Connexin 26 gene mutations in non-syndromic hearing loss among Kuwaiti patients

OBJECTIVE

To study connexin 26 (Cx26) gene mutations among autosomal recessive non-syndromal hearing loss in Kuwaiti patients and evaluate their effect on phenotypes.

SUBJECTS AND METHODS

This cross sectional study included 100 patients aged between 6 months and 18 years, who were referred to the Sheikh Salem Al-Ali Centre for audiology and speech evaluation of autosomal recessive non-syndromic sensorineural hearing loss confirmed by clinico-genetic evaluation and a battery of diagnostic tests. Gene profiling and sequencing were performed to detect the presence and nature of Cx26 mutation.

RESULTS

Of the 100 patients, mutation of Cx26 gene was detected in 15 patients (15%) of which 9 (60%) cases were heterozygous and 6 cases (40%) were homozygous. Eighty per cent of the 15 Cx26 positive cases resulted from the 35delG mutation. Among the heterozygous cases, 6 (66.6%) were positive for 35delG. All 6 homozygous patients were positive for the 35delG mutation. A significant correlation was found between genetic findings (p = 0.013) and family history (p = 0.029), as well as the onset (p = 0.015), course (p = 0.033), degree and configuration of hearing loss (p = 0.001).

CONCLUSION

Among the selected Kuwaiti population sample, the Cx26 gene mutation was responsible for 15% of autosomal recessive non-syndromic sensorineural hearing loss. We recommend that screening for Cx26 gene mutation be considered in the screening strategy of patients with non-syndromic childhood hearing loss for counselling and management purposes. .

'Universal retraction suture' for the overprojecting nasal tip

Achieving a proper nasal tip projection is a crucial element of a successful rhinoplasty. A large number of correction methods and manoeuvres have been proposed in the medical literature as solutions for the prominent nasal tip, thus complicating the surgeon's strife to choose the ideal plan of action. In the present article, a single straight-forward technique, christened the 'universal retraction suture', is suggested to tackle the overprojecting tip in a simplified, controlled and efficient fashion.

Extraluminal perforation complicating foreign bodies in the upper aerodigestive tract

OBJECTIVES

Ingestion of a foreign body is a common problem in nearly all otolaryngology practices. One of the uncommon complications of ingested foreign bodies is penetration and migration of the object, which may lead to serious morbidity and/or death. This study will evaluate the presentation, complications, and management of different sites of penetration.

METHODS

We present a retrospective study of a series of 11 patients who presented with a penetrating foreign body of the upper aerodigestive tract in the past 10 years.

RESULTS

All of the patients had radiologic evidence of a foreign body, but negative findings on rigid endoscopy. A computed tomographic scan was done to confirm the presence of a penetrating foreign body. The foreign body was lodged in the extrapharyngeal tissue in 6 patients, was lodged in the upper thyroid pole in 2 patients, had penetrated a Zenker's diverticulum in 2 patients, and had migrated to the thoracic retroesophageal tissue in 1 patient. All patients underwent extraction of the foreign body by an external approach.

CONCLUSIONS

Although the occurrence is rare, impacted foreign bodies in the upper digestive tract can perforate and migrate into the soft tissue of the neck. In the presence of negative findings on endoscopy, a computed tomographic scan of the neck is essential for the prompt diagnosis and management of perforating foreign bodies.

Polydimethylsiloxane: An effective immune adjuvant and slow-release cytokine medium for local cancer treatment

Background and Aim

Silicone oil or gel has well-defined chemotactic properties on monocytes and lymphocytes in vivo. It results in fibrotic reaction when spread into the human tissues either incidentally or purposely and can slowly release any physically-enclosed lyophilized compounds due to its viscosity. Our aim is to investigate whether polydimethylsiloxane could be considered as an effective medium in the local treatment of cancer.

Materials and Methods

Our study was conducted between January 2004 and December 2006 on 15 patients with various types of cancer. The criteria for selection included patients with locally-advanced tumor that was rapidly growing and life threatening and those who had poor quality of life and general wellbeing. The patients were already discharged from the cancer centre before joining the study, after they had already received their chemoradiation protocol. Once a week for one month, different areas of the tumor were injected with 0.25 ml of polydimethylsiloxane medical grade (viscosity: 350 centistokes at 30°C), mixed with 300,000 units of lyophilized human IL-2. Tumor biopsies were taken before the study was started and one week after the last injection for the histopathological analysis of the percentage of severe inflammatory reaction using an image analysis system. CT scans of the tumor were taken before the injection cycle was started and one week after the last injection in order to determine the percentage change in the size of the tumor. The quality of life and general wellbeing of the patients was assessed at the beginning of the stud, and one week after the study was over by using the Karnofsky performance test.

Results

Our treatment was well tolerated by the patients. They had a significant improvement in their quality of life and general well being (p = 0.0005). The prognosis of the patients before the beginning of the study ranged between 1 and 6 months, while their overall survival after treatment was between 2 and 12 months, with three patients still remaining alive. A significant decrease in the tumor size was observed at the end of the study in 12 patients (p < 0.0001). Such a decrease was associated with a significant increase in the percentage of the tumor containing a severe immune reaction (p <0.0001). A significant correlation was found between the percentage reduction in tumor size and the percentage of tumor immune reaction (r² = 0.968; p < 0.0001).

Conclusion

Polydimethylsiloxane could be used as an effective cytokine medium in the local treatment of cancer. When injected inside the tumor, it is capable of creating and modulating an effective, slow and persistent antitumor immune response. Moreover, it is capable of improving the overall survival as well as the quality of life and general well being of the cancer patients.

Securebox: a multibiopsy sample container for specimen identification and transport

OBJECTIVE

To describe an original multicompartment disposable container for tissue surgical specimens or serial biopsy samples (Securebox).

STUDY DESIGN

The increasing number of pathology samples from a single patient required for an accurate diagnosis led us to design and manufacture a unique container with 4 boxes; in each box 1 or more biopsy samples can be lodged. A magnification lens on a convex segment of the plastic framework allows inspection of macroscopic details of the recovered specimens. We investigated 400 randomly selected cases (compared with 400 controls) who underwent multiple biopsies from January 2006 to January 2007 to evaluate compliance with the new procedure and detect errors resulting from missing some of the multiple specimens or to technical mistakes during the procedure or delivery that might have compromised the final diagnosis.

RESULTS

Using our Securebox, the percentage of oatients whose diagnosis failed or could not be reached was O.5% compared to 4% with the traditional method (p = 0.0012). Moreover, the percentage of medical and nursing staff who were satisfied with the Securebox compared to the traditional methodwas 85% vs. 15%, respectively (p < 0.0001). The average number of days spent bto reach a proper diagnosis based on the usage of the Securebox was 3.38 +/- 1.16 SD compared to 6.76 +/- 0.52 SD with the traditional method (p < 0.0001).

CONCLUSION

The compact Securebox makes it safer and easier to introduce the specimens and to ship them to the pathology laboratories, reducing the risk of error.

An innovative method to evaluate the suture compliance in sealing the surgical wound lips

BACKGROUND AND AIM

The increasing number of surgical procedures performed with local anesthesia, followed by immediate patient discharge from the hospital, emphasizes the need for a tight waterproof suture that is capable of maintaining its tensile strength in the postoperative phase when the wound tumescence, edema due to the anesthetic drug, and surgical trauma disappear. Moreover, the issue of having an accurate surgical wound closure is very relevant in vivo in order to prevent hemorrhage and exogenous microbial infections. This study aimed at designing a new a lab technique that could be used for evaluating the best surgical material. Using such a technique, we compared the wound-lip-sealing properties of three commonly-used suture threads, namely polyurethane, polypropylene, and polyamide.

MATERIALS AND METHODS

The mechanical properties of same-size suture threads made from polyurethane, polypropylene, and polyamide, were compared in order to define the one that possess the best elastic properties by being able to counteract the tension-relaxation process in the first 12 hours following surgery. The tension holding capacity of the suture materials was measured in both in vivo and in vitro experiments. The surface area of the scar associated with the three different suture threads was measured and compared, and the permeability of the three different suture threads was assessed at 0 minute, 2 minute, 4 minute, 6 minute, and 8 minute- interval.

RESULTS

Results showed that polyurethane suture threads had significantly (P < 0.05) better tensile strength, elongation endurance before breakage, and better elasticity coefficient as compared to polypropylene and polyamide suture threads. Moreover, polyurethane suture threads were significantly (P < 0.05) more impermeable as compared to the other two suture thread types (polypropylene and polyamide). This impermeability was also associated with a tighter wound-lip-sealing ability, and with significantly (P < 0.05) less scar formation.

CONCLUSION

Among the main concerns that surgeons, physicians, and patients often have is the development infection, oozing, and scar at the incision site following suturing. This always raises the question about which suture to use to avoid the above problems. This study provides evidence that the new technique developed in our lab could be used to compare the wound-lip sealing properties of different surgical suture threads. Using such a technique, the results show that polyurethane is significantly better than other commonly-used suture threads, like polypropylene and polyamide, in relation to wound sealing and scar formation.

Adenotonsillar granuloma: histopathological correlation

OBJECTIVES

This study was undertaken to investigate the presence and nature of granulomatous changes in the adenotonsillar tissues and their relation to systemic disorders.

MATERIALS AND METHODS

The study was a retrospective clinicopathological review; 21,410 specimens of tonsil and adenoid tissue were subjected to histological examination during the period from 1995 to 2003. Twenty-three cases of tonsillar and adenoid granuloma (12 males and 11 females) were identified. Haemotoxylin and eosin stains were reviewed and clinical features noted.

RESULTS

Of 23 cases, 11 were adenotonsillectomies, 10 tonsillectomies, 1 adenoidectomy and 1 excision biopsy of the right tonsil. Histologically, the slides reviewed showed 4 types of granulomatous inflammation that can affect the adenotonsillar tissues. The most common type was non-caseating epithelioid granulomas. Clinically, 22 cases presented with symptoms of chronic tonsillitis, nasal obstruction and obstructive sleep apnoea. None had any systemic granulomatous disorders. Only 1 case had tuberculosis.

CONCLUSION

In all the cases but one there was no obvious systemic aetiology for the granulomatous changes in the adenotonsillar tissues. Hence, the cost effectiveness of clinicopathological examination of the resected adenoid and tonsil is still questionable.

Perforating and migrating pharyngoesophageal foreign bodies: a series of 5 patients

Ingestion of a foreign body is a problem seen in nearly all otolaryngologic practices. One of the least common complications of foreign-body ingestion is penetration and migration, which may lead to serious morbidity or even death. We report the findings of a retrospective review of a series of 5 patients who had presented with a complete foreign-body penetration. All of them had radiologic evidence of a foreign body, but findings on rigid endoscopy were negative. Computed tomography is the radiologic study of choice to identify penetrating foreign bodies. The foreign bodies in all 5 patients were extracted via an external approach.

Perforating and Migrating Pharyngoesophageal Foreign Bodies: A Series of 5 Patients

Ingestion of a foreign body is a problem seen in nearly all otolaryngologic practices. One of the least common complications of foreign-body ingestion is penetration and migration, which may lead to serious morbidity or even death. We report the findings of a retrospective review of a series of 5 patients who had presented with a complete foreign-body penetration. All of them had radiologic evidence of a foreign body, but findings on rigid endoscopy were negative. Computed tomography is the radiologic study of choice to identify penetrating foreign bodies. The foreign bodies in all 5 patients were extracted via an external approach.

Early identification of rhinocerebral mucormycosis

OBJECTIVES

Mucormycosis is an acute and often fatal infection caused by a fungus of the Mucorales order of the Zygomycetes class. In the majority of cases, it is associated with an underlying disorder, such as diabetes mellitus with ketoacidosis, or with immunocompromising factors, but it may appear in healthy people, although rarely. Early diagnosis and treatment are critical to prevent an otherwise fatal outcome. This article presents and discusses the early (alarming) signs and symptoms and the predisposing factors that should be considered to avoid delays in diagnosis.

METHODS

We review seven cases of rhinocerebral mucormycosis admitted to our hospitals from 1998 to 2003.

RESULTS

All patients had an underlying immunocompromising factor and/or diabetes mellitus. Five patients had palatal necrotic ulcers and/or black eschars. Three patients had unilateral blindness, and two patients required orbital exenteration. Four patients died because of a delayed diagnosis.

CONCLUSIONS

Early diagnosis is critical in the prevention of intracranial extension of the infection, which is the cause of death in 80% of cases. Therefore, a high index of clinical suspicion is essential in immunocompromised or diabetic patients with acute sinus infection. Identification of a fungal organism on histopathology is the most specific element for diagnosis. A team approach to management is recommended for early surgical debridement, correction of diabetic ketoacidosis, and systemic antifungal agents. Timely medical-surgical treatment proves extremely important for prognosis.

Non-traumatic cerebrospinal fluid rhinorrhea: diagnosis and management

BACKGROUND

Although the majority of cerebrospinal (CSF) fistulas in the anterior skull base are traumatic in nature, the minority is non-traumatic or primary. Non-traumatic CSF leak can be a diagnostic and treatment challenge.

PATIENTS AND METHODS

We describe the diagnosis, modified methods of localization, and surgical repair of a series of nine patients who presented with non-traumatic CSF rhinorrhea and were managed between July 2000 and October 2002.

RESULTS

Eight patients were managed via an endoscopic approach and one patient through an intracranial approach. The RI/T2-FLAIR test was used for localization of the site of the leak. The test confirmed the site of CSF leak in 6 patients. Successful repair of CSF rhinorrhea was achieved in 7 of 8 patients with a single endoscopic procedure; one patient required two procedures after a re-leak 18 months following the first repair.

CONCLUSION

Non-traumatic CSF rhinorrhea is a relatively rare condition and occurs secondary to different etiologies. Among multiple techniques available for localization, MRI/FLAIR is effective, but requires further evaluation and polishing. In the absence of a large skull base lesion or tumor, endoscopic repair of CSF fistula carries a high success rate with a high margin of safety and low morbidity rate.

Surgical management of nonmalignant parotid masses in the pediatric population: the Montreal Children's Hospital's experience

Nonmalignant parotid masses in children can have protean etiologies ranging from infective parotitis to a benign neoplastic, vascular, or congenital origin. We review the 10-year experience of a tertiary care pediatric centre with respect to the surgical management of nonmalignant parotid masses. In total, 15 patients with nonmalignant masses of the parotid gland region underwent surgery. Five children were diagnosed with lymphoepithelial cyst or first branchial cleft cyst. Three children were diagnosed with parotid abscess, one of whom had atypical mycobacteria. Other diagnoses included lymphangioma (three cases), chronic inflammation (two cases), and epidermoid cyst (one case). One patient who presented with a parotid cyst was diagnosed postoperatively with plexiform neurofibroma of the facial nerve. She was the only patient with postoperative facial nerve paresis, affecting the orbital branch. Presentation and postoperative complications of these surgically managed nonmalignant parotid masses are reviewed. The history and physical examination are of the utmost importance in predicting the diagnosis, although ultrasonography and computed tomography can be useful. Fine-needle aspiration cytology was not well tolerated by children and appears of little use as the accurate diagnosis was provided by the surgical pathology specimen.

Vestibular-evoked myogenic potentials as a test of otolith function

OBJECTIVES

To evaluate the use of 75 auditory clicks rather than the usual 100-256 for production of the vestibular-evoked myogenic potential (VEMP) response and to assess if the VEMP correlates with measures of cochlear function such as hearing loss (decibels on pure-tone testing) or auditory brainstem response (ABR).

SUBJECTS AND METHODS

Testing of the VEMP was carried out on 24 subjects: 7 normal individuals and 13 hard-of-hearing patients, 2 patients with known vestibular lesions, 1 with profound sensorineural hearing loss and 1 patient with unilateral acoustic neuroma prior to resection. The recording was performed using a conventional ABR machine. Using 75 refraction clicks as auditory stimuli, VEMP responses were measured from a surface electrode applied to the sternocleidomastoid muscle. The 75 responses were averaged.

RESULTS

A consistent unilateral biphasic response, the first negative and the second positive (nI, pII), was elicited from 39 of 40 ears (7 normal and 13 hard-of-hearing subjects with no known vestibular dysfunction). No statistical difference was found between the right and left ear responses for nI or pII wave latencies. Two patients with loss of peripheral vestibular function showed no VEMP responses on the affected side. The responses, however, were elicited bilaterally in a patient with congenital profound sensorineural hearing loss. In addition, ABR latencies did not correlate with VEMP latencies.

CONCLUSION

Clear VEMP responses were elicited by using only 75 auditory clicks. This shortens the testing time and facilitates the procedure for the tested subject. Our data also indicate that the VEMP is generated secondary to auditory stimulation of the vestibular end organs (specifically the saccule) and does not correlate with cochlear function.

Evaluation of vestibular evoked myogenic potentials

In previous studies, electromyographic potentials, recorded in response to auditory clicks, have been attributed to stimulation of the otolith (saccule) and have been termed vestibular evoked myogenic potentials (VEMPs). In this study, we assessed the VEMPs in subjects with normal auditory brainstem evoked responses, with no history of vestibular symptoms or neck and other skeletal muscle abnormalities. To this effect, 32 subjects (64 ears), after ethics committee approval, were exposed to 75, 150, and 300 clicks at 100 dB, and the responses were averaged. Electromyographic activity was recorded by applying surface electrodes over the sternocleiodomastoid muscle under the following three conditions: no muscle contraction/no clicks, muscle contraction/no clicks, and muscle contraction/clicks. Our findings suggest that electromyographic responses have to be obtained, during muscle contraction, first without and then with clicks. Our data also suggest that comparison of these two recordings is necessary for meaningful results.

Penetrating craniofacial injury in a pediatric patient

Penetrating craniofacial injuries are rare especially in the pediatric age group. They are potentially life-threatening and challenging injuries. We describe an unusual trauma in a 30-month-old child who suffered a craniofacial injury caused by TV antenna. Clinical examination and radiological investigation showed the antenna penetrating the hard palate, left posterior nasal choana, sphenoid sinus, and skull base, up to pituitary fossa. There was no evidence of great vessels injury that confirmed by cerebral angiography. Transpalatal approach was used to remove the antenna and repair the skull base defect. There was no neurological or visual activity deficit postoperatively. The child developed diabetes insipidus that is well controlled using desmopressin.

An aggressive approach to the surgical management of suspicious thyroid nodules

Thyroid cancer accounted for about 2.5% of all new cancers among Canadian females in the year 2000. The surgical management of well-differentiated thyroid cancer remains controversial. We reviewed 100 consecutive cases of total thyroidectomy for thyroid masses suspicious for malignancy done between 1998 and 1999. When feasible, a capsular dissection was performed using only the bipolar cautery for hemostasis. The accuracy of preoperative diagnosis and complications of surgery are evaluated. We suggest that total thyroidectomy can be performed, without excessive morbidity. If performed for all suspicious thyroid nodules, it will eliminate the need for completion thyroidectomies and high ablative does of 131I.

Bilateral chylothorax following neck dissection: a new method of treatment

Chylothorax is a serious condition with a high rate of morbidity that may lead to death. Although it is encountered more frequently with certain thoracic procedures, it is considered to be a rare complication of neck dissection. Different forms of management have been postulated; however, no consensus of treatment has been achieved. A case of severe bilateral chylothorax that developed after bilateral neck dissection in a patient with laryngeal carcinoma is presented. Somatostatin injection was successful after total parenteral nutrition failed to control the chylothorax. On the basis of this case and the review of the literature discussed here, we advocate the use of somatostatin with other conservative measures in the management of chylothorax.

Skull Base Meningioma: Delayed Extracranial Presentation

Meningiomas are common intracranial tumors that rarely extend to extracranial sites. When they occur extracranially near the skull base, their diagnosis and management represent tremendous challenges. Although the extracranial component tends to manifest at the same time as the intracranial component, this is not always the case. In the patient reported in this article, 13 years separated the diagnosis of the intracranial tumor from the appearance of an extracranial component. The clinical presentation, radiologic findings, and management of this large skull base meningioma are discussed with reference to the literature. A high index of suspicion and clinical acumen are needed to ensure that the extracranial component of these frequent tumors is discovered, especially when it presents later than the intracranial component.

Systemic steroids for the management of obstructive subglottic hemangioma

Subglottic hemangioma is a recognized cause of paediatric upper airway obstruction. We present 14 patients with subglottic hemangioma treated between 1984 and 1997,4 of whom had associated extralaryngeal hemangiomatous lesions (28%). The degree of upper airway obstruction ranged between 20% and 90%. Patients with subglottic hemangioma who had obstruction of the laryngeal lumen more than 25% and those with obstructive symptoms were treated with systemic steroids. The patients were followed clinically, radiographically, and with repetitive bronchoscopies. Nine of 10 patients (90%) have responded clinically to systemic steroids. There were no major complications from the systemic steroid treatment. One patient developed a cushingoid face that was reversed after the cessation of steroid therapy. The purpose of this study is to show that systemic steroids, with or without short-term intubation after diagnostic bronchoscopy, can be used as a safe and effective alternative in the management of obstructive paediatric subglottic hemangiomas.