Isolated Fracture of the Malleus: An Overlooked Cause of Conductive Hearing Loss?

OBJECTIVE

To report the largest case series of isolated malleus fractures with systematic review to characterize the disease's presentation and natural history, and provide suggestions for management.

DATA SOURCES

PubMed, Embase, Cochrane Library.

REVIEW METHODS

Retrospective cohort study was performed on 12 patients with isolated malleus fractures. History, physical exam, pre- and post-treatment audiograms, and imaging were obtained. Systematic review of the literature was performed.

RESULTS

Including the cases herein, 58 isolated malleus fractures were identified, the majority of which were published in the 21st century. Mean time to presentation after injury was 34.4 months. Most common etiology was external auditory canal (EAC) manipulation. Physical exam and imaging did not identify any abnormality at presentation in 16% and 21% of cases, respectively. The majority of fractures involved the manubrium. Air-bone gap (ABG) at initial presentation ranged from 16 to 26 dB, and was greater at higher frequencies. Thirty-six cases underwent surgery. ABG improvement was greater at all frequencies for those who underwent surgery. Final ABG was significantly less than initial ABG at nearly every frequency for those who underwent surgery (p < 0.05), while not at any frequency for those who were observed.

CONCLUSIONS

Isolated malleus fractures may occur more often than historical data suggests, and are perhaps underdiagnosed. Abrupt removal of a finger from the EAC with pain and hearing loss is nearly pathognomonic. Conductive hearing loss with ABG greater at higher frequencies is most often observed. Observation is unlikely to produce spontaneous improvements in hearing, while surgery demonstrates reliable decreases in ABG. Laryngoscope, 134:1032-1041, 2024.

Imaging of Alternobaric Facial Palsy: An Etiologic Hypothesis

OBJECTIVE

To report a case of alternobaric facial palsy (AFP) with a hyperpneumatized temporal bone and to review the relevant literature in order to propose a new facet of AFP pathogenesis.

METHODS

A patient with a hyperpneumatized temporal bone was found to have recurrent episodes of facial palsy associated with air travel. Systematic review of PubMed, Cochrane Library, and Embase characterized all articles related to transient facial palsy associated with altitude changes or diving with a focus on demographics and imaging findings.

RESULTS

A 25 year-old male was referred for recurrent facial palsy associated with commercial air travel. Imaging demonstrated a hyperpneumatized and well-aerated temporal bone. Total air cell volume was calculated to be 8.59 cc on the affected side. A systematic review of the literature identified 49 cases of AFP. Mean age was 34 years old and 80% were male. Twelve cases had imaging of the temporal bone for evaluation, of which 85% demonstrated at least 1 area of hyperpneumatization. Hyperpneumatization was most frequently encountered in the mastoid, zygomatic root, and inferior petrous apex.

CONCLUSION

Hyperpneumatization of the temporal bone is critical to AFP etiology as it predicts higher middle ear pressure, if atmospheric pressure changes cannot be equilibrated, via reduced efficacy of normal tympanic membrane pressure buffering. This hypothesis helps to better account for the rarity of the condition and male preponderance.

Sudden sensorineural hearing loss after non-otologic surgery

Sudden sensorineural hearing loss following non-otologic surgery is a rare event described in the medical literature. Cardiopulmonary bypass surgery is most commonly associated with this type of hearing loss. Our case report and review of the literature describe two cases with postoperative hearing loss - neither of which are cardiac surgeries - making them exceedingly rare in the medical literature. Regardless of the rarity of this unfortunate event, the possibility for permanent hearing loss is a potentially devastating unanticipated complication and one that all surgeons should be aware.

Molecular mechanisms of acrolein-mediated myelin destruction in CNS trauma and disease

Myelin is a critical component of the nervous system facilitating efficient propagation of electrical signals and thus communication between the central and peripheral nervous systems and the organ systems that they innervate throughout the body. In instances of neurotrauma and neurodegenerative disease, injury to myelin is a prominent pathological feature responsible for conduction deficits, and leaves axons vulnerable to damage from noxious compounds. Although the pathological mechanisms underlying myelin loss have yet to be fully characterized, oxidative stress (OS) appears to play a prominent role. Specifically, acrolein, a neurotoxic aldehyde that is both a product and an instigator of OS, has been observed in studies to elicit demyelination through calcium-independent and -dependent mechanisms and also by affecting glutamate uptake and promoting excitotoxicity. Furthermore, pharmacological scavenging of acrolein has demonstrated a neuroprotective effect in animal disease models, by conserving myelin's structural integrity and alleviating functional deficits. This evidence indicates that acrolein may be a key culprit of myelin damage while acrolein scavenging could potentially be a promising therapeutic approach for patients suffering from nervous system trauma and disease.

Barriers to podiatric care among diabetic patients in the San Francisco Bay area

This study investigates the provision of general medical and foot care, the barriers to access for foot care, and the awareness of foot risks in an urban diabetic population. A survey composed of 26 questions was mailed to 2375 diabetic patients in the San Francisco Bay area who are members of the American Diabetes Association (ADA). Three hundred ninety-two surveys were returned for a response rate of 16%. Of the 392 respondents, 7 (1.8%) indicated that they were not receiving any medial care for their diabetes, with another 15 (3.8%) receiving general medical care from an alternative health care provider. Among the respondents, 87 (22%) did not have their feet examined by any health care provider. The remainder of the patients were receiving foot care from a health care provider with 191 (48.7%) under the care of a provider other than a podiatrist. Of those not receiving any foot care, 53 (61%) reported that they did not seek any pedal care because they do not have any apparent foot or leg problems. Another 12 (13.8%) indicated that they did not know whom to see for their lower extremity problems. Lack of insurance or inability to afford medical care was the main reason that prevented 7 (8%) of the patients from receiving routine foot care. With respect to the patient's knowledge of diabetes-associated foot disorders, the majority (72%-79%) knew that poor circulation, neuropathy, ulcers, painful leg and foot conditions, infection, and amputation were associated with diabetes. From all the surveyors, 106 (27%) reported that they were not advised or educated on the potential lower extremity complications of diabetes by their health care provider. The results of this study indicate that in an urban population of diabetic patients, all of whom were members of ADA, a significant number are not adequately educated on the importance of routine foot care.

Foot and ankle injuries related to rock climbing. The role of footwear

Interest in rock climbing has grown dramatically over the past decade. Although considerable research has been conducted on upper-extremity injuries sustained during rock climbing, there has been no comprehensive evaluation of lower-extremity injuries and related biomechanics. The authors performed a retrospective investigation of rock-climbing injuries using a survey of 104 active rock climbers of varying levels of expertise. The results show that 81% of the respondents have suffered acute or chronic pain or associated pathology in the foot or ankle during or after climbing. The authors propose that this morbidity has biomechanical etiologies related to the common practice among rock climbers of wearing climbing shoes that are smaller than their street shoes.

The efficacy of ANSAID (flurbiprofen) as an analgesic in foot surgery

Eighty-three patients scheduled for outpatient surgery were enrolled in this double-blind, randomized trial designed to compare the safety and efficacy of single and multiple doses of flurbiprofen 50 mg. and acetaminophen 300 mg. plus codeine phosphate 30 mg. During the multiple dose segment, statistically significant differences were observed during the first 24 hour postoperative period regarding relief of pain and pain intensity. Flurbiprofen provided greater relief of pain than the acetaminophen with codeine phosphate combination. This study supports the use of flurbiprofen as a suitable alternative to acetaminophen plus codeine phosphate in the treatment of postoperative pain following foot surgery.

Torsion of the tendon of peroneus brevis

The authors present a previously undescribed torsion located within the tendon of peroneus brevis. The musculotendinous unit of peroneus brevis was isolated from 46 lower extremities of cadavers. A goniometer was constructed and utilized to quantify the degree of torsion located within each peroneus brevis tendon. Torsion was present in all 46 cadaver specimens, with a mean of 38.5 degrees and a range of 26 degrees to 56 degrees. The regional anatomy and biomechanical functions of peroneus brevis are discussed, and proposed bases for the embryologic origins and functional significance of the torsion are presented.

Management of painful diabetic neuropathy. A treatment algorithm

Peripheral neuropathy manifests as a painful syndrome in a significant number of individuals suffering from diabetes mellitus. Painful diabetic neuropathy may interfere with sleep, work, and activities of daily living. Patients and practitioners alike often view this challenging disorder as incurable. A broad spectrum of therapeutic alternatives and physiologic approaches to this complex clinical problem are available. Careful assessment and a rational approach based on the nature and location of pain will lead to success. The authors review the etiology, clinical presentation, and diagnosis of diabetic peripheral neuropathy. Available therapeutic alternatives are emphasized and an original treatment algorithm is presented.

Functional significance of torsion of the tendon of tibialis posterior

The authors describe the anatomical necessity and functional significance of torsion of the tendon of tibialis posterior. A wooden model of the right lower extremity has been constructed which includes representations of the ankle, subtalar, and oblique midtarsal joints. The model is used to show that the presence of torsion within the tendon of tibialis posterior eliminates the need for any longitudinal slippage between individual tendon fibers during triplane movement of the joints of the lower extremity.

Torsion of the human Achilles tendon

An understanding of torsion in the human Achilles tendon would assist in more efficient percutaneous tendon lengthening procedures. Tendoachilles torsion was measured on 16 human cadaver specimens. Significant torsion was found in all tendons studied. The authors developed a method to quantify the degree of tendon torsion, explore a possible relationship to external anatomical landmarks, and suggest that the development of tendoachilles torsion closely follows postnatal development of the tibia.

Torsion of the tendon of tibialis posterior

The authors present a previously undescribed torsion located within the tendon of tibialis posterior. The musculotendinous unit of tibialis posterior was isolated from 17 lower extremities of cadavers. A small goniometer was constructed and used to quantify the degree of torsion located within each tibialis posterior tendon. Torsion was present in all 17 cadaver specimens, with a mean of 47.5 degrees and a range from 21 degrees to 62 degrees. The regional anatomy and biomechanical functions of tibialis posterior are discussed, and proposed bases for the embryologic origins and functional significance of the torsion are presented.

Direct activation of murine peritoneal macrophages for nitric oxide production and tumor cell killing by interferon-gamma

Interferon-gamma (IFN-gamma) is known to prime macrophages for tumor cell lysis and nitric oxide (NO) production as measured by enhanced sensitivity to lipopolysaccharide (LPS). In the present study, the ability of IFN-gamma to directly activate peritoneal macrophages from C57BL/6 and Balb/c mice for tumor cytotoxicity and NO production was evaluated. Macrophage-mediated tumor cell killing was measured by an 18 h 51Cr release assay using P815 mastocytoma cells as targets. Concurrent NO production was measured as nitrite in the supernatants of macrophage cultures. Incubation of macrophages with IFN-gamma resulted in activation of macrophages for tumor cell lysis. IFN-gamma alone also activated macrophages for NO production under identical conditions. Addition of LPS along with IFN-gamma resulted in synergism in the activation of macrophages for both cytolysis and NO production. LPS contamination of the IFN-gamma preparation was absent as evidenced by the following criteria: (1) the IFN-gamma preparation as well as the reagents used were shown to be free of LPS contamination based on LAL endotoxin tests (sensitivity 25 pg/ml), (2) the ability of IFN-gamma to activated macrophages was not abrogated by prior treatment of the cytokine with polymyxin B, whereas the effect of LPS was inhibited (70-100%) under similar conditions, (3) pretreatment of the IFN-gamma preparation with a specific endotoxin neutralizing protein did not abrogate the ability of IFN-gamma to induce macrophage activation, and (4) heat treatment of solutions containing IFN-gamma alone or IFN-gamma+LPS abolished only the effect of IFN-gamma, not that of LPS.(ABSTRACT TRUNCATED AT 250 WORDS)

Medical management of the diabetic patient during podiatric surgery

Diabetes mellitus commonly causes complications of the foot that can lead to surgery. The appropriate perioperative management of diabetic patients can reduce the morbidity and mortality associated with diabetic foot surgery and enhance wound healing. The authors review the effects of hyperglycemia, detail preoperative, intraoperative, and postoperative care, and describe anesthetic choices. An algorithm for management of hypoglycemia is offered.

Painful diabetic peripheral neuropathy. A stepwise approach to treatment

The stepwise approach to the treatment of painful diabetic peripheral neuropathy allows the practitioner to use a broad spectrum of therapeutic modalities and physiologic approaches to this complicated clinical problem. The authors review the etiology and clinical presentation of diabetic neuropathy. Available therapeutic alternatives are discussed and an original stepwise algorithm is presented. Pharmacologic profiles of the most commonly used drugs are also described.

Intraosseous lipoma of the os calcis

The authors present three cases of a rare calcaneal tumor, intraosseous lipoma. The differentiation of intraosseous lipoma from other benign tumors is discussed. The diagnosis and treatment are reviewed.

The distal saphenous vein cutdown procedure

Distal saphenous vein cutdown is an excellent method for intravenous access. It allows for a rapid infusion of fluids. Although the saphenous vein cutdown is not commonly performed, the podiatrist should be familiar with this procedure, as it may be necessary during an emergency situation.

Diagnosis and treatment of tinea pedis. A review and update

Fungal foot infections are becoming an increasingly common public health problem as the population ages. New studies have shown that some of the traditional therapeutic antifungal agents have multiple actions that enable them to be more efficacious than previously thought, and more efficacious than other agents without multiple actions. In this review article, the pedal infections commonly referred to as tinea pedis, or athlete's foot, are described. The etiologic agents involved in the pathogenesis, the methodologies for proper diagnosis, and the therapeutic agents commercially available for treatment are reviewed.