Biomedical subjects
Publications and source records attributed to R Youngs.
Symptoms of sinusitis are among the most common reasons for patients presenting to primary care physicians. There is considerable controversy regarding appropriate management of both acute and chronic sinus disease. This article reviews etiologic mechanisms in these conditions and presents recent evidence to provide a logical basis on which to make decisions regarding medical and surgical therapy.
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Twenty patients who had undergone open cavity mastoidectomy for chronic middle ear disease were selected for study. Following initial microscopic aural toilet, each cavity was painted in its medial aspect with a marker solution of Bonney's Blue dye. Each patient was assessed at weekly intervals for a minimum of three months following application of dye, and a photographic record made of the cavity. Information was also sought regarding the clinical behaviour of the mastoid cavities, with particular regard to degree of otorrhoea, and accumulation of debris. Migration of epithelium inferred by visible movement of dye occurred in 17 of the 20 mastoid cavities. In all these cases migration occurred in a medial to lateral direction, towards the exterior. In two cases there was no visible migration throughout the period of observation, and inspection after six months revealed the dye to be still present in the original position. Both these cases were of dry trouble-free cavities in which accumulation of debris did not appear to be a problem. This finding calls into question the assumption that clean trouble-free cavities are maintained by a satisfactorily functioning epithelial migration. In the four cavities which suffered from intermittent otorrhoea, epithelial migration occurred at a similar rate to that in dry cavities.
Open cavity mastoidectomy remains the principle surgical treatment of middle ear cholesteatoma in the United Kingdom. A significant proportion of mastoid cavities are prone to intermittent or continuous discharge. In this study the temporal bone histopathology of four patients who had undergone open cavity mastoidectomy is presented. Cavities were predominantly lined with stratified keratinizing squamous epithelium. Residual air cells were obliterated by fibrous tissue, with no evidence of persistent respiratory epithelium. Where inflammatory changes were found, these consisted of areas of granulation tissue in association with epithelial ulceration. Residual cholesteatoma pearls (epidermoids) were not associated with significant inflammatory changes.
Open cavity mastoidectomy remains the principal surgical treatment of middle ear cholesteatoma in the United Kingdom. A significant proportion of mastoid cavities are prone to intermittent or continuous discharge. In this study the histopathological features of material removed from 159 mastoid cavities at revision surgery were reviewed. Findings included squamous epithelium with acute and chronic inflammation, foreign body granuloma and aural polyps. Of particular note was the very infrequent finding of discharging cavities lined with respiratory epithelium, suggesting that retained mucosa in mastoid air cells is not a common cause of persistent otorrhoea.
A patient who presented with an isolated soft-tissue tumor in the lateral portion of the external auditory canal, which after removal was diagnosed histopathologically as a peripheral nerve sheath neurothekeoma, is presented. Peripheral nerve sheath myxomas (neurothekeomas or perineural myxomas) have been reported to occur on the central area of the face, arms and shoulders. This is the first case in which a tumor of this type has been reported to develop in the external auditory canal. The distinguishing histopathological characteristics and the differential diagnosis of this tumor are discussed.
Fifty-five children with bilateral middle ear effusions were entered into a prospective randomized double blind trial to determine whether aspiration of middle ear effusions prior to ventilation tube insertion influences ventilation tube extrusion time or the development of tympanosclerosis. Following myringotomy, aspiration of the left or right ear only was performed randomly prior to ventilation tube insertion. The tympanic membranes were inspected six-monthly to determine whether ventilation tube extrusion had occurred, and at 24 months after surgery for the presence of tympanosclerosis. Results showed no significant difference in extrusion time between aspirated and non-aspirated ears. Aspiration was found to be a factor in the development of tympanosclerosis. We conclude that routine aspiration of the middle ear effusion prior to ventilation tube insertion is associated with an increased risk of tympanosclerosis.
To our knowledge, this article represents the second temporal bone case report in the literature of profound bilateral sensorineural deafness resulting from a lightning strike to the neck. Initial survival permitted antemortem audiologic testing, the results of which suggested severe cochlear abnormalities. Both temporal bones showed widespread inner-ear changes with absent organs of Corti, rupture and collapse of Reissner's membrane, strial degeneration, and a decreased spiral ganglion cell population. The occurrence of inner-ear trauma with an intact tympanic membrane and normal middle-ear structures suggests that a mechanism other than blast injury was responsible for the pathologic changes in this case.
Producing deliberate damage to the facial nerve in the middle ear is an established method of treating idiopathic hemifacial spasm. However, no previous electrophysiological studies have investigated the effect of this operation on facial nerve function. Eleven patients undergoing transtympanic facial nerve needling were investigated with electromyography. Following operation reduction in the abnormal discharges and synkinesis typical of hemifacial spasm was seen in the majority of patients. The success of this type of operation, although temporary in some patients, together with other neurophysiological studies conflicts with the hypothesis that this disorder is due to ephaptic transmission caused by vascular compression of the facial nerve in the cerebello-pontine angle.
A patient with a laryngeal paraganglioma is presented in which overtly malignant behavior occurred despite a four-year period of symptoms prior to diagnosis. A review of the world literature reveals 52 reported cases of laryngeal paragangliomas. The incidence of malignancy in these neoplasms is often underestimated, as at least 25% of reported cases exhibited a clinically malignant natural history. We believe that the treatment of laryngeal paragangliomas should be based on the assumption that all tumors have a potential for malignant growth. Wide-field surgical excision is the applicable treatment for tumors still localized to the larynx. The results of radical neck dissection for established nodal disease are discouraging. In those patients with palpable lymph nodes, widespread dissemination has usually taken place.
The incidental post-mortem finding of a small epidermal cyst in the middle ear of a 78-year-old female is presented. The epidermal cyst was attached to the chorda tympani nerve adjacent to the body of the incus, but was not associated with bony erosion or any other suggestion of enlargement or invasive growth. The pathological relationship of this lesion to previously reported "congenital cholesteatomas" of the middle ear is discussed.
While intradermal nevi are common benign pigmented skin tumors, their occurrence within the external auditory canal is uncommon. The clinical and pathologic features of an intradermal nevus arising within the external auditory canal are presented, and the literature reviewed.
Using skin dissected from the external auditory canals of fresh cadaveric temporal bones, the structure of the stratum corneum was investigated by the techniques of alkaline expansion of cryostat sections, silver staining of epidermal sheets, and scanning electron microscopy. Ordered epidermal column formation was observed in the stratum corneum from skin obtained from both the bony and cartilaginous portions of the canal. Occasionally, in areas of skin where the stratum corneum was considerably thickened, this vertical organization was lost, and the corneocytes randomly arranged. This orderly cellular architectural arrangement is a feature of the non-migratory skin of lower mammals, and has also been reported to occur in some areas of human skin. The functional relevance of this finding in the skin of the external canal is that the whole of the stratum corneum must migrate as one in order to preserve a regular vertical structure, suggesting that epidermal migration occurs in the deeper layers of the meatal epidermis.
Benign osteitis of the external auditory canal is a distinct clinical entity characterized by localized ulceration in the skin of the floor of the bony external auditory meatus with underlying osteitis and sequestration of the underlying tympanic bone. Consideration of clinical and pathological data suggests that continued self-inflicted minor trauma is an etiological factor in at least some cases. The purpose of this paper is to review benign osteitis of the external auditory canal, presenting further clinical documentation and to offer etiological suggestions based upon clinical, pathological and experimental observations. The benign nature of this condition is emphasized.
This report documents the spatial architecture of corneocytes in the human tympanic membrane and external auditory meatus. Using specimens of tympanic membrane and meatal skin dissected from fresh cadaveric temporal bones, the structure of the stratum corneum was investigated by the techniques of scanning electron microscopy and silver staining of epidermal sheets. An ordered vertical architecture was demonstrated in the skin obtained from both bony and cartilaginous portions of the auditory meatus, whereas the corneocytes of the tympanic membrane were randomly distributed. This orderly cellular configuration is a feature of the non-migratory skin of lower mammals, and some areas of human skin, but has not been previously reported to occur in the human external auditory meatus. The implication of these findings in terms of lateral epithelial migration is that in the external auditory meatus in order to maintain a vertically aligned structure the stratum corneum must move as one layer, being passively transported above the deeper epidermal layers in which migration occurs. In the tympanic membrane, however, net epithelial dispersion occurs by random insertion of new cells into a pavement-like layer of corneocytes.
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