Tympanostomy tubes and otic suspensions: do they reach the middle ear space?

The treatment of patients with tympanostomy tubes (TTs) and otorrhea with medicated otic suspensions is well known, but confirmation of penetration into the middle ear is difficult. To address this question, we created an in vitro model of the human head and ear and then tested it with 5 different types of liquid exposure: tap water, soapy water, polymyxin B sulfate (Cortisporin), tobramycin and dexamethasone (TobraDex), and ciprofloxacin (Cipro) suspensions. A positive test result corresponded to liquids entering the middle ear through the TT. No positive test result was elicited with tap water (0/20), but soapy water did enter the middle ear (10/40) and was statistically significant (P = 0.0112). Without the use of slight tragal pressure, Cortisporin, TobraDex, and Cipro drops did not consistently pass through the TT (0/20, 1/25, 1/25). By placing the drops with the addition of tragal pressure, a statistically significant difference was obtained for each solution (20/20, 20/20, and 20/20, respectively [P < 0.0001]). We conclude that with a clean external auditory canal, patent TT, and no middle ear fluid, medicated otic suspensions enter the middle ear only when combined with slight tragal pressure.

Tympanostomy tubes and water exposure: a practical model.

OBJECTIVE: To determine whether water exposure causes middle ear contamination in patients with collar button tympanostomy tubes (TTs). METHOD AND DESIGN: An in vitro model of a human head that contained an auricle, external auditory canal, tympanic membrane with TT, middle ear, eustachian tube, and mastoid cavity was developed. Two electrodes connected to an external ohmmeter resided in the middle ear to detect water entry. The model was tested with 4 types of water exposure: showering, bathing, hair rinsing, and swimming. Statistical analysis was performed by the Fisher exact test. MAIN OUTCOME MEASURES: A positive test result corresponded to water entering the middle ear via the TT, confirmed by a resistance reading of zero on the ohmmeter. A negative test result indicated no change in the initial high resistance reading. RESULTS: No positive test results were obtained for showering (0 of 60 tests), hair rinsing (0 of 60 tests), or head submersion (12.7 cm) in clean tap water (0 of 60 tests). Ten positive test results were obtained for head submersion in soapy water (10 of 97 tests), which was statistically different from clean water (P< or =.007). Swimming pool depths of 30, 45, 60, and 75 cm elicited positive test results in 2 of 16, 3 of 18, 2 of 20, and 11 of 20 tests, respectively. A higher incidence of water entry into the middle ear occurred at depths of more than 60 cm (P< or =.001). No statistical difference between depths of 60 cm or less occurred (P= .88). CONCLUSIONS: Showering, hair rinsing, and head submersion in clean tap water do not promote water entry into the middle ear. Submersion in soapy water increases the probability of water contamination. Pool water infrequently enters the middle ear with head submersion, but the incidence increases with deeper swimming (>60 cm). These data provide further evidence that many water precautions frequently advised in patients with TTs are unnecessary.

Whole salivary flow rates following submandibular gland resection.

BACKGROUND: Patients with head and neck neoplasms receive therapeutic neck dissections which may include the submandibular gland unilaterally or bilaterally. The clinical consequences of salivary gland resection could be reduced salivary output, altered cariogenic microflora, and increased incidence of dental caries. METHODS: This investigation evaluated whole salivary flow rates of patients who had received unilateral (n = 29) or bilateral (n = 8) submandibular gland resections and compared them with noncancer control subjects (n = 29). RESULTS: Unstimulated and stimulated (paraffin) flow rates were significantly lower in both resection groups compared with those of the noncancer group, ranging from p < .002 to p < .02. Although flow rates were lower in the bilateral group than in the unilateral group, the differences between these two groups were statistically significant (p < .02) only for stimulated saliva. Xerostomia was reported by one third of the resection subjects. CONCLUSION: In view of the significantly lower flow rates observed in the resection groups (especially for unstimulated saliva), topical fluoride therapy should be considered for those patients whose past caries activity would indicate an increased caries risk associated with partial loss of salivary function.

Antibody response to measles-mumps-rubella vaccine of children with mild illness at the time of vaccination.

OBJECTIVE: To examine the response to measles-mumps-rubella (MMR) vaccine among children with and without mild illness. DESIGN: Prospective cohort. PARTICIPANTS: A total of 386 children aged 15 to 23 months. MAIN OUTCOME MEASURES: Seroconversion rates to measles, mumps, and rubella in ill and well children. SETTING: Six public health immunization clinics in two counties in the greater metropolitan Atlanta, Ga, area from February 1992 to April 1993. RESULTS: Acute upper respiratory tract infection, otitis media, and diarrhea were observed in 128 (33%), 41 (11%), and 13 (3%) of the children (groups are not mutually exclusive); 157 children had one of these mild illnesses and 229 were well. Overall seroconversion rates were 98% for measles, 83% for mumps, and 98% for rubella antigens. Measles seroconversion rates for ill children compared with well children, respectively, were as follows: upper respiratory tract infection, 99% vs 97%; mild fever, 98% vs 97%; otitis media, 98% vs 98%; diarrhea, 100% vs 98%; and any mild illness, 99% vs 97%. Estimates of the magnitude of antibody response to measles, mumps, and rubella antigens were the same for children with and without mild illness. There was no association of mild illness with increased rates and severity of adverse events reported in the 2 weeks after vaccination. CONCLUSIONS: Vaccinating children who present with mild illnesses with MMR vaccine is a safe and efficacious practice. These results support recommendations of the Advisory Committee on Immunization Practices and the American Academy of Pediatrics.

Molecular epidemiology of measles virus: identification of pathways of transmission and implications for measles elimination.

The nucleotide sequences of either the hemagglutinin or nucleoprotein genes from wild type measles viruses isolated in the United States between 1989 and 1992 differed by < 0.5%. This suggests that the majority of viruses associated with resurgence of measles in the United States belonged to a single indigenous genotype. In contrast, wild type viruses isolated from sporadic outbreaks of measles in the United States during 1994 were genetically heterogeneous. These viruses were more closely related to wild type viruses previously circulating in Europe, Africa, or Japan and were epidemiologically linked to importations or no known source. In addition to demonstrating the utility of genetic analysis in understanding the epidemiology of measles, these data suggest that the transmission of the indigenous virus was interrupted after the 1989-1992 epidemic. Measures to further reduce the incidence of measles in the United States should include efforts to control importation and subsequent spread of measles.

Complete dentures for the obturator patient.

Treatment of the edentulous obturator patient requires the same basic fundamentals as used in the treatment of the complete-denture patient. Problems and considerations unique to the development, delivery, and follow-up of the complete maxillary obturator prosthesis and mandibular denture in the patient with an acquired maxillary defect are discussed. Combining laboratory and clinical research in maxillofacial prosthodontics and plastic and reconstructive surgery continues to improve the rehabilitation of these patients.

Patient appointments during interim obturation: is it cost-effective?

PURPOSE: The purpose of this study was to quantify the number of patient appointments needed during the interim obturator service period in the Department of Dental Oncology at MD Anderson Cancer Center (Houston, TX). MATERIALS AND METHODS: A retrospective study evaluating 100 patient records of patients who underwent maxillectomies between 1989 and 1993. RESULTS: Of the 100 patients analyzed, 42 patients had a definitive prosthesis fabricated within 90 days after surgery. On average, 12 appointments (range, 6-24 appointments) were recorded for each patient during this 90-day global interim obturator period. CONCLUSIONS: The 12 appointments reflect a considerable amount of clinical and laboratory effort and reinforces the national concern of proper reimbursement.

Partial denture framework design for bone-grafted mandibles restored with osseointegrated implants.

Unilateral osseous reconstruction of a dentate mandible after tumor ablation may be restored with implants and a removable partial denture. Often the remaining dentition is in a "straight line" that does not allow cross-arch stabilization of the framework. Framework design incorporating existing unilateral lingual or buccal retention in the natural dentition and unilateral implant attachments affords a stable, retentive definitive prosthesis for this patient population.

Use of nonconductive tubing for nasal stent fabrication.

A new and effective technique for making and delivering a nasal stent that can be used for surgical, interim, and definitive stents is presented. The materials used are easily obtainable and inexpensive.

Maxillofacial restoration after tumor ablation.

Communication between the surgeon and the maxillofacial prosthodontist before, during, and after surgery is the most important aspect to successful prosthetic rehabilitation of the head and neck cancer patient. Surgeons should understand the problems and limitations involved in prosthetic rehabilitation so that the patient is adequately educated during rehabilitation. Osseointegrated implants, although an important advancement in this field, should not take the place of proper defect preparation. The use of implants in the irradiated patient is currently being evaluated by controlled studies. However, if implants are used, then their position and number should be carefully planned in the pretreatment phase. Preparation of the defect by skin grafting and controlling the position of the remaining structures is important to the overall aesthetic and functional result of the prosthesis.

Technique for controlling the thickness of a facial prosthesis when an acrylic resin core is used.

A technique for evaluating the acrylic resin core before processing a silicone facial prosthesis is described. The technique involves the use of either irreversible hydrocolloid impression material or silicone to identify thin areas in the pattern. This simple yet effective procedure ensures adequate thickness and strength of the silicone prosthesis, which in turn decreases the amount of chair and laboratory time needed at the delivery appointment.

Epidemiology of Aeromonas infections in California.

In May 1988, California became the first state to make aeromonas infection a reportable condition, thereby permitting the first population-based study of the epidemiology of infection caused by Aeromonas organisms. Case investigations were carried out on 219 of the 280 patients whose infections were reported during the first year of notification. The overall incidence rate for Aeromonas isolation was 10.6 cases per 1 million population. The gastrointestinal tract was the most commonly reported site from which Aeromonas was isolated (81%), with wounds being the next most common source (9%). Five (2%) of the 219 patients died; all five had serious underlying medical conditions apart from aeromonas infection. No common-source enteric outbreaks were reported. The high rate of gastrointestinal symptoms and isolation of organisms from medically vulnerable patients and the fact that other bacterial enteric pathogens were rarely isolated from symptomatic patients support evidence from previous studies that Aeromonas is an enteric pathogen. The evidence from these case reports in California suggests that aeromonas infections are not an important public health problem and are largely nonpreventable. Thus, public health surveillance is not necessary and mandatory reporting has been discontinued.

Female employee participation in a worksite mammography screening program.

We conducted a survey of 1,184 women 35 years of age or older who were employees of a company in Los Angeles County, California, to determine why some women participated in a worksite mammography screening program whereas others did not. Of the 111 who accepted a mammogram, 90 responded to the survey; of the 1,073 who declined mammography, 620 responded. The women were predominantly white, were well educated, and had health insurance. Of the 111 women who received mammograms, one was diagnosed with carcinoma. Seventy-three percent of the respondents to the survey 40 years of age or older who declined mammograms had already fulfilled American Cancer Society (ACS) guidelines for mammography screening at the time of the program. Women who accepted a mammogram were more likely to have had at least one previous mammogram than were women who had not met ACS guidelines yet who declined screening. We conclude that many female employees who are white, are well educated, and have health insurance may not participate in a worksite mammography screening program because they have been screened elsewhere. Companies providing worksite mammography screening should target education to women who have not met ACS guidelines, especially those who have never had a mammogram.

A flasking technique for microwave processing of silicone prostheses.

Polyvinylchloride plumbing parts provide a readily available source of material to use in making facial prostheses. Inexpensive pipe fittings (end cap attachments and closet flanges) can be combined to provide a durable container for stone molds that can be tightened in a strong curing press. The entire unit can be cured in a microwave oven in 30 minutes.

Extraoral retention of an obturator prosthesis.

In this study, a technique is described by which large obturators can be retained with an acrylic resin head plate. The technique entails attaching the prosthesis to an acrylic resin plate with a 2-mm-diameter wire and then attaching the plate to the patient's forehead with skin tape.

A shade guide for acrylic resin facial prostheses.

The value and success of a well-fitting and anatomically correct prosthesis are compromised if the color does not match the adjoining tissue. Color and color science are reviewed to help develop a simplified acrylic resin shade guide to aid in fabricating acrylic resin facial prostheses. This guide will help the clinician obtain a good intrinsic shade and minimize extrinsic coloration.

Multidisciplinary teamwork in the treatment and rehabilitation of the head and neck cancer patient.

The advantages of multidisciplinary treatment planning of head and neck cancer patients is described. Planning rehabilitation concurrently with curing the malignancy results in the most effective application of treatment modalities coordinated with rehabilitative care. Concentrated multidisciplinary treatment reduces post treatment morbidity by shortening recovery and rehabilitation time.