Ventilating tubes in tympanoplasty

The successful surgical treatment of chronic otitis media or its sequela is frequently related to a ventilated tympanic cavity. Tubes at tympanoplasty have been recommended to assure ventilation until eustachian tube and middle ear mucosal functions have been restored and to prevent the complications of graft loss, atelectasis, cholesteatoma and ossicular destruction. This presentation reviews the literature on the subject and documents our results in 40 patients treated by tympanomastoid surgery with ventilating tubes. The types of tubes used, the surgical technique involved, and the selection of cases suitable for this method are described. Cholesteatoma was the primary disease in 32 patients, 6 had chronic otitis media, 1 cholesterol granuloma, and 1 eosinophilic granuloma. Complete healing of grafts following extrusion or removal of the tubes occurred in 34 patients, 2 tubes remain in place, 3 patients had persistent tube site perforations, and 1 was lost to follow-up. None of the patients had graft breakdown as a result of tube placement, and there has been no recurrence of cholesteatoma. In all cases, the follow-up period is a minimum of 18 months and extends to 92 months.     

Intact canal wall tympanoplasty in the management of cholesteatoma

There are presently two schools of thought on the proper surgical management of cholesteatoma associated with chronic ear disease: one feels that the ear should be exteriorized and left "open"; the other takes the position that the disease can be removed, and the ear left in its normal anatomical and functional state. The latter group are known to favor a "closed" or more conservative procedure. The purpose of this paper is to review a series of patients who have had cholesteatoma managed by an intact canal wall procedure that prevents a postoperative cavity. Out of a series of 590 chronic ear surgeries performed between January 1, 1970, and December 31, 1974, there were 179 done for cholesteatoma (30 percent). There were 153 patients, 26 of whom had bilateral disease. Twenty-three patients were lost to follow-up, giving an overall total of 154 surgeries with from one to five-year information. The overall follow-up rate was 85 percent. Recurrent cholesteatoma was the most bothersome complication and occurred in 14 percent of the series. Residual cholesteatoma was managed by doing all procedures in two stages. The authors feel that the intact canal wall tympanoplasty is a procedure that will gain acceptance and will be more widely used in the future.     

Improvement of the surgical technique of anterior tympanoplasty in cholesteatoma

Technical improvements in anterior tympanotomy with a transmastoid approach in cholesteatoma surgery are reported. Mastoidectomy must be extended to the root of the zygoma and the space anterior to the malleus head must be opened. For this purpose, the visual axis must coincide with the external meatal axis. In this head position, complete removal of the anterior attic bony plate becomes possible only through the transmastoid approach, without touching the ossicular chain. In the case of the pyramidal type bony plate with a normal ossicular chain, the incudo-malleal joint is temporary subluxated, as this is more convenient for access and removal of pathology than incudostapedial joint subluxation. Our clinical results on postoperative hearing showed no damage to the inner ear by the improved technique.     

Pregnancy in patients with pulmonary autograft valve replacement

AIM: The purpose of this study is to determine the outcome and complications of pregnancy in women with pulmonary autograft valve replacement for aortic valve disease. METHODS AND RESULTS: The records of all women who had undergone pulmonary autograft valve replacement at the National Heart Hospital (now Royal Brompton Hospital) since 1968 were reviewed. From 1968 to 1993, 27 hospital survivors were female and among eight of them there were 14 pregnancies. All women were in Ability Index 1 at time of pregnancy with normal ventricular function, mild aortic regurgitation (six), mild pulmonary regurgitation (three) and mild pulmonary stenosis (two). None took anticoagulants. There was no maternal death, thromboembolic or haemorrhagic event or evidence of deterioration in valve function during pregnancy. Except for one woman (Ability Index 3) who developed dilated cardiomyopathy without aortic or pulmonary valve disease 6 months after delivery, the women remained in Ability Index 1 after pregnancy. There was no significant progression of aortic regurgitation (mild after seven pregnancies), pulmonary regurgitation (mild after six) or right-sided obstruction (mild after four). Reoperation for right-sided obstruction was carried out in two patients 4 and 7 years after a second pregnancy (9 and 15 years after the pulmonary autograft). CONCLUSION: No valve-related complications occurred during pregnancy and pregnancy appeared to have no effect on the function of the pulmonary valve autograft or the right-sided homograft. The pulmonary autograft is thus an ideal procedure for a young female needing aortic valve replacement.     

Long-term outcome of tympanoplasty in chronic suppurative middle ear infection in childhood

Controversy continues regarding tympanoplasty for central perforations due to chronic otitis media in children. Between 1972 and 1988, 144 children (160 cases) were operated on for central perforations after chronic otitis media and were managed at the ENT Hospital of the University of the Saarland, Homburg/Saar. Eighty-seven of these children were evaluable for this study. Post-operative follow-up was more than 5 years in 94% of the cases. The tympanic membrane was closed in 90% of the cases at follow-up examination. The age of the patient did not influence the success rate. Social hearing was improved from 49% before operation to 86% after operation and at follow-up. At follow-up, air-bone gaps were closed to within 10 dB in 67% of the cases, within 20 dB for 88% and within 30 dB for 96%. These very good and stable results show that an early operation can be recommended for children with chronic otitis media to prevent further damage to the middle ear.     

Orthotopic transplantation of a partial hepatic autograft in dogs

The purpose of this study was to investigate the availability of an orthotopic transplantation of partial hepatic autograft in dogs as a means of surgical training. Male mongrel dogs weighting 10-15 kg were used. The left lobe of the liver was harvested while preserving the left branches of the portal vein, hepatic artery and bile duct, and the left hepatic vein. The remnant liver was removed while preserving the inferior vena cava using a veno-venous bypass. Orthotopic transplantation of the autograft was performed while anastomosing the left hepatic vein to the inferior vena cava, portal and arterial reconstruction, and external biliary drainage. Thirteen out of 29 dogs survived more than 48 h after transplantation. However, 6 out of 13 dogs were sacrificed after developing bile peritonitis due to a dislodgement of the biliary catheter, and only two dogs were able to survive for 7 days after transplantation. The arterial ketone body ratio recovered to 1.0 within 1 h after reperfusion, and the ratio of the dogs that survived for more than 48 h remained above 1.0 until sacrifice. Orthotopic transplantation of a partial hepatic autograft is a useful and simple procedure to train surgeons for partial liver transplantation.     

Preliminary functional results of tympanoplasty with palisade cartilage]

This paper reviews recent literature concerning the use of music and music therapy in health care. Focusing particularly on the elderly, the use of music in relation to patients with dementia and Parkinsonism is examined. Brief reference is also made to the use of music in pain control. Although in this case, literature is not specific to care of the elderly settings, the results are still relevant to gerontological nursing. Projects which achieved positive results in controlling pain perception could be transferable to a care of the elderly scenario, where chronic pain is often part of daily life.     

Pterygium excision with free conjunctival autograft (FCG) versus postoperative strontium 90 (90Sr) beta-irradiation. A prospective study

In a prospective study the results of a pterygium excision in 54 patients (57 eyes) who underwent a superficial free conjunctival autograft (FCG) were compared to those of patients who were treated with postoperative 90Sr-irradiation. In 51 cases the minimum follow-up was six months, the maximum follow-up seven years. We divided the study up into a randomized part and an open part. In the randomized part, surgery of a primary pterygium was performed in 25 eyes, of which 16 were treated with a FCG and compared with 9 eyes with primary pterygium surgery and postoperative 90Sr beta-irradiation. In the same period 16 eyes were treated because of a recurrent pterygium: 8 with FCG and 8 with 90Sr-irradiation. In the open part of the study 16 eyes with primary pterygium were successively treated with FCG alone. The results showed in the randomized, as well as in the open study on primary surgery with a minimum follow-up of six month, one recurrence in each of the FCG-groups (2 out of 31 eyes = 6.4%), and no recurrences in the 90Sr-group (0%). In the randomized group of patients treated for a recurrent pterygium one recurrence developed in the FCG group (1 out of 8 eyes = 12.5%) and one in the 90Sr-group (1 out of 7 = 14.6%). Analysis of other clinical parameters showed that postoperative treatment with corticosteroids, nonsteroidal anti-inflammatory drugs, and artificial tears was necessary for a longer period in the FCG group than in the 90Sr-group.     

Pulmonary autograft reoperation: incidence and management

BACKGROUND: Pulmonary autograft replacement of the aortic valve is accepted in the young, those with an active life style, and those who are not candidates for anticoagulation. However, concern remains about autograft or homograft valve failure. METHODS: One hundred ninety-five operative survivors of the Ross operation (August 1986 through December 1995) were reviewed for operative pathology and factors associated with reoperation or valve dysfunction. RESULTS: Actuarial freedom from reoperation (autograft or homograft) is 89% +/- 3% at 5 years, 92% +/- 3% for the autograft alone. Early autograft valve failures (< 6 months) were due to technical error in 2 patients and persistent endocarditis in 1. Late autograft valve failure (1 to 6.2 years) was due to aortic annulus dilatation in 5 patients, bacterial endocarditis in 1, and valve degeneration in 2. Six autograft valves were replaced and five were repaired. Five patients required reoperation for pulmonary homograft stenosis (1 to 5.4 years) involving obstruction of the conduit distal to the pulmonary valve. CONCLUSIONS: Pulmonary autograft replacement of the aortic valve has a low incidence of reoperation for autograft dysfunction or homograft obstruction. Autograft dysfunction can be corrected by autograft repair in patients with central insufficiency and aortic annular dilatation.     

Xenograft rejection of porcine islet-like cell clusters in immunoglobulin- or Fc-receptor gamma-deficient mice

The aim of the present study was to evaluate the role of xenoreactive antibodies in islet-like cell cluster (ICC) xenograft rejection. For this purpose, normal mice, mice with a targeted disruption of the Fc-receptor (FcR) gamma-chain, or the membrane exon of the immunoglobulin mu-chain gene, were transplanted with fetal porcine ICC under the kidney capsule. Mice lacking the FcR gamma have no functional FcR for IgG or IgE. Mice with disruption of the immunoglobulin mu-chain cannot produce antibodies, because B cell development is arrested at the stage of preB cells. All animals, irrespective of recipient group, readily rejected the ICC xenograft. Analyses of the pattern of cellular infiltration revealed only minor dissimilarities between the different experimental groups. Xenograft destruction was evident on day 6 after transplantation, and a large number of mononuclear cells were found to be evenly distributed throughout the ICC graft. The majority of the infiltrating cells were large, macrophage-like cells expressing the macrophage-specific phenotype marker F4/80. CD3-positive T lymphocytes were found to be mainly accumulated in the peripheral parts of the ICC xenograft. This study has demonstrated that xenoreactive antibodies are not crucial to ICC xenograft rejection in the pig-to-mouse model.     

Morphologic alterations and cytokinetic studies of tracheal autograft epithelium in rabbits

BACKGROUND: Although tracheobronchoplasty has been used widely in the field of thoracic surgery, few details of the morphologic changes in and cytokinetics of the graft epithelium have been reported. The aim of this study was to focus on these aspects in autografted rabbit tracheas. METHODS: Resected cervical tracheas were anastomosed immediately after removal, retrieved on postoperative days 1 through 28, and examined morphologically. Mitotic and bromodeoxyuridine-labeling indices of the graft epithelium were analyzed. RESULTS: On postoperative days 1 to 4, the graft epithelium showed focal desquamation at the anastomoses. Ciliated cells disappeared during postoperative days 4 to 7 and then increased gradually. Nonciliated cells retained a somewhat columnar shape on postoperative days 4 to 7, except at denuded foci. Thereafter, the grafts were covered completely with pseudostratified mucociliary epithelium. On postoperative day 4, both indices were maximal and appeared higher at the anastomotic than midgraft sites. CONCLUSIONS: Most of the graft epithelium was preserved during acute ischemia and then started to regenerate. The increased regenerative activity near the anastomoses may be attributable to mechanical damage or different nutritional conditions.     

Limbal cell autograft transplantation for severe ocular surface disorders

OBJECTIVE: To determine if poor dietary intake can explain the cobalamin-related abnormalities often seen in the elderly. DESIGN: Prospective laboratory survey with a follow-up dietary assessment. SETTING: Social centers for the elderly and an outpatient clinic. SUBJECTS: Ninety-five free-living subjects >60y old with abnormal or suspicious findings in cobalamin-related tests and 78 subjects >60y old with normal results. INTERVENTIONS: Serum cobalamin, methylmalonic acid and homocysteine determinations to assess cobalamin status and a one year food-frequency questionnaire to assess cobalamin intake. RESULTS: Only three of the 173 subjects (1.7%), one of whom had normal cobalamin status, ingested <2 microg cobalamin/d, the Recommended Daily Allowance. Sixty-nine subjects (39.9%) ingested <6 microg/d, but they did not have more abnormal serum cobalamin or metabolite values than those ingesting >6 microg. Ordering all subjects by quintiles according to cobalamin intake revealed no significant trends or differences in any of the serum values either. Moreover, arranging subjects by results of tests of cobalamin status showed that the subjects with abnormal cobalamin status did not differ in cobalamin intake from those with normal cobalamin status, although they did differ in use of supplements. Finally, cobalamin intake, with or without supplements, did not correlate with serum cobalamin or metabolite levels. The absence of any association between cobalamin status and intake contrasts sharply with the significant correlation between folate intake and folate status (P = 0.0001). CONCLUSIONS: The high frequency of mildly abnormal cobalamin status in the elderly cannot be attributed to poor intake of cobalamin. Nondietary explanations, such as malabsorption and other phenomena, must always be sought to explain mild cobalamin deficiency in the elderly.     

Manipulating the mobile stapes during tympanoplasty: the risk of stapedial luxation

Manipulating the mobile stapes is a central procedure during tympanoplasty, i.e., mounting a prosthesis onto the stapedial head or dissecting cholesteatoma matrix off the oval window niche. An excessive displacement of the stapedial suprastructure as caused by these manipulations with hand-held instruments might result in a rupture of the annular ligament. Bacteria invading through this perilymphatic fistula threaten the inner ear. In experiments with temporal bones, the author investigated the rupture mechanisms of the annular ligament with definite stapedial manipulations. Leaks, which became detectable by exerting pressure on the inner ear fluid, occur only when all suspension fibers are completely ruptured. Further clinical aspects with different directions of stapedial manipulations are demonstrated.     

Autologous tissue in initial type I and type III tympanoplasty operations in chronic suppurative otitis media

We reviewed 192 patients who had been treated for chronic otitis media. All operations were carried out at the Department of Otolaryngology, University of Tübingen. No patient had a previous ear operation and revision operations were excluded. The observation period varied from a minimum of 1 year to a maximum of 4 1/2 years. The ossicular chain was partially destroyed in 43 ears (22.4%). Ossiculoplasty was performed using autologous ossicles. An inens was used in 31 ears and a malleus in 12 cases. The overall failure rate was 20.8%. Most recurrent perforations were found in middle-aged patients. Children had only a 14% incidence of recurrent perforations. Fascia was the material associated with the highest failure rate (28.6%). After using perichondrium 6.8% of the cases had recurrent perforations, whereas the perichondrium-cartilage transplant was not successful in 4.8%. Overall, 62.7% of the patients were found to have an air-bone gap of 10 dB or less at 1.5 kHz 3-6 months after surgery. An air-bone gap of 20 dB or less was found in 91.2% of the patients. The main problem seen in the patients with chronic otitis media was not reconstruction of the ossicular chain but a lasting closure of the tympanic membrane. The perichondrium-cartilage transplant permitted the best results and is now recommended especially for patients with unfavorable middle ear conditions. A long-lasting closure of the tympanic membrane was also found in children (< or = 15 years of age). For this reason we also recommend an early operation in order to allow children to lead a normal life.