High resolution gamma ray tomography scanner for flow measurement and non-destructive testing applications.

We report on the development of a high resolution gamma ray tomography scanner that is operated with a Cs-137 isotopic source at 662 keV gamma photon energy and achieves a spatial image resolution of 0.2 line pairs/ mm at 10% modulation transfer function for noncollimated detectors. It is primarily intended for the scientific study of flow regimes and phase fraction distributions in fuel element assemblies, chemical reactors, pipelines, and hydrodynamic machines. Furthermore, it is applicable to nondestructive testing of larger radiologically dense objects. The radiation detector is based on advanced avalanche photodiode technology in conjunction with lutetium yttrium orthosilicate scintillation crystals. The detector arc comprises 320 single detector elements which are operated in pulse counting mode. For measurements at fixed vessels or plant components, we built a computed tomography scanner gantry that comprises rotational and translational stages, power supply via slip rings, and data communication to the measurement personal computer via wireless local area network.

Diagnosis of jugular paraganglioma by radionuclide angiography: concise communication.

Jugular paraganglioma is a highly vascular tumor, slowly growing, extending into the surrounding structures and causing otologic and/or neurologic symptoms according to its location in the jugular bulb region or the middle-ear. In our study, modified vertex and posterior head scintiangiography was used in seven cases. Scintiangiography was positive in all seven, whereas concomitant radiographic studies were limited: four of the seven gave positive findings by transmission computerized tomography (TCT). Only four patients underwent angiography, with positive results in two. Hypocycloidal tomography was positive in three cases. However, some radiographic studies, particularly TCT, may be useful in detecting local extension, bone destruction, and soft-tissue infiltration. Radionuclide angiography proved highly reliable and should be used initially whenever a jugular paraganglioma is suspected.

The effect of prostaglandins E2 and F2a on brain and tracheal ciliary activity.

Prostaglandins E2 and F2a have a mild stimulatory effect (+11% to 18% from baseline) on the in vitro ciliary beat frequency in tracheal rings, which contain mucus-producing cells, and in brain slices, which are devoid of mucus. Results are compared with previous studies and the merits of the used experimental models are discussed.

Structural changes and protein expression in the mastoid bone adjacent to cholesteatoma.

OBJECTIVE: Cholesteatoma of the mastoid and middle ear causes erosion of nearby bone. In this study we examined the mastoid bone adjacent to cholesteatoma and compared it with normal mastoid bone. In particular, noncollagenous proteins, which have a special structural and functional role in bone, were addressed. STUDY DESIGN: Nine mastoid specimens with cholesteatoma and four normal specimens obtained at surgery were examined. METHODS: Histological and immunohistochemical methods were employed to evaluate the nature of structure and noncollagenous protein content changes in the mastoid bone affected by cholesteatoma. RESULTS: The bone associated with cholesteatoma had structural changes as a noncontinuous periosteum, empty lacunae, irregular cement lines, and, specifically, the appearance of eosinophilic vesicles at the interface between the bone and cholesteatoma Immunohistochemistry demonstrated that noncollagenous proteins were apparently absent in the affected mastoid bone. Bone remote from the cholesteatoma seemed normal. CONCLUSIONS: These findings demonstrate for the first time the changes in the noncollagenous protein content in the mastoid bone affected directly by cholesteatoma These changes could be a result of a direct influence of cholesteatoma-derived products on the osteoblast.

Vasoactive therapy versus placebo in the treatment of sudden hearing loss: a double-blind clinical study.

Twenty-seven patients suffering from sudden sensorineural hearing loss (SHL) were randomly assigned to one of two groups: a treatment group (n = 13) receiving intravenous procaine and low-molecular-weight dextran, and a placebo control group (n = 14). The effect of treatment was analyzed by means of an analysis of variance and covariance procedures. Results indicated nonsignificant differences between the groups on all outcome indices measured. Sex, age, time since the onset of symptoms to the initiation of therapy, audiogram configuration, and initial severity of hearing loss did not significantly affect the results. These findings suggest that the therapeutic effects of this vasodilator are not superior to a placebo.

Conservative management of adult epiglottitis.

A 10-year retrospective study of 30 adults suffering from acute epiglottitis is reported. Two clinical forms of onset were noted: gradual and accelerated. Abscess formation was present in 27% of cases. None of the patients required intubation or tracheotomy. In contrast to the accepted interventionist approach in children, conservative management in adults is recommended.

Care of the terminal head and neck cancer patient in the hospice setting.

The ratio of incidence to mortality is somewhat less than 3:1 for head and neck cancer, and the 5-year relative survival rate is 50%. Despite the high mortality rate, few reports have focused on patients with terminal head and neck cancer. A growing number of these patients end their lives in a hospice facility. A retrospective analysis was undertaken of 67 patients with terminal head and neck cancer who were admitted to the Tel Hashomer Hospice between 1988 and 1992. Patient data were reviewed and analyzed, and the particular characteristics of this population were defined. This study found that terminal head and neck cancer patients seem to receive better support in a hospice than in a general hospital or some family settings.

Benign osteonecrosis of the external ear canal.

Benign osteonecrosis (BON) of the external ear canal (EEC), also termed as focal or circumscribed necrotizing lesion, is an infrequent phenomenon with distinctive features and of an obscure origin. Five patients with BON of the EEC presented with aggressiveness and extension of varying degree including involvement of the middle ear. It seems that the disease might have a self limited course (two patients) though, at times, extensive measures including hyperbarric oxygen therapy (one patient) should be applied.

Laryngotracheal anastomosis: primary and revised procedures.

OBJECTIVES: Acquired upper airway stenosis is usually associated with a complex of pathological conditions at the high tracheal and the subglottic levels. Reported reconstructive techniques include widening by incorporation of grafts, segmental resection, and anastomosis or combined procedures. The management of recurrent stenosis after reconstructive surgery is a major challenge and has rarely been discussed in the literature. The purposes of the present study are to compare the clinical course of primary versus revised reconstructive procedures and to analyze the effect of age, diabetes, chronic lung disease, grading of stenosis, extent of resection, and revised procedures on the operative rate of success. STUDY DESIGN: A cohort study in a tertiary referral medical center. METHODS: The clinical course of 23 consecutive patients undergoing laryngotracheal anastomosis was studied comparing a group of 13 primary with 10 revision procedures. Seventeen patients underwent cricotracheal and six patients thyrotracheal anastomoses. All patients but one were tracheotomized before the definitive reconstructive procedure. Suprahyoid release was routinely performed except for two cases, and only one patient required sternotomy. The Wilcoxon test was used to examine the relationship between preoperative clinical parameters and the postoperative success (i.e., airway patency). RESULTS: Twenty-two of 23 patients (95.6%) had successful decannulation. Four patients required a revision procedure because of repeat stenosis at the site of the anastomosis (2) or distal tracheal malacia (2). Residual airway stenosis of less than 50% was noted in six patients, although only three complained of dyspnea during daily-activity exertion. There was no associated mortality. Complications included subcutaneous emphysema (4), granulation tissue formation (3), pneumonia (2), cardiac arrhythmia (2), and one each of pneumomediastinum, neck hematoma, and urosepsis. Protracted aspirations were noted in one patient who had revision surgery. Age was the only parameter that correlated with postoperative airway patency (P <.07), whereas the presence of chronic obstructive lung disease and diabetes, grade of stenosis, type of surgery, and revision surgery were found to be insignificant. CONCLUSIONS: The clinical course of laryngotracheal anastomosis in primary and revised procedures was similar in our group of patients. The operation can be performed safely, with an expected high rate of success and acceptable morbidity.

Postsurgical prevertebral abscess of the cervical spine.

OBJECTIVES: Prevertebral abscess formation is an uncommon occurrence following cervical spine fusion surgery. Abscesses may present early or in a delayed fashion and require surgical drainage and long-term antibiotic treatment. The issues of osteomyelitis and the need for plate removal remain unresolved. STUDY DESIGN: A case series of six tetraplegic patients admitted for rehabilitation to the Chaim Sheba Medical Center (Tel Hashomer, Israel) is presented. METHODS: Five patients were trauma patients; one patient underwent repeated procedures and irradiation for tumor of the cervical spine. All patients developed prevertebral abscesses after a mean period of 30 days from their fusion surgery. Computed tomography scan was used in all patients to establish the diagnosis and define the extent of the infective process. All patients underwent one or more drainage procedures. The plate was removed in two patients at 1 and 4 months. RESULTS: Infection completely resolved in four patient and was refractory in one patient with malignant tumor, and a chronic small fistula remained in one case. Staphylococcus aureus was the main infective organism, but mixed infections were the rule. Even for a protracted course of infection, no significant osteomyelitis was encountered. CONCLUSIONS: Abscess formation after instrumentation of the neck may be more common than formerly recognized. Despite the prolonged course of disease and treatment, osteomyelitis is not a major concern. There is no automatic indication for plate removal to control infection, although plating may be safely removed after 10 to 12 weeks if the neck is explored and the cervical spine is stable. A high index of suspicion is warranted, and early recognition and diagnosis, prompt surgical drainage under general anesthesia, and long-term antibiotic treatment are key for eradication of the infective process. Prophylactic antibiotics may be of value. Meticulous antisepsis and surgical technique should be maintained to reduce the incidence of these severe complications.

Clozapine for tardive dyskinesia in adolescents.

Thousands of adolescents use neuroleptic drugs over extended periods of time for a wide range of mental disorders. One of the most severe adverse effects of neuroleptic drugs is tardive dyskinesia (TD), for which no successful treatment is currently available. Clozapine is a known atypical neuroleptic drug with few extrapyramidal side effects. It has been suggested that clozapine may be beneficial for the treatment of tardive dyskinesia in adolescents. However, the efficacy of the drug in adolescents is unknown. This report describes the beneficial effect of clozapine on tardive dyskinesia in two adolescents with schizophrenia.

The combined use of classified bone and gallium scans in the management of frontal sinusitis.

Bone and gallium scans of the sinus regions were performed in 32 patients presenting with frontal sinusitis. Bone scans, classified according to 99Tcm-methylenediphosphonate (MDP) distribution patterns indicated both active and resolving sinusitis as well as surgically related bone trauma. Gallium scan uptake intensity correlated well, however, with final outcome and differentiated between active and resolving sinusitis, more specifically than corresponding bone scans. Thus combined studies appear to have a significant role in the diagnosis and management of patients suspected for frontal sinusitis.

Salivary flow dynamics after parotid surgery: a preliminary report.

BACKGROUND: Tumors in the parotid gland may affect salivary flow. The effects of tumor on glandular function and postoperative changes in both resected gland and contralateral gland were not formerly reported. We prospectively evaluated salivary flow rates and composition in patients undergoing parotidectomy preoperatively and postoperatively. METHOD: Stimulated parotid saliva from 17 patients undergoing parotidectomy was collected bilaterally preoperatively and postoperatively by using a parotid cup. Subjective complaints were recorded. Salivary flow rates, sodium, potassium, and amylase levels were evaluated. RESULTS: None of the patients complained of "dry mouth" before or after surgery. Analysis of the individual results revealed 3 patterns of preoperative and postoperative response, compatible with either a preoperative or postoperative compensatory mechanism in the contralateral gland. The postoperative decrease in flow rate corresponds with the amount of gland removed. Salivary electrolyte composition was unchanged. CONCLUSION: This study is the first to demonstrate the effects of parotid tumors and their surgery on salivary flow and a compensatory response and its different patterns in human parotid glands after their excision.

Pain in the neck after neck dissection.

BACKGROUND: Reports of disability after neck dissection have been directed toward shoulder dysfunction and pain. We could find no report addressing the issue of pain localized to the actual operative site. We have conducted a combined prospective and retrospective study of pain in patients undergoing neck dissection. METHODS: Eighty-eight disease-free patients were evaluated in 3 groups for neck pain. One group was followed up prospectively for 1 to 8 months after surgery, and 2 retrospective groups were followed up for more than 2 years or for 6 months to 2 years. Pain was assessed by a body map and visual analog scale. RESULTS: None of 31 patients followed up for more than 2 years reported neck pain. Four of 27 patients followed up for 6 to 24 months had pain, with a mean visual analog scale score of 3.7. Seventy percent of the prospective group of 30 patients had pain during the first postoperative week, and only 1 patient had pain persisting for more than 2 months. Shoulder pain and disability after radical neck dissection were encountered in all groups, comparable with the incidence reported in the literature. No postoperative neuromas were found. CONCLUSIONS: Chronic pain localized to the operative site is an uncommon occurrence even after radical neck dissection. Chronic pain in the shoulder region may follow radical neck dissection, whereas modified neck dissection is usually a painless procedure.

Auricular reconstruction with a postauricular myocutaneous island flap: flip-flop flap.

Surgical defects of the concha-helix part of the ear larger than 2 cm may pose a reconstructive challenge. Split- or full-thickness skin grafts or local flaps may be used, and a number of these have been described. Yet cosmetic results are often unsatisfactory. Our experience with a postauricular myocutaneous island flap is described. Eleven patients (12 ears), aged 48 to 89 years, underwent the procedure under local anesthesia following excision of conchal bowl malignant tumors that included the cartilage underlying the skin. The surgical technique is described in detail. Few complications were encountered, and cosmetic results were excellent. In four ears, resection margins extended into the ear canal, and that portion was allowed to heal satisfactorily by secondary intention. We recommend the use of this flap for practical, safe, and early good cosmetic results.

Intracochlear schwannoma and cochlear implantation.

A case of intracochlear schwannoma in a 58-year-old candidate for cochlear implantation is described. The tumor was located in the basal turn of the cochlea and was discovered only during surgery. Computed tomography and magnetic resonance imaging obtained prior to surgery failed to detect the tumor. Intralabyrinthine schwannomas are rare tumors that grow either in the vestibule, as intravestibular schwannomas, or in the cochlea, as intracochlear schwannomas. Complete removal of this tumor was achieved through a posterior tympanotomy approach. Cochlear implantation, which resulted in good hearing, was successfully performed 3 years later.

Multifocal cholesteatoma of the external auditory canal following blast injury.

Posttraumatic cholesteatoma of the external auditory canal is a rare condition that may present years after the original injury. A unique case of multifocal cholesteatoma of the external auditory canal following blast injury is presented and discussed.

Peritonsillar abscess: repeated needle aspiration versus incision and drainage.

The study evaluates the management of peritonsillar abscess (PTA) by comparing needle aspiration versus incision and drainage of the abscess. Twenty-four of 86 patients treated by needle aspiration underwent a single aspiration, and 38 had 2, 19 had 3, and 5 had 4 aspirations before the abscess resolved. A significant amount of pus, up to 8, 5, and 3 mL, respectively, was detected in the subsequent aspirations. Recurrent PTA was noted in 20 patients (23.26%). In 9 of these patients (10.47%) the recurrent episode occurred immediately (in less than 1 month) and was considered residual disease. Seventy-four patients were treated by incision and drainage, and none had an immediate recurrence. Only 3 (4.05%) patients developed a late recurrent episode. The difference in the recurrence rate between the two groups is statistically significant. A history of recurrent tonsillitis prior to abscess formation did not show a significant influence on the recurrence rate. A high incidence of streptococcal infections was noted in both groups, with anaerobes detected in only 15% of samples. There was a good response to penicillin-resistant organisms. Although needle aspiration is a tempting modality for treating PTA in community clinics, one should be aware of the risks of a higher incidence of residual and recurrent disease in comparison to incision and drainage, as well as the need for repeated aspirations.

Conversion deafness.

Conversion deafness is very rarely encountered among adults. This report will illustrate two cases of this somatoform disorder following different traumatic experiences. It emphasizes the difficulties in establishing the diagnosis and reviews various aspects of treatment.

Acquired tracheoesophageal fistula in critically ill patients.

Acquired benign tracheoesophageal fistula (TEF) is an infrequent complication of prolonged intubation and tracheostomy. Not infrequently, it is associated with severe circumferential malacia of the trachea and a need for concomitant correction of both. Controversy exists as to whether this should be performed in a single-stage or a 2-stage procedure. Four patients with acquired TEF underwent operation in a tertiary referral medical center between 1995 and 1997. The operations were performed through either an anterior (3) or a lateral (1) neck approach. Three patients underwent closure of the fistula with tracheal resection and anastomosis in a single stage and are doing well. One patient with complete subglottic stenosis underwent closure of the TEF and was planned for tracheal reconstruction in a second stage. This patient died in the early postoperative period. The complications included aspiration of blood leading to pneumonia (2), spontaneously resolving pneumomediastinum (1), subcutaneous emphysema (2), and cardiac arrhythmia ( 1). Residual fistula, noted in 1 patient, was treated conservatively and resolved spontaneously within several weeks. We conclude that acquired TEF is amenable to repair through a cervical approach. A single-stage correction of the TEF with reconstruction of the trachea is suitable and successful in most patients. Several stages seem justified when concurrent laryngotracheal reconstruction is needed.