Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
Nederlandse Keel-Neus-Oorheelkundige Vereniging 139ste Vergadcring te Rotterdam, 25 en 26 oktober 1974 Dutch Oto-Rhino-Laryngological Society 139th Meeting, Rotterdam, October 25 and 26, 1974 President: G.A. Hoogland
Secretary: E. Hammelburg
Patient with a Blow-Out Fracture P C. de Jong ENT Department (Head: Prof. W.H. Struben), Erasmus University, Rotterdam Demonstration of a 4 1-year-old woman with diplopia, caused by a blow-out fracture of the right orbit after a traffic accident. The lesion was clearly visible on tomographic and antroscopic examination. In accordance with data from Putterman et al. (vol. 77, Am. J. Ophthal., 1974), no surgical treatment was given. The result was satisfactory.
The following case is reported: a 37-year-old man develops the following symptoms after an upper respiratory tract infection: severe left retro-orbital pain, later on radiating to the occiput, diplopia and a post-nasal drip. One year earlier he had also had a transient period of diplopia. At admission the examination initially shows a palsy of the left abducens nerve, later on a total left ophthalmoplegia. There is an axial protrusion of the left eye (2 mm) and some engorgement and redness of the left optic disc. The left pupil is smaller than the right but reacts to light and convergence; visual acuity is undisturbed. Visualevoked responses show little lower values on the left side than on the right. Orbitscan, skull, orbit, and sinus X-rays are normal. Tomograms of the paranasal sinuses show a clouded left sphenoidal sinus. The sinus is well pneumatized and has on the left side an extension in the left sphenoid wing; further there is hyperostosis of the lesser sphenoid wing Cerebral angiography shows no abnormality. With systematic antibiotic and corticosteroid therapy a complete functional recovery occurs with disappearance of clouding of the left sphenoid sinus. The course of illness and response to steroids warrant the diagnosis of painful ophthal moplegia or Tolosa-Hunt syndrome. This syndrome has to be separated from other, more grave causes of ophthalmoplegia. Craniotomy seems to be contraindicated, and corticoste roid advocated. The possible aetiology is an indolent inflammation localized in the superior
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Painful Ophthalmoplegia E.A. Baarsma ENT Department (Head: Prof. W.H. Struben), Erasmus University, Rotterdam
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
357
orbital fissure or the cavernous sinus. A portal of entry of this inflammation can be a sphenoidal sinusitis, especially when there is a good pneumatization, thin bone walls and dehiscences. In this case there is a recession of the sphenoid sinus in the lesser sphenoid wing that encloses the superior orbital fissure. Exacerbations, as they occur in this syndrome, could be explained by this portal entry. It seems possible that more cases of painful ophthal moplegia can be explained so. Therefore, it is always necessary to make a tomogram of the paranasal sinuses, because a routine sinus X-ray gives insufficient information.
Various tests of the tubal function are suggested in the literature, but none of these tests seems to be accepted. We shall describe our attempt to evaluate the tubal function. We compare our results with the clinical usage of examining the aeration of the middle ear cleft and the effects of a Valsalva and a Politzer manoeuvre. The tubal function is then evaluated according to the assumptions that a valsalva generates a pressure in the nasopharynx of 40-80 cm of water, and the politzer of 100 -200 cm of water. We found this evaluation often deceptive, although the assumptions seem to be fairly accurate. The majority of the tested patients have perforated eardrums (see the paper by Bos). Our method is developed primarily for these patients. A slightly modified procedure can be used for patients with intact tympanic membranes. We control and measure the pressure in the middle ear by the pump and the pressure transducer of an impedance meter. The pressure in the nasopharynx is monitored by an other pressure transducer through a nose olive, held by the patient in one of his nostrils. Some thresholds of air passage through the tube are determined. They are listed with our notation and normal values in centimetres of water in parentheses. Valsalva: the minimum pressure in the nasopharynx that forces the tube to let air through (V 40). Antivalsalva: the minimum pressure in the middle ear that forces the tube to let air escape and the resulting pressure in the middle ear (AV 20/4). Politzer: the minimum pressure in the nasopharynx at which swallowing causes an increase of the pressure in the middle ear (P 5). Antipolitzer: the minimum pressure in the middle ear (as well positive as negative) at which swallowing causes an alteration of the pressure in the middle ear cleft (AP + 1/-1). For the interpretation of our results we suppose the tube to be made up of a bony protympanon, a narrow isthmus and a cartilaginous duct, which will be opened by swallow ing. So a dysfunction of this duct will result in either normal valsalva values and politzer values equal to the valsalva values (dysfunction of the muscles), or in normal politzer values (P and AP) and increased valsalva (V and AV) values (a swollen and gluey lining of the duct). In the former case we observe clinically an easy valsalva and politzer but, if the eardrum is intact, a badly aerated ear (AP to high); in the latter case we observe a negative valsalva and a positive politzer (suggesting that the tube opens for pressures over 80 cm of water) and an aerated ear (normal antipolitzer). Interesting is the case of different values for AP+ and A P -. We have only observed cases in which AP - was higher than AP +. This can be explained either by a swelling of the middle ear lining or by a swelling just underneath the isthmus. In the former case the positive pressure squeezes the lining. This will facilitate the passage of air. The negative
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Method to Determine the Function of the Eustachian Tube J. Verschuure, C.E. Bos, R.N.P. Berkovits, P. Swagemakers and E.M. Kwadijk ENT Department (Head: Prof. W.H. Struben ), Erasmus University, Rotterdam
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
358
pressure enhances the swelling and will inhibit the passage of air. So we measure the usual valsalva values and higher politzer values. We observe clinically a positive valsalva and most likely a positive politzer and a badly aerated ear. In the latter case the passage of air to the middle ear will be mechanically blocked. We observe a normal AP + and slightly raised antivalsalva and very high values for all other tests. We observe clinically a negative valsalva and politzer and a badly aerated ear. A stenosis of the tube will cause an equal increase of the politzer values until the valsalva values are approached. A more severe kind of stenosis will produce equal values for all tests. We observe clinically a badly aerated ear. The valsalva and politzer will be increas ingly difficult. This survey indicates that it is necessary to have the quantified results of all four tests in order to determine the tubal function.
Since 1970, selected cases of cholesteatoma were operated according to the combined approach technique with an intact bony wall. The intervention is done in two stages, in the first operation the cholesteatoma matrix or the epithelial ingrowth is carefully dissected and the drum is repaired. After about 1 year a second control is made and if there is no recidive the ossicular chain is repaired. The results in the first 40 patients who were treated according to the above-mentioned scheme are as follows: In 23 patients no recidive of the cholesteatoma or the epithelial ingrowth in the middle ear was found and the ossicular chain was reconstructed. In 3 patients a deep retraction-pocket was found in the attic region. This was due to a defect in the lateral attic bony wall. The pocket was removed and the attic wall was repaired with cartilage, the ossicular chain was reconstructed. In 3 other patients small epithelial pearls were found measuring 1 -2 mm. In one case the epithelial pearl was not in the place of the original epithelial ingrowth in the middle ear. After removal of the epithelial pearls the ossicular chain was reconstructed in these patients. In 11 patients a recidive of the cholesteatoma or the epithelial ingrowth in the middle ear was found. In three cases the recidive was small and after removal the ossicular chain was reconstructed. In five cases the recidive was more extensive and after removal a third control after 1 year was planned. These were young persons and it was felt that they should have another chance. In 3 cases it was decided to remove the bony wall and to do a tympano plasty type Wullstein IV, the mastoid bone was obliterated by temporal muscle. The pre liminary conclusions are: (1) The recurrences were found especially in the sinus tympany, therefore, posterior tympanotomy is essential for this type of surgery. (2) Extirpation of the cholesteatoma matrix or the epithelial ingrowth has to be done very carefully. Some recur rences gave the impression that implantation of pieces of matrix in other places of the operation cavity is possible. (3) The operation has to be done in two stages. The second intervention should not be done too early, otherwise a small recurrence could be missed. (4) Tympanoplasty with intact bony canal wall is not a panacea for cholesteatoma: the operation should not be done in every case. The choice of the type of surgical treatment in cholesteatoma (open or closed) is especially dependant on the cochlear reserve and the age of the patient.
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Necessity of Staging in the Combined Tympanoplasty in Cholesteatoma T. Bottema ENT Department, Vrije Universiteit (Head: Prof. 0. de Wit), Amsterdam
Society Transactions • Gesellschaftsberichte ■Comptes rendus de sociétés
359
Preservation of Hearing in Children with Chronic Otitis Media with Cholesteatoma Formation J. Anker Gouda In the child a cholesteatoma behaves exactly like a tumour. Its constant production of cholesterol-rich cellular debris in a small enclosed space like the middle ear can lead to a very dangerous situation. It behaves as a space-occupying lesion which eventually destroys the anatomy of the middle ear. Hidden behind the eardrum, the process of progressive destruction is initially practi cally symptomless. The only symptoms are occasional purulent discharge, itching and eczema in the ear and reversible deafness. The condition is usually painless. The pathogno monic feature is the faecal odour of the discharge. The condition generally comes to light through the school physician who discovers deafness. An interesting point about the deaf ness is that in the majority of cases a marked improvement can be obtained by a short preoperative treatment to the affected ear. Paradoxically, this raises difficulties for the surgeon because while dealing with the cholesteatoma he has to keep in mind the fact that any post-operative deterioration in the deafness will be interpreted by the parents as failure of the surgical procedure. Moreover, the quality of the hearing is no indication to the amount of destruction one finds in the ear. In quite a number of children we found severe destruction in the mastoid and epitympanum with practically normal preoperative hearing. In other cases the cholesteatoma grew round the ossicles without interruption of the chain. One word about the operation. Operating on a chronically infected ear of a child is a very demanding task, not least due to the delicate anatomy involved. In my view radical surgery has no place in children. In the interest of the child it might be advisable to leave this sort of microsurgery to one experienced in this field. In my opinion every teaching centre should have one or two surgeons with a special interest in this field.
Hearing Loss Due to Gentamicin Therapy E.H. Huizing and E.G.J. Carrière ENT Department, University of Leiden (Head: Prof. P.H. Schmidt), Leiden
Nature o f the Damage The present series consisted of 16 patients with hearing loss caused by gentamicin, 11 belonging to the above-mentioned group and 5 referred from elsewhere. Tone audiometry. Cases with limited damage showed only high-tone loss with a rather sharply descending threshold curve. In cases with moderately severe impairment the audio
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Some years ago we observed a number of cases of hearing loss due to gentamicin therapy (Huizing, 1972). This led to the establishment, early in 1972, of an audiometric service for patients treated with ototoxic medicaments in the Leiden University Hospital. Since then, in collaboration with the Department of Infectious Diseases, we have investi gated audiometrically, and in some cases also electronystagmographically, 86 patients to whom gentamicin was administered. Some of the results of this study can be summarized as follows:
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
360
gram showed an almost normal threshold for the low frequencies, followed by a sharp drop at about 1,000 Hz and an appreciable (sometimes flat) loss in the high-tone region. In many cases the threshold curve resembled the Z-shaped audiogram, previously reported in investi gations on the degeneration pattern in progressive hereditary sensory-neural hearing loss (.Huizing et al., 1967). In cases with severe damage there were more or less considerable hearing residues in the low and middle range. Speech audiometry. In some patients the speech audiogram showed more serious anomalies than could be expected on the basis of the threshold loss. The discrimination losses found suggest that, especially in the more severe lesions, marked neuronal damage had taken place. SISl-test, tone-decay test. In general, the SISI scores were moderately high to high, whereas the tone-decay test gave normal results. These findings are in agreement with the results of animal experiments which showed that gentamicin primarily destroys the hair cells (e.g. Federspil, 1972, 1973; Brummen et al.. 1972). Symptomatology. The order of frequency and appearance of symptoms of gentamicin damage was as follows in our patients: (1) high-tone loss at audiometry; (2) tinnitus (highpitched); (3) subjective hearing deterioration, and (4) dizziness, sometimes with nausea. Progression o f hearing loss after termination o f treatment. One patient showed an appreciable increase of the hearing loss, both on tone and speech audiometry, after the termination of very prolonged treatment with gentamicin.
References Brummen, R.E.; Himes, D.; Same, B., and Vernon, J.: A comparative study of the ototoxic ity of tobramycin and gentamicin. Archs Otolar. 96: 505-512 (1972). Federspil, P.: Über die Aufzeichnung der Kochleaschäden beim Meerschweinchen. Z. Lar. Rhinol. Otol. 51: 633-637 (1972). Federspil, P.: Vergleichende experimentelle Untersuchungen zur Ototoxicität des Tobramycins und Gentamycins. Arch. Ohr.- Nas.- KehlkHeilk. 205: 266-269 (1973). Huizing, E.H.: Bolhuis, A.H. van, and Odenthal, D.A.: Studies on progressive hereditary perceptive deafness in a family of 335 members. Acta oto-lar. 61: 35-41, 161-167 (1967). Huizing, E.H.: Doofheid en evenwichtsstoornissen door gentamicine. Ned. Tijdschr. Geneesk. 116: 1261-1264 (1972).
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Factors Involved in Gentamicin Hearing Loss The most important factors playing a role in the origin of gentamicin damage was the dosage applied and the kidney function; in other words, the blood level of the drug (i.e. the perilymph level) and the duration of its administration. Kidney function. It has long been known that when the kidney function is disturbed there is a greatly increased risk of gentamicin damage. This is confirmed once again by our series. Of the 16 patients who suffered hearing loss, 10 had a reduced kidney function. Dosage. The usual dosage is 3 4 mg gentamicin/kg body weight divided over three doses per 24 h. The relationship between dosage, duration and hearing impairment in pa tients with a normal kidney function was investigated. For 24 patients with normal kidney function given gentamicin for more than 5 days, audiometry could be performed before, during and after the administration of the drug. Hearing loss was found in 7 cases. In this group, 4 patients had undergone prolonged treatment (> 40 days), 1 had been given a very high dose (6 mg/kg body weight) for a short time, and 2 had received a high dose (> 4 mg/kg) for a long period (> 40 days). The patients who had been given gentamicin for a shorter period in the normally prescribed dosage did not show measurable damage.
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
361
Beethoven’s Deafness R.T.R. Wentges ENT Department (Head: Prof. W.F.B. Brinkman), University of Nijmegen, Nijmegen In his letters, Beethoven described the symptoms of his deafness very accurately; furthermore, his contemporaries have left us a detailed account of his illness. In addition, an autopsy, at which the temporal bones were studied, was carried out the day after Beethoven’s death; interesting information can be gleaned from the report of this autopsy, but the temporal bones themselves are unfortunately now lost. Finally, Beethoven’s mortal remains were exhumed on two further occasions to allow measurements of his skull. It is probably no longer possible to come to a diagnosis of the cause of Beethoven’s deafness using the available data, but several syndromes can be excluded with virtual cer tainty. It is most likely that Beethoven had a bone disease affecting the internal auditory meatus, possibly Paget’s disease or hyperostosis corticalis generalisata (Van BuchemHadders). Syphilis, although less probable, cannot be excluded with certainty.
Nasal Disodium Cromoglycate (DSCG) A.S. Viner Loughborough There are two questions that I propose to try and answer: (1) Does DSCG work in allergic rhinitis? (2) What has been learnt about rhinitis in recent years?
Antigen Challenge Studies It is important to know if the drug works in the laboratory situation. To this end a number of antigen challenge studies have been performed by Taylor, using both DSCG powder and solution. All his studies have involved patients with hay fever and have been conducted in the winter when there is no pollen in the atmosphere. Briefly, his technique is to apply the pollen to the nose in increasing concentrations until a reaction occurs which increases the NAR to twice the baseline level, this he calls the NAR200. By this means he is able to assess the sensitivity of each subject to grass pollen and he uses that dose in the subsequent challenges that are repeated hourly with NAR measurement until the latter rises and thus the subject is no longer protected. The result of a study in 13 subjects showed that the majority of them were protected for 3 -4 h. A proportion had a late reaction which will be returned to later. A similar study by Engstrom using children sensitive to birch pollen has been done with DSCG solution. Again a baseline sensitivity was obtained and each child was given the
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Mode o f Action o f DSCG It has been known for some time that mast cells are involved in the allergic reaction in the nose. Following an antigen challenge they degranulate. The first stage in degranulation is the production of a halo-effect and the composition of the granule changes so that the granules on the surface are extruded. The mast cell remains viable and alive so that it is ready to discharge further granules on the next challenge. From work in our laboratories we know that DSCG in some way protects mast cells, not only against degranulation following an antigen-antibody reaction, but also against specific degranulation such as 48/80, dextran and phospholipase A. It would seem quite logical, therefore, to use such a drug in the treatment of allergic rhinitis if one accepts the fact that an antigen-antibody reaction is involved and that mast cells are important.
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
362
Clinical Trials To conduct a good hay fever trial is quite difficult. One has problems on the onset of the season, the daily challenge, individual challenges. The daily pollen count can be variable. This fact prevents the use of a crossover design in which one compares each patient with himself; instead, we found that the only possible design is a group comparative trial where two random groups are studied. The use of a spore trap to record the daily pollen count is extremely useful so that it is possible to analyse results during a period of challenge. Many hay fever trials have been inconclusive because of a high placebo response which will occur when the challenge is low. A seasonal rhinitis trial should be short, sharp and decisive. In the summer of 1973 we carried out a trial in the UK in a group practice just outside London. The object was to compare DSCG powder and solution in two random groups of hay fever patients sensitive to grass. It was decided to start when the grass pollen count had reached a level at which all patients were symptomatic, i.e. 50 grains/m3 of air sampled. The trial was to last exactly 21 days for all patients. They started with the trial on the same day. It is not always possible to say when the season will begin, however. Dr. Davies, who is in charge of the Microbiology Unit at St. Mary’s Hospital and a world authority on pollen, is now able to predict when the season will start from meteorological data obtained during the months of April and May. Tlius on June 1st he stated that the pollen count during the month of June would be significant on the 12th. All patients were sent letters to commence the treatment on that date and to report back in 21 days for a final assessment. With daily pollen counts we knew that the challenge had occurred throughout the trial and as all patients lived in the same area it can be assumed that they were roughly exposed to the same daily challenge. This in my view is about the best design one can achieve except for the use of matched pairs; the latter is extremely difficult to achieve and therefore doomed to failure. Incidentally, the trial showed that powder and solution were equally effective. With reference to perennial rhinitis we had a large study involving over 100 patients (not yet published). It was a double-blind crossover trial of 8 weeks duration. Patients with a clinical diagnosis of perennial rhinitis were selected and divided into tow equal groups on the basis of a positive or negative skin test. They were classified as allergic if they had a positive skin test and intrinsic if the result was negative. Each of the two main groups was subdivided according to the predominant symptom: ‘blocking’ or ‘running’. Thus in the end there were four equal groups and each was analysed separately. The interesting point was that positive results in favour of DSCG were obtained in the allergic and intrinsic ‘runners’ but not in the ‘blockers’. This suggests that skin testing should not be the only criteria for a diagnosis of allergic rhinitis. In fact we know that some patients with negative skin tests have positive nasal provocation tests. It also suggests that the symptoms may be related to other factors with histological changes in the mucosa such as increased goblet cells, chronic inflammatory changes in the mucosa (possibly initiated by immunological factors) or non specific factors such as irritation by physical factors, e.g. tobacco, S O ,, etc. In this study it was interesting to see how many patients had been entered into the various groups at the halfway stage. The most difficult group to fill was that of the intrinsic ‘blockers’; in fact when sufficient allergic ‘runners’ had entered the trial, there were only nine intrinsic blockers. It is certainly my impression that in perennial rhinitis the majority of
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
active solution or placebo double-blind and challenged. If the child was able to tolerate at least a 10-fold increase in concentration, this was considered a success. The challenge was given 10 min after DSCG administration, and again at 4 h. There was a significant difference in favour of the active drug at 10 min, but not at 4 h. Other studies have been carried out by Orie, in perennial rhinitis, and by Jenssen in seasonal rhinitis. They showed positively that DSCG (solution) protects in the majority of patients.
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
363
patients can be classified as allergic if one looks at patients closely so that a diagnosis of vasomotor rhinitis is relatively uncommon. Why then do some patients complain of ‘blocking’ and others of ‘running’? Some light on this can be gleaned from Taylor’s work. He studied a group of patients sensitive to grass pollen and looked at skin tests and nasal tests and observed the reactions for some hours. All had immediate type 1 reactions but 30 % had had a late skin reaction and 37 % a late nasal reaction usually appearing between 4 - 6 h. The immediate skin showed a typical wheal and flare, the immediate nose was associated with sneezing and running. The late skin showed erythema, induration and late nose-blocking. These findings resemble those of One in the asthmatic lung. He found a group of patients who had a late bronchial reaction which is not a typical type 111 reaction. The timings are similar as are the severity of the reaction. It is clear that the nose and the lung should be considered together as a part of the respiratory tract. Taylor biopsied some late skin reactions and found perivascular infiltration with mononuclear cells and polymorphs. We have observed the same histology in a few patients nose and they did not respond to DSCG. Therefore, we can suggest that allergic perennial rhinitis is a complicated disease, that one might divide into two main groups (these differ immunologically, histologically, clini cally and in response to treatment): The first group, which is the majority, has only a type I IgE-mediated reaction which results in a vasodilatation and oedema of the mucosa so that patients complain of running. The second group may be about 30 % of the total has a dual response, i.e. immediate and late reactions; the latter predominates and is leading to subacute or chronic inflamma tory changes with thickening of the submucosa and increase in goblet cells. Logically, group I should respond to DSCG, but group II should not as DSCG has a limited benefit on late reactions and also it is not an anti-inflammatory agent.
Comparison between the Destruction of the Respiratory Mucous Membrane Caused by Viral Infection and by Iatrogenic Trauma J.D. Bleeker ENT Department (Head: Prof. P.E. Hoeksema), University of Groningen, Groningen A description is given of the great similarity between the lesions of the respiratory mucous membrane caused by influenza virus A in the human bronchial tree and the lesions induced experimentally by bronchoscopy and tantalum bronchography in the dog. Secondary bacterial infection, especially of the Staphylococcus aureus is seen much more frequently after influenza virus infection than after iatrogenic trauma. Attention is drawn to the fact that the mucous layer is already present 1 h after the trauma covering the lesions. The possibility is suggested that the virus infection causes mainly a stop in the mucus production and that part of the epithelial lesions are secondary to exsiccation of the mucous membrane.
The origin, course and function of the autonomic nerve supply of the respiratory part of the nasal mucosa in rats is traced, using the results of histological, electron-microscopic,
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Autonomic Innervation of the Nasal Mucosa J.J. Grote, W. Kuijpers and P.L.M. Huygen ENT Department (Head: Prof. W.F.B. Brinkman), University of Nijmegen, Nijmegen
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
364
neurohistochemical and physiological investigations in normal rats and in those in which the appropriate autonomic nerves had been selectively transected. In the normal animal the vascular structures of the nasal mucosa appear to be inner vated by both adrenergic and cholinergic nerve fibres. The nucosal glands, however, display only cholinergic innervation. Close interconnection appears to exist between the perivascu lar and periacinar nerve plexuses. The main source of the sympathetic fibres is the superior cervical ganglion, the main parasympathetic nerve trunk being the greater petrosal nerve. The autonomic fibres reach the nose mainly via the pterygopalatine nerve and along the supplying blood vessels. Transection of the supplying nerves showed after an initial disappearance of the autonomic nerve endings in the nasal mucosa, a reinnervation between 2 and 12 months postoperatively. The results obtained by physiological and histometrical investigation of the patency of the nasal lumen support these findings. A model of the origin and course of the autonomic nerve supply was constructed from the results. Expecially the reinnervation stress the importance of obtaining more insight into the events occurring after vidian neurectomy used in humans to cure severe cases of vasomotor and atopic rhinitis.
Rotating chairs, rotating rooms, flight simulators or torsion swings are used for the investigation of semicircular canals. The possible movements of the existing rooms are very limited. These rooms are accelerated with a small acceleration up to a certain velocity and then stopped within a few seconds. The stimulus is a step in the velocity or an impulse of the acceleration. The resulting movement of the cupula is the impulse response. The new rotating room of the ENT clinic of the University of Utrecht can rotate with a constant adjustable acceleration. Flight simulators, which are limited in their angle of rotation, are used for sinusoidal stimulation. Torsion swings, which are also used for sinusoidal stimula tion, have the disadvantage that the frequency is difficult to adjust. We made the demand for our new rotating room that the following movements should be possible: a step in the velocity, constant adjustable acceleration and sinusoidal movements with adjustable fre quency between 0 and 8 Hz. During the determination of the vestibular ocular frequency, characteristic optokinetic and proprioceptive stimuli must be absent. By using a correlation technique it is possible to determine the vestibular-ocular characteristic, while reactions to visual and proprioceptive stimuli are present. Therefore, we have made the demand that stochastic signals can also be used as stimuli. If Coulomb friction is present in the bearing, the room will not move smoothly during very low velocities, which happen during sinusoidal movements. This effect is most pro nounced at the zero crossing of the velocity. We have eliminated Coulomb friction by applying a hydrostatic bearing. The hydrostatic bearing consists of two parts: an axial and a radial bearing (fig. 1). The axial forces consist of the weight of the room and its content. The axial bearing is nothing more than a tableland floating on a fluid layer. Variation of the loading results in a vertical displacement of the room. This displacement is not more than 2 mm and does not influence the rotation performance of the room. The radial force is
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
A Continuously Adjustable Rotating Room for Vestibular Research M. Rodenburg and I.P.C. Teerhuis ENT Department (Head: Prof. W.H. Slruben), Erasmus University, Rotterdam, and Laboratory for Measurement and Control (Head: Prof. R.G. Boiten), Technical Univer sity, Delft
365
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
0
10
20
30
Time, sec
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Fig. 2. Acceleration and velocity of the rotating room with a triangular signal as an input.
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
366
mainly determined by the stretching force of the drive belt. The radial bearing consists of a stationary double conical box within a cylinder, which is connected to the rotating room. Oil is supplied under pressure by holes in the conical box and is drained via the wedgedshaped space between the box and the cylinder to the tank. The stiffness of this bearing is very high. With perfect performance of the hydrostatic bearing there is no metallic contact between box and cylinder so that no Coulomb friction is present. An electro-hydraulic rotating servo-motor drives the room via a belt. The speed of rotation is adjustable between + 120°/sec and -120°/sec, while the torque is maintained. The dynamic behaviour of the room is that of a slightly damped second order system. The characteristic frequency (1.5 Hz) is determined by the stiffness of the belt and the moment of inertia of the rotating mass. High-frequency vibrations caused by the motor are attenuated by the mass-spring system, which is made up by the room and the drive belt. The damping originates from the viscous friction of the oil film in the bearing. We have increased the damping by applying acceleration feedback so that the transfer characteristic changed in that of an overcritical damped second order system. The maximum acceleration is presently 30°/sec2 but can be increased by changing the stretching force of the drive belt. Thanks to the absence of Coulomb friction the room also moves smoothly at very low speeds. Figure 2 presents a triangular movement and shows that these are no disturbances at the zero crossing point.
Orbital Complications H. Fermin and B.H.C. Nieuwenhuis-Koster ENT Department (Head: Prof. W.H. Struben), Erasmus University, Rotterdam Orbital complications occur in connection with inflections of the frontal and the ethmoid sinuses or infection of all sinuses: (1) swelling and abscess of the eyelid; (2) sub periosteal abscess; (3) fistula of the eyelid; (4) orbital cellulitis; (5) cavernous sinus throm bosis; (6) orbital apex syndrome; (7) frontal osteomyelitis. When serious complications are present or imminent, surgical drainage must be per formed. In acute infections a trephine operation on the frontal sinus is carried out. In chronical infections an outlet to the nose, through the ethmoid is made and a siliconated drain is left in place for a couple of weeks.
In the past 6 years four patients were admitted to the Ear-Nose and Throat Depart ment of the University Hospital in Groningen with complaints about hoarseness and slowly progressive dyspnoe, caused by a chondrosarcoma of the larynx. The clinical picture, the histology and the therapy of this rare tumor of the larynx is discussed by means of case reports and X-rays. It is pointed out that, because of the slowly progressive course of this kind of tumor, a laryngofissure is sufficient. A total larynx extirpation can in the future still be performed.
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Chondrosarcoma of the Larynx A.A. Annyas, P.E. Hoeksema and R. Eibergen ENT Department (Head: Prof. P.E. Hoeksema), University of Groningen, Groningen
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
367
Intra-Arterial Infusion with Methotrexate in the Rat P.J. Sindram, G.B. Snow and L.M. van Putten Radiobiology Institute TNO, Rijswijk, and the ENT Department (Head: Prof. G. de Witt), Vrije Universiteit, Amsterdam The superiority of intra-arterial infusion with methotrexate (MTX) over its systemic use in the treatment of head and neck tumours is still being questioned. A model in the rat, suitable for intra-arterial administration of MTX could be constructed. In this model three schedules have been investigated: (1)7 days continuous intra-arterial infusion with MTX; (2) the same schedule combined with leucovorin (CF) 6-hourly intra-peritoneally after Sullivan et al. (1959); (3) intermittent administration of MTX 2 X 24 h intra-arterial infu sion on day 1 and 4, while on day 2, 3, 5, 6 and 7 the catheter is kept open by the continuous intra-arterial infusion of saline. For all the three schedules intra-arterial MTX proved to be superior to its systemic use. Fractionated intra-arterial MTX proved to be better than continuous administration.
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Sindram. P.J.; Snow, G.B., and Putten, L.M. van: Intra-arterial infusion with methotrexate in the rat. Br. J. Cancer 30: 1 (1974).
Nederlandse Keel-Neus-Oorheelkundige Vereniging 139ste Vergadcring te Rotterdam, 25 en 26 oktober 1974 Dutch Oto-Rhino-Laryngological Society 139th Meeting, Rotterdam, October 25 and 26, 1974 President: G.A. Hoogland
Secretary: E. Hammelburg
Patient with a Blow-Out Fracture P C. de Jong ENT Department (Head: Prof. W.H. Struben), Erasmus University, Rotterdam Demonstration of a 4 1-year-old woman with diplopia, caused by a blow-out fracture of the right orbit after a traffic accident. The lesion was clearly visible on tomographic and antroscopic examination. In accordance with data from Putterman et al. (vol. 77, Am. J. Ophthal., 1974), no surgical treatment was given. The result was satisfactory.
The following case is reported: a 37-year-old man develops the following symptoms after an upper respiratory tract infection: severe left retro-orbital pain, later on radiating to the occiput, diplopia and a post-nasal drip. One year earlier he had also had a transient period of diplopia. At admission the examination initially shows a palsy of the left abducens nerve, later on a total left ophthalmoplegia. There is an axial protrusion of the left eye (2 mm) and some engorgement and redness of the left optic disc. The left pupil is smaller than the right but reacts to light and convergence; visual acuity is undisturbed. Visualevoked responses show little lower values on the left side than on the right. Orbitscan, skull, orbit, and sinus X-rays are normal. Tomograms of the paranasal sinuses show a clouded left sphenoidal sinus. The sinus is well pneumatized and has on the left side an extension in the left sphenoid wing; further there is hyperostosis of the lesser sphenoid wing Cerebral angiography shows no abnormality. With systematic antibiotic and corticosteroid therapy a complete functional recovery occurs with disappearance of clouding of the left sphenoid sinus. The course of illness and response to steroids warrant the diagnosis of painful ophthal moplegia or Tolosa-Hunt syndrome. This syndrome has to be separated from other, more grave causes of ophthalmoplegia. Craniotomy seems to be contraindicated, and corticoste roid advocated. The possible aetiology is an indolent inflammation localized in the superior
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Painful Ophthalmoplegia E.A. Baarsma ENT Department (Head: Prof. W.H. Struben), Erasmus University, Rotterdam
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
357
orbital fissure or the cavernous sinus. A portal of entry of this inflammation can be a sphenoidal sinusitis, especially when there is a good pneumatization, thin bone walls and dehiscences. In this case there is a recession of the sphenoid sinus in the lesser sphenoid wing that encloses the superior orbital fissure. Exacerbations, as they occur in this syndrome, could be explained by this portal entry. It seems possible that more cases of painful ophthal moplegia can be explained so. Therefore, it is always necessary to make a tomogram of the paranasal sinuses, because a routine sinus X-ray gives insufficient information.
Various tests of the tubal function are suggested in the literature, but none of these tests seems to be accepted. We shall describe our attempt to evaluate the tubal function. We compare our results with the clinical usage of examining the aeration of the middle ear cleft and the effects of a Valsalva and a Politzer manoeuvre. The tubal function is then evaluated according to the assumptions that a valsalva generates a pressure in the nasopharynx of 40-80 cm of water, and the politzer of 100 -200 cm of water. We found this evaluation often deceptive, although the assumptions seem to be fairly accurate. The majority of the tested patients have perforated eardrums (see the paper by Bos). Our method is developed primarily for these patients. A slightly modified procedure can be used for patients with intact tympanic membranes. We control and measure the pressure in the middle ear by the pump and the pressure transducer of an impedance meter. The pressure in the nasopharynx is monitored by an other pressure transducer through a nose olive, held by the patient in one of his nostrils. Some thresholds of air passage through the tube are determined. They are listed with our notation and normal values in centimetres of water in parentheses. Valsalva: the minimum pressure in the nasopharynx that forces the tube to let air through (V 40). Antivalsalva: the minimum pressure in the middle ear that forces the tube to let air escape and the resulting pressure in the middle ear (AV 20/4). Politzer: the minimum pressure in the nasopharynx at which swallowing causes an increase of the pressure in the middle ear (P 5). Antipolitzer: the minimum pressure in the middle ear (as well positive as negative) at which swallowing causes an alteration of the pressure in the middle ear cleft (AP + 1/-1). For the interpretation of our results we suppose the tube to be made up of a bony protympanon, a narrow isthmus and a cartilaginous duct, which will be opened by swallow ing. So a dysfunction of this duct will result in either normal valsalva values and politzer values equal to the valsalva values (dysfunction of the muscles), or in normal politzer values (P and AP) and increased valsalva (V and AV) values (a swollen and gluey lining of the duct). In the former case we observe clinically an easy valsalva and politzer but, if the eardrum is intact, a badly aerated ear (AP to high); in the latter case we observe a negative valsalva and a positive politzer (suggesting that the tube opens for pressures over 80 cm of water) and an aerated ear (normal antipolitzer). Interesting is the case of different values for AP+ and A P -. We have only observed cases in which AP - was higher than AP +. This can be explained either by a swelling of the middle ear lining or by a swelling just underneath the isthmus. In the former case the positive pressure squeezes the lining. This will facilitate the passage of air. The negative
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Method to Determine the Function of the Eustachian Tube J. Verschuure, C.E. Bos, R.N.P. Berkovits, P. Swagemakers and E.M. Kwadijk ENT Department (Head: Prof. W.H. Struben ), Erasmus University, Rotterdam
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
358
pressure enhances the swelling and will inhibit the passage of air. So we measure the usual valsalva values and higher politzer values. We observe clinically a positive valsalva and most likely a positive politzer and a badly aerated ear. In the latter case the passage of air to the middle ear will be mechanically blocked. We observe a normal AP + and slightly raised antivalsalva and very high values for all other tests. We observe clinically a negative valsalva and politzer and a badly aerated ear. A stenosis of the tube will cause an equal increase of the politzer values until the valsalva values are approached. A more severe kind of stenosis will produce equal values for all tests. We observe clinically a badly aerated ear. The valsalva and politzer will be increas ingly difficult. This survey indicates that it is necessary to have the quantified results of all four tests in order to determine the tubal function.
Since 1970, selected cases of cholesteatoma were operated according to the combined approach technique with an intact bony wall. The intervention is done in two stages, in the first operation the cholesteatoma matrix or the epithelial ingrowth is carefully dissected and the drum is repaired. After about 1 year a second control is made and if there is no recidive the ossicular chain is repaired. The results in the first 40 patients who were treated according to the above-mentioned scheme are as follows: In 23 patients no recidive of the cholesteatoma or the epithelial ingrowth in the middle ear was found and the ossicular chain was reconstructed. In 3 patients a deep retraction-pocket was found in the attic region. This was due to a defect in the lateral attic bony wall. The pocket was removed and the attic wall was repaired with cartilage, the ossicular chain was reconstructed. In 3 other patients small epithelial pearls were found measuring 1 -2 mm. In one case the epithelial pearl was not in the place of the original epithelial ingrowth in the middle ear. After removal of the epithelial pearls the ossicular chain was reconstructed in these patients. In 11 patients a recidive of the cholesteatoma or the epithelial ingrowth in the middle ear was found. In three cases the recidive was small and after removal the ossicular chain was reconstructed. In five cases the recidive was more extensive and after removal a third control after 1 year was planned. These were young persons and it was felt that they should have another chance. In 3 cases it was decided to remove the bony wall and to do a tympano plasty type Wullstein IV, the mastoid bone was obliterated by temporal muscle. The pre liminary conclusions are: (1) The recurrences were found especially in the sinus tympany, therefore, posterior tympanotomy is essential for this type of surgery. (2) Extirpation of the cholesteatoma matrix or the epithelial ingrowth has to be done very carefully. Some recur rences gave the impression that implantation of pieces of matrix in other places of the operation cavity is possible. (3) The operation has to be done in two stages. The second intervention should not be done too early, otherwise a small recurrence could be missed. (4) Tympanoplasty with intact bony canal wall is not a panacea for cholesteatoma: the operation should not be done in every case. The choice of the type of surgical treatment in cholesteatoma (open or closed) is especially dependant on the cochlear reserve and the age of the patient.
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Necessity of Staging in the Combined Tympanoplasty in Cholesteatoma T. Bottema ENT Department, Vrije Universiteit (Head: Prof. 0. de Wit), Amsterdam
Society Transactions • Gesellschaftsberichte ■Comptes rendus de sociétés
359
Preservation of Hearing in Children with Chronic Otitis Media with Cholesteatoma Formation J. Anker Gouda In the child a cholesteatoma behaves exactly like a tumour. Its constant production of cholesterol-rich cellular debris in a small enclosed space like the middle ear can lead to a very dangerous situation. It behaves as a space-occupying lesion which eventually destroys the anatomy of the middle ear. Hidden behind the eardrum, the process of progressive destruction is initially practi cally symptomless. The only symptoms are occasional purulent discharge, itching and eczema in the ear and reversible deafness. The condition is usually painless. The pathogno monic feature is the faecal odour of the discharge. The condition generally comes to light through the school physician who discovers deafness. An interesting point about the deaf ness is that in the majority of cases a marked improvement can be obtained by a short preoperative treatment to the affected ear. Paradoxically, this raises difficulties for the surgeon because while dealing with the cholesteatoma he has to keep in mind the fact that any post-operative deterioration in the deafness will be interpreted by the parents as failure of the surgical procedure. Moreover, the quality of the hearing is no indication to the amount of destruction one finds in the ear. In quite a number of children we found severe destruction in the mastoid and epitympanum with practically normal preoperative hearing. In other cases the cholesteatoma grew round the ossicles without interruption of the chain. One word about the operation. Operating on a chronically infected ear of a child is a very demanding task, not least due to the delicate anatomy involved. In my view radical surgery has no place in children. In the interest of the child it might be advisable to leave this sort of microsurgery to one experienced in this field. In my opinion every teaching centre should have one or two surgeons with a special interest in this field.
Hearing Loss Due to Gentamicin Therapy E.H. Huizing and E.G.J. Carrière ENT Department, University of Leiden (Head: Prof. P.H. Schmidt), Leiden
Nature o f the Damage The present series consisted of 16 patients with hearing loss caused by gentamicin, 11 belonging to the above-mentioned group and 5 referred from elsewhere. Tone audiometry. Cases with limited damage showed only high-tone loss with a rather sharply descending threshold curve. In cases with moderately severe impairment the audio
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Some years ago we observed a number of cases of hearing loss due to gentamicin therapy (Huizing, 1972). This led to the establishment, early in 1972, of an audiometric service for patients treated with ototoxic medicaments in the Leiden University Hospital. Since then, in collaboration with the Department of Infectious Diseases, we have investi gated audiometrically, and in some cases also electronystagmographically, 86 patients to whom gentamicin was administered. Some of the results of this study can be summarized as follows:
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
360
gram showed an almost normal threshold for the low frequencies, followed by a sharp drop at about 1,000 Hz and an appreciable (sometimes flat) loss in the high-tone region. In many cases the threshold curve resembled the Z-shaped audiogram, previously reported in investi gations on the degeneration pattern in progressive hereditary sensory-neural hearing loss (.Huizing et al., 1967). In cases with severe damage there were more or less considerable hearing residues in the low and middle range. Speech audiometry. In some patients the speech audiogram showed more serious anomalies than could be expected on the basis of the threshold loss. The discrimination losses found suggest that, especially in the more severe lesions, marked neuronal damage had taken place. SISl-test, tone-decay test. In general, the SISI scores were moderately high to high, whereas the tone-decay test gave normal results. These findings are in agreement with the results of animal experiments which showed that gentamicin primarily destroys the hair cells (e.g. Federspil, 1972, 1973; Brummen et al.. 1972). Symptomatology. The order of frequency and appearance of symptoms of gentamicin damage was as follows in our patients: (1) high-tone loss at audiometry; (2) tinnitus (highpitched); (3) subjective hearing deterioration, and (4) dizziness, sometimes with nausea. Progression o f hearing loss after termination o f treatment. One patient showed an appreciable increase of the hearing loss, both on tone and speech audiometry, after the termination of very prolonged treatment with gentamicin.
References Brummen, R.E.; Himes, D.; Same, B., and Vernon, J.: A comparative study of the ototoxic ity of tobramycin and gentamicin. Archs Otolar. 96: 505-512 (1972). Federspil, P.: Über die Aufzeichnung der Kochleaschäden beim Meerschweinchen. Z. Lar. Rhinol. Otol. 51: 633-637 (1972). Federspil, P.: Vergleichende experimentelle Untersuchungen zur Ototoxicität des Tobramycins und Gentamycins. Arch. Ohr.- Nas.- KehlkHeilk. 205: 266-269 (1973). Huizing, E.H.: Bolhuis, A.H. van, and Odenthal, D.A.: Studies on progressive hereditary perceptive deafness in a family of 335 members. Acta oto-lar. 61: 35-41, 161-167 (1967). Huizing, E.H.: Doofheid en evenwichtsstoornissen door gentamicine. Ned. Tijdschr. Geneesk. 116: 1261-1264 (1972).
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Factors Involved in Gentamicin Hearing Loss The most important factors playing a role in the origin of gentamicin damage was the dosage applied and the kidney function; in other words, the blood level of the drug (i.e. the perilymph level) and the duration of its administration. Kidney function. It has long been known that when the kidney function is disturbed there is a greatly increased risk of gentamicin damage. This is confirmed once again by our series. Of the 16 patients who suffered hearing loss, 10 had a reduced kidney function. Dosage. The usual dosage is 3 4 mg gentamicin/kg body weight divided over three doses per 24 h. The relationship between dosage, duration and hearing impairment in pa tients with a normal kidney function was investigated. For 24 patients with normal kidney function given gentamicin for more than 5 days, audiometry could be performed before, during and after the administration of the drug. Hearing loss was found in 7 cases. In this group, 4 patients had undergone prolonged treatment (> 40 days), 1 had been given a very high dose (6 mg/kg body weight) for a short time, and 2 had received a high dose (> 4 mg/kg) for a long period (> 40 days). The patients who had been given gentamicin for a shorter period in the normally prescribed dosage did not show measurable damage.
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
361
Beethoven’s Deafness R.T.R. Wentges ENT Department (Head: Prof. W.F.B. Brinkman), University of Nijmegen, Nijmegen In his letters, Beethoven described the symptoms of his deafness very accurately; furthermore, his contemporaries have left us a detailed account of his illness. In addition, an autopsy, at which the temporal bones were studied, was carried out the day after Beethoven’s death; interesting information can be gleaned from the report of this autopsy, but the temporal bones themselves are unfortunately now lost. Finally, Beethoven’s mortal remains were exhumed on two further occasions to allow measurements of his skull. It is probably no longer possible to come to a diagnosis of the cause of Beethoven’s deafness using the available data, but several syndromes can be excluded with virtual cer tainty. It is most likely that Beethoven had a bone disease affecting the internal auditory meatus, possibly Paget’s disease or hyperostosis corticalis generalisata (Van BuchemHadders). Syphilis, although less probable, cannot be excluded with certainty.
Nasal Disodium Cromoglycate (DSCG) A.S. Viner Loughborough There are two questions that I propose to try and answer: (1) Does DSCG work in allergic rhinitis? (2) What has been learnt about rhinitis in recent years?
Antigen Challenge Studies It is important to know if the drug works in the laboratory situation. To this end a number of antigen challenge studies have been performed by Taylor, using both DSCG powder and solution. All his studies have involved patients with hay fever and have been conducted in the winter when there is no pollen in the atmosphere. Briefly, his technique is to apply the pollen to the nose in increasing concentrations until a reaction occurs which increases the NAR to twice the baseline level, this he calls the NAR200. By this means he is able to assess the sensitivity of each subject to grass pollen and he uses that dose in the subsequent challenges that are repeated hourly with NAR measurement until the latter rises and thus the subject is no longer protected. The result of a study in 13 subjects showed that the majority of them were protected for 3 -4 h. A proportion had a late reaction which will be returned to later. A similar study by Engstrom using children sensitive to birch pollen has been done with DSCG solution. Again a baseline sensitivity was obtained and each child was given the
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Mode o f Action o f DSCG It has been known for some time that mast cells are involved in the allergic reaction in the nose. Following an antigen challenge they degranulate. The first stage in degranulation is the production of a halo-effect and the composition of the granule changes so that the granules on the surface are extruded. The mast cell remains viable and alive so that it is ready to discharge further granules on the next challenge. From work in our laboratories we know that DSCG in some way protects mast cells, not only against degranulation following an antigen-antibody reaction, but also against specific degranulation such as 48/80, dextran and phospholipase A. It would seem quite logical, therefore, to use such a drug in the treatment of allergic rhinitis if one accepts the fact that an antigen-antibody reaction is involved and that mast cells are important.
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
362
Clinical Trials To conduct a good hay fever trial is quite difficult. One has problems on the onset of the season, the daily challenge, individual challenges. The daily pollen count can be variable. This fact prevents the use of a crossover design in which one compares each patient with himself; instead, we found that the only possible design is a group comparative trial where two random groups are studied. The use of a spore trap to record the daily pollen count is extremely useful so that it is possible to analyse results during a period of challenge. Many hay fever trials have been inconclusive because of a high placebo response which will occur when the challenge is low. A seasonal rhinitis trial should be short, sharp and decisive. In the summer of 1973 we carried out a trial in the UK in a group practice just outside London. The object was to compare DSCG powder and solution in two random groups of hay fever patients sensitive to grass. It was decided to start when the grass pollen count had reached a level at which all patients were symptomatic, i.e. 50 grains/m3 of air sampled. The trial was to last exactly 21 days for all patients. They started with the trial on the same day. It is not always possible to say when the season will begin, however. Dr. Davies, who is in charge of the Microbiology Unit at St. Mary’s Hospital and a world authority on pollen, is now able to predict when the season will start from meteorological data obtained during the months of April and May. Tlius on June 1st he stated that the pollen count during the month of June would be significant on the 12th. All patients were sent letters to commence the treatment on that date and to report back in 21 days for a final assessment. With daily pollen counts we knew that the challenge had occurred throughout the trial and as all patients lived in the same area it can be assumed that they were roughly exposed to the same daily challenge. This in my view is about the best design one can achieve except for the use of matched pairs; the latter is extremely difficult to achieve and therefore doomed to failure. Incidentally, the trial showed that powder and solution were equally effective. With reference to perennial rhinitis we had a large study involving over 100 patients (not yet published). It was a double-blind crossover trial of 8 weeks duration. Patients with a clinical diagnosis of perennial rhinitis were selected and divided into tow equal groups on the basis of a positive or negative skin test. They were classified as allergic if they had a positive skin test and intrinsic if the result was negative. Each of the two main groups was subdivided according to the predominant symptom: ‘blocking’ or ‘running’. Thus in the end there were four equal groups and each was analysed separately. The interesting point was that positive results in favour of DSCG were obtained in the allergic and intrinsic ‘runners’ but not in the ‘blockers’. This suggests that skin testing should not be the only criteria for a diagnosis of allergic rhinitis. In fact we know that some patients with negative skin tests have positive nasal provocation tests. It also suggests that the symptoms may be related to other factors with histological changes in the mucosa such as increased goblet cells, chronic inflammatory changes in the mucosa (possibly initiated by immunological factors) or non specific factors such as irritation by physical factors, e.g. tobacco, S O ,, etc. In this study it was interesting to see how many patients had been entered into the various groups at the halfway stage. The most difficult group to fill was that of the intrinsic ‘blockers’; in fact when sufficient allergic ‘runners’ had entered the trial, there were only nine intrinsic blockers. It is certainly my impression that in perennial rhinitis the majority of
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
active solution or placebo double-blind and challenged. If the child was able to tolerate at least a 10-fold increase in concentration, this was considered a success. The challenge was given 10 min after DSCG administration, and again at 4 h. There was a significant difference in favour of the active drug at 10 min, but not at 4 h. Other studies have been carried out by Orie, in perennial rhinitis, and by Jenssen in seasonal rhinitis. They showed positively that DSCG (solution) protects in the majority of patients.
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
363
patients can be classified as allergic if one looks at patients closely so that a diagnosis of vasomotor rhinitis is relatively uncommon. Why then do some patients complain of ‘blocking’ and others of ‘running’? Some light on this can be gleaned from Taylor’s work. He studied a group of patients sensitive to grass pollen and looked at skin tests and nasal tests and observed the reactions for some hours. All had immediate type 1 reactions but 30 % had had a late skin reaction and 37 % a late nasal reaction usually appearing between 4 - 6 h. The immediate skin showed a typical wheal and flare, the immediate nose was associated with sneezing and running. The late skin showed erythema, induration and late nose-blocking. These findings resemble those of One in the asthmatic lung. He found a group of patients who had a late bronchial reaction which is not a typical type 111 reaction. The timings are similar as are the severity of the reaction. It is clear that the nose and the lung should be considered together as a part of the respiratory tract. Taylor biopsied some late skin reactions and found perivascular infiltration with mononuclear cells and polymorphs. We have observed the same histology in a few patients nose and they did not respond to DSCG. Therefore, we can suggest that allergic perennial rhinitis is a complicated disease, that one might divide into two main groups (these differ immunologically, histologically, clini cally and in response to treatment): The first group, which is the majority, has only a type I IgE-mediated reaction which results in a vasodilatation and oedema of the mucosa so that patients complain of running. The second group may be about 30 % of the total has a dual response, i.e. immediate and late reactions; the latter predominates and is leading to subacute or chronic inflamma tory changes with thickening of the submucosa and increase in goblet cells. Logically, group I should respond to DSCG, but group II should not as DSCG has a limited benefit on late reactions and also it is not an anti-inflammatory agent.
Comparison between the Destruction of the Respiratory Mucous Membrane Caused by Viral Infection and by Iatrogenic Trauma J.D. Bleeker ENT Department (Head: Prof. P.E. Hoeksema), University of Groningen, Groningen A description is given of the great similarity between the lesions of the respiratory mucous membrane caused by influenza virus A in the human bronchial tree and the lesions induced experimentally by bronchoscopy and tantalum bronchography in the dog. Secondary bacterial infection, especially of the Staphylococcus aureus is seen much more frequently after influenza virus infection than after iatrogenic trauma. Attention is drawn to the fact that the mucous layer is already present 1 h after the trauma covering the lesions. The possibility is suggested that the virus infection causes mainly a stop in the mucus production and that part of the epithelial lesions are secondary to exsiccation of the mucous membrane.
The origin, course and function of the autonomic nerve supply of the respiratory part of the nasal mucosa in rats is traced, using the results of histological, electron-microscopic,
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Autonomic Innervation of the Nasal Mucosa J.J. Grote, W. Kuijpers and P.L.M. Huygen ENT Department (Head: Prof. W.F.B. Brinkman), University of Nijmegen, Nijmegen
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
364
neurohistochemical and physiological investigations in normal rats and in those in which the appropriate autonomic nerves had been selectively transected. In the normal animal the vascular structures of the nasal mucosa appear to be inner vated by both adrenergic and cholinergic nerve fibres. The nucosal glands, however, display only cholinergic innervation. Close interconnection appears to exist between the perivascu lar and periacinar nerve plexuses. The main source of the sympathetic fibres is the superior cervical ganglion, the main parasympathetic nerve trunk being the greater petrosal nerve. The autonomic fibres reach the nose mainly via the pterygopalatine nerve and along the supplying blood vessels. Transection of the supplying nerves showed after an initial disappearance of the autonomic nerve endings in the nasal mucosa, a reinnervation between 2 and 12 months postoperatively. The results obtained by physiological and histometrical investigation of the patency of the nasal lumen support these findings. A model of the origin and course of the autonomic nerve supply was constructed from the results. Expecially the reinnervation stress the importance of obtaining more insight into the events occurring after vidian neurectomy used in humans to cure severe cases of vasomotor and atopic rhinitis.
Rotating chairs, rotating rooms, flight simulators or torsion swings are used for the investigation of semicircular canals. The possible movements of the existing rooms are very limited. These rooms are accelerated with a small acceleration up to a certain velocity and then stopped within a few seconds. The stimulus is a step in the velocity or an impulse of the acceleration. The resulting movement of the cupula is the impulse response. The new rotating room of the ENT clinic of the University of Utrecht can rotate with a constant adjustable acceleration. Flight simulators, which are limited in their angle of rotation, are used for sinusoidal stimulation. Torsion swings, which are also used for sinusoidal stimula tion, have the disadvantage that the frequency is difficult to adjust. We made the demand for our new rotating room that the following movements should be possible: a step in the velocity, constant adjustable acceleration and sinusoidal movements with adjustable fre quency between 0 and 8 Hz. During the determination of the vestibular ocular frequency, characteristic optokinetic and proprioceptive stimuli must be absent. By using a correlation technique it is possible to determine the vestibular-ocular characteristic, while reactions to visual and proprioceptive stimuli are present. Therefore, we have made the demand that stochastic signals can also be used as stimuli. If Coulomb friction is present in the bearing, the room will not move smoothly during very low velocities, which happen during sinusoidal movements. This effect is most pro nounced at the zero crossing of the velocity. We have eliminated Coulomb friction by applying a hydrostatic bearing. The hydrostatic bearing consists of two parts: an axial and a radial bearing (fig. 1). The axial forces consist of the weight of the room and its content. The axial bearing is nothing more than a tableland floating on a fluid layer. Variation of the loading results in a vertical displacement of the room. This displacement is not more than 2 mm and does not influence the rotation performance of the room. The radial force is
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
A Continuously Adjustable Rotating Room for Vestibular Research M. Rodenburg and I.P.C. Teerhuis ENT Department (Head: Prof. W.H. Slruben), Erasmus University, Rotterdam, and Laboratory for Measurement and Control (Head: Prof. R.G. Boiten), Technical Univer sity, Delft
365
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
0
10
20
30
Time, sec
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Fig. 2. Acceleration and velocity of the rotating room with a triangular signal as an input.
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
366
mainly determined by the stretching force of the drive belt. The radial bearing consists of a stationary double conical box within a cylinder, which is connected to the rotating room. Oil is supplied under pressure by holes in the conical box and is drained via the wedgedshaped space between the box and the cylinder to the tank. The stiffness of this bearing is very high. With perfect performance of the hydrostatic bearing there is no metallic contact between box and cylinder so that no Coulomb friction is present. An electro-hydraulic rotating servo-motor drives the room via a belt. The speed of rotation is adjustable between + 120°/sec and -120°/sec, while the torque is maintained. The dynamic behaviour of the room is that of a slightly damped second order system. The characteristic frequency (1.5 Hz) is determined by the stiffness of the belt and the moment of inertia of the rotating mass. High-frequency vibrations caused by the motor are attenuated by the mass-spring system, which is made up by the room and the drive belt. The damping originates from the viscous friction of the oil film in the bearing. We have increased the damping by applying acceleration feedback so that the transfer characteristic changed in that of an overcritical damped second order system. The maximum acceleration is presently 30°/sec2 but can be increased by changing the stretching force of the drive belt. Thanks to the absence of Coulomb friction the room also moves smoothly at very low speeds. Figure 2 presents a triangular movement and shows that these are no disturbances at the zero crossing point.
Orbital Complications H. Fermin and B.H.C. Nieuwenhuis-Koster ENT Department (Head: Prof. W.H. Struben), Erasmus University, Rotterdam Orbital complications occur in connection with inflections of the frontal and the ethmoid sinuses or infection of all sinuses: (1) swelling and abscess of the eyelid; (2) sub periosteal abscess; (3) fistula of the eyelid; (4) orbital cellulitis; (5) cavernous sinus throm bosis; (6) orbital apex syndrome; (7) frontal osteomyelitis. When serious complications are present or imminent, surgical drainage must be per formed. In acute infections a trephine operation on the frontal sinus is carried out. In chronical infections an outlet to the nose, through the ethmoid is made and a siliconated drain is left in place for a couple of weeks.
In the past 6 years four patients were admitted to the Ear-Nose and Throat Depart ment of the University Hospital in Groningen with complaints about hoarseness and slowly progressive dyspnoe, caused by a chondrosarcoma of the larynx. The clinical picture, the histology and the therapy of this rare tumor of the larynx is discussed by means of case reports and X-rays. It is pointed out that, because of the slowly progressive course of this kind of tumor, a laryngofissure is sufficient. A total larynx extirpation can in the future still be performed.
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Chondrosarcoma of the Larynx A.A. Annyas, P.E. Hoeksema and R. Eibergen ENT Department (Head: Prof. P.E. Hoeksema), University of Groningen, Groningen
Society Transactions • Gesellschaftsberichte • Comptes rendus de sociétés
367
Intra-Arterial Infusion with Methotrexate in the Rat P.J. Sindram, G.B. Snow and L.M. van Putten Radiobiology Institute TNO, Rijswijk, and the ENT Department (Head: Prof. G. de Witt), Vrije Universiteit, Amsterdam The superiority of intra-arterial infusion with methotrexate (MTX) over its systemic use in the treatment of head and neck tumours is still being questioned. A model in the rat, suitable for intra-arterial administration of MTX could be constructed. In this model three schedules have been investigated: (1)7 days continuous intra-arterial infusion with MTX; (2) the same schedule combined with leucovorin (CF) 6-hourly intra-peritoneally after Sullivan et al. (1959); (3) intermittent administration of MTX 2 X 24 h intra-arterial infu sion on day 1 and 4, while on day 2, 3, 5, 6 and 7 the catheter is kept open by the continuous intra-arterial infusion of saline. For all the three schedules intra-arterial MTX proved to be superior to its systemic use. Fractionated intra-arterial MTX proved to be better than continuous administration.
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 6:09:12 AM
Sindram. P.J.; Snow, G.B., and Putten, L.M. van: Intra-arterial infusion with methotrexate in the rat. Br. J. Cancer 30: 1 (1974).
