An extensive posterior circulation infarction secondary to primary hyperthyroidism accompanied with superior mesenteric artery syndrome: A case report and description of patho-physiological association.

INTRODUCTION: Hyperthyroidism-related anterior circulation ischemic events have been well documented; however, posterior circulation infarction is rarely reported, not to mention with superior mesenteric artery syndrome (SMAS), which has never been reported concurrently. We describe, to the best of our knowledge, the first case of hyperthyroidism-related cerebellar infarction accompanied with SMAS. PATIENT CONCERNS: A 22-year-old women presented with palpitation, postprandial vomiting, and acute body weight loss. Enlarged thyroid gland was discovered in physical examination and Graves disease was diagnosed by blood test; therefore, Propylthiouracil and ß-blocker were prescribed. Sudden onset conscious disturbance accompanied with apnea was noted during hospitalization. DIAGNOSIS: Computed tomography (CT) revealed cerebellar infarction with severe cerebellar swelling and tonsil herniation; hence, emergent suboccipital craniotomy and bilateral tonsillectomy were performed. INTERVENTIONS: Nevertheless, persisted poor passage of liquid diet during nasogastric tube feeding was noted after operation. CT of abdomen showed a sharp aorta-SMA angle (15°) and a short distance between aorta and SMA (6 mm) indicating a diagnosis of SMAS. OUTCOMES: After parental nutrition supplement and progressive rehabilitation program, she recovered to a modified Rankin Scale of 3. CONCLUSION: Although rarely reported, hyperthyroidism-related sympathetic hyperstimulation, vasculopathy could result in potentially deadly posterior circulation infarction. Furthermore, SMAS should be considered in the cases of hyperthyroidism with prolonged gastrointestinal symptoms even after treatment and should be treated simultaneously, since SMAS exacerbates depletion of intravascular volume. Further study to clarify the relation between hyperthyroidism and posterior circulation hemodynamic status is suggested.

[Occult peritonsillar abscess: an unusual cause of unilateral tonsillar enlargement].

Peritonsillar abscess is a suppurative infection of the tissues adjacent to the palatine tonsil and is regarded in otolarygologic practice as a complication of pharyngotonsillitis. The most common presentation is gradually increasing pain, fever, trismus, drooling and a muffled voice. Asymmetric tonsils are common in clinical practice. Differential diagnosis includes infectious, granulomatous, congenital and neoplastic lesions. This is a case study of two patients evaluated for unilateral tonsillar enlargement who were found to have a previously unexpected peritonsillar abscess at tonsillectomy. The patients had no other signs or symptoms of acute pharyngotonsillar or peritonsillar infection. To our knowledge, this is the first report of an occult peritonsillar infection causing unilateral tonsillar enlargement.

Correlations between Apnea/Hypopnea Index and selected morphological and clinical parameters in patients with unilateral or bilateral impairment of nasal patency.

INTRODUCTION: The aim of this work was to evaluate the correlation between Apnea/Hypopnea Index (AHI) and selected parameters of morphological and clinical character in the patients with a unilateral or bilateral impairment of nasal patency. MATERIAL AND METHODS: The study covered 60 adults, including 37 male and 23 female subjects, 19-69 years of age. In the Department, these subjects were divided into 3 groups: I - 20 patients with unilateral impairment of nasal patency, II - 20 patients with bilateral impairment of nasal patency, III - controls with normal nasal patency. METHODOLOGY: A subjective examination (questionnaire with a sleepiness scale), an objective examination (general examination of the neck and waist diameter, body weight, height, length of the uvula), otorhinolaryngological examination (Pirquet test of the palatine tonsils), X-ray and CT of the head and paranasal sinuses) to determine the cause and location of the obturation of air passages, physiological tests and polysomnography. The correlations between the neck circumferenceheight ratio (NHR) and AHI, waist-hip ratio (WHR) and AHI. The statistical analysis of the study results was conducted in Stata®/Special Edition Program, 14.1 version (StataCorp LP, College Station, Texas, USA). RESULTS: Clinically, the study group revealed: shallow breathing in 47.5% and apnea in 52.5% of the studied patients whereas the control group did not show any sleep disorders. Statistical fluctuations between controls and the study groups were noticed (p<0.001). CONCLUSION: By the Epworth scale, moderate and severe sleepiness was found in merely 12.5% of the patients. The differences in the length of the uvula and the size of the pharyngeal tonsils between the studied groups were not statistically significant. No statistical significance was found between NHR and AHI, BMI and AHI, WHR and AHI in the studied group.

Obstructive sleep apnea in patients with human immunodeficiency virus (HIV) disease.

Adenotonsillar hypertrophy has been identified as an early manifestation of human immunodeficiency virus (HIV) disease. Three patients with HIV disease were identified with obstructive sleep apnea (OSA) due to adenotonsillar hypertrophy. In order to examine the relationship between HIV-induced adenotonsillar hypertrophy and OSA, 134 patients with asymptomatic HIV disease were screened with a self-administered sleep survey designed to detect OSA and excessive daytime somnolence. Patients meeting trigger score criteria were studied with overnight polysomnography and nine additional patients were identified with OSA. The only consistent risk factor for OSA in this young and primarily nonobese population was the presence of adenotonsillar hypertrophy, found in 11 of 12 patients with OSA. Three patients had tonsillar biopsy or tonsillectomy and all displayed benign follicular lymphoid hyperplasia. Scores on the Epworth Sleepiness Scale (ESS) were significantly higher for patients with OSA, indicating a greater degree of hypersomnolence (mean ESS scores: OSA+ = 11.4 +/- 3.6, OSA- = 7.8 +/- 4.6, p = 0.012). In our population, patients with HIV disease had a prevalence of OSA of 7%. HIV-induced adenotonsillar hypertrophy is a risk factor for the development of OSA. HIV patients with complaints of excessive daytime sleepiness and snoring who are found to have adenotonsillar hypertrophy on exam should undergo a sleep evaluation to rule out the presence of OSA.

Clinical role of magnetic resonance imaging in the neurosurgical patient.

The results of magnetic resonance (MR) evaluation in 18 patients with common neurosurgical problems, including cerebrovascular lesions, intracranial tumors, and craniovertebral junction pathological conditions, are presented. The results are compared with those of routine diagnostic studies. Overall, MR imaging was equivalent or superior to computed tomography in 16 of 18 cases. In 2 cases, MR demonstrated pathological changes when standard diagnostic imaging procedures failed to demonstrate the lesion responsible for the patient's deterioration. MR is a versatile, noninvasive imaging technique that is capable of demonstrating a wide range of disease processes, without exposure to ionizing radiation or contrast agents.

Head and neck manifestations of Beckwith-Wiedemann syndrome.

Beckwith-Wiedemann syndrome is a congenital disorder manifested by organomegaly, omphalocele, hypoglycemia, and macroglossia. We have found a significant number of these children to be at risk for upper airway obstruction during infancy or childhood. In this review of 13 children, 2 required tracheotomy during infancy for cor pulmonale caused by macroglossia. Seven of nine children older than 1 year required tonsillectomy and adenoidectomy to relieve upper airway obstruction. Although macroglossia can be a cause of airway obstruction in infants with Beckwith-Wiedemann syndrome, we have found that airway obstruction during childhood is related to tonsillar and adenoidal hypertrophy and not to macroglossia. Anterior tongue reduction is reserved for the correction of malocclusion, articulation errors, or cosmesis, whereas tonsillectomy and adenoidectomy may be curative of obstructive symptoms.

Cervical diastematomyelia in cervico-oculo-acoustic (Wildervanck) syndrome: MRI findings.

Cervico-oculo-acoustic (COA) or Wildervanck syndrome is characterized by the triad of Klippel-Feil anomaly, bilateral abducens palsy with retracted bulbs (Duane 'syndrome') and hearing loss. The clinical findings of this syndrome have been well documented. A few case reports with MRI findings have appeared in the literature showing brainstem and cerebellar hypoplasia and vertebral segmentation anomalies. Our case is unique in that diastematomyelia of the lower medulla and cervical cord was accompanied by vermian hypoplasia, tonsillar herniation and resulting triventricular hydrocephalus in a child with Wildervanck syndrome. This case is presented with MR images. Children with Wildervanck syndrome should be investigated for craniospinal abnormalities with MR imaging.

Body growth in relation to tonsillar enlargement.

Severe airway obstruction caused by tonsillar enlargement can result in disturbances in body growth. In this study, 1136 children between 7 and 12 years of age, were evaluated and the size of their tonsils was investigated with regard to height and weight. This study was performed in the course of school screening, and correlation between estimated tonsil size and height and weight of the children was sought. Statistically, no such correlation was found (P > 0.05).

Ipsilateral absence of tonsil and microtia with ectopic salivary gland. A case report.

This case of congenital unilateral absence of the faucial tonsil and microtia, with atresia of the external auditory canal, and an ectopic salivary gland has not been reported previously; it differs from other congenital abnormalities reported earlier.

Otoneurological manifestations in Chiari-I malformation.

The type I Chiari malformation consists of a caudal displacement of the cerebellar tonsils through the foramen magnum into the cervical spinal canal. The most common presenting symptoms, such as pain, weakness and headache, are frequently preceded by otoneurological symptoms. Sensorineural hearing loss, vertigo, nystagmus, dysequilibrium, tinnitus and other cranial nerve involvement have been reported in Chiari-I malformation. A case report is presented and the clinical features of the disease are discussed with emphasis on the otoneurological aspects.