Safety and efficacy of topical mitomycin C in myringotomy patency.

OBJECTIVE: To develop an alternative method for prolonged middle ear ventilation using topical mitomycin C. STUDY DESIGN AND SETTING: Twenty guinea pigs with normal ears had bilateral myringotomies performed using the argon laser. After myringotomy, either mitomycin C (0.4 mg/mL) or saline pledgets were applied topically. Monitoring consisted of otomicroscopy and distortion-product otoacoustic emissions. RESULTS: Before myringotomy, all tympanic membranes were intact, and distortion-product otoacoustic emissions were measurable. After myringotomy, none (0%) of the saline-treated myringotomies were patent at day 7 as compared with 100% of the mitomycin C-treated myringotomies. At day 42, 10 (52.6%) of 19 mitomycin-treated myringotomies remained patent and 4 (28.6%) of 14 were patent at 131 days. Five (13.1%) ears developed purulent otorrhea; 3 were mitomycin C-treated and 2 were treated with saline solution.- Distortion-product otoacoustic emissions testing did not document any evidence of ototoxicity. CONCLUSION: Topical mitomycin C appears to be safe and effective at prolonging the duration of myringotomy patency in the guinea pig. SIGNIFICANCE: Mitomycin C may be useful as an adjunct for preventing myringotomy closure.     

Preapplication of mitomycin C for enhanced patency of myringotomy.

OBJECTIVES: Ventilation tubes are the mainstay of surgical treatment for eustachian tube dysfunction and have been used successfully for many years. Certain disadvantages of ventilation tubes, however, have prompted research into alternative techniques including laser myringotomy. We investigated the use of KTP laser myringotomy in conjunction with topical mitomycin C to delay healing and prolong the patency of the myringotomy. METHODS: Twenty myringotomies were created in 10 Sprague-Dawley rats. A solution of mitomycin C was applied to the intact tympanic membrane for 15 minutes. The solution was then suctioned free, and a myringotomy was created with a KTP laser. Fifty-three rats with saline application serving as controls from a previous study were used to allow statistical assessment. RESULTS: The myringotomies remained open for a median of 9.5 weeks. Control myringotomies, which received saline solution instead of mitomycin C, healed within a median of 1.5 weeks. The difference was statistically significant at P < 0.0001. No complications were noted. CONCLUSION: Topically administered mitomycin C before laser myringotomy is effective in prolonging the patency of laser myringotomies in rats. The patency rate is similar to that achieved in experiments in which topical mitomycin C is placed into the myringotomy site created by the laser.     

Creating a stable tympanic membrane perforation using mitomycin C.

OBJECTIVE: To determine the ability of topically applied mitomycin C to create a stable tympanic membrane perforation. STUDY DESIGN AND SETTING: Twenty-four rats underwent subtotal removal of the tympanic membranes bilaterally. Forty ears received 0.2 mg/ml of mitomycin C. The remaining 8 received phosphate-buffered saline solution (control). Photographs taken every 3 to 5 days for 44 days were digitally scanned and computer analyzed to calculate the percentage of residual perforation. Application of solutions, photography, and data analysis were performed in a blinded fashion. RESULTS: The mitomycin C treated ears had delayed closure time and healing rate (from day 0 to 25) compared to the control group. All controls healed by day 14. By day 44, 92.5% of the mitomycin C treated ears healed. CONCLUSION: Mitomycin C prolongs the closure and healing rate of myringotomies in rat tympanic membranes. SIGNIFICANCE: Myringotomy with concurrent mitomycin C application may be useful for creating an animal model for chronic tympanic membrane perforation and should be tested in human beings as a method to maintain myringotomy patency for long-term ventilation.     

Preventing myringotomy closure with topical mitomycin C in rats

The purpose of this study was to determine whether mitomycin C could be used to prolong the patency of the myringotomy site in the absence of ventilation tubes in rats. We examined the effect of increased exposure time and repeat application of mitomycin C to the myringotomy site. Sixty animals were separated into 4 groups: group A had a single application of mitomycin C for 10 minutes; group B had a single application for 20 minutes; group C received 2 10-minute applications separated by 1 week; and group D received 2 applications (20 and 10 minutes) separated by 1 week. Mitomycin C and bacteriostatic saline solution were applied to the right and left myringotomy sites in each rat, respectively. Experimental ears in groups A, B, C, and D remained open for a median time of 6.5, 5.5, 6.5, and 8.5 weeks, respectively. The control ears healed within 1. 5 weeks. This difference was statistically significant with P < 0.001 for each group. We conclude that mitomycin C is effective in prolonging the patency of myringotomies in rat tympanic membranes. Increased exposure time or repeat application of mitomycin C did not statistically alter the patency rate.     

Dose-response relationship of topically applied mitomycin C for the prevention of laser myringotomy closure.

OBJECTIVE: We sought to determine a dose-response curve for topical mitomycin C when used to prolong the patency of laser-assisted myringotomies. STUDY DESIGN AND SETTING: Bilateral myringotomies were performed using the argon laser in 40 guinea pigs with normal ears. Pledgets with (0.05, 0.2, 0.4, or 2.0 mg/mL) mitomycin C were applied topically. Monitoring consisted of weekly or biweekly otomicroscopy. RESULTS: As in previous studies, all saline-treated myringotomies closed by day 7. By day 14, all myringotomies (100%) in the 0.05 mg/mL group were closed. By contrast, all myringotomies (100%) remained patent in the 0.2 and 0.4 mg/mL treatment groups, and 56% of the myringotomies remained patent in the 2.0 mg/mL group at day 14. By day 56, all myringotomies were closed in the 2.0 mg/mL group, 5 (50%) myringotomies were patent in the 0.4 mg/mL group, and 1 (11%) myringotomy was patent in the 0.2 mg/mL group. The study was terminated on day 84 (12 weeks). At that time, only the 0.4 mg/mL group had patent myringotomies (n = 3; 30%). The highest dose (2.0 mg/mL) of mitomycin was significantly associated with otorrhea. Otorrhea also appeared to be associated with earlier myringotomy closure. CONCLUSION: There is a dose-response curve for topical mitomycin C when used for prolonging myringotomy patency in doses up to 0.4 mg/mL. Higher doses do not appear to prolong patency and are associated with greater otorrhea, suggesting middle ear toxicity.     

Laser-assisted tympanostomy in pediatric patients with serous otitis media.

OBJECTIVES: To evaluate prognostic factors related with cure rate, in pediatric patients with serous otitis media treated with laser-assisted tympanostomy without ventilation tubes, in a single institution. PATIENTS AND METHOD: The procedure was performed on 124 ears in 88 individuals, from 3 to 14 years old. External auditory canal anatomy, type of anesthesia, tympanic membrane and middle ear fluid characteristics, myringotomy size, and laser parameters, in relation to cure rate, were accordingly studied. RESULTS: The overall cure rate by ear at the end of the 2-month follow-up period was 54.83%, whereas 45.17% still suffered from otitis media. Multivariate statistical analysis demonstrated that the presence of a thick tympanic membrane is significantly correlated with pure outcome in children with serous otitis media, when laser-assisted tympanostomy without ventilation tubes is performed favoring a worse cure rate (P < 0.023). Other parameters did not statistically correlate with the outcome. A 41% parental dissatisfaction rate was noticed. CONCLUSION: This study addresses selection bias for children with serous otitis media, candidates for laser-assisted tympanostomy. These are related to the duration of serous otitis media, the condition of middle ear mucosa, the thickness of the tympanic membrane, the type of anesthesia, and the cost of laser apparatus. There is likely to be a causal relationship between outcome and tympanic membrane appearance in children undergoing laser-assisted tympanostomy.     

Topical application of cod liver oil ointment accelerates wound healing: an experimental study in wounds in the ears of hairless mice.

The effect of topical cod liver oil ointment on the rate of wound epithelialisation and neovascularisation was studied using the hairless mouse ear wound model (experiment I). The effect of local application of vitamin A in increasing concentrations was tested in the same model (experiment II). Experiment I: Bilateral standardised full thickness dermal wounds were created on the ears of 42 mice divided into three groups: group I: 25% cod liver oil ointment (n = 10) applied topically to one ear and vehicle (vaseline) to the other; group II: 25% cod liver oil ointment (n = 10) and saline; and group III: vehicle (n = 22) and saline. Experiment II: Using the same model and procedures wounds were made on 12 mice randomised to vitamin A treatment in various doses (250-3000 IU/g) on one ear and vehicle (vaseline) on the other ear. Using in-vivo microscopy and digitised planimetry, wound epithelialisation and neovascularisation were measured at regular intervals until the processes were complete. Wounds treated with 25% cod liver oil ointment epithelialized significantly (p < 0.05) faster (mean (SEM) 8.9 (0.7) days) than control ears treated with vehicle alone (13.9 (1.9) days). Neovascularisation developed significantly faster (p < 0.01) in the ears treated with cod liver oil ointment (22.5 (1.3) days) compared with their vehicle control (29.1 (0.6) days). Neovascularisation was also significantly (p < 0.05) faster in the ears treated with cod liver oil ointment (23.1 (1.4) days) than in those treated with saline (26.8 (1.1) days). There was no significant difference in speed of epithelialisation between cod liver oil ointment and saline. The vitamin A dose study showed that epithelialisation and neovascularisation of the vitamin A treated wounds pass at the same rate as wounds treated with cod liver oil ointment. In conclusion, topical 25% cod liver oil ointment significantly accelerated both the epithelial and the vascular component of healing compared with saline. Vitamin A seems to have an important role in accelerating wound healing and could be the active component in cod liver oil.     

TOPICAL APPLICATION OF COD LIVER OIL OINTMENT ACCELERATES WOUND HEALING: AN EXPERIMENTAL STUDY IN WOUNDS IN THE EARS OF HAIRLESS MICE

The effect of topical cod liver oil ointment on the rate of wound epithelialisation and neovascularisation was studied using the hairless mouse ear wound model (experiment I). The effect of local application of vitamin A in increasing concentrations was tested in the same model (experiment II). Experiment I: Bilateral standardised full thickness dermal wounds were created on the ears of 42 mice divided into three groups: group I: 25% cod liver oil ointment (n = 10) applied topically to one ear and vehicle (vaseline) to the other; group II: 25% cod liver oil ointment (n = 10) and saline; and group III: vehicle (n = 22) and saline. Experiment II: Using the same model and procedures wounds were made on 12 mice randomised to vitamin A treatment in various doses (250-3000 IU/g) on one ear and vehicle (vaseline) on the other ear. Using in-vivo microscopy and digitised planimetry, wound epithelialisation and neovascularisation were measured at regular intervals until the processes were complete. Wounds treated with 25% cod liver oil ointment epithelialised significantly (p &lt; 0.05) faster (mean (SEM) 8.9 (0.7) days) than control ears treated with vehicle alone (13.9 (1.9) days). Neovascularisation developed significantly faster (p &lt; 0.01) in the ears treated with cod liver oil ointment (22.5 (1.3) days) compared with their vehicle control (29.1 (0.6) days). Neovascularisation was also significantly (p &lt; 0.05) faster in the ears treated with cod liver oil ointment (23.1 (1.4) days) than in those treated with saline (26.8 (1.1) days). There was no significant difference in speed of epithelialisation between cod liver oil ointment and saline. The vitamin A dose study showed that epithelialisation and neovascularisation of the vitamin A treated wounds pass at the same rate as wounds treated with cod liver oil ointment. In conclusion, topical 25% cod liver oil ointment significantly accelerated both the epithelial and the vascular component of healing compared with saline. Vitamin A seems to have an important role in accelerating wound healing and could be the active component in cod liver oil.     

Airway Complications from Topical Mitomycin C

OBJECTIVE: Topical application of mitomycin C appears to be a useful adjunct in reducing cicatricial scarring of the airways. Human and animal studies have demonstrated the efficacy and safety of mitomycin C topically in the treatment of airway stenosis at concentrations ranging from 0.4 mg/mL to 10 mg/mL. Although no reports of mitomycin C toxicity have been reported in the otolaryngology literature, the ophthalmologic literature has documented serious, vision-threatening complications resulting from the use of topical mitomycin C. The purpose of this study is to report complications related to mitomycin C use in the treatment of glottic and subglottic stenosis. Risk factors associated with these complications are identified. STUDY DESIGN AND SETTING: A retrospective chart review of all patients treated by the senior author for laryngotracheal stenosis with endoscopic CO(2) laser incisions/dilation and adjuvant topical mitomycin C was performed to determine the incidence of complications. Variables studied included patient age and gender, location and severity of stenosis, medical comorbidities, length of procedure, postoperative instrumentation of the airway, and mitomycin C concentration. RESULTS: Eighty-five cases of adjuvant topical mitomycin C use after CO(2) laser endoscopic treatment and dilation for upper airway stenosis were identified in a total of 44 patients. Complications that were believed to be caused by the local toxicity of mitomycin C occurred in 4 cases out of 85 (or 4.7%), manifested by accumulation of fibrinous debris at the operative site, resulting in partial airway obstruction and the need for emergent airway intervention. CONCLUSIONS: Caution should be exercised when topical mitomycin C is used in the treatment of airway stenosis.     

Anaesthesia for myringotomy

The effect of two methods of anaesthesia on the findings at myringotomy in children with secretory otitis media was studied. One group of patients spontaneously breathed a mixture of nitrous oxide, oxygen and halothane whereas a second group had assisted ventilation, tracheal intubation and breathed a mixture of halothane and oxygen. Nitrous oxide diffused significantly into middle ears which had gas under reduced pressure (with or without fluid present) when compared with normal ears (p less than 0.05). Assisted ventilation prior to tracheal intubation did not introduce gas into the middle ear. It is concluded that impedance audiometry is a reliable method of assessing the middle ear prior to surgery.     

Topical diltiazem ointment in the treatment of chronic anal fissure

BACKGROUND: Chronic anal fissure has traditionally been treated surgically. Initial enthusiasm for chemical sphincterotomy has waned because of poor outcomes with glyceryl trinitrate ointment. In this study the use of topical 2 per cent diltiazem ointment has been investigated as an alternative method of chemical sphincterotomy. METHODS: A prospective assessment of 71 consecutive patients with a chronic anal fissure treated with 2 per cent topical diltiazem ointment for a median duration of 9 (range 2--16) weeks was performed. RESULTS: Fifty-one patients (75 per cent) experienced healing of the fissure after 2--3 months of treatment with topical diltiazem. Seventeen patients who did not heal were treated for a further 8 weeks with topical diltiazem. Eight of these patients subsequently healed with diltiazem. Fifty-nine of 67 patients who completed follow-up therefore healed on diltiazem ointment. Four patients experienced perianal dermatitis and one patient experienced headaches. No other side-effects were recorded. After a median of 32 (range 14--67) weeks' follow-up following completion of treatment, 27 of 41 patients available remain symptom free. Six of seven patients with recurrent fissure were treated successfully by repeat chemical sphincterotomy. CONCLUSION: Topical 2 per cent diltiazem ointment used as an agent for chemical sphincterotomy for chronic anal fissure offers significant healing rates but does not have a significant side-effect profile, which may aid compliance to treatment. Early recurrences are common but usually amenable to further chemical sphincterotomy.     

Feasibility and safety of airway bypass stent placement and influence of topical mitomycin C on stent patency

OBJECTIVE: Airway bypass via transbronchial fenestration has been shown to improve forced expiratory volume and flow in explanted human emphysematous lungs. The aim of this study was to evaluate the feasibility and safety of in vivo airway bypass stent placement by using a canine model and to assess the influence of topical mitomycin C on the prolongation of stent patency. METHODS: With dogs under general anesthesia, suitable segmental and subsegmental bronchial wall sites were selected by direct visualization with a flexible bronchoscope. Peribronchial blood vessel injury was avoided by using a Doppler probe. Transbronchial fenestration was formed with a 22-gauge transbronchial needle, and the passage was then dilated with a 2.5-mm angioplasty balloon. A balloon expandable stainless-steel stent (3 mm long x 3 mm wide) with a sleeve of silicone rubber covering was placed within the fenestration. Animals were bronchoscoped weekly to assess stent patency. Seventy stents were placed in 12 dogs. Thirty-five served as controls, and the other 35 received transbronchoscopic topical application of mitomycin C once weekly to evaluate the effect on the maintenance of stent patency. Mitomycin C stents were divided into 4 groups according to the number of treatments: group A, 1 treatment only; group B, 4 weeks; group C, 7 weeks; and group D, 9 weeks. Each once-weekly mitomycin C application consisted of 0.2 mL at a concentration of 1 mg/mL, delivered through a small polyethylene catheter. RESULTS: Four instances of minor and brief bleeding occurred during stent placement and resolved without incident. One pneumothorax occurred and was treated by chest tube placement, without any adverse sequelae. There was no mortality associated with stent placement. No delayed hemorrhage or pneumothorax occurred. All control stents were occluded at the 1-week follow-up. The median durations of stent patency for group A (n = 8), group B (n = 9), group C (n = 10), and group D (n = 8) were 3, 8, 13, and greater than 20 weeks, respectively. CONCLUSIONS: Airway bypass stent placement can be performed safely. In an animal model, most stents became occluded within 1 week, but topical mitomycin application resulted in significant prolongation of patency.     

Bacterial findings in middle ear effusion in children

During 1983-87, tympanostomy tubes were inserted in a total of 4952 ears of 2575 children remitted to the ENT Department of our hospital because of chronic or recurrent otitis media problems. The children were included in a prospective study and referred to one of three groups for comparison of findings. Group 1 included all 6- to 12-month-old infants undergoing primary tube treatment; group 2, all children 1 year or older who had their first ventilation tube(s) inserted in connection with adenoidectomy; and group 3, all children in whom tympanostomy had been performed one or more times previously. Middle ear effusion was aspirated from 2392 ears (48%); 67.6% of all ears were negative for bacteria and 22.1% of the ears with effusion grew pathogenic bacteria. S. pneumoniae was the most frequently cultured pathogen among the 6 to 12 month olds in group 1, but in groups 2 and 3 H. influenzae occurred more frequently than S. pneumoniae. Beta-lactamase-producing strains of pathogenic bacteria were formed in only 4% of all ears with effusion: H. influenzae in 1.2% and B. catarrhalis in 2.8%. Compared with figures from the United states, the frequency of beta-lactamase-producing strains is low in the present series. This is probably explained by differences in antimicrobial treatment practices; in Finland and the Scandinavian countries, penicillin V is the primary drug for acute otitis media. In light of present results, it seems well-suited for treatment of otitis media in young children.     

Mitomycin protection of peridural fibrosis in lumbar disc surgery

OBJECT: In this prospective, randomized clinical study the authors sought to evaluate the effects of locally applied mitomycin C on peridural fibrosis during lumbar microdiscectomy. METHODS: Patients undergoing lumbar disc surgery were randomly divided into 2 groups. Thirty patients had 1 mg/ml mitomycin C applied at the site of discectomy for 5 minutes, and 30 age- and sex-matched patients underwent lumbar microdiscectomy without mitomycin C application as the control group. The groups were compared for degree of postoperative neurological function, radicular/back pain, and degree of peridural fibrosis on MR imaging 6 months after the operation. RESULTS: The median follow-up was 18 months. No serious drug adverse effects and no clinically significant laboratory adverse effects were reported in patients in the mitomycin C group. Patients in both groups showed similar clinical recoveries postoperatively. On postoperative evaluation of the MR images, pain scores, and neurological function, patients given mitomycin C have shown no reduction of peridural fibrosis either clinically or radiographically. CONCLUSIONS: Mitomycin C is easy to use and safe in patients undergoing lumbar microdiscectomy. However, no benefit was observed either clinically or radiographically in this study.     

Endoscopic treatment of laryngeal and tracheal stenosis-has mitomycin C improved the outcome?

OBJECTIVE: The management of laryngeal and tracheal stenosis remains a challenging problem despite advances in endoscopic surgical techniques. Scar formation and restenosis is the main cause of failure, and this study assesses the efficacy of two adjuvant treatments: endoscopic steroid injection and topical mitomycin C application.Study design and setting This is a retrospective cohort study comparing the efficacy of 3 endoscopic techniques: (1) carbon dioxide (CO(2)) laser incisions with bronchoscopic dilatation, (2) CO(2) laser with dilatation followed by steroid injection into the stenotic area, and (3) CO(2) laser with dilatation followed by topical application of mitomycin C. Included in the statistical analysis were 47 procedures performed by the senior investigator in a tertiary medical center between 1994 and 2001 based on their success or failure. RESULTS: The percentages of successful outcomes in the study groups were 15%, 18.2%, and 75% with the CO(2) laser, CO(2) laser with steroid injection, and CO(2) laser with mitomycin C, respectively. Statistical comparisons reveal that the differences in outcomes were statistically significant (P < 0.05) between the mitomycin group and each of the other two treatment groups, whereas there was no statistically significant difference between the laser only and laser with steroid groups. There were no complications noted with the use of adjuvant medications. CONCLUSION: These patient group results indicate a statistically significant increase, from <20% to 75%, in the success rate of endoscopic treatment of acquired upper airway stenosis when topical mitomycin C is added to the treatment regimen. No benefit has been demonstrated for using intraoperative local steroid injections as an adjunct to laser treatment.Clinical significance Mitomycin C appears to be an effective and safe adjuvant treatment in the endoscopic management of laryngeal and tracheal stenosis.     

Effect of Mitomycin C on Recurrence of Ganglion Cysts in the Foot and Ankle

Ganglion cysts are among the most common benign soft tissue masses. Although surgery has been shown to be effective, ∼12% to 42% of cases with long-term follow-up have been reported to recur. The purpose of this study was to determine the impact of the topical application of mitomycin C used as an adjuvant to surgery on recurrence rate of ganglion cysts. A retrospective analysis was done on all patients surgically treated by 1 surgeon for ganglion cysts. The primary end point was local recurrence after the procedure, determined clinically and by ultrasound. Secondary outcomes included wound complication rate, adverse effects, and overall patient satisfaction. A total of 98 consecutive patients were included in this study and assigned to a study group in a nonrandomized manner. The control group (n = 52) consisted of patients who underwent surgical resection only. The study group (n = 46) consisted of patients who underwent surgical resection with application of topical mitomycin C. No patients were lost to follow-up. Of the 52 patients in the control group, 13 (25.0%) had recurrence of the ganglion cyst. In contrast, in the experimental study group, 2 patients (4.3%) had a recurrence. There was no difference in superficial wound infections between the 2 groups. In this study, we found that the use of topical mitomycin C as an adjuvant to surgical resection significantly reduced the recurrence rate. Wound infection and overall nonrecurrence complication rates were similar to those of other studies.     

Thermosensitivity in a reconstructed microtic ear

The aim of this study was to evaluate thermo-thresholds in autologous reconstructed microtic ears. Nineteen patients with unilateral microtia were investigated no less than two years after the last operation (3.6+/-1.7 years). Their normal corresponding ear acted as controls. Eight healthy children were also investigated to illustrate technical differences between measuring the two sides. Thermal sensitivity was tested quantitatively using a SENSELab MSA Thermotest. The skin temperature was also tested. Three different areas of the ear were examined: the lobe, the antihelix, and the helix. The reconstructed ear had a significantly higher skin temperature for all investigated areas compared with the normal ear (reconstructed ear 30.2+/-1.2 degrees C, normal ear 28.6+/-0.9 degrees C). For the controls there were no significant differences in any area. For the patients there were small differences in perception of cold between the reconstructed and the normal ear. There were significant differences in the antihelix region and the helix in heat perception in the reconstructed ear compared with the normal one (helix reconstructed ear 43.9+/-3.8 degrees C, helix normal ear 38.3+/-3.0 degrees C, antihelix reconstructed ear 39.9+/-3.0 degrees C, antihelix normal ear 36.4+/-1.7 degrees C). The reconstructed ear had a changed thermosensitivity, but there did not seem to be any clinical disadvantages.     

Follow-up of 366 ears after tympanostomy tube insertion: why is it draining?

OBJECTIVE: Tympanostomy tube insertion is one of the most frequently performed procedures in otolaryngology. Complications, such as otorrhea, tympanosclerosis, and cholesteatoma, have been reported in the literature after its application. STUDY DESIGN: This study reports the complications encountered with 239 children (439 ears) with a follow-up of 7 to 73 months (median, 29 months) after tympanostomy tube insertion. Hearing results and middle ear pressures were compared and complications were noted in 366 ears that were available for the study. RESULTS: Otorrhea developed in 3 (0.8%) cases. Tympanosclerosis was seen in 74 (20.2%) cases. Tympanic membrane perforation, retraction pocket, granulation tissue, and atelectasis were seen in 4.6%, 5.2%, 1.1%, and 6%, respectively. No patients developed cholesteatoma after tube insertion. Hearing results were improved postoperatively in 93.4% of patients (median, 14.2 dB) and worse in 6.6% of patients (median, 8.3 dB). The average extrusion time was 7.3 months for grommet and 16.3 months for T-tubes. CONCLUSION: Multifactor etiologies show some unsolved or misunderstood underlying pathology, or unmentioned environmental factor such as atopy due to rich flora and humidity might exist to consider in the pathophysiology of the otorrhea.     

Equivalent efficacy of mitomycin C plus doxorubicin instillation to bacillus Calmette-Guerin therapy for carcinoma in situ of the bladder

BACKGROUND: To elucidate the most efficient topical therapy for carcinoma in situ of the bladder, the efficacy of intravesical mitomycin C plus doxorubicin therapy was compared with bacillus Calmette-Guerin (BCG) therapy. The clinical behavior of the tumor was analysed according to the histological grade. METHODS: Forty-two patients with carcinoma in situ of the bladder were randomized to intravesical BCG (21 patients) or mitomycin C plus doxorubicin sequential therapy (21 patients) as first line treatment. The non-responders underwent the subsequent instillation of the other intravesical therapy alternately. Of the patients, 27 had grade 2 and 15 had grade 3 cancer. RESULTS: Both topical therapies were equally effective with initial response rates of 86% (18/21) for BCG and 81% (17/21) for mitomycin C plus doxorubicin, irrespective of the tumor grade. Of seven initial non-responders, five patients achieved a complete response by subsequent instillation, resulting in a total response rate of 95%. After a mean follow-up of 47 months, five patients (12%) developed disease progression. The progression rates were not different between the topical therapies, but were significantly higher in grade 3 than in grade 2 cases. CONCLUSION: It appears likely that mitomycin C plus doxorubicin instillation has an equivalent efficacy to BCG as the initial therapy of carcinoma in situ and the combination of them would be the most efficient treatment for the disease. Moreover, histological grading would be clinically useful in defining the tumor characteristics and behavior of carcinoma in situ of the bladder.     

Flexible intramedullary nailing for radial neck fractures in children

ObjectiveThe aim of this study was to analyze the outcomes of treatment and the rate of complications in children treated with flexible intramedullary nailing (FIN) for radial neck fractures.MethodsThe study included 26 children (11 males and 15 females) with a median age of 9.5 years, treated with FIN for the radial neck fractures between May 2011 and May 2018. Immobilization after the surgery was not used. The median follow-up was 41 months. According to the Judet classification, 15 fractures were classified as type III and 11 as Type IV. For each patient, clinical, radiological, and disability of the arm, shoulder, and hand (DASH) scores were calculated.ResultsAll patients achieved complete radiographic healing at a median of 5 weeks. The nails were removed at a median of 4 months. The rate of complications was 11.5%, including 1 radial head necrosis, 1 angulation of 15°, and 1 displacement of the radial head. Twenty patients (76.9%) achieved a perfect clinical healing, while 23 patients (88.5%) achieved a perfect radiological healing. The median DASH score was 1.25. No cases of delayed healing were recorded. After removing of the nails, all patients returned to full function of the extremity and all complications were resolved.ConclusionThe use of FIN for treating fractures of the radial neck in children shows very good functional and cosmetic results. It allows mobilization with rapid pain reduction. It is a minimally invasive, simple, and reproducible technique with a low rate of complication. Owing to excellent results, surgical stabilization of radial head and neck fractures using FIN is recommended in children and adolescents.Level of EvidenceLevel IV, Therapeutic study