FNT Departments in the united kingdom are faced with increasing, managementand the colleges responsible for surgical training to intrtoduce formal medical self audit. The plethora of guidelines and publi-cations on the subject rarely address the differences in clinical pratice medicine or surgery and that of otoaryngology. Clearly the lead in the introduction of medical audit will come from the appropriate specilaist associations; however. this paper aims to share the experienceof the implementation of audit otoaryngology, head and neck surgery unit and offer suggestions for a programme elsewhere.

Ventilation tube (VT) insertion is an accepted treatment for chronic otitismedia with effusion (OME) in children. One hundred and eighty five children with bilateral OME were treated by unilateral myringotomy and VT insertion with no treatment to the contralateral ear. During a 5 year follow-up 95 of the children required only one VT but the remainer required more than one but always treatment was carried out to the same ear. The rate of development of tympanosclerosis was measured and scored. After 2–3 yearsthe extent of the sclerotic changes stabilised and the rate of development reached 37–39 per cent in ears receiving only one VT, compared with 47–49 per cent in ears treated by more than one tube. The extent of the changes was no different whether or not one or more than one tube had been inserted. There was no overall evidence of resolution of sclerotic change with time.

In patients with peripheral vertigo the presence of an asymmetrical hearingloss is an important lateralizing sign, having both diagnostic and prognostic significance. In a consecutive series of 83 patients undergoing retro-labyrinthine vestibular nerve section for uncontrolled vertigo, asymmetrical hearing loss was associated with an 83 percent incidence of complete control of vertigo and a 49 per cent incidence of complete relief from dysequilibrium. In the absence of a lateralizing hearing loss, the figures were 50 per cent and 24 per cent respectively (p<0.01 and p<0.05). The explanation for this finding may be that the presence of a hearing loss is more often associated with an exclusively peripheral disorder (controllable by peripheral surgical ablation), whereas inpatients with symmetrical hearing there may be an unrecognized central or contralateral pathology resulting in lesseffective results from a unilateral peripheral surgical approach. The bithermal caloric test did not give such useful diagnostic or prognostic information.

Ossification of the inner ear is the result of multifactorial pathogeneses, such as infection or malignant infiltration, and otosclerosis. Ossification of the innerear spaces is a well documented sequela of suppurative labyrinthitis. In this study of human temporal bones, sections from 14 patients (28 temporal bones)were studied. In additionto the osseous tissue within the inner ear, findings included neoplasms, otosclerosis, otitis media, trauma, and Fabry's disease. We have attempted to correlate these conditions and their influence on the formation of osseous tissue within the spaces of the inner ear. Tympanogenic infection and vascular compromise were found to play an important role in ossification. The scala tympani ofthe basal turn of the cochlea was frequently the site involved.

Bilateral facial nerve palsies are rare. This article details the Cape Townexperience of 24 patients with this condition seen over the past 20 years and highlights the three main groups in which these bilateral facial nerve palsies occurred. These are Bell's palsy, fracture of the temporal bones and sclerosteosis. Avariety of other rare causes was also found. Bell's palsy remains a diagnosis of exclusion though there has been some evidence to suggest implication of the Herpes simplex virus. The mechanism whereby temporal bone fractures cause bilateral facial nerve palsies is discussed. The clinical presentation and management of sclerosteosis is also discussed

A new imaging technique is described, in which photographic subtraction as practised in angiography, is combined with Gadolinium enhanced Magnetic Resonance (GdMR)imaging and applied to the investigation of the paranasal sinuses and skull base. The densities on the subtraction image are dependent upon the blood supply of the tissues examined, thus producing a record of their vascularity: in effect a vasculogram. The method has proved to be technically feasible, and is advantageousin certain situations, particularly those in which the anatomy is complex as in theskull base or where normal structures havebeen distorted by previous surgery. The technique provides a more accurate record of tumour extent than that shown on unsubstracted GdMR scans.

The significance of the beta adrenergic system in the nasal mucosa isunclear. The authors have used the technique of autoradiography to localize and classify beta adrenoceptors in human nasal mucosa. The receptors have been found to beexclusively of thebeta-2 subtype and the highest density is found in the glandularducts. It is suggested that the beta-adrenergic system may have a physiologically important role in controlling the electrolyte composition of nasal secretions.

Severe, diffuse polyposis can be adequately treated through a transnasal approach which combines microscopic and endoscopic surgery. The operating microscope is used to perform ethmoidectomy, usually from the front to the back, and to open the sphenoid sinus and the antral window. The telescopes allow the sphenoid and maxillary sinuses to be cleaned under direct view control as well as enabling good drainage to be performed from the frontal sinuses. The results from 22 consecutive patients were good, with a very low rate of minor post-operative complications.

Vasoconstrictor agents are often used to reduce bleeding and hence improvethe operative field in surgery. These agents are potentially dangerous. A trial was undertaken to compare the use of adrenaline 1:80,000 with saline alone as an infiltrating agent in 30 consecutive patients undergoing septoplasty under general anaesthesia. This study, based on a small number of patients can draw no firm conclusions. There are no really dramatic differences between 1:80,000 adrenaline and saline, in terms of blood loss, operative time and the condition of the operative field between the two groups. However, there is a possibility that there are substantial differences, which, because of the variability of these outcomes, could not be detected in a study as small as this. It is recommended that a randomized trial involving patients is used to answer the question.

Seventy-three patients with lip carcinoma were treated from 1970 to 1988 inthe Otolaryngology Department of the Beilinson Medical Center. The most common histological type was squamous cell carcinoma which occurred in 68 patients; four tumours were basal cell carcinoma and one acinic cell carcinoma. Carcinoma of the lip is more frequent in males. Nevertheless, the frequency of carcinoma in females in our series was substantially higher than the average reported in the literature. Forty-nine patients were treated surgically and 24 patients were treated by irradiation. Analysis of the results among thosetreated by surgery and those treated by irradiation shows a difference in tumour local control which was statistically significant (p = 0.025). Surgical treatment is recommended because of the advantage of tumour margin assessment, avoidance of radiotherapy complications and rapid rehabilitation. Two rare cases of carcinoma of the lip in young patients (age under 20 years) are presented.

Oral cancers in the Asir region of Saudi Arabia have been observed to occurmostly among patients who have been long-term khat users. In a survey that reviewed cancers for the past two years there were 28 head and neck cancer patients, 10 of whom presented with a history of having chewed khat. One of these was a case of metastatic cervical lymph node and unknown primary, one was a parotid tumour, and the remaining eight presented with oral cancers. All were non-smoking khat chewers and all of them had used itover a period of 25 years or longer. We conclude that this strong correlation between khat chewing and oral cancer warrants attention.

One hundred and four larynges removed from infants registered as dying fromSudden Infant Death Syndrome (SIDS) and 20 control larynges from infants of matching ages, were examined histologically. Excessive amounts of subglottic submucosal glandular tissue had reduced the available airway by more than half in 35 per cent of the SIDS larynges within the age group two to four months. In 30 per cent of this group the airway reduction was more than 60 per cent. It is suggested that hyperplasia of subglottic mucous glands is one cause of fatal hypoxia in sudden unexpected infant death.

The distribution of ear drops in normal ears is variable. A new product Otomize® (Stafford-Miller) containing dexamethasone and neomycin has a non-aerosol spray mist delivery system. This has been applied to normal ears and found to be superior in its distribution to generally available ear drops previously assessed.

Sickle cell disease is a world-wide problem which has been noted to cause high tone sensorineural hearing loss. We report a case with sudden onset bilateral hearingloss which progressed to total sensorineural deafness. To our knowledge there has been noreport of such a case occurring previously.

A cochlear fistula found in a naturally healed mastoid cavity is reported. The patient is a 53-year-old Japanese woman who was complaining of unsteadiness. She hada long history of otorrhoea in childhood. Her tympanic and mastoid cavities were widely open and were covered by thin epithelium. The posterior wall of the ear canal was missing. She had no hearing in the ear but responded to electrical promontory testing. Exploratory surgery was indicated at which fistulae of the basal turn of the cochlea and the horizontal semicircular canal were found. These fistulae were sealed by pieces of bone andmuscle.

Intralabyrinthine schwannomas are rare tumours which present with symptomssimilar to Meniere's disease. Preoperative diagnosis is rarely possible and most are foundincidentally during labyrinthectomy for persistent vertigo. A further case of this tumouris reported together with a review of the literature.

Fibrous dysplasia is a benign localized bone disorder of unknown aetiologyin which endocrinopathies, abnormal pigmentation of the skin and mucous membranes may formpart of the disease. Five cases involving the facial and cranial bones are described to illustrate the various presentations and radiological appearances including computerized tomography and magnetic resonance imaging. Some of these cases demonstrate that serial radiology may be adequate for diagnosis and management without the necessity for histological confirmation. The place of limited surgical treatment for the craniofacial sites is debated.

Submandibular duct transposition is now a standard surgical procedure for the treatment of severe drooling. However, this is our first experience of a plunging ranula arising as a complication of the technique. In the surgical management of this complication, the single most important step is excision of the sublingual gland to prevent recurrence.

A cystic dilatation of a paranasal sinus by an entrapped air mass has beentermed pneumosinus dilatans or a pneumocoele. The occurrence of this condition in the maxillary sinus is quite rare. In the present case, a mid-face mass mimicking an osteoma was the presenting sign of the disease. The pathogenesis, clinical features and radiological aspects of this entity are reviewed. In order to avoid confusion with other conditions ofdifferent aetiopathogenesis, we propose to label the lesion as ‘air cyst’ of the paranasal sinus, a term that best describes the nature of the lesion.

A case of extraskeletal myxoid chondrosarcoma of the maxillary sinus in a 45-year-old man is reported and discussed. This is the first report of this tumour in thissite.