A case report of orbital haemorrhage associated with endoscopic sinus surgery and reversible sight loss: a multidisciplinary approach to management.

We report a case of intraoperative orbital haemorrhage as a complication of endoscopic sinus surgery performed under general anaesthesia. Initial unilateral complete visual loss occurred, but recovered due to accurate and early diagnosis combined with urgent surgical intervention. This patient's case is reported to illustrate the importance of early recognition of clinical signs and how a stepwise approach to management can result in a favourable visual outcome. Moreover, the mechanisms and pathophysiology of visual loss due to orbital haemorrhage following endoscopic sinus surgery are discussed.

Idiopathic intracranial hypertension in otolaryngology.

Idiopathic intracranial hypertension (IIH) is defined as increased intracranial pressure in the absence of intracranial mass or obstructive hydrocephalus. Over 80% of patients are overweight women. IIH is usually encountered in the neurology and ophthalmology practise as headaches, visual disturbance and papilloedema are the characteristic features of this syndrome. Patients with IIH also experience tinnitus, hearing loss, balance disturbance, cerebrospinal fluid (CSF) otorrhoea or rhinorrhoea and in some cases these otorhinological symptoms can be presenting features of this syndrome. IIH is also associated with obstructive sleep apnoea. Otolaryngologists should be familiar with this important condition as it can manifest a variety of symptoms that are more frequently seen in their clinics. Sometimes otolaryngologists may be involved in the surgical management of this condition, such as repair of CSF rhinorrhoea or otorrhoea or endoscopic optic nerve decompression. The aim of this review article is to familiarise the otolaryngologists with the important features of this unusual syndrome which may remain unrecognised in the otolaryngology practice.

Cotton bud in external ear canal causing necrotising otitis externa and subdural abscess.

Necrotising otitis externa (NOE) is an infection originating in the soft tissues of the external auditory canal (EAC) spreading to the surrounding bone and rarely causing intracranial complications. It is usually caused by Pseudomonas aeruginosa and has historically occurred in elderly patients with diabetes or immunodeficiency. EAC foreign body is a risk factor for otitis externa but has not been described in NOE. A healthy 31-year-old man presented with new-onset seizures and worsening left-sided otalgia and otorrhoea. Brain imaging revealed left temporal subdural abscesses superior to the petrous bone. A retained cotton bud was identified in the left EAC, along with osseocartilaginous junction and mastoid granulation tissue. The foreign body was removed; a cortical mastoidectomy performed and intravenous antibiotic administered. At 10 weeks, the patient remained well, with no neurological deficit and no residual ear symptoms, and CT demonstrated complete resolution of the intracranial abscesses.

Pulsatile nystagmus secondary to semicircular canal dehiscence.

We report the case of a 69-year-old man with a history of mastoidectomy for cholesteatoma, who developed spontaneous spinning vertigo on debridement of his cavity. Subsequent CT confirmed a lateral semicircular canal fistula, which was surgically closed with mastoid cavity obliteration. Following surgery, he developed a spontaneous, pulse-synchronous horizontal pendular nystagmus. We discuss the pathophysiology of this rare clinical sign.

Cochlear implants and ex vivo BDNF gene therapy protect spiral ganglion neurons.

Spiral ganglion neurons often degenerate in the deaf ear, compromising the function of cochlear implants. Cochlear implant function can be improved by good preservation of the spiral ganglion neurons, which are the target of electrical stimulation by the implant. Brain derived neurotrophic factor (BDNF) has previously been shown to enhance spiral ganglion survival in experimentally deafened ears. Providing enhanced levels of BDNF in human ears may be accomplished by one of several different methods. The goal of these experiments was to test a modified design of the cochlear implant electrode that includes a coating of fibroblast cells transduced by a viral vector with a BDNF gene insert. To accomplish this type of ex vivo gene transfer, we transduced guinea pig fibroblasts with an adenovirus with a BDNF gene cassette insert, and determined that these cells secreted BDNF. We then attached BDNF-secreting cells to the cochlear implant electrode via an agarose gel, and implanted the electrode in the scala tympani. We determined that the BDNF expressing electrodes were able to preserve significantly more spiral ganglion neurons in the basal turns of the cochlea after 48 days of implantation when compared to control electrodes. This protective effect decreased in the higher cochlear turns. The data demonstrate the feasibility of combining cochlear implant therapy with ex vivo gene transfer for enhancing spiral ganglion neuron survival.

Pneumomediastinum following Ecstasy (methylenedioxymetamphetamine, MDMA) ingestion in two people at the same 'rave'.

Ecstasy is a class A controlled drug often consumed by the young population for recreational purposes. Documented complications of its use include hyperpyrexia, disseminated intravascular coagulation (DIC), renal failure and rhabdomyolysis. We report on two patients who developed pneumomediastinum after Ecstasy abuse. Both patients obtained and consumed the drug at the same establishment and presented to the same hospital within half an hour. The possible pathogenesis of this complication are discussed and the literature reviewed. Pneumomediastinum should be recognized as a possible complication of Ecstasy use. Conservative management is appropriate.

An unusual transorbital penetrating injury and principles of management.

The objective of this study was to present an unusual low velocity transorbital penetrating injury. The study design was a clinical record (case report). A 38-year-old gentleman tripped and fell face first onto the wing of an ornamental brass eagle. This penetrated the inferomedial aspect of the right orbit, breaching the lamina papyracea to extend into the ethmoid sinuses and reaching the dura of the anterior cranial fossa. The foreign body was removed in theater under a joint ophthalmology and ENT procedure. The patient was left with reduced visual acuity in the right eye but no other long-term sequelae. Transorbital penetrating injury presents unusual challenges to investigation and management requiring a multidisciplinary approach to prevent significant morbidity and mortality. If managed well the prognosis is good.

Transient auditory dysfunction: a description and study of prevalence.

Transient auditory dysfunction (TAD) is a previously undescribed symptom complex of unknown cause. It is characterized by short-lasting sensorineural hearing loss (unilateral or bilateral), it is associated with tinnitus, it resolves completely within minutes, and it is not accompanied by vestibular symptoms. We conducted a cross-sectional prospective study to define TAD, find its prevalence, and discuss its significance. Two hundred healthy subjects between the ages of 16 and 49 years were surveyed using a questionnaire. Of these subjects, 41 (20.5%) reported experiencing symptoms of TAD. The mean number of episodes was 5.9 times per month, the mean duration was 41 seconds, and 80% experienced concomitant tinnitus. We conclude that TAD is a common finding in a healthy population. This may have implications for the pathogenesis of sudden-onset sensorineural hearing loss. Further longitudinal studies and detailed audiologic evaluation of patients with TAD are required to ascertain the significance, etiology, and pathophysiology of this condition.

Successful management of a catecholamine-secreting glomus jugulare tumor with radiosurgery alone.

Secretory glomus jugulare tumors are often resected surgically to control the systemic effects of the catecholamines they produce. This involves complex skull base surgery, which carries significant risks and frequent morbidity. Stereotactic radiosurgery (SRS) is a recently recognized treatment for glomus jugulare tumors, though little is known about its use in secretory tumors. Case Report A young fit patient with a catecholamine-secreting glomus jugulare tumor was treated with SRS alone and over the following 37 months her urinary catecholamine excretion fell to near normal levels, and serial magnetic resonance imaging (MRI) confirmed a reduction in tumor volume. Discussion Radiosurgery is an accepted treatment for glomus jugulare tumors and is now readily available to skull base surgeons. In this case a catecholamine-secreting tumor was successfully controlled with radiosurgery alone. Further research and long-term follow-up will determine the role of this treatment in the nonsurgical management of secreting glomus jugulare tumors.