Patient with antithrombotic medication. Which do bleedings or preoperative?

Antithrombotic medication can be performed by means of heparins (non-fractionated heparin, low molecular heparins) or the pentasaccharide Fondaparinux as well as with oral vitamin K antagonists. The use of a low molecular heparin is initially recommended for the sake of practicability and safety in case of patients suffering from deep venous thrombosis of the leg and pelvis with subsequent long-term oral medication using a vitamin K antagonist (Marcumar) for anticoagulation. The most frequent indications for long-term anticoagulation are deep leg and pelvis thromboses, pulmonary embolism with atrial fibrillation, artificial prosthetic valves and open oval foramen with ischaemic cerebral infarction. In case of patients with chronic atrial fibrillation it is expedient to initiate permanent anticoagulation according to a risk score. For the purpose of controlling oral anticoagulation it is recommended to employ the INR value in place of Quick's value because these data are better comparable. In case of atherothrombotic diseases secondary prevention will always indicate administration of a thrombocyte aggregation inhibitor. In such cases acetylsalicylic acid is recommended as the standard preparation.     

How to manage patients with hard-to-recognize postnasal drip?

Postnasal drip (PND), commonly regarded as a phenomenon wherein nasal fluid drips into the pharynx, is one of the main symptoms of chronic sinusitis and other nasal lesions. This definition is controversial, however, because some patients have PND with no evidence of fluid either in the oropharynx or around the choanae. Among 220 patients in whom PND was diagnosed at the University of Tokyo Hospital between January 1996 and December 1997, 19 (8.6%) had hard-to-recognize PND on routine examination. Through careful observation, responsible lesions could be identified in all patients with hard-to-recognize PND. Seven patients had latent chronic sinusitis, 5 had nasopharyngeal lesions, such as Tornwaldt's cyst and inflammation, 3 had "old man's PND", 2 had "reflux PND", and 2 had polyps around the sphenoid ostium. Five patients received no treatment. In the other patients, medical therapy, mainly long-term treatment with low doses of macrolides, now regarded as a standard regimen for intractable chronic sinusitis in Japan, was effective in alleviating symptoms regardless of the cause.     

Investigations in paediatric obstructive sleep apnoea: do we need them?

Ninety percent of normal children with obstructive sleep apnoea (OSA) improve, or are cured, with adenotonsillectomy. However, 10% of apparently normal children show no improvement following this operation and it has a very poor outcome in Down's syndrome, where only about one in six children improve. Adenotonsillectomy is also rarely curative in children with cerebral palsy or craniofacial syndromes. In these children investigations of the site and severity of their obstruction is necessary. Taking a detailed history and asking the parents to fill in a questionnaire for data collection will identify most children with OSA. Pulse oxymetry has some limitations but is a good screening tool. It does not provide enough information for the management of children with complex upper airway obstruction who are likely to have on going problems with OSA throughout their childhood despite intervention. For these children formal sleep studies are needed. Full polysomnography is the gold standard investigation to ascertain the severity of OSA. To ascertain the site of upper airway obstruction during sleep, sleep nasendoscopy has been found to be an excellent tool. This is performed under a light general anaesthetic in main theatres and is demonstrated using video footage in the presentation. This is a new classification to document the site of airway obstruction in paediatric OSA. A micro-layryngobronchoscopy is also required in any child who has daytime noisy breathing, a previous history of cardiac malformation or Down's syndrome, in whom a more distal site of airway obstruction may be present.     

What do patients with hereditary deafness think of genetic studies?

Objective

We conducted an attitude survey for patients with hearing loss (HL). The aim of this study was to investigate the opinions of patients or parents of deaf children regarding the deafness gene, genetic testing and a gene related HL.

Method

A questionnaire was sent to 201 individuals who visited the Department of Otolaryngology, Tokyo Medical and Dental University and who received genetic testing for HL from September 2000 to January 2006. There were 14 questions in the questionnaire that were classified into four topics related to a deafness gene and hereditary HL, genetic testing, outpatient department of medical genetics/genetic counseling, and the results of genetic testing. The study consisted of 140 respondents (70%) of 201 administered surveys.

Result

Before visiting our department, only 36% of the respondents were aware that a genetic factor was a cause of HL. Despite our explanation of a deafness gene and hereditary HL, 23% of 134 respondents answered that they had not received any such explanation. Furthermore, 14% of the 103 respondents who had answered that they receive the explanation, however, they did not fully understand it. Thirty-nine percent of the respondents made their own decision regarding the genetic testing, whereas 53.5% received the tests upon the advice of a physician or family member. In contrast, 91% of the respondents had a positive attitude towards other future genetic tests. The existence of the genetic outpatient department or genetic counseling has been seldom acknowledged, but upon learning of its availability, nearly one third of the respondents indicated that they would like to receive genetic counseling. Although no respondent had social and/or family problems after being informed that they had a deafness gene mutation, some respondents worried about the result.

Conclusion

The results of the survey suggested that the vast majority of the respondents were satisfied with genetic testing for HL and that the barriers to take the genetic test were less than expected. However, some respondents have a negative attitude towards genetic testing and counseling. Furthermore, the issue of disclosure may be burdensome to patients.     

Bone-anchored hearing aid: Why do some patients refuse it?

Objective

Bone-anchored hearing aid (BAHA™) is a proven tool to improve hearing. Nevertheless, there are patients who are candidates for BAHA™ implants that end up refusing the surgery. The objective of this study is to review our BAHA™ experience with particular emphasis on reasons behind the refusal of some candidates.

Methods

A prospective cohort of 100 consecutive new candidates referred to The BAHA™ program in a tertiary health care center. Candidates’ demographics, hearing status, Co-morbidities and audiometeric tests were all recorded. Patients’ acceptance or refusal was noted alongside the reasons to refuse BAHA™.

Results

100 new candidates were seen for BAHA™ assessment, 10 patients were excluded due to incomplete data. There were 68 children and 22 adults. Unilateral Conductive Hearing Loss was the most common reason for consultation (40%), followed by unilateral SNHL (23.3%). Aural Atresia was the commonest clinical finding (36.6%). The commonest reason for refusal was social acceptance by the parents due to concern with cosmesis.

Conclusion

The main reason of BAHA™ surgery refusal, in otherwise eligible candidates, is related to cosmesis. Patients with congenital anomalies were the most likely candidates to accept BAHA™ implants.     

Is there a better way to do laser-assisted uvulopalatoplasty?

OBJECTIVE: To assess the subjective and objective short- and medium- to long-term results of laser-assisted uvulopalatoplasty (LAUP) for snoring and obstructive sleep apnea. DESIGN: A nonrandomized, prospective, before-after trial. PATIENTS AND INTERVENTIONS: Twenty-five patients underwent a modified procedure of LAUP termed one-stage LAUP, and a matched control group of 24 patients underwent uvulopalatopharyngoplasty. MAIN OUTCOME MEASURES: Subjective analysis of LAUP included a preoperative and 2 postoperative evaluations of the state of snoring (4 weeks and after a mean +/- SD of 12.2 +/- 9.9 months). A score on 5 other sleep-related symptoms was recorded before and after completion of LAUP. The objective polysomnographic outcomes were compared with a control group undergoing uvulopalatopharyngoplasty. RESULTS: In 25 patients, improvement in the state of snoring significantly declined from 76% (n = 19) to 32% (n = 8), and worsening increased from 12% (n = 3) to 32% (n = 8) (P<.001). Evaluation of 5 other sleep-related symptoms showed that 52% of patients (n = 13) improved and 20% (n = 5) worsened. Polysomnography of LAUP patients showed that the mean postoperative respiratory disturbance index worsened significantly (33.1 +/- 23.1) compared with the preoperative one (25.3 +/- 14.3) (P =.05); also, 20% of the procedures were successful and 36% revealed marked worsening. The respiratory disturbance index of uvulopalatopharyngoplasty patients changed from 26.0 +/- 18.0 to 18.7 +/- 21.3, yet improvement did not reach statistical significance (P =.09). Furthermore, 58% (n = 14) of the surgical procedures were successful and only 8% (n = 2) revealed marked worsening. CONCLUSIONS: The favorable, subjective, short-term results of modified LAUP deteriorated over time. The procedure might also lead to aggravation of existing apnea. These findings are probably related to progressive palatal fibrosis and velopharyngeal narrowing originated by the laser beam.     

Endoscopic sinus surgery in cystic fibrosis: do patients benefit from surgery?

OBJECTIVE: To examine the effects of endoscopic sinus surgery on the pulmonary status of cystic fibrosis (CF) patients through the objective parameters of steroid use, pulmonary function tests (PFTs), and inpatient hospital days (IHDs). METHODS: Retrospective chart review of all patients with CF who underwent endoscopic sinus surgery from 1993 to 1999 at a tertiary care children's hospital. Preoperative pulmonary function, inhaler and steroid use, and IHDs were compared to postoperative parameters within a 1-year period. RESULTS: Sixty-six patients, including eight lung transplant patients, underwent a total of 112 endoscopic sinus surgery procedures; 25 patients underwent more than one procedure. Patients were taking oral steroids preoperatively in 28% of procedures and inhaled steroids in 40%. Postoperatively, there was no statistically significant change in oral or inhaled steroid use, or in postoperative pulmonary function. If the index hospitalization, which was often for reasons not related to sinus disease, was considered part of the preoperative time period, endoscopic sinus surgery (ESS) was noted to result in a marked reduction (9.5 days (adjusted), P=0.001) in hospital days during the subsequent 6 months. If the date of the procedure alone was used to define pre- and postoperative time periods, the reduction in postoperative days was more modest and not statistically significant (3.5 days (adjusted), P=0.21). CONCLUSIONS: Although we found no statistically significant difference in PFTs, or steroid requirements following ESS, ESS may have resulted in a reduced need for hospitalization in the 6 months following the procedure. Future prospective studies in a larger number of patients and using more detailed outcome measures are needed to better evaluate the effects of endoscopic sinus surgery in pediatric patients with CF.     

Is there a need for audiologic evaluation in patients with Behçet disease?

Beh?et disease is known to be a multisystem condition. We conducted a study to determine the prevalence of hearing loss in patients with Beh?et disease and to identify any associations between audiologic findings and other clinical manifestations and treatment. Our study group was made up of 41 adults with Beh?et disease and 41 healthy sex- and age-matched controls. All patients and controls underwent a complete clinical otolaryngologic examination, which included pure-tone audiometry, acoustic impedance testing, and otoacoustic emissions testing. Audiology revealed that the prevalence of sensorineural hearing loss (SNHL) was significantly higher in the Beh?et patients than in the controls-68.3 vs. 22.0% (p < 0.002). The duration of Beh?et disease had no significant impact on whether patients did or did not experience hearing loss. Hearing loss was the fourth most common clinical finding in the Beh?et group, after oral ulcers, genital ulcers, and skin lesions. We conclude that SNHL is present in a significant number of Beh?et patients, and we suggest the need for an adequate investigation of hearing in the routine follow-up of these patients.     

Do you need to operate following recovery from complications of pediatric acute sinusitis?

Objectives

There are many studies that evaluate the role of surgery in the treatment of complications of pediatric acute sinusitis; however there are few studies, if any that report the incidence of surgery following recovery from acute complicated sinusitis. The goal of this study was to report the incidence and indications for surgical intervention after recovery from complications of pediatric acute sinusitis.

Methods

We reviewed the records of all children admitted to a tertiary care children's hospital between January 2005 and September 2010 with a diagnosis of sinusitis and an orbital or intracranial complication. Eighty-six patients met inclusion criteria. Charts were reviewed for type of complication, initial treatment (medical or surgical), type of procedure, secondary procedures, age, and comorbidities. Statistical analysis was completed using independent samples student t-tests and Mann–Whitney tests.

Results

A total of 86 patients with a mean age of 6.38 years (2 months to 18 years) were identified. Eighty patients had orbital complications while six presented with intracranial complications. Twenty-seven patients (31%) underwent sinus surgery during the acute phase of their illness whereas 59 patients (69%) were treated medically. After hospitalization and recovery for acute complicated sinusitis, surgery was performed on nine patients (mean age 4.86 years) within 1 month to 2 years post hospitalization. Of the nine patients who required secondary surgery following resolution of the initial complicated sinusitis, four patients were following initial surgical intervention and five patients had initially resolved their complication with medical therapy alone. Indications for subsequent surgery included failure of medical therapy for persistent rhinosinusitis (8 patients) and second complication (1 patient).

Conclusions

This study suggests that following resolution of complicated pediatric rhinosinusitis, very few patients may need further surgical intervention. Subsequent intervention is best guided by clinical judgment, symptoms during outpatient clinic visits, and failure of medical therapy.     

Recruiting your Baha patients made easy and successfully--How I do it如何轻松成功积累Baha植入患者

骨导助听装置(bone anchored hearing aid,Baha)声音处理器系统从1996年开始在香港成功的应用于治疗特殊听力疾病。近年来随着技术水平的大幅度提高,Baha植入体表面涂层、桥基设计、数字化声音处理和处理器增益输出等技术与手术适应证和手术技巧同步发展。对于外科医师和Baha植入者来说,这种直接骨导听