This article describes the anatomy of the visual pathways and how they should be assessed under anaesthesia. The differential diagnosis of asymmetrical pupils is illustrated with clinical examples and a strategy as to how they should be examined.

Grommet insertion is a widely accepted method of treatment of glue ear in children. There have been questions raised over the last few years about the indications for grommets and whether assessing the hearing alone is an efficient outcome measure. Parental pressure accounts for one of the factors that is taken into consideration when the decision to insert grommets for glue ear is made. In this paper, a prospective questionnaire is used to investigate the parental perceptions of the effectiveness of grommet insertion in children, focusing on alternative outcome measures such as general health, language, and social skills. The results of this survey suggest that grommet insertion causes improvement in many factors other than hearing and this seems to account for the parental pressure for siblings to have grommet insertion.

The most important prognostic factor in cancer of the larynx is the presence of cervical metastatic disease, which is the most common type of recurrence in such patients. Because micrometastases cannot be detected pre-operatively at present, selective lateral neck dissection is increasingly recommended as the standard treatment for patients with a clinically negative neck in order to reduce the recurrence rate. In cases of N+ disease, selective lateral neck dissection can be as valid as modified radical neck dissection, providing patients have only limited, occult metastatic disease.

Reports on the relationship between diabetes and hearing loss have been controversial. The present study examined this relationship in 1,740 Mexican American adults using data from the Hispanic Health and Nutrition Examination Survey. Hearing threshold levels were obtained for each participant at the following frequencies: 500,1000, 2000, and 4000 Hertz (Hz). The thresholds from the worse hearing ear were used in the analyses. Diabetes and insulin use were assessed by self-report. The mean crude hearing thresholds in diabetics were significantly higher than in non-diabetics at each of the four frequencies. However, after adjustment for age, gender, and socioeconomic status, diabetics had a significantly higher mean threshold than non-diabetics only at 500 Hz (mean difference ± SE: 2.8 ± 1.2, p = 0.04). Diabetics who were not using insulin had significantly higher thresholds than those who were using insulin at 2000 (mean difference ± SE: 5.6 ± 2.6, p = 0.03) and 4000 Hz (7.7 ± 3.3, p = 0.02). Also, at 4000 Hz, insulin users had a significantly lower mean threshold than non-diabetics (mean difference ± SE: –4.9 ± 1.6, p = 0.02). Our data suggest that associations between diabetes and decreased hearing acuity in the higher frequencies are present only amongst diabetic Mexican-Americans who do not use insulin.

Purpose The purpose of this study was to investigate the outcome of different injuries to the facial nerve.

Materials and methods Six patterns of injuries (exposure, compression, crushing, stretching, division and post-division anastomosis) were produced in the buccal branches of the facial nerve in 60 rabbits. Electroneuronography (ENoG) and histology at definite time were used to evaluate the results.

Results and conclusions Exposure and compression injuries produced a neuropraxic injury and rapid recovery. Crushing and stretching injuries resulted in axonotmesis and whilst complete recovery can take place it may be very slow. Division and post-division anastomosis fall into neurotmesis injury and do not completely recover within six months; the former recovers slower and later than the latter.

Nineteen patients previously treated with 52 implants for anchorage of craniofacial prostheses were subjected to implant stability measurements by means of resonancefrequency analysis (RFA), six months to 15 years after implant placement. The resonance frequency (RF) of a transducer attached to the implant abutment was measured by using a frequency response analyser, a personal computer (PC) and dedicated software. Statisticallysignificant higher RF values were seen for implants in the temporal bone as compared to implants in the nose and periorbital regions. There was a positive correlation with time since implant placement for the period from six months up to seven years. It was concludedthat the preliminary results suggest that implant stability increases with time and that implants in temporal bone are more stable than implants in the bone in the nose and periorbital regions, probably reflecting differences in bone density.

During setting and hardening, the hybrid bone substitute ionomeric cement (lonocem®) achieves a stable and durable bond with the apatite of the adjacent bone without interpository soft tissue. Fluid contact during setting results in the release of aluminium ions which may reach critical levels as high as 3000 μg/l. On epidural application it is, therefore, essential to prevent cement constituents from gaining access to the intradural space. After the cement has hardened, the presence of aluminium is demonstrable in the adjacent bone to a maximum depth of 20 μm (EDX microanalysis). In rabbits, epiduralplacement of freshly mixed cement causes slight thickening of the dura. There is reason to believe that human dura, with a thickness 10 times greater, is impermeableto components of the cement. After epidural application of the freshly mixed cement in the frontobasal and laterobasal regions and at the skull cap and petrous apex, 76 patients in all have been followed for up to 6.5 years. During this period no complications have arisen and functional (and cosmetic) results are promising. The availability of preformed implants (lonoroc®, lonocast®) permitted the peridural placement of minimal quantities of freshly mixed cement. These implants were fixed to localized sites on the adjacent calvarial bone by use of lonocem®. Notwithstanding the stringent manufacturer guidelines, there have been reports in the literature that during the vulnerable stage of setting neurotoxic aluminium ions were released into the dural space with a fatal outcome intwo cases. In view of potential intradural complications, such as may occur in case of dural leaks, it was considered that further application of the material adjacent to the dura was no longer warranted. The production of lonocem® was discontinued in May 1995.

Acquired medial canal fibrosis is a discrete clinicopathological entity characterized by formation of fibrous tissue in the bony external auditory meatus.

Over a seven-year period, a total of 14 operative procedures were performed on 12 ears involving 10 patients. Four cases had followed otitis externa, two were complications of suppurative otitis media, and three cases were iatrogenic. The cause could not be identified in three ears involving two patients.

Treatment entails excision of all the fibrous tissue and involved skin, a wide canaloplasty, a meatoplasty, and then reconstruction by split skin graft. Two cases of canal cholesteatoma were encountered. Average follow-up of two years showed hearing improvement in all patients. The only complication was a recurrence of the stenosis in two ears. The paper discusses terminology, aetiology, pathophysiology, diagnosis, and principles of treatment of this condition.

Hagiographical texts of the Byzantine period contain a significant number of miraculous treatments of several diseases of the ear, nose and throat. The comparison of the conservative treatments referred to as well as the often concealed surgical interventions of these texts with those known from the medical texts of the eminent Byzantine physicians, lead the writers to conclude that a series of real treatments were carried out in the churches or in the Xenones (hospitals) of Byzantium.

The authors have used the nasal endoscope for the precise identification of pathological abnormalities of the nasal septum in relation to the lateral nasal wall including the osteo-meatal complex and in its ultraconservative management. The aim of the study was to compare the efficacies of endoscope-aided septoplasty (EAS) over traditional septoplasty (TS) in treating the pathological septum and turbinates, performed in 30 cases each. The subjective assessment was carried out by visual analogue scores and objective assessment by nasal endoscopy. This study demonstrates the superiority and limitations of the endoscopic approach in managing a deviated nasal septum and the turbinates. The endoscope-aided technique was found to be more effective in relieving the contact areas and nasal obstruction (p = ≤0.05). The authors advocate a combined approach – an endoscopic approach for inaccessible posterior deviation and the conservative traditional technique for accessible anterior deviation of the nasal septum.

Mucoceles are the most common lesions causing expansion of the paranasal sinuses. The sinuses most commonly involved are, in decreasing order of frequency, frontal sinus, ethmoid sinuses, maxillary sinus and sphenoid sinus. We reviewed 46 cases of surgically proven mucoceles and the purpose of this study was to report five cases of mucoceles in an uncommon location.

Botulinum toxin type A (BTA) is known to inhibit the release of acetylcholine from cholinergic nerve endings. Owing to the characteristics of BTA, we thought that it could be used for the treatment of intrinsic rhinitis acting as an anticholinergic drug. In a double-blind placebo-controlled study four units of BTA were injected into the middle turbinate (two units) and inferior turbinate (two units) in each nasal cavity. Rhinorrhoea, nasal obstruction, and sneezing were recorded in a symptom diary on the basis of a scale of 5 and the number of paper tissues used per day was also recorded for 24 weeks. Rhinorrhoea was significantly diminished in severity (24.1–41.5 per cent reduction) and paper tissue use (54.3 per cent reduction) in the BTA group compared with the placebo group. This effect could be maintained for four weeks. Sneezing and nasal stuffiness were not affected by BTA. These results suggest that BTA can be used to treat rhinorrhoea in intrinsic rhinitis patients, however, the effective period is short.

The aim of the study was to evaluate the long-term results after surgery for acquired cholesteatoma in children and to contribute to the search for predictors of recurrence. During a 15-year period, 114 children underwent surgery. The patients were re-evaluated with a median observation time of 5.8 years. At the last re-evaluation 85 per cent of the ears were dry with an intact drum. Recurrence of cholesteatoma developed in 27 ears. The cumulated total recurrence rate was 24 per cent using the incidence rate calculation, applying Kaplan-Meier survival analysis the corresponding recurrence was 33 per cent. Recurrent disease occurred significantly more frequently in children younger than eight years, with a negative pre-operative Valsalva, with ossicular resorption and with large cholesteatomas. In conclusion, young children with poor Eustachian tube function and a large cholesteatoma with erosion of the ossicular chain, are at special risk of recurrence and should be observed for several years after surgery.

Temporal bone dissection is considered to be an important aspect of the otological training of the Specialist Registrar with dissection skills being formally assessed in the Intercollegiate Fellowship Examination. However the procurement of cadaveric specimens suitable for dissection may be fraught with difficulties. The authors take an historical perspective to clarify the existing legal issues and outline the means available to improve supply.