Non-echoplanar diffusion weighted imaging in the detection of post-operative middle ear cholesteatoma: navigating beyond the pitfalls to find the pearl.

UNLABELLED: Non-echoplanar diffusion weighted magnetic resonance imaging (DWI) has established itself as the modality of choice in detecting and localising post-operative middle ear cleft cholesteatoma. Despite its good diagnostic performance, there are recognised pitfalls in its radiological interpretation which both the radiologist and otologist should be aware of. Our article highlights the various pitfalls and provides guidance for improving radiological interpretation and navigating beyond many of the pitfalls. It is recommended radiological practice to interpret the diffusion weighted images together with the ADC map and supplement with the corresponding T1 weighted and T2 weighted images, all of which can contribute to and enhance lesion localisation and characterisation. ADC values are also helpful in improving specificity and confidence levels. Given the limitation in sensitivity in detecting small cholesteatoma less than 3 mm, serial monitoring with DWI over time is recommended to allow any small residual cholesteatoma pearls to grow and become large enough to be detected on DWI. Optimising image acquisition and discussing at a joint clinico-radiological meeting both foster good radiological interpretation to navigate beyond the pitfalls and ultimately good patient care. TEACHING POINTS: • Non-echoplanar DWI is the imaging of choice in detecting post-operative cholesteatoma. • There are recognised pitfalls which may hinder accurate radiological interpretation. • Interpret with the ADC map /values and T1W and T2W images. • Serial DWI monitoring is of value in detection and characterisation. • Optimising image acquisition and discussing at clinico-radiological meetings enhance radiological interpretation.

The Agreement between Protocols for the Investigation of Asymmetrical Audiovestibular Symptoms.

OBJECTIVE: There are a number of published criteria for the investigation of asymmetrical audiovestibular symptoms. Our aim was to determine the agreement between these protocols when determining whether to investigate a group of patients treated at our institution. MATERIALS AND METHODS: Retrospective audit of the indications for arranging 854 consecutive magnetic resonance imaging scans of the internal auditory meatus. These indications were compared to the Oxford, Northern, Charing Cross, and Nashville guidelines on the investigation of asymmetrical audiovestibular symptoms. RESULTS: The level of agreement was low, with kappa values ranging between 0.15 and 0.58 between the four selected protocols. DISCUSSION: While these criteria seem very similar in nature, due to the number of patients with mild asymmetry and subtle distinctions such as the inclusion or exclusion of tinnitus, there are low levels of agreement between protocols. This study highlights another area of difficulty when determining which patients to investigate.

Ossicular malposition in Larsen syndrome: a case report.

Larsen syndrome is a rare condition that causes multiple large joint dislocations and characteristic flattened facies. We present a case of a patient with Larsen syndrome with a conductive hearing loss due to ossicular malposition/dislocation. We discuss the aetiopathogenesis of hearing loss in Larsen syndrome.

Tuberculosis with secondary vasculitis presenting as a nasal septal perforation.

A 45 years old man with tuberculosis (TB) and secondary vasculitis presented with perforation of the nasal septum, involving skin and cranial nerves. Vasculitis is a recognized, tough rare complication of tuberculosis and has not been previously described in the literature as a cause of nasal septal perforation. It presents a diagnostic dilemma. The diagnostic challenges of this case are outlined, and the clinical implications are discussed.

Reconstruction of pharyngolaryngectomy defects using the jejunal free flap: a 10-year experience from a single reconstructive center.

BACKGROUND: Reconstruction following pharyngolaryngectomy presents a complex reconstructive challenge, and a single-stage, reliable reconstruction allowing prompt discharge from the hospital and return of swallowing and speech function is required. The authors present their 10-year experience of 43 jejunal free flaps for pharyngolaryngectomy reconstruction by a single team and outline their operative algorithm to minimize postoperative morbidity. METHODS: The data for patients who underwent jejunal free flap reconstruction of circumferential pharyngoesophageal defects between March of 2000 and September of 2009 were reviewed retrospectively. All cases were included for analysis. RESULTS: There were 31 male patients and 12 female patients, with 100 percent acute flap survival. The authors' overall benign pharyngocutaneous fistula rate was two of 43 (5 percent), with two of 29 (7 percent) occurring in the group without a prophylactic pectoralis muscle flap and zero of 14 occurring in the group that had a prophylactic pectoralis muscle flap. No fistulas occurred when the anastomosis was performed with the gastrointestinal stapler (zero of 48). The authors' overall benign stricture rate was six of 43 (14 percent). Thirty-six patients received either a primary or secondary tracheoesophageal puncture; of these, 28 of 36 (78 percent) used their tracheoesophageal puncture as their primary mode of communication. CONCLUSION: The authors' recommendations for minimizing fistulas and stricture rate, following free jejunal reconstruction, include the gastrointestinal stapler for bowel anastomosis whenever possible, and the use of a prophylactic pedicled pectoralis major muscle flap for patients exposed to previous radiotherapy.

Call-fleming syndrome: an extraordinary complication of tonsillectomy.

A 36 years old woman underwent tonsillectomy for recurrent tonsillitis. At about one week in the postoperative period, she developed sudden onset severe ("thunderclap"), recurrent headaches and focal neurological signs including visual disturbances, ataxia and myoclonic jerks. Serial imaging with MRI, MRA and CT angiography revealed reversible white matter focal edema and segmental cerebral vasoconstriction. A diagnosis of Call-Fleming syndrome was made based on her symptoms and imaging findings, and she was started on nimodipine. She made a slow recovery but still has slight unilateral foot drop even 12 months since the initial event. This is the first case of Call-Fleming syndrome occurring following an ENT procedure.

Intracranial polyps in patients with Samter's triad.

BACKGROUND: We describe three patients with Samter's triad (nasal polyps, aspirin intolerance, and asthma) with skull base dehiscence in whom the polyps extended into the extradural space and also resulted in hypertelorism and widening of the nasal bridge. METHODS: One patient died in a road traffic accident while awaiting surgery. The other two patients underwent endoscopic resection of the polyps with a combined osteoplastic flap. RESULTS: Histology confirmed benign eosinophilic polyps with edematous stroma and a markedly thickened basement membrane. There were no complications or revision procedures. Both are symptomatically well with improvement of the hypertelorism. CONCLUSION: These cases indicate that polyps in Samter's triad may be extremely aggressive, resulting in intracranial extension. A combined endoscopic and osteoplastic flap approach is a safe and effective surgical option.