The purpose of this work was to compare pre- and post-operative facial nerve function between unmonitored and monitored cases of skull base lesions. The study involved 32 patients suffering from lateral skull base tumours (10 unmonitored and 22 monitored). Facial nerve function was monitored intraoperatively by an acoustic facial electromyographic system (NIM-2). Post-operative facial function was graded according to the House-Brackmann scale. In the group of monitored cases, facial nerve function was normal (Grade 1 or 2) in 79 per cent of the patients, while the unmonitored patients showed normal function in only 50 per cent of the cases.

These results confirm previous observations that audible evoked electromyographic monitoring significantly reduces permanent facial nerve dysfunction.

The human cadaveric styloid process was used as a homograft material for ossicular chain reconstruction in 41 cases of chronic suppurative otitis media over a five-year period. Although technical success was achieved in about 88.23 per cent of the cases, actual patient benefit was around 70.58 per cent; this is comparable to results obtained with most other homologous graft materials. The problem of breakage while remodelling the bone has also increased the risk of transmitting the AIDS virus and consequently undermines the use of this material.

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.

Non-explosive blast injury of the ear refers to the otological trauma caused by a blow to the ear that seals the external auditory meatus. It results in a sudden increase of air pressure within the ear canal that strikes the tympanic membrane. The present study portrays the various aspects of middle and inner ear damage in 91 patients resulting from an assault we entitled a ’non-explosive blast injury' to the ear. Sixty cases were caused by a slap or a fist, 13 patients suffered sport accidents, mostly in ball games, and 18 patients were injured during swimming and water sports activities. The common symptoms were hearing loss, earache, tinnitus, vertigo and otorrhoea. All 91 patients presented with acute perforations of their eardrums. The mean conductive hearing loss was 11.2 dB. A high tone sensorineural hearing loss was detected in only 20 per cent of the patients. A spontaneous closure of the perforation with a conservative management approach was observed in 94.8 per cent of the patientsHealing of the perforation was always associated with closure of the air-bone gap, while the results of the sensorineural hearing loss recovery were less favourable.

Incomplete recovery from Bell's palsy was observed in some patients even after the intake of corticosteroids. This prospective study was performed on 160 patients with unilaterial nonrecurrent Bell's palsy in order to investigate the role of prednisolone on the prognosis of Bell's palsy. Ninety-three patients were given prednisolone tablets (1 mg/kg body wt/day up to 70 mg) for six successive days, then the dose was reduced gradually over the next four days. The remaining 67 patients were not given prednisolone (control group). Facial nerve recovery was assessed clinically and electrophysiologically for up to one year. The results of this study suggested that the most probable contributing factor for the success of prednisolone in improving the prognosis of Bell's palsy was its early intake (within the first 24 hours following onset).

Sinus radiographs have been carried out on 240 new cases of childhood otitis media with effusion (OME). When the films were suggestive of infection, maxillary sinus washouts were carried out as part of the surgical treatment. Abnormal X-rays were obtained in 28 per cent of the study group, but only 16 cases (seven per cent) of sinus infection were confirmed on antral lavage. In those with positive washouts, there was an apparent relationship between the findings in the maxillary sinuses and middle ears of the same side in some of the cases. There was also evidence of improvement of the middle ear disease when the sinus infection was successfully treated. It does not appear that sinus infection is an important cause of OME, though it may be relevant in a small number of cases.

Commissural lip pits, pinna dysplasia, pre-auricular sinus and hearing loss constitute a recently described autosomal dominant branchial arch syndrome. In a large family, eight out of the 74 members were also affected by conductive hearing loss. No inner ear abnormalities could be demonstrated on the CT scans. In three patients (four ears) out of four patients (six ears), exploratory tympanotomy revealed serious ossicular chain anomalies. In one ear, round window aplasia was also present. Long-term hearing improvement could only be achieved in one ear.

Four theories have been suggested to explain the aetiology of lateral cervical cysts. Ascherson (1832) suggested that the cysts arose due to incomplete obliteration of branchial cleft mucosa, which remained dormant until stimulated to grow later in life. His (1886) suggested these cysts were vestiges of the precervical sinus. Wenglowski (1912) believed lateral cervical cysts developed from the third pharyngeal pouch (thymopharyngeal duct).

A number of investigators during the 19th century noted the close relationship between lateral cervical cysts and lymphoid tissue (Lucke, 1861). Luschka (1848) suggested that cystic degeneration of cervical lymph nodes was the mechanism by which lateral cervical cysts were formed. This theory received little support until King (1949) studied the histology of a large number of lateral cervical cysts and concluded that these cysts resulted from cystic transformation of cervical lymph nodes.

The evidence for and against these theories of aetiology is discussed. The debate is centred on a study of 20 patients with lateral cervical cysts operated on in the Department of Otolaryngology, Bedford Hospital, between January 1986 and December 1991. In all twenty cases the wall of the cyst was found to be composed of lymphoid tissue, histologically identical to that present in lymph nodes. The mean age of presentation was 31 years, and in no case was a tract or cord found which connected the cyst to the skin or pharynx.

The evidence strongly suggests that lateral cervical cysts develop from the cystic transformation of cervical lymph nodes. Mechanisms by which this may occur are discussed.

Long-term results of allograft ossiculoplasty with erosion of the long process of the incus in 44 patients are described. The pyramidal-shaped allograft leans on the stapes, the remaining part of the incus and the side of the malleus - forming a ‘tripod’ shape or construction.

The study includes two groups of patients: group A (34 patients) in whom the pre-operative three-frequency average air-bone gap was 20 dB or more and group B (10 patients), in whom the pre-operative air-bone gap was less than 20 dB. In the latter group the indication for surgery was not their hearing loss, but a different pathological condition (infected retraction pocket, a cholesteatoma, etc.) which necessitated surgical disconnection of the chain during the operation.

The average period of follow-up 46 months for group A and 24.9 months for group B. In group A, the preoperative average air-bone gap was 33 dB. Following surgery, the air-bone gap was 20 dB or less in 27 ears (79 per cent), and 10 dB or less in 18 of them (53 per cent). In group B, pre-operatively, the average air-bone gap was 11 dB. Following surgery, the air-bone gap was either better than before the operation or did not increase by more than 5 dB in eight patients (80 per cent).

Comparison of the audiometric results of 20 patients after mean follow-up times of 23.8 months and 64.9 months shows that no deterioration of hearing occurred in the intervening period. Graft extrusion was not observed in any of the operated ears.

Serum leucine aminopeptidase (LAP) activity was assayed in patients with head and neck cancer. The levels were found to be significantly higher than the controls. However, the rise in serum LAP was nearly the same in all the patients studied, irrespective of the character or histopathology of the lesion but varied with respect to the site involved, i.e. from about 40 per cent in cancer of the hypopharynx to more than 100 per cent in cancer of the nasopharynx. Serum LAP activity was found to increase with the extent of the lymph node spread. After treatment the levels were found to be reduced.

A variety of solutions were tested in vitro to find a suitable solvent which could be used in clinical practice for cholesteatoma debris. Though a little weak as a solvent, a liquid soap composed mainly of plant oil did not cause irritation of the middle ear mucosa, and was thought to be a promising solvent with which to rinse away tenacious debris, especially when used in combination with hydrogen peroxide.

Rhinoscleroma is a chronic specific granulomatous inflammatory condition that has an affinity with the mucosa of the upper respiratory tract. Involvement of the eustachian tube is uncommon. In the present study nasopharyngoscopy was performed in 20 patients with rhinoscleroma to find out the type, nature and site of the lesion at the orifices of the eustachian tube. A lesion involving the eustachian tube was found in six cases (30 per cent). Lesions occurred in the form of atrophic changes with crusting, granuloma and fibrotic thick areas. Involvement of the eustachian tube was found to be associated with intranasal scleroma and was more common at the granulomatous stage. Eustachian tube scleroma had a possible association with subsequent changes in the tympanogram pattern. Nasopharyngoscopy was found to be of therapeutic value in removing the crust, discharge and granulations at the eustachian tube orifices.

Twenty-five children (mean age six years) with de novo bilateral ear effusions received a ‘trimmed’ high grade silicone (HGS) Shah permavent ventilation tube in one ear and a conventional polyethylene Shah grommet in the other.

The extrusion rate and the degree of tympanosclerosis formation was examined. At 29 months the conventional grommet had extruded in 90 per cent of children and a recurrent middle ear effusion was found in over 50 per cent of these ears.

The average length of stay for the conventional grommet was 12.5 months. Five permavent tubes had extruded, one was extruding but the remainder were all in place and patent. Comparing ears on each side the amount of tympanosclerosis was worse in the ear with the conventional grommet in 47 per cent of children and worse on the permanent side in 11 per cent of the children.

The ‘trimmed permavent’ appears to act as a medium to long-term grommet which self extrudes without serious complications. Its use at the primary operation in young children may save repeated insertions of conventional grommets.

The technique of microscope examination and hot wire cautery in a prospective study of 100 consecutive patients with acute epistaxis is described. The method was successful in arresting haemorrhage in 94 per cent of patients bleeding at the time of examination, and in 86 per cent, discharge home within one hour was possible. Due to improved illumination, magnification and control of the cautery instrument, nasal packing was required in only nine per cent of cases. By achieving this and by reducing the overall need for admission to 20 per cent, we recommend this method of treatment both as a successful cost saving measure, as well as advantageous to the patient.

Perilymphatic fistula (PLF) remains one of the most challenging problems in otological practice. Fifty-two consecutive patients (53 ears) who underwent explorative tympanotomy for suspected PLF between 1985–1992 were included in this study. The clinical picture, history, patients' complaints and laboratory tests were analysed and compared with the operative findings. The conclusions of our work are that the diagnosis of PLF is based mostly on the clinical picture and a battery of laboratory diagnostic tests, but no one test is truly diagnostic for PLF.

Four cases with a neopharyngeal diverticulum following total laryngectomy are presented. Each patient required surgery for complications directly related to the pouch. The relevance of these diverticulae is discussed with reference to their aetiology, complications and management.

The use of the rigid endoscope has been evaluated during transsphenoidal microsurgery of 10 pituitary adenomas: three were prolactin-secreting adenomas; five growth hormone (GH)-secreting adenomas; and two without evidence of known endocrine activity. The use of the endoscope allowed close inspection and differentiation between tumour tissue and glandular remains. This resulted in microdissection of the tumour with maximum preservation of pituitary function. The angled view of the telescope helped total gross removal of tumour tissue from the less accessible supra- and para-sella extensions. More cases and a longer period of follow-up are necessary to provide long-term results.

The Foley balloon catheter has been used in the management of posterior epistaxis for several decades. Despite a lack of uniformity in balloon use, it is frequently successful in arresting haemorrhage. A better understanding of the balloon's characteristics may further increase its effectiveness by more appropriate use in some individuals.

Inflation characteristics were assessed in vitro by measurement of balloon length and diameter at various inflation volumes. Deflation of air-filled balloons was found to be consistent for each balloon type. The deflation rate was unaffected when BIPP (bismuth-iodoform-paraffin paste) or liquid paraffin soaked gauze were applied to the catheter.

Recommendations for catheter use are made.

Two cases of hereditary haemorrhagic telangiectasia are presented. Epistaxis was intractable in both patients. Young's procedure proved successful in controlling nose bleeds. One of the patients has been followed-up for 14 years. Methods of treatment are discussed with a review of the literature.

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.