Use of potassium titanyl phosphate (KTP) laser Dermastat in the treatment of recurrent anterior epistaxis - a new technique.

OBJECTIVE: To evaluate the short- to medium-term effectiveness of potassium titanyl phosphate (KTP) laser Dermastat in patients with recurrent anterior epistaxis. METHOD: Fifty-eight patients presenting with recurrent anterior epistaxis were treated using potassium titanyl phosphate laser Dermastat. Those with recurrent epistaxis arising from prominent vessels in Little's area, and/or those for whom treatment with silver nitrate cautery failed, were included. The main outcome measure was resolution of epistaxis at two months. RESULTS: Fifty-eight patients were treated; 27 were under 18 years old. Thirty patients had prominent vessels. Thirty-one patients had undergone previous cautery treatment. Thirty-eight patients had treatment to the left side, 19 to the right and 1 to both. At two months, 74 per cent reported resolution of epistaxis with no complications. This increased to 78 per cent at further follow up. CONCLUSION: Our technique is a successful, safe treatment for recurrent anterior epistaxis in an otherwise treatment-resistant group. A single procedure is effective. The handpiece and tip are reusable and sterilisable, resulting in cost-effectiveness.

How safe is diathermy in patients with cochlear implants?

INTRODUCTION: Cochlear implants are surgically inserted electrical devices that enable severely or profoundly deaf individuals to interpret sounds from their environment and communicate more effectively. As a result of their electrical nature, they are susceptible to electromagnetic interference and can be damaged by excessive electrical energy. Surgical diathermy is one source of such potentially damaging energy. The British Cochlear Implant Group guidelines advise that monopolar diathermy should not be used in the head and neck region in patients with cochlear implants and that bipolar diathermy should not be used within 2cm of the implant (http://www.bcig.org.uk/site/public/current/safety.htm). METHODS: A questionnaire was provided to 36 surgeons working in different specialties in the head and neck region, inquiring as to their knowledge of the safety considerations when using diathermy in cochlear implant patients. Thirty-five surgeons provided responses. RESULTS: Overall, 77% of the respondents were unaware of the existence of published guidelines. Even when given an option to seek advice, 11% erroneously felt it was safe to use monopolar diathermy above the clavicles with a cochlear implant in situ and 49% felt that there was no restriction on the use of bipolar diathermy. CONCLUSIONS: There is a significant deficit in the knowledge of safe operating practice in the rapidly expanding population of patients with cochlear implants which threatens patient safety. Through this publication we aim to increase awareness of these guidelines among members of the surgical community and this paper is intended to act as a point of reference to link through to the published safety guidelines.

Guillotine versus dissection tonsillectomy: randomised, controlled trial.

OBJECTIVE: This trial aimed to compare the guillotine technique of tonsillectomy with 'cold steel' dissection, the current 'gold standard'. DESIGN: A single centre, randomised, controlled trial. METHODS: One hundred children aged 3 to 11 years who were listed for bilateral tonsillectomy were recruited. Patients had one tonsil removed by each technique, and were blinded to the side. The operative time, intra-operative blood loss, haemostasis requirement and post-operative pain scores were recorded and compared. RESULTS: Operative time and intra-operative blood loss were both significantly less for the guillotine technique (p < 0.001) and there was a significantly reduced haemostasis requirement (p < 0.001). Pain was also less on the guillotine side (p < 0.001). There were no tonsillar remnants or palatal trauma for either technique. There was no significant difference between techniques in the frequency of secondary haemorrhage. CONCLUSION: This study provides level Ib evidence that guillotine tonsillectomy in children with mobile tonsils is an effective and time-efficient procedure which produces less intra-operative blood loss and post-operative pain than cold steel dissection.

Laryngeal debridement: an alternative treatment for a laryngopyocele presenting with severe airway obstruction.

The laryngocele is an abnormal saccular dilatation of the ventricle of Morgagni, which maintains its communication with the laryngeal vestibule. Three types of laryngoceles have been described: internal, external, and combined or mixed in relation to the position of the sac with respect to the thyrohyoid membrane. If the laryngocele becomes obstructed and infected it leads to the so-called laryngopyocele which, although a rare disease (8% of laryngoceles), can become an emergency causing severe airway obstruction needing urgent management, even tracheostomy. An alternative method is presented of emergency management of an internal laryngopyocele causing severe airway obstruction using a laryngeal microdebrider and avoiding tracheostomy.

Cutaneous sensory deficit following post-auricular incision.

INTRODUCTION: Post-auricular incisions are performed for a range of otological procedures. Anecdotally, many patients suffer some numbness of the pinna or post-auricular skin post-operatively, but for most this appears to reduce with time. This study aimed to investigate this phenomenon. METHODS: A single centre, questionnaire-based study was undertaken, assessing the presence of numbness beyond eight months post-surgery, its location, how it changed, and its impact on the patient. Patients whose numbness had resolved provided details of any temporary deficit. Data were acquired for 35 primary and 16 revision procedures. RESULTS AND CONCLUSION: Sixty-nine per cent of patients undergoing primary surgery experienced post-operative numbness. Twenty-six per cent had continued numbness after at least eight months' recovery, but only 3 per cent were constantly aware of the deficit. Of those with an ongoing deficit, 78 per cent felt there had been a reduction in the severity, and 67 per cent in the area size, over time. Recovery appeared to be slightly worse in revision cases.

Thermal properties of operative endoscopes used in otorhinolaryngology.

OBJECTIVES: To measure the thermal properties of operative endoscopes used in otorhinolaryngological practice. METHODS: A series of endoscopes of varying diameters and angulations were attached to a light source and temperature measurements taken of their shaft and tip; a measurement was also taken 5 mm in front of the endoscope tip. RESULTS: Temperature changes took place rapidly. The amount of heat produced by the endoscopes was maximal at the tip, with larger diameter endoscopes attaining a higher temperature. Temperatures on the shaft and in front of the tip reached relatively constant temperatures independent of the type of endoscope. The maximum temperature achieved was 104.6 degrees C for the 4 mm, 0 degrees endoscope. Cooling occurred rapidly after the light source was switched off. CONCLUSION: The heat produced by some endoscopes is sufficiently great to cause thermal injury to tissues. Awareness of the temperatures produced by these endoscopes should prompt clinicians to actively cool their endoscopes during a procedure, before any thermal injury is caused.

Peripheral mediation of effects of clenbuterol on locomotor and investigatory behavior in rats.

Clenbuterol is one of the few beta adrenergic agonists that readily passes the blood-brain barrier. Hence, the behavioral effects in rats of systemic administrations of clenbuterol have been used as a reflection of the activation of central beta receptors. The present experiments were designed to test the hypothesis that the reduction in locomotor activity induced by clenbuterol is mediated by central rather than peripheral beta receptors. First, dose-dependent reductions in ambulation, holepoking, and rearing were established following intraperitoneal injections of 0.004 to 1.0 mg/kg clenbuterol. These effects were then found to be similar to those of 0.4 mg/kg isoproterenol, a mixed beta adrenergic agonist that does not enter the brain after systemic administration. The behaviorally suppressive effects of either 0.4 mg/kg isoproterenol or 0.05 mg/kg clenbuterol were found to be completely antagonized by pretreatment with a 10.0 mg/kg dose of nadolol, a beta antagonist that does not penetrate the brain when administered systemically. Nadolol itself had no significant effects on behavior. These results indicate that these behavioral effects of systemic administrations of clenbuterol are mediated by the activation of peripheral rather than central beta adrenergic receptors.

Structural alteration of hair cells in the contralateral ear resulting from extracochlear electrical stimulation.

Chronic electrical stimulation of the auditory nerve in patients with profound sensori-neural deafness is becoming increasingly routine. Therefore, it is important to understand more about the long-term consequences of this procedure. Hitherto, structural studies in animals after electrocochlear stimulation have concentrated on the stimulated cochlea. Here we have examined the effects of unilateral extracochlear electrical stimulation on the spiral organ of both the ipsilateral and contralateral ears of the mature guinea pig, and have found alterations in the structure of the outer hair cells and their efferent nerve terminals in the contralateral as well as the ipsilateral cochlea. This is the first evidence for a structural influence of efferent activity on the cochlea. Although the importance of the efferent system, consisting of the crossed and uncrossed olivo-cochlear bundles, is well established in providing central control of the sensory pathways, its exact role in hearing is incompletely understood. However, it is known that the outer hair cells and their efferent innervation are important in their contribution to inner hair cell responses and in modulating the micromechanics of the whole cochlea. These efferent functions now appear to be related to an important part of cochlear morphology, and are also relevant to our understanding of cochlear neurobiology, normal development and the management of hearing disability in both adult and child.