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Intrathecal fluorescein usage in CSF fistula
Otolaryngology Head and Neck Surgery Volume 115 Number 2
the cochlea that was initially thought to represent postoperative changes. This area continued to enlarge and was suspicious for recurrent tumor. The patient subsequently had the recurrent tumor removed through a transotic approach. Tumor was found filling the entire basal turn of the cochlea, vestibule, and internal auditory canal. A 68-year-old woman was found to have a small, intracanalicular vestibular schwannoma with intracochlear extension on MRI. Because of refractory episodic vertigo, the patient had a translabyrinthine resection of the vestibular schwannoma with tumor left in the basal turn of the cochlea. This patient has been observed for 42 months without evidence of tumor growth on serial MRI scans. Discussion: These patients on close examination of the preoperative and postoperative scans had vestibular schwannoma within the basal turn of the cochlea. The tumor within the basal turn of the cochlea was not removed at the initial translabyrinthine surgical resection because the basal turn could not be adequately accessed through this approach. Conclusion: Vestibular schwannoma recurrence may occur after translabyrinthine resection due to residual tumor within the basal turn of the cochlea. This area should be examined on the preoperative MRI scans with consideration given to the transotic approach if tumor is identified there. Patients with evidence of intracochlear vestibular schwannoma who have already had translabyrinthine tumor removal should be followed up closely with serial MRI scans.
173
Intrathecal Fluoresceln Usage In CSF Fistula FIDELIA YUAN-SHIN BUTT, MD, and HILARY BRODIE, MD, PhD, Sacramento and Stockton, Calif.
Cerebrospinal fluid (CSF) otorrhea and rhinorrhea commonly present to the otolaryngologist as a result of head trauma; iatrogenic otologic, rhinologic, and neurosurgical procedures; congenital anomalies; and erosive disease processes involving the skull base. Identification and localization of the CSF fistula are crucial in the management of these patients. Many of the techniques are available to assist in the identification of CSF leaks including CT scanning with intrathecal contrast, radionuclide scans, various intrathecal dyes, and analysis of obtained fluid samples for 13-2 transferrin. Intrathecal fluorescein dye has been demonstrated to be a very sensitive and effective means of CSF fistula identification. The fluorescein dye fluoresces brightly with a Woods lamp and can be easily identified on micropledgets placed strategically within the nasal cavity and adjacent to the torus tubarius. The dye also effectively localized fistula intraoperatively. Enthusiasm for the use of intrathecal fluorescein has been dampened by reported complications, including transient hemiparesis and grand mal seizures. These complications occurred with high doses of the fluorescein.
Scientific Posters
P211
However, with appropriate dosing of 0.5 ml 5% solution mixed with 10 ml CSF, the risk of neurologic complications is quite low. The literature is reviewed for the relative sensitivity of intrathecal fluorescein to identify CSF fistula compared.with the other available techniques, as well as the relative safety.
174
Oro-Rhino-Orbltal-Cerebral Mucormycosis Following Dental Extraction JAMES K. FORTSON, MD, TIENCHIN HO, MD, and JONE KIM, DDS, MS, Fresno, Calif.
The purpose of this paper is to present a case report of mucormycosis in 57-year-old truck driver with uncontrolled diabetes. The patient had refused insulin therapy because he would lose his occupation. He opted to take oral hyperglycemic agents. Two days before admission he was seen by his dentist for increasing teeth pain. He underwent extraction of his second and third left maxillary molar teeth. He began receiving Keflex for facial and cheek swelling. Over the next 24 hours the patient noticed increased swelling with erythema and numbness of his left cheek and eye. He noted progressive visual loss in his left eye. He presented to Valley Medical Center with blindness in his left eye and swelling with ecchymosis of left forehead, periorbital area, and cheek. His blood glucose level was 407, and he admitted to poor compliance with his oral hypoglycemic agents. Physical examination at the time of admission revealed left-sided orbital, cheek, and facial cellulitis. He had paralysis of his third, fourth, fifth, sixth, and seventh nerves. There was no vision in his left eye. Ophthalmoplegia, chemosis, and proptosis were present. The nasal examination revealed a deviated septum with scant secretions from the middle meatus. The oral cavity had a dark area with clot at the extraction site. The rest of the physical examination was essentially normal. He was admitted and began receiving intravenous antibiotics. Laboratory values revealed an elevated white blood cell count, anemia, low pH, and elevated glucose and creatinine. Consultations were obtained by internal medicine, neurology, infectious disease, otolaryngology, and ophthalmology. A CT scan revealed a mild sinusitis but no obvious masses. The patient underwent endoscopic sinusotomies with biopsies and cultures. He began receiving high-dose broadspectrum antibiotics and amphotericin B. His clinical course rapidly deteriorated. He developed black spots on his face and hard and soft palates. Biopsies were positive for mucormycosis. The patient's Glasgow coma scale began to deteriorate, and he died 72 hours after admission. Patients with diabetes have considerable risk during surgical procedures. If the diabetes is uncontrolled, catastrophic consequences may result. A thorough history should precede any surgical procedure by physician or dentist. Diabetes as well as other medical problems should be corrected before surgery.
the cochlea that was initially thought to represent postoperative changes. This area continued to enlarge and was suspicious for recurrent tumor. The patient subsequently had the recurrent tumor removed through a transotic approach. Tumor was found filling the entire basal turn of the cochlea, vestibule, and internal auditory canal. A 68-year-old woman was found to have a small, intracanalicular vestibular schwannoma with intracochlear extension on MRI. Because of refractory episodic vertigo, the patient had a translabyrinthine resection of the vestibular schwannoma with tumor left in the basal turn of the cochlea. This patient has been observed for 42 months without evidence of tumor growth on serial MRI scans. Discussion: These patients on close examination of the preoperative and postoperative scans had vestibular schwannoma within the basal turn of the cochlea. The tumor within the basal turn of the cochlea was not removed at the initial translabyrinthine surgical resection because the basal turn could not be adequately accessed through this approach. Conclusion: Vestibular schwannoma recurrence may occur after translabyrinthine resection due to residual tumor within the basal turn of the cochlea. This area should be examined on the preoperative MRI scans with consideration given to the transotic approach if tumor is identified there. Patients with evidence of intracochlear vestibular schwannoma who have already had translabyrinthine tumor removal should be followed up closely with serial MRI scans.
173
Intrathecal Fluoresceln Usage In CSF Fistula FIDELIA YUAN-SHIN BUTT, MD, and HILARY BRODIE, MD, PhD, Sacramento and Stockton, Calif.
Cerebrospinal fluid (CSF) otorrhea and rhinorrhea commonly present to the otolaryngologist as a result of head trauma; iatrogenic otologic, rhinologic, and neurosurgical procedures; congenital anomalies; and erosive disease processes involving the skull base. Identification and localization of the CSF fistula are crucial in the management of these patients. Many of the techniques are available to assist in the identification of CSF leaks including CT scanning with intrathecal contrast, radionuclide scans, various intrathecal dyes, and analysis of obtained fluid samples for 13-2 transferrin. Intrathecal fluorescein dye has been demonstrated to be a very sensitive and effective means of CSF fistula identification. The fluorescein dye fluoresces brightly with a Woods lamp and can be easily identified on micropledgets placed strategically within the nasal cavity and adjacent to the torus tubarius. The dye also effectively localized fistula intraoperatively. Enthusiasm for the use of intrathecal fluorescein has been dampened by reported complications, including transient hemiparesis and grand mal seizures. These complications occurred with high doses of the fluorescein.
Scientific Posters
P211
However, with appropriate dosing of 0.5 ml 5% solution mixed with 10 ml CSF, the risk of neurologic complications is quite low. The literature is reviewed for the relative sensitivity of intrathecal fluorescein to identify CSF fistula compared.with the other available techniques, as well as the relative safety.
174
Oro-Rhino-Orbltal-Cerebral Mucormycosis Following Dental Extraction JAMES K. FORTSON, MD, TIENCHIN HO, MD, and JONE KIM, DDS, MS, Fresno, Calif.
The purpose of this paper is to present a case report of mucormycosis in 57-year-old truck driver with uncontrolled diabetes. The patient had refused insulin therapy because he would lose his occupation. He opted to take oral hyperglycemic agents. Two days before admission he was seen by his dentist for increasing teeth pain. He underwent extraction of his second and third left maxillary molar teeth. He began receiving Keflex for facial and cheek swelling. Over the next 24 hours the patient noticed increased swelling with erythema and numbness of his left cheek and eye. He noted progressive visual loss in his left eye. He presented to Valley Medical Center with blindness in his left eye and swelling with ecchymosis of left forehead, periorbital area, and cheek. His blood glucose level was 407, and he admitted to poor compliance with his oral hypoglycemic agents. Physical examination at the time of admission revealed left-sided orbital, cheek, and facial cellulitis. He had paralysis of his third, fourth, fifth, sixth, and seventh nerves. There was no vision in his left eye. Ophthalmoplegia, chemosis, and proptosis were present. The nasal examination revealed a deviated septum with scant secretions from the middle meatus. The oral cavity had a dark area with clot at the extraction site. The rest of the physical examination was essentially normal. He was admitted and began receiving intravenous antibiotics. Laboratory values revealed an elevated white blood cell count, anemia, low pH, and elevated glucose and creatinine. Consultations were obtained by internal medicine, neurology, infectious disease, otolaryngology, and ophthalmology. A CT scan revealed a mild sinusitis but no obvious masses. The patient underwent endoscopic sinusotomies with biopsies and cultures. He began receiving high-dose broadspectrum antibiotics and amphotericin B. His clinical course rapidly deteriorated. He developed black spots on his face and hard and soft palates. Biopsies were positive for mucormycosis. The patient's Glasgow coma scale began to deteriorate, and he died 72 hours after admission. Patients with diabetes have considerable risk during surgical procedures. If the diabetes is uncontrolled, catastrophic consequences may result. A thorough history should precede any surgical procedure by physician or dentist. Diabetes as well as other medical problems should be corrected before surgery.