Salvage intratympanic steroid therapy for sudden sensorineural hearing loss: our real-life experience in 32 patients.

OBJECTIVE: To examine the role of salvage intratympanic steroid injections in patients presenting with idiopathic sudden sensorineural hearing loss following a poor response to initial oral steroid treatment. METHODS: A retrospective analysis of patient records over the course of four years was conducted, and pure tone thresholds were reviewed before treatment, after oral steroid therapy and six weeks after intratympanic steroid injection therapy. RESULTS: After oral steroid therapy alone, there was a mean average threshold change of 6.2 dB HL (range, -13.8-33.8 dB). This change was statistically significant for severely affected patients (those with an average presenting threshold of over 71 dB). The mean average threshold improvement following intratympanic steroid injection therapy was 2.9 dB (range, -22.5-61.3 dB); this was not statistically significant. CONCLUSION: Some patients experienced moderate improvement following intratympanic steroid injection therapy; however, no specific subgroup was identified to benefit more from intratympanic steroid injection therapy.

Patulous eustachian tube after percutaneous balloon microcompression for trigeminal neuralgia: case report.

OBJECTIVE: To report a case of patulous eustachian tube which occurred after percutaneous balloon microcompression of the Gasserian ganglion. METHOD: Retrospective case review. RESULTS: A 41-year-old man was referred to our audiovestibular medicine department following episodes of autophony. These symptoms appeared two weeks after percutaneous balloon microcompression performed to treat severe trigeminal neuralgia secondary to multiple sclerosis. A diagnosis of patulous eustachian tube was indicated by clinical examination and tympanometry. The symptoms were present for less than six months and improved without any specific treatment. CONCLUSION: Percutaneous balloon microcompression is a procedure used for refractory trigeminal neuralgia that can cause transient sensory and motor deficits of any of the trigeminal nerve branches. It is proposed that injury to the mandibular division in this case caused temporary tensor veli palatini dysfunction with consequent patulous eustachian tube.

The Picture Archiving and Communication System: a useful tool in a case of upper oesophageal foreign body.

We present a case of an oesophageal foreign body (approximately 2x2 cm) which was not seen on the initial lateral soft tissue neck X-ray but was detected following manipulation of the X-ray using the Picture Archiving and Communication System of X-ray viewing. This system gives the user much greater flexibility, including a choice of magnification and contrast.

Potential ototoxicity from triamcinolone, neomycin, gramicidin and nystatin (Tri-Adcortyl) cream.

Although rare, ototoxicity from the use of aminoglycoside drops is well recognized. Ototoxicity has not been described with the use of combination aminoglycoside-steroid-antifungal creams or ointments. We present the case of a 60-year-old man with a perforated tympanic membrane who suffered a total hearing loss after the instillation of cream containing triamcinolone, neomycin, gramicidin and nystatin (Tri-Adcortyl cream) into his ear canal. On balance, we believe that a number of potentially ototoxic constituents in this cream were responsible. Other possible causes of sensorineural hearing loss and the possible mechanisms of ototoxicity of this cream are discussed. The reasons why such creams may be particularly ototoxic, compared with drops, are also considered. The authors caution against the use of such creams or ointments in the ear if there is any suspicion of a tympanic membrane perforation.

Can the Sino-nasal Outcome Test (SNOT-22) be used as a reliable outcome measure for successful septal surgery?

Septoplasty and submucous resection are common procedures in the UK. This study looks prospectively at 40 patients undergoing surgery at two hospitals. A pre- and postoperative assessment (3 months) was made using the Sino-nasal Outcome Test. This test was originally designed for rhinosinusitis but our study suggests that it is a useful tool in nasal septal surgery, in that it combines both nasal specific and general health questions, which can be analysed individually or together. Improvements in nasal obstruction (75%), facial pain (33%) and catarrh (10%) were noted.

The prevalence of latex allergy in patients with rhinitis.

Natural rubber latex hypersensitivity to the constituent proteins of natural rubber latex is now an international health problem. This study investigates the prevalence of latex allergy in patients presenting with rhinitis. Fifty-nine consecutive patients, who presented to a general Otolaryngology out-patient clinic with symptoms suggestive of rhinitis, completed a questionnaire and underwent skin prick testing. Three out of 59 (5.1 per cent) tested positive to latex. The overall positive rate (all standard aeroallergens) was 45.8 per cent. Our data supports the hypothesis that the prevalence of latex allergy in patients with rhinitis is higher than the general population and that rhinitis may be a presenting symptom.

Integrated care pathways for vascular surgery: an analysis of the first 18 months.

OBJECTIVES: A review of the use of previously described integrated care pathways (ICPs) established for three elective vascular surgical procedures. DESIGN: A retrospective analysis of information gathered prospectively over an initial 18 month period of use of vascular surgical ICPs. SUBJECT: Patients admitted to a single vascular unit for "open" repair of abdominal aortic aneurysm (AAA), carotid endarterectomy, or femoropopliteal bypass grafting. METHODS: An analysis of variance data, length of stay, and costings after the use of ICPs, compared with previous clinical practice. RESULTS: Variance data were gathered for each of the three procedures. Variances of medication prescribing and delays in discharge were common to all procedures. In particular: (i) gastrointestinal complications were more specific to AAA repair and (ii) wound drains were removed a day later than originally proposed after femoropopliteal bypass. Overall, improved efficiency due to use of ICPs reduced the length of stay for all procedures, which was reflected in a potential cost saving of some 25%. CONCLUSION: There are clear benefits to the use of ICPs, resulting in more structured, efficient, and cost effective patient care. Recommended changes to current practice based on variance analysis will require continued audit to sustain this "evidence based" approach.

A rare case of dysphagia: hypopharyngeal amyloidosis masquerading as a post-cricoid tumour.

Amyloidoses are a group of disorders in which deposition of abnormal amounts of protein complexes (amyloid) occurs in a variety of tissues. The upper aerodigestive tract may be affected, particularly the larynx, but hypopharyngeal involvement is rarely reported. We present a unique case of amyloidosis of the post-cricoid region causing dysphagia. This case report highlights the need for otolaryngologists to consider the possibility of submucosal amyloid deposition, in the absence of mucosal lesions, in patients who present with dysphagia secondary to an obstructive lesion of the post cricoid region.

Co-ordination of the expression of the protein tyrosine kinase p56(lck) with the pre-T cell receptor during thymocyte development.

The protein tyrosine kinase p56(lck) is essential for the regulation of early thymocyte development by transducing pre-T cell receptor (pre-TCR) mediated-signals. Here we have investigated the developmental timing of expression of p56(lck) in the thymus. We show that p56(lck) transcripts are detectable in each CD4(-)CD8(-) double-negative (DN) thymocyte subset defined by CD25 and CD44. The steady-state level of p56(lck) mRNA with these four DN subsets is similar, varying by less than 2-fold. However, p56(lck) protein levels are undetectable in DN subsets 1 and 2, but are at least 20-fold up-regulated between DN subsets 2 and 3. Analysis of independent transgenic mouse lines in which the proximal p56(lck) promoter was used to drive expression of a green fluorescent protein (GFP) reporter gene revealed a lack of correlation between GFP mRNA expression and transgene copy number and variable expression of GFP protein in different lines. Taken together these results show that the expression of the p56(lck) gene is developmentally regulated at the post-transcriptional level at the precise developmental stage at which its upstream receptor complex, the pre-TCR, is expressed. These results also have implications for the interpretation of the phenotype of transgenic mice which utilize the p56(lck) proximal promoter.

Integrated care pathways for vascular surgery.

OBJECTIVES: a trial of the use of integrated care pathways (ICPs) for elective vascular surgical procedures. DESIGN: a 12-month prospective study, following a multi-disciplinary group construction of current "best practice" ICPs, with changes in practice only occurring following careful audit of results. MATERIALS: patients admitted to a single vascular unit for "open" repair of abdominal aortic aneurysm, carotid endarterectomy or femoropopliteal bypass grafting. METHODS: patients followed ICPs on a daily basis with signatures required to confirm that action had been taken and careful recording of variances from the ICPs. Audit of variance data allowed changes in the ICPs and, hence, provision of the best possible nursing and clinical practice. RESULTS: ICPs were well received by patients and staff. They improved communication, promoted an appreciation of each health group's role in patient care, increased nursing autonomy, reduced calls to junior medical staff, improved patient education and confidence and caused a marked reduction in hospital "length of stay". CONCLUSIONS: ICPs have clear benefits. This study realises that benefits might be maximal for high throughput, high-cost procedures. Successful use of ICPs depends upon "clinical champions" and effective project management. Sufficient resource and training are essential.

Community-based disaster management during the 1997 Red River Flood in Canada.

This paper examines the relationship between community preparedness and response to natural disaster and their level and pattern of community development. This is done by investigating preparation and response to the 1997 Red River Flood by three rural communities in Manitoba, Canada. The communities were selected because of their different ethnic mix and associated level and pattern of community development. The hypothesis was supported that the level and pattern of community development affect community capacity to respond to flooding. Communities characterised by higher levels of physical, human and social capital were better prepared and more effective responders to the flood. However, where the pattern of community development was characterised by high levels of social capital, decision-making processes were complicated.

Vascular surgical society of great britain and ireland: integrated care pathways for vascular surgery

BACKGROUND: Integrated care pathways (ICPs) represent a multidisciplinary approach to clinical patient care. METHODS: A 1-year prospective trial of the use of ICPs for elective vascular surgical procedures was undertaken. A multidisciplinary group constructed ICPs for patients admitted for open repair of abdominal aortic aneurysm, carotid endarterectomy or femoropopliteal bypass grafting. Patient management followed ICPs on a daily basis with signatures required to confirm that each action had been taken. Variances from the ICPs were carefully recorded. Audit of variance data allowed subsequent revision of the ICPs and hence provision of the best possible nursing and clinical practice. METHODS: A total of 33 patients were entered into the study; 16 had a femoropopliteal bypass graft, eight carotid endarterectomy and nine open repair of an abdominal aortic aneurysm. ICPs were well received by patients and staff. They improved communication, promoted an appreciation of each health group's role in patient care, increased nursing autonomy, reduced calls to junior medical staff, improved patient education and confidence, and caused a marked reduction in length of hospital stay. Overall, patients were discharged 13 per cent earlier after open abdominal aortic aneurysm repair, 22 per cent earlier after carotid endarterectomy and 38 per cent earlier after femoropopliteal bypass grafting. CONCLUSION: ICPs have clear benefits. They improve overall clinical efficiency and enhance clinical governance. Successful use of ICPs depends upon 'clinical champions' and effective project management. Sufficient resources and training are essential.

Ultrasound-guided cutting-needle biopsy of the parotid gland.

We describe the technique of ultrasound-guided 18 gauge (1.2 mm) needle biopsy in 16 patients with parotid gland lesions. This provides material suitable for histological analysis and can be performed quickly and safely under local anaesthesia. Thirteen of the patients had non-diagnostic blind fine-needle aspiration cytology (FNAC) with a 21 gauge (0.8 mm) needle prior to biopsy. Initial ultrasound was found to be superior to clinical examination in 31 per cent of cases. The ultrasound-guided technique provided a diagnostic specimen in 100 per cent of patients and was helpful where FNAC had been inconclusive. There was a diagnostic accuracy of 100 per cent in the patients who underwent subsequent surgery. This method should be considered when FNAC is non-diagnostic and surgical treatment is being considered. It is particularly useful in patients with diffuse enlargement of the gland and does provide a core of material for accurate assessment of tissue architecture. In this series, nine patients avoided unnecessary surgery.

Human leukocyte antigen class I/II alleles and development of human papillomavirus-related cervical neoplasia: results from a case-control study conducted in the United States.

The host immune response to human papillomaviruses (HPVs) is believed to be an important determinant of progression of HPV-associated cervical neoplasia. Human leukocyte antigens (HLAs) are important in the presentation of foreign antigens to the immune system. Previous studies have suggested a possible association between HLA and cervical neoplasia, but the specific alleles found to be associated with disease have varied between studies. To further evaluate this issue, we conducted a nested case-control study within a 24,000-woman cohort study in the United States. A total of 711 women were selected for the study: 141 women diagnosed with high-grade squamous intraepithelial lesions (HSILs) of the cervix; 202 women diagnosed with low-grade SILs (LSILs); 166 women with no history of cervical neoplasia, but evidence of HPV-16 infection; and 202 women with no history of cervical abnormalities and who were HPV negative during follow-up as part of our cohort. Cervicovaginal lavage samples collected from participants were used for HPV testing by L1 consensus primer PCR and the Hybrid Capture tube test methods. DNA extracted from these same lavage samples were used for PCR-based HLA genotyping. Our results suggest a positive association between HLA B7 and HLA DQB1*0302 and disease. A negative association with disease was observed for HLA DRB1*1501-DQB1*0602 and DRB1*13. Associations were strongest when analyses were restricted to HPV-16-positive cases as follows. Compared with women who were cytologically normal and HPV negative, HLA B7 was associated with a 1.5-fold increased risk of HPV/LSIL [95% confidence interval (CI) = 0.95-2.5] and a 2.5-fold increased risk of HSIL (95% CI = 1.2-5.1). HLA DQB1*0302 was associated with a 1.5-fold increased risk of HPV/LSIL (95% CI = 0.94-2.4) and a 1.7-fold increased risk of HSIL (95% CI = 0.84-3.5). HLA DRB1*1501-DQB1*0602 was associated with a decreased risk of HSIL [relative risk (RR) = 0.21; 95% CI = 0.07-0.62]. HLA DRB1*13 was associated with a decreased risk of HPV/LSIL (RR = 0.78; 95% CI = 0.51-1.2) and HSIL (RR = 0.63; 95% CI = 0.30-1.3). Individuals who were either homozygous for DQB1*0302 or carriers of both B7 and DQB1*0302 were found to be at highest risk of disease (RR = 4.5, 95% CI = 1.5-14 for HPV/LSIL; and RR = 9.0, 95% CI = 2.4-34 for HSIL). No synergistic effect was observed for the alleles found to be associated with reduced risk of cervical neoplasia. Our findings support previous studies that have found HLA B7 and DQB1*0302 to be positively associated with cervical neoplasia and are consistent with those that have suggested that DRB1*13 is negatively associated with disease, but do not confirm previous assertions that DRB1*1501-DQB1*0602 increases the risk of cervical disease.

Distinct roles of the interleukin-7 receptor alpha chain in fetal and adult thymocyte development revealed by analysis of interleukin-7 receptor alpha-deficient mice.

Mouse mutants lacking expression of the IL-7 receptor (IL-7R) alpha chain are defective in thymopoiesis. The adult thymus has multiple defects, including reduced cell numbers and proportions of the more mature thymocyte subsets, a complete absence of CD25+ cells and a reduced level of RAG1 and RAG2 expression. We show here that, in contrast to the profound developmental arrest observed in the adult thymus, fetal thymocytes from IL-7Ralpha-/- mice have normal proportions of all of the major thymocyte subpopulations, including CD25+ thymocytes and the most mature single-positive subsets. Moreover, normal levels of RAG1 and RAG2 were observed. Total thymocyte numbers, however, remained reduced. These data suggest that the IL-7Ralpha chain is a key regulator of both survival and proliferation during thymocyte development but that it is not essential for the production of T cells during fetal thymopoiesis.

Comparison of the hybrid capture tube test and PCR for detection of human papillomavirus DNA in cervical specimens.

The strong association of human papillomavirus (HPV) and cervical cancer makes it important to study HPV detection methods that may play a role in cervical cancer screening. We compared two DNA methods that are commonly used for HPV research in the United States: the MY09/MY11 L1 consensus primer PCR-based test and the first-generation Hybrid Capture tube method (HCT). Laboratory assays by each method were performed with 596 cervicovaginal specimens collected from participants in a large cohort study conducted in Portland, Oreg. Included were 499 specimens from women whose cytology was normal and 97 specimens from women with squamous intraepithelial lesions (SILs). The overall HPV DNA positivity for known types was 22.5% by PCR compared to 13.6% by HCT. When the analysis was restricted to the 14 HPV types detectable by both methods, the sensitivity of HCT, with PCR used as the standard for HPV status, was higher for specimens from women with concurrent SILs (81.0%) than for specimens from women with normal cytology (46.7%). Among specimens testing positive by both methods, 97.2% of the time the two methods agreed on whether specimens were positive for cancer-associated HPV types. Both of these HPV test methods provide information that supplements the information provided by the Pap smear. The PCR method has higher analytic sensitivity than HCT in detecting HPV, but HCT may be helpful in identifying women with concurrent SILs.

A transgenic T cell receptor restores thymocyte differentiation in interleukin-7 receptor alpha chain-deficient mice.

Interleukin-7 (IL-7) receptor alpha chain-deficient (IL-7R alpha-/-) mice have severely depleted lymphocyte populations and thymocyte development is arrested at the double-negative (DN) stage. We show that thymocyte development in these mice can be reconstituted by the introduction of a transgenic T cell receptor (TCR), implying that one function of the IL-7R alpha chain is to initiate TCR gene rearrangement. Expression of the recombinase-activating genes RAG1 and RAG2 was greatly reduced in the IL-7R alpha-/- thymuses, and in DN thymocytes from the TCR transgenic IL-7R alpha-/- mice, but was restored in double-positive thymocytes from the TCR transgenic IL-7R alpha-/- mice. These data suggest that the IL-7R alpha chain controls RAG expression and initiation of TCR beta chain VDJ rearrangement in DN cells. In contrast, once cells have progressed beyond the DN stage of development the IL-7R alpha chain becomes no longer essential for RAG expression.