Characterisation and objective monitoring of balance disorders following head trauma, using videonystagmography.

OBJECTIVE: To characterise balance disorders occurring after head trauma, using videonystagmography, and to test the efficiency of videonystagmography as a diagnostic and monitoring tool. METHOD: Prospective, cohort analysis of 126 head trauma patients managed with vestibular evaluation, monitoring and treatment, in a tertiary referral centre. Analytical parameters included: head injury severity; balance disorder type, severity and time of onset; and patient recovery and outcome. RESULTS: Head trauma was minor in 31.7 per cent, mild in 36.6 per cent, moderate in 19 per cent and severe in 12.7 per cent. Balance disorder symptoms included vertigo in 42.9 per cent, unsteadiness in 15.9 per cent, dizziness in 9.5 per cent and none in 31.7 per cent. Videonystagmographic balance disorder diagnosis type was peripheral vestibular in 23.8 per cent, central in 7.9 per cent, mixed in 12.7 per cent, benign paroxysmal positional vertigo in 4.8 per cent and no findings in 50.8 per cent. Balance disorder was immediate in 47.6 per cent (this included all moderate and severe trauma cases). Benign paroxysmal positional vertigo developed within the first week in two-thirds of cases. More severe trauma cases had longer recovery times. Peripheral, mixed and central balance disorders recovered within the first three months. Early rehabilitation of acute balance disorders led to early recovery regardless of diagnosis. CONCLUSION: Videonystagmography enables precise, simple, cost-effective monitoring of balance disorders after head trauma, and improves care and outcomes.

Lymphangiomatosis: a differential diagnosis of lytic lesions of the temporal bone.

OBJECTIVE: We report a histologically proved case of lymphangiomatosis of the skull, involving the temporal bone and presenting as multiple lytic bone lesions. METHOD: A case report and a review of the literature concerning lymphangiomatosis are presented. RESULTS: Lymphangiomatosis affecting bones is a rare disorder caused by a congenital malformation of the lymphatic system, resulting in diffuse proliferation of the lymphatic channels and involving bones, parenchymal organs and soft tissue. Involved bones show massive osteolysis and progressive, localised bone resorption. CONCLUSION: Lymphangiomatosis should be kept in mind in the differential diagnosis of lytic lesions of the skull.

Identification of internal acoustic canal in the middle cranial fossa approach: a safe technique.

BACKGROUND: The middle cranial fossa approach (MCFA) is a very valuable functional approach in the armamentarium of the neuro-otologic surgeon. Identification of the internal acoustic canal (IAC) in MCFA is one of the most tedious steps. Many techniques have been described to locate the IAC safely when using the MCFA. OBJECTIVE: We sought to describe a safe technique for identification of the IAC and to demonstrate its feasibility in temporal bone dissections, as well as to discuss our clinical experience with this technique. METHODS: The surgical anatomy of the 20 temporal bones were evaluated and measured, especially by defining the medial and lateral ends of the IAC and relations to the nearby located structures. Measurements were obtained at 3 levels: the width of the IAC at the level of the fundus, the width of the IAC at the level of the porus, and the safe distance around the IAC at the meatal level. The medial and lateral IAC end widths were compared with each other and with the safe area at the meatal level. RESULTS: The smallest, the largest, and the mean values were recorded. The mean width of the IAC at the level of the porus was found to be more than 3-fold that of the width of the IAC at the level of the Bill's bar, and the ratio between the width of the medial safe area around the IAC and the lateral end of the IAC was found to be more than 7-fold as wide. CONCLUSION: This technique offers direct quick exposure of the IAC, without handling the facial nerve and the inner ear structures. Forty-five cases of operations with the same technique showed excellent ease and safety of identifying the IAC medially in the MCFA.

Subtemporal exposure of the intrapetrous internal carotid artery. An anatomical study with surgical application.

This work describes the exposure of the intrapetrous internal carotid artery (ICA) through the subtemporal approach. The anatomical details of 25 fresh temporal bones were studied and provided the initial background for this procedure. Bone drilling in the meatal plane anterior to the internal auditory canal could create a four-sided quadrangular area. The exposure of the ICA through this area was applied on three occasions. It proved safe as regards the surrounding structures and also provided an ample working space for the extirpation of tumours surrounding the artery.

Chlamydia trachomatis: an underestimated cause for rhinitis in neonates.

The incidence of Chlamydia trachomatis genital tract infection among randomly selected attendants of the ante-natal clinic of the Suez Canal University Hospital, Ismailia, Egypt, during 1996 was detected. It was found to be 9% by examining endocervical swabs using the direct immunofluorescent test and 13% after serological detection by the indirect immunofluorescent test. The incidence of neonatal Chlamydia infection in the same population assessed by nasal and conjunctival swabs tested for Chlamydia using the direct immunofluorescent test was found to be 9%. In spite of the low incidence of neonatal Chlamydia infection detected in this study, neonates 'at risk' i.e. born to infected mothers, showed a high rate of Chlamydia transmission (57%) with 21.4% of the infected neonates presenting with this specific rhinitis. This study documents Chlamydia trachomatis as an underestimated cause of rhinitis in neonates characterized by being resistant to empirical remedies.

PIP: An estimated 25% of neonates of infected mothers acquire Chlamydia trachomatis infection during passage through the birth canal and 30-50% of these infants contract conjunctivitis. The present study assessed the incidence of Chlamydia rhinitis among neonates born to 160 women attending the antenatal clinic at the Suez Canal University Hospital in Ismailia, Egypt, in 1996. According to the direct immunofluorescence technique, 14 pregnant women (9%) were infected with Chlamydia trachomatis; when the indirect immunofluorescence method was used, 21 women (13%) had positive results. Conjunctival and nasal swabs could be collected from only 98 infants in this series. 5 had positive conjunctival swabs and 4 gave positive nasal swabs. Mothers of 8 of the 9 infants with infected discharge had tested positive for Chlamydia, for a maternal-infant transmission rate of 57% (8/14). In neonates who present with rhinitis and do not respond to standard remedies, the mother's file should be consulted for evidence of Chlamydia infection so appropriate treatment can be provided.

Normal hearing in acoustic neuroma patients: a critical evaluation.

A series of 128 acoustic neuromas (ANs) managed in our center in the last 6 years were evaluated. Sixteen cases (12.5%) were found to have normal pure tone audiograms. A comparatively younger age was an important characteristic of these patients. Tinnitus, dysequilibrium, and subjective hearing loss or distortion were their most common complaints. Pure tone audiometry showed a mean pure tone average of 14.5 dB. Speech discrimination score and performance intensity phonetically balanced index were very insensitive and showed very high false-negative results. Auditory brainstem responses proved to be a reliable test, being positive in 93.8% of cases. The mean tumor size did not show any significant difference when compared with acoustic neuroma cases with abnormal hearing. The combination of otologic and neurotologic symptoms in a young patient should prompt the clinician to investigation further even if hearing is within normal limits. A high index of suspicion is a prerequisite for the early diagnosis of such subtle lesions.

Surgical management of epitympanic cholesteatoma with intact ossicular chain: the modified Bondy technique.

The results of 37 cases surgically treated with the modified Bondy technique during a 6-year period at the Gruppo Otologico-Piacenza, Italy, are reported. This technique, indicated in epitympanic cholesteatoma with good hearing and intact ossicular chain and pars tensa, provides a one-stage mastoid cavity exteriorization with radical removal of cholesteatoma while preserving the preoperative hearing levels. The technique, indications, results, and comparison with other current techniques are discussed in this article.

Surgical anatomy of the petrous apex as it relates to the enlarged middle cranial fossa approaches.

This work was designed to study the surgical anatomy of the petrous apex as it relates to the enlarged middle cranial fossa approaches, on 25 temporal bones. In this study we suggest dividing the petrous apex into two topographic areas: an anterior triangular and a posterior quadrangular area with respect to the posterior border of the Gasserian ganglion. Anatomic descriptions endorsed by relevant measurements of these areas are provided in this study.

Cochlear polyamines: markers of otitis media-induced cochlear damage.

High-performance liquid chromatography (HPLC) set to the femtomole [corrected] sensitivity level was used to identify and quantify the polyamines spermidine and spermine as well as the diamine putrescine in the different tissues of the inner ears of guinea pigs with experimentally induced otitis media. The tissues examined were the lateral wall (stria vascularis and the spiral ligament), the organ of Corti, and the cochlear nerve. The difference in polyamine profile in the different tissues of the control noninfected guinea pigs suggests a relation to the particular function of each of these tissues [see erratum notice re: preceding sentence]. The difference in polyamine profile in infected different inner ear tissues compared to controls encourages the assumption that the polyamines may be involved in a repair process of the inner ear after injury and that they may be considered as biochemical markers for inner ear damage secondary to acute otitis media.

The enlarged translabyrinthine approach for removal of large vestibular schwannomas.

This study was carried out to validate the enlarged translabyrinthine approach for the surgical management of large vestibular schwannomas. A retrospective review of the charts of 53 patients with large tumours removed via the enlarged translabyrinthine approach at the Gruppo Otologico, Piacenza, Italy, during the last five years was carried out. The ability to control large tumours and the achievement of total removal with low morbidity and very few complications, demonstrate that tumour size does not influence the use of the enlarged translabyrinthine approach for managing large tumours.

Decision making in acoustic neuroma management: the only hearing ear.

Patients with acoustic neuroma in their only hearing ear are not frequently seen in clinical practice. Managing this group of patients is a challenge to both patient and surgeon. In this study we report on five cases of acoustic neuroma in an only hearing ear. Our decision for nonsurgical management of those patients with regular follow-up using auditory brainstem responses and magnetic resonance imaging is discussed. Other management options currently available are considered as well.