A retrospective comparison between non-conveyed and conveyed patients in ambulance care.

BACKGROUND: Not all patients where an ambulance is dispatched are conveyed to an emergency department. Although non-conveyance is a substantial part of ambulance care, there is limited insight in the non-conveyance patient population. Therefore, the study aim was to compare demographics, initial on-scene reasons for care, and vital signs between conveyed and non-conveyed patients attended by an ambulance. METHODS: A retrospective study of ambulance runs from 2 EMS regions in the Netherlands in 2016 was performed. For each ambulance run demographics (age, gender and geographical location), initial reasons for care categorised into the ICD-10 classification system, and vital functions or observational scales (according to the national ambulance care protocol) were collected and analyzed. RESULTS: 54.797 ambulance runs met the inclusion criteria, of which 14.383/54.797 (26.2%) resulted in non-conveyance. There was no significant difference in gender, but the non-conveyance group was significantly younger (48.5 (±26.4) years) compared to the conveyance group (60.7 (±22.2) years) (p = .000). The most common initial reasons for care for the conveyance group could be classified into chapter-9 diseases of the circulatory system, chapter-19 injury, poisoning and certain other consequences of external causes, and chapter-10 diseases of the respiratory system. The most common reasons for care in the non-conveyance group could be classified into the chapter-9 diseases of the circulatory system, chapter-19 injury, poisoning and certain other consequences of external causes, and -chapter-5 mental, behavioral and neurodevelopmental disorders. The total percentage abnormal vital functions/observation scales between the conveyance (69.5%) and non-conveyance group (58.6%) was significantly different (p = .000). 15 out of 17 vital functions/observation scales are significantly different between the conveyance and non-conveyance group. CONCLUSIONS: This study shows that non-conveyed patients are younger, are more likely to be in (highly) rural areas, and more often have initial reasons for care related to mental, behavioral and neurodevelopmental disorders (ICD-10 chapter 5). Although abnormal vital functions/observation scale were more prevalent in the conveyance group, 58.6% of the non-conveyed patients had at least one abnormal vital function/observation scale.

Early experience on a modern, thin cochlear implant family. A retrospective, international multicenter study.

RATIONALE: Cochlear implantation is the most effective method of rehabilitation for patients with severe to profound sensorineural hearing loss. Binaural hearing forms the basis of the development of hearing-associated cortical networks in infants and toddlers, but simultaneous bilateral implantation is often postponed due to the demands of classical surgical methods, which are associated with large incisions and a deep bony well. OBJECTIVE: The authors report on the use of a modern, thin implant type and the possibilities it provided to simplify the surgical technique. METHODS AND RESULTS: Recent models of the Cochlear™ Nucleus® implant family were studied in an international retrospective multi-center study: 6 otolaryngologists in 5 centers shared their experiences on 73 consecutively implanted, thin implants. The surgical incision could be made shorter than before and only shallow bony wells or none at all were created in 4 out of 5 centers. No complications occurred. DISCUSSION: This study underlines that implants with thin electronics capsules enable a simplified, fast and safe implantation procedure that allows simultaneous bilateral cochlear implantation.

Clinical assessment of a new computerised objective method of measuring facial palsy.

OBJECTIVE: To compare the results using a new computerised objective method of assessing the degree of facial palsy with the results obtained using traditional clinical methods. DESIGN: Prospective computerised pixel change analysis and clinical evaluation of videos. SETTING: Tertiary referral centre. PARTICIPANTS: Subjects with varying degrees of unilateral facial palsy. METHODS: Comparison of the results obtained from an objective computerised method, the Glasgow Facial Palsy Scale, with the standard subjective clinical methods of the House-Brackmann Scale, Yanagihara, Sunnybrook Grading Scales and the objective clinical Stennert-Limberg-Frentrup Scale. RESULTS: Statistical analysis of the results from the objective computerised system indicated that there is an averagely strong correlation with the results from the House-Brackmann (Spearman's coefficient of 0.64), Sunnybrook (Pearson coefficient of 0.7) and Stennert-Limberg-Frentrup Scale (Pearson coefficient of 0.65), and it therefore has the ability to produce consistent results that agree with traditional clinical methods. It has a strong correlation with the Yanagihara Grading Scale (Pearson coefficient of 0.72) indicating that it may also have the ability to detect and record variations in the different regions of the face. CONCLUSION: This new computerised objective method of assessing the degree of facial palsy shows promise as a standardised objective method of assessing the degree of facial palsy.

Pharyngeal and hypopharyngeal reconstruction after multilating surgery for malignant hypopharyngeal cancers.

The authors summarise their reconstructive surgical experience after the radical excision of hypopharyngeal tumours. In selective cases the preservation of the larynx is a reliable surgical option and supraglottic surgery is sufficient to remove the tumour. Myocutaneous paddle flaps were used in every case after the surgical resection for the reconstruction of the pharyngo-oesophageal entrance. After total circular pharyngo-laryngectomy, the continuity of the upper digestive tract was reconstructed by tubed myocutanous flaps.

Distortion-product otoacoustic emission (DPOAE) following pure tone and wide-band noise exposures.

The aim of our investigations was to determine how the intensity of distortion-product otoacoustic emission (DPOAE) changes following different sound and noise exposures. We performed examinations on 20 healthy people with normal hearing. DPOAEs were recorded scanning the 0.5-6 kHz frequency interval before and after the exposures. We exposed the subjects to 0.5, 1, 2, 4 and 6 kHz pure tones and wide-band noise (intensity: 80 dB HL, duration: 3 minutes). We conclude that the amplitudes of DPOAEs changed immediately after exposures at most frequencies. DPOAE intensities decreased at some frequencies in the middle frequency range (1-2 kHz), and increased at low and particularly at high frequencies.

Brainstem auditory-evoked potential examinations in diabetic patients.

Brainstem auditory-evoked potential (BAEP) examinations were performed in 15 patients with long-standing type-1 diabetes mellitus (DM). Cardiovascular reflex tests were applied for assessment of autonomic neuropathy. The aim of our investigation was to compare the BAEP results of this patient group with controls and to look for a possible correlation between the alteration of the auditory brainstem function and the cardiovascular autonomic neuropathy. Analysis of the latencies (waves I, II, III and V) and the inter-peak latencies (waves I-III and I-V) of BAEPs revealed a significant difference between diabetics and healthy controls. The amplitudes of waves I, III and V were definitely lower in comparison with those of healthy controls. A positive correlation was observed between the overall autonomic score and the latencies (waves III and V) and inter-peak latencies (waves I-III and I-V). These data support the hypothesis that long-standing DM and diabetic neuropathy might be related as a cause of certain dysfunctions of the central auditory pathways.

Peroral endoscopic removal of a regurgitated giant polisegmented fibrovascular polyp of the esophagus.

BACKGROUND: Giant fibrovascular polyps (FVP) are relatively rare benign neoplasm of the upper esophagus and hypopharynx. Without previous history, their diagnosis might be difficult as the endoscopic findings are sometimes misinterpretedMaterials and methods: The present report describes a case, in which the patient regurgitated his giant polypoid mass into his mouth and captured it between his teeth and buccal surface until the emergency endoscopic removalResults: After one-year of follow-up, the patient is going well, without recurrence of his polypConclusion: Although the adequate therapy for these lesions is mainly the open surgical resection, most often via cervical esophagotomy, in our case the polyp was removed successfully by peroral endoscopic operation.

"Early" vocal cord laterofixation for the treatment of bilateral vocal cord immobility.

OBJECTIVES: Vocal cord immobility (VCI) is commonly caused by a nonlaryngeal malignancy, thyroid surgery, or a presumed viral insult etc. The paralysis is often transient or temporary, thus the care of the patient should be optimized to avoid unnecessary diagnostic and therapeutic endeavours. This article reports on the result of the concept of early vocal cord laterofixation, which provides a minimally invasive solution to dyspnea in the critical early, potentially reversible, period of bilateral VCI. STUDY DESIGN: A prospective study of 25 consecutive patients (ages 33 to 81 years) who were diagnosed with a bilateral VCI. This condition had developed after thyroid surgery in 22 of the patients and after a blunt trauma of the neck in one case. In another case, a cricoarytenoid joint fixation was revealed, and aetiology remained unknown in one further patient. METHODS: The surgical procedure was performed endoscopically with a modification of Lichtenberger's endo-extralaryngeal suture lateralization technique. The abducted vocal cord position was achieved by inserting a non-resorbable thread around the vocal process and tying on to the prelaryngeal muscles. Regular spirometric measurements and radiological aspiration tests were conducted on the patients. RESULTS: Adequate postoperative airway was achieved in all patients except one. Significant spontaneous vocal cord medialization was observed in two cases within a year and in three patients in the second and the third year. Partial or complete vocal cord recovery was observed in 17 cases. Further voice improvement followed in 9 patients when the threads were removed, due to vocal cord medialization or recovery. The mild postoperative aspirations ceased in the first postoperative days in all cases except one. CONCLUSIONS: The concept of "early" laterofixation satisfies the important criteria: it can provide an immediate and long-lasting adequate airway, and it can be considered potentially reversible from the point of view of laryngeal functions. Thus the procedure is a reliable primary treatment for bilateral VCI.

Combined use of endoscopic CO2 laser excision of a marginal laryngeal tumor, radical neck dissection, and perioperative laterofixation of the opposite vocal cord.

We report the use of endoscopic laser excision of a marginal laryngeal tumor, radical neck dissection, and laterofixation of a paralyzed vocal cord in a 66-year-old man who had an early-stage right supraglottic endolaryngeal tumor and ipsilateral neck metastasis. He had a left vocal cord paralysis after a left pneumonectomy that was performed 5 years previously. The primary laryngeal tumor was excised by endoscopic CO2 laser resection, and a simultaneous radical neck dissection was carried out. Postoperatively, severe inspiratory dyspnea developed because of the surgical intervention on the right side causing moderate laryngeal edema and limited movement of the right vocal cord in addition to the paralyzed left side. An endolaryngeal laterofixation of the paralyzed left vocal cord was performed to provide the patient with an adequate airway instead of tracheostomy. This patient had a 2 years' follow-up without recurrence of tumor. In the meantime movement of the right vocal cord has returned, so that the patient's voice was socially acceptable and he has a functioning larynx.

Airway complication after thyroid surgery: minimally invasive management of bilateral recurrent nerve injury.

OBJECTIVES: After bilateral vocal cord paralysis, the consequent paramedian position usually necessitates tracheostomy for at least 6 months, when the paralysis is potentially reversible. In the present study a reversible endoscopic vocal cord laterofixation procedure was used instead of tracheotomy. STUDY DESIGN: Prospective study of 15 consecutive patients aged 33 to 73 years who suffered bilateral recurrent laryngeal nerve paralysis after thyroid surgery. METHODS: The operation was performed endoscopically with a special endo-extralaryngeal needle carrier instrument. Two ends of a monofilament nonresorbable thread were passed above and under the posterior third of the vocal cord and knotted on the prelaryngeal muscles, permitting the creation of an abducted vocal cord position. If movement of one or both vocal cords recovered, the suture was removed. Regular spirometric measurements and radiological aspiration tests were conducted on the patients. RESULTS: During the follow-up period of 3 to 40 months, airway stability was demonstrated in all but one patient. After the repeated lateralization procedure, this patient's breathing improved. Partial or complete vocal cord recovery was observed in eight patients. In six patients further voice improvement was achieved when the threads were removed after vocal cord medialization or recovery. Mild postoperative aspirations ceased in the first postoperative days. CONCLUSIONS: This management approach offers an alternative to tracheostomy in the early period of paralysis, avoids terminal loss of voice quality, and provides a "one-stage" solution for permanent bilateral recurrent nerve injuries.

Leiomyosarcoma of the larynx. Review of the literature and report of two cases.

Leiomyosarcoma of the larynx is an extremely rare malignancy. Until now, only 35 cases have been reported, and only 19 were reported in English. We present 2 new cases observed in the last 3 years at our department. Correct histologic diagnosis can only be made on immunohistochemical and electron microscopic grounds. A 65-year-old man previously treated for a premalignant vocal cord lesion and a 31-year-old woman who previously underwent operation on a benign vocal cord lesion are presented. Only surgical treatment (total laryngectomy and endolaryngeal laser resection) was performed. Thirty-six and 22 months after the initial surgical intervention, both patients are alive and well, with no evidence of local recurrence or distant metastasis.

Minimally invasive surgery for posterior glottic stenosis.

Posterior glottic stenosis most commonly results from prolonged endotracheal intubation. The tube causes decubitus and perichondritis with a consequent scar tissue formation in the posterior commissure that often limits the abduction of the vocal cords. Many different surgical methods are known for the treatment, but in most cases temporary tracheostomy is required. We recommend a minimally invasive method to avoid tracheostomy, which is a very inconvenient state for the patient. The scar of the posterior commissure is excised endoscopically with the CO2 laser, and a modification of the endoextralaryngeal vocal cord laterofixation described by Lichtenberger is used to lateralize 1 or both vocal cords until the posterior commissure is completely reepithelialized. In this article we report on the first 5 cases. All patients had satisfactory airways immediately after the laterofixation procedure, which proved to be stable later on as well. In the cases of moderate stenosis, further scarring was prevented, and after the healing of the mucosa in the posterior glottic area, the laterofixation sutures were removed. The vocal cord mobility was recovered in the cases in which the cricoarytenoid joint was not fixed. In 1 case of severe stenosis (bilateral cricoarytenoid joint fixation), the procedure yielded only partial improvement.

Cochlear implantation in osteogenesis imperfecta.

A case is reported in which a Nucleus 22 channel intracochlear implant was applied to a Hungarian woman (age 50 yr) with profound deafness associated with osteogenesis imperfecta. Successful intracochlear insertion of the 22 electrodes resulted in a 70 dB hearing improvement at frequencies 250-2000 HZ. Nevertheless, a characteristic facial twitching appeared upon activation of electrodes 9-13. Inactivation of these electrodes abolished the non-acoustic nerve excitation with preservation of acoustic performance. Osteogenesis imperfecta may involve a state of risk for non-acoustic nerve activation in cochlear implant patients possibly resulting from a reduced impedance to current spread by abnormal bone tissue. This, however can be overcome by simple programming manoeuvres.

Pharyngeal localizations of branchial cysts.

Two cases with unusual pharyngeal localizations of branchial cysts medial to the great neck vessels and pharyngeal constrictor muscle are presented. The authors reviewed the theories of origin of the branchial cysts and the surgical treatment options. In their first case the transoral approach was chosen. Because of previous unsuccessful attempts at surgical treatment, the pharyngeal cyst was extremely adherent to adjacent tissue with much scar tissue, and it was very difficult to remove. As a result of this disappointing operation, an external neck exploration was indicated in the second patient. Histological examinations confirmed that the excised cysts were branchial in both cases.

Vocal cord laterofixation as early treatment for acute bilateral abductor paralysis after thyroid surgery.

Bilateral vocal cord palsy due to a lesion of the recurrent laryngeal nerves is a serious complication of thyroid operations, with the airway obstruction usually necessitating tracheostomy. In the cases presented, a stable airway was ensured with endolaryngeal cord laterofixation instead of tracheostomy. The operation was performed with the endo-extralaryngeal needle carrier instrument devised by Lichtenberger. During the operation, only minor surgical trauma occurred in the larynx. The fixing thread was then removed following recovery of contralateral vocal cord function, resulting in an improvement in the voice. Four patients are described who suffered bilateral recurrent laryngeal nerve palsy after thyroid gland operations. During the follow-up period of 3-12 months, airway stability was demonstrated by regular spirometric measurements. The simple method recommended spares patients the possible complications of tracheostomy.

Cochlear implantation in a patient with grand mal epilepsy.

A case is reported in which a Nucleus 22 channel intracochlear implant was used to treat a deaf Hungarian woman (aged 37 years) with a 34-year history of grand mal (GM) epilepsy maintained on carbamazepine-diazepam combination therapy who had not benefited from conventional hearing aids. Pre-operative electrical stimulation of the acoustic nerve, however, exhibited a good nerve function with no evidence of abnormal waveforms in the electroencephalogram (EEG). Successful intracochlear insertion of the 22 electrode resulted in a 40 dB hearing improvement at frequencies 250-2000 Hz in the implanted ear with no signs of pathologic wave activity at either the previously recognized epileptic focus (fronto-precentral region) or indeed, in other regions of the brain at use of the implant. We conclude that intracochlear implantation per se is not a hazardous intervention in patients with fronto-precentral epileptic foci.

Cochlear implantation of a Hungarian deaf and blind patient with discharging ears suffering from Behçet's disease.

A case is reported in which a Nucleus 22 channel intracochlear device was implanted a deaf/blind Hungarian adult with discharging ears suffering from Behçet's disease. Preconditioning surgery was employed three months prior to the implantation procedure to ensure a sterile, dry protected environment for the electrodes. One month after implantation, the patient exhibited excellent auditory discrimination capability at the time of the first switch on. We suggest that some deaf/blind individuals may serve as very good candidates for intracochlear implantation.

The prognostic value of facial nerve conduction velocity in patients with Bell's palsy.

The facial nerve conduction velocity was measured in 30 healthy subjects (60 sides) and in 51 patients with a unilateral Bell's palsy. The normal value was 47.8 +/- 5.1 m/s. Incomplete recovery was common in Bell's palsy when the velocity was below 30 m/s. Mild synkinesis was observed in only one patient when the nerve conduction velocity was above 30 m/s. When the degree of degeneration revealed by electroneuroneography did not exceed 60%, the conduction velocity was in the normal range. For degrees of degeneration in excess of this, the conduction velocity decreased in parallel with the increase in the degree of degeneration.

Involvement of glibenclamide-sensitive potassium channels in vasorelaxation by cochlear nerve stimulation.

Rabbit aortic rings relaxed with an increase in cyclic guanosine monophosphate and cyclic adenosine monophosphate content in response to exposure to organ fluid of isolated cochleas of the guinea pig following field stimulation (50 Hz, 80 V, 0.2 ms). Relaxations were blocked by 30 microM N(G)-nitro-L-arginine methyl ester added to the vessel rings. This inhibitory effect was reversed by 3 mM L-arginine. Removal of the vascular endothelium also blocked the relaxation response. Glibenclamide attenuated vasorelaxation in a concentration-dependent manner. We conclude that cochlear nerve stimulation induces an endothelium-dependent vasorelaxation involving activation of adenosine triphosphate-sensitive potassium channels.