Transient MR changes and symptomatic epilepsy following gamma knife treatment of a residual GH-secreting pituitary adenoma in the cavernous sinus

To report a rare side effect of gamma knife treatment of pituitary macroadenoma.

Evaluation of hydroxyapatite cement for frontal sinus obliteration after mucocele resection

OBJECTIVES: To retrospectively evaluate our experience with frontal sinus obliteration using hydroxyapatite cement (BoneSource; Stryker Biotech Europe, Montreux, Switzerland) and compare it with fat obliteration over the approximate same period. Frontal sinus obliteration with hydroxyapatite cement represents a new technique for obliteration of the frontal sinus after mucocele resection. METHODS: Exploration of the frontal sinus was performed using bicoronal, osteoplastic flaps, with mucosal removal and duct obliteration with tissue glue and muscle or fascia. Flaps were elevated over the periorbita, and Silastic sheeting was used to protect the BoneSource material from exposure as it dried. The frontal table was replaced when appropriate. RESULTS: Sixteen patients underwent frontal sinus obliteration with fat (fat obliteration group), and 38 patients underwent obliteration with BoneSource (BoneSource group). Fat obliteration failed in 2 patients, who underwent subsequent BoneSource obliteration, and none of the patients in the BoneSource group has required removal of material because of recurrent complications. Frontobasal trauma (26 patients [68%] in the BoneSource group and 9 patients [56%] in the fat obliteration group) was the most common history of mucocele formation in both groups. Major complications in the BoneSource group included 1 patient with skin fistula, which was managed conservatively, and 1 patient with recurrent ethmoiditis, which was managed surgically. Both complications were not directly attributed to the use of BoneSource. Contour deficit of the frontal bone occurred in 1 patient in the fat obliteration group and in none in the BoneSource group. Two patients in the fat obliteration group had donor site complications (hematoma and infection). Thirteen patients in the BoneSource group had at least 1 prior attempt at mucocele drainage, and no statistical relation existed between recurrent surgery and preservation of the anterior table. CONCLUSION: Hydroxyapatite is a safe, effective material to obliterate frontal sinuses infected with mucoceles, with minimal morbidity and excellent postoperative contour.

Uveitic glaucoma and Rosai-Dorfman disease (sinus histiocytosis)

PURPOSE: To report a novel association of uveitic glaucoma with Rosai-Dorfman disease. METHODS: Case report. RESULTS: A 67-year-old Caucasian woman presented with a chronic bilateral granulomatous uveitis which did not respond to conventional topical steroid therapy. She also had raised intraocular pressures, glaucomatous optic disc changes and diffuse nodular fibrous skin lesions. Subsequent skin biopsy immuno-cytochemistry showed S-100 staining, consistent with Rosai-Dorfman disease. The uveitis and glaucoma were highly resistant to standard medical treatments, but completely resolved together with the systemic features of the disease after six months. CONCLUSIONS: Rosai-Dorfman disease has not previously been reported to cause uveitic glaucoma and should be considered in non-responsive cases presenting with a rash. The disease is entirely self-limiting and early diagnosis may therefore avoid unnecessary trabeculectomy and/or systemic immune suppression.

Unexplained syncope--is screening for carotid sinus hypersensitivity indicated in all patients aged >40 years?

OBJECTIVE: To determine the frequency, age distribution and clinical presentation of carotid sinus hypersensitivity (CSH) among 373 patients (age range 15-92 years) referred to two autonomic referral centres during a 10-year period. METHODS: Carotid sinus massage (CSM) was performed both supine and during 60 degree head-up tilt. Beat-to-beat blood pressure, heart rate and a three-lead electrocardiography were recorded continuously. CSH was classified as cardioinhibitory (asystole > or = 3 s), vasodepressor (systolic blood pressure fall > or = 50 mm Hg) or mixed. All patients additionally underwent autonomic screening tests for orthostatic hypotension and autonomic failure. RESULTS: CSH was observed in 13.7% of all patients. The diagnostic yield of CSM was nil in patients aged < 50 years (n = 65), 2.4% in those aged 50-59 years (n = 82), 9.1% in those aged 60-69 years (n = 77), 20.7% in those aged 70-79 years (n = 92) and reached 40.4% in those > 80 years (n = 57). Syncope was the leading clinical symptom in 62.8%. In 27.4% of patients falls without definite loss of consciousness was the main clinical symptom. Mild and mainly systolic orthostatic hypotension was recorded in 17.6%; evidence of sympathetic or parasympathetic dysfunction was found in none. CONCLUSIONS: CSH was confirmed in patients > 50 years, the incidence steeply increasing with age. The current European Society of Cardiology guidelines that recommend testing for CSH in all patients > 40 years with syncope of unknown aetiology may need reconsideration. Orthostatic hypotension was noted in some patients with CSH, but evidence of sympathetic or parasympathetic failure was not found in any of them.

An implantable carotid sinus baroreflex activating system: surgical technique and short-term outcome from a multi-center feasibility trial for the treatment of resistant hypertension

OBJECTIVES: To assess perioperative outcomes and blood pressure (BP) responses to an implantable carotid sinus baroreflex activating system being investigated for the treatment of resistant hypertension. METHODS: We report on the first seventeen patients enrolled in a multicenter study. Bilateral perivascular carotid sinus electrodes (CSL) and a pulse generator (IPG) are permanently implanted. Optimal placement of the CSL is determined by intraoperative BP responses to test activations. Acute BP responses were tested postoperatively and during the first four months of follow-up. RESULTS: Prior to implant, BP was 189.6+/-27.5/110.7+/-15.3 mmHg despite stable therapy (5.2+/-1.8 antihypertensive drugs). The mean procedure time was 202+/-43 minutes. No perioperative strokes or deaths occurred. System tests performed 1 or up to 3 days postoperatively resulted in significant (all p < or = 0.0001) mean maximum reduction, with standard deviations and 95% confidence limits for systolic BP, diastolic BP and heart rate of 28+/-22 (17, 39) mmHg, 16+/-11 (10, 22) mmHg and 8+/-4 (6, 11) BPM, respectively. Repeated testing during 3 months of therapeutic electrical activation demonstrated a durable response. CONCLUSIONS: These preliminary data suggest an acceptable safety of the procedure with a low rate of adverse events and support further clinical development of baroreflex activation as a new concept to treat resistant hypertension.

CT radiation dose for computer-assisted endoscopic sinus surgery: dose survey and determination of dose-reduction limits

BACKGROUND AND PURPOSE: Computer-assisted navigation is increasingly used in functional endoscopic sinus surgery (FESS) to prevent injury to vital structures, necessitating preparative CT and, thus, radiation exposure. The purpose of our study was to investigate currently used radiation doses for CT in computer-assisted navigation in sinus surgery (CAS-CT) and to assess minimal doses required. MATERIALS AND METHODS: A questionnaire inquiring about dose parameters used for CAS-CT was sent to 30 radiologic institutions. The feasibility of low-dose registration was tested with a phantom. The influence of CAS-CT dose on technical accuracy and on the practical performance of 5 ear, nose, and throat (ENT) surgeons was evaluated with cadaver heads. RESULTS: The questionnaire response rate was 63%. Variation between minimal and maximal dose used for CAS-CT was 18-fold. Phantom registration was possible with doses as low as 1.1 mGy. No dose dependence on technical accuracy was found. ENT surgeons were able to identify anatomic landmarks on scans with a dose as low as 3.1 mGy. CONCLUSIONS: The vast dose difference between institutions mirrors different attitudes toward image quality and radiation-protection issues rather than being technically founded, and many patients undergo CAS-CT at higher doses than necessary. The only limit for dose reduction in CT for computer-assisted endoscopic sinus surgery is the ENT surgeon's ability to cope with impaired image quality, whereas there is no technically justified lower dose limit. We recommend, generally, doses used for the typical diagnostic low-dose sinus CT (120 kV/20-50 mAs). When no diagnostic image quality is needed, even a reduction down to a third is possible.

Loss of pulp sensitivity and pain as the first symptoms of a Ewing's sarcoma in the right maxillary sinus and alveolar process: report of a case

This case report describes the diagnosis and treatment of a Ewing's sarcoma in the right maxillary sinus and alveolar bone of a 19-year-old female patient. The first clinical symptoms were a loss of sensitivity of the premolars and first molar in the right maxilla and acute pain located in the area of these teeth. Initially, the referring dentist had treated these findings as an acute apical periodontitis with root canal medication. Because swellings on the palatal and buccal aspects of the teeth occurred and could not be treated with incision and drainage, the dentist referred the patient. Cone-beam computed tomography revealed a proliferation of soft tissue in the right maxillary sinus, with a radiopaque material at the tip of the mesiobuccal root of the first molar and resorptive signs of the mesiobuccal and distobuccal roots of the first molar. The palatal cortical bone of the right alveolar process seemed to be intact. After explorative surgery with biopsies from the buccal, palatal, and sinus proliferation areas, the pathologist diagnosed the lesion as a Ewing's sarcoma. Treatment of the patient consisted of initial chemotherapy, hemimaxillectomy, and postsurgical chemoradiotherapy.

Comparison between intravitreal and orbital floor triamcinolone acetonide after phacoemulsification in patients with endogenous uveitis

PURPOSE: To compare the effect of intravitreal and orbital floor triamcinolone acetonide (TA) on macular edema, visual outcome, and course of postoperative inflammation after cataract surgery in uveitis patients. DESIGN: Prospective, randomized clinical trial. METHODS: Monocenter study (40 patients) with chronic endogenous uveitis who underwent phacoemulsification with intraocular lens implantation with either 4 mg intravitreal TA (n = 20) or 40 mg orbital floor TA (n = 20). The primary outcome was influence on cystoid macular edema (CME). Secondary outcome measures were best-corrected visual acuity (BCVA), anterior chamber cell grade, laser flare photometry, giant cell deposition, posterior capsule opacification (PCO), and intraocular pressure. RESULTS: Mean central foveal thickness decreased in the intravitreal TA group and increased in the orbital floor TA group (P < .001 at one and three months). CME improved in 50% of patients after intravitreal TA, whereas it was unchanged after orbital floor TA (difference between the groups at three months, P = .049). Mean BCVA (logarithm of the minimal angle of resolution) improved postoperatively (P < .001) from 0.76 and 0.74 to 0.22 and 0.23 in the intravitreal TA and orbital floor TA group, respectively. Anterior chamber cell count at one month was lower in the intravitreal TA than in the orbital floor TA group (P = .02). Laser flare photometry values and giant cell numbers were slightly higher after orbital floor TA than after intravitreal TA. The groups did not differ with respect to PCO rate and ocular hypertension. CONCLUSIONS: The CME improvement and anti-inflammatory effect after intravitreal TA was better than after orbital floor TA injection in cataract surgery in uveitis patients.

Ridge augmentation and maxillary sinus grafting with a biphasic calcium phosphate: histologic and histomorphometric observations

OBJECTIVES: This retrospective study reports on histologic and histomorphometric observations performed on human biopsies harvested from sites augmented exclusively by biphasic calcium phosphate [BCP: hydroxyapatite (HA)/ tricalcium phosphate (TCP) 60/40] and healed for a minimum of 6 months. MATERIALS AND METHODS: Five patients benefited from three augmentation regimens (i.e.: one-stage lateral augmentation; two-stage lateral augmentation; and two-stage sinus grafting). In all patients, a degradable collagen membrane served as a cell-occlusive barrier. Core biopsies were obtained from lateral as from crestal aspects 6-10 months after augmentation surgeries. For histologic and histomorphometric evaluations, the non-decalcified tissue processing was performed. RESULTS: The histological examination of 11 biopsies showed graft particles frequently being bridged by the new bone, and a close contact between the graft particles and newly formed bone was seen in all samples. The mean percentages of newly formed bone, soft tissue compartment, and graft material were 38.8% (+/-5.89%), 41.75% (+/-6.08%), and 19.63% (+/-4.85%), respectively. Regarding bone-to-graft contact values, the percentage of bone coverage of graft particles for all biopsies ranged from 27.83% to 80.17%. The mean percentage of bone coverage was 55.39% (+/-13.03%). CONCLUSIONS: Data from the present study demonstrated osteoconductivity scores for the BCP material (HA/TCP 60/40) in patients resembling those previously shown for grafting materials of xenogenic and alloplastic origin.

Pelvic floor stimulation: what are the good vibrations?

OBJECTIVE: The aim of this study was to determine if two different whole body vibration, sinusoidal vibration (SV) and stochastic resonance vibration (SRV), using various intensities lead to a reactive activation of pelvic floor muscles. STUDY DESIGN: We compared the pelvic floor muscle response of a healthy control group with that of a post partum group with weakened pelvic floor contraction. Activation effects of stochastic resonance vibration and sinusoidal vibration with six increasing vibration intensities were investigated using pelvic floor EMG and compared to activity during rest and maximum voluntary contraction. RESULTS: Both whole body vibration systems were able to activate pelvic floor muscles significantly depending on vibration intensity. Generally, the SRV achieved a significantly higher activation than maximum voluntary contraction, especially in women post partum and using a frequency of 6-12 Hz. CONCLUSION: SRV, compared to SV, leads to higher pelvic floor muscle activation in subjects with weakened pelvic floor muscles and achieves higher pelvic floor activation than maximum voluntary contraction alone. Neurourol. Urodynam. 28:405-410, 2009. (c) 2009 Wiley-Liss, Inc.