow.

Small chemodectomas in the middle ear cavity can be recognised by otoscopy, but only radiology will show i f the jugular bulb is involved. This assessment can be difficult, but largely governs the surgical approach. Magnetic resonance is a valuable adjunct to CT, providing some tissue characterisation. The relative value of various imaging techniques is discussed.

A preliminary report on a technique of myringoplasty is presented with the idea of minimizing graft rejection, and to combat anterior blunting and lateralization of the graft. The grafts were generally stable and mobile. Out of 200 cases there was only a 2 per cent rate of graft rejection, with no evidence of anterior blunting or lateralization. The hearing improved considerably. The technique is simple and relatively quick.

The value of Politzerization as a method of treatment in atelectatic ears and secretory otitis media is controversial. In some places it has been used routinely for decades, in others it has been almost forgotten. A quantitative study of its therapeutic value has been difficult to find.

The present study is an attempt to evaluate the therapeutic value of such an ‘air douche’ in atelectatic ears. Thirteen middle ears with atelectasis were Politzerized daily with air or N2 for up to five consecutive days. Once Politzerized, the atelectasis and retraction pockets disappeared in all the ears examined. However, continuous observation of the Politzerized ears with the surgical microscope revealed that all the ear drums returned swiftly to their retracted position. The time it took for a drum to return to its original place varied from 15 minutes up to a maximum of 335 minutes. Our observations show that even an increased number of Politzerizations did not alter the speed of reappearance of the atelectasis. It would therefore seem that the therapeutic value of Politzerization in atelectatic ears is doubtful.

The authors report on a series of 24 patients in whom open cavity mastoidectomy cavities were obliterated with bone pâté. The aim of the procedure is to provide the patients with a dry ear which then also reduces the need for frequent out-patient attendances.

Labyrinthectomy for unilateral Meniere's disease may be complicated by persistent unsteadiness post-operatively. The aim of this study is to identify the unfavourable factors in recovery following labyrinthectomy. Twenty-one patients gave a detailed history and underwent neuro-otological, opthalmic and cardiovascular examination, as well as psychological and psychiatric assessment. Sedentary occupations, external health locus of control, extraverted personality, and an anxious and/or depressed psychiatric state were associated with poor post-operative recovery. These factors therefore should be taken into consideration in the pre-operative assessment and post-operative rehabilitation of labyrinthectomy patients.

The aim of the study was to compare synthetic monofilament suture materials with chromic catgut and silk in aural wound closure. Forty patients undergoing mastoidectomy or tympanoplasty were randomized to closure with either 30 PDS (Polydioxanone) to fascia plus 30 Prolene to skin, or 20 chromic catgut to fascia plus 30 silk to skin. Known or suspected factors affecting wound healing were recorded. Nine patients had post-operative wound infections. The infection rate was significantly lower in wounds closed with PDS and Prolene (χ2 = 6.05, p<.05), and in tympanoplasty operations (χ2 = 4.42, p<.05). Four patients suffered wound dehiscence, all four had been closed with catgut and silk. No other complication of wound healing was noted in the trial. In conclusion, PDS and Prolene are superior suture materials to catgut and silk in the closure of aural wounds.

Fifty patients with diabetes mellitus of varying duration were divided into two groups according to whether they were on treatment with insulin or not. Nasal mucosal blood flow was investigated and the results were compared with a reference material from healthy subjects, and were also related to the degree of retinopathy. Patients with diabetes mellitus had normal mucosal blood flow. There was no correlation between the duration of diabetes and nasal blood flow, nor was there any correlation between the degree of retinopathy and nasal blood flow. Diabetes mellitus does not seem to be accompanied by changes in blood flow in the nasal mucosa.

Local anaesthetic with vasoconstrictor combinations are often used to reduce bleeding and hence improve the operating field in septal surgery. Two commonly used combinations are lignocaine with adrenaline and prilocaine with felypressin (citanest with octapressin). Most surgeons prefer to use lignocaine with adrenaline but because of the risks of cardiac dysrhythmias when used with halothane anaesthetists prefer prilocaine with felypressin. In a trial with lignocaine 2 per cent and adrenaline 1 in 200,000 against prilocaine 3 per cent and felypressin 0.03 international units/ml in 18 patients undergoing septal surgery with local anaesthesia alone there was significantly less blood loss in the lignocaine with adrenaline group, p>0.01. The mean blood loss in the adrenaline group was 7.5 ml. and 32.7 ml. with felypressin. Both combinations were equally effective in producing adequate local anaesthesia. It is concluded that lignocaine with adrenaline is superior to prilocaine with felypressin in achieving a dry operating field in septal surgery under local anaesthesia.

Information obtained from the case-records and completed questionnaires from 478 patients operated in the 5-year-period 1980 through 1984 with either septoplasty or submucous resection (SMR), has been analysed on an average 31 months after surgery. Two hundred (42 per cent) underwent SMR and 278 (58 per cent) septoplasty. Twenty per cent presented for a clinical follow-up examination. Of the 478 patients, 63 per cent were satisfied. More patients were satisfied with the functional results after septoplasty, which also resulted in fewer and smaller perforations than SMR. Septoplasty ought to replace the latter as the routine procedure. 10 per cent had troublesome crusting independent of the technique used. Change in the external shape of the nose is a minor problem for the patients, and was not regarded as an indication for re-operation. Patients with allergic rhinitis may undergo septal surgery on general lines.

Conventional treatments for non-allergic perennial rhinitis have proven somewhat unsuccessful in the control of rhinorrhoea when it is the predominant symptom. Hence, a double-blind cross-over trial of Ipratropium, a parasympatholytic, and placebo were carried out over a 12-week period. There was a significant reduction in rhinorrhoea during active treatment, with the most noticable effect being in the moderate-to-severe rhinorrhoea group. No significant effect was noted on nasal obstruction or sneezing and no serious side-effects were seen. A carry-on effect was noted when active treatment was used initially. However, the group given active treatment following placebo had a better result overall. A strong placebo effect was also noted in both groups, in keeping with a trial of this order.

Each of the three types of ethmoidectomy: intra-nasal, trans-antral and external, has its supporters and detractors who argue about the efficacy and safety of the procedures. One hundred and five ethmoidec-tomies for nasal polyps are reviewed retrospectively. Regardless of the approach used, approximately half of these had recurrence of polyps and some patients had several revision operations. There were six complications specific to the surgery. None was serious but most occurred with external ethmoidectomy. The limitations of ethmoidectomy for nasal polyps, the reasons for the good safety record and the best means of training juniors in the procedures are discussed.

In a nine-year period 50 nasopharyngeal angiofibromas, of whom 13 had recurrent tumour, were treated surgically at the All India Institute of Medical Sciences, New Delhi. A new staging system according to the regions involved was used; 31 patients in whom the tumour was limited to the nasopharynx (Stage I) and those with superior spread into the ethmoid or sphenoid sinuses (Stage IIA) had their tumours removed by a transpalatal route, alone or in combination with other approaches. Tumours with lateral extensions into the pterygopalatine or infratemporal fossae or the cheek (Stage IIB), and those with simultaneous superior and lateral spread (Stage HI) underwent a transmaxillary excision (19 cases). In two of the three cases with intracranial extension (Stage IV), the tumour was removed successfully from below. There was no mortality. The usefulness of the transmaxillary approach, especially in recurrent cases, is emphasized. No adjuvant modalities were employed in this series and blood loss was acceptable.

‘Benign metastasizing mixed tumours’ are enigmatic lesions of the parotid gland. The authors, through the illustrations of a case and review of the literature, conclude that the tumours are unrecognized and currently unclassified malignancies.

Tonsillectomy frequently results in a significant degree of post-operative pain. Conventional management consists of the administration of intra-muscular opiates prior to the commencement of oral analgesia and is often inadequate, producing variable levels of pain relief.

One of the recommended uses of benzocaine lozenges is the relief of throat discomfort following tonsillectomy, but there are no clinical trials to support this claim. Therefore, a prospective placebo controlled trial was undertaken to compare the efficacy of benzocaine lozenges (10 mg.) with standard oral analgesia in the management of post-operative pain following tonsillectomy in an adult population.

Consecutive patients undergoing elective tonsillectomy were randomised to receive either benzocaine lozenges (10 mg.) or placebo. Intake of supplementary oral analgesia was recorded, and the level of postoperative pain was assessed by use of a visual linear analogue scale. There was no significant difference in analgesic intake or pain severity as measured by linear analogue between the two groups.

These results suggest that there is no benefit in administering benzocaine lozenges for the relief of post-tonsillectomy pain, and its use in this situation cannot be recommended.

A technique for endoscopic fine needle aspiration cytology (FNAC) of the larynx is presented and its use in a preliminary study of twelve patients is discussed.

One hundred and one patients presenting with a squamous cell carcinoma of the larynx underwent surgery i n our department between January 1980 and May 1985. In most of these patients, nodes were removed from the main lymphatic drainage pathways and subjected to immediate frozen section examination. The results from frozen section examination of the nodes were then compared with those from the surgical specimens of cervical neck dissections performed on the patients according to the classic rules. In addition, margin resections were made and examined by frozen section after removal of the tumour. In the event of a positive finding, these resections were continued until healthy tissue was reached, the specimens being examined in addition by classic methods.

Immediate frozen sections enable the margins of the resection to be verified correctly. In our series we were brought to extend the limits of resection in 10 cases out of 68 (15 per cent). It can also be seen that the accuracy of the pathologist's reading of the frozen sections is satisfactory. The overal level of error is three out of 68 (4.5 per cent). All the errors correspond to false negatives.

The aim of avoiding neck dissections in the presence of N0, thanks to nodal selection with frozen section, is not attained. We find a 6/61 rate of false negatives for N0 - N1 (10 per cent) when we compare the frozen sections of the selected nodes and the neck dissections. This is due to the fact that the surgeon may be led astray by a reactive hyperplastic node whilst other less inflammatory neighbouring nodes are in fact the site of metastasis.

In recent years endotracheal tubes with low pressure cuffs have become available with the aim of reducing trauma to the trachea and larynx. This paper uses laryngographic methods to analyse intubation trauma in 20 short to medium term intubations.

No difference in laryngeal trauma was found between low pressure, large diameter cuffs when compared ot standard cuffs.