Maxillomandibular advancement for obstructive sleep apnea.

Objective: : We aimed to present our clinical experience with maxillomandibular advancement (MMA) for the treatment of obstructive sleep apnea (OSA) syndrome and to compare our results with literature data. Materials and Methods: : The patients who were operated for OSA in the last 10 years were included in the study. A detailed patient's charts review was retrospectively performed. Inclusion criteria were to be available with preoperative and postoperative polysomnography data. Results: : There were totally 7 cases who underwent MMA procedure for OSA in our clinic. The mean age was 38.6 ± 8.1 years. Surgical success was achieved in all cases (100%). The mean preoperative and postoperative apnea-hypopnea indexes were 63.3 ± 35.2 and 7.5 ± 3.4, respectively (P < 0.05). The most common complication was inferior alveolar nerve deficit following bilateral sagittal split osteotomy. The facial numbness was temporary in 4 (57.1%), and permanent in one case (14.3%). Conclusion: Our surgical results in MMA is compatible with literature data. MMA is the choice of treatment in severe OSA in case of positive airway pressure therapy intolerance.

Congenital neck masses in children and their embryologic and clinical features.

Congenital neck masses in children and their embryologic and clinical features. Neck masses of congenital origin can be diagnostic and therapeutic challenges for internists, paediatricians and surgeons. Treatment modalities of congenital neck masses are different depending on their nature, symptoms and location. Differential diagnosis includes a variety of diseases that can cause cervical masses such as infectious and neoplastic neck tumours. Our objective is to review the embryologic and clinical features of some of the most common congenital neck masses such as the haemangioma, branchial cleft anomalies, thyroglossal duct cyst, ectopic thyroid, congenital midline cervical cleft, congenital cervical teratoma, lymphangioma, cervical thymic cyst, dermoid cyst and congenital muscular torticollis.

Impact of prognostic factors on recovery from sudden hearing loss.

OBJECTIVE: To define the impact of patient-related and audiovestibular parameters on the prognosis of sudden hearing loss. METHODS: Eighty-three patients were included in this retrospective study. All were treated medically. We recorded the patients' demographic parameters, systemic diseases, time elapsed between onset of sudden hearing loss and initiation of treatment, tinnitus, vestibular symptoms, type of initial audiogram, pure tone averages and speech discrimination scores. For all patients, audiological measurements were performed on initial admission and at the completion of treatment on the 10th day. RESULTS: There was no correlation between the hearing gain and recovery rate scores and patients' gender or age (p>0.05). However, a correlation was found between gender and relative hearing gain. Vertigo was not correlated with hearing gain and recovery rate scores (p0.05); time elapsed between onset of sudden hearing loss and initiation of treatment (p>0.05); type of audiogram on initial admission (p>0.05), except for midfrequency type of audiogram; and tinnitus (p>0.05). CONCLUSIONS: The outcome of sudden hearing loss was unaffected by systemic disease, tinnitus or type of audiogram (except for midfrequency type). The following were poor prognostic factors in the outcome of sudden hearing loss: female gender, presence of vertigo, initiation of treatment more than seven days after onset of hearing loss, and >40 dB hearing loss on admission.

A study on the prevalence of accessory auricle anomaly in Turkey.

OBJECTIVE: Accessory auricular anomaly is a small elevation of skin containing a bar of elastic cartilage localized most commonly just anterior to the tragus or ascending crus of the helix. The anomaly may exist isolated or may be associated with other congenital anomalies of the first arch. The purpose in this study is to detect prevalence of accessory auricle in Turkey and find out whether it is associated with other craniofacial anomalies or hearing loss. METHODS: The study was performed on 850 children from the age of 7 to 9 during a screening program in primary schools. Complete otolaryngologic examination and acoustic reflectometry measurements were performed on all the children. Full physical examination, tympanometric and audiometric evaluation and EEG measurements were added to the cases with accessory auricle anomaly. RESULTS: Among 850 children examined, four had accessory auricle anomaly and prevalence of the anomaly was calculated as 0.47% (95% confidence interval (CI), 0.13-1.20%). Children were developmentally normal, and no other congenital craniofacial or systemic anomaly was detected in any of the cases. Further, tympanometric, audiometric evaluations and EEG tests were in normal limits. CONCLUSIONS: In this study, the prevalence rate of the condition was calculated as 0.47%. Although one study from China reported this prevalence as 0.22%, the difference between the reported prevalances was not statistically significant. Further, although external ear anomalies may present together with cranifacial anomalies and neurologic disorders like epilepsy, neuromotor retardation and EEG disorders, in our cases, mental and motor development was normal and epilepsy history or abnormal EEG patterns do not exist. On the other hand, no hearing loss was found to be associated with accessory auricles.

Tympanometry and acoustic reflectometry in ears with chronic retraction without effusion.

OBJECTIVE: Purpose of this study was to find out test accuracy and predictivity of tympanometry (TYMP) and parameters (reflectivity and curve angle) of acoustic reflectometry (AR) in the ears with prior clinic and otoscopic evidences of effusion in which no effusion was detected by myringotomy, by comparing with the data found in normal ears and in those with effusion. METHODS: While study group included 31 ears with chronic retraction in which no effusion was detected by myringotomy, control group included 150 fully normal ears and 150 ears with effusion confirmed by myringotomy. B tracings in TYMP, and values of reflectivity higher than 5 and curve angle lower than 75 degrees in AR were accepted as indicators of effusion; in the combined test, the ears with non-B tracings in which curve angle higher than 75 degrees were accepted as those without effusion. RESULTS: False positivity values of TYMP, reflectivity and curve angle and the combined test found in the ears with chronic retraction without effusion (29, 23, 19 and 35% respectively; chi(2)-test, P > 0.1) were significantly higher than normal ears (chi(2)-test, P < 0.001), but lowe than those of effusion (chi(2)-test, P<0.0001). Further, although negative predictivity values of TYMP, reflectivity and curve angle were found to be lower in these ear, compared to normal ears (chi(2)-test, P < 0.01), the combined test reached to a perfect negative predictivity, as much as in normal ears. On the other hand, positive predictivity values were decreased in the ears with chronic retraction without effusion by only reflectivity. CONCLUSIONS: By both TYMP and AR alone, it is more difficult to find out the ears without effusion among the ears clinically and otoscopically diagnosed as otitis media than to find out normal ears. Therefore, in clinical work, false positivity of these devices were higher, and their specificity and negative predictivity were lower; although the combined test solved problem of low negative predictivity, high number of false positive ears in clinical work, that is lower specificity, continues to be an unsolved problem by either TYMP or AR alone, or both together.

Associations between the eustachian tube and craniofacial skeleton.

OBJECTIVE: Growth and development of the anatomic region where the Eustachian tube (ET) is located are associated with the parameters related to other parts of the craniofacial skeleton (CFS). It has been suggested that ET dysfunction is as an important factor in pathogenesis of otitis media in childhood which is associated with its postnatal growth and development process. The purpose of this study was to evaluate associations of length of the ET with various craniofacial parameters. METHODS: On lateral cephalometric radiographs of 50 Japanese adult (25 male and 25 female), the dimension of the region where the ET is located ('length of the ET') and 22 (15 linear and seven angular) craniofacial parameters were measured by using a digitiser and computer. Correlation and regression analyses were performed between this dimension and other craniofacial parameters. RESULTS: It was found that the dimension of the region in which the ET is located ('length of the ET') was associated with many craniofacial parameters belonging to different subunits of the CFS. However, the stepwise regression analysis showed that total cranial base length, posterior upper face height and maxillary depth had determinative effects on this dimension. CONCLUSION: Development of the ET was associated with development of the cranial base and nasomaxillary complex. Therefore, it could be hypothesised that any cessation or aberration in these parts of the CFS cause corresponding imbalances in the ET, which may predispose to otitis media.

Relief of posttonsillectomy pain with low-dose tramadol given at induction of anesthesia in children.

OBJECTIVE: Pain is major problem regarding quality of life in children undergoing tonsillectomy. Preemptive analgesia by medicine given before commencement of surgery is a new way recommended for relief of pain during and after operation. The purpose in this study to evaluate preemptive efficacy and safety of lower dose of tramadol, which was recently introduced in children undergoing tonsillectomy. METHODS: This study was performed on 45 children undergoing tonsillectomy with or without adenoidectomy as a double-blinded trial, by using tramadol in two dosages (1 and 0.5 mg kg(-1)) and placebo. Pain assessment was done by facial pain score (FPS), visual analog scale (VAS) and postoperative analgesic requirement; further, duration of anesthesia and duration of awakening time, heart rate (HR) and mean arterial pressure (MAP) during and after anesthesia, postoperative nausea and vomiting (PONV) and recall of intraoperative events were recorded. RESULTS: It was found that 73% children in placebo group needed analgesic medicine at the end of the first hour after operation, although no analgesic medicine was needed in tramadol groups (chi(2) test, P<0.001). However, statistically significant decrease in FPS and VAS in tramadol groups were only found up to 15th and 30th min after operation, respectively (Kruskall-Wallis test, P<0.05). On the other hand, intraoperative HR (10th, 20th and 30th min) and MAP (10th and 20th min) were found to be higher in placebo groups (ANOVA variance analysis, Tukey-Kramer test adjusted paired t-test, P<0.001 and <0. 01, respectively). No significant difference was found in the other parameters, and no surgical complication and adverse side effect were occurred in this number of study sample. CONCLUSION: Tramadol in lower doses (0.5-1 mg kg(-1)) was an efficient preemptive analgesic that could be used at induction of anesthesia in adenotonsillectomies of children for providing both good analgesia during operation as supplementation to propofol anesthesia and postoperative analgesia in only early period.

Predictive value of acoustic reflectometry (angle and reflectivity) and tympanometry.

OBJECTIVE: Tympanometry and acoustic reflectometry are suggested tools for confirmation of otoscopic diagnosis of secretory otitis media. The issues on sensitivity and specificity of both devices are contradictory. In this study, our purpose was to compare sensitivity and specificity of both devices and to look for whether it is possible to reach higher values by combining them. METHODS: This study included 150 normal ears and 150 ears with chronic effusion. In tympanometry, only B tracings were accepted as predictor of effusion. In acoustic reflectometry, reflectivity (cut point: 5) and curve angle with two cut-points (75 degrees and 90 degrees) were used. RESULTS: Acoustic reflectometry presented higher specificity by both reflectivity (cut point: 5) and by curve angle (cut point: 75 degrees) (99.33% by both) than tympanometry (92%) (chi2 analysis, P < 0.001). But, their sensitivities (65.33 and 78%) were lower than tympanometry (96%) (chi2 analysis, P < 0.001). With curve angle of 90 degrees, specificity of acoustic reflectometry decreased to 85.33%, sensitivity increasing to 97.33%, which was not different from tympanometry (chi2 analysis, P > 0.1). When data of curve angle and tympanometry were combined, specificity and sensitivity of the combined test were found to be 91.33 and 100%, respectively. CONCLUSIONS: (i) Acoustic reflectometry should not be proposed as a better device than tympanometry, because its test efficiency was not higher than tympanometry. (ii) The only advantage of AR (reflectivity > or = 5 and curve angle < or = 75 degrees) was its high specificity to effusion. In addition, higher curve angles than 90 degrees were found to be highly predictive for normal ears as much as tympanometry. But, predictivity of curve angle between 76 degrees and 90 degrees was low. (iii) When tympanograms and curve angle were combined, it was found that prediction of this combination for curve angles between 76 degrees and 90 degrees was perfect. (iv) We consider that both test devices provide complementary data to each other, which would be particularly important for screening studies and that they are good tools for confirmation of clinical impression, particularly for less experienced clinicians.

Analysis of the craniofacial skeleton in cleft children with otitis media with effusion.

Various aspects have been proposed as the cause of otitis media with effusion (OME) in cleft lip and/or palate (CL/P) populations (i.e. abnormal anatomic relation of Eustachian tube (ET) musculature and soft palate; the lack of intact palatal partition; reduction of nasal patency or chronic rhinitis; timing and type of surgery). However, the role of deviated craniofacial skeleton (CFS) in CL/P has been neglected, although the role of the craniofacial development on poor ET function has been advocated in non-cleft children. In this study, we evaluated clinical and cephalometric data of 37 Japanese children with unilateral complete cleft lip and palate (UCLP, 25) or isolated cleft palate (ICP, 12) and compared them to 40 non-cleft children, who were proportionally matched for age and sex. Data showed that OME was more often in children with unilateral cleft lip and palate-UCLP (76%) and those with isolated cleft palate-ICP (67%) than non-clefts (10.00%). In addition to a number of skeletal abnormalities (i.e. short dimensions related to the posterior cranial base and backward and upward position of the maxilla) detected in CL/P cases, mastoid depth and height were also shorter in cleft cases than normal subjects. On the other hand, a small tendency to recurrent upper airway infection (RUAI) was observed in cleft cases with OME. Further, it was found that the following differences in the mastoid-middle ear-Eustachian tube (M-ME-ET) system were associated with a tendency to OME in UCLP cases: more horizontal ET in relation to the posterior cranial base; short bony ET; short height and antero-posterior depth of the mastoid air cell system.

Radiographic evaluation of children with nasopharyngeal obstruction due to the adenoid.

The adenoidal-nasopharyngeal ratio (ANR) was proposed as a convenient and practical method to evaluate adenoidal enlargement. We analyzed cephalometric radiographs of 150 children divided into 6 subgroups according to clinical assessment (possible adenoidectomy candidates [PACs] and controls) and age. Our purpose was to investigate the predictive reliability of different ANRs calculated on the same reference line. Each of the ANRs described in this study presented statistically significant differences between PACs and control groups, and highly significant correlations with clinical symptoms of nasal obstruction. Further, the mean adenoidal depth was significantly larger in PACs than in normals, and it was found that the adenoidal depth in PACs did not show a significant decrement with age. in contrast to normals. On the other hand, although nasopharyngeal depth was not different between PACs and normals, an age-dependent increment was observed in PACs, in contrast to normals. Thus, it could be said that the ANR is a more reliable method for determining whether adenoidal hyperplasia is clinically significant or not, rather than the size of the adenoid or nasopharynx.

Clinical importance of the Korner's septum.

OBJECTIVE: To evaluate the clinical importance of the petrosquamosal lamina (Korner's septum [KS]), which is not only a bony plate dividing the mastoid cells at the level of antrum, but is also a lamina starting from the posterior aspect of the glenoid fossa that extends above the middle ear cavity and courses in an inferior direction lateral to the facial canal and proceeds to the mastoid apex. STUDY DESIGN AND SETTING: A retrospective review of 688 mastoidectomies performed in University Hospital from 1987 to 1992. PATIENTS: The study group consisted of 389 males and 299 females (mean age 30.85 +/- 12.80, the youngest being 8 and the oldest being 67 years of age). MAIN OUTCOME MEASURES: The main outcome measures were the prevalence of KS encountered during mastoidectomies and comparison of prevalence of retraction pockets (RPs) or retraction and/or adhesion of the whole tympanic membrane (R/A-TM) between ears with KS and without KS. RESULTS: The prevalence of KS was 30.4% among the ears with RP or R/A-TM, 6.58% in normal ears, and 17.4% in ears with chronic otitis media without RP or R/A-TM. CONCLUSIONS: KS is an important anatomic handicap predisposing the individual to chronic otitis media, particularly when it is characterized by attic retraction pockets and cholesteatoma, and adhesive otitis media, because KS contributes to attic blockage. This statement is in accordance with the original articles written by Cheatle (1910, 1923) and Williams (1966), and recently published data related to supratubal recess and the cog (Tono et al., 1996).

The eustachian tube caliber and craniofacial skeleton in guinea pigs.

The temporal bone and eustachian tube (ET) keep developing up to adulthood in conjunction with facial growth, and the researchers considered that insufficient tubal function in childhood might be related to size, shape and position of the ET. In this study, we performed correlation and stepwise regression analyses between craniofacial skeletal parameters and diameter of the cartilaginous ET in 90 guinea pigs. Data showed that, not the potency of the lumen at the superior part of the cartilaginous ET, but the configuration of the cartilage surrounding the superior part of the ET, and position of the lateral lamina appeared to be significantly associated with the balance of the growth potentials between the naso-premaxillary unit, maxillo-zygomatic unit and the anterior cranial base. Therefore, we may hypothesize that the balance between these subunits of the developing craniofacial skeleton has determinative effect on tensor veli palatini muscle (TVPM).

Experimental otitis media induced by coagulase negative staphylococcus and its L-forms.

In a previous study, we found 15% L-forms of bacteria (predominately coagulase negative staphylococci (CNS)) in ears which gave negative cultures by conventional methods. In this study, we used an animal model to test whether CNS and its L-forms can be pathogenic and whether L-forms have a crucial role in the tendency to secretory otitis media (SOM). We inoculated the tympanic bullas of guinea pigs, in 2 groups, with CNS and its L-forms (revertant forms). We observed that both CNS and its L-forms had the capability of causing infection. However, it was milder for the L-forms than CNS. We clearly noticed that on day 30 60% of the ears inoculated with L-forms had effusion and/or retraction of the tympanic membrane. These ears were histopathologically characterized by hypertrophied pseudostratified epithelium or stratified squamous epithelial metaplasia. The ears inoculated with the original form of CNS had only 16.66% effusion. On day 60 we observed similar findings. Thus, it might be proposed that L-forms could be responsible for chronic irritation to middle ear mucosa leading to SOM.

Otitis media with effusion and craniofacial analysis-II: "Mastoid-middle ear-eustachian tube system" in children with secretory otitis media.

Secretory otitis media (SOM) is a disease of childhood, and this period is characterized by active growing of the craniofacial skeleton (CFS). In this study, we purposed to answer the question 'how deviations in CFS play a role in ethiopathogenesis of SOM'? Therefore, we evaluated the 'mastoid-middle ear-Eustachian tube (M-ME-ET) system' in 30 SOM cases and 30 healthy children by using lateral cephalographies on which reference points and one line related to CFS and 'M-ME-ET system' were pointed. The results disclosed that the bony Eustachian tube, the vertical portion of the tensor veli palatini (TVP) muscle and the mastoid air cell system were smaller in SOM cases. In the view of the statements of Enlow (1990) on craniofacial growth, we suggest that the deviations in the growth process of the nasomaxillary complex lead to corresponding imbalances in the bony tube and vertical portion of the TVP. However, since regional imbalances often tend to compensate for one another to provide functional equilibrium (Enlow, 1990), improvement of the tubal function occurs with age.

Preliminary report on L-forms: possible role in the infectious origin of secretory otitis media.

Infection and inflammation of the middle ear cleft are important factors in the pathogenesis of secretory otitis media. Although high percentages of negative cultures are confronted in many studies, strong evidence pointing to the infectious nature of this disease could not be overlooked. Many authors agree about the failure of conventional culture methods in identifying the responsible pathogen or pathogens. Besides, some agents, such as some kinds of antibiotics, lysozyme, and perhaps some undetected materials, are capable of changing bacterial behavior and consequently the clinical course. Effusions taken from 40 ears with secretory otitis media were cultured by means of conventional brain-heart infusion broth and special hypertonic thioglycollate broth. Strikingly, bacterial L-forms were detected in 6 specimens in thioglycollate broth, with no growth in the conventional broth. We concluded that these atypical forms of bacteria, the L-forms, may play an important role in the bacteriologic aspect of secretory otitis media.