Ear lobule deformities can occur as a result of trauma. Surgical reconstruction can be challengin... more Ear lobule deformities can occur as a result of trauma. Surgical reconstruction can be challenging. There does not appear to be a consensus on the best form of repair. We report the case of a 27-year-old woman who suffered traumatic loss of the ear lobule during childhood. A novel technique is described using a posterior based bi-lobar flap to completely reconstruct the ear lobule in two stages. This form of repair has the advantage of a well-hidden scar, with the donor site providing skin of similar thickness and pigmentation.
Cholesteatoma is a non-neoplastic, keratinising lesion which has two forms: congenital and acquir... more Cholesteatoma is a non-neoplastic, keratinising lesion which has two forms: congenital and acquired. Congenital cholesteatoma develops behind a normal, intact tympanic membrane, whilst acquired cholesteatoma is associated with a defect in the tympanic membrane. The pathological substrate of cholesteatoma is keratinising stratified squamous epithelium, but the origin of this epidermal tissue in the middle ear is controversial. Here, we review the most relevant and recent evidence for the principal aetiopathogenic theories of both forms of cholesteatoma, in the light of recent otopathological findings. Congenital cholesteatoma is most plausibly explained by the persistence of fetal epidermoid formation. Conclusive 'proof' awaits the unambiguous demonstration of the metamorphosis of an epidermoid nidus into a lesion in vivo. Acquired cholesteatoma may develop by various mechanisms: immigration, basal hyperplasia, retraction pocket and/or trauma (iatrogenic or non-iatrogenic). However, squamous metaplasia of the normal cuboidal epithelium of the middle ear is a highly unlikely explanation. Chronic inflammation seems to play a fundamental role in multiple aetiopathogenic mechanisms of acquired cholesteatoma. Therefore early treatment of inflammatory conditions might reduce their sequelae, perhaps by preventing the development of hyperplastic papillary protrusions. Continued otopathological, cellular and molecular research would enhance our limited understanding of cholesteatoma and may lead to new therapeutic strategies for this erosive disease, which often defies surgical treatment.
Following laryngectomy, a distinct population of patients fails to achieve successful tracheoesop... more Following laryngectomy, a distinct population of patients fails to achieve successful tracheoesophageal voice. These patients' voices range from strained and effortful to none at all. Such patients may present with severe hypertonicity or spasm of the pharyngoesophageal segment. Botulinum toxin has been used to chemically denervate the pharyngeal musculature, and is an alternative to invasive surgical procedures. The aim of this article is to review the evidence for using botulinum toxin to achieve an improvement in post-laryngectomy voice. A Medline literature review (1966 to January 2009) and a search of the Cochrane database were performed. Foreign language articles and those not pertaining to post-laryngectomy voice restoration were excluded. Nine articles reporting a total of 134 patients were identified. Although there were differences in the outcome measures used, objective improvement in voice production occurred in between 70 and 100 per cent of cases. Botulinum toxin can be used as a safe and cost-effective treatment in patients with confirmed pharyngoesophageal segment hypertonicity and/or spasm following laryngectomy, to obtain an improvement in voice quality.
Simulators are becoming an increasingly important part of surgical training. Temporal bone surger... more Simulators are becoming an increasingly important part of surgical training. Temporal bone surgery is one area in which simulators, such as the Voxel-Man TempoSurg simulator, are likely to play a significant role in training. We present learning curve data from novice trainees using this simulator to learn cortical mastoidectomy, exposure of the sigmoid sinus, and exposure of the short process of the incus. We measured the time taken to perform the procedures, the volume of reference bone removed, and the structures damaged during dissection. We found improvement in a number of parameters over the course of the study. The overall scores, structural damage scores and time taken improved, to differing degrees, for each task. The volume of reference bone removed remained constant. These results indicate that the trainees' efficiency improved as they became more proficient at removing a given volume of reference bone.
The use of keels in the treatment of anterior glottic stenosis is well established. A variety of ... more The use of keels in the treatment of anterior glottic stenosis is well established. A variety of methods for keel fixation have previously been documented. We describe a simple technique of securing a Silastic keel, placed endoscopically, with a simple percutaneous suture, after laser vaporization of an anterior commissure web.
The regeneration capacity of spinal cord axons is severely limited. Recently, much attention has ... more The regeneration capacity of spinal cord axons is severely limited. Recently, much attention has focused on promoting regeneration of descending spinal cord pathways, but little is known about the regenerative capacity of ascending axons. Here we have assessed the ability of neurotrophic factors to promote regeneration of sensory neurons whose central axons ascend in the dorsal columns. The dorsal columns of adult rats were crushed and either brain-derived neurotrophic factor (BDNF), glial cell line-derived neurotrophic factor (GDNF), neurotrophin-3 (NT-3) or a vehicle solution was delivered continuously to the lesion site for 4 weeks. Transganglionic labelling with cholera toxin b subunit (CTB) was used to selectively label large myelinated Ab ®bres. In lesioned rats treated with vehicle, CTB-labelled ®bres were observed ascending in the gracile fasciculus, but these stopped abruptly at the lesion site, with no evidence of sprouting or growth into lesioned tissue. No CTB-labelled terminals were observed in the gracile nucleus, indicating that the lesion successfully severed all ascending dorsal column axons. Treatment with BDNF did not promote axonal regeneration. In GDNF-treated rats ®bres grew around cavities in caudal degenerated tissue but did not approach the lesion epicentre. NT-3, in contrast, had a striking effect on promoting growth of lesioned dorsal column axons with an abundance of ®bre sprouting apparent at the lesion site, and many ®bres extending into and beyond the lesion epicentre. Quanti®cation of ®bre growth con®rmed that only in NT-3-treated rats did ®bres grow into the crush site and beyond. No evidence of terminal staining in the gracile nucleus was apparent following any treatment. Thus, although NT-3 promotes extensive growth of lesioned axons, other factors may be required for complete regeneration of these long ascending projections back to the dorsal column nuclei. The intrathecal delivery of NT-3 or other neurotrophic molecules has obvious advantages in clinical applications, as we show for the ®rst time that dorsal column axonal regeneration can be achieved without the use of graft implantation or nerve lesions.
To evaluate the diagnostic performance of half-Fourier-acquisition single-shot turbo-spin-echo (H... more To evaluate the diagnostic performance of half-Fourier-acquisition single-shot turbo-spin-echo (HASTE) diffusion-weighted magnetic resonance imaging in the detection, localisation and prediction of extent of cholesteatoma following canal wall up mastoid surgery. Prospective blinded observational study. University affiliated teaching hospital. Forty-eight patients undergoing second-look surgery after previous canal wall up mastoid surgery for primary acquired cholesteatoma. All patients underwent non-echo planar HASTE diffusion-weighted imaging prior to being offered 'second-look' surgery. Radiological findings were correlated with second-look intra-operative findings in 38 cases with regard to presence, location and maximum dimensions of cholesteatoma. Half-Fourier-acquisition single-shot turbo-spin-echo diffusion-weighted imaging accurately predicted the presence of cholesteatoma in 23 of 28 cases, and it correctly excluded in nine of 10 cases. Five false negatives were caused by keratin pearls of <2 mm and in one case 5 mm. Overall sensitivity and specificity for detection of cholesteatoma were 82% (95% confidence interval [CI] 62-94%) and 90% (CI 55-100%), respectively. Positive predictive value and negative predictive value were 96% (CI 79-100%) and 64% (CI 35-87%), respectively. Overall accuracy for detection of cholesteatoma was 84% (CI 69-94%). Half-Fourier-acquisition single-shot turbo-spin-echo diffusion-weighted imaging has good performance in localising cholesteatoma to a number of anatomical sub-sites within the middle ear and mastoid (sensitivity ranging from 75% to 88% and specificity ranging from 94% to 100%). There was no statistically significant difference in the size of cholesteatoma detected radiologically and that found during surgery (paired t-test, P = 0.16). However, analysis of size agreement suggests possible radiological underestimation of size when using HASTE diffusion-weighted imaging (mean difference -0.6 mm, CI -5.3 to 4.6 mm). Half-Fourier-acquisition single-shot turbo-spin-echo diffusion-weighted imaging performs reasonably well in predicting the presence and location of postoperative cholesteatoma but may miss small foci of disease and may underestimate the true size of cholesteatoma.
All cases that exhibited an uptake of 18 FDG received a histological diagnosis of surgical specim... more All cases that exhibited an uptake of 18 FDG received a histological diagnosis of surgical specimens with a confirmed recurrence of IP, whereas the case that did not show 18 FDG uptake received a histological diagnosis of absence of recurrence of IP.
Cholesteatoma is often treated surgically using canal wall-preserving techniques. Clinical and ot... more Cholesteatoma is often treated surgically using canal wall-preserving techniques. Clinical and otoscopic diagnosis of residual or recurrent disease after this form of surgery is unreliable and thus radiological imaging is often used prior to mandatory "second-look" surgery. Imaging needs to be able to differentiate residual or recurrent disease from granulation tissue, inflammatory tissue or fluid within the middle ear cavity and mastoid cavity. Highresolution computed tomography (HRCT), conventional magnetic resonance imaging (MRI), and delayed contrast MRI have all been used in detecting postoperative cholesteatoma. Although delayed contrast MRI performs better than HRCT and conventional MRI, the sensitivities and specificities of these different imaging methods are relatively poor. Diffusion-weighted MRI (DWI and, in particular, non-echo planar DWI) has been shown to have a high sensitivity and specificity for detecting recurrent cholesteatoma. In this review we provide examples of postoperative imaging appearances following cholesteatoma surgery and we review the relevant literature with an emphasis on studies evaluating the diagnostic accuracy of DWI.
Ear lobule deformities can occur as a result of trauma. Surgical reconstruction can be challengin... more Ear lobule deformities can occur as a result of trauma. Surgical reconstruction can be challenging. There does not appear to be a consensus on the best form of repair. We report the case of a 27-year-old woman who suffered traumatic loss of the ear lobule during childhood. A novel technique is described using a posterior based bi-lobar flap to completely reconstruct the ear lobule in two stages. This form of repair has the advantage of a well-hidden scar, with the donor site providing skin of similar thickness and pigmentation.
Cholesteatoma is a non-neoplastic, keratinising lesion which has two forms: congenital and acquir... more Cholesteatoma is a non-neoplastic, keratinising lesion which has two forms: congenital and acquired. Congenital cholesteatoma develops behind a normal, intact tympanic membrane, whilst acquired cholesteatoma is associated with a defect in the tympanic membrane. The pathological substrate of cholesteatoma is keratinising stratified squamous epithelium, but the origin of this epidermal tissue in the middle ear is controversial. Here, we review the most relevant and recent evidence for the principal aetiopathogenic theories of both forms of cholesteatoma, in the light of recent otopathological findings. Congenital cholesteatoma is most plausibly explained by the persistence of fetal epidermoid formation. Conclusive 'proof' awaits the unambiguous demonstration of the metamorphosis of an epidermoid nidus into a lesion in vivo. Acquired cholesteatoma may develop by various mechanisms: immigration, basal hyperplasia, retraction pocket and/or trauma (iatrogenic or non-iatrogenic). However, squamous metaplasia of the normal cuboidal epithelium of the middle ear is a highly unlikely explanation. Chronic inflammation seems to play a fundamental role in multiple aetiopathogenic mechanisms of acquired cholesteatoma. Therefore early treatment of inflammatory conditions might reduce their sequelae, perhaps by preventing the development of hyperplastic papillary protrusions. Continued otopathological, cellular and molecular research would enhance our limited understanding of cholesteatoma and may lead to new therapeutic strategies for this erosive disease, which often defies surgical treatment.
Following laryngectomy, a distinct population of patients fails to achieve successful tracheoesop... more Following laryngectomy, a distinct population of patients fails to achieve successful tracheoesophageal voice. These patients' voices range from strained and effortful to none at all. Such patients may present with severe hypertonicity or spasm of the pharyngoesophageal segment. Botulinum toxin has been used to chemically denervate the pharyngeal musculature, and is an alternative to invasive surgical procedures. The aim of this article is to review the evidence for using botulinum toxin to achieve an improvement in post-laryngectomy voice. A Medline literature review (1966 to January 2009) and a search of the Cochrane database were performed. Foreign language articles and those not pertaining to post-laryngectomy voice restoration were excluded. Nine articles reporting a total of 134 patients were identified. Although there were differences in the outcome measures used, objective improvement in voice production occurred in between 70 and 100 per cent of cases. Botulinum toxin can be used as a safe and cost-effective treatment in patients with confirmed pharyngoesophageal segment hypertonicity and/or spasm following laryngectomy, to obtain an improvement in voice quality.
Simulators are becoming an increasingly important part of surgical training. Temporal bone surger... more Simulators are becoming an increasingly important part of surgical training. Temporal bone surgery is one area in which simulators, such as the Voxel-Man TempoSurg simulator, are likely to play a significant role in training. We present learning curve data from novice trainees using this simulator to learn cortical mastoidectomy, exposure of the sigmoid sinus, and exposure of the short process of the incus. We measured the time taken to perform the procedures, the volume of reference bone removed, and the structures damaged during dissection. We found improvement in a number of parameters over the course of the study. The overall scores, structural damage scores and time taken improved, to differing degrees, for each task. The volume of reference bone removed remained constant. These results indicate that the trainees' efficiency improved as they became more proficient at removing a given volume of reference bone.
The use of keels in the treatment of anterior glottic stenosis is well established. A variety of ... more The use of keels in the treatment of anterior glottic stenosis is well established. A variety of methods for keel fixation have previously been documented. We describe a simple technique of securing a Silastic keel, placed endoscopically, with a simple percutaneous suture, after laser vaporization of an anterior commissure web.
The regeneration capacity of spinal cord axons is severely limited. Recently, much attention has ... more The regeneration capacity of spinal cord axons is severely limited. Recently, much attention has focused on promoting regeneration of descending spinal cord pathways, but little is known about the regenerative capacity of ascending axons. Here we have assessed the ability of neurotrophic factors to promote regeneration of sensory neurons whose central axons ascend in the dorsal columns. The dorsal columns of adult rats were crushed and either brain-derived neurotrophic factor (BDNF), glial cell line-derived neurotrophic factor (GDNF), neurotrophin-3 (NT-3) or a vehicle solution was delivered continuously to the lesion site for 4 weeks. Transganglionic labelling with cholera toxin b subunit (CTB) was used to selectively label large myelinated Ab ®bres. In lesioned rats treated with vehicle, CTB-labelled ®bres were observed ascending in the gracile fasciculus, but these stopped abruptly at the lesion site, with no evidence of sprouting or growth into lesioned tissue. No CTB-labelled terminals were observed in the gracile nucleus, indicating that the lesion successfully severed all ascending dorsal column axons. Treatment with BDNF did not promote axonal regeneration. In GDNF-treated rats ®bres grew around cavities in caudal degenerated tissue but did not approach the lesion epicentre. NT-3, in contrast, had a striking effect on promoting growth of lesioned dorsal column axons with an abundance of ®bre sprouting apparent at the lesion site, and many ®bres extending into and beyond the lesion epicentre. Quanti®cation of ®bre growth con®rmed that only in NT-3-treated rats did ®bres grow into the crush site and beyond. No evidence of terminal staining in the gracile nucleus was apparent following any treatment. Thus, although NT-3 promotes extensive growth of lesioned axons, other factors may be required for complete regeneration of these long ascending projections back to the dorsal column nuclei. The intrathecal delivery of NT-3 or other neurotrophic molecules has obvious advantages in clinical applications, as we show for the ®rst time that dorsal column axonal regeneration can be achieved without the use of graft implantation or nerve lesions.
To evaluate the diagnostic performance of half-Fourier-acquisition single-shot turbo-spin-echo (H... more To evaluate the diagnostic performance of half-Fourier-acquisition single-shot turbo-spin-echo (HASTE) diffusion-weighted magnetic resonance imaging in the detection, localisation and prediction of extent of cholesteatoma following canal wall up mastoid surgery. Prospective blinded observational study. University affiliated teaching hospital. Forty-eight patients undergoing second-look surgery after previous canal wall up mastoid surgery for primary acquired cholesteatoma. All patients underwent non-echo planar HASTE diffusion-weighted imaging prior to being offered 'second-look' surgery. Radiological findings were correlated with second-look intra-operative findings in 38 cases with regard to presence, location and maximum dimensions of cholesteatoma. Half-Fourier-acquisition single-shot turbo-spin-echo diffusion-weighted imaging accurately predicted the presence of cholesteatoma in 23 of 28 cases, and it correctly excluded in nine of 10 cases. Five false negatives were caused by keratin pearls of <2 mm and in one case 5 mm. Overall sensitivity and specificity for detection of cholesteatoma were 82% (95% confidence interval [CI] 62-94%) and 90% (CI 55-100%), respectively. Positive predictive value and negative predictive value were 96% (CI 79-100%) and 64% (CI 35-87%), respectively. Overall accuracy for detection of cholesteatoma was 84% (CI 69-94%). Half-Fourier-acquisition single-shot turbo-spin-echo diffusion-weighted imaging has good performance in localising cholesteatoma to a number of anatomical sub-sites within the middle ear and mastoid (sensitivity ranging from 75% to 88% and specificity ranging from 94% to 100%). There was no statistically significant difference in the size of cholesteatoma detected radiologically and that found during surgery (paired t-test, P = 0.16). However, analysis of size agreement suggests possible radiological underestimation of size when using HASTE diffusion-weighted imaging (mean difference -0.6 mm, CI -5.3 to 4.6 mm). Half-Fourier-acquisition single-shot turbo-spin-echo diffusion-weighted imaging performs reasonably well in predicting the presence and location of postoperative cholesteatoma but may miss small foci of disease and may underestimate the true size of cholesteatoma.
All cases that exhibited an uptake of 18 FDG received a histological diagnosis of surgical specim... more All cases that exhibited an uptake of 18 FDG received a histological diagnosis of surgical specimens with a confirmed recurrence of IP, whereas the case that did not show 18 FDG uptake received a histological diagnosis of absence of recurrence of IP.
Cholesteatoma is often treated surgically using canal wall-preserving techniques. Clinical and ot... more Cholesteatoma is often treated surgically using canal wall-preserving techniques. Clinical and otoscopic diagnosis of residual or recurrent disease after this form of surgery is unreliable and thus radiological imaging is often used prior to mandatory "second-look" surgery. Imaging needs to be able to differentiate residual or recurrent disease from granulation tissue, inflammatory tissue or fluid within the middle ear cavity and mastoid cavity. Highresolution computed tomography (HRCT), conventional magnetic resonance imaging (MRI), and delayed contrast MRI have all been used in detecting postoperative cholesteatoma. Although delayed contrast MRI performs better than HRCT and conventional MRI, the sensitivities and specificities of these different imaging methods are relatively poor. Diffusion-weighted MRI (DWI and, in particular, non-echo planar DWI) has been shown to have a high sensitivity and specificity for detecting recurrent cholesteatoma. In this review we provide examples of postoperative imaging appearances following cholesteatoma surgery and we review the relevant literature with an emphasis on studies evaluating the diagnostic accuracy of DWI.
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Papers by S. Khemani