Patients want to know more about their condition and its proposed treatment. Gaining patients' confidence before treatment reduces the chances of their seeking legal redress for an unexpected outcome. As part of a prospective study of informed consent for surgery we have assessed the attitudes of patients towards informed consent when different types of consent interview are used.

We found that most patients are happy to do as their doctor advises but think the informal consent interview is important because it gives them information; they also want to know about most, but not all, complications of the procedure. One quarter worried about the anaesthetic, about one eighth worried about ‘not waking up’ nd similar proportions worried about complications and other things such as pain and nausea. Most patients think that the consent form is a legal document.

In addition patients who had an informal interview felt obliged to sign the consent form and thought it had medicolegal implications. In contrast those who had a structured interview felt less obliged to sign the consent form and more involved in the decision to operate.

Amplitude of the Nl component of the cortical response was used to objectively determine threshold of hearing at 1 kHz and 4 kHz in a series of consecutively referred medicolegal cases with alleged occupational noise induced hearing loss and a control group of patients with Ménière's disease who were not seeking compensation for their hearing loss. The cortical response thresholds were compared with the subjective pure tone audiometric (PTA) thresholds at the same frequencies. The cortical and PTA thresholds were ‘;within 10 dB’; for 84 and 92 per cent of the cases of noise induced hearing loss (NIHL) and Ménière's disease respectively, confirming the validity of CERA as a means of denning accurately the frequency specific thresholds and the audiometric configuration. Of the remaining 16 per cent of NIHL, 13 per cent exaggerated their PTA thresholds at 1 kHz and 10 per cent at 4 kHz whilst the error in cortical threshold estimation was beyond the 10 dB level for three and six per cent of cases at those frequencies respectively. The median exaggeration of threshold was 25 dB. For eight per cent of the Ménière's patients, thresholds exceeded 10 dB at both 1 and 4 kHz, four per cent of whom exaggerated their PTA thresholds and four per cent had a test error greater than 10 dB. A similar percentage (four per cent) of both groups revealed a cortical test error greater than 10 dB whereas three times as many cases of noise induced hearing loss (13 per cent) revealed exaggeration of their subjective audiometric thresholds compared with the Ménière's group (four per cent).

The value of latency criteria in the assessment of cortical threshold was established. The latency of Nl close to threshold was invariably greater than 150 ms and at 30 dB above threshold, irrespective of absolute levels, it was within 10 ms of 100 ms, thereby providing another criterion for the improved measurement of threshold.

Speech audiometry was performed on 15 children with secretory otitis media pre-and post-operatively and the findings compared with the pre-and post-operative pure tone audiograms. The results showed that in 30 per cent of cases pre-operatively the speech audiogram suggested a significantly worse hearing ability than that suggested by the pure tone audiogram (PTA). Where a PTA gives a borderline threshold disproportionate parental concern should be taken seriously as the hearing ability may well be worse than the PTA suggests.

Sensorineural hearing loss (SNHL) has been a well-documented complication of sickle cell disease in the literature from West Africa, West Indies, United States of America and the Middle East. We present a study of 52 patients with homozygous sickle cell disease and 36 control patients with haemoglobin genotype AA, matched for age and sex. Seven patients with sickle cell disease (13.5 per cent) were found to have sensorineural hearing loss i.e.>20 dB at two or more frequencies, while all the patients in the control group had normal hearing (p<0.05).

Our study shows the incidence of SNHL in the UK to be similar to that reported in the US A and much lower than that found in malaria endemic areas of the tropics.

We highlight the factors which we consider responsible for these differences and suggest that the crucial period in the development of SNHL in sickle cell disease may be intra-uterine or during the first few years of life. All sickle cell patients should be encouraged to have regular hearing assessment.

The results of stapedectomy were compared between 162 otosclerotic ears operated on using the posterior crus technique and 182 otosclerotic ears undergoing Teflon piston stapedectomy. The large fenestra technique with fascia seal to the oval window was used in all cases. Mean follow-up period was 9.6 years. Neither short- nor long-term hearing results showed any significant differences between the two surgical technique groups. Complications of surgery were more common in patients undergoing Teflon piston stapedectomy. On the other hand, a re-operation for recurring conductive deafness was performed significantly more often in patients undergoing posterior crus stapedectomy.

This paper reports on 16 cases of primary malignant melanoma of the external ear and the patients were followed up for two to 116 months. Fourteen patients had surgical excision with wide margins as initial treatment, whilst two had an amputation performed. Eleven patients had no recurrences, two died of other diseases, and four died of malignant melanoma. The five patients who developed recurrences received further surgery and two also radiotherapy.

Seven of the cases were histologically of the nodular type, six were superficial spreading, two were in situ melanoma, and one was a lentigo maligna. The thickness ranged from 0.15 to 11.5 mm. Classification according to Clark et al. (1969) revaled that as many as nine cases were Clark level IV or more. Immunostaining with PCNA yielded strong positivity in all cases, however, statistical analysis did not reveal any differences that could be correlated to the prognosis. Estimation of the vascularization at the base of the tumours by means of immunostaining with CD31 did not reveal any significant differences either.

We concluded that in our material the thickness of the tumour is of greater prognostic value than the estimation of proliferation by PCNA and vascularization by CD31. The value of PCNA and CD31 as possible prognostic parameters needs to be evaluated in a larger series. It is emphasized that malignant melanoma of the external ear is a highly malignant tumour, and that four of our 16 patients died of their disease, three of them within a year after diagnosis. Malignant melanoma of the external ear is readily inspected and thereby an early diagnosis should be possible.

The standard recommended treatment for lateral sinus thrombosis is intravenous antibiotics. For those that fail, some authors recommend anticoagulant therapy, others internal jugular vein ligation. Despite these recommendations, there is still a significant mortality in all reported large series and the main reason this is that the cause of the failure has not been found or investigated.

Over a six-year-period, from January 1985 to December 1990,36 patients were admitted with lateral sinus thrombosis. The initial treatment consisted of intravenous antibiotics and surgery. The surgery included cortical mastoidectomy for non-cholesteatomatous ears and modified radical mastoidectomy for cholesteatomatous ears and drainage of the intracranial collection of pus in patients with subdural empyema and brain abscess.

There were nine failures (25 per cent) with this treatment regimen. Blood cultures and pus swab of the ears were taken from these patients. The blood cultures were positive in four patients and the organisms isolated included (3-haemolytic Streptococcus sp. in two, Proteus mirabilis and Streptococcuspneumoniae in one each). From the ear swab mixed cultures were found in eight and a single organism in one.

Gram-negative organisms were isolated in nine (100 per cent), Proteus mirabilis in eight (89 per cent) and Enterobacter sp. in two. Both these organisms were resistant to ampicillin and penicillin but were sensitive to amikacin.

Amikacin was then added to the treatment regimen and a dramatic response with a fall in the temperature, and improvement in the patients' general condition was noted within 24 hours, in all patients. There was not a single death, despite the fact that 42 per cent of the patients had other associated intracranial complications. The conclusion is that the treatment of choice for patients refractory to the conventional antibiotic therapy and surgery is amikacin therapy and not internal jugular vein ligation, or anticoagulant therapy.

Clinical, histopathological and ultrastmctural studies in three cases of rhinosporidiosis show complete remission of infection within one year of therapy with dapsone. Light and electron microscope studies confirmed arrest of the maturation of the spores and accentuated granulomatous response with fibrosis following dapsone therapy.

We reviewed the records of 66 consecutive patients with previously untreated supraglottic laryngeal carcinoma who underwent a supraglottic laryngectomy in our department between 1970 and 1989. There were 23 T1, 30 T2 and 13 T3 cases. Eight patients had neck metastases and underwent neck dissection also. Twentyfour (36 per cent) patients received post–operative radiotherapy. Two–year and five–year survival rates were 88.9 per cent and 82.2 per cent respectively. When the survival rates of the patients with T1, T2 and T3 lesions were calculated separately and compared with each other the differences were not statistically significant. Recurrences, post-operative complications, time to progression and indications for supraglottic laryngectomy are discussed.

Successful restoration of phonation, as well as swallowing in laryngopharyngeal surgery for patients with advanced pyriform carcinoma still remains a major challenge. In a five-year period, near-total laryngectomy perations were performed on 21 patients with laryngopharyngeal carcinoma. This report particularly emphasizes the value of near-total laryngopharyngectomy with a pectoralis major myocutaneous flap for four extensive hypopharyngeal carcinoma cases (three of which were of pyriform origin). All four patients regained intelligible shunt speech and smooth swallowing. The follow-up period ranged from 19 to 44 months. They ave had no recurrence of disease since surgery.

The authors suggest that an advanced pyriform carcinoma case, with a normal contralateral hemilarynx and pyriform sinus, is a candidate for a near-total excision of the laryngopharynx.

This prospective study compares the results of pre-operative clinical examination and simple ultrasound examination of the neck in 18 patients with proven head and neck primary tumours and palpable cervical lymphadenopathy, who then underwent 21 radical neck dissections. Neck palpation and ultrasound examination were compared with histological examination. Ultrasound did not add significantly to the information obtainable by simple neck palpation in this group of patients.

A simple device is described which enables the patient with a tracheo–oesphageal valve and a large tracheostome to easily occlude the stoma, avoiding the need for stomaplasty.

A new procedure for aspiration which closes the larynx at the level of the false cords is reported. This method is not harmful to the vocal folds and maintains arytenoid movement, thus preserving phonatory function. With the advance of the operative technique for aspiration and swallowing rehabilitation, patients who have recovered from aspiration can be helped. Our procedure can be recommended for such cases.

To the best of our knowledge, this is the first report of external ear canal schwannoma in the English literature. Several detailed clinical and pathological features were demonstrated. We suggest that if a tender, encapsulated mass is found in the external ear canal, the diagnosis of schwannoma should be taken into consideration.

Presented herein is a case report of sudden sensorineural hearing loss in the setting of haemoglobin SC disease. The relationship of the two is rare; the authors have found that this is only the second report in the literature. In this instance, partial exchange transfusions were performed in an attempt to decrease viscosity and improve blood flow. Thereafter, hearing stabilized and then slowly improved. The evidence for the beneficial role of these transfusions in this setting is, at best, circumstantial, but it is theoretically sound and worthy of further study.

Leishmaniasis is an uncommon condition in Western Europe, except around the Mediterranean coast. However, it may occasionally be seen in the United Kingdom, in patients who acquired the infection in foreign lands. An unusual case of localized cutaneous leishmaniasis recidiva affecting the nose after septal surgery is presented.

Aspergillus sp. are the most common contaminants of the paranasal sinuses with the maxillary sinus as the site most frequently involved. Fungal sphenoid sinusitis can be a life-threatening situation, thus aggressive therapy is indicated. The treatment is primarily surgical. The transnasal endoscopic technique offers excellent visualization and an atraumatic approach to the sphenoid sinus. Surgical exteriorization and aeration of the involved sinus, without using antifungal chemotherapeutic agents is curative. A rare case of sphenoid sinus aspergiUosis which was successfully treated by transnasal endoscopic sphenoidotomy is reported.

Acute visual loss may occur in association with sinusitis either as a complication of orbital cellulitis or, less frequently, as a part of the orbital apex syndrome. We describe two cases of temporary monocular visual loss caused by sinusitis. In one case the visual loss was due to orbital cellulitis; while in the other patient it was due to incompletely developed orbital apex syndrome. This later mode of presentation is called ‘partial orbital apex syndrome’ by some authors and ‘posterior orbital cellulitis’ by others.

The relationship between sinusitis and blindness is discussed.

The melanotic neuro-ectodermal tumour of infancy is an uncommon benign tumour of neural crest origin occurring in infants with a predilection for the anterior maxilla. This lesion shows a good response to conservative surgical excision with few recurrences but it should be followed up for long periods of time because of the rare malignant change possible in the tumour.