Effect of primary neopharyngeal repair on acoustic characteristics of tracheoesophageal voice after total laryngectomy.

OBJECTIVES: The tracheoesophageal puncture technique of voice restoration enables successful voice rehabilitation after total laryngectomy. Because post-operative voice quality can vary significantly, depending on which type of hypopharyngeal repair is chosen, the aim of this study was to evaluate the effect of such repair on tracheoesophageal puncture voice after total laryngectomy. STUDY DESIGN: Prospective, clinical study. SETTING: Otolaryngology department, Tanta University, Egypt. METHODS: Tracheoesophageal puncture voice was quantitatively and qualitatively evaluated in 40 patients using a Provox 2TM prosthesis after standard total laryngectomy. The patients were divided, according to the type of hypopharyngeal repair, into four groups of 10 cases each, as follows: group one, pharyngoesophageal myotomy; group two, pharyngeal plexus neurectomy; group three, non-muscle vertical repair; and group four, transverse repair. These surgical groups were compared with each other with respect to different voice parameters. RESULTS: Patient profiles were almost equivalent in all surgical groups. The mean values of most of the parameters of quantitative tracheoesophageal puncture voice did not differ significantly, comparing the four surgical groups; however, a slightly significant difference was observed regarding loud intensity in the non-muscle repair group, and soft and loud jitter in the transverse repair group. Mean values for qualitative measures of intelligibility and communicative effectiveness did not show significant difference. However, a slightly significant difference was observed regarding fluency, word correctness, speaking rate and wetness, with higher values for all these parameters except wetness in the myotomy group, and higher values for wetness in the non-muscle repair group. CONCLUSION: The four hypopharyngeal repair types--primary pharyngoesophageal myotomy, pharyngeal plexus neurectomy, non-muscle vertical repair and transverse hypopharyngeal repair--were almost equivalent in prevention of pharyngoesophageal spasm in total laryngectomy patients who had undergone primary tracheoesophageal puncture for voice restoration.

Differential appearance of T cell subsets in the large and small intestine of neonatal mice.

We examined the appearance of intestinal intraepithelial lymphocytes (IEL) during the first 12 wk of life to gain insight into postnatal factors that contribute to the differences found between IEL in the large and small intestines of adult mice. Intestinal T cells were very infrequent at birth, but increased in number in the large and small intestine during the first 4 wk of life and then stabilized. The small intestinal epithelium at 2 wk of age contained mostly T cell receptor (TCR) alphabeta+, CD2+ T cells, unlike IEL in adult mice, which were composed of nearly equal proportions of CD2-, TCR alphabeta+ and TCR gammadelta+ cells. Between 2 and 3 wk of age, TCR gammadelta+, CD2- IEL increased greatly in the small intestine, whereas TCR alphabeta+ cells expressing CD2 decreased. By contrast, IEL in the large intestine at 2 and 3 wk of age were mostly TCR alphabeta+, CD2+ T cells similar to large intestinal IEL in adult mice. And finally, the expression of CD69 increased earlier and to higher levels on TCR alphabeta+ and TCR gammadelta+ IEL in the small intestine than in the large intestine. Our results demonstrate that IEL in the large and small intestine are phenotypically similar during suckling and that differences between these populations are established after weaning. Furthermore, the earlier accumulation of IEL with an activated adult IEL phenotype in the small intestine suggests that these T cells mature or expand in the gut and contribute to the maturation of immune function during postnatal life in mice.

Superior laryngeal nerve preservation in peri-apical surgery by mobilization of the viscerovertebral angle.

Iatrogenic lesions of the superior laryngeal nerve (SLN) are much more common than is generally recognized. Since injury to this nerve may cause transient or even persistent changes either in quality of voice or in deglutition, an attempt should be made to localize and identify the nerve during surgery. This study included 74 patients who underwent surgical dissection near the thyroid apex in the neck. Effective prevention of SLN injury during surgery was achieved by anatomical localization of the nerve in the viscerovertebral angle and its functional identification with the nerve stimulator. Post-operative analysis consisted of subjective interview, rigid laryngoscopy, acoustic analysis, laryngeal videostroboscopy and cricothyroid electromyography. Four patients complained of post-operative voice changes; two were diagnosed as SLN injury (2.4 per cent), one as reflux laryngitis and the fourth as intubation granuloma. Surgical access to the SLN in the periapical area may be achieved through mobilization of the viscerovertebral angle. The use of a nerve stimulator during difficult situations should keep SLN injury at a minimum.

Endoscopic revision surgery for recurrent epiphora occurring after external dacryocystorhinostomy.

Recurrent epiphora after external dacryocystorhinostomy (DCR) can be a frustrating experience for both the patient and the physician. We present the results of a retrospective study of 18 patients with epiphora recurring after external DCR who were operated upon to recreate lacrimal drainage through an endoscopic endonasal approach. The procedure was successful in 83.3% of cases, with no major complications. The results are comparable to those of an external approach, but the cosmetic advantages are clear. It is a 1-stage procedure that permits correction of associated intranasal disease that may be a causative factor in the recurrence of lacrimal obstruction. The endoscopic endonasal approach is a relatively safe and reliable option in the management of recurrent epiphora.

Amino acid substitutions reveal distinct functions of serine 186 of the ZEBRA protein in activation of early lytic cycle genes and synergy with the Epstein-Barr virus R transactivator.

The ZEBRA protein mediates the switch between the latent and lytic life cycles of Epstein-Barr virus. Z(S186A), a point mutant in ZEBRA's basic domain in which serine 186 is changed to alanine, is unable to induce expression of lytic cycle mRNAs or proteins from the latent EBV genome even though it retains the ability to activate transcription from reporters bearing known ZEBRA-responsive promoters (A. L. Francis et al., J. Virol. 71:3054-3061, 1997). We now describe three distinct phenotypes of ZEBRA mutants bearing different amino acid substitutions at S186. These phenotypes are based on the capacity of the mutants to activate expression of the BRLF1 and BMRF1 genes, which are targets of ZEBRA's action, and to synergize with the BRLF1 gene product Rta (R transactivator) in activating expression of downstream genes. One mutant class, represented by Z(S186T), was similar to the wild type, although reduced in the capacity to activate BRLF1 and BMRF1 early lytic cycle genes from the latent virus. A second class, represented by Z(S186C) and Z(S186G), was impaired in transcriptional activation, unable to activate early lytic cycle products from the latent virus, and not rescued by overexpression of Rta. A third class, Z(S186A), although unable by itself to activate BRLF1 or other lytic cycle genes, synergized with Rta. Rta rescued the capacity of Z(S186A) to activate the BMRF1 early lytic cycle gene from the latent virus. All mutant classes bound to DNA in vitro, although their capacity to bind to different ZEBRA response elements varied. Serine 186 of ZEBRA is a critical residue that is required for the distinct activities of induction of BRLF1 expression and for synergy with Rta. Since only Z(S186T) among the mutants behaved similarly to the wild type, activation of BRLF1 likely requires phosphorylation of S186. However, since Z(S186A) could synergize with Rta, synergy with Rta does not appear to be dependent on phosphorylation of S186. S186 likely mediates DNA recognition on the BRLF1 promoter in the context of the latent virus, protein-protein interactions, or both. The Z(S186) mutants define the amino acid side chains required for these functions.

A correlative manometric and endoscopic study of tubal function in chronic otitis media with effusion.

Since return of normal ventilation of the middle ear is a prerequisite for maintenance of an effusion-free ear state after tube fallout, it was our policy to study the tubal function in patients with chronic otitis media with effusion that had been treated with ventilation tubes (VT), and to correlate the manometric with the endoscopic findings. Normal manometric and endoscopic results indicated good tubal function, with an effusion recurrence rate of 11.1%. Abnormal manometric and endoscopic results indicated organic tubal obstruction that was, in most cases, correctable. Nasal endoscopy proved to be indispensable in diagnosing, localizing and even treating "hidden" lesions in their key areas that may be responsible for the obstruction. Thus, correction of the organic tubal obstruction must precede VT removal if recurrence of effusion is to be prevented. Whenever tubal obstruction is diagnosed as functional or idiopathic, ventilation of the middle ear should be maintained by frequent intubation or the insertion of long-term VT, and a guarded prognosis given.

Endoscopic transseptal sphenopalatine artery ligation for intractable posterior epistaxis.

The rigid nasal endoscope was used through a transseptal approach to reach the sphenopalatine foramen and to ligate its artery in 9 patients with intractable posterior epistaxis. Immediate and complete cessation of the bleeding uniformly occurred, except in 1 case, in which there was persistent bleeding on endoscopic examination of the nasal cavity at the end of the procedure. The ligature was checked and the artery was reclipped. Thereafter, the patient's recovery was uncomplicated and free of further epistaxis. Endoscopic transseptal sphenopalatine artery ligation offers a reliable option in the treatment of intractable posterior epistaxis. The submucoperiosteal dissection reduces bleeding, shortens operation time, and allows relatively easy identification of the sphenopalatine foramen. The procedure allows direct positive control of the major vessel supplying the posterior nasal cavity. It avoids the complications associated with transantral and pterygopalatine fossa surgery.

Stapedectomy for far-advanced otosclerosis.

Patients with far-advanced otosclerosis (FAO) may appear to be suffering from profound sensorineural hearing loss and are frequently directed to cochlear implantation programmes. In order to avoid such misdiagnosis, FAO should be considered in patients with non-measurable bone-conduction levels and air-conduction levels exceeding 85 dB. Specific clues can lead the clinician to suspect otosclerosis as the aetiology of hearing loss. A review of eight patients (nine ears) with FAO who underwent stapedectomy from 1985-1995 reveals that six of the eight (75 per cent) who had been unable to use a hearing aid preoperatively obtained serviceable hearing with a hearing aid after surgery. This confirms that cochlear implantation is not the best treatment for all profoundly deaf patients; some are better off with stapedectomy.

Proteoglycans from adult worms of Schistosoma haematobium.

Different types of proteoglycans (PGs) from adult worms of Schistosoma haematobium, were sequentially extracted using chaotropic agents under associative conditions (0.5 M GnCl), dissociative conditions (4 M GnCl) and detergents (Triton X-100 and SDS). The extracts were designated F1, F2, F3 and F4, respectively. The highest amount of uronic acid and carbohydrate was detected in the associative extract (F1) while the highest amount of protein was detected in the SDS extract (F4). Agarose polyacrylamide gel electrophoresis (A-PAGE) indicated the presence of a different PG in each extract with different electrophoretic mobilities. Agarose gel electrophoresis of glycosaminoglycan (GAG) separated from GnCl, associative and dissociative extracts, and the residue suggested the presence of dermatan sulphate in the two extracts and the residue, in addition to a GAG-like material found in the associative extract only. This glycosaminoglycan showed resistance to digestion with all mucopolysaccharidases and nitrous acid treatment. Gel filtration chromatography of associative extract on Sepharose CL-6B indicated the presence of three main uronic acid peaks (P1, P2 and P3). Chondroitin sulphate was the main GAG that could be detected in peak one (P1). Peak two (P2) contains carbohydrate and uronic acid but has no protein or absorbance at 280 nm. P2 has two types of GAGs: dermatan sulphate and a GAG-like material. The role of this PG in helping the adult schistosomes in evading immobilization by the host blood clotting cascade is discussed. Antibodies to peak one and peak two were detected in hamster sera infected with S. haematobium and S. mansoni using the ELISA test. The specificity of peak two was found to be evident in its low cross-reactivity (18.9%) when confronted with S. mansoni infected sera.

Endoscopic transseptal vidian neurectomy.

OBJECTIVE: Evaluation of the endoscopic transseptal approach of vidian neurectomy. DESIGN: A case series, with a follow-up of 12 to 24 months. SETTING: A referral center. PATIENTS: A consecutive sample of 11 adult patients with resistant vasomotor rhinitis: eight with severe rhinorrhea and three with recurrent nasal polyposis. All patients had a negative history of allergy and negative skin tests. All patients completed the study. INTERVENTION: The rigid nasal endoscope was used through a transseptal approach to reach the sphenopalatine foramen and to cut the vidian nerve. MAIN OUTCOME MEASURES: Intraoperative identification and cutting of the vidian nerve under direct endoscopic vision. Postoperative evaluation of rhinorrhea, sneezing, and recurrent disease. RESULTS: The vidian nerve was identified and sectioned bilaterally in all cases. Immediate and complete cessation of rhinorrhea uniformly occurred. Paroxysms of sneezing were vastly reduced. No recurrence was detected, except in one case. Three patients complained of dry eyes, but they had symptomatic relief with artificial teardrops. CONCLUSION: The technique of endoscopic transseptal vidian neurectomy is a minor surgical procedure with high efficacy and minimal postoperative morbidity. More cases and longer follow-up are necessary to provide long-term results.

The role of transcanine surgery in antrochoanal polyps.

During a period of two years, 24 cases of antrochoanal polyps were diagnosed by clinical examination, nasal endoscopy and computerized tomography. Surgery started with endoscopic transnasal removal of the polyp. Every attempt was made to remove the antral portion of the polyp through the wide ostium. Then transcanine sinuscopy was performed. Remnants of the polyp were detected and removed in five cases. One or more other cysts were found and extirpated in 11 cases. Endoscopic follow-up for 18 months to three years revealed no recurrence. It is recommended that endoscopic middle meatal surgery should be combined with transcanine sinuscopy to ensure complete removal of antrochoanal polyps.

The use of the rigid endoscope in trans-sphenoidal pituitary surgery.

The use of the rigid endoscope has been evaluated during transsphenoidal microsurgery of 10 pituitary adenomas: three were prolactin-secreting adenomas; five growth hormone (GH)-secreting adenomas; and two without evidence of known endocrine activity. The use of the endoscope allowed close inspection and differentiation between tumour tissue and glandular remains. This resulted in microdissection of the tumour with maximum preservation of pituitary function. The angled view of the telescope helped total gross removal of tumour tissue from the less accessible supra- and para-sella extensions. More cases and a longer period of follow-up are necessary to provide long-term results.

Manometric and endoscopic study of tubal function in drum perforation.

Since good ventilation of the middle ear is a prerequisite to successful myringoplasty, it was our policy to study the tubal function in dry central perforation of the drum and to correlate the manometric with the endoscopic findings. Normal manometric results with patency of the tube (as proved by fluorescein-endoscopy) indicated good tubal function, with good prognosis for myringoplasty. Abnormal manometric results with failure of fluorescein to pass into the nasopharynx indicated mechanical tubal obstruction that was, in most cases, correctable. Nasal endoscopy proved to be indispensable in diagnosing, localizing, and even treating "hidden" lesions in their key areas that may be responsible for the obstruction. Thus, the correction of the mechanical tubal obstruction must precede ear surgery. Whenever tubal obstruction is diagnosed as functional or idiopathic, the ventilation of the middle ear should be facilitated during ear surgery by addition of a tympanostomy tube to the graft or drum remnant, with guarded prognosis.

Endoscopic management of posterior nasal obstruction.

The use of the rigid endoscope has been investigated in the management of 63 cases with posterior nasal obstruction. It was found to be a true advance in rhinology, since it visualizes and localizes the site of the obstruction which is classified into pre-choanal, and post-choanal. Moreover, the nasal endoscope allowed complete and safe removal of most of the obstructing lesions under direct endoscopic vision.

Radiological and endoscopic study of the maxillary sinus in primary atrophic rhinitis.

The maxillary sinuses of 40 patients suffering from primary atrophic rhinitis (ozaena) were studied radiologically, antroscopically and histopathologically. Sixty per cent of the patients showed thick bony walls and a small cavity of the maxillary sinus on X-ray and on antroscopy. On the other hand, 25 per cent of the cases revealed signs of infection including mucopurulent secretion on antroscopy associated with corresponding histopathological changes. It is concluded that poor pneumatization of the antrum plays a more important role in the pathogenesis of ozaena than infection.

Endoscopic transcanal myringoplasty.

The role of the rigid endoscope has been evaluated in the management of 36 cases with dry central perforation of the tympanic membrane. The graft take rate was 91.7 per cent and the air-bone gap was closed to less than 10 dB in 83.3 per cent. The use of the rigid endoscope in the management of dry central perforation of the drum represented a significant advance in middle ear surgery. It is used, in correlation with manometry, to evaluate the tubal function before ear surgery and to treat hidden causes of tubal obstruction. It replaces the operating microscope in observation and surgery of the tympanic membrane perforation. It overcomes anatomical variations that hamper access to the entire tympanic membrane during ear surgery. It provides an extremely sharp image with high resolution.

Endoscopic endonasal surgery of posterior choanal atresia.

The use of the rigid endoscope in the management of posterior choanal atresia represents a significant advancement in choanal surgery. It provides an extremely sharp image with a magnified overview. It enables the surgeon to see the tips of his instruments, so that the bone is removed safely under direct endoscopic vision. It allows assessment of the size of the opening, in comparison to the normal choana. It ensures greater precision in flap preservation. The technique is short in time and safe, with early recovery and short hospitalization.

The role of endoscopic laterofixation of the vocal cord in the treatment of bilateral abductor paralysis.

Different techniques were compared in management of 36 patients with bilateral abductor paralysis of the vocal cords. Ten patients were treated by microsurgical arytenoidectomy through a mid-line thyrotomy, with successful decannulation in only three. Fifteen patients were treated by endolaryngeal microsurgical arytenoidectomy, with failure to decannulate four cases. The procedure of endoscopic laterofixation of the vocal cord was used to treat 11 patients. Ten patients had an adequate long-lasting airway with a socially acceptable voice function. One patient had a revision surgery and was successfully decannulated. The technique was found to be a reliable option in the management of bilateral abductor paralysis. It is a modifiable procedure with a feasibility to adjust the position of the vocal cord under endoscopic control. It can be combined with endolaryngeal arytenoidectomy if the gain in the airway size produced by laterofixation is found insufficient.

A correlative manometric and endoscopic study of tubal function in dry central perforation of the tympanic membrane.

Since good ventilation of the middle ear is a pre-requisite for successful myringoplasty, it was our policy to investigate the tubal function in dry central perforation of the eardrum and to correlate the manometric and endoscopic findings. Nasal endoscopy proved to be indispensable in diagnosing mechanical tubal obstruction and in localizing and even treating 'hidden' lesions in key areas, with probable normalization of the tubal function. The correction of the mechanical tubal obstruction must precede ear surgery. Whenever tubal obstruction is diagnosed as functional or idiopathic, the ventilation of the middle ear should be guaranteed during ear surgery by addition of a tympanostomy tube to the graft or drum remnant, and a guarded prognosis given.