Assessment of a left circumflex coronary artery-left ventricle fistula by multimodality imaging in a child.

Multimodality imaging revealed a left circumflex coronary artery-left ventricle fistula in a 4-year-old boy. MRI tissue tracking revealed a slight abnormality in the left ventricular myocardial strain. Early surgery was suggested to avoid serious complications.

The assessment and management of inner ear barotrauma in divers and recommendations for returning to diving.

Inner ear barotrauma (IEBt) constitutes a spectrum of pressure-related pathology in the inner ear, with antecedent middle ear barotrauma (MEBt) common. IEBt includes perilymph fistula, intralabyrinthine membrane tear, inner ear haemorrhage and other rarer pathologies. Following a literature search, the pathophysiology, diagnosis, and treatment of IEBt in divers and best-practice recommendations for returning to diving were reviewed. Sixty-nine papers/texts were identified and 54 accessed. Twenty-five case series (majority surgical) provided guidance on diagnostic pathways; nine solely reported divers. IEBt in divers may be difficult to distinguish from inner ear decompression sickness (IEDCS), and requires dive-risk stratification and careful interrogation regarding diving-related ear events, clinical assessment, pure tone audiometry, a fistula test and electronystagmography (ENG). Once diagnosed, conservative management is the recommended first line therapy for IEBt. Recompression does not appear to cause harm if the diagnosis (IEBt vs IEDCS) is doubtful (limited case data). Exploratory surgery is indicated for severe or persisting vestibular symptoms or hearing loss, deterioration of symptoms, or lack of improvement over 10 days indicating significant pathology. Steroids are used, but without high-level evidence. It may be possible for divers to return to subaquatic activity after stakeholder risk acceptance and informed consent, provided: (1) sensorineural hearing loss is stable and not severe; (2) there is no vestibular involvement (via ENG); (3) high-resolution computed tomography has excluded anatomical predilection to IEBt and (4) education on equalising techniques is provided. There is a need for a prospective data registry and controlled trials to better evaluate diagnostic and treatment algorithms.

Transperineal perineal ultrasound versus magnetic resonance imaging in the assessment of perianal Crohn's disease.

BACKGROUND: To assess the accuracy of transperineal ultrasound (TPUS), in comparison with magnetic resonance imaging (MRI), in classifying perianal Crohn's disease (CD) according to Parks' classification and the American Gastroenterological Association criteria. METHODS: Fifty-nine consecutive patients with confirmed or suspected perianal CD underwent TPUS and MRI within 10 days. An independent expert surgical evaluation, which took into account proctological and MRI findings, was used as the gold standard. Fistulae and perianal disease were classified according to Parks' classification and American Gastroenterological Association criteria, respectively. RESULTS: Forty-six patients showed 64 fistulae (9 intersphincteric, 34 transsphincteric, 2 suprasphincteric, 9 extrasphincteric, and 10 anovaginal) and 23 abscesses were also found. Fifty-one of 54 perianal fistulae (per-lesion sensitivity: 94.4%) and 9 of 10 anovaginal fistulae (sensitivity: 90.0%) were detected and 58 were correctly classified by TPUS (sensitivity: 90.6%; positive predictive value: 93.4%). Overall, TPUS correctly detected and classified the fistulae in 89% of patients and the agreement for classifying perianal fistulae between TPUS and MRI was excellent (K value: 0.783). In contrast, 11 of 23 abscesses were correctly diagnosed by TPUS (sensitivity: 47.8%); although 14 abscesses were diagnosed by TPUS, only 11 were confirmed by MRI (positive predictive value: 78.6%). Overall, TPUS correctly detected and classified fistulae and associated abscesses in 67.3% of patients. Agreement between MRI and TPUS in discriminating simple (15) and complex (29) perianal disease was fairly good (K value: 0.57). CONCLUSIONS: TPUS is a simple and accurate diagnostic method for classifying perianal fistulae in CD and could be used for the preliminary assessment and follow-up of perianal CD.

Hydrogen peroxide aids assessment of pharyngeal closure after laryngectomy.

OBJECTIVE: Pharyngocutaneous fistula is a serious complication following total laryngectomy. We report a simple technique which is useful in assessing the adequacy of pharyngeal closure following total laryngectomy. METHOD: Installation of 1.5 per cent hydrogen peroxide into the oral cavity, while observing for leakage at the pharyngeal repair. RESULTS: We have found this technique to be useful in 22 patients undergoing total laryngectomy with pharyngeal resection and neck dissection. CONCLUSION: This method ensures that pharyngeal closure has been technically adequate.

Intraoperative assessment of perilymphatic fistulas with intrathecal administration of fluorescein.

OBJECTIVES: Assessment of perilymphatic fistulas remains a diagnostic problem. Because of a lack of reliable clinical tests, exploratory tympanotomy is necessary to detect membrane leaks in the middle ear. To improve objectivity in the intraoperative visualization of perilymphatic fistulas, we used intrathecal fluorescein for perilymph staining to increase the sensitivity and specificity of diagnosis of perilymphatic fistulas. STUDY DESIGN: Prospective study in the setting of a tertiary, referral, and academic center. METHODS: Twenty-eight patients with suspected traumatic, idiopathic, iatrogenic, or inflammatory perilymphatic fistulas were admitted for exploratory tympanoendoscopy for perilymphatic fistula detection. Twenty-five to 100 mg sodium fluorescein 10%, diluted with cerebrospinal fluid, was administered by lumbar puncture 2.5 to 23.5 hours before tympanoendoscopy. The oval and round window niches were microscopically and endoscopically observed with white and blue light, using specific filters. RESULTS: In two patients (7%), obvious fluorescence was detected behind the round window membrane with blue light. Direct observation of perilymph in stapedectomy and in semicircular canal fistula revealed no staining. Neurological complications of intrathecal fluorescein, as reported by other authors, were not observed. CONCLUSIONS: Probably because of a different patency of the cochlear aqueduct, intrathecal fluorescein for intraoperative detection of perilymphatic fistula resulted in a significant perilymph staining in only a few patients. Considering the possible complications of this method, we would not recommend it for routine evaluation of perilymphatic fistula.

Transtympanic electrocochleography in the assessment of perilymphatic fistulas.

An objective method for the pre-operative diagnosis and the post-operative assessment of a presumed perilymphatic fistula (PLF) using transtympanic electrocochleography is presented. Three cases are reported in which the history of the disease and the symptoms strongly suggested the presence of a PLF. Pre-operative transtympanic electrocochleography (TT ECoG) recordings at rest showed changes similar to those of endolymphatic hydrops and signs of instability of the inner ear hydrodynamic system during raised intrathoracic pressure. Surgery revealed a visible leak in two of the three cases. Both windows were repaired in all the patients. All patients were relieved from their vestibular symptoms at the time when the post-operative TT ECoG was conducted 3-6 months later. The post-operative recordings were stable during raised intrathoracic pressure and the previously elevated summating potentials decreased which was interpreted as an objective indication of the recovery of the hydrodynamic system. However, later one of the patients again developed recurrent vertigo. Twenty patients with well-documented Ménière's disease were used as a control group. TT ECoG was conducted during raised intrathoracic pressure. The Ménière patients showed stable recordings. It is suggested that among patients with suspected PLF and signs of hydrops in TT ECoG, a dependence on the intrathoracic pressure reflected in the recordings may indicate a possible fistula.

Fluorescein as an easy, low-cost, indirect, or reverse intraoperative marker to rule out perilymph versus local injection.

Clear fluid found in the dependent portions of the middle ear (round and oval windows) is generally assumed to be perilymph (PL). However, all clear fluid observed at middle ear exploration is not necessarily PL. PL should be distinguished from local injection. An accumulation of the local injection could be confused with perilymph fistula (PLF) diagnosis. There is no standard way of distinguishing perilymph from local injection, as both are clear, watery fluids. Fluorescein, tagged with a mixture of xylocaine and epinephrine (FLOTAX) was used as the local injection in 10 patients undergoing middle ear exploration for possible PLF.FLOTAX was injected into the vascular strip and ear canal skin in routine fashion. Transtympanic endoscopy and special Zeiss custom fluorescein filters were used to document any accumulation of fluid in the dependent portions of the middle ear and confirm whether any fluorescein (from the FLOTAX) was present. The middle ear was checked both before (endoscopically) and after raising the tympanomeatal flap. After the "local" injection, FLOTAX was observed to accumulate in dependent portions of the middle ear before raising the tympanomeatal flap in six of 10 ears. In the other four ears, FLOTAX slowly seeped into the middle ear cleft after the tympanomeatal flap was elevated and manipulated. Fluorescein can be used as an inexpensive, indirect intraoperative marker or "reverse test" for possible PLF. By eliminating a likely and common offender (local injection), any accumulation or reaccumulation of clear fluid that is not fluorescein tagged may more confidently be identified as possibly perilymph. The use of FLOTAX helps eliminate the confusion between the local injection and potential PLF. It does not in any way eliminate the possibility of other transudates from incisions, allergic reactions, or other manipulation of the tympanomeatal flap or middle ear mucosa.

Electrocochleography in the diagnosis of perilymphatic fistula: intraoperative observations and assessment of a new diagnostic office procedure.

The intraoperative electrocochleogram (ECochG) was investigated during stapedectomy surgery and during cochleostomy surgery. This provided the justification for obtaining recordings with the oval window (OW) or round window (RW) intact and then when there was a definite fistula. It was noteworthy that no ECochG changes occurred on merely opening the OW or RW, but that marked changes occurred on removing perilymph, even by gentle suction. On raising the intrathoracic pressure and replacing the perilymph, the ECochG potentials usually recovered. Based on these intraoperative observations, an office procedure was designed. The subject was asked to raise the intrathoracic pressure on several occasions and changes in the amplitude of the ECochG potential were noted. An increase of over 15 percent in the action potential (AP), with or without a decrease in the negative summating potential (SP) during the period of raised intrathoracic pressure, was used as the diagnostic criteria for a perilymphatic fistula. A decrease in the AP with or without an increase in the negative SP immediately on relaxing after a period of raised intrathoracic pressure was also treated as a positive diagnostic criterion. Seventy-one normal ears were investigated and a positive result was recorded in two ears (false positive rate: 2.8%). Two hundred and six ears, strongly suspected as having a perilymph leak on the basis of the clinical history and vestibular signs have been investigated over the past 4 years. Ninety positive diagnoses have been reached and 46 of these ears have been surgically explored.(ABSTRACT TRUNCATED AT 250 WORDS)

Fístula coronário-cavitária: contribuiçäo da eco-color-doppler-cardiografia para o diagnóstico no 1§ ano de vida: relato de três casos / The value of colordopplerechocardiography in cases of congenital coronary cavitary fistula in the first year of life: report of three cases

Säo apresentados os aspectos clínicos e semiológicos de três crianças do sexo feminino e com menos de um ano de idade, de fístulas coronário-cavitárias (coronária esquerda em dois casos e coronária direita em um caso). Enfase especial foi dada à ecocardiografia bidimensional, capaz de estabelecer com segurança este diagnóstico confirmado no ato cirúrgico e a color-dopplercardiografia, capaz de localizar com precisäo o local da drenagem da fístula, em dois pacientes