Assessment of Infraorbital Hypesthesia Following Orbital Floor and Zygomaticomaxillary Complex Fractures Using a Novel Sensory Grading System.

PURPOSE: Introduction of a novel sensory grading system to assess the incidence and long-term recovery of infraorbital hypesthesia following orbital floor and inferior orbital rim fractures. METHODS: Patients who presented for evaluation of orbital floor and/or zygomaticomaxillary complex (ZMC) fractures between January 2015 and April 2016 were analyzed. Two-point subjective infraorbital sensory grading in 5 discrete anatomic areas was performed. Fractures were repaired based on traditional criteria; hypesthesia was not an indication for surgery. The sensory grading system was repeated a mean 21.7 months (range 18-28) after initial fracture. RESULTS: Sixty-two patients (mean 41.8 years) participated in the initial symptom grading, and 42 patients (67.7%) completed the 2-year follow-up. Overall, 20 of 42 patients (47.6%) had some infraorbital hypesthesia. There were fewer with isolated orbital floor fractures versus ZMC fractures (31.8% vs. 68.4%; p = 0.019). Two years postinjury, 9.1% and 40.0% with isolated floor and ZMC fractures, respectively, had persistent sensory disturbance (p = 0.0188). Of patients with sensory disturbance on presentation, 71.4% with isolated floor fractures and 38.5% with ZMC fractures experienced complete sensory recovery (p = 0.1596). Patients with isolated floor fractures had improved recovery after surgery (100% vs. 33.3% recovery; p = 0.0410). Patients with ZMC fractures showed no difference in sensory prognosis between those repaired and observed. CONCLUSIONS: In this pilot study, isolated orbital floor fractures carried a good infraorbital sensory prognosis, further improved by surgical repair. Zygomaticomaxillary complex fractures portended a worse long-term sensory outcome, unaffected by management strategy. This study validates the novel sensory grading system in post-fracture analysis.

Reliability of the "Ten Test" for assessment of discriminative sensation in hand trauma.

"Ten Test" (TT) is a bedside measure of discriminative sensation, whereby the magnitude of abnormal sensation to moving light touch is normalized to an area of normal sensation on an 11-point Likert scale (0-10). The purposes of this study were to determine reliability parameters of the TT in a cohort of patients presenting to a hand trauma clinic with subjectively altered sensation post-injury and to compare the reliability of TT to that of the Weinstein Enhanced Sensory Test (WEST). Study participants (n = 29, mean age = 37 ± 12) comprised patients presenting to an outpatient hand trauma clinic with recent hand trauma and self reported abnormal sensation. Participants underwent TT and WEST by two separate raters on the same day. Interrater reliability, response stability and responsiveness of each test were determined by the intraclass correlation coefficient (ICC: 2, 1), standard error of measurement (SEM) with 95% confidence intervals (CI) and minimal detectable difference score, with 95% CI (MDD95), respectively. The TT displayed excellent interrater reliability (ICC = 0.95, 95% CI 0.89-0.97) compared to good reliability for WEST (ICC = 0.78, 95% CI 0.58-0.89). The range of true scores expected with 95% confidence based on the SEM (i.e. response stability), was ±1.1 for TT and ±1.1 for WEST. MDD95 scores reflecting test responsiveness were 1.5 and 1.6 for TT and WEST, respectively. The TT displayed excellent reliability parameters in this patient population. Reliability parameters were stronger for TT compared to WEST. These results provide support for the use of TT as a component of the sensory exam in hand trauma.

Assessment of olfactory detection thresholds in children with autism spectrum disorders using a pulse ejection system.

BACKGROUND: Atypical responsiveness to olfactory stimuli has been reported as the strongest predictor of social impairment in children with autism spectrum disorders (ASD). However, previous laboratory-based sensory psychophysical studies that have aimed to investigate olfactory sensitivity in children with ASD have produced inconsistent results. The methodology of these studies is limited by several factors, and more sophisticated approaches are required to produce consistent results. METHODS: We measured olfactory detection thresholds in children with ASD and typical development (TD) using a pulse ejection system-a newly developed methodology designed to resolve problems encountered in previous studies. The two odorants used as stimuli were isoamyl acetate and allyl caproate. RESULTS: Forty-three participants took part in this study: 23 (6 females, 17 males) children with ASD and 20 with TD (6 females, 14 males). Olfactory detection thresholds of children with ASD were significantly higher than those of TD children with both isoamyl acetate (2.85 ± 0.28 vs 1.57 ± 0.15; p < 0.001) and allyl caproate ( 3.30 ± 0.23 vs 1.17 ± 0.08; p < 0.001). CONCLUSIONS: We found impaired olfactory detection thresholds in children with ASD. Our results contribute to a better understanding of the olfactory abnormalities that children with ASD experience. Considering the role and effect that odors play in our daily lives, insensitivity to some odorants might have a tremendous impact on children with ASD. Future studies of olfactory processing in ASD may reveal important links between brain function, clinically relevant behavior, and treatment.

Optimizing the duration of assessment of stage-1 sacral neuromodulation in nonobstructive chronic urinary retention.

OBJECTIVES: The duration of test stimulation using two-stage sacral neuromodulation (SNM) is not studied. This study will determine the restoration of normal bladder sensation and resultant voiding in chronic urinary retention (CUR) after stage-1 SNM. MATERIALS AND METHODS: Two-stage SNM used in 24 female patients with CUR. After stage-1 SNM, patients were assessed over an eight-week period and asked to record the restoration of normal bladder sensation and voiding. Qualitative and quantitative statistics were used to assess the outcomes and the influence of prognostic factors. RESULTS: The mean age of patients was 37.0 ± 9.7 years. Normal bladder sensation was restored on the same day as switching on the battery after stage-1 in seven patients (29.2%), while in 17 patients it occurred between day 2-31 (mean: nine days). Similarly, the mean onset of voiding was also nine days (range: 2-31 days). After day 15, 21% of patients voided. The mean lag time between the restoration of bladder sensation and voiding was 3.6 days. By day 17, a cumulative percentage of 90% of patients had a normalized bladder sensation and 80% had commenced voiding. Infection of the externalized lead occurred in only one case. There were no correlations between the outcome parameters with age (p > 0.05), symptom duration, or concomitant diagnosis of overactive bladder or chronic pelvic pain (p = 0.418, p = 0.114). CONCLUSION: Stage-1 SNM may be left in situ for up to four weeks to ensure the maximum chance of restoring normal bladder function in this complex group of patients.

Useful application of the Neuropad test for assessment of diabetic polyneuropathy.

OBJECTIVE: Examination of sudomotor function is now recommended to assess peripheral autonomic dysfunction. The aim of this study was to evaluate the clinical usefulness of Neuropad, a simple visual indicator test, for assessment of diabetic polyneuropathy (DPN). METHODS: This study examined 87 diabetic patients with a mean age of 61.1±8.8 years, a mean diabetes duration of 13.0±7.5 years and a mean HbA1c of 8.8±1.7%. Diagnosis of DPN was based on clinical examinations using modified Toronto Clinical Neuropathy Score (mTCNS). The patients also underwent 4-g monofilament test and heart rate variability by coefficient of variation of R-R intervals (CV(R-R)) was determined with the patients at rest. The Neuropad test was applied on the plantar aspect of the great toe and removed after 10 minutes to evaluate the color change as normal (blue to completely pink), patchy (patches of blue and pink) and abnormal (remained blue). RESULTS: Twenty-eight patients showed a normal, 45 patchy and 14 abnormal response to the Neuropad test. Patients with an abnormal response had significantly longer diabetes duration than those with a normal or a patchy response, but HbA1c levels were similar among the three groups. The C(R-R) at rest was significantly lower in patients with an abnormal response than those of normal and patchy response, respectively. Abnormal responders showed significantly higher mTCNS and lower monofilament results as well as higher prevalence of orthostatic hypotension, retinopathy or nephropathy than normal responders. CONCLUSION: The Neuropad test is a useful screening test for detecting DPN.

New paradigm for patient-reported outcomes assessment in foot & ankle research: computerized adaptive testing.

BACKGROUND: Accurately measuring, reporting and comparing outcomes is essential for improving health care delivery. Current challenges with available health status scales include patient fatigue, floor/ceiling effects and validity/reliability. METHODS: This study compared Patient Reported Outcomes Measurement Information System (PROMIS)-based Lower Extremity Physical Function Computerized Adaptive Test (LE CAT) and two legacy scales -the Foot and Function Index (FFI) and the sport module from the Foot and Ankle Ability Measure (spFAAM) -for 287 patients scheduled for elective foot and ankle surgery. We documented the time required by patients to complete the instrument, instrument precision, and the extent to which each instrument covered the full range of physical functioning across the patient sample. RESULTS: Average time of test administration: 66 seconds for LE CAT, 130 seconds for spFAAM and 239 seconds for FFI. All three instruments were fairly precise at intermediate physical functioning levels (i.e., Standard Error of Measurement < 0.35), were relatively less precise at the higher trait levels and the LE CAT maintained precision in the lower range while the spFAAM and FFI's had decreased precision. The LE CAT had less floor/ceiling effects than the FFI and the spFAAM. CONCLUSION: The LE CAT showed considerable advantage compared to legacy scales for measuring patient-reported outcomes in orthopaedic patients with foot and ankle problems. CLINICAL RELEVANCE: A paradigm shift to broader use of PROMIS-based CATs should be considered to improve precision and reduce patient burden with patient-reported outcome measuremen foot and ankle patients.

Childhood diabetic neuropathy: functional impairment and non-invasive screening assessment.

AIM: Sensory diabetic neuropathy, determined by nerve conduction studies, is common in children with Type 1 diabetes. Diabetic neuropathy diagnoses are rarely made in paediatric daily care because they are asymptomatic, vibration detection is mostly normal and nerve-conduction testing is impractical. The present study aims to: (1) describe somatosensory dysfunction in children with diabetes, (2) test whether diabetes duration and HbA(1c) are related to somatosensory dysfunction and (3) identify the best screening test for large-fibre dysfunction, as indicated by nerve conduction studies. METHODS: Forty-five children (age 13.2 ± 2.5 years) with Type 1 diabetes for 6.7 ± 2.5 years and matched control subjects were assessed by neurological examinations, nerve conduction tests and quantitative sensory testing on the feet using the protocol of the German Research Network on Neuropathic Pain. Abnormal nerve conduction was used as gold standard to define neuropathies. RESULTS: We found a high prevalence of mechanical (38%) and thermal (24%) hypoesthesia often associated with hyperalgesia (47%). Tactile hypoesthesia (33%) was more frequent than pallhypaesthesia (11%). Only cold detection and mechanical pain thresholds were related to HbA(1c). Tactile hypoesthesia had the highest sensitivity (75%), specificity (89%) and positive (75%) and negative (89%) predictive values for neuropathies defined by nerve conduction tests (31% abnormal). CONCLUSIONS: Almost half of the children with diabetes have subclinical large- and small-fibre neuropathies. Tactile detection was better than vibration for neuropathy assessment. Quantitative sensory testing is a valuable tool for assessment of neuropathy as well as a target of interventional studies in children with diabetes.

Postoperative hypoesthesia and pain: qualitative assessment after open and laparoscopic inguinal hernia repair.

BACKGROUND: Chronic pain is an important outcome variable after inguinal hernia repair that is generally not assessed by objective methods. The aim of this study was to objectively investigate chronic pain and hypoesthesia after inguinal hernia repair using three types of operation: open suture, open mesh, and laparoscopic. METHODS: A total of 96 patients were included in the study with a median follow-up of 4.7 years. Open suture repair was performed in 40 patients (group A), open mesh repair in 20 patients (group B), and laparoscopic repair in 36 patients (group C). Hypoesthesia and pain were assessed using von Frey monofilaments. Quality of life was investigated with Short Form 36. RESULTS: Pain occurring at least once a week was found in 7 (17.5%) patients of group A, in 5 (25%) patients of group B, and in 6 (16.6%) patients of group C. Area and intensity of hyposensibility were increased significantly after open nonmesh and mesh repair compared to those after laparoscopy (p = 0.01). Hyposensibility in patients who had laparoscopic hernia repair was significantly associated with postoperative pain (p = 0.03). Type of postoperative pain was somatic in 19 (61%), neuropathic in 9 (29%), and visceral in 3 (10%) patients without significant differences between the three groups. CONCLUSIONS: The incidence of hypoesthesia in patients who had laparoscopic hernia repair is significantly lower than in those who had open hernia repair. Hypoesthesia after laparoscopic but not after open repair is significantly associated with postoperative pain. Von Frey monofilaments are important tools for the assessment of inguinal hypoesthesia and pain in patients who had inguinal hernia repair allowing quantitative and qualitative comparison between various surgical techniques.

Spatial and temporal assessment of orofacial somatosensory sensitivity: a methodological study.

AIMS: To evaluate the sensitivity and reproducibility of a multimodal psychophysical technique for the assessment of both spatial and temporal changes in somatosensory function after an infraorbital nerve block. METHODS: Sixteen healthy volunteers with a mean (+/- SD) age of 22.5 +/- 3.4 years participated in 2 identical experimental sessions separated by 2 weeks. The subjects rated the perceived intensity of standardized nonpainful tactile, painful pinprick, warm, and cold stimuli applied to 25 points in 5 x 5 matrices in the infraorbital region of each side. The reproducibility of single points was tested, and a mean difference of 1.4 +/- 0.5 was found. A 0-50-100 numerical rating scale (NRS) with 50 denoting "just barely painful" was used. A modified ice hockey mask with adjustable settings was developed as a template to allow stimulation of the same points in the 2 sessions. Assessment of somatosensory function was carried out before the injection (baseline) and after 30 and 60 minutes on both the anesthetized and contralateral (control) side. In addition, the applicability of the psychophysical techniques was tested in pilot experiments in 2 patients before maxillary osteotomy and 3 months afterward. RESULTS: The overall analysis of mean NRS scores, number of points, and center-of-gravity coordinates for all stimulus modalities showed no significant main effects of session. Post-hoc tests for all stimulus modalities demonstrated significantly lower mean NRS scores and significantly more points (hyposensitivity) at 30 and 60 minutes postinjection compared to baseline values on the injection side (Tukey tests: P < .002). In the 2 maxillary osteotomy patients, the psychophysical techniques could successfully be applied, and bilateral hyposensitivity to all stimulus modalities was demonstrated at the 3-month follow-up. CONCLUSION: The present findings indicate that the psychophysical method is sufficiently reproducible, with no major differences between sessions in healthy subjects. All stimulus modalities demonstrated adequate sensitivity. Furthermore, measurement of points in 5 x 5 matrices allowed a spatial description of somatosensory sensitivity. This method may be valuable for studies on changes in somatosensory sensitivity following trauma or orthognathic surgery on the maxilla.

Application of metrics constructed from vibrotactile thresholds to the assessment of tactile sensory changes in the hands.

Two tools for assessing tactile sensory disturbances in the hands have been constructed from mechanoreceptor-specific vibrotactile threshold shifts, and thresholds changes with time, and employed in a prospective study of forest workers (N=18). Statistically significant positive threshold shifts (i.e., reductions in sensitivity compared to the hands of healthy persons) were found in five hands at study inception (13.9%), and 15 hands at follow-up (41.7%). Four patterns of threshold shift could be identified, involving selectively the median and/or ulnar nerve pathways and/or end organs. Statistically significant positive threshold changes (i.e., reductions in sensitivity with time) were recorded in 69.4% of the hands over a five-year period, even though a majority of the workers remained symptom free. If the thresholds recorded from subjects not working with power tools are used to control for aging, lifestyle, and environmental factors during the five year period, then 40% of the remaining subjects are found to be experiencing work-related threshold changes in their hands. The ability of the threshold shift metric to predict the numbness reported by these subjects shows that it is closely associated with the tactile sensory changes occurring in their hands.

Simplifying the assessment of the recovery from surgical injury to the lingual nerve.

OBJECTIVE: To determine the sensitivity of conventional sensory assessment in monitoring lingual nerve recovery subsequent to third molar surgery and to evaluate if the assessment methods can be predictive of injury outcome. METHOD: A prospective case series of 94 patients presenting with lingual nerve injuries evaluated using objective mechanosensory and subjective methods during the recovery period of up to 12 months. RESULTS: The conventional tests were often unable to diagnose the presence of injury due to variability and they were not predictive of outcome. As a result of this study, we are able to identify patients more likely to have permanent rather than temporary lingual nerve injury at four to eight weeks post injury, using patient reported subjective function. The subjective function test also minimises the requirements for specialist training or equipment providing an ideal method for general dental practice. CONCLUSIONS: The development of these simple subjective tests may enable us to identify which patients are at risk of permanent lingual nerve injuries in the early post injury phase, thus allowing expeditious therapy when indicated.

Assessment of trigeminal somatosensory evoked potentials in burning mouth syndrome.

OBJECTIVE: The measurement of pain threshold (PT) and the assessment of trigeminal somatosensory evoked potentials (TSEPs) were performed. These experiments indicated the pathological conditions of nerve afferent and efferent pathways in patients with burning mouth syndrome (BMS). This study also explored the probable pathophysiological mechanisms in BMS. MATERIALS AND METHODS: The dorsum linguae of 38 samples in 19 subjects (22 BMS with pain, 10 BMS with numbness, and 6 controls) were stimulated by electroneuromyography. PT was measured as the lowest stimulation intensity the subjects could detect. N3, P4 latency, and spike potential latency of TSEP were recorded by stimulating the lingual nerve. RESULTS: Pain thresholds were significantly lower, N3, P4 latencies were significantly shorter, and the spike potential appeared earlier in the BMS with pain group (P < 0.01). The opposite tendency of these values presented in the BMS with numbness group (P > 0.05). CONCLUSIONS: The results indicated that the nerve sensitivity was elevated in the BMS with pain group, and that these patients were easily affected by etiological factors. In the BMS with numbness group, partial or complete nerve blockage may have been indicated. This study suggested that selfreports of BMS pain appeared to be of value, and that there were pathological conditions in nerve transmission. It supported the theory that peripheral or central nervous system involvement might play an important role in BMS. It was possible to show the pathogenesis of BMS. All of these objectively explain the clinical understanding of BMS, and may be of assistance in the treatment of BMS.

Assessment of inferior alveolar and lingual nerve disturbances after dentoalveolar surgery, and of recovery of sensitivity.

In a follow-up of 1107 dentoalveolar operations in the postcanine region, 24 (2.2%) temporary sensitivity disturbances of the inferior alveolar nerve and 16 (1.4%) of the lingual nerve were found. Permanent disturbances were not present. Complete recovery had occurred by 6 months in all cases. The incidence of temporary sensitivity disturbances depended on the different surgical interventions performed. For evaluation and follow-up purposes, a computer-aided pain and thermal sensitivity (PATH) tester was used. By PATH testing, spontaneous recovery can already be ascertained at the third or fourth postoperative month.

[A simple method for semiquantitative assessment of thermesthesia]. / Eine einfache Methode zur semiquantitativen Prüfung der Thermaesthesie.

A technically simple method based on the Peltier effect was employed to determine semiquantitatively thermesthesia in normal individuals, patients with functional disorders, and patients with cortical and spinal complaints and peripheral affections of the CNS. The results demonstrate the suitability of the method in principle for use in routine examination.