Can MRI predict olfactory loss and improvement in posttraumatic olfactory dysfunction?

BACKGROUND: Although most patients with post-traumatic olfactory dysfunction (PTOD) undergo MRI, there is no consensus about its diagnostic or prognostic value. The aims were: 1) to classify the extent of post-traumatic neurodegeneration; 2) to determine its relationship with chemosensory dysfunction (smell, taste, trigeminal); and 3) to establish whether MRI can predict olfactory improvement. METHODOLOGY: We conducted a retrospective cohort study based on a series of 56 patients with PTOD. All patients underwent validated psychophysical tests of their smell, taste, and trigeminal functions, otorhinolaryngologic evaluation, and MRI. An experienced radiologist blinded to patient data evaluated 40 chemosensory-relevant brain regions according to a four-point scale (0=no lesion to 3=large lesion). Follow up data after 4 years (on average) were available in 46 patients. RESULTS: The cluster analysis showed 4 brain lesion patterns that differed in lesion localization and severity. They are associated with diagnostic categories: anosmia, hyposmia and normosmia. Two clusters were highly specific for anosmia (100% specificity)and could accurately predict this condition (100% positive predictive value). No clusters were associated with trigeminal or taste dysfunction. Regarding improvement, 72.7% of patients in the cluster with mild lesions experienced subjective and measurable olfactory improvement whereas this was only the case in 21.7-37.5% of patients with larger lesions. The odds of subjective smell improvement were 5.9 times higher in patients within the milder cluster compared to larger ones. CONCLUSIONS: The analysis of brain lesions in PTOD allows corroboration of smell test results and prediction of subjective and measurable improvement.

Predictive factors of involuntary weight loss in patients with smell and taste disorders.

BACKGROUND: Chemosensory dysfunction (olfaction, taste, and trigeminal) affects quality of life, potentially impacting eating behaviors. We investigated which factors are associated with weight loss in patients with smell and taste disorders. METHODS: Retrospective study of consecutive adult patients seen in the smell and taste clinic during a 10-year period. Patients were asked about smell, flavor and taste impairment. Psychophysically, smell was assessed with Sniffin' Sticks, flavor with a retronasal test, and taste with Taste Strips. RESULTS: A total of 554 patients (313 females) were included with a median age of 51 years (IQR 23). Seventy-six (13.7%) reported involuntary weight loss (median 6 kg, IQR 6) due to chemosensory disorders. The odds of losing weight were 2.1 times higher when patients reported subjective changes in flavor perception. Parosmia was a significant predictor of weight loss. Patients with symptoms lasting longer than two years were less likely to present with weight loss. Post-traumatic chemosensory dysfunction was a significant predictor of losing weight. On psychophysical testing, the probability of a patient losing weight increased by 8% for every 1-unit reduction in Taste Strips score. CONCLUSION: Factors associated with weight loss were self-reported changes in flavor perception, parosmia, duration of symptoms for less than two years, head injury, and psychophysically measured low Taste Strips score. These data help to identify patients at risk of weight loss from smell or taste impairment.

Trigeminal impairment in treatment-refractory chronic nasal obstruction.

BACKGROUND: Patients with anatomically unexplained, chronic nasal obstruction (CNO) that is refractory to medical treatment pose a challenge for clinicians. A surgical solution, addressing mechanical obstacles, is unsuited for these patients. CNO may result from disrupted airflow perception due to activation of the intranasal trigeminal system; therefore, aim of this study is to evaluate if intranasal trigeminal function of these CNO patients is decreased. METHODS: In this retrospective cross-sectional study, we compared 143 CNO patients and 58 healthy volunteers, between 18 to 80 years old. We assessed nasal patency by means of rhinomanometry (RM) and measured susceptibility of intranasal trigeminal system by the trigeminal lateralization task (TLT). RESULTS: TLT scores were significantly lower in CNO patients compared to controls (p less than 0.001), but RM scores were not different between groups. Accordingly, TLT allowed to identify CNO patients with an accuracy of the area under the curve (AUC) of 0.78, while the value for RM was at chance (AUC=0.47). CNO patients showed normal reaction to vasoconstrictive agents with significantly lower RM values after Xylomethazoline application. CONCLUSION: Results suggest that reported nasal obstruction in CNO patients without any obvious anatomical obstacle and resistant to medical treatment may be linked to decreased perception of nasal airflow rather than physical obstruction. In this sub-set of CNO patients, trigeminal testing more adequately reflects the reported obstruction than nasal resistance assessment does. In future studies, the relation of the trigeminal status and the subjective sensation of nasal obstruction needs to be addressed with validated patient rated outcome measures (PROMs).

Application of the European Test of Olfactory Capabilities in patients with olfactory impairment.

A central issue in olfaction concerns the characterization of loss of olfactory function: partial (hyposmia) or total (anosmia). This paper reports the application in a clinical setting of the European Test of Olfactory Capabilities (ETOC), combining odor detection and identification. The study included three phases. In phase 1, anosmics, hyposmics and controls were tested with the 16-items version of the ETOC. In phase 2, a short version of the ETOC was developed: patients with and controls without olfactory impairment were tested on a 6-items ETOC. In phase 3, to predict olfactory impairments in new individuals, the 16-items ETOC was administered on samples of young and older adults, and the 6-items version was applied in samples of young, elderly participants and Alzheimer patients. In phase 1, linear discriminant analysis (LDA) of ETOC scores classified patients and controls with 87.5 % accuracy. In phase 2, LDA provided 84 % correct classification. Results of phase 3 revealed: (1) 16-items ETOC: whereas in young adults, 10 % were classified as hyposmic and 90 % as normosmic, in elderly, 1 % were classified as anosmic, 39 % hyposmic and 60 % normosmic; (2) 6-items ETOC: 15 % of the young adults were classified as having olfactory impairment, compared to 28 % in the older group and 83 % in Alzheimer patients. In conclusion, the ETOC enables characterizing the prevalence of olfactory impairment in young subjects and in normal and pathological aging. Whereas the 16-items ETOC is more discriminant, the short ETOC may provide a fast (5-10 min) tool to assess olfaction in clinical settings.

Diarrheagenic enteroaggregative Escherichia coli causing urinary tract infection and bacteremia leading to sepsis.

We report a case of a 55-year-old immunocompromised female who presented to the emergency department with severe diarrhea and vomiting following travel to the Philippines. Stool bacteriology revealed a mixed infection involving an enteropathogenic Escherichia coli and two distinct strains of enteroaggregative Escherichia coli (EAEC). During hospitalization, urine and blood culture tested positive for one of the diarrheagenic EAEC strains, necessitating urinary catheterization, intensive care, and antimicrobial treatment with trimethoprim-sulfamethoxazole, followed by meropenem. Although known to occasionally cause urinary tract infections, EAEC have not been previously associated with sepsis. Our report highlights the potential of EAEC to cause severe extraintestinal infections.

[Non-union of the maxilla: a rare complication after Le Fort I osteotomy]. / Pseudarthrose du maxillaire après ostéotomie de Le Fort I.

INTRODUCTION: Maxillary non-union following Le Fort I osteotomy is a rare complication in orthognathic surgery. We report our experience and analyze the possible etiological factors. PATIENTS AND METHOD: We retrospectively analyzed the files of 150 patients having undergone Le Fort I osteotomy, between 1996 and 2006, screening for maxillary non-union. We documented patients' features of: sex, age, medical history, indication, orthodontics, osteotomy type(s) and displacement(s), osteosynthesis, quality of dental occlusion, orthodontics, clinical signs supporting a diagnosis of non-union, radiologic examinations, peroperative observations and surgical revision, outcome after surgical revision. RESULTS: Maxillary non-union was observed in four patients (2.6%). They were female patients with a mean age of 34 years (30 to 38 years) without any specific medical history. All underwent bimaxillary osteotomy (including one Le Fort I segmented osteotomy) for a class III (retromaxillary and promaxillary) associated to vertical disharmony (open-bite and/or transverse discrepancy). Maxillary displacements were always associated to advancement (average: 6mm, 4 to 8mm) and a vertical displacement (upward in three cases, downward in one case). In every case the maxilla was osteosynthesized with titanium miniplates, with four holes and 1.5 screws. Postoperative dental occlusion was deficient in every case, requiring surgical revision of orthodontics between four to six weeks after osteotomy. Clinical signs suggesting non-union were in every case maxillary mobility associated in three cases to discomfort. The mean delay between osteotomy and the non-union was 15.5 months (six to 56 months). These signs appeared after infection in three cases (maxillary sinusitis in two cases, dacryocystitis in one case). Conventional radiological (panoramic and lateral cephalometric radiographs) suggested non-union (plate fracture) in two cases and 3D computed tomography was required in every case to make a diagnosis. Surgical revision was decided for all patients (osteotomy site curettage, bone graft and a more stable osteosynthesis using 2.0 screws). Bone healing was achieved in every case after revision surgery. DISCUSSION: The incidence of non-union in our series was superior to that of published data (0.33 to 0.8%). Non-union always appeared in instable occlusion settings, and in three cases because of postoperative infection, but the main risk factor seemed to be osteosynthesis instability. Maxillary mobility is the key sign to screen for. Osteosynthesis material rupture or loosening is present every time but not always visible on standard radiography. 3D CT scan always allows observing non-union. Revision surgery combines curettage, bone graft, and a stronger osteosynthesis.

[Dental implants and radiotherapy]. / Implants dentaires et radiothérapie.

Dental implants on irradiated and often grafted bone, in patients previously treated for head and neck cancer is a controversial issue. For some specialists, particularly in North-America they constitute a formal contra indication. However, a review of 21 studies reported mainly by European specialists argues that these implants can be done with an acceptable rate of complications, confirming our clinical observation. Patients have reported significant improvements in their quality of life after dental implantation.

[Anhidrotic ectodermal dysplasia. Rehabilitation]. / Dysplasie ectodermique anhidrotique. Réhabilitation.

INTRODUCTION: Anhidrotic ectodermal dysplasia (EAD) is an inherited syndrome with an incidence of one per 100,000 live births and is characterized by hypotrichosis, anhidrosis or hypohidrosis, and oligodontia. Various treatment options for the dental rehabilitation of children presenting with this disease have been published. There is however no consensus on what age implants should be placed. Our purpose was to describe the disease and rehabilitation with early implants through two case reports. OBSERVATION: Our two patients, a brother and sister, aged 14 and 15 years respectively, presented with EAD, maxillary hypodontia, and mandibular anodontia. They benefited from an orthodontic surgical treatment followed by prosthetic treatment. We designed a removable prosthesis on mandibular implants for the boy when he was 14, which was later replaced by a fixed prosthesis on implants. We shifted the lateral maxillary incisors orthodontically to a canine position, then performed autologous bone grafting for the placement of six implants. The same bone graft technique was used for the sister to insert four maxillary implants. The follow-up after implant placement was 7 and 4years, respectively. On the latest follow-up, the results were stable, functional, and esthetic. DISCUSSION: Dental implants are a reliable oral rehabilitation treatment for children presenting with ectodermal dysplasia.

Olfactory function and nasal nitric oxide.

OBJECTIVE: To determine the relationship between nasal nitric oxide (nNO) concentration and its influence on olfactory function. SETTING: Tertiary otolaryngology care centre. PARTICIPANTS: Sixty-four patients suffering from chronic rhinosinusitis and 20 healthy subjects participated. STUDY DESIGN: Prospective study. OUTCOME MEASURES: The nNO concentration was measured by chemiluminescence and olfactory thresholds were measured with the phenyl ethanol threshold of the Sniffin' Sticks. In chronic rhinosinusitis patients this measure was done preoperatively and 3 months after endoscopic sinus surgery. RESULTS: Healthy subjects had significantly higher nNO concentrations and better olfactory thresholds compared to the chronic rhinosinusitis patients, both before and after those had undergone sinus surgery. Olfactory thresholds and nNO concentrations remained unchanged after surgery in the chronic rhinosinusitis group. In the chronic rhinosinusitis group, nNO concentrations correlated positively with the olfactory threshold preoperatively (P < 0.0001) and 3 months after surgery (P < 0.05). In the control group, nNO production did not correlate with the olfactory thresholds (P > 0.05). CONCLUSION: Olfactory function and nNO concentration correlate in chronic rhinosinusitis patients but not in healthy subjects. This suggests that both parameters do rather not directly influence each other but it might be the inflammatory processes found in chronic rhinosinusitis that affects olfaction and nNO. Nasal nitric oxide produced by the paranasal sinuses seems not to directly influence olfactory function.

[Needle breakage: a rare and potentially dangerous complication during local anaesthesia]. / Bris d'aiguille: complication rare mais potentiellement dangereuse d'une anesthésie locale.

INTRODUCTION: Needle breakage is a rare complication during local oral anesthesia administration. The authors describe the surgical procedure used to remove a broken dental needle and how to prevent this complication. CASE REPORT: The authors present the case of a 52-year-old man who was referred by his general dental practitioner for needle breakage during an inferior alveolar nerve block. Surgical management involved localizing the broken needle using radioscopy and removing it under general atomax 00041 anesthesia. DISCUSSION: Today, needle breakage during local anesthesia is mainly attributed to an incorrect anesthetic injection technique. The prevention, investigation, and management of such complication are discussed.

[A proposed algorithm for medicodental care of patients treated with bisphosphonates]. / Proposition d'un algorithme de prise en charge médico-dentaire pour les patients traités par bisphosphonates.

Bisphophonates (BP) were first named diphosphonates. They are potent inhibitors of osteoclastic activity and so reduce bone remodeling. Additionally they have anti-angiogenic properties and contribute to progressive disappearance of bony micro-vascular blood supply. Administrated orally, BP are generally used to prevent and treat osteoporosis. Injectable BP are used in patients with multiple myeloma and metastatic solid tumors. Scientific evidence dealing with a potentially devastating side effect of BP, osteochemonecrosis of the jaws, is growing rapidly. Clinical signs and symptoms include absent or delayed soft tissue healing with bony exposure following dental extraction or spontaneous gum dehiscence. Patients are usually asymptomatic but may develop pain if the bone becomes secondarily infected. At the beginning, no radiographic manifestations are seen, but in some cases a vast zone of necrotic bone can be seen on MRI, larger than what could be expected. Surgical debridements, bone curettage, local irrigation and or hyperbaric oxygen therapy have proven to be unsuccessful. Up to now, no definitive treatment strategy has been published to manage those patients leaving the dentist or the stomatologist resourceless. This article proposes recommendations for general practitioners, dentists, oral surgeons and designed for three types of patients: 1. patients to be treated with BP; 2. patients treated with BP without bisphosphonate-associated osteonecrosis; 3. patients with bisphosphonate-associated osteonecrosis. The proposed guidelines are not definitive and practitioners remain free to choose their treatment. Of upmost importance is to recognize the risks of oral complications before, during and after surgery in patients treated with BP and to inform them of such risks.

[Infracondylar abscess formation: a rare complication of local anesthesia]. / Abcès sous condylien: complication rare d'une anesthésie locale.

INTRODUCTION: Ninety percent of oro-facial infections arise from a dental origin. The remaining 10% are the consequence of oro-pharyngeal, cutaneous or iatrogenic problems, such as in the present case. CASE REPORT: A 24-year-old patient consulted the emergency room because of a left mandibular swelling, accompagnied by trismus. Four days earlier, extraction of the 38 was performed under inferior alveolar nerve block anesthesia. A first drainage by vestibular approach was performed under general anesthesia. Because of the absence of improvement, a CT-scan was performed and an abscess localized at the base of the condyle, surrounding the posterior margin of the mandible, very high above the lingula. Outcome was favourable after a second surgery. DISCUSSION: Formation of an abscess very high above the lingula, around the condylar neck is rarely reported in the literature. In this patient it was certainly a complication resulting from the injection of local anesthesic with a vasoconstrictor. CT-scan should be performed to guide diagnosis in the event of an unusual course after the first surgical procedure and an adequate antibiotic regimen.

[Flap techniques in secondary alveoloplasty: a comparison between two types of flap]. / Techniques de couverture lors d'alvéoloplasties secondaires: comparaison de deux types de lambeaux.

INTRODUCTION: The aim of this study was to compare two surgical soft tissue coverage techniques of secondary alveolar grafts in cleft lip and palate patients: the gingival mucoperiostal slidind flap and the mucosal rotation flap. MATERIAL AND METHOD: Fifty-two secondary alveolar bone grafts were retrospectively included in the study. Four clinical parameters were evaluated: post-operative dehiscence, oro-nasal fistula relapse, canine eruption through the graft and postoperative secondary periodontal procedures. RESULTS: Gingival mucoperiostal flaps had less postoperative dehiscence, more fistula relapse and needed less secondary periodontal procedures. DISCUSSION: Based on this study and on literature data, gingival mucoperiostal flap provides better quality of soft tissue coverage. Flap design doesn't influence canine eruption. Bone graft complications are increased with poor oral hygiene, if canine eruption occurred before surgery and in older patients.

Ratings of overall olfactory function.

The aim of this study was to investigate the accuracy of self-reported ratings of olfactory function in 83 healthy subjects. Such ratings were compared with quantitative measures of olfactory function, as well as with ratings of nasal patency. In experiment 1 subjects rated olfactory function and nasal patency before olfactory testing, whereas in experiment 2 the reverse was the case. No feedback regarding test results were provided until after completion of the testing. The principal findings were: (i) when ratings preceded measurements of olfactory function, there was no significant correlation between the two parameters. However, ratings of olfactory function correlated significantly with ratings of nasal airway patency. (ii) In contrast, when measurements of olfactory function preceded the ratings, this constellation switched. Now ratings of olfactory function correlated significantly with measured olfactory function, whereas there was no significant correlation between ratings of nasal airway patency and ratings of olfactory function. In conclusion, these data suggest that ratings of olfactory function are unreliable in healthy, untrained subjects. The ratings seem to reflect changes of nasal airway patency to a larger degree than measurable olfactory function. The results further indicate that this is mainly due to the limited attention the sense of smell receives in daily life.

[Treatment of recurrent luxation of the temporomandibular joint with botulinum toxin]. / Traitement de la luxation temporo-mandibulaire récidivante par toxine botulique.

We report the case of a 70-year-old man who suffered recurrent dislocations of the temporomandibular joint secondary to severe Parkinson syndrome. The patient was given repeated injections of botulinum toxin. After 3 injections over a 9-month period, no further dislocation occurred. Botulinum toxin may be an alternative to surgery.

Duplex sonographic registration of age and diabetes-related loss of renal vasodilatory response to nitroglycerine.

BACKGROUND: Nitroglycerine effects dilatation of the vas afferens in the kidney by its active metabolite nitric oxide (NO). In diabetic nephropathy, NO appears to cause hyperfiltration and proteinuria. The aim of this study was to investigate the potential of duplex Doppler ultrasonography in recording changes in resistive indices following nitroglycerine and whether the extent of changes in diabetic nephropathy is reduced as a result of the arteriolar dilatation mediated by NO. METHODS: Fifty-three subjects made up three groups: group 1, 12 young healthy volunteers (5 male, 7 female, 28+/-6 years); group 2, 21 older healthy volunteers (7 male, 14 female, 62+/-8 years); group 3, 20 patients (13 male, 7 female, 56+/-18 years) with mild diabetic nephropathy. The resistive index (RI) was measured in the interlobar arteries before, and 1, 3 and 5 min after administration of 0.8 mg sublingual nitroglycerine. RESULTS: The initial RI of 0.592 decreased in group 1 by 10.8% (P<0. 01) after nitroglycerine, in group 2 the initial figure of 0.631 decreased by 5.9% (P<0.01), and in group 3 the initial figure of 0. 669 decreased by 3.4% (P<0.01). Initial RI values differed significantly between groups 1 and 3 (P<0.01) and groups 1 and 2 (P<0.01), as did values between all healthy volunteers (groups 1 and 2, n=33) and patients with nephropathy (P<0.005). The extent of DeltaRI differed significantly between groups 1 and 3 (P<0.01), 1 and 2 (P<0.02), and between all volunteers and group 3 (P<0.003). In groups 1 and 2 the initial RI was dependent on age (P<0.03), in group 3 on age and creatinine clearance (P<0.02 and P<0.05 respectively). DeltaRI correlated with age in the healthy subjects (P<0.01) and with duration of diabetes in diabetic nephropathy (P0. 03). CONCLUSIONS: Haemodynamic changes in renal perfusion caused by nitroglycerine can be detected using duplex ultrasonography. In healthy subjects, DeltaRI declines with increasing age. In diabetic nephropathy patients, the response to nitroglycerine is reduced. The increased initial RI in such patients suggests fixed arteriolar damage.

A joint labor-management hazard communication training program: a case study in worker health and safety training.

The 1983 OSHA Hazard Communication Standard requires training of employees exposed to hazardous chemicals. The authors provide a detailed look at the successes and failures of a joint labor-management training program that was designed to bring a firm with more than 50 manufacturing facilities into compliance with the standard.