Mucormycosis of the mandible after dental extractions in a patient with acute myelogenous leukemia.

Mucormycosis is a fulminant fungal infection that occurs most often in diabetic and immunocompromised patients including those with hematologic malignancies. In this case, a patient with acute myelogenous leukemia developed mucormycosis in a recent mandibular extraction site. The successful management of this patient demonstrated that early diagnosis, aggressive surgical and medical treatment and resolution of the underlying disease could improve the prognosis for survival. A case is made for the role of smoking as an initiator of mucormycosis, and treatment considerations for controlling periodontal and pulpal disease before chemotherapy are discussed.

Update on idiopathic perilymphatic fistulas.

Idiopathic perilymphatic fistula has been confirmed with clinical-temporal bone histopathologic studies as a separate inner ear disease. Criteria for its diagnosis are sudden or progressive sensory hearing loss, or for vestibular components, a positive fistula test, constant disequilibrium, and positional nystagmus or postural vertigo. Nonsurgical treatment, such as keeping the head higher than the heart and avoiding heavy lifting, can be tried. When it is ineffective or when there is sudden hearing loss without improvement, surgical sealing of the leak should be attempted.

Postural vertigo. Quick relief from the postural vertigo component of vestibular diseases.

Patients who had disorders of the vestibular system with a component of benign postural vertigo as a symptom were studied, using an examination table suitable for the canalith (otolith) repositioning maneuver as described by Epply, followed by lack of recumbency for 48 hours. The patients regularly had resolution or decreased intensity of symptoms, as did those described by Epply. A repeated positioning maneuver may be needed in some of the patients. The application of a vibrator, as previously described has not been found to be essential.

Basophilic deposits on the cupula: preliminary findings describing the problems involved in studies regarding the incidence of basophilic deposits on the cupula.

In this study, the possibility of whether basophilic deposits adhered to the cupulas in the semicircular canals was investigated histologically. Results indicated that basophilic deposits were present in all three cupulas of the semicircular canals. The overall incidence of basophilic deposits in the superior, lateral and posterior semicircular canal cupulas was 26%, 41% and 37%, respectively. The incidence of basophilic deposits bound to the cupulas increased with age. The possible origin of these basophilic deposits on the cupulas and the increased incidence of basophilic deposits with increasing age are discussed.

Idiopathic perilymphatic fistulas. A temporal bone histopathologic study with clinical, surgical, and histopathologic correlations.

OBJECTIVE: To report a case of idiopathic perilymphatic fistulas diagnosed and successfully treated during life and confirmed histopathologically post mortem. METHODS: Perilymphatic fistulas were diagnosed clinically and repaired surgically. Light microscopic histopathologic studies were made of both temporal bones after death. RESULTS: Vestibular symptoms had improved postoperatively. Postmortem histopathologic examination of the temporal bones demonstrated patencies of the labyrinth capsule that had been predicted clinically during life, the qualities of the membranous labyrinth in both the operated-on and the unoperated-on ears, and the elements of the surgical repair. Notably, there was no evidence of endolymphatic hydrops. CONCLUSIONS: The histopathologic findings document the relationships of the fistula ante fenestram and the fissure connecting the round window niche and the posterior semicircular canal to idiopathic perilymphatic fistulas. Also, the diagnostic features reported herein allowed this patient with fluctuating hearing loss, episodic vertigo, and tinnitus to be distinguished from a patient with Meniere's syndrome. These findings have implications regarding past and future studies of vestibular and cochlear disorders.

High resolution two-dimensional electrophoresis: technique and potential applicability to the study of inner ear disease.

Technologic progress in two-dimensional polyacrylamide gel electrophoresis (2-D Page), in combination with immunoblotting, amino acid sequencing, and computer-assisted image analysis, allowed establishment of human body fluid and tissue "reference maps," which in turn enabled meaningful comparison of data from various clinical and research centers. Altered protein profiles have been observed in plasma/serum, cerebrospinal fluid, urine, and other body fluids in numerous systemic or localized pathologic entities. Human perilymph, obtained during ear surgery or post mortem, exhibits a protein profile differing from plasma in several ways. Most interesting are the extremely high levels of high density lipoprotein-associated proteins, a group of proteins thought to play a role in atherosclerosis, nerve damage/regeneration, chronic inflammation, and Alzheimer's disease, among others. A technique is described for collection and analysis of human perilymph, using a state-of-the-art standardized 2-D Page technique. It is expected that, as in other body fluids, disease-specific protein patterns will be identified. With the possible exception of presumed perilymphatic fistula, it is not envisioned that analysis of perilymph will be used for diagnostic purposes but rather as an aid for the elucidation of the mechanisms underlying inner ear disease, whether localized or as part of systemic alterations.

Idiopathic perilymphatic fistulae: a temporal bone histopathological study. Clinical, surgical and histopathological correlations.

The temporal bone histopathological findings herein reported are the first to be from a patient who had, during life, the diagnosis of idiopathic perilymphatic fistulae. The patient received surgical treatment followed by rapid improvement of his vestibular symptoms. These specimens histopathologically demonstrate the patencies of the labyrinth capsule that were diagnosed (predicted) clinically during life, the qualities of the membranous labyrinth in both the operated and unoperated ears, and the elements of the surgical repair. Notably there is no evidence of endolymphatic hydrops. The diagnostic features which allowed this patient with fluctuating hearing loss, episodic vertigo, and tinnitus to be distinguished from a patient with Meniere's syndrome are discussed as are the implications regarding future and past studies of vestibular and cochlear disorders.

Protein profile of human perilymph: in search of markers for the diagnosis of perilymph fistula and other inner ear disease.

Recent developments in high-resolution two-dimensional polyacrylamide gel electrophoresis, combined with amino acid sequencing and computer-assisted image analysis, have allowed separation of approximately 100 proteins and identification and quantitation of some 30 proteins in human perilymph. The majority of proteins were found to be present in perilymph at levels in basic agreement with the total protein gradient between perilymph and plasma (1:35). However, several striking differences were observed: (1) beta 2-transferrin, known to be absent from normal plasma but present in cerebrospinal fluid, was detected in perilymph at a concentration roughly equal to that in cerebrospinal fluid; and (2) two high-density lipoprotein-associated apolipoproteins--apo D (formerly PLS:33) and apo J or NA1 and NA2 (formerly PSL:29/30), the latter showing identity with SP40/40, or cytolysis inhibitor--were found to be present at concentrations 1 to 2 orders of magnitude higher when examined in terms of total protein and to be comparable with or higher than plasma levels when examined in terms of absolute concentrations. The functional significance of the extremely high levels of the two apolipoproteins is not known at this time. An attempt was made to use beta 2-transferrin, as well as apo D and apo J (NA1/NA2), as markers for the diagnosis of perilymph fistula, one of the most controversial and challenging problems for the otologist today. It was determined that the technique is indeed applicable when relatively pure fistula samples are analyzed. Limitations and potential improvements of the technique are discussed. In addition, the potential usefulness of two-dimensional polyacrylamide gel electrophoresis in other pathologic conditions of the inner ear is discussed briefly.

Evaluation of cefixime in the treatment of bacterial maxillary sinusitis.

The efficacy and safety of cefixime, the first oral third-generation cephalosporin, were evaluated in a multicenter clinical trial involving 118 adult patients with acute sinusitis or acute exacerbations of chronic sinusitis. Patients received a single daily dose of 400 mg of cefixime for a mean duration of 10 days; 106 patients completed a course of therapy. Clinical cure and improvement were achieved in 90% of these patients (61% cured and 29% improved). Among the patients evaluated again 2 weeks after therapy, 91% had a sustained clinical cure or improvement. Sinus exudate specimens were obtained from all patients by transantral puncture before therapy. Pathogens were isolated from 76 patients (66%), the most common pathogens being Haemophilus influenzae, alpha-hemolytic streptococci, and Streptococcus pneumoniae. Eighty-six percent of pathogens were presumed eradicated. Three patients discontinued therapy because of side effects. The most frequently reported adverse effects were gastrointestinal, with 20% of patients reporting diarrhea. Cefixime was effective in the treatment of bacterial sinus infections in adults and was well tolerated.

Perilymph fistulas. Clinical criteria.

A perilymph fistula may be defined as an abnormal opening between the inner ear and the external surface of the labyrinth capsule, which allows the escape of perilymph and causes specific disorders of hearing, balance, or both. Its diagnosis remains somewhat controversial. This communication presents a defined set of clinical diagnostic criteria, the historic context by which those criteria have been developed, the histopathologic and clinical studies by which they have been challenged or substantiated, and the deficiencies that remain in our understanding of the pathogenic mechanisms that allow for abnormal cochlear or vestibular function.

The histologic characteristics of the core of the fissula ante fenestram.

In earlier studies of perilymphatic fistulae, we described their histologic criteria and the clinical criteria for the identification and prediction of patencies of the labyrinth capsule related to disorders of hearing and balance. These patencies were either of the fissula ante fenestram or of the round window niche-posterior canal ampulla fissure. The permeability of the fibrous core of a patent fissula ante fenestram has been questioned, authors of some earlier articles arguing that the tissue is loose, others that it is dense. This study demonstrates loose fibrous and cellular structure in the fissula's tract, dense collagen at the circumference. The loose arrangement of tissue suggests that fluid can pass through this patency, and it appears similar to that of the spiral ligament which has been shown to contain perilymph by way of intercellular communications with the perilymphatic space.

Clinical diagnosis of anterior inferior cerebellar artery thrombosis. Autopsy and temporal bone histopathologic study.

A patient having the diagnosis of an anterior inferior cerebellar artery insufficiency died 36 hours after the onset of the symptoms that allowed this diagnosis. The special features of this study include a known symmetric 40-dB hearing loss 1 year prior to the onset of the symptoms, the noted decrease in hearing and severe vertigo heralding the vascular accident, the ensuring neurologic deficits, and the short duration of the patient's life after the onset of her symptoms. The patient's clinical course and the histopathologic findings of the brain stem involved the vestibular nuclei, facial nerve, nuclei of nerve V, restiform body and middle cerebellar peduncle and labyrinth including loss of sensory epithelium of the cochlea and vestibular system and the ganglion cells of Scarpa's ganglion. These findings are correlated with previous animal studies and those of Reye's syndrome. To the authors' knowledge this is the first report of a temporal bone histopathologic study from a patient having had the diagnosis of a labyrinthine arterial vascular accident.

Airway obstruction in LeFort fractures.

Airway obstruction associated with fractures of the midfacial skeleton can be life-threatening if not recognized promptly and treated appropriately. One hundred seventeen patients with LeFort fractures were treated between 1978 and 1984. Of the 117 patients, 21 had a LeFort I fracture, 46 had a LeFort II fracture, 14 had a LeFort III fracture, and 36 had various combinations of the three types of LeFort fractures. Thirty-one patients (26.5%) presented with airway obstruction, decreased respiration, or both, requiring either tracheotomy or endotracheal intubation. Of the 31 patients undergoing emergent tracheotomy or endotracheal intubation, 26 (83.9%) had loss of consciousness relating to their injuries. Thirty-nine (33.3%) additional patients had an elective tracheotomy either at the time of surgical repair of their fractures or for prolonged endotracheal intubation. Age and sex of the patients played no role in the incidence of airway complications in patients with LeFort fractures. Patients with LeFort III fractures and those with associated injuries such as mandible fracture, laryngeal and pharyngeal injury, and chest or closed head injury are at greater risk for requiring emergent control of the airway.