Contrary to previous estimates, GH elimination kinetics follows a bi-exponential model and in normal subjects the GH half-life of the second phase is 13.8 +/- 1.6 minutes. Uraemic patients have impaired clearance of GH, suggesting that the kidney plays a role in GH disposal. However, the degree of impairment does not fully explain the alterations in GH secretion previously described in chronic renal failure.

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Paragangliomas are rare, typically benign neuroendocrine tumors that represent a small portion of head and neck tumors. A small percentage of these are known to have malignant potential. They arise from the carotid body, jugular bulb or vagus nerves. There is limited literature discussing the management of malignant vagal paragangliomas. We present a case of a 25 year old female with a left malignant vagal paraganglioma. The following case presentation will describe the presentation, classic radiologic findings, and management of a malignant vagal paraganglioma along with a review of the literature.Keywords Paraganglioma Á Carotid body tumor Á Malignant paraganglioma HistoryA 25 year-old female reported to the emergency department for evaluation of a severe headache. An avid singer, she incidentally complained of difficulty with vocal range and stamina over several months. Family history was negative for head and neck cancer. Physical exam revealed fullness with mild generalized erythema of both the left posterior nasopharynx and the oropharynx. On palpation of the left oropharynx there was no discrete mass, however, the patient endorsed mild tenderness on palpation. Flexible fiberoptic laryngoscopic exam revealed normal bilateral true vocal fold motion and appearance. No cervical lymphadenopathy was appreciated and cranial nerves II-XII were intact. Radiographic FeaturesComputed tomography (CT) identified a 6 9 4 9 3 cm left post-styloid parapharyngeal space avidly enhancing mass (Fig. 1). Magnetic resonance imaging (MRI) confirmed a mass within the left parapharyngeal space that was isointense on T1, slightly hyperintense on T2, and showed multiple flow voids with gadolinium enhancement. The mass was posterior to the carotid bifurcation and anterolateral to the internal jugular vein. Radiographic findings were highly suspicious for a vagal paraganglioma or nerve sheath tumor. Urine catecholamines, vanillylmandelic acid (VMA) panel and thyroid function studies were all within normal limits. Succinyl dehydrogenase (SDH) gene testing was negative.Disclaimer: The opinions and assertions expressed herein are those of the authors and are not to be construed as official or representing the views of the Department of the Navy or the Department of Defense. I certify that all individuals who qualify as authors have been listed; each has participated in the conception and design of this work, the writing of the document, and the approval of the submission of this version; that the document represents valid work; that if we used information derived from another source, we obtained all necessary approvals to use it and made appropriate acknowledgements in the document; and that each takes public responsibility for it. We are military service members.

Objective: A vagal nerve stimulator (VNS) is a FDA-approved device implanted for treatment of intractable epilepsy and major depression in adults and children. Recently, otolaryngologists are becoming more involved in the implantation and care of side effects for these devices. Method: A retrospective chart review was performed. Our local surgical database was searched for cases of VNS implantation during a period of 40 months. Fourteen cases performed by otolaryngologists were identified. Medical records were then reviewed for outcomes including medication reduction, seizure frequency and duration, device-related complications, and surgical complications. Results: Of the 14 cases performed by otolaryngologists over 40 months, 11 (78.6%) cases demonstrated either a decrease in medications required, seizure frequency, or duration. The most common side effect was voice alteration during device initiation. There were no early postsurgical complications. Conclusion: These data provide support for the qualification of otolaryngologists for performing VNS implantation and monitoring postoperative and laryngeal side effects of the VNS.

A 32-year-old woman presented with a 1-year history of facial swelling and pruritus; histologic examination revealed periductal inflammatory infiltrate with eosinophils. What is your diagnosis?

Objectives: Vestibular migraine (VM) is considered to be the second most-common cause of vertigo and the most common cause of spontaneous episodic vertigo. Topiramate has been used effectively for the prevention of migraine headaches, however, there are few quality studies showing its effectiveness for the prophylaxis of VM. We seek to determine the efficacy of topiramate for the treatment of VM. Methods: Retrospective chart review over a 24-month period (2010-2012) of patients evaluated at a tertiary neurotology clinic. A coding query was performed to identify potential patients with a diagnosis of VM. Records were reviewed for diagnostic criteria for VM and the use of topiramate as a primary prophylactic treatment. The subjective reduction in the frequency and severity of vertigo attacks was the primary measured outcome. Results: Of 109 patients identified with a diagnosis of vestibular migraine, 30 (27.5%) met the accepted diagnostic criteria for probable vestibular migraine and 22 (20.2%) met criteria for definite vestibular migraine. Nineteen (19) of those patients were treated with topiramate, out of which 13 (68%) reported significant improvement in the frequency or severity of vertigo attacks during a 10 month average follow up. Two patients discontinued topiramate due to side effects despite efficacy. No medication adverse events occurred on these patients. Conclusions: Given its safety and efficacy in classic migraine prophylaxis, topiramate has been proposed as a treatment for VM. Data from this preliminary cohort supports its role in vestibular migraine prophylaxis. Larger, prospective studies are needed to confirm these findings.

Syrup of ipecac is an important component of the emergency management of acute toxic ingestion in children. It is generally safe for acute emergency use, and is recommended for first aid kits in homes with children. However, there are important toxic effects of excessive or long-term ingestion of syrup of ipecac. Cardiomyopathy is a potentially fatal, but often reversible, toxic manifestation of ipecac abuse, most commonly occurring in patients with bulimia. Another setting in which ipecac abuse occurs is Munchausen's syndrome by proxy. We report two cases, one fatal, of cardiomyopathy from ipecac toxicity secondary to Munchausen's syndrome by proxy.

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