We describe the technique of ultrasound-guided 18 gauge (1.2 mm) needle biopsy in 16 patients with parotid gland lesions. This provides material suitable for histological analysis and can be performed quickly and safely under local anaesthesia. Thirteen of the patients had non-diagnostic blind fine-needle aspiration cytology (FNAC) with a 21 gauge (0.8 mm) needle prior to biopsy. Initial ultrasound was found to be superior to clinical examination in 31 per cent of cases. The ultrasound-guided technique provided a diagnostic specimen in 100 per cent of patients and was helpful where FNAC had been inconclusive. There was a diagnostic accuracy of 100 per cent in the patients who underwent subsequent surgery. This method should be considered when FNAC is non-diagnostic and surgical treatment is being considered. It is particularly useful in patients with diffuse enlargement of the gland and does provide a core of material for accurate assessment of tissue architecture. In this series, nine patients avoided unnecessary surgery.

Sonographically guided core biopsy is a highly accurate technique for evaluation of parotid lesions and can be safely performed as an outpatient procedure. Sonographically guided core biopsy has potential advantages over fine-needle aspiration cytologic examination, particularly in the typing and grading of lymphoma and carcinoma and in improved differentiation of reactive nodal hyperplasia from lymphoma. The use of sonographically guided core biopsy may help reduce the need for surgical biopsy and facilitates prompt referral to the appropriate clinical team.

Some 497 of 3085 patients with squamous cell carcinoma of the head and neck treated between 1963 and 1990 had a later radical neck dissection at some time after initial treatment. The histological slides were all reviewed, firstly to confirm the presence of squamous cell carcinoma within the neck, and secondly to ascertain whether the metastasis was to soft tissue, to a lymph node or to both. The presence of extracapsular rupture in lymph node deposits was also assessed. Of the 497 patients, 138 had soft tissue deposits only, and 359 had nodal deposits only. Of the patients with nodal deposits 165 had extracapsular rupture and 194 did not. The 5-year survival of the 138 patients with soft tissue metastases was 27% compared with 33% for patients with extracapsular rupture and 50% for patients with no extracapsular rupture. Weighted logistic regression showed that soft tissue deposits were significantly more common in patients in poor general condition, plus poorly differentiated squamous cell carcinoma plus T4 tumours (P < 0.005), and in patients with poorly differentiated squamous cell carcinoma plus T4 tumours (P < 0.025). Cox's multivariate analysis with backward elimination showed that gender, histological differentiation, site of primary tumour and age of patient had no statistically significant effect on survival. The number of nodes (P < 0.0001), the presence of extracapsular rupture (P < 0.0001) and the presence of soft tissue free metastases (P < 0.001) were all highly significant. The N-status at recurrence also reached statistical significance (P < 0.0001).

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Pharyngo-cutaneous fistula following laryngectomy is a serious complication. The incidence worldwide varies from 7.6 to 50 per cent. The value of prophylactic antibiotics in preventing fistulae is well recognized but the type of antibiotics and the length of administration of the antibiotics is variable depending on the individual surgeon.Below we present the Plymouth Head and Neck Unit experience where, in the last five years, 33 patients underwent laryngectomy (30 total, three vertical hemi-laryngectomies).The prophylactic antibiotics used in all patients was parenteral cefotaxime 1G or cefuroxime 750 mg, given at eight hours pre-operatively, with the premedication and at eight, 16 and 24 hours post-operatively. Only two patients developed pharyngo-cutaneous fistulae, both after total laryngectomy (six per cent of total). Three patients developed skin cellulitis and five patients developed chest infection which required further treatment with antibiotics.

Aneurysms of the extracranial portion of the internal carotid artery are rare, particularly in young patients. They usually develop following trauma, or secondary to infection involving the parapharyngeal space that extends to the vessel wall. This is a case of an internal carotid artery aneurysm presenting acutely following chiropractic neck manipulation with hypoglossal and glossopharyngeal nerve palsy. The imaging findings and subsequent operative management are described.

Sinus-induced intracranial sepsis can represent a genuine medical and surgical emergency. We review 12 cases presenting to our hospitals over a five-year period. Nine were male and three were female with an age range of 16 to 74 years (mean 35.5 years). Four patients had their sinusitis diagnosed prior to admission and eight did not. Nine patients had bilateral sinus disease, the most common sinus involved was the frontal followed by the ethmoid, maxillary and sphenoid. Neurosurgical drainage was via a craniotomy in seven cases and burr hole in three. Nine patients underwent sinus surgery and three did not. Of the nine who had sinus surgery three had frontal drainage, four fronto-ethmoidal and two transsphenoidal drainage. The most common organism was Streptococcus milleri. Our series confirms that sinus-induced intracranial sepsis is a serious problem needing early diagnosis and aggressive treatment. We would recommend a high index of suspicion of sinusitis in patients with intracranial infection.

A double blind controlled prospective trial investigated the analgesic effect of topical Bupivacaine in 15 adult patients undergoing bilateral tonsillectomy. Each patient had one tonsillar fossa exposed to Bupivacaine 0.5 per cent solution and the other to normal saline. When visited four to six hours post-operatively, 12 out of 15 patients (80 per cent) stated that the Bupivacaine exposed side to be more uncomfortable than the saline exposed side. On the first post-operative mornning 9 out of 15 patients (60 per cent) confirmed the same. The remaining patients were unable to detect a significant difference and no patient found the Bupivacaine side to be more comfortable.These results suggest that topical Bupivacaine 0.5 per cent solution has no place in providing post-operative analgesia in adult tonsillectomy.