A randomised controlled trial of sodium citrate spray for non-conductive olfactory disorders.

OBJECTIVES: Previous research has suggested that sodium citrate improves hyposmia by decreasing mucus calcium levels in the nose. This study aimed to confirm or refute this effect in a single application and assess potential side-effects. DESIGN: Study design was a randomised double-blind controlled trial of sodium citrate nasal spray (intervention) vs sterile water (control). Fifty-five patients with non-conductive olfactory loss were randomised to receive the intervention or placebo. SETTING: Tertiary care clinic. MAIN OUTCOME MEASURES: The primary outcome measure was improvement in measured olfactory thresholds for phenyl ethyl alcohol (PEA) over 2 hours. Other outcome measures assessed were improvement in olfactory thresholds in 1-butanol, eucalyptol and acetic acid; number of responders with a clinically relevant response in each arm; and adverse effects. RESULTS: A significant effect was seen in the intervention arm for PEA and for 1-butanol and eucalyptol when compared to the control arm (P<.05); 32% of the intervention arm responded in terms of improved sensitivity towards some of the odours. Minor adverse effects noted included sore throat, nasal paraesthesia, slight rhinorrhoea and itching. The duration of effect of the citrate is transient, peaking at 30-60 minutes after application. CONCLUSIONS: Sodium citrate yields some potential as a treatment for non-conductive olfactory loss; however, these findings require corroboration in further clinical trials looking at longer term regular use of the spray as a viable therapeutic option for patients where it would be applied at frequent intervals such as before mealtimes.

The Leicester semi-automated olfactory threshold test--a psychophysical olfactory test for the 21st century.

OBJECTIVE: Develop a useful and cost-effective olfactometer for routine clinical use by providing a standardised threshold test for patients with olfactory disorders presenting in the ENT clinic. METHOD OF STUDY: A prospective study of olfactory thresholds in 48 healthy volunteers on 2 consecutive occasions, undergoing quantitative testing with an olfactometer. Further studies of 10 subjects performing 20 tests and 100 subjects performing a single test were performed. An olfactometer was designed to deliver a semi-automated threshold test for an odour. It contains 8 logarithmic dilutions of an odour along with a control valve operated by software from a laptop computer. Common potential variables for olfactory threshold testing were considered including peak inspiratory flow rate. The odours used were phenethyl alcohol (PEA) and eucalyptol (EUC). Subjects were asked to perform 2 tests within 1 month of each other and the mean threshold score for each was calculated to derive a test-retest score. MAIN RESULTS: Consistent olfactory thresholds for PEA were achieved with a mean concentration of 10-4. Test-retest reliability score (r(x)) for the olfactometer was r(x) = 0.78 (95% CI 0.67 to 0.89). PRINCIPAL CONCLUSIONS: The Leicester Olfactometer provides a simple and cost-effective method of reliably assessing olfactory thresholds in the outpatient clinic.

The presence of ovarian hormone receptors in the nasal mucosa and their relationship to nasal symptoms.

BACKGROUND: There is evidence in the literature showing a link between ovarian hormones and changes to nasal physiology. OBJECTIVES: The aim of this pilot study was to identify and quantify female hormone receptor positive cells in the nasal mucosa and to establish if there is a correlation with rhinitic symptoms. METHODS: Twenty-five adult patients attending a university hospital for routine, elective nonrhinological ENT procedures under general anaesthetic (mainly tonsillectomy) were recruited pre-operatively. Background information about each participant was recorded. Biopsies were taken from the inferior turbinates. These were analysed using immunohistochemistry techniques to assess for the presence of Progesterone, Oestrogen-alpha (ERalpha) and Oestrogen-beta (ERbeta) receptors. The mean number of cells positive for the receptors in each biopsy was deduced using a stratified random sampling technique. RESULTS: All nasal biopsies were negative for progesterone and ERalpha receptors. ERbeta receptors were present in the mucosal glands in 24 out of the 25 biopsies. Using unpaired t-tests to compare the sexes, smoking status and atopic history no statistical difference was shown between any of these groups (p > 0.05). However, the rhinitis quality of life questionnaire score and the mean number of ERbeta receptor positive cells per biopsy showed a positive correlation (Pearson correlation of 0.4, p < 0.05). CONCLUSIONS: The number of oestrogen receptor positive cells appears unaffected by sex, smoking history, hormone status, age or atopy. However, there is a significant positive relationship between the mean number of ERbeta positive cells and nasal symptoms. Pharmacological downregulation of ERbeta positive cells may reduce rhinitic symptoms and is the subject of further research.

Does odour cross contamination alter olfactory thresholds in certain odours?

OBJECTIVES: To determine if 1) there is cross contamination between odours tested on thresholds achieved, 2) a delay period is necessary between testing different odours. METHODS: Thirty-five subjects underwent threshold testing with phenethyl alcohol (PEA), ethylmercaptan (MER), acetic acid (ACE), and eucalyptol (EUC) using serial logarithmic dilutions. On separate occasions subjects were exposed to high concentrations of PEA, ACE and EUC in random order for two minutes, and thresholds for all four odours re-tested. Pre- and post-high concentration odour thresholds were compared. RESULTS: Exposure to high concentrations of PEA, ACE and EUC does not alter olfactory thresholds by more than 10-2 for the other odours except in specific circumstances with ACE and EUV. CONCLUSIONS: There is limited cross contamination with ACE and EUC, which is avoided by specifying presentation order as: PEA, MER, ACE, EUC. Odours PEA, MER, ACE and EUC are recommended for olfactory testing.

Estimation of trace elements in some anti-diabetic medicinal plants using PIXE technique.

Trace elemental analysis was carried out in various parts of some anti-diabetic medicinal plants using PIXE technique. A 3MeV proton beam was used to excite the samples. The elements Cl, K, Ca, Ti, Cr, Mn, Fe, Ni, Cu, Zn, Br, Rb and Sr were identified and their concentrations were estimated. The results of the present study provide justification for the usage of these medicinal plants in the treatment of diabetes mellitus (DM) since they are found to contain appreciable amounts of the elements K, Ca, Cr, Mn, Cu, and Zn, which are responsible for potentiating insulin action. Our results show that the analyzed medicinal plants can be considered as potential sources for providing a reasonable amount of the required elements other than diet to the patients of DM. Moreover, these results can be used to set new standards for prescribing the dosage of the herbal drugs prepared from these plant materials.

Percutaneous transatrial mitral commissurotomy: immediate and intermediate results.

OBJECTIVES: The purpose of this study was to evaluate the immediate and follow-up results of percutaneous transatrial mitral commissurotomy in 600 patients with rheumatic mitral stenosis. BACKGROUND: Percutaneous transatrial mitral commissurotomy has emerged as an effective nonsurgical technique for patients with symptomatic mitral stenosis. Several studies have shown that the immediate results are comparable to closed and open mitral valvotomy. METHODS: Percutaneous transatrial mitral commissurotomy was performed in 600 patients with rheumatic mitral stenosis by the double-balloon (290 patients [48.3%]) and flow-guided Inoue balloon (310 patients [51.7%]) techniques. There were 154 male (25.6%) and 446 female (77.4%) patients with a mean [+/- SD] age of 27 +/- 8 years (range 8 to 60). Atrial fibrillation was present in 26 patients (4.3%), mitral regurgitation < or = grade 2 in 62 (10.3%) and densely calcific valve in 12 (2%). All patients had clinical and echocardiographic (two-dimensional, continuous wave Doppler, color flow imaging) follow-up at 3-month intervals. RESULTS: Percutaneous transatrial mitral commissurotomy was successful in 589 patients (98.1%), and optimal commissurotomy was achieved in 562 (93.6%), with an increase in mitral valve area from (mean +/- SD) 0.75 +/- 0.18 to 2.2 +/- 0.38 cm2 (p < 0.001) and a decrease in transmitral end-diastolic gradient from 27.3 +/- 6.1 to 3.8 +/- 4.2 mm Hg (p < 0.001). Mitral regurgitation developed or increased in 208 patients (34.6%). Six patients (1%) with mitral regurgitation required mitral valve replacement. Cardiac tamponade occurred in 8 patients (1.3%). Six patients (1%) died. Restenosis developed in 10 patients (1.7%) during a mean follow-up period of 37 +/- 8 months (range 6 to 66). CONCLUSIONS: Percutaneous transatrial mitral commissurotomy is an effective, safe procedure with gratifying intermediate results. It should be considered the treatment of choice for rheumatic mitral stenosis.

Passive immunization with an antibody to the beta-subunit of ovine luteinizing hormone as a method of early abortion--a feasibility study in monkeys (Macaca radiata).

Antiserum to the beta-subunit of ovine luteinizing hormone (oLH-beta) raised in monkeys (Macaca radiata) has been tested by a variety of criteria both in vivo and in vitro to establish its ability to neutralize oLH, hLH, and human chorionic gonadotropin (hCG). Passive administration of this antiserum caused inhibition of ovulation and termination of pregnancy in recipient monkeys as indicated by premature vaginal bleeding and a significant reduction in serum progesterone and estrogen levels. The results suggest that antiserum raised in monkeys against oLH-beta can neutralize monkey LH as well as monkey CG.

Preliminary characterization of mucin from effusions of cleft palate patients.

Middle ear effusions from children undergoing myringotomy were classified into three groups-cleft palate, thick (mucoid), and thin (serous). Mucin was purified from each of the three groups using CsCI equilibrium density gradient centrifugation. Analysis of the cleft palate mucin on Sepharose CL-2B showed it was excluded and therefore of large molecular weight. It could be broken down into smaller glycopeptide units by proteolysis and these glycopeptides had, based on elution position, a larger hydrodynamic size than those from the thick mucin. Intrinsic viscosity measurements demonstrated that the intact mucins could be ranked in order of molecular space occupancy; cleft palate > thick > thin. Amino acid analysis showed the cleft palate mucin to have an amino acid composition similar to other mucins, with serine, threonine, and proline constituting 41% by weight of the protein core. Thiol analysis gave evidence of a possible difference in polymerization between the three mucins, in that thin (the smallest mucin) contained the lowest number of thiols. This preliminary analysis of cleft palate mucin suggests a mucin with larger glycopeptide units forming an intact mucin of larger hydrodynamic size than either thick or thin middle ear mucins from anatomically normal children.

The Nottingham System: objective assessment of facial nerve function in the clinic.

The House-Brackmann is the most widely accepted system for the clinical assessment of facial nerve function. It is, however, being subjective and discontinuous, prone to interobserver variation. The need for an objective system persists. The Nottingham System is described and compared to the Burres-Fisch system in a study of 29 subjects with varying degrees of facial nerve function, ranging from normal to total paralysis. Within-group component of variance analysis was 7% for the Nottingham System compared to 26% for the Burres-Fisch system. Bland and Altmans' analysis showed the Burres-Fisch system to be biased, overestimating small percentage scores, and underestimating large ones. The Nottingham System proved unbiased. The Nottingham System is recommended as an accurate objective continuous grading system for the rapid assessment of facial nerve function in the clinic.

Carcinoma in situ of the glottis: radiotherapy or excision biopsy?

Excision biopsy, radiotherapy, and laryngofissure cordectomy have all been used, but the best treatment regimen for glottic carcinoma in situ remains controversial. A 20-year experience of 37 cases is reported. For the first 10 years biopsy with radiotherapy was the first-line treatment (n = 20), but for the last 10 years surgical or laser excision biopsy alone has been performed (n = 17). The T stage of the carcinoma in situ does not determine its premalignant potential. Malignancy appears to be a recurrence, rather than a new expression of carcinogenesis. Excision biopsy alone provides local control results (75%) comparable to those of primary radiotherapy (85%). Excision biopsy alone, however, retains the option of subsequent radiotherapy with preservation of laryngeal function, but very close follow-up, especially in the first year, is required.

Tussometry: an objective assessment of vocal cord function.

A number of techniques have recently been developed for altering laryngeal function, including structural framework surgery, reinnervation procedures, augmentation of the vocal cords, electrical stimulation, and pharmacologic intervention. The application of such procedures to appropriate disorders would be facilitated by better objective measures of the outcome. This study describes the new technique of tussometry, which investigates the airflow pattern produced during coughing. The value of 1 parameter, peak value time, is shown by a study of 35 vocal cord palsies versus a control, and of 17 vocal cord palsies before and after augmentation, to be an accurate assessment of vocal cord position. The technique is independent of lung function parameters and intraoral pressures. It is truly objective, having an interobserver variation of 0%, and is eminently reproducible, with an intrasubject coefficient of variation of 3.1% to 5.7%. Tussometry is a rapid, noninvasive technique providing inexpensive objective assessment of vocal cord function in the office setting.

Recurrent laryngeal nerve palsy following heart-lung transplantation: three cases of vocal cord augmentation in the acute phase.

Three cases of left recurrent laryngeal nerve palsy following heart-lung transplantation are described. In each case, within twelve hours of extubation, the left vocal cord was injected with Teflon, and the paralyzed vocal cord thus displaced to the midline. Effective closure of the glottis was then possible, permitting an adequate cough, adequate clearing of the bronchial tree and minimising the risk of aspiration. Augmentation under general anaesthesia as soon as possible after discovery of vocal cord dysfunction is advocated. Suitable materials for injection are discussed. To our knowledge, this is the first reported series of vocal cord augmentation in the acute phase following heart-lung transplantation.

Previously undiagnosed congenital vascular ring presenting as dysphagia in a six-week post-partum female.

We report the first case of dysphagia due to engorgement of a congenital vascular ring as a result of the haemodynamic changes of pregnancy. The clinician should be aware of this in the differential diagnosis. Spontaneous recovery may occur six months post partum as the haemodynamic changes resolve, but if further pregnancies are planned surgery is effective.

Diathermy haemostasis at tonsillectomy: current practice--a survey of U.K. otolaryngologists.

The use of diathermy in achieving haemostasis at tonsillectomy was assessed by means of a postal questionnaire sent to consultant otolaryngologists practising in the U.K. A response of 81 per cent was obtained. Forty-four per cent presently use diathermy. Few considered the age of the patient or a history of a quinsy a contraindication to its use. The diathermy experience of users and non-users with regard to speed, post-operative pain and haemorrhage differs markedly. This dichotomy of opinions is confirmed by a review of the literature. Clearly there is a need for further studies to clarify the role of diathermy in tonsillectomy.

First case of full-thickness palatal necrotizing sialometaplasia.

Necrotizing sialometaplasia is an uncommon, benign, self-limiting condition which can stimulate malignancy. The commonest site of occurrence is the hard palate. We report the first case with full thickness palatal involvement. The clino-pathological features of this condition are discussed.

First case of surgically corrected puberphonia.

Puberphonia is predominantly a male condition which, normally affecting teenagers, may present in later life. It is defined as the failure to change from the high-pitched voice of the pre-adolescence to the lower pitched voice of adulthood. Patient previously reported have responded to voice therapy alone. We report the first surgically corrected case.

Early inappropriate secretion of antidiuretic hormone after trans-sphenoidal pituitary adenomectomy.

The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a rare but life-threatening complication of trans-sphenoidal pituitary adenomectomy. It has previously only been described as a late phenomenon. We report an early presentation within the first week. The pathophysiology, clinical features and treatment are discussed.

Bilateral vocal fold paralysis in infants: tracheostomy or not?

Tracheostomy has, in the past, been performed in the majority of children under one year with bilateral vocal fold paralysis. We present our experience of 11 cases over a ten-year period during which tracheostomy was avoided whenever possible. Ten cases were managed conservatively but in the youngest a tracheostomy was required. Full bilateral vocal fold mobility developed in all cases at a mean age of 11.5 months (range 5-26 months). Our experience suggests that the airway can commonly be managed expectantly without a tracheostomy.

Traumatic myositis ossificans of the superior belly of the omohyoid.

The first case of traumatic myositis ossificans (TMO) involving a strap muscle of the neck is reported. TMO typically presents with an unresolved mass following trauma or surgery, requiring differentiation from other soft tissue and bone neoplasms. Opacification may be present on soft tissue X-rays. Computed tomography (CT) scan may demonstrate a characteristic zoning phenomenon to establish the diagnosis. The disorder is frequently self-limiting but surgery may be required for persistent symptoms.

Branchial cyst--to endoscope or not?

Cervical cystic metastases are uncommon, originating predominantly from an oropharyngeal primary. Pre-operative differentiation from a branchial cyst can prove difficult. Three cases which presented clinically as branchial cysts but were subsequently found to be cystic metastases are described, and the literature is reviewed. Endoscopy, ipsilateral tonsillectomy and blind biopsies of Waldeyer's ring, combined with excision of the cervical lesion are recommended in patients over 40 years old.