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A method for determining three-dimensional vibration in the ear.

In the classical concept of the middle ear function the malleus rotates around a fixed axis which implies that at small amplitudes of vibration its displacement is essentially one dimensional. As a consequence malleus vibrations have been measured previously along a single viewing axis. As a first step in the study of the complete malleus motion we determined the three dimensional components at a single point (umbo) of the manubrium. To define 3-D motion it is in principle necessary to measure the vibrations from widely different observation angles. The viewing angles are limited however in our case by the ear canal geometry to about +/-15 degrees. In order to resolve the 3-D components under these conditions it is necessary to measure the vibration components with high accuracy. Amplitude and phase of the umbo vibrations were measured with a heterodyne interferometer over a wide frequency range (100 Hz to 20 kHz). The system included a two axis goniometer with the axes of rotation positioned at the focal plane of the interferometer objective lens. It was therefore possible to change the viewing angle in small increments around two orthogonal axes while keeping the same point in focus. From a redundant set of measurements the three orthogonal components of vibration were calculated by least squares fitting. The vector sum of the three components gives the three dimensional motion of the observed point. The vibration of the point on the umbo was found not to follow a straight line but an elliptical path instead. The shape of the ellipse and the inclination of the plane of the ellipse with respect to the stationary malleus position changed with frequency. These observations are consistent with our earlier findings that the mode of malleus vibration changes with frequency [Decraemer et al. (1991) Hear. Res. 54, 305-318].

Acoustic Stimulation↗

Surgery for primary, invasive and metastatic malignancy of the chest wall.

Forty-four patients with primary (n = 6), invasive (n = 19) and metastatic (n = 21) chest tumours underwent complete resection between 1986 and 1989 in a total of 46 consecutive procedures. Nineteen patients were female and 25 male; 2 patients, 1 male, 1 female, had second operations. The underlying disease was bronchial carcinoma in 17 (14 male), mesenchymal tumours in 17, metastatic breast cancer in 7 and miscellaneous in 5. The chest wall resection included up to 6 ribs. The manubrium was resected in 2 patients, the corpus sterni in 5. Pulmonary resection was performed in 36 cases in an en-bloc fashion. Other concomitant resections included the pericardium, diaphragm or transverse process of the vertebrae. Amputation of the right arm was necessary in two cases. Reconstruction of the thoracic cage was accomplished with PTFE soft tissue patches in 7, methyl methacrylate implants in 2, Marlex mesh in 1 and Vicryl net in 6 cases. In the majority of cases, particularly in dorso-apical and posterior defects, no substitutes were used. A variety of plastic procedures including the use of omentum, musculo- and fasciocutaneous flaps was employed for the reconstruction of the integument. There was no operative mortality. Fourteen patients died after surviving 2-25 months. Serious infection occurred in 1 patient and minor delay of healing in 2. Good palliation can be achieved at low risk. The effect on long-term survival remains uncertain, depending on the basic pathology.

Adolescent↗

An alternative method of neck flexion after tracheal resection.

Tracheal resections for benign and malignant disease are well described. The addition of release procedures, including suprathyroid and suprahyoid laryngeal release, has increased the capability of extended tracheal resection and primary reconstruction. Constant neck flexion by a suture between the skin of the point of the chin and midline of the chest over the manubrium is also widely considered paramount to successful tracheal resections. We designed a straightforward alternative to this method for patient comfort and compliance.

Airway Obstruction↗

Achilles tendon for sternal synthesis in the treatment of mediastinitis.

Surgical approaches to postoperative mediastinitis that imply wire removal achieve earlier infection recovery but leave the patient with sternal instability. In 10 patients after wound surgical debridement, my colleagues and I achieved sternal synthesis by using Achilles tendons retrieved from multiorgan donors and stored in glutaraldehyde. Three tendons were used in each patient; they were passed through the bone at the manubrium and parasternally at the midsternum and the lower sternum. Thirty-day computed tomographic scan results, infection recovery, and quality of life were satisfactory.

Achilles Tendon↗

Resorption of auditory ossicles and hearing loss in mice lacking osteoprotegerin.

Bones conduct sound in the middle ear. The three ossicles-the malleus, incus, and stapes-form a chain that transmits vibrations from the tympanic membrane to the oval window of the inner ear. Little is known about bone remodeling events in these ossicles and about potential effects of osteoporosis on hearing loss. Osteoclastic bone resorption is enhanced in Opg(-/-) mice lacking osteoprotegerin, which is a soluble decoy receptor for the osteoclastogenic cytokine RANKL. We asked whether auditory ossicles are resorbed in Opg(-/-) mice, and whether these mice suffer from impaired auditory function. All three ossicles in Opg(-/-) mice showed thinning, especially at the malleal manubrium and incus body. Most notably, unlike in the case in wild-type mice, the junction between the stapes and the otic capsule was fixed in Opg(-/-) mice, and the stapedial footplate was thinner and broader. Radiological analyses revealed that malleal cortical thickness was positively correlated with tibial bone mineral density in Opg(-/-) and control littermate mice. Furthermore, progressive hearing loss was detected in Opg(-/-) mice starting at 6 to 15 weeks of age. These data suggest that osteoprotegerin plays a crucial role in hearing by protecting the auditory ossicles and otic capsule from osteoclastic bone resorption.

Acoustic Stimulation↗

Suture anchors for treatment of sternoclavicular joint instability.

Instability of the sternoclavicular joint is a difficult problem to treat and can present with gross limitation in activities. Eight sternoclavicular joint stabilization procedures were performed over an 8-year period. The patients' ages ranged from 16 to 48 years (mean, 23.5 years). The indication for stabilization was pain associated with instability of the sternoclavicular joint. The joint was stabilized by use of suture anchors on the manubrium and capsular plication. The functional outcome was evaluated by use of the Constant score and patient-based Oxford Shoulder Questionnaire. At a mean follow-up of 4.5 years (range, 1-7.6 years), none of the patients had instability at the sternoclavicular joint, and all except one had returned to their previous employment. The Oxford score was 16 (range, 12-38). The mean Constant score was 74.88 (range, 33-87). We had only 1 poor result (Constant score of 33). Stabilization of the sternoclavicular joint can safely be performed by use of suture anchors. The technique is recommended for symptomatic sternoclavicular joint instability.

Adolescent↗

Influence of sternal size and inadvertent paramedian sternotomy on stability of the closure site: a clinical and mechanical study.

BACKGROUND: The influence of sternal size and of inadvertent paramedian sternotomy on stability of the closure site is not well defined. METHODS: Data on 171 consecutive patients undergoing cardiac surgery through a midline sternotomy were prospectively collected. Intraoperative measurements of sternal dimension included thickness and width at the manubrium, the third and fifth intercostal spaces; paramedian sternotomy was defined as width of one side of the sternum equaling 75% or more of the entire width, at any of the three levels. The chest was closed with simple peristernal steel wires and inspected to detect deep wound infection and/or instability for 3 postoperative months. The sternal factors and several patient/surgery-related factors were included in a multivariate analysis model to identify factors affecting stability. An electromechanical traction test was conducted on 6 rewired sternal models after midline or paramedian sternotomy and separation data were analyzed. RESULTS: Chest instability was detected in 12 (7%) patients and wound infection in 2 (1.2%). Patient weight (P = .03), depressed left ventricular function (P = .04), sternum thickness (indexed to body weight, P = .03), and paramedian sternotomy (P = .0001) were risk factors of postoperative instability; paramedian sternotomy was the only independent predictor (P = .001). The electromechanical test showed more lateral displacement of the two rewired sternal halves after paramedian than midline sternotomy (P = .002); accordingly, load at fracture point was lower after paramedian sternotomy (220 +/- 20 N vs 545 +/- 25 N, P = 0.001). CONCLUSIONS: Inadvertent paramedian sternomoty strongly affects postoperative chest wound stability independently from sternal size, requiring prompt reinforcement of chest closure.

Aged↗

[Usefulness of panfungal PCR for the diagnosis of fungal infection in immunocompromised patients].

The diagnostic of invasive fungal infection is often difficult because of the low sensitivity of fungal culture from infected tissues. Here we have assessed the ability of a panfungal PCR targeted on the DNA region encoding the RNA genes followed by sequencing of the amplification products to detect and identify fungi from tissue biopsies. This assay allowed us to identify the microorganism responsible for an invasive fungal infection in three of our patients. In two cases, hepatosplenic candidiasis was suspected and Candida albicans DNA was detected from liver biopsies. The third patient was cared for a thymome and developed a manubrium osteitis caused by Scedosporium apiospermum.

Adult↗

Access to the superior mediastinum.

Surgical access for diseases that involve the superior mediastinum can be achieved without thoracotomy by utilizing the suprasternal approach with extension of the head and neck and transection of the interclavicular ligament, median sternotomy, resection of the medial third to one half of the clavicle, or resection of the manubrium sterni. There has been minimal morbidity and no operative or postoperative mortality in a review of 53 consecutive patients. There has been no significant disability. Combined with exposure at the base of the neck, the access to the superior mediastinum is good to excellent.

Clavicle↗

Validation of a bone analog model for studies of sternal closure.

BACKGROUND: The incidence of serious sternal wound complications may be reduced with improvements in closure methods. Biomechanical testing of median sternotomy closures in cadavers has proven useful but is limited by availability, high cost, and wide variations in the material properties of the sterna. This study tests whether artificial sterna can be used to replace whole cadavers in sternal closure testing. METHODS: Two common wire closure techniques were tested using both whole cadavers and artificial sternal models formed from bone analogue material. Sternal models were molded from polyurethane foam (20 lbs/ft3) to simulate the mechanical properties observed in human cadaveric sterna. The force vector previously identified as the most detrimental to sternal cohesion (lateral traction) was used to stress the closures. Separation of the incision site was measured at the manubrium, midsternum, and xiphoid and data were compared between cadaver and bench test groups. RESULTS: Sternal separations recorded in cadavers were found to be similar to bench test results for both closure types. Data variability within test groups was found to be consistently lower using artificial sterna, where peak standard deviations for sternal motion averaged less than half that measured in cadavers. CONCLUSIONS: Results suggest that anatomic sternal models formed from solid polyurethane foam can be used to approximate the biomechanical properties of cadaveric sterna and that reliable information regarding sternal closure stability can be secured through this means. Moreover, bench test data were shown to be less variable than cadaveric results, thus enhancing the power to detect small differences in sternal fixation stability.

Biomechanical Phenomena↗

T-modification of sternotomy to accommodate a low-lying tracheostomy.

A low-lying tracheostomy can complicate a sternotomy for coronary artery bypass grafting. A modified "T" exposure, transecting the manubrium at the first intercostal space, can be utilized to maintain sternoclavicular architecture and avoid injury to the tracheostomy at the sternal notch.

Humans↗

Less invasive cardiac operations through a median sternotomy: 100 consecutive cases.

BACKGROUND: In the beginning of 1997, we developed a routine approach to intracardiac operations through a less invasive median sternotomy. A limited (6 to 9 cm) median skin incision followed by a subcomplete (manubrium and body) median sternotomy makes opening and closing of the chest easier; conventional central cardiopulmonary bypass is instituted, and no modifications to the surgical techniques are necessary. METHODS: In 100 consecutive patients (mean age, 62.04 years; range, 9 to 92 years), 70 aortic, 13 mitral, and 17 other cardiac procedures were performed. Surgical technique required many self-made instruments; anesthetic "fast-tracking" management was performed. RESULTS: Four patients died. One conversion to a standard sternotomy and five reoperations for bleeding were necessary. Cross-clamp time ranged from 33 to 140 minutes (mean +/- standard deviation, 69.23 +/- 20.99 minutes) and total drainage loss ranged from 120 to 1,800 mL x m(-2) x 24 h(-1) (mean, 288 mL x m(-2) x 24 h(-1)). The postoperative course was shorter than usual, and one complication in the healing wound was observed. The scar was shorter than 9 cm in all patients. CONCLUSIONS: Our work shows that a less invasive approach to many cardiac operations is possible through a modified median sternotomy. This technique provides many potential and practical advantages: there is less trauma and pain reported by patients, and the small wound reduces the risk of infection and blood loss. Patients are extubated and discharged from the hospital earlier.

Adolescent↗

Analysis of radiohippuran renogram by subtraction of extrarenal radioactivity.

A method is presented for the simple, non-computerized analysis of the radiohippuran renogram by subtraction of the extrarenal radioactivity as monitored simultaneously by a detector centered over the manubrium sterni. This method requires the application of a calibration factor, relating the level of radioactivity recorded by the sternal detector to that over each kidney area at the end point of the phase of initial rise on each side separately. The results in 15 normal individuals showed a narrow range of values, indicating a high degree of resolution. Verification of the basis of this method of analysis was obtained by accounting for all of the counting rate as extrarenal sources in the tracings of nephrectomized subjects. A further advantage is that the tracing recorded by the sternal detector may be used to calculate renal blood flow.

Adult↗

CT-targeted irradiation of the breast and internal mammary lymph nodes using a 5-field technique.

PURPOSE: To develop an effective and resource-efficient radiotherapy technique to treat the breast and regional nodes, including the ipsilateral internal mammary nodes. METHODS AND MATERIALS: Eighty female patients who underwent MRI scans for a variety of indications had coronal, T1-weighted images of the chest performed to determine the position of the internal mammary chain (IMC). Based on these results, a 5-field treatment technique was developed that would include the breast, supraclavicular fossa, and ipsilateral IMC, while maintaining a low dose to the heart, lungs, and contralateral breast. This technique was implemented in a cohort of 13 patients. RESULTS: The lateral position of the right and left IMC were measured in three cephalo-caudad positions: at the clavicular heads, upper manubrium, and midsternum (at the 2nd/3rd rib interspace). The mean lateral separation between the right and left IMC chains at each level (and 95% confidence interval) at each level were 5.8 cm (4.67-7.00), 5.6 cm (4.49-6.73), and 5.9 cm (4.66-7.19), respectively. Treatment was delivered to 13 patients using a 5-field technique, with tangential photon fields for the breast, anterior and posterior supraclavicular/axillary field, and a matching anterior electron field. Three-dimensional treatment planning of a representative case confirmed adequate coverage of the planning target volume (PTV). The median dose to the whole heart was 10 Gy, and 20% of the ipsilateral lung received more than 20 Gy. Seven of the 13 patients treated experienced moist desquamation at the junction of the electron field and breast tangents, and 1 patient had persistent ulceration at 3 months' follow-up. CONCLUSION: The 5-field technique described in this paper provides good coverage to the breast and regional nodes with acceptable toxicity, and without requiring three-dimensional treatment planning or intensity-modulated radiotherapy techniques.

Axilla↗

Effect of middle ear components on eardrum quasi-static deformation.

Eardrum deformation induced by quasi-static middle ear pressure was studied at progressive stages of dissection of gerbil temporal bones. With our high resolution moiré interferometer we recorded the shape and deformation of the eardrum along a line perpendicular to the manubrium and through the umbo, at different middle ear pressures. The deformation was measured from the medial side, after serially removing the cochlea, removing the stapes, cutting the tensor tympani, exposing the incudo-mallear joint, and cutting the anterior bony process which connects the malleus to the tympanic bone. The mean displacement as a function of pressure was also determined at all stages of dissection. Removing the cochlea and stapes, and cutting tensor tympani has no effect on static eardrum deformation. Exposing the incudo-mallear joint increases eardrum movement, and cutting the anterior bony connection between malleus and temporal bone strongly changes eardrum rest position and further increases its displacement.

Animals↗

Mineralization and osteogenesis in the human first rib cartilage.

Mineralization and osteogenesis in the human first rib cartilage were studied radiologically and by means of normal and polarized light microscopy. Onset of mineralization occurs at the end of puberty and is located directly beneath the perichondrium. Bone is formed in a typical spur-like pattern, arising medially from the upper edge of the manubrium sterni and laterally from the caudal rim of the bony part of the rib. From the middle of the second decade, large cartilage canals with several blood vessels and loose perivascular connective tissue are seen in central areas of the first costal cartilage. These parts are the last to be mineralized and ossified in old age. The type of osteogenesis cannot be classified according to common patterns. In spite of the subperichondral localization it cannot be intramembranous, because the new bone is separated from the perichondrium by a layer of mineralized cartilage. Osteogenesis cannot be called endochondral compared with the epiphyseal plate for the following reasons: there are no hypertrophied chondrocytes; an immunoreactivity for collagen type X is missing; areas where bone is formed directly on hyaline cartilage could be proved. Vascularization and onset of osteogenesis are separated in time and localization. Mineralization and osteogenesis in human first rib cartilage are physiological age-related changes, which cannot be regarded as degenerative processes. Ossification is not directly correlated with the invasion of blood vessels and cannot be classified as one of the classical concepts of intramembranous or endochondral osteogenesis.

Adolescent↗

The surgical airway.

Traumatic airway injuries are rare in children, partly due to their unique anatomy. The larynx is well protected from direct blows behind the mandibular arch, and only a small portion of the trachea is unprotected above the manubrium due to the relatively short neck. Furthermore, the tracheobronchial tree is less prone to injuries as compared with adults due to its elasticity. A high index of suspicion is thus needed to adequately diagnose and manage pediatric airway injuries. Laryngotracheal injuries in particular may present with discreet initial symptoms that if undiagnosed may rapidly progress to loss of airway. The most important signs of laryngeal injury include hoarseness and subcutaneous emphysema. Tracheobronchial injuries often present with dramatic symptoms, the most common being pneumothorax, which does not resolve after placement of chest tube, or large persistent air leaks. Endoscopy is mandatory on suspicion of injury to the larynx, trachea, or bronchi. CT scan may be helpful in determining the extent of injury to the larynx. Correct management of the airway in laryngotracheal injuries has a direct impact on morbidity and mortality. Endotracheal intubation over a flexible bronchoscope during spontaneous ventilation and in halothane anesthesia is the method of choice in children, but it should be performed in the operating room with the possibility of emergency tracheotomy. Cricothyroidotomy should be avoided in all laryngotracheal injuries because this method may aggravate the injury. Most laryngotracheal injuries in children can be conservatively managed. Extensive injuries, including displaced fractures of the cartilage, injuries to the recurrent nerves, and laryngotracheal separation, require surgical intervention. Injuries to bronchi and the thoracic trachea that do not cause a persistent air leak, and where the lungs expand completely after insertion of chest tubes, may be managed conservatively. All other injuries to the tracheobronchial tree should be repaired surgically as soon as feasible. Induction of anesthesia and opening of the chest may make ventilation difficult and are best managed by selective intubation of the contralateral lung. Long-term outcome after laryngeal, tracheal, and bronchial injuries in children, if managed swiftly and accurately, is usually excellent unless other injuries are present. The final result is improved by early recognition and early surgical intervention. These children need to be followed endoscopically for months and sometimes years in order to diagnose and treat stenoses as soon as they occur. Long-term pulmonary function has been shown to be excellent. Children with bilateral recurrent nerve paralysis may not fully recover voice or airway.

Airway Obstruction↗

Sequential audiometric evaluations of cats with regrowing tympanic membranes.

Audiometric evaluations were made for cats which were undergoing TM regeneration. For a one month period of regrowth and testing, there was an improvement in thresholds over the range of frequencies which were tested and the final evaluations (complete TM regrown) indicated greater auditory deficits in the high frequencies. The greater high frequency losses started at 1 to 2 kHz. and increased with frequency. The pattern of greater high frequency loss is thought to result from the fact that the regrown TMs did not adhere to the manubrium, but rather grew straight from the fibrous annulus and formed a flat rather than conical membrane.

Animals↗