Cavernous sinus thrombosis secondary to allergic fungal sinusitis.

Cavernous sinus thrombosis (CST) is a rare and serious complication secondary to invasive fungal sinusitis, but rarer still in cases of allergic fungal sinusitis. Current recommendations for cavernous sinus thrombosis are controversial, especially regarding anticoagulation, secondary to the rarity of the diagnosis. Early surgical debridement and intravenous antibiotics are crucial to prevent mortality and decrease morbidity. Because thrombosis is thought to be caused by a bacterial superinfection, which follows a response to Aspergillus, antifungals may not be necessary. Despite the controversy, most physicians opt to treat with anticoagulation.

Using social media to disseminate education about Alzheimer's prevention & treatment: a pilot study on Alzheimer's universe (www.AlzU.org).

BACKGROUND: The use of social media may be a valuable tool for dissemination of patient education interventions. However, in Alzheimer's disease (AD), little data exists about the effectiveness, associated cost, or conditions for utilization. METHODS: Alzheimer's Universe (www.AlzU.org) is an online educational portal that provides evidence-based educational content for the public and a variety of activities related to optimizing AD management. The primary goal of our study was to assess the effectiveness of using the social media platform Facebook.com as a tool to recruit subjects to visit AlzU.org via targeted advertising and evaluate the associated costs. Secondary outcomes included AlzU.org join rates, lesson and activity completion rates, user demographics and attitudes about the education research platform. RESULTS: A total of $706 generated 4268 visits to AlzU.org via a series of page posts promoted with targeted advertising to individuals with previously expressed interest in 'Alzheimer's disease,' to those who had 'liked' the Alzheimer's Association page, and followers of www.facebook.com/AlzheimersDisease. Advertising used different promotional taglines in the Facebook Advertising manager tool using 'Cost Per Click' and the 'Optimized for Engagement' settings. Across all strategies combined, 503 visitors joined AlzU.org (11.8% join rate), 412 engaged with at least one lesson/activity (82%), and 100 completed all available lessons and activities (19.8%). Users were primarily women (79.8%) and the most common age group was 50's (43.3%, range 22-92). The majority joined AlzU.org to learn more about AD prevention or treatment (66.3% and 65.3%, respectively). Over 90% were satisfied with their experience. DISCUSSION: Subjects were quickly and cost-effectively recruited to AlzU.org. Completion rates of education content and activities were adequate, and subjects were highly satisfied with their experiences. Overall, targeted advertising on Facebook.com was an effective means of disseminating AD education online.

Current management of Ménière's disease in an only hearing ear.

OBJECTIVE: Ménière's disease in an only hearing ear is rare. Our objective is to define the current practice patterns for this problem. SUBJECTS: Clinically active members of the American Otological Society and the American Neurotology Society. MAIN OUTCOME MEASURE: Survey responses. RESULTS: Three hundred fifty-four surveys were sent out, and 165 were returned (48%). Ninety-nine percent recommended dietary modification as first line. Only 39% recommended oral corticosteroids. Second-line treatments were, in order of significance, the Meniett device (Medtronic ENT, Jacksonville, FL, USA), intratympanic corticosteroids, endolymphatic mastoid shunt, intratympanic gentamicin, and endolymphatic sac vein decompression. Interestingly, 71.5% of respondents would operate on an only hearing ear provided the appropriate circumstances. CONCLUSION: We have documented current practice patterns for treatment. Second-line treatments vary, but the Meniett is recommended most frequently, and further recommendations may not logically progress from least to most invasive. Many respondents eventually offer surgery.

Unilateral congenital facial nerve paralysis secondary to a benign epithelioid peripheral nerve sheath tumor.

OBJECTIVE: A benign epithelioid peripheral nerve sheath tumor is described in the setting of congenital facial nerve (FN) paralysis. This is the first reported case in the English literature. PATIENT: A 10-month-old girl with unilateral congenital FN paralysis. INTERVENTIONS: Auditory brainstem evoked potential study, gadolinium-enhanced magnetic resonance imaging, temporal bone computed tomography, and transmastoid FN decompression with tumor resection. MAIN OUTCOME MEASURES: Follow-up for tumor recurrence and postoperative FN function. RESULTS: The child underwent a transmastoid FN exploration with resection of a 0.6-cm spherical tumor analyzed to be a benign epithelioid peripheral nerve sheath tumor. There is no evidence of recurrence, and FN function was unchanged at 1 year postoperatively. CONCLUSION: Benign epithelioid peripheral nerve sheath tumor can cause congenital facial nerve palsy.

Idiopathic temporal bone encephaloceles in the obese patient.

OBJECTIVES: Our aims were to introduce temporal bone encephalocele (TBE) to the differential diagnosis of persistent middle ear effusion, cerebrospinal fluid otorrhea, or chronic otitis media in obese adults and to demonstrate the basic pathophysiologic principles of morbid obesity as it may lead to the cascade of increased intra-abdominal pressure, increased central venous pressure, benign increased intracranial pressure, and TBE. METHODS: A retrospective review of the medical records was performed to determine the location, nature, and etiology of the encephaloceles identified at our institution from 1989 to 2005. Body mass index was calculated from the patient height and weight data. RESULTS: Eight patients with spontaneous, idiopathic TBE were identified. Body mass index values ranged from 32.0 to 67.5 kg/m(2) with a mean of 48.6 kg/m(2). All patients identified with a spontaneous, idiopathic TBE were obese. CONCLUSION: TBE is associated with morbid obesity in our population and should be considered in the differential diagnosis when evaluating mastoid and middle ear disease in the morbidly obese.

Postoperative imaging and follow-up of vestibular schwannomas.

OBJECTIVE: No standards exist regarding patient follow-up after complete vestibular schwannoma resection. We surveyed neurotologists and neurosurgeons to determine practice patterns. STUDY DESIGN: A nonrandomized sample of American Neurotology Society and North American Skull Base Society members was surveyed. Questions concerned years in practice, experience with vestibular schwannoma surgery, and postoperative follow-up algorithms given the scenario of complete gross tumor removal. Data were collected, tallied, and statistically analyzed. SETTING: Academic and private practice neurotologists and neurosurgeons. SUBJECTS: Nonrandom sample of American Neurotology Society and North American Skull Base Society members. MAIN OUTCOME MEASURES: Number of postoperative magnetic resonance imaging scans, timing of magnetic resonance imaging scans, timing of final magnetic resonance imaging scan, timing of final visit, and variability between specialties. RESULTS: Four hundred ninety-eight surveys were sent and 135 were returned (27.1%). The average number of postoperative magnetic resonance imaging scans was 3.6 for neurotologists (range, 1-11) and 5.6 for neurosurgeons (range, 1-13). This was statistically significant (p >0.001). There was no correlation between number of magnetic resonance imaging scans and either years in practice or tumor experience. Average length of follow-up varied greatly (1 year to lifetime) but was most commonly 5 years. Eight percent of neurotologists varied their postoperative routine on the basis of surgical approach, whereas none of the neurosurgeons did. CONCLUSION: There remains no standard postoperative imaging algorithm for patients after complete vestibular schwannoma resection.

Pediatric temporal bone fractures in a rural population.

OBJECTIVE: To examine pediatric temporal bone fractures in a rural population. STUDY DESIGN AND SETTING: A retrospective chart review of pediatric temporal bone fractures between January 1, 1996, and December 31, 2000, at a rural academic medical center. RESULTS: A total of 108 patients were identified. Common etiologies include falls, bicycle-related injuries, and motor vehicle accidents. Animal-related injuries were identified primarily in patients under 5. Facial nerve injuries were noted in 7%, hearing loss in 16%, additional skull base fractures in 65%, and intracranial injuries in 75%. CONCLUSIONS: Temporal bone fracture etiology in the rural pediatric population is associated with age. Young children may suffer fractures secondary to animal-related accidents. Patterns of injury differ little between rural and urban settings. SIGNIFICANCE: Animal-related accidents may be a significant cause of temporal bone trauma in rural young children. Our data remain unique in that we report additional skull base fractures as well as intracranial injuries in this population.

Arachnoid cyst of the fallopian canal: a surgical challenge.

OBJECTIVE: Spontaneous cerebrospinal fluid (CSF) leaks from the fallopian canal are exceedingly rare, with only 6 reports appearing in the world literature. We report a seventh case that is unique in that it involves an arachnoid cyst of the fallopian canal and an associated facial nerve palsy. STUDY DESIGN: Case report. SETTING: International tertiary care referral center. CONCLUSION: CSF otorhinorrhea associated with a facial nerve palsy may be indicative of an arachnoid cyst of the fallopian canal. These fistula are extremely rare. Surgical management involves sealing the fistula while preserving facial nerve function and is extremely challenging.

Clinical associations between tinnitus and chronic pain.

OBJECTIVE: We sought to estimate the prevalence and severity of tinnitus in patients with chronic pain. STUDY DESIGN AND SETTING: We conducted a prospective nonrandomized study in which a survey and the Tinnitus Handicap Inventory (THI) were distributed at a tertiary chronic pain clinic. RESULTS: Seventy-two patients participated. 50 women (mean age, 53 years) and 22 men (mean age, 47.5 years); 54.2% reported having tinnitus. There was an even distribution of patients reporting the onset of tinnitus as before versus after the onset of pain. Four patients reported a direct association between tinnitus and pain. The mean THI score was 27 (of 100) (n = 35). Fifteen subjects scored less than 16, indicating no handicap, and 4 scored over 58, indicating a severe handicap. CONCLUSION: The study results suggest a high incidence of tinnitus within this population. There were few strong associations between pain and tinnitus. Tinnitus does not significantly handicap the majority of these patients. SIGNIFICANCE: Tinnitus is a common symptom in the chronic pain population but is not a significant problem for these patients.

Acellular porcine intestinal submucosa as fascial graft in an animal model: applications for revision tympanoplasty.

OBJECTIVE: To demonstrate regeneration of muscle fascia appropriate for future harvest with the use of acellular porcine intestinal submucosa in a rat model. STUDY DESIGN: Animal cohort study. SETTING: Tertiary care academic medical center. SUBJECTS AND METHODS: Sixteen male Sprague-Dawley rats underwent excision of rectus abdominis muscle fascia. A sheet of acellular porcine intestinal submucosa was placed in the fascia harvest defect. Graft and underlying muscle were harvested at three-, six-, and nine-week intervals. Histologic examination, including immunohistology for anti-von Willebrand factor, was performed at each timepoint. Additional selected specimens were subjected to latex vascular perfusion casts to examine vessel growth patterns within the graft. RESULTS: Gross examination revealed a new tissue plane, indistinguishable from surrounding native fascia. Histology revealed an initial inflammatory response within the graft. Progressive influx of native tissue was noted over successive timepoints. Via collagen-specific staining, we noted progressive reorganization and maturation of the graft collagen matrix. At the final nine-week time point, a new loose connective tissue plane was reestablished between the graft and underlying muscle. Immunohistochemistry and latex perfusion both demonstrate an initial development of small capillaries that progresses over time to greater organization and arteriole formation. CONCLUSION: Fascia regeneration may be possible with use of an acellular porcine intestinal submucosa graft in an animal model. Future studies may prove beneficial in restoring fascia in humans. Implications for potential advantages in tympanoplasty are discussed.

New-onset facial paralysis and undiagnosed recurrence of cutaneous malignancy: evaluation and management.

Perineural invasion of cranial nerves, including the facial nerve by squamous cell carcinoma of the skin, is a poor prognostic factor for recurrent disease and disease-specific mortality. We discuss 2 patients who presented to the Otolaryngology/Head and Neck Surgery service with complete facial nerve paralysis and a history of skin cancer. Based on our experience with these patients, we recommend that patients who present with facial nerve paralysis and a history of cutaneous malignancy undergo aggressive management including early intervention and complete exploration of the facial nerve from the geniculate ganglion out to the periphery. Such rigorous care achieves the best possible oncologic outcomes for a proven aggressive disease.

Peritonsillar and parapharyngeal space abscess in the older adult.

OBJECTIVE: To review the presentation and management of peritonsillar (PTA) and parapharyngeal space (PPSA) abscesses in older adults and compare this with the usual presentation and management in the younger patient. STUDY DESIGN: An 18-year retrospective review at a tertiary care hospital. METHODS: The patient database was searched by using the diagnosis codes for PTA and PPSA. The search included inpatient and outpatient visits of patients 50 years of age and older from 1983 to 2001. The charts were reviewed, and data regarding presentation, management, and outcome were recorded. Comparisons to the current literature were made. RESULTS: Fourteen patients were identified, 8 with PTA and 6 with PPSA. The most common symptoms in both groups were sore throat and dysphagia. Only 1 patient in either group was febrile. All vital signs were within normal limits in all other patients. Only 1 patient in each group experienced trismus, and no patients showed drooling. Five of the PTA patients required inpatient care, and 2 were taken to the operating room. CONCLUSIONS: PTA and PPSA are uncommon infections in the older adult, with only 14 patients identified at a tertiary care hospital over an 18-year period. Complaints of new onset sore throat and dysphagia of several days duration in patients over 50 years old should alert the evaluating physician to these 2 clinical entities, even in afebrile, nontoxic patients. PTA in this group may be more likely to require inpatient care along with surgical treatment in the operating room.

Differential diagnosis and treatment of hearing loss.

Hearing loss is a common problem that can occur at any age and makes verbal communication difficult. The ear is divided anatomically into three sections (external, middle, and inner), and pathology contributing to hearing loss may strike one or more sections. Hearing loss can be categorized as conductive, sensorineural, or both. Leading causes of conductive hearing loss include cerumen impaction, otitis media, and otosclerosis. Leading causes of sensorineural hearing loss include inherited disorders, noise exposure, and presbycusis. An understanding of the indications for medical management, surgical treatment, and amplification can help the family physician provide more effective care for these patients.