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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.  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
3.  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
4.  Total auricular reconstruction with autogenous costal cartilage framework for congenital microtia (grade-III) 
The Auricular deformity of congenital microtia (Grade-llll can cause devastating physical and psychological trauma in children. liven crude duplications of the normal ear are of great emotional value to the child or adult who is horn with only a nubbin. Diverse materials ranging from altografts (polyethylene, nylon mesh. Teflon. Silicone,etc), cartilage homo and hcterografts haw been tried for framework construction of the ear. Converge (1985) and Tanzer (1959) popularized the use of autogenous rib cartilage, carved in a solid block. We describe our experience with autogenous costal cartilage graft as framework for total auricular reconstruction in 13 patients (15 ears) with congenital microlia(grade-lll). Atresia repair was performed in two patients. with bilateral grade-Ill deformity.
PMCID: PMC3450440  PMID: 23119889
Auricular Reconstruction; Autogenous Costal Cartilage; Microtia
5.  “Turkey Ear” as a Cutaneous Maniestation of Tuberculosis 
Lupus vulgaris is the most common morphological variant of cutaneous tuberculosis. Classical lupus lesions are often seen in the head and neck region. Turkey ear is a clinically descriptive term, previously being used for the earlobe with reddish indurated plaque lesions, which recently can be a sign for lupus vulgaris. A 65-year-old man presented with lupus vulgaris of the earlobe. The diagnosis was confirmed by conventional laboratory investigations and the patient showed well response to antituberculous therapy. This is the second reported case of “turkey ear” as a manifestation of cutaneous tuberculosis.
PMCID: PMC3519274  PMID: 23248385
Earlobe dermatitis; lupus pernio; lupus vulgaris; turkey ear
6.  Evaluation of EMLA Cream for Preventing Pain during Tattooing of Rabbits: Changes in Physiological, Behavioural and Facial Expression Responses 
PLoS ONE  2012;7(9):e44437.
Ear tattooing is a routine procedure performed on laboratory, commercial and companion rabbits for the purpose of identification. Although this procedure is potentially painful, it is usually performed without the provision of analgesia, so compromising animal welfare. Furthermore, current means to assess pain in rabbits are poor and more reliable methods are required. The objectives of this study were to assess the physiological and behavioural effects of ear tattooing on rabbits, evaluate the analgesic efficacy of topical local anaesthetic cream application prior to this procedure, and to develop a scale to assess pain in rabbits based on changes in facial expression.
Methodology/Principal Findings
In a crossover study, eight New Zealand White rabbits each underwent four different treatments of actual or sham ear tattooing, with and without prior application of a topical local anaesthetic (lidocaine/prilocaine). Changes in immediate behaviour, heart rate, arterial blood pressure, serum corticosterone concentrations, facial expression and home pen behaviours were assessed. Changes in facial expression were examined to develop the Rabbit Grimace Scale in order to assess acute pain. Tattooing without EMLA cream resulted in significantly greater struggling behaviour and vocalisation, greater facial expression scores of pain, higher peak heart rate, as well as higher systolic and mean arterial blood pressure compared to all other treatments. Physiological and behavioural changes following tattooing with EMLA cream were similar to those in animals receiving sham tattoos with or without EMLA cream. Behavioural changes 1 hour post-treatment were minimal with no pain behaviours identifiable in any group. Serum corticosterone responses did not differ between sham and tattoo treatments.
Ear tattooing causes transient and potentially severe pain in rabbits, which is almost completely prevented by prior application of local anaesthetic cream. The Rabbit Grimace Scale developed appears to be a reliable and accurate way to assess acute pain in rabbits.
PMCID: PMC3436883  PMID: 22970216
7.  Complications of auricular correction 
The risk of complications of auricular correction is underestimated. There is around a 5% risk of early complications (haematoma, infection, fistulae caused by stitches and granulomae, allergic reactions, pressure ulcers, feelings of pain and asymmetry in side comparison) and a 20% risk of late complications (recurrences, telehone ear, excessive edge formation, auricle fitting too closely, narrowing of the auditory canal, keloids and complete collapse of the ear). Deformities are evaluated less critically by patients than by the surgeons, providing they do not concern how the ear is positioned. The causes of complications and deformities are, in the vast majority of cases, incorrect diagnosis and wrong choice of operating procedure. The choice of operating procedure must be adapted to suit the individual ear morphology. Bandaging technique and inspections and, if necessary, early revision are of great importance for the occurence and progress of early complications, in addition to operation techniques. In cases of late complications such as keloids and auricles that are too closely fitting, unfixed full-thickness skin flaps have proved to be the most successful. Large deformities can often only be corrected to a limited degree of satisfaction.
PMCID: PMC3199843  PMID: 22073079
auricular correction; complications; corrective operations
8.  Tattooing and the Risk of Wrong-Site Ear Surgery 
Wrong-site surgery could occur in cases of bilateral pathology or in patients with normal tympanic membranes such as those undergoing stapedectomy. This report highlights the pitfalls in current surgical checklists despite best efforts being put into their design. The practice of marking the earlobe in ear surgery may be less safe than using larger arrows on the neck to indicate the side of surgery.
PMCID: PMC2966249  PMID: 19909607
Wrong-site surgery; Tattooing; Ear surgery
9.  Post operative sensorineural hearing loss after middle ear surgery 
Mild Sensorineural hearing loss subsequent to middle ear surgery has till today been an important complication to middle ear surgery inspite of advances in surgical techniques, operative instruments, monitoring devices and better treatment options. Lack of proper knowledge about this problem is because of under reporting of exact magnitude of hearing loss on account of difficulty in measuring hearing threshold of patients in immediate postoperative period as it may lead to post operative infection and discomfort to the patient.
In our study of 80 cases carried out at ENT department, Baroda Medical College and S.S.G Hospital, Baroda, we have utilized weber’s lateralisation principle and measured bone conduction thresholds of patients undergoing middle ear surgery for evaluation of postoperative Sensorineural loss as a result of middle ear surgery. Probable causes of post operative hearing loss in a patient undergoing middle ear surgery are, noise due to drills, continuous suction irrigation, vibrations, inner ear injury, manipulation of ossicles and a few unknown reasons.
PMCID: PMC3451895  PMID: 23120088
Mild Sensorineural hearing loss; middle ear surgery
10.  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
11.  Evoked Pain Analgesia in Chronic Pelvic Pain Patients using Respiratory-gated Auricular Vagal Afferent Nerve Stimulation 
Pain Medicine (Malden, Mass.)  2012;13(6):777-789.
Previous Vagus Nerve Stimulation (VNS) studies have demonstrated anti-nociceptive effects, and recent non-invasive approaches; termed transcutaneous-VNS, or t-VNS, have utilized stimulation of the auricular branch of the vagus nerve in the ear. The dorsal medullary vagal system operates in tune with respiration, and we propose that supplying vagal afferent stimulation gated to the exhalation phase of respiration can optimize t-VNS.
counterbalanced, crossover study.
patients with chronic pelvic pain (CPP) due to endometriosis in a specialty pain clinic.
We evaluated evoked pain analgesia for Respiratory-gated Auricular Vagal Afferent Nerve Stimulation (RAVANS) compared with Non-Vagal Auricular Stimulation (NVAS). RAVANS and NVAS were evaluated in separate sessions spaced at least one week apart. Outcome measures included deep tissue pain intensity, temporal summation of pain, and anxiety ratings, which were assessed at baseline, during active stimulation, immediately following stimulation, and 15 minutes after stimulus cessation.
RAVANS demonstrated a trend for reduced evoked pain intensity and temporal summation of mechanical pain, and significantly reduced anxiety in N=15 CPP patients, compared to NVAS, with moderate to large effect sizes (eta2>0.2).
Chronic pain disorders such as CPP are in great need of effective, non-pharmacological options for treatment. RAVANS produced promising anti-nociceptive effects for QST outcomes reflective of the noted hyperalgesia and central sensitization in this patient population. Future studies should evaluate longer-term application of RAVANS to examine its effects on both QST outcomes and clinical pain.
PMCID: PMC3376238  PMID: 22568773
12.  Congenital upper auricular detachment: Report of two unusual cases 
Two unusual cases of congenital bilateral ear deformity have been presented. The deformity is characterized by upper auricular detachment on the right side with anotia on the left side in the first case and upper auricular detachment on the left side with normal ear on the right side in the second case. An attempt has been made to correlate the presented deformity with the embryological – foetal development of the auricle. Satisfactory correction can be obtained by repositioning the auricle back in to its normal position.
PMCID: PMC2845381  PMID: 20368874
Congenital ear anomaly; partial auricular; detachment; upper auricular; anomalier
13.  Surgery and Perioperative Intralesional Corticosteroid Injection for Treating Earlobe Keloids: A Korean Experience 
Annals of Dermatology  2009;21(3):221-225.
The aesthetic implications of ear keloids, which affect people of all races, are serious and the treatment of earlobe keloids is known to be difficult. The high rate of recurrence following excision alone has led to investigating various types of adjuvant therapy, including intralesional corticosteroid injection.
We evaluated the efficacy of excision combined with perioperative intralesional triamcinolone acetonide injection for treating earlobe keloids of Korean patients.
From 1997 to 2006, eighteen keloids on the earlobes of fifteen Korean patients were treated. The patient age ranged from 15 to 32 years (mean age: 24 years). All the patients were female and the keloids occurred after ear piercing. Preoperative intralesional triamcinolone acetonide (TA) injection was administered twice at a 1-month interval. Postoperative intralesional TA injections were given every 1 month for several months, depending on the patient's clinical progress.
The follow-up period ranged from 4 to 42 months (mean: 18.5 months). After the surgery, TA intralesional injections were given 2 to 13 times (mean: 5.2 times). Of the treated keloids, eleven showed good results (61.1%) and three recurred (16.6%). No complications from the TA intralesional injection were observed.
Among the various treatments for earlobe keloids, we suggest that excision with corticosteroid intralesional injection can be used as the first line therapy when considering its effect and economic advantage.
PMCID: PMC2861230  PMID: 20523793
Earlobe keloid; Excision; Intralesional injection; Triamcinolone acetonide
14.  A Child Presenting with a Bullet in the Middle Ear: Case Report 
Foreign bodies in the external auditory canal are common in both adults and children. Removal of the foreign body requires skill, but is usually successfully performed in the emergency department. We report a case of a child with a bullet in ear canal which was pushed into the middle ear during an attempt to remove it.
Case Presentation
A 6-year-old Thai boy went to the community hospital with his parents, who reported that their child had pushed a bullet into his ear. Otoscopic examination revealed a metallic foreign body in his external auditory canal. The first attempt to remove the foreign body failed and the child was referred to an otolaryngologist. We found that the tympanic membrane was ruptured, with granulation tissue in the middle ear and the bullet was located in the hypotympanum. The foreign body was removed via a post-auricular approach.
Removal of a foreign body from external auditory canal is an essential skill for physicians. Careful removal can prevent further trauma and complications. When the first attempt fails, referral to an otolaryngologist is recommended.
PMCID: PMC3257066  PMID: 22262944
foreign body; middle ear; auditory canal
15.  Sequential Bilateral Cochlear Implantation in a Patient with Bilateral Meniere’s Disease 
This case study describes a 45 year old female with bilateral, profound sensorineural hearing loss due to Meniere’s disease. She received her first cochlear implant in the right ear in 2008 and the second cochlear implant in the left ear in 2010. The case study examines the enhancement to speech recognition, particularly in noise, provided by bilateral cochlear implants.
Speech recognition tests were administered prior to obtaining the second implant and at a number of test intervals following activation of the second device. Speech recognition in quiet and noise as well as localization abilities were assessed in several conditions to determine bilateral benefit and performance differences between ears. The results of the speech recognition testing indicated a substantial improvement in the patient’s ability to understand speech in noise and her ability to localize sound when using bilateral cochlear implants compared to using a unilateral implant or an implant and a hearing aid. In addition, the patient reported considerable improvement in her ability to communicate in daily life when using bilateral implants versus a unilateral implant.
This case suggests that cochlear implantation is a viable option for patients who have lost their hearing to Meniere’s disease even when a number of medical treatments and surgical interventions have been performed to control vertigo. In the case presented, bilateral cochlear implantation was necessary for this patient to communicate successfully at home and at work.
PMCID: PMC3431798  PMID: 22463939
Cochlear implant; hearing aid; Meniere’s disease; sensorineural hearing loss; speech recognition; vertigo
16.  Topical anaesthesia with local anaesthetic (lidocaine and prilocaine, EMLA) cream for cautery of genital warts. 
Genitourinary Medicine  1987;63(5):316-319.
Removal of genital warts by thermocautery was performed in 108 patients (57 men and 51 women) under topical anaesthesia with a local anaesthetic cream, lidocaine and prilocaine (EMLA). Most men had warts in the preputial cavity, most women had warts situated on the mucous membranes of the vulva, and warts at multiple sites were common. About 1 ml of cream per lesion was applied to the warts for 20 to 105 minutes before the operation. Plastic film (Glad, Union Carbide) was applied over the cream when natural occlusion, such as under the prepuce or on the introitus, was not present. Local pallor was seen in 30% of the patients, redness in 53%, and oedema in 15%, but did not cause any discomfort and were clinically insignificant. Analgesia was sufficient in 96% of the men and in 40% of the women. Additional local infiltration was given to 60% of the women, but was not as painful as injections generally are in the genital area. The analgesic efficacy on women may be further improved by optimising the application time on the genital mucosa.
PMCID: PMC1194100  PMID: 3315960
17.  Otorrhagia bleeding due to leech bite 
Leeches are blood-sucking hermaphroditic parasites that attach to vertebrate hosts, bite through the skin, and suck out blood. When leeches feed, they secrete an anticoagulant (hirudin), which helps them get a full meal of blood. This is the first report of leech removal from external auditory canal. Previous leech involvement cases were explained in nasopharynx, larynx, pharynx, eye, and gastrointestinal tract. Prominent sign of all cases was active bleeding from the leech attachment site; that stopped with leech removal. A 24-year-old man was presented to Al-Zahra hospital with left otorrhagia and otalgia from 2 days ago. After suction of ear a small soft foreign body was seen in the external ear near the tympanic membrane, then the ear filled with glycerine phenice, the patient explained decreased movement of foreign body. Four hours later the bloody discharge stopped and otalgia decreased. After suction of clots, a leech was extruded from external auditory canal by alligator. Leech infestation is a rare cause of otorrhagia and should be suspected in the endemic region in all of unusual bleeding; it can be diagnosed and treated by exact inspection and removal.
PMCID: PMC3507012  PMID: 23210074
Ear; external; leeches
18.  Implant-Retained Auricular Prosthesis: A Case Report 
European Journal of Dentistry  2010;4(1):71-74.
Extraoral implant retained prosthesis have been proven to be a predictable treatment option for maxillofacial rehabilitation. This case report describes the clinical and laboratory procedures for fabricating an auricular prosthesis.
In this case report, an auricular prosthesis was fabricated for a patient who lost the left and right external ear in an electrical burn. Extraoral implants and bar-and-clip retention for the proper connection of the auricular prosthesis to implant were used. This prosthesis was acceptable to the patient because of excellent support, retentive abilities and the patient’s appearance.
PMCID: PMC2798793  PMID: 20046483
Auricular prosthesis; Implant retained prosthesis
19.  Antigen-Specific Cellular and Humoral Responses Are Induced by Intradermal Mycobacterium leprae Infection of the Mouse Ear▿  
Infection and Immunity  2007;75(11):5290-5297.
Leprosy is caused by infection with Mycobacterium leprae. The immune response of leprosy patients can be highly diverse, ranging from strong cellular responses accompanied by an apparent deficit of M. leprae-specific antibodies to strong humoral responses with a deficit of cell-mediated responses. Leprosy takes many years to manifest, and this has precluded analyses of disease and immune response development in infected humans. In an attempt to better define development of the immune response during leprosy we have developed an M. leprae ear infection model. Intradermal inoculation of M. leprae into the ear supported not only infection but also the development of a chronic inflammatory response. The inflammatory response was localized, comprising a T-cell infiltration into the ear and congestion of cells in the draining lymph nodes. The development of local chronic inflammation was prevented by rifampin treatment. Importantly, and in contrast to subcutaneous M. leprae footpad infection, systemic M. leprae-specific gamma interferon and antibody responses were detected following intradermal ear infection. These results indicate the utility of intradermal ear infection for both induction and understanding of the immune response during M. leprae infection and the identification or testing of new leprosy treatments.
PMCID: PMC2168264  PMID: 17724073
20.  Comparison of dexmedetomidine and clonidine (α2 agonist drugs) as an adjuvant to local anaesthesia in supraclavicular brachial plexus block: A randomised double-blind prospective study 
Indian Journal of Anaesthesia  2012;56(3):243-249.
Background and Objectives:
Alpha-2 agonists are mixed with local anaesthetic agents to extend the duration of spinal, extradural and peripheral nerve blocks. We compared clonidine and dexmedetomidine as an adjuvant to local anaesthetic agent in supraclavicular brachial plexus block with respect to onset and duration of sensory and motor block and duration of analgesia.
Sixty ASA I and II patients scheduled for elective upper limb surgeries under supraclavicular brachial plexus block were divided into two equal groups in a randomized, double-blinded fashion. Group C received clonidine 1 μg/kg and Group D received dexmedetomidine 1 μg/kg added to bupivacaine 0.25% (35 cc). Onset and recovery time of sensory and motor block, duration of analgesia and quality of block were studied in both the groups.
Duration of sensory block and motor block was 227.00±48.36 and 292.67±59.13 min, respectively, in group C, while it was 413.97±87.13 and 472.24±90.06 min, respectively, in group D. There was no statistically significant difference in onset of sensory and motor block between the two groups. The duration of analgesia (time to requirement of rescue analgesia) in group D was 456±97 min, while in group C, it was 289±62 min. Statistically, this difference was significant (P=0.001). The number of patients achieving grade IV quality (excellent) of block was higher in group D (80%) as compared with group C (40%) (P<0.05).
Dexmedetomidine when added to local anaesthetic in supraclavicular brachial plexus block enhanced the duration of sensory and motor block and also the duration of analgesia. The time for rescue analgesia was prolonged in patients receiving dexmedetomidine. It also enhanced the quality of block as compared with clonidine.
PMCID: PMC3425283  PMID: 22923822
Clonidine; dexmedetomidine; supraclavicular block
21.  A Case of Atypical Granuloma Annulare Involving Both Ears 
Annals of Dermatology  2009;21(4):413-415.
We report a rare case of granuloma annulare (GA), affecting both ear antihelixes, in a 28-year old male patient that presented with a 1-year history of non-tender, firm, skin-colored, 1~5 mm papules on both ear antihelixes. There was no history of trauma. An excisional biopsy specimen taken from one of the lesions of the right ear revealed infiltration of histiocytes and lymphocytes around a zone of collagen alteration in the dermis. Based on the clinical and pathological findings, the patient was diagnosed with a rare case of bilateral GA of both antihelixes; this is the first report in the Korean dermatology literature.
PMCID: PMC2861265  PMID: 20523836
Bilateral ear antihelical area; Granuloma annulare
22.  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
23.  Earlobe reconstruction by the Gavello technique and bilobed flap* 
Anais Brasileiros de Dermatologia  2013;88(2):272-275.
The earlobe is an anatomical structure that has a significant aesthetic role. Its surgical repair places a challenge due to the difficulty of obtaining a natural appearing and durable outcome. The authors present two options: the Gavello technique and the bilobed flap, after the excision of malign neoplasms of the earlobe. The Gavello technique makes use of a bilobed flap with an anterior base to mold the new earlobe. D'Hooghe's bilobed flap with a pre and post-auricular lobe allows the reconstruction of small earlobes. Both techniques, although old, acquire an important and current interest in earlobe reconstruction, by reason of the moderate degree of difficulty, the use of a single time surgical act and under local anesthesia, with a proper aesthetic result.
PMCID: PMC3750896  PMID: 23739705
Carcinoma, basal cell; Ear; Ear neoplasms; Melanoma; Surgical flaps
24.  Unilateral Attico Antral Ear Disease with Bilateral Intracranial Complications 
A 12 year old female patient, who had attico antral type of ear disease on right side, was brought to tertiary care centre for the management of fever, vomiting and headache. Patient had unilateral attico antral type of ear disease with bilateral intracranial complication. Along with the right attico antral type of ear disease and right lateral sinus thrombosis, patient had brain abscess in the left occipital lobe. Brain abscess was drained first and later mastoidectomy was done to eradicate the source of infection and to prevent further complications due to ear disease. Patient recovered well and patient was free from any problem during follow up period of 6 months. Bilateral intra cranial complications occurring simultaneously in a patient with a unilateral attico antral type of ear disease is not reported in the literature.
Electronic supplementary material
The online version of this article (doi:10.1007/s12070-011-0127-8) contains supplementary material, which is available to authorized users.
PMCID: PMC3244583  PMID: 23459017
Unilateral; Bilateral; Intra cranial complication; Attico antral
25.  Perioperative risk of complete heart block in patients with bifascicular block and prolonged PR interval. 
Thorax  1981;36(1):14-17.
Because there is a paucity of information on the perioperative risk of developing complete heart block among patients with bifascicular block (either right bundle branch block and left anterior hemiblock or left bundle branch block) and a long PR interval on the surface electrocardiogram, we undertook an analysis of 76 such patients. Twenty-three patients had right bundle branch block and left axis deviation with a long PR interval and 53 had left bundle branch block with along PR interval. Thirty patients had 37 general anaesthetics, 23 had 32 spinal anaesthetics, and 50 had 64 local anaesthetics or endoscopic procedures. No patient developed complete heart block. Four patients developed sinus bradycardia during general anaesthetics, responsive to atropine or isoproterenol. Similarly, none of the 23 such patients in the literature reviewed had developed complete heart block. Because placement to temporary pacemakers is not without risk, we conclude that prophylactic pacing is not necessary in asymptomatic patients with bifascicular block even in the presence of a long PR interval. Since we did not study patients with recent syncope or myocardial infarction, caution should be exercised in applying these results to such patients.
PMCID: PMC471434  PMID: 7292375

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