This is an anthropological study of the development of the mastoid process in the four ethnic groups of Pakistani races: Turko-Iranian, Indo-Aryan, Scytho-Dravidian, and Aryo-Dravidian.

Cephalometric studies have established that the majority of Pakistanis are brachio to ultrabrachiocephalic (Cephalic Index 82–x). Radiological evaluation of normal mastoids and their planimetric measurements show that the mastoid process is smaller (Av: 10.24 sq.cm. ± 0.8) than the Caucasian Western races (Av: 12–15 sq.cm.).

Neither combined approach tympanoplasty, nor mastoid obliteration technique may be required, nor technically possible in a small mastoid. Natural epithelization of a small ‘peanut size’ mastoidectomy cavity does not justify these procedures. A modified radical mastoidectomy and tympanoplasty reconstruction provides a satisfactory result in chronic discharging ears.

Audiological and vestibular tests were administered conjointly in a neurological or general ORL clinic to exclude cerebellopontine angle (CPA) tumours. This study aimed to assess the efficiency of various tests in achieving that exclusion with the minimum of unnecessary investigations. All patients received the full battery of auditory brainstem responses, acoustic reflex thresholds and decay, alternate binaural loudness balance and ENG and caloric testing. All patients who did not have normal auditory brainstem responses proceeded to high resolution CT scanning. One hundred and fifteen patients were investigated and four acoustic neuromas were diagnosed. The efficiency of these tests in a general ORL clinic is very much poorer than often suggested, due largely to the number of occasions on which the tests cannot be done, and to the very small proportion of the test population who have CPA tumours.

Otitis media with effusion was the presenting symptom in 23 per cent of patients suffering from chronic sinusitis. The inter-relationship between chronic sinusitis and otitis media with effusion was studied in 29 patients. Endoscopic evaluation of intranasal structures including sinus ostia and Eustachian tube orifices was carried out. We further suggest that otitis with media with effusion is not a separate entity but a presentation of sinus disease, predominantly of the ethmoid system. Patients with otitis media with effusion should be evaluated for sinusitis and vice versa. The value of careful nasendoscopy is demonstrated.

Practice in the Temporal Bone laboratory is a fundamental part of Otological training. Performing a stapedectomy on a normal temporal bone is handicapped by the mobility of the footplate. We describe a simple method of producing stapes footplate fixation in a normal temporal bone so that the operative conditions found in otosclerosis are more closely simulated.

Contralateral Auditory Brainstem Response (ABR) findings in a series of 79 patients with unilateral acoustic neuroma are presented. Sixty-four patients (81 per cent) had a normal contralateral ABR, thirteen (16.4 per cent) had latency abnormalities contralaterally and in two patients (206 per cent) no consistent responses could be recorded despite good hearing. Abnormalities in the contralateral ABR were analysed and five patients had abnormal III-V interwave intervals, in seven patients the I-III intervals were abnormal and in one patient, only the fifth wave was present and of abnormal latency. The tumour size was assessed by computed axial tomography (CT) and the relationship between tumour size and contralateral ABR findings established. Large tumours (>2.5 cm.) were associated with contralateral ABR abnormalities in 25.6 per cent of the patients, medium tumours (1.0-2.5 cm.) with ABR abnormalities in 14 per cent and there were no abnormalities in the small group (intracanalicular). The implications for interpretation of ABR recordings contralateral to an acoustic neuroma are discussed in relation to brainstem compression and its effect on the wave generator sites.

Acoustic neuromas may be resected either by a suboccipital craniectomy or translabyrinthine approach; the latter gives good access without unduly traumatising the brainstem, but can lead to a higher incidence of cerebrospinal fluid (CSF) leaks. The surgical management of these leaks can be difficult; we describe a transmastoid extracranial technique using pedicled sternomastoid muscle that has produced complete resolution of the leak in all cases managed in this way.

To determine whether translabyrinthine acoustic surgery may result in a drill-generated, bone-conducted sensorineural hearing impairment in the contralateral ear, the audiograms from 50 consecutive patients with acoustic neuromas undergoing the translabyrinthine approach were compared before and three months after surgery. No case of sensorineural hearing impairment could be demonstrated post-operatively.

An analysis of a series of 100 patients aged 60 years or over, referred by their General Practitioner to the Department of Otolaryngology, Addenbrooke's Hospital, specifically for the provision of a hearing aid, is presented.

Forty-six per cent of patients failed to satisfy the criteria suggested by the Technicians, Therapists and Scientists in Audiology as a screening for treatable pathology.

This study has shown that the existing referral pattern of general practitioner to consultant otolaryngologist for the provision of a hearing aid reflects the highest quality of care for the patient.

Direct referral or open access of patients for hearing aid fitting may risk failure to diagnose early and treatable conditions.

Fifty insulin-dependent diabetics and 50 non-diabetics without a history of nasal disease have been studied for nasal problems including mucociliary function complicated by diabetes mellitus. For the diabetics, the mean value of nasal mucociliary clearance was considerably decreased and this was more often associated with dry noses but increased pH-values, both of which were higher than those for non-diabetics (p<0.05). As suggested in earlier literature, more aggressive nasal moistening therapy must be recommended for those patients presenting with these conditions in the light of systemic diabetic abnormalities.

Scleroma is a chronic progressive granulomatous disease predominantly affecting the mucous membrane of the upper respiratory tract, endemic in temperate and tropical zone countries including Egypt. Many patients in early stages respond to medical treatment while others do not. In these patients an antileprotic agent Clofazimin (Lamprene®) was tried in 76 patients and the therapeutic results are very promising, especially for the early stages of the disease.

Although the association of maxillary sinusitis with nasal polyps is widely recognized little has been written on its precise incidence and degree. Antroscopy of 70 antra with ipsilateral polyps showed a high incidence of mucosal abnormalities, retained secretions and ostial narrowing. Comparison of these findings with pre-operative X-rays showed the latter were unreliable in detecting retained antral fluid. It is concluded that in nasal polyposis the antra warrant careful assessment and that antroscopy is a highly satisfactory method for this purpose.

Laryngeal tuberculosis is one of the rarer forms of extrapulmonary tuberculosis. A retrospective analysis of 26 patients seen in the last nine years in our hospital was conducted to illustrate the various modes of clinical presentation. Of the 26 patients, twenty were male and six female. The average age of presentation was 47 years with an age range of 15 months to 71 years. Hoarseness (92.3 per cent) was the commonest symptom. The laryngoscopic appearances often simulated malignancy. Most patients (69.2 per cent) outnumbered ulcerative ones (38.5 per cent). Laryngeal oedema was infrequent (7.7 per cent). Diagnosis was based on a laryngeal biopsy in 18 patients and on evidence of associated pulmonary tuberculosis and response to anti-tuberculous therapy in eight. Chest X-rays showed apical cavitation and infiltration as the commonest findings. Three patients had miliary tuberculosis and one had no pulmonary lesion. Diabetes mellitus was present in seven (26.9 per cent) patients. Four illustrative cases are described. The problems in diagnosis and management of laryngeal tuberculosis are discussed.

A 64-year-old man had complete excision of an acoustic schwannoma via the translabyrinthine route and the mastoid cavity was packed with fat. Post-operatively there were two episodes of aseptic meningitis and CT scanning demon strated migration of fat into the basal subarachnoid CSF spaces. This unusual complication should be recognized and differentiated from both true infective meningitis and aseptic meningitis from other causes.

A young girl with objective tinnitus is presented. Using tympanic membrane displacement, the probable origin of the tinnitus has been demonstrated. The patient has responded well to treatment with a tinnitus masker.

Angiosarcoma (malignant haemangioendothelioma) of the nasal cavity and paranasal sinuses is extremely rare. Only a few cases have been reported in literature. A case of angiosarcoma of the nasal cavity and maxillary antrum in a 38-year-old male patient is reported. He was treated with pre-operative external radiotherapy followed by wide excision of the tumour. He currently remains free of the disease 10 months after diagnosis (and seven months after completing therapy).

We present a case of diabetes insipidus in a young man caused by Langerhan's cell histiocytosis of the sphenoid sinus with involvement of the pituitary gland. Diagnosis and management of this rare condition is discussed, along with a brief view of the literature.

The youngest patient reported to date with granular cell tumour of the larynx is presented, with a review of other reported cases in childhood. The basis of histological diagnosis of granular cell tumour is described.