[E-PTFE Membrane for the Management of Perforated Corneal Ulcer]. / E-PTFE Membran für die Behandlung von perforiertem Hornhautulkus.

Purpose: To present the surgical management of perforated corneal ulcer using PRECLUDE® Pericardial Membrane, composed of expanded polytetrafluoroethylene (e-PTFE; GORE-TEX®), as an alternative surgical procedure in patients at high risk of graft rejections and to evaluate side effects for a prolonged period. Patients and Methods: The study included all patients who were admitted to our department and underwent surgical repair of perforated corneal ulcer with the e-PTFE membrane between 2010 and 2015. In total, 8 patients (8 eyes) were enrolled. Medical records of all patients were retrospectively reviewed. The operation was performed under peribulbar anaesthesia. Non-absorbable, microporous, watertight 0.1 mm thick e-PTFE membrane was used to close the corneal ulcer. The membrane was cut to overlap the defect adequately and to achieve the desired tissue attachment without preparing the conjunctiva or superficial trephination of the cornea. The membrane was fixed to the healthy cornea with several non-absorbable sutures (Prolene® 10.0), in order to achieve the proper stress without wrinkling. Results: Five of 8 patients were treated for systemic immunological diseases. Sjögren's syndrome was diagnosed in 2 patients, granulomatosis with polyangiitis in one, vasculitis with a history of previous sclerokeratitis in one and systemic lupus erythematosus in one. In 2 patients, corneal perforation was observed as a complication of corneal infection and in one patient as a late complication of a severe chemical burn. Corneal perforations were successfully covered with e-PTFE membrane in all patients. E-PTFE membrane was well tolerated in all patients and the eye was always preserved. After 3 to 4 months, the membrane was removed in 7 patients. The underlying cornea was thin, firm, stable and vascularised. In one patient with Sjögren's syndrome, the e-PTFE membrane is still in place. Conclusion: Surgical management of perforated corneal ulcer using E-PTFE membrane may be the method of choice for eye preservation or for delayed corneal transplantation. Our results confirmed that the procedure is safe and effective, especially in high risk patients. After removing the membrane, penetrating keratoplasty can be performed as a definitive treatment in all eyes where an improvement in visual acuity is expected.

[Clinical Findings in Patients with Non-Arteritic Anterior Ischemic Optic Neuropathy (NA-AION) Under 50 Years of Age]. / Klinische Befunde bei Patienten mit nicht arteriitischer anteriorer ischämischer Optikusneuropathie (NAION) unter 50 Jahren.

BACKGROUND: The aim of our study was to determine the prevalence of NA-AION patients younger than 50 years among all our NA-AION patients and to compare clinical findings between young and elderly NA-AION patients. METHODS: This was a retrospective review of complete ophthalmic examinations, including fluorescein angiography and visual field testing, performed on all patients with the first attack of acute NA-AION admitted to our department during the period of ten years (2004 to 2013). Of 120 NA-AION patients, 10 (8.3 %) were under 50 years of age. RESULTS: The majority of these were men: 8 of 10 (80 %). The average best corrected visual acuity on admission was 0.34 (fingers counted up to 1.0) and on discharge 0.53 (fingers counted up to 1.0). Of 10 eyes, 6 were emmetropic and 4 hyperopic, from + 0.50 D to + 2.0 D. Aside from the clinical picture of AION, other ophthalmological findings were normal. In fluorescein angiography, typical changes for ischaemic optic neuropathy were observed in all patients. In a majority of patients, an inferior altitudinal visual field defect was found. As regards systemic risk factors, hyperlipidaemia was observed in 7, arterial hypertension in 3, diabetes mellitus without diabetic retinopathy in 3, and ischaemic heart disease in 1 of 10 patients. One patient was treated for rheumatoid arthritis without signs of vasculitis. In 3 patients, more than one systemic risk factor was observed. Two of our patients had no systemic risk factors except moderate hyperopia. Bilateral manifestation was observed only in one patient 8 months after the first attack. None of the patients experienced recurrent attacks. CONCLUSION: The prevalence of younger patients in our study was lower than in previous studies. The reason could be the better medical prevention in our region. Our study confirmed that even in young NA-AION patients, moderate hyperopia could be a predisposing factor. Our study did not confirm the differences between young and elderly NA-AION patients as observed in previous studies. During a period of 10 years, we did not observe recurrences, high risk of other eye involvement or severe vision loss in our young patients compared to the elderly.

[Ocular symptoms as the initial signs of Wegener's granulomatosis]. / Augensymptome als Initialzeichen von Wegener-Granulomatose.

OBJECTIVE: Wegener's granulomatosis (WG) is a systemic, necrotising, granulomatous vasculitis of unknown aetiology. Ocular involvement is present in up to 60 %. The aim of our study was firstly to evaluate the presence of ophthalmic manifestations as the first sign of WG in patients without obvious systemic manifestations of WG, and secondly to evaluate the clinical manifestation of ocular symptoms as the initial signs of WG. METHODS: The medical records of all patients with a diagnosis of WG examined at the Department of Rheumatology and Immunology during the 5-year period from January 2003 to January 2008 were reviewed. Initial manifestation of WG, initial ocular presentation, biopsy results, laboratory testing results, treatment and the final outcome were determined. Only patients in whom WG was not diagnosed at the time of the ocular symptoms were included in the study. RESULTS: Fifteen patients diagnosed with WG were identified. Six patients (40 %) developed no ocular symptoms before and after WG was diagnosed. Two patients (13.3 %) had a systemic disease first and subsequently developed ocular symptoms. Seven patients (46.7 %) had ocular symptoms as the first signs of WG (necrotising sclerokeratitis in two patients, peripheral ulcerative keratitis in two patients, non-granulomatous uveitis in one patient, anterior necrotising sclerokeratitis and nodular posterior scleritis with serous retinal detachment in one patient, severe retinal and chorioidal vascular occlusions with ischaemic optic disc neuropathy and complete visual loss in one patient). CONCLUSIONS: In nearly 50 % of patients with WG, ocular symptoms were observed as the initial signs before WG was diagnosed. The initial symptoms may be obscure and may vary from one patient to another. Knowledge of the ocular initial symptoms of WG is very important and can contribute to a better prognosis and prevention of visual loss.

Superglue in otology.

BACKGROUND: The use of stitches and staples for the closure of surgical wounds is associated with complications for both the surgeon and the patient. Histoacryl (butyl1-2cyanoacrylate glue) is widely used for wound closure in Accident and Emergency departments, in particular for facial and scalp wounds. METHOD: We have used Histoacryl for closure of various surgical incisions in a series of 50 cases and assessed the cosmetic outcome at three to four weeks. RESULTS: There were no wound related complications in the form of infection or dehiscence. In one case however, there was formation of synechiae in the external auditory meatus following an endaural incision. CONCLUSION: We recommend the use of Histoacryl over traditional closure using skin suture material in otological surgery. Our experience was also successful in parotid cases.

Ossiculotympanic transplantation.

Continued investigations into current tympanoplasty problems have been carried out in the Eye and Ear Clinic, Royal Victoria Hospital, Belfast. Retrospective studies have been helpful in identifying some of the main problems responsible for many of our unsatisfactory results, both in the irradication of disease and the restoration of aural function. Prospective studies into the behavior of grafting materials for tympanic reconstruction in the experimental animal have led us to an overwhelming preference for natural materials as opposed to plastics or stainless steel. Both homologous and autologous bone and cartilage appear to offer good prospects in ossicular replacement techniques. The most satisfactory material we have used for repair of tympanic membrane defects continues to be either autologous or homologous temporalis fascia. The long-term success of these materials in functional restoration is utterly dependent on continued aeration of the tubotympanic cleft.

Smoking and middle ear ciliary beat frequency in otitis media with effusion.

The middle ear mucociliary system has been shown to play an important role in clearing middle ear effusions. There is conflicting epidemiological evidence, however, as to whether exposure to tobacco smoke plays a significant role in persistence of middle ear effusion in patients with otherwise normal mucociliary function. Samples of middle ear mucosa from 33 patients with persistent otitis media with effusion (OME) were taken at myringotomy, together with corresponding nasal brushings. The aim of this study was to observe the mean ear ciliary beat frequency (CBF) and to compare it with nasal ciliary activity. Nasal brushings were collected from 33 age and sex matched non-smoking controls with no history of nasal atopy or topical nasal treatment. Ear CBF in OME was significantly reduced in comparison to paired nasal samples (p < 0.001). Ear CBF in adult OME patients who smoked or in children who were passive smokers was significantly less than in patients who were not exposed to cigarette smoke (p < 0.01). This study indicates that impaired ciliary function due to tobacco smoke exposure is an aetiological factor in persistent OME.

Antral washout with nasal polypectomy: should both be combined?

Two hundred and sixteen patients with nasal polyps were studied. All patients had antral washouts performed at the same time as nasal polypectomy. Two hundred and sixty aspirates were sent for culture and microscopy; bacteria were cultured from 58 of these specimens in 38 patients. One hundred and one patients had pre-operative sinus radiographs of which 94 were reported as abnormal with a 52% false-positive result. It is concluded that antral washouts should be routine in all patients having nasal polypectomy. Sinus radiographs are an unnecessary pre-operative investigation in patients with uncomplicated nasal polyps.

Objective assessment of posterior choanae and subglottis.

The assessment of children with suspected stenosis of the posterior choanae and the subglottis can be arbitrary and subjective. A study was therefore undertaken to assess the normal size of both posterior choanae and subglottis in normal children and ascertain their relationship. The size of the posterior choanae in 72 children ranged from 3-9.3 mm (3-5.5 mm when less than one year old, and 6.1-9.3 mm when older than one year). The two sides were of equal size in 51 children (p < 0.001), in 16 children the right side was larger than the left (p < 0.01), and in 5 children the left was larger than the right side. The subglottic size in 52 children ranged between 4.2-9.3 mm (1.2-5.5 mm when less than one year old, and 6.1-9.3 mm, when older than one year). The size of the subglottis was of equal size or within 1.0 mm of the average size of the two posterior choanae in 41 children (p < 0.001), and of different sizes in 11 children. Accurate and objective assessment of either area can therefore be made by measuring and comparing the two sizes in the same child.

Does nasal septal deviation influence adult posterior choanal size?

Despite the development of modern imaging techniques, no study has been carried out to establish the normal size (particularly the area) of the adult posterior choanae. In this study we present our findings of the normal anatomical sizes of the adult posterior choanae and its relationship to septal deviation, by analysing MRI images of 70 patients. Coronal sections through the sphenoid rostrum and axial sections through the nasal septum were used. There were 32 males and 38 female patients. The age ranged between 18 and 73 years (mean 35.6). Our results show that the posterior choanal dimensions were as follows: right area: 1.35-6.1 cm2 (mean 2.7 cm2); left area: 1.4-5.9 cm2 (mean 2.7 cm2); right width: 0.9-2.1 cm (mean 1.5 cm); left width: 0.9-2.2 cm (mean 1.5 cm); right height: 2.5-4.0 cm (mean 2.6 cm); and left height: 1.5-4.0 cm (mean 2.5 cm). Chi-square analysis showed no statistically significant differences between left- and right-sided measurements. Twenty-three patients had a deviated septum towards the left side, 22 patients towards the right side, and 25 patients had no septal deviation. Chi-square analysis showed no statistical correlation between deviation of the nasal septum and any of the three dimensions of the posterior choanae studied.

The incidence of sinusitis in patients with multiple sclerosis.

A retrospective study was performed to assess the incidence of sinus disease in patients with MS. The MRI scans of 108 patients referred to a regional Neurosciences Unit with a diagnosis of multiple sclerosis were examined. There were 71 females and 37 males with an age range of 22 to 67 years (mean: 39.7 years). The sagittal and axial images were reviewed and the degree of sinus disease noted. This was graded as absent, minimal, polypoid and pansinus. Fifty-seven patients (53%) had disease, the most common sinus involved was the maxillary followed by the ethmoid, frontal and sphenoid. Thirty-six patients had bilateral disease affecting the ethmoid sinuses most commonly. Three patients had fluid levels and four patients had retention cysts. The incidence of sinus disease is higher than in some other studies of normal populations.

Pneumosinus dilatans: a discussion of four cases and the possible aetiology.

Pneumosinus dilatans is an abnormal dilatation of the paranasal sinuses, which contains only air and is lined by normal mucosa. It is a rare condition, the aetiology of which is unclear. We describe four patients who presented to our department with pneumosinus dilatans. The aetiology was either developmental hydrocephalus (n = 1), post-traumatic (n = 1) or idiopathic (n = 2). Two patients underwent surgery, and follow-up is at least 12 months to date. The radiological aspects of this rare condition and the possible aetiologies are discussed.

Wegener's granulomatosis--a diagnostic challenge.

Wegener's granulomatosis is a systemic vasculitis characterized by necrotizing granulomatous lesions in the upper and lower respiratory tracts, glomerulonephritis and vasculitis involving other organs. Limited forms have been described in which some features of the disease may be absent. Four patients with this disease are being reported with special emphasis on differences in presentation, the ensuing diagnostic problems, and individual outcome. In three, the disease began as a limited form with upper respiratory tract and eye involvement, while in one patient, onset was systemic including affection of the lower respiratory tract. The mean delay from first symptoms to diagnosis was 20 months--much longer for the three limited forms than for the one with systemic onset, in whom the condition was recognized after 2 months following initial misdiagnosis of respiratory and urinary tract infections. One patient developed endocarditis and required aortic valve replacement. Immunofluorescence revealed antineutrophil cytoplasmic antibodies in all, three showing a cytoplasmic pattern and antibodies to proteinase 3, and the fourth a perinuclear pattern and antibodies to myeloperoxidase. Upper respiratory tract biopsies were not specific. Kidney biopsies were performed in all the patients and were crucial for definitive diagnosis and treatment of the disease, which was successful in three patients.

The clinical significance of antinuclear antibodies in connective tissue disease.

Antinuclear antibodies (ANA) are often present in connective tissue diseases. In 279 non-selected patients with connective tissue disease, inflammatory and degenerative joint disease, in some patients with chronic infectious diseases and malignancies and in the presence of some unclear pathologic conditions in patients whose serum reacted positively to ANA, we analyzed the type of immunofluorescence and the presence of extractable antinuclear antibodies (ENA). In systemic lupus erythematosus, the prevailing immunofluorescence is type H (homogenous) (60.6%), anti-Ro/SS-A appears in 24.2%, anti-Sm and anti-RNP in 12.1%. In Sjögren's syndrome, type S prevails (47.6%), anti- Ro/SS-A and anti-La/SS-B are present in 52.4%, only anti-Ro/SS-A in 28.6%. In systemic sclerosis, the prevailing immunofluorescence is type S (37.5%), in 75% a positive anti-Scl-70 antibody is present. In mixed connective tissue disease, anti-RNP appears in 85.7%. In dermatopolymyositis, the anti-Jo-1 antibody is present in 33.3%. In undifferentiated connective tissue disease, type S immunofluorescence appears in 70%. In rheumatoid arthritis the prevailing immunofluorescence is type H (homogenous) (46.4%) and type S (speckled) (41.0%), while the presence of ENA is rare (anti-Ro/SS-A in 4.6%). In spondylarthritis, type S immunofluorescence appears most often (62.5%). Patients with chronic infectious disease, malignancies, undefined conditions and degenerative joint disease present with various types of immunofluorescence; the presence of ENA is extremely rare in these patients. The results of this study underline the significance of ANA and, particularly ENA, in the diagnosis of connective tissue disease. These antibodies however, can also be identified in various infectious and malignant diseases as well as in inflammatory and degenerative joint diseases.

Enterogenic cyst of the nasopharynx.

An 'enterogenic cyst' of the nasopharynx is presented. The term 'enterogenic' is preferred to the currently used term 'cyst of the bursa pharyngea embryonalis'.

A valuable device in the management of epistaxis.

A suction end for use in epistaxis is presented. It has advantages over commonly used devices in offering a comfortable length for handling and adequate diameter for effective control of severe haemorrhage. It is also disposable which reduces the risk of blood borne transmission of diseases.

The ENT problems following the Birmingham bombings.

The ENT problems following the Birmingham bombings of 1974 are presented. It is during the positive phase of bomb blast that the tympanic membrane ruptures. Spalling is a likely explanation for the mechanism of rupture of the tympanic membrane specially in large perforations. Tympanic membrane defects involving 80 per cent of the surface area of the drumhead or more persisted, whereas those involving less than 80 per cent healed with conservative treatment. The majority of perforations (81.4 per cent) healed spontaneously, with a three-layered membrane. A month should be allowed for the healing of every 10 per cent loss of the surface area of the drumhead. During surgical repair of persistent perforations, the malleus handle was found to be on a deeper plain than the long process of the incus. Tympanic membrane perforations did not protect the inner ear, the sensorineural deafness producing either a high tone or a flat loss. One in four of the victims seen in the hospital complained of deafness. A patient who suffered blast injuries to the lung also developed cord palsy.

Herpes zoster of the larynx--how common?

Herpes zoster of the larynx is considered to be rare, but on reviewing the literature it is noted that some authors considered it to be more common than already acclaimed. Herpes may prove to be a common cause of cord palsies presently labelled as idiopathic and serological tests for herpes should be asked for. Of note is the fact that the cord palsy of a herpetic lesion can be short-lived and that earache is a common symptom. In this paper four cases of herpes laryngis are presented. It is advised that the larynx should be examined in all cases of herpes zoster of the head and neck.

Plasmacytoma of the larynx.

Plasmacytoma of the larynx is rare; thirty-one cases are reported in the literature and in this paper a further case is presented. The difficulty in diagnosing plasmacytoma is mentioned. Investigations to exclude multiple myeloma are mandatory to be sure that the disease is a localized lesion. Treatment of a localized lesion is essentially by radiotherapy but in the case of widespread or systemic disease, chemotherapy is recommended. A scoring system utilizing different parameters is suggested to decide whether the case has passed the borderline between local and systemic disease, a line which is invariably difficult to define.

Extramedullary plasmacytoma of the head and neck, parotid and submandibular salivary glands.

Twenty-two cases of extramedullary plasmacytomas (EMP) were diagnosed in the Birmingham region during 1962-1973. Five cases of EMP of the head and neck are discussed, including cases involving the parotid and submandibular salivary glands. Comparative data on incidence, age, sex, and survival is presented. A multidisciplinary approach is important for diagnosis, treatment and follow-up. It is mandatory to carry out investigations to exclude multiple myeloma. Radiotherapy is the treatment of choice; clinical, radiological and pathological evidence are cited. However, a residuum may be left after an initial response to radiotherapy which may require surgical removal. Chemotherapy has a place in multiple site lesions. A proportion of cases proceed to multiple myeloma after a variable period of time and thus follow-up should be life-long.

Intratympanic keratoma following grommet insertion.

An intratympanic keratoma following myringotomy and multiple Shepard's grommet insertions is presented.