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Pneumoperitoneum as a result of pneumomediastinum has been described already. Amongst the causes pneumoperitoneum due to a complication of adenotonsillectomy, has not previously been described. We describe a five-year-old girl with tension pneumoperitoneum with respiratory and circulatory insufficiency half an hour after adenotonsillectomy. Removal of the intra-abdominal air with a 14 gauge needle restored normal respiration and circulation.

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12 patients suffering from a Treacher-Collins syndrome, or mandibulo-facial dysostosis, were operated on in the Nijmegen University Hospital between 1960 and 1990. An early diagnosis is generally reached when there is a congenital atresia of the auditory canal. Auditory rehabilitation with a conventional prosthesis of the bone or a BAHA is preferable to surgical reconstruction. In minor cases, deafness must be screened as early as possible, with a bone hearing aid prosthesis. Surgical exploration can be performed at best as the age of 10, but the chances of success are less than those of other functional reconstructions because of the associated malformation.

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Voice disorders related to occupation and work environment are often observed in ENT consultations. Advising these patients requires not only the investigation of their vocal capacities but also knowledge about their vocal load. The patient will name extreme demands as the reason for vocal problems whereas the employer will want to know if the patient is capable of doing the work required of him. For an objective measurement of vocal load, a voice accumulator has been developed. This portable instrument records total speaking time and sound level over a period of several hours. The data can be transferred to a personal computer which analyses voiced time (s) between 60 and 112 dB(A)s. Thus, more precise and objective documentation of vocal demands in some professions can finally be obtained. With these results, it is possible to monitor vocal ability or disability during vocal rehabilitation.

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The autosomal dominant hereditary Treacher Collins syndrome manifests itself phenotypically in dysmorphogenesis of particularly the first, but also the second branchial arch system. Consequently, 50% of patients with Treacher Collins syndrome have a congenital, generally pure conductive hearing loss resulting from a major or minor ear anomaly. The outcome of surgery to improve patients' hearing varies and is sometimes even disappointing. Thorough analysis of 33 cases (39 operated ears) and the strict application of a classification for the anomaly to each ear enabled us to gain insight into the most suitable surgical policy and to form a prognosis for reconstructive ear surgery.

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The results and complications of translabyrinthine and transotic surgery for petrous apex lesions between 1980 and 1992 are presented. An acoustic neuroma was found in 52 patients. In 1988, the translabyrinthine approach was modified into the transotic approach and replaced the former technique. There was no mortality in this series, but two patients had mild brainstem infarcts and there was post-operative bleeding into the cerebellopontine angle in one. Cerebrospinal fluid (CSF) leakage was seen in six patients and meningitis in two. Three suffered deep vein thrombosis in their legs. There was one case each of herniation of the cerebellum and gastric bleeding. Post-operative facial nerve function was good in 88%, moderate in 10% and poor in 2%. In the case of acoustic neuromas the aim was total tumour removal, but if there was a serious risk of damaging the nerve anatomically, near total or subtotal removal was performed. During the study period, there was a gradual decrease in facial nerve morbidity and surgical complications. This was attributed to increasing experience, the modified wider approach and better post-operative care.

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Previously we have described the presence of Waldeyer's ring equivalent (WRE) lymphoid tissue in the rat, and pointed out the importance of such an experimental model for studying the immunological role of nasopharyngeal lymphoid tissue. Here we extend this work with immunohistological data in terms of compartmentalization and distribution of the various lymphoid and non-lymphoid cells of this WRE lymphoid tissue in situ. WRE tissue consists of distinct T cell and B cell areas. B cell areas predominate; they are located directly under the mucosal epithelium and consist mainly of follicles. These follicles frequently contain a germinal center with IgD negative B cells interspersed with scattered CD4 (helper/inducer) T cells. Follicular dendritic cells are present in the germinal centers. T cell areas, on the other hand, are predominantly present at the abluminal side of the WRE in interfollicular areas. In these areas high endothelial venules and both CD4 and CD8 (suppressor/cytotoxic) T cell populations with a clear preponderance of CD4 over CD8 cells can be observed. MHC class II positive interdigitating dendritic cells are also scattered throughout these T cell areas. Mononuclear phagocytes (ED1-positive monocytes/macrophages) are scattered throughout the WRE, but especially in the T cell areas. A subpopulation of (ED3-positive) mononuclear phagocytes, e.g., the lymphoid tissue macrophage, is exclusively scattered between the small blood vessels along the abluminal side of the lymphoid tissue. Here, plasma cells, including those of the IgA type, are located. The data show that nasopharyngeal lymphoid tissue in the rat can be considered as an immunologically fully equipped and active mucosal lymphoid organ presumably executing similar immune functions as the tonsils in the human Waldeyer's ring.

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We have studied lymphocyte traffic to the Waldeyer's ring equivalent (WRE) lymphoid tissue of the rat, by measuring the in vitro binding of various lymphocyte subsets to high endothelial venules (HEV) in the WRE. In addition, we studied the in situ distribution of these lymphocyte subsets. WRE tissue consists of B and T cell areas; the latter contain HEV. B cells outnumber T cells, and T helper (CD4) cells outnumber T suppressor/cytotoxic (CD8) cells (T/B ratio = 0.7; CD4/CD8 ratio = 5.1). In vitro studies of lymphocyte binding showed that lymphocytes adhere almost equally well to HEV in WRE tissue as to HEV in lymph node (LN) tissue, and much better to HEV in WRE than to HEV in Peyer's patch (PP) tissue. T cells bind better than B cells to HEV in WRE (T/B binding ratio = 1.8), and CD8 cells better than CD4 cells (CD8/CD4 ratio of 2.9-3.2, dependent on cell source). The observed preference of T over B cells in binding to HEV is not reflecting the distribution of these lymphocyte sets in situ. In this respect the WRE takes a unique position, since in other lymphoid organs T/B binding ratios parallels T and B cell distribution in situ. This may suggest a much more rapid passage of T cells through the WRE than through other lymphoid tissues, although other mechanisms cannot be ruled out. The CD8/CD4 binding ratio to HEV in WRE contrasts with situ distribution of these cells also; however, this is found for LN and PP lymphoid tissue too.(ABSTRACT TRUNCATED AT 250 WORDS)

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By means of serial sectioning of the head and neck a paired, rod shaped, parachoanic lymphoid organ was identified in Lewis rats. Histological, ultrastructural studies and FACS analysis showed this organ to be a lympho-epithelial organ with high endothelial venules (HEV) and a preponderance of B over T and T helper over T suppressor cells. Consequently this organ resembles the pharyngeal tonsil of man, and it is called the Waldeyer ring equivalent (WRE). The lymphatic drainage of this organ occurs predominantly to the deep, and to a lesser extent to the superficial cervical lymph nodes. Migration studies with 51Cr labeled cells show that the WRE lymphoid cells migrate into the lymphoid organs with HEV (peripheral lymph nodes. Peyer patches and WRE). In this respect they resemble peripheral lymph node cells more than cells from the Peyer patches. Thus the WRE lymphoid tissue in the rat is undoubtedly involved in local oronasopharyngeal immune surveillance and may also contribute to mucosal and systemic immune responses.

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The latency, the rise time and the influence of the acoustic reflex on sound transmission were investigated in the adult rat during ketamin anesthesia. This was done by recordings of the cochlear microphonics (CM) and electromyographic (EMG) recordings of the reflex responses of the tensor tympani muscle. The acoustic reflex was elicited by contralateral acoustic stimuli of which the intensity and frequency was varied. Ipsilaterally, the effect on sound transmission was determined by estimating the change in amplitude of the CM's of ipsilateral administered subliminal stimuli. It was shown that both the tensor tympani muscle and the stapedius muscle contribute in the reflex. The latency as well as the rise time of the reflex determined by CM recordings showed to be short (minimal values: 12 and 7 ms respectively). The mean latency of the tensor tympani muscle reflex, measured by EMG, was about 7 ms. The attenuation of 0.25-8 kHz tone bursts upto 115 dB SPL is limited to a mean maximum of 15 dB SPL. The maximal attenuation was shown to occur at 1 kHz. Frequencies above 2 kHz appeared to be the best elicitor of the middle ear muscle reflex.

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Measurement of the middle ear muscle reflex is an important tool in audiologic examination; however, the precise function of the tensor tympani and stapedius muscle is not fully understood. The function of the middle ear muscles in speech discrimination and noise-induced hearing loss is the main object of our study. Morphologic and enzyme-histochemical properties of the middle ear muscles of the rat indicate a complex, fine-tuned function of the middle ear muscles. Both middle ear muscles are merely composed of relatively small fast-twitch fibers. Almost all fibers possess an enzymatic profile that allows aerobic as well as anaerobic metabolism. The innervation of the muscles is extensive, and motor end plates are well developed. In a parallel study, middle ear muscle contraction (to be analyzed by electromyography) will be correlated with a change of the sound transmission characteristics of the middle ear (measured by the electrocochlear and brainstem auditory evoked responses). Preliminary results of the electrophysiologic measurements (electrocochleogram and brainstem auditory evoked response) are presented.

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An additional classification of type II of congenital aural atresia (to Altmann) is presented. This subclassification proved to be useful in predicting the change on a servicable hearing level after a canal plasty procedure. Also a correlation has been noted between the postoperative hearing level and the degree of malformation of the auricle. In type II A atresia the rate of success is so good, that a small group of patients with unilateral atresia and this class of anomally can also be expected to benefit from surgery.

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The divergent views concerning indications, ideal age for surgery, and surgical approach to achieve better hearing illustrate the complexity of cases of congenital aural atresia. Whether the anomaly is unilateral or bilateral also influences the criteria on which the surgical decision is based. In the thirty-six ears operated on between 1972 and 1983 using the canal plasty technique, the average hearing gain was 20 dB, with 18 ears having an air conduction threshold of 35 dB or better after a long follow-up.

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A rare case of carcinoid tumour of the middle ear in a 51-year old woman is presented. The clinical features and the light and electron microscopical appearances are discussed. Carcinoid tumour should be included in the differential diagnosis when tumours of the middle ear present with adenomatous pattern. Electron microscopy will identify characteristic intracellular neurosecretory granules. Formaldehyde-induced fluorescence corresponding to the pattern of distribution of these granules confirms the diagnosis of carcinoid tumour.

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The four surgical methods currently in use to improve hearing in patients with congenital aural atresia are (i) fenestration of the lateral semicircular canal, (ii) type III tympanoplasty, (iii) canal plasty and (iv) canal plasty with homograft tympanoplasty. Because the surgery is difficult and the functional results are not always good, the criteria for surgery are also influenced as to whether the anomaly is unilateral or bilateral and what the cosmetic goal is. When aural rehabilitation and cosmetic surgery are contemplated, co-ordinated planning by the otological and plastic surgeon is necessary to attain the best end result. Of the 36 ears with a type II anomaly operated on at the University of Nijmegen between 1972 and 1983 by the technique of canal plasty, the average hearing gain was 20 db, with 18 patients having a 35 dB or better air conduction threshold. The functional results seem to be related to the degree of malformation involved. Classification of the malformations has proved to be useful in discussing the surgical results.

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