Positive impact of stroke unit establishment on patient recovery in Firoozgar hospital

Background: Firoozgar Comprehensive Stroke Center started up as the first organized care unit in the country in 2014; this study was performed to investigate quality indicators such as reduction in mortality, morbidity and hospital stay. Methods: Two groups of ischemic stroke patients were compared. The first group had been admitted in general neurology ward (non-stroke unit patients) and the second one received specialized stroke care in the stroke unit within a period of two years (stroke unit patients). Non-stroke unit patients were selected from a pool of patients admitted two years before establishment of stroke unit. Variables compared were factors such as modified Rankin Scale (mRS), confinement days in stroke unit or Intensive Care Unit, total days of hospitalization, history of prior stroke, receiving recombinant tissue plasminogen activator (rtPA) and the stroke category indicating anterior or posterior circulation infarct. Quantitative testing was conducted using independent t-test as well as "Mann-Whitney U Test"; Chi-squared test was used for qualitative testing. Results: A total number of 129 patients enrolled in the study (66 cases of non-stroke unit patients and 63 cases of stroke unit patients). The average total days of hospitalization were 17.32 (95% CI: 0.15-36.1) in non-stroke unit patients and 21.19 (95% CI: 4.99 - 38.1) in stroke unit patients (p=0.2). Results for stroke unit patients showed a lower mRS score (OR=1.48, p=0.01). Conclusion: It was concluded that stroke unit patients tend to have a better outcome and a lower mRS score at discharge. No significant difference in hospitalization period was noted between the two groups.

Effect of mastoid oscillation on the outcome of the canalith repositioning procedure

OBJECTIVE

The canalith repositioning procedure (CRP), as described by Epley, is a well-established method of treatment for benign paroxysmal positional vertigo (BPPV). Debate exists as to whether simultaneous application of a mastoid oscillator confers any added benefit. The aim of this study was to examine this question.

STUDY DESIGN

Prospective randomized study.

METHOD

Eighty-four subjects with unilateral posterior canal BPPV were randomized into two groups. The oscillator group was treated by CRP with mastoid oscillation and the nonoscillator group was treated by CRP alone. Positive outcome was regarded as complete resolution of symptoms and a negative Dix-Hallpike's test after a 4 to 6 week follow-up period.

RESULTS

Five patients were lost to follow-up. Twenty-eight (72%) patients from the oscillator group and 26 (65%) patients from the nonoscillator group had a positive outcome. This difference was not significant (chi = 0.17, P =.68)

CONCLUSION

For the treatment of posterior canal BPPV, concurrent mastoid oscillation with CRP does not significantly alter the short-term outcome.

Management of chronic parotitis: a review

Chronic parotitis is an insidious inflammatory disorder, which is characterized by a recurrent, often painful, swelling of the gland or glands. Sialography remains the investigation of choice. Diagnostic siladenoscopy may complement or supersede sialography as the diagnostic procedure of choice, as more experience is gained in this technique and its use becomes more widespread. The management options are conservative or surgical, but controversy exists regarding the timing and method of surgical intervention. The surgical methods that have been described include injection of methyl violet - a sclerosing agent, ductal ligation, ductoplasty, tympanic neurectomy, and parotidectomy. Parotidectomy is considered the ultimate surgical option but because of its significant morbidity the exact technique and procedure that should be used remains contentious.

p53 Expression and keratinocyte hyperproliferation in middle ear cholesteatoma

Keratinocytes in middle ear cholesteatoma have hyperproliferative properties. There is controversy regarding the role of p53 and its effect on cellular proliferation in cholesteatoma. This study was instituted to examine this. Cholesteatoma and deep meatal skin control specimens were analysed for MIB-1 (n = 7, controls = 7), a marker of cellular proliferation, and p53 (n = 17, controls = 17) expression by immunocytochemistry. Expression of p53 was minimal or absent in both cholesteatoma and controls (P = 0.2). MIB-1 expression was higher, but not significantly so, in cholesteatoma than in controls (P = 0.09). Our study has shown no significant p53 expression in cholesteatoma epithelium. This suggests that there is no dysfunction in the p53-mediated cell cycle control mechanisms in cholesteatoma.

Self citations and impact factors in otolaryngology journals

Self citation of a journal may affect its impact factor. Self citations during 1997 and 1998 were investigated in six 'general' otolaryngology journals. The citations each journal gave to other journals, including itself, and the citations each journal received from the other journals, differed significantly among the six journals (chi2= 2794, d.f. = 25, P < 0.0001). Acta Otolaryngologica and Laryngoscope had the highest self-citing rates (11.9% and 10.02%). Clinical Otolaryngology had the lowest self-citing rate (4%). There was no significant correlation between self-citing rates and impact factors for the six otolaryngology journals (r = -0.3143, P = 0.56).

MIB-1 and p53 expression in radiotherapy-resistant T1aN0M0 glottic squamous cell carcinoma

Radiotherapy of T1aN0M0 glottic carcinoma results in a local control rate of 80-94%. This homogenous group, which is the earliest recognisable invasive malignancy in the head and neck region, provides a 'unique model' for studying possible biological markers of radiosensitivity. p53 and MIB-1 were investigated as possible markers of radiosensitivity in such a group. In all, 107 patients with T1aN0M0 glottic squamous cell carcinoma treated with radiotherapy were identified. Cases not responsive to radiotherapy were compared with matched radiosensitive controls by immunohistochemistry using monoclonal primary antibodies to MIB-1 (n = 18; controls = 10) and p53 (n = 6; controls = 11). No significant difference in p53 expression was noted between the two groups (P = 0.73). A greater MIB-1 expression was found in the radiosensitive group but only a trend towards significance was observed (P = 0.06). MIB-1 is a potential marker of radiosensitivity. A larger multicentre study is required for a more definitive answer.

Glossal palpation of the eustachian tube cushion: an unusual cause of globus sensation

Globus sensation, the sensation of a lump in the throat, is a common symptom which, in its chronic form, accounts for 4% of first-patient visits to ENT clinics. We describe a rare cause of globus sensation and stress the importance of thorough investigation to exclude any possible organic causes.

Are p53 and MIB-1 overexpressed in cholesteatoma?

INTRODUCTION: There is controversy regarding the expression of p53 and MIB-1 in cholesteatoma.1 This study was instituted to study this. p53 is an intracellular protein which plays a critical role in control of the cell cycle at the G1 check point. MIB-1 is recognized as a marker of cellular proliferation. Using deep meatal skin controls, the question addressed was, 'are p52 and MIB-1 overexpressed in cholesteatoma'? METHOD: Immunocytochemistry using the avidin-biotin technique on frozen tissue sections with primary antibody to p53 (n = 17, controls = 17) and MIB (n = 17, controls = 7) was performed on cholesteatoma and deep meatal skin control specimens. Appropriate positive and negative controls were employed for each antibody. Slides were analysed in a blind fashion by two independent observers. Statistical analysis was performed using the Mann-Whitney test. RESULTS: Expression of p53 was minimal or absent in both cholesteatoma and controls. No significant difference in p53 expression was found between the two groups (P = 0.02). MIB-1 expression was higher in cholesteatoma than in controls, although this was not statistically significant (P = 0.09). CONCLUSION: This study did not demonstrate an increased expression of p53 cholesteatoma, indicating no evidence of a dysfunctional cell cycle. MIB-1 results showed a possible trend towards significance, which requires a more powerful study to evaluate this further. The probability that there is an increased rate of cellular proliferation in cholesteatoma, when compared to deep meatal skin controls, cannot be excluded.

Gradenigo's syndrome

Gradenigo's syndrome, which is characterised by the triad of suppurative otitis media, pain in the distribution of the trigeminal nerve, and abducens nerve palsy may give rise to potentially fatal complications. Knowledge of the aetiology and appropriate investigations can lead to early diagnosis. A case is reported which illustrates this.

Recurrent facial nerve palsy on flying

We report a case of a patient who experienced transient recurrent facial nerve palsies during flights on commercial aeroplanes. Although this condition is well recognized in divers, only six cases have been reported to occur on flying. The pathophysiology of this condition is discussed.

Treatment of otitis media with effusion in children with mucopolysaccharidoses

Otitis media with effusion (OME) is a constant finding in children with mucopolysaccharidoses (MPS). Affected children may also present the anaesthetist with a difficult airway. A 7-year retrospective review of the management of OME in individuals with MPS was carried out. Nine patients were identified. All had a number of short-term ventilation tube insertions (one to four, mean two) before a diagnosis of MPS was made. Following diagnosis three required repeated short-term ventilation tubes insertions (two to four, mean three), four had long-term ventilation tube insertions once only. Five children who had residual hearing loss were provided with hearing aids but compliance was poor in two. Once a diagnosis of MPS has been made, a hearing aid, if compliant, or a long-term ventilation tube would be a better option than a short term one in order to minimise the anaesthetic risk. A 'watch and wait' policy is not recommended.

Primary amyloidosis of the larynx

Primary laryngeal amyloidosis is a rare benign disease of unknown aetiology. It can present with dysphonia or stridor. A woman presenting with airway compromise, who required a tracheostomy, is reported.

Acute pulmonary oedema complicating adenotonsillectomy for obstructive sleep apnoea

Acute pulmonary oedema can sometimes complicate adenotonsillectomy carried out for obstructive sleep apnoea. Early recognition and adequate oxygenation are the key to management. We report such a case; the pathophysiology and management of this rare complication of a common procedure are discussed.

ENT aspects of the mummification of the head in ancient Egypt: an imaging study

This study of a mummified head from the British museum by high resolution computer tomography and 3D reconstruction illustrates, without mutilation of the specimen, some aspects of mummification of the head; namely the extraction of the brain through the nose and filling the cranium with linen like material, packing of the oral cavity and the presence of false eyes. These findings alone allow one to date the mummy to no sooner than the 20th dynasty, a time when this custom was at its peak. ENT aspects of the mummification of the head are discussed.

The predictive value of diagonal ear-lobe crease sign

Studies on selected cardiac patients have supported the association between diagonal ear-lobe crease (ELC) sign and coronary artery disease (CAD). The aim of this study was to assess the value of this sign as a predictor of the presence of CAD in the non-cardiac patient population, to see if any association exists between the two and to compare any association with other established risk factors. A significant association exists between ELC and a history of CAD, which is not solely attributable to the increased prevalence of the sign with increasing age. A higher correlation was found between CAD and ELC than between CAD and other risk factors. The sensitivity of the sign was 48%, the specificity 88%, and the positive predictive value 16%. In this population the finding of an ELC is of little clinical value.

Claudication on mastication following bilateral external carotid artery ligation for posterior epistaxis

This case highlights a potentially disabling complication of intermittent claudication in the region of the masseter muscles on mastication, following bilateral external carotid artery ligation for epistaxis. Although there have been few reports of this complication this may be a reflection of the fact that the operation is rarely performed, and not because the complication is rare. Its potentially disabling nature, and its possible common occurrence after this procedure make awareness of it by surgeons who may carry out this procedure important.

Synergistic necrotizing cellulitis resulting from peri-tonsillar abscess

This case demonstrates the rare but potentially fatal condition of synergistic necrotizing cellulitis of the head and neck. Although similar to necrotizing fasciitis, this is more extreme as it also destroys muscle. Peri-tonsillar abscess is a recognized cause, but has not previously been described in this country, however it is a condition commonly referred to otolaryngologists and awareness of the complication of synergistic necrotizing cellulitis is necessary to allow early recognition and prompt treatment. This should be by broad-spectrum intravenous antibiotics with extensive surgical debridement and drainage procedures repeated as necessary. Although this case had a successful outcome, many patients do not survive, particularly if treatment is delayed or inadequate.

Chondromatosis of the temporomandibular joint arising in the meniscus

A rare case of chondromatosis of the temporomandibular joint is presented in which the chondral bodies appear to have developed by chondrometaplasia of the meniscus.

Arthroplasty of the temporomandibular joint with use of a vitallium condyle prosthesis: report of three cases

We have devised a Vitallium intramedullary prosthesis to replace the deformed arthritic condyle in cases that require bilateral condylectomy or in rare long-term failures of a single condylectomy. Experience has led to modification of this prosthesis. Recently a rectangular stem that prevents rotation of the prosthesis in the condylar stub has been added (Fig 11). In bilateral condylectomies, replacement of only one side by the Vitallium condylar prosthesis is adequate, because it stabilizes the mandible by maintaining its original fulcrum in the temporomandibular joint. Three cases of replacement with the Vitallium condyle prosthesis are reported, with follow-up studies of two to three years postoperatively. The results to date have been gratifying.

Surgical correction of spastic thumb-in-palm deformity

A series of 31 operations on 27 patients for correction of the spastic thumb-in-palm deformity is reported. 19 patients were followed four years or longer post-operatively; the remainder have been followed for at least one year. In approximately 70 per cent of the operations, supplementary procedures were performed on the hand or forearm, as the deformity is usually only one facet of a complex spastic disability of the upper extremity. The surgical technique and illustrative cases are presented. Augmentation of a markedly weak extensor-abductor motor function is necessary, otherwise the spastic thumb-in-palm deformity will recur, as in two cases in the present series which required a second operation. The remainder of the patients were classified as improved, indicating that the thumb was no longer clenched in the palm, could be used in gross grasping activities, and the hand had become more useful. In no instance did the spastic hand become the primary functioning hand post-operatively.

Increase in sialic acids removable by neuraminidase during the shape change of platelets

Human or rabbit platelets were activated by ADP or 5-hydroxytrypatamine and rapidly fixed with glutaraldehyde. The shape change associated with activation gave rise to an increase in sialic acids removable by neuraminidase. This increase, like the shape change, was prevented by adenosine or methysergide added before ADP or 5-hydroxytryptamine respectively. The results indicate the exposure of additional glycoprotein(s) on the platelet surface.

Shape change and aggregation of blood platelets: interaction between the effects of adenosine and diphosphate, 5-hydroxytryptamine and adrenaline

1 The interaction of effects between 5-hydroxytryptamine (5-HT) and adenosine diphosphate (ADP) on human or rabbit platelets was investigated in vitro. The initial platelet shape change and their aggregation were measured in stirred, citrated platelet-rich plasma (PRP) at 37 degrees C by recording the rate and extent of changes in light scattering and light transmission. 2 Both the velocity and extent of aggregation and the velocity and extent of the rapid morphological change caused by ADP were enhanced by simultaneous addition of 5-HT. Methysergide but not imipramine inhibited the 5-HT effects. 3 Platelets were made refractory to the aggregating and shape changing effect of either ADP or 5-HT by repeated aggregation with the particular agent; platelets made refractory to ADP retained their responsiveness to 5-HT and platelets made refractory to 5-HT responded to ADP. Platelets pre-incubated for 3-10 min with 5-HT without aggregation showed greatly reduced aggregation on subsequent addition of ADP. Methysergide inhibited all the effects of 5-HT whilst imipramine was inactive. 4 When the shape change or aggregation of platelets induced by ADP was submaximal, addition of 5-HT increased it further. Pre-incubation of PRP with 5-HT before the addition of ADP resulted in failure of the secondary induction of aggregation or shape change by 5-HT. The secondary induction by 5-HT also did not occur in the presence of methysergide; imipramine had no inhibitory effect. Similar secondary induction of aggregation was shown by adrenaline injected during aggregation by ADP; the adrenaline effect was removed by phentolamine but not by propranolol. 5 Our results show that the initial change in shape of platelets and their aggregation can be induced by ADP or 5-HT in specific manner. The interaction of the effect of these substances on platelets can result in either increase in platelet sensitivity or, under certain conditions, decrease in platelet responsiveness. The increase or depression of platelet reactivity appears to be a highly specific effect and is probably mediated at specific receptors involved with platelet activation.