Hearing loss after cardiopulmonary bypass surgery.

Hearing loss (HL) is a rare complication following cardiac surgery with extracorporal circulation (CSWEC) or other non-otologic surgery under general anesthesia, as is HL caused by loss of cerebrospinal fluid during neurosurgery or spinal anesthesia. The incidence of HL after CSWEC is not known since preoperative hearing testing is not commonly done and a perioperative HL may occur unnoticed. We present four cases of profound sensorineural hearing loss following CSWEC for coronary artery bypass or cardiac valve surgery. The hearing loss was noticed immediately on waking from anesthesia in three of the patients, whereas the fourth patient noticed decreased hearing during the first postoperative week. In all patients audiological investigation suggested a cochlear etiology of the HL. The possible mechanisms for HL are discussed. HL after CSWEC is most likely caused by a microembolism generated by atheromatous material.

[Is the use of surgical microscope justified in thyroid surgery? 10-year experience with thyroid surgery performed by means of microsurgical technique]. / Har operationsmikroskopet sin berettigelse ved thyreoideakirurgi? Ti års erfaring med thyreoideakirurgi udført med mikrokirurgisk teknik.

Paralysis of the recurrent laryngeal nerve is the most disastrous complication following thyroid surgery. In order to minimize this complication, different devices have been used to identify the recurrent laryngeal nerve during surgery. The presently available devices are reviewed and we present our results with the device we used, the surgical microscope. Five hundred and seventy-three patients had thyroid surgery, 451 had benign lesions and 122 malignant. Calculated as nerves at risk, primary surgery in benign/malignant disease resulted in 0.6 per cent/3.5 per cent permanent paralysis and in recurrent and completion surgery this complication rate was 4.5 per cent/2.9 per cent. These results are pleasing but also stress that primary surgery should be radical so as to avoid completion or recurrent surgery.

Microsurgical technique in thyroid surgery--a 10-year experience.

OBJECTIVE: To report the results of thyroid surgery in a University department of ENT--head and neck surgery, and to evaluate the benefits of the use of the surgical microscope in thyroid surgery. DESIGN: A retrospective evaluation of the records of all patients who underwent thyroid surgery in the 10-year period 1987-1996. METHODS: In addition to standard surgical principles the Zeiss multi-discipline universal surgical microscope with a 250 mm ocular lens was used in all cases. Total thyroidectomy was performed in all malignant cases, while unilateral lobectomy plus isthmus resection was the standard procedure in benign cases. PATIENTS: There were 573 patients, aged 11-87 years, 444 females and 129 males. Four hundred and fifty-one had benign lesions, 122 malignant. Four hundred and eighty-nine had primary surgery, 84 underwent completion surgery or surgery for recurrent disease. RESULTS: Primary thyroid gland surgery in benign/malignant disease resulted in permanent recurrent laryngeal nerve palsy in 0.6 per cent/3.5 per cent of the patients respectively, when calculated as nerves at risk (NAR). In benign recurrent or malignant completion surgery this complication rate was 4.5 per cent/2.9 per cent respectively. CONCLUSION: Thyroid surgery in our University ENT--Head and Neck Department with the use of the surgical microscope provides pleasing results, especially considering the diversity of surgeons, due to the departments' teaching responsibilities.

[Large epiglottic lipoma. Intubation method for large tumors in the pharynx and larynx]. / Stort epiglottislipom. Intubationsstrategien ved større tumorer i pharynx og larynx.

Large benign tumours in the aperture of the larynx are uncommon, and they are especially rare on the epiglottis. They are, however, important as they may cause fatal airway obstruction particularly at induction of general anaesthesia. We present a patient with a large lipoma originating in the vallecula epiglottica and the lingual surface of the epiglottis. The difficulties involved in tracheal intubation and possible solutions are discussed. In this case intubation was performed under local anaesthesia with the patient fully awake. A commissure laryngoscope was used for visualisation of the laryngeal inlet and a flexible bougie was inserted into the trachea. After removal of the laryngoscope a 7 mm ID endotracheal tube was advanced over the bougie into the trachea. After securing the airway in this way general anaesthesia was induced and the table tennis ball sized lipoma was uneventfully removed.

Mediastinitis-a rare complication of a peritonsillar abscess.

We report a case of mediastinitis, in an otherwise healthy 25-year-old man, resulting from a peritonsillar abscess with extension through the parapharyngeal and retropharyngeal spaces. In our case the patient was primarily treated with needle aspiration, a method described in many publications as a safe alternative to incision and drainage. We emphasize that for peritonsillar abscesses a tonsillectomy or wide incision and drainage, instead of needle aspiration, might prevent the extension of the condition, thus preventing serious complications.

[Extrapulmonary tuberculosis--important differential diagnosis]. / Ekstrapulmonal tuberkulose--en vigtig differentialdiagnose.

In this paper, we present two cases of extrapulmonary tuberculosis, the first case with tuberculosis of the larynx and the second with tuberculosis lymfadenitis. In both cases malignant lesions were primarily proposed. We emphasize that definitive diagnosis requires culture and specification of Mycobacterium tuberculosis. We draw attention to the fact that extrapulmonary tuberculosis is still a differential diagnostic consideration.

[Acute upper airway obstruction caused by esophageal achalasia--a rare complication]. / Akut vejrtraekningsbesvaer forårsaget af achalasia esophagi--en usoedvanlig komplikation.

Acute upper-airway obstruction due to achalasia of the oesophagus is a rare condition. Two newly-treated cases are described. It is stressed that when the diagnosis is established, one should primarily decompress the entire oesophagus. The final treatment is balloon dilation or in some cases Heller's extramucosal myotomy.

[Acute epiglottitis. 27 years of experience with and future development of nasotracheal intubation]. / Epiglottitis acuta. Syvogtyve års erfaring med nasotrakeal intubation og den fremtidige udvikling.

During a 27-year period 295 patients in Copenhagen County were treated for acute epiglottitis. One hundred and eight-two were adults and 113 were children. Most children were treated by nasotracheal intubation while only a few adults required nasotracheal intubation in order to secure the airway. The incidence of acute epiglottitis in children less than five years old was calculated to be 8.7/100,000 with minor annual variation. Since vaccination against Haemophilus influenzae type b has been implemented in Denmark from May 1993, this figure will probably be markedly reduced, and the disease even may be even eradicated in children, but in adults the same reduction cannot be expected as the causative agent in this group is less frequently Haemophilus influenzae type b. It is emphasized that this reduced incidence will make it even more important that each department engaged in the treatment of suspected acute epiglottitis have a departmental protocol for management of the condition, so that the future rarity of acute epiglottitis does not cause the mortality rate to rise.

Submandibular gland excision: short- and long-term complications.

During a 10-year period, 159 benign submandibular gland excisions were performed in 157 patients. 86 of the patients were available for follow-up evaluation. Both short- and long-term complications were listed. Neurapraxia to the mandibular branch of the facial nerve was frequent after the operation, but restoration of function was seen in 92.3%. Scar problems, sensation changes, reduced salivation and taste perception were noticed by the patients in several cases, but rarely caused dissatisfaction. 18.2% of the patients in the salivary stone group had residual stones in Wharton's duct after the operation. The indication for removal of both glands should be carefully considered because of development of xerostomia.

[Attitudes of Danish physicians to consumer charges in the health care system]. / Danske laegers holdning til brugerbetaling i sundhedssektoren.

Consumer charges in connection with visits to a doctor are common in a number of countries often used for comparison but are not employed in Denmark. The Danish Medical Association is opposed to consumer charges in health care and a test sample out of 1,000 of the Medical Association chosen at random showed a definite majority opposed to consumer charges. A minority of the profession was in favour of a nominal fee of less than 70 Danish crowns (approximately 7 pounds) for visits to a doctor while scarcely 4% considered that the fee should be more than 100 Danish crowns (approximately 10 pounds). 40% of the participants considered that the consumer charge would have to exceed 100 Danish crowns before it was of any consequences for the health of the patient. In addition, this study revealed that female doctors were more opposed to consumer charges than their male colleagues. At present, more women than men commence the medical curriculum in Denmark and it must therefore be anticipated that the percentage of women in the Danish Medical Association will soon exceed the present 30%. The resistance os the Danish Medical Association to consumer charges in health care will, therefore, probably be retained.

[Attitude of Danish physicians to the health care services]. / Danske laegers holdning til service i sundhedssektoren.

In recent years, Danish society has focused on the service and the information available for patients in health care. A test sample out of 1,000 members of the Danish Medical Association selected at random revealed that the majority had positive attitudes to service and information in health care. The study also indicated that doctors do not consider that any particular dress code is particularly appropriate but consider that personal appearance and the way patients are addressed are individual matters. This individualistic attitude which is consistent with Mintzberg's sociological structural theory does not invariably seem appropriate.

Acute epiglottitis--25 years experience with nasotracheal intubation, current management policy and future trends.

During a 25-year period 168 adults and 111 children in Copenhagen County were treated for acute epiglottitis. Four patients, two children and two adults died, of these the two children and one adult had a cardiac arrest on arriving at the hospital. Most children were treated by nasotracheal intubation while only some adults required nasotracheal intubation in order to secure the airway. Our data indicate that intubation of adults with epiglottitis is technically more difficult than in children. The fibrelaryngoscope, a new diagnostic tool, is advocated, and was in this study used to establish the diagnosis in 12 unclear cases of acute epiglottitis. The incidence of acute epiglottitis in children was calculated at 3.2/100,000 with a minor annual variation. As vaccination against Haemophilus influenzae type b becomes more common, the incidence will probably be markedly reduced, maybe even eradicated in children, but in adults the same reduction cannot be expected as the causative agent in this group is less frequently Haemophilus influenzae type b.

[Lateral cervical cysts as primary manifestation of tonsillar cancer]. / Laterale halscyster som primaer manifestation ved tonsilcancer.

Of 59 patients with tonsillar carcinoma, eight presented with a cervical cyst which was judged to be a branchial cyst clinically and after fine needle aspiration. In all cases, the cyst was removed and microscopic examination revealed malignancy. The correct diagnosis, carcinoma of the tonsil with cystic lymph node metastasis, was revealed during the primary operation in two cases, in four cases the diagnosis was made at a second operation where ipsilateral tonsillectomy was performed and in two cases the diagnosis was first made several years later. It is concluded that, in patients who are over the age of 40 years, the diagnosis of branchial cyst should not be accepted primarily even if fine needle aspiration does not give any suspicion of malignancy.

[Anesthesia in ear surgery. A resource economical analysis and patient assessment of general anesthesia versus local anesthesia in ear surgery]. / Anaestesi ved øreoperationer. En ressourceøkonomisk analyse og forbrugervurdering af generel anaestesi kontra lokalanaestesi ved øreoperationer.

Although it has long been known that surgery on the middle ear may be carried out under local anaesthesia (LA), the majority of ear operations in Denmark are carried out under general anaesthesia (GA). A prospective review is presented of 103 ear operations of which 71 were undertaken under local anaesthesia and 32 under general anaesthesia. Local anaesthesia has considerable advantages as compared with general anaesthesia, particularly that the anaesthetic capacity is released and can be employed for other purposes. Employment of local anaesthesia does not present any disadvantages for the surgeon and the procedure appears to be acceptable for the majority of patients. In order not to bring the procedure into disrepute, patients should be assessed meticulously preoperatively by an experienced surgeon so that operation under local anaesthesia is not performed in unsuitable patients.

Acute epiglottis in children and adults. Nasotracheal intubation, tracheostomy or careful observation? Current status in Scandinavia.

A review was performed of the treatment of 92 patients with acute epiglottitis with special reference to the different procedures employed in children and adults. Intubation was performed in 74 per cent of the children but in only six per cent of the adults. More than half of the children were initially observed only, but of these 58 per cent eventually needed intubation. No deaths occurred. We present our management protocol as well as a survey of the routine management of acute epiglottitis in children in the five Scandinavian countries. The number of initially observed patients ranged from nil per cent in Iceland to 35 per cent in Finland. When an artificial airway is needed, 92-100 per cent of the patients are intubated, 0-8 per cent tracheostomized, and 0-5 per cent one or the other, as a standard procedure. Tracheostomy is performed in departments where the facilities do not permit sufficient observation of patients treated by intubation.

Atypical histiocytic granuloma with eosinophilia.

Atypical histiocytic granuloma in the oral mucosa has recently been described as a benign non-neoplastic ulcero-proliferative lesion of histiocytic origin with eosinophilia. The disease is confined to the oral mucosa where the lesion is solitary. These lesions, which heal spontaneously, are not associated with systemic disease or dissemination. This report deals with such a case, and it stresses the benign nature of the lesion despite the worrying clinical and microscopic appearance. The morphological diagnosis was substantiated by the use of a series of immunohistochemical reactions.