The significance of vascular loops in the internal auditory meatus: a true incidental imaging finding?

PURPOSE: To determine the clinical significance of vascular loops (VL) in the internal auditory meatus (IAM) and cerebellopontine angle (CPA). METHODS: We carried out a retrospective case series in a tertiary referral centre. Out of 6978 patients undergoing magnetic resonance imaging (MRI) of the IAM for unilateral cochleovestibular symptoms we identified the ones with VLs and reviewed their medical notes. We performed a statistical correlation between the laterality of the VL in the IAM/ CPA as graded according to the Chavda classification (type 1 in the CPA, type 2 extending in the IAM, type 3 extending to the distal IAM end), the laterality of symptoms and the patient's age. RESULTS: A total of 77 VL were identified in 64 patients (0.9%); 39 patients had the VL on the same side of the main symptom, while 25 patients had the VL on the contralateral side. There were 37 Type 1 loops, 29 Type 2 loops and 11 Type 3 loops. The comparison between the grading of the VL and the laterality of symptoms did not reach the level of significance (p = 0.321). There was also no association between the presence of the loop and the patients' age (p = 0.5). All patients were reassured and discharged without any representation in three years follow-up. CONCLUSIONS: We did not identify any significant correlation between the laterality of VLs and the laterality of symptoms, irrespective of the grading of the loop or the patients' age. Such VLs should be considered an incidental rather than causal findings.

Intramural oesophageal abscess: an unusual complication of tonsillitis.

Tonsillitis is an extremely common condition, usually it is self-limiting, of viral origin, and managed conservatively in general practice. Rarely patients require inpatient management, usually when bacterial infection is present or when the cause is virulent organisms such as Epstein Barr virus. Complications can be divided into non-suppurative; sepsis, scarlet fever, rheumatic fever, glomerulonephritis and Lemierres disease, and suppurative; quinsy, parapharyngeal abscess and retropharyngeal abscess, respectively. Anecdotally, there is concern that modern medical practice that counsels vigilance against overuse of antibiotics, could lead to increased complications of tonsillitis. We report a case of an otherwise healthy man who presented with dysphagia, odynophagia and neck pain following a sore throat. Despite antibiotic treatment he developed an intramural oesophageal abscess, to our knowledge, an unreported complication of tonsillitis.

Lemierre's syndrome: a rare cause of sepsis presenting with an absence of throat symptoms.

A 16-year-old boy presented to hospital with a 6-day history of diarrhoea, vomiting and abdominal pain. During his admission he was found to be hypotensive, tachycardic and persistently feverish. Blood cultures taken on admission isolated Fusobacterium necrophorum CT scanning of his neck showed a non-occlusive thrombus of the right internal jugular vein and a small right parapharyngeal abscess. CT scans of the chest and abdomen revealed multiple pulmonary abscesses, bilateral pleural effusions and splenomegaly. Treatment consisted of an unfractionated heparin infusion and intravenous antibiotics. A right-sided intercostal drain was inserted for a complex right-sided empyema. He subsequently developed a left-sided pleural effusion which was treated with a video-assisted thoracoscopic surgery (VATS) pleurodesis procedure. His fever resolved after his VATS pleurodesis procedure 3 weeks after initial presentation. Clinically he made a slow recovery but now is improved after 6 weeks of intravenous antibiotics and was discharged home.

Paraganglioma of the skull base presenting as nasal polyps.

The authors report a case of paraganglioma of the skull base presenting as nasal polyps. A 29-year-old patient presented with epistaxis and was found to have nasal polyps. The patient underwent a nasal polypectomy. After pathology showed an unusual appearance, the mass was subsequently excised endoscopically using radiofrequency coblation, and it was found to be originating from the skull base. The diagnosis was made using a combination of clinical findings, radiology, and histopathology examination. It is important to consider paraganglioma in the differential diagnosis of unusual tumors of the nose and skull base.