The effect of inflammation on spiral ganglion cell density measurements in the cat cochlea.

The quantitative analysis of spiral ganglion cells is important in assessing the biological safety of cochlear implants. Quantitative analysis of ganglion cells in a histological section is conventionally expressed as cell density, the number of ganglion cells within Rosenthal's canal being divided by its area. The area of Rosenthal's canal conventionally excludes the area of blood vessels within it. Previous work has shown that the blood vessel area within Rosenthal's canal increases with cochlear inflammation. Consequently, excluding this area may result in an underestimate of ganglion cell loss and a tested implant parameter may be wrongly passed as safe. This study investigates whether the increase in blood vessel area with grade of inflammation has an effect on ganglion cell density measurements made by excluding blood vessel area. Eighteen implanted and stimulated cat cochleae were serially sectioned. Using computer image analysis we measured ganglion cell number, the area of Rosenthal's canal and its blood vessels. A 'blind' histologist graded the inflammation in each cochlea. Ganglion cell densities calculated by excluding and including blood vessel area showed no divergence with increasing inflammation (B = -163, P = 0.001 and B = -160, P = 0.001). The increase in the blood vessel area with inflammation has no effect on cell density measurements made by excluding that area.

Adult tonsillectomy: what proportion would accept same day discharge?

Day case surgery is increasing to improve health care cost efficiency. The economic benefits of day surgery depend on how many patients accept same day discharge. This study aims to investigate what proportion of adults undergoing tonsillectomy would accept same day discharge and reasons for refusal. Fifty consecutive adults undergoing in-patient tonsillectomy who satisfied criteria for day surgery were prospectively studied. All patients had the same day case; anaesthetic, tonsillectomy technique, analgesia and antiemetic. Eight hours after surgery patients were given discharge information and asked whether they would accept discharge. Those patients who refused discharge were asked to specify why. Additional morphine requirements were noted. Fifty-two percent of patients would accept same day discharge. Reasons for refusal were; pain 46%, nausea 33%, dizziness 13% and pain and nausea 8%. Those refusing discharge were three times more likely to have received additional morphine. These results compare unfavourably with oversees studies and this may be due to sampling bias. Further studies are required.

On which day is pain worst following adult tonsillectomy?

Anecdotal evidence from several ENT departments suggests that pain following tonsillectomy is worst on the second and/or third days after surgery. This study tests this hypothesis. A pilot study with 19 subjects suggested this theory might well be true. A fuller study was then carried out on 91 subjects with standardised surgical and anaesthetic techniques, and standardised analgesia for five days postoperatively. Pain on the second and third postoperative days was compared with that eight hours after the operation and on the first, fourth and fifth postoperative days. No statistically significant difference was found. There is increasing pressure for early discharge from hospital after surgery. If pain following tonsillectomy is not going to become worse at home, this will tend to make early discharge more acceptable to patients.

The effect of inflammation on blood vessel area in Rosenthal's canal in the cat cochlea.

The quantitative analysis of spiral ganglion cells is important. It is conventionally expressed as a cell density, the number of cells within Rosenthal's canal divided by its area. The area of Rosenthal's canal conventionally excludes the areas of blood vessels within it. If blood vessels proliferate in an inflammatory response then excluding their area may result in an under-estimate of cell loss. This study investigates whether blood vessel area increases with inflammation. Eighteen implanted and stimulated cat cochleas were studied. Using computer aided analysis techniques we measured the areas of Rosenthal's canals and its blood vessels. A histologist quantitatively graded the inflammation in each cochlea. Blood vessel area increased with the grade of inflammation. Multiple regression analysis showed this effect was significant (P < 0.01). This increase in blood vessel area may have an effect on density measurements made by excluding that area, leading to an under-estimate of ganglion cell loss.

Day case tonsillectomy in adults: how many are suitable?

Day case surgery is increasing to improve health care cost efficiency. The economic benefits of day surgery depend on how many patients are suitable. Adult tonsillectomy is a common operation. This study aims to define what proportion of adults undergoing tonsillectomy are suitable for day case surgery. One hundred consecutive adults undergoing elective in-patient tonsillectomy were studied prospectively. Patients were questioned, examined and investigated for any general medical or social contra-indications to day surgery as specified by the Royal College of Surgeons of England. They were also questioned about specific contra-indications to day case tonsillectomy, including NSAID contra-indications and tonsillectomy indicated for biopsy, quinsy or with another procedure. Seventy-six per cent patients satisfied the requirements. The most common reasons for failure were social. A high proportion of adults are suitable for day case tonsillectomy and therefore significant economic benefits are possible. However, prior to such surgery further work on operation suitability is required.

Rosenthal and the spiral canal of the modiolus.

Rosenthal's spiral canal of the modiolus of the cochlea is mentioned numerous times in the literature, but there are few references to both the man who discovered it and the article in which it was first described. Standard medical dictionaries attribute its discovery to the wrong Rosenthal. The correct Rosenthal is identified and his original description is referred to. The possibility of an even earlier description of the canal is discussed. This description links the origins of the electric telegraph and multiple-channel cochlear prostheses.

Would day-case adult tonsillectomy be safe?

Day-case surgery is increasing to improve health care efficiency. Adult tonsillectomy is performed on an inpatient basis in the UK because of safety concerns regarding primary haemorrhage. This study aims to investigate the likely safety of day-case tonsillectomy in adults, by defining the incidence and timing of primary haemorrhage and therefore to establish a safe time period for same-day discharge. Prospectively recorded data on 2,157 adult tonsillectomies over a five-year period were reviewed. Serious primary haemorrhage was uncommon (0.8 per cent). The 95 per cent reference range of time to primary haemorrhage was within 0 to 6.8 hours of surgery and the 95 per cent confidence interval (C.I.) of its upper limit was 5.2 to 8.4 hours. The results compare favourably with the UK inpatient and US adult day-case literature. We conclude that day-case tonsillectomy would probably be safe in adults if the patients are discharged after 8.4 hours.

Should prophylactic antibiotics be used in the management of cerebrospinal fluid rhinorrhoea following endoscopic sinus surgery? A review of the literature.

This review article investigates whether prophylactic antibiotics should be used in the management of cerebrospinal fluid rhinorrhoea following endoscopic sinus surgery. A medline database was used to retrieve all English articles from 1970 to the present, cross-indexing cerebrospinal rhinorrhoea, antibiotics and endoscopic sinus surgery. All relevant articles retrieved were reviewed together with their bibliographies. The use of prophylactic antibiotics is neither recommended nor condemned by evidence of efficacy. However, their use is cautioned against by evidence of a subsequent change in nasopharyngeal flora to potentially more invasive organisms. The review concludes that, at present, it is usually justifiable to withhold prophylactic antibiotics and to observe for the symptoms and signs of meningitis instituting antibiotic therapy when this complication develops.

The effect of fibrin sealant haemostasis on post-operative pain in tonsillectomy.

Pain following tonsillectomy is an important problem. It is caused by the surgical trauma of excision and haemostasis. Numerous surgical and pharmacological solutions have been tried, with disappointing results. Fibrin sealant is a widely used atraumatic haemostatic agent. This study aims to determine whether tonsillectomy with fibrin sealant haemostasis results in less post-operative pain than that with the conventional technique of diathermy. Fifty consecutive adult patients undergoing tonsillectomy were prospectively studied. They were randomized to receive either fibrin sealant or diathermy haemostasis. Other pain variables were controlled. Pain was measured by a visual linear analogue scale and inter-incisor distance on both the day of operation and the first post-operative day. The patients and pain measurer were blind to the randomization. The results showed that tonsillectomy with fibrin sealant haemostasis was significantly (P < 0.05) less painful than that with diathermy on both days studied and by both methods of pain measurement.

Laryngotracheal stenosis: a serious complication of percutaneous tracheostomy.

Tracheostomy in patients requiring prolonged artificial ventilation in intensive care is increasingly being performed by a percutaneous dilatational technique, in preference to the standard surgical method. Since its introduction numerous series have reported favourably on its general safety in the short-term, but there have been few reports of longer term follow-up of patients. We present four cases of laryngotracheal stenosis, a previously unreported complication associated with the technique, and discuss the relevance of these to the future practice of percutaneous tracheostomy.

Darier's disease of the external ear.

Darier's disease is a hereditary dermatological condition characterized by crusted papules distributed over the seborrhoeic areas of the trunk and head. A case of Darier's disease presenting to the Otolaryngology department because of severe involvement of the pinna is reported. The typical histological appearances are described and treatment discussed.

Metabolic stridor: bilateral vocal cord abductor paralysis secondary to hypokalaemia?

A previously unreported association between bilateral abductor paralysis and hypokalaemia is reported in a patient presenting with stridor. Both the stridor and the bilateral abductor paralysis gradually resolved as the serum potassium was corrected. A casual link is suggested though the mechanism is unclear.