Deafness: malaria as a forgotten cause.

BACKGROUND: Ototoxicity from antimalarials is a well publicised cause of deafness and a great deal of time and resources are spent assessing it in relation to new drugs. The effect of the malaria parasite itself on hearing is, however, poorly documented and most evidence is anecdotal. This paper aims to collate existing evidence of this association. METHODS: Two systematic literature searches were performed on Ovid Medline, first for 'malaria' and 'hearing loss' or 'hearing impairment' or 'deafness', and secondly for 'cerebral malaria' and 'neurologic' or 'neurological' or 'neurocognitive sequelae'. The articles were then individually studied for relevance. RESULTS: Malaria has been implicated as a rare cause of hearing loss in various studies, but recommendations and hypotheses have not been taken seriously or investigated. Searches also returned numerous studies of neurological sequelae after cerebral malaria, a small proportion of which observed hearing impairments on follow-up. However, no attempt was made to distinguish between treatment and disease as the cause. A few antimalarial drug trials which assessed hearing before treatment found unexplained hearing loss which improved with elimination of the parasite. CONCLUSION: Evidence from this review suggests that the falciparum parasite is a potential cause of hearing loss. Malaria is a disease of such high prevalence that even if only a small proportion of survivors develop this impairment the effects on children's education could be detrimental. More attention should be focussed on investigating this association as the clinical and pathophysiological implications are potentially considerable.

Nutritional factors in the pathogenesis of ear disease in children: a systematic review.

BACKGROUND: Ear disease is a major health problem in poorly resourced countries. The role of nutritional deficiencies in its pathogenesis and in relation to chronic suppurative otitis media (CSOM) has not been reviewed previously. METHODS: A systematic review was undertaken using Pubmed, SCOPUS, Cinahl on Ovid, the Cochrane Database and selected medical journals, with no language restriction. Nutritional mechanisms potentially related to ear disease and CSOM risks were reviewed. All studies (observational, case-control, cohort and clinical trials including randomised controlled trials) with nutrition-related information were included. The titles and/or abstracts of all retrieved studies were reviewed and full articles were obtained for relevant studies. Exclusion criteria were multiple publication or studies which did not report nutritional information. RESULTS: Supplementation studies using single micronutrients and vitamins to determine efficacy in reducing acute or chronic otitis media provided some evidence for an association of middle-ear pathology with deficiencies of zinc or vitamin A. Multi-micronutrient supplementation studies provided further support for a beneficial effect, although the number of studies was small and they were heterogeneous and uncontrolled. No human study was identified which specifically examined the association between copper, selenium or vitamin D status and middle-ear disease or infection. CONCLUSION: Particularly in developing countries, research on micronutrient status and vitamin deficiency and their influence on middle-ear disease is required to improve knowledge of the pathogenesis of middle-ear infection and to determine the relevance of nutritional interventions in prevention and treatment.

Detection of hearing impairment and handicap in Paget's disease of bone using a simple scoring system: a case control study.

Paget's disease of bone is known to be associated with hearing loss but there are limited data on the prevalence of hearing impairment and handicap in people with Paget's disease. Previous published population studies have used patient-completed questionnaires or review of GP records, none have included audiometry. 80 Paget's subjects were selected at random from a hospital database, 75 (94%) entered the study and were matched by age and gender with 76 controls. All participants completed a screening questionnaire for hearing handicap, the HHIE-S; a questionnaire on perception of hearing-related handicap, noise exposure, hearing aids and GP consultations regarding hearing; and audiometry. The results show significant problems from hearing loss in people with Paget's disease of bone. Paget's patients were significantly more likely to perceive hearing handicap (P=0.0001), 41% Paget's patients rated themselves moderate-severe compared to none of the controls. Paget's patients were significantly more likely to report difficulties such as hearing normal speech, watching TV or hearing over background noise (all P=0.0001). They were more likely to consult their GP due to hearing problems (P=0.004) or tinnitus (P=0.0001), or use a hearing aid (P=0.0001). Audiometry confirmed higher rates of deafness in Paget's patients. 41/75 Paget's patients compared to 19/76 controls had at least 40 decibels hearing loss (dBHL) (P=0.0001). The HHIE-S proved to be an effective screening tool. A score of greater than 8 increased the odds ratio of detecting moderate hearing impairment (>40 dBHL) in people with Paget's disease by 5.1. The specificity of HHIE-S >8 as a screening tool to select for audiometry appears good, 1/46 (2%) of Paget's patients would have proved to have normal hearing thresholds. The sensitivity is better with worse hearing loss, 7/16 Paget's patients with moderate loss (>40 dBHL) and 2/25 with severe-profound loss (>60 dBHL) would have been missed. In conclusion, 55% unselected Paget's patients have at least moderate levels of hearing loss, compared to 25% of age and gender matched controls. Paget's patients and controls under-reported hearing problems, many of which can be ameliorated. Screening for hearing problems in Paget's disease of bone can be done using the HHIE-S.

Carcinoma in situ of the larynx.

A series of 28 cases of carcinoma in situ of the larynx treated over the last 16 years is reviewed. The majority of the patients were treated with endolaryngeal stripping of the cords. In the few cases in which the treatment failed, early detection of disease was made and radiotherapy was successful in controlling the carcinoma. The use of radiotherapy is only advocated for selected cases because there is often difficulty in assessing a radiated larynx; radiotherapy may induce field changes, and if treatment fails, laryngectomy may have to be carried out as a salvage procedure.

The extrusion rate of grommets.

A prospective study was performed to determine the factors influencing the extrusion rate of tympanostomy tubes. Nine hundred thirty-nine tubes were inserted in 589 patients and the extrusion of these tubes was reviewed up to a period of 27 months. The eight tubes used in the survey were the Shepard, Exmoor, Bobbin, Armstrong, Paparella, Shah, Arrow, and collar button. These tubes were inserted in strict rotation, the operator using the designated tube. The position, type of incision, presence of fluid, quality of tympanic membrane, and degree of difficulty of insertion were all recorded at operation. The sex, age, side of operation, and any simultaneous operative procedures were also recorded. The patients were reviewed the day after operation and then every 3 months thereafter until the tube was extruded. A definite pattern was identified for the extrusion of each type of tube. At one end of the spectrum, Exmoor and Shepard tubes were, for the most part, extruded between 6 and 9 months after insertion, while at the other end, most of the collar button tubes were still functioning at 18 months. The design of the tube was the only factor found to be a significant determinant of the extrusion of the tube, although the experience of the surgeon affected the extrusion rate of the Arrow tube. The different dimensions of the Exmoor and collar button tubes are examined and compared.

Posture changes in diabetes mellitus.

The weight distribution and postural sway was measured in diabetic subjects with, and without, neuropathy, and then compared with age and sex matched non-diabetic subjects using a cheap and highly portable sway plate - SwayWeigh. The SwayWeigh was found to be very practical and the results obtained confirmed the increased postural sway in the absence of proprioceptive information in neuropathy subjects. The study shows that peripheral neuropathy increases the postural sway especially in the absence of visual clues but this did not result in postural strategies causing significant limb load asymmetry.

The complications of sphenoid sinusitis.

Five patients are described who presented with various complications of infective sphenoid sinusitis. Their clinical course and management is narrated and the importance of making this diagnosis and its simple effective treatment is stressed.

Embryonal rhabdomyosarcoma of the sphenoid sinus.

Rhabdomyosarcoma is a diagnostic and therapeutic problem in the management of childhood tumours. A case of embryonal rhabdomyosarcoma affecting the sphenoid sinus and involving the cavernous sinus is presented. It has become evident that modern combined modality therapy, including surgery when required, radiation and adjuvant multi-drug chemotherapy offers the best chance of survival.

The parapharyngeal space.

A series of 73 lesions presenting in the parapharyngeal space is presented. There were 53 (73 per cent) patients with deep lobe parotid benign or malignant tumours, five (7 per cent) patients with tumours of neurogenous origin, seven (9 per cent) patients with abscesses, five (7 per cent) patients with enlarged lymph nodes, two with branchial cysts, and one with a lipoma. The anatomy emphasizes the expansile nature of the space and also the close proximity of vital structures. The importance of the use of combined CAT scan and sialography is discussed in the diagnosis of these patients. The various prognostic factors are mentioned and a description is given of the best way to approach the parapharyngeal space without damaging the facial nerve. With careful planning and preparation of the planned operation, the morbidity of the facial nerve may be considerably reduced.

Factors affecting the extrusion rates of ventilation tubes.

A survey in which 939 ventilation tubes of 8 different patterns were inserted and reviewed (up to a maximum of 2 1/4 years) is analysed. Various factors determining the rate of extrusion are discussed. The Sheehy Collar Button tube remained functional for a longer period than any of the other tubes included in the survey.

The surgical approach to recurrent pleomorphic adenoma of the parotid gland.

This is a retrospective study of 19 patients who were referred to the Department of Otolaryngology, Edinburgh Royal Infirmary with recurrent pleomorphic adenoma of the parotid gland. In the majority of patients, a superficial parotidectomy was performed as primary treatment. Recurrence of the tumour was either due to tumour implantation or inadequate surgical excision. Permanent facial paralysis occurred in three patients after revision parotidectomy. Change from pleomorphic adenoma at first operation to carcinoma in pleomorphic adenoma (malignant mixed tumour) at the second was noted in three patients who are still alive and free of recurrent tumour. Eighteen out of the 19 patients did not have further recurrences after revision parotidectomy. The surgical principles in the prevention of tumour recurrence and revision parotidectomy are discussed.

Management of the parotid pleomorphic adenoma, the problem of exposing tumour tissue at operation. The logical pursuit of treatment policies.

The objective of treatment of a parotid pleomorphic adenoma is to remove all tumour cells with minimal short- and long-term morbidity and minimal recurrence rates. If an enucleation is carried out, the facial nerve may be put at risk and tumour fragments will inevitably be left in the wound. Most surgeons suggest that after enucleation, radiotherapy must be given to reduce the recurrence rate to an acceptable level. If during a formal superficial parotidectomy the tumour capsule is visualised, the objective of removing the tumour with an intact cuff of normal tissue has failed and the operation has in effect become an enucleation. This paper defines the problem and discusses its management.

A case-control study of nutritional factors associated with chronic suppurative otitis media in Yemeni children.

BACKGROUND/OBJECTIVES: Undernutrition and chronic suppurative otitis media (CSOM) in children are common in low resource settings, but there are few studies of their interactions. The aim is to evaluate nutritional factors associated with CSOM in Yemeni children. SUBJECTS/METHODS: A case-control study of 75 children with CSOM and 74 healthy controls. Assessment included dietary history, anthropometry, haemoglobin (Hb) and serum analytes zinc (Zn), copper (Cu), selenium (Se), iron, calcium, phosphate (PO(4)) and total 25-hydroxy vitamin D (25(OH)D). RESULTS: Cases had lower mean Z-scores for weight-for-age, weight-for-height, body mass index and mid-upper arm circumference (MUAC) (all P<0.05), and lower mean concentrations of serum Zn (P=0.032), Se (P<0.001) and calcium adjusted for albumin (P=0.026). Age-adjusted Hb and iron biomarkers did not differ between cases and controls. There was high prevalence of low serum Zn concentration (≥ 90%) and vitamin D deficiency in both cases (80%) and controls (96%). Duration of ear discharge was negatively correlated with total 25(OH)D (P=0.028), calcium adjusted for albumin (P<0.001), PO(4) (P=0.002), transferrin receptor/log ferritin ratio (P<0.001) and Cu (P<0.001), and positively correlated with child age and MUAC (both P<0.001). CONCLUSIONS: Children with CSOM were more undernourished than controls with lower mean serum Zn, Se and calcium concentrations. Vitamin D-deficient and iron-replete children had longer duration of infection, although this association was lost with age adjustment. Trials evaluating specific micronutrients are required in order to investigate specific nutrient-infection interactions in CSOM.

Transphenoidal meningohydroencephalocoele.

A case of transsphenoidal meningohydroencephalocoele is presented. The clinical features and pathogenic factors are discussed briefly. An awareness of this condition should prevent attempted biopsy--which might otherwise prove disasterous. Air or contrast cisternography, with plain or computerised tomographic radiology, would seem to be the investigation of choice.

Recurrent pleomorphic adenomas of the parotid gland.

In this retrospective study of 19 cases of recurrent pleomorphic adenoma of the parotid gland, all 19 patients underwent primary surgery elsewhere, namely, lumpectomy in five cases and superficial parotidectomy in 14 cases. The age at which those patients with recurrence had originally been seen was significantly earlier than those seen in our series of cases of primary surgery for pleomorphic adenoma. If the primary operation had been a parotidectomy, the average time interval between the first and second operation was 7.7 years; however, if it had been a lumpectomy, it was ten months. Implantability of the tumor and inadequate surgery were reasons for tumor recurrence. The suggested treatment of recurrence is total parotidectomy with preservation of the facial nerve. Revision surgery has been successful in all cases with no further recurrences, except in two cases in which multiple operations had already been performed.