Otolargyngology

Vasama
J-P, Linthicum FH Jr. (House
Ear Inst,Los Angeles)


Meniere’s Disease and
Endolymphatic Hydrops Without
Meniere’s Symptoms:Temporal Bone Histopathology


Acta Otolaryngol (Stock)
119:297-301,1999

 


This
is a good article from another
authentic 
study of T.Bare Sections
studied in 21 yrs. Wherein
E.Hydrops is noted 
without any symptoms of
Meniere’s .This study
therefore is interesting in
comparing histopathological
finding in so-called 
“normal” EARS with
those of of patients with
Meniere’s Disease.
Nevertheless it is an
established fact that E. Hydrops
is the most important
pathological finding correlating
Meniere’s disease patients.

  

Yazawa
Y,Suzuki M,Kitano H,et al
(Shiga Univ,Otsu , Japan)


Intraoperative Mitomycin C in
Endolymphatic Sac Surgery for
Meniere’s Disease : A pilot  Study.


ORL J Otorhinolyngol Relat
Spec 61:188-194,1999

  


The
use of mitomycin –C to prevent  postoperative fibrosis is the basis in this sac surgery done
in 14 patients who in 6 months
follow-up has shown no vertigo
,10db improvement in hearing in
5 patients and reduction of
tinnitus.

  


This
may be of benefit in sac surgery
provided long-term results are
available .Long-term results of
sac surgery 
without mitomycin show
definitely unsatisfactory
results hence use of mitomycin
in sac surgery may prove long
term 
results.

   

Yotsuyanagi T, Nihei Y, Yokoi K, et al (Hirosaki Univ, Japan)

Functional Reconstruction Using a Depressor Anguli Oris Musculocutaneous Flap for Large Lower Lip Defects, Especially for Elderly Patients.

Plast Reconstr Surg 103: 850-856, 1999

    


The most common lesion of the malignant lesions of oral cavity is lower lip squamous carcinoma

     


In planning the reconstruction of large excision defect the following factors should be kept in mind.

    


– Maintenance of sphineteric action

– Retention of sensation

– A large enough opening for the mouth

– Acceptable cosmetic appearance.

    


In surgical technique described – Nerve supply and Blood supply is well preserved.

      

Raulin C, Schroeter CA, Weiss RA, et al (Laserklinik, Karlsruhe, Germany; Med Centre, Maastricht, The Netherlands; Johns Hopkins Univ, Baltimore, Md; et al)

Treatment of Port-Wine Stains With a Noncoherent Pulsed Light Source: A Retrospective Study.

Arch Dermatol 135: 679-683, 1999

   


Thirty-seven patients with 40 port-wine stains between 1994 to 1997, aged 1 to 68 years were treated with intense pulsed light source (IPLS). Before and after treatment, photographs were taken. All side effects recorded. The treatment appears to be safe and effective.

    

Franceschi S, Levi F, La Vecchia C, et al (Centro di Riferimento Oncologico, Aviano, Italy; Registre Vaudois de Tumeurs, Lausanne, Switzerland; Instituto di Ricerche Farmacologiche “M Negri”, Milano, Italy; et al )

Comparison of the Effect of Smoking and Alcohol Drinking Between Oral and Pharyngeal Cancer

Int J Cancer 83: 1-4, 1999

   

The relationship of exposure to alcohol and tobacco is established. However, the separate and combined effects of alcohol and tobacco between oral and pharyngeal cancer were compared in case-control investigation.

    

274 patients with oral cancer and 364 with pharyngeal cancer, 1254 controls matched were studied. 

    

Observation-Conclusion – Alcohol has a stronger effect on oral cancer than on pharyngeal cancer. This may help explain why oral cancer mortaility is rising in men from many developing countries after many years of declining.

    

Pritikin
JB, Caldarelli DD, et al (Rusb-Presbyterian-St Luke’s Med Ctr, Chicago)

Endoscopic Ligation of the Internal Maxillary Artery for Treatment of Intractable Posterior Epistaxis

Ann Otol Rhinol Laryngol 107: 85-91, 1998

      

Ten patients treated with ligation of internal maxillary artery branches, along with ligation of sphenopalatine artery in sphenopalatine fossa had success rate of 100%.

    

This is another approach and has minimal morbidity. Problem is only verified with small number of patients. Appears to be a promising method.

     

Cheng D, Iriarte GC (Kaiser Permanente, Downey, Calif)

The Paper Clip Nasal Dilator

Laryngoscope 108: 1247-1248, 1998.

    

A narrow nasal valve results in serve nasal obstruction.

     

Plastic coated nasal clip shaped and inserted in rounded end of nostril, kept for one month serves the purpose very well.

      

Shoseyov D, Bibi H, Shai P, et al (Hadassa Med School, Jerusalem, Israel; Brazilai Hosp, Ashkelon, Israel; SHIRAM Asaf Harofe Med Ctr, Zerifin, Israel; et al)

Treatment with Hypertonic Saline versus Normal Saline Nasal Wash of Pediatric Chronic Sinusitis.

J Allergy Clin Immunol 101: 602-605, 1998.

     

Thirty patients were studied randomly with double-blind study. 

     

Instilling 1 -mL hypertonic saline (HS) 3 times daily for 1 month improves the clinical and radiological conditions of children with chronic sinusitis. This treatment is tolerable and inexpensive.

     

This is an interesting study supporting the use of HS. The exact mechanism is not known.

   

Waridel F, Monnier P, Agrifoglio A (Univ Hosp, Lausanne, Switzerland)

Evaluation of the Bone Resistance of the Sphenoid and Ethmoid Sinuses.

Laryngoscope 107: 1667-1670, 1997

   

This cadaveric study included 21 specimens. Resistance to breakage of these bony structures was determined critically by dynamometric assessment. 

     

This anatomical study identified highly fragile sites which correlate with location of surgical complication of functional endoscopic sinus surgery.

    

R. A. Otto comments: This simple study attempts to quantify bony resistances. It differs from Stankiewicz and Kainz and Stammberger, have stated that the weakest area is the area around the anterior ethmoidal artery, in the region of anterior base skull.

    

Metson R, Gliklich RE (Haravard Med School)

Clinical Outcome of Endoscopic Surgery for Frontal Sinusitis

Arch Otolaryngol Head Neck Surg 124: 1090-1096, 1998.

   

Clinical results of this procedure was evaluated in 87 patients over a period of 2 yrs.

   

To avoid surgical failures, authors now use bilateral drillout technique in all patients with frontal sinusitis after a Lynch procedure.

    

R..A Otto comments:Though the results appear promising, long term follow-up are needed to determine it as a procedure of choice.

   

Casiano RR, Livingston JA (Univ of Miami, Fla)

Endoscopic Lothrop Procedure: The University of Miami Experience.

Am J Rhinol 12: 335-339, 1998.

   

This 2 year study included 21 patients with persistent or recurrent frontal sinusistis. Lothrop procedure seeks to create a common frontal sinus ostium. Ostium patency rate of 75% was reported. This prospective study sought to pick up patients who will benefit from Endoscopic Lothrop procedure.

   

A 57% patency rate was noted in recurrent sinusitis patients in whom conventional endoscopic tecnhiques failed. The chances of ostium patency was improved by maintaining a common frontal ostium of greater than 8mm in the anterioposterior dimension and 16 mm in the lateral dimension by Lothrop technique.

   

Authors provide some useful information correlating ostia size and patency rates. The study is limited and has short-term follow-up – R.A. Otto.

    

Lawson W, Reino AJ (Moutn Sinai Med Ctr, New York)

Isolated Sphenoid Sinus Disease: An Analysis of 132 Cases.

Laryngoscope 107: 1590-1595, 1997.

    

Sphenoid sinus disease raises difficult diagnostic issues. To distinguish from primary to secondary sinusitis or even primary to malignant disease is difficult. The 22 year study retrospectively was reviewed and signs and symptoms and radiographic findings were analysed.

     

Headache was most common and visual disturbances being the next symptom.

    

The key to diagnosis of isolated sphenoid disease is CT, with adjunct MRI as indicated. Findings of bone expansion, thinning and remodelling indicated Mucoceles and benign tumours. Bone erosion is pointed to malignant disease. A signal void in the sinus cavity on MRI is a sign of fungal sinusitis.

    

Authors presented a CT algorithm to facilitate diagnosis and treatment selection.

    

Dolbie
RA [Univ of Texas, San Antonio]

A review of Randomized
Clinical Trials in Tinnitus

Laryngoscope 109: 1202-1211,
1999



Most patients with tinnitus have subjective cases associated with sensorineural hearing loss attributable to aging, noise exposure, head injury, and other causes. Many patients with tinnitus have no hearing loss at all.



None of these treatments provided replicable long-term relief of tinnitus compared with placebo. Nonspecific support and counseling may help, as do trycyclic antidepressants in patients with severe cases.



This author has done a very comprehensive study of the current state of the art in terms of randomized clinical trials regarding tinnitus. His study is quite appropriate and his conclusions quite relevant. As he mentions, non-specific supportive counseling helps, as do antidepressants in severe cases. I would add that behavioral listening seems to be the most important and useful method we have in dealing with these patients.

Veling
MC, Windmill I, Bumpous JM [Univ
of Louisville, Ky]

Sudden Hearing Loss as a
Presenting Manifestation of
Leukemia

Otolaryngol Head Neck Surg
120: 954-956, 1999



Sudden hearing loss is a rare initial manifestation of hematologic disorders. This report described a case in which sudden hearing loss was one of the presenting manifestations of leukemia.



Woman, 65, was seen with acute-onset back pain. She reported a 6-day history of tinnitus and a 1-day history of sudden-onset bilateral hearing loss. Physical examination revealed bilateral serous middle ear effusions with intact tympanic membranes and clear external auditory canals. Laboratory tests revealed a white blood cell count of 33,200. Results of a bone marrow aspirate were consistent with acute lymphocytic leukemia. Audiologic examination revealed bilateral 

profound sensorineural hearing loss. The patient received induction chemotherapy, with leukocytosis resolution. Audiologic examination results demonstrated significant improvement. The patient was discharged and has remained in remission. 



This case was unusual in that deafness was one of the presenting symptoms of leukemia. 



Typically, leukemia will cause deafness during its terminal stages. Leukemia can be seen as a presenting symptom of sudden deafness. The pathology of such patients, as seen from studies in temporal bones, suggests an immediate infiltration of pathologic leukemic cells throughout the labyrinthine spaces, followed by secondary degeneration of the sensory end organs and their cellular components.

Heiland
KE, Goode RL, Asai M, el al [
Stanford Univ, Calif; Ehime-Univ,
Ehime 

City, Japan; Universitasspital
Zurich, Switzerland]

A Human Temporal Bone Study
of Stapes Footplate Movement

Am J Otol 20 : 81-86, 1999



Below the level 0f 2.0 kHz, stapes vibration was primarily pistonlike. Above 2.0 kHz, Anterior-posterior rocking motion rose logarithmically with frequency. Near the 4.0 kHz level, rocking and pistonlike motion were almost equal.



Stapes footplate vibration was mostly pistonlike upto 2.0 kHz. The motion became more complex at higher frequencies because of a rise in anterior-posterior rocking motion. Hingelike motions were not seen. This information may be of use in the design of ossicular replacement prostheses that mimic or improve upon normal stapes vibration.



It is interesting that they identify similar findings in that there is pistonlike action, but with higher frequencies, a more complex rocking motion takes place. Such studies are of interest not only from a physiologic point of view but also for those who do surgery in this area to repair pathologic structures

Chauvin
K Bratton C, Parkins C
[Louisiana State Univ, New
Orleans]

Healing large Tympanic
Membrane Perforations Using
hyaluronic Acid, 

Basic Fibroblas Growth Factor,
and Epidermal Growth Factor

Otolaryngol Head Neck Surg
121: 43-47, 1999



Although 88% of tympanic
membrane perforations heal
spontaneously, the remainder
require expensive

tympanoplasty to avoid chronic
problems. Use of epidermal
growth factor [EGF] has improved
nonsurgical closure rates

dramatically in guinea pigs.



Complete closure of the
perforation occurred in all ears
treated with HA and EGF There
was no evidence of 

cholesteatoma in any middle ear



It could be nice to see such a
study done in higher types of
animals such as cats or monkeys.
Perforations in animals such as

guinea pigs have a remarkable
propensity for self-healing.

Shea PF, Ge X, Shea JJ Jr [Univ of Tennessee, Memphis]

Stapedectomy for Far-advanced Otosclerosis

Am J Otol 20: 425-429, 1999, Pg.54

Stapedectomy is indicated for those patients with far-advanced otosclerosis even in the absence of air conduction [AC]. 



The negative Rinne test distinguished far-advanced otosclerosis from other types of hearing loss. Most patients with far-advanced otosclerosis benefited from stapedectomy. 



These patients seem to be the most grateful because they are essentially deaf to begin with, but then achieve useful hearing. 

Bajaj Y, Bais AS, Mukherjee B [Lady Hardinge Med College, Delhi, India; SSK Hosp, Delhi , India: Kalawati Saran Children’s Hosp, Delhi, India]

Tympanoplasty in Children : A Prospective Study

J Laryngol Otol 112 : 1147-1149, 1998, Pg.89



All children had a central perforation without cholesteatoma. Ears had to be dry for at least 6 weeks before surgery. Patients underwent type-I tympanoplasty with autograft temporalis fascia.



Surgery is least successful in children with large or bilateral perforations. 

Golz A, Netzer A, Joachims HZ, et al [ Technion-Isreal Inst of Technology, Haifa; Westerman Research Associates Inc, Shrewsbury, NJ]

Ventilation Tubes and Persisting Tympanic Membrane Perforations

Otolaryngol Head Neck Surg 120: 524-527, 1999, Pg.90

Myringotomy with ventilation tube insertion is the most common pediatric otologic operation. 



A perforation was considered permanent if it persisted for more than 1 year after spontaneous extrusion or removal of tubes.



Persistent perforations were also significantly more common among children under 5 years of age.

Eisenman
DJ, Parisier SC [Lenox Hill
Hosp, New York]

Meatoplasty : The cartilage
of the Floor of the Ear
Canal 

Laryngoscope 109: 840-842,
1999



An adequate meatal opening is
important in postoperative ear
care.



The success of otologic
procedures frequently depends on
a adequate meatal opening,
Excision of the cartilage of
the 

floor of the ear canal is an
important part of successful
meatoplasty.



It is important to have good
meatus in order to allow
self-cleansing of the enlarged
canal or mastoid cavity.

Soultan Z, Wadowski S, Rao M, et al [State Univ of New York, Brooklyn]

Effect of Treating obstructive Sleep Apnea by Tonsillectomy and/or Adenoidectomy on Obesity in Children

Arch Pediatr Adolesc Med 153: 33-37, 1999, Pg. 195



Obese children with enlarged tonsils or adenoids can have obstructive sleep apnea, which may cause poor growth and a failure to thrive. Effects of obstructive sleep apnea in children are disturbed sleep and sleep deprivation with subsequent daytime hypersomnolence and decreased activities, Obesity may be caused by this decreased energy expenditure.



Increased gain in height, weight, and body mass index is associated with treating obstructive sleep apnea by tonsillectomy or adenoidectomy in most children, including the obese.

Fitzpatrick
RE [Univ of California, San
Diego]


Treatment of
Inflamed Hypertrophic Scars
Using Intralesional 6-FU

Dermatol Surg 25: 224 -
232, 1999, Pg 165.

  

Intralesional
injections of 5-FU in a
concentration of 50 mg/ml were
administered in doses ranging
from 2 to 50 mg.

  

Mixing 0.1 ml of Kenalog
[Westwood Squib, Buffalo, NY]
and 0.9 ml of 5-FU in the same
syringe caused less pain and
had greater efficacy.

   

It was rare for a scar to not
respond favorably. Scars with
the greatest response were
typically red, the most
inflamed,
the most symptomatic,
and most firmly 
indurated. The first
signs of response were
typically reduced pain and
itching, followed by softening
of the scar, then flattering
and decreased redness.
Hypertrophic scars were more
responsive than keloids.

   

The use of intralesional
injections alone or in
combination with Kenalog with
pulsed dye laser is safe and
effective in the treatment and
prevention of hypertrophic
scars and some small, isolated
keloids.

Feder HM, Jr. Gerber MA, Randolph MF, et al [ Univ of connecticut, Farmington; Univ of connecticut, Hartford; Danbury, conn; et al]

Once-daily therapy for Streptococcal Pharyngitis With Amoxicillin

Pediatrics 103: 47-51, 1999, Pg. 199



Patients with group A b-hemolytic streptococcal [GABHS] pharyngitis may be better able to comply with once-daily oral amoxicillin therapy than with treatment taken several times a day.



Once-daily amoxicillin treatment is as effective as penicillin V therapy given 3 times daily in the treatment of GABHS
pharyngitis.

Henriksson G, Westrin KM, et al (Huddinge Univ Hosp, Sweden; Karolinska Hosp, Stockholm)

Recurrent Primary Pleomorphic Adenomas of Salivary Gland Origin: Intrasurgical Rupture, Histopathologic Features, and Pseudopodia.

Cancer 82: 617-620, 1998.

    

Retrospective study of 230 patients operated for benign salivary gland pleomorphic adenoma between 1974 to 1993 was done.

   

Occurrence of pseudopodia (fingerlike extensions) appears to be important risk factor for local recurrences. This explains the lower recurrence rate in patients undergoing radical surgery, than those patients with enucleation and limited excisional surgeries with so called normal parotid tissue surrounding the tumour mass. If pseudopodia are present then long-term follow-up (to detect and treat recurrence) is required.

     

The Authors reinforce the importance of appropriate surgical procedure because surgeon is not aware of presence of extensive pseudopodia at the time of surgery.

    

Goode
RK, Auclair PL, et al (Armed Forces Inst of Pathology, Washington, DC: Natl Naval Dental Ctr, Washington, DC)

Mucoepidermoid Carcinoma of the Major Salivary Glands: Clinical and Histopathologic Analysis of 234 Cases with Evaluation of Grading Criteria.

Cancer 82: 1217-1224, 1998.

    

High, intermediate and low grades have been reported. One study denotes the presence of cystic component of less than 10% is considered as high grade.

    

In this study, 337 patients were analysed which included follow-up data. 84% were in parotid. 13% in submandibular gland and 3% in the sublingual gland. Four groups were formed Group I, survival free of disease. Group II, survival with local recurrence, Group III, survival with local metastases and Group IV, death of disease.

    

This study identifies prognostic factors. Outcome varied significantly according to site and grade of the tumour. Metastases from submandibular glands were more frequent. The treatment should be based on clinical stage of the disease and histopathologic guide. Even low grade tumours in submandibular gland needs aggressive treatment and close follow-up.

    

Laskawi R, Rodel R, et al (Univ of Gottingen, Germany)

Retrospective Analysis of 35 Patients with Acinic Cell Carcinoma of the Parotid Gland.

J OralMaxillofac Surg 56: 440-443, 1998.

   

This is a rare tumour, occurs in late middle age commonly in females. Retrospectively studied because of its rarity. The study included 35 patients treated between 1945 and 1994. Surgery is the therapy of choice. The response to radiation is not favourable either to prevent recurrences or increase in survival period. The latter part is of particular interest in management.

     

Yang CY, Andersen PE, et al (Oregon Health Sciences Univ, Portland)

Nodal Disease in Purely Glottic Carcinoma: Is Elective Neck Treatment Worthwhile?

Laryngoscope 108: 1006-1008, 1998.

   

All patients were included with glottic cancer between 1984 to 1994. Ninety-two patients were identified who had at least 2 yrs of follow-up for T stage, cord mobility, CT scan, nodal disease, lesion extension, treatment modality and tumour pathology. Recurrences were reviewed.

    

Occult nodal disease with NO glottic carcinoma was low with 0% incidence in T1 and T2 stage disease and 19% in T3 and T4 stage disease. Only paratracheal level II and III nodes were at high risk. Therefore, elective neck dissection should be performed for advanced disease in case with low morbidity. CT scanning was not useful for staging in these patients.

    

Asakage T, Yokose T, Mukai K, et al (Natl Cancer Ctr Hosp East, Chiba, Japan; Tohoku Univ, Miyagi, Japan)

Tumor Thickness Predicts Cervical Metastasis in Patients with State I/II Carcinoma of the Tongue.

Cancer 82: 1443-1448, 1998

       

The retrospective study included 44 patients with previously untreated stage I/II carcinoma of tongue involving the anterior two thirds of the tongues. They were treated by partial glossectomy only. Twenty-one patients had cervical metastasis and 23 were without. Tumour thickness and other variables were compared.

       

Tumour thickness more than 4mm thickness are at higher risk of cervical metastases and were regarded as having latent metastasis. Conservative supramyohyoid neck dissection, as performed for T1N1 or T2N1 carcinoma of the tongue may be suitable.

        

This article confirms depth of invasion in more predictive of cervical metastasis than T classification. Spiro et al suggested this even for 2mm thickness and more.

    

Cruz
IB, Snijders PJF, Meijer CJ, et al (Univ Hosp Vrije Universiteit, Amsterdam; Academic Centre for Dentistry, Amsterdam)

p53 Expression above the Basal Cell layer in Oral Mucosa is an Early Event of Malignant Transformation and Has Predictive Value for Developing Oral Squamous Cell Carcinoma.

J Pathol 184: 360-368, 1998.

    

Majority of oral squamous cell carcinoma have mutations in the oncogene p53.

    

To determine the relationship, immunohistochemical staining was performed on 11 premalignant lesions in which carcinoma developed. Therefore, p53 expression appears on early event in the carcinogenesis of premalignant lesions. 

   

This combined with histologic criteria of dysplasia is danger sign. If more continued studies demonstrate this, it will be of great value in the management of patients with dysplastic biopsy specimens.

     

Int J Radiat Zakotnik B, Smid L, Budihna M, et al (Inst of Oncology, Ljubljana, Slovenia: Univ Dept. of Otorhinolaryngology and Cervicofacial Surgery, Ljubljana, Slovenia)

Concomitant Radiotherapy with Mitomycin C and Bleomycin Compared with Radiotherapy Alone in Inoperable Head and Neck
Cancer: Final Report.

Oncol Biol Phys 41: 1121-1127, 1998.

    

Sixty-four patients were randomly treated in 2 groups. One group received radiotherapy alone and other group received radiotherapy with concomitant above mentioned chemotherapy.

    

Other group receiving radiotherapy with concomitant chemotherapy had significantly higher complete remission, disease free survival and better survival rates.

C.
Gaelyn Garrett, MD, and Robert
H, Ossoff, DMD, MD
From the Department of
Otolaryngology, Vanderbilt Voice
The Otolaryngologic Clinics of
North America

Phonomicrosurgery II:
Surgical Techniques

Volume 33, Number 5, October
2000, Pg. 1063-1070

  

Vocal
fold stripping almost always
results in the removal of normal
epithelium and a significant
portion of the superficial layer
of the lamina propria [SLLP].
Frequently, the vocal fold heals
with significant scarring within
the lamina propria tethering the
mucosal cover to the underlying
vocal ligament.  Vocal fold vibration is hampered.

  

In the treatment of
benign nonneoplastic lesions,
vocal fold stripping techniques
should therefore be abandoned in
favor of treatments that spare
epithelial and mucosal tissue.

  

Newer
microlaryngeal techniques
attempt adequate excision of the
lesion without removing
surrounding normal tissue.

  

The CO₂ laser causes
tissue ablation to a depth of
approximately 200 mm
at optimal laser settings.

  

It has hemostatic properties for
the microcirculation [vessels
< 50mm],
making it ideal for lesions such
as palilloma that are highly
vascular and involve the
epithelium.

 

Unfortunately, laser energy
causes thermal damage to
surroundings normal tissue,
including the epithelial layer
and deeper portions of the
lamina propria, unnecessarily
increasing the risk for
postoperative scarring.

 

Therefore, do not routinely use
the laser for excision of benign
nonneoplastic vocal fold lesions
when sparing of the mucosal
cover is indicated.

   

Surgical Approach

   

Phonomicrosurgical
techniques have been developed
to preserve as much as possible
the cover-body vibration of the
true vocal fold.
These techniques have
been described as microflap
or mini-microflap
approaches.

   

They take advantage of a natural
surgical plane within the mostly
avascular Superficial  Layer of
the Lamina Propria SLLP.

 

Clinical reviews have
reported excellent results with
the microflap technique.
The goal of the
dissection is to excise the
lesion within the SLLP without
injuring the overlying
epithelium and underlying vocal
ligament.

 

Postoperative Care

  

Patients
are placed on strict voice rest
for 1 to 2 weeks gradual
resumption of voice use under
the guidance of the surgeon and
a speech and language
pathologist. 
Most complaint patients
can expect to achieve 90% or
more of their premorbid voice by
3 months following surgery.



    

Forrest LA, Schuller DE, Karanfilov B, et al (Ohio State Univ, Columbus)

Update on Intraoperative Analysis of Mandibular Margins

Am J Otolaryngol 18: 396-399, 1997

   

In 61 patients with involvement of alvelous, the study of serial frozen section biopsy of the cancellous bone at the mandibular stump demonstrated 100% corelation, and thus the extent of resection of the mandibule could be decided accordingly.

    

This article provides some evidence of the effectiveness of this technique in assessing resection.

    

De Stefani E, Boffetta P, Oreggia F, et al (Registro Nacional de Cancer, Montevideo Uruguay; Inernatl Agency for Research on Cancer, Lyon, France; Academia Nacional de Medicina, Montevideo, Uruguay, et al).

Smoking Patterns and Cancer of the Oral Cavity and Pharynx: A Case-Control Study in Uruguay.

Oral Oncol, Eur J Cancer 34: 340-346, 1998.

    

Four hundred and twenty-five men with confirmed lesions and 427 hospitalized controls were studied.

   

Smoking black tobacco cigarettes seems significant in oral and pharyngeal carcinogenesis. Risk was decreased with filter use and cessation of smoking. Black tobacco contained high tobacco-specific nitrosamines. A high tar content was noted in hand-rolled cigarettes thus combination has more risk of oral cancer.

    

This interesting article can help physicians counseling their patients – particularly impact of tobacco type and use of filtered cigarettes.

    

Colletier
PJ, Garden AS, Morrison WH, et al (Univ of Texas, Houston)

Postoperative Radiation for Squamous Cell Carcinoma Metastatic to Cervical Lymph Nodes from an Unknown Primary Site: Outcomes and Patterns of Failure.

Head Neck 20: 674-681, 1998.

   

Out of 136 patients with cervical metastasis from unknown primary sites, 39 patients underwent excisional biopsy and rest of them various types of neck dissection. All received radiotherapy subsequently. 58 months follow-up was done.

   

Excisional biopsy and radiotherapy offers excellent disease control and survival rates. Those with ECE (extracapsular extension) and multiple nodal involvement the results are not as good. Radiation should start within 3 to 4 weeks and should be of full required dose.

   

Excisional biopsy did not have any reduction in disease control or survival rates. However, it should not be an argument in all cases. Detrimental effects of ECE and multiple nodal involvement is confirmed by this study further. R.A. Otto.

    

Simon D, Koehrle J, Reiners C, et al (Heinrich-Heine-Univ, Dusseldorf, Germany; Unvi of Wurzburg, Germany; Univ of Essen, Germany)

Redifferentiation Therapy with Retinoids: Therapeutic Option for Advanced Follicular and Papillary Thyroid Carcinoma.

World J Surg 22: 569-574, 1998.

   

About 33% of differentiated thyroid carcinoma (DTC) show loss of differentiation during progression of disease and then become refractory to standard treatment.

   

Retinoid treatment (13-cis-retinoic acid) reduces tumour growth and reinduces iodide uptake suggesting that redifferentiation in cancerous growth in (DTC). This is not so in on anaplastic cancer.

   

A 65% response rate was shown among patients of advance DTC. Thyroglobulin levels always do not accompany this response. Therapy is well tolerated with few side effects. No conclusions as the survival rates have been drawn.

   

This study has offered a ray of hope in the management of advanced DTC patients and further studies may offer better hopes. R.A. Otto.

  

Gimm O, Ukkat J, Dralle H (Martin-Luther-Univ Halle-Wittenberg, Germany)

Determinative Factors of Biochemical Cure After Primary and Reoperative Surgery for Sporadic Medullary Thyroid Carcinoma.

World J Surg 22: 562-568, 1998.

  

Twenty-seven patients underwent total thyroidectomy and compartment based microdissection of nodes. Thirty-seven patients with continuously elevated serum calcitonin levels underwent 4-compartment lymphodectomy at reoperation.

   

The report of 100% normalizaiton in serum of calcitonin levels in node negative and pT1 patients is notable. Postoperative calcitonic level is powerful prognostic factor. However, it is not clear whether the patients who are biochemically cured have better outcome. By correlating tumour size with the presence and location of lymph node metastasis, this study provides useful guidelines for the extent of nodal dissection necessary at the time of primary operation of Medullary Thyroid Carcinoma. R.A. Otto.

    

Dralle H, Gimm O, Simon D, et al (Martin-Luther-Universitat Halle-Wittenberg, Germany; Heinrich-Heine Universitat, Dusseldorf, Germany; Gemeinschaftspraxis Innere Medizin-Endokrinologie, Heildelberg, Germany; et al)

Prophylactic Thyroidectomy in 75 Children and Adolescents with Hereditary Medullary Thyroid Carcinoma: German and Austrian Experience.

World J Surg 22: 744-751, 1998.

    

In 1993, the RET proto-oncogene was identified as responsible for hereditary medullary thyroid carcinoma (MTC), since then patients with MTC based genetic screening have achieved biochemical cure by undergoing prophylactic thyroidectomy which prevents MTC and lymph node metastasis from developing.

     

  A major breakthrough in the diagnosis and treatment with identification of this genetic defect in thyroid tumours. Biochemical estimation of serum calcitonin to screen in no longer required. 

    

These authors provide a sensible algorithm for management of these patients. The achievement in 96% patients of a biochemical cure is remarkable. Time will tell if biochemically curing these patients is superior. R.A. Otto.

   

Nilsson O, Lindeberg J, Zedenius J, et al (Karolinska Hosp, Stockholm; Lund Univ Hosp, Sweden; Uppsala Univ Hosp, Sweden)

Anaplastic Giant Cell Carcinoma of the Thyroid Gland: Treatment and Survival Over a 25-Year Period.

World J Surg 22: 725-730, 1998.

    

Between 1930 and 1970, 50% of patients with ATC died within 3 months mainly by suffocation from the local tumour growth. Now only one similar death has occurred since 1989. Local tumour control has been achieved with debulking and pre and post operative doxorubicin and hyperfractionated accelerated radiotherapy.

    

Patel PC, Pellitteri PK, Patel NM, et al (Penn State Geisinger Health System, Danville,Pa)

Use of a Rapid Intraoperative Parathyroid Hormone Assay in the Surgical Management of Parathyroid Disease.

Arch Otolaryngol Head Neck Surg 124: 559-562, 1998.

    

During parathyroid surgery patients underwent neck exploration and the parathyroid hormone assay is done by preremoval of parathyroids and postoperative, during operative procedure, thus guiding whether enough functioning of parathyroid tissue is received. If adenoma is suspected then preoperative 99mTc-sestamibi scanning was used to localize.

   

Thus combination of preoperative scanning and intraoperative parathyroid hormone assay can guide unilateral exploration of neck.

   

Dhingra
JK, Zhang X, McMillan K, et al (Tufts Univ, Boston; Lahey Clinic Med Ctr, Burlington, Mass; Massachusetts Inst of Technology, Cambridge)

Diagnosis of Head and Neck Precancerous Lesions in an Animal Model Using Fluorescence Spectroscopy.

Laryngoscope 108: 471-475, 1998.

     

This animal experiment using laser induced fluorescence spectroscopy demonstrated the utility in the diagnosis of premalignant lesions like leukoplakia or erythroplakia and histologically as metaplasia and dysplasia. 

   

If this technique could be used to enhance over clinical skills (60%-80% reliability) such a tool could be very useful. G.R. Holt.

    

Shaari CM, Farber D, Brandwein MS, et al (Mount Sinai School of Medicine, New York; City Univ of New York)

Characterizing the Antigenic Profile of the Human Trachea: Implications for Tracheal Transplantation

Head Neck 20: 522-527, 1998.

     

This study of 10 human tracheal wall detects Class I (Human leukocyte Antigens A,B and C) and Class II (human leukocyte antigen DR) histocompatibility antigens.

   

Different areas of the trachea have greatly different antigenicity. Minor salivary glands in the wall are highly antigenic. Antigenicity of the perichondrium varies. Mucopolysaccharide matrix is nonantigenic but the chondrocytes have antigenic properties. These differences in antigenicity indicate that some tracheal grafts would be more immunogenic than others and therefore more prone to rejection.

   

This article forms an important foundation upon which tracheal transplantation is an exciting possibility, if all the hurdles are overcome. R.A. Otto.

   

London SD, Park SS, Gampper
TJ, et al (Univ of Virginia, Charlottesville)

Hyperbaric Oxygen for the Management of Radionecrosis of Bone and Cartilage.

Laryngoscope 108: 1291-1296, 1998.

   

Sixteen patients included in this study suggests good results with HBO therapy for the management of radionecrosis of the head and neck. Subjective and objective outcomes improved greatly.

   

HBO therapy has become an important portion of the equation in the prevention and treatment of osteoradionecrosis and
chondroradionecrosis.

    

Davison SP, Sherris DA, Meland NB (Mayo Clinic, Rochester,
Minn; Mayo Clinic, Scottsdale,
Ariz)

An Algorithm for Maxillectomy Defect Reconstruction.

Laryngoscope 108: 215-219, 1998

   

One hundred and eight patients over a period of 5 yrs underwent reconstruction of maxillary defects.

   

The majority can be best reconstructed with a prosthesis,
obturator. The guidelines are :-

    

– First choose a technique that retains greatest residual hard palate without comprising growth excision. 

– Second, position the resection in the socket of an extracted tooth, to preserve tooth adjacent to the defect. 

– Third, consider a split thickness skin graft. 

– Fourth, to avoid the influence with the obturator bulb, remove the inferior turbinate. 

– Fifth, if possible, use a feasible preserve palatal disease free mucosa for tissue coverage.

   

Finally consider the removal of residual adynamic soft palate if 50% or more has to be
resected. Preoperative planning of the surgical approach is crucial, and the authors offer an algorithm to assist in this process.

   

KJ Doyle, Y
Sininger, A Starr (Univ of California, Irvine; House Ear Inst, Los Angeles)


Auditory Neuropathy in Childhood.


Laryngoscope 108: 1374-1377, 1998

    


Auditory neuropathy has the following clinical features: Hearing loss for pure tones, impaired word discrimination, abnormal auditory brain stem responses, and NORMAL outer hair cell function. The results of audiologic testing in 8 children with hearing deficits most likely caused by neuropathy of the eighth nerve were reported.

   


The assessments suggested that, though cochlear outer hair cell function was normal, the lesion was located at the eighth nerve.

  

JK
Thiringer, MA Arriaga (Lackland Air Force Base, Texas; Pittsburgh Ear Associates, Pa)


Stapedectomy in Military Aircrew


Otolaryngol Head Neck Surg 118:9-14, 1998.

   

Stapedial surgery may pose a considerable risk for those in certain occupations e.g. military aircrews who challenge the function of the cochleovestibular system with each mission. Aircrew members who have had stapedectomies have been rejected for all flying duties by the Surgeon General of the Air Force. As additional clinical experience was gained, waivers for flight duty were granted on an individual basis. The aeromedical outcome for aircrew members who returned to flight duty after stapedectomy was reviewed.

   


Before aircrew members returned to flight duty, patients were subjected to centrifuge and altitude -chamber testing, electronystagmography, rotational chairs, and actual test flights. In the entire group studied, no episodes of sudden hearing loss or vestibulopathic conditions occurred.

    

JP
Leonetti, T Origitano, et al (Loyola Univ, Maywood, III)


Intracranial Complications of Temporal Bone Osteoradionecrosis


Am J Otol 18:223-229, 1997

  

Osteoradionecrosis of the temporal bone may follow radiation to the brain, parotid gland, nasopharynx, or superior cervical area. Life-threatening intracranial complications may follow.

  


In 4 patients studied, complications observed were multiple brain abscesses, aneurysm of the internal carotid artery; a cholesteatoma of the external auditory canal with extensive destruction of the mastoid bone leading to thrombosis and meningitis of the sigmoid sinus; meningitis with a small epidural abscess over the middle fossa dura; and prolonged infection of the ear canal, middle ear, and mastoid resulting in fatal otitic meningitis. The 3 patients who underwent surgery (mastoid) survived requiring careful and regular follow-up.

  

PA Fagan, JP Sheehy, et al (St. Vincent’s Hosp, Sydney, Australia)


The Cerebellopontine Angle: Does the Translabyrinthine Approach Give Adequate Access?


Laryngoscope 108: 679-682, 1998



It was previously believed that the translabyrinthine approach provided inadequate access to the cerebellopontine angle. The authors after analyzing 33 patients undergoing translabyrinthine surgery and 13 undergoing the posterior fossa approach have concluded that the translabyrinthine approach enables superior visualization through a wider angle of surgical access with minimal cerebellar retraction.

HM
Dunniway, DB Welling (Ohio State Univ, Columbus)


Intracranial Tumors Mimicking Benign Paroxysmal Positional Vertigo.


Otolaryngol Head Neck Surg, 118:429-436, 1998.



Benign positional vertigo may not always be benign, as indicated in this study where intracranial tumors were identified in five patients who presented as “benign paroxysmal vertigo.”



When patients of “benign paroxysmal vertigo” do not improve after particle repositioning manoeuver, further assessment is needed to rule out intracranial new growths.

   

RC O’Reilly, SB Kapadia, D.B. Kamerer (Univ of Pittsburgh, Pa)

Primary Extracranial Meningioma of the Temporal Bone.

Otolaryngol Head Neck Surg 118:690-694, 1998.



Though meningiomas typically occur intracranially, they may rarely arise de novo in the temporal bone. Because of the invasive nature of this tumor, surgical resection is difficult, and postoperative surveillance is necessary.

AE-M
Moussa, KA Abou-Elhmd (South Valley Univ, Sohag, Egypt)

Wegener’s Granulomatosis Presenting as Mastoiditis

Ann Otol Rhinol Laryngol 107:560-563, 1998.



Wegener’s granulomatosis is an uncommon auto-immune disorder, which has a peak incidence in the fifth decade of life with a slight male predominance. Typically, nasal problems are the initial manifestation. Otologic symptoms are rare.



The authors report 2 cases of Wegener’s granulomatosis manifesting as mastoiditis (a fourteen-year-old girl and a 20-year-old woman).

   

Harti DM, P Aidan, O Brugiere, et al (Universite Paris VII)

Wegener’s Granulomatosis Presenting as a Recurrence of Chronic Otitis Media.

Am J Otolaryngol 19: 54-60, 1998.





This is a case report of Wegener’s Granulomatosis manifesting otitis media with facial palsy. Plasma antineutrophil cytoplasm antibodies were detected by means of immunofluorescence. After three weeks of immunosuppressive therapy, facial palsy disappeared, the ESR had normalized and the size of pulmonary nodules had decreased.



This case report highlights the need to bear in mind non-infectious causes of chronic otitis media with
otorrhea.

R
Indudharan, T Arni, KK Myint, et al (Universiti Sains Malaysia, Kelantan; Hosp Tengku Ampuan Afzan, Kuantan, Malaysia)

Lymphoblastic Lymphoma/Leukemia Presenting as Perichondritis of the Pinna.

J Laryngol Otol 112: 592-594, 1998





A patient treated for perichondritis of the pinna was eventually determined to have B-lineage lymphoblastic lymphoma evolving to a leukemic phase. There was no pre-existing immunodeficiency.



Though lymphoma is the second most common malignancy of the head and neck region, the pinna as the extranodal site of lymphoma, has been previously reported only once. Hence the need to broaden one’s diagnostic horizon when inflammatory lesions do not heal within a reasonable period.

  

G
Venkatraman, DE Mattox (Univ of Maryland Baltimore)

External Auditory Canal Wall Cholesteatoma: A Complication of Ear Surgery.

Acta Otolaryngol (Stockh) 117 :293-297, 1997.





Large primary cholesteatomas of the external auditory canal are rare. Cases arising from previous surgery are even less common.



This article presents five cases of cholesteatomas arising from the floor of the external auditory canal after ear surgery. In all these patients, the cholesteatomas were extensive enough to require surgery. The authors postulate that a careful surgical technique would help prevent canal wall cholesteatoma.

   

E
Gur, A Yeung, M Al-Azzawi, et al (Univ of Toronto)

The Excised Preauricular Sinus in 14 Years of Experience : Is There a Problem ?

Plast Reconstr Surg 102: 1405-1408, 1998.





A few of the patients having a congenital pre-auricular sinus suffer from recurrent infections. In such cases surgical excision of the sinus tracts is required. Recurrence is very likely if the tract is not excised completely.



The authors have reviewed 165 primary preauricular excision procedures in 146 patients over a period of 14 years.



The recurrence rate was higher (15.79%) in patients who had active infection during surgery than in patients who did not have active infection (8.22%). The recurrence rate was higher (16.7%) in patients who had surgical drainage of an abscess before the procedure, and 8.16% in those who did not.



Recurrence rates can be reduced by excising a piece of cartilage at the base of the tract and by demonstrating the sinus with dye injection and/or probing at the time of surgery.

    

Steven
M Zeitels, MD

Phonomicrosurgery I :
Principles and Equipment

The Origin and Development of
Endoscopic Laryngeal Surgery

From the Department of Otology
and Laryngology, Harvard Medical
School; and the Division of
Laryngology, Massachusetts Eye
and Ear Infirmary, Boston,
Massachusetts

The Otolaryngologic Clinics
of North America Volume
33, Number 5, October 2000, Pg.
1047-1062

    

PHONOMICROSURGERY-

  

Phonomicrosurgery is a means of
maximally preserving the layered
microstructure of the vocal
fold, that is, the epithelium
and lamina propria.

   

Tissue Dissection : Laser
Versus Cold Instruments.

Unlike the laser, cold
instruments provide tactile
proprioception during delicate
microdissection.

  

Infusion into the superficial
lamina propria is often helpful,
whether a laser or cold
instruments are used.

  

Precise tangential
dissection within the
superficial lamina propria
[i.e., subepithelial cyst
dissection] is better
accomplished with cold
instruments.

  

Cold instruments facilitate
maximal preservation of the
layered microstructure [lamina
propria and epithelium] of the
vocal folds.

   

The CO₂ laser is
typically used for vocal fold
surgery and enhances cold fd  
instruments when the
pathologic condition is vascular
or is too large.

   

The Rationales of
Phonomicrosurgery.

Phonomicrosurgical
procedures are designed to
improve aerodynamic efficiency
and vocal quality by creating a
smooth vocal fold edge that is
not excavated with overlying
flexible epithelium.

    

There is a little difficulty in
the growth and regeneration of
normal epithelium, as occurs
after a cordectomy that is left
to heal secondarily.

     

The subepithelial infusion of
saline ad epinephrine into the
superficial lamina propria has
further enhanced the precision
of microlaryngoscopic vocal fold
surgery with the use of both
laser and cold instruments.

   

The author has used
cold-instrument epithelial
incision as a standard approach
for the management of such
pathologic conditions as cysts,
epithelial atypia, and cancer.

   

During the last 4 years, this
approach has been extended to
the management of nodules,
polyps, ectasias, and varices,
so a subepithelial resection of
these traumatic lesions has
become standard.

    

Phonomicrosurgery has emerged as
a physiologically based approach
for benign and malignant
disease.

      

T Hoshino, Y Ueda, H Mukohdaka, et al (Hamamatsu Univ, Japan)


Acute Granulomatous Myringitis


J Laryngol Otol 112: 150-153, 1998

   

Acute and chronic myringitis seem to be caused by two different entities. 

    

Acute myringitis manifests the following – otalgia, a granulomatous bulge along the malleus, and no middle ear infection.

    

Chronic myringitis is characterized by erosion or thin granulation of the tympanic membrane – it can recur after debridement and cautery.

    

Granulomatous changes of the tympanic membrane are rare. This article describes five causes of acute granulomatous
myringitis.

NH Blevins, BL Carter (Tufts-New England Med Ctr, Boston)

Clinical Forum: Routine Preoperative Imaging in Chronic Ear Surgery,

Am J Otol 19: 527-538, 1998.

    

Imaging studies, especially CT, can demonstrate the nature and extent of chronic otitis media, which may not be apparent on clinical findings per se. Such findings can affect operative treatment, especially in difficult and/or revision procedures. However, there is a view that routine radiography of the mastoid may suffice in being very helpful in most cases.

   

TS
Karhuketo, HJ Puhakka (Tampere Univ, Findland)

Middle Ear Imaging Via the Eustachian Tube With a Superfine Fiberoptic Videomicroendoscope.

ORL J Otorhinolaryngol Relat Spec. 60: 30-34, 1998.

   

With a fibreoptic videomicroendoscope inserted through the Eustachian tube, 56% of predetermined anatomical objects in the middle ear were visualized. 

   

However, one may find obstructive sites or mucosal folds that may prevent a complete view of all the contents of the middle ear cleft.

    

RL Hebert II, GE King, JP Bent III (Med College of Georgia, Augusta)


Tympanostomy Tubes and Water Exposure: A Practical Model.


Arch Otolaryngol Head Neck Surg 124: 1118-1121, 1998.

   

Myringotomy with tympanostomy tube placement is one of the very common otolaryngologic procedures done nowadays.

   

Contrary to previous thinking, the authors have shown that entry of water into the middle ear is not promoted by showering, hair rinsing, or submersion of the head in clean tap water. The chances of water contamination increase by submersion in SOAPY water or swimming at a depth of more than 60 cms.

   

Many of the previously advised water precautions are unnecessary in patients with tympanostomy tubes.

    

Rath
T, Millesi W, Lang S, et al
(Univ of Vienna)

Mucosal Prelamination of
a Radial Forearm Flap for
Intraoral Reconstruction.

Eur J Plast Surg 21:
166-170, 1998.

   

In 5 patients the use of a
distal radial forearm flap
to which buccal mucosal
grafts were meshed in
reconstructing oral defects
after radical resection of
squamous cell carcinoma is
described. It was safe, easy
to use and successful.
Although the time is needed
between creation of the flap
and its insertion, this time
can be used to deliver
preoperative radiation and
chemotherapy.

  

Yotsuyanagi
T, Yokoi K, et al (Hirosaki
Univ, Japan)

A Supportive Technique
Using a Splint to Obtain
Definite Contour and
Desirable Protrusion After
Reconstruction of Microtia

Plast Reconstr Surg
101: 1051-1055, 1998

    

The use of thermoplastic
splint is used in 17
patients directly to the
newly constructed ear, to
prevent deformity resulting
from odema and scarring.
Patients were monitored for
3 yrs. The splints were used
after the first and second
stage of costal cartilage
grafting.

    

This technique is worth
consideration. G.R. Holt.

      

Personelle
J, de Souza Pinto EB, Ruiz
RO (Sao Paulo, Brazil)

Injection of Vitamin A
Acid, Vitamin E, and Vitamin
C for Treatment of Tissue
Necrosis.

Aesthetic Plast Surg
22: 58-64, 1998.

   

Experimental animals used
were rats. Injection of ACE
pool, composed of all-transretinoic
acid, vitamin A, and vitamin
E is useful for the
treatment of necrosis after
routine plastic surgery.

   

The antioxidants and their
general health effects were
used orally in selected
patients to better prepare
their tissue for surgery by
G.R. Holt and found this
regimen to be useful. 

   

Well controlled clinical
trial is needed – G.R. Holt.

  

Abou
Chebel N, Beziat J-L,
Torossian J-M (CHU Lyon-Nord,
Cedex, France)

Le Lambeau Myo-Muqueux de
Buccinateur Pedicule sur les
Vaisseaux Faciaux: Interet
Dans la Reconstruction du
Plancher de la Cavite
Buccale: A Propos de 10 Cas.

Ann Chir Plast Esthet
43: 252-257, 1998

   

Ten patients were given the
flap. The musculomucous
buccinator flap described
provided excellent-
functional and esthetic
results in the repair of the
floor of the mouth. Its
flexibility ensures good
tongue mobility. However, it
requires extraction of the
mandibular molars and also
must have intact facial
artery that can be raised
with the flap. The Doppler
could also be used to
identify the course of the
facial artery intraorally.
The flap must be placed
anterior to the parotid duct
and opening. The patient
must now chew if the flap
crosses alveolar ridge. G.R.
Holt.

    

Kuhn
J, Toohill RJ, Ulualp SO, et
al (Med College of
Wisconsin, Milwaukee)

Pharyngeal Acid Reflux
Events in Patients with
Vocal Cord Nodules.

Laryngoscope 108:
1146-1149, 1998.

    

This study with controls
demonstrated patients with
vocal nodules were
significantly more likely to
experience pharyngeal acid
reflux and pharyngeal
episodes were more frequent.
These finding suggests a
contributory role for GEPR
in pathogenesis of vocal
cord nodules. Given this
association, the vocal cord
nodules in some patients
should follow antireflux
precautionary steps like
elevating the head while
sleeping and avoiding food 3
to 4 hrs before bedtime.

    

Barium swallow is a poor
indicator of reflux. It
should also use empirical
therapy of reflux in
patients without any cause
for development of vocal
nodules. G.R Holt.

    

Rosenbower
TJ, Morris JA Jr, Eddy VA,
et al (Vanderbilt Univ,
NashvilleTenn)

The Long-term
Complications of
Percutaneous Dilatational
Tracheostomy.

Am Surg 64: 82-87,
1998.

   

Out of 237 patients admitted
in trauma centre, 95
patients underwent
percutaneous tracheostomy.
Fifty-five patients were
available for final
follow-up.

    

The long-term complication
rate of PDT is comparable to
that of open tracheostomy.
It is rapid, safe, easy,
cost effective and is useful
in patients requiring
prolonged ventilatory
support.

     

Ebraheim
NA, Lu J, Skie M, et al (Med
College of Ohio, Toledo)

Vulnerability of the
Recurrent Laryngeal Nerve in
the Anterior Approach to the
Lower Cervical Spine.

Spine 22: 2664-2667,
1997.

    

This is cadaveric study.
Anatomy demonstrated suggest
danger of injury to
recurrent laryngeal nerve
more on right side because
the nerve courses outside
esophagotracheal groove and
runs in oblique direction
relative to the sagittal
plane. Inferior thyroid
vessel should be ligated as
laterally as possible and
the retractor should be
blunt tipped to retract the
longus colli muscle to
provide intermittent
retraction of the midline
structures.

    

This article highlights the
rationale of using left
sided approach to the spine
when possible. If right
sided approach is used then
above precautions are
necessary to prevent injury
to recurrent laryngeal
nerve.

    

Postma
GN, Shockley WW (Naval Med
Ctr, Portsmouth, Va; Univ of
North Carolina, Chapel Hill)

Transient Vocal Fold
Immobility

Ann Otol Rhinol
Laryngol 107: 236-240, 1998

    

Common causes of adult vocal
fold immobility (VFI)
include, thyroid surgery,
nonlaryngeal malignancy and
viral insult. The 3 patients
had acute VFI, an unusual
condition.

    

This VFI lasts for 4 weeks
or less. Anything lasting
more than 12 months is
called permanent. A variety
of causes of transient and
temporary VFI, have been
identified: metabolic,
traumatic, infectious or
inflammatory, autoimmune,
CNS, mechanical and
neoplastic. Some cases are
idiopathic.

   

This is nice article about
the temporal differences
between transient, temporary
and permanent vocal fold
immobility. These are to be
identified before any
therapy is undertaken.

   

Filler
RM, Forte V, Chait P (Univ
of Toronto; Hosp for Sick
Children, Toronto)

Tracheobronchial Stenting
for the Treatment of Airway
Obstruction

J Pediatr Surg 33:
304-311, 1998

   

A balloon expandable stent,
the Palmaz stent, was
inserted into 16 children
with a variety of major
airway obstructions. Thirty
stents were inserted in 24
separate procedures during
the 5 yrs.

   

Results showed they are
extremely useful in the
treatment of neonates and
infants with localized
tracheomalacia and
bronchomalacia in those with
airway obstruction caused by
surgery for congenital
tracheal stenosis, in
patients with incurable
congenital heart disease.
The stents can be inserted
easily and can be left for
long periods if necessary.

    

More clinical studies need
to be performed using
improved stent designs, to
optimize the results – G.R.
Holt.

   

Yumoto
E, Sanuki T, Hyodo M, et al
(Ehime Univ, Japan)

Three-Dimensional
Endoscopic Mode for
Observation of Laryngeal
Structures by Helical
Computed Tomography.

Laryngoscope 107:
1530-1537, 1997.

   

Helical scanning CT was used
to produce high quality 3D
endoscopic images of larynx.
The method has been
described. The method used
was in 12 patients with
normal and affected larynx,
either by cancer, nerve
palsy and atrophy. This
method provided useful
diagnositc and therapeutic
information in patients with
RLN palsy. In cancer
patients axial images
allowed better assessment of
characteristic lesions than
CT endoscopic images alone.

   

This new technology can take
3D data and through
obstruction technique,
produce an image than
appears as the
“New” of the
larynx through an endoscope.
G.R.Holt.

    

Riley
RW, Powell NB, Guilleminault
C, et al (Stanford Univ,
Calif)

Obstructive Sleep Apnea
Surgery: Risk Management and
Complicaitons

Otolaryngol Head Neck
Surg 117: 648-652, 1997.

    

Patients who undergo surgery
for obstructive sleep apnea
syndrome (OSAS) are at
increased risk for
postoperative airway
obstruction, hypoxemia,
hypertension and death.

    

In 182 patients with 210
surgeries for OSAS, the risk
factors were identified and
were overcome.

    

The use of fibre optic
intubation can reduce
intraoperative complications
with OSAS who have large
neck circumference and
facial skeletal deficiency.
Hypertension is a
significant risk factor, and
requires aggressive
treatment. Nasal continuous
positive airway pressure (CPAP)
prevents hypoxemia.

    

This article provides useful
tips for the perioperative
management of OSAS patients.
R.A. Otto.

    

Osterlund
A, Engstrand L (Univ Hosp,
Uppsala, Sweden)

An Intracellular
Sanctuary for Streptococcus
Pyogenes in Human Tonsillar
Epithelium: Studies of
Asymptomatic Carriers and In
Vitro Cultured Biopsies.

Acta Otolaryngol (Stockh)
117: 883-888, 1997.

    

Streptococcus pyogenes was
found in epithelial cells
for both symptomatic and
asymptomatic patients. This
intracellular reservoirs
could serve as the source
for reinfection. Perhaps
antibiotics with good
intracellular penetration
should be used.

    

This study provided the
novel hypothesis that the
inner harbor for S.pyogenes
in the tonsils may be
intracellular and therefore
requires the antibiotics
capable of penetrating and
destroying this
intracellular bacteria,
thereby, completely
eradicating the bacteria and
the chances of reinfection
or passing on the infection
to others. G.R. Holt.

    

Ament
PW, Paterson A (Latrobe Area
Hosp, Penn)

Drug Interactions with
the Nonsedating
Antihistamines

Am Fam Physician 56:
223-230, 1997.

    

The nonsedating
antihistamines – which
include astemizole,
fexofenadine, loratadine and
terfenadine – are very
commonly prescribed drugs.

   

Terfenadine and astemizole
cause serious adverse
effects in interaction with
macrolide antibiotics or the
antifungal agents, quinine
Such interaction appears to
be less likely with
fexofenadine and Loratadine.

    

To avoid an adverse effect
(drug-drug interactions) one
must avoid prescribing any
medication that may
influence cytochrome P450
system.

    

Iro
H, Zenk J, Waldfahrer F, et
al (Saarland Univ, Homburg,
Germany; Univ of Erlangen-Nuremberg,
Germany; Dr. Horst-Schmidt-Klinikum,
Wiesbaden (EII) Germany) 

Extracorporeal Shock Wave
Lithotripsy of Parotid
Stones: Results of a
Prospective Clinical Trial.

Ann Otol Rhinol
Laryngol 197: 860-864, 1998.

    

A total of 76 patients
ranging form 2 to 80 yrs
were treated. These patients
were treated with routine
treatment of sialogogues,
bougienage, gland massage
etc. with no resolution.

   

This effective treatment
gives reliable long-term
results. With this
treatment, parotidectomy and
its accompanying
complications can be
avoided.

    

Marvez-Vals
EG, Ernst AA, Gray J, et a
(Louisiana State Univ, New
Orleans; Vanderbilt Univ Med
Ctr, Nashville, Tenn)

The role of Betamethasone
in the Treatment of Acute
Exudative Pharyngitis.

Acad Emerg Med 5:
567-572, 1998.

    

The double-blind clinical
trial was performed over 3
months. Forty-six patients
were randomized to placebo
and 46 to Betamethasone.

     

Betamethasone, used as an
adjunct to antibiotic
therapy reduces the time to
pain relief. Most effective
in patients with
streptococal positive.

      

Naumann
M. Zellner M, Tokya KV, et
al (Bayerische Julius -Maximilians
Universitat, Wurzburg,
Germany)

Treatment of Gustatory
Sweating with Botulinum
Toxin.

Ann Neurol 42:
973-975, 1997.

    

Gustatory sweating (Frey’s
syndrome) has been treated
with scopolamine or aluminum
hydrochloride and tympanic
nerve destruction.

    

Intracutaneous injections of
botulinum toxin (BTX) type A
are more effective.
Forty-five patients were
treated. 50% patients
reported complete relief and
50% showed substantial
improvement.

   

This is safe and effective
method. Long-term follow up
is needed. G.R. Holt.

    

Adair-Bischoff
CE, Sauve RS (Univ of
Calgary, Alberta, Canada)

Environment Tobacco Smoke
and Middle Ear Disease in
Preschool-Age Children.

Arch Pediatr Adolesc
Med 152: 127-133, 1998

    

Six hundred and twenty-five
eligible children for this
study were reviewed.

    

Conclusions: Exposure to
environmental tobacco smoke
(ETS) during the first 3yrs
of life significantly
increased the risk of middle
ear diseases (MED) in these
first-grade children.
Greater exposure to (ETS)
had greater risk for MED.

    

Avoding ETS during the first
3 years of life could have
significant impact on MED
and its associated
morbidities.

     

Berrylin
J Ferguson (Divn. Of
Sino-nasal Disorders and
Allergy, Dept. of
Otolaryngology, Univ. of
Pittsburgh School of
Medicine, Pennsylvania)

Mucormycosis of the Nose
and Paranasal Sinuses

Otolaryngo Clinics of
North America, Vol.33(2),
April 2000; 349-365

      

It is uncommon and rarely
affects healthy host. But
for the afflicted patient,
the speed with which it
progresses and leads to the
death, warrants immediate
diagnosis and emergency
treatment. It can be seen in
diabetics and other
immunocompromised patients.
It starts in sinonasal
region but rapidly
progresses to rhinocerebral
region and orbit producing
proptosis and
ophthalmoplegia.

     

Aetiopathology

It is a term used to refer
to fungal infections of the
order Mucorales which
belongs to the class
zygomycetes. These are
termed as zygomycosis. This
would also incorporate the
other order of the class
Entomophthorales. This
latter is a tropical
granulomatous infection of
the subcutaneous tissues and
paranasal sinuses by
Basidiobolus and Delacroixia,
which responds to local care
in contrast to the order of
mucorales.

    

Most pathogenic species are
members of the family.
Mucoraceae, Rhizopus, Oryzae
is the predominant pathogen
and accounts for 60% of all
forms of mucormycosis and
90% of rhinocerebral cases
of mucormycosis.
Apohysomyces elegans is the
most recently recognised
agent and caused
mucormycosis in an
immunocompetent individuals.

    

Diabetics in ketoacidosis
are disproportionately
affected. Out of 26 patients
with rhinocerebral
mucormycosis, 70% were
diabetic.

    

Other risk factors include
neutropenia, systemic
steroids, protein calorie
nutrition, solid organ and
bone marrow transplant,
immunodeficiency, leukaemia,
intravenous drug abusers who
may inject spores of
mucorales with their drugs
and then present with
space-occupying lesions of
the central nervous system.
The relative infrequency of
mucormycosis in patients
with AIDS probably reflects
the ability of neutrophils
to prevent growth of the
fungus.

    

Signs and symptoms reported
in patients within 72 hours
of onset of
Rhino-Orbital-Cerebral
Mucormycosis.

    

¨ Fever

¨ Nasal ulceration or
necrosis

¨ Periorbital or facial
swelling

¨ Decreased vision

¨ Ophthalmoplegia

¨ Sinusitis

¨ Headache

¨ Facial pain

¨ Decrease in mental status

¨ Nasal discharge or
stuffiness

¨ Corneal cellulitis

¨ Orbital cellulitis

¨ Proptosis

¨ Palatal or gingival
necrosis

¨ Afferent pupillary defect

¨ CN VII palsy

¨ Periorbital pain

¨ Chemosis (without orbital
cellulitis)

¨ Epistaxis

¨ Facial numbness

¨ Diplopia

¨ Facial necrosis

¨ Hemiplegia/stroke

¨ Malaise

¨ Ptosis (without
ophthalmoplegia)

¨ Decreased hearing

¨ Toothache

¨ Earache.

   

   

Treatment

      

    1)
Reversal of cause of
immunocompromisation

      

    2)
Systemic Antifungal
Amphotericin B

       
Systemic amphotericin can be
administered 1 to 1.5mg/kg
per day intravenously by
monitoring patients

     

    3)
Repeated and extensive
surgical debridement

       
External techniques like
external ethmoidecormy or
Caldwell-Luc procedure,
preferred to endoscopic

       
management

       
Orbital exenteration was
advocated but is now
controversial.

         

    4)
Topical application of
amphotericin is 50mg vial
and intravenous amphotericin
B and 10mL of sterile

        
water. This can be nebulized
with a Rhinoflow device into
the nose. The dosage is 4 mL
in each

        
nostril 2 to 6 times a day.

        

    5)
Hyperbaric oxygen can be
used. It helps reverse the
ischaemic acidotic
conditions that perpetuates

       
fungal growth. Usually given
at two atmospheres for 1 hr
on a daily basis upto 30
treatments. It then

       
limits deformity by
decreasing tissue of
debridement.

          
  

Kenneth
M Grundfast, Nicole Siparsky
and Diana Chuong 

Genetics and Molecular
Biology of Deafness- Update

The Otolaryngologic
Cl. Of North America,
Vol.33(6), Dec.
2000,p.1367-1394

     

Incidence of acquired types
of hearing impairment
diminished, but a growing
proportion of all childhood
hearing impairment is seen.

    

Until recently only genes
for HHI (Hereditary Hearing
Impairment) were identified
as syndromic causes. However
in last 5 yrs many non-syndromic
HHI were identified
contributing to the HHI.
Fifty-three loci have been
identified for nonsyndromic
HHI. Otolaryngologists,
therefore, should have basic
knowledge of HHI in order to
diagnose, treat and prevent
sensorineural hearing
losses.

   

Currently 25% of hearing
impairment are congenital.
50% of these are hereditary.
2/3rd of these hereditary
are nonsyndromic and 1/3rd
are syndromic. 

    

Apart from monitoring of
infants at risk by OAE (otoacoustic
emissions) and auditory
brainstem response (ABR),
newborn screening should
include genetic testing
(GJB2) as well, but is
prohibitively expensive.

   

Almost 50% of inherited
deafness is caused by
mutations in GJB2, which
encodes connexin -26, a gap
junction component on
chromosome 13.

   

In such early detection,
early interventional
programmes give larger
benefit to these infants and
children.

   

Definition of Hearing
loss vs Hearing Impairment

Hearing loss means
hearing was lost at birth

Hearing Impairment means
child was born with hearing
impairment.

   

Deafness versus hearing
Impairment

Deaf patient uses sign
language primarily while
hearing impaired patient
uses speech as communication
method.

    

Congenital Hearing
Impairment (CHI) versus
Hereditary Hearing
Impairment (HHI)

CHI means deafness
present at birth. It may be
because of genetic mutation
or pathologic process which
occurs either during
pregnancy or labour.

   

HHI is the result of genetic
mutation. It can manifest at
birth or develop later in
life.

    

HHI present at birth is
congenital hereditary
hearing impairment, while
HHI develops later is
delayed onset hereditary
hearing impairment. One of
the most common types of HHI
is autosomal dominant
nonsyndromic delayed-onset
of progressive hearing loss.
Depending on the severity in
the family, hearing loss
will progress with the age.
Several other family members
affected helps it to
differentiate this
hereditary disorder from
autoimmune inner ear
disorder.

    

Syndromic versus
Hereditary Hearing
Impairment

The cause of a syndrome
is either genetic or
exogenous factors.

   

Genetic examples are
Usher’s, Pendred’s,
Waardenburg’s,
branchio-oto-renal
syndromes. Exogenous
examples are gene mutation
caused cytomegalovirus,
rubella or Goldenhar’s
syndromes.

    

It is important to remember
that gene mutation can occur
spontaneously so that a
child affected may not have
other relatives who are also
affected.

    

Syndromic versus Genetic
Disorder

 It is important to
note that syndromes which
include hearing loss, may
not manifest with it but can
have other features. For
example, Waardenburg’s
syndrome only 17% have
hearing loss. This is
because of variability of
gene expression.

   

   

SYNDROMES AND
NONSYNDROMIC HEARING LOSS

    

There are 200 different
syndromes with hearing
impairment. Nearly,
two-third is termed
nonsyndromic which are
associated with no other
anomalies. Various modes of
inheritance is seen in both
viz autosomal recessive,
autosomal dominant and
X-linked transmission.
Identification and location
of many genes will further
enhance understanding of
this disorder.

   

Inheritance Patterns

Hereditary implies
genetic basis of disorder.
Three classical types being
autosomal recessive,
autosomal dominant or
X-linked recessive. Though
inheritance pattern varies
in classical Mendelian
patterns, the HHI is
secondary to the interaction
of several genes or the
result of an interplay
between genetic and
environmental factors.

   

(a) Autosomal Recessive

Autosomal recessive
comprises of 80% of
hereditary deafness and the
most common pattern. In the
recessive transmission, the
parents have normal or near
normal hearing, inspite of
possessing recessive gene.
Typically there is a 25%
chance that offspring might
suffer. This is
characterized by horizontal
pattern. For offspring to
exhibit, both parents must
be carriers of the genetic
disorder.

    

(b) Autosomal Dominant

Approximately 18% of
cases. A vertical pattern of
transmission. When one
parent is a carrier, 50% of
the offsprings suffer. If
new mutation occurs in gene,
it is inherited in dominant
fashion. – thus offspring
may be the first affected in
the family.

   

(c) X-Linked Recessive

1% to 3% suffer. Genes
located on X-chromosomes are
involved. Affects males.
This pattern of inheritance
is similar to that of
haemophilia, where mothers
being the carriers but their
male offspring are affected
individuals.

    

Abnormalities in
Mitochondrial DNA

This is another mode of
inheritance of HHI. Maternal
oocyte is the sole
contributor of mitochondria.
So any mitochondrial DNA
mutation responsible for HHI
in the mother will be
transmitted to all of that
mother’s offsprings. In some
families, hearing loss may
be the only mitochondrial
disease.

    

Mitochondrial DNA encodes
mitochondrial proteins, tRNA
and rRNA. Mutation in tRNA
and rRNA are associated with
nonsyndromic hearing loss.
Another suspect in
mitochondrial HHI is a
mitochondrial import protein
deafness/dystonia peptide (DDP).

   

The expression of
mitochondrial HHI varies
greatly. Several other
mitochondrial genes
associated with nonsyndromic
hearing loss and syndromic
is already listed. Mutation
in mitochondrial DNA
encoding tRNA have been
linked to HHI whereas
mutation of Rrna is
associated with
susceptibility to
aminoglycoside ototoxicity.
DNA mutation mt3243 is
associated with two
syndromes (1) maternally
inherited diabetes and
deafness (MIDD) and (2)
myopathy-encephalopathy-lactic
acidosis stroke (MELAS).

      

      

PENETRANCE, EXPRESSIVITY,
AND GENETIC HETEROGENEITY

The diagnosis of HHI
inherited by autosomal
recessive and autosomal
dominant is not easy in some
cases because of lack of
manifestation of the
features.

      

The penetrance is the
terminology used to indicate
manifest expression of a
gene. It is all-or-none
phenomenon. So there are
penetrant and non-penetrant
genes. The expressivity is
used to indicate the degree
to which a penetrant gene
will cause expression of
abnormal function.

      

Expression may be varied,
even though the two
individuals may possess the
same gene. Recent research
suggests that the sex of the
parent from whom a gene
mutation is inherited will
influence the expression.
This is termed as Genomic
Imprinting.

    

Genetic heterogenicity
implies that different
mutations involving
different genes can result
in an identical or similar
phenotype. Not to be
confused with a polygenic
disorder, which is a
phenotype that results from
the interaction of multiple
genes.

    

Classification of
Hereditary Hearing
Impairment

     

a) Syndromic
Hereditary Hearing
Impairment

Syndromic are upto 30% of
children with hereditary
hearing impairment. There
are many causative genes for
these syndromes which have
been identified. These are
clinical syndrome. Hearing
loss is conductive or mixed.

    

b) Nonsyndromic
Hereditary Hearing
Impairment

Almost 2/3rd in numbers. It
is almost exclusively caused
by mutations of single gene
and these hearing
impairments are not
associated with any other
abnormalities.

    

There are several modes of
inheritance of nonsyndromic
HHI genes. Several genes
have been isolated and
cloned. The long list of
genes, their loci and
location on the chromosomes
of autosomal recessive
nonsyndromic HHI has been
given and will be increasing
as the research continues (Ref:
Data from Van Camp G, Smith
RJH: Hereditary Hearing Loss
Homepage.)

    

The list of syndromes out of
few hundred, with inherited,
gene, loci and location on
chromosomes is prepared (Ref:
Data from Van Camp G, Smith
RJH: Hereditary Hearing Loss
Homepage.)

    

Hearing Loss Genes and
Their Gene Products:

    

Almost all genes implicated
in HHI are identified in
last 10 years. These genes
encode related proteins
which are studied in detail
and include:

   

a) Connexin genes

b) Myosin genes

c) POU genes

d) Ion channel genes

    

In addition number of genes
have been identified (Ref:
Data from Van Camp G, Smith
RJH: Hereditary Hearing Loss
Homepage.)

     

(a) Connexin genes:

This family is comprised of
a group of genes that encode
plasma membrane channel
proteins of the alpha (A)
and beta (B) types.

     

(b) Myosin genes

This family is related to
the super family of myosin
genes expressed throughout
the body.

   

(c) The POU genes

Members of POU gene family
encode transcription
factors, some of which are
expressed in the inner and
middle ear.

   

(d) The potassium
channel gene super family
includes genes that are
expressed in the inner ear.

    

One day genetic testing may
be a useful diagnostic tool
in the evaluation of Hearing
Impairment.

    

With growing understanding
of genetic mutations and
their effect on auditory
function, scientists hope to
develop treatments for many
genetic disorders.
Researchers explore the
possibility of gene therapy
for HHI and novel therapies
to treat the deficiencies
that arise due to genetic
mutations. In the future,
individuals carrying a
genetic mutations
responsible for progressive
hearing loss may be able to
receive a sufficient amount
of normal gene product in
order to prevent auditory
dysfunction.

     

     

CLINICAL APPROACH

a) Family History -
should be taken in details
and should include all under
age 30 with hearing
problems.

    Certain
hereditary traits should be
inquired into.

    

b) Physical Examination – to
look at the patient as
whole, to detect other
abnormalities pointing to

   
syndromes.

      

c) Audiologic Testing -
Cochlear and vestibular
testing.

    

d) Laboratory Testing 

   

d) Radiologic Testing – CT
and MR imaging

   

e) Genetic Testing

    

    

Christopher
J Hartnick, Robin T Cotton

Congenital Laryngeal
Anomalies

Otolaryngologic Cl.of
North Am. Vol.33(6),
Dec.2000, pg.1293-1309

    

Otolaryngologists face
congenital laryngeal
anomalies, which may be
minor to severe. Such
problems present at birth
may require immediate
attention. He should
therefore have firm
understanding of these
aberrations in embryologic
development. This article
deals with pertinent
embryology, relating to
congenital laryngeal
anomalies, reviews, the
diagnosis and management in
details.

   

Embryology

In 1885, His described
the appearance of the
respiratory primordium (RP)
from an outpouching of the
cephalic portion of the
pharynx by the third week of
gestation.

   

The following description of
the development occurs at
different stages of
development.

   

According to Carnegie
staging system for human
embryologic development,
there are two periods of
development.

   

The first period or the
embryonic period is 8 weeks
and comprises 23 stages.

The second period is Foetal
period spans the remaining
32 weeks of gestation.

   

The larynx begins to develop
during stage II (at 25 to 28
days) when RP appears as
epithelial thickening on
ventral aspect of the
foregut.

   

As the RP develops, outpouch
of foregut lumen, the
respiratory diverticulum
(RD) grows into RP. As the
RD develops from primitive
pharyngeal floor at the
level of adult glottis. The
pharyngeal floor is
separated from the primitive
pharyngeal floor by
primitive laryngopharynx
which later becomes adult
supraglottic region.

   

Anomalies at this point can
result into a number of
larynotracheal anomalies.

RD develops and extends
inferiorly at stage 13 and
14 and get separated from
developing heart and hepatic
primordium by the septum
transversum (ST).

   

The esophagus get separated
from RD by tracheoesophageal
septum. Anomalies of septum
transversum leads to
bronchobiliary fistula.
Arrest of cranial (upward)
development of
tracheoesophageal septum
leads to tracheoesophageal
or laryngeal c lefting and
tracheoesophageal fistula.
Anomalies of the RD itself
can cause tracheal agenesis,
tracheal stenosis, or
complete tracheal rings.

   

During stage 15 the ventral
lumen of primitive
laryngopharyngeal region
becomes obliterated and
gives rise to epithelial
lamina (EL). In stage 19 to
23, EL recanalizes,
reestablishing the
connection between the
ventral laryngeal portion
and dorsal pharyngoglottic
duct.

    

Failure of recanalization of
EL causes spectrum of
disorder from laryngeal webs
to laryngeal stenosis. With
working knowledge, various
anomalies can be adhered
individually, starting from
supraglottis to glottis,
subglottis and upper
trachea.

    

    

LARYNGEAL WEBS

Seventy-five percent
webs occur at the level of
the glottis. Severity of
symptoms will depend on
severity of webbing which
are classified by Cohen as
follows:-

   

Type I – Anterior web
involving 35% of glottis. 

          
– The true vocal cords are
visible. 

          
– There is little or no
subglottic extension, voice
abnormal, slightly
hoarseness.

   

Type II – 35% to 50% glottic
involvement. 

           
– Thick anterior webbing
with subglottic involvement.
Cricoid abnormalities. 

           
– Airway symptoms are
uncommon, only during
infection or intubation
trauma. 

           
– The voice is husky and
weak.

   

Type III – 50% to 70%
glottic involved.

            
– Web thick anteriorly

            
– True vocal cords invisible

            
– Cricoid abnormalities

            
– Marked vocal dysfunction

            
– Airway symptoms severe and
require artificial airway.

    

Type IV – 75% to 90% glottis
involved

            
– Uniformly thick anterior
and posterior

            
– True cords, not visible

           
– Subglottis narrowed

           
– Aphonic

           
– Airway – immediate help.

  

Diagnosis is either by
flexible laryngoscopy, or by
good quality lateral
radiograph. It will also
demonstrate cricoid
abnormality.

    

Management :

– Type I membranous web
observed until the child is
3 to 4 years old and then
web divided by a CO2 laser.

– Type II cutting web on
each side of the interval of
2 weeks and dilation. Keel
placement by endoscopy.
Tracheostomy is necessary.

– Type III & IV. Also
delayed till 3 to 4 yrs with
tracheostomy and later by
various reconstructive
procedures.

  

Congenital supraglottic webs
are unknown. They could be
in anterior part or more
rarely in posterior part.

    

Laryngeal Stenosis and
Atresia

It is the most severe
form of anomalies. Glottic
or supraglottic atresia
requires immediate
trachneostomy in the labour
room and has high mortality
ratio. These are also many
times associated with host
of other anomalies like
tracheoesophageal fistula,
esophageal atresia, urinary
tract abnormalities and limb
defects.

     

Congenital subglottic
stenosis is associated with
abnormally shaped cricoid
cartilage first described by
Hollinger in 1954. It is to
be differentiated from
acquired stenosis, by
history only i.e. absence of
infection and
instrumentation.

   

When lumen of cricoid is
less than 4mm in newborn or
less than 3mm in premature,
it is congenital subglottic
stenosis.

    

Symptoms will depend on
severity of stenosis. Myer-cotton
Grading system uses
endotracheal tubes to grade. 

    

It is graded in 4 grades –

Grades I – 0-50%
obstruction,

Grade II – 51% to 70%
obstruction,

Grade III -71% to 99%
obstruction

Grade IV – Total
obstruction.

  

Congenital S.G.S. also
improves as the larynx
grows. Less than 50% require
tracheostomy. Dilation has
little to offer in
cartilaginous stenosis.

   

In some patients, anterior
cricoid split may be
necessary to avoid
tracheostomy. There are
indications worked out by
paediatric otolaryngologists:

   

1. Extubation failure on at
least two occasions because
of subglottic malformation.

2. Weight greater than 1500g

3. No ventilator support for
at least 10 days before
procedure

4. Supplemental oxygen
requirement less than 30%

5. No congestive heart
failure for at least 1 month
before the procedure

6. No acute respiratory
tract infection

7. No antihypertension
medication for at least 10
days before the procedure.

    

Grade I and Grade II lesion
– Role of endoscopic laser
treatment and short term
stenting exists.

    

Grade III and Grade IV -
Open operative procedure of
reconstruction are required.

    

Laryngeal Clefts

   

Posterior laryngeal clefts (PLCs)
and laryngotracheal
esophageal clefts (LTECs)
derive from a common
embryonic anomaly. 30% of
these are associated with
polyhydramnios. They are
also associated with
different syndromes with
anomalies of other organs.

   

Two classifications exists:

A) Evan’s system. – LTEC,
type I – supraglottic
interaytenoid that extend,
above the level of glottis.
Cricoid is

    
uninvolved. Type II -
Cricoid and cervical trachea
is involved. Type III -
Extends to thoracic trachea.

    

B) Benjamin’s Classification
is modified Evans.

    Type I -
cleft above vocal cord

    Type II -
partial cricoid cleft and
extends to vocal cords

    Type III
– Total cricoid cleft with
or without cervical tracheal
cleft.

    Type IV -
A cleft extending to
thoracic trachea with or
without involvement of
bronchi.

     

Symptom of Posterior
Laryngeal Clefts (PLCs) -
copious secretions,
aspiration, cyanosis during
feeding and recurrent
pulmonary infecitons.

    

Diagnosis : Flexible
laryngoscopy

Contrast esophagrams.

     

Management : Repair
of PLCs and LTECs requires
control of the airway.
Special instrument if any to
be done endoscopically or by
external operation procedure
like laryngofissure or
lateral pharyngotomy.

    

Hussam
K, EL-Kashlan and Steven A
Telian (Univ. of Michigan)

Diagnosis and initiating
treatment for peripheral
system disorders: Imbalance
and Dizziness with Normal
hearing

Otolaryng Clinics of
N. America, vol.33(3), June
2000

   

Peripheral vestibular system
consists of :

(a) Vestibular
labyrinth harbouring
neuroepithelium responsible
for identifying position and
movements of head.

   

(b) Vestibular nerve
(part of cochlear vestibular
nerve) carrying nerve fibres
from labyrinth to CNS

   

Disorder of Peripheral
systems definitely affects
hearing loss along with
balance affected. However,
certain following conditions
cause dizziness without
hearing loss.

  

(1) Benign paroxysmal
positional vertigo (BPPV)

(2) Vestibular neuritis

(3) Recurrent vestibulopathy

(4) Familial vestibulopathy 

(5) Bilateral idiopathic
vestibulopathy.

   

Detailed clinical
interrogation should include
(I) mode of onset and
description of first
episode. (ii) frequency and
duration of each episode
(iii) spontaneous or
provoking causes (iv)
associated auditory causes
(v) EAR disease or any
surgery on ear in the past.

   

(1) Benign Paroxysmal
Positional Vertigo (BPPV)

It is brief episodes of
vertigo precipitated by head
movement in certain places.
The most common cause, in
elderly patients though no
identifiable cause is known,
commonly follows head trauma
sequalea of vestibular
neuritis, otologic surgery,
infection or prolonged bed
rest.

    

BPPV characteristic clinical
feature is that patient
experiences giddiness
following head movements
like getting into or out of
bed, rolling over or looking
up and is associated with
the nystagmus with
distinctive characteristics-

    

a) Latency period following
provocative position 

b) Intensifies gradually and
has crescendo-decrescendo
manner.

c) Only 20-30 seconds
duration even if position
remains same.

d) The nystagmus is
torsionally beating towards
undermost of the (offending
ear) i.e. fast phase towards
down ear. It is accompanied
by a vertical up or down
beating component because of
post canal wall and anterior
canal wall component
respectively.

e) Usually recurs and
changes direction when
patient moves back to
sitting position.

f) The response is
fatiguable.

   

PATHOGENESIS of BPPV

Though there are two
theories of mechanisms as to
how vertigo occurs, the
basic mechanism is
accumulation of otoconial
debris with higher specific
gravity than endolymph
within semicircular canal.
It responds to linear
acceleration including
gravitation force.

    

1) Schuknecht’s cupulithisis
theory-

The debris gravitates to
adhere to the cupola of
semicircular canal and
changes in head position
stimulates to cause
giddiness. The theory,
however, cannot explain all
classical features of BPPV.

    

2) Canalithiasis theory by
Hall et al and supported by
many authors.

This theory postulates clot
formation of floating
otoconial debris near
cupola. A clot moving in
ampullofugal direction acts
as a plunger on the
endolymph, producing
pressure or suction in the
canal producing deflection
of cupola and attack BPPV.

    

VARIANTS OF BPPV

Any of three semicircular
canals may be involved. The
direction of nystagmus will
depend upon involvement of
canal. 91% cases of
posterior canal is involved.
3% anterior and 6% of
lateral semicircular canals
are involved.

    

– Both vertical canals (i.e.
anterior and posterior)
produce torsional nystagmus.
Vertical component will
identify the canal.
Upbeating nystagmus will be
in a posterior canal,
whereas, down beating
nystagmus will point towards
anterior canal. Provocative
movement for vertical canal
will be moving from a
sitting position to a head
hanging position.

   

– Horizontal canal variant
was proposed first by
McClure procedures pure
horizontal nystagmus and is
caused by lateral head turn
in supine position. The
nystagmus changes direction
as the head is turned from
one side to the other
lateral side. It may be
geotropic (fast phase
towards dependent ear) or
ageotropic (fast phase away
from the dependent ear)

   

– In canalithiasis it is
geotropic whereas in
cupulothiasis it is
ageotropic.

   

TESTS FOR BPPV

– Hallpike-Dix Test -
for vertical canal BPPV

   

– Side-Lying test – for
vertical canal. It is more
comfortable and is used in
elderly patients.

   

– Roll-test -f or horizontal
canal BPPV.

   

Treatment 

Medical therapy of
vestibular suppressants is
not effective. In fact, it
may affect central
habituation process when
relieves symptoms.

   

(a) Single treatment
Approach

Aim is to maneuver the
debris from canal into
vestibule.

The two most commonly used
methods are those described
by Epley or Semont et al.

   

(b) Habituation Exercises
Approach

In 1980, Brandt and Daroff
proposed the exercises which
are sequence of lateral
head/trunk tilts, repeated
many times a day for 2-3
weeks to promote lossening
and ultimately, dispersion
of the debris towards the
utricular cavity. These
relieves patients vertigo
but difficult to perform by
patients because of
experience of vertigo during
these exercises. This is in
sharp contrast to single
manuvers of Epley or Semonts
procedure.

   

Surgical Approaches

a) Gacek’s singular
neurectomy.

b) Postcanal plugging
-procedure of choice by most
otologists for BPPV.

    

(2) Vestibular Neuritis

   

This is the 3rd most common
cause after BPPV and
Menier’s.

   

Clinical features:

i) Sudden onset of vertigo
with nausea and vomiting of
a few days/

ii) Absent audiologic
findings and symptoms or
signs.

iii) Absent neurologic
symptoms or signs.

iv) Associated mostly with
recent or concurrent URI
(upper respiratory
infection)

v) Reduced or absent caloric
response in one ear.

vi) URIs – therefore can be
seen in epidemics.

vii) Autopsy reports axonal
degeneration of one or more
vestibular trunk points
towards virus.

    

Acute vertigo and
spontaneous nystagmus which
lasts a few days improves
gradually though during
recovery period any moment
may provoke dizziness.
Improvement is seen because
(a) recovery of labyrinthine
function (b) central
compensation by adaptation
though vestibular weakness
can be demonstrated on one
side. In elderly, it lasts
longer.

– BPPV has been reported
following some vestibular
neuritis patients.

– Vestibular neuritis is
single episode but some
patient’s recurrent episodes
may occur. Sequential
vestibular neuritis in both
ears may lead to
differential diagnosis of
bilateral vestibular
neuritis.

    

During investigations -
vestibular neuritis showed
reduced partial vestibular
response in 90% of patients
upto one month and 80% after
6 months. 42% patients
showed recovery to normal
caloric response in 10 year
follow up study.

   

– Peculiarly superior
division of vestibular
neuritis trunk is commonly
affected. This supplies
horizontal and anterior
semicircular canals, maculae
of the utricle and
anterosuperior part of
saculae. Inferior division
supplying posterior
semicircular canal is
spared.

  

This is corroborated by
findings of temporal bone
pathology and analysis of
3-dimensional properties of
vestibulo occular nystagmus,
in patients with vestibular
neuritis.

   

Differential Diagnosis:-

   

– Cerebellar infarction

– Wallenberg’s syndrome

– Meniere’s disease

– Acoustic neuromas

– Migraine equivalent
vertigo, 

– Paraneoplastic syndrome, 

– Metastatic carcinoma

– Multiple sclerosis.

   

Treatment : Symptomatic and
supportive. Acute phase
treated by labyrinthine
sedatives and antiemetics.
Possibly good effects of
corticosteroids.

    

Antiviral – No response

Most of them have complete
recovery. Those with
persistent unsteadiness,
have to undergo customised
vestibular rehabilitation
programme.

   

(3) Bilateral Idiopathic
Vestibulopathy

Bilateral loss of vestibular
function is induced most
commonly by vestibuloxic
effects of aminoglycosides
gentamycin. This often has
hearing loss in higher
frequencies. Majority have
no hearing loss but
bilateral vestibular
weakness. 20% with bilateral
vestibulo hypofunction have
no identifiable cause.

    

Patterns of symptoms – 2
patterns are seen

(i) present with initial
vertigo

(ii) present with insidius
progressive unsteadiness
without vertigo.

   

Patients complain
dysequilibrium which is
worse at night and also
accompanied by oscillopsia.
This is caused by loss of
bilateral vestibulo-ocular
reflex {VOR}. Clinically
this is tested by making
patient to read a Snellen’s
chart with steady head and
then during horizontal head
oscillations at a frequency
of about 2Hz. Normal
vestibular response show a
one-line deterioration in
visual acuity and with
bilateral vestibular
involvement. Five line
deterioration is seen.

   

Testing is by bilateral
thermal caloric responses
and rotational chair
testing.

  

Management of patients with
bilateral vestibular loss is
difficult. 50% show some
improvement with adaptable
exercise. Emphasis is placed
on maximizing and optimizing
visual and proprioceptive
sensory inputs to substitute
for the lost vestibular
inputs. Risk of drowning is
seen.

  

FAMILIAL VESTIBULOPATHY – 

Described by Baloh et al
in 1994 and is presumed to
have autosomal dominant mode
of inheritance. It is
characterised by brief
episodes of vertigo for
several years. Subsequently,
it results in chronic
dysequilibrium and
oscillopsia. Bilateral
vestibular weakness and
response on caloric testing,
electronystagmography
vestibulo ocular reflex
reduced. Gain on rotation
chair testing.

   

All tests were normal,
audiologic, imaging and
neurological findings.
Migraine headaches were an
important feature of this
syndrome. All members and
their parents suffer from
migraine.

   

Treatment : All patients
responded well to treatment
with acetazolamide with
resolution of attack of
vertigo. The location of
site of lesion is unknonwn.

  

Another familial syndrome
with episodes of little
longer lasting vertigo and
essential treatment migraine
has been identified. No
progressive bilateral
vestibular weakness
develops. Acetazolamide was
helpful in reducing vertigo
and migraine.

   

RECURRENT VESTIBULOPATHY

This clinical entity was
described by LeLiever and
Barber in 1981. Recurrent
spontaneous episodes of
vertigo similar to that of
Meniere’s disease. However,
no audiologic, neurologic
symptoms and signs noted.
The natural history is
different from that of
Menieres. 73 patients
followed up for 8.5 yrs, 72%
retained original diagnosis,
however the diagnosis was
changed to Meniere’s disease
in 14% and 8% in BPPV.

   

There is no known cause.
Viral cause has been
suggested. Periodic blockade
of afferent activity of one
vestibular nerve by
reactivation of dominant
virus is postulated as a
mechanism. 22% patients
showed reduced unilateral
caloric response.

   

Treatment: Symptomatic and
assurance. The prognosis for
spontaneous resolution is
good.

      

David
Solomon

Distinguishing and
Treating Causes of Central
Vertigo

Otolaryn Cl.of North
Americal, vol.33(3), June
2000, pg. 579- 

   

When evaluating a case of
acute vertigo, it is
important to make sure to
distinguish between
peripheral and central
cause. Central causes
require urgent intervention
or may require intensive
care unit (ICU) monitoring.

  

How history, examination and
laboratory testing can help
to confirm a central
etiology is considered.

  

History – patient feel
“woozy”,
“about to black
out,”
“disoriented” or
“lightheadedness”.
Worse while standing. These
are connected with blood
flow circulation to brain,
therefore central.

   

Causes : 1) Hyperventilation

2) Orthostatic hypotension

3) Vasovagal attacks

4) Cause of decreased
cardiac output

5) Psychophysiologic

6) Hypoglycemic

7) Drug toxicities – like
alcohol, barbiturates,
benzodiazepine and 

anticonvulsants.

8) Postconcussion syndrome

9) Infarction of labyrinth,
brainstem or cerebellum

10) Migraine headache.

   

Examination and testing

a) complete neurologic
examination

b) study of nystagmus and
its induction test.

   

Absence of a positive head
impulse test in acute
vertigo attack makes a
central cause. 

   

Bedside examination
findings suggestive of
nonperipheral etiology.

   

Position Provoked Vertigo
–

Brainstem and cerebellar
lesion can cause persistent
vertigo with vertical
nystagmus or torsional
nystagmus.

   

1. Direction changing or
purely vertical nystagmus

2. Sustained or nonfatiguing
positional nystagmus

3. Dissociated
(disconjugate) nystagmus

4. Abnormal posture when
seated, inability to stand

5. Focal motor deficit

6. Dysarthria, dysphagia,
diplopia, dysmetrial (limb
ataxia)

7. Horner’s syndrome
(sympathetic paresis of the
pupil, with unilateral
failure to dilate in
darkness and ptosis)

8. Loss of pin prick or
temperature sensation on one
side of the face, or on the
other side of the body.

9. Intractable hiccups.

   

Ocular Motor Signs of
Central Disease

Persistent vertical
nystagmus is certainly of
central origin. It indicates
brainstem involvement as
well as diffuse cerebellar
region.

   

Diagnoses in Patients
with Downbeat Nystagmus

   

Infarction 25%

Cerebellar (spinocerebellar)
degeneration 24%

Multiple sclerosis 13%

Developmental anomaly (e.g.
Chiari, basilar
invagination) 12%

Drug toxicity (phenytoin,
carbamazepine) 4%

Trauma 3%

Neoplasm 3%

Alcoholic cerebellar
degeneration 2%

Arteriovenous malformation
2%

AIDS, familial periodic
ataxia, viral encephalitis,
radiation 1% (each)

No cause 5%.

   

– Disconjugate recordings
are indicative of lesions of
the medical longitudinal
fasciculus.

– Perverted nystagmus is
related to lesion of
vestibular nuclei

– Sea-saw nystagmus – cuased
by midline compressive
lesions in suprasellar area
in which it is generally
pendular.

– Unilateral lesions in the
rostral midbrain cause a
jerk waveform see-saw
nystagmus.

– Vertical diplopia – sign
of supranuclear or
infranuclear pathology.

– Periodic alternating
nystagmus occur with lesion
of posterior cerebellar
vermis.

   

Characteristics of
Central Nystagmus:

Central spontaneous
nystagmus is direction
changing pure vertical, or
torsion, is not suppressed
by vision and is associated
with normal head impulse
test and ataxia even for
sitting patients cannot
stand.

   

Cerebellar signs:

Whatever may be the
aetiology, signs are as
follows:

  

1. Gaze-evoked,
direction-changing
horizontal nystagmus

2. Rebound nystagmus

3. Vertical, typically
downbeat nystagmus, often
worse in lateral gaze.

4. Alternating skew
deviation

5. Saccadic dysmetria and
major saccadic oscillations
(flutte,r macrosquare-wave
jerks)

6. Position-provoked vertigo
(not fitting benign
paroxysmal positional
vertigo)

7. Oscillopsia at rest
(caused by nystagmus) and
head movement.

8. Wide-based gait ataxia
with poor tandem gait,
inability to maintain
Romberg position even with
eyes open

9. Poor horizontal and
vertical smooth pursuit
(absent VOR cancellation)

10. Tremor, dysarthria, limb
ataxia.

   

Spinocerebellar atrophy

Migraine

Multiple sclerosis

Internuclear ophthalmoplegia

Vascular disease

Lateral Medullary Syndrome

Positive syndrome

Cerebellar infarction.

   

Vascular malformtion and
headache

Neoplastic disease

Other conditions – Palatal
tremor

– Wernicke’s encephalopathy

– Epilepsy

  

All the above conditions are
central cause of nystagmus.

     

NH
Blevins, BL Carter (Tufts-New England Med Ctr,
Boston)

Clinical Forum: Routine Preoperative Imaging in
Chronic Ear Surgery,

Am J Otol 19: 527-538, 1998.

  

Imaging studies, especially CT, can demonstrate the
nature and extent of chronic otitis media, which may
not be apparent on clinical findings per se. Such
findings can affect operative treatment, especially
in difficult and/or revision procedures. However,
there is a view that routine radiography of the
mastoid may suffice in being very helpful in most
cases.

   

TS
Karhuketo, HJ Puhakka (Tampere Univ, Findland)

Middle Ear Imaging Via the Eustachian Tube With a Superfine Fiberoptic Videomicroendoscope.

ORL J Otorhinolaryngol Relat Spec. 60: 30-34, 1998.

   

With a fibreoptic videomicroendoscope inserted through the Eustachian tube, 56% of predetermined anatomical objects in the middle ear were visualized. 

  

However, one may find obstructive sites or mucosal folds that may prevent a complete view of all the contents of the middle ear cleft.

    

Michael
J Ruckenstein, (Univ of Pennsylvania)

Vertigo & Dysequilibrium with Associated
Hearing Loss

Otolaryng. Cl.of N.America, June 2000.
Vol.33(3), pg.535-562

  

CONGENITAL

Congenital malformations of the membranous or
osseomembranous components of the inner ear results
from defects in inner ear development during the
fourth to eighth week of fetal gestation.

   

The overall incidence of congenital is 1 in 1000
live births. It is either syndromic or nonsyndromic
presentation.

  

Clinical presentation is with hearing loss which is
either congenital or within two decades of life.
Only 20% complained of vertigo or imbalance.

   

CT Scan on MRI of high resolution reveal the
abnormalities. Abnormal vestibular findings are
recorded on vestibular testing.

   

CLASSIFICATION OF CONGENITAL LABYRINTHINE
ANOMALIES

Malformations of the membranous labyrinth

Complete membranous dysplasia

Partial membranous dysplasia

Cochleosaccular (Scheibe)

Cochlea – basal turn (Alexander)

   

Malformations of the osseous and membranous
labyrinth

Complete labyrinthine aplasia (Michel)

Cochlear

Aplasia

Hypoplasia

Incomplete partition (Mondini)

Common cavity

Labyrinthine

Dysplasia of the semicircular canals

Aplasia of the semicircular canals.

   

Malformations of the vestibular aqueduct

Narrow or wide internal auditory canal.

   

Treatment:

Hearing amplification with hearing aids or cochlear
implants are the mainstay of treatment. Vestibular
suppressant medication are indicated for bouts of
vertigo if any.

   

ACQUIRED

Trauma – Temporal Bone

  

Blunt trauma or penetrating trauma. Auto accidents
or bullet or knife injuries to inner ear damage
results into sensorineural hearing loss. Facial
nerve may be damaged.

   

Clinical presentation:

Vertigo and hearing loss or facial nerve
paralysis, bleeding from ear or watery fluid
(Cerebrospinal fluid – CSF) from the ear. CT Scan
may reveal fracture line in temporal bone.

   

Treatment will depend upon the presentation and
investigative findings. Exploration of ear and
mastoid of facial nerve or CSF leak is present or
conductive hearing loss is present.

    

Barotrauma

Rapid changes in ambient pressure may result in
pressure transmitted to inner ear, thus causing
temporary or permanent inner ear dysfunction.

   

Aetiological factors are seen in drivers, airplane
flight or forceful sneezing or airblast injuries.
Treatment will depend upon the aetiological factors.

    

Perilymph Fistula

   

Three possible mechanisms:

(a) Congenital dehiscences in labyrinth

(b) Disruption of oval or round windows by secondary
to trauma which may be iatrogenic, (poststapedectomy)
or penetrating or severe implosive pressure trauma.
Even barotrauma may cause the fistula.

(c) Spontaneous – controversial

   

Clinically – present with sudden sensorinueral loss
associated with tinnitus and vertigo. Fluctuating
hearing loss.

    

Investigations: No valid or accurate diagnostic
tests. Audioventricular testing is done. 

Present – Exploration of middle ear and locating the
leak and sealing it

   

Otosclerosis

Usually conductive hearing loss and the
diagnosis is easy by audiological testing.
Clinically young adults with tinnitus and conductive
hearing loss. Family history may suggest
otosclerosis.

   

Usually no vestibular complaints. If at all any,
then they complain of vertigo. Three possible
patterns are noted. Positional vertigo or Meniere’s
like syndrome or small number manifest as recurrent
episodes of vertigo.

   

Treatment : 

It is by stapedectomy. Small number with
sensorineural loss or mixed loss are treated with
fluoride.

  

Neoplasm:

Cerebellopontine angle tumours, vestibular
schwannoma, meningioma or petrous apex
cholesteatomas.

   

Clinically present with vertigo, hearing loss,
tinnitus or facial nerve paryngitis. Very large
tumours may demonstrte 5th, 9th, 10th or 11th with
cerebellar signs.

    

Diagnosis : By CT scan or MRI

Treatment : It is operative treatment.

   

Infectious:

Labyrinthins: Either by bacteria or virus,
depending upon otitis media or general viral
infection. Herpes infection.

    

Clinical presentation is by sudden severe hearing
sensorineural hearing loss, with vertigo lasting for
days. Hearing may be irreversibly damaged.

   

Treatment will be by antibiotics and corticosteroid.
Operative treatment for those with cholesteatoma or
chronic mastiditis.

   

Syphilis: 

Is rare nowadays. It is diagnosed by VDRL. FTA -
ABS or MHA – TP tests are done to confirm. Treatment
is by antibiotics and steroids.

   

Ototoxicity

Most agents are toxic to cochlea. Aminoglycoside
antibiotics are major vestibulotoxic drugs used
today. Individual succeptibility, in addition to
renal failure, hepatic failure or old age,
concurrent use of other ototoxic drugs, familial
history are other aetiological factors.

   

The most common are Gentamycin and streptomycin and
tobramycin. Outer hair cells of the vestibule is
affected mainly. The basal regions of cochlea, the
apices of the cristae, and the striolar regions of
the maculae are affected most.

   

Clinically – acute onset of hearing loss or
imablance with oscillopsia is seen. These occurs
while patient is on treatment or up to several weeks
after treatment. Usually bilaterally affected.
Vestibular damage is permanent. Bilateral vestibular
reduced response is seen on caloric testing or ENG.

  

Treatment is mainly by monitoring the effects of
drug to prevent. Once it occurs then only
symptomatic treatment is given.

  

Immunologic:

Autoimmune Inner Ear Disease

Patients own immune system becomes reactive to
self-antigens resulting into autoimmune disease.
Multisystemic autoimmune disease like systemic lupus
erythematosus may be associated. 

  

It  is rare cause. Degeneration of organ of
Corti, vestibular sensory organs, stria vascularis
and dark cell layers, as well as fibrosis and
osteoneogenesis is seen.

   

Clinical Presentation :

Rapidly progressive bilateral asymmetric
sensorineural hearing loss is seen. Hearing levels
fluctuates and 25-50% patients complain of vertigo.

   

Cogan’s syndrome :

Patients present with interstitial keratitis
with vertigo, hearing loss and tinnitus. Ocular and
labyrinthine pathology occur together or within 6
months of each other.

  

Other Multisystemic Autoimmune Diseases:

Wegner’s granulomatosis, polyartertitis nodosa,
rheumatoid arthritis, systemic lupus erythematosus,
sarcoidosis and ulcerative colitis may involve the
inner ear.

  

Investigations are mainly various antigen antibody
tests but are not very helpful. Only probable
diagnosis is proved by positive response to
imunosuppressant drugs like corticosteroids. 

  

Dose is 1 to 2mg/kg/day for 1 month. Other drugs are
methotrexate or cyclophosphamide. The maintenance of
the dosages are required.

  

IDIOPATHIC

Meniere’s disease

Symptom complex of vertigo,hearing loss, tinnitus
and aural fullness. Pathology is endolymphatic
hydrops.

   

Clinically it presents as episodic vertigo
associated with fluctuating and progressive hearing
loss, chronic tinnitus and fullness of ears.

    

Investigations – audiometric test

ECOG

FTA-AB – serological test

   

Treatment – Medical – vestibular suppressants

– diuretics

– vasodilatation

  

Surgical – Endolymphatic sac surgery procedure

Gentamycin perfusion

Vestibular nerve section

Labyrinthectomy.

   

Craig
S, Derkay, MD, and David H. Darrow, MD

Voice Disorders and Phonosurgery II

From the Department of Otolaryngology – Head and
Neck Surgery, Eastern Virginia Medical School,
Norfolk, Virginia

The Otolaryngologic Clinics of North America
Volume 33, Number 5, Ocober 2000, Pg. 1127

   

Recurrent respiratory papillomatosis [RRP] is a
disease of viral origin, caused by human
papillomavirus.

  

Although it is a benign disease, RRP has potentially
morbidconsequences because of its involvement of the
airway and the risk of malignant conversion.

   

Recurrent respiratory papillomatosis is the most
common benign neoplasm of the larynx among children
and is the second most frequent cause of childhood
hoarseness. 

  

Although is usually involves the larynx, RRP may
involve the entire aerodigestive tract.

  

Because the most common symptoms of RRP are related
to airway obstruction, it is not uncommon for
children to be misdiagnosed initially as having
asthma, croup, or chronic bronchitis.

   

The hallmark of RRP in children is the triad of
relentlessly progressive hoarseness, stridor, and
respiratory distress.

  

ORIGIN

  

Human Papillomavirus

  

Until the 1990s, HPV had been suspected but not
confirmed as the causative agent in RRP.

  

This uncertainty developed from an inability to
culture the virus in vitro, and from the failure to
demonstrate viral particles consistently in
papilloma lesions using electron microscopy of HPV
antibodies.

  

With the use of viral probes, HPV DNA has been
identified in almost every papilloma lesion studied. 

  

The most common types identified in the airway are
HPV 6 and HPV 11, the same types responsible for
genital warts.

   

An association between cervical HPV infection in the
mother and the incidence of RRP has been well
established.

    

Adult-onset respiratory papillomas could reflect
either activation of virus present since birth or an
infection acquired in adolescence or adult life.

  

Recurrent Respiratory Papillomatosis

The most common sits for RRP are the limen vestibuli,
the nasopharyngeal surface of the soft palate, the
midline of the laryngeal surface of the epiglottis,
the upper and lower margins of the ventricle, the
undersurface of the vocal folds, the carina, and at
bronchial spurs.

  

Surgical Management

No single modality has consistently been shown to be
effective in eradicating RRP.

   

The CO2 laser has been favored over cold instruments
in the treatment of RRP involving the larynx,
pharynx, upper trachea, and nasal and oral cavities.

  

Although the CO laser allows surgical precision and
excellent hemostasis, multiple procedures are often
necessary.

    

Because currently no therapeutic regimen reliably
eradicates the HPV, when there is a question about
whether papilloma in an area needs to be removed, it
is prudent to accept some residual papilloma rather
than risk damage to normal tissue and producing
excessive scarring.

  

Even with the removal of all clinically evident
papilloma, latent virus may remain in adjacent
tissue; this remaining latent virus may explain the
recurrent nature of RRP.

   

Adjuvant Treatment Modalities

The most commonly recommended adjuvant therapy is
alpha-interferon. The exact mechanism by which
alpha-interferon elicits its response is unknown.

      

Common interferon side effects fall into two
categories: acute reactions [fever and generalized
flu-like symptoms, chills, headache, myalgias, and
nausea that seem to decrease with prolonged therapy]
and chronic reactions [decrease in the growth rate
of the child, elevation of liver transaminase
levels, leukopenia spastic diplegia, and febrile
seizures.

   

Acetaminophen has been found to relive the fevers
effectively, and interferon injections are best
tolerated at bedtime. 

   

Photodynamic therapy [PDT] in the treatment of RRP
has been studied extensively:-

    

Photodynamic therapy is based on the transfer of
energy to a photosensitive drug. The drug originally
used was dihematoporphyrin ether [DHE], which has a
tendency to concentrate within papillomas more than
in surrounding normal tissue.

    

Ribavirin is an antiviral drug, used to treat
respiratory syncytial virus pneumonia in infants,
that has also shown some promise in the treatment of
aggressive laryngeal papillomatosis. 

     

Another antiviral drug that has been advocated in
the treatment of RRP is acyclovir.

   

It has been postulated that acyclovir may be most
effective when there are comorbidities, such as a
simultaneous infection with herpes simples virus.

   

Two recent reports have stimulated interest in the
intralesional injection of cidofovir [Vistide ]
[HPMPC], a drug currently FDA-approved for use for
HIV patients with CMV retinitis.

     

P. Chang, Los Angeles, USA.

Controversies in Vestibular Schwannoma Treatment: Surgery versus Irradiation.


ENT News, 9(5), Nov./Dec.2000, p.14-15

     


Cropping of these controversies has been because of irradiation as an alternative to surgery. Microsurgery is the present day choice for vestibular schwannoma.

     


The following questions arise in the critical minds of patients:

a) What is the expected morbidity of surgery?

b) Is hearing preservation possible?

c) Can benign tumour be irradiated without any long-term side effects?

d) How effective radiation is?

e) Are the results competitive to that of surgery. Will all be judged in justifying the alternative treatment of Vestibular Schwannoma?

      



Tumour: 


Vestibular schwannoma tumours arise from neural sheaths and are benign. Their situation in internal auditory canal and cerebellopontine angle, make them dangerous by position. The tumour consists of nothing but proliferating Schwann cells, which is very slow viz. 1 to 2 mm per year. Majority grows producing progressive hearing loss. This growth however, exceptionally can be unpredictable. That is why in fit patient, intervention is required. Technological advances in early precise diagnosis by imaging techniques and advances in management have proved the surgical outcomes much favourable.

    


However, technological advances in radiotherapy have also offered an alternative treatment.

      



Surgical Background:


It has come a long way from removal of tumour by finger, by Balance in London in 1894 to perfection of precise removal by translabyrinthine, retrosigmoid and middle fossa approaches derived by Dr. William House in 1964, almost without mortality and minimal of morbidity. Today there is likelihood of complete removal with zero mortality rate, near normal facial nerve function in 95% and less than 0.3% recurrence rate and 70% rate of preservation of hearing in selected patient makes the treatment by surgical excision treatment of choice.

     


The negative points are that it is intracranial procedure with its attendant risks of C.S.F leak, meningitis and intracranial bleed. It incurs cost and 4-5 days of hospitalization.

    


Today the treatment by radiation may be opted to (a) Medically unfit patients (b) Recurrent tumours (c) Elderly patients (d) Who refuse surgery. The use of radiotherapy as primary mode of treatment of vestibular schwannoma has also been promoted.

     



Background of Radiotherapy


Lars Leksell (1971) at Sweden (Karolinska Institute in Stockholm) first reported gamma radiation ports administered stereotactically during a single sitting to arrest the tumour growth.

     


The principle is to target the lesion, minimising, the radiation dose to surrounding neural tissues. The term “stereotactic radiosurgery” was coined and particular technique used was called the ‘gamma knife’.

     


The treatment evolved in last decades. The radiation dosage of 25Gy has been reduced optimally to 13Gy delivered by Linear accelerator and is now fractionate. This has resulted into improvement in tumour control and preservation of normal neural tissue.

     



The Controversy


– Because of close relations of tumour capsule to 7th and 8th nerve, it is impossible to avoid radiation to these nerves.

   


– The effects of radiation are cell deaths and delayed vasculitis. Vasculitis is not observed because of sparse blood supply as against seen in
glomus.

      


– Subsequent surgical intervention, if required in these irradiated tumour, lead to hazzardous dissection resulting in poor hearing and facial nerve function.

      


So the alternative treatment is reserved for those patients who are unfit or unwilling to undergo microsurgical removal of
tumour.

      

John Diaz Day, (Neurological and Skull Base Surgeon, House Ear Clinic, Los Angeles, USA)

Radiotherapy or microsurgery – which treatment and why?


ENT News, vol.9(5),Nov/Dec.2000, p.16-17

      


The microsurgical excisions are currently exceeded and continue to improve.

If the results are compared with those centres with inexperienced teams doing small number of cases, the stereotactic radiotherapy gains momentum.

      


Patients with tumours 3cm or larger most agree are candidates for surgery. Relief of mass effect and hydrocephalus is well achieved. Facial nerve function and hearing preservation in anyway par with large tumours. The extent of 60% in facial nerve function preservation is good.

    


Main debate over patients with small or medium tumours, intracanalicular tumours tilt in favour of surgery for number of reasons.

    


At this institution in 372 patients over the last 5 yrs had 95% of facial nerve function preservation and about 70% hearing preservation was seen. These results of function preservation are durable. This is not so in stereotactic radiosurgery where hearing may further deteriorate with time.

    


Recurrent rate in surgery is 0.5% as against radiation which is 6-10%, where the tumor recurs or grows further.

    


He also points out that if radiation fails subsequent microdissection results in poor function of facial nerve preservation and hearing preservation.

    


Radiosurgical series still must stand the test of time when utilizing ‘control’ as a means of establishing efficacy. They must do better than the natural history of vestibular schwannomas left untreated. When roughly two-thirds of tumours will not change their appearance on serial imaging with no treatment, how do we can say that my treatment is effective at ‘controlling’ tumour growth over a similar follow-up period with a similar number of tumours not demonstrating
growth ?

     

Andras A Kemeny, Royal Hallamshire Hospital, Sheffield, England


What is the role of radiosurgery in Vestibular Schwannoma treatment?


ENT News, Nov/Dec.2000, vol.9(5), p.19

    


It is a surgical technique, the concentrated radiation is achieved by crossfiring 201 fine gamma ray beams focused into a single point. Initially with poor imaging and slow computers, this was difficult to achieve. But with the introduction of high resolution, volume acquisition MR imaging and powerful 3D computational software the true potential of this technique could be realised. 

     


Since 1985, 540 accoustic neuromas were treated with mean age 51, 48% males, 21% (116) were bilateral tumours. The median diameter was 6-57mm. 36% had at atleast one previous resectional surgery. A large proportional had neurological deficit particularly with those who had surgical intervention. Even since 1995, only 20% have normal facial nerve function and 13% had none. Seventy-two cases of previously operated cases had complete deafness.

    


In 1980, when 25Gy dose was given, facial weakness in 85% and hearing preservation was poor. With reduction of dose to 13-15Gy, radiological tumour control remained around 88% with minimum follow-up of 5 years. Useful hearing was preserved in 76% and facial weakness only in 5.2%. These results compare well with larger surgical series.

     


Radiosurgical failures are not declared for at least 3 yrs and no surgery should be undertaken on this basis.

     


The risks and difficulty of surgery after radiosurgery is exaggerated.

     


A warning by nonpractising radiosurgeons is given to patietns of possibility of malignant change in later years. Very rarely seen. To date about 15000 acoustic neuromas are treated and by telephone survey, only 5 cases of sarcomatous change were confirmed after radiosurgery. Nevertheless, the alertness is necessary.

     


Which cases should be referred to radiosurgery? Probably the answer is which should not be?

    


Lesions beyond 3.5cm that produce larger mass effect may need surgical decompression. Tumours incidentally found may be monitored radiologically and audiometrically.

    


Those above 65 years of age, the medically infirm and those who can’t afford even a low risk of surgical mortality will be more and more considered for radiosurgery.

    


There is a demand for noninvasive methods of treatment with less disruption to their life. Those who are well informed by internet and those who are in medicolegal climate should be informed of availability of radiosurgery of these tumours.

     

Dr. Paul A Fagan, St. Vincent’s Hospital, Sydney, Australia

How does the outcome of radiotherapy compare with microsurgery for vestibular schwannomas?


ENT News, Nov./Dec.2000. vol.9(5), p.20

    


The article discusses pros and cons of both treatment but tilts more in tumour of surgery.

   


In summary, the author states surgery for acoustic neuroma is a proven, safe and effective treatment with reproducible results. In particular, the long-term safety of this treatment is well documented. Radiotherapy, on the other hand, does not achieve a cure, the early results are little different to the natural history of the disease and serious long-term complications can occur.

     

L Dade Lunsford, Ajay Niranjan, (Pittsburg, Philadelphia)

What are the results and rationale of stereotactic radiotherapy in the management of vestibular schwannomas?


ENT News, Vol.9(5), Nov./Dec.2000. P.23

     


For acoustic neuromas, the surgical alternatives are microsurgery and gamma knife.

     


Today, good imaging technique achievers have very early diagnosis with minimal symptoms. The goals of management have shifted from tumour removal to preservation of neurological function viz. facial nerve function and hearing preservation.

     


The goals of radiosurgery are to inactivate the tumour, as against physical removal by microsurgery. The gradual tumour reduction in size is noted over the next two to seven years period. The aim is to prevent further growth, while preserving 7th and 8th nerve function and other neurological and employment status. 

    


At the University of Pittsburgh, 622 patients have undergone gamma knife radiosurgery over a period of 13 years.

     


Currently, 13Gy to the tumour margin in a single session is utilized. Usually within 6-18 hours patient is discharged. All patients are followed up with MRI and audiometric studies at 6-months, 1,2,4 and 8 years.

     


Analysis of 5-10 year outcome of 162 unilateral tumours treated with radiosurgery between 1987 and 1992, a 98% tumour control rate has been achieved. Only 2% of patients required tumour resection. No additional difficulties were encountered in resection procedure.

     


No patient with an intracanalicular tumour developed new facial or trigeminal neuropathies, 21 of 487 patients (4.3%) had improvement in hearing.

     


With all patients, the concept of tumour growth control versus tumour removal should be discussed. All options should be put forward. According to him by 2001, many patients with newly diagnosed acoustic tumours should undergo gamma knife radiosurgery as the management option of choice.

          

Som PM, Curtin HD, Mancuso AA

Imaging of the Neck 


ORL 2000; 62: 186-198

     


This article relates to the use of C-T scanning in staging of neck in details. A full written classification is given in the text together with diagnosis explaining each of the levels. It is very clear and consistent set of guidelines to help stage the neck on radiological grounds -
CJW.

     

Kau R J, Alexiou C, Stimmer H, Arnold W.

Investigations for neck nodes


ORL, 2000; 62: 199-203

   


This well-written article from Germany provides an overview of the current methods used in status of neck nodes in head and neck malignancies. It compares CT, MRI, ultrasound (US), US guided FNAC, colour doppler US and PET with clinical staging.

    


The least accurate method of detecting lymph node, though the cheapest method of palpation gives 69.7% accuracy. Ultrasound with its limitation of 72.7%, and US guided FNAC 89%.¸CT has 84.9%, MRI 85%. PET scanning most accurate at 90.5% but is not easily available. Colour doppler studies -show reactive nodes have increased hilar blood flow, while metastatic nodes have peripheral blood flow.

   


The advantage of US guided FNAC is that it gives histological diagnosis and staging. However, its invasive procedure is to be kept in mind.

    

Fertilo A, Som PM, Rinaldo A, Mondin V

Classification of neck dissection


ORL -2000; 62: 212-216

    


Many terms are used in various neck dissection procedures but to describe accurately what procedure has been done is still confusing.

    


The most commonly accepted classifications designed by Fertilo in 1998. This divides into (1) comprehensive neck dissection (2) selective neck dissection and (3) extended neck dissection.

    


1. Comprehensive neck dissection – (including radical or modified radical) involves dissection of I-V level.

2. Selective neck dissection 

In this one or more lymph node levels are left in situ.

3. Extended neck dissection – it implies removal of all I-V level nodes and additional lymph nodes or structures, which are not removed in radical neck. Additional structures include accessory nerve, jugular vein, or sternocleidomastoid muscle.

     


The authors suggest the staging of the neck by P M Som to be methodology and then described the surgical procedures in the above manner i.e. level of lymph nodes and additional structures removed or preserved. This is simple method to record and compare.

      

Fertilo A, Silver CE, Rinaldo A, Smith RV 

Surgical options for the neck


ORL 2000: 62: 217-225.

   


This article summarises the surgical options for both NO and node positive necks. It also discusses the adjuvant treatment of radiotherapy or chemotherapy.

     


(A) In clinical and radiological negative neck – selective lateral neck dissection with levels II to IV or VI as necessary with or without preservation of 11th, Jugular vein or sternocleidomastoid.

     


(B) In the necks – treatment varies on N stage.

     (a) High N stage neck – Radical neck dissection including VI and VII where necessary.

     (b) However, N stage neck – more selective neck dissections after levels I to V including VI or VII.

    


Postoperative adjuvant therapy are best reserved for extracapsular spread. Authors prefer primary surgery as it allows accurate p-staging with obvious prognostic implications.
CJW.

     

Ferjaoui M, Kooli H, Najeh D, Hajri H

The nose in Crohn’s disease


Revue De Laryngologie Otologie Rhinologie, 1999: 5: 341-342

     


This is a case report of very aggressive type of primary atrophic rhinitis. With marked crustastions, destruction of the turbinates and septum with saddling of nose and involvement of maxillary sinus.

    


The second biopsy done during (intestinal exacerbation) showed typical features of Crohn’s disease.

     


The systemic therapy of intestinal disease improved all nasal pathology.

    


The issue is to ask, patients of Primary Atrophic Rhinitis, about gastrointestinal symptoms and other lesions suggestive of Crohn’s disease.

    

Krouse JH 

Staging of Inverted Papilloma


Laryngoscope 2000: 110: 965-968

    


Formerly medical maxillectomy through an external incision was treatment of choice as against that today endoscopy is the treatment followed by most of them. This is controversial because of an association of inverted papilloma with malignancy.

    


This study utilized a literature review to develop a simple and easily applied staging system – based on endoscopic examination of the nasal cavity and CT scanning.

    


The staging system is as follows:-

Stage I – Disease is limited to nasal cavity.

Stage II – It is limited to the ethmoid sinuses and medial and superior portion of the 

maxillary sinuses.

Stage III – Involves the lateral or inferior aspects of maxillary sinuses or extension 

into the frontal or sphenoid sinuses.

Stage IV – Involves tumour spread outside the confines of the nose.

    

Moreau PR 

Laser Laryngeal Surgery


Laryngoscope 2000; 110: 1000 – 1006


    


This study is a retrospective analysis of 160 patients treated for laryngeal cancer with CO2 laser endoscopic microsurgery.

    


Glottic tumours were treated with progressively more extensive cordectomies, extended if necessary to the contralateral cord. Supraglottic tumours had an excision limited to the vestibule, a trans-preepiglottic resection or a radical subglottic dissection. The results are as follows:-

    


Five year survival was 97% for 98 tumours (infiltrative glottic tumours) and 100% for the 18 infiltrative supraglottic tumour and 27 in situ carcinoma. No local recurrences were noted in either group of 118 tumours (in whom two precancerous lesions were treated with a further excision) as in 27 in situ. Local control was thus 100%.

   

Rogers RR

Oral applicances for OSA


Sleep and Breathing, 2000: 4: 2: 79-83


    


Currently used intra-oral devices are discussed. Oral Appliances Therapy (OAT) is used as an alternative to palatal surgery and/or continuous positive airway pressure (CPAP).

    


The devices are – Mandibular Repositioning Devices (MRD), Tongue Retaining Devices (TRD). These devices are well tolerated, non-invasive and associated with low morbidity. They bring about objective changes in polysomnographic parameters and should always be considered as therapeutic options.

    

Coppit III G L, Perkins JA, Manning SC

Hairy polyps ?


International Journal of Pediatric Otorhinolaryngology 2000: 52: 3: 219-227.

    


The authors report four cases of nasopharyngeal dermoids and teratomas along with review of literature which include 40 cases. These lesions colloquially are called hairy polyps. Clinically two distinction described by Arnold’s classification, which basically divides the lesions into dermoids, teratoids, true teratomas and epignathi. Dermoids comprise lesions containing two germinal layers (ectoderm and mesoderm). The other has 3 germinal layers with progressive degrees of differentiation.

     


The major problem is that the teratomas are much more likely to be associated with polyhydramios and other congenital anomalies and possibly require intensive airway management – DS.

      

RD deShazo, M O’Brien, K Chapin, et al (Univ of South Alabama, Mobile)

A New Classification and Diagnostic Criteria for Invasive Fungal
Sinusitis

Arch Otolaryngol Head Neck Surg 123:1181-1188, 1997.

    

There is no consensus regarding the classification of fungal sinusitis, and there are no clinical criteria for diagnosis. The authors suggest a new classification system and diagnostic criteria for invasive fungal sinusitis. They are based on a series of patients undergoing surgery for chronic bacterial sinusitis and a review of the pertinent literature.

    

There are 3 forms of invasive fungal sinusitis which the authors recommend to be termed granulomatous, acute fulminant and chronic invasive. The 2 patients in this series had the chronic invasive form. Two diagnostic criteria have been proposed by the authors: (1) sinusitis confirmed by radiologic imaging and (2) histopathologic evidence of hyphal forms within sinus mucosa, submucosa, blood vessels, or bone. 

   

Diagnosis is made primarily by surgical findings as well as CT scan, and reasonable treatment can be obtained in terms of classification of sinusitis. Chronic invasive fungal sinusitis is thought to be seen primarily in immunocompromised and in diabetics, and the treatment should involve both antifungal treatment and surgery.

      

S Elwany, M Bassiouny, (Alexandria Univ, Egypt)

Topical Levocabastine for the Treatment of Perennial Allergic Rhinitis

J Laryngol Otol 111: 935-940, 1997.

     

Oral H1-receptor antagonists which have found the primary treatment for chronic allergic rhinitis are associated with severe systemic side effects. Topical therapy should theoretically avoid these events, while producing a higher concentration at the site. A study reported shows the use of a nasal spray containing levocabastine which is a potent and highly selective H1-receptor antagonist, on the nasal mucosa in patients with chronic allergic rhinitis.

   

The study has some remarkable findings in that there has been a reappearance of normal cilia and microvilli and more acinar cells in the post-treatment specimens collected in the biopsy. The number and activity of goblet cells and serous glands decreased as was the evidence of vascular congestion. These changes reduced the formation of edema fluid, and the reduction in the number of pinocytotic vesicles reduced the transmission of fluid across epithelial cells. Degranulated mast cells and eosinophils however, were still present at the end of the short study. 

    

Although perhaps not as impressive as topical corticosteroids induced changes, the reported findings certainly suggest moderate anti-inflammatory properties of this topical antihistamine. Hence one should look beyond just the antihistaminic actions of these agents by probably combining with leukotriene and lipoxygenase inhibition studies.

Bergenius J, Perols O (Karolinska Hosp, Stockholm; Norrtalje Hosp, Sweden)

Vestibular Neuritis : A Follow-up Study

Acta Otolaryngol (Stockh) 119:895-899, 1999



Vestibular neuritis usually involves one attack. 19 patients were followed up long term to determine, their auditory or vestibular symptoms.



At 7 to 8 years after an initial attack of vestibular neuritis, half of 19 patients had a recurrence or episodic vestibular symptoms. These symptoms were related to the vestibular tests at onset and the patient’s age. Elevated stapedius reflex threshold at onset and a slower normalisation of canal response was correlated.



Vestibular neuritis is a ablative problem of peripheral vestibular system and can be compared with Bell’s Palsy, which results into degeneration of axons followed by regeneration similarly vestibular neuritis, some mechanism causes recovery which can be demonstrated by ventribular functional recovery. However 1/3rd patients develop positional vertigo possibly because of retrograde degeneration of otoconia. It responds to treatment as well as idiopathic B.P.P.V. This is good article on long- term sequelae of vestibular neuritis.