Eva Maria Braun

Low molecular weight heparin therapy in pediatric otogenic sigmoid sinus thrombosis: A safe treatment option?

OBJECTIVE Septic thrombosis of the sigmoid and lateral sinus is a rare complication of acute otitis media, mastoiditis and cholesteatoma. Hence, the aim of this chat review was to analyze the demographics, presenting symptoms, diagnosis, and therapeutic management of otogenic sigmoid sinus thrombosis. Especially the role of low molecular weight heparin in the therapy of septic intracranial sinus thrombosis in children should be illuminated. METHODS A retrospective chart review was performed. RESULTS Six patients were included in this trial. One patient was treated completely conservatively. All other patients underwent surgical treatment consisting of mastoidectomy (n=5), additional thrombectomy (n=3) and ligation of the internal jugular vein (n=2). All patients received intravenous antibiotics and anticoagulants. Unfractionated heparin was administered for three days after surgery followed by an anticoagulant therapy with low-molecular weight heparin for three months. The activated partial thromboplastin time (aPTT) and the anti-factor-Xa-plasma-levels were monitored during anticoagulation in short term intervals. There were no complications related to the anticoagulant therapy. Recanalization was found in all patients who were treated without thrombectomy or ligation of the internal jugular vein and in the case of complete conservative treatment. CONCLUSION Simple mastoidectomy combined with broad spectrum antibiotics is the therapy of choice. Our results indicate that anticoagulants represent a safe treatment option if they are administered correctly.

Misdiagnosis of acute peripheral vestibulopathy in central nervous ischemic infarction.

Introduction Vertigo is a very common symptom at otorhinolaryngology (ENT), neurological, and emergency units, but often, it is difficult to distinguish between vertigo of peripheral and central origin. Patients and Methods We conducted a retrospective analysis of a hospital database, including all patients admitted to the ENT University Hospital Graz after neurological examination, with a diagnosis of peripheral vestibular vertigo and subsequent diagnosis of central nervous infarction as the actual cause for the vertigo. Twelve patients were included in this study. Results All patients with acute spinning vertigo after a thorough neurological examination and with uneventful computed tomographic scans were referred to our ENT department. Nine of them presented with horizontal nystagmus. Only 1 woman experienced additional hearing loss. The mean diagnostic delay to the definite diagnosis of a central infarction through magnetic resonance imaging was 4 days (SD, 2.3 d). Conclusion A careful otologic and neurological examination, including the head impulse test and caloric testing, is mandatory. Because ischemic events cannot be diagnosed in computed tomographic scans at an early stage, we strongly recommend to perform cranial magnetic resonance imaging within 48 hours from admission if vertigo has not improved under conservative treatment.

Management of otogenic sigmoid sinus thrombosis.

Objectives: To analyze the demographics, presenting symptoms, diagnosis, and management of otogenic sigmoid sinus thrombosis and to propose an algorithm in diagnosis and treatment. Methods: A retrospective chart review was performed. Six patients who were treated at the ENT University Hospital Graz between 2005 and 2010 were included. Results: The mean age of the patients was 11.7 years. Patients were experiencing symptoms for 9.8 days on average. Presenting symptoms were headache, neck stiffness, fever, otalgia, postauricular pain, and erythema. One patient presented with sixth nerve palsy. The otoscopic findings were abnormal in all cases. Computed tomography with contrast enhancement was performed in all patients. It was possible to detect the thrombosis in all cases with computed tomographic scans after contrast administration. An additional magnetic resonance imaging was performed in 3 patients. One patient was treated completely conservatively. All other patients underwent surgical treatment consisting of mastoidectomy. Additional thrombectomy was performed in 3 patients, and ligation of the internal jugular vein was performed in 2 of these 3 patients. All patients were administered intravenous antibiotics and anticoagulants. There were no complications related to the therapy. Recanalization was found in all patients who were treated without thrombectomy or ligation of the internal jugular vein and in the patient with complete conservative treatment. Conclusion: Otogenic sigmoid sinus thrombosis is a rare complication of otitis media. Early treatment with broad-spectrum antibiotics combined with simple mastoidectomy is the standard treatment. Anticoagulants represent a safe treatment option if they are administered correctly.

Feasibility of Piezoelectric Endoscopic Transsphenoidal Craniotomy: A Cadaveric Study

Objective. Endoscopic transsphenoidal approach has become the gold standard for surgical treatment of treating pituitary adenomas or other lesions in that area. Opening of bony skull base has been performed with burrs, chisels, and hammers or standard instruments like punches and circular top knives. The creation of primary bone flaps—as in external craniotomies—is difficult.The piezoelectric osteotomes used in the present study allows creating a bone flap for endoscopic transnasal approaches in certain areas. The aim of this study was to prove the feasibility of piezoelectric endoscopic transnasal craniotomies. Study Design. Cadaveric study. Methods. On cadaveric specimens (N = 5), a piezoelectric system with specially designed hardware for endonasal application was applied and endoscopic transsphenoidal craniotomies at the sellar floor, tuberculum sellae, and planum sphenoidale were performed up to a size of 3–5 cm2. Results. Bone flaps could be created without fracturing with the piezoosteotome and could be reimplanted. Endoscopic handling was unproblematic and time required was not exceeding standard procedures. Conclusion. In a cadaveric model, the piezoelectric endoscopic transsphenoidal craniotomy (PETC) is technically feasible. This technique allows the surgeon to create a bone flap in endoscopic transnasal approaches similar to existing standard transcranial craniotomies. Future trials will focus on skull base reconstruction using this bone flap.

Medullary Infarction After Vertebral Artery Dissection Presenting as Acute Peripheral Vertigo

Although vertigo is a very common symptom at an ENT, neurologic, or emergency department, it often is difficult to distinguish between peripheral and central vertigo. There are certain additional symptoms, such as nystagmus, cranial nerve palsy, focal neurologic deficits, or vegetative symptoms, that could lead to the right diagnosis. Nevertheless, in some cases, the origin of this symptom remains uncertain in an early stage.

Conductive Hearing Loss in Association With Urate Deposits in the Middle Ear.

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Sudden unilateral hearing loss as first sign of cerebral sinus venous thrombosis? A 3-year retrospective analysis.

Introduction Recently, several studies and case reports have dealt with the topic of cerebral sinus venous thrombosis (CSVT) and focused on sudden hearing loss as an early and rare symptom, to diminish the delay in diagnosing this serious disease. Materials and Methods We conducted a retrospective analysis over 3 years and investigated MRIs of all inpatients who were treated for sudden sensorineural hearing loss. The aim of the study was to evaluate whether sudden hearing loss could be an early indicator, or the first sign, of CSVT. Results In total, 554 patients were included. Only 2 patients with CSVT could be identified. In both, sudden unilateral sensorineural hearing loss was not the only symptom. They also reported headache, and 1 patient also reported tinnitus and vertigo. Conclusion In our opinion, sudden unilateral sensorineural hearing loss alone is not a reliable indicator of CSVT. In combination with headache or visual impairment, this rare vascular disease should be taken into account.

Pyramidal apex metastasis as primary manifestation of hepatocellular carcinoma.

As of today, no report exists about a hepatocellular carcinoma metastasis of the pyramidal apex. Most studies describe progressive cancer of the middle ear involving the pyramidal apex (1). Diagnosis of metastasis often is difficult because of occult growth. They mostly become symptomatic when cranial nerves are involved and palsies are seen (2). Hall et al. (3) report one of the first series of breast cancer metastasis in skull base in 10 patients. They report an involvement of cranial nerve V and VII in 60 to 70% of the patients, whereas no intracranial metastasis was reported. As of our knowledge, we report the first case of a metastasis of the pyramidal apex presenting with abducens nerve palsy and trigeminal neuralgia, which had not been diagnosed until transnasal transsphenoidal biopsy confirmed the diagnosis.

Otogenic Brain Abscess Mimicking as Stroke.

Intracranial complications of acute and chronic otitis media are rare with modern antibiotic therapy but remain potentially life threatening. The most severe complication is brain abscess formation. The symptoms of otogenic brain abscesses are inhomogeneous, although in most cases, they are accompanied by headache as a warning symptom. The following report describes a patient with an otogenic brain abscesswhopresentedwith atypical signs and symptoms.

Giant middle ear squamous cell carcinoma mimicking as cholesteatoma.

Malignancies of the ear are rare findings, and mostly, they arise from the external auditory canal. Middle ear carcinomas are a subset of temporal bone malignancies accounting for 0.2% of all head and neck cancer (1Y3). Several types have been described in the literature, such as adenocarcinoma, rhabdomyosarcoma, lymphoma, multiple myeloma, plasmocytoma, squamous cell carcinoma, mucoepidermoid carcinoma, andmetastatic disease (1,2,4). Benign lesions such as inverted papilloma, probably ascending from the nasal cavity via the Eustachian tube, have been reported turning into carcinoma in the course of time (5). Primary squamous cell carcinoma of the middle ear account for most lesions, with a rate of 62.9% as described by Gurgel et al. (2) in their study. However, they remain very rare compared with other head and neck carcinomas. The diagnosis is hampered by long symptom-free intervals or misdiagnosis as chronic otitis media. We report the case of a female patient referred to us with a diagnosis of chronic otitis media with cholesteatoma, which was identified histologically as giant squamous cell carcinoma.