Preseptal transconjunctival approach for orbital floor fracture repair: ophthalmologic results in 209 patients.

CONCLUSIONS: The transconjunctival approach to orbital floor fractures permits excellent exposure of the inferior orbit and provides a good surgical outcome, especially with regard to ocular motility. OBJECTIVE: Surgical access to orbital floor fractures can be accomplished via the transconjunctival approach. The majority of studies on this subject deal with surgical aspects and complications. The purpose of this study was to report the ophthalmologic outcome after transconjunctival orbital floor fracture repositioning in a significant number of patients. MATERIAL AND METHODS: In a retrospective study, the data of 209 patients with orbital floor fractures treated via the transconjunctival approach with (n=181) and without (n=28) lateral canthotomy were analyzed. RESULTS: The commonest cause of injury was forms of violence (32%). An isolated fracture of the orbital floor had occurred in 62 cases, while concomitant facial fractures were present in the remaining 147. A total of 24 patients (11%) had an exophthalmos and 13 (9%) an enophthalmos. Most patients (69%) complained of infraorbital dysesthesia. When elevating the eyeball, the majority of patients showed a marked or severe disturbance of ocular motility (53% in abduction; 51% in adduction) and diplopia (37% in abduction; 36% in adduction). Thirteen patients required repeat surgery. After a follow-up period of 2 years, infraorbital dysesthesia was observed in only three patients, one of whom presented with a considerable persistent enophthalmos of 4 mm, and only four patients had persistent reduced motility and diplopia.

Interference between muscle relaxation and facial nerve monitoring during parotidectomy.

CONCLUSION: There is a worst case scenario involving a small risk of facial nerve injury and dysfunction of facial nerve monitoring. With regard to patient safety the use of a short-acting muscle relaxant and the analysis of neuromuscular blockade are necessary because these permit documentation of the temporal course of relaxation and the progress of surgery. OBJECTIVES: The use of muscle relaxant may disturb facial nerve monitoring during parotidectomy. The aim of the study was to analyze the duration of muscle relaxation in relation to the progress of surgery. STUDY DESIGN/METHODS: Twenty-one patients who underwent parotidectomy were enrolled in this prospective study, where the short-acting muscle relaxant mivacurium (0.2 mg/kg) was used. The neuromuscular blockade was monitored on the basis of train-of-four (TOF) peripheral stimulation. The time of intubation, skin incision, facial nerve identification and the end of surgery were documented. RESULTS: The mean times of the TOF ratios (2/4; 3/4; 4/4), skin incision, and facial nerve identification differed significantly (chi(2)=0.05; df=1; p>0.05). For the earliest skin incision (21 min), 14.3% of patients have a TOF ratio smaller than 2/4 at which a neuromuscular block of the facial nerve is possible.

Localization of a remembered target under the influence of different head and body positions.

Previous investigations analyzed the effect of semicircular canal stimulation on the localization of a remembered target and found additional indications that different head positions affect the test results. Therefore, the aim of the present study was to analyze the influence of different head and body positions on the localization performance towards a remembered target. The pointing error (PE) towards a remembered target was investigated in 24 right-handed volunteers (12 females, 12 males; mean age 23 years) under six different head and body positions (sitting upright with the head tilted forward/backward by 45 degrees ; sitting upright with a head displacement of 90 degrees to the right/left relative to the body; lying on the right/left side of the body). Evaluation parameters were the horizontal and vertical PE (in degrees). Head displacement to the left relative to the body led to a PE to the right side and head displacement to the right led to a PE to the left (ANOVA P<0.001; df=5; F=16.92). An upward PE occurred when the head was tilted forward by 45 degrees and a downward PE could be proved when the head was tilted backward by 45 degrees (ANOVA P<0.001; df=5; F=35.78). In summary, any change in the relation between head and body position led to a systematic PE towards the frontal plane of the body (i.e. the plane located in the axis between both shoulders). Taken together, the systematic PE in direction to the frontal body plane suggests that the location of the remembered target is coded and remembered in a frame linked to the body and not transformed into a head-centered frame of reference.

Effect of the status after ear surgery and ear pathology on the results of infrared tympanic thermometry.

Most publications that deal with infrared tympanic thermometry (ITT) have performed a comparison between the established temperature measurements and ITT. However, to date an understanding of the influence of pathological ear findings on ITT test results is incomplete. Therefore, in the present study ITT was performed in healthy adults (n =21), adult patients with monaural central perforation (n =31) or strong scar formations (n =24) of the tympanic membrane and 18 adult patients after monaural canal wall down surgery. Right and left ear and oral temperature were measured three times by one investigator in a room with a constant temperature of 20-22 degrees C. Between every measurement there was a free time interval of 2 min. In healthy adults (36.50 degrees C vs. 36.51 degrees C) patients with monaural central perforation of the tympanic membrane (36.41 degrees C vs. 36.34 degrees C) and with monaural strong scar formations in the tympanic membrane (36.39 degrees C vs. 36.45 degrees C), no significant difference between the right and left ear could be proved. In contrast to this, a significantly higher temperature in the surgically treated ear compared to the healthy side (36.97 degrees C vs. 36.31 degrees C; P <0.001) occurred in patients with a status of after monaural canal wall down surgery. In summary, it could be demonstrated that, in contrast to minor ear surgery, major ear surgery such as canal wall down has a significant influence on the results of ITT. If a patient's history gives reference to previous ear surgery, an otoscopic examination is necessary in order to exclude the presence of an after-canal-wall-down surgery status and thus to avoid false ITT test results.

The minimal ice water caloric test compared with established vestibular caloric test procedures.

Caloric testing of the vestibular labyrinth is usually performed by classical caloric test procedures (CCTP) using water warmed to 30 degrees C and 44 degrees C. Ice water irrigation (4 degrees C) is usually not performed, although it might be useful as a bedside test. To verify the validity of the Minimal Ice Water Caloric Test (MIWCT), comparative video-oculographic investigations were performed in 22 healthy subjects using ice water (0.5 ml, 1.0 ml, 2 ml), CCTP, and cold air (27 degrees C). Frequency, amplitude, slow phase velocity (SPV), the onset, and the duration of nystagmus were documented. After addition of three ice cubes, the temperature of conventional tap water (16 degrees C) fell within 13 min to 4 degrees C. In pessimum position the subjects demonstrated no nystagmus response. Compared to CCTP, MIWCT was associated with a significantly later onset of nystagmus and a significant prolongation of the nystagmus reaction. In contrast to air stimulation (27 degrees C), a significant Spearman's correlation was noted between MIWCT (1 and 2 ml) and established CCTP in respect of essential nystagmus parameters (frequency, amplitude and SPV). Furthermore, MIWCT (0.5 and 1 ml) showed a higher sensitivity and specificity with regard to the detection of canal paresis based on Jongkees' formula compared to stimulation with air 27 degrees C. Thus, MIWCT appears to be a suitable procedure for bedside investigation of vestibular function outside the vestibular laboratory, e.g. in a hospital ward, where bedridden patients with vertigo occasionally require vestibular testing.

Juvenile psammomatoid ossifying fibroma of the neurocranium. Report of four cases.

Juvenile psammomatoid ossifying fibroma (JPOF) is a benign fibroosseous lesion predominantly arising within the paranasal sinuses in children and young adults. Neurocranial occurrence is exceedingly rare and a location within the neurocranial portion of the temporal bone has not been described. The authors report on one case of sinonasal JPOF secondarily extending into the cranial cavity and three cases primarily affecting the neurocranial bones to increase clinical awareness of this uncommon tumor, which may be easily mistaken for meningioma. Moreover, the absence of activating missense mutations of the GNAS1 gene in two cases strongly argues against a relationship between JPOF and fibrous dysplasia.

Effect of angular acceleration on the localization performance of a remembered target.

Both the influence of a remembered "earth-fixed" target (RT) on the vestibulo-ocular reflex and the effect of "unilateral cold caloric vestibular stimulation" on the localization of a RT have previously been proved. As "unilateral caloric stimulation" is not a physiological stimulus, the aim of the present study was to analyze whether even physiological "bilateral vestibular stimulation" (rotation) is able to affect the RT position. The pointing error (PE) towards an RT both without and following angular acceleration was investigated in 24 healthy volunteers. Postrotatory nystagmus response was recorded by electronystagmography. Evaluation parameters were "nystagmus frequency", "total amplitude" and "velocity of the slow phase"; the horizontal and vertical PE. The fixation of an RT led to a significant reduction of about 28% in nystagmus amplitude compared to the test condition in darkness. "After rotatory stimulation" a systematic horizontal PE in the direction of the fast phase of the postrotatory nystagmus (direction of "illusory self-rotation") occurred and the magnitude of this PE increased significantly compared to the test situation "without vestibular stimulation", but showed only a non-uniform negative correlation with two of the nystagmus parameters. It has to be concluded that "after rotatory stimulation", in contrast to "unilateral cold caloric vestibular stimulation", the subjective sense of "illusory self-motion" leads to a horizontal PE in the direction of the nystagmus fast phases.

Comparison of ultrasonography and conventional radiography in the diagnosis of nasal fractures.

OBJECTIVE: To compare the diagnostic findings of ultrasonography and radiography in nasal fractures. DESIGN AND MAIN OUTCOME MEASURES: In this prospective study, 63 patients (23 female and 40 male; mean age, 26.8 years) with clinical signs of a nasal bone fracture were investigated. All patients underwent radiography (lateral view of the nose plus occipitomental view) and ultrasonography (10-MHz ultrasound scanner) of the nasal dorsum and the lateral nasal walls and a clinical examination by 2 consultants. Thirty-six patients underwent nasal fracture reduction. Two radiographs and 3 ultrasound images of each patient were analyzed by 2 experienced readers at different times. After assessing the nasal dorsum and lateral nasal walls in radiographs and ultrasound images, they decided whether the nose was fractured or not or whether the results were uncertain. The results were analyzed by various statistical testing methods (for sensitivity, specificity, positive and negative predictive value, and accuracy). RESULTS: Assessment of the lateral nasal walls revealed that ultrasonography was statistically superior (P = .04) to radiography. In contrast, assessment of the nasal dorsum showed radiography to be statistically superior (P = .01) to ultrasonography. Assessment of the nasal pyramid revealed no statistical difference between radiography and ultrasonography (P = .91). CONCLUSION: In assessment of the nasal pyramid, ultrasonography can be considered an alternative to radiography, with equivalent diagnostic performance.

Clinical and experimental investigations of spontaneous impedance changes of the middle ear.

The major symptoms of glomus tympanicum tumors are pulsatile tinnitus and spontaneous impedance changes (SICs) of the middle ear. On the other hand, SICs often occur even in the absence of pathological findings. The aim of this study was to analyze the occurrence of SICs in patients and healthy volunteers. We retrospectively evaluated 184 patients with SICs and/or complaints of periodic tinnitus. Most of them (n = 134) showed pulse-synchronous SICs. Pathological findings were recorded in only 66 patients. Binaural SICs were registered significantly (p = .03) more frequently in patients with arterial hypertension (63% versus 18%). Because of the positive correlation between arterial hypertension and the occurrence of SICs, the influence of increasing blood pressure (systolic blood pressure > 160 mm Hg after physical activity) on the occurrence of SICs was investigated in a prospective trial in healthy test subjects (n = 42). In 17 of them, pulse-synchronous SICs occurred for the first time or were registered at a lower sensitivity level after an increase in blood pressure. In summary, only half of the patients with pulse-synchronous SICs showed pathological findings. A significant correlation between high blood pressure and binaural pulse-synchronous SICs was demonstrated in patients with arterial hypertension and healthy volunteers after physical activity.

Effect of ethanol on visual-vestibular interactions during vertical linear body acceleration.

BACKGROUND: Ethanol led to disturbed dynamic visual acuity (DVA) during vertical linear acceleration (VLA; amplitude, 5 cm; frequency, 1.2 Hz). The aim of this study was to analyze whether suppression of visual-oculomotor or vestibular pathway is responsible for the disturbance of DVA. METHODS: Twenty volunteers were investigated before and after ethanol consumption (mean breath alcohol concentration, 0.32 mg/liter). Vertical eye movements and linear head acceleration were recorded. Tested stimuli were vestibular (VLA in the dark), visual (smooth pursuit), and combined (VLA plus fixation on an earth-fixed target) stimulation; visual suppression (VLA plus fixation of a head-fixed target); static visual acuity; and DVA. Parameters of analysis were gain, sensitivity, eye velocity and amplitude, latency between onset of head acceleration and start of eye movement, correct and wrong answers during static visual acuity and DVA testing, feeling of drunkenness (FOD), and breath alcohol concentration. RESULTS: Both during isolated visual and during combined visual-vestibular stimulation, alcohol induced a significant latency increase. Furthermore, DVA was disturbed after ethanol consumption. Test subjects with a strong alcohol-induced disturbance of DVA presented during isolated visual stimulation a significantly higher latency change than volunteers with a minor alcohol-induced disturbance of DVA. On the basis of the FOD, two groups were formed (one with a slight and one with a strong FOD). The two groups differed significantly concerning the alcohol-induced latency increase during isolated visual stimulation and the alcohol-induced disturbance of DVA. CONCLUSIONS: Ethanol leads to a disturbance of the visual-oculomotor system and, thus, even during combined visual-vestibular stimulation, to a latency increase. This "delay" is responsible for the disturbance of DVA. This alcohol-induced suppression of the visual-oculomotor system and the disturbance of DVA show a significantly positive correlation with the subjective FOD.

Bacteria and granulation tissue associated with Montgomery T-tubes.

OBJECTIVES: Although complications (infection, development of granulation tissue) of silicone Montgomery T-tubes have been reported, the microbiological consequences and the origin of granulation tissue have not yet been evaluated. STUDY DESIGN: A prospective trial. METHODS: Twenty-three Montgomery T-tubes from 10 patients were analyzed with regard to the development of granulation tissue, bacterial growth (including genotyping with polymerase chain reaction), and results of sensitivity testing. Furthermore, stent sterilization (n = 6) was investigated. RESULTS: Granulation tissue occurred with 74% of the stents, and all specimens showed signs of infection but no foreign body reaction. The predominant organisms were Staphylococcus aureus (35%) and Pseudomonas aeruginosa (17%). The differences between groups with and without granulation tissue were significant for P aeruginosa. Polymerase chain reaction fingerprinting of the S aureus obtained from 15 stents (n = 3 patients) revealed a total of seven different genotypes. Whereas two of these patients harbored six different genotypes of S aureus, the third patient was persistently colonized by S aureus over a 15-month period with the identical genotype. Susceptibility testing showed most commonly (65%) sensitivity to a combination of amoxicillin-clavulanate and ofloxacin. After sterilization, 92% of analyzed stent segments showed no bacterial growth. CONCLUSIONS: Granulation tissue commonly occurred next to the silicone (subglottic area, stoma) where S aureus and P aeruginosa were commonly isolated. A combination of mechanical irritation and bacterial infection seems to account for the development of granulation tissue. Polymerase chain reaction fingerprinting showed both prolonged persistence and a change of colonizing strains after multiple stent replacements. A combination of amoxicillin-clavulanate and ofloxacin is the most effective antibiotic therapy. Sterilization of the cost-intensive silicone stents is feasible, and reuse in the same patient is justifiable from economic aspects.

The vertical linear vestibulo-ocular reflex in patients with a hyperactive response during horizontal angular acceleration.

OBJECTIVE: In clinical routine, some patients show a bilateral hyperactive response of the angular vestibulo-ocular reflex (AVOR). The aim of this prospective study was to determine whether these patients also show hyperactivity of the linear VOR (LVOR). MATERIAL AND METHODS: In 10 patients with a hyperactive AVOR (total amplitude of post-rotatory nystagmus > 400 degrees per 30 s) and 10 healthy subjects the AVOR (stopped after 180 s of rotation at 90 degrees/s) and vertical LVOR (amplitude 5 cm, frequency 1.2 Hz) were tested with eyes open in the dark. During vertical linear acceleration, each subject was instructed to look at an earth-fixed target and they performed vertical smooth pursuit as stationary observers. RESULTS: The mean eye velocity of the AVOR was significantly higher in the patients than the healthy subjects (19 vs 5 degrees/s; p = 0.00016). During vertical linear acceleration in darkness (49 vs 23 degrees/s; p = 0.004) and combined maculo-visual stimulation (88 vs 52 degrees/s; p = 0.007) the patients showed a significantly higher mean vertical eye velocity. When vertical smooth pursuit was performed, no significant differences were registered. All 20 subjects showed a significant (p = 0.01) positive Spearmnan correlation (rs = 0.79) between the eye velocities of AVOR and LVOR. CONCLUSION: Patients with a hyperactive AVOR also showed hyperactivity of the LVOR. Because two different sensory end organs and neuronal pathways are involved in these responses, a central rather than a peripheral vestibular lesion must be held responsible.

The effect of optical devices and repeated trials on the velocity of saccadic eye movements.

OBJECTIVE: The purpose of this prospective study was to analyze the effect of glasses and contact lenses on the latency and velocity of visually evoked saccadic eye movements. MATERIAL AND METHODS: A saccadic test was performed 10 times on 20 emmetropic controls (Group A) and 20 ametropic test subjects with myopia (Group B) who were using glasses (Subgroup Bg) or contact lenses (Subgroup Bc). RESULTS: No training or fatigue effect on either latency or eye velocity was registered. Regardless of visual acuity (Group A or B) or of the optical device used (Subgroup Bg or Bc), no significant intergroup difference in latency could ultimately be established. Subgroup Bc showed a significantly slower eye velocity than Group A. Regardless of the optical device used, subjects with a higher degree of myopia (> 6 D) showed a lower eye velocity than the Group A controls. Additionally, saccadic velocity was lower in this subgroup ( > 6 D) in subjects using contact lenses than in those using glasses. CONCLUSION: These results demonstrate that optical devices have an influence on the electronystagmographical analyses of the vestibulo-ocular reflex that must be taken into consideration, particularly in scientific investigations.