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The object of this study was to compare the effect on the hearing of the insertion of a grommet, with or without adenoidectomy, against a non–surgically managed control ear in children with persistent hearing impairment due to otitis media with effusion.Seventy–eight children (44 boys, 34 girls, mean age 5.8 years) with documented bilateral otitis media with effusion associated with a bilateral hearing impairment (pure tone average air conduction thresholds over 0.5, 1 and 2 kHz of ≥25 dB HL) over a three month period were admitted to a randomized, controlled trial. Each child was randomized to have or not to have an adenoidectomy. The ears in each child were then randomly allocated to have a grommet (tympanostomy tube) inserted. The children's hearing status was reviewed six and 12 months post–operatively. During follow–up, should a child redevelop a persistent bilateral hearing impairment (as defined above) for three months they were managed with a hearing aid. Thus no child had repeat insertion of a grommet.Surgery of each type had an effect on the hearing and the presence of otitis media with effusion at six months post–operatively but not at 12 months when it was no different from natural resolution.If resolution of the otitis media with effusion is the outcome measure, then adenoidectomy alone is significantly better than no surgery but only in boys rather than in girls. Even in boys it only resolves about 60 per cent of effusions. However, when combined with a grommet (one insertion) adenoidectomy gives no greater resolution (89 per cent compared with 86 per cent).If improvement in hearing is the outcome measure, the overall results are similar. Adenoidectomy alone has an effect but if a grommet is inserted, adenoidectomy in addition does not improve the overall effect. However, these findings are not the case when analysed regarding the sex of the subject mainly because of the higher natural resolution rate in girls. In them, at six months surgery of any type or combination has no effect whereas in boys there is an additive effect of adenoidectomy on grommet insertion. Hopefully further studies can be conducted in larger numbers to investigate the differing effect in boys and girls suggested in this study.

Alveolar rhabdomyosarcoma of the parotid gland is a rare condition. The treatment should involve an aggressive multi-modality approach incorporating surgical removal of the tumour, radiotherapy, and multi-agent chemotherapy. The presentation of this condition along with the most appropriate line of treatment is discussed.

A postal survey was undertaken to assess otolaryngologists’ awareness, implementation and perceived weaknesses of the Scottish Intercollegiate Guidelines Network (SIGN) clinical guideline for the Management of Sore Throat and Indications for Tonsillectomy. The reply rate was 77 per cent. There was high awareness of the guideline and while 84 per cent of the correspondents felt that they followed the guideline, or a guideline based on it, only 35 per cent were able to accurately recall the four main criteria recommended for listing for tonsillectomy. Twenty-five per cent of the surgeons were in departments that had ongoing implementation programmes for these guidelines but only 10 per cent of surgeons were in departments that had audited their compliance. The most common criticism of the guideline (22 per cent) was that it failed to consider the impact of the disease process on the patient’s quality of life. Suggestions made to improve the guideline are included.

A double-blind randomized prospective case-control pilot study was performed to assess tissue distortion caused by the infiltration of local anaesthetic to the dorsum of the nose and to see if this was altered by the addition of hyaluronidase. Forty patients undergoing nasal manipulation for fractured nasal bones were randomized to receive either 4 ml of twoper cent lignocaine and adrenaline 1:200000 or 4 ml of two per cent lignocaine and adrenaline 1:200000 with 1500 IU hyaluronidase, which was infiltrated subcutaneously over the nasal dorsum.One surgeon using a standardized technique performed the nasal infiltration. Other outcome measures were ease of manipulation, adequacy of the reduction, patient satisfaction with cosmesisand patient analgesia requirements. There were trends for decreased tissue distortion and improved ease of manipulation in the hyaluronidase group. Larger trials are required to confirm these results.

Short-term results of laser palatoplasty have been encouraging. This study was undertaken to evaluate if there is a deterioration of benefit with time as seen in uvulopalatopharyngoplasty (UPPP). The Glasgow benefit inventory (GBI) was applied retrospectively by means of a postal questionnaire to measure the quality of benefit and to evaluate any deterioration in benefit with increasing post-operative time. Our results show that laser palatoplasty benefited 53 per cent of patients. With increasing postoperative time there was a decrease in the percentage of patients who felt the operation had made no difference, with a corresponding increase in the percentage of patients who felt worse. Although the number of patients who benefited remained fairly constant, there was deterioration in the quality of benefit in the first year, after which the benefit remained stable. This has implications in the pre-operative counselling of patients.

The monitoring of children with otitis media with effusion ties up considerable resources in audiology departments. Impedance audiometry is frequently used when investigating these children. It has been shown to be highly sensitive in detecting middle ear effusion, but its value in identifying those children with a significant hearing impairment secondary to this is in question because of the wide range of hearing impairments possible with a type B tympanogram. This study quantified the sensitivity and specificity of impedance audiometry in detecting a hearing impairment greater than or equal to 25 dB HL due to otitis media with effusion. The subjects were 285 children of whom 20% had hearing thresholds greater than or equal to 25 dB HL. A peaked tympanogram (types A or C) virtually eliminated the possibility (98% confidence) of such a hearing impairment. A flat type B tympanogram was satisfactorily sensitive (93%) in detecting a hearing impairment, but non-specific (76%). The positive predictive value was 49%, i.e. 51% of ears with this type of tympanogram had hearing within acceptable limits. Assuming that a sensorineural impairment has been excluded and a population is being monitored for hearing impairment associated with otitis media with effusion, it is suggested that the presence of a peaked tympanogram indicates normal hearing, whereas those children with a flat tympanogram would require their hearing to be evaluated. Increased use of impedance audiometry to monitor children with otitis media with effusion would reduce the number requiring full pure-tone audiometry with a subsequent reduction in the workload of an audiology department.

The frequency of the resonance peak of the external auditory canal was measured in 250 children aged 3 to 12 years. The mean resonance peak frequency was greatest in the younger age groups (3089 Hz in 4 year olds, range 2298 to 3763) and then decreased with age until 7, the age at which adult values were reached. Children less than 7 years of age have mean resonance frequencies significantly different from adults, suggesting that the "adult" length of external auditory canal is not reached until the age of 7. This alteration in resonance frequency with age may have practical implications by affecting the insertion gain of hearing aid systems in children.

Wegener’s granulomatosis is a systemic disease characterized by a granulomatous lesion that can affect any organ throughout the body.This case-report illustrates the problem posed by a patient presenting with bilateral serous otitis media with marked sensorineural hearing loss, facial nerve paralysis and an atypical serological picture. The importance of early diagnosis and the protocol for the management of a patient with an uncertain diagnosis is discussed. Due to atypical presentations, only a high index of suspicion will ensure an early diagnosis.

Clinical voice testing forms part of the routine assessment of children's hearing. However, its role in paediatric practice has not been defined. In particular, the sensitivity and specificity of the test in detecting the presence of a hearing impairment is not known. The value of the test as a screen was assessed by comparison of the results of free-field clinical voice testing with pure-tone audiometric thresholds in 141 children aged 5-12 years. In order to pass the screen, a child had to respond to a whispered voice 2 feet (60 cm) from the test ear. The mean pure-tone average (average at 0.5, 1.0 and 2.0 kHz) of those ears that passed was 14 dB HL compared with 31 dB HL for those that failed (P less than 0.001). The test was 80% sensitive (95% specific) in detecting a hearing impairment greater than or equal to 25 dB HL, and 89% sensitive (90% specific) in detecting a hearing impairment greater than or equal to 30 dB HL. Therefore, clinical voice tests will fail to detect a significant proportion of children with a hearing impairment and cannot be advocated as a screening method. The test would appear to be of limited value in a specialist situation where facilities for pure-tone audiometry exist.

A middle ear effusion has been shown, in KEMAR, to increase the height of the resonant peak of the external auditory canal by 6 dB SPL. It has also been shown that the hearing impairment due to otitis media with effusion is related to the volume of middle ear fluid. Therefore, it was hypothesized that measurement of the height of the resonant peak of the external auditory canal could be used as a method of assessing the magnitude of any hearing impairment due to otitis media with effusion. 182 ears from 182 children aged 3–12 (mean 6.3) years were studied. Pure-tone audiometry and impedance tympanometry were performed, and the acoustics of the external auditory canal were measured using the Rastronics CCI-10 frequency response analyser. The mean height of the resonant peak (17.9 dB SPL) of children with a type A tympanogram was significantly different from the mean value (23.6 dB SPL) of those with a type B tympanogram. There was a significant correlation between the height of the resonant peak and the speech frequency average of the pure-tone thresholds. The sensitivity and specificity of using the height of the resonant peak to detect hearing impairments in different age groups were calculated and compared with the sensitivity and specificity of tympanometry. The test did not provide the same degree of sensitivity as tympanometry but was more specific. The additional advantages of the test are that it is quick, taking less than 1 min per ear, and is well tolerated by children in whom there was a 99% compliance. It is suggested that measurement of the height of the resonant peak of the external auditory canal holds potential as a quick and objective method of screening and monitoring the hearing impairment of children with otitis media with effusion.

An audit of blood-ordering practices was carried out to compare the number of units of blood cross-matched and the number transfused during elective head and neck surgery. Routine cross-matching of blood for laryngectomy or radical neck dissection was found to be unnecessary, and it is suggested that a preoperative policy of blood grouping, screening for irregular antiboidies and saving patients’ serum be adopted. Should blood then be required, this procedure enables un-crossmatched ABO-Rh(D) group specific blood to be released in an emergency with a high degree of safety. The routine cross-matching of blood can be supported for the remainder of the major head and neck operations, and guidelines as to the number of units that should be corss-matched are suggested. Implementation of these policies will reduce the number of units of blood unnecessarily cross-matched, decrease the amount of time-expired blood, and lead to increased efficiency of blood utilization.

Recent investigations have demonstrated an association between sniff-induced negative middle ear pressure and otitis media with effusion. This is taken as evidence of Eustachian tube malfunction. Adenoidectomy is frequently performed as part of the surgical management for otitis media with effusion, but whether this affects Eustachian tube function is uncertain. The aim of this study was to investigate the hypothesis that if adenoidectomy improved Eustachian tube function, children who had undergone adenoidectomy would show less tendency to generate a high negative intratympanic pressure by sniffing. Eustachian tube function was studied actively in 40 children with otitis media with effusion. Twenty children, selected at random, underwent adenoidectomy and all 40 had a unilateral grommet inserted. Eighty-five percent of the children could create a negative middle ear pressure by sniffing, but there was no difference in the number of 'sniff + ve' children between the adenoidectomy and control groups (P greater than 0.5), or in the magnitude of the negative pressure induced. It is concluded that a high percentage of children with otitis media with effusion are capable of inducing a negative middle ear pressure by sniffing, but this parameter of Eustachian tube function is not affected by adenoidectomy.

Patients with adult onset otitis media with effusion are generally subjected to an examination and biopsy of the nasopharynx under a general anaesthetic to exclude a neoplasm of the post-nasal space. The likelihood in Caucasian countries of a tumour being detected has not been clearly defined. The clinical features of the 55 patients with nasopharyngeal malignancy presenting to the Glasgow hospitals since 1970 have been analysed, and the incidence of malignancy in all adults presenting with middle ear effusions has been assessed in order to define the association of the 2 conditions. The study confirmed that while an effusion is commonly associated with a nasopharyngeal tumour (33%), in only 2% was it the sole clinical manifestation at the initial consultation. In addition, adults with effusions, but without other symptoms and signs suggestive of a tumour, are unlikely to harbour a tumour, the incidence in this review being 0.4%. Therefore, an examination and biopsy of the nasopharynx under general anaesthesia is likely to give a very low yield of additional information in cases of isolated middle ear effusions in adults, and the cost effectiveness of the procedure should be questioned.

Tonsillectomy frequently results in a significant degree of post-operative pain. Conventional management consists of the administration of intra-muscular opiates prior to the commencement of oral analgesia and is often inadequate, producing variable levels of pain relief.One of the recommended uses of benzocaine lozenges is the relief of throat discomfort following tonsillectomy, but there are no clinical trials to support this claim. Therefore, a prospective placebo controlled trial was undertaken to compare the efficacy of benzocaine lozenges (10 mg.) with standard oral analgesia in the management of post-operative pain following tonsillectomy in an adult population.Consecutive patients undergoing elective tonsillectomy were randomised to receive either benzocaine lozenges (10 mg.) or placebo. Intake of supplementary oral analgesia was recorded, and the level of postoperative pain was assessed by use of a visual linear analogue scale. There was no significant difference in analgesic intake or pain severity as measured by linear analogue between the two groups.These results suggest that there is no benefit in administering benzocaine lozenges for the relief of post-tonsillectomy pain, and its use in this situation cannot be recommended.

The management of otitis media with effusion in adults The management of 38 patients with idiopathic adult onset otitis media with effusion was evaluated retrospectively. Data from 50 ears were reviewed. The standard treatment consisted of myringotomy and grommet insertion. The patients were followed up for an average period of 27 months. Only 2 ears maintained a significant improvement in the air-bone gap when reviewed approximately 3 months following grommet extrusion. In all of the others, the hearing impairment recurred, and continued to recur despite multiple grommet insertions in several patients. It is concluded that adult onset otitis media with effusion has a low tendency to resolve, and that conventional surgical measures have little to offer in its management.

NO ONE will deny the importance of instruction in this — among the most recent additions to specialized knowledge in medicine and surgery. In the teaching of medicine and surgery, we do not aim, especially in the undergraduate period, to produce specialists. The object of all undergraduate medical education is to give the student a view of the whole field of medicine and surgery. The breadth and depth of that view depend upon his ability to assimilate what is given him in four or five years of study in the professional school. The extent to which radiology should be taught should be commensurate with the time and stress given the other subjects of the medical curriculum, with the exception of the practice of medicine and surgery. In many schools the amount of time accorded radiology is not more than one hour a week for a college year, supplemented with the examining of radiographs illustrating medical or surgical cases assigned to the student. The question before us resolves itself into, How can the time ...

To the Editor: —I have been interested in the references of one or two of your correspondents to the clinical thermometer (The Journal, Oct. 21, 1911, p. 1357; June 8, 1012, p. 1756, and July 6, 1912, p. 52). It is a small instrument, but how very important! I believe it is a pardonable offense if a physician appears overfastidious in the presence of his patient in regard to the cleaning of his thermometer. We revolt at using a spoon or knife and fork that is not absolutely clean; how much more so when it comes to taking into our mouths a thermometer which we know has been the rounds of people suffering from various diseases! A thermometer case, which suspended by its chain, is always upright, is very convenient, I have found. Into it I pour once a week a few drops of a dilute formaldehyd solution. This together