Ectopic adenoid tissue in the choanae.

A series of 19 patients with often long-lasting nasal stenosis despite repeated treatment attempts, including in many cases repeated adenoidectomy, were found to have ectopic adenoid tissue in the choanae which could only be removed transnasally by forceps. It did not emerge from the rhinopharynx but from the roof of the choanae, the posterior part of the nasal septum and in some cases also from the lateral wall of the choanae. The diagnosis was established by anterior rhinoscopy using a flexible rhinopharyngo-laryngoscope. The treatment was successful in all 19 patients, many of whom had had symptoms for years. It is estimated that about two per cent of patients with adenoid symptoms have such ectopic choanal adenoid tissue, that cannot be removed by the usual oral approach. In young patients with long-lasting nasal stenosis attention should be focused on the bottleneck of the nasopharyngeal airway formed by the choanae, primarily by fibre-optic endoscopic examination.

[Surgical treatment of severe snoring. Long-term effects]. / Operativ behandling af excessiv snorken. Langtidseffekt.

AIM: The long-term results of uvulopalapharyngoplasty (UPPP) reported by patients who had been operated for severe snoring but without clinically significant obstructive sleep apnoea were explored. METHODS: Median three years (one to eight years) after the operation follow-up results were obtained from 80 of 85 patients (94%), using a questionnaire. RESULTS: In nine patients (11%) the operation had been without any effect. Eleven patients (14%) indicated that they were completely cured of snoring. In sixty patients (75%) snoring was reduced. In about half of these the initial effect had been more pronounced than the present. About 60% of the patients felt better during daytime, were less tired or sleepy than before the operation. Slight or temporary side effects were present in 30% of the patients. Eighty percent of the patients would recommend the operation to others. CONCLUSION: This study confirms that UPPP is effective in relieving the symptoms in non-apnoeic snorers, without significant side effects. A certain reduction of the positive effect occurs during the first two years in about half of the patients. Nevertheless most patients are satisfied with the operation and would recommend it to others.

Titanium implants for bone-anchored hearing aids--host reaction.

In a series of 31 prospectively followed patients equipped with bone-anchored hearing aids (BAHA), 7 titanium implants (19.4%) were lost in 6 patients after a median of 42 months (range: 27-78 months), often after visible resorption of bone around the superficial part of the implant. Expressed in a sample life table, no implants were lost during the first 2 years. After 3-4 years, the success rate dropped to about 85% and after 6-7 years to about 75%. Research that aims to define the factors which influence the extrusion rate is needed.

Choanal adenoid syndrome--a preliminary report.

A series of 19 patients with long-lasting nasal stenosis despite repeated treatment attempts, including, in many cases, repeated adenoidectomy, was found to have ectopic adenoid tissue inside the choanae. The choanal adenoid tissue could not be removed by curettage, only transnasally using forceps. The treatment was successful in all 19 patients. It is estimated that in at least 2% of the patients with long-lasting nasal stenosis, attention should be focused on the bottleneck of the nasopharyngeal airway represented by the choanae, primarily by fibre optic endoscopic examination.

Histologic evaluation of retrieved craniofacial implants.

A retrieval study was performed on implants placed extraorally in the craniofacial region. The study included 19 implants retrieved from 16 patients. The implants were all stable at the time of removal. For various reasons, 5 of the implants were never loaded, whereas 14 of the implants had a known loading period of 3 months to 7 years 7 months. The reasons for removal varied but included the following: death in 1 case; poor results of the bone-anchored hearing aid in 7 cases; host-related reasons, varying from soft tissue irritation to infection or pain, in 6 cases; change of treatment plan in 1 case; and scheduled direct removal at the time of insertion in 1 case. The results of the histologic evaluation were similar to those reported in retrieval studies of a corresponding design used intraorally.

Does bismuth subgallate have haemostatic effects in tonsillectomy?

Previous studies have shown that bismuth subgallate added to gauze swabs in tonsillectomy reduces the time to achieve haemostasis and probably reduces the risk of postoperative haemorrhage. All these studies have used bismuth subgallate in combination with adrenaline. In this randomised clinical study we investigated the effect of bismuth subgallate alone. A total of 204 patients were randomised into two groups. One hundred and six patients had swabs with bismuth subgallate. In the control group (n = 98), plain swabs were used. Operating time time to achieve haemostasis, peroperative blood loss, and incidence of postoperative haemorrhages were recorded. There were no significant differences between the two groups. We conclude that the evidence for using bismuth subgallate as a haemostatic agent in tonsillectomy is weak. The effect observed in previous studies can probably be ascribed to the effect of adrenaline.

The non-specific effect of endolymphatic sac surgery in treatment of Meniere's disease: a prospective, randomized controlled study comparing "classic" endolymphatic sac surgery with the insertion of a ventilating tube in the tympanic membrane.

A prospective, randomized study was carried out comparing the effect of two surgical modalities in the treatment of patients with Meniere's disease: insertion of an endolymphatic sac shunt and insertion of a ventilating tube in the tympanic membrane. A total of 29 patients, 12 males and 17 females, age 27-71 years, were operated on in two ear, nose and throat (ENT) departments. Of these patients, 15 had an endolymphatic shunt inserted and 14 had a ventilating tube inserted in the tympanic membrane. Postoperative follow-up was carried out in the department in which the patients had not been operated. The severity of the disease was scored pre- and postoperatively, and the results evaluated under the guidelines of the Committee on Hearing and Equilibrium (1995) for the diagnosis and evaluation of therapy in Meniere's disease. The patients in both groups had a statistically significant reduction in dizzy spells, measured 6 and 12 months postoperatively, and there was no difference between the groups. The pathophysiological explanation for the reduction in dizzy spells in each of the treatment modalities is debatable and the effect is non-specific. The patients' hearing and tinnitus were statistically unaffected by the treatment in both groups, though 2 patients in the shunt group developed severe hearing loss (anacusis/70 dB).

[Is postoperative hemorrhage a risk in ambulatory tonsillectomy?]. / Er efterblødning en risiko ved dagkirurgisk tonsillektomi?

Day-case surgery is being used increasingly to improve health care efficiency. In Denmark, tonsillectomy is performed on an in-patient basis because of safety concerns regarding primary haemorrhage. This study aims at investigating the likely safety of day-case tonsillectomy by defining the incidence and timing of primary haemorrhage and thereby to establish a safe time period for a possible same day discharge. Retrospectively recorded data on 2,888 tonsillectomies were reviewed. Serious primary posttonsillectomy haemorrhage arose in 34 patients (2.7 percent), of which 65 percent presented within eight hours and 95 percent within 23 hours postoperatively. In view of the fact that one quarter of the patients with a primary posttonsillectomy haemorrhage experience it more than 12 hours postoperatively, tonsillectomy cannot be recommended as a safe routine day-case procedure.

Extensive cholesteatoma: long-term results of three surgical techniques.

During the years 1979-81, three different surgical techniques were used in the treatment of 87 ears with extensive cholesteatoma. All procedures were performed in one stage by the same surgeon. Ten to 13 years after the operations about 70 per cent of ears operated on by the canal wall up technique had developed a new cholesteatoma, which in most cases was recurrent, or a deep retraction pocket. A modification of this technique with mastoid obliteration resulted in a similar failure rate. In contrast, ears operated on by the canal wall down technique (in most cases with mastoid obliteration) had acceptable stability with a long-term recurrence rate of about 15 per cent. Most patients in the canal wall down group had a dry ear without significant cavity problems. Hearing in these patients was as least as good as hearing in patients with a preserved canal wall. We conclude that a meticulous one-stage canal wall down technique in ears with extensive cholesteatoma results in a high percentage of unproblematic, stable ears with satisfactory function. In contrast, if the posterior canal wall is preserved, recurrent cholestealoma is the rule more than the exception.

Facial palsy in acute otitis media.

During the 17-year period from 1977 to 1994 a total of 23 patients in Copenhagen County were admitted to hospital with facial palsy, developed during acute otitis media. This corresponds to an annual incidence of 2.3 per million inhabitants. In the pre-antibiotic era it was estimated that 0.5% of patients with acute otitis media developed facial palsy. Our figures indicate a decrease of this complication by a factor of 100, to 0.005%. Although fourteen of the patients were children, the risk of an acute otitis media being complicated by facial palsy seems to be highest in adults (who have a low incidence of acute otitis media). All the children were < or = 3 years of age and 2/3 of the adults > or = 50 years of age. Complete remission was seen in all patients, except one. The time interval to complete remission was correlated significantly with the degree of the facial palsy on admission, as it was longest in the most severe facial palsies.

First branchial cleft anomaly.

A first branchial cleft anomaly is an unusual clinical condition and the clinical picture is similar to that seen in other much more common diseases. This combination may result in a diagnostic delay and insufficient and dangerous primary surgery, resulting in facial nerve damage. This paper reviews the embryological background of first branchial cleft anomalies, the varying clinical presentation and the surgical treatment, illustrated by three case histories. A revision of the most common classification system is proposed.

Can ear irrigation cause rupture of the normal tympanic membrane?: an experimental study in man.

Rupture of the tympanic membrane (TM) during ear irrigation is a rare but unhappy event. In this study the maximum overpressures obtained in the deep part of the external auditory meatus (EAM) during ear irrigation were measured postmortem in 20 cadavers. The highest pressures were obtained in normal- or wide-dimension EAMs when a metal syringe was used. With this device, the median maximum overpressure was 240 mmHg (range 200-300 mmHg). Experiments with simulation of an obturating wax plug did not increase the maximum overpressure. Compared with the lowest overpressures which can rupture TMs the pressures measured in this study were insufficient to rupture normal TMs but sufficient to rupture atrophic TMs with the lowest tensile strength. This finding may have medicolegal implications.

Modified midfacial degloving. A practical approach to extensive bilateral benign tumours of the nasal cavity and paranasal sinuses.

Midfacial degloving is a well-known technique for entering the nasal and paranasal cavities, the rhinopharynx and the base of the skull. We report our experience with a modification of midfacial degloving, applied to two patients with extensive bilateral benign tumours in the nasal cavities and the paranasal sinuses. No rhinoplastic procedure is necessary in this modification, and the access to the upper part of the nasal cavity is improved.

Epithelial migration in mastoid cavities.

The epithelial migration in 18 dry ears with a cavity after surgery was studied by the ink-dot method and compared with the epithelial migration in 15 normal ears. A qualitatively normal centrifugal migration pattern was observed in all cavity ears. Considerable variation in migration speed was observed within the same cavity ear, thus a comparison with the migration speed in normal ears was impossible. No definite relationship was apparent between migration speed and the self-cleansing ability of the ear, which primarily appeared to be a function of the macroscopic appearance of the cavity (i.e. the presence of pockets or ridges). We conclude that epithelial migration is as important in maintaining the self-cleansing function and non-infected state in cavity ears as it is in normal ears.

Implantation of electromagnetic ossicular replacement device.

Semi-implantable hearing aids consisting of permanent middle ear implanted magnet, either partial ossicular replacement prostheses (PORP's) or total ossicular replacement prostheses (TORP's) driven by an electromagnet placed in the ear canal have been tested on six patients undergoing surgery for chronic otitis. The surgical and audiological problems are described. The audiological results were excellent in all six cases. A functional gain of 40-70 dB can be obtained for entire frequency range of the audiogram.

[Surgical treatment of otosclerosis. Long-term results]. / Kirurgisk behandling af otosklerose. Langtidsresultater.

UNLABELLED: At Glostrup Hospital, Copenhagen, exceptionally few stapedectomies were performed during the period 1979-1985. The audiological results five to eleven years after the operation were investigated in 64 patients. About half of the patients were operated using large fenester technique, the other half using small fenester technique. All patients but two were operated by the same expert surgeon. The initial results showed good stability with an unchanged median hearing gain of 30 dB. Eighty-five percent of the patients had an SRT < or = 35 dB HL in contrast to 89% at the 1-year follow-up (and five percent preoperatively). Eighty-two percent had an air-bone gap < or = 20 dB in contrast to 93% at 1-year follow-up (and 10% preoperatively). None of the patients had spontaneously developed severe sensorineural hearing loss, which was, however present in two patients as a direct result of the operation. In one of the patients it was caused by granuloma formation around the prosthesis, in the other patient it developed after a revision procedure. Both patients were operated using large fenester technique, which in general gave less satisfactory primary hearing improvement and less stable thresholds than small fenester technique. IN CONCLUSION: Even under conditions with few operations per year the overall long term results of stapedectomy are satisfactory when performed by few trained ear surgeons, and in particular if small fenester technique is used. The risk of sensorineural hearing loss is primarily related to the operation.

Experimental pressure induced rupture of the tympanic membrane in man.

The size of the overpressure in the ear canal which causes rupture of the tympanic membrane (TM) in man (rupture pressure, RP) was determined in 90 subjects 7-112 h post mortem in connection with the autopsy. The equipment allowed an overpressure in the ear canal to be applied either gradually or suddenly. In 144 normal TMs it was demonstrated that the tensile strength of the TM increases post mortem. Corrected to the time 0 post mortem, RP of normal TMs ranged 0.5-2.1 kp/cm2, median 1.2 kp/cm2. It was found to be correlated to the age of the patient, i.e. RP decreased with increasing age. No correlation was found between RP and the application speed of the overpressure. Ninety-nine percent of the ruptures were localized to the pars tensa (63% to the anterior part of this structure) and typically had the shape of a minor tear. The RP of 23 TMs with atrophic scars was significantly lower, 0.3-0.8 kp/cm2, and the rupture typically had the shape of a larger defect. The results of this study indicate large intersubject variability of the tensile strength of the human TM. Some individuals are at increased risk of TM rupture at minor overpressures in the ear canal (e.g. during certain watersports, such as diving) which may carry medicolegal implications.

Permanent, skin penetrating, bone-anchored titanium implants. A clinical study of host-reaction in bone and soft tissue.

In 12 patients with a skin penetrating retroauricular titanium-implant (Brånemark) the reaction in bone and soft tissue was studied. Observation time was 6 to 36 months. All implants were "osseointegrated", as assessed by repeated manual test, X-ray examination and 99mTC-scintigraphy. Soft tissue reactions appeared to be slight and clinically insignificant. However, all patients produced crusts around the abutment. When the abutment was removed varying degrees of inflammatory reaction in the skin penetration could be observed in most patients. A theory for the development and cause of the soft tissue reactions is proposed and changes in the operative procedure and the design of the abutment to reduce the host reaction are suggested. It is stressed that the clinical significance of this host reaction is uncertain and above all has to be weighed against the important benefits this implant system offers to a severely handicapped group of patients.

The bone-anchored hearing aid. Osseointegration and audiological effect.

The results of treatment of the first 12 Danish patients with the Brånemark titanium implant system and the bone-anchored hearing aid (BAHA) are reported. All implants were osseointegrated, judged by 99mTC-scintigraphy, X-ray examination and clinical examination. Skin reactions were few, transient and short lasting. The patients experienced the BAHA to be superior to both conventional BC hearing aids and AC hearing aids in practically all respects. Speech discrimination scores in quiet and in noise were similar for the 3 types of hearing aids.