The great auricular nerve is often sacrificed in superficial parotidectomy, even though its posterior branch often can be preserved. By cautious dissection of the great auricular nerve it is possible to preserve the posterior branch in 70.5 per cent of the operations.

Ninety-five patients who had undergone superficial parotidectomy were included. A significantly higher number of patients had subjective sequelae if the posterior branch of the nerve had been cut, compared to the patients with a preserved nerve. A significantly higher rate of sensory morbidity was found if the nerve had been cut. In patients with a preserved posterior branch of the great auricular nerve there was no increase in other potential sequelae after parotidectomy.

Therefore, this additional dissection should be considered, where appropriate, in routine parotid surgery.

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are an important cause of morbidity and mortality in the surgical patient. The first guideline produced by the Scottish Intercollegiate Guidelines Network was for the prophylaxis of venous thromboembolism. Patients undergoing major head and neck cancer surgery commonly exhibit risk factors for venous thromboembolism. Currently, however, there are no data on its incidence in these patients. A questionnaire survey was performed to assess the current practice of consultant otolaryngologists regarding DVT prophylaxis in patients undergoing head and neck cancer surgery. Of those respondents who managed these patients, 57 per cent did not use routine DVT prophylaxis while 43 per cent did. A wide variety of techniques were employed among those practising DVT prophylaxis.

A consensus is needed concerning the use of thromboembolism prophylaxis in head and neck surgery patients.

A one-year prospective audit (1989) of patient non-attendance for elective surgery in our department showed that of those summoned, five per cent defaulted on the day of admission without contacting the hospital (Hampal and Flood, 1992). Contributing factors such as lengthy waiting lists and inefficient communication with the patients were amenable to correction by the hospital. However, the current admission policy made inevitable a significant waste of theatre time.

The pre-admission clinic (PAC), an outpatient attendance shortly before planned surgery, was recommended in ENT practice by Robin (1991) and introduced into our department that year. Failure to attend the PAC allowed adequate time' for replacement on the theatre list and was recommended as a solution to the problem of unfilled theatre sessions (Dingle et al., 1993).

A subsequent four-year experience of conducting PACs has confirmed several expected advantages. However, some of the hopes for development expressed in our earlier work (Dingle et al., 1993) have failed to materialize. This study aims to review retrospectively our experience and compare it with the admission practice and desires of ENT departments in the United Kingdom as revealed by a postal survey. The findings are of relevance to all surgical specialties and to anaesthetic departments wishing, to adopt this system of admission.

We present a case report which describes a rare cause of a common clinical problem; eustachian tube dysfunction. A seven-year-old child presented with a history of chronic draining ears, despite rigorous medical therapy and multiple ventilation tubes. At myringotomy a mass was noted in the middle ear, and she was taken to the operating room for exploration. The patient was found to have a pedunculated lipoma arising from the anterior medial aspect of the middle-ear cleft producing intermittent obstruction of the eustachian tube orifice. This case represents the fourth case of a middle-ear lipoma in the world literature. We present a review of the literature and an exploration of possible aetiologies of this unusual entity in the differential diagnosis of eustachian tube dysfunction.

A case is reported in which a Nucleus 22 channel cochlear implant was inserted into the basal turn of the cochlea of a patient with advanced otosclerosis. It then passed out of the anterior end of the basal turn into an otospongiotic cavity related to the cochlea. Seven electrodes were located in the basal turn and it was possible to map them sufficiently well for the patient to derive considerable benefit from the implant. The problem of implant induced facial nerve stimulation in otospongiosis is also discussed.

The main challenge after total laryngopharyngeal and cervical oesophageal resection for laryngopharyngeal carcinoma, is to provide a suitable feeding conduit which improves the quality of life for the patient. Reconstruction with a tubed free forearm flap can solve the feeding problem to some extent, providing a thin and pliable fasciocutaneous conduit that accommodates well with the thin mucosa of the pharynx and oesophagus.

In this study immediate reconstruction of the pharyngo-oesophagus by free forearm flaps is reported in nine patients with advanced laryngopharyngeal and oropharyngeal carcinoma. The vascularization of the flap is very good, thus rendering this flap to be reliable. The average time for the commencement of oral feeding was 16 days. There was one flap failure (11 per cent), due to venous thrombosis which was replaced by a deltopectoral flap. Long term stenosis did not occur because of the two triangles created at the distal end of the flap which were inserted to the opposite triangular defects at the proximal oesophageal stump.

Donor site morbidities were minimal and scarring of the forearm was acceptable for all the patients.

The endoscopic approach to the fronto-ethmoidal recess (FER) in the treatment of chronic frontal sinus disease is now widely accepted. The Lothrop procedure was first described in 1914, but was largely replaced with more invasive open frontal sinus proceduresuntil the advent of the rigid Hopkins' rod, since when it has enjoyed enewed popularity.

We describe a modification of this technique which allows both transnasal endoscopic and external direct visualization of the FER and frontal sinus and a direct approach to the anterior buttress (or “nasofrontal beak”) which allows its quick and simple removal.

The results of orbital decompression for thyroid eye disease are presented in a cohort of 33 patients. It was performed by an external Patterson approach in 21 individuals and in 13 by an endonasal endoscopic approach. The endoscopic approach was entirely comparable in respect of improvement in axial proptosis, giving a mean improvement of 4.4 mm as compared with a mean of 3.8 mm for the external approach, and produced a demonstrable improvement in visual acuity and perception of colour in three individuals, where this was compromised, and was associated with fewer complications.

With improved control of cancer above the clavicles, distant metastases (DM) are frequently more seen and are becoming a more common cause of morbidity and mortality. The present study defined the incidence of distant metastases in a cohort of terminal head and neck cancer patients (HNCP) and compared it to current reported data. The incidence of distant metastases in relation to the primary tumour was evaluated and their impact on survival was assessed. A retrospective survey of patient charts was made, based on the hospice database and original referring hospital charts. Data of 59 patients admitted to the hospice were evaluated. The incidence and location of locoregional and distant disease were studied and effects on survival analyzed.

The overall survival from diagnosis to demise was 42.7 months. Thyroid cancer was seen in 20.3 per cent of cases and squamous cell cancer was seen in 59.3 per cent. Distant metastases were found in 83 per cent and 48.6 per cent of patients respectively. Laryngeal cancer patients had a 54.5 per cent incidence of distant metastases. Locoregional disease was seen in 47 per cent of cases and 35.7 per cent of them had distant metastases while a 64.3 per cent incidence of distant metastases was found in cases without locoregional disease. Mean survival was 47.3 months with distant metastases vs 36.5 months without metastases. The difference was not statistically significant.

The incidence of distant metastases in squamous cell cancer in terminalHNCP was 48.6 per cent. This is the highest reported incidence of metastases in a clinical series. Patients without locoregional disease had almost a two-fold incidence of metastases. Survival was not affected by metastases in this series.

A case is presented of a 36-year-old male with narrowing of the external meatus due to a diffuse neurofibroma. This unusual variety of neurofibroma spreads superficially and has many ectatic blood vessels. The size, vascularity, uncertain edges and a tendency to recur makes surgical removal difficult. The treatment options are discussed.

It has been postulated that the bacteraemia rate following guillotine tonsillectomy is lower than that following dissection tonsillectomy due to intra-operative compression of tonsillar blood vessels by the guillotine. The aim of this study was to evaluate the incidence of bacteraemia following dissection and guillotine tonsillectomy. Sixty-four patients undergoing elective tonsillectomy for recurrent acute tonsillitis were randomly selected, 32 underwent dissection tonsillectomy and 32 guillotine tonsillectomy. Positive intra-operative blood cultures were obtained in 16 patients (25 %), nine (28.1 %) of the dissection group and seven (21.8 %) of the guillotine group. There was no significant difference between the two methods (Chi-squared test, p = 0.77).

Nasendoscopy is an essential tool in assessing the dynamic function and structure of the velopharyngeal sphincter during speech and swallowing.

Flexible fibre-optic nasendoscopy has been used by the cleft palate team at Withington Hospital, Manchester since 1989. Seventy-six patients were referred between 1989 and 1994 for evaluation of velopharyngeal function during speech. Flexible nasendoscopic evaluation was attempted in 50 patients, and successfully carried out in 43 patients. The age range was four years to 77 years (mean 21 years). The patients were divided into two groups: Group 1 consisting of patients with cleft palate and Group 2 comprised of patients with non-overt cleft palate-related velopharyngeal dysfunction of various aetiologies; such as, submucous cleft, post-tonsillectomy, post-adenoidectomy, neurological and post-traumatic.

Based on the findings on nasendoscopy, videofluoroscopy and clinical speech/voice analysis the following treatment options were recommended: 17 (40 per cent) for pharyngoplasty, five (11 per cent) for revision pharyngoplasty, 15 (35 per cent) for speech therapy, four for an obturator and one for tonsillectomy. Two previously undetected submucous clefts were diagnosed.

Haemangiomas of the maxillary sinus are very rare. In this paper we present one case with an inaccurate preoperative diagnosis which was treated by entire excision of the tumour. One year aftersurgery there is no evidence of recurrence. The literature on the topic is reviewed.

A suction end for use in epistaxis is presented. It has advantages over commonly used devices in offering a comfortable length for handling and adequate diameter for effective control of severe haemorrhage. It is also disposable which reduces the risk of blood borne transmission of diseases.

A new device is introduced for holding temporal bones during dissection. It is structurally very different, more practical and effective for securing the bone than the temporal bone holding bowl which has been in use so far.

We present the case history of a patient who was severely immunocompromised due to infection with the human immunodeficiency virus (HIV), and who subsequently developed acute mastoiditis due to Aspergillus fumigatus. Fungal otomastoiditis is a rarely reported complication of HIV infection. A high index of suspicion is required in these patients to facilitate early diagnosis and appropriate therapy.

The incidence of tracheal stenosis following conventional tracheostomy has been reported as lying between one and 30 per cent. Methods used to assess the degree of stenosis include CT scanning, fibreoptic visualization and plain X-ray tomographs. The aim of this study was to assess the degree of stenosis in patients following percutaneous dilatational tracheostomy (PDT) using MRI scanning. This method has not been reported in the literature previously. Nine patients without symptoms of tracheal stenosis were studied for at least six months following PDT performed in the intensive therapy unit. The tracheas were assessed for scarring and stenosis using a three dimensional volume scanning MRI technique. Although scarring could be detected in the wall of the trachea and subcutaneous tissues of all patients, tracheal stenosis was not demonstrated at the insertion site or at the site of the cuff (p>0.05). MRI scanning provides an excellent non-invasive method of assessing the tracheal lumen. Our patients who had undergone PDT do not appear to have any degree of post-operative stenosis.

A rare case of extracranial meningioma presenting as a tumour of the external auditory meatus is reported. Biopsy indicated a diagnosis of meningioma, but the radiological appearance was unusual. For example, computed tomography (CT) scans showed an unenhanced tumour mainly located in the squamous part of the temporal bone which expanded into the external meatus destroying the temporal bone. Magnetic resonance imaging (MRI) revealed that the tumour did not extend into the intradural space.

This meningioma, had an obvious tendency for extracranial development. According to the operative findings, the tumour arose from the middle cranial fossa dura and extended through the air cells of the temporal bone into the external meatus, instead of growing intracranially.

Secondary extracranial meningiomas of the temporal bone usually have a large intracranial component and cause neurological symptoms. However, this was a very rare case of a small meningioma causing no symptoms except for conductive hearing loss.

Wegener's granulomatosis is a systemic vasculitis that may present with a Variety of findings and be difficult to diagnose. We report a case of a patient who presented with serous otitis media and subsequently developed a suspected primary lung tumour. Thoracotomy and pulmonary mass excision were required to establish the diagnosis. Otological manifestations of Wegener's granulomatosis, differential diagnosis, pathological findings and c-ANCA test role are discussed.

A case of nevoid basal cell carcinoma syndrome (Gorlin-Goltz syndrome) with basal cell carcinoma of the external auditory canal is reported. This is only the second such case.