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Blood vessel growth and remodelling are essential during embryonic development and disease pathogenesis. The diversity of endothelial cells (ECs) is transcriptionally evident and ECs undergo dynamic changes in gene expression during vessel growth and remodelling. Here, we investigated the role of the histone acetyltransferase HBO1 (KAT7), which is important for activating genes during development and for histone H3 lysine 14 acetylation (H3K14ac). Loss of HBO1 and H3K14ac impaired developmental sprouting angiogenesis and reduced pathological EC overgrowth in the retinal endothelium. Single-cell RNA sequencing of retinal ECs revealed an increased abundance of tip cells in Hbo1-deficient retinas, which led to EC overcrowding in the retinal sprouting front and prevented efficient tip cell migration. We found that H3K14ac was highly abundant in the endothelial genome in both intra- and intergenic regions, suggesting that HBO1 acts as a genome organiser that promotes efficient tip cell behaviour necessary for sprouting angiogenesis. This article has an associated ‘The people behind the papers’ interview.

Acute undifferentiated leukemia (AUL) is rare and defined by the absence of bona fide myeloid and lymphoid markers. Little is known about its incidence, survival and optimal management in the recent time period. Based on a case observed in our clinic, we queried the Surveillance, Epidemiology, and End Results database between 2000 and 2016. A total of 1,888 cases of AUL were diagnosed (1.34 per million person-years). The incidence of AUL has significantly decreased over time. Compared to other acute leukemias, patients with AUL have the highest median age (74 years); in contrast to acute myeloid leukemia (AML, 65) and acute lymphoblastic leukemia (ALL, 12). Excluding patients with preexisting malignancies, 1,444 patients with AUL were analyzed for survival. Only 35% of AUL patients had received chemotherapy. Comparatively, 94% of ALL and 71% of AML cases received chemotherapy. Among AUL patients who received chemotherapy, the median survival was 12 months as opposed to 1 month in the group who did not receive chemotherapy (or unknown status). Among adults, AUL patients had the worst prognosis, with a median overall survival (OS) of 9 months, compared to 27 months in ALL and 13 months in AML. Among children, the median OS was superior for all three groups of leukemias, the OS of AUL patients being better than in AML and very similar to ALL. On multivariate analysis, older age and time period were associated with worse outcome. We describe here the largest series of cases with AUL published to date.

Applying Rasch analysis to evaluate the internal structure of a lexical tone perception test known as the Cantonese Tone Identification Test (CANTIT).A 75-item pool (CANTIT-75) with pictures and sound tracks was developed. Respondents were required to make a four-alternative forced choice on each item. A short version of 30 items (CANTIT-30) was developed based on fit statistics, difficulty estimates, and content evaluation. Internal structure was evaluated by fit statistics and Rasch Factor Analysis (RFA).200 children with normal hearing and 141 children with hearing impairment were recruited.For CANTIT-75, all infit and 97% of outfit values were 2.0. RFA revealed 40.1% of total variance was explained by the Rasch measure. The first residual component explained 2.5% of total variance in an eigenvalue of 3.1. For CANTIT-30, all infit and outfit values were 2.0. The Rasch measure explained 38.8% of total variance, the first residual component explained 3.9% of total variance in an eigenvalue of 1.9.The Rasch model provides excellent guidance for the development of short forms. Both CANTIT-75 and CANTIT-30 possess satisfactory internal structure as a construct validity evidence in measuring the lexical tone identification ability of the Cantonese speakers.

This study examines subjects' level of consciousness with bispectral analysis in sedation endoscopy of the upper airway.A prospective study.University hospital.Bispectral analysis levels recorded in natural sleep of 43 patients with obstructive sleep apnea during an overnight polysomnographic sleep study were directly compared with the levels recorded during midazolam sedation sleep endoscopy in the same subjects. The possible muscle relaxation effect of midazolam was examined via surface chin electrodes. Supine Müller maneuver findings in 50 patients with obstructive sleep apnea were also compared with soft tissue dynamics during midazolam sedation sleep endoscopy.In our study of the 43 patients with bispectral analysis during natural sleep and midazolam sedation sleep endoscopy, a predominance of bispectral analysis values indicating N1 and N2 sleep was observed during the sedation study. Midazolam failed to achieve deeper levels of sleep with minimal N3 and no convincing rapid eye movement. As N1 and N2 are the stages during which maximal dynamic activities occur, and they make up an average of 70.5% of total sleep time, from 210 sleep studies at our laboratory, the present technique would be ideal as a surgical assessment tool. No muscle relaxation effect could be detected at our protocol dose of midazolam. The supine Müller maneuver findings were significantly different from those observed during sedation sleep.These findings support the value of sleep endoscopy as an efficient and informative technique for the examination of upper airway dynamics relevant to focused surgical planning.

Background: Geographic accessibility to health facilities represents a fundamental barrier to utilisation of maternal and newborn health (MNH) services, driving historically hidden spatial pockets of localized inequalities. Here, we examine utilisation of MNH care as an emergent property of accessibility, highlighting high-resolution spatial heterogeneity and sub-national inequalities in receiving care before, during, and after delivery throughout five East African countries.Methods: We calculated a geographic inaccessibility score to the nearest health facility at 300 x 300 m using a dataset of 9,314 facilities throughout Burundi, Kenya, Rwanda, Tanzania and Uganda. Using Demographic and Health Surveys data, we utilised hierarchical mixed effects logistic regression to examine the odds of: 1) skilled birth attendance, 2) receiving 4+ antenatal care visits at time of delivery, and 3) receiving a postnatal health check-up within 48 hours of delivery. We applied model results onto the accessibility surface to visualise the probabilities of obtaining MNH care at both high-resolution and sub-national levels after adjusting for live births in 2015.Results: Across all outcomes, decreasing wealth and education levels were associated with lower odds of obtaining MNH care. Increasing geographic inaccessibility scores were associated with the strongest effect in lowering odds of obtaining care observed across outcomes, with the widest disparities observed among skilled birth attendance. Specifically, for each increase in the inaccessibility score to the nearest health facility, the odds of having skilled birth attendance at delivery was reduced by over 75% (0.24; CI: 0.19–0.3), while the odds of receiving antenatal care decreased by nearly 25% (0.74; CI: 0.61–0.89) and 40% for obtaining postnatal care (0.58; CI: 0.45–0.75).Conclusions: Overall, these results suggest decreasing accessibility to the nearest health facility significantly deterred utilisation of all maternal health care services. These results demonstrate how spatial approaches can inform policy efforts and promote evidence-based decision-making, and are particularly pertinent as the world shifts into the Sustainable Goals Development era, where sub-national applications will become increasingly useful in identifying and reducing persistent inequalities.

This study investigated the contributions of temporal periodicity cues and the effectiveness of enhancing these cues for Cantonese tone recognition in noise. A multichannel noise-excited vocoder was used to simulate speech processing in cochlear implants. Ten normal-hearing listeners were tested. Temporal envelope and periodicity cues (TEPCs) below 500 Hz were extracted from four frequency bands: 60-500, 500-1000, 1000-2000, and 2000-4000 Hz. The test stimuli were obtained by combining TEPC-modulated noise signals from individual bands. For periodicity enhancement, temporal fluctuations in the range 20-500 Hz were replaced by a sinusoid with frequency equal to the fundamental frequency of original speech. Tone identification experiments were carried out using disyllabic word carriers. Results showed that TEPCs from the two high-frequency bands were more important for tone identification than TEPCs from the low-frequency bands. The use of periodicity-enhanced TEPCs led to consistent improvement of tone identification accuracy. The improvement was more significant at low signal-to-noise ratios, and more noticeable for female than for male voices. Analysis of error distributions showed that the enhancement method reduced tone identification errors and did not show any negative effect on the recognition of segmental structures.

Objectives/Hypothesis: To evaluate diagnostic reliability of contact rhinoscopy in patients with nasopharyngeal carcinoma. Study Design: A cross-sectional randomized single-blinded study was carried out to evaluate the reliability of the findings of contact rhinoscopy in patients with nasopharyngeal carcinoma assessed by different observers. Methods: Random images of contact endoscopy of 157 subjects including normal patients and patients with nasopharyngeal carcinoma, both prior to external beam radiation therapy (RT), the non-RT group, and after external beam radiation therapy, the post-RT group, were available for analysis. Three independent observers of varying clinical experience and histopathologic knowledge viewed the images and made a diagnosis for each image. The diagnosis of each image was correlated with the histology of the biopsy from the corresponding patient. Results: In the non-RT group, Kappa values for inter- and intraobserver reliability to differentiate normal epithelium from primary nasopharyngeal carcinoma were 0.894, 1.000, 0.794 and 0.694, 1.000, 0.776 for the house officer, radiologist, and pathologist, respectively. There were no significant differences in interobserver and intraobserver reliabilities between the assessors. In the post-RT group, Kappa values for the inter- and intraobserver reliability to diagnose recurrent carcinoma or atypia, squamous metaplasia, and radiation change for the three observers were 0.820, 0.718, 0.775 and 0.731, 0.622, 0.734, respectively. There were no significant differences in interobserver and intraobserver reliabilities between the assessors. Conclusions: The clinical diagnosis of nasopharyngeal carcinoma by contact endoscopy is highly reliable and is not dependent on the clinical experience or knowledge of histopathology of the observers. Laryngoscope, 119:523–527, 2009

CANDILET-N is a closed-set speech-recognition test to assess lexical tone recognition in noise for Cantonese speakers. The test consists of 60 test items in a four-alternative forced-choice test paradigm, with male and female speaker versions. Each test plate consists of two disyllabic-word lexical tone minimal pair test items and their respective phonemic distracters. Psychometric performance SNR (signal-to-noise ratio) functions from 26 normal hearing adult subjects were fitted to a logistic regression model to obtain the SNR for 50% correct score (SNR-50%) for individual test items. The mean SNR-50% of the 60 test items for the female and male test sets were – 10.3 dB and – 11.1 dB, respectively. The SNR-50% varies across test items and their SNR need to be adjusted to improve the homogeneity among them. Copyright © 2009 John Wiley & Sons, Ltd.

The goal of this study was to examine tonal language perception in adults with cochlear implants who are native speakers of Cantonese. Ten adult subjects were implanted with HiRes 90K devices and participated in the study. Baseline data were obtained with standard HiRes and compared with HiRes 120. Subjects were evaluated using a tone identification test and a questionnaire. While objective outcome measures with the tone identification test did not show significant differences between standard HiRes and HiRes 120, subjective evaluation with the questionnaire showed significant differences in the overall satisfaction perceived by subjects. HiRes 120 received a significantly higher rating and the majority of subjects preferred HiRes 120. Copyright © 2009 John Wiley & Sons, Ltd.

Sixty prelingually deaf children were tested on Cantonese tone production ability at seven time intervals. Results of linear regression showed children in general improved in tone production performance over time. The magnitude of improvement, nevertheless, was different for children implanted at different ages. For children to acquire tone acquisition satisfactory, a critical age of four to receive implant is suggested. Optimally, children should receive their implant before two where they will be able to achieve around 80% accuracy in tone production within 1 yr of implant use. Children received their implant from two to just below 4 yr old achieved high tone production accuracy but needed a longer duration of implant experience. Children who received their implants at the age of 4 yr or older made little, if any, progress in producing tones correctly even after four to 5 yr of implant use.

Prehospital spinal immobilization (PSI) for patients with suspected spinal injury has been the universal standard of practice for emergency medical services (EMS) in the United States since the early 1970s. PSI research has faced numerous methodological difficulties, including an inability to evaluate whether the immobilizations being studied were carried out appropriately. The purpose of this study was to assess the quality of spinal immobilization to a long spine board in patients presenting via EMS to an emergency department (ED).All noncritically ill patients presenting to a tertiary care academic trauma center who had been immobilized on a long spine board for EMS transport were approached for enrollment. Each subject was evaluated for the number and location of restraining straps and their degree of tightness.Of 50 consenting subjects, 15 (30%) had at least one unattached strap or piece of tape that should have attached their head to the board. Of 50 subjects, 44 (88%) were found to have greater than 2 cm of slack between their body and at least one strap. Among those with any straps looser than 2 cm, the average number of loose straps was 3.4.This study suggests that many patients are not well immobilized on arrival at the Emergency department.

To evaluate the outcome of closed reduction from a patient's point of view, because there is increasing evidence that closed reduction of nasal fractures fails to address deformities of the cartilaginous nasal framework and the septum.We performed a retrospective study of 62 patients who underwent a closed reduction of nasal fracture between July 1, 2002, and June 30, 2005. All patients were interviewed regarding the esthetic and functional outcomes after closed reduction.Eighteen patients (29%) expressed dissatisfaction with the esthetic outcome of the reduction, and 18 (29%) said they would consider further surgery to correct the residual nasal deformity.A stringent preoperative assessment of the nasal fracture, other nasal deformities, and nasal function is essential before offering patients a simple closed reduction of their nasal fractures. A septorhinoplasty, as the definitive procedure, should be offered to patients when a closed reduction is deemed unable to address all deformities.

Objective: To establish an olfactory test in the Hong Kong Chinese population. Study design: Prospective analysis of the results of a combined olfactory test (COT) for patients with olfactory dysfunction and for normal subjects attending a secondary and tertiary ear, nose and throat centre.Method: Our COT was based on and modified from the Connecticut Chemosensory Research Centre test. It consisted of an odour identification test involving nine substances and a threshold test using a series of threefold dilutions of 1-butanol. From September 1998 to June 2002, 188 Hong Kong Chinese patients with olfactory dysfunction and subjects with normal olfaction were prospectively recruited. The subjects were categorized into normal, hyposmic and anosmic groups. The olfactory function of the main group of subjects (n = 153) was assessed with the COT by a blinded observer and also quantified with a visual analogue scale; the results were analysed to validate the discriminative ability of the COT. Another subgroup of subjects (n = 35) was tested with the COT twice with a two-week interval to evaluate test–retest reliability.Results: There were 42 normal, 68 hyposmic and 43 anosmic subjects within the main group (total n = 153). The identification scores, threshold scores and combined olfactory scores were statistically significantly different between the anosmic, hyposmic and normal groups of subjects (p p n = 35).Conclusion: The satisfactory discriminative ability and test–retest reliability of the COT have been demonstrated in this study. The COT is a feasible method for assessing sense of smell in the Hong Kong Chinese population.

Objectives: To study the effects of age at implantation and duration of implant use on the performance of spoken word recognition of pediatric cochlear implantees in a tonal language setting over a period of 5 years. Design: Sixty-four children, given implants between the ages 1:01 and 14:09 (years:months), were divided into three age groups. They were tested on open-set word recognition ability at seven time intervals from before surgery to 5 years after surgery. Analyses of variance with repeated measurements were used to examine the effect of their age at implantation and the duration of implant use. Results: Duration of implant experience was significant in spoken word recognition across the three age groups (p < 0.01). Children given implants below the age of 3 years caught up with the performance of the older children at 12 months after implantation. The difference in score reached statistical significance at 2 and at 3 years after surgery (p = 0.03, p = 0.00). Conclusions: The performance of Cantonese-speaking children was similar to that of English-speaking children in that better outcomes were associated with longer implant experience as well as when implantation occurred at a younger age. The children implanted before the age of 3 and who had an implant experience of more than 2 years outperformed the children who were given implants after the age of 6 and also sustained these higher scores throughout 5 years of postimplant testing.

Objective To evaluate the potential use of contact endoscopy for the diagnosis of persistent and recurrent nasopharyngeal carcinoma in postirradiated patients. Study Design Prospective study to examine 64 consecutive patients who have been irradiated for nasopharyngeal carcinoma in a clinic setting using contact rhinoscopes (Karl Storz, Tuttlingen, Germany [7215 AA, 0°, and 7215 BA, 30°; 23 cm long. 4 mm in diameter]). Methods The superficial cells of the posterior walls of the nasopharynx were stained with 1% methylene blue and examined with contact rhinoscopes with the patient under local anesthesia at high magnifications (×60 and ×150). Biopsy of the areas under examination was performed. The contact endoscopic images were analyzed and correlated with the corresponding histological sections of the biopsy tissues. Results Contact endoscopy was performed in 64 patients (54 men; mean age, 42 y) with the use of local anesthesia. Four patterns of contact endoscopic findings were identified: squamous metaplasia (43 cases), postirradiation atypia (10), granulation tissue (6), and malignancy (5). In the last group, the nasopharynx appeared normal in two patients (40%). The findings of contact endoscopy correlated well with the histological findings (kappa reliability coefficient = 0.847;P

Migraine is an extraordinarily common brain disorder for which treatment options continue to be limited. Agonists that activate the δ-opioid receptor may be promising for the treatment of migraine as they are highly effective for the treatment of chronic rather than acute pain, do not induce hyperalgesia, have low abuse potential and have anxiolytic and antidepressant properties. The aim of this study was to investigate the therapeutic potential of δ-opioid receptor agonists for migraine by characterizing their effects in mouse migraine models.Mechanical hypersensitivity was assessed in mice treated with acute and chronic doses of nitroglycerin (NTG), a known human migraine trigger. Conditioned place aversion to NTG was also measured as a model of migraine-associated negative affect. In addition, we assessed evoked cortical spreading depression (CSD), an established model of migraine aura, in a thinned skull preparation.NTG evoked acute and chronic mechanical and thermal hyperalgesia in mice, as well as conditioned place aversion. Three different δ-opioid receptor agonists, SNC80, ARM390 and JNJ20788560, significantly reduced NTG-evoked hyperalgesia. SNC80 also abolished NTG-induced conditioned place aversion, suggesting that δ-opioid receptor activation may also alleviate the negative emotional state associated with migraine. We also found that SNC80 significantly attenuated CSD, a model that is considered predictive of migraine preventive therapies.These data show that δ-opioid receptor agonists modulate multiple basic mechanisms associated with migraine, indicating that δ-opioid receptors are a promising therapeutic target for this disorder.

Objectives To evaluate the potential use of contact endoscopy for the diagnosis of nasopharyngeal carcinoma (NPC). Study Design Prospective study to examine the nasopharynx of 30 patients with nasopharyngeal carcinoma and 18 subjects with normal nasopharynx in a clinic setting using contact rhinoscopes (Karl Storz, Tuttlingen, Germany, 7215 AA, 00 and 7215 BA, 300; 23 cm long; 4 mm in diameter). Methods The superficial cells of the normal nasopharynx and the nasopharyngeal tumors were stained with 1% methylene blue and examined with contact rhinoscopes at high magnifications (×60 and ×150). The areas under examination were then biopsied. The contact endoscopic images were compared with the corresponding hematoxylin and eosin-stained histologic sections of the biopsied tissues. Results Sixty-six procedures were performed in 48 patients. The images of normal pseudostratified ciliated epithelium and squamous epithelium were readily recognized by contact endoscopy in all subjects with normal nasopharynx (10 men and 8 women; mean age, 51.9 y). Twenty-six of 30 patients with NPC (86.6%; 18 men and 8 women; mean age, 50.6 y) were successfully examined by contact endoscopy under local anesthesia. In these 26 patients, two patterns of malignant cells were identified with contact endoscopy. The patterns of contact endoscopic images corresponded well with the histologic findings. Conclusion Contact endoscopy is an accurate and reliable office-based procedure, which allows for in-vivo diagnosis of nasopharyngeal carcinoma.

Alloplastic nasal augmentation with silicone elastomer (Silastic) is popular in areas of Asia. Although the silicones are bio-inert, they have been implicated in a number of adverse reactions after implantation. We report our experience of three patients who presented with late complications after nasal augmentation using Silastic implants. The mechanisms of implant failure are proposed. It is advised that this material should only be used on an individual basis in carefully selected cases.

The present study validates and evaluates the sensitivity and specificity of four internationally popular questionnaires, translated into Chinese, for assessing suspected obstructive sleep apnea (OSA) patients, namely, the Berlin questionnaire, the ASA checklist, the STOP questionnaire and the STOP–BANG questionnaire. Their predictive values in OSA risks in patients presenting with OSA symptoms are examined. Questionnaires may be helpful in prioritizing polysomnography (PSG) and in treatment for the more severe cases. All patients attending our sleep laboratory for overnight PSG were recruited. They were asked to complete three questionnaires (Berlin, ASA checklist and STOP) 2 weeks before and on the same night as the PSG. STOP–BANG questionnaire, an extended STOP with demographic data, ‘B’-body mass index (BMI), ‘A’-age, ‘N’-neck circumference and ‘G’-gender was completed by our technologists using the patient’s completed STOP. A number of 141 patients were recruited. The sensitivities and specificities for STOP–BANG with cutoffs at PSG’s RDI = 5, RDI = 15 and RDI = 30 were 81 % to 86 % and 34 % to 57 %, respectively. The high-risk group patients identified by STOP–BANG had significantly higher respiratory disturbance index and lower minimum oxygen saturation than the low-risk group patients. Among the four questionnaires studied, STOP–BANG, with only eight questions and the highest sensitivity, is the best questionnaire of the four for OSA screening. This can potentially assist in prioritizing PSG and can be helpful in clinical or self-evaluation by the general public.

This study investigates the pattern of pediatric nasal foreign body impaction and its management in a metropolitan area. Data was obtained from 147 children presenting to the Accident and Emergency Department over a 4-year period. The majority of foreign bodies were toys and household products. Complications which occurred, such as ingestion of the foreign body or epistaxis were usually related to attempts at removal. Fourteen cases of local complications resulted from button battery impaction. Most of these patients can successfully be managed without complication if correct procedures are adopted.

A prospective study of all foreign body complaints presenting through our Accident and Emergency Department was conducted in a population where the condition is endemic. All patients were managed by otolaryngologists. Six hundred and eight patients were attended to yielding 179 foreign bodies. Making use of modern equipment and a practical approach, the requirement for examination under general anaesthesia was 6.3 per cent. In this series there was a complication rate of 0.5 per cent.

Objective In tone languages such as Cantonese, a change in tone denotes a change in lexical meaning. The present study investigates the functional benefit of hearing devices in assisting tone perception among children with profound hearing impairment. Subjects Fifty-two children with profound hearing loss were categorized into two groups based on their primary type of hearing device - a hearing aid group and cochlear implant group. Methods A 75-item tone identification test covering all 15 Cantonese tone contrast pairs was administered to each subject under two conditions - unaided (hearing devices turned off) and aided (devices turned on). The proportion of correct responses was computed as the total score for all items and subtotal contrast scores for each of the 15 tone contrasts. Results The results indicated no significant differences between the children wearing hearing aids and those with cochlear implants under the unaided or the aided condition (z = -0.91, p = 0.36; z = -0.40, p = 0.69, respectively). Regardless of the type of device used, the total scores under the aided condition were higher than those under the unaided condition (z = -3.55 for the hearing aid group; z = -4.87 for the cochlear implant group, both ps Conclusion Children wearing hearing devices generally have a satisfactory functional gain in tone perception. No major observable difference was noted between children using cochlear implants and those using hearing aids. Tone contrast pairs with dissimilar fundamental frequency at onset and dissimilar tone contour patterns were more easily identified.

Complete second branchial fistula is a rare clinical entity. The classical presentation of second branchial fistula is recurrent discharge from the external opening with or without recurrent painful neck swelling. We report an unusual case whose presenting symptom was a long-standing history of throat discomfort with recurrent blood stained saliva. Her symptoms resolved after her branchial fistula was excised.

To evaluate the safety and effectiveness of totally implantable hearing aid (Carina) was assessed in adult patients with bilateral moderate to severe hearing loss.Surgical implantations of Carina were performed in three adult patients with bilateral moderate to severe hearing loss. The safety and effectiveness were evaluated in a more than 12 months follow-up by comparison of outcomes of PTA and speech audiometry pre and post-operatively. The daily usage of implants was observed and compared with traditional hearing aids.The average elevation of unaided threshold elevation on surgical side was 8.3 dB postoperatively. The average functional gain in four speech frequencies of PTA was 35.4 dB HL and the average threshold decrease of speech discrimination was 22.5 dB HL. The subjective scoring of performance of the implants is significantly higher than traditional hearing aid.Totally implantable hearing aid (Carina) is an ideal implant to treat moderate to severe hearing loss. Long term follow-up is needed to validate the results.

Early symptoms of nasopharyngeal carcinoma (NPC) can often be deceptive and confusing. Most patients with nasopharyngeal carcinoma present at an advanced stage with metastatic cervical nodes present at the time of diagnosis. A deep neck abscess as the presenting feature has not been reported. We report two cases of nasopharyngeal carcinoma which presented with retropharyngeal abscesses and persistent lymphadenopathy. These two patients illustrate that refractory lymphadenopathy, despite adequate treatment of the associated infection, should prompt a search for underlying disease. The relationship between nasopharyngeal carcinoma and retropharyngeal abscess is discussed.

Bcl-2 family proteins play an important role in the growth and biological behavior of tumors. This study aimed to determine Bcl-2 family proteins in laryngeal carcinoma and to examine their relationship with spontaneous apoptosis. The material studied was from 39 patients with laryngeal carcinoma. It was found that the expression of both Bak and Bax was lower in tumor tissues than in nontumor tissues. However, there was no difference in the expression of Bcl-2 between tumor and nontumor tissues. The frequency of spontaneous apoptosis was lower in tumor tissues than in nontumor tissues but was not significantly related to the expression of Bak, Bax, or Bcl-2. Bak was decreased in moderately differentiated tumors compared to well-differentiated tumors. In contrast to Bak, the expression of Bcl-2 was increased in moderately differentiated tumors compared to well-differentiated tumors. These results indicate that the reduction in Bak may be associated with an increase in tumor grade and dedifferentiation in laryngeal carcinomas. The lack of correlation between apoptosis and the expression of Bcl-2 family proteins suggests that spontaneous apoptosis in laryngeal carcinoma is a complex process and that molecules other than Bak, Bax, and Bcl-2 participate in it.

Malignancy is a major cause of vocal fold paralysis. Nevertheless, metastatic disease at the brainstem leading to high vagal paralysis is rarely encountered. We illustrate an unusual case of unilateral vocal fold paralysis caused by dural metastasis directly compressing on the nucleus ambiguus. The median position of the paralysed vocal fold is inconsistent with the Wagner and Grossman theory predicting the location of the lesion.

Congenital laryngeal cysts are a rare cause of neonatal upper airway obstruction which may lead to serious morbidity and mortality if diagnosis and treatment are delayed. We reviewed our experience with nine patients over a six-year period. The annual incidence of this condition was 1.82 per 100,000 live births. The diagnosis can be confirmed safely by flexible laryngoscopy before definitive surgery is contemplated. Contrary to other studies, we found that endoscopic removal of cysts can achieve an effective cure without recurrence. Endoscopic deroofing is as effective as endoscopic excision but is technically simpler and thus is recommended as the treatment of choice.

Over a 6.5-year period, 5,848 patients who had ingested a foreign body were admitted to the ENT unit at the Prince of Wales Hospital in Hong Kong. Potentially serious complications developed in 12 patients (0.21%). Eight patients had an esophageal perforation; three had clinical evidence that their injury had been caused by the foreign body itself and five were deemed to have been injured iatrogenically during esophagoscopy. One of the latter group eventually developed an abscess. Four patients originally presented with an abscess. Three of these patients and the patient who later developed an abscess were treated with neck exploration and surgical drainage. One of the patients who initially presented with an abscess refused surgical treatment and was treated conservatively. Conservative treatment was also initiated for all patients who had a perforation. Patients on the conservative regimen were administered intravenous broad-spectrum antibiotics and were not permitted to take any food or liquids by mouth; they received their nutrition via either enteral feeding or total parenteral nutrition. Conservative treatment was successful in all seven patients with a perforation and no abscess and in the one patient with an abscess who refused surgery. Moreover, all four patients who underwent surgical treatment recovered. Our experience demonstrates that esophageal perforation related to an ingested foreign body can be safely treated by conservative means if the diagnosis is made before significant contamination occurs. Conversely, abscesses (cervical or mediastinal) related to an ingested foreign body should be explored and surgically drained.

Studies have shown that while children acquire all Cantonese tones by age two, they are not able to label them reliably until approximately age 10. One possible explanation for the large age discrepancy may be the different methodologies used. This study aimed to (1) investigatea new research design for the collection of reliable tone perception data from young children; (2) compare lexical and nonlexical items for testing tone perception ability; and (3) identify the relative ease of perceiving the three basic tone contrasts in Cantonese, that is, high level/high rising (T1 /T2), high level/low falling (T1/T4), and, high rising/low falling tones (T2/T4). The three tone pairs were presented to 31 children in the form of word and nonword stimuli. It was found that the research design could be used to assess the tone perception knowledge of children as young as 2;09. Significant differences were found between word and nonword stimuli and also in the identification of the T2/T4 contrast in comparison with the other two pairs. Children's overall tone perception abilities are discussed in detail with reference to the role of lexical knowledge and the potential for tone perception confusions arising from differences in fundamental frequencies for tone onset and offset.

We evaluated a modified technique of administering anesthesia without a tube and with spontaneous respiration during video-assisted tele-laryngo-tracheo-broncho-endoscopy (TLTBE). The endoscopy was performed as an alternative to rigid ventilatory bronchoscopy during screening for synchronous tumors in the tracheobronchial tree in patients who had head and neck malignancies. Thirty consecutive patients who required diagnostic panendoscopy were selected for this study. During direct-suspension laryngoscopy, anesthesia was delivered by administering intravenous bolus injections of propofol at 0.5 to 2 mg/kg every 5 to 10 minutes. A good view of the larynx, trachea, and main bronchi was obtained with a 50-cm 0 degree telescope, which caused no obstruction of the airway. During laryngoscopy, arterial oxygen saturation levels, pulse rates, and blood pressures were stable in all patients. No apnea was associated with the use of propofol during any procedure, and we observed no intraoperative or postoperative complication in any patient. Video-assisted TLTBE is appropriate for patients with a grade 1 or 2 larynx, good cardiopulmonary function, and no significant airway obstruction. It is a safe and time-saving alternative to rigid ventilatory bronchoscopy for staging primary tumors and for screening for synchronous tumors in the respiratory tract.

Most tone perception tests for Cantonese-speaking cochlear implant users have been based on tone identification tasks which require significant cognitive development to be successfully completed. Results from such tests suggest that cochlear implant child users are performing at about chance level and may not be receiving much information about pitch using the implant. This paper reports on the ability of cochlear implant child users to discriminate pitch variations in Cantonese by using an experimental procedure based on play audiometry. As part of the study, the usefulness of higher rates of electrode stimulation for aiding tone discrimination is also examined. Cochlear implant users are shown to derive sufficient information about pitch to discriminate most tone contrasts relatively successfully, with performance being most variable for contrasts involving tones clustered in the lower register of the speaker's fundamental frequency range. Contrary to hypothesis, higher electrode stimulation rates are not found to offer significant benefits for aiding pitch discrimination.

This review was carried out to assess the effectiveness of our protocol designed for the management of ingested foreign bodies. It was a retrospective review of 5240 patients with ingested foreign bodies admitted over a five-year period to the Ear Nose and Throat Unit. These patients were managed according to a standardized protocol which was adopted and modified from our previous study. Under his management protocol, the mean hospital stay was 1.6 days. Flexible oesophagoscopy under local anaesthesia, and rigid oesophagoscopy under general anaesthesia, were performed in 1.5 per cent and 7.7 per cent of cases respectively. Major complications including oesophageal perforation and deep neck abscesses occurred in 0.19 per cent of patients. There was no mortality. This management protocol for ingested foreign bodies was both safe and cost-effective when compared to similar studies reported in the literature.

Objective : To determine the preferable management protocol of foreign body ingestion in pediatric patients. Methods : All pediatric patients aged less than 12 years who presented with suspected foreign body ingestion in a hospital setting over a period of 3 years were prospectively studied. The usefulness of symptoms and various diagnostic procedures to identify the impacted foreign bodies were analyzed. Results : Of 311 children aged 4 months to 12 years, 115 foreign bodies were encountered. The presentations in children aged younger than 5 years were markedly different from the older children, who behaved more like adults. All sharp foreign bodies (107 cases or 93%), mostly fish bones (90.4%), were found in the oropharynx under direct vision using either tongue depressor (57%), Macintosh laryngoscope (6%), indirect laryngeal mirror (2%) or transnasal flexible endoscopy (28%). Coins (eight cases or 7%) were the only foreign body impacted at or below the level of cricopharyngeus. A plain cervical X-ray has a low sensitivity (15.9%) and a high specificity (99.5%) in identifying the foreign bodies. Conclusions : As the majority of the foreign bodies were sharp bones and situated in the oropharynx, a management protocol involving examination with a tongue depressor, transnasal laryngoscope, selective lateral soft tissue neck X-ray, chest X-ray and watchful observation is usually adequate. Removal of these foreign bodies can be accomplished using a tongue depressor and Macintosh laryngoscope. Patients with a suspected coin ingestion have to be evaluated by X-ray, and a rigid pharyngo-oesophagoscopy should be the mainstay of treatment.

Objectives To compare the long-term recurrence rate of the standard technique (simple sinectomy) and the supra-auricular approach (wide local excision) for the surgical management of preauricular sinuses. Study Design Retrospective cohort. Methods Fifty-four patients with a preauricular sinus excised between May 1986 and December 1996 were included in this study. All patients were categorized into one of two groups based on the type of surgery performed: the standard technique or the supra-auricular approach. The medical records were then reviewed and the latest information concerning the recurrence of a preauricular sinus were updated by phone interview. The recurrence rate of these two groups was statistically analyzed by the Fisher exact test. Results Forty-nine of 54 patients were successfully contacted with data updated and analyzed. The 32% recurrence rate of the standard excision (n = 25) was significantly higher than the 3.7% recurrence rate of the supra-auricular approach (n = 27; two-tailed test, P = .01). Conclusion The supra-auricular approach for excision of a preauricular sinus has a statistically lower recurrence rate in comparison to the standard technique.

Purpose: The use of a Montgomery T-tube as a palliative measure in the treatment of patients with respiratory obstruction due to cancer is described. Patients and Method: Six patients with terminal malignant disease presented with airway obstruction caused by direct infiltration of the trachea by tumor. The primary carcinoma originated in the esophagus in five cases, whereas one patient had metastatic carcinoma of the breast. In each case, the airway was initially secured using a rigid ventilating bronchoscope that was advanced past the area of tracheal obstruction. Tumor was removed from the lumen of the bronchoscope with suction and cup forceps. Anesthesia was continued through the bronchoscope while the trachea was exposed through a cervical incision and a window cut in the anterior tracheal wall. A Montgomety T-tube was inserted as the bronchoscope was withdrawn. Results: This technique allowed dramatic relief of airway obsruction in all cases. The tube relieves the obstruction by stenting the airway and permits speech in most patients. The authors stress the need for frank discussion with patients and family when considering the appropriateness for this form of palliation.

Objectives To determine the action of the Foley catheter in the posterior nasal cavity in relation to balloon volume, and to deduce its implications in the treatment of posterior epistaxis. Design Human cadaveric study. Materials Twenty nasal fossae of 10 adult cadavers. Interventions A Foley catheter (size 14) was inserted into the nasopharynx via each nostril. The catheter balloon was inflated to its recommended maximum volume with 15 mL of water. Firm traction was applied to the catheter. Colored liquid was instilled into the ipsilateral aspect of the nasal cavity, and liquid leakage into the contralateral side was monitored using a nasoendoscope. The balloon was reduced in volume by 1-mL steps, and the same fluid infusion and documentation procedures were performed for each reduced volume until the balloon slipped out of the nose. The procedure was repeated in the opposite nostril. Main Outcome Measures Successful choanal sealing and anterior balloon shift into the nasal fossa in relation to the balloon size. Results The Foley catheter balloon sealed the choana without any leakage of infused liquid into the contralateral side at appropriate inflation volumes in 17 (85%) of 20 nasal fossae. Complete sealing between volumes of 12 and 15 mL was achieved in 13 fossae (65%), between 11 and 15 mL in 10 nasal fossae (50%), and between 5 and 15 mL in 3 nasal fossae (15%). Failure to seal at any volume occurred in 3 nasal fossae (15%). Bimodal seal (ie, complete seal at high [15 mL] and low volumes [4-7 mL], but leakage in intermediate volumes) occurred in 3 nasal fossae (15%). The balloon remained in the nasopharynx under traction and did not slip past the choanal rim to encroach on the middle and inferior turbinates until the balloon volume was reduced to between 4 and 7 mL. The balloon slid out of the nose at a volume of 5 mL or less. The inflation volumes ranging from 8 to 12 mL were statistically more effective in sealing the choana than lower volumes (4-7 mL) ( P 2 test). Conclusions At different inflation volumes, the Foley catheter balloon acts primarily (1) as a platform for an anterior gauze pack (at 4-15 mL); (2) as an effective seal of the choana (at 8-15 mL usually and at 4-7 mL occasionally); and (3) as a compressor of the region behind the middle and inferior turbinates (at 4-7 mL), provided that the balloon under traction does not slip out of the nose.

The results of a retrospective study of 22 patients with inverted papillomas resected by the endoscopic approach are presented with a follow-up of 33 to 96 months. Twenty-one patients had unilateral disease and one patient had bilateral involvement. None of the patients had orbital or cranial extension. One patient had synchronous carcinoma in situ. Eight patients had undergone previous surgical procedures. Following endoscopic surgery, six patients had residual disease requiring further revisions. Three of these six patients eventually required excision via limited external approaches. No patient required lateral rhinotomy or mid-facial degloving procedures. No complication occurredin any of the patients. The advantages of endoscopic surgery include precise determination of tumour extent, preservation of normal mucosa and bony structures and avoidance of external scars. Close endoscopic follow-up is mandatory to ensure early recognition and treatment of recurrent disease. Although the endoscopic approach is gaining popularity for the treatment of inverted papilloma, indiscriminate application may result in a high recurrence rate. The endoscopic approach should be performed by experienced surgeons and restricted to carefully selected patients with nasal, ethmoidal and limited maxillary disease. More extensive disease should be managed by radical external approaches or by combining endoscopic with limited external approaches.

E sophageal perforation due to a traumatic intubation is exceedingly rare. If not noticed immediately or treated promptly, however, the morbidity and mortality is significant. Most cases present within 24 h after the event. A delay in symptoms that signal esophageal perforation after a traumatic endotracheal intubation has serious clinical implications. We report a case of traumatic esophageal perforation due to endotracheal intubation for elective sinus surgery under general anesthesia with a delay in onset of symptoms and signs. The diagnosis and management of this complication are discussed.