False-positive positron-emission tomography-CT of a Teflon granuloma in the parapharyngeal space occurring after treatment for a patulous eustachian tube.

This report presents a 55-year-old woman who underwent 2 Teflon injections in 1971 for a patulous eustachian tube. The patient returned in 2006 with a bloody left otorrhea. A positron-emission tomography-CT scan demonstrated a 2-cm hypermetabolic parapharyngeal mass, initially interpreted as a skull base tumor. Repeat neck CT confirmed a 2-cm hyperattenuated left parapharyngeal granulomatous mass. This is the first reported case of a Teflon granuloma presenting as a false-positive parapharyngeal mass.

Combined cytoreductive laser therapy and immunotherapy for palliation of metastatic renal cell carcinoma to the head and neck.

Interleukin-2 (IL-2) remains the mainstay of treatment for metastatic renal cell carcinoma (RCC), but minimally invasive surgical techniques have provided new options for the combined treatment of RCC. Two patients with metastatic RCC to the head and neck treated by combined laser-induced thermal therapy and IL-2 were described in this case report. Both patients had an extended survival compared to the historical survival of 10 months for metastatic RCC but eventually succumbed to progressive disease. The authors' initial experience with metastatic RCC suggests that laser thermoablation and immunotherapy in selected patients with metastatic RCC is warranted as a palliative treatment, but a larger study with long-term follow-up is necessary to determine the effectiveness of this approach.

Otological manifestations of Churg-Strauss syndrome.

OBJECTIVES/HYPOTHESIS: To describe the clinical features, pathogenesis, and management of the otological complications in Churg-Strauss syndrome (CSS). STUDY DESIGN: Retrospective review of five patients with documented CSS who had otological manifestations in the later stages of CSS. METHODS: The history, treatment, and outcome were evaluated using office and hospital chart data in these five cases. RESULTS: In all cases, otological manifestations occurred during an advanced stage of CSS and was characterized by the presence of dense aural discharge, granulomatous eosinophilic infiltration into mastoid and middle ear, and subacute severe to profound hearing loss. In all cases, the recurrent aural discharge and granulomatous infiltrate was unresponsive to conventional treatment including repeated myringotomies and aggressive antibiotics. Systemic steroid administration resulted in a rapid, complete cessation of aural discharge and reversal or stabilization of hearing loss. Otological manifestations have been stable over a range of follow-up from 1 to 20 years on a maintenance regimen of steroids. CONCLUSIONS: Temporal bone involvement in CSS is rare. Surgical intervention of the temporal bone is relegated to complications that may include infectious mastoiditis and intracranial involvement. Recognition of the association between CSS and otological disease is important because it is highly responsive to systemic steroids, and early steroid treatment may prevent progression to irreversible hearing loss, infectious otomastoiditis, or intracranial complications.

An interpretation of the structural changes responsible for the chronicity of rhinoscleroma.

OBJECTIVE: To identify the structural changes of the proliferative phase of rhinoscleroma which could be responsible for the chronicity of the disease. STUDY DESIGN: Observational research. METHODS: Samples of friable tissue taken from the nasal mucosa of nine untreated patients were processed for light and ultrastructural microscopy. RESULTS: The majority of changes contributing to the chronicity of the disease occurred in the subepithelium and followed three closely related but distinct events. In the first (infiltrative), subepithelial invasion by the Klebsiella was followed by its active multiplication and proliferation of capillaries. In the second (neutrophilic), large numbers of neutrophils were delivered into this space. Neutrophils actively phagocytized the Klebsiella but appeared to die at an accelerated rate without completing digestion of the microorganisms. In the third event (histiocytic), histiocytes entered the subepithelium and engaged in unrestrained phagocytosis of decaying neutrophils, Klebsiella, and debris. During this process, the histiocytes' phagosomes underwent massive dilation, thus becoming Mikulicz cells. Mikulicz cells were unable to consistently destroy the Klebsiella and eventually ruptured, releasing them into the interstitium. Evidence was found that an autophagic process might contribute to phagosome distention and to the rupture of the vacuolar membranes and cell wall. CONCLUSIONS: Several critical changes responsible for the chronicity of rhinoscleroma occur during the proliferative phase of the disease. The majority of these take place in the subepithelium and include: 1) factors leading to the transformation of histiocytes into Mikulicz cells, 2) the inability of these cells to consistently destroy the Klebsiella, 3) their rupture releasing viable Klebsiella, and 4) the intrinsic resistance of the pathogen.

Antonio Scarpa and the discovery of the membranous inner ear.

OBJECTIVE: To give a historical perspective of Antonio Scarpa's contributions to otology, specifically the discovery of the inner ear organs as the foundation for the experimental work that followed. BACKGROUND/METHOD: Scarpa's original descriptions of the human inner ear were translated from the Latin text, and his illustrations were analyzed and compared with current knowledge. CONCLUSIONS: Antonio Scarpa's anatomic and clinical studies place him among the great scientists of the eighteenth century. His discoveries about the inner ear established the limit of what could be learned without advanced histologic techniques and provided the foundation for the work that eventually led to the modern understanding of ear physiology.

Retrolabyrinthine vestibular nerve section: a current appraisal.

We report our experience (1987-1993) with Meniere's disease patients treated with a retrolabyrinthine vestibular neurectomy. The current literature was reviewed and our results have been compared with those of previous reports. The overall success rate for vertigo relief was 96.7%, with no serious or permanent complications resulting from the procedure. The technical elements of the operation, as they apply to our approach and those of others, have been analyzed, with special attention given to the anatomical features of the region and their influence on success or failure. We conclude that the retrolabyrinthine approach for vestibular nerve section remains a safe and highly successful technique which merits continued use.

Recurrent pleomorphic adenoma of the parotid gland involving the osseous external auditory canal. With a note on the foramen of Huschke.

A recurrence of a parotid pleomorphic adenoma presenting as an external ear canal mass is reported. The route of extension was radiographically documented as an incompletely closed foramen of Huschke. The historical and developmental features of this foramen and the mechanisms of tumor extension as they relate to it are discussed.

Rhinocerebral mucormycosis: evolution of the disease and treatment options.

Rhinocerebral mucormycosis is recognized as a potentially aggressive and commonly fatal fungal infection. The classic presentation is involvement of nasal mucosa with invasion of the paranasal sinuses and orbit. Mucormycosis is most commonly seen in association with diabetic ketoacidosis, but disease demographics have changed with the onset of AIDS and the advent of powerful immunosuppressive drugs. Treatment includes aggressive debridement, systemic antifungal therapy, and control of underlying comorbid factors. Although surgical intervention remains essential, advances in medical therapy have permitted a more limited surgical approach to minimize functional loss without compromising survival. We present the UCLA experience with rhinocerebral mucormycosis from 1955 to 1995, with emphasis on the evolution of disease presentation and alternative treatment options.

Cryptococcosis presenting as a neck mass.

A rare case of cryptococcal infection presenting as a neck mass in an otherwise healthy individual is reported. The mass resulted in lytic destruction of portions of the cervical vertebrae and produced a focal neurologic deficit in one of the upper extremities. Although other lesions in the skull, femur, and humerus were identified, no involvement of the lungs or central nervous system could be detected. The patient was initially treated with amphotericin B and flucytosine, but eventually also required fluconazole and surgical debridement for complete resolution of the infection. The diagnosis, treatment, and manifestations of cryptococcosis in the head and neck are discussed.

The effect of periosteal preservation on osteogenesis in a canine rib autograft model: tetracycline fluorescence incident photometry.

In the first portion of this study, we describe a new technique, tetracycline fluorescence incident photometry (TFIP) for quantifying new bone formation. In this portion, we use routine histology, Microfil vascular injection, and tetracycline incidence fluorescence (TFIP) to determine the effect of periosteal preservation on bone formation in canine rib autografts. We found that periosteal preservation significantly enhanced new bone formation in both cortical and trabecular bone (83-70% of control) when compared with autografts without the periosteum (76-60% of control) (p < 0.05). In addition, periosteal preservation favorably influenced graft revascularization. We found that the periosteum of the transferred rib autografts was made up of 3 distinct layers: (1) the inner (cambial) layer of osteogenic cells, (2) the middle (fibrous) layer of osteogenic reserve cells, and (3) the outer vascular network of arterioles and venules, which communicate with the trabecular vessels internally. This outer vascular network has not been previously described in transferred bone grafts and is responsible for early graft revascularization.

The petrosal approach with hearing preservation.

Twenty-six patients with petroclival lesions were operated on via a petrosal approach designed to preserve hearing. The surgical pathology included 14 meningiomas, three chordomas, three epidermoid cysts, four vertebrobasilar aneurysms, and two pontine cavernous malformations. The approach allowed complete resection of 14 of 20 tumors and definitive treatment of all six vascular lesions. Complications included cerebrospinal fluid leakage in three patients, high-frequency sensorineural hearing loss in three, meningitis in one, and cranial nerve palsies (which were usually transient). This approach allows a wide exposure of the petroclival region with decreased operating distance. Cerebellar and temporal lobe retraction are minimized, dural sinus patency is maintained, and the inner ear structures are not sacrificed. The approach is suitable for neoplastic or vascular lesions involving the petroclival region, the ventral pons, or the basilar artery trunk. The surgical technique, indications, and neuro-otological considerations are discussed.

Magnetic resonance imaging-guided fine needle aspiration for the diagnosis of skull base lesions.

Magnetic resonance imaging (MRI)-guided fine needle aspiration was used to obtain tissue from lesions of the skull base for cytologic diagnoses in 14 patients. Our technique utilized a guiding system to enable three-dimensional orientation in a two-dimensional scan and a high nickel content 22 gauge needle to minimize significantly MRI artifact. Needle access to the skull base was provided through a subzygomatic or retromandibular approach. In seven of nine cases an accurate diagnosis was established by this technique and later confirmed by surgical exploration and histologic analysis. Failure to obtain a representative specimen from the lesion occurred in one case and difficulty in interpreting the cytologic features of the tissue was encountered in another case. The indications, limitations, and technical details of the procedure are described.

Nonneoplastic enhancing lesions mimicking intracanalicular acoustic neuroma on gadolinium-enhanced MR images.

The authors describe five patients with nonneoplastic lesions of the facial and/or vestibulocochlear nerves that demonstrated focal enhancement within the internal auditory canal on magnetic resonance (MR) images. MR and surgical findings for four patients with unilateral sensorineural hearing loss and one with Ramsay Hunt syndrome were reviewed. Three patients with hearing loss underwent surgical exploration and decompression of the internal auditory canal. The MR findings in all four patients with hearing loss were similar: Focal enhancement of the internal auditory canal was depicted on postcontrast T1-weighted images. Nonneoplastic lesions of the seventh and eighth cranial nerves may show focal enhancement on MR images, which mimics the appearance of a small intracanalicular neuroma. This potential for misdiagnosis may have important therapeutic implications.

Auditory screening of infants.

Within the last 20 years, infant hearing screening has progressed from a laudable goal to a state-mandated reality in many areas of the United States. The high risk register provides a means by which history and neonatal physical examination can be used to identify the infant at risk for hearing loss. Two procedures (crib-O-gram and auditory brainstem-evoked response) have been the most common methods of screening for hearing loss in the newborn or in intensive care nurseries. Evoked cochlear emissions reportedly are identifiable in 90 to 100% of normal-hearing infants. This observation has lead to the use of evoked otoacoustic emissions as a hearing screening procedure with infants.

Early structural changes in vascularized periosteal flaps studied in situ.

This study examines the very early stages of osteogenesis in vascularized periosteal flaps and completes a characterization of their behavior after decortication. Pleuroperiosteal flaps based on the intercostal artery were developed in nine dogs and studied in situ by histologic and tetracycline fluorescence methods over periods varying from 1 to 7 days. The earliest changes were noted at 72 hours and were characterized by cellular and capillary proliferation, osteoid deposition, and bright fluorescence. The potential function of retained osseous spiculae was investigated separately. It was concluded that microscopic fragments of mature bone trapped within the flaps appear to assist and consolidate new bone formation.

Extended retrolabyrinthine transtentorial approach to petroclival lesions.

In this communication, an extension of the retrolabyrinthine approach that has permitted safe, effective access to the petrous tip and clivus is presented. The basic technique involved complete mastoidectomy, preservation of the middle and inner ear structures, removal of the sigmoid and middle fossa plates, middle and posterior fossa craniotomies, ligation of the superior petrosal sinus, and division of the tentorium. Nine cases that exemplified the versatility of this approach constituted the basis of this paper: 2 cholesteatomas, 2 basilar artery aneurysms, 2 chordomas, and 3 meningiomas. The indications for, and complications of, this method have been discussed.