Falls and dizziness in the elderly

The complaint of dizziness is one of the most common reasons that older adults feel constrained to visit the doctor's office. Because of a growing number of older people in the industrial society the problem grows. Therapeutic process of elderly people with vertigo and dizziness needs more than vestibular diagnostics. In addition to sufficient anamnesis, presence of visual deficits, extrasensory changes and even psychological circumstances are necessary. Frequently the indication and the encouragement of vestibular rehabilitation have significant value. The initiation of fall prevention may also be essential.

[The use of artificial neural networks in evaluation of posturographic data]

BACKGROUND

Posturography methods have been applied in clinical neurootology to evaluate the equilibrium function of patients. Methods of statistical analysis play an important role for improving data processing and to support the interpretation of the results. In contrast to conventional statistics, artificial neural networks are model-free and non-parametric. The aim of the presented study was to investigate how accurately these methods are able to discriminate between healthy and equilibrium-disturbed subjects.

PATIENTS AND METHODS

51 healthy volunteers participated in this study. 2 static posturography measurements were recorded before and 40 min after alcohol intake (0.4‰-0.6‰). Recorded signals were processed by 4 different methods in order to estimate power spectral densities (0 Hz-25 Hz). 11 different methods of artificial neural networks were investigated. The ability of artificial neural networks for classification was evaluated in patients with an acute unilateral vestibular loss.

RESULTS

It turned out that estimating power spectral densities by means of autoregressive modelling and subsequent classification by Support-Vector Machine or by Learning Vector Quantization Networks are most accurate. Validation analysis yielded mean classification errors for the test set of 4.2 ± 2.2%.

CONCLUSIONS

Analysis of neurootological data by artificial neural networks proved to be a sensitive recognition method of even small changes of the postural system.

Sonotubometry with perfect sequences: First results in pathological ears

CONCLUSION

Sonotubometry with perfect sequences (PSEQ) was able to detect eustachian tube (ET) openings in both normal and pathological ears. Impaired ears showed ET openings in almost all cases; however, these proved to be not only less frequent, but also with lower amplitude and shorter duration.

OBJECTIVES

To investigate the function of impaired ET under physiological conditions, using a novel kind of sound stimulus for sonotubometry – the PSEQ.

METHODS

Twenty otologically healthy subjects (40 normal ears) and 32 patients with ear diseases (40 pathological ears) were examined sonotubometrically using noise signals with an ideally flat spectrum (PSEQ). Dry swallowing, water swallowing, and Toynbee maneuver were used to induce ET openings. Analysis was performed regarding the frequency of occurrence, duration, amplitude, and form of the ET openings.

RESULTS

PSEQ allowed the detection of an ET opening in all 40 normal ears (91% of the performed maneuvers) and in 87.5% of the ears with impaired ET function (but only 47% of the maneuvers). The average amplitude of the openings in healthy ears was 16.86 dB, the average duration was 363 ms. In diseased ears these values were significantly lower: 9.73 dB, p < 0.001 and 280 ms, p < 0.05.

[Vertigo and falls in the elderly: Part 2: Fall diagnostics, prophylaxis and therapy]

In many acute or chronic vestibular diseases in old age, the risk of falling is increased. A fear of falling often develops together with further limitations to physical activity and subsequent physical and psychological consequences. Falls represent a substantial health-related risk factor. A regular balance, walking and muscle training is an effective prophylaxis. Components of the treatment of vestibular diseases in old age are counselling and encouragement (psychotherapy), treatment of the specific organic disease, specific vestibular rehabilitation and a symptomatic medication therapy. Vertigo in old age is a multifactorial process. The differential diagnosis of disorders of the equilibrium function in old age represents a challenge which can only be overcome by interdisciplinary cooperation.

[Vertigo and falls in the elderly. Part 1: epidemiology, pathophysiology, vestibular diagnostics and risk of falling]

Disorders of the equilibrium function in the elderly will increase in the coming years due to demographic changes in Germany. In addition to a reduction in the quality of life of affected patients, the risk of suffering from a fall increases with age. At the morphological level age-specific changes of the peripheral vestibular structures, somatosensory pathways and vision can be found, such as degenerative alterations, reduced number of cells and receptors and an accumulation of lipofuscin. Disorders of the equilibrium function in old age are individual-specific, complex procedures which develop from age-related physiological, degenerative alterations in the components of the sensomotor system which maintain equilibrium and can come into being together with vestibular and non-vestibular accompanying diseases as well as psychological factors.

Bilateral posterior semicircular canal aplasia and atypical paroxysmal positional vertigo: a case report

Isolated congenital malformations of semicircular canals are rare abnormalities. Most inner ear abnormalities occur in syndromes and are associated with hearing loss. Unilateral or bilateral single aplasia of one semicircular canal does not usually result in vertigo, but these become clinically important if there are clinical complaints of vertigo. Computed tomography imaging and high resolution magnetic resonance imaging may reveal inner ear abnormalities. The case is presented here of a 46-year-old male with a 10-year history of recurrent positional vertigo with strong onset when changing position to the left side. Magnetic resonance imaging of the inner ear showed a bilateral posterior semicircular canal aplasia as well as an enlarged vestibule on both sides. Dix-Hallpike positional manoeuvre revealed a positional nystagmus in the left head-hanging position of short duration and latency of a few seconds. When rising, vertigo occurred, but no nystagmus was visible. The fast phase of the nystagmus was mainly vertical down-beating with a slight torsional component to the uppermost ear. Although benign paroxysmal vertigo of the anterior canal was suspected, physical therapy was not effective using a modified liberatory manoeuvre. Brandt-Daroff therapy was effective permanently.

Presbyvertigo-aging of otoconia and vestibular sensory cells

Imbalance is a common clinical problem in elderly persons. Subsequently falls and fractures may occur. Age-related balance problems constitute an underestimated but prominent public health problem and a socioeconomic burden. At the histological level the peripheral vestibular system in animals and humans exhibits a variety of age-related changes. The number of otoconia in the utricule and the saccule is reduced with increasing age. Degenerated otoconia caused by aging showed distinct changes of the shape. Moreover age-related decreasing hair cell counts, lipofuscin inclusions and deformation of cilia are observed in human vestibular sensory and supporting cells. Results of vestibular function testing of age-related balance disorders still remain controversially. Regular balance training and vestibular rehabilitation results in less more falls and imbalance.

First clinical experience with β-trace protein (prostaglandin D synthase) as a marker for perilymphatic fistula

A diagnosis of perilymphatic fistula is still controversial. Recently, a case report indicated that β-trace protein (prostaglandin D synthase) might be a potential marker for perilymphatic fluid. In this multicentre clinical case series study β-trace protein was used as a marker for perilymphatic fluid fistula. Fifteen fluid samples were collected during diagnostic tympanoscopy. In addition, five samples were collected from patients with tympanic membrane perforation for use as as negative controls. Samples were obtained using precision glass capillaries and were analysed for β-trace protein using laser nephelometry. The diagnosis of perilymphatic fistula was defined by the patient's history, the audiological and vestibular investigation and the findings at tympanoscopy. The cut-off level of β-trace protein for perilymph-positive samples was chosen at 1.11 mg/l. The sensitivity and specificity were calculated using a 2 × 2 contingency table. There was no false positive result, but in two cases a false negative result was found. The specificity was 1 and the sensitivity was 0.81. The material of this first clinical study is small owing to the rarity of patients undergoing diagnostic tympanoscopy for perilymphatic fluid fistula. However, according to these preliminary results β-trace protein might be a promising marker in the diagnosis of perilymphatic fluid fistulas.

Endoscopic examination of the eustachian tube: a step-by-step approach

OBJECTIVE

The aim of this study was to develop a step-by-step approach for endoscopic examinations of the eustachian tube on awake patients and to report anatomic and functional findings.

STUDY DESIGN

Prospective study.

SETTING

University hospital.

PATIENTS

Convenience sample of seven individuals without a history of ear disease.

INTERVENTION

Diagnostic transnasal-transpharyngeal videoendoscopy of the eustachian tube with 30- and 70-degree rigid Hopkins rod endoscopes, 2.5- and 0.8-mm, 0-degree flexible fiber endoscopes performed under local anesthesia in 12 eustachian tubes.

MAIN OUTCOME MEASURES

Utility of the various endoscopes for the diagnosis in the different parts of the eustachian tube; quality of vision and the patient's comfort during the procedure.

RESULTS

The 2.5-mm flexible endoscope was most useful for examination of the pharyngeal ostium and the cartilaginous lumen of the tube. The isthmus region could only be passed using an 0.8-mm fiberscope. In all cases, it was possible to insert the endoscope into the middle ear cavity. Eleven of the 12 tube examinations showed normal findings. The mobility of the tubal cartilage could be visualized with sufficient quality. In 50% of all examinations, application of local anesthesia via a tube catheter was necessary to make the procedure tolerable.

CONCLUSION

The presented approach allows an assessment of both anatomic and functional changes to the eustachian tube in awake patients. The assessment of middle ear structures is limited. To ensure a comfortable and safe procedure, the use of topical anesthesia in a supine position and, in certain cases, additional anesthesia via eustachian tube catheter is recommended.

Endoskopische Untersuchungen der Eustachi-Röhre

BACKGROUND AND OBJECTIVE

Endoscopy of the eustachian tube allows direct examination of endoluminal alterations in the course of the organ. The aim of this study was to describe anatomic and functional findings in healthy awake subjects.

PATIENTS/METHODS

Ten eustachian tubes in six healthy individuals with no history of tube dysfunction were examined under local anesthesia using different types of rigid and flexible endoscopes.

RESULTS

Nine of ten tubes presented with no pathologic finding. The motility of the tube cartilage could be visualized in all cases and showed a wide variety. Prior anesthesia of the mucosa with the subject in the supine position, if necessary supplemented by a tube catheter, rendered the procedure more comfortable.

CONCLUSION

The eustachian tube shows a wide spectrum of anatomic and functional varieties in normal subjects. The method allows comprehensive evaluation of anatomic and functional stenoses of the eustachian tube. The transnasal-transpharyngeal approach allows only limited evaluation of the middle ear structures.

[Infectious mononucleosis]

The primary infection with Epstein-Barr virus in an immunocompetent individual leads to infectious mononucleosis with symptoms of diphtheroid angina, lymph node swelling in the neck and hepatosplenomegaly. The most common age of infection lies between 15 and 25 years. The illness can affect a number of organs simultaneously and thus requires interdisciplinary diagnostics. For differential diagnosis, a differential blood analysis and a EBV quick test are required. The presence of IgM antibodies demonstrates the presence of the infection. Ultrasound of the abdomen can be made to determine the involvement of additional organs. In most cases, recovery occurs without complications. Acute cases can usually be handled successfully with medication. If symptomatic treatment fails, pharyngeal airway obstruction is possible and a tonsillectomy may be necessary. Otherwise, surgical treatment is obsolete. Generally, the prognosis is good. Severe courses and complications are rare.

Procedures for restoring vestibular disorders

This paper will discuss therapeutic possibilities for disorders of the vestibular organs and the neurons involved, which confront ENT clinicians in everyday practice. Treatment of such disorders can be tackled either symptomatically or causally. The possible strategies for restoring the body's vestibular sense, visual function and co-ordination include medication, as well as physical and surgical procedures. Prophylactic or preventive measures are possible in some disorders which involve vertigo (bilateral vestibulopathy, kinetosis, height vertigo, vestibular disorders when diving (Tables 1 (Tab. 1) and 2 (Tab. 2)). Glucocorticoid and training therapy encourage the compensation of unilateral vestibular loss. In the case of a bilateral vestibular loss, it is important to treat the underlying disease (e.g. Cogan's disease). Although balance training does improve the patient's sense of balance, it will not restore it completely.In the case of Meniere's disease, there are a number of medications available to either treat bouts or to act as a prophylactic (e.g. dimenhydrinate or betahistine). In addition, there are non-ablative (sacculotomy) as well as ablative surgical procedures (e.g. labyrinthectomy, neurectomy of the vestibular nerve). In everyday practice, it has become common to proceed with low risk therapies initially. The physical treatment of mild postural vertigo can be carried out quickly and easily in outpatients (repositioning or liberatory maneuvers). In very rare cases it may be necessary to carry out a semicircular canal occlusion.Isolated disturbances of the otolith function or an involvement of the otolith can be found in roughly 50% of labyrinth disturbances. A specific surgical procedure to selectively block the otolith organs is currently being studied. When an external perilymph fistula involving loss of perilymph is suspected, an exploratory tympanotomy involving also the round and oval window niches must be carried out. A traumatic rupture of the round window membrane can, for example, also be caused by an implosive inner ear barotrauma during the decompression phase of diving. Dehiscence of the anterior semicircular canal, a relatively rare disorder, can be treated conservatively (avoiding stimuli which cause dizziness), by non-ablative "resurfacing" or by "plugging" the semicircular canal. A perilymph fistula can cause a Tullio-phenomenon resulting from a traumatic dislocation or hypermobility of the stapes, which can be surgically corrected. Vestibular disorders can also result from otosurgical therapy. When balance disorders persist following stapedectomy it is necessary to carry out a revision operation in order to either exclude a perilymph fistula or shorten the piston. Surgically reducing the size of open mastoid cavities (using for example porous hydroxylapatite or cartilage) can result in a reduction of vertiginous symptoms while nursing or during exposure to ambient air. Vestibular disturbances can occur both before and after vestibular nerve surgery (acoustic neuroma). Initially, good vestibular compensation can be expected after surgically removing the acoustic neuroma. An aberrant regeneration of nerve fibers of the vestibulocochlear nerve has been suggested as a cause for secondary worsening. Episodes of vertigo can be caused by an irritation of the vestibular nerve (vascular loop). Neurovascular decompression is generally regarded as the best surgical therapy. In the elderly, vestibular disturbances can severely limit quality of life and are often aggravated by multiple comorbidities. Antivertiginous drugs (e.g. dimenhydrinate) in combination with movement training can significantly reduce symptoms. Administering antivertiginous drugs over varying periods of time (e.g. transdermal scopolamine application via patches) as well as kinetosis training can be used as both prophylactically and as a therapy for kinetosis. Exposure training should be used as a prophylactic for height vertigo.

[Time-dependent vestibular function loss of semicircular canals and otolith organs in Menière's disease]

INTRODUCTION

Since Dohlmann's investigations the extremely variable interindividual natural course of Menière's disease has been documented. The description of sub-entities of Menière's disease shows, the localisation of dysfunction within the labyrinth is of considerable importance. The selective investigation of crista and macula sensor organs and its time-dependent progression even provides information for the disease's staging.

METHODS

In the retrospective trial presented here, 126 patients suffering from vertigo were tested by the methods described above. 10 of these patients who showed a triad of symptoms including vertigo attacks, unilateral sudden hearing loss and tinnitus were selected for this study. All 10 patients were tested within 48 hours after the last acute vertigo attack by means of caloric irrigation and VEMPs.

RESULTS

The function loss verified in saccular testing could be found in Menière's disease progression at an earlier stage than the utricular function loss. Most patients with a long history of vertigo attacks also suffered from a dysfunction of the semicircular canals.

DISCUSSION

The differential testing of the otolith function is a valid tool for the recognition of early labyrinth dysfunction in Menière's disease and could lead to an earlier onset of specific therapy. It also provides the base for a differentiated staging prior to therapy planning.

Otolithenfunktionstests - Ein differenziertes, qualitätsgesichertes Screeningsystem

INTRODUCTION

More than 30% of all otogenic vestibular disorders are related to isolated macular dysfunction. Videooculographic examination techniques for the otolith-ocular reflex, e. g. by means of eccentric rotation tests, are not widely used in clinical routine as these put a considerable strain on technical and staff resources. Thus, there is a considerable risk of "false negative" classification of vertigo disorders being labelled as "non-otogenic". By means of vestibular-evoked myogenic potentials (VEMPs) and caloric irrigation in prone and supine position, several examination techniques for a side-related investigation of macula-induced vestibulo-ocular reflexes are available. The objective of this study is to compare and evaluate these techniques as screening tests.

METHODS

In 32 patients with vestibular disorders we performed investigations for VEMPs, eccentric rotation tests, as well as caloric irrigation for macular reaction in prone and supine position. In addition, we performed other audiologic and vestibular function tests which were complemented by the clinical course in order to differentiate each case between otogenic and non-otogenic vertigo with or without macular affection.

RESULTS

The technical feasibility as well as patients' acceptance for VEMP testing is better than for eccentric rotation tests. The sensitivity index for VEMPs (89%) as well as for caloric irrigation in prone and supine position for macular examination (71%) is satisfactory. However, the specificity of VEMPs is inferior (53%) to eccentric rotation (100%).

DISCUSSION

Both the examination for VEMPs as well as caloric macular testing in prone and supine position carry features which make them feasible for screening, even though these two procedures test for two different parts of the otolith system. However, to confirm a diagnosis and to set up a therapeutic concept for macular function disorders, eccentric rotation should be added.

[Thermal irritation of the organ of equilibrium by means of heat radiation (NIR)]

BACKGROUND AND OBJECTIVE

Convection and conduction are the main factors involved in caloric response. Heat radiation has also been discussed as an important factor. The present work tests whether heat radiation is an essential part of the caloric response and whether caloric irritation of the semicircular canals is possible using two sources with a different near infrared (NIR) spectrum. In addition, we tested whether it is possible to induce a detectable nystagmus reaction using either NIR-radiation sources.

RESULTS

NIR is able to penetrate bone tissue. The temperature elevation in dry and wet bones was almost immediately registered. With high optical power, specific temperature maxima could be seen by focal and selective broad spectrum and monochromatic NIR irritation of the three semicircular canals. Nystagmus could be generated after using both NIR emission sources in five probands.

CONCLUSIONS

NIR generates temperature differences and nystagmus. By using a broad scale as well as a monochromatic NIR-emission source, it is possible to generate a nystagmus. The procedure of NIR-irritation occurs without physical contact, is painless and quiet.

Untersuchungen zum Zoster oticus

BACKGROUND

Herpes zoster oticus is a rare illness with cutaneous symptoms (eruptions) and a colored picture of brain nerve failures. The clinical symptoms, the symptom constellation, diagnostics and therapy, however, have been examined till now only in few studies.

PATIENTS AND METHODS

In this study 91 cases of a zoster oticus were looked at in retrospect from the complete archives of the university ENT clinic Jena/Germany in the period from 1932 to 2001. Inclusion criterion was the occurrence eruptions in the ear region. The demographic data, subjective and objective symptoms, the symptom constellations, diagnostic methods and the therapy were arranged.

RESULTS

Women (68.1 %) were concerned more frequently than men (31.9 %). The average illness age was 51.2 days. The prodromal stage lasted for 2.2 days in the average. Earache (50.2 %) and headache (11.0 %) were the most frequent first symptoms. No prodroma appeared in 27.5 % of the cases. The facial nerve (86.8 %) was most frequently affected, the vestibular nerve in 76.9 % and the cochlear nerve in 36.3 %. Other brain nerve damages were extremly rare. The therapy success was identical with regard to the brain nerve regeneration at all times. A positive antibody titer for VZV-IgM and/or IgA or an IgG is a sign for an acute infektion. VZV-IgA antibody titers appeared more constantly, frequent and early than an IgM.

CONCLUSIONS

Women have a greater risk of falling ill at a zoster oticus than men. Although more than 72 hours is behind the beginning of the symptoms in this study, treatment with virostatic drugs should always be carried out in zoster oticus. Different therapy methods do not have any influence to the success therapy of the therapy. The facial nerve showed the best cure trend. A postzosteric pain develops approximately the half of the cases at the zoster oticus. The serological diagnostic is not necessary in clinically clear cases.

[Selective stimulation of the equilibrium organ using monochromatic near infrared]

BACKGROUND

The aim of this study was, to establish, if a selective thermal warm-stimulation using monochromatic near infrared radiation (NIR) in healthy persons, patients with chronic otitis media (chronic mucosal inflammation) and after radical surgery of one ear shows quantitative or qualitative changes of the nystagmus reaction.

PATIENTS AND METHODS

Healthy persons (n = 3), patients with a large central defect of the tympanic membrane (n = 5) and after radical ear surgery (n = 6) were examined. In healthy persons a stimulation with monochromatic NIR (lambda = 980 nm) of several areals of the external auditory canal was performed. In patients with large defects of the tympanic membrane the promontorium was stimulated. In patients with a radical cave of the ear a selective NIR-stimulation of the region of the vertical and the anterior semicircular canal was performed. The horizontal semicircular canal was visible as a landmark. Registration of the nystagmus was performed by means of videonystagmography.

RESULTS

In healthy persons the mean slow phase velocity of the nystagmus depended on the stimulated region. But there was no qualitative change of three dimensional eye movement. Stimulation of the promontorium showed a strong directional horizontal nystagmus. In patients with a radical cave the stimulation of the regions of the three semicircular canals showed a qualitative difference in three dimensional eye movement. NIR-stimulation showed in all cases a nystagmus into the stimulated ear.

CONCLUSIONS

The method of monochromatic near infrared stimulation can be used for selective stimulation of several regions of the external auditory canal, the promontorium and the regions of the semicircular canals in a radical cave of the ear as well as to prove the warm reaction of the equilibrium organ. A specific nystagmus after stimulation of the semicircular canal-region in a radical cave of the ear could be an indication for a normal semicircular canal function.

[Near infrared stimulation of the equilibrium organ--first clinical experiences]

BACKGROUND

A new method for the stimulation of the organ of equilibrium by means of a broad-scale and monochromatic near infrared emission was developed. This method should be examined within the framework of a pilot study, evaluated and its clinical possible applications examined.

PATIENTS AND METHODS

Healthy probands (n = 15), patients with a radical cave of the ear (n = 5), patients with a defect of the tympanic membrane (n = 5) and spontaneous nystagmus (n = 5) were examined. In healthy probands an irritation with broad-scale as well as monochromatic near infrared (NIR) was performed and compared with a water irrigation (44 degrees, 50 ml in 30 seconds). The subjective, local feelings during the application and the appearance of giddiness according to irritation were recorded and the nystagmus was registered by means of videonystagmography. In patients with radical cave of the ear and tympanic membrane defects, a broad-scale NIR-irritation before a comparative irritation with warm air (44 degrees) was performed exclusively.

RESULTS

In all healthy probands, a nystagmus reaction could be seen with broad-scale and monochromatic NIR. Compared to the hot water irritation slow phase velocity (SPV) was decreased however registrable by means of Frenzel glasses and electronystagmography during the culmination stage. In patients with radical cave (n = 4) and tympanic membrane defects (n = 3) showing paradoxical nystagmus reaction during hot air irritation, a nystagmus to the site of stimulation resulted by means of light calorisation. In patients with a spontaneous nystagmus an attenuation (n = 1) or inversion (n = 2) could be achieved by NIR-radiation.

CONCLUSIONS

The method of the NIR-radiation is suitable in clinical practice for the caloric test proofing warm reaction. Vaporization cold does not occur. The application of heat charm is better proportionable and steerable than during air irritation. The procedure is sterile, noiseless and non-contact. Difficulties in interpretation of results of vestibular tests because of evaporation coldness do not occur.

[Lyme disease--a reason for sudden sensorineural hearing loss and vestibular neuronitis?]

BACKGROUND

Lyme disease has been described as one possible cause of sudden sensorineural hearing loss and vestibular neuronitis. The necessity of serological diagnosis and its therapeutic consequences have been discussed controversially.

PATIENTS AND METHODS

344 patients with acute sensorineural hearing loss and 66 patients with vestibular neuronitis were examined in retrospect. By means of ELISA (Enzygnost Borreliosis, Dade Behring Marburg) the specific prevalences of IgG- and IgM-antibodies against borrelia in serum were evaluated. The frequency of seroprevalences for both diseases were compared to those given in the literature. Neurootological findings of the seropositive patients were compared with those of seronegative and analysed statistically.

RESULTS

15.7 % of the patients with sudden sensorineural hearing loss had positive levels of IgG-antibodies. IgM-titers were elevated in 4.7 % of the patients. The seroprevalences for IgM and IgG were above those described by other investigators for the healthy population. Patients with positive IgM-antibodies showed more often low frequency hearing loss than IgG-positive patients. 18.2 % of the patients with neuronitis vestibularis had IgG- and 1.5 % IgM-antibodies against Borrelia. Whereas IgG occurred more often than known for the healthy population, IgM was within the limit for the healthy population. The seropositive group did not show any remarkable neurootological signs compared with the seronegative group.

CONCLUSIONS

Because of the elevated seroprevalences Borrelia infections may be one possible but very rare cause of sudden sensorineural hearing loss and vestibular neuronitis. Low frequency hearing loss may be a sign for an infection with Borrelia as an etiological factor especially in combination with seropositive titers. In case of the presence of IgM-antibodies, patients may be treated with oral antibiotics (Doxycyclin, Cefuroxim). In patients with neuronitis vestibularis a neuroborreliosis should be excluded by means of lumbar puncture.

[Acute and fulminant fungal sinusitis in immunosuppressed patients]

BACKGROUND

Acute and invasive fungal sinusitis represent rare diseases which can lead to life threatening complications. Immunosuppressed patients are affected primarily. The expansion of transplantation medicine and the progress in therapy of malignant diseases of the lymphatic system are associated with an increase of opportunistic systemic mycoses. Therefore the otorhinolaryngologist is confronted increasingly with these problems and questions for surgery, especially if the symptom of a periorbital inflammation occurs as a sign for a beginning orbital complication and radiological signs of involvement of the paranasal sinuses exist.

PATIENTS

We report exemplary about two immunosuppressed patients with an invasive and fulminant fungal aspergillosis of the paranasal sinuses. In spite of systemic antifungal therapy and surgical intervention, intracranial and systemic complications caused a lethal course.

CONCLUSIONS

In immunosuppressed patients with clinical and radiological signs for a sinusitis and a periorbital inflammation an invasive fungal sinusitis should be considered. Pathogenic aspergillus species are the most common identified in fungal sinusitis. The disease with often lethal outcome requires a careful and fast diagnostic and therapy as well as interdisciplinary co-operation. If and when limited or extensive surgery should be performed remains, because of the rarity and the lacking experience with this disease, still a controversially discussed issue and depends on several factors: the kind of disease, the immunity, the subtype of invasive fungal sinusitis and the degree of tissue invasion.

[Degenerative changes in parapharyngeal schwannoma "ancient schwannoma". Case report and review of the literature]

Schwannomas are rare, slow-growing, benign neoplasms derived from the schwann cells of the nerve sheath of peripheral nerves. Extracranial schwannomas are most frequently localized within the extremities or the head and neck region. For example, they are common in the skull base, the carotid sheath, and the parapharyngeal space. Beneath several histological variants, schwannomas showing prominent degenerative changes (so-called,,ancient schwannomas") are exceedingly rare. Histopathological features, such as degenerative changes and nuclear atypias in ancient schwannomas, may be easily confused with malignant mesenchymal neoplasm.We present the case of a 32-year-old female who required surgery for a parapharyngeal neoplasm. Histological examination revealed features of an ancient schwannoma.