Infant communicating hydroceles—do they need immediate repair or might some clinically resolve?

Purpose

Infant hydroceles that are communicating by history (fluctuation in size) or examination (reducible fluid) are often repaired soon after presentation. We have followed a series of infant boys with such hydroceles and reviewed their early natural history.

Materials and Methods

Since 1998, we have followed 174 infant boys presenting with an apparent communicating hydrocele without immediate surgical repair. All boys were initially seen before 18 months of age and most (168) by 12 months. Most had been full term at delivery, although 32 had been premature (<37 weeks' gestational age) and 11 extremely so (<32 weeks). Most boys (120) had bilateral hydroceles at presentation.

Results

Of the 110 boys followed to disposition, 69 (62.7%) had complete resolution without surgery by a mean age of 11.7 months. Forty-one patients (37.3%) underwent surgery for correction at a mean age of 14 months because of persistence in size or development of a hernia. Six developed a hernia during observation, none of whom had any episode of incarceration. Only 2 patients with apparent resolution subsequently had recurrence with a hernia. Age at presentation and gestational age at birth showed no effect on resolution. The hydroceles of 64 boys had improved in size after a mean follow-up of 13.9 months when last seen.

Conclusions

Many infant hydroceles that are communicating by history or examination do resolve clinically without surgery and deserve observation. Progression to hernia was rare in our experience and did not result in incarceration. Consequently, little risk is taken by initial observation.     

The radiologic evaluation of tinnitus

Tinnitus (“ringing in the ears”) is a prevalent symptom in the general population, and often brings patients to medical attention. Many causes of tinnitus are evident radiographically. The most frequently-encountered causes of tinnitus are discussed, and imaging recommendations are provided.     

Phosphatidylserine and caffeine attenuate postexercise mood disturbance and perception of fatigue in humans

Phosphatidylserine (PS) may attenuate the adverse effects of physical fatigue. Therefore, we investigated the effects of a multi-ingredient supplement containing 400 mg/d PS and 100 mg/d caffeine (supplement [SUP]) for 2 weeks on measures of cognitive function (CF), reaction time (RT), and mood (MD) following an acute exercise stress. It is hypothesized that PS will maintain preexercise CF and RT scores, while attenuating postexercise fatigue. Participants completed 2 acute bouts of resistance exercise (T1 and T2) separated by 2-week ingestion of SUP or control (CON). Outcome measures were assessed pre- and postexercise. When collapsed across groups, a significant decrease in RT performance was seen in the 60-second reaction drill from pre- to postexercise at T1. All other RT tests were similar from pre- to postexercise at T1. Reaction time was not significantly changed by PS. When collapsed across groups, a significant increase in performance of the serial subtraction test was seen. A significant increase (8.9% and 7.1%) in the number of correct answers and a significant decrease (8.0% and 7.5%) in time to answer were seen from pre- to postworkout at T1 and T2, respectively. A significant increase in total MD score from pre- to postworkout was observed for CON but not for PS at T2. Phosphatidylserine significantly attenuated pre- to postexercise perception of fatigue compared to CON. Ingestion of SUP for 14 days appears to attenuate postexercise MD scores and perception of fatigue, but does not affect CF or RT, in recreationally trained individuals.     

The utility of fine needle aspiration to identify unusual pathology in a parapharyngeal mass

The parapharyngeal space is a complex and well-defined anatomical zone lying lateral to the pharynx and medial to the ramus of the mandible. Although tumors of this space are rare, the parapharyngeal space is difficult to examine clinically; and diagnostic modalities of computerized tomographic scanning and magnetic resonance imaging are primarily used in the evaluation of parapharyngeal space lesions. We present a case report of a second branchial cleft sinus of the parapharyngeal space diagnosed with the assistance of fine needle aspiration (FNA), and we recommend FNA of parapharyngeal masses to provide definitive preoperative diagnoses.     

Yield of Neck CT and Barium Esophagram in Patients with Globus Sensation

BACKGROUND AND PURPOSE:Globus sensation is common and difficult to treat. The purpose of our study was to compare the diagnostic and therapeutic efficacy of barium esophagram and neck CT in patients with isolated globus sensation, to determine which of these modalities should be preferred in the evaluation of this condition.MATERIALS AND METHODS:We retrospectively identified patients presenting with isolated globus sensation from January 1, 2005, to December 31, 2012, who underwent neck CT or barium esophagram. We calculated the proportion of patients with abnormal findings, tabulated the nature of the abnormality, and reviewed the medical records to determine whether imaging changed management.RESULTS:One hundred forty-eight neck CTs and 104 barium esophagrams were included. Five (3.4%) patients with neck CTs and 4 (3.9%) with barium esophagrams demonstrated significant findings related to the history of globus sensation. Of these, 1 (0.7%) neck CT and 1 (1.0%) barium esophagram resulted in a change in clinical management.CONCLUSIONS:Imaging evaluation of the patient with uncomplicated globus sensation is unlikely to identify clinically significant imaging findings and is very unlikely to result in a change in clinical management, with a combined therapeutic efficacy of 0.8%. Thus, the routine use of imaging in the evaluation of patients with globus sensation cannot be recommended.

Globus sensation (GS), an intermittent or persistent painless sensation of a foreign body or lump in the throat, is a long-lasting and often frustratingly difficult-to-treat clinical entity.¹ It is a relatively common condition, accounting for up to 4% of new referrals to otolaryngology clinics, with a prevalence of up to 35% in males and over 50% in females, with a relative peak in middle age.^2–4 A range of etiologies has been suggested and described, including lingual and tonsillar hypertrophy, psychogenic factors, cervical osteophytes, upper aerodigestive tract malignancy, thyroid disease, and esophageal motor disorders.^5–8 More recently, there has been increasing focus on gastroesophageal reflux disease as a cause of GS.^9–13 The myriad potential etiologies of GS have made it difficult to establish standard treatment and imaging strategies for affected patients.The imaging approach to the patient with GS varies widely in clinical practice. A neck CT, usually ordered with contrast, is well-suited to detect many structural causes of GS and is a useful tool to exclude a large upper aerodigestive tract malignancy, while a barium esophagram is well-suited for detailed evaluation of esophageal motility and mucosal and submucosal lesions of the esophagus. While a barium esophagram may also detect (but cannot exclude) intermittent esophageal reflux, if evaluation for esophageal reflux is of primary concern, then esophageal manometry, endoscopy, esophageal pH monitoring, or a trial of empiric therapy is the preferred diagnostic test.^14–16The imaging approach to the patient with GS varies widely in clinical practice. Because an evidence-based approach to imaging GS is lacking in current clinical practice, practitioner and locoregional biases strongly influence the decision to use neck CT or barium esophagram. This may adversely impact the clinical value of these studies because the value of a diagnostic test is largely dependent on the prevalence (or the clinician''s estimate of the pretest probability) of the target disorder, and abnormalities detectable on neck CT and barium esophagram are statistically unlikely etiologies in a general sample of patients with GS. Because overuse of diagnostic tests contributes to both the rising cost and the overall quality of health care, defining the value of diagnostic tests has become an important goal of health care reform. We conducted the present study to determine the incidence and nature of abnormalities on neck CT and barium esophagram examinations performed in the work-up of patients with isolated GS and to assess which imaging technique contributed most effectively to the clinical management of these patients.     

A biomechanical comparison of three lower extremity tendons for ligamentous reconstruction about the knee

Purpose: The purpose of this investigation was to evaluate 3 previously unreported allograft tendons for use in knee surgery. These are the doubled tibialis anterior (TA), doubled tibialis posterior (TP), and doubled peroneus longus (PL) tendons. Type of Study: A biomechanical evaluation of the properties of the TA, TP, and PL. Methods: Sixteen fresh-frozen cadaveric lower limbs were used for testing. All specimens had the TA, TP, and PL tendons harvested. All specimens were tested in a custom-designed hydraulic testing machine using dry ice clamps. Each tendon was elongated at a rate of 1 mm/s. Load and displacement were recorded with an analog to digital interface board. Stiffness, modulus of elasticity, and stress and strain at failure were calculated. Results: The average tested lengths of the TA, TP, and PL were 37 cm (range, 13–68 cm), 33 cm (range, 7–74 cm), and 42 cm (range, 17–69 cm), respectively. The average cross-sectional areas of the doubled TA, TP, and PL were 38 mm², 48 mm², and 37 mm², respectively. The average failure loads for the doubled TA, TP, and PL tendons were 3,412 N, 3,391 N, and 2,483 N, respectively. The maximum stresses of the 3 tendons did not differ significantly (85–108 Mpa). The TA had the greatest stiffness (344 N/mm), followed by the TP (302 N/mm) and the PL (244 N/mm). Previous authors have documented the biomechanical strength of grafts for ACL reconstruction between 1,700 and 2,900 Newtons. The ultimate tensile strength and stiffness reported for the TA and TP grafts exceeded that for all previously reported grafts, including the doubled semitendinosus-gracilis. Conclusions: The TA, TP, and PL tendons showed excellent biomechanical properties when compared with historical data evaluating other graft sources. The biomechanical properties observed for the TA, TP, and PL were noted in specimens despite an average age of 78.3 years.