Nasal nerve ablation, nasal swell body and inferior turbinate reduction for nasal obstruction and congestion relief.

OBJECTIVE: Nasal obstruction and congestion can occur because of turbinate and septal variations with or without rhinitis. A combined treatment for nasal obstruction and congestion was examined retrospectively in cases where the nasal swell body was addressed with inferior turbinectomy, with or without posterior nasal nerve ablation. METHODS: A 940 nm laser was utilised for contact (nasal swell body, septum and inferior turbinate) and non-contact (posterior nasal nerve) ablation. Total Nasal Symptoms Score, visual analogue scale pain score, complications and procedure location (office vs operating theatre) were recorded. RESULTS: All 242 patients underwent nasal swell body reduction with inferior turbinate reduction, and 150 had posterior nasal nerve ablation also. No laser complications were observed. An 80 per cent reduction in medication usage was noted. Total Nasal Symptoms Score decreased by 73 per cent; rhinorrhoea and congestion scores decreased by 54 per cent and 81 per cent respectively. Crusting, epistaxis and infections were minimal, and resolved within two weeks. CONCLUSION: Nasal swell body with inferior turbinate reduction, with or without posterior nasal nerve ablation, is a new method of treating nasal obstruction and congestion. Laser posterior nasal nerve ablation can be utilised as a complementary tool to deliver anatomical obstruction relief.

Intravenous thrombolysis for patients with in-hospital stroke onset: propensity-matched analysis from the Safe Implementation of Treatments in Stroke-East registry.

BACKGROUND AND PURPOSE: Recent cross-sectional study data suggest that intravenous thrombolysis (IVT) in patients with in-hospital stroke (IHS) onset is associated with unfavorable functional outcomes at hospital discharge and in-hospital mortality compared to patients with out-of-hospital stroke (OHS) onset treated with IVT. We sought to compare outcomes between IVT-treated patients with IHS and OHS by analysing propensity-score-matched data from the Safe Implementation of Treatments in Stroke-East registry. METHODS: We compared the following outcomes for all propensity-score-matched patients: (i) symptomatic intracranial hemorrhage defined with the safe implementation of thrombolysis in stroke-monitoring study criteria, (ii) favorable functional outcome defined as a modified Rankin Scale (mRS) score of 0-1 at 3 months, (iii) functional independence defined as an mRS score of 0-2 at 3 months and (iv) 3-month mortality. RESULTS: Out of a total of 19 077 IVT-treated patients with acute ischaemic stroke, 196 patients with IHS were matched to 5124 patients with OHS, with no differences in all baseline characteristics (P > 0.1). Patients with IHS had longer door-to-needle [90 (interquartile range, IQR, 60-140) vs. 65 (IQR, 47-95) min, P < 0.001] and door-to-imaging [40 (IQR, 20-90) vs. 24 (IQR, 15-35) min, P < 0.001] times compared with patients with OHS. No differences were detected in the rates of symptomatic intracranial hemorrhage (1.6% vs. 1.9%, P = 0.756), favorable functional outcome (46.4% vs. 42.3%, P = 0.257), functional independence (60.7% vs. 60.0%, P = 0.447) and mortality (14.3% vs. 15.1%, P = 0.764). The distribution of 3-month mRS scores was similar in the two groups (P = 0.273). CONCLUSIONS: Our findings underline the safety and efficacy of IVT for IHS. They also underscore the potential of reducing in-hospital delays for timely tissue plasminogen activator delivery in patients with IHS.

Benefit of thrombolysis for stroke is maintained around the clock: results from the SITS-EAST Registry.

BACKGROUND AND PURPOSE: The outcome of thrombolysis for early morning and sleep time strokes may be worse because of uncertainty of stroke onset time or differences in logistics. The aim of the study was to analyze if stroke outcome after intravenous thrombolysis differs depending on time of day when the stroke occurs. METHODS: The data collected in the Safe Implementation of Treatments in Stroke - Eastern Europe (SITS-EAST) Registry between September 2000 and December 2011 were used. Strokes were categorized as night-time 00:00-07:59, day-time 08:00-15:59 and evening-time 16:00-23:59 and were compared in terms of several outcome measures. All results were adjusted for baseline differences. RESULTS: A total of 8878 patients were enrolled: 18% had night-time, 54% day-time and 28% evening-time strokes. Onset-to-treatment time in patients with night-time strokes was 10 min longer than in day-time and evening-time strokes (P < 0.001). Symptomatic intracerebral hemorrhage by ECASS II definition occurred in 5.6%, 5.6% and 5.3% (adjusted P = 0.41) of the night-time, day-time and evening-time stroke patients, respectively; by SITS definition it occurred in 2.5%, 1.9% and 1.3% (adjusted P = 0.013) and by NINDS definition in 7.8%, 7.6% and 7.5% (adjusted P = 0.74). Patients with night-time, day-time and evening-time strokes achieved modified Rankin Scale score 0-1 in 33%, 31%, 31% (adjusted P = 0.34) and 0-2 in 52%, 51%, 50% (adjusted P = 0.23), and 13%, 15%, 16% respectively of patients died (adjusted P = 0.17) by 3 months. CONCLUSIONS: The time when stroke occurs (day versus evening versus night) does not affect the outcome after thrombolysis despite the fact that patients with night-time strokes have worse time management.

Methicillin-resistant Staphylococcus aureus bacteraemia associated with Lemierre's syndrome: case report and literature review.

BACKGROUND: Community-acquired methicillin-resistant Staphylococcus aureus is a growing health concern. Lemierre's syndrome is a septic jugular thrombophlebitis that primarily affects young adults. This paper aimed to identify a possible sub-group of Lemierre's syndrome cases associated with community-acquired methicillin-resistant Staphylococcus aureus. METHOD: This paper reports the case of a 16-year-old male who was admitted for increasing fever, tachycardia, tachypnoea and neck pain. The patient was diagnosed with methicillin-resistant Staphylococcus aureus bacteraemia associated with Lemierre's syndrome. A literature review was subsequently conducted. RESULTS: Following intravenous antibiotic treatment and the sterilisation of blood cultures, the patient improved. The literature review indicated a rise in the past 2 years of Lemierre's syndrome associated with methicillin-resistant Staphylococcus aureus among patients less than 18 years of age. CONCLUSION: Community-acquired methicillin-resistant Staphylococcus aureus bacteraemia can lead to pulmonary sequelae. When it is associated with pharyngitis, nasopharyngitis or parapharyngeal lymphadenitis, the affected patient may be predisposed to Lemierre's syndrome. As bacterial carriage is predominantly nasal, pharyngitis may not be present. Methicillin-resistant Staphylococcus aureus should be included as an offending bacterium where there is suspicion of Lemierre's syndrome. It is unclear whether anticoagulation alters the course of the bacterium, and surgery is probably contraindicated.

Image-guided keyhole evacuation of spontaneous supratentorial intracerebral hemorrhage.

INTRODUCTION: Treatment of spontaneous supratentorial intracerebral hemorrhage (SICH) is controversial. This study aims to evaluate the outcome and invasiveness of one surgical approach that provides complete evacuation of SICH, the image-guided keyhole evacuation. METHODS: The technique was employed in 20 consecutive patients, nine of whom harbored deep hematomas. The hematoma was evacuated through a keyhole minicraniotomy, 2.5 cm in diameter. Computerised tomographic (CT) scan was performed at the end of the procedure to confirm completeness of evacuation. Invasiveness was assessed by comparing initial neurological status determined by Glasgow Coma Scale (GCS) scores and National Institutes of Health Stroke Scale (NIHSS) scores with the third and seventh postoperative day scores, and by radiological findings. Outcome at six months was assessed by the Extended Glasgow Outcome Scale, and by comparing the initial and 6 month modified Rankin Scale scores. RESULTS: Mean age was 63.7+/-14.8 years, mean volume was 41.6+/-17.5 mL, and mean time to surgery was 17.6+/-13.2 h. CT scans at the end of the procedure showed complete evacuation (mean 97.5%), and 60% decrease of both mean midline shift and mean edema volume (p=0.005). Neurological assessment at the end of the first postoperative week showed significant improvement (p<0.0001). At six months, 90% of the patients had achieved recovery to independence, and one patient had died. CONCLUSION: The image-guided keyhole approach allowed prompt evacuation of SICH and resulted in a high rate of functional recovery and low mortality. This is a minimally invasive technique that is highly effective in immediate and complete hematoma evacuation.

Lethal photosensitization of oral pathogens via red-filtered halogen lamp.

UNLABELLED: OBJECTIVE OF INVESTIGATION: The ability of laser irradiation in the presence of photosensitizing agent to induce lethal effect on oral bacteria is well documented. We designed an in-vitro experiment to achieve phototoxic results on two common oral pathogens, using a high intensity, red filtered halogen lamp. Our goal was to determine the minimum duration of light exposure and drug dilution to achieve at least 50% reduction in bacteria counts. METHODS: Two common oral pathogens, Porphyromonas gingivalis and Prevotella intermedia were used in experiments. The source for light energy was a continuous working, high intensity, red filtered, halogen lamp (HL) with light transmitted through a flexible light guide over petri dishes containing live bacteria. Microorganisms were exposed to light for 5, 10 and 20 min. Methylene Blue (MB) in concentrations of 0.1, 0.075, 0.05, 0.025 and 0.01% was used as a photosensitizing agent. Light energy alone and MB alone was used as controls. RESULTS AND DISCUSSION: Optimum lethal photosensitization (50% or more bacteria killing) of oral pathogens was achieved using halogen light illumination for 5 min and longer with 0.05% MB or exposure to light for 20 min in the presence of 0.025 and 0.01% MB. Light exposure of 20 min in the absence of MB was not effective in killing bacteria. In the absence of light, MB at concentrations of 0.025 and 0.001% was not effective. Reduction of bacteria with the use of 0.05% MB alone was also insignificant. However, 0.075 and 0.1% MB, even in the absence of light was found to be bacteriocidal. CONCLUSIONS: Our in-vitro data indicate that we were able to achieve lethal photosensitization of two common oral pathogens with high intensity red filtered HL in the presence of diluted MB. In this era of increased incidence of antibiotic resistance, bacterial killing with laser or light energy in the presence of photosensitizing agent can prove to be a valuable treatment modality.

Stroke unit versus neurology ward--a before and after study.

INTRODUCTION: Few studies have tested the hypothesis of whether the beneficial effect of Stroke Units (SUs) can be reproduced in routine clinical practice and whether SU are also superior to neurological wards [NWs]. We aimed to compare the outcomes of patients of a newly implemented SU to the outcomes of patients hospitalized in a NW. METHODS: We made a before-after comparison of 352 SUs and 352 NWs patients after adjusting for case-mixes by the multivariate method. Subgroup analyses were also performed to evaluate which patient groups benefit the most. In-hospital case-fatality, proportion of independent patients at discharge, length of hospital stay (LOHS), medical complication rate were the main outcome measures. RESULTS: Adjusted in-hospital case fatality was significantly reduced in the SUs (OR: 0.44, 95 % CI: 0.26-0.76; p = 0.003). The proportion of independent patients at discharge and patients having medical complications was not different. Length of hospital stay was shorter in SU patients (13.76 days vs. 16.72 days, p = 0.003). Treatment in the SUs decreased case fatality in many subgroups [men, elderly, early admitted, severe stroke, co-morbidity present and ischemic stroke groups]. DISCUSSION: The results of randomized trials in favor of SUs can be reproduced in routine clinical practice. The benefit of SU care seems to be more apparent with advancing age and increasing stroke severity. Stroke Unit seems to be a better alternative to an experienced NW.

Endoscopic treatment of Zenker's diverticulum using CO2 laser.

OBJECTIVES: The objective of the present study was to review the technique of endoscopic laser-assisted esophagodiverticulostomy (ELAED) for the treatment of Zenker's diverticulum. METHODS: We reviewed 83 cases of ELAED performed for the treatment of Zenker's diverticuli during the past decade. RESULTS: ELAED-treated patients had a reduced hospital stay and were able to start an oral diet earlier than were patients who underwent other surgical procedures. Two (2.4%) of our patients developed small fistulas, which closed spontaneously. An additional 2 (2.4%) of our patients required conversion to an open approach due to inadequate endoscopic exposure, and 5 (6%) required a revision endoscopic procedure for persistent symptoms. CONCLUSIONS: Our series of 83 patients treated at 2 large academic centers during the past decade with an average follow-up of 4 years demonstrates that ELAED is a safe and effective procedure for the management of Zenker's diverticulum.

Internuclear ophthalmoplegia and cerebellar ataxia: report of one case.

Deep hemispheric or brainstem small infarcts can lead to atypical lacunar syndromes. Unilateral internuclear ophthalmoplegia (INO) and cerebellar ataxia has not been reported previously. A 57-year-old hypertensive female presented with bilateral appendicular and left truncal cerebellar ataxia and right INO. Cranial MRI showed a right paramedian infarct of lacunar size located in the tegmentum of caudal mesencephalon. At this level the involvement of medial longitudinal fascicle (MLF) led to right INO and the lesion of brachium conjunctivum caused the bilateral cerebellar ataxia. Ipsilateral involvement of both cerebellofugal fibers, before and after decussation, was responsible for bilateral cerebellar ataxia.

Venous infarction of brainstem and cerebellum.

The authors describe 2 cases of posterior fosa venous infarction. A 56-year-old woman with essential thrombocytemia presented with fluctuating complaints of headache, nausea, vomiting, left-sided numbness-weakness, and dizziness and became progressively stuporous. Cranial magnetic resonance imaging (MRI) showed bilateral parasagittal fronto-parietal and left cerebellar contrast-enhancing hemorrhagic lesions. On magnetic resonance venography, the left transverse and sigmoid sinuses were occluded. The second patient, a 39-year-old woman, presented with acute onset of diplopia, numbness of the tongue, vertigo, and right-sided weakness following a gestational age stillbirth. MRI revealed lesions in the right half of midbrain and pons and in the superior part of the right cerebellar hemisphere. Digital subtraction angiography showed right transverse and sigmoid sinus occlusion. The authors suggest that one should investigate the possibility of venous infarction in the presence of posterior fossa lesions that are often hemorrhagic and are not within any arterial territory distribution but respect a known venous drainage pattern. Recognition of the observed clinical and neuroimaging features can lead to earlier diagnosis and, potentially, more effective management.

Cerebral vasculitis and ischaemic stroke in Behçet's disease: report of one case and review of the literature.

INTRODUCTION: Behçet's disease (BD) is a multisystemic, recurrent, inflammatory disorder. Neurological involvement is well-known but cerebral vasculitis and ischaemic stroke are unusual. CASE DESCRIPTION: A 43-year-old male patient presented with acute left hemiparesis, he had recurrent oral aphthae and scrotal ulcerations. Two episodes of transient brainstem ischaemia and an episode of right hemiparesis were reported in the past 2 years. Cranial magnetic resonance (MR) imaging showed a right striatocapsular infarction and multiple segmental stenosis, fusiform enlargement and beading of the arteries of the polygone of Willis were seen on angiography. Cerebro-spinal fluid (CSF) examination disclosed lymphocytic pleocytosis. Skin pathergy test was positive. A diagnosis of BD with cerebral vasculitis was made and immunosuppressive therapy was started. Some improvement of the arterial lesions on MR angiography and normalization of CSF were observed after 1 year of treatment. DISCUSSION: Low grade chronic meningo-encephalitis is the core neuropathological process in neuro-Behçet's disease. Nevertheless BD is a systemic disease known to cause vasculitis and can exceptionally lead to cerebral vasculitis and brain infarction. While BD is usually not part of the differential diagnosis of cerebral vasculitis, it should be borne in mind especially in endemic areas of the disease and in patients from these areas.

Management of nasopharyngeal stenosis after uvulopalatoplasty.

OBJECTIVE: The objective of this study is to evaluate the management of nasopharyngeal stenosis (NPS) with the CO(2) laser and a customized nasopharyngeal obturator. STUDY DESIGN: An 8-year retrospective study based at a tertiary care teaching hospital consisting of 18 patients with NPS after uvulopalatoplasty treated over an 8-year period with the CO(2) laser and a nasopharyngeal obturator. Patients with grade I stenosis were treated in the office and did not require a nasopharyngeal obturator. More severe cases (grades II and III) were treated in the operating room and required a nasopharyngeal obturator. RESULTS: Eighteen patients with NPS, stages I to III, were treated with a CO(2) laser with or without a nasopharyngeal obturator with good results. CONCLUSION: The repair of NPS with a CO(2) laser and a nasopharyngeal obturator in severe cases helps in restoring nasopharyngeal patency. SIGNIFICANCE: This technique provided a reliable method of correcting postuvulopalatoplasty NPS.

Laser-assisted tympanostomy.

Laser-assisted tympanostomy (LAT) was performed in 70 ears to ventilate the middle ear space without using a pressure-equalizing tube. Using a CO2 laser attached to an operating microscope with a Microslad (microscope laser adaptor device), tympanostomies of 1.0 to 3.0 mm (average, 1.6 mm) in diameter were created and remained patent for an average of 3.14 weeks. Patency time was directly related to the size of the opening. Nearly all (97.9%) of the tympanostomies healed with no noticeable scarring and no persistent perforations. Seventy-eight percent of patients at the Florida Ear & Sinus Center (FESC, Sarasota, Fla.) and 84% of patients at the Head & Neck Surgery Group (New York) showed no evidence of recurrent effusion after a minimum follow-up of 3 months. LAT appears to be a safe, cost-effective procedure which can easily be performed in an office setting when bloodless opening in the tympanic membrane is needed for either treatment or diagnosis using endoscopes.

Nd:YAG laser turbinate surgery animal experimental study: preliminary report.

The chronically hypertrophic nasal turbinate is a challenging problem for otolaryngologists. Although some success has been achieved with a number of medical and surgical methods, other forms of treatment are still needed. In this study, encouraging results were achieved using the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser on canine turbinates. Clinical and histological results showed that with Nd:YAG laser surgery, coagulation occurs in the deep cavernous vessels and submucosal glands of the turbinate, while the overlying mucosa remains intact.

[Downbeat nystagmus and vertebrobasilar arterial dolichoectasia]. / Nystagmus battant vers le bas et dolichoectasie artérielle vertébrobasilaire.

A 66-year-old man presented with a downbeat nystagmus. The underlying cause was unknown. A dolichoectasia of the vertebrobasilar artery was the only identifiable abnormality at Magnetic Resonance Image which also disclosed distortion of the anterolateral aspect of the medulla. Compression of the caudal brain-stem by an enlarged and tortuous vertebrobasilar arterial system may be the cause of downbeat nystagmus in cases unassociated with the more commonly recognized causes.

Sarcoidosis of the sinonasal tract: a new staging system.

Sarcoidosis is a chronic multisystem granulomatous disease that has a predilection for pulmonary and upper respiratory tract involvement. Because the initial signs and symptoms of sarcoidosis may be identical to those of other forms of chronic sinonasal inflammatory disease, these patients will often first seek treatment from an otolaryngologist. We present a series of 28 patients whose primary symptoms was involvement of a sinonasal tract. A new staging system is proposed to categorize the severity and sites of involvement and to guide the aggressiveness of therapy. Sarcoidosis should be considered in the differential diagnosis of inflammatory sinonasal disease.

Laser-assisted serial tonsillectomy.

Laser ablation of the palatine tonsils is a useful alternative to tonsillectomy in adults. Cryptic tonsillitis is a common problem causing recurrent infection, sore throat, and halitosis. Elimination and/or obliteration of surface pockets (crypts) of the palatine tonsils utilizing the CO2 laser was effective in 86 patients treated in the past 4 years. Ablation of the tonsil surface was performed in stages under local anesthesia in an office setting; CO2 laser energy delivered through the "SwiftLase" handpiece extension provided char-free, superficial layer ablation of tissue. "SwiftLase" is easily installed onto existing CO2 laser units and provides high-power densities by utilizing a focused laser beam in an extremely fast uniform scan over an extended area (up to 4 mm) within a fraction of a second. This method and results of its use are discussed.

Laser-assisted uvula-palatoplasty for snoring.

Laser-assisted uvula-palatoplasty (LAUP) is a new and effective surgical method for the elimination of habitual snoring. LAUP is safely performed under local anesthesia in the office, and it provides progressive enlargement of the oropharyngeal air space by reshaping and restructuring the uvula, soft palate, and pharyngeal pillars utilizing the CO2 laser with special attachments. LAUP can also reduce oropharyngeal obstruction that may occur during sleep in patients with obstructive sleep apnea syndrome. Our experience includes over 335 patients evaluated and treated within the past year. Successive laser ablation of the vibrating structures, such as the uvula, soft palate, and posterior pharyngeal pillars, provided an 84% cure rate. In addition, 7% of the patients reported significant improvement in the loudness of their snore. The major advantage of this surgical technique is that it is a safe, simple, reliable, and bloodless procedure that can be performed in the office. This method and the results of its use are discussed.