Early Management of Laryngeal Injuries

The results of acute laryngeal trauma sustained by 44 patients are reported. Three major aetiological groups are identified: road traffic accidents, blunt injury and penetrating injury. Road traffic accidents appear to produce severe injury, but the long-term follow-up results are similar to those laryngeal injuries which were not recognized initially and who developed a chronic stenosis. The blunt injury group sustained less forceful trauma; 14 of the 18 were treated conservatively and all patients had a good result. The majority of the penetrating injury group developed good breathing and a good voice following operation. Some of the technical expertise normally used to treat chronic laryngeal stenosis has been included in this series to good effect.

The Uvulopalatopharyngoplasty Operation: The Edinburgh Experience

The experience of the uvulopalatopharyngoplasty operation, performed on 24 patients for the relief of loud or heroic snoring, is presented. The operation successfully reduced the severity of snoring in 96% of patients. Postoperative complications were uncommon but included nasal regurgitation and intrapharyngeal adhesions in one patient. The role of the uvulopalatopharyngoplasty operation in the treatment of obstructive sleep apnoea is undecided but the authors do not perform this operation on such patients.

Increasing incidence of oral cancer amongst young persons: what is the aetiology?

The reasons for an increasing incidence of oral cancer, particularly amongst younger persons is unclear. It has been hypothesised either to be a result of an increase in exposure to known risk factors amongst certain groups in the community, or to be due to new aetiological agents. Prior to conducting large expensive population-based studies, it seems appropriate to conduct initial smaller-scale surveys to assess evidence for each of these two hypotheses. This survey of young persons with oral cancer suggest that most are exposed to traditional risk factors of tobacco smoking, drinking alcohol and a low consumption of fruit and vegetables.

Hyalinizing clear cell carcinoma of the oral cavity and of the parotid gland

Hyalinizing clear cell carcinoma (HCCC) is a rare, recently described tumor of salivary gland origin. Differential diagnosis includes benign lesions as clear cell change in a pleomorphic adenoma or in oncocytoma and malignant tumors - i.e. epithelial-myoepithelial carcinoma, polymorphous low-grade adenocarcinoma, mucoepidermoid carcinoma, clear cell acinic carcinoma, clear cell squamous carcinoma, clear cell malignant melanoma, clear cell odontogenic carcinoma, clear cell rhabdomyosarcoma, sebaceous carcinoma and metastasis of renal carcinoma. A favorable prognosis after wide local excision has been evidenced. Three new cases of HCCC (2 in the oral cavity and 1 in the parotid gland) are presented.

Local research ethics committee approval for a national study in Scotland

The handling of research proposals by different ethics committees has been reported as varying widely from one district to another. Multicentre research projects are particularly liable to delay when dealing with several individual committees. We recently performed a nation-wide postal questionnaire study in Scotland on young patients with oral or oropharyngeal cancer. Our experience indicates that despite calls for standardization of the processes involved wide variations still exist between committees. Fifteen out of 19 committees approached had unique application forms, the number of copies of forms and other documentation required ranged from one to 20, and the time to final approval ranged from 39 to 182 days (mean of 90 days). Improved training and a standardized constitution of committee members is required. A uniform national application form and improved co-operation between neighbouring committees is needed.

Trends in randomized controlled trials in ENT: a 30-year review

There is a growth in the demand for clinical practice to be evidence based. Recent years have seen a rise in the number of randomized controlled clinical trials (RCTS). Such trials while acknowledged as the gold standard for evidence can be difficult to perform in surgical specialities. We have recently identified a low proportion of RCTS in the otolaryngology literature. Our aim was to identify any trend in the number of published RCTS within the ENT literature over a 30-year period and to identify which areas of our speciality lend themselves to this form of study design. A Medline search of 10 prominent journals published between 1966 and 1995 was performed. Two hundred and ninety-six RCTS were identified. Only five were published before 1980. Two hundred (71 per cent) of RCTS were in the areas of otology and rhinology. An encouraging trend is seen in RCTS within ENT literature.

Is there an evidence base for the practice of ENT surgery?

In order to assess the strength of the 'evidence base' for the practice of otolaryngology a review of recent journal articles was undertaken. A review of all articles published during the period 1990-1994 in five major general otolaryngology journals was performed. The articles were classified according to a standardized scheme from the abstract or, if necessary, the full paper. Papers were grouped into observational studies (descriptive or analytical, hypothesis-testing), controlled trials, randomized controlled trials, audits, non-clinical and others. One true meta-analysis was found. Randomized controlled trials comprised 0.7%-4% of articles across the journals studied; other controlled trials comprised 0.8-2%; and other analytical studies 7.6-21.9%. Very few true audits were seen. Descriptive studies were by far the commonest type of paper seen. This literature review suggests there is a poor evidence base for our specialty if one regards randomized controlled trials as the gold standard.

Wegener's granulomatosis presenting as major salivary gland enlargement

Salivary gland involvement is rare in Wegener's granulomatosis. We report the first case of widespread major salivary gland enlargement as part of the presentation of this disease. A review of the few reported cases in the literature suggests that salivary gland involvement may be associated with a limited form of the disease and an improved prognosis. The anti-neutrophil cytoplasmic antibody (c-ANCA) assay remains the gold standard of diagnosis but care should be exercised in the interpretation of results. This patient responded well to current immunosuppressive therapy.

The function of free jejunal autografts in the pharyngo-oesophageal segment

Eight patients were studied 6 weeks to 16 months following pharyngo-oesophageal reconstruction using a free jejunal interposition graft. Ambulatory manometry was carried out using an intraluminal strain gauge assembly linked to a portable microprocessor. In one patient, the assembly could not be passed because of a redundant jejunal loop. In four subjects, the jejunal interposition appeared to function as a passive conduit with very little manometric activity. In the remaining three patients, however, there was evidence of both propagated peristaltic waves within the graft and regular contractile activity, characteristic of Phase III of the intestinal Migrating Motor Complex (MMC). The presence of MMC activity at only 7 weeks following surgery confirms its independence of extrinsic intestinal innervation. Spontaneous contractile activity, however, was not interrupted by propagated water swallows and may contribute to post-operative dysphagia in some individuals.

Swallowing performance in patients with vocal fold motion impairment

Twenty-seven patients with vocal fold motion impairment underwent detailed pharyngoesophagel manometry with a strain gauge assembly linked to a computer recorder. Nine were known to have lesions of the central vagal trunk or nucleus, 9 had recurrent laryngeal nerve (RLN) palsy, and the remainder were idiopathic. The site of the lesion was a more important determinant of subjective swallowing performance than the position of the involved cord at laryngoscopy. Patients with central lesions had lower tonic and contraction upper esophageal sphincter (UES) pressures than 25 age-matched controls, suggesting that high cervical branches of the lower cranial nerves are important in UES excitatory innervation. RLN palsy patients showed significantly increased pharyngeal contraction amplitude and reduced pharyngoesophageal wave durations. The results suggest that the dysphagia associated with vocal fold motion impairment is not simply due to the disruption of laryngeal deglutitive kinetics, but to independent effects on pharyngeal function.

Endoscopic sinus surgery

Endoscopic nasal surgery has become the single major advance in the specialty of otolaryngology since the introduction of the operating microscope and middle ear surgery. The value of improved assessment of nasal and sinus pathology using the endoscope diagnostically cannot be overstated. Once pathology is better evaluated, therapy will at least be more appropriate. It is now possible to carry out such nasal surgery as polypectomy, antrostomy and turbinoplasty more accurately and more safely, as well as provide better postoperative care. The use of the endoscope has afforded a useful sub-cranial route for the repair of at least small cerebrospinal fluid leaks, while it is likely that such procedures as dacrocystorhinostomy will eventually be mostly performed using the nasal endoscope. Some orbital decompressions will also be suitable for medial orbitotomy via the endoscope. Additionally, assessment of the extent of extrusion of orbital contents after blow-out injury has been invaluable, as is evaluation of the posterior wall of the frontal sinus after frontal bone trauma. Functional endoscopic sinus surgery (FESS) has an undoubted place in the surgery of frontoethmoidal mucocoeles. While few oncologists would be sanguine about its use in the surgery of nasal tumors, it is still of great value in evaluation and biopsy. Although FESS confined to the osteomeatal complex in the presence of early sinus disease is almost certainly an advance, what is still not proven, is the place of endoscopic sphenoethmoidectomy in the treatment of chronic rhinosinusitis.

A prospective analysis of incidental paranasal sinus abnormalities on CT head scans

A prospective analysis of the incidence of paranasal sinus opacification in 100 patients referred for cranial computerized tomography (CT) for non-sinus related problems is described. The findings were correlated with symptomatic assessment. Twenty-seven per cent of asymptomatic patients had sinus opacification. The study illustrates the importance of careful clinical correlation when interpreting CT scans of the paranasal sinuses.

Nasoantral window assessment by acoustic rhinometry

Twenty-five patients who had each had inferior meatal antrostomies performed were endoscopically examined and assessed with acoustic rhinometry six weeks and six months after surgery. No significant increase in nasal cross-sectional area could be demonstrated at the site of the antrostomy in the post-operative cases, although the nasoantral window was found to be patent in 44 of the 50 nasal cavities.

Women in surgery in Scotland. A Working Party of the Royal College of Surgeons of Edinburgh

Despite the fact that 50% of medical undergraduates are female, women comprise fewer than 1% of consultant general surgeons. The possible reasons for this were addressed by a working party of the Royal College of Surgeons of Edinburgh, which now reports the results of a survey of 35 women surgeons of SHO 3 grade and above working in Scotland. Findings were compared with those of 12 anaesthetists and 10 house officers. Surgeons had had an accurate perception of the work patterns their job would entail but no preparation for the lifestyle implications. The experience of gender discrimination was similar in all three groups but perceived discrimination was much more prevalent among surgeons/ophthalmologists. In contrast to the other groups surveyed, the surgical cohort was not deterred by training length, but rather discouraged by the lack of responsibility offered. Other factors which seem to contribute to the underrepresentation of women among surgeons may be the lack (1) of time for child rearing and (2) of same-sex role models.

The nature of the head and neck cancer

Squamous cell carcinoma of the head and neck is a disease predominantly of males and is due to a variety of known environmental irritants, notably cigarette smoke. Dietary, viral and immunological factors may also be relevant. Head and neck squamous cancers express epidermal growth factor receptors and some show weak levels of oestrogen receptor activity, but a reliable serum marker of tumour burden remains to be identified. The prognosis is found to be less favourable in females, in those with advanced T stage, in association with multiple node involvement, especially where extracapsular spread is present and where the T4/T8 ratio is elevated. Administration of heterologous blood during therapy may also have an adverse effect on prognosis. Interested clinicians must remember that most cases are preventable.

Otolaryngological indicator operations: one year's experience

One year's experience of otolaryngological indicator operations is presented. Of 59 myringoplasties, 47 (79%) were successful; trainees performed 44 (74%) of the procedures. Seventy patients undergoing septal surgery reported significant improvements in nasal obstruction (P < 0.001), catarrh and facial pain (P < 0.005). Seventeen laryngectomies were performed for stage III and IV disease. The median operative time of 3.1 h rose to 5.1 h with a concomitant neck dissection. Eleven complications ensued, and the median stay for an uncomplicated laryngectomy was 16 days and 30 days following complications. Forty-one parotidectomies, 19 submandibular gland excisions and 10 ductal procedures were performed with 5 wound complications and 5 minor temporary facial nerve weaknesses. We have established a baseline for comparison of our practice with others and concluded that septal surgery gives good symptomatic relief, trainees perform reasonable numbers of myringoplasties, and improvements remain to be made in our outpatient septal surgery data collection.

Epidermal growth factor receptors and oestrogen receptors in the head and neck

We report a pilot study of the levels of epidermal growth factor receptors (EGFR) in normal and neoplastic tissues of the head and neck. Specimens from 20 consecutive patients undergoing major head and neck surgery showed that squamous cell carcinomas had detectable but widely varying levels of EGFR. EGFR expression was greater in normal salivary gland tissue than in benign salivary neoplasms. Oestrogen receptors were not detected in clinically significant amounts in any of the tumours assayed.

Salvage laryngectomy after radical radiotherapy for laryngeal carcinoma

Of 376 patients who were treated by radical radiotherapy for squamous carcinoma of the larynx, 56 subsequently underwent total laryngectomy. Residual or recurrent tumour was identified in 43 of the resection specimens, and necrosis alone in 13 cases, although a positive biopsy had been obtained in 3 of these prior to salvage laryngectomy. No disease related factors such as site or stage of the original tumour, or treatment related factors such as radiation type or dose, were found to be predictive of whether or not tumour was present. The clinical opinion of an experienced surgeon was found to have a positive predictive value of 0.86 for the presence of tumour. The fistula rate of salvage laryngectomy, 15 out of 56, was similar to that of other series. The actuarial cause specific 5-year survival for patients with tumour was 0.589, and for patients with necrosis only was 0.923. Intercurrent, smoking related disease was the cause of death in 16 of the 33 patients who have died.

The quantitative analysis of dysphonia

A clinical method of measuring 'hoarseness' is presented. Its value is assessed in 3 different types of vocal cord lesion and compared against normal values. There are shown to be significant differences between the normal and the abnormal voice and also differences between each type of vocal cord lesion. We feel that this quantification of hoarseness is useful in the treatment of patients as well as in monitoring their progress under therapy.

Relationships between surgical ability ratings and spatial abilities and personality

Twenty-two trainee surgeons were tested on high level tests of intelligence, a detailed battery of paper-and-pencil and computerized spatial ability tests, and personality tests. They were also rated for operating ability, clinical decision-making ability, and for overall performance by consultant surgeons who knew them well. Ability ratings were high, indicating very little dissatisfaction with the performance of trainee surgeons. There were no significant correlations between surgical ability ratings and intelligence test scores. The only significant correlation between spatial ability and ability ratings was with one subtest, and was in the opposite direction to that expected. Trends in the data suggested that those trainees rated as superior tended to be more introverted and conscientious, and tended to have better stereoscopic depth perception. The discussion questions the necessity for aptitude testing in surgery and points out some statistical pitfalls in the area. It is concluded that little advance may be made with the application of aptitude testing in the selection of surgeons until there are more objective criteria of surgical ability in different surgical specialties.

Cricopharyngeal dysfunction

The aim of the study was to determine the manometric patterns in dysphagic patients with radiologic evidence of upper esophageal sphincter (UES) dysfunction. Nineteen patients with radiographic abnormalities of the UES underwent measurement of several parameters of UES tonic pressure and pharyngoesophageal water swallow dynamics. At least two UES tonic pressures were elevated in six subjects, compared with a control group of 67 healthy volunteers. No patients had UES achalasia. The cricopharyngeal impression in the remaining patients may represent muscular hypertrophy or deficiency of UES opening, despite manometric relaxation, but its relationship to the patient's symptoms remains unknown. Cricopharyngeal myotomy appears to be a reasonable treatment for patients with manometric UES hypertonicity.

The effect of laryngeal irradiation on pharyngoesophageal motility

The upper esophageal sphincter (UES) receives the full radiation dose during external beam radiotherapy to the adjacent larynx. The aim of the study was to assess the effects, if any, of radical laryngeal radiotherapy on motility patterns in the pharyngoesophageal segment. A strain gauge assembly and a digital manometric recorder were used to assess 19 patients 13 to 71 months after irradiation of T1 to T3 glottic cancer to a central dose of 52.5 to 55.7 Gy in 20 daily fractions. Results were compared with those of 23 healthy controls. Tonic lower esophageal sphincter (LES) pressure, distal peristaltic contraction, tonic UES pressure, and eight parameters of pharyngoesophageal dynamics during water and bread swallows were studied. No difference was found between the two groups in tonic LES pressure, peristaltic amplitude, or tonic UES pressure. Water swallow pharyngoesophageal wave velocity was significantly lower in patients than in controls, and the irradiated group also showed a trend toward increased duration of the distal esophageal peristaltic wave. The reduction in upper esophageal wave velocity was associated with the interval following irradiation. The post-treatment interval was also inversely related to the amplitude of UES after-contraction, and associated with an increase in wave duration throughout the pharyngoesophageal segment. A study of 23 laryngectomy specimens, 5 of which had been removed following radiotherapy, failed to identify pathological features in nerves or muscle which characterised previous laryngopharyngeal irradiation. We conclude that laryngeal irradiation has no effect on upper or lower esophageal sphincter tone but causes an increase in wave duration and a reduction in wave velocity in the pharyngoesophageal segment. These changes are independent of age and sex and are not associated with pathological features like the neural degeneration described in the myenteric plexus of irradiated rectum.

The Edinburgh FESS Trainer: a cadaver-based bench-top practice system for endoscopic ethmoidal surgery

Functional endoscopic sinus surgery (FESS) requires cadaver-based practice to acquire the necessary technical expertise. To enable this to be undertaken as a bench-top activity the Edinburgh FESS Training system has been developed. This involves the en-bloc removal of the relevant parts of the nasal cavity and sinuses from cadavers and their embedding and mounting in a simulated head.

Reinke's oedema and thyroid function

Reinke's oedema (RO) of the vocal folds is a condition of unknown aetiology. Cigarette smoking and vocal abuse may contribute to its development. Hypothyroidism has been described as an aetiological factor but, to date, no controlled study has been published confirming this association. This prospective, controlled study compared thyroid function in 61 consecutive RO patients with an age and sex matched control group (n = 65) without laryngeal disease. Thyroid function was assessed by measuring serum thyroid stimulating hormone (TSH), free thyroxine (T4) and tri-iodothyronine (T3). Hypothyroidism was diagnosed when TSH was above normal with a T3 and T4 below the normal range. Four RO patients were hypothyroid at the time of diagnosis, compared to five of the control group. Six RO patients had past or present hypothyroidism compared to seven of the controls. One RO patient and two controls were euthyroid with marginally elevated TSH levels. Although the incidence of hypothyroidism in this group of Reinke's oedema patients is higher than expected in a normal population, it is similar to that in an age and sex matched control group, reflecting the prevalence of hypothyroidism in middle aged women. This study suggests that hypothyroidism is not an aetiological factor in the development of Reinke's oedema.

The persistence of symptoms in patients with globus pharyngis

A follow-up study of 104 patients with globus sensation was performed by postal questionnaire. All were asked to complete the Eysenck Personality Questionnaire (EPQ) and a 12-item Throat Symptom Questionnaire. Seventy-two of these patients were sent a follow-up General Health Questionnaire (GHQ). Replies were received from 89 patients (86%), 68 females and 21 males, a mean of 31 months after initial presentation. The feeling of something stuck in the throat had disappeared completely in 27% of patients, but only 4% were never aware of the throat. Throat symptoms showed a reduction with increasing age, but not with increasing interval since presentation. The 15 patients initially treated with antacid therapy had significantly greater dyspepsia scores at review than untreated patients, but no other difference was found between the two groups. GHQ scores showed a small but significant reduction over time. Of EPQ parameters, only the lower lie score in female patients showed any significant difference on repeat testing. Those with persistently high throat scores had significantly lower EPQ lie scores and a trend towards higher GHQ scores at follow-up. None of the psychological parameters measured at the first interview was found to be of prognostic significance. We conclude that, although there is a reduction in occult psychiatric morbidity in patients with the globus sensation over time, underlying personality traits remain stable and that there is a remarkable persistence of pharyngeal symptoms.

Parotid salivary secretory pattern in bulimia nervosa

Parotid gland enlargement occurs in about 25% of patients with the binge eating syndrome of bulimia nervosa. The parotid salivary secretory patterns in 28 bulimics were determined in order to investigate the functional abnormality in the glands. Bulimia patients had a reduced resting flow rate. Bulimics who developed sialadenosis (4 patients) had reduced resting and stimulated flow rates. The salivary amylase activity was increased in both the resting and stimulated states in bulimics and the sialadenosis group. The resting total protein levels were greater in the bulimics. The electrolyte and immunoglobulin levels were within normal limits. The possibility of protein and enzymatic secretory disturbances due to autonomic nerve disorders as an explanation for the development of sialadenosis in bulimia nervosa is discussed.

Informed consent in head and neck surgery

Informed consent is the fastest growing problem in the medical negligence debate. It was highlighted recently in the United Kingdom in the Sidaway case. Informed consent comprises the advice you would give the patient, the consequences of not taking your advice, the specific risks of the surgery or treatment you have in mind, and the risks of surgery in general. In an attempt to identify what the present practice in otolaryngology was, a postal survey was carried out of the members of the Scottish and North of England Otolaryngological Societies.

What's new in surgery: otolaryngology

It is a decade since the last review article on otolaryngology in this Journal. In that time there have been significant advances in the practice of an ever-changing specialty which originally started off as a surgical specialty designed to drain abscesses from the bony boxes in the head, namely the mastoids and the sinuses. It is impossible, in an article like this, to do anything other than superficially indicate the changes but a list of further reading is given for each section.

The effects of age, sex, and smoking on normal pharyngoesophageal motility

Previous reports of normal pharyngoesophageal motility have described normal ranges in small numbers of young adults. In this study, the results of upper esophageal sphincter (UES) manometry with a microtransducer assembly in 67 healthy volunteers aged 17-77 yr have been analyzed for possible effects of age, sex, and cigarette smoking. Older subjects were found to have only marginally lower UES tonic pressures, but markedly elevated pharyngeal contraction pressures. Increasing age was associated with a reduction in duration of upper esophageal contractions and, for bread swallows, an increase in pharyngoesophageal wave velocity which may represent compensatory mechanisms for airway protection. Male subjects showed greater UES axial asymmetry than females, perhaps due to sex differences in laryngeal anatomy, whereas females had greater UES wet swallow after-contraction pressures which may be relevant to the generation of globus sensation. All results were independent of cigarette smoking. We conclude that normal values obtained in small numbers of young adults form an inadequate basis for the interpretation of UES tonic and pharyngeal contraction pressures, which are reported to be abnormal in older patients with dysphagia, and that manometric investigation of dysphagic patients requires the analysis of multiple parameters of dynamic pharyngoesophageal function.

Mucosal immunodeficiency in smokers, and in patients with epithelial head and neck tumours

Cigarette smoking influences the risk of orogastrointestinal disease in both protective (ulcerative colitis), and inductive (squamous tumours of the head, neck and oesophagus) roles. In order to study the effects of smoking on mucosal immunity, salivary immunoglobulins were measured in pure parotid saliva from groups of healthy non-smokers, smokers, and exsmokers and from patients with epithelial head and neck tumours, both untreated and after radiotherapy. Of the healthy individuals, smokers had significantly lower salivary IgA and higher IgM concentrations than did non-smokers. The effect on IgA was dose related, and reversible after cessation of smoking. Likewise, in patients with head and neck tumours (the majority being smokers), salivary IgA concentration was reduced and IgM increased when compared with non-smoking controls. Results were similar before and after radiotherapy. This study provides evidence of the effects of smoking on mucosal immunity as evaluated by parotid salivary immunoglobulins. Further studies of the influence of smoking on secretory immunity are indicated.

Metastatic salivary pleomorphic adenoma

Pleomorphic adenomas of the salivary gland are usually regarded as benign tumours. We report a case in which a solitary pulmonary metastasis arose from a pleomorphic adenoma of the right parotid gland. The mechanism of metastasis is discussed.

Pharyngoesophageal dysmotility in globus sensation

Ambulatory esophageal pH monitoring, radiologic examination, endoscopy, and manometry were undertaken in 142 patients with globus. The results demonstrate that abnormal gastroesophageal reflux occurred in 23% of patients, implying that, while reflux may be responsible for globus in some patients, it is not the cause of globus sensation in the majority of individuals with this symptom. Comparing patients with globus and control subjects, there were no differences in lower esophageal sphincter pressures, esophageal body motility, or tonic upper esophageal sphincter pressures, but patients with globus exhibited higher pharyngeal and upper esophageal sphincter after-contraction pressures during deglutition. The physiological significance of this pharyngeal and upper esophageal dysmotility is not clear and it may be no more than a secondary phenomenon. Alternatively, it may contribute to the generation of globus, perhaps in combination with other physical and psychological triggers.

Radical neck dissection: a 19-year experience

A series of 394 radical neck dissections performed over the 17 year period 1969-1986 is presented. The shortest period of follow-up is two years. Of the major complications reviewed, wound breakdown was associated with T stage, prior radiotherapy and incision used but not with age or N stage. Cervical recurrence was associated with N stage, prior radiotherapy and surgical incision and inversely associated with age. Wound breakdown and recurrence were lowest in parotid primary tumours. Carotid artery rupture occurred in 17 patients (4.3 per cent), was fatal in all cases and was strongly associated with wound breakdown and previous radiotherapy. The importance of the choice of incision, clearance of the posterior belly of the digastric muscle and carotid artery protection are discussed.

Gastroesophageal reflux and posterior laryngitis

Esophageal acid exposure was assessed by 23-hour ambulatory pH monitoring and compared with a biopsy of the posterior larynx and proximal esophagus in 97 patients with hoarseness, burning pharyngeal discomfort, or globus sensation. Patient results were compared with normal acid exposure times obtained in 54 control subjects. In 24 patients there were laryngeal abnormalities but both esophageal biopsy results and acid exposure times were normal. Laryngeal disease was found in association with prolonged acid exposure time or esophagitis in only 17 of the 97 patients (17.5%) studied. Recent reports appear to have overestimated the importance of acid reflux as a cause of posterior laryngitis.

Is globus hystericus?

Forty-six patients, 9 male, 37 female, presenting to an ear, nose and throat department with a principal complaint of globus sensation were investigated by radiology, manometry, endoscopy and prolonged ambulatory pH monitoring to exclude a physical basis for their symptoms. Patients also underwent assessment by the Eysenck Personality Inventory (EPI) and General Health Questionnaire (GHQ). The only organic abnormalities detected were an abnormal degree of oesophageal acid exposure (seven patients) and oesophageal spasm (one patient). Female patients were neurotic introverts on EPI testing; males were stable ambiverts. High GHQ scores were present in 13 females (35%) and one male and there was a significant correlation between N scores (in the EPI) and GHQ scores. We propose that globus is a useful, single-symptom model for the study of conversion disorders.

The aetiology of laryngocoele

Dimensions and volumes of 200 hemilarynges were measured to establish the normal range of laryngeal air sac size in males and females. Large saccules reaching the upper border of the thyroid cartilage were unilateral in 23 and bilateral in 20. Saccular volume is significantly related to ventricular volume but not to age, sex or laryngeal size. Large bilateral saccules are common and, therefore, a likely underlying factor in laryngocoele. However, the unilaterality of the disease, its male predominance and its age distribution, suggest that local laryngeal pathologies are perhaps the determinant factor in the pathogenesis of the disease.

Globus sensation is not due to gastro-oesophageal reflux

Oesophageal manometry and prolonged ambulatory pH monitoring were performed in 47 patients with the globus sensation, 48 control subjects and 28 patients with documented oesophagitis. Globus patients also underwent video-recorded barium examination and rigid endoscopy. Manometry was normal in 38 of the globus group (94%). The mean percentage time below pH 4 was 4.16 in controls, 5.11 in globus patients (NS) and 18.54 in oesophagitis patients (P less than 0.0005). Oesophageal acid exposure did not correlate with sex, smoking or heartburn and correlated with age only in oesophagitis patients (P less than 0.001). Biopsy showed mild laryngitis in 2 globus patients and distal oesophagitis in 6 (13%). Abnormal oesophageal acid exposure and distal oesophageal dysmotility are not aetiological factors in the majority of patients with globus pharyngis.

Fine needle aspiration biopsy and the otolaryngologist

A survey of the diagnostic value of fine needle aspiration cytology in ENT practice was carried out over a 3-year period. The 119 aspirates were taken from a variety of head and neck sites and examined by an experienced cytopathologist. Cytology was accurate in 111 (93 per cent), with two false negative aspirates (1.7 per cent) and no false positive results. There were no complications and the technique was found to be a rapid, safe and cost-effective diagnostic tool.

Pneumosinus dilatans

Pneumosinus dilatans is an extremely rare condition in which facial deformity is caused by gross enlargement of apparently normal paranasal sinuses. To our knowledge, this is the first case to be reported in the English literature.

A pathological classification of nasal fractures

The management of nasal fractures has been found by several authors to be inadequate. The reason for this is obscure but may be poor understanding of the pathology of nasal fractures. There is no adequate comprehensive classification of nasal fractures. Various weights were dropped on cadavers' noses and the resultant fractured nasal pyramid was dissected out. The fracture lines are described and particular reference is directed to the involvement of the septum in grossly deviated noses. Confirmation of septal involvement is obtained using a CAT scanner. It has been found that correction of this septal involvement at the time of manipulation significantly improves the end-results (Murray and Maran, 1984).

Small bowel permeability in patients with nasal polyposis

Small bowel absorption defects have been noted in a proportion of patients with atopic eczema. Eighteen patients with recurrent nasal polyps had the cellobiose/mannitol ratio test performed in order to assess their small bowel function. Evidence for atopy was found in 11 of 18 patients. Histologically the polyps were described as allergic but the cellobiose/mannitol ratio was normal in all cases. No evidence for a small bowel absorption defect was obtained.