Newer surgical tools, which have been widely accepted as important adjuncts in otological surgery, include the laser, otoendoscopy and facial nerve monitoring. A confidential postal questionnaire survey was carried out to evaluate the usage of these newer techniques among the Consultant members of the British Association of Otorhinolaryngology-Head and Neck Surgery. Our study revealed that the usage of otoendoscopy, laser and/or facial nerve monitoring is not as widespread as might be thought among otological surgeons in the United Kingdom.

The treatment of allergic rhinitis has been revolutionized by the introduction of topical nasal steroids, which are one of the commonest prescriptions from otolaryngology departments. With so many different sprays available on the market, the literature was reviewed for the efficacy, side-effect profile and relative cost of each product and the following conclusions made:

(1) A meta-analysis of randomized controlled trials comparing the efficacy of intranasal corticosteroids and oral antihistamines in the treatment of allergic rhinitis showed a clear benefit in favour of intranasal steroids in relieving nasal symptoms.

(2) There is no clear evidence to support the suggestion that one steroid spray is more effective than another in the treatment of seasonal or perennial allergic rhinitis.

(3) All the sprays have a similar side-effect profile; the commonest being epistaxis with a reported incidence between 17 and 23 per cent. In all the clinical trials, the placebo spray had an appreciable rate of epistaxis of between 10 to 15 per cent.

(4) Fluticasone causes a reduction in endogenous cortisol secretion but no significant adrenal suppression was seen with triamcinolone, beclomethasone, budesonide or mometasone.

(5) There is little evidence that skeletal growth is restricted by the administration of topical nasal steroid sprays.

(6) There is considerable variation in the daily cost of each spray. Beclomethasone, dexamethasone and budesonide are significantly cheaper than fluticasone, mometasone or triamcinolone.

The mastoid air cell system is an important contributor to the pathophysiology of middle-ear inflammatory disease. The mastoid cavity is not only an air reservoir, but also an active space for gas exchange. Various methods of temporal bone imaging have been designed to investigate mastoid pneumatization. In this study, we examined 100 normal temporal bones for the evaluation of mastoid pneumatization. Mastoid air cell systems were measured by reconstructed axial and coronal high resolution computed tomography (HRCT) images. The reconstructions were made by a three-dimensional multiplanar volume rendering (3D MPVR) technique. The mean volume of the mastoid air cell pneumatization was 7.9 cm3 (4.0-14.0 cm3, SD = 2.3 cm3). The ears were allocated to the groups with respect to measured mastoid air cell pneumatization. Twenty-eight per cent of the ears have small pneumatization with an aircell system not exceeding 6 cm3. Fifty-two per cent had an air cell system between six and 10 cm3, and 20 per cent had an air cell system exceeding 10 cm3. With its excellent imaging quality and the ability to eliminate bone and soft tissue, HRCT is the best method for evaluating the mastoid air cell system. The 3D MPVR technique must be used tomeasure the temporal bone/mastoid pneumatization for the best results.

There is little information in the current literature about the management of dizziness in Primary Care (General Practice). An attempt was made to evaluate this by carrying out a postal survey of General Practitioners’ (GPs) treatment methods in four Health Authorities in England and Wales. The survey revealed that eight out of every 1000 individuals are likely to consult their GP on account of dizziness in a 12-month period. The symptom is mostcommon in the 60–80 years’ age group, with ’labyrinthitis’ being the commonest diagnosis. In the majority of cases (74.9 per cent) there was an improvement in the symptoms and only 13 per cent were referred to a specialist clinic. The survey also highlighted the need for additional resources to improve the management of these patients.

The incidence of inferior vestibular nerve disorders in patients suffering from unilateral vestibular neuritis and the recovery of these disorders were evaluated by monitoring the vestibular-evoked myogenic potential (VEMP). Eight patients ranged from 21 to 73 years that suffered from unilateral vestibular neuritis underwent VEMP and caloric testing. Abnormal VEMP was observed in two of the eight patients with unilateral vestibular neuritis. Two patients were diagnosed as having an inferior vestibular nerve disorder. One of these patients showed recovery of the inferior vestibular nerve function as assessed by the VEMP. Disorders of the inferior vestibular nerve function and their recovery was confirmed by our current results. The time course of recoveries of the superior and inferior vestibular nerve systems were similar in the two patients.

Chronic parotitis is an insidious inflammatory disorder, which is characterized by a recurrent, often painful, swelling of the gland or glands. Sialography remains the investigation of choice. Diagnostic siladenoscopy may complement or supersede sialography as the diagnostic procedure of choice, as more experience is gained in this technique and its use becomes more widespread. The management options are conservative or surgical, but controversy exists regarding the timing and method of surgical intervention. The surgical methods that have been described include injection of methyl violet – a sclerosing agent, ductal ligation, ductoplasty, tympanic neurectomy, and parotidectomy. Parotidectomy is considered the ultimate surgical option but because of its significant morbidity the exact technique and procedure that should be used remains contentious.

Snoring is a significant problem with both social and medical manifestations. This article addresses the current management of the simple snorer from initial out-patient assessment to definitive treatment.

The management of four cases of lateral sinus thrombosis (LST) over a four-year period at the Royal Darwin Hospital is presented in this retrospective review. The patients were aboriginal and presented with otalgia, otorrhoea and sepsis. Two cases had an associated complication of an otitic hydrocephalus and a subperiosteal abscess. Cholesteatoma was found in three cases. Computed tomography (CT) scan confirmed the LST in three cases. Three patients were anaemic and thrombocytopenic. All patients had positive blood cultures. The organismswere predominantly mixed anaerobes and Bacteroides species. Three patients were managed surgically as a two-stage procedure. One patient was managed as a single-stage procedure with a modified radical mastoidectomy. Therapeutic anticoagulation was utilized in one case. There were no deaths. The prognosis of LST is good if treatment is instituted early with broad-spectrum intravenous antibiotics and surgery. Therole of clot removal at surgery and the use of anticoagulation are discussed in this paper.

Ménière’s disease is a vestibular disorder characterized by episodic vertigo, tinnitus, fluctuant hearing loss, and ear fullness, with vertiginous attacks being the most disabling complaint. The effectiveness of conservative treatment has been variable, while surgical techniques provide more permanent relief from vertigo, but pose possible morbidity and cochlear risk. Intratympanic administration of gentamicin has been proposed as an alternative for patients with debilitating Ménière’s disease who have failed to respond to standard medical treatment. The goal of such treatment is to control vertigo by partially or completely destroying the vestibular system, while at the same time maintaining hearing.

In this review we present the current medical literature on pathophysiology, pharmacokinetics, administration methods, dosage, treatment protocols, and problems related to intratympanic administration of gentamicin for patients with MD.

Intratympanic gentamicin administration is a simple medical modality for treatment of persistent vertigo in patients with Ménière’s disease. According to recent world research protocols, we propose the instillation of gentamicin by transtympanic injection, as a quick, easy, well-tolerated, ambulatory and cost-effective technique. Drug solution concentrations should be dependent on the frequency, intensity and duration of vertigo spells, as well as the degree of existing hearing loss, thus providing progressive vertigo relief with a low possibility of secondary deafness.

The function of Shrapnell’s membrane (pars flaccida; PF) in middle-ear mechanics is still an enigma, though numerous proposals have been put forward, e.g. protection of pars tensa, equalizing of middle-ear pressure, sound transmission, and the site of origin of otitis media. In this study the PF was studied in a mammal (the hooded seal) which exposes itself to extreme pressure differences (from 1 to 100 atmospheres) when diving.

Formaldehyde-fixed temporal bones obtained from newborn, one-year-old, and adult seals (three of each) were cleansed and decalcified in 10 per cent EDTA. The lateral wall of the middle-ear cavity, including the whole tympanic membrane with its bony surroundings, was then excised and photodocumented. Thin sections were cut parallel with, and perpendicular to, the handle of the malleus, stained with haematoxylin-eosin, toluidine blue or Giemsa stain and examined under a light microscope. One seal head was subjected to high resolution computerized tomography (HRCT) before sectioning. The PF was observed to be a narrow fissure measuring a maximum of 0.8 mm between processus brevis of the malleus and the notch of Rivinus in pars squamosa (pars tensa diameter 10–12 mm). It seems unlikely that the PF of the hooded seal participates in pressure equalization in the middle ear. The main function of the lateral wall of the attic, including the minimal PF, appears to be to protect the middle-ear ossicles and allow movement of the malleus.

With cigarette smoking declining in the modern world, the tobacco industry has to look for other products that can keep the old customers and attract new ones. Different forms of smokeless tobacco are currently massively promoted and are gaining in importance. Dry nasal snuff – the oldest known form of tobacco in Europe – is one of them. The health risks associated with it are different to those attributed to smoking and oral wet snuff. The nicotine contained leads to dependency. Its resorption rate is similar to that of smoking, so it could be seen as an adequate substitutional therapy. The risk for cardiovascular diseases is lower, compared to that for smokers. Chronic abuse leads to morphological and functional changes in the nasal mucosa. Although it contains substances that are potentially carcinogenic, at present, there is no firm evidence, relating the use of nasal snuff to a higher incidence of head and neck or other malignancies.

In 1908 Sluder described a symptom complex consisting of neuralgic, motor, sensory and gustatory manifestations that he attributed to the sphenopalatine ganglion. He stated that treatment directed at the ganglion successfully alleviated these symptoms. Over the last 90 years several reports have described patients as having sphenopalatine neuralgia and have directed treatment at the ganglion. The symptoms described and the criteria for patient selection in these studies has often been varied and deviated from Sluder’s description. In reports claiming cures with treatment directed at the ganglion the duration of post-treatment follow-up has been short. This article discusses Sluder’s description and attempts to analyse its features in the light of current understanding of the different mechanisms and categories of facial pain. It is proposed that the condition described by Sluder is a neurovascular headache that most closely resembles cluster headache in its aetiology and clinical manifestations. Wepropose that the term Sluder’s neuralgia should be discarded as there are serious flaws in its original description and many authors have misused the term leading to persistent confusion about it.

The author describes his personal reminiscences of the Royal National, Throat, Nose and Ear Hospital during World War II. Many of the colourful characters of this era arediscussed.

Ni-Ankh-Sekhmet has always been referred to as the first rhinologist in history. Translations of the hieroglyphics depicted on all the illustrations accompanying previous publications do not substantiate this claim. The research presented is a result of an investigation of the original monument related to the doctor at its present location in the Egyptian Museum, Cairo. The research proves that Ni-Ankh-Sekhmet was the first rhinologist in history.

The origins of immunology and allergy are founded upon the early 19th century microbiological studies of Jenner and Pasteur. It was discovered that the immune system could cause harm. The subspecialty of allergy began with the coining of the term by Von Pirquet in 1906 to describe disorders resulting from hyper-reaction to normally innocuous environmental agents.

Understanding the scientific basis of the immune system and allergy allowed Noon and Freeman, and later Cooke, to develop allergen immunotherapy. Initially the technique was crude, but with the subsequent key discovery of IgE, more accurate methods of diagnosis (such as the radioallergosorbent test (RAST)) and treatment ensued. The efficacy of specific immunotherapy has been demonstrated by many double-blind trials culminating in the WHO position paper.

DNA recombinant technology has provided detailed molecular understanding of allergic disorders, which has resulted in several novel methods of immunotherapy that are potentially safer and more effective. Use of recombinant allergens, T-cell peptides, DNA vaccination with CpG motifs or plasmid vectors and anti-IgE strategies with monoclonal antibodies are showing promise.

Congenital aural atresia repair is difficult owing to unpredictable anatomy. Benefits may be gained from computer-aided surgery (CAS), but its exact role has yet to be clearly defined. This is a retrospective study of 18 patients with bony type C (Schuknecht classification) congenital atresia. In the first group (n = 9), repair was performed with CAS while in the second group (n = 9), similar intervention was applied without CAS. Intra- and post-operative clinical and audiological findings were compared. CAS computed tomography (CT) images correlated well with intra-operative findings giving the surgeon more security and reducing operative time by 25 minutes. In our estimation, CAS is valuable for type C congenital aural atresia repair. It serves as an educational tool and as a guide for the experienced surgeon in critical situations where anatomical landmarks are distorted and where access is limited.

A retrospective study of patients who underwent myringoplasty as a day-case procedure in two freestanding day-surgery units during a five-year period was carried out.

Their case notes were identified and details including age, site and size of perforation, grade of surgeon, surgical approach, graft material, post-operative dressings, overnight stay, complications, and outcome were noted and analysed.

The total number of patients including both children and adults who had myringoplasty as a day case was 144. Of these, 125 patients with 143 procedures were included in this study. Their ages ranged from four to 74 years (mean = 31 years). The perforation size was small in 40 cases, medium in 61 cases, and large/subtotal in 42 cases. The overnight stay rate was 2.7 per cent and this was for immediate post-operative problems such as nausea and bleeding from the wound. The readmission rate for post-operative complications was 2.1 per cent. The follow-up ranged from six months to five years (mean = 19 months). The success rate was 83.3 per cent and thresholds on pure tone audiometry improved in 69.2 per cent of cases. The age of the patient, grade of the surgeon, and graft material did not influence the surgical outcome. There was no case of dead ear as a result of surgery.

Myringoplasty can be safely performed in both adults and children as a day-case procedure with low overnight stay and readmission rates. Success rates are comparable to when the procedure is performed on an in-patient basis.

Optimal imaging protocols for cochlear implantation have yet to be determined. Pre-operative computed tomography (CT) and magnetic resonance image (MRI) scans are used to assess cochlear anatomy and patency, to delineate surgical access, and to aid in choice of side for implantation. However, opinion still differs as to which modality provides more information in pre-operative assessment, or if, indeed, a combination of the two is superior.

The first 88 patients on the Irish National Cochlear Implant Programme (NCIP) were retrospectively studied to determine the accuracy of pre-operative CT and MRI in predicting abnormalities at the time of surgery. Correlation with surgical findings was determined in three separate groups of patients (those who had CT only, those who had MRI only, and those who had both CT and MRI performed).

Of the 24 patients that had both CT and MRI performed, both modalities had a 79 per cent correlation with surgical findings. CT and MRI reports concurred in 75 per cent of cases. Specificity and negative predictive value were high (86 per cent and 90 per cent, respectively). CT alone (47 cases) correlated with surgery in 39 cases (83 per cent); MRI alone (17 cases) correlated in 15 cases (88 per cent).

The findings of this study suggest that CT and MRI are effective at predicting normal inner ear anatomy, and thus at predicting the patient and the cochlea most suitable for implantation. Both modalities are useful in determining the side of implantation, thus avoiding potential surgical difficulties in cases of unilateral abnormalities. There was no significant difference between the ability of MRI and CT to detect abnormalities at the time of surgery. In this series the combination of CT and MRI has not been shown to be superior to either modality used alone, although anecdotal evidence to the contrary was noted.