A Patient With Cryptotia Corrected With Intraoperative Tissue Expansion and Superior Auricular Muscle Transfer Through a Small Hairline Incision.

Cryptotia is a relatively common auricular congenital anomaly in Asia. Nonsurgical molding is easy in infancy. However, surgical correction is often necessary after infancy. The authors report a case of cryptotia in which intraoperative tissue expansion and superior auricular muscle transfer were performed through a small incision at the hairline with good results. The patient is a 7-year-old girl. Three years after the operation, successful results were obtained. This method is advantageous as the procedure is simple, risk of relapse can be reduced by also treating the auricular muscle, and scarring is relatively inconspicuous. In addition, it is possible to switch to another technique when the improvement is poor.

Labia Minora Transplantation With Local Flap for Reconstruction of Full-Thickness Defect of the Lower Eyelid.

Large lower eyelid full-thickness defects require reconstruction before closure. Although several methods for replantation of the posterior lamella are reported, there are advantages and disadvantages. Herein, the authors report reconstruction of the posterior lamella of the lower eyelid by labia minora transplantation. A 70-year-old woman developed basal cell carcinoma of the right lower eyelid. Excision of the tumor resulted in a full-thickness defect of 25 mm in width on the central portion of the lower eyelid. The posterior lamella was reconstructed by labia minora transplantation, whereas the anterior lamella was reconstructed using the angular flap. There were no perioperative problems, and 2 years after the operation, the esthetic appearance and function was favorable. The labia minora mucosa has almost no donor trouble functionally and has both hardness and elasticity. Although there are some disadvantages, labia minora transplantation would be useful for posterior lamella reconstruction of the lower eyelid.

Use of an Orbital Septum Flap for Correcting Severe Blepharoptosis.

BACKGROUND: Several surgical procedures are available for the treatment of severe blepharoptosis with poor levator function. However, the procedures have advantages and disadvantages. Particularly, complications such as lagophthalmos and lid lag are commonly observed after conventional interventions. Thus, the present study aimed to introduce a surgical technique that uses an orbital septum flap without the orbital oculi muscle for the correction of severe blepharoptosis. METHODS: The technique utilizes the orbital septum flap, which is connected with the frontalis muscle via the galea aponeurosis and frontal periosteum, to suspend the tarsal plate. In this case series, the technique was used for the correction of blepharoptosis in 16 eyes from 12 patients. RESULTS: The margin reflex distance in all patients improved at 6 months after surgery. Two patients presented with lagophthalmos and three with mild recurrence. However, revision surgery was not required, and none of patients presented with lid lag. CONCLUSIONS: For the correction of blepharoptosis, the use of the orbital septum flap without the orbital oculi muscle can be easily selected compared with other conventional methods that are more likely to cause overcorrection and closure disorders. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Multiple Minute Pulmonary Meningothelial-like Nodules;Report of a Case].

A 57-year-old woman was referred to our hospital for investigation of multiple tiny nodules in the lung fields bilaterally on computed tomography (CT). Video-assisted thoracoscopic lung biopsy was performed to diagnose the pulmonary lesions. Histological analysis showed nodular lesions with interstitial proliferation of uniform, round to oval cells with variable widening of the alveolar septa. Immunohistochemically, the cells were positive for EMA, CD56 and the progesterone receptor, but negative for chromogranin and synaptophysin. The diagnosis was "diffuse pulmonary meningotheliomatosis", with multiple diffuse "minute pulmonary meningothelial-like nodules". Diffuse pulmonary meningotheliomatosis should be kept in mind when we encounter small nodular shadows on a CT scan.

[Pancreatic Pleural Effusion;Report of a Case].

A 50-year-old man was admitted with respiratory failure. Chest X-ray and computed tomography revealed massive left pleural effusion and mediastinal shift. Pleural effusion showed abnormally high amylase levels of 42,600 IU/l and a high protein level of 3.2 g/dl. The serum amylase level was also 42,100 IU/l, and the proportion of pancreatic-type amylase was 88%. We diagnosed the patient with pancreatic effusion. Chest and abdominal enhanced computed tomography and magnetic resonance cholangiopancreatography revealed no pancreaticopleural fistula. He underwent a thoracoscopic examination that revealed brown pleural effusion as well as fibrin clots and thickness of the pleura. Histologically, there was no malignancy and the cause of pleural effusion was considered to be chronic pancreatitis.

An anatomic study of nipple position and areola size in Asian men.

BACKGROUND: In planning gender-reassignment surgery for biological women and treating men with gynecomastia, surgeons must have a thorough understanding of anatomically correct nipple positions and appropriate areola sizes in men. OBJECTIVES: The authors sought to determine whether body height or body mass index (BMI) affects nipple position or areola size in men. METHODS: Anatomic measurements of the nipples and areolae of 50 Japanese men were obtained. A relative coordinate system was defined, where the medial-lateral and superior-inferior positions of the nipple were quantitatively indicated by distance ratios between anatomic landmarks. Nipple positions were evaluated for each patient by referring to this coordinate system, and the positions were compared between groups categorized by body height or BMI. RESULTS: Nipple position was not significantly affected by body height. However, the nipple tended to be located more laterally in participants with higher BMI. The vertical nipple position differed between standing and supine positions. Tall men had larger areolae than short men; however, areola size did not differ with respect to BMI. CONCLUSIONS: Nipple position and areola size vary by body shape. Consideration of the differences is recommended when performing procedures such as female-to-male gender-reassignment surgery or correction of gynecomastia.

Acquired Cutis Laxa on the Upper Eyelids and Earlobes: A Case Report and Literature Review.

Acquired cutis laxa is a rare disease. Owing to few reports on the condition, no statistical data have been produced. Cutis laxa is characterized by drooping skin, caused by decreased levels of dermal elastin, leading to reduced skin elasticity. The disease usually emerges on the neck or trunk and spreads throughout the body; however, it rarely involves the extremities. 2 Moreover, cases localized to the face are rare. The objective of this clinical case report was to highlight this unusual disease in a 24-year-old female, with localization on the face and neck. The patient underwent surgery for treatment of bilateral ear lobe and eyelid skin laxity.

Incidence, Characteristics, Clinical Course, and Risk Factors of Ulcerative Colitis-related Lung Diseases.

BACKGROUND: Ulcerative colitis (UC) is a chronic GI inflammatory disorder involving various extraintestinal organs, including the lungs. Although UC-related lung diseases (UC-LDs) have been widely recognized, much remains unclear. RESEARCH QUESTION: What are the incidence, characteristics, clinical course, and risk factors of UC-LD? STUDY DESIGN AND METHODS: This study retrospectively identified and classified UC-LDs by reviewing the medical records of consecutive patients with UC. The incidence, characteristics, and clinical course of each UC-LD type were investigated, and the clinical characteristics of patients with and without each UC-LD type were compared. RESULTS: Among 563 patients with UC, 28 (5.0%) developed UC-LD during a mean follow-up period of 77 months. A majority of them displayed airway disease (AD) (n = 13 [2.3%]) or organizing pneumonia (OP) (n = 10 [1.8%]); there were six cases of interstitial pneumonias other than OP (IP) (0.8%) and one of pleuritis (0.2%). All 13 patients with AD responded favorably to inhaled or systemic corticosteroids, although five experienced frequent exacerbations. Older age and a history of colectomy were identified as the risk factors for developing AD. Nine of the 10 cases of OP were possibly due to drug-induced pathogenesis. Only one case showed recurrence, and all cases of OP exhibited a favorable clinical course with discontinuation of the suspicious drug and/or initiation of corticosteroid. The clinical course of IP depended on the existence of fibrosis, and IP with fibrosis was associated with gradual deterioration. Older age was associated with the development of IP. INTERPRETATION: A nonnegligible number of patients with UC may develop UC-LD. AD, OP, and IP without fibrosis show good prognosis following steroid therapy along with the specific management for each UC-LD type, whereas IP with fibrosis shows gradual deterioration with poor prognosis. Our results provide cues to establish better management of UC-LDs.

A pitfall of reconstruction for severe enophthalmos: role of the posterior wall of the maxillary sinus-2.

This report describes a pitfall of reconstruction for severe enophthalmos after time has passed following traumatic injury. In severe cases, hypoglobus may be refractory to reconstructive surgery. The posterior wall of the maxillary sinus is sometimes implicated in severe enophthalmos. Thus, we considered that reconstruction of this posterior wall is critical for improvement in hypoglobus. In addition, a satisfactory contour and improvement in hypoglobus were maintained postoperatively.

A pitfall of decompression for severe exophthalmos: role of the posterior wall of the maxillary sinus-1.

This report addresses a pitfall of decompression for severe exophthalmos. In mild cases, removal of the orbital floor is an effective treatment, but in severe cases, the results of this approach are sometimes unsatisfactory, and only decompression is necessary. In these cases, orbital decompression in 3 areas including the medial wall, the lateral wall, and the orbital floor is usually performed. A 5.0-mm mean reduction in exophthalmos is observed, but more reduction is difficult to achieve.We considered the possibility that removal of the posterior wall of the maxillary sinus is critically important to achieving greater recovery. It is proposed that this technique is effective in creating about 10 mm of improvement for severe exophthalmos.

Primary pulmonary epithelioid sarcoma: a case report.

BACKGROUND: Epithelioid sarcoma most frequently occurs in the dermal or subcutaneous area of the distal extremities. To date, there have been three cases of primary pulmonary epithelioid sarcoma reported. We report a case of epithelioid sarcoma that is considered a primary lung tumor. CASE PRESENTATION: A 65-year-old asymptomatic Asian male patient underwent chest radiography during a routine health examination, and an abnormal mass was detected. His past medical history was unremarkable. He smoked 40 cigarettes every day and had slightly obstructive impairment on spirometry. He worked as an employee of a company and had no history of asbestos exposure. He underwent partial resection of the right lung by thoracoscopy. A histological examination of the tumor revealed a cellular nodule of epithelioid and spindle-shaped cells. Some of the tumor cells displayed rhabdoid features and reticular arrangement in a myxomatous stroma. Immunohistochemically, the tumor cells were positive for vimentin, smooth muscle actin (SMA), CD34, and epithelial membrane antigen (EMA); loss of the BAF47/INI1 protein in the tumor cells was also confirmed. A diagnosis of epithelioid sarcoma was established. Careful screening by whole-body positron emission tomography for another primary lesion after surgery did not detect any possible lesion. He had no cutaneous disease. CONCLUSION: To our knowledge, this is the fourth case of a proximal-type epithelioid sarcoma considered as a primary lung tumor.

[Clinical and radiological features of tuberculous pneumonia in patients with emphysema].

PURPOSE: To elucidate the clinical and radiological features of tuberculous pneumonia in patients with pulmonary emphysema. MATERIAL AND METHOD: Three emphysematous cases diagnosed with tuberculous pneumonia are clinically and radiologically reviewed. RESULT: Case 1 was a 62-year-old male with an infiltrate in the right upper lobe. A CT scan showed diffuse emphysema and a nonsegmental infiltrate without typical signs of bronchogenic spread. Sputum was negative for acid-fast bacilli. The infiltrate showed a nonsegmental spread unresponsive to antibiotics. Mycobacterium tuberculosis grew from a needle biopsy specimen five weeks after admission. The infiltrate disappeared with antituberculous treatment. Case 2 was an 82-year-old male, who presented with seven weeks of low-grade fever followed by high fever and lobar pneumonia in the right upper lobe. Sputum was positive for acid-fast bacilli on smear and tuberculosis PCR, leading to a diagnosis of tuberculous pneumonia. Case 3 was a 57-year-old male who had a history of dry cough lasting for one month. CT findings included a diffuse emphysematous change and a left upper lobe infiltrate, indistinguishable from bacterial pneumonia. His bronchoalveolar lavage was positive for tuberculosis PCR, which led to a diagnosis of tuberculous pneumonia. CONCLUSION: Tuberculous pneumonia in emphysematous patients can be nonsegmental, lacks bronchogenic spread, is indistinguishable from bacterial pneumonia, and clinically shows a poor inflammatory reaction, which is distinct from classical "caseous pneumonia.

Indocyanine green fluorescence videoangiography for reliable variations of supraclavicular artery flaps.

BACKGROUND: Pedicled flaps are useful for reconstructive surgery. Previously, we often used vascularized supraclavicular flaps, especially for head and neck reconstruction, but then shifted to using thoracic branch of the supraclavicular artery (TBSA) flaps. However, limited research exists on the anatomy of TBSA flaps and on the use of indocyanine green (ICG) fluorescence videoangiography for supraclavicular artery flaps. We utilized ICG fluorescence videoangiography to harvest reliable flaps in reconstructive operations, and describe the results herein. METHODS: Data were retrospectively reviewed from six patients (five men and one woman: average age, 54 years; range, 48-60 years) for whom ICG videoangiography was performed to observe the skin perfusion of a supraclavicular flap after it was raised. Areas where the flap showed good enhancement were considered to be favorable for flap survival. The observation of ICG dye indicated good skin perfusion, which is predictive of flap survival; therefore, we trimmed any areas without dye filling and used the remaining viable part of the flap. RESULTS: The flaps ranged in size from 13×5.5 cm to 17×6.5 cm. One patient received a conventional supraclavicular flap, four patients received a TBSA flap, and one patient received a flap that was considered to be intermediate between a supraclavicular flap and a TBSA flap. The flaps completely survived in all cases, and no flap necrosis was observed. CONCLUSIONS: The TBSA flap is very useful in reconstructive surgery, and reliable flaps could be obtained by using ICG fluorescence videoangiography intraoperatively.

Rat Bite Fever Caused by Streptobacillus moniliformis in a Cirrhotic Patient Initially Presenting with Various Systemic Features Resembling Henoch-Schönlein Purpura.

We herein report the case of a 61-year-old Japanese cirrhotic patient who developed rat bite fever (RBF) and whose first presentation was serious clinical features mimicking those of Henoch-Schönlein purpura (HSP). In addition to the critical clinical conditions, since the histopathology from purpuric skin eruptions was not inconsistent with that of HSP, therapy with prednisolone was promptly started in order to prevent his death. However, initial blood culture on admission yielded a small and slow-growing bacterial growth, which was gradually revealed by further subculture to be a peculiar bacterium, Streptobacillus moniliformis, leading to a definitive diagnosis of RBF. After the immediate cessation of prednisolone, the patient was treated with a more appropriate antibiotic and consequently made a full recovery. An immunocompromised condition with seriously decompensated liver cirrhosis together with moderately severe chronic kidney disease (CKD) in this patient probably exacerbated the severity of the disease.

[A case of recurrent Helicobacter cinaedi-associated bacteremia in a small cell lung cancer patient during chemotherapy].

A 46-year-old man was admitted to our hospital, because of cough and exertional dyspnea. We diagnosed small cell lung cancer, clinically staged as T2N3M0, limited disease. Radiation therapy was performed at first to relieve the severe stenosis of the proximal airway, followed by anti-cancer chemotherapy. Fever developed on the fifth day of chemotherapy, and he was successfully treated with intravenous antibiotics. A blood culture yielded Helicobacter cinaedi on the seventh day of incubation. H. cinaedi bacteremia occurred again during the second course of chemotherapy. The same bacteria were also found in his intestinal contents, with no gastrointestinal symptoms. We assume that the bacteria found in the blood was derived from his own intestinal contents. When bacteremia occurs in lung cancer patients during chemotherapy, an uncommon strain such as H. cinaedi is a possible causative agent.

[Two cases of respiratory infection complicating treatment with infliximab].

Infliximab, an anti-TNF-alpha agent, is highly effective against rheumatoid arthritis and Crohn's disease. However, respiratory infection can occur as a complication. We report two cases complicated by respiratory infection following administration of infliximab. The first case, a 67-year-old woman with rheumatoid arthritis, developed pneumocystis pneumonia after three courses of infliximab therapy. The second case, a 31-year-old man with Crohn's disease, developed pulmonary tuberculosis after four courses of infliximab therapy. Respiratory complications associated with anti-TNF therapy include infectious diseases such as pneumocystis pneumonia, tuberculosis, and bacterial pneumonia. They often lead a fulminant course, and early diagnosis is essential. The final report of a survey of the initial 5000 cases with rheumatoid arthritis treated with infliximab in Japan was released in April 2006; pulmonary infectious complications included 22 cases of pneumocystis pneumonia, 14 cases of tuberculosis, and 108 cases of bacterial pneumonia. The growing use of anti-TNF therapy might lead to increasing pulmonary complications. Accumulation of similar cases is expected to elucidate the mechanism of the complications and methods for effective prophylaxis.

An anatomical study on the availability of contralateral recipient vessels in hemi-mandibular reconstruction with vascularised free fibula transfer.

BACKGROUND: In mandibular reconstruction with vascularised free fibula transfer, there are situations where the neck on the operated site lacks recipient vessels for vascular anastomosis due to previous radiological/surgical interventions. METHODS: The present study aims to clarify the availability of neck vessels on the contralateral side in such situations. Experimental surgery was conducted on 20 fresh cadavers (six males and 14 females). After the left half of the mandible was removed, free vascularised fibula of equivalent length was transferred to fill the defect. The possibility of connecting the peroneal artery and vein to the superior thyroid artery (STA), transverse coli artery (TCA), internal jugular vein (IJV), and external jugular vein (EJV) of the contralateral side was evaluated. RESULTS: In all samples, the peroneal vessels could reach the STA and EJV. However, the peroneal vessels could reach the TCA and IJV of the contralateral side in only 45% and 64.2% of cases, respectively. The average and standard deviation of the lengths by which vessels were insufficient were 1.1 ± 13.9 mm for IJV and 8.8 ± 24.7 mm for TCA. CONCLUSIONS: In reference to these findings, it is concluded that, in situations where neck vessels of the defect side are unavailable, availability of the superior thyroid artery and external jugular vein should be examined first. When these vessels are available as recipient vessels, direct vascular anastomosis is highly likely to be successful. In cases where these vessels are unavailable and the transverse coli artery or internal jugular vein is used as the recipient, vascular interposition might be necessary.

[A case of salazosulfapyridine-induced pneumonitis presenting with multiple pulmonary nodules and lymphadenopathy].

We report a rare case of drug-induced pneumonitis, probably caused by salazosulfapyridine, showing a radiographic pattern of multiple pulmonary nodules and lymphadenopathy. An 18-year-old woman was admitted to our hospital because of fever, skin rash, dry cough and dyspnea on exertion. She had been given salazosulfapyridine for two weeks to treat Crohn's disease. A chest radiograph and computed tomographic scan showed multiple nodular shadows in both lung fields, mediastinal lymphadenopathy, and bilateral pleural effusions. Cessation of salazosulfapyridine followed by corticosteroid therapy led to an immediate symptomatic improvement. The drug-induced lymphocyte stimulation test for salazosulfapyridine was negative. The same symptoms reappeared with rechallenge of SASP, however, which led to diagnosis as salazosulfapyridine-induced pneumonitis. This is apparently the first case report of salazosulfapyridine-induced pneumonitis with a radiographic pattern of multiple pulmonary nodules; accumulation of similar case reports are needed to confirm the association.