Axial osteomalacia: report of a new case with selective increase in axial bone mineral density

We report a case of a rare congenital nasal malformation. A young male patient was seen with a unilateral duplication of the left nostril. According to the morphogenetic classification, described by van der Meulen, this nasal malformation could be classified as a type IV nasal dysplasia. The other observed abnormalities that were seen were part of the CHARGE association, which is defined as coloboma of the iris, heart deformities, choanal atresia, retarded growth, genital and ear deformities. The patient underwent a surgical correction of the nose using an L-approach, yielding a satisfactory result 1 year postoperatively. Details of the case and a review of the scarce literature are presented.     

Cartilage-sparing otoplasty: a review with long-term results

Prominent ears are the most frequent congenital deformity in the head and neck region. Anatomy of normal and prominent ears as well as the psychological aspects of prominent ears are reviewed. Two types of surgical technique are described with emphasis on the cartilage-sparing technique. A sound pre-operative analysis, focusing on all parts of the deformity, and surgical techniques which are gradually applied to these deformities should result in pleasing, permanent changes for the vast majority of patients. In our opinion, a combination of cartilage-sparing techniques augmented with cartilage-weakening procedures give predictable long-term results with a natural appearing ear and concomitant few, easily treated complications.     

Validation of the heat treatment step used in the production of diaspirin crosslinked hemoglobin (DCLHb) for viral inactivation--effect of crosslinking

During the years 1979-81, three different surgical techniques were used in the treatment of 87 ears with extensive cholesteatoma. All procedures were performed in one stage by the same surgeon. Ten to 13 years after the operations about 70 per cent of ears operated on by the canal wall up technique had developed a new cholesteatoma, which in most cases was recurrent, or a deep retraction pocket. A modification of this technique with mastoid obliteration resulted in a similar failure rate. In contrast, ears operated on by the canal wall down technique (in most cases with mastoid obliteration) had acceptable stability with a long-term recurrence rate of about 15 per cent. Most patients in the canal wall down group had a dry ear without significant cavity problems. Hearing in these patients was as least as good as hearing in patients with a preserved canal wall. We conclude that a meticulous one-stage canal wall down technique in ears with extensive cholesteatoma results in a high percentage of unproblematic, stable ears with satisfactory function. In contrast, if the posterior canal wall is preserved, recurrent cholestealoma is the rule more than the exception.     

Congenital deformities of the middle and external ear

Congenital deformities of the external and middle ears were shown by tomography in 246 patients. Surgical exploration has been undertaken at some time in many of these ears. The appearance of the tomograms and their significance were reviewed in the light of the operative findings and the authors' experience of congenital ear lesions. In nearly every case a middle ear cavity could be demonstrated although this varied from a normally aerated middle ear and mastoid in association with an isolated unilateral atresia of the external auditory meatus to a small slit-like hypotympanum in patients with craniofacial abnormalities. The ossicles were nearly always present but deformed. The typical appearances of the ossicles and the frequently aberrant pathways of the facial nerve are described.     

Regional dermolipectomy as treatment for sequelae of massive weight loss

Dermolipectomy is the most important procedure for treatment of the deformities engendered by massive weight loss. It remains the only treatment for excising redundant skin. Although liposuction is useful for removing fatty deposits without traditional surgical incisions, its application is limited by the ability of the skin to contract and conform to the newly sculpted figure. Thus liposuction may serve as an adjunct when treating the sequelae of weight loss but not as a primary procedure. In response to changing expectations, reconstructive surgeons have developed increasingly ingenious and specific dermolipectomy procedures to minimize or hide scars, lessen morbidity, and enhance function. Liposuction in combination with dermolipectomy has expanded the applicability of traditional procedures to a wider variety of patients. Surgical history, patient selection, surgical planning, a spectrum of regional dermolipectomy procedures, and potential complications are discussed herein.     

The surgical correction of a deviated anterior maxilla in a horse

The surgical correction of facial deformities of the horse have rarely been undertaken. The surgical and medical management of submucous clefting of the anterior maxilla in a young colt is described.     

Surgical treatment of children with brachial plexus paralysis

OBJECTIVE AND METHODS: A variety of surgical procedures exist for early repair of the nerve injury in obstetrical brachial plexus palsy, including neuroma excision and nerve grafting, neurolysis and neurotization. Secondary deformities of the shoulder, forearm, and hand can similarly be reconstructed using soft tissue and skeletal procedures. This review describes our surgical approach to maximize the ultimate functional outcome in infants and children with obstetrical brachial plexus palsy.     

Modified canal wall-up mastoidectomy with mastoid obliteration for severe chronic otitis media

Mastoid tympanoplasty with a canal wall-up technique provides better conditions for a healthy skin lining than canal wall-down techniques. The formation of retraction pockets in residual pneumatized cavities is however a major cause of cholesteatoma recurrence with canal wall-up techniques. We have therefore attempted to combine the advantages of both canal wall-down and canal wall-up techniques. The posterior wall is kept up, the mastoid is obliterated with adipose tissue, the attic is exteriorized in the ear canal and hearing is restored with a minimal-size hypotympanic cavity only. Preliminary results from 41 cases with a follow-up of 6 months to 6 years suggest that skin conditions in the enlarged ear canal are adequate and that cholesteatoma do not recur.     

Combined tibio-talar and subtalar arthrodesis by retrograde nail in hindfoot rheumatoid arthritis

PURPOSE OF THE STUDY: Many techniques for ankle arthrodesis have been described. Some are not applicable to patients with severe rheumatoid arthritis (RA) because of osteopenia and deformities. This study describes a new surgical technique for arthrodesis in painful valgus deformity of the hind-foot in advanced rheumatoid arthritis (RA) with severe osteopenia. MATERIALS: The present series included 9 patients. Eleven talocrural and talocalcaneal arthrodeses were performed for degenerative changes secondary to RA involving hind-foot joints. All patients were reviewed after an average follow-up of 6 years. Mean duration of RA was 34 years. All patients had severe osteopenia, including major deformations of the hind-foot in 5 cases. METHODS: After removal of talocrural and talocalcaneal articular surfaces using an anterolateral approach, deformities were corrected by removal of an appropriate bone wedge. A Küntscher nail was then positioned in the calcaneal plantar cortical through the plantar surface of the foot and driven proximally into the medullary canal of the tibia through the talus. This nail allowed both deformity correction and fixation. Aftercare required immobilization in a short leg cast. Weight bearing was allowed with the cast approximately 5 weeks after surgery. The ankle was immobilized for 7.5 weeks. DISCUSSION: Results showed a 80 per cent fusion rate. Two non-unions occurred (one recurrence of valgus deformity after early nail migration requiring removal of the nail; and the other asymptomatic). A complication occurred in one foot (delayed healing). At follow-up, all patients but one were satisfied with respect to pain relief and residual deformities. Our results are comparable with those of other series and should be considered in the context of severe RA. CONCLUSION: This technique of vertical retrograde transarticular nailing allows an easy control of hind-foot deformities correction. Other techniques are preferable in case of solid bone. This technique is an acceptable alternative in advanced RA.     

Management of the mastoid air cell system in chronic otitis media

The influence of the Mastoid Air Cell System in Chronic Otitis Media is subject to much speculation. Does a mastoidectomy influence the surgical results following chronic inflammatory ear surgery? An understanding of the pathology associated within the mastoid air cell system is necessary before a discussion of the need for a mastoidectomy can be presented. Most mastoid air cell systems are sclerotic in chronic otitis media patients. The report summarizes one author's experiences with the influence of mastoidectomy upon surgical reconstruction for chronic inflammatory diseases of the ear. Emphasis is directed toward the eustachian tube rather than the mastoid air cell system.     

Surgical correction of dural herniation into the mastoid cavity

A temporoparietal craniotomy as the approach of choice employed by the authors is presented for the surgical correction of dural herniation into the mastoid cavity in our series of four cases of middle fossa defects caused by previous operative procedures (mastoidectomy for removal of cholesteatoma) performed elsewhere. At the Triological Meeting a color movie accompanied the presentation of this paper.     

Influence of the concentration of ions and foramen diameter on the accuracy of electronic root canal length measurement--an experimental study

The controversy regarding the best procedure for treating middle ear cholesteatoma has lasted over 100 years. This paper discusses our current methods for dealing with cholesteatoma, always through external ear or transmeatal mastoidectomy. We present the results of three years of follow-up. MATERIAL AND METHODS: A prospective study was made of 215 ears operated for cholesteatoma using a transcanal approach with one of three techniques: "on demand" DAA mastoidectomy, modified radical mastoidectomy, and radical mastoidectomy with obliteration. Three parameters were used to evaluate results: stability of the mastoid cavity, integrity of the neotympanum, and evolution of hearing. RESULTS: The rate of cholesteatoma recurrence in ears operated with these techniques was much lower than that found in canal-wall-up techniques. Only 3 of the 215 cases (1.4%) remained unstable due to different causes three years after surgery. DISCUSSION AND CONCLUSIONS: Due to the high rate of cholesteatoma recurrence, canal-wall-up mastoidectomy has been abandoned in our clinic. Open techniques using a transmeatal approach, with or without obliteration, and the so-called "on demand" mastoidectomy, have yielded more stable results, although postoperative care is more critical.     

Correction of the crooked nose

Correcting the crooked nose remains one of the most challenging problems in rhinoplasty. When faced with a twisted nose, rhinoplasty surgeons tend to be divided into those who perform an anatomic reconstruction and those who prefer camouflage techniques. Regardless of the approach used, the revision rate remains fairly high. An anatomic correction of the twisted nose through an open approach was performed. The septum was freed from the extrinsic forces of the deformed nasal bones and upper and lower lateral cartilages. The residual true septal injury was then evaluated. The septal deformity was addressed through quadrangular cartilage resection, repositioning of the caudal septum in the anatomic midline, and correction of the dorsal septal deformity with horizontal control sutures. The skeletal support was then reconstructed with the use of a spreader-extension graft on the concave side and a batten graft on the opposite side. The nasal tip was set relative to the dorsum by fixation to the extension grafts. Residual lateral crus deformities were corrected by a combination of lateral crural spanning sutures or alar spreader grafts. With this approach, straightening the crooked nose without compromising skeletal support or nasal aesthetics was successful.     

Influence of the gas exchange function through the middle ear mucosa on the development of sniff-induced middle ear diseases

To investigate the influence of gas exchange function through the middle ear mucosa on the development of sniff-induced middle ear diseases, the authors examined the mastoid pneumatization among patients with sniffing habit using computed tomography, and also examined the change of negative middle ear pressure induced by sniffing using tympanogram. In 20 ears with cholesteatoma or adhesive otitis media, the areas of mastoid cavity measured at the level of the lateral semicircular canal were significantly smaller than those in 26 ears with otitis media with effusion (OME) or attic retraction and in eight normal ears with sniffing habit (P < .01 and P < .0001, respectively). In 26 ears with OME or attic retraction, the areas of mastoid cavity were significantly smaller than those in eight normal ears with sniffing habit (P < .0001). By contrast, in the four ears with sniff-induced middle ear disease, the recovery of negative middle ear pressure in 5 minutes without swallowing was less than 10 mm H2O, whereas in all seven ears with normal eardrum, negative middle ear pressure recovered by more than 20 mm H2O in 5 minutes. These findings suggested that impairment of gas exchange function through the middle ear mucosa, as well as eustachian tube dysfunction, might be closely related to the development of sniff-induced middle ear diseases.     

Brodie's syndrome. A report of 2 atypical cases

The aim of the authors is to show the treatment of Brodie's syndrome even in atypical cases where this pathology can not offer typical signs but can be associated to other skeletal deformities of the face. There are two atypical cases of Brodie's syndrome both of them came to our out patient's department. They were grown-up (one 20 one 22 years old), one of them with an extreme vertical expansion of lower third of the face and with a big transverse expansion of the upper maxillary bone, all typical signs of Brodie's syndrome; the other patient was with an extreme transverse expansion of the upper maxilla associated to a II class and a defect of 11, 12, 21, 22. The first patient was treated with orthodontic Tweed technique continued with surgical operation setting out to the contraction of the transverse diameter of the upper maxilla, associated to a Le Fort I osteotomy and an Epker osteotomy of the jaw. This orthodontic-surgical correction, allowed us to achieve a good aesthetic and functional result. The second patient was treated with orthodontics followed by surgical correction of the excessive transverse expansion of the upper maxilla after a Le Fort I osteotomy; a sagittal split of the jaw on Gotte technique was performed to correct the III class. We gave the patient a good aesthetic result with the restoration of the lost teeth in the upper maxilla, reaching in this way a good aesthetic and a well functioning result. We think it's possible to treat patients with atypical Brodie's syndrome with orthodontics or surgery in the same way we treat Brodie's syndrome and other deformities of the face reaching good aesthetic-functional results.     

The Mitchell procedure for the treatment of adolescent hallux valgus. A long-term study

Thirty patients who had had a total of fifty-one Mitchell procedures to correct adolescent hallux valgus deformities were examined clinically and radiographically an average of seven years (range, three to seventeen years) after the operation. The average age of the patients at the time of the operation was fifteen years (range, ten to nineteen years). The result was excellent in nineteen feet, good in sixteen, fair in six, and poor in ten. The fair and poor results were associated with recurrence of the deformity, stiffness (real or perceived), and unsightly scars. The cause of the fair and poor results was inadequate correction at the time of the operation in six feet and loss of fixation in two; the loss of fixation resulted in one recurrence and one malunion. The remaining eight patients who had a fair or poor result were not totally satisfied and had reservations about more than one of three categories (relief of discomfort, appearance, or range of motion). Seventeen feet had a plantar callosity beneath the second metatarsal head, suggesting increased load-bearing by the second metatarsal. Although sixteen callosities caused no symptoms at the most recent follow-up evaluation, the long-term implications of this altered pattern of weight-bearing are unknown.     

Indications for middle ear obliteration within the scope of cochlear implant management

BACKGROUND: Cochlear implants have gained worldwide acceptance as a reliable method of rehabilitation of profoundly hearing-impaired patients. Due to thorough patient selection major postoperative complications rarely occur and are flap related in most cases. Deafness can develop during chronic suppurative otitis media, either coincidentally or secondary to the medical treatment; normally this condition is regarded as a contraindication for cochlear implantation. In cases with a mastoid cavity after surgical treatment for cholesteatoma, the electrode covered only by the epithelial lining will likely become exposed or extruded. Therefore we suggest the obliteration of the middle ear cleft with abdominal fat and the blindsac closure of the external ear canal before cochlear implantation in these conditions. PATIENTS: The average age of our 12 patients was 48 years, whereas the youngest was 2 1/2 years of age. Due to chronic inflammatory ear disease. 11 patients had a mastoid cavity on both ears. Eight patients had a cholesteatoma, the chronic bone destroying process in the temporal bone of two female patients was considered as a fibroinflammatory pseudotumor. The child had a congenital deafness in both ears with a Mondini dysplasia in CT scan. She had already developed two episodes of pneumococcal meningitis which was caused by a defect in the stapes footplate through which a liquor-filled cystic sac herniated in the middle ear. Because of a massive liquorrhoea after opening of the sac, we decided to obliterate the middle ear cleft after successful insertion of the electrode array. RESULTS: All active electrodes of 10 Nucleus implants (Cochlear) and two Clarion devices (Advanced Bionics Corp.) were successfully inserted in the cochlea of the 12 patients. After an average follow-up of 15 months, a temporary facial palsy in one patient and an insufficient closure of a retroauricular fistula over the mastoid cavity in two cases were observed as postoperative complications. One patient with a fibroinflammatory pseudotumor developed a massive inflammatory reaction in the implanted ear two months after cochlear implantation, which could not be controlled by conservative treatment. The implant had to be removed and local conditions settled after administration of immunosuppressive treatment with cyclophosphamide. The patient received a new implant seven months ago. CONCLUSIONS: Implantation of a foreign body in a potentially infected space which communicates intracranially means a surgical challenge which can be managed by obliteration of the middle ear after subtotal petrosectomy with abdominal wall fat combined with a reliable closure of the external ear canal. In case of massive inflammation we would prefer a two-stage procedure.     

Surgical management of pectus deformities

We analyzed the long-term results in 87 patients who had pectus deformities repaired at Fitzsimons Army Medical Center during the period 1953 to 1975. Seventy-one patients had operations for correction of pectus excavotum; 16 had pectus carinatum deformities repaired. A variety of surgical techniques was used in these patients. Our findings show that in excavatum deformities the best results were obtained by removing all deformed cartilage, mobilizing the sternum, using an anterior osteotomy, and stabilizing the chest with a metal strut (which was removed after one year). For carinatum defects, the Ravitch procedure has produced good results. We are encouraged to be more aggressive in advocating repair of the deformities, not only for cosmetic results but because the patients seem to feel healthier both physically and mentally after repair. For these reasons we advocate operation for pectus deformity as any age.     

A novel surgical method of repair for Stahl's ear: a case report and review of current treatment modalities

Stahl's ear is a congenital malformation of the auricle, which is uncommon in non-Oriental societies. A number of different treatment modalities have been suggested, many of which yield unpredictable results. We review current treatment modalities from the English literature and describe a novel, simple surgical method of repair. First, a helical rim incision is made to expose the abnormal third crus and upper pole of the ear. The third crus is excised as a narrow wedge of cartilage and posterior skin, and the defect is closed primarily. The free third crus cartilage is then grafted onto the scaphal cartilage in an anatomically correct position to form a superior crus. The anterior skin flap is redraped and bolstered over this graft. Only a very small scar on the helical rim remains visible anteriorly.     

Fetal surgery in the head-neck area. Current status and new possibilities with the endoscope

Fetal surgery is defined as the intrauterine surgical correction of malformations that endanger the unborn child's life in prenatal stages of development or lead to death or severe damage of the child postnatally. Such surgery is a clinical reality now. Indications for intrataurine surgical procedures also exist for head and neck abnormalities, especially in the upper respiratory tract. These include exposure and temporary obstruction of the fetal trachea for correction of pulmonary hypoplasia in cases with congenital diaphragmatic hernias, prenatal tracheotomy in cases of laryngeal atresia for the correction of lethal pulmonary overdistension, and resection of embryonic tumors that obstruct the respiratory tract. The relatively high surgical risk resulting in particular from preterm labor occurring postoperatively may be reduced by employing minimally invasive techniques. Endoscopic procedures render opening of the uterus unnecessary and are of particular importance. In part of the procedures, only endoscopic surgery has led to therapeutic success rates justifying its clinical use. Further reduction of the operative risk suggests prenatal interventions, even in cases with non-lethal conditions. More diseases of the head and neck may thus be included in the spectrum of indications. One example is prenatal correction of a cleft lip and palate, which until now has only been performed in animal experiments. The particular characteristics of fetal wound healing allow this to take place without scarring up to a certain stage in pregnancy. This offers the prospect of a surgical correction that is invisible externally and avoids growth-impeding scars. The particular ethical and legal aspects of fetal surgery are discussed.