One hundred patients with tracheobronchial tumours were treated with the neodymium YAG (yttrium-aluminium-garnet) or If clearance of the airways was considered inadequate at the first attempt, we were prepared to give up to three sessions of laser treatment during the initial admission to hospital, after which no further treatment was attempted if the patient did not improve. Follow up treatments were given at one to three month intervals, depending on the speed with which symptoms recurred, for as long as further response was seen and breathlessness or haemoptysis remained predominant symptoms.Response to treatment was assessed by the patients' account of their symptoms and by the results of pulmonary function tests, which included peak expiratory flow rate, spirometric values, and a flow-volume loop. Exercise tolerance was measured by the six minute walking test.5 Full pulmonary function testing was not completed in a few of our early patients and could not be performed in some patients because of extreme breathlessness, but peak flow rate was always attempted on the ward with a Wright peak flow meter. These tests were performed before and after treatment and repeated at outpatient sessions and before subsequent treatments. A symptomatic improvement was recorded if the patient said that he or she felt better and if there was an improvement in the six minute walk. Objective improvement was recorded if there was a grea-341 Hetzel, Nixon, Edmondstone, Mitchell, Millard, Nanson, Woodcock, Bridges, Humberstone ter than 25% rise in peak flow rate, since this information was consistently available. Such cases usually showed improvement in spirometric indices and flow-volume loops as well. In patients with an unrecordable peak flow 601 min-' was taken as the starting point for this calculation.In patients treated for haemoptysis diary charts were recorded from the time of admission for assessment for laser treatment. After discharge home records were continued by the patient, who was asked to record each day whether blood had been coughed up and if so how much. An objective response was defined as complete cessation of haemoptysis for at least one month. A symptomatic response was defined as a significant reduction in frequency and quantity of haemoptysis. It was considered unjustifiable to delay treatment for more than a few days to monitor haemoptyses before the first treatment. In patients who were subsequently treated again (for recurrence of haemoptyses after initial good control) it was, however, possible to compare pre-treatment and post-treatment records covering several weeks. Diary charts were also used to help in deciding when further treatment was indicated.The first 14 patients were treated with the argon laser (Spectra Physics), wavelength 488 and 514 nm, output 12 w. All other patients were treated with the neodymium YAG laser (Barr and Stroud or Medilas), wavelength 1060 nm, maximum output 100 w. The laser beam was transmitted through a 200 um quartz (argon) or 600 micron glass (Nd YAG) opti...

Ninety seven patients with tracheobronchial tumours have been treated with the neodymium yttrium-aluminium-garnet (Nd YAG) laser over a period of 33 months. Fifty one of these patients were treated under local anaesthesia and 46 under general anaesthesia. The results obtained with the two methods have been compared retrospectively. The numbers of patients responding to treatment, the magnitude of the response, and the duration of palliation were similar in the two groups; significantly more treatment sessions, however, were required during each course of treatment under local anaesthesia. This advantage of general anaesthesia was thought to arise from the ability to continue treatment for longer and with greater efficiency. The use of the rigid bronchoscope with jet ventilation under general anaesthesia was also thought to provide better control of the airway and to allow more efficient clearance of blood and mucus. Two operative deaths occurred under local anaesthesia, when bleeding led to asphyxiation, but none have occurred under general anaesthesia. Treatment under general anaesthesia is not, however, without risk and is potentially hazardous in patients with severe chronic hypoxic lung disease.During the last six years the neodymium yttriumaluminium-garnet (Nd YAG) laser has become established as an important method of palliative treatment in patients with tracheobronchial tumours." The thermal action of the laser is used to resect and cauterise intraluminal tumour within the proximal tracheobronchial tree and breathlessness and haemoptysis can be relieved in selected patients.Treatment may be given under either local or general anaesthesia. Although each method has gained favour among different groups, no attempt has been made to compare them. We describe our experience with both methods in two hospitals. Methods DESIGN OF THE STUDYThe results of treating patients under local and general anaesthesia have been compared in a retrospective study. Our initial experience with the Nd YAG laser was obtained with local anaesthesia. It is therefore possible that our early data on local Address for reprint requests: Dr P J M George, University College Hospital, London WC1E 6AU. Accepted 7 March 1987anaesthesia might be prejudiced by lack of experience with a new technique. To reduce possible bias in favour of general anaesthesia, the data on local anaesthesia obtained during our first 18 months' work with the laser have been discarded and more recently acquired data relating to local anaesthesia have been compared with our earliest data on general anaesthesia. PATIENTSDuring the period of the study, 51 patients (33 men and 18 women) were treated under local anaesthesia (January 1983 to September 1985

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References lAlexopoulos KA. The importance of breech delivery in the pathogenesis of brain damage. Clin Pediatr (Phila) 1973;12:248-9.

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The present study reports the results of an evaluation of three types of multiple choice questions--the five choice completion, and assertion-reason. Fifty-four questions, eighteen of each type and measuring the candidate on the same scientific principle and classified as either factual or comprehension, were developed and included in the General Surgery certifying examination of the Royal College of Physicians and Surgeons of Canada. In addition to using descriptive statistics, the multitrait-multimethod technique was used to investigate whether the item types measured different aspects of examinee capabilities. Results indicated that performance on the five choice completion and the multiple completion type questions was roughly the same, whereas performance on the assertion-reason type was lower. The results of the multitrait-multimethod validation revealed that the three item types were unable to discriminate between the two traits of factual and comprehension.

Neurilemoma of the larynx is not common. Thus far, 86 cases have been described in the literature. In this study, another case, occurring in a 67-year-old woman, is discussed. The potential danger of the lesion is emphasized. The most common nerve of origin is thought ot be the internal branch of the superior laryngeal nerve. Removal via a lateral pharyngotomy is advocated for larger tumors.