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PubMed2001

Meralgia paresthetica occurring 40 years after iliac bone graft harvesting: case report.

OBJECTIVE AND IMPORTANCE: Meralgia paresthetica is an entrapment neuropathy involving the lateral femoral cutaneous nerve. We describe an unusual case in which meralgia paresthetica occurred many years after iliac bone graft harvesting. CLINICAL PRESENTATION: An 81-year-old man presented with a 1-year history of pain, dysesthesia, and hypesthesia in the anterolateral aspect of the right thigh. This patient had undergone iliac bone grafting when he sustained a calcaneal fracture 40 years previously. Radiographs and computed tomographic scans of the pelvis revealed a bony excrescence in the anterosuperior iliac spine. INTERVENTION: The patient underwent neurolysis of the lateral femoral cutaneous nerve and excision of the bony excrescence. At surgery, the nerve was densely adherent to the bony excrescence. CONCLUSION: The etiology of meralgia paresthetica in this patient is considered to be heterotopic ossification on the anterosuperior iliac spine and pubic symphysis degeneration. A significant relationship between pubic symphysis degeneration with increasing age and meralgia paresthetica has been reported. One should be aware of meralgia paresthetica as a late complication of iliac bone graft harvesting.

Aged↗
PubMed2002

Intracranial trigeminal neuroma involving the infratemporal fossa: case report and review of the literature.

OBJECTIVE AND IMPORTANCE: Intracranial trigeminal neuroma extending extracranially is not a common finding. We report the case of a patient with a right cystic trigeminal neuroma arising in the middle temporal fossa and infratemporal areas. The clinical, radiological, and intraoperative features of these unusual lesions are discussed, and the relevant literature is reviewed. CLINICAL PRESENTATION: A 35-year-old woman presented with a 4-year history of right serous otitis media associated with recent right facial paresthesia. A neurological examination revealed hypesthesia in the mandibular division of the right trigeminal nerve. Computed tomographic and magnetic resonance imaging scans demonstrated a 6 x 6 x 4-cm well-enhancing cystic mass arising from the middle temporal fossa and extending extracranially to the infratemporal fossa through the enlarged foramen ovale. INTERVENTION: The tumor was extradural and originated from the right mandibular nerve. It was subtotally removed via a subtemporal-intradural and extradural approach. A pathological examination revealed a cystic neuroma. The patient has remained well during 12 months of follow-up, and no evidence of recurrence has been noted on magnetic resonance imaging studies. CONCLUSION: Unilateral serous otitis media by obstruction of the eustachian tube is a rare initial manifestation of trigeminal neuroma. We emphasize the benefit of neuroradiological examinations (both computed tomographic scanning and magnetic resonance imaging), which provided the clearest preoperative localization of this large intra- and extracranial tumor. A combined frontotemporal and infratemporal fossa approach is preferred, considering the difficulty of surgical removal. The prognosis for most patients was good. Twenty-five previously reported cases were also reviewed.

Adult↗
PubMed1979

Orbital floor fractures--should they be explored early?

One hundred consecutive cases of orbital floor fractures from varying causes are reviewed, and the admission symptoms and signs are compared to the late results. We considered the early findings of diplopia, infraorbital rim step-off, and hypesthesia (with an associated clinical diagnosis of malar bone involvement) an indication for exploration of the orbital floor and possible placement of silicone sheeting. When this was done, minimal complications resulted.

Adolescent↗
PubMed2000

Otoplasty: anterior scoring technique and results in 500 cases.

Corrective otoplasty is a commonly performed procedure to change the shape of the auricular cartilage. Many techniques use permanent sutures to maintain the cartilage folding, whereas other techniques rely on cartilage incisions (partial thickness or full thickness). At this institution, a cartilage cutting and anterior scoring technique has been used for more than 30 years with pleasing results. The surgical techniques published in the past have been reviewed and compared with the procedure used at this institution to point out the advantages, disadvantages, and differences of these various techniques. Also reviewed were 500 consecutive cases operated on under local or general anesthesia between January of 1993 and December of 1995 to determine the incidence of early and late complications. The patients were contacted by mail to return for a follow-up examination or answer a questionnaire, at least 2 years after the procedure. Early complications were bleeding in 13 cases (2.6 percent) and hematoma in 2 cases (0.4 percent). There were no infections or ear necrosis. A small cutaneous wound was present on the anterior skin in three patients (0.6 percent), and there was one wound dehiscence (0.2 percent). Late complications were keloids in two cases and inclusion cysts in three cases. Residual deformity was noted in 22 cases and asymmetry in 28 cases. Secondary surgery was performed in six cases. The questionnaire was answered by 387 patients (77.4 percent response rate): pain when the ear is touched was present in 22 cases (5.7 percent), hypesthesia in 15 cases (3.9 percent), occasional cutaneous irritation in 38 cases (9.8 percent), asymmetry in 71 cases (18.4 percent), and abnormal ear shape in 17 cases (4.4 percent). Twenty-nine patients (7.5 percent) also noted that the ear was more sensitive to cold or touch. The satisfaction rate was 94.8 percent: very satisfied, 74 percent; satisfied, 20.8 percent; dissatisfied, 4.2 percent; and very dissatisfied, 1 percent. These results were compared with other published series of complications and late results after otoplasty; the complication rates are similar or lower in this study. Therefore, it can be concluded that the cartilage cutting and anterior scoring technique otoplasty is a safe procedure with a high patient-parent-surgeon satisfaction rate.

Adolescent↗
PubMed2002

Porous polyethylene implants in orbital floor reconstruction.

The purpose of this article is to present the authors' experience with the use of porous polyethylene ultrathin sheets for orbital floor reconstruction. Thirty-two patients with orbital floor fractures were treated with porous polyethylene ultrathin sheets. Sixteen cases corresponded to orbitozygomatic fractures, 11 cases corresponded to pure orbital floor fractures, and five corresponded to panfacial fractures. The subciliary approach was used in 15 patients and the transconjunctival approach in nine; another three patients were operated on through a preexisting eyebrow wound, two were operated on with a subtarsal approach, two were operated on through an eyebrow extension of a facial wound, and one patient was operated on through the facial wound. Intraoperatively, all patients received a prophylactic dose of intravenous antibiotics. Postoperatively, 24 patients received amoxicillin clavulanate for 5 to 7 days, two patients received clindamycin, and six patients received no antibiotics. Enophthalmos was corrected in 15 of 24 patients (62.5 percent), and hypoglobus in nine of 11 (82 percent). Diplopia was resolved in 25 of 28 patients (89.3 percent) with preoperative impairment. Extrinsic eye movement impairment was resolved in 25 of 27 patients (92.6 percent). A preoperative visual acuity deficit was present in four patients (12.5 percent) and was resolved in one (from 20/100 to 20/20). Visual acuity improved in one patient (from 20/60 to 20/30). In the other two patients, visual acuity remained altered (from 20/30 to 20/30). One patient (3.1 percent) suffered blindness induced by surgery. Nine of 26 patients (34.6 percent) had residual infraorbital nerve hypesthesia and five (19.2 percent) had residual paresthesias. Postoperatively, epiphora was present in six patients (18.8 percent) and ectropion in five (15.6 percent). Although there was no statistical significance between the surgical approach and the presence of epiphora (p = 0.211) and ectropion (p = 0.422), patients who were treated using the transconjunctival approach suffered reduced ectropion (0 percent) compared with patients treated using the subciliary approach (20 percent). However, patients treated using the transconjunctival approach suffered increased epiphora (22.2 percent) compared with those treated with the subciliary approach (13.3 percent). There were four cases (12.5 percent) of postoperative facial infections. Two of these cases were resolved with systemic antibiotics, one was resolved with bone sequestrum resection, and one patient needed removal of the implant. Orbital infections were related in all cases to titanium osteosynthesis miniplates or skull bone graft. When comparing patients who were treated with and without antibiotics, no statistical differences (p = 0.958) were found relative to the presence of infections. Correction of hypoglobus is technically easier than enophthalmos, because enophthalmic correction requires a wide, deep subperiosteal dissection and implant positioning, posterior to the equator of the globe, with the inherent risk of orbital apex injury.

Adolescent↗
PubMed1978

Carpal tunnel syndrome in pregnancy.

Occurrence of the carpal tunnel syndrome in pregnancy was studied by examining 100 consecutive obstetric admissions. Twenty-one patients reported paresthesias or hypesthesia in the median nerve sensory distribution of the hand during the pregnancy; eight of these had decreased sensation subjectively at the time of examination one to three days after delivery; two had trophic changes, loss of sudomotor function, thenar atrophy, and decreased two-point discrimination; and one had a delay in motor conduction time across the carpal tunnel. Of the 21 patients, 18 became asymptomatic before or shortly after delivery. The remaining three were asymptomatic three months after delivery. We conclude that the incidence of symptoms is probably greater than usually appreciated, but that few patients require treatment. Steroid injection may occassionally be necessary, but the need for surgical intervention is rare.

Carpal Tunnel Syndrome↗
PubMed1994

Multiple cranial neuropathies associated with leprosy.

We report on a Samoan man with dysphagia, voice hoarseness, facial erythema, and edema. Neurologic examination revealed hypesthesia at the site of the facial rash, enlarged auricular nerves, a right facial palsy, decreased gag reflexes, and voice hoarseness. Laryngoscopic examination showed paralysis of the left vocal cord, and a barium swallow revealed a possible compressive lesion. A skin biopsy specimen was diagnostic of tuberculoid leprosy. This patient has an unusual case of leprosy with multiple cranial neuropathies.

Adult↗
PubMed1996

Intramedullary tuberculous abscess: a case report.

STUDY DESIGN: This case report shows an intramedullary thoracic spinal cord abscess secondary to Mycobacterium tuberculosis in a 7-year-old boy with chronic progressive paraparesis and hypesthesia below T10. OBJECTIVES: The treatment of this patient involved drainage of pus followed by appropriate chemotherapy. SUMMARY OF BACKGROUND DATA: Abscess and tuberculomas of the spinal cord are rare entities. They are indistinguishable from neoplasms. The possibility of tubercular abscess or granuloma should be kept in mind when an intraspinal mass is found, provided that the clinical history is unusual for tumor. METHODS: A left T7-T8 hemilaminectomy was performed. A quantity of pus was drained through a small myelotomy. A small specimen was taken, and antituberculosis treatment was given after surgery. RESULTS: Excellent clinical outcome was obtained with a combination of medical and surgical management. CONCLUSION: The treatment of intramedullary abscess consists of surgical evacuation of the pus. Appropriate treatment offers a favorable prognosis even in cases with severe deficits.

Abscess↗
PubMed2000

The clinical presentation of uppermost cervical disc protrusion.

OBJECT: The purpose of this study is to clarify the clinical presentation of the C2-C3 cervical herniation disc. SUMMARY OF BACKGROUND DATA: Uppermost cervical disc protrusion is an uncommon condition. The pattern of large central fragments of nucleus impinging on the highest cervical disc region is often poorly localized according to its clinical presentation. METHODS: Eight patients treated with anterior cervical discectomy with fusion for C2-C3 disc herniation participated in a detailed clinical and radiologic review to determine early detection and clarify potential hazards. Each patient's neurologic function was tested and recorded successively by a team of physicians and qualified physiotherapists. RESULTS: Reviewing the symptomatology, most patients presented ascending radicular symptoms secondary to trivial trauma, characterized by suboccipital pain, loss of hand dexterity, and paresthesia over face and unilateral lateral arm. Six (75%) patients had remarkable improvement postoperatively in neurologic function, except for some residual sensory embarrassment in at least 6 months follow-up. CONCLUSIONS: Clinical neurologic examination provides a less precise anatomic basis, to point to a particular upper cervical disc protrusion. Nonspecific neck and shoulder pain, a variety of cervical radiculopathy, and myelopathy may present. However, this rare spondylotic pattern is usually characterized by impairment of motor and sensory function more in the upper extremities than lower extremities and mostly starting following trauma. Radiculopathy generally outweighs the cord sign. Cruciate paralysis associated with vague diffuse and patch regions of hypesthesia over perioral distribution may help to localize this upper cervical lesion. The present study demonstrates that early detection and adequate anterior decompression may provide excellent outcome.

Aged↗
PubMed2004

Bilateral horizontal gaze palsy in presumed paraneoplastic brainstem encephalitis associated with a benign ovarian teratoma.

A 28-year-old woman with a previous history of recurrent benign ovarian teratoma developed a bilateral horizontal gaze palsy, a right facial paresis, and bilateral trigeminal hypesthesia. Magnetic resonance imaging disclosed high signal in the rostral pons. Results of all other laboratory studies, including those for antineuronal antibodies (anti-Hu, anti-Yo, anti-Ri, anti-Tr, anti-Ma1, anti-Ma2, and anti-CV2/CRMP5), were negative. Pelvic ultrasound revealed a residual mass in the left ovary, which was confirmed as teratoma on surgical pathological examination. Complete neurologic recovery occurred within two weeks of surgical removal of the teratoma and treatment with intravenous corticosteroids and immunoglobulin. This case demonstrates that a search for an occult neoplasm is extremely important in the diagnosis of presumed paraneoplastic encephalitis even if antineuronal antibodies are not found.

Adult↗
PubMed2003

Clinical recommendations for repair of orbital facial fractures.

PURPOSE OF REVIEW: Orbital facial fractures are a common result of facial trauma. Enophthalmos, diplopia resulting from extraocular muscle dysfunction, and infraorbital nerve hypesthesia may occur. The indications and timing for fracture repair are debated. RECENT FINDINGS: The timing and treatment indications for orbital facial fractures are evolving. For orbital floor fractures, nonresolving oculocardiac reflex, the "white-eyed" blowout fracture, and early enophthalmos or hypoglobus are indications for immediate surgical repair. Surgery within 2 weeks is recommended in cases of symptomatic diplopia with positive forced ductions and evidence of orbital soft tissue entrapment on computed tomography examination or large orbital floor fractures, which may cause latent enophthalmos or hypo-ophthalmos. For midfacial, lateral, supraorbital, medial wall, and nasoethmoidal fractures, repair within 2 weeks is indicated to avoid difficult repair from immediate posttraumatic wound healing. SUMMARY: Orbital facial fracture management is germane to ophthalmologists, plastic surgeons, otolaryngologists, and others who treat patients.

Facial Bones↗
PubMed2002

Osteoporotic vertebral compression fracture causing neurologic deficit.

Osteoporotic vertebral fractures rarely cause neurologic deficits. We discuss a 69-year-old man who presented with the signs of impaired function of the left L5 nerve root. Imaging revealed a fracture of the posterior upper edge of the fifth lumbar vertebra with a bony fragment protruding into the spinal canal. The fracture was attributed to sneezing and coughing in this man with osteoporosis secondary to hypogonadism. Literature search revealed 64 cases of neurologic deficit associated with osteoporotic vertebral fracture. Most osteoporotic fractures with neurologic deficit (72%) occur at the thoracolumbar junction. The symptomatology of girdle-like pain and hypesthesia is not specific and may be misinterpreted as an abdominal problem or renal pain. A typical sign is the slowly progressive neurologic deficit, occurring spontaneously or after minor trauma such as a fall on the buttocks. Surgical treatment confirms the diagnosis and usually leads to remission of the neurologic signs. With increasing frequency of osteoporotic fractures in the developed world because of the expanding elderly population, cases with neurologic problems become more important.

Journal Article↗
PubMed2006

Minimally invasive thyroidectomy.

PURPOSE OF REVIEW: Based on recent advances in ultrasonography, color-Doppler sonography and ultrasound-guided fine needle aspiration biopsy, minimally invasive thyroidectomy has been widely employed for treating thyroid tumors. Minimally invasive procedures have recently been adopted for the surgical treatment of thyroid disease as a means of preventing prominent scars, hypesthesia and paresthesia. RECENT FINDINGS: We have developed axillary and anterior chest approaches for endoscopic thyroidectomy. The mean operating time for the endoscopic procedure was significantly longer than that for conventional open surgery. All patients who were treated using the axillary approach were satisfied with the cosmetic results. The incidence of complaints after endoscopic surgery is significantly lower than that after open surgery. The minimally invasive mini-incision approach has been performed under direct and endoscopic vision to minimize surgical invasiveness and improve cosmetic results. Our procedure differs from conventional thyroidectomy in requiring a 3-cm skin incision, and in not raising of a skin flap and not dissecting the sternohyoid muscle. SUMMARY: Endoscopic thyroidectomy is the procedure of choice in well selected patients with thyroid disease. The present indications for this procedure include benign follicular adenomas less than 4 cm in diameter, low-risk papillary carcinomas less than 10 mm, oxyphilic cell tumors less than 4 cm and Graves' disease as imaged on preoperative ultrasonography. The minimally invasive mini-incision approach is indicated for patients with low-risk, well differentiated carcinomas. Total thyroidectomy and bilateral modified neck dissection is possible, if the tumor is not large.

Biopsy, Needle↗
PubMedDate not supplied

Cavernous sinus/orbital apex syndrome associated with indwelling orbital catheter use.

A 46-year-old man with a history of right orbital fractures and blindness underwent simultaneous fracture repair and enucleation with orbital implantation. During surgery, an orbital catheter was placed for administering local anesthesia to control postoperative pain. After administration of local anesthesia through the catheter on postoperative day 1, the patient had development of a complete ptosis, total ophthalmoplegia, mydriasis, vision loss from 20/20 to NLP, and hypesthesia of the V1 and V2 trigeminal nerve distribution. Intraocular pressures and dilated funduscopic examination were normal. There was no evidence of central nervous system effects or respiratory depression. After 4 hours of observation, the vision, sensation, motility, ptosis, and pupil response all returned to normal. Although rare, contralateral cavernous sinus/orbital apex syndrome may occur with indwelling orbital catheter administration of local anesthetic in an orbit with fractures.

Anesthesia, Local↗
PubMed2002

Anatomicohistologic study of the retaining ligaments of the face and use in face lift: retaining ligament correction and SMAS plication.

Plastic surgeons have sought to improve nasolabial folds, jowls, jaw lines, and cervical contour with face-lifting procedures that are abundant in the literature. The retaining ligaments of the face support facial soft tissue in normal anatomic position, resisting gravitational change. As this ligamentous system attenuates, facial fat descends into the plane between the superficial and deep facial fascia, and the stigmata of facial age develop. In this study, surgical correction of the retaining ligaments and plication of the superficial musculoaponeurotic system (SMAS) to reposition the structures that have descended with gravitation are discussed. The anatomy of the facial retaining ligaments was studied in 22 half-faces of 11 fresh cadavers, and the localization, extension, and width of the ligaments were examined macroscopically and histologically. Surgical correction of the retaining ligaments and plication of the SMAS have been accomplished in 27 face-lift patients with this anatomicohistologic study taken into consideration. There was hematoma in one patient at the cheek region and a permanent dimple caused by postoperative edema in two patients, with a localization of one zygomatic and two parotidomasseteric ligaments. In one patient, hypesthesia in the mandibular nerve region was seen, which remitted at 14 weeks. There were no other complications, and with a follow-up of 24 months, excellent aesthetic results and a high level of patient satisfaction were encountered.

Adult↗
PubMed2003

Free flap from the flexor aspect of the wrist for resurfacing defects of the hand and fingers.

The distal portion of the flexor aspect of the forearm has been used as the donor site of full-thickness skin grafts, venous skin grafts, and Chinese forearm flaps. This article describes the use of a free flap harvested from the flexor aspect of the wrist and based on the superficial palmar branch of the radial artery to repair skin defects of the hand and fingers. The advantages of this flap are as follows: (1) the operative field is the same; (2) the radial artery is preserved; (3) it is thin, pliable, and hairless and thus can supply a gliding surface for tendons beneath it; (4) when it involves a palmaris longus tendon and/or the palmar cutaneous branch of the median nerve, it can be used as a vascularized tendon or nerve graft; and (5) in view of the flow-through type of the pedicle of the flap, the digital artery can be reconstructed simultaneously. However, it should be noted that a hypesthesia in the proximal central carpal area remains when the palmar cutaneous branch of the median nerve is harvested as a vascularized nerve graft. The scar of the donor site should be left in the distal wrist crease. If it is not lying in the distal wrist crease, it may suggest that the patient has tried to commit suicide.

Adolescent↗
PubMed2004

Ultrasound-assisted lipoplasty treatment for axillary bromidrosis: clinical experience of 375 cases.

Bromidrosis is a condition of abnormal offensive body odor caused mostly by apocrine gland secretion from the axilla. Although no morbid sequelae are known, the odor can be disturbing enough to cause social impairment and psychological distress. Medical care is available but is temporary and yields limited clinical benefit. Surgical treatment may provide a more definite remedy through reduction of the apocrine gland. However, there are risks for complication following surgical treatment such as subdermal excision, subcutaneous shaving, en bloc excision, and liposuction. The search for a less invasive but still effective procedure has led the authors to use ultrasound-assisted liposuction, which has reduced the risk of complication and recurrence. The purpose of this article was to evaluate the long-term outcome of ultrasound-assisted liposuction for the treatment of bromidrosis. From August 1998 to September 2002, 375 consecutive patients underwent ultrasound-assisted liposuction for bromidrosis of the axilla. The average age of the patients was 25.7 years (range, 15 to 55 years) and the average follow-up period was 18.8 months (range, 7 to 56 months). Subjective complaints of recurrences were noted in 22 patients (5.9 percent) and secondary ultrasound-assisted liposuction was performed, resulting in no further complaints. Complications other than recurrences were mild skin sloughing (3.2 percent), hematoma (1.3 percent), subcutaneous band (0.3 percent), and hypesthesia of the hand (0.3 percent), all of which healed spontaneously. Through a questionnaire that was answered by 264 patients, a subjective satisfaction rate was measured. Among the completed questionnaires, 91.7 percent reported satisfactory reduction of odor. Ultrasound-assisted liposuction to treat bromidrosis of the axilla provides advantages such as rapid recovery, less restriction of movement, unnoticeable scars, and a low rate of recurrence. The long-term outcome supports the benefits of this procedure. The authors recommend the use of ultrasound-assisted liposuction as first-line treatment for bromidrosis of the axilla.

Adolescent↗
PubMed2005

Donor-site morbidity of the pedicled rectus femoris muscle flap.

The rectus femoris muscle flap is well known for its reliable anatomy, the ease with which it can be harvested, and its great versatility. As a pedicled or free flap, it is used to cover soft-tissue defects and to recreate motor function. Although the muscle is very reliable, it is not well respected because of its assumed donor-site morbidity, such as weakened knee extension force and decreased range of motion of the knee. To date, these clinical assumptions have only rarely been quantified in terms of objective scores, concerning force deficit and functional or aesthetic outcome. From 1995 to 2002, the authors treated 24 patients with pedicled rectus femoris muscle flaps. Fourteen patients were followed up. Follow-up time ranged from 3 to 56 months postoperatively. The results were evaluated by a standard questionnaire in which pain in relation to walking distance, subjective feeling of weakness, sensibility disorders, everyday function, and aesthetic aspects were assessed. Range of motion in the hip and the knee was measured. For objective verification of a decrease of maximal voluntary contraction force of the remaining quadriceps muscle and for detecting differences in true muscular capacity and voluntary activation, 10 patients with unilateral rectus femoris flaps were tested using the twitch interpolation technique. The authors' patients assessed the remaining function and the aesthetic result of the thigh as at least satisfactory. Two patients complained about pain and weakness in the thigh. Eight patients reported hypesthesia in the lateral suprapatellar region. The maximal voluntary contraction and true muscular capacity values were reduced by 21.8 percent and 18 percent, respectively, when compared with the healthy leg. The range of motion in the knee and hip was not influenced by muscle harvesting. The twitch interpolation technique revealed a mild voluntary activation deficit, probably caused by inhibitory regulation in the spinal cord. In conclusion, donor-site morbidity of the rectus femoris muscle flap is evident but well compensated. There is no decrease in active range of motion in the knee and hip. Patient satisfaction with the functional and aesthetic outcome was high.

Adult↗