COMQ-12 scores in adult patients without chronic middle ear disease

OBJECTIVE

To determine the COMQ-12 score in an adult population without active COM.

DESIGN

Analysis of COMQ-12 scores in participants without active COM.

SETTING

East Anglia, United Kingdom.

PARTICIPANTS

70 healthy volunteers recruited from two local hospitals.

MAIN OUTCOME MEASURES

COMQ-12.

RESULTS

The median COMQ-12 score overall was two and the modal score was 0 with 27 (39%) participants achieving this score.

CONCLUSION

We recommend that the 'normal' values defined in this study be seriously considered before contemplating intervention, especially when patients with low scores are considered for surgery.

The intra-operative incidence of Fallopian canal dehiscence during surgery for cholesteatoma: a prospective case-control study and review of the literature

OBJECTIVE

To investigate Fallopian canal dehiscence (FCD) during cholesteatoma surgery.

STUDY DESIGN

Prospective case-control study.

PATIENTS

Four hundred and one patients with cholesteatoma and 172 with otosclerosis.

INTERVENTIONS

Therapeutic.

SETTING

District general hospital.

MAIN OUTCOME MEASURES

(i) Intra-operative incidence of FCD during (a) surgery for cholesteatoma versus a homogeneous control group (patients with otosclerosis); (b) revision surgery for cholesteatoma as compared to primary surgery. (ii) Intra-operative incidence of a fistula if FCD is present.

RESULTS

Data were prospectively collected and analysed using chi-square tests. FCD was found in 19% of cases versus 5.2% of controls. Intra-operative incidence of (i) FCD during cholesteatoma surgery versus otosclerosis surgery was statistically very highly significant (P < 0.0001, OR = 5.43); (ii) FCD during revision versus primary cholesteatoma surgery was not statistically significant (P = 0.83); and (iii) encountering a fistula in the presence of FCD during cholesteatoma surgery was statistically very highly significant (P < 0.0001, OR = 6.71).

CONCLUSIONS

A surgeon is more likely to encounter FCD during cholesteatoma surgery than in stapes surgery. If during cholesteatoma surgery FCD is found, then a fistula is also more likely to be present, mainly of the semicircular canal. The incidence of FCD is not increased in revision surgery. These findings are very relevant for any otologist undertaking cholesteatoma surgery.

Evidence review and ENT-UK consensus report for the use of aminoglycoside-containing ear drops in the presence of an open middle ear

BACKGROUND AND OBJECTIVES OF REVIEW: The use of aminoglycoside drops in the presence of a perforation/grommet is still a common practice amongst the UK ENT community, in spite of theoretical risk of ototoxicity. Mindful of the need to produce clinical guidelines based on the best available evidence, it was the intention of the Clinical Audit and Practice Advisory Group of the British Association of Otolaryngologists - Head and Neck Surgeons (ENT-UK) to produce evidence-based guidelines. In the absence of good evidence, intentions were shifted towards producing consensus guidelines using validated methodology.

TYPE OF REVIEW

Literature review, review of international guidelines and consensus guidelines.

SEARCH STRATEGY

A MEDLINE literature search (1966 to August 2006) was conducted, using the following strategies: 'ototoxicity and drops', 'ototoxic and drops', 'vestibulotoxicity and drops', 'vestibulotoxic and drops', 'cochleotoxicity and drops', 'cochleotoxic and drops'. Foreign language articles were not excluded. RESULTS OF THE LITERATURE REVIEW: The inclusion of foreign language articles and manually searching the reference sections of identified articles revealed further evidence not considered in previous reviews on this subject. However, the available 'evidence' that does exist remains to be of poor quality, consisting of data from a number of case reports and small case series. Prospective studies into the ototoxic effects of aminoglycoside ear drops either support their use but lack power to statistically confirm this, or are performed in conditions that are not representative of normal clinical conditions.

EVALUATION METHOD

In the light of issues raised from the literature review, a questionnaire was produced. The questionnaire was initially completed by council members of the British Society of Otology, then revised and presented at a meeting of the British Society of Otology, where a consensus panel was formed.

CONCLUSIONS

ENT-UK recommends that when treating a patient with a discharging ear, in whom there is a perforation or patent grommet: if a topical aminoglycoside is used, this should only be in the presence of obvious infection. Topical aminoglycosides should be used for no longer than 2 weeks. The justification for using topical aminoglycosides should be explained to the patient. Baseline audiometry should be performed, if possible or practical, before treatment with topical aminoglycosides.

The learning curve in stapes surgery and its implication for training

OBJECTIVE

To identify the 'stapedotomy' learning curve of 2 UK otolaryngologists.

STUDY DESIGN

A retrospective review of the outcome of the first 100 stapedotomy operations by each surgeon. Included in the study was a postal survey of the incidence of stapes surgery by UK otolaryngologists.

SETTING

Two tertiary referral centres.

PATIENTS

All ears in which primary stapedotomy was performed for otosclerosis. Non-otosclerotic cases and malleus stapedotomy cases were excluded.

INTERVENTION

One surgeon used the technique of small fenestra stapedotomy with either a Teflon wire or titanium piston, but without vein graft interposition, whilst the second employed the technique of stapedotomy with vein graft interposition, and a Teflon piston.

MAIN OUTCOME MEASURES

The first 100 stapes operations performed by each surgeon were subdivided into consecutive groups of 10. Using a postoperative air-bone gap of 20 dB or better as a definition of 'success', the 'success rates' of each group were plotted on graphs - the learning curves. The end point of the learning curve was defined as the point 'where the curve reaches its plateau'.

RESULTS

The learning curves of both surgeons included 70-80 operations. Both surgeons had one 'dead ear' in their first 15 cases. The postal survey showed that some trainers only perform a small number of stapes surgeries, whereas some otolaryngologists who regularly perform stapedotomies were not trainers.

CONCLUSIONS

This is a mismatch of trainers and trainees in stapes surgery. If the current trend of decline in stapes surgery continues, it will take many years for some otolaryngologists to complete their learning curves.

How we do it: the viability of free mucosal grafts on exposed bone in lacrimal surgery - a prospective study

To ascertain viability of free mucosal of grafts on bare bone and degree of contracture in vivo. Prospective study to ascertain graft survival where a small piece of mucosa, with a single centrally placed prolene suture for future identification, removed during endoscopic dacrocystorhinostomy (DCR) was replaced to cover exposed bone at the end of the procedure. The presence of the graft and the degree of contracture was assessed endoscopically in outpatients at the second and fourth weeks. All patients who fulfilled the inclusion criteria who underwent DCR in the study period April-October 2002. All the grafts survived intact at 4 weeks after the operation. Grafts underwent up to 20% contracture over this period. Free mucosal grafts survive well when applied to denuded bone in DCR operation.

The learning curve in stapes surgery and its implication to training

OBJECTIVE

To identify the stapedotomy learning curve of two U.K. otolaryngologists.

STUDY DESIGN

A retrospective review of the outcome of first 100 stapedotomy operations by each surgeon. Included in the study was a postal survey of the incidence of stapes surgery by U.K. otolaryngologists.

SETTING

Two tertiary referral centers.

PATIENTS

All ears in which primary stapedotomy was performed for otosclerosis. Nonotosclerotic cases and malleus stapedotomy cases were excluded.

INTERVENTION

One surgeon used the technique of small fenestra stapedotomy with either a Teflon-wire or titanium piston but without vein graft interposition, whereas the second used the technique of stapedotomy with vein graft interposition and a Teflon piston.

MAIN OUTCOME MEASURES

A moving average with a window of 15 dB was used to plot learning curves for the postoperative air-bone gaps. Using a postoperative air-bone gap of 20 dB or better as a definition of 'success,' the success rates with the increase in surgical experience of both surgeons were plotted on graphs, the learning curves. The end point of the learning curve was defined as the point where the curve reached its peak, and the results were sustainable.

RESULTS

There was no clear-cut end point in both learning curves, although it appears that there is a landmark point at 60 to 80 cases for both surgeons. Both surgeons also had one "dead ear" in their first 15 cases. The postal survey showed that some trainers only performed small numbers of stapes surgery, whereas some otolaryngologists who performed stapedotomies regularly were not trainers.

CONCLUSIONS

The study supports a learning curve in stapes surgery. To maximize the training opportunity of trainee surgeons, it may be advisable for learning centers to form network to provide target training for the trainee who has demonstrated the necessary dexterity and temperament of an otologist.

Mastoid Obliteration with Hydroxyapatite Cement: The Ipswich Experience

OBJECTIVE

This article reports the outcomes of a series of patients who underwent obliteration of the mastoid cavity using hydroxyapatite cement. A comparison is made with a group of patients who underwent similar surgery in the same period using hydroxyapatite granules.

STUDY DESIGN

Nonrandomized observational analysis.

SETTING

Tertiary otology unit.

PATIENTS AND INTERVENTIONS

All patients requiring mastoid surgery and primary obliteration or revision mastoid surgery and obliteration.

MAIN OUTCOME MEASURES

Dry cavity with full epithelialization and good tolerance to swimming at 1 year postoperatively.

RESULTS

In four of eight patients who had obliteration using hydroxyapatite cement, there was infection of the obliteration site, requiring revision. All of the patients who had obliteration with hydroxyapatite granules had dry and well-epithelialized mastoid cavities at 1-year follow-up, with ears that tolerated swimming.

CONCLUSION

The use of hydroxyapatite cement is not recommended in mastoid obliteration surgery.

Ipswich lacrimal tube: pedicle nasal septal tube for the reconstruction of lacrimal drainage passage

Canalicular blockage of the lacrimal system still remains a major challenge for oculoplastic surgeons. The conventional treatment of conjunctival dacryocystorhinostomy using the Lester Jones bypass tube is often associated with tube migration and foreign body reaction. The authors report a new technique to reconstruct the lacrimal passage on a single patient with severe canalicular obstruction following repeated failures from previous Lester Jones tube operations. An epithelial-lined tube was recreated between the nasal cavity and the conjunctiva using a superiorly based mucoperichondrial flap from the nasal septum (Ipswich lacrimal tube). The pedicle of the flap was divided six weeks following the operation. The patient was still symptom free two years following the operation together with a positive dye test confirming the patency of the new lacrimal tube.

Ceravital revisited: lessons to be learned

OBJECTIVE

To report the long-term results in a series of ossiculoplasties using Ceravital prostheses.

STUDY DESIGN

Retrospective case review.

SETTING

District general hospital.

PATIENTS

Ossiculoplasties using Ceravital prostheses were performed in 25 patients with a mean age of 39 years. Cholesteatoma was present in 9 cases and absent in 16 cases before surgery. The reconstruction was single stage in 23 cases and second stage in 2 cases.

MAIN OUTCOME MEASURES

Hearing gain and prosthesis-related complications. The mean length of follow-up was 6 years 6 months.

RESULTS

In the short term, the mean air-bone gap improved from 43 dB preoperatively to 24 dB 6 months postoperatively. In the long term, the results were as follows: good in 4 cases, absorption of the prosthesis in 9 cases, slippage of the prosthesis in 4 cases, extrusion of the prosthesis in 3 cases, atelectasis of the tympanic membrane in 2 cases, and unknown in 3 cases. The mean time for complications to become apparent was 6 years 4 months for absorption, 3 years 3 months for extrusion, 7 months for slippage, and 1 year 9 months for atelectasis. Revision surgery was performed on 11 of the 18 cases in which the results were poor.

CONCLUSIONS

Ceravital prostheses highlight the potential complication of absorption of ossicular prostheses. Absorption takes much longer to become apparent than other complications such as extrusion, slippage, or atelectasis. The much higher rate of absorption in this series than in previous series with shorter follow-up times suggests that the rate of absorption increases significantly over time.

Delayed hypersensitivity reaction to topical aminoglycosides in patients undergoing middle ear surgery

Repeated exposure to a topical aminoglycoside in patients with ear discharge can induce a delayed hypersensitivity reaction eventually. A postal survey conducted by the authors showed that 75% of UK otolaryngologists routinely prescribe topical aminoglycosides to their patients following ear surgery. This is a prospective study on the result of skin patch testing on 119 patients with chronic otitis media and 30 patients with otosclerosis who were scheduled for otosurgery. Any history of previous exposure to antibiotic eardrops for each patient was recorded. Overall, 14.1% of the patients had a positive skin reaction to one of the aminoglycosides (13.4% for Gentamicin; 12.8% for Neomycin and 4.5% for Framycetin). Sixteen per cent (16%) of the patients with chronic otitis media and 6.7% of the patients with otosclerosis were allergic to one of the aminoglycosides commonly found in antibiotic eardrops. Patients who received more than five courses of antibiotics eardrops previously had a greater tendency of developing allergy to the aminoglycosides (35.3%).

A study of the intra-operative effect of the Argon and KTP laser in stapes surgery

The intraoperative effect of the Argon and KTP laser was studied on 20 patients who had primary stapes surgery under local anaesthetic; 10 had Argon and 10 had KTP laser stapedotomy. Symptoms of inner ear disturbance such as dizziness and tinnitus were systematically recorded during the laser procedure. Both dizziness and tinnitus were relatively uncommon when the laser was used on the promontory. When the laser was used to transect the posterior crus, all the patients reported transient dizziness, probably from the thermal effect through the posterior crus into the inner ear. However, tinnitus was unusual during this stage. When the laser was used to fenestrate the footplate, only 30% of patients reported a transient dizziness as less laser energy was used. On the other hand, 55% of the patients experienced tinnitus during this stage, which indicates an acoustic effect on the inner ear. There is no difference between the Argon and KTP laser.

Analysis of the results of surgical endoscopic dacryocystorhinostomy: effect of the level of obstruction

AIM

One of the main factors in determining success rate of lacrimal surgery is the level of obstruction in the lacrimal drainage system. There are only few reports which quantify this, and none on endoscopic dacryocystorhinostomy (DCR).

METHODS

A case series of patients who had endoscopic DCR for anatomical obstruction of the lacrimal drainage system was performed. All patients who had lacrimal blockage referred to a district general hospital, irrespective of the level of blockage, had endoscopic DCR as the initial treatment by the authors. A total of 191 endoscopic DCRs were performed between 1994 and 1999. No other forms of lacrimal surgery were performed during this period. The level of the obstruction was assessed by the ophthalmologist before the operation and confirmed at surgery. All cases were followed up for a minimum of 6 months, and 96 cases were also reviewed 12 months after surgery. The outcome of the endoscopic DCR operation for each eye was categorised into complete cure, partial cure, or no improvement according to the degree of symptomatic relief following the operation.

RESULTS

Complete relief from epiphora was achieved in 89% of cases overall at 6 months. The success rate in cases with lacrimal sac/duct obstruction (93%) or common canalicular blockage (88%) was comparable. In canalicular obstruction, however, the complete cure rate was lower at 54%. The benefit of the operation was maintained at 12 months.

CONCLUSION

This study demonstrates that the success rate of surgical (non-laser) endoscopic DCR is comparable to that reported for external DCR. Moreover, the technique is appropriate for initial treatment of patients with common canalicular or even canalicular obstruction.

A comparison of the user-friendliness of hydroxyapatite and titanium ossicular prostheses

Both hydroxyapatite (Ha) and titanium (Ti) are well-accepted alloplastic materials for ossicular prostheses. Many different designs of Ha and Ti prostheses are presently available. Fourteen surgeons of different seniority and surgical experience were asked to 'test-drive' four different types of ossicular prostheses in cadaveric temporal bones to investigate the user-friendliness of these protheses. The Goldenberg design Ha incus prosthesis and the Dusseldorf design Bell Ti prosthesis were used as partial ossicular replacement prostheses (PORP). The Richards design Ha incus-stapes prosthesis and the Dusseldorf design Aerial Ti prosthesis were used as a total ossicular replacement prostheses (TORP). Nine out of 14 surgeons found the Ha PORP to be more user-friendly because of the notch design in the head. The Ti prosthesis was found to be more difficult to manipulate because it was too light. Half of the surgeons preferred the Ti TORP because of the open design of the top-plate. The Ha TORP was thought to be too top-heavy and to have a tendency to fall over.

The use of middle ear endoscopy: has residual cholesteatoma been eliminated?

Oto-endoscopes allow surgeons to control blind pockets within the middle ear. Many surgeons credit the reduction of residual cholesteatoma in their practice to the use of oto-endoscopes. Since 1988, the author has been using rigid endoscopes in combination with the operating microscope in cholesteatoma surgery. Between 1988 and 1999, 231 primary cholesteatoma operations were performed. The operations included closed cavity mastoidectomy (53 patients), small cavity mastoidectomy (115 patients), open mastoidectomy with primary canal wall reconstruction (44 patients) or mastoid obliteration (19 patients). The median follow-up period was 6.5 years. The incidence of residual cholesteatoma is closed cavity mastoidectomy (9.4 per cent) was found to be similar to that of open cavity mastoidectomy (8.7 per cent). Site analysis of the residual cholesteatoma revealed an incidence of 3.6 per cent in the epitympanum, 10.5 per cent in the sinus tympani and 0.7 per cent in the mastoid bowl. This study showed that residual cholesteatoma has not been eliminated with the use of middle-ear endoscopy, although the incidence has reduced the figures for closed cavity mastoidectomy to single figures.

Adult-onset otitis media with effusion: results following ventilation tube insertion

The outcome of otitis media with effusion (OME) in children is generally good. However, it is less clear in adults. All adult patients who had a ventilation tube inserted for OME at the Ipswich Hospital between 1996 and 1997 were studied. Of 53 patients studied, 28 had had a previous history of ventilation tube insertion. Furthermore, at 15-27 months following ventilation tube insertion, the ventilation tube had already extruded in 31 patients and the OME had already recurred in 19 of these. Endoscopic examination revealed that many patients still had evidence of inflammation at the lateral nasal wall (26.4 per cent) and at the eustachian tube orifice (51 per cent). There is also a strong history of atopy in the studied group and the skin prick test was positive in 57 per cent of the patients. This study shows that many patients with adult-onset OME have underlying pathology that could lead to recurrence of OME following ventilation tube extrusion.

Lacrimal fossa block: an audit of a minimally invasive regional anaesthetic technique for endoscopic dacryocystorhinostomy (DCR)

The lacrimal fossa block (LFB), a new development to provide regional anaesthesia for endoscopic dacryocystorhinostomy, is reported. Cadaveric study showed that the block needle, inserted as described, made direct contact with the periosteum of the frontal process of the maxilla within the lacrimal fossa. This technique enables both relevant divisions of the trigeminal nerve to be anaesthetized through a single entry site and, as this injection is confined to the anterior part of the orbit, ocular complications are minimized. An audit of 66 patients has shown that this technique, combined with standard intranasal local anaesthesia, provides good intraoperative analgesia, causes minimal diplopia and has a high level of patient acceptability.

Adenoma in the middle ear: a report of two cases

Middle-ear adenoma has been reported only in small numbers by surgeons. The few large series reported have been presented by histopathologists. We add two cases of middle-ear adenoma to the published literature, together with pre-, per- and post-operative imaging of one case, as a demonstration of this rare clinical entity. We discuss the pathology of middle-ear adenoma, its diagnosis and treatment, and suggest ways of improving its management.

Endoscopic dacryocystorhinostomy: anatomical approach

Dacryocystorhinostomy is the surgical treatment for nasolacrimal blockage. In recent years, the endoscopic approach has become more popular due to the development of nasal endoscopes and the ease of surgery in comparison to the external approach. In order to identify the lacrimal duct during surgery, surgeons insert a light pipe into the lacrimal duct and then drill or chisel the hard bone of the frontal process of the maxilla to remove the bony covering of the sac and duct. It is obvious that knowledge of the anatomy of the lacrimal sac/duct within the nose is essential for the surgeon. The lacrimal apparatus in the nose was studied using 10 cadaveric half-heads (5 males and 5 females) to establish the anatomical landmarks and most accessible part of the lacrimal duct from within the nose. Although there was solid bone covering the whole length of the sac and the duct, the posteromedial aspect of the lower sac and upper duct was covered by the ultra thin lacrimal bone (average thickness 0.057 mm) which was consistently found to be lying immediately anterior to the uncinate process in the middle meatus, thus constituting a "surgical window" (average size 2.5 mm x 7.2 mm) whereby surgical entry into the lacrimal duct becomes relatively easy. The lower part of the lacrimal sac and the upper part of the lacrimal duct can therefore be easily accessed from within the nose by following this anatomical approach, thus avoiding the need to drill or chisel the dense frontal process of the maxilla.

Peritonsillar abscess: the rationale for interval tonsillectomy

Although peritonsillar abscess (quinsy) and peritonsillitis are common ENT emergencies, management strategies in the United Kingdom still vary among otolaryngologists. In order to obtain data on the success of the various strategies, we conducted two surveys--one concerned itself with patient outcomes, while the other sought information on physician preferences. The survey of 571 practicing ENT surgeons revealed that 83% advise interval tonsillectomy only for patients who have a history of tonsillitis; they prefer to take a wait-and-see approach for a single attack of quinsy. Conversely, 15% advise a routine interval tonsillectomy following even a single isolated attack of quinsy/peritonsillitis. Only 6.8% still perform a quinsy tonsillectomy in selected cases. Survey responses from 192 adults and 15 children who had been hospitalized for the treatment of quinsy/peritonsillitis revealed that the vast majority of patients who did not undergo an interval tonsillectomy were still asymptomatic 2 to 8 years later. These results indicate that a wait-and-see policy is indeed suitable for most patients who present with an isolated attack of quinsy/peritonsillitis without a history of tonsillitis. We recommend that tonsillectomy be performed as a definitive treatment for quinsy/peritonsillitis in patients who have a history of tonsillitis. Such a history is a reliable indicator of recurrent quinsy or tonsillitis following an attack of quinsy/peritonsillitis in both children and adults. Quinsy tonsillectomy should be reserved for those few patients who do not respond to conservative measures.

The effect of nasal continuous positive airway pressure on normal ears and on ears with atelectasis

OBJECTIVES

The effect of short-term nasal continuous positive airway pressure (CPAP) on normal and atelectatic ears was studied to investigate the effect of positive pressure on these ears.

STUDY DESIGN AND SETTING

This is a prospective study performed at the ear, nose, and throat clinic of a district general hospital. No randomization was designed for this study.

PATIENTS

The study on the normal ears was performed on healthy volunteers, whereas the study on atelectatic ears was performed on patients who had difficulty in performing the Valsalva maneuver.

INTERVENTION

Tympanometry, audiometry, and electronystagmography were performed on normal subjects before, during, and immediately after a single use of nasal CPAP. In the group of atelectatic ears, otoscopy and audiometry were performed before and immediately after the use of nasal CPAP (3 hours).

MAIN OUTCOME MEASURE

The change in the middle ear pressure and hearing on the normal ears during the use of nasal CPAP was measured. In the group with atelectatic ears, the incidence of reinflation of the collapsed eardrum after the use of nasal CPAP was measured.

RESULTS

Positive pressure was recorded in all the middle ears during the use of nasal CPAP, resulting in a reversible hearing impairment. More than two thirds of the atelectatic eardrums could be reinflated by a single use of nasal CPAP.

CONCLUSION

Nasal CPAP could be used to deliver positive pressure into the middle ear and, hence, could be used as a device to reinflate a collapsed eardrum in many atelectatic ears.

The anatomy of the lacrimal bone at the lateral wall of the nose: its significance to the lacrimal surgeon

The position, dimension and thickness of the exposed lacrimal bone at the lateral nasal wall in 10 cadaveric half-heads were examined. In all cases, the lacrimal bone at the lateral nasal wall was found to be just anterior to the mid-third of the uncinate process. The average length and width was 7.4 mm and 2.5 mm, respectively. In nine of the 10 half-heads, the lacrimal bone was very thin with an average thickness of 57 mm. In all the cases, the position of the lacrimal passage covered by the lacrimal bone corresponded to the postero-medial aspect of the upper lacrimal duct and the lower lacrimal sac. This study shows that the uncinate process is a reliable landmark for the lacrimal bone in endoscopic nasal surgery. The paper-thin lacrimal bone allows a bone rongeur to infracture through and nibble away the bony covering of the lacrimal sac in a dacryocystorhinostomy.

Type IV tympanoplasty revisited

OBJECTIVE

There has been a great improvement in the material and design of prosthesis used for total ossicular reconstruction in recent years. As a result, the indication for type IV tympanoplasty has become more restricted. The long-term follow-up of type IV tympanoplasties performed by the author is presented.

STUDY DESIGN AND SETTING

This is a retrospective study of 31 patients who had type IV tympanoplasties performed by the author at the ear, nose, and throat clinic of a district general hospital.

PATIENTS

All the patients had chronic active otitis media with total loss of ossicles that were unsuitable for ossicular reconstruction.

INTERVENTION AND MAIN OUTCOME MEASURES

The preoperative and postoperative air and bone conduction thresholds of all the patients who underwent type IV tympanoplasty were measured.

RESULTS

Twenty-six percent of the patients had a postoperative hearing level <40 dB and 58% had an air-bone gap <30 dB. The indication for type IV tympanoplasty can be categorized into four groups: severe atelectasis, patients with cleft palate, erosion of the footplate, and surgery on the better-only hearing ear.

CONCLUSION

There still is a place for type IV tympanoplasty in modern otology.

Endoscopic inferior dacryocystorhinostomy

Conventional dacryocystorhinostomy (DCR) usually involves extensive removal of bone at the lacrimal fossa and hence risks disruption of the lacrimal pump mechanism. A physiological operation for nasal lacrimal blockage is described whereby only the inferior portion of the lacrimal sac and the adjacent duct are marsupialized into the nose. The operation is safe, quick and does not involve sophisticated instruments. Result of 81 consecutive endoscopic inferior DCRs reveals a success rate of over 90% which is maintained with time. Most patients had a wide lacrimal window with preserved lacrimal pump movement at the superior sac remnant.

Permanent mastoid vent: a new treatment for persistent eustachian tube obstruction

To date, there is no satisfactory treatment for persistent eustachian tube blockage or negative pressure in the middle ear. Conventional ventilation tubes are usually either occluded or extruded with time. A new treatment of percutaneous mastoid vent provides permanent ventilation to the middle ear cleft without putting a tube through the eardrum. A titanium tube is inserted through the skin into the mastoid antrum using the established technique of osseo-integration and hence becomes truly permanent. It can also be connected to a CPAP machine to re-inflate a collapsed eardrum. Initial trials consist of six vents inserted and followed up for 6-16 months. There was no sign of extrusion or a foreign body reaction. However, an inner Teflon tube is essential to keep the vent patent for permanent ventilation to the middle ear cleft.

Retraction of the pars tensa--long-term results of surgical treatment

Severe retraction of the pars tensa usually requires surgical treatment. Long-term follow-up of patients is essential as they may still suffer from eustachian tube dysfunction, resulting in a recurrence of the condition. Seventy-two tympanoplasties for retraction of the pars tensa (32 posterior retraction pockets and 40 completely collapsed tympanic membranes) were followed up for between 3 to 8 years. The long-term outcome of surgery for the posterior retraction pockets was favourable with at least 80% of the patients free of subsequent recurrence of the retraction pocket. The hearing gain and the post-operative hearing results were good. The surgical outcome for the completely collapsed tympanic membranes was disappointing with re-collapse in 50% of patients. Consequently, the postoperative hearing results were poor.

Day-case adenoidectomy: how popular and safe in a rural environment?

In spite of previously favourable reports on day-case adenoidectomy, there are still worries amongst otolaryngologists that such practice is unsafe, especially in a rural environment. A national survey was therefore carried out which shows that only 41 per cent of respondents perform adenoidectomy routinely as day-case, and even fewer in rural areas. A regional audit on day-case adenoidectomy, covering five hospitals, was conducted in East Anglia. Between 1994 to 1995, 73 day-case adenoidectomies were performed and the outcome was compared to those of 183 in-patient adenoidectomies during the same period. The children in the day-case group recovered post-operatively even better than the in-patient group. None of them stayed overnight or required re-admission. There was no increased in post-operative consultation to the general practitioner. The parents in the day-case group were mostly in favour of the day-case arrangement (88 per cent). The results suggest that day-case adenoidectomy is safe and popular with parents even in a rural environment.

The use of hydroxyapatite granules in mastoid obliteration

The problems of open radical mastoid cavities are well known. One of the ways to manage such problems is obliteration of the mastoid cavity. Most biological materials, such as muscle flap or bone chips/paste, tend to be resorbed with time, resulting in reformation of the cavity. The author reports a series of 34 mastoid obliteration operations using hydroxyapatite granules and an inferiorly based periosteal flap. The follow-up period was between 1 and 5 years. The obliterated cavities remained small, stable and trouble-free. Water was tolerated in the cavities allowing most patients to enjoy water sports. Only one patient had permanent discharge due to incomplete epithelialization of the obliterated cavity.

Local anaesthesia in middle ear surgery: survey of patients and surgeons

The use of local anaesthesia for middle ear surgery is long established and has many advantages. However, it is only performed by a small number of UK otolaryngologists (20%). This lack of enthusiasm is due to concerns that patients may not tolerate the discomfort during the operation. Therefore, a survey was conducted on patients who had middle ear operations: stapedotomy, myringoplasty, ossiculoplasty and mastoidectomy. The intense sensation of noise during the operation (29.6% of patients) and anxiety (24%) were the most common discomforts, followed by dizziness (14.8%), backache (13.9%), claustrophobia (9.3%) and earache (1.9%). In spite of these discomforts, 89% of patients still preferred local anaesthesia to general anaesthesia for a similar procedure. The author suggests that good patient selection, pre-operative explanation and the use of appropriate sedation are the important factors for local anaesthesia ear procedures to be acceptable to patients.

Small cavity mastoidectomy--5 year review

It has been recognized that the traditional method of open mastoid surgery often produces a larger mastoid cavity than necessary. Small cavity mastoidectomy is advocated to reduce the size of the mastoid cavity by exteriorizing the cholesteatoma from the epitympanum backwards. When this operation is performed in a sclerotic mastoid bone, the resulting cavity is very small. The 5 year review of 39 ears with small cavity mastoidectomy is presented. Not only were the mastoid cavities small, they remained stable and trouble-free. It also enabled the patients to enjoy swimming and minimizing wax accumulation within the cavities. The hearing results after 5 years were comparable to that of the closed technique. Formation of cholesterol granuloma behind the concho-meatal flap was an uncommon complication.

Myringoplasty for subtotal perforation

It is often reported that the repair of subtotal perforations is less successful than that of smaller perforations, mainly because it is technically more difficult. The author's surgical technique for subtotal perforations is presented and the results compared with that of myringoplasty for smaller perforations. The study shows that subtotal perforations are associated with a higher incidence of abnormal middle ear mucosa (chi 2 = 11.75, d.f. = 2) and damage to the malleus (chi 2 = 5.60, d.f. = 1) than smaller perforations. However, the success rate of subtotal perforation closure (92.5%) is as good as the closure rate for smaller perforations (94.1%). It is concluded that the size of the perforation is not a major factor in determining whether the graft will be successful in myringoplasty.

Changes in the brainstem evoked responses following jugular vein ligation

Blockage of both jugular veins is often followed by signs of intracranial hypertension. The use of brainstem evoked responses (BSER) in the detection of brainstem compression following jugular vein ligation in guinea pigs was studied. Thirty pigmented guinea pigs were studied. Unilateral jugular vein ligation was performed in 10 animals and bilaterally in 10. Ten animals were controls. The BSER to clicks at 20 db above hearing thresholds before and 6 hours following ligation of one or both jugular veins were recorded. No change in the hearing threshold was observed following jugular vein(s) ligation. However, prolongation of the I-III and III-IV interpeak intervals were observed following both unilateral and bilateral jugular vein ligation. The results suggest that BSER monitoring may be useful in the early detection of brainstem compression following jugular vein ligation in head and neck surgery.

Prognostic factors in labyrinthectomy

Labyrinthectomy for unilateral Menière's disease may be complicated by persistent unsteadiness postoperatively. The aim of this study is to identify the unfavourable factors in recovery following labyrinthectomy. Twenty-one patients gave a detailed history and underwent neuro-otological, ophthalmic and cardiovascular examination, as well as psychological and psychiatric assessment. Sedentary occupations, external health locus of control, extraverted personality, and an anxious and/or depressed psychiatric state were associated with poor post-operative recovery. These factors therefore should be taken into consideration in the pre-operative assessment and post-operative rehabilitation of labyrinthectomy patients.

A method for preparation of fibrin glue

Otorhinolaryngological operations would be facilitated by the use of a safe, cheap, surgical adhesive. Though commercial fibrin glue is effective, it is both relatively expensive and, because it is prepared from pooled human blood, there has been concern that it carries the risk of transmitting viral disease, in particular hepatitis and acquired immune deficiency syndrome. We describe a rapid, cheap method of preparing sufficient fibrin glue, of adequate bonding power, from a small quantity of the patient's own blood, and therefore with no risk of contracting viral disease. Our method of preparation of fibrin glue promises to provide a valuable adjunct to otorhinolaryngological surgical practice.

Intratympanic ototoxicity: influence of post-injection survival period

Many studies have been reported on the intratympanic ototoxicity of different drugs in animal models. The recovery periods of the animals following intratympanic drug applications varied among these studies. The present study compares the cochlear damage caused by intratympanic kanamycin following short (4 days) and long (30 days) post-injection survival periods, using the guinea pig as the animal model. The degree of cochlear damage 4 days after kanamycin injection was consistent among the tested animals. The degeneration was mainly confined to the outer hair cells and almost all inner hair were spared. The change 30 days after kanamycin injection was more variable among the animals and both inner and outer hair cells were damaged. This shows that, although the damage to the cochlea after intratympanic aminoglycoside injection is progressive, a short post-injection recovery period is suitable for comparative intratympanic ototoxicity studies.

Cochleotoxic effects of spermine and kanamycin

Aminoglycosides are organic bases that contain multiple amino groups. The ototoxic potential of these amine groups was studied using spermine, which is a polyamine with four amine groups (two amino and two imino). Twenty-four pigmented guinea pigs were studied. One-tenth milliliter of different concentrations of kanamycin A sulfate or spermine were given intratympanically. The temporal bones were removed 4 days after the injections, and the cochleas were examined using the scanning electron microscope. The damage to the hair cells was recorded in cytocochleograms. The results show that spermine is cochleotoxic when given intratympanically. Dosage of 50 mumol for kanamycin A sulfate and 5 mumol for spermine caused total damage of the outer hair cells in all ears. Lower dosage of kanamycin A sulfate (20 mumol) and spermine (1 mumol) did not cause any histologically discernible changes.

Interaction of kanamycin A and kanamycin B with phospholipids

It has been suggested that the aminoglycoside drugs are ototoxic because they contain amine groups that interact with membrane phospholipids. The interaction of kanamycin A and kanamycin B with vesicles containing various phospholipids was assessed from studies of vesicle aggregation and of the fluorescence of the probes 1-anilino-8-naphthalene sulfonic acid (ANS) and 1,6-diphenyl-1,3,5-hexatriene (DPH) added to the system. Kanamycin B, with 5 amino groups, showed a stronger interaction with the acidic phospholipids than kanamycin A, with only 4 amino groups. The evidence indicated that the interaction was an ionic one involving the charged groups of both components with penetration of the hydrocarbon interior of the bilayers. Of all the phospholipids tested polyphosphoinositide showed the greatest ability to interact with the kanamycins, supporting the proposal that interaction with this phospholipid may be the basis of the ototoxicity of aminoglycosides.

A correlation of the surgical anatomy of the dura to head and neck surgery

Head and neck surgery may be complicated by penetration of the dura resulting in meningitis, cerebrospinal rhinorrhoea, cerebral abscess or other intracranial complications. The strength of the dura mater both protects the brain and spinal cord and makes dura an ideal material for grafting (when needed). This study examines the thickness and histological composition of dura mater at various sites encountered in head and neck surgery. Dura was removed from eight specified locations in 14 adult cadavers. Microscopically, this dura was found to consist predominantly of collagen fibres, although the thickness of the dura varied between sites. Dura was significantly thinner in relation to the ethmoid sinus (P less than 0.01), tegmen (P less than 0.05) and sigmoid sinus (P less than 0.001), indicating its greater susceptibility to possible injury at these sites during surgery. The variety of its thickness also makes dura a more versatile homograft material than hitherto realised.

Comparative ototoxicity of kanamycin A and kanamycin B in the guinea pig

It has previously been shown that simple compounds with multiple amine groups are ototoxic, the degree of ototoxicity depending on the number of amine groups in the molecule. The relationship between the number of amino groups and ototoxicity in aminoglycoside was studied using kanamycin A and kanamycin B, which contain 4 and 5 amino groups respectively. Forty-five pigmented guinea pigs were injected intratympanically with 0.1 ml of different concentrations of kanamycin A and kanamycin B. The animals were sacrificed 4 days after injection and the organ of Corti was studied by scanning electron microscopy. It was found that on an equimolar basis, kanamycin B (with 5 amino groups) is more cochleotoxic than kanamycin A (with 4 amino groups). The greater cochleotoxic potential of kanamycin B may be explained by the higher cationic nature of the molecule due to protonation of the amino--NH2 groups at physiological pH, resulting in a greater affinity between the drug and the cell membrane.

The binding of polyamines to phospholipid bilayers

Previous studies have shown that amine groups are ototoxic. The interaction between different polyamines and phospholipid vesicles was studied using vesicle aggregation and fluorescence techniques (DPH and ANS as the fluorescence probes). The results showed that the interaction between polyamines (spermine, spermidine and 1,3-diaminopropane) and acidic phospholipids (PS, PE, PI and PIP2) is an ionic one. The polyamine with the highest positive charges and the phospholipid with the highest content of negative groups showed the strongest ionic interaction. There was no indication of any hydrophobic interaction within the phospholipid bilayer. The strong interaction between amine groups and PIP2 support the proposal that the latter is crucially involved in aminoglycoside toxicity in the inner ear and kidney.

Cochleotoxicity of amine groups

It has previously been shown that polyamines are ototoxic. The relationship between the number of amine groups and ototoxicity was studied using spermine, spermidine and 1,3-diaminopropane, which are polyamines with differing numbers of amine groups. Fifty pigmented guinea pigs were studied by injecting 0.1 ml of different concentrations of spermine, spermidine or 1,3-diaminopropane intratympanically. The animals were sacrificed 4 days after the injection and the organ of Corti was studied by scanning electron microscopy. It was found that on an equimolar basis, spermine (with 4 amine groups) is more cochleotoxic than spermidine (with 3 amine groups), which is in turn more cochleotoxic than 1,3-diaminopropane (with 2 amine groups). The cochleotoxic potential of the amine groups may be a result of their cationic nature at physiological pH (7.4). This property might be part of the explanation of the ototoxicity of the aminoglycosides.

An improved morphological technique for the study of cochleotoxicity in guinea pigs

Scanning electron microscopy is commonly used to study the normal or pathologically altered cochlear epithelium. It is especially useful for the study of ototoxicity in humans or animals. A cochlear microdissection technique in the guinea pig is presented which permits examination of the whole membranous cochlea with little artefactual damage to the sensory structures under study.

Electrocochleography during intravenous infusion of cisplatin

Extratympanic electrocochleography was performed on three patients following tobramycin injection and ten patients during cisplatin (cis-dichlorodiamine platinum II infusion. The compound eighth nerve action potential and the cochlear microphonic decreased considerably in magnitude up to 45 to 60 minutes after tobramycin injection, followed by a gradual recovery to normal in all three patients. During the eight hours of continuous cisplatin infusion, there was no significant change in the eighth nerve action potential and cochlear microphonic. The immediate effect of tobramycin on the cochlear output may be due to interference with the metabolism of the inner ear by the drug. The absence of electrocochleographic change during cisplatin infusion may be due to differences in the mechanism between cisplatin and aminoglycoside ototoxicity, or it may reflect the relatively nonototoxic potential of our chemotherapy regimen.

Are cervical spine radiographs of value in elderly patients with vertebrobasilar insufficiency?

Radiographs of the cervical spine of 32 elderly patients clinically diagnosed as having vertebrobasilar insufficiency secondary to cervical spondylosis were compared with 32 age- and sex-matched controls. The mean age was 77.6 years. There was no significant difference in the severity of the radiological changes between the two groups as judged by the narrowing of disc space and marginal osteophyte formation. It is concluded that there is no place for routine examination of the cervical spine in patients thought to have vertebrobasilar insufficiency secondary to cervical spondylosis.

Brainstem electric audiometry: is routine sedation necessary?

Decreased EEG and EMG waves in sedated adults might produce more sensitive and better defined brainstem electric response. This was investigated by comparing the brainstem electric response to click stimulation in 10 adult volunteers before and during sedation with chloral hydrate. The results showed that there is no increase in sensitivity of the test in cooperative and relaxed adult subjects. The definition of wave I did not improve after sedation. It is therefore concluded that routine sedation is not advantageous in brainstem electric response audiometry in cooperative subjects.

Respiratory resistance of tracheostomy tubes

One of the main results of tracheostomy is to reduce the airflow resistance and power of breathing. The airflow dynamics of three types of commonly used tracheostomy tubes were studied. A generator was used to produce a sinusoidal airflow wave to simulate normal breathing. The flow resistance and the power required to overcome this resistance were measured. A difference was observed in the flow resistance and the power of breathing between the inspiratory and expiratory phase of all the tubes. It was also observed that the Portex and Jackson tubes have a lower flow resistance and power of breathing than the similar gauge Shiley tube. This difference was due to the greater length, shorter radius of curvature, and rougher inner surface of the Shiley tube.

Squamous epithelium in the subglottic region of paediatric larynges

A macroscopic staining method was used to display and measure the extent of squamous epithelium in the subglottis of stillborn babies and of babies less than 3 months old. Squamous epithelium was found to be present in some babies without a previous history of intubation (3 of 8) and in some stillborn babies (3 of 11). Squamous epithelium in the subglottic space of the human is thus present at birth.

Myringoplasty: hearing gain in relation to perforation site

One hundred perforations of the tympanic membrane with successful myringoplasties have been reviewed. A partially reversible impairment of bone conduction was noted, being more obvious in posterior and subtotal perforations. It was also shown that the site of perforation affects the degree of hearing loss and the degree of subsequent improvement after myringoplasty; marginal and malleolar perforations had a greater hearing loss and less post-operative hearing improvement than central and non-malleolar perforations. It was also shown that posterior perforations had a greater hearing loss than anterior perforations.