Otogenic intracranial abscess: concurrent craniotomy and mastoidectomy--changing trends in a developing country

OBJECTIVES

To evaluate (1) the clinical profile, treatment, and outcome of adult and pediatric patients presenting with intracranial abscess of otogenic origin and (2) the advantages of concurrent craniotomy and mastoidectomy.

DESIGN

A prospective case series.

SETTING

An academic tertiary referral center in India.

PATIENTS

Thirty-six patients clinically diagnosed as having intracranial abscess that was secondary to suppurative otitis media and confirmed by computed tomographic scanning.

INTERVENTION

Concurrent craniotomy and mastoidectomy.

RESULTS

Children were more commonly affected than adults, and there was a male preponderance. All patients had cholesteatoma at surgery, although one third of the children had only granulation tissue on otoscopy. More than two thirds of the patients in both the groups presented with more than one intracranial complication and definitive surgical intervention was done later than 24 hours. Meningitis was the most frequent intracranial complication, followed by cerebellar abscess. There was no significant intraoperative or postoperative morbidity, mortality, recurrence of intracranial complications, or residual neurological deficits. Three children (14%) showed evidence of recidivism cholesteatoma requiring revision surgery.

CONCLUSIONS

In suppurative otitis media with intracranial complications, it is accepted practice to treat the neurosurgical complication first, followed by mastoidectomy at a later date after the patient has been stabilized. Craniotomy with concurrent mastoidectomy is not only safe, but it also removes the source of infection at the same time the complications are being treated, thus avoiding reinfection while the patient is awaiting the ear surgery. In addition, the treatment is completed with a single, shorter hospital stay, which is more economical for the patient.

Histological studies in primary neuritic leprosy: changes in the nasal mucosa

The nasal mucosae of 39 cases of primary neuritic leprosy (PNL) registered at Karigiri were studied histologically to determine nasal mucosal involvement in PNL and its relevance to the pathogenesis of the disease. Specific changes of leprosy were seen in 20 (51%) biopsies, ranging from macrophage granulomas with acid fast bacilli, to epithelioid granulomas and nerve inflammation. The remaining biopsies revealed chronic inflammatory changes of the mucosa or mild non-specific nerve changes. These findings show that there are widespread effects of the disease even in PNL patients in whom the disease is believed to be confined to the peripheral nerves. The findings also show that early leprosy involvement can be found in the nasal mucosa even before lesions become apparent in the skin or other parts of the body. The nasal mucosa could be one of the sites for the primary lesion in leprosy. Clinical and histological examination of the nasal mucosa may be useful and important in the early diagnosis of leprosy and especially in contacts.

Bilateral simultaneous hearing preservation mastoidectomy in otogenic meningitis

Bilateral simultaneous hearing conservation mastoidectomy has not been previously documented. We present our experience with this procedure. Three patients with pyogenic meningitis secondary to bilateral unsafe ears had hearing preservation surgeries of both ears in a single sitting. Although ear surgery carries risk of inner ear damage, in our series there was no deterioration of inner ear function in the 6 ears operated on. The air conduction threshold improved in 3 (50%) of the ears. When meningitis results from bilateral otogenic foci as in our series, simultaneous mastoidectomy in both ears may be the preferred method of treatment to eradicate the source of infection.

Intrinsic differences in hearing performances between ears revealed by the asymmetrical shooting posture in the army

Left ear noise-induced hearing losses are dominant in the army. The common explanation is the asymmetrical effect of the shooting posture. However, firm evidence to support this possibility is still lacking. In the French army shooters, eye preference rather than hand preference for shooting determines the side of shooting and hence the ear more exposed to noise. To test whether left-right asymmetry of hearing thresholds really relates to the shooting posture, we analyzed audiograms from 644 officers of the infantry and artillery branches. The interaural differences reached 7 dB for right-eyed subjects, and less, about 5 dB, for left-eyed subjects at 6-7 kHz, both with disadvantage for the left ear. In contrast, hearing thresholds of both groups in the low frequency range were significantly better for left ears. Our results suggest each ear has different intrinsic characteristics. The right cochlea might be a less sensitive but more robust sensor than the left cochlea, which might be a finer sensor but more sensitive to noise.

Light and electron microscopic findings in rhinosporidiosis after dapsone therapy

Morphological findings in serial nasal mucosal biopsies from three cases of rhinosporidiosis on dapsone therapy were compared with biopsies from 33 patients taken before dapsone or surgical treatment was initiated. All biopsies were examined by light microscopy and five by electron microscopy. Counts of histologically intact and degenerated organisms showed a decreasing proportion of intact forms with treatment.

Autograft ossicle selection in cholesteatomatous ear disease: histopathological considerations

In order to determine whether selection of autograft ossicles in cholesteatomatous ear disease should be based upon their appearance under the surgical operating microscope, we studied the histopathological features of 113 such ossicles. We attempted to correlate the extent of erosion of the ossicle, as noted under the surgical operating microscope, with their histopathological appearance. There were 60 mallei and 53 includes. Seventy-nine ossicles were eroded and 34 were intact. The commonest abnormality noted was erosion of the long process of the incus (75 per cent). Both intact and eroded ossicles had similar histological features. There was no evidence of intra-ossicular cholesteatoma. The results suggest that the extent of erosion of these ossicles as seen under the surgical operating microscope should in no way prejudice their use as autografts when required.

Recurrent laryngeal lipoma

A rare case of laryngeal lipoma is reported with review of literature. We describe our technique of intra laryngeal excision of this tumour by microlaryngeal dissection.

Ludwig's angina

A 13 year review of patients diagnosed to have Ludwig's angina admitted to the Christian Medical College and Hospital, Vellore, India, between March 1982 and April 1995 is presented. The patients were either admitted to the ENT or paediatric surgical units. There were 41 patients, 24% being children and 76% adults. The clinical profile and outcome of these two groups were compared. In the paediatric group, none had dental caries while in the adult group, 52% had associated dental caries. In children, 70% were controlled with conservative medical management unlike the adults of whom 81% needed incision and drainage. Tracheostomy was necessary in 10% of the children and in 52% of the adults. The mortality was 10% in both groups.

Hearing impairment and otitis media in a rural primary school in south India

In order to determine the prevalence of hearing impairment and otitis media in rural primary school children, a pilot study of 284 children aged 6-10 years was performed. These children were screened by otoscopy, pure tone audiometry and tympanometry. The overall prevalence of otological abnormalities (excluding wax) was 21.5%. Hearing impairment was detected in 34 children (11.9%). Conductive hearing impairment was predominant (10.9%). Otitis media was diagnosed in 17.6% of children. While 91.2% of children with hearing impairment had associated middle ear disease, only 53.4% of those with middle ear disease were detected as have hearing impairment. The importance of including tympanometry as part of the screening protocol is highlighted.

VISAUDIO: a Windows software application for Bekesy audiogram analysis and hearing research

A Windows software system has been designed to facilitate hearing research programs and decision aid for epidemiological surveys in a military context. VISAUDIO provides graphical displays of audiograms with the results of various processing (smoothing, pathological patterns detection and classification), audiograms with pathological patterns like scotoms and recruitments are described (number, impaired frequencies, severity of loss for scotoms). Classical French ORL indexes are calculated (Index 42 which is the French legal index in occupational medicine, PAM or Lafon's index, IPA from the French norm NF S31-013 and IRB, a new occupational medicine index). An audiometric pattern classification is done for each audiogram using discriminant factorial analysis. The program allows audiogram comparisons on the same screen. The processing and analysis results can also be copied to any Windows software package via a PC clipboard. This prototype software is to be tested in a quasi real-time audiological information system comprising audiogram acquisition, processing, analysis and storage in a database. VISAUDIO software functions are illustrated with examples of screen displays.

Use of digoxigenin-labeled RNA probe to test hepatitis A virus antiviral drugs

A nucleic acid hybridization assay was used to evaluate inhibitory activity of antiviral compounds against hepatitis A virus (HAV) in cell culture and compared to radioimmunoassay by analysis of variance procedure. The 5' genomic end of the HM-175 strain was used as digoxigenin-labeled RNA probe. Dot-blot examination showed a reduction of detectable HAV RNA in infected cells when treated with amphotericin B. An antiviral dose-effect was shown by statistical analysis of densitometric measures of hybridization signals. Comparison between molecular hybridization assay and radioimmunoassay by analysis of variance procedure showed the equivalence of both methods. Data previously obtained on selected drugs by antigen and infectious titres determinations were confirmed by hybridization assay and make possible digoxigenin-labeled RNA probe use to measure an antiviral dose-effect for screening of hepatitis A antiviral compounds.

A three-dimensional representation of an athletic female knee joint using magnetic resonance imaging

Intense interest in knee joint mechanics has resulted in the development of numerous models to predict forces acting at the knee. However, few models have accounted for the unique geometric characteristics of the knee joint's articular surfaces when predicting the mechanical response of the joint. The purpose of this study was to stimulate accurately the complex geometric characteristics of the tibiofemoral joint for input into a finite element model representing the knee joint of athletic females. The right knee of an athletic female with no history of knee joint trauma was imaged using a 0.5 T magnetic resonance imaging (MRI) unit. Twelve cross-sectional slices of the knee were scanned in each of three orthogonal planes (coronal, sagittal and axial) at slice intervals of 6 mm, 7 m, and 8 mm respectively. A scan plan (two coronal images and an axial image) was also generated to enable calculation of the orthogonal scans with respect to one another. Select anatomical reference points representing cancellous and compact bone, major ligament attachment areas, and articular cartilage of the distal femur and proximal tibia were digitized from the processed shadowgraphs. The processed digitized data were input into a computer graphics program which was the pre- and post-processing software for the finite element analysis package. Contours of the cancellous and compact bone of the tibial and femoral condyles were generated using beta and cubic spline curves. Bezier quadratic and cubic polynomials were used to reconstruct the tibial and femoral shafts.(ABSTRACT TRUNCATED AT 250 WORDS)

Medical therapy of rhinosporidiosis with dapsone

Clinical, histopathological and ultrastructural studies in three cases of rhinosporidiosis show complete remission of infection within one year of therapy with dapsone. Light and electron microscope studies confirmed arrest of the maturation of the spores and accentuated granulomatous response with fibrosis following dapsone therapy.

[Detection of hepatitis A virus by riboprobe labeled with digoxigenin: comparison of methods]

A riboprobe (RNA probe), corresponding to the 5' end of the HM175 hepatitis A virus (HAV) genome, was synthetized in vitro and was digoxigenin-labeled. Then the riboprobe was used to detect the CF53 HAV strain. Conditions of virus denaturation (with or without SDS and proteinase K, timing of assay) to release viral RNA were tested by dot-blot hybridization on a ten fold dilution of HAV suspension. Densitometric measures of dot-blot spots allowed to appreciate optimization of the method. Sensitivity of hybridization was compared with sensitivity of radioimmunoassay (RIA) and cell culture methods. Hybridization signals and scale of HAV suspension were consistent when 0.05% SDS, 0.17 micrograms/ml Proteinase K, 37 degrees C, 30 mn or 3 hours are used. 8.10(2) TCID50 HAV was detected by hybridization with digoxigenin-labeled RNA probes. Detection threshold was the same as radioimmunoassay and lower comparatively to cell culture.

[Early effects of neutron-gamma or gamma irradiation on the group toxicity induced by (+) amphetamine in mice]

To better understand the mechanism of action of gamma and neutron radiation on the dopaminergic system, the influence of the two irradiation modalities on the group toxicity of (+) amphetamine was studied in mice. Neutron-gamma irradiation (3.6-4.95 Gy) leads to an early toxicity reduction, while gamma-exposure (7-12 Gy) induces an increase in toxicity. This suggests that these two types of radiation induce different early effects on central dopaminergic system. Possible mechanisms are discussed.

Laryngeal stridor in myasthenia gravis

Two patients with laryngeal stridor secondary to myasthenia gravis are reported. The cause of bilateral abductor weakness in myasthenia is discussed; anticipation of the stridor in myasthenic patients is highlighted.

Medical management of pseudocyst of the auricle

Four male patients with pseudocyst of the auricle were successfully treated with oral corticosteroids. This condition is an asymptomatic, non-inflammatory, cystic swelling, usually located in the scaphoid or triangular fossa of the anti-helix which if untreated, leads to deformity of the pinna. All successful methods of treatment described in the literature so far have been invasive. All four patients in the above series responded to oral steroid therapy alone.

Solitary fibrous tumour of the nasopharynx

A case of benign ‘Solitary Fibrous Tumour of the Nasopharynx’, a rare, recently recognized entity, is presented and the clinical and pathological details discussed.

Roentgen examination of maxillary sinus, antral puncture and irrigation--a comparative study

The various radiological findings of maxillary sinus were compared to those at antral puncture and irrigation in patients with chronic maxillary sinusitis. It was noted that roentgen findings of opacity and fluid level of the maxillary sinus are definite evidences of sinus infection and a mucosal thickening is not an indication of sinus infection.

Reactional states in the nasal mucosa: a clinical and histopathological study

Twenty leprosy patients in the reactive phase of the disease were studied clinically and histologically for evidence of reactive lesions in the nasal mucosa. Ten of 14 patients with erythema nodosum leprosum (ENL) showed characteristic polymorphonuclear leukocytic infiltration and two patients showed vasculitis. The histological changes of reversal reactions in the nasal mucosa, one with upgrading reaction and the other with downgrading reaction, are reported.