Primary tuberculous petrositis

Tuberculous osteomyelitis of the temporal bone is a rare and dangerous entity that should be included in the differential diagnosis of infectious processes of the base of the skull. We present the case of an 11-year-old child who presented with diplopia, ear discharge and hearing loss. The radiological and histopathological findings revealed tuberculous otitis with osteomyelitis and an abscess in the petrous apex. The child responded to anti-tuberculous chemotherapy. The diagnosis and management of tuberculous osteomyelitis are discussed and a brief review of the literature is presented.     

Petrous apex effusion: a clinical disorder

Introduction: Petrous apex fluid accumulations without evidence of acute infection are routinely managed as “leave alone lesions” without potential morbidity. Are petrous apex fluid accumulations (effusions) in the absence of acute infection always asymptomatic without the need for treatment? If petrous apex effusions can produce symptoms separate from acute infections, what are the clinical outcomes in these patients? Study Design: Retrospective clinical review. Methods: A retrospective record review of 31 patients presenting with petrous apex effusions was performed with recording of clinical characteristics, interventions, and outcomes. Results: Eighteen of the 31 patients had clinical symptoms referable to the petrous apex effusion with the following characteristics: indolent and previous infections (4), hearing loss (3), headache and pressure alone (8), facial spasms (1), and positional vertigo (2). Overall, 5 of 18 symptomatic patients resolved with antibiotics, steroids, or positioning maneuvers. Three of five infracochlear drainages produced symptom resolution. Three of four patients undergoing retrolabyrinthine drainage had symptom resolution, and four of seven middle fossa drainages yielded symptom resolution. In contrast, infratemporal fossa drainage procedures did not resolve the patients' symptoms. Conclusions: Isolated petrous apex effusions are rare, but they can cause symptoms. If medical management fails, surgical drainage based on the location is appropriate. The surgical drainage approach selected (infracochlear, infralabyrinthine, middle fossa, and endoscopic transnasal) should be based on an anatomic consideration of the involved petrous apex air cells (superior vs. inferior) and the relative position of the carotid artery and jugular bulb.     

巨大岩尖胆脂瘤诊治初探（附2例临床分析）

目的：探讨岩尖胆脂瘤的临床特征、手术进路和方法,以提高手术疗效,减少并发症。方法：对2例巨大颞骨岩尖胆脂瘤患者采用迷路进路切除病灶,对其中1例成功施行了耳内镜辅助下迷路进路病灶切除术。结果：2例术后均无脑脊液漏和感染,无眩晕或平衡失调。结论：颞骨CT扫描及MRI对临床诊断及手术进路的选择有重要作用。手术清除病灶为本病治疗的惟一措施,经迷路进路为彻底清除胆脂瘤、处理面神经及脑脊液漏提供了最直接的途径,而彻底清除病变和术后长期严格随访、定期清理术腔是预防复发的关键。     

结核性中耳乳突炎13例临床分析并文献复习

目的：探讨结核性中耳乳突炎的临床特点及治疗方法。方法：回顾性分析13例结核性中耳乳突炎患者的l‰眯资料。治疗方法采取单纯手术治疗l例．单纯抗结核治疗l例．手术结合抗结卡囊治疗11例。结果：l例行单纯于术患者在术后7个月复发,行抗结核药物治疗后随访7个月未J见复发;余12例未虬复发。结论：对于结中蔓性中耳乳突炎,正规抗结核治疗足最基本的治疗方法,手术町清除中耳内炎性肉芽组织及死骨．缩钮痫狂。     

结核性中耳乳突炎的临床特征(附2例报告)

目的：探讨结核性中耳乳突炎的临床特征。方法：报告２例此种患者的临床资料,其临床特征是：病程短,发展快,耳内分泌物较稀薄;鼓膜可有穿孔（１个或数个）,亦可无明显穿孔,耳内有较苍白的肉芽组织,影像学检查可见死骨形成;可有肺结核史或家族史等。结果：两侧经搞痨和手术治疗均痊愈。结论：对本病诊治若及时、正确,预后是良好的。     

结核性中耳乳突炎的误诊原因探讨

目的：探讨结核性中耳乳突炎的临床特征并分析其误诊原因。方法：回顾分析9例结核中耳乳突炎的临床资料。结果：9例患者仅1例在术前明确为结核中耳乳突炎,其余8例术前误诊为慢性中耳乳突炎,术后病检才确诊为结核中耳乳突炎。结论：结核性中耳乳突炎临床特征与慢性化脓性中耳乳突炎相似,临床上易混淆。临床医生应重视此病,结合病史、影像学检查、病理检查及其他特殊检查以明确诊断,减少误诊。     

Management of lateral sinus thrombosis.

OBJECTIVES: Review the clinical signs and symptoms, management, bacteriology and outcomes of patients treated for lateral sinus thrombosis. STUDY DESIGN: A retrospective review of six patients, treated from 1993 through 1998, with an intraoperatively confirmed diagnosis of lateral sinus thrombosis. METHODS: All charts from 1993 through 1998 coded for sinus thrombosis, meningitis, brain abscess, otitic hydrocephalus, subdural abscess, and mastoidectomy were reviewed. Operative reports, radiological examinations, laboratory data, culture data and other pertinent data were reviewed. RESULTS: The presenting symptoms ranged from headache to mental status changes. All patients had a history of chronic ear disease and all had at least one additional intracranial complication. The range of additional intracranial complications included otitic hydrocephalus, epidural abscess, and brain abscess. All of the infections were polymicrobial, with a predominance of anaerobes. There were no mortalities; morbidities included anacusis, acute respiratory distress syndrome, reoperation, seizures, septic cardiomyopathy, transfusion, ventriculoperitoneal shunt and nutritional supplementation. CONCLUSION: In patients with otologic disease, complaints of headache, earache or photophobia should warrant an evaluation. The presence of lateral sinus thrombosis mandates further investigation for additional intracranial complications. Conservative surgical intervention, consisting of removal of all perisinus infection and needle aspiration of the sinus, has been found to be effective. Lateral sinus thrombosis is an uncommon complication of otitis media, with potentially significant morbidities, necessitating a high index of suspicion.     

Petrous apex aspergillosis as a long-term complication of cholesterol granuloma

Aspergillus infection of the petrous apex is a rare and devastating condition. To date, only two such cases have been reported, which resulted from direct extension of chronic Aspergillus otitis media. We present a case of petrous apex aspergillosis occurring years after surgical drainage of a petrous apex granuloma cyst. Because of the potential lethal nature of this condition, aggressive surgical therapy should be considered early in this illness and may provide the best chance for survival.     

Intracranial Extension of Acquired Aural Cholesteatoma

Objective Cholesteatoma of the petrous bone extending into the intracranial region is an unusual occurrence. Most cases have been attributed to secondary extension of a primary epidermal blastomatous malformation of the temporal bone into the middle or posterior fossae. Within the past two and a half decades, intracranial extension of acquired aural cholesteatoma has been recognized as a likely alternative to this mechanism. Recent literature has rejoined this observation by considering both primary and secondary cholesteatoma of the petrous bone as a single group, petrosal cholesteatoma. The present study is presented to analyze the clinical presentation, imaging findings, and surgical treatment of six patients with acquired aural cholesteatoma extending into the intracranial region. Findings in this study are compared with the extant literature on congenital and acquired cholesteatoma of the petrous bone. This study proposes that petrosal cholesteatoma is a valid anatomical construct; however, the pathogenesis of petrosal cholesteatoma is still important in understanding the clinical presentation and management of cholesteatoma that extends beyond the usual confines of the middle ear and mastoid. Study Design Retrospective case review conducted at a tertiary referral center. Methods From 1985 to 1999, 477 patients were surgically treated for acquired aural cholesteatoma. Patients with intracranial extension of cholesteatoma were studied. Clinical presentation, imaging studies, operative findings, surgical treatment, and postoperative results were evaluated. Results Six cases in a series of 477 patients with acquired aural cholesteatoma had intracranial extension of disease. In this series, the most frequent pathway for intracranial extension was supralabyrinthine through the supratubal recess into the middle cranial fossa. A less frequent pathway was via the retrofacial air cells into the posterior cranial fossa. Surgical access for removal of intracranial cholesteatoma was accomplished through several approaches including translabyrinthine, transcochlear, retrolabyrinthine, and middle cranial fossa. In two patients who had reoperation for possible residual disease, one was free of residual disease and one was found to have residual cholesteatoma in the region of the horizontal facial nerve. Conclusion Acquired aural cholesteatoma can extend into either the middle or posterior cranial fossae. In this study, cholesteatoma extended into the middle fossa through the supratubal recess along the labyrinthine facial nerve and into or above the internal auditory canal. A less frequent path is through the retrofacial air cells into the posterior fossa. Intracranial acquired cholesteatoma is generally small and presents with complaints related to underlying otitis media rather than the neurological deficits that are often associated with primary petrous bone cholesteatoma. While computed tomography and magnetic resonance imaging are both required to differentiate congenital petrous cholesteatoma from other lesions of the petrous bone, computed tomography of the temporal bone is usually sufficient to diagnosis and define intracranial extension of acquired aural cholesteatoma. These lesions can be completely excised rather than exteriorized.     

Selective Indications for the Management of Extensive Anterior Epitympanic Cholesteatoma via Combined Transmastoid/Middle Fossa Approach

Objectives/Hypothesis Cholesteatoma that is present in the anterior epitympanic space may extend medially along the supralabyrinthine route to the geniculate ganglion, labyrinth, and cochlea and medially toward Kawase's triangle and the anterior petrous apex. Superiorly it may erode into the middle fossa. Contemporary microsurgical techniques allow for optimal management of these lesions with minimal morbidity, provided that the irregular and complex osteology of the petrous base is understood. The objective of the study was to review the relevant regional anatomy, pathobiology, and current algorithm used in treatment of this select patient population using a combined transmastoid/middle fossa (TM/MF) approach. Methods A retrospective review was performed of all clinical and radiographic data from patients undergoing combined TM/MF management of extensive anterior epitympanic cholesteatoma between July 1984 and June 1998. Data from physical examinations, preoperative imaging studies, and operative findings and other relevant data were tabulated and analyzed for patients undergoing TM/MF management of cholesteatoma. Results Of 488 patients with cholesteatoma treated by the otological service between 1984 and 1998, 11 patients underwent TM/MF exposure and removal of anterior epitympanic cholesteatoma. Total cholesteatoma removal was accomplished in six patients. In three patients, because of facial nerve involvement, labyrinthine fistulae, or internal carotid artery involvement, open‐cavity surgery was performed. In two patients, residual or recurrent cholesteatoma was exteriorized at “second‐look” procedures. In this small cohort of patients the majority had extension to the arcuate eminence, geniculate ganglion, or Kawase's triangle or had “blue‐lining” of the cochlea or labyrinth. To a lesser degree, the middle ear and mastoid contents were involved. Further facial nerve dysfunction or sensorineural hearing loss was not noted after surgery. Conclusions Selective TM/MF removal of cholesteatoma provides an optimal route for removing complex cholesteatoma in patients with intact sensorineural function and medial cholesteatoma extension.     

Aural tuberculosis at the start of the 21st century. Literature review according to SWiM guidelines. Part 2: Treatment

ObjectivesSystematic review of the scientific literature dedicated to treatment modalities and results for aural tuberculosis published since the start of the 21^st century.Material and methodsSearch of the Medline, Cochrane and Embase databases for the period 2000 - 2020. Selection of articles in English, French and Spanish devoted to clinical cases and series documenting treatment of auricular tuberculosis. Extraction of data on pre-established files documenting treatment modalities and results. Reading of articles by two authors. Analysis performed according to SWiM guidelines, evaluating cure, tuberculosis-related death, treatment-related complications, improvement in facial palsy, and hearing sequelae rates.ResultsOne hundred and twenty eight articles: 118 case reports (159 patients) and 10 cohorts (177 patients) from 42 countries were analyzed. Female/male sex ratio was 1.2 with ages ranging from 1 month to 87 years. Medical treatment consisted in 5 to 24 months’ antitubercular antibiotic treatment using 2 to 8 antibiotics. Mastoidectomy, tympanoplasty and facial nerve decompression were associated to medical treatment in 64.7%, 17.4% and 6.2% of cases, respectively. Overall rates of cure, death, treatment-related complications, facial sequelae and hearing sequelae were 96.8%, 2%, 9.5%, 35.8% and 75.5%. In case reports, BCG vaccination did not appear to protect against facial palsy and severe intracranial complications (P > 0.6). There was no significant correlation (P > 0.3) between death and the clinical variables tested, and facial nerve decompression did not appear to influence outcome for facial function (P = 0.4).ConclusionMedical treatment is very effective but not without risk of death, complications and sequelae. It is the same as for pulmonary tuberculosis. Indications for and benefit of major auricular surgery during medical treatment deserve further studies.     

Malignant otitis externa with subsequent internal jugular vein thrombosis and hypoglossal palsy: a report and review of literature

Inflammation of a part or whole of the temporal bone and surrounding soft tissue is termed as malignant otitis externa, which typically spreads to skull base to involve cranial nerves VII. Rarely can it also effect one or more of cranial nerves IX, X, XI, and XII. We present a case of malignant otitis externa which presented with symptomatic palsy of IX and XII nerves sparing the VII cranial nerve. The patient though later on had internal jugular vein thrombosis, which we presume is due to the involvement of the parapharyngeal space that prompted us to reconsider the diagnosis, and later on, to aggravate the therapy. With proper blood sugar control and appropriate long term antibiotics, not only that the patient is disease free at one year follow up, but the cranial nerve deficits also recovered. Apart from sharing the clinical and management details of this patient, we have reviewed the relevant literature in the discussion, which has shed some light onto some of the interesting facts about this condition and its prognosis.     

颞骨岩部胆脂瘤的手术治疗

目的探讨颞骨岩部胆脂瘤的临床特征、手术治疗及疗效。方法对1993～2002年收治的14例颞骨岩部胆脂瘤均经过手术证实和病理确诊。其中先天性3例，后天性11例。均有重度感音神经性聋或全聋和不同程度的周围性面瘫。手术取颅中窝入路9例，经迷路入路3例，迷路一颅中窝联合入路2例。术中见14例有耳蜗、骨迷路骨质破坏。颈内动脉暴露4例，颈内静脉暴露3例。面神经连续性存在，行全程而神经减压5例；而神经迷路段中断6例，行面神经改道吻合4例，2例因难以辨别中枢段断端，未行手术修复；内听道段损伤1例，因标志不清，无法修复；另外2例术前面肌萎缩，术中面神经未予手术修复。结果术后随访8个月至6年，除l例因复发行4次手术外，其余病人均未见胆脂瘤复发。按House-Brackmann面神经功能评级标准，全程减压5例中3例由Ⅲ级恢复到Ⅱ级，2例无恢复。面神经吻合4例中3例由Ⅳ级恢复到Ⅲ级，1例无变化。结论颞骨CT扫描在临床诊断上具有重要意义。手术是唯一的治疗方法，比较理想的手术入路为颅中窝或颅中窝-迷路联合入路。术中以完全清理病灶为主，尽量一期修复面神经功能。