Patulous eustachian tube after percutaneous balloon microcompression for trigeminal neuralgia: case report.

OBJECTIVE: To report a case of patulous eustachian tube which occurred after percutaneous balloon microcompression of the Gasserian ganglion. METHOD: Retrospective case review. RESULTS: A 41-year-old man was referred to our audiovestibular medicine department following episodes of autophony. These symptoms appeared two weeks after percutaneous balloon microcompression performed to treat severe trigeminal neuralgia secondary to multiple sclerosis. A diagnosis of patulous eustachian tube was indicated by clinical examination and tympanometry. The symptoms were present for less than six months and improved without any specific treatment. CONCLUSION: Percutaneous balloon microcompression is a procedure used for refractory trigeminal neuralgia that can cause transient sensory and motor deficits of any of the trigeminal nerve branches. It is proposed that injury to the mandibular division in this case caused temporary tensor veli palatini dysfunction with consequent patulous eustachian tube.

Primary ventriculitis caused by Streptococcus intermedius.

Streptococcus intermedius is increasingly being recognised as an aetiological agent in central nervous system infections. Primary ventriculitis caused by this organism has not been reported so far. We present a case of primary ventriculitis, which resulted in adhesions and multiloculated hydrocephalus, necessitating numerous surgical procedures to control it. No predisposing factor(s) could be identified. Although the organism could not be cultured from CSF, as he was already on antibiotic treatment, it could, however, be identified by 16S rDNA polymerase chain reaction on the CSF sample. It appears important to recognise this condition and to treat it aggressively to prevent complications such as adhesions and multiloculated hydrocephalus.

New proposals for training in neurosurgery.

The rapidly evolving changes in working patterns, career structure and the regulation of training of doctors have provided an ideal opportunity for proposals to improve the programme for the training of neurosurgeons. The Education and Training Committee of the Society of British Neurological Surgeons (D.G. Hardy, A. J. W. Steers, N. T. Gurusinghe, P. M. Foy, P. van Hille, R. A. Cowie, H. A. Crockard, O. Sparrow and S. Burn) has, in recent months, worked closely with the Specialist Advisory Committee (SAC) in neurosurgery, Department of Health (Modernizing Medical Careers Group, H. A. Crockard, A. Havers, T. Hobbs) and colleagues from the major neuroscience specialties to develop a new programme based on a 'Common Stem' approach. This article describes the principles of the programme. The proposals have received approval by the Council of the SBNS, the Presidents of the four Surgical Royal Colleges and the Senate of Surgery.

Can spontaneous spinal epidural haematoma be managed safely without operation? A report of four cases.

The presentation, investigation, and management of four patients with spontaneous spinal epidural haematoma is presented. In each case the diagnosis was made by MRI. At the time of diagnosis spontaneous recovery had started in each patient and therefore they were all treated conservatively. In each case follow up MRI confirmed rapid reduction in the size of the haematoma and no underlying cause was demonstrated. The presentation, diagnosis, and rationale for treatment are discussed. Conservative treatment is safe in some cases of spinal epidural haematoma if early neurological recovery has started.

Spinal tuberculosis in developed countries: difficulties in diagnosis.

A review of 21 cases of patients with spinal tuberculosis has been performed, with special attention being paid to methods of diagnosis and the surgical treatment undertaken. We found that the clinical presentation of the condition was often similar to that of malignant disease within the spine, with the commonest presenting features being back pain (95%), an evaluated erythrocyte sedimentation rate (ESR) (100%) and neurological deficits (47%). The radiological appearances were diagnostic of spinal tuberculosis in less than 50% of cases. Microbiological confirmation of the diagnosis was possible only by direct analysis of tissue or pus, either at operation or from a vertebral biopsy. The difficulty of diagnosing this condition and the implications that this has on the timing and nature of surgery in patients presenting with neurological deficits are discussed.

A prospective comparison of fibre-optic and fluid-filled single lumen bolt subdural pressure transducers in ventilated neurosurgical patients.

A clinical comparison was made between fibre-optic and fluid-filled Bolt subdural pressure transducers in ventilated head injured patients. Twelve subjects had both devices inserted in neighbouring sites. In two patients there were obvious technical problems with the fibre-optic system and the results were therefore excluded from further analysis. In the remaining 10 patients, 2167 pairs of simultaneous recordings were made for up to 9 days and the degree of correspondence studied. A quarter of paired readings differed by more than 5 mmHg. There was no evidence of any overall bias, but in individual patients one device often read higher or lower than the other. The proportion of closely corresponding readings tended to diminish after 4 days. Therapeutically relevant episodes, where treatment might have been initiated on the basis of the readings from only one of the two systems, were equally likely with both devices and occurred on average approximately every 30 h. The relative accuracy of the two devices remains uncertain, but there is evidence suggesting that both were prone to errors.

Postoperative hematoma: a 5-year survey and identification of avoidable risk factors.

This study examines the surgical practice at the Wessex Neurological Centre over the 5-year period from 1989 to 1993 to determine the incidence of postoperative hematoma and to identify risk factors for a perioperative bleeding disorder. The study includes only those postoperative hematomas (at any site) that followed and were related to a neurosurgical operation and were surgically evacuated. The study is prospective for the year 1993 and retrospective for the preceding years. Over the 5 years, 6668 operations were performed and 71 postoperative hematomas were surgically evacuated, accounting for an overall rate of 1.1% of operations. The records were available for 69 cases. The most frequent diagnosis leading to postoperative hematoma was meningioma surgery with a rate of 6.2% of cases (13 of 211); followed by craniotomy for trauma, 3.7% (7 of 192); aneurysm surgery, 2.6% (11 of 428); and intrinsic supratentorial tumors, 2.2% (10 of 451). Postoperative hematomas were intraparenchymal in 43% of cases, subdural in 5%, extradural in 33%, mixed in 8%, and confined to the superficial wound in 11%. The overall mortality was 32% (37% for intraparenchymal and 12% for extradural). Risk factors for a perioperative bleeding disorder were present in two-thirds of the patients. Administration of antiplatelet agents (aspirin and nonsteroidal anti-inflammatory drugs) was the most commonly associated risk factor. At least 75% of these identified risk factors could potentially have been avoided or corrected.

Repair of facial nerve after removal of cerebellopontine angle tumors: a comparative study.

The results of repair of 18 facial nerves were examined by means of a modified House-Brackmann grading system. Six were repaired by end-to-end anastomosis and 12 by nerve graft. The reliability of the simplified House-Brackmann grading system was also assessed, using the kappa statistic to analyze the agreement between pairs of observers who examined the function of 40 nerves in 37 patients. Facial nerves studied had been either preserved, repaired or grafted, or divided and treated by faciohypoglossal nerve anastomosis. One nerve was not treated. The grading system proved to be somewhat unreliable, with complete agreement between observers in only 25% of cases. Facial nerve repair produced a fair return of function in just under two-thirds of the cases. The ability of an examiner ignorant of the patient's history to assess from the end result how the nerve had been managed was also estimated. Observers showed little ability to decide correctly on the previous treatment of the nerve when the patient showed moderate dysfunction postoperatively. The implications of these findings for grading systems and for management of the facial nerve in acoustic nerve tumor surgery are discussed.

Cerebellopontine angle tumours in black South Africans--how rare are acoustic schwannomas?

Previous reports of intracranial neoplasms from Africa have all shown a very low incidence of acoustic schwannomas (neuromas). In this series a group of 11 cerebellopontine angle solid tumours from black Africans were studied. On conventional histological examination only 3 had the features of a schwannoma. However, by using immunohistochemistry, a further 3 examples were identified. As controls, the same antisera were also applied to known schwannomas and meningiomas. During the period of the study, 163 patients with primary intracranial neoplasms were seen and thus acoustic schwannomas accounted for 3.7%. Although this figure is low by world standards, it still represents a far higher figure than has previously been reported from Africa. This study therefore emphasises the value of immunohistochemistry in the diagnosis of brain tumours and, furthermore, shows that acoustic schwannoma must be considered in the appropriate clinical setting, even in a group previously regarded as low-risk.

The surgical correction of fronto-ethmoidal meningo-encephaloceles.

One-stage correction of fronto-ethmoidal meningo-encephaloceles and related stigmata, via an orbito-cranial approach, is recommended. A bifrontal craniotomy is only required when simultaneous correction of hypertelorism is to be undertaken. A combined intra- and extracranial approach is essential. The possibility of a high relapse rate for repaired fronto-ethmoidal meningo-encephaloceles, together with the possibility of prolonged postsurgical cerebrospinal fluid leakage, meningitis and other complications is invited when either a transcranial bifrontal craniotomy surgical approach, or an extracranial approach via the facial lesion, is undertaken alone. Modification of existing craniofacial surgical approaches in order to avoid a frontal craniotomy, allowed for good repair of the encephalocele together with significant benefits in terms of simplification of the surgical procedure, operating time, blood loss, frontal lobe retraction and complications.

Laboratory performance of single-piece ventriculoperitoneal shunts with distal slit-valve control.

Three different types of single-piece ventriculoperitoneal shunts with distal slit-valve control (Codman Unishunt, Codman Unishunt with chambers, and Heyer-Schulte one-piece shunt) in their low- and medium-pressure forms were assessed in the laboratory by both static and dynamic tests. A statistical analysis of variance showed large differences in performance which were not confined to the different pressure ranges as may have been expected. Substantial variation occurred between nominally identical shunts and between identically rated shunts of different makes. Guidelines for an industry standard are proposed.

Craniofacial polyostotic fibrous dysplasia.

Three cases of gross craniofacial polyostotic fibrous dysplasia are presented, together with a brief review of the condition, and pertinent points regarding the cases are discussed. As complete excision of the lesion and immediate reconstruction is rarely feasible or possible, and partial excision may result in accelerated growth of the lesion during the patient's active growth phase, resection only to protect, maintain or restore certain important functions (e.g. vision) during this period are advocated, after which close follow-up is mandatory until the lesion becomes quiescent, when further surgical procedures may be undertaken.