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.

The presence of aerobic and facultative anaerobic bacteria on the surface of pacifiers used by children with acute otitis media was investigated. The surface of 40 recently used pacifiers was swabbed after they were allowed to dry for five to six minutes. The swabs were processed quantitatively for the presence of aerobic bacteria. The antibacterial activity of the pacifier material was tested in vitro. Microorganisms were isolated from 21 (52.5 per cent) pacifiers. The number of colonies per pacifier varied between one and 35 (average six). The isolates included eight α-haemolytic streptococci, six Staphylococcus epidermis, five Candida albicans, five α-haemolytic streptococci, three Neisseria spp. and two Staphylococcus aureus. The pacifier material was shown to be inhibitory against S. aureus. This study illustrated that pacifiers do not contain high numbers of organisms and therefore are not likely to serve as a source of persistence of transfer of organisms.

Prior to flexible transnasal endoscopy (FTE) topical intranasal agents such as cocaine or combinations of a local anaesthetic and vasoconstrictor agent are generally recommended for local anaesthesia, easier access, and better examination of the interior of the nose, especially the middle meatus. This double-blind study involved 60 patients. Each had five per cent cocaine sprayed in one nostril and normal saline in the other. The pain/discomfort and gag scores showed no statistical difference.

Forty-two (70 per cent) patients had a moderate/marked deviation of the nasal septum. A significant pain score (3–5) was obtained in 33.3 per cent of cases with the deviation towards the cocaine side and in 37 per cent of cases with the deviation towards the saline side. Ease of procedure scores for both sides were also comparable, when deviation of the nasal septum was taken into account.

Despite the dramatic reduction in the incidence of laryngeal tuberculosis after the 1950s, the topic has now gained new interest due to claims that the disease has changed its clinical pattern. In the past, the typical patient was 20–40 years old with ulcerated laryngeal lesions, perichondritis, and advanced cavitary lung disease. We studied nine cases of laryngeal tuberculosis confirmed by histological examination. The microlaryngoscopy revealed tumour-like lesions and/or chronic non-specific laryngitis. There were no significant ulcerations or signs of perichondritis. The patients' ages ranged from 48.5 years to 69.3 years (mean, 59.4 years). In three of our patients (33 per cent) we did not find any pulmonary involvement, thus suggesting primary laryngeal tuberculosis or haematogenous spread. In conclusion, the numerous physicians who deal with the various laryngeal symptoms and diseases should be aware of the existence of laryngeal tuberculosis and the changing patterns of the disease (at least in the developed countries).

The expression of cyclin D1 gene was investigated in 74 laryngeal squamous cell carcinomas (LSCCs) in order to determine its clinical and prognostic value. Overexpression of cyclin Dl was detected immunohistochemically using DCS6 monoclonal antibody on formalin-fixed, paraffin-embedded tissue sections. Cyclin D1 expression was detected in 22 of the 74 cases investigated (30 per cent), thirteen of which presented nodal metastases (59 per cent); of the patients without any detectable cyclin D1 protein expression, six presented nodal metastases (12 per cent). Cyclin D1 protein expression was found in five per cent of the specimens of normal mucosa, eight per cent of thosewith low-grade dysplasia and 20 per cent of those with high-grade dysplasia. A statistically significant association was found between cyclin D1 expression and the supraglottic site (p<0.05), tumour extension (p<0.001), the presence of lymph node metastases (p<0.001), and advanced clinical stage (p<0.001). Cyclin D2 expression analysis is an important tool in the selection of LSCC patients with an aggressive clinical course.

The endoscopic approach is a simple and cost-effective option in the treatment of hypopharyngeal diverticula. Whereas almost a third of all endoscopic myotomies performed by UK otolaryngologists are carried out with the stapling technique, CO2 laser diverticulotomy has not been given as much consideration (Koay et al., in press).

We report on the first British series of 15 patients treated between 1985 and 1993 with microscopic laser diverticulotomy. The follow-up period was four to 11 years. Complications occurred in three patients, two patients required a repeat myotomy and 11 patients have been satisfied with their swallow since the operation.

Our results are similar to those of larger studies. The laser technique is more established than the stapling gun myotomy and it has the advantage of superior visualization. It may also be used in small pouches which do not admit the insertion of a stapling gun.

A seven-day course of cephazolin and metronidazole chemoprophylaxis for clean-contaminated head and neck oncological procedures is compared to results with previously published antibiotic regimens. Aetiological factors associated with increased rates of wound complications are analyzed. Retrospective analysis of procedures over asix-year period was performed. The overall wound complication rate was 28.1 per cent, comparing favourably with previously published results. A major fistula was the most common complication with a rate of 9.2 per cent. Factors statistically associated with increased rates of wound complications included: radical neck dissection, extended surgical procedures requiring flap reconstruction, previous tracheotomy, and race. This is the largest single institutional study to show thata seven-day course of cephazolin and metronidazole is an effective chemoprophylactic regimen in head and neck surgery.

The endoscopic approach to the fronto-ethmoidal recess (FER) in the treatment of chronic frontal sinus disease is now widely accepted. The Lothrop procedure was first described in 1914, but was largely replaced with more invasive open frontal sinus proceduresuntil the advent of the rigid Hopkins' rod, since when it has enjoyed enewed popularity.

We describe a modification of this technique which allows both transnasal endoscopic and external direct visualization of the FER and frontal sinus and a direct approach to the anterior buttress (or “nasofrontal beak”) which allows its quick and simple removal.

Haemangiomas of the maxillary sinus are very rare. In this paper we present one case with an inaccurate preoperative diagnosis which was treated by entire excision of the tumour. One year aftersurgery there is no evidence of recurrence. The literature on the topic is reviewed.

A case of a large dentigerous cyst containing a canine tooth in the maxillary antrum is presented. This case is of interest due because of its extensiveness and thepresence of a canine tooth in the roof of the maxillary sinus. In addition, this caused aright-sided epiphora. Enucleation of the cyst containing the ectopic tooth was made.

Sphenoid sinus mucocoeles can stimulate a variety of pathological conditions and patients can present to a range of specialists. Because of the relative rarity of sphenoid sinus mucocoeles, diagnosis is often delayed and these lesions can progressively expand and cause direct mechanical compression on adjacent structures. We present three cases which presented with an abducens nerve palsy. Early surgical intervention is advocated and these patient's symptoms resolved following surgery. Although several conditions can present with an abducens nerve palsy, it is important to consider a sphenoid sinus mucocoele in the differential diagnosis.

Thyroid carcinoma metastatic to the paranasal sinuses is extremely rare, with only 11 cases reported in the English and European literature. We report a case of metastatic follicular thyroid carcinoma to the clivus with extension into the sphenoid and posterior ethmoid sinuses. Pathological diagnosis was obtained using an intranasal endoscopic biopsy. As with our patient, metastatic thyroid carcinoma may present with symptoms related to distant metastases rather than the primary lesion. Distant metastases in differentiated thyroid carcinoma portends a poor prognosis. Our case of metastatic thyroid carcinoma to the paranasal sinuses is summarized in the context of the 11 additional cases, and treatment options are discussed.

Impaction of a foreign body in the larynx is a serious event. While inhaledforeign bodies may occasionally impact in the larynx especially in children, a laryngeal foreign body as a complication of percutaneous tracheostomy has not been reported in the literature. We describe the case of a fragment of a Seldinger wire retained in the larynxfor two years following a percutaneous tracheostomy and review the literature on the complications of this procedure.

A case of laryngeal squamous cell carcinoma recurrence presenting as multiple cutaneous metastases is presented. Such metastases are rare and are associated with a poor prognosis. Treatment is usually aimed at providing pain relief in these patients with a limited life expectancy.

The relative rarity of pharyngeal lipomas and paucity of clinical manifestations in the early stages of tumour growth conspire to task the diagnostic acumen of the clinician. A high index of suspicion and meticulous examination are essential in order to arrive at the diagnosis, which may be achieved pre-operatively by computerized axial tomography, revealing a mass lesion with a characteristic low attenuation value. A case of pharyngeal chondrolipoma in a 25-year-old male is reported. It is suggested that this conceptually intriguing and rarely encountered lesion can be explained on the basis of neoplastic transformation of the second to fourth pharyngeal cleft mesenchymal rests displaying both adipose and cartilaginous differentiation. Alternatively, the cartilage could represent vestigial remnants of non-neoplastic pharyngeal cleft tissue entrapped within a primarily lipomatous neoplasm. Slow growth may occur over a period of several years, prior to overt clinical manifestation.

Successful communication following laryngectomy usually involves an electrolarynx or oesophageal speech. Only within the past decade has tracheoesophageal puncture been advocated for alaryngeal speech and evolved into the procedure of choice. Successful production of speech after total laryngectomy using tracheoesophageal speech may be impaired secondary to anatomical and functional difficulties. The primary limitation of tracheoesophageal speech is pharyngoesophageal spasm occurring in the upper oesophageal sphincter impeding airflow through this segment. Our report presents four patients who underwent a pharyngeal myotomy with the potassium-titanyl-phosphate (KTP) laser. Post-operatively, each patient was able to communicate with functional alaryngeal speech. A transmucosal pharyngeal myotomy may represent an alternative for patients with speech failure after tracheoesophageal puncture.

Two cases of asymptomatic posterior tracheal wall diverticula, one single and one multiple, found unexpectedly at laryngectomy are described. The embryonal development and pathogenesis of tracheal abnormalities are discussed, and possible clinical implications speculated upon.