Andrea Ciofalo

Osteomyelitis of the Skull Base with Atypical Onset and Evolution

Skull base osteomyelitis arises as a complication of malignant external otitis, but it can be also due to middle ear and/or mastoid infection. Other causes can be infections of the paranasal sinuses or of the mandible or maxilla due to odontic caries. Generally, osteomyelitis involves elderly patients affected by diabetic immunodeficiency or microvascular disease. In this paper, we present 3 new cases of skull base osteomyelitis with atypical onset and evolution. The difficulties of diagnosis and details of the management are discussed.

Solitary Fibrous Tumor of the Oral Cavity: Case Report and Pathologic Consideration

A 94-year-old Caucasian man affected by senile dementia came under our observation due to a bulky mass of the oral cavity advancing from the labial rim. Due to his mental condition, the patient had always refused surgical treatment. On clinical examination the ovoid-shaped mass was located on the mucosa of the right cheek, approximately 1 cm below the Stensen’s duct orifice; it was reddish-brown in color, had a hard-elastic consistency, and bled easily during manipulation (Fig 1). The neoplasm, which had been present for about 5 years, slowly increased in volume reaching the dimensions reported above, thus causing dysphagia and bleeding due to the presence of superficial microlesions induced by chewing. The tumor was removed surgically with an easy enucleation from healthy cheek tissues. After the excision the mass measured 7.5 5 4 cm. (Fig 2). The patient was discharged after 3 days. Twenty-four months later, no recurrence was detected. Microscopically, the lesion did not appear to be encapsulated, however, it was well-demarcated (Fig 3),

Taste and Olfaction in Middle Ear Surgery

Objective: The aim of this study was to assess pre- and postoperative taste ability in patients undergoing middle ear surgery for otosclerosis or chronic otitis media. Olfactory function was also evaluated to rule out taste deficits due to concomitant nasal pathology. Methods: All patients underwent ear, nose, and throat examination, otomicroscopy, nasal endoscopy, anterior rhinomanometry, taste testing, and olfactory testing. Patients were evaluated at 1 to 5 days preoperatively (T0), and at 1 (T1), 6 (T6), and 12 (T12) months postoperatively. Results: Both groups of patients experienced worsening of the mean taste threshold postoperatively. This phenomenon was more serious in poststapedotomy patients. Follow-up showed progressive improvement in both groups. All values of olfactory testing were within the normal range for otosclerosis patients. Patients with chronic otitis media showed variable postoperative findings. Conclusion: Chorda tympani function can be negatively affected by middle ear surgery. Deficits may be more marked in stapedotomy patients than in those undergoing tympanoplasty. Postoperative recovery of taste is satisfactory, although with different timelines for the 2 types of pathology.

Eustachian tube evaluation in patients with obstructive sleep apnea syndrome

Abstract Objectives: Investigate the presence of Eustachian Tube Dysfunction (ETD) in Obstructive sleep apnea (OSA) patients. Correlate the ET function and the severity of the sleep apnea syndrome. Correlate nasal resistance and nasal mucociliary clearance with the onset of ETD in these patients. Materials and methods: Forty patients affected by OSA were enrolled in our clinical prospective study. Thirty patients were also investigated as a control group. All of the analyzed subjects underwent ENT examination, anterior rhinomanometry and test for mucociliary transport time. To evaluate Eustachian tube function the Eustachian tube score-7 (ETS-7) were employed. Results: Twenty percent of the patients with a diagnosis of OSA had a diagnosis of ETD (ETS-7 ≤ 7) with a statistical difference with control group (p = .03). No differences regarding ETD in OSA sub-groups were found. Conclusion: This study showed that ET blockage or delayed openings were found in most adult patients with OSA when evaluated by a sensible score as the ETS-7. Our data suggest that an evaluation of the Eustachian tube function should be performed in patients suffering from obstructive sleep apnea syndrome.

Paraneoplastic pemphigus: Insight into the autoimmune pathogenesis, clinical features and therapy

Paraneoplastic pemphigus is a rare autoimmune skin disease that is always associated with a neoplasm. Usually, oral, skin, and mucosal lesions are the earliest manifestations shown by paraneoplastic pemphigus patients. The pathogenesis of paraneoplastic pemphigus is not yet completely understood, although some immunological aspects have been recently clarified. Because of its rarity, several diagnostic criteria have been proposed. Besides, several diagnostic procedures have been used for the diagnosis, including indirect immunofluorescence, direct immunofluorescence, and ELISA. We reviewed the most recent literature, searching on PubMed “paraneoplastic pemphigus”. We included also papers in French, German, and Spanish. We found 613 papers for “paraneoplastic pemphigus”. Among them, 169 were review papers. Because of its varying clinical features, paraneoplastic pemphigus still represents a challenge for clinicians. Furthermore, diagnosis and management of paraneoplastic pemphigus requires close collaboration between physicians, including dermatologist, oncologist, and otorhinolaryngologist.

Nasal histamine responses in nonallergic rhinitis with eosinophilic syndrome.

Background Nonallergic rhinitis with eosinophilic syndrome (NARES) is persistent, without atopy, but with ≥25% nasal eosinophilia. Hypereosinophilia seems to contribute to nasal mucosa dysfunction. Objectives This analytical case-control study aimed at assessing the presence and severity of nonspecific nasal hyperactivity and at finding out whether eosinophilia may be correlated with the respiratory and mucociliary clearance functions. Materials The symptom score was assessed in 38 patients and 15 controls whose nasal smear was also tested for eosinophils and mucociliary transport (MCT). Nonspecific nasal provocation tests (NSNPT) with histamine were also carried out, and total nasal resistance (TNR) was determined. Results The symptom score of NARES after NSNPT were not significantly different from the control group, and there was poor or no correlation among the single symptoms and the differences studied for every nasal reactivity class. This correlation improved when using the composite symptom score. The most severe eosinophilia was observed in high reactivity groups, and it was correlated with an increase in TNR. MCT worsened as eosinophilia and nasal reactivity increased. Unlike controls, a significant correlation was observed between the increase in MCT and TNR. Conclusions In NARES, nonspecific nasal hyperreactivity is the result of epithelial damage produced by eosinophilic inflammation, which causes MCT slow down, an increase in TNR, and nasal reactivity classes, with possible impact on classification, prognosis, and treatment control.

How to classify the stylohyoid complex syndrome in the ICHD

We have read the International Classification of Headache Disorders, third edition (beta) (ICHD-3 beta) (1), and for the first time headaches are attributed to inflammation of the stylohyoid ligament (SL). It is included among the secondary headaches in ‘‘Headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structure.’’ This is positive news because stylohyoid complex syndrome (SHCS) is an uncommon disease and now plays a role in ICHD-3 beta, as suggested by Montalbetti et al. in 1995 in this same journal (2). Therefore, it is our opinion that SHCS is not fully understood in ICHD-3 beta. SHCS is an uncommon condition related to degeneration or anatomical malformation of the stylohyoid complex (SHC), composed of the styloid process (SP), the lesser cornu of the hyoid bone and the SL that connects them. Three pathological conditions can develop in the SHCS: elongated SP, ossification or inflammation of the SL and an elongated hyoid bone. In SHCS there are two clinical groups: the classic variety presents with chronic neck pain, odynophagia, otalgia, dysphagia and foreign body sensation; the second variety is uncommon, since patients have neck and face pain plus headaches that are not relieved by common analgesics. In the first group one of the three pathological conditions of SHCS can provoke inflammation of soft tissues and neck nerves, while in the second symptom group the impingement of the SP on carotid vessels produces inflammation of the sympathetic nerve plexus in the arterial sheath with functional deficit. The mechanism is similar to cluster headaches in which carotid vasodilation pushes against the sympathetic plexus, producing a sympathetic deficit with release of vasoconstrictor tone. In the English literature we have found seven cases of headaches caused by styloid process impingement on carotid vessels and in three cases three-dimensional (3D) computed tomography (CT) imaging (CT-3D) of the neck showed elongated SP and the diagnosis of SHCS was made (3). Koebke also reveals typical characteristics of early arteriosclerosis at the point of SP impingement on carotid vessels (4). We have been treating a 35-year-old man who has been suffering from headaches for 10 years and who reported pain in the left cervical region. The 3D-CT imaging revealed a left cervical carotid artery compression due to an elongated SP. This procedure facilitates visualization of the SL and the relationship between the SP and the carotid artery (Figure 1). In conclusion, we believe that ICHD-3 beta can be improved: Point 11.8 states ‘‘headache or facial pain attributed to inflammation of the stylohyoid ligament,’’ but this is just one of three conditions in the SHCS. The right title should be ‘‘headache or facial pain attributed to SHCS.’’ For this reason, we propose that diagnostic B criteria should include radiologic evidence of ‘‘inflammation of the SL and/or elongated SP and/or the horn of the elongated hyoid bone’’ and that the C2 criteria should include pain caused by or exacerbated by head turning, chewing and swallowing. It is our opinion that the second variety of SHCS in ICHD-3 beta should also be considered. We propose that the pressing of SP on the carotid artery can be classified as secondary headache at point

Mild traumatic brain injury: evaluation of olfactory dysfunction and clinical–neurological characteristics

ABSTRACT Objective: To evaluate olfactory function and clinical–neurological characteristics in a group of patients with mild head trauma. Methods: A total of 352 patients with MTBI underwent olfactory function evaluation. The site of head trauma, loss of consciousness <20 min, memory loss, subjective presence or absence of olfaction and other clinical, neurological and radiological aspects were evaluated and compared with the olfactory dysfunction. Results: A total of 33.5% patients enrolled in the study had an olfactory dysfunction. Eighty-seven percent of the patients had a diagnosis of anosmia whereas 13% had a diagnosis of hyposmia. Statistical analysis did not show a correlation between radiologically detected head lesions and different types of olfactory dysfunction (p > 0.05). Besides, no difference between head lesion site and different olfactory dysfunction was reported (p = 0.5). Regarding olfactory sub-tests a low detection threshold was present in these patients. Conclusion: The possibility of olfactory dysfunction should be considered in any case of MTBI appears differently than expected, a minor head injury causes anosmia much more frequently than hyposmia.

Adult-Type Rhabdomyoma of the Larynx: Clinicopathologic Study of an Uncommon Tumor in a Rare Location

Rhabdomyoma is an uncommon benign mesenchymal tumor with skeletal muscle differentiation that may occur either in the heart or in extracardiac sites. Even though the head and neck region is the most common area of extracardiac rhabdomyoma, the larynx is rarely involved. We present the case of an 85-year-old woman who reported a 10-day history of breathing difficulties, dysphagia, and dysphonia. A computed tomography scan of the head and neck showed a contrast-enhanced, solid hypopharyngeal-laryngeal neoplasm with well-defined margins causing subtotal obliteration of the right pyriform sinus and a reduction in air lumen of the laryngeal vestibule. The patient underwent complete endoscopic removal of the lesion; histologic examination revealed an adult-type rhabdomyoma based on the histologic features and the immunoreactivity of the neoplastic cells for desmin, myoglobin, and muscle-specific actin but not for cytokeratin, S-100, CD68R, chromogranin-A, and synaptophysin. Since clinical and imaging features are not specific for rhabdomyoma, histologic examination and immunohistochemical analyses play a central role in the differential diagnosis of the adult-type rhabdomyoma from other laryngeal neoplasms. A correct diagnosis is mandatory to avoid inappropriate treatment.

Massive Cerebrospinal Fluid Leak of the Temporal Bone

Cerebrospinal fluid (CSF) leakage of the temporal bone region is defined as abnormal communications between the subarachnoidal space and the air-containing spaces of the temporal bone. CSF leak remains one of the most frequent complications after VS surgery. Radiotherapy is considered a predisposing factor for development of temporal bone CSF leak because it may impair dural repair mechanisms, thus causing inadequate dural sealing. The authors describe the case of a 47-year-old man with a massive effusion of CSF which extended from the posterior and lateral skull base to the first cervical vertebrae; this complication appeared after a partial enucleation of a vestibular schwannoma (VS) with subsequent radiation treatment and second operation with total VS resection.