Every day orthodontists observe the consequences habitual mouth breathing has in their patients’ oral cavities and the limitations this dysfunction places on their orthopedic and orthodontic treatments. Orthodontists can enlist the assistance of their ENT colleagues for the elimination of hypertrophied adenoidal and tonsillar tissue, but when asked to perform surgical correction of malformed nasal septa and turbinates for young children most otolaryngologists usually advise strongly against such procedures. Even surgery for labio-maxillo-palatal clefts is still entangled in the same web of dogmatic disapproval. For these unilateral or bilateral cleft patients, 75 % of whom breathe primarily through their mouths, the potential for growth is considered to be limited and unpredictable. This belief, we feel, is related to the tendency of workers in our field to pay insufficient attention to nasal breathing. But in our practice, for the past thirty years we have been re-establishing it for patients at about the age of 6 and now we are doing it for children between the ages of 4 and 5. For the last 13 years we have helped affected children to breathe nasally at the age of 6 months by means of an ambitious but rigorous surgical procedure on all patients with total clefts. The current results on the nasal and maxillary growth of these children are good enough to encourage us to continue along the same lines, with the expectation of very soon being able to confirm our results as they reach the end of their growth periods.

A literature review reveals that gout has been described as affecting many sites in the head and neck region, both in the arthritic and tophaceous form. Gout can often mimic malignancy or infection, and has been described as causing acute airway problems requiring emergency tracheotomy. Here we describe the first published case of tophaceous gout affecting the soft tissues overlying the nasal bones. The patient presented with a bony, hard, dorsal hump and requested aesthetic rhinoplasty.

We also describe an endoscopic technique for removal of tophi using a powered microdebrider system with a protected burr head. Endoscopic powered microdebrider blade excision of tophi affecting the limbs has already been described, with reduced complications when compared with conventional curettage and debridement techniques. This is the first such application to the nose.

To ascertain whether local anaesthetic use is of clinical benefit in nasal surgery, a prospective double-blind randomized controlled trial of topical bupivacaine on post-operative pain in patients packed after bilateral nasal surgery was carried out. Each patient received a bupivacaine-soaked and a saline-soaked Merocel pack, thereby acting as their own control. Power analysis ascertained the number of patients required to enter the trial to detect a statistically significant difference in pain. Fifty-seven patients completed the trial. Visual analogue scales determined the level of post-operative pain at different time points in each nostril. Less pain was demonstrated in nostrils containing bupivacaine-soaked packs compared with saline-soaked packs at two hours (p < 0.0001), four hours (p = 0.0183) and six hours (p = 0.0476) post-operatively. Although not statistically significant, less pain was noted on pack removal on the local anaesthetic sides. These results provide clinical-based evidence for the use of bupivacaine as a local anaesthetic in reducing pain following nasal surgery with packing.

Fifty patients were included in a single blind study to evaluate the effectiveness of ephedrine-naphazoline (0.5 and 0.125 per cent respectively) nasal spray as against nasal packing with lignocaine (4 per cent) and adrenaline solution (1:50,000).

Cocaine is commonly used in ENT practice for its vasoconstrictor and anaesthetic properties. It is sometimes combined with adrenaline. The laser Doppler Flowmeter was used to compare the effect of 5 per cent concaine alone or with adrenaline (1 in 1,000) on nasal mucosal blood flow.

The results show an average fall in blood flow of 76.7 per cent for cocaine with adrenaline, compared to 61.2 per cent with concaine alone. The difference is significant (P<0.05). The time taken for the blood flow to fall was an average of 131 s and 160 s respectively. These differences are not significant.

We report our experience of submucous resection of the nasal septum under local anaesthesia as an outpatient procedure. We have audited 50 consecutive cases and compared the results with a similar group of patients in whom the operation was carried out in the usual way under general anaesthesia. We have found the procedure to be safe, effective and economically advantageous.

Sixty-three patients undergoing surgery to the nasal septum followed by bilateral packing had pre- and post-operative tympanometry in order to determine the effect on eustachian tube function. Fifty-five of the 126 ears tested (46 per cent) developed a reduction in middle ear pressure of at least 50 daPa; 76 per cent became normal within 24 hours of removing the nasal packs. All ears were asymptomatic and no patient had evidence of middle ear effusion. Nasal packing following septal surgery is a frequent cause of shortlasting eustachian tube dysfunction but rarely severe enough to cause symptoms or middle ear effusion. Tubal dysfunction is most likely due to a combination of surgical oedema and a direct effect of the nasal packing.