Mastoid pneumocoele with skull base and cervical spine pneumatisation

Very uncommonly, Eustachian tube dysfunction can lead to symptomatic chronic elevation of middle ear pressure with aeration of bone and adjacent structures in the skull base and upper cervical spine, and an increased risk of fracture. We present a case demonstrating the natural history of this condition over 11 years before treatment and 10 months after treatment.     

A study of temporal bone fractures

Many young adults are now killed and injured in accidents than from another causes. More than 75% of these injuries are to the head, and the ear being the most frequently injured sensory organ of the body. Temporal bone or basilar skull fractures are extremely common in any head injury. Injuries to the temporal bone may be considered in three groups: Those affecting the external auditory meatus (extralabyranthine fractures), those largely affecting middle ear cleft (tympanolabyranthine) and those affecting the internal ear (labyrinthine fractures). Many injuries, however, involve all these structures.The sudden onset of facial paralysis, vertigo and hearing impairment after a head injury is a matter of great concern for the patients and clinicians. Presence of cerebrospinal fluid leak (CSF Otorrhoea) can be a challenge for both the neurosurgeons and otologists. We hereby present 86 patients of temporal bone fractures who presented in the departments of emergency, Neurosurgery or ENT of Himalayan Institute of Medical Sciences, Dehradun during last 10 years (1996–2006).     

Malignant Fibrous Histiocytoma/Undifferentiated High-Grade Pleomorphic Sarcoma of the Maxillary Sinus

Malignant fibrous histiocytoma (MFH) also known as undifferentiated high-grade pleomorphic sarcoma (UHPS) is a soft tissue sarcoma, composed of undifferentiated mesenchymal tumors possessed fibrohistiocytic morphology without definite true histiocytic differentiation. Head and neck localization is very rare, showing an incidence ranging from 4 % to 10 % in different series of investigations. The most frequent involved sites in UHPS are the neck and parotid, followed by the scalp, face, anterior skull base and orbit. Upper aerodigestive tract, lateral skull base and ear are rare locations. The incidence of the lymphatic metastases is also rare. The aim of this article is to report a case of UHPS in the maxillary sinus with palatal, orbital and ethmoidal involvement, with lymphatic metastasis and its surgical treatment. In addition, we review the literature of similar cases of the past 12 years.     

Vertigo in whiplash injury: A presentation of prevalent butterfly patterns of caloric tests

The most common cause of whiplash injury today is the road traffic accidents. These patients report to a neurotologist with complaints of long-standing duration including vertigo, nausea, hearing loss and tinnitus. In addition to neck trauma there is also intracranial trauma due to movement of the brain within the skull thus affecting the brainstem and the supratentorial structures. In this retrospective study 426 patients of whiplash injury were selected from databank NODEC IV of the University head centre, Wurzburg, Germany. The results of monaural caloric test by means of butterfly chart in all these patients were analysed. The authors present the most prevalent caloric butterfly patterns of this study and pathophysiology explaining them. The study reveals that the more frequent pathological patterns in this study are the central brainstem lesions.     

Unusual case of skull metastasis secondary to pancreatic adenocarcinoma

Skull metastasis must be kept in mind when considering the differential diagnosis of a skull tumor. Skull metastases cause local swelling that is usually painless, and rarely they lead to neurologic dysfunction. Despite the fact that hematogenous skull metastases can be caused by nearly all types of tumors (lung, prostate, thyroid carcinoma, malignant melanoma), breast cancer is associated with the highest rate of metastatic skull lesions. We report an extremely rare case of skull metastasis from a pancreatic adenocarcinoma, in a 65-year-old woman, presented with painless frontoparietal scalp swelling which developed within three months. To the best of our knowledge, this is the second case involving the skull secondary to a pancreatic adenocarcinoma, and the first case when skull metastasis was the first evidence of a pancreatic adenocarcinoma.     

Osteoclastoma of the nasopharynx

Osteoclastoma involves the long bones of the extremities and some of the flat bones such as the sacrum, mandible patella and vertebrae. Eggston and Wolff (1947) mentioned the possibility of its origin from bones of the upper jaw, ethmoid and sphenoid sinuses. Amongst the skull bones, Rosenwasser (1969) described a case of giant cell tumour of the middle ear, yet such a tumour arising from the nasopharynx and sphenoid seems to be extremely rare. A rare case of osteoclastoma of the nasopharynx with extensive local invasion, multiple cranial nerve involvement and fatal termination is described. The differential diagnosis and histological features have been discussed.     

Carotid and Vertebral Artery Trauma: Clinical and Angiographic Features

Injury to the carotid or vertebral artery is an important clinical entity that requires angiography for definitive diagnosis and evaluation. The common carotid artery may be injured by penetrating trauma while the internal carotid artery is usually damaged by either trivial or blunt trauma. With trivial trauma extracranial internal carotid artery dissection should be considered if there is unilateral headache, Honer's syndrome or delayed transient ischaemic attack, and intracranial dissection if a profound neurological defect occurs immediately following trauma. Injury to the internal carotid artery following blunt trauma includes dissection of the extracranial internal carotid artery, carotid-cavernous fistula and pseudoaneurysm formation. These should be considered in a patient with delayed neurological deficit, mandibular or skull fracture, a constellation of orbital signs or diffuse subarachnoid haemorrhage, respectively. Vertebral artery injury is less frequent. Dissection typically follows abrupt cervical rotation and occurs at C1-2, whereas penetrating trauma may involve either the proximal or distal vertebral artery and occlusion, arteriovenous fistula or pseudoaneurysm may be found. Endovascular techniques may be used in either the carotid or vertebral artery to close fistulae or occlude an extensively damaged vessel.     

甲状腺癌患者术中喉返神经的显露及损伤预防

背景与目的:喉返神经(recurrent laryngeal nerve,RLN)损伤是甲状腺手术最为严重的并发症之一,尤其在甲状腺癌手术时更易发生.喉返神经损伤和防护一直是甲状腺外科关注的焦点.本文旨在探讨甲状腺癌患者术中RLN显露及损伤的预防.方法:同顾性分析2002年1月至2006年7月收治的282例行甲状腺癌手术患者临床资料.结果:282例甲状腺癌患者术前4例发现RLN损伤,9例术中发现RLN受累,在环状软骨弓外下方2～3 cm区域气管食管间沟附近稍加分离即能见到RLN 505条(505/564,89.5%).所有患者在行颈淋巴结清扫前均未全程显露RLN,分离时紧靠甲状腺进行;对行颈部淋巴结清扫的患者先行RLN的全程显露.本组无手术死亡,术后并发症包括血肿1例,乳糜漏1例.1例冈肿瘤侵犯行单侧RLN切除;2例再手术患者行RLN松解及1例RLN吻合术,术后发音有所改善;术前检查无声带麻痹者,发生暂时性声嘶9例,永久性声嘶2例,1例因肿瘤侵犯喉行全喉切除及气管造口术.结论:RLN位于环状软骨弓外下方2～3 cm区域处位置表浅,易于显露.甲状腺癌在行甲状腺切除时,不必全程显露RLN:若需行颈淋巴结清扫,可先切除甲状腺,在其局部显露部位开始显露其全程,精细无血操作,能有效预防术中RLN损伤.损伤一经诊断应尽早修复.     

Bioavailability,Skin-and Nailpenetration of Topically Applied Antimycotics*

Summary: The penetration and permeation of econazol, oxiconazol and dimethylmorpholinohydrochlorid in the human skin and nails have been performed using the measurement of radio labelled substances (C¹⁴? 250 μCi/ml) in vitro (penetration chamber) and in vivo. The penetration of the antimycotics inside the horny layer of the skin and the layers of the nail (10 μg/ml) ist sufficient enough to inhibit the growth of fungi by fungistatic mechanism. DMSO increases the penetration rate into the nail plate. Antimycotics solved in tinctures show a better penetration into the nails than the ointments which have advantages in penetrating the skin. The small fungicid effect and low dose in the deeper nails explains the long time topical treatment necessary at least for 6 months respectively the moulting process of the nail keratin.     

Skull Metastasis from Ampulla of Vater Adenocarcinoma: Case Report

We report a rare case of skull metastasis from ampulla of Vater adenocarcinoma in a patient with controlled primary neoplasm. This 65-year-old Korean man presented with headache and painful parietal scalp swelling, but he did not show any neurological deficits. Computed tomography revealed an osteolytic mass that invaded and expanded through the skull tables in full-thickness. On magnetic resonance images following Gadolinium injection, the mass appeared slightly hypointense signal on all sequences and intense heterogeneous enhancement. He underwent surgical excision with artificial grafting of calvaria and dura. Postoperative radiation therapy was ensued for metastatic adenocarcinoma, and he was well for the follow-up period of 3 months. To the best of our knowledge, this is the first such case that involved the skull.     

Radiation-induced brain injury after a conventional dose of intensity-modulated radiotherapy for nasopharyngeal carcinoma:a case report and literature review

A 61-year-old female nasopharyngeal carcinoma patient was admitted to the hospital with sudden cognitive dysfunction one month after Volumetric Intensity Modulated Arc Therapy(VMAT)conventional dose radiotherapy,and the initial diagnosis was radiation-induced brain injury(RBI).After comprehensive treatment with steroid hormones,the patient’s condition rapidly improved.Typically,in nasopharyngeal carcinoma patients treated with VMAT,the incidence of RBI is extremely low when the temporal lobe dose is less than 65 Gy or 1%of the volume is less than 65 Gy.When this limit is exceeded,RBI may occur in varying degrees.However,in this case,even though the temporal lobe dose was under the prescribed limit,the patient still experienced RBI.The rare observations in this case can be used as a reference,and clinicians should seriously consider the possibility of RBI in similar cases.     

Contouring the middle and inner ear on radiotherapy planning scans

The purpose of this study was to establish guidelines that help radiation oncologists contour the inner and middle ear on treatment planning scans. The radiotherapy computed tomography (CT) scans of 15 previously treated patients were reviewed for the ability to identify 3 separate auditory structures. The middle ear, the cochlea, and the vestibular apparatus were identified and contoured on each scan using anatomic landmarks. The volume and maximum axial dimension of each contour were calculated. The middle ear, cochlea, and vestibular apparatus were identified on all scans. The middle ear was defined by the tympanic membrane laterally and by the interface between air and the temporal bone in all other directions. The plane of the internal auditory canal through the temporal bone was the landmark distinguishing the vestibular apparatus from the cochlea. The mean volume of the middle ear, vestibular apparatus, and cochlea were 0.58 cm3, 0.44 cm3, and 0.14 cm3, respectively. The maximum axial dimension across the contour averaged 1.57 cm for the middle ear, 1.10 cm for the vestibular apparatus, and 0.69 cm for the cochlea. A reference atlas was constructed that shows the contour of each structure on 5 consecutive CT images. Accurate identification of the middle ear and inner ear structures on radiotherapy planning scans is possible and is necessary if critical auditory organs are to be spared during radiotherapy of targets that are located near the base of the skull. The information generated in this study will help radiation oncologists contour auditory structures accurately.     

Dystrophic onychomycosis due to Microsporum gypseum

A case of onychomycosis with nail dystrophy due to Microsporum gypseum in a healthy 35-year-old woman is described. The infection had a 2-year history, occurring in the site of a nail trauma sustained in a fall from a horse. Diagnosis was based on mycological examination (direct microscope observation and culture). Clinical and mycological recovery was achieved after local treatment with ciclopiroxolamine nail solution and pulsed systemic terbinafine therapy.     

颅底良性肿瘤立体定向放射外科治疗

 目的 探讨颅底良性肿瘤的SRS治疗效果。方法 1994 年7 月至1996 年12 月对22例（23 个肿瘤） 手术后残存或者复发的颅底良性肿瘤实施了SRS治疗。结果 治疗后大多数病人（1822） 的临床症状获得改善,无治疗相关的永久性颅神经损伤发生。影像学观察提示有9 个肿瘤体积缩小,13 个肿瘤体积无变化,1 例肿瘤增大。有813 例（61-5 % ） 神经鞘瘤病变中心表现出CT影像的低密度。结论 对经过选择的颅底良性肿瘤实施SRS治疗,可以获得良好的局部肿瘤控制效果和比较低的治疗并发症。     

Skull base malignant lymphoma: a case report and review of the literature.

A case of primary malignant lymphoma of the skull base is reported. A 62-year-old man was admitted with headache and diplopia. Computed tomography and magnetic resonance imaging showed an abnormal mass in the right parasellar region. The final diagnosis after surgery was primary malignant lymphoma of the skull base. Primary malignant lymphomas sometimes occur in the central nervous system but those in the skull base are exceptional. The present paper presents just such a rare case of malignant lymphoma of the skull base. Diagnosis and combined therapy consisting of surgery, radiotherapy and chemotherapy for the disease are discussed, and the literature on recent clinical problems of central nervous system lymphomas is reviewed.     

Penetrating injury neck — An unusual presentation

In a patient presenting with a penetrating injury of the neck, the problems contemplated can be very many and life threatening as well. This case demonstrates an unusual presentation of only a simple rupture of the Sternocleidomastoid muscle sparing all the vital structures beneath it following the penetration of a metallic rod of approx. 1.5 cm diameter in the neck.     

Glass foreign body in the kidney

A rare case is reported of a glass foreign body which hit the kidney of a 25-year-old man in the moment of left lumbar injury with window glass. A large fragment of the glass was removed outpatiently, but the second fragment which penetrated into the left kidney was not detected. The patient was admitted to the urological hospital 2 months after the injury. The wound on the left side of the low back has healed, but the patient had macrohematuria, pains and declined function of the left kidney. Echography and x-ray detected a foreign body in the parenchyma of the left kidney upper segment penetrating into the upper caliculus and pelvis. After lumbotomy and pyelotomy the fragment 6.2x0.8x0.3 cm was taken out from the kidney. A complete recovery of renal function followed.     

Clinical and pharmacokinetic investigations of oral itraconazole in the treatment of onychomycosis

A clinical study was carried out in 19 patients with onychomycosis in whom itraconazole was orally administered in a single daily dose of 100 mg. A follow-up period was instituted subsequent to the administration period to that the course of the nail lesions could be monitored. The concentrations of the drug in the plasma and in the nails were also determined. In patients in whom itraconazole was administered for 12-16 weeks, the decrease in the turbidity and thickening of the nails was maintained even after the administration period was completed. The efficacy rating in the overall evaluation at 12 weeks was 84.2% (16/19). In the evaluation performed at 24 weeks, the rating was 94.7% (18/19). These data indicate that the effect of itraconazole was maintained even after completion of the administration period. The retention of the drug in the nail after completion of the administration period was investigated in terms of the mean concentration of the drug in the nail with the passage of time in patients administered itraconazole for 10-16 weeks. It was found that a certain level of itraconazole was retained in the nail until at least the 24th week. Adverse reactions seen in this study consisted of diarrhoea and drug eruption, one case cach, and elevations of glutamic oxaloacetic transaminase and glutamic pyruvic transminase in one case.     

Resolution of Sudden Sensorineural Hearing Loss Following a Roller Coaster Ride

We report a case of sudden unilateral sensorineural hearing loss of sudden onset during an aeroplane flight, which completely resolved during a roller coaster ride at Alton Towers theme park. A review of the literature concerning sudden idiopathic sensorineural hearing loss and spontaneous resolution are discussed. Initially, pure-tone audiometry showed a profound sensorineural hearing loss in the right ear and mild sensorineural hearing loss in the left ear (of note, the hearing was normal prior to the episode). Following resolution of the patient’s symptoms during a roller coaster ride, pure-tone audiometry showed normal hearing thresholds in both ears. Sudden sensorineural hearing loss is a symptom of cochlear injury and the mechanism of the patient’s symptoms was attributed to a patent cochlear aqueduct.     

Mucormycosis of the Middle Ear: A Case Report with Review of Literature

Mucor is a saprophytic organism and commonly invades the nose and paranasal sinuses of immunocompromised and diabetic patients involvement of the middle ear and mastoid in a nondiabetic patients is very rare and this may be the first case report clinical presentation of ear pain with reference to the mastoid and upper neck may be the early symptoms unlike the foul smelling ear discharge as seen in atticoantral disease. Radical debridement in the form of M.R.M with or without the use of amphotericin B may suffice in non-diabetic patients this case is reported to highlight the point that mucormycosis can also involve middle ear and mastoid in nondiabetic patients.