Head-Jolting Nystagmus: Occlusion of the Horizontal Semicircular Canal Induced by Vigorous Head Shaking

IMPORTANCE

We report a new syndrome, which we are calling head-jolting nystagmus, that expands the differential diagnosis of head movement-induced paroxysmal vertigo.

OBSERVATIONS

Two male patients (65 and 58 years old) described rotational vertigo after violent and brief (1- to 2-second) oscillations of the head (head jolting) that triggered intense horizontal nystagmus lasting 45 seconds. Accelerations of the head required to induce these episodes could only be achieved by the patients themselves. In case 1, the episodes gradually disappeared over a 6-year period. In case 2, magnetic resonance imaging (3-T) suggested a filling defect within the left horizontal semicircular canal. He underwent surgical canal plugging in March 2013 that resolved the symptoms.

CONCLUSIONS AND RELEVANCE

We attribute head-jolting nystagmus to dislodged material within the horizontal semicircular canal and provide a mechanistic model to explain its origin.

HEAD JOLTING NYSTAGMUS: HEAD-SHAKING-INDUCED OCCLUSION OF THE HORIZONTAL SEMICIRCULAR CANAL

Background and aims

We report a new syndrome (head jolting nystagmus, HJN) that expands the differential diagnosis of head-movement induced paroxysmal vertigo.

Methods and results

Two male patients (65 and 58 yrs) described rotational vertigo after violent and brief (1–2 s) oscillations of the head (head jolting) that triggered intense horizontal nystagmus lasting 45s. Accelerations of the head required to induce these episodes could only be achieved by the patients themselves. In Patient 1 the episodes gradually disappeared over a 6–year period. In Patient 2, 3–Tesla MRI suggested a filling defect in the left horizontal semicircular canal. He underwent surgical canal plugging that resolved the symptoms.

Conclusion and relevance

We attribute HJN to dislodged material within the horizontal semicircular canal, and provide a mechanistic model to explain its origin.

Delayed Presentation of a Congenital Cholesteatoma in a 64-year-old Man: Case Report and Review of the Literature

Introduction Congenital cholesteatomas of the temporal bone are epidermoid cysts of embryologic origin that result in progressive desquamation and trapping of squamous epithelium behind an intact tympanic membrane. They are benign, slowly progressive lesions that can be found in various areas of the temporal bone. We report a case of a patient with a massive cholesteatoma first detected at the age of 64 years, causing significant destruction of the mastoid and petrous temporal bones, and adjacent occipital bone.

Methods We reviewed the literature and a case report of a patient seen in our institution recently. The Medline database was used to search multiple terms including “congenital” and “cholesteatoma.”

Results The patient's congenital cholesteatoma was detected incidentally on a computed tomography scan when the patient's only symptoms were unilateral conductive hearing loss with a family history of hearing loss. It was subsequently successfully operated on with minimal postoperative complications.

Conclusions Congenital cholesteatomas of mastoid origin can often exist for many years in a subclinical state and develop into a massive size before causing symptoms. A high index of suspicion is necessary to detect congenital cholesteatomas in patients with unilateral conductive hearing loss who are otherwise asymptomatic and have a normal tympanic membrane.

Bone-Anchored Hearing Devices in Children with Unilateral Conductive Hearing Loss: A Patient-Carer Perspective

Objectives:

We sought to determine the outcome of implantation of a bone-anchored hearing device in children with unilateral conductive hearing loss.

Methods:

A retrospective case note analysis was used in a tertiary referral pediatric hospital to study 17 consecutive cases of pediatric patients with unilateral conductive hearing loss who were fitted with a bone-anchored hearing device between 2005 and 2010.

Results:

The average age of the patients at the time of bone-anchored hearing device fitting was 10 years 6 months (range, 6 years 3 months to 16 years). Qualitative subjective outcome measures demonstrated benefit. The vast majority of patients reported improved social and physical functioning and improved quality of life. All 17 patients are currently using their bone-anchored hearing device on a daily basis after a follow-up of 6 months.

Conclusions:

This study has shown improved quality of life in children with unilateral hearing loss after implantation of their bone-anchored hearing device. There was a high degree of patient satisfaction and improvement in health status reported by children and/or carers. Bone-anchored hearing devices have an important role in the management of children with symptomatic unilateral hearing loss. Perhaps earlier consideration of a bone-anchored hearing device would be appropriate in selected cases.

Perioperative considerations for children undergoing bone anchored hearing device surgery: an observational study

The objective of the study was to identify important factors in the perioperative management of children undergoing bone anchored hearing device (BAHD) surgery in a paediatric tertiary centre. We also aim to compare current practice and identify any changes in practice with the previous study carried out in the same paediatric tertiary centre in 2000. Children undergoing BAHD surgery between January 2008 and January 2011 were identified on a departmental database. A retrospective case note review was performed and compared with data collected prior to 2000. In the study period, 194 children were identified to have had BAHD surgery. 134 case notes were available for analysis and of these children, 353 anaesthetics were identified. 45.5% of the children had a recognised syndrome or dysmorphism and 17% had a congenital cardiac anomaly. 16% of the children were classified as a grade 3 or 4 laryngoscopy, but 83.3% were managed with a laryngeal mask. 11.9% of the children had an intraoperative complication and 4.8% a postoperative complication. 88.4% of children were managed as day cases. Compared with the previous study in 2000, there was a smaller proportion of syndromic or dysmorphic children and a larger proportion of children were managed with a laryngeal mask. As BAHD surgery has become more common and as its indications have expanded, the perioperative management has evolved. The proportion of children with congenital heart disease has remained constant, but there has been a marked reduction in the number of children with syndromes involving the head and neck. We have found that even in complex craniofacial cases, the laryngeal mask is increasingly being used with good results. However, advanced paediatric airway experience was still required in a small number of cases, heightening the awareness that specialised paediatric support services are necessary for a comprehensive BAHD programme.

Bone-anchored hearing aids versus conventional hearing aids

Hearing amplification technology has been evolving since the 19th century. Currently in most audiology departments, the mainstay of hearing rehabilitation is performed with conventional air and bone conduction aids. These are cost-effective, non-invasive hearing aids but are not without their drawbacks. This chapter explores the advantages and disadvantages of conventional hearing aids compared with the bone-anchored hearing aids. Although the bone-anchored hearing aids are a more expensive invasive option, there is increasing evidence that the benefits outweigh the disadvantages. Users report improved quality of life, health status and audiological rehabilitation.

How well equipped are ENT wards for airway emergencies?

INTRODUCTION

With increased cross cover of specialities at night and more direct triaging of casualty patients to ENT wards, there is an increased need to ensure that there is adequate provision of emergency airway management. There are currently no national guidelines on what equipment should be available on ENT wards, and the authors have devised a portable airway box with all equipment deemed necessary to manage an acute airway. We believe that all junior doctors covering ENT should have airway training and access to an airway box. The aim of this study was to determine the provision of on-ward airway equipment and training on ENT wards in England.

MATERIALS AND METHODS

A telephone survey of all English hospitals with in-patient ENT services.

RESULTS

A total of 103 departments were contacted with 98% response rate. Most wards were covered by a combination of ENT and other specialties. Results indicated that only 18% of departments had an airway box and 28% had some training in airway management.

CONCLUSIONS

Results suggest poor provision of emergency airway equipment and training on wards. We recommend the use of an airway box, and list of minimal equipment required.

Recurrent squamous cell carcinoma in the neopharynx treated successfully with topical 5-fluorouracil

We present the first reported case of a squamous cell carcinoma recurrence on a reconstructed flap in the pharynx treated successfully with topical chemotherapy. The patient, treated for a pharyngeal cancer with resection and reconstruction with a free radial forearm flap, and post-operative radiotherapy, developed a tumour on the flap more than two years after surgery. The recurrence was also squamous carcinoma, but there was only superficial infiltration. This was treated with 5-fluorouracil paste placed in the pharynx, with resolution of the tumour. The patient was alive and well more than 28 months after this treatment, with no sign of disease recurrence. Topical chemotherapy for treatment of oral cancer is well described for early disease, but we show that it may be a useful treatment in recurrent disease in selected patients.

Plasma cortisol is often decreased in patients treated in an intensive care unit

OBJECTIVE

To investigate the prevalence of adrenal hypofunction, as assessed by plasma cortisol (p-cortisol) and its relationship to clinical events.

DESIGN

Prospective, consecutive.

SETTING

General intensive care unit in a university hospital.

PATIENTS

Fifty-five patients (34 men and 21 women) were studied (surgery 40 patients, hemodialysis 5, ventilator treatment 45, sepsis 21).

METHODS

Morning basal levels of p-cortisol were determined. Previous reports define adrenal insufficiency to be present if p-cortisol under stressful conditions is lower than either 400 or 500 nmol/l. The tetracosactoid test (250 microg Synacthen) was performed in 16 patients and urinary 24-h excretion of cortisol in 24 (none on corticosteroid treatment).

RESULTS

Median p-cortisol was 550 nmol/l (range 20-1764). In 36% of patients p-cortisol was lower than 400 nmol/l and in 47% lower than 500 nmol/l. There was a significantly increased probability (P < 0.05) of p-cortisol being below 400 nmol/l in patients admitted due to trauma or cerebral disorder and in patients on ventilator therapy or on mannitol. Thirty minutes after tetracosactoid administration p-cortisol response was lower than 200 nmol/l in 56% of the patients.

CONCLUSIONS

Several patients had low p-cortisol and attenuated responses to tetracosactoid, indicative of adrenal insufficiency. There seem to be certain risk factors for adrenal hypofunction which may justify more frequent use of physiological doses of corticosteroid in selected patients.