Itzhak Braverman

Computed Tomography Diagnosis of Esophageal Bone Impaction: A Prospective Study:

A prospective study was performed on 45 patients for an assessment of the use of computed tomography (CT) in the management of a suspected esophageal fish bone or chicken bone. All patients had negative findings on laryngoscopy; therefore, pharyngeal and hypopharyngeal foreign bodies were excluded from further consideration. The patients underwent radiographic examination with plain films and a cervical CT scan without contrast material. Patients with positive findings were taken to the operating room, where they underwent rigid esophagoscopy under general anesthesia, while those with negative findings remained for observation for 24 hours. Thirty CT scans were positive for an esophageal foreign body, and in all cases but 1, a foreign body was found during the operation. Fourteen of 15 patients with normal CT scan findings managed well with no further intervention. One patient with persistent complaints underwent esophagoscopy, but no foreign body was found. Our conclusion is therefore that CT is a simple and reliable method for diagnosing esophageal bone impaction and may reduce the rate of unnecessary esophagoscopies.

Prednisone Treatment for Vestibular Neuritis

Objective: To evaluate the value of corticosteroids in the treatment of vestibular neuritis (VN). Design: Prospective controlled randomized. Methods: Thirty VN patients, 15 in the study and 15 in the control group, were the subjects of the study. The study group was treated by 1 mg/kg prednisone for 5 days, followed by gradually reduced doses of prednisone for an additional 15 days, and vestibular sedatives for symptomatic relief during the first 5 days after presentation. The control group received a placebo and similar vestibular sedatives. The patients had a baseline evaluation and follow-up examinations after 1, 3, 6, and 12 months. The groups were compared for the presence of symptoms and signs, caloric lateralization on the electronystagmography (ENG), the presence of other pathologic findings in the ENG, and Dizziness Handicap Inventory scores. Results: No differences were found between the groups in the occurrence of symptoms and signs, degree of caloric lateralization, presence of other ENG pathologic findings, and Dizziness Handicap Inventory scores at the end of the study. Complete resolution was observed in 64% of the study and in 80% of the control group. The study group showed earlier recovery of ENG lateralization at the 1- and 3-month follow-up evaluations and higher rates of complete resolution at the 3- and 6-month follow-up points. Conclusion: Prednisone therapy might enhance earlier recovery but does not improve the long-term prognosis of VN. The clinical and laboratory parameters in VN are not correlated, and both are required for complete patient evaluation.

A rare recessive distal hereditary motor neuropathy with HSJ1 chaperone mutation.

Distal hereditary motor neuropathies (dHMN) form a clinically and genetically heterogeneous group of disorders, characterized by muscle weakness and atrophy predominating at the distal part of the limbs, due to the progressive degeneration of motor neurons in the spinal cord. We report here a novel rare variant of dHMN with autosomal recessive inheritance in a large Jewish family originating from Morocco. The disease is characterized by a predominance of paralysis at the lower limbs and an early adulthood onset. We performed a genetic study in this family to identify and characterized the causing mutation.

Histology of the nasal septal swell body (septal turbinate)

OBJECTIVE: To analyze the vascular and glandular elements of the nasal septal swell body (NSB) and quantitatively compare these to the inferior turbinate (IT) and non-swell body portion of septum. STUDY DESIGN: Fourteen healthy adults undergoing septoplasty and IT reduction were submitted to unilateral biopsies of the NSB, the adjacent inferior turbinate, and inferior septum. Photomicrography with morphometric analysis was used to determine the relative area proportions of each tissue type. RESULTS: NSB was rich in seromucinous glands (49.9% ± 7.0%) compared to IT (19.9% ± 5.5%), P < 0.01. Conversely, IT mucosa demonstrated increased area proportion of venous sinusoids (28.3 ± 13.9) compared to NSB (10.0 ± 6.0), P < 0.01. Inferior septal mucosa had glandular and vascular elements similar in proportion to that of NSB. CONCLUSIONS AND SIGNIFICANCE: NSB is a highly glandular structure of the anterior-superior septum, with moderate proportion of venous sinusoids. Located at the distal valve segment, the NSB appears structured for secretory function and vasoactive airflow regulation.

Partial inferior turbinectomy using the microdébrider.

BACKGROUND A microdébrider was selected to accomplish partial inferior turbinectomy, allowing for controlled and rapid removal of hypertrophic soft tissue while preserving the general turbinate form. OBJECTIVE To assess the clinical outcome, healing, and any adverse consequences from the microdébrider partial turbinectomy procedure. SETTING A public hospital in north-central Israel. DESIGN A nonrandomized prospective study of 35 adults who were referred for nasal airway surgery, including turbinectomy. METHODS All patients underwent bilateral inferior turbinate reduction with the microdébrider, with removal of mucosa from the medial and inferior portions of the inferior turbinates. Detailed follow-up was accomplished at 4 or more months postoperatively, including a visual analogue scale questionnaire and videoendoscopy. For seven patients, pre- and postoperative mucosal biopsies were available to evaluate healing and epithelial regeneration. RESULTS Nasal endoscopy showed well-healed turbinate membranes and preservation of the turbinate form, with widening of the inferomedial nasal airway space. Subjective nasal patency improved after surgery, p < .01, and the subjective sense of smell was improved, p < .01, without associated crusting, pain, irritation, sneezing, or dryness. Postoperative biopsies showed subepithelial fibrosis and regenerated epithelium, generally of respiratory differentiation. CONCLUSION Inferior turbinate reduction can be accomplished efficiently with the microdébrider device, without undue side effects. SIGNIFICANCE Further experience and long-term follow-up with this technique are warranted.

Effects of passive smoking on odour identification in children.

BACKGROUND AND OBJECTIVE The effect of passive smoking on odour identification in children has rarely been reported. This study assessed the ability of such young subjects to identify a variety of odours. METHODS The study population consisted of 20 children, 10 who were exposed to passive smoke at home and 10 with nonsmoking parents. Ten odourants were tested: vinegar, ammonia, peppermint, roses, bleach, vanilla, cough drops, turpentine, licorice, and mothballs. Each child was presented with five test trays containing all 10 odourants in random order. RESULTS Of the total of 500 odours presented, the control group correctly identified 396 (79%) and the study group identified 356 (71%) (p < .005). The study group tended to misidentify 4 of the 10 odourants tested, namely, vanilla, roses, mothballs, and cough drops-56 of 200 (28%), compared with 96 of 200 (48%) in the control group. This was a highly significant finding (p < .0005). CONCLUSION This work demonstrated that children exposed to passive smoke have difficulty identifying odours in comparison with children raised in relatively smoke-free environments. The identification of four odourants, vanilla, roses, mothballs, and cough drops, was particularly diminished in this study group.

Spontaneous Vertebral Artery Dissection Mimicking Acute Vertigo Case Report

A patient with acute vertigo, and normal findings on neurologic examination, was found to have vertebral artery dissection (VAD). This case shows that the clinical picture of VAD can mimic vertigo of labyrinthine (ie, peripheral) origin.

Hyponasality Caused by Retronasopharyngeal Air as a Symptom of Pneumomediastinum

During a 6-month period we encountered five patients with acute hyponasality as a presentation of pneumomediastinum (Table 1). All were male, ranging in age from 16 to 74 years. Three patients had spontaneous pneumomediastinum, and two patients had posttraumatic pneumothorax and pneumomediastinum. Two patients had spontaneous pneumomediastinum caused by asthma and respiratory infection. In one case it was the result of a ruptured pulmonary bleb. Chest pain was present in four patients, and shortness of breath was present in three patients. Pneumothorax was Hyponasality caused by retronasopharyngeal air as a symptom of pneumomediastinum

How did it get there? A coiled metal foreign body in an unusual cervical position

A 50-year-old man was seen at the emergency department at Carmel Medical Center because of an FB sensation in his right throat and odynophagia after eating a hamburger in a restaurant 1 hour earlier. He had the feeling of something in his throat and introduced a finger in an attempt to take it out, but the feeling persisted. On examination the patient had no difficulty in breathing, but he said it was difficult for him to swallow. No FB or mucosal tear was evident in his mouth or pharynx. No fluctuance or crepitance of the cervical soft tissues was present. The patient was afebrile. Plain radiographs of the neck in the lateral and anteroposterior position were performed and both showed a 3-cm long hyperdense coiled FB in the right pharynx at the level of the first to third cervical vertebrae (Fig 1). Surprisingly the cranial end of the FB was located laterally whereas the caudal end was located medially, close to the mucosa of the hypopharynx. With the patient under general anesthesia, a rigid pharyngoscopy found no evidence of an FB in the pharynx or hypopharynx, and no injury site to the mucosa was seen. A CT of the neck using contrast material found the same FB tranversing the right parapharyngeal space and embedded in the vascular space, close to the external carotid artery. While hospitalized the patient was hemodynamically stable and afebrile, and his blood count showed no leukocytosis but he still complained of the same odynophagia. After 3 days of close follow-up, the patient was discharged with the rationale that if the feeling was not better in 10 days, a new CT scan and even surgery might be required. Because the patient continued to complain of odynophagia, a new tomography study was made in which the FB was found in close proximity to the external carotid artery, and it was decided to remove it. A transoral approach through the pharynx was taken behind the posterior tonsillar pillar and almost reaching the vascular space. The FB could not be located with a dynamic intraoperative fluoroscopy. Next an exploration of the neck was performed through the vascular space. Because of the access from both sides, an orocutaneous fistula was made. After the major vessels in the vascular space were controlled using the intraoperative stereotactic dynamic fluoroscopy, a 3-cm long metallic coiled FB was located in close vicinity to the external carotid artery and was carefully withdrawn (Fig 2). A drain was left in the neck, and because of the orocutaneous fistula, a nasogastric tube was introduced. The patient was fed enterally and antibiotics administered perioperatively. After 2 days the drain and the nasogastric tube were taken out without any evidence of fistula. The antibiotics were stopped, and the patient was discharged after 6 days. On followup he was symptom-free.

Trigeminal herpes zoster/chocolate-vanilla tongue ☆ ☆☆ ★

pain on the left side of his face and oral cavity, dysphagia, fever, and facial vesicles. He had difficulty eating and drinking but had no dyspnea. His history revealed hypertension and hyperlipidemia, which were treated medically. He had undergone coronary artery bypass surgery 4 years earlier because of ischemic heart disease. On examination he looked ill and had a temperature of 38°C. The left side of his face was swollen with multiple vesicles, which were also found in the left oral cavity and on the left half of his tongue, which was swollen and edematous. There was some tenderness in the left submandibular area, but no lymphadenopathy was present. An ophthalmologic examination showed signs of hypertensive retinopathy with no other involvement. The rest of the otolaryngologic and physical examination was within normal limits. After 5 days the tongue was less swollen, but pain increased, and his left hemitongue turned a dark brown-red color (Fig 1). His blood analyses were within normal limits with no leukocytosis. Treatment with intravenous hydration and per oral acyclovir 0.8 g 5 times/day, analgesics, and mouth washes was started. After 1 day the facial and lingual swelling were worse, and he was treated with intravenous steroids and an antibiotic (doxacillin 2 g 4 times/day). After 1 week there was some improvement, and the patient was discharged with left facial pain. He was treated by a pain clinic, and 11 days after hospitalization, the face and tongue lesions disappeared, but a left facial palsy developed. Findings of a CT scan of the brain at that time were within normal limits. He had facial pain for several months, which gradually improved, as did the facial palsy. Herpes zoster is caused when the varicella/zoster virus that has remained latent since an earlier varicella infection is reactivated. It is a common viral illness presenting with vesicular eruptions in a dermatomal distribution. Ophthalmic herpes zoster can result in ophthalmoparesis, which is a frequent complication of this condition.1,2 Involvement of the third segment of the trigeminal nerve causes trigeminal neuralgia and facial eruptions and can affect the oral cavity with odontalgia.3 A previous case has been reported of herpes zoster oticus with involvement of the mandibular division of the trigeminal nerve and loss of taste sensation in the anterior two thirds of the tongue.4 Another report of mandibular branch involvement of the trigeminal nerve describes the diagnosis without evidence of a vesicular eruption but with demonstration of a high IgG antibody titer during the acute phase of the disease and clinical findings of pain in the mandibular nerve distribution.1 Our patient had common trigeminal herpes zoster, but his lingual involvement and its “chocolate-vanilla ice cream” appearance were unusual. To the best of our knowledge, such a clinical appearance of trigeminal herpes zoster has not been reported.