The worldwide decline in surgery for otosclerosis had been reflected by a similar pattern here in Great Britain. Unless we are prepared to accept poorer results than have formerly been achieved, we will have to adopt measures to ensure that the skills of stapes surgery are transferred to the next generation of surgeons. Using the results of our experience, at the Queen Elizabeth Hospital, over the past 18 years, I have examined the implications for surgical training and for the management of future patients with otosclerosis.

One-hundred-and-fifty patients with Zenker's diverticulum were reviewed; twelve patients received no treatment; 26 patients were treated endoscopically by dilatation, five of these had a diverticulectomy performed at a later stage.

One-hundred-and-ten patients had a diverticulectomy performed (a total of 115 primary operations were performed). Eighteen of the patients operated upon had a recurrence and six underwent re-operation.

Local complications occurred in 24 patients. Seven patients had a fistula and two had mediastinitis. Ten patients had recurrent nerve palsy, of which five were permanent. Thirteen patients had other complications, usually infection. One death occurred.

Post-operative prophylactic treatment with antibiotics was found to significantly reduce the number of local infectious complications and a correlation was found between the occurrence of local, infectious complications and later recurrence of the pouch.

There have been many approaches advocated over the years for the surgical management of hypopharyngeal diverticulum, and this is a reflection of the absence of an ideal method both in terms of the surgical technique and of the frequency and severity of complications. Further experience with the use of the surgical staple gun is presented together with a discussion of its use in comparison with other operative methods. The ease and speed of the technique combined with a negligible complication rate suggest that it is a viable method for the management of large diverticula.

On the basis of the authors' experience with 20 patients, CO2 laser resection of palatal tumours has proved to be a good alternative to conventional surgical resection. The CO2 laser beam permits precise resection, due to only slight intra-operative bleeding coupled with use of the operating microscope. Wound healing is good and post-operative pain remarkably little.

Uvulopalatopharygoplasty has become widely performed for chronic snoring and for cases of obstructive sleep apnoea. Unfortunately this operation is not without morbidity and complications. We report our results of a prospective series of 50 patients undergoing uvulopalatopharyngoplasty with a minimum follow-up of one year. Snoring was abolished in 18 (36 per cent) and substantially reduced in the remainder. Obstructive sleep apnoea syndrome, identified in 11 patients pre-operatively, was reduced in severity in all but three. Troublesome complications were seen in 18 (36 per cent) patients, namely intermittent velopharyngeal incompetence in five (10 percent), pharyngeal dryness in 11(22 per cent) and loss of taste in five (10 per cent). One patient had nasopharyngeal stenosis requiring correction. A cautious approach to this operation is required with rigorous case selection. The importance of full assessment and careful follow-up should not be underestimated.

A retrospective view of 37 Per-Lee tubes inserted into 29 patients over a period of four years. At the time of review all the tubes were in situ but eleven had to be removed due to recurrent otorrhoea or perforations causing increasing deafness particularly in children. Per-Lee tubes are not suitable for long-term ventilation of the middle ear cavity in children.

In our series of 400 Chinese children with foreign body aspiration (FBA),343 cases were evaluated by fluoroscopy and/or plain chest X-rays before endoscopic removal of the foreign bodies. The majority of the foreign bodies (FBs) were organic (378/400, 94.5 per cent). The results showed that mainstem bronchial foreign bodies were diagnosed correctly in 68 per centof cases compared with 65 per cent correct diagnoses with segmental bronchial foreign bodies, but only 22 per cent correct diagnoses with tracheal, and 0 per cent correct diagnosis in those with laryngeal foreign bodies. Eighty per cent (32/40) of the children with laryngotracheal FBs had normal X-ray findings, whereas 67.7 per cent (205/303) of the children with bronchial FBs had abnormal chest X-ray findings. The most common positive radiological signs in the children with tracheobronchial FBs were obstructive emphysema (131/213, 62 per cent) and mediastinal shift (117/213, 55 percent). The incidence of major complications was related not only to the size of the foreign body and its location but also the duration since aspiration. The most common types of bronchial obstructions by airway FBs are discussed.

The results of revision endolymphatic sac surgery on 30 patients with unilateral Meniére's disease are presented. Good control is achieved in 73.3 per cent of cases at six months, falling to 56.7 per cent at one year and only 33.3 per cent by four years. The long-term results are disappointing but are more favourable if the initial surgery was successful, if the hearing remains fluctuant and improves on glycerol dehydration prior to the revision procedure and also if the sac is intubated. The current place of endolymphatic sac surgery is discussed and revision surgery only recommended for carefully selected cases.

Correction of a saddle nose deformity due to atrophic rhinitis is a formidable task. The thick and puckered skin secondary to long standing disease makes the creation of a dorsal subdermal pocket difficult. On the one hand, these patients tolerate synthetic implants poorly and on the other they show an unusually high rate of absorption of autologous bone graft. Our experience of treating 15 patients with saddle nose defor mity secondary to atrophic rhinitis is presented.

Inspiratory and expiratory airflow rates were measured in 30 subjects during quiet respiration (at a pressure gradient of 150 Pa) and at peak flow rates.

For low flow rates airflow rate was greater for inspiration than for expiration. Conversely at peak flow rates flow was greatest during expiration. Thus there was a reversal in the phase relationship between inspiration and expiration as flow rate increased.

It was also found that peak inspiratory flow rate correlated better with values for nasal resistance than did peak expiratory flow rate. Flow rate measured by rhinomanometry during quiet respiration was more sensitive to physiologically induced changes in nasal resistance than was peak flow rate.

The findings are discussed with reference to previous work on the physiology of nasal airflow.

Lateral sinus thrombosis in now a rare complication of ear disease in the developed world, since the advent of the widespread use of antibiotics. The classic picture is often modified by previous antibiotic treatment making diagnosis and management difficult. Lack of familiarity with this condition amongst present day otologists may lead to late diagnosis and treatment.

We review three cases that we have managed recently and compare their clinical courses with the classic description of the disease

Mucosal thickening is commonly seen on X-rays of the paranasal sinuses taken in the ENT department. This sometimes leads to a sinus washout, which is clear, even though the X-rays were strongly suggestive of disease.

This paper examines the prevalence of sinus X-ray anomalies in a general population, having facial X-rays for conditions other than possible sinus disease. The study suggests that up to 50 per cent of the socalled normal population may have sinus X-ray appearances consistent with sinus disease, and this may partly explain clear returns on sinus washout.

Submucosal diathermy (SMD) is a common surgical procedure carried out to improve the nasal airway. A case is presented in which it was followed by profuse epistaxis which required transfusion of 28 units of blood, eight units of fresh frozen plasma (FFP) and four units of platelets within 14 days.

A control series of biplane CT scans of the paranasal sinuses, derived from patients examined for orbital tumours, is described. The scans were assessed for the presence of anatomical variants in the middle meatus, said to contribute to meatal stenosis, and for signs of asymptomatic infection revealed by the presence of clouding or mucosal thickening in the sinuses.

Of the anatomical variants, only concha bullosa (pneumatisation of the middle turbinate) was associated with a high incidence of infection in the sinuses (85 per cent). Evidence of asymptomatic sinus infection was as high as 39 per cent overall, the highest incidence occurring in the ethmoid cells (28 per cent). Isolated ethmoid clouding on CT was observed in 15 per cent and is likely to be found in as many as one in seven of the adult population in the UK. It is concluded that in the majority of patients clouding confined to a few ethmoid cells shown on CT is without clinical significance.

The evidence from the control series did not support the concept that most sinus infection starts in the middle meatus. The presence of a large reservoir of quiescent or chronic sinus infection in the control group suggests that in most instances sinusitis derives from a recrudescence of this pre-existing infection.

The incidence of multiple primary malignancies (MPM) was analysed in 1297 patients with malignant tumours of the nasal cavities and paranasal sinuses. The patients were followed for a minimum of six years or until death. The incidence of MPM was 3.4 per cent (44/1297) which is lower than in patients with malignant tumours of other regions in the upper aerodigestive tract. Five of the 44 patients had second malignancies within previously irradiated areas. There was a difference between the proportion of histologies occurring in irradiated tissues compared with the overall 1297 patients. This finding suggests that radiotherapy may induce a second cancer.

The results of a consecutive series of 1,349 fine needle aspiration (FNA) biopsies from the head and neck region of 1,193 patients has been reviewed in order to evaluate the efficacy of this method in the diagnosis of tuberculous lymphadenopathy (TBLN). Of the 108 patients whose fine needle aspiration cytology (FNAC) showed granulomatous changes, 68 had subsequent surgery and histological confirmation of the cytological appearance. Sixty-three had TBLN, thus the specificity of FNAC was 93 per cent in diagnosing tuberculous related granulomatous lymphadenopathy. One false positive FNAC was reported histologically to be metastatic mucoepidermal carcinoma.

Of the 1,193 patients, 90 patients had subsequently TBLN confirmed histologically. Of these 90 patients, FNA from 69 showed granulomatous changes or acid fast bacilli (AFB), thus the sensitivity of FNAC in detecting tuberculous lymphadenopathy was 77 per cent. Fifty-two cytological smears were stained for acid fast bacilli. Nineteen (37 per cent) contained AFB. It is evident from this review that FNAC is an efficient way to detect cervical tuberculous lymphadenopathy.

In the ENT Department of the Royal Victoria Hospital, Belfast, the impression (supported only by anecdotes) was that electro-cautery was superior to chemical cautery in the treatment of simple anterior epistaxis. Since no evaluation of the relative merits of electro and chemical cautery has been reported, a prospective randomized study was conducted to assess the effectiveness of electro-cautery and cautery with silver nitrate. The results of the study showed that there was no statistically significant difference between the two methods in either controlling the epistaxis or in the incidence of complications. It is concluded that since cautery with a silver nitrate tipped applicator is simpler, and of equal effectiveness, it would appear to be the treatment of choice for simple anterior epistaxis.

This paper presents an analysis of the relationship of the amount of hyalinization of the spiral ligament, secondary to cochlear otosclerosis (spongiosis), to the amount of hearing loss. This relationship was previously studied by Parahy and Linthicum. It was found that the larger the amount of hyalinization, the greater the hearing loss. This hyalinization is a measure of the amount of toxic enzymes being excreted into the inner ear fluid. These enzymes are suspected to affect the metabolic function of the hair cells.

Symptoms at first onset and on initial examination were analyzed in 845 patients with maxillary sinus carcinoma. About 20–30 per cent of the patients became aware of swelling of cheek, nasal obstruction, nasal discharge and epistaxis as first symptoms. About 50–80 per cent of the patients complained of such symptoms on initial examination. Symptoms of maxillary sinus carcinoma are similar to those of chronic sinusitis which results in a delay in diagnosis. Such symptoms should be recognized to improve survival rate. CT and MRI scans are useful for early diagnosis and determination of tumour extension. Sinoscopy with biopsy is most important to detect the earliest tumour stage.

Vocal fold sulcus is a cause of dysphonia which has not been recognized until recently. Awareness of its existence combined with use of laryngostroboscopy would enhance the management of this group of patients. Five such cases were treated initially by voice therapy and subsequently combined with microlaryngeal Teflon injections of the vocal cord. Representative photomicrographs and the end results of treatment are presented. A good voice, subjectively and objectively, was obtained in three patients, with satisfactory improvement in the other two.