The value of non-echo planar HASTE diffusion-weighted MR imaging in the detection, localisation and prediction of extent of postoperative cholesteatoma.

OBJECTIVE: To evaluate the diagnostic performance of half-Fourier-acquisition single-shot turbo-spin-echo (HASTE) diffusion-weighted magnetic resonance imaging in the detection, localisation and prediction of extent of cholesteatoma following canal wall up mastoid surgery. STUDY DESIGN: Prospective blinded observational study. SETTING: University affiliated teaching hospital. PATIENTS: Forty-eight patients undergoing second-look surgery after previous canal wall up mastoid surgery for primary acquired cholesteatoma. INTERVENTIONS: All patients underwent non-echo planar HASTE diffusion-weighted imaging prior to being offered 'second-look' surgery. MAIN OUTCOME MEASURES: Radiological findings were correlated with second-look intra-operative findings in 38 cases with regard to presence, location and maximum dimensions of cholesteatoma. RESULTS: Half-Fourier-acquisition single-shot turbo-spin-echo diffusion-weighted imaging accurately predicted the presence of cholesteatoma in 23 of 28 cases, and it correctly excluded in nine of 10 cases. Five false negatives were caused by keratin pearls of <2 mm and in one case 5 mm. Overall sensitivity and specificity for detection of cholesteatoma were 82% (95% confidence interval [CI] 62-94%) and 90% (CI 55-100%), respectively. Positive predictive value and negative predictive value were 96% (CI 79-100%) and 64% (CI 35-87%), respectively. Overall accuracy for detection of cholesteatoma was 84% (CI 69-94%). Half-Fourier-acquisition single-shot turbo-spin-echo diffusion-weighted imaging has good performance in localising cholesteatoma to a number of anatomical sub-sites within the middle ear and mastoid (sensitivity ranging from 75% to 88% and specificity ranging from 94% to 100%). There was no statistically significant difference in the size of cholesteatoma detected radiologically and that found during surgery (paired t-test, P = 0.16). However, analysis of size agreement suggests possible radiological underestimation of size when using HASTE diffusion-weighted imaging (mean difference -0.6 mm, CI -5.3 to 4.6 mm). CONCLUSION: Half-Fourier-acquisition single-shot turbo-spin-echo diffusion-weighted imaging performs reasonably well in predicting the presence and location of postoperative cholesteatoma but may miss small foci of disease and may underestimate the true size of cholesteatoma.

Imaging of postoperative middle ear cholesteatoma.

Cholesteatoma is often treated surgically using canal wall-preserving techniques. Clinical and otoscopic diagnosis of residual or recurrent disease after this form of surgery is unreliable and thus radiological imaging is often used prior to mandatory "second-look" surgery. Imaging needs to be able to differentiate residual or recurrent disease from granulation tissue, inflammatory tissue or fluid within the middle ear cavity and mastoid cavity. High-resolution computed tomography (HRCT), conventional magnetic resonance imaging (MRI), and delayed contrast MRI have all been used in detecting postoperative cholesteatoma. Although delayed contrast MRI performs better than HRCT and conventional MRI, the sensitivities and specificities of these different imaging methods are relatively poor. Diffusion-weighted MRI (DWI and, in particular, non-echo planar DWI) has been shown to have a high sensitivity and specificity for detecting recurrent cholesteatoma. In this review we provide examples of postoperative imaging appearances following cholesteatoma surgery and we review the relevant literature with an emphasis on studies evaluating the diagnostic accuracy of DWI.

Haemangioma or vascular malformation of the tympanic membrane? a case report and review of literature.

Benign vascular lesions are rarely found on the tympanic membrane. We report a case of such a lesion in a novel location, with review of the relevant literature. We also highlight the significance of accurate classification of such lesions, proposing adoption of more pathophysiologically-correct nomenclature of "haemangioma" and "vascular malformation".

Evidence-based review of aetiopathogenic theories of congenital and acquired cholesteatoma.

Cholesteatoma is a non-neoplastic, keratinising lesion which has two forms: congenital and acquired. Congenital cholesteatoma develops behind a normal, intact tympanic membrane, whilst acquired cholesteatoma is associated with a defect in the tympanic membrane. The pathological substrate of cholesteatoma is keratinising stratified squamous epithelium, but the origin of this epidermal tissue in the middle ear is controversial. Here, we review the most relevant and recent evidence for the principal aetiopathogenic theories of both forms of cholesteatoma, in the light of recent otopathological findings. Congenital cholesteatoma is most plausibly explained by the persistence of fetal epidermoid formation. Conclusive 'proof' awaits the unambiguous demonstration of the metamorphosis of an epidermoid nidus into a lesion in vivo. Acquired cholesteatoma may develop by various mechanisms: immigration, basal hyperplasia, retraction pocket and/or trauma (iatrogenic or non-iatrogenic). However, squamous metaplasia of the normal cuboidal epithelium of the middle ear is a highly unlikely explanation. Chronic inflammation seems to play a fundamental role in multiple aetiopathogenic mechanisms of acquired cholesteatoma. Therefore early treatment of inflammatory conditions might reduce their sequelae, perhaps by preventing the development of hyperplastic papillary protrusions. Continued otopathological, cellular and molecular research would enhance our limited understanding of cholesteatoma and may lead to new therapeutic strategies for this erosive disease, which often defies surgical treatment.

Pulsatile tinnitus.

Pulsatile tinnitus is an uncommon otological symptom. Objective pulsatile tinnitus has numerous causes, including benign intracranial hypertension, glomus tumours and atherosclerotic carotid artery disease. History and physical examination can give important information as to the underlying diagnosis. Radiographic evaluation is essential in all patients with pulsatile tinnitus. Many patients have a treatable underlying aetiology. Early diagnosis and appropriate intervention may save patients from unnecessary morbidity.

Efficacy of tibolone and transdermal estrogen therapy on psychological symptoms in women following surgical menopause.

OBJECTIVE: This study investigated the efficacy of tibolone and transdermal estradiol therapy on menopausal and psychological symptoms in women following surgical menopause. METHOD: Seventy-five women who had undergone surgical menopause were randomized to a 6-month double-blind interventional study treatment with oral 2.5 mg/day tibolone, transdermal 3.9 mg/week estradiol or oral placebo. The patients were assessed using Kupperman's Scale, Hamilton Depression Rating Scale (HDRS) and Hamilton Anxiety Rating Scale (HARS) before and at the end of the 6 months of treatment. RESULT: Sixty-five subjects completed the study: 23 on tibolone, 21 on transdermal estradiol and 21 on placebo. At the end of the 6 months of therapy, highly significant improvements in menopausal symptoms, depression and anxiety scores were observed in both groups (tibolone and transdermal estradiol groups) as compared with baseline values (p<0.001). However, in the placebo group, there were no significant differences on changes from baseline to the end of treatment (p>0.05). CONCLUSION: These results suggest that tibolone and transdermal estradiol therapy significantly improve menopausal and psychological symptoms in women following surgical menopause.

Metastatic choniocarcinoma of the nasal cavity-presenting as intractable expistaxis.

There are numerous known causes of epistaxis Neoplasms of the nose and paranasal Sinuses as causes of epistaxis are rare Choriocarcinoma is a highly malignant germ cell tumor occurring in the reproductive and midline regions of the body Metastasis may be principally by the lymphatic route as in other germ cell tumors but chonocarcinoma is known for Us propensity to spread haematogenously We report a rare case of metastatic chonocarcinoma of the nasal cavity presenting with intractable epistaxis in a 32 year old African gentleman which rapidly proved fatal The literature is briefly reviewed.

Columelloplasty: a new suture technique to correct caudal septal cartilage dislocation.

Deviation of the nasal septum is a common finding in patients with nasal obstruction and, when such deviation is severe, a septoplasty or submucous resection with or without turbinate reduction is commonly recommended for the relief of the patient's symptoms. In cases where there is anterior subluxation of the septum, the caudal margin frequently presents on one or either side of the midline at the external nares. We report a simple suture technique which, when subluxation is not severe, will correct this caudal displacement. The technique can either be used as an adjunct to conventional septoplasty or it can be undertaken as an isolated procedure in patients having routine rhinoplasty.

Improving the reproducibility of acoustic rhinometry in the assessment of nasal function.

Acoustic rhinometry readings are very position dependent, and it was hypothesized that this accounts for its relative lack of reproducibility on a day-to-day basis. Multiple readings on each visit were taken to investigate their impact, if any, on improving the day-to-day reproducibility of the method. Measurements of the minimal cross-sectional area of the nose as measured by acoustic rhinometry were studied in 10 subjects following nasal decongestion. For each individual, acoustic rhinometry was performed ten times. The ten recordings were repeated again, in an identical manner on a separate day. The subjects were repositioned and the nasal probes reinserted between each measurement. The mean coefficient of variation for minimal cross-sectional area readings in all 10 subjects was calculated as 9.92%. This is comparable to the day-to-day variability of acoustic rhinometry as measured by other workers and thus supports the hypothesis that the high measurement error of the device (rhinometer) is a function of positional variation during data acquisition. We were able to demonstrate a minimal gain in intervisit reproducibility by doing multiple recordings per person, with a plateau effect of reproducibility after 7 repeat readings.

Treatment of external nasal valve (alar rim) collapse with an alar strut.

Alar (external valve) collapse may be iatrogenic or can occur as a consequence of ageing or trauma. We have utilized an autogenous cartilage graft inserted as an underlay graft to the alar rim to treat 17 patients who have presented with nasal obstruction due to alar collapse. We report the short- and medium-term functional results and the cosmetic sequelae of our approach and conclude that this procedure offers an improvement in nasal airway performance in patients with external valve collapse without producing serious adverse cosmetic sequelae.

Assessing the reproducibility of nasal spirometry parameters in the measurement of nasal patency.

The reproducibility of nasal spirometry was assessed in ten subjects at two visits. Topical nasal decongestion was applied to minimise mucosal variation. Eleven parameters of flow volume were measured. Data analysis using Spearman's rank correlation coefficients revealed peak inspiratory flow rate (PIFR) followed by forced expiratory volume in first one second (FEV1) to be the most reproducible measures, yielding significance values of < 0.05. For all other spirometric parameters significance was not reached. Analysis revealed that using a naso-pulmonary index (a ratio of nasal to pulmonary flow) was detrimental to reproducibility. We conclude that future nasal spirometric studies should use PIFR and FEV1 as their derived variables of flow-volume loops in the assessment of nasal patency, and the naso-pulmonary index is of no value.

A prospective randomised study to assess the efficacy of differenct medications for relief of post-operative nasal obstruction.

Surgery to the nasal septum and to the turbinates constitutes a significant part of the workload of an otolaryngologist. The patient invariably experiences short-term nasal obstruction following such surgery and different medications are commonly used to relieve this and to promote a sense of airway patency. However the efficacy of topical and systemic medication, given in the post-operative period is hot well documented. A prospective randomized trial was therefore undertaken to compare the efficacy of a topically applied vasoconstrictor and an anticholinergic agent in reducing the sensation of airway obstruction in the first week following simple nasal airway surgery. 0.5% Ephedrine hydrochloride nasal drops, Pseudoephedrine tablets and a combination of the two were compared to a control group who received no treatment. Eighty patients were randomised into four groups and nasal patency assessed by patients using a visual analogue sacle (VAS). When compared to the control group both medications were effective in relieving nasal congestion but a combination of topical and systemic therapy, given together, was superior to either agent used alone. The results achieved were independent of the seniority of the surgeon undertaking the operation.

Penetrating neck injury: case report and evaluation of management.

Greater urban violence has resulted in an increased incidence of penetrating neck trauma. Penetrating neck wounds can present difficult diagnostic and therapeutic dilemmas. The evaluation and management of such injuries, however, remains controversial. There is no universally accepted specific approach to the management of patients with penetrating neck injuries, with some surgeons advocating mandatory neck exploration whilst others believe in selective surgical intervention. We believe that an equal willingness for both conservative and surgical intervention as dictated by serial bedside evaluation with adequate radiological and endoscopic support can provide the clinician a safe and effective means of managing a potentially complex and lethal problem.

Lipoma in fossa of Rosenmüller.

We report the first case of a lipoma originating in the fossa of Rosenmüller. Although lipomas are a common benign tumour in the body, lipomas of the nasopharynx are rare.

Gradenigo's syndrome.

Gradenigo's syndrome, which is characterised by the triad of suppurative otitis media, pain in the distribution of the trigeminal nerve, and abducens nerve palsy may give rise to potentially fatal complications. Knowledge of the aetiology and appropriate investigations can lead to early diagnosis. A case is reported which illustrates this.