Spontaneous tumour shrinkage in 1261 observed patients with sporadic vestibular schwannoma.

OBJECTIVE: To determine the rate of spontaneous tumour shrinkage in a group of patients with sporadic vestibular schwannoma managed with a 'wait and scan' approach. PATIENTS: All patients with a unilateral cerebello-pontine angle tumour resembling a vestibular schwannoma were registered prospectively in a national database in Denmark. Patients registered with tumour shrinkage were identified and all computed tomography and magnetic resonance imaging scans retrieved, re-evaluated and related to the clinical data. RESULTS: Of 1261 observed patients, 48 displayed spontaneous shrinkage (3.81 per cent). Mean absolute shrinkage was 6.25 mm, equivalent to 52.1 per cent. Absolute shrinkage correlated with tumour size and followup period, whereas relative shrinkage was significantly greater for tumours which were purely intrameatal at diagnosis. There was no correlation between age and the degree of shrinkage. CONCLUSION: Four per cent of sporadic vestibular schwannomas shrink spontaneously. These findings substantiate the 'wait and scan' strategy for tumours with a largest extrameatal diameter of up to 20 mm.

Residual tumour after vestibular schwannoma surgery.

OBJECTIVE: To evaluate residual tumour occurrence after vestibular schwannoma surgery, based on intra-operative registration and magnetic resonance imaging one year post-operatively. METHODS: Patients undergoing translabyrinthine surgery for vestibular schwannoma in Denmark between 1976 and 2008 were registered in a national database covering 5.5 million inhabitants. RESULTS: Translabyrinthine surgery was undertaken on 1143 patients. Of these, 978 had total, 140 near-total and 25 subtotal tumour excision, as assessed intra-operatively by the surgeon. One year after surgery, 65 per cent of small tumour remnants and 11 per cent of large tumour remnants were not visible on magnetic resonance imaging. The mean pre-operative size was significantly smaller for totally excised tumours, compared with near-totally and subtotally excised tumours. Revision surgery was performed for 14 patients (1.2 per cent), of whom 2 had received total, 5 near-total and 6 subtotal excisions initially. CONCLUSION: Most residual tumours disappear spontaneously, probably due to devascularisation. Few patients with a small residual vestibular schwannoma will require revision surgery or secondary radiotherapy.

Hearing outcomes of vestibular schwannoma patients managed with 'wait and scan': predictive value of hearing level at diagnosis.

AIMS: This study aimed to evaluate the predictive value of both hearing level (at various frequencies) and speech discrimination for forecasting hearing outcome after a period of observation, in patients with vestibular schwannoma. SUBJECTS: Over a 33-year period, 1144 patients with vestibular schwannoma were allocated to 'wait and scan' management, with annual magnetic resonance imaging and audiological examination. Two complete pure tone and speech discrimination audiograms were available for 932 patients. RESULTS: The predictive value of initial hearing level better than 10 dB for forecasting hearing outcome after observation increased from 59 per cent at 250 Hz to 94 percent at 4000 Hz. At diagnosis, hearing level of 10 dB or better at 4000 Hz was found in only 18 of the 932 VS ears, while good speech discrimination was found in 159 patients (17 per cent). Of the latter patients, 138 maintained good hearing after observation. CONCLUSION: In vestibular schwannoma patients, good high frequency hearing and good speech discrimination at diagnosis are useful tools in predicting good hearing after observation.

Change in hearing during 'wait and scan' management of patients with vestibular schwannoma.

AIM: To evaluate hearing changes during 'wait and scan' management of patients with vestibular schwannoma. SUBJECTS: Over a 10-year period, 636 patients have prospectively been allocated to 'wait and scan' management, with annual magnetic resonance scanning and audiological examination. RESULTS: At the time of diagnosis, 334 patients (53 per cent) had good hearing and speech discrimination of better than 70 per cent; at the end of the 10-year observation period, this latter percentage was 31 per cent. In 17 per cent of the patients, speech discrimination at diagnosis was 100 per cent; of these, 88 per cent still had good hearing at the end of the observation period. However, in patients with even a small initial speech discrimination loss, only 55 per cent maintained good hearing at the end of the observation period. CONCLUSION: After comparing the hearing results of hearing preservation surgery and of radiation therapy with those of 'wait and scan' management, it appears that, in vestibular schwannoma patients with a small tumour and normal speech discrimination, the main indication for active treatment should be established tumour growth.

Recurrence of attic cholesteatoma: different methods of estimating recurrence rates.

One problem in cholesteatoma surgery is recurrence of cholesteatoma, which is reported to vary from 5% to 71%. This great variability can be explained by issues such as the type of cholesteatoma, surgical technique, follow-up rate, length of the postoperative observation period, and statistical method applied. The aim of this study was to illustrate the impact of applying different statistical methods to the same material. Thirty-three children underwent single-stage surgery for attic cholesteatoma during a 15-year period. Thirty patients (94%) attended a re-evaluation. During the observation period of 15 years, recurrence of cholesteatoma occurred in 10 ears. The cumulative total recurrence rate varied from 30% to 67%, depending on the statistical method applied. In conclusion, the choice of statistical method should depend on the number of patients, follow-up rates, length of the postoperative observation period and presence of censored data.

Reasons for reperforation after tympanoplasty in children.

In 116 children and 124 ears with non-cholesteatomatous chronic otitis media operated on during a 13-year period from 1968 to 1980 via transcanal tympanoplasty and followed with several re-evaluations 15-27 years after operation, the causes of reperforation have been analysed. In total, 14 ears (11%) had reperformation; in 7 ears (5.6%), the reperforations occurred early (during the first 3 months) and in 7 ears late (after 6 months), but most often the reperforations occurred after 10 years. The early reperforations were presumably failures in surgery. Less experienced surgeons and inflamed, wet middle ear mucosa during the primary surgery seemed to be the two most important causal factors. Young age at surgery, size and site of the perforation and Eustachian tube function seemed to be of no importance for reperforation. The early reperforations were closed at surgery and remained closed into adulthood. The reasons for late reperforations are less clear; they were presumably caused by acute otitis media with perforation in an atrophic part of the drum, which did not heal. The reperforations were small, but it was possible to close all of them surgically if the patients wanted to be reoperated. It is concluded that tympanoplasty, even in young children, is a rewarding option with good and stable results.

Results of tympanoplasty in children after 15 to 27 years.

Results of tympanoplasty in children with noncholesteatomatous chronic otitis media are presented in a 16- to 27-year follow-up. During the 13-year period from 1968 to 1980, 116 children (124 ears) were operated on, and they were submitted to several follow-ups with audiometry and otomicroscopy. The attendance at the last follow-up was 70%, and the minimum time since surgery for these patients was 15 years. All dry ears were operated on transcanally with a fixed ear speculum, without any lateral incision of the ear canal skin. Cumulatively, in total, 14 ears (11%) had reperforation: 7 ears early and 7 ears late. At 6 months, there were 6% early reperforations; some were surgically closed and some reappeared later, even after several years, as late perforations. At 2 to 15 years of follow-up, there were 4% reperforations, and at 16 to 27 years, 6%. Hearing was good and stable. The results were the same in ears operated on at the ages of 2.5 to 7 years and 8 to 14 years, as well as with preoperatively positive and negative Valsalva maneuvers. In total, 14% of ears were revised during the entire observation period. It is concluded that transcanal tympanoplasty, even in young children, has good long-term stability and can definitively and permanently solve the problem of noncholesteatomatous chronic otitis in children.

Cholesteatoma in children, predictors and calculation of recurrence rates.

The aim of the study was to evaluate the long-term recurrence rate after surgery for acquired cholesteatoma in children, to search for predictors of recurrency and to analyse the impact of the applied statistical method on the outcome of the results. During a 15-year period, 114 children underwent first-time surgery for acquired cholesteatoma. The patients were re-evaluated with a median observation time of 5.8 years, range 1-16 years. Recurrence of cholesteatoma developed in 27 ears. The cumulated total recurrence rate was 24% using standard incidence rate calculation, applying Kaplan-Meier survival analysis the recurrence rate was 33%. Recurrent disease occurred significantly more frequent in children < 8 years, with negative preoperative Valsalva, ossicular resorption and with large cholesteatomas. In conclusion, young children with poor Eustachian tube function, large cholesteatoma and erosion of the ossicular chain, are at special risk of recurrence and should be observed several years after surgery.

Anti-neutrophil cytoplasmic antibody-associated mucocutaneous allergic vasculitis with oral manifestations caused by propylthiouracil.

A 49-year-old woman treated with increasing dosage of propylthiouracil (PTU) in order to control hyperthyroidism, developed progressive necrotic ulcers in the oral cavity, oropharynx and rhinopharynx and vasculitic ulcers on both auricular pinnae after a few days. The PTU treatment was immediately discontinued and the mucosal and skin manifestations resolved promptly. Laboratory findings, including anti-neutrophil cytoplasmic antibodies (ANCA), suggested allergic vasculitis. This is to our knowledge the first reported case of oral manifestations of PTU-induced allergic vasculitis.

New modification of hot-water irrigation in the treatment of posterior epistaxis.

BACKGROUND: Tamponade treatment for epistaxis is painful and traumatic to the nasal mucosa, and may necessitate hospitalization for several days. Hot-water irrigation (HWI) was introduced as a treatment of epistaxis more than 100 years ago. In a previous study the treatment proved to be effective, less painful, and less traumatic, and required a shorter hospital stay than tamponade treatment. However, HWI has the risk of aspiration during treatment. To minimize this risk, a special catheter has been designed. OBJECTIVES: To evaluate the modified HWI and to compare the results with tamponade treatment, with respect to patient compliance, effectiveness, recurrence of bleeding, pain, complications, and length of hospital stay. PATIENTS: A total of 122 patients, hospitalized for posterior epistaxis, were randomized to receive either HWI or tamponade treatment. RESULTS: In the HWI group, 31 (55%) of the patients could be discharged from the hospital after the initial treatment only, compared with 29 (44%) of the patients treated with tamponade. Using a 10-cm visual analog scale, the mean pain score during treatment was 4.7 in the HWI group compared with 7.5 in the tamponade group. The mean hospital stay was 2.9 days for the HWI group vs. 4.0 days for the tamponade group. After discharge from the hospital, necrosis or synechia was found on rhinoscopy in 12 patients (40%) in the tamponade group compared with none in the HWI group. CONCLUSIONS: Compared with tamponade treatment, HWI is as effective, requires a significantly shorter hospital stay, is less traumatic to the nose, and is significantly less painful.

Surgery for acquired cholesteatoma in children: long-term results and recurrence of cholesteatoma.

The aim of the study was to evaluate the long-term results after surgery for acquired cholesteatoma in children and to contribute to the search for predictors of recurrence. During a 15-year period, 114 children underwent surgery. The patients were re-evaluated with a median observation time of 5.8 years. At the last re-evaluation 85 per cent of the ears were dry with an intact drum. Recurrence of cholesteatoma developed in 27 ears. The cumulated total recurrence rate was 24 per cent using the incidence rate calculation, applying Kaplan-Meier survival analysis the corresponding recurrence was 33 per cent. Recurrent disease occurred significantly more frequently in children younger than eight years, with a negative pre-operative Valsalva, with ossicular resorption and with large cholesteatomas. In conclusion, young children with poor Eustachian tube function and a large cholesteatoma with erosion of the ossicular chain, are at special risk of recurrence and should be observed for several years after surgery.

Autoinflation: historical highlights and clinical implications.

In 1563, Eustachius first described the tube that came to be named for him. In 1704, Valsalva described the maneuver that bears his name, and in 1836 Deleau became one of the first to advocate infusion of pure air through the eustachian tube using a catheter. Politzer devised his own method for actively inflating the middle ear without using a catheter in 1863. Most modern studies examining the use of autoinflation in the treatment of secretory otitis media have shown a beneficial effect, with effusion being cleared in 52 to 62% of ears up to nine months after the treatment. In two studies, no effect of autoinflation could be demonstrated, and in one publication the autoinflation group had deteriorated compared to the control group. In light of the fact that secretory otitis media is a benign and transient condition, that treatment with antibiotics or insertion of ventilation tubes is not without problems, and that the chance of improving the condition by autoinflation is approximately 50%, it is concluded that autoinflation should be considered first-line treatment, before antibiotic or surgical treatment is planned.

[Barotrauma in children and adults after flying. Prevalence and treatment with Otovent]. / Barotitis hos børn og voksne efter flyvning. Praevalens og behandling med Otovent.

To prevent barotitis during descent in aviation, the ears have to be cleared several times by performing the Valsalva's manoeuvre. The manoeuvre is difficult for children to perform, and they are therefore at high risk of developing barotitis. The treatment of barotitis is either inflation by a Politzer balloon or myringotomy. An alternative treatment is autoinflation using the Otovent. This prophylaxis/treatment can be performed by the child with assistance from its parents as soon as or preferably before the descent has started. The prevalence of barotitis amongst 45 children and 49 adults in transit was found to be highest in children, 28%, compared with adults, 10%. Only 6% of the children with negative middle ear pressure after flight managed a successful Valsalva manoeuvre, whereas 33% could normalise the middle ear pressure by inflating the Otovent. In conclusion we recommend autoinflation using the Otovent set by children and adults who have problems clearing their ears during flight.

[Occurrence of eardrum pathology in a cohort of adults born 1955]. / Forekomst at trommehindepatologi hos en kohorte af voksne født i 1955.

The aim of this study was to estimate the prevalence of the different types of eardrum pathology in a cohort (cohort 1955) who were children before the era of ventilation tubes, and to compare these findings with the prevalence of eardrum pathology in a previous published cohort study on 222 children followed since the age of four years (cohort 1975) in the era of ventilation tubes. All inhabitants of Hillerød county born in 1955 were invited to a screening examination including otomicroscopy, tympanometry and audiometry. All eardrum pathology was recorded. In cohort 1955, 59% of 460 possible, attended the examination. In addition 9% returned a questionnaire enquiring their otologic history. In the cohort with no grommets, retraction of Shrapnell's membrane was found in 4% of the ears compared to 20% in the cohort with grommets. Tensa pathology was found in 6% of the ears in the old cohort and in 24% in the young cohort. Despite the increased attention to the diagnosis of secretory otitis, and the increased rate of surgical treatment, the prevalence of eardrum pathology seems to have increased. The reason for this increase is discussed.

Point prevalence of barotitis in children and adults after flight, and effect of autoinflation.

The most common cause of barotitis is pressure changes during descent in aviation. Equilibration is normally achieved by swallowing, jaw movements, yawning, or chewing, but some have to perform a Valsalva maneuver several times during descent and even by these means some fail. The aim of the study was to estimate the point prevalence of barotrauma in children and adults after flight, and to test the effect of an autoinflation device (Otovent), in improving negative middle ear pressure after flight. Questionnaires and Otovent, were distributed to all air passengers in eight incoming flights. The questionnaires inquired about nasal allergy, nasal congestion, previous and actual ear pain, use of decongestants and experience of inflating the Otovent set during descent. After flight, the passengers were offered an ear examination including otoscopy and tympanometry both before and after a Valsalva maneuver, as well as after Otovent inflation. Otoscopic signs of barotitis were found in 10% of the adults and in 22% of the children. Negative middle ear pressure of more than 10 hPa after landing was found in 20% of the adults and in 40% of the children. The Valsalva maneuver normalized the pressure in 46% of the adults and in 33% of the children. Of the adults, 73%, and of the children, 69% with an unsuccessful Valsalva maneuver could improve or normalize the middle ear pressure by inflating the Otovent set. In conclusion, we recommend autoinflation using the Otovent set to air passengers with problems clearing the ears during flight.

Barotitis in children after aviation; prevalence and treatment with Otovent.

Barotitis is an acute or chronic inflammation caused by environmental pressure changes. The most common cause is the pressure change during descent in civil aviation. To prevent barotitis the middle ear pressure has to be equalised several times during descent. This can be achieved by performing the Valsalva manoeuvre, but for children, many of whom have a dysfunction of the Eustachian tube, this is difficult to perform and they are therefore at high risk of developing barotitis during flight. The traditional treatment modalities of barotitis are inflation by a Politzer balloon, myringotomy or prophylactic grommet insertion. An alternative treatment or prophylactic measure is autoinflation using the Otovent treatment set. This prophylaxis/treatment can be performed by the child with assistance from its parents as soon as possible or rather before the descent has started. The prevalence of barotitis amongst transit passengers was found to be highest in young children, 25 per cent, compared with adults, five per cent. Only 21 per cent of the youngest children with negative middle ear pressure after flight managed a successful Valsalva's manoeuvre, whereas 82 per cent could increase the middle ear pressure inflating the Otovent set. In conclusion we recommend autoinflation using the Otovent set by children and adults with problems clearing the ears during flight.

[Hot water irrigation in the treatment of posterior epistaxis]. / Varmtvandsskylning som behandling af posterior epistaxis.

Tamponade treatment in epistaxis is painful and the patient needs hospitalisation. Irrigation with hot water was introduced as a treatment of epistaxis 100 years ago. This study compares the two treatments with respect to effect, recurrence, pain, and length of hospital stay. Forty-four consecutive patients with posterior epistaxis were randomized to receive treatment with either hot water (HWI) or tamponade. In the group of patients treated with HWI, the treatment had to be stopped in seven patients (33%) because of lack of cooperation; nine patients (43%) could be discharged from hospital with no need for further treatment, whereas five patients (24%) had recurrent epistaxis requiring additional tamponade treatment. Among patients treated with tamponade, 14 patients (61%) could be discharged from hospital with no need for further treatment, while nine patients (39%) had recurrent epistaxis requiring additional tamponade treatment. Compared with the tamponade treatment, HWI is almost as effective, the hospital stay is shorter, and the treatment is significantly less painful.

Histological changes in the nasal mucosa after hot-water irrigation. An animal experimental study.

Many years ago the treatment of posterior epistaxis was irrigation with hot water through the bleeding nose cavity, and the treatment was successful in many cases. The aim of this study is to explain how "hot-water irrigation" can cause haemostasis. Twenty-four rabbits were divided into 12 groups and their noses were irrigated for 5 min with hot water at temperatures ranging from 40-60 degrees C. After irrigation, the nose was fixed, sliced, stained, and evaluated blindly by a pathologist. The morphological changes-narrowing of intranasal lumen, vasodilation and stasis, extravasation of erythrocytes, and epithelial necrosis-were recorded. No changes were recorded after irrigation with water of 40-44 degrees C. Only light changes were present in the 46 degrees C group. Vasodilation occurred at a temperature of 48 degrees C or higher. From 48 degrees C, oedema of the mucosa and subsequent narrowing of the intranasal lumen was seen. Severe changes including epithelial necrosis, were found only in the groups treated with 52 degrees C or higher. The results of the study indicate that the haemostatic effect of hot water treatment for epistaxis may be caused by: (1) oedema and narrowing of the intranasal lumen, (2) vasodilation of the mucosal vessels, and (3) cleaning of the nose from blood coagulates.

Hot-water irrigation as a treatment of posterior epistaxis.

The commonly-used tamponade treatment for posterior epistaxis is painful and the patient may need hospitalization for several days. Irrigation with water of 50 degrees C was introduced as a treatment for posterior epistaxis more than 100 years ago. This study compares the two treatment modalities with respect to effect, recurrence, pain, and length of hospital stay. Forty-four consecutive patients with posterior epistaxis were randomized to receive treatment with either hot water (21 patients) or tamponade (23 patients). In the group of patients treated with hot water, the treatment had to be stopped in seven patients (33%) because of lack of cooperation; nine patients (43%) could be dismissed from hospital with no need for further treatment, whereas five patients (24%) had recurrent epistaxis requiring additional tamponade treatment. Among the patients treated with tamponade, 14 patients (61%) could be dismissed from hospital with no need for further treatment, while nine patients (39%) had recurrent epistaxis requiring additional tamponade treatment. The median stay in hospital was five days for the group treated with hot water, and six days for the group treated with tamponade. Compared to the tamponade treatment, hot-water irrigation is almost as effective, the hospital stay is shorter, and the treatment is significantly less painful.