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Repetitive transcranial magnetic stimulation (rTMS) has shown potential in reducing tinnitus symptoms. We evaluated effects of electric field (E-field) navigated rTMS targeted neuroanatomically according to tinnitus pitch.In this open methodological pilot study, the patients received E-field navigated 1-Hz rTMS in daily treatment sessions to the left superior temporal gyrus, targeted according to tonotopic representation of their individual tinnitus pitch. Patients rated their tinnitus intensity and annoyance with a numeric rating scale (NRS) from 0 to 10 at the baseline and after each rTMS session. They also rated their global impression of change (scale - 3 to + 3) after the treatment.Thirteen patients (mean age 53 years; 10 men, 3 women) with chronic, intractable tinnitus.The mean intensity was 7.1 (SD 1.8) at the baseline, decreasing to 4.5 (SD 2.2) after the rTMS (p0.0001). The mean annoyance 7.0 (SD 1.8) at the baseline decreased to 4.0 (SD 2.4) after the treatment (p0.0001). Intensity diminished at least 30% in 8/13 patients and annoyance in 9/13 patients. A total of 10/13 patients felt subjective benefit from the treatment.These preliminary observations suggest that E-field-rTMS may improve the current treatment options for intractable tinnitus.

Severe obstructive sleep apnea (OSAS) is most often accompanied by metabolic syndrome, obesity, diabetes and coronary disease. In its most severe form, it is a life-threatening condition, requiring active and immediate help. Nasal continuous positive airway pressure (CPAP) is the most efficient nonsurgical treatment for patients with OSAS. However, for anatomical, disease-related and subjective reasons, many patients cannot accept this treatment. A permanent tracheostomy may be one alternative in such patients who, in addition, often suffer from extreme obesity and severe heart disease. In this paper, we describe the long-term follow-up results of 7 patients suffering from OSAS and treated with permanent tracheostomy. All the patients (5 men, 2 women) were diagnosed using the static charge sensitive bed method and night-time oximetry for sleep analysis. The mean body mass index (BMI) of the patients ranged from 34 to 60 and the age from 41 to 64 years. All the patients had severe OSAS and long periods of low oxygen saturation (SaO2) levels. Six patients had a CPAP trial before tracheostomy. Only 2 patients tolerated the trial but, despite the continuous use of CPAP, they were nonresponders. Permanent tracheostomy was done according to normal routine in each patient. After primary healing of 2 days, they used silver cannulae, which also allowed them to speak. The patients were evaluated every year after the tracheostomy. After some practical difficulties including proper maintenance of the cannula, all the patients quickly learned the correct management. In postoperative sleep studies, nadir SaO2 levels had improved significantly, obstructive apneas had disappeared and the subjective quality of life had improved. No marked changes in BMI were found.

Forty-one patients with unilateral acoustic neuroma (AN) were diagnosed by magnetic resonance imaging (MRI) between 1992 and 1997. All cases were analyzed with respect to tumor location and the results of audiometric examinations, auditory brainstem response (ABR) testing, and electronystagmography (ENG). Tumor location was determined by MRI and cases were divided into intracanalicular and extracanalicular sites. Intracanalicular tumors were significantly smaller than the extracanalicular ones The pure-tone hearing thresholds were better in ears with intracanalicular lesions than in those with extracanalicular ones. Respectively, speech reception thresholds were 33 dB and 45 dB, and speech discrimination scores 79% and 65%. ABR was abnormal in 98% of ANs, but was insufficient for determining tumor location. The ENG pursuit test was more frequently normal and the caloric side difference was smaller in ears with intracanalicular than extracanalicular AN. These findings show that the results of pure-tone and speech audiometry and ENG are better in ears with intracanalicular AN, while ABR results are similar regardless of tumor location.

A total of 663 unselected 7-, 10- and 14-year-old school children were examined for both ultrasound and X-ray maxillary sinus findings. Ultrasound and X-ray findings were normal in 84.5% and 83.9% of the children, respectively. In a comparison of the findings, the sensitivity of ultrasound examination compared to abnormal maxillary sinus X-ray findings was low. However, a negative ultrasound finding was a sound basis for excluding the disease. According to the results of the present study, it is perhaps justified to say that a negative ultrasound finding excludes the occurrence of radiographic sinusitis, whereas a positive ultrasound finding has little or minor significance.

Objective: To measure the hearing threshold levels by air conduction in a group of unselected and a group of selected (otologically normal) school-aged children. Design: Six hundred eighty-seven unselected school children representing three age groups and 471 selected, otologically normal children were examined by pure-tone audiometry. Results: The obtained results showed that hearing levels improved with age from 7 to 10 yr in children in both groups. The pure-tone averages (PTAs) of the right and the left ear in otologically normal children were, respectively, 1.8 and 1.2 dB HL in 7-yr-old children, -0.9 and -1.7 dB HL in 10-yr-old children, and -1.3 and -2.0 dB HL in 14-yr-old children. The PTAs were 0.2 to 1.9 dB poorer in the groups of unselected children. Conclusions: The present study provides new data on the hearing sensitivity among unselected 7-, 10-, and 14-yr-old school children. Furthermore, it provides normative values on the hearing thresholds of otologically normal children in these three age groups.

Objective : The purpose of the present study was to obtain the median values and distributions of tympanometric variables and the distributions of acoustic reflex thresholds for three age groups of unselected school-aged children. Furthermore, the investigation was undertaken to provide normative immittance data for selected, otologically normal 7-, 10-, and 14-yr-old children. Design : A total of 687 children, aged 6 to 15 yr, were thoroughly examined clinically, audiometrically, and tympanometrically. The same examinations were made in 471 otologically normal children, selected from the total population on the basis of the findings that both tympanic membranes were otomicroscopically healthy, and the hearing thresholds were better than or equal to 25 dB HL at all frequencies. Results : The results showed that the median equivalent ear canal volume (V ec ) increased from 0.65 ml to 1.00 ml with increasing age both in the unselected and selected populations. The median peak admittance values (Y tm ) were between 0.55 and 0.5 mmho in the respective study groups, somewhat higher in older than in younger children. The same tendency was also seen in gradient and tympanometric peak pressure (TPP) results. Depending on the age, the median tympanometric peak pressures were 5 to 10 daPa higher in otologically normal children than in the unselected population. The median TPP was -10 daPa in a group of unselected children, and -5 daPa in a group of otologically normal children. The distribution of ipsi- and contralateral acoustic reflex thresholds is presented. Thresholds were higher in younger than in older children. Conclusions : The obtained results give new information on immittance findings in an unselected sample of school-aged children who were representative of children in the general population. Furthermore, the results are useful as normative immittance values in 7-, 10-, and 14-yr-old children when the limitations relating to the equipment are taken into account.

A comprehensive otolaryngologic examination, including otomicroscopy, was performed for 687 school children for morphologically to study the distribution of normal and abnormal tympanic membrane findings and the association of different factors with the abnormal TM finding in 6 to 15-year-old children. Two-thirds of the children had completely healthy tympanic membranes without any visible pathological change. The findings were more often normal the older the child. In the total population, individual tympanic membrane findings were normal as follows: color 90.7%, position 93.8%, mobility 93.7%, structure 91.8% and position of pars flaccida 88.5%. Contrary to normal findings, tympanic membrane abnormalities were not in general associated with each other. The study provides new information on the occurrence of tympanic membrane changes among school-aged children.

A total of 687 school children, aged six to 15 years, were examined clinically, radiologically and audiometrically. Lateral radiological examination of paranasal sinuses was carried out in 663 (96.5 per cent) children for evaluation of the size of adenoids. The size of the soft tissue shadow (adenoids) was assessed as normal or large. It was large in 133 (25 per cent) children, three times more frequently in seven-year-old than in 14-year-old children. The occurrence of adenoidal symptoms (blocked nose, mouth breathing, snoring, snuffling or rhinitis) varied from 14.3 to 30.1 per cent in children with large adenoids compared to 7 to 9.8 per cent in children with normal adenoids. Logistic regression analysis revealed that only recurrent snoring and the child's age were significantly associated with radiologically large adenoids. The hearing thresholds were 1.1 to 4.2 dB poorer and mean middle ear pressure values were 60 to 70 mmH2O lower in children with large adenoids compared to those with normal size adenoids. Large adenoids have an influence on the hearing level of a child, but probably via the negative middle ear pressure.

The association of a conspicuous nasal septal deviation with otomicroscopic, audiometric, and impedance findings was studied in 687 school children, aged 6–15 years. Changes in color and structure of pars tensa and the retraction of pars flaccida were indirectly associated with clinically significant septal deviation as a result of an increased incidence of upper respiratory tract infections, but no association was found between hearing loss and pathological impedance findings and clinically significant septal deviation.

A total of 687 school children between the ages of 6 and 15 years were examined for nasal septal deformities as part of a comprehensive epidemiological ENT study. Stepwise logistic regression analysis showed that the occurrence of clinically significant septum deviation was associated with age, sex, and dental malocclusion. The authors could not demonstrate any unambiguous correlation between respiratory symptoms or infections and nasal septal deformities, although there was a tendency for an increased frequency of infections in children with clinically significant septum deformity.

The purpose of the investigation was to study the symptoms that may provide clues to the early diagnosis of vestibular schwannoma (VS). The symptoms associated with VS in 41 patients were compared with the tumour locations detected by magnetic resonance imaging (MRI). There were 9 (22%) mainly intracanalicular and 32 (78%) mainly extracanalicular tumours. MRI visualized the enhancement of the intracanalicular nerve in 27 of 32 extracanalicular schwannomas. Hearing impairment was found as an initial symptom equally frequently in patients with intra- or extracanalicular VS. Tinnitus was reported as the first symptom more often in patients with extracanalicular VS and dizziness more often in patients with intracanalicular tumours. At the time of diagnosis, unilateral hearing loss was present in 98% of patients, independent of tumour location. Likewise, dizziness was found equally frequently in both patient groups. Instead, tinnitus was found almost significantly more frequently in patients with intracanalicular VS (p = 0.07). Although statistically insignificantly so, neurological symptoms were more common in patients with extracanalicular VS (p = 0.45).

Dysphagia is a common symptom in various neurological disorders affecting pharyngeal functions. Cricopharyngeal dysfunction is one of the major findings in these patients. The most effective treatment for restoring normal swallowing function in persistent cricopharyngeal dysfunction is cricopharyngeal myotomy, especially when mechanical obstruction or a well-localized neuromuscular dysfunction, such as a cricopharyngeal muscle spasm, is present. However, when there is a more diffuse neurological disorder present the results of surgery are more disappointing. In unclear cases, or in patients with temporary problems, no good method other than swallowing training, bougienage, and tube feeding are available. During the past decade, botulinum toxin has been found to be of therapeutic value in the treatment of a variety of neurological disorders associated with inappropriate muscular contractions such as torticollis and spasmodic dysphonia. Recently, injections of botulinum toxin in patients with cricopharyngeal muscle dysfunction have been reported to result in marked relief of dysphagia. In this article we describe our experiences with botulinum toxin injections to treat four patients suffering from deglutition problems and cricopharyngeal dysphagia of different origins. Botulinum toxin was injected into the cricopharyngeus muscle that was identified by endoscopy under general anesthesia. In this study, no major side effects were observed. Three patients obtained a significant improvement of esophageal symptoms after the first injection. The treatment had limited effect in one patient who had reflux disease and only slight cricopharyngeus dysfunction.

Two hundred and ninety maxillary sinuses in 206 patients, suspected of having acute or prolonged maxillary sinusitis, were examined using ultrasound (US) and then irrigated with isotonic saline. The results of the antral lavage and the US were compared and various US recording variables were analyzed. The sensitivity of US examination to find maxillary sinus secretion was 77% and the specificity 49%. The distance from the initial echo to the back wall echo (BWE) and the ratio of the echo-free area to the distance from the initial echo to the BWE were sensitive indicators of the presence of maxillary sinus secretion. The results suggest that US is a relatively sensitive method also in the diagnosis of prolonged maxillary sinus inflammations. However, its low specificity weakens its value in clinical work. The usability of US in the diagnosis of maxillary sinusitis can be increased by intermittently controlling US findings by sinus puncture. This is of particular importance for general practitioners, but also for specialists.

In the beginning, external otitis is an inflammation of the skin of the external ear canal. Partial or total obliteration of the meatus causes cleaning problems, which worsen the obliteration, and hence, the infection. Immunosuppressive medication or illness, certain dermatological problems or frequent infections may lead to irreversible changes and to the malignant form of external otitis with life-threatening sequelae. Conservative treatments in the beginning are aimed at regaining the normal skin functions by helping the cleaning process and curing the acute infection with repeated irrigation, proper antibacterial medication and corticosteroids and anti-inflammatory analgesics. In rare prolonged cases, surgical procedures are needed to help the cleaning process by removing the irreversibly thickened skin and bone affections, and using grafts. On the basis of our experience, even the removal of the diseased skin and enlarging of the external ear canal are insufficient procedures in the most difficult cases. In the present paper, we describe a new surgical method that we have performed to treat chronic bilateral obliterative external otitis in 2 patients, with favorable results.

The use of electrocochleography (EcoG) is considered to be of clinical value in otological diagnosis. Non-invasive ear canal (EC) and tympanic membrane (TM) EcoG recording techniques, and invasive transtympanic (TT) technique are the methods used for objective assessment of cochlear function. In this study, eight adults (16 ears) with suspected Meniere's disease were examined using a newly designed, disposable tympanic electrode and a traditional, thin transtympanic needle. The amplitudes of the TT electrode responses were 4-6-fold larger than those produced by the TM electrode. The morphology of the waveforms for the two recording techniques was nearly identical. The mean amplitudes of the action potential (AP) obtained with the TM electrode were 2.39-3.73 microV, and with the TT electrode 14.08-19.60 microV, depending on the stimulus intensity. For the summating potential (SP), the TM and TT electrodes had mean amplitudes of 0.82-1.60 microV and 3.53-5.81 microV respectively. The SP/AP ratios were larger with the TM electrode than with the TT electrode. They were inconsistent in four ears (25%) when measured with the TM and TT electrodes. All patients were more satisfied with the TT examination, since it was quite painless, unlike the TM examination. The authors recommend the use of the TT recording technique as a painless examination in which the electrode is close to the inner ear, allowing a good signal-to-noise ratio and large amplitudes. Diagnostic interpretations are easier and more reliable with the TT electrode than with the TM electrode.

In 1995-96 we selected a group of 26 patients who were suffering from severe invalidating idiopathic tinnitus (IT) in order to evaluate the efficacy of rehabilitation and some alternative therapies. All patients were assessed thoroughly by means of audiology and radiology regarding any objective cause for the symptom. In order to help patients control their symptom by increasing knowledge and adding supportive elements, they were given basic education (presentations of the anatomy and physiology of the ear and hearing system, psychological and social aspects of IT, guided and non-guided group discussions, relaxation therapy, physiotherapy, music therapy) for 4 months, comprising one 2-h session bi-weekly. This type of group therapy was found to be extremely helpful, although no objective evaluation revealed effects on IT sensation (VAS) or psychometric measures (SLC-90). In a second limb of the study, the same patients attended a 6-day intensive course in a spa. The purpose was to evaluate the possible usefulness of the widely recommended alternative therapies for IT. All patients had an opportunity to sample the treatments. Six months later only a few had tried any of these treatments, but all reported that the lessons were the most helpful in association with supportive group discussions. The results indicated that none of these therapies can be recommended, based on rational medical practise.

Hemangiopericytoma (HP) is an uncommon, slowly growing tumor that originates in "pericyte" cells. Biologically it can be benign or malignant; however, it is difficult to predict tumor behavior based on histomorphology alone. The cytomorphology of this tumor has been described only rarely. Other spindle cell mesenchymal tumors can mimic HP on fine needle aspiration biopsy (FNAB).A 60-year-old man presented with cough and a left lung mass on chest roentgenography and multiple smaller bilateral lung nodules on computed tomographic scan. FNAB of the dominant left lung mass showed a moderately cellular aspirate with clusters and single spindle-shaped cells morphologically similar to those of hemangiopericytoma excised from the posterior part of the neck 11 years previously. With immunocytochemical studies, the tumor cells were negative for cytokeratin, factor VIII-related antigen, S-100 protein and HHF35 but positive for vimentin and CD34.FNAB is a valuable tool in evaluating nonepithelial metastatic lung tumors. In the appropriate clinical setting, it is possible to render a diagnosis of HP on FNAB in patients with previously documented HP based on morphologic comparison and ancillary studies, especially immunocytochemical stains.

A total of 663 unselected 7-, 10- and 14-year-old school children were examined for both ultrasound and X-ray maxillary sinus findings. Ultrasound and X-ray findings were normal in 84.5% and 83.9% of the children, respectively. In a comparison of the findings, the sensitivity of ultrasound examination compared to abnormal maxillary sinus X-ray findings was low. However, a negative ultrasound finding was a sound basis for excluding the disease. According to the results of the present study, it is perhaps justified to say that a negative ultrasound finding excludes the occurrence of radiographic sinusitis, whereas a positive ultrasound finding has little or minor significance.

We examined the electrocochleography (ECochG) parameters in patients suffering from Meniere's disease (n = 5) or other type of vertiginous disorder (n = 4). Fourteen ears were examined by introducing a needle electrode through the tympanic membrane to the promontorium. The summating potential (SP), action potential (AP) and the SP/AP ratio were measured from the alternating polarity click response, and the latency difference from the condensation and rarefaction click responses. These 2 patient groups differed from each other most clearly as to the audiometry results and the duration of symptoms. We also found differences in electrocochleographic results, especially in latency differences between the condensation and rarefaction click responses. Although the present material is small we conclude that transtympanic electrocochleography is a sensitive method to measure cochlear potentials, and might be a valuable addition in diagnosing patients suffering from various cochleovestibular disorders.

Pure-tone audiometric and impedance examinations were performed in 687 Finnish school children in the first, fourth and eighth grades (ages, 7, 10 and 14 years old) to study the sensitivity and usability of hearing and tympanometric screening examinations in schools. There were 138 children (20.1%) with a hearing loss > 15 dB in at least one frequency. Among these children, 103 were found to have pure sensorineural losses while 35 children had conductive losses. Of all the sensorineural losses, 118 of the cases involved slight high-frequency changes. Six children had hearing losses at speech range and all had been previously diagnosed. Six other children had 20-30 dB losses at 3-6 kHz, with 5 of these children diagnosed for the first time. Twenty-four of the children with conductive losses had middle ear effusions that were found at a 15 dB screening level for hearing. When the limit of normal tympanometric peak pressure was-150 daPa, 36 of 38 ears with middle ear effusions were found tympanometrically. Judging by the findings of the present study, we recommend that routine pure-tone audiometric screening for 7- and 10-year-old children in schools could be discontinued but should be continued for 14-year-old children. In contrast, tympanometry with a tympanometric peak pressure limit at-150 daPa should be used as a screening procedure for 7-year-old children on school entry.

The Rinne and the Weber tests were carried out using a 256-Hz tuning fork on 687 6- to 15-year-old school children, the majority of whom were normally hearing subjects. The Rinne test was positive in 97% of ears with normal hearing or sensorineural hearing loss and negative in 72% of ears with conductive hearing loss. The Rinne test changed from positive to negative at 13 dB when performed using the normal loudness comparison method. In midline Weber results, the mean value of the air conduction difference at 0.25 kHz between the right and left ear was 1.4 dB. The lateralization in the Weber test occurred at a difference of 2.5 dB between the right and left ear. The Weber test was in midline in 96-98% of ears with bilateral normal hearing or sensorineural hearing loss. It lateralized to the poorer ear in 63% of ears with unilateral conductive hearing loss. The values of the Rinne and Weber tests were not good in the diagnosis of mild conductive hearing loss when the air-bone gap was 5-35 dB.

A total of 687 school children, aged 6-15 years, were examined for nasal septal deviations with anterior rhinoscopy and maxillary sinus radiography. Septum deviations were divided into four different categories and the final evaluation included the clinically significant deviation, based on purely morphological findings. Columella deviation was an exceptional condition in 0.7% of children, septum spurs were found in 3.8%, bending of the quadrilateral cartilage was present in 13.4%, and premaxillary luxation in 28.7%. A clinical diagnosis of septum deviation was made in 9.5% of children. The occipitomental projection of the maxillary sinus X-ray was a good diagnostic tool in evaluating the clinical significance of septum deviation.

Six-hundred-and-eighty-seven 6 to 15-year-old children were examined for the association between tympanic membrane (TM) changes and audiometric or immittance findings. The hearing thresholds were between 20 and 30 dB in ears with amber TM, but between 25 and 45 dB in ears with adhesive TM, When the TM was retracted or the mobility decreased, the hearing thresholds were about 10 dB poorer than in ears with normal TM position or mobility. Thick TM caused hearing loss in the high-frequency areas. The hearing loss was only marginal (3–4 dB) in ears with retracted pars flaccida compared with ears with normal position of pars flaccida. The mean and median middle ear pressure value was lower than -200 da Pa in ears with dull, amber, retracted, poorly movable, adhesive or thick TM. It was between -100 and -200 da Pa in ears with red TM, locally retracted pars tensa or retracted pars flaccida. Stapedius reflex thresholds were higher in ears with one or several abnormal findings than in normal ears.

In the present study, pure-tone audiometry was used in 687 Finnish school children, aged 6–15 years, to determine the prevalence of a 6 kHz acoustic dip and related factors among three age groups. Trained audiometricians tested air conduction thresholds in a sound-proof room. A total of 57 children (8.3%) had a clear-cut dip of at least 20 dB at 6 kHz. This dip was more pronounced in older children and in boys. A thorough case history was obtained by questionnaire, with logistic regression analysis showing that low birth weight (< 2500 g) and childhood measles were the only factors associated with occurrence of the 6 kHz dip in school-aged children.

Otitis media with effusion (OME) is one of the most important and, with respect to treatment, one of the most problematic of the common diseases of childhood. A variety of medical regimens and surgical procedures have been tried in the management of middle ear effusion. Conservative treatment has included long-term chemotherapy antihistamines, and decongestants, but definitive evidence that the clinical course of the disease is significantly shortened by any of these therapies has yet to be presented. Corticosteroid treatment has also been used both in allergic and nonallergic children. Evaluating the results of ampicillin and prednisone therapy in 160 children with OME, PERSICO et al. (1978) concluded that the steroid had a beneficial effect on Eustachian tube function. SCHWARTZ et al. (1980a) found that middle ear effusion cleared in 62S% of children with secretory otitis media as a result of treatment with 1 mg of prednisone per day. Following treatment with intranasal beclomethasone the middle ear effusion resolved in only 48% of children (SCHWARTZ et al., 1980b). A placebo-controlled trial by LINDHOLDT and KORTHOLM (1982) also failed to show a significant difference in favour of intranasal beclomethasone therapy. To obtain information on the role of prednisolone in the management of OME, we performed a clinical study in children with secretory middle ear effusion. The study was designed as a double-blind trial to compare the effects of prednisolone, sulfatrimethoprim and placebo. The outcome of therapy was assessed in a clinical follow-up of 2 months.

A total of 97 children with acute otitis media were entered into a single-blind, parallel-group study to compare the efficacy and tolerance of suspensions of bacampicillin, given twice daily, with amoxycillin, given three times daily. The daily dosage was about 40 mg/kg body weight in each case and the duration of treatment was 10 days. Patients were examined before the start of treatment, at an early follow-up visit within 2–3 weeks after the start of treatment and at a late follow-up visit 4–6 weeks after the start of treatment. The initial bacteriology revealed a relatively high proportion of Branhamella catarrhalis and a low incidence of pneumococci. In total, 92 patients were evaluated for efficacy at early follow-up, where both bacampicillin and amoxycillin showed equal and good treatment results in approximately 90% of cases. Evaluation at the last valid visit showed that 80–90% of the patients were either cured or improved. The failure frequency tended to be somewhat higher with amoxycillin.

From January 1967 to August 1978, 65 patients with cervical abscesses were referred to the ENT Clinic of Turku University Hospital. The origin of these deep neck infections was odontogenic in 19, tonsillitis or tonsillectomy in 14, trauma in seven, salivary glands in five and branchiogenic cysts in five and other known causes in three cases. In 12 cases the origin was unknown. The cervical abscesses of odontogenic origin were located mostly in the submandibular space (11/19). The rest of the deep cervical infections were mostly found in the parapharyngeal space (25/46). Etiological factors and treatment of these severe infections are discussed.