Endoscopic Anatomy of the Tensor Fold and Anterior Attic.

Objectives The objectives of the study were to (1) study the anatomical variations of the tensor fold and its anatomic relation with transverse crest, supratubal recess, and anterior epitympanic space and (2) explore the most appropriate endoscopic surgical approach to each type of the tensor fold variants. Study Design Cadaver dissection study. Setting Temporal bone dissection laboratory. Subjects and Methods Twenty-eight human temporal bones (26 preserved and 2 fresh) were dissected through an endoscopic transcanal approach between September 2016 and June 2017. The anatomical variations of the tensor fold, transverse crest, supratubal recess, and anterior epitympanic space were studied before and after removing ossicles. Results Three different tensor fold orientations were observed: vertical (type A, 11/28, 39.3%) with attachment to the transverse crest, oblique (type B, 13/28, 46.4%) with attachment to the anterior tegmen tympani, and horizontal (type C, 4/28, 14.3%) with attachment to the tensor tympani canal. The tensor fold was a complete membrane in 20 of 28 (71.4%) specimens, preventing direct ventilation between the supratubal recess and anterior epitympanic space. We identified 3 surgical endoscopic approaches, which allowed visualization of the tensor fold without removing the ossicles. Conclusions The orientation of the tensor fold is the determining structure that dictates the conformation and limits of the epitympanic space. We propose a classification of the tensor fold based on 3 anatomical variants. We also describe 3 different minimally invasive endoscopic approaches to identify the orientation of the tensor fold while maintaining ossicular chain continuity.

Not all that vesicles is herpes.

BACKGROUND: Eczema coxsackium (EC) can manifest in patients with underlying atopic dermatitis (AD) as a diffuse vesicular rash in a febrile child. The presentation overlaps clinically with the feared diagnosis of eczema herpeticum (EH), which makes differentiating between the conditions very important. CASE PRESENTATION: A 6-month-old girl with known AD presented with fever and rapidly spreading vesicular rash. The patient had multiple exposures including a new antibiotic prescription, introduction of new foods, 6-month vaccinations and a sick contact. She was treated empirically with acyclovir for EH until herpes simplex virus (HSV) polymerase chain reaction (PCR) returned negative and enterovirus PCR returned positive. Once the diagnosis of EC was confirmed, antiviral therapy was discontinued and she was treated successfully with supportive measures without sequelae. CONCLUSIONS: Differentiating EC from EH is important clinically as EC is self-limiting and resolves spontaneously whereas EH may cause severe complications if not treated early. While morphology alone cannot reliably distinguish between the conditions, clinical suspicion based on history can prompt proper testing and improve patient outcomes.