Preservation or removal of the lateral nasal wall in endoscopic management of maxillary sinus neoplasia: A comparison of approach related morbidity.

BACKGROUND: The endoscopic modified medial maxillectomy (MMM) and prelacrimal approach (PLA) are two routinely performed endoscopic approaches to the maxillary sinus when access via a middle meatal antrostomy is insufficient. However, there is no data in the literature that has compared outcomes and complication profile between the two procedures to determine which approach is superior. OBJECTIVE: To compare the approach related morbidity of PLA and MMM. METHODS: A retrospective cohort study of all consecutive adult patients undergoing either MMM or PLA from 2009 to 2023 were identified. The primary outcome was development of epistaxis, paraesthesia, lacrimal injury, iatrogenic sinus dysfunction within a minimum of 3 months post-operative follow up. RESULTS: 39 patients (44 sides) underwent PLA and 96 (96 sides) underwent MMM. There were no statistically significant differences between the rates of paraesthesia (9.1 % vs 14.6 %, p = 0.367) or prolonged paraesthesia (2.3 % vs 5.2 %, p = 0.426), iatrogenic maxillary sinus dysfunction (2.3 % vs 5.2 %, p = 0.426) or adhesions requiring removal (4.5 % vs 4.2 %, p = 0.918). No cases of epiphora or nasal cavity stenosis occurred in either arm in our study. CONCLUSIONS: According to our data, the endoscopic modified medial maxillectomy and prelacrimal approach are both equally safe approaches with their own benefits to access.

A semi-quantitative sport-specific assessment of recurrent traumatic brain injury: the TraQ questionnaire and its application in American football.

Chronic traumatic encephalopathy (CTE) is very frequent and studied among contact sport players, above all American Football. Now, the defined diagnosis is only post-mortem and, consequently, more detailed diagnostic in-vivo instruments are needed to facilitate diagnosis and to allow a follow up. This clinical questionnaire (Trauma Questionnaire-TraQ) has been designed to investigate in parallel the traumatic load and clinical and cognitive subjective symptoms. It evaluates 4 anamnestic fields (specific sport activity, all previous pathological events, clinical manifestations compatible with TBI (traumatic brain injury) or CTE and subjective perception of personal memory efficacy with PRMQ questionnaire). The aim of TraQ questionnaire is to allow a standardized follow-up of active players and to identify subclinical disturbances that may become warnings. A pilot comparative study with TraQ on 105 subjects (75 AF players and 30 comparable people without a history of contact-sports activity) revealed that AF players have an increased amount of severe head trauma, an amplified level of subjective aggressiveness, more olfactory deficits but also more speech subjective problems, previously never related with CTE. In view of the obtained results, the TraQ seems to be useful (1) to obtain a better quantification of the traumatic load; (2) to differentiate the risk of long-term neurological consequences, allowing better management of different athletes right from the pre-symptomatic phases; (3) to manage prevention strategies if regularly applied to periodic visits to sports fitness; and (4) to identify the predisposing factors for the development of CTE and other neurological consequences of TBI with follow-up studies.

Assessment of Frontalis Myocutaneous Transposition Flap for Forehead Reconstruction After Mohs Surgery.

Importance: Forehead reconstruction after Mohs surgery has become a challenge for dermatology surgeons, and achieving an excellent cosmetic and functional result is imperative in this location. Objective: To highlight the utility of a frontalis myocutaneous transposition flap (FMTF) for forehead reconstruction after Mohs surgery. Design, Setting, and Participants: Surgical technique case series including 12 patients with large forehead defects recruited between January 2010 and June 2017 at the Dermatology Department of the University Clinic of Navarra, Spain. All patients underwent Mohs micrographic surgery for skin cancer (5 basal cell carcinomas, 4 melanomas, 2 squamous cell carcinomas, and 1 adnexal tumor) located on the forehead (8 paramedian, 2 midline, and 2 lateral subunits) resulting in defects ranging from 9 to 28 cm2 in size. Intervention: Mohs micrographic surgery followed by FMTF. Taking into account the defect's size and location, a lateral lobulated flap is designed with an inferior pedicle and incision lines are made vertically to the hairline containing part of the frontalis muscle or its fascia. The flap swings into the primary defect and direct closure of the donor site is achieved. Additional corrections for removing skin folds or a guitar-string suture can be made. Main Outcomes and Measures: Absence of acute complications and achievement of high aesthetic and functional goals in postoperative follow-up. Results: Satisfactory cosmetic and functional results were achieved for all 12 patients (7 men and 5 women; mean age, 62.7 years [range, 47-86 years]) and there were no postoperative complications. All the myocutaneous flaps survived without any acute complications, such as episodes of local bleeding, infection, flap margin necrosis, or congestion. Postoperative follow-up ranged from 6 months to 3 years. No patient needed scar revision. Six patients presented with paresthesia in areas of the forehead and scalp. Sensory recovery tended to improve over time, and paresthesia gradually decreased, disappearing in 5 of 6 cases after 12 months. In 3 patients there was a minimal hair transposition that required laser treatment. Conclusions and Relevance: The FMTF provides a simple method for 1-stage reconstruction of large forehead defects as an alternative to classic advancement flaps.

Assessment of indications and clinical outcome for the endoscopy-assisted combined subciliary/transantral approach in treatment of complex orbital floor fractures.

BACKGROUND: The treatment of complex orbital floor fractures with extensive orbital prolapse remains a surgical challenge in craniomaxillofacial traumatology and is still controversially discussed. Reduction of orbital tissue via a transcutaneous or transconjunctival approach alone can be very difficult and lead to unsatisfying results. METHODS: Over a 3-year-period, we enrolled 13 patients who underwent endoscopy-assisted reconstruction of isolated orbital floor fractures via a combined subciliary and transantral approach. Patient data, imaging and ophthalmologic examination were reviewed prospectively. RESULTS: Ten patients underwent primary surgical treatment, 3 patients had secondary surgical treatment because of unsatisfactory results of primary surgical intervention. All patients had an uneventful postoperative course without ophthalmologic deterioration, no further surgical procedures were necessary. CONCLUSIONS: The additional use of an endoscopy-assisted transantral approach provides a reliable treatment modality in selected cases. To our knowledge, this is the only study of patients treated with a combined subciliary and transantral approach. Special emphasis was given to postoperative functional results, a short algorithm for use of an additional transantral endoscopy-assisted approach is presented.

One-port (uniportal) video-assisted thoracic surgical resections--a clear advance.

One-port (uniportal) video-assisted thoracic surgery (VATS) consists of approaching an intrathoracic target lesion through a sagittal, craniocaudal plane through 1 single-port incision. The use of articulating instruments inserted parallel to the videothoracoscope enables the surgeon to mimic inside the chest the maneuvers that are usually performed during open surgery. Through this VATS approach, several thoracic conditions can be addressed, including lung cancer in selected patients. Unlike conventional, 3-port VATS, the uniportal VATS technique enables the surgeon to bring the operative fulcrum inside the chest when the target lunge lesion is approached through a sagittal plan, thanks to articulating instruments. Uniportal wedge VATS resections of peripheral nodules can help in solving diagnostic dilemmas, be of therapeutic benefit, and provide tissue for biomolecular studies.

Occlusal dysesthesia: a qualitative systematic review of the epidemiology, aetiology and management.

Occlusal dysesthesia refers to a persistent complaint of uncomfortable bite sensation with no obvious occlusal discrepancy. This systematic review aimed to draw a picture of such patients, to present an agreement of previously reported diagnostic criteria and to analyse the evidence level of the recommended management approaches. An electronic search for all relevant reports on occlusal dysesthesia was thoroughly performed based on previous nomenclatures (e.g. phantom bite, occlusal hyperawareness) in PubMed and The Cochrane Library in July, 2011. A total of 84 reports were matched, among which only 11 studies were included after a two-step (abstract and detailed full-text revision) screening process. Additionally, a thorough manual review of reference lists of the included reports enabled the inclusion of two additional studies. Data analysis revealed that 37 occlusal dysesthesia patients presented a mean age of 51.7 ± 10.6 years and were predominantly women (male/female: 1/5.1) with symptom duration of more than 6 years (average: 6.3 ± 7.5 years) and with concomitant psychological disturbances (e.g. mood disorders, somatoform disorders, personality disorders). Only four authors presented diagnostic criteria for occlusal dysesthesia, which served as the basis for an agreement in the diagnostic criteria. Treatment approaches included psychotherapy, cognitive/behaviour therapy, splint therapy and prescription of anti-depressants or anti-anxiety drugs. Classification of evidence level of management approaches, however, revealed that most of them were expert opinions with single- or multiple-case report(s). Future studies are necessary for a deeper understanding of the mechanisms behind the occlusal dysesthesia symptoms, and consequently, for improvements in evidence-based management approaches.

Keratocystic odontogenic tumors and Carnoy's solution: results and complications assessment.

OBJECTIVE: Keratocystic odontogenic tumors (KOTs) can be treated with Carnoy's solution, although this treatment modality is not free from complications. It is important to verify the incidence of complications after the use of Carnoy's solution and compare these with the literature. MATERIALS AND METHODS: This study verified the effects of a complementary treatment for KOTs and assessed the incidence of such complications as recurrence, infection, sequestrum formation, mandibular fracture, dehiscence, and neuropathy. RESULTS: Twenty-two KOTs treated with Carnoy's solution combined with peripheral ostectomy were included, and the follow-up period varied from 12 to 78months with a mean of 42.9months. Complications included recurrence (4.5%), dehiscence (22.7%), infection (4.5%), and paresthesia (18.2%). No difference was found among lesions associated (9.1%) or not (0%) with nevoid basal cell carcinoma syndrome (P>0.05). Dehiscence was influenced by marsupialization (P<0.05), and paresthesia was observed exclusively in cases of mandibular canal fenestration (P<0.01). CONCLUSIONS: Complementary treatment with Carnoy's solution and peripheral ostectomy appear to provide efficient treatment for KOTs. Complications originating from the use of the solution are less frequent and less serious than complications associated with cryotherapy. Neuropathy seems to be related to direct contact between the solution and the epineurium.

Results of endovenous ClosureFast treatment for varicose veins in an outpatient setting.

OBJECTIVE: Endovenous methods are increasingly used to treat varicose veins. We evaluated the outcome of patients treated with the new radiofrequency ablation (RFA)-ClosureFast catheter in an outpatient setting. METHOD: Retrospective analysis of postinterventional duplex ultrasound (DUS), complication rate and quality of life of patients treated for incompetent saphenous veins. RESULTS: Between 2007 and 2009, 155 patients had been treated with ClosureFast. DUS was available from 73 (47%) patients (102 great [GSV] and 16 small [SSV] saphenous veins). After a mean follow-up of 12.2 months (range 1-29 months), DUS showed six (5.9%) open GSV and an occlusion of all treated SSV. One pulmonary embolism had occurred. Mean patient's satisfaction was 8.7 (10 = very satisfied), pain after one week 2.0 (no pain = 0, maximal = 10) and absence of work was 0.9 day (range 0-14 days). CONCLUSION: RFA for incompetent saphenous veins can safely be performed in an outpatient setting with a low complication rate, minimal pain and fast recovery.

Assessment of trigeminal nerve functions by quantitative sensory testing in patients and healthy volunteers.

PURPOSE: Orofacial sensory dysfunction plays an important role in oral and maxillofacial surgery. Quantitative sensory testing (QST) is a psychophysical approach to evaluate thermal and mechanical somatosensation. PATIENTS AND METHODS: The present human study 1) collected normative QST data in extraoral and intraoral regions, 2) analyzed effects of age, gender, and anatomical sites on QST, and 3) applied QST in 11 patients with iatrogenic inferior alveolar nerve lesions. Sixty (30 male and 30 female) healthy volunteers were tested bilaterally in the innervation areas of infraorbital, mental, and lingual nerves. Ten patients with sensory disturbances in innervation areas of the mental nerve were investigated at 1, 4, and 8 weeks after surgery. Another patient with a complete sensory loss after surgery was repetitively tested within 453 days after primary surgery (dental implant) and subsequent surgical reconstruction of the inferior alveolar nerve by autologous graft. RESULTS: Older subjects were significantly less sensitive than younger subjects for thermal parameters. Thermal detection thresholds in infraorbital and mental regions showed higher sensitivity in women. Sensitivity to thermal stimulation was higher in the infraorbital region than in the mental and lingual regions. QST monitored somatosensory deficits and recovery of inferior alveolar nerve functions in all patients. CONCLUSIONS: Age, gender, and anatomic region affect various QST parameters. QST might be useful in the diagnosis of inferior alveolar nerve disorders in patients. In dentistry, the monitoring of afferent nerve fiber functions by QST might support decisions on further interventions.

Upper extremity paraesthesia: clinical assessment and reasoning.

The art of clinical assessment involves an accurate determination of the cause(s) of a patient's symptoms. Given that a set of symptoms can be influenced by many contributing factors and features, assessment needs to differentially evaluate these. Accurate and appropriate treatment depends on differential assessment based on sound clinical reasoning. Many conditions derive from multiple causes demanding evaluation of as many etiological features as can be identified. The case review presented here involves a patient presenting with paraesthesia spreading into her right upper extremity. A complex history, involving her neck and contralateral upper extremity was assessed. The patient was found to have at least seven underlying, predisposing, and etiological, conditions capable of initiating, aggravating, or maintaining the presenting symptoms. Weighing the relative contributions of these often interacting features, and correlating this with the history, helped to identify a successful course of treatment.

Clinical assessment of the relationship between the third molar and the inferior alveolar canal using panoramic images and computed tomography.

PURPOSE: To predict the relationship between lower third molars and the inferior alveolar canal (IAC) from panoramic radiographs, and to establish criteria for using computed tomography (CT). MATERIALS AND METHODS: A retrospective cohort study was performed involving 443 patients (695 teeth). Predictor variables were the distance between the third molar and the IAC, and findings according to the Rood's criteria. Outcome variables were the absence of cortication between the third molar and the IAC on the CT image, and injury of the inferior alveolar nerve (IAN). Statistical analysis was performed to assess the relationship between predictor and outcome variables. RESULTS: All patients had preoperative panoramic radiographs, and 71 patients (119 teeth) also had CT images. On CT examination, 48 teeth (40.3%) showed absence of cortication. Injury of the IAN was reported in 7 cases (1.0%), 5 of which exhibited absence of cortication; the remaining 2 did not have CT scans. Five of the 48 cases showing absence of cortication exhibited IAN injury, and none of the cases with cortication exhibited IAN injury. On the panoramic images, the following signs were strongly correlated with absence of cortication: a superimposed relationship between the third molar and the IAC; darkness of the root; and diversion and narrowing of the IAC. CONCLUSION: Presence of Rood's criteria was a predictor for a contact relationship between the third molar and the IAC, and an indication for CT examination. However, a superimposed relationship and the absence of Rood's criteria did not necessarily signify a separate relationship between third molar and the IAC.

Resection of intramedullary spinal cord tumors in children: assessment of long-term motor and sensory deficits.

OBJECT: With modern surgical advances, radical resection of pediatric intramedullary spinal cord tumors (IMSCTs) can be expected to preserve long-term neurological function. Nevertheless, postoperative neurological decline is not uncommon after surgery, and many patients continue to experience long-term dysesthetic symptoms. Preoperative predictors of postoperative neurological decline and sensory syndromes have not been investigated and may serve as a guide for surgical risk stratification. METHODS: Neurological function (as determined using the modified McCormick Scale [mMS]) preoperatively, postoperatively, and 3 months after surgery was retrospectively recorded from patient charts in 164 consecutive patients undergoing resection of IMSCTs. A median 4 years (interquartile range [IQR] 1-8 years) after surgery, long-term motor and sensory symptoms were assessed by telephone interviews and corroborated by subsequent medical visits in 120 available patients. This long-term assessment was retrospectively reviewed for the purposes of this study. The authors reviewed this series to assess long-term motor, sensory, and urinary outcomes and to determine independent risk factors of postoperative neurological decline and long-term sensory dysfunction. RESULTS: Patients were 8.6 +/- 5.7 years old and presented with a median mMS of 2 (IQR 2-4). Three months after surgery, 38 patients (23%) continued to experience decreased neurological function (1 mMS point) incurred perioperatively. Increasing age (p = 0.028), unilateral symptoms (p = 0.046), and urinary dysfunction at presentation (p = 0.004) independently predicted persistent 3-month perioperative decline. At long-term follow-up (median 4 years), 39 (33%) exhibited improvements in their mMS scores, 13 (30%) had improvement in their urinary dysfunction, and 27 (30%) had resolution of their dysesthesias. Seventy-eight patients (65%) experienced long-term dysesthetic symptoms. Increasing age (p = 0.024), preoperative symptom duration > 12 months (p = 0.027), and worsened postoperative mMS score at hospital discharge (p = 0.013) independently increased the risk of long-term dysesthesias. CONCLUSIONS: In the authors' experience, nearly one third of patients may experience improvement in motor, sensory, and urinary dysfunction years after IMSCT resection, whereas the majority will continue to experience long-term dysesthetic symptoms. Improvement in motor deficits preceded improvement in sensory syndromes, and urinary dysfunction typically resolved much longer after surgery. The risk of persistent perioperative motor decline was increased with older age, unilateral symptoms, preoperative urinary symptoms, and less severe preoperative neurological deficit. The risk of long-term dysesthesias was increased with older age, increased duration of symptoms prior to resection, and greater postoperative neurological deficit.

The prophylactic extraction of third molars: a public health hazard.

Ten million third molars (wisdom teeth) are extracted from approximately 5 million people in the United States each year at an annual cost of over $3 billion. In addition, more than 11 million patient days of "standard discomfort or disability"--pain, swelling, bruising, and malaise--result postoperatively, and more than 11000 people suffer permanent paresthesia--numbness of the lip, tongue, and cheek--as a consequence of nerve injury during the surgery. At least two thirds of these extractions, associated costs, and injuries are unnecessary, constituting a silent epidemic of iatrogenic injury that afflicts tens of thousands of people with lifelong discomfort and disability. Avoidance of prophylactic extraction of third molars can prevent this public health hazard.

Lymphedema in breast cancer survivors: assessment and information provision in a specialized breast unit.

OBJECTIVE: Assessment and adequate treatment of lymphedema is required by the European Society of Mastology. The purpose of our study was the evaluation of self-reported incidences of lymphedema in breast cancer survivors and the effect of providing the patients with information about lymphedema on the extent to which lymph-drainage massage services and compression garments were used. METHODS: A total of 742 breast cancer survivors were analysed in this questionnaire-based survey. The associations between lymphedema and the patients' medical history; morbidity located in the breast, axilla, and arm; the amount of information the patients had received concerning lymphedema; and the extent to which lymph-drainage massage services and compression garments were analyzed. RESULTS: 31.67% of the patients stated to have lymphedema. Radiotherapy was identified as a significant risk factor. Pain, paresthesia, and functional limitations were associated with the occurrence of lymphedema. The only independent positive predictive factor found to be associated with the use of lymph-drainage massage services (OR 5.74) was the provision of information about the condition. CONCLUSIONS: Self-reported assessment of lymphedema is feasible. The observed lymphedema incidence of approximately 30% may be able to serve as a basis for benchmarking in quality-assurance procedures at breast centers. PRACTICE IMPLICATIONS: Control mechanisms are required to assess if the indication for lymphdrainage is adequate and the compliance to this subject is sufficient.

Iatrogenic paresthesia in the third division of the trigeminal nerve: 12 years of clinical experience.

BACKGROUND: Iatrogenic paresthesia in the third division of the trigeminal nerve remains a complex clinical problem with major medicolegal implications. However, most lawsuits can be prevented through better planning of procedures and by obtaining informed consent. The purpose of this article is to present the authors" clinical experience over the past 12 years, to review the principles of prevention and management of trigeminal paresthesia and to highlight the resulting medicolegal implications. METHODS: The files of all 165 patients referred to the oral and maxillofacial surgery department for evaluation of iatrogenic paresthesia in the third division of the trigeminal nerve were reviewed. The characteristics of the subgroup of patients who had taken an attending dentist to court were compared with those of the other patients. RESULTS: Surgical extraction of impacted molars was the main cause of paresthesia in 109 (66%) of the 165 subjects. The alveolar nerve was affected in 89 (54%) subjects, the lingual nerve in 67 (41%) subjects, and both nerves were affected in 9 (5%) subjects. There were more female than male patients (ratio 2.2:1). Lawsuits were initiated in 33 (20%) of the cases; patients who initiated lawsuits were younger, were more likely to have experienced anesthesia and were more likely to need microsurgery (all p < 0.001). Poor surgical planning and lack of informed consent were the most common errors on the part of the dentists. CONCLUSIONS: An accurate evaluation of surgical indications and risk, good surgical technique, preoperative informed consent and sufficient postoperative follow-up should help to reduce the frequency of neurosensory deficits after dental treatment and attendant lawsuits.

Assessment of material- and technique-related complications following sagittal split osteotomies stabilized by biodegradable polylactide screws.

OBJECTIVE: The aim of this retrospective clinical study was to determine whether there are any material-related problems and increased occurrence of postoperative mandibular nerve and temporomandibular joint dysfunctions in connection with the use of biodegradable self-reinforced poly-L-lactide (SR-PLLA) screws for bone fixation after bilateral sagittal split osteotomies (BSSO). STUDY DESIGN: Forty consecutive patients who underwent BSSO and mandibular advancement that included fragment fixation using SR-PLLA screws were monitored for an average of 2.2 years postoperatively. RESULTS: The osteotomy sites healed uneventfully with no adverse reactions. The incidence of postoperative sensory disturbances of the inferior alveolar nerve was 27%. Symptoms of temporomandibular joint disorders (TMJD) observed preoperatively in 73% of patients were reduced to 48% after surgery. CONCLUSION: The occurrence of postoperative sensory disturbances and TMJD symptoms in this study did not deviate strikingly from that of other studies using conventional osteosynthesis. No specific complications related to the screw material were observed.

Cold provocation testing and hand-arm vibration syndrome--an audit of the results of the Department of Trade and Industry scheme for the evaluation of miners.

BACKGROUND: Hand-arm vibration syndrome (HAVS) is a major industrial disease that causes considerable morbidity among workers exposed to vibration. Compensation is paid to those affected in civil claims against employers and (in the UK) in claims made under Social Security legislation rules for Prescribed Disease A11. Diagnostic tests have been proposed but most are not objective. The cold provocation test (CPT), which is objective, is often included in the evaluation of HAVS. METHODS: A continuous audit was made of the findings recorded at the 18 HAVS test centres in the UK established to evaluate miners. The audit, and its outcome, were monitored by the Medical Reference Panel who advise the Department of Trade and Industry. This audit report constitutes the second analysis of the findings relating to the CPT. RESULTS: The CPT, with measurement of digital rewarming times, is of no value in assessing vibration-induced damage to the hands. CONCLUSION: In its present format, the CPT should not be used for evaluating the vascular component of HAVS.

[A system of comprehensive assessment of symptoms in chronic prostatitis (CAS-XII)]. / Sistema summarnoi otsenki simptomov pri khronicheskom prostatite (COC-XII).

The system proposed for overall assessment of symptoms in chronic prostatitis was applied in the assessment of 75 patients. The system facilitates detection and analysis of the complaints, quantitates the disease symptoms, provides overall objective characteristics of all the multiplicity of clinical manifestations of chronic prostatitis in each patient by means of digital order. The system is rather effective for dynamic control of the patients' condition and treatment efficacy.