Petrous apex arachnoid cyst extending into Meckel's cave

A rare case of arachnoid cyst involving the petrous apex with an unusual clinical presentation has been described with special emphasis in the imaging features and importance of accurate presurgical diagnosis. Differentiation from the other benign lesions involving the petrous apex and the role of newer MR techniques in the diagnosis of these lesions has been highlighted.     

Congenital cholesteatoma of the middle ear and petrous bone

A retrospective analysis of 51 cases of congenital cholesteatoma of the middle ear and the petrous bone is reported. Of the 44 congenital middle ear cholesteatomas, 21 were localised to the posterosuperior mesotympanum and this was in complete contrast to the commonly reported anterosuperior location which was seen in only 2 cases. The remaining 21 patients had cholesteatoma involving mesotympanum and/or epitympanum. All the patients except one were treated using a closed tympanoplasty. A second stage procedure was performed in 33 patients. Residual disease was seen in 19 (57%) patients undergoing second stage surgery. Thirtyeight (85%) patients had a preoperative air bone gap of 30 dB or more. Of the 33 patients considered for hearing results, 16 (48%) had a postoperative gap within 10 dB. Amongst the 7 congenital petrous bone cholesteatomas, facial nerve dysfunction and sensorineural deafness were the commonest symptoms. The modified transcochlear approach was the most preferred approach in management of these patients.     

Thanatophoric Dwarfism

A case of Thanatophoric Dwarfism is described in which the foramen magnum was found to be grossly reduced in size. The distance between the petrous temporal bones was also reduced in size but were anatomically normal. It is thought that the size of the foramen magnum may be associated with areflexia and hypotonia and the lethal nature of the disease. Radiography forms the basis of accurate diagnosis. From this, reporting, precise classification and incidence follow.     

Temporomandibular Joint Air in Fractures of the Skull Base

Basilar skull fractures involving the temporal bone extend through the tympanic part of the temporal bone in two-thirds of cases. The anatomical relationship of this part of the temporal bone and the temporomandibular joint enables air to pass from the auditory canal into the joint. Air in the temporomandibular joint is demonstrated on CT scans as an indirect sign of temporal bone fracture.     

Metastatic hepatocellular carcinoma in the tympanic membrane

Primary tympanic membrane cancer is very rare; metastatic cancer to the tympanic membrane is extremely rare and presents diagnostic challenges. We report a case of metastatic hepatocellular carcinoma in the tympanic membrane. The presenting symptom was hearing loss. Physical examination revealed a friable granulomatous mass over the left anterior tympanic membrane extended from the external auditory canal. Computed tomography scan of the temporal bone revealed one soft tissue mass involving the left external auditory canal and tympanic membrane. A left middle ear mass biopsy was performed. The tumor cells were uniformly positive for cytokeratin and hepatocyte paraffin-1, confirming a diagnosis of metastatic tympanic membrane. A tympanic membrane mass might easily be misdiagnosed and improperly treated. This case serves as a reminder that the differential diagnosis of acute hearing loss in cancer patients should include the metastasis occurring in the auditory canal or tympanic membrane, and that tissue biopsies are necessary to establish the definitive diagnosis for such lesions.     

Atropic Tympanic Membrane and Hearing Assessment

The hearing threshold in atrophic tympanic membrane is assessed in 35 individuals. Assessment of hearing threshold in patients having atrophic tympanic membrane. Prospective clinical study. Tertiary referral centre. Thirty-five patients who had atrophic tympanic membrane in one ear and normal tympanic membrane of the other ear which was used as control, were selected Hearing threshold of patients having atrophic tympanic membrane. Twenty-nine patients with atrophic tympanic membrane had absolutely normal PTA of the ear and the opposite ear with normal tympanic membrane had similar normal PTA. Majority of the patients with atrophic tympanic membrane have normal hearing.     

Atypical subtrochanteric femur fracture in patient with metastatic breast cancer treated with zoledronic Acid

Several case series have suggested an association exists between atypical femoral subtrochanteric fractures and long-term use of bisphosphonates. It is thought that prolonged use of bisphosphonates may lead to adynamic, fragile bone. The radiologic features of atypical fractures include diffuse cortical thickening, transverse fracture, and beaking at the lateral subtrochanteric area. Atypical subtrochanteric femur fractures have been reported after use of alendronate, but there have been rare reports of atypical femur fractures occurring after administration of zoledronic acid. A 56-year-old female with metastatic breast cancer treated with zoledronic acid presented with pain in the right hip. X-rays showed a right subtrochanteric fracture, and she underwent operation. Four months later after having undergone an operation, the patient struggled with walking and X-ray showed delayed union of the fracture site.     

A Study of Closure of Tympanic Membrane Perforations by Chemical Cauterisation

To study the effectiveness of chemical cautery with patching on chronic tympanic membrane perforations of the pars tensa. Thirty-eight patients with dry tympanic membrane perforations due to inflammatory or traumatic etiology were selected after treating the primary etiological factors like septal deviation and allergic rhinitis. Fifty percentage silver nitrate was used to cauterize the margin and the perforation was covered with thin sterile aluminium foil as a patch. A maximum number of five applications were made, and the patients were followed up for the next 5 years. In this series of 38 patients, highest success was noted among those patients with traumatic perforation, while larger perforations were reduced to small pinhole sizes which were successfully closed by myringoplasty. An overall success rate of 73.75% was achieved. This is a time tested useful method which was popularized by Derlacki (1953), to close small to moderate sized tympanic membrane perforation and should be considered as a first line management in the treatment of tympanic membrane perforation prior to any surgical intervention. Apart from being a simple and economical mode of treatment, it is associated with minimal complications. Though various materials have been used to modify this technique, the principle remains the same and the results obtained in this study is comparable with the previous ones.     

Giant cell tumour of the petrous bone.

Giant cell tumours (GCT) are rare in the skull bones. In the cranium the sphenoid bone is the most common site. The petrous bone is a very uncommon location for such tumours. The chance location of GCT at the base of the skull makes total surgery difficult and hazardous. A case of GCT of the petrous bone is presented. The clinical course in the patient and role of primary radiotherapy in GCT in such an unusual site is discussed.     

Longitudinal tibial stress fractures

The tibia is a fairly common site for stress fractures of both the fatigue and insufficiency types. The majority are transverse or, less frequently, oblique. The present report outlines four cases of vertical stress fractures, an orientation that is very uncommon and leads to bone scan findings which can be misleading.     

Fat plug myringoplasty

Fat plug myringoplasty is a technique described to repair small dry central tympanic membrane perforations. It is a simple office procedure with minimal morbidity to the patient. The present study is a prospective review of 18 patients who underwent 20 fat plug myringoplasty procedures over three and a half year penod. The success rate of 90% closure of tympanic membrane was achieved at an average of six months follow up. The patient selection criteria have to be adhered strictly to gain good outcome. The study concludes that fat plug myringoplasty is a simple, quick and minimally invasive procedure which can be done as OPD procedure resulting in a safe and dry ear.     

Bilateral symptomatic petrous apex effusion

Petrous apex effusions can present with aural fullness, hearing loss and dizziness. Although they can be followed-up when asymptomatic, clinical management of symptomatic patients is controversial. In this study, we present clinical and radiological findings of a 24-year-old patient with bilateral petrous apex effusion. She had been complaining of bilateral aural fullness and dizziness for 2 years. Radiological examinations revealed bilateral petrous apex effusion. After medical treatment, her symptoms gradually disappeared. In all previous published studies, unilateral petrous apex effusions were reported. To our best knowledge, this is the first patient with trapped fluid in bilateral petrous apex.     

Successful treatment of parotid fistula with tympanic neurectomy

Background

Parotid fistula is a cause of great distress and embarrassment to the patient. A host of treatment modalities have been described in past but no unanimity exists regarding the most satisfactory of all. Tympanic neurectomy is an effective procedure for persistent parotid fistula with no significant side effects.

Objective

To describe our experience with tympanic neurectomy for the treatment of persistent parotid fistula and discuss the other treatment modalities described.

Setting

Tertiary care referral centre.

Methods

Two cases with post traumatic parotid fistula recalcitrant to conservative therapy were treated with tympanic neurectomy between 2004–2005. The cases were followed up regularly for any recurrence of fistula.

Results

Successful and immediate cessation of flow from parotid fistula with no recurrence in subsequent followup.

Conclusion

Tympanic neurectomy is a safe and effective procedure for the successful treatment of persistent parotid fistula.     

Randomized controlled trial to evaluate laparoscopic surgery for colorectal cancer: Japan Clinical Oncology Group Study JCOG 0404

A randomized controlled trial was started in Japan to evaluate whether laparoscopic surgery is the optimal treatment for colorectal cancer. Patients with T3 or deeper carcinoma in the colorectum without transverse and descending colons are pre-operatively randomized to either open or laparoscopic colorectal resection. Surgeons in 24 specialized institutions will recruit 818 patients. The primary end-point is overall survival. Secondary end-points are relapse-free survival, short-term clinical outcome, adverse events, the proportion of conversion from laparoscopic surgery to open surgery, and the proportion of completion of laparoscopic surgery.     

A rare case of ceruminous tumor of the cerebellopontine angle

In this case report we describe the development in the cerebellopontine angle of a very rare tumor, ceruminous adenoma. In the few cases described in the literature this tumor occurred in the external acoustic meatus. In four cases it developed in the cerebellopontine angle by infiltration of the petrous bone or by subcutaneous spread. In the present case no connection was found between the cerebellopontine angle and the external acoustic meatus. The most likely pathogenetic hypothesis in this case is that of a tumor of dysembryogenetic origin.     

The Comparison of Treatment Plans

The comparison of plans, once done by looking from one isodose plot to another, has become in hyper-dimensional planning a sophisticated matter. I have described here a number of tools that support plan evaluation and comparison, namely:

1. 1. Side-by-side display of dose distributions: using color-wash to represent dose; displays on any section, transverse, sagittal, coronal, oblique; ostensive (mouse-driven cursor) interrogation of dose at a point; pan and zoom to highlight a specified volume of interest.

2. 2. Dose-volume histograms: cumulative and (optionally) differential; with superposed constraint points.

3. 3. Dose statistics: minimum, mean, maximum dose to a volume of interest; minimum dose received by a specified proportion of a VOI; proportion of a VOI which receives at least a specified dose; numerical score based on deviation from specified dose or dose-volume constraint.

4. 4. Biophysical models: tumor control probability; normal tissue control probability.

The greater complexity that this tool kit implies has, of course, its downside: although the clinician has much more useful information at his or her fingertips, it can take longer to use it. For this reason I have emphasized here the importance of speed and inter-activity in the programs and of tools to help users in the evaluation process. These are becoming increasingly available in the new generation of treatment-planning programs; pressure from the consumer is needed to keep researchers on their toes and manufacturers responsive!     

Paraganglioma of external auditory canal

In the ear, paragangliomas are commonly found in the tympanic cavity or in juglar bulb. We, here, present a case of paraganglioma originating from the external auditory canal as it has not been reported in the world literature. The clinico-pathologic features of such a case has been described.     

Does Endoscopic Surgery Reduce Recurrence of the Petrous Apex Cholesteatoma?

The aim of this study is to present the clinical symptoms, complications and treatments of the petrous apex cholesteatoma and is to describe the current role of oto-endoscopy. This was a retrospective non-randomized study of 14 petrous apex cholesteatoma surgeries performed between 1994 and 2012. Petrosectomy was performed according to the location of the cholesteatoma, hearing level of the patients and facial nerve function. Oto-endoscopy was used in the petrous apex and the cerebellopontine angle for residual cholesteatoma. 14 patients, seven were men and seven women were included in this study between 1994–2012. The most common symptom was hearing loss (85.7 %) and tinnitus (50 %) at the presentation. During the surgeries, it was observed that cholesteatoma involved most frequently facial nerve, dura and labyrinthines. Labyrinthectomy, middle cranial fossa approach and petromastoidectomy was performed to these patients. Four of six patients operated without the endoscope assistance between 1994–2006 had recurrences after the operation. These patients were re-operated and in the follow up, there was no recurrence. In the endoscopy assisted surgery, there was no recurrence observed (significance level p = 0.014). The most common complication after the surgery was hearing loss (42.8 %) but it was not significant after surgery (p > 0.05). The petrous apex and mastoid cavity was obliterated with fat tissue in eight patients while six patients were exteriorized to follow the recurrence and it was insignificant in recurrences (p > 0.05) Conclusion: Endoscope-assisted surgery allows to remove residual the cholesteatoma around the carotid artery, dura and facial nerve in the petrous apex resulting in less invasive surgery and less recurrence in blind spots.     

鼻咽癌患者放疗对鼓室压影响的研究

[目的]研究鼻咽癌(NPC)患者放疗对鼓室压的影响.[方法]首次诊断为鼻咽癌患者60例(90耳)放疗前随机分为两组,并且他们语频区听力正常(<30db)和鼓室压图为A型曲线.甲组除接受放射治疗外,同时接受鼻腔和鼻咽部局部治疗,乙组仅接受常规放射治疗,在放疗结束时检测甲乙两组鼓室压.[结果]在放疗结束时甲乙两组平均鼓室压(z=-5.159,P<0.005)存在明显差异.[结论]在放疗结束时,鼻咽癌患者鼓室更大负压值主要和咽鼓管器质性阻塞有关,鼻腔和鼻咽部局部冲洗治疗可保护咽鼓管功能.     

The whirl sign: A non-specific finding of mesenteric rotation

The whirl sign has been described as a computed tomography (CT) finding of volvulus of the gut. Six cases are presented with a range of clinical diagnoses (a volvulus, adhesive obstruction with volvulus and previous left hemicolectomy, adhesions alone, transverse colectomy, and right hemicolectomy). All demonstrated a whirl sign. A further case simulating a whirl sign is also presented. We propose that the whirl sign, although a finding highly suggestive of volvulus, can occur in any situation that produces rotation or twisting of bowel and its mesenteric attachment.