Cartilage Ossiculoplasty from Stapes to Tympanic Membrane in One-Stage Intact Canal Wall Tympanoplasty for Cholesteatoma.

OBJECTIVE: To report hearing results of cartilage interposition ossiculoplasty in one-stage intact canal wall (ICW) tympanoplasty for cholesteatoma with intact stapes. MATERIALS AND METHODS: A retrospective study of pre and postoperative hearing status was conducted at a tertiary referral otologic center in a series of 61 patients having undergone one-stage ICW tympanoplasty for cholesteatoma with intact stapes and cartilage ossiculoplasty during the same procedure. RESULTS: In the preoperative period, the mean air conduction thresholds (AC), air-bone gap (ABG), and speech reception thresholds (SRT) were 35.3, 20.14, and 35.6 dB, respectively. Postoperatively, with a mean follow-up of 29 months, AC, ABG, and SRT were 27.8, 13.34, and 28.8 dB, respectively. Mean hearing gain was 6.8 dB and mean SRT improvement was 6.8 dB. Mean bone conduction thresholds for 1, 2, and 4 kHz remained stable after surgery (17.6 dB preoperatively vs. 18 dB postoperatively). CONCLUSION: Cartilage ossiculoplasty from stapes to tympanic membrane in one-stage ICW tympanoplasty for cholesteatoma is a safe, reliable, easy, and effective procedure, with no additional cost.

Descending necrotizing mediastinitis: contemporary trends in etiology, diagnosis, management, and outcome.

OBJECTIVE: To evaluate contemporary trends in etiology, diagnosis, management, and outcome of descending necrotizing mediastinitis (DNM) and to draw the clinician's attention on this probably underappreciated disease. SUMMARY OF BACKGROUND DATA: An uncommon but one of the most serious forms of mediastinitis is DNM which is caused by downward spread of deep neck infections and arises as a major complication of "banal" odontogenic, pharyngeal, or cervicofacial foci. As most studies are based on small patient populations, current data on risk factors, etiology, and outcome vary significantly. Also, the optimal form of treatment remains controversial. METHODS: This retrospective study, which is the largest single-center study since 1960, is based on the management of 45 patients with DNM treated over a period of 12 years. Additionally, a meta-analysis of 26 studies on DNM published between 1999 and 2008 was performed and compared with own data and 2 previous meta-analyses covering the interval from 1960 to 1998. RESULTS AND CONCLUSIONS: Today DNM most commonly arises from pharyngeal foci and mixed polymicrobial aerobic and anaerobic infections. Reduced tissue oxygenation and impaired immune function promotes its development. Most cases of DNM are limited to the upper mediastinum and can be adequately drained by a transcervical approach. Formal thoracotomy should be reserved for cases extending below the plane of the tracheal bifurcation. Although DNM remains an aggressive infection with high morbidity, a favorable outcome can now be obtained in 85% of patients, even with this selective approach. Early diagnosis and surgical intervention are crucial.

Computed tomography-based workup of conductive hearing loss with normal middle ear: don't forget superior semicircular canal dehiscence.

Patients with superior semicircular canal dehiscence (SSCD) may have conductive hearing loss (CHL) with normal middle ear (ME). A patient with CHL and normal tympanic membrane at otoscopy underwent tympanotomy for presumed otosclerosis but had negative intraoperative findings. A high-resolution computed tomography (CT) scan of the temporal bone performed a few years later showed the absence of middle-ear disorder (especially the absence of imaging signs of otosclerosis) and revealed a bony dehiscence of the superior semicircular canal. High-resolution CT scan is the test of choice for diagnosing SSCD; it mimics otosclerosis by manifesting itself as CHL with a normal ME. The aim of this study is to remind radiologists and otolaryngologists that SSCD should be systematically considered among the etiologies of CHL with normal ME.

Delayed ventricular fibrillation following blunt chest trauma in a 4-year-old child.

A 4-year-old boy who was involved in a motor vehicle accident as a pedestrian and suffered blunt chest trauma was admitted to the emergency room. Unpredictable delayed ventricular fibrillation was diagnosed and treated successfully 2 h later. This case cannot be classified as commotio cordis as the ventricular fibrillation (VF) developed so long after the sustained chest injury. At the same time, other possible etiologies of VF such as cardiac pathology or electrolyte and metabolic disorders had been ruled out. Thus, an etiological link between the chest trauma and the subsequent VF could not be ruled out and is in fact plausible despite the late onset.

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.

Cochlear implantation in children with otitis media: second stage of a long-term prospective study.

OBJECTIVE: To present the findings of the second stage of an ongoing prospective study of the outcome of cochlear implantation in otitis media (OM)-prone and non-OM-prone children who were treated according to a structured protocol designed to control OM prior to implantation. PATIENTS AND METHODS: Of 60 children referred for cochlear implantation during the study period, 34 were classified as OM-prone (Group A) and 26 as non-OM-prone (group B). Group A patients were managed according to a structured protocol aimed at pre-implantation control of OM. A ventilating tube (with or without adenoidectomy) was inserted in the affected ear(s) of these children, if necessary more than once. Post-implantation follow-up ranged from 3 to 45 months (average 20 months). RESULTS: In the OM-prone group of children, the mean age at referral and at implantation was significantly lower and the mean interval between referral and implantation significantly higher than in the healthy group. During implantation, 21 children (19 from the OM-prone group A) had thick middle ear mucosa that had to be removed to allow identification of the round window niche. After implantation, 13 of the OM-prone children (38%) and 2 of the non-OM-prone children (7.6%) developed acute OM in the implanted ear. Five of these cases, all belonging to the OM-prone group, proved to be recurrent and therapeutically challenging, and 2 of them also developed acute mastoiditis. There were no other OM-related complications. CONCLUSIONS: Early referral led to early implantation, even in children susceptible to OM. The incidence of OM decreased after implantation, but was still significantly higher in the OM-prone group. On the basis of these results, we recommend the continuous use of a ventilating tube in OM-prone pediatric implantees until they outgrow their susceptibility to OM.

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.