The Birmingham Mummy is of a warrior, 25–35 years of age, from the Graeco-Roman period. He was struck from the front by an arrow, which penetrated the soft tissues of the neck to some depth and lodged in the right infratemporal fossa. It is suggested that the wound became infected and that muscle spasm induced the torticollis which was not fully corrected on mummification.

A retrospective study of 74 Shah Permavent tube insertions is presented. These were inserted into 74 ears of 55 patients during the period between 1985 and 1988. At the time of review, 35 tubes had extruded spontaneously, 11 tubes had been removed for recurrent infections, 10 tubes had been removed electively and 10 tubes were still in situ. On examination of the ears approximately 12 months after the tubes had extruded, the overall rate of tympanic membrane perforation was 18.2 per cent. In ears in which the Permavent tube extruded spontaneously the perforation rate was 22.2 per cent. In ears in which the tube was removed because of infection the perforation rate was 20.0 per cent. However in ears in which the tube was removed electively the perforation rate was zero. This finding has implications in the use and management of long-term ventilation tubes.

The aim of this study was to compare the prevalence of the different types of eardrum pathology in a cohort of adults not previously treated by grommet insertion with corresponding findings obtained in a cohort previously treated with grommet insertion.

A cohort born in 1955 were invited to a screening examination including otomicroscopy. In the untreated cohort, retraction of Shrapnell's membrane was found in four per cent of the ears compared to 20 per cent in the cohort treated with grommets. Tensa pathology, including atrophy and myringosclerosis, was found in six per cent of the ears in the untreated cohort and in 17 per cent in the treated cohort. Normal eardrums were found in 91 per cent of the ears. Despite the increased awareness of secretory otitis, as well as the increased rate of surgical treatment, the prevalence of eardrum pathology seems to be increasing. The reasons for this are discussed.

Twenty patients who had undergone open cavity mastoidectomy for chronic middle ear disease were selected for study. Following initial microscopic aural toilet, each cavity was painted in its medial aspect with a marker solution of Bonney's Blue dye. Each patient was assessed at weekly intervals for a minimum of three months following application of dye, and a photographic record made of the cavity. Information was also sought regarding the clinical behaviour of the mastoid cavities, with particular regard to degree of otorrhoea, and accumulation of debris. Migration of epithelium inferred by visible movement of dye occurred in 17 of the 20 mastoid cavities. In all these cases migration occurred in a medial to lateral direction, towards the exterior. In two cases there was no visible migration throughout the period of observation, and inspection after six months revealed the dye to be still present in the original position. Both these cases were of dry trouble-free cavities in which accumulation of debris did not appear to be a problem. This finding calls into question the assumption that clean trouble-free cavities are maintained by a satisfactorily functioning epithelial migration. In the four cavities which suffered from intermittent otorrhoea, epithelial migration occurred at a similar rate to that in dry cavities.

The air conduction thresholds in the right and left ears, and the interaural asymmetry of thresholds at 0.5, 1, 2, 3, 4 and 6 kHz were measured in a group of 225 soldiers exposed to a variety of weapon noise who were referred for assessment because of a deterioration in hearing on routine testing. At 0.5 and I kHz the threshold levels rarely exceeded 25 dB and the interaural asymmetry was 10 dB or less in 90 per cent of cases. The degree of hearing loss and interaural asymmetry increased as the frequency increased, with the average loss being significantly greater in the left ear at 2, 3, 4 and 6 kHz.

Recommendations are made for the selection of cases of asymmetrical hearing loss exposed to weapon noise which require further investigation to exclude a retrocochlear cause or to define spurious hearing threshold levels.

Eighty-seven patients who were treated by laser mucotomy (L-mucotomy) of the inferior turbinates were followed-up for one year. Patients presented for laser surgery because of one of the three following symptoms: sneezing, rhinorrhoea, or nasal obstruction. All of them had had prior conservative or surgical treatments for their symptoms without improvement in their complaints and/or quality of life. L-mucotomy is a simple procedure performed under local anaesthesia on an ambulatory basis. A controlled amount of tissue from the inferior turbinates is ablated with improvement in the symptoms, as reported by the patients one year after laser surgery.

The procedure is easy to perform, there is no bleeding, it is painless and without complications, but it requires rather expensive surgical equipment.

The place of conservative treatment in sinogenic orbital complications has not been fully explained in the literature. The question that remains unresolved is – at which stage of the disease is surgery indicated?

A study was undertaken in 240 patients with sinogenic orbital complications, to determine this. The patients were divided into three groups according to the stage of the disease as determined clinically: Group 1 (52 patients) with early stage disease, as detected by cellulitis only; Group 2 (76 patients) with intermediate stage, as detected by periorbital cellulitis and proptosis, but with full range of eye movement and unaltered vision: Group 3 (122 patients) with late stage disease, as detected by periorbital cellulitis and gross proptosis. with limitation of eye movement and altered vision.

Group I and Group 2 patients were treated conservatively, with intravenous antibiotics and antral lavage. Group 3 patients were treated with intravenous antibiotics and surgery. External frontoethmoidectomy was performed in 31 (bilateral in two), ethmoidectomy in 91 (bilateral in five), sphenoidectomy in 15 and bilateral antral washout in all (122 patients). There was 100 per cent success with conservative treatment in Group 1 patients, whilst in Group 2 there was 98.6 per cent failure. The 75 patients in whom conservative treatment failed were successfully treated with surgery: frontoethmoidectomy was performed in 66 and ethmoidectomy in nine. In Group 3 patients, 100 per cent success was achieved with intravenous antibiotics and surgery.

Sinogenic orbital complications can be treated conservatively and surgically, depending on the stage of the disease on presentation. Conservative treatment is only suitable for early complications, i.e. patients with periorbital cellulitis only. For disease beyond this stage i.e. intermediate and late stage disease, surgery is the treatment of choice.

A retrospective analysis of 34 cases of sino-nasal squamous cell or undifferentiated carcinoma in patients admitted between 1984 and 1992 was undertaken. Multimodality therapy incorporated radiation, surgery and chemotherapy. The five-year survival rate was 53 per cent. The local control rate was 82 per cent. Patients died of local failure (six), distant metastases (six), lymph node metastases (one) and other causes (three). Twenty-eight patients with local control were separated into groups: G1–2 (well and moderately differentiated) and G3–4 (poorly differentiated and undifferentiated) and evaluated to find the association between differentiation and metastasis. Lymph node metastasis was not related to the degree of differentiation. Distant metastasis was significantly related to the degree of differentiation (Fisher's exact test: p = 0.007). The result of the combination therapy is poor for patients with poorly differentiated or undifferentiated carcinoma because of distant metastases. Adjuvant chemotherapy may be necessary for them to prevent distant metastasis.

For a long time uvulopalatopharyngoplasty (UPPP) has been used to treat the obstructive sleep apnoea syndrome (OSAS). The diverse surgical effects, the inadequate understanding of operation effect consistency, the possibility of disease progression, and the few reported papers for long-term evaluation after UPPP aroused our interest in designing this study. Fifteen OSAS patients who had undergone UPPP with pre-operative, initial post-operative and long-term post-operative polysomnographic studies were included in this study. Long-term post-operative polysomnography was undertaken more than five years after surgery. The polysomnographic evaluations included respiratory disturbance index (RD I), duration of saturation SaO2 <85 per cent (DOS), and the lowest O2 saturation (LOS). Amongst them, 10 patients with initial post-operative RDI reduction > 50 per cent were considered responders. In these responders, the long-term follow-up results of all three parameters showed improvement compared to the preoperative data. In a comparison between the initial and long-term post-operative sleep study results, LOS and DOS showed no significant difference. However, the long-term post-operative RDI result became significantly worse. More than 80 per cent of all cases had subjective symptomatic improvement in the long-term post-operative evaluation. The subjective improvement after operation is not adequately correlated to the polysomnographic result. We suggest that long-term follow-up for patients after UPPP is necessary.

The incidence, severity and pattern of post-intubation laryngotracheal sequelae in a 12 bed multidisciplinary intensive care unit (ICU) were assessed in this prospective study. One-hundred and fifty consecutive patients requiring intubation for more than 24 hours for various indications were studied. Evaluation of the larynx and trachea was done using a fibreoptic bronchoscope introduced through the endotracheal tube prior to elective extubation. Rigid bronchoscopy and direct laryngoscopy were performed in very small children and adults requiring tracheostomy. One-hundred and thirty-one (87.6 per cent) patients had visible laryngeal pathology in the immediate post-extubation period. Thirteen (8.6 per cent) had long term sequelae. A high incidence of long term sequelae was noted in patients with seizures (25 per cent) followed by patients with head injury (19 per cent). Steroid therapy failed to offer any significant protection but resulted in doubling of pulmonary sepsis. A grading system was adopted to classify acute laryngotracheal injury and a significant correlation was found between the presence of slough in the immediate post-extubation period and subsequent development of long term sequelae. There was also a significant correlation between a deeper insertion of the endotracheal tube and development subsequently of long term sequelae. The significance of these findings is discussed.

This paper presents the results of a national confidential comparative audit of stapedectomy: 185 operations by 28 consultants over a two-year period were retrospectively analysed. This included 10 revision procedures. Small fenestra stapedectomies accounted for 63 per cent of the total. Thirty-nine per cent of consultants operated on the second ear. Of the 168 stapedectomies in which the hearing change was known at six months, 87 per cent achieved improved hearing, eight per cent had no change and five per cent were worse. The overall complication rate was 30 per cent with a ‘dead ear’ rate of two per cent.

An audit project was undertaken to appraise the outcome of 95 cases of septal surgery over a 12-month period, taking into account the subjective alteration of symptoms, appearances at anterior rhinoscopy and complications. Seventy-three patients (76.8 per cent) attended the follow-up clinic three to six months (median four months) after surgery. There was an improvement in short-term nasal breathing and in the clinical appearance of the septum in 84.9 and 96.9 per cent respectively; a complication rate of 10.9 per cent and an overall satisfaction rate of 81.3 per cent were also noted. These results support those of other reported series and suggest that routine follow-up of uncomplicated cases of septal surgery is unnecessary.

Loss of a single nerve function in the peripheral network responsible for taste perception is traditionally considered clinically insignificant. However, we report the case of a 27-year-old woman who experienced significant selective taste loss for salt after manipulation of the chorda tympani during tympanoplasty. This effect may be explained by disorder of the functional neuroanatomy of salty taste perception together with strong lateralization of mastication to the affected side in this patient. Recently described inhibition of cranial nerve IX by cranial nerve VII is hypothesized as contributing to the contradiction between this case and the commonly accepted role of the chorda tympani in taste perception.

Nasal tuberculosis represents a rare manifestation of infection by Mycohacteriurn tuberculosis: a case is presented together with a review of the literature. The correct management is documented, especially the need to treat the patient as if there was a generalized condition, and the problems concerning drug resistance are also considered. The incidence of this disease is rising and its importance must once again he highlighted.

A 12-year-old schoolgirl presented with severe obstructive sleep apnoea due to the Robin sequence. The sleep apnoea, together with the associated findings of daytime sleepiness, nocturia, right heart strain and growth retardation, were successfully reversed by nasal CPAP therapy. This therapy allows postponement of a decision concerning corrective surgery until after full growth has occurred.

Two cases of non-fatal airway obstruction by nasal secretions are described. The diagnosis was made after laryngoscopy and the features which suggested this previously undescribed aetiology were: depression of conscious level: poor oral hygiene; and irregular friable mass with mucoid areas obstructing the airway. The diagnosis was confirmed by histological examination of the obstructing material which was composed of laminated fragments of squamous epithelium, keratin debris and mucus. It is suggested that these masses form in the post-nasal space and then become dislodged descending into the larynx, where they cause partial laryngeal obstruction and stridor.

In patients whose conscious level is depressed and who have poor oral hygiene, nasal secretions should be considered as a cause of sudden unexplained airway obstruction and stridor.

Tonsillar haemorrhage is a rare complication of infectious mononucleosis. We present a case of life-threatening tonsillar haemorrhage secondary to infectious mononucleosis in a young man whose predominant symptoms at presentation were haematemesis and melaena. The origin of the haemorrhage was not obvious until the patient was examined under anaesthesia. The bleeding was controlled by emergency tonsillectomy.

Candida epiglottitis has been reported in immunocompromised patients, but in only one paediatric patient with human immunodeficiency virus. We present possibly the first reported case of Candida infection of the epiglottis in an adult with human immunodeficiency virus treated with oral fluconazole. We review the symptoms, diagnosis. and management of the published cases of Candida epiglottitis in patients without the human immunodeficiency virus. Laryngoscopy and culture are diagnostic.

We present two cases of supraglottic transection, with concomitant neurotemesis of the superior laryngeal nerve. Both cases were repaired primarily and a temporary tracheostomy was used to protect the airway. In both cases subsequent decannulation was achieved within four weeks, following the initial injury. No long-term swallowing or voice disturbance was noted in either case. We recommend that in such cases it is unnecessary to repair the nerves directly, but that careful repair of the wound itself will achieve a functional result.

Benign salivary gland tumours in childhood are rare. We present a case of a pleomorphic adenoma arising in a minor salivary gland within the hard palate, review the literature and discuss the diagnostic and therapeutic features of the condition.