Lymphocytic hypophysitis - various course of the disease and individualized therapeutic approach. An algorithm of the follow-up

INTRODUCTION

Lymphocytic hypophysitis (LH) is a rare inflammatory disorder of the pituitary or/and hypothalamus with variable disease course: from spontaneous remission to pituitary atrophy. The diagnosis, treatment and follow-up remain challenging. The aim of the study is to present long-term data and an individualized therapeutic approach and propose an algorithm for the follow-up of patients with probable LH.

MATERIAL AND METHODS

A retrospective analysis of 18 consecutive adult patients (13 W/5 M, mean age 45.2 years) with LH diagnosed and treated in a tertiary referral center.

RESULTS

The first manifestations were headaches (50.0%), polyuria/polydipsia (33.3%) and symptoms of hypopituitarism (16.7%). Somatotropic, adrenal, gonadal and thyroid axis insufficiencies were found in 44.4%, 33.3%, 33.3%, and 27.8% of patients, respectively. Arginine vasopressin deficiency was diagnosed in 8 patients (44.4%). Some of the dysfunctions were transient. Magnetic resonance imaging (MRI) revealed thickened pituitary stalk in all but 2 cases. In 2 patients an anterior pituitary lesion, most likely inflammatory was described. Four patients were given steroids (severe headaches) with clinical recovery and stable/improved MRI. One woman was operated on due to the progressive mass-related symptoms - histopathological examination confirmed LH. In the remaining 13/18 patients watchful waiting approach allowed to obtain hormonal and radiological stabilization/improvement.

CONCLUSIONS

LH is a disease with a complex clinical picture and challenging diagnosis. Treatment requires an individual approach: vigilant observation is the cornerstone of therapy, with steroid/surgical treatment reserved for cases with mass-related symptoms. Further multicenter research might help in better understanding of the LH and creating standards of care in this rare disease.

Management of frontal sinus fractures requiring surgical intervention: An analysis of a case series

<b><br>Introduction:</b> Isolated frontal bone fractures constitute 5-15% of traumatic facial fractures cases, with frontal sinus fractures categorized into anterior wall, posterior wall, or complex fractures. The approach is tailored to fracture type and bone fragment displacement. This paper presents the summary of surgical management in patients with isolated and complex fractures of the anterior wall of the frontal sinus.</br> <b><br>Material and Methods:</b> Five patients with different frontal sinus fractures were treated surgically. The same management protocol - diagnosis and surgical intervention was implemented in all cases The retrospective analysis included fracture assessment, surgical approach, and long-term outcomes evaluation.</br> <b><br>Results:</b> The most common cause of fractures was falls, while two complex fractures involved the anterior and posterior walls. External approach, bone fragment removal, endoscopy, and external stabilization were employed in all cases. One patent required delayed revision surgery due to retaining metallic foreign body. Follow-up radiological examinations showed proper healing and cosmetic outcomes were satisfactory in all of the cases.</br> <b><br>Conclusion:</b> Surgical management of isolated fractures of the frontal sinus anterior wall, involving bone fragment removal, realignment, and endoscopy, yielded satisfactory functional and cosmetic outcomes without internal or external stabilization. Long-term monitoring and symptom assessment are crucial, especially in cases with penetrating injuries and foreign body risk.</br>.

Do face masks affect the way we hear?

<b><br>Aim:</b> The aim of the study was to assess if wearing a face mask, hung from the ears, had an effect on the understanding of speech and the perception of surrounding sounds.</br> <b><br>Materials and Methods:</b> Assessment of auditory perception using verbal noise audiometry in two clinical conditions; without a face mask and with a face mask. To assess the auditory perception ability, two parameters were measured; word recognition score (WRS) and sound intensity at maximal WRS.</br> <b><br>Results:</b> Without wearing facial masks, the maximum values of WRS for the study group ranged from 75% to 100% with 52% of respondents achieved WRS 100%. While wearing face masks, the highest calculated WRS for the study group ranged from 80% to 100%, with 32% of individuals achieved WRS of 100%.</br> <b><br>Conclusion:</b> The wearing of face masks do not change the speech recognition scores. This may indicate a stronger role of psycho-sociological aspects of hearing difficulties during the Covid-19 pandemic.</br>.

Bone Conduction Threshold Measurements in Patients with Bone Conduction Devices: A Comparison of Available Methods

BACKGROUND

The semi-implantable bone conduction devices connect the skull to the hearing device by means of an implant. This implant affords us 3 possible methods for conducting bone conduction evaluation, which may produce a different result for the same patient, and comparisons of results from different centers may therefore be interpreted incorrectly. Thus, the authors attempt to quantify the audiometric differences between the obtained auditory results and to check whether the results of standard pure tone audiometry could be replaced with the results obtained by alternative measurement methods.

METHODS

Measurements were conducted in a group of 53 adult patients implanted with bone conduction devices in 3 modes: bone conduction-direct, when the bone conduction device itself is used to assess the audiometric threshold; bone conduction-pure tone audiometry with audiometric oscillator placed over mastoid aside of an implant; and bone conduction-indirect with oscillator placed on an implant.

RESULTS

The analysis revealed differences between obtained results, which can reach up to 21.48 dB with a mean of 10 dB across all frequencies. The lowest values, regardless of the type of implant connection ("magnetic"; "snap"), were recorded for bone conduction-indirect mode whereas the highest mean all-frequency thresholds were recorded in the mode defined as bone conduction-direct.

CONCLUSION

The method that provides the most comparable thresholds is when the oscillator is positioned on the mastoid, aside from an implant. It should be the method of choice for any hearing evaluation in patients fitted with bone conduction devices, because of standardized equipment and the availability of preoperative data obtained with the same method.

Pituitary stalk metastasis of a neuroendocrine tumour of unknown origin

Not required for Clinical Vignettes.

Pituitary tumours in MEN1 syndrome - the new insight into the diagnosis and treatment

Pituitary tumours are a common pathology affecting 15-20% of the population. Only about 1‰ of adenomas are clinically manifested; among them, about two/thirds are hormonally active, most often secreting prolactin or growth hormone. Pituitary tumours are mainly an isolated pathology, without any genetic background. However, the latest studies pay special attention to the possibility of developing an adenoma as a result of genetic mutation. Among pituitary adenomas, the leading group of genetically determined lesions is related to a mutation in AIP or MEN1, followed by PRKAR1A, GRP101, DICER, and SDHx. The genetic basis of these pituitary tumours is related to positive family history, young age of the patient, aggressive clinical process, and resistance to treatment. Pituitary tumours occur in over 40% of patients with MEN1 syndrome - often in women, they are more than 1 cm in diameter, and secrete prolactin. They are usually diagnosed in the fourth decade of life and show a worse response to pharmacotherapy than sporadic ones. Confirmation of the genetic background of the pituitary tumour implies measurable implications; it might help to direct the diagnosis in patients' family members, partially predict the development of the disease, and, above all, extend patients' life expectancy.

Traumatic brain injuries induced pituitary dysfunction: a call for algorithms

Traumatic brain injury affects many people each year, resulting in a serious burden of devastating health consequences. Motor-vehicle and work-related accidents, falls, assaults, as well as sport activities are the most common causes of traumatic brain injuries. Consequently, they may lead to permanent or transient pituitary insufficiency that causes adverse changes in body composition, worrisome metabolic function, reduced bone density, and a significant decrease in one's quality of life. The prevalence of post-traumatic hypopituitarism is difficult to determine, and the exact mechanisms lying behind it remain unclear. Several probable hypotheses have been suggested. The diagnosis of pituitary dysfunction is very challenging both due to the common occurrence of brain injuries, the subtle character of clinical manifestations, the variable course of the disease, as well as the lack of proper diagnostic algorithms. Insufficiency of somatotropic axis is the most common abnormality, followed by presence of hypogonadism, hypothyroidism, hypocortisolism, and diabetes insipidus. The purpose of this review is to summarize the current state of knowledge about post-traumatic hypopituitarism. Moreover, based on available data and on our own clinical experience, we suggest an algorithm for the evaluation of post-traumatic hypopituitarism. In addition, well-designed studies are needed to further investigate the pathophysiology, epidemiology, and timing of pituitary dysfunction after a traumatic brain injury with the purpose of establishing appropriate standards of care.

Radiological and hormonal improvements in a 22-year-old patient with lymphocytic hypophysitis - the watchful waiting approach

Not required for Clinical Vignette.

Risk factors of tympanoplasties in long-term observation

OBJECTIVES

The aim of the study was to evaluate risk factors influencing the results of tympanoplasties on the base of material taken from the Department of Otolaryngology and Laryngological Oncology Collegium Medicum of Nicolaus Copernicus University in Bydgoszcz between 2004-2009. In this period 98 operations were done. The time from operation to hearing examination was 3 to 7 years, mean 5,43. Tympanoplastic operation were divided according to Tos classification. Measuring hearing results, tonal audiometry was done and mean air bone gap on four frequencies was assesed (500, 1000, 2000, 3000 Hz), according to AAO-HNS guidelines (1995). This parameter was compared between groups separated according to risk factors, that could potentially affect the results. Those risk factors were: disfunction of the Eustechian tube, localisation and size of the perforation of the tympanic membrane, damage of the ossicles, the state of the mastoid process, the number of operations, the presence of the cholesteatoma or granulating tissue, chronic otitis media in the opposite ear, smoking cigarettes, mastoidectomy, canal wall down technique. The results were analysed using statistical test.

RESULTS

The most impotant risk factor affecting treatment&apos;s results (besides discharge from the ear) is damage of the ossicles, especially the malleus and stapes. Well done operation ensures good hearing results irrespectively of the presence of cholesteatoma or granulating tissue, and also in case of reoperation. For all types of tympanoplasties neither the localisation, nor the size of perforation do not influence on hearing results in long term observation.

Temozolomide therapy for aggressive pituitary Crooke's cell corticotropinoma causing Cushing's Disease - a case report with literature review

CONTEXT

Aggressive pituitary tumours causing Cushing's Disease are very rare, difficult to treat, and usually resistant to conventional therapy. There is growing evidence for the use of temozolomide (TZM), an alkylating chemotherapeutic agent, as first line chemotherapy in tumours resistant to repeated neurosurgery, radiotherapy and adrenalectomy.

OBJECTIVE

To present the response to TMZ in a rare case of an aggressive pituitary tumour in the course of Cushing's Disease and to review the literature referring to similar cases.

PATIENT

In this report, we present the case of a 61 year old male patient who was diagnosed with Cushing's Disease in the course of a pituitary invasive macroadenoma in 2011. The patient underwent 4 transphenoidal non-radical neurosurgeries (2012,2013) with rapid tumour progression, repeated non-radical bilateral adrenalectomy (2012, 2013) and stereotactic radiotherapy, and gamma knife surgery (2013, 2015). Histopathological examination revealed macroadenoma with high cell polymorphism and the presence of Crooke's cells, Ki- < 2%. Since 2015 the patient has been treated with 6 cycles of TMZ (320 mg per day for 5 consecutive days, 28-day cycle) with clinical and biochemical improvement and stabilized tumour size and no side effects. TMZ was continued for up to 9 cycles with a stable serum level of cortisol and ACTH being observed. However, clinical symptoms like headaches, visual field impairment, and finally hearing loss started to progress from the eighth cycle. After the ninth cycle of TMZ, there was a sudden increase in the size of the tumour, impairment of the cortisol and ACTH level, marked deterioration of the clinical status with the recurrence of severe headaches, narrowing of the visual field and hearing loss. At the beginning of 2016, a sudden clinical status and sight deterioration, strong headaches, drop of the right eyelid with widening of the pupil were observed. The patient died in February 2016.

LESSONS

The case of our patient suggests that the response to the TMZ treatment monotherapy in aggressive pituitary tumour causing Cushing's Disease could be partial and restricted to 7-8 cycles followed by rapid progression of the tumor mass. Therefore, further research should be carried out with regard to new methods to extend the responsiveness and duration of TMZ treatment and to investigate predictors of responsiveness. < p > < /p >.

Pituitary insufficiency following traumatic thoracic injury in an adolescent male patient: A case report and literature review

RATIONALE

Traumatic thoracic injuries in adolescents are rare but could be connected with traumatic brain injuries (TBI) and development of chronic hypopituitarism. Early recognition of these endocrine problems is a significant challenge to clinicians. We present difficulties in diagnosis of hypothalamic-pituitary insufficiency following traumatic thoracic injury in adolescence. We also review the literature of similar cases.

PATIENT CONCERNS

We present a case of a 24-years-old male. In 2007, at the age of 15 he underwent a severe traffic accident followed by thoracic injury with concussion, hemothorax and dissection of the aorta requiring aortic stent-graft implantation.

DIAGNOSES

During the post-traumatic period, transient polydipsia and polyuria symptoms were observed. The patient had no medical history of any serious disease before the accident, his growth and pubertal development was normal. After the accident the patient did not undergo any routine medical check-ups. In 2013 gonadal axis deficiency was diagnosed during investigation of libido problems. Following the diagnosis testosterone replacement therapy was initiated.

INTERVENTIONS

Further endocrinological investigation was carried out in 2016. The patient's main complaints were decreased mood and poor physical fitness. BMI was 27.34 kg/m, with a tendency to abdominal fat distribution. The patient's height is 160 cm, while Mid Parental Height (MPH) is 173.5 cm. Decreased bone density was found in DEXA examination. Serum growth hormone level (GH) was normal while insulin-like growth factor-1 (IGF-1) level was below normal. Insulin tolerance test (ITT) and low levels of IGF-1 confirmed somatotropic axis deficiency. Nuclear magnetic resonance (NMR) of the hypothalamo-pituitary region showed no abnormalities. PROP 1 and other common genetic mutations associated with GH deficits were excluded. Testosterone treatment was continued. The patient increased physical activity and implemented diet.

OUTCOMES

The patient has lost weight, improved physical activity performance and is feeling better. The procedure to start GH supplementation is now in process.

LESSONS

Based on our case and available literature we suggest that adolescent patients after traumatic brain injuries may require precise investigation and strict monitoring due to the possibility of unrecognized hypopituitarism.