Complications of otitis media - a potentially lethal problem still present / Complicações das otites média - um problema potencialmente letal ainda presente

ABSTRACT INTRODUCTION: It is an erroneous but commonly held belief that intracranial complications (ICCs) of chronic and acute otitis media (COM and AOM) are past diseases or from developing countries. These problems remain, despite improvements in antibiotic care. OBJECTIVE: This paper analyzes the occurrence and clinical characteristics and course of the main ICCs of otitis media (OM). METHODS: Retrospective cohort study of 51 patients with ICCs from OM, drawn from all patients presenting with OM to the emergency room of a large inner-city tertiary care hospital over a 22-year period. RESULTS: 80% of cases were secondary to COM of which the incidence of ICC was 0.8%; 20% were due to AOM. The death occurrence was 7.8%, hearing loss in 90%, and permanent neurological sequelae in 29%. Patients were 61% male. In the majority, onset of ear disease had occurred during childhood. Delay of diagnosis of both the initial infection as well as the secondary ICC was significant. ICCs included brain abscess and meningitis in 78%, and lateral sinus thrombosis, empyema and otitic hydrocephalus in 13%, 8% and 1% of cases, respectively. Twenty-seven neurosurgical procedures and 43 otologic surgery procedures were performed. Two patients were too ill for surgical intervention. CONCLUSION: ICCs of OM, although uncommon, still occur. These cases require expensive, complex and long-term inpatient treatment and frequently result in hearing loss, neurological sequelae and mortality. It is important to be aware of this potentiality in children with COM, especially, and maintain a high index of suspicion in order to refer for otologic specialty care before such complications occur.

Resumo Introdução: É uma crença comum, porém errônea, que complicações intracranianas (CICs) de otite média tanto aguda (OMA) quanto crônica (OMC) sejam doenças do passado ou de países em desenvolvimento. No entanto, esses problemas continuam, apesar de melhorias na terapia antimicrobiana. Objetivo: Analisar a ocorrência, as características clínicas e a evolução das principais CICs secundárias às otites médias (OM) Método: Estudo de coorte retrospectivo de 51 pacientes com CIC secundárias a OM, provenientes do pronto-socorro de um Hospital Universitário ao longo de um período de 22 anos. Resultado: No total, 80% dos casos de CICs foram secundários a OMC, cuja incidência foi de 0,8%, e apenas 20% foram secundárias a OMA. A letalidade foi de 7,8%, perda auditiva em 90%, com sequela neurológica permanente em 29%. Dentre os pacientes, 61% eram do sexo masculino. Na maioria, o início da doença otológica tinha ocorrido durante a infância. A demora no diagnóstico, tanto da infecção primária como da complicação secundária, foi significativa. CICs, incluindo abscesso cerebral e meningite, corresponderam a 78%, e trombose do seio lateral, empiema e hidrocefalia otítica em 13%, 8% e 1% dos casos, respectivamente. Foram realizados 27 procedimentos neurocirúrgicos e 43 cirurgias otológicas. Dois pacientes não apresentavam condições clínicas para a intervenção cirúrgica Conclusão: CICs de OM, embora incomuns, ainda ocorrem. Esses casos exigem tratamento hospitalar oneroso, complexo e de longo prazo, e frequentemente resultam em perda auditiva, sequelas neurológicas e mortalidade. É importante estar ciente dessa potencialidade especialmente em crianças com OMC e manter um alto índice de suspeita, encaminhar para avaliação otológica e antecipar a ocorrências de tais complicações.

Complications of otitis media - a potentially lethal problem still present.

INTRODUCTION: It is an erroneous but commonly held belief that intracranial complications (ICCs) of chronic and acute otitis media (COM and AOM) are past diseases or from developing countries. These problems remain, despite improvements in antibiotic care. OBJECTIVE: This paper analyzes the occurrence and clinical characteristics and course of the main ICCs of otitis media (OM). METHODS: Retrospective cohort study of 51 patients with ICCs from OM, drawn from all patients presenting with OM to the emergency room of a large inner-city tertiary care hospital over a 22-year period. RESULTS: 80% of cases were secondary to COM of which the incidence of ICC was 0.8%; 20% were due to AOM. The death occurrence was 7.8%, hearing loss in 90%, and permanent neurological sequelae in 29%. Patients were 61% male. In the majority, onset of ear disease had occurred during childhood. Delay of diagnosis of both the initial infection as well as the secondary ICC was significant. ICCs included brain abscess and meningitis in 78%, and lateral sinus thrombosis, empyema and otitic hydrocephalus in 13%, 8% and 1% of cases, respectively. Twenty-seven neurosurgical procedures and 43 otologic surgery procedures were performed. Two patients were too ill for surgical intervention. CONCLUSION: ICCs of OM, although uncommon, still occur. These cases require expensive, complex and long-term inpatient treatment and frequently result in hearing loss, neurological sequelae and mortality. It is important to be aware of this potentiality in children with COM, especially, and maintain a high index of suspicion in order to refer for otologic specialty care before such complications occur.

Expression of aquaporin 2 following facial nerve crush in rats.

CONCLUSION: We demonstrated an early increase in aquaporin 2 (AQP2) expression in a motor nerve (extratemporal facial nerve, FN) following acute peripheral compression (crush), concomitant to effective development of motor dysfunction (facial palsy). The early increase in AQP2 expression that occurred concomitantly with the appearance of a deficit in a peripheral motor nerve suggests that this protein is involved in the physiological events associated with post-injury edema, similar to the already demonstrated behavior of AQP4 in the central nervous system (CNS). OBJECTIVE: The aim of this study was to assess the expression of AQP2 in the FN of rats up to 7 days after crush. METHODS: The extratemporal trunk of the right FN of rats was subjected to mechanical crush, and the expression of AQP2 in the affected (right) and non-affected (left) FN was measured by means of western blotting at days 1, 3, and 7 after injury. Behavioral analysis of the development of facial palsy was also performed over the same time period. RESULTS: Increased expression of AQP2 was shown in the affected FN compared with its corresponding control at day 1 after compression, simultaneously with the appearance of facial palsy.

Experimental video analysis of eye blink reflex in a primate model.

BACKGROUND: The establishment of reliable methods for functional assessment in experimental models of peripheral nerve regeneration is crucial. METHODS: We present a straightforward method for video analysis of the eye blink reflex in a model of facial nerve damage in a nonhuman primate (Callithrix sp.). RESULTS: Our 6-level dynamic analysis demonstrated good reproducibility between independent observers, as measured by Cohen's kappa index. Our static analysis, which was based on 4 semiautomated metric parameters, showed low correlation during the early stage of facial movement recovery (the first and second weeks), but the correlation was excellent during the later stage of recovery (the third and fourth weeks). CONCLUSION: Altogether, our results establish a viable and readily accessible method with good reproducibility and correlation for the analysis of functional facial nerve recovery in an experimental model and based on video images of the eye blink reflex.

Experimental model of facial paralysis by nerve compression in primates (Callithrix sp.): a new model of facial paralysis in small nonhuman primates.

CONCLUSION: We conclude that facial nerve injury induced by compression is associated with a reasonable time window (4 weeks) that allows possible neurotrophic effects to be analyzed. Additionally, there are no hints of cross-innervation by the contralateral facial nerve or parallel innervation by other nerves in the hemiface ipsilateral to the injured nerve. OBJECTIVE: The aim of this work was to develop an experimental model of facial nerve injury in nonhuman primates (Callithrix sp.). METHODS: In this study, individuals of the non-human primate species Callithrix sp. were subjected to three different types of facial nerve injury, and they were observed for 27 days after surgery by video to record their facial movements. RESULTS: Two types of nerve compression caused severe initial facial paralysis followed by gradual recovery until normal levels were reached at the end of the evaluation period. Injury induced by nerve resection was followed by a complete lack of facial movement recovery.

The action of topical basic fibroblast growth factor in facial nerve regeneration.

OBJECTIVE: To analyze the influence of the topical use of basic fibroblast growth factor (bFGF) in the regeneration of the facial nerve in rats. STUDY DESIGN: Experimental study. MATERIALS AND METHODS: Twenty-eight Wistar adult male rats underwent complete section of the facial nerve trunk, followed by end-to-end anastomosis with epineural sutures. An osmotic minipump equipped with a delivery catheter was implanted subcutaneously near the neural anastomosis. During the subsequent 14 days, 14 animals received a solution containing 25 microg/ml of bFGF, 250 UI/ml of sodium heparin, and 1,000 microg/ml of human albumin diluted in Ringer lactate, and 14 animals received a control solution of the same components without bFGF. To evaluate facial nerve regeneration, the number of myelinated fibers evident on histologic sections was counted on the 14th (7 experimental and 8 control animals) and the 28th days (7 experimental and 6 control animals) after surgery, and the facial movements of vibrissae and the blink reflex were evaluated on alternate days until the 28th day. RESULTS: On histologic evaluation, the number of myelinated fibers was similar between groups on the 14th day and greater in the group that received bFGF on the 28th day. Behavioral evaluation showed that the animals of the bFGF group presented better functional results between the 6th and 16th days for the blink test and the 14th to the 16th days for vibrissae movements. CONCLUSION: This study showed that the regeneration of the facial nerve occurred earlier and resulted in significantly more myelinated nerve fibers in the animals that received topical bFGF.

Padronização dos critérios de seleção em estudos sobre medicações nasais / Standardizing selection criteria in nasal medication studies

Estudos clínicos sobre medicações tópicas nasais exigem a padronização de "normalidade nasossinusal" na constituição de grupos controle através de uma avaliação específica da via aérea superior. Objetivo: Padronizar a avaliação de candidatos a grupos controle em estudos clínicos sobre medicações tópicas nasais. Material e métodos: Voluntários do sexo masculino, de 18 a 50 anos, que se declararam saudáveis, livres de doenças e assintomáticos nasossinusais foram submetidos a uma avaliação sequencial e excludente composta de uma avaliação clínica, teste cutâneo de hipersensibilidade imediata, teste da sacarina, nasofibroscopia flexível e citograma nasal. Desenho do estudo: Coorte contemporânea com corte transversal. Resultados: Dos 33 indivíduos inicialmente incluídos, 14 (42,4 por cento) foram excluídos na avaliação clínica. Dos 19 restantes, 2 (10,5 por cento) apresentaram atopia no teste cutâneo, sendo excluídos. 17 foram submetidos ao teste da sacarina demonstrando em todos os casos uma depuração mucociliar normal, sendo avaliados por nasofibroscopia flexível que detectou anormalidade em 2 casos (11,8 por cento) e excluídos. Os 15 restantes foram submetidos ao citograma nasal, demonstrando normalidade, representando 45,5 por cento dos indivíduos inicialmente incluídos. Conclusão: O protocolo proposto de avaliação sequencial e excludente foi efetivo na definição de candidatos à constituição de grupos controle em estudos clínicos sobre medicações tópicas nasais.

Clinical studies on nasal topical medications require the standardization of "nasosinusal normality" in order to establish control groups through a specific evaluation of the upper airways. AIM: to standardize the evaluation of candidates for control groups in clinical studies on nasal topical medications. Material and methods: healthy male volunteers of 18 to 50 years of age, asymptomatic from the nasosinusal standpoint were subjected to a sequential and excluding assessment made up of clinical evaluation, immediate hypersensitivity skin test, saccharin test, flexible nasofibroscopy and nasal cytology. Study design: Cross-sectional contemporary cohort. Results: Of the 33 people originally enrolled, 14 (42.4 percent) were excluded for clinical reasons. Of the 19 remaining, 2 (10.5 percent) had atopy diagnosed in the skin test and were excluded. 17 were tested with saccharin and presented normal mucociliary clearance. Evaluation by nasal endoscopy showed abnormality in 2 cases (11.8 percent) and these were excluded. The remaining 15 were submitted to nasal cytology, which proved normal, representing 45.5 percent of those initially included. Conclusion: The proposed protocol for sequential and excluding evaluation was effective in defining candidates for the establishment of control groups in clinical studies on nasal topical medications.

Standardizing selection criteria in nasal medication studies.

UNLABELLED: Clinical studies on nasal topical medications require the standardization of 'nasosinusal normality' in order to establish control groups through a specific evaluation of the upper airways. AIM: to standardize the evaluation of candidates for control groups in clinical studies on nasal topical medications. MATERIAL AND METHODS: healthy male volunteers of 18 to 50 years of age, asymptomatic from the nasosinusal standpoint were subjected to a sequential and excluding assessment made up of clinical evaluation, immediate hypersensitivity skin test, saccharin test, flexible nasofibroscopy and nasal cytology. STUDY DESIGN: Cross-sectional contemporary cohort. RESULTS: Of the 33 people originally enrolled, 14 (42.4%) were excluded for clinical reasons. Of the 19 remaining, 2 (10.5%) had atopy diagnosed in the skin test and were excluded. 17 were tested with saccharin and presented normal mucociliary clearance. Evaluation by nasal endoscopy showed abnormality in 2 cases (11.8%) and these were excluded. The remaining 15 were submitted to nasal cytology, which proved normal, representing 45.5% of those initially included. CONCLUSION: The proposed protocol for sequential and excluding evaluation was effective in defining candidates for the establishment of control groups in clinical studies on nasal topical medications.

Influence of cyclic AMP on facial nerve regeneration in rats.

UNLABELLED: Promoting facial nerve regeneration is a significant challenge. AIM: To evaluate the possible neurotrophic influence of cyclic AMP on facial nerve regeneration of Wistar rats. METHOD: The right facial nerve of thirty-two animals were completely transected and immediately sutured, followed by exposure or not to topical cyclic AMP. Behavioral and histometric analyses were done at 14 and 28 days. RESULTS: Statistical differences (p<0.05) were found in the behavioral and histometric analyses on the 14th day, suggesting an early regenerative response of the facial nerve to cAMP exposure. CONCLUSION: This study demonstrates a possible neurotrophic effect of cAMP on facial nerve regeneration in rats.

Influência do AMP cíclico na regeneração do nervo facial em ratos / Influence of cyclic AMP on facial nerve regeneration in rats

Estimular a regeneração do nervo facial é ainda hoje um desafio. OBJETIVO: Estudar a possível influência neurotrófica do nucleotídeo cíclico adenosina monofosfato (AMPc) na regeneração do nervo facial de ratos Wistar. MÉTODO: Trinta e dois animais foram submetidos à transecção completa com sutura imediata do nervo facial direito, sendo divididos em expostos ou não expostos à aplicação tópica de AMPc, com análises comportamentais (movimentação de vibrissas e fechamento da rima palpebral) e histométrica (contagem de fibras mielinizadas) em dois períodos, 14 e 28 dias após a lesão. RESULTADO: Encontramos diferenças estatísticas (p<0,05) nas análises comportamental e histométrica no 14º dia, sugerindo uma precocidade na regeneração do nervo facial exposto ao AMPc. CONCLUSÃO: Nosso estudo constatou uma possível ação neurotrófica do AMPc na regeneração do nervo facial em ratos.

Promoting facial nerve regeneration is a significant challenge. AIM: To evaluate the possible neurotrophic influence of cyclic AMP on facial nerve regeneration of Wistar rats. METHOD: The right facial nerve of thirty-two animals were completely transected and immediately sutured, followed by exposure or not to topical cyclic AMP. Behavioral and histometric analyses were done at 14 and 28 days. RESULTS: Statistical differences (p<0.05) were found in the behavioral and histometric analyses on the 14th day, suggesting an early regenerative response of the facial nerve to cAMP exposure. CONCLUSION: This study demonstrates a possible neurotrophic effect of cAMP on facial nerve regeneration in rats.

Anatomical study of a temporal bone from a non-human primate (Callithrix sp).

UNLABELLED: The search for experimental (animal) models is essential to the development of clinical studies. AIM: To demonstrate, by means of micro dissection techniques, the anatomical structures of temporal bones from the primate Callithrix sp. STUDY DESIGN: Experimental. METHODS: Dissection of temporal bone structures of Callithrix sp and photographic documentation. RESULTS: We identified the main constituents of the temporal bone (external, medium and inner ear and facial nerve). CONCLUSION: The non-human primate Callithrix sp. is an adequate experimental model for the studies of temporal bone structures given its close anatomical similarities to that found in humans.

Study of distortion-product otoacoustic emissions during hypothermia in humans.

AIM: To evaluate the function of cochlear outer hair-cells under the influence of extra-corporeal circulation and moderate hypothermia during cardiac surgery. STUDY DESIGN: Prospective clinical study. METHODS: Distortion-product otoacoustic emissions (DPOAE) were registered before surgery, immediately after general anesthesia induction, during extra-corporeal circulation with moderate hypothermia and after the surgical procedure. RESULTS: Comparison of response-amplitudes before and after surgery and before and after general anesthesia initiation did not demonstrate statistical difference. Comparison of amplitudes before and after extra-corporeal circulation with moderate hypothermia demonstrated a statistically significant decrease in responses amplitudes during hypothermia. CONCLUSIONS: The amplitudes of DPOAE decreased during moderate hypothermia induced during extra-corporeal circulation.

Estudo anatômico do osso temporal de um primata não-humano (Callithrix sp) / Anatomical study of a temporal bone from a non-human primate (Callithrix sp)

A busca por modelos experimentais constitui passo fundamental para o avanço da medicina. OBJETIVO: Demonstrar, através da dissecção com técnicas microcirúrgicas, as estruturas anatômicas do osso temporal do primata Callithrix sp. FORMA DE ESTUDO: Experimental. MÉTODO: Dissecção de ossos temporais de Callithrix sp e documentação fotográfica. RESULTADOS: Identificamos as principais estruturas do osso temporal (orelhas externa, média e interna, e nervo facial). CONCLUSÃO: O primata não-humano Callithrix sp representa aparentemente um modelo viável para o estudo do osso temporal uma vez que apresenta alta similaridade anatômica com humanos.

The search for experimental (animal) models is essential to the development of clinical studies. AIM: To demonstrate, by means of micro dissection techniques, the anatomical structures of temporal bones from the primate Callithrix sp. STUDY DESIGN: Experimental. METHODS: Dissection of temporal bone structures of Callithrix sp and photographic documentation. RESULTS: We identified the main constituents of the temporal bone (external, medium and inner ear and facial nerve). CONCLUSION: The non-human primate Callithrix sp. is an adequate experimental model for the studies of temporal bone structures given its close anatomical similarities to that found in humans.

Estudo das emissões otoacústicas por produto de distorção durante a hipotermia em humanos / Study of distortion-product otoacoustic emissions during hypothermia in humans

As células ciliadas externas da cóclea desempenham papel fundamental na audição. OBJETIVO: Avaliar o funcionamento das células ciliadas externas da cóclea durante a cirurgia cardíaca com circulação extracorpórea e hipotermia moderada. DESENHO DO ESTUDO: Estudo clínico prospectivo. MÉTODOS: Registro das emissões otoacústicas por produto de distorção (EOAPD) antes da cirurgia, após a indução anestésica, após o estabelecimento da circulação extracorpórea com hipotermia moderada e no pós-operatório. RESULTADOS: Comparações da resposta em amplitude das EOAPD pré e pós-operatórias e pré e pós-estabelecimento da anestesia não demonstraram diferenças estatisticamente significantes. Comparações pré e pós-estabelecimento da circulação extracorpórea com hipotermia moderada demonstraram uma diminuição estatisticamente significante na amplitude das EOAPD. CONCLUSÕES: A amplitude das EOAPD diminui durante a hipotermia moderada.

AIM: To evaluate the function of cochlear outer hair-cells under the influence of extra-corporeal circulation and moderate hypothermia during cardiac surgery. STUDY DESIGN: Prospective clinical study. METHODS: Distortion-product otoacoustic emissions (DPOAE) were registered before surgery, immediately after general anesthesia induction, during extra-corporeal circulation with moderate hypothermia and after the surgical procedure. RESULTS: Comparison of response-amplitudes before and after surgery and before and after general anesthesia initiation did not demonstrate statistical difference. Comparison of amplitudes before and after extra-corporeal circulation with moderate hypothermia demonstrated a statistically significant decrease in responses amplitudes during hypothermia. CONCLUSIONS: The amplitudes of DPOAE decreased during moderate hypothermia induced during extra-corporeal circulation.

Modelo experimental comportamental e histológico da regeneração do nervo facial em ratos / Behavioral and histologic experimental model of facial nerve regeneration in rats

O estabelecimento de modelos experimentais é o passo inicial para estudos de regeneração neural. OBJETIVO: Estabelecer modelo experimental de regeneração do nervo facial. MATERIAIS E MÉTODOS: Ratos Wistar com secção completa e sutura do tronco do nervo facial extratemporal, com análise comportamental e histológica até 9 semanas. FORMA DE ESTUDO: Estudo prospectivo experimental. RESULTADOS: Progressiva recuperação clínica e histológica dos animais. CONCLUSÃO: Estabelecemos um método aceitável para o estudo de regeneração do nervo facial em ratos.

To setup an experimental model is the first step to study neural regeneration. AIM: Setting up an experimental model on facial nerve regeneration. MATERIAL AND METHODS Wistar rats with complete sectioning and suturing of the extratemporal facial nerve trunk; with a behavioral and histological analysis for 9 weeks. STUD DESIGN: Experimental prospective study. RESULTS: Progressive clinical and histological recovery of the animals. CONCLUSION: Our method is acceptable to study facial nerve regeneration in rats.

Standardization of techniques used in facial nerve section and facial movement evaluation in rats.

AIM: Standardization of the technique to section the extratemporal facial nerve in rats and creation of a scale to evaluate facial movements in these animals before and after surgery. STUDY DESIGN: Experimental. METHOD: twenty Wistar rats were anesthetized with ketamine xylazine and submitted to sectioning of the facial nerve near its emergence through the mastoid foramen. Eye closure and blinking reflex, vibrissae movement and positioning were observed in all animals and a scale to evaluate these parameters was then created. RESULTS: The facial nerve trunk was found between the tendinous margin of the clavotrapezius muscle and the auricular cartilage. The trunk was proximally sectioned as it exits the mastoid foramen and the stumps were sutured with a 9-0-nylon thread. An evaluation and graduation scale of facial movements, independent for eye and vibrissae, was elaborated, together with a sum of the parameters, as a means to evaluate facial palsy. Absence of eye blinking and closure scored 1; the presence of orbicular muscle contraction, without blinking reflex, scored 2; 50% of eye closure through blinking reflex, scored 3, 75% of closure scored 4. The presence of complete eye closure and blinking reflex scored 5. The absence of movement and posterior position of the vibrissae scored 1; slight shivering and posterior position scored 2; greater shivering and posterior position, scored 3 and normal movement with posterior position, scored 4; symmetrical movement of he vibrissae, with anterior position, scored 5. CONCLUSION: The rat anatomy allows easy access to the extratemporal facial nerve, allowing its sectioning and standardized suture. It was also possible to establish an evaluation and graduation scale of the rat facial movements with facial palsy based on the clinical observation of these animals.

Acupuncture for tinnitus immediate relief.

The treatment of tinnitus, which is defined as conscientious perception of a sound originated in the ears or nervous system, represents until the current days a great challenge. The use of Acupuncture (ACP) is based on the stimulation with needles of specific points on the human anatomy. A prospective, randomized and double-blinded study was carried through in 76 patients taken care of in the Clinic of Tinnitus of the Department of Otorhinolaryngology and Head and Neck Surgery of the UNIFESP-EPM in the period understood between April and June of 2005. All the patients had humming complaint and had been submitted to clinical anamnese, physical examination and subsidiary exams in order to investigate its etiology. The patients then were directed to a first researcher that determined an initial numeric value of the humming through Visual Analoge Scale(VAS), varying from 0 to 10 points. After this, had been directed for another room in which an acupuncturist doctor, who did not have access to the initial evaluation, separated the patients in Group Control and Group Study according to the attendance order, in alternating way. The ACP point used in patients of the Group Study places 6,5 cm above of the apex of the auditory pavilion in the parietal region. The point used in the Group Control places 3 cm above of the previous point, in the same vertical line. Then they had been sent back to the initial room for a new evaluation by the first researcher, where they had been guided to redefine the subjective score of the humming. Among the 76 studied patients, 29 were male (38,2%) and 47 female (61,8%), with average age 56,9 + 12,0 years. The Groups Study and Control had counted on 38 patients each. Through the Anova test it was evidenced that it had significant difference (p<0,001) between the moments pre and post needling and that in the group Study this improvement is more evident (p=0,0127). The t-independent test showed that it had a significant difference (p=0,017) between the two moments in the groups Study and Control. We conclude that there was significant reduction of the counting of the moments pre and post needling in both the groups, and in the group study the reduction is greater that in the group control.