Ear,Nose & Throat Journal

Recent evidence has demonstrated that neurogenic vascular headaches are a combinationof neurological primary events and secondary vasomotor changes. The neurological events involve the hypothalmus and sensory cortex with sympathetic hypofuncti on and noradrenergic abnormalities. A platelet theory has been proposed but has not really been confirmed as a legitim ate cause of the neurogenic vascular head aches. Food and chemicals in foods can act as a precipitating factor in the food-sen sitive neurogenic vascular headache patient. In these patients evidence is now being demonstrated to confirm this, but larger patient studies are needed. The food-sensitive migraine patient and cluster headache patient must give a good history and food diary to go along with active challenges and provocative testing in order to determine the causative foods. Any concomitant allergies of inhalants or environmentals must also be treated. The treatment modalities of elimination and rotation diets or provocation neutralizationmay successfully control the headaches without the need for continuous medications.

Nowhere in medicine is a test or battery of tests more needed than in the diagnosis of adverse reactions to foods. Such tests are not at present a reality. Research produces tests that individually appear to show validity, but when challenged with the entire range ofpossible adverse reactions and their results, the tests fall short. Considering the range of mechanisms involved in adverse reactions to foods, this is to be expected.

There is a tendency to discount positive test results when they fail to cover all of the parameters desired. The inherent weakness in any test is that all available formats explore a single or limited reaction route. The reality is the presence of multiple routes, multiple target organ s, and multiple external variable s not subject to programming into a single test. Considering the range of possibil ities, it is amazing that any existing tests show any clinical validity at all. We as scientists should not denigrate any study that shows a significant degree of reliability, even within a limited range. This simply halts progress. An encouraging study should be used as a stepping stone to a more comprehensive format for evaluating the overall range of adverse reactions and providing us with at least some inroads in coping with this most difficult problem. To quote Sir Peter Medawer on receiving the Nobel Prize in Science: “Nothing must be said or written that diminishes the likelihood that someone else will get at the truth.”

Intraturbinal injection of repository corticosteroid has been widely used by otolaryngologists for over four decades. The potential for visual loss when retinal embolization or vasospasm complicate this procedure and the introduction of topical nasal steroid preparations have gradually reduced its usage and reshaped the role of intraturbinal steroid injection in the management of a variety of rhinologic disorders. A review by the author of twenty-five years’ experience, including over thirteen thousand intraturbinal corticosteroid injections, shows no visual complications in this large series. However, a decline in the use of this procedure was noted, possibly influenced by several factors. Appropriate roles for intraturbinal steroid injection and topical corticosteroid nasal sprays are suggested.

This study involves ten consecutive anosmic patients who underwent pansinus surgery and have been followed and tested a minimum of one year. They all had advanced obstructive bilateral nasal polyposis and pansinusitis. Persistent severe loss of smell was one of the chief complaints in all ten patients. The surgery performed included bilateral nasal polypectomies, bilateral sphenoidethmoidectomies and bilateral nasal antral windows. Post-operatively, all were treated with a topical corticosteroid nasal spray. Seven of these patients were asthmatic and three were also aspirin-sensitive, some being cortisone-dependent. The University of Pennsylvania Smell Identification Test (UPSIT) was administered pre-operatively and then at six-month intervals in the post-operative period. Significant initial improvement in smell acuity occurred in seven of the ten patients. One of the seven, however, developed recurrence of the nasal polyposis and again lost his smell capabilities somewhere between the twelfth and eighteenth post-operative months. Another of the patients who did not improve smell sensitivity post-operatively occasionally is aware of fleeting periods of return.

Meniere's disease (MD) is considered a complex otologic disorder characterized by exacerbation and remission periods which of ten make its natural course unpredictable. Several studies in the past have analyzed the evolutionary course of MD through comparison between patients under medical treatment and those surgically treated. The present paper aimed to study the evolution of MD in a group of patients who were selected for endolymphatic sac surgery on the basis of a fluctuating stage and uncontroll able recurrent vertigo; some of them, however, did not undergo surgery for different reasons and were used as control for MD at a homogenous stage. Vertigo and tinnitus were improved by surgery in a significant number of patients in comparison with the non-surgical gro up. Hearing function, which improved few months after surgery in some patients, was found to deteriora te in the long run, in surgical and non-surgical groups. Sac surgery yielded significantly better results for two out of three Meniere's symptoms, i.e. vertigo and tinnitus, and can be considered to play a significant role in the therapy of MD at the fluctuating stage.

A laryngocele associated with squamo us cell carcinoma of the larynx is reported in a 20-yea r-old man without a history of smoking. This is the youngest reported case of carcinoma associated with laryngocele in the literature. This association is supported by the patient's young age and his nonsmoking status. However, this case does not appear to support the conclusion that laryngoceles predispose to the development of squamous cell carcinoma. The clinical history supports the tumor obstruction theory, whereby a laryngocele developed from an obstructing carcinoma of the ventricle.

Chronic recurrent parotitis (CRP) is recurrent parotid inflammation with non-obstructive sialectasis. Therapies which produce acinar atrophy or remove the acini are effective in treating CRP. Parotidectomy, tympanic neurectomy, duct ligation, and radiation therapy have either a low success rate or a high risk of morbidity. Intraductal antibiotic instillation has been proposed as a possible method of treatment. We hypothesized that the cytotoxic effects of tetracycline could produce acinar atrophy. A double-blind experiment of intraductal tetracycline instillation was performed in ten rabbits. Acinar atrophy and acute inflammation were found in 40% of the tetracycline treated glands; controls had a complete absence of these histologic changes. These results support the use of tetracycline instillation to produce acinar atrophy and therefore, intraductal tetracycline may be an effective, low-risk therapy for CRP. The clinical features of CRP will be reviewed and therapeutic implications discussed.