Annals of Otology,Rhinology & Laryngology

A comparison was made of the overall postoperative results for a group of 50 patients who had undergone a wire-gelfoam stapedectomy procedure for otosclerosis and a group of 106 patients who had undergone a wire-vein graft procedure. All operations were performed by the same surgeon and all testing was conducted in sound treated rooms by experienced audiologists using calibrated equipment. The results for the wire-vein group were consistently superior. At the four-month postoperative test date, air-bone closure for the wire-vein group was better at all frequencies by approximately 2 to 4 dB. Also, the four-month postoperative speech discrimination scores showed a decrement of only 1.8% for the wire-vein group in contrast to a decrement of 5.9% for the wire-gelfoam group. Furthermore, while no serious postoperative complications occurred for the wire-vein group, two instances of fistulae and one instance of wire migration occurred for the wire-gelfoam group. These results, coupled with recently proved long-term stability for the wire-vein graft prosthesis, support our initial clinical impression favoring the wire-vein graft stapedectomy procedure.

Tumors of the lacrimal sac are rare, and are discussed primarily in the ophthalmological literature. The otolaryngologist, however, often performs the definitive surgery and must, therefore, be familiar with this disease. The lacrimal apparatus secretes and then drains lubricating fluid from the eye. This report focuses on the drainage mechanism which is anatomically and functionally a single structure composed of the canaliculi, the lacrimal sac, and the nasolacrimal duct. By 1963, 184 lacrimal sac tumors had been reported in the world literature. We have collected an additional 21 patients from the literature. This brings the total malignant tumors to 125, of which 74 were of epithelial origin. One sarcoma and four poorly differentiated epidermoid tumors treated in our department are presented in detail. The diagnosis is often evasive though the history of mass and epiphora is typical. Conservative treatment for dacryocystitis only temporizes. Work-up should include external and slitlamp examination, complete rhinological evaluation, sinus x-rays, tomograms of the bony lacrimal sac area, and dacryocystograms. Biopsy gives pathological confirmation. The largest group is epidermoid carcinoma, mostly of the poorly differentiated nonkeratinizing type. The treatment for benign lesions is local excision. Preoperative irradiation is indicated for epidermoid carcinoma, followed by wide local excision. Radical maxillectomy may be reserved for recurrences, and neck dissection for palpable nodes may be helpful. Mesenchymal tumors respond best to radiotherapy. Death in lacrimal sac cancer results from metastases, most often to the neck and lung. Five year survival rates appear to be slightly greater than 50%.

Although osteogenic sarcoma occurs in the head and neck, it is almost exclusively limited to the maxilla and the mandible. Single, rare cases of this tumor in other facial bones are mentioned in foreign reports, but a discussion in the English literature has not come to our attention. The case history of a 58-year-old woman with a nonspecific frontal sinus pain and right-sided proptosis is presented. Plain radiographs of the paranasal sinuses revealed a radiopaque, calcific mass in the right frontal sinus approximately 3 × 5 cm in diameter. It was noted that the mass had an “onionskin” lamination. Laminography aided in the exact localization of the mass; further, it was noted on arteriography that the frontal sinus mass did not invade the dura. A frozen section biopsy at the time of craniotomy suggested a benign histologic lesion. However, subsequent review of permanent sections showed findings typical of an osteogenic sarcoma. The patient was treated with irradiation and in the first postoperative year has done well.

The technique of fluorochromasia has been used to study cellular permeability of the inner ear tissues. The hair cells of the organ of Corti show variations in permeability which are dependent on the previous history of in vivo exposure to physiologically normal levels of sound. Permeability was also sensitive to oxygen deprivation. Gross mechanical stimulation of the hair cells is sufficient to render the hair cell permeable to large molecules. The cilia of the hair cells seem to have a membrane structure independent of the hair cell itself.

Forty-three of 2500 consecutive ENG monitored caloric-induced nystagmus examinations gave no response to 5 cc of ice water in either ear. Among these, nine had CNS neoplasms, of which six were in the midline posterior fossa, six had autoimmune or collagen disease, six were caused by infections (meningitis, otitis, syphilis), five were congenital involving only the ear, five were drug induced, four had combined visual and eighth nerve hereditary disorders. Infection excepted, hearing losses were an irregular associated finding in roughly 50% and were less common in the CNS and systemic disease categories. Neither clinical symptoms nor other ENG findings were good predictors for finding no response to caloric tests.

Temporal bone findings are described in a 66-year-old white man with a one and one-half year history of Meniere's syndrome. Unilateral advanced endolymphatic hydrops of the cochlea and saccule, and numerous outpouchings of the utricle and semicircular ampullae were present. There was displacement of the utricle into the perilymphatic space of all the ampullae, as well as retrograde endolymphatic hydrops of most of the crus commune. The endolymphatic duct and intermediate portion of the endolymphatic sac demonstrated a rather straight course to the posterior fossa, with virtually no lateral curving. This same finding, however, was present in the opposite side where there was no evidence of endolymphatic hydrops. The cochlea, on the involved side, demonstrated considerable decrease in spiral ganglion cells and outer and inner hair cells throughout, most severe in the beginning of the basal turn. Degenerative changes were present in all the vestibular sensory receptor areas. Incidental histological otosclerosis of the oval window was found bilaterally. An unusual finding was bilateral focal nodular hyperplasia of the Schwann cells of the facial nerve within the internal auditory canal, with no compression of adjacent nerve trunks. This condition is rare and may simulate true tumors. The etiology here was unassociated with any other neurological disorder and is unexplained.

This paper deals with the problem of finding the optimal treatment for acute maxillary sinusitis. Only sinuses with secretion were included. Comparison between the different modes of treatment was made by the aid of a radiological gradation of the sinus changes. Each treatment group consisted of 50 patients whose sinuses were radiologically investigated on day 1, 5, 10 and 15. Treatment was given for 10 days. Irrigation was performed every second day until the lavage content was clear. Side effects were investigated. All groups were statistically similar initially. There was no statistical difference between the four treatment groups with regard to healing after 5, 10 and 15 days of treatment. Few side effects were noted on doxycycline but some on spiramycin. Both antibiotics thus afford the advantage of omitting irrigation from the treatment.

Biochemical characteristics of middle ear effusions (MEE) should provide a better understanding of the etiopathogenesis of serous otitis media. In order to develop another parameter for the biochemical characterization of the MEE, lactate dehydrogenase (LDH) and LDH isoenzyme patterns in the serous middle ear effusion and serum from 20 patients with serous otitis media were compared. The LDH activity was measured by the usual spectrophotometric method. The isoenzyme patterns were compared on electropherograms using cellulose polyacetate strips. The LDH activity in MEE was significantly higher (P < 0.001) than it was in serum. Fractions of isoenzymes 1 and 2 were each smaller in MEE than in serum. Isoenzymes 4 and 5 have a significantly higher (P < 0.001) fraction in MEE than in serum. Since LDH is an intracellular enzyme and middle ear mucosa is reported to have high content of isoenzymes 4 and 5, the inflammatory changes in the middle ear mucosa which may release intracellular LDH, are suggested as the cause of both higher activity of LDH and the higher fractions of isoenzymes 4 and 5 in MEE than those in the serum.

Quantitative analysis of immunoglobulins (IgG, IgA and IgM) by radial immunodiffusion technique and double diffusion analysis of secretory immunoglobulin A (SIgA) were performed on specimens of middle ear effusion for the purpose of investigating the nature of middle ear effusion. Specimens consisted of 34 serous (15 acute and 19 chronic type) and 15 mucoid effusions (9 acute and 6 chronic type). Mean values of the IgG level in effusions and sera of each category were nearly the same. The IgA concentrations of mucoid effusions were significantly higher than those in serous effusions. Mean values of the IgM level in effusions of acute and chronic cases of both categories were lower than those in the sera. SIgA was found in 9 out of 34 (26.5%) serous effusions, while 14 out of 15 (93.3%) mucoid effusions were found to have SIgA. Results of this study suggest that middle ear effusion is a mixture of the transudate from the serum and of secretion by secretory cells present in the mucosa of the middle ear cavity; and that the nature of the mucoid effusion is similar to exudate, while the serous effusion for the most part comes from the serum.

In conjunction with a controlled study of the effect of vitamin C on susceptibility to experimentally induced rhinovirus infections in man, we have conducted a study of nasal mucociliary function in the subjects volunteering for the study. In the 21 volunteers an average mucociliary flow rate (measured by the Quinlan tagged particle technique) of 7.5 mm/min was found in those with normal nasal morphology and 4.0 mm/min in those with abnormal nasal morphology. The rates decreased during infection in both groups but at different times after induction of infection. Ascorbic acid had no effect on either susceptibility to induced rhinovirus infection or mucociliary transport.

A calcified neurilemoma was discovered in a 73-year-old man whose main complaint was of progressive hoarseness associated with recent dysphagia. The tumor was located above the level of the right vocal cord, measured 4×3×3 cm and showed extensive cystic degeneration, in addition to calcification. At microscopic examination both Antoni A and B patterns were identified at the periphery of the degenerate tumor. At the ultrastructure level the tumor was composed of collagen fibrils with scattered elongated cells. Cells had a definite basement membrane and cytoplasmic substructures as described in neurilemoma. These benign encapsulated neoplasms are very rare in the larynx and the initial symptom usually is longstanding progressive hoarseness as in this report. Local excision is satisfactory treatment for laryngeal neurilemomas when practical.

Secretory immunoglobulin-A (IgA) in nasal mucus exerts a major protective function for the respiratory tract, and low amounts of IgA are reported to correlate with susceptibility to disease. Therefore, a study has been made of the variability in amount of IgA present in human nasal mucosa. Subjects' IgA production has been found to vary substantially during the day and to reach very low values from time to time. Subjects sampled themselves by a nasal wash procedure. The samples were analyzed for IgA and for total soluble protein Because the total protein is relatively constant, use of the ratio of these two quantities reduces the effect of sampling differences and gives a better measure of IgA production. Samples were collected five and six times daily in November and March. The results were similar with no seasonal effect. A three- to four-fold change was found in the IgA production of most subjects during an average day. The peak usually appeared between midnight and 8:00 a.m., with a broad low period during the afternoon, displaying a typical circadian cycle. The greatest number of low-value samples appeared in the period between 2:00 and 5:00 p.m. Subjects differed in their average level of IgA production. Most subjects had periods of consecutive low samples, often showing that their IgA production was low for four or more hours. All subjects had some periods of low IgA production. Some were consistently low, and these reported having a higher incidence of respiratory disease than average. These low periods and the variation between subjects may be important as to the susceptibility to respiratory disease. The method of determination is well worked out. It is recommended that physicians utilize this analysis to help diagnose the patient with frequent respiratory sickness, including those of the bronchial mucosa, sinus and middle ear. The present study shows that a serial observation of four samples over the day would be best for finding a hypo condition. However, if only one sample can be taken, the later part of the afternoon is the best time in order to discover the deficiency, if any. The existence of a circadian cycle suggests possible control by the adrenal hormone system which has a similar cycle. If confirmed by further research this finding would point to a study of methods of treatment to increase IgA production.

Tracheobronchiomegaly is a condition of abnormal, probably congenital, enlargement of the trachea, main bronchi, and segmental bronchi. In addition, it is characterized usually by diverticula and sacculations between the cartilaginous rings. As an aid to diagnosis, the authors measured the transverse and anterior-posterior diameters of the trachea and main bronchi at autopsy of 100 men to determine the normal limits. Transverse diameters of the trachea greater than 25 mm, of the right main bronchus greater than 23 mm, and of the left main bronchus greater than 20 mm should raise the suspicion of tracheobronchiomegaly. The diagnosis can be strengthened if bronchographic abnormalities such as sacculations or unusual deformity are found. In using bronchographic measurements, a correction for the slight magnification that results from this technique must be made. Diagnosis also depends on clinical features such as a whooping, chronic cough, poor ability to raise secretions, and repeated episodes of bronchitis and pneumonitis. A routine chest roentgenogram may show a widened tracheal air column. Therapy should include vigorous use of antibiotics and postural drainage.

Stimulation of the larynx, as during intubation, can produce significant cardiac arrhythmias. Investigation of the cause of these arrhythmias has led us to believe that they are in part due to stimulation of a baroreceptor reflex pathway which passes through the larynx rather than to initiation of a simple reflex in the larynx itself. Pressure sensors (baroreceptors) in the aortic arch form part of a system which monitors systemic blood pressure. Stimulation of these baroreceptors produces, via a medullary reflex arc, a slowing of the heart rate, a decrease in sympathetic vascular tone, and as a result a drop in blood pressure. The pathway from the aortic arch baroreceptors has heretofore been thought to run directly through the vagus nerve. We have shown, however, that in the rat a significant number of fibers from aortic arch baroreceptors run in the left recurrent laryngeal nerve (RLN), through the larynx into the left superior laryngeal nerve (SLN), and only then into the vagus. Blocking or cutting the left RLN produces a significant drop in overall baroreceptor reflex activity, and furthermore, nerve fibers have been isolated in the left RLN which show exactly the same patterns of discharge as those from arterial baroreceptors elsewhere. It is our belief that at least some of the arrhythmias produced during laryngeal manipulation can be explained on the basis of mechanical compression producing stimulation of the baroreceptor fibers as they pass along the thyroid cartilage through the ramus communicans between the RLN and SLN. Further work needs to be done to show that compression does in fact stimulate the baroreceptor pathway, but there is now little doubt that, in experimental animals, such a pathway exists.

Idiopathic peripheral facial paralysis is a common clinical condition, but the etiology and preferred mode of treatment are still undecided. The currently popular etiological theory centers around disturbances of microvascular circulation. The literature contains conflicting statements on the incidence of this condition in pregnancy. Six cases are reported, one bilateral, in all of which the paralysis developed within six weeks of delivery. The incidence of facial paralysis was not significantly different in our pregnant and nonpregnant populations of similar age groups. A battery of tests failed to reveal any specific etiologic factors. None of the patients had toxemia, therefore, hypertension is not a causative factor. Comparison with the Melkersson-Rosenthal syndrome would indicate that tissue edema is not involved in the pathogenesis of the idiopathic paralysis of pregnancy. Both idiopathic sudden deafness and idiopathic facial paralysis occur preferentially in the later stages of pregnancy and the early puerperium. Further research into the pathophysiology of this stage of pregnancy may clarify some of the etiological problems of these two conditions.

The purpose of this study was to map the distribution and density of goblet cells in the clinically normal middle ear. From 12 temporal bones, derived from 12 adult patients with clinically normal middle ears, the mucosa was prepared and stained by the PAS-alcian blue whole-mount method. In six of the patients the middle ears with meticulous gross and microscopic investigation showed mild sequelae of previous otitis media, called the slightly abnormal series, whereas the other six patients who had entirely normal middle ears were designated the normal series. Each middle ear was investigated in 12 different areas: tympanic orifice, hypotympanum anteriorly and posteriorly, round window niche, oval window niche, promontory anteriorly, in the middle, and posteriorly, epitympanum, antrum, and mastoid process. In each middle ear area the goblet-cell density and distribution were determined on the basis of 30 to 50 counts of 0.01768 mm² epithelial surface, a total of at least 4800 counts. In six patients goblet cells were found in all 12 areas, in three patients in 11, and in three patients in 10. In both series there was a distinct decrease in goblet-cell density from the tympanic orifice, towards the posterior areas of the middle ear and the mastoid process. However, two patients of the slightly abnormal series exhibited a considerably greater density in the posterior than in the anterior part of the hypotympanum. The mean goblet-cell density in the slightly abnormal series was distinctly greater in all middle ear areas than in the normal series. Correspondingly, goblet cells were demonstrated in the antrum and mastoid process in all patients of the slightly abnormal series, but in only half of the normal series. Therefore, the greater goblet-cell density in the slightly abnormal series presumaby results from a previous past disease condition of the middle ear.

Attention is drawn to the difficulties of estimating the viscoelasticity of organic liquid as bronchial secretion. Neither the capillary viscometer nor the cone-plate viscometer is suitable for this purpose. A new type of viscometer is described which conforms to the requirements of mucus. The instrument operates on the principle of a torsion bar. Use of this instrument showed that the viscoelasticity of bronchial secretion, obtained from the tracheotomies of laryngectomized patients, show great fluctuations in the course of each day. Thus, viscoelasticity measurements made once a day to estimate the effect of a therapeutic procedure, especially if sputum is used, possess no significant value. Only a comparison of day curves will give useful information.

Bony hemangiomas, while occurring with some frequency in the axial skeleton, are rare in the maxilla. A case is described bring the total in the world literature to 12. Presenting symptoms and signs can include a pulsatile cheek mass, bruit, and toothache. If conventional x-ray reveals a honeycomb effect and resorption of bone, angiography may establish the diagnosis preoperatively. Maxillectomy is probably the treatment of choice. Biopsy is fraught with danger, and should only be undertaken at the time of definitive surgery.

The two major indications for common or internal carotid ligation are the resection of neoplasm and the control or prevention of hemorrhage. Sixty percent of those undergoing elective carotid ligation and 12% of those undergoing emergency ligation survive these procedures without evidence of neurological sequelae. This uncompromised survival is based upon the presence or rapid developmnt of collateral circulation to the cerebral vascular bed. Arteriographic studies are utilized to illustrate the development of intra- and extracranial collateralization to the internal carotid artery after interruption of the ipsilateral common carotid. The major collateral circuits demonstrated via a case report are as follows: 1) from the vertebral artery to the external carotid and hence to the internal carotid; 2) from the posterior communicating artery to the internal carotid; and 3) from the ophthalmic artery to the internal carotid.