Monkey finger mycology? First case of otomycosis externa caused by Trichophyton simii after encounter with a monkey

Unilateral ear pain, ear canal blockage and reduced hearing in an 18-year-old Canadian male who had travelled to India revealed, on examination of a swab, secretions bearing unusual fungal filaments visually suggestive of dermatophyte elements. Culture yielded Trichophyton simii, an unusual skin infecting species with a worldwide distribution but most often seen from India. The patient recalled swimming in the Ganges River but also had had his ear manipulated by a street monkey.

Maxillary sinus hypoplasia, embryology, and radiology

Maxillary sinus hypoplasia has been observed in up to 10% of radiological studies of the face or head. Although this may be a coincidental finding, it has been associated with chronic sinusitis and facial pain. Associated abnormalities of the lateral nasal wall, orbit, and ostiomeatal complex are common. The importance of this condition is, first, in the differential diagnosis of an "opaque" maxillary sinus and, second, as a potential hazard to the orbit of such patients, should they undergo functional endoscopic sinus surgery.

Pharyngeal suspension suture with repose bone screw for obstructive sleep apnea

OBJECTIVE

Multilevel surgery for obstructive sleep apnea syndrome (OSA) may improve success. This study's goal is to prospectively evaluate the feasibility and short-term subjective effectiveness of a new tongue-suspension technique.

METHODS

A multicenter nonrandomized open enrollment trial used the Repose device to treat tongue obstruction in 39 snoring and OSA patients. Outcomes include 1- and 2-month subjective reports of general health, snoring, and sleep.

RESULTS

Twenty-three patients completed 1 month and 19 completed 2 months of follow-up. In OSA patients, activity level, energy/fatigue, and sleepiness improved. Two-month outcomes were less (activity level, energy/fatigue, and sleepiness). Fewer changes were observed in snorers than in OSA patients. There were 6 complications (18%), including sialadenitis (4), gastrointestinal bleeding (1), and dehydration (1) after the procedure.

CONCLUSION

A pharyngeal suspension suture changes subjective outcomes. Improvement is incomplete. The procedure is nonexcisional, but significant complications may occur. Further evaluation is required to demonstrate effectiveness.

Clinical photographs as teaching aids: how reliable are they?

A study to investigate the value and reliability of clinical photographs as teaching aids was undertaken. Twenty colour photographs were taken using the StarMed video-otoscopic system. The pictures, which were a mixture of normal and abnormal ears, were shown to 21 experienced otolaryngologists from the UK and Canada. These clinicians were asked to identify the abnormality if any. The median score for correctly identified pictures was 15 (range 12-18). This score was identical for both the UK and Canadian subgroups. Although the abnormalities were consistently well recognized with an average correct identification rate of 90 per cent (range 67-100 per cent), the 'normals' were recognized significantly less well at only 41 per cent (range 5-71 per cent) (chi-squared = 110.6; 1 df; p < 0.001). This result is probably due to failure of the camera to capture the huge variation and subtleties in the range of normal, and the clinicians' natural inclination to identify pathology, when in doubt. We would conclude that as long as this failing is recognized, clinical photographs, and specifically those from the video-otoscope, represent a useful and reliable teaching tool.

Continuous intrathoracic pressure monitoring with a new esophageal microchip catheter in sleep-related upper airway obstructions

A new small-diameter microchip catheter, especially developed for continuous intrathoracic pressure monitoring to assess the degree of respiratory obstruction and effort in patients with sleep-related upper airway obstructions, was investigated. The technical performance and clinical applicability of the catheter was tested in a simplified screening study comprising 122 sleep recordings in patients with varying complaints of snoring and daytime tiredness. In six obese snorers, sensitivity of the catheter to apneas, hypopneas, and nonapneic snoring was compared to the traditional assessment of respiratory events by conventional polysomnography. The catheter was found to be easy to handle and introduce, with technical qualities meeting the demands for overnight recordings of intrathoracic pressure variations. Patient tolerance was high (93%), and sensitivity to apneas and hypopneas was equivalent to that of traditional polysomnography. Periods with upper airway obstruction and increased respiratory effort on the borderline between asymptomatic obstructions and obstructions resulting in significant blood-gas changes could be detected primarily with intrathoracic pressure monitoring. Monitoring the intrathoracic pressure variations in the esophagus has been shown previously to reflect respiratory effort. Increased respiratory effort might be one of the explanations for the fragmented sleep patterns and sleep related daytime symptoms sometimes seen in patients without a pathologic respiratory index. In addition to being applicable for the detection of apneas and hypopneas, continuous nocturnal monitoring of the intrathoracic pressure variations also detects small increases in respiratory effort and thus may constitute a valuable tool for the understanding and diagnosis of upper airway resistance syndrome and obstructive sleep apnea syndrome.

Diagnostic imaging of fungal sinusitis: eleven new cases and literature review

Fungal sinusitis should always be considered in the differential diagnosis of chronic or recurring sinusitis resistant to adequate medical treatment. A high index of suspicion is necessary for the diagnosis, and the clinical examination is rarely conclusive. The definitive diagnosis depends on the pathologist in most cases. We reviewed retrospectively the imaging findings, specifically computed tomography (CT) and magnetic resonance (MR), in a series of fungal sinusitis patients. Non-enhanced CT scan is more sensitive than conventional X-ray in detecting the classical focal areas of hyper-attenuation and calcification seen in soft-tissue masses of fungal sinusitis. MR findings of hypo-intense signals on T1-weighted sequences which progress to signal-void area on T2-weighted sequences, are characteristic features of fungal sinusitis; however, it is reserved for cases where intracranial invasion is suspected or CT findings are inconclusive.

Continuing medical education interests of Canadian otolaryngologists

A questionnaire was sent to Canadian otolaryngologists to assess their continuing medical education interests. One hundred and eighty-seven completed questionnaires were returned, a response rate of 28.5%. The categories of highest interest were nose/sinus, otology/vestibular, and general otolaryngology. Lower overall ratings were found for head and neck surgery and facial plastic/reconstructive surgery topics.

The early development of sino-nasal mucosa

The development of human nasal mucosa was studied in 20 fetal heads between 8 and 24 weeks of gestation. Initially the nasal cavity is lined by a single layer of flattened cells, which produces two to three layers of undifferentiated spherical cells. Olfactory epithelium lines the cranial portion of the human fetal nasal cavity at 8 weeks of gestation. Pseudostratified ciliated cuboidal or columnar epithelium appears at 9 weeks of gestation in the nasal cavity and between 14 and 16 weeks of gestation in the primitive ethmoid sinuses and maxillary sinus infundibulum. Goblet cells and glandular acini appear between 12 and 14 weeks of gestation. Initially these goblet cells/glands are found predominantly in the anterior nasal cavity but are more evenly distributed at 24 weeks of gestation. The epithelial development of the nasal septum generally precedes that of the lateral nasal wall. This study documents nasal mucosal maturation and associated anatomic development in the human fetus.

The uncinate process: a histological and morphological study

The uncinate process (UP) has become a familiar anatomical landmark to otolaryngologists due to the increasing popularity of functional endoscopic sinus surgery (FESS) in recent years. This study examines the histological and morphological features of UPs removed from a group of patients undergoing FESS operations for chronic sinusitis. The structure of the UP by light microscopy (LM) is reported. A relatively high proportion of goblet cells and seromucous glands was noted. Scanning electron microscopy (SEM) identified four surface cell types on the UP. Furthermore, four categories of surface morphology were noted. The most common appearance was of predominantly ciliated cells. A nonciliated surface ultrastructure is associated with a longer history of sinonasal symptoms and a higher incidence of surgical intervention.

Computer generated three-dimensional reconstruction of the bony labyrinth in Mondini's dysplasia

The bony labyrinth obtained at necropsy in four cases was studied by a new computer-generated three-dimensional (3-D) system. One case was normal (control) and the other three were histopathologically confirmed cases of Mondini's dysplasia. In case 1, the cochlea had only 2 turns and the lateral semicircular canal did not make a circle but appeared as a spherical mass projecting from the utricle even though the posterior semicircular canal made a normal circle. In case 2, there were no turns in the cochlea even though the semicircular canals and the vestibule appeared normal. In case 3, the cochlea showed 1 to 1 and 1/2 turns and the semicircular canals were premature showing only bud-like projections. This 3-D imaging system, which utilizes the toggling method, provides a way of obtaining satisfactory images without markers, and the time required to obtain these 3-D images was reduced by using a video camera instead of a digitizer. One of the problems associated with the use of 3-D imaging is the long processing time. We resolved this by inputting the section images with a video camera and by picking up structures using density segmentation instead of tracing with a digitizer.

The spectrum of thromboembolization in the central circulation

The right heart and great veins can be the harbinger of septic and aseptic thromboemboli, which can result in a spectrum of clinical syndromes. This report presents five distinct clinical scenarios of thromboembolization, the occurrence of which in the central circulation resulted in life-threatening sepsis and hemodynamic and pulmonary insufficiency. Recommendations for therapeutic intervention and a review of the literature also are presented.

CT imaging in the diagnosis and treatment of sinus disease: a partnership between the radiologist and the otolaryngologist

We consider that the nasal cavity and the paranasal sinuses cannot be declared completely normal without a normal CT scan. While CT scans are clearly useful in the evaluation of patients with recurrent sinusitis, it is important to emphasize that they should not be employed exclusively for diagnosis. Nasal endoscopy and clinical evaluation still form the basis for the diagnosis of chronic and recurring sinusitis. The CT technique described should be used only to supplement the clinical data obtained during history-taking and the rhinoscopic/endoscopic examination and is essential before functional endoscopic sinus surgery. The complexity of the diagnostic process is simplified to patient benefit when the radiologist and the otolaryngologist form a functional interactive partnership.

CT scanning for functional endoscopic sinus surgery: analysis of 200 cases with reporting scheme

An analysis of the computed tomograms of the paranasal sinuses from 200 patients with sinonasal complaints is presented. The results of our study are similar to those of other reported series despite a different patient selection. We have developed a simple systematic reporting scheme which includes all of the relevant abnormalities, and which allows a much more detailed picture of the disease pattern to be generated for both clinical use and for analytical studies.

An anatomical study of vidian neurectomy using an endoscopic technique: a potential new application

Vasomotor rhinitis is a common problem in contemporary rhinology. Although this disease has been described for decades, the pathophysiology and treatment are yet to be fully understood or described. A review of the literature of vasomotor rhinitis focusing mainly on pathophysiology and treatment is presented. Following detailed cadaver dissections a new treatment approach that takes advantage of endoscopic techniques has been proposed. Comparison with existing techniques and discussion of the pathophysiology of vasomotor rhinitis is presented. Treatment suggestions conclude the analysis, with the authors commending the endoscopic technique when symptoms merit division of the vidian nerve.

Presbycusis: correlations of clinical audiology with morphological changes in the cochlea and the ventral cochlear nucleus

Five cases of presbycusis are presented. Analysis included audiological tests, cochlear hair cell and ganglion cell counts, assessment of degree of strial atrophy, and ventral cochlear nucleus neuron counts. One case showed a reduction in cochlear nucleus neuron counts without significant cochlear changes, indicating that this pattern of pathological changes is a possible cause of high tone sensorineural deafness.

Swirls, wrinkles and the whole ball of wax (the source of keratin in cerumen)

Recent work carried out at the Ear Pathology Research Laboratory has demonstrated that cerumen plugs consist of a large amount of keratin debris. In this study the site of origin of this keratin was investigated. This was done by histologically examining these cerumen plugs without disturbing the natural relationship between the plug and the surrounding epithelium. We have clearly demonstrated that a cerumen plug consists of keratin arising from the migratory epithelium of the deep external auditory canal and epithelium of the superficial external auditory canal.

Granular myringitis: a review

Granular myringitis is the result of a localized chronic inflammation of the lateral surface of the tympanic membrane which is characterized by the development and persistence of granulation tissue over the involved area. The onset of the disease is insidious, and the symptoms, which are minor, are usually confined to chronic otorrhea and mild discomfort in the involved ear. Granular myringitis is a disease which is poorly understood and has received relatively little attention in the literature. The clinical features of this disease are outlined, the pathologic changes in the tympanic membrane illustrated, the literature reviewed and a strategy for treatment presented.

Nasal polyps, bronchial asthma and aspirin sensitivity

The ASA triad comprises bronchial asthma, acetylsalicylic acid (ASA) sensitivity and nasal polyps. It presents as chronic rhinitis followed by bronchial asthma and ASA sensitivity, and later nasal polyps. The pathogenesis of the ASA triad may involve interrelationships between disease in the upper and lower airway and hypersensitivity to cyclo-oxygenase inhibiting medications. Treatment of the nasal polyps has been shown to improve the patients' asthma.

The Incidence and Distribution of Cupular Deposits in the Labyrinth

Findings of large basophilic staining deposits on the cupula of the posterior semicircular canal ampulla have been used in part to explain the clinical phenomenon of benign positional vertigo (BPV). Although it is generally agreed that cupulolithiasis may involve other canal ampullae, the precise nature, distribution, and origin of these deposits remains unclear. In order to provide a better understanding of this finding, a series of 566 temporal bone specimens from the Ear Pathology Research Laboratory at the University of Toronto were reviewed. The results from this survey and speculations concerning the nature and formation of these deposits are discussed.

The secondary middle turbinate

During functional endoscopic sinus surgery, the ethmoidal infundibulum and bulla are accessed through the middle meatus. This paper describes a secondary middle turbinate which arises from the lateral wall of the middle meatus, posterosuperior to the infundibulum and points superiorly within the meatus. A secondary middle turbinate was identified bilaterally in 6 out of 400 coronal CT scans of the nasal cavity and paranasal sinuses. The secondary middle turbinate did not obstruct the osteomeatal complex in any of our patients.

Pitfalls in computed tomography of the paranasal sinuses

The advent of functional endoscopic sinus surgery has created the need for high-quality radiographic images to assess the paranasal sinuses, document the detailed anatomy of the lateral nasal wall and provide an anatomical map allowing safe functional endoscopic sinus surgery. This paper will discuss our experience of 410 paranasal sinus coronal CT scans performed by the technique described by Zinreich prior to consideration of functional endoscopic sinus surgery. The main indications for the scans were acute recurrent sinusitis, abnormal diagnostic nasal endoscopic examination and persistent facial pain. We will consider both the radiological and surgical difficulties that have arisen from the use of this technique and highlight some of the methods to avoid these difficulties. Claustrophobia and limitation of neck movements, particularly in patients over the age of 60, were the most common factors leading to suboptimal scans. Ensuring that the patient was in a symptom-free interval, the differential diagnosis of the opacified paranasal sinus and patients with gross polypoid disease created the most difficulty in interpretation. The anatomical assessment of the frontal recess and the identification of the optic nerve posterolateral to the posterior ethmoidal cell have created the greatest anatomical difficulty.

Ethmomaxillary sinus and hypoplasia of maxillary sinus

In a series of 410 coronal CT scans performed to assess paranasal sinus disease, we have identified eight cases in which an ethmomaxillary sinus was present. The ethmomaxillary sinus was unilateral in five cases and bilaterally present in three. The sex incidence was equal. Four patients had generalized mucosal disease of their paranasal sinuses which included the ethmomaxillary sinus whereas four patients had osteomeatal complex disease and sparing of their ethmomaxillary sinus. The characteristic radiological features of an ethmomaxillary sinus were drainage into an enlarged superior meatus, reduction in the size of the maxillary sinus and a normal bony orbital cavity. The differential diagnosis of an apparently hypoplastic maxillary sinus is briefly discussed.

Computed tomographic findings in atrophic rhinitis

Computed tomography (CT) has been used increasingly in the assessment of patients with symptoms of sinonasal disease since the introduction of functional endoscopic surgery for the treatment of chronic sinusitis. The association of sinusitis and atrophic rhinitis will inevitably lead to more frequent imaging of patients with atrophic rhinitis. Correct interpretation of the CT appearances of atrophic rhinitis is important as misinterpretation may have serious implications during sinus surgery. These appearances have not been described previously. We describe and discuss the CT findings in three patients with clinical evidence of atrophic rhinitis.

Exostosis of the external auditory canal: an interesting histopathological finding

Perforation of the tympanic membrane is a frequent complication of surgery for exostoses of the external auditory canal. We report an unusual histopathological finding in a temporal bone containing external canal exostoses which suggests that some of these perforations may be unavoidable.

The motility of keratinocytes in cholesteatoma: an ultrastructural approach to epithelial migration

Eight cases of attico-antral cholesteatoma were studied by transmission electron microscopy concentrating on the mechanisms involved in intercellular adhesion. Desmosomes were found in large numbers throughout the epidermis and were arranged in various orientations around the keratinocytes. Those desmosomes found in the stratum corneum were significantly less dense than those in deeper layers and were associated with a large number of intercellular spaces, which would reduce the cohesive strength of this layer. The tortuous basement membrane features numerous hemidesmosomes along its length. The findings of this study were compared with previous ultrastructural observations made on the pars flaccida and pars tensa of the tympanic membrane and external canal skin. This revealed that the morphological characteristics of cholesteatoma resemble pars flaccida and external canal skin rather than pars tensa. The implications of these findings are discussed.

The embryonic development of the lateral nasal wall from 8 to 24 weeks

This histological study of 20 fetal heads aged between 8 and 24 weeks of gestation demonstrates and describes the embryonic development of the lateral wall of the nose. The three turbinates (inferior, middle, and superior) arise as soft-tissue swellings (preturbinates) by 8 weeks' gestation. A cartilage capsule surrounds the nose at 8 weeks and by 9 weeks, medially directed flanges of cartilage have invaded all three preturbinates. The uncinate process arises from the medial surface of the lateral cartilaginous capsule and is first identifiable by 10 weeks. An "air space" progressively develops from 11 to 12 weeks lateral to the cartilaginous uncinate process and from this space, the embryonic channel to the maxillary sinus develops. The embryonic woven bone of the maxilla can be identified from 9 to 10 weeks and enlarges both absolutely and relatively to the nasal cavity, so that by 13 to 14 weeks, this expanding bone forms the lateral wall of the inferior meatus as the cartilaginous nasal capsule regresses.

Persistence of the foramen of Huschke in the adult: an osteological study

The foramen of Huschke, which appears during the embryological development of the tympanic bone, usually closes by the age of five years. A review of 377 dried skulls revealed that the foramen of Huschke was present in adult life in 7% of the skulls examined. A patent foramen of Huschke in the adult may, in rare cases, be the cause of temporomandibular joint herniation or fistulization through the anterior wall of the bony external canal.

Sequelae of experimental tympanic and inferior canal wall perforations: the double meaning of epithelial migration

The term "epithelial migration" has been used to describe both the normal surface movement of the tympanic epithelium and the movement of epithelial basal cells in repair processes. In an attempt to distinguish between these two processes and to determine their role in the repair of a wounded tympanic membrane, 20 guinea pig tympanic membranes were perforated inferiorly and tattooed with ink through an external incision. Sequential histology of whole temporal bones at intervals from the time of injury up to three weeks showed evidence of movement of the superficial layers of epidermis which was effective in the clearance of cellular debris but not in the closure of the perforation. Drum closure was effected more by the accumulation of exudate and epithelial hyperplasia. The migration of the epithelial basal cells was slow when compared to surface movement. It is suggested that tympanic epithelial surface movement is best described by a passive term such as "epithelial displacement" and that the term migration should be restricted to the activities of the living layers of epidermis.

Ossicular erosion by cholesteatoma: investigation by scanning electron microscopy utilizing a new preparation technique

A new technique for removing the soft tissues from middle ear ossicles to prepare them for scanning electron microscopy is described. The technique involved use of a solution of hypochlorite. The bony surface of normal ossicles was studied as a control group after preparation by the technique and no morphological distortion was observed. Ossicles eroded by cholesteatoma were then studied, and we propose that the erosion occurs in three stages; pumicing, pitting and cavitating. The mucoperiosteum of normal ossicles and otosclerotic foci were also studied.

The organic composition of earwax

Earwax is a mixture of desquamated keratinocytes and hair combined with the secretions of both the ceruminous and the sebaceous glands of the external ear canal. This study analyzed earwax using the combination analytical technique of gas chromatography and mass spectrometry. The major organic components of earwax identified were long chain fatty acids, both saturated and unsaturated, alcohols, squalene and cholesterol. This study demonstrated that it is not currently possible to quantify statistically the substances which constitute earwax with accuracy. The presence of foreign substances within earwax was identified as a complicating factor in the analysis of earwax.

Sudden hearing loss due to AIDS-related cryptococcal meningitis--a temporal bone study

We have presented the clinical history and temporal bone findings in a patient who manifested sudden hearing loss, and who subsequently was found to have cryptococcal meningitis associated with AIDS. The histopathologic findings are similar to earlier reports in patients without AIDS. Because cryptococcal infection is so much more common in AIDS patients than in the general population, it must be considered a causative factor when presented with an AIDS patient with progressive or sudden hearing loss. This offers the patient a chance for timely and effective treatment.