[Atypical pain and a unilateral swelling of the neck: a patient with TIPIC-syndrome]

BACKGROUND

TIPIC-syndrome (Transient Perivascular Inflammation of the Carotid Artery) as a cause of a painful lump in the neck is not often described in the literature. This self-limiting perivascular inflammation of the carotid bifurcation is relatively unknown.

CASE

We describe a 50-year old patient, in whom a CT-scan that was performed because of unilateral pain in the neck and paranasal sinuses revealed the unexpected diagnosis of TIPIC-syndrome.

CONCLUSION

Knowledge of the symptoms at presentation and the following clinical course of TIPIC-syndrome can prevent unnecessary use of additional tests.

Epidemiology, the cherry on the cake

PURPOSE

In guideline development the evidence is more and more coming exclusively from randomized-controlled trials (RCTs), while all other evidential levels are too easily brushed aside. This adopted creed is based on the radical ideas of Archibald Cochrane. Randomize until it hurts-which should presumably be read as a stimulus to perform better research-was the initial suggestion of Cochrane.

METHODS

This commentary is based on quotes from Cochrane's original work.

RESULTS

Cochrane's statements were figured out in a long-gone era in which medical and social inequality prevailed. Adhering to the orthodoxy nowadays hurts both clinicians and patients. I doubt that this was ever Cochrane's intention.

CONCLUSION

In my opinion, the most important part of guideline development should be making inferences of the total medical content (all available evidence including expert opinion); a process that can only be done by subject experts. Methodological assessment, which is undoubtedly the most essential point in the planning of future studies, should come only second place in guideline development and should be used for grading of the evidential level, not for the decision to reject studies completely. Otherwise, far too much relevant evidence is ignored.

Neurocap Use for the Treatment of Iatrogenic Neuropathic Pain: Preliminary Operative Results in 3 Patients

Painful neuromas are a devastating condition that is notoriously difficult to treat. The large number of techniques that have been attempted suggest that no one technique is superior. Neuromas often occur in the extremities, but iatrogenically caused pain in the head and neck area has also been described. This article describes 3 consecutive patients diagnosed with traumatic neuroma who underwent transection of the causative nerve, followed by capping of the nerve stump with a Neurocap. With a follow-up of 7 to 24 months, our results show a marked reduction in the pain scores of all 3 patients. The preliminary results indicate that this technique might be a viable treatment option for patients with a suspected neuroma in the head and neck area.

Treatment of Frontal Secondary Headache Attributed to Supratrochlear and Supraorbital Nerve Entrapment With Oral Medication or Botulinum Toxin Type A vs Endoscopic Decompression Surgery

Importance

Endoscopic surgical decompression of the supratrochlear nerve (STN) and supraorbital nerve (SON) is a new treatment for patients with frontal chronic headache who are refractory to standard treatment options.

Objective

To evaluate and compare treatment outcomes of oral medication, botulinum toxin type A (BoNT/A) injections, and endoscopic decompression surgery in frontal secondary headache attributed to STN and supraorbital SON entrapment.

Design, Setting, and Participants

Prospective cohort study of 22 patients from a single institution (Diakonessen Hospital Utrecht) with frontal headache of moderate-to-severe intensity (visual analog scale [VAS] score, 7-10), frontally located, experienced more than 15 days per month, and described as pressure or tension that intensifies with pressure on the area of STN and SON. A screening algorithm was used that included examination, questionnaire, computed tomography of the sinus, injections of local anesthetic, and BoNT/A in the corrugator muscle.

Interventions

Different oral medication therapy for headache encountered in the study cohort, as well as BoNT/A injections (15 IU) into the corrugator muscle. Surgical procedures were performed by a single surgeon using an endoscopic surgical approach to release the supraorbital ridge periosteum and to bluntly dissect the glabellar muscle group.

Main Outcomes and Measures

Headache VAS intensity after oral medication and BoNT/A injections. Additionally, early postoperative follow-up consisted of a daily headache questionnaire that was evaluated after 1 year.

Results

In total, 22 patients (mean [SD] age, 42.0 [15.3] years; 7 men and 15 women) were included in this cohort study. Oral medication therapy reduced the headache intensity significantly (mean [standard error of the mean {SEM}] VAS score, 6.45 [0.20] [95% CI, 0.34-3.02; P < .001] compared with mean [SEM] pretreatment VAS score, 8.13 [0.22]). Botulinum toxin type A decreased the mean (SEM) headache intensity VAS scores significantly as well (pretreatment, 8.1 [0.22] vs posttreatment, 2.9 [0.42]; 95% CI, 3.89-6.56; P < .001). The mean (SEM) pretreatment headache intensity VAS score (8.10 [0.22]) decreased significantly after surgery at 3 months (1.30 [0.55]; 95% CI, 5.48-8.16; P < .001) and 12 months (1.09 [0.50]; 95% CI, 5.71-8.38; P < .001). There was a significant decrease of headache intensity VAS score in the surgical group over the BoNT/A group (mean [SEM] VAS score, 2.90 [0.42]) after 3 months (mean [SEM] VAS score, 1.30 [0.55]; 95% CI, 0.25-2.93; P < .001) and 12 months (mean [SEM] VAS score, 1.09 [0.50]; 95% CI, 0.48-3.16; P < .001) after surgery.

Conclusions and Relevance

Endoscopic decompression surgery had a long-lasting successful outcome in this type of frontal secondary headache. Even though BoNT/A had a positive effect, the effect of surgery was significantly higher.

Level of Evidence

3.

Entrapment Neuropathy: A Concept for Pathogenesis and Treatment of Headaches-A Narrative Review

Entrapment neuropathy is a known cause of neurological disorders. In the head and neck area, this pathophysiological mechanism could be a trigger for headache. Over the last few decades, injection of botulinum toxin type A in the muscles that are causing the compression as well as surgical decompression have proved to be effective treatment methods worldwide for large numbers of patients with daily headaches. In particular the entrapment of the supraorbital nerves in the glabellar musculature and the occipital nerves in the neck musculature are triggers for headache disorders for which many patients are still seeking an effective treatment. This article reviews the literature and aims to bring the concept of neural entrapment to the attention of a wider audience. By doing so, we hope to give more exposure to an effective and relatively safe headache treatment.

Motion-based equilibrium reprocessing therapy a novel treatment method for chronic peripheral vestibulopathies: A pilot study

Rehabilitation for vestibular disease is a safe method to partially alleviate symptoms of vertigo. It was hypothesized that principles of military aviation vestibular desensitization procedures that have a success rate of more than 80% can be extrapolated to chronic vestibular disease as well.The virtual reality motion base computer-assisted rehabilitation environment was used as treatment modality in 17 patients. They were exposed to sinusoidal vertical passive whole body motion in increasing intensity for a maximum of 12 sessions. The Dizziness Handicap Inventory (DHI) was used for assessment of the subjective complaints of vertigo.The median DHI scores of 50 points at baseline dropped to 22 points (P <.001) at follow-up. Post hoc analysis showed significant differences in outcome between measurements at baseline and at the end of the treatment, between baseline and follow-up, but not between end of treatment and follow-up.This pilot study concerning motion-based equilibrium reprocessing therapy (MERT) shows that it is a simple, quick, and well-tolerated treatment option to alleviate symptoms in patients with chronic peripheral vestibulopathies.

Framing of feedback impacts student's satisfaction, self-efficacy and performance

Feedback is considered important to acquire clinical skills. Research evidence shows that feedback does not always improve learning and its effects may be small. In many studies, a variety of variables involved in feedback provision may mask either one of their effects. E.g., there is reason to believe that the way oral feedback is framed may affect its effect if other variables are held constant. In a randomised controlled trial we investigated the effect of positively and negatively framed feedback messages on satisfaction, self-efficacy, and performance. A single blind randomised controlled between-subject design was used, with framing of the feedback message (positively-negatively) as independent variable and examination of hearing abilities as the task. First year medical students' (n = 59) satisfaction, self-efficacy, and performance were the dependent variables and were measured both directly after the intervention and after a 2 weeks delay. Students in the positively framed feedback condition were significantly more satisfied and showed significantly higher self-efficacy measured directly after the performance. Effect sizes found were large, i.e., partial η (2) = 0.43 and η (2) = 0.32 respectively. They showed a better performance throughout the whole study. Significant performance differences were found both at the initial performance and when measured 2 weeks after the intervention: effects were of medium size, respectively r = -.31 and r = -.32. Over time in both conditions performance and self-efficacy decreased. Framing the feedback message in either a positive or negative manner affects students' satisfaction and self-efficacy directly after the intervention be it that these effects seem to fade out over time. Performance may be enhanced by positive framing, but additional studies need to confirm this. We recommend using a positive frame when giving feedback on clinical skills.

Hyperbaric Oxygen Therapy in Acute Acoustic Trauma: A Rapid Systematic Review

In this rapid systematic review, we studied the clinical question, What is the effect of hyperbaric oxygen therapy on hearing thresholds in patients who suffered a recent acute acoustic trauma? After screening for eligible titles and abstracts and extracting duplicates, 6 original research papers could be found. The general methodology of the studies was weak and the differences between these studies were too profound to pool the data, especially because of heterogeneity in adjuvant therapies, follow-up, and treatment protocol. The mean dB of hearing recovery in these studies ranged from 17 to 47 dB in the groups treated with hyperbaric oxygen versus 5 to 46 dB in the groups who did not receive hyperbaric oxygen therapy. We conclude that the effect of hyperbaric oxygen therapy on hearing thresholds in patients with hearing loss caused by a recent acute acoustic trauma remains unclear. A well-designed randomized controlled trial with enough power is advised to answer this clinical question.

A Small Effect of Adding Antiviral Agents in Treating Patients with Severe Bell Palsy

In this evidence-based case report, the authors studied the following clinical question: What is the effect of adding antiviral agents to corticosteroids in the treatment of patients with severe or complete Bell palsy? The search yielded 250 original research articles. The 6 randomized trials of these that could be used all reported low-quality data for answering the clinical question; apart from apparent flaws, they did not primarily include patients with severe or complete Bell palsy. Complete functional facial nerve recovery was seen in 75% of the patients receiving prednisolone only and in 83% with additional antiviral treatment. The pooled risk difference of 7% (95% confidence interval, −1% to 15%) results in a number needed to treat of 14 (ie, slightly favors adding an antiviral agent). The authors conclude that although a strong recommendation for adding antiviral agents to corticosteroids to further improve the recovery of patients with severe Bell palsy is precluded by the lack of robust evidence, it should be discussed with the patient.

[Paediatric breathlessness caused by aspiration of a foreign body in food]

Two one-year-old boys were seen by a paediatrician with symptoms of increasing breathlessness and inspiratory stridor. Upon the probable diagnosis subglottic laryngitis and toddler's asthma, respectively, they were admitted to hospital for medical treatment. Because they failed to recover sufficiently with this treatment, an ENT specialist subsequently performed a laryngotracheobronchoscopy under general anaesthesia. A fish-bone and chicken-bone, respectively, were found and removed from the larynx. In retrospect, the parents of both children realized that onset of symptoms followed a choking incident. These case histories illustrate the importance of active questioning concerning the onset of symptoms in order to differentiate between possibly causes. Endoscopy of the airways is required when parents mention a triggering moment or if the course of respiratory complaints is atypical.

Is microvascular compression of the vestibulocochlear nerve a cause of unilateral hearing loss?

OBJECTIVES

We sought to confirm earlier findings in the literature that microvascular compression of the vestibulocochlear nerve might cause unilateral sensorineural hearing loss. We measured the length and width of the internal auditory canal (IAC) to investigate a possible association between a narrow porus, the presence of an anterior inferior cerebellar artery (AICA) loop, and the development of a microvascular compression syndrome.

METHODS

We performed a prospective blinded analysis of 167 magnetic resonance imaging scans of the cerebellopontine angle. The presence of an AICA loop was scored. We analyzed these 167 patients for unilateral sensorineural hearing loss, which was defined as an interaural difference of 20 dB at 1 frequency or 10 dB at 2 or more frequencies. Furthermore, the width and length of the IAC on magnetic resonance imaging were measured.

RESULTS

An AICA loop was identified in 94% of the 167 patients. There were 196 type I loops, 106 type II loops, and 14 type III loops. Sixty-six patients had unexplained unilateral hearing loss. There was no association between type II and III vascular loops, the width of the IAC, and unilateral hearing loss (p > .05).

CONCLUSIONS

In this study we found no association between the depth of extension of the AICA loop into the IAC and the presence of unilateral hearing loss.

Grading Facial Nerve Function

OBJECTIVE

To compare the interobserver variability of a new grading system to the currently recommended House-Brackmann Grading Scale.

STUDY DESIGN

Prospective case-control study.

SETTING

Tertiary referral center.

PATIENTS

All patients with a facial nerve paresis/paralysis (whatever the cause).

INTERVENTION

All patients were evaluated for their facial nerve function by three observers, independently, using both the new system and the House-Brackmann Grading Scale.

MAIN OUTCOME MEASURE

The level of agreement between the three observers using both scales.

RESULTS

With the movement, rest, secondary defects, and subjective scoring grading scale, a higher percentage of agreement between the observers was noticed than with the House-Brackmann Grading Scale.

CONCLUSION

The movement, rest, secondary defects, and subjective scoring grading system is more useful for grading facial nerve dysfunction in clinical practice than the House-Brackmann Grading Scale.

Odor and Irritation Thresholds for Ammonia: A Comparison between Static and Dynamic Olfactometry

Odor and lateralization (irritation) thresholds (LTs) for ammonia vapor were measured using static and dynamic olfactometry. The purpose of the study was to explore the test-retest reliability and comparability of dynamic olfactometry methodology, generally used to determine odor thresholds following European Committee for Standardization guidelines in the context of odor regulations to outside emissions, with static olfactometry. Within a 2-week period, odor and LTs for ammonia were obtained twice for each method for 24 females. No significant differences between methods were found: mean odor detection thresholds (ODTs) were 2.6 parts per million (ppm) for either method (P = 0.96), and mean LTs were 31.7 and 60.9 ppm for the static and dynamic method, respectively (P = 0.07). Test-retest reliability was higher for the dynamic than for the static method (r = 0.61 vs. 0.14 for ODTs and r = 0.86 vs. 0.45 for LTs). The choice of optimal method for any application, however, depends not only on psychometric factors but also on practical factors such as physicochemical properties of the compound, availability of equipment and expertise, task efficiency, and costs.

Morbidity of parotid gland surgery: results 1 year post-operative

Patients operated on for parotid gland tumours were evaluated prospectively to study morbidity after this procedure. Nowadays, major complications such as recurrence of tumour and permanent facial nerve paresis are rare after primary surgery. Therefore, this study especially takes minor complications such as Frey's syndrome and sensory deficits into account. The study documents morbidity in 45 patients who completed a 1 year follow-up. Among those with primary benign tumours, we found no recurrences and no permanent paresis, nor did starch-iodine testing reveal any cases of Frey's syndrome. However, two patients who had previously been operated on multiple times did test positive for Frey's syndrome, as did two others after surgery for malignancy. Furthermore, we found that patients whose posterior branch of the great auricular nerve was sacrificed had a larger area of sensory deficit than those whose nerve was preserved. We conclude that the morbidity of parotid gland surgery can be reduced further by giving minor complications more attention.

The location of parotid gland tumors in relation to the facial nerve on magnetic resonance images and computed tomography scans

PURPOSE

The facial nerve, which cannot be visualized radiographically in its intraparotid part, divides the parotid gland into 2 lobes. When planning surgery, it is important to know where to locate a parotid gland tumor in relation to the facial nerve, because the location can influence the duration and difficulty of the operation. In this study, an anatomic line that predicts the course of the facial nerve in the parotid gland, is applied clinically and compared with another line recently described to evaluate the usefulness of both tools in the use of computed tomography scans and magnetic resonance images.

MATERIALS AND METHODS

We reviewed 28 scans (15 computed tomography and 13 magnetic resonance) and used both lines to predict tumor location in the parotid gland. The accuracy of each prediction was checked later by referring to the surgical report.

RESULTS

This new anatomic line helped us to correctly predict tumor location in relation to the facial nerve in 24 cases (85.7%), whereas the other line was helpful in 20 cases (71.4%).

CONCLUSION

Our new line may be a very useful tool to predict the location of parotid gland tumors.