An obese 49-year-old man, with a 2-week history of intermitant neck and shoulder stiffness, was referred for evaluation. He denied dysphagia, odynophagia, fever, sweats, or chills. There was no history of foreign body ingestion or throat discomfort. Review of systems was negative for immunocompromising factors or diabetes mellitus.Physical examination revealed an obese white man in no distress. He was afebrile, with stable vital signs. The oral cavity and pharynx were clear. No trismus was present. Neck examination revealed no tenderness or masses. Results of a fiberoptic examination showed the nasopharynx, hypopharynx, and larynx to be within normal limits. The remainder of the physical examination was within normal limits. Laboratory evaluation was significant for a white blood cell count of 13.6 thousand, with a normal differential.A lateral soft tissue roentgenogram demonstrated a retropharyngeal space of 32 mm at the level of C, (Fig. 1). Computerized tomography (CT) confirmed the presence of a large, midline, cystic-appearing mass that extended from the level of C, to C, (Fig. 2).The patient was taken to the operating room. After endoscopic evaluation and a tracheotomy were performed, a lateral pharyngotomy approach was used to drain a large prevertebral abscess. A necrotic sequestrum of bone was found. Wound cultures, as well as admission blood cultures, subsequently grew staphylococcus aureus. The patient underwent a 6-week course of intravenous nafcillin, at which time a normal gallium scan confirmed successful treatment of osteomyelitis. The patient did well post-treatment and remained without clinical or radiographic evidence of disease.
Previous studies have shown that beginning 5 to 7 days from wounding, the tensile strength of wounds closed under tension in rats is significantly higher than the tensile strength of wounds closed without tension. This study evaluated the effects of increased closing tension, zyplast implant (ZI), and human recombinant platelet-derived growth factor (PDGF) on the tensile strength of wounds. Six groups of 12 rats each were divided into two main subsets: wounds were closed without tension in three groups and with high tension of approximately 100 g in the three other groups. In both no-tension and high-tension groups, one subgroup received no intervention (controls), one subgroup received ZI (zyplast controls), and one subgroup received ZI-PDGF (ZI used as a carrier for PDGF). Healing was evaluated by tensile strength determinations at 5 days. For the controls, wounds closed under tension showed a trend toward higher tensile strength, but statistical significance was not reached. Compared with controls, tensile strength was 45% lower in the wounds with ZI and closure with tension (P = .0063) and 38% lower in the wounds with ZI and closure without tension (P = .007). Treatment with ZI-PDGF resulted in 69% higher tensile strengths (P = .049) as compared with ZI controls for wounds closed with tension. This study demonstrated the beneficial effect of PDGF in accelerating healing in wounds closed under tension. Although ZI was able to deliver PDGF to the wound, the use of this substance as a carrier is questioned since it was detrimental to healing.
The patient with an acoustic neuroma may present to the otologist with a variety of clinical features. Classically these include a retrocochlear pattern of sensorineural hearing loss, reduced vestibular response on caloric testing and radiological asymmetry of the internal auditory canals (IAC). The absence of any or all of these features, however, does not exclude the presence of tumour. Five cases are presented to illustrate the potential for diagnostic delay unless a routine battery of investigations is undertaken in patients with neuro-otological disorders. All patterns of subjective audiometry are encountered, auditory brain stem response testing may be unreliable where hearing loss is profound, vestibular testing is normal in half of small tumours and the intracanalicular tumour may be radiologically undetectable unless IAC meatography is employed.
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