Unilateral blindness following septoplasty.

Visual loss following routine nasal surgery is an extremely rare and devastating complication. We report a case of unilateral blindness due to orbital apex syndrome following septoplasty. We also review the literature and discuss probable causes. To the best of our knowledge, this is only the second published report of this complication.

Results of exploratory tympanotomy following sudden unilateral deafness and its effects on hearing restoration.

In cases of acute unilateral deafness, no consensus exists as to whether tympanotomy and sealing of the round window should be performed routinely. To further address this issue, we conducted a retrospective study of pre-, intra-, and postoperative findings in 97 patients who had undergone exploratory tympanotomy (EXT) after the onset of sudden and severe unilateral deafness. Our goal was to ascertain, if we could, whether the benefits of EXT outweigh the risks. We also took into account the effects of perilymph fistula (PLF) on the etiology of sudden hearing loss and postoperative outcomes. We found that routine EXT was indeed beneficial for these patients. It was associated with a very low surgical complication rate, and its effects on hearing as assessed by objective measures were beneficial. The greatest benefits were seen in patients who underwent EXT within 7 days after the onset of their hearing loss. With respect to PLF, we found that the presence or absence of the "typical history" of PLF (i.e., a sudden unilateral hearing loss within 48 hours after a precipitating trauma or physical exertion) had no bearing on whether a PLF was actually present in our group; nor was vertigo a reliable predictor of PLF. We recommend that EXT be performed on all patients with new-onset acute unilateral deafness, barring any contraindications, of course. The absence of a typical history of PLF should not dissuade the surgeon from proceeding with EXT.

Endovascular embolization of a hemorrhagic jugular bulb diverticulum.

A jugular bulb diverticulum (JBD) is considered to be a rare venous anomaly. In exceptional cases it extends into the middle ear cavity with no bony covering, and slight oozing to massive bleeding might be encountered during routine middle ear surgical procedures. We report a case of massive bleeding from a dehiscent jugular bulb diverticulum that appeared during myringotomy and was successfully managed by endovascular embolization. This report emphasizes the value of interventional neuroradiology in otosurgical cases in which preoperative control of blood vessels or vascular malformations is crucial to avoid severe complications.

Inferior turbinate schwannoma: report of a case.

Schwannomas of the nasal cavity are extremely rare. We evaluated a 42-year-old woman who presented with a 4-year history of slowly progressive nasal obstruction. The cause of the obstruction was identified as a schwannoma in the left inferior turbinate. The tumor was completely excised, and no sign of recurrence was evident at the 1-year follow-up. To the best of our knowledge, this is only the third case of a schwannoma originating in the inferior nasal turbinate that has been reported in the English-language literature. We review the clinical and pathologic features of this case.

Hepatotoxicity of combined treatment with cisplatin and gentamicin in the guinea pig.

The damaging effects on the liver tissue of treatment with cisplatin followed by the aminoglycoside antibiotic gentamicin were studied in guinea pigs. The ultrastructural findings revealed foci of damage in the liver parenchyma, including its vascular component. Injurious effects to cytoplasmatic organelles such as mitochondria and endoplasmic reticulum as well as to nuclei were observed. In addition, abundance of lysosomes, autophagic vacuoles, and amorphous-granular bile in the lumina of bile canaliculi was found. Focal sinusoidal lining damage and capillarization of sinusoids were also present. In vascular lumina, some erythrocytes showed a deformed shape ("ropalocytosis"). Taken together, these findings indicate that the combined treatment with cisplatin followed by gentamicin is toxic to components of liver tissue. Since toxic changes have been shown in vessels of the inner ear and in renal-glomerular capillaries, the present observations of hepatotoxicity indicate the potential vascular damage to various tissues. The injurious effects of the cisplatin-aminoglycoside combination should be considered during its use in clinical conditions.

Bee stings of children: when to perform endotracheal intubation?

Hymenoptera stings account for more deaths in United States that any other envenomation. Oropharyngeal stings, although rare, may produce life-threatening airway obstruction by way of localized swelling. We present 4 cases of bee stings in children that necessitated tracheal intubation and mechanical ventilation. Two children had breathing difficulties at admission; the other 2 presented with minimal symptoms but were preventively intubated and mechanically ventilated. Orofacial bee sting victims should be given parenteral treatment with epinephrine, steroids, antihistamines, and inhalational bronchodilators even when they initially present with minimal symptoms, with general anaphylaxis management in large envenomations, as well as immediate endotracheal intubation and mechanical ventilation for at least 24 hours in patients with signs of airway compromise.

Recurrent syncope as presenting symptom of Burkitt's lymphoma at the carotid bifurcation.

Burkitt's lymphoma is rare outside of Africa, and head and neck manifestations of this disease are even more uncommon. We report a case of Burkitt's lymphoma localized at the bifurcation of the right common carotid artery in a 64-year-old man. The presenting symptoms were recurrent syncopes that necessitated a pacemaker, followed by a rapid onset of cranial nerve palsies. The tumor had infiltrated cranial nerves IX, X, XI, and XII and was resected by selective neck dissection. The patient was subsequently treated with a chemotherapeutic regimen consisting of a combination of cytosine arabinoside, vincristine, ifosfamide, prednisone, and an intrathecal application of methotrexate. He also underwent external-beam irradiation of the neck. The patient has been followed up for a period of 42 months and has no evidence of recurrent disease. Repeated diagnostic testing and a coordination of multiple disciplines can speed diagnosis and therapeutic management. The current literature is reviewed and discussed.

Amyloid tumor of the larynx associated with plasma cell infiltration: differential diagnosis.

Localized amyloidosis of the larynx is uncommon, accounting for fewer than 1% of all benign laryngeal tumors. We report 2 cases of laryngeal amyloidosis in which dense plasma cell infiltrates were found in the vicinity of the amyloid deposits; in view of this finding, we suspected a hematologic disease--plasmacytoma in particular: However, molecular genetic analysis did not demonstrate any light-chain restriction, indicating that the plasma cells were of polyclonal origin and therefore consistent with chronic inflammation. We also discuss the available literature with respect to diagnostic and therapeutic procedures in patients with amyloidosis of the upper airway.

Lateral upper arm free flap for primary reconstruction of pharyngeal defects in ablative oncological surgery. Report of six consecutive cases.

Free microvascular flaps are an established method for soft tissue reconstruction following ablative oncological surgery in the head and neck. Functional reconstructions of the hypopharynx and the pharyngoesophageal segment (PES) are of particular relevance, as they are highly demanding surgical procedures. So far, the radial forearm free flap (RFFF) and the free jejunal transfer have been the transplants predominantly used for this purpose. The lateral upper arm free flap (LUFF) presents an alternative method for the fasciocutaneous tissue transfer. We report on our experience with the LUFF in a 56-year-old male patient with a pT3pN0M0 squamous cell carcinoma of the hypopharynx. A pharyngocutaneous fistula developed 5 days after pharyngolaryngectomy with bilateral neck dissection. The fistula was localized between the pharyngeal constrictor muscle and the esophagus and was closed with an LUFF from the left arm. Excellent flap adaptation to the remaining pharyngeal mucosa was observed. Although the length of the vascular pedicle and the diameter of the vessels in the LUFF are smaller than those in the RFFF, neither pedicle length nor vessel diameter proved to be a problem. The LUFF can be recommended as a well-vascularized, relatively safe and reliable flap for reconstruction of tubular structures such as the hypopharynx and the PES after tumor ablation and as an alternative to the RFFF. The flexibility of the LUFF allows surgeons to reconstruct the anatomy of the lost soft tissues as adequately as possible.

Stapedius muscle myoclonus.

Myoclonus of the middle ear is a very rare condition. We present the case of a 20-year-old soldier who was exposed to intense artillery noise during a fierce battle and immediately afterward complained of an incapacitating tinnitus in both ears. Microscopic examination of the ears demonstrated rapid rhythmic movements of the tympanic membrane coinciding with the tinnitus, which was also easily heard by the examiner. There was no evidence of palatal myoclonus, and thus the diagnosis of middle ear myoclonus was made. Exploratory tympanotomy confirmed the diagnosis of stapedial muscle myoclonus. Bilateral sectioning of the stapedial tendons brought immediate relief of the tinnitus to the patient. We review the literature of middle ear myoclonus and discuss the symptoms, evaluation, and management of this rare condition.

Early complications of tracheostomy performed in the operating room.

Tracheostomy is one of the oldest operations in medicine. The intraoperative and postoperative complications associated with this procedure are well established. Recently, percutaneous and open bedside tracheostomy in the intensive care unit has been reported as an alternative to tracheostomies performed in the operating room. We investigated the early complications in 70 consecutive tracheostomies performed in the operating room in Bnai Zion Medical Center in Haifa, Israel. The study revealed no complications related to patient transportation to and from the operating room. The complication rate of standard surgical tracheostomy performed in the operating room was very low.

Postdural puncture headache: an imaging-guided management protocol.

IMPLICATIONS: We propose an imaging-based algorithm for the management of headache caused by the inadvertent puncture of dura that occurs sporadically during epidural analgesia. Its implementation can identify those postdural puncture headache cases that cannot benefit from epidural blood patches, and their unnecessary application can consequently be avoided.

Paper patching for chronic tympanic membrane perforations.

OBJECTIVE: This study was designed to evaluate the results of paper-patch myringoplasty in patients with chronic perforations of the tympanic membrane of different sizes. STUDY DESIGN AND SETTING: A retrospective survey of paper-patch myringoplasties performed in a tertiary referral academic medical center on 77 patients with chronic perforations of the eardrum was carried out. Data consisted of the causes of the perforations, time the perforations had been present, their size, number of patch applications, duration of application, and number of successfully closed perforations. RESULTS: Closure rate was 63.2%, 43.5%, and 12.5% for small, medium, and large perforations, respectively. Small perforations needed the least number of repeated applications and the least time for closure. CONCLUSIONS AND SIGNIFICANCE: Paper patching is technically simple, time saving, safe to perform, cost effective, and suitable as an outpatient procedure and has a good success rate, It should be tried in perforations smaller than 5 mm before a patient is referred for surgery.

Bilateral tinnitus due to middle-ear myoclonus.

Tinnitus is a common otological symptom. Usually it is subjective (perceived only by the patient); very rarely is it objective (heard by both the patient and the examiner) Objective tinnitus due to middle-ear myoclonus is extremely rare, with only a few case reports published in the literature. We present three cases of objective tinnitus caused by middle-ear myoclonus. All patients were cured by tympanotomy with stapedial and tensor tympani tendon section.

Effect of submucosal diathermy in chronic nasal obstruction due to turbinate enlargement.

Nasal obstruction is one of the most common chronic presenting symptoms encountered by otolaryngologists. In most patients, the cause of nasal obstruction is either nasal septal deviation or turbinate hypertrophy owing to vasomotor or perennial allergic rhinitis. Most cases of hypertrophic turbinate are usually mild and respond to antihistamine therapy, local decongestions, or allergy desensitization; however, surgery is required in some cases. Surgical treatment is controversial, and many surgical methods of treatment have been proposed. We have recently evaluated the results of our experience with submucosal diathermy (SMD) on 51 patients suffering from chronic nasal obstruction. We have found that diathermy demonstrated good results in 78% of the cases at 2 weeks postoperatively and in 76% of the cases 2 months following the procedure. Patients who had no complaints and had good nasal airflow were not followed-up after 2 months. In the present study, we have carried out a long-term follow-up of another group of patients who had undergone SMD diathermy because of hypertrophy of the inferior turbinates. Patients were examined at 2 months postoperatively and after 1 year, with both subjective and objective assessments of nasal breathing. Two months postoperatively 64 of 91 patients (70.3%) experienced subjective improvement in nasal breathing, where as 73 patients (80.2%) had good nasal breathing as indicated with the Gertner-Podoshin plate. During the follow-up year, secondary operations were deemed necessary for 16 patients because of unsatisfactory results of the original procedure. Of these secondary procedures 4 were revision SMD, 9 patients underwent a septoplasty, in 2 patients functional endoscopic sinus surgery was conducted, and 1 patient had a submucosal turbinectomy. This group of patients was excluded from the 1 year follow-up evaluation. At the 1-year follow-up visit, 65 patients (of the 75) were symptom-free with respect to nasal breathing (86.7%), and 67 patients (89.3%) had good nasal breathing as examined with the Gertner-Podoshin plate. No means were apparent for predicting preoperatively which patients would benefit most from submucosal diathermy. Submucosal diathermy is carried out under local anesthesia and can be implemented as an office procedure. It does not require expensive instrumentation and is a safe, effective procedure for improving nasal breathing in patients with chronic obstructive inferior turbinates, both on a short-term and long-term basis.

Diagnostic value of fine-needle aspiration from parotid gland lesions.

BACKGROUND: Fine-needle aspiration is a widely accepted method in the preoperative evaluation of head and neck tumors. However, its effectiveness in the interpretation of salivary gland disorders is controversial. OBJECTIVES: To evaluate the effectiveness of FNA as a preoperative diagnostic tool of parotid lesions. METHODS: Reports of 52 FNA from various parotid gland lesions were compared with the final pathologic diagnoses. RESULTS: We noted 31 true positive, 5 true negative and 16 false negative results. There were no false positive FNA reports. The calculated sensitivity, specificity and accuracy of FNA diagnosis in this study were 66%, 100%, and 69.2% respectively. CONCLUSIONS: The high rate (30.8%) of false negative FNA results was partly explained by sampling errors, therefore specificity of the procedure could be improved by the precise selection of a representative aspiration site.

Frey syndrome--delayed clinical onset: a case report.

Frey syndrome is a disorder characterized by unilateral sweating and flushing of the facial skin in the area of the parotid gland occurring during meals. The syndrome is a sequela of parotidectomy and may follow other surgical, traumatic, and inflammatory injuries of the parotid and submandibular glands and the cervical and upper thoracic portions of the sympathetic trunk. Pathogenesis is based on regeneration of sectioned parasympathetic fibers with inappropriate innervation of cutaneous sweat glands. Various studies have reported the clinical incidence of Frey syndrome after parotidectomy to be as high as 53%. The reported incidence of Frey syndrome in patients not undergoing intraoperative preventive measures is 96% in patients evaluated by means of an iodine-starch test 12 months postoperatively. We present a case in which a patient developed symptoms of Frey syndrome 8(1/2) years after superficial parotidectomy. Although most patients with Frey syndrome have only mild-to-moderate symptoms (only 6% of patients experience severe symptoms), the potential for appearance of Frey syndrome years after the parotidectomy must be discussed with the patient before surgery in the parotid region.

Intracochlear insertion of electrodes using hyaluronic acid in cochlear implant surgery.

Hyaluronic acid has been proposed as a lubricant for improving the outcome of cochlear implant surgery. We describe a method which includes coating the electrodes with a thin layer of hyaluronic acid as well as using a droplet of the lubricant on the cochleostomy to provide additional magnification, like a lens, that facilitates the insertion of the electrode array. The use of hyaluronic acid reduces trauma to the cochlea and avoids contaminating perilymph by blood or by saline used during the operation. It is an efficacious and reliable method for cochlear implant surgery.

Simple on-line endotracheal cuff pressure relief valve.

Ischemic injury of the tracheal mucosa in the endotracheally intubated patient is directly proportional to the tracheal tube cuff pressure. At a cuff pressure of 30 cm H2O, the tracheal mucosal blood flow becomes partially obstructed, and at a pressure of 45 cm H2O, the obstruction to the tracheal mucosal blood becomes total, leading to tracheal mucosal damage and subsequent complications. In our institute, we have developed a simple and very inexpensive method to gauge the cuff pressure. We use a regular 20-mL syringe attached in line with the connector of the endotracheal tube cuff. In this manner, we monitored the intracuff pressure in 120 patients who underwent ear or neck surgery. The syringe was connected to the tube cuff and inflated with 15 mL of air. The syringe was left constantly connected to the cuff. In addition, the cuff pressure was measured with the Mallinckrodt Hi-Lo aneroid pressure gauge at the beginning of surgery and hourly thereafter for the duration of surgery. At the same time, a check for leakage around the cuff was made by auscultation with a stethoscope above the sternal notch. Multiple comparisons between the repetitive intracuff pressure measurements revealed that there were no significant differences in the intracuff pressure values measured at the different times of surgery. These results indicate that there was an adequate venting of the excess intracuff pressure and also that there was no leakage around the cuff.