A consecutive sample of 97,537 miners seeking compensation for Hand-Arm Vibration Syndrome were examined in a medical assessment process which included documentation of age, hand dominance, Dupuytren's disease, years of vibration exposure, history of diabetes, smoking habits and units of alcohol consumption per week. The prime determinant of prevalence of Dupuytren's disease was age, and all other factors investigated were corrected for age. There was no statistically significant correlation between years of exposure to vibration and the prevalence of Dupuytren's disease. There was a statistically significant association with smoking, alcohol consumption and diabetes mellitus, with the heaviest smokers having an odds ratio (OR) of 1.31 (95% CI, 1.17, 1.47), the heaviest drinkers (in excess of 22 units a week) having an OR of 1.59 (95% CI, 1.47, 1.72) and diabetes mellitus patients having an increase in the odds of having Dupuytren's disease of 1.52 (95% CI 1.30, 1.77).

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In the United Kingdom the diagnosis of Hand-arm Vibration Syndrome varies depending on the purpose of that diagnosis. The criteria differ in three situations. More than 100,000 miners and ex-miners with claims for HAVS have been examined using a Medical Assessment Process which included the use of standardised tests. This contract is unique but it has had significant effects on the two other processes. The Industrial Injuries Disablement Benefit Scheme provides a benefit that can be paid to an employed earner because of an accident or Prescribed Disease. New recommendations have been published to remove the anomalies in the present format for assessing HAVS. If implemented the new scheme will recognise the Stockholm Workshop Scales and workers with neurological problems will also be compensated. The Health and Safety Executive will issue new guidance in the near future on the hazards of hand-arm vibration. Health surveillance in the workplace will be fundamental and the HSE propose a tiered approach with levels 1 to 5. Specialist occupational nurses and doctors with training in the diagnosis and assessment of HAVS will be needed for levels 3 and 4. Only at this level may a diagnosis of HAVS be made. The Medical Assessment Process has demonstrated that it is possible to examine a large number of claimants in a standardised manner. The IIAC and HSE recommendations contain very important improvements on the existing positions in the UK and it must be hoped that they will be implemented in the near future.

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In its present format, the CPT should not be used for evaluating the vascular component of HAVS.

Two patients with primary mastoid cysts are presented. These examples stress the importance of regular follow-up of patients with chronic serous otitis media so that the complications or associated abnormalities may be treated early prior to extensive destructive erosion. The formation of these cysts may be due to changes brought about by chronic serous otitis media, or they may be of congenital origin with middle ear effusion as a sequela.

Experimental production of serous effusion in the middle ear of animals has been achieved by other investigators by direct attack upon the Eustachian tube with cautery or ligation.l-" It would appear that the bullar effusion which results may be caused by one of three processes: 1) trauma to the tubal lumen may induce infection which could extend to the bulla and cause an outpouring of inflammatory exudate; 2) tubal edema or fibrosis could result in tubal obstruction followed by effusion ex vacuo; or 3) peritubal lymphatic compromise, may lead to extravasation of fluid from the bullar lymphatic vessels.In the present experiment an attempt was made to separate these factors. Accordingly, an aseptic external approach via the base of the skull without violation of the tubal lumen was carried out, followed by ligation of the Eustachian tube in order to ensure definitive obstruction without infection. The variable of lymphatic obstruction remained, and it was hoped that it might be controlled by providing middle ear ventilation through myringotomy. If bullar effusion is indeed due to diminished pressure and not to lymphatic compromise or infection, it should not occur if middle ear pressure is kept equal with that of the outside world. METHODThe tympanic membranes of healthy cats were examined under intravenous pentobarbital sodium anesthesia using a Zeiss surgical microscope for illumination and magnification. Twenty-three cats with normal-appearing drum membranes and clean ear canals were retained in the experiments.