Asim Aslan

A clinico-anatomic study of the auricular branch of the vagus nerve and arnold's ear-cough reflex

The results of a clinico-anatomic study of the auricular branch of the vagus nerve (ABVN) and Arnold’s ear-cough reflex are presented. The frequency of the ear-cough reflex was found to be 2.3% (12 out of 514 patients). It was bilateral in 3 cases (0.6%). The reflex was elicited by palpation of the postero-inferior wall of the external acoustic meatus (EAM) in 11 patients, and by palpation of the antero-inferior wall in one patient (0.2%). The reflex was frequently noticed to occur after a short latent period. The course of the ABVN inside the jugular foramen (JF), and distribution of the terminal branches of the ABVN in the external acoustic meatus were determined in 8 male cadavers (16 sides). In addition, the length of the mastoid canaliculus (MC) and the relationships of the ABVN with the facial nerve and stylomastoid foramen (SMF) were studied in both cadavers and 25 dry skulls (50 sides). High-resolution computed tomography (HRCT) scanning was also performed in all cadavers prior to microdissections. The ABVN emerged from the superior ganglion of the vagus nerve in all the cadavers. It ran between the internal jugular vein (IJV) and the bony wall of the jugular foramen. The ABVN was encased in a partial bony canal during its course from the jugular foramen to mastoid canaliculus in 18% of all specimens. The average length of the mastoid canaliculus was 5.6 mm (4.2–6.5), and it ran transversely towards the tympanomastoid suture 4.5 mm (4–5.1) above the stylomastoid foramen. The mastoid canaliculus was well demonstrated in all the HRCT scans.

Mastoidectomy in Noncholesteatomatous Chronic Suppurative Otitis Media: Is it Necessary?

Chronic suppurative otitis media (CSOM) without cholesteatoma, the surgical treatment of which is still controversial, is a common diagnosis in otologic practice. A retrospective analysis of 323 patients who underwent surgery for noncholesteatomatous chronic otitis media in the Gruppo Otologica, Piacenza, Italy, between April 1983 and December 1993 is presented. Cases were separated into three groups according to different surgical treatment modalities and conditions of the ears at the time of operation. Group I (n = 53) consisted of cases of CSOM treated by tympanoplasty without mastoidectomy (TLWOM). Group II (n = 28) included cases of CSOM treated by tympanoplasty with mastoidectomy (TLWM). Intact canal wall technique was used in these cases. The ears in both these groups were discharging severely at the time of surgery. Group III (n = 242) included patients whose ears were dry at the time of surgery but who had had previous recurrent episodes of suppuration and who were treated by TLWOM. At the last follow-up, graft success rates for groups I, II, and III were 90.5%, 85.7%, and 89.2%, respectively, and mean residual gaps were 17.2 dB, 20.1 dB, and 19.4 dB, respectively. There was no statistically significant difference between the three groups either on graft success rates (p > 0.05) or on final functional hearing outcome (p > 0.05). TLWM is the preferable treatment modality for most surgeons in noncholesteatomatous CSOM. Nevertheless, in our experience TLWOM yields comparable results for this group of patients. In addition, we could not find any significant difference in results of graft success and final functional hearing rates between dry and discharging ears (p > 0.05).

CT study on morphometry of frontal sinus

The aim of this study was to determine the prevalence and morphological characteristics of the frontal sinus in an adult population. This study was conducted retrospectively on paranasal CT scans in the axial and coronal planes of 300 cases (123 male and 177 female). The mean age was 40.74 ± 13.34 (range 20–83). Measurements of the width, height and anteroposterior length for each sinus and total width were obtained from CT scans. Measurements were compared statistically with relation to side and sex. The cases were divided into subgroups according to age for each sex and each measurement parameter was also compared among the subgroups. All measurements tended to be larger on the left side and were significantly larger in males than females. There was a significant difference in the anteroposterior lengths of right and left sides in both males and females and height for males and width for females. In both sexes, the highest values of measurements were usually observed at the 31–40 age group and there was a tendency to decrease with aging. The larger diameters of the left frontal sinus imply that it may be more possibly violated during surgical interventions. Morphometric features differed significantly in the two sexes at different ages and comparison with previous studies presented great regional variability. The size of the frontal sinus was seen to be related to age and sex. The knowledge provided in the present study is useful for some surgical procedures and widens the anthropometric knowledge of humanity. Clin. Anat. 21:287–293, 2008.

The jugular foramen: A comparative radioanatomic study

BACKGROUND Advances in microsurgical techniques made possible the removal of advanced jugular foramen (JF) lesions, which once had been accepted as unoperable. However, successful surgery requires detailed knowledge of the JF anatomy. METHODS Sixteen jugular foramina in eight formalin-preserved adult cadavers were scanned with axial and coronal high resolution computed tomography (HRCT) prior to dissection. After craniectomy and removal of brain tissue, the relationships of the neurovascular structures in the JF were determined by drilling the temporal bones from superior to inferior on planes parallel to the skull base. RESULTS No bony partition of the JF was observed. A dural band consistently divided the JF into two parts. Anterior to it was the glossopharyngeal nerve (IX) while the vagus (X) and accessory (XI) nerves were located posteriorly. There was a notch in which the IX nerve entered the JF. It was also identified on the CT scans and defined as the glossopharyngeal recess. The IX nerve made a genu within the JF in all specimens. Then, it ran inferiorly through a bony canal in three specimens (18.75%), and through an incomplete bony canal in two (12.5%), which were also defined on the CT images. The inferior petrosal sinus ran through a sulcus anteromedial to the glossopharyngeal recess. The posterior meningeal artery was found to be located between the X and XI nerves within the JF. CONCLUSIONS This study revealed a complex and highly variable pattern of the relationships of the neurovascular structures in the JF, and their HRCT images correlated well with the anatomic microdissections.

Injury to the Lacrimal Apparatus After Endoscopic Sinus Surgery: Surgical Implications From Active Transport Dacryocystography

In order to evaluate the lacrimal drainage system injury after functional endoscopic sinus surgery, surgical records and postoperative active transport dacryocystography imaging of 31 patients were analyzed. Presence of the lacrimal bone dehiscence and no passage of the contrast material into the inferior meatus were noted as the signs of injury to the lacrimal canal on active transport dacryocystography. Bony dehiscence was detected in 53.2% of the operated sides but 20% of the nonoperated sides. No passage of the contrast material into the inferior meatus was observed in 14.9% of the operated sides. There were no cases of epiphora postoperatively. The lacrimal drainage system injury was more frequently observed on the left sides operated. We conclude that lacrimal drainage system injury might occur in various extents during functional endoscopic sinus surgery. However, it does not necessarily result in postoperative epiphora. Performing the middle meatal antrostomy in posteroinferior direction, and uncinectomy with backbiting forceps or a shaver might help in reducing the lacrimal injury. Active transport dacryocystography can be adopted as an alternative diagnostic tool in detection of the lacrimal injury.

Facial nerve paralysis in chronic suppurative otitis media: Ankara Numune hospital experience

Although the incidence of facial nerve paralysis (FNP) decreased with the use of contemporary diagnostic tools and the advent of antibiotics, it is still a challenging problem. In this retrospective study, the charts of 1188 patients with chronic suppurative otitis media (CSOM), treated between 1988 and 1996 in the First ENT Clinic of Ankara Numune Hospital, Turkey, were analysed to establish the pre-operative incidence of FNP in CSOM. There were 20 (1.7%) patients with FNP secondary to CSOM. Of these, 14 (70%) had cholesteatoma. There was a defect on the fallopian canal in 14 patients (70%) and it was most commonly located on the tympanic segment of the canal (35.7%). Paralysis was incomplete in all patients. A total of 14 patients had ear drainage more than 3 years. FNP was associated with vertigo in three patients (15%) and tinnitus in one patient (5%).

Comprehensive microsurgical anatomy of the jugular foramen and review of terminology

The microsurgical anatomy of the jugular foramen was studied in 12 formalin preserved cadavers (24 foramina) and 40 dry-skulls (80 foramina). The jugular foramen was exposed by microsurgical dissection with drilling from a superior to inferior direction. Observations regarding dural architecture of the jugular foramen and relationships between neurovascular structures passing through the foramen were noted in cadavers. Normal bony construction of the foramen and its variational anatomy were examined in dry-skull specimens. Using photographs and drawings, the anatomy of the jugular foramen is presented and related terminology is discussed in the light of a literature review.

Sucralfate for posttonsillectomy analgesia

Pain is one of the most troublesome complications of tonsillectomy. The pain appears as throat pain, otalgia, or both, and continues until mucosal recovery on the tonsillar fossae is complete. Some surgical and hemostasis techniques may increase pain. Analgesics, antibiotics, steroids, and local and topical anesthetics are used to relieve posttonsillectomy pain, but none has the desired effectiveness. The pain reliever must not increase bleeding and must have minimal side effects. Sucralfate, a basic amino salt of sucrose octasulfate, binds to the matrix protein of a peptic ulcer and produces a protective barrier. Tonsillectomy leaves two large ulcerous wounds, and sucralfate may bind those wounds as it does peptic ulcers. In this controlled study, the efficacy of sucralfate on posttonsillectomy throat pain, otalgia, analgesic requirement, degree of strength, bleeding, body temperature, and mucosal recovery is investigated in 80 patients. Sucralfate is found to significantly reduce throat pain and analgesic requirement after surgery.

Morphometric analysis of anatomical relationships of the facial nerve for mastoid surgery

Surgical anatomical relationships of the facial nerve (FN) with several landmarks used in mastoid surgery were studied in temporal bone axial high resolution CT scans of 90 patients (180 ears). The shortest distances between the FN and external auditory canal (EAC), sigmoid sinus (SS), posterior fossa dural plate (PFD), and joint of the bony EAC with the lateral surface of the mastoid (M) were measured. These measurements were also analysed in respect of pneumatization and side differences. On average, it was found that FN-EAC was 2.9 mm, FN-SS was 10.5 mm, FN-PFD was 7.3 mm and FN-M was 15.3 mm. FN-EAC was found to be longer in poorly pneumatized bones whereas other distances were longer in pneumatized bones. FN-M was found to be longer on the right side.

Titration Streptomycin Therapy in Meniere's Disease: Long-Term Results

As soon as the use of streptomycin was started for the treatment of tuberculosis, its ototoxic effect was discovered. Initial reports demonstrated that streptomycin was successful in reducing vestibular responses while preserving cochlear activity. Streptomycin sulfate has been used for almost half a century for the treatment of vertigo in patients with Menieres disease. At the Gruppo Otologico, Piacenza, Italy, between 1987 and 1995 we treated 16 patients with either bilateral Menieres disease or with Menieres disease in their only hearing ear, adopting the titration streptomycin therapy protocol of Graham et al. Three patients with follow-up periods of less than 2 years were not included in this study. The ages of the patients ranged from 36 to 64 years with a mean of 49.2 years. The patients were observed for 2 to 8.8 years. The dose of administered streptomycin varied from 14 to 49 gm. Episodic vertigo was totally relieved in all of the patients after initial treatment, whereas hearing remained the same or was improved when compared with the pretreatment levels. Five of the patients experienced recurring vertigo during a period of 4 to 24 months after initial treatment. Oscillopsia persisted in two patients and ataxia in darkness persisted in another two patients. Hearing was unchanged in 14 ears, improved in 2 ears, and worsened in 4 ears at the last follow-up evaluation. The overall outcome indicated that intramuscular titration streptomycin therapy seems to be one of the most important therapeutic options in the treatment of disabling vertigo in patients with either bilateral Menieres disease or Menieres disease in an only hearing ear.