[Hemostatic management of patients undergoing ear-nose-throat-surgery]. / Perioperatives Hämostasemanagement bei HNO-Eingriffen.

Perioperative hemostatic management is increasingly important in Otolaryngology. This review summarizes the key elements of perioperative risk stratification, thromboprophylaxis, and therapies for bridging of antithrombotic treatment. It gives a practical advise based on the current literature with an emphasis for patients undergoing ear-nose-throat surgery.

[Tympanic membrane reconstruction with non-autogenous transplants and alloplastic materials]. / Trommelfellrekonstruktion mit nicht-autogenen Transplantaten und alloplastischen Materialien.

Autogenous tissue has been the grafting material of choice in reconstruction of permanent tympanic membrane perforations. Although donor site complications are infrequent and morbidity from such harvest is usually quite low, there are nevertheless risks associated with additional incisions when autogenous tissue is used. In addition, in patients who have undergone several grafting attempts, there may be no suitable grafting material in the vicinity of the operative field. Several alternatives to native grafting material have recently become available, which have shown similar success rates of perforation closure as well as postoperative audiologic results. This article gives an overview on these non-autogenous grafts and alloplastic materials.

[Prevalence of chronic tympanic membrane perforation in the adult population]. / Prävalenz chronischer Trommelfellperforationen in der erwachsenen Bevölkerung.

BACKGROUND: The goal of this study was to evaluate the prevalence of chronic tympanic membrane perforation in the adult population. MATERIALS AND METHOD: The study population included 1,000 subjects (453 males, 547 females) aged 18-93 years. In addition to interview data, ear examinations were performed. RESULTS: There were eight subjects with unilateral chronic tympanic membrane perforation and a single subject with a bilateral perforation. The age adjusted prevalence of chronic tympanic membrane perforation was 0.45% (95% confidence interval: 0.03-0.87). Eight out of nine subjects disliked tympanoplasty. CONCLUSION: The high proportion of subjects with chronic tympanic membrane perforations who do not want to be operated suggests that there is a considerable need for novel therapeutic procedures.

Effect of homocysteine-induced oxidative stress on endothelial function in coronary slow-flow.

BACKGROUND AND OBJECTIVE: Coronary slow-flow (CSF) phenomenon is characterized by delayed opacification of vessels in a normal coronary angiogram, but its etiopathogenesis remains unclear. Plasma homocysteine (Hcy) level can severely disturb vascular endothelial function and may play a role in the pathogenesis of CSF. In our study, endothelial function in patients with CSF and their relationship with Hcy and oxidative stress parameters are investigated. METHOD: Forty-four patients with angiographically proven CSF and 44 cases with normal coronary flow pattern with similar risk profile were enrolled in the study. Coronary flow patterns of the cases are determined by Thrombolysis in Myocardial Infarction (TIMI) frame count method. Endothelium dependent flow mediated dilatation (FMD) and independent vasodilatation characteristics are evaluated by high frequency ultrasound over the brachial artery. Superoxide dismutase (SOD) and reduced glutathione (GSH) and reduction of oxidative material in the body and the end product of lipid peroxidation, malondialdehyde (MDA) are measured as oxidative stress markers in blood samples. RESULTS: Plasma Hcy level (micromol/l) of patients with CSF was found to be significantly higher than in controls (12.2 +/- 4.9 vs. 8.5 +/- 2.8, p = 0.0001). FMD was 7.87 +/- 2.0% in controls and 4.98 +/- 1.1% in patients with CSF (p = 0.0001). GSH was reduced in patients with CSF. SOD and MDA activity were found higher in patients with CSF than control subjects. Plasma Hcy level was significantly positively correlated with mean TIMI frame count and negatively correlated with FMD in correlation analysis (r = 0.58, p = 0.0001; r = -0.41, p = 0.022; respectively). CONCLUSION: The present findings allow us to conclude that patients with CSF have increased levels of Hcy and oxidative stress markers and impaired endothelial cell function.

[Fibrin gel for treatment of tympanic membrane perforations: an experimental animal model]. / Behandlung von Trommelfellperforationen mit Fibringel: Eine tierexperimentelle Studie.

BACKGROUND: The goal of this study was to evaluate the effects of a fibrin gel on the healing of tympanic membrane perforation in rats. METHODS: Prolonged tympanic membrane perforations in 12 rats were created by application of mitomycin C to the intact tympanic membranes followed by bilateral myringotomy. Repeated applications of a fibrin gel to the perforation site of one tympanic membrane were performed in each animal. Tympanic membranes were observed for a total of 8 weeks. RESULTS: One perforation in each group was already patent at the end of the observation period. The mean healing period of the remaining tympanic membranes was found to be 16.7 days in the fibrin gel group and 19.6 days in the control group. CONCLUSION: A fibrin sheet does not seem to promote the wound healing process of tympanic membranes. However, the sheet might serve as a drug-delivery system for growth factors in the treatment of tympanic membrane perforations, because of its biocompatibility.

QT dispersion and left ventricular hypertrophy in athletes: relationship with angiotensin-converting enzyme I/D polymorphism.

BACKGROUND: QT dispersion (QTd) is a measure of inhomogeneous repolarization of myocardium and is used as an indicator of arrhythmogenicity. QTd is increased in myocardial hypertrophy secondary to systemic hypertension. The relation between left ventricular (LV) enlargement in endurance trained subjects and QTd is unknown. The cloning of the angiotensin-converting enzyme (ACE) gene has made it possible to identify a deletion (D)-insertion (I) polymorphism that appears to affect the level of serum ACE activity. The aim of this study was to assess whether physiologic left ventricular hypertrophy as a result of physical training is associated with an increased QT length or dispersion depending on ACE I/D polymorphism. METHODS: 56 endurance athletes and 46 sedentary subjects were included in this study, and they underwent both complete echocardiographic and electrocardiographic examination, the QT interval was measured manually as an average based on a 12-lead ECG. We also analysed ACE I and D allele frequencies in all patients. RESULTS: Athletes had a significantly increased LV mass (235.1 +/- 68.5 g vs. 144.9 +/- 44.5 g, p < 0.001) and corrected QTd (QTcd) (55.5 +/- 18.1 ms vs. 42.9 +/- 17.2 ms, p < 0.001) in comparison to control subjects. There was a positive correlation between left ventricular mass index and QTcd in athletes (r = 0.3, p = 0.024). Left ventricular mass and mass index in ACE DD, DI and II genotypes were significantly different (p < 0.001). QTcd was significantly different between ACE DD (63.2 +/- 12.8 ms) and ACE II (44.9 +/- 17.6 ms) genotypes in athletes (p < 0.05). CONCLUSION: These data show that myocardial hypertrophy induced by exercise training might be associated with increased QTd as observed in systemic hypertension and might be affected by ACE I/D polymorphism.

Angiotensin-converting enzyme polymorphism in healthy young subjects: relationship to left ventricular mass and functions.

OBJECTIVES: Angiotensin-converting enzyme (ACE) is a key enzyme in the production of angiotensin II and thus may participate in the modulation of cardiac growth. The cloning of the ACE gene has made it possible to identify a deletion (D)-insertion (I) polymorphism that appears to affect the level of serum ACE activity. The aim of the study is to analyse the ACE gene I/D polymorphisms in healthy young subjects and to evaluate its relationship to left ventricular mass and functions. METHODS: 38 women and 40 men (mean age 21.1 +/- 1.7 and 21.4 +/- 1.7 years) were studied. They underwent complete echocardiographic assessment and analysis of ACE insertion (I) and deletion (D) allele frequencies in peripheral blood by polymerase chain reaction. Thickness of interventricular septum (IVS) and posterior wall (LVPW) and left ventricular mass (LVM) and LVM index (LVMI) were measured by M-mode. Left ventricular ejection fraction (LVEF) was calculated by Simpson's method. RESULTS: There was no statistically significant difference among the DD, DI and II genotypes, concerning age, body mass index, heart rate, systolic and diastolic blood pressures.The thickness of IVS (9.5 mm), LVPW (9.0 mm), LVM (204.5 g) and LVMI (105.5 g/m2) in DD genotypes were higher than both DI (8.3 mm; 8.1 mm; 168.1 g; 90.9 g/m2) and II genotypes (8.2 mm; 7.0 mm; 141.7 g; 77.8 g/m2) in men, but not in women. LVEF among the 3 genotypes were not statistically different. CONCLUSION: Our findings suggest that left ventricular hypertrophy is partially determined by genetic disposition especially in men but not in women.

Early onset neonatal bacterial infections.

The evaluation of a neonate with suspected sepsis is one of the most common, most demanding, and most important tasks of the pediatrician or neonatologist. This review summarizes the difficulties in the prompt diagnosis of neonatal sepsis and the appropriate utilization of screening laboratory tests of blood, urine, and cerebrospinal fluid in this setting. The appropriate utilization of these laboratory tests requires careful consideration of the inherent limitations and appreciation of the sensitivity and specificity of these tests for the diagnosis of early onset bacteremia and sepsis.

Safety and efficacy of nitric oxide in chronic lung disease.

BACKGROUND: Therapies for neonatal chronic lung disease (CLD) of prematurity have had limited success. AIMS: To determine whether inhaled nitric oxide (INO) administered to very low birthweight infants with developing CLD might improve oxygenation without adverse effects. METHODS: Subjects were 10-30 days of age, birth weight < 1250 g, with developing or established CLD, and requiring mechanical ventilation with mean airway pressure > or = 7 cm H2O and FIO2 . or = 0.40. We monitored changes in oxygenation and FIO2 requirement during treatment with INO (initial dose 20 ppm). Tracheal aspirate samples obtained before, during, and after treatment were analysed for interleukin 1beta (IL-1beta), IL-8, 8-epi-prostaglandin F2alpha (8-epi-PGF2alpha), laminin, and endothelin 1 (ET-1) to assess any potential effects of INO on markers of inflammation peroxidation, basement membrane injury, or vasoactivity. RESULTS: Thirty three patients met entry criteria. Mean gestational age was 25 (SD 2) weeks; birth weight was 736 (190 g); age of study infants was 19 (6) days (range 9-29). Mean FIO2 decreased from baseline (0.75) to 0.58 at 72 hours. Duration of therapy was seven days. Tracheal aspirate concentrations of IL-1beta, IL-8, 8-epi-PGF2alpha, ET-1, and laminin were unchanged between baseline and 48 hours of INO, and 48 hours after discontinuation of INO. No new cases of, nor extension of, intraventricular haemorrhage occurred. Four infants died. CONCLUSION: INO (< or = 20 ppm) improved oxygenation in most infants with early CLD, without inducing changes in markers of inflammatory or oxidative injury.

Nasopharyngeal endoscopy adds to reliability of clinical diagnosis of infectious mononucleosis.

Frequently, the clinical picture in the oropharynx alone does not lend itself to a reliable differentiation between acute pharyngotonsillitis in infectious mononucleosis and a streptococcal inflammation. Such a differentiation, however, is essential for the indication of antibiotic therapy. Therefore, it was the aim of the present study to investigate whether or not endoscopic verification of larger-than-normal lymphatic tissue with fibrinous membranes in the nasopharynx would enhance the reliability of diagnosis. Fifty hospitalized patients exhibiting the clinical picture of acute pharyngotonsillitis were examined for the following parameters: nasopharyngeal endoscopy, determination of glutamine-oxaloacetic transaminase (GOT), glutamine-pyruvic transaminase (GPT), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), leucocytes and haemogram, antibodies to viral capsid antigen (VCA)-IgM, Epstein-Barr virus nuclear antigen (EBNA), and cytomegalovirus (CMV). In 24 patients with acute tonsillitis/peritonsillar abscess, and in 26 patients with infectious mononucleosis, the total leucocyte count in the blood and the blood/erythrocyte sedimentation rate were comparable. Atypical lymphocytes or absolute lymphocytosis were not seen in acute tonsillitis, but were found in 88.5 per cent of patients with infectious mononucleosis. Elevated transaminase levels were noted in 77 (GOT) and 88.5 per cent (GPT) of patients with infectious mononucleosis, and in acute tonsillitis in 4.2 (GOT) and 12.5 per cent (GPT) of patients. The CRP was higher than normal in 91.7 per cent of patients with acute tonsillitis, and in 57.7 of patients with infectious mononucleosis. In none of the patients with acute tonsillitis was lymphatic tissue with fibrinous membranes seen in the nasopharyngeal cavity. In contrast, nasopharyngeal endoscopy in infectious mononucleosis was positive in 24 out of 26 patients. Hence, the sensitivity was 92.3 per cent, the specificity 100 per cent, and the prediction value for a positive test turned out to be 1. Endoscopy of the nasopharngeal cavity employed as a simple and supplementary procedure adds to the reliability of diagnosis of infectious mononucleosis.

[Mondini dysplasia: traumatic cerebrospinal fluid otorrhea with meningitis]. / Mondini-Dysplasie: Traumatische Otoliquorrhö mit Meningoenzephalitis.

Mondini dysplasia is a rare malformation of the inner ear commonly associated with loss of hearing and vestibular function. Children with Mondini dysplasia are predisposed to developing a spontaneous cerebrospinal fluid (CSF) leak and recurrent meningitis. If there is no CSF leak but a unilateral hearing loss, the condition may go undiagnosed for years. We describe a 65-year-old man with unrecognized unilateral Mondini dysplasia who presented with CSF leak and meningoencephalitis after minor head trauma. Two operative interventions were undertaken to close the defect properly. Patients with Mondini dysplasia or their parents should be cautioned about the potential hazards of any head trauma.

An asymptomatic case with single atrium.

Single atrium or common atrium is a rare, isolated defect. We report here an adult patient with single atrium detected by transthoracic echocardiography.

Effect of insulin resistance on left ventricular structural changes in hypertensive patients.

Both left ventricular (LV) hypertrophy and insulin resistance (IR) have often been demonstrated in patients with essential hypertension (EH). Insulin may exert a direct growth promoting effect on cardiomyocytes rather than affecting the LV internal diameter. The purpose of this study was to examine the effect of IR on LV geometry. We enrolled 105 patients (71 females, mean age, 49.2 +/- 13.6 years) with recently diagnosed and untreated hypertension (blood pressure > 140 and/or 90 mmHg, fasting glucose < 110 mg/dL), and grouped them as normal (N) (39 patients, 26 females, mean age, 48.5 +/- 14.7 years) if all M-mode echocardiographic measurements were within normal limits, concentric remodeling (CR) (22 patients, 15 females, mean age, 50.5 +/- 14.8 years) if relative wall thickness was increased but left ventricular mass index (LVMI) was normal, concentric hypertrophy (CH) (13 patients, 9 females, mean age, 50.3 +/- 10.8 years) if both ventricular thicknesses and the LVMI were increased, and eccentric hypertrophy (EH) (31 patients, 21 females, mean age, 48.6 +/- 12.9 years) if ventricular thicknesses were normal, but LVMI was increased. Transthoracic echocardiography was performed in all subjects, and interventricular septal thickness (IVS), posterior wall thickness (PWT), sum of wall thickness (SWT), left ventricular end-diastolic internal diameter (LVED), relative wall thickness (RWT), and LVMI were recorded. Blood samples for routine biochemical examination and fasting insulin levels were obtained and then the homeostasis model assessment (HOMA) index was calculated by the formula: HOMA Index = Fasting Blood Glucose (mg/dL) x Immunoreactive Insulin (microU/mL)/405, for the assessment of IR. There were no significant differences among the groups with respect to age, blood pressure (BP) levels, fasting blood glucose (FBG), LDL-cholesterol (LDL-C), HDL-cholesterol (HDL-C), total cholesterol (TC), or triglyceride (TG) levels. Insulin levels were significantly higher in the CR and CH groups in comparison with the N group (P = 0.004), and the HOMA index was higher in the CH group compared to the N group (P = 0.024). In Pearson's correlation analysis, insulin was found to be directly correlated with IVS (r = 0.29, P = 0.002), SWT (r = 0.25, P = 0.009), and RWT (r = 0.33, P = 0.0001). The HOMA index was also directly correlated with IVS (r = 0.33, P = 0.001), SWT (r = 0.29, P = 0.002), and RWT (r = 0.29, P = 0.003). Cardiac changes in hypertensive patients include increased LVMI and altered LV geometry. The concentric LV geometry seen in hypertensive patients might be mediated, at least in part, by increased insulin levels and the HOMA index.

Cigarette smoking induced oxidative stress may impair endothelial function and coronary blood flow in angiographically normal coronary arteries.

BACKGROUND: Smoking contributes to the progression of atherosclerotic heart disease by causing endothelial dysfunction. In the present study the effect of smoking on endothelial functions and coronary flow was investigated, as well as the relationship of these factors with oxidative stress parameters, in subjects with normal coronary arteries. MATERIALS AND RESULTS: The study group comprised 87 patients with angiographically normal coronary arteries (36 smokers, 51 nonsmokers). Coronary flow patterns were determined by the Thrombolysis In Myocardial Infarction (TIMI) frame count method. Endothelial function was evaluated by high-frequency ultrasound imaging of the brachial artery. Superoxide dismutase (SOD) and reduced glutathione (GSH) and reduction of oxidative material in the body and the endproduct of lipid peroxidation, malondialdehyde (MDA), were measured as oxidative stress markers. Mean TIMI frame count was significantly higher in smokers than nonsmokers (42.2 +/- 16 vs 29.5 +/- 9.5, p = 0.0001). Endothelium-dependent flow-mediated dilatation was 6.81+/-1.95% in nonsmokers and 5.7 +/- 2.2% in smokers (p = 0.0001). The smokers had dramatically higher levels of SOD and MDA and lower levels of GSH than the nonsmoker group. CONCLUSION: Smoking induced oxidative stress deteriorates coronary blood flow by disturbing endothelial function.

[Systemic corticoid application in combination with topical mitomycin or dexamethasone. Inhibition of wound healing after tympanic membrane perforation]. / Systemische Kortikoidgaben und additive lokale Applikation von Mitomycin oder Dexamethason. Hemmung der Wundheilung nach Trommelfellperforation.

BACKGROUND: The purpose of this study was to determine whether systemic glucocorticoid application, in combination with topical mitomycin or dexamethasone, prolongs the patency of a tympanic membrane perforation. METHOD: Bilateral myringotomies were performed on 24 rats. The 48 ears were separated into eight groups. Treatment with combined systemic and topical dexamethasone or mitomycin differed between these groups. After the first 2 weeks, the animals were checked weekly for a total of 12 weeks. RESULTS: A combination of systemic and topical dexamethasone delayed tympanic membrane closure after myringotomy. Perforation size increased in all tympanic membranes treated with mitomycin plus systemic dexamethasone. CONCLUSION: Topical mitomycin plus systemic glucocorticoid may lead to a massive malfunction of tympanic membrane healing.

[Changes of the late acoustically evoked potentials in postlingually deaf patients with cochlear implants]. / Veränderungen der späten akustisch evozierten Potenziale bei postlingual ertaubten CI-Trägern.

BACKGROUND: The speech recognition performances in postlingually deaf patients, which had a long duration of deafness, seem to be poorer than in patients with a short duration of deafness. The reason could be a functional reorganization in the auditory cortex. A long time of auditory deprivation may decrease neuronal activity in the auditory related cortices. As the late acoustically evoked potentials are generated in this region, we compared the speech recognition performances and also the late acoustically evoked potentials with the individual duration of deafness in a series of postlingually deaf patients. METHODS: In 9 patients (cochlear implant (CI), MED EL) with postlingual deafness the late acoustically evoked potentials and the HSM-set-test on the quiet were measured. Additionally 1 patient with prelingual deafness was examined. The CI-operation was done, when he was 14 years old. The relations between the late acoustically evoked potentials and the speech recognition performances in dependence of the duration of deafness were examined. RESULTS: Typical late acoustically evoked potentials could be measured in 3 patients only. The speech recognition in these patients was very good. The longest time of deafness in these patients was 6 years. In 6 patients the minimum duration of deafness was 12 years. Here were measured the N1-potentials only, the P2- and the N2-potentials were absent. In these patients the scores of the HSM-set-test were lower than in the others. In the 15-years old patient with prelingual deafness the speech recognition was absent. The late acoustically evoked potentials of this patient showed an atypical form. CONCLUSIONS: The results of this study showed a correlation between the duration of deafness, the forms of the late acoustically evoked potentials and the speech perception. The duration of deafness preceding CI-implantation should be very small in deaf children and in postlingually deaf patients.

Improved endothelium dependent vasodilation in endurance athletes and its relation with ACE I/D polymorphism.

BACKGROUND: Aerobic exercise enhances endothelium-dependent vasodilation in healthy individuals. It is thought that exercise increases nitric oxide (NO) production and decreases NO inactivation, leading to an increase in NO bioavailability. Angiotensin II and NO have important roles in maintaining vascular tone. There are polymorphisms of the angiotensin converting enzyme (ACE) gene and the presence of the deletion (D) allele has been associated with higher concentrations of circulating and tissue ACE. In this study, the relationship between endothelial function and ACE gene polymorphisms was investigated in athletes and sedentary subjects. METHODS AND RESULTS: The study group comprised 56 endurance athletes and 46 sedentary subjects who underwent brachial artery ultrasonographic examination. ACE insertion (I) and D allele frequencies were analyzed in all patients. Baseline brachial artery diameter and resting blood flow were similar in athletes and controls (p > 0.05). The flow-mediated dilation (FMD) was 8.48+/-3.65% in athletes and 5.16+/-2.5% in controls (p = 0.0001). FMD was significantly different between ACE genotypes in the athletes (p < 0.0001): it was higher in ACE II (10.5+/-1.6%) subjects than in the DI (8.4+/-2.3%) or DD (7+/-1.2%) subgroups. CONCLUSION: Regular isotonic exercise can improve endothelium-dependent vasodilation especially in those with the ACE II genotype.

[Traumatic tympanic membrane perforactions. Local application of an alginate matrix loaded with epidermal growth factor in an animal model]. / Traumatische Trommelfellperforationen. Einfluss einer den Wachstumsfaktor EGF freisetzenden Folie auf die Heilung im Tiermodell.

BACKGROUND: The aim of this study was to evaluate the effects of an alginate matrix releasing epidermal growth factor on healing after acute tympanic membrane perforation in rats. METHOD: A total of 20 male rats were divided into two groups. In each animal, a randomly chosen tympanic membrane was perforated by heat. A piece of alginate matrix (control group) or alginate matrix loaded with 0.25 microg epidermal growth factor (EGF group) was then placed on the perforation. The rat ears were examined after days 3, 6, 9, and 14 and every week thereafter for a total of 11 weeks. Each matrix was removed on day 9. To examine the status of the tympanic membranes on day 14, one randomly chosen membrane from each group was histopathologically examined. RESULTS: By day 6, complete closure of the tympanic membrane perforation was achieved in 56% of the EGF group, whereas it was achieved in only 10% in the control group. By day 14, all tympanic membrane perforations were closed in both groups. There were no complications and no significant differences in the histopathologic parameters between the EGF group and the control group. CONCLUSION: An alginate matrix seems to be a useful EGF-delivery system to the tympanic membrane.