The ultrastructure of the sensory hairs and associated organelles of the cochlear inner hair cell, with reference to directional sensitivity.

From the apical end of the inner hair cell of the organ of Corti in the guinea pig cochlea protrude four to five rows of stereocilia shaped in a pattern not unlike the wings of a bird. In the area devoid of cuticular substance facing toward the tunnel of Corti lies a consistently present centriole. The ultrastructure of this centriole is similar to that of the basal body of the kinocilium located in the periphery of the sensory hair bundles in the vestibular and lateral line organ sensory cells and to that of the centrioles of other cells. The physiological implications of the anatomical orientation of this centriole are discussed in terms of directional sensitivity.

Combined laser phototherapy and growth factor treatment of bronchial obstruction after lung transplantation.

Lung transplantation has resulted in dramatic functional improvement in patients with end-stage pulmonary diseases. Among the complications of lung transplantation are dehiscence and stenosis at the site of the bronchial or tracheal anastomosis. In this case report, we describe a single lung transplant recipient in whom partial bronchial dehiscence, followed by exuberant growth of granulation tissue, resulted in obstruction of the bronchial lumen. After mechanical dilation failed to produce lasting relief of bronchial obstruction, a novel approach to this problem was successfully employed: YAG laser phototherapy was used to remove obstructing granulation tissue, followed by application of a preparation derived from autologous blood platelets to promote epithelialization of the bronchial anastomosis. The bronchus remains patent and fully epithelialized six months after therapy.

Mucoceles with intracranial and extracranial extensions. Report of two cases.

Two cases of unusual childhood mucocele are presented. These serve to illustrate the great potential these lesions have for slow, insidious development and insinuation of themselves into regions of the head and face where they are difficult to remove surgically. A description of the staged surgical excision is presented to emphasize the importance of radical removal of these benign lesions.

An endoscopically-introducible T-tube for tracheal stenosis.

Five cases of tracheal stenosis are presented, and aspects of etiology and pathophysiology of the disease are discussed. A new soft, flexible T-tube is described along with a method of endoscopic introduction. Although many patients with tracheal stenosis will eventually need tracheal reconstruction, stenting may be definitive in selected cases.

Long-term results with nasofrontal duct reconstruction.

The findings and results of 50 consecutive nasofrontal duct reconstructions are analyzed and presented. Postoperative recurrence of frontal sinus disease occurred in 14% of the cases and there were no significant postoperative or intraoperative complications. There was no instance of failure in patients with a history of trauma to the nasofrontal duct and only two recurrences in patients with mucocele or pyocele. Nasofrontal duct reconstruction offers more direct access to the ethmoid cell system than osteoplastic flap obliteration. In addition, it is a lesser procedure with fewer complications. The physiologic function of the sinus is restored without the risk of burying disease. Nasofrontal duct reconstruction is an effective option for the treatment of chronic frontal sinus disease if the sinus mucosa is not irreversibly damaged.

Transnasal transsphenoidal approach to the sella.

The transnasal transsphenoidal approach to the sella turcica has been refined and perfected through advances in medicine and technology. Originally performed for excision of pituitary adenomas, its present primary use is pituitary ablation is hormonally dependent diseases. Our study of 55 patients who have undergone this procedure during the years 1970-1975 demonstrates that this microscopic technique gives excellent exposure and visualization of intrasellar contents. Our method gives excellent exposure and visualization of intrasellar contents. Our method with several instrument modifications is discussed. It is technically an easy procedure with a minimum of morbidigy and mortality.

Microcystic adnexal carcinoma: management options based on long-term follow-up.

Microcystic adnexal carcinoma (MAC), a recently described neoplasm that frequently affects the head and neck, presents a confusing problem for the clinician due to its unusual behavior. The individual cells have a bland microscopic appearance, and there is a predilection for neural invasion. Four cases of MAC are reported. All four cases demonstrate the difficulty with pathologic diagnosis. Follow-up of as long as 33 years begins to delineate the protracted nature of MAC. In addition, this paper includes the first report of a case of lymph node metastasis. Although resection may result in a significant defect, negative margins may not be achieved. Despite this, the defect can heal, as demonstrated by the cases described. In addition, MAC may recur many years later, irrespective of the status of the margins at the time of surgery. Given these unusual characteristics and the slowly progressive nature of MAC, strong consideration must be given to less radical surgical procedures, with close follow-up for grossly recurrent disease.

In search of missing links in otology. III. Development of a new animal model for cholesteatoma.

An experimental study was conducted in chinchillas regarding the pathogenesis of acquired cholesteatoma (keratoma). The placement of a chemically modified gelatin membrane from the external auditory canal to the promontory through a tympanic membrane perforation stimulated squamous epithelial cell migration. Cholesteatoma formation with the presence of keratin debris and inflammatory reactions was observed in the middle ear and anterior bulla in 53.5% of the experimental animals. These experimental findings show for the first time the presence of epithelial migration and true cholesteatoma formation in the middle ear of chinchillas in an experimental model with deliberate perforation of the tympanic membrane. Erosion of the cochlear walls was observed in areas with granulation tissue and cholesteatoma. The importance and significance of the migration of squamous epithelium and of the middle ear inflammatory reaction in the genesis of acquired cholesteatomas are discussed.

Medial canthoplasty: early and delayed repair.

Naso-orbital trauma can cause medial orbital wall disruption and detachment of the medial canthal ligament. Damage to the nasolacrimal drainage apparatus, cerebrospinal fluid rhinorrhea and frontal sinusitis can occur. Twelve cases of naso-orbital trauma have been reviewed. There is a high incidence of associated injury to adjacent structures. Medial canthal ligament separation was missed acutely in a number of cases leading to the necessity of delayed repair. Important diagnostic and therapeutic points are stressed in the acute and delayed management, particularly medial canthal ligament separation. A wire to intranasal button technique for the delayed repair of traumatic telecanthus is presented.

Local vs systemic effects of acoustic trauma on cochlear structure and transport.

Whether certain effects of acoustic trauma on cochlear structure and function were due to local or systemic agents was investigated in the chinchilla. After unilateral ossicular disarticulation, the animals were given a noise exposure known to cause cochlear damage and vessel transport changes in the stria vascularis. The cochleas with disarticulated ossicular chains received an effective exposure well below one that causes pathologic damage. Only the cochleas with intact ossicular chains showed an increase in the permeability of the strial vessels to horseradish peroxidase tracer and manifested strial edema and organ of Corti damage. These results indicate that the effects of acoustic trauma on cochlear structure and strial vessel transport are induced locally, not systemically. In addition, the minimum time of exposure to 120-dB, 700- to 2800-Hz noise that causes massive cochlear damage in the chinchilla was shown to be between five and ten minutes.

Frontal sinus fractures. Analysis of treatment results.

A retrospective study of 112 consecutive patients with frontal sinus fractures who were available for follow-up is presented. Significant complications are possible, especially with fracture of the posterior sinus wall. When indicated, the sinus is reconstructed with wire using free denuded fragments if available. Severe complications in displaced posterior wall fractures were less common when treatment was by sinus obliteration than by cranialization. Computed tomography has improved the evaluation, especially when a posterior wall fracture is suspected.

Bacterial tympanogenic labyrinthitis, meningitis, and sensorineural damage.

Pathologic changes (sensorineural hearing loss, labyrinthitis, meningitis) can follow otitis media. Various macromolecular substances demonstrably enter the inner ear via the round window membrane, but its permeability to bacteria is less known. We inoculated Streptococcus pneumoniae type 7F bilaterally into the middle ears of two groups of chinchillas, with and without grafted round window membranes. Inner ears of inoculated animals were observed by light and electron microscopy. None with continuous grafts had labyrinthitis. Bacteria penetrated all three layers of nongrafted round window membranes and into all cochlear turns, entering Schuknecht's channels and following neuronal pathways; nerves were often degenerated, hair cells were damaged or missing, and the stria vascularis was edematous and hemorrhagic. The neural damage suggests a mechanism for the hearing loss that can follow otitis media. Absence of labyrinthitis and meningitis in grafted animals suggests a tympanogenic pathway for the bacteria.

The permeability of the round window membrane during otitis media.

Studies of the permeability of the round window membrane (RWM) during otitis media are important because toxins and cellular components that occur in otitis media as well as pharmacologic agents used in treating the disease have the potential to cross the RWM and pass into the inner ear. Twenty-five cats were evaluated electron microscopically as to the passage of a tracer, horseradish peroxidase, through normal RWMs and RWMs three days, one week, and two weeks following eustachian tube obstruction. Passage at three days following obstruction was similar to passage through the normal RWM. Following one to two weeks of obstruction, the permeability of the membrane was drastically reduced. The reduction in permeability was probably due to the presence of residual effusion overlying the membrane, the presence of granulation tissue within the niche, and a thickening of the RWM.

Juvenile nasopharyngeal angiofibroma: diagnosis and treatment.

Juvenile nasopharyngeal angiofibroma (JNA) is an uncommon, histologically benign vascular tumor that occurs almost exclusively in adolescent males. While occasional mention is made of the occurrence of JNA in females and in older males, only four cases have withstood rigorous clinicopathological review. This neoplasm accounts for less than 0.05% of all benign lesions that originate in the nasopharynx. Its clinically malignant behavior is a result of its propensity for locally destructive growth and fatal hemorrhage. The evolution in the management of these tumors has been the subject of much interest and much confusion. The advents of computed tomographic (CT) scanning, selective angiography with embolization, and refinements in surgical approaches have revolutionized operative management of these lesions by allowing more realistic selection of surgical candidates, better preoperative planning, and more flexible (yet aggressive) primary surgical treatment. The attendant reduction in morbidity and mortality of contemporary surgical management of this disease has largely obviated the argument of those who advocate use of radiotherapy as the primary treatment modality for this benign lesion. This latter view is based on the reports of massive hemorrhage, significant incidence of incomplete removal, and mortality reported in the older surgical literature. This article details our experience with a series of 31 patients who had clinicopathological diagnoses of JNA and were treated between 1954 and 1984. It furthermore represents an update of our previously reported series.

Carcinoma of the tonsillar region: a comparison of radiation therapy with combined preoperative radiation and surgery.

Ninety-six patients with cancer of the tonsillar region in all stages were studied to compare full-course radiation therapy with surgical salvage to planned radiation and surgery. Full-course radiation therapy was effective in controlling T1 and T2 tumors without neck node involvement. Combined therapy was much more effective in treating T3 tumors with neck node disease. Patients with T4 tumors did poorly regardless of therapy.

Cochlear vessel permeability to horseradish peroxidase in the normal and acoustically traumatized chinchilla: a reevaluation.

A method involving incubation of intact cochleae using the small protein, horseradish peroxidase, has revealed that a barrier exists between the blood and the stria vascularis. This barrier is more tenuous than the barrier that exists across other cochlear vessels. The stria-strial vessel barrier can be altered physiologically by acoustic trauma or artifactually by dissection.

Spontaneous regression of juvenile nasopharyngeal angiofibroma.

There is debate concerning the natural history of juvenile nasopharyngeal angiofibromas, especially whether or not they can spontaneously regress. Often claimed, spontaneous regression has not been well documented. To our knowledge, this is the first report in which a biopsy-proven juvenile nasopharyngeal angiofibroma spontaneously resolved. A second, less well-documented case is discussed.

Effects on cochlear morphology of repeated insults to the stria vascularis.

The interrelationship of stria vascularis and organ of Corti integrity was investigated. Strial morphology was altered by repeated injections of ethacrynic acid in the chinchilla. Although prolonged temporary strial damage was created, neither strial atrophy nor organ of Corti damage resulted.

Delineation of cochlear glycogen by electron microscopy.

Two techniques for the demonstration and identification of glycogen by electron microscopy were applied to the cochlear duct tissues of normal guinea pigs and chinchillas. A modified osmium tetroxide fixative (with potassium ferricyanide) has been described by De Bruijn to selectively stain the glycogen particle. Identification of the stained particle was effected by its selective removal from the tissue with amyloglucosidase, an enzyme specific in its degradation of the glycogen molecule. Glycogen particles were noted in several cell types within the cochlear duct, but concentrations were greater in outer hair cells of both species and in the stria vascularis of the chinchilla. The fact that amyloglucosidase completely eliminated these particles from the liver of both species as well as cochlear tissue, led to the conclusion that these particles are indeed glycogen.

Sinusitis with contiguous abscess involvement of the clivus and petrous apices. Case report.

A wide spectrum of diseases may involve the clivus, such as primary neoplasms, metastatic disease, and inflammatory, vascular, hematopoietic, and infectious processes. Of these, osteomyelitis of the skull base and/or clival-petrous abscess are unusual, but may occur as a result of contiguous spread from the paranasal sinuses, namely, the posterior ethmoid and sphenoid, as was demonstrated by this patient. In this case report we discuss the pertinent anatomy, imaging studies, pathogenesis, and medical and surgical management of this case.