Tonsillectomy with argon plasma coagulation (APC): evaluation of pain and hemorrhage

OBJECTIVE: Argon plasma coagulation (APC) offers a new possibility for tonsillectomy (TE) because of its effective hemostasis and limited penetration depth of the coagulation zone. The APC dissector allows dissection and hemostasis in a one-step procedure. The aim of this prospective, randomized, single-blinded study was the evaluation of pain and hemorrhage of the "hot" argon-plasma-coagulation tonsillectomy (TE(APC)) compared with a conventional "cold" non-electrosurgery tonsillectomy (TE(Conv)). METHODS: Two hundred one consecutive patients undergoing tonsillectomy were included in a single-blinded, randomized, prospective study with stratification in two age groups. RESULTS: There was no statistical significant difference between TE(APC) and TE(Conv) in the intensity of postoperative pain and primary or secondary hemorrhage in both age groups. In the TE(APC) group, the mean duration of tonsillectomy was significantly reduced by more than 50% in both age groups (P <.01). The blood loss was 90% decreased in the TE(APC) compared with the TE(Conv) in both age groups (P <.01). CONCLUSIONS: The APC technique does not face the general problem of electrosurgery or thermal coagulation techniques in which the postoperative pain is often increased compared with conventional cold techniques. It offers an innovative new tonsillectomy method with significant reduced blood loss and surgical time.     

The admission of patients with peri‐tonsillar abscess to a general ENT ward and its influence on secondary post‐tonsillectomy haemorrhage

The admission of patients with peri‐tonsillar abscess to a general ENT ward and its influence on secondary post‐tonsillectomy haemorrhage Patients with peri‐tonsillar abscess require hospitalization. The aim of this prospective study was to determine whether the admission of patients with peri‐tonsillar abscess to the same ward as those undergoing tonsillectomy influences the incidence of secondary post‐tonsillectomy haemorrhage. We included all adult patients undergoing in‐patient tonsillectomy (n = 183) and all patients with proven peri‐tonsillar abscess (n = 46) over a 1‐year period. Both patient groups were nursed in the same general otolaryngology ward. The operation dates of those patients who developed secondary post‐tonsillectomy haemorrhage were matched to the dates when patients with peri‐tonsillar abscess were admitted. Out of the 71 patients who had tonsillectomy on days when patients with peri‐tonsillar abscess were admitted, 10 developed secondary haemorrhage. Out of the 112 patients who had tonsillectomy on days when no one in the ward had peri‐tonsillar abscess, 16 developed secondary haemorrhage. No difference was demonstrated (χ² = 0.0014, P > 0.05). In this study, admission of patients with peri‐tonsillar abscess to a general otolaryngology ward does not influence the incidence of secondary post‐tonsillectomy haemorrhage in patients undergoing elective surgery.     

Candidate's Thesis: Platelet‐Activating Factor–Induced Hearing Loss: Mediated by Nitric Oxide?

Objectives/Hypothesis Platelet‐activating factor (PAF)in middle ear effusion is thought to induce hearing loss. The purpose of this study is to investigate the role of nitric oxide (NO) in the mechanism of PAF‐induced hearing loss by studying the effects of PAF application on the round window membrane (RWM) with and without PAF‐antagonist NO‐blocker. Study Design Longitudinal study on randomized guinea pigs using PAF to induce hearing loss. Methods Guinea pigs were divided into four groups: PBS, PAF, PAF‐antagonist, and L‐NAME. The PBS group received phosphate buffered saline (PBS) and the PAF groups received 10, 20, and 40 μg of PAF soaked into gelfoam and placed on the RWM. PAF‐antagonist (WEB 2170) and NOS inhibitor NG‐nitro‐l‐arginine‐methylester (L‐NAME) were injected intraperitoneally prior to PAF 20 μg application on the RWM. The following three tests were performed on each animal group: Hearing was tested with an auditory brainstem response (ABR) test over 24 hours. At the end of 24 hours, cochlear hair cells were examined by scanning electron microscopy (SEM) and immunohistochemistry was carried out on the cochlea to test the expression of inducible nitric oxide synthase (iNOS). Results The PAF group developed significant elevation of ABR threshold and cochlear hair cell damage in the SEM group as compared with the PBS control group. The PAF‐antagonist (WEB 2170) and the L‐NAME groups did not show significant elevation of ABR threshold and cochlear hair cell damage compared with the group administered PAF 20 μg, but in the PAF‐antagonist group, the elevation of ABR threshold was significant compared with that of the PBS control group, whereas it was not significant compared with the PBS group in the L‐NAME group. Strong expression of iNOS on cochlea was observed in the PAF group and lighter expression was seen in PBS, WEB 2170, and L‐NAME groups. Conclusions This study demonstrated that PAF placed on the RWM induced hearing loss and cochlear hair cell damage. The PAF‐antagonists and L‐NAME prevented the PAF‐induced hearing loss and inhibited iNOS expression in the cochlea. These findings suggest that the PAF‐induced hearing loss caused by cochlear hair cell damage may have been mediated by NO. PAF‐antagonists and L‐NAME may have future therapeutic implications in preventing sensorineural hearing loss associated with chronic otitis media. The results of this study have significant potential clinical application.     

The test and treatment methods of benign paroxysmal positional vertigo and an addition to the management of vertigo due to the superior vestibular canal (BPPV‐SC)

A review of the tests and treatment manoeuvres for benign paroxysmal positional vertigo of the posterior, horizontal and superior vestibular canals is presented. Additionally, a new way to test and treat positional vertigo of the superior vestibular canal is presented. In a prospective study, 57 out of 305 patients' visits are reported. They had residual symptoms and dizziness after the test and the treatment of benign paroxysmal positional vertigo of the horizontal canal (BPPV‐HC) and posterior canal (PC). They were tested with a new test and treated with a new manoeuvre for superior canal benign paroxysmal positional vertigo (BPPV‐SC). Results for vertigo in 53 patients were good; motion sickness and acrophobia disappeared. Reactive neck tension to BPPV was relieved. Older people were numerous among patients and their quality of life (QOL) improved.     

Cricothyroid approximation and subluxation in 21 male-to-female transsexuals

OBJECTIVES: To evaluate the medium-term outcome of cricothyroid approximation and subluxation (CTAS) with postoperative speech therapy for pitch elevation in male-to-female transsexuals. STUDY DESIGN: Retrospective study of male-to-female transsexuals who underwent pitch-raising surgery between November 1996 and August 2001. METHODS: Twenty-one male-to-female transsexuals opted for surgical feminization of their voices after inadequate improvements with speech therapy alone. Electrolaryngographic measurements were obtained by a single speech therapist of modal fundamental frequencies and the percentage of irregularities before, at 2 weeks, and 6 months after surgery. All 21 patients underwent CTAS, and 20 underwent simultaneous cosmetic thyroid chondroplasty by a single surgeon. RESULTS: Electrolaryngographic results 2 weeks after surgery showed an average postoperative gain in modal frequency of free speech of 71.05 Hz (95% confidence interval [CI]: 42.9-99.2, P < .001). There was a concomitant average rise in irregularities of 9.9% (95% CI 0.7-18.5, P = .03). At median follow-up of 6 months after six sessions of speech therapy (n = 15), there was a decrease in irregularities to preoperative levels. The overall gain at 6 months in modal frequency of free speech was 56.9 Hz (95% CI 38.3-75.4, P < .001). Smoking and age did not predict a worse outcome. CONCLUSIONS: Cricothyroid approximation effectively raises pitch in male-to-female transsexuals. There is a concomitant rise in voice irregularities that is effectively addressed by speech therapy.     

End-to-side neurorrhaphy and lateral axonal sprouting in a long graft rat model

OBJECTIVE/HYPOTHESIS: Controversy exists regarding collateral axonal sprouting across an end-to-side neurorrhaphy to provide functional motor reinnervation of a target organ without compromise of the donor nerve. Rat models may be limited in the study of end-to-side repair given potential contamination from the proximal nerve stump of the recipient distal nerve and the use of antagonistic muscle groups for donor and recipient. The current study attempts to address these issues by using a rat model in which an end-to-side coaptation is performed with a long graft interposed between the intact donor tibial nerve and the divided, distal contralateral tibial nerve. MATERIALS AND METHODS: The graft used in proximal end-to-side coaptation consisted of both sciatic nerves in a donor syngeneic animal. The distal repair to the contralateral tibial nerve was done immediately or in a delayed fashion to allow potential motor axons to transverse the graft before division of the recipient tibial nerve. RESULTS: After 24 weeks, axons were noted to transverse the entire distance of the graft and into the contralateral distal posterior tibial nerve. A significant increase in axonal numbers was observed in the immediate repairs compared with the delayed. No animal recovered functional motor ability on the contralateral side as assessed by walking tracks. CONCLUSIONS: These findings suggest the importance of immediate distal neurotrophic factors in encouraging nerve regeneration even in a long graft end-to-side repair. Our model is successful in demonstrating innervation through an end-to-side coaptation but questions its use given the lack of motor recovery.     

FDG PET for mucosal malignant melanoma of the head and neck

OBJECTIVES/HYPOTHESIS: To evaluate imaging findings using positron emission tomography (PET) and 18F-fluorodeoxyglucose (FDG) in mucosal malignant melanoma (MMM) of the head and neck. STUDY DESIGN: Retrospective evaluation. METHODS: Eighteen PET examinations were performed for initial staging and/or follow-up in 10 patients with MMM. Medical records of 6 male and 4 female patients (age range, 43--81 y; mean, 67 y) were reviewed retrospectively with regard to the patients' history, symptoms, and clinical course. Primary melanoma elsewhere in the body was excluded at the time of diagnosis. RESULTS: All MMM were visible in staging PET examinations, but FDG uptake depended on lesion size and anatomic site. Big lesions with a nodular growth, as seen in pathologic specimens, were better visible compared with lesions with a more superficial spread within the mucous membranes. Lesions in the anterior part of the nasal cavity were more difficult to detect than those in the posterior sinonasal complex because of possible interference with nonspecific uptake in muscles of the mouth and pronounced appearance of the skin when imaging was performed using filtered back projection without attenuation correction. CONCLUSION: We found that MMM of the head and neck can be visualized using FDG PET. Furthermore, locoregional and distant metastases can be evaluated much like those of cutaneous malignant melanoma. Therefore, PET may be suitable for the staging and/or restaging of these patients. Further studies have to elucidate the potential role of FDG PET in patient management.     

The role of positron emission tomography/computed tomography in the management of recurrent papillary thyroid carcinoma

OBJECTIVES/HYPOTHESIS: The aim of the study was to evaluate the role of combined positron emission tomography/computed tomography (PET/CT) fusion imaging in the detection and management of recurrent papillary thyroid cancer. STUDY DESIGN: A retrospective analysis of 33 patients with suspected recurrent papillary thyroid carcinoma who had undergone PET/CT was performed. PET/CT was compared with standard imaging techniques in each patient to determine whether PET/CT contributed to the therapeutic management plan. Histopathological findings were correlated to PET/CT in patients who underwent surgery. METHODS: The senior author reviewed the charts of 33 patients with recurrent papillary thyroid carcinoma to determine the impact PET/CT had on management. PET/CT was compared with conventional imaging results. In surgical patients, PET/CT was compared with histopathological findings to determine its sensitivity, specificity, accuracy, positive predictive value, and negative predictive value. RESULTS: In 67% of the cases (22 of 33), PET/CT supplied additional information that altered or confirmed the management plan. Twenty of 33 patients underwent surgery with 36 sites assessed by histopathological analysis. PET/CT correlated with histopathological findings in 25 of 36 distinct anatomical sites, with an accuracy of 70%. The sensitivity of PET/CT in identifying recurrence was found to be 66%, with a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 27%. CONCLUSION: Combined PET/CT fusion scanning was most useful in the detection and management of recurrent papillary thyroid cancer in patients who had average thyroglobulin levels greater than 10 ng/mL and when the tumor no longer concentrated radioactive iodine. In 100% of the cases in which PET/CT localized a region suspicious for malignancy, histopathological analysis confirmed the results. When PET/CT is positive, it is a powerful tool for predicting exact locations of recurrent papillary thyroid cancer, thus making it a reliable guide for surgical planning. PET/CT is a supplement to conventional imaging and fine-needle aspiration in the workup of recurrent papillary thyroid cancer. A negative finding on PET/CT is not sufficiently reliable to preclude further investigation and treatment.     

L-n-acetyl-cysteine protection against cisplatin-induced auditory neuronal and hair cell toxicity

OBJECTIVES: The aim of this study is to determine the efficacy of L-N-acetyl-cysteine (L-NAC) as a protectant for inner ear auditory sensory cells against the toxic effects of cisplatin. STUDY DESIGN: Prospective laboratory study of the otoprotective effect of L-NAC on auditory neurons and hair cells in vitro. METHODS: The study has two arms. The first arm evaluated the neuroprotective effect of L-NAC on early postpartum auditory ganglion cell cultures. Two culture media were used. The two media differed in that one of them was enhanced by the addition of neurotrophins (neurotrophin type 3 and brain-derived neurotrophic factor) and a growth factor (transforming growth factor-beta1). Then the survival of cisplatin-treated auditory neurons was studied before and after pretreatment with protective levels of L-NAC. The second arm of the study evaluated the effect of L-NAC on cisplatin damage initiated to auditory hair cells. Early-postpartum organ of Corti explants were grown in culture. Their rate of survival was studied after exposure to toxic levels of cisplatin. Then, survival of cisplatin-damaged hair cells was studied after they were pretreated with L-NAC. RESULTS: Pretreatment of cultures with L-NAC protected both auditory neurons and hair cells from the effects of exposure to toxic levels of cisplatin. This observed otoprotective effect was dose dependent. CONCLUSIONS: Our in vitro studies have demonstrated that L-NAC protected both auditory neurons and hair cells from the toxic effects of cisplatin. Because it protects both of these inner ear structures, L-NAC may be potentially useful in protecting hearing, in general, from cisplatin-induced damage. In addition, L-NAC has low systemic and mucosal toxicity. It also has a low molecular weight that may allow it to readily cross the round window membrane. All these characteristics make it potentially suitable for transtympanic application for the prevention of the ototoxicity of cisplatin in vivo.     

Interstitial high-dose-rate-brachytherapy in advanced esthesioneuroblastoma

Esthesioneuroblastoma is a rare neuroectodermal tumor of the nasal vault with an aggressive biological behavior that is characterized by local recurrence, atypical distant metastasis, and poor long-term prognosis. The treatment regimen consists of surgical resection, radiation therapy, and chemotherapy in various, mainly stage-dependent, combinations. We report two cases of primary metastatic and locally recurrent disease, which were treated with computed tomography-guided interstitial high-dose-rate brachytherapy in palliative and curative intent, respectively. Computed tomography-guided interstitial high-dose-rate brachytherapy should be considered as a feasible treatment option for advanced esthesioneuroblastoma.     

Pitch-raising surgery in fourteen male-to-female transsexuals

OBJECTIVE: To evaluate the indications and results of pitch-raising surgery in male-to-female transsexual patients. STUDY DESIGN: Retrospective study of male-to-female transsexual patients who underwent pitch-raising surgery between 1994 and 2001 at a single institution. METHODS: The 14 patients had inadequate improvements after speech therapy alone. After anterior commissure advancement (n = 2), cricothyroid approximation (n = 9), or both (n = 3), results were evaluated subjectively by the patients and speech therapists and objectively by electroglottographic measurement of fundamental frequencies (usual, maximal, and minimal), postoperative gain in usual fundamental frequency, and the percentage of irregularities. RESULTS: Cricothyropexy disruption occurred in two patients. Median follow-up was 6.5 months. Subjective success rates were 78.5% and 71.5% according to the patients and speech therapists, respectively. Usual, maximal, and minimal frequencies increased significantly; median postoperative gain in usual fundamental frequency was 11 Hz. Three of the four patients with a poor objective result continued to smoke after surgery. CONCLUSION: Pitch-raising surgery induces subjective and objective improvements but should be reserved for patients in whom speech therapy is not sufficiently effective.