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Stapedectomy and stapedotomy are the techniques currently used in the surgical treatment of otosclerosis. During the period 1977-81, a total of 60 consecutive patients were subjected to surgery for otosclerosis according to the method of Schuknecht (Gelfoam and wire prosthesis). Another 55 consecutive otosclerotic patients were operated on during 1987-91with stapedotomy, according to the method advocated by Fisch (Fisch-type piston). Independent of the surgical technique used, the maximal hearing gain was obtained 1 year after surgery. In the frequency range 0.5-3 kHz, the mean value of the averaged pure tone thresholds improved from 52 to 28 dB in the stapedectomy group and from 57 to 26 dB in the stapedotomy group. In the frequency range 4-6 kHz, the subjects' hearing was not significantly improved in the stapedectomy group, whereas the subjects' hearing in the stapedotomy group improved from 61 to 44 dB. Per- and postoperative complications were low in both groups, except for one patient in the stapedectomy group who experienced the serious complication of a deaf ear after surgery.

A baby boy presented with a double tongue combined with a median cleft palate. He was otherwise normally developed. The double tongue was reconstructed to form one tongue 40 days after birth. At follow-up examination when he was 6 months old the tongue was well formed with normal function.

Fibronectin and 1% hyaluronan, two extracellular matrix components, were applied to tympanic membrane (TM) perforations, using the laboratory rat as an animal model. The perforations occupied the upper, posterior quadrant of the TM. Saline-treated and untreated perforations of equal size served as controls. Fifty percent of the perforations treated daily with hyaluronan healed prior to the first closures of the other groups. The use of fibronectin did not enhance the healing rate. The hyaluronan-treated perforations were covered initially by a sheet of keratin and hyaluronan containing abundant inflammatory cells. Within this keratin-hyaluronan cover, hyperplastic stratified keratinizing epithelium advanced and bridged the gap of the perforation ahead of the approaching connective tissue. These findings indicate that exogenously applied hyaluronan could be valuable in the clinical situation and should be tried to improve the healing of TM perforations.

A controlled randomized study was performed in 60 patients with 64 chronic, dry tympanic membrane (TM) perforations. The perforations were randomly allocated to either resection of the perforation rim and instillation of 1% hyaluronan (Healon; HYA) in the perforation gap once daily for 7 days (33 ears) or resection of the perforation margin and application of a sterile rice paper prosthesis (31 ears). The treatment effect was documented by TM photography and morphometric measurements of the perforation area. The hearing was assessed with puretone and high-frequency audiometry. After 2 months, 5 of the HYA-treated perforations (15%) and 4 of the rice-paper-treated TMs (13%) were healed. After 1 year, 18 perforations (9 in each treatment group) were healed. In neither group were there any persistent adverse effects on hearing. It is noteworthy that 28% (18/64) of the chronic, long-standing TM perforations could be repaired by these technically simple and time-saving methods. Both procedures should be considered as easy first-choice alternatives to myringoplasty in selected cases.

In 1996 a telemedicine link was established between two primary-care centres of Västerbotten county and the University Hospital. Specialties involved at the University Hospital were otoloaryngology, orthopaedics and dermatology. Videoconferencing used ISDN at 384 kbit/s. The primary-care centres were equipped with video-endoscopes. During the first 21 months, there were 32 otolaryngology consultations. The average time for each consultation was between 15 and 30 min. Patients, general practitioners and specialists were interviewed using questionnaires with answers on a six-point scale, in which a score of six was best. Patient satisfaction produced a mean score of 5.7. The specialist doctors rated the video-consultation satisfactory for diagnosis. Roughly 40% of the referrals could be avoided by telemedicine. The general practitioners rated the educational effect of the consultation very highly.

Already within 24 h, splitting of the soft palate in rats caused production of effusion in the attic space. During the next couple of days the effusion material filled the meso- and hypotympanon. The production of a serous fluid in the attic space appeared concomitant with an elevated histamine content in the middle ear cavity, irrespective of whether the ears were ventilated or not. In the artificially ventilated middle ears no effusion appeared in the meso- and hypotympanon and the hypotympanal mucosal lining remained normal. The serous effusion filling the middle ear cavities with the intact tympanic membranes was replaced at about 7 days by a purulent effusion material containing mainly Gram-negative enteric rods. Thus it seems that a serous otitis media and a purulent otitis media occur in a continuum. The change to a purulent infection could be prevented by artificial ventilation, but as soon as the myringotomies were healed or the tympanostomy tubes got clogged a flocculent, pus-like effusion also appeared in these middle ear cavities.

In an animal model (rat) a polyethylene tympanostomy tube was repeatedly inserted (four periods lasting 2 weeks) into the upper rear quadrant of the right tympanic membrane (TM). The intervals between the different tubulation periods (TPs) lasted 3 weeks. The corresponding quadrant of the left TM was subjected to repeated myringotomies (four times). The structural changes in the TMs were evaluated otomicroscopically and by histological techniques 3 weeks and 3 months after the final TP. Repeated tympanostomy tube insertion caused a dramatically thickened pars tensa. The thickened areas were characterized by a scar tissue exhibiting sclerotic plaques and a dense connective tissue with bone-like formations. Occasionally, islands of keratinizing stratified squamous epithelium were noted within the thickened pars tensa as well as interrupting the epithelial lining facing the tympanic cavity. Similar structural changes occurred after myringotomy without tube insertion, but they were not so pronounced as after repeated tympanostomy tube insertion. The changes were not restricted to the manipulated quadrants, but also affected the untouched anterior quadrants. Throughout the observation period the anterior quadrants improved, while the rear quadrants remained severely affected.

Dysphagia is a common disability after a stroke. This paper presents the diagnosing, training and surgical treatment of a patient with dysphagia of pharyngeal–oesophageal type after a brain stem infarction. Before the training started the patient had not been able to swallow for 18 months. He was nourished through a Witzel fistula. During his first stay in hospital training was concerned with the physical phase of swallowing. A myotomy of the cricopharyngeal muscle was performed during his second stay in hospital, and after this surgery the patient trained to eat normal food. The third and fourth times he stayed in hospital the psychological and social aspects of eating were focused upon. The patient became able to eat normal food together with others and the Witzel fistula was removed.

The rat eustachian tube (ET), from the nasopharyngeal orifice to the tympanal orifice, is about 4.5 mm long, of which the naso-medial membranous part (the nasopharyngeal orifice) measures about 1.5 mm and the occipito-lateral bony portion about 3 mm. The nasopharyngeal orifice is surrounded by two soft, lip-like, mucosal swellings--one ventral and one cranial--both easily mobile. The muscles related to the tubal opening mechanisms are the salpingopharyngeus, the tensor veli palatini and the levator veli palatini muscles. The salpingopharyngeus muscle originates partly from the cranial lip, whereas the palatal muscles originate partly from the ventral lip. The tympanal two thirds of the mucosal lining of the ET is cranially guided by a cartilage and incompletely framed by bony structures. The tympanal orifice is situated in the nasal part of the medial wall, well above the floor of the bulla. The tensor tympani muscle does not seem to take part in the opening and closing mechanisms of the ET. The mucosal lining of the ET consists of a respiratory epithelium with numerous glands in the lamina propria. It is suggested that the tubal muscles control the passage through the ET by moving the lip-like folds of the nasopharyngeal orifice. The anatomy of the rat ET is comparable to that described in Homo and it can be concluded that the rat ET might be a good model for studying the function of the human ET.

The effects of hyaluronan-coated polyethylene tympanostomy tubes on the tympanic membrane structure were investigated and compared with non-coated polyethylene tubes without the coating. The tubes were inserted into the tympanic membrane (TM) and removed 3 weeks later. After 3 weeks the tubes were reinserted. This tube insertion and removal and reinsertion sequence was repeated 4 times and the tympanic membrane structure was examined histologically at 3 weeks and 12 weeks later. The study did not reveal any differences regarding the thickness and light microscopical appearance when comparing the TMs with the hyaluronan-coated tubes to those with the non-coated polyethylene tubes. However, the present way of evaluating the effects of different tube materials may be too crude. In future experiments aimed at elucidating the effects of different surface coatings of tympanostomy tubes other experimental designs must be employed, e.g. fewer tube insertion sequences and less traumatizing extractions.

A recently developed animal model was used to study the effect of tympanostomy tubes (TTs) on the spontaneous development of purulent otitis media. In 35 rats with soft-palate clefts a TT was inserted into the right tympanic membrane. The left ear was left intact. Serous effusion occurred in the attic space within 2 days after surgery, whether or not the middle ear cavity (MEC) was artificially ventilated. Between days 7 and 21 the intact-ear MEC was gradually filled with effusion material that turned purulent. Effusion material did not develop in the mesotympanum and hypotympanum of the intubated ears. Microbiologic examination of the effusion material showed a microflora similar to that in the nasopharynx. Ventilation through a TT reduced the number of colonized MECs (4 vs. 10) on day 21. In the individual culture-positive MEC with a TT there were fewer colonies than in the corresponding ear without a TT. These results support the contention that a TT may prevent the development of purulent otitis media.

Summary In adult Sprague-Dawley rats a dysfunction or a total blockade of the Eustachian tube was established by various experimental procedures. The appearance of effusion material in the attic was subsequently considered to be evidence of incomplete ventilation of the middle ear cavity. Though the salpingopharyngeus muscle (SPM) seemed to be the muscle which could open the Eustachian tube maximally, splitting of the soft palate and consequent interference with the tensor veli palatini muscle (TVPM) and the levator veli palatini muscle (LVPM)—but obviously not with the salpingopharyngeus muscle (SPM)—caused the effusion material to be produced in the middle ear cavity. Neither blockade by about 80% of the tympanal orifice nor severing of the tendon of the tensor tympani muscle (TTM) close to the malleus produced any signs of effusion material whatsoever. Our findings strongly suggest that the most important part of the Eustachian tube, as regards ventilation, is the nasopharyngeal portion, as a normally functioning TVPM and LVPM seems to be an absolute prerequisite to prevent effusion material from developing in the attic.

A case report concerning a meningioma located in the subfrontal region and nasal cavities is presented, with clinical, radiological and pathological findings. The literature concerning meningiomas in this location is reviewed. Some possibilities of differential diagnoses are discussed. Indications of a primary origin in the nasal cavities are given.

Cleavage of the soft palate will cause purulent otitis media bilaterally in 100% of experimental animals (the rat) within 2 weeks. In this model a tympanostomy tube was inserted unilaterally. At 2, 7, and 21 days after the surgery the middle ear status was mapped in the otomicroscope and microbiological samples collected from the middle ear cavities and the nasopharynx. All intact ears became infected and developed purulent otitis media. Most of the tubulated ears exhibited normal middle ear cavities and remained culture negative. The few ventilated ears which were infected, however, showed a lower bacterial count than the corresponding intact ear. Thus in this model the insertion of a tympanostomy tube prevents the purulent otitis media from occurring.

In order to examine whether a myringotomy made with a CO2-laser might be an alternative of a ventilation tube, a perforation was made in the upper rear quadrant bilaterally, of 22 rats. The laser-made perforations showed a delayed healing pattern, about twice the closing time of a similar-sized perforation made with a myringotomy lancet. Serous effusion was constantly observed in the attic space during the first 9 days but only in one ear was there actual discharge through the perforation. The size of the perforation started to diminish when the hyperplastic keratinizing squamous epithelium reached the perforation border.

Topical application of hyaluronic acid (Healon®) onto the borders of rat tympanic membrane perforations accelerated the rate of wound healing. The closure time was roughly 60% of that of the untreated perforations. Epithelial cells fused with opposing cells slightly in advance of supporting connective tissue and thus bridged the remaining gap. It seems as if hyaluronic acid, topically applied, can serve as a supporting and orienting matrix for the proliferating squamous epithelium.