The ultrastructural details of normal middle ear mucosa have been reported in detail in the literature. This study was aimed at investigating the superficial structure of middle ear epithelium with the scanning electron microscope in patients with persistent otitis media with effusion (OME) and chronic suppurative otitis media (CSOM), especially in the light of the authors' recent findings regarding decreased ciliary beat frequency (CBF) in patients exposed to tobacco smoke.

Mucosal biopsies were taken from the anterior mesotympanum in four patients with OME and another four patients with CSOM. There was no significant abnormality of cellular surface structure in patients with chronic middle ear disease. Furthermore, no significant difference was observed between smoke exposed and nonsmoke exposed patients. It is concluded that the effect of tobacco smoke on CBF is functional and not related to any anatomical abnormality observed by scanning electron microscopy (SEM).

The bone-anchored hearing aid (BAHA) is an alternative to the conventional bone conduction hearing aid. The transducer is coupled to a percutaneous titanium implant which is traditionally inserted into the temporal bone in two stages. This study focusses on a one-stage surgical technique for the implantation of percutaneous implants. The preliminary clinical results of 33 one-stage implants in 33 patients are presented.

Post-operative necrosis of the skin grafts did not occur. After a follow-up which varied from nine to 25 months, 31 out of the 33 fixtures (94 per cent) were anchored firmly in the skull. Twenty-six out of the 33 implants (79 per cent) remained free from potentially dangerous skin reactions. The results were statistically comparable to those obtained with two-stage implants at the same clinic. Although longer follow-up is needed before a general statement can be made about replacing the two-stage technique, the preliminary one-stage results are promising.

Twenty-three patients with intradural lesions of the petroclival region and prepontine cistern were managed in our centres by the modified transcochlear approach. Total tumour removal was accomplished in 17 patients, while a second stage was planned for the remaining six patients. Two cases died in the immediate postoperative period. All the remaining cases showed a good outcome and returned to work. The basic approach type A is further classified according to its anterior, superior and inferior extension into types B, C and D respectively. The surgical procedure, classification, illustrative case reports and patients' summaries are presented.

Nasal airflow modifies the pattern of ventilation presumably due in part to nervous signals arising in the nose and transmitted along the trigeminal nerve to the respiratory centre. Nasal receptor tissue must also be important in determining the sensation of airflow at a conscious level but little attention has been paid to the distribution and function of these receptors.

An experimental model to deliver a pulse of air at different velocities to various nasal test sites is described. In this way nasal sensitivity to an air jet can be mapped out. Sensitivity of the nose to an air jet is greatest at the entrance to the nose – the region of the nasal vestibule.

Sixteen biopsies of rhinosporidiosis (15 nasal and one conjunctival) from 16 Southern Indian male immigrant workers showed mucosal lymphoplasmacellular infiltrates together with transepithelial elimination of nodular bodies and destruction of some late stage nodular bodies in histiocytic granulomata with central neutrophilic microabscesses. Early nodular bodies were immunohistochemically positive for alpha1-AT, alpha1-ACT, CEA, S100, fibronectin, amyloid-p-component, IgG, IgA, CIq and C3. Electron microscopy showed organized

concentric lamellated bodies in early nodular bodies and not in end-stage nodular bodies which contained mostly amorphous electron dense materials. Structures formerly regarded as ‘sporangia’ and ‘spores’ are believed to be lysosomal bodies loaded with indigestible residues to be cleared via transepithelial elimination or segregated/destroyed by secondary immune/granulomatous responses.

During a period of two years, 24 cases of antrochoanal polyps were diagnosed by clinical examination, nasal endoscopy and computerized tomography. Surgery started with endoscopic transnasal removal of the polyp. Every attempt was made to remove the antral portion of the polyp through the wide ostium. Then transcanine sinuscopy was performed. Remnants of the polyp were detected and removed in five cases. One or more other cysts were found and extirpated in 11 cases. Endoscopic follow-up for 18 months to three years revealed no recurrence.

It is recommended that endoscopic middle meatal surgery should be combined with transcanine sinuscopy to ensure complete removal of antrochoanal polyps.

This study was designed to compare the differences in morphology of the mast cells from the adenoid in children with otitis media with effusion (OME) and those from children with recurrent tonsillitis. Tissue for electron microscopy was prepared in the standard manner and between three and 10 blocks were examined for each child. All the mast cells with nuclei were photographed and the condition of the granules noted. The number of electron dense granules in each cell was assessed on a scale between zero and 10. Sixteen unselected children with OME were compared with 19 children with recurrent tonsillitis. There were no obvious differences in the degree of degranulation between the two groups although there was more vacuolation than reviously described in the normal nose but less than in those patients with perennial allergic rhinitis. Allergy and mast cell reactions do not seem to predispose to OME. It was concluded that the adenoids are not the ideal tissue in which to study normal mast cells.

A prospective study was designed to compare the effects on voice capacities after either suspension microlaryngoscopic surgery or indirect microlaryngostroboscopic surgery. Patients where the clinical diagnosis 'dysphonia due to a benign lesion of the vocal fold' was made, and who could be operated in either way, entered the study. Post-operative voice evaluation was performed on 21 patients after suspension microlaryngoscopic or indirect microlaryngostroboscopic surgery. The long-term voice results following indirect microlaryngostroboscopic surgery and suspension microlaryngoscopic surgery demonstrate a statistically significant improvement for the maximum intensity, maximum dynamic intensity range, dynamic intensity range at habitual speaking pitch, and melodic pitch range. In selected cases indirect microlaryngostroboscopic surgery offers a very good functional result.

For many years it has been recognized that seemingly benign neck cysts may contain carcinoma. The true incidence is unknown. This paper investigated nine out of 270 patients presenting with a neck mass — which proved to contain a squamous carcinoma. Records (from a 30-year period) of over 3400 patients with squamous carcinoma of the head and neck, were examined. The histology slides were reviewed, the number of cystic lesions was noted and also the clinical outcome. Out of the 270 patients nine presented with a cystic lesion and these were studied. Six cystic lesions were originally diagnosed as branchial cysts although the youngest age was 39 years. All patients underwent a simple excision.

In six cases the tonsil was the primary site, in one the primary was in the base of tongue and in two the primary remained occult. One-third of the patients had died of their disease by the time this report was written and the maximum follow-up time for the remaining patients was 18 months. Therefore 16 per cent of branchial cysts in this series represented metastases from squamous cell carcinoma.

At the Royal Liverpool University Hospital only 25 patients had branchial cysts excised between 1988 and 1993: out of these only four contained squamous carcinoma.

In patients over 40 years of age panendoscopy and ipsilateral tonsillectomy is mandatory prior to cyst excision.

For overseas doctors, looking for higher training posts, the chance of being employed in the developed countries is becoming bleaker. This article considers the need for an increase in the number of local postgraduate training programmes in the Arab world in keeping with other developing countries. The model used for this study was an internal audit, of the postgraduate programme in ENT offered by King Faisal University in Dammam, Saudi Arabia. A dropout rate of more than 30 per cent among those who joined the programme reflected either the tougher standard of the course, or an inappropriate selection process. A major reason was the frustrating inability of the trainees to cope with the basic sciences course. This point was also addressed in the audit with a view to rationalizing the course to meet specific objectives.

Neonates with symptoms of stridor from birth, present a difficult diagnostic problem. We have demonstrated that by the use of a laryngeal mask airway in an anaesthetized baby breathing spontaneously, we are able to reach a diagnosis. This is accomplished by the introduction of a rigid fibre-optic endoscope through a Portex swivel connector and visualizing the glottis and larynx.

Congenital first branchial cleft fistulae, their embryology, anomalies, varied relationships to the facial nerve and surgical techniques for their excision have been well described in the literature. We report a case of a type II first cleft fistula in a three-year-old child which required a modification of the standard surgical approach to achieve safe and complete excision with identification and preservation of the facial nerve.

We report a case of persistent epistaxis in a seven-month-old child with Wilms' tumour who had an associated von Willebrand's type bleeding diathesis. Correction of the bleeding diathesis to control the epistaxis required treatment of the tumour with chemotherapy.

Nasal myiasis is the infestation of the nasal cavities by larvae (maggots) of Diptera flies. Several species of flies deposit their ova in the nose and the larvae feed on the host's tissues. We present a case of nasal myiasis by larvae of Oestrus ovis – Sheep Nasal Bot Fly. The larvae of Oestrus ovis are well known parasites in the nasal cavities and paranasal sinuses of sheep and goat. In Britain very rarely larvae may be deposited in the eye, nostrils or outer ear of man, usually husbandry workers. Reputedly, the larvae never survive beyond the first stage with acute catarrhal symptoms lasting only a few days.

This is the first reported case in the UK of an urban-dwelling patient infected by mature, third instar larvae of O. ovis. His nasal infestation resolved after endoscopic removal of the live maggots.

A patient suffering from persistent hoarseness was eventually shown to have laryngeal leishmaniasis. The incubation period for the disease must have been at least 16 years, following infection in Southern Europe. Mucosal leishmaniasis is rare in the Eastern hemisphere, and laryngeal leishmaniasis has not previously been reported in the UK. Previous Mediterranean cases have run a similar chronic course and have caused diagnostic difficulty, in particular being mistaken for malignancy. Treatment with aminosidine was ineffective, but the patient responded to liposomal amphotericin.

A case of laryngeal leishmaniasis, with symptoms of hoarseness and odinophagia which had developed over the past year, is presented. Clinical features and histological findings are discussed. Visceral leishmaniasis is increasingly associated with HIV infection and some authors have suggested the possibility of including it as a diagnostic criterium for AIDS in HIV-positive patients.

When any case of leishmaniasis presents atypical clinical features, localization or treatment response in endemic areas, HIV infection should be ruled out.

Voice restoration following laryngectomy can be achieved by the now well accepted technique of inserting a ’Blom–Singer‘ prosthesis through a tracheo-oesophageal fistula created either primarily or secondarily. Recognized complications of primary puncture and valve insertion include haemorrhage, oesophageal perforation, peristomal cellulitis and aspiration of saliva. We describe the previously unreported complication of a submental abscess developing probably as a result of air being forced from the fistula up between the trachea and the pharynx, this plane not having fully healed as a result of previous radiotherapy. The problem was compounded by the patient's over-zealous attempts to phonate. To prevent this problem arising in future we recommend leaving the fistula at least six weeks to mature before inserting the valve, when the patient has had previous radiotherapy, and encouraging relaxation when learning to phonate with this technique.

A case of left pyriform sinus fistula in a 20-year-old male is presented. The surgical management of this uncommon condition is discussed. Its embryological and clinical aspects are reviewed.

Necrobacillosis is a potentially life-threatening septicaemic illness occurring in the previously fit and healthy. The authors illustrate a case presenting as an atypical pharyngotonsillitis with renal complications, initially misdiagnosed as poststreptococcal glomerulonephritis. Necrobacillosis should be considered in cases of unusual pharyngotonsillitis.