Treatment strategies for orbital gas-producing necrotizing fasciitis secondary to odontogenic maxillary sinusitis: Technical notes.

This paper presents treatment strategies for orbital necrotizing fasciitis (NF) in a case of a 33-year-old male diagnosed with orbital NF, which developed after dental root canal treatment. Although orbital NF is rare, it is rapidly progressive and can easily lead to the loss of tissue and visual function, sometimes to a life-threatening extent. Prompt and adequate treatment has been a challenge yet remains quite essential. In addition to the conventional approach to NF, such as immediate antibiotic administration and drainage, orbital NF patients like this case were often treated by incorporating additional steps, which include: 1) performing minimally invasive but adequate removal of necrotic tissue through intraoperative use of ultrasound equipment and postoperative use of proteolytic enzyme-containing ointment for chemical debridement; 2) managing intraorbital pressure by lateral cantholysis and orbital floor removal (decompression); and 3) maintaining the aerobic conditions of the wound after surgical drainage via orbital wall removal. Thus far, satisfactory results in patients with extensive NF of the orbit, including the presented case, were achieved with regards to preserving periorbital tissues, vision, and ocular motility through a multidisciplinary approach. These should be considered as optional means of preserving the orbital tissue and visual function.

Characteristics and utility of combined duplex color-coded ultrasonography in the cervical rotational position with head MRI and MRA in the differential diagnosis of apogeotropic direction-changing positional nystagmus.

Objective: To determine whether cervical ultrasonography, magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA) are useful in the differential diagnosis of etiology and understanding the pathophysiology in cases of apogeotropic direction-changing positional nystagmus (DCPN). Methods: Thirty patients with apogeotropic DCPN were classified into 11 cases of central disease, seven cases of mixed central and peripheral disease, and 12 cases of peripheral disease by differential diagnosis based on various balance function, neuro-otological, and imaging tests.Cervical ultrasonography using the cervical rotation method and MRI and MRA of the head and neck were performed in most patients with apogeotropic DCPN. We reviewed the presence of abnormal imaging findings according to the disease etiology. Results: Of the 30 patients with apogeotropic DCPN, 23 showed vascular abnormalities or central lesions on imaging. Vascular lesions were found in six of the 12 patients with peripheral disease. Cervical ultrasonography with cervical rotation detected blood flow disturbance in the vertebral artery in eight patients in whom the disturbance could not be detected by MRI or MRA of the head and neck. Discussion: We hypothesize that the causative disease of apogeotropic DCPN may be strongly associated with circulatory insufficiency of the vertebrobasilar and carotid arteries, and that impaired blood flow in these vessels may affect peripheral vestibular and central function. In patients with apogeotropic DCPN, examinations of vestibular function, central nervous system symptoms, and brain hemodynamics are valuable for differential diagnosis.

A Report of Two Cases of Malignant Tumor of the Maxillary Sinus Diagnosed Using Fine-Needle Aspiration Cytology.

Primary and metastatic malignancies arising in the sinuses are rare and histologically diverse. The role of fine-needle aspiration cytology (FNAC) and the cytomorphologic characteristics of these tumors have not been specifically addressed. We described two cases of suspected malignant maxillary sinus tumors in 85- and 90-year-old patients with comorbid conditions, both of whom underwent tissue biopsies that failed to yield a definitive diagnosis. We performed FNAC after imaging confirmed that the malignant tumors were outside the maxillary sinus. The 85- and 90-year-old patients were diagnosed with squamous cell carcinoma (SCC) and adenocarcinoma, respectively. In the latter, the cell block method was used to prepare the specimen, rendering individual cells identifiable. Atypia of the histological structure was confirmed without the influence of cell duplication, a known weakness of FNAC. Thus, the diagnosis was made quickly. We believe that FNAC would be utilized more frequently for the definitive diagnosis of sinonasal tumors as the technique and diagnostic technology improve further.

Orbital Abscess Developed Apart From Paranasal Sinusitis and Dacryocystitis in Fibrous Dysplasia.

A 48-year-old man visited the emergency department of our hospital with swelling of the left upper and lower eyelids from the day before. On the first examination, he had severe swelling of the left upper and lower eyelids, proptosis, and chemosis. Left intraocular pressure was 33 mmHg. Computed tomographic images showed an orbital abscess in the anterosuperolateral orbital space, maxillary and ethmoidal sinusitis, and dacryocystitis. The orbital abscess was not contiguous to maxillary and ethmoidal sinusitis and dacryocystitis. Ground-glass appearance was seen in the frontal, maxillary, and ethmoid bones, and most of the space of the frontal sinus was obliterated due to the expansion of the frontal bone. Emergent drainage of orbital abscess, dacryocystorhinostomy, and endoscopic sinus surgery were performed under general anesthesia. Intravenous tazobactam/piperacillin was administered. A culture test of the sinus pus and orbital abscess showed growth of Streptococcus intermedius (2+). At one month postoperatively, there was no recurrence of orbital abscess, paranasal sinusitis, and dacryocystitis.

Lemierre Syndrome Due to Dialister pneumosintes: A Case Report.

Although Dialister pneumosintes is a commensal microorganism of the oral cavity, it may sometimes cause severe systemic infections. We report a case of Lemierre syndrome (LS), which developed after D. pneumosintes infection, in a 73-year-old Japanese woman who was admitted to the hospital for throat pain, neck swelling, and fever for 3 days. She had a 3-month history of neglected dental caries, gingivitis, and periodontitis. Physical examination revealed right tonsillar erythema and swelling, and computed tomography (CT) showed peritonsillar and retropharyngeal abscesses. Ampicillin/sulbactam was promptly administered after collecting two sets of blood cultures. Surgical drainage for peritonsillar and retropharyngeal abscesses was also conducted on the second hospital day. Although only commensal oral microflora grew in the culture from the drained pus, Gram-negative bacilli were confirmed in the anaerobic blood cultures. Metronidazole was administered intravenously; however, the fever and neck swelling persisted. Repeat CT performed on the fifth hospital day revealed right internal jugular vein thrombosis, a known complication of tonsillitis and pharyngitis once the infection extends beyond the oropharynx. We diagnosed she had coexisting LS, and anticoagulant therapy was added to her treatment regimen. Her condition improved, and she was discharged after completing 3 weeks of antibiotics. Conventional methods failed to identify the isolated bacterium, and 16S rRNA sequencing ultimately identified it as D. pneumosintes. In a literature review of bacteremia due to D. pneumosintes, poor oral hygiene was considered a probable risk factor for invasive D. pneumosintes infection. We consider this to be the case in our patient who presented with dental caries, gingivitis, and periodontitis. In addition, all cases revealed that the 16S rRNA gene sequencing is useful for identifying this species. Although the diagnosis of LS by physical examination is difficult, physicians should always consider it as a potential complication of infections in the pharyngeal area.

Large Cholesterol Granuloma of the Middle Ear Eroding into the Middle Cranial Fossa.

BACKGROUND: Cholesterol granuloma of the middle ear is extremely rare in comparison to cholesterol granuloma of the petrous apex but sometimes shows an aggressive course. CASE REPORT: We report herein a case involving a large, aggressive cholesterol granuloma of the middle ear that eroded the middle cranial fossa. A 64-year-old woman presented with pain in the left ear and hearing loss. Cholesterol granuloma was finally diagnosed from diffusion-weighted imaging, and cortical mastoidectomy was performed with canal wall down tympanoplasty type III. Recovery was uneventful recovery and the patient well at the 3-year follow-up. CONCLUSION: This case demonstrates the rare but clinically important pathology of aggressive cholesterol granuloma of the middle ear.

Lacrimal dacryostenosis with severe facial pain misdiagnosed as trigeminal neuralgia.

A 47-year-old woman developed intermittent shooting pain around the right side of the nose and eyes. A neurologist initially diagnosed trigeminal neuralgia, but carbamazepine did not improve the pain. Two months later, she presented with a pus-like eye discharge and was referred to us for further examination. Poor saline irrigation from the lacrimal puncta and computed tomography findings of a swollen lacrimal sac indicated a diagnosis of lacrimal dacryostenosis. At this point, the pain and dizziness as a side effect of carbamazepine had become intolerable. Endoscopic intranasal dacryocystorhinostomy confirmed stenosis of the nasolachrymal duct and a thickened lacrimal sac. The postoperative course was uneventful, and the facial pain disappeared. This experience suggests the importance of recognizing lacrimal dacryostenosis as a differential diagnosis of facial pain around the eyes and nose. We also recommend a review of an original diagnosis of trigeminal neuralgia if carbamazepine fails to relieve facial pain.

[Histological study on the effects of ethanol injection on mouth mucosa contraction loss].

We previously reported that a loss of contraction in the mucosal tissue of the palate arch is effectively induced by ethanol injections of moderate concentration and dosage. The present study was performed to obtain more information on how such ethanol injections induce contraction loss in mucosa tissue. Guinea pigs of both sexes were used in this study. The left arch of the palate mucosa was injected with 2 microliters of 70% ethanol and used as the experimental group. The right arch of the palate mucosa of the same animal was injected with saline and used as a control. One, three, five, eight, 10, 30, 50, and 90 days after injection, the mucosal tissues that received the injection were resected under anesthesia and processed for light microscopy using standard procedures. One day after the ethanol injection, severe coagulative degeneration of the mucosal tissue of the palate was seen. However, the damaged area was strictly restricted to the arch of the palate. Coagulative degeneration of the tissue peaked three days after the injection. Thereafter, the mucosal epithelial and mucosal connective tissues regenerated, and the damaged mucosal tissue quickly began to repair. An apparent cicatricial contraction loss was observed 10 days after the ethanol injection, along with the progression of fibrotic changes in the submucosal connective tissue of the arch of the palate. The regenerative action of the mucosal arch of the palate abated 30 days after the ethanol injection, and the reduced mucosal tissue appeared to have become denser as a result of an increase in dense fibrous connective tissue in the submucosal layer. No cell malignancies were seen throughout the entire 90-day observation period. In conclusion, cicatricial contraction loss of the mucosal arch of the palate resulting from the injection of an appropriate concentration and dosage of ethanol leads to the regeneration of the mucosal epithelium and fibrotic changes in the submucosa. The ethanol injection described here seems to be extremely safe, since it exerted no malignant effects on the cells and tissues either morphologically or functionally.

[Immunohistochemical study for monoamine neurons in the brain of unilateral inner ear impaired rats].

Patients with inner ear impairment have complaints of vertigo and also occasionally depression. The present study was undertaken in order to evaluate changes in monoamines which have reportedly been closely related to depression, using cisplatin-induced unilateral inner-ear impaired rats. A dose of 0.5 mg/kg of cisplatin was injected into the right tympanic cavity under pentobarbital Na+ anesthesia. One or two weeks later, animals were fixed with paraformaldehyde, and thereafter immunohistochemical stainings for monoamine-containing cells in the brain were carried out. To visualize 5-hydroxytryptamine (5-HT), noradrenaline (NA) and dopamine (DA) neurons, we used mouse antibodies against 5-HT, NA, and DA syntheses, i.e., tryptophan hydroxylase (TRH), tyrosine hydroxylase (TH) and dopamine-beta-hydroxylase (DBH). The number of TRH immunoreactive neurons significantly decreased in the lateral dorsal raphe nucleus of the ipsilateral side when compared with the contralateral side. The number of DA neurons, which were immunoreactive to TH, but not to DBH, significantly decreased in the hypothalamus of the ipsilateral side. The number of NA neurons which were immunoreactive to both TH and DBH significantly decreased in the locus coeruleus and ventral lateral pons of the ipsilateral side. An additional control study with saline-injected rats showed a lack of differences in monoamine syntheses between the injected and contralateral sides, the expressions of the synthesis on both sides being similar to that obtained in the contralateral side in cisplatin-injected rats. These results indicated the decreases in monoamine syntheses at the ipsilateral side only in the cisplatin-administered rats. We conclude that inner ear impairment may diminish the ipsilateral amount of monoamines in the brain but not the cotralateral, possibly inducing a vestibular compensation such as an upregulation of monoamine receptors.