This is an anthropological study of the development of the mastoid process in the four ethnic groups of Pakistani races: Turko-Iranian, Indo-Aryan, Scytho-Dravidian, and Aryo-Dravidian.

Cephalometric studies have established that the majority of Pakistanis are brachio to ultrabrachiocephalic (Cephalic Index 82–x). Radiological evaluation of normal mastoids and their planimetric measurements show that the mastoid process is smaller (Av: 10.24 sq.cm. ± 0.8) than the Caucasian Western races (Av: 12–15 sq.cm.).

Neither combined approach tympanoplasty, nor mastoid obliteration technique may be required, nor technically possible in a small mastoid. Natural epithelization of a small ‘peanut size’ mastoidectomy cavity does not justify these procedures. A modified radical mastoidectomy and tympanoplasty reconstruction provides a satisfactory result in chronic discharging ears.

Clinical tests of hearing are regularly used in adults but their role, now that pure-tone audiometry is almost universally available, has not been evaluated by modern methods of analysis including sensitivity and specificity.

Free-field voice testing was carried out in 101 patients and the Rinne tuning-fork test in a different group of 127 patients prior to clinical or audiometric evaluation. The results were subsequently compared to air and bone conduction pure-tone thresholds assessed using rigorous standards.

Depending on the audiometric definition as to what constitutes a hearing impairment, the sensitivity of free-field voice testing to identify such an impairment because of an inability to hear a whispered voice at two feet (60 cm.) was 86 per cent or better with the specificity being in the region of 90 per cent.

In the Rinne test the 256 Hz fork was superior to the 512 Hz fork (p<0.05) and the loudness comparison method superior to the threshold decay method (p<0.01) in detecting an air-bone gap. Combining the responses to the two forks did not improve the results. The Rinne test with the 256 Hz fork will identify correctly 48 per cent of individuals with a 15 dB, 69 per cent with a 20 dB, 87 per cent with a 25 dB, and 95 per cent with a 30 dB conductive impairment. In all instances the specificity is greater than 90 per cent.

A study was undertaken to evaluate the prevalence and antibiotic susceptibility of bacteria present in the middle ear of patients with otitis media with effusion. Middle ear effusions (MEE), nasopharyngeal and throat swabs were obtained at operation and cultured for aerobic and anaerobic bacteria. Two hundred and fifty-nine effusions were obtained from 152 subjects examined. Haemophilus influenzae was isolated from 32 (12.3 per cent) effusions. Streptococcus pneumoniae from seven (2.7 per cent), Staphylococcus aureus from seven (2.7 per cent), Branhamella catarrhalis from one (0.4 per cent)—Group A β haemolytic streptococci from one (0.4 per cent) and Staphylcoccus epidermidis from three (1.9 per cent). The occurrence of respiratory pathogens in MEE reflected their prevalence in the upper respiratory tract. Significantly fewer children who had received antibiotics prior to surgery had organisms present in the MEE. Eight and a half per cent of H. influenzae and 64 per cent of B. catarrhalis were resistant to ampicillin. The present study confirms that bacteria are present in the middle ear in a significant number of patients with otitis media with effusion.

Acute otitis media (AOM) has been epidemiologically related to viral respiratory tract infections, and viral antigens have also been detected in middle ear secretion in some AOM episodes. Successive serum samples from children followed prospectively for three years from birth were analysed for IgG antibodies against respiratory syncytial virus (RSV), adenoviruses and influenza A virus.

Values from serum antibody activity gradually decreased during the first six months of life, followed by a gradual increase. Various relationships were found to obtain between age and the increases of antibody activity against the different viruses. Thus, three quarters of those tested had manifested increased antibody activity against RSV by 18 months of age, and against adenoviruses by 30 months of age. No increase of antibody activity against influenza A was noted before 12 months of age, and then only seen in two thirds of those tested during the entire three-year observation period. With regard to age, however, the proportion of children with increased antibody activity to RSV, adenoviruses or influenza A virus did not differ between otitis-prone and non-otitis-prone children. Thus, as compared to non-otitis-prone children, development of the ability to produce antibodies against these viruses was not found to be delayed in otitis-prone children.

This study presents the results of a 20 year review of maxillary sinus wash-outs performed on children. The results show a decreasing incidence of purulent sinusitis over the study period.

Only 17 per cent of antral wash-outs undertaken yielded pus, indicating that surgical practice has failed to adequately take account of the changing disease incidence.

For many years nasal resistance to airflow measured by rhinomanometry has been regarded as the objective measure of nasal patency. However, recently it has become apparent that this may not be the case.

The present study was designed to affirm or refute this view by using large numbers of subjects and observations.

Five hundred estimations of (objective) nasal resistance to airflow and (subjective) nasal sensation of airflow where carried out.

No correlation could be demonstrated between these two parameters.

It is concluded nasal resistance to airflow and nasal sensation of airflow are two separate modalities which are not directly related. The possible reasons for this finding are discussed with reference to previous work on nasal sensation.

Middle-ear effusion in children is considered to be the result of multiple factors. Swimming in chlorinated water has been incriminated as one such possible aetiological factor. To test the hypothesis that the chemical disinfectant in the swimming pool is probably responsible for the Eustachian tube dysfunction, 30 children between the ages of four and eight years were selected at random from the community health department computer records and were randomly allocated into two groups. Eustachian tube function was assessed by standard tympanometry both immediately prior to swimming (control) and 30 to 45 minutes following swimming in Group 1 and approximately 14 hours following swimming in Group 2. The results of the study showed no significant change (p>0.05) between pre- and post-swimming tympanometry. It is therefore concluded that swimming on the surface of chlorinated water does not compromise the Eustachian tube function in children with healthy middle ears.

An investigation into the causes of sensorineural hearing loss in young children has been used as a basis for determining risk factors for parents of children with a hearing loss of unknown origin having a further affected child and for the defect to be passed on to a subsequent generation. The degree of hearing loss likely to be found if further children are affected, is examined.

Conjunctival innoculation is a previously unrecognized hazard for the otologist during mastoid surgery. This experiment assesses the spread of droplet contamination during temporal bone dissection. The results suggest that otologists and assistants should wear eye protection during exposure of the mastoid antrum by drilling.

Single stage surgery was used for 174 operations for cholesteatoma. The results were analysed using months at risk (actuarial) statistics. The methods of data collection and of creating a life-table for cholesteatoma follow-up are described. Ninety-one canal-down procedures are compared with 82 canal-up procedures as to the recidivism rate as well as hearing results. The actuarial tables showed a 50 per cent cumulative success rate for canal-up procedures versus a 90 per cent rate for canal-down operations. The successful canal-up procedures, however, demonstrated slightly better hearing results. These success rates seemed to be comparable to those using planned staged surgery.

It was concluded that if single stage canal-up procedures were used with larger mastoids and canal-down procedures with smaller mastoids, 80 per cent of patients could be controlled without either residual or recurrent disease appearing. For the others, it was felt safe to wait for the disease to reappear rather than to do planned two-stage procedures for all patients. It was further urged that actuarial statisties be employed when reporting the results of surgery for cholesteatoma.

Oxymetazoline has been used as decongesting nosedrops for more than 25 years but so far no objective does-response study of the drug has been published. In this double-blind clinical trial the decongestant effect on the nasal mucosa by the doses and concentrations traditionally used of oxymetazoline were studied.

In 106 men with acute infectious rhinitis, a significant dose-response relationship was found when the decongestant effect was measured objectively by anterior rhinomanometry and subjectively by symptom scores.

The concentration and volumes of the drug recommended from clinical experience seem to be adequate.

Audiological and vestibular tests were administered conjointly in a neurological or general ORL clinic to exclude cerebellopontine angle (CPA) tumours. This study aimed to assess the efficiency of various tests in achieving that exclusion with the minimum of unnecessary investigations. All patients received the full battery of auditory brainstem responses, acoustic reflex thresholds and decay, alternate binaural loudness balance and ENG and caloric testing. All patients who did not have normal auditory brainstem responses proceeded to high resolution CT scanning. One hundred and fifteen patients were investigated and four acoustic neuromas were diagnosed. The efficiency of these tests in a general ORL clinic is very much poorer than often suggested, due largely to the number of occasions on which the tests cannot be done, and to the very small proportion of the test population who have CPA tumours.

Changes in ciliary interconnections in the organ of Corti are described after acoustic overstimulation using a special high resolution scanning electron microscope and tannic acid-osmium staining technique, giving an almost three dimensional view. Guinea pigs were exposed to a 3.85 kHz pure tone at an intensity of 120 dB for 22.5 minutes. The first detectable change was a disarrangement of the cilia with a loosening of the interconnections. The ciliary plasma membrane presented with an abnormally smooth appearance. The tip links connecting the tips of the stereocilia to their taller neighbours were also affected showing elongation or even disappearance. The fine granules which cover the tips of the tallest stereocilia of the outer hair cells were decreased. These findings suggest that acoustic overstimulation may affect the carbohydrate metabolism exceding to degeneration of ciliary interconnections resulting in a disarrangement and detachment of cilia. The tip links, which may participate in sensory cell transduction, seem also to be affected by acoustic overstimulation.

The effect of amiloride on the murine endolymphatic sac was investigated. The amiloride caused collapse of the lateral intercellular spaces in the endolymphatic sac epithelium and a subsequent mild endolymphatic hydrops. These changes indicated a decreased absorption of endolymph in the endolymphatic sac. Amiloride is known to inhibit the transcellular fluid transport without inducing any changes in the paracellular fluid transport. It is therefore suggested that amiloride specially inhibits the fluid and ion exchange in the apical portion of the epithelial cells resulting a decrease in transcellular fluid transport across the endolymphatic sac epithelium. The transcellular fluid transport seems to be one of the main mechanisms in the endolymphatic sac fluid exchange system.

The effect of gentamicin on the glycoconjugates in the vestibular end organs is demonstrated using FITC-lectins. Five milligrams of gentamicin dissolved in 0.1 ml. saline was injected in a single dose into the middle ear of adult guinea pigs. Seven days after the injection, the fluorescent reactivity of Wheat germ agglutinin (WGA), Abrus precatorius agglutinin (APA), Concanavaline A (Con A), and Latyrus odoratus agglutinin (LOA) was decreased in the apical epithelial cell surface as well as in the gelatinous layer of the otolithic membrane of the maculae. In the cupula of the crista ampullaris, the reactivity for WGA and Con A was reduced. The otoconia, however, showed no detectable changes. This indicates that gentamicin may induce an altered carbohydrate metabolism resulting in a decrease of N-acetyl-glucosamine, mannose, galactose and glucose in the glycocalyx lining the epithelial cells as well as in the gelatinous layer of the otolithic membrane or cupula in the vestibular end organs.

The authors now report on the histological appearance of two very long-term ossicles, an autologous incus removed from the middle ear at revision surgery 21 years after repositioning and a homologous incus removed from the middle ear after 20 years. Having been placed in formalin immediately after removal from the ear, both specimens were later decalcified by ethylene diamine tetra-acetic acid, embedded in parrafin wax, serially sectioned and stained with haematoxylin and eosin.

Neurological surgery of the paralysed face can be rewarding if performed early using appropriate surgical techniques. The results of 32 operations are analyzed. Excellent restoration of facial function is achieved with early surgical intervention but some results are poor. The reasons for failure are analyzed.

The use of antroscopy by otolaryngologists in the UK was assessed by means of a postal questionnaire. A response of 70 per cent was obtained. Thirty-three per cent of otolaryngologists currently perform antroscopy; the principal reason for not using the technique being lack of suitable equipment. Twenty-four per cent of non-users believed that antroscopy would not alter their management of patients, and 19 per cent of all responders thought that antroscopy had no proven clinical role. Few surgeons recognized a role for antroscopy in the treatment of antral disease.

Antroscopists preferred to operate on in-patients (73 per cent), under a general anaesthetic (60 per cent) and via the inferior meatus (66 per cent); 76 per cent consider that morbidity is insignificant.

There is clearly a need for studies clarifying the role of antroscopy in clinical practice and to establish the cost-effectiveness of the technique.