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Objective: To establish the prevalence of new vestibular and otological symptoms in a group of patients who had sustained a low grade (Quebec grades one or two) whiplash injury., Methods: A retrospective review of the case records of 109 patients undergoing assessment by a single practitioner for the purposes of compiling a medicolegal report on their whiplash injury., Results: Four patients complained of short-lived, non-specific dizziness symptoms in the acute phase following their original injury. There were no reports of vertigo, tinnitus or hearing loss after a mean period of 149 days following the whiplash injury., Conclusions: No patients reported otological or persistent vestibular symptoms in the acute phase following their whiplash injury. This suggests that caution should be exercised when attributing these symptoms to such an injury. Before whiplash injuries are admitted as an aetiological factor in the development of such symptoms, other causes should be excluded.

Background: Balance function is known to change with age during infancy and childhood. However, the relative contributions of the three primary inputs to position sense are not fully understood., Methods: In this paper we report the computerised dynamic posturography findings in a group of 60 healthy children from the age of five to 17., Results: The results confirm that there is a progressive improvement in balance function with age. The EquiTest system that was used gave indications of the relative contributions of the three principal contributors to overall balance function and showed that somatosensory function was intact throughout the age range tested and that there are significant increases in vestibular function with age and visual contribution with height. The technique used was found to be reliable and repeatable in this paediatric sample., Conclusions: It is hoped that a better understanding of the normal age related development of balance will be helpful in dealing with children presenting with disequilibrium and vertigo.

Deviation of the nasal septum is a common finding in patients with nasal obstruction and, when such deviation is severe, a septoplasty or submucous resection with or without turbinate reduction is commonly recommended for the relief of the patient's symptoms. In cases where there is anterior subluxation of the septum, the caudal margin frequently presents on one or either side of the midline at the external nares. We report a simple suture technique which, when subluxation is not severe, will correct this caudal displacement. The technique can either be used as an adjunct to conventional septoplasty or it can be undertaken as an isolated procedure in patients having routine rhinoplasty.

Acoustic rhinometry readings are very position dependent, and it was hypothesized that this accounts for its relative lack of reproducibility on a day-to-day basis. Multiple readings on each visit were taken to investigate their impact, if any, on improving the day-to-day reproducibility of the method. Measurements of the minimal cross-sectional area of the nose as measured by acoustic rhinometry were studied in 10 subjects following nasal decongestion. For each individual, acoustic rhinometry was performed ten times. The ten recordings were repeated again, in an identical manner on a separate day. The subjects were repositioned and the nasal probes reinserted between each measurement. The mean coefficient of variation for minimal cross-sectional area readings in all 10 subjects was calculated as 9.92%. This is comparable to the day-to-day variability of acoustic rhinometry as measured by other workers and thus supports the hypothesis that the high measurement error of the device (rhinometer) is a function of positional variation during data acquisition. We were able to demonstrate a minimal gain in intervisit reproducibility by doing multiple recordings per person, with a plateau effect of reproducibility after 7 repeat readings.

The reproducibility of nasal spirometry was assessed in ten subjects at two visits. Topical nasal decongestion was applied to minimise mucosal variation. Eleven parameters of flow volume were measured. Data analysis using Spearman's rank correlation coefficients revealed peak inspiratory flow rate (PIFR) followed by forced expiratory volume in first one second (FEV1) to be the most reproducible measures, yielding significance values of < 0.05. For all other spirometric parameters significance was not reached. Analysis revealed that using a naso-pulmonary index (a ratio of nasal to pulmonary flow) was detrimental to reproducibility. We conclude that future nasal spirometric studies should use PIFR and FEV1 as their derived variables of flow-volume loops in the assessment of nasal patency, and the naso-pulmonary index is of no value.

Alar (external valve) collapse may be iatrogenic or can occur as a consequence of ageing or trauma. We have utilized an autogenous cartilage graft inserted as an underlay graft to the alar rim to treat 17 patients who have presented with nasal obstruction due to alar collapse. We report the short- and medium-term functional results and the cosmetic sequelae of our approach and conclude that this procedure offers an improvement in nasal airway performance in patients with external valve collapse without producing serious adverse cosmetic sequelae.

Surgery to the nasal septum and to the turbinates constitutes a significant part of the workload of an otolaryngologist. The patient invariably experiences short-term nasal obstruction following such surgery and different medications are commonly used to relieve this and to promote a sense of airway patency. However the efficacy of topical and systemic medication, given in the post-operative period is hot well documented. A prospective randomized trial was therefore undertaken to compare the efficacy of a topically applied vasoconstrictor and an anticholinergic agent in reducing the sensation of airway obstruction in the first week following simple nasal airway surgery. 0.5% Ephedrine hydrochloride nasal drops, Pseudoephedrine tablets and a combination of the two were compared to a control group who received no treatment. Eighty patients were randomised into four groups and nasal patency assessed by patients using a visual analogue sacle (VAS). When compared to the control group both medications were effective in relieving nasal congestion but a combination of topical and systemic therapy, given together, was superior to either agent used alone. The results achieved were independent of the seniority of the surgeon undertaking the operation.

The aim of this study was to determine the effect of reducing mAs on the diagnostic quality of images and the radiation dose to the orbits in patients undergoing sinus CT. We studied 40 consecutive patients undergoing paranasal sinus CT for inflammatory disease prior to functional endoscopic sinus surgery (FESS). Four groups of 10 patients were scanned at 200 mAs, 150 mAs, 100 mAs and 50 mAs, respectively. Orbital radiation dose was measured using thermoluminescent dosemeters. Images were reviewed independently by two observers who were unaware of the mAs setting used. Image quality was evaluated using a semi-quantitative scoring system for six anatomical structures. The osteomeatal complex, uncinate process, infundibulum, frontal recess, middle turbinate and optic nerve were assessed as: clearly demonstrated (2 points); demonstrated but not clearly visualized (1 point); or not seen (0 points). No significant difference was shown between any of the four groups in terms of image quality according to the scoring system used in this study. Mean radiation dose to the orbit was reduced by 77%, from 13.5 mGy at 200 mAs to 3.1 mGy at 50 mAs (p<0.05). CT of the sinuses can be performed in patients prior to FESS at greatly reduced mAs without loss of diagnostic quality of the images. This is important in reducing the radiation dose to the lens.

There is confusion in the literature concerning the physiology and pathology of the nasal valve, and some debate as to whether there is one valve or two. In an attempt to clarify these uncertainties we have measured nasal function by assessing nasal minimum cross-sectional area, inspiratory resistance and peak inspiratory flow under baseline conditions and after the application of a topical vasoconstrictor. These measurements were then repeated following the application of external and internal nasal splints. Whatever test was employed the results showed that vasoconstriction tended to be the most potent stimulus which changed nasal function producing significant expansion of the minimum cross-sectional area, a decrease in inspiratory resistance and an increase in peak inspiratory flow. External splints also increased the minimal cross sectional area but they had no effect on inspiratory resistance or on the tendency of the vestibular rim to collapse at high inspiratory flow rates. The tendency for lower lateral cartilage collapse was, however, prevented by internal splintage using alar dilators. The results of this study suggest that there is an internal valve at the nasal isthmus where the principal alterations in airway patency follow changes in mucosal congestion, and a mobile external valve where airflow is limited by the tendency of the alar cartilages to collapse. These should be considered as separate entities with differing pathophysiology and these differences should be taken into account when treating patients with airway obstruction due to pathology at these sites.

Nasal continuous positive airway pressure (nCPAP) is now the treatment of choice for patients with sleep apnoea syndrome. Side-effects and adverse reactions have been described in isolated reports with this device. We have, therefore, systematically studied the side-effects of nCPAP therapy in 300 consecutive patients referred to the London Chest Hospital Ventilatory Support Unit. Ninety-six per cent of patients complained of at least one side-effect resulting from the therapy, with 45 per cent complaining of a side-effect specific to the nasal mask. There was no correlation between the side-effects and level of pressure used during nCPAP. The rate of compliance remained high in spite of the side-effects, with a daily use of 7.8 hours (SD 8.05) and with 83 per cent of the patients using the device every night. Although nCPAP treatment remains acceptable to most patients there exists a high incidence of adverse effects.

Tonsillectomy is frequently associated with a considerable post-operative morbidity. In some cases reactionary or secondary haemorrhage occurs and all patients suffer a degree of post-operative pain. The use of bipolar diathermy excision has become popular because it reduces intra-operative blood loss, but all diathermy inevitably produces a degree of damage to adjacent normal soft tissues. In turn this inadvertent injury must act to increase the post-operative pain. Monopolar dissection using a fine tungsten diathermy needle (the Colorado needle) allows sharp dissection at low power levels and in previous studies has been shown to produce a reduction in collateral tissue damage. In this prospective study the morbidity associated with tonsillectomy using this needle was compared to that following a standard bipolar dissection. Using the monopolar needle produced no enhanced risk of reactionary or secondary haemorrhage while causing significantly less post-operative pain and a reduction in eschar. We believe that excision using this needle preserves the advantages associated with bipolar dissection while reducing local soft tissue damage.

We present the first case report in the English literature of an intramuscular haemangioma of the geniohyoid muscle. This occurred in a 24-year-old female and the diagnosis was not made prior to resection. Haemangiomas are uncommon tumours of the head and neck and intramuscular haemangiomas account for fewer than one per cent of the total. Diagnosis of the vascular nature of the tumour is often missed. Recurrence is common and usually due to incomplete excision. A review of the literature and a case report of these locally destructive lesions is presented.

There is concern about the burden day-stay surgery created upon community services. We have followed 128 children and 38 adults undergoing day-stay tonsillectomy and a similar cohort of adults and children undergoing tonsillectomy as inpatients and looked at the demands made on general practice and casualty services over the 2 weeks after discharge. Twelve adults (18%) and four children (3%) required overnight admission after day-stay surgery. Within the first 2 weeks, 27 adults (48.2%) and 62 children (50%) visited their GP and 13 adults (23.2%) and six children (4.8%) visited the casualty department. There was no statistically significant difference for either adults or children when comparing the day-stay and inpatient cohorts. Adult day-stay tonsillectomy is associated with a high admission rate. Both adult and paediatric tonsillectomy lead to considerable demand for general practice and casualty services, but this demand is high regardless of whether the day-stay or inpatient route is chosen.

We present a case of life-threatening necrotising fasciitis of the neck with acute pharyngeal perforation following a parapharyngeal abscess caused by tonsillitis. The joint occurrence of cervical necrotising fasciitis and acute pharyngeal perforation has not been previously reported. A new way of reconstructing the pharyngeal defect using an islanded submental perforator flap is presented.

Grafting of the tympanic membrane (myringoplasty) has traditionally been performed as an in-patient procedure in the UK. We have performed day-stay myringoplasty on 21 consecutive patients (15 adults and six children) under general anaesthesia using an underlay temporalis fascia graft. In 18 cases there was complete healing of the tympanic membrane and in three cases the patients developed perforations at four weeks. This success rate is consistent with previously reported studies. All patients were discharged on the day of admission with no major complications. We have compared the results with a group of patients having the same operation as an in-patient and have concluded that day-stay myringoplasty under general anaesthesia is as safe and effective as in-patient surgery for the majority of patients.

A 53-year-old white woman presented with a 5-month history of throat pain. The soft palate was biopsied and histological examination confirmed the diagnosis of infiltrating squamous cell carcinoma. She refused surgery and radiotherapy and was therefore offered photodynamic therapy which she accepted. She was treated with 20 J/cm2 at 100 m W/cm2 over a 3 cm area. She was discharged three days later having made an uncomplicated recovery, though substantial analgesia was required. Healing was complete after 2 months, with no loss of palatal function and at most recent follow-up (16 months) there was no sign of residual disease and she remained well.

Photodynamic therapy (PDT) is a new and promising treatment modality for the treatment of malignant disease. This paper reports the preliminary experience of our group in the use of this therapy for the treatment of tumours arising in the head and neck. The majority of treatments in these cases have used a second generation systemic photosensitizer, meta-tetrahydroxyphenylchlorin (m-THPC). Two other cases were treated with either Photofrin 2 (a first generation systemic sensitizer) or with the topical photosensitizer, delta-aminolaevulinic acid (delta-ALA). The initial results have been encouraging with good clinical responses evident in patients presenting with a variety of differing tumour types. We feel there is now sufficient evident of the efficacy of this treatment to warrant a multicentre prospective study into the treatment of early head and neck cancer with PDT.

Premature excision biopsy of a cervical lymph node infiltrated by metastatic carcinoma may compromise patient survival since it is associated with an increased incidence of local wound recurrence and distant metastases. Seventy per cent of such patients have an identifiable head and neck primary, obviating the need for an excision biopsy. It is important therefore that they are examined by surgeons who are experienced in inspecting the upper aerodigestive tract and who are competent in performing definitive head and neck surgery. A questionnaire sent to all general practitioners of an Inner London and a District Health Authority revealed that only 18% and 33% respectively referred patients who they suspected of having a metastatic neck node to a department with an experienced head and neck surgeon. We conclude that greater emphasis on the correct management of these patients at both an undergraduate and postgraduate level may encourage subsequent generations of general practitioners to review their referral patterns.

High definition CT has been advocated for the evaluation of chronic suppurative otitis media (CSOM) either generally or in selected cases. It is said to be capable of producing the fine detail needed to detect lateral canal fistulae, exposed dura and facial canal dehiscences, and to demonstrate the ossicular chain. At present there is no agreement on either the indications for CT scanning in CSOM or the most appropriate scanning plane. To determine the value of high definition CT in CSOM and to decide a unit policy for its application, 36 cases of CSOM underwent pre-operative CT scanning and their scans were compared with the operative findings. Our results show CT to be highly sensitive to the presence of soft tissue disease and bone erosion, moderately sensitive to the presence of lateral canal fistulae but less sensitive to the presence of small areas of exposed dura, ossicular continuity and facial canal dehiscence. Axial scans were better able to demonstrate the lateral canal but otherwise coronal scans were superior; ideally patients should be scanned in both planes. The principle value of CT in CSOM is its ability to demonstrate disease which is not clinically apparent.

One of the well known complications of radical neck dissection is a chylous fistula, which results from injury to the thoracic duct as it enters the left subclavian vein. Such fistulae may cause considerable increased morbidity to a patient who is already debilitated by malignancy and by the increased catabolic response to surgery. Further surgery may be appropriate for those with a high fistula output but conservative therapy is normally advocated for the remainder. Nutritional and electrolyte support for these patients is essential and poses potential problems in management. We present three such patients. One was fed parenterally and two enterally and in all cases the fistulae closed spontaneously. We examine the known physiological stimuli to chyle production and conclude that the enteral feedings of these patients with fat or an isomolar enteral feed does not, contrary to current belief, increase chyle flow or delay the healing of these fistulae.

The results of revision endolymphatic sac surgery on 30 patients with unilateral Menière's disease are presented. Good control is achieved in 73.3 per cent of cases at six months, falling to 56.7 per cent at one year and only 33.3 per cent by four years. The long-term results are disappointing but are more favourable if the initial surgery was successful, if the hearing remains fluctuant and improves on glycerol dehydration prior to the revision procedure and also if the sac is intubated. The current place of endolymphatic sac surgery is discussed and revision surgery only recommended for carefully selected cases.

The case of an 18-year-old man who presented with a large cystic mass in the floor of the mouth extending into the left submandibular triangle of the neck is reported. Histopathology of this mass, which was totally excised by a combined intra-oral and cervical approach, confirmed it to have originated in ectodermal remnants (congenital dermoid cyst) and to be actively secreting sebum. This case is reported both because dermoids at this site are rare because they may present some problems in management.

The neuro-otological findings are described in 3 unrelated patients who had xeroderma pigmentosum. All had impaired hearing. Routine audiometric assessment suggested that the hearing loss was of cochlear origin; brainstem evoked potentials in 2 patients and electrocochleography in 1 support this conclusion. Two adult patients had a supranuclear ophthalmoplegia. Vestibular function was mildly deranged and visual suppression of the vestibulo-ocular reflex impaired.

A clinical scale, the Acoustic Neuroma Suspicion Index (ANSI) is presented. It was based initially on the retrospective analysis of 397 patients suspected of having an acoustic neuroma of whom, following full investigation, 263 (66%) were found to have space occupying lesions. After minor modifications, the Index was re-tested on 98 patients of whom 56 proved to have tumors while 47, who did not, formed a control group. All tumor cases were confirmed surgically. Neuro-otological investigations can be expensive, time consuming and occasionally unpleasant for patients; furthermore they are not always readily available. Though the diagnosis of an acoustic tumor or other cerebellopontine angle lesion is often straightforward, atypicality of presentation occurs often. The ANSI uses simple selected data from the history and clinical examination, with routine audiological, vestibular and radiological investigations to calculate a score. If this score exceeds the predetermined threshold, further investigations should be undertaken.

Three members of a family have presented in adult life with a succession of invasive malignancies. No known premalignant condition has been apparent in this group, and a limited study of immune competence has failed to reveal any abnormality. In spite of this there is strong evidence to suggest a so far undetected immunogenetic abnormality as the basis of this phenomenon.

We present a study of 22 patients with perennial non-atopic rhinitis who have been treated with a course of topical beclomethasone dipropionate (Beconase). All subjects were skin-test negative for the common inhaled allergens and had normal total and specific IgE levels. The results of treatment were assessed by symptom scoring and by active anterior rhinomanometry, and are compared to measurements of resistance made in 22 untreated controls and an equal number of normal volunteers.

Measurements of nasal airways resistance in normal subjects have shown a significant difference between values obtained in the two respiratory phases. Higher overall values are found during expiration in both the unprepared and decongested nose but these differences fail to maintain statistical significance after application of a decongestant. This indicates that the phase of respiration in which measurement is made must be routinely recorded especially when measurement is made without decongestant, and comparisons of data made only with recordings from equivalent parts of the nasal cycle.

The findings of a neuro-otological evaluation of 100 normal school children and 21 adults are presented. The results show changes in the vestibulo-ocular reflex with age which are of importance in the interpretation of future tests. They also give a fascinating insight into the maturation processes taking place in the growing child.

The histamine H2-receptor antagonist, cimetidine, when given topically or parenterally, did not affect net luminal Na+ gain or net luminal H+ loss in vagally-denervated pouches of antrectomised dogs. Cimetidine did not affect disruption of the mucosal barrier by 5 mmol/l or 20 mmol/l sodium taurocholate.

15(R)-methyl PGE2 methyl ester (15MPG) and 16,16-dimethyl PGE2 methyl ester (16DMPG) were assessed for their effect on gastric mucosal permeability to Na+ and H+ in dogs prepared by antrectomy and vagally-denervated fundic pouches. 15MPG did not increase mucosal permeability to either ion when given topically (18.75-300 microgram) or parenterally (30 microgram), and did not affect permeability increases induced by topical 5mM sodium taurocholate in acid solution. 16DMPG caused significant increases in net Na+ gain when given topically (18.75-75 microgram) but did not affect net H+ loss from the pouch lumen. Attempts to use higher doses of 16DMPG were abandoned because of bleeding from the pouch, and perforation in one animal. It is conceivable that 16DMPG could cause adverse effects on the gastric mucosal barrier if used to suppress gastric secretion therapeutically. 15MPG does not share this potentially harmful property and remains worthy of further study as an inhibitor of gastric secretion with therapeutic promise.

A patient with obstructive sleep apnea due to Shy-Drager syndrome, who has been successfully managed by cord lateralization, is presented. This has allowed successful rehabilitation of the patient without prejudicing subsequent surgery, and appears to be an effective procedure in this rare condition.

Forty-nine patients participated in a randomized double-blind, parallel group comparison of beclomethasone dipropionate aqueous nasal spray with terfenadine tablets in the treatment of hay fever. Symptom scores for nasal and ocular symptoms as well as grass pollen counts were registered daily for at least 1 month. Evaluation of daily symptom scores and the physicians' and patients' assessments of treatment demonstrated that both treatments were effective in controlling the symptoms of hay fever, with a similar incidence of side-effects. The beclomethasone dipropionate group, in general, had lower nasal symptom scores than the terfenadine group and this reached statistical significance on high pollen count days. In contrast, the terfenadine group had lower eye symptom scores than the other group and these were statistically significant during the first half of the study period. However, the use of additional medication for control of eye symptoms was similar in both groups. It is concluded that treatment with both beclomethasone dipropionate and terfenadine throughout the season was effective in controlling hay fever symptoms, but beclomethasone dipropionate is likely to provide better overall control since it prevented breakthrough of troublesome nasal symptoms during high pollen count days.

The case of a 57-year-old male with a large and rapidly growing mass in the retropharyngeal space is presented. Whilst this lesion had many of the features of malignancy, histopathological examination has shown it to be due to Hashimoto's thyroiditis, which appears to have developed in ectopic thyroid remnants. A rapid and sustained resolution of the mass has followed conventional therapy.

The diagnosis of a perilymph fistula is normally made on clinical grounds. Thus in most cases suspicion is raised by the clinical history and the presence of a fistula confirmed at operation. In children such fistulae may be relatively silent and the diagnosis difficult to establish. This paper reports the results of using an impedance bridge and ENG-controlled fistula test in the routine screening of 24 children with unilateral sensorineural deafness, and compares the results obtained to those found from testing 21 normal and asymptomatic children of comparable age and sex. These tests have shown that fistula testing may mimic a previously recorded gaze or positional nystagmus and hence give false positive results. In the routine testing of patients with deafness only 1 subject had nystagmus invoked by fistula testing alone, and in this case it was obvious from all other criteria that no fistula was present. The conclusions drawn are that the method is prone to error if spontaneous, gaze and positional nystagmus are not recorded and that in routine clinical use the test may produce erroneous results. New criteria for the interpretation of the test in children are suggested, but it seems that the best means of diagnosis still remains an accurate history and a readiness to explore the ear to confirm the diagnosis.

Squamous cell carcinomas of the middle ear cleft are highly unpleasant tumors which pose many problems for the otologist. We have retrospectively reviewed the hospital notes of 21 patients (22 ears) who presented with this disease in order to try to clarify those features which are of prognostic significance. We confirmed that a history of chronic suppuration with or without cholesteatoma predisposes the patient to tumor development and that, in the presence of continuing otorrhea, patients are not protected by mastoid surgery. These patients have been treated with conservative surgery and radiotherapy without en bloc resection of the temporal bone and, in these circumstances, the histological grade of the tumor at presentation appears to bear a direct relationship to survival.