Effects of droperidol in management of vestibular disorders.

The chemo-therapy of vestibular disease has involved a wide spectrum of pharmacological agents insofar as their mode of action is concerned. In our experience, however, droperidol is one pharmaceutical agent which is remarkably effective in depressing vestibular disturbance regardless of etiology. This medication (also called Inapsine) belongs to a relatively new class of compounds known as butyrophenones and its pharmacological action can best be described as a dopa blocking agent. The activity of droperidol on the nervous system first became evident when it was used in combination with the potent analgesic fentanyl citrate in order to produce an anesthetic condition that has been termed neuroleptanalgesia. This mixture (also called Innovar) is rapid in action and results in complete suppression of vestibular activity of both normal subjects and those with Ménière's disease as described by Dowdy, et al., in a preliminary report. These impressive results have prompted us to evaluate the effectiveness of this medication in the treatment of different disorders of the labyrinth. The patients chosen for evaluation were referred for vestibular examination at the Toronto General and St. Michael's Hospitals. Electronystagmography was used to record objectively the effects of the drugs being tested while subjective symptoms including side effects were also noted. These studies involved 20 patients receiving Innovar while 12 patients were tested with Inapsine. Innovar administered in a single dose (droperidol 5 mg, fentanyl 0.1 mg) to patients undergoing acute episodes of vestibular disease (vestibular neuronitis and Ménière's disease) was found effective in the following symptoms and/or signs: nausea, vertigo, nystagmus, the positive past-pointing test and the Romberg test. Innovar appeared to be effective in the amelioration of vomiting although the population was too small to demonstrate statistical significance in this regard. The drug mixture appeared to have no effect on improving auditory acuity and had no significant effects on tinnitus. Adverse reactions to the drug combination were unusual, and, occurring in three patients, were mild as manifested by drowsiness. Since the above findings confirmed the marked effectiveness of the fentanyl-droperidol mixture in the management of vestibular disease, it was decided to determine the relative effectiveness of the droperidol component alone and this was determined by comparing the effectiveness of the drug with placebo in a double-blind study. Review of our findings involving this double-blind study indicates significant responses to Inapsine. This therapy clearly provided the statistically significant response (p less than 0.1, Fisher's Exact Test). This was particularly apparent at the 60-minute evaluation point. While some of the patients receiving Inapsine had recovered earlier, by 60 minutes none of the placebo patients but all of the Inapsine patients had recovered from the vestibular symptoms of Ménière's disease...

Nasal nitric oxide and the nasal cycle.

OBJECTIVES: To establish the relationship between nasal patency and the nitric oxide (NO) concentration in the nasal airways. METHODS: Unilateral nasal NO concentration (n = 11) and inhaled nasal NO concentration at oropharynx (n = 9) were measured in healthy adult volunteers. Subjects breathed normally through the nose with a known resistance (ranged from none to total occlusion) placed in one nostril. In a subgroup (n = 7), the unilateral nasal NO concentrations were determined with nasal cavity congestion induced by lateral decubitus. RESULTS: When the added nasal resistance was less than 6 cm H(2)0 per liter per second, the peak NO concentrations in the nose remained below 80 parts per billion (ppb). Thereafter, the higher the resistance, the greater the NO concentration. It was up to 1109.7 ppb when the front nostril was totally occluded. There was no correlation between oropharyngeal NO concentrations and resistance in the front of the nose (r = 0.4). There was a significantly negative correlation between nasal cavity volumes and nasal NO concentrations (r = -0.8, P <.001). CONCLUSIONS: Increases in nasal resistance to levels encountered in the nasal cycle and in recumbency augments the NO concentration within the obstructed side of the nose. Although that within the nose changes with patency, the NO concentration is constant down to the lower airways. The modulation role of the upper airways to the inhaled NO concentration remains unclear.

The technique for endoscopic pituitary tumor removal.

A number of milestones have marked the development of transsphenoidal pituitary tumor resection this century. The introduction of headlamp illumination, followed by the use of the operating microscope and fluoroscopy have allowed neurosurgeons to perform this surgery in a safe and highly effective manner. With the aid of a case report, we describe the incorporation of endoscopic techniques in pituitary tumor resection. The technique described is minimally invasive, avoiding septal dissection and allowing unsurpassed, unobstructed, and panoramic visualization of the region of interest to the surgeon and operative team.

The surgical complications of thyroidectomy.

The surgical complications of thyroidectomy are relatively few but still need to be carefully considered before an operation is recommended. The major problems that lead to continuing morbidity are those of permanent hypoparathyroidism and recurrent laryngeal nerve damage. The incidence of both rises dramatically whenever a total thyroidectomy is performed, particularly when this is for a malignancy, or when the patient has undergone previous surgery to the thyroid or parathyroid glands. Other complications of thyroidectomy are relatively uncommon.

Surgery of the nasal dorsum.

Careful pre-operative planning is required before the nasal dorsum is changed in profile or width. The highlights of assessment are discussed together with a description of how the surgery should be performed. The advantages of using the external approach to the nasal dorsum are stressed.

External septorhinoplasty--why the fuss?

External approach rhinoplasty has engendered controversy. The merits of the procedure are discussed, together with an outline of indications for its use. It is felt that this operation is a useful addition to the rhinoplastic art.

Ultrasonic tonsillectomy.

High-frequency ultrasound is an effective mechanism for cutting and coagulating tissue. It is widely used in laparoscopic surgery and may have advantages in tonsillectomy. Twenty-five consecutive cases of tonsillectomy were performed using an ultrasonic scalpel; these were compared with a similar previous consecutive group performed by conventional cold dissection and monopolar electrocautery. There was no undue primary bleeding in either group and no immediate or late postoperative bleeding. Since adenoidectomy was often performed and the total blood loss in each group was so small, no statistical difference could be determined between the groups. No complications were noted in either group. The ultrasonic scalpel has the potential to produce a bloodless tonsillectomy and less collateral tissue damage and is easy to use. There may be less postoperative pain, although this could not be shown statistically in this retrospective study. Ultrasonic tonsillectomy appears to be a safe, and possibly a superior, method of performing this common operation.

Self-induced vertigo.

Benign paroxysmal positional vertigo is the most commonly recognized form of self-induced vertigo. This paper describes other means by which patients have been able to induce vertigo to the extent that at times it has been incapacitating. Hypotheses for the production of these phenomena are suggested in a number of the cases. Some of the features cannot be explained on the basis of our present knowledge of the vestibular system.

Ménière's disease associated with serous retinopathy.

A case history is presented of a patient suffering from classical Ménière's disease who concurrently developed central serous retinopathy. On review, these conditions are found to have several features in common and on the basis of the changes seen by fluorescein angiography in the eye, an hypothesis is presented for the development of endolymphatic hydrops.

Actinomycosis of the parotid. Is it usually a masticator space infection?

Three cases of Actinomycosis involving the facial region are presented with a discussion of the problems which can be encountered in the diagnosis and localization of this infectious disease.

Jugular foramen syndrome.

The jugular foramen syndrome (JFS) specifically refers to paralysis to the IX-XIth cranial nerves. In a more general meaning, however, any combination of palsies affecting the last four cranial nerves has been referred to as a JFS. The anatomy of the jugular foramen and the structures which traverse it are reviewed. Two cases histories of a JFS are described; the first with chronic otitis media, and the second with a glomus tumor. A variety of neoplasms, vascular insults, infections, and trauma have been reported to cause JFS. Treatment is directed toward the underlying cause. A variety of radiological techniques which are useful in the investigation of JFS are outlined.

Frontal sinusitis--a 10 year experience.

Frontal sinusitis follows upper respiratory infections, sinus trauma, and swimming. Complications, often life threatening, still occur although less frequently than in the pre-antibiotic era. The course of 40 patients admitted to St. Michael's Hospital with a diagnosis of frontal sinusitis between the years 1973-83 is reviewed. The regional complications as well as the surgical procedures required to manage these problems are discussed. The osteoplastic flap with obliteration of the sinus cavity by osteoneogenesis has become the procedure of choice in dealing with most cases of chronic frontal sinusitis.

Comprehensive presentation of semicircular canal sensitivity.

It is generally agreed that in order to determine any difference in vestibular sensitivity between the two inner ears, the best clinical procedure involves a quantitative expression of the slow phase nystagmus response to standardized caloric (or rotatory) stimulation. The preferred procedure has involved averaging the slopes of a few of the nystagmus responses during the period of most intense activity and this has been accomplished either arithmetically or by means of an electronic computer. Although, such a sampling is often sufficient to enable a reliable diagnosis, occasions do arise when the results can be misleading unless comprehensive total presentations of the responses from the two labyrinths are available for reliable comparative evaluation. Such a procedure has been developed at the University of Toronto and used for clinical assessment at St. Michael's Hospital. The reliability of the method has been established as the result of testing over 800 patients with various vestibular disorders.

Does nasal nitric oxide come from the sinuses?

OBJECTIVE: The purpose of this study was to assess nitric oxide (NO) output by the nose and sinuses. METHOD: In one volunteer, the osteomeatal complex and sphenoethmoidal recess were occluded to isolate the nose from the sinuses. The antrum and frontal sinus were each punctured by two catheters and irrigated with air at constant flow. Nitric oxide output and its rate of accumulation in the absence of air flow were measured in each sinus and in the adjacent nasal cavity. RESULTS: Prior to ostial occlusion, NO output in the nose was 96 nL/min. It decreased by 12% after blockage of all of the ostia. In the isolated sinuses, it was 190 nL/min (antrum) and 68 nL/min (frontal). After 5 minutes stagnation; NO concentration [NO] rose in the occluded sinuses to 24,700 nL/L in the antrum and 22,300 nL/L in the frontal sinus. In the nose, it increased to 29,000 nL/L. When the period of stagnation was prolonged in the frontal sinus, the [NO] reached a plateau. NO output and accumulation were not altered in the nose or either sinus by opening their ostia. In the antrum and frontal sinus, lidocaine reduced NO output and the rate of NO accumulation, but not in the nose. CONCLUSIONS: In this volunteer, 88% of nasal NO was derived from the nose itself. Nitric oxide exchange between the frontal sinus, antrum, and nose was negligible. In the absence of air flow, [NO] rose to a plateau in the nose and frontal sinus. Lidocaine inhibited NO output in the sinuses but not the nose.

A practical guide for the diagnosis and treatment of acute sinusitis.

OBJECTIVE: To develop guidelines for the diagnosis and management of acute sinusitis. OPTIONS: Diagnostic clinical criteria and imaging techniques, the role of antimicrobial therapy and duration of treatment, and the role of adjunct therapy, including decongestants, glucocorticosteroids and nasal irrigation. OUTCOMES: Improved accuracy of clinical diagnosis, better utilization of imaging techniques and rational use of antimicrobial therapy. EVIDENCE: A MEDLINE search for relevant articles published from 1980 to 1996 using the MeSH terms "sinusitis," "acute sinusitis," "respiratory infections," "upper respiratory infections," "sinusitis" and "diagnosis," "sinusitis" and "therapy," "sinusitis" and "etiology," and "antimicrobial resistance" and search for additional articles from the reference lists of retrieved articles. Papers referring to chronic sinusitis, sinusitis in compromised patients and documented nonbacterial sinusitis were excluded. The evidence was evaluated by participants at the Canadian Sinusitis Symposium, field in Toronto on April 26-27, 1996. VALUES: A hierarchical evaluation of the strength of evidence modified from the methods of the Canadian Task Force on the Periodic Health Examination was used. Strategies were identified to deal with problems for which no adequate clinical data were available. Recommendations arrived at by consensus of the symposium participants were included. BENEFITS, HARMS AND COSTS: Increased awareness of acute sinusitis, accurate diagnosis and prompt treatment should reduce costs related to unnecessary investigations, time lost from work and complications due to inappropriate treatment. As well, physicians will be better able to decide which patients will not require antimicrobial therapy, thus saving the patient the cost and potential side effects of treatment. RECOMMENDATIONS: Clinical diagnosis can usually be made from the patient's history and findings on physical examination only. Five clinical findings comprising 3 symptoms (maxillary toothache, poor response to decongestants and a history of coloured nasal discharge) and 2 signs (purulent nasal secretion and abnormal transillumination result) are the best predictors of acute bacterial sinusitis (level I evidence). Transillumination is a useful technique in the hands of experienced personnel, but only negative findings are useful (level III evidence). Radiography is not warranted when the likelihood of acute sinusitis is high or low but is useful when the diagnosis is in doubt (level III evidence). First-line therapy should be a 10-day course of amoxicillin (trimethoprim-sulfamethoxazole should be given to patients allergic to penicillin) (level I evidence) and a decongestant (level III evidence). Patients allergic to amoxicillin and those not responding to first-line therapy should be switched to a second-line agent. As well, patients with recurrent episodes of acute sinusitis who have been assessed and found not to have anatomic anomalies may also benefit from second-line therapy (level III evidence). VALIDATION: The recommendations are based on consensus of Canadian and American experts in infectious diseases, microbiology, otolaryngology and family medicine. The guidelines were reviewed independently for the advisory committee by 2 external experts. Previous guidelines did not exist in Canada.