Hot nasal packing with hot saline irrigation for hemostasis after adenoidectomy: A prospective randomized controlled study.

OBJECTIVE: This study aimed to investigate the efficacy of hot posterior nasal packing and hot saline irrigation in bleeding control after adenoidectomy. METHODS: A total of 130 patients scheduled for adenoidectomy were included in the study, and randomized into two groups at the beginning of the surgical operation. After adenoidectomy, saline impregnated tampon, and saline irrigation at room temperature (22 °C) was applied to the patients in one group while 50 °C saline impregnated tampon and saline irrigation at the same temperature were applied to the patients in the other group. We recorded hemostasis for up to 3 min after tamponade for bleeding control, and the amount of bleeding into the nasopharynx. RESULTS: The age of the patients ranged from 1.5 to 13 years (mean ± SD: 6.07 ± 3.08 years, and 5.33 ± 2.55 years, 22 °C and 50 °C saline irrigation groups, respectively). There were 37 males and 28 females in the 22 °C saline group, while 34 males and 31 females in the 50 °C saline group. When comparing the two groups, there was no statistically significant difference in terms of duration of hemostasis (p = 0.64). However, bleeding scores at 2 nd min after the tamponade were significantly lower in the 50 °C saline group (p = 0.007). The amount of bleeding in the 50 °C saline group was also significantly lower than the 22 °C saline group (p = 0.015). CONCLUSION: In this study, application of 50 °C saline impregnated tampon, and hot saline irrigation was found to be more effective in the control of bleeding after adenoidectomy by reducing the amount of bleeding compared to 22 °C saline impregnated tampon application and saline irrigation at 22 °C. However, hot nasal packing and hot saline irrigation did not affect duration of hemostasis and cauterization.

Is it more reasonable to categorize frontal cells on the basis of their location rather than on their type?

Frontal cells appear in two locations-in the frontal recess and in the frontal sinus. The aim of this study was to analyze the anatomic and clinical differences between the frontal cells at each location. The author reviewed 487 left and right sides of coronal computed tomography (CT) scans of the sinuses obtained from 300 consecutively presenting patients (600 sides) who were being evaluated for chronic sinusitis. For the purposes of this study, the frontal cells were classified according to location; group A cells were located in the area of the frontal recess (Bent and Kuhn cell types I and II), and group B cells were those that had invaded the frontal sinus itself (Bent and Kuhn cell types III and IV). The presence or absence of frontal sinusitis and concha bullosa was determined, as was the degree of frontal sinus pneumatization. Analysis revealed statistically significant differences between group A and group B in all three parameters; the prevalence of frontal sinusitis and hyperpneumatization of the frontal sinus was higher in group B, and the prevalence of concha bullosa was higher in group A (all p < 0.05). These findings imply that it might be more reasonable both clinically and anatomically to categorize frontal cells based on their location rather than on their Bent and Kuhn type.

Controlled hypotension with desflurane combined with esmolol or dexmedetomidine during tympanoplasty in adults: A double-blind, randomized, controlled trial.

BACKGROUND: Controlled hypotension is a technique that is used to limit intraoperative blood loss to provide the best possible surgical field during surgery. OBJECTIVE: The aim of this double-blind, randomized, controlled study was to compare the effects of desflurane combined with esmolol or dexmedetomidine on the amount of blood in the surgical field, recovery time, and tolerability in adult patients undergoing tympanoplasty. METHODS: Turkish patients aged 18 to 60 years, classified as American Society of Anesthesiologists physical status I or II, who were scheduled for tympanoplasty were randomly divided into 2 groups: the esmolol group or the dexmedetomidine group. After the anesthesia induction in the esmolol group, a loading dose of esmolol was infused intravenously over 1 minute at 1 mg/kg, followed by a maintenance rate of 0.4 to 0.8 mg/ kg/h. In the dexmedetomidine group, a loading dose of dexmedetomidine was infused intravenously over 10 minutes at a rate of 1 µg/kg, followed by a maintenance rate of 0.4 to 0.8 µg/kg/h. The infusion rates were then titrated to maintain mean arterial pressure (MAP) of 65 to 75 mm Hg. General anesthesia was maintained with desflurane 4% to 6%. Heart rate (HR) and MAP were recorded during anesthesia. The following 6-point scale was used to assess the amount of bleeding in the operative field: 0 = no bleeding, a virtually bloodless field; 1 = bleeding that was so mild that it was not a surgical nuisance; 2 = moderate bleeding that was a nuisance but did not interfere with accurate dissection; 3 = moderate bleeding that moderately compromised surgical dissection; 4 = bleeding that was heavy but controllable and that significantly interfered with surgical dissection; and 5 = massive bleeding that was uncontrollable and made dissection impossible. Scores ≤2 were considered to be optimal surgical conditions. The sedation score was determined at 15, 30, and 60 minutes after tracheal extubation using the following scale: 1 = anxious, agitated, or restless; 2 = cooperative, oriented, and tranquil; 3 = responsive to commands; 4 = asleep, but with brisk response to light, glabellar tap, or loud auditory stimulus; 5 = asleep, sluggish response to glabellar tap or auditory stimulus; and 6 = asleep, no response. Time to extubation and to total recovery from anesthesia (Aldrete score ≥9 on a scale of 0-10), adverse effects (eg, intraoperative hypotension [blood pressure <65 mm Hg], bradycardia [HR <50 beats/min]), intraoperative fentanyl consumption, and postoperative nausea and vomiting were recorded. Arterial blood gas analysis and kidney and liver function tests were conducted. All patients were evaluated by the same attending surgeon and anesthesiologist, both of whom were blinded to the administered study drugs. RESULTS: Fifty-two consecutive white patients undergoing tympanoplasty were identified. Two patients had to be excluded because of hypertension and 2 refused to participate. Forty-eight patients were equally randomized to either the esmolol group (n = 24 [16 women, 8 men]; mean [SD] age, 38.4 [10.5] years) or the dexmedetomi-dine group (n = 24 [17 women, 7 men]; mean age, 35.5 [14.7] years). Sedation scores were not collected for 1 patient in the esmolol group; therefore, analysis was conducted for 23 patients. The median (range) of the scores for the amount of blood in the surgical field in the esmolol and dexmedetomidine groups was 1 (0-3) and 1 (0-2), respectively (P = NS). Mean intraoperative fentanyl consumption in the esmolol group was significantly higher than in the dexmedetomidine group (50.0 [3.0] vs 25.0 [2.5] µg/min; P = 0.002). In the esmolol group, the mean times to extubation and to recovery from anesthesia were significantly shorter than those of the dexmedetomidine group (7.0 [1.4] vs 9.1 [1.9] minutes, respectively; 5.9 [2.1] vs 7.9 [2.3] minutes; both, P = 0.001). The mean sedation scores were significantly lower in the esmolol group (n = 23, because of intent-to-treat analysis) compared with the dexmedetomidine group at 15 minutes (2.5 [0.6] vs 3.6 [0.5]; P = 0.001) and 30 minutes (2.6 [0.6] vs 3.3 [0.6]; P = 0.001) postoperatively. No significant differences were found between the study groups in regard to blood urea nitrogen or creatinine concentration, aspartate aminotransferase or alanine aminotransferase activities, pH, partial pressure of carbon dioxide, or bicarbonate, before or after the operation. CONCLUSIONS: Both esmolol and dexmedetomidine, combined with desflurane, provided an effective and well-tolerated method of achieving controlled hypotension to limit the amount of blood in the surgical field in these adult patients undergoing tympanoplasty. Esmolol was associated with significantly shorter extubation and recovery times and significantly less postoperative sedation compared with dexmedetomidine.

Paraganglioma in pituitary fossa.

Paragangliomas are neuroendocrine tumors of paraganglionic tissue which are extremely rare in the sellar area. We present a case of sellar paraganglioma with parasellar and suprasellar extension in a 70-year-old man who presented with headache. CT demonstrated sellar mass with suprasellar and right parasellar extension. The lesion was removed subtotally via a trans-sphenoidal approach. Histopathological diagnosis was paraganglioma. Differential diagnosis between paragangliomas and unusual types of pituitary adenomas, especially null-cell adenomas, is made by presence of cell nests (Zellballen) in paraganglioma, lack of immunopositivity for pituitary hormones, cytoplasmic immunopositivity for chromogranin A and neuron-specific enolase, and immunonegativity for cytokeratin 19, cytokeratin 20 and endomysial antibody. In the case of a mass in the sellar region, paraganglioma, although rare, should be included in the differential diagnosis.

Rhinolithiasis: clinical, radiological, and mineralogical features.

BACKGROUND: Rhinolithiasis is a rare and under-diagnosed clinical entity whose etiology and pathogenesis is poorly understood. OBJECTIVE: The objective of the study is to review the clinical and radiologic features of rhinolithiasis and mineralogical-chemical composition of the rhinoliths with the aim of shedding light on its etiology and pathogenesis. METHODS: Our subjects consisted of 8 rhinolithiasis cases. Clinical presentations, signs, and symptoms of the patients with radiologic findings are presented, and X-ray diffraction analyses of the stones were carried out to assess their mineralogical composition. RESULTS: Nasal obstruction appeared to be the chief symptom, followed by nasal discharge and facial pain. Neither exogenous nor endogenous nidi were identified in any of the cases. Mineralogical analyses of the rhinoliths revealed Whitlockite [(Ca,Mg)3 (PO4)2] in one and Dahllite [Ca5 (PO4,CO3)3OH] in 7 cases. CONCLUSION: We hypothesized that some substances or organic objects form the nidi of the rhinoliths and are disintegrated over the course of mineral precipitation. This hypothesis was supported by radiologic and microscopic findings.

Clinical investigation of the transient evoked otoacoustic emission test in Crimean-Congo hemorrhagic fever.

OBJECTIVE: The aim of this study was to investigate cochlear damage in Crimean-Congo hemorrhagic fever (CCHF) infection. METHODS: Thirty-two CCHF patients (study group) and 13 healthy people (controls) were included in the study. CCHF patients were also grouped for the presence of fever. CCHF was diagnosed with the presence of CCHF virus-specific IgM antibody or CCHF virus (CCHFV) antigen by ELISA. Cochlear damage was determined by a 'fail' in the transient evoked otoacoustic emission (TEOAE) test. RESULTS: The proportion of TEOAE test 'fail' results in the CCHF patients was significantly higher than in the control group (p<0.05). We found no increase in the proportion of TEOAE test 'fail' results related to fever in the study group. CONCLUSIONS: CCHF disease damages cochlear function regardless of fever.

Radiological correlation between pneumatization of frontal sinus and height of fovea ethmoidalis.

BACKGROUND: We need more data about the variations of skull base to minimize the complications of ethmoidectomy. The aim of this study was to analyze the relationship between the pneumatization of the frontal sinus and height of the fovea ethmoidalis. METHODS: Paranasal coronal computed tomography (CT) scans of 487 sides of 300 patients were evaluated. The presence of the frontal cell and pneumatization of the frontal sinus were studied with respect to the height of the fovea ethmoidalis. RESULTS: We found a statistically significant correlation between the frontal cell and frontal sinus hyperpneumatization (p = 0.000). We determined that there was a deeper fovea ethmoidalis in the sides that have a frontal cell (p

Karyometric analysis of nasal polyps.

OBJECTIVES: Nuclear characteristics of epithelial cells in nasal polyps were analyzed. PATIENTS AND METHODS: The slides of 35 patients who underwent surgery for nasal polyposis and 18 slides of normal mucosa were examined. The specimens were stained with hematoxylin-eosin. Tissue sections were analyzed by a CCD camera and the Karyotype Program of Human Cytogenetics Nomenclature System on a Macintosh computer (OS 9). Fifty epithelial cells in each slide were randomly selected and transferred to the automated karyotyping system and photographed. The diameters of the nuclei were measured and some peculiar nuclear features were examined, including unsmooth appearance of the nuclear membrane, anaphase-bridge, and binucleation. RESULTS: There were significant differences between nasal polyp and normal mucosa groups in terms of nuclear diameter, perimeter, and volume, with all variables being greater in the nasal polyp group (p=0.001). Unusual nuclear features differed significantly (unsmooth nuclear membrane appearance, p<0.001; anaphase-bridge, p=0.041; binucleation, p=0.018), as well. CONCLUSION: Epithelial cells of nasal polyps exhibit nuclear instability.

Effect of climate on the bacteriology of chronic suppurative otitis media.

OBJECTIVES: We evaluated the correlation between the microbial content of chronic suppurative otitis media (CSOM) and regional climatic parameters. METHODS: We assessed the interrelations between monthly mean records of temperature, maximum temperature, atmospheric pressure, and humidity and the aerobic microbial flora in CSOM. RESULTS: Forty-three bacteria of Enterobacteriaceae, 67 staphylococcal spp, 51 Pseudomonas aeruginosa, 9 Streptococcus pneumoniae, 1 alpha-hemolytic Streptococcus, 1 Enterococcus sp, and 2 Edwardsiella tarda strains were recovered from 173 patients with CSOM. There was a good relationship between enteric bacteria and monthly mean temperature (r = 0.501) and significant colonization rates due to increasing monthly mean temperature (p = .040) and monthly mean maximum temperature values (p = .048). CONCLUSIONS: When the weather warmed, the frequency of isolation of enteric bacteria increased significantly. Temperature changes may affect the enteric bacterial colonization of CSOM.

Effect of intratympanic dexamethasone on noise-induced temporary threshold shift.

OBJECTIVE: To evaluate the effects of intratympanic treatment of dexamethasone (IT-DEX) and combination of DEX and hyaluronic acid (DEX/HA) for noise-induced temporary threshold shift (NITTS). MATERIALS AND METHODS: NITTS was experimentally performed in 60 rats. Electrophysiologic hearing thresholds of the rats were measured before and right after noise exposure. Then, the rats were placed into two groups, the first 30 rats in an IT-DEX group and the second in an IT-DEX/HA group. Treatments were performed in the two subgroups (30 ears in one subgroup) of each group. In the IT-DEX group, one ear of each rat was treated with 0.02 mL IT-DEX, and the other ear was treated with IT 0.02 mL physiologic solution of serum saline. In the IT-DEX/HA group, one ear of each rat was treated with combination of 0.01 mL IT-DEX and 0.01 mL HA, and the other ear was treated with IT 0.02 mL of physiologic solution of serum saline. One week after the treatments, electrophysiologic hearing thresholds of all rats were measured again. RESULTS: No statistically significant difference was observed in recovery values of electrophysiologic hearing thresholds between IT-DEX and serum saline (P = .641) in the IT-DEX group. Also, we found no statistically significant difference in the recovery values of electrophysiologic hearing thresholds between IT-DEX/HA and serum saline (P = .344) in the IT-DEX/HA group. CONCLUSION: There is no effect of either IT-DEX and DEX/HA for NITTS.

Early effect of exogenous Na hyaluronate on mucociliary clearance.

BACKGROUND: An animal study is performed to determine the early effect of 1% Na hyaluronate on mucociliary clearance function. METHODS: One percent of Na hyaluronate was introduced into the maxillary sinuses of rabbits by anterior antrostomy. A physiological solution of 1% NaCl was introduced into the maxillary sinuses of a control group to equalize the influence of Na for both groups. The treatment material was sprayed with an atomizer for coating the maxillary sinus lining. Technetium-99m diethylenetriamine pentaacetate dynamic scintigraphic imaging was performed to evaluate mucociliary clearance function on all rabbits 72 hours after the surgical procedure. RESULTS: Although the mean rate of mucociliary clearance of the Na hyaluronate group was slightly worse than the control group; there was no statistically significant difference between them. CONCLUSION: There is no early effect of exogenous 1% Na hyaluronate on mucociliary clearance function.

Fracture of skull base with delayed multiple cranial nerve palsies.

This report describes a pediatric case of delayed glossopharyngeal nerve, vagus nerve, and facial nerve palsies after a head injury. Computed tomography scan of the skull base revealed the fracture of the petrous part of the temporal bone, and the fracture involved the tip of petrous pyramid, in front of the jugular foramen. The anatomical features, mechanisms, diagnosis, and treatment are discussed.

Preventive therapy for postoperative purulent otorrhea after ventilation tube insertion.

OBJECTIVE: Treatment modalities which are intraoperative irrigation of the middle ear with isotonic saline, postoperative oral antibiotic treatment, and postoperative topical antibiotic use have been compared with each other and with control group regarding their efficiency in preventing postoperative purulent otorrhea after ventilation tube insertion. Moreover, the costs of the treatment modalities were analyzed. STUDY DESIGN: Each group consisted of 70 patients, and a total of 280 patients were followed up for purulent otorrhea 2 weeks after the surgery. The study was a single-blind randomized clinical trial. RESULTS: Ten (14.28%) patients in the oral antibiotic group, 11 (15.71%) patients in the isotonic saline irrigation group, 6 (8.57%) patients in the topical antibiotic drops group, and 21 (30%) patients in the control group had postoperative purulent otorrhea. Statistical analysis determined a significant difference between each treatment modalities and control group but did not show any significant difference between the treatment groups. When the treatment options were compared according to their cost, however, the cost per successfully treated patient was significantly lower in the saline irrigation group. CONCLUSION: Intraoperative saline irrigation of the middle ear provides an effective, easy, and cheap treatment in preventing postoperative purulent otorrhea.

Synovial sarcoma of the nasal septum.

No case of synovial sarcoma of the nasal septum has so far been reported. We present a patient with synovial sarcoma of the nasal septum and review the related literature. The patient underwent local excision without adjuvant therapy. There was no local recurrence or distant metastasis in the 18-month follow-up period.

Cold dissection versus bipolar cauterizing tonsillectomy for bacteriemia.

OBJECTIVE: The purpose of this study is to compare transient bacteriemia ratios between cold dissection tonsillectomy and bipolar cauterizing tonsillectomy, and also to analyze the bacteria detected with superficial/central tonsillar cultures. METHODS: A total of 86 patients that were grouped as 46 patients of cold dissection tonsillectomy and 40 patients of bipolar cauterizing tonsillectomy were included in this study. Preoperative surface swab cultures, intraoperative central swab cultures of tonsils, and preoperative and postoperative blood culture samples were obtained. Antibiotic sensitivity tests were determined. Fischer exact chi 2 test was performed to compare the results of postoperative bacteriemia of both techniques statistically. RESULTS: Postoperative bacteriemia was detected in 6 (13%) patients of cold dissection tonsillectomy group. In 5 (83.3%) of the 6 postoperative bacteriemia patients of cold dissection tonsillectomy group, isolated microorganism was confirmed both in the blood cultures and in the central swab cultures of tonsils, and resistance to penicillin was established. No patient of bipolar cauterizing tonsillectomy group appeared with postoperative bacteriemia. There was a statistically significant difference (P=.028) for postoperative bacteriemia between cold dissection tonsillectomy group and bipolar cauterizing tonsillectomy group. CONCLUSION: We recommend bipolar cauterizing tonsillectomy for high-risk patients.

Nasal septal suture technique versus nasal packing after septoplasty.

BACKGROUND: The aim of this study was to compare eustachian function and blood gas changes with nasal packing (NP) and nasal septal suturing (NSS) after septoplasty. METHODS: Eighty patients who have nasal septal deviation and who otherwise are healthy were studied. Forty of these patients had finger glove NPs in their nasal cavities for 48 hours after septoplasty. Another 40 patients had NSS performed after septoplasty. Acoustic tympanometry and pH, P(CO2), and P(O2) analyses of arterial blood were performed preoperatively and 48 hours postoperatively. RESULTS: We observed a statistically significant increase in middle ear pressure (p < 0.001) and a significant reduction of P(O2) (p < 0.001) and increase of P(CO2) (p = 0.041) in the NP group but no difference in the NSS group, postoperatively. CONCLUSION: NSS should be preferred as an alternative to intranasal packing.

An analysis of correlation between the unusual location of the jugular bulb and audiovestibular symptoms.

OBJECTIVE: Case reports indicate that abnormal location of the jugular bulb (JB) may result with some vestibular and audiological symptoms. The aim of this study is to analyze the correlation between the radiological view of the JB and audiovestibular findings and to clarify its possible role for Meniere-like problems. METHOD: Fifty-six patients, who had abnormal view of the JB on computerized tomography (CT) were selected to the study in this prospective case review. They were classified in three groups (Group-I; Lateral, Group-II; Intermediate and Group-III; Medial), according to the location of the JB. Patients were subjected to audiogram and vestibular tests (Dix-Hallpike maneuver, fistula test, vestibulospinal tests, electronystagmography (ENG)). RESULTS: JB was compressing on the cochlear aqueduct (CA) in two patients in group-II. Seventeen out of 25 patients in group-III had radiological evidence of obstruction of vestibular aqueduct (VA). 19 patients had neurosensorial and four patients had conductive hearing loss. All of the patients in group-I and nine of the patients in group-II gave normal caloric response to stimulation. Twelve of 19 patients in group-III demonstrated canal paresis ranging from 22 to 80%. CONCLUSION: Present study points out that there is a high correlation between HJB and vestibular problems in symptomatic cases. In patients who have HJB without classic vertigo attacks subclinical involvement of the vestibular system has been observed on ENG recordings. These findings imply that radiological existence of HJB may be a predisposing factor for Meniere-like complaints.

Rosai-Dorfman disease associated with neurosensorial hearing loss in two siblings.

Rosai-Dorfman disease (RDD) is an uncommon pathologic condition of unknown ethiology with an idiopathic proliferation of the hystiocytes. It is generally presented with massive bilateral hypertrophy of the cervical lymph nodes. But other lymph nodes may also be involved. Approximately, 30% of these patients have extra nodal mass or lesion with different signs or symptoms depending on localization. We present two male siblings with Rosai-Dorfman disease who have classical cervical lymphadenopathy associated with progressive neurosensorial hearing loss and dural-based intracranial lesions.

A case of giant sialolith of the submandibular salivary gland.

Sialolithiasis is the most common disease of the salivary glands. This report describes the case of a patient who had an unusually large submandibular gland sialolith that was completely encased in the glandular substance. The author describes the management of this patient and reviews the literature.

Bacteriology in patients with chronic sinusitis who have been medically and surgically treated.

Chronic sinusitis is a disease that afflicts a significant percentage of the population and causes considerable long-term morbidity. The common use of multiple broad-spectrum oral antibiotics and endoscopic sinus surgery to treat this condition may alter the pathogenes that promote persistence of chronic sinusitis. Forty-eight culture-positive patients with chronic sinusitis who had been medically treated for at least 3 months and had undergone sinus surgery were bacteriologically evaluated. Swab specimens of the middle meatus and sphenoethmoid recess were aseptically obtained endoscopically and cultured for aerobes. Coagulase-negative staphylococci were the most common isolates (45.8%), followed by Streptococcus pneumoniae (16.7%), Enterobacteriaceae (16.7%), Staphylococcus aureus (10.4%), and Pseudomonas aeruginosa (10.4%). Coagulase-negative staphylococci were the most frequently isolated organisms in our study, as in many other studies. Despite the significant predominance of these organisms, they have always been assumed to be contaminants, and their presence in culture has been discounted. Coagulase-negative S aureus may be a pathogen in the chronic sinusitis process, and sensitivities of this isolate should be obtained for evaluation and possible treatment of the disease.