Congenital stenosis of the lower esophagus associated with leiomyoma and leiomyosarcoma of the gastrointestinal tract

Congenital esophageal stenosis: a rare malformation of the foregut

Congenital esophageal stenosis (CES) is a type of esophageal stenosis, and three histological subtypes (tracheobronchial remnants, fibromuscular thickening or fibromuscular stenosis, and membranous webbing or esophageal membrane) are described. Symptoms of CES usually appears with the introduction of the semisolid alimentation. Dysphagia is the most common symptom, but esophageal food impaction, respiratory distress or failure to thrive can be clinical manifestations of CES. Wide spectrum of differential diagnoses leads to delayed definitive diagnosis and appropriate treatment. Depends on hystological subtype of CES, some treatment procedures (dilation or segmental esophageal resection) are recommended, but individually approach is still important in terms of frequency and type of dilation procedures or type of the surgical treatment. Dysphagia can persist after the treatment and a long follow-up period is recommended. In 33% of patients with CES, a different malformations in the digestive system, but also in the other systems, are described.

Benign paroxysmal positional vertigo in a child: an infrequent complication following a fairground ride and post-cochlear implant surgery

OBJECTIVE AND IMPORTANCE

Benign paroxysmal positional vertigo (BPPV) is an uncommon complication that can develop after cochlear implantation. This condition has been documented in adults as a complication of cochlear implant surgery. However, there is no reported literature on BPPV in children who have undergone cochlear implant surgery.

CLINICAL PRESENTATION

A 13-year-old girl underwent the insertion of a cochlear implant and developed BPPV as a result of visiting fairground rides approximately 2 years after surgery.

INTERVENTION

We performed a right Epley's maneuver. She was advised to do Brandt-Daroff exercises for 6 weeks. She became symptom free within a few weeks of doing vestibular rehabilitation exercises. Nevertheless, she had been compliant with vestibular rehabilitation for 6 weeks.

CONCLUSION

The vibration injury to the labyrinth caused during the various rides could be analogous to the mechanism of trauma to the labyrinth as occurs during head injury. The other possibility could be dislodgement of the otoconia from the already vulnerable utricle that has been subject to cochlear implantation. It is presumed that the vulnerability of the labyrinth following the cochlear implantation happened as the child suffered from dizziness in the immediate post-operative period. However, a chance association between the insertion of the cochlear implant and the development of the symptoms of BPPV in this patient cannot be ruled out.

[Present state of cochlear implant treatment in adults and children]

The technique of cochlear implantation was the first method which allowed replacement of a sense organ by a (partially) implantable electronic prosthesis. By this method the cells of the spiral ganglion of the cochlea are directly stimulated by the electrodes introduced into the cochlea, bypassing the functions of the outer and middle ear as well as the cochlea. Treatment with a cochlear implant (CI) has been established over the last 20-30 years as a reliable method for restoring hearing in adults and children with severe hearing disorders and is now a routine method in many centers. For optimal results in understanding speech and for children in the speech development phase, rehabilitation must be an integral part of the total treatment and follow soon after implantation. To achieve this early diagnosis of hearing difficulties or deafness is necessary, which is simplified by a consistent hearing screening of newborns, now a statutory procedure in Germany.

Skin flap thickness in cochlear implant patients - a prospective study

The thickness and quality of the skin overlying a cochlear implant is important for its integrity. It should be thick enough to protect the implant and prevent flap breakdown yet should not be so thick that it impedes the electronic signal or causes difficulty wearing the coil because of loss of the magnetic coupling. The principle of this study was to devise a method to assess the thickness of skin over a cochlear implant receiver stimulator package and prospectively measure this thickness during the first year following surgery. All patients studied were implanted with MED-EL COMBI 40+ implants. The first cohort consisted of 35 adults; the second 23 children. Various methods of measurement were assessed. In this study the principle of the Hall Effect electrode was used to measure the magnetic flux density of the magnet within the receiver stimulator package. Following standardization, results showed that skin thickness significantly thinned in the adult group before stabilizing. This was less obvious in children, probably due to the effect of the skin thickening as the child grows. Knowledge of skin thickness has implications relating to the functioning of an implant and avoiding potential flap related complications.

Rescuing the imperiled cochlear implant: a report of four cases

OBJECTIVE

To report experience with exposed cochlear implants in patients with risk factors that may contribute to flap failure.

STUDY DESIGN

Retrospective review.

SETTING

University-based tertiary referral center.

PATIENTS

Four patients with exposed cochlear implants who presented with various risk factors that compromise healing.

INTERVENTION

After beginning antibiotic therapy, we took steps to correct the thyroid levels and blood glucose levels when indicated. We administered hyperbaric oxygen therapy in one case. At surgery, we debrided all devitalized and infected tissue. In one case, it was necessary to obliterate the mastoid bowl and relocate the device to a different site around the ear. In all four cases, we covered the implant with well-vascularized rotation flaps.

MAIN OUTCOME MEASURES

Wound healing, resolution of infection, and preservation of implant function.

RESULTS

In each case, the infection cleared and the implant covered. Nevertheless, one of the patients suffered implant failure 6 months after salvage surgery, and another suffered implant failure 3 years after salvage.

CONCLUSION

All exposed or infected implants need not be removed. By using sound wound handling technique and by optimizing the patient's medical status, many exposed implants can be salvaged.

Facial nerve stimulation after cochlear implantation

OBJECTIVES

This study was designed to compare the incidence and nature of facial nerve stimulation (FNS) in patients receiving cochlear implants (CI) manufactured by Cochlear Corporation, Advanced Bionics Corporation, and MedEl.

STUDY DESIGN

Retrospective chart review at a tertiary referral center.

METHODS

The charts of 600 patients who received CIs from 1993 to 2003 with at least 1 year of follow-up were reviewed for significant FNS (FNS on at least 1 channel at functional stimulation levels). Data collected included age, sex, etiology of deafness, device type, electrode, FNS onset after initial stimulation, number and location of electrode contacts causing FNS, and loudness level at which FSN occurred. Nucleus straight and perimodiolar electrodes were also compared.

RESULTS

Thirty-nine of 600 (6.5%) patients had FNS on at least one channel, (MedEl 3 of 43 [7.0%], Nucleus 29 of 440 [6.6%], and Clarion 7 of 117 [6.0%]). The incidence of FNS in Nucleus perimodiolar electrodes (16 of 250 [6.4%]) was similar to straight electrodes (13 of 190 (6.8%]), as was the mean number of electrodes causing FNS per patient (11 vs. 12). However, straight electrodes caused stimulation at significantly softer perceived loudness levels than perimodiolar electrodes (P < .0001).

CONCLUSIONS

In this large series of CI FNS, the overall incidence of FNS is consistent with previous reports. All devices had a similar incidence of FNS, but perimodiolar electrodes produced FNS only at significantly higher loudness levels than straight electrodes, making them preferable for patients at risk for FNS receiving Nucleus devices.

The Suprameatal Approach: An Alternative Surgical Approach to Cochlear Implantation

The suprameatal approach is an alternative method for performing cochlear implantation developed in the Sheba Medical Center in 1999. This technique eliminates the need for mastoidectomy and posterior tympanotomy. The middle ear is entered through a retroauricular tympanotomy flap, and the electrode is introduced into the cochlea via a tunnel drilled in the suprameatal region superior to Henle's spine. The suprameatal approach is a simple and safe technique that does not endanger the facial nerve nor the chorda tympani. A wide exposure of the promontory enables exact determination of scala tympani and smooth introduction of the electrodes into the cochlea. This technique may also be used in malformed or ossified cochlea. Until now 140 patients were operated in our department and an additional 48 patients were operated on in the department of Otorhinolaryngology at the University of Vienna employing the suprameatal approach technique.

Minimal access surgery for pediatric cochlear implantation

OBJECTIVE

To develop a minimal access approach for pediatric cochlear implantation to improve the acceptability of the procedure for parents, children, and the wider community, and to reduce flap-related complications of the procedure.

STUDY DESIGN

Prospective evaluation of a new surgical technique.

METHOD

A new approach was developed through a short, oblique, straight postauricular incision without shaving any hair. It involved drilling the bony well for the implant inside a small subperiosteal pocket.

PATIENTS

Twenty-three consecutively implanted children with the Nucleus implanted system, whose median age was 3.2 years (mean 4.1 years, range 1.6-11.2 years.

RESULTS

The technique proved feasible in all the 23 children, and no major complications were encountered. Three instances of wound edema were observed early in the series; by minimizing tissue elevation and overzealous retraction, these complications were not encountered subsequently. The approach was warmly endorsed by parents, children, and caregivers, who greatly appreciated the minimal impact of the approach.

CONCLUSION

The proposed new approach is very well accepted by implanted children and their families, reduces the psychologic trauma of the intervention, and has less risks of flap complications.

Congenital gastrointestinal stromal tumour is morphologically indistinguishable from the adult form, but does not express CD117 and carries a favourable prognosis

AIMS

The histological and immunohistochemical features of a congenital stromal tumour of the jejunum are compared with those of adult gastrointestinal stromal tumours (GIST). The literature concerning the diagnosis and prognosis of congenital small intestinal stromal tumours is reviewed.

METHODS AND RESULTS

A term female infant presented with intestinal obstruction, from birth. Histology of a 15-mm jejunal nodule showed a predominantly spindle-cell tumour with epithelioid areas. There was a low mitotic count and mild nuclear pleomorphism, extensive necrosis and haemorrhage, and focal calcification. Immunohistochemically, tumour cells stained for muscle specific actin and vimentin. Staining for CD117 (c-kit), S100, desmin and CD34 was negative. The features were compared to those of seven adult cases: no morphological feature was specific to the congenital tumour, which was smaller than the adult cases. There were no ultrastructural features specific for a particular line of differentiation. Immunohistochemical staining patterns were similar, except for CD117, which was strongly positive in all adult tumours, but negative in the congenital tumour.

CONCLUSIONS

This congenital jejunal stromal tumour morphologically resembled adult GIST, but lack of c-kit expression suggests that it is nosologically distinct. Despite the presence of histological features which would cause the tumour to be categorized as malignant in an adult, it is apparent from previous reports of congenital small intestinal stromal tumours that the prognosis is favourable.

Topographical relationships among the facial nerve, chorda tympani nerve and round window with special reference to the approach route for cochlear implant surgery

The topographical relationships among the facial nerve (FN), chorda tympani nerve (CT), and round window (RW) in 22 temporal bone specimens were analyzed morphometrically in order to examine which route is widest through the facial recess between the FN and CT during cochlear implant surgery and in order to establish some criteria to assist in the evaluation of the best surgical approach. Two lines, i.e., the FN-RW line and CT-RW line, were speculated as limitations of a visual field for this surgery. According to the relative position of these structures, including the posterior wall of the external auditory canal (EAC) and an inserted pin-gage that indicates the hypothetical widest approach route, the relationships were classified into five types. Most frequently, the widest approach route through the facial recess did not point directly at the RW, but at the basal turn at the promontory. Moreover, this approach route crossed the FN-RW line in a posterior to anterior direction and the CT-RW line frequently crossed the posterior wall of the EAC. The latter seemed to provide a critical landmark for avoiding damage to the CT during cochlear implant surgery. Therefore, we recommend inserting the electrode into the basal turn.

Does malignant transformation of benign soft-tissue tumours occur? A clinicomorphological study of ten initially misdiagnosed soft-tissue sarcomas

Ten soft-tissue sarcomas out of a consecutive series of 201 neoplasms are described, in which the clinical histories were suggestive of malignant transformation of a benign lesion excised from the same location 2-97 months before. Each of the 10 preceding soft-tissue neoplasms was reviewed histologically and reclassified as either highly (n = 8) or moderately differentiated (n = 2) sarcomas. Irrespective of the primary treatment, these initially misdiagnosed tumours showed an overall better prognosis than the whole group of soft-tissue sarcomas (5- and 10-year survival rates 76% versus 44%, and 52% versus 30% respectively). Their clinical course was, however, characterized by up to 6 (mean 2.9) local recurrences. From the total series of 201 tumours the authors conclude that soft-tissue sarcomas other than malignant schwannomas in the setting of von Recklinghausen's disease only exceptionally, if ever, arise from benign precursors.

Esophageal sarcomas

The clinical and pathologic characteristics of five patients with esophageal sarcomas are presented, including the only recorded esophageal Triton tumor (malignant schwannoma), the third recorded synovial sarcoma, two patients with carcinosarcoma, and one with leiomyosarcoma. All five patients were males who presented with dysphagia. Three tumors were in the cervical esophagus, and the remaining two were in the distal esophagus. On endoscopic examination, three of the tumors were noted to be polypoid, while the other two were sessile. Two patients presented with disseminated disease, and a third was locally unresectable. These three patients were treated with palliative intent. The remaining two patients underwent surgical excision and postoperative radiation therapy, and are alive and well 6 and 7 years following treatment. This experience suggests that combined modality therapy employing postoperative radiation may be effective in managing these rare lesions.

Disseminated leiomyosarcoma in a child with acquired immune deficiency syndrome

A child with disseminated leiomyosarcoma and acquired immune deficiency syndrome (AIDS) is reported. She was originally believed to have peptic ulcer disease by radiographic and endoscopic evaluation but was found subsequently to have hypergastrinemia, hypochlorhydria, and a smooth muscle tumor. Leiomyosarcoma in children and its evolution in AIDS are discussed.