[Facial prosthetics: grounds and techniques]. / Aangezichtsprothetiek: indicaties en technieken.

Surgical treatment of advanced facial tumours is often physically, functionally and emotionally debilitating. The resulting defects often give grounds for surgical reconstruction, prosthetic reconstruction or a combination of both. During the past two decades, huge advances have been achieved in the development of prostheses. This has led to improved rehabilitation of facial defects. In the clinic of the Netherlands Cancer Institute - Antoni van Leeuwenhoek, both adhesive- and implant-retained facial prostheses are used. In recent decades, implant-retained prostheses have been used increasingly often. Patient satisfaction rates are very high for both types of prostheses.

[Pain as the primary symptom of a malignant parotid tumour]. / Pijn als primair symptoom van een maligne parotistumor.

The differential diagnosis of peri-auricular pain is comprehensive and arriving at a correct diagnosis is not always easy, which may result in a delay of treatment or even malpractice. Two patients presented themselves with facial peri-auricular pain. After a period of follow-up and control this pain turned out to be related to a malignant tumor in the glandula parotidea. These two cases show the importance for the dentist to refer patients with peri-auricular pain, with or without concomitant facial nerve palsy, to a specialist in a timely manner.

Paradigm change in the treatment of non-melanoma skin cancer of the auricle: reconstruction with full thickness skin grafting instead of wedge excision.

Non-melanoma skin cancer (NMSC) has become an epidemic disease and is predominantly located in the head and neck area. While historically auricular NMSCs are treated by means of a wedge excision, we describe a more elegant technique with excellent esthetical results. We conducted a retrospective cohort study of 43 consecutive patients with NMSC of the auricle who underwent reconstruction with a full thickness skin graft (FTSG). All grafts survived. Two patients (5%) showed crust formation, but fully recovered. One patient had an irradical resection for which he required a limited re-excision. All patients showed excellent esthetical results. When treating NMSC of the auricle, reconstruction with a FTSG demonstrates several important advantages. It is a relatively simple but oncological safe technique; it leads to excellent esthetical and functional outcomes, and shows high patient and surgeon satisfaction.

Corrugator supercilii transection for headache emanating from the frontal region: a clinical evaluation of ten patients.

Chronic daily headache (CDH) located in the frontal region is a common problem. We have previously described the positive results that were achieved with botulinum toxin (BTX) injections in the musculus corrugator supercilii (MCS) for this disorder. Nowadays, we offer transection of this muscle to patients following a minimum of two BTX injections, provided these injections result in a significant reduction of pain. This procedure is based on the assumption that the pathophysiological mechanism in some of these patients suffering from CDH is a neural entrapment of the supratrochlear nerve in the corrugator muscle. To assess the effect of transection, we have evaluated all the consecutive patients (n = 10) so far. Treatment was successful in nine of these patients. Prior to the treatment, the mean pain score in the 9 successfully treated patients was 8.1 (range 6-9), after transection this had been reduced to 0.8 (range 0-3). All of these successfully treated patients ceased their daily use of pain relief medication for their frontally localised headaches. Moreover, they stated that they would definitely undergo surgery, if they were to find themselves in the same situation again. Therefore, we conclude that transection of the MCS is an efficient and successful procedure for a carefully selected group of patients suffering from CDH in the frontal region. Most of all we intend to popularise this pathophysiological concept based on the distinct possibility that some headaches might be due to neural entrapment.

Surgical technique--unwrapping the neck node levels around a sternocleidomastoid muscle bar: a systematic way of performing (modified) radical neck dissection.

AIM: Description of a systematic approach to the neck for removal of lymph node bearing tissues in levels I-V. METHOD: A (modified) radical neck dissection is divided in three steps: (1) Dissection of levels I-IV, (2) dissection of level V and (3) transection of SCM bar and finalisation of the dissection. The sternocleidomastoid muscle (SCM) is used as a "bar", around which the different neck levels can be systematically unwrapped, warranting permanent cranio-caudal tension of the neck specimen, while anatomical relations remain intact. RESULTS: In a group of 115 (modified) radical en bloc neck dissections with or without post-operative radiotherapy 10% regional recurrences, 2% post-operative chylous fistulas and < 5% post-operative wound infections occurred. The overall 5 years survival was 45% (95% confidence interval: 36-54%). CONCLUSION: A systematic unwrapping of lymph node levels around the sternocleidomastoid bar provides a reliable systematic method for performing (modified) radical neck dissections without a negative influence on clinical outcome.

Quantitative assessment of the rat stria vascularis.

Stria vascularis tissues from standardized regions in the basal, middle and apical turns of the rat cochlear duct were assessed quantitatively. Strial width, number of marginal cells across the strial width, radial area, as well as the volume density of the different components of the stria vascularis were determined for each standardized region. Strial width, number of marginal cells across the strial width and the radial area were greatest in the basal region and least in the apical region of the cochlea. The volume density of intermediate cells and capillary space was statistically unchanged in the three examined regions of the stria vascularis. However, the volume density of marginal cells and that of basal cells were different between regions. The volume density of marginal cells was highest in the basal turn while the volume density of basal cells was greatest in the apical turn. An objective assessment of the response of the stria vascularis to environmental conditions can be made by kant of its cellular architecture, providing a means to compare the effects of various agents between animal models used to study human inner ear dysfunction.

The rat cochlea in the absence of circulating adrenal hormones: an electrophysiological and morphological study.

Circulating adrenal hormones affect strial function. Removal of endogenous levels of adrenal steroids by bilateral adrenalectomy (ADX) in rats causes a decrease of Na(+)/K(+)-ATPase activity in the cochlear lateral wall [Rarey et al., 1989. Arch. Otolaryngol. Head Neck Surg. 115, 817-821] and a decrease of the volume of the marginal cells in the stria vascularis [Lohuis et al., 1990. Acta Otolaryngol. (Stockh.) 110, 348-356]. To study further the effect of absence of circulating adrenocorticosteroids on cochlear function, 18 male Long Evans rats underwent either an ADX or a SHAM operation. Electrocochleography was performed 1 week after surgery for tone bursts in a frequency range of 1-16 kHz. Thereafter, the cochleas were harvested and examined histologically. No significant changes in the amplitude growth curves of the summating potential (SP), the compound action potential (CAP) and the cochlear microphonics (CM) were detected after ADX. However, visually, there appeared to be a decrease of endolymphatic volume (tentatively called imdrops). Reissner's membrane (RM) extended less into scala vestibuli in ADX animals than in SHAM-operated animals. The ratio between the length of RM and the straight distance between the medial and lateral attachment points of RM were used as an objective measure to quantify this effect in each sub-apical half turn of the cochlea. The decrease in length of RM was statistically significant. Thus, circulating adrenal hormones appear to be necessary for normal cochlear fluid homeostasis. Absence of one or more of these hormones leads to shrinkage of the scala media (imdrops). However, the absence of adrenal hormones does not affect the gross cochlear potentials. Apparently, the cochlea is capable of compensating for the absence of circulating adrenal hormones to sustain the conditions necessary for proper cochlear transduction.

Signs of endolymphatic hydrops after perilymphatic perfusion of the guinea pig cochlea with cholera toxin; a pharmacological model of acute endolymphatic hydrops.

There are indications that endolymph homeostasis is controlled by intracellular cAMP levels in cells surrounding the scala media. Cholera toxin is a potent stimulator of adenylate cyclase, i.e. it increases cAMP levels. We hypothesized that perilymphatic perfusion of cholera toxin might increase endolymph volume by stimulating adenylate cyclase activity, providing us with a pharmacological model of acute endolymphatic hydrops (EH). Guinea pig cochleas were perfused with artificial perilymph (15 min), with or without cholera toxin (10 microg/ml). The endocochlear potential (EP) was measured during and after perfusion. The summating potential (SP), evoked by 2, 4 and 8 kHz tone bursts, was measured via an apically placed electrode 0, 1, 2, 3 and 4 h after perfusion. Thereafter, the cochleas were fixed to enable measurement of the length of Reissner's membrane, reflecting EH. After perfusion the EP increased significantly over time in the cholera toxin group as compared to the controls. Also, the SP increased gradually at all frequencies in the cholera toxin group. Comparison within animals showed that the increase in SP became significant after 2 h at 4 kHz, after 3 h at 2 kHz and after 4 h at 8 kHz. In the control group the SP did not change significantly. The compound action potential (CAP) amplitude decreased monotonically over time at all frequencies in both the cholera toxin group and the control group, but it decreased faster in the cholera toxin group. Also, the cochlear microphonics amplitude decreased over time at all frequencies in both groups, but the decrease was significant only in the cholera toxin group after 3 h at 2 and 4 kHz. Quantification of the length of Reissner's membrane showed a small but insignificant enlargement in the cholera toxin treated animals compared to controls. These results are in accord with our view that EH is accompanied by an increase in SP and a decrease in CAP. Our results partially confirm previous results of Feldman and Brusilow (Proc. Natl. Acad. Sci. USA (1973) 73, 1761-1764). New aspects in relation to that study are the significantly increased EP and SP. In the classical EH model, based on obstruction of the absorptive function of the endolymphatic sac, increased SPs are accompanied by decreased EPs. In this cholera toxin model of EH, it is unlikely that the endolymphatic sac is involved. Apparently, EH can be based on mechanisms located in the cochlea itself as opposed to mechanisms located in the endolymphatic sac.

Response of the stria vascularis to corticosteroids.

Structural changes in the cellular architecture of the stria vascularis in adrenalectomized rats were quantitated by stereological methods after the administration of either aldosterone or dexamethasone. The volume densities of the differing strial components from steroid-administered animals were determined to approximate those of sham-adrenalectomized animals in general. The increased volume density of intercellular space as was observed following adrenalectomy, however, was only restored after the administration of aldosterone. These data correlate a recovery of the cellular architecture of the stria vascularis in adrenalectomized animals with the restoration of endogenous levels of adrenal steroids. These findings provide further information with regard to the effects of varying serum levels of corticosteroids on inner ear morphology.

Ventricular fibrillation caused by electrocoagulation during laparoscopic surgery.

A 35-year-old man with morbid obesity was admitted to our hospital to undergo gastric banding gastroplasty by the laparoscopic approach. Aside from his morbid adiposity, with a body mass index (BMI) of 49.9 kg/m2, the patient was healthy. During the procedure, he developed ventricular fibrillation (VF) while a diathermic knife was being used. After defibrillation, his heart rate returned to normal. The postoperative clinical course was uneventful, and there was no evidence of permanent heart failure. Although the VF could have been caused by patient- or material-related variables, it was most likely the result of unwanted electrical effects. Specifically, the occurrence of an arc between the patient's tissue and the tip of the electrode during cutting in the coagulation mode can lead to low-frequency current. The modified low-frequency current may produce arrhythmias. Thus, the use of the coagulation mode to cut tissue in the cardiac region during laparoscopic procedures could increase the risk for arrhythmias. An understanding of the physical principles of electrosurgery, as well as familiarity with the equipment and its various functions, is essential for the patient's safety. In addition, cardioversion equipment should be readily available on every surgical unit.

Q-fever in a patient with a ventriculo-peritoneal drain. Case report and short review of the literature.

Although Q-fever is still a relatively rare disease in the Netherlands, its incidence seems to be increasing. In this article we describe the case-history of a 65-year-old woman with a Pudenz-drain, who acquired Q-fever pneumonia while manuring her garden. The course of the disease was deviant, which most likely was caused by colonization of the ventriculo-peritoneal drain with Coxiella burnetii. Q-fever usually presents as a self-limiting illness. In the case of chronic Q-fever, complications such as endocarditis, hepatitis or meningo-encephalitis can be fatal and require long-term treatment. Patients with artificial drains or valves carry a greater risk of developing such complications. Therefore, especially in patients at risk, Q-fever should be included in the differential diagnosis when dealing with a patient with unexplained fever.

Summating potential in the guinea pig cochlea after perilymphatic perfusion with arginine-vasopressin.

We hypothesized that arginine-vasopressin (AVP), the natural vasopressin in the guinea pig, might increase the cochlear summating potential, indicating an increase in endolymphatic volume. Guinea pig cochleas were perfused with artificial perilymph for 15 min, with or without AVP (2 x 10(-6) M). In 1 group of animals, summating potentials (SP), compound action potentials and cochlear microphonics evoked by 2, 4 and 8 kHz tone bursts were measured with an apically placed electrode 15 min, 1 and 2 h after perilymphatic perfusion. In another group of animals the SP and endocochlear potential (EP) were measured simultaneously in the scala media during and after perfusion. In both groups the SP had increased significantly 15 min after perfusion with AVP and this increase was reversible. At the concentration of AVP used the increase in SP was not related to EP alterations. On light microscopic examination of the cochlea no evident increase in scala media volume could be detected. The increase in the SP (a sensitive indicator of acute endolymphatic hydrops) after perfusion with AVP suggests that this neuropeptide plays a role in the regulation of the ion and fluid balance in the cochlea.

Modulation of the rat stria vascularis in the absence of circulating adrenocorticosteroids.

Structural changes in the cellular morphology of the rat stria vascularis from a standardized region of the basal region and from a standardized region in the apical region of the rat cochlear duct were measured using stereological methods after removal of endogenous levels of adrenal steroids by bilateral adrenalectomy. Although there were some inconsistent and insignificant alterations in the volume density of intermediate and basal cells, a decreased volume density of marginal cells in both the basal region and in the apical region in adrenalectomized (ADX) animals as compared to sham animals was consistent with a concomitant significant increased (p less than or equal to 0.05) volume density of intercellular space as observed in both the basal and apical regions of the stria vascularis of ADX animals. Findings of this study indicate that the strial cells of the stria vascularis react differently and independently in response to the removal of adrenal steroids, and such strial responses occur uniform in both the base and apex.

Acute candidiasis of the oro- and hypopharynx as the result of topical intranasal steroids administration.

Topical nasal steroids have become increasingly popular for the treatment of allergic and other types of rhinitis. However, undesirable local effects of intranasal steroids, such as nasal irritation and burning, crusting and epistaxis are quite common. Candidiasis of the pharyngeal mucosa is a complication, which has not been described so far after treatment of rhinitis with intranasal topical corticosteroids. Between March 1997 and September 1998, we managed to treat successfully three patients with acute erythematous candidiasis of the pharynx, which was the result of the use of intranasal topical steroids. Mechanism, clinical features of acute pharyngeal candidiasis, differential diagnosis and treatment are discussed.

Leishmania braziliensis presenting as a granulomatous lesion of the nasal septum mucosa.

Differential diagnosis of granulomatous lesions of the nasal mucosa is difficult. One of the possible causes is an infection with Leishmania braziliensis as reported in this case. Therefore leishmaniasis should be included in the differential diagnosis of granulomatous lesions of the nasal mucosa in patients who have travelled to endemic areas.

Treatment of chondrodermatitis nodularis with removal of the underlying cartilage alone: retrospective analysis of experience in 37 lesions.

Most otolaryngologists treat patients with chondrodermatitis nodularis (CDN) by wedge excision. Although the results of this technique are generally good, it can leave the patient with an asymmetric, deformed ear. In the dermatological literature, a relatively straightforward technique has been described for the treatment of CDN by smoothing only the underlying cartilage. This is based on the assumption that CDN is caused by pressure necrosis of protuberant cartilage, and thus is primarily not a skin disease. Reports on this technique claim excellent cosmetic results with only a small chance of recurrence. In the present study we analyse the application of this technique to 34 patients with 37 CDN lesions. All patients were symptom-free with a minimum follow-up of three months according to their medical reports. Seventeen patients with 19 lesions were interviewed later by telephone. In a mean follow-up of 30.7 months, 34 of these patients remained symptom-free and only one required revision surgery. The authors recommend this safe and simple technique to other physicians who treat patients with CDN.

Management of an epidermoid cyst in the nasal tip of a child: aesthetic and surgical considerations.

BACKGROUND: A simple subcutaneous lesion such as an epidermoid cyst can present a challenge when located in the nasal tip, as regards aesthetic surgical management. Even when performed parallel to relaxed skin tension lines, a direct transcutaneous incision (commonly used for epidermoid cyst removal) distorts the nasal tip subunit, resulting in a conspicuous, disfiguring scar. This should be avoided, especially in children. CASE REPORT: A 13-year-old girl was referred by her dermatologist for diagnosis and treatment of a slowly progressive dermoid cyst located on the tip of her nose. The cyst was removed using a subcutaneous open rhinoplasty approach, leaving the aesthetic nasal tip subunit intact. CONCLUSION: For aesthetic reasons, open rhinoplasty should be considered as a treatment option in patients with subcutaneous lesions in the nasal tip.

Stent repair of an anastomotic pseudoaneurysm of the carotid artery after free fibula transplantation.

We describe an anastomotic pseudoaneurysm of the carotid artery as a complication after free fibular transplantation. The treatment of choice was endovascular placement of a stent, although this could have occluded the arterial supply to the graft. In our case, the graft remained vital.

Optimizing exposure of the posterolateral maxillary and pterygoid region: the lower cheek flap.

AIM: Description of an alternative surgical approach to the posterolateral maxillary and pterygoid region. PATIENTS AND METHOD: Three patients with posterior maxillary/pterygoid lesions are described in whom a lower cheek flap was used to achieve optimal surgical exposure. After midline division of the soft tissues of the lower lip and chin, the incision is extended posteriorly in the inferior gingivobuccal sulcus and continued lateral from the retromolar trigone in the upward direction lateral from the maxillary tuberosity. The flap is elevated under the periosteum towards the angle of the mandible with detachment of the masseter muscle. By marginal resection of the anterior part of the ascending mandible, visualisation of the posterolateral maxillary and pterygoid region can be optimized. CONCLUSION: As compared to the transoral approach, the lower cheek flap creates an optimal surgical exposure of the posterolateral maxillary sinus wall and pterygoid plates and should be considered for maxillary lesions extending into the pterygoid plate and pterygoid muscles.