Low-dose warfarin maternal anticoagulation and fetal warfarin syndrome.

Fetuses exposed to warfarin during pregnancy are at an increased risk of developing an embryopathy known as fetal warfarin syndrome or warfarin embryopathy. The most consistent anomalies are nasal hypoplasia and stippling of vertebrae or bony epiphyses. Management of pregnant patients on anticoagulation is challenging. Current guidelines suggest the use of warfarin if the therapeutic dose is ≤5 mg/day. We report the case of a newborn with signs of warfarin embryopathy born from a mother anticoagulated with warfarin due to mechanical mitral and aortic heart valves. Warfarin was required at the dose of 5 mg/day and was withheld without medical advice between weeks 8 and 10 with no other anticoagulation. The newborn presented with skeletal abnormalities and a ventricular septal defect that have not required specific treatment during the first year of life. Low-dose warfarin is associated with a lower risk of warfarin-related fetopathy but the risk of embryopathy seems unchanged.

Intubación submental: experiencia con 30 casos / Submental intubation: experience with 30 cases

Introducción. Cuando un paciente se encuentra politraumatizado, involucrando fracturas serias en la región maxilofacial, así como en la base del cráneo, se opta por realizar una traqueostomía con el fin de permitir un abordaje simultáneo para los diferentes tercios faciales afectados. La intubación submental ofrece una alternativa a dicho manejo de la vía aérea, significando menor riesgo para el paciente por su seguridad y versatilidad en el manejo de las fracturas nasales y el establecimiento de la oclusión. Materiales. Un total de 30 pacientes con diferente afección de los tercios faciales (superior, medio e inferior) fueron tratados por nuestro equipo, llevando a cabo una intubación submental para mantener la vía aérea. Las fracturas afectaban los huesos nasales y la oclusión dentaria. Resultados. En todos los casos se logró una adecuada reducción de las fracturas nasales y obtención de la oclusión dental correcta, sin presentar eventualidades durante o después de la intubación mencionada. Conclusiones. La intubación submental es una buena alternativa para poder tratar adecuadamente a los pacientes politraumatizados con afección de la cavidad nasal y oral sin tener que realizar una traqueostomía en casos que no la requieran (AU)

Introduction. When a patient has multiple injuries, involving serious fractures in the maxillofacial region and base of skull, a tracheostomy is often performed to approach the different affected facial thirds simultaneously. Submental intubation offers an alternative to this type of airway management, involving a decreased risk for the patient due to its safety and versatility in treating nasal fractures and re-establishment of dental occlusion. Materials. A total of 30 patients with different degrees of involvement of the facial thirds (superior, middle and inferior) were treated by our team, performing a submental intubation to maintain the airway. These fractures affected nasal bones and dental occlusion. Results. In all cases we accomplished an adequate reduction of nasal fractures and obtained an accurate dental occlusion, with no incidents during or after this intubation. Conclusions. Submental intubation is a good alternative to treat multiple injury patients who have nasal and oral cavities involvement, avoiding the use of tracheostomy in cases that do not need it (AU)

Maxillary fragment stabilization after Le Fort I fracture with 1 screw pair per plate.

PURPOSE: The aim of the present study was to determine whether plates with only 1 screw pair can be used for Le Fort I fracture management. Good postoperative results motivated the direct application of mandible fixation principles to the fractured midface region without additional experimental research. However, the amount and distribution of the forces in the midface region is different from those on the mandible. MATERIALS AND METHODS: Testing was conducted on plastic anatomic models. The validity of the experimental model was tested before the fixation techniques were compared. Standard miniplates and miniscrews were used for fixation of the maxilla. The model surface strain analysis was conducted using the noncontact object grating method, which enabled the surface strain measurement without direct influence on the measured model. RESULTS: In 2 screw pair fixation, the outer screw pair has little effect on the local strain distribution, but it lowers the contact forces along the crack. One screw pair fixation is stable enough for fixation, but it has a greater strain peak at the crack edges. CONCLUSION: Our results showed that 1 screw pair per plate was enough for stable fixation, and 2 or more screw pairs should only be used when the bone fragment at the fracture site cannot sufficiently transmit forces along the crack.

Z-shaped asymmetric hump resection and unilateral osteotomy for treatment of deviated noses.

Numerous techniques have been described to correct deviated nose deformities. This article discussed the Z-shaped asymmetric hump resection combined with unilateral osteotomy. Fifty-eight cases that we operated between 2003 and 2009 for deviated nose deformity were included in the study. In this study, septoplasty was performed in all patients, and hump was resected Z-shaped whereas osteotomy was carried out in a unilateral low to low fashion. Edema and periorbital ecchymosis were minimal on the nonosteotomy side in early postoperative period in all cases, and deviation was noted to be satisfactorily corrected in the late postoperative period. Three cases were reoperated in late stage for mucosal synechiae and 1 case for a new postoperative trauma (6.8% revision). Z-shaped asymmetric hump resection combined with unilateral osteotomy is one of the minimally traumatic methods that can safely be used to correct deviated nose.

[Rhinosurgery in children: developmental and surgical aspects of the growing nose]. / Rhinochirurgie bei Kindern: Entwicklungsphysiologische und chirurgische Aspekte der wachsenden Nase.

The anatomy of the nasal skeleton in newborns and adults are not alike. The complete cartilaginous framework of the neonatal nose becomes partly and gradually ossified during the years of growth and is more vulnerable to trauma in that period. Injury in the early youth may have large consequences for development of a nasal deformity which will increase during growth and reach its peak during and after the adolescent growth spurt. To understand more of the underlying problems of nasal malformations and their treatment (septoplasty) these items became the focus of multiple animal studies in the last 40 years. The effects of surgery on the nasal septum varied considerably, seemingly depending on which experimental animal was used. In review, however, it appeared that the very different techniques of surgery might be even more influential in this respect. Study of one of the larger series of experiments in young rabbits comprised skeletal measurements with statistical analysis and microscopic observations of the tissues. The behaviour of hyaline cartilage of the human nose appeared to be comparable to that of mammals. Cartilage, although resilient, can be easily fractured whereas its tendency to integrated healing is very low, even when the perichondrium has been saved. Also surgical procedures - like in septoplasty - may result in growth disturbances of the nasal skeleton like deviation or nasal spine. Loss of cartilage, as might occur after a septum abscess, is never completely restored despite some cartilage regeneration. In this article the many experimental studies are reviewed and compared. Still there remains a lack of real consensus in the literature concerning the developmental effects of rhinosurgry in children. Based on their observations in animals and a few clinical studies, mostly with small numbers of patients but with a long follow-up, the authors have compiled a list of guidelines to be considered before starting to perform surgery on the growing midface in children.

Evaluation of treatment modality for skeletal Class III malocclusion with labioversed upper incisors and/or protrusive maxilla: surgical movement and stability of rotational maxillary setback procedure.

The purpose of this study was to evaluate the range of surgical movement and stability of rotational maxillary setback (MXS) procedure as treatment modality for skeletal class III malocclusion with labioversed upper incisors and/or protrusive maxilla (CIII/LUI-PM). The samples consisted of 20 adult patients (mean [SD] age, 23.55 [4.30] y) who had CIII/LUI-PM and were treated with rotational MXS and mandibular setback using LeFort I osteotomy and bilateral sagittal split ramus osteotomy. The lateral cephalograms were obtained 1 week before (T0), 1 week after (T1), and 1 year after surgery (T2). The amounts of surgical movement, relapse, and stability rate of the upper central incisor (UIE), upper first molar (U6MBC), point A (A), incisive canal point, and posterior nasal spine (PNS) in relation to the reference planes were statistically analyzed. During T1 - T0, there were backward and downward movements of UIE and A, backward and upward movements of U6MBC, and upward and slight forward movements of PNS due to rotational MXS. The center of rotation of the maxilla was placed between A and the upper premolar area. During T2 - T1, skeletal landmarks showed clinically insignificant counterclockwise rotational relapse (<0.5 mm). The anteroposterior (AP) and vertical positions of skeletal landmarks were more stable than dental landmarks. The U6MBC was more stable in the vertical aspect than UIE (P < 0.01). Posterior nasal spine showed significantly higher stability rate in both vertical and AP aspects (P < 0.01, respectively), whereas UIE showed a lower value in the vertical aspect (P < 0.05). Rotational MXS procedure in cases with CIII/LUI-PM can be regarded as a stable one, especially in the vertical and AP positions of PNS. Vertical relapse in UIE should be managed with postoperative orthodontic treatment.

Maxillary protraction with and without maxillary expansion: a finite element analysis of sutural stresses.

INTRODUCTION: In this finite element study, we compared the stress patterns along the various craniofacial sutures with maxillary protraction with and without expansion. METHODS: Two 3-dimensional analytic models were developed, 1 simulating maxillary protraction and the other simulating maxillary protraction with expansion. The model consisted of 108799 10 node solid 92 elements (tetrahedron), 193633 nodes, and 580899 degrees of freedom. RESULTS: The overall stresses after maxillary protraction with maxillary expansion were significantly higher than with a facemask alone. The magnitude of stress on the craniofacial sutures with maxillary protraction alone was in the range of a few millinewtons per square millimeter, whereas, with maxillary protraction with maxillary expansion, the stresses ranged from a few newtons per square millimeter to a few hundred newtons per square millimeter. The pattern of stress distribution also differed with the 2 treatment modalities as did the sutures experiencing maximum and minimum stresses. CONCLUSIONS: The osteogenic potential of such low stresses after maxillary protraction can be questioned. High stresses generated in various craniofacial sutures after maxillary protraction with expansion are responsible for disrupting the circummaxillary sutural system and presumably facilitating the orthopedic effect of the facemask.

Maxillary expansion in customized finite element method models.

INTRODUCTION: The aims of this study were to develop a method for constructing a 3-dimensional finite-element model (FEM) of the maxilla and to evaluate the effects of transverse expansion on the status of various midpalatal sutures. METHODS: A 3-dimensional FEM of the craniofacial complex was developed by using computed-tomography images and Bionix modeling software (version 3.0, CANTIBio, Suwon, Korea). To evaluate the differences between transverse expansion forces in the solid model (maxilla without a midpalatal suture), the fused model (maxilla with suture elements), and the patent model (maxilla without suture elements), transverse expansion forces of 100 g were applied bilaterally to the maxillary first premolars and the first molars. RESULTS: The fused model expressed a stress pattern similar to that of the solid model, except for the decreased first principal stress concentration in the incisive foramen area. The patent model, however, had a unique stress pattern, with the stress translated superiorly to the nasal area. The anterior nasal spine and the central incisors moved downward and backward in both solid and fused models but moved primarily downward with a slight backward movement of the anterior nasal spine in the patent model. CONCLUSIONS: Clinical observations of maxillary expansion can be explained by different suture statuses. This efficient and customized FEM model can be used to predict craniofacial responses to biomechanics in patients.

Dynamic analysis of the effects of upper lip pressure on the asymmetry of the facial skeleton in patients with unilateral complete cleft lip and palate.

OBJECTIVE: Our purpose was to assess quantitatively the effect of increased upper-lip pressure on asymmetry of the facial bones in patients with unilateral complete lip-alveolar-palatal clefts. METHODS: We collected computed tomographic images from 16 patients with unilateral complete lip-alveolar-palatal clefts and classified them into two groups based on absence/presence of alveolar bone grafting. We categorized eight patients (9.6 +/- 2.0 years old) who had not been treated with alveolar bone grafting as the ABG(-) group and the other eight patients (9.3 +/- 1.6 years old) who had received alveolar bone grafting as the ABG(+) group. After producing a computer-aided design model for each patient, we applied a uniform load on the anterior aspects of the maxilla, alveolus, and teeth of the model to simulate the upper-lip pressure. Then we calculated the degree of distortion each model presented using the finite element method. We compared the distortion pattern between the ABG(-) and ABG(+) groups. RESULTS: In the ABG(-) patients, asymmetry of distortion between the cleft and noncleft sides was present in wide areas involving the orbit, nasal bone, piriform margin, and anterior wall of the maxillary sinus. In the ABG(+) patients, asymmetry of distortion was limited to rather small areas. CONCLUSIONS: In unilateral complete lip-alveolar-palatal clefts patients, the upper-lip pressure works to dislocate the cleft-side segment to a more posterior position than the noncleft-side segment. This finding implies that the increased lip pressure exacerbates facial asymmetry of these patients. The exacerbating effect on facial asymmetry is alleviated by alveolar bone grafting.

Sutural strain in orthopedic headgear therapy: a finite element analysis.

INTRODUCTION: The goal of this study was to analyze the strains induced in the sutures of the midface and the cranial base by headgear therapy involving orthopedic forces. Does the mechanical signal induced in the sutures sufficiently account for a growth-influencing effect? METHODS: A finite element model of the viscerocranium and the neurocranium was used. It consisted of 53,555 tetrahedral elements and 97,550 nodes. The strain induced in the sutures of the cranial base and the midface when applying orthopedic headgear forces of 5 and 10 N was computed and recorded with an interactive measurement tool. RESULTS: The magnitude and the distribution of the measured strains depended on the level and the direction of the acting force. Overall, the strain values measured at the sutures of the midface and the cranial base were moderate. The measured peak values at a load of 5 N per side were usually just below 20 microstrain irrespective of the force direction. A characteristic distribution of strain values appeared on the anatomical structures of the midface and the cranial base for each vector direction. The measurements based on the finite element method provided a good overview of the approximate magnitudes of sutural strains with orthopedic headgear therapy. The signal arriving in the sutures is apparently well below threshold, since the maximum measured strains in most sutures were about 100 fold lower than the minimal effective strain. A skeletal effect of the orthopedic headgear due to a mechanical effect on sutural growth cannot be confirmed from these results. CONCLUSIONS: The good clinical efficacy of headgear therapy with orthopedic forces is apparently based mainly on dentoalveolar effects, whereas the skeletal effect due to inhibition of sutural growth is somewhat questionable.

Silent sinus syndrome presenting as enophthalmos long after orbital trauma.

Late enophthalmos is a well-known consequence of large orbital floor fractures. In rare cases, late enophthalmos can occur after direct trauma to the maxillary ostiomeatal complex and present as silent sinus syndrome (SSS). We report two cases of SSS manifesting as enophthalmos years after facial trauma. The first patient developed SSS 4 years after a minimally displaced orbital floor fracture. The second patient had progressive enophthalmos as a result of atelectasis of the maxillary sinus years after facial trauma and surgical repair of nasal fractures. There have been two prior reports of SSS presenting after orbital trauma. Our patients differ from these prior reports in that the enophthalmos was discovered years after the initial facial trauma. In the first patient, surgery addressing the blockage of the ostiomeatal complex arrested the enophthalmos; in the second patient, it reversed the enophthalmos.

Biomechanical effects of rapid palatal expansion on the craniofacial skeleton with cleft palate: a three-dimensional finite element analysis.

OBJECTIVE: To explore the biomechanical effects of rapid palatal expansion (RPE) on the craniofacial skeleton with cleft palate. DESIGN: A finite element model of a patient's skull with cleft lip and palate (CLP) was generated using data from spiral computed tomographic (CT) scans. Finite elemental analysis (FEA) was performed to depict the physiological changes and stress distribution in craniofacial structures loaded with orthopedic forces that created 5 mm of displacement on the region of the maxillary first premolar and first molar crown. PATIENTS, PARTICIPANTS: A 14-year-old girl with left complete unilateral CLP was included in this study. INTERVENTIONS: Spiral CT was carried out prior to any treatment. MAIN OUTCOME MEASURE(S): Three-dimensional (3D) features of displacement and stress distribution were analyzed following application of transverse orthopedic force. RESULTS: Marked amount of displacement and deformation occurred in the dental region. Asymmetric displacement and deformation of UCLP under RPE were evident. The stress generated by RPE was dispersed around the cleft palate and nasal cavity, and was distributed at the buttress of the maxilla-inferior border of the nasal cavity, outboard of the orbit, and central frontal bone near the nasion. CONCLUSIONS: Application of RPE to UCLP patients induces a pyramid-like displacement of the nasomaxillary complex along with fan-like expansion of the upper dental arch. The uniqueness of RPE with UCLP, however, lies in the asymmetric expansion and dispersed stress distribution around the lateral maxilla buttress and outboard of orbit.

Changes in mitotic rate and GFAP expression in the primary olfactory axis of streptozotocin-induced diabetic rats.

Many diabetic individuals develop anosmia but the mechanism(s) causing the dysfunction in the olfactory system is (are) unknown. Glial fibrillary acidic protein expression is reduced in diabetic retinopathy and is also reduced, with unknown consequences, in other brain regions of diabetic rats. We used immunohistochemistry and immunoblotting from untreated control and streptozotocin-induced type 1 (insulin dependent) diabetic rats to investigate main olfactory epithelial mitotic rate and glial fibrillary acidic protein expression in the lamina propria of the sensory epithelium and in the olfactory bulb. Numbers of bromodeoxyuridine-positive cells were significantly lower in the diabetic sensory epithelium compared to non-diabetic controls. Immunohistochemical observations suggested a qualitative difference in glial fibrillary acidic protein expression in both regions examined especially in the olfactory bulb external plexiform layer and the lamina propria. Immunoblot analysis confirmed that the diabetic olfactory bulb and lamina propria expressed less glial fibrillary acidic protein compared to the non-diabetic control group. The lower expression levels in the olfactory bulb external plexiform layer suggested by immunohistochemistry do not reflect a change in the number of astrocytes since the numbers of S100B(+) cells were not different between the two groups.

Influence of the Furlow palatoplasty for patients with submucous cleft palate on facial growth.

The purpose of this study was to investigate the facial growth in patients with submucous cleft palate operated on using the Furlow palatoplasty. A total of 30 patients with submucous cleft palate underwent Furlow palatoplasty from 1993 to 1998. The mean follow-up period was 4 years and 3 months. Twenty-five of 30 patients were followed up. Mid-facial growth was measured using lateral cephalograms in 18 patients whose age was greater than 8 years. The parameters obtained in the lateral cephalogram were compared with those of a healthy population in Korea. Eleven (61.1%) of 18 patients observed were within the clinical normal range for the age group for the parameter of the span between the anterior nasal spine and posterior nasal spine, 6 patients (33.3%) were over the range, and 1 patient (5.6%) was below the range. For the sella-nasion-subspinale angle, 55.6% of patients were within the clinical normal range, 27.8% were over the range, and 16.6% were below the range. For the sella-nasion-supramentale angle, 55.6% of patients were within the clinical normal range, 22.2% were over the range, and 22.2% were below the range. For the sella-nasion-subspinale-sella-nasion-supramentale angle, 72.2% of patients were within the clinical normal range, 27.8% were over the range, and none were below the range. For the span between the basion and posterior nasal spine, 50.0% of patients were within the clinical normal range, 27.8% were over the range, and 22.2% were below the range. In conclusion, our results suggest that the Furlow palatoplasty is a useful procedure as an initial treatment of submucous cleft palate and that this technique has a less harmful effect on facial growth because there is no excessive surgical intervention on the hard palate and alveolar process.

The optimal medial osteotomy: a study of nasal bone thickness and fracture patterns.

The use of medial osteotomies as an adjunct in rhinoplasty represents an ongoing challenge to the surgeon. Despite previous descriptions, it remains difficult to obtain a consistent, aesthetically pleasing result. Nasal skin is thin and unforgiving in the region of the medial osteotomy, thus irregularities may be created. Also, bony collapse is possible with overmobilization of the osteotomy segment. The present study was undertaken to understand nasal bone thickness and osteotomy fracture tendencies to provide consistent and aesthetically pleasing results when performing medial osteotomy. Seventeen cadavers with known demographics were studied. Left heminoses were skeletonized to bone; 1-mm drill holes in a 3 x 3-mm grid were made from the midline up to the laterocephalic extent of the bony vault. On right hemi- noses, medial osteotomies were performed at either 0 or 15 degrees from the midline and combined with "low-to-low" lateral osteotomies with digital greenstick infracture. Soft tissue was removed to examine fracture patterns and narrowing. A transition in bone thickness was found both with increasing thickness from caudal to cephalic and lateral to medial, leading to a natural cleavage plane, evident in all 17 cadavers. Zero-degree osteotomies caused contour irregularities with rocker-like deformities in seven of eight noses. Fifteen-degree medial osteotomies produced narrowing without contour deformities in all cases (nine of nine), which was significantly different from the result with 0-degree osteotomies (p = 0.0004). Sharp, thin osteotomes were preferred to perform the osteotomies. The order of the osteotomies (medial, lateral) did not affect resultant narrowing or cause contour deformity. Fifteen-degree medial osteotomies followed the natural cleavage plane formed by bone thickness transition, whereas 0-degree osteotomies cut into much thicker bone, resulting in thick spicules of bone attached to the mobilized segment. When 15-degree medial osteotomies were combined with low-to-low lateral osteotomies with digital greenstick infracture, the resultant narrowing was sufficient and the greenstick reliable and controlled, without any evidence of contour deformity. The smooth contour is readily apparent clinically.

Pott's puffy tumor treated by endoscopic frontal sinusotomy.

Pott's puffy tumor is a serious extracranial complication of frontal sinusitis. The formation of this entity is facilitated by the close anatomic relationship between the paranasal sinuses and the frontal bone. Furthermore, the rich diploic venous drainage of the region enhances the spread of the infection. We report on successful functional endoscopic frontal sinusotomy in a series of four cases of Pott's puffy tumor following acute frontal sinusitis, between the years 1994 and 1997. We emphasize the advantages of this approach over the external approaches as follows: the technique treats the causative source of the disease, the morbidity is low, and it avoids facial cosmetic trauma and sequela.

Rhinostomies: an open and shut case?

AIMS: To analyse bone fragments from rhinostomies of patients undergoing revisional dacryocystorhinostomy, looking for evidence of new bone formation. METHODS: 14 consecutive patients undergoing secondary lacrimal surgery were included in this study. In each case the existing rhinostomy was enlarged with bone punches, care being taken to use the punches with the jaws cutting perpendicularly to the edge of the rhinostomy, to allow accurate orientation of the specimens. The fragments were examined histologically for evidence of new bone formation. RESULTS: Histological sections showed fragments of bone with variable fibrosis at the edge of the rhinostomy. There was evidence of only very little new bone formation. CONCLUSION: This study has clearly shown that, at the edge of a rhinostomy, healing is predominantly by fibrosis and there is only very limited new bone formation.

Biomechanics of nasal septal trauma.

Fractures of the nasal complex are the most common facial fracture. This is due to the fact that the nose is the most anteriorly projecting facial structure and is a composite structure of bone, cartilage, and soft tissue. Furthermore, the forces required to cause significant injury are less than that causing other facial fractures. Because of the wide range of activities and mishaps that cause nasal trauma, the instruments of injury range from bicycle handles to elbows. The causes, clinical anatomy, and future considerations regarding nasal septal trauma are discussed in this article.

Evaluación quirúrgica y evaluación de las septoplastias en el Hospital Base Goyeneche 1980 a 1995

El presente estudio se realizó con el objeto de evaluar a los pacientes intervenidos quirúrgicamente por desviación septal en el Servicio de Otorrinolaringología del Hospital Goyeneche de Arequipa entre los años 1980 a 1995. El compromiso del tabique nasal tuvo mayor incidencia en el sexo masculino, en su mayoría estudiantes, siendo la causa preponderante la traumática. El cuadro clínico se caracterizó por obstrucción nasal, además de presentar concominantemente deformidad de la pirámide nasal e hipertrofia de cornetes y, algunos casos acompañados de otra patología respiratoria. La desviación septal se localizó mayormente en el cartílago cuadrangular siendo el tipo de deformidad más frecuentemente la desviación. En el acto operatorio la anestesia más utilizada fue la local, al igual que las incisiones de Killian y Cottle en las septoplastías. la evolución fue favorable en su mayoría

Nasal myiasis in leprosy leading to unusual tissue destruction.

Nasal mucosal involvement is a constant feature in lepromatous leprosy (1). Granulomatous infiltration of nasal mucosa and consequent sensory loss may result in atrophic rhinitis and or painless ulceration, which is usually asymptomatic except for later complications of epistaxis, septal perforation, inflammation, and/or myiasis in long neglected patients. An unusual destruction of nasal architecture mimicking cancrum oris caused by myiasis in lepromatous leprosy is described for its rarity.