Standardised method of selecting surgical approaches to benign parapharyngeal space tumours, based on pre-operative images.

Many approaches to the parapharyngeal space have been reported. However, few reports describe parapharyngeal space tumours and the best surgical approach to these tumours. We retrospectively examined the surgical approaches we used to resect 22 parapharyngeal space tumours. In order to determine the best surgical approach for each tumour, we first subdivided the parapharyngeal space into six compartments, based on anatomical landmarks seen on computed tomography and/or magnetic resonance imaging scans. We then determined the location of each tumour relative to these six parapharyngeal space compartments. In our series of cases, we found that large tumours spanning the superior portion of the parapharyngeal space could be completely removed through a skull base approach. To remove a large tumour in the middle and inferior portion of the parapharyngeal space, a transparotid approach was the most suitable. Finally, a tumour in the inferior portion of the parapharyngeal space was best accessed through a transcervical approach.

Association of dietary habits with symptoms of temporomandibular disorders in Bangladeshi adolescents.

The prevalences of signs and symptoms of temporomandibular disorder (TMD) in Bangladeshi adolescents and their associations with intake of various hard food items were investigated. A group of 1200 randomly selected high school students aged 12-17 years from three communities (rural, semi-urban and urban) completed a questionnaire on dietary habits and presence of TMD symptoms and were examined clinically. In bivariate analysis, no significant relationship was observed between TMD symptoms and eating of hard foods. However, in logistic regression analysis, clicking showed a significant correlation with consumption of hard vegetable and fruits more than three times per week (P < 0.05). A statistically significant correlation was also observed between consumption of all hard food items (at least one item in each of the four categories of hard food) more than 12 times per week and pain in the temporomandibular joint (TMJ) (P < 0.05). A positive association was found between pain in the TMJ and older age (15-17 years) (P < 0.001). The prevalence of pain in the TMJ was significantly higher in males (P < 0.01). Prevalences of clicking and pain in the TMJ were significantly higher in subjects living in a rural area than in subjects living in an urban area (P < 0.01 and P < 0.01, respectively). Subjects having one or more decayed, missing and filled teeth (DMFT) showed significantly higher prevalences of clicking (P < 0.01) and restricted mouth opening (P < 0.01). The results suggest that prevalence of TMD symptoms are related to prolonged consumption of hard food items.

Extended sigmoid-shaped free jejunal patch for reconstruction of the oral base and pharynx after total glossectomy with laryngectomy.

The procedure for reconstruction of the extensive defect after total glossectomy with total laryngectomy has not been standardised so far. We have devised a new method in which a free jejunal patch is extended to a sigmoid-shaped form specifically optimised for reconstruction of the defect that consists of the entire floor of the mouth and the antero-lateral walls of the pharyngoesophageal tract. After a jejunal segment of about 40 cm has been longitudinally opened in full length, the proximal quarter is folded parallel to the second quarter, which is then folded parallel to the third quarter in the opposite direction, to be laid out in a S-shaped form. Side-by-side sutures are then placed along each of the folded borders and corrective trimming is done to fit the defect. This widely extended patch replaces the whole oral base, whereas the remaining distal quarter of the patch replaces the antero-lateral walls of the hypopharynx and cervical esophagus. Because of the encouraging functional results with satisfactory restoration of oral alimentation, this procedure is considered to be ideal for the reconstruction of the defect which follows total glossectomy with total laryngectomy.

Surgical results of skull base surgery for the treatment of head and neck malignancies involving skull base: multi-institutional studies on 143 cases in Japan.

We analyzed 143 cases of skull base surgery collected from the eight institutions of the Study Group supported by the Grant-in-Aid for Cancer Research from the Ministry of Health and Welfare of Japan. Histologically, the most common type was squamous cell carcinoma (n = 78), which was followed by olfactory neuroblastoma (n = 16) and adenoid cystic carcinoma (n = 16). The most frequent surgical approach was frontal craniotomy (n = 66), followed by front-temporal craniotomy (n = 54) and infratemporal fossa approach (n = 8). For repair of dura matter, fascia lata was used in 37 cases. galeopericranial flap in 35 and temporal muscle fascia in 16. The 5-year survival rate by Kaplan-Meier method of nose and paranasal sinus carcinoma (n = 119) was 48%. As for histological classification, the survival rates were both 65%) in adenoid cystic carcinoma (n = 12) and bone soft tissue malignancy (n = 10), 62% in olfactory neuroblastoma (n = 16), 46% in squamous cell carcinoma (n = 62) and 33% in adenocarcinoma (n = 11). All the three cases of malignant melanoma died within 1 year, so we considered skull base surgery to be contraindicated for this disease. Complications were observed in 62 out of the 143 cases (43%); local infection was most frequent in 29 cases. liquorrhea in 18, abscess in 16, necrosis of the flap and meningitis in ten cases, DIC in four, rupture of the internal carotid artery in two and cerebral thrombosis in one. Death caused directly by surgery was in ten cases (7%). It is important that a multi-center registry be maintained to have a large enough database for comparison of results, and prognosis for each histological entity and further define the role of multidisciplinary treatment.

False-positive magnetic resonance image in the diagnosis of small acoustic neuroma.

A patient presented with sudden hearing loss on her first visit to our department. Gadolinium-DTPA-enhanced magnetic resonance imaging (MRI) of the posterior cranial fossa portrayed an intracanalicular tumour image (2-3 mm), and the pure tone average (PTA) and speech discrimination score (SDS) values were 65 dB and 60 per cent, respectively. Surgical intervention to remove the suspected tumour was scheduled by the translabyrinthine approach. Intracanalicular observations by the retrolabyrinthine approach revealed limited oedema on the inferior vestibular nerve with vascular dilation. The tumour image disappeared two years after the operation. Surgical findings and the post-operative course advocate that gadolinium-DTPA-enriched MRI image of an intracanalicular lesion such as arachnoiditis might produce a false-positive result.

Use of vertical median forehead flap in the reconstruction of the anterior skull base: report of two cases.

Improvements in reconstruction of the skull base have made craniofacial surgery safe. Reconstruction of the anterior skull base must provide a seal between the cranial cavity and upper respiratory tract, as well as offer structural support for the brain. A wide variety of local flaps have been designed. The choice of flap in individual cases depends on the location and size of the defect. We report a reconstructive technique for the anterior skull base with vertical median forehead flaps which we used to treat two patients, one patient with adenocarcinoma and the other with leiomyosarcoma. Both were lesions of the ethmoid sinuses and nasal cavity.

Pigmented villonodular synovitis of the temporomandibular joint.

Pigmented villonodular synovitis is a proliferative disorder affecting the synovium and may be an aggressive local process with bone destruction and invasion of contiguous structures. Involvement of the temporomandibular joint is very rare. We report a rare case of pigmented villonodular synovitis of the temporomandibular joint that invaded the infratemporal fossa with bone destruction of the mandibular condyle. Magnetic resonance imaging was effective in delineating the extent of the lesion in the infratemporal fossa. Fine-needle aspiration cytology showed multinucleated giant cells and round or spindle-shaped cells with hemosiderin deposits. The tumor was resected en bloc through a combined temporocervical and infratemporal fossa approach. The postoperative histological diagnosis was a variant of pigmented villonodular synovitis. Fine-needle aspiration cytology and magnetic resonance imaging proved to be useful in the preoperative diagnosis of pigmented villonodular synovitis of the temporomandibular joint and in the preoperative planning that is required to obtain adequate surgical margins.

Rhinogenous optic neuritis with drastic diurnal variation of visual function.

We report a case of rhinogenous optic neuritis in a 50-year-old man demonstrating drastic diurnal variation in visual function. His left vision was 20/15 in the morning, which gradually decreased to counting fingers at night. Pupillary reaction and visual field showed the same fluctuation as vision. Complete remission of visual symptoms was achieved after endonasal ethmoid sinusotomy.

[Skull base surgery using the degloving technique--an approach without facial scarring].

Skull base surgery has been performed in 16 cases for en bloc resection of the nasal cavity and paranasal sinus carcinoma invading the anterior and middle skull base in our department. The surgical approach to skull base surgery is mainly a combined craniofacial approach, which includes craniotomy via a coronal incision intracranially and a transfacial or transoral approach extracranially. The direct transfacial approaches, such as lateral rhinotomy, Weber-Furguson incision, and midfacial split, resultin facial scarring. The midface degloving procedure was reported by Casson in 1974. This method can expose the midfacial skeleton by lifting the soft tissue from the face through an intraoral approach without external scarring. The authors have modified Casson's facial degloving technique and applied it to skull base surgery. The entire cranium and facial skeleton can be extensively degloved by using coronal, gingival and conjunctival incisions. Then, en bloc resection of the craniofacial compound segment can be accomplished through this degloving approach without external scarring of the face in anterior and middle skull base surgery. The authors have performed this procedure in 2 cases, and proved it to be an extremely valuable technique, displaying excellent cosmetic and functional results with minimal complications.

[Low-dose MTX(methotrexate) pulse therapy in a patient with putsulotic-arthro-osteitis (PAO) accompanied with Basedow's disease].

A 62-year-old woman, who had suffered from putsulosis palmaris et plantaris for about two years, was admitted to our hospital due to lumbago, sweating and palpitation. On the basis of physical and endocrinological examinations, she was diagnosed as Basedow's disease. X-ray findings revealed ossification in the left costo-clavicular joints, and characteristic syndesmophytes of PAO in vertebral bodies. These lesions were followed by high accumulation of 99mTc in bone scintigrams. PAO is considered to be in a category of seronegative spondylarthropathy or rheumatic disease. Previous reports of PAO accompanied with autoimmune diseases are few. The association of PAO and Basedow's disease has not been reported. As PAO in this case was refractory to conventional therapies, low-dose MTX pulse therapy(oral 7.5mg/day administration on every week) was initiated. MTX markedly improved both putsulotic palmaris et plantalis and PAO.

Cutaneous malignant lymphoma in an infant.

A case of cutaneous malignant lymphoma in a 7-month-old infant is described. The skin was the only apparent organ involved. Immunophenotypic studies revealed that the infiltrate was positive for B4 (CD19), J5 (CD10), and cytoplasmic mu chain, and lambda chain, but negative for B1 (CD20). The significance of these findings is discussed. We believed the tumor was of B-cell origin. The reported cases of cutaneous malignant lymphoma in infancy are briefly reviewed.

[Clinical applications of three-dimensional CT images for diseases of the anterior and middle cranial base].

UNLABELLED: CT scanning has made significant contributions to the diagnostic, therapeutic and prognostic aspects for the managements of the lesions in the paranasal sinuses and the orbit. The current availability of 3-D imaging reformatted from CT scans has added a new dimension to anatomic investigations and pre- and postoperative evaluations of the skull base structures. Twenty-five craniomaxillofacial 3-D CT examinations were performed during the year of the 1989 for the purpose of the diagnosis of the pathology, surgical planning and postoperative evaluation in reconstructive surgery of the skull base. RESULTS: 1. The use of 3-D CT improves the display of the location and volume of the pathology and affords the accurate therapeutic and surgical planning. 2. Preoperative 3-D CT imagings are useful for the display of the bony erosion of the skull base. Stereotaxic 3-D CT imagings are particularly appreciated in the diagnostic aspects of the management of the pathology. 3. In the reconstructive surgery of the skull base, an accurate prefabricated model of the bony defect can be made to aid the surgery. 4. A major limitation of 3-D CT is its inability to reconstruct the pathology of soft tissues with the same fidelity afforded bony structures.

[Comparative study on cefmetazole and cefazolin in the treatment of suppurative otitis media].

Cefmetazole (CMZ) was compared to cefazolin (CEZ) for efficacy and safety in the treatment of suppurative otitis media (including acute otitis media and chronic otitis media in acute aggravating stage) under well controlled clinical trials. The therapeutic effects were analyzed statistically in 172 patients (82 administered CMZ, 90 administered CEZ). The adverse reactions were also analyzed statistically in 199 patients (CMZ 99, CEZ 100) in whom the judgement was possible. 1. The efficacy rate of CMZ (72.3% for good to excellent response) was assessed by physicians in charge to be similar to that of CEZ (59.3%). This was the same being assessed by the committee, too (CMZ 64.6%, CEZ 56.7%). 2. When patients were classified into 2 groups (acute otitis media, chronic otitis media in acute aggravating stage) with respect to diagnosis, statistically significant difference in clinical efficacy assessed by physicians in charge was observed in the cases with chronic otitis media (CMZ, CEZ). In addition, the improvements of flares on the drum membrane and the mucous membrane of eardrum were significantly better in the CMZ group than in the CEZ group. 3. Bacteriologically, 16 cases (19.8%) of S. aureus were resistant to CEZ, while only 1 case (1.2%) to CMZ. CMZ was judged to be effective in 5 of the 6 cases in which CEZ-resistant strains were detected. 4. Side effects were found in 2 cases (2.0%) treated with CMZ: one complained of retching and abdominal pain and the other developed skin eruption. On the other hand, only 1 case (1.0%) developed skin eruption in the CEZ group. These results suggest that CMZ is a new antibiotic agent which is highly valuable in the treatment of suppurative otitis media.

Epidermal origin of the amyloid in localized cutaneous amyloidosis.

A case of localized cutaneous amyloidosis which developed after a lichen planus-like skin reaction is reported. The amyloid consisted of amyloid fibrils enveloped by heparan sulphate granules. These amyloid fibrils reacted to anti-human keratin antibody, indicating an epidermal origin for the fibrils.

[Acute generalized pustular bacterid: a variety of pustular Andrew's bacterid]. / Akutes generalisiertes pustulösen Bakterid: Eine Abart des pustulöses Bakterid andrews.

Eight cases of acute pustular bacterid preceded by angina of beta-streptococcal origin are summarized. Although this disease appears to be an acute type of pustular bacterid Andrews, the elevated antistreptolysin titers and the histological features of vasculitis with perivascular deposits of C3 and IgM seem to be remarkable findings. One of the patients' skin symptoms were complicated by a glomerulonephritis. The skin lesions improved rapidly after systemic administration of glucocorticosteroids.