The relationship between temporal bone pneumatization and the location of the lateral sinus and length of the mastoid process was investigated in 60 fresh frozen adult temporal bones, by plain X-rays, computed tomography and surgical dissection including otomicroscopic findings. Temporal bone pneumatization was classified as small, moderate and large. After drilling, the shortest distances between the middle fossa dura and mastoid tip representing the mastoid length and between the sigmoid sinus and posterior border of external auditory canal were measured and compared to the degree of pneumatization. The distances in the specimens with pathological eardrum and adhesions in the middle ear were compared to the ones without gross pathology. The length of mastoid process was significantly shorter in specimens with small pneumatization than those with large (Mann Whitney P<0.001).

The specimens with a pathological eardrum and middle ear adhesions had a significantly shorter mastoid length than those without gross pathology. There was no significant difference between degree of pneumatization and the shortest distance between sigmoid sinus and external auditory canal (Mann Whitney P>0.05). It is demonstrated that the ‘under-developed’ mastoid process can be a consequence of hampered pneumatization.

Six cases of otitis media with effusion associated with Chlamydia pneumoniae, a currently recognized respiratory tract pathogen, are presented. The organism was isolated from the middle ear fluids and serological evidence confirmed it as the infectious agent. The study population is small; however, these reports suggest C. pneumoniae as a causative agent of middle ear diseases.

The role of the rigid endoscope has been evaluated in the management of 36 cases with dry central perforation of the tympanic membrane. The graft take rate was 91.7 per cent and the air-bone gap was closed to less than 10 dB in 83.3 per cent.

The use of the rigid endoscope in the management of dry central perforation of the drum represented a significant advance in middle ear surgery. It is used, in correlation with manometry, to evaluate the tubal function before ear surgery and to treat hidden causes of tubal obstruction. It replaces the operating microscope in observation and surgery of the tympanic membrane perforation. It overcomes anatomical variations that hamper access to the entire tympanic membrane during ear surgery. It provides an extremely sharp image with high resolution.

Contrary to previous practice, the eradication of posterior mesotympanic cholesteatoma can frequently be achieved using a transcanal approach and without the need for more major surgery. For success, certain specific steps are necessary. These are described and the results reported.

In the quest for hearing preservation in patients with acoustic schwannomas it is essential that surgeons do not lose sight of the concept of ‘useful’ hearing. There is an important difference between hearing preservation which pleases the surgeon and that which will be appreciated by the patient.

Tumour size, pure tone audiogram average differences between ears and speech discrimination scores have been recorded in a series of 114 patients with unilateral acoustic schwannomas. Criteria for useful hearing are presented in terms of pure tone audiogram average difference and speech discrimination scores.

There were 11 patients (10 per cent) with a speech discrimination score of 50 per cent or more, a pure tone audiogram average difference of 30 dB or better and a tumour size of no more than 2 cm. Only one patient (0.9 per cent) had a speech discrimination score of 50 per cent or more, a pure tone audiogram average difference of 20 dB or better and a tumour size of no more than 1 cm.

It is concluded that hearing preservation techniques may be applicable to between 1 and 10 per cent of patients with unilateral acoustic schwannomas.

The diagnosis of CSF rhinorrhoea on clinical grounds alone can be difficult. We describe how the use of noninvasive electrophoretic analysis of nasal secretions for tau protein (asialotransferrin) helped in the management of cases where the existence of a CSF leak was in doubt. Patients were thus saved unnecessary invasive investigations or surgery. A modification of the method of analysis, which improves diagnostic accuracy, is described.

Whilst it is generally accepted that the standard management for anterior or benign epistaxis is either cautery or anterior nasal packing, that of posterior or intractable epistaxis remains controversial. Various modalities of treatment, ranging from posterior nasal packing to arterial ligation and embolization, have been advocated but none have been unanimously accepted as the treatment of choice.

The purpose of this paper was to determine the efficacy of internal maxillary arterial ligation versus combined internal maxillary arterial ligation and anterior ethmoid arterial coagulation in intractable epistaxis.

Over a six year period, from 1985 to 1990,454 patients were admitted and treated for epistaxis. Forty-seven patients were diagnosed as having intractable epistaxis on the basis that the epistaxis failed to settle on anterior nasal packing. They were moved to the next step in management, which was combined anterior and posterior nasal packing. There were 30 failures, one was found to have choriocarcinoma of the maxilla, and was treated wtih cytotoxics, and the other 29 were moved to the next step, which was arterial ligation. Fifteen patients had internal maxillary arterial ligation, and 14 combined internal maxillary arterial ligation and anterior ethmoidal arterial coagulation.

Large windows were created in both the anterior and posterior walls of the maxillary sinuses and all identifiable branches of the internal maxillary artery were dissected out carefully and two medium size ligating clips were placed over the main trunk, the sphenopalatine and the descending palatine branches. Single clips were placed on all other identifiable branches. Coagulation of the anterior ethmoidal artery was performed with a bipolar cautery. There were three (20 per cent) failures in the internal maxillary arterial ligation group and none in the combined internal maxillary arterial ligation and anterior ethmoidal arterial coagulation group. Furthermore, the three failures were successfully treated with anterior ethmoidal arterial coagulation. The conclusion is that combined internal maxillary and anterior ethmoidal arterial occlusion is the treatment of choice in intractable epistaxis.

Devitalized homologous costal cartilage is widely employed as an implant in the management of the saddle nose. The tissue response induced by the implant is a combination of enveloping fibrosis and implant resorption, which will probably, ultimately, be complete. We have studied the balance between resorption and fibrosis, following different modes of cartilage preparation, in the mouse. Homologous costal cartilage was devitalized by four common methods—irradiation, formalin, glutaraldehyde and alochol. Segments of this cartilage were inserted at separate sites in the subcutaneous plain of the tail. These implants were harvested after one year for histology. Variations in the mode of cartilage devitalization, while inducing variations in the degree of the tissue response, did not influence the balance between fibrosis and resorption. Thus the long term maintenance of tissue bulk following homologous cartilage implantation is not influenced by the mode of preparation. Evidence suggests that the ultimate cosmetic results of autologous and homologous costal cartilage implantation would be much the same, and the use of homologous cartilage must be justified on other grounds.

The result of a study conducted on 30 patients of lepromatous leprosy regarding laryngeal involvement is presented. The incidence of leprous laryngitis is 36.6 per cent in this part of India in lepromatous leprosy patients. Leprosy is long standing disease so laryngeal lesions developed gradually and may be asymptomatic in some cases while others have been found to have variety of clinical manifestation in form of congestion, infiltration, nodulation, thickening and fibrosis. Anti-leprosy chemotherapy is equally effective on these lesions. A screening survey of laryngeal pathology in such cases should be done periodically.

The Groningen valve was first used in Sheffield in 1986 in a patient who underwent laryngectomy for malignant disease. Since then it has been the main tracheo-oesophageal prosthesis used on our Unit for speech rehabilitation post-laryngectomy. This biflanged device inserted primarily or as a secondary procedure remains in situ until failure occurs either because of leakage or because increased effort is required to produce satisfactory phonation. This in vitro study we examined the differences between new valves prior to insertion and those removed for failure. The mean forward opening pressures were shown to be similar in the two populations but the mean forward resistances were increased in those valves which were defective (P<0.001). In addition the mean reverse opening pressure was found to be significantly lower in the defective valves when compared with their new counterparts (p<0.05).

The bedside assessment of dysphagia may be difficult, due to the inability to witness the act of swallowing directly. The milk test described in this paper gives a good assessment of swallowing, is cheap and easily portable and allows an instant decision to be made without recourse to special investigations.

The use of the rigid endoscope in the management of posterior choanal atresia represents a significant advancement in choanal surgery. It provides an extremely sharp image with a magnified overview. It enables the surgeon to see the tips of his instruments, so that the bone is removed safely under direct endoscopic vision. It allows assessment of the size of the opening, in comparison to the normal choana. It ensures greater precision in flap preservation. The technique is short in time and safe, with early recovery and short hospitalization.

Kallman's syndrome is a multifaceted congenital disorder with predominantly endocrine abnormalities. We have characterized the associated mixed hearing loss and identified consistent radiological evidence of abnormal temporal bone anatomy. Abnormal labyrinthine morphology is accompanied by a complete absence of response to vestibular stimulation with caloric or rotational chair testing.

The endocrine abnormalities are correctable and Kallman's syndrome is a diagnosis worthy of consideration when assessing children with congenital hearing loss.

A case of bilateral mastoiditis with subperiosteal abscesses complicating acute otitis media in a two and a half year old girl is presented. Contrast enhanced computerized tomography confirmed the diagnosis of right lateral sinus thrombosis. The aetiology, diagnosis and management of these conditions are discussed.

A patient with multiple, synchronous, non-familial head and neck paragangliomas is reported. There were three primary neoplasms, a glomus tympanicum and glomus vagale on the right side and a glomus tumour of the carotid body on the left. Such a combination has never been reported previously.

The reports of all the series with paragangliomas in the literature, as well as the reports of single cases with multiple tumours during the last three decades, are reviewed. Specific problems in diagnosis and management of multiple glomus tumours are discussed.

We present a case of nasal deformity due to sarcoidosis. The surgical management is discussed. The risk of secondary involvement of implanted autologous cartilage by the disease is emphasized. For this reason an inert allograft (silastic) is recommended for augmentation in this group of patients.

Therapeutic radiation for malignant conditions is known to cause sarcomatous change in an irradiated field after a latent period; equally this change may occur following radiotherapy to benign conditions which may result in a more difficult management problem later. Radiotherapy to benign conditions should be reserved for use after failure of conventional surgery or other interventional techniques.

An unusual case of a chordoma of the parapharyngeal space is presented with no direct involvement of the axial skeleton. Diagnosis was confirmed with the aid of immunocytochemical tests.

We are reporting four cases of clear cell neoplasm. Local infiltration and destruction was observed in one case while in a second case, originating in the sublingual gland, metastasis to the lymph nodes occurred. The behaviour of these neoplasms has prompted the suggestion that these tumours be designated carcinomas rather that noncommittally tumours or neoplasms (Batsakis and Regezzi, 1977).

The histopathological characteristics of our four cases conform to those that have been articulated and believed to be the distinctive features of these tumours (Batsakis and Regezzi, 1977). It is hoped that ours and similar reports will be helpful towards clearing the diagnostic and taxonomic confusion regarding these tumours.

Impaction of a foreign body in the oesophagus is common in children. If the event is not witnessed by an adult or the object is radiolucent the diagnosis is difficult as respiratory symptoms may predominate. We report a three-week-old child with respiratory symptoms who had both a respiratory syncytial virus infection and a radio-lucent oesophageal foreign body. This case is the youngest yet reported and serves as a reminder of the difficulties in the diagnosis of this important condition.