Rinaldo F. Canalis

Rhinocerebral Mucormycosis: Evolution of the Disease and Treatment Options†

Rhinocerebral mucormycosis is recognized as a potentially aggressive and commonly fatal fungal infection. The classic presentation is involvement of nasal mucosa with invasion of the paranasal sinuses and orbit. Mucormycosis is most commonly seen in association with diabetic ketoacidosis, but disease demographics have changed with the onset of AIDS and the advent of powerful immunosuppressive drugs. Treatment includes aggressive debridement, systemic antifungal therapy, and control of underlying comorbid factors. Although surgical intervention remains essential, advances in medical therapy have permitted a more limited surgical approach to minimize functional loss without compromising survival. We present the UCLA experience with rhinocerebral mucormycosis from 1955 to 1995, with emphasis on the evolution of disease presentation and alternative treatment options.

Otologic manifestations of AIDS : The otosyphilis connection.

Five cases of otosyphilis presenting in patients with HIV infection are discussed. The group is representative of the known stages of the disease, from asymptomatic carrier to the fully expressed immunodeficiency syndrome, and it is of relevance because otosyphilis appears to have developed at an accelerated rate from the primary infection. Four patients had been treated with penicillin 2 to 5 years previously and had a positive fluorescent treponemal antibody absorption (FTA‐ABS) test. The fifth had concurrent neurosyphilis and was VDRL‐test (Venereal Disease Research Laboratory) negative 2 years prior to the onset of symptoms. In all five patients, syphilis was in the latent stage. It is proposed that it is during this phase of the disease that HIV may alter its course and hasten the development of otosyphilis. It is also suggested that otosyphilis can present at any stage of HIV infection and should be considered in seropositive patients presenting with otologic complaints.

Mucormycosis of the Temporal Bone

Mucormycosis of the temporal bone is described in a 60-year-old female with uncontrolled diabetes mellitus whose symptoms related to cranial nerve palsies and hearing loss, following spread of infection from the nasopharynx. The infection spread along the eustachian tube and tensor tympani muscle to the base of the skull, involving the internal carotid artery with mycotic thrombosis and rupture. Subsequent spread occurred from this area predominantly along nerve pathways and as mycotic emboli in blood vessels of the labyrinth and middle ear. Infection also spread from the anterior middle ear wall through the oval window into the vestibule. The temporal bone changes were those of granulomatous inflammation with necrosis and ischemic infarction.

Studies on the osteogenic potential of vascularized periosteum: behavior of periosteal flaps transferred onto soft tissues.

We investigated the basic properties of vascularized periosteal autografts. A pleuroperiosteal flap based on the intercostal vessels was developed In a canine model. Fourteen animals had vascularized periosteal flaps rotated onto the soft tissues of the chest wall. These animals were killed at intervals of 7 to 90 days and the flaps were studied by tetracycline labeling and light microscopy. Four other animals had similar flaps transplanted onto the soft tissues of the neck by microvascular techniques. All harvested flaps showed periosteal bone production, leading to the following observations: (1) Osteogenesis begins as early as 7 days after grafting; (2) the rate and extent of periosteal osteogenesis Is proportional to the vascular supply; (3) bone formation starts in small foci of active osteoblasts that grow and become confluent; and (4) Intimate bony periosteal contact Is not necessary for periosteal osteogenesis to take place, but it appears to influence the rate and amount of bone formation.

Klebsiella Rhinoscleromatis: A Clinical and Pathogenic Enigma

Rhinoscleroma is a chronic, slowly progressive, infectious disease of the respiratory tract that can produce disability and death, if untreated. Once considered an anomaly in the United States, the disease is now seen more frequently in this country, owing to increased travel from endemic areas. This report presents a comprehensive review of the several types of therapy that have been published in the literature. The results of a clinical experiment are also presented.

An interpretation of the structural changes responsible for the chronicity of rhinoscleroma.

Objective To identify the structural changes of the proliferative phase of rhinoscleroma which could be responsible for the chronicity of the disease.

Otological Manifestations of Churg-Strauss Syndrome

Objectives/Hypothesis To describe the clinical features, pathogenesis, and management of the otological complications in Churg‐Strauss syndrome (CSS).

Composite hyoid-sternohyoid interposition graft revisited: ucla experience 1974–1984†

The surgical correction of severe laryngotracheal stenosis remains a challenging problem. We report on a series of 20 patients treated with the composite hyoid‐sternohyoid interposition graft (HSIG). They range in age from 1 to 66 years and all had severe subglottic stenosis refractory to dilatation and stenting procedures. The major cause of stenosis was prolonged endotracheal intubation (16/20); the majority of patients (13/20) had severe medical illness complicating their airway management. Postoperative results were judged on the basis of decannulation, voice strength, and quality as well as activity tolerance. Follow‐up periods were over 24 months in all cases. Twelve patients were decannulated and three keep their tracheotomy tubes permanently plugged. All have socially acceptable voices and good activity tolerance. Seven patients who were aphonic had voice improvement. There were three complete failures; one secondary to infection, one due to severe scleroderma, and one because of graft displacement. Each patient underwent an average of four postoperative endoscopies for airway evaluation and removal of granulation tissue. CAT scanning was useful in diagnosing postoperative problems, especially graft displacement, which was impossible to diagnose by endoscopic examination. We conclude that the composite hyoid‐sternohyoid interposition graft is a useful and reliable tool in the treatment of subglottic stenosis.

Laryngeal sarcoidosis with airway obstruction.

Sarcoidosis is a chronic systemic granulomatous disease that occasionally affects the larynx. When the degree of involvement is marked, significant airway obstruction can occur. We present four cases of laryngeal sarcoidosis that resulted in airway obstruction. The clinical features of sarcoidosis of the larynx are discussed, and current methods of treatment are summarized. The laryngologist should include laryngeal sarcoidosis in the differential diagnosis of patients with airway obstruction, and should play a major role in its management.

Hemangiopericytoma of the cerebellopontine angle: a case report and review of the literature.

BACKGROUND Intracranial hemangiopericytoma represents a rare intracranial tumor that is typically difficult to distinguish from meningioma based on clinical presentation and radiographic findings. These inherently aggressive neoplasms have been observed to occur in numerous intracranial compartments; however, isolated involvement of the CPA is essentially unreported. The authors present a case of a young lady with presumed right acoustic schwannoma, which proved to be HPC on histopathology. The case is described; and a review of the literature pertaining to the diagnosis, optimal management, and follow-up for these lesions is provided. CASE DESCRIPTION A 37-year-old Asian woman presented with a 7-month history of right ear and mandible numbness, as well as subjective hearing loss involving the right ear. Magnetic resonance imaging demonstrated the presence of a homogeneously enhancing extraaxial lesion in the right CPA, radiographically suggestive of an acoustic schwannoma. The lesion proved to be an intracranial HPC on histologic sections. Review of the neurosurgical literature yielded only one prior detailed account of HPC confined to the CPA. The patient underwent right retrosigmoid craniotomy for gross total resection of the mass, followed by stereotactic radiotherapy several weeks postoperatively. CONCLUSION Given the fundamentally different treatment approach for HPCs over other more common CPA tumors, it is imperative that the treating surgeon consider this rare diagnosis when evaluating patients with lesions localized to this area. Specifically, gross total resection, followed by adjuvant SRT, provides patients with the highest probability for disease-free survival, based on current evidence in the neurosurgical literature.