The knowledge of the Byzantine physicians in the field of otorhinolaryngology and especially of the eminent ones, Oribasius, Aetius of Ameda, Paul of Aegina and Alexander of Tralles is noteworthy. They knew an adequate number of diseases of the ear, nose and throat and treated them with a plethora of drugs and some of them, especially tonsillitis and tonsillar abscess, with operations. The writer, based on the texts of the Byzantine historians and chroniclers, presents information previously unknown. This includes analysis of cases of an epidemic of angina, speech defects, instances of otitis, epistaxis, ulcer of the mouth, acute laryngitis or pharyngitis and psychogenic aphonia. Most cases concern emperors and other prominent figures of the State and Church. This information complements, from the historical point of view, the scientific knowledge of the medical writersin the field of otorhinolaryngology.

Barotitis is an acute or chronic inflammation caused by environmental pressure changes. The most common cause is the pressure change during descent in civil aviation. To prevent barotitis the middle ear pressure has to be equalised several times during descent. This can be achieved by performing the Valsalva manoeuvre, but for children, many of whom have a dysfunction of the Eustachian tube, this is difficult to perform and they are therefore at high risk of developing barotitis during flight. The traditional treatment modalities of barotitis are inflation by a Politzer balloon, myringotomy or prophylactic grommet insertion. An alternative treatment or prophylactic measure is autoinflation using the Otovent® treatment set. This prophylaxis/treatment can be performed by the child with assistance from its parents as soon as possible or rather before the descent has started. The prevalence of barotitis amongst transit passengers was found to be highest in young children, 25 per cent, compared with adults, five per cent. Only 21 percent of the youngest children with negative middle ear pressure after flight managed a successful Valsalva's manoeuvre, whereas 82 per cent could increase the middle ear pressure inflating the Otovent® set. In conclusion we recommend autoinflation using the Otovent® set by children and adults with problems clearing the ears during flight.

Posterior fossa vistibular neurectomy has become one of the most effective surgincal procedures for control of vertigo symptoms in Menière's disease. A small group patients continue to have vertigo and demonstratablke vestibular function by electronystagmography (ENG) post-operatively. Another group of patients may have also. In an effort to correlate hitological findings with clinical outcome, nerve biopsies were comapared with clinical, audiometric and ENG results. Results of this study demonstratge that complete reduction of vestibylar response (on calorica testing) and clinical cure of vertigo can be obtained despite a variable number of nerve fibres at vestibular neurectomy.

Active chronic suppurative otitis media poses a management problem when patients are being considered for surgical treatment. Topical antibiotics have demonstrated varying degrees of success in the management of discharging ears. The introduction of quinolones has revived interest in these topical agents. This double-blind study compares two antibiotics, namely ofloxacin and neomycin-polymyxin B, with similar in vitro sensitivities to Gram positive and Gram negative organisms. Fifty-two patients were selected randomly and the results show that ofloxacin eardrops have marginal benefits in symptomatic improvement (89 per cent versus 79 per cent, p = 0.27) and bacterial eradication (81 per cent versus 75 per cent, p = 0.81) in active chronic suppurative otitis media. Significantly fewer patients (seven per cent versus 29 per cent, p = 0.04) in the ofloxacin group had active disease at the end of the two-week treatment. We recommend the use of ofloxacin eardrops in managing active chronic suppurative otitis media since it has high clinical efficacy, contains no steroid component and has no demonstrated risk of ototoxicity.

This review article discusses the surgical treatment of patients suffering from unilateral vocal fold paralysis who have already been assessed and considered appropriate candidates for surgery. There are currently three main methods of surgical rehabilitation; injection medialisation; laryngeal framework surgery; re-innervation procedures.

Timely cricothyrotomy may be life-saving, but it is not without its complications. Together with tracheostomy performed too high, there are high incidences of stenosis and voice changes afterwards – often neglected because the patient has so many other problems. Jackson warned of these problems over 70 years ago – his message is still relevant.

Medial meatal fibrosis is a rare entity which is linked to inflammatory and traumatic factors. This pathology significantly benefits from surgical management. Criteria for achieving successful results are strict and concern the complete removal of the fibrous tissue and covering of the bony canal with skin graft. The aim of this paper is to present our experience with this rare pathology and to discuss current approaches.

Laryngeal paraganglioma originates in the neural crest cells in the laryngeal paraganglia. Two distinct types may be cited on the basis of clinical features, but biopsy is essential for diagnosis. By light microscopy, the Zellballen pattern appears pathognomonic. The treatment consists of surgical excision.

In this article, due to the rareness of the tumour, one case of laryngeal paraganglioma is presented. The general knowledge and the available literature are reviewed. The difficulties in the differential diagnosis are stressed and treatment principles are discussed.

Regional specialist societies offer a valuable mechanism for the conduct of medical audit. The experience of the audit sub-committee of The Scottish Otolaryngological Society in conducting an audit on laryngeal cancer encouraged us to undertake a larger audit of tonsillectomy practice in Scotland. Although the number of tonsillectomies performed has declined over the last 10 years, they still account for about 20 per cent of all operations performed by otolaryngologists and as such are a major consumer of resources (Personal communication – Directorate of Information Services, Information and Statistics Division. NHS in Scotland, Management Executive, Edinburgh). The Scottish tonsillectomy audit was devised to define current practice, review indications for surgery and recommend such modifications in practice as may be necessary to optimise patient care and the use of resources. Funding was obtained from the Clinical Resource and Audit Group (CRAG) of the Scottish Home and Health Department.

Data on current practice was collected during the period February 1992 to January 1993. Proformas were completed by medical, administrative and secretarial staff in all participating hospitals, collected by an audit secretary and passed to the relevant data collection centre. Data was then entered into a specially designed database before being forwarded to the audit co-ordinator based in Dundee for collation. Six and 12 months following surgery, all inpatients were sent a questionnaire to obtain data on the efficacy of the operation.

Data were obtained from a total of 9 773 patients. Two thousand and seventy-nine of these were seen as both outpatients and inpatients, 4 309 were outpatients only and 3 385 were inpatients only. Four thousand, one hundred and one patients returned at least one follow-up questionnaire.

The topics audited included source and reason for referral, indications for surgery, grade of staff involved, type of surgery and length of stay in hospital. In agreement with previous studies (H.M.S.O., 1989), differences were found in the rates of tonsillectomy performed in different Health Boards. Although the highest referral and operation rates were found in the Highland region, referral and operation rates did not correlate in all other areas. Recurrent tonsillitis was the most frequent principal reason for the decision to operate although there were differences between Health Boards for other indications including obstructive symptoms. Most patients had symptoms for two to three years although some patients had been affected for 40 years prior to being listed for tonsillectomy. Some area ENT services were consultant-based while others involved more junior staff. The grade of staff involved did not appear to affect the decision made at the Outpatient Department (OPD) or the outcome of the operation.

Ninety-eight per cent of patients who returned the questionnaire were glad that the operation had been performed.

Recommendations regarding changes in tonsillectomy practice are given.

The effect of aerobic bacteriology on the clinical presentation, complications of the disease and long-term results of surgical treatment was assessed in a cohort of 368 patients with chronic suppurative otitis media. Bacteriological findings showed no significant difference between child and adult patients. Staphylococcus aureus was isolated in cholesteatoma ears more frequently than Pseudomonas aeruginosa, in chronic ears without cholesteatoma the situation was reversed. Bacteriological findings had no significant effect on the incidence of complications caused by the disease. Failures after surgical treatment were most common in Pseudomonas ears. The bacteriology had no significant effect on pre-operative hearing levels nor postoperative hearing results. It was concluded that, in order to improve results of chronic ear sugery, more attention should be paid to pre-operative conservative treatment of chronically discharging ears, especially those infected by P. aeruginosa.

Since 1988, 309 patients have been referred to the Birmingham bone anchored hearing aid programme for assessment. One hundred and eighty-eight have been fitted with bone anchored hearing aids (BAHA). Of these 169 have been fitted with a BAHA alone and 20 with a BAHA and auricular prosthesis(es).

Only four (2.1 per cent) are not wearing their BAHAs. Three cases because the hearing had continued to deteriorate and in one case because of repeated failure to integrate. Nineteen patients (10.1 per cent) have lost fixtures but all but one of these have been successfully reimplanted. Of these 19 patients 10 (52.6 per cent) were syndromal and 10 (52.6 per cent) were under 16 years of age.

A surgical method has been evolved both to cope with predictable failure of integration and soft tissue control.

A prospective randomized controlled study was carried out to investigate the effect of prophylactic antibiotic ear drops used for five days after bilateral grommet insertion. The average improvement in the hearing threshold was significantly better in ears in which there was an effusion (16 dB) compared with no effusion (9 dB). The drops had no significant effect upon grommet function at three months measured by blockage rates, extrusion rates or improvement in pure tone audiometry whether or not there was an effusion. The drops were not therefore cost-effective.

Residual cholesteatoma was experimentally produced in guinea pigs by transplanting a free skin graft into the middle ear bulla. In group A, the graft was placed on the mucosa after scratching the surface with a pick, while in group B, it was placed on the bone surface following removal of the mucosa and drilling with a diamond burr. The group A procedure was conducted on the left ear and the group B procedure on the right ear in 12 guinea pigs. The animals were sacrificed at two, four and eight weeks after transplantation. In all 12 ears of group A, the graft kept its original flat shape, resembling an open type residue. In eight of 12 ears of group B, the graft grew forming a squamous pearl, while in the remaining four ears it retained a flat shape. The difference in configuration is thought to be due to the amount of granulation around the graft.

The aim of this study was to assess whether client centred hypnotherapy (CCH) which required three sessions with a trained therapist was superior to a single counselling session in reducing the impact of tinnitus.

Patients were randomly allocated to receive either counselling (n = 42) or CCH (n = 44). The outcome measures were: tinnitus loudness match, subjective tinnitus symptom severity score, trend of linear analogue scale, request for further therapy and whether the patient had an impression of improvement in their tinnitus after treatment.

CCH was no better than counselling in reducing the impact of tinnitus using the three quantative measures of tinnitus, and requests for further follow up.

The only significant difference between the two therapies was that 20 (45.5 per cent) of the CCH group reported a general sense of improvement compared to six (14.3 per cent) in the counselling group, this is significant p<O.Ol. The study did not demonstrate whether this was a genuine hypnotic effect or simply a response to the additional attention from the therapist.