The clinical and pathological features of glandular tumours of the external auditory meatus are presented. Their heterogenous clinical and pathological features make the collective term ‘ceruminoma’ ambiguous andmisleading. The spectrum of pathological behaviour and histological features demonstrated by these interesting tumours necessitate a broader classification system. In our hospital 32 patients presented with tumours of the external auditory meatus over a 30-year period, of which seven were glandular in origin. A review of the histology of these glandular tumours enabled us to reclassify them as adenoma, cylindroma, adenoid cystic carcinoma or ceruminous adenocarcinoma. Together with the less common mucoepidermoid carcinoma and pleomorphic adenoma this subdivision forms a basis for a more meaningful classification system with prognostic and therapeutic implications specific to each tumour type. The term ‘ceruminoma’ should no longer be used unqualified.

For many years vestibular testing has relied on measurements of the vestibulo-ocular reflex (VOR). More recently quantified assessment of balance, using fixed or moving force platforms and magnetometry have been applied to clinical research. These are objective attempts to quantify the vestibulospinal reflex (VSR). This study evaluates whether SwayWeigh, a simple device which measures lateral body sway, can provide an objective assessment of balance dysfunction. Forty patients with a balance disorder and 31 subjects with normal balance were tested with eyes opened and eyes closed whilst they were standing on a flat surface and then on an air bed. The lateral sway in patients with a balance disorder was compared to that in the normal subjects and highly significant differences (p<0.0001) were observed. The results also confirmed the importance of vision and proprioception in the maintenance of posture.

The Sway Weigh balance platform is a simple and economical device which objectively measures balance dysfunction.

Facial pain is a common symptom. Patients with this symptom without any overt disease of nose and paranasal sinuses are often diagnosed as having chronic rhinosinusitis. Thirty-six cases were seen and treated surgically by middle turbinectomy or septal surgery in this series. The xylocaine (10 per cent) test seemed to be a good prognostic aid for the surgical procedures. Medical treatment did not seem to relieve the symptoms. Larger series with control trials are recommended in order to establish this practice.

A total of 687 school children, aged six to 15 years, were examined clinically, radiologically and audiometrically. Lateral radiological examination of paranasal sinuses was carried out in 663 (96.5 per cent) children for evaluation of the size of adenoids. The size of the soft tissue shadow (adenoids) was assessed as normal or large. It was large in 133 (25 per cent) children, three times more frequently in seven-year-old than in 14-year-old children. The occurrence of adenoidal symptoms (blocked nose, mouth breathing, snoring, snuffling or rhinitis) varied from 14.3 to 30.1 per cent in children with large adenoids compared to 7 to 9.8 per cent in children with normal adenoids. Logistic regression analysis revealed that only recurrent snoring and the child's age were significantly associated with radiologically large adenoids. The hearing thresholds were 1.1 to 4.2 dB poorer and mean middle ear pressure values were 60 to 70 mmH2O lower in children with large adenoids compared to those with normal size adenoids. Large adenoids have an influence on the hearing level of a child, but probably via the negative middle ear pressure.

There have been many attempts at identifying substances and describing methods that would assist the surgeon and be of benefit to the patient undergoing a tonsillectomy. The use of bismuth subgallate as a haemostatic adjunct during tonsillectomy has only been described previously in retrospective studies. A controlled prospective randomized trial of 100 paediatric patients, in which 50 patients had a tonsillectomy performed using bismuth subgallate as a haemostatic agent and in which the remainder did not have any associated haemostatic substance, is presented here.

Data on 72 patients was analysed, 39 patients belonging to the bismuth subgallate group and the remaining 33 to the control group. The time for haemostasis was three to 18 (mean 7.8) minutes in the bismuth group. It was four to 16 (mean 9.9) minutes in the non-bismuth group. These figures are statistically significant.

The range of ties used in the bismuth group was none to three (mean 1.5) ties and one to seven (mean 3.4) ties in the non-bismuth group. These figures are also statistically significant. The remainder of the recorded parameters did not differ significantly.

It was found that bismuth subgallate/adrenaline paste decreases operating time by significantly reducing the haemostasis time and the number of ties required but does not decrease post-operative morbidity.

The aims of this study were to demonstrate the effect of bismuth subgallate and adrenaline paste application to the tonsillar fossae on operating time and peroperative blood loss during tonsillectomy. Ninety-eight patients were included in a prospective randomized trial.

Bismuth subgallate powder is mixed with 10 ml of normal saline and 0.03 ml of 1:1000 adrenaline to make a paste. This paste is used as a topical haemostatic agent during tonsillectomy. Bismuth subgallate activates Factor XII and therefore accelerates the coagulation cascade. Adrenaline causes vasoconstriction and promotes platelet aggregation. The application of bismuth subgallate and adrenaline paste to the tonsillar fossae during tonsillectomy reduces operating time by 23 per cent for Consultant staff (p<0.05) and 32 per cent for Junior staff (p<0.05). Blood loss is reduced by 21 per cent (p>0.05), for the average paediatric tonsillectomy.

A prospective randomized study was carried out to assess the post-tonsillectomy morbidity of the electrodissection technique as opposed to the blunt dissection and ligation technique. One hundred and four patients, each serving as his or her own control, were randomized to have either the right or left tonsil removed by electrodissection. There was significantly less pharyngeal pain on the electrodissection side in the first postoperative day in adult patients. This, however, was transient as there was increased pharyngeal discomfort and otalgia, both in severity and duration, on the electrodissection side by the end of first week. There was no difference in the incidence of haemorrhage between the two techniques.

Polysomnography is currently used for diagnosis, evaluation and selection of therapy in patients with obstructive sleep apnoea (OSA), but clinically successful uvulopalatopharyngoplasty (UPPP) is not necessarily reflected by post-operative improvement of polysomnographic recordings. Post-operative polysomnography may suggest deterioration of pre-existing OSA or, in snorers, de-novo precipitation of OSA. Thus, if polysomnography is a reliable indicator of OSA, then OSA may be a post-operative risk of UPPP. The aims of our study were: (i) to assess the possible deleterious effect of UPPP on sleep patterns; (ii) to further define the role of cardioisotope scanning in the evaluation of OSA; (iii) to assess the reliability of polysomnography given the clinical and cardioisotope scan findings. Symptoms, polysomnography and radionuclide ventriculography were prospectively compared pre- and post-operatively in 41 patients undergoing UPPP. In 12 patients (29 per cent), there were disparate results between pre- or post-operative polysomnography and the clinical and/or radionuclide ventriculography, as follows: In four of 16 patients with abnormal pre-operative ventricular performance, there was pre-operative symptomatology of severe OSA and a bedmate's reports of apnoeic episodes. This was in contrast to normal or near normal sleep apnoea recordings. In eight patients, post-operative improvement of symptoms was reported, despite deterioration of post-operative polysomnographic recordings. In these patients the post-operative improvement of symptoms was also reflected by improved ventricular performance. Worsening of ventricular performance was not demonstrated in any patient. In conclusion, UPPP does not induce OSA. Polysomnography may underestimate or even misdiagnose cases of OSA. The diagnostic importance of patient symptomatology should be stressed particularly in those patients with only mildly abnormal or even completely normal sleep studies. A combination of polysomnographic and cardiovascular evaluation in patients with symptomatology consistent with OSA is recommended.

Following radiation treatment for carcinoma of the larynx it may be very difficult to differentiate between persistent or recurrent tumour and severe radiation effects particularly chondroradionecrosis. Despite repeated negative biopsy it may be necessary to perform total laryngectomy where the concern about persistent cancer remains and the larynx is non-functioning. We report nine cases presenting as chondroradionecrosis over a five-year period. Two patients settled on medical treatment. Of seven patients treated with laryngectomy the histology on two revealed residual or recurrent carcinoma.

We outline the dilemmas in diagnosis and propose management strategies to deal with this condition including recommendations for prevention and treatment.

Fifty-six total laryngectomy cases are presented with special reference to post-operative fistula formation. All these patients were operated upon at the Department of Otorhinolaryngology at the Bnai Zion Medical Centre by one surgeon over a 16-year period, from 1976–1992. The incidence of fistula was 12.5 percent. This paper could not verify reports that any specific factors were significantly related to fistula formation, although there was a preponderance of fistulas in patients presenting with late stage tumours. No relationship was found with rate of infection, age, or between previous neck irradiation (ranging from 5500 to 7000 cGy) and fistula formation in the patient population.

If a fistula occurs, the administration of oral solid food keeping the nasogastric tube in place for administration of fluids may lead to spontaneous closure of the fistula, with no need for secondary surgical repair.

Concern has been expressed in the recent literature regarding the problem of a dwindling number of stapedectomy cases and an increasing number of surgeons trained to do this operation. In Singapore, the problem is made worse by the very low incidence of this disease in its main ethnic groups of Chinese and Malays who together make up more than 90 per cent of the population.

We report here an audit of 47 ears that underwent stapedectomy in a teaching hospital over a six-year period. The hearing results for consultants and surgical trainees were compared. Closure of the air–bone gap to within 10 dB was obtained in 64 per cent of Consultants' cases and 68 per cent of trainees' cases. These results fall short of the 90 to 95 per cent figure reported by experts in this procedure and only comparable to the less satisfactory results of several series recorded by residents in North America.

We conclude that the unsatisfactory results arise from the small number of surgical cases available for each surgeon to improve and maintain his skills in a technically demanding procedure. It is proposed that such cases be directed to those pursuing otology as a subspecialty rather than all otolaryngologists in general.

In middle ear surgery via the permeatal approach, aural specula are frequently used to improve visualization of the operative field. Mechanical holders designed for retaining the aural speculum, are expensive and require sterilization for reuse. A simple technique for retaining the speculum which overcomes the drawbacks of a mechanical holder is described.

Tuberculoma is a rare but known complication of tuberculosis. It rarely occurs in the mastoid bone. When it occurs in the middle ear cleft, it can lead to intracranial complications if there is a delay in the diagnosis and management.

A rare case of tuberculosis of the middle ear cleft which presented as tuberculoma of the mastoid bone with infranuclear facial palsy is described. The tuberculoma was removed and a canal wall down tympanomastoidectomy was performed. Post-operatively the patient was kept on antituberculous therapy. The various problems encountered in the diagnosis and management of this case are discussed.

Metastatic melanoma of the tonsils is rare. This paper describes one such case, highlighting the histopathology and the mode of spread.

Concern has been expressed regarding the seeding of viral DNA, in laryngeal papillomatosis, to other sites in the respiratory tract during treatment. Controversy exists regarding the concept of seeding by the laser plume. However, instrumentation and anaesthetic intubation are also strongly implicated in seeding DNA to the proximal respiratory tract. No cases of recurrent laryngeal papillomatosis and subsequent papilloma in the paranasal sinuses have been reported.

A case of carcinoma ex pleomorphic adenoma arising in the soft palate is reported. The tumour presented had enlarged gradually over 10 years and finally occupied the oral cavity. The patient was admitted to our hospital due to disturbance of her speech and swallowing, and a sudden haemorrhage from the tumour. The initial pathological diagnosis by open biopsy was benign pleomorphic adenoma. After total resection, histological examination revealed that the tumour was composed partly of benign pleomorphic adenoma and partly of an adenocarcinomatous component. The carcinoma cells with prominent nucleoli were spheroid or polygonal in shape, and frequently formed ductal structures with areas of necrosis. Mitoses were also found. These findings showed that this tumour was a secondary carcinoma which had developed in a preexisting pleomorphic adenoma.

We report on a family exhibiting a range of congenital anomalies consistent with the G syndrome of Opitz. Three members of the family had laryngo-tracheo-oesophageal clefts, one of which succumbed. There was a strong family history of perinatal mortality on the maternal side of the family. We note also the paucity of reported cases of this syndrome in the otolaryngological literature and stress the necessity of early diagnosis in the management.

A pharyngocele is a rare condition. According to the literature and our own experience it is usually not recognized or is mistaken for a laryngocele.

short review of the literature, a description of the condition and three cases are reported.