Tactile corpuscle-like structures in a case of plexiform neurofibromatosis.

Tactile corpuscle-like structures were identified in a plexiform neurofibroma, which was localized on the right cranial hemisphere os a 16-year-old boy and had necessitated repeated surgery. These structures were studied by light and electron microscopy. The origin of their component cells is, however, still controversial. We believe to have accumulated sufficient evidence for a Schwann cell origin of these cells.

A review of surgical procedures designed to increase the functional height of the resorbed alveolar ridge.

By raising the alveolar ridge, relatively or absolutely, in partially or totally edentulous patients, preprosthetic surgery makes possible an improvement in the bed for the denture. Raising the height of the ridge, relatively, by deepening the sulci surrounding the jaw, can be achieved by vestibuloplasty and grafts to the floor of the mouth. However, for these procedures it is essential that there still be sufficient bone (at least 20 mm in the mandible). Long term observations show that the main problem is a reduction in the vestibular depth initially obtained by surgery. The most durable results follow vestibuloplasties with free skin or mucosal grafts, the latter being preferred. If resorption or atrophy is far advanced the jaw bone has to be reconstructed, so that an absolute increase in the ridge height is the aim. This is secured by onlay grafting, preferably of autologous bone, or inlay grafting (sandwich technique: horizontal osteotomy with bone interposition). In the lower jaw there is also the possibility of 'displacement grafting' (visor osteotomy: vertical osteotomy and visor-like displacement) and grafting to the lower border in cases of extreme mandibular atrophy. In the long term onlay grafts show a high degree of resorption; in appropriate circumstances, the results of the other methods are encouraging. A feature common to all procedures is a greater or lesser functional disturbance of the mental nerve.

[Partial gluing in extra-intracranial microvascular anastomoses (author's transl)]. / Zur partiellen Klebung von Mikrogefässanastomosen im intrakraniellen Bereich.

In an extensive series of experimental studies conducted on the common carotid artery in rats, a combined technique involving suture and gluing with human fibrin glue has been developed. In view of the good results achieved, this technique was then applied in 12 patients in whom anastomosis between the superficial temporal artery and a cortical branch of the middle cerebral artery was carried out. This modified surgical technique shortened the duration of operation and also reduced the incidence of complications. Late results, too, seem to be more satisfactory, as far as can be ascertained within the given observation period. 10 patients showed a marked improvement in the clinical neurological findings. Working capacity was completely restored in 5 out of these patients. In one patient, clinical symptoms deteriorated on account of an intra-operative contralateral cerebral haemorrhage. The condition of one patient remained unchanged.

[Clinical, histological and electron microscopic findings in neurofibromatosis (Recklinghausen's disease) occurring in childhood (author's transl)]. / Klinische, licht- und elektronenmikroskopische Befunde im Gesichtsbereich bei kindlicher Neurofibromatose Recklinghausen

A follow-up study was carried out of the clinical symptoms and the radiological and histological alterations in five cases of neurofibromatosis (Recklinghausen's disease) with onset during early childhood. The clinical manifestation of the disease was predominantly restricted to the face. In the histological ultrastructural investigation different types of neurofibroma were detected (plexiform neurofibroma, argyrophilic neurofibroma and diffuse neurofibrma). Preliminary results are presented on the basis of a correlation between the clinical findings and the histological types of neurofibroma with special reference to the demarcation of the tumours, recurrence following surgical removal and the prognosis as to the clinical course of the disease. Nevertheless, definite conclusions will be possible only by continuous observation of a larger number of patients by means of standardized clinical, radiological and histological methods of investigation.

[Water-tight closure of spinal dura with a new clot suture technique (author's transl)]. / Spinale Duraklebung mit "Fibrinkleber".

A new clot-suturing Technique (using high-concentration fibrinogen solutions) for water-tight closure of the dura is reported. Six dogs underwent laminectomy of the thoracic spine with medial longitudinal incision in the chordal dura. After the dural split had been sealed with natural tissue adhesive and closure of the wound in layers, the animals were sacrificed at intervals of 1 to 21 days postoperatively and the chordal segments involved were removed and histologically examined. Early fibrinolysis of the clot was prevented by adding a natural proteinase inhibitor and factor XIII concentrate to the clotting substances. Histological analysis showed that healing was almost complete after 2 weeks, with delicate connective tissue overgrowing the dural split. After complete reabsorption of fibrin, the originally abundant absorbent granulation tissue had largely disappeared. Among the satisfactory results of fibrin suturing are optimum healing tendency in the fibrin-sutured region, absence of tissue irritation and neurotoxicity, which are known attributes of the synthetic alkl-cyano-acrylate tissue adhesives.

Talismans and amulets in the Pediatric Intensive Care Unit: legendary powers in contemporary medicine.

BACKGROUND: For centuries talismans and amulets have been used in many cultures for their legendary healing powers. METHODS: We asked the parents of every child (Jews and Arabs) admitted to the Pediatric Intensive Care Unit over a 2 month period to complete a questionnaire, which included demographic data on the patient and the family, the use of talismans or other folk medicine practices, and the perception of the effects of these practices on the patient's well-being. A different questionnaire was completed by the ICU staff members on their attitude toward the use of amulets. RESULTS: Thirty percent of the families used amulets and talismans in the ICU, irrespective of the socioeconomic status of the family or the severity of the patient's illness. Amulets and talismans were used significantly more by religious Jews, by families with a higher parental educational level, and where the hospitalized child was very young. The estimated frequency of amulet use by the children's families, as perceived by the staff, was significantly higher than actual use reported by the parents. In Jewish families the actual use of amulets was found to be 30% compared to the 60% rate estimated by the medical staff; while in Moslem families the actual use was zero compared to the staff's estimation of about 36%. Of the 19 staff members, 14 reported that the use of amulets seemed to reduce the parents' anxiety, while 2 claimed that amulet use sometimes interfered with the staff's ability to carry out medical treatment. CONCLUSIONS: The use of talismans in a technologically advanced western society is more frequent than may have been thought. Medical and paramedical personnel dealing with very ill patients should be aware of the emotional and psychological implications of such beliefs and practices on patients and their families.

Management of upper midfacial injuries.

Midfacial fractures may extend into orbital roofs, frontal sinus walls, and ethmoidal and sphenoidal bones if the traumatic impact is of sufficient force. The cranium and facial skull are affected and there is the risk of intracranial complications. Management thus requires a teamwork approach. Isolated compound fractures of the anterior frontal sinus may be reconstructed by direct access through the wound. We prefer a coronal hairline incision in most cases. In isolated (compound) fractures of the orbital roof, combined frontomaxillary fractures without dural involvement, and frontobasal fractures that necessitate an intracranial approach for dural closure, primary upper midfacial reconstruction is attempted. In frontal comminution, preservation of the frontal bone or orbital roof is impossible. Secondary management is indicated after an interval of at least six months for fronto-orbital reconstruction with autologous or alloplastic material.

Combined cranio-facial fractures.

Clinically, fronto-maxillary injuries may constitute a diagnostic problem, as their severity need not correlate with the patient's general condition. To establish a definitive radiological diagnosis, both normal standard films and tomographs are required. These will help to identify fracture lines involving the base of the skull. Most serious among the complications which may be associated with fronto-maxillary injuries is the occurrence of cerebrospinal rhinorrhoea with potential ascending infection. Other complications include oculomotor dysfunction, obstruction of lacrimal drainage and nasal airways as well as dental malocclusion. Primary surgical management is indicated in compound fractures, suspected intracranial haemorrhage and compression of the optic nerve, while fractures with associated dural injuries and involvement of orbital roofs as well as all other combined maxillo-facial fractures with functional impairment require early secondary management. Open exposure of the fracture site is best obtained through a coronal hair-line incision. Dural injuries are preferentially approached through craniotomies.

Topographical anatomy of the total osteotomy of the midface.

In this study, the operating conditions for total osteotomy of the middle part of the face have been simulated in a cadaver and the topography of the organs at risk has been examined. The area of the maxillary tuberosity is the region which is mainly exposed to considerable injury to vessels; here an uncontrolled fracture as compared with a systematic osteotomy is the safer method under the given anatomical conditions.

Cephalometric observations in premature craniosynostosis.

Forty patients with premature craniosynostosis of variable extent and severity were subjected to cephalometry. The majority of the children and adolescents involved had undergone bilateral cranial fenestration at age 6 months to 11 years. Lateral cephalometric radiographs were used for analysis. The measurements obtained were compared with normal values of comparable age groups. In two thirds of the patients examined facial skull growth was found to be impaired, the clinical appearance ranging from pronounced faciostenosis to abortive forms. In some cases the clinical appearance was normal. One of the conclusions derived from the cephalometric data is that inhibited growth primarily affects the anterior portions of the skull base, which are found to be shorter than normal. The defect appears to involve the spheno-ethmoidal, intersphenoidal and sphenofrontal synochondroses.

[Traumatic intraclinoidal aneurysm of the internal carotid artery]. / Traumatisches intrakranielles Aneurysma der Arteria carotis interna bei longitudinaler Fraktur des Orbitadaches.

A case of traumatic supraclinoidal aneurysm of the internal carotid artery is presented. The patient with adventitious multiple lesions of the midface was successfully treated by a team consisting of a neurosurgeon, a traumatologist, and a dental surgeon. As an example, this case presents the diagnostic problems, and the operative treatment. Problems of post-traumatic intracranial vasospasm are discussed.

Concept of cytostatic therapy in advanced tumours of the head and neck.

In cases with inoperable tumours of the head and neck some benefit may still be derived from cytostatics and radiotherapy. One treatment concept is based on intraarterial infusion therapy (bleomycin, methotrexate), while the systemic intravenous application of cytostatic substances (bleomycin, cyclophosphamide) is considered as an alternative of the intra-arterial approach is ruled out. Of the 31 intra-arterially and the 30 intravenously treated patients (all except 2 had squamous cell carcinomas), 64,5% and 20%, respectively, went into remission. This documents the validity of our treatment concept.

Different types of benign nerve sheath tumors. Light microscopy, electron microscopy and autoradiography.

In a light-, electronmicroscopic and autoradiographic study different types of nerve sheath tumors were classified. Their cellular population was quantitatively evaluated in the electron microscope. In the neurinoma the predominant cell was found to be the Schwann cell, but in the different types of neurofibromata a variable content of connective tissue cells was noted. T-HE DIFFUSE NEUROFIBROMATA SHOWED A QUANTITATIVE CELLULAR COMPOSITION SIMILAR TO NORMAL PERIPHERAL NERVES. In the plexiform neurofibroma a large number of fibroblasts were present and in the argyrophilic neurofibroma high content of perineurial cells was found. In autoradiographic sections the tumors showed in general a low proliferation rate (L.i. 1-3.6%). In the argyrophilic neurofibrom a higher labelling index (9.5%) was found.