Effectiveness of screening for colorectal cancer with a faecal occult-blood test, in Finland.

BACKGROUND: Screening for colorectal cancer (CRC) with guaiac-based faecal occult-blood test (FOBT) has been reported to reduce CRC mortality in randomised trials in the 1990s, but not in routine screening, so far. In Finland, a large randomised study on biennial FOB screening for CRC was gradually nested as part of the routine health services from 2004. We evaluate the effectiveness of screening as a public health policy in the largest population so far reported. METHODS: We randomly allocated (1:1) men and women aged 60-69 years to those invited for screening and those not invited (controls), between 2004 and 2012. This resulted in 180 210 subjects in the screening arm and 180 282 in the control arm. In 2012, the programme covered 43% of the target age population in Finland. RESULTS: The median follow-up time was 4.5 years (maximum 8.3 years), with a total of 1.6 million person-years. The CRC incidence rate ratio between the screening and control arm was 1.11 (95% CI 1.01 to 1.23). The mortality rate ratio from CRC between the screening and control arm was 1.04 (0.84 to 1.28), respectively. The CRC mortality risk ratio was 0.88 (0.66 to 1.16) and 1.33 (0.94 to 1.87) in males and females, respectively. CONCLUSIONS: We did not find any effect in a randomised health services study of FOBT screening on CRC mortality. The substantial effect difference between males and females is inconsistent with the evidence from randomised clinical trials and with the recommendations of several international organisations. Even if our findings are still inconclusive, they highlight the importance of randomised evaluation when new health policies are implemented. TRIAL REGISTRATION: 002_2010_august.

Effect of exercise on bone structural traits, physical performance and body composition in breast cancer patients--a 12-month RCT.

In this 12-month RCT, we examined whether aerobic impact exercise training (3x/week) could facilitate breast cancer survivors' recovery by enhancing their bone structural strength, physical performance and body composition. After the adjuvant chemo- and/ or radiotherapy, 86 patients were randomly assigned into the training or control group. Structural bone traits were assessed with pQCT at the tibia and with DXA at the femoral neck. Agility (figure-8 running), jump force and power (force platform), grip strength and cardiovascular fitness (2-km walk test) were also assessed. Training effects on outcome variables were estimated by two-way factorial ANCOVA using the study group and menopausal status as fixed factors. Bone structural strength was better maintained among the trainees. At the femoral neck, there was a small but significant 2% training effect in the bone mass distribution (p=0.05). At the tibial diaphysis, slight 1% to 2% training effects (p=0.03) in total cross-sectional area and bone structural strength were observed (p=0.03) among the postmenopausal trainees. Also, 3% to 4% training effects were observed in the figure-8 running time (p=0.03) and grip strength (p=0.01). In conclusion, vigorous aerobic impact exercise training has potential to maintain bone structural strength and improve physical performance among breast cancer survivors.

Effect of supervised and home exercise training on bone mineral density among breast cancer patients. A 12-month randomised controlled trial.

UNLABELLED: The ability of combined step aerobic- and circuit-training to prevent bone loss after breast cancer treatments was related to skeletal site and patients' menopausal status. Among premenopausal breast cancer survivors, a 12-month exercise intervention completely prevented bone loss at the femoral neck, whereas no exercise effect was seen at lumbar spine or at neither site in postmenopausal women. INTRODUCTION: The primary objective of this randomised clinical trial was to determine the preventive effect of supervised weight-bearing jumping exercises and circuit training on bone loss among breast cancer patients. METHODS: Of 573 breast cancer survivors aged 35-68 years randomly allocated into exercise or control group after adjuvant treatments, 498 (87%) were included in the final analysis. The 12-month exercise intervention comprised weekly supervised step aerobic- and circuit-exercises and similar home training. Bone mineral density (BMD) at lumbar spine and femoral neck were measured by dual-energy X-ray absorptiometry. Physical performance was assessed by 2-km walking and figure-8 running tests, and the amount of physical activity was estimated in metabolic equivalent-hours/week. RESULTS: In premenopausal women, bone loss at the femoral neck was prevented by exercise, the mean BMD changes being -0.2% among the trainees vs. -1.4% among the controls (p = 0.01). Lumbar bone loss could not be prevented (-1.9% vs. -2.2%). In postmenopausal women, no significant exercise-effect on BMD was found either at the lumbar spine (-1.6% vs. -2.1%) or femoral neck (-1.1% vs. -1.1%). CONCLUSIONS: This 12-month aerobic jumping and circuit training intervention completely prevented femoral neck bone loss in premenopausal breast cancer patients, whereas no effect on BMD was seen in postmenopausal women.

Early detection of colorectal cancer with faecal occult blood test screening.

BACKGROUND: Faecal occult blood test (FOBT) screening has been shown to decrease the incidence and mortality from colorectal cancer. This study compared the stage profile of patients with colorectal cancer diagnosed at the first FOBT screening round with that of an unscreened control group. METHODS: Subjects aged 60-64 years were allocated randomly to biennial FOBT screening (52 998 subjects) or a control group (53 002) in a Finnish prospective public health policy in 2004-2006. FOBT was performed with a guaiac test. At the end of 2007 the screened and control populations were linked to the Finnish Cancer Registry database, and the colonoscopic findings in the screen positives were analysed. RESULTS: Early-stage colorectal cancer was observed in 52 per cent of the FOBT-positive subjects, in 42.2 per cent of the total screened population and in 38 per cent of the control population (P = 0.191 for FOBT positives, P = 0.592 for total screened population). The prevalence of adenomas and colorectal cancer was 31.5 and 8.2 per cent respectively among the 806 subjects with a positive FOBT. Some 27.3 per cent of all colorectal tumours in the screened population were interval cancers. The tumour was located in the right colon in 28.9 per cent of the screened subjects and 22 per cent of controls (P = 0.255). CONCLUSION: Biennial FOBT screening improves detection of colorectal cancer at the first screening round, but the high percentage of interval cancers is a cause for concern.

Apoptosis and regression of embryonic mesenchyme in the development of the middle ear spaces.

Apoptosis was studied using temporal bones from three fetuses representing different times of gestation and from three neonates. Paraffin-embedded sections 20-microm thick were studied using the terminal deoxynucleotide transferase-mediated dUTP nick-end labeling method based on 3'-end-labeling of fragmented DNA. Phenotyping of the immune cells was performed using regular monoclonal antibodies. In the bone marrow the granulocyte series dominated and the number of cells in the macrophage series was noticeably fewer, with apoptotic cells occurring in both. In the embryonic mesenchyme, solitary apoptotic cells occurred in all locations in both the fetuses and neonates. Apoptosis is a basic factor in the regression of embryonal mesenchyme, but may not be preprogrammed. Basic scientific data obtained from modified tissue cultures show that mechanical forces cause cells to switch between different genetic programs. It is suggested that the act of swallowing causes periodic changes in the amniotic fluid pressure and provides the necessary force for regression of the mesenchyme by apoptosis.

Antisense inhibition of protein phosphatase 2C accelerates cold acclimation in Arabidopsis thaliana.

Two related protein phosphatases 2C, ABI1 and AtPP2CA have been implicated as negative regulators of ABA signalling. In this study we characterized the role of AtPP2CA in cold acclimation. The pattern of expression of AtPP2CA and ABI1 was studied in different tissues and in response to abiotic stresses. The expression of both AtPP2CA and ABI1 was induced by low temperature, drought, high salt and ABA. The cold and drought-induced expression of these genes was ABA-dependent, but divergent in various ABA signalling mutants. In addition, the two PP2C genes exhibited differences in their tissue-specific expression as well as in temporal induction in response to low temperature. To elucidate the function of AtPP2CA in cold acclimation further, the corresponding gene was silenced by antisense inhibition. Transgenic antisense plants exhibited clearly accelerated development of freezing tolerance. Both exposure to low temperature and application of ABA resulted in enhanced freezing tolerance in antisense plants. These plants displayed increased sensitivity to ABA both during development of frost tolerance and during seed germination, but not in their drought responses. Furthermore, the expression of cold-and ABA-induced genes was enhanced in transgenic antisense plants. Our results suggest that AtPP2CA is a negative regulator of ABA responses during cold acclimation.

Foreign body neonatal otitis media in infants.

HYPOTHESIS: An influx of amniotic fluid cellular content (AFCC) into the middle ears during birth may lead to the development of a chronic inflammatory process in the form of varying amounts of granulation tissue even if signs of otitis media are absent. This foreign body neonatal otitis media may predispose the child to recurrent otitis media. BACKGROUND: Foreign body neonatal otitis media caused by AFCC was described by Aschoff and elaborated by Wittmaack 100 years ago. Recent studies have shown how AFCC spreads to various middle ear compartments and causes histologic changes, the severity of which is related to the amount of AFCC. Specific elements become phagocytized after the first months of life but have caused the formation of inflammatory polyps and granulation tissue with round cell secretions in the meantime. METHODS: Ten temporal bones from the Temporal Bone Foundation, derived from infants aged 5 months to 1 year 11 months, were serially sectioned at 20 microm, saved at 0.2-mm intervals, numbered, and stained with hematoxylin and eosin. Every slide was studied for the presence, nature, and stage of pathologic tissue changes of the middle ear and the mastoid antrum. RESULTS: Pseudocystic granulation tissue was massive in the temporal bone of the 8-month-old child born through thick meconium. Severe changes were present in the temporal bones of two infants aged 5 months, one of which showed traces of AFCC. In the temporal bones of two older children, long-standing changes were minor, one of them still showed traces of AFCC. Fresh acute changes and long-standing histologic changes occurred side by side. CONCLUSIONS: Neonatal otitis media caused by AFCC can give rise to extensive granulation tissue and round cell secretion, which is likely to make the ear susceptible to infectious otitis media. Cumulative development of granulation tissue as a result of infection may lead to blockage of attic aeration and drainage pathways, causing irreversible adhesive otitis media. A data base should be formed of all neonates born through meconium-stained amniotic fluid to allow a comparison with those born through clear fluids. Surgery with the creation of auxiliary aeration pathways becomes advisable in the treatment of ears with massive development of granulation tissue.

Spread and fate of amniotic fluid cellular content in the middle ear.

In this study, 24 temporal bones with an age range from neonates to 23-month-old infants were serially sectioned and studied for the spread and fate of amniotic fluid cellular content (AFCC) in the middle ear and mastoid. Most children had had either a moderate or massive contamination. AFCC clusters were found to spread to all compartments, with the sites of predilection being the stapes region, the lower lateral attic and the tympanic isthmus. AFCC created an intensive foreign body giant cell reaction and the foreign material practically dissolved in 5 months as a result of the organization process. Tiny remnants of AFCC appeared as late as 15 months after birth. It seems likely that AFCC contamination predisposes the ears to recurring otitis media. The sequalae of the massive granulation tissue development involves obliteration of Prussak's space and its aeration routes, as well as blockage of the tympanic isthmus, leading to extensive disease in the major attic compartments.

Aeration and drainage pathways of Prussak's space.

OBJECTIVE: the purpose of this study was to document the aeration and drainage pathways of Prussak's space. METHODS: 55 temporal bones with an age range from neonate to 11 years of age were serially sectioned to 20 microns, every 10th section was saved and stained by Hematoxylin eosin. Each consecutive section was studied as to the connections of Prussak's space to adjacent compartments and measurements of the dimensions were made for both Prussak's space and its aeration pathways. RESULTS: the classic aeration pathway via the posterior pouch, as described by Prussak in 1867, was found in 34 ears (62%). In 19 (36%), aeration occurred superior to the posterior pouch in the region of the lower lateral attic and the upper mesotympanum. In these ears the posterior pouch had formed, but its superior limit ended blindly in the tympanic membrane. In two temporal bones the aeration pathway was from the anterior pouch and in these cases also a blind posterior pouch had developed. In one temporal bone an auxiliary pathway in addition to the route via the posterior pouch was through the roof (the lateral malleal ligamental fold) of Prussak's space to the overlying lateral malleal space. The height of the posterior pouch varied with a range from 0.5 to 2.4 mm, and the greatest width, which was towards the posterior tympanic spine, varied from 1.6 to 3.2 mm. The superiorly blind posterior pouch was shorter, ranging from 0.4 to 1.2 mm in height. The most frequent route of the chorda tympani nerve was running from 0.5 to 1 mm medial to the posterior malleal ligament in the anterior half of the pouch, joining it posteriorly, or it was connected to it by a short fold, 37 ears (67%). In 18 cases (33%) the chorda was surrounded by its own fold, thus entirely separate from the posterior malleal ligamental fold during its entire course across the tympanum. CONCLUSIONS: we have made a detailed documentation of the aeration and drainage pathways of Prussak's space and the findings concur, with important modifications, with Prussak's original description. There is no evidence for contemporary claims that Prussak's space would be aerated superiorly between the lateral incudal and malleal folds. Prussak's space and its aeration pathway is an unit of its own, entirely separate of the major epitympanic compartments which are aerated via the tympanic isthmus. Due to frequent disease processes in the lower lateral attic and posterior mesotympanum, Prussak's space and its aeration pathway are likely to become blocked. This may lead to obliteration of Prussak's space and to the development of retraction pocket or papillary ingrowth cholesteatoma.

One-stage revision surgery for pediatric cholesteatoma: long-term results and comparison with primary surgery.

OBJECTIVE: Few studies report on revision surgery for pediatric cholesteatoma, even if most studies of primary surgery show high recurrence rates. We present independently evaluated long-term results of revision surgery and compare the results with those of primary surgery. METHODS: The series consisted of 42 consecutive pediatric (age <16 years) cholesteatoma revision operations in the Helsinki University ENT Department. The primary and revision surgery was non-staged, all mastoids were obliterated and the bony ear canals were reconstructed. The preoperative, surgical and annual control data were recorded in a database. The last control was independently performed (J.S.) with an average follow-up of 4.3 years and 87% attendance. RESULTS: The recurrence rate for revision operations was 38%. A retraction process developed in 38% of the ears and 67% of these retractions turned into active cholesteatomas. There was a non-significant difference for these figures as compared with primary surgery. Postoperative discharge and poor middle ear ventilation were associated with recurrence. The following factors showed significant differences between primary and revision surgery: increased number of bare facial nerve in the revision group, lower recurrence rate for experienced surgeons (as for both groups together) and improved hearing results for ears without recurrence in the revision group. CONCLUSIONS: Recurrent disease after revision surgery appears either in the attic or in the mesotympanum, or develops from a retraction pocket in a similar manner as was seen in patients receiving primary surgery. Recurrence is associated with discharging and poorly ventilated ears. Pediatric cholesteatoma surgery should be done or be supervised by experienced surgeons. The present operation methods result in many recurrences after primary and revision surgery. New surgical methods are needed to create additional aeration pathways to the epitympanum in order to improve middle ear aeration and to prevent some of the retractions.

Improved tolerance to salinity and low temperature in transgenic tobacco producing glycine betaine.

Glycine betaine is an osmoprotectant found in many organisms, including bacteria and higher plants. The bacterium Escherichia coli produces glycine betaine by a two-step pathway where choline dehydrogenase (CDH), encoded by betA, oxidizes choline to betaine aldehyde which is further oxidized to glycine betaine by the same enzyme. The second step, conversion of betaine aldehyde into glycine betaine, can also be performed by the second enzyme in the pathway, betaine aldehyde dehydrogenase (BADH), encoded by betB. Transformation of tobacco (Nicotiana tabacum), a species not accumulating glycine betaine, with the E. coli genes for glycine betaine biosynthesis, resulted in transgenic plants accumulating glycine betaine. Plants producing CDH were found to accumulate glycine betaine as did F1 progeny from crosses between CDH- and BADH-producing lines. Plants producing both CDH and BADH generally accumulated higher amounts of glycine betaine than plants producing CDH alone, as determined by 1H NMR analysis. Transgenic tobacco lines accumulating glycine betaine exhibited increased tolerance to salt stress as measured by biomass production of greenhouse-grown intact plants. Furthermore, experiments conducted with leaf discs from glycine betaine-accumulating plants indicated enhanced recovery from photoinhibition caused by high light and salt stress as well as improved tolerance to photoinhibition under low temperature conditions. In conclusion, introduction of glycine betaine production into tobacco is associated with increased stress tolerance probably partly due to improved protection of the photosynthetic apparatus.

Attic aeration in temporal bones from children with recurring otitis media: tympanostomy tubes did not cure disease in Prussak's space.

HYPOTHESIS: Blockage of the aeration pathways to the attic may cause circumscribed or widespread alterations that are difficult to diagnose clinically. The narrow route via the posterior pouch to Prussak's space is especially vulnerable to obstruction in recurring otitis media. BACKGROUND: Recent studies of the epitympanic diaphragm and compartments have clarified the anatomy of the attic aeration and drainage pathways and emphasized the role of their patency in the healing process of middle ear infections. In neonatal otitis media, the amniotic fluid cellular content (AFCC) has proved to be a good indicator in outlining the areas where inflammation products concentrate, possibly causing early blockage of ventilation. METHODS: Twenty-eight temporal bones from 14 children were studied; 4 of these children had experienced bilateral recurring otitis media. In the latter group, 1 ear was studied by microdissection and the other by serial sectioning. RESULTS: Prussak's space was involved in all 4 pairs of bones and either contained thick mucus, contained secretion in the process of organization, or was obliterated. The tympanic isthmus was fully obstructed in 1, partially blocked in 2, and open in 5 specimens. CONCLUSIONS: If a thick mature connective tissue mass develops under the epidermal layer of Shrapnell's membrane during an obliteration process of Prussak's space, the condition may stay stable and benign. Severe retraction of Shrapnell's membrane represents a likely forerunner of a retraction pocket cholesteatoma. Systematic otomicroscopy allows early detection, and cure can be achieved by minor surgery. In some children, despite the treatment of recurring otitis media with ventilation tubes, the attic and mastoid can be extensively involved, necessitating atticomastoidectomy and the creation of new pathways for attic aeration.

Effect of amniotic fluid cellular content on attic aeration pathways: histologic observations of infants aged 2 to 4 months.

HYPOTHESIS: The tissue-fixed amniotic fluid cellular content (AFCC) in the middle ear and mastoid antrum causes foreign body type reactions that may later severely restrict the aeration pathways to the main attic and to Prussak's space. BACKGROUND: It was shown by Aschoff 100 years ago that AFCC remained in the neonate ears and caused sterile otitis media. Recent data show that children born through thick meconium are at risk for large quantities of AFCC entering the middle ear cleft, the ensuing inflammatory reaction being related to the amount of AFCC. Spread of AFCC in the neonate occurred along the aeration pathways with corresponding tissue fixation but further systematic data in young infants are lacking. METHODS: Five temporal bones of three infants aged 2 to 4 months were embedded in celloidin, serially sectioned at 20 microns, and every 10th section stained with Hematoxylin and eosin and mounted on slides. All slides were studied and relevant details of aeration pathways and all compartments photographed. RESULTS: The histologic changes were characterized by the development of masses of pseudocystic granulation tissue, with some remnants of the original AFCC, mainly in the form of fragments of hair. The tympanic isthmus was involved to varying extent, maximally to half of its size. Posterior tympanum and the stapes region had masses of fresh granulation tissue, the maturing of which might cause marked indrawing of the posterior pars tensa and further reduction of the tympanic isthmus. Aeration of Prussak's space was severely involved in two bones, favored by the narrow pathway through the posterior pouch. Features of recent acute or secretory otitis media were associated with the early changes caused by AFCC. CONCLUSIONS: The granulation tissue in this age group is immature and its final fate is decided by the nature of the future ear disease. If the AFCC contamination is slight, the granulation tissue after maturing may appear only in the form of thin cords and sheets, a frequent chance finding in ear surgery. Large amount of AFCC may lead to chronic inflammation, which may predispose the child to recurring middle ear infections during infancy. Further histologic and clinical studies in older infants and young children are needed to find out the final outcome after a massive AFCC contamination of the new-born middle ear.

Supratubal recess in neonates and infants.

OBJECTIVE: The fetal development of the supratubal recess and of the tensor fold was described by Hammar in 1902. Recent studies claim that neither structure is regularly present in neonates and controversial views have been presented of the separation of the anterior attic and supratubal recess. The objective of this study is to clarify these issues. METHODS: Twenty temporal bones, 13 neonate and seven infant, were studied either by microdissection of fresh (five bones) or formalin stored (two) specimens, or by serial sectioning after formalin fixation and decalcification (13 bones). The serial sections were cut to 20 microm, every tenth section saved and stained by hematoxylin eosin. RESULTS: In all specimens the separating structure between the anterior attic and supratubal recess was the tensor fold. It was intact in 15 bones while five showed a membrane defect. In vertically oriented folds the recess was deep and in horizontally oriented folds shallow. In 19 bones the tensor fold inserted superiorly to a soft tissue insertion ring of varying thickness and only once directly to a shallow transverse crest. The breadth of the tensor fold near the tensor tendon showed only little variation, whereas its height, and the distance from the tensor tendon to the supratubal tegmen varied in larger limits. CONCLUSIONS: The tensor fold and the supratubal recess are present already in the neonate and thus develop during the fetal period. The shape of the recess is determined by the fold direction and its size grows in conjunction with the other middle ear spaces. The transverse crest has no apparent influence on the position of the tensor fold. The easiest method to study the integrated whole of the anterior attic and supratubal recess is to view them alternatively from the anterior and superior microdissection approaches. Clinically, removal of the tensor fold creates an efficient additional aeration route from the supratubal recess to the anterior attic.

Short communication: subcellular localization of ozone-induced hydrogen peroxide production in birch (Betula pendula) leaf cells.

The atmospheric air pollutant ozone (O3) is one of the environmental stresses that induce formation of reactive oxygen species (ROS) in plants. Previously, the toxicity of O3 has been believed to be a result of ROS formation from O3-degradation. Recently, however, it has been shown that O3 induces active ROS production, which suggests that O3-responses may be mechanistically similar to pathogen-induced responses and that O3-damage could be a result of deleterious firing by the ROS of pathways normally associated with the HR. The subcellular localization of O3-induced H2O2 production was studied in birch (Betula pendula). O3 induced H2O2 accumulation first on the plasma membrane and cell wall. Experiments with inhibitors of possible sources for H2O2 in the cell wall suggested that both NADPH-dependent superoxide synthase and the cell wall peroxidases are involved in this H2O2 production. The H2O2 production continued in the cytoplasm, mitochondria and peroxisomes when the O3-exposure was over, but not in chloroplasts. The timing of mitochondrial H2O2 accumulation coincided with the first symptoms of visible damage and, at the same time, the mitochondria showed disintegration of the matrix. These responses may not be directly connected with defense against oxidative stress, but may rather indicate changes in oxidative balance within the cells that affect mitochondrial metabolism and the homeostasis of the whole cell, possibly leading into induction of programmed cell death.

Pediatric one-stage cholesteatoma surgery: long term results.

The long-term results of pediatric cholesteatoma are dispersed and there is no consensus on operation methods and on factors affecting outcome of surgery. We analyzed the independently evaluated long-term results and possible reasons for recholesteatoma. Eighty-four consecutive pediatric (age < 16 years) cholesteatoma operations were undertaken in the Helsinki University Central Hospital ENT Department. The operations were not staged; all mastoids were obliterated and bony ear canals reconstructed without open cavities. The pre- and perioperative and annual control data were recorded in a database. The last control was independently performed (J.S.) with an average follow-up of 4.8 years and 87% attendance. The total recholesteatoma rate was 29% (24/84), and it was not dependent on the size of cholesteatoma, mastoid status, cholesteatoma in the window niches or stapedial erosion. A retraction process developed in 25% (21/84) of the ears and 42% (9/21) of these turned into retraction pocket cholesteatomas as late as 13 years postoperatively. Retractions and postoperative discharge, especially in combination, predisposed to recholesteatoma. Of the healed ears, 37% became atelectatic. Hearing was maintained on the preoperative level. Reduced middle ear and attic ventilation led to retractions, and atelectasis and a tendency to discharge accelerated the process. Pitfalls in mastoid obliteration and attic reconstruction and the failure to create new ventilation routes were important reasons for recholesteatoma.

Long-term results of pediatric primary one-stage cholesteatoma surgery.

The long-term results of surgical treatment for pediatric cholesteatoma are variable and there is no consensus on operation methods and on factors affecting outcome of surgery. We analyzed the independently evaluated long-term results and possible reasons for recurrence of cholesteatoma. A total of 84 consecutive pediatric (age < 16 years) cholesteatoma operations in the Helsinki University Central Hospital ENT Department. The operations were not staged, and all mastoids were obliterated and bony ear canals reconstructed without open cavities. The pre- and postoperative and annual control data were recorded in a database. The last control was independently performed (JS) with an average follow-up of 4.8 years and 87% attendance. The total recurrence rate was 29% (24/84), and it was not dependent on the size of cholesteatoma, mastoid status, cholesteatoma in the window niches or stapedial erosion. A retraction process developed in 25% (21/84) of the ears and 42% (9/21) of these turned into retraction pocket cholesteatomas as late as 13 years postoperatively. Retractions and postoperative discharge, especially in combination, predisposed to recurrence. Of the healed ears, 37% became atelectatic. Hearing was maintained on the preoperative level. Reduced middle ear and attic ventilation led to retractions, and atelectasis and a tendency to discharge accelerated the process. Pitfalls in mastoid obliteration and attic reconstruction and the failure to create new ventilation routes were important reasons for recurrence of cholesteatoma.

Spread of amniotic fluid cellular content within the neonate middle ear.

Six full-term neonatal temporal bones, with meconium contaminated amniotic fluid aspiration of varying degrees, were serially sectioned at 20 microm and every tenth section was stained by hematoxylin eosin and mounted on slides. All stained sections were studied, the data recorded and relevant details of all compartments photographed. In addition, four normal neonate temporal bones were studied, one by serial sectioning and three by microdissection. The lateral incudomalleal and tensor folds were present in all, membrane defects in the tensor fold were seen in two normal ears. Three ears in the aspiration group had much fetal tissue present rendering Prussak's space small. Four ears with aspiration had remnants of incus intercrural (medial) folds. The amniotic fluid cellular content (AFCC) was sparse or nonexistent in the supratubal recess, Prussak's space and hypotympanum. It concentrated to the areas around the stapes, to sinus tympani and round window niche, to lower lateral attic and posterior pouch, medial attic and in lesser amounts to superior attic, mastoid antrum and air cells. Massive amounts of AFCC in tympanic isthmus and posterior pouch may lead to formation of granulation tissue and blockage of the aeration pathways to attic proper and to Prussak's space. These changes may initiate the development of chronic secretory otitis media in infants.

Chronic inflammatory ear disease and cholesteatoma: creation of auxiliary attic aeration pathways by microdissection.

HYPOTHESIS: The attic compartments, except for Prussak's space, are aerated through the tympanic isthmus. The aim of this study was to develop aeration pathways that would bypass the isthmus in surgery for chronic inflammatory ear disease and cholesteatoma. BACKGROUND: Microdissection of the epitympanum has shown that the anterior attic and the supratubal recess are separated by the tensor fold, the excision of which creates a large new aeration pathway. METHODS: Earlier surgical experience was reexamined as to the access to the tensor fold. Twenty temporal bones were dissected to create clinically useful new surgical routes for tensor fold removal in the presence of an intact ossicular chain. RESULTS: An endaural atticotomy, extended to the supratubal recess, allows excision of the tensor fold; however, the excision must be performed blindly. Cutting the neck of the malleus to allow lateral lifting of the manubrium exposes the tensor tendon and allows rapid excision of the fold. The elasticity of the tendon assists in approximation of the cut edges. In canal wall up surgery, removal of the lateral attic bone until the root of the zygoma exposes the anterior surface of the head of the malleus and the lateral portion of the transverse crest. Drill-out of the crest leads directly to the posterior side of the tensor fold, allowing its excision under direct vision. Thinning of the attic bone lateral to the body and short process of the incus allows simultaneous removal of the lateral incudomalleal fold. CONCLUSIONS: When the ossicular chain is discontinuous, tensor fold resection can be made under direct vision. With an intact chain, cutting of the neck of the malleus used in tympanic glomus tumors causes no hearing changes, allows complete fold excision, and is adaptable to chronic ear surgery. The frontolateral attic route for removal of tensor fold, together with the lateral incudomalleal fold, can be used in the canal wall up surgery to improve attic aeration.