Prolonged paroxysmal sympathetic storming associated with spontaneous subarachnoid hemorrhage.

Paroxysmal sympathetic storming (PSS) is a rare disorder characterized by acute onset of nonstimulated tachycardia, hypertension, tachypnea, hyperthermia, external posturing, and diaphoresis. It is most frequently associated with severe traumatic brain injuries and has been reported in intracranial tumors, hydrocephalous, severe hypoxic brain injury, and intracerebral hemorrhage. Although excessive release of catecholamine and therefore increased sympathetic activities have been reported in subarachnoid hemorrhage (SAH), there is no descriptive report of PSS primarily caused by spontaneous SAH up to date. Here, we report a case of prolonged PSS in a patient with spontaneous subarachnoid hemorrhage and consequent vasospasm. The sympathetic storming started shortly after patient was rewarmed from hypothermia protocol and symptoms responded to Labetalol, but intermittent recurrence did not resolve until 3 weeks later with treatment involving Midazolam, Fentanyl, Dexmedetomidine, Propofol, Bromocriptine, and minimizing frequency of neurological and vital checks. In conclusion, prolonged sympathetic storming can also be caused by spontaneous SAH. In this case, vasospasm might be a precipitating factor. Paralytics and hypothermia could mask the manifestations of PSS. The treatment of the refractory case will need both timely adjustment of medications and minimization of exogenous stressors or stimuli.

Tonsillar carcinoma in the contralateral tonsil.

OBJECTIVE: We report a series of patients treated for carcinoma of the tonsil who either presented with bilateral carcinomas or later developed a second primary carcinoma of the contralateral tonsil. This report raises awareness of this occurrence. STUDY DESIGN: Case series. METHODS: Four cases have been identified of either concomitant or subsequent carcinoma of the contralateral tonsil inpatients treated for tonsillar carcinoma from the practices of 3 head and neck surgeons in a single demographic area over a 35 year span. RESULTS: Four patients were identified who were treated for tonsillar carcinoma with concomitant or subsequent carcinoma of the contralateral tonsil: One patient with bilateral metastatic carcinoma in cervical lymph nodes was found to have bilateral occult tonsillar primaries.Three patients who were treated for tonsillar primary carcinomas subsequently developed carcinoma of the contralateral tonsil. CONCLUSIONS: A small population of patients with unilateral tonsil carcinoma will developed a second in the contralateral tonsil. This raises the question of whether removal of the contralateral tonsil at the time of initial treatment might have spared the morbidity/mortality of the subsequent contralateral tonsil cancer.