Cartilage rim augmented fascia tympanoplasty: a more effective composite graft model than temporalis fascia tympanoplasty.

OBJECTIVE: To validate a newly introduced cartilage rim augmented temporalis fascia tympanoplasty technique by statistically comparing it with the morphological and audiological outcomes of traditional temporalis fascia tympanoplasty. METHODS: A retrospective comparative study was conducted on 115 patients who underwent tympanoplasty during 2013 and 2015. Fifty-eight patients underwent temporalis fascia tympanoplasty and 57 underwent cartilage rim augmented fascia tympanoplasty. RESULTS: In the cartilage fascia group, graft healing was achieved in 94.7 per cent of cases; in the temporalis fascia group, the graft take-up rate was 70 per cent. In those with a normal ossicular chain, the post-operative air-bone gap was within 20 dB in 92.6 per cent of cartilage fascia group cases and in 69.7 per cent of the temporalis fascia group cases, which was a statistically significant difference. Among the defective ossicular chain cases, the post-operative air-bone gap was within 20 dB in 76.9 per cent in the cartilage fascia group, as against 57.1 per cent in the temporalis fascia group. CONCLUSION: Cartilage rim augmented temporalis fascia tympanoplasty has a definite advantage over the temporalis fascia technique in terms of superior graft take up and statistically significant hearing gain in those with normal ossicular mobility.

Readiness factors for lean implementation in healthcare settings--a literature review.

PURPOSE: The purpose of this paper is to determine the readiness factors that are critical to the application and success of lean operating principles in healthcare organizations through a review of relevant literature. DESIGN/METHODOLOGY/APPROACH: A comprehensive review of literature focussing on lean and lean healthcare was conducted. FINDINGS: Leadership, organizational culture, communication, training, measurement, and reward systems are all commonly attributed readiness factors throughout general change management and lean literature. However, directly related to the successful implementation of lean in healthcare is that a setting is able to authorize a decentralized management style and undertake an end-to-end process view. These can be particularly difficult initiatives for complex organizations such as healthcare settings. RESEARCH LIMITATIONS/IMPLICATIONS: The readiness factors identified are based on a review of the published literature. The external validity of the findings could be enhanced if tested using an empirical study. PRACTICAL IMPLICATIONS: The readiness factors identified will enable healthcare practitioners to be better prepared as they begin their lean journeys. Sustainability of the lean initiative will be at stake if these readiness factors are not addressed. ORIGINALITY/VALUE: To the best of the knowledge, this is the first paper that provides a consolidated list of key lean readiness factors that can guide practice, as well as future theory and empirical research.

Sialendoscopy for the diagnosis and treatment of juvenile recurrent parotitis.

PURPOSE: The aim of the current study was to analyze the use of sialendoscopy for the diagnosis and treatment of juvenile recurrent parotitis (JRP), note possible complications, and the rate of disease recurrence. We believe that this cutting edge procedure may be very effective both for the diagnosis and treatment of JRP, with few complications and low rates of recurrence. PATIENTS AND METHODS: A retrospective descriptive case study was conducted on a sample of patients presenting with JRP. Data was collected from the patient's medical records. Diagnostic sialendoscopy was performed to identify and classify the ductal pathology, treated by interventional therapeutic sialendoscopy. We carefully noted all complications and the disease recurrence rates. RESULTS: The patient sample included 50 children presenting with JRP (33 M, 17 F; age range: 2 to 16 years). Seven children presented with bilateral parotitis, the remaining 43 with unilateral parotitis. The study was conducted from 2003 to 2012. There was a statistically significant association between sialendoscopic data and the actual outcome. Seven children underwent additional sialendoscopy because of recurrence. They were all in the group of children presenting with unilateral parotitis. DISCUSSION: Our results validate the expected outcome. Sialendoscopy is an accurate technique for the diagnosis of JPR, and an effective tool for the treatment of JRP, with a low rate of complications and recurrence.

Bimanual, intra-operative, fluoroscopy-guided removal of nasopharyngeal migratory fish bone from carotid space.

AIM: We report a rare and unusual case of a patient with an ingested fishbone which migrated from the oropharynx to the anterior compartment of the retropharyngeal space and then to the deep neck space in the nasopharynx (i.e. the carotid space). This report aims to describe a successful, minimally invasive method of foreign body removal which avoided both major skull base surgery and any potential life-threatening complications. A secondary aim is to highlight the role of intra-operative fluoroscopy, an under-used tool. CASE REPORT: We present a 67-year-old man with a history of fish bone impaction but no fish bone visible on plain X-ray or flexible endoscopy. The diagnosis of fish bone lodged in the retropharyngeal space was confirmed by computed tomography. Surgical exploration of the anterior retropharyngeal space failed to locate the fish bone, as it had migrated to a new, unknown location. Intra-operative fluoroscopy was vital for the removal of the fish bone, as it was impossible to see with the naked eye and had migrated from its previously imaged position. The fish bone was finally retrieved bimanually using external pressure on the submandibular region, which displaced the fish bone, and fluoroscopic guidance, which assisted its removal from the nasopharyngeal lumen. CONCLUSION: To the best of our knowledge, this is the first reported case of bimanual, intra-operative, fluoroscopy-guided, intra-luminal removal of a migratory fish bone from the deep neck space in this region of the nasopharynx.

The use of ciliary neurotrophic factor to promote recovery after peripheral nerve injury by delivering it at the site of the cell body.

Despite a body of evidence showing that various neurotrophic factors support the survival of nerve cells and stimulate axonal outgrowth, doubt remains about their optimal site of application as well as the more compelling question of what clinical benefit, if any, they would confer. Ciliary neurotrophic factor (CNTF) supports the survival of motorneurons in vitro and in vivo. Direct delivery of CNTF to the cell bodies may help reduce the side effects and overcome the problem of rapid systemic clearance. The aim of this study was to establish whether nerve regeneration may be improved upon by the controlled addition of a specific humoral neurotrophic substance (CNTF) at the level of the cell body. Three groups of five adult sheep were used. The first group acted as normal controls. In the second and third groups, the median nerve was divided and repaired using an epineurial suture technique. In the second group, CNTF was supplied into the CSF at the level of C6 by an implanted osmotic pump. In the third group physiological saline was placed in the osmotic pump. The animals underwent comprehensive electrophysiological and isometric tension experiments at six months. All of the animals had reduced electrophysiological, morphometric and isometric tension indices after surgery compared to normal. The CNTF group had better results than the saline group in the following; (1) area and amplitude of the muscle action potential (2) the percentage of tetanus and muscle mass preserved after repair. These differences were only statistically significant for amplitude of the muscle action potential. No statistical difference was found in the morphological indices (fibre diameter, axon diameter, myelin thickness and internodal length) between the CNTF and saline groups. CNTF does not confer a functional benefit when applied at the level of the cell body.

Tonsillar actinomycosis: a clinicopathological study.

Actinomycosis has been known to involve virtually every anatomic site in the body. Although actinomycosis has been identified in resected tonsils, its possible role in adeno-tonsillar disease has received little attention. A clinicopathological study of 302 patients who had adeno-tonsillar surgery is presented. Tonsillar actinomycosis was present in 86 (28.5%) patients. The statistical analysis revealed a significant association (P<0.0001) of actinomycosis and tonsillar hypertrophy (56.8%) compared to only 10.3% in the recurrent tonsillitis group. A statistically significant association (P<0.0001) of tonsillar actinomycosis and sickle cell anaemia, beta thalassaemia, bronchial asthma and beta haemolytic streptococcal infections was also seen. This data supports a predisposition of the above conditions to tonsillar actinomycosis and adeno-tonsillar hypertrophy and a possible etiopathologic role of this organism in adeno-tonsillar hypertrophy and disease. Although the clinical association of actinomycosis and tonsillar hypertrophy and beta haemolytic streptococcal infection has been described before the association of actinomycosis with sickle cell anaemia, beta thalassaemia and bronchial asthma is being observed for the first time in literature.

The use of conventional and invaginated autologous vein grafts for nerve repair by means of entubulation.

Nerve repair by entubulation has re-emerged recently as a possible means of enhancing the microenvironment at the site of repair by inclusion within the tube of various trophic factors. To this end, a modification of the vein-graft technique has been used by turning it inside out before repair, to expose the adventitial surface to the regenerating axons. A comparative study of standard vein grafting versus the inside-out technique was carried out in two equal-sized groups of inbred Lewis rats. Jugular vein isografts were derived from litter mates. The sciatic nerve was transected and repaired by entubulation using the standard vein graft in one group and the inside-out graft in the other group. Morpho-metric and electrophysiological assessment were carried out 3 months after repair. When the animals were assessed it was found that both the standard-vein-graft group and the inside-out group exhibited a reduction in all of the morphometric and electrophysiological variables when compared to normal nerves. The mean axon diameter, fibre diameter and myelin sheath thickness were, however, found to be greater in the group that underwent the inside-out repair. The superior morphometric results seen in the inside-out group were not matched by improved electrophysiological performance. It is concluded that the use of the inside-out technique confers no functional benefit over standard vein grafting.

Heterotopia of the tonsil.

The histopathological finding of heterotopias or choristoma is rare. This paper describes two patients who presented with chronic recurrent tonsillitis and underwent tonsillectomy. Histological examination revealed heterotopic cartilage in the tonsil of one patient and bone in that of the other.