Prevention of oculocardiac reflex (O.C.R) during extraocular muscle surgery.

In the present study the effectiveness of intravenous atropine sulphate which blocks the peripheral muscarinic receptors at the heart and retrobulbar xylocaine hydrochloride which blocks the conduction at ciliary ganglion on the afferent limb of OCR was studied during strabismus surgery. The study was conducted on fifty three patients of either sex having squint of more than ten years duration. The patients were randomly allocated into four groups. No preanaesthetic medication with atropine or retrobulbar block with xylocaine was given in control group of patients. In the second group, only preanaesthetic medication with atropine was given; while in the third group only retrobulbar injection of xylocaine was given five minutes before operation. In the last group both atropine as preanaesthetic medication and xylocaine as retrobulbar block were given. The electrocardiographic recordings were taken before and throughout the operative procedure. It was interesting to note that in the group where atropine and xylocaine were used none of the patients exhibited activation of OCR. Results have been discussed.

Secondary neotympanic membrane and total ossicular chain reconstruction. A preliminary report.

This new tympanoplasty technique with homo-ossicles (25 cases) has evolved as a reliable, effective, and durable technique to construct the middle ear conduction system when the total ossicular chain is missing. The isolated footplate is driven by two (primary and secondary) neotympanic membranes; hence this new technique is designated as "twin tympanoplasty." The initial hearing results (air-bone gap closure to 10 dB or less in 88% of the cases) have been good, and follow-up (six to 14 months) audiograms suggest that the hearing gain may survive the test of time. Toenail autograft could be one substitute for the ossicle as proved by satisfactory results in five cases.

Tensor tympani, a 'tuner' of tensor palati muscle.

The author has proved experimentally (in two dogs) that there is reflex hypertonia of the tensor palati muscle, synchronous with the 'shortening' reaction of the tensor tympani muscle in response to its "static" relaxation during the gradual passive inward displacement of the drum resulting from the negative intratympanic 'dip' due to absorption of air imprisoned within the middle ear. The author coined the term 'tuning' for the reflex hypertonia of tensor palati which is directly proportional to the degree of the slackness of its 'tuner', the muscle-tensor tympani. The degree of opening of the eustachian tube on swallowing depends upon the degree of 'tuning' of the tensor palati. The 'untuned' tensor palati fails to open the eustachian tube during swallowing. Presumably the excitation of tympanic chemoreceptors (glomus body) by the excess of CO2 during hypoxia of the tympanic cleft strengthens the 'shortening' reaction as well as the excitability of the tensor tympani muscle.

Functional veloplasty in bilateral palatal palsy.

A new technique for the treatment of bilateral palatal palsy involves the submucosal transposition of the tensor palati muscles of both sides to form an active muscular sling for the elevation of the paralyzed soft palate. The effect of the rerouted tensor palati muscle on Eustachian tube function and its efficacy as a substitute for the levator palati muscle in lifting the soft palate was evaluated by animal experimentation. Subsequently, two patients with bilateral palatal palsy, who failed to show improvement during a six-month period, were treated successfully with this new surgical technique, "functional veloplasty", without complication.

Functional eustachian tuboplasty: a new surgical technique.

Until recently, there was no answer for the "physiologic" stenosis of the Eustachian tube (occurring in 20% of all cases of tubal occlusion). We describe a newly devised surgical procedure-tensor palati tendon "strengthening"-for the management of physiologic stenosis of the Eustachian tube. After the initial dissection of 20 cadavers, the basic surgical procedure was worked out. Then, the experimental study was conducted in four dogs to evaluate the effects of this new operation on the Eustachian tube functions as well as on the soft palate movements. Finally, four patients with physiologic tubal stenosis were treated successfully. The follow-up period ranged from 16 to 20 months. Strict selection of patients is encouraged.

Functional anatomy of tensor palati and levator palati muscles.

An experimental study of the modus operandi of tensor and levator palati muscles over the Eustachian tube was conducted in two dogs. The tensor palati muscle is divisible into four functional units: (1) anterior part, vertical fibers; (2) middle part, oblique fibers; (3) posterior part, horizontal fibers; and (4) posterior-most part, osseous origin. Though the levator palati passively fixes the medial lamina and narrows the pharyngeal ostium, it dilates the lumen of the isthmus by two mechanisms: (1) rectification of the isthmus "kink" by bringing the cartilaginous and osseous segments into a stright line; and (2) pushing away the surrounding soft tissue pressure that is being exerted over the medial wall of the tube (not protected by cartilage). The peculiar absence of the medial cartilaginous lamina near the isthmus is attributed to the following: (1) freedom of movement of cartilaginous tube; (2) better anchorage of tubal cartilage passively by levator palati; (3) "kinking" of canal; and (4) compression of the lumen.

Physiological tympanostomy. A new technique of middle ear ventilation.

Physiological tympanostomy is advanced as a 'substitute' eustachian tube because it opens regularly only on swallowing, as does the 'natural' eustachian tube. The efficacy of the physiological tympanostomy operation was first proved in experimental animals (two dogs). Subsequently, six patients with eustachian insufficiency were successfully managed by this new surgical technique within period of one year, with no post-operative complications. The hearing improved and the middle ears remained air-filled. The method seems to have the following merits: permanent ventilation of the tympanum with preservation of an intact drum (from the functional point of view); no tympanophonia or autophonia; simple technique, short operative period (five minutes); no risk of postoperative complications; and no danger of ascending infection of the middle ear from the ear canal. The demerits appear to be: drainage not ensured; no facility to increase the middle ear pressure by the Valsalva manoeuvre or, Politzerization.

Neurogenic concept of bell's palsy. Medical decompression of facial nerve.

According to the author it is the 'transmyringal' portion of the chorda tympani nerve which in practice remains exposed to the cold atmospheric air and triggers the pathologic process involved in Bell's palsy, affecting the facial nerve secondarily, rather than a primary condition of the facial nerve. This theory was proved by creating a Bell's palsy (paralysis a frigore) with cold-air-stimuli to the tympanic membrane in experimental animals (two monkeys). On the basis of this observation the author recommend's 'medical decompression' of the facial nerve by means of infra-red fomentation of the drum, and eustachian insufflation of hydrocortisone, in cases of Bell's palsy before retrograde extension of oedema from the chorda tympani to the facial nerve can cause irreversible damage. Subsequently, the author has successfully managed fourteen cases (93-4 per cent) of Bell's palsy with a definite history of exposure to cold (paralysis a frigore). It is suggested that the ear canal be plugged with cotton as a preventive measure; and that chorda tympani neurectomy be performed to eliminate the chances of recurrence of the disease in cases of recurrent Bell's palsy.

Tympano-nasopharyngeal shunt operation. A new method of middle ear ventilation.

The tympano-nasopharyngeal shunt operation is recommended as a "substitute" Eustachian tube. An experimental study regarding the efficacy of tympano-nasopharyngeal shunt operation was conducted in two dogs. Finally, four patients with complete tubal stenosis were operated on by this new method within a period of one year, with no postoperative complications. The hearing improved and patients were able to inflate their middle ears. The method is claimed to have the following advantages: permanent ventilation of the middle ear with preservation of an intact drum; the middle-ear pressure can be increased by Valsalva or Politzer manoeuvres; moderate technical difficulties; no risk of postoperative complications; and suitable in children as well as adults. The disadvantages seem to be: drainage not ensured; minor risk of ascending infection.