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Background: Tumor-associated tissue eosinophilia (TATE) has been associated with an improved prognosis in a variety of neoplasms., Methods: Diagnostic biopsy specimens from 96 patients with nasopharyngeal carcinoma (NPC) were reviewed for the presence of TATE by an observer blinded to the patients' clinical histories. Comparisons between patients with and without TATE with respect to the probabilities of local recurrence, distant metastasis, and survival were performed using the log rank test on Kaplan-Meier product-limit estimates and the Cox proportional hazards model., Results: The prevalence of TATE in these patients was 32%, and was not significantly associated with local recurrence, distant metastasis, or survival., Conclusions: These results are discordant with those of studies in other tumor models, although comparison is hampered by varying definitions of TATE. The differing results may be due to variations in the degree of activation of the eosinophils present in TATE in different tumors.

In order to study the features of sinonasal polyposis (SNP) on CT, 100 consecutive coronal sinus CT examinations done for chronic inflammatory sinonasal disease were reviewed. The CT findings of the 27 fully documented SNPs were analyzed. All our SNPs were bilateral. There was a strong tendency for extensive involvement. Nasal polyps were seen in 22 of 27(81%); bony trabecular deossification in 23 of 27 (85%); widening of infundibulum in 26 of 27 (96%). We discovered a new sign "truncation of the bony middle turbinate", where the bulbous part of bony middle turbinate was missing, in 15 of 26 (58%) of SNP patients without a previous history of middle turbinectomy, 12 of 15(80%) were bilateral. The one SNP patient (1 of 27) with previous middle turbinectomy was not regarded to be real truncation. Truncation of the bony middle turbinate is a characteristic and easily recognizable ancillary sign, and is not seen in other patterns of sinusitis. Together with other features on coronal sinus CT, this adds diagnostic confidence in diagnosing sinonasal polyposis.

Photodynamic therapy (PDT) is a promising new modality in the treatment of cancer. In Hong Kong where nasopharyngeal carcinoma (NPC) is endemic, radiotherapy has been the primary treatment of choice. For recurrent disease after radiotherapy, there is no effective treatment. This latter report summarizes our initial experience in using PDT for these patients. Twelve patients (three females and nine males) with ages ranging from 33 to 65 years were treated with an infusion of hematoporphyrin derivative (5 mg/kg) 48-72 h before exposure to 200 J/cm2 light (wavelength, 630 nm) delivered from a gold vapor laser. All 12 patients showed a dramatic response as judged by computed tomography or magnetic resonance imaging at 6 months post-PDT. Of the eight patients in whom cure was aimed for, three remained disease-free at 9-12 months after a single treatment. Three of the remaining four patients achieved useful palliation. Skin hypersensitivity occurred in two patients and was the only significant complication encountered. This experience indicates that PDT can be an encouraging palliative or definitive management for recurrent superficial NPC.

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 classical modified radical mastoidectomy offers the advantages of combining the mastoid cavity, the attic and the external canal into one cavity that remains open for inspection. However the ultimate goal to predictably produce well healed, dry and safe mastoid cavities despite receiving much attention has not been fulfilled. By employing basic surgical principles of wide access to facilitate meticulous removal of all cholesteatoma and then eliminating all raw surfaces of the bony cavity with pedicled vascularized deep temporalis fascia, the Hong Kong Flap technique achieves the highest percentage of dry, stable, disease free ears. This living fibrous tissue layer provides the optimal substrate for epithelial resurfacing while separating the mucosa and bone of the middle ear and mastoid from the surface epithelium. Excellent healing even under unfavourable circumstances is ensured by the rich blood supply to the pedicled temporalis fascia flap. Furthermore the technique obviates the need for second look procedures in more than two-thirds of cases as the cavity lining becomes transparent and simple observation is safe. The Hong Kong Flap was used to reconstruct 107 cavities between October 1988 and October 1992. 86 were performed for primary cholesteatoma removal and 21 for revision of discharging cavities. 103 (96%) healed soundly. There were 4 dry perforations. Minor complications occurred in 8 (7%) patients. 84 (78%) required n+o second exploratory operation. This is a straight forward procedure requiring no special technical skills. The concept is rational and provides the ideal management for cholesteatoma by achieving a dry, safe ear with one operation.

Critical evaluation of the outcome of surgery for cholesteatoma has favoured open cavity techniques. These methods have however been plagued by an inability to consistently produce healthy well healed cavities. The strength and stability of the normal tympanic membrane depends upon the separation of squamous epithelium from the middle ear mucosa by a fibrous tissue layer. Traditional methods of dealing with the cavity fail to reproduce a similar anatomically stable arrangement. In order to achieve the highest percentage of dry, stable disease-free ears after employing basic surgical principles of wide access to facilitate meticulous removal of all cholesteatoma, we have utilized a vascularized deep temporalis fascia flap for complete coverage of the cavity eliminating all raw areas. This fibrous layer provides the optimal substrate for epithelial resurfacing. Excellent healing even under unfavourable circumstances is ensured by the rich blood supply to the pedicled temporalis fascia flap. Considering patient preferences and cost effectiveness, the optimal treatment for cholesteatoma must be one operation, provided it achieves a dry safe ear. Based upon rational concepts, the 'Hong Kong Flap' technique of reconstructing the mastoid cavity involves a straightforward procedure requiring no special technical skill that consistently achieves this ideal.

High resolution ultrasound is a promising technique in the assessment of laryngeal carcinoma, yet few published studies have appeared concerning its use. We set out to assess if ultrasound could correctly identify the site and size of known lesions, if unsuspected extralaryngeal spread or nodal involvement could be shown and if the results could be used to influence patient management. Fourteen patients with advanced laryngeal cancer (Stage T2 or above) were prospectively evaluated by systematic ultrasound technique, with the sonologist blind to the clinical findings. The results were correlated with clinical assessment and with histopathological findings in six patients who subsequently underwent surgery. Eleven of 14 tumours were visible on ultrasound and the site and size correctly identified in each. Unsuspected extralaryngeal spread was found in four cases increasing the tumour stage to T4; spread to the pre-epiglottic space was also shown in four cases. Nodal staging was correctly raised in two cases and incorrectly in one. Patient management was significantly influenced in 8/14 cases. Ultrasound can identify the majority of laryngeal tumours of Stage T2 and above, and detect extralaryngeal spread. Small tumours may not be visible but in this preliminary study, ultrasound complemented the clinical assessment and was useful in patient management.

Using 21 microsatellite polymorphic markers spanning both p and q arms, we have performed detailed deletion mapping on chromosome 9 in 18 primary nasopharyngeal carcinomas. All 18 tumors were informative at multiple loci. Eleven of the 18 cases (61%) demonstrated allelic deletion of chromosome 9. Among these 11, 6 cases are likely to be tumors with monosomy of chromosome 9. The other 5 cases demonstrated partial deletion by showing multiple areas of allelic loss. In one of the 5 cases, a homozygous deletion region was identified which includes D9S126, D9S171, and IFNA loci at 9p21-22, situated between loci D9S161 (9p21) and D9S162 (9p21-22). The presence of a homozygous deletion strongly suggests the presence of tumor suppressor gene(s) involved in the tumorigenesis of nasopharyngeal carcinoma. The same region has been reported to include some potential tumor suppressor gene loci in other cancers. This is the first reported finding of frequent genetic loss observed on chromosome 9 in nasopharyngeal carcinomas in addition to allelic loss on chromosome 3p at specific regions. Our results suggest that tumorigenesis and progression of nasopharyngeal carcinomas, like other solid tumors, involves multiple genetic changes associated with the inactivation of tumor suppressor genes.

This study has investigated the expression of the p53 tumour suppressor gene in 41 cases of primary nasopharyngeal carcinomas (NPC) using the p53 monoclonal antibody BP53-12. Moderate p53 expression was found in 54% and strong expression in 12% of the specimens. There was no correlation between p53 expression and any of the clinicopathological parameters or survival. Surprisingly, three research groups have investigated p53 mutations in NPC and found no fresh tumour specimens to contain p53 mutations in exons 4-8 of the gene. It may be argued that as p53 overexpression has been demonstrated in 70% of the patients investigated in this study, that the mutations lie outside the 4-9 exon region. We are in the process of testing this hypothesis.

Purpose: To evaluate the operative conditions and safety of a tubeless technique of anesthesia for carbon dioxide laser surgery of the larynx., Materials and Methods: This prospective study evaluated 78 consecutive procedures in 72 adult patients undergoing carbon dioxide laser microlaryngeal surgery. Anesthesia was maintained by an intravenous infusion of Propofol (ICI Pharmaceuticals, Cheshire, UK) while the patient breathed spontaneously without endotracheal intubation., Results: The operative conditions were optimal in 76 of the 78 procedures providing a clear uninterrupted view of the larynx with no combustible material in the surgical field., Conclusions: This series shows the technique described to be safe without risk of combustion and provides an unobstructed view to the larynx.

Tuberculous tracheobronchial stricture is a rare disease entity at the present time. We report our experiences with carbon dioxide laser treatment for four patients with tuberculous strictures that were resistant to conventional management. All patients were relatively young but were debilitated by the disease. The lesions differed from other forms of benign tracheal strictures as they tended to involve the trachea and right side of the lung and were often multiple. The reasons for this are related to the organism per se and the anatomical arrangement of the tracheobronchial airway. The pathophysiology of tuberculous strictures in the tracheobronchial airway and the technique of bronchoscopic laser resection are outlined.

We present a prospective analysis of the lung function of 22 patients with unilateral vocal cord paralysis before and after Teflon injection. In the majority of patients the vocal cord paralysis was caused by an underlying malignant condition. Full spirometric and flow-volume loop studies demonstrated an increase in airway resistance after Teflon injection which was not clinically evident. The improvement in symptom score for aspiration was greater than that for dysphonia.

Foreign bodies in the nose are commonly encountered in ORL practice. Miniature button battery impaction in the nose has rarely been reported. Seven such cases have been encountered, each suffering complications directly attributable to the button battery. The complications included septal burns in five patients leading to septal perforation in one child, one case of severe nasal bleeding and one case of necrosis of the lateral nasal wall. The site of maximal damage corresponded with the negative pole of the battery in every case. The possible explanation for this and mechanisms of cellular injury are proposed. This paper underlines the potential hazards of button batteries as foreign bodies in the nose and emphasizes the need for rapid removal and long-term follow-up of these patients.

Lugol's iodine dye indicates the presence of unsuspected early oesophageal cancers during endoscopy at which such cancers fail to show the characteristic black colour change. We evaluated Lugol's iodine dye-enhanced endoscopy in 17 patients with oesophageal cancer. In a further 37 patients with head and neck cancer we examined the use of Lugol's iodine since these patients have a 29% risk of synchronous oesophageal cancer. The oesophagus was sprayed with Lugol's iodine (1.5%) during endoscopy. Any areas not turning black were biopsied. In 13 patients with oesophageal cancer discrete areas beyond the macroscopically obvious primary tumour showed no change in colour. Biopsy revealed cancer in all cases. Six synchronous cancers were found in the head and neck group, one of which was identified only by the use of Lugol's iodine. Lugol's iodine augmented the information gained about the oesophageal mucosa during endoscopy. It revealed unsuspected cancer which altered the management of patients with primary oesophageal cancer as well as those with head and neck cancer. We recommend the routine use of Lugol's iodine-enhanced endoscopy for surveillance of all 'at risk' oesophageal cases.

One hundred eleven patients who underwent esophagectomy for squamous carcinoma of the esophagus were followed up during a 42-month period. Forty-three patients who had normal swallowing in the postoperative period had recurrent dysphagia on follow-up. The causes were benign anastomotic stricture (n = 15), malignant anastomotic recurrence (n = 2), recurrent laryngeal nerve palsy (n = 22), and no known cause (n = 4). Twenty-six patients were assessed by laryngoscopy and 15 were deemed suitable for Teflon injection of the vocal cord. All but one patient had improved swallowing and phonation after the procedure. Mean survival time after Teflon injection was 5 1/2 months. A significant proportion of swallowing problems after esophagectomy are not caused by mechanical obstruction. Teflon injection of a unilateral paralyzed vocal cord provides good palliation in these patients.

A double blind trial, using lateral neck radiographs of 100 patients with proven impacted fish bones and 100 normal cases, was conducted to assess the sensitivity, specificity and positive predictive value of radiography for impacted fish bones. Values of 25.3%, 86.3% and 72.7% respectively were obtained. The results are correlated to the clinical findings and reasons for the poor performance of radiography are discussed. It is recommended that routine radiography for suspected impacted fish bones should be abandoned.

Plain radiographs, computed tomographic (CT) scans and clinical records of 100 patients with nasopharyngeal carcinoma were studied. CT scans and plain radiographs provided similar information in 46 patients. There were 54 cases in which the two techniques disagreed. In 45 cases CT demonstrated abnormalities not seen in plain radiographs and in nine cases plain radiographs demonstrated abnormalities not seen with CT scanning. Based on the total information gained from clinical examination, the imaging investigations, biopsies, and subsequent clinical course and investigations it appeared that none of the abnormalities predicted by plain radiographs alone could be substantiated. Conversely the CT abnormalities could be supported as being correct. We conclude that CT alone is the undoubted investigation of choice where this is available. Plain films provide less information, are unreliable and, where CT is available, superfluous.

The clinicopathological features of 10 adult patients with nasopharyngeal tuberculosis (TB) are presented. 9 patients had no evidence of chest or systemic disease. 7 patients presented with cervical lymphadenopathy, and only 4 had nasal symptoms. Examination of the nasopharynx showed no abnormality in 2 patients, lymphoid hyperplasia in 4 patients, and a tumour-like mass in 4 patients. These findings suggest that nasopharyngeal TB may occur more frequently as part of an isolated upper respiratory tract infection than as secondary to pulmonary infection. The nasopharynx may be a portal of entry for tubercle bacilli in patients who develop cervical lymphadenitis. Involvement of the nasopharynx by TB may be underdiagnosed because it does not produce obvious symptoms or physical signs in all cases.

Multiple symmetrical lipomatosis (Madelung's disease) is a very rare condition that is commonest in countries bordering the Mediterranean. The disease is associated with symmetrical unencapsulated fat deposits over the neck and upper trunk. We present the first reported occurrence in the Chinese. Although lesions can initially mimic a head and neck malignancy, management is essentially symptomatic, with conservative removals done as indicated clinically or for cosmesis.

Purpose: The use of a Montgomery T-tube as a palliative measure in the treatment of patients with respiratory obstruction due to cancer is described., Patients and Method: Six patients with terminal malignant disease presented with airway obstruction caused by direct infiltration of the trachea by tumor. The primary carcinoma originated in the esophagus in five cases, whereas one patient had metastatic carcinoma of the breast. In each case, the airway was initially secured using a rigid ventilating bronchoscope that was advanced past the area of tracheal obstruction. Tumor was removed from the lumen of the bronchoscope with suction and cup forceps. Anesthesia was continued through the bronchoscope while the trachea was exposed through a cervical incision and a window cut in the anterior tracheal wall. A Montgomery T-tube was inserted as the bronchoscope was withdrawn., Results: This technique allowed dramatic relief of airway obstruction in all cases. The tube relieves the obstruction by stenting the airway and permits speech in most patients. The authors stress the need for frank discussion with patients and family when considering the appropriateness for this form of palliation.

Flexible and rigid endoscopes allow good visualization of the nasopharynx using local anesthesia, and permit biopsies to be taken under direct vision. Little information is available on the accuracy of biopsies taken using local anesthesia, and general anesthesia is usually recommended for evaluation and biopsy of the nasopharynx to avoid missing small or submucosal lesions. We report the results from 260 patients biopsied using local anesthesia (188) and general anesthesia (72). All biopsies were taken using large nasal biopsy forceps under direct vision. The sensitivity of this technique in diagnosing nasopharyngeal carcinoma was 95.1% using local anesthesia and 95.6% using general anesthesia. We suggest that general anesthesia is rarely necessary for definitive biopsy of the nasopharynx. In the majority of patients, an accurate diagnosis can be obtained using large biopsy forceps under direct vision using local anesthesia.

Accepted treatment of secretory otitis media, in the presence of nasopharyngeal carcinoma treated with radiotherapy, includes the insertion of a grommet. This study analyses the incidence of otorrhoea following this treatment as compared to a control group. Results show that persistent otorrhoea occurred frequently (68%) in the study group and was refractory to antibiotic therapy. Alternative methods of management of the secretory otitis, such as a hearing aid, should be considered to avoid the complications of grommet insertion in this group of patients.

Spontaneous rupture of hepatic metastases is rare, there being only 22 cases documented in the literature. We report here the first such case owing to nasopharyngeal carcinomatous metastases. This is of interest because in South East Asia ruptured hepatocellular carcinoma is the usual cause of fatal haemoperitoneum.

Spontaneous rupture of hepatic metastases is rare, there being only 22 cases documented in the literature. We report here the first such case due to nasopharyngeal carcinomatous metastases. This is of interest because in South East Asia ruptured hepatocellular carcinoma is the usual cause of spontaneous fatal haemoperitoneum.

Nasopharyngeal carcinoma (NPC) is a common malignancy among the southern Chinese people and has a poor prognosis. The aim of this study was to describe in detail the presentation of NPC as found between 1984 and 1988 at Prince of Wales Hospital, Hong Kong. Our study confirmed that patients present with an advanced stage of malignancy; 70% were stage III to V. Eighty-two percent of patients were between 21 and 60 years of age. The symptoms often suggested benign disease and most patients would delay seeking treatment for at least 5 months. We recommend inspection of the nasopharynx with flexible nasoendoscopy for all persons in high-risk areas on a regular basis and advise a policy of active health education for both physicians and the general population to reduce the stage of NPC at first presentation.

Abdominal ultrasonograms were performed on 81 unselected patients with newly-diagnosed nasopharyngeal carcinoma without clinical evidence of distant metastases. Two patients had ultrasonographic features suspicious of, but not diagnostic of, hepatic metastases. One of these two patients developed hepatic metastases six months after the examination while the other was free of metastases at follow-up 33 months afterwards. Of the 79 patients without evidence of metastases on ultrasonogram, two developed hepatic metastases after 22 and 32 months. Based on these results, we do not recommend abdominal ultrasonography as a routine staging investigation for nasopharyngeal carcinoma.

The efficacy of budesonide, terfenadine and a combination of budesonide and oxymetazoline in the treatment of perennial rhinitis was evaluated by a double blind, parallel group study. Adult patients with perennial rhinitis were randomized into three groups. Group 1 patients received budesonide nasal aerosol 400 micrograms/day for 21 days and oxymetazoline nasal drops for the first three days. Group 2 and 3 patients received budesonide 400 micrograms/day and terfenadne tablet 60 mg twice/day respectively. Nasal symptoms were assessed by the patients before and daily during the treatment period using a simple scoring system. One hundred and forty-two patients were recruited and 130 completed the study. Budesonide, but not terfenadine, significantly reduced all nasal symptoms from baseline (p less than 0.05). Terfenadine could significantly relieve the nasal blockage (p less than 0.05) more than other nasal symptoms. Budesonide with or without oxymetazoline nasal drops provided a better control of nasal symptoms than terfenadine (p less than 0.05). Budesonide with oxymetazoline for the first three days showed a faster relief of nasal blockage than budesonide alone (p less than 0.05). Mild and transient adverse effects were encountered in all three groups. It is concluded that nasal symptoms of perennial rhinitis are more adequately controlled by budesonide than by terfenadine.

A case of localized amyloidosis of the subglottis is described. Urgent endotracheal intubation and later tracheostomy were required for upper airway obstruction. The amyloid was completely resected endoscopically using the CO2 laser. There is no evidence of recurrence two-and-a-half years after surgery.

To assess the prevalence of use of Personal Cassette Players (PCP) among youths in a residential community in Hong Kong, we interviewed 487 youths aged 15-24 years who attended various activities in eight Youth Centres in Shatin, Hong Kong. 394 (81%) reported using the Personal Cassette Player regularly. The mean duration of PCP use was 2.8 years with a median of 2 years. The mean time of listening to PCP was 4.5 hours per week. We further examined 124 subjects by otoscopy and of the 103 otoscopically normal individuals, audiometric tests were performed. Among the 78 PCP users and 25 non-users, no significant difference in the mean hearing threshold was observed for the frequencies tested. The mean ear canal sound level was 70.4 dBA. Four subjects were habitually exposed to sound levels higher than 85 dBA. One was exposed to 116 dBA and was found to have a 4000 Hz dip on his audiogram, suggestive of noise-induced hearing loss. In general, despite the high prevalence of PCP use, most youths used their PCP at relatively safe sound levels with low risk of hearing loss. However, education directed towards the youth with respect to the potential hazard on hearing due to improper and prolonged use of PCP is still warranted.

Clinical manifestations in the first 100 patients with nasopharyngeal carcinoma to attend the ENT outpatient clinic at the Prince of Wales Hospital, Hong Kong, commencing in February 1986, are presented. All tumours were non-keratinising or anaplastic carcinomas, World Health Organisation types 2 and 3. Cervical lymphadenopathy was the commonest presenting complaint (43%), followed by nasal symptoms (32%) and aural symptoms (18%). On clinical examination 73% had cervical lymph node metastases, and 72% of patients were in stages III-V at presentation. Trivialisation of the symptoms by the patient and delay by the referring physician contributed to lateness of diagnosis.

Although radiotherapy is the mainstay of treatment, operations play an important role in the management of problem cases of NPC. The selection of patients and the surgical approaches for residual and recurrent disease in the nasopharynx and neck are discussed.

The forms of presentation of NPC, as related to the signs and symptoms of the disease, were studied in 215 patients over a 2-year period. A neck mass was the most common presenting symptom. Seventy percent of the patients were in Ho's stages III to V. This evidence emphasizes the need for earlier diagnosis to improve the prognosis of the disease. This earlier diagnosis could be achieved by increasing the awareness of both the patient and the clinician, particularly in countries where the incidence of NPC is high.