On the rationale of the alpha-hydroxybutyrate dehydrogenase (HBD) determination

The discriminating power of HBD, LD and of the HBD/LD ratio in comparison with LD1/LD2 and LD5/LD4 ratios in acute myocardial infarction and hepatic disease is evaluated. The results demonstrate that there are no clinical reasons for the determination of the HBD when a method using the conditions of the Committee of Enzymes of the Scandinavian Society for Clinical Chemistry (SCE) is used.

Post-operative roentgenological findings and changes after mastoid obliteration

This study consisted of the evaluation of the plain X-ray findings of films taken at early follow-up (mean 1.5 months after surgery) and at late follow-up (4-14 years after the early films) of 211 ears which had been operated on radically and obliterated. Residual cells which were detected on the basis of the early films were associated with a more frequent occurrence of post-operative infection and were thus hallmarks of a poorer prognosis. Changes in the bone surrounding the surgical cavity and the radiological quality of the walls of the surgical cavity, the presence of new bone formation in the cavity and other radiological features did not yield useful information about post-operative complications. New bone formation was associated with a smaller amount of post-operative cavitation. Post-operative X-ray examination of the obliterated ear is a prognostically useful examination, but it does not significantly contribute further to the information available by clinical and otomicroscopic examination in regards to the complications of infection and cholesteatoma.

The differential diagnosis of bacterial and aseptic meningitis using cerebrospinal fluid laboratory tests

The lactate, lysozyme, C-reactive protein and serum amyloid-A protein concentrations in cerebrospinal fluid were measured in 11 patients with bacterial meningitis, 27 patients with aseptic meningitis and in 31 control patients. The mean concentration of each parameter was significantly higher (p less than or equal to 0.0001) in patients with bacterial meningitis than in those with aseptic meningitis or those without meningitis. The reliability of these tests in the differential diagnosis of bacterial and aseptic meningitis was compared with leucocyte counts in cerebrospinal fluid. Gram staining for bacteria, and protein and glucose levels. The cerebrospinal fluid lactate level proved to be more sensitive than lysozyme. C-reactive protein or serum amyloid-A protein and had a high degree of specificity.

Late post-operative hearing results correlated with the severity of tissue changes in ears with chronic otitis media

Late hearing results in 627 ears (574 patients) operated on radically for chronic otitis media are presented. Clinically, the ears were followed-up annually for 5-14 years. The results are correlated with the severity of histopathological changes in the tympanic cavity and in the mastoid air-cell system and also with the management of the tympanic mucosa and ossicular chain at operation. The mean post-operative air-bone gap was significantly better in ears with mild histopathological changes than in ears with severe histopathological changes in the middle ear (17.0 db./33.1 db.; p less than 0.001) or mastoid (29.0 db./34.2 db.; p less than 0.01) at operation. The difference in hearing results in favour of the former group was more significant in ears in which the tympanic mucosa had been saved at operation (p less than 0.01/p less than 0.001) than in ears in which the mucosa had been removed (p less than 0.05).

Late results of tympanoplasty using ossicle or cortical bone

Hearing results are presented for 164 ears with chronic otitis media which were operated on radically and obliterated with a musculo-periosteal flap (Palva flap), and in which tympanoplasty was performed. The ears were followed-up annually for 5-13 years (mean 6.8 years). Results are compared with the method of ossiculoplasty and with the condition of the stapes superstructure at operation. Ossiculoplasty using autogenous cortical bone columellas resulted in a somewhat greater improvement in the post-operative air-bone gap than ossiculoplasty with auto- or homo-graft ossicles, when compared with the pre-operative gap. Similarly, the post-operative gap improved more in ears with an intact stapes superstructure than in ears in which the stapes superstructure was absent. The use of an autogenous cortical bone columella can be recommended in cases in which the patient's own ossicles are affected by disease and cannot be used.

Post-operative ear canal volume measurements

Post-operative volume determinations have been made of the ear canals of 93 chronic ears operated on radically (removing the bony posterior meatal wall at operation, obliterating the surgical cavity by musculoperiosteal flap, and reconstucting the meatus, by soft-tissue only in 81 ears, or by cortical bone chips and soft tissue in 12 ears), and of 30 normal ears, using a liquied-filling method and by determining the compliance of the ear canal at a pressure of +200 mm. H2O.

The liquid-filling method gave more exact results than did the impedance measureemnts, and the results of the later showed more dispersion in all groups of ears. In 51 ears without post-operative cavities and reconstructed without bone chips, the mean value of the ear canal volume was 0.9 ml. by the liquid-filling method, and 1.5 ml, by the compliance method (p<0.001). The corresponding values for 30 ears with post-operative cavities, but without bony reconstruction of the meatus, were 1.5 ml. and 1.9 ml. (p<0.01). The values were 0.9 ml. and 1.2 ml. in 12 ears with posterior canal walls reconstructed with bone chips (p<0.01), and 0.8 ml. and 1.0 ml. in 39 normal ears (p<0.001). The liquid method seems to be a very exact method, but quite trouble-some in routine clinical use; the compliance method is suitable in most ears in which there has been bony reconstruction of the posterior meatal wall, but not in ears in which the posterior ear canal wasll has been reconstructed with solft tissues only, because the soft posterior meatal wall was mobile at +200 mm. H2O pressure.

Late changes in hearing results after mastoid obliteration with tympanoplasty

Hearing results are presented for 627 ears with chronic otitis media that were operated on radically and obliterated (Palva flap) and in which a tympanoplasty was performed. The ears were examined annually for five to 14 years (mean, 8.8 years). The long-term improvement (five to 14 years after the surgery) was the greatest in ears with an intact ossicular chain and in ears with ossicular reconstruction using autograft or homograft ossicles or autogenous cortical bone columellae. As a whole, the early (one year after the operation) improvement in the air-bone gap was 8.0 dB when compared with the preoperative gap and the late deterioration in gap after the first year was 6.0 dB. To detect the late changes in hearing results, the ears operated on must be followed up for a least five to ten years.

The preoperative state of infection in chronic otitis media correlated with postoperative hearing results

The postoperative long-term hearing results, with special reference to the state and management of the tympanic mucosa at operation, in 627 ears (574 patients) after an annual clinical follow-up period of 5-14 years are presented. The ears were operated on radically due to chronic otitis media, using the obliterative radical operation technique developed by T. Palva. The air-bone gap improved from the preoperative level significantly more in ears where the tympanic mucosa had been preserved than in ears where it had been removed at operation (p less than 0.001). The improvement was also significantly better in dry ears than in ears which were moist or discharging at operation (p less than 0.05). The mean late deterioration in the air-bone gap after the first follow-up year was significant in all the groups of ears (p less than 0.05), and the mean long-term change in air-bone gap from pre- to late postoperative examination was the improvement of 3.0 dB in ears with, and a deterioration of 2.0 dB in ears without ossicular reconstruction.

Post-operative cholesteatomas and retraction pockets after obliterative surgery in ears without cholesteatoma

The frequency of post-operative cholesteatomas, epidermizations and retraction pockets in a series of 343 chronically infected ears (315 patients) without cholesteatoma at primary surgery was evaluated. The ears were operated on radically, exclusively by the Palva method, with removal of the bridge in 248 ears and preservation of it in 95 ears. Musculo-periosteal obliteration and seclusion of the aditus were performed in every case with a Palva flap and with a temporalis muscle-fascia graft. The primary operations took place over the period 1964-1972, and all the ears without cholesteatoma at primary surgery were included; they were followed up annually. The evaluation of this material was carried out in 1976-1979 and the follow-up time was on an average of 8.5 years (5-15 years). Cholesteatoma was found in six (6/343; 1.7 per cent), epidermization of the tympanum in four (4/343; 1.2 per cent), and retraction pockets without cholesteatoma in six (6/343; 1.7 per cent) of the ears. Preservation or removal of the bridge at operation did not cause any significant difference in the frequency of the post-operative complications mentioned (p greater than 0.05). Most of the complications were discovered after the first postoperative year.

Symptoms of carcinoma of the oesophagus

Cancer of the oesophagus in its early stages is relatively asymptomatic, and the establishment of the diagnosis may be delayed because of the failure of the patient to seek early medical attention, or because the initial examining physician made an incorrect diagnosis. A good knowledge of the symptoms of the disease as well as an active role in diagnostic studies aid the physician in rapidly achieving the diagnosis. The most common symptoms in 162 patients with cancer of the oesophagus were: difficulty in swallowing (96%), loss of weight (42%), vomiting (25%), pain in the upper part of the abdomen (20%) and retrosternal pain (20%). The mean duration of symptoms before first presentation for medical attention was 3.1 months, and the correct diagnosis was generally established four to six weeks after the initial visit at the doctor's office. In 21.6% of cases, the initial visit did not lead to the correct diagnosis.

Symptoms and diagnostic delay in patients with carcinoma of oesophagus and gastric cardia: a retrospective study of 225 patients

A retrospective review of 225 patients was made with regard to the symptoms of carcinoma of the oesophagus and gastric cardia, and the duration of the symptoms before medical attention was sought and before the establishment of the diagnosis. The age of the patients was 37-84 (mean 62·5) years (139 male, 86 female). The most common symptoms were dysphagia (93%), loss of weight (46%), vomiting (33%), gastric pain (25%) and thoracic pain (21%).

The average duration of the symptoms before the establishment of the diagnosis was 4·1 months in carcinoma of the oesophagus and 4·3 months in carcinoma of the gastric cardia. The patients with oesophageal disease had sought medical attention on average 5 weeks earlier than those with gastric disease. The role of the physician who initially examines the patient is decisive for early diagnosis.

Bacteriological studies after obliterative mastoid operations

This study evaluates the post-operative bacteriology and the clinical state of postoperatively infected ears which were operated on using obliterative techniques and relates these bacteriological findings with the disease present. Out of the 85 ears with post-operative infection, the discharge was mucous in nine ears, mucopurulent in 18 ears, and seropurulent in 34 ears. Twenty-four ears were moist. Epitympanal or antral cholesteatoma was noticed in seven ears and meso- or hypotympanal cholesteatoma in 12 ears. The post-operative Valsalva-test was positive in 61 ears and negative in 24 ears. The types of bacteria did not significantly depend on the quality of the post-operative discharge, existence of post-operative cholesteatoma, or clinical function of the Eustachian tube (estimated by the Valsalva test). This study indicates that the bacteriology of the post-operatively moist or discharging ear does not significantly depend of the clinical state of the ear, nor can it be predicted on the basis of the clinical picture of the ear. A bacteriological examination of the ear seems to be the only way to control chemotherapy properly.

Late changes in ear canal volumes after mastoid obliteration

In this study, preoperative and postoperative ear canal volumes of ears subjected to obliterative radical mastoidectomy were assessed. The measurements were performed using sterile saline solution both at the preoperative stage (V0) and at the early (one year, V1) and the late (five to 13 years, V2) postopertive stages. The mean V0 was 0.8 mL (SD, 0.2 mL; V1, 1.0 mL (SD, 0.3 mL); and V2, 1.2 mL (SD, 0.4 mL). The differences were highly significant. Clinically, the widening of the ear canals was mainly slight and appeared evenly in the epitympanic area and in the posterior ear canal wall.

[Bacteria in the middle ear and nasopharynx in patients with chronic otitis media]

The pre- and postoperative aural and postoperative nasopharyngeal bacteriology of 104 ears (100 patients), still moist or discharging after surgery, were studied. Preoperatively aural and postoperatively dry ears (83 patients) of reference group were registered as well. All ears had been operated on radically with obliterative technique as described by Palva (1963, 1973) because of chronic otitis media with or without cholesteatoma. The preoperative bacteriology of the postoperatively moist or discharging cars did not differ statistically from that of the ears in the reference group. The same bacteria were detected pre- and postoperatively in the same ears in 44.1% of the ears in the former group and this situation was noticed highly significantly often regarding Pseudomonas aeruginosa (p less than 0.001) and almost significantly often regarding Proteus sp. (p less than 0.05). The postoperative nasopharyngeal bacteriology of the two groups mentioned did not differ statistically and only in six out of 100 cases the same pathogenic bacteria could be simultaneously cultured in the postoperatively moist or discharging ear and nasopharynx of the same patient.

Bacteriology in chronic otitis media correlated with the clinical state of ears

Bacteriologic findings in 702 cases of chronic otitis media were correlated with the clinical conditions of the ears. Statistically significant correlations with the severity of the clinical infection were noticed concerning Pseudomonas aeruginosa, St, aureus and E. coli. The bacteriological findings did not correlate with the results of Valsalva test. Pseudomonas aeruginosa was statistically more often present in ears without than in ears with cholesteatoma.

Correlation of postoperative ear canal volumes with obliteration material and with volume of operation cavity

In this study the preoperative and early and late postoperative volumes of ear canals of 131 operated chronic ears were measured by filling the ear canals with saline solution. The ears were operated on using the Palva method of obliteration of the operative cavity and reconstruction of the ear canal after removing the posterior, bony canal wall at operation. The average preoperative ear canal volume (V0) was 0.8 ml, the early postoperative volume (V1) was 1.0 ml, and the late postoperative volume (V2) was 1.2 ml. There was significantly more widening of the volume of the ear canals in the ears with a larger (greater than 7 ml) operation cavity as compared to ears with smaller (3-7 ml) operation cavity (p less than 0.05). Widening of the ear canals was smaller in the 12 ears with obliteration of the surgical cavity with musculoperiosteal flap and anorganic bone (Ossar) as compared to the 119 ears obliterated with musculoperiosteal flap only, but the difference was not statistically significant (p greater than 0.05).

Late results of obliterative cholesteatoma surgery

Radical obliterative cholesteatoma surgery was performed on 463 ears. Post-operative cholesteatomas were found in 22 of 463 of the ears during the follow-up periods that ranged from five to 15 years. Eight of them were of the residual type, and 14 were of the recidive type. A substantial portion of the postoperative cholesteatomas (11 cases) was discovered as late as the sixth to the tenth postoperative years. Four of the postoperative cholesteatomas extended to the antrum or the operation cavity from the tympanic cavity or meatus, but none of them originated in the cavity area. The surgical method that was used was safe. Annual follow-up examinations for at least ten years are recommended after the obliterative radical operation for ears with cholesteatomas.

Role of atopic allergy in chronic otitis media. Evaluation based on serum IgE and nasal/aural cytologic findings in patients with operated chronic ears

Serum IgE levels and nasal/aural secretion eosinophils and basophils cells were studied in 84 patients with ear discharge despite previous radical operation, in 83 patients with postoperatively dry ears, and in 30 normal persons. Serum IgE values suggesting atopy (greater than 100 U/ml, PRIST) were more frequent (p less than 0.05) among patients with draining ears than among persons with healthy ears. Normal IgE concentrations showed reversed frequency distribution. Nasal secretion eosinophils and/or basophilic cells were also found more frequently (p less than 0.05) among patients with discharging ears than in other groups. Analogously, those with both serum IgE of greater than 100 U/ml and 'positive' nasal cytology more often had infected than dry (p less than 0.01) or normal (p less than 0.05) ears. Aural secretions showed eosinophils and/or basophilic cells in 14 (17%) patients; 11 of them had such cells in their nasal secretions too. It would seem that atopy is probably one cause of persistent therapy-resistant otitis media and it must be taken into account when considering the treatment of a chronic ear.

Late hearing results after paraffinplasty or silastic sheeting

The long-term hearing results are presented for 135 ears operated on radically. In 59 of the ears temporary paraffin filling of the tympanic cavity was employed after the removal of the tympanic mucosa ot operation. The filling material was removed, and the ossiculoplasty was performed about 6 months later. In 76 ears a one-stage operation with tympanoplasty and Silastic sheeting was employed. There were no statistical differences between the groups of ears mentioned according to hearing results early (1 year) or late (5-15 years) postoperatively or in the deterioration of the air-bone gaps after the first postoperative year (P greater than 0.05). The late change in the air-bone gap was significant in both groups (paraffin group: 6.1 dB; Silastic sheeting group: 5.7 dB; P less than 0.05). The total improvement of hearing late after surgery (as compared to the preoperative hearing) was significantly better in the paraffin group than in ears with Silastic sheeting (P less than 0.05). Paraffinplasty seems to be a suitable way to avoid tympanic adhesions.

Comparison of pre- and post-operative bacteriology of chronic ears

The over-all distribution of the pre-operative bacteria of 806 ears and the post-operative bacteria of 109 post-operatively moist or discharging ears correlated very well, the only clear difference being the detection of diphtheroid bacilli more often post-operatively than pre-operatively. When comparing the pre- and post-operative bacteriology of 109 post-operatively infected chronic ears which had undergone radical surgery and obliteration with Palva flaps (and which were drawn from a group of 806 ears originally operated on and followed yearly for 5-14 years) it was noticed that Pseudomonas aeruginosa and Proteus sp were cultured more often post-operatively than pre-operatively in the same ears. Statistically, other bacteria were not found to be significantly present in the same ears.

Atlantoaxial subluxation. An unusual complication after local anesthesia for tonsillectomy

After tonsillectomy, atlantoaxial subluxation occurred in two patients. Operations had been performed with the use of local anesthesia, and it was assumed that, during the injection of anesthetics, bacteria infected the prevertebral space. The initial symptoms of the prevertebral space infection were neck pain and stiffness; the movements of the neck were minimal, and opening of the mouth caused pain due to spasm of the deep cervical muscles. Both patients had persistent fever. The roentgenographically observed subluxation developed in one to two months after tonsillectomy. One of the patients was treated only with antibiotics; the other patient required atlantoaxial spondylodesis. Healing of the subluxation lasted about six months in both cases.