Clinical assessment of a new computerised objective method of measuring facial palsy.

OBJECTIVE: To compare the results using a new computerised objective method of assessing the degree of facial palsy with the results obtained using traditional clinical methods. DESIGN: Prospective computerised pixel change analysis and clinical evaluation of videos. SETTING: Tertiary referral centre. PARTICIPANTS: Subjects with varying degrees of unilateral facial palsy. METHODS: Comparison of the results obtained from an objective computerised method, the Glasgow Facial Palsy Scale, with the standard subjective clinical methods of the House-Brackmann Scale, Yanagihara, Sunnybrook Grading Scales and the objective clinical Stennert-Limberg-Frentrup Scale. RESULTS: Statistical analysis of the results from the objective computerised system indicated that there is an averagely strong correlation with the results from the House-Brackmann (Spearman's coefficient of 0.64), Sunnybrook (Pearson coefficient of 0.7) and Stennert-Limberg-Frentrup Scale (Pearson coefficient of 0.65), and it therefore has the ability to produce consistent results that agree with traditional clinical methods. It has a strong correlation with the Yanagihara Grading Scale (Pearson coefficient of 0.72) indicating that it may also have the ability to detect and record variations in the different regions of the face. CONCLUSION: This new computerised objective method of assessing the degree of facial palsy shows promise as a standardised objective method of assessing the degree of facial palsy.

Prolonged asystole during intraoperative myocardial reperfusion: an experimental study.

It has been observed in a proportion of patients, that clinically cardiac asystole persists for a prolonged period during intraoperative reperfusion. To evaluate this phenomenon, isovolumic functional indices (left ventricular [LV] balloon) and myocardial oxygen consumption (MV02) were compared in 22 canine preparations before and after two different interventions. After 45 minutes of normothermic global ischemia, (1) the control group (N = 11) was maintained on cardiopulmonary bypass with the hearts beating empty and (2) the experimental group (N = 11) was subjected to cardioplegia reperfusion at normothermia for one hour. In contradistinction to the initial hypothesis, functional recovery was better in the experimental group compared with the controls. Significant differences were observed in recovery of LV peak developed pressure (LVPDP) (controls, 66.8 +/- 7.3% [mean +/- standard error of the mean], and experimental group, 99.5 +/- 8.9%; p less than 0.05), maximum rate of rise of LV pressure (controls, 116.6 +/- 16.2%, and experimental group, 147.7 +/- 10.1; p less than 0.05), and maximum fall of LV pressure (controls, 100.3 +/- 15.8%, and experimental group, 143.1 +/- 11.5%; p less than 0.05). Correlation between LVPDP and MVO2 was also better preserved in the experimental group (controls: r = 0.15, N = 74, p = 0.18; experimental group: r = 0.47, N = 75, p less than 0.001). Values for myocardial water content and total creatine kinase in the two groups were similar. It was concluded that prolonged asystole during intraoperative reperfusion is not detrimental; on the contrary, there is enhanced functional recovery of the myocardium similar to that seen after secondary cardioplegia.

Deaf animal models for studies of a multichannel cochlear prosthesis.

Pathological alterations of the cochlea were studied in three different deaf animal (cat) populations. The ototoxic drug neomycin sulfate, was administered in one experimental series by direct infusion into the cochlear perilymph; a second group was given a series of intramuscular injections of the drug; and in a third experiment a mechanical lesion was made in the basilar membrane of the basal turn and the animals subsequently deafened by systemic neomycin. Hearing losses were tracked by monitoring thresholds of auditory brainstem responses to click stimulation. These deaf cat preparations fairly efficiently model pathologies recorded in man and are highly predictable over an acceptable time frame. Such preparations are of practical value for experiments involving intracochlear electrical stimulation (e.g., with model cochlear prosthesis electrodes).

Klippel-Feil syndrome and conductive deafness.

The Klippel-Feil syndrome is usually associated with sensorineural deafness and reports of conductive or mixed deafness are rare. Four additional cases are presented in this paper. The middle ear anomalies found in this syndrome are discussed. The results of middle ear surgery are reviewed and found to be poor.

Endolymphatic sac surgical anatomy and transmastoid decompression of the sac for the management of Ménière's disease.

BACKGROUND: Decompression of the endolymphatic sac for Ménière's disease gives unpredictable results. This may be because the sac is difficult to identify and decompress accurately without causing surgical trauma. METHODS: In order to test this idea, transmastoid decompression was simulated in 5 cadaver half heads and the anatomy of the endolymphatic sac was reviewed in a further 14 specimens. RESULTS: The endolymphatic sac was found and confirmed by histology in all five simulated decompressions. A newly described feature, a trapezoid thickening of dura, was a useful guide. The review showed that the sac was constant proximally, but variable distally. The posterior semicircular canal, posterior fossa dura and sigmoid sinus are at risk during dissection. CONCLUSION: The endolymphatic sac may be identified on inspection by an overlying patch of dura, thereby reducing exploratory dissection. It is best to decompress the sac as far proximally as possible, whilst protecting the posterior semicircular canal.

Key methods of identifying the horizontal facial nerve during difficult middle-ear surgery.

BACKGROUND: The key to avoiding damage to the horizontal facial nerve in middle-ear surgery is to formally identify the nerve in the early stages of the procedure. METHODS: In the non-infected ear this can be achieved relatively easily by identifying the oval window niche. However, in the infected ear with cholesteatoma, the safest landmark to use is the processus cochleariformis, which can be identified by three different methods. CONCLUSION: In an infected ear that is full of granulation tissue and/or cholesteatoma, the horizontal facial nerve can be reliably identified by locating the processus cochleariformis using the three methods described. This avoids damage to the nerve and important structures around it.

Identification of the accessory nerve by its relationship to the great auricular nerve.

OBJECTIVES: To describe the use of the great auricular nerve as a 'road map' for locating the accessory nerve in the anterior and posterior triangle, in comparison with other methods described in the literature. DESIGN: A review of the literature using Medline and Embase searches was performed. Illustrative photographs were taken from consenting, elective patients. RESULTS: Various methods have been described, using different anatomical landmarks. We describe a new method, based on the fact that the great auricular nerve runs, with relation to the edges of the sternocleidomastoid muscle, 1 cm superior to the accessory nerve anteriorly and 1 cm inferior posteriorly. CONCLUSIONS: This is a reliable and safe method, used by the senior authors in their extensive work as head and neck and skull base surgeons. It allows the accessory nerve to be located in both the anterior and posterior triangle. This avoids the inherent dangers of following the nerve's tortuous course through the sternocleidomastoid.

A clinical study of vestibular schwannomas in type 2 neurofibromatosis.

All 13 patients with neurofibromatosis 2 (NF2) who presented over a period of 17 years at the Institute of Neurological Sciences, Glasgow were reviewed and compared to patients with sporadic vestibular schwannomas. The NF2 patients presented at a younger age than those with sporadic vestibular schwannomas. A significant number had normal pure tone audiograms and a small number also had normal auditory brainstem responses at presentation. Vestibular schwannomas in NF2 patients grow more often and more rapidly than sporadic unilateral ones. They are more liable to infiltrate the cochlear and facial nerves making hearing and facial nerve preservation more difficult to achieve. Because the relatives of these patients often have normal audiograms and normal auditory brain stem responses in the presence of a schwannoma, our recommended method of screening of relatives of NF2 patients is magnetic resonance image scanning with Gd-DTPA enhancement.

Oral tranexamic acid in the management of epistaxis.

This study evaluated oral tranexamic acid as an adjunct in controlling epistaxis and preventing or reducing recurrent epistaxis. Patients entered into the trial were randomized in double blind fashion to placebo or tranexamic acid 1 g, 3 times daily. Treatment continued for 10 days. The patients were reviewed daily and any rebleeds categorized into minor, moderate or severe according to length and briskness of bleed and subsequent treatment. Of the 89 patients who completed the course of tablets, 25 (57%) in the placebo group and 21 (47%) in the treatment group had a rebleed. More patients in the placebo group had minor and moderate rebleeds, but the same number of patients in the placebo and treatment groups had severe rebleeds; this difference was not statistically significant. Oral tranexamic acid is, therefore, of no proven value as an adjunct in the treatment of epistaxis in patients requiring hospital admission.

Sensorineural hearing loss in chronic otitis media.

Although many studies have demonstrated an association between chronic otitis media (COM) and sensorineural hearing loss (SNHL), there still remains disagreement about the relationship. A retrospective study was conducted to examine the relationship between sensorineural hearing loss and chronic otitis media. Forty-one patients met the following criteria: unilateral COM and no history of head injury, meningitis or previous otological surgery. The differences in preoperative bone conduction threshold between diseased and control (contralateral normal) ear were statistically significant (P < 0.01) and varied from 5.24 to 9.02 dB across the frequency range. The effect of duration of disease on the degree of SNHL was also analysed but no correlation was found. The presence of cholesteatoma and/or ossicular erosion was not associated with a significantly increased risk of sensorineural hearing loss.

The protective effect of a conductive hearing loss in workers exposed to industrial noise.

There is controversy as to whether a conductive hearing loss protects the inner ear from the effects of loud noise. A retrospective study was carried out on 24 patients with a combination of unilateral conductive hearing loss and noise-induced hearing loss. This allowed subjects to act as their own controls. There was no statistical difference in thresholds between the two ears; possible explanations for this finding are discussed.

A comparison of conservative, radical and laser palatal surgery for snoring.

Reports of snoring are common among serviceman in the armed forces. Continuous positive airway pressure (CPAP) is usually an inappropriate modality for servicemen, but surgery, although requested, is very painful. In an attempt to reduce the pain, a laser has been used to perform uvulopalatopharyngoplasty and the more conservative uvulopalatoplasty has also been performed. Before proceeding to a randomized trial, this retrospective study was performed by questionnaire comparing these operations with conventional uvulopalatopharyngoplasty. Fifty-two completed replies from 63 patients were analysed. The results have to be interpreted with caution because of the small sample sizes; however, the results in the three groups were similar. The study suggests that each operation works well, but that any reduction in pain from performing uvulopalatoplasty or by using a laser is likely to be small. The study also found that the incidence of dryness as a complication is much higher than previously estimated.

A clinical and audiological investigation of osteogenesis imperfecta.

Fifty-six patients with osteogenesis imperfecta underwent clinical and audiological assessment. They completed questionnaires regarding their physical and otological disabilities, and attended various centres for audiological testing. It was found that 31 patients had a hearing loss. Hearing loss began in the second and third decades as a conductive loss, and progressed to a mixed loss. Eight patients, found in all age groups, had a pure sensorineural loss in one or both ears. Patients with osteogenesis imperfecta congenita suffered more fractures, became more physically disabled and had more severe hearing loss than those with osteogenesis imperfecta tarda. Tympanometry was found to give unpredictable results and was unhelpful in assessing middle ear function in these patients.

Results of stapes surgery on patients with osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is a heterogeneous group of connective tissue disorders. The classic triad of blue sclerae, spontaneous fractures and hearing loss is known as the Van der Hoeve and De Kleyn syndrome. Between 1989 and 2000, six patients with OI presented with conductive hearing loss. Five of them proceeded to stapedotomy. All the patients who had surgery had significant hearing gain. None of the patients had any complications. This study presents a higher incidence of spontaneous fractured crura as the cause of the conductive hearing loss than previously reported, and that the presence of a fractured crura with mobile footplate can be anticipated by the presence of a large conductive hearing loss. The pre- and postoperative results are presented and support the view that stapes surgery in OI can have encouraging results, provided the operator anticipates the possibility of a fractured crura and a mobile footplate.

Growth rate of non-vestibular intracranial schwannomas.

A group of nine patients with non-vestibular intracranial neuromas (four jugular, four facial, one trigeminal) underwent an interval scanning management policy, with serial annual magnetic resonance (MR) imaging. Tumour volume was assessed by manual measurement of the tumour area by MR imaging. Tumour volume was assessed by manual measurement of the tumour area on MR imaging axial cuts. The mean tumour size at presentation was 4.6 cm(3) (range 0.7-17.8 cm(3)). During a mean follow-up of 36 months (range 22-50 months), five out of nine tumours grew significantly at a rate of more than 5% of their initial volume per year. Only those tumours growing at a rate of more than 20% initial volume per year exhibited symptom progression. During a 36-month period of interval scanning, just over 50% of non-vestibular intracranial neuromas exhibited significant growth. Symptom progression was found to be a strong indicator of a high growth rate. This proportion exhibiting growth is higher than that demonstrated by unilateral sporadic vestibular schwannomas, but less than in patients with neurofibromatosis II. Early treatment of non-vestibular intracranial neuromas should therefore be considered.