Sinus barotrauma is a common occupational disease of divers, with the incidence of descent barotrauma approximately double that of ascent. Pain chronologically associated with the change of pressure is the most dominant symptom and is seen in 92% of the cases presented for treatment. The majority complain of a frontal distribution of pain, with ethmoidal and maxillary being much less significant. Epistaxis is the second commonest symptom, and may be the sole symptom in some ascent cases. A history of recent or past sinus barotrauma or upper respiratory tract pathology is very common. Clinical examination supports the evidence of upper respiratory tract pathology in many cases. The radiological signs of abnormality were present in over three quarters of the cases examined. Of these the maxillary sinus was affected in most cases, the frontal in approximately one quarter and the ethmoidal in less than a fifth. The pathology was more commonly that of mucosal thickening, but in 12% of cases there was a fluid level. It is noted that although symptoms were predominantly frontal, x-ray changes were most often present in the maxillary sinuses.
Successful techniques for arthroscopic repair of subscapularis tendon tears have been previously described in the literature. Recommendations regarding portal placement, tissue mobilization, and suture passage have been published. We present a novel technique that uses a shuttle suture passed with the Viper suture passer (Arthrex, Naples, FL) through a standard anterior arthroscopy portal. The described technique easily passes a suture through the subscapularis tendon while the surgeon visualizes suture placement from the posterior portal.
The multichannel auditory brainstem implant (ABI) provides the potential for hearing restoration in patients with neurofibromatosis type 2 (NF2). Programmes for auditory brainstem implantation have been established in two Australian centres. Eight patients have been implanted under the protocol of an international multi-centre clinical trial. Three patients had ABI insertion at the time of first side tumour removal, four at second side tumour removal and one after previous bilateral surgery where there was some residual tumour. The translabyrinthine approach was used in all cases. Successful positioning of the electrode array was achieved in seven of eight patients, all of whom achieved auditory perception with electrical stimulation. Intra-operative electrically evoked auditory brainstem response testing was successful in four patients and was useful in confirming correct electrode position. In six cases post-operative psychophysical and auditory perception testing demonstrated that useful auditory sensations were achieved. Five of these patients regularly used the implant. In one patient electrode placement was unsuccessful and only non-auditory sensations occurred on stimulation. In the remaining patients non-auditory sensations were minimal and avoidable by selective electrode programming. Auditory brainstem implantation should be considered in patients with NF2. The greatest benefit is seen in patients without debilitating disease who have non-aidable hearing in the contralateral ear.
Facial nerve schwannomas are slow-growing tumors that may involve any part of the facial nerve. When they present with moderate to total facial palsy, complete resection is clearly indicated. However, in cases with mild or no facial dysfunction, the best course of treatment is less obvious. A series of 22 patients with facial nerve schwannoma is presented, of whom 12 underwent definitive excision and 10 were managed more conservatively. The best postoperative facial function in the group who had tumor removal was a House-Brackmann grade III, while 8 of the conservatively treated group had normal facial function up to 10 years after presentation. As well, no significant tumor growth was noted on serial radiologic imaging of those being observed. Delaying surgical resection of facial nerve schwannomas may allow patients to retain normal facial function indefinitely.
Bacterial endocarditis with positive blood culture occurred on six occasions in a series of 140 mitral valve replacements. In three of these, extensive detachment of the prosthesis with severe mitral incompetence resulted. Re-operation was undertaken in two of these cases. Intra-atrial thrombosis occurred twice. In three other cases, in which intra-atrial thrombosis occurred, infection was strongly suspected to have been the responsible factor. Mitral regurgitation presented no difficulty in diagnosis, as all patients had severe congestive cardiac failure and typical physical signs. Confirmation was established by cinéangiography. Intra-atrial thrombosis presented difficulty in diagnosis. A persistently positive blood culture, continued pyrexia, and a history of sepsis were the most consistent and significant findings in the cases reported. The antibiotic regime described by Amoury and his colleagues has been used for the past year. There has not been a single case of bacterial endocarditis, intra-atrial thrombosis, or wound infection in 120 consecutive valve replacements on this regime. Because of the high mortality associated with intra-atrial thrombosis, and the close association between endocarditis and thrombosis, the presence of endocarditis with or without regurgitation might well be a compelling reason for re-operation. The mortality from these complications could, we believe, be reduced by the use of a more extensive antibiotic cover and a more vigorous attitude to surgical intervention. We have not had to consider re-operation since adopting the policy outlined, as these complications have not occurred.
The reversible hearing loss in the nonoperated ear noted by patients after ear surgery remains unexplained. This study proposes that this hearing loss is caused by drill noise conducted to the nonoperated ear by vibrations of the intact skull. This noise exposure results in dysfunction of the outer hair cells, which may produce a temporary hearing loss. Estimations of outer hair cell function in the nonoperated ear were made by recording the change in amplitude of the distortion‐product otoacoustic emissions before and during ear surgery. Reversible drill‐related outer hair cell dysfunction was seen in 2 of 12 cases. The changes In outer hair cell function and their clinical implications are discussed.
An integral part of intact canal wall mastoidectomy (ICWM) is an adequate canalplasty.1 Extensive soft tissue mobilization can result in stenosis of the membranous canal, so that no matter how effective a bony canal widening procedure has been, an easily inspected self-cleaning ear will not be obtained. When standard adequate meatoplasty techniques23 are employed in conjunction with ICWM, there is a significant risk of creating a mastoid-cutaneous fistula. Z-meatoplasty4 allows for adequate cartilage resection with the creation of a wide meatus as well as providing soft tissue and skin cover to the posterior canal wall, obviating the risk of fistula. The procedure is usually carried out under general anesthesia as part of the ICWM, but in an existing stenosis the surgery can be done under local anesthesia, as an outpatient procedure. Left ear: surgeon's view. An incision runs along the roof of the external auditory canal (EAC) beginning laterally at the inter-tragal notch (a-d). A second incision (b-c), parallel to the first, begins at the junction of the floor of the EAC and the conchal cartilage. A third incision (a-b) runs along or just behind the free edge of the conchal cartilage. Elevation of flaps d,a,b and c,b,d exposes a wide area of conchal cartilage (shaded area), which is then resected. The flaps are then transposed and sutured with 4 × 0 Dexon. An end-aural incision (A–D) is carried into the roof of the external auditory canal (EAC) (Fig. 1). A second parallel incision begins near the floor of the EAC at the conchal junction and extends upward and backward (B–C). The third incision runs along or just behind the conchal free margin to connect points A and B (Fig. 2). Elevation of flap A,B,C gives access to the area of the conchal cartilage to be resected. Soft tissue deep to the cartilage can be resected as required. Flap D,A,B is also elevated, then the flaps are transposed and fixed with 4 × 0 interrupted Vicril sutures (Fig. 3). The EAC is then packed in the usual fashion. View of Z-meatoplasty at conclusion of procedure. Closure of the skin in a broken line (the Z line) prevents retraction and reduces the stenosis of the meatus. Stenosis secondary to wound disruption has not occurred in our experience. Although many methods of meatoplasty have been published,5-7 the authors are not aware of any description of the Z-meatoplasty. The maneuver is simple and quick to perform and represents an effective treatment and prevention of lateral canal stenosis in intact canal wall surgery.
A 34-year-old multiparous woman presented at 22(+6) weeks' gestation with severe abdominal pain which preceded a mechanical fall down the stairs. On admission, fetal movements were felt and fetal heart rate was detected by Doppler ultrasound. Over the course of 12 h, although she maintained her vital signs, repeat laboratory and radiological investigations suggested sinister intra-abdominal pathology. Subsequently, fetal movements and heart rate ceased and the patient began to decompensate. A CT scan confirmed uterine rupture. Subsequent emergency laparotomy revealed a 2 l haemoperitoneum and lifeless fetoplacental unit in the abdominal cavity. It is postulated that this rupture occurred as a rare yet life-threatening complication of a hysteroscopic resection of fibroid that the patient underwent 1 year previously. There are no known published cases of a spontaneous uterine rupture following a hysteroscopic procedure at such an early gestation. The patient made a full physical recovery.
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