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A cross-sectional randomised single blind study was conducted to assess how concentrations of chromogen (vital stain) and the characteristics of the assessors affect the assessment of contact rhinoscopy. Twenty-eight patients who had undergone external radiotherapy for nasopharyngeal carcinoma were assessed by contact rhinoscopy using 0.5 per cent and 1 per cent methylene blue stain on opposite sides of the nasopharynx. Three independent observers assessed the visual clarity of the 45 contact endoscopic images showing squamous metaplasia according to a visual analogue scale. The intraclass correlation coefficients were 0.916 to 0.957 and 0.839 to 0.964 for intra-observer reliability of assessors in the groups of 0.5 per cent and 1 per cent stains, respectively. The intraclass correlation coefficients for inter-observer reliability of assessors were 0.884 and 0.885 in the groups of 0.5 per cent and 1 per cent stains, respectively. The mean scores of clarity of the cellular details were statistically higher in the group of 1 per cent stain among all assessors. These results showed that the assessment of squamous metaplasia by contact endoscopy is highly reliable irrespective of the clinical experience and knowledge of histopathology of the assessors. One per cent methylene blue should be the vital stain of choice in contact endoscopy.

Video sleep nasendoscopy is a valuable technique for the study of upper airway dynamics in obstructive sleep apnea syndrome. The authors' 10-year experience with its use in Hong Kong has allowed technique refinement for safety and optimal evaluation. Its use in the evaluation of patients who snore, patients with obstructive sleep apnea syndrome, and continuous positive airway pressure titration is presented.

Objectives: To evaluate the potential use of contact endoscopy for the diagnosis of nasopharyngeal carcinoma (NPC)., Study Design: Prospective study to examine the nasopharynx of 30 patients with nasopharyngeal carcinoma and 18 subjects with normal nasopharynx in a clinic setting using contact rhinoscopes (Karl Storz, Tuttlingen, Germany, 7215 AA, 00 and 7215 BA, 300; 23 cm long; 4 mm in diameter)., Methods: The superficial cells of the normal nasopharynx and the nasopharyngeal tumors were stained with 1% methylene blue and examined with contact rhinoscopes at high magnifications (x 60 and x 150). The areas under examination were then biopsied. The contact endoscopic images were compared with the corresponding hematoxylin and eosin-stained histologic sections of the biopsied tissues., Results: Sixty-six procedures were performed in 48 patients. The images of normal pseudostratified ciliated epithelium and squamous epithelium were readily recognized by contact endoscopy in all subjects with normal nasopharynx (10 men and 8 women; mean age, 51.9 y). Twenty-six of 30 patients with NPC (86.6%; 18 men and 8 women; mean age, 50.6 y) were successfully examined by contact endoscopy under local anesthesia. In these 26 patients, two patterns of malignant cells were identified with contact endoscopy. The patterns of contact endoscopic images corresponded well with the histologic findings., Conclusion: Contact endoscopy is an accurate and reliable office-based procedure, which allows for in-vivo diagnosis of nasopharyngeal carcinoma.

The management of patients with posterior epistaxis remains a challenging problem for the ENT surgeon. In most units, failure of conservative management results in more invasive techniques, involving either major artery ligation or percutaneous embolization of the internal maxillary artery. However, there are complications in more than 25% of patients undergoing these techniques. Endoscopic ligation of the sphenopalatine artery (ELSPA) is emerging as a minimally invasive alternative. We report our experience of ELSPA in 13 patients with a mean follow-up of 13 months. Epistaxis was controlled in 92% and to date no complications have been associated with the procedure. We conclude that ELSPA is a treatment option that is easy to perform and is safe and effective for patients with refractory posterior epistaxis.

Objectives: To determine objective data to improve the methods of identification of the anterior ethmoidal artery during endoscopic dissection., Study Design: Cadaveric dissection of adult human heads., Methods: A 0 degrees, 4-mm rigid endoscope was used to guide uncinectomy and frontoethmoidectomy. The location of the anterior ethmoidal artery was first determined visually and then confirmed by passing a needle through the anterior ethmoidal foramen from the orbit into the nose in all cases. The distances were endoscopically measured using a simple ruler between two nasal landmarks and the anterior ethmoidal artery., Results: Fifty-six nasal fossae in 28 cadavers were dissected endoscopically. The median distance between the artery and the "axilla" formed by the anterior attachment of the middle turbinate to the lateral nasal wall was 20 mm (range, 17-25 mm), irrespective of the side. The measurement differed by less than 2 mm between the sides in the same individual. The median distance between the artery and the "axilla" formed by the medial and lateral crura of the lower lateral cartilage (superomedial edge of the nostril) was 62 mm (range, 55-75 mm) for both sides. The artery was found to be in direct alignment with the two "axillae" formed by the middle turbinate and the nostril edge., Conclusions: The distance between the ethmoidal artery and the axilla of the middle turbinate showed the least intraindividual and interindividual variations. The tip of the endoscope (or the ruler) points directly at the anterior ethmoidal artery in the fovea ethmoidalis when its edge is aligned with the two nasal landmarks. These simple guidelines can aid the identification of the artery in endoscopic frontoethmoidectomy.

Objective: Traditional endoscopic dacryocystorhinostomy (DCR) involves creation of a lacrimal sac side hole that may close down in the presence of a partially patent lower lacrimal drainage system. Endoscopic terminal DCR is a modified DCR procedure designed to prevent this problem., Methods: From September 1996 to June 1999, 16 patients (17 sides) had endoscopic terminal DCR that involved resection of the lacrimal sac-duct junction to achieve total separation of the lacrimal sac from the nasolarcrimal duct and creation of a terminal DCR opening., Results: Ten of the 17 DCRs were primary and 7 were revisions. The follow-up ranged from 3 to 36 months. There were two failures. One failure was due to canalicular obstruction and the other was due to prolapse of orbital fat hindering proper fashioning of the mucosal flap. The overall success rate was 88%., Conclusions: Instead of creating a side hole in the lacrimal sac as proposed by most endoscopic DCR studies, we advocate total diversion of tear flow by performing a terminal DCR opening that would further improve the success rate of endoscopic DCR, particularly in cases of idiopathic and partial obstruction.

The results of a retrospective study of 22 patients with inverted papillomas resected by the endoscopic approach are presented with a follow-up of 33 to 96 months. Twenty-one patients had unilateral disease and one patient had bilateral involvement. None of the patients had orbital or cranial extension. One patient had synchronous carcinoma in situ. Eight patients had undergone previous surgical procedures. Following endoscopic surgery, six patients had residual disease requiring further revisions. Three of these six patients eventually required excision via limited external approaches. No patient required lateral rhinotomy or mid-facial degloving procedures. No complication occurred in any of the patients. The advantages of endoscopic surgery include precise determination of tumour extent, preservation of normal mucosa and bony structures and avoidance of external scars. Close endoscopic follow-up is mandatory to ensure early recognition and treatment of recurrent disease. Although the endoscopic approach is gaining popularity for the treatment of inverted papilloma, indiscriminate application may result in a high recurrence rate. The endoscopic approach should be performed by experienced surgeons and restricted to carefully selected patients with nasal, ethmoidal and limited maxillary disease. More extensive disease should be managed by radical external approaches or by combining endoscopic with limited external approaches.

A prospective study of all foreign body complaints presenting through our Accident and Emergency Department was conducted in a population where the condition is endemic. All patients were managed by otolaryngologists. Six hundred and eight patients were attended to yielding 179 foreign bodies. Making use of modern equipment and a practical approach, the requirement for examination under general anesthesia was 6.3 per cent. In this series there was a complication rate of 0.5 per cent.

Plasma adrenaline and noradrenaline concentrations were measured in 10 consecutive patients during functional endoscopic sinus surgery (FESS). Surgery was preceded by nasal packing with 5 ml 2% cocaine solution, followed by infiltration with 1:80,000 adrenaline and 2% lignocaine. All patients showed a marked rise in plasma adrenaline concentration within 4 min of commencing infiltration, which was not related to the patient's sex, age, weight, the total amount injected, nor the amount injected into the nose. Surgeons should be aware of this marked, but unpredictable, systemic absorption of locally infiltrated vasoconstrictors. Pulse and ECG monitoring should be considered mandatory for such procedures, even when surgery is performed under local anaesthesia.

The use of flexible nasopharyngoscopy with biopsy forceps for the removal of fish bones found in the oropharynx and hypopharynx is described. One hundred and sixty-eight patients with ingested fish bones in the upper aero-digestive tract were studied over a 12-month period. Of these, 73 per cent were removed per-orally, or by indirect laryngoscopy. Fifteen per cent were removed using the fibreoptic nasopharyngoscope. Twelve per cent required a general anaesthetic and rigid oesophagoscopy for removal of fish bones at or below the level of the cricopharyngeus muscle. The technique has proven to be quick, well tolerated and low in morbidity. It is invaluable in patients in whom indirect laryngoscopy is unsatisfactory.