1Wo hundred and thirty-five consecutive Saudi patients aged between two and fifty-three years undergoing elective tympanoplasty (n =32), septorhinoplasty (n = 68) or adenotonsillectomy (n =135) were studied. They were randomized to receive either a total intravenous anaesthetic (10 ears, 23 noses, 44 throats) consisting of propofol for induction of anaesthesia followed by a propofol infusion, a combined intravenous-inhalational anaesthetic (11 ears, 22 noses, 46 throats) consisting of the above with isof/urane in oxygen-enriched air, or a balanced inhalational anaesthetic (11 ears, 23 noses, 45 throats) consisting of thiopentone for induction of anaesthesia and oxygen in nitrous oxide with isof/urane for maintenance. During tympanoplasty, all three anaesthetic techniques produced stable heart rates and arterial pressures. During septorhinoplasty, blood pressure rose in patients who received total intravenous anaesthesia, while combined and balanced techniques produced haemodynamic stability. During adenotonsillectomy, total intravenous anaesthesia produced a rise in both heart rate and blood pressure, the combined technique produced a rise in heart rate alone while balanced anaesthesia produced haemodynamic stability. Pastoperatively, vomiting, pain scores and analgesic requirements were similar following all three types of anaesthetic within each surgical site subgroup. Our findings support the choice of balanced inhalational anaesthesia for all three types of ENT surgery and, where cost and facilities permit, total intravenous anaesthesia for tympanoplasty and combined intravenous-inhalational anaesthesia for septorhinoplasty.

1 Vomiting and restlessness following ENT and eye surgery are undesirable, and may be related to the emetic and analgesic effects of any analgesic given to augment anaesthesia during surgery. 2 To rationalise the choice of analgesic for routine ENT surgery we examined the intraoperative, recovery and postoperative effects following the administration of either buprenorphine (3.0 to 4.5 pg kg-'), diclofenac (1 mg kg-'), fentanyl (1.5 to 2.0 pg kg-'), morphine (0.1 to 0.15 mg kg-'), nalbuphine (0.1 to 0.15 mg kg-'), pethidine (1.0 to 1.5 mg kg-') or saline (as control) given with the induction of anaesthesia in 374 patients. A standardised anaesthetic technique with controlled ventilation using 0.6-0.8% isoflurane in nitrous oxide and oxygen was employed. The study population constituted 7 similar groups of patients. 3 Intraoperatively, their effects on heart rate and blood pressure, airway pressure and intraocular pressure, were similar. This implies, most surprisingly, that neither their analgesic nor their histamine releasing effects were clinically evident during surgery. By prolonging the time to extubation at the end of anaesthesia, only buprenorphine, fentanyl, morphine and pethidine provided evidence of intraoperative respiratory depression. 4 Postoperatively, buprenorphine was associated with severe respiratory depression, prolonged somnolence, profound analgesia and the highest emesis rate. Diclofenac exhibited no sedative, analgesic, analgesic sparing, emetic or antipyretic effects. Fentanyl provided no sedative or analgesic effects, but was mildly emetic. Morphine provided poor sedation and analgesia, delayed the requirement for re-medication and was highly emetic. Nalbuphine and pethidine produced sedation with analgesia during recovery, a prolonged time to re-medication and a mild emetic effect. None provided evidence, from analysis of postoperative re-medication times and analgesic consumption, of any pre-emptive analgesic effect.5 We conclude that nalbuphine (mean dose 0.13 mg kg-') and pethidine (mean dose 1.35 mg kg-'), given individually as a single i.v. bolus during induction of anaesthesia, are the most efficacious analgesics for routine in-patient ENT surgery.

Two hundred and seventy-eight patients scheduled for all types of surgery and premedicated with diazepam and metoclopramide were randomly allocated to one of four groups to compare the relative pain of an injection of 0.25 ml of lignocaine 1% via a 25 gauge needle with the pain of the siting of a 21 gauge Butterfly (Abbott), 23 gauge Butterfly or a 20 gauge Venflon (Vigo Spectramed). The injection of lignocaine and insertion of the 23 gauge Butterfly were associated with the least complaints of pain and least observed responses to pain. The 21 gauge Butterfly and 20 gauge Venflon were associated with complaints of greater pain and more pain responses. We conclude that a pre-cannulation injection of lignocaine causes minimal discomfort and is the most appropriate means of reducing the discomfort of venous cannulation when not using skin penetrating analgesic creams.