From 1900 to 1940 the theory of focal sepsis was invoked to justify a number of dubious surgical procedures. Surgeons believed they were acting rationally. Patrick Watson-Williams advocated suction exploration of the paranasal sinuses for mental patients, claiming to cure criminal insanity by sphenoidotomy. Favourable contemporary reviews showed international approval. The rational basis of treatment was emphasised, but there was little systematic evaluation of outcome. Current enthusiasm for functional endoscopic sinus surgery is also based on a rational approach, logical deductions from pathophysiological ‘facts’. Outcome has still not been evaluated scientifically. We should learn from history. Treatment should not be based too readily on what seems to be rational now. Ideas of physiology and pathology change. What seems logical today may appear ridiculous tomorrow. Careful analysis of outcome, preferably by controlled clinical trials, is needed as a rational treatment requires empirical validation just as much as any other.

The following hypothesis is presented: that the susceptibility of an individual patient to hearing loss as a result of cis-platinum administration can be predicted on the basis of eye colour. The rationale is that the melanin content of the inner ears is related to that of the eyes; dark eyes contain more melanin than lightcoloured eyes; and melanin causes the accumulation of the ototoxic drug within the inner ear. Hence those with dark eyes will suffer greater damage to the hearing than those with pale eyes. An investigation that confirmed this hypothesis is reported. In addition to cochlear damage there is a significant likelihood of damage to the auditory nerve as a result of the treatment.

Submucous diathermy of the inferior turbinates is a widely practised procedure. Three cases are presented in which surgery was complicated by avascular necrosis of the turbinate bone. Each patient required a debridement procedure before healing and recovery of normal mucociliary function could take place.

Posterior epistaxis is usually treated by repeated nasal packing and in failed situations by ligation of feeding arteries with considerable morbidity and mortality. The most logical approach should be location of the bleeding site and arrest of haemorrhage by local treatment. The exact location of the bleeding area can be identified in actively bleeding noses with the fibreoptic naso-laryngoscope and the bleeding arrested by chemical, or thermal cautery and in failed situations by using small nasal packs confined to the bleeding site. This approach to the management of posterior epistaxis is effective and reduces the duration of hospital stay. It significantly reduces the discomfort to the patient. The current practice of indiscriminate blind nasal packing in the hope of arresting nasal haemorrhage by incidental pressure on the bleeding site should be re-evaluated.

Computerized tomographic (CT) imaging provides detailed information on the paranasal sinuses and is now well established as an alternative to standard radiographs. The planning and safety of surgery to the paranasal sinuses is greatly improved by CT imaging. We describe a new CT protocol comprising a limited coronal and axial scan series, based on ourexperience with the previously described ‘CT Mini-series’.

Two-hundred-and-twenty-one patients with squamous carcinoma of the oropharynx treated by irradiation are presented.

The primary recurrence rate at five years in the previously untreated patients was 27%, but was dictated by neither host factors (age, sex and general condition) nor tumour factors (site, T-stage and histological grade).

Pre-operative histological diagnosis had a very high sensitivity but a low specificity, indicating that false positives are common but false negatives unusual. Twenty per cent of patients with a recurrent primary tumour were untreatable.

The five year survival after a primary recurrence was 31 per cent. Sixty-eight per cent of patients undergoing major surgery recovered without a major complication, and the hospital mortality rate was three per cent, due entirely to major medical catastrophes. The major complication rate in those undergoing flap repair after major resection was seven percent.

The metastatic rate in lymph nodes was 44 per cent at five years, and again this did not depend on any host or tumour factors. The survival at five years after node recurrence was a mere 19 per cent, and the length of survival was related to the primary site of the original tumour and the presence of extranodal disease. Two-thirds of patients had advanced disease (N2 and N3) when node recurrence was diagnosed and about 15 percent were unsuitable for surgery.

Epithelial cells were scraped from the tonsillar surfaces of 15 patients with current acute tonsillitis (AT) and of 15 individually matched healthy persons. The cellular mixture was stained with acridine orange and bacteria seen to be attached to the epithelial cells under the fluorescent microscope were calculated. Conventional bacterial culturing was also performed simultaneously. Significantly more bacteria were attached to epithelial cells from the AT group than from the controls (>10 attached bacteria per cell p = 0.0103, >50 attached bacteria per cell p 0.0212). In vivo determination of bacteria attached to epithelial cells offers prospects of gaining a better understanding of the aetiopathogenesis of acute tonsillitis.

We report on the use of a little-known instrument for tonsillectomy.

Removing an acoustic schwannoma using the translabyrinthine approach has previously been considered incompatible with hearing preservation. By modifying the approach and preventing the loss of endolymph, we have successfully removed an intracanalicular acoustic schwannoma, which originated from the inferior vestibular nerve, and preserved hearing in the operated ear. This report represents the preliminary findings using this particular technique in the management of an intracanalicular acoustic tumour.

An unusual case of squamous cell carcinoma of the middle ear and mastoid in which syncope was a major presenting feature is reported. No such case has been reported in the literature. A possible explanation is offered.

The literature on this rare tumour has been reviewed and three cases of nasal plasmacytoma are described. Immunohistochemistry demonstrated cytoplasmic IgA and Kappa determinants in all cases. Two patients are disease-free at the present time, the third developed an IgG-k multiple myeloma, previously not described in the literature.

Cranial nerve palsies are an unexpected complication of radiotherapy for head and neck tumours. We present a case of this radiation-induced cranial palsy.

An 18-year-old female with nasopharyngeal carcinoma developed a right hypoglossal nerve palsy 42 months after cancericidal doses of radiotherapy. In addition, she developed a bilateral vocal cord palsy 62 months after therapy. Follow-up over four years has demonstrated no evidence of tumour recurrence and no sign of neurological improvement.

Identification of an intramural oesophageal fishbone at operation is difficult. Such a case is discussed with an attempted accurate radiological localization of site pre-operatively. No such case has so far been reported.

A sterling silver tracheostomy tube broke in use resulting in the death of a child. The nature of the fracture in the brazed joint is described, and corrosion identified as the mechanism of degradation of the joint. The corrosion is due either to exposure to body fluids over a long period, or to the use of hypochlorite solutions for cleaning and disinfection. The silver braze used had inferior corrosion resistance. It is recommended that appropriate grades of silver brazing alloy be used in the future, and that the mechanical integrity of medical devices joined with silver braze be regularly checked to anticipate failure in use.

Squamous carcinomas of the oro-pharynx are associated with a high incidence of distant metastases at post-mortem. A case of a massive distant metastasis from a squamous cell carcinoma of the tonsil is presented. This occurred despite excellent local control. The pathology and the possible management implications are discussed.