Initial experience of a rapid-insertion bone-anchored hearing system: series of 20 consecutive implants.

Objective: The loading of bone-anchored hearing system sound processors usually occurs two to three months after surgical implant. This study examined a new bone-anchored hearing system coupling mechanism that permits loading at two weeks post-implantation without compromising osseointegration. Methods: Twenty implants were implanted into 15 patients. The interval between operation and time of processor loading was recorded, along with the cause of any delay and any late complications. Results: Two patients were fitted with implants at seven and nine weeks. The delay was a result of administrative errors; the patients reported no skin problems. Of the remaining 17 implants, 8 processors were fitted at 2 weeks, 1 at 3 weeks, 4 at 4 weeks, 3 at 7 weeks and 1 at 8 weeks. For those nine implants fitted later than two weeks, the delay was because of incomplete skin healing. Conclusion: The Oticon Medical Xpress system allowed processor loading at two weeks post-operatively, providing skin healing was adequate. Early loading occurred in approximately half of the patients. All patients were fitted within the two to three months traditionally allowed. Prolonged skin healing time was the main reason for the delayed fitting of sound processors.

A smart micro-drill for cochleostomy formation: a comparison of cochlear disturbances with manual drilling and a human trial.

BACKGROUND: Cochleostomy formation is a key stage of the cochlear implantation procedure. Minimizing the trauma sustained by the cochlea during this step is thought to be a critical feature in hearing preservation cochlear implantation. The aim of this paper is firstly, to assess the cochlea disturbances during manual and robotic cochleostomy formation. Secondly, to determine whether the use of a smart micro-drill is feasible during human cochlear implantation. MATERIALS AND METHODS: The disturbances within the cochlea during cochleostomy formation were analysed in a porcine specimen by creating a third window cochleostomy, preserving the underlying endosteal membrane, on the anterior aspect of the basal turn of the cochlea. A laser vibrometer was aimed at this third window, to assess its movement while a traditional cochleostomy was performed. Six cochleostomies were performed in total, three manually and three with a smart micro-drill. The mean and peak membrane movement was calculated for both manual and smart micro-drill arms, to represent the disturbances sustained within cochlea during cochleostomy formation. The smart micro-drill was further used to perform live human robotic cochleostomies on three adult patients who met the National Institute of Health and Clinical Excellence criteria for undergoing cochlear implantation. RESULTS: In the porcine trial, the smart micro-drill preserved the endosteal membrane in all three cases. The velocity of movement of the endosteal membrane during manual cochleostomy is approximately 20 times higher on average and 100 times greater in peak velocity, than for robotic cochleostomy. The robot was safely utilized in theatre in all three cases and successfully created a bony cochleostomy while preserving the underlying endosteal membrane. CONCLUSIONS: Our experiments have revealed that controlling the force of drilling during cochleostomy formation and opening the endosteal membrane with a pick will minimize the trauma sustained by the cochlea by a factor of 20. Additionally, the smart micro-drill can safely perform a bony cochleostomy in humans under operative conditions and preserve the integrity of the underlying endosteal membrane.

Biofilm formation on bone-anchored hearing aids.

OBJECTIVE: To investigate microbiological biofilm contamination of retrieved bone-anchored hearing aids. MATERIALS AND METHODS: Nine failed, retrieved bone-anchored hearing aids and 16 internal screws were examined by scanning electron microscopy. A fixture from a failing implant, which had been removed and disassembled under aseptic conditions, was cultured. Finally, an internal screw from a new, unimplanted fixture was examined by scanning electron microscopy. RESULTS: Debris was seen on the fixture and abutment of all bone-anchored hearing aids, and on the heads of the 16 internal screws. On eight screws, biofilm extended down the shaft to the threads, where it was several micrometres thick. Culture of a failing fixture yielded staphylococcus. The new, unimplanted fixture internal screw showed evidence of scratching and metallic debris on the threads, which may interfere with close fitting of the screw and subsequently facilitate microleakage. CONCLUSION: There may be a link between internal microbial contamination and failure of bone-anchored hearing aids.

The bone-anchored hearing aid in the rehabilitation of single-sided deafness: experience with 58 patients.

OBJECTIVES: To assess the efficacy of the bone-anchored hearing aid (BAHA) in the rehabilitation of single-sided deafness (SSD). STUDY DESIGN: Retrospective case-control series review. SETTING: Tertiary referral unit. PATIENTS: Fifty-eight consecutive patients that had a bone-anchored hearing aid for single-sided deafness completed outcome questionnaires, building upon earlier audiological assessment of 19 patients. Single-sided deafness controls (n = 49) were mainly acoustic neuroma patients. MAIN OUTCOME MEASUREMENTS: speech discrimination testing in directional noise, speech and spatial qualities of hearing questionnaire and the Glasgow Benefit Inventory (GBI). RESULTS: The mean follow-up time was 28.4 months. Five (13%) of the bone-anchored hearing aid patients were non-users because of lack of benefit. The audiometric testing confirmed that when noise was on the bone-anchored hearing aid side speech perception was reduced but benefited when noise was on the side of the hearing ear. There was no difference between the Speech and Spatial Qualities of Hearing Scores in bone-anchored hearing aid users and controls. In particular there was no difference in the spatial subscores. In the bone-anchored hearing aid users the median Glasgow Benefit Inventory score was 11. If the non-users are included then 13 (22%) patients had no or detrimental (negative) Benefit scores. No or negative benefit scores were more frequent in those deaf for <10 years. In open-field questions, patients felt the bone-anchored hearing aid was most useful in small groups or in 'one-to-one' conversation. CONCLUSIONS: Bone-anchored hearing aid rehabilitation for single-sided deafness is less successful than for other indications, reflected here by relatively low median Glasgow Benefit Inventory scores. There was also no significant difference between controls and bone-anchored hearing aid users in the Speech and Spatial Qualities of Hearing Questionnaire. Patients with a longer duration of deafness report greater subjective benefit than those more recently deafened, perhaps due to differing expectations.

Robotics can lead to a reproducibly high-quality operative result for ear, nose, and throat patients.

The success rates and morbidity of operations on the ear, nose, and throat (ENT) have improved markedly in the last 20-25 years. This has been largely due to improved vision, by microscopes and endoscopes, and has led to a greatly reduced hospital stay. During this time there has been minimal improvement in surgical tools. This paper discusses the need for robotic tools, detailing the clinical constraints that proposed solutions need to adhere to, and presenting a recently trialled micro drilling robot for creating a cochleostomy in the cochlear implant procedure.

Unusual complication following trauma to a bone-anchored hearing aid: case report and literature review.

OBJECTIVE: We report the second published case of a child with a serious traumatic injury involving the fixture and abutment of their bone-anchored hearing aid. METHOD: Case reports and review of the world literature concerning unusual complications following trauma to bone-anchored hearing aids. RESULTS: A nine-year-old girl with Dubowitz syndrome sustained an intrusion injury of her bone-anchored hearing aid fixture and abutment following a fall. No other injury was sustained, and there was no neurological complication. The patient underwent immediate removal of the implant and subsequently made a full recovery. Such serious and unusual complications are fortunately very rare. On review of the literature, four cases of similar complications were identified. Only one involved a traumatic injury in a child. CONCLUSION: Provision of bone-anchored hearing aids involves many clinicians. All clinicians involved in this procedure must be aware of the need to monitor their patients carefully, and to remember that unusual and unexpected complications, although rare, do happen. The patient's need for care continues long after the surgery is complete.

An autonomous surgical robot for drilling a cochleostomy: preliminary porcine trial.

OBJECTIVE: To produce an autonomous drilling robot capable of performing a bony cochleostomy whilst minimising the damage to the underlying cochlear endosteum. DESIGN: In this laboratory based study, a robotic drill was designed to measure the changes in force and torque experienced by the tool point during the drilling process. This information is used to predict the point of breakthrough and stop the drill prior to damaging the underlying endosteal membrane. SETTING: Aston University. PARTICIPANTS: Five porcine cochleas. MAIN OUTCOMES MEASURES: An assessment was made of whether a successful bony cochleostomy was performed, the integrity of endosteal membrane was then assessed. RESULTS: The autonomous surgical robotic drill successfully performed a bony cochleostomy and stopped without damaging the endosteal membrane in all five cases. CONCLUSIONS: The autonomous surgical robotic drill can perform a cochleostomy whilst minimising the trauma to the endosteal membrane. The system allows information about the state of the drilling process to be derived using force and torque data from the tool point. This information can be used to effectively predict drill breakthrough and implement a control strategy to minimise drill penetration beyond the far surface.

ENT challenges at the small scale.

BACKGROUND: In this paper we consider two relatively frequently performed operations in the field of ear, nose and throat (ENT) surgery and consider how they could be improved by using robotic applications. We consider currently available robots and propose theoretical robotic solutions. METHODS: The application of robotic systems for both cochlear implantation and endoscopic sinus surgery was considered. Currently available robotic systems were reviewed and those with potential use in ENT surgery were identified. For aspects of operations where there is no available technology, hypotheses are presented on how robots could help. RESULTS: Three robotic systems were identified with potential usage in ENT: the Pathfinder neurosurgical robot, the Acrobot knee replacement system and the autonomous smart drill for drilling a cochleostomy. CONCLUSIONS: The challenge for the future of ENT is being able to perform tasks beyond the level of human perception and abilities. The examples presented here demonstrate that microtechnologies could be used to reduce complications, decrease operating time and improve clinical results.

Redescription of Steinernema longicaudum Shen & Wang (Nematoda: Steinernematidae); geographic distribution and phenotypic variation between allopatric populations.

Steinernema longicaudum Shen & Wang is redescribed based on a comparative morphological study of specimens from the type isolate from China, and two other isolates recovered from Korea and the USA. For the first and second generation female, the location of the vulva, shape of the vulval lips, and shape and length of the tail were newly observed diagnostic characters. A more detailed description of the morphology of the male spicules and gubernaculum, and the arrangement of the genital papillae is included. A description, based on scanning electron microscopy observations, of the lateral field pattern of the third-stage infective juveniles is also provided. Additionally, restriction fragment length polymorphism profiles based on the internal transcribed spacer region, and cross-breeding tests supplement the description of this species.

Identifying the more patent nostril before nasotracheal intubation.

We have studied the reliability of two simple pre-induction tests used to select the more patent nostril for nasotracheal intubation by comparing their results with those obtained from fibreoptic examination of the nostrils, in 75 maxillo-facial patients requiring nasotracheal intubation under general anaesthesia, who had no history of nasal obstruction. The tests comprised (1) estimation of the rate of airflow through each nostril during expiration by palpating the passage of air when the contralateral nostril was occluded, and (2) asking for the patient's assessment of airflow through the nostrils, following the administration of a vasoconstrictor. After each test, noses were classified as left or right nostril clearer or nostrils equally clear. After the induction of general anaesthesia, bilateral nasendoscopies were performed and videotape recordings of these were later analysed by an otolaryngologist who had no knowledge of the test results. Intranasal abnormalities were identified and noses were again classified as left or right nostril clearer or nostrils equally clear. There was no significant difference between the overall diagnostic success rates of the two tests (44% and 47%, respectively). In patients with intranasal abnormalities, the numbers of correct diagnoses made by the two tests were not significantly different and were also not significantly different from the number of correct selections made if only the right nostril or only the left nostril had been used for the intubation. In view of the relatively high diagnostic failure rates, anaesthetists should not rely on the two tests investigated when selecting the best nostril for nasotracheal intubation.

Reduction of pentylenetetrazole-induced seizure activity in awake rats by seizure-triggered trigeminal nerve stimulation.

Stimulation of the vagus nerve has become an effective method for desynchronizing the highly coherent neural activity typically associated with epileptic seizures. This technique has been used in several animal models of seizures as well as in humans suffering from epilepsy. However, application of this technique has been limited to unilateral stimulation of the vagus nerve, typically delivered according to a fixed duty cycle, independently of whether ongoing seizure activity is present. Here, we report that stimulation of another cranial nerve, the trigeminal nerve, can also cause cortical and thalamic desynchronization, resulting in a reduction of seizure activity in awake rats. Furthermore, we demonstrate that providing this stimulation only when seizure activity begins results in more effective and safer seizure reduction per second of stimulation than with previous methods. Seizure activity induced by intraperitoneal injection of pentylenetetrazole was recorded from microwire electrodes in the thalamus and cortex of awake rats while the infraorbital branch of the trigeminal nerve was stimulated via a chronically implanted nerve cuff electrode. Continuous unilateral stimulation of the trigeminal nerve reduced electrographic seizure activity by up to 78%, and bilateral trigeminal stimulation was even more effective. Using a device that automatically detects seizure activity in real time on the basis of multichannel field potential signals, we demonstrated that seizure-triggered stimulation was more effective than the stimulation protocol involving a fixed duty cycle, in terms of the percent seizure reduction per second of stimulation. In contrast to vagus nerve stimulation studies, no substantial cardiovascular side effects were observed by unilateral or bilateral stimulation of the trigeminal nerve. These findings suggest that trigeminal nerve stimulation is safe in awake rats and should be evaluated as a therapy for human seizures. Furthermore, the results demonstrate that seizure-triggered trigeminal nerve stimulation is technically feasible and could be further developed, in conjunction with real-time seizure-predicting paradigms, to prevent seizures and reduce exposure to nerve stimulation.

Genomic variability within laboratory and wild isolates of the trichostrongyle mouse nematode Heligmosomoides polygyrus.

PCR-RFLP techniques have been used to characterize wild and laboratory isolates of the trichostrongyle nematode Heligmosomoides polygyrus from the wood mouse Apodemus sylvaticus and the laboratory mouse Mus musculus respectively. Both isolates can be distinguished by eight endonuclease digestions of the ITS region of the rDNA repeat namely, Alu I, Dde I, Hpa II, Hae III, Hinf I, Hha I, Pvu II and Sal I. In two of the digests, Hinf I and Rsa I, a minor polymorphism was observed in the wild isolate of H. polygyrus which has been cultured in laboratory-bred A. sylvaticus for several generations when compared with H. p. polygyrus from wild A. sylvaticus. A minor polymorphism was also identified in further wild isolates of H. polygyrus collected from A. sylvaticus in a field site in Egham, Surrey. However no evidence of polymorphism was observed in the laboratory isolate of H. polygyrus from the CD1 strain of M. musculus and the laboratory-bred A. sylvaticus. Reasons for this are discussed and further studies on the population genetics of H. polygyrus are suggested.

Immune responses of the argasid tick Ornithodoros moubata moubata induced by infection with the filarial worm Acanthocheilonema viteae.

Investigations were undertaken to determine whether the tick Ornithodoros moubata moubata mounted a detectable immune response to primary and secondary infections with Acanthocheilonema viteae. Uninfected control tick survival rate was 70%, but only 45% in the primary infection group. Post-secondary infection survival rate (82%) was comparable to controls, indicating that these selected ticks had some protective advantage. Mean A. viteae infective larvae recovery from ticks with secondary infections was 31.4% lower than expected, suggesting the development of immunity. SDS-PAGE of haemolymph for proteins induced post-primary infection yielded a stronger signal at 45 kDa than controls, which was further elevated post-secondary infection. Proteins at 48, 22 and 16 to 18 kDa were detected in haemolymph from infected ticks but not seen from controls. The direct effect of haemolymph on microfilarial viability was examined using a novel in vitro assay; in these preliminary trials no differences were observed in parasite viability when exposed to haemolymph from infected or uninfected groups of ticks.

Occurrence and distribution of the entomopathogenic nematodes Steinernema spp. and Heterorhabditis indica in Indonesia.

Soil samples from 79 sites on five islands of Indonesia were baited with insects for the recovery of entomopathogenic nematodes. Heterorhabditis and Steinernema were equally prevalent, and were recovered from 11.7% of samples representing 20.3% of sites sampled. Both genera were recovered from coastal sites only. Entomopathogenic nematodes were more prevalent on the Moluccan islands of Ambon and Seram than on Java or Bali. They were not detected on Sulawesi, where non-coastal sites only were sampled. RFLP analysis was used in the identification of nematode isolates. Heterorhabditis indica was the only heterorhabditid identified. Two RFLP types of Steinernema were identified.

Determination of lipids in infant formula powder by direct extraction methylation of lipids and fatty acid methyl esters (FAME) analysis by gas chromatography.

Fatty acid methyl esters (FAMEs) of pure triglyceride standards, oils, and fat from dry matrixes were formed by transesterification using sodium methoxide in methanol-hexane. FAMEs were produced by direct addition of sodium methoxide-hexane to samples and heating to simultaneously extract and transesterify acyl lipids. FAMEs were quantitated by capillary gas chromatography (GC) over a fatty acid concentration range of 0 to 1.7 mg/mL (r > or = 0.9997). Total fat was calculated as the sum of individual fatty acids expressed as triglyceride equivalents, in accordance with nutrition labeling guidelines. Saturated, polyunsaturated, and monounsaturated fats were calculated as sums of individual free fatty acids. Absolute recoveries determined from individual fatty acids in test samples ranged from 69.7 to 106%. Recoveries (relative to the C13:0 internal standard) for individual fatty acids in test samples ranged from 95 to 106%. Reproducibility was constant at each fatty acid level in the reaction mixture (n = 5, coefficient of variation [CV] < 2%). Absolute recovery determined from the sum of total fatty acids in standard reference material (SRM) 1846 (powdered infant formula) was 96.4%. Analysis of SRM 1846 gave results that agreed closely with the certified fat and fatty acid values. Analysis of commercial infant formula gave results that were comparable to those obtained with AOAC Method 996.01. The direct extraction methylation procedure is rapid, and the transesterification of acyl lipids to form FAMEs is complete within 15 min. Classical saponification and refluxing are not required. This method provides FAMEs free of interferences and easily quantitated by GC or confirmed by GC/mass spectrometry (MS). Unambiguous MS identification of individual FAMEs derived from pure standards, SRM 1846, and powdered infant formula product was obtained.

Novel application of PhastSystem polyacrylamide gel electrophoresis using restriction fragment length polymorphism--internal transcribed spacer patterns of individuals for molecular identification of entomopathogenic nematodes.

différences! [editorial] [editorial]onomic way of identifying and assigning nematodes to taxons, which had already been determined either by comparative sequence analysis of nuclear rDNA internal transcribed spacer (ITS) region or by other methods of molecular or conventional taxonomy, is provided. Molecular identification of entomopathogenic nematodes (EPN) can be upgraded by basing it on PhastSystem polyacrylamide gel electrophoresis (PAGE) analysis of restriction fragment length polymorphism (RFLP) patterns of polymerase chain reaction (PCR)-amplified DNA derived from single nematodes of Steinernema or Heterorhabditis spp. Although analysis from single worms has previously been made on agarose gel, the resolution on PhastSystem PAGE gel is much higher. The DNA sequences selected for analysis were those constituting the internal transcribed spacer region between the 18S and 26S rDNA genes within the rRNA operon. RFLP analysis was carried out by gel electrophoresis on the PhastSystem (Pharmacia) as detailed elsewhere (Triga et al., Electrophoresis 1999, 20, 1272-1277. The downscaling from conventional agarose to PhastSystem gels resulted in pattern of DNA fragments differing from those obtained with agarose gel electrophoresis under conventional conditions by increasing the number of detected fragments. The approach supported previous species identifications and was able to identify several unclassified isolates, such as those from Hungary and Ireland, and provides a method for identification of previously unclassified strains. We confirmed that Heterorhabditis "Irish Type", represented by two strains of different geographical origin, comprise a species different from H. megidis. We also confirmed that strain IS5 belongs to the species H. indicus rather than to H. bacteriophora, as had been suggested previously.

Asymptomatic intranasal abnormalities influencing the choice of nostril for nasotracheal intubation.

We have studied the prevalence of intranasal abnormalities that may influence the choice of nostril for intubation, using the fibreoptic laryngoscope, in 60 oral surgery patients presenting for nasotracheal intubation under general anaesthesia, who had no symptoms or signs of nasal obstruction. Videotape recordings were made during each nasendoscopy and later analysed by an anaesthetist and an otolaryngologist. A total of 68% of patients had intranasal abnormalities (10% bilateral and 58% unilateral) which resulted in one nostril being more patent than the other and therefore considered more suitable for intubation. The most common abnormality was deviated nasal septum which occurred in 57% of the study group; 22% were minor deviations, 13% were major deviations and 22% were impactions. Other abnormalities were simple spurs, unilateral polyp and hypertrophy of the inferior turbinate. In view of the relatively high incidence of intranasal pathology revealed on endoscopic examination, anaesthetists should consider using the fibreoptic laryngoscope to select the best nostril when performing nasotracheal intubation.

Zero control reference materials for infant formula methods development.

A zero control reference material (ZRM) for milk and soy-based infant formula was manufactured and characterized. The ZRM was free of retinyl palmitate and all-rac-alpha-tocopheryl acetate. The composition was similar to commercially available infant formula. The ZRM provides a valuable tool to ascertain method performance.

Learning fibreoptic skills in ear, nose and throat clinics.

We have compared the progress of anaesthetists taught fibreoptic techniques on awake patients in ear, nose and throat clinics with that of anaesthetists taught by traditional methods. Twelve anaesthetists participated in the study and were randomly allocated to the ear, nose and throat group or to the traditional training group. Each individual in the ear, nose and throat group attended the outpatient clinic and performed ten nasendoscopies on awake patient, whose upper airway had been anaesthetised with cocaine, under the supervision of an ear, nose and throat surgeon. Each individual in the traditional roup performed ten nasendoscopies on anaesthetised oral surgery inpatients under the supervision of an anaesthetist. To assess the effectiveness of the two training methods, each anaesthetist in each group then attempted ten fibreoptic nasotracheal intubations on anaesthetised oral surgery patients. There was no significant difference between either the success rates or mean successful tracheoscopy times between the two groups. Nasendoscopy training in the ear, nose and throat clinic appears to be good way of learning fibreoptic skills, which can then be readily applied to fibreoptic tracheal intubation in anaesthetic practice.

Prevalence and habitat specificity of steinernematid and heterorhabditid nematodes isolated during soil surveys of the UK and the Netherlands.

Entomopathogenic nematodes were isolated from soil samples collected during three separate surveys, two in the United Kingdom and one in the Netherlands. The nematodes were identified by their restriction fragment length polymorphisms on hybridization of Southern blots with a ribosomal DNA repeat unit clone. A total of eight steinernematid species/RFLP types and two heterorhabditids were isolated. The distributions of the majority of these species/RFLP types were significantly different between the three surveys and some of the species displayed a close association with certain habitat types.