Managing patients with failed canal wall down mastoidectomy, requires a meticulous approach to control the disease and restore hearing. The present article reviews the causes of failure of the primary procedure and pitfalls encountered in 105 patients referred to our centre for revision canal wall down mastoidectomy. At post-revision surgery there were no cases with residual or recurrent cholesteatoma. The failures in our revision procedure were due to tympanic membrane perforation which occurred in five percent (n = 4) and intermittent otorrhoea in two percent (n = 2). A dry cavity with adequate middle ear space allowed for optimum audiological function even in revision canal wall down procedures.

After a mean follow-up period of 7.3 years, a recurrence was found in 43 (12.3 percent) out of 349 consecutive patients undergoing surgical treatment for acquired cholesteatoma. The great majority of residual cholesteatomas detected in the ‘second-look’ operations arose from the oval window area.Chronic otorrhoea and a reperforation were the most common signs of late recurrences. In eight ears a recurrent cholesteatoma developed from a retraction pocket. The recurrence rate was higher in children than in adults. The type of surgical technique had no significant effect on recurrence rate. Recurrences were more frequent in pre-operatively discharging ears than in dry ears. Some suggestions have been made to improve the results of surgery for cholesteatoma.

A cohort of 214 patients, who were operated on to insert implants in the mastoid process for the retention of bone-anchored hearing aids and auricular prostheses, was followed-up over a five-year period. About half the group were operated on using the conventional two-stage procedure allowing three to four months for osseointegration. In the second group (one-stage group) the skin penetrating coupling was connected at the time of the implant insertion. The success rate for stable implants was found to be the same in both groups. In the one-stage group four out of 161 implants inserted were lost and in the two stage group three out of 120. The cumulative success rate was also found to be the same. A ‘worst case’ table where patients lost to follow-up, patients who died during the study period, and patients who for some reason left the study is also included. The importance of this ‘worst case’ scenario when follow-up data are presented is discussed.

Motorcyclists are known to be exposed to excessive wind noise levels when riding. The potential adverse effects of this exposure on their hearing was investigated. Temporary threshold shift (TTS) was assessed by asking 18 riders to undertake a standard test run of one hour at a steady 80 mph, and performing audiometry before and immediately afterwards. Permanent threshold shift (PTS) was assessed by performing pure-tone audiograms on a highly screened group of 246 motorcyclists and comparing their hearing thresholds with those of an appropriate control group obtained from the MRC National Study of Hearing.

Significant TTS was found at 0.25, 0.5,1 and 2 kHz. The greatest TTS occurred at 1 kHz, with a mean hearing loss of 10.3 dB. The hearing thresholds of the motorcyclists were significantly worse than the controls at 0.25, 0.5, 1 and 2 kHz, andwas most marked at 0.5 and 1 kHz where their hearing loss (PTS) was, respectively, 3.7 and 3.6 dB greater than expected.

These findings demonstrate evidence of both temporary and permanent hearing loss from motorcycling and present a strong argument for the need for some form of remedial action.

The records of 94 consecutive developmentally retarded children with speech retardation and suspected hearing loss who underwent auditory assessment by both conventional behavioural observation audiometry (BOA) and brain stem evoked response audiometry (BERA) were analysed. In 54 children (57.4 percent) there was good agreement between the results of both techniques leading to a clearcut diagnosis. In 22 children a diagnosis was possible only by the results of BERA as the results of BOA were inconclusive. Of the remaining 18 children, two groups could be identified whose results posed a dilemma. Group 1 (n = 7) consisted of children whose BOA test results differed considerably from their BERA results. Group 2 (n = 11) consisted of children in whom there was no discernible response by BERA while the response by BOA was either inconsistent (n = 5) or not elicitable (n = 6). The specific strategies to be adopted for hearing assessment in these situations are discussed.

The position of the jugular bulb (JB) is of great clinical significance to the otologist. A high and laterally situated jugular bulb may pose difficulties when dealing with the middle ear while a high and medially sited jugular bulb can create problems in neuro-otological surgery. This paper aims to study possible racial differences in the position of the jugular bulb.

Fine-cut computed tomogram (CT) scans of temporal bones (in the axial plane) of 34 Caucasians and 34 Chinese were studied. The position of the jugular bulb was determined with reference to the midpoint of the lumen at the inferior limit of the cochlea (mpC).

Of the 60 Caucasian and 58 Chinese temporal bones with identifiable jugular bulbs, 33 jugular bulbs of the Caucasian (55 percent) and 34 jugular bulbs of the Chinese (58.6 percent) were at the same height or higher than the mpC (p = 0.2; chi-squared test). The midpoint of the jugular bulb was 8.67 ± 1.73 and 8.61 ± 2.49 mm posterior to the mpC for the Caucasian and Chinese respectively (p = 0.2; t-test). However, the midpoint of the jugular bulb of eight Caucasian (24.2 percent) and 22 Chinese (64.7 percent) were medial to the mpC (p<0.001; chi-squared test).

Race does not influence the height of the jugular bulb nor its position in the sagittal plane but can influence whether a high jugular bulb is medially or laterally situated.

Septal surgery (submucous resection and septoplasty) has been performed as a day-case procedure routinely under general anaesthesia and local anaesthesia with sedation at the Ipswich Hospitalsince 1992. The outcome of the day-case septal surgery over a period of 18 months has been audited. A total of 95 cases were operated on of which 48 were under general anaesthesia (GA) and 47 under local anaesthesia (LA) with sedation using midazolam intravenously. The bleeding rate and overnight admission rate were 10.5 and 11.4 percent respectively. The bleeding rate was the same in both GA and LA groups. The combination of local anaesthesia and sedation has been foundto be safe, effective and acceptable to patients. It is concluded that septal surgery is suitable as a day procedure and that local anaesthesia combined with sedation has a definite place ifcarried out properly.

Post-operative nasal medications are commonly used following routine septal or turbinate surgery but their efficacy in removing blood clots, improving the sensation of a patent airway and promoting healing are unknown. This prospective randomized trial of patients undergoing septal and/or turbinate surgery assessed the efficacy of three commonly used nasal medicines, 0.5 per cent ephedrine hydrochloride nasal drops, betamethasone sodium phosphate (Betnosol®) nose drops and alkaline nasal douches, in producing the sensation of a patent airway in the 14 days following surgery. Ninety-seven patients were randomized into the three treatment groups and a control group who received no nasal medication. Patients assessed their nasal patency by means of a visual analogue scale (VAS) and any complications of treatment were recorded. Statistical analysis of the 76 complete sets of results using the Mann-Whitney U-test showed that there was a significant difference in the distribution of all of the treatments for each of the time intervals (p<0.05). Glass rank biserial correlation coefficients were all small (rg<0.085) but the most significant differences were between ephedrine and the control group at two hours, two, seven and 10 days (0.02, 0.054, 0.057, 0.085 respectively), alkaline nasal douches being most significant at four and 14 days (0.06 and 0.0722 respectively).

The arrangement and number of intralaryngeal ganglia and their neurons in five mammals (dog, rat, guinea pig, rabbit and cat) were examined morphologically. Intralaryngeal ganglions were situated mainly in branches of the internal branch of superior laryngeal nerve (Int-SLN), dorsal and/or dorsolateral to the posterior cricoarytenoid muscle, and around the inferior laryngeal nerve in dogs, rats, guinea pigs and cats, but they were identified at the branching out point ofthe Int-SLN exclusively in rabbits. The ganglion of each animal was spindle-shaped, with a surrounding fibrous capsule, and it contained many ganglionic neurons, vessels and connective tissue cells. The ganglionic neuron was oval-shaped and had a round nucleus: the diameter was smaller (20–25 μm) in the rat than in the other mammals (25–30 μm). More than 80 percent of ganglionic neurons occurred in the supraglottis of all the animals except the rat. In the rat, this value was approximately 40 percent.

The expression of EGF/EGFR in 47 laryngeal surgical specimens from 44 patients was examined. PCNA analysis as an index of proliferating cells was also performed in 32 cases of laryngeal cancer, six cases of pre-cancerous lesions and nine cases of normal laryngeal mucosa. EGFR failed to show a significant correlation with tumour behaviour, but EGF expression was statistically significantly higher in malignant (SCC) than in non-malignant tissues (pre-cancerous and normal tissues) (p<0.006), and PCNA also showed a statistically significant difference (p<0.016) between the two. In malignant tissues when EGF/EGFR in ‘double-positive’ and ‘double-negative’ cases was compared, a statistically significant difference in PCNA was found (p<0.029); but this was not seen in non-malignant tissues. Our results support the hypothesis that an autocrine mechanism exists in laryngeal cancer and in this mechanism EGF may play an important role in tumour progression, especially when EGFR is overexpressed.

The alpha-amylase activity in tracheobronchial secretions of 16 consecutive patients with a total laryngectomy was studied. None of these patients had a tracheopharyngeal fistula or pulmonary disorder which might affect the amylase activity. This study proves the presence of amylase in tracheobronchial secretions of laryngectomized patients with a normal lung at a level between x and y and the quantitative analysis of the amylase activity is discussed. The relevance of investigating laryngectomy patients is because of the nature of the surgery the lower respiratory tract is permanently and physically isolated from any other source of salivary amylase. No similar study of the analysis of amylase in normal lung tissue had been reported before.

This information may be of value in order to detect salivary aspiration in patients with a tracheostomy or endotracheal intubation if the level in the aspirate is in the order of a-b times greater than that found in normal tracheobronchial secretions, (x = 35 and y = 1125 i.u./l; a = 31.8 and b = 628.6 i.u./l).

This study was undertaken to assess any salivary aspiration in seriously ill patients with tracheostomies in an Intensive Care Unit setting. The alpha-amylase activity in the tracheostomies in an Intensive Care Unit setting. The alpha-amylase activity in the tracheobronchial secretions of 15 such patients were analysed to evaluate the incidence of salivary aspiration. None of the patients had clinical or radiological evidence of lung disorder at the time of the commencement of the study. Six out of 15 patients showed very high levels of alpha-amylase activity in their tracheobronchial secretions on Day 3 and all six subsequently developed severe chest infections. The other nine patients showed a low level of amylase activity in their secretions. Two patients in the latter group developed severe pulmonary disease. This study demonstrates that a high level of alpha-amylase activity in the tracheobronchial secretions of tracheotomized, ventilated patients indicates that salivary aspiration may be taking place, and further suggests that progressively increasing levels may indicate the likelihood of a major pulmonary complication developing.

Although some form of temporal bone holder is in use in virtually all ENT postgraduate teaching departments, a paucity of information in the literature may cause problems in selecting the most appropriate model to those responsible for equipping temporal bone laboratories.

The bone holder which we describe is based on existing designs but incorporates a built-in irrigation system which offers considerable advantages to the unassisted operator.

An unusual case of a retained airgun pellet in the ethmoid sinus is presented. The patient's only complaint was a severe neuralgic headache. Anatomical basis for this symptom, imaging and successful endoscopic removal of the foreign body are discussed. The philosophy for removal of innocuous foreign bodies, potential pitfalls in surgical management, and a review of the literature are included in the discussion.

Traumatic internal carotid artery aneurysm presenting with epistaxis is rare. Epistaxis often occurs after a delay of weeks to months following head injury. The present case had bouts of recurrent massive epistaxis nearly four months after head injury. Diagnosis was made after carotid angiography. Epistaxis ceased after ipsilateral carotid ligation.

Lateral laryngeal saccular cysts of the larynx that herniate through the thyrohyoid membrane are quite rare. We present a case of a huge midcervical cyst which occurred as a result of extreme neglect of a lateral saccular cyst. This case provided us with a unique opportunity to characterize the late stages of this pathology. The differential diagnosis of cervical cysts and treatment approaches are discussed.

Lemierre syndrome, also known as postanginal sepsis, is an illness characterized by the development of a fusobacterial septicaemia with multiple metastatic foci following an attack of acute tonsillitis. It typically affects previously healthy adolescents and young adults who, following an attack of sore throat, become acutely ill with hyperpyrexia, rigors and multiple metastatic abscesses. The clinical picture tends to vary widely because of the possible involvement of a number of body systems and organs in the disease process. This serious complication of oropharyngeal sepsis had a mortality rate in excess of 90 percent in the pre-antibiotic era. Although now rarely seen and often forgotten, it remains a potentially life-threatening condition. We present four cases of post-tonsillitis fusobacterial septicaemia to illustrate the variability of the clinical presentation and stormy clinical course frequently associated with this rare syndrome.

Benign tumours of the tonsils are rare. Only a few cases of tonsillar lipoma have been previously reported. The case of a pedunculated polypoid lipoma of the palatine tonsil in a 44-year-old Japanese woman is presented. The ‘polyp’ was excised and an histopathological examination was carried out. The ‘polyp’ contained dilated lymphatics in the dense fibrous connective tissue beneath the overlying mucosal epithelium and below the mature fat tissue with intervening strands of fibrous tissue.

We report an unusual case of a large vascular lesion of the floor of the mouth of rapid onset in a 50-year-old man who presented with an external swelling in the submental region and a history of fluctuating swelling of the tongue. The clinical features, investigations, treatment and course of this rare condition are discussed.

Ectopic cervical salivary tissue may present as a discharging sinus if a duct system and cutaneous orifice are present. Where described in previous reports these openings have been located along the anterior border of sternomastoid or in the anterior triangle, making this a differential diagnosis of a branchial sinus. We report on a patient who presented with an ectopic salivary gland in the posterior triangle of the neck.