Conquering the castle: a novel technique for the middle fossa approach in facial decompression.

OBJECTIVE: To describe 2 subapproaches of the middle fossa approach: the transillumination method and transection of lines using the foramen spinosum, greater superficial petrosal nerve, and trigeminal impression to locate the malleus head for safe identification and decompression of the geniculate ganglion and facial nerve. STUDY DESIGN: Cadaver study. SETTING: A tertiary university hospital anatomy laboratory. SUBJECTS AND METHODS: The present study was conducted using 7 formalin-fixed cadaver heads (14 sides). A 0° endoscope was introduced into the external ear canal toward the posterosuperior quadrant of the tympanic membrane, after which transillumination was used to locate the malleus head. The brightest point indicated the convergence of the greater superficial petrosal nerve and a line drawn along the superior semicircular canal. An additional line was drawn parallel to the petrous ridge from the foramen spinosum and along the pathway of the greater superficial petrosal nerve. A third line connected the trigeminal impression to the zygomatic root. The area posterior to the intersection of these 2 lines separately with the third line was considered the zone of location of the malleus head. Among 17 patients undergoing surgery for facial paralysis between 1993 and 2011, transillumination was used in 6 patients to identify the malleus head to locate the geniculate ganglion. RESULTS: These techniques were proven to be reliable in locating the malleus head to find the geniculate ganglion in 14 dissected cadaveric temporal bones. CONCLUSION: Two methods of locating the malleus head for facial decompression were defined.

Prevention of cisplatin ototoxicity: Efficacy of micronized flavonoid fraction in a guinea pig model.

OBJECTIVE: To evaluate the effectiveness of micronized flavonoid fraction in preventing cisplatin ototoxicity in a guinea pig model. METHODS: This study was conducted on 23 guinea pigs in the Animal Laboratory of Izmir Atatürk Training and Research Hospital. Animals were divided into three groups: Group 1 consisted of eight animals receiving cisplatin only; Group 2 contained eight animals receiving cisplatin+micronized flavonoid fraction; and Group 3 contained seven animals that received micronized flavonoid fraction only. Their cochlear reserve was evaluated by measuring the distortion product otoacoustic emission on days 0 and 7. RESULTS: In Groups 1 and 2, the intragroup signal-noise ratios were statistically different at all frequencies tested (based on negative ranks, p<0.05). In Group 3, the intragroup signal-noise ratios did not differ significantly at the frequencies tested (p>0.05). Comparison of the three groups showed statistically significant differences among the groups (p<0.05). The post hoc Bonferroni correction showed statistically significant differences among all three groups (p<0.016). The median signal-noise ratio of the three groups tended to increase (z-value was positive for all the frequencies tested; p<0.01). CONCLUSION: Micronized flavonoid fraction (Daflon) is effective against cisplatin-induced ototoxicity in guinea pigs.

Increased expression of VEGF, iNOS, IL-1ß, and IL-17 in a rabbit model of gastric content-induced middle ear inflammation.

OBJECTIVE: To investigate the histopathological changes and the expression of vascular endothelial growth factor (VEGF), inducible NO-synthase (iNOS), endothelial NO-synthase (eNOS), interleukin (IL)-1ß, and IL-17 in the rabbit middle ear mucosa after direct gastric content exposure. METHODS: Exploratory controlled study in which histological and immunochemical features were studied after gastric content-induced inflammation was established in rabbits. Sixteen healthy rabbits were divided into two equal groups. Gastric contents of an animal were injected into the middle ear of the same animal for 20 days. Saline was injected into the middle ear of the animals in the control group. The rabbits were humanely killed on day 27. Inflammation was assayed by light microscopy. Immunochemical staining was performed for VEGF, iNOS, eNOS, IL-1ß, and IL-17 expression. Experimental and control animals were examined using the same protocol. RESULTS: The expression levels of VEGF, iNOS, IL-1ß, and IL-17 differed significantly between the experimental and control groups (p=0.018, p=0.010, p=0.002, and p=0.002, respectively). The expression level of eNOS was not significantly different between the two groups (p=0.132). CONCLUSION: This study demonstrates that gastroesophagial reflux induced middle ear inflammation is associated with increased expression of VEGF, IL-1ß, IL-17, and iNOS.

Serum matrix metalloproteinases and tympanosclerosis.

AIM: To investigate levels of matrix metalloproteinases 2 and 9, and of their tissue inhibitor (i.e. tissue inhibitor matrix metalloproteinase 1), in the serum of patients with tympanosclerosis. MATERIALS AND METHOD: We included 40 patients (age range 13-63 years) who had undergone surgery in the ENT department of Izmir Atatürk Training and Research Hospital between 2002 and 2007. Twenty had uncomplicated chronic otitis media and 20 had tympanosclerosis. We also included as the control group 20 individuals with no history of previous otic complaints or systemic or infectious disease. Serum levels of serum matrix metalloproteinases 2 and 9 and of tissue inhibitor matrix metalloproteinase 1 were measured in all subjects and compared. RESULT: Significantly higher levels of serum matrix metalloproteinases 2 and 9 were found in the tympanosclerosis group, compared with the chronic otitis media and control groups. There was no statistically significant difference in tissue inhibitor matrix metalloproteinase 1 level between the three groups. CONCLUSION: Tympanosclerosis surgery has poor success rates, since the pathological process is still active. We suggest that high levels of matrix metalloproteinases may play a role in the continuation of the disease process.

Correlation between the serum values of soluble intercellular adhesion molecule-1 and total sialic acid levels in patients with breast cancer.

BACKGROUND: In this study, we aimed to investigate serum total sialic acid (TSA) and soluble intracellular adhesion molecule-1 (sICAM-1) levels in breast cancer patients to find a correlation with the cancer stage. METHODS: The parameters from sera of 61 patients with breast cancer were measured. The concentrations of serum sICAM-1 and TSA were measured in serum samples from 61 patients with breast cancer and 25 healthy control subjects using enzyme-linked immunoassay and thiobarbituric acid method. RESULTS: Mean serum sICAM-1 and TSA levels were significantly higher in the total patient group than in the control group (p < 0.001). Thus, the correlation between TSA and sICAM-1 became more significant in metastatic breast cancer. There were significant positive correlations between TSA and sICAM-1 in stage I+II (r = 0.59, p < 0.05), stage III (r = 0.47, p < 0.05), and stage IV (r = 0.89, p < 0.01), and total patient group (r = 0.56, p < 0.001). CONCLUSION: SerumsICAM-1 and TSA levels were higher in patients with breast cancer, than that of the control group, and also in the metastatic breast cancer group. Significant correlations between serum sICAM-1 and TSA may reflect the similar function of these molecules as adhesion molecules, and their roles in the carcinogenesis of breast cancer as well as metastasis.

Intussusception in adults.

To review clinical, radiological and histopathological findings of adult intussusception and its management, 18 adult patients who had been treated surgically because of intussusception were reviewed. Of the patients, 5 (27.8%) had idiopathic intussusceptions, while the other 13 (72.2%) had a definable intraluminal pathology. The site of the intussusception was more common in the small bowel (83.3%) than the colon (16.7%). Ultrasonography and computed tomography were successful in demonstrating "target lesion" in 80% and 75% respectively. Patients with idiopathic intussusception were treated with simple reduction, while the others underwent segmental resection because of the possibility of malignant tumour. In contrast to intussusception in childhood, intussusception in adults usually has a definable lead point and resection of the involved bowel, rather than simple reduction, is indicated.

Neurological complications of prolonged hunger strike.

We investigated neurological findings in 41 prisoners (mean age: 28.6) who participated in a hunger strike between 2000 and 2002. All cases were evaluated using neuropsychological, neuroradiological, and electrophysiological methods. The total duration of fasting ranged from 130 to 324 days (mean 199 days). All cases had 200-600 mg/day thiamine orally for 60-294 days (mean 156) during the hunger strike, and had neurological findings consistent with Wernicke-Korsakoff syndrome. All 41 patients exhibited altered consciousness which lasted from 3 to 31 days. All patients also presented gaze-evoked horizontal nystagmus and truncal ataxia. Paralysis of lateral rectus muscles was found in 14. Amnesia was apparent in all cases. Abnormal nerve conduction study parameters were not found in the patient group, but the amplitude of compound muscle action potential of the median and fibular nerves and sensory nerve action potential amplitude of the sural nerve were lower than the control group, and distal motor latency of the posterior tibial nerve was significantly prolonged as compared with the control group. The latency of visual evoked potential was prolonged in 22 cases. Somatosensory evoked potential (P37) was prolonged but not statistically significant. Our most significant finding was that the effect of hunger was more prominent on the central nervous system than on the neuromuscular system, despite the fact that all patients were taking thiamine. In our opinion, partial recovery of neurological, and neurocognitive signs in prolonged hunger could be a result of permanent neurological injury.

Late complications of incisional hernias following prosthetic mesh repair.

BACKGROUND: Incisional hernias still continue to be a serious problem for surgeons. In this study, we aimed to investigate the effects of polypropylene mesh and mersilene mesh, which are frequently employed in incisional hernias, as well as the effects of their application techniques on late complications. METHODS: Two-hundred-sixty-four open abdominal hernia repairs were performed between 1986--2000, using prosthetic materials: polypropylene mesh and mersilene mesh were used in hernia repair. Mesh was placed as onlay, underlay and sandwich techniques. Follow-up data were obtained from medical records. RESULTS: Comparisons were made with respect to surgical techniques and to late complications such as recurrence, enterocutaneous fistula, intestinal obstruction, and infections. Enterocutaneous fistulas developed in two patients. Recurrence occurred in 6.4 per cent. Chronic infection and wound sinus formation occurred in 5 per cent. The causes of recurrence included smoking, cellulitis, chronic infection/sinus tract, upper abdominal localization, and obstruction. Fistula formation occurred in patients with no peritoneal prevention, which was statistically significant (p=0.012). Chronic infection/sinus tract was high in patients for whom mersilene mesh was used, and enterocutaneous fistula occurred in 2 patients. CONCLUSION: To prevent late complications, it is necessary to avoid the contact of mesh with bowel.

A brief behavioural treatment of chronic post-traumatic stress disorder in earthquake survivors: results from an open clinical trial.

BACKGROUND: Natural disasters such as earthquakes affect large numbers of people. Given the extent of the mental health problem following earthquakes, brief, effective and cost-effective treatment interventions are urgently needed. The present study examined whether cognitive-behavioural treatment could be shortened to a minimum number of sessions without undermining its effectiveness in post-traumatic stress disorder (PTSD). METHOD: The study participants (N=231) were consecutive referrals to five project sites in the earthquake region in Turkey a mean of 13 months after the disaster. A modified behavioural treatment (BT) was used, which involved self-exposure instructions based on an enhancement of 'sense of control' rather than a habituation rationale and minimal cognitive interventions. The duration of treatment was variable, involving as many sessions as required for clinical improvement. Survival analysis was used to explore the minimum number of sessions required for clinical improvement, and multiple regression analysis to examine the predictors of outcome. RESULTS: The survivors received a mean of 4-3 sessions. Significant treatment effects and clinically meaningful effect sizes were noted on all measures. The treatment improved all PTSD and depression symptoms. The cumulative proportion of improved cases was 76% after one session and 88% after two sessions. No baseline variable predicted treatment outcome. CONCLUSIONS: The modified BT appears to be promising as an effective one- or two-session intervention for earthquake survivors. It may be particularly useful in large-scale disasters as a cost-effective treatment that can be relatively easily disseminated to mass populations. Further research is needed to clarify the possible role of a treatment focus on sense of control in rapid recovery from traumatic stress.

Olanzapine efficacy in the treatment of essential tremor.

We investigated the anti-tremor effect of olanzapine, a novel atypical antidopaminergic drug, in 37 patients with essential tremor (ET) in an open-label and prospective study by clinical scoring and patient self-evaluation. Olanzapine monotherapy appears to be efficacious for the treatment of ET. Further clinical trials with control groups are indicated to establish the efficacy of olanzapine in patients with ET.

Intrabiliary rupture in liver hydatid cysts: results of 20 years' experience.

To assess the diagnostic tools and results of treatment of biliary rupture observed in liver cyst hydatids, clinical findings of 562 patients with hepatic hydatid disease were reviewed. Imaging techniques were not very effective to determine intrabiliary ruptures. Rates of rupture sizes determined in the patients were as follows; 22 (%24.7) large, 38 (%42.7) small, and 29 (%32.6) occult. Most frequently utilized procedures for patients with intrabiliary rupture were Roux-en-y cystojejunostomy, tube drainage + omentoplasty, sutured fistula + omentoplasty, and sutured fistula + tube drainage. Of the total 25 external biliary fistulas, 21 closed spontaneously. Of the four fistulas that did not close, one was managed by internal drainage and three by endoscopic sphincterotomy. Preoperative diagnosis of biliary rupture in liver hydatid cyst allows early planning of operation and helps the surgeon design the operative strategy. In the treatment of cases with large rupture, internal drainage may be proposed.

Anal canal amputation and necrosis of the anal sphinchter due to electric current injury.

The pathophysiology of electrical burns differs from thermal and chemical burns and electrical injuries which are associated with significant morbidity and mortality. We report on a patient who suffered anal canal amputation and necrosis of the anal sphinchter as a result an electric current injury.

Importance of psychiatric intervention in intolerances in endoscopic procedures.

Despite the fact that pre-medication, in a number of different drug combinations, has been used for a long time in endoscopy units, and has been subject to extended clinical studies, it is still not possible to claim that it has attained an ideal state with regard to patient tolerance to endoscopy procedures. In this clinical study, we have investigated the effects of psychological intervention in addition to medication, which we used on patients with intolerance to endoscopy. Intolerance was very high in all endoscopic procedures (15.8% total). It was observed that average midazolam doses were significantly higher in intolerant than in tolerant patients. It was found that in patients who had received psychiatric intervention, the decrease in midazolam dose was statistically significant in a subsequent endoscopy procedure.

Beliefs, sense of control and treatment outcome in post-traumatic stress disorder.

BACKGROUND: Few studies have shown that maladaptive beliefs relate to treatment outcome. METHOD: In a randomized controlled study, 87 patients with post-traumatic stress disorder (PTSD) had exposure therapy alone or cognitive restructuring alone, or both combined, or relaxation. Independent blind assessors assessed patients at pre-, mid- and post-treatment and at follow-up; at those times patients rated cognitive, behavioural and emotional aspects of their disorder. RESULTS: Baseline beliefs about mistrust, helplessness, meaninglessness and unjustness of the world related to baseline PTSD symptoms but did not predict treatment outcome, though improvement in certain beliefs correlated with more symptom improvement. Several 'key' beliefs changed after, and none before, symptoms improved. At post-treatment, sense of control and attribution of gains to personal efforts predicted maintenance of gains at follow-up. CONCLUSIONS: Baseline beliefs and improvement in beliefs did not predict outcome. Post-treatment sense of control/internal attribution predicted maintenance of gains at follow-up. How much sense of control is produced by or causes improvement deserves testing.

[Thromboembolic prophylaxis after major abdominal surgery]. / Büyük karin ameliyatlarindan sonra tromboembolik profilaksi.

PURPOSE: To investigate the efficacy of prophylaxis modalities after major abdominal surgery. PATIENTS AND METHODS: Patients who underwent major abdominal surgery between October 1998 and October 1999 were randomly divided into 3 groups. The patients in Group 1 received compression stockings, in Group 2 0.3 ml low-molecular weight heparin (nadroparine calcium 0.3 ml, 2850 IU AXa LMWH) subcutaneously and in Group 3 compression stockings and 0.3 ml LMWH. All symptomless patients evaluated with low extremity deep venous Doppler ultrasonography (DUSG), and patients who had pulmonary embolus (PE) suspicion evaluated with pulmonary scintigraphy. RESULTS: There were 91 patients in Group 1, 91 patients in Group 2 and 92 patients in Group 3. The mean age was 57.25 +/- 13.12, 54.53 +/- 13.54, and 53.65 +/- 13.28 respectively. Male/female ratio was 51/38, 56/35 and 62/30, in Group 1, 2 and 3 respectively. Twenty-seven patients in Group 1, 26 patients in Group 2 and 37 patients in Group 3 had risk factors. DUSG showed deep venous thrombosis (DVT) on the 7th postoperative day in 10 patients in Group 1, in 8 patients in Group 2 and in 3 patients in Group 3. Pulmonary scintigraphy showed PE suspicion in 6 patients in Group 1, 1 patient in Group 2 and 1 patients in Group 3. Wound hematoma and hemorrhage from abdominal drains were developed in 1/0, 8/2 and 3/1 patients in Groups 1, 2 and 3 respectively. Four patients in Group 1 and 2 patients in Group 2 died during the treatment (2.2%). Satistical analysis showed significant differences in PE and wound hematoma between Groups 1 and 2, in DVT and PE between Groups 1 and 3, in risk factors between Groups 2 and 3 (p < 0.05). The differences in DVT and PE and hematoma between group 2 and 3 were not significant. CONCLUSION: All treatment modalities could not prevent all thromboembolic complications. In our study combined treatment was the most effective one.

A study of the validity of a screening instrument for traumatic stress in earthquake survivors in Turkey.

The validity of a Traumatic Stress Symptom Checklist (TSSC), which was developed as part of a Screening Instrument for Traumatic Stress in Earthquake Survivors (SITSES), was examined in 130 survivors of the recent earthquake in Turkey. Data were obtained on the TSSC, which consists of 17 DSM-IV posttraumatic stress disorder (PTSD) items and 6 symptoms of depression. The Clinician-Administered PTSD Scale and the Major Depressive Episode module of the Semistructured Clinical Interview for DSM-IV were used for comparison with the TSSC. The results indicated that the TSSC has high internal consistency and satisfactory sensitivity and specificity in predicting the diagnosis of PTSD and major depression. The SITSES appeared to be a useful instrument in screening earthquake survivors for PTSD, major depression, illness severity, and risk factors associated with traumatic stress responses.

[Perforated peptic ulcers]. / Peptik ülser perforasyonlari.

Two hundred forty-eight patients were operated for perforated peptic ulcer between 1983 and 1998. Of the patients 112 (45.1%) had chronic, 34 (13.7%) had acute ulcer history and 102 (41.2%) had no ulcer history. Of the patients 228 (92.0%) had duodenal, 9 (3.6%) had juxtapyloric, 6 (2.4%) had marginal, and 5 (2.0%) had antral ulcer. Forty two patients (16.9%) admitted within 12 hours and 206 patients (83.1%) between 12 hours and six days after perforation. Simple closure and omental patch was performed in 32 patients (12.9%) who had severe concomitant illness and 126 (50.8%) intraabdominal sepsis, truncal vagotomy + pyloroplasty in 32 (12.9%), simple closure + omental patch + truncal vagotomy + gastroenterostomy in 34 (13.7%), simple closure + omental patch + parietal cell vagotomy in 21 (8.5%), truncal vagotomy + antrectomy in 3 (1.2%). Patients who didn't have definitive procedure received H2 receptor blockers or proton pomp inhibitors. One hundred ninety-three patients (77.8%) underwent endoscopic control. Two of 53 patients with definitive procedure (3.8%) and 34 of 140 patients (24.3%) with simple closure had recurrence. Two patients in simple closure group underwent parietal cell vagotomy, the others received medical treatment. The recurrence rate was significantly higher in simple closure group (p < 0.01).

Long-term effects of alprazolam on memory: a 3.5 year follow-up of agoraphobia/panic patients.

BACKGROUND: Benzodiazepines (BZs) can impair explicit memory after a single dose and also when taken repeatedly for treatment of anxiety disorders. A previous study with agoraphobia/panic patients found that the BZ alprazolam impaired memory during an 8-week treatment and residual impairments were still manifest several weeks after drug withdrawal (Curran et al. 1994). The present study followed up the same group of patients 3.5 years after treatment to determine whether those memory impairments persisted. METHOD: Thirty-one patients, 15 who had originally been treated with alprazolam and 16 with placebo, were assessed on a battery of psychometric tests and self-rating scales. RESULTS: Ex-alprazolam patients performed at the same levels as ex-placebo patients on the memory task and on other objective tests. Performance levels of both groups were similar to pre-treatment baselines, however there were differences in subjective ratings whereby ex-alprazolam patients rated themselves as less attentive and clear headed and more incompetent and clumsy than ex-placebo patients. CONCLUSIONS: Explicit memory impairments found while patients were taking alprazolam and weeks after drug withdrawal did not persist 3.5 years later. We suggest that the memory impairments observed in our previous study weeks after withdrawal of alprazolam were not residual effects of alprazolam but rather were due to the drug's interference with practice effects on the tests and habituation of anxiety over repeated exposure to the test situation.

Surgical treatment of hydatid disease of the liver: review of 304 cases.

HYPOTHESIS: To review the results of different modalities of treatment of hydatid disease of the liver. DESIGN: Retrospective study of 304 patients. SETTING: A university hospital in Turkey. PATIENTS: Three hundred four patients with hepatic hydatid disease who underwent operation between 1981 and 1996. MAIN OUTCOME MEASURES: Mortality and morbidity. RESULTS: Two hundred thirty-eight patients had a cyst on the right lobe, 41 patients had a cyst on the left lobe, and 25 patients had a cyst on both lobes. Forty-five patients had multiple hepatic cysts and 18 patients had coexisting cysts in other intra-abdominal organs. Surgical procedures were tube drainage, capitonnage, omentoplasty, cystectomy, segmentectomy, and cystoenterostomy. Of the patients with tube drainage, 36 developed an infection of the remaining cavity, 10 developed long-lasting biliary fistula, 8 developed cholangitis, and 6 developed septicemia. Four patients died of unreleated complications. Of the patients with capitonnage, 7 developed cholangitis and 3 developed an infection of the remaining cavity. Of the patients with omentoplasty, 1 developed an infection of the remaining cavity and 1 developed cholangitis. One patient who underwent segmentectomy developed pulmonary complications. Of the patients with cystoenterostomy, 1 developed cholangitis, 1 developed septicemia, and 1 developed pulmonary complications. CONCLUSION: For management of hydatid disease of the liver, capitonnage, omentoplasty, cyst excision, segmentectomy, or cystoenterostomy are all superior to tube drainage.