Pediatric Epistaxis-Effectiveness of Conservative Management.

OBJECTIVES: Epistaxis is an emergency medical condition that sometimes requires admission to the emergency department. Pediatric epistaxis differs from epistaxis in the older population in terms of etiology, severity, and management. Our objective was to identify the distinctive features of pediatric epistaxis and determine the appropriate management. METHODS: This was a retrospective study of 231 medical records of children (<18 years old) with epistaxis of a total of 1171 cases in the general population who presented to our medical center's emergency department between 2013 and 2018. RESULTS: Among 231 admissions, 10 children (4.3%) presented more than once. Male patients accounted for the majority of cases (64.5%), and the average age was 9.4 years. Two children were treated with aspirin because of cardiac valve disease. Anterior bleeding was detected in 101 cases (43.7%), whereas posterior origin was observed in 8 cases (3.5%). In 122 cases (52.8%), there was no active bleeding observed. Nose injury was the cause of epistaxis in 24 cases (10.4%), and 16 admissions (6.9%) followed nasal surgical interventions. Nineteen children (8%) had abnormal coagulation tests, and 7 patients (3%) received blood transfusions. Chemical cauterization was performed in 89 cases (39.3%), and anterior packing was needed in only 9 cases (3.9%). Nine children required hospitalization (3.9%), and 2 needed surgical intervention to control bleeding. Compared with the adult population, there were significantly fewer cases of active bleeding, recurrent epistaxis, anterior packing, or need for hospitalization in the pediatric population. CONCLUSIONS: Epistaxis is significantly less severe in the pediatric population, with only a few cases requiring major intervention. Endoscopic examination of the entire nasal cavity and routine coagulation tests are not mandatory unless there is a history of recurrent epistaxis, known coagulopathy, antiplatelet/anticoagulation therapy, or a suspicion of juvenile idiopathic angiofibroma. We suggest using absorbable packs, which offer advantages over cauterization or nonabsorbable packs.

[AUDITORY BRAINSTEM IMPLANTS (ABI) IN CHILDREN: CASE SERIES IN SHAARE ZEDEK MEDICAL CENTER].

BACKGROUND: Cochlear implants (CI) are the treatment of choice for individuals with severe to profound sensorineural hearing loss. A small group of patients, with pathology central to the cochlea, cannot benefit from CI. Examples in children include absence of the cochlear-nerve or cochlear aplasia. In these cases, implantation of an auditory brainstem implant (ABI), directly stimulating the cochlear nucleus, bypassing the inner-ear and auditory-nerve, may be beneficial. OBJECTIVES: Describe a series of children with ABI's treated in Shaare-Zedek, including the first ABI implantation in Israel (2017). METHODS: Of 9 patients with ABI's treated in Shaare Zedek Medical Center ,7 were children implanted between ages 2-8.6 years. Five boys and two girls. Surgeries were conducted in collaboration between neurosurgeons, neurotologists and audiologists (five implanted in Shaare-Zedek and two in New-York University). Follow-up was between 2-6 years. Hearing evaluation was conducted, mainly, with audiograms, categories of auditory performance (CAP), speech perception testing when possible and estimation of device use per day. RESULTS: Six of the seven children, who initially underwent unsuccessful CI, had deficient auditory-nerves. One child had cochlear-aplasia. In 3 children hearing loss was part of the CHARGE syndrome. CAP scores ranged from 0-7 (0,1,3,5,5,7). One child was able to achieve open-set speech perception. CONCLUSIONS: Although functional auditory outcomes for children with ABI are inferior to CI recipients and are highly variable, some children were able to obtain significant benefit. In these children, who are not candidates for CI, the ABI presents the only chance for auditory awareness and may be recommended. DISCUSSION: John Thomas Roland is a consultant and recipient of research support from Cochlear Americas.

Time from sudden sensory neural hearing loss to treatment as a prognostic factor.

Introduction: The widely accepted treatment for sudden sensorineural hearing loss (SSNHL) is corticosteroid treatment (oral or intratympanic). The main goal of this work is to define the significance of the time between symptom onset and treatment initiation, as well as other prognostic factors, for hearing improvement. Methods: This retrospective study included 666 patients treated for SSNHL. Demographic data, audiometry, treatment method, time since symptom onset, and associated symptoms were recorded for each patient. The patients were divided into five groups according to the treatment initiation time-half a week, one week, 2 weeks, 3 weeks, or 4 weeks and over-after symptom onset. The degree of improvement was assessed by comparing the audiometry at the beginning and the end of the treatment. Results: The average period of hearing loss from symptom onset to treatment initiation was 10.8 days. Significant differences were found between the groups of half a week, one week, and 2 weeks and the groups of 3 weeks and 4 weeks and over (each separately, p < 0.001). No difference was found between the half-week, one-week, and two-week groups, nor was there a difference between the three-week and four-week-and-over groups. A correlation was found between the treatment initiation time in days and the degree of improvement in hearing for both speech recognition threshold (SRT) and discrimination, R = 0.26 p < 0.001 and R = 0.17 p < 0.001, respectively. No correlation was found for gender, age of the patients, comorbidities, or associated symptoms. Conclusion: The threshold for treatment initiation time is up to 2 weeks, after which the amplitude of hearing improvement decreases significantly. The other prognostic factors measured were not found to be statistically significant predictors.

Posisep Versus PureRegen Gel for Post ESS Nasal Packing - A Randomized Blinded Prospective Study.

OBJECTIVE: Endoscopic sinus surgery (ESS) is the procedure of choice for chronic rhinosinusitis (CRS). Adhesions are the most common postoperative complications, causing recurrent disease and revision surgery. Postoperative care is thus essential for the healing of the operated cavity. A wide variety of packing materials are used to prevent bleeding and adhesions postoperatively. Two main absorbable packing materials are used: Foam-based packs (e.g., Posisep and Nasopore) and gel-based packs (PureRegen Gel - PRG). The current study is a randomized, blinded, prospective analysis of cavity healing using Posisep and PRG in ESS, aiming to compare the pros and cons of the two. METHODS: Patients with bilateral symmetric CRS were recruited for the study. At the end of surgery, one side was randomly packed with Posisep, whereas the other was packed with PRG. The postoperative cavity cleaning was video recorded and a blinded physician evaluated the mucosal healing. RESULTS: The side packed with Posisep had significantly less middle turbinate (MT) lateralization and adhesions yet dissolved significantly slower than the PRG, causing more mucosal edema. Severe MT scarring requiring recurrent medialization and adhesiolysis was exclusively observed in the PRG group. All differences were observed in the early postoperative period (up to 12 weeks after surgery). By that time, only the MT position was significantly different between groups, despite recurrent adhesiolysis and medialization. CONCLUSION: The authors recommend using Posisep for MT support only when it is unstable or lateralized. Packing the surgical cavity in other cases with PRG is more beneficial. LEVEL OF EVIDENCE: 2 Laryngoscope, 133:1834-1838, 2023.

The management of acute supraglottitis patients at the intensive care unit.

INTRODUCTION: Acute supraglottitis is a potentially life-threatening condition that often necessitates intensive care unit (ICU) admission for airway monitoring. The objective of this study was to identify clinical criteria that predict a benign course for patients with acute supraglottitis. METHODS: A prospective observational study was performed. Adult patients hospitalized in the ICU between 2007 and 2019 diagnosed with acute supraglottitis were included. All patients were treated with antibiotics and corticosteroids. Fiber optic laryngoscopy (FOL) was performed every 12 h, with each exam defined as "improving", "no change" or "deteriorating" based on the presence of airway edema. Need for airway intervention was correlated to changes in the FOL exam. RESULTS: Of 146 patients included, 14 (10%) required intubation, ten on admission, and four during the first 6 h of ICU admission. FOL follow-up was performed on 528 occasions-427 (81%) exams showed improvement, 16 (3%) deterioration, and 85 (16%) with no change. On no occasions was improvement in FOL followed by deterioration. The median ICU length of stay was 3 (IQR 2-3.5) vs. 1 (IQR 1.0-1.25) day for patients who did or did not require intubation (p < 0.001), respectively. CONCLUSION: Improvement in FOL exam accurately predicted the absence of need for intubation and might represent a criterion for early ICU discharge.

Vascular Anomaly in the Fallopian Canal Encountered Unexpectedly During Cochlear Implantation.

A 68-year-old male with progressive sensorineural hearing loss underwent left cochlear implant surgery. While developing the posterior tympanotomy and identifying the facial nerve mastoid segment, gentle stimulation by the nerve stimulator resulted in unexpected profuse venous bleeding. After achieving hemostasis with Surgicel and Spongostan, the posterior tympanotomy was extended exposing a large aberrant vein running parallel to the tympanic and mastoid segments of the facial nerve in the fallopian canal. Good exposure and careful palpation of the vein assisted in ruling out facial nerve hemangioma. An intraoperative decision to proceed with implantation, taking into account limited benefit from future magnetic resonance imaging, was taken. The patient had a temporary 3-month post-operative facial nerve weakness, probably from pressure applied during hemostasis. Auditory cochlear implant function was excellent. A larger than normal diameter of the tympanic and mastoid segments of the facial nerve was seen in re-reviews of the preoperative computed tomography. We believe drawing the readers' attention to this anomaly, which to the best of our knowledge has not been previously described, can assist in the choice of preoperative imaging and increase awareness of deviation from the norm of facial nerve diameter. In addition, knowledge of possible venous anomalies may aid surgeons in such intraoperative decisions.

Is it Beneficial to Treat Patients Presenting Three Weeks or Longer after the Onset of Sudden Sensorineural Hearing Loss?

OBJECTIVES: The accepted treatment for idiopathic sudden sensorineural hearing loss (ISSNHL) consists of oral or intratympanic steroids. The time from onset to treatment is considered as an important prognostic factor, although there is no clear cutoff point when treatment is no longer beneficial. This study aimed to assess the efficacy of treatment with oral or intratympanic steroids and carbogen, in patients presenting 21 days or later after the onset of hearing loss. MATERIALS AND METHODS: A total of 895 patients with ISSNHL was seen in our center between 2010 and 2018. The study cohort included 103 patients treated with oral or intratympanic steroids or both with carbogen 21 days or longer after experiencing hearing loss. Retrospective analysis of files and audiometry was conducted, and pre- and post-treatment audiograms were compared. Improvement was defined by SRT (≥15 dB improvement), discrimination (≥15% improvement), or 15 dB improvement at specific frequencies (250-500, 4000-6000 Hz). RESULTS: Hearing improvement, according to the study definition, was seen in 22.3% (23/103) of patients within the time period of the treatment. All the 23 patients had functional hearing after treatment and 16 of them returned to their baseline or normal hearing. While the time from onset of ISSNHL to treatment varied, most patients demonstrating improvement were treated 21-30 days after onset. CONCLUSION: In this patient cohort treated late for sudden sensorineural hearing loss (SSNHL), a small but significant number of patients improved during the time of treatment. Although the lack of a control group makes it difficult to prove that the improvement resulted from the treatment, we recommend not to rule out treatment systematically in patients presenting late after ISSNHL. Additional prospective studies are warranted.

Revision cochlear implantation using a double array device in the post-meningitis ossified cochlea.

PURPOSE: To describe the surgical technique and outcome in a series of patients who underwent revision cochlear implantation using a double array or split electrode device. All patients developed ossified cochleae due to meningitis and were functioning poorly with the previous implant. METHODS: Four patients between the ages of 4-15 years underwent revision with five double-array cochlear implant devices. One patient underwent bilateral revision surgery. All patients had previous meningitis with CT and MRI imaging studies that demonstrated completely ossified cochleae. The time interval range between the disease and the initial cochlear implantation and was 4 months to 3 years. The patient's data were retrospectively analyzed with emphasis on the surgical technique, the number of electrodes inserted, and the number of active electrodes at follow-up. In addition, pre and post-revision surgery function was compared. RESULTS: The revision surgery was carried out 2-11 years after the initial surgery. Two tunnels, basal and apical, were drilled in the ossified cochlea. In each of the tunnels, 5 to 11 electrodes were inserted. While the number of active electrodes before revision was 0-5, after revision with the double array, it was increased to 8-12, resulting in improved auditory and speech function. CONCLUSION: Revision cochlear implantation with a double array implant using the two tunnel technique can increase the number of active electrodes. This leads to a better outcome in post-meningitis children with completely ossified cochleae and a poor functioning previous device.

Supraglottoplasty for severe laryngomalacia. Can we predict success?

OBJECTIVES: Laryngomalacia is the dynamic collapse of supraglottic structures during inspiration, leading to a variable degree of airway obstruction. Clinical symptoms appear in the first months of life and are usually mild and resolve by the age of 12-18 months. In severe cases, surgical intervention may be considered. The goal of the study was to review the clinical outcome of pediatric patients who underwent supraglottoplasty for laryngomalacia. MATERIAL AND METHODS: Clinical and demographic data were retrieved from medical records of children diagnosed with laryngomalacia by laryngo-bronchoscopy between 2013 and 2019. Indications, outcome and long-term follow-up were collected from children undergoing surgery. RESULTS: During the study period, 115 children were diagnosed with laryngomalacia. The median age at diagnosis was 3 months. Synchronous airway lesions were diagnosed in 20% of patients. Ten (8.7%) children underwent surgical treatment because of significant respiratory symptoms and/or failure to thrive. Three of them had comorbidities. All otherwise healthy children had significant respiratory and nutritional improvement after surgery while those with comorbidities had less successful outcomes. CONCLUSION: We conclude that in severe cases of laryngomalacia, supraglottoplasty has an important role to play in management. In children with comorbidities, the surgical results may be less successful. Therefore, we recommend that the decision to operate should be individualized, ensuring full disclosure to the family regarding the probable benefit along with the limitations of surgery.

Nasal blowing induces subcutaneous emphysema post penetrating mastoid tip trauma.

We describe the case of a child with an isolated penetrating trauma to the mastoid tip. Nasal blowing consequently induced air bubbles coming through the mastoid cutaneous fistula and causing extensive subcutaneous neck emphysema. A computed tomography (CT) demonstrated a right mastoid tip bone fracture with extensive cervical subcutaneous emphysema. The patient was treated conservatively with antibiotics and did not require operative intervention. His subsequent course was uncomplicated. This case emphasizes the importance of taking seriously even what seems to be a minor skin laceration.

Starplasty tracheostomy: case series and literature review.

OBJECTIVES: The starplasty tracheostomy (SPT) technique has been suggested to reduce the short-term complications of tracheostomy, including accidental decannulation and pneumothorax. The aim of the present study was to conduct a review of key parameters prior to and following treatment of neonates and children with the SPT technique, including indications, complications, perioperative department stay, and overall length of stay in one University-Affiliated Medical Center. METHODS: A retrospective chart review of all children under the age of 18 underwent SPT in a single center between February 2006 and January 2012. RESULTS: Among the 39 patients reviewed, the median age at the time of surgery was 14.5 months, ranging from 3 days to 8.8 years. The most common indication for SPT was respiratory insufficiency resulting from central nervous system disorders (15, 38.4%) followed by neuromuscular disorders (14, 35.9%). Ten (25.6%) operations were performed on neonatal intensive care unit (NICU) patients and 29 (74.4%) on pediatric intensive care unit (PICU) patients. The median postoperative hospital stay was 19.5 days (range of 3-207 days); however, the median postoperative stay in the PICU was 13.5 days. There were no decannulations or any other short-term complications after SPT, and no SPT-related deaths occurred. CONCLUSIONS: In our series, pediatric SPT was not associated with any major complications. Therefore, we conclude that SPT should be considered as a safe and advantageous alternative for traditional tracheotomy, especially in patients with low probability of future decannulation, and, therefore, at low risk of a persistent tracheocutaneous fistula.

Bipolar tonsillotomy: A novel and effective tonsillotomy technique.

OBJECTIVE: To present, for the first time, tonsil size reduction using reusable bipolar forceps electrocautery (RBFE), as a treatment for pediatric OSAS and to assess the safety and efficacy of the procedure. METHODS: A prospective interventional design study was performed. Thirty children aged 2-15 years with OSAS (AHI>5) diagnosed by means of polysomnography were included. All children were treated with adenoidectomy and RBFE tonsillotomy without dissection. Re-polysomnography was performed after 1 year. The size of the tonsils was blindly assessed by two ENT specialists and the parents were asked to fill out 'Pediatric Sleep Questionnaires' (PSQ), before surgery, and one month and one year after surgery. RESULTS: There were no complications during or after surgery. There were no events involving postoperative bleeding or dehydration. The surgery mean time, including adenoidectomy, was 20.6min. The AHI was 10.9 before surgery and decreased to 1.8 after surgery (p<0.001), minimum saturation (SaO2 min) increased from 86.1% to 93.2% (p<0.001). The size of the tonsils decreased from a mean of +3.3 before surgery to +1.3 and +1.4 one month and one year after surgery, respectively. The mean of the PSQ scores went down from 23.6 to 5.5 and to 6.2 one month and one year after surgery, respectively. CONCLUSION: We demonstrated that simple cauterization of the tonsils using a RBFE device with an adenoidectomy is a safe and effective treatment to decrease tonsil size in OSAS. In addition, the method is inexpensive, rapid and does not cause bleeding, which may be particularly interesting in the presence of coagulation problems.

The Immune Interplay between Thyroid Papillary Carcinoma and Hepatic Fibrosis.

BACKGROUND: A high prevalence of thyroid papillary cancer was reported in hepatitis-C-virus (HCV) positive patients. However, the mechanistic role of hepatic-fibrosis in thyroid malignancy progressions is still unclear. AIM: We aimed to study the immune-modulatory interactions between thyroid papillary carcinoma and hepatic-fibrosis. METHODS: Hepatic-fibrosis was induced in nude-nu-male mice by intra-peritoneal administration of carbon-tetrachloride. To induce thyroid-tumor, a thyroid papillary carcinoma cell line (NPA) was injected subcutaneously in the backs. Fibrotic profile was estimated by α-smooth-muscle-actin (αSMA) expression in liver tissue extracts using western-blots and RT-PCR. Intra-hepatic NK cells were isolated and stained for NK activity (CD107a) by flow cytometry. Liver histopathology (H&E staining), thyroid tumor mass and serum alanine aminotransferase (ALT), serum vascular endothelial growth factor (VEGF) and free-T4 levels were also assessed. RESULTS: Ex-vivo: NPA cells were co-cultured with intra-hepatic NK cells isolated from fibrotic mice with/without the tumor were analyzed for CFSE-proliferations. Both tumor groups (with/without hepatic-fibrosis) excreted higher serum free T4 levels. Hepatic-fibrosis increased tumor weight and size and serum free-T4 levels. In addition, tumor induction increased liver injury (both hepatic-fibrosis, necro-inflammation and serum ALT levels). In addition, tumor-bearing animals with hepatic-fibrosis had increased NK activity. NPA tumor-bearing animals increased fibrosis in spite of increased NK activity; probably due to a direct effect through increased serum free-T4 excretions. Serum VEGF levels were significantly increased in the fibrotic- bearing tumor groups compared to the non-fibrotic groups. In-vitro, NK cells from fibrotic tumor-bearing animals reduced proliferation of NPA cells. This decrease is attributed to increase NK cells activity in the fibrotic animals with the NPA tumors. CONCLUSIONS: Our results propose that NK cells although were stimulated in advanced fibrosis with tumor, they lost their anti-tumor and anti-fibrotic activity probably due to secretions of T4 and VEFG and may explain increased risk of thyroid tumors in chronic HCV patients.

Is Needle Aspiration for Peritonsillar Abscess Still as Good as We Think? A Long-term Follow-up.

OBJECTIVE: The aim was to study the therapeutic management, recurrence, and need for tonsillectomy in patients who underwent needle aspiration for peritonsillar abscess (PTA). METHODS: A prospective observational design study was performed. Patients hospitalized in Shaare Zedek Medical Center between the years 2004 and 2007 with a diagnosis of PTA who underwent needle aspiration obtaining pus were included. A minimum 5-year follow-up was required for all patients. Recurrences, complications, the need for a repeated surgical procedure, length of hospital admission, and tonsillectomy were the primary end points. RESULTS: The study included 117 patients. One hundred four patients (88.9%) improved after 1 needle aspiration without any other intervention, whereas 13 patients (11.1%) required an additional procedure. Broad spectrum antibiotics showed a statistical advantage over penicillin only, regarding need for recurrent procedure (14.7% vs 4.7%, P = .02). No short- or long-term complications were documented. Seventeen patients (14.5%) had any recurrence. Primary recurrent tonsillitis, female sex, and younger age were predictive risk factors for recurrent events of PTA (32% vs 10%, P < .01). A total of 18 patients (15.4%) eventually underwent tonsillectomy. CONCLUSION: Needle aspiration is an effective first line procedure for patients with PTA. Tonsillectomy is not necessary in most cases. In our study, young age, female sex, and recurrent tonsillitis are negative prognostic factors for recurrence. These patients should be managed accordingly. Broad spectrum antibiotics may offer additional advantages when compared to penicillin only.

Multiple electrostimulation treatments to the promontory for tinnitus.

OBJECTIVES: To assess the safety and efficacy of multiple sessions of electrostimulation by a transtympanic needle electrode on the promontory for tinnitus relief. STUDY DESIGN: Prospective open, unblinded, uncontrolled clinical trial. SETTING: Tertiary academic referral center. PATIENTS: Ten patients (8 male and 2 female subjects), mean age 50.1 ± 12 years (range, 34-67) with severe unilateral tinnitus completed all stages of the study. Patients with tinnitus duration between 6 months to 3 years were included. INTERVENTION: The patients underwent 3 consecutive 30-minute sessions, every other day, of biphasic, charge balanced electrostimulation pulses to the promontory delivered by a transtympanic needle electrode. MAIN OUTCOME MEASURES: 1) Tinnitus loudness reported by visual analog scale (VAS) between 1 and 10, at baseline, before and after each treatment, and 1, 2, 3, and 4 weeks after the last treatment. 2) Tinnitus Handicap Inventory (THI) questionnaire at baseline and 4 weeks after treatment. 3) Basic audiometry and tinnitus specific tests such as minimum masking level, tinnitus loudness, and pitch. RESULTS: No long-term adverse safety outcomes were noted in physical examination or audiologic evaluation. VAS levels decreased by ≥2 levels in 5 patients (50%) and returned to baseline 4 weeks after treatment. The VAS decrease was found significant (p = 0.048) in those patients. A statistically significant decrease in THI score was noted 4 weeks after treatment. Tinnitus specific tests at that time were unchanged from baseline. CONCLUSION: Multiple sessions of electrostimulation to the promontory seem to be safe and may be beneficial for some tinnitus patients. Further clinical trials are warranted.

Harmonic scalpel assisted superficial parotidectomy.

OBJECTIVE: The Harmonic Scalpel (HS) has been recently widely used to perform a variety of surgical procedures. We reviewed our experience with the use of HS in superficial parotidectomy to determine the safety and efficacy of this procedure, with regard to operative time, postoperative facial nerve function, and drainage output. STUDY DESIGN: Nonrandomized retrospective review. MATERIALS AND METHODS: The medical records of all patients who underwent superficial parotidectomy for benign pathology at Shaare Zedek Medical Center from January 2006 to July 2009 were retrospectively reviewed. Patients with prior facial nerve weakness or prior parotid surgery or who had undergone concurrent neck dissection or total parotidectomy were excluded. RESULTS: Fifty-eight patients were reviewed; 26 patients underwent HS parotidectomy and 32 patients underwent conventional (cold knife) parotidectomy (control group). Harmonic Scalpel assisted parotidectomy was associated with significantly decreased length of surgery from 163.12 ± 21.8 minutes for controls to 137.3 ± 18.6 minutes in the HS assisted group (P < .05). The incidence of temporary postoperative facial nerve paresis was significantly reduced from 43% in the controls to 23% in the HS group (P < .05). No permanent facial nerve paralysis was reported. There were differences in the overall postoperative drain output between the HS and control groups, 68 ± 22.3 mL and 73.5 ± 38.2 mL, respectively, but these differences did not achieve significance. CONCLUSION: This study shows that HS assisted superficial parotidectomy for benign pathology is a safe technique and associated with reduced surgical time and incidence of temporary postoperative facial nerve paresis compared with conventional techniques.

[Fluoroscopic assisted cochlear implantation in children with inner ear malformations].

BACKGROUND: Cochlear implants are the treatment of choice for individuals with severe to profound sensorineural hearing loss. In most cases, the anatomy is normal and the insertion of the electrode-array is straightforward, complete and in the correct position. In the presence of inner-ear malformations, the risk of an intra or extra-cochlear malpositioned electrode-array increases. OBJECTIVES: To describe the technique of fluoroscopic assisted cochlear implantation in children with severe inner-ear malformations and present the results with respect to the number of active electrodes and function. METHODS: Fifteen fluoroscopy assisted implantations in 9 children were conducted at the Shaare Zedek Cochlear Implant Center between 2009-1014. All implanted ears had severe anatomic malformations. Mean implantation age was 3.5 years (range 1-11). Six children underwent sequential bilateral implantation. Two children underwent revision surgery due to a malpositioned electrode initially implanted without fluoroscopy at other centers. RESULTS: There was no radiologic or electro-physiologic evidence of kinking, bending or electrode damage in all 15 implantations. Complete insertion was achieved in all ears except one with partial insertion. There were no extra-cochlear or intrameatal placements. In 9 ears, all electrodes were active at switch-on and in the remaining, 15-20 were active. In all ears the Ling-6 sounds were detected and in 13 they were also identified. CONCLUSION: Fluoroscopy is an effective tool in complex cochlear implant surgeries and its use is simple and safe. As demonstrated in this study, with fluoroscopy assistance, good results are achieved in children with inner-ear malformations.

The effect of topically applied antimycotic agents on inner ear vestibular and cochlear function.

OBJECTIVES/HYPOTHESIS: To assess and compare the effect of commonly used topical antimycotic agents and their solvents on the function of the vestibular and cochlear parts of the sand rat's inner ear. STUDY DESIGN: Prospective, controlled, animal study. METHODS: Forty-five fat sand rats were randomly assigned to five major groups, each receiving topical application of a different agent: saline (control), gentamicin (ototoxic control), and three antimycotic agents: nystatin, clotrimazole solution (Agisten), and bifonazole solution (Agispor). All animals underwent a right labyrinthectomy, and a polyethylene tube was inserted into the left middle ear followed by baseline recording of vestibular evoked potentials (VsEPs) and auditory nerve and brainstem responses (ABR). Subsequently, each animal received five consecutive daily applications of the specific agent into the left middle ear. Evoked potential recordings were repeated 3 and 10 days after the last application and compared to baseline. For clotrimazole and bifonazole solutions, the effect of the solvents was assessed by comparing ABR recordings at similar intervals. RESULTS: Administration of saline did not affect VsEPs or ABR. Both could not be recorded following gentamicin application. In all three antimycotic agents, no statistically significant difference was found between VsEPs recordings before and after application. Clotrimazole and bifonazole solutions caused a significant ABR threshold elevation similar to that caused by their solvents. Nystatin caused a less significant ABR threshold elevation. CONCLUSIONS: The three commonly used topical antimycotic agents investigated here did not affect vestibular function but had a toxic effect on inner ear cochlear function. It seems the main offenders were the solvents.

Remifentanil-nitroglycerin combination as an anesthetic support for ex utero intrapartum treatment (EXIT) procedure.

A 21 year old healthy parturient was diagnosed as having a fetus with micrognathia. She was scheduled for an ex-utero intrapartum treatment (EXIT) procedure. General anesthesia consisted of remifentanil, nitrous oxide, and midazolam. Intravenous nitroglycerin was used for uterine relaxation. This technique offered hemodynamic stability and provided uterine relaxation that may be rapidly terminated. For the fetus, it provided excellent transplacental anesthesia. Supplemental direct fetal anesthesia is recommended to prevent the rapid decline of analgesia/anesthesia that occurs after placental separation.

The effect of noise on ears with a hole in the vestibule.

CONCLUSION: A hole in the vestibule of the inner ear leads to augmentation of the hearing loss following noise exposure. Further research is needed to ascertain the mechanism. OBJECTIVES: The possible effects of a hole in the wall of the inner ear at the vestibule on noise-induced hearing loss were assessed. METHODS: The study was conducted on a total of 14 sand rats. Of these 14 animals, 10 underwent baseline auditory nerve and brainstem evoked response (ABR) threshold measurements in each ear separately (insert earphone), opening of middle ear bulla in both ears and drilling of a hole in the vestibule of one inner ear. The other ear was sham-operated. Following immediate re-assessment of ABR threshold, the 10 animals were exposed to 113 dB SPL broadband noise during 4 nights, and 3 days later ABR measurements were repeated. Four additional animals with a hole in one vestibule, not exposed to noise, served as controls. RESULTS: Following noise exposure, ABR thresholds were elevated by 28.5 +/- 9.1 dB in the ears with the hole, and by 15.5 +/- 7.2 dB in the opposite ear without the hole (significant difference, p < 0.003). In the four control ears, ABR threshold was not elevated a week after drilling the hole.