Perilymphatic Fistulas and Superior Semi-Circular Canal Dehiscence Syndrome

Perilymphatic fistulas (PLF) and superior semi-circular canal dehiscence syndrome (SCDS) are 2 conditions that can present with sound and/or pressure-induced vertigo. PLF should be suspected in cases of trauma or surgery, while a spontaneous PLF is a diagnosis of exclusion. Research is ongoing to identify an ideal biomarker for perilymph. The diagnosis of SCDS continues to evolve with further research into vestibular-evoked myogenic potentials, electrocochleography, and higher resolution CT imaging. Treatment advances include the transmastoid approach, smaller middle fossa craniotomies, and usage of endoscopes. Temporal bone studies have furthered the understanding of pressure dynamics within the ear and how this relates to recommendations for repair versus alternative treatments such as round window plugging.

Semicircular Canal Dehiscence Syndrome and Vestibular Dysfunction Disqualify a Military Student Pilot

BACKGROUND

Humans detect motion and gravity via the labyrinthine system of the inner ear, which consists of the vestibule and the semicircular canals. The vestibular system provides three major functions for maintaining balance and orientation. First, it maximizes the effectiveness of the visual system. Second, it provides orientational information necessary for performing both skilled and reflexive motor activities. Third, in the absence of vision, the vestibular system provides a reasonably accurate perception of motion and position. Although these organs provide important cues for basic orientation on the ground, they often provide misleading information during flight. A superior semicircular canal dehiscence can cause an individual to experience disorientation and vertigo-like symptoms.

CASE REPORT

A 30-yr-old male student pilot experienced airsickness on his first several flights in the T-6A Texan II aircraft. Airsickness is common among student pilots in the early stages of flight training; however, the subject pilot's symptoms lasted well beyond the normal 24 h, and included vertiginous symptoms lasting days after his last flight. His persistent symptoms required he be held out of training for further evaluation. Comprehensive vestibular and audiological testing were normal; however, a CT scan of the temporal bones showed a left superior semicircular canal dehiscence, and he was diagnosed with left labyrinthine fistula as the cause of his vertigo. He was medically eliminated from pilot training and permanently disqualified from U.S. Air Force flying duties.

DISCUSSION

Spatial disorientation remains one of the deadliest factors related to aircraft mishaps every year. In this case, an abnormal presentation of airsickness that prompted further evaluation may have prevented a dangerous situation in the air. In standard airsickness, the goal is to keep the pilot flying to expedite adaptation, so this case highlights the importance of distinguishing between normal airsickness and a spatially disorienting medical condition.Dreibelbis JA, Organ BE. Semicircular canal dehiscence syndrome and vestibular dysfunction disqualify a military student pilot. Aerosp Med Hum Perform. 2018; 89(10):923-926.

Empyema caused by a colopleural fistula: A case report

RATINALE

Empyema is a condition in which pus gathers in the area between the lungs and the inner surface of the chest wall. An empyema caused by colo-pleural fistula is a rare but potentially life-threatening condition.

PATIENT CONCERNS

We describe a case of 42-year-old man was brought to our Emergency Department for chest pain with dyspnea and fever.

DIAGNOSES

The final diagnoses are empyema caused by colo-pleural fistula and colon cancer.

INTERVENTIONS

The patient underwent laparotomy surgery, during which a tumor was found in the splenic flexure of the descending colon. The tumor penetrated the colonic serosa and invaded the left side of the diaphragm. A left hemicolectomy was performed.

OUTCOMES

After the operation, the patient recovered smoothly and was discharged on postoperative day 14. It's been over 3 years now, CT and colonoscopy assessments show no recurrence or metastasis.

LESSONS

This case serves as a reminder to test for pathogens in patients with an unexplained empyema. If normal intestinal bacteria are detected, the empyema may be derived from intestinal disease. In addition, an abdominal examination should be performed in patients with an empyema of unknown origin.

[The microbiological study of purulent focus of inflammation in patients with chronic osteomyelitis of long bones]

The article presents analysis of results of microbiological study of pathologic samples from fistula and surgical wounds of 155 patients with chronic osteomyelitis of long bones in the period of exacerbation of disease during 2014-2015. In totality, 126 samples from fistula and 95 samples from wounds were analyzed. Correspondingly, 164 and 102 strains of bacteria were separated. The microbial contamination of fistula and wounds was established. The species composition of microflora was analyzed. It is established that in the analyzed groups the main agent still continues to be staphylococcus and priority pathogen Staphylococcus aureus differing slightly in rate of occurrence and coefficient of resistance. MRSA was separated up to 5.6% more often from surgical wounds than from fistula. The highest detection rate of strains S. aureus and MRSA falls on 2009-2010. In 2015, the lowest detection rate of S. aureus was marked with relatively high rate of detection of MRSA. The disk diffusion D-test was applied to determine resistance of inducible type to Clindamycin of 17 strains of S. aureus resistant to Erythromycin and sensitive to Clindamycin. The inducible resistance to Clindamycin for strains from surgery pounds made up to 62.5% that is three times higher than in case of strains separated from fistula. The important role in development of chronic of osteomyelitis of long bones is played by Gram-negative microorganisms (E. coli, Enterobacter, P. aeruginosa, etc.). The rate of detection of these microorganisms in surgery wounds makes up to 22.5% and 17.1% in fistula.

Predialysis care and dialysis outcomes in hemodialysis patients with a functioning fistula

BACKGROUND/AIMS

Predialysis care has been associated with improved first-year outcomes. We investigated types of predialysis care associated with improved patient outcomes in patients initiating dialysis with a fistula and at least 2 years of predialysis care.

METHODS

In this retrospective cohort of incident hemodialysis patients with ≥2 years of Medicare coverage before dialysis initiation, care patterns and patients were determined using Medicare claims. Fistula use at initiation was ascertained from the Medical Evidence Report.

RESULTS

Patients aged ≥67 years who initiated hemodialysis with a fistula (n = 14,459) differed demographically and clinically from patients who initiated with other vascular access types; however, 55% had diabetes, 28% heart failure, and 40% ischemic heart disease. In the year preceding initiation, 88% of these patients visited a nephrologist, 66% a cardiologist, 9% an endocrinologist, and 3% a dietician; most underwent routine laboratory measurements. In the first year of dialysis, 50% were hospitalized and 1.3% underwent transplant; the mortality rate remained constant (∼20 per 100 patient-years). Of predialysis care factors evaluated, only fistula placement more than 1 month before dialysis initiation was associated with lower hospitalization and mortality risk and greater likelihood of transplant. Other potentially modifiable factors included more contact with cardiologists and endocrinologists.

CONCLUSION

Patients initiating dialysis with a functioning fistula appear to receive substantial predialysis preparation. This selected population does not show the excess mortality risk often observed early in dialysis treatment. Earlier fistula placement and referral to cardiology and endocrinology appear to be important aspects of predialysis care.

Utero-peritoneal fistula, a rare complication of laparoscopic myomectomy scar dehiscence: a case Report

OBJECTIVE

The objective is to report a case of utero-peritoneal fistula caused by laparoscopic myomectomy dehiscence, diagnosed by colour Doppler ultrasound scan and confirmed by x-ray HSG and MRI. The aim of our report lies on the importance of imaging in the diagnosis of fistulous processes involving the uterus.

CASE REPORT

A 36 year old woman (G6,P0)presented with intense dysmenorrheal and intermenstrual spotting since laparoscopic myomectomy 2 years before. A laparoscopic myomectomy dehiscence with utero-peritoneal fistula was diagnosed by pelvic ultrasound, hysterosalpingogram (HSG) and magnetic resonance imaging (MRI).

Type A aortic dissection complicated with fistulization into the right atrium and right-to-left shunt

Fistulization between the aorta and the right atrium is a rare complication of ascending aortic dissection. Because of the typical haemodynamic unstability, the diagnosis is often made by bedside or intraoperative transoesophageal echocardiography. The treatment is surgical, but with very high mortality. We describe a case of type A aortic dissection complicated with shock and fistulization into the right atrium with the right-to-left shunt through a patent foramen ovale. Surgical repair was successful.

[Spinal dural arteriovenous fistula: frequently diagnosed late]

BACKGROUND

The diagnosis of spinal dural arteriovenous fistula (SDAVF) is often established relatively late. In this case, we describe early clinical and radiological signs of SDAVF.

CASE DESCRIPTION

A 53-year-old patient presented with sensory deficits and disturbances related to gait, mictition and defecation. Neurological examination revealed signs of polyradiculoneuropathy. An MRI scan of the vertebral column showed swelling of the myelum and dilated perimedullary vasculature; digital subtraction angiography revealed an SDAVF. The fistula was approached surgically by hemilaminectomy after which it was successfully occluded.

CONCLUSION

An SDAVF is a connection between a radicular arteria and a radicular vein, resulting in venous hypertension and obstruction of the venous flow. Consequently, oedema forms beneath the fistula and congestive ischaemia of the myelum develops. Initial symptoms are sensory or disturbances related to gait; later, disturbances in micturition, defecation or erection may occur. Digital subtraction angiography is the gold standard. Treatment consists of surgical or endovascular occlusion of the fistula. Early recognition and treatment of SDAVF are essential for a good prognosis.

Delayed left ventricle-to-right atrial fistula following aortic valve replacement

Fistula development between the left ventricular outflow tract and right atrium is a rare complication of aortic valve replacement (AVR), typically seen with calcific aortic stenosis or endocarditis. The case is reported of a left ventricle-to-right atrial fistula following mechanical AVR for aortic insufficiency.

Successful surgical management of a delayed pharyngo-esophageal perforation after anterior cervical spine plating

A case report of a 41-year-old man who had a delayed pharyngo-esophageal perforation without instrumentation failure 7 years after anterior cervical spine plating is presented and the literature on this issue is reviewed. This injury resulted from repetitive friction/traction between the retropharyngo-esophageal wall and the cervical plate construct leading to a pseudodiverticulum and perforation. Successful treatment of the perforation was obtained after surgical repair using a sternocleidomastoid muscle flap. This case stresses the necessity of careful long-term follow-up in patients with anterior cervical spine plating for early detection of possible perforation and the use of muscle flap as the treatment of choice during surgical repair.

Coronary flow characteristics of multiple coronary artery-left ventricular microfistulae in young monozygotic twins

Coronary artery multiple fistulae of the left ventricular chamber are extremely rare congenital malformations. We report on 13-year-old monozygotic twin brothers who have identical abnormalities of coronary flow reserve as well as the same morphological findings of multiple coronary fistulae of the 3 major coronary arteries to the left ventricular chamber. The left circumflex coronary artery (LCX) had abundant fine communications with the left ventricular chamber and had a higher flow rate than the left anterior-descending coronary artery. The coronary flow reserve obtained from the LCX was lower than the normal value matched for the same age group. The increased shunt flow resulted in enlargement of the left ventricular chamber. This is the first report of coronary flow characteristics in children with multiple coronary fistulae.

Transclival cerebrospinal fluid fistula in a patient with Marfan's syndrome

Marfan's syndrome is a disease associated with reduced structural integrity of connective tissues. We report a 36-year-old patient with Marfan's syndrome who presented with rhinorrhoea, occipital headache and vomiting. Physical examination revealed typical Marfan's syndrome features including dolicocephalous, mandibular micrognathia, tall stature, disproportionately long limbs and digits, and hypermobility of the joints. A high-resolution CT scan demonstrated pneumoencephalous, cerebrospinal fluid (CSF) filling the sphenoidal sinus, and a small bone defect of the clivus. Surgery performed through a transsphenoidal approach revealed the sphenoid sinus to be filled with CSF and a small fenestration in the clivus. The arachnoid diverticulum and the fenestration were repaired and covered with a graft of abdominal fat. In this patient, a deficiency in bone development associated with Marfan's syndrome gave rise to a clival fenestration and a transclival CSF fistula. Although abnormalities of the spinal meningeal membranes have been reported in Marfan's syndrome, to our knowledge, this is the first report of a fistula located in the cranial base in this condition.

Hormonal dependence of fistulas communicating with the uterus

The conventional management of urogenital fistulas is surgical but a recent review of world data showed a high efficacy of hormonal manipulation by the induction of amenorrhea in the treatment of vesicouterine fistulas (VUFs). In fact, VUFs were first demonstrated to be hormonally regulated due to the fistulous canal being lined by endometrium. In this report, we suggest and discuss that, in women of reproductive age, the phenomenon of hormonal regulation is likely to be present in other fistulas communicating with the uterus, like ureterouterine and enterouterine fistulas.

Lymphorrhea responds to negative pressure wound therapy

Lymphoceles and lymph fistulas are common complications of femoral exposure for vascular procedures. Three patients who required readmission after their vascular interventions were treated with negative pressure wound therapy. Once adequate control of the drainage was obtained, the patients were discharged home with a portable suction unit. The mean time to stop lymph leak was 14 days, and the mean length of hospital stay was 7.3 days. This method of management offers early control of fluid drainage, rapid control of the wound, earlier closure, and the potential for reduced length of stay. Patient acceptance and convenience may be enhanced by outpatient management and return to work in appropriately motivated individuals.

PRE- AND POSTTHORACENTESIS CHEST RADIOGRAPHIC FINDINGS DO NOT PREDICT ABNORMAL PLEURAL ELASTANCE

STUDY OBJECTIVES

Pneumothorax following ultrasound-guided thoracentesis is rare. Our goal was to explain the mechanisms of pneumothorax following ultrasound-guided thoracentesis in a setting where pleural manometry is routinely used.

METHODS

We reviewed the patient records and procedure reports of 401 patients who underwent ultrasound-guided thoracentesis. When manometry was performed, pleural space elastance was determined. A model assuming dependence of the pleural space elastic properties on respiratory system elastic properties was used to isolate cases with presumed normal pleural space elastance. Elastance outside mean +/- SD x 2 of the isolated sample was considered abnormal. Four radiographic criteria of unexpandable lung were used: visceral pleural peel, lobar atelectasis, basilar pneumothorax, and pneumothorax with ipsilateral shift.

RESULTS

There were 102 diagnostic thoracenteses, 192 therapeutic thoracenteses with pleural manometry, and 73 therapeutic thoracenteses without manometry. There was one pneumothorax that occurred from lung puncture and eight unintentional pneumothoraces, all of which showed radiographic evidence of unexpandable lung. Four of eight unintentional pneumothoraces had abnormal elastance; none had excessively negative pleural pressure (< -25 cm H(2)O).

CONCLUSIONS

Unintentional pneumothoraces cannot be prevented by monitoring for symptoms or excessively negative pressure. These pneumothoraces were drainage related rather than due to penetrating lung trauma or external air introduction. We speculate that unintentional pneumothoraces are caused by transient, parenchymal-pleural fistulae caused by nonuniform stress distribution over the visceral pleura that develop during large-volume drainage if the lung cannot conform to the shape of the thoracic cavity in some patients with unexpandable lung. These fistulae appear to be pressure dependent, and the resulting pneumothoraces rarely require treatment. Drainage-related pneumothorax is an unavoidable complication of ultrasound-guided thoracentesis and appears to account for the vast majority of pneumothoraces occurring in a procedure service.

Observations on the potential across the rumen of the sheep

1. The electric potential difference between rumen contents and jugular venous blood was measured in anaesthetized sheep. In order to investigate the effect on the potential of changing the ionic concentrations within the rumen, the digesta were removed from the rumen and various salt solutions were substituted. The reticulo-rumen sac was isolated before the experiment by ligation of the oesophagus and the reticulo-omasal junction. 2. The observation of Dobson & Phillipson (1958) that the rumen contents are normally of the order of 30 mV negative to the blood was confirmed. 3. For potassium concentrations between 25 and 100 mM the potential at constant [Na+] varied linearly with log [K+]. With sulphate as the anion, the slope for a 10-fold concentration change was 39.7 +/- 3.0 mV when [Na+] was around 50 mM. The slope showed a tendency to increase when [Na+] was lowered, and to decrease when [Na+] was raised. 4. When chloride was substituted for sulphate, both the slope and the absolute size of the potential were slightly reduced. 5. When the sodium concentration was varied at constant [K+], the potential increased as an approximately linear function of [Na+]. At around 10 mM-K the mean slope was 0-32 +/- 0.07 mV/mM; at the highest potassium concentrations it fell to 0-13 +/- 0 05 mV/mM. 6. In most of these experiments isotonicity was maintained with sucrose. The results of a few tests in which Li+ was substituted for Na+ or K+ suggested that the rumen epithelium behaves in a relatively inert fashion towards this ion.

Ventriculoperitoneal shunt insertion for the treatment of refractory perilymphatic fistula

Object

The goal of this study was to provide preliminary data regarding clinical and functional outcome, including postoperative morbidity, related to ventriculoperitoneal (VP) shunt insertion for refractory perilymphatic fistula.

Methods

The authors retrospectively reviewed the records of seven consecutive patients who had undergone VP shunt insertion for medically and surgically refractory perilymphatic fistula between 1996 and 2004. Patients were also contacted by telephone and asked to assess retrospectively their symptomatic improvement, changes in functional status, and changes in work status following shunt placement. Preoperative and postoperative functional statuses were assessed using a standardized instrument. In each patient, preoperative opening pressure was measured via lumbar puncture. Pressures ranged from 160 to 300 mm H2O, with a mean of 241 mm H2O.

All patients reported significant improvement in symptom severity following surgery. Two patients reported complete resolution of symptoms. Three patients were able to resume full-time work. Clinically significant improvement in functional status was noted in six of seven patients. All patients would recommend the procedure to others in a similar situation.

Conclusions

Data in this study suggest that some patients with disabling vertigo, tinnitus, and headache due to perilymphatic fistula, whose conventional medical and surgical therapies have failed to produce a cure, benefit from VP shunt insertion. The authors hypothesize that VP shunt placement blunts intracranial pressure increases, which would cause secondary elevations in perilymphatic fluid pressure. Shunt insertion reduces perilymph leakage into the middle ear and may permit closure of the fistula.

Vestibulär evozierte myogene Potenziale

The recording of vestibular evoked myogenic potentials is a relatively new neuro-otologic method which gives specific information about the function of the sacculus and the inferior vestibular nerve on each side separately. The main indications for this method are vestibular schwannoma and fistula of the labyrinth, involvement of the sacculus or the inferior vestibular nerve in Menière's disease and vestibular neuritis, vertigo of unknown etiology, and forensic questions.

[Analysis of auditory steady-state response to multiple simultaneous stimuli and cochlea morphology in guinea pigs with posterior semicircular canal fistula]

OBJECTIVE

To observe the changes of auditory steady-state response (ASSR) threshold in guinea pigs with posterior semicircular canal fistula.

METHODS

In 10 guinea pigs, a window was opened in the posterior semicircular canal of the left ear with the right ear serving as the control for testing the ASSR under anesthesia with pentobarbital sodium.

RESULTS

The mean and standard deviation of ASSR threshold (dB SPL) at 0.5, 1, 2, and 4 kHz in the left ear was 35.00+/-14.33, 25.50+/-12.37, 20.00+/-9.37 and 20.00+/-9.18, respectively, and was 31.00+/-16.19, 25.50+/-12.34, 18.00+/-6.96 and 18.50+/-6.71 in the right ear, respectively. Paired-sample t test showed no significant difference in the ASSR at the same frequency between the two ears.

CONCLUSION

Small fistula by surgery causes no significant hearing loss in guinea pigs.

Oro-nasal fistula development and velopharyngeal insufficiency following primary cleft palate surgery--an audit of 148 children born between 1985 and 1997

We present an audit of primary cleft palate surgery in our unit including rates of two important post-operative complications. Multidisciplinary audit clinics ran from March 1998 to April 2002 to follow up all local patients with a cleft lip or palate who had undergone primary palatal surgery in our unit. One hundred and forty eight patients were studied. Patient ages at follow-up ranged from 3 years and 10 months to 17 years and 4 months. Two surgeons performed the primary surgery. One hundred and twenty eight Wardill-Kilner and 20 Von Langenbeck repairs were performed. We found a 4.7% rate of oro-nasal fistula development requiring surgical closure, and a 26.4% rate of velopharyngeal insufficiency (VPI) requiring subsequent pharyngoplasty. We noted that the type of cleft involved affected the rate of VPI, 16% of patients with unilateral cleft lip and palate versus 29.2% of patients with a solitary cleft palate requiring secondary surgery. Outcome of surgery was determined by a 'Cleft Audit Protocol for Speech' (CAPS) speech therapy assessment at follow-up clinics. Only 14.9% of all patients assessed demonstrated any degree of hypernasality. Our results compare favourably with other recent studies including the Clinical Standards Advisory Group (CSAG) report into treatment of children with cleft lip and palate.

Rapid fluctuations in conscious state in a patient with an extensive spinal dural fistula

A man with a spontaneous spinal dural fistula and significant fluctuations in level of consciousness is discussed. The presentation was that of headache and vomiting followed by an initially enigmatic acute reduction in the level of consciousness. This required urgent evacuation of bilateral chronic subdural haematomas, believed to be causative. Following mobilisation, several episodes of presumed orthostatic intracranial hypotension occurred rendering the patient rapidly unconscious. A large spinal extradural CSF collection extending through the full length of the vertebral canal was later diagnosed however, the precise location of the fistulous leak could not be found radiologically. Non-operative management was successful. To the best of our knowledge, this is the first description of a spontaneous spinal cerebrospinal fluid leak of this magnitude. The case, pathogenesis, investigations and management of this rare entity are considered and the literature reviewed.

Efficacy of Standard Trauma Craniectomy for Refractory Intracranial Hypertension with Severe Traumatic Brain Injury: A Multicenter, Prospective, Randomized Controlled Study

To compare the effect of standard trauma craniectomy (STC) versus limited craniectomy (LC) on the outcome of severe traumatic brain injury (TBI) with refractory intracranial hypertension, we conducted a study at five medical centers of 486 patients with severe TBI (Glasgow Coma Scale score </= 8) and refractory intracranial hypertension. In all 486 cases, refractory intracranial hypertension, caused by unilateral massive frontotemporoparietal contusion, intracerebral/subdural hematoma, and brain edema, was confirmed on a CT scan. The patients were randomly divided into two groups, one of which underwent STC (n = 241) with a unilateral frontotemporoparietal bone flap (12 x 15 cm), and the second of which underwent LC (n = 245) with a routine temporoparietal bone flap (6 x 8 cm). At 6-month follow-up, 96 patients (39.8%) in the STC group had a favorable outcome on the basis of the Glasgow Outcome Scale, including 62 patients who had a good recovery and 34 who showed moderate deficits. Another 145 patients (60.2%) in the STC group had an unfavorable outcome, including 73 with severe deficits, nine with persistent vegetative status, and 63 who died. By comparison, only 70 patients (28.6%) in the LC group had a favorable outcome, including 41 who had a good recovery and 29 who had moderate deficits. Another 175 patients (71.4%) in the LC group had an unfavorable outcome, including 82 with severe deficits, seven with persistent vegetative status, and 86 who died (p < 0.05). In addition to these findings, the incidence of delayed intracranial hematoma, incisional hernia, and CSF fistula was lower in the STC group than in the LC group (p < 0.05), although the incidence of acute encephalomyelocele, traumatic seizure, and intracranial infection was not significantly different in the two groups (p > 0.05). The results of the study indicate that STC significantly improves outcome in severe TBI with refractory intracranial hypertension resulting from unilateral frontotemporoparietal contusion with or without intracerebral or subdural hematoma. This suggests that STC, rather than LC, be recommended for such patients.

Severe craniofacial fractures with frontobasal involvement and cerebrospinal fluid fistula: indications for surgical repair

BACKGROUND

The management of posttraumatic cerebrospinal fluid (CSF) fistulae is a controversial topic. Although recent literature shows that endoscopic repair of CSF fistula is efficacious and minimally invasive, in specific conditions open operative approach remains imperative.

METHODS

A series of 36 patients underwent surgery for posttraumatic CSF fistula according to specific selection criteria. These criteria included: bone displacement more than 1 cm (5 cases), location of fracture in proximity to the midline (6 cases), involvement of cribriform plate (12 cases), presence of encephalocele (3 cases), and failure of the conservative treatment (10 cases). The dural defect was closed using vascularized pericranium and fibrin glue. Closure of the basal bone defect was necessary in very large fractures or in special localization of the fistula, such as near the optic nerve. Mean clinical follow-up was 5.7 years.

RESULTS

Two patients presented meningitis without sequelae, and 12 with hyposmia. One patient died of the severity of the primary brain injury and associated extracranial lesions. None of the patients had recurrence.

CONCLUSIONS

Our results indicate that surgical dural repair in selected cases is related to low morbidity and mortality preserving from delayed risks such as recurrence and infections.

Effect of parenteral and enteral nutrition combined with octreotide on pancreatic exocrine secretion of patients with pancreatic fistula

AIM: To evaluate the effect of parenteral and enteral nutrition combined with octreotide on pancreatic exocrine secretion of the patients with pancreatic fistula.

METHODS: Pancreatic juice, drained directly from the pancreatic fistula, was collected, and the volume, protein, amylase, HCO₃^-, K⁺, Na⁺ and Cl^- were determined on d 1, 4 and 7 before and after 7-d treatment with octreotide, respectively.

RESULTS: No differences in exocrine pancreatic secretion were observed during the enteral and parenteral nutrition period (t = 2.03, P > 0.05); there were significant decreases in pancreatic juice secretion volume, protein, amylase, HCO₃^-, K⁺, Na⁺ and Cl^- after parenteral and enteral nutrition combined with octreotide compared with octreotide pretreatment (t = 4.14, P < 0.05).

CONCLUSION: There is no stimulatory effect on the pancreatic secretion by intrajejunal nutrition and parenteral nutrition. Octreotide is effective on the reduction of pancreatic fistula output.

Relationship between encephalopathy and portal vein-vena cava shunt: Value of computed tomography during arterial portography

AIM: To assess the value of computed tomography during arterial portography (CTAP) in portal vein-vena cava shunt, and analysis of the episode risk in encephalopathy.

METHODS: Twenty-nine patients with portal-systemic encephalopathy due to portal hypertension were classified by West Haven method into grade I (29 cases), grade II (16 cases), grade III (10 cases), grade IV ( 4 cases). All the patients were scanned by spiral-CT. Plane scans, artery phase and portal vein phase enhancement scans were performed, and the source images were thinly reconstructed to 1.25 mm. We reconstructed the celiac trunk, portal vein, inferior vena cava and their branches and subjected them to three-dimensional vessel analysis by volume rendering (VR) technique and multiplanar volume reconstruction (MPVR) technique. The blood vessel reconstruction technique was used to evaluate the scope and extent of portal vein-vena cava shunt, portal vein emboli and the fistula of hepatic artery-portal vein. The relationship between the episode risk of portal-systemic encephalopathy and the scope and extent of portal vein-vena cava shunt, portal vein emboli and fistula of hepatic artery-portal vein was studied.

RESULTS: The three-dimensional vessel reconstruction technique of spiral-CT could display celiac trunk, portal vein, inferior vena cava and their branches at any planes and angles and the scope and extent of portal vein-vena cava shunt, portal vein emboli and the fistula of hepatic artery-portal vein. In twenty-nine patients with portal-systemic encephalopathy, grade I accounted for 89.7% esophageal varices, 86.2% paragastric varices; grade II accounted for 68.75% cirsomphalos, 56.25% paraesophageal varices, 62.5% retroperitoneal varices and 81.25% dilated azygos vein; grade III accounted for 80% cirsomphalos, 60% paraesophageal varices, 70% retroperitoneal varices, 90% dilated azygos vein, and part of the patients in grades II and III had portal vein emboli and fistula of hepatic artery-portal vein; grade IV accounted for 75% dilated left renal vein, 50% paragallbladder varices, all the patients had fistula of hepatic artery-portal vein.

CONCLUSION: The three-dimensional vessel reconstruction technique of spiral-CT can clearly display celiac trunk, portal vein, inferior vena cava and their branches at any planes and angles and the scope and extent of portal vein-vena cava shunt. The technique is valuable for evaluating the episode risk in portal-systemic encephalopathy.

Can low frequency sound stimulation during posturography help diagnosing possible perilymphatic fistula in patients with sensorineural hearing loss and/or vertigo?

Perilymphatic fistula (PLF) is often difficult to diagnose because of the similar symptomatology, such as vertigo, tinnitus and hearing loss, which is found in several inner ear diseases. We attempted to correlate a positive result of low frequency sound (LFS) stimulation tests in posturography with the presence or absence of a PLF confirmed by transtympanic endoscopy in 209 patients with various inner ear diseases (Meniere's disease ( n=128), vestibulopathy ( n=41), cochleopathy ( n=28) and sudden deafness ( n=12). LFS provoked unsteadiness in posturography without PLF in 24 patients with Meniere's disease, in 5 patients with vestibulopathy, in 3 patients with cochleopathy and in 2 patients with sudden deafness. In one patient, tympanoscopy revealed fistula in the round window membrane that was covered with a fibrinous layer. In four cases there was abnormal light reflex in the round window but without PLF. In eight cases, Hennebert's sign was present with nystagmus, without PLF. We conclude that pathological responses to the LFS test in posturography can also be encountered in other inner ear diseases without PLF.

Stress electrocochleography

Electrocochleographic recordings after changes of middle-ear and intracranial pressure were studied in a group of otologically normal subjects and in patients with suspected Ménière's disease. Electrocochleography performed under these conditions was called stress electrocochleography. It was useful to distinguish among Ménière's disease, benign positional vertigo, and a round-window fistula. Changes of middle-ear pressure, whether positive or negative, always resulted in a rise of the SP/AP ratio. Raised intracranial pressure after Trendelenburg positioning showed fluctuations of the SP/AP ratio in both normal subjects and symptomatic patients. However, in normal subjects, a congruent pattern of these fluctuations was apparent, whereas symptomatic patients exhibited a discordant pattern. The discordant pattern, typical for Ménière's disease, showed an increase of the SP voltage, whereas the AP voltage decreased. In benign positional vertigo, the SP voltage decreased, and the AP voltage increased, once during Trendelenburg positioning and again at the end of the test when starting position was resumed. During raised intracranial pressure after the Queckenstedt maneuver, round-window fistulas showed an increase of the SP voltage, whereas the AP voltage decreased considerably. At our clinic, stress electrocochleography has become an important neurootological test in the differential diagnosis of Ménière's disease.

An unusual complication of coil embolization of a large coronary-pulmonary fistula

A 58-year-old man with hemoptysis was found to have a large fistula from his circumflex artery to the pulmonary system. Coil embolization was performed. This resulted in occlusion of the fistula, including a small branch likely supplying the sinus node. Following the procedure he developed junctional bradycardia but remained hemodynamically stable. He had a brief period of atrial fibrillation which, after 48 hours, reverted to a rhythm from an ectopic focus in the low right atrium. This case highlights an unusual complication of fistula embolization and emphasizes the need for caution when occluding vessels which may supply the sinus node.

Biliary-venous fistula complicating transjugular intrahepatic portosystemic shunt presenting with recurrent bacteremia, jaundice, anemia and fever

A 50-year-old White man with noncirrhotic portal hypertension presented with bleeding from gastric varices. Bleeding was initially managed with band ligation and subsequent transjugular intrahepatic portosystemic shunt (TIPS). Over the next few months, the patient had recurrent episodes of anemia, jaundice, fever and polymicrobial bacteremia. Computed tomography (CT) of the abdomen and chest, upper and lower endoscopy, endoscopic retrograde cholangiopancreatography (ERCP), and echocardiography failed to explain the bacteremia and anemia. Follow-up CT scan and Doppler sonography 9 months after placement showed TIPS was occluded. Repeat ERCP showed a bile leak with free run-off of contrast from the left hepatic duct into a vascular structure. The patient's status was upgraded for liver transplantation with Regional Review Board agreement and subsequently received a liver transplant. Gross examination of the native liver demonstrated a fistula between the left bile duct and the middle hepatic vein. Pathologic evaluation confirmed focal necrosis of the left hepatic duct communicating with an occluded TIPS and nodular regenerative hyperplasia consistent with noncirrhotic portal hypertension. Infection is rarely reported in a totally occluded TIPS. Biliary fistulas in patent TIPS have been treated by endoluminal stent graft and endoscopic sphincterotomy with biliary stent placement. Liver transplantation may be the preferred treatment if TIPS becomes infected following its complete occlusion.

Labyrinthine fistulae: pathobiology and management

PURPOSE OF REVIEW

This article reviews literature on three manifestations of these pathologic mechanisms: leakage of perilymph from the inner ear into the middle ear, disruption of the bone of the labyrinth caused by cholesteatoma or other manifestations of chronic otitis media, and superior semicircular canal dehiscence syndrome.

RECENT FINDINGS

Labyrinthine fistulae are caused by abnormal communications between the inner ear and surrounding structures. Under normal circumstances, the fluid-filled spaces of the membranous labyrinth are encased in the dense bone of the otic capsule with only two places of increased compliance: the oval window and the round window. Disruption of the labyrinthine bone can lead to areas of increased compliance, with symptoms and signs that can be understood based upon abnormal pressure transmission in the system. Communication between the endolymphatic and perilymphatic spaces of the labyrinth or passage of perilymph from the labyrinth into the middle ear or mastoid can lead to hearing loss and/or vestibular disturbances.

SUMMARY

Findings on clinical examination as well as CT imaging of the temporal bone can be useful in making the diagnosis. Management is based upon the specific pathological factors and the impact of the symptoms and signs on the patient.

Percutaneous, Catheter-Based Coil Embolization of Coronary Fistula:

A 55-year-old male with angina-like chest pain and positive thallium-scintigraphy was admitted to our hospital. Cardiac catheterization was performed for suspected coronary artery disease. The coronary angiogram showed no significant epicardial stenosis, but a large coronary fistula, connecting the left anterior descending artery with the pulmonary artery. Swan-Ganz catheter measurements, intracoronary Doppler, and quantitative coronary angiography were used to determine cardiac output, coronary blood flow, and coronary-to-pulmonary artery shunt fraction. These measurements showed a hyperdynamic cardiac output of 17 L/min, a coronary blood flow of 140 mL/min in the left anterior descending coronary artery with an estimated shunt fraction of 58% into the pulmonary circulation. Percutaneous, catheter-based coil embolization was performed to occlude the fistula. After embolization of one coil, coronary angiography showed the fistula's stump only. Cardiac output (9 L/min) and coronary blood flow (48 mL/min) were almost normalized. The patient was discharged from the hospital the day after the procedure. After a 6-month follow-up, there were still no complaints, angina-like symptoms or signs of myocardial ischemia in stress tests.

[Results in terms of hearing results after surgical closure of labyrinthine fistulas]

OBJECTIVES

We investigated the results achieved in terms of hearing in 36 patients who had each undergone resection of a cholesteatoma and closure of a labyrinthine fistula.

PATIENTS AND METHODS

These patients included 28 who had a fistula of the semicircular canal, in 7 of them with an opened perilymphatic space. In 8 cases we found a fistula of the cochlea, with with a perilymphatic leak 7 in of them. We compared the sensorineural threshold before and after surgery and also the results in the two groups. Patients who were deaf preoperatively were excluded from further analysis.

RESULTS

Hearing did not improve in any of the patients (n=5) who were deaf preoperatively. There was no significant difference in changes to the hearing threshold between patients with fistula of the cochlear and those with fistula of the semicircular canal with opened perilymphatic space; nor did patients with a fistula of the semicircular canal without perilymphatic leakage have a better outcome than patients with an open membranous labyrinth.

CONCLUSIONS

The outcome of cholesteatoma resection and closure of the fistula in a single operation was good. Perilymphatic leakage seems to be predictive of a poorer result in terms of hearing.

[Prognostic factors in hearing recovery following sudden unilateral deafness]

A perilymph fistula is a possible cause for sudden unilateral sensory deafness. In this retrospective study the data of 73 patients with unilateral sudden deafness were analyzed. All of them underwent an exploratory tympanotomy during which both windows were packed with soft tissue. Postoperatively all patients received rheological therapy with pentoxifyllin and steroids. The following possible prognostic indicators were analyzed: age, sex, tinnitus, vertigo, vomiting, spontaneous nystagmus, positive fistula test, time between onset of symptoms and therapy, intraoperative proof of a perilymph fistula, and signs of barotrauma in the patient's history. A significant postoperative recovery of the hearing loss (>20%) was found in 29 patients (39.7%) (group 1), and 44 patients (60.3%) showed only an increase of <20% (group 2). The statistical analyses showed the following significant difference: The symptoms vertigo (p=0.002) and spontaneous nystagmus (p=0.014) occurred more frequently in group 2 (patients with a poor hearing recovery) than in group 1. Patients with a barotrauma,however, had an overproportionally good outcome (50-100% hearing recovery). A perilymph fistula was seen intraoperatively equally often in both groups. In summary, the symptoms vertigo and spontaneous nystagmus are indicators of complex damage in cases of sudden deafness and are associated with a worse prognosis concerning hearing recovery. Exploratory tympanotomy in combination with drug treatment is a reasonable therapy as an ultima ratio in every case of unilateral sudden deafness.

[Perilymphatic fistula: report of a case which resolved spontaneously in five days and literature review]

AIMS

We report a patient with a perilymphatic fistula and review the literature on this topic.

CASE REPORT

The patient was a 50 years old male with a five days history of intense and continuous vertigo associated with nausea, vomiting and sweating, which was initiated after a sudden noise in the left ear. The symptoms resolved spontaneously over five days, without surgical treatment. The clinical picture resembles those previously reported for perilymphatic fistula. The current literature on this topic has been reviewed in this article.

CONCLUSION

The patient presented an early recovery, what corroborates the current tendency of waiting a few weeks before indicating surgery.

[Perilymphatic fistulas of the labyrinth: diagnostic problems]

Basic diagnostic criteria for perilymphatic fistulas of the labyrinth (PFL) comprise previous trauma or psychoemotional stress, unilateral acute affection of the acoustic and vestibular functions, severe noise in the ears, mixed hypoacusis, lower hearing thresholds in change of the head position, alteration of stabilogram parameters in rising pressure in the external acoustic meatus.

[Etiology of labyrinthine perilymphatic fistula]

The examination of 120 patients with verified labyrinthine fistulas (LFs) has demonstrated that perilymphatic LFs most often are caused by rupture of the cochlear window's membrane (54%). Among other reasons were broken base of the stapes (6%), the defect in the area of both windows (17%), rupture of the annular ligament of the stapes (15%), defects in the area of semicircular canals. Incompetence of the stapedial piston prosthesis is documented.

[Audiological and equilibrium study of perilymphatic fistulas]

We clinically analyzed 15 cases of perilymphatic fistulas--11 caused by barotraumas and 4 idiopathic--identified by surgery between March 1995 and March 1999 at the Hyogo College of Medicine and affiliated hospitals. Subjects were 11 men and 4 women (aged 14 to 79 years (mean: 46.7 years)). All showed hearing loss in audiography and 12 cases reported tinnitus--stream-like in 5 and poping in 4. Dysequilibrium was seen in 9 cases. Perilymph leakage was detected intraoperatively from the oval window in 9, from the round window in 4, and from both windows in 1, while another had leakage from the fissura ante fenestram. After surgery, hearing level improved by over 10 dB in 9 of the 11 cases operated on within 14 days after onset. Hearing did not improve in 3 of 4 operated on later. Vertigo disappeared after surgery. Dizziness tended to persist in those having canal paresis or paralytic nystagmus before surgery. We suggest that patients with progressive hearing loss should be operated on as soon as possible and that patients with dysequilibrium or without response to conservative treatment undergo surgery within 14 days of onset.

Endoscope-guided round window fistula repair

OBJECTIVE

Endoscope-guided round window membrane repair was performed to evaluate whether the approach is feasible in the treatment of a round window fistula.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary care academic center.

PATIENT

A 27-year-old man had been scuba diving 6 days previously in the Australian Great Barrier Reefs. He had poor hearing with tinnitus in the left ear and a vertiginous sensation.

INTERVENTION

A myringotomy was incised, and a tympanoscope was introduced into the middle ear cavity. With the patient under general anesthesia, the middle ear and the oval and round window areas were examined with a tympanoscope. In endoscopic visualization, a round perforation could be seen in the round window membrane. After detection of the round window perforation, a small piece of temporal fascia was obtained to seal the membrane perforation.

RESULTS

One month after the operation, the patient's hearing was significantly better. The myringotomy had healed.

CONCLUSION

A transmyringeal endoscopic procedure for round window fistula repair is feasible and combines the best features of minimally invasive surgery and aural endoscopy.

Perilymph fistula associated with pulse-synchronous eye oscillations

Three-dimensional eye movements (scleral search coil system) were recorded in a patient with a surgically acquired perilymph fistula of the left horizontal semicircular canal. Spontaneous horizontal pendular nystagmus was found to be related to the heart rate and may be caused by pressure transfer of blood pulses to the labyrinth. In addition, a contralesional horizontal jerk nystagmus was elicited by Valsalva maneuver, indicating that Ewald's first law may not only be valid for excitation but also for inhibition.