Individual prefabricated titanium implants and titanium mesh in skull base reconstructive surgery. A report of cases.

Titanium implants can be shaped by traditional hand forming, press shaping, modular construction by welding, construction on full-size models shaped from CT coordinates and, most recently, by computer-assisted design and computer-assisted manufacturing (CAD/CAM) that consist in the direct prefabrication of individual implants by milling them out of a solid block of titanium. The aim of our study was to present a set of preliminary cases of an ongoing program of reconstructive procedures of the skull base using titanium implants. The subjects underwent ablative procedures of the skull base with reconstruction either by titanium mesh or individual prefabricated CAD/CAM implants. Six patients have been operated on successfully since 2000: two received prefabricated CAD/CAM titanium plates and four others underwent reconstruction with titanium mesh. The stability of CAD/CAM plates is superior to that of mesh, thus it is more useful in reconstructing large lesions of the frontal skull base and the temporal and occipital bones. Titanium mesh was successfully used for defects smaller than 100 cm(2) or where selected viscerocranial defects are complicated in design and less reproducible by CAD/CAM. The intraoperative design, shaping and adjustment characteristic of titanium mesh can be dispensed with when CAD/CAM implants are used. The 3-D data set used in the CAD/CAM process also operates in the navigated simulation and planning of the ablation contours, the latter being of great assistance in establishing the optimal future defect. As a disadvantage, CAD/CAM technology is more expensive than titanium mesh, and the process is time-consuming as it is carried out in advance of surgery.

[PFAPA Syndrome: Current Standard of Knowledge and Relevance for the ENT Specialist]. / Das PFAPA-Syndrom: Aktueller Wissensstand und Bedeutung für den HNO-Arzt.

BACKGROUND: The symptoms fever, aphthous stomatitis, pharyngitis and cervical lymph node enlargement are among the most frequent complaints that particularly make children and adolescents consult an ENT specialist. In cases where these symptoms occur periodically, a PFAPA syndrome may be present. PATIENTS AND METHODS: We report on an atypical process in a 22 year old woman in whom the PFAPA syndrome first occurred during early infancy with recurrences since adolescence. RESULTS: Since the age of eight months the patient suffered from periodically occurring fever and pharyngitis with cervical lymph node enlargement. Therefore, by age four a tonsillectomy was performed and the symptoms disappeared. At age 15 similar symptoms occurred again with fever thrusts over approximately four to five days with temperatures up to 39.8 degrees C associated with pharyngitis, weakness and cervical lymphadenitis. Those symptoms relapsed periodically every four weeks. Treatment regimens with different antibiotics, Dimepranol and Inosin did not show any effect. Hyper-IgD syndrome and cyclic neutropenia were excluded. There were no signs for a humoral or cellular immune defect or a juvenile idiopathic arthritis. CONCLUSIONS: It is often very difficult to make the right diagnosis in a child or a young adolescent presenting with periodically occurring fever. So far the PFAPA syndrome is relatively unknown. Nevertheless, we think that it should be considered in the differential diagnosis by the ENT specialist patients with periodic fever, aphthous stomatitis, pharyngitis and cervical lymphadenopathy.

Coincident Warthin's tumor and intraparotid dermatopathic lymphadenopathy. Report of a case.

A 52-year-old patient underwent excision of a parotid lump which was fond to consist of a Warthin's tumor coexistent with a lymph node involved in dermatopathic lymphadenopathy. A preoperative fine-needle aspiration specimen contained brown pigment-granule-laden macrophages within the background of many lymphocytes. Failure to correctly diagnose the parotid tumor was likely due to a sampling error.

Cheilitis granulomatosa Miescher: treatment with clofazimine and review of the literature.

Cheilitis granulomatosa Miescher is a rare condition of unknown cause characterized by intermittent lip swelling that gradually persists and causes cosmetic deformity. We report the case of a young woman with cheilitis granulomatosa as a monosymptomatic manifestation of Melkersson-Rosenthal syndrome successfully treated by the antileprosy agent clofazimine, and propose clofazimine as an alternative treatment in cases refractory to corticosteroids. The differential diagnosis and current methods of treatment are summarized, and the literature is reviewed and discussed.

Malignant tumors of the nose and paranasal sinuses: a retrospective review of 291 cases.

Malignant neoplasms of the nose and paranasal sinuses are not common among the general population. We present a retrospective study of 291 cases of malignant tumors of the nose and paranasal sinuses that were diagnosed in a northern Romanian population over a period of 35 years. We review the etiology, diagnosis, prognosis, and treatment of these tumors.

The effects of noise on the vestibular system.

PURPOSE: Subjects with noise-induced hearing loss sometimes also complain about balance disorders, but reports of clinical series that give contradictory results are highly controversial. This study was designed to evaluate the effects of intense noise on the vestibular labyrinth, both in subjects with symmetrical hearing loss and in subjects with asymmetrical loss, and to examine the correlation between the subjects' complaints and the results of the vestibular function tests. METHODS: A total of 258 male military personnel, heavily exposed to various intense noises, were included in the study. They were divided into 2 groups according to their hearing; 134 had a symmetrical high-tone hearing loss, and 124 had asymmetrical losses. Each group was divided into 2 subgroups according to the presence or absence of vestibular complaints. All of the subjects underwent a complete audiological and electronystagmographic evaluation. RESULTS: We found that vestibular damage caused by intense noise exposure might be expressed clinically in subjects with asymmetrical hearing loss. There was a strong correlation between the subjects' complaints and the results of the vestibular function tests. There was no correlation between the severity of the hearing loss and the vestibular symptomatology and pathology. CONCLUSIONS: Subjects exposed to intense noise may have evidence of vestibular pathology only when there is an asymmetrical hearing loss. Whenever hearing loss is symmetrical, an equal damage to the vestibular system of both ears is most probably responsible for the absence of abnormal findings on the vestibular function tests. The results of this study have important medicolegal implications for individuals exposed to intense noises.

Epiglottic tuberculosis: differential diagnosis and treatment. Case report and review of the literature.

A case of a 40-year-old man with tuberculous involvement of the epiglottis suffering from unsuspected pulmonary tuberculosis is described. The laryngeal lesions were primarily considered to be highly suspicious for a neoplastic process rather than an infectious one. After diagnosis, the patient was treated according a standard protocol and followed up for a period of 2 years. He is still free of disease. The clinical presentation, diagnosis, pathological findings, and therapy of the condition are described. The differential diagnosis and management of epiglottic tuberculosis are reviewed and discussed. Even though these cases are rare, otorhinolaryngologists should keep in mind the possibility of tuberculosis in the differential diagnosis of laryngeal tumors, as the incidence of tuberculosis in developed countries is steadily increasing.

Tinnitus as a prognostic sign in idiopathic sudden sensorineural hearing loss.

Idiopathic sudden sensorineural hearing loss remains a controversial problem with respect to etiology and the factors that might predict a favorable prognosis. This study evaluated the possible prognostic factors of recovery in 67 patients with idiopathic sensorineural hearing loss treated with steroids (prednisone), plasma expanders (intravenous dextran), and vasodilators (papaverine). Clinical recovery was estimated by contrasting the audiometric results on admission and those at discharge 10 days later. The correlation between various potential prognostic factors and audiological improvement was calculated. Only two factors were found to be associated significantly with hearing improvement: tinnitus (p < .04) and the slope of audiogram on admission (p < .045). Tinnitus and the presence of an ascending audiogram were found to be correlated with a favorable outcome in idiopathic sensorineural hearing loss.

Laryngeal sarcoidosis: treatment with the antileprosy drug clofazimine.

Sarcoidosis is a chronic systemic granulomatous disease that occasionally affects the larynx. When the larynx is affected, the symptoms are frequently mild, but severe airway obstruction can occur. Although systemic corticosteroids are helpful, patients may become refractory to further drug administration. The current methods of treatment are here summarized, and the patient literature is reviewed. We also report a case of a young patient suffering from laryngeal sarcoidosis successfully treated by the antileprosy agent clofazimine and propose it as an alternative treatment of laryngeal sarcoidosis in patients refractory to corticosteroids.

Inferior turbinectomy versus submucosal diathermy for inferior turbinate hypertrophy.

In order to compare and evaluate bilateral inferior turbinectomy (BIT) and submucosal diathermy (SMD), we retrospectively examined these two well-known techniques for treatment of nasal obstruction due to bilateral congestion of the inferior turbinates. One hundred patients with bilateral nasal obstruction were divided into 4 groups according to their nasal airflow patency. Forty-nine patients underwent BIT, and 51 patients underwent SMD. All 100 patients were followed for 2 months after surgery. Patients with difficult postoperative courses were followed up to 1 year after surgery, in order to decide on the necessity of operative revision. Postoperative improvement in nasal breathing after BIT was reported for 96% of patients 2 weeks after surgery, and for 88% 2 months after surgery. Only 1 BIT patient had to undergo revision operation. Diathermy showed good results in 78% of cases 2 weeks after surgery. The efficacy of the procedure was reduced to 76% 2 months after surgery. Twenty percent of SMD patients were advised to undergo operative revision. Postoperative bleeding occurred in 20% of BIT patients and in only 4% of SMD patients. We found that the extent of postoperative improvement does not depend on preoperative conditions; therefore, it is impossible to predict the extent of postoperative improvement on the basis of the results of preoperative assessment. Both procedures can be performed under local anesthesia, are relatively safe and effective, and do not need expensive instrumentation that may not be available in many medical centers.

Cat-scratch disease of the parotid gland: an often-misdiagnosed entity.

A case of cat-scratch disease involving the parotid area in a young adult is presented. Thanks to meticulous history-taking, the correct diagnosis was suggested and later established, thus preventing unnecessary surgery. The pertinent literature is discussed.

Pneumomediastinum due to Venturi jet ventilation used during microlaryngeal surgery in a previously neck-irradiated patient.

Serious complications secondary to Venturi jet ventilation used during microlaryngoscopy are rare, but when they occur, they may pose a life-threatening emergency. We report the case of a 45-year-old woman, previously treated with 70 Gy of irradiation for a T1 laryngeal carcinoma, who developed pneumomediastinum and subcutaneous emphysema after the use of Venturi jet ventilation. Keeping in mind the histologic changes to the irradiated structures, we suggest more caution when using Venturi jet ventilation in patients who have recently undergone neck irradiation therapy.

Cholesteatomas associated with ventilation tube insertion.

OBJECTIVES: To determine the incidence of cholesteatoma formation associated with ventilation tube (VT) placement and to identify and analyze the variables and risk factors that may predict or predispose to this complication. DESIGN: We reviewed the medical records of 2829 children following VT insertion between the years 1978 and 1997 to obtain 1- to 20-year follow-up data. SETTING: Departments of Otolaryngology-Head and Neck Surgery and outpatient clinics of 2 tertiary referral academic medical centers. PATIENTS: A study population of 2829 children, ranging in age from 1.2 to 14 years (5575 ears), underwent a total of 6701 VT placements. MAIN OUTCOME MEASURE: Cholesteatomas were considered a complication of VT placement whenever they developed at or near the site of the tube insertion. RESULTS: Cholesteatomas directly attributed to VT placement occurred in 1.1% of the ears that were operated on. A higher incidence occurred (1) in children younger than 5 years, (2) when Goode T-tubes were used, (3) in cases with repeated insertions of tubes, (4) with intubation exceeding 12 months, and (5) in cases with frequent post-operative otorrhea. CONCLUSIONS: Cholesteatoma formation associated with VT placement occurs in 1.1% of the ears that are operated on, and therefore it should be discussed with patients or parents prior to surgery. Periodic and long-term follow-up microscopic examinations of the eardrum should be performed in all patients following tubal extrusion or removal, especially in those at high risk for developing a secondary cholesteatoma, to detect this complication as early as possible.

Effect of caudal block on the plasma adrenaline and noradrenaline concentrations in paediatric patients undergoing ilioinguinal herniorrhaphy.

This study compared the effect of two anaesthetic techniques on the catecholamine levels in children undergoing ilioinguinal herniorrhaphy. Forty male paediatric patients ASA class I were allocated randomly to one of two groups: the control group (n = 20) received general anaesthesia including intravenous fentanyl; and the caudal group (n = 20) received caudal anaesthesia with bupivacaine 0.25% 1 mL kg-1 combined with general anaesthesia but without opioids. Plasma adrenaline and noradrenaline concentrations were measured at induction, at the end of surgery and in the post-anaesthesia care unit (PACU). In the caudal group, there were significant decreases in the adrenaline and noradrenaline concentrations at the end of surgery and in the PACU compared with baseline concentrations. In the control group, there was a significant increase in PACU concentrations of adrenaline and noradrenaline compared with baseline concentrations. These findings suggest that the addition of a caudal block to general anaesthesia in children undergoing ilioinguinal herniorrhaphy decreases significantly the neurohormonal responses to surgery.

Diagnostic and therapeutic management of bilateral carotid artery occlusion caused by near-suicidal hanging.

In cases of attempted suicide by hanging, a combination of mechanisms causing local destruction of the pharynx, larynx, vessels, and spine, as well as neurologic complications, has to be considered. We present a case of hanging in which a deeply unconscious patient without any palpaple pulsation of the carotid arteries was referred to our otolaryngology department. Computed tomography and angiography showed parapharyngeal air, complete obstruction of both common carotid arteries, and a compensatory circulation through the vertebral arteries. Three hours after the trauma, surgical exploration with resection of the enrolled intima of both carotid arteries and repair of the pharynx was performed. The patient awoke with an infarct of the right hemisphere with incomplete left hemiparesis the next day, but symptoms slowly declined during the following months, and the patient learned swallowing again perfectly. We conclude from our experience that in near-hanged patients a prompt onset of adequate diagnostic and therapeutic measures is mandatory, as good neurologic and functional results may occur even in cases with coma and severe destruction of the carotid arteries and pharyngeal and laryngeal structures. Surgical repair of blunt carotid lesions is recommended and may be crucial for a good outcome.