Mastoid obliteration with hydroxyapatite vs. bone pâté in mastoidectomy surgery performed on patients with cholesteatoma and chronic suppurative otitis media: a retrospective analysis.

PURPOSE: To compare the efficacy and safety of hydroxyapatite vs. bone pâté as obliteration material in mastoidectomy surgery for patients with chronic suppurative otitis media and cholesteatoma. METHODS: This is a retrospective, multi-center, cohort study. All patients were followed up with micro-otoscopy, audiometry, and, if indicated, MRI with diffusion-weighted imaging. The following outcome parameters were analyzed: procedure safety (wound infections and complications), cholesteatoma recidivism rates (residual/recurrent), control of infection (Merchant's scale), and hearing results (pure-tone averages at 500/1000/2000/4000 Hz). RESULTS: Eighty-three cases were included: 45 obliterated with hydroxyapatite and 38 with bone pâté, with a mean follow-up time of, respectively, 25 and 24 months. Wound infections were only detected in the bone pâté group (4.8%) and successfully treated with oral or intravenous antibiotics and surgical drainage (p = 0.026). No other major surgical complications were observed in both groups. Cholesteatoma recidivism was observed in 15% using hydroxyapatite and 12% using bone pâté (p = 0.471). Complete control of infection (Merchant 0) was achieved in 76.2% using bone pâté and 86.8% using hydroxyapatite at 12 months postoperatively (p = 0.223). All patients showed good postoperative healing without complete failure to manage infection (Merchant 3). Pre- and postoperative audiometry showed significant improvement in hearing results in both groups. No significant difference between the obliteration materials was observed. CONCLUSIONS: Evaluation of mastoid obliteration reveals that hydroxyapatite and bone pâté are safe and effective obliteration materials, with high success rates in achieving a dry ear, low recidivism rates, and good hearing outcome, respecting the short-term limitation. In addition, our study shows that hydroxyapatite results in fewer postoperative wound infections compared to bone pâté.

Bioactive glass (S53P4) as obliteration material in subtotal petrosectomy: initial experience.

BACKGROUND: Subtotal petrosectomy for chronic suppurative otitis media requires obliteration of the mastoid cavity and middle ear. Usually, abdominal fat is used for this purpose. However, infection is a risk of using fat, which might require revision surgery. The use of S53P4 bioactive glass with antibacterial properties seems an attractive alternative. METHODS: Two patients with a history of chronic suppurative otitis media, complicated by profound perceptive hearing loss, had already been surgically treated, and were thereafter extensively treated conservatively. Because of recurrent chronic otorrhoea and pain, subtotal petrosectomy with obliteration of the cavity with S53P4 bioactive glass was performed. RESULTS: Follow-up duration was 84 months and 18 months, respectively. No complications occurred peri-operatively. A dry ear was obtained and no late adverse events were observed. CONCLUSION: S53P4 bioactive glass is feasible to use for obliteration after subtotal petrosectomy. Elimination of chronic suppurative otitis media can be achieved with this technique. The bioactive glass granules might be an attractive alternative to abdominal fat, which has a risk of infection.

A possible case of complex regional pain syndrome of the nose?

OBJECTIVE: We present a case report of a patient with a putative diagnosis of complex regional pain syndrome of the nose. We would like to bring this disorder to the attention of rhinologists. CASE REPORT: A 53-year-old man presented with a history of extreme, constant, debilitating pain in his nose that started after he underwent several extensive nasal surgeries. Examination revealed atrophic nasal mucous membranes at the nasal septum. No other abnormalities were found. The pain did not diminish despite administration of analgesics and neuropathic pain medications. We propose a diagnosis of complex regional pain syndrome of the nose. CONCLUSION: The large number of nasal surgeries performed worldwide and the far reaching consequences of this debilitating syndrome indicate that it merits further investigation to determine whether it is a distinct disorder that should be recognized as such.

Treatment of non-tuberculous mycobacterial cervicofacial lymphadenitis in children: critical appraisal of the literature.

BACKGROUND: Surgical excision has historically been the treatment of choice for non-tuberculous mycobacterial cervicofacial lymphadenitis. Emerging data suggests antibiotic treatment alone could be an attractive alternative to surgery. We questioned (1) what treatment offers best cure rates in children with this condition and (2) the evidence for antibiotic treatment alone. TYPE OF REVIEW: Structured literature search according to the Evidence Based Medicine guidelines. SEARCH STRATEGY/METHODS: A structured search was conducted in PubMed, Embase and the Cochrane Library from 1966 up to November 2007. Relevant papers were critically appraised. RESULTS: Six papers were included, one of which was a randomised controlled clinical trial (RCT). In general, treatment sequencing was not consistent. Surgery and medical treatment were often used in combination, resulting in high overall cure rates. In the RCT surgery and antibiotic treatment were compared as single modalities. The outcome of surgery was far superior (96%versus 66% cure rate, respectively). Other studies indicated that substantial cure rates (up to 67%) were achieved with medical management alone, but failed to identify factors predicting response. CONCLUSION: Surgical excision still is the backbone in the management of cervicofacial non-tuberculous mycobacterial lymphadenitis, although a considerable number of children can be cured with antibiotics alone or combined modality treatment. To date it is unclear which subset of patients can benefit from antibiotic treatment only.

A novel local treatment strategy for advanced stage head and neck rhabdomyosarcomas in children: results of the AMORE protocol.

The AMORE protocol is a local treatment regimen for head and neck rhabdomyosarcomas (HNRMS), consisting of Ablative surgery, Moulage technique brachytherapy and surgical Reconstruction. The aim of AMORE is to intensify local treatment for children with HNRMS and to avoid external beam radiation therapy (EBRT) and its long-term sequelae. All children with primary irresectable, non-orbital HNRMS in whom EBRT was indicated, were evaluated for the feasibility of AMORE. In 20 children, AMORE was performed (15 with parameningeal disease and five with non-parameningeal disease). Complete remission was achieved in all 20 patients. Local complications were limited. 5 patients experienced a local relapse and 1 patient developed distant metastases. Estimated 5-year OS and EFS were 67.5 and 64.1% for the entire group, and 64.2 and 60.0% for the parameningeal subgroup. We conclude that the AMORE protocol is a feasible strategy, with a good local control rate. Long-term sequelae of EBRT might be avoided although, to date, the follow-up is too short for definitive conclusions regarding these sequelae.

Recovery of kiwifruit vines from transient waterlogging of the root system.

The extent to which kiwifruit vines (Actinidia deliciosa var. deliciosa) recovered from transient waterlogging of the root system was determined under controlled conditions. Vines were waterlogged for periods varying from 1 to 7 days. The effects of decreasing concentrations of oxygen in the root zone on growth of the vine were rapid with substantial reductions occurring after being exposed to oxygen concentrations in the surrounding water of less than 0.125 mmol l1 for as little as 1 day. There was no evidence of recovery of growth once aeration was restored to the roots, except for the appearance of new roots at the base of the stems of vines that had been waterlogged for less than 5 days. The quantity of new roots grown was inversely related to the time of waterlogging. Although new roots were also found on the control vines, the quantities involved were very much less than for the vines stressed for up to 4 days. No new roots were found for vines waterlogged for more than 4 days. The substantial loss of dry weight of roots of vines waterlogged for more than 3 days was due in part to a lack of growth and to a physical loss of root tissue. The loss of tissue resulted from the detachment of the cortex from the central stele through the dissolution of an entire layer of cortical cells which, in the control vines, were filled with starch. A microscopic examination of the cells of the root from waterlogged vines showed the cortical cells to be generally distorted with much of the intercellular material missing. The closure of the stomata within 2-3 h of the roots being waterlogged and the rapid desiccation of the leaves that followed the closure, was consistent with earlier findings with kiwifruit vines. Some recovery of stomata activity occurred for vines that had been waterlogged for less than 4 days once the oxygen supply to the root was restored. For vines that had their roots submerged for only 1 day, stomatal activity was fully restored 3 days after the vines were removed from the water. In contrast, there was no recovery of stomatal activity for vines that had been waterlogged for more than 3 days. A feature of stomatal behaviour that was not related to the effects of oxygen stress was the cyclic pattern which developed. Each cycle repeated itself every 4-6 days and consisted of a period of high stomatal conductance followed by a sharp decline to a much lower level. A highly significant negative relationship was found between the level of photosynthetically active radiation and stomatal behaviour. It was concluded that the speed with which the roots die and the associated damage to the leaves under anoxic conditions greatly limits the ability of kiwifruit vines to resume growth once oxygen supply to the root has been restored.

Imaging and analysis of perivascular nerves in human mesenteric and coronary arteries: a comparison between epi-fluorescence and confocal microscopy.

Perivascular nerves supplying human arteries can be visualised after immunohistochemical staining for a variety of markers. The pattern and density of perivascular nerves vary with region, age and disease. Quantification of the nerve plexus, which may be performed by image analysis, is a prerequisite to assess differences in nerve density. The use of epi-fluorescence microscopy (EFM) presents difficulties in visualising the nerve plexus in certain tissues, which can affect the reliability with which specific staining can be localised and distinguished from non-specific staining. In this study, confocal scanning laser microscopy (CSLM) was used in parallel with EFM, in order to compare images from both techniques. In a comparison of identical areas of nerve plexuses of human mesenteric and coronary arteries stained for protein gene product (PGP) 9.5 and imaged using CSLM and EFM, higher values for area percent (area occupied by nerves), and intercept density (ID/mm, which reflects the number of nerve bundles detected) were found in CSLM images. Similar comparisons of unmatched epi-fluorescence and confocal images from a group of 45 mesenteric arteries revealed no significant difference for area percent, but significantly higher values for ID/mm in CSLM images. These findings illustrate that the better image quality in CSLM influences image analysis and can be very useful in studies of dynamic changes in nerve plexuses. We recommend CSLM for tissues that suffer from high background staining, such as human mesenteric and coronary arteries.

The AMORE protocol as salvage treatment for non-orbital head and neck rhabdomyosarcoma in children.

AIM: To investigate the feasibility and outcome of the AMORE protocol as salvage treatment in paediatric head and neck rhabdomyosarcoma (HNRMS). METHODS: The AMORE protocol is a local treatment regimen, consisting of Ablative surgery, Moulage technique brachytherapy and surgical Reconstruction, scheduled in 1 week. Patients with recurrent or residual non-orbital HNRMS were eligible for AMORE salvage treatment. RESULTS: The procedure was feasible in nine out of 11 eligible patients. Five patients were treated for recurrent or residual parameningeal RMS after prior chemoradiation. Local complete remission was achieved in all five patients and maintained in four. Three patients are without evidence of RMS with a follow-up duration of 4-10 years. Two patients developed a distant relapse, together with a local recurrence in one. Both patients died of their disease. Four patients were included for recurrent non-parameningeal HNRMS. Long-term local control at the site of recurrence was obtained in all four patients (follow-up 5-10 years). CONCLUSIONS: The AMORE protocol is a feasible salvage strategy for non-orbital HNRMS even after external beam radiotherapy. The local salvage rate in this series is promising.

[Annual chest X-ray in patients after treatment for laryngeal or oral cancer: only a limited number of second primary lung cancers detected]. / Jaarlijkse thoraxfoto bij patiënten na behandeling wegens een larynx- of een mondholtecarcinoom: slechts beperkt rendement ten aanzien van tweede primaire tumoren in de long.

OBJECTIVE: To evaluate the detection of second primary lung cancer in patients treated for laryngeal or oral cancer by means of the current annual chest radiography screening program. DESIGN: Retrospective follow-up. METHOD: In a source population of Utrecht University Hospital consisting of patients treated for laryngeal or oral cancer, the occurrence of non-simultaneous second primary lung cancer was analysed. The charts of the patients who developed second primary lung cancer were reviewed with respect to diagnosis (either by means of routine annual chest radiography or triggered by symptoms and signs) and treatment of lung cancer. A Kaplan-Meier survival analysis was performed for both routes of diagnosis and for each form of lung cancer treatment. RESULTS: The source population consisted of 2067 patients. Second primary lung cancer was diagnosed in 44 patients (37 with laryngeal and 7 with oral cancer). In 21 patients lung cancer was diagnosed by means of annual chest radiography (routine group). The remaining 23 patients presented with symptoms and signs (symptomatic group). In 13 patients, surgery with curative intent was performed. These patients had the best prognosis. Of the surgical cases, 12 out of 13 patients (27% of the total of 44) were in the routine group. Patients in the routine group had better survival than those in the symptomatic group. CONCLUSION: In view of the limited number of patients with second primary lung cancer and the small percentage of patients eligible for curative surgical treatment detected by annual radiography, screening in its present form is of little benefit.

Botulinum toxin A injection into corrugator muscle for frontally localised chronic daily headache or chronic tension-type headache.

OBJECTIVE: To describe our results with botulinum toxin type A injection for headache in carefully selected patients, and to present the rationale behind this therapy. SETTING: Tertiary referral centre. PATIENTS AND METHODS: This article describes a case series of 10 consecutive patients with frontally localised headache, whose pain worsened when pressure was applied at the orbital rim near the supratrochlear nerve. The patients received a local anaesthetic nerve block with Xylocaine 2 per cent at this site. If this reduced the pain, they were then offered treatment with botulinum toxin. INTERVENTION: Injection with 12.5 IU of botulinum toxin A into the corrugator supercilii muscle on both sides (a total of 25 IU). MAIN OUTCOME MEASURE: Pain severity scoring by the patients, ranging from zero (no pain) to 10 (severe pain) on a verbal scale. RESULTS: Following injection, all patients had less pain for approximately two months. This treatment did not appear to have lasting side effects. CONCLUSION: Xylocaine injection is a good predictor of the effectiveness of botulinum toxin injection into the corrugator muscle as treatment of frontally localised headache. We hypothesise that this pain is caused by entrapment of the supratrochlearis nerve in the corrugator muscle. Furthermore, we found botulinum toxin injection to be a safe and effective means of achieving pain relief in this patient group.

Accumulation and partitioning of dry matter and mineral nutrients in developing kiwifruit vines.

Size, dry weight and mineral nutrient content of fruit, leaves, shoots, canes, leader, stem and roots of kiwifruit (Actinidia deliciosa (A. Chev.) C.F. Liang et A.R. Ferguson var. deliciosa) vines, aged from one to five years, were measured. The distribution of fruit yield among single canes was examined in three of the vines. Total dry weight increased from a mean of 1.29 kg vine(-1) for one-year-old vines to 29.2 kg vine(-1) for five-year-old vines. The proportion of total dry weight in roots declined from the first to the third year (55 to 40%) and then remained approximately constant, whereas the proportion of dry weight in fruits increased from the first to the third year before attaining a more or less constant value. The proportion of total canopy dry weight contained in the current season's growth (fruit, leaves and shoots) averaged 75% for all ages. Roots of five-year-old vines had only penetrated a small proportion of the total soil volume available. Total fruit yield increased linearly with number of floral shoots for whole vines and single canes within vines, but with cane size (length or dry weight) for whole vines only. The productivity of single canes declined from 2.5 kg m(-1) for canes shorter than 0.25 m to about 1.1 kg m(-1) for canes longer than 1.0 m, in accordance with a declining bud density with increasing cane length. For vines of all ages, mineral nutrient concentrations in various tissues were similar, except that Ca in leaves and S in leaves and shoots increased with vine age. Major sites of accumulation of N, Ca, Mg, S, Fe, Mn and B were the leaves, whereas P and K accumulated predominantly in the fruits, Zn in the leader, and Na and Cu in the roots. Estimated annual mineral nutrient uptake increased with vine size and fruit yield, and for five-year-old vines the values per hectare were 141 kg N, 19 kg P, 169 kg K, 161 kg Ca, 28 kg Mg, 32 kg S, and less than 2 kg for Na and all micronutrients. The nutrient content of the harvested fruit provided an inaccurate estimate of annual nutrient uptake of the developing vines.

Canopy photosynthesis and respiration of kiwifruit (Actinidia deliciosa var. deliciosa) vines growing in the field.

Net CO(2) assimilation (A) for canopies of kiwifruit (Actinidia deliciosa var. deliciosa) vines enclosed in a whole-canopy cuvette was measured continuously for three periods of 15-20 days during late summer, near Hamilton, New Zealand (latitude 38.2 degrees S). Canopy A showed an asymptotic response to incident radiation (PAR), saturating at about 1300 micromol m(-2) s(-1) for one vine and about 800 micromol m(-2) s(-1) for two other vines. Radiation interception at low solar angles and low leaf area apparently limited the response of A to PAR. Radiation saturated rates of A were 25-30 micromol CO(2) m(-2) s(-1) for one vine, and 12-18 micromol CO(2) m(-2) s(-1) for two other vines. At any PAR, canopy A was often lower in the afternoon than in the morning. Canopy respiration averaged 8.9 micromol CO(2) m(-2) s(-1) at 12 degrees C, but increased only 24-34% over the range 7-17 degrees C. Net daily C gains for the whole canopy, calculated as the temporal integral of A, ranged from -0.8 g C m(-2) for a cloudy day (PAR

Carbon dioxide efflux from roots of calamodin and apple.

The specific rate of CO(2) efflux (respiration) from roots of intact fruiting calamodin plants (Citrus madurensis Lour.) showed no diel trend, and did not respond significantly to short-term (2 day) changes in shoot irradiance. Mean root respiration rate was about 8.4 nmol CO(2) g(-1) s(-1) at 20 degrees C, and increased with temperature with a Q(10) of about 2. In calamodin plants, the proportion of total root length that was white averaged 6.0 mm m(-1). Respiration of roots of apple plants (Malus domestica Borkh.), planted in spring as rootstocks and grown at high irradiance and N supply, declined from about 5.3 to 2.8 nmol CO(2) g(-1) s(-1) between 46 and 138 days after bud burst. At 50% irradiance, root respiration was reduced more than 25% at 46 and 92 days after bud burst, but was not significantly affected later in the season. Reducing shoot irradiance reduced the proportion of total root length that was white, e.g., from 217 to 146 mm m(-1) at 46 days after bud burst. For plants previously grown at low irradiance, increasing shoot irradiance for 6 days increased the rate of root respiration by 5 to 10%. For plants previously grown at high irradiance, reducing shoot irradiance for 6 days reduced root respiration by about 20% early in the season, but had no significant effect later in the season. For plants grown with low-N supply (5% of the high-N), root respiration was reduced early in the season, but was not significantly affected later. Reducing the N supply increased slightly the proportion of total root length that was white. For plants previously grown with low-N, increasing the N supply for 6 days reduced further the rate of root respiration. For plants previously grown with high-N, reducing the N supply for 6 days did not significantly affect the rate of root respiration. Specific respiration rates of root systems excised from mature trees growing outdoors peaked in June, at about 2.4 nmol CO(2) g(-1) s(-1), and then declined for the remainder of the growing season.