The bulla ethmoidalis: lamella or a true cell?

BACKGROUND: The anterior ethmoidal region, including the bulla ethmoidalis, is the most common area addressed during functional endoscopic sinus surgery. Therefore, a detailed understanding of the bulla is essential for safe and effective surgery. HYPOTHESIS: Based on a review of historical articles on sinus anatomy and review of the current understanding of sinonasal embryology, it is suggested that the ethmoidal bulla is a "lamella" structure rather than a "cell," as it is widely accepted to be. OBJECTIVE: To analyze the anatomic conformation and nature of the ethmoidal bulla. METHODS: Detailed gross anatomic sagittal dissection of 14 sinonasal complexes with special attention to the ethmoidal bulla and surrounding structures and pneumatization tracts. RESULTS: The ethmoidal bulla consisted of a distinct bony lamella in all cases. The degree of development and pneumatization was variable, ranging from a rudimentary torus to a relatively well-pneumatized "bulla"-like structure. A pneumatization tract originating from the retrobullar recess was present in all specimens. This pneumatization excavated into the lamella, creating the bulla-like appearance as viewed from the middle meatus. However, the bulla was not a discrete individual ethmoid cell as it did not have a complete or discrete posterior bony wall. Rather, the posterior wall of this pneumatization tract was formed by the basal lamella. CONCLUSION: The ethmoidal bulla lacks a distinct posterior wall and therefore is not a separate cell but rather a bony lamella with an air space behind it. From an anatomic perspective, bulla is perhaps not the best term for this structure.     

The aborted early history of the translabyrinthine approach: a victim of suppression or technical prematurity?

OBJECTIVE: To ascertain the reasons translabyrinthine (TL) approach to acoustic neuroma, initially attempted in 1911, became relegated to obscurity for nearly half a century. STUDY DESIGN: A scholarly review of more than 40 publications in German and English from the late 19th to the mid-20th century. LITERATURE SUMMARY: Surgeons who first contemplated approaching the cerebellopontine angle recognized that the shortest route from the surface was through the petrous bone. In the late 19th century, otologic surgeons devised numerous procedures to deal with infection in and around the semicircular canals. This familiarity led R. Panse of Dresden to propose (but not actually perform) a TL approach (1904). F.H. Quix of Utrecht performed the first pure TL approach (1911), but others before him had used petrosectomy to augment the suboccipital approach. Subsequent TL attempts by other surgeons met with variable results. Devastating criticism of the method was proffered by leading acoustic neuroma surgeons of the day such as H. Cushing (1921) and W. Dandy (1925). The most important criticisms were that the approach provided only a deep and narrow field of action, was surrounded by major vascular structures, and led to great difficulty with cerebrospinal fluid leakage. HISTORICAL PERSPECTIVE: The literature on this subject is replete with erroneous citations. Panse is often miscited as having performed the first surgery. It has also become traditional to give Quix great credit, even though his procedure failed to remove much of the tumor. Poor outcome and intense criticism led surgeons to abandon the TL approach until W.F. House, armed with operating microscope and high-speed drill, successfully resurrected it in the 1960s. He concisely summarizes the pioneers' efforts: "They had the ideas and desire, but not the technical tools."     

Teratoma of the middle ear: a real entity or a non-entity?

Space-occupying lesions of the middle ear range from wholly benign developmental anomalies to highly virulent and aggressive malignancies. Amongst the benign entities classed with the family of developmental anomalies, the middle ear choristoma is well known. But what of the middle ear teratoma? Recent reports suggest that, while rare, teratomas of the middle ear do exist. Middle ear teratomas are defined as tumors consisting of benign tissues derived from all three embryologic layers: endoderm, mesoderm and ectoderm. They are lesions of the neonatal period and early infancy. While complete surgical excision will be curative, a thorough histologic examination of the specimen is recommended to exclude the possibility of immature and/or frankly malignant elements being admixed with the benign teratomatous elements.     

Scleroma of the larynx and associated squamous cell carcinoma: a causal relationship?

The known risk factors for development of laryngeal carcinoma are smoking, alcohol drinking, air pollution, laryngeal keratosis, single adult papillomas, and previous irradiation. Laryngeal scleroma as a risk factor for the development of laryngeal carcinoma has not been mentioned in the English-language literature, to my knowledge. This is a report of 2 cases of proven long-term rhinolaryngoscleroma that have changed to laryngeal carcinoma.     

The concept of bimaxillary transverse osteodistraction: a paradigm shift?

Severe crowding due to narrow upper and lower apical bases can be corrected by the extraction of four premolars, or by bimaxillary transverse osteodistraction. The first strategy is prone to unaesthetic changes in lip posture, nasolabial angle and buccal corridors. Life-long retention is necessary because of the known correlation between increased intercanine distance and relapse of crowding. The second strategy involves surgery and the final outcome regarding stability is not yet known. Theoretically, because the canines have not been moved outside of the skeletal envelope, and because the functional matrix positively influences the dental arches, relapse of crowding should be less. Facial appearance is improved because of the reduction of the buccal corridors and the fullness of the mouth both at rest, and upon smiling.     

The hygiene theory: fact or fiction?

PURPOSE OF REVIEW: The "hygiene hypothesis" offers a potentially credible and parsimonious explanation for the increasing prevalence of allergy noted in many westernized populations. The authors review recent evidence both for and against this hypothesis. RECENT FINDINGS: A strong body of epidemiologic evidence indicates that the original observations, namely of a birth order effect and increased risk of atopic disorders in those born into small, affluent households, are robust findings. Improved hygiene is believed to mediate its effect through decreased exposure to infectious agents in early life, and recent evidence has focused attention on the importance of the gastrointestinal microbial environment. In particular, infection with hepatitis A, Helicobacter pylori, and toxoplasma in those living in temperate climates, and geoheminths in those living in endemic areas, have been shown to be associated with reduced risk of atopic manifestations. It is postulated that these infections exert their effect through critically altering T-helper (Th)1/Th2 regulation, which is supported by the examination of the cytokine profiles of cord mononuclear cells when exposed to gastrointestinal flora and, furthermore, emerging evidence on the benefits of probiotics on symptoms of atopic dermatitis. Attempts to identify an inverse relation between Th1- and Th2-mediated disorders (as might be predicted by the Th1/Th2 paradigm) have, however, yielded conflicting results, raising the possibility that this model may be something of an oversimplification. SUMMARY: The hygiene hypothesis remains a credible but nonspecific explanation for observed variations over time, place and persons at risk for developing atopic allergic disorders. More prospective studies are needed to unravel which infectious agents exert a protective effect and the time period of importance for sensitization. The clinical implications of these advances in our understanding of the etiology of atopic allergic disorders are currently limited.     

CHARGE: An association or a syndrome?

Introduction

CHARGE “association” is a rare clinical entity with multiple congenital anomalies that necessitates a multidisciplinary approach. Its diagnosis is important not only for the pediatric surgery practice but also for the otorhinolaryngology practice as it complicates with a number of major surgical anomalies. The aim of this paper is to present the latest evidences on the genetic basis of the disease.

Materials and methods

In order to evaluate, a computed literature review was undertaken using PubMed and OMIM databases.

Results

Heterozygous mutations within the chromodomain helicase DNA binding protein 7 (CHD7) were reported in every two of three CHARGE patients. CHD protein family is located on chromosome 8q11.2 and is known to regulate chromatin remodeling which plays an essential role in the developmental gene expression. That is why the haploinsufficiency of CHD7 gene due to heterozygous mutations results in not only the postnatal but also the prenatal developmental regulation errors. The wide expression of this gene in the prenatal period overlaps with the broad spectrum of the phenotypic symptoms of the disease.

Conclusion

CHD7 gene haploinsufficiency is expected to be the underlying basis of CHARGE. Even though the genetic basis is unsolved in one-third of the patients, the current evidence supports the term “syndrome” rather than an “association” should be more appropriate for CHARGE.     

The smell map: is there a commonality of odour perception?

The normal perception of odour quality is poorly understood, so formulating meaningful tests of olfaction is difficult. While tests of odour discrimination and odour detection threshold have helped quantify olfactory dysfunction, there are not yet predictive relationships between sensitivity to particular odours and particular forms of olfactory dysfunction. Using 11 commonly encountered odours, 20 normosmics performed similarity ratings of odour pairs. Multidimensional scaling, a standard behavioural sciences data analysis method, was used to explore the perceptual relationships between the odours based on their pair-wise similarity ratings. Smell maps were created for each individual as was a common or archetypal map which indicated a commonality in individuals' odour perception, far greater than chance alone (P < 10(-6)). A preliminary analysis of four hyposmics suggests that they do not conform to the normosmic archetype. Future studies assessing the relationship between odours in the archetype should improve the selection of odours to be included in tests of odour discrimination.     

Radiosurgery of recurrent acoustic neurinoma or: the elegant solution of a surgical problem?

BACKGROUND: Stereotactic radiosurgery has proved to be an effective alternative to microsurgical resection in treatment of acoustic neuroma. Still, microsurgery is considered by many to be the therapy of choice. In case of recurrence microsurgical resection is much more difficult because of scarring and has a higher risk of complications. Therefore in cases of recurrence the role of radiosurgery needed to be evaluated. PATIENTS AND METHODS: From April 1992 to July 1997 135 patients suffering from acoustic neuroma were treated at the Neurosurgical Department of the University Medical School of Graz by means of the gamma-Knife. 12 patients had recurrence after a single or several microsurgical resections. The age distribution was between 38 and 71 years with a mean of 57 years. The diameter of the tumors varied between 10.5 and 31.2 mm. RESULTS: In all 12 cases the tumors could be inactivated biologically in a mean follow-up period of 58.8 months by means of stereotactic radiosurgery. Tumor shrinkage was achieved in 3 cases (25%), central necrotic areas were observed in 8 cases (67%). No additional cranial nerve palsies occurred. CONCLUSIONS: Stereotactic radiosurgery has proven to be a safe and effective treatment option instead of repeated microsurgery. Stereotactic radiosurgery should be considered as the therapy of choice in cases of recurrent acoustic neuromas.     

The hearing aid revolution: fact or fiction?

OBJECTIVE: To present the experiences of consumers with traditional hearing aids (T-HAs) and digital signal processing hearing aids (DSP-HAs) during the period 1999-2001, based on data obtained from an ongoing quality assurance programme. MATERIAL AND METHODS: A questionnaire is mailed to subjects fitted with HAs 3-4 months after the fitting, and includes questions concerning satisfaction with the HA, frequency of use of the HA, ability to manipulate the HA, satisfaction with the overall services of the department and need (if any) for additional appointments. RESULTS: The response rate was 69.5%, and thus information was obtained from 14 325 subjects (44.9% male, 55.1% female; median age 72 years; range 18-97 years). Of the respondents, 7,983 (55.7%) had been provided with T-HAs and 6,342 (44.3%) with DSP-HAs. The results of the questionnaire were as follows: 71.4% of those fitted with a T-HA were very satisfied/satisfied with it, compared to 68.1% with a DSP-HA (p < 0.05); 91.6% and 89.1%, respectively used their HA daily/weekly (p < 0.05); 80.5% and 82.2%, respectively, were able to manipulate their HA; 96.2% and 97.3%, respectively were satisfied with the overall services of the department; and 32.5% and 48.5%, respectively, indicated a need for an additional appointment (p < 0.05). A comparison between high- and low-cost DSP-HAs showed that 68.4% and 68.2%, respectively were very satisfied/satisfied with their HA (p = NS). CONCLUSIONS: According to consumers the "HA revolution" has failed to materialize; the significantly higher proportion of subjects with DSP-HAs who need an additional appointment represents a heavy burden on the hearing health services. The lack of a difference between the benefits obtained with low- and high-cost DSP-HAs emphasizes the need for appropriately designed and performed trials before new HA technology is launched.     

The smell map: is there a commonality of odour perception?1

The normal perception of odour quality is poorly understood, so formulating meaningful tests of olfaction is difficult. While tests of odour discrimination and odour detection threshold have helped quantify olfactory dysfunction, there are not yet predictive relationships between sensitivity to particular odours and particular forms of olfactory dysfunction. Using 11 commonly encountered odours, 20 normosmics performed similarity ratings of odour pairs. Multidimensional scaling, a standard behavioural sciences data analysis method, was used to explore the perceptual relationships between the odours based on their pair-wise similarity ratings. Smell maps were created for each individual as was a common or archetypal map which indicated a commonality in individuals’ odour perception, far greater than chance alone (P < 10 ^{1 - 6} ). A preliminary analysis of four hyposmics suggests that they do not conform to the normosmic archetype. Future studies assessing the relationship between odours in the archetype should improve the selection of odours to be included in tests of odour discrimination.     

The COCH gene: a frequent cause of hearing impairment and vestibular dysfunction?

The identification of genes leading to hereditary hearing impairment is one of the ways to elucidate the functioning of the inner ear. Over the past few years, several genes responsible for non-syndromal hereditary hearing impairment have been identified. One of these genes, named COCH, is responsible for autosomal dominant progressive sensorineural hearing loss associated with vestibular impairment (DFNA9). Histopathological analysis in patients with a COCH mutation revealed the presence of an acidophylic mucopolysaccharide deposit in the inner ear. An overview of the clinical, pathological and genetic studies on COCH is given, and the possible role of COCH in the pathology of DFNA9 is discussed.     

Radiotherapy or CO2 laser surgery as treatment of T1a glottic carcinoma?

Both radiotherapy and laser surgery give excellent results in the treatment of T_1a glottic carcinoma. In this study, we compared the outcome of these treatment options. Demographic details and continuous follow-up with exact cause of death have been recorded prospectively for 351 patients with T_1a glottic carcinoma at a tertiary referral centre in two consecutive decennia 1986–2005. Patients were treated with radiotherapy (163 patients) until 1996 when laser surgery was adopted as primary treatment (188 patients). The minimum follow-up time was 29 months. Neither the estimated 5-year disease-free survival, the disease-specific survival nor the crude survival differ between the two treatment options. The incidence of mainly local recurrences was equal during the first 3 years, followed by an increase in number of recurrences in the laser-operated patients. The odds ratio for a laryngectomy was 13.5 in patients treated with radiotherapy (P = 0.002), but mortality due to recurrence did not differ between the groups. The incidence of second primaries was equal (11%) but death due to second primaries differed significantly, favouring laser-treated patients (P = 0.003). In conclusion, the relative risk for a laryngectomy when a tumour recurs is 12.7 times higher in patients primarily treated with irradiation for T_1a laryngeal carcinoma, compared with patients treated with laser surgery. Regarding the treatment costs, treatment impact on patients and organ preservation, we consider laser therapy to be the better treatment option for patients with T_1a glottic cancer as no difference in survival could be observed.     

The Zuckerkandl tubercle: problematic or helpful in thyroid surgery?

The Zuckerkandl tubercle is a residue from the embryological development of the thyroid gland. Although it is undeniably well known in surgery, this is not so among otolaryngologists. Our objective is to highlight the importance of the Zuckerkandl tubercle, as it has proven to be a reliable point of reference to locate the upper parathyroid, the lower thyroid artery and the recurrent nerve. In order to study the Zuckerkandl tubercle, we made a prospective analysis of the posterolateral border of the thyroid lobes in 107 thyroidectomies (88 total thyroidectomies and 19 hemithyroidectomies) carried out by the same surgeon; in total, 195 thyroid lobes were analysed. The Zuckerkandl tubercle was certainly detected in 155 thyroid lobes (79.48 %). The Zuckerkandl tubercle was most frequent in the right thyroid lobe (P = 0.06). When the Zuckerkandl tubercle was present, we localised the upper parathyroid due to its relationship with the tubercle in 80 right thyroid lobes (95.23 %) and in 65 left (91.54 %). On 147 occasions (94.83 %), the recurrent nerve was directed towards the cricothyroid membrane beneath the Zuckerkandl tubercle, laterally to the tracheal surface in relation with the Berry ligament. The lower thyroid artery and some of the distal branches, such as the recurrent nerve, also ran under the Zuckerkandl tubercle. The areolar tissue underlying the Zuckerkandl tubercle is difficult to dissect, and so this protuberance constitutes a surgical difficulty but it is fundamentally helpful to find those important structures that must be preserved in thyroid surgery.     

Prevention of acute mastoiditis: fact or fiction?

Acute mastoiditis is the most common complication of acute otitis media (AOM). In recent years routine antibiotic treatment for acute middle ear infections was questioned and even abandoned in some countries. The goal of our study was to investigate the influence of antibiotic treatment on the occurrence and clinical outcome of acute mastoiditis and to analyze the bacteriological findings. A retrospective case record study of 48 patients with 50 episodes of acute mastoiditis hospitalized at our tertiary-care center between 1992 and 1999 was performed. Twenty-three patients (48%) received antibiotic treatment before admission whereas 25 (52%) did not. The group of patients without antibiotic pretreatment were younger (mean, 6 years) than patients with antibiotics (mean, 18 years) and their referral was delayed. The most common isolated single pathogen was Streptococcus pneumoniae. All pneumococci were sensitive to penicillin. Acute mastoiditis may be the first clinical sign of a middle ear infection, especially in very young children. Adequate antibiotic pretreatment cannot invariably prevent the development of acute mastoiditis even in the absence of penicillin resistant pathogens.