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Monographien des RGZM

Introduction. Necrotising otitis externa (NOE) is a rare life-threatening complication of simple otitis externa which can be difficult to diagnose and manage. It is very rarely centred on the temporomandibular joint (TMJ). Fungi cause NOE in approximately 5–20% of patients, and a high index of suspicion is required for diagnosis, particularly when there is no improvement with prolonged topical and intravenous antibiotic therapy. Objective. To report a novel case of fungal NOE centred on the left TMJ in an immunocompromised adult male with a focus on investigations and optimal management. Case Report. A 67-year-old male with comorbid chronic renal impairment presented to our otolaryngology department with prolonged left otalgia and otorrhoea. Subsequent cross-sectional imaging demonstrated left NOE centred on the TMJ. Poor resolution with prolonged courses of systemic and topical anti-pseudomonal antibiotics prompted maxillofacial surgical input for left TMJ exploration, washout, and biopsy from the joint capsule. The causative organism was identified as Aspergillus flavus on PCR analysis. The patient was successfully treated with oral posaconazole and repeated topical insertions of amphotericin B-soaked ribbon gauze to the left ear. Discussion. A combination of various imaging modalities including CT, MRI, Tc-99, and gallium-67 are utilised in clinical practice both to diagnose NOE and subsequently monitor disease progression or resolution. Immunocompromised patients with confirmed fungal NOE may require a combination of treatments including surgical debridement and prolonged antifungal therapy for a number of months, if not lifelong, treatment. Initiating empirical antifungal therapy may be justified in some patients. However, this should be judged on a case-by-case basis and guided by discussion with the local microbiology and infectious diseases departments. However, there is no national guideline or consensus regarding treatment of these patients, especially in cases of fungal NOE.

Our understanding of genomic heterogeneity in lung cancer is largely based on the analysis of early-stage surgical specimens. Here we used endoscopic sampling of paired primary and intrathoracic metastatic tumors from 11 lung cancer patients to map genomic heterogeneity inoperable lung cancer with deep whole-genome sequencing. Intra-patient heterogeneity in driver or targetable mutations was predominantly in the form of copy number gain. Private mutation signatures, including patterns consistent with defects in homologous recombination, were highly variable both within and between patients. Irrespective of histotype, we observed a smaller than expected number of private mutations, suggesting that ancestral clones accumulated large mutation burdens immediately prior to metastasis. Single-region whole-genome sequencing of from 20 patients showed that tumors in ever-smokers with the strongest tobacco signatures were associated with germline variants in genes implicated in the repair of cigarette-induced DNA damage. Our results suggest that lung cancer precursors in ever-smokers accumulate large numbers of mutations prior to the formation of frank malignancy followed by rapid metastatic spread. In advanced lung cancer, germline variants in DNA repair genes may interact with the airway environment to influence the pattern of founder mutations, whereas similar interactions with the tumor microenvironment may play a role in the acquisition of mutations following metastasis.

Hyporheic exchange between a river channel and its floodplain region assists in mediating processes such as nutrient removal and temperature regulation. Floodplain restoration in the form of levee setbacks are often carried out to improve the hyporheic exchange. In this study Light Detection and Ranging (LiDAR) data were used along with the head data from observation wells and stage data from rivers to setup and calibrate a groundwater model for 458 km 2 of area within Gap to Gap reach of the Yakima River, WA. This area has witnessed several efforts of floodplain restoration in the form of levee setbacks. The groundwater model was used to quantify hyporheic flow emerging from the Yakima River in steady and transient states during pre-restoration (using LiDAR data of 2008) and post-restoration period (after levee setback using LiDAR data of 2013). The comparison of results from the model runs during pre and post-restoration periods showed that the length of the pathlines increased after levee setback for both steady and transient state model simulations. The largest increase of about 62 m was noticed in the month of September 2014 (pre: 398 m and post: 460 m). The study also showed that the direction of the flow changed following levee setback, expanding the area for hyporheic flux exchange between surface and groundwater. The model run during transient state also suggested that pathlines were longer during drier months compared to wet months. Overall, the study showed that levee setbacks improved the hyporheic connection between surface and groundwater in the Yakima floodplain which demonstrates that levee setback can provide a valuable hydrologic tool to restore ecosystem processes in previously leveed rivers.

Background: Bronchoscopic transbronchial cryobiopsy is increasingly used for the histological assessment of diffuse parenchymal lung disease. Diagnostic performance may be improved by more accurate targeting of biopsy to radiologic abnormalities, and complication rates may be reduced by avoiding biopsy of pleura or larger vessels. Objectives: To report the preliminary experience of using CT-fluoroscopic guidance for accurate targeting of bronchoscopic transbronchial cryobiopsy. Methods: Bronchoscopic cryobiopsy was performed in a hybrid CT theatre. 3D CT images were acquired following positioning of the cryoprobe in a distal airway segment. Where cryoprobe position was observed to be too close to the chest wall/diaphragm pleura, or not within the region of interest within the lung parenchyma, re-positioning of probe was undertaken and repeat 3D images were acquired to confirm positioning prior to cryobiopsy. Results: CT-fluoroscopic transbronchial cryobiopsy was successfully performed in 4 patients: 3 patients with interstitial lung infiltrates, and one with an enlarging left upper lobe mass. Images were reviewed following each acquisition to accurately assess the probe position within the lung parenchyma, and relative to other thoracic structures. Intra-procedural imaging was of sufficient quality to allow the accurate positioning of the cryoprobe tip with respect to both the parenchymal region of interest and pleural surfaces. No complications were experienced, and all procedures yielded diagnostic specimens. Conclusions: Our preliminary experience confirms the feasibility of performing transbronchial cryobiopsy under CT-fluoroscopic guidance. Accurate targeting of transbronchial cryobiopsy may be achieved using CT-fluoroscopic guidance. Positioning of the probe tip, both with respect to parenchymal region of interest and to pleural surfaces, can be established with high accuracy.

Introduction: Acute following a chronic exertional compartment syndrome (CECS) is a known but uncommonly encountered complication of sports activity and its physiologic profile remains unclear to date. Failure to recognize and promptly treat this condition can lead to disastrous sequelae. Case Report: We present the case of a 13-year-old lacrosse player with a history of CECS who developed unprovoked acute compartment syndrome. Despite emergent fasciotomy, she experienced intermittent episodes of peroneal nerve deficits. A peroneal nerve neurolysis was later performed which resulted in full resolution of her symptoms. Conclusion: This case stresses the importance of a high index of suspicion for compartment syndrome which if not treated in a timely fashion can have devastating consequences.

Transesophageal introduction of the endobronchial ultrasound (EBUS) videobronchoscope allows pulmonologists to perform endoscopic ultrasound fine-needle aspiration (EUS-B-FNA) of mediastinal lesions. Safety, diagnostic accuracy, and feasibility of EUS-B-FNA in evaluation of pulmonary parenchymal lesions are not established.All patients undergoing pulmonologist-performed EUS-B-FNA of parenchymal lung lesions at 2 tertiary centers were included in this prospective observational cohort study.EUS-B-FNA sampling of parenchymal lesions was performed in 27 patients. Mean (±SD) lesion size was 36±16 mm. Seven lesions were ≤18 mm. Pneumothorax occurred in 1 patient (3.7%, 95% confidence interval, 0.001%-19%). Ten target lesions (36%) were in locations inaccessible to bronchoscopic sampling via the airways, and 9 lesions were inaccessible to EBUS-guided transbronchial needle aspiration and in locations associated with low diagnostic yield from radial EBUS. EUS-B-FNA was diagnostic in 26 patients (96%), and sensitivity of EUS-B-FNA was 100% (95% confidence interval, 87%-100%) for both lung cancer (n=21) and for pulmonary metastatic lesions (n=5).Pulmonologist-performed EUS-B-FNA is safe and accurate in the evaluation parenchymal lung lesions. Diagnostic accuracy is high. EUS-B-FNA may achieve access to sites not amenable to other forms of bronchoscopic sampling, or increase diagnostic accuracy in patients where anatomic position predicts a low diagnostic yield.

Background Transoesophageal endobronchial ultrasound (EBUS) video-bronchoscope insertion provides pulmonologists access to conduct endoscopic fine-needle aspiration (EUS-B-FNA) of mediastinal lymph node (LN) lesions and also assist in lung cancer staging by sampling left adrenal gland (LAG) lesions. Limited literature has described additional diagnostic value whilst maintaining patient safety. To elicit whether combining endoscopic transoesophageal fine-needle aspiration using convex probe bronchoscope (EUS-B-FNA) and EBUS bronchoscopy enhances the diagnostic yield of mediastinal nodal staging in lung cancer, whilst maintaining safety. Methods All eligible patients with paraoesophageal lesions on thoracic computed tomography (CT) underwent pulmonologist-performed EUS-B-FNA at two tertiary centres and were included in this prospective observational cohort study. Results EUS-B-FNA sampling was performed at 69 mediastinal LN lesion sites, including 17 sites inaccessible to bronchoscopic sampling. Four LAG lesions were sampled via EUS-B-FNA. There were no complications. EBUS-TBNA was augmented by EUS-B-FNA because of accessibility of sampling lesions otherwise unamenable bronchoscopically, thereby increasing diagnostic utility. Diagnostic sensitivity of EUS-B-FNA for malignancy in mediastinal LN lesions was 88% (51 of 58). For mediastinal LN lesions not amenable to EBUS-TBNA, the sensitivity for diagnosis of malignancy via EUS-B-FNA was 88% (15 of 17). Diagnostic sensitivity of EUS-B-FNA for malignancy in LAG lesions was 50% (2 of 4). Conclusion EUS-B-FNA is a precise and safe approach in the evaluation and staging of lung cancer when performed by a pulmonologist. It complements and increases the diagnostic utility of EBUS-TBNA by further coverage of mediastinal LN stations and access to LAG lesions.

To our knowledge, the imaging features of costochondral grafts (CCGs) on cone-beam computed tomography (CBCT) have not been documented in the literature. We present the case of a CCG in the facial soft tissue to the anterior mandible, with changes mimicking a cartilaginous neoplasm. This is the first report to describe the CBCT imaging features of a long-standing graft in the anterior mandible. Implants or grafts may be incidental findings on radiographic images made for unrelated purposes. Although most are well-defined and radiographically homogeneous, being of relatively inert non-biological material, immune reactions to some grafts may stimulate alterations in the appearance of surrounding tissues. Biological implants may undergo growth and differentiation, causing their appearance to mimic neoplastic lesions. We present the case of a cosmetic autogenous CCG that posed a diagnostic challenge both radiographically and histopathologically.

Failed anterior cruciate ligament reconstruction is a complex problem. However, mastering evaluation and management of the failed graft can assist the surgeon in helping an increasingly active patient population. The key to a successful revision surgery is determining why the index operation failed. A detailed history, physical examination, and evaluation of appropriate radiology will give the surgeon an outstanding opportunity to plan to move forward. Understanding the most common reasons for failure outlined in this chapter will assist the skilled sports medicine surgeon in individualizing patient care.

Background: Hamstring tendon autografts, for ACL (anterior cruciate ligament) reconstruction, have demonstrated a higher re-rupture rates when graft diameter of 8 mm diameter was then selected. The comparison group was matched based on age within 3 years. Graft failure was defined as revision ACL reconstruction or evidence of graft failure on clinical exam (no end point on lachman or pivot shift) or MRI evidence of retear. International Knee Documentation Committee (IKDC), Marx Activity, and Knee injury Osteoarthritis and Outcome (KOOS) scores were obtained. Patients were contacted to obtain information regarding outcome scores, revision procedures, return to sport, and complications. A minimum follow up time was set at 12 months. Results: Forty-six patients met criteria for inclusion in this study and had follow up data. The hybrid group had a total of 23 patients consisting of 7 men and 16 women with an average age of 31 years (Range 17-51 years). The autograft group had a total of 23 patients consisting of 17 men and 6 women with an average age of 33.3 years (Range 15-48). The average follow-up between both groups was 31.5 months (range 12-63 months). The graft failure rate in the hybrid group was 8.7% (2 of 23 patients), while the autograft group demonstrated a graft failure rate of 4.3% (1 of 23 patients) (p=0.49). In the hybrid ACL group, the mean IKDC was 67.8 (CI 59.8-75.9) compared to 73.8 (CI 66.6-80.9) in the autograft group (p=0.26). The average KOOS scores for the hybrid group was 75.8 (CI 67.5-84.1) compared to 86.5 (CI 81.4-91.7) in the autograft group (p=0.03). Conclusions: In an adult population, allografts augmented hybrid ACL grafts showed no statistically significant difference compared to hamstring autograft in graft failure rates. The autograft ACL group demonstrated a higher KOOS score, though the IKDC was equivalent.