New insights into tip supporting structures. Consequences for nasal surgery.

BACKGROUND: Knowledge of tip supporting structures is crucial for successful rhinoplastic surgery. The aim of this study was to provide detailed anatomical and histological descriptions of the tip supporting structures. METHODS: Serial coronal sections of the entire external noses from seven cadavers were studied after staining by Mallory-Cason and Verhoeff-Van Gieson procedures. RESULTS AND CONCLUSIONS: We found no histological evidence of ligaments between the cartilaginous- and bony parts of the nasal skeleton, and between the skin and the nasal skeleton. Instead, we found a perichondrial-periosteal lining within the soft tissue envelope. The main tip supporting and shaping structures are: septal and lobular cartilages, premaxillae, and the soft tissue envelope including the periosteal-perichondrial envelope/membrane. These findings may have clinical relevance in functional and aesthetic rhinoplasties.

Functional anatomy of the nasal bones and adjacent structures. Consequences for nasal surgery.

The periosteum of the nasal bones, the periosteal-perichondrial nasal envelope, and the cartilaginous support of the bony vault were studied in serial coronal sections of four human cadaver noses. To differentiate between the various tissue components, the sections were stained according to Mallory-Cason and Verhoeff-Van Gieson stain. The results demonstrated: 1. the presence of clearly distinguishable layers of the periosteum covering the nasal bones; 2. the presence of a continuous periosteal-perichondrial covering of the bony and cartilaginous nasal vaults; 3. the way the cartilaginous support of the bony vault is constructed. The findings described in the present study may have clinical relevance in nasal surgery.

Nonsyndromic hearing impairment is associated with a mutation in DFNA5.

Nonsyndromic hearing impairment is one of the most heterogeneous hereditary conditions, with more than 40 loci mapped on the human genome, however, only a limited number of genes implicated in hearing loss have been identified. We previously reported linkage to chromosome 7p15 for autosomal dominant hearing impairment segregating in an extended Dutch family (DFNA5). Here, we report a further refinement of the DFNA5 candidate region and the isolation of a gene from this region that is expressed in the cochlea. In intron 7 of this gene, we identified an insertion/deletion mutation that does not affect intron-exon boundaries, but deletes five G-triplets at the 3' end of the intron. The mutation co-segregated with deafness in the family and causes skipping of exon 8, resulting in premature termination of the open reading frame. As no physiological function could be assigned, the gene was designated DFNA5.

CT of cochlear otosclerosis (otospongiosis).

High-resolution CT is the method of choice in determining the extent of demineralization in otospongiosis. By comparing the maximum and minimum densities, this examination has become of clinical importance in the diagnostic approach to otosclerosis and in the follow-up of fluorine therapy.

Cisplatin-induced ototoxicity; electrophysiological evidence of spontaneous recovery in the albino guinea pig.

For 8 days albino guinea pigs (n = 48) were treated with cisplatin (cis-diamminedichloroplatinum(II), 1.5 mg/kg body weight/day). Compound action potentials (CAP), cochlear microphonics (CM) and summating potentials (SP) were recorded from the apical surface of the cochlea in response to tone bursts ranging in frequency from 0.5 to 16 kHz. The recordings were collected in different groups of animals, 1 day, 1 week, 2, 4, 8 and 16 weeks after cisplatin treatment, respectively. One day after the 8-day treatment we found frequency-dependent loss in the amplitudes of the three cochlear potentials, with the larger losses occurring at the higher frequencies. In terms of threshold shift the losses were larger for the CAP than for the hair cell-related potentials SP and CM. A salient improvement in both CAP and CM amplitude occurred over the next 8 weeks. Also, the SP showed improvement. These results indicate that guinea pig cochlear transduction recovers spontaneously after cisplatin injury. Recovery of the hair cell-related potentials suggests that recovery occurs already at the hair cell level. The question whether this recovery originates with the formation of new hair cells or with repair of damaged hair cells should be answered on the basis of subsequent morphological investigations.

Dose-dependent effect of 8-day cisplatin administration upon the morphology of the albino guinea pig cochlea.

Numerous studies investigating cisplatin ototoxicity in animals have been performed, but it is difficult to derive a clear dose-effect relation from these studies. The degree of cisplatin-induced ototoxicity depends on a multitude of factors. Many parameters, such as dose, mode of administration, dosage schedule and concomitant administration of protective additives, vary among the published studies. Therefore, we performed a basic dose-effect study on cisplatin ototoxicity in the guinea pig. Albino guinea pigs were treated with cisplatin at daily doses of either 0.7, 1.0, 1.25, 1.5 or 2.0 mg/kg for 8 consecutive days. Electrocochleography was performed on day 10 after which the cochleas were removed and processed for histological examination. The electrophysiological results showed a marked transition from almost no ototoxic effect to a large effect between a daily dose of 1.25 and 1.5 mg/kg (Stengs et al., 1998). Outer hair cell (OHC) counts corresponded well with the electrophysiological results. At daily doses of 0.7, 1.0 and 1.25 mg/kg no statistically significant OHC loss was observed, whereas OHC loss averaged 60% and 65% in the basal turns at daily doses of 1. 5 and 2.0 mg/kg, respectively. Morphological changes in the stria vascularis were present only in cochleas from animals treated with cisplatin doses of 1.0, 1.25 and 1.5 mg/kg/day. Cochleas from animals treated with a daily cisplatin dose of 2.0 mg/kg for 8 consecutive days showed an endolymphatic hydrops. The present study shows that cisplatin, administered at a daily dose of 1.5 mg/kg for 8 consecutive days, provides a degree of OHC loss that is well suited to study the effects of putative protective agents and possible hair cell recovery.

Cisplatin-induced ototoxicity: morphological evidence of spontaneous outer hair cell recovery in albino guinea pigs?

Cisplatin is frequently used in the treatment of various forms of malignancies. Its therapeutic efficacy, however, is limited by the occurrence of sensorineural hearing loss. Little is known about the course of hearing loss over longer time intervals after cessation of cisplatin administration. Infrequently, recovery of hearing has been described in animals and humans. Stengs et al. (1997) treated guinea pigs with cisplatin at a daily dose of 1.5 mg/kg for 8 consecutive days and subsequently studied cochlear function after survival times varying from 1 day to 16 weeks. Spontaneous improvement of the hair cell-related potentials (cochlear microphonics and summating potentials) was observed starting 2 weeks after cessation of treatment. In the present study we examined light microscopically the cochleas used in the study of Stengs et al. (1997). One day after cessation of cisplatin administration outer hair cell (OHC) loss in the basal cochlear turn averaged 66%. In the 1-week survival group, OHC counts were similar to those of the 1-day survival group. In the 4-week survival group, however, a relatively small loss of OHCs was found in the basal cochlear turn; OHC loss averaged only 15%. A similar loss was found after 8 weeks. In the 16-week survival group, OHC loss in the basal turn increased to 48%, but this was not statistically significant. Our histological observations are in line with the electrophysiological data from the same animals. Our findings suggest that OHCs recover from cisplatin-induced damage 1-4 weeks after treatment. However, the results do not allow a conclusion as to whether the observed recovery is due to the formation of new OHCs or to (self-)repair of damaged OHCs.

Histological effects of co-administration of an ACTH((4-9)) analogue, ORG 2766, on cisplatin ototoxicity in the albino guinea pig.

Cisplatin is one of the most potent antineoplastic drugs presently known, but its therapeutic efficacy is seriously limited by several side effects such as ototoxicity. Several compounds that are known for their nephroprotective effects also seem to reduce the incidence and severity of cisplatin-induced ototoxicity. Hamers et al. (1994) and De Groot et al. (1997) investigated the possibly protective effect of concomitant administration of the ACTH((4-9)) analogue ORG 2766 upon cisplatin ototoxicity in guinea pigs. Animals were treated with cisplatin at a daily dose of 2.0 mg/kg for 8 consecutive days and ORG 2766 at a daily dose of 75 mcg/kg for 9 days. Concomitant administration of cisplatin plus ORG 2766 resulted in a bimodal distribution of the electrophysiological data (compound action potential and cochlear microphonics amplitudes) and the histological data (outer hair cell (OHC) counts). It was surmised that this dichotomy might occur at a certain cisplatin dose. We investigated whether this protective effect of ORG 2766 could be enhanced by reducing the daily dose of cisplatin while maintaining the same dose of ORG 2766. Thirty-six animals were treated with daily i.p. injections of cisplatin at a dose of 1.0 mg/kg (n=18) or 1.5 mg/kg (n=18) for 8 consecutive days. When comparing the mean OHC counts of the different experimental groups, treatment with cisplatin at a daily dose of 1.5 mg/kg for 8 consecutive days resulted in a considerable loss of OHCs, which was significantly reduced after co-administration of ORG 2766. Co-treatment with ORG 2766 did not result in a change in the volume of the scala media. The present results are in agreement with the electrophysiological results published earlier (Stengs et al., 1998b).

Cisplatin ototoxicity. An electrophysiological dose-effect study in albino guinea pigs.

Recently, the effect of the ACTH(4-9) analog, ORG2766, on cisplatin ototoxicity was studied by Hamers et al. (1994). This study showed that the ACTH(4-9) analog partially prevents the ototoxicity of cisplatin. The authors suggested that the daily dose of 2.0 mg/kg/day for 8 days might have been too high to obtain full protection. Knowledge about dose-effect relations for cisplatin ototoxicity is rather meager. Therefore, we conducted a basic dose-effect study for cisplatin without any concomitant additives. A follow-up of the Hamers et al. (1994) study, based on dose-effect data from this paper, is presented in a companion paper. The effects of cisplatin on the compound action potential (CAP), cochlear microphonics (CM) and summating potential (SP) were determined in acute experiments, in different groups of albino guinea pigs, each group injected with a different dose of cisplatin. Daily doses ranged from 0.7 to 2.0 mg/kg/day cisplatin (i.p.) for 8 consecutive days. Electrocochleography was performed at day 10. The measurements were performed over a broad range of frequencies (0.5-16 kHz). The results showed clustering of the data in two groups, the first group concerning the treatments of 1.5 and 2.0 mg/kg/day with large frequency-dependent losses in the three cochlear potentials, the second group concerning the treatments with lower doses of cisplatin (0.7, 1.0 and 1.25 mg/kg/day) where almost no losses in the three cochlear potentials were found. The threshold curves regarding the lower doses (0.7-1.25 mg/kg/day) were almost indistinguishable from the control threshold curve except at the higher frequencies (12 and 16 kHz). Thus, a marked transition from almost no ototoxic effect to a large effect seems to occur between cisplatin doses of 1.25 and 1.5 mg/kg/day for 8 days. The small difference between the effects found for 1.5 mg/kg/day and 2 mg/kg/day suggests that a smaller dose than the one of 2 mg/kg/day for 8 days used previously (Hamers et al., 1994) might better suit research into protection against cisplatin ototoxicity.

Protective effects of a neurotrophic ACTH(4-9) analog on cisplatin ototoxicity in relation to the cisplatin dose: an electrocochleographic study in albino guinea pigs.

Cisplatin is a potent cell cycle non-specific chemotherapeutic agent that produces side effects including high-frequency hearing loss. Hamers et al. (1994) studied electrophysiologically the effect of an ACTH(4-9) analog, also known as ORG2766, on the ototoxicity of cisplatin (administered at 2 mg/kg/day for 8 days) in guinea pigs. ORG2766 was given concomitantly with cisplatin during the 8 day period and an additional dose was given on day 9. The conclusion of this study was that ORG2766 might partially prevent cisplatin ototoxicity, but that the chosen cisplatin dose (2 mg/kg/day; 8 days) might have been too high. Because of the high cisplatin dose the protective power of the co-treatment with ORG2766 might not have stretched to all animals. In this study the results of co-treatment with the same dose and daily schedule of ORG2766 and cisplatin doses of 1.0 mg/kg/day and 1.5 mg/kg/day for 8 days are presented. The measurements were performed over a broad range of frequencies (0.5-16 kHz). Electrocochleography was performed at day 10. In the 1.0 mg/kg/day group there was no beneficial effect of ORG2766, although a tendency towards a division between a subgroup resembling control animals and a subgroup with severe cisplatin effects was noted in the co-treated group. In the 1.5 mg/kg/day co-treated group three animals showed compound action potential (CAP) amplitudes close to those of the controls at all frequencies except the very highest (12 and 16 kHz), the remaining three had CAP amplitudes comparable to those of animals in the cisplatin alone group. The effect of ORG2766 on the latter group of six animals taken together was statistically significant. The dichotomy in the results for the 1.5 mg/kg/day group co-treated with ORG2766 suggests that ORG2766 may have a protective effect against cisplatin ototoxicity which, however, depends on a factor currently unknown.

The effect of nimodipine on cochlear potentials and Na+/K(+)-ATPase activity in normal and hydropic cochleas of the albino guinea pig.

In experimental endolymphatic hydrops (EEH) a decrease in the endocochlear potential (EP) has been reported and is thought to be due to decreased activity of the enzyme Na+/K(+)-ATPase in the stria vascularis. By stimulating Na+/K(+)-ATPase, the EP, and thereby cochlear function as a whole, might be restored. On the other hand, stimulation of stria vascularis Na+/K(+)-ATPase might result in excessive production of endolymph and thus produce or augment hydrops. In this study we have investigated the effect of intraperitoneally applied nimodipine on cochlear potentials and on Na+/K(+)-ATPase activity in the stria vascularis, both in normal cochleas (control) and in cochleas with EEH. Nimodipine is an L-type Ca(2+)-channel blocking agent with Na+/K(+)-ATPase stimulating properties at concentrations as low as 1.5 nM. The compound action potential (CAP), evoked by 2,4 and 8 kHz tone bursts was found to be depressed in the EEH ears with and without nimodipine treatment, and in the nimodipine treated control ears. Statistical analysis (ANOVA) showed that the effects of EEH and nimodipine on the CAP were additive. The negative summating potential (SP), measured extracochlearly at the apex, in response to 4 and 8 kHz tone bursts was significantly enhanced in the EEH ears. Nimodipine treatment did not affect the SP, neither in the control, nor in the EEH ears. Cytochemically, Na+/K(+)-ATPase activity appeared to be decreased in the oedematous stria vascularis of hydropic cochleas. No effect of nimodipine on Na+/K(+)-ATPase activity could be established ultracytochemically, neither in the controls nor in the EEH ears. In the lower turns of some of the nimodipine treated control cochleas a mild hydrops was seen during light-microscopic evaluation. Although it was not possible to prove a stimulatory effect of nimodipine on the enzyme Na+/K(+)-ATPase cytochemically, the finding of mild endolymphatic hydrops in nimodipine treated control ears suggests (a history of) increased endolymph production. This hydrops might be responsible for the depression of the CAP in the nimodipine treated ears.

Induction of endolymphatic hydrops in the guinea pig by perisaccular deposition of sepharose beads carrying and not carrying immune complexes.

We tried to induce endolymphatic hydrops in guinea pig cochleas by unilateral, perisaccular deposition of sepharose beads carrying immune complexes. Controls consisted of the deposition of sepharose beads without immune complexes and the contralateral, untreated ear. The effects of the treatment were studied by light microscopy and electrophysiological recordings of the gross cochlear potentials 1, 2, and 6 weeks after treatment. Each condition included six animals. Analysis of variance of the morphometric data concerning the ears treated with deposition of the beads showed a statistically significant difference (P = 0.04) between the degree of hydrops found for the beads with immune complexes and for those without. The difference between the treated ears and the contralateral untreated ears was significant (P = 0.01) for the beads with immune complexes and not significant (P = 0.8) for those without immune complexes while there was no significant effect of post-treatment time interval. Analysis of variance of the electrophysiological data, collected in response to tone bursts at the apex of the cochlea, showed no significant differences between the results for the beads with and without immune complexes. Therefore these results were pooled. One week after treatment the pooled results for the compound action potential showed a small decrease in amplitude, just significant at 2 kHz, but not at 4 and 8 kHz. This decrease disappeared completely after 6 weeks. The pooled results for the negative summating potential (SP) showed a significant increase in magnitude at all frequencies decreasing with post-treatment interval. The cochlear microphonics did not demonstrate any change in amplitude after treatment. The results indicate that deposition of sepharose beads with immune complexes induces endolymphatic hydrops. Also, deposition of the sepharose beads itself may have induced hydrops together with enhancement of the SP. SP enhancement may be related to the development of endolymphatic hydrops rather than to the presence of hydrops as such. This may be based on pressure build-up while hydrops develops.

Advances in oto-immunology: new trends in functional pathology of the temporal bone.

By using monoclonal and polyclonal antibodies against cell-membrane receptors and cytoskeletal proteins, the cellular and tissue composition of any organ can be far better determined. This is illustrated in the tympanic membrane, middle ear mucosa, and cholesteatoma. Immunotechnology applied to the temporal bone is shown with an animal-ototoxicity model. Antibodies to keratin and vimentin (i.e., to proteins of the fibrillar components that make up the cytoskeleton) stain specific tissue compartments. Langerhans' cell and T-lymphocyte subsets predominate in a cholesteatoma. The normal human tympanic membrane is devoid of these cells. Gentamicin can be traced with a polyvalent anti-gentamicin antiserum in serial sections of the cochlea and kidney. The drug accumulates in the outer hair cells and proximal tubular cells, respectively. A new technique of CT-scanning, microslicing, plastic embedding, and semithin sectioning of undecalcified human temporal bone is described. Perspectives in applying immunotechnology to this method of human temporal bone processing are discussed.

Physiologic and hypertonic saline solutions impair ciliary activity in vitro.

OBJECTIVE/HYPOTHESIS: Physiologic saline (NaCl 0.9%) is commonly used in treating acute and chronic rhinosinusitis. Moreover, physiologic saline is used as a control medium, vehicle, or solvent in studies on ciliary beat frequency (CBF). Hypertonic saline (NaCl 7% and 14.4%) has been applied in attempts to enhance mucociliary transport in patients with cystic fibrosis or asthma and in healthy subjects. Therefore the objective of this study is to document in vitro effects of saline solutions in different concentrations on CBF. STUDY DESIGN: Experimental, in vitro. METHODS: The effects on CBF of cryopreserved mucosa of the sphenoidal sinus was measured by a photoelectrical method. Initial frequencies, measured in Locke-Ringer's solution (LR), were compared with CBF after exposure to NaCl in concentrations of 0.9%, 7.0%, and 14.4% (w/v). RESULTS: NaCl 0.9% has a moderately negative effect on CBF. The 7% solution leads to a complete ciliostasis within 5 minutes, although this effect turns out to be reversible after rinsing with LR. A hypertonic solution of 14.4% has an irreversible ciliostatic effect. CONCLUSION: LR is an isotonic solution that has no effect on CBF. Therefore it is probable that this solution is more appropriate than saline for nasal irrigation and nebulization or antral lavage. Moreover, the results of this study suggest that mucolytic effects induced by hyperosmolarity should be attained preferably with hypertonic saline 7% in patients with cystic fibrosis or asthma. At this concentration, the ciliostatic effect is reversible, whereas irreversible changes are to be expected at higher concentrations.

A functional anatomic study of the relationship of the nasal cartilages and muscles to the nasal valve area.

The functioning of the nasal valve area is largely determined by the stability and the mobility of the lateral nasal wall. To gain insight into the kinematics of the lateral nasal wall, we studied the functional anatomy of the nasal muscles and the intercartilaginous and osseous-cartilaginous junctions. We performed gross and microscopic nasal dissection and serial sectioning in 15 human cadaveric noses. In addition, two noses were used for three-dimensional reconstruction of the nasal cartilages. We conclude that the lateral nasal wall can be seen as made up of three parts. At the level of the osseous-cartilaginous chain of bone, lateral nasal cartilage, and lateral crus, the lateral nasal wall is relatively stable, limited mobility being allowed by translation and rotation in the intercartilaginous joint and a coupled distortion of the cartilages. At the level of the hinge area the lateral nasal wall is supported by one or more accessory cartilages, embedded in soft tissue, and therefore much more compliant. The alar part of the nasalis muscle, which originates from the maxilla and inserts on these cartilages, may dilate the valve area by drawing this hinge area laterally. The third and most compliant part of the lateral nasal wall is the part that is not supported by cartilage, the ala. The dilatator naris muscle largely occupies the ala and is attached to the lateral crus; it opens the vestibule and nostril. The third nasal muscle that influences the lateral nasal wall is the transverse part of the nasalis muscle. It overlies the nose but is not attached to it. This muscle stabilizes the lateral nasal wall, in particular, the lateral nasal cartilage, the intercartilaginous junction, and the hinge area, by moving the nasal skin.

Influence of cocaine and lidocaine on human nasal cilia. Beat frequency and harmony in vitro.

The effects of cocaine and lidocaine on ciliary beat frequency and ciliary beat harmony were studied in biopsy specimens of normal human nasal mucosa. Cocaine was investigated in increasing concentrations (0.875%, 1.75%, 3.5%, and 7%) in five samples; lidocaine (0.125%, 0.25%, 0.5%, 1%, and 2%), in four samples. Ciliary beat was recorded photoelectrically and the signal was analyzed. Cocaine was found to decrease ciliary beat frequency and ciliary beat harmony at concentrations of 1.75% and higher. Partially reversible ciliostasis was seen at 7%. Lidocaine was found to decrease ciliary beat frequency and ciliary beat harmony at concentrations of 0.25% and higher. Irreversible ciliostasis was seen at 2%. Cocaine and lidocaine affected ciliary beat frequency and ciliary beat harmony in the same way.

Immunobiology of Langerhans' cells migrating into aural cholesteatomas.

Immunohistochemical and submicroscopic analyses of human cholesteatoma matrices reveal the presence of Langerhans' cells and T lymphocytes. Through cell-to-cell interaction, Langerhans' cells probably play a key role in skin-related disorders, including cholesteatomas. They originate from a mobile cell population of monocyte origin and migrate into and out of the body's lining. Their custodial function is always carried out in close relation with T lymphocytes. Various monoclonal antibodies directed against Langerhans' cell and T lymphocyte membrane receptors reveal the presence of these cell populations in cholesteatoma matrices but not in the tympanic membrane. Langerhans' cell and T cell traffic through cholesteatomas are discussed in relation to the pathogenesis, natural course, and recurrence rate of cholesteatomas. Through immunopathologic evaluation the clinical aggressiveness of a cholesteatoma will probably become predictable. Medical manipulation of Langerhans' cell and T cell functions- as an adjuvant to surgery - may have consequences for the future handling of cholesteatomas.

Early hair cell loss in experimental hydrops.

One, 2, and 4 months after surgical obliteration of the endolymphatic sac, the sequence of degenerative changes in the organ of Corti of the guinea pig was studied. The block surface technique with interference differential (Nomarski) microscopy was used for this investigation to study the morphological changes in the organ of Corti. The hair cell loss was calculated and mapped in cytocochleograms. One month postoperatively a minimal loss of only outer hair cells was observed in the apical cochlear turn. At 2 months a progression of outer hair cell loss was seen, which proceeded in the 4-month group. At 4 months the inner hair cells showed a slight tendency to degenerate, again beginning in the most apical part of the cochlea.

Expression of intermediate filament proteins in the adult human cochlea.

The immunohistochemical localization of intermediate filament proteins was studied in frozen sections of chemically fixed, nondecalcified adult human cochleas. Cytokeratins were found in all epithelial cells lining the cochlear duct (including most supporting cells of the organ of Corti) but were absent in the hair cells. Neurofilament proteins were present in the nerve endings at the hair cells, in the neural bundles, and in the ganglion cells. Vimentin staining occurred in most of the supporting structures and was roughly complementary to the regions showing cytokeratin staining and neurofilament staining. However, the region of the spiral prominence and outer sulcus, as well as the pillar cells and Deiters' cells in the organ of Corti, showed coexpression of vimentin and cytokeratins. No definite immunostaining was observed with antibodies to desmin and glial fibrillary acidic protein.

Labyrinthine otosclerosis studied with a new computed tomography technique.

Forty-two patients (84 ears) with surgically confirmed otosclerosis were examined with a computerized tomographic scanner (Philips Tomoscan 310) equipped with a table swivel mechanism. All ears were scanned in the horizontal and a new semilongitudinal plane. In patients with an unimpaired bone conduction threshold, a normal labyrinthine capsule was found in all ears except two. Normal bone conduction does not exclude extensive labyrinthine otospongiosis. In cases with bone conduction impairment, the bony labyrinth appeared normal in about half the ears. In the other half, areas of bone resorption were present and a positive correlation was found between the degree of bone loss and the amount of bone conduction threshold loss.