The 2002 Graham Fraser Memorial Lecture deals first with the French origins of cochlear implantation in Paris in the 1950s and the role of André Djourno and Charles Eyriès. Following this work in Paris Dr William House in Los Angeles continued work on cochlear implants and, subsequently, experimental implant programmes were started in California, Paris, Vienna and Melbourne.

The next section of this lecture covers the experimental work of Galvani in establishing the role of electricity in physiology. The results of his first experiments were published in 1791, the year that Mondini produced the first account of a cochlear malformation in a congenitally deaf child.

At around the same time sign language for congenitally deaf children was being developed for the first time in Paris by Epée and the first disputes occurred between oralists and those who promoted signing for the education of congenitally deaf children.

In a present day cochlear implant programme good results from implanting congenitally deaf children at an early age and implanting adults who have become profoundly deaf are now taken for granted. We do have much to learn, however, from more complex implant candidates and some examples of such candidates are presented.

Lastly, looking to the future, the use of PET scanning to try and gain information about how the brain handles the information provided to it by a cochlear implant is described.

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.

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.

Testing of otoacoustic emissions (OAE) has been successfully applied to study outer hair cell function. We used this methodology to evaluate and compare the effect of topically applied normal saline, and gentamicin- and ciprofloxacin-containing drops into the middle ear of guinea pigs. All three solutions similarly decreased the distortion product OAE (DPOAE) and all three caused an inflammatory reaction in the guinea pig’s middle-ear. OAE failed to detect adequately the ototoxicity of topically administered drops in this animal model because the opening of the bulla affected DPOAE, and both inflamed middle-ear mucosa and osteoneogenesis caused a decrease in DPOAE amplitude.

This is the first report examining the influence of topically used otic drops on inner ear function as demonstrated by OAE.

The possible cochlear toxicity of topically applied povidone-iodine solution was investigated in guinea pigs by measuring transiently evoked otoacoustic emissions (TEOAEs). Seven adult pigmented guinea pigs (14 ears) with a normal acoustic pinna reflex were used. After the baseline TEOAE measurements, 0.1mL of povidone-iodine solution was applied transtympanically into the middle ear in the study group. Saline solution and gentamicin were used as negative and positive control, respectively. TEOAE measurements were repeated on the 10th day, and four weeks after the first application. Tympanometric measurements were also carried out for both ears of all animals at the end of the study. Responses in all ears, which had povidone-iodine applied to them, disappeared in a way similar to those recorded in gentamicin-treated ears. Tympanometric measurements at the end of the study showed ’type A’ tympanograms in all ears of all animals. The present study showed that povidone-iodine could have a cochleotoxic effect in guinea pigs. A study in humans with TEOAE before and after middle-ear surgery, where povidone-iodine can reach into the middle-ear cavity, may be useful for evaluating this result for clinical practice.

Coblation is a new soft tissue surgical technique that is being used for tonsillectomy. Published results show a significant decrease in the amount of post-operative pain experienced y patients undergoing coblation tonsillectomy. There has been no published work to date on the incidence of post-operative haemorrhage. From August 2001 to November 2002 one surgeon performed 36 coblation tonsillectomies on adults. On another list he performed 29 by his standard method of dissection and bipolar coagulation. Retrospective analysis found a significant increase in the secondary haemorrhage rate in adult patients undergoing coblation tonsillectomy (22.2 vs. 3.4 per cent). At our department coblation tonsillectomy has been abandoned until further work into its safety has been published.

Otolaryngologists occasionally perform simultaneous procedures on their patients, the indication being co-existent pathology. This is not a universally accepted practice as some feel that the post-operative morbidity is increased in such patients.

Tonsillectomy is a common otolaryngological procedure and the main life-threatening complication, haemorrhage is easily identifiable. This study compares the incidence of post-operative haemorrhage requiring admission in patients undergoing tonsillectomy alone with that in patients undergoing tonsillectomy and nasal surgery.

A retrospective study was undertaken of all adult patients undergoing tonsillectomy alone or tonsillectomy and synchronous nasal surgery in Aberdeen Royal Infirmary.

Seventy-one patients (34 male) with a mean age of 23 years underwent tonsillectomy and synchronous nasal surgery over a nine-year period 1991–1999. The commonest nasal procedure was reduction of the inferior turbinates (in 48 cases). Three hundred and ninety-eight patients (131 male) with a mean age of 23 years underwent tonsillectomy alone over a nine-month period, July 1998 to April 1999.

The incidence of post-tonsillectomy haemorrhage in the synchronous nasal surgery group was 12.7 per cent (9 out of 71) compared with four per cent (16 out of 398) in the tonsillectomy alone group (p <0.01, Chi-squared test). There was no difference in hospital stay between the two groups (mean two days).

Synchronous nasal surgery increases the incidence of post-tonsillectomy haemorrhage.

Sistrunk’s procedure for thyroglossal duct remnants has a very high success rate, there remains the occasional patient, however, that will have recurrent disease despite a competently performed operation. Applied anatomy and embryology proffer a solution to this problem. Extending the Sistrunk operation, with an anterior wide local excision remaining within normal tissue, enables removal of the entire thyroglossal tract remnant.

A retrospective case note review was conducted to study our experience using this extended procedure to treat patients with thyroglossal tract disease that had recurred after a previous Sistrunk’s operation.

Six patients aged from five to 33 years were included in the study. There was one recurrence and the complication rate was comparable to the standard operation.

It was concluded that a wide local excision is a valuable extension of the Sistrunk operation for the management of recurrent disease.

The use of photodynamic therapy for the treatment of malignant and non-malignant conditions is increasing. This paper demonstrates the efficacy of a second-generation photosensitizer, Foscan®, in the primary treatment of a wide range of mucosal head and neck squamous cell carcinomas. Tumours ranged in stage from T1 to T3. A complete response to primary treatment was seen in 19/21 patients (90 per cent). In laryngeal cancer recurrent after radical radiotherapy, one out of four patients treated obtained a complete response (25 per cent). Six patients (24 per cent) required surgery after photodynamic therapy, for local recurrence or dysplasia. Mean follow up was for 27.3 months (standard deviation 20.6 months).

A secondary tracheo-oesophageal puncture is required for voice restoration post-laryngectomy either for reasons of closure of the primary fistula or as a planned secondary procedure. A method of doing this safely is described using an endotracheal tube and a flexible nasopharyngoscope in especially difficult cases.

Warts are common lesions. The prevalence and incidence of squamous papilloma of the nasal vestibulum are not known, and it is not certain how often human papilloma viruses are involved. Numerous medical or surgical treatment modalities have been reported in the literature with variable, sometimes unsatisfactory results. Imiquimod cream is a topically applied immunomodulator. It is used for warts and other skin tumours on different locations of the body. We report results of six patients treated with imiquimod five per cent cream for nasal squamous papilloma.

Identification of the pathogen is crucial for the selection of an appropriate antibiotic in the management of sinusitis. We describe an original instrument that provides contamination-free culture from the sinus in endoscopic sinus surgery.

Keratosis obturans is a rare condition characterized by the accumulation of desquamated keratin material in the bony portion of the external auditory canal. Classically, it is reported to present with severe otalgia, conductive deafness and global widening of the canal. A case of keratosis obturans is described in which the principal symptom was a metallic taste and the main finding was extensive erosion of the hypotympanum with exposure of the facial nerve and the annulus of the tympanic membrane. This presenting symptom and resorption pattern are atypical of keratosis obturans and have not been documented previously.

Arachnoid cysts (AC) often present with symptoms depending on their anatomical location within the skull; while supratentorial cysts grow causing relatively few symptoms, infratentorial ones may impair liquor circulation at the level of the fourth ventricle, giving rise to intracranial hypertension, or may stretch the complex nerve network in the cerebello-pontine angle. We report the singular clinical history of a 54-year-old male, who suddenly began to feel dizzy while sitting at his workplace, complaining of left tinnitus and aural fullness, in a classic clinical picture of Ménière’s disease. The anomalous findings at otoneurological examination (markedly the left deviation at the Fukuda test) made a magnetic resonance image (MRI) scan mandatory and a huge AC was found in the left fronto-parietal lobe. The mass provoked an evident clockwise rotation of the brainstem that we suppose to be the cause of acoustico-facial bundle stretching explaining the vestibular symptomatology.

Salivary duct carcinoma is a rare and invasive malignant tumour with rapid distant metastasis and dismal prognosis. Clinically, perineural invasion of the salivary duct carcinoma is commonly noted. Here, we present a case of salivary duct carcinoma of submandibular gland origin with perineural invasion of the trigeminal nerve proximal to the intracranium, that was well demonstrated by a magnetic resonance image (MRI) and was consistent with the clinical presentation. This case received radical resection and radiotherapy with inclusion of the skull base within the field. There was no tumour recurrence and distant metastasis 24 months post-operatively.

Intramuscular vascular lesions in the tongue are rare and are usually the capillary form of haemangioma. A case is described of a lingual mass that resembled intramuscular haemangioma but had unique histological features that do not appear to have been described previously. The term intramuscular capillary hamartoma is suggested to describe it.

Ewings’ sarcoma involving the facial bones is rare although it is the second most frequent bone malignancy. For the diagnosis a biopsy is needed. Currently the treatment is the combination of chemotherapy and radiotherapy with surgery indicated in only a few instances. We report a case of Ewing’s sarcoma of the mandible and describe its clinicopathologic features and the treatment of this disease.

Ectopic submandibular thyroid tissue is a rare entity and poses difficult diagnostic and management problems. The first case of ectopic submandibular thyroid with a normotopic multinodular goitre is presented