Spontaneous CSF Leaks From the Temporal Bone

Spontaneous cerebrospinal fluid leaks from the temporal bone seem to be rare; however, increasing numbers of cases are being reported. This paper reports 14 cases. The presenting symptoms included hearing loss, external leaks, mass in the middle ear and external meatus, and facial paresis. All cases were evaluated with computed tomography (CT), eight with CT cisternography, and six with magnetic resonance imaging. In all patients the defect was found in the tegmen; in two, an additional defect could be detected in the posterior fossa. All were surgically treated by a transmastoid extradural technique. There are no recurrences after a mean follow-up period of 1.2 years (5 months to 2.4 years).

Occult otologic fistulas as a cause of recurrent meningitis

OBJECTIVE

Occult perilymph fistulas may be the cause of unexplained non-epidemic meningitis.

MATERIAL AND METHOD

To review the case reports of 5 patients (3 females and 2 males aged 4-56) presenting with unexplained meningitis. All had sensorineural hearing loss of variable duration.

RESULTS

All patients were submitted to CT, MRI and MRI cisternography. All underwent exploratory tympanotomy to seal the fistula. In all patients the fistula could be located and sealed. All had no further attacks of meningitis and those who had serviceable hearing did not show any further deterioration.

CONCLUSION

In any case of recurrent meningitis an occult perilymph leak should be sought. A high degree of suspicion should exist if there are auditory or vestibular symptoms. Detecting and sealing of the defect will protect the patient against further attacks and deterioration of hearing.

Functional septal surgery: computer simulated surgery

Septal surgery is one of the most commonly performed nasal surgeries. It aims at restoring nasal patency and symmetrical air passages. However classical surgery may narrow the originally wider side necessitating additional surgery at the level of the turbinates. This study was performed to demonstrate that properly targeted and tailored surgery with limited interference at the level of specific areas may not only be enough but it may also more efficacious than more extensive surgery. The coronal CT scans of 16 patients with septal deviation were transferred to a computer and the cross-sectional areas (CSA) of both passages calculated before and after various simulations of septal surgery. In 8/16 cases the more limited surgery resulted in a wider total CSA and also more symmetrical right and left passages. This is more physiological both in terms of function and subjective feeling by the patients. We suggest that for all patients planned to undergo septal surgery a pre-operative coronal CT should be studied and the surgery planned to achieve the most optimal result rather than remove indiscriminately all deviated elements.

Complicated fungal sinusitis. Clinical and therapeutic aspects

Fungal infections of the sinuses are becoming more common and increasing number of cases are being reported in immunocompetent patients. Unfortunately a significant number of cases present with a complication. In this review of 140 patients with fungal sinusitis, 16 (11.4%) presented with an extrasinus, orbital or intracranial complication. The different fungal types, presentation and therapeutic approaches are discussed. This emphasizes the need for vigilance in dealing with patients with atypical sinus disease and to suspect fungal infections pre- and intraoperatively. Combined surgical and long term medical treatments are usually needed to prevent recurrences and spread of the infection.

Simple clinical system for the prediction of recurrence of nasal polypi

OBJECTIVE

A trial to determine a simple way to predict recurrence of nasal polypi to determine the need for long term medical therapy.

METHODS

Retrospective clinical analysis of the records of 100 patients with nasal polypi and studying various parameters including radiological, intra-operative and bacteriological data.

RESULTS

Among the various parameters studied, maxillary antral involvement, and positive bacterial cultures seemed the most predictive criteria of recurrence. Patients without polypoid involvement of the maxillary sinus and/or with negative cultures were less likely to have early recurrence of their disease.

CONCLUSION

Using simple clinical criteria, two patient populations could be defined. One in which recurrence is inevitable requiring continuous local steroid therapy after surgery and another group requiring occasional local treatment after an initial short course of local steroid spray.

Neurohistological changes after facial nerve rerouting

The present study was devised to examine possible structural changes in the facial nerve after rerouting. Changes were studied in 20 adult guinea pigs using different stains for the different nerve structures. Animals were anesthetized and the facial nerve rerouted. The animals were then separated into two groups, an "early" group killed after 7 days and a "late" groups after 15 days. The rerouted facial nerve was sectioned and stained to determine what structural changes had taken place. In both groups there were marked changes in the axons, Schwann cells and connective tissue elements, as well as a marked cellular infiltrate. Although these latter changes in the late group were slightly less than in the early group, the reticulin network was much thicker and there was greater disruption of the nerve bundles. These findings show that facial nerve rerouting causes significant structural changes that may persist for variable periods after surgery. Any attempts at facial rehabilitation clinically should be delayed to allow enough time for nerve function to recover.

Inclusion of pethidine in lidocaine for infiltration improves analgesia following tonsillectomy in children

BACKGROUND

Previous work has demonstrated that pethidine exerts local anaesthetic effects on peripheral nerves in vivo. We examined the effects of infiltration anaesthesia by a combination of pethidine and lidocaine on post-tonsillectomy pain and restlessness in children.

METHODS

Eighty children were randomly allocated to receive peritonsillar infiltration postoperatively with 3 ml of lidocaine 2% (1.5 ml on each side) combined with either 0.1 ml pethidine, 10 mg.ml-1, (pethidine group) or 0.1 ml normal saline (control group). Pain and behaviour were assessed at 1, 3, 6 and 12 h postoperatively and on the following morning by the patients and by a nurse blinded to previous treatment.

RESULTS

Patients in the pethidine group had lower pain scores than those in the control group at rest as well as swallowing during the whole observation period (P < 0.05). Paracetamol was given to 34/40 children in the control group and to 6/40 children in the pethidine group. The corresponding figures for pethidine administration were 6/40 and 0/40, respectively. Patients in the pethidine group displayed a more rapid return to calm wakefulness than those in the control group (P < 0.01).

CONCLUSION

Inclusion of a low dose of pethidine in lidocaine for tonsillar infiltration improves pain relief after tonsillectomy in children.

Detection of adenoidal hypertrophy using acoustic rhinomanometry

Adenoidal hypertrophy is the commonest cause of nasal obstruction in the pediatric population. It may cause marked morbidity as regards respiratory physiology, facial growth and middle ear function. Determination of adenoidal presence and size is not easy. Nasal endoscopy and radiology are the most accepted modes of diagnosis and each has its disadvantages. We have used acoustic rhinometry to determine the size of adenoids. Changes in nasal volume and resistance were recorded and an easy formula was devised to determined adenoid size. This technique is easy, non-invasive and reproducible with a 93.5% predictive value.

Fluticasone propionate is associated with severe infection after endoscopic polypectomy

OBJECTIVE

To test whether the use of fluticasone dipropionate nasal spray after endoscopic ethmoidectomy for multiple polyps is associated with a high incidence of infection. DESIGN. Randomized control study comparing the incidence of infection with the use of beclomethasone dipropionate or fluticasone propionate nasal spray after functional endoscopic sphenoethmoidectomy. Patients were followed up for 6 to 12 months.

PATIENTS AND METHODS

Sixty patients with recurrent bilateral nasal polyps underwent functional endoscopic sphenoethmoidectomy and were then randomly allocated into 2 groups of 30 patients each. One group received beclomethasone dipropionate spray (100 micrograms in each nostril every 12 hours), and the other group received fluticasone propionate spray (100 micrograms/d in each nostril).

RESULTS

In the fluticasone propionate group, 6 patients (20%) developed acute gram-positive pansinusitis requiring hospitalization and discontinuation of treatment.

CONCLUSION

The use of fluticasone dipropionate aqueous nasal spray for the postoperative control of recurrent nasal polyps seems to be associated with a high incidence of acute pansinusitis.