Sinus Infection Leads to Skull Removal in Child

The UK reported a 9 years old boy who had an extremely rare sinusitis complication that ultimately resulted in the left skull being removed temporarily.

Briefly, in Feb 2013, the child developed headaches and a droopy eyelid. Surgeons ultimately had to remove his left skull due to brain swelling and concern the bone itself was infected. Over the next few months, the child had to wear a bike helmet to protect his brain which was no longer protected by his skull. A few weeks ago, he underwent another surgery to cover the hole in his left skull with a custom-shaped ceramic plate.

No mention was made in the media about which sinus cavity led to this horrible problem.

But here's a guess without benefit of more information...

Based on the skull defect shown (see pics here), it appears that the parietal and temporal skull bones were removed. There are actually no sinus cavities in these regions. As such, the only thing that makes sense to me is that the left cerebral dural sinus (large blood vessels of the brain) became clotted off and infected secondary to a sinus infection, probably the ethmoid sinus cavities located between the eyes.

The blood supply from the ethmoid sinus cavities communicates with the cavernous sinus found at the bottom of the brain. This anatomic structure is a major source of venous drainage of the brain.

If the cavernous sinus gets inflamed/infected due to a sinus infection, it could lead to multiple facial abnormalities due to injury of the numerous cranial nerves that go through it including:

• Inability to move the eyeballs (CN3, 4, 6)
• Numbness, pain of the skin over the forehead and cheeks (CNV1, V2)
• Loss of pupillary constriction (CN3)
• Visual loss/changes (CN1)

Ultimately, the cavernous sinus could also become thrombosed.

Cavernous Sinus shown by red arrow. Taken from Sonoworld.

From there, the infection can spread to the rest of the brain via the dural sinus cavities and potentially can even lead to death if not treated promptly and aggressively.

How aggressively? In this particular case, the child had half his skull removed!

Thankfully, the vast, vast, vast majority of sinus infections do not lead anywhere close to this type of complication.

Source:

Boy, 9, has half his skull removed after sinus infection spreads to his brain - but he still manages to attend school thanks to a BICYCLE HELMET. MailOnline 8/26/13

Read More

The Facial Triangle of Danger (Even Death)

Image by SpooSpa from Wikipedia

If you draw a line between the eyebrow to the corners of the lip, a triangle is created which delimits a region esoterically known as the "danger triangle".

Why is this region considered dangerous?

It's because infections within this region can lead to infections of the brain (rarely). Why? The blood supply within this triangular area communicates with the cavernous sinus found at the bottom of the brain. This anatomic structure is a major source of venous drainage of the brain.

If the cavernous sinus gets inflamed/infected due to a rip-roaring pimple of the upper lip, it could lead to multiple facial abnormalities due to injury of the numerous cranial nerves that go through it including:

• Inability to move the eyeballs (CN3, 4, 6)
• Numbness, pain of the skin over the forehead and cheeks (CNV1, V2)
• Loss of pupillary constriction (CN3)
• Visual loss/changes (CN1)

The cavernous sinus could also become thrombosed.

Cavernous Sinus shown by red arrow. Taken from Sonoworld.

From there, the infection can spread to the rest of the brain and potentially can even lead to death if not treated promptly and aggressively.

Of course, tiny infections like a small pimple or a small laceration due to biting a lip is not going to cause problems.

However, rapidly progressive major infections of the skin with abscess formation do need to be treated cautiously.  Typically, such patients are hospitalized on IV antibiotics until definite and significant improvement can be seen at which time patients can be discharged home on oral antibiotics.

At which point a "minor" infection becomes "major" requiring hospitalization is a judgement call.

Read More

Why Is Eustachian Tube Balloon Dilation to Treat Eustachian Tube Dysfunction Slow to Catch On?

Eustachian tube dysfunction is a phenomenon whereby a person is unable to pop their ears to relieve symptoms of ear pressure, clogging, or fullness. It is much akin to the ear pressure a person experiences when flying, but at ground level. Traditionally, treatment of this condition involved medications like steroid nasal sprays and prednisone along with active valsalva (watch video below). Once medical treatment has failed, ear tube placement has been the step of last resort.

However, a promising new treatment called eustachian tube balloon dilation has been described in March 2011 to address eustachian tube dysfunction at the source (the eustachian tube) surgically rather than indirectly with tube placement across the eardrum. In essence, a balloon is inserted into the eustachian tube and than inflated thereby opening it up (the balloon is "popping" the ear for you). The balloon is than deflated and removed.

Dr. Dennis Poe in Boston, MA is the researcher who first described this technique in March 2011 and at this time, is offered only in a few centers.

Why has something so simple with equipment so readily available been so slow to gain acceptance by ENTs?

Well, there are several reasons, not the least of which is the fact that this procedure is still considered "experimental" and in the research stage only.

However, there is the cost of the balloon itself which is typically not covered by insurance even if a patient wishes to proceed with an unproven treatment. The material cost of the balloon is around $2000 or more. Compare this to the cost of a tube which is around $30 or less. In other words, hospitals would lose money by offering this procedure with current fee schedules.

Furthermore, there are potentially huge, albeit rare risks associated with balloon dilation of the eustachian tube. These risks are clearly reported by Dr. Dennis Poe who "invented" this procedure in his landmark paper.

The internal carotid artery supplies blood to the brain and can be found right next to the eustachian tube. Take a look at this CT scan of the ear:

ET is the eustachian tube and ICA is the (internal) carotid artery. These structures are found right next to each other!

The balloon catheters used for eustachian tube dilation have a fairly pointy tip (though not sharp), but when placed in a directed fashion inside of small diameter tunnel like the eustachian tube, there is the chance that the catheter tip may puncture or injure the carotid artery leading to risk of:

1) horrible bleeding
2) stroke
3) arterial wall dissection or aneurysm formation
4) death

In most individuals, there is a thin layer of bone that separates the carotid artery from the eustachian tube that does proffer some protection. But, this bone is not always present and therefore can not be counted on to protect the artery from any unintentional injury.

So to summarize, given ear tube placement has profoundly less risk, much cheaper, and long history of effectiveness compared to balloon dilation of the eustachian tube which has significant risks, expensive, and unproven long-term results, it is actually no wonder that the balloon method has been slow to gain acceptance.

Indeed, in another published article, it specifically states balloon sinuplasty to be a "gizmo" of uncertain safety and efficacy... in fact, the title of the article says it all "Balloon Dilation of the Eustachian Tube Is Indeed a 'Gizmo' Until Future Research Proves Safety and Efficacy."


Reference:
Balloon Dilation of the Cartilaginous Eustachian Tube. Otolaryngol Head Neck Surg April 2011 vol. 144 no. 4 563-569

Balloon catheter dilatation of eustachian tube: a preliminary study. Otol Neurotol. 2012 Dec;33(9):1549-52. doi: 10.1097/MAO.0b013e31826a50c3.

Balloon Dilation of the Eustachian Tube Is Indeed a "Gizmo" Until Future Research Proves Safety and Efficacy.Otolaryngol Head Neck Surg. 2014 Jun 3. pii: 0194599814538232.

Balloon Dilation of the Cartilaginous Portion of the Eustachian Tube. Otolaryngol Head Neck Surg. 2014 Apr 4;151(1):125-130. [Epub ahead of print]

Read More

Sheryl Crow Blames Brain Tumor on Cell Phone Use

On the inaugural episode of Katie Couric's new talk show Katie, Sheryl Crow described her history with a brain tumor called meningioma which was found in her right temporal lobe. This diagnosis was reported in a previous blog post.

Most interestingly, during the show, she blames the meningioma on excessive cell phone use years ago when she was on the phone for hours promoting her records using one of those archaic analog cell phones.

The relationship between cell phone use and brain tumors including benign tumors like meningioma has been discussed in prior blog posts.

Watch the interview here:

Read More