An Elusive Diagnosis: Delays in Treatment and Opportunities for Improvement in Temporal Encephalocele and CSF Leak.

Objective: Symptoms of temporal encephalocele or cerebrospinal fluid (CSF) leak causing middle ear effusion or otorrhea can be nonspecific and mistaken for other common diagnoses, leading to delays in diagnosis, failed treatments, and a risk of meningitis. This study sought to investigate the association between symptomatology and time to definitive surgical management. Study Design: Retrospective cohort. Setting: Single tertiary care academic medical center. Patients: Adults treated surgically for temporal encephalocele or CSF leak. Revision cases were excluded. Interventions: Chart review was performed to identify pertinent symptoms at presentation. Multivariable regression was performed to analyze the association between symptoms and time to definitive management. Main Outcome Measures: Otologic and related symptoms present prior to middle cranial fossa (MCF). Time between symptom onset and surgical treatment. Results: Thirty-four patients had symptoms present a median of 15.5 months (interquartile range, 8-35 months; range, 1 month to 12 years) prior to surgery. The most common symptoms were subjective hearing loss in the affected ear (76.5%) and aural fullness (73.5%). Otorrhea was present in 55.9%, and 42.9% had a history of otorrhea after myringotomy with or without tube insertion. Meningitis occurred in 5 patients (14.7%). Only the absence of otalgia was statistically significantly associated with decreased time between symptoms onset and surgery (P = 0.01). Conclusions: Encephalocele and CSF leak were most commonly associated with aural fullness and hearing loss. Medical treatment for presumed Eustachian tube dysfunction or chronic ear disease were commonly observed. Patients had symptoms for a median of almost 1 and a half years prior to surgical management.

An uncommon case of lip swelling: Granulomatous cheilitis associated with Crohn's disease.

Unbeknownst to most otolaryngologists, there is quite a range of oral manifestations which commonly manifest in the context of inflammatory bowel disease. As providers who will encounter such patients in consultation it is beneficial to be aware of that association. Lip swelling (granulomatous cheilitis) is just one such presentation, which is often otherwise mistaken for angioneurotic edema and can lead to unwarranted testing and misdirected treatment. We present such a case to highlight the educational value of this patient encounter.

Transmastoid Trans-facial canal approach to facial nerve tumors.

Facial nerve tumors within the temporal bone present several surgical challenges due to the tortuous course of the facial nerve and the nerve's close relationship to other important structures. Surgical approaches often have either sacrificed hearing/vestibular function or involved brain retraction. We present a case of a patient who was diagnosed with a facial nerve schwannoma (House-Brackmann IV/VI). Magnetic resonance imaging (MRI) showed the tumor was limited to the middle ear. The patient had already undergone facial reanimation procedures and elected to have the tumor removed. A transmastoid trans-facial canal surgical approach was used to remove the tumor without disturbing the ossicular chain. The patient's hearing and vestibular function remained intact. Operating from within the facial canal provides the surgeon additional room to dissect facial nerve tumors from the middle ear to the geniculate ganglion when using a transmastoid approach. This surgical approach is similar to the previously described transmastoid/supralabyrinthine approach to excise facial nerve tumors within the temporal bone but modified to keep the ossicles intact. While the described approach has a limited application, in certain cases of facial nerve tumors within the temporal bone when surgery is warranted, a transmastoid trans-facial canal approach may have advantages over previously-described approaches.