Base of Skull Metastatic Adenocarcinoma from the Breast 23 Years after the Primary Diagnosis

Breast cancer metastases to the base of the skull with concomitant infiltration into the paranasal sinuses and nasopharynx are exceptionally rare with only small numbers of reported literatures. Greenberg et al. in 1981 described five clinical syndromes with regards to the base of skull metastases and the clinical presentation of each syndrome related to its anatomical location. Often, metastases to the base of the skull remain asymptomatic until the lesion has increased to a considerable size causing bony destruction and impingement to the surrounding structures. When involving the paranasal sinuses or nasopharynx, the most common presenting symptoms mimic those of rhinosinusitis and, hence, may delay the accurate diagnosis. We are reporting a case of base of skull metastasis from breast carcinoma, 23 years after the primary diagnosis. To the best of our knowledge, our case is the first case to report latent metastasis of more than 20 years

Disseminated tuberculosis in an immunocompetent young adult involving the middle ear, mastoid, brain, larynx and lungs – a case report

Introduction: Tuberculosis (TB) infection still poses worldwide public health issues, infecting almost a quarter of world’s population. Involvement of multiple organs in disseminated disease is particularly rare and often diagnosed late. Case Report: We are reporting a case of disseminated TB infection involving the middle ear, mastoid bone, brain, larynx, and the lungs in an immunocompetent 21-year-old male, likely following reactivation of latent pulmonary TB, 20 years after his initial exposure to maternal pulmonary TB infection. Results: Destructive nature of the disease as seen on high-resolution computed tomography (HRCT) of the temporal bone, without clinical signs of aggressive infection supports our diagnosis of tuberculous otomastoiditis. Magnetic Resonance Imaging (MRI) of the brain was suggestive of right sided multiloculated tuberculous intracerebral abscesses with significant cerebral oedema and right uncal herniation. Chest radiograph showed presence of reticulonodular opacities with bronchiectatic changes over bilateral upper zones and calcified nodules over left upper zone indicating chronic lung infection. The diagnosis of disseminated TB was also made based on our intra-operative findings of cheesy material occupying the right mastoid antrum and the middle ear cavity and moth-eaten appearance of the larynx. The diagnosis was further validated by the histopathological and microbiological results of positive Acid-Fast Bacilli, TB polymerase chain reaction and Gene-Xpert for Mycobacterium tuberculosis. Patient made excellent recovery after 9 months of anti-TB medications. Conclusion: A fullblown disseminated TB in an immunocompetent young adult who had completed the required vaccination is a rare entity. High clinical suspicion and early imagings will expedite delivery of treatment, thus improve prognosis. Although primarily treated with anti-TB medications, some cases may require surgical intervention to obtain tissue to confirm diagnosis, to remove infected sequestrum and when there is clinical evidence of potentially life-threatening complications

Auditory performance in early implanted children with cochleovestibular malformation and cochlear nerve deficiency

OBJECTIVES: This study aimed to report the auditory performance in children with cochleovestibular malformation (CVM)/cochlear nerve deficiency (CND) who were implanted early at the Universiti Kebangsaan Malaysia Medical Centre, using Categorical Auditory Performance (CAP)-II score and Speech Intelligibility Rating (SIR) scales, and to compare the outcome of their matched counterparts. MATERIALS and METHODS: A total of 14 children with CVM/CND with unilateral cochlear implant (CI) implanted before the age of 4 years old were matched and compared with 14 children with normal inner ear structures. Their improvement in auditory performance was evaluated twice using CAP-II score and SIR scales at 6-month intervals, with the baseline evaluation done at least 6 months after implantation. RESULTS: The average age of implantation was 31±8 and 33±7 months for the control group and the case (CVM/CND) group, respectively. Over-all, there were no significant differences in outcome when comparing the entire cohort of case subjects and their matched control subjects in this study. However, the improvement in CAP-II scores and SIR scales among the case subjects in between the first and second evaluations was statistically significant (p=0.040 and p=0.034, respectively). With longer duration of CI usage, children with CVM/CND showed significant speech perception outcome evident by their SIR scales (p=0.011). CONCLUSION: Children with radiographically malformed inner ear structures who were implanted before the age of 4 years have comparable performance to their matched counterparts, evident by their similar improvement of CAP-II scores and SIR scales over time. Hence, this group of children benefited from cochlear implantatio

Petrous apicitis and otogenic internal jugular vein thrombosis post cortical mastoidectomy: lessons to learn

Introduction: Petrous apicitis (PA) is a rare and potentially life-threatening condition following otitis media and mastoiditis. Given its rarity and presumed low incidence in the post-antibiotic era, it is often underdiagnosed. Although otogenic lateral sinus thrombosis is widely discussed, not many papers have reported otogenic right internal jugular vein (IJV) thrombosis, specifically in the jugular bulb. Case Report: A 50-year-old female presented with severe right otalgia, retro-orbital pain, and abducens nerve palsy, 2 weeks after emergency cortical mastoidectomy was done in another centre for acute on chronic otitis media with mastoiditis and PA. She was discharged 4 days after the surgery with 1 week of oral antibiotic. Results: Computed Tomography (CT) Venogram showed erosion of the medial wall of the right jugular fossa and the right occipital condyle. The right internal jugular vein (IJV) appeared distended with focal thrombosis at the proximal part of the right IJV within the jugular bulb. Diagnosis of PA complicated with IJV thrombosis was made and medical therapy was initiated. Her treatment regime includes intravenous Ceftriaxone 2 grams twice daily for 2 weeks, followed by oral Cefuroxime 500 milligrams twice daily for 4 weeks. Warfarin 3 milligrams once daily was concurrently prescribed for 12 weeks. Her symptoms improved remarkably after completion of treatment except for persistent diplopia. Conclusion: Advances in radiological assessments coupled with improved antibiotic regime permit more conservative approach in the management of PA. Based on our experience and literature review, we proposed minimum 6 weeks of antibiotic treatment for the management of PA. When concomitant otogenic venous thrombosis is present, selective use of anticoagulant is recommended. If patient clinically worsens or slow to improve with medical therapy, surgical intervention is warranted to reduce disease burden and hasten restoration of middle ear and mastoid aeration via ventilation tube insertion or mastoidectomy