Polyurethane stent obstruction as a cause of recurrent epiphora. Case report.

SUMMARY: A Song's nasolacrimal duct stent was placed in a patient with epiphora due to primary nasolacrimal duct obstruction and the stent was kept for 32 months. Mitomycin C 0.02% eye drops four times a day were prescribed for four weeks following polyurethane stent placement procedure. No epiphora-related complaints occurred for thirty months after then the epiphora started. Nasolacrimal stent was removed from nasal cavity endoscopially and the tissues within the extruded stent were examined histopathologically. The patient's complaints were relieved following stent removal. Dacryocystogram revealed normal passage and a filling defect within the lacrimal sac. Macroscopic evaluation of the stent revealed a firm mass in the stent mushroom, causing complete obstruction. Pathological examination of the mass revealed chronic inflammation, increased connective tissue and vascular proliferation. Nasolacrimal polyurethane stents can be removed easily by nasal approach. Nasolacrimal passage may be left open temporarily after stent removal. The use of Mitomycin C drop is a novel approach in nasolacrimal stent placement cases. However, when the long-term results of endoscopic and external dacryocystorhinostomy are considered, further research is needed on the biocompatibility of stent material.

Non-invasive imaging methods before fine-needle aspiration in the diagnosis of cervical masses.

A carotid body tumour is a vascular tumour usually located at or around the bifurcation of the carotid artery and originating from the tunica adventitia. Carotid body tumours, which are generally non-functional and asymptomatic, grow slowly, which is why diagnosis can be delayed. Because of the vascular structures, fine-needle aspiration biopsy may be dangerous and impractical. Efficient and reliable methods of diagnosis, such as colour Doppler ultrasound, magnetic resonance imaging, computerised tomography and arteriography, can be useful. We report on a 58-year-old woman with diarrhoea, flushing and a cervical, hard, non-tender, fixed mass. An unsuccessful diagnostic fine-needle aspiration biopsy was performed after palpation of the cervical mass. A carotid body tumour was finally diagnosed. We concluded that non-invasive imaging methods should be evaluated before fine-needle aspiration in cervical masses. It should also be kept in mind that asymptomatic cervical masses may be related to non-local symptoms.

Audio-vestibular evaluation in patients with Behçet's syndrome.

A prospective controlled clinical study was carried out at the Department of Ophthalmology and ENT, Inönü University Medical Faculty, Turgut Ozal Medical Center, Research Hospital, to evaluate the audio-vestibular involvement in patients with Behçet's syndrome compared with controls. Twenty-five consecutive patients with Behçet's syndrome (mean age +/- SD, 34.96 +/- 8.50) and 20 age- and sex-matched healthy volunteers (hospital staff) as control subjects (mean age +/- SD, 34.45 +/- 9.16) were included in this study. Behçet's patients were divided into two groups according to the number of criteria, complete (all four major criteria) and incomplete (three major criteria without ocular involvement). The groups were compared with each other or controls regarding inner ear involvement. Audiometric pure-tone thresholds at 125 to 8000 Hz were obtained in all subjects in both groups, and pure tone average (PTA) hearing thresholds were calculated for the middle, high and low frequencies. In addition, short increment sensitivity index (SISI), tone decay and BERA examinations were performed in all Behçet's patients. Sensorineural hearing loss (SNHL) was present in six of 25 patients with Behçet's syndrome. Two Behçet's patients had unilateral total SNHL, two had bilateral moderate level SNHL, one had bilateral low-frequency SNHL and one bilateral high frequency SNHL. In two, BERA, and in five SISI, examination disclosed inner ear involvement. In control subjects, the past medical history was normal and there was no consistent audio-vestibular complaint. Their PTA thresholds were all in the normal range. Otoscopic examination findings were normal, with intact, mobile tympanic membranes in both groups. The present study showed that audio-vestibular involvement is not infrequent in Behçet's syndrome compared with age- and sex-matched healthy controls, and it is under-estimated. All Behçet's patients should regularly be followed by an otolaryngologists and be given information about the possibility of inner ear involvement. According to our results, hearing loss occurs more often in older patients and also in the complete form of Behçet's syndrome.

Facilitated tissue expansion with topical estriol.

Tissue expansion is a helpful technique in reconstructive plastic surgery. Unfortunately, tissue expansion still needs to be improved. Twenty-four male Wistar rats were used to evaluate the effect of estriol on tissue expansion. The agents hyaluronidase, estriol, and base cream (as a control) were applied topically to separate animal groups for 5 weeks, and their effects were studied on tissue expansion. Both hyaluronidase (p < 0.05) and estriol (p < 0.001) enhanced the rate of expansion when compared with control animals. Estriol was more effective than hyaluronidase (p < 0.05). Breaking strengths were measured in the estriol and the control groups. Breaking strength was not evaluated in the hyaluronidase group because of the necrotic changes seen at the end of the fifth week. The breaking strength was higher in the control group than in the estriol group (p < 0.05). The authors suggest that topical estriol be used as an adjunctive agent to facilitate tissue expansion.

Identification of internal acoustic canal in the middle cranial fossa approach: a safe technique.

BACKGROUND: The middle cranial fossa approach (MCFA) is a very valuable functional approach in the armamentarium of the neuro-otologic surgeon. Identification of the internal acoustic canal (IAC) in MCFA is one of the most tedious steps. Many techniques have been described to locate the IAC safely when using the MCFA. OBJECTIVE: We sought to describe a safe technique for identification of the IAC and to demonstrate its feasibility in temporal bone dissections, as well as to discuss our clinical experience with this technique. METHODS: The surgical anatomy of the 20 temporal bones were evaluated and measured, especially by defining the medial and lateral ends of the IAC and relations to the nearby located structures. Measurements were obtained at 3 levels: the width of the IAC at the level of the fundus, the width of the IAC at the level of the porus, and the safe distance around the IAC at the meatal level. The medial and lateral IAC end widths were compared with each other and with the safe area at the meatal level. RESULTS: The smallest, the largest, and the mean values were recorded. The mean width of the IAC at the level of the porus was found to be more than 3-fold that of the width of the IAC at the level of the Bill's bar, and the ratio between the width of the medial safe area around the IAC and the lateral end of the IAC was found to be more than 7-fold as wide. CONCLUSION: This technique offers direct quick exposure of the IAC, without handling the facial nerve and the inner ear structures. Forty-five cases of operations with the same technique showed excellent ease and safety of identifying the IAC medially in the MCFA.

Comparative external versus endoscopic dacryocystorhinostomy: results in 115 patients (130 eyes).

BACKGROUND: Epiphora is an annoying symptom, embarrassing the patient both socially and functionally. The two widely accepted treatment modalities of epiphora resulting from obstruction of the nasolacrimal ductus are external and endoscopic dacryocystorhinostomy (DCR). OBJECTIVE: The aim was to compare the results, operative time, and complications of external and videoendoscopic endonasal DCR performed between December 1994 and December 1998. METHODS: In group 1, conventional primary external DCR with or without silicone tube intubation was performed in 79 patients (66 women and 13 men) with unilateral dacryocystitis. In group 2, endoscopic primary endonasal DCR with hammer-chisel removal of bone located over the lacrimal sac was performed in 51 eyes of 36 patients, 33 women and 3 men (15 bilateral procedures). RESULTS: The follow-up period was 6 to 48 months (mean 25 months) after surgery. The age range was from 4 to 76 years (mean 38.5 years). The success rates of external and endoscopic hammer-chisel DCR were found to be 89.8% and 88.2%, respectively. A lower complication rate was observed in the endoscopic group, with minimal morbidity and shorter operative time compared with the external approach. CONCLUSIONS: Hammer-chisel endoscopic DCR is practical, less traumatic, less time-consuming, and cosmetically more convenient than the external approach. The success rate of the endoscopic DCR procedure is comparable with that of traditional external DCR, and it also allows simultaneous correction of any intranasal pathology.

Assessment of ventricular repolarization in deaf-mute children.

The long QT syndrome is a congenital disease with frequent familial transmission, characterized primarily by prolongation of the QT interval and by the occurrence of life-threatening arrhythmias. The syndrome may be familial, with or without congenital deafness, or it may be idiopathic. We attempted to assess ventricular repolarization and to identify patients with the Jervell and Lange-Nielsen syndrome among 132 deaf-mute school children. Five deaf-mute subjects had Jervell and Lange-Nielsen syndrome. The deaf-mute subjects were divided into two subgroups according to the length of their QT intervals: group 1 included 5 cases with the long QT interval (>440 msec), and group 2 included 127 subjects with the normal QT interval (< or =440 msec). Group 3 was composed of 96 control subjects. The mean QT, QTc, JT, and JTc intervals (418+/-70, 500+/-38, 302+/- 65, and 389+/-36 msec, respectively) in group 1 were significantly longer than those of group 2 (344+/-23, 408+/-22, 249+/-34, and 291+/-28 msec, respectively) and group 3 (325+/-11, 383+/-26, 228 +/-36, and 269+/-46 msec, respectively). The dispersion (d) values (QT-d, QTc-d, JT-d, and JTc-d; 63+/-10, 73+/-8, 60+/-8, and 62+/-11 msec, respectively) of group 1 were significantly longer than those of group 2 (49+/-16, 43+/-11, 48+/-21, and 45+/-18 msec, respectively) and group 3 (33+/-13, 33+/-14, 28+/-16, and 27+/-14 msec, respectively) at similar mean RR intervals. Also, the mean QT, QTc, JT, and JTc intervals and the dispersion values (QT-d, QTc-d, JT-d, and JTc-d) in group 2 were significantly longer than those of group 3 at similar mean RR intervals. Consequently, in this study, we determined that the deaf-mute children who did not meet the criteria for Jervell and Lange-Nielsen syndrome still had evidence of subtle derepolarization abnormalities evidenced by intermediate prolongation of QTc, JTc, and the corresponding measures of dispersion, and we believe an electrocardiogram examination of deaf-mute subjects will reveal this potentially life-threatening syndrome.

Conservative facial nerve management in jugular foramen schwannomas.

OBJECTIVE: Although transposition of the facial nerve is crucial in infiltrative vascular lesions involving the jugular foramen, the objective was to show that a conservative approach to management of the facial nerve is sufficient with jugular foramen neuromas because of their noninfiltrative, less vascular nature and medial location in the jugular foramen. STUDY DESIGN: Retrospective case review. SETTING: Tertiary, private, multiphysician, otologic practice. PATIENTS: Sixteen patients with jugular foramen schwannoma (18 procedures) treated between January 1975 and October 1995. The 8 male and 8 female patients ranged in age from 13 to 66 years (mean age 47.7 years). INTERVENTION: One-stage, total jugular foramen neuroma removal without transposition of the facial nerve, using a variety of surgical approaches. MAIN OUTCOME MEASURES: Facial nerve transposition (yes or no), House-Brackmann facial nerve grade, lower cranial nerve status, complications. RESULTS: One-stage total tumor removal was accomplished in all the cases. In 13 (72%) of the neuromas, removal was accomplished without facial nerve transposition. Transposition was performed in 2 revision cases in which scar tissue from a previous operation prevented complete control of the carotid artery and safe removal, 2 cases with large tumor extension anteriorly to the petrous apex, and 1 case with extensive involvement of the middle ear. A House-Brackmann facial nerve Grade I or II was obtained in 16 of the 18 procedures, with 1 Grade III and 1 case that remained Grade V, as it was preoperatively. CONCLUSIONS: One-stage, total tumor removal can be achieved with excellent control of the important vascular structures and without transposition of the facial nerve in a majority of jugular foramen schwannomas.

Retrolabyrinthine vestibular nerve section: a current appraisal.

We report our experience (1987-1993) with Meniere's disease patients treated with a retrolabyrinthine vestibular neurectomy. The current literature was reviewed and our results have been compared with those of previous reports. The overall success rate for vertigo relief was 96.7%, with no serious or permanent complications resulting from the procedure. The technical elements of the operation, as they apply to our approach and those of others, have been analyzed, with special attention given to the anatomical features of the region and their influence on success or failure. We conclude that the retrolabyrinthine approach for vestibular nerve section remains a safe and highly successful technique which merits continued use.

Lower skull base: anatomic study with surgical implications.

With advances in the lateral approaches to the skull base and the increasing success of the management of jugular foramen lesions, a thorough knowledge of the anatomy of this region is needed. The purpose of the present work is to study the detailed microsurgical anatomy of the lower skull base and the jugular foramen area as seen through the lateral approaches. Forty preserved skull base specimens and 5 fresh cadavers were dissected. The shape of the jugular bulb and its relationship to nearby structures were recorded. The different venous connections of the bulb were noted. The hypoglossal canal was identified and its contents were observed. The lower cranial nerves were studied at the level of the upper neck, at their exit from the inferior skull base, and in the jugular foramen. The results of the present study showed the complex and variable anatomy of this area. The classic compartments of the jugular foramen were not always present. Cranial nerves IX through XI followed different patterns while passing through the jugular foramen, being separated from the jugular bulb by bone, thick fibrous tissue, or thin connective tissue.

Surgical management of epitympanic cholesteatoma with intact ossicular chain: the modified Bondy technique.

The results of 37 cases surgically treated with the modified Bondy technique during a 6-year period at the Gruppo Otologico-Piacenza, Italy, are reported. This technique, indicated in epitympanic cholesteatoma with good hearing and intact ossicular chain and pars tensa, provides a one-stage mastoid cavity exteriorization with radical removal of cholesteatoma while preserving the preoperative hearing levels. The technique, indications, results, and comparison with other current techniques are discussed in this article.

Revision stapes surgery: a critical evaluation.

Fifty-six revision stapes surgeries performed during the last 9 years were evaluated retrospectively for their preoperative symptoms, intraoperative findings, and postoperative results according to the causes of failure, at the Gruppo Otologico, Piacenza, Italy. The most frequent causes of failure were found to be prosthetic misalignments, a reaction to the surgical trauma in the form of excess fibrous tissue reaction or new bony regrowth at the oval window, and ossicular chain problems. The location of the pathology was found to be an important factor in the outcome. Sixty percent of cases resulted in 0- to 20-dB air-bone gap. The causes of these failures, management, and their prevention during primary surgeries are also discussed.

Surgical anatomy of the petrous apex as it relates to the enlarged middle cranial fossa approaches.

This work was designed to study the surgical anatomy of the petrous apex as it relates to the enlarged middle cranial fossa approaches, on 25 temporal bones. In this study we suggest dividing the petrous apex into two topographic areas: an anterior triangular and a posterior quadrangular area with respect to the posterior border of the Gasserian ganglion. Anatomic descriptions endorsed by relevant measurements of these areas are provided in this study.

The enlarged translabyrinthine approach for removal of large vestibular schwannomas.

This study was carried out to validate the enlarged translabyrinthine approach for the surgical management of large vestibular schwannomas. A retrospective review of the charts of 53 patients with large tumours removed via the enlarged translabyrinthine approach at the Gruppo Otologico, Piacenza, Italy, during the last five years was carried out. The ability to control large tumours and the achievement of total removal with low morbidity and very few complications, demonstrate that tumour size does not influence the use of the enlarged translabyrinthine approach for managing large tumours.

Surgical anatomy of the extended middle cranial fossa approach.

The extended middle cranial fossa approach includes removal of the petrous bone from its subtemporal surface in order to expose widely the internal auditory canal and the posterior fossa dura around its porus while preserving all the important and closely related anatomical structures. We have dissected 25 temporal bones and five fresh cadavers in order to define the limits of this approach. Measurements were obtained between the different structures to find reliable angles and distances that could guide working in this area. A new method of identification of the internal auditory canal is discussed based on the measurements taken.The results of the present work showed wide variations in the different structures. The arcuate eminence was coincident with the superior semicircular canal in only 48% of bones. Dehiscence of the geniculate ganglion and of the internal carotid artery was noted in 16% and 20% of specimens, respectively. The angles measured between the different structures showed great variations. However, the angle between the internal auditory canal and superior petrosal sinus was constant. Though the extended middle cranial fossa is a versatile approach, it affords a limited access to the cerebellopontine angle. A thorough understanding of the complex and variable anatomy of this area is necessary should this approach be utilized.