Botulinum toxin in the treatment of cricopharyngeal dysphagia.

Dysphagia is a common symptom in various neurological disorders affecting pharyngeal functions. Cricopharyngeal dysfunction is one of the major findings in these patients. The most effective treatment for restoring normal swallowing function in persistent cricopharyngeal dysfunction is cricopharyngeal myotomy, especially when mechanical obstruction or a well-localized neuromuscular dysfunction, such as a cricopharyngeal muscle spasm, is present. However, when there is a more diffuse neurological disorder present the results of surgery are more disappointing. In unclear cases, or in patients with temporary problems, no good method other than swallowing training, bougienage, and tube feeding are available. During the past decade, botulinum toxin has been found to be of therapeutic value in the treatment of a variety of neurological disorders associated with inappropriate muscular contractions such as torticollis and spasmodic dysphonia. Recently, injections of botulinum toxin in patients with cricopharyngeal muscle dysfunction have been reported to result in marked relief of dysphagia. In this article we describe our experiences with botulinum toxin injections to treat four patients suffering from deglutition problems and cricopharyngeal dysphagia of different origins. Botulinum toxin was injected into the cricopharyngeus muscle that was identified by endoscopy under general anesthesia. In this study, no major side effects were observed. Three patients obtained a significant improvement of esophageal symptoms after the first injection. The treatment had limited effect in one patient who had reflux disease and only slight cricopharyngeus dysfunction.

Long-term results of tracheostomy for severe obstructive sleep apnea syndrome.

Severe obstructive sleep apnea (OSAS) is most often accompanied by metabolic syndrome, obesity, diabetes and coronary disease. In its most severe form, it is a life-threatening condition, requiring active and immediate help. Nasal continuous positive airway pressure (CPAP) is the most efficient nonsurgical treatment for patients with OSAS. However, for anatomical, disease-related and subjective reasons, many patients cannot accept this treatment. A permanent tracheostomy may be one alternative in such patients who, in addition, often suffer from extreme obesity and severe heart disease. In this paper, we describe the long-term follow-up results of 7 patients suffering from OSAS and treated with permanent tracheostomy. All the patients (5 men, 2 women) were diagnosed using the static charge sensitive bed method and night-time oximetry for sleep analysis. The mean body mass index (BMI) of the patients ranged from 34 to 60 and the age from 41 to 64 years. All the patients had severe OSAS and long periods of low oxygen saturation (SaO2) levels. Six patients had a CPAP trial before tracheostomy. Only 2 patients tolerated the trial but, despite the continuous use of CPAP, they were nonresponders. Permanent tracheostomy was done according to normal routine in each patient. After primary healing of 2 days, they used silver cannulae, which also allowed them to speak. The patients were evaluated every year after the tracheostomy. After some practical difficulties including proper maintenance of the cannula, all the patients quickly learned the correct management. In postoperative sleep studies, nadir SaO2 levels had improved significantly, obstructive apneas had disappeared and the subjective quality of life had improved. No marked changes in BMI were found.

Audiovestibular findings and location of an acoustic neuroma.

Forty-one patients with unilateral acoustic neuroma (AN) were diagnosed by magnetic resonance imaging (MRI) between 1992 and 1997. All cases were analyzed with respect to tumor location and the results of audiometric examinations, auditory brainstem response (ABR) testing, and electronystagmography (ENG). Tumor location was determined by MRI and cases were divided into intracanalicular and extracanalicular sites. Intracanalicular tumors were significantly smaller than the extracanalicular ones The pure-tone hearing thresholds were better in ears with intracanalicular lesions than in those with extracanalicular ones. Respectively, speech reception thresholds were 33 dB and 45 dB, and speech discrimination scores 79% and 65%. ABR was abnormal in 98% of ANs, but was insufficient for determining tumor location. The ENG pursuit test was more frequently normal and the caloric side difference was smaller in ears with intracanalicular than extracanalicular AN. These findings show that the results of pure-tone and speech audiometry and ENG are better in ears with intracanalicular AN, while ABR results are similar regardless of tumor location.

Pure-tone audiometric and impedance measurements in school-aged children in Finland.

Pure-tone audiometric and impedance examinations were performed in 687 Finnish school children in the first, fourth and eighth grades (ages, 7, 10 and 14 years old) to study the sensitivity and usability of hearing and tympanometric screening examinations in schools. There were 138 children (20.1%) with a hearing loss > 15 dB in at least one frequency. Among these children, 103 were found to have pure sensorineural losses while 35 children had conductive losses. Of all the sensorineural losses, 118 of the cases involved slight high-frequency changes. Six children had hearing losses at speech range and all had been previously diagnosed. Six other children had 20-30 dB losses at 3-6 kHz, with 5 of these children diagnosed for the first time. Twenty-four of the children with conductive losses had middle ear effusions that were found at a 15 dB screening level for hearing. When the limit of normal tympanometric peak pressure was-150 daPa, 36 of 38 ears with middle ear effusions were found tympanometrically. Judging by the findings of the present study, we recommend that routine pure-tone audiometric screening for 7- and 10-year-old children in schools could be discontinued but should be continued for 14-year-old children. In contrast, tympanometry with a tympanometric peak pressure limit at-150 daPa should be used as a screening procedure for 7-year-old children on school entry.

Transtympanic electrocochleography in evaluation of cochleovestibular disorders.

We examined the electrocochleography (ECochG) parameters in patients suffering from Meniere's disease (n = 5) or other type of vertiginous disorder (n = 4). Fourteen ears were examined by introducing a needle electrode through the tympanic membrane to the promontorium. The summating potential (SP), action potential (AP) and the SP/AP ratio were measured from the alternating polarity click response, and the latency difference from the condensation and rarefaction click responses. These 2 patient groups differed from each other most clearly as to the audiometry results and the duration of symptoms. We also found differences in electrocochleographic results, especially in latency differences between the condensation and rarefaction click responses. Although the present material is small we conclude that transtympanic electrocochleography is a sensitive method to measure cochlear potentials, and might be a valuable addition in diagnosing patients suffering from various cochleovestibular disorders.

The hearing threshold levels of children at school age.

OBJECTIVE: To measure the hearing threshold levels by air conduction in a group of unselected and a group of selected (otologically normal) school-aged children. DESIGN: Six hundred eighty-seven unselected school children representing three age groups and 471 selected, otologically normal children were examined by pure-tone audiometry. RESULTS: The obtained results showed that hearing levels improved with age from 7 to 10 yr in children in both groups. The pure-tone averages (PTAs) of the right and the left ear in otologically normal children were, respectively, 1.8 and 1.2 dB HL in 7-yr-old children, -0.9 and -1.7 dB HL in 10-yr-old children, and -1.3 and -2.0 dB HL in 14-yr-old children. The PTAs were 0.2 to 1.9 dB poorer in the groups of unselected children. CONCLUSIONS: The present study provides new data on the hearing sensitivity among unselected 7-, 10-, and 14-yr-old school children. Furthermore, it provides normative values on the hearing thresholds of otologically normal children in these three age groups.

Immittance findings in school-aged children.

OBJECTIVE: The purpose of the present study was to obtain the median values and distributions of tympanometric variables and the distributions of acoustic reflex thresholds for three age groups of unselected school-aged children. Furthermore, the investigation was undertaken to provide normative immittance data for selected, otologically normal 7-, 10-, and 14-yr-old children. DESIGN: A total of 687 children, aged 6 to 15 yr, were thoroughly examined clinically, audiometrically, and tympanometrically. The same examinations were made in 471 otologically normal children, selected from the total population on the basis of the findings that both tympanic membranes were otomicroscopically healthy, and the hearing thresholds were better than or equal to 25 dB HL at all frequencies. RESULTS: The results showed that the median equivalent ear canal volume (Vec) increased from 0.65 ml to 1.00 ml with increasing age both in the unselected and selected populations. The median peak admittance values (Ytm) were between 0.55 and 0.5 mmho in the respective study groups, somewhat higher in older than in younger children. The same tendency was also seen in gradient and tympanometric peak pressure (TPP) results. Depending on the age, the median tympanometric peak pressures were 5 to 10 daPa higher in otologically normal children than in the unselected population. The median TPP was -10 daPa in a group of unselected children, and -5 daPa in a group of otologically normal children. The distribution of ipsi- and contralateral acoustic reflex thresholds is presented. Thresholds were higher in younger than in older children. CONCLUSIONS: The obtained results give new information on immittance findings in an unselected sample of school-aged children who were representative of children in the general population. Furthermore, the results are useful as normative immittance values in 7-, 10-, and 14-yr-old children when the limitations relating to the equipment are taken into account.

C1-tuning fork tests in school-aged children.

The Rinne and the Weber tests were carried out using a 256-Hz tuning fork on 687 6- to 15-year-old school children, the majority of whom were normally hearing subjects. The Rinne test was positive in 97% of ears with normal hearing or sensorineural hearing loss and negative in 72% of ears with conductive hearing loss. The Rinne test changed from positive to negative at 13 dB when performed using the normal loudness comparison method. In midline Weber results, the mean value of the air conduction difference at 0.25 kHz between the right and left ear was 1.4 dB. The lateralization in the Weber test occurred at a difference of 2.5 dB between the right and left ear. The Weber test was in midline in 96-98% of ears with bilateral normal hearing or sensorineural hearing loss. It lateralized to the poorer ear in 63% of ears with unilateral conductive hearing loss. The values of the Rinne and Weber tests were not good in the diagnosis of mild conductive hearing loss when the air-bone gap was 5-35 dB.

Prevalence of septal deviations in school-aged children.

A total of 687 school children, aged 6-15 years, were examined for nasal septal deviations with anterior rhinoscopy and maxillary sinus radiography. Septum deviations were divided into four different categories and the final evaluation included the clinically significant deviation, based on purely morphological findings. Columella deviation was an exceptional condition in 0.7% of children, septum spurs were found in 3.8%, bending of the quadrilateral cartilage was present in 13.4%, and premaxillary luxation in 28.7%. A clinical diagnosis of septum deviation was made in 9.5% of children. The occipitomental projection of the maxillary sinus X-ray was a good diagnostic tool in evaluating the clinical significance of septum deviation.

Adenoids in school-aged children.

A total of 687 school children, aged six to 15 years, were examined clinically, radiologically and audiometrically. Lateral radiological examination of paranasal sinuses was carried out in 663 (96.5 per cent) children for evaluation of the size of adenoids. The size of the soft tissue shadow (adenoids) was assessed as normal or large. It was large in 133 (25 per cent) children, three times more frequently in seven-year-old than in 14-year-old children. The occurrence of adenoidal symptoms (blocked nose, mouth breathing, snoring, snuffling or rhinitis) varied from 14.3 to 30.1 per cent in children with large adenoids compared to 7 to 9.8 per cent in children with normal adenoids. Logistic regression analysis revealed that only recurrent snoring and the child's age were significantly associated with radiologically large adenoids. The hearing thresholds were 1.1 to 4.2 dB poorer and mean middle ear pressure values were 60 to 70 mmH2O lower in children with large adenoids compared to those with normal size adenoids. Large adenoids have an influence on the hearing level of a child, but probably via the negative middle ear pressure.

Influence of tympanic membrane changes on audiometric and immittance findings in school-aged children.

Six-hundred-and-eighty-seven 6 to 15-year-old children were examined for the association between tympanic membrane (TM) changes and audiometric or immittance findings. The hearing thresholds were between 20 and 30 dB in ears with amber TM, but between 25 and 45 dB in ears with adhesive TM. When the TM was retracted or the mobility decreased, the hearing thresholds were about 10 dB poorer than in ears with normal TM position or mobility. Thick TM caused hearing loss in the high-frequency areas. The hearing loss was only marginal (3-4 dB) in ears with retracted pars flaccida compared with ears with normal position of pars flaccida. The mean and median middle ear pressure value was lower than -200 da Pa in ears with dull, amber, retracted, poorly movable, adhesive or thick TM. It was between -100 and -200 da Pa in ears with red TM, locally retracted pars tensa or retracted pars flaccida. Stapedius reflex thresholds were higher in ears with one or several abnormal findings than in normal ears.