Percutaneous dilatational tracheostomy versus conventional surgical tracheostomy. A clinical randomised study.

BACKGROUND: As no clinical randomised studies have previously been performed comparing complications with the Ciaglia Percutaneous Dilatational Tracheostomy Introducer Set (PDT) and conventional surgical tracheostomy (TR), we designed a study with the aim of comparing the efficacy and safety of the two techniques. METHODS: Sixty patients selected for elective tracheostomy were randomised for either PDT (30 patients) or TR (30 patients). All patients had general anaesthesia and were ventilated with 100% oxygen. Furthermore, lidocaine with epinephrine 1% (3-5 ml) was used for local analgesia and to minimise bleeding during the procedure. RESULTS: The median time for insertion of the tracheostomy tube was 11.5 min (range 7-24 min) in the PDT group and 15 min (range 5-47 min) in the TR group (P<0.01). Complications during the procedure were cuff puncture of the endotracheal tube in 5 cases in the PDT group. Minor bleeding was encountered in 6 cases in the PDT group as opposed to 24 cases in the TR group (P<0.01), major bleeding in none versus 2 cases, respectively. In 8 cases in the PDT group, increased resistance to insertion of the tracheostomy tube was met by further dilatation. During the post-tracheostomy period, complications occurred with minor bleeding in 2 cases in the PDT group as opposed to 9 cases in the TR group (P<0.05), and major bleeding was encountered in 1 case in each group. Minor infections were encountered in 3 cases in the PDT group as opposed to 11 cases in the TR group (P<0.01). Major infection was encountered in none versus 8 cases, respectively (P<0.01). CONCLUSION: Our results indicate that the percutaneous dilatational tracheostomy technique performed with the Ciaglia Introducer Set is effective, safe and superior to conventional surgical tracheostomy as immediate complications as well as complications with the tracheostomy tube in situ are fewer and of less severity.

[Percutaneous dilatation tracheostomy. A preliminary study]. / Perkutan dilatationstrakeostomi. En proeliminoer undersøgelse.

Fifteen patients electively selected for percutaneous dilatational tracheostomy as performed with the Ciaglia Percutaneous Tracheostomy Introducer Set are reported in this preliminary study. The median time for insertion of the tracheostomy tube was 13.1 min. Complications were cuff puncture of the translaryngeal tube at an early stage of the procedure in one case, and minor bleeding controllable by the compressible effect of the dilatational procedure in three cases. During the posttracheostomy period complications included one case of minor bleeding controllable by digital compression and one case of minor infection, i.e. cellulitis in a few millimetres around the stoma without purulent secretion. Our preliminary results indicate that the technique as performed with the Ciaglia Introducer Set is effective and safe with only minor complications. Furthermore, we now use it as a bed-side procedure in the ICU, thus avoiding the transportation of critically ill patients to the operating theatre. A conclusion on the superiority of percutaneous tracheostomy to dissectional tracheostomy has to await clinical randomized studies including more patients.

Percutaneous dilatational tracheostomy.

METHODS: Fifteen patients electively selected for percutaneous dilatational tracheostomy as performed with the Ciaglia Percutaneous Tracheostomy Introducer Set are reported in this preliminary study. RESULTS: The median time for insertion of the tracheostomy tube was 13.9 min. Complications were cuff puncture of the translaryngeal tube at an early stage of the procedure in one case, and minor bleeding controllable by the compressible effect of the dilatational procedure in three cases. During the posttracheostomy period, complications were one case of minor bleeding controllable by digital compression and one case of minor infection, i.e. cellulitis in a few millimetres around the stoma without purulent secretion. CONCLUSIONS: Our preliminary results indicate the technique as performed with the Ciaglia Introducer Set to be effective and safe with only minor complications. Furthermore, we now use it as a bedside procedure in the ICU, thus avoiding the transportation of critically ill patients to the operating theatre. The conclusion of the superiority of percutaneous tracheostomy to dissectional tracheostomy has to await clinical randomized studies, including more patients.

Fusobacterium pneumonia and death following uvulo-palato-pharyngoplasty.

A case with a fatal outcome caused by infection with Fuso-bacterium species was seen in a patient recently operated on for heavy snoring with uvulo-palato-pharyngoplasty (UPPP). The mechanism of infection is discussed. It is concluded that a febrile episode seen in patients less than 2 weeks postoperatively should be considered a serious symptom and be treated intensively after thorough examination.

Immunohistochemical quantitation of collagen types I, II, IV and V in the ventilated and non-ventilated rabbit middle ear with otitis media with effusion.

Morphometric quantitation of the area fractions of collagen types I, II, IV and V was determined in the normal rabbit middle ear mucosa and in relation to otitis media with effusion (OME) using a three-layered peroxidase-antiperoxidase technique. The effects of substituting normal low-oxygen middle ear gas (non-ventilated) with atmospheric air (ventilated) were studied in both healthy ears and ears with OME. Based upon previous histological examinations in rabbits, only ears with OME for more than 8 weeks were included to ensure the presence of chronic inflammation (COME). Atmospheric air was introduced into the middle ears by insertion of ventilation tubes or by an enlarged myringotomy. Collagen type I was predominant in all groups studied. The area fractions of collagen types I, II and IV were increased significantly in COME, with collagen type II elevated in particular. Ventilation of the normal ears resulted in a significantly increased area fraction of cells, while the area fractions and distributions of the collagen types were unaffected. None of the ventilated ears in COME improved or healed spontaneously. The total fraction of collagen in COME was not changed significantly by the introduction of atmospheric air. However, the individual distribution of the collagen types was altered, with significantly larger area fractions of types II and V found in ventilated ears with COME. Possible explanations for the differences found are discussed, including the role of oxygen-derived free radicals.

Accuracy of an automatic impedance apparatus in a population with secretory otitis media: principles in the evaluation of tympanometrical findings.

INTRODUCTION: The primary demand for a screening procedure for secretory otitis media (SOM) is to identify an objective test with sufficient sensitivity and specificity to meet the needs of the screening program. This study was designed to estimate the value of a portable automatic impedance apparatus to meet these needs. SUBJECTS AND METHODS: Two hundred twenty children with unilateral or bilateral SOM were evaluated in a double-blind, cross-sectional study. All have fulfilled two of the following three criteria for surgical intervention: (1) SOM by physical examination, (2) greater than 20 dB hearing impairment, and/or (3) adenoid symptoms. All ears were evaluated using tympanometry, following which myringotomy was performed. RESULTS: Otomicroscopy showed fluid behind the tympanic membrane in 393 ears. All underwent myringotomy. Thirteen percent (51 ears) were empty. Of the otomicroscopic findings consistent with SOM, 82% had B curves, 6% had C2 curves, 8% had C1 curves, and 4% had A curves. Both C2 and B curves were considered abnormal. Sensitivity of the apparatus is 94.4% and of the specificity is 52.9%. There was no statistical correlation between tympanometrical findings and fluid viscosity. RESULTS: A test intended for screening has to be simple, easy, and quick to perform. Furthermore, the test should have high sensitivity. The automatic impedance apparatus is able to meet these demands; however, the individual results have to be confirmed by another method, eg, otomicroscopy, pure-tone audiometry, and/or manual tympanometry.

[Juvenile recurrent parotitis]. / Juvenil, recidiverende parotit.

Juvenile recurring parotitis is a relatively rare condition. The clinical picture as illustrated by a characteristic case history is reviewed. The condition shows a tendency to remission around puberty. Sialographic examination is characterised by the configuration of the parotid gland said to resemble a bunch of grapes. Biochemical tests do not contribute to the diagnosis which is established by the clinical picture and the typical sialographic findings. No systemic disease can be demonstrated in the patients who are healthy in other respects. The cause of the condition appears to be congenital sialectic changes localised to the parotid gland with resultant secondary ascending bacterial infection. In treatment during the acute stages, attempts should be made to stimulate secretion of saliva with sour foodstuffs and chewing gum. Treatment with penicillin for one week is recommended. On account of the benign character of the condition and the good long-term prognosis, operative intervention should not prove necessary.

Histological examination of the rabbit middle ear in secretory otitis media with and without a ventilation tube.

To study the time-related histopathological lesions in secretory otitis media as it develops into the chronic stage, including the influence of ventilation of the middle ear, we examined the middle ear mucosa in a rabbit model. The observation period was from two weeks until 18 months. The histological method applied included haematoxylin-eosin and Sirius red staining for morphometric quantification of the goblet cells, the thickness of the connective tissue layer, the area fractions of blood vessels, inflammatory cells, fibroblasts and collagen fibres. In conclusion, the middle ear mucosa in secretory otitis media exhibited inflammatory changes correlating with the duration of the disease. Ventilation of the middle ear in secretory otitis media did not improve the changes.

Local application of N-acetylcysteine in secretory otitis media in rabbits.

The middle ears of patients with secretory otitis media treated by ventilation tubes are exposed to two abnormal conditions: an inflammatory process and a hyperoxic condition. Both are known to cause changes in the mucosa, fibrosis in particular. N-acetylcysteine has been demonstrated to exhibit anti-inflammatory effects as well as being an oxygen radical scavenger. In an attempt to elucidate if N-acetylcysteine is capable of preventing the changes caused by secretory otitis media and ventilation tubes we administered different doses of the substance locally to the middle ear of an animal model. The results showed that N-acetylcysteine reduced the extent of the inflammation in the middle-ear mucosa and prevented the long-term fibrotic changes associated with secretory otitis media.

[Treatment of vocal cord paresis with Teflon injections]. / Behandling af stemmebåndsparese med Teflon-injektion.

Twenty-five patients suffering from unilateral paresis of the vocal cord of differing durations caused by benign diseases and 25 patients with unilateral paresis caused by malignant tumours in the thorax/mediastinum were treated with Teflon injection of the paretic vocal cord. The results of treatment were evaluated by a speech therapist by voice recording pre-operatively, three weeks post-operatively and at a later control. This evaluation together with self-assessment demonstrated a satisfactory result even the long term result. In 2/3 of the patients good voice function was found at later control. The results indicated that the injection of Teflon is effective and should also be offered to patients with malignant diseases in spite of the poor prognosis quo ad vitam. No serious complications were seen in the post-operative period.

Zinc in the management of tinnitus. Placebo-controlled trial.

To assess any possible beneficial effect from zinc on tinnitus we performed a placebo-controlled, randomized, double-blind investigation. Forty-eight patients with tinnitus were randomized to either placebo or the administration of zinc sulfate as sustained-release tablets of 22 mg Zn++ (Zinklet). The tablets were administered three times daily for 8 weeks. Every week the patients stated the severity of tinnitus on a number scale from 0 to 10. The levels of zinc and albumin in serum were determined both before and after treatment. Of 48 patients with tinnitus, hypozincemia was found in only one patient. The zinc level increased significantly in the patients treated with zinc. We could not demonstrate any beneficial effect from zinc on tinnitus. One of the essential reasons for this finding could be that the zinc levels in serum were in the normal range previous to treatment.

Impedance measurement in divers during a scuba-diving training programme.

An assessment of the strain on the tympanic membrane caused by diving was performed using impedance measurement of the middle ear in 21 untrained young men going through a scuba-diving training programme (scuba, self-contained under-water breathing apparatus). Tympanometry was carried out just before and after diving. The divers made 104 dives between them (median 5 each, range 2-7) at depths from 2 to 12 m (median 6 m). The results showed a significant increase in middle ear compliance on diving. The increase in compliance was significant at different depths, was transient, and fell to the initial level between the dives. We conclude that the strain exerted on the tympanic membrane and middle ear from barotrauma due to diving results in a reversible impairment of the recoiling capacity of the elastic fibrils of the tympanic membrane. This transient increase in compliance, we think, is the first measurable change in elasticity of the tympanic membrane. If barotrauma continue the changes could be irreversible.

[Zinc therapy of tinnitus. A placebo-controlled study]. / Zinkbehandling af tinnitus. En placebokontrolleret undersøgelse.

Forty-eight patients with tinnitus of various etiologies underwent a placebo-controlled, randomized, double-blind trial to assess whether treatment with zinc had any favourable effect on tinnitus. The trial tablets contained either 100 mg zinc sulphate as a depot tablet = 22 mg Zn++ (Zinclet) or placebo. The patients took tablets thrice daily for eight weeks. They indicated the severity of the tinnitus once weekly on a table graduated from 0 to 10. Serum zinc and serum albumin were measured before and after treatment. Out of the 48 patients with tinnitus, only one had hypozincaemia. During treatment, the serum zinc rose significantly in the group treated with zinc. No favourable effect of zinc treatment on tinnitus could be demonstrated. The fact that the serum zinc levels of the patients were within the normal range was probably an important reason for this.

[A case report of spontaneous otoacoustic emissions]. / Et tilfaelde med spontane oto-akustiske emissioner.

A case with audible spontaneous oto-acoustic emissions (SOAE) in an infant aged four months is presented. The frequency was determined to be approximately 6,100 Hz and the volume to 27 dB sound pressure level (SPL). The mechanism involved in SOAE is summarized.

Results in treatment of carcinoma of the external auditory canal and middle ear.

Of 31 patients treated for carcinoma of the external auditory canal and/or middle ear, 19 patients (61%) presented with a long-term history of otitis. Thirteen patients (42%) had cranial nerve involvement. The patients were treated by surgery, radiotherapy, or a combined treatment of surgery and radiotherapy. The overall 5-year crude survival rate was 29%. Irrespective of the final outcome, 19 patients (61%) obtained pain relief after initial treatment. Three of the patients with facial nerve involvement survived 5 years after the initial treatment. Postmortem examinations of ten patients revealed distant metastases in four patients.

Tracheopathia osteoplastica in the larynx.

Reports of tracheopathia osteoplastica localized to the larynx are few. Such a rare case is reported in a 66-year-old male with life-long symptoms resulting in tracheotomy and resection of some of the osteoplastic tissue. A review of the disease and a discussion about aetiology are described.

Cholesteatoma of the maxillary sinus (a case report).

A rare case of a cholesteatoma of the maxillary sinus is presented, together with a brief discussion of its aetiology.