Manometry of the normal upper esophageal sphincter and its alterations in laryngectomy.

Rapid pull-through pressure profiles of the normal human upper esophageal sphincter (UES) were simultaneously studied with a conventional three-orifice Honeywell solid-state probe, an eight lumen radially perfused (RP) probe, and a circumferentially sensitive (CS) probe designed to measure UES pressure (UESP) without regard to probe orientation. Pressure curves were digitized and analyzed by computer. The Honeywell probe recorded significantly lower peak pressures than the other two methods, and had wide intrasubject pressure variations (average coefficient of variation, 53%). In contrast, UESP measured with the CS probe was constant for each subject (mean peak UESP, 121 mm Hg; average coefficient of variation, 15%). Anteroposterior RP probe UESP were identical to CS probe pressures. Thus, peak perfused anteroposterior UESP correlates with circumferentially measured sphincter squeeze.Computer programs were written that allowed RP probe pressures to be mapped in three dimensions. Normal three-dimensional maps were characterized by anteroposterior accentuation of peak pressures and also by consistent axial asymmetry with anterior peak pressures occurring 0.8+/-0.2 cm closer to the pharynx. After defining the normal two- and three-dimensional UESP configuration, patients who had undergone laryngectomy were studied. Peak pressures measured with the RP probe decreased to congruent with50 mm Hg and radial pressure asymmetry vanished. Like normals, CS probe pressures corresponded to peak RP probe pressures. UES length did not change significantly. Three-dimensional mapping showed that axial asymmetry also vanished. It therefore appears that the anatomic alterations produced by laryngectomy abolishes UESP asymmetry.

Auditory dysfunction in aging and senile dementia of the Alzheimer's type.

OBJECTIVE: To determine the prevalence and type of auditory dysfunction in older volunteer subjects with mild probable Alzheimer's disease (pAD). METHODS: Pure-tone thresholds, word recognition in quiet, Synthetic Sentence Identification with Ipsilateral Competing Message or Contralateral Competing Message, distortion-product otoacoustic emissions, and auditory brain-stem responses were done in 82 elderly volunteer subjects whose cognitive, psychologic, and neurologic status had been determined through annual testing in a research center. Based on clinical criteria and the Clinical Dementia Rating (CDR) scale, 40 subjects had been judged to be nondemented (CDR score, 0), and 42 had a clinical diagnosis of pAD, with 22 in the questionable (CDR score, 0.5) and 20 in the mild (CDR score, 1) categories. RESULTS: The mean age-adjusted pure-tone average thresholds (0.5, 1.0, and 2.0 kHz) were poorer in the subjects with pAD by 5.1 dB in the right ears and 6.1 dB in the left ears; these differences were not statistically significant. Word recognition in quiet did not differ by CDR category. The age-adjusted scores on the Synthetic Sentence Identification with Ipsilateral Competing Message or Contralateral Competing Message were significantly reduced in the subjects with mild pAD. Distortion-product otoacoustic emission amplitudes and auditory brain-stem response thresholds and latencies paralleled the pure-tone threshold results and did not differ across the CDR groups. CONCLUSIONS: Central auditory dysfunction was evident in subjects with even mild cases of pAD, whereas peripheral auditory function was not different from that in age-matched control subjects. Additional research is needed to delineate the mechanisms of central auditory dysfunction and to establish the sensitivity and specificity of auditory testing in subjects with Alzheimer's disease. We recommend auditory assessment, including Synthetic Sentence Identification with Ipsilateral Competing Message or Contralateral Competing Message, for older patients in general and in particular for those in whom dementia is suspected.

Hearing loss and antiretroviral therapy in patients infected with HIV-1.

OBJECTIVE: To explore the association between hearing loss and antiretroviral therapy in human immunodeficiency virus type 1 (HIV-1)-infected persons. DESIGN: Case-control study. SETTING: University-based HIV clinic. PARTICIPANTS: Volunteer sample of 99 HIV-infected patients. INTERVENTIONS: Standardized interview focusing on risks for hearing loss, review of clinic pharmacy records, and hearing tests by portable audiometry. MAIN OUTCOME MEASURE: Hearing loss, defined as threshold of more than a 25-dB hearing level at 4000 Hz in 1 or both ears. RESULTS: Hearing loss was common, seen in 29 subjects (29%). It was significantly associated with age and history of ear infection and tended to be more common in subjects prescribed antiretroviral agents. An interaction existed between age and antiretroviral therapy; the association between hearing loss and antiretroviral therapy was significant for subjects aged 35 years or older, but not for subjects younger than 35 years. In subjects aged 35 years or older, this association remained significant using a multivariate model that included those variables found to have the greatest potential for confounding (odds ratio, 4.6; 95% confidence interval, 1.0-20.5; P = .05). CONCLUSIONS: Hearing loss is common among HIV-infected individuals and is associated with antiretroviral therapy in those aged 35 years or older.

Safety of ofloxacin otic and other ototopical treatments in animal models and in humans.

To assess the safety of topical agents in the middle ear, animal studies were reviewed. Compared with aminoglycoside-containing preparations, which caused significant loss of hair cells in the basal turn of the cochlea, ofloxacin caused no loss of hair cells, even at concentrations higher than used clinically. Moreover auditory brainstem testing revealed no change in auditory thresholds in the ofloxacin-treated animals, whereas neomycin-treated animals showed substantial threshold shifts. In human studies, use of topical ofloxacin 0.3% was not associated with any change in hearing. Topical ofloxacin has no demonstrable adverse effects on middle ear or cochlear function.

Controversy over tubes and adenoidectomy.

Dr. Bluestone then summarized the panelists' discussion by stating that there is now evidence that myringotomy alone for chronic otitis media with effusion has some efficacy but is probably no better than watching the child and not performing surgery. He also stated there are now some data to show that myringotomy and tube insertion for chronic otitis media with effusion appear to be more beneficial than either watching a child over a long period of time or performing myringotomy alone. However, the panelists made a plea that each child should be individualized on the basis of the duration of the effusion, the child's response to medication, the time of the year, distance from health care providers and other factors. Dr. Gates stressed that hearing loss was an important factor, but if hearing loss is a deciding factor, then serial audiograms or at least some assessment of hearing in the clinician's office should be performed. He also stated that there is now evidence that adenoidectomy is effective in certain children, but there is still an 80% recurrence rate and a 15% rate of failure in which children require repeat surgery. Dr. Bluestone suggested that parents and the child (if old enough) should be informed of what is known about the risks, costs and benefits of these surgical procedures. He recommended the clinician discuss with the parents the pros and cons of performing or not performing surgery, including the complications and sequelae of otitis media and also of tube insertion.(ABSTRACT TRUNCATED AT 250 WORDS)

Functional MR spectroscopy of the auditory cortex in healthy subjects and patients with sudden hearing loss.

PURPOSE: To use MR spectroscopy to study the biochemical changes produced by auditory stimuli in patients with sudden sensorineural hearing loss and to compare these findings with the biochemical changes seen in healthy volunteers. METHODS: Single-voxel MR spectroscopy was used to study biochemical changes in the auditory cortex in 11 control subjects and 19 patients with sudden sensorineural hearing loss. MR spectroscopic signals were measured during three different sound conditions (scanner noise, music, and sirens). RESULTS: A lower MR spectroscopic lactate signal was observed in control subjects during the music stimulus than during the other sound conditions. This music-induced lactate change was not observed in patients with hearing loss. The other proton metabolites (choline, creatine, N-acetylaspartate [NAA]) remained stable during the different auditory stimuli. However, the NAA/creatine ratio was higher in the auditory cortex of patients than in the control subjects, and was not dependent on the sound condition. CONCLUSION: The detection of stimulus-induced and stable biochemical MR spectroscopic changes in patients with hearing loss may be useful in assessing disease activity.

Longitudinal threshold changes in older men with audiometric notches.

Age-related hearing loss (presbycusis) is a multifactorial process that results chiefly from the accumulating effects of noise damage and aging on the cochlea. Noise damage is typically evidenced clinically by a discrete elevation (notch) of the auditory thresholds in the 3-6 kHz region of the audiogram whereas aging affects the highest frequencies first. To determine whether the presence of such high-frequency notches influences auditory aging, we examined the 15 year change in audiometric thresholds in 203 men from the Framingham Heart Study cohort. The mean age at the first hearing test was 64 years (range 58-80). Occupational and recreational noise exposure over the 15 years was assumed to be minimal due to the age of the subjects. The presence or absence of a notch was determined using a piecewise linear/parabolic curve fitting strategy. A discrete elevation of the pure-tone thresholds of 15-34 dB in the 3-6 kHz region was deemed a small notch (N1), and elevations of 35 dB or greater were deemed large notches (N2). Absence of a notch (N0) was encoded those ears with <15 dB elevation in the 3-6 kHz region. The presence and absence of notches correlated with the subjects' history of noise exposure. The 15 year pattern of change in age-adjusted pure-tone thresholds varied significantly by notch category. There was less change over time in the notch frequencies (3-6 kHz) and significantly greater change in the adjacent frequency of 2 kHz in the N2 group as compared to the N0 and N1 groups. The adjacent frequency of 8 kHz showed a significant, but smaller, change in the N1 group as compared to the N0 and N2 groups. The change at 2 kHz was independent of the starting hearing level at E15, whereas the changes at 4-8 kHz were influenced by the hearing level at E15. These data suggest that the noise-damaged ear does not 'age' at the same rate as the non-noise damaged ear. The finding of increased loss at 2 kHz suggests that the effects of noise damage may continue long after the noise exposure has stopped. The mechanism for this finding is unknown but presumably results from prior noise-induced damage to the cochlea.

Nerve excitability testing: technical pitfalls and threshold norms using absolute values.

Percutaneous stimulation of the facial nerve is used widely in tests to judge the severity and prognosis of facial paralysis. Several test paradigms are used including nerve excitability threshold (NET), the maximum stimulation test (MST), and electroneuronography (EnoG). Consistent technique and careful control of variables are essential to achieve accurate test results. The sources of variability examined in this study were age, gender, body weight, and the use of electrode paste; the NET was used as the test method. The facial NET in 120 adults without a history of facial paralysis increased linearly with age (P = .0004) and with body weight (P < .0001) and was higher in men than in women adjusted for age and weight (P = .0001). The mean NET +/- SD was 0.7 +/- 0.27 mA in the upper division using the eyelid twitch as an end point, and 1.2 +/- 0.40 mA in the lower division. There was no statistically significant difference in the results between sides. The NET was falsely elevated by the use of electrode paste, presumably due to current shunting away from the nerve. Based on the technique described herein, an absolute NET of > or = 1.25 mA in the upper division or an absolute NET > or = 2.0 mA in the lower division of the human facial nerve is statistically abnormal. These norms are not applicable to grossly obese patients or patients with facial edema or inflammation. Statistical norms allow the NET results to be reported on a continuous scale rather than the dichotomous scale used in the past. The predictive power of the NET will be greatly enhanced by basing test interpretation on both statistical and clinical significance.

Clinimetrics of Meniere's disease.

Two clinically useful measures to quantify the morbidity of Meniere's disease are the daily vertigo diary card and the Meniere's Disease Patient-Oriented Severity Index (MD POSI). The development and application of these outcomes instruments for patients with vertigo are discussed.

Upper esophageal sphincter: pre and post-laryngectomy--a normative study.

Correlation of anatomical, surgical, manometric, and radiographic observations leads to the conclusion that the normal high pressure zone of the pharyngoesophageal junction is composed of two parts: an annular muscular sphincter in the most proximal part of the upper esophagus and, above this, a complex pinchcock sphincter composed of the cricoid cartilage anteriorly and cricopharyngeus muscle laterally and posteriorly. The pinchcock part of the sphincter produces a high pressure zone in a predominantly anteroposterior direction. After laryngectomy, the sphincter becomes completely annular and behaves like a pure musculare constrictor; it is likely that both the cricopharyngeus and the upper esophageal circular muscles constitute the postlaryngectomy pharyngoesophageal high pressure zone. The relative contributions of the pinchcock segment (upper part) and annular constrictor segment (lower part) to the overall function of the upper esophageal sphincter have yet to be established in man.

Masked mastoiditis.

With the advent of broad-spectrum antibiotics, the clinical course of middle ear disease has been altered. One result has been the occasional suppression of the presenting signs and symptoms of mastoiditis secondary to acute middle ear disease, causing the clinician to have a false sense of security following apparent resolution of the middle ear infection. The course may be so insidious that the first awareness of the mastoiditis may be following presentation of an intracranial complication such as meningitis, lateral sinus thrombosis, or brain abscess. The authors report 9 patients seen in the past 5 years with masked mastoiditis, ranging in age from 4 months to 43 years. The presenting symptoms were all vague and non-classical; however, intracranial complications of meningitis, facial paralysis, brain abscess, and papilledema were present on admission in 7 patients, and another 2 patients had unsuspected epidural abscess upon surgical exploration. The mastoid radiographs were uniformly positive, while the CT scan was positive in 3/9 patients. All patients recovered following mastoidectomy and intracranial therapy except one patient who expired after brain herniation. The clinician is urged to maintain a high suspicion of masked mastoiditis in the high-risk patient, including newborn, diabetic, elderly, immunosuppressed or debilitated patients.

Laryngotracheoplasty for acquired subglottic stenosis in infants and children: experience with six cases.

Six children aged 6-50 months with acquired subglottic stenosis persisting after medical and endoscopic treatment underwent 7 open resections of the stenotic tissue followed by internal stenting. Five were successfully decannulated after an average treatment time of 6.8 months; the sixth died after accidental extubation. All 5 have satisfactory vocal and respiratory function 11 to 36 months postoperatively (6-18 months postextubation). Transcartilaginous open resection of subglottic stenosis is a feasible treatment option which can be used, even in the infant, when expectant observation is not advisable.

Noise-induced hearing loss in young adults: the role of personal listening devices and other sources of leisure noise.

CONCEPT: No consensus exists regarding the magnitude of the risk of noise-induced hearing loss (NIHL) associated with leisure noise, in particular, personal listening devices in young adults. OBJECTIVE: Examine the magnitude of hearing loss associated with personal listening devices and other sources of leisure noise in causing NIHL in young adults. STUDY DESIGN: Prospective auditory testing of college student volunteers with retrospective history exposure to home stereos, personal listening devices, firearms, and other sources of recreational noise. METHODS: Subjects underwent audiologic examination consisting of estimation of pure-tone thresholds, speech reception thresholds, and word recognition at 45 dB HL. RESULTS: Fifty subjects aged 18 to 30 years were tested. All hearing thresholds of all subjects (save one-a unilateral 30 dB HL threshold at 6 kHz) were normal, (i.e., 25 dB HL or better). A 10 dB threshold elevation (notch) in either ear at 3 to 6 kHz as compared with neighboring frequencies was noted in 11 (22%) subjects and an unequivocal notch (15 dB or greater) in either ear was noted in 14 (28%) of subjects. The presence or absence of any notch (small or large) did not correlate with any single or cumulative source of noise exposure. No difference in pure-tone threshold, speech reception threshold, or speech discrimination was found among subjects when segregated by noise exposure level. CONCLUSION: The majority of young users of personal listening devices are at low risk for substantive NIHL. Interpretation of the significance of these findings in relation to noise exposure must be made with caution. NIHL is an additive process and even subtle deficits may contribute to unequivocal hearing loss with continued exposure. The low prevalence of measurable deficits in this study group may not exclude more substantive deficits in other populations with greater exposures. Continued education of young people about the risk to hearing from recreational noise exposure is warranted.

Effect of adenoidectomy upon children with chronic otitis media with effusion.

To investigate the mechanism whereby adenoidectomy influences the subsequent course of patients with chronic otitis media with effusion, we analyzed, on the basis of adenoid size, the outcomes of 476 children randomly assigned to receive, after paracentesis and aspiration of the middle ear, either no treatment, tympanostomy tubes, adenoidectomy, or both. The two groups receiving adenoidectomy did significantly better than those who did not, and the effect was independent of adenoid size. This suggests that reduction of the adenoidal bacterial reservoir may be the mechanism whereby adenoidectomy is effective.

Post-tympanostomy otorrhea.

Otorrhea is the most common complication of surgical drainage of the tympanum for the treatment of chronic secretory otitis media. Otorrhea present at the first postoperative visit may be due to the operative procedure, the underlying disease process, or both. After analyzing data from 525 operations on 1045 ears of 396 children with chronic secretory otitis media, and finding an over-all incidence of immediate postoperative otorrhea of 3.4%, we conclude that preparations of the ear canal with povidone iodine and the postoperative prophylactic use of an antimicrobial-corticosteroid topical preparation provides optimal control of postoperative wound infection. Sporadic increases in the incidence of postoperative otorrhea may be due to extrinsic factors such as outbreaks of upper respiratory infection.

An IgD extramedullary plasmacytoma involving the sphenoid sinus at onset: an immunohistochemical study.

A 60-year-old man developed a left VIth-nerve paralysis and underwent biopsy of an extramedullary plasmacytoma in the sphenoid sinus. Immunohistochemistry demonstrated cytoplasmic IgD and lambda determinants. Subsequent specimens from left clavical and thoracic epidural lesions also showed a plasma cell neoplasm with IgD and lambda determinants. No abnormal plasma cells were found in bone marrow specimens. Lambda Bence-Jones protein and monoclonal IgD-lambda protein in the serum were detected several months after onset. The patient died with disseminated plasmacytoma 1 year after diagnosis. The mode of presentation, pattern of metastasis, and secretory features were typical of extramedullary plasmacytoma arising in the upper airway. Immunohistochemistry was more productive than serum electrophoresis and immunoelectrophoresis for following the course of this neoplasm.

Combined intracranial and extracranial excision of nasopharyngeal angiofibroma.

Of all angiofibromas, 10% to 20% may have intracranial extensions or receive vascular supply from the internal carotid artery. Until recently, the treatment of intracranial involvement has been radiation therapy. However, with improved anesthetic and neurosurgical techniques, transfusion capabilities and embolotherapy, the combined intracranial and extracranial excision of an angiofibroma has resulted in a low morbidity and mortality and a greater chance for complete excision of the tumor. The authors present the management of three patients with intracranial involvement of their tumors. Use of the midfacial degloving approach to the nasal cavity and paranasal sinuses has resulted in a significant improvement in the cosmetic appearance postoperatively.

Optic nerve decompression via the lateral facial approach.

Two cases of visual loss after lateral orbital wall fracture are presented: one with retrobulbar hematoma and evidence of optic nerve compression who failed to respond to lateral canthotomy and high-dose corticosteroid administration, and the second with immediate, total blindness associated with fracture of the bony optic canal. In both, extradural decompression of the orbit and optic nerve was achieved through the lateral facial approach with partial return of visual acuity and without surgical complications. The role of orbital and optic nerve decompression in the management of patients with blindness following orbital trauma is controversial. Orbital decompression may be of value for cases of post-traumatic visual loss unresponsive to medical management. If optic nerve injury is suspected as the cause, the additional step of decompression of the optic nerve is a logical but unproven procedure. The indications for optic nerve decompression are not established and should be considered only within the context of the specific needs of the individual patient.

Pseudomonas mastoiditis.

Opportunistic infections of the external auditory canal or the middle ear due to Pseudomonas aeruginosa occurring in patients with low resistance to infection have a 35 percent mortality rate. Once the process extends into the pneumatized temporal bone, eradication becomes more difficult and the mortality rate increases to 72 percent because of the high incidence of involvement of cranial nerves, adjacent intracranial vessels, and meningitis. Treatment is directed towards the underlying condition, administration of systemic carbenicillin and gentamicin, topical colistin therapy, and judicious surgical debridement. Pseudomonas vaccine may be of help. Fifteen cases are presented. Nine follow the pattern of malignant external otitis and six began as a primary acute otitis media.

Anatomic considerations in botulinum toxin type A therapy for spasmodic dysphonia.

Chemodenervation by injection of botulinum toxin type A into the vocal fold(s) has become the preferred treatment for patients with adductor spasmodic dysphonia. Injection may be done either perorally or transcutaneously; each method has its advocates and advantages. The authors have used the transcutaneous transcricothyroid membrane route exclusively with satisfactory results in more than 50 patients. Temporary breathliness and aspiration are common. The preferred injection site should be as close as possible to the motor end plates of the affected muscle. The thyroarytenoid muscle end plates are distributed throughout the muscle, whereas in the lateral cricoarytenoid muscle they are located in band in the center of the muscle. The transcutaneous injection site is below and posterior to the midpoint of the vibrating vocal fold as visualized by indirect laryngoscopy. The proximity of this site to the lateral cricoarytenoid muscle suggests that postinjection breathiness and aspiration may be related to spread of botulinum toxin type A to the lateral cricoarytenoid muscle. However, it is likely that thyroarytenoid muscle paresis is mainly responsible for this side effect and that the rapid clearing of the breathy dysphonia in the face of prolonged relief of spasmodic dysphonia symptoms suggests the action of an adaptive neural response, such as axonal sprouting. Further research of this subject is warranted.