[New Swedish National care process for pediatric obstructive sleep disordered breathing]

Obstructive sleep disordered breathing (OSDB) is a spectrum from habitual snoring and labored breathing to obstructive sleep apnea (OSA), which is common and potentially serious in children. The process contains a new question at child care centers, directed at caretakers with children at age 18 months and 3 years, concerning habitual snoring (3 times a week or more). A primary care doctor verifies the suspicion of OSDB in case of a positive answer to one of 7 additional questions or 4 status findings (e.g. tonsil hypertrophy). The process starts with the suspicion of OSDB, from the age of 18 months to 18 years, and ends when symptoms are improved after watchful waiting or upper airway surgery. National equality is a goal, with increased access to nocturnal respiratory recordings of children with comorbidities or doubtful cases. Also, with short waiting time to first visit at ORL department, and to surgery. Children with comorbidities or severe symptoms get postoperative follow-ups with a nurse after 6 months. The new ICD code for OSDB is R06.8A.

High rate of early recurrence of peritonsillar abscess among adolescents and young adults

BACKGROUND

Peritonsillar abscess (PTA) can be treated with aspiration or incision for drainage, but a subsequent PTA can occur if tonsillectomy is not performed. Better understanding is needed of when tonsillectomy should be performed to avoid PTA recurrence.

OBJECTIVE

This study investigated the recurrence rate of PTA following aspiration or incision for drainage and evaluated the risk factors for recurrence.

METHODS

The medical records of 292 patients treated for PTA were reviewed. Recurrence of PTA and elective or quinsy tonsillectomy were the primary endpoints. A Cox proportional hazards regression model for PTA recurrence was constructed with sex, age, and PTA history as predictors.

RESULTS

Young age was the only significant predictor of PTA recurrence. Patients aged 15 to 24 years had a 30-day recurrence rate of 15.5% and a total recurrence rate of 26.6%. The total recurrence rate among patients over 30 years of age was significantly less at 4.0% (Fisher's exact test, p < .05).

CONCLUSION AND SIGNIFICANCE

Based on our results, tonsillectomy should be considered for PTA patients between 15 and 25 years of age and, to effectively avoid future recurrence of PTA, should be performed urgently.

High prevalence of pharyngeal bacterial pathogens among healthy adolescents and young adults

The pharyngeal mucosa can be colonized with bacteria that have potential to cause pharyngotonsillitis. By the use of culturing techniques and PCR, we aimed to assess the prevalence of bacterial pharyngeal pathogens among healthy adolescents and young adults. We performed a cross-sectional study in a community-based cohort of 217 healthy individuals between 16 and 25 years of age. Samples were analyzed for Group A streptococci (GAS), Group C/G streptococci (SDSE), Fusobacterium necrophorum, and Arcanobacterium haemolyticum. Compared to culturing, the PCR method resulted in more frequent detection, albeit in most cases with low levels of DNA, of GAS (20/217 vs. 5/217; p < 0.01) and F. necrophorum (20/217 vs. 8/217; p < 0.01). Culturing and PCR yielded similar rates of SDSE detection (14/217 vs. 12/217; p = 0.73). Arcanobacterium haemolyticum was rarely detected (3/217), and only by PCR. Overall, in 25.3% (55/217) of these healthy adolescents and young adults at least one of these pathogens was detected, a rate that is higher than previously described. Further studies are needed before clinical adoption of PCR-based detection methods for pharyngeal bacterial pathogens, as our findings suggest a high incidence of asymptomatic carriage among adolescents and young adults without throat infections.

Ultrastructural Characterization of Stem Cell-Derived Replacement Vestibular Hair Cells Within Ototoxin-Damaged Rat Utricle Explants

The auditory apparatus of the inner ear does not show turnover of sensory hair cells (HCs) in adult mammals; in contrast, there are many observations supporting low‐level turnover of vestibular HCs within the balance organs of mammalian inner ears. This low‐level renewal of vestibular HCs exists during normal conditions and it is further enhanced after trauma‐induced loss of these HCs. The main process for renewal of HCs within mammalian vestibular epithelia is a conversion/transdifferentiation of existing supporting cells (SCs) into replacement HCs.In earlier studies using long‐term organ cultures of postnatal rat macula utriculi, HC loss induced by gentamicin resulted in an initial substantial decline in HC density followed by a significant increase in the proportion of HCs to SCs indicating the production of replacement HCs. In the present study, using the same model of ototoxic damage to study renewal of vestibular HCs, we focus on the ultrastructural characteristics of SCs undergoing transdifferentiation into new HCs. Our objective was to search for morphological signs of SC plasticity during this process. In the utricular epithelia, we observed immature HCs, which appear to be SCs transdifferentiating into HCs. These bridge SCs have unique morphological features characterized by formation of foot processes, basal accumulation of mitochondria, and an increased amount of connections with nearby SCs. No gap junctions were observed on these transitional cells. The tight junction seals were morphologically intact in both control and gentamicin‐exposed explants. Anat Rec, 303:506–515, 2020. © 2019 The Authors. The Anatomical Record published by Wiley Periodicals, Inc. on behalf of American Association of Anatomists.

Desmin and dystrophin abnormalities in upper airway muscles of snorers and patients with sleep apnea

BACKGROUND

The pathophysiology of obstruction and swallowing dysfunction in snores and sleep apnea patients remains unclear. Neuropathy and to some extent myopathy have been suggested as contributing causes. Recently we reported an absence and an abnormal isoform of two cytoskeletal proteins, desmin, and dystrophin, in upper airway muscles of healthy humans. These cytoskeletal proteins are considered vital for muscle function. We aimed to investigate for muscle cytoskeletal abnormalities in upper airways and its association with swallowing dysfunction and severity of sleep apnea.

METHODS

Cytoskeletal proteins desmin and dystrophin were morphologically evaluated in the uvula muscle of 22 patients undergoing soft palate surgery due to snoring and sleep apnea and in 10 healthy controls. The muscles were analysed with immunohistochemical methods, and swallowing function was assessed using videoradiography.

RESULTS

Desmin displayed a disorganized pattern in 21 ± 13% of the muscle fibres in patients, while these fibers were not present in controls. Muscle fibres lacking desmin were present in both patients and controls, but the proportion was higher in patients (25 ± 12% vs. 14 ± 7%, p = 0.009). The overall desmin abnormalities were significantly more frequent in patients than in controls (46 ± 18% vs. 14 ± 7%, p < 0.001). In patients, the C-terminus of the dystrophin molecule was absent in 19 ± 18% of the desmin-abnormal muscle fibres. Patients with swallowing dysfunction had 55 ± 10% desmin-abnormal muscle fibres vs. 22 ± 6% in patients without swallowing dysfunction, p = 0.002.

CONCLUSION

Cytoskeletal abnormalities in soft palate muscles most likely contribute to pharyngeal dysfunction in snorers and sleep apnea patients. Plausible causes for the presence of these abnormalities is traumatic snoring vibrations, tissue stretch or muscle overload.

Neurotrophic factor BDNF is upregulated in soft palate muscles of snorers and sleep apnea patients

Objectives

Neuromuscular injuries are suggested to contribute to upper airway collapse and swallowing dysfunction in patients with sleep apnea. Neurotrophins, a family of proteins involved in survival, development, and function of neurons, are reported to be upregulated in limb muscle fibers in response to overload and nerve damage. We aimed to investigate the expression of two important neurotrophins, brain‐derived neurotrophic factor (BDNF) and nerve growth factor (NGF), in muscle fibers of uvula from snorers and sleep apnea patients and to compare these findings with pharyngeal function.

Methods

Uvula muscle biopsies from 22 patients and 10 controls were analyzed for BDNF, NGF, and cytoskeletal protein desmin using immunohistochemistry. Pharyngeal swallowing function was assessed using videoradiography.

Results

BDNF, but not NGF, was significantly upregulated in a subpopulation of muscle fibers in snoring and sleep apnea patients. Two major immunoreaction patterns for BDNF were observed; a fine grainy point like BDNF staining was displayed in muscle fibers of both patients and controls (41 ± 23 vs. 25 ± 17%, respectively, P = .06), while an abnormal upregulated intense‐dotted or disorganized reaction was mainly observed in patients (8 ± 8 vs. 2 ± 2%, P = .02). The latter fibers, which often displayed an abnormal immunoreaction for desmin, were more frequent in patients with than without swallowing dysfunction (10 ± 8 vs. 3 ± 3%, P = .05).

Conclusion

BDNF is upregulated in the upper airway muscles of snorers and sleep apnea patients, and especially in patients with swallowing dysfunction. Upregulation of BDNF is suggested to be a response to denervation, reinnervation, and repair of injured muscle fibers. Our findings propose that damaged upper airway muscles might heal following treatment for snoring and sleep apnea.

Level of Evidence

NA

Bacterial flora and the epidemiology of staphylococcus aureus in the nose among patients with symptomatic nasal septal perforations

Conclusions Patients with symptomatic perforations of the nasal septum had a high prevalence of S. aureus in the nasal mucosa. Pulsed field gel electrophoresis (PFGE) analysis revealed a high genetic heterogeneity of S. aureus among both patients and controls. This indicates that presence of different strains of S. aureus can maintain a chronic inflammation in symptomatic nasal septal perforations. Objective The purpose of this study was to investigate the microbial flora around nasal septal perforations in patients having severe symptoms regarding bleeding, obstruction, and crustation associated with their perforation. Methods Twenty-five patients with untreated symptomatic nasal septal perforations were included. For culture, swabs around the perforations were collected. Bacteria were identified with standard laboratory techniques including a MALDI-TOF mass spectrometer. Epidemiological analysis was done using PFGE protocols. Bacteriological data were compared with data from a healthy control group. Results Staphylococcus aureus was present in the mucosa surrounding the nasal perforation significantly more often (p < 0.0001) in the patients (88%) compared to a control group (13%). Corynebacterium spp. and Propionibacterium spp. were significantly more frequently identified in the control group. The PFGE analysis of S. aureus strains revealed a high genetic heterogeneity and no specific S. aureus genotypes were associated with septal perforation.

Tonsillectomy in adults with obstructive sleep apnea

OBJECTIVES/HYPOTHESIS

To study whether tonsillectomy is effective on obstructive sleep apnea (OSA) in adults with large tonsils.

STUDY DESIGN

A multicenter prospective interventional study.

METHODS

The study comprised 28 patients with OSA, an apnea-hypopnea index of > 10, large tonsils (Friedman tonsil size 3 and 4), and age 18 to 59 years. They were derived from 41 consecutive males and females with large tonsils referred for a suspicion of sleep apnea to the ear, nose, and throat departments in Umeå, Skellefteå, and Sunderbyn in northern Sweden. The primary outcome was the apnea-hypopnea index, measured with polygraphic sleep apnea recordings 6 months after surgery. Secondary outcomes included daytime sleepiness, as measured with the Epworth Sleepiness Scale, and swallowing function, using video-fluoroscopy.

RESULTS

The apnea-hypopnea index was reduced from a mean of 40 units per hour (95% confidence interval [CI] 28-51) to seven units per hour (95% CI 3-11), P < 0.001, at the 6-month follow-up after surgery. The apnea-hypopnea index was reduced in all patients and 18 (64%) were cured. The Epworth Sleepiness Scale was reduced from a mean of 11 (95% CI 8-13) to 6.0 (95% CI 4-7), P < 0.001. A swallowing dysfunction was found in seven of eight investigated patients before surgery. Of those, swallowing function improved in five patients after surgery, whereas no one deteriorated.

CONCLUSION

Tonsillectomy may be effective treatment for adult patients with OSA and large tonsils. Tonsillectomy may be suggested for adults with OSA and large tonsils.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2859-2862, 2016.

Unique expression of cytoskeletal proteins in human soft palate muscles

The human oropharyngeal muscles have a unique anatomy with diverse and intricate functions. To investigate if this specialization is also reflected in the cytoarchitecture of muscle fibers, intermediate filament proteins and the dystrophin-associated protein complex have been analyzed in two human palate muscles, musculus uvula (UV) and musculus palatopharyngeus (PP), with immunohistochenmical and morphological techniques. Human limb muscles were used as reference. The findings show that the soft palate muscle fibers have a cytoskeletal architecture that differs from the limb muscles. While all limb muscles showed immunoreaction for a panel of antibodies directed against different domains of cytoskeletal proteins desmin and dystrophin, a subpopulation of palate muscle fibers lacked or had a faint immunoreaction for desmin (UV 11.7% and PP 9.8%) and the C-terminal of the dystrophin molecule (UV 4.2% and PP 6.4%). The vast majority of these fibers expressed slow contractile protein myosin heavy chain I. Furthermore, an unusual staining pattern was also observed in these fibers for β-dystroglycan, caveolin-3 and neuronal nitric oxide synthase nNOS, which are all membrane-linking proteins associated with the dystrophin C-terminus. While the immunoreaction for nNOS was generally weak or absent, β-dystroglycan and caveolin-3 showed a stronger immunostaining. The absence or a low expression of cytoskeletal proteins otherwise considered ubiquitous and important for integration and contraction of muscle cells indicate a unique cytoarchitecture designed to meet the intricate demands of the upper airway muscles. It can be concluded that a subgroup of muscle fibers in the human soft palate appears to have special biomechanical properties, and their unique cytoarchitecture must be taken into account while assessing function and pathology in oropharyngeal muscles.

Morphological and morphometric characterization of direct transdifferentiation of support cells into hair cells in ototoxin-exposed neonatal utricular explants

We have studied aminoglycoside-induced vestibular hair-cell renewal using long-term culture of utricular macula explants from 4-day-old rats. Explanted utricles were exposed to 1 mM of gentamicin for 48 h, during 2nd and 3rd days in vitro (DIV), and then recovering in unsupplemented medium. Utricles were harvested at specified time points from the 2nd through the 28th DIV. The cellular events that occurred within hair cell epithelia during the culture period were documented from serial sectioned specimens. Vestibular hair cells (HCs) and supporting cells (SCs) were systematically counted using light microscopy (LM) with the assistance of morphometric software. Ultrastructural observations were made from selected specimens with transmission electron microscopy (TEM). After 7 DIV, i.e. four days after gentamicin exposure, the density of HCs was 11% of the number of HCs observed in non-gentamicin-exposed control explants. At 28 DIV the HC density was 61% of the number of HCs observed in the control group explant specimens. Simultaneously with this increase in HCs there was a corresponding decline in the number of SCs within the epithelium. The proportion of HCs in relation to SCs increased significantly in the gentamicin-exposed explant group during the 5th to the 28th DIV period of culture. There were no significant differences in the volume estimations of the gentamicin-exposed and the control group explants during the observed period of culture. Morphological observations showed that gentamicin exposure induced extensive loss of HCs within the epithelial layer, which retained their intact apical and basal linings. At 7 to 14 DIV (i.e. 3-11 days after gentamicin exposure) a pseudostratified epithelium with multiple layers of disorganized cells was observed. At 21 DIV new HCs were observed that also possessed features resembling SCs. After 28 DIV a new luminal layer of HCs with several layers of SCs located more basally characterized the gentamicin-exposed epithelium. No mitoses were observed within the epithelial layer of any explants. Our conclusion is that direct transdifferentiation of SCs into HCs was the only process contributing to the renewal of HCs after gentamicin exposure in these explants of vestibular inner ear epithelia obtained from the labyrinths of 4-day-old rats.

Effects of Radiofrequency versus sham surgery of the soft palate on daytime sleepiness

OBJECTIVES/HYPOTHESIS

To evaluate the effect of radiofrequency surgery of the soft palate on daytime sleepiness in snoring men with mild or no sleep apnea.

STUDY DESIGN

Randomized controlled trial.

METHODS

Thirty-five men were recruited from consecutive patients referred to the Ear, Nose, and Throat Clinic due to snoring and complaints of daytime sleepiness. The inclusion criteria were an apnea-hypopnea index (AHI) of ≤ 15, male gender, and age 18 to 65 years. Patients were randomized to either radiofrequency or sham surgery of the soft palate. All but one chose and received the option of three treatments. All patients participated in a follow-up, including an overnight sleep apnea recording and questionnaires 12 months after the last treatment. The primary outcome was daytime sleepiness measured with the Epworth Sleepiness Scale (ESS) and other questionnaires. Secondary outcomes were effects on the AHI and subjective snoring.

RESULTS

Thirty-two of 35 patients-19 of 20 patients in the radiofrequency surgery group and 13 of 15 patients in the sham surgery group-completed the study. No differences between the two groups in relation to the ESS or AHI were found at follow-up.

CONCLUSION

Radiofrequency surgery of the soft palate has no effect on daytime sleepiness, snoring, or apnea frequency in snoring men with mild or no sleep apnea 1 year after surgery.

LEVEL OF EVIDENCE

1b. Laryngoscope 124:2422-2426, 2014.

Morphological and morphometric characteristics of vestibular hair cells and support cells in long term cultures of rat utricle explants

A method for long term culture of utricular macula explants is demonstrated to be stable and reproducible over a period of 28 days in vitro (DIV). This culture system for four-day-old rat utricular maculae is potentially suitable for studies of hair cell loss, repair and regeneration processes as they occur in post-natal mammalian inner ear sensory epithelia. The cellular events that occur within utricular macula hair cell epithelia during 28 days of culture are documented from serial sections. Vestibular hair cells (HCs) and supporting cells (SCs) were systematically counted using light microscopy (LM) and the assistance of morphometric computer software. Ultrastructural observations were made with transmission electron microscopy (TEM) for describing the changes in the fine detailed morphological characteristics that occurred in the explants related to time in vitro. After 2 DIV the density of HCs was 77%, at 21 DIV it was 69%, and at 28 DIV it was 52% of HCs present at explantation. Between 2 DIV and 28 DIV there was a 1.7% decrease of the vestibular macula HC density per DIV. The corresponding decrease of SC density within the utricular explants was less than 1% per DIV. The overall morphology of the epithelia, i.e. relationship of HCs to SCs, was well preserved during the first two weeks in culture. After this time a slight deterioration of the epithelia was observed and although type I and type II HCs were identified by TEM observations, these two HC types could no longer be distinguished from one another by LM observations. In preparations cultured for 21 DIV, SC nuclei were located more apical and further away from the basal membrane compared to their position in macula explants fixed immediately after dissection. The loss of cells that occurred was probably due to expulsion from the apical (i.e. luminal) surface of the sensory epithelia, but no lesions of the apical lining or ruptures of the basal membrane were observed. There were no significant changes in the volume of the vestibular HC comprising macular epithelium during the observation period of 28 DIV.

The microbial flora in the nasal septum area prone to perforation

To explore the colonizing bacterial flora of the nasal septum area, that is mostly afflicted by perforations, 101 healthy police students had swab samples taken from that location. The described culture strategy recovered positive cultures from 95% of the test subjects and from 60% with more than one organism. In total, 191 bacterial isolates were classified according to colony morphology, Gram-stain and a panel of standard laboratory techniques. A part of the bacteria was identified to species-level by biochemical methods and by sequencing of the 16S rRNA gene. The predominant finding was Gram-positive irregular rods - 65 presumptive Corynebacterium isolates, both lipophilic and non-lipophilic, and 37 anaerobic Propionibacterium isolates. The second largest bacterial group was Gram-positive catalase-positive cocci, of which 13 isolates were identified as Staphylococcus aureus and 53 as coagulase-negative staphylococci. The few potential airway pathogens included Streptococcus pneumonia (n = 1) and Moraxella catarrhalis (n = 3) isolates. The bacterial flora colonizing the nasal septum mainly consists of Gram-positive bacteria. Although of low virulence, the microbial flora may impact on occlusion treatment of nasal septum perforations with silicone obturators.

Lack of plasminogen does not alter the early inflammatory response following a tympanic membrane perforation: a study in plasminogen-deficient mice

CONCLUSIONS

The results of the present study show that the early inflammatory response in plasminogen (plg)-deficient mice is not altered compared to that in wild-type (wt) mice. Therefore the chronicity of the perforation in the long-term healing experiment cannot be explained by an impairment of the early inflammatory response, but rather by an impairment in activation of the inflammatory cells. These findings give further insight into the mechanisms resulting in a clinically seen chronic tympanic membrane (TM) perforation and thus possible therapeutic strategies to replace today's conventional surgical treatment of these perforations.

OBJECTIVES

Plg has been shown to play an essential role in the healing of TM perforations. In plg-deficient mice a completely arrested healing reaction was seen, resulting in a chronic TM perforation. The mechanisms involved seem to be an abundant neutrophil recruitment, an accumulation of macrophages, an arrested keratinocyte migration, and a massive deposition of fibrin along the TM tissue. However, the exact functional role of plg in the early inflammatory response during healing of TM perforation remains unclear. This study aimed to evaluate the early inflammatory response, mainly the occurrence of macrophages and neutrophils, during the first 48 h following a perforation in the pars tensa (PT) of the TM, in mice lacking the plasminogen gene compared to the corresponding response in wt mice.

MATERIALS AND METHODS

The TMs were perforated in 45 plg-deficient and 39 wt mice. Otomicroscopic evaluation was performed at 3, 6, 9, 12, 18, 24, and 48 h after the perforation was made. Mice were harvested at all time points and prepared for morphology including immunohistochemistry (IHC). IHC was performed with antibodies targeting macrophages, neutrophils, T and B cells, cytokeratin, and fibrin(ogen). Morphometry was performed regarding the volume percentage of TM tissue occupied by the different inflammatory cells.

RESULTS

Perforation of the TM resulted in early otomicroscopic changes of the pars flaccida (PF) in both genotypes. Infiltration of inflammatory cells to PF and the presence of edema occurred as early as 6 h after the perforation was made, in both plg-deficient and wt mice. Morphometry did not reveal any significant differences between the genotypes concerning the occurrence of inflammatory cells. In contrast to the PF, the PT showed only sparse reactions during the experimental period. Furthermore, the migration pattern of keratinocytes did not differ between the genotypes throughout the experimental period.

Treatment of nasal septal perforations with a custom-made prosthesis

We present the fabrication and clinical use of a custom-made nasal septal silicone button that can be inserted transnasally into a perforation of the nasal septum by the physician as an office procedure, or by the patients themselves in their home. Questionnaire and retrospective chart review were used to evaluate the efficacy of this prosthesis as treatment of disturbing symptoms from nasal septal perforation. The study included 41 patients (27 women) with a nasal septal perforation. The follow-up time ranged from 1 to 9 years. Symptoms investigated were nasal obstruction, crusting, feeling of dryness, pain, epistaxis, and whistling from the nose. The degree of experienced symptoms was estimated on a VAS-scale. The questionnaire was answered by 37 of the 41 patients. Fourteen patients were still using their button at the follow-up. Treatment with the prosthesis greatly diminished all the investigated symptoms. Also, use of the silicone button resulted in an improved quality of life. No case of infection was noted in connection with use of the silicone prosthesis.

Physical findings in the upper airways related to obstructive sleep apnea in men and women

CONCLUSIONS, There are gender differences when it comes to the risk factors for sleep apnea. Large tonsils, a high tongue and a wide uvula are risk factors for sleep apnea in men, while large tonsils and a retrognathic mandible are risk factors in women. Upper airway abnormalities including mandibular retrognathia are, however, unable to predict sleep apnea among snorers being investigated for suspected sleep apnea.

OBJECTIVES

To identify gender-specific risk factors for obstructive sleep apnea and the diagnostic performance from physical upper airway examinations among snoring men and women investigated because of suspected sleep apnea.

PATIENTS AND METHODS

The dimensions of the uvula, tonsils, velopharynx and tongue, and nasal septal deviation, mandibular position, neck circumference, weight, and height were systematically scored in 801 consecutive snoring patients (596 men and 205 women), who had been referred for a primary sleep apnea recording.

RESULTS

In men, large tonsils, a high tongue, and a wide uvula were independent factors associated with an apnea-hypopnea index of >15. In women, large tonsils and mandibular retrognathia were independent factors associated with an apnea-hypopnea index of >15. The positive predictive values for upper airway abnormalities ranged between 0.20 and 0.25 in men and between 0.09 and 0.15 in women.

Prediction and risk of dysphagia after uvulopalatopharyngoplasty and uvulopalatoplasty

OBJECTIVE

To test the hypothesis that preoperative asymptomatic pharyngeal swallowing dysfunction predisposes for the development of symptoms of dysphagia after uvulopalatopharyngoplasty (UPPP) and uvulopalatoplasty (UPP).

MATERIAL AND METHODS

A total of 42 patients who snored were scheduled to undergo UPPP (n = 20) or UPP (n = 22). UPP was performed using either a CO2 laser or a conventional steel scalpel. Preoperatively and 1 year postoperatively all patients were examined videoradiographically to assess pharyngeal swallowing function. They also completed a questionnaire pre- and postoperatively concerning their snoring problems and swallowing function as well as the outcome of surgery.

RESULTS

Preoperatively, 7 (17%) patients reported dysphagia. Pharyngeal swallowing dysfunction was demonstrated in 6/7 patients with preoperative dysphagia while pharyngeal swallowing dysfunction was evident preoperatively in 18/35 non-dysphagic patients. Of the 35 patients without preoperative dysphagia, 10 (29%/) developed dysphagia after surgery. There was no significant risk of development of postoperative dysphagia for patients with compared to patients without preoperative pharyngeal swallowing dysfunction. Only one of the seven patients with preoperative dysphagia experienced worsening of the problem. A total of 93% of the patients reported a decrease in snoring and 95% reported a decrease in daytime sleepiness.

CONCLUSIONS

Preoperative pharyngeal swallowing dysfunction was not proven to predict the development of dysphagia after UPPP or UPP. The surgical method did not influence the frequency of postoperatively acquired dysphagia. The results do not indicate that patients with preoperative dysphagia should be excluded from treatment with UPPP or UPP.

Spontaneous hair-cell renewal following gentamicin exposure in postnatal rat utricular explants

We have established an in vitro model of long-time culture of 4-day-old rat utricular maculae to study aminoglycoside-induced vestibular hair-cell renewal in the mammalian inner ear. The explanted maculae were cultured for up to 28 days on the surface of a membrane insert system. In an initial series of experiments utricles were exposed to 1 mM of gentamicin for 48 h and then allowed to recover in unsupplemented medium or in medium supplemented with the anti-mitotic drug aphidicolin. In a parallel control series, explants were not exposed to gentamicin. Utricles were harvested at specified time points from the second through the 28th day in vitro. Whole-mount utricles were stained with phalloidin-fluorescein isothiocyanate and their stereociliary bundles visualized and counted. In a second experimental series 2'-bromo-5'deoxyuridine labeling was used to confirm the antimitotic efficacy of aphidicolin. Loss of hair-cell stereociliary bundles was nearly complete 3 days after exposure to gentamicin, with the density of stereociliary bundles only 3-4% of their original density. Renewal of hair-cell bundles was abundant (i.e. 15x increase) in cultures in unsupplemented medium, with a peak of stereociliary bundle renewal reached after 21 days in vitro. A limited amount of hair-cell renewal also occurred in the presence of the anti-mitotic drug, aphidicolin. These results suggest that spontaneous renewal of hair-cell stereociliary bundles following gentamicin damage in utricular explants predominantly follows a pathway that includes mitotic events, but that a small portion of the hair-cell stereociliary bundle renewal does not require mitotic activity.

Unique antitumour effects of L-2,4 diaminobutyric acid on cultured hepatoma cells

A single hepatoma cell line was grown in vitro and incubated with L-2,4 diaminobutyric acid (DAB), a non-metabolizable amino acid, under various conditions. The tumour cells were irreversibly damaged by incubation for 8 hours with 8 mmol/L of DAB. The tumour cell-destroying effect of DAB was dose- and time-dependent with no effect at a DAB concentration of 1.6 mmol/L. The presence of N-methyl alpha-aminoisobutyric acid (a specific substrate of amino acid transport system A) in the incubation medium abrogated the tumour cell destructive effect of DAB in a dose-dependent fashion. The presence of non-physiological amino acids in the incubation medium per se was not the cause of tumour cell destruction, since inclusion of alpha-amino-isobutyric acid and N-methyl alpha-aminoisobutyric acid in the incubation medium did not influence the viability of hepatoma cells. We conclude that the tumour cell destructive effect of DAB was the result of a huge and unlimited uptake of DAB energized by the Na(+)-gradient and that this uptake was not subjected to the law of saturation kinetics. This was combined with a tumour cell energy crisis in attempts to restore the Na(+)-gradient.

Myringotomized tympanic membranes cultured in vitro do not develop myringosclerosis

The aim of this study was to evaluate the development of myringosclerosis in in vitro-cultured tympanic membranes. Sprague-Dawley rats were myringotomized bilaterally and the tympanic membranes were excised after sacrifice. The explants were placed in inserts in wells filled with a nutrient medium. Every second day the tympanic membranes were photodocumented and after 9 days the explants were prepared for histology. On the 4th day the explants had attached to the bottom of the inserts and the specimens had thickened. From the perforation borders and the dissection edges a thin outgrowth was extending across the surface. By Day 9 the perforation had clearly diminished in size when examined in a stereomicroscope. In a light microscope the keratin layer was seen to protrude towards the centre of the perforation and, at the borders, epithelial cells were bridging the gap. Neither the pars tensa nor the pars flaccida showed any sclerotic lesions. The pars flaccida had thickened and the basal cells of the outer keratinized epithelium had invaded the connective tissue. Inflammatory cells were sparse in both the pars tensa and pars flaccida. The in vitro-cultured myringotomized tympanic membrane therefore shows a similar healing pattern to that in vivo. However, inflammatory reactions are sparse and there is no development of myringosclerosis.

Round window membrane delivery of L-methionine provides protection from cisplatin ototoxicity without compromising chemotherapeutic efficacy

Cisplatin (cis-diamminedichloroplatinum(II) (CDDP)) is a widely used, highly effective, oncolytic agent that has serious ototoxic side-effects. To test the effectiveness of local delivery, of L-methionine (L-Met) as an otoprotective agent against CDDP ototoxicity, we used a rat model of a highly metastatic breast cancer tumor, i.e. Fisher 344 rats implanted with MTLn3 breast cancer cells. Four experimental groups were evaluated--I: untreated; II: CDDP-treated (three dosages); III: systemically-delivered L-Met + CDDP-treated; IV: locally delivered L-Met + CDDP-treated. The integrity of the outer hair cells (OHCs) was determined using scanning electron microscopy (SEM); hearing was assessed by recording auditory brainstem responses (ABRs) at multiple frequencies. The chemotherapeutic effectiveness of CDDP was quantified by measuring changes in tumor mass and the presence of tumor metastasis. L-Met provided otoprotection of the OHCs against CDDP toxicity in the cochleae of rats following either systemic (III) or local (IV) administration. The ABRs were unchanged in each of the L-Met protection Groups (III and IV) and in the untreated animals of Group I. Treatment with CDDP only (II) induced significant hearing losses at both 16 and 18 kHz when compared to ABRs of untreated rats(I). CDDP was effective in controlling the MTLn3 initiated breast cancer tumors in the CDDP-treated (II) and the local L-Met protection, CDDP-treated (IV) Groups. In contrast, the tumors in the systemic L-Met protection, CDDP-treated Group (III) were not controlled by the CDDP treatment regime. This study demonstrates that local delivery of L-Met to the scala tympani of the cochlea via the round window membrane (IV) provides effective protection against CDDP ototoxicity without compromising its ability to control a highly metastatic form of cancer.

Antitumour effect of L-2,4 diaminobutyric acid on a hepatoma cell line

Pharmacological treatment of malignant disease is often insufficient highlighting the need for more efficient treatment based on new principles. We have observed that the amino acid analogue diaminobutyric acid (DAB), accumulates in malignant cells apparently without saturation kinetics, leading to hyperosmosis and subsequently to cell lysis. In the first in vitro part of the present study hepatoma cells were incubated with DAB in miniwells in the presence or absence of physiological amino acids. In the in vivo part malignant cells were inoculated into rat liver after laparotomy. The tumour was treated by continuous infusion of DAB via a catheter, the tip of which was placed in the center of the tumour. DAB had a significant antitumour effect both in vitro and in vivo. The principle of action of DAB as an antitumour agent is unique and therefore would be the ideal partner to practically any other cytostatic drug for a combined treatment to achieve a synergistic effect.

Swallowing dysfunction related to snoring: a videoradiographic study

Biopsy studies of the soft palatal and oropharyngeal tissues in habitual snorers and patients suffering from obstructive sleep apnoea have shown signs of neurogenic lesions. These lesions might affect the pharyngeal swallowing function, which is dependent on adequate sensitivity. The objective of the present study was to test the hypothesis that snoring is associated with aberrant pharyngeal swallowing function. Forty-one consecutive patients without dysphagia, seeking medical attention because of heavy snoring and various degrees of daytime sleepiness, were prospectively selected. Fifteen non-snoring volunteers without dysphagia served as controls. Patients and volunteers were videoradiographically examined in lateral and posteroanterior views during the oral and pharyngeal phases of swallowing. The hypothesis was verified. Snoring patients demonstrated deviant pharyngeal swallowing function seven times more frequently than did the non-snoring volunteers. Deviant pharyngeal swallowing function was observed in 22 (54%) of the snorers compared with 1 (7%) of the non-snoring volunteers. Impaired bolus control with premature leakage of bolus into the pharynx and a delayed evocation of the swallowing reflex was the most common finding, followed by bolus residual in the pharynx and laryngeal penetration. The conclusion was that snoring is associated with subclinical pharyngeal swallowing dysfunction.

Fine structure of extracellular matrix and basal laminae in two types of abnormal collagen production: L-proline analog-treated otocyst cultures and disproportionate micromelia (Dmm/Dmm) mutants

L-Azetidine-2-carboxylic acid (LACA), a naturally occurring vegetable imino acid, can be incorporated into mammalian proteins in place of proline, thereby eliciting an inhibitory effect on collagen secretion. Exposure of explants of the embryonic mouse inner ear to LACA reduces the number of collagen fibrils in the otic capsule, gives rise to a dose-dependent derangement of the basal lamina, and ultimately results in dysmorphogenesis and retarded differentiation of the inner ear. Disproportionate micromelia (Dmm) is an incomplete dominant form of dwarfism characterized by a reduced quantity of type II collagen in the cartilaginous extracellular matrix (ECM). Abnormal morphogenesis in homozygotic Dmm mice resembles the abnormal morphogenesis observed in LACA-exposed otic explants, resulting in malformed inner ears with a bulky cartilaginous capsule and a lack or reduction of defined perilymphatic spaces (Van De Water and Galinovic-Schwartz, 1987). In this study, we examined by ultrastructural analysis LACA-exposed otic explants and inner ears of Dmm/Dmm mouse embryos for abnormalities in the collagenous constituents of the basal laminae and capsular ECM. We demonstrate, in comparison to normal embryonic mouse inner ears, a reduction in collagen fibrils and irregular cytodifferentiation of chondrocytes in the ECM of LACA-exposed and Dmm/Dmm inner ears as well as in the basal laminae of LACA-exposed specimens. In addition, we provide evidence of dysmorphogenesis of the otic capsule and perilymphatic spaces in LACA-exposed explants. Moreover, while previous studies demonstrated the anomalous development of sensory structures in otocyst explants following LACA exposure, in this study we provide evidence of the normal morphogenesis of otic epithelial-derived sensory structures in homozygotic Dmm/Dmm mouse embryos.

Falls leading to femoral neck fractures in lucid older people

OBJECTIVE

To analyze the mechanisms of falls that result in femoral neck fractures among lucid older people.

DESIGN

A cross-sectional study.

SETTING

An orthopedic university hospital department.

PARTICIPANTS

A consecutive series of 123 lucid patients, 65 years of age or more, who were admitted for femoral neck fractures.

MEASUREMENTS

On admission, the subjects were interviewed about fracture accident characteristics, and falling mechanisms were classified. An arterial blood gas sample was taken from each patient soon after admission. Based on data regarding drug consumption and social and medical characteristics, a fall-risk index was calculated for each subject.

RESULTS

It was ascertained that 95% of the fractures were caused by falls and < 2% were spontaneous. Most accidents (68%) took place indoors, 47% of the falls were classified as extrinsic, 24% as intrinsic, 7% as nonbipedal, and 22% remained unclassified. Almost all outdoor falls were extrinsic; however, intrinsic falls were as common as extrinsic falls indoors (P < .001). Extrinsic fallers presented a significantly lower fall-risk index score than subjects with fractures caused by intrinsic, nonbipedal, and unclassifiable falls. A large proportion of subjects (24%) wre hypoxemic (pO2 < 8 kPa) on admission, and patients who sustained fractures at night had lower oxygen tension than that of daytime fallers (P = .006).

CONCLUSIONS

Accidental falls are the primary cause of femoral neck fractures. Preventive actions should be directed toward intrinsic, as well as extrinsic, risk factors for falls. Hypoxemia might be a risk factor for falls, especially those falls that occur at night.

Borreliosis as a cause of peripheral facial palsy: a multi-center study

Borreliosis is known to be a common cause of peripheral facial palsy in Stockholm and its vicinity. The aim of the present study was to investigate the frequency and characteristics of borreliosis among patients with peripheral facial palsy in different parts of Sweden. All serological tests were performed in one laboratory. Ten Swedish Ear Nose and Throat clinics participated in a prospective 1-year study of patients seeking medical attention for acute peripheral facial palsy. Twenty-eight (6%) out of totally 446 patients fulfilled the criteria for the diagnosis of borreliosis. The frequency varied between 1 and 16% and was highest along the southeast coast of Sweden whereas no case was reported from the northern part of the country. Borreliosis was more common among children with facial palsy than among adults. The infection occurred during all seasons although it appears to be less frequent during the spring months. Only a minority of the borrelial patients had a history of a preceding tick bite or erythema migrans. The fairly low overall frequency of this secondary stage of borreliosis in the study may be a result of better knowledge of the disease and earlier treatment of its early manifestations. In Sweden's endemic areas borreliosis is a common cause of peripheral facial palsy, and therefore all patients with facial palsy in these regions should be examined for borrelial infection.

Characteristic ionic composition of endolymph is maintained in cultured inner ear

Inner ear anlagen from mouse were explanted on the 16th gestational day (gd) and cultured for 5 days, i.e. corresponding to the time of birth. By using energy dispersive X-ray technique an elemental composition characteristic for endolymph was found within the membranous labyrinth of the explants. The sodium to potassium ratio in the endolymphatic space of the cultured inner ears corresponded to endolymph of the 16th gd fetus in vivo. There was no difference in the endolymph compartment between the cochlear and vestibular halves of the in vitro specimens. Differences in Na to K ratio between endolymph of the inner ears and the surrounding medium were statistically significant. Thus, endolymph-regulating mechanisms are active also under organ culture conditions, although not fully optimal.

Age-dependent disruption of basal lamina and extracellular matrix formation in L-proline analog treated otic explants

L-azetidine-2-carboxylic acid, LACA, a naturally occurring vegetable imino acid, can be incorporated into mammal proteins instead of proline. This incorporation has an especially inhibitive effect on collagen secretion. Exposure of embryonic mouse inner ear explants to LACA causes dysmorphogenesis and retarded differentiation, reduces the number of collagen fibrils in the perilymphatic spaces and capsules, and gives rise to a dose-dependent derangement of the basal lamina. In control specimens, both in vivo and in vitro, the inner ear epithelia had a dense contiguous basal lamina overlying a well-developed network of collagen fibrils. When the inner ears were exposed to LACA at a concentration of 150 micrograms per ml of medium, there was a loss of the collagen network and gaps appeared in the basal lamina. At exposure to 300 micrograms LACA/ml, scarcely any collagen fibrils were present and the basal lamina was disrupted in many areas, especially beneath the sensory epithelia.

A geriatric-anesthesiologic program to reduce acute confusional states in elderly patients treated for femoral neck fractures

The aim of this study was to evaluate the effect of a geriatric-anesthesiologic intervention program for the prevention and treatment of acute confusional states (ACS) in elderly patients treated for femoral neck fractures. The intervention program was based on the results of previous prospective studies in similar patient populations. The outcome of the intervention, comprising 103 patients, was compared with that of an earlier study comprising 111 patients. The intervention program consisted of pre- and post-operative geriatric assessments, oxygen therapy, early surgery, prevention and treatment of peri-operative blood pressure falls and treatment of post-operative complications. The incidence of ACS was lower, 47.6%, in the intervention study compared with 61.3% (P less than 0.05) in the control study. Furthermore, the ACS that occurred in the intervention study was less severe and of shorter duration than that in the control study. The incidence of post-operative decubital ulcers, severe falls, and urinary retention was also lower. The mean duration of orthopedic ward stay was 17.4 days in the control study and 11.6 days in the intervention study (P less than 0.001). It can be concluded that the intervention program reduced the incidence, severity, and duration of ACS which resulted in a shortened orthopedic ward stay.

Intermediate filament proteins in the embryonic inner ear of mice under normal conditions and after exposure to ototoxic drugs

The expression of the intermediate filament subclasses cytokeratins (CKs), vimentin, and neurofilament triplet proteins (NFs) was analysed in the embryonic inner ear of the CBA/CBA mouse, in vivo and in vitro, using well-defined monoclonal antibodies. Some of the cultured inner ears were exposed to 1-10 micrograms/ml of the ototoxic drugs gentamicin, ethacrynic acid or cisplatin. There was no difference in the expression of IF pattern in the cultured inner ears as compared with the in vivo developed labyrinths. Exposure to the ototoxic drugs did not affect the expression of CKs, vimentin, or NFs. CKs 8 and 18 were identified in all inner ear epithelia. In the mature hair cells, only the apical surfaces showed immunoreactivity to CKs. In addition, CKs 7 and 19 were visualized in the epithelia involved in maintaining endolymph homeostasis. The ganglion cells showed co-expression of CKs, vimentin and NFs, each having a characteristic localization in the cells.

Lack of differentiation of the isolated murine statoacoustic ganglion during organ culture

The isolated 12th gestational day statoacoustic ganglion (SAG) of the CBA/CBA mouse was cultured in vitro for 4-8 days. After 4 days, 25% of the SAG had survived, having nerve fibers growing in a circular pattern around the SAG. A further separation into a vestibular and a cochlear part, which occurs in vivo, was not observed. It is concluded that a trophic interaction between the SAG and target tissues is needed for further differentiation of the SAG.

Acute confusional states in elderly patients treated for femoral neck fracture

The aims of this study were to estimate the incidence of acute confusional state (ACS), its predisposing factors and consequences in 111 consecutive patients operated for fractured neck of the femur. The incidence of ACS was 61 percent and the predicting factors were old age and dementia. Drugs with anticholinergic effect, depression, and previous stroke were factors that seemed to be associated with the development of ACS. Ninety-two percent of the patients who had severe perioperative blood pressure drops developed ACS. The consequences of ACS were prolonged ward-stay at the orthopedic department, a greater need for long-term care after discharge, and poor walking ability at discharge and six months after surgery. The confused patients also had more complications, such as urinary problems, feeding problems and decubital ulcers, as compared with the nonconfused patients.

Tissue binding kinetics of tobramycin. An experimental study in the mouse inner ear in vitro

The tissue-binding capacity of tritiated tobramycin (TM) was analysed in an organ culture system in the embryonic inner ear of the mouse. A rapid and probably irreversible binding of TM occurs within 10 min, showing about 100 micrograms TM per gram protein in the vestibular half and about 75 micrograms TM per gram protein in the cochlear half of the labyrinth. A steady state is reached within 60 min. The TM uptake was then 390 micrograms TM per gram protein in the vestibular part and 270 micrograms in the cochlear part of the inner ear. A minor fraction of TM, of the same magnitude as initially bound, becomes irreversibly bound, whereas the slow accumulation which reaches the steady state level seems reversible.

Formation of junctional complexes in otocysts developed in vitro. A freeze-fracture study

The thirteenth gestational day inner ear anlage (otocyst) was explanted to an in vitro system and cultured for 8 days, i.e. to a time corresponding to birth. The freeze fracturing technique was used to evaluate morphological differentiation, particularly as regards cell membrane specializations. The epithelial cells were found fully differentiated, e.g. there were regularly arranged stereocilia on the hair cells. The development of tight junctions and gap junctions followed the same pattern as in vivo, but tight junctions did not reach the same degree of regularity and maturation as they did in vivo. There were very few gap junctions in our in vitro specimens. Several tight junctions had an odd appearance, with loss of the normally punctate structure of the strands and areas with considerable thickening. It is possible that this specific morphology can be explained by differentiation in the in vitro system.

Postoperative confusion after anesthesia in elderly patients with femoral neck fractures

Fifty-seven patients, all over the age of 64, with femoral neck fracture were randomized to receive epidural or halothane anesthesia to see if the anesthetic technique influenced the incidence of postoperative confusion. All patients were lucid on admission. Using the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III) as criteria for confusion, we found that 44% of the patients developed confusion that correlated closely to a history of mental depression (P less than 0.01) and to the use of drugs with anticholinergic effect (P less than 0.005). There was no difference in the incidence of confusion between the two anesthetic groups. In patients given halothane, however, early postoperative hypoxemia was associated with confusion (P less than 0.05). Patients with confusion had significantly more postoperative complications and almost four times longer hospitalization times. It is concluded that anticholinergic medication and a history of mental depression are predominant risk factors for development of postoperative confusion and in this respect are more important than the anesthetic technique.