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two cases of fixed dilated pupils after nebulized ipratropium. There are at least two reports of angle closure glaucoma following treatment with nebulized ipratropium alone and one report of acute glaucoma after treatment with nebulized ipratropium and salbutamol34. The effects of salbutamol on the eye are an increase in aqueous humour production of about 35%6,7. Aqueous outflow is increased by an even higher amount. The net effect is to lower intraocular pressure. Kalra and Bone8 showed that ipratropium bromide and salbutamol in aerosol form can be absorbed through the cornea after escaping from the face mask. Their cases did not develop angle closure glaucoma because the patients received only one dose. However, the drugs are normally used several times a day, so an accumulative effect is likely. We suggest the following sequence of events. Ipratropium escapes from the face mask, diffuses through the cornea producing pupil dilatation and, in eyes with susceptible angles, angle closure. Salbutamol is absorbed in a similar way and increases aqueous humour production by its effect on the ciliary body, resulting in increased aqueous flow. Pushing the eyes forward could cause angle closure even without pupil dilatation5. Physicians and ophthalmologists should be aware that treatment with nebulized ipratropium and salbutamol can cause acute glaucoma. Patients may not complain when in

Simultaneous temporal lobe and cerebellar abscess complicating acute otitis media

M G Dilkes FRCS M F PeUFRAcs J M Rice Edwards BA FRCS Regional Neurosciences Unit, Charing Cross Hospital; Fulham Palace Road; London W6 Keywords: intracerebral abscess; bilateral; acute otitis media

Intracerebral abscesses are a recognized complication of otitis media, usually chronic suppurative otitis media with cholesteatoma'. An intracerebral abscess is a localized suppurative process occurring within the brain substance. It is a relatively rare condition, with an incidence in Great Britain of three or four cases per million per year3. When arising from a focal suppurative process such as an otitis media, it is invariably as a single abscess. Infection may spread through congenital or traumatic defects into the extradural space, or via structures such as the cochlea, labyrinth or via communicating veins. Multiple cerebral abscesses are usually haematogenous in origin, and are more common in the immunosuppressed patient3. We present a case which presented as an acute otitis media that was complicated by simultaneous cerebellar and temporal lobe abscesses. This is a rare occurrence, and raises some interesting points with respect to aetiology, presentation and management of these conditions. Case report A 21-year-old Caucasian woman presented to the ENT department at Charing Cross Hospital, London, with a one week history of left otalgia, variable hearing loss, and paroxysmal vertigo. A diagnosis of otitis media with

Correspondence to: Mr M G Dilkes, The Royal London Hospital, Whitechapel, London El 1BB

severe respiratory distress. However, symptoms of blurred vision or ocular pain in patients on these drugs should, therefore, be investigated. References 1 Kanski JJ. Clinical ophthalmology, 2nd edn. Butterworths, 1989 2 Helprin GA, Clarke GM. Unilateral fixed dilated pupil associated with nebulised ipratropium bromide (letter). Lancet 1986;ii:1469 3 Malani JT, Robinson GM, Seneviratne EL. Ipratropium bromide induced angle closure glaucoma (letter). N Z Med J 1982;95:749 4 Holst PE, Gebbie T, Martin PD, O'Donnell TV. A long term trial of ipratropium in asthmatic patients. Aust N Z J Med 1976; 6:367-8 5 Packe GE, Cayton RM, Mashoudi N. Nebulised ipratropium bromide and salbutamol causing closed-angle glaucoma (letter). Lancet 1984;i:691 6 Miichi H, Nagataki S. Effects of pilocarpine, salbutamol and timolol on aqueous humour formation in Cynomolgus monkeys. Invest Ophthalmol Vis Sci 1983;Sept:1269-75 7 Coakes RL, Siah PB. Effects of adrenergic drugs on aqueous humour dynamics in the normal human eye. I Salbutamol. Br J Ophthalmol 1984;68:393-7 8 Kalra L, Bone MF. The effect of nebulised broncho-dilator therapy on intraocular pressures in patients with glaucoma. Chest 1988;93:739-41

(Accepted 25 June 1991)

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superimposed otitis externa was made and topical antibiotic treatment was commended. The condition did not resolve spontaneously, and it was necessary to admit her for 3 days of intravenous antibiotic therapy. Following this, a reasonable improvement occurred, until she was seen again one week later with a left-sided headache, persistent nausea and unsteadiness of gait. On examination there was bulging of the left postero-superior meatal wall, with left-sided cerebellar signs. Urgent computerized tomography (CT) scan of the head with contrast enhancement showed an abscess in the left lateral lobe of the cerebellum, and an abscess in the left temporal lobe (Figure 1). Following initial resuscitation she underwent a left lateral posterior fossa craniectomy, and 7 ml of grey pus was obtained on open drainage ofthe cerebellar abscess, with

0141-0768/92 080500-02/$02.00/0 © 1992 The Royal Society of Medicine

Journal of the Royal Society of Medicine Volume 85 August 1992

the majority of the abscess wall being excised. The pus was sent for microbiological analysis, which isolated Escherichia coli. The temporal lobe abscess was not drained. She was ventilated overnight because ofbrain swelling. The following day she was woken, and made a rapid recovery with full return of function after 5 days. Ten days after her initial operation, a modified radical mastoidectomy was performed on the left side, during which a moderate amount of cholesteatoma was found in the middle ear cleft, the sac ofwhich had a narrow neck opening onto Shrapnell's membrane. Discussion Small cerebral abscesses can be treated conservatively, if the pathogen is known, and the patient is given the appropriate antibiotic therapy. This is particularly true in the case of multiple abscesses or those located deep in the cerebral hemisphere, where aspiration would be difficult unless performed under stereotactic conditions4. The route of spread of the infection in this case can only be postulated. The tentorial barrier to the two abscesses suggests that they may either have arisen from a structure which passes through the tentorial hiatus, such as in a

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lateral venous sinus thrombophlebitis, or have arisen from a structure which directly borders these two areas, such as the labyrinthine apparatus. Middle ear infections causing cerebral abscess are usually chronic in nature, although before the advent of antibiotics acute infections were the commonest preceding cause. References 1 Arseni C, Ciurea AV. Cerebral abscesses secondary to otorhinological infection. A study of 386 cases. Zentralbi Neurochir 1988;49:22-36 2 Maurice-Williams RS. Intracranial abscess. Hospital Update 1989:118-25 3 Levy RM, Pons VG, Rosenblum ML. Central nervous system mass lesions in the acquired immunodeficiency syndrome (AIDS). J Neurosurg 1984;61:9-16 4 Rosenblum ML, Mampalam TJ, Pons VG. Controversies in the management of brain abscesses. Proceedings of the Congress of Neurological Sciences. In: Little JR, ed. Clinical Neurosurgery. Williams and Wilkins, 1985:603-32 (Accepted 18 June 1991)

Meeting reports Oregon health decisions: common sense pursued Keywords: Oregon; health service finance; health care systems

It was fitting that this meeting was held on the day after the Independent on Sunday ran a story about a girl who, it was alleged, was refused admission to a Trust hospital's intensive care unit because it was unclear whether the district from which she came would pay for her treatment. The Society's Open Section, along with so many others, has in the past debated the principles of how health services should be funded. We have examined other countries' systems, we have juggled with figures and with the exception of those at the extreme ends of the political spectrum we have retired baffled. The people of Oregon have debated the topic, grasped the nettle and, although their scheme has not been fully implemented, at least there has been an attempt at balancing need with resources within a democratic framework; Dr Ralph Crawshaw, one of the founders of the approach, came to tell us about it. From the chair Dr Anthony Hopkins introduced Dr Crawshaw as a psychiatrist and therefore someone with a more humane and wider ranging view of medicine than most. Dr Crawshaw, for his part, admitted that the scheme he was about to describe was the product of his state and he was aware of the cultural gap that exists between the United States and Great Britain. He went on to describe with clarity

and force an approach to the funding of health care that was neither finished nor perfect but had the merit of, at least in theory, overcoming many of the obstacles that bedevil the schemes of others. Oregon is a West Coast state, some 300 by 400 miles. The American national system being what it is - better care for fewer people at higher prices - the rich have private insurance, the very poor have access to Medicaid but 400 000 of Oregon's 2.6 million inhabitants have no access to medical care at all. In essence, Oregon has faced up to the fact that resources for health care, as for anything else, are finite and that some form of rationing is inevitable. Looking at an aging population needing more care, sophisticated consumers demanding more whether they need it or not, costs climbing and a depressed economy the group known as Oregon Health Decisions sought public opinion. In 1984, having conducted 300 grass roots community meetings, they convened a Health Care Parliament (in a parliament one speaks, in Congress people get together to play politics) to debate and to pass on, from bottom upwards, citizen generated issues. Subsequently 15 community values were hammered out, including the key one dealing with the allocation of health resources which put forward the view that decisions on what money can be spent should be based, in part at least, on a scale of public attitudes that quantify the trade offbetween length and quality of life. In 1989 a Health Services Commission was set up and, among other things, made a requirement of all employers that they provide a Standard Benefit Package for their staff by 1994. The crucial and controversial work of the Commission, which was made up of physicians, health care experts and those with no medical training, was

Report of meeting of Open Section, 2 March 1992

0141-0768/92 080501-02/$02.00/0 © 1992 The Royal Society of Medicine

Simultaneous temporal lobe and cerebellar abscess complicating acute otitis media.

500 Journal of the Royal Society of Medicine Volume 85 August 1992 two cases of fixed dilated pupils after nebulized ipratropium. There are at least...
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