[MILESTONES IN THE HISTORY OF ORTHOPEDICS].

INTRODUCTION: Orthopedics (also - orthopedic surgery) is a field of medicine that deals with diseases, defects, infections, tumors and injuries of the skeletal system, joints and muscles in the human body. The term orthopedics (Greek Orthos = alignment, Pais = child) was first coined in 1741 by the French surgeon Nicolas Andry de Bois-Regard, from Lyon in France, to describe correction and prevention of spinal deformities in children. Only in the second half of the 18th century, did orthopedics separate from general surgery and became a separate specialty in medicine. Much development in the field of orthopedics was achieved due to the various wars and their inevitable results - combat injuries, and following various developments in medicine such as understanding the importance of sterility in surgery, the possibility of surgery under general anesthesia, the use of antibiotics, the development of arthroscopy and fiber-optic equipment and the various imaging options. This article intends to review milestones in the development of orthopedics from the dawn of history in ancient Egypt to the present day, and the first steps of orthopedics in Israel.

[DR. ARIEH LEIB SHIMONI-MEKLER - EYE, EAR, NOSE AND THROAT SPECIALIST].

Although the inauguration of the new hospital in Zefat built by Baron Rothschild took place in 1910, the building was not used as a hospital until World War I when it was confiscated by the Turks for patients affected with typhus, and later it was converted into a military hospital. The second inauguration of the renewed hospital was in June 1919, and the medical activity was assigned to the American Zionist Medical Unit for Palestine' (AZMU), later - 'Hadassah Medical Organization'. Among the first doctors that were sent to Zefat by AZMU was Dr. Arieh Leib Shimoni-Mekler - Eye, Ear, Nose and Throat specialist. Dr. Shimoni-Mekler worked in the hospital during the years 1921-2.

[The pioneer otolaryngologists in Eretz-Israel: 1911-1948].

Until 1911 there was no ear nose and throat (ENT) specialist in Eretz-Israel. Dr. Moshe Sherman, an ENT specialist, disembarked at the port of Jaffa on August 4, 1911. He had trained in Moscow, and was the first otolaryngologist in the country. Between 1911 and 1948, over 100 otolaryngologists arrived in Eretz-Israel and were dispersed throughout the country from Safed and Tiberias in the North to Rehovot in the South. These physicians brought modern and advanced European medicine to Israel. Many left their imprint on the development of ENT medicine in the country, laying the foundations of today's otolaryngologic services both in clinical and academic spheres. ENT medicine, like other fields of medicine, evolved following the establishment of the State of Israel in 1948. Many departments were opened and equipped with the best modern instruments and technology. Department heads are the pupils of our pioneer physicians. The memory of these talented and dedicated physicians should be remembered and cherished by their successors and all physicians in Israel.

[Dr. Moshe Sherman--the first otolaryngologist in Eretz-Israel: 100 years since his arrival].

On 4.8.1911 Dr. Moshe Sherman landed at the port of Jaffa. He was the first otolaryngologist in Eretz-Israel and for one year he was the only specialist in the country. Dr. Sherman was born in Nikolayev (Russia) in 1881. He started his medical education in Odessa, continued in Berlin, graduated in 1907 at the University of Dorpat (Estonia) and pursued postgraduate studies in otolaryngology at Moscow University. He settled in Jaffa, started a private practice and soon became a famous specialist. He volunteered at the Jewish hospital in Jaffa--"Shaar Zion", and twice a year spent several weeks in Jerusalem seeing patients and performing small operations. On January 1912 Dr. Sherman, together with another 5 physicians, laid the foundations for the first doctors' organization in Israel: "The Medical Society of Jaffa and Jaffa district". In 1918 Dr. Sherman was elected consultant at the Hadassah Hospital in Tel Aviv, and in 1932 a department for ear, nose and throat diseases was established there under his management. He was the founder and first chairman of the Ototaryngology Society in Eretz-Israel, and in 1935 was elected the chairman of the Jewish Medical Association in Eretz-Israel (later--its honorary president). He was the initiator and founder of the "World Fellowship", and the Editor in Chief of 'Harefuah' and "Michtav Lachaver". Dr. Sherman was the author of numerous papers related to his specialty and to the history of Jewish organizations in Eretz-Israel and, later, in the State of Israel. Dr. Sherman died in Tel Aviv on July 17th 1969.

[A prophet without honor in his own country: Dr. Ernst Wodak (1891-1962)].

Among all otolaryngologists who lived in Israel during the first half of the 20th century, one was most prominent - Dr. Ernst Wodak. Ernst Wodak was born in Czechoslovakia in 1891 and he graduated from the German University of Prague in 1915. Dr. Wodak was a knowledgeable clinician and an outstanding researcher. He was mainly interested in the vestibular system, and already started to publish the results of his observations in 1914. In a short time Dr. Wodak became famous all over Europe. He was on the Editorial Boards of the Acta Oto-Laryngologica, and of the Excerpta Medica, and a member of the International Collegium Otolaryngologicum. In 1939, following the invasion of Czechoslovakia by the Germans, Dr. Wodak had to leave his work, and soon after he immigrated to Israel and settled in Tel-Aviv. For 5 years he volunteered in the ENT department in 'Hadassah' Hospital. Even though he was already famous worldwide, Dr Wodak was not appreciated by most of his colleagues nor by the academic authorities. He could not continue his research and was forced to work only in his private clinic and mainly performed plastic and cosmetic operations. In spite of his frustration, Dr. Wodak did not lose the drive to publish and continued to contribute important papers to medical journals both in Israel and abroad. He published more than 200 papers and also wrote a few books. Dr Wodak died on 27.4.1962 following a prolonged period of pain and suffering, away from his wife and daughter and abandoned by most of his friends.

Prednisone treatment for vestibular neuritis.

OBJECTIVE: To evaluate the value of corticosteroids in the treatment of vestibular neuritis (VN). DESIGN: Prospective controlled randomized. METHODS: Thirty VN patients, 15 in the study and 15 in the control group, were the subjects of the study. The study group was treated by 1 mg/kg prednisone for 5 days, followed by gradually reduced doses of prednisone for an additional 15 days, and vestibular sedatives for symptomatic relief during the first 5 days after presentation. The control group received a placebo and similar vestibular sedatives. The patients had a baseline evaluation and follow-up examinations after 1, 3, 6, and 12 months. The groups were compared for the presence of symptoms and signs, caloric lateralization on the electronystagmography (ENG), the presence of other pathologic findings in the ENG, and Dizziness Handicap Inventory scores. RESULTS: No differences were found between the groups in the occurrence of symptoms and signs, degree of caloric lateralization, presence of other ENG pathologic findings, and Dizziness Handicap Inventory scores at the end of the study. Complete resolution was observed in 64% of the study and in 80% of the control group. The study group showed earlier recovery of ENG lateralization at the 1- and 3-month follow-up evaluations and higher rates of complete resolution at the 3- and 6-month follow-up points. CONCLUSION: Prednisone therapy might enhance earlier recovery but does not improve the long-term prognosis of VN. The clinical and laboratory parameters in VN are not correlated, and both are required for complete patient evaluation.

Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography imaging in patients with carcinoma of the nasopharynx: diagnostic accuracy and impact on clinical management.

PURPOSE: To assess the value of (18)F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in patients with nasopharyngeal carcinoma as compared with PET and conventional imaging (CI) alone, and to assess the impact of PET/CT on further clinical management. METHODS AND MATERIALS: Thirty-three patients with nasopharyngeal carcinoma had 45 PET/CT examinations. The study was a retrospective analysis. Changes in patient care resulting from the PET/CT studies were recorded. RESULTS: Positron emission tomography/computed tomography had sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 92%, 90%, 90%, 90%, and 91%, respectively, as compared with 92%, 65%, 76%, 86%, and 80% for PET and 92%, 15%, 60%, 60%, and 60% for CI. Imaging with PET/CT altered further management of 19 patients (57%). Imaging with PET/CT eliminated the need for previously planned diagnostic procedures in 11 patients, induced a change in the planned therapeutic approach in 5 patients, and guided biopsy to a specific metabolically active area inside an edematous region in 3 patients, thus decreasing the chances for tissue sampling errors and avoiding damage to nonmalignant tissue. CONCLUSIONS: In cancer of the nasopharynx, the diagnostic performance of PET/CT is better than that of stand-alone PET or CI. Positron emission tomography/computed tomography had a major impact on further clinical management in 57% of patients.

The role of FDG-PET/CT imaging in head and neck malignant conditions: impact on diagnostic accuracy and patient care.

BACKGROUND: To assess the value of positron emission tomography/computed tomography (PET/CT) with 18F-Fluorodeoxyglucose (FDG) in patients with head and neck carcinoma as compared with PET and conventional imaging alone, and to assess the impact of PET/CT on further clinical management. STUDY DESIGN: Prospective nonrandomized study. SETTING: Ninety patients with head and neck tumors had 107 PET/CT examinations. RESULTS: The study analysis showed that PET/CT had a sensitivity of 89%, specificity 95%, PPV 94%, NPV 90%, and accuracy of 92%. PET/CT altered management in 51 patients (56%). PET/CT eliminated the need for previously planned diagnostic procedures in 24 patients, induced a change in the planned therapeutic approach in 21 patients and guided biopsy in 6 patients. CONCLUSIONS: PET/CT is an imaging modality with high diagnostic performance in the assessment of head and neck cancer, and induced a change in further clinical management in more than half of the study population.

[Frontal sinus fractures: five years of treatment experience].

BACKGROUND: Frontal sinus fractures are commonly encountered in major trauma centers. They are almost exclusively seen in young adults and are usually caused by high velocity impacts. The intimate association of the frontal sinuses with structures such as frontal lobes and the eyes makes the appropriate management of this injury essential. PURPOSE: To review patients that suffered from frontal sinus fractures and underwent surgery, and to evaluate the efficacy and complications of this treatment. METHODS: This is a retrospective study. The study population included all the patients that suffered from frontal sinus fracture and underwent a surgical intervention between the years 1998-2002. The data that was collected included demographic parameters, cause of injury, timing and kind of surgery, postoperative complications and patient satisfaction. RESULTS: A total of 47 patients were operated on due to frontal sinus fractures during the years 1998-2002. Only 38 had adequate follow-up. Seventy percent of the patients suffered from bitable fractures. The other 30% had only anterior wall fractures. A total of 47% of the patients had additional facial fractures and 39% had intracranial injuries. Most of the patients were operated on during the first 24 hours (50%). The incidence of major postoperative complications was 2.5% (1 patient had meningitis). Minor complications occurred in 15% of the patients (mainly decreased forehead sensation). CONCLUSIONS: Frontal sinus fractures are commonly seen in major trauma centers. High index of suspicion, careful physical examination and imaging assistance are essential for accurate diagnosis. Lack of appropriate treatment can lead to serious intracranial complications. The surgical intervention achieves good cosmetic and functional outcomes in a majority of the patients.

Fluorodeoxyglucose-positron emission tomography/computed tomography imaging in patients with carcinoma of the larynx: diagnostic accuracy and impact on clinical management.

OBJECTIVES: The objectives of this study were to assess the value of F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in patients with carcinoma of the larynx as compared with PET and CT alone and to assess the impact of PET/CT on further clinical management. STUDY DESIGN: This was a prospective, nonrandomized study. MATERIALS AND METHODS: Forty-two patients with laryngeal cancer had 51 PET/CT examinations. There were 34 men and eight women, aged 39 to 80 years. All studies were interpreted prospectively with knowledge of the clinical history and results of previous imaging tests. The performance of different imaging modalities was compared on both a study- and lesion-based analysis for sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and accuracy. Changes in patient care resulting from the PET/CT studies were recorded. RESULTS: The study analysis showed that PET/CT had a sensitivity of 92%, specificity 96%, PPV 96%, NPV 92%, and accuracy of 94% as compared with 92%, 73%, 76%, 91%, and 82% for PET, and 88%, 8%, 48%, 40%, and 51% for CT, respectively. There were 112 suspicious sites evaluated in the 51 studies. PET/CT altered management in 25 patients (59%) by sparing previously planned diagnostic procedures (n=13), by changing the planned therapeutic approach (n=9), and by guiding a biopsy to a metabolically active laryngeal area (n=3). CONCLUSIONS: The performance of PET/CT is better than standalone PET or CT in patients with cancer of the larynx. PET/CT had a major impact on management of 59% of patients.

Does otitis media in early childhood affect reading performance in later school years?

OBJECTIVE: To evaluate reading performance in children with recurrent otitis media during childhood once middle-ear diseases have resolved and the children grew older. STUDY DESIGN AND SETTING: Seventy-five children with middle-ear problems during childhood and poor reading performance in first grades and 60 healthy controls free of middle ear diseases were enrolled in the study. All children underwent an otologic and audiologic evaluation followed by reading tests. RESULTS: Reading performance was not affected once otitis media had been cured and hearing restored; reading scores of the healed children were almost the same as those of the otitis-free children (3.39% and 3.1%, respectively). Children who still suffer from middle-ear problems and hearing loss had an average percentage of reading mistakes of 7.3%. CONCLUSIONS AND SIGNIFICANCE: Once children are cured from their middle-ear diseases and hearing is restored, previously noted reading impairments are no longer evident. Reading is still impaired among children who continue to suffer from middle-ear problems and hearing loss even when they grow older. EBM RATING: B-2b.

[Safe extraction of an impacted open safety pin from the esophagus: a new technique and five case studies].

Esophageal foreign bodies are common, especially in children less than 5 years old. However, the presence of an open safety pin in the esophagus is quite rare. When this occurs, immediate removal of the safety pin is recommended due to its propensity to pierce the esophagus and surrounding structures causing severe and sometimes even lethal complications. Between the years 1990 and 2003, fifteen infants were referred to the Department of Otolaryngology-Head and Neck Surgery at the Rambam Health Care Campus with a history of safety pin ingestion. Plain neck, chest and abdomen radiographs showed the presence of an open safety pin impacted in the esophagus and pointing upwards in nine of the cases, and in the remainder (six infants) a closed pin was demonstrated in the stomach or in the duodenum. This report focuses on five cases in which during esophagoscopy only the clasp of the safety pin was visible, whereas the sharp point was impossible to be grasped, as it seemed to be stuck in the mucosa of the esophagus. In these cases the pin was pushed into the stomach, where it was closed, and then it was pulled outside without any harm to the mucosa or the gastric and esophageal walls. We present a new technique on how to safely close an open safety pin in the stomach and remove it, without any complications, using a flexible endoscope.

Percutaneous tracheotomy in bone marrow transplant patients with severe thrombocytopenia.

OBJECTIVE: Evaluation of percutaneous tracheotomy in bone marrow transplant patients with severe thrombocytopenia. DESIGN: A retrospective outcome study. PATIENTS: A retrospective study of 26 percutaneous tracheotomies was performed at the Bone Marrow Transplant Unit, Rambam Medical Center, Haifa, Israel. Age, sex, underlying disease, reason for intubation, complete blood count, coagulation profile, and the incidence of renal failure were collected. All patients received 6 units of platelets one hour prior to the procedure. RESULTS: The mean platelets count was 14,300 +/- 5500. Twenty-five of the 26 percutaneous tracheotomies were completed successfully, without any intraoperative complications. One patient suffered from moderate bleeding during the procedure, which was immediately stopped and converted to open tracheotomy. In the postoperative period 4 patients suffered from mild bleeding around the stoma, which was managed conservatively. No other late complications were encountered. CONCLUSIONS: Percutaneous tracheotomy can be safely performed in patients with severe thrombocytopenia when the surgeon and anesthesiologist are experienced in the procedure, and platelets are given perioperatively.

Reading performance in children with otitis media.

OBJECTIVE: To examine whether middle ear diseases and the associated hearing loss in early childhood affect reading performance later at school. STUDY DESIGN AND SETTING: One hundred and sixty children, 6.5 to 8 years of age, were enrolled in this study: 80 children with a history of recurrent infections and/or prolonged periods of effusions of the middle ear before the age of 5 years, and 80 healthy children without any history of middle ear disease. Data were collected from the medical records of the children. Every child underwent a complete otological and audiological evaluation, followed by special reading tests. RESULTS: The study group performed more poorly, in all reading tests, as compared to the controls ( P < 0.001). CONCLUSION: Children with recurrent or prolonged middle ear diseases during the first five years of life tend to be at greater risk for delayed reading than aged-matched controls with no previous middle ear diseases.

Antioxidants in treatment of idiopathic sudden hearing loss.

OBJECTIVE: Assuming that superoxide anion radicals (O(2)-) may play a role in damage to the inner ear, the authors investigated the possible benefit of vitamin E as an antioxidant in the treatment of idiopathic sudden hearing loss. STUDY DESIGN: Prospective, double-blind study. SETTING: The Department of Otolaryngology of Rambam Medical Center serves as a tertiary referral center for a population of 1.2 million people. PATIENTS: A total of 66 patients, aged 15 to 70 years, with diagnoses of idiopathic sudden hearing loss of less than 7 days' duration during 1998 to 2001, were included in the study. All were treated with bed rest, steroids, magnesium, and carbogen inhalation. The study group received vitamin E in addition. RESULTS: The recovery rate, calculated as hearing gain divided by the difference in hearing level between the affected and unaffected ear, was better than 75% in 41 of 66 (62.12%) patients. This rate was achieved in 26 (78.78%) patients in the study group treated with vitamin E, compared with 15 (45.45%) patients in the control group. CONCLUSIONS: Patients treated with the addition of vitamin E achieved better recovery than did the control patients. Further studies should be directed toward a better understanding of the role of antioxidants in idiopathic sudden hearing loss.

Magnesium: a new therapy for idiopathic sudden sensorineural hearing loss.

OBJECTIVE: To determine whether treatment with Mg(2+) improves the outcome of idiopathic sudden hearing loss and to investigate which variables influence its prognosis. STUDY DESIGN: Prospective randomized study. SETTING: Department of Otolaryngology-Head and Neck Surgery, Rambam Medical Center, Haifa, Israel. PATIENTS: The study group included 133 patients. Sixty patients were treated with carbogen inhalation, and 73 were treated with a combination of carbogen inhalation and intravenous MgSO(4). RESULTS: The mean improvement rate was 66.4% in the Mg(2+) group and 49.9% in the carbogen group (p < 0.01). Recovery was achieved in 35 patients (48%) in the Mg(2+) group and only in 19 patients (31.6%) in the carbogen group (p < 0.01). Significant improvement was seen in 20 patients (27.4%) in the Mg(2+) group and in 14 patients (23.3%) in the carbogen group. Partial improvement was seen in eight patients (10.9%) in the Mg(2+) group and in 12 patients (20%) in the carbogen group. No improvement was achieved in 10 patients (13.6%) in the Mg(2+) group and in 15 patients (25%) in the carbogen group. Patients with vestibular symptoms had a poorer hearing outcome compared to those without vertigo (p < 0.04). Patients who commenced the treatment 8 days or more after onset had poorer recovery as compared with those who started treatment earlier (p < 0.03), regardless of the treatment regimen. Age, sex, and tinnitus had no significant impact on hearing recovery. CONCLUSION: We found that Mg(2+) improved hearing recovery in cases of idiopathic sudden hearing loss. Vertigo and treatment delay beyond 8 days were poor prognostic factors for recovery.

Percutaneous dilation tracheotomy versus surgical tracheotomy: our experience.

BACKGROUND: Percutaneous dilation tracheotomy (PDT) is becoming a popular alternative to surgical tracheotomy. In our department, we recently adopted the use of the PDT in intensive care unit patients. Here, we compare the results of the use of these 2 techniques on 150 patients, all performed by the same surgeon. We discuss the pros and cons of PDT and present our experience with the technique compared with surgical tracheotomy (ST). MATERIALS AND METHODS: A prospective study of 75 PDTs and a retrospective study of 75 surgical tracheotomies (ST) were performed at the Department of Otolaryngology-Head and Neck Surgery, Rambam Medical Center, Haifa, Israel. Age, sex, duration of intubation before surgery, time interval between the decision to perform and the performance of tracheotomy, and cost were compared. RESULTS: One hundred fifty tracheotomies were reviewed. The indication for tracheotomy in both groups was prolonged mechanical ventilation. Seven patients were found unsuitable for PDT and underwent ST. Complications included 3 cases of mild postoperative hemorrhage in the ST group, and 1 case of subcutaneous emphysema, 1 case of stomal cellulitis and 2 cases of mild postoperative hemorrhage in the PDT group. The average waiting interval was between 2 to 5 days for ST and 1 to 24 hours for PDT. The intraoperative time for ST was 20 minutes; for PDT, 5 minutes. The cost was 565 dollars for ST and 274 dollars for PDT. CONCLUSIONS: PTD provides an easy, less expensive, and convenient alternative to ST and should be added to the otolaryngologists' armamentarium of surgical airway procedures. The procedure is advantageous for the patient. Complication rates of both techniques are similar and low; however, PDT is a blind technique of obtaining a surgical airway and therefore holds more potential for serious complications. It is our conclusion that this technique is suitable for many, but not all, critical care patients and that the procedure should be performed only by surgeons who are capable of urgently obtaining a surgical airway or exploring the neck should the PDT fail.

Ventilation tubes and persisting tympanic membrane perforations.

Surgical management of otitis media with effusion and recurrent acute otitis media includes myringotomy and the use of ventilation tubes. Since this procedure was reintroduced by Armstrong in 1954, it has become one of the most commonly performed operations in otolaryngology. In most series perforation of the tympanic membrane in some patients has been reported after spontaneous extrusion or removal of the tympanostomy tubes. We present a retrospective review designed to examine the incidence of persisting perforations of the tympanic membrane in our series of 2604 operated ears. The study also identifies and analyzes the variables and the contributing risk factors. Perforations occurred in 3.06% of the ears: with a greater incidence in children younger than 5 years, when the indication was recurrent purulent otitis media, with the use of long-term Goode T tubes, in cases with repeated insertions of ventilation tubes, and in cases in which postoperative otorrhea was frequent.

Paper patching for chronic tympanic membrane perforations.

OBJECTIVE: This study was designed to evaluate the results of paper-patch myringoplasty in patients with chronic perforations of the tympanic membrane of different sizes. STUDY DESIGN AND SETTING: A retrospective survey of paper-patch myringoplasties performed in a tertiary referral academic medical center on 77 patients with chronic perforations of the eardrum was carried out. Data consisted of the causes of the perforations, time the perforations had been present, their size, number of patch applications, duration of application, and number of successfully closed perforations. RESULTS: Closure rate was 63.2%, 43.5%, and 12.5% for small, medium, and large perforations, respectively. Small perforations needed the least number of repeated applications and the least time for closure. CONCLUSIONS AND SIGNIFICANCE: Paper patching is technically simple, time saving, safe to perform, cost effective, and suitable as an outpatient procedure and has a good success rate, It should be tried in perforations smaller than 5 mm before a patient is referred for surgery.