Christian Barna Teszler

Descending necrotizing mediastinitis: contemporary trends in etiology, diagnosis, management, and outcome.

Objective:To evaluate contemporary trends in etiology, diagnosis, management, and outcome of descending necrotizing mediastinitis (DNM) and to draw the clinicians attention on this probably underappreciated disease. Summary of Background Data:An uncommon but one of the most serious forms of mediastinitis is DNM which is caused by downward spread of deep neck infections and arises as a major complication of “banal” odontogenic, pharyngeal, or cervicofacial foci. As most studies are based on small patient populations, current data on risk factors, etiology, and outcome vary significantly. Also, the optimal form of treatment remains controversial. Methods:This retrospective study, which is the largest single-center study since 1960, is based on the management of 45 patients with DNM treated over a period of 12 years. Additionally, a meta-analysis of 26 studies on DNM published between 1999 and 2008 was performed and compared with own data and 2 previous meta-analyses covering the interval from 1960 to 1998. Results and Conclusions:Today DNM most commonly arises from pharyngeal foci and mixed polymicrobial aerobic and anaerobic infections. Reduced tissue oxygenation and impaired immune function promotes its development. Most cases of DNM are limited to the upper mediastinum and can be adequately drained by a transcervical approach. Formal thoracotomy should be reserved for cases extending below the plane of the tracheal bifurcation. Although DNM remains an aggressive infection with high morbidity, a favorable outcome can now be obtained in 85% of patients, even with this selective approach. Early diagnosis and surgical intervention are crucial.

Navigation as a quality management tool in cochlear implant surgery.

This cadaver study assessed the value of navigation in cochlear implant surgery. Cochlear implantation was simulated on a cadaver using a Stryker-Leibinger navigation system and a Nucleus 24 Contour implant. A conventional surgical strategy consisting of mastoidectomy, posterior tympanotomy, and cochleostomy was performed. The navigated surgical procedure was evaluated for accuracy, reliability, reproducibility, and practicability. The technology of computer-assisted surgery is applicable in cochlear implantation and beneficial in as much as the navigation-controlled implantation constitutes a non-invasive instrument of quality management. Nevertheless, in order to keep the point accuracy below one millimeter, a referencing method using concealed bordering anatomical structures may be further needed to perform the cochleostomy reliably under the guidance of a navigation system. More reproducible reference systems are needed if navigated lateral skull base surgery is to be fully relied upon.

Cochlear implantation in healthy and otitis-prone children: a prospective study.

Objective To evaluate and compare the timing of surgery, intraoperative findings, and otitis media‐related outcome of cochlear implantation in children who are otitis‐prone with their counterparts who are not otitis‐prone.

Solitary Fibrous Tumors in the Head and Neck: New Insights and Implications for Diagnosis and Treatment

Objectives: The solitary fibrous tumor (SFT) is a potentially malignant spindle cell neoplasm of mesenchymal origin that was originally described as a thoracic lesion originating from pleural tissue. Recently, numerous extrapleural sites of origin have been described, frequently affecting the head and neck region. The purpose of this article is to focus on a formerly underestimated neoplasm and to highlight its appearance in the head and neck region. Methods: The authors present 2 illustrative cases, including what is probably the first reported case of an SFT arising in the human tonsillar fossa, and give a clinical and pathological literature review. Results: The clinical, histologic, and radiologic features are presented, and the surgical treatment is described. The international medical literature concerning SFTs in general and SFTs of the head and neck in particular is reviewed, and the changing concept of SFTs and hemangiopericytomas is discussed on the basis of the updated World Health Organization classification of soft tissue tumors. Conclusions: It is nowadays recognized that the large majority of lesions formerly classified as hemangiopericytomas are, in fact, variants of SFTs. Although still a rare occurrence, SFTs have become increasingly recognized, and clinicians should be aware of their presentation.

Endolymphatic sac tumours : Surgical management

BACKGROUND Endolymphatic sac tumours (ELSTs) have been known as an individual tumour entity only since 1984. ELSTs may occur either solitarily and sporadically or as a hereditary manifestation associated with von Hippel-Lindau (VHL) disease. The latter association was first observed in 1992 and confirmed by molecular genetic analysis of the VHL gene. No consensual diagnostic and treatment strategy of ELST exists at present. METHODS Based on imaging criteria in computed tomography, magnetic resonance imaging (MRI), and magnetic resonance angiography, we developed a staging system to classify ELST in a series of seven consecutive patients in an attempt to custom-tailor the surgical approach. Type A referred to tumours that were locally confined without temporal bone erosion or infiltration of the dura (n = 2); type B tumours showed evidence of bone infiltration of the osseous labyrinth and sensorineural hearing loss (n = 2); and in type C, the tumour further invaded the sigmoid sinus and jugular bulb (n = 3). Two patients suffered from VHL disease. RESULTS In all patients, the tumour was completely removed. Stage-adapted surgical approaches included various transpetrosal procedures, from the translabyrinthine to the infratemporal approaches. The functional integrity of the facial nerve was maintained in all tumour stages, whereas the vestibulocochlear nerve could be preserved only in patients with type A tumours. Follow-up MRI demonstrated no local tumour recurrence during a postoperative observation period ranging from 4 to 38 months. CONCLUSION Stage-based surgical strategy enables the complete removal of ELST with minor morbidity. Transmastoid approaches are most efficient for resection of the tumour matrix to prevent local recurrence.

Beneficial effect of contralateral amplification in cochlear implant users

Cochlear implants and conventional hearing aids use different stimulating signals. The beneficial effect of contralateral hearing aids in cochlear implantees, in terms of added speech perception, is still a matter of debate. The aim of this study was to evaluate the possible enhancement in speech perception in unilateral cochlear implantees who wear a conventional hearing aid in the non-implanted ear. Speech perception was evaluated after the patients had achieved a stable cochlear implant map and were comfortable with their binaural bimodal hearing.

Delayed ventricular fibrillation following blunt chest trauma in a 4-year-old child.

A 4‐year‐old boy who was involved in a motor vehicle accident as a pedestrian and suffered blunt chest trauma was admitted to the emergency room. Unpredictable delayed ventricular fibrillation was diagnosed and treated successfully 2 h later. This case cannot be classified as commotio cordis as the ventricular fibrillation (VF) developed so long after the sustained chest injury. At the same time, other possible etiologies of VF such as cardiac pathology or electrolyte and metabolic disorders had been ruled out. Thus, an etiological link between the chest trauma and the subsequent VF could not be ruled out and is in fact plausible despite the late onset.

Does adding intravenous fentanyl to caudal block in children enhance the efficacy of multimodal analgesia as reflected in the plasma level of catecholamines

Background and objective: Several studies showed that single analgesic modality management can attenuate perioperative stress, but little is known about the effect of multimodal analgesia on catecholamine responses to surgical trauma in children. Methods: Fifty children (American Society of Anesthesiologists Grade I or II) were randomly allocated to one of two groups: one received general anaesthesia and a caudal block (control group), and one group was given general anaesthesia, caudal block and intravenous (i.v.) fentanyl 2 &mgr;g kg−1 (fentanyl group). Plasma epinephrine and norepinephrine concentrations were measured three times during the perioperative period: at induction time (T0), at the end of surgery (T1) and when the children were fully awake in the postanaesthesia care unit (T2). Results: There was a significant reduction in the catecholamine levels in the two groups when (T1) and (T2) were compared with T0. When plasma epinephrine levels (at T0, T1 and T2) between the two groups were compared, a statistically significant reduction at T2 was obtained in the fentanyl group, when compared with the control group. However, plasma norepinephrine levels showed no statistically significant difference between the two groups (at T0, T1 and T2). Conclusion: These findings suggest that the multimodal analgesic approach of adding i.v. low‐dose fentanyl to a caudal block may decrease the plasma epinephrine release in children undergoing inguinal herniotomy.