Metastatic breast carcinoma presenting as unilateral pulsatile tinnitus: a case report.

Pulsatile tinnitus is a rare symptom, yet it may herald life-threatening pathology in the absence of other symptoms or signs. Pulsatile tinnitus tends to imply a vascular cause, but metastatic disease also can present in this way. Clinicians should therefore adopt a specific diagnostic algorithm for pulsatile tinnitus and always consider the possibility of metastatic disease. A history of malignant disease and new cranial nerve palsies should raise clinical suspicion for skull base metastases. We describe the case of a 63-year-old woman presenting with unilateral subjective pulsatile tinnitus and a middle ear mass visible on otoscopy. Her background included the diagnosis of idiopathic unilateral vagal and hypoglossal nerve palsies 4 years previously, with normal magnetic resonance imaging (MRI). Repeat MRI and computed tomography imaging were consistent with metastatic breast carcinoma. This case raises important questions about imaging protocols and the role of serial scanning in patients at high risk of metastatic disease.

Obstructed kidney and sepsis secondary to urethral catheter misplacement into the distal ureter.

An 86-year-old woman underwent routine catheter replacement in the community. The new catheter failed to drain urine. Attempts to remove the catheter failed, both by the community nurse as well as by the urology team in the hospital. A CT scan confirmed that the catheter balloon was inflated in the distal right ureter. The patient was started on antibiotics and listed for cystoscopy under general anaesthetic. The catheter was visualised entering the right ureter and the balloon punctured using a wire under image intensifier guidance. Once removed, a new catheter was inserted. Very dilated ureteric orifices were noted. Post operatively the patient required HDU support for 48 h due to sepsis and on recovery was discharged home. The key learning point in this case is to always consider catheter misplacement in the ureter if it is not draining well and the patient presents with pain.