Cerumen is the product of the secretion of the sebaceous, ceruminous or apocrine glands together with cells exfoliated from the cornified stratum of the epithelium of the external auditory canal (EAC).

In the present study we identified and quantified common flora of human cerumen. The mean count obtained was 106 microorganisms per ml of cerumen suspension.

In 24 pools of cerumen (33.3 per cent) the isolates were monomicrobial, Staphylococcus epidermidis (12), Corynebacterium spp (10), Staphylococcus aureus (1) and Streptococcus saprophyticum (1). In 48 pools (66.6 per cent) we found polymicrobial isolates.

The most commonly isolated bacteria in these polymicrobial isolates were S. epidermidis (35) and Corynebacterium spp. (43). It is noteworthy that there were isolates of Candida albicans in three cases; in one case of Pseudomonas stutzeri, in one case of Pseudomonas aeruginosa, and, on seven occasions, of S. aureus.

The organisms isolated as common bacterial components of human cerumen in our experience were similar to those found by other authors. However, the mean count was much higher. This could be related t o climatic conditions and to the length of time the cerumen had remained in the external auditory canal.

The aetiology of idiopathic facial nerve palsy (Bell's palsy) and sudden deafness are not known, although viruses have been suspected as a cause of them. We investigated the relationship between Bell's palsy or sudden deafness, and reactivation of cytomegalovirus, human herpesvirus 6 (HHV-6) and 7 (HHV-7).

Paired sera were collected from 22 patients with Bell's palsy and 24 patients with sudden deafness. IgG antibody titres to HHV-7 were increased in one patient with Bell's palsy. IgG antibody titres to HHV-6 were increased in one patient with Bell's palsy and two with sudden deafness. IgG antibody titres to cytomegalovirus were increased in one patient with sudden deafness. Titres of the three viral antibodies were not increased simultaneously in any patients. These viruses may contribute to the development of Bell's palsy or sudden deafness in some cases. It is, however, unlikely that these viruses are the main cause of Bell's palsy and sudden deafness in the majority of patients.

This article describes the anatomy of the visual pathways and how they should be assessed under anaesthesia. The differential diagnosis of asymmetrical pupils is illustrated with clinical examples and a strategy as to how they should be examined.

Forty patients were treated or followed up for aesthesioneuroblastoma between 1980 and 1995 at Institut Gustave Roussy, France. There were three T1; seven T2, 15 T3 and 15 T4 lesions. The cervical metastatic rate at presentation was 18 per cent. Distant metastases were detected by bone marrow biopsy and bone scan in three patients at presentation. Treatment modalities included surgery alone in eight patients, radiotherapy alone in three patients, combined modality surgery plus radiotherapy in 11 patients, chemotherapy alone in two patients, chemotherapy plus radiotherapy in 10 patients, and multimodality therapy chemotherapy plus surgery plus radiotherapy in six patients.

The five-year survival rate was 51 per cent. Multimodality treatment offered better survival (63 per cent at five years) and disease-free interval (54 months). Overall local, regional, and distant failure rates were 58 per cent, 15 per cent and 40 per cent respectively. Distant metastases commonly occurred in bone (82 per cent). Cervical metastasis was an unfavourable prognostic indicator (0 per cent survival at two years).

In conclusion, aesthesioneuroblastoma is sensitive to chemotherapy and radiotherapy. Multimodality therapy should be used initially.

Fifty-five samples of pus were collected from 51 acute, non-perforated, two spontaneously ruptured and two recurrent peritonsillar abscesses (35 males and 18 females; median age 18 years) and analysed regarding (i) aerobic and anaerobic bacteria (standard culturing), (ii) morphology of bacteria and inflammatory cells (direct microscopy of acridine orange-stained material), and (iii) the percentage of bacteria coated with immunoglobulins IgG, secretory IgA (SIgA) andIgM and complement cleavage product C3b (immunofluorescence assay). Seventy-one per cent of the abscesses harboured a mixed bacterial flora of various aerobes and anaerobes. In none of the cases with a single bacterial species (27 per cent) could immunoglobulin- or complement-coated bacteria be found. In abscesses with a mixed flora, 18 per cent harboured IgG-coated, 15 per cent SIgA-coated, five per cent IgM-coated and five per cent C3b-coated bacteria, respectively. All pus samples contained inflammatory cells in abundance but they were mostly deformed and only occasionally could intracellular bacteria be recognized. Insufficient immunoglobulin-coating of bacteria might be an important aetiopathogenic factor in the development of a peritonsillar abscess. Bactericide in the abscesses is accomplished chiefly by protective mechanisms not dependent on antigen recognition by antibodies.

Our ongoing evaluation of the results of laser assisted uvulopalatoplasty (LAUP) for snoring is presented. Follow-up between 18 and 24 months post-treatment completion, of patients with a successful result at six months, reveals that 22 per cent of these patients suffer failure of snoring control between these two evaluation points. This equates to an overall success rate at this time of 55 percent.

LAUP, like other surgical remedies for snoring, has a continued relapse rate. This must be considered when counselling patients.

Aural ventilation tube insertion is the most common otological operation and is usually the first operation learnt by trainees. The limited supply of temporal bones as well as expensive commercial models hampers training in the procedure. This paper describes a simple solution making a model of the ear canal and drum out of materials available on an ENT ward.

After placement of a nasogastric tube through a rigid oesophagoscope it is necessary to transfer the proximal end from the mouth to the nose. Observation of surgeons performing this apparently simple task has indicated that many find it somewhat difficult. We describe a simple solution to the problem.

We present a case of bilateral absence of the eighth cranial nerve in the internal auditory meatus (IAM). This caused total failure of responses after cochlear implantation in a six-year-old patient with congenital deafness. Pre-operative magnetic resonance (MR)imaging is important to show not only the anatomy of the middle and inner ears but also the structures in the IAM.

Acoustic neuromata (AN) account for nearly 90 per cent of internal auditory canal (IAC) and cerebello-pontine angle (CPA) tumours. The second most common tumour is meningioma. Rare lesions include primary cholesteatoma, facial neuroma, lipoma, angioma and various cysts.

Two cases of IAC tumour are presented, one of hamartoma in which smooth muscle was prominent and the other of lymphangioma. Of interest are the specific clinical and radiological features associated with these lesions.

A case of non-traumatic/non-iatrogenic CSF rhinorrhoea, presenting with tension pneumocephalus and hemiparesis is described. The possible pathological processes involved in this rare case are discussed. Cases in the literature of idiopathic CSF rhinorrhoea and also those of spontaneous pneumocephalus are reviewed.

Nasal polypectomy is a common ENT operation. Cerebrospinal fluid (CSF) rhinorrhoea and pneumocephalus are rare complications. We present a patient who developed both these complications after biopsy of nasal polyps which subsequently proved to be an inverted papilloma. He had a defect in the ethmoid roof, which was repaired.

Whilst endoscopic repair of CSF leak is increasing in popularity, in this patient because of his pathology and difficulty of access a more traditional lateral rhinotomy approach was made with a successful outcome. An overview of the management of these complications is presented.

Isolated sphenoethmoid recess (SER) polyps are rare. They usually arise from the sphenoid sinus. We report six patients with SER polyps as the only abnormal clinical finding at initial presentation. All cases were investigated with outpatient biopsy and computed tomography (CT) or magnetic resonance (MR) imaging. Pre-operative histology revealed three cases of inflammatory disease, two cases with inverted papilloma, and one case of an ectopic pituitary adenoma arising from the sphenoid sinus. One of the inflammatory polyps arose directly from the mucosa around the sphenoid ostium. The other five cases involved the sphenoid sinus. Except for the ectopic pituitary adenoma all the polyps were managed by transnasal endoscopic surgery. We emphasize that isolated SER polyps may signify existing sphenoid pathology and a pre-operative biopsy is valuable for planning surgery.

Formerly a fatal condition, Wegener's granulomatosis is now treated with good results. Although the annual incidence of Wegener's granulomatosis in the general population is not known, most European and American studies revealed an incidence in the range of one for every 250,000 of the population. The estimated total population of Bahrain as of June 1997 is 586,110; here we report the first diagnosed case of Wegener's granulomatosis in Bahrain.

Our patient presented with epistaxis, and from the clinical features, the very high ESR, the operative, histopathological and the radiological findings, and a high index of suspicion we could confirm the diagnosis along with the appropriate immunological test (positive cANCA). Standard treatment with cytotoxic agents and corticosteroids has been used. On follow-up the patient has shown a progressive improvement in her clinical and laboratory parameters.

Choroid metastasis of primary nasopharyngeal carcinoma is an infrequent event. Here, we report a case of nasopharyngeal carcinoma with metastases to the choroid successfully treated by external beam radiotherapy.

Laryngeal rhabdomyosarcoma is a rare disease. Only nine of these tumours have been adequately described in world literature in the adult population. Adult patients with laryngeal rhabdomyosarcoma often present at a later stage than other laryngeal tumours, including squamous cell carcinoma. Diagnosis is made by identification of cross-striations histochemically or cytoplasmic myoglobin by immunohistological methods. We present a 66-year-old woman with pleomorphic rhabdomyosarcoma of her larynx. This is the first female in the adult age group to be presented. Surgical treatment with adjuvant radiotherapy is currently the treatment of choice for this disease. We provide a review of the literature on laryngeal rhabdomyosarcoma, including presentation, pathology and management of this rare disease.

Intralaryngotracheal thyroid is a rare clinical condition with only about 125 cases described so far in the literature. We present an unusual case of intralaryngotracheal thyroid which had many clinical features of malignancy and yet appeared benign on histology. As in this case, well-differentiated thyroid cancer can present with locally aggressive clinical features and can pose a dilemma in management if treatment decisions are guided solely by histological features.

Haemangiomas are the commonest benign tumours of the head and neck in childhood, but they are extremely rare on the palate. We report a case of a palatal haemangioma presenting with feeding difficulties in a young infant. Clinical diagnosis and pathological features are discussed and we suggest a classification which may help in the diagnosis of these cases.

We present an unusual case of generalized erosion of the skull base. We have not found a similar case reported in the world literature. The presenting symptom was spontaneous cerebrospinal fluid (CSF) rhinorrhoea which arose from a bony defect associated with herniation of the right temporal lobe into the sphenoid sinus. We discuss the management of such a case including imaging of the skull base and the endoscopic repair of the bony defect.