Skull base osteomyelitis: Comprehensive analysis and a new clinicoradiological classification system.

OBJECTIVE: Skull baseosteomyelitis (SBO) is a rare phenomenon that typically occurs in diabetic or immunocompromised patients, causing significant morbidity and mortality. This study aimed to analyze a single institution's treatment results in SBO patients and propose anew integrated clinicoradiological classification system. METHODS: The medical records of 32 SBO patients that were treated at a tertiary care center between 2006 and 2017 were retrospectively reviewed. A scoring system based on anatomical involvement according to MRI was created. Subsequently, the scoring system was integrated with cranial nerve dysfunction status and a clinical grading system (CGS) was proposed. RESULTS: Among the 32 patients, 78.1% were diabetic and 63% had cranial nerve dysfunction at presentation. Bone erosion based on CT was greater in the patients without regression (P = 0.046). The regression rate decreased from clinical grade (CG)1 to CG3 (P = 0.029). Duration of hospitalization increased as CG increased (P = 0.047). Surgery had no effect on regression status at the time of discharge (P = 0.41). The 1-year, 2-year, and 5-year overall survival rates were 82.2%, 70.8%, and 45.8%, respectively. CG was significantly correlated with overall survival but not with disease-specific survival (log-rank; P = 0.017, P = 0.362, respectively). CONCLUSION: SBO continues to pose a challenge to clinicians, and causes significant morbidity and mortality. The proposed new classification system can be an option for grouping SBO patients according to clinical and radiological findings, helping clinicians estimate prognosis.

Temporal Bone Chondroblastoma: Systematic Review of Clinical Features and Outcomes.

OBJECTIVE: Chondroblastoma is an uncommon benign neoplasm of cartilaginous origin usually involving the long bones. The temporal bone is a rare location for this tumor. The clinical profile, optimal medical and surgical management, and outcomes of treatment for temporal bone chondroblastoma remain unknown. METHODS: We performed a systematic review of the SCOPUS, PubMed, and CENTRAL databases for case reports and case series on patients with histopathologically proven temporal bone chondroblastoma. Data on demographics, clinical manifestation, surgical management, adjuvant treatment, and outcome on last follow-up were collected. RESULTS: A total of 100 cases were reported in the literature, including one described in the current study. The mean age of patients was 42.3 years (range, 2-85 years), with a slight male predilection (1.3:1). The most common clinical manifestations were otologic symptoms (e.g., hearing loss [65%], tinnitus, and otalgia) and a palpable mass. Surgical excision was performed in all cases, with gross total excision achieved in 58%. Radiation therapy was performed in 18% of cases, mostly as adjuvant treatment after subtotal excision. There were no deaths at a median follow-up of 2 years. Among the patients with detailed status on follow-up, 58% had complete neurologic recovery, 38% had partial recovery, and 4% had progression of symptoms as a result of tumor recurrence. CONCLUSIONS: Temporal bone chondroblastoma has a distinct clinical profile from chondroblastoma of long bones. Surgery is the mainstay of treatment, and radiation therapy may be given after subtotal excision. Outcomes are generally favorable after treatment.

Hemorrhage within the tympanic membrane without perforation.

BACKGROUND: Hemotympanum refers to both the presence of blood in the middle ear cavity and to ecchymosis of the tympanic membrane (TM), and a systematic study of intra-TM (iTM) hemorrhage without bleeding in the middle ear cavity has not been conducted. The goals of our study were to analyze the causes of iTM hemorrhage without TM perforation or bleeding in the middle ear cavity, and to demonstrate the clinical characteristics of the disease. METHODS: This Case series study included five patients with iTM hemorrhage between August 2014 and August 2017. An iTM hemorrhage was diagnosed when otoendoscopic examination demonstrated minor bleeding behind the intact TM, a hemorrhage was observed between the TM annulus and the epidermal layer, and temporal bone computed tomography revealed thickening of the TM without soft tissue density within the tympanic cavity or temporal bone fracture. Initial symptoms, and serial findings of otoendoscopy and pure tone audiometry (PTA) were investigated. RESULTS: iTM hemorrhage developed due to blunt head trauma in two patients, descent barotrauma during scuba diving in two patients, and spontaneous epistaxis in one patient. Otalgia and ear fullness were the most common symptoms, but PTA showed no or minimal conductive hearing loss in all patients. CONCLUSIONS: An iTM hemorrhage may develop after blunt head trauma, barotrauma due to scuba diving, or spontaneous epistaxis; otological symptoms included otalgia, tinnitus, and aural fullness. An iTM hemorrhage resolved spontaneously without specific treatment, usually within 1 month.

Manifestation of granulomatosis with polyangiitis in head and neck.

OBJECTIVES: Granulomatosis with polyangiitis is a rare autoimmune disease of the group of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides. Involvement of the ear, nose and throat (ENT)-region is only described in a few case series and case reports. The objective of this study is to systematically characterise the ENT-involvement in a large series of GPA patients. METHODS: GPA patients examined in the Department of Otorhinolayngology of the Christian-Albrechts-University of Kiel between 1990 and 2012 were included. Diagnosis was based on histological, serological and clinical parameters. GPA patients were examined in a standardised way based on the Ear Nose and Throat Activity Score (ENTAS) or its precursor. Medical history, ENT examination, diagnostic findings (ear, nose) and cranial radiology were documented cumulatively. RESULTS: A total of 230 GPA patients were included in this study. Over 95% of them showed ENT-involvement. 59% of the patients showed nasal obstructions, 57% a loss of smell. A hearing loss was diagnosed in 23% of the patients, 50% involvement in MR or CT scans and 15% showed laryngeal involvement. CONCLUSIONS: The data of the largest monocentric study presented here demonstrate a frequent ENT-involvement in GPA patients. Rhinological and ontological manifestations are most common.

Retroauricular pain caused by Eagle syndrome: A rare presentation due to compression by styloid process elongation / Dor retroauricular causada pela síndrome de Eagle: uma apresentação rara por compressão pelo alongamento do processo estiloide

Summary Eagle syndrome is a rare condition presenting with retroauricular pain (usually as main symptom) associated with dysphagia, headache, neck pain on rotation and, much rarelier, stroke. This occurs due to styloid process elongation. Sometimes, there is also styloid ligament calcification, which can cause compression of nerves and arteries and the symptoms above. Treatment can be conservative with pain modulators (e.g. pregabalin) or infiltrations (steroids or anesthetics drugs). In refractory cases, surgical approach aiming to reduce the size of the styloid process can be performed. We present a rare case of Eagle syndrome (documented by computed tomography) with good response to clinical treatment.

Resumo A síndrome de Eagle é uma condição rara na qual ocorre dor retroauricular (usualmente é o principal sintoma) associada a disfagia, cefaleia, cervicalgia durante a rotação da cabeça e, mais raramente, a AVC. Isso ocorre por conta do alongamento do processo estiloide e, às vezes, há também calcificação do ligamento estiloide. Essas estruturas podem comprimir nervos e artérias causando os sintomas citados. O tratamento pode ser conservador com moduladores da dor, como pregabalina, ou com infiltrações (corticoides ou drogas anestésicas). Em casos refratários, cirurgia para reduzir o tamanho do processo estiloide pode ser realizada. É apresentado um caso raro de síndrome de Eagle (documentado com tomografia computadorizada) com boa resposta ao tratamento clínico.

The nervus intermedius: a review of its anatomy, function, pathology, and role in neurosurgery.

BACKGROUND: Geniculate neuralgia, although uncommon, can be a debilitating pathology. Unfortunately, a thorough review of this pain syndrome and the clinical anatomy, function, and pathology of its most commonly associated nerve, the nervus intermedius, is lacking in the literature. Therefore, the present study aimed to further elucidate the diagnosis of this pain syndrome and its surgical treatment based on a review of the literature. METHODS: Using standard search engines, the literature was evaluated for germane reports regarding the nervus intermedius and associated pathology. A summary of this body of literature is presented. RESULTS: Since 1968, only approximately 50 peer-reviewed reports have been published regarding the nervus intermedius. Most of these are single-case reports and in reference to geniculate neuralgia. No report was a review of the literature. CONCLUSIONS: Neuralgia involving the nervus intermedius is uncommon, but when present, can be life altering. Microvascular decompression may be effective as a treatment. Along its cisternal course, the nerve may be difficult to distinguish from the facial nerve. Based on case reports and small series, long-term pain control can be seen after nerve sectioning or microvascular decompression, but no prospective studies exist. Such studies are now necessary to shed light on the efficacy of surgical treatment of nervus intermedius neuralgia.

Global doctor opinion versus a patient questionnaire for the outcome assessment of treated temporomandibular disorder patients.

PURPOSE: Accurately assessing treatment outcomes has become increasingly important for maintaining hospital privileges. When these assessments are based on the judgment of the treating doctor, there is often an inherent positive bias. As a result, there has been increased interest in using patient-based assessments. The purpose of this study was to compare doctor's and patient's assessments of the outcomes of treatment in a series of patients with various temporomandibular disorders (TMDs). MATERIALS AND METHODS: Fifty-two consecutive TMD patients were initially given a questionnaire designed to evaluate their pain, problems eating and sleeping, the occurrence of headache and earache, the presence of temporomandibular joint pain and/or jaw stiffness in the morning, and interference with daily activity. The patients then filled out the same questionnaire at each post-treatment visit, and the findings were compared with the baseline information. At each visit, the treating doctor also recorded a global evaluation of the patient's progress as excellent, good, fair, or poor. RESULTS: Comparison of the doctor's global evaluation with the patient's evaluation based on the questionnaire showed a discrepancy in 44% of the cases. When there was a discrepancy, the doctor scored the improvement better than the patient 54.5% of the time and worse than the patient 45.5% of the time. CONCLUSIONS: The results of this study confirm the unreliability of using a global opinion by the treating doctor for outcome assessment in patients with various TMDs.

Mandible protrusion and decrease of TMJ sounds: an electrovibratographic examination

This study quantified by, electrovibratography, the amount of mandible protrusion required to decrease significantly temporomandibular joint (TMJ) vibratory energy as an aid in the diagnosis of the recapture of anteriorly displaced disk. Eighteen patients diagnosed as having anterior disk displacement with reduction and TMJ clicking were submitted to electrovibratographic examination at the first appointment and treated with a stabilizing appliance and anterior positioning appliance with 1 to 5 mm protrusion. Vibratory energy was checked in each of these positions. Baseline data were used as control. At the first appointment, the patients had vibrations with more elevated intensities at the middle and late phases of the mouth opening cycle. At only one clinical step, mandible protrusion was obtained with the anterior repositioning appliance, ranging from 1 to 5 mm protusion. At each new position, a new electrovibratographic exam was made. After the 5-mm mandibular projection, only 2 patients presented vibration, with means between 0.6 and 2.8 Hz. Data were analyzed statistically by ANOVA and Tukey's test (alpha=0.05). The outcomes of this study indicate that 3 mm is the minimum amount of mandible protrusion to significantly decrease the TMJ vibratory energy and to recapture the displaced articular disk.

Este trabalho teve por finalidade quantificar a protrusão mandibular necessária para diminuir significativamente a energia vibratória da articulação temporomandibular (ATM), verificada por meio da eletrovibratografia, como um meio auxiliar de diagnóstico da recaptura do disco articular deslocado anteriormente. Dezoito pacientes com diagnóstico de deslocamento anterior do disco com redução e estalos na ATM foram submetidos ao exame eletrovibratográfico na consulta inicial e tratados com placa oclusal estabilizadora e placa reposicionadora anterior com protrusão variando de 1 a 5 mm, checando-se a energia vibratória em cada uma destas posições. Os dados obtidos na consulta inicial foram usados como grupo controle. Na consulta inicial, os pacientes apresentaram vibrações com intensidades mais elevadas no meio e final da abertura bucal. Em uma única sessão, a protrusão era realizada a partir de 1 mm por meio de placa reposicionadora anterior e realizado novo exame de imediato, até atingir 5 mm. Após a mandíbula ser protruída 5 mm, apenas 2 pacientes apresentavam alguma vibração, com uma média de 0,6 a 2,8 Hz. A análise estatística foi realizada por análise de variância e teste de Tukey (a=0,05). Os resultados indicaram que 3 mm seria a protrusão mínima necessária para reduzir significantemente a energia vibratória e recapturar o disco articular.

Sinais e sintomas associados à otalgia na disfunção temporomandibular / Signs and symptoms associated to otalgia in temporomandibular disorder

A otalgia pode ocorrer de causas otológicas, como otite externa, otite média, mastoidite, assim como de causas não otológicas. Especula-se que as disfunções temporomandibulares (DTM) sejam uma das causas mais comuns...

Otalgia is a symptom that can be caused by otological diseases, such as external otitis, otitis media, mastoiditis, as well as by non otological factors. It is speculated that the temporomandibular disorders (TMD) is one of the most common causes of non otological otalgia...

Choking, sore throat with referred otalgia and dysphagia in a patient with diffuse idiopathic skeletal hyperostosis (DISH).

A patient with a progressively increasing immobilisation of the cervical spine, severe impaired swallowing (choking), sore throat with referred right-sided otalgia, mild voice disorder and dysphagia due to extrinsic bone compression of the posterior hypopharyngeal wall and oesophagus is presented. Radiographic investigation demonstrated the underlying condition to be a diffuse idiopathic skeletal hyperostosis with prominent and bumpy alteration of the anterior longitudinal ligament impinging the hypopharynx. Via an anterolateral approach towards the cervical spine the anterior irregular part of the ossification was removed and the surface of the spine flattened. The postoperative evolution was uneventful.

Cervical spine meningioma presenting as otalgia: case report.

OBJECTIVE AND IMPORTANCE: Cervical spine meningiomas have not been reported to present as otalgia. It is important to include otalgia in the differential diagnosis and workup, especially when more common causes of ear pain have been excluded. CLINICAL PRESENTATION: A 66-year-old woman presented to her primary care physician with severe ear pain. She underwent routine diagnostic testing and eventually was referred to a neurologist. After conservative management failed, the patient underwent cervical spine magnetic resonance imaging, which revealed a large meningioma encompassing C2-C3. INTERVENTION: The patient underwent a cervical laminectomy with complete resection of the tumor. She experienced immediate postoperative resolution of her symptoms. CONCLUSION: This case illustrates the importance of aggressive evaluation of otalgia when routine diagnostic studies are inconclusive. Cervical meningiomas are associated with significant potential morbidity and should be excluded early in the diagnostic process.

Ear pain in patients with oropharynx carcinoma: how MRI contributes to the explanation of a prognostic and predictive symptom.

Reflex otalgia is a predictive and prognostic parameter for local control in patients with oropharynx carcinoma. Can a morphologic correlate of this important symptom be detected by MRI? Thirty-six patients were prospectively evaluated by MRI before radical radiotherapy. Sixteen patients had reflex otalgia; 20 did not. The oropharynx and adjacent regions were analyzed. Alteration was defined as effacement of anatomical structures, signal alteration or enhancement after contrast medium administration. The chi(2)-test was used to compare categorical parameters. In patients with reflex otalgia, alteration of the following structures innervated by the glossopharyngeal nerve were found significantly more often: nasopharynx, hard palate, superior constrictor pharyngis muscle, palatine tonsil, palatopharyngeus muscle, palatoglossus muscle, stylopharyngeus muscle, hyoglossus muscle and preepiglottic space. No difference was found for the muscles of mastication, levator and tensor veli palatini muscles, styloglossus muscle, genioglossus muscle, intrinsic muscles of the tongue, digastric muscles, mucosal surface of the lateral and posterior pharyngeal wall, uvula, valleculae, parapharyngeal space and larynx. An alteration of structures innervated by the glossopharyngeal nerve was visualized on MRI significantly more often when reflex otalgia was present. Involvement of structures innervated by other cranial nerves did not show the same association with ear pain.

Otite média aguda recorrente / Acute otitis Media

Os autores fazem uma revisão bibliográfica sobre a otite média recorrente (OMR), visto que a mesma é a doença mais comum na infância, depois do resfriado. Além disso, é uma das principais causas de atendimento em pediatria, causando muita dor e sofrimento às crianças e aos seus pais

Otalgia.

The patient presenting with otalgia poses a diagnostic challenge for which orderly and diligent evaluation and management is needed. The etiology of otalgia can be either primary or referred, and a detailed history and physical examination with directed studies as indicated can elucidate the cause of the pain.

Osteomielitis de la base del cráneo: presentación de cinco casos / Osteomyelitis of the cranial base: presentation of five cases

Se hace una revisión retrospectiva de cinco casos de osteomielitis de la base del cráneo observados en el servicio de O.R.L. del Hospital General de la ciudad de México para determinar el cuadro clínico y valorar el manejo terapéutico de los pacientes. Todos los pacientes fueron diabéticos, de edades entre 58 y 82 años, presentaron dolor local y trastornos de nervios craneanos. Un paciente tenía otorrea. cuatro pacientes tuvieron cultivo positivo para Pseudomonas aeruginosa; a un paciente no se le hizo cultivo antes de iniciar el tratamiento. Un paciente abandonó el tratamiento; los otros cuatro pacientes curaron con antibioterapia múltiple y los nervios craneanos afectados recuperaron su función. El padecimiento se distingue claramente de la otitis externa necrosante, donde los datos de infección del oído externo son claros

Otalgia in infants and children--a manifestation of gastroesophageal reflux.

To investigate if there is a relationship between gastroesophageal reflux and ear pain in the pediatric age group, a series of children presenting with this picture were analyzed. Infants and children are often seen in an emergency room setting because of fretfulness, irritability, and pulling on the ears. A diagnosis of otitis media is usually made, but in some cases the diagnosis may be referred otalgia secondary to gastroesophageal reflux. Six children who presented with the above picture were seen by one of the authors (W.S.G.) the following morning and noted to have a normal ear exam. These children were studied for gastroesophageal reflux by esophageal pH monitoring and in some cases esophagoscopy with biopsy. All children exhibited gastroesophageal reflux and an anti-reflux regimen eliminated the pattern of 'recurring otitis media'. This paper will review the mechanism of referred otalgia along with data supporting the concept of GE reflux as a cause of otalgia in infants and children.

Referred otalgia.

Referred otalgia is a challenging symptom, with the burden on the physician to identify the source. Only by careful patient history and physical examination can all causes in this extensive differential diagnosis be excluded. In the absence of primary otologic pathology, referred pain from a head and neck carcinoma must be considered foremost and ruled out.

Referred otalgia.

The diagnosis and management of otalgia may be a very simple task or a very complex and frustrating experience for both physician and patient. A thorough understanding of the anatomy of the head and neck is required. A basic knowledge of neuroanatomy, with emphasis on the cranial nerves, their course, distribution, and function, is also necessary. The complexity of this field may sometimes require the treating physician to call for consultations from colleagues in the fields of oral surgery, neurology, or neurosurgery. It is often through the collaboration of different specialists that patients are provided with the appropriate medical care they deserve. This has never been more true than in the area of the head and neck.

Aural pain resulting from acoustic reflex.

We present an unusual case of physical discomfort, as opposed to objective or subjective tinnitus, caused by a unilateral acoustic reflex. The cause of the discomfort was identified audiologically by the use of acoustic impedance audiometry. The dull pain that was elicited upon contraction and relaxation of the stapedius muscle was eliminated with sectioning of the stapedial tendon. No explanation of the mechanism for the pain is suggested at present.