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1.  Imaging of auriculotemporal nerve perineural spread 
ecancermedicalscience  2013;7:374.
Adenoid cystic carcinomas (ACCs) are relatively rare tumours, notorious for wide local infiltration and perineural spread. Perineural extension commonly occurs along branches of the trigeminal and facial nerves, and its presence represents a poor prognostic factor with implications for treatment approach.
We report the case of a 61-year-old female presenting with worsening left facial numbness and weakness. On magnetic resonance imaging, the patient was found to have perineural spread of a left parotid tumour along the auriculotemporal nerve. There was involvement of the V2 and V3 branches of the trigeminal nerve. An ultrasound-guided biopsy of the mass demonstrated ACC.
Conclusions and relevance:
The auriculotemporal nerve may serve as a route for tumour spread, particularly in the setting of head and neck malignancy. Moreover, this particular suspicion should be raised when patients with known malignancy experience concomitant trigeminal (V) and facial (VII) nerve dysfunctions.
PMCID: PMC3837488  PMID: 24282445
perineural spread; head and neck malignancy; MRI; CT
2.  Silicone Foley's catheter: A useful splint in ear surgeries 
Maintenance of ear projection and post auricular sulcus in staged ear reconstruction in microtia is a trying problem. So also is the maintenance of the patency of the external auditory meatus following recanalization and meatoplasty. Numerous splints and dressing techniques have been described for the above situations. Some of the problems encountered include the availability of the materials, cost, expertise in fabrication and compliance.
To devise a simple, reliable, inexpensive and readily available splint for the maintenance of post auricular sulcus and external auditory meatus opening.
Settings and Design:
A silicone catheter is made out of a soft and inert material that doesn't cause tissue necrosis or any loss of skin graft. The basic design is that of a simple, self-retaining type of splint that doesn't dislodge and can be prepared within minutes on the operating table.
Materials and Methods:
This splint has been used in four cases of microtia reconstruction and one case of congenital external auditory meatus stenosis between June 2006 and August 2007. A 14 or 16 Fr silicone Foley's catheter was used. The proximal end of a catheter of required length was retained and the distal part was cut off. The catheter was looped into a circle around the base of the reconstructed ear and secured in position with a suture. A similar construct was used in cases of external auditory meatus reconstruction or recanalization. The funnel-shaped distal drainage end was sutured to the circular frame near the region of the tragus. This funnel was inserted into the external auditory canal.
The catheter was found to sit snugly in the newly created sulcus, thereby maintaining the sulcus and ear projection. It aided in maintaining the meatal opening of a satisfactory diameter in the case of external auditory canal recanalization. It was never found to slip or get dislodged in any of the cases. There was no skin graft loss or tissue necrosis due to the use of the splint.
The silicone Foley's catheter is found to be a simple, readily available, inexpensive and reliable self-retaining splint following ear elevation in microtia and external auditory meatus recanalization. The catheter is easily constructed and applied intraoperatively. The results following its usage have been uniformly good in all cases without causing any adverse events at the operated site or discomfort to the patient ensuring good compliance.
PMCID: PMC2739556  PMID: 19753201
External auditory meatal stenosis; microtia; silicone Foley's catheter
3.  Anomalous Bilateral Communication between the Inferior Alveolar Nerve and the Auriculotemporal Nerve: A Rare Variation 
Branches of the posterior division of the mandibular nerve show various anomalous communications in the infratemporal region. Understanding such communication has relevance in the management of neuropathies and surgical procedures in this region. This study was conducted to explore such communicating branches, anticipating that they might provide information of clinical significance. A total of 15 human cadavers (30 infratemporal regions) were studied to explore such communicating branches in infratemporal region. The branches of the posterior division of the mandibular nerve were carefully dissected, and these branches were studied and analysed for any abnormal course. In one case, a rare type of bilateral communication between the auriculotemporal nerve and the inferior alveolar nerve, forming a loop with no association with any structure, was observed. It is possible that such communicating branches may be associated with delayed regression of the first arch vessels. The clinical implications of these anomalous communications require further detailed study for improved management of neuropathies and surgical procedures.
PMCID: PMC4418129  PMID: 25977637
mandibular nerve; auriculotemporal nerve; inferior alveolar nerve; variation
4.  Pattern of otitis externa in Kaduna Nigeria 
Otitis externa (OE) is an inflammation or infection of the external auditory canal (EAC), the auricle, or both this condition has been reported to be found in all age groups. The aims and objectives were, study/determine the prevalence of Otitis externa in the specialist otolaryngology clinic in National Ear Care Center Kaduna, study the pattern of presentation among patients with otitis externa in the specialist otolaryngology clinic in National Ear Care Center Kaduna, and evaluate the choice of drug treatment for otitis externa in the specialist otolaryngology clinic in National Ear Care Center Kaduna.
Data of patients diagnosed with otitis externa between January 2009 and March 2013 were extracted from the recorded cases of ear disease seen within the same period. The ages, sex/ gender, complains(symptoms), duration of symptoms, clinical examination findings, diagnosis, mode of drug treatment, number of visits and complication records were extracted from the case notes of the patients and analyzed descriptively using SPSS (Statistical package for Social Sciences) version.
Out of 13,328 cases of ear diseases seen within the period under review, 133 cases were diagnosed with otitis externa across all age groups. Hospital prevalence stands at 1.0%. There were 81(60.9%) males and 52(39.1%) females in ratio 1.5:1. Children age 0-15 constitute 55(41.3%) while young adults and adults were 78(58.6%). The minimum age at presentation was one year, while maximum age was 64 years. Mean age was 24 years with a standard deviation of ± 1.12 Years. Ear pain as only presenting symptom was the major complain found in this study accounting for 68(51.1%). Acute diffuse otitis externa was the commonest diagnosis accounting for 101(75.9%) and associated clinical findings ranging from tragal tenderness, hyperaemia and oedema of ear canal in 57 (54.9%). Ear swab was not routinely done and only 6(15.8%) of the discharging ears had microscopy done and the organisms were Pseudomonas spp and klebsiella. Empirical treatment was the commonest treatment modality and about 91% of the patients had complete symptom resolution by second visit. Complication was observed in only one case of necrotizing otitis externa who was retro-viral positive.
Otitis externa accounted for small fraction of cases seen in our clinic (1%). Acute diffuse otitis externa is the commonest diagnosis made with symptoms ranging from ear pain, ear discharge, hearing loss and itchiness. Most patients were treated empirically with significant success within first two visits. No major complication was recorded within the period under study.
PMCID: PMC4546771  PMID: 26328002
Pattern; otitis externa; Kaduna
5.  Cochlear Implantation in Adults with Asymmetric Hearing Loss 
Ear and Hearing  2012;33(4):521-533.
Bilateral severe-to-profound sensorineural hearing loss is a standard criterion for cochlear implantation. Increasingly, patients are implanted in one ear and continue to use a hearing aid in the non-implanted ear to improve abilities such as sound localization and speech understanding in noise. Patients with severe-to-profound hearing loss in one ear and a more moderate hearing loss in the other ear (i.e., asymmetric hearing) are not typically considered candidates for cochlear implantation. Amplification in the poorer ear is often unsuccessful due to limited benefit, restricting the patient to unilateral listening from the better ear alone. The purpose of this study was to determine if patients with asymmetric hearing loss could benefit from cochlear implantation in the poorer ear with continued use of a hearing aid in the better ear.
Ten adults with asymmetric hearing between ears participated. In the poorer ear, all participants met cochlear implant candidacy guidelines; seven had postlingual onset and three had pre/perilingual onset of severe-to-profound hearing loss. All had open-set speech recognition in the better hearing ear. Assessment measures included word and sentence recognition in quiet, sentence recognition in fixed noise (four-talker babble) and in diffuse restaurant noise using an adaptive procedure, localization of word stimuli and a hearing handicap scale. Participants were evaluated pre-implant with hearing aids and post-implant with the implant alone, the hearing aid alone in the better ear and bimodally (the implant and hearing aid in combination). Postlingual participants were evaluated at six months post-implant and pre/perilingual participants were evaluated at six and 12 months post-implant. Data analysis compared results 1) of the poorer hearing ear pre-implant (with hearing aid) and post-implant (with cochlear implant), 2) with the device(s) used for everyday listening pre- and post-implant and, 3) between the hearing aid-alone and bimodal listening conditions post-implant.
The postlingual participants showed significant improvements in speech recognition after six months cochlear implant use in the poorer ear. Five postlingual participants had a bimodal advantage over the hearing aid-alone condition on at least one test measure. On average, the postlingual participants had significantly improved localization with bimodal input compared to the hearing aid-alone. Only one pre/perilingual participant had open-set speech recognition with the cochlear implant. This participant had better hearing than the other two pre/perilingual participants in both the poorer and better ear. Localization abilities were not significantly different between the bimodal and hearing aid-alone conditions for the pre/perilingual participants. Mean hearing handicap ratings improved post-implant for all participants indicating perceived benefit in everyday life with the addition of the cochlear implant.
Patients with asymmetric hearing loss who are not typical cochlear implant candidates can benefit from using a cochlear implant in the poorer ear with continued use of a hearing aid in the better ear. For this group of ten, the seven postlingually deafened participants showed greater benefits with the cochlear implant than the pre/perilingual participants; however, further study is needed to determine maximum benefit for those with early onset of hearing loss.
PMCID: PMC3383437  PMID: 22441359
Asymmetric hearing loss; Bilateral; Bimodal; Cochlear implant; Speech recognition
6.  Clinical and Audiological Profiles in Children with Chronic Otitis Media with Effusion Requiring Surgical Intervention 
To determine the characteristic presenting symptoms, otoscopic findings, audiological profiles and the intraoperative findings of children with chronic otitis media with effusion who required surgical intervention. A prospective cross sectional study was undertaken in the otorhinolaryngology clinic of USM Hospital (HUSM) involving 25 cases (50 ears) of children with chronic otitis media with effusion requiring surgical intervention from June 1999 to September 2001. Their ages ranged from 3 to 12 years old. The gender distribution included males at 72 % and females at 28 %. The presenting symptoms noted were hearing impairment (52%), otalgia (18%), ear block (16%) and tinnitus (14%). The otoscopic findings were fluid in the middle ear (40%), dullness (32%) and retraction of the tympanic membrane (28%). On audiometry, 24 ears had moderate deafness (48%), 16 ears had mild deafness (32%) while 4 ears had severe deafness (8%). With tympanometry, 42 ears out of the total 50 had a flat type B curve (84%) while 6 ears had type As curve (12%). During myringotomy, middle ear secretion was seen in 38 ears (76%) out of the 50 ears; 22 ears had mucoid secretion while 16 ears had serous secretion. Clinically, the commonest presenting symptom was hearing impairment (52%) while the most common otoscopic finding was fluid in the middle ear (40%). Audiologically, most patients had moderate conductive hearing loss (48%) and a type B curve (84%) on tympanometry. On myringotomy middle ear fluid was found in 76 % of the ears.
PMCID: PMC3442623  PMID: 22993488
Clinical; Audiology; Otitis media with effusion
7.  Cochlear Implantation in Non-Traditional Candidates: Preliminary Results in Adolescents with Asymmetric Hearing Loss 
Traditionally, children are cochlear implant (CI) candidates if bilateral severe to profound hearing loss is present and amplification benefit is limited. The current study investigated abilities of adolescents with asymmetric hearing loss (one ear with severe to profound hearing loss and better hearing contralaterally), where the poorer ear received a CI and the better ear maintained amplification.
Study Design
Within-subject case study
Pediatric hospital, outpatient clinic
Participants were five adolescents who had not met traditional CI candidacy due to one better hearing ear, but did have one ear that met criteria and was implanted. All maintained hearing aid (HA) use in the contralateral ear. In the poorer ear pre-implant, three participants had used amplification and the other two had no HA experience.
Main Outcome Measure
Participants were assessed in three listening conditions: HA alone, CI alone, and both devices together (bimodal) for speech recognition in quiet and noise, and sound localization.
Three participants had CI open-set speech recognition and significant bimodal improvement for speech recognition and localization compared with the HA or CI alone. Two participants had no CI speech recognition and limited bimodal improvement.
Some adolescents with asymmetric hearing loss who are not typical CI candidates can benefit from a CI in the poorer ear, compared to a HA in the better ear alone. Additional study is needed to determine outcomes for this population, especially those who have early onset profound hearing loss in one ear and limited HA experience.
PMCID: PMC3600103  PMID: 23222962
8.  Keloid: A case report and review of pathophysiology and differences between keloid and hypertrophic scars 
Keloids extend beyond the borders of the original wound invading normal skin. Usually appear as firm nodules, often pruritic and painful, and generally do not regress spontaneously. Most often occur on the chest, shoulders, upper back, back of the neck, and earlobes. The aim of the paper is to discuss a case of keloid, review the pathophysiology and also to highlight the differences between keloid and hypertrophic scars. A 26-year-old female complains of swelling on ear lobe since 3 years. Swelling was firm, non-tender, dumbell-shaped with central wooden stick still present, measuring 3 cm in diameter medial to the inferior part of the helix. A clinical diagnosis of keloid was given. Histopathological sections showed hyperorthokeratinized stratified squamous epithelium with deep dermal sclerosis showing large dense bundle of glassy collagen diagnostic of Keloid. Special stain like Van Gieson's was used to identify collagen bundles. The sections were also subjected to immunohistochemical markers such as α-SMA (alpha Smooth muscle actin), Desmin, and S-100. Despite decades of research, the pathophysiology of keloids remains incompletely understood. Recent studies indicate that TGF-β (Transforming growth factor beta) and PDGF (Platelet-derived growth factor) play an integral role in the formation of keloids. In future, development of selective inhibitors of TGF-β might produce new therapeutic tools with enhanced efficacy and specificity for the treatment of keloids. Patients with a previous history of keloid or other risk-factors should avoid body piercing and elective cosmetic procedures. Keloid scars should be sent for histopathology in order to avoid missing potentially malignant conditions particularly those showing unusual features.
PMCID: PMC3687166  PMID: 23798844
Ear lobe; fibrogenic response; glassy collagen; hypertrophic scars; keloid
9.  Observations on the Current Bacteriological Profile of Chronic Suppurative Otitis Media in South Eastern Nigeria 
Chronic suppurative otitis media (CSOM) is a disease well-known for its recurrence and persistence despite treatment. The situation is compounded by the increasing resistance to antimicrobial agents by bacteria these days.
This study was carried out to examine the current local bacteriological profile of CSOM and to compare the profile of either ear in bilaterally discharging ears.
Materials and Methods:
We carried out a retrospective analysis of ear swab cultures from 133 unilateral and 73 bilateral consecutive tubotympanic CSOM cases seen at the Ear-Nose-Throat clinics of a referral health institution during a 4 year period ending 2013. Sensitivities to eight locally available antibiotics were analyzed. Aerobic bacterial isolates were analyzed separately for the unilateral and bilateral cases. Comparison was made between the ears in the bilateral cases.
We analyzed 279 ear swab culture results from 206 patients with age ranging from 5 months to 86 years and a mean of 21.3 (19.5) years. Pseudomonas aeruginosa was the most common isolated bacteria (44% [109/250]) followed by Staphylococcus aureus (17% [42/250]), and Proteus Mirabilis (15% [38/250]). The most and least sensitive bacteria were Klebsiella Spp and Escherichia Coli, respectively. The most effective antibiotics were gentamicin and ciprofloxacin. The two ears differ significantly in the rates of isolation of S. aureus and E. coli (P = 0.01 and P = 0.04, respectively).
Pseudomonas is the most common bacteria involved in CSOM in this part of the country. Ciprofloxacin as ear drops is recommended as first-line drug in the management of active CSOM as it is cheap, less ototoxic, and locally available. Separate ear swab culture should be obtained in bilateral CSOM.
PMCID: PMC4389327  PMID: 25861532
Bilateral; Chronic; Culture and sensitivity; Otitis Media; Pseudomonas
10.  A quasi-randomised controlled trial of water as a quick softening agent of persistent earwax in general practice. 
BACKGROUND: Earwax is a common problem in general practice. The incidence of complaints owing to earwax in general practice in the Netherlands is 39.3 per 1000 patients. AIM: To determine the feasibility of a strategy using water as a quick dispersant for persistent earwax, compared with the usual strategy using oil as a dispersant for three days in a general practice setting. DESIGN OF STUDY: Practice based, prospective controlled intervention study. SETTING: Forty-two patients (59 ears) in four general practices in the Netherlands. METHOD: Patients with persistent earwax were randomised into an intervention group and a control group. For patients in the intervention group, water drops at body temperature were dropped into the impacted ear and the auditory meatus was blocked with a wet wad of cotton. After the patient had waited for 15 minutes in the waiting room a series of attempts at syringing was completed. Patients in the control group received the usual strategy and were instructed to soften the earwax with oil each night before sleeping and to block the auditory meatus with a wad of cotton, for three days. They were asked to come back after three days for the second attempt of syringing. For both strategies the mean number of syringing attempts (and 95% confidence interval) was calculated and compared by testing the difference between the means using a t-test for independent samples. All ears in which the wax was still persistent after another five syringing attempts were given the value of 6 in the calculations. RESULTS: The mean number of syringing attempts needed per patient in the intervention group was 3.0 (95% CI = 2.4 to 3.6) and for the control group, the mean was 2.4 (95% CI = 1.7 to 3.1). The difference between means (0.6, 95% CI = 0.3 to 1.5) was not statistically significant (P = 0.18). CONCLUSION: A patient with persistent earwax can stay in the waiting room following the initial series of five attempts at syringing, with water instilled in the ear canal. After 15 minutes, the earwax is removed as easily as in the usual strategy using oil instilled for three days. The strategy using water as a dispersant for persistent earwax is quick and more convenient for the patient.
PMCID: PMC1314073  PMID: 11510392
11.  Prediction of arterial blood gas values from arterialized earlobe blood gas values in patients treated with mechanical ventilation 
Arterial blood gas (ABG) analysis is useful in evaluation of the clinical condition of critically ill patients; however, arterial puncture or insertion of an arterial catheter may sometimes be difficult and cause many complications. Arterialized ear lobe blood samples have been described as adequate to gauge gas exchange in acute and chronically ill pediatric patients.
This study evaluates whether pH, partial pressure of oxygen (PO2), partial pressure of carbon dioxide (PCO2), base excess (BE), and bicarbonate (HCO3) values of arterialized earlobe blood samples could accurately predict their arterial blood gas analogs for adult patients treated by mechanical ventilation in an intensive care unit (ICU).
A prospective descriptive study
Sixty-seven patients who were admitted to ICU and treated with mechanical ventilation were included in this study. Blood samples were drawn simultaneously from the radial artery and arterialized earlobe of each patient.
Regression equations and mean percentage-difference equations were derived to predict arterial pH, PCO2, PO2, BE, and HCO3-values from their earlobe analogs. pH, PCO2, BE, and HCO3 all significantly correlated in ABG and earlobe values. In spite of a highly significant correlation, the limits of agreement between the two methods were wide for PO2. Regression equations for prediction of pH, PCO2, BE, and HCO3- values were: arterial pH (pHa) = 1.81+ 0.76 × earlobe pH (pHe) [r = 0.791, P < 0.001]; PaCO2 = 1.224+ 1.058 × earlobePCO2 (PeCO2) [r = 0.956, P < 0.001]; arterial BE (BEa) = 1.14+ 0.95 × earlobe BE (BEe) [r= 0.894, P < 0.001], and arterial HCO3- (HCO3-a) = 1.41+ earlobe HCO3(HCO3-e) [r = 0.874, P < 0.001]. The predicted ABG values from the mean percentage-difference equations were derived as follows: pHa = pHe × 1.001; PaCO2 = PeCO2 × 0.33; BEa = BEe × 0.57; and HCO3-a = HCO3-e × 1.06.
Arterialized earlobe blood gas can accurately predict the ABG values of pH, PCO2, BE, and HCO3- for patients who do not require regular continuous blood pressure measurements and close monitoring of arterial PO2 measurements.
PMCID: PMC2738313  PMID: 19742254
Arterialized earlobe blood gas; critically illness; mechanical ventilation
12.  A Study of the Etiology of Referred Otalgia 
Otalgia is one of the complaints which may occur at any age. The etiology of the pain may be in the ear, structures around the ear or other head and neck structures. This is caused by the complex nervous connections in the head and neck areas, the ear, the pharynx and the nose. Since understanding the etiologies of referred otalgia can help in the assessment and treatment of the disease, this research was conducted to identify the etiologies of referred otalgia in patients visiting the ENT Clinic in Gorgan, Iran.
Materials and Methods:
This prospective research was conducted on patients who visited the ENT Clinic with an earache, but in initial assessments the ear was normal. Patients’ data consisting of sex, age, complaint, the inflicted side, physical findings in the ear, the nose, the throat and head and neck were recorded in a questionnaire. These data were then analyzed with SPSS software.
Of 770 patients with otalgia, 94 patients (12.2%) had referred otalgia. Of these patients 27.7% were men and 72.3% were women. The most common etiology of referred otalgia was dental problems (62.8%), and one patient who was being treated for pharyngitis had carcinoma of the base of the tongue. In 47.8% of cases the pain was in the left ear, in 43.4% in the right ear, and in 8.7% it was bilateral.
In view of the fact that a significant proportion of the patients who complained of otalgia had no pathologies in the ear, thorough physical examination in adjacent structures especially teeth should be performed and malignancies should be considered as a possible etiology of otalgia.
PMCID: PMC3846197  PMID: 24303405
Cases; Earache; Pain; Referred
13.  Randomized trial of superficial peribulbar compared with conventional peribulbar anesthesia for cataract extraction 
Evaluate efficacy of superficial peribulbar anesthesia for cataract extraction compared with conventional peribulbar anesthesia.
Department of Ophthalmology, Al Nahdha Hospital (Tertiary Ophthalmic and ENT Hospital) and Magraby Eye & Ear Center, Muscat, Sultanate of Oman.
Patients scheduled for cataract extraction with intraocular lens implantation were randomly divided into two groups according to anesthetic technique used. The first group patients were anesthetized using superficial peribulbar anesthesia, while second group patients were anesthetized using conventional peribulbar block. The efficacy of the blockade was judged by onset and degree of akinesia and volume of local anesthetic needed to obtain acceptable akinesia, sensation of pain during surgery, effect on intraocular pressure, degree of patient satisfaction, and incidence of complications.
Nine hundred patients scheduled for cataract extraction with intraocular lens implantation during the period of June 2003 and October 2006 were included in this study. Five hundred cases were anesthetized using superficial peribulbar anesthesia and four hundred cases were anesthetized using conventional peribulbar block. The two groups were comparable as regards age, weight, gender, duration of surgery, and degree of analgesia. Superficial peribulbar anesthesia provided faster onset, higher degree of akinesia with less volume of local anesthetics used, no need for supplementary reinjection, no effect on intraocular pressure, and better patient satisfaction score compared with conventional peribulbar anesthesia. There were no serious complications in both groups. The incidence of subconjunctival hemorrhage was significantly higher in superficial peribulbar group (18%) compared with conventional peribulbar block (0.5%).
Superficial peribulbar anesthesia is a safe, simple, quick to perform, and effective method of anesthesia for cataract surgery with better patient satisfaction, better akinesia, and comparable analgesia compared with conventional peribulbar block. Subconjunctival hemorrhage is a self-limited complication associated with this technique.
PMCID: PMC2699986  PMID: 19668466
regional anesthesia; cataract surgery; peribulbar block
14.  Predictive Value of Auricular Diagnosis on Coronary Heart Disease 
The ear has a reflexive property; therefore, various physical attributes may appear on the auricle when disorders of the internal organs or other parts of the body exist. Auricular diagnostics is an objective, painless, and noninvasive method that provides rapid access to information. Thus, the association between auricular signals and coronary heart disease (CHD) should be further investigated. A case control study was conducted to determine the predictive value of auricular signals on 100 cases of CHD (CHD+ve = 50; CHD−ve = 50) via visual inspection, electrical skin resistance measurement, and tenderness testing. The results showed that the presence of an ear lobe crease (ELC) was significantly associated with coronary heart disease. The “heart” zone of the CHD+ve group significantly exhibited higher conductivity on both ears than that of the controls. The CHD+ve group experienced significant tenderness in the “heart” region compared with those in the CHD−ve group in both acute and chronic conditions. Further studies that take into consideration the impact of age, race, and earlobe shape on ELC prevalence in a larger sample should be done.
PMCID: PMC3544543  PMID: 23326290
15.  Mechanisms of Hearing Loss in Neurofibromatosis Type 2 
PLoS ONE  2012;7(9):e46132.
Patients with neurofibromatosis type 2 (NF2) develop bilateral cochleovestibular schwannomas (CVSs) that cause binaural deafness in most individuals. Hearing loss occurs in an unpredictable manner and the underlying mechanisms are not known. To gain insight into the pathophysiologic basis for hearing loss in NF2, we performed a prospective cross-sectional study of untreated ears in NF2 patients.
One hundred consecutive NF2 patients in a prospective natural history study were included. Clinical and audiometric data were analyzed for treatment naïve ears. In addition to standard MR-imaging sequences, alterations in intralabyrinthine protein content were determined utilizing high resolution FLAIR, the presence of cochlear aperture obstruction was determined by examining 3D T2 sequences, and endolymphatic hydrops was identified on delayed post-contrast FLAIR sequences.
Eighty-nine ears harboring 84 untreated CVSs in 56 consecutive NF2 patients (age 30±16 years) were analyzed. Thirty-four (38%) ears had varying degrees of hearing loss. Elevated intralabyrinthine protein was identified in 70 (75%) ears by FLAIR MR-imaging and was strongly associated with the presence of hearing loss (32/34 hearing loss ears; 94%)(Fisher's exact test; P = .005). Elevated intralabyrinthine protein was associated with the presence of CVS-associated cochlear aperture obstruction (64 of 67 ears with elevated protein; 96%)(Fisher's exact test; P<0.0001) in both normal and hearing loss ears. Elevated intralabyrinthine protein was not identified in ears without CVS (5 ears). While larger tumor size was associated with hearing loss (P = 0.006), 16 hearing loss ears (47%) harbored CVSs less than 0.5 cm3, including 14 ears (88%) with block of the cochlear aperture and elevated protein.
These findings are consistent with a model in which hearing loss develops as a result of cochlear aperture obstruction and accumulation of intralabyrinthine protein. MRI based identification of elevated intralabyrinthine protein may help identify the ear at-risk for developing hearing loss.
PMCID: PMC3458837  PMID: 23049959
16.  Relapsing polychondritis with different types of ocular inflammations 
We were presented with two cases of relapsing polychondritis (RP) associated with different types of ocular inflammation. The first case was a 35-year-old man who had bilateral hyperemic conjunctiva and ocular pain, and was referred to Chiba University Hospital with a diagnosis of episcleritis refractory. He was treated with dexamethasone eye drops. He developed tinnitus, deafness in both ears, and left auriculitis. A left auricular biopsy showed an infiltration of lymphocytes surrounding the cartilage. He was diagnosed with RP and treated with 30 mg/day oral prednisolone. After tapering the prednisolone, the scleritis in both eyes improved. The second case was a 71-year-old man who was deaf in both ears and had bilateral scleritis. At the first visit to our hospital, his left eyelid and right auricula were reddish and swollen, and he reported some pain. He was treated with intravenous antibiotics, and the left orbital cellulitis quickly improved. However, he developed right scleritis and left gonitis. Magnetic resonance imaging showed bilateral posterior scleritis and right auricular perichondritis. Auricular biopsy showed an infiltration of lymphocytes into the periauricular tissue. He was diagnosed with RP, and 40 mg/day oral prednisolone was given and his symptoms improved. Although RP is rare, it is a life-threatening disease. Thus, ophthalmologists should consider RP in patients with both ocular and auricular inflammation.
PMCID: PMC4581778  PMID: 26425107
relapsing polychondritis; scleritis; oral prednisolone; ocular cellulitis
17.  Local anaesthetic infiltration for peri-operative pain control in total hip and knee replacement: systematic review and meta-analyses of short- and long-term effectiveness 
Surgical pain is managed with multi-modal anaesthesia in total hip replacement (THR) and total knee replacement (TKR). It is unclear whether including local anaesthetic infiltration before wound closure provides additional pain control.
We performed a systematic review of randomised controlled trials of local anaesthetic infiltration in patients receiving THR or TKR. We searched MEDLINE, Embase and Cochrane CENTRAL to December 2012. Two reviewers screened abstracts, extracted data, and contacted authors for unpublished outcomes and data. Outcomes collected were post-operative pain at rest and during activity after 24 and 48 hours, opioid requirement, mobilisation, hospital stay and complications. When feasible, we estimated pooled treatment effects using random effects meta-analyses.
In 13 studies including 909 patients undergoing THR, patients receiving local anaesthetic infiltration experienced a greater reduction in pain at 24 hours at rest by standardised mean difference (SMD) -0.61 (95% CI -1.05, -0.16; p = 0.008) and by SMD -0.43 (95% CI -0.78 -0.09; p = 0.014) at 48 hours during activity.
In TKR, diverse multi-modal regimens were reported. In 23 studies including 1439 patients undergoing TKR, local anaesthetic infiltration reduced pain on average by SMD -0.40 (95% CI -0.58, -0.22; p < 0.001) at 24 hours at rest and by SMD -0.27 (95% CI -0.50, -0.05; p = 0.018) at 48 hours during activity, compared with patients receiving no infiltration or placebo. There was evidence of a larger reduction in studies delivering additional local anaesthetic after wound closure. There was no evidence of pain control additional to that provided by femoral nerve block.
Patients receiving local anaesthetic infiltration spent on average an estimated 0.83 (95% CI 1.54, 0.12; p = 0.022) and 0.87 (95% CI 1.62, 0.11; p = 0.025) fewer days in hospital after THR and TKR respectively, had reduced opioid consumption, earlier mobilisation, and lower incidence of vomiting.
Few studies reported long-term outcomes.
Local anaesthetic infiltration is effective in reducing short-term pain and hospital stay in patients receiving THR and TKR. Studies should assess whether local anaesthetic infiltration can prevent long-term pain. Enhanced pain control with additional analgesia through a catheter should be weighed against a possible infection risk.
PMCID: PMC4118275  PMID: 24996539
Hip replacement; Knee replacement; Anaesthesia; Systematic review; Meta-analysis
18.  Otologic and Audiologic Manifestations of Hutchinson-Gilford Progeria Syndrome 
The Laryngoscope  2011;121(10):2250-2255.
To define the audiologic and otologic phenotype of Hutchinson-Gilford Progeria syndrome (HGPS).
Study Design
Prospective case series.
Fifteen patients with HGPS were enrolled in a prospective natural history study; fourteen were evaluated in the neurotology clinic and eleven received audiologic evaluations. The physical exam and audiologic findings of these patients were reviewed to define an otologic and audiologic phenotype for HGPS in the largest series of subjects in the literature.
All patients were noted to have stiff auricular cartilages, small or absent lobules and hypoplasia of the lateral soft tissue portion of the external ear canal leading to a shortened canal. Ten of 14 patients (71%) had dry cerumen impaction and four of 14 patients (29%) reported a history of recurrent otitis media. Nineteen of 22 ears (86.4%) demonstrated low frequency conductive hearing loss in the 250 Hz to 500 Hz range. Sixteen of 22 ears (73%) had type A tympanograms; three of 22 ears (14%) displayed bimodal or "W" peaked tympanograms; two of 22 ears (9%) had type B tympanograms; one of 22 ears (4%) had a type C tympanogram. Nine of 10 patients had distortion product otoacoustic emissions consistent with normal peripheral hearing sensitivity.
HGPS is caused by a mutation in the LMNA gene resulting in the production of an abnormal nuclear protein; this in turn affects nuclear structure and function. Patients with HGPS have characteristic otologic features due to cartilaginous and subcutaneous tissue abnormalities and typically demonstrate low frequency conductive hearing loss despite largely normal tympanometry. It is important to be aware of these conditions in managing these patients.
PMCID: PMC3688450  PMID: 21898437
Hutchinson-Gilford Progeria Syndrome; hearing loss; Progeria; middle ear; external ear
Nagoya Journal of Medical Science  2014;76(3-4):355-360.
Middle ear adenoma is a rare disease that is thought to originate in the middle ear mucosa. It occurs over a wide age range, has no gender predilection, and is not characterized by specific symptoms or findings. The most frequent complaints are unilateral hearing loss and ear fullness. We report a 48-year-old woman with middle ear adenoma who had a history of unilateral ear fullness and hearing loss on the left side. Middle ear adenoma was suspected following a biopsy performed under local anesthesia. To remove the tumor, the patient underwent a left postauricular canal wall-up tympanoplasty type IIIc. Microscopic examination and immunohistochemistry confirmed a middle ear adenoma. In this case, we diagnosed the lesion as middle ear adenoma with neuroendocrine differentiation on the basis of the pathological findings. The patient has shown no recurrence for almost 5 years, but since this adenoma showed neuroendocrine differentiation, long-term observation is required.
PMCID: PMC4345687  PMID: 25741045
middle ear adenoma; tympanoplasty
20.  Bilateral Type 1 Tympanoplasty in Chronic Otitis Media 
A theoretical risk of iatrogenic sensorineural hearing loss during surgery has induced a reluctance to perform bilateral tympanoplasty type I among some otosurgeons. This paper presents results of bilateral surgery in 14 patients (28 ears). Fourteen patients with bilateral, dry tympanic membrane perforations caused by chronic otitis media were selected prospectively for bilateral tympanoplasty type I (28 ears) at a tertiary referral center. All patients had a HL corresponding to the size and localization of the perforation (no suspicion of ossicular chain defect or other pathology). Mean age was 37.5 years. There were seven males and seven females in our study. All but five ears were operated through an endaural or endomeatal approach, and five ears operated by postaural approach. The Underlay technique was used in all cases. Total ten cases operated using Fascia Lata and four cases operated using Temporalis fascia as graft material. Follow-up examination and hearing tests (pure tone audiometry) were performed up to 20 months after surgery. The graft take rate was 96%, with no retraction pockets or displaced grafts observed during follow-up. One patient had small residual perforation which healed at the end of 3 months. Hearing improved significantly, and the air-bone gap was significantly reduced. The air-bone gap was closed to within 10 dB in 92% and within 20 dB in 100% of the ears. Surprisingly good hearing was found during postoperative, bilateral ear canal gauze packing. Iatrogenic sensorineural HL did not occur. We conclude that bilateral myringoplasty is safe, with good results, reduces costs, and leaves the patient satisfied. The hearing impairment during postoperative ear canal packing is surprisingly modest and readily acceptable by the patients.
PMCID: PMC3851503  PMID: 24427585
Chronic otitis media; Bilateral tympanoplasty; Hearing loss; Underlay
21.  Effect of addition of fentanyl to local anesthetic in brachial plexus block on duration of analgesia 
A comparative study was carried out to evaluate the analgesic efficacy and side effects of addition of fentanyl to local anesthetic undergoing surgeries on forearm and elbow. All patients were hemodynamically stable, and there were no serious side effects in any of the patients in both the groups. The difference in the mean duration of analgesia between the groups was statistically significant (P<0.01). So we can conclude- Addition of Fentanyl to local anaesthetic in brachial plexus block increases duration of analgesia.
Materials and Methods:
Patients were randomly divided into two groups: group I (control) and group II (study). All the patients were subjected to brachial plexus block with supraclavicular approach. After obtaining paraesthesia, drugs were administered as follows: Group I (control): bupivacaine 0.5% 20 mL + lignocaine 2% 10 mL + NS 1 mL Group II (study): bupivacaine 0.5% 20 mL + lignocaine 2% 10 mL + fentanyl 1 mL (50 microgm). Observations were noted. All the relevant information was recorded on a pretested, predefined, semi-open pro forma sheet. Regular monitoring of PR, BP and RR, side effects,degree of sedation were recorded. Evaluation of pain and pain relief was done according to McGill pain questionnaire (0- no pain to 5- excruciating pain). When patients complained of discomforting pain (McGill grade II), parenteral analgesic was prescribed, and the total number of doses in the 24-hour period was noted.
The duration of analgesia in group II (study) was significantly longer (695±85 min) than those in group I (415±78 min). However, onset time of analgesia was prolonged in group 2. We conclude that the addition of fentanyl to local anesthetics causes an improved success rate of sensory blockade but a delayed onset of analgesia, although this may be accounted for by the decreased pH caused by fentanyl. There was no statistically significant difference in the incidence of side effects between the two groups.
This study has shown that the mean duration of analgesia is extended if fentanyl is added to local anesthetics, without increasing the side effects.
PMCID: PMC4173362  PMID: 25885298
Analgesia; brachial plexus; bupivacaine; fentanyl; lignocaine
22.  Alterations in the Contra lateral Ear in Chronic Otitis Media 
Chronic otitis media (COM), a persistent and durable inflammation and infection of the middle ear, is a common disorder. Alterations in the contralateral ear in sufferers have been observed in recent years. Because only a few studies have been reported in this area, we performed this study in order to assess alterations in the contralateral ear of patients with COM.
Materials and Methods:
Cross-sectional and descriptive methods were used in 100 patients with COM who were selected for surgical treatment and admitted to hospital. An information form was completed for all patients including demographic data, medical history of otoscopy and paraclinical examinations such as pure tone audiometry (PTA), tympanometry, Schuller radiography, and high resolution computed tomography (HRCT). All data were processed using SPSS (version 18) software and descriptive statistical tests.
According to otoscopy, PTA, tympanometry and graphical analysis, 60% of patients experienced disorders of the contralateral ear. Otoscopy analysis showed 54% of patients had a disorder of the contralateral ear, with the most common disorder being perforation of the ear drum. PTA showed a 48% incidence of contralateral ear problems (85% conductive hearing impairment; 12.5% sensorineural hearing impairment; 1.2% mixed). A total of 73.2% of patients with conductive hearing loss had a problem across all frequencies, while half of the patients with sensorineural hearing impairment had problems at frequencies greater than 1000 Hz. According to tympanometry, 38% of patients had problem in the contralateral ear. HRCT and Schuller graphical analyses indicated 31.5% and 36% occurrence of contralateral ear disorders, respectively.
More than 50% of patients with COM in one ear have a chance of also presenting with the disease in the other ear. Outcomes of this study and previous studies have shown that COM should not be perceived as a disease limited to one ear, because in most cases the progress of the disease can affect both ears.
PMCID: PMC3846270  PMID: 24303427
Hearing impairment; Middle ear infection; Tympanometry
23.  Cochlear Implantation in Patients with Chronic Otitis 
Skull base surgery  1998;8(3):127-131.
Normally, active chronic suppurative otitis media is regarded as a contraindication for cochlear implantation. In case of a radical cavity after surgical treatment for cholesteatoma, the electrode covered by the epithelial lining of the mastoid will likely become exposed or extruded. Under these circumstances we suggest the subtotal petrosectomy, obliteration of the middle ear cleft with abdominal fat, and the blindsac closure of the external ear canal before cochlear implantation.
Fourteen patients with chronic otitis media were successfully implanted with an intracochlear multichannel cochlear implant. After an average follow-up of 28 months a temporary facial palsy in one patient and an insufficient closure of a retroauricular fistula over the mastoid cavity in two cases were observed as postoperative complications. One patient with a tumefactive inflammatory pseudotumor developed a massive inflammation in the implanted ear 2 months after surgery which could not be controlled by conservative treatment. The implant had to be removed and after administration of cyclophosphamide she could be successfully reimplanted 7 months later.
Implantation of a foreign body in a potentially infected space which communicates with the endocranium means a surgical challenge which can be managed by obliteration of the middle ear. In case of massive inflammation we prefer a two-stage procedure.
PMCID: PMC1656671  PMID: 17171047
24.  Evaluation of the efficacy of a novel radical neck dissection preserving the external jugular vein, greater auricular nerve, and deep branches of the cervical nerve 
OncoTargets and therapy  2013;6:361-367.
Conventional radical neck dissection often causes a variety of complications. Although the dissection method has been improved by retaining some tissues to reduce complications, the incomplete dissection may cause recurrence of disease. In the present study, we developed a novel radical neck dissection, which preserves the external jugular vein, the greater auricular nerve, and the deep branches of the cervical nerve, to effectively reduce complications and subsequently, to promote the postoperative survival quality.
A total of 100 cases of radical neck dissection were retrospectively analyzed to evaluate the efficacy, rate of complication, and postoperative dysfunction of patients treated with the novel radical neck dissection. Data analysis was performed using the Chi-square test.
Compared with conventional radical neck dissection, the novel radical neck dissection could significantly reduce complications and promote postoperative survival quality. Particularly, the preservation of the external jugular vein reduced the surgical risk (ie, intracranial hypertension) and complications (eg, facial edema, dizziness, headache). Preservation of the deep branches of the cervical nerve and greater auricular nerve resulted in relatively ideal postoperative functions of the shoulders and ear skin sensory function (P < 0.05), while the two types of dissection procedures showed no differences in the recurrence rate (P > 0.05).
Our novel radical neck dissection procedure could effectively reduce the complications of intracranial hypertension, shoulder dysfunction, and ear sensory disturbances. It can be used as a regular surgical approach for oral carcinoma radical neck dissection.
PMCID: PMC3627341  PMID: 23596353
oral cancer; head and neck cancer; squamous cell carcinoma; survival quality; neck dissection; recurrence
25.  In situ tissue engineering with synthetic self-assembling peptide nanofiber scaffolds, PuraMatrix, for mucosal regeneration in the rat middle-ear 
Middle-ear mucosa maintains middle-ear pressure. However, the majority of surgical cases exhibit inadequate middle-ear mucosal regeneration, and mucosal transplantation is necessary in such cases. The aim of the present study was to assess the feasibility of transplantation of isolated mucosal cells encapsulated within synthetic self-assembling peptide nanofiber scaffolds using PuraMatrix, which has been successfully used as scaffolding in tissue engineering, for the repair of damaged middle-ear. Middle-ear bullae with mucosa were removed from Sprague Dawley (SD) transgenic rats, transfected with enhanced green fluorescent protein (EGFP) transgene and excised into small pieces, then cultured up to the third passage. After surgical elimination of middle-ear mucosa in SD recipient rats, donor cells were encapsulated within PuraMatrix and transplanted into these immunosuppressed rats. Primary cultured cells were positive for pancytokeratin but not for vimentin, and retained the character of middle-ear epithelial cells. A high proportion of EGFP-expressing cells were found in the recipient middle-ear after transplantation with PuraMatrix, but not without PuraMatrix. These cells retained normal morphology and function, as confirmed by histological examination, immunohistochemistry, and electron microscopy, and multiplied to form new epithelial and subepithelial layers together with basement membrane. The present study demonstrated the feasibility of transplantation of cultured middle-ear mucosal epithelial cells encapsulated within PuraMatrix for regeneration of surgically eliminated mucosa of the middle-ear in SD rats.
PMCID: PMC3728305  PMID: 23926427
nanofiber; synthetic self-assembling peptide scaffolds; regeneration; middle-ear mucosa; in situ tissue engineering

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