Spontaneous cerebrospinal fluid leakage and middle ear encephalocele in seven patients

Isolated cases of spontaneous cerebrospinal fluid (CSF) leakage with and without middle ear encephalocele have been reported. These leaks are usually accompanied by episodes of recurrent meningitis, hearing loss, or chronic headache. In this article, we report seven new cases of spontaneous CSF leakage. Six of these patients had conductive hearing loss and serous otitis media, and three had recurrent meningitis. Prior to a definitive diagnosis, six patients had received myringotomy tubes, which produced profuse clear otorrhea. Three patients had positive beta-2 transferrin assays. Computed tomography and magnetic resonance imaging confirmed a defect in the temporal bone tegmen. A combined transmastoid and middle fossa surgical approach with a three-layer closure was used to repair the tegmen defect. All patients had a lumbar drain placed prior to surgery. In addition to describing the seven new cases, we review the history of CSF leakage and discuss diagnostic methods, surgical findings, and our recommendations for management.

Dexamethasone pharmacokinetics in the inner ear: comparison of route of administration and use of facilitating agents

There is growing otologic interest in treating inner ear disorders, such as sudden sensorineural hearing loss and acute or unremitting Meniere's disease, with intratympanic dexamethasone (IT-DEX). Although anecdotally reported, there are no scientific clinical papers and few prior laboratory research publications on the subject. This study compares perilymph dexamethasone concentrations after systemic and intratympanic administration and assesses the role of 3 potential transport facilitators of IT-DEX into perilymph. Forty guinea pigs (79 ears) were randomly separated into 5 groups. Dexamethasone levels were measured by radioimmunoassay. IT-DEX resulted in higher perilymph steroid levels than intravenous dexamethasone (P < 0.05). Histamine facilitator resulted in significantly higher perilymph steroid levels than IT-DEX alone (P < 0.05). Neither hyaluronic acid nor dimethylsulfoxide was a potent facilitator. This study demonstrates that IT-DEX administration results in superior perilymph levels within 1 hour of administration and does not result in systemic absorption. Histamine is a potent facilitating agent. The clinical implications are considerable.

Cutaneous metastatic lung cancer: literature review and report of a tumor on the nose from a large cell undifferentiated carcinoma

Cutaneous metastatic disease is a prognostically important diagnosis. We report the case of a 64-year-old man who had an uncommon histologic type of lung cancer--a large cell undifferentiated carcinoma, which was metastatic to the skin of the nose. The relative frequency of cutaneous metastasis is similar to that of primary cancers. Cutaneous disease as the first sign of metastasis is most often seen in cancer of the lung. However, its appearance as a large tumor on the nose, which was observed in this case, is unusual.

Otologic and audiologic evaluation of human immunodeficiency virus-infected patients

PURPOSE

To quantify the incidence of ear disease in patients infected with human immunodeficiency virus (HIV).

MATERIALS AND METHODS

This is a descriptive case series of HIV-positive patients, with data collected using an otologic questionnaire. otologic examination, audiologic evaluation, and chart review. The study was performed at an urban University Hospital's outpatient Infectious Disease and Otolaryngology clinics. A consecutive sample of 50 HIV-infected patients volunteered for this study. Ten subjects refused. Almost all patients received public assistance for medical care. Descriptive results were tabulated. Audiometric data were analyzed for ear, Centers for Disease Control (CDC) group, otologic complaint, and age effects. Data were compared with established norms.

RESULTS

Twenty-three men and 27 women with a mean age of 40 years and mean duration of HIV disease of 3.5 years were studied. Eighteen percent of patients were in category CDC-A, 38% in CDC-B, and 44% in CDC-C. Otologic complaints were more prevalent than expected: 34% of patients reported aural fullness, 32% dizziness, 29% hearing loss, 26% tinnitus, 23% otalgia, and 5% otorrhea. Results of the neuro-otologic examination were abnormal in 33%. Tympanometric examination was abnormal in 21%. A significant degree of high-frequency sensorineural hearing loss was observed. CDC-B and CDC-C patients had worse hearing than CDC-A patients at 3 frequencies. Patients who complained of hearing loss had significantly worse otoacoustic emission results and hearing results than patients who did not, at all frequencies except 1,000 Hz. Patients in their 30s had better hearing in the speech frequencies than did all other patients.

CONCLUSIONS

Ear disease affects up to 33% of HIV-infected patients. Otitis media is a frequent finding. Sensorineural hearing loss is more severe in patients with more severe HIV infection. Patients with ear complaints have demonstrable otopathology. Continuation of this preliminary descriptive work is necessary.

Nasal toxicity of cocaine: a hypercoagulable effect?

Nasal insufflation of cocaine injures the nasal mucosa and can perforate the septum. Cocaine-induced vasoconstriction resulting in ischemia is one of the methods that may be responsible for this damage. We are determining whether cocaine also produces a hypercoagulable state that may compound factors which have been previously established to cause damage to the nasal mucosa and septum. This study uses Modified Recalcification Time (MRT), a test developed in our laboratory that has the ability to measure the overall coagulation process. Our study revealed no connection between cocaine and enhanced platelet function or monocyte-released tissue factor. The coagulation process was unaffected by the addition of the drug, so we conclude that cocaine does not cause a hypercoagulable state and cannot assist in the explanation regarding the ischemic changes of the nasal septum.

Mutilating facial sarcoidosis

We report a patient with massive facial sarcoidosis. While skin involvement is a common manifestation of sarcoidosis, it is unusual to see it in the dramatic form of cutaneous tumors with mutilation of the central face. There are few reports of tumoral cutaneous sarcoidosis like that of our patient.

Cortical representation of swallowing in normal adults: functional implications

OBJECTIVE

Dysphagia of neurogenic or postsurgical origin presents management and therapeutic challenges to the otolaryngologist. Improvements in management and therapeutic approaches may be facilitated by understanding how the central nervous system controls swallowing. The purpose of this investigation was to utilize functional magnetic resonance imaging to determine patterns of cortical activity during swallowing in normal, healthy adult subjects.

STUDY DESIGN

Functional magnetic resonance imaging (fMRI) was performed on eight healthy adult subjects using conventional BOLD (blood oxygenation level dependent) techniques.

METHODS

Subjects performed three different swallowing tasks including dry and bolus swallows, and performed a control finger movement task. Statistical maps of cortical activation were generated using a cross-correlation analysis. One-way and two-way ANOVA statistical analyses were performed to compare activated areas among the different tasks and to determine the effects of task sequence.

RESULTS

Activation during the three swallowing tasks occurred in the primary motor cortex, primary somatosensory cortex, and other cortical and subcortical sites. Cortical representation of swallowing and finger movement followed somatotopic maps. Differential distribution of cortical activation was observed for the different swallowing tasks.

CONCLUSIONS

Activation of the primary motor and somatosensory cortices, as well as other sensory-motor areas, occurs with swallowing in normal adults. Differential distribution of cortical activity with different swallowing tasks suggests differential functional organization for different swallowing tasks. Understanding these mechanisms may facilitate improved management and therapeutic intervention for neurogenic and postsurgical dysphagia.

Type A immunoglobulin deficiency presenting as a mixed polymicrobial brain abscess: case report

OBJECTIVE AND IMPORTANCE

We present a case report of a patient with a left frontal brain abscess. Cultures obtained from the abscess at the time of surgery were identified as dental flora known to establish a synergistic relationship in polymicrobial infections. This type of synergistic relationship makes the clearance of an infection more difficult for an intact immune system. A serum immunoglobulin (Ig) Type A deficiency was identified postoperatively. This immunodeficiency may have contributed to the development of the abscess.

CLINICAL PRESENTATION

The patient presented with headaches and photophobia. Computed tomography of the head performed with intravenously administered contrast demonstrated a left frontal brain abscess.

INTERVENTION

The patient was operated on through a left frontal approach, carefully avoiding the frontal sinus. The abscess was aspirated, and the patient was treated with intravenous antibiotics for several weeks. Postoperatively, the patient did well. There were no signs of enhancement on follow-up computed tomographic scans at 7 and 12 months postoperatively.

CONCLUSION

Through a comprehensive immunological workup, an IgA deficiency was identified postoperatively. Although the deficiency of a single type of Ig may be asymptomatic, complications from recurrent or chronic bacterial infections may occur. The deficiency of IgA, combined with a synergistic polymicrobial infection, contributed to the development of an intracranial abscess. A patient presenting with a brain abscess without any predisposing medical history should be evaluated for an underlying immune deficiency.

Encephalocoele as a complication of intranasal sinus surgery: optimal evaluation with magnetic resonance imaging

We report a case of post-operative frontal basal encephalocoele evaluated using a new magnetic resonance imaging (MRI) sequence, fast inversion recovery for myelin suppression (FIRMS). FIRMS was developed to enhance the differentiation between grey and white matter. In this case, the sequence was beneficial in distinguishing the encephalocoele from adjacent nasal mucosa and secretions.

Role of flexible laryngoscopy in evaluating aspiration

Flexible fiberoptic laryngoscopy is used to evaluate dysphagia, but its clinical utility has not been compared to that of the videofluorographic swallowing study (VFSS). This study correlates parameters of both procedures and identifies laryngoscopic predictors of aspiration in 105 patients. Presence of aspiration, pharyngeal residue, laryngeal sensation, vocal cord mobility, and glottic closure during flexible laryngoscopy (FL), and gag reflex were correlated with aspiration during the VFSS. An algorithm for laryngoscopically detecting aspiration was synthesized. Aspiration (p = .004) and pharyngeal residue (p < .00001) were highly correlated between the two studies. Aspiration during the VFSS was correlated with pharyngeal residue (p < .00001) and laryngeal sensation (p = .027) during FL, but not glottic closure (p = .169) nor vocal cord mobility (p = .056). Patients with a normal gag reflex and without aspiration or pharyngeal residue during FL had a 2.94% risk of aspiration during the VFSS. Flexible laryngoscopy can be used as a relatively safe, portable screening test for aspiration, but cannot always replace the VFSS to identify the presence or cause of aspiration.

The frequency of cricopharyngeal dysfunction on videofluoroscopic swallowing studies in patients with dysphagia

PURPOSE

Dysphagia associated with cricopharyngeal dysfunction (CPD) is of particular interest to the otolaryngologist because it may respond to cricopharyngeal myotomy. There is a wide variation in the reported incidence of cricopharyngeal dysfunction in patients with dysphagia. This can be attributed to the different populations being studied, the lack of uniform criteria for diagnosis, and to different techniques used to evaluate patients. We have reviewed videofluoroscopic swallowing studies (VSS) conducted on 443 consecutive patients with complaints of dysphagia to identify the incidence of cricopharyngeal dysfunction.

PATIENTS AND METHODS

The patient population consists of 443 veterans with complaints of dysphagia who were evaluated by videofluoroscopic swallowing studies at the Department of Veterans Affairs Medical Center, East Orange, NJ, between November 1988 and March 1993.

RESULTS

Cricopharyngeal dysfunction was diagnosed radiologically as the appearance of a shelf in the posterior column of barium at the level of the cricoid cartilage. It was identified in 10 of 177 (5.7%) patients with neurological disorders, in 7 of 142 (4.9%) patients with head and neck or esophageal tumors, and in 11 of 124 (8.9%) patients with other medical problems.

CONCLUSION

These results do not support the notion that cricopharyngeal dysfunction is an important factor in a significant proportion of patients with dysphagia. It is recognized that videofluoroscopy may not always detect cricopharyngeal dysfunction and that better criteria for identifying this entity are needed.

Endoscopic closure of the eustachian tube for repair of cerebrospinal fluid leak

Techniques to repair cerebrospinal fluid (CSF) leak through the eustachian tube (ET) include temporary or permanent CSF diversion; middle fossa craniotomy and packing of the ET from above; and packing of the ET from behind, through the middle ear. We report a case of endoscopic closure of the ET in the nasopharynx (the front). A 26-year-old woman underwent a translabyrinthine removal of a 4.5-cm vestibular schwannoma. One year later, she developed CSF rhinorrhea and meningitis. Attempts at control of this leak included traditional approaches mentioned previously (shunting, middle fossa, middle ear packing). The leak recurred 2-3 months after each procedure. An endoscope was used transnasally to expose the ET orifice, which was incised, inverted, and cauterized. She has remained free of leak for 1 year. Our success in this difficult case suggests that this is a useful procedure for treatment of CSF rhinorrhea originating in the posterior fossa. Greater experience is needed to verify its long-term effectiveness and utility as a primary procedure for the treatment of CSF rhinorrhea.

Visual loss reversed after treatment of acute bacterial sinusitis

Visual loss is a rare complication of acute bacterial sinusitis (ABS). Very few cases have been reported in the literature. Only two cases of visual loss reversed after treatment of ABS are found in the English-language literature. We present three cases in which significant visual loss was reversed after treatment of ABS. The experience with visual loss associated with ABS is small; therefore, no definitive statement about treatment can be made. However, on the basis of our experience, it appears that immediate surgical drainage with antibiotic therapy may be important in restoring vision.

Voice Failure after Tracheoesophageal Puncture: Management with Botulinum Toxin

Primary or secondary tracheoesophageal puncture with a speaking prosthesis has provided rehabilitation of speech in most patients after total laryngectomy. Persistent constrictor spasm is thought to be responsible for a small percentage of these patients' inability to speak with the prosthesis. Management of these patients has included bougienage and pharyngeal myotomy and/or pharyngeal neurectomy. Botulinum toxin injections of the cricopharyngeus muscle complex in six patients have been successfully used diagnostically and therapeutically for tracheoesophageal puncture failures. The assessment, technique, and results are discussed.

Voice failure after tracheoesophageal puncture: management with botulinum toxin

Primary or secondary tracheoesophageal puncture with a speaking prosthesis has provided rehabilitation of speech in most patients after total laryngectomy. Persistent constrictor spasm is thought to be responsible for a small percentage of these patients' inability to speak with the prosthesis. Management of these patients has included bougienage and pharyngeal myotomy and/or pharyngeal neurectomy. Botulinum toxin injections of the cricopharyngeus muscle complex in six patients have been successfully used diagnostically and therapeutically for tracheoesophageal puncture failures. The assessment, technique, and results are discussed.

Relationship of biopsy and final specimens in evaluation of tumor thickness in floor of mouth carcinoma

A number of studies have suggested that tumor thickness may be a valuable prognostic indicator in the evaluation of head and neck cancers. This study examined the relationship between tumor thickness measured in preliminary biopsy specimens with the final specimens obtained in 31 patients with floor of mouth epidermoid carcinoma. There was a significant statistical correlation between biopsy and final specimens. The Pearson's product-moment correlation coefficient was 0.58, which corresponded to a significance level of P < .0005. The results of this study showed that those patients who had biopsies with a thickness less than or equal to 1 mm were likely to have final specimens with a thickness less than 2 mm. All patients with a thickness greater than 2 mm had a final specimen with a thickness greater than 3.5 mm. Modification of current biopsy techniques may result in values more predictive of final thickness measurements.

Invasive rhinosino-orbital aspergillosis with precipitous visual loss

OBJECTIVE

To describe the clinicopathological and radiologic features in five cases of primary and secondary orbital aspergillosis.

DESIGN

Case series.

SETTING

Ophthalmology department of a university hospital.

PATIENTS

Five patients over 65 years of age with invasive rhinosino-orbital aspergillosis.

RESULTS

Presenting features were abrupt onset of proptosis, ophthalmoplegia and blepharoptosis with precipitous visual loss. All had debilitating periorbital pain or headache, but none had orbital inflammatory signs or appeared "toxic." Predisposing causes included alcoholism, low-dose prednisone therapy and insulin-dependent diabetes mellitus. One patient, suspected of having mucormycosis based on tissue biopsy and results of potassium hydroxide preparations, harboured Aspergillus fumigatus, which grew on culture. Secondary bacterial infections developed in three patients. Three patients died from their disease despite aggressive surgical treatment, including exenteration and sinus extirpation. The one patient with primary orbital aspergillosis survived after exenteration.

CONCLUSIONS

Sinonasal aspergillosis with orbital extension and primary orbital aspergillosis have a precipitous clinical course that mimics that of mucormycosis and may be fatal despite early exenteration. Computed tomography and magnetic resonance imaging of the sinuses, orbit and head provide complementary diagnostic signs. While results of potassium hydroxide preparations and tissue biopsy guide treatment of fungal infection, definitive diagnosis requires fungal culture. Relatively good vision may be associated with massive orbital and secondary intracranial extension.

Significance of tumor thickness in soft palate carcinoma

Tumor thickness is an important prognostic factor in tumors outside of the upper aerodigestive tract, such as cutaneous melanoma, colorectal carcinoma, and cervical carcinoma. Some studies have also suggested that tumor thickness may have similar prognostic value in the upper aerodigestive tract. This study examined the relationship between tumor thickness (measured with an ocular micrometer) and nodal disease and that between tumor thickness and survival in 44 patients with soft palate epidermoid carcinoma. There was a significant correlation between tumor thickness and nodal disease. None of the 24 lesions less than or equal to 2.86 mm had cervical adenopathy. All of the 15 lesions greater than or equal to 3.12 mm had palpable adenopathy. Tumor thickness correlated more directly with nodal disease than did T stage. Thicker lesions were associated with poorer survival. Tumor thickness is an important parameter in the head and neck and deserves further study.

Surgical management of swallowing disorders

Many patients with severe swallowing disorders will require surgical intervention at some point in the course of their illness. Surgery should be designed to address specific dysfunctions identified by a thorough evaluation. Defining a patient's problem is usually a multidisciplinary effort, requiring the skills of several specialists.

Distribution of blood flow in an experimental palatal carcinoma

Tumor perfusion is an important factor in the success of many common and potential therapeutic and diagnostic modalities. We studied blood flow of an experimental squamous cell carcinoma of the rat palate using the radionuclide-labeled microsphere injection method. Tumors (N = 14) were studied for level and distribution of blood flow, and changes in blood flow with increasing size. The results show a wide variation in the absolute level of perfusion among the tumors, but a consistent pattern of blood flow distribution, with poor perfusion in the central parts and a sharp increase in perfusion at the periphery. The blood flow (in mL/min/100 g) in the five zones from center to periphery were 2.32 +/- 5.7, 5.62 +/- 16.3, 4.20 +/- 6.87, 15.04 +/- 23.6, and 32.31 +/- 41.8. The average level of perfusion decreased as tumor size increased, but the pattern of blood flow distribution remained constant. The data from this study provide an understanding of the basic pattern of blood flow in an experimental squamous cell carcinoma of the head and neck, and will serve as a foundation to further explore the hemodynamic characteristics of head and neck carcinomas.

Metastatic disease to the mandible

Metastatic lesions to the mandible are rare, comprising less than 1% of all malignancies. Twenty-two cases of metastatic disease to the mandible were seen from 1938 to 1985. The records of 17 cases were available for detailed review. The age range was from 27 to 80 years with a female to male ratio of 12 to 5. A mandibular or paramandibular mass or swelling was the most common presenting sign. Three patients presented with mandibular metastasis prior to the discovery of the primary tumor. In the other 14 patients, the mandibular lesion appeared from 2 months to 20 years following discovery of the primary tumor. The mandibular lesion was the initial sign of distant metastatic disease in 11 of the 17 patients. Breast, lung, and colon cancer were the most common primary tumors. When presented with an isolated mandibular mass, a high index of suspicion is necessary to make the diagnosis of metastatic disease. Since plain x-rays may initially be normal, technetium or CT scan may be necessary to demonstrate osseous destruction. Inferior alveolar nerve anesthesia should be considered an indication of tumor until proven otherwise. Treatment is often of a palliative nature because of the presence of widespread metastatic disease; however, surgical resection may be considered in the rare patient with a well-documented, solitary mandibular metastasis.

The opacified maxillary sinus: CT findings in chronic sinusitis and malignant tumors

To distinguish opacification owing to inflammatory conditions (sinusitis) from that caused by nasomaxillary malignancy, computed tomography scans in 24 proved cases of sinusitis or tumor were reviewed for features related to sinus size, wall thickness, and character of bone erosion. An anatomic system was defined for classifying lesions according to the surface and type of bony involvement. In 12 cases of chronic maxillary sinusitis, the involved sinus was usually small and thick walled. The nasal surface of the involved sinus usually was eroded; often the orbital surface was eroded. The erosion was, however, short, irregular, and in the region of a normal dehiscence (semilunar hiatus or infraorbital canal) in all cases. The infratemporal surface was never eroded. In 12 cases of nasomaxillary neoplasia, the sinus was enlarged, one or more walls of the involved sinus being thinned and expanded. Bone erosion was present in all cases; erosion of the infratemporal surface was specific for neoplasia and significant as the usual site of recurrence.

The role of supraomohyoid neck dissection at the time of supraglottic laryngectomy

Uncontrolled cervical metastasis is the most common source of failure in the surgical treatment of supraglottic carcinoma. This study was designed to determine the value of supraomohyoid neck dissection in patients undergoing supraglottic laryngectomy. The rationale for considering the role of supraomohyoid neck dissection is that such a dissection encompasses the subdigastric and midjugular nodes which are the first echelon of lymphatic drainage of the supraglottic larynx. Thirty-eight patients with a diagnosis of epidermoid carcinoma of the supraglottis were treated by subtotal supraglottic laryngectomy (SSL). Ten patients underwent SSL with no neck dissection, 16 patients underwent SSL with supraomohyoid neck dissection (SOHD)--9 unilateral and 7 bilateral, and 12 patients underwent SSL with radical neck dissection (RND). The 3 groups had comparable T classifications. All of the SSL and SSL with SOHD patients were classified as N0. Of the 12 patients treated with SSL and RND, 4 were classified as N0, 4 as N1, 3 as N2, and 1 as N3. The patients were studied to determine the incidence and pattern of subsequent neck disease, survival, complications, and length of hospitalization. The data indicates that supraomohyoid neck dissection offers little benefit as an adjunct to supraglottic laryngectomy.

The role of the psychiatrist in otolaryngology

The patient, staff, and physician benefit when the otolaryngologist and psychiatrist are able to work closely together. Not only is clinical care improved, but time can be spent more efficiently in dealing directly with the patient's problem.

Nutritional considerations in the management of head and neck cancer patients

Head and neck cancer patients are often malnourished. In addition, these patients also face nutritional problems related to the site of the tumor. Surgery and chemotherapy create additional difficulties in maintaining adequate nutritional status. Proper attention to the nutritional needs of these cancer patients is an important aspect of their overall management.

Computed tomography of the carotid space and related cervical spaces. Part II: Neurogenic tumors

Fourteen neurogenic tumors of the neck were examined with computed tomography (CT) and, in ten cases, angiography. Schwannomas and paragangliomas occurred in the carotid space. These tumors could be distinguished on CT from those occurring more anteriorly, in relation to the parapharyngeal space, and more posteriorly, in relation to the paraspinal space. Schwannomas alone occurred in the paraspinal space. Schwannomas were heterogeneously hypodense before contrast enhancement and at least partially hyperdense after contrast enhancement, with displacement of adjacent vessels on CT, and, if they were of vagal origin, anteromedial displacement of the internal carotid artery on angiography. Paragangliomas usually were homogeneously hyperdense after contrast enhancement, with incorporation of adjacent vessels on CT, and, if they were of carotid body origin, lateral displacement of the internal carotid artery on angiography.