Eighty-nine cases of attic type cholesteatoma were operated on during a three and a half-year period. Of these, eight cases were characterized by bony tissue proliferation at the aditus ad antrum or mastoid antrum. Sex, age, and hearing levels were not significant in these cases. Bony fixation of the incus and the malleus was seen in six cases. Bony tissue blocked further expansion of attic cholesteatoma at the aditus in four cases, narrowed the epithelial tract to the antrum in two cases, and completely separated the cholesteatoma into two cholesteatomas in two cases. Infectious stimuli, at an early stage of the disease, might stimulate such osteoplastic activity at the aditus. Axial CT scans give useful information regarding structure before surgery.

A questionnaire was sent to all Full Members of the British Association of Otolaryngologists to ascertain whether and what type of eye protection surgeons and theatre nurses wear during mastoid surgery. Despite Department of Health recommendations only 58 per cent of surgeons and 19 percent of theatre nurses routinely wear any form of eye protection.

Forty cases of failed combined approach tympanoplasty were analysed. The commonest cause of failure was adhesions between the facial ridge and the tympanic membrane, causing segmental attico-mastoid malaeration in 51.3 per cent of cases followed-up continually. Other causes were, large dermoids, incomplete removal of squamous epithelium, and eustachian tube obstruction. Eustachian tube dysfunction did not appear to be a major cause of failure.

Sensorineural hearing loss in rheumatoid arthritis (RA) has been reported to be the result of the extraarticular manifestation of the disease (rheumatoid nodular vasculitis) or due to drug ototoxicity.

In an attempt to investigate the presence of sensorineural hearing loss and the possible causes for it we investigated prospectively 45 RA patients (42 female; three male) with a mean age of 52.5±10.7 years and a mean disease duration of 8.5±7.3 years. All patients underwent a complete physical examination and audiological evaluation which included pure tone audiometry and impedance audiometry (tympanogram, static compliance, acoustic reflex, reflex decay, acoustic reflex latency test.

We found a sensorineural hearing loss >20 dB HL in 44.4 per cent (40/90) ears. In all cases the site of hearing loss was the cochlea and in most of them it was bilateral and symmetric (16 patients out of 45 had bilateral sensorineural hearing loss i.e. 35.5 per cent.

There was no correlation between sensorineural hearing loss and age, sex, disease duration, articular and extra-articular manifestations and the presence of autoantibodies in our patients. In addition, no correlation was found between sensorineural hearing loss and drug therapy for one at least of the following drugs: NSAIDs, d-penicillamine, plaquenil and methotrexate.

We noticed a prologation of acoustic reflex latency in five patients (10 per cent) which was found to be correlated with the temporomandibular joint involvement and the presence of rheumatoid factor (RF).

We conclude that inner ear involvement in RA is expressed by: (1) mild symmetric, bilateral sensorineural hearing loss of cochlear type in 35.5 per cent of patients; (2) normal acoustic reflex thresholds; (3) nondecay; and (4) prologation of acoustic reflex latency which appeared in a small number of patients (10 per cent).

Forty-eight patients with syphilitic labyrinthitis have been treated and followed up for periods of six months to 25 years; interpretation of the hearing results must be in the light of the natural history of this condition which is perceived to be progression of hearing loss to profound deafness.

At the beginning of the series treatment was with ampicillin alone and on this treatment 11 ears with useful hearing were maintained at this level. The group with combined ampicillin and prednisone treatment, which included some failures from ampicillin alone, maintained useful hearing in 28 out of 29 ears. Those treated initially with ampicillin and prednisone and later also given regular injections of ACTH, maintained hearing in 16 out of 17 ears.

At the outset, there were 29 profoundly deaf ears. One of these recovered some useful hearing but two ears with useful hearing at the outset became profoundly deaf so that at the end there were 30 profoundly deaf ears. However, all patients as opposed to ears, with useful hearing at the outset were left with some hearing; no patient became profoundly deaf.

Between 1991 and 1993, 13 children (25 hearing ears) underwent recordings of the auditory brain stem response (ABR) under a general anaesthetic. The anaesthetic technique was similar for each child. Fourteen of these ears had fluid aspirated after myringotomy with insertion of grommets prior to the auditory brain stem response investigation. On subsequent hearing assessment six of these 14 ears (43 per cent) showed clear evidence of a threshold shift of 15 dB or greater. Eleven ears had either dry myringotomies or did not have a myringotomy prior to ABR and none of these showed evidence of a temporary threshold shift. Using Fisher's Exact probability test this difference is significant (p = 0.034). We feel it is important to report these observations so that unexpected high ABR thresholds following aspiration of glue are interpreted with caution.

Cryotherapy is an established method of treating hypertrophic obstructive inferior turbinates. The long-term effectiveness of the technique is assessed in this study, using the need for alternative nasal surgery as an objective way of distinguishing success from failure. Over 50 per cent of patients with obstructive symptoms, including those with minor septal deviation or allergy derived lasting benefit from the technique. Cryotherapy is an effective means of treating nasal obstruction due to mucosal hypertrophy of the turbinates and may replace the need for more radical surgery.

Tonsillectomy is a common operation in children performed by a variety of techniques. Recently we have introduced a modified form of electrodissection tonsillectomy using bipolar diathermy. A prospective study was designed to evaluate this technique against the conventional dissection/snare technique. Sixty children were entered into each section of the study (total 120 children). There is a statistically significant shorter operating time (mean 11.2 minutes) and lower intraoperative blood loss (mean 5 ml) using the bipolar diathermy technique. Post-operatively, the children who had bipolar diathermy tonsillectomy were found to be able to drink and eat significantly earlier than the cold dissection group. There was no measurable difference in analgesia requirements before discharge and the time of discharge between the two methods. Post-operative haemorrhage occurred in two out of 60 (3.4 per cent) and one out of 60 (1.7 per cent children) in the conventional and bipolar diathermy dissection, respectively, but this was not statistically significant.

Three hundred and seventeen patients with hypopharyngeal tumours presented at Assuit University Hospital and were studied retrospectively with regard to sex and age incidence. Postericoid tumours form the majority (50.1 per cent) followed by pyriform fossa tumours (26.5 per cent) and finally posterior pharyngeal wall tumours (23.4 per cent). Men form the majority (211 out of 317, i.e. 69.7 per cent). The age incidence shows two peaks at 31–35 years and 56–60 years. The first peak is formed mainly of women while the second peak is formed mainly of men.

A study to investigate the value and reliability of clinical photographs as teaching aids was undertaken. Twenty colour photographs were taken using the StarMed video-otoscopic system. The pictures, which were a mixture of normal and abnormal ears, were shown to 21 experienced otolaryngologists from the UK and Canada. These clinicians were asked to identify the abnormality if any.

The median score for correctly identified pictures was 15 (range 12–18). This score was identical for both the UK and Canadian subgroups. Although the abnormalities were consistently well recognized with an average correct identification rate of 90 per cent (range 67–100 per cent), the ‘normals’ were recognized significantly less well at only 41 per cent (range 5–71 per cent) (chi-squared = 110.6; 1 df; p<0.001).

This result is probably due to failure of the camera to capture the huge variation and subtleties in the range of normal, and the clinicians' natural inclination to identify pathology, when in doubt. We would conclude that as long as this failing is recognized, clinical photographs, and specifically those from the video-otoscope, represent a useful and reliable teaching tool.

WR 2721 (ethiofos) protects against the toxic effects of the heavy metal compound cisplatin. which is used in the treatment of solid tumours. In a Phase I protocol designed to determine the maximum dose of WR 2721 which could be tolerated when administered in combination with cisplatin and radiation therapy to patients with cervical carcinoma. 11 patients were evaluated by audiologic testing before and after cisplatin WR 2721 administration in an attempt to identify the degree of ototoxicity. Forty-five per cent were noted to have significant hearing threshold changes. predominantly in the high frequencies. There were no significant changes in the speech frequencies in this series. This contrasts with the greater degrees of ototoxicity observed in controls treated in the same way who received cisplatin without WR 2721 protection.

We describe a simple and objective practical method for the detection of recovery from facial paralysis by multiple photographic assessments. The photographs are printed as life-size transparencies representing maximal effort. Each time the patient attends for review the new transparency is overlapped on the previous one and the difference can be detected easily. The prints are filed with the patient's notes for future reference. To achieve this system a specific photographic protocol is mandatory in order to avoid technical artefacts. We believe that this system avoids many of the complexities of other grading systems and is very suitable for use at outpatient follow-up.

This is a case report of non-Hodgkin's lymphoma of the external auditory canal, and infratemporal fossa, which presented with multiple cranial nerve palsies. The diagnosis was achieved via biopsy of tissue from the external auditory canal, and treatment with radiation therapy led to improvement of the symptoms. The management of AIDS-related lymphoma of the skull base with cranial neuropathies is reviewed.

A 47-year-old man developed a complete facial nerve palsy secondary to non-cholesteatomatous suppurative otitis media. At operation, this was seen to be due to destruction of the nerve from halfway along the horizontal segment to a point just distal to the second genu. The history of recent renal transplantation and subsequent immunosuppression was judged to be significant in the pathogenesis of the palsy.

Metastatic carcinoma of the ethmoids is very rare. Of the few cases reported in the literature, the majority are renal in origin. Although metastases from the gastrointestinal tract have been reported. there are no known cases of metastases from the stomach.

We present a rare case of metastatic adenocarcinoma of the ethmoids in a patient previously treated for adenocarcinoma of the stomach and describe the possible mechanisms of spread. The patient had a craniofacial resection of the tumour but unfortunately died four weeks post-operatively from acute liver failure probably caused by a liver metastasis.

Malignant transformation of respiratory papillomata is not uncommon in the presence of precipitating factors such as tobacco smoking and therapeutic irradiation. Respiratory papilloma changing to carcinoma in the absence of smoking and irradiation is seldom seen, with only about 20 documented cases presented in the literature. Here we report one such case in a 30-year-old male patient.

A rare case of a salivary megalith with a sialo-cutaneous and a sialo-oral fistula in an elderly man is presented. A brief review of the literature is made.

Paralysis of the tongue due to isolated bilateral hypoglossal nerve palsy is a rare occurrence. Due to a trauma the cause in our case may have been a traction injury to both hypoglossal nerves at the base of skull. In some cases a contributing factor may be malformation of the skull base. Most cases have a good prognosis for recovery.

We present a patient with a lipoma of the deep lobe of the parotid gland. Despite the common occurrence of this tumour in other regions of the body, we believe that this is only the second report in the literature of a lipoma in this location. We believe that these tumours are easily dealt with by simple enucleation, and that superficial parotidectomy should be reserved for tumours deep to the facial nerve.

Adenoid cystic carcinoma of the cervical trachea is rare and its diagnosis and surgical management challenging. We report a case with an unusual presentation and discuss the diagnosis and management. The preferred surgical management is tracheal resection, however this is often not feasible and many alternative techniques have been used. Here an anterior castellated approach is described, a modification of that more commonly used for benign tracheal strictures. We found it gave excellent access to the posterior tracheal wall which we feel is superior to a straight vertical tracheal incision. It also facilitates a tracheal widening procedure if indicated, and safeguards the recurrent laryngeal nerves which are particularly vulnerable in the cervical part of the trachea.