Reanimation surgery in patients with acquired bilateral facial palsy.

Acquired bilateral facial palsy is rare and causes difficulty with speech and eating, but dynamic reanimation of the face can reduce the effect of these problems. Of 712 patients who had these procedures during our study period, two had an acquired bilateral facial paralysis. In both, reanimation was completed in a single operation using a free-functional transfer of the latissimus dorsi muscle that was coapted to the masseteric branch of the trigeminal nerve. Both patients achieved excellent non-spontaneous excursion and an improvement in function. Careful evaluation of the available donor nerves including thorough examination and electromyographic testing should always be completed before operation.

The outcomes of digital tip amputation replacement as a composite graft in a paediatric population.

UNLABELLED: Limited studies exist on the outcome of replacing an amputated fingertip as a composite graft. We report the outcomes and predictors for composite graft survival along with the long-term morbidity. A retrospective review of all patients <16 years who underwent composite graft replacement of an amputated fingertip was performed. Long-term morbidity was evaluated through a standardized parental questionnaire. A total of 120 patients were identified, of whom 97 were eligible for inclusion. Parental questionnaires were completed for 42 (43%) patients. There was a 10% complete and 34% partial graft survival rate. Patients aged ⩽4 were significantly more likely to have complete graft take than those >4. Of the patients, 17% developed post-operative complications; 48% of patients reported a hook-nail deformity and 17% reported cold intolerance. Only 5% of patients reported any functional difficulties long term. The rate of complete composite graft survival in a paediatric population is low, although the long-term function of these patients is good. LEVEL OF EVIDENCE: 3.

Reanimation of the brow and eye in facial paralysis: Review of the literature and personal algorithmic approach.

Facial palsy patients suffer an array of problems ranging from functional to psychological issues. With regard to the eye, lacrimation, lagophthalmos and the inability to spontaneously blink are the main symptoms and if left untreated can compromise the cornea and vision. There are a multitude of treatment modalities available and the surgeon has the challenging prospect of choosing the correct intervention to yield the best outcome for a patient. The accurate assessment of the eye in facial paralysis is described and by approaching the brow and the eye separately the treatment options and indications are discussed having been broken down into static and dynamic modalities. Based on our unit's experience of more than 35 years and 1000 cases of facial palsy, we have developed a detailed approach to help manage these patients optimally. The aim of this article is to provide the reader with a systematic algorithm that can be used when consulting a patient with eye problems associated with facial palsy.

Awareness of and attitudes towards skin-cancer prevention: a survey of patients in the UK presenting to their general practice.

BACKGROUND: The rate of skin cancer in the UK continues to rise. AIM: To identify the current knowledge and awareness of and attitudes towards the avoidance of skin cancer among a variety of patient groups to aid the design of future UK sun-awareness campaigns. METHODS: Patients aged ≥ 16 years presenting to one of three general practices (two urban, one rural) in the UK during the period 1 June to 31 July 2010 were invited to complete a paper-based questionnaire collecting data on their sun-exposure behaviour, with significance assessed by the Fisher exact test. RESULTS: In total, 1000 patients (327 male, 673 female) responded. Those aged 16-30 years were significantly more likely to get sunburn than the older age groups. The understanding of ways to avoid skin cancer in 16-30-year-olds was also rated as significantly worse than that of all other age groups. Compared with the older age groups, this group was also less likely to avoid midday sun exposure (P < 0.001) or to cover up in the sun (P < 0.001). There was no significant difference in sun exposure or frequency of sunburn between those with or without a personal or family history of skin cancer. Those with a positive history were more likely to wear sunscreen (P < 0.01), but not to cover up or avoid the midday sun. CONCLUSIONS: UK-based sun-awareness programmes should target younger age groups. In addition, healthcare professionals must ensure that opportunities are taken to reinforce the importance of safe sun exposure for patients presenting with skin cancer.

Two-color thermal detector with thermal chopping for infrared focal-plane arrays.

Micromachined thermal infrared (IR) detectors are emerging into the marketplace to provide high-performance thermal (IR) imagery at low cost. Thermal detectors can be improved when a tunable wavelength response is provided and when a thermal chopper is incorporated into the detector by use of microelectromechanical (MEM) elements. Most thermal detectors require a chopper, continuous synchronous chopping in the case of pyroelectric detectors, or asynchronous chopping in the case of staring microbolometers. Mechanical choppers are bulky and costly. We present the fundamental principles of micromachined thermal detectors that possess tunable wavelength or color response and a technique for thermal chopping. A micromirror, switching between two spatial positions under the detector, provides a response to two wavelength windows by tuning the optical resonant cavity. The image can then be integrated at the readout level to achieve a multicolor IR picture. A thermal MEM chopper can be used instead of a mechanical chopper to maintain the same video frame rate and to allow for an interlaced resetting of staring thermal arrays. Unlike the second generation of uncooled IR arrays, the actual temperature of objects can be obtained by a comparison of the response in two wavelength windows, in addition to the direct measurement of IR power that they radiate in the entire 8-14-microm spectral region.

Comparison of nonsteroidal anti-inflammatory drugs, ibuprofen and flurbiprofen, with methylprednisolone and placebo for acute pain, swelling, and trismus.

Pain, swelling, loss of function, and hyperthermia are acute postoperative sequelae of inflammation due to tissue injury during surgical procedures. Pharmacologic strategies for minimizing the clinical manifestations of surgical trauma are often directed toward blocking the formation or inhibiting the effects of the biochemical mediators of acute inflammation. This study compared two nonsteroidal anti-inflammatory drugs (NSAIDs), flurbiprofen and ibuprofen, with a prototype glucocorticoid, methylprednisolone, in two replicate placebo-controlled studies for suppression of inflammation due to the surgical removal of impacted third molars. The results indicate that NSAIDs produce greater initial analgesia than do steroids, whereas steroids result in greater suppression of swelling and less loss of function. Examination of the pooled data from the two studies indicates that NSAID pretreatment results in a modest suppression of swelling in comparison with placebo. These data suggest that the acute analgesic effects of NSAIDs in the oral surgery model are due to suppression of a nociceptive process, presumably prostaglandin formation, rather than a generalized anti-inflammatory effect.

Occurrence of multiple dentigerous cysts in a patient with the Maroteaux-Lamy syndrome (mucopolysaccharidosis, type VI).

The mucopolysaccharidoses (MPS) are a group of genetic lysosomal storage diseases. These diseases result from a defect in specific lysosomal enzymes required for the degradation of specific mucopolysaccharides. These incompletely degraded saccharides accumulate in tissues and are excreted in the urine. A general characteristic of these diseases is dysostosis multiplex. Dental complications can be severe and include unerupted dentition, dentigerous cystlike follicles, malocclusions, condylar defects, and gingival hyperplasia. This report examines multiple dentigerous cysts in a patient with a deficiency in N-acetylgalactosamine-4-sulfatase, Maroteaux-Lamy syndrome (MPS VI). The inability to hydrolyze the sulfate group from N-acetylgalactosamine-4-sulfate residue of dermatan sulfate due to a deficiency in this enzyme results in the accumulation of dermatan sulfate in tissues and its excretion in the urine. Examination of dentigerous cyst fluid revealed glycosaminoglycan content of 397 microgram per milliliter. Compositional analyses revealed 60% hyaluronic acid, 30% chondroitin 4- and -6-sulfate, and only 10% dermatan sulfate. This was consistent with dentigerous cyst fluid derived from persons without mucopolysaccharide-storage disorders but distinctly different from glycosaminoglycans assayed from other body fluids of this patient.

Comparison of conorphone, a mixed agonist-antagonist analgesic, to codeine for postoperative dental pain.

The analgesic efficacy of two doses of conorphone (20 and 40 mg), a mixed agonist-antagonist analgesic, were compared to two doses of codeine for postoperative pain in the oral surgery model. Each subject received 2 of the 4 possible treatment at two separate sessions in an incomplete block, single crossover design. Both doses of conorphone and the 60 mg dose of codeine were superior to 30 mg of codeine for the various indices of analgesic activity. The 40 mg dose of conorphone resulted in a high incidence of side effects (25/30 subjects) such as drowsiness, dizziness, nausea and vomiting. The low dose of conorphone resulted in side effects similar to 60 mg of codeine with the exception of a greater incidence of drowsiness. These data suggest that while 40 mg of conorphone may not be well tolerated clinically, 20 mg of conorphone may be an alternative to 60 mg of codeine for postoperative pain.

Evaluation by thoracic impedance cardiography of diazepam, placebo, and two drug combinations for intravenous sedation of dental outpatients.

The cardiovascular and respiratory effects of three common intravenous premedicants were examined noninvasively in a population of 20 dental outpatients scheduled for surgical removal of third-molars. Two third molars from one side of the mouth were removed at each appointment. Group 1 received a diazepam titration (mean dose = 25.6 mgs) at one appointment and placebo at the other appointment. Group 2 received a combination of diazepam (12.5 mg), fentanyl (0.1 mg), and methohexital (mean dose = 18.0 mg) at one appointment and the combination of diazepam (15.0 mg) and methohexital (mean dose = 27.0 mg) at the other appointment. Noninvasive measurement of cardiac output revealed little change during intravenous drug administration, but a significant increase was seen in all groups following local anesthesia and during surgery. Heart rate was elevated and stroke volume decreased during administration of the two-drug combinations. Oxygen saturation was greatly decreased following the combination of diazepam, fentanyl, and methohexital. These findings indicate that the combination of diazepam, fentanyl, and methohexital results in decreased oxygen saturation, a transient decrease in stroke volume, and an elevated heart rate when used as an intravenous premedicant for dental outpatients.

Cardiovascular and respiratory response to intravenous diazepam, fentanyl, and methohexital in dental outpatients.

The cardiovascular and respiratory responses to a combination of diazepam and methohexital (D-M) were compared to those from a combination of diazepam, fentanyl, and methohexital (D-F-M). Both caused significant tachycardia after administration and during surgery. The D-F-M combination caused a significant decrease in both respiration rate and oxygen saturation. Surgeons preferred this combination for the production of sedation and cooperation of patients. Comparison of efficacy to toxicity suggests that the increase in patient cooperation for the D-F-M combination is at the expense of respiratory depression. The use of oxygen supplementation and monitoring of respiration is recommended during the use of the combination.

Thrombophlebitis after intravenous use of anesthesia and sedation: its incidence and natural history.

A number of technical and clinical conditions reportedly associated with diazepam-related thrombophlebitis were investigated. Diazepam alone and in combination with fentanyl and methohexital was administered intravenously to 519 healthy, predominantly young adult patients undergoing routine oral surgery for removal of third molars. Indirect evidence is provided to show that two slightly different vasculopathies are involved: thrombophlebitis, in which pain and induration are both present but in which there is a slight delay in the time of inception of the condition; and phlebothrombosis, in which the reaction is almost immediate but pain is not significant and induration of the vein is the predominant feature. The overall incidence was 2.3% for thrombophlebitis and 9.8% for phlebothrombosis. There were four significant variables associated with phlebothrombosis: use of tobacco, use of oral contraceptives, multiple injections of diazepam, and pain during injection. The only significant variable associated with thrombophlebitis was the site of injection.

The relationship of smoking to localized osteitis.

The relationship between smoking and localized osteitis was studied in 200 patients who had 400 mandibular third molars removed. Information on how much patients smoked each day and whether cigaretts, cigars, or a pipe was smoked, as well as the postoperative smoking habits of each patient, was recorded. Results indicated that there is a signficant difference in the incidence of postoperative localized osteitis at extraction sites of mandibular third molars between smokers and nonsmokers; smoking after extraction caused a definite increase in the incidence of localized osteitis.

Comparison of recovery tests after intravenous sedation with diazepam-methohexital and diazepam-methohexital and fentanyl.

A model for the assessment of recovery to street fitness from two commonly used techniques for intravenous sedation is described. Well-known psychometric research methods and simple paper-and-pencil tests that could be given by interested clinicians were used. The speed of recovery from diazepam-methohexital, and diazepam-methohexital and fentanyl (with naloxine reversal), did not differ significantly. Psychomotor skills were recovered before both perceptual and cognitive functions. Two simple paper-and-pencil tests easily identified perceptual and cognitive deficits at least three hours postoperatively.

Predisposing and operative factors: effect on the incidence of localized osteitis in mandibular third-molar surgery.

Five hundred and four bilateral mandibular third-molar extraction sites were examined postoperatively for localized osteitis. All sites received a mechanical lavage of either 350 ml, or 175 ml. of sterile normal saline solution. No significant differences were observed relative to the effect of lavage volume on the incidence of iocalized osteitis. A preoperative antimicrobial mouthrinse of chloramine-T (sodium-p-toluene sulfonchloramide) was also used by one half of the patients. Although only slight differences were noted in healing with the different lavage volumes of the chloramine-T, certain predisposing factors contributed significant differences.

Conscious sedation with intravenous drugs: a study of amnesia.

A comparison of amnesia that is produced by two intravenous sedation techniques commonly used to reduce anxiety in ambulatory oral surgery patients showed that both techniques induce high levels of safe, predictable amnesia. More than 200 patients undergoing surgical extraction of third molars were asked to verbally identify visual and cutaneous-tactile stimuli intraoperatively. The patients responded via written questionnaires at the postoperative interview sessions. No retrograde amnesia was observed. Complete amnesia was attained for the local anesthetic injections. Amnesia for visual stimuli was significantly lower than for cutaneous-tactile stimuli. No significant differences in amnesia were observed between the two drug combinations studied.