Wegener's granulomatosis presenting as otomastoiditis. A case report.

A 55-year-old male presented with left-sided otorrhoea, hearing loss and tinnitus of 3 months duration. On clinical examination polypoid tissue was seen prolapsing in the external ear canal. A CT scan of the mastoid cells and middle ear showed otomastoiditis with osteolysis. Oral antibiotic therapy and eardrops were started. When a facial nerve paresis appeared one month later, a mastoidectomy was performed. The mastoid cells and middle ear were filled with a connective tissue-like substance. Postoperative corticosteroids were administered. Despite the therapy the facial nerve problem aggravated and the patient developed severe parietotemporal headache, meningeal irritation and somnolence. The diagnosis of neurosarcoidosis was hypothesised. Blood analysis, including c-ANCA's, culture of the otorrhoea and biopsies of the connective tissue were inconclusive. A CT scan of the brain showed thickening of the left tentorium. A biopsy of the dura indicated a diagnosis of Wegener's granulomatosis. The patient was treated with immunosuppressive medication with satisfactory results.

Laparoscopic splenectomy after arterial embolisation.

Laparoscopic splenectomy remains a challenging procedure, as haemorrhage causes the most complications. In order to reduce this risk, preoperative selective embolisation of the splicing artery has been performed in a series of six successful laparoscopic splenectomies in one male and five female patients with a mean age of 34.6 years (range 17-53 yrs). Indications for surgery were immune thrombocytopenic purpura (ITP)(n = 3), non-Hodgkin lymphoma with secondary haemolytic anaemia (n = 1), autoimmune haemolytic anaemia (n = 1) and congenital spherocytosis (n = 1). The mean splenic length was 12.3 cm (range 9-16 cm) and no accessory spleens were identified. Mean operative time was 96.7 min (range 90-150 min). There were no deaths nor haemorrhagic or septic complications. Recovery after surgery was excellent with a mean hospital stay of 5.2 days (range 2-10 days). We conclude that selective embolisation of the splenic artery, just prior to laparoscopic splenectomy adds to the safety, and operating time may be shortened.