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This is a prospective incidence study of 250 secondary post-tonsillectomy haemorrhages from a population of 2706 tonsillectomies performed over a seven-year period, which aims to ascertain the incidence and character of post-tonsillectomy secondary haemorrhage. Out of 250 post-tonsillectomy secondary bleeds (9.2 per cent of total; 95 per cent CI = 8.2 per cent - 10.4 per cent), 39 patients had a severe bleed (1.4 per cent; 95 per cent CI = 1.2 per cent - 2.1 per cent). The incidence of secondary tonsillectomy haemorrhage increased with age, peaking at 30-34 years in both men and women (p < 0.001), with no statistically significant difference between the two sexes (p = 0.23). The incidence of serious haemorrhage increases in the older age categories (p = 0.005) but is not influenced by gender (p = 0.50). The majority of secondary tonsillectomy haemorrhages presented between the fourth and seventh day post-operation (69.8 per cent). These results now provide the basis for informed consent for a tonsillectomy in our department.

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Alzheimer's family caregivers (N = 122) reported on physical and mental health, as well as stress process variables, at baseline and at a 1-year follow-up. Hierarchical regression analyses of stress process models revealed that increases in primary stressors (e.g., patient self-care and behavioral problems) did not directly affect changes in the mental and physical health outcome variables. However, analyses of models of direct, mediated, and moderated effects revealed that psychosocial resource variables (appraisals, coping responses, and social support) were related to caregiver outcomes over time through several mechanisms. In particular, benign appraisals of stressors, the use of approach coping, and greater levels of social support were associated with more positive caregiver health outcomes over time.

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BACKGROUND: The Mini-Mental State Exam (MMSE) is widely used to assess cognitive impairment. Although education and race have been shown to affect the validity of the MMSE in detecting dementia, whether race and education influence the validity of the MMSE in gauging severity of dementia is unknown. METHODS: Patients diagnosed with Alzheimer's and other dementias (59 African American, 112 White) were administered the MMSE, and information was gathered on patient functional impairment, including Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), and the Memory and Behavior Problems Checklist (MBPC). Demographic information, including patient and caregiver education, and patient age, was also assessed. RESULTS: African American and White patients did not differ significantly on the MMSE or functional impairment variables, but White patients had higher educational attainment. Hierarchical multiple regression analysis showed that race and education did not predict functional impairment, and MMSE scores were strong predictors of ADL and IADL levels for both African American and White patients. MMSE predicted variability in MBPC scores for White patients only, perhaps related to racial differences in subjective caregiver report of behavioral problems. CONCLUSIONS: While race and education may affect the validity of the MMSE in detecting the presence of cognitive impairment, the MMSE can be a useful predictor of degree of ADL and IADL impairment in patients diagnosed with dementia, regardless of race.

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Family caregivers of patients with Alzheimer's disease (AD) commonly have high levels of psychological distress. Black caregivers often report less depression than White caregivers, but the process underlying this difference is poorly understood. With the use of a stress process model, 123 White and 74 Black family caregivers of patients with AD and other progressive dementias were studied. Black caregivers appraised patient problems as less stressful and reported higher self-efficacy in managing caregiving problems and less depression than did White caregivers. White and Black caregivers also differed significantly in coping responses but not in social supports. Structural equation analyses indicated that the correlational structure of the stress process was similar in White and Black caregivers. Caregiving stressors and race did not affect well-being through direct paths, but they were mediated by effects for appraisal, social support and activity, and coping. Possible cultural mechanisms explaining the better adjustment among Black caregivers are discussed.

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Psychological, social, and health variables were compared in 175 Black and White family caregivers of patients with dementia and 175 Black and White noncaregivers. Caregivers and noncaregivers did not differ within race on demographic variables. Caregiving was associated with increased depression and decreased life satisfaction only in White families. However, caregiving appears to have similar social consequences for Black and White families, including restriction of social activity and increased visits and support by family from outside of the home. Race, but not caregiving, was associated with physical health variables. Methodological issues in comparing well-being in Black and White caregivers, in particular the importance of including noncaregiving comparison subjects are discussed.

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The air conduction thresholds in the right and left ears, and the interaural asymmetry of thresholds at 0.5, 1, 2, 3, 4 and 6 kHz were measured in a group of 225 soldiers exposed to a variety of weapon noise who were referred for assessment because of a deterioration in hearing on routine testing. At 0.5 and 1 kHz the threshold levels rarely exceeded 25 dB and the interaural asymmetry was 10 dB or less in 90 per cent of cases. The degree of hearing loss and interaural asymmetry increased as the frequency increased, with the average loss being significantly greater in the left ear at 2, 3, 4 and 6 kHz. Recommendations are made for the selection of cases of asymmetrical hearing loss exposed to weapon noise which require further investigation to exclude a retrocochlear cause or to define spurious hearing threshold levels.

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A case of a direct burn to the pharynx and larynx is described. This occurred after a patient swallowed a microwaved treacle tart. The potential danger of excessive heating of food in microwave ovens is discussed.

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The reported incidence of persistent tympanic membrane perforation after the extrusion or removal of Goode-type tympanostomy tubes varies from 3 per cent to 47.5 per cent. A prospective randomized study of 152 Goode-type T-tube removals is presented. In one group of 79 ears, the edge of the defect was just freshened, but in the other 73 ears, the edge was freshened and a small piece of 0.13 mm silastic sheeting placed over the defect. Follow-up was performed at six weeks and three, six and nine months and shows that the use of silastic sheeting increases the rate of closure of the perforation and also significantly decreases the number of persistent perforations at nine months.

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A new endoscopic method of measuring the cross-sectional area of a subglottic stenosis is presented. The method was tested against existing techniques using a model. By standardizing the distance from the objective of the endoscope to the stenotic area we were able to measure the cross-sectional area using a graduated grid held against the video screen. This technique was then compared with the standard one of estimating the diameter of a stenosis from the external diameter of the bronchoscope which can be passed through the stenosis. The methods were found to be equally accurate in measuring the lumen diameter. However, when measuring the minimum cross-sectional area, three of five observers were significantly better (P less than 0.01) using the photometric method rather than the standard method (Wilcoxon's rank sum test for paired data). The photometric technique of measuring the cross-sectional area of the subglottis is easily performed, non-traumatic, and allows a visual record to be kept.

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We present a retrospective study of 106 patients with branchial cleft and pouch anomalies who presented to the Hospital for Sick Children between 1948 and 1990. The relevant embryology of the branchial apparatus is summarized and a theoretical description of individual anomalies given. Second branchial cleft sinuses were the most common anomalies, and the majority were managed simply, with adequate excision and a low recurrence rate. Five cases of first branchial cleft anomalies are presented, emphasizing the delay in diagnosis, the need for complete excision to prevent recurrence, and for a parotidectomy incision to protect the facial nerve from damage. The two third branchial pouch anomalies presented with a cystic neck swelling, one with recurrent infection and discharge, and the other with stridor. In both, the diagnosis was made at operation. The single fourth branchial pouch cyst was an unexpected finding in a patient with stridor.

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Fraser Syndrome is a rare autosomal recessive disorder (Gupta and Saxena, 1962; Smith, 1982). The most consistent feature is cryptophthalmos (hidden eye), but frequently abnormalities of the ears (meatal stenosis, dysplastic pinna), nose (hypoplastic notched nares, choanal stenosis or atresia), and larynx (glottic web, subglottic stenosis), as well as numerous other anomalies are encountered. We present four cases that have been treated at the Hospital for Sick Children in the last ten years, and describe the various ENT anomalies characteristic of this syndrome.

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Submandibular duct transposition is now a standard surgical procedure for the treatment of severe drooling. However, this is our first experience of a plunging ranula arising as a complication of the technique. In the surgical management of this complication, the single most important step is excision of the sublingual gland to prevent recurrence.

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Primary extracranial meningiomas are uncommon; they have been documented in the ear, skin, orbit, parapharyngeal space, parotid gland, mediastinum, and rarely the paranasal sinuses. Tuberous sclerosis is an autosomal dominant neurocutaneous syndrome characterized by multiple connective tissue tumours. We report the first case of a tuberous sclerosis patient with a maxillary antral meningioma.

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In assessing the usefulness of the acoustic reflectometer we have evaluated its performance on a selected group of patients, finding it to be of equivalent predictive value to those screening tests in common use. We feel that the advantages of the instrument combined with its performance will provide the general practitioner with a useful diagnostic aid.

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A retrospective study is presented of 31 patients who required ventilatory support via a tracheostomy for periods of one month to 27 years whilst in a tertiary referral centre for the care of patients with restrictive respiratory insufficiency. All patients underwent closure of a long-standing tracheostomy. Post-operative follow-up periods of up to 16 years are documented. The indications for and the complications of tracheostomy closure in patients with severe chronic restrictive respiratory insufficiency requiring long-term respiratory support are discussed. It is concluded that the benefits of operative tracheostomy closure outweigh the disadvantages in this unusual type of patient.

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A case of malignant external otitis is presented. This occurred in a healthy 72-year-old non-diabetic, non-immuno-compromised man after ear syringing. The infection was treated with oral ciprofloxacin for eight weeks with complete resolution.

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Deviation of gait in a stepping test has been proposed as a useful indicator of peripheral labyrinthine dysfunction. A prospective study of 26 patients suspected of having uncompensated peripheral labyrinthine dysfunction and 49 normal patients with normal labyrinthine dysfunction showed no significant difference in performance of the Unterberger stepping test between patients with electronystagmographically significant canal paresis and those with normal vestibular function.

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Pulsatile tinnitus resulting from an abnormal communication between the occipital artery and the transverse or lateral sinus is a rare clinical entity. We report three cases which presented over a period of three years who had such abnormalities demonstrated angiographically and were cured of their symptoms by exploration and ligation of the occipital artery.

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Male Wistar strain rats were fed a diet providing an intake of 0 or 400 mg cyclohexylamine (CHA)/kg body weight/day for 1, 3, 7, 9, or 13 weeks. At the end of the appropriate feeding period the rats were perfused-fixed with Karnovsky's fixative. The weights of the fixed testes were recorded and the testes, epididymides, and spermatic cord were sampled and processed into methacrylate resin. Histopathological examination of the testes showed changes after 3 weeks of CHA administration. The most frequent and consistent lesion consisted of a focal, basal vacuolation of the Sertoli cell cytoplasm associated with the local loss of spermatocytes and spermatogonia. After a 7-week administration, the Sertoli cell vacuolation was extensive, while the germ cell population showed mild to moderate degeneration and depletion. After longer periods of treatment the lesion was more severe and affected a greater number of tubules leading to general disruption of the germinal epithelium. Cocultures of Sertoli and germ cells were prepared from the testes of Wistar strain rats and exposed to (CHA) or its metabolite 4-aminocyclohexanol (4ACH) at concentrations ranging from 0.1 to 10 mM for periods of 24-72 hr. The cultures were fixed, stained, and examined by light microscopy. Cultures exposed to CHA or 4ACH showed morphological changes comparable with those seen in vivo. Sertoli cell vacuolation was the earliest change with progressive germ cell degeneration and exfoliation from the Sertoli cell monolayer. At equimolar concentrations, CHA produced more marked changes than 4ACH. These results suggest that CHA itself acts directly on the testis and that its primary cellular target is the Sertoli cell.

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