Sinonasal cerebrospinal fluid leaks: management of 97 patients over 10 years.

INTRODUCTION: Although endoscopic closure is now the treatment of choice in the majority of patients with sinonasal cerebrospinal fluid (CSF) leaks, there is a recurrence rate of up to 10% in most series. OBJECTIVES: Our aim was to review our experience in the management of CSF leaks and in particular the cause of recurrent leaks. METHODS: We prospectively collected data on all cases referred as a suspected CSF leak to us, a tertiary referral center, over a 10 year period between 1994 and 2004. RESULTS: The 121 patients referred with an apparent CSF leak had a mean age of 51 (range 2-87) years. Fifty-three percent were male, and 47% were female. In 24 cases, investigations revealed that there was in fact no CSF leak, and in 17 posttraumatic cases, the leak ceased spontaneously. Twenty-nine patients had a spontaneous CSF leak. Of the 80 cases surgically repaired, 72 had an endoscopic approach, with a success rate of 90%, increasing to 97% after a second procedure and 99% by a third procedure. Eight patients with a posterior wall frontal sinus leak underwent an external frontal sinus procedure. There were 8 failures, and 6 occurred in the 13 patients with a spontaneous leak and evidence of raised intracranial pressure (ICP). CONCLUSIONS: In conclusion, our endoscopic repair rate for sinonasal CSF leaks are good and compare well with the standards in the literature. Raised ICP is the most common reason for recurrent CSF leak after repair. Patients with a spontaneous CSF leak and evidence of raised ICP had a 46% failure rate. When consenting such patients for surgery, they must be informed of the lower success rate and that they may need additional procedures, including shunting.

Bow-shaped tracheal rings: the lesson learnt from an endotracheal intubation.

Tracheal abnormalities are extremely rare and can occur as a single congenital anomaly, as part of a wider spectrum of abnormalities [such as the syndrome of vertebral defects, anal atresia, tracheoesphageal fistula and/or oesophageal atresia, radial dysplasia, and renal defects (VATER), and the syndrome of vertebral defects, anal atresia, cardiovascular defects, tracheoesphageal fistula and/or oesophageal atresia, radial dysplasia, and renal and limb defects (VACTERL)] or in tracheomalacia. Congenital complete and near-complete tracheal rings are the more common morphological abnormalities that occur. A case of a long segment of bow-shaped, as opposed to horseshoe-shaped, tracheal rings is presented, along with a review of tracheal anatomy and embryology. This abnormality presented when, during repeated attempts at endotracheal intubation, the anaesthetist was consistently unable to ventilate the patient, whereas they were able to do so with a facemask. Bronchoscopy showed the posterior tracheal wall prolapsing into the airway, and radiology demonstrated this to be due to wide tracheal rings without any intrathoracic abnormality.

Relationship between Heberden's nodes and underlying radiographic changes of osteoarthritis.

OBJECTIVE: To determine whether clinically determined Heberden's nodes (HN) and Bouchard's nodes (BN) are associated with underlying individual radiographic changes of osteoarthritis (OA). METHODS: 232 index patients with symptomatic large joint and/or hand OA, and 257 of their first degree relatives were included. HN were graded 0-2; BN were scored as present/absent. Joint space narrowing (JSN) and osteophyte (OST) were each scored 0-3 using the OARSI atlas. A weighted kappa test was used to examine intraobserver reproducibility. Odds ratio (OR) was estimated for the relationship between nodes and associated JSN and OST. RESULTS: The adjusted OR of HN for underlying JSN in the same digit was 1.72 (95% CI 1.47 to 2.02), whereas for OST it was higher at 5.15 (95% CI 4.37 to 6.08). A similar trend was seen with BN and underlying OA, with OST having a higher OR (OR = 2.98, 95% CI 2.55 to 3.47) than JSN (OR = 1.62, 95% CI 1.37 to 1.91). CONCLUSION: There is a positive relationship between HN/BN and underlying radiographic changes of OA, especially OST. Nodes do appear to link pathologically to OA in interphalangeal joints.