Identification of rhinoscleroma by immunoperoxidase technique

Rhinoscleroma is a chronic disease of the respiratory system. Its onset is insidious and its symptoms are often nonspecific. Yet rhinoscleroma is a progressive disease that can lead to significant disability. The proper diagnosis is difficult because of the nonspecific presentation and rarity of rhinoscleroma. Biopsy tissue often is not properly cultured. Diagnostic histologic features may not be readily apparent or may be overlooked by the unsuspecting pathologist. A case of rhinoscleroma is reported in which an immunoperoxidase technique was applied to retrospectively confirm the diagnosis. The usefulness of this new technique in the diagnosis of rhinoscleroma is discussed.     

Recognition of craniomandibular disorders.

Craniomandibular disorders often mimic diseases related to the ear, nose, and throat, so patients often seek the care of an otolaryngologist for these problems. After ruling out otolaryngologic disease, craniomandibular disorders should be considered in the differential diagnosis. If a clinical diagnosis is supported by history, symptoms, and clinical evidence, the patient should be referred in a timely manner to a dentist who is competent to manage the patient. In addition to dentists, other health care practitioners may be called on by the primary treating physician to aid in the diagnosis and treatment. These can include a neurologist, radiologist, ophthalmologist, physiatrists, physical therapist, and internist. With recent advances in imaging techniques (computed tomography and magnetic resonance imaging), precise bioelectronic measurement of mandibular movement and electromyography of masticatory function, and conservative orthotic and dental restorative treatments as well as surgical techniques including arthroscopic examination of the TMJ, craniomandibular disorders can be objectively and precisely diagnosed and treated (Figs. 10 through 16).     

Evaluation of olfaction

The sense of smell is often taken for granted until it is impaired or lost. Chemosensory disorders involving a decreased, absent, or distorted sense of smell can be devastating to those who suffer them and may have an impact on an individual's health, safety, and quality of life in a number of ways. It is necessary to approach the diagnosis of chemosensory disorders in a systematic manner that may reveal reversible pathology and to provide patients with counseling that can help them accommodate their disability.     

Subacute thyroiditis. A diagnosis in otolaryngology.

Subacute thyroiditis is often unrecognized and patients may be treated for pharyngitis, laryngitis, otitis media or similar disorders connected with otolaryngology. It is conceivable that these patients may seek treatment in ENT departments. The difficulties encountered in making a correct diagnosis are illustrated here on the basis of 12 consecutive cases. Eight of these patients were initially misdiagnosed resulting in useless therapy. Subacute thyroiditis is a self-limiting illness, and permanent myxoedema is rare. Nevertheless, one case with this sequela is reported.     

Diagnosis and determination of the clinical significance of type 1A laryngeal clefts by gelfoam injection

Laryngeal clefts are rare congenital disorders, classified by multiple different schemes. Type IA (Armitage) and type I (Benjamin and Inglis) laryngeal clefts exhibit absence or hypoplasia of the interarytenoid muscles with an intact cricoid ring. Submucous or "occult" clefts occur with intact mucosa but absent underlying cartilage and/or muscle. Children with a diagnosis of posterior laryngeal cleft often have other congenital anomalies or medical disorders, including gastroesophageal reflux, tracheomalacia, syndrome complexes, and developmental delay. These associated disorders often confuse the diagnostic picture, as they may contribute to or account for the presenting symptoms of a laryngeal cleft. We propose a method to help clarify the clinical significance of the laryngeal clefts in these patients, and determine which patients would benefit from cleft repair. Eight patients with type IA laryngeal clefts are presented who were treated with a "test dose" Gelfoam injection into the interarytenoid area at the time of endoscopic diagnosis. All patients exhibited clinical improvement, and 4 patients showed improvement on the postinjection videofluoroscopic swallow study as compared to preoperative studies. One patient has gone on to surgical repair of the cleft after multiple injections. Endoscopic Gelfoam injection at the time of diagnosis can both alleviate symptoms and provide clarification of the posterior laryngeal cleft's contribution to the clinical status of the patient in these often complex cases.     

Neuralgia of the superior laryngeal nerve caused by phonatory malfunctions

Clinical observations show a close relationship between neuralgia of the superior laryngeal nerve and disorders of the larynx. Neuralgia, and more minor symptoms are usually caused by hyper- and hypotonic phonatory disorders. An unphysiological compensation for glottic insufficiency causes irritation of the sensory telodendrons of the superior laryngeal nerve. As incomplete adduction of the vocal cords can often be found in patients with an autonomic laryngeal dystonia, a syndrome related to anxiety, these disturbances are often misinterpreted as "globus hystericus". However, this diagnosis does not take into account the cause and should therefore no longer be used.     

Diagnostic difficulties of chondrosarcoma of the jaw. Apropos of a case and review of the literature

Chondrosarcoma is an uncommon malignant mesenchymal tumor characterized by the production of cartilaginous tissue and the absence of production of bone tissue. Maxillary and mandibular localizations are extremely rare and have a poor prognosis. The clinical and radiographic findings are similar to those seen in other tumors of the jaw, often delaying diagnosis and treatment and subsequently jeopardizing prognosis. In the literature, the mean delay from first clinical signs to diagnosis is about 8 months. As in all tumoral diseases, pathology confirms the diagnosis. We report a case of chondrosarcoma of the maxillary bone and review the literature, focusing on the difficulty in establishing the diagnosis, even at the pathology examination. We propose wide surgical excision, which, in agreement with other reports in the literature, is the only therapeutic possibility. We observed no sign of recurrence at 5-year follow-up. Radiotherapy and chemotherapy may be useful in certain cases.     

Malignancy of the temporal bone

Malignant tumors of the temporal bone are extremely rare, and the diagnosis is often delayed because of the difficulty of differentiating neoplasms from more common disorders found in the ear canal and middle ear. The degree of surgical extirpation is planned according to the determined clinicoradiographic extent of the tumor. Unfortunately, the radiographic assessment often underestimates the tumor involvement of neurovascular or bony structures, which may lead to an inadequate resection and life-threatening tumor recurrence.     

Infiltrating Lipomata of The Head and Neck

Recent discovery and subsequent excision of two histologically benign but unusual infiltrating intramuscular lipomas prompted a review of available literature and a collection of lipomatous disorders of interest to the head and neck surgeon. Such lesions may, by their position, cause significant symptoms. Other instances occur wherein their unusual location causes initial confusion in diagnosis. Finally, accurate histologic identification may be obscured by the inclusion of other tissues within the benign fatty tissue.     

Neuroanatomy and physiology of the vestibular system relevant to dysequilibrium in the elderly

Vestibular disorders will often be seen in the company of nonvestibular disorders, rendering the care of the affected patient a multidisciplinary challenge. It is the particular role of the otolaryngologist to provide expertise on the diagnosis and management of vestibular system dysfunction.     

Internal jugular phlebectasia in Menkes disease

Pediatric neck masses should trigger a high index of suspicion for certain genetic disorders of connective tissue. To highlight this, we report on three infants with Menkes disease, an inherited disorder of copper transport, who developed large, unilateral neck masses at between 7 and 17 months of age. All were identified in imaging studies as internal jugular phlebectasia. The masses, which enlarged on crying or exertion, have remained clinically benign in these patients for 20, 17, and 2 months, respectively. While arterial tortuosity and aneurysms have been reported often in Menkes disease, venous phlebectasia has rarely been described. We speculate that low activity of the copper-dependent enzyme, lysyl oxidase, leading to reduced tensile strength in the deep cervical fascia comprising the carotid sheath may predispose to internal jugular phlebectasia in these individuals. Improved survival and neurological outcomes in infants with Menkes disease due to advances in early diagnosis and treatment may be associated with recognition of novel clinical stigmata of this condition such as internal jugular phlebectasia.     

Diagnostik und Therapie von schlafbezogenen Atmungsstörungen Teil 1: Begriffliche Systematik

ENT specialists are now being asked for help by increasing numbers of snoring patients who complain about nocturnal apnea and excessive daytime sleepiness. A final diagnosis is often made in a sleep disorders center. Sleep medicine has emerged as a new inter-disciplinary specialty during the last decade, although otorhinolaryngologists commonly are unable to fully interpret clinical findings. This report discusses the terms and information often detailed at a sleep disorders center. The evaluation of diagnostic and therapeutic procedures is explained.     

The diagnosis of autoimmune inner ear disease: evidence and critical pitfalls

The purpose of this paper is to review the current diagnostic work-up for patients with suspected Autoimmune Inner Ear Disease (AIED). AIED is a rare disease accounting for less than 1% of all cases of hearing impairment or dizziness, characterized by a rapidly progressive, often fluctuating, bilateral SNHL over a period of weeks to months. While specific tests for autoimmunity to the inner ear would be valuable, at the time of writing, there are none that are both commercially available and proven to be useful. Thus far, most of the identified antigens lack a clear association with localized inner ear pathology and the diagnosis of AIED is based either on clinical criteria and/or on a positive response to steroids. For clinical practice, we recommend an antigen-non-specific test battery including blood test for autoimmune disorders and for conditions that resemble autoimmune disorders. Nevertheless, if financial resources are limited, a very restricted work-up study may have a similar efficiency.     

Pigmented villonodular synovitis of the temporo mandibular joint. Differential diagnosis and therapy

For the temporomandibular joint (TMJ), functional disorders are common but tumors and tumor like lesions are rare, although these are often mistaken for functional ailments. Early examination by computed tomography or, as a method of choice, magnetic resonance imaging is recommended in case of persisting TMJ problems. Pigmented villonodular synovitis (PVNS) is a rare benign but locally destructive fibrohistiocytic lesion originating in synovial tissue. Involvement of the temporomandibular joint is extremely rare, with the average age of patients being 44.6 years. This paper reports on a 13-year-old patient with diffuse PVNS involving the middle ear and middle cranial fossa. The treatment of choice involves wide local excision and reconstruction of the temporomandibular joint with long-term follow-up. Pathogenesis and differential diagnosis are discussed.     

Psychosomatische Schwindelerkrankungen

Somatoform vertigo is one of the most frequent forms of vertigo, alongside neuropathia vestibularis and benign peripheral positional vertigo. False diagnoses often lead to patients suffering from symptoms for periods of months or even years, which imposes significant limitations on their working and private lives. An early interdisciplinary diagnosis and the consequent timely commencement of a specific psychosomatic therapy is thus essential. Somatoform vertigo can be caused by many different psychological disorders. The clinical symptomatology, diagnosis and differential diagnosis are described and illustrated by case vignettes. Risk factors and preventive measures are briefly summarized.     

Imaging of temporal bone brain hernias: atypical appearances on magnetic resonance imaging.

Brain tissue with or without its dural covering may protrude into the temporal bone through a defect in the tegmen tympani. Infection or granulation tissue, with or without cholesteatoma may make diagnosis difficult. While computed tomography (CT) may demonstrate a bony defect, it is difficult to distinguish between herniated brain, cholesteatoma or granulation tissue. Magnetic resonance imaging (MRI) clearly demonstrates healthy herniated brain tissue, but ischaemic or necrotic elements may mimic other lesions. We present a series of five patients with brain hernia, highlighting the spectrum of preoperative radiological appearances, and some of the difficulties encountered in interpreting these images. MRI demonstrated herniation of healthy brain in two patients but in three, showed irregular soft tissue with signal characteristics consistent with cholesteatoma. Surgery in these three patients demonstrated necrotic brain with coexisting cholesteatoma in two. Brain hernias are often necrotic and may have morphological and signal characteristics similar to cholesteatoma with which they may coexist.     

Imaging of temporal bone brain hernias: atypical appearances on magnetic resonanance imaging

Brain tissue with or without its dural covering may protrude into the temporal bone through a defect in the tegmen tympani. Infection or granulation tissue, with or without cholesteatoma may make diagnosis difficult. While computed tomography (CT) may demonstrate a bony defect, it is difficult to distinguish between herniated brain, cholesteatoma or granulation tissue. Magnetic resonance imaging (MRI) clearly demonstrates healthy herniated brain tissue, but ischaemic or necrotic elements may mimic other lesions. We present a series of five patients with brain hernia, highlighting the spectrum of preoperative radiological appearances, and some of the difficulties encountered in interpreting these images. MRI demonstrated herniation of healthy brain in two patients but in three, showed irregular soft tissue with signal characteristics consistent with cholesteatoma. Surgery in these three patients demonstrated necrotic brain with coexisting cholesteatoma in two. Brain hernias are often necrotic and may have morphological and signal characteristics similar to cholesteatoma with which they may coexist.     

Headache and facial pain associated with head injury

Head injury frequently results in headache and at times facial pain. Controversy concerns the relationship of injury in the head and neck area to chronic headache, particularly when no apparent structural traumatic lesion is demonstrable. Neuropathological studies suggest with concussion there is neuronal injury without gross pathology. Closed head injury of seemingly minor degrees may lead to chronic symptoms, often stereotypic, similar to those following concussion, and they have been described by the term post head trauma syndrome or postconcussional syndrome. Headache after head injury in an individual warrants careful medical, neurological, and neuroimaging assessment. The use of neuroimaging has greatly enhanced diagnosis in head-injured patients but has not satisfactorily clarified post head trauma symptoms in the less severely traumatized. Differential diagnosis is critical to avoid missing disabling, progressive, and life-threatening entities. In patients with head trauma neck injury should be sought. The headache may be nonspecific or mimic common nontraumatic headache disorders such as tension, migraine, and cluster. Recovery may include headache, psychological symptoms, and cognitive impairment. Neuropsychological assessment can be helpful in demonstrating deficiencies in mildly impaired individuals and explain the poor response to headache therapy in some patients suggesting more widespread injury. Therapy of head and facial pain follows the careful diagnosis and, if needed, assessment of the psychological status. Surgery, drug therapy, physical modalities, and at times a comprehensive neuropsychological rehabilitation program are necessary. Simple analgesics such as nonsteroidal antiinflammatory agents for short-term treatment and tricyclic antidepressants for chronic pain are most often effective in patients without structural damage. More complex medication regimens may include beta adrenergic blockers and monamine oxidase inhibitors. Since many injuries result from motor vehicle accidents, work-related factors, and other instances in which litigation may result, legal elements may be involved. Most often the prognosis is favorable for resolution of symptoms but a small percentage of patients will have persistent symptoms after three years. The notion that litigation prolongs the duration of the illness is not valid. In the past two decades great advances have been made in neurodiagnosis, and parallel therapeutic advances are expected in the near future.     

A radiologic advance in the diagnosis of disorders of the larynx

The cervical spine greatly reduces the usefulness of anteroposterior soft tissue radiologic examination of the larynx. Fractures of the laryngeal and cricoid cartilages are difficult to diagnose by soft tissue technique, and time-consuming laminagraphy is often required. A new technique for single exposure anteroposterior soft tissue radiography of the cartilages and airway is described. An esophageal cassette containing ultraspeed dental film placed in a retrolaryngeal position is shown to yield detailed radiographs of high contrast. The feasibility of this technique is illustrated by the presentation of radiographs from patients with laryngeal disorders. The new technique is compared with existing examinations available to the clinician and its application in other disorders of laryngeal cartilages and soft tissue is discussed.     

Management von Sprachentwicklungsstörungen und Aussprachestörungen bei Kindern

Compared to other countries, the prevalence of speech-language disorders among children and also the intervention frequency appear to be much higher in Germany. Since otorhinolaryngologists often initiate speech-language interventions, the first part of this review systematically outlines the guideline-conform diagnostic pathway from examination to therapeutic intervention. The process of first developing a suspected diagnosis which justifies speech-language tests is explained. Beyond this, the rational selection of a set of tests from all those available—some of which the otorhinolaryngologist can perform, some of which require referral—is discussed, as is how these results can be used to assess the severity of the disorder. A special focus of this paper is the differential diagnosis of underlying causes, e.?g., hearing disorders and global developmental disorders. A complete set of tests permits a working diagnosis and ICD-10 classification of the case.