Fungal skull base osteomyelitis: Emerging microbial identification techniques

Culture‐based pathogen identification in skull base osteomyelitis, particularly for fungi, is often inaccurate. We report the case of patient with fungal skull base osteomyelitis cured by sustained antifungal therapy after 16 months of debilitating illness. Due to medical complications, a strong clinical rationale was needed to justify long‐term antifungal therapy. The offending fungus was identified by experimental molecular technology (Ibis T5000 universal biosensor); invasive fungal disease was corroborated by biochemical assays. Our discussion will help familiarize the otolaryngologist with existing biochemical and molecular diagnostics for invasive fungal disease. We encourage future investigators to study their application in cases of skull base osteomyelitis. Laryngoscope , 127:E5–E7, 2017     

内镜下经眶外下壁入路颅底手术应用解剖研究初探

目的通过尸头解剖来探索经眶外下壁入路内镜手术所能达到的解剖通道、解剖标志及解剖方法等。方法对5具尸头（10侧）进行内镜下经眶外下壁入路颅底手术的细分解剖,通过逐步解剖来界定该入路所能达到解剖通道、颅内外重要解剖标志、解剖边界等。结果本研究界定了内镜下经眶外下壁入路颅底手术所能达到的5个通道,它们分别是三叉神经通道、破裂孔通道、海绵窦通道、岩锥及后颅窝通道、中颅窝通道,它们的边界、解剖标志、解剖通道、解剖步骤及方法都得以明确的界定。结论内镜下经眶外下壁入路颅底手术可以到达旁中线颅底、中颅窝,甚至是部分侧颅底及后颅窝,而且对于上颌神经、下颌神经颅内外段的暴露能提供很好的视野。当然,这还需要进一步的解剖研究及临床实践加以完善及检验。     

Acquisition of surgical skills for endonasal skull base surgery: a training program

Introduction : Endonasal surgery represents a radical change in the practice of cranial base surgery and requires the acquisition of new knowledge and surgical skills. The optimal training program for surgeons has not been established. Methods : We reviewed our experience with endonasal cranial base surgery from 1998 to 2006 to develop a training plan for the acquisition of surgical skills. It consists of a modular and incremental approach to endonasal skull base surgery that is designed to train surgeons to function as a team, learn endoscopic skull base anatomy, and develop fundamental endoscopic skills. Results : Stages of training are established for the otolaryngologist–head and neck surgeon and the neurosurgeon that are based on level of technical difficulty, potential risk of vascular and neural injury, and unfamiliar endoscopic anatomy. Mastery of each level is recommended before attempting procedures at a higher level. Conclusions : Standardization of training and the adoption of a modular, incremental training program are expected to facilitate the training of endonasal surgeons in both surgical specialties. Adherence to such a program during the growth phase of endoscopic skull base surgery may decrease the risk of complications as the surgeon's knowledge and surgical expertise develop.     

Transcochlear repair of persistent cerebrospinal fluid leaks.

OBJECTIVE: The purpose of this study is to demonstrate the utility of a modified transcochlear obliteration of the petrous apex in repair of persistent cerebrospinal fluid (CSF) leaks. A review of temporal bone computed tomography (CT) scans and histological preparations for potential air cells leading to such leaks is also presented. STUDY DESIGN: Retrospective case review in an academic tertiary referral center. METHODS: Patients for inclusion in this study had previously undergone either a suboccipital or translabyrinthine removal of an intracranial tumor with subsequent transmastoid and middle ear obliteration of air cell tracts to stop a CSF leak. Ninety CT scans and 178 temporal bones were reviewed and assessed for peritubal and petrous apex pneumatization. RESULTS: Four patients had initial obliteration of the orifice of the eustachian tube and middle ear that failed to prevent leakage of CSF. The leak was ultimately controlled by a transcochlear petrous apicectomy. From The Ohio State University temporal bone collection, 178 specimens were available for examination. Peritubal pneumatization was found in 42% of the bones examined. The CT scans showed unilateral petrous apex pneumatization in 30% of the specimens and bilateral pneumatization in 11%. CONCLUSIONS: Continuity of air cell tracts from the petrous apex surrounding the internal auditory canal to the medial eustachian tube can provide a path for CSF rhinorrhea that is difficult to stop by conventional means. A modified transcochlear approach successfully terminated persistent leaks in four such patients.     

眶颧入路切除蝶眶脑膜瘤的显微外科治疗

目的探讨经眶颧入路治疗蝶眶脑膜瘤的手术效果和操作技巧,以提高全切率,降低并发症。方法回顾性分析2003年1月~2016年9月收治的21例蝶眶脑膜瘤的临床资料,包括患者发病年龄、性别、症状、影像学、手术方法、术后并发症和肿瘤复发率等。结果蝶眶脑膜瘤患者眼球突出和局部疼痛是主要的发病症状,少数可伴有视力轻度下降。肿瘤长径3~7 cm,平均4.5 cm。18例采用适当剪裁的眶颧（orbito zygomatic approach,OZ）入路开颅,3例翼点开颅保留眶缘、仅磨除肿瘤周围骨质（其中1例术后52个月因肿瘤复发再次手术）。21例患者其中切除14例（66.7%）,近全切除6例（28.6%）,部分切除1例（4.8%）。术后随访3个月以上,术后患者出现眼睑下垂、瞳孔扩大3例（14.3%）,术后3个月复查时症状消失;1例偏瘫,后肌力恢复至IV+级。结论采用“适当剪裁”的眶颧入路,蝶眶处的脑膜瘤可良好显露;硬膜外预先处理肿瘤基底,血供可大大减少肿瘤出血;结合显微外科技术,可获满意的肿瘤切除效果和生存质量。     

Wound breakdown after middle cranial fossa craniotomy: An unusual complication after rhytidectomy

Wound complications after middle cranial fossa craniotomy are rare. We describe a patient who underwent a left middle fossa craniotomy for resection of a small internal auditory canal tumor with subsequent development of wound breakdown and infection 1 week postoperatively. Prompting of the patient elicited a history of bilateral rhytidectomies. Wound debridement, hyperbaric oxygen therapy, dermal regeneration template placement, and prolonged antibiotic treatment were performed. Complete secondary intention healing occurred with an acceptable cosmetic outcome. Prior rhytidectomy scars must be identified and incorporated into the surgical planning prior to performing middle fossa craniotomy incisions. Laryngoscope, 124:554–557, 2014     

颅内—面联合进路治疗累及或邻近前颅底部肿瘤

１９８６～１９９５年间以颅内—面联合进路治疗累及或邻近前颅底部肿瘤１２例，其中颅—面联合进路７例及额—面联合进路５例。１２例中恶性７例，良性５例。随访３～１０８个月，良性者效果良好，均无复发；恶性者３例无瘤健在１～５年，另４例术后３～３６个月因局部复发及／或远处转移死亡。本文还讨论了颅内—面进路手术的优点、适应症、术式的选择与手术并发症。     

Mandibular subluxation for distal cervical exposure of the internal carotid artery

INTRODUCTION: Surgical access to the distal segment of the cervical internal carotid artery (ICA) is a challenge because of the limited exposure imposed by bony structures and concern regarding cranial nerve and major vasculature injury. Our objective is to quantify the additional exposure of the distal cervical ICA obtained with mandibular subluxation (MS) compared with maneuvers that do not mobilize the mandible. METHODS: Thirty dissections of the cervical ICA and common carotid artery bifurcation were performed on fresh cadavers. The length of the ICA exposure was measured from the carotid bifurcation to the most distally exposed ICA after sectioning the posterior belly of the digastric and stylohyoid muscles, removal of the styloid process, and MS. RESULTS: After MS, a 5.52 +/- 1.00 cm mean exposure of the cervical ICA was obtained. Comparison between the second and third measures revealed an average additional exposure of the ICA of 0.77 cm, corresponding to an additional 16.2% (P < .001). Neck length, sex, and age showed no correlation with the ICA exposure. CONCLUSION: MS provided an additional exposure of the distal segment of the cervical ICA and may be useful in selected cases to improve access. However, staged maneuvers should be used, and the need for MS depends on the level and extension of the lesion.     

免疫治疗对变应性鼻炎患者鼻分泌物中螨变应原特异性IgG1和IgG4抗体水平的影响

目的检测变应性鼻炎患者和健康人群鼻分泌物中螨变应原特异性IgG1和IgG4抗体水平,以了解变应原特异性IgG亚型抗体在人群鼻分泌物中的分布和免疫治疗对抗体浓度的影响.方法利用负压吸引法收集健康人群、变应性鼻炎未治疗组和免疫治疗组患者的鼻分泌物,采用间接非竞争生物素-链亲和素酶联免疫法检测鼻分泌物中粗制螨变应原、螨纯化变应原Der fⅠ和Der fⅡ各变应原特异性IgG1和IgG4亚型抗体浓度.结果变应性鼻炎患者鼻分泌物中螨粗制变应原特异性IgG1和IgG4抗体浓度均高于健康人(Z=-3.623、-3.061,P均<0.01);免疫治疗组患者IgG1和IgG4抗体浓度均高于非治疗组(Z=-2.453、-3.408,P均<0.01).免疫治疗组变应性鼻炎患者鼻分泌物中螨纯化变应原Der fⅠ特异性IgG4抗体水平较健康人群增高(Z=-3.518,P<0.01);而免疫治疗组Der f Ⅱ特异性IgG1和IgG4抗体水平均高于健康人(Z=-2.366、-2.936,P均<0.01)和未治疗组(Z=-2.366、-2.937,P均<0.01).IgG1和IgG4亚群抗体中,螨粗制抗原、Der fⅠ和Der f Ⅱ特异性抗体水平相互间具有相关性;三类变应原特异性IgG1和IgG4抗体间存在相关性;免疫治疗组患者鼻分泌物中螨粗制变应原IgG1和IgG4抗体与血清中特异性IgE抗体间具有相关性. 结论健康人群和变应性鼻炎患者均具有对其环境变应原产生特异性IgG1和IgG4抗体的能力,而变应性鼻炎患者具有更高的反应性,能产生高于健康人的特异性IgG亚型抗体,而变应原特异性免疫治疗能显著增加鼻分泌物中IgG1和IgG4抗体的水平.鼻分泌物中IgG1和IgG4抗体的增加可能是免疫治疗有效的机制之一.     

Preservation of vestibular function after scala vestibuli cochlear implantation

A 58-year-old man, in whom the cochlear implant (CI) had been inserted into the left ear, had right middle-ear cancer. The CI was removed immediately before receiving subtotal removal of right temporal bone. Four months later, the CI was again inserted in his left cochlea. Because of obliterated scala tympani, the 22 active electrodes of the CI were placed into the scala vestibuli. After the surgery, the patient complained that he experienced rotary vertigo and “jumbling of vertical direction” of objects on walking. Using rotation test, we evaluated vestibular function of remaining left ear. Numerous horizontal nystagmus beats were induced during earth-vertical axis rotation, whereas vertical downbeat nystagmus was scarcely induced during off-vertical axis rotation. The horizontal vestibulo-ocular reflex (VOR) was almost normally induced by sinusoidal stimulation at 0.8 Hz. These data suggest that the scala vestibuli insertion of CI would be not so invasive against the lateral semicircular canal.     

经鼻内镜翼腭窝和颞下窝应用解剖学研究

目的探索经鼻内镜翼腭窝、颞下窝恒定的解剖标志,为手术处理该区域病变奠定基础。方法对11例尸头行鼻内镜侧颅底解剖学研究。经鼻内镜经中鼻道、蝶腭孔、上颌窦后壁入路,暴露翼腭窝及颞下窝的重要血管、神经及骨性解剖标志,并测量各解剖标志间的距离。结果经鼻内镜可恒定暴露蝶腭孔、翼管、圆孔、蝶腭神经节、眶下神经、卵圆孔、棘孔等重要侧颅底标志。鼻小柱基底到蝶腭孔、翼管、圆孔、卵圆孔、棘孔、破裂孔的距离分别为（69±3）、（73±3）、（75±3）、（90±5）、（96±4）、（88±3）mm。结论经鼻内镜可显露翼腭窝及颞下窝重要解剖结构,且各解剖结构可通过相互之间的距离及位置在鼻内镜二维平面上互相定位,以更直观、安全的处理该区域的病变。