The Management of Trigonoscaphocephaly as a Result of Combined Metopic and Sagittal Synostosis.

BACKGROUND: The combination of sagittal and metopic synostosis is rare, resulting in a scaphocephalic shape, but with an absence of frontal bossing and therefore varying degrees of trigonocephaly and occipital prominence. Treatment is primarily surgical, with a combination of procedures to address both the scaphocephaly and trigonocephaly required involving multiple operations. The authors discuss their experience of treating combined trigonoscaphocephaly in a single-stage procedure and propose a management strategy based on the severity of the presenting deformity. METHODS: The Oxford Craniofacial Unit database was searched from inception in October of 2004 to August of 2013 to identify all patients with combined sagittal and metopic synostosis. Case notes were then manually searched to identify those patients who had true trigonoscaphocephaly. RESULTS: Of 2856 patients in the authors' database, a total of nine were identified as having had true trigonoscaphocephaly. Seven of these patients underwent a combined single-stage procedure with an average cephalic index of 68.7 percent preoperatively and 80.3 percent postoperatively. CONCLUSIONS: Management of trigonoscaphocephaly has been traditionally performed by multiple, staged surgical procedures. The authors propose that it can instead be managed in a single surgical procedure, with the choice of procedure determined by the severity of the deformity. If the deformity is mild to moderate with no occipital bullet, a combined fronto-orbital advancement remodeling and subtotal calvarial remodeling can be performed; however, if there is an occipital bullet, the authors propose the combination of fronto-orbital advancement remodeling and total calvarial remodeling performed in one operation with the patient turned from prone to supine intraoperatively. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Flexible cystoscopy a valuable diagnostic tool for lower urinary tract pathology.

OBJECTIVE: To assess the role of flexible cystoscopy in the diagnosis of lower urinary tract pathologies and its suitability as a routine diagnostic protocol in outdoor patients. METHODS: The quasi-experimental study was conducted at the Urology Department, Pakistan Ordinance Factory Hospital, Wah Cantt., from June 2009 to June 2010. All adult patients presenting with lower urinary tract symptoms to outdoor department were included on the basis of universal non-probability sampling technique. Cystoscopy was performed as a clinic-based procedure without sedation. SPSS 17 was used for data analysis. RESULTS: Of the 1500 patients in the study, 810(54%) were females and 690(46%) were male. Lower urinary tract pathologies were found in 480(32%) patients. The most common pathology among males was enlarged prostate in 127(8.4%) patients. Among females, urethral stenosis was the most common pathology in 57(3.8%) patients. Transitional cell carcinoma was seen in 57(3.8%) patients having haematuria with inconclusive ultrasound and intravenous urography. All patients tolerated the procedure well. CONCLUSIONS: Flexible cystoscopy is an effective, well-tolerated and easy way of detecting lower urinary tract pathologies among outpatients.

Congenital alveolar synechiae with cleft palate.

Congential maxillomandibular fusion or jaw adhesions is a rare entity. It is often associated with other congenital anomalies like cleft palate and is characterized by restricted mouth opening. This unusual presentation of congenital alveolar synechiae is highlighted in a 15 days old baby boy. Under inhalational anaesthesia his fibrocartilagenous adhesions were excised and endotracheal tube was then placed. Good recovery without any residual scars or adhesions and a 25 mm mouth opening was achieved.

Schwannoma of the brachial plexus; report of two cases involving the C7 root.

Brachial plexus schwannomas are rare tumors. They are benign nerve sheath tumors and only about 5% of Schwannoma arise from the brachial plexus. They pose a great challenge to surgeons due to their rare occurrence and complex anatomical location. We present two cases who presented with a supraclavicular swelling, that were proven to be schwannoma on histopathology.

A developing world experience with distal foot amputations for diabetic limb salvage.

OBJECTIVES: To evaluate the functional outcome, morbidity, and viability of foot salvage in diabetic patients. MATERIALS AND METHODS: This prospective case series was conducted from March 2007 to December 2012 at the department of surgery Pakistan Ordnance Factories Hospital, Wah Cantt, Pakistan. 123 males and 26 female patients were included in the study. All the patients were treated after getting admitted in the hospital and wounds were managed with daily dressings, nursing care and debridement of necrotic tissue with adequate antibiotic coverage. RESULTS: In total, 149 patients (mean age: 56±7.52 years) with 171 amputations were included in the study. The mean duration of diabetes mellitus (DM) was 9±4.43 years. Ninety-seven percent of the patients were diagnosed with type 2 DM. Wound debridement was performed under general anesthesia in 48 (33.2%) patients, whereas local anesthesia was used for the rest of the patients after having good glycemic control and improvement in general health. The most common pathogen isolated from the infected wounds was Staphylococcus aureus in approximately 46% cases. Regarding the types of amputation, partial toe amputation was performed in 21 (12.2%) cases, second-toe amputation in 60 (35%) cases, hallux amputation in 41 (24%) cases, multiple toe amputations in 29 (17%) cases, bilateral feet involvement was observed in 16 (9.3%) cases, and transmetatarsal amputation was performed in 4 (2.3%) cases. The wounds healed well except in 19 cases where amputation had to be revised to a more proximal level. Thirty-nine patients died during the study period: 3 died of wound-related complications and 36 died of systemic complications. CONCLUSION: With the ever-increasing epidemic of DM, the number of patients with diabetic foot ulcers has also significantly risen. Early surgical management with good glycemic control and foot care with close monitoring can decrease amputations and thus foot salvage can be successfully achieved.

Acute appendicitis in the elderly; Pakistan Ordnance Factories Hospital, Wah Cantt. experience.

OBJECTIVE: To review the clinical experience in diagnosis, management and outcome of elderly patients presenting with acute appendicitis at the Pakistan Ordnance Factories Hospital, Wah Cantt. METHODS: All patients of age 60 years and above presenting with abdominal pain were prospectively reviewed. Patients who were diagnosed as acute appendicitis were included in this case series which was conducted at Pakistan Ordnance Factories Hospital, Wah Cantt, from December 2006 to May 2008. Detailed history and clinical examination, co-morbid conditions, clinical manifestations and post-operative outcome were recorded. The diagnosis was made on the basis of history and clinical examination. The diagnosis was also confirmed on histopathology. All the details were recorded on a questionnaire. Approval from our own ethical committee was taken. SPSS 16 was used for statistical analysis. RESULTS: A total of 75 patients presented with acute abdominal pain. Of them 42 were admitted with tenderness in right iliac fossa and lower abdomen. Finally, 36 (48%) were diagnosed as acute appendicitis and were included in the study. There were 20(56%) men and 16(44%) women with age range of 60 to 78 years and a mean age of 65.5 +/- 4.2 years. Associated illness occurred in 25(70%) patients. Symptoms included abdominal pain in 32(90%), nausea in 17(48%), and emesis in 9(25%) patients. Signs included right lower quadrant tenderness in 26(74%) patients, leukocytosis in 17(47.2%), and fever (>99'F) in 11(30.5%). Laparoscopy was used as an important diagnostic as well as therapeutic modality. Of the patients, 9 (25%) had gangrenous appendix, while 12 (33.3%) had perforated appendix. A total of 12 (33.4%) patients developed complications. Hospital stay was considerably increased in patients with a delayed diagnosis (5-7 days), perforations (5-9 days) and postoperative complications (5-15 days). One patient, a known case of ischaemic heart disease, died of cardiopulmonary arrest. CONCLUSION: Acute appendicitis needs to be considered in the differential diagnosis of all patients with abdominal pain. A high index of suspicion is necessary to guard against mis-diagnosis, especially in the elderly. Delays in presentation and diagnosis are associated with higher rates of perforation and, hence, higher morbidity. Repeated clinical examination, a high index of suspicion and urgent investigations are necessary for a correct and rapid diagnosis.

Fournier's gangrene--an experience in POF Hospital, Wah Cantt.

OBJECTIVE: To share our experience of treating patients with Fournier's Gangrene and their outcomes at POF Hospital, Wah Cantt. METHODS: A descriptive study was conducted at the Urology Department, POF Hospital, Wah Cantt from October 2006 to March 2007. A total of 22 patients, all men with ages ranging from 30-75 years, were included in the study. The diagnosis was established on the basis of history and clinical examination. The gangrenous patches with crepitus due to subcutaneous collection of seropurulent fluid was a diagnostic sign. RESULTS: A total of 22 patients were included in the study. All patients were men of ages ranging from 30 to 75 years. Of the 22 patients, 10 were diabetic, 02 had history of CVA and 10 had no co-morbids. In 10 patients, genitals and anterior abdominal wall was involved whereas 04 patients had genital and perineal involvement. In 05 patients only genitals were involved whereas 03 patients presented with scortal infection. All patients received broad spectrum antibiotics and underwent regular debridement. Secondary suturing was done in 13 patients, 07 patients needed skin grafting whereas orchidectomy was done in 02 patients. CONCLUSION: Fournier's gangrene is an uncommon but life threatening condition with high associated mortality and morbidity. Early diagnosis and treatment decrease the morbidity and mortality of this life threatening condition.