Jugular Bulb Prolapse: One New Case-Juniper Publishers

 Juniper Publishers- Open Access Journal of Case Studies

Jugular Bulb Prolapse: One New Case

Authored by Z Chafiki

Abstract

The constatation of a right retrotympanic blue mass imposes a precise exploration before any surgery. By reporting an observation of a jugular bulbprolapse, Hence the interest of tomographyin the positive diagnosis of these anomalies to avoid despaises and serious complications during otological surgery.

Keywords: Bulb; Jugularvein; Eardrum; Tomography

Introduction

The anatomical variations of the hypotympanum essentially combine the more or less marked prolapse and dehiscences of the bulb of the jugular and the internal carotidartery. These abnormalities should not be over looked as they may alter the normal course of the surgical sequence. A recent observation illustrates that a well-conducted clinical examination may not always suggest a prolapse bulb of the jugular in the middle earcavity. This raises the question of the value of systematic imaging before any surgery of the middle ear with pathological ear drum.

Case Report

A 45-year-old woman with a chronicotorrhea, hypoacousia of the right ear for 2 years without vertigo or facial paralysis. The clinical examination shows an uncontrollable anterior retraction pocket with a bluish appearance postero inferior. The contralateralear was normal.

Computed Tomography of the patient’s temporal bones was requested. This imagery allows us to discover an anatomical anomaly, in the form of an important anectatic right Jugular Bulb, located at the postero-inferior part of the middle-ear cavity (Figure 1 & 2). In addition to that a lateral sinus prolapse was observed (Figure 3).

A technique: tympanoplasty in closed technique was proposed. The topography of this anatomical variant of the jugular vein encourages us to be more cautious during the procedure. A careful dissection allows a complete detachment of the flap, and a good progress of the continuation of the intervention, weper formed a resection of the malléusand the incus with reinforcement pocket of retraction by cartilage of the conch.

Discussion

The anatomical variations of the middle ear are well known. The ones about the jugular bulb remains uncommon [1], Whereas the dehiscences of the carotidduct, although they are more often described in the classical works [2-3], are even more rarer (1.4%) [4]. Indeed, dehiscence of the bulb is diagnosed in 2.4% [5] to 3.9% [4] of cases, whereas the presence of a Highriding jugular bulb covered with a bonelamellais more frequent, Up to 20% of cases for Atilla et al. [4]. Development appears to be increasingly important on the right [6-7], which is indeed the case in the present case.

If the variations in height and topography are numerous, more emphasis will be placed on the clinical presentation of such an anomaly. A clinical examination, with a normal or subnormal eardrum, mayevoke an ectopia of the bulb if we notice an coving or a bluish mass by transparency. In the case of chronicotitis media, with an inflammatory tympanum or the presence of a polypus, examination is much more difficult.

The systematic demand for computed to mography allows us to make a lesional assessment of the cholestéatome, as well as its extension. It also shows the classic anatomical landmarks and, finally, looks for possible anatomical abnormalities. The interest of such research is to guide us, not so much in the indication as in the topographical approach of the the middle ear cavity. Indeed, a classic approach to the lower part of the frame would have immediately led to a profuse bleeding of venous blood with postponed surgery. The principle of haemostasis is limited to local compression with the head decolding in order to prevent gasembolism [8].

The more posterior approach allowed us to correctly expose the abnormal region. Therefore, dissect with more security.

Conclusion

The anatomical variations of the bulb of the jugular are not so rare. Those that may be problematic are related to significant prolapse and / or associated dehiscence, making the venous wall vulnerable.

There is a real surgical haemorrhagic risk. Is it necessary to do imaging before any ear surgery? Certainly not. In the particular case of cholestéatome, the systematic use of a computed tomography (CT) was reported at the Sixth Frenchspeaking Congress of ENT and CCF in Beirut. The problem is to target situations where this exploration is justified. The current medico-legalevolution, which requires us to inform the patient of the risks of surgery, is an additional reason for requesting a preoperative scan of the rock in the presence of an abnormaleardrum in its postero-inferior part.

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Clarification of Psychological Symptoms by Orthopaedic Expert Witness: Outcome of Ten Cases-Juniper Publishers

Juniper Publishers- Open Access Journal of Case Studies  

Clarification of Psychological Symptoms by Orthopaedic Expert Witness: Outcome of Ten Cases

Authored by Koch HCH

Abstract

The orthopaedic expert witness is frequently faced with one or more psychological symptoms during a typical personal injury interview. This paper describes the common psychological symptoms presented by either adults or children. It highlights the benefits arising from an early recommendation in the orthopaedic report for a further report from a psychologist.

Introduction

Providing an Orthopaedic opinion as an expert witness in a civil claim is a complex role. Notwithstanding the myriad of physical factors that need to be considered with the appropriate supporting records and scans, the orthopaedic expert will also be cognizant of other symptoms, including psychological and social signs. Although these will be largely outside his/ her competence and training, orthopaedics expert will be minded to make reference to these if only to recommend a full, comprehensive psychological assessment be commissioned.

This paper illustrates the types of symptoms to consider including in the general questioning of a claimant in a personal injury case for a road traffic collision (RTC).

Short Communication

The first author reviewed the most recent ten cases he had assessed in his medico-legal orthopaedic clinic to identify the several psychological symptoms which required mentioning.

(Table 1 & 2) below indicate the commonest type of psychological symptoms that the orthopaedic expert is likely hear or elicit during the orthopaedic assessment.

1. Early psychological assessment.
2. Early advice or treatment recommendation.
3. As a result of [1,2] the prognosis can improve i.e. shorter duration of symptoms; less entrenched or habitual behaviours (e.g. travel avoidance).
4. Reduction of work - related disability due to psychological factors.

One additional area worthy of mention is that of chronic pain. The orthopaedic expert may identify non-verbal, verbal and motivational issues in relation to the claimant’s chronic pain. He may/may not diagnosis an orthopaedic/physical disorder but the accompanying functional overlay may will point to a pain disorder/somatic symptom disorder with associated psychological factors and hence a further report from a psychologist with a special interest in chronic pain can be recommended.

In each particular legal case, a lawyer and administrator, plus a medical advisor if available, would review the orthopaedic expert’s comments and decide if the recommendation for a further psychological/psychiatric assessment was appropriate and warranted. Typically, a recommendation of this type would be accepted and expedited.

Conclusion

This short paper should be of interest to all orthopaedic expert witnesses and highlights the types of psychological symptoms or behaviours that will be beneficial to note and flag up in the orthopaedic interview, some of which can usefully be included in the orthopaedic report with a recommendation for a psychological report. These symptoms can then be rigorously assessed by a psychologist in term of diagnosis, attribution and prognosis.

 

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