玩具激光枪致黄斑区损伤1例

患者男,26岁。2015年3月18日无意中被玩具激光枪照射右眼后,自觉视物模糊2 d来我院就诊。既往双眼视力正常,无眼病、眼外伤及全身其他病史。眼部检查：右眼裸眼视力0.8,不能矫正,左眼裸眼视力1.0,双眼眼压正常。双眼前节检查未见异常。眼底镜检查可见右眼视盘边界清晰,颜色淡红,视网膜血管走行正常,黄斑中心偏鼻下可见一黄白色斑,中心凹反光未见（图1）。左眼眼底正常。OCT检查可见右眼黄斑中心凹形状尚可,黄斑中心凹下方神经上皮层脱离,黄斑偏鼻下可见神经上皮层脱离伴团状中高反射信号影,视网膜色素上皮层（RPE）光带正常（图2、3）。     

家族性渗出性玻璃体视网膜病变1例

1 资料与方法 患儿,女,8岁,因家长发现右眼球萎缩、左眼视力差于2010年5月入我院.入院查体示V:左眼0.03,右眼无光感;IOP:双眼Tn,患儿左眼角膜透明,前房深浅适中,房闪(-),瞳孔圆,直径3 mm,光反射灵敏,晶体无混浊,眼底:视盘边界清,色可,杯盘比0.3,周边网膜见新生血管伴出血,网膜轻微黄白色渗出灶,可发现视盘轻微牵拉移位视网膜皱襞明显,呈条带状,自视盘发出,终止于颞侧周边网膜,未见视网膜脱离.     

渗出性视网膜脱落自愈1例

患者,男,55岁,因右眼眼前黑影遮盖1个月于本院就诊,眼科检查:视力左眼0.5、右眼0.4,眼压左眼15 mmHg、右眼11 mmHg,双眼角膜透明,瞳孔圆,对光反射灵敏,晶状体密度增高,玻璃体内无明显混浊,右眼颞上方网膜9:00-12:00青灰色隆起,血管爬行其上,未见明显裂孔,黄斑区稍水肿,余网膜色泽稍灰暗,未见出血及渗出,左眼视网膜色泽稍灰暗,中心凹反光欠清.     

蝶窦囊肿术后感染致单眼失明一例

患者男，40岁。因左眼渐进性视力下降7年，加重伴头痛半年，以“蝶窭占位性病变”收住我院。入院前曾在院外因“左眼视神经萎缩．视网膜炎”多次给予抗生素、扩血管药、神经营养药物治疗，视力时好时坏。入院查体：体温36.4℃，血压135／85mmHg(1mmHg=0．133kPa)。左眼球轻度突出，视力：右眼1．0．左限0.6；左眼底检查：视盘色淡，动脉变细，动静脉比例超过1：2。     

眼外肌广泛纤维化综合征1例

患者,男,22岁.双眼睑上提障碍,眼球运动受限22年.患者生后即双眼睑不能上提,眼球"对眼".眼球转动不灵活,喜仰头视物.10岁时在当地就诊,以"睑下垂(双)"收入院,并行睑下垂矫正术,术后效果欠佳.患者为足月顺产,其父有斜视,睑下垂史.检查示心肺正常,神经系统检查无病理征发现,全身辅助检查无特殊.右眼视力0.5,左眼视力0.25,双眼均不能矫正,双眼睑下垂,遮盖瞳孔约1/2,提上睑肌肌力:右眼3mm,左眼2mm,外眼及眼底未见异常,屈光间质透明,角膜映光法示双眼呈下斜位约10～15度,眼球单眼运动,右眼水平运动无受限,向上不到中线,呈下斜位,向下运动障碍,可过中线15度,左眼向内转-1～2mm,向外-2～3mm,向上不到中线,向下运动受限,可过中线10度.双眼运动,左上注视,双眼基本不动,左侧注视,左眼落后,右上注视,双眼不动,右侧注视,左眼落后,右下注视,右眼落后.双眼向上,向左侧运动时,双眼做集合运动,双眼向下运动时,表现为分开.头位面向左,视线向右,下颌上抬,头向左肩倾,无BELL现象.牵拉试验示双眼向上牵拉明显受限,向下牵拉中度受限,双眼下直肌无主动收缩.同视机检查示,自觉:各方向同侧复视,他觉(映光法)双眼均下斜15度,新斯的明试验(-).眼B超示双眼外肌未见明显增粗,钙化.诊断为眼外肌广泛纤维化综合征,屈光不正,弱视.     

以单眼失明为首发症状的鼻咽癌1例报告

患者,男性,５１岁。因鼻塞头痛８月余伴左眼失明３月。患者于去年（１９９８年）３月开始鼻塞头痛。以左前额部疼痛为主,无明显规律性。鼻塞呈间歇性交替性。鼻腔流少量脓性分泌物。无涕中带血。同年８月左眼视力下降。在市级医院眼科就诊。左眼视力０．３,不能用屈光矫正,右眼视力１．５,双眼瞳孔圆等大,光反射敏感。眼底：视网膜动脉轻度变细。视乳头边界清。眼眶ＣＴ示;无异常发现。鼻窦ＣＴ示：双筛上颌窦炎。认为左眼视力下降与眼病无直接关系。可能系鼻病引起。当时由于农忙患者未及时复诊,至１１月因症状加重明显而来我科就…     

先天性蝶窦脑膜脑膨出一例

患者男 ,16岁。因发育迟缓 10余年 ,双眼视力渐进性下降伴多饮多尿 8年 ,于 2 0 0 3年 3月入院。 10余年前无明显诱因出现发育迟缓 ,8年前逐渐出现双眼视力下降 ,尤以左眼为主 ,同时出现多饮及多尿 ,每日需饮水 7～ 10L ,尿量与饮水量相似。病程中无脑脊液鼻漏及反复发作性脑膜炎病史。患儿出生时顺产。入院体检 :身高 1 4 0m ,颅外形正常 ,头围 5 0cm ,皮肤粗糙 ,双瞳孔等大、同圆 ,直径 6 5mm ,对光反射迟钝 ,左眼视力黑朦 ,右眼视力 0 1,双侧眼底原发性视神经萎缩 ,左侧视野全盲 ,右侧视野颞侧偏盲 ,双眼运动正常。血清垂体激素及甲状…     

误诊为“中心视网膜炎”的Vogt 小柳-原田综合征1例

1 病例资料 患者男,37岁,因"右眼视力下降3d,头痛7d"来我院就诊,1d前曾在外院诊为"中心视网膜炎".询问病史患者述视物不清,5d前即有明显头痛,现加重,目前视物变形、变暗,无耳鸣、白发等症状.查体:视力:右眼0.1,左眼1.0.右角膜后KP(+),左角膜清,双眼前房(-),瞳孔圆,光反射存在,晶状体清.眼底:右眼视盘边界欠清,后极部网膜水肿,黄斑中心光反射不清,未见明显渗出.左眼视盘边界欠清,后极部网膜水肿,黄斑中心光反射弥散.眼压:右眼11.1 mmHg,左眼11.9 mmHg.     

鼻内镜下右眶尖异物取出1例

患者,男,42岁。因枪弹伤后右眼胀痛伴视力下降2个月,于2005年12月24日收入我院。体检:右眶周皮下少许淤血,轻压痛;右鼻前庭处有轻压痛。眼科检查:右眼视力0.4,左眼视力1.5;双眼球运动自如,眼压正常。双眼角膜清、晶体透明。双视盘界清,右视盘色苍白,右黄斑中心区可见黄白色斑点     

眼球贯通伤并眶内金属异物1例

患者,男,44岁,因被砂轮碎片崩伤左眼,肿痛出血,视物不清2h,于2014年6月19日入住天津市眼科医院。患者否认既往全身疾病史和手术史。入院全身检查未见明显异常。眼部检查：右眼视力1．0,左眼视力0．2。右眼前节和眼底检查未见明显异常。左眼眼睑肿胀,皮下出血,下睑鼻侧见不规则形状伤口,8mm×5mm。左眼结膜弥漫充血,结膜下出血。鼻下方巩膜可见不规则形伤口,4mm×3mm,未见眼内容物脱出,可见伤口内色素膜。左眼角膜透明,上皮光滑完整。前房深浅可,房水闪光（＋）。虹膜无脱出,无嵌夹,瞳孔圆,直径约3mm,直、间接光反应迟钝。晶状体轻度混浊。玻璃体混浊,眼底窥不清。眼球运动尚自如。眼眶CT检查显示：①左眼眶肌锥内邻近内直肌处有一长条形高密度异物;②左侧玻璃体和肌锥内小气泡,考虑眼球后壁损伤（图1）。入院诊断：①左眼球贯通伤;②左眼巩膜穿通伤;③左眼玻璃体积血;④左眼眶内异物;⑤左眼睑裂伤。入院当日急诊行左眼巩膜伤口修复＋眼睑裂伤修复术。术眼球后阻滞麻醉。术中见一长约5mm的巩膜伤口,位于8点子午线方向,距离角膜缘后约4mm。伤口未横跨直肌,8-0线间断缝合。8-0可吸收缝线连续缝合结膜伤口,间断缝合下睑皮下组织。5-0缝线间断缝合下睑皮肤伤口。术后左眼视力0．2,眼睑肿胀,皮下淤血,下睑伤口对合良好,缝线在位,结膜弥漫充血,结膜下出血,角膜轻度水肿,前房深度正常,房水闪光（＋）,虹膜无脱出,无嵌夹,瞳孔圆,直径约3mm,对光反应迟钝,晶状体轻度混浊,眼底窥不清,眼球运动自如。给予抗炎、抗感染对症治疗。并预防应用破伤风抗毒素。考虑患者左眼贯通伤病史明确,CT检查提示眶内异物,急诊行左眼巩膜伤口修复术后10d,眼球情况基本稳定,考虑行左眼眶内异物取出术。于2014年7月3日全麻下行左眼眶内异物取出术,做牵引线固定眼球于外下转位,暴露鼻上方穹窿部结膜,剪开鼻上方球结膜,沿眶缘分离并打开眶隔,于鼻上方眼球后发现金属异物,未嵌顿于眼球内,远端位于眶脂肪内,镊子夹出20mm×2mm金属异物,压迫止血后,连续缝合鼻上方球结膜,手术顺利结束。术毕给予绷带加压包扎。术后第1天,左眼视力0．3,下睑可见皮肤瘢痕,结膜充血水肿,巩膜伤口、结膜术口对合良好,缝线在位,角膜透明,前房闪光（＋）,晶状体轻度混浊,玻璃体混浊,眼底窥不清,眼压Tn,眼球上转及内转受限,眶压正常。术后7d行眼部B超示左眼玻璃体积血,建议患者考虑行玻璃体切除手术。后转入玻璃体视网膜科进一步治疗。     

One‐stop neck lump clinic: phase 2 of audit. How are we doing?

One‐stop neck lump clinic: phase 2 of audit. How are we doing? Regular monitoring and audit of a service are integral to ensuring maintenance of efficiency and standards. This is particularly important where the quality of the service is operator dependent, as is the case in the clinical diagnosis of neck lumps and fine needle aspiration cytology. The one‐stop neck lump clinic has now been running in the department for more than 20 months. A previous article described the results of the first phase audit carried out at 6 months and had identified a waiting time to be seen that was longer than that recommended by the British Association of Otorhinolaryngologists, Head and Neck Surgeons. Measures were implemented to reduce this waiting time and a second audit was carried out after another 10 months with the aims of assessing if modification of the means of referral reduces waiting time and if the outcomes of clinical performance in phase 1 could be maintained or improved. We discuss the results of phase 2 in the audit spiral.     

A Decrease in Maxillary Sinus Pressure,as Seen in Upper Airway Allergy or Infection,Results in an Increase in Upper Airway Nitric Oxide Levels

The paranasal sinuses are connected to the nasal cavity via small osties. Ostial occlusion, caused by mucosal swelling, will result in a slowly increasing negative pressure inside the sinus cavity. In parallel, the oxygen content in the sinus will decrease, resulting in the development of relative hypoxia. Hypoxia is a powerful inducer of nitric oxide (NO) synthase, and inducible NO synthase has been shown to be present in considerable amounts in the upper airways, including the sinuses. The present study was designed to investigate whether a reduction in sinus pressure would affect upper airway NO production. Thirteen healthy volunteers were investigated. A pressure chamber was used to lower the ambient pressure to-4.9 kPa. NO was sampled from one nostril or via a drainage tube inserted into the maxillary sinus before, during and after the hypobaric exposure. When the pressure was decreased, NO levels increased from 256 &#45 15 to 316 &#45 19 ppb ( n =13, p <0.001). The NO levels remained elevated (282 &#45 21 ppb; p <0.05) when measurements were repeated 20 min after leaving the chamber. The nasal airway resistance (V2 tot ) also increased as a result of the chamber session (from 16 &#45 2° before to 21 &#45 3° after; p <0.05). An increase in NO levels was also found when the experiments were repeated with NO sampled directly from the maxillary sinus (225 &#45 6 before and 265 &#45 9 ppb after; n =6, p <0.001). For control purposes the nasal analyses were repeated again, this time under hyperbaric conditions (+4.9 kPa). This resulted in a slight decrease in the NO levels (from 273 &#45 22 to 241 &#45 17 ppb; n =10, p <0.001), but there was no change in the nasal airway resistance. We conclude that a reduction in sinus pressure, as seen in upper airway allergy or infection, may result in an increase in upper airway NO production.     

A case of cortical deafness and anarthria

The nasal epithelium protects the underlying tissue from damage. Epithelial cell growth is controlled by epidermal growth factor (EGF) and is possibly affected by toxic proteins, e.g. eosinophil cationic protein (ECP). The aims of this study were to examine nasal fluid epithelial cell counts and their relations to EGF, eosinophils and ECP in 23 patients with seasonal allergic rhinitis and 20 healthy controls. Nasal fluid epithelial cell counts were lower in patients than in controls. EGF levels did not differ between patients and controls, and correlated with epithelial cell counts in controls but not in patients. Eosinophils and ECP were higher in patients than in controls, but did not correlate with epithelial cell counts. The role of growth factors, such as EGF, in regulating epithelial cells merits further study.     

A simple objective evaluation and grading for facial paralysis outcomes

Matrix metalloproteinase (MMP)-2 and -9 degrade type IV collagen, which is one of the major components of the basement membrane in normal tissue and expressed in the surroundings of the cancer nest in squamous cell carinoma. The degeneration of type IV collagen is an essential step in the metastasis to lymph nodes and distant organs. In this study, we examined MMP-2 and -9 levels of cancer tissue and serum obtained from patients with head and neck squamous cell carcinoma (HNSCC) in order to evaluate the relationship between the clinicopathologic features and MMPs. We examined the production of MMP-2 and -9 in cancer tissue homogenates of 73 patients who had HNSCC and the serum MMP levels of 16 patients with HNSCC and 8 healthy volunteers. We also studied the localization of MMP-2 in the carcinoma using an immunohistochemical approach. The concentrations of MMP-2 and -9 in the tissue homogenates and serum were measured by means of a sandwich enzyme immunoassay using a monoclonal antibody. Immunohistochemical analyses were performed with monoclonal antibody to MMP-2. The concentration of MMP-2 in the tumor tissue homogenates was unrelated to tumor size, but that in patients with lymph node metastases was significantly higher than in those without lymph node metastases. The concentration of MMP-9 was unrelated to lymph node metastasis and tumor size. The levels of both MMP-2 and -9 in serum were unrelated to lymph node metastasis. Immunohistochemistry indicated that MMP-2 was mainly expressed in cancer cells. Because MMP-2 degrades type IV collagen, the level of MMP-2 in carcinomas may be a useful indicator of the degree of invasion and metastasis.     

Speech production in deaf implanted children with additional disabilities and comparison with age-equivalent implanted children without such disorders

OBJECTIVE: To assess the long-term speech intelligibility in implanted children with additional disorders and compare them with age-equivalent implanted children without such disorders. PATIENTS: 175 profoundly deaf children 5 years following cochlear implantation; 67 children with additional difficulties and 108 children without such difficulties. All children were implanted under 5-year-old. MAIN OUTCOME MEASURE: Speech intelligibility rating (SIR) scale that can be readily applied to young deaf children irrespective of their performance and is reliable between observers. RESULTS: Five years following implantation, 47 (70%) children with additional difficulties developed connected intelligible speech versus 104 (96%) in the control group. However, the quality of speech was quite different between the two groups, as only 11 (16%) children with additional difficulties achieved the two higher categories (intelligible to all or to people with little experience), whereas 66 (61%) children in the control group did (P<0.000001). The total number of additional disorders had the strongest correlation with the outcome. Language and communication disorders were the most important contributing factor, followed by physical, cognitive, and autistic spectrum disorders. CONCLUSION: The majority of deaf children with additional disorders develop connected intelligible speech 5 years following implantation; however, a significant proportion do not develop any speech at all. Thus a third of this group did not realise one of the most important objectives for parents of implantation. Benefit from implantation should not be restricted to speech production alone in this specific population.     

Suction cautery and electrosurgical risks in otolaryngology

BACKGROUND: Flash fires, mucosal injuries and commissure burns during otolaryngology procedures have been largely attributed to anesthetic and surgical errors. Reports of direct electrosurgical device related events are rare. The discovery of thermal damage to the oral commissure during routine suction cautery adenoidectomy at our institution prompted a detailed investigation of the device's thermal properties. We complement this analysis with a review of electrocautery device related injuries reported in otolaryngology literature. METHODS: FLIR Systems Thermovision A40 infrared camera was used to evaluate temperature changes along the electrosurgical wand of suction cautery devices. Shaft temperatures were measured at specific times of continuous use, distances along the shaft, and cautery settings. A literature search of electrocautery-associated injuries during upper aerodigestive procedure was then performed. Nine pediatric otolaryngologists were then interviewed for historical experience with electrocautery injuries. RESULTS: Temperatures exceeding 60 degrees C, and sufficient to cause thermal soft tissue damage, occurred along the suction cautery wand at a setting of 40 Watts (W). These temperatures traveled far enough to appose the oral commissure when the device was simultaneously in continuous use, in the fulgurate mode, and with the suction turned off. Literature review identified eleven articles specifically pertaining to electrosurgical injuries during routine oropharyngeal procedures. Flash fires and their associated burns were the most frequently reported complication. Conversely, seven of ten cases elicited from peer interviews were oral or commissure burns attributed to improper insulation of electrocautery devices. CONCLUSIONS: Inadvertent electrosurgical injuries during routine otolaryngology procedures can result from inadequate equipment insulation. Techniques to reduce the likelihood of these events are discussed.     

Bilateral versus unilateral cochlear implantation in young children

Objectives

To compare the preverbal communication skills of two groups of young implanted children: those with unilateral implantation and those with bilateral implantation.

Material and methods

The study assessed 69 children: 42 unilaterally and 27 bilaterally implanted with age at implantation less than 3 years. The preverbal skills of these children were measured before and 1 year after implantation, using Tait Video Analysis that has been found able to predict later speech outcomes in young implanted children.

Results

Before implantation there was no significant difference between the unilateral group and the bilateral group. There was still no difference at 12 months following implantation where vocal autonomy is concerned, but a strongly significant difference between the groups for vocal turn-taking and non-looking vocal turns, the bilateral group outperforming the unilateral group. Regarding gestural turn-taking and gestural autonomy, there was a strongly significant difference between the two groups at the 12 month interval, and also a difference before implantation for gestural autonomy, the unilateral group having the higher scores. Multiple regression of non-looking vocal turns revealed that 1 year following implantation, bilateral implantation contributed to 51% of the variance (p < 0.0001), after controlling for the influence of age at implantation and length of deafness which did not reach statistical significance.

Conclusions

Profoundly deaf bilaterally implanted children are significantly more likely to use vocalisation to communicate, and to use audition when interacting vocally with an adult, compared with unilaterally implanted children. These results are independent of age at implantation and length of deafness.     

Autoimmunity in Sudden Sensorineural Hearing Loss: Possible Role of Anti-endothelial Cell Autoantibodies

In order to verify whether anti-endothelial cell autoantibodies (AECAs) can be used as serological markers of inner ear vasculitis in sudden sensorineural hearing loss (SSHL), 32 patients affected by idiopathic SSHL were investigated. All patients underwent a routine general physical examination and extensive audiovestibular, microbiological and immunological investigations. Fourteen normal subjects without a history of HL, autoimmune or metabolic disease served as controls. Detection of AECAs was performed using an indirect immunofluorescence technique. AECA-positive patients were treated with methylprednisone, while AECA-negative patients were treated with a combined regimen of steroids, plasma expander and aspirin. The average hearing recovery for 5 frequencies (0.25-4 kHz) was analyzed in each subject 1 month after treatment and every 3 months thereafter; median follow-up was 12 months (range 9-18 months). A total of 15/32 patients (46.8%; 11/19 females, 4/13 males) were AECA-positive and thus differed significantly from the normal population in whom only 2/14 tested cases were positive ( p =0.03). Severe hearing loss was associated with being AECA-positive in 8/11 cases. During follow-up, 25/32 patients improved their hearing and 17 of these patients were AECA-negative. The seven cases without hearing improvement were all AECA-positive. In patients with SSHL, immune-mediated vascular damage may have a pathogenetic role and AECAs may represent a serological marker of vasculitis even if they are not inner ear-specific and even if they represent an epi-phenomenon rather than the only cause of SSHL.     

Correction of the Glosso-Larynx and Resultant Positional Changes of the Hyoid Bone and Cranium

In ankyloglossia with deviation of the epiglottis and larynx (ADEL) the tongue is located forward and as a result the epiglottis is elevated and leans towards the mouth. The larynx is also raised and curves ventrally. Various symptoms have been observed as a result of this condition. Correction of the glosso-larynx (CGL) is the operation performed to treat ADEL. The CGL procedure and the results obtained with it are reported in this paper. In addition, we studied the following six parameters using head and neck X-rays before and after CGL (the changes in these parameters as a result of CGL are shown in parentheses): ( i ) the shortest vertical length between the hyoid bone and mandible (+10.3 mm); ( ii ) the vertical length between the hyoid bone and the tangent line of C2-4 (+4.6 mm); ( iii ) the shortest length between the hyoid bone and the chin (+2.9 mm); ( iv ) the angle between the hyoid bone and the tangent line of C2-4 (+3.3°); ( v ) the length of H-M, where H is the intersection of a tangent line of C2-4 and a vertical line from the hyoid bone and M is the intersection of a tangent line of C2-4 and the mandible (+7.4 mm); and ( vi ) the width of the narrowest part of the hypopharynx (+3.0 mm). The changes in all the measured parameters after CGL were significantly different ( p <0.05).