Realtime transfer of live video images in parallel with three-dimensional modelling of the surgical field in computer-assisted telesurgery.

We have carried out three-dimensional, computer-assisted, functional endoscopic sinus telesurgery. Surgeons at different locations up to 300 km apart could not only see and transfer video images but also transfer three-dimensional computer models and manipulate them in realtime during surgery. Two different approaches were used. In the first telesurgery procedure we used M-JPEG compression and transmitted the data using fibre optic connections (ATM OC-3) at a bandwidth of 155 Mbit/s. In the second telesurgery procedure video images were transmitted over four E1 digital lines, amounting to about 8 Mbit/s of bandwidth, with better compression standards, such as MPEG1 and 2. We found that MPEG2 video compression produced the best picture quality for the operating field and endoscopic cameras. For conferencing and consultation between two or more connected sites during the surgery, we used JPEG and MPEG1 video compression with audio. The main feature of our three-dimensional telesurgery was the use of three-dimensional modelling of the operative field. This is important for emergency surgical interventions. We do not advocate that inexperienced surgeons operate on patients, not even with the guidance of a remote surgeon. However, three-dimensional telesurgery may become very valuable for experienced surgeons in the future.

Tympanometric findings in cleft palate patients: influence of age and cleft type.

Tympanometry was analysed according to cleft type with respect to age in 239 cleft palate patients (57 with bilateral cleft lip and palate (BCLP)), 122 with unilateral cleft lip and palate (UCLP) and 60 with isolated cleft palate (ICP). The frequency of type B tympanograms was 46.5 per cent in the BCLP group, 50.6 per cent in the UCLP group and 58.3 per cent in the ICP group. Type A tympanograms were more frequently observed in older patients (median age 11 years) in comparison to type B (median age five years; p < 0.001) and type C (median age six years; p < 0.001). The total sample showed an age-related decrease in the frequency of type B tympanograms (rs = -0.3942; p < 0.001). The frequency of type A tympanograms increased significantly with age (rs = 0.4263; p < 0.001), whereas type C was not correlated with age. In the UCLP group, the frequency of type B tympanograms decreased with age (rs = -0.4430; p < 0.001), the decrease being faster than in the BCLP group (rs = -0.3186; p = 0.001) and the ICP group (rs = -0.3378; p < 0.0001)). Type B tympanograms had the highest correlation with a hearing loss of 21-40 dB at mean hearing level at speech frequencies (MHLSF) (rs = 0.4574; p < 0.001), a lower correlation with a hearing loss of 11-20 dB (rs = 0.2184; p = 0.02) and the lowest correlation with hearing loss above 40 dB. At the ages of one to three, the frequency of type B is higher in UCLP patients than in the BCLP and ICP groups, decreasing at seven to 12, increasing again at 13 to 15, and thereafter showing a continuous decrease. In the BCLP group, the frequency of type B increased significantly at the ages of four to six and then decreased continuously from seven to 18. In ICP patients, the changes in the frequency of type B with age are not significant until the age of 15; at the age of seven, it is higher than in the BCLP and ICP groups. The type C tympanogram is not typically found in cleft palate patients and its frequency is not correlated with age. It can be presumed that each type of cleft lip and palate, due to its characteristic conditions in the epipharynx, will favour a different mode of pathophysiological development of middle-ear disease.

Congenital bony fixation of the malleus.

Bony fixation of the malleus seems to be one of the most controversial clinical entities among various congenital disorders of the auditory ossicles. According to various theories, it could be caused by trauma, chronic infection of the ear, otosclerosis or even development failures in the tympanic cavity itself. Histological analysis of 1,108 temporal bones showing a normal middle ear structure was performed. All bones were cut in serial sections of 20 microns. Audiograms and the data on ear trauma or chronic infection were analysed from case histories belonging to each bony specimen. Bony fixation of the malleus was found in 14 cases. It was almost always unilateral. The most frequent site of the fixation was the lateral epitympanal wall. The forms of fixation differed from a thin bony lamella to a solid bony bridge. The mallear ligaments were not involved in any case. No relationship to chronic ear infection, ear trauma or otosclerosis was found. Only a slight conductive hearing impairment up to 20 dB was recorded in 6 out of 14 cases. The most probable predisposing anatomical factors for the onset of the bony fixation of the malleus and the most recent preoperative diagnostic possibilities are discussed.

Our experience with FESS in children.

Between 1993 and 1996 we operated on 50 children with one of the following surgical indications: 17 children with a complication of acute rhinosinusitis and the propagation of the process towards the orbit (periorbitis), six children with an ethmoid and sphenoid foreign body (shrapnels shells), 11 children with an antrochoanal polyp, four children with nasal polyposis in cystic fibrosis and 12 children with chronic rhinosinusitis after 2-4 acute reinfections. The surgery was done under endotracheal anesthesia with hypotension. CT axial and coronal tomograms were done during the preoperative treatment. During the 2 weeks preoperative treatment, the patients with polyposis and antrochoanal polyps were treated with 4-8 mg of cortisone per os or i.m., and also with Fluticasone Propionate 100 mg twice a day and antibiotics in chronic and acute rhinosinusitis. The children's age was between 7 and 15 years. In the patients with nasal polyposis and antrochoanal polyps (n = 15) post-operatively, we had four cases of synechiae, recurrent polyposis in two and antrochoanal polyps in two cases.

Effectiveness of ultrasonography in diagnosis of maxillary sinus disease: a prospective comparison with radiographic and sinusoscopic examinations.

AIM: To assess the diagnostic accuracy of ultrasonography in comparison to radiographic and sinusoscopic techniques of maxillary sinuses examinations in acute and chronic sinus inflammations. METHODS: Ninety diseased sinuses in 50 patients (32 male and 18 female) were examined radiographically, ultrasonographically, and sinusoscopically. Ultrasonography was performed with Sinuscan 102 Sinusprint with 3.0 MHz transducer frequency, with A-mode curve display and Bulk-display. Radiography was performed in occipitonasofrontal and occipitonasomental projection, and sinusoscopy by local anesthesia using an optic instrument under 0 degrees, 30 degrees, and 70 degrees. Statistical assessment of ultrasonography sensitivity and specificity in relation to radiographic and sinusoscopic techniques was carried out. The data were compared using McNemar's test for paired data. RESULTS: Negative ultrasonographic agreed with negative radiographic findings in 18 of 20 sinuses. When ultrasonographic findings revealed mucosal thickening, complete filling, polyp or cyst, the agreements with radiographic findings were 24/30, 21/25, and 11/15, respectively. Negative ultrasonography agreed with negative sinusoscopic findings in 17/20 sinuses. When ultrasonographic findings revealed mucosal thickening, complete filling, polyp or cyst of the maxillary sinuses, the agreements with sinusoscopic findings were 26/30, 23/25, and 13/15, respectively. In comparison to radiological findings, the sensitivity of ultrasonography was 0.93 and specificity 0.60, and in comparison to sinusoscopic examination, sensitivity of ultrasonography was 0.93 and specificity 0.74. CONCLUSIONS: Ultrasonography can be used as a diagnostic method in the early diagnosis of sinus diseases. Compared to radiographic and sinusoscopic findings, it shows a high agreement in negative and positive findings, i.e., a high sensitivity and specificity.

Hearing levels and age in cleft palate patients.

Tonal audiometry was used to compare hearing levels in patients with bilateral cleft lip and palate (BCLP) (57 patients). unilateral cleft lip and palate (UCLP) (124 patients) and isolated cleft palate (ICP) (62 patients), and according to age groups. Patients with isolated cleft palate showed greater improvement in hearing level with age than patients with UCLP and BCLP; as adults they showed the lowest frequency of ears with hearing level of less than 40 dB, and the highest frequency of ears with hearing levels of 11-20 dB. Patients with BCLP had a higher frequency of ears with a hearing level of 21-40 dB during early childhood and adult age than patients with ICP. Patients with UCLP and BCLP showed a slower decrease with age in the frequency of ears with hearing loss than patients with ICP; the hearing level in patients with UCLP and BCLP improved only in groups with hearing levels of 21-40 dB, while those with hearing levels above 40 dB showed no significant improvement with age.

Pierre Robin syndrome: characteristics of hearing loss, effect of age on hearing level and possibilities in therapy planning.

Hearing loss was studied in 22 patients with Pierre Robin syndrome (PRS) aged three to 12 years (median 5.0 years). The results were compared to those obtained in 62 patients with isolated cleft palate (ICP) aged one to 27 years (median 5.5 years). Hearing loss was more frequently found in PRS (73.3 per cent) than in ICP (58.1 per cent) patients (p = 0.02). PRS patients had more ears with moderate (21-40 dB) and severe (> 40 dB) hearing loss, disturbing their social contact, with no tendency to normalization with age (Spearman r = 0.065). In contrast to PRS, ICP patients showed a significant tendency to hearing level normalization with ageing (Spearman r = -0.453; p = 0.001). Planigraphs of temporal bones showed inadequately developed pneumatization of the mastoid bone in all PRS patients and in most ICP patients. No malformation of the inner or middle ear was found in either group. PRS patients have a significantly higher risk of conductive hearing loss than those with ICP. Use of tympanostomy (ventilation) tubes is therapy of choice in patients with Pierre Robin syndrome, and it should be introduced as early as possible, even at the same time as palatoplasty.

Arachidonic acid metabolites and sinonasal polyposis. I. Possible prognostic value.

PURPOSE: The etiology of sinonasal polyps is sometimes obscure. This study was undertaken to evaluate the potential role of arachidonic acid metabolites (AAm) on recurrent polyposis. MATERIALS AND METHODS: Tissue production of prostaglandin E2 (PGE2), 6-keto-prostaglandin F1-alpha (PGI2), thromboxane A2 (TxA2), and leukotriene C4 (LTC4) by nasal mucosa was determined by radioimmunoassay in 27 patients with sinonasal polyposis (SNp) and in 10 volunteers. RESULTS: The group of patients with SNp with the evidence of recurrences in postoperative period (Group 1) showed significantly lower PGE2 concentrations than group of patients with SNp recurrences (Group 2). The differences in concentrations of PGI2 in mentioned groups were insignificant. In comparison with other groups, a group of patients who underwent surgery several times for SNp (Group 4) had a higher mean TxA2 concentration. The LTC4 concentrations were the highest in groups of patients where SNp recurrences were observed. When the incidence of polyposis recurrences (within 18 months after surgery) was correlated with the level of LTC4 production at the time of surgery, the rate of recurrence was significantly higher in patients with increased LTC4 level than in those with normal LTC4 levels. CONCLUSIONS: LTC4 might have a prognostic value. The possible role of AAm in occurrence of SNp is apparent and suggests possible role for medical intervention.

A-mode diagnostic ultrasound of maxillary sinuses: possibilities and limitations.

The diagnostic possibilities and limitations of A-mode ultrasound of maxillary sinus diseases are presented. A group of 219 subjects suffering from various sinus diseases was examined. All cases were analyzed in parallel by means of X-rays, sinoscopy and ultrasonography. The investigated group was divided into seven subgroups, according to clinical entity (polypoid degeneration, polyps, cysts, et cetera). The comparison of the three techniques was made for each clinical entity. Some divergent findings that can be reached by these techniques were explained from the clinical point of view as well. The ultrasound A-mode technique plays a complementary role in the diagnostic process of maxillary sinus diseases. The main advantages of ultrasound technique are its harmlessness and non-invasivity.

Acute upper respiratory tract infections and indications for tonsillectomy in children. I. Immunoglobulin synthesis in the palatine tonsil tissue.

Current viewpoints and practice concerning indications for tonsillectomy are presented. The annual specific risk for upper respiratory infection in children aged up to 15 is 1.1. The risk is higher in the youngest age group, in whom it rises to 1.8, decreasing with age and being lowest among children aged 12-15 years (0.5). The proportion of tonsillitis among acute upper respiratory tract infections is highest in the age group up to 3 years (36.9%); at the age of 4-5 years it is 37.1%, and is lowest among children aged 12-15 years (21.9%). The risk of tonsillitis caused by streptococci is highest among children aged up to 5 years. Statistical significance of differences in the synthesis of immunoglobulins (G, M, A and sA) and lysozymes in the palatine tonsil tissue of tonsillectomized children and healthy volunteers was tested by non-parametric tests for independent samples. Significant differences of the above mentioned syntheses were found in all entities studied. Any contribution to the documentation on the nature and cause of each tonsillitis in childhood is of great clinical value, because it is the only basis for rational consideration of indications for tonsillectomy.

CO2 laser anterior turbinectomy in the treatment of non-allergic vasomotor rhinopathia. A prospective study upon 78 patients.

Preliminary results obtained in the treatment of non-allergic vasomotor rhinopathia by CO2 laser are presented. A group of 78 subjects, 35 males and 43 females, aged 18-48 years, mean age 27.6 years, were followed: subjective assessment of nasal breathing quality, anterior rhinomanometry, cytologic findings and saccharine test of nasal clearance. The parameters were observed preoperatively and after surgery. A 400 CO2 Surgical Laser Coherent Medical was used (power density, 140 w/cm2). The beam was applied upon the upper medial quadrant of the head of inferior turbinate by a continuous pulse (7-10 sec) through a Carl Zeiss surgical microscope, at a 10x magnification and focal length of 400 mm. The mean preoperative values of the anterior rhinomanometry were 0.669 and 0.851 Pa sec/ccs for inspiration and expiration, respectively. After the surgery, the mean values were even better, i.e. 0.361 Pa sec/ccs for inspiration, and 0.456 Pa sec/ccs for expiration. The morphological and functional conditions of nasal mucosa were also examined. The former was evaluated using cytologic smears of the nasal mucosa layer, and the latter by the saccharine test of nasal clearance. Normal cytologic findings were found preoperatively in 87% of all cases studied. Saccharine test was normal in 67% of cases. After laser surgery, the cytologic findings and saccharine test results were normal in 92% and 89% of cases, respectively. The subjective patients' assessment of nasal patency pointed to obvious success in 41 out 45 subjects treated.

Rhinomanometrical findings after septoplasty in children.

40 children of both sexes, aged 5-12, with deviations or fractures of the nasal septum were tested. These children were selected for septoplasty on the basis of anamnestic data, ENT examination and anterior rhinomanometry with and without anamnestic data. The control group consisted of 15 children, of approx. the same age and sex distribution, with normal nose breathing and rhinomanometrical findings. The operated group underwent clinical and rhinomanometrical examination 3 and 12 months after surgery, and the control group 12 months after the initial examination. Septoplasty was performed under general anaesthesia with locally applied vasoconstrictors. The results showed that rhinomanometrical resistances prior to surgery were significantly higher in all the subjects in the operated group than those in the control group. Rhinomanometrical resistances were lower in 29 operated cases 3 months after septoplasty than before septoplasty, and significantly lower in 32 operated cases 12 months after septoplasty. Rhinomanometrical resistances in the operated group 12 months after surgery were a little higher than those in the control group 12 months after the initial examination. Failures and complications after septoplasty are commented upon, as is their influence on rhinomanometrical resistances.