[ENT surgery in anticoagulate patients]. / HNO-Chirurgie bei Patienten unter oraler Antikoagulation und Plättchenhemmer-Therapie.

BACKGROUND: In elective ENT surgery, one frequently sees -patients on oral anticoagulants and platelet inhibitors. While continuation of these therapies increases the risk of bleeding complications, indiscriminate discontinuation can have severe thromboembolic consequences. Furthermore, the number of -anticoagulants and platelet inhibitors in use has increased. The ENT-specialist is regulary confronted with the question of continuation, discontinuation, or bridging of this therapy. METHODS: Review of the available literature on bleeding complications associated with ENT interventions performed with and without anticoagulants. Overview of the indications for anticoagulants and the different mechansims of action and properties of the different agents. Development of protocols for risk stratification and for perioperative management. CONCLUSIONS: Patients on oral anticoagulants and platelet inhibitors have significant morbidity and mortality not only due to the underlying diseases, but also due to the perioperative management of these therapies. Perioperative management should be based on well-established treatment guidelines or, in high-risk patients, on multidisciplinary consultation. Even though the recommendations here are evidence-based and cover a multitude of clinical contingencies, they cannot replace clinical decision making, which must consider the specific characteristics and circumstances of the patient, the planned intervention, and the surgical environment.

Manifestations of immunoglobulin G4 related disease in otolaryngology: case reports and review of the literature.

BACKGROUND: Immunoglobulin G4 related disease is an inflammatory condition characterised by the presence of fibrotic lesions infiltrated by immunoglobulin G4 positive plasma cells. It can arise from almost any region of the body and it is being increasingly recognised in the head and neck. Regardless of the site of involvement, the histopathological resemblance is remarkable. Dense lymphoplasmacytic infiltration, overabundance of immunoglobulin G4 bearing plasma cells and presence of storiform fibrosis are typical findings. CASE REPORTS: This paper presents two cases of immunoglobulin G4 related disease in which there was involvement of the orbit, the infraorbital nerve and the infratemporal fossa. Diagnosis was established in both cases by biopsying radiologically abnormal tissue in the infratemporal fossa. CONCLUSION: An awareness of this condition is required to establish the diagnosis and initiate appropriate therapy. Glucocorticoids are the mainstay of initial treatment. The effectiveness of B-lymphocyte depletion with rituximab has also been reported. Correct diagnosis may spare patients from unnecessarily radical surgery.

[The content of nitrite and N-nitroso compounds of plasma as a diagnostic test of nonspecific inflammation].

The authors' enzymatic sensor was applied to identify the content of nitrite and nitroso compounds of blood plasma in normal condition and under various inflammatory diseases. It is established that in normal conditions blood plasma contains nitrite, N-nitroso compounds (RNNO) and S-nitroso compounds (RSNO) in concentrations less than 100 nm. The plasma pool of nitroso compounds includes basically thiolferous nitrosate ferrum complex in concentration 3-20 microm. The concentration of nitrite in plasma is from 10 to 150 microm. The concentration (nitrite+RNNO) increases dramatically under inflammatory diseases. This indicator was 0.3-1.0 microm in examined patients with acute and chronic pancreatitis, cholecystitis, ENT diseases of inflammatory character and ARD. In the case of acute appendicitis the indicator reached 10 micro. In case of successful treatment the content (nitrite+RNNO) decreased to the concentration lower than 100 nm. The content of other nitrite and N-nitroso compounds had no reliable variations. Because of this, largely implemented evaluation of intensity of nitric oxide production by the aggregate indicator of nitrites content (NO(x)) in blood seems ambiguous. The reason is that in normal conditions nitrite is presented in trace amount and considerable quantity of nitrate can enter the organism in an exogenous way. Besides that the content of nitrite can depend on kidneys filterability. At the same time, based on the obtained data, the content (nitrite+RNNO) in plasma in concentrations higher than 150 nm are definitely to be considered as pathology.

[Serological diagnosis and nasopharyngeal washings in pediatric infections]. / Diagnostic sérologique et prélèvements nasopharyngés dans les infections pédiatriques.

In the course of respiratory infections, the efficacy of microbiologic diagnosis has increased years after years, in term of specificity, sensitivity and rapidity. New pathogenic agents have been described such as: Legionella pneumophila, Chlamydia pneumoniae, Hantavirus. Some viruses have been well characterized as responsible for seasonal outbreaks using rapid tools for identification. Needs for efficient diagnostic tools became more obvious when specific antiviral drugs appeared on the market. So technologic developments improved the efficacy of microbiologic diagnosis and anticipate a better specificity as well as sensitivity with the help of molecular biology. Respiratory syncytial virus is one of the major infectious agents found in respiratory infections in young children and newborns. On the whole it was detected in more than one third of pediatric nasopharyngeal aspirations received in our laboratory and more than 50% during the peak of the winter epidemics. The method of direct antigen detection by immunofluorescence with the help of monoclonal antibodies allowed us to establish an incidence curve of these recurrent outbreaks, beginning in December to stop usually by the end of April. During this same period, influenza A virus, seldom influenza B virus, were detected in many nasopharyngeal specimens. Other viruses, parainfluenza 1 to 3 and Adenovirus, were irregularly detected all along the year. In the great majority of nasopharyngeal aspirations with a positive virus detection, one virus only was observed. Antigen detection methods were also developed for some bacteria such as Chlamydia pneumoniae, Legionella pneumophila. Although serology is not frequently used by pediatricians, it is still necessary for the diagnosis of Mycoplasma pneumoniae infections. A direct antigen detection test is now available, but its sensitivity needs to be evaluated. On the other hand serologic diagnosis may be extremely useful when long lasting or treatment resistant respiratory infections occur. Seroconversion or four-fold increasing titers to one pathogen may be observed when a second serum sample is tested together with the first serum of this patient. The diagnostic yield will be all the more efficient that time between both samples is long. Molecular biology techniques will significantly change the way to investigate an infection. Presently these methods are used in research laboratories, but automated technologies will facilitate routine laboratory workload. Screening methods using multiplex PCR are also promising.

[Mivacurium--a new muscle relaxant compared with atracurium and vecuronium]. / Mivacurium--ein neues Muskelrelaxans im Vergleich zu Atracurium und Vecuronium.

This study investigates the effects of mivacurium (3 times ED95) on neuromuscular block, intubation conditions and general safety in comparison with equipotent doses of atracurium and vecuronium. Following Ethical Care Committee approval and informed consent, 90 ASA I+II patients aged 18 to 65 were studied undergoing elective ENT surgery. Anaesthesia was induced with 1.5 mg/kg propofol and 0.2 mg/kg alfentanil and maintained through continuous infusion of propofol (8 to 10 mg . kg-1 . h-1) and nitrous oxide in oxygen. After achieving stable anaesthesia, the patients received bolus injections of mivacurium (0.20 mg/kg, n = 30), atracurium (0.69 mg/kg, n = 30) or vecuronium (0.14 mg/kg, n = 30) for endotracheal intubation. Intubation was attempted 120 s after drug application and the intubation conditions were assessed. Relaxation was recorded using peripheral nerve stimulation (Train of four). During the observation period, signs of histamine release, respiratory difficulty, cardiovascular events or other adverse signs were monitored. Onset of relaxation was longer for mivacurium (2.3 +/- 1.3 min) compared with atracurium (1.4 +/- 0.7 min) or vecuronium (1.3 +/- 0.3 min). Intubation conditions 120 s after drug application were good or very good in only 67% of cases given mivacurium compared with 90% given atracurium and 100% given vecuronium. The recovery time (DUR 25) was shorter in the mivacurium group (19.5 +/- 7.9 min) compared with atracurium (54.7 +/- 6.6 min) and vecuronium (44.3 +/- 8.6 min). Heart rate and blood pressure were similar in all groups. Facial flushing and mild bronchospasms as signs of histamine release resulted more often in the mivacurium (20%) and atracurium groups (23%) than in the vecuronium group (3%). In contrast to atracurium and vecuronium, recovery from mivacurium-induced neuromuscular blockade is rapid. However, the onset time after 3 times ED95 was significantly longer for mivacurium than for atracurium or vecuronium.

[Von Willebrand syndrome--risk of hemorrhage in ENT interventions in childhood]. / Von Willebrand-Syndrom--Blutungsrisiko bei HNO-Eingriffen im Kindesalter.

Von Willebrand's disease (vWD) is the most common inherited bleeding disorder. Typical clinical features such as bleeding after surgery or trauma might suggest the disease. We present a series of 24 patients with vWD treated between 1989 and 1992. Diagnosis was confirmed by a reduction in plasma factor VIII antigen concentration, reduction of ristocetin cofactor activity and reduced factor VIII activity. Seventeen of the patients underwent surgery (7 adenoidectomies, 8 tonsillectomies, 2 paranasal sinus operations) and received preoperative stimulation of von Willebrand factor (vWF) using DDAVP. This resulted in a rapid increase in plasma vWF concentration from an average of 56% before stimulation to 190% of the normal value after stimulation. A reduction of partial thromboplastin time from an average of 44.4 seconds to 34.4 seconds was observed following DDAVP. No bleeding complications or other side-effects occurred. Preoperative stimulation of vWF using DDAVP proved to be a safe method to reduce the risk of bleeding in patients with vWD undergoing surgery.

Diagnostic specificity of anti-neutrophil cytoplasmic antibodies (ANCA) in otorhinolaryngological diseases.

The incidence and titer of ANCA were examined with 871 sera from patients with otorhinolaryngological diseases at our hospital. The cytoplasmic pattern of ANCA (c-ANCA) whose titer was more than 16 was detected only in the sera of patients with Wegener's granulomatosis (WG). The incidence of c-ANCA in active WG was more than 90%. The perinuclear staining pattern of ANCA (p-ANCA) was detected in almost 40% of patients with Sjögren's syndrome, 2.0% of inflammatory diseases and 1.0% of tumorous diseases. A high diagnostic value of c-ANCA in WG was found in patients with otorhinolaryngological diseases.

[Study of cells harvested in nasal secretions after lavage. Improvement of the cytologic technique and application to ORL and bronchial pathology]. / Etude des cellules recueillies dans les secrétions nasales apres lavage. Mise au point de la technique cytologique et application aux pathologies orl et bronchiques.

The study of the cells found in the nasal lavage fluid is now a very used method. It has many advantages and it is better than the study of nasal smears obtained by nose blowing and/or swabbing. In this work, we have studied the nasal cytology of patients with a nasal or bronchial pathology. A count of inflammatory cells in a hemocytometer is performed in 301 noses then the percentage of various cell types (eosinophils, lymphocytes and neutrophils) is performed on a glass slide stained by May Grunwald Giemsa. The results are correlated with the literature. The patients with a known NARES have a mean nasal eosinophilia of 26.8%; in the allergic rhinitis, the eosinophilia is 41.4%; the patients with a Fernand Widal Syndrome or with a nasosinusal polyposis have respectively a eosinophil percentage of 24.2% and 18.8%.

An assessment of the incidence of iron deficiency in paediatric otolaryngology inpatients.

The aims of this study were: to determine whether there is an increased incidence of iron deficiency in paediatric otolaryngology inpatients compared with other surgical controls; and to establish whether preoperative screening of haemoglobin level is warranted in such patients. Children aged 1-10 years admitted electively for ENT surgery or for general surgical procedures had blood taken for haemoglobin level, mean cell volume and serum ferritin. Their age, weight, socioeconomic class and ethnic background were recorded. A total of 100 patients entered the study, in a six-month period. The mean ages and weights for the two groups were statistically different, so allowance was made for this in calculations. Social class was not significantly different. No relationship could be established between haemoglobin level and ferritin level for individual patients. Multiple regression analysis for haemoglobin level, mean cell volume and for ferritin level showed that allowing for the age and weight differences these variables were not significantly different for the two groups. This study has therefore shown no increased incidence of iron deficiency in paediatric ENT inpatients. Each Department should formulate its own policy on pre-operative haemoglobin screening, based on local considerations.

[Otolaryngological surgical procedures and HIV infection]. / Zabiegi i operacje ORL a zakazenia wirusem HIV.

The authors present the problem with HIV positive patients which have an ear, nose and throat disease. ENT doctors are the group of high risk of AIDS. Up to now we haven't got a test useful for early diagnosis in AIDS (specially this period between infection and seroconversion+--"serological window"). This fact requires special cautions from ENT surgeons++. The authors describe the methods of individual prevention from AIDS and, the surgical instruments sterilization.

[The clinical application of oxygen saturation pulse oximeter in otolaryngological field].

Recently, we had opportunity to use an oxygen saturation pulse oximeter (minolta pulsox-7) which is a compact, light-weight device and allows continuous, percutaneous easy determination of arterial blood oxygen saturation. We obtained the following results from clinical application of this device in the field of otorhinolaryngology. 1. There was a high coefficient of correlation (0.899) between the values of oxygen saturation determined with a Minolta Pulsox-7 and an arterial blood gas analyzer. 2. This instrument was simple to handle and was clinically applicable, and seems to be highly useful for a) timing of tracheostomy, b) objective evaluation of dyspnea, c) monitor of nasal surgery under local anesthesia.