Henryk Jordan (1842-1907)--a dedicated Krakow physician, health promotor and welfare worker]

We present 2 cases of Haemophilus influenzae meningitis. The first is a patient with atypical simptomatology: abdominal pain, fever and two days later pain in the back of his legs. Abdominal pathology was not found. The cerebrospinal fluid (CSF) showed polymorphonuclear cells, hyperproteinorachia and lowered glucose. CSF culture revealed Haemophilus influenzae, blood culture was sterile. The second had suffered surgery at maxilar and ethmoid sinuses four years before, and unknown germ meningitis 6 months before. Haemophilus influenzae was isolated from CSF cultures and CSF rhinorrhea was detected by isotopic cisternography.     

Immobilization of beta-fructofuranosidases from Aspergillus on methacrylamide-based polymeric beads for production of fructooligosaccharides

Three cases of chondromyxoid fibroma arising in the skull base are reported. The tumors arose in females 34, 65, and 66 (median 55) years of age. Two women presented with headaches, and one with nasal obstruction. Radiographic studies revealed that all three lesions were expansile soft tissue masses centered in the clivus, at least 4 cm in greatest diameter. One lesion involved primarily the clivus, the others extended from the clivus into the sphenoid and ethmoid sinuses. Two of the three cases were initially misdiagnosed as chordoma or chondrosarcoma. The initial treatment was curettage of gross disease in all three cases. One patient also received radiation therapy. One patient had local progression of disease, which was treated with surgery and radiation therapy. All patients are clinically free of disease 11 to 26 months following the most recent treatment. Chondromyxoid fibroma can and should be distinguished from chondrosarcoma and chordoma, two tumors which more commonly arise in the skull base and which have the potential to metastasize.     

Implementation of guidelines for No-CPR orders by a general medicine unit in a teaching hospital

Improvements in reconstruction of the skull base have made craniofacial surgery safe. Reconstruction of the anterior skull base must provide a seal between the cranial cavity and upper respiratory tract, as well as offer structural support for the brain. A wide variety of local flaps have been designed. The choice of flap in individual cases depends on the location and size of the defect. We report a reconstructive technique for the anterior skull base with vertical median forehead flaps which we used to treat two patients, one patient with adenocarcinoma and the other with leiomyosarcoma. Both were lesions of the ethmoid sinuses and nasal cavity.     

Bitemporal hemianopsia after skull base fracture

We report a case of bitemporal hemianopsia after skullbase fracture. An 18-year-old male presented with frontal head hit due to a traffic accident. Consciousness level on admission was JCS 10. Initial CT scan revealed traumatic SAH and pneumocephalus. We treated him conservatively. Ten hours after the accident, consciousness level went down, and CT imaging disclosed bilateral frontal hemorrhage. The three dimensional CT (3D-CT) imaging showed two fracture lines from the roof of the ethmoid sinus to the planum sphenoidale. Although his consciousness improved gradually, he complained of rhinorrhea, anosmia and double vision. On preoperative visual field examination, bitemporal hemianopsia was noticed. Repair operation for CSF rhinorrhea was performed. Operative findings revealed two fracture lines corresponding to the 3D-CT scan. The optic chiasm was compressed by the tuberculum sellae. We could not find obvious tearings or stretchings of the chiasm. Reports on operative findings of traumatic chiasmal syndrome are rare, and most of the reports presume that bitemporal hemianopsia results from tearing or stretching of the chiasm. We could confirm that, in some cases, bitemporal hemianopsia could result from direct pressure of the tuberculum sellae.     

Non-Hodgkin lymphoma of the central skull base: MR manifestations

OBJECTIVE: The aim of this study was to demonstrate the MR characteristics of non-Hodgkin lymphoma of the skull base to help in the differential diagnosis of this neoplasm from other conditions. MATERIALS AND METHODS: MR of five patients, 7-64 years old, with pathologically proved lymphomas of the skull base were reviewed. Three cases had primary skull base lesions involving the sphenoid bone and the cavernous sinus. One case with a nasal cavity lesion involving the skull base and one with a relapsing skull base lesion of previously treated tonsillar lymphoma were included. RESULTS: The lesions had signal intensities that were similar to that of gray matter of brain on both T1- and T2-weighted imaging. Bilateral cavernous sinuses were involved with encasement of internal carotid arteries in every case. Postcontrast MR showed homogeneous enhancement of the tumor with dural infiltration along the planum sphenoidale, clivus, or tentorium. The clivus was destroyed or replaced by tumors in adult cases but in two children the clivus was preserved with intact sphenooccipital synchondrosis. In one case the tumor extended to the extracranial portion through the jugular foramen. CONCLUSION: The MR findings of a permeative lesion of the skull base, invasion of the cavernous sinus without arterial narrowing, infiltration along the dural surface, and an iso- or hypointensity with brain on T2-weighted imaging should suggest lymphoma.     

Differential expression of costimulatory molecules in chronic inflammatory periodontal disease tissue

OBJECTIVES: To present the technique of the extended subcranial approach to the anterior skull base and to review the results in 55 patients who underwent the procedure. STUDY DESIGN: Retrospective review of the records of 55 patients who underwent the extended subcranial approach to the anterior skull base between 1994 and 1998 for the treatment of various neoplasms originating in the nasal cavity, nasopharynx, paranasal sinuses, orbit, or meninges, as well as for the repair of complex craniofacial trauma and/or cerebrospinal fluid (CSF) leak. Preoperative patient evaluation and the surgical technique are also reviewed. METHODS: Patient records were retrospectively reviewed and tabulated for age, sex, and indications for procedure, with special focus on early outcome and complications. RESULTS: Twenty-six patients underwent oncologic resections, 22 patients had reduction of complex fronto-naso-orbital and skull base fractures, and seven patients had repair of CSF leak. Significant complications in the oncologic group consisted of one hematoma requiring needle aspiration and two cases of temporary nontension pneumocephalus. In the fracture group, one patient died because of extensive intracerebral damage and multiorgan failure, and one patient had nontension pneumocephalus coupled with CSF leakage and one patient had temporary nontension pneumocephalus. The most common late complication in all three groups was anosmia. CONCLUSIONS: Based on their review, the authors conclude that the extended subcranial approach to the anterior skull base is a safe, versatile, and effective procedure for the surgical treatment of various pathological conditions involving the anterior skull base.     

Frontal sinus mucocele mimicking a metastasis of papillary thyroid carcinoma

Radioiodine scans are highly specific for detecting metastases of well-differentiated thyroid carcinomas. However, false-positive 131I whole-body scans may occur as illustrated in the following case report. In a 53-yr-old patient, abnormal 131I uptake was found in the right frontal skull 4 wk after total thyroidectomy and radioiodine therapy for papillary thyroid cancer. Bone scans and planar x-rays of the skull were unremarkable and the serum thyroglobulin level was within normal limits. X-ray CT revealed a small nodule in the right frontal sinus corresponding to the pathological focus of 131I uptake. Surgical removal and histopathological examination of this lesion yielded a mucocele, a slow-growing lesion of the paranasal sinuses accumulating mucous material. The postoperative 131I scan was unremarkable. The possibility of a false-positive finding on radioiodine scans should be considered, particularly when the serum thyroglobulin level is not elevated.     

Surgery of the anterior skull base

Inflammatory disease of the frontal, ethmoid, and sphenoid paranasal sinuses may extend to the adjacent anterior skull base and then intracranially. The potential for this serious complication of sinus disease must be recognized by the primary otolaryngologist-head and neck surgeon, and alternative management strategies must be taken once it is diagnosed. Topics discussed in this article include cranial anatomy, surgical techniques and variations, complications, and special considerations.     

Fertility and schizophrenia: evidence for increased fertility in the relatives of schizophrenic patients

BACKGROUND AND PURPOSE: We present a rare case of desmoplastic fibroma of the skull. Desmoplastic fibroma is a distinctive and rare neoplasm of bone that histologically and biologically mimics desmoid soft tissue tumor. Only 6 cases have been reported in the skull and none of these was diagnosed by MRI. CLINICAL PRESENTATION: A 64 year-old woman, operated on in June 1991 for left mastectomy due to a ductal adenocarcinoma and again in October 1994 for a left frontal metastatic adenocarcinoma, was admitted in our Department of Neurosurgery because a control cerebral MRI had detected a diploic lesion, isointense on T1-weighted images and hyperintense on T2, with moderate enhancement, localized in a right parietal site. Neurological examination was negative. The lesion was surgically removed and a cranioplasty was performed. Histological diagnosis was desmoplastic fibroma. Twelve months after treatment she has no neurological symptoms or signs of cerebral lesions (MRI) or systemic metastasis (total body CT). CONCLUSION: In the literature the number of desmoplastic fibroma is too small and the follow-up period too short to permit any conclusions regarding the aggressiveness of the tumor.     

Experiences with hemangiopericytoma in cranial base surgery

BACKGROUND: Haemangiopericytomas are rare vascular neoplasms which show either slow local tumour growth or aggressive progression in size with a high tendency of recurrence and metastasis. Manifestations of haemangiopericytomas in the area of the nose and sinuses are supposed to have a relatively benign course. To date clinical and histological parameters for prognosis are uncertain. Therefore in a quite large number of cases only the clinical course allows to evaluate the dignity of a haemangiopericytoma. PATIENTS AND RESULTS: We present our experience with five haemanglopericytomas in contact with the skull base out of a total number of 457 skull base tumours. The site of origin of these five haemangiopericytomas were: nasal septum, pterygopalatine fossa, oronasopharynx, temporal bone, and parotid gland. All neoplasms showed primary or recurrent tumor in contact with the skull base and an intracranial extension was observed twice. One patient died postoperatively of a cerebral infarction. Three patients showed one or more recurrences which were treated surgically. In one case 5 recurrences occurred. Despite of 4 surgical procedures within a period of 15 months, the tumour could be controlled only for a short period of time, and the patient died 16 months after the first operation. CONCLUSION: One has to consider that haemangiopericytomas of the head and neck show a potential malignant course. The vascular tumor may recur decades later. Adequate therapy and life-long follow-up are therefore mandatory in haemangiopericytomas. Complete surgical resection of the tumour is usually the treatment of choice, in spite of the high degree of surgical skill required, especially in advanced tumour and in case of recurrence.     

Delayed complications of ethmoid fractures: a "growing fracture" phenomenon

Delayed complications of ethmoid fractures are considered relatively rare. However, meningitis, recurrence of previously ceased cerebrospinal fluid rhinorrhea and delayed onset of cerebrospinal fluid rhinorrhea are possible even years after trauma. We report 10 consecutive patients with delayed complications of ethmoid fractures, whom we treated over the past 11 years. All patients had previously sustained a closed head injury and had remained anosmic. Variously after trauma (ranging from 2 months to 31 years), these patients were re-admitted because of meningitis (6 cases), recurrence of previously ceased cerebrospinal fluid rhinorrhea (3 cases), and delayed onset of cerebrospinal fluid rhinorrhea (1 case). In all cases the delayed complications were associated with relatively large defects of the ethmoid bone. These bone lesions were now evident even in those patients whose radiological assessments had been normal after trauma. All patients underwent a successful surgical repair and remained well during the follow-up. We discuss the possibility that delayed complications of ethmoid fractures are due to a mechanism like that of "growing fractures" in children.     

Effect of estradiol metabolites on the susceptibility of low density lipoprotein to oxidation

The presence of a benign osteoblastoma in the ethmoid sinus is rare and only a few cases have been reported. This is a case of a benign osteoblastoma arising from the perpendicular plate of the ethmoid bone with extension to the nasal cavity. The diagnosis and management of this unusual lesion, as well as the histopathology and the imaging characteristics are reviewed. We also review the previously reported cases of benign osteoblastomas of different origin, with nasal cavity involvement.     

Platyhelminthes have a hox code differentially activated during regeneration, with genes closely related to those of spiralian protostomes

BACKGROUND: Congenital, posttraumatic, inflammatory or tumours skull base lesions with CSF leakage require reconstruction to mechanically stabilize the CNS and to securely seal the CSF space. PATIENTS AND METHODS: Ionomeric cement was used from 1988 until 1994 in 44 patients for skull base reconstruction at the Department of Otolaryngology-Head and Neck Surgery, University of Würzburg. Thirty-five patients were reexamined. The longest follow-up time was 8 years. The program for the present follow-up study comprised a general ENT and neurological examination as well as CT scans of the skull base, MRI tomography of the CNS, and the determination of the aluminium plasma concentration. RESULTS: None of the patients reexamined presented with complaints. Neurological examinations and MRI tomography in all patients did not reveal any pathological finding related to ionomeric cement application. Aluminium plasma concentrations in patients who received ionomeric cement implantations were not significantly elevated when compared to controls. General ENT examinations and CT scans in thirty-two patients demonstrated regular postoperative findings. The cement at the anterior skull base was not covered completely by mucosa in three patients. In one these cases, CT scans revealed dislocation of the ionomeric cement so that revision surgery was performed for removal. None of the patients to date presented with a CSF leak. CONCLUSION: Long-term results of the present study show that ionomeric cement is a suitable material for closure of osseous skull base lesions to permanently seal the CSF space. These results, however, can only be obtained when handling and application of the material is adequate. Unfortunately, the production of ionomeric cement has been stopped since 1995 following four cases of aluminium encephalopathy reported in the literature.     

Chondroma of the petrous bone. A contribution to differential skull base tumor diagnosis

INTRODUCTION: Cartilaginous tumors of the mid-face and the skull base are rare. CASE REPORT: For the first time, a case report of a chondroma of the base of the ear in a 56-year-old woman is presented. In 1974 the patient developed a facial nerve paralysis while she was pregnant. Twenty-two years later the patient developed persistent headache and CT studies of the head were obtained, which showed an extensive tumorous lesion located at the base of the ear. A tumor was resected through an otoneurosurgical approach. The histological examination showed a chondroma. CONCLUSIONS: Even the rare diagnosis of a chondroma should be considered for a differential diagnosis of skull base tumors.     

Pore-forming leukotoxins from Staphylococcus aureus: variability of the target cells and 2 pharmacological processes

A combination study of cerebrospinal fluid scintigraphy and nasal pledget counts was performed using 37 MBq of 111In-DTPA in 12 patients with suspected rhinorrhea. A pledget was inserted and dwelled in each nasal cavity for 6 hours, with the patient prone during at least 30 minutes. A total of 18 studies was implemented and nasal pledget counting method successfully diagnosed all of CSF rhinorrhea. Diagnosis was possible when pledget counts were greater than 1 kcpm. In patients with persistent, intermittent and occult/no nasal discharge, rhinorrhea was found in 100% (5/5), 60% (3/5), 25% (2/8), respectively. Two cases only exhibited positive scintigraphy. MRI or CT cisternography should be first performed in patients with persistent discharge, but in patients with intermittent/occult discharge pledget counting method might take priority of other diagnostic modalities. In conclusion, nasal pledget counting method is a simple and useful tool for detecting rhinorrhea.     

Tactile sensor for tissue differentiation in minimally invasive ENT surgery

BACKGROUND: In endoscopic surgery, stereoscopic vision and tactile information about tissue consistency are no longer available to the surgeon. METHODS: To compensate for these sensory deficits, various tissues can be characterized with an electromechanical sensor that records their resonance frequencies. In the future, the sensor will be integrated into surgical instruments, providing the surgeon with information about tactile properties of the tissue. We determined the impedance of tissues removed interoperatively (nasal polyps, lymph nodes, cartilage, bone) and different bony structures in a skull specimen. The examinations were carried out with an experimental setup and subsequently with a prototype of the tactile sensor. RESULTS: Resonance frequency increased with tissue hardness. Measurements with the experimental setup showed resonance frequencies for soft tissues between 15 and 30 Hz. We found that the bony septa of the ethmoid have a resonance frequency of 240-320 Hz and the thicker bony structures at the frontal skull base have a frequency of 780-930 Hz. Measurements of tumors in the upper aerodigestive tract showed that it is possible to differentiate between healthy mucosa, carcinomateous infiltrated mucosa, and carcinomateous undermined mucosa. In case of undermining tumor, the resonance frequency was one third higher than healthy mucosa. These results obtained with the experimental setup were reproduced with the tactile sensor prototype. CONCLUSIONS: The use of tactile information in endoscopic otolaryngological surgery may improve intraoperative tissue differentiation in the future. The safety of minimal invasive operations in head and neck surgery can be increased.     

Value of B-image ultrasound in diagnosis of paranasal sinus diseases in comparison with computerized tomography

BACKGROUND: In diagnostic imaging of the paranasal sinuses, the A-mode technique is increasingly being substituted by B-mode ultrasonography. To assess the value of B-mode sonography we compared in a double-blind study computed tomography with our ultrasound findings. PATIENTS AND METHODS: Seventy-eight patients were examined by CT and subsequently by ultrasound, two-thirds before endonasal surgery and one-third for diagnosis of serious facial pain and swelling. RESULTS: Among 114 pathological maxillary sinus tomograms, 83 findings could also be diagnosed by ultrasound (sensitivity 72.8%). In the frontal sinuses only 12 of 52 of pathological findings could be detected (23.1%) and only 9 of 80 in the frontal ethmoid (11.3%). Except for circumscribed polyps and moderate general swelling of the mucosa, the detection rate by sonography was 97.4% for the maxillary sinuses, 31.5% for the frontal and 18% for the ethmoid sinuses. CONCLUSIONS: Ultrasound usually only demonstrates the presence of absence or unspecific findings. Differential diagnosis between tumors and sinusitis is generally difficult. The healthy individual is correctly assessed as healthy due to the total reflection of the air-filled healthy sinus. According to our findings ultrasound has a certain value in the diagnosis of maxillary sinuses. It can be used to obtain a preliminary diagnosis and as a screening method although a negative result never excludes a disease of the sinuses. As it does not involve radiation exposure, ultrasonography can be recommended as first step in diagnosis for children, pregnant women, and young women especially in acute sinusitis, because in acute sinusitis the maxillary sinuses are generally affected.     

A resolving sign of acute subdural hematoma: from report of two cases

A 7-year-old-boy (Case 1) and a 60-year-old-man (Case 2) presented with rare spontaneous resolution of acute subdural hematoma (ASDH). They were admitted with consciousness disturbance, drowsy in Case 1 and sleepy in Case 2. Initial CT showed ASDH associated with a low density band between the hematoma and the inner wall of the skull base, combined with right parietal contusion in Case 2. Repeat CT showed that the hematoma had resolved spontaneously after a few hours, and the patients regained clear consciousness next day in Case 1 within a few days in Case 2 without surgical treatment. The mechanism of spontaneous resolution of ASDH was thought to involve pulsatile flow of cerebrospinal fluid (CSF) through the tear in the arachnoid membrane, resulting in redistribution and dispersal of the hematoma, and retrograde flow into the subarachnoid space. The characteristic feature of the CT findings, the low density band between the hematoma and the inner wall of the skull bone, probably shows this process. Spontaneous resolution of ASDH requires that the brain compensatory function maintains the normal outflow of CSF, and controls the intracranial pressure by CSF buffering, blood outflow via the venous system, and brain elasticity. The low density band may be a useful finding to distinguish cases with good and bad prognosis.     

The methodological bases of topographic neuropathomorphology

This paper describes the major features of topographic and anatomical studies of CNS structures, CSF circulation system, extracerebral structures and vertebral column. These methods include brain fixation, which is able to prevent post mortem brain deformation due to decalcification (even for block-preparations like "brain-skull base" or "posterior cerebral fossa-cervical spine"). The author also presents the following methods: spatial reconstruction of the brain and skull base subtracted from the series of slices of different thickness and various planes of transection; biopsy investigation of cerebral midline structures and CSF system in relation with skull base and convex structures; staged microdissection of tumors; filling of arterial and venous systems. All these modalities were used in examining the topographical features of craniopharyngiomas, hypophyseal adenomas, parasagittal and sagittal meningiomas, pineal tumors, VIII cranial nerve neurinomas, arachnoid cysts and in developing surgical approaches to the tumors of the third ventricle, skull base and foramen magna.     

Meningiomas of the anterior skull base expanding into the orbit, paranasal sinuses, nasopharynx, and oropharynx

The natural progression of the infiltrative anterior skull base meningioma, expanding into orbit, paranasal sinuses, nasopharynx, and oropharynx during 12 years is presented. The development of the lesion is demonstrated on computed tomography. The patient was operated on six times from the age of 14. Pathological investigation revealed infiltrative meningoteliomatous meningioma without signs of malignancy.