Necrotizing external otitis: diagnostic clues in the emergency department.

PURPOSE: The assessment of necrotizing external otitis requires a high index of suspicion by the attending physician. The purpose of the study is to determine the accuracy of parameters available at the Emergency Department for the diagnosis of this pathology. METHODS: Retrospective diagnostic accuracy study. Patients consulting at the Emergency Department for longstanding ear swelling, severe otalgia, and failure to respond to topical treatment were included. Otoscopy, physical examination, CT appearance, and analytical results were tested for the diagnosis of necrotizing external otitis, using nuclear imaging as gold standard. Sensitivity, specificity, likelihood ratios and ROC curves were calculated. RESULTS: 24 patients were included; 13 cases were necrotizing external otitis, and 11 cases were other external ear pathologies. Erythrocyte sedimentation rate and C-reactive protein levels were significantly associated with necrotizing external otitis (AUC 0.92 p < 0.001, and 0.8 p < 0.001). Positive likelihood ratios were 10.15 for values of erythrocyte sedimentation rate over 26 mm/h, and 8.25 for C-reactive protein levels over 10 mg/L. Negative likelihood ratios were 0.08 and 0.28, respectively. These results were significant. The rest of clinical and radiological parameters were less accurate. CONCLUSIONS: Erythrocyte sedimentation rate and C-reactive protein are useful parameters in the evaluation of a case of longstanding otitis with clinical suspicion of necrotizing external otitis. If any of them is elevated, the probability of suffering this condition is significantly increased. If they are within normal ranges, an alternative diagnosis should be sought.

Injection laryngoplasty under ultrasonographic control.

BACKGROUND: Cervical ultrasound allows real-time visualization of the laryngeal structures. We describe its application for injection laryngoplasty in the voice clinic. METHODS: Hyaluronic acid infiltration of the vocal fold under ultrasonographic control. CONCLUSIONS: With this technique, the position of the needle in the depth of the vocal fold and its spatial relations with nearby structures can be assessed. This allows for an accurate infiltration of the material in contrast to other techniques and avoids discomfort related to the gag reflex with nasofibrolaryngoscopy. No specific complications have been observed so far, however, this technique may be difficult in cases with calcified cartilages or uncooperative patients.

Greater palatine artery pedicled flap for nasal septal perforation repair: radiological study and case series.

PURPOSE: The greater palatine artery (GPA) is one of the main vessels supplying the nasal septum. We recently described a novel technique to reconstruct a nasal septal perforation (NSP) using a GPA flap. This radiological study explores the feasibility and limits of using a GPA flap for an anterior NSP repair. METHODS: We describe our technique for repairing anterior-most NSP. Radiological measurements of the GPA flap and their limits were analysed. Additionally, a cohort of four patients who underwent reconstruction of a NSP with a GPA flap was included. RESULTS: The radiological study of 150 nasal cavities showed a 31.5 ± 2.7 cm2 maximum flap area. Taking into account the retraction process (30%), the remaining area was 22.0 ± 1.9 cm2. The septal area anterior to the GPA was 6.1 ± 2.1 cm2. The septal portion of the flap was larger than the area anterior to the GPA pedicle in all cases. Complete NSP repair was achieved in four patients. All cases of NSP remained closed during the follow-up. CONCLUSION: The unilateral GPA pedicled flap is a useful technique suitable for the reconstruction of anterior-most perforations that are difficult to cover with other endonasal techniques.

Validation of the Hearing Handicap Inventory for Adults Scale for Spanish-Speaking Patients.

OBJECTIVE: To perform translation, cross-cultural adaptation, and validation of the hearing handicap inventory for adults scale (HHIA) to the Spanish language. STUDY DESIGN: Prospective study. SETTING: Tertiary neurotologic referral center. PATIENTS: The study included 104 hearing impaired persons. Inclusion criteria were adults with untreated hearing loss, diagnosed in the past 12 months. A control group of 30 normal hearing subjects was also recruited. INTERVENTION: HHIA was translated and translated back, and a pretest trial was performed. Feasibility, internal consistency, test-retest reliability, construct validity, and ceiling and floor effects were assessed for the present study. MAIN OUTCOME MEASURES: The mean overall score of the HHIA was 31.9 (0-100 scale, lowest to highest handicap). Cronbach's α was 0.95. Intraclass correlation coefficient was performed for each item, with an overall score of 0.95. The k coefficient scores ranged between moderate and almost perfect in all patients. The emotional score of the HHIA was correlated with the mental component of the SF-12. CONCLUSIONS: Feasibility, internal consistency, reliability, and construct validity outcomes in the current study support the validity of the Spanish version of the HHIA.

Cochlear Implantation in Postlingual Adult Patients With Long-Term Auditory Deprivation.

OBJECTIVE: The role of long-term hearing deprivation in cochlear implant performance is not well established, and the limits for implanting an auditory deprived ear are still unknown. The objective of this study was to evaluate the effect of long-term auditory deprivation time on cochlear implant results. STUDY DESIGN: Retrospective case review study. SETTING: Cochlear implantation tertiary referral center. PATIENTS: Adult patients with postlingual deafness. INTERVENTION: Unilateral cochlear implantation between 2001 and January 2015. MAIN OUTCOME MEASURES: Age at implantation, sex, etiology of hearing loss, and duration of auditory deprivation in the implanted ear were collected. Cochlear implants results were expressed in terms of vowel identification, disyllabic word recognition, and sentence recognition.Spearman's correlation test was applied to determine the relationship between auditory deprivation time and speech recognition scores. Additionally, patients were divided according to their auditory deprivation time before implantation in group A (less than 10 yr) and group B (more than 10 yr). RESULTS: One hundred three patients met inclusion criteria for this study. There were 61 patients in group A, with a mean deprivation time of 2.52 years. There were 42 patients in group B, with a mean deprivation time of 19.67 years.There were no statistically significant differences between both groups regarding speech recognition scores.Deprivation time in the implanted ear was not statistically correlated with cochlear implantation performance. CONCLUSIONS: Long-term auditory deprivation in the ear to be implanted does not negatively influence cochlear implantation results and should not be considered criterion to reject cochlear implantation.

Validation of the Penn Acoustic Neuroma Quality-of-Life Scale (PANQOL) for Spanish-Speaking Patients.

Objective To perform translation, cross-cultural adaptation, and validation of the Penn Acoustic Neuroma Quality-of-Life Scale (PANQOL) to the Spanish language. Study Design Prospective study. Setting Tertiary neurotologic referral center. Subjects and Methods PANQOL was translated and translated back, and a pretest trial was performed. The study included 27 individuals diagnosed with vestibular schwannoma. Inclusion criteria were adults with untreated vestibular schwannoma, diagnosed in the past 12 months. Feasibility, internal consistency, test-retest reliability, construct validity, and ceiling and floor effects were assessed for the present study. Results The mean overall score of the PANQOL was 69.21 (0-100 scale, lowest to highest quality of life). Cronbach's α was 0.87. Intraclass correlation coefficient was performed for each item, with an overall score of 0.92. The κ coefficient scores were between moderate and almost perfect in more than 92% of patients. Anxiety and energy domains of the PANQOL were correlated with both physical and mental components of the SF-12. Hearing, balance, and pain domains were correlated with the SF-12 physical component. Facial and general domains were not significantly correlated with any component of the SF-12. Furthermore, the overall score of the PANQOL was correlated with the physical component of the SF-12. Conclusion Feasibility, internal consistency, reliability, and construct validity outcomes in the current study support the validity of the Spanish version of the PANQOL.

Clinical Assessment of Glottal Insufficiency in Age-related Dysphonia.

OBJECTIVES: Incomplete glottal closure is one of the key clinical aspects of presbylarynx. The objective of the present study is to determine the diagnostic yield of several tests for the assessment of glottal competence in age-related dysphonia. STUDY DESIGN: Cross-sectional prospective. METHODS: One hundred and four healthy patients 65 years and older with a maximum phonation time below 12 seconds for women and 15 seconds for men were included. The glottal closure was assessed with laryngostroboscopy, and this observation was used as gold standard. Continuous light endoscopy, s/z ratio, electroglottography, and aerodynamic analysis of voice were performed, and their accuracy parameters for the diagnosis of the glottal gap in this context were calculated. RESULTS: A spindle-shaped gap was observed in 47 cases. Sensitivity of vocal fold bowing to predict glottal gap in phonation was 93.6% with a negative likelihood ratio of 0.15. Specificity of s/z ratio was 91.4% with a positive likelihood ratio of 6.17. Electroglottography and aerodynamic measurements of voice resulted to be inaccurate for the diagnosis of glottal insufficiency in phonation. CONCLUSIONS: Conventional endoscopy and s/z ratio are good diagnostic tests for an initial assessment of glottal insufficiency in age-related dysphonia that would allow general otolaryngologists early identification and prompt treatment of this pathology.

The Aging Voice: Influence of Respiratory and Laryngeal Changes.

OBJECTIVES: To evaluate the impact on voice quality of 2 pathogenic factors involved in age-related dysphonia: glottal gap and decline in respiratory function. STUDY DESIGN: Cross-sectional prospective. SETTINGS: Tertiary referral center. SUBJECTS AND METHODS: A total of 105 healthy patients ≥65 years old were included, with a maximum phonation time ≤15 seconds for men and ≤12 seconds for women. Laryngostroboscopy and spirometry were conducted to assess the glottal gap and respiratory function, and 4 profiles were defined according to their combination: glottal deficit, respiratory deficit, combined deficit, and no deficit. Differences across profiles in phonation times, acoustic parameters, and GRBAS scale and Voice Handicap Index-10 scores were analyzed according to Kruskal-Wallis and Mann-Whitney nonparametric tests. Multiple regression was performed to estimate the influence of each pathogenic factor. RESULTS: Respiratory deficit was the most frequent profile (37%). When compared to the other groups, patients with combined deficit had shorter phonation times for men (8.5 seconds; Kruskal-Wallis, P = .009) and women (7.8 seconds; P = .003), worse jitter (8.3%; P = .001), GRBAS scale (5.8; P < .001), and Voice Handicap Index-10 (7.7; P = .002). CONCLUSION: Age-related respiratory and laryngeal changes have a negative impact on vocal quality, especially when both deficits are present.

Long-term results of the transattical approach: an alternative technique for cochlear implantation.

Cochlear implantation through the standard posterior tympanotomy approach may sometimes be challenging. In cases with complicated anatomy or malformations, an alternative surgical technique may be chosen. The transattical approach is a simple technique based on a mastoidectomy and a transmeatal cochleostomy. The electrode is driven to the middle ear through the attic. This way it overcomes some of the standard technique's drawbacks. Our aim is to assess the value of this alternative approach in cochlear implant surgery. We conducted a comparative retrospective study; we included 74 patients operated by transattical approach and 59 patients operated with the standard technique. Auditory performance and complications at long term follow-up were compared. The consequences of the different trajectory of the electrode in the transattical approach were also studied. No significant differences were found between both groups regarding complication rates and cochlear implant performance. The electrode's integrity was not significantly affected by its different position and angles, when compared to the standard approach. We conclude that transattical approach is a safe technique for cochlear implantation. It may be considered as an alternative to the posterior tympanotomy approach for those cases where this cannot be performed.

Effect of BCG vaccination in asthmatic schoolchildren.

Recent studies have explored the effect of Bacilli Calmette-Guerin (BCG) or Mycobacterium vaccae vaccination in asthmatic patients, yielding conflicting results. We investigated the effect of BCG vaccination in asthmatic schoolchildren, especially focusing on the cytokine pattern released by mononuclear cells. After a 1-yr run-in period, 67 asthmatic schoolchildren received intradermal immunization with BCG (33 patients) or placebo (34 patients). Both groups were followed during 1 yr. Serum immunoglobulin E (IgE) levels did not change after BCG (407.1 +/- 86.6 vs. 415.1 +/- 86.7 IU/ml, mean +/- s.e.m.), but increased after placebo (406.7 +/- 67.0 vs. 619.7 +/- 90.7 IU/ml, p = 0.001) administration. Interleukin (IL)-4 and interferon (IFN)-gamma measured in the supernatant of stimulated cultured blood mononuclear cells did not change in the BCG group (10.8 +/- 2.3 vs. 17.9 +/- 5.7 pg/ml, and 348.6 +/- 118.0 vs. 354.8 +/- 139.0 pg/ml, respectively), while in the control group IL-4 increased (from 6.7 +/- 1.3 to 16.1 +/- 6.0 pg/ml, p < 0.05), and IFN-gamma decreased (from 279.9 +/- 82.1 to 232.1 +/- 109.6 pg/ml, p = 0.01). In comparison with their initial status, most patients maintained the same asthma severity and the same proportion of emergency room visits at the end of the study. The proportion of those in whom asthma improved or worsened was the same in both groups. We concluded that, contrary to the common hypothesis, BCG vaccination in asthmatic children was unable to cause a long-term reinforcement of Th(1) response, although it could avoid the increased Th(2) response observed in control patients.

[Origins of the rachial administration of cocaine in Spain]. / Orígenes de la raquicocainización en España.

The use of a rachidial pathway for the obtaining of anaesthesia has been the consequence of two events: The discovering of cocaine by Köller and the description made by Corning of the intraspinal passage. If we add to it the attempt to avoid side-effects from ether and chloroform, we find, at the beginning of the century, an enormous increase in the use of the intrarrachidial technique. In the present work, we endeavour to trace the origins of this technique in Spain as well as exposing it and the most outstanding results.

[Intra-arterial regional anesthesia]. / La anestesia regional intraarterial.

One of the most easy and effective ways for obtaining insensibility at the extremities, with a minimal danger for the patients, is the intravenous regional anesthesia. However, the origin of this type of anesthesia still remains controversial. Some of the questions suggested by this theme are answered in this article. It is very likely that the basis of this technique were established by Dr. José Goyanes Capdevila, who by the beginning of this century was a lecturer in Surgery at Madrid's University. It must be considered that he used the arterial pathway following the anatomical and physiological criteria in use then.

[Spinal anesthesia using a strychnine-stovaine combination in Spain]. / La raqui-estrieno-estovainización en España.

Since, in 1898, Augustus Bier developed the injection of anesthetic agents in the intradural space following Corning's technique, there have been many changes in the technique to the present day. One of the most popular was rachi-striene-stovainization, which was introduced by Jonnesco and attempted to replace general anesthesia (general rachianesthesia). We describe the original technique, its development and the modifications introduced by two Spanish physicians, Drs. Sagarra and Bartrina. We also discuss its advantages and drawbacks.