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Complications following stapedectomy are the most common cause of litigation involving otological cases in the USA. Manipulation and placement of the prosthesis during a stapedectomy may have a profound effect on the final hearing results. Concerns have been raised over the reduced number of cases, training of residents, and the maintenance of the necessary skills to achieve consistently good results. Temporal bone dissection is an important adjunct to developing the required skills to perform stapedectomies. However the reduced availability of specimens limits their use for teaching or practising the procedure. In order to circumvent these problems an inexpensive and easily constructed middle-ear simulator has been developed based on materials readily available in any ENT ward. It is believed that this might help trainees develop the necessary skills to master the procedure.

We present a series of three case reports of patients over the age of 40 with cystic swellings in the lateral neck. Clinically they masqueraded as branchial cysts, but subsequently were diagnosed as being squamous cell carcinoma cystic lymph node metastasis arising from an occult tonsillar primary. Currently there is an absence of national guidelines for the treatment of lateral neck cysts in the over 40s' age group that subsequently prove to be cystic metastases from occult tonsillar primaries. This disease process is more common than thought, with up to 80 per cent of so-called branchial cysts in the over 40s' age group being malignant. We recommend that patients over the age of 40 presenting with lateral cystic swellings in the neck should have a high suspicion of malignancy and require a panendoscopy, ipsilateral tonsillectomy and blind biopsies of Waldeyer's ring. This avoids inadvertent excision of a possible cystic lymph node metastasis. If the panendoscopy histology proves to be benign, then proceed to excision of the cyst with frozen section analysis of it. If this confirms it to be benign then that is all that is necessary; if the frozen section is however positive for carcinoma then the surgeon can proceed at that time to a formal neck dissection and therefore avoid a further procedure. In the event of an occult tonsillar malignancy, excision of the cyst as part of a neck dissection with post-operative radiotherapy is recommended. It is our aim to treat a cystic lymph node metastasis as you would a solid lymph node metastasis.

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