Dissection versus diathermy for tonsillectomy.

BACKGROUND: This is an update of a Cochrane Review first published in The Cochrane Library in Issue 4, 2001 and previously updated in 2003.Tonsillectomy is a commonly performed surgical procedure. There are several operative methods currently in use, but the superiority of one over another has not been clearly demonstrated. OBJECTIVES: To compare the morbidity associated with tonsillectomy by two different techniques - dissection and diathermy. SEARCH STRATEGY: We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 3), PubMed, EMBASE, CINAHL, Web of Science, BIOSIS Previews, ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 1 October 2010, following a previous update search in 2003. SELECTION CRITERIA: Randomised controlled trials of children and adults undergoing tonsillectomy or adenotonsillectomy by dissection or diathermy techniques. DATA COLLECTION AND ANALYSIS: Two review authors selected studies, extracted data and assessed risk of bias independently. MAIN RESULTS: Two studies (254 participants) are included in the review. The overall risk of bias in the included studies was low, although we excluded pain data from one study due to unclear risk of bias. One study compared monopolar dissection diathermy with conventional cold dissection in children and the other compared microscopic bipolar dissection with cold dissection in children and adults. These studies demonstrate reduced intraoperative bleeding, but increased pain in the diathermy group. There was no difference in the rate of secondary bleeding overall, although the power of both studies to detect a small difference was insufficient. AUTHORS' CONCLUSIONS: There are insufficient data to show that one method of tonsillectomy is superior. There is evidence that pain may be greater after monopolar dissection. Large, well designed randomised controlled trials are necessary to determine the optimum method for tonsillectomy.

Permanent and transient effects of locally delivered n-acetyl cysteine in a guinea pig model of cochlear implantation.

Protection of residual hearing after cochlear implant surgery can improve the speech and music perception of cochlear implant recipients, particularly in the presence of background noise. Surgical trauma and chronic inflammation are thought to be responsible for a significant proportion of residual hearing loss after surgery. Local delivery of the anti-oxidant precursor n-acetyl cysteine (NAC) to the cochlea via round window 30min prior to surgery, increased the level of residual hearing at 24-32kHz 4weeks post surgery compared to controls. The hearing protection was found in the basal turn near the site of implantation. Coincidentally, the basal turn was also the location that sustained the greatest hearing loss. As well as protecting residual hearing, NAC-treated animals demonstrated a reduction in the chronic inflammatory changes associated with implantation. While these findings indicate that anti-oxidant therapy can be used to reduce the hearing loss associated with surgical trauma, the local delivery of NAC was associated with a transient increase in hearing thresholds, and osseoneogenesis was seen in a greater number of NAC-treated animals. These side-effects would limit its clinical use through local cochlear administration. However, it is not known yet whether these effects would also be produced by other anti-oxidants, or ameliorated by using a different route of administration.

Targeted therapy of the inner ear.

BACKGROUND: There is experimental evidence that targeted delivery of steroids to the inner ear can protect hearing during cochlear implant surgery. The best protection appears to be achieved through pre-treatment of the cochlea, but the time period required for treatment is long compared with the duration of surgery, and needs further optimization. The stability of hearing thresholds is determined over a 3-month period after hearing preservation cochlear implantation. METHODS: Adult guinea pigs were implanted with a miniature cochlear implant electrode, and pure tone auditory brainstem response (ABR) thresholds were estimated in response to pure tones of 2-32 kHz immediately after surgery and at 1 week, 1 month and 3 months. Spiral ganglion cell (SGC) densities were estimated from mid-modular histological sections of the cochlea. Thirty minutes prior to implantation, a polymeric sponge (Seprapack, Genzyme) was loaded with either a 2% solution of dexamethasone phosphate or normal saline (control) and placed onto the round window. RESULTS: Implantation was associated with an immediate elevation in thresholds across frequencies, with a full recovery below 2 kHz over the next week and a partial recovery of thresholds at higher frequencies. These thresholds remained unchanged for the next 3 months. There was an immediate and sustained reduction in the elevation of thresholds at 32 kHz in dexamethasone-treated animals. SGC densities were greater in steroid-treated animals than controls in the basal turn of the cochlea (at the region of implantation) 3 months after implantation. CONCLUSION: It is concluded that ABR thresholds remain stable for 3 months after cochlear implantation in the guinea pig, and that local application of steroids to the inner ear prior to implantation is an effective method of preserving SGC populations when there is residual hearing at the time of implantation.

Otosclerosis: selection of ear for cochlear implantation.

OBJECTIVES: 1. To examine whether speech perception after implantation is correlated with the total duration of deafness, the duration of deafness in the implanted ear, or age at implantation. 2. To examine whether the rate of facial nerve stimulation postoperatively is correlated with the type of electrode used. STUDY DESIGN: Retrospective case note review. SETTING: Tertiary referral center. PATIENTS: Fifty-nine adults with profound postlingual sensorineural hearing loss due to otosclerosis. INTERVENTION: Cochlear implantation with the Nucleus device using either a straight (n = 35) or Contour (n = 29) electrode array. MAIN OUTCOME MEASURES: Speech perception scores for patients at 3, 6 and 12 months postimplantation were correlated against duration of deafness in the implanted ear, duration of total deafness, and age at implantation. Data on facial nerve stimulation rates postoperatively were collected. RESULTS: Implantation in the shortest deafened ear conferred an initial advantage for speech perception 3 months after surgery; however, this effect was lost by 6 months. There were no significant correlations between the duration of bilateral deafness and hearing outcomes. Age at implantation was negatively correlated with outcome at 3 months, but not at 6 and 12 months. Fourteen of 35 patients with straight electrodes and 0 of 24 patients with Contour electrodes experienced facial nerve stimulation during mapping sessions (p < 0.005, chi). CONCLUSION: Patients with otosclerosis are not disadvantaged in the long term by implantation in the longest deafened ear. Increasing age at implantation did not predict poorer outcomes. A perimodiolar design of electrode should be used in otosclerotic patients when possible to reduce the risk of facial nerve stimulation.

Idiopathic laryngeal spasm: management and long-term outcome.

Idiopathic laryngeal spasm (ILS) is an uncommon disorder characterised by brief episodes of stridor, occurring at any time. Subsequent outpatient ENT examination is normal. These episodes cause considerable anxiety for both patient and physician. Little is known about the initiating event(s) in this condition or the long-term outcome. Using a combination of telephone and postal questionnaires with case note review, we have reviewed a cohort of 21 patients with this diagnosis managed by the senior author over the last 15 years. None of the 19 patients who responded were worse; 13 (68%) described improvement or complete resolution of symptoms. ILS is difficult to classify in the spectrum of vocal cord disorders, but appears distinct to those previously described. The condition responds well to a conservative management approach of reassurance and counselling.

Oncocytic cyst presenting as laryngocele with surgical emphysema.

We present a case of laryngeal oncocytic cysts presenting as bilateral laryngoceles and surgical emphysema of the neck. Although there is a rare, but well-documented association of laryngoceles with laryngeal carcinoma, coexistence with another laryngeal pathology is less well reported.

Prognostic value of the blink reflex in acoustic neuroma surgery.

OBJECTIVE: The study goal was to demonstrate that blink reflex analysis can predict postoperative facial nerve outcome in cerebellopontine angle tumor surgery. STUDY DESIGN, SETTING, AND PATIENTS: In an open and prospective study conducted at a single tertiary care center over 3 years, 91 subjects with a vestibular schwannoma filling the internal auditory meatus were enrolled and operated on via a translabyrinthine approach. The difference in latency of the early response (DeltaR1) of the blink reflex between the pathologic side and the healthy side was calculated in every patient during a complete electrophysiologic examination of the facial nerve performed on the day before surgery. MIN OUTCOME MEASURES: DeltaR1 was compared with the other preoperative data (tumor volume, facial function), with the perioperative observations (difficulties with the dissection of the facial nerve), and especially with the postoperative status after 1 year. The statistical study was conducted using polynomial regression. RESULTS: Patients with a negative or zero DeltaR1 have normal facial function at 1 year. For those with a positive DeltaR1 the outcome is not favorable unless the tumor is small. For patients presenting with an immediate complete facial paralysis, the value of DeltaR1 is also indicative of facial function outcome. CONCLUSION: Statistical analysis shows that the blink reflex, through DeltaR1, has an excellent prognostic value in anticipating the difficulties with facial nerve dissection and postoperative facial function after 1 year.