Andrei Borin

Intracranial complications of otitis media: 15 years of experience in 33 patients:

OBJECTIVES: Complications in the central nervous system (CNS) from acute otitis media (AOM) and chronic otitis media (COM) are becoming fewer, although they still represent a challenge for early recognition, adequate treatment, and satisfactory results. This retrospective study analyzed clinical data and therapeutic options in 33 patients with intracranial involvement resulting from otitis media. Important clinical features of intracranial complications and the sequence of the most efficient therapeutic maneuvers are discussed. METHODS: Charts of six patients with AOM and 27 patients with COM associated with CNS complications were analyzed for clinical presentation, imaging, and therapeutic approach. RESULTS: Ages ranged from 6 months to 79 years, with no gender predilection. Persistent fever, headache, and purulent otorrhea were the main symptoms. Proteus mirabilis, Enterococcus, and Pseudomonas aeruginosa were the most common microorganisms in COM, and Pneumococus and Haemophilus were the most common microorganisms in AOM. Nineteen patients (58%) presented with more than 1 CNS complication, resulting in a total of 56 complications, including 26 cases of otogenic brain abscess, 21 cases of meningitis, 5 cases of lateral sinus thromboses, two cases of subdural empyemas, 1 case of epidural empyema, and 1 case of meningocele. Surgical interventions included craniotomy and drainage of the abscess (n = 17), open mastoidectomy with abscess drained through the mastoid (n = 10), open mastoidectomy alone (n = 8), and closed mastoidectomy (n = 2). Twelve patients who underwent craniotomy had subsequent mastoidectomy for recurrent abscess. At the 6-month, 66% of patients presented without sequelae, 24% presented with sequelae, and 9% died. CONCLUSION: Early identification and prompt clinical and surgical intervention with mandatory drainage of the middle ear (primary disease), was essential for better outcome.

O uso da acupuntura para alívio imediato do zumbido

O zumbido, definido como percepcao consciente de um som originado nas orelhas ou no sistema nervoso do paciente, representa ate os dias atuais um grande desafio no que concerne seu tratamento, baseia-se na estimulacao com agulhas de pontos especificos definidos sobre a anatomia humana. A utilizacao da Acupuntura (ACP) em sintomas como o zumbido assemelha-se ao modelo aplicado nos quadros algicos, ja que ambos estao relacionados como experiencia sensorial e emocional subjetiva e desagradavel. OBJETIVO: Estudar a eficacia da acupuntura no alivio sintomatico de forma aguda no zumbido. FORMA DE ESTUDO: Clinico prospectivo. MATERIAL E METODO: Foi realizado um estudo prospectivo, randomizado e duplo-cego em 76 pacientes atendidos no Ambulatorio de Zumbido do Departamento de Otorrinolaringologia e Cirurgia de Cabeca e Pescoco da UNIFESP-EPM no periodo compreendido entre abril e junho de 2005. Todos os pacientes tinham queixa de zumbido e foram submetidos a anamnese clinica, exame fisico e exames subsidiarios a fim de se investigar sua etiologia. Os pacientes eram entao encaminhados a um primeiro pesquisador que determinou um valor numerico subjetivo inicial do zumbido atraves de Escala Visual Analogica (EVA), variando de 0 a 10 pontos. Apos isto, foram encaminhados para outra sala na qual um medico acupunturista, que nao tinha acesso a avaliacao inicial, separou os pacientes em Grupo Controle e Grupo Estudo de acordo com a ordem de atendimento, de maneira alternada. O ponto de ACP utilizado nos pacientes do Grupo Estudo situa-se a 6,5cm acima do apice do pavilhao auditivo na regiao temporo-parietal. O ponto utilizado no Grupo Controle situa-se 3cm acima do ponto anterior, na mesma linha vertical. Foram entao encaminhados a sala inicial para uma nova avaliacao pelo primeiro pesquisador, onde foram orientados a redefinir o escore subjetivo do zumbido. RESULTADOS: Dos 76 pacientes estudados, 29 eram do sexo masculino (38,2%) e 47 do sexo feminino (61,8%), com idade media 56,9 + 12,0 anos. Os Grupos Estudo e Controle contaram com 38 pacientes cada. Atraves do teste Anova foi constatado que houve diferenca significante (p<0,001) entre os momentos pre e pos-agulhamento e que no grupo Estudo essa melhora e bem maior (p = 0,0127). O teste t-independente mostrou que houve uma diferenca significante (p=0,017) entre os escores pre e pos-agulhamento nos grupos Estudo e Controle. CONCLUSAO: Concluimos que houve reducao significante da contagem dos momentos pre e pos-agulhamento em ambos os grupos (controle e estudo), sendo que no grupo estudo a reducao e maior que no grupo controle.

Acupuncture for tinnitus immediate relief

The treatment of tinnitus, which is defined as conscientious perception of a sound originated in the ears or nervous system, represents until the current days a great challenge. The use of Acupuncture (ACP) is based on the stimulation with needles of specific points on the human anatomy. A prospective, randomized and double-blinded study was carried through in 76 patients taken care of in the Clinic of Tinnitus of the Department of Otorhinolaryngology and Head and Neck Surgery of the UNIFESP-EPM in the period understood between April and June of 2005. All the patients had humming complaint and had been submitted to clinical anamnese, physical examination and subsidiary exams in order to investigate its etiology. The patients then were directed to a first researcher that determined an initial numeric value of the humming through Visual Analoge Scale(VAS), varying from 0 to 10 points. After this, had been directed for another room in which an acupuncturist doctor, who did not have access to the initial evaluation, separated the patients in Group Control and Group Study according to the attendance order, in alternating way. The ACP point used in patients of the Group Study places 6,5 cm above of the apex of the auditory pavilion in the parietal region. The point used in the Group Control places 3 cm above of the previous point, in the same vertical line. Then they had been sent back to the initial room for a new evaluation by the first researcher, where they had been guided to redefine the subjective score of the humming. Among the 76 studied patients, 29 were male (38,2%) and 47 female (61,8%), with average age 56,9 + 12,0 years. The Groups Study and Control had counted on 38 patients each. Through the Anova test it was evidenced that it had significant difference (p<0,001) between the moments pre and post needling and that in the group Study this improvement is more evident (p=0,0127). The t-independent test showed that it had a significant difference (p=0,017) between the two moments in the groups Study and Control. We conclude that there was significant reduction of the counting of the moments pre and post needling in both the groups, and in the group study the reduction is greater that in the group control.

Standardization of techniques used in facial nerve section and facial movement evaluation in rats

AIM Standardization of the technique to section the extratemporal facial nerve in rats and creation of a scale to evaluate facial movements in these animals before and after surgery. STUDY DESIGN Experimental. METHOD twenty Wistar rats were anesthetized with ketamine xylazine and submitted to sectioning of the facial nerve near its emergence through the mastoid foramen. Eye closure and blinking reflex, vibrissae movement and positioning were observed in all animals and a scale to evaluate these parameters was then created. RESULTS The facial nerve trunk was found between the tendinous margin of the clavotrapezius muscle and the auricular cartilage. The trunk was proximally sectioned as it exits the mastoid foramen and the stumps were sutured with a 9-0-nylon thread. An evaluation and graduation scale of facial movements, independent for eye and vibrissae, was elaborated, together with a sum of the parameters, as a means to evaluate facial palsy. Absence of eye blinking and closure scored 1; the presence of orbicular muscle contraction, without blinking reflex, scored 2; 50% of eye closure through blinking reflex, scored 3, 75% of closure scored 4. The presence of complete eye closure and blinking reflex scored 5. The absence of movement and posterior position of the vibrissae scored 1; slight shivering and posterior position scored 2; greater shivering and posterior position, scored 3 and normal movement with posterior position, scored 4; symmetrical movement of he vibrissae, with anterior position, scored 5. CONCLUSION The rat anatomy allows easy access to the extratemporal facial nerve, allowing its sectioning and standardized suture. It was also possible to establish an evaluation and graduation scale of the rat facial movements with facial palsy based on the clinical observation of these animals.

Microscopic anatomy of the carotid canal and its relations with cochlea and middle ear

UNLABELLED The knowledge of the relations between the noble and vital structures of temporal bone is still a great challenge for the otologic surgeon. The microscopic anatomic studies of the temporal bone are one of the greatest help to prevent lesions during surgical intervention. AIM To study the anatomic correlations between the carotid canal and the cochlea, and the occurrence of dehiscence of the carotid canal in the middle ear tympanic cavity. MATERIAL AND METHODS Microscopic study of 122 human temporal bones. RESULTS The average distance between the carotid canal and the cochlea were: the shortest distance, 1.05 mm; basal turn, 2.04 mm; middle turn, 2.32 mm; and apical turn, 5.70 mm. The occurrence of dehiscence of the carotid canal inside the tympanic cavity was 35.2%. CONCLUSION The small distances between the cochlea and carotid canal, and the high incidence of dehiscence in the tympanic cavity remind us that anatomical knowledge of the temporal bone is required for the best qualification of otologists.

Padronização das técnicas de secção do nervo facial e de avaliação da mímica facial em ratos

AIM: standardization of the technique to section the extratemporal facial nerve in rats and creation of a scale to evaluate facial movements in these animals before and after surgery. STUDY DESIGN: Experimental. METHOD: twenty Wistar rats were anesthetized with ketamine xylazine and submitted to sectioning of the facial nerve near its emergence through the mastoid foramen. Eye closure and blinking reflex, vibrissae movement and positioning were observed in all animals and a scale to evaluate these parameters was then created. RESULTS: The facial nerve trunk was found between the tendinous margin of the clavotrapezius muscle and the auricular cartilage. The trunk was proximally sectioned as it exits the mastoid foramen and the stumps were sutured with a 9-0-nylon thread. An evaluation and graduation scale of facial movements, independent for eye and vibrissae, was elaborated, together with a sum of the parameters, as a means to evaluate facial palsy. Absence of eye blinking and closure scored 1; the presence of orbicular muscle contraction, without blinking reflex, scored 2; 50% of eye closure through blinking reflex, scored 3, 75% of closure scored 4. The presence of complete eye closure and blinking reflex scored 5. The absence of movement and posterior position of the vibrissae scored 1; slight shivering and posterior position scored 2; greater shivering and posterior position, scored 3 and normal movement with posterior position, scored 4; symmetrical movement of he vibrissae, with anterior position, scored 5. CONCLUSION: The rat anatomy allows easy access to the extratemporal facial nerve, allowing its sectioning and standardized suture. It was also possible to establish an evaluation and graduation scale of the rat facial movements with facial palsy based on the clinical observation of these animals.

Behavioral and histologic experimental model of facial nerve regeneration in rats.

UNLABELLED To setup an experimental model is the first step to study neural regeneration. AIM Setting up an experimental model on facial nerve regeneration. MATERIAL AND METHODS Wistar rats with complete sectioning and suturing of the extratemporal facial nerve trunk; with a behavioral and histological analysis for 9 weeks. STUDY DESIGN Experimental prospective study. RESULTS Progressive clinical and histological recovery of the animals. CONCLUSION Our method is acceptable to study facial nerve regeneration in rats.

Modelo experimental comportamental e histológico da regeneração do nervo facial em ratos

To setup an experimental model is the first step to study neural regeneration. AIM: Setting up an experimental model on facial nerve regeneration. MATERIAL AND METHODS Wistar rats with complete sectioning and suturing of the extratemporal facial nerve trunk; with a behavioral and histological analysis for 9 weeks. STUD DESIGN: Experimental prospective study. RESULTS: Progressive clinical and histological recovery of the animals. CONCLUSION: Our method is acceptable to study facial nerve regeneration in rats.

Complications of otitis media - a potentially lethal problem still present.

INTRODUCTION It is an erroneous but commonly held belief that intracranial complications (ICCs) of chronic and acute otitis media (COM and AOM) are past diseases or from developing countries. These problems remain, despite improvements in antibiotic care. OBJECTIVE This paper analyzes the occurrence and clinical characteristics and course of the main ICCs of otitis media (OM). METHODS Retrospective cohort study of 51 patients with ICCs from OM, drawn from all patients presenting with OM to the emergency room of a large inner-city tertiary care hospital over a 22-year period. RESULTS 80% of cases were secondary to COM of which the incidence of ICC was 0.8%; 20% were due to AOM. The death occurrence was 7.8%, hearing loss in 90%, and permanent neurological sequelae in 29%. Patients were 61% male. In the majority, onset of ear disease had occurred during childhood. Delay of diagnosis of both the initial infection as well as the secondary ICC was significant. ICCs included brain abscess and meningitis in 78%, and lateral sinus thrombosis, empyema and otitic hydrocephalus in 13%, 8% and 1% of cases, respectively. Twenty-seven neurosurgical procedures and 43 otologic surgery procedures were performed. Two patients were too ill for surgical intervention. CONCLUSION ICCs of OM, although uncommon, still occur. These cases require expensive, complex and long-term inpatient treatment and frequently result in hearing loss, neurological sequelae and mortality. It is important to be aware of this potentiality in children with COM, especially, and maintain a high index of suspicion in order to refer for otologic specialty care before such complications occur.

The action of topical basic fibroblast growth factor in facial nerve regeneration.

Objective: To analyze the influence of the topical use of basic fibroblast growth factor (bFGF) in the regeneration of the facial nerve in rats. Study Design: Experimental study. Materials and Methods: Twenty-eight Wistar adult male rats underwent complete section of the facial nerve trunk, followed by end-to-end anastomosis with epineural sutures. An osmotic minipump equipped with a delivery catheter was implanted subcutaneously near the neural anastomosis. During the subsequent 14 days, 14 animals received a solution containing 25 &mgr;g/ml of bFGF, 250 UI/ml of sodium heparin, and 1,000 &mgr;g/ml of human albumin diluted in Ringer lactate, and 14 animals received a control solution of the same components without bFGF. To evaluate facial nerve regeneration, the number of myelinated fibers evident on histologic sections was counted on the 14th (7 experimental and 8 control animals) and the 28th days (7 experimental and 6 control animals) after surgery, and the facial movements of vibrissae and the blink reflex were evaluated on alternate days until the 28th day. Results: On histologic evaluation, the number of myelinated fibers was similar between groups on the 14th day and greater in the group that received bFGF on the 28th day. Behavioral evaluation showed that the animals of the bFGF group presented better functional results between the 6th and 16th days for the blink test and the 14th to the 16th days for vibrissae movements. Conclusion: This study showed that the regeneration of the facial nerve occurred earlier and resulted in significantly more myelinated nerve fibers in the animals that received topical bFGF.