Zenker’s diverticulitis: a bitter pill to swallow

Acute oesophageal obstruction from food bolus impaction is often triggered by underlying oesophageal pathology, both benign and malignant. These can be readily detected with standard investigations such as oesophagoscopy or computed tomography. Zenker’s diverticulum (ZD) is a benign condition frequently presenting with chronic dysphagia or may be asymptomatic. We report the case of an 81-year-old man with a previously undiagnosed 1-cm ZD causing complete oesophageal obstruction secondary to localized oedema from an impacted ibuprofen tablet. Although initial clinical, endoscopic and radiological findings were equivocal and suspicious for upper oesophageal malignancy, symptoms rapidly settled in response to systemic corticosteroids. The diagnosis was later confirmed on barium swallow with no other clinical, radiological or histopathological abnormalities identified. In conclusion, ZD is an uncommon cause of acute oesophageal obstruction which may occur in diverticula of all sizes. Surgery should be performed in patients with recurrent symptoms or large diverticula.

Concurrent management of suppurative intracranial complications of sinusitis and acute otitis media in children

OBJECTIVE

Intracranial complications of sinusitis and acute otitis media (AOM) are rare but life-threatening events. In children with suppurative intracranial complications, concurrent neurosurgical and otolaryngological (ORL) intervention has been recommended to optimize outcomes. The aim of this study was to investigate outcomes following concurrent neurosurgical and ORL intervention.

METHODS

A retrospective cohort study of children undergoing neurosurgical intervention for intracranial complications of sinusitis or AOM in two neurosurgical centres in Ireland was conducted.

RESULTS

65 children were identified. Mean age was 11.9 years. The most prevalent symptoms were headache, pyrexia, altered level of consciousness, facial swelling, and vomiting. Subdural empyema (n = 24, 36.9%) and extradural abscess (n = 17, 26.2%) were the most common complications. 54 underwent same admission ORL intervention; 47 (87%) were performed concurrently or earlier. For rhinogenic infections, 35 (64.8%) underwent endoscopic sinus surgery (ESS), 13 (24.1%) underwent frontal sinus trephine, and 5 (9.3%) underwent maxillary sinus washout alone. For otogenic infections, 10 (90.9%) underwent mastoidectomy and 7 (63.6%) underwent tympanostomy tube placement. 19 (29.2%) had post-operative neurological deficits, of which 2 (3.1%) were permanent. Streptococcus intermedius was the most common pathogen (n = 30, 46.2%). Concurrent intervention reduced the prevalence of residual collection (p = 0.018) and the need for revision neurosurgical intervention (p = 0.039) for sinogenic complications. The same trends did not achieve statistical significance for the otogenic group. Mortality was 0%.

CONCLUSION

Intracranial complications of sinusitis and AOM are best managed in a specialist centre with multidisciplinary input. Concurrent ORL and neurosurgical intervention reduces abscess recurrence and requirement for revision neurosurgery in sinogenic complications and should represent the standard of care. ESS is the ORL modality of choice in experienced hands.