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PubMed1984

The perforating disorders.

This article reviews the diseases that may show epidermal perforation as a histologic feature. Many of these represent examples of transepithelial elimination (TEE), a mechanism by which the skin rids itself of abnormal substances. After a review of disorders in which perforation is an occasional finding, four diseases that have been considered essential perforating disorders are discussed: elastosis perforans serpiginosa (EPS), reactive perforating collagenosis (RPC), perforating folliculitis (PF), and Kyrle 's disease (KD). A review of the literature, including recent reports of perforating diseases associated with chronic renal failure, suggests that there may be considerable clinical and histologic overlap among PF, KD, and the adult form of "perforating collagenosis." A working classification for the perforating disorders is suggested.

Collagen Diseases↗
PubMed1989

Nature of spontaneous tympanic membrane perforation in acute otitis media in children.

The study was undertaken to define the characteristics of spontaneous eardrum perforation in acute otitis media. Eighty (29.5 per cent) out of 271 children with acute otitis media had eardrums which perforated. An increased incidence of perforation was associated with a previous history of otitis media. All perforations were small and limited exclusively to the pars tensa. In 85 per cent of the patients, the perforation was located in the anterior-inferior quadrant. It had smooth margins enabling free drainage of pus-and was associated with a favourable clinical course. In the remaining 15 per cent of the cases, the perforation was located in the posterior-superior quadrant. It had a nipple-like shape with a tiny opening that did not allow pus to drain sufficiently from the middle ear. The perforation closed in 94 per cent of the patients within one month. The healing process was gradual and following perforation closure, there was evidence of middle ear effusion for some time before normal aeration was regained.

Acute Disease↗
PubMed2002

[The role of perforating vein dissection in the treatment concept of venous ulcers--myths and evidence].

Crural ulcers represent the most serious form of chronic venous incompetence (CVI). According to duplex studies superficial venous incompetence predominate in this stage of the disease, but combined refluxes of superficial and deep veins are also common. Despite a positive correlation between the number of incompetent perforators and the stage of CVI isolated incompetence of perforating veins in venous ulcers are rarely found. Additionally, only a minority of incompetent perforators depict larger reflux volumes. Therefore, doubts about a causal role of perforators incompetence in ulcer genesis are justified. According to phlebodynamometric studies the risk of crural ulcer development increases with the degree of hemodynamic compromise. Ulcer healing can only be achieved after complete normalization of ambulatory venous hypertension. In case of superficial refluxes and concomitant incompetence of perforating veins exclusion of the superficial component is sufficient to achieve this goal. Incompetent perforators normalize their function consecutively. In contrast, venous hypertension persists after exclusion of superficial refluxes in case of incompetent perforators and irreversible damage of the deep venous system. Surgical therapy studies exactly reflect the results of these hemodynamic examinations. Therefore, the role of endoscopic subfascial perforator dissection (ESPD) in the treatment of venous ulcers remains unclear. Future therapy studies should take into account that the definite role of ESPD in ulcer healing can only be examined without additional treatment of refluxes in the saphena system. Additionally, all study patients should be classified according to the CEAP nomenclature and Hach's classification of chronic compartment syndrome. Methodological differences in technique and extent of ESPD have also to be taken into account.

Angioscopy↗
PubMed1999

Double gloving and a glove perforation indication system during the dental treatment of HIV-positive patients: are they necessary?

AIM: The aim of this study was to compare the incidence of glove perforation when double gloved or single gloved during the routine treatment of HIV-positive patients. In addition, a glove perforation indication system based on a double gloving technique was assessed. DESIGN: Prospective, randomised and open study of glove perforation. METHODS: 138 consecutive HIV-positive patients underwent routine dental treatment by senior dental staff and dental hygienists in a teaching hospital. Staff wore either single gloves (Regent Biogel D or standard surgical gloves) or double gloves (Regent 'Reveal' perforation indication system or standard surgical gloves). A subjective assessment of glove comfort, sensitivity and ease of donning was made using a visual analogue scale. RESULTS: The incidence of glove perforation/procedure was low, 2.9%. There were no skin penetrating injuries, visible exposure to body fluids or unnoticed perforations. Double gloving was subjectively less comfortable and sensitive than single gloving (P < 0.0001). The glove perforation indication system did not increase the detection of intra-operative perforations. CONCLUSIONS: There is unlikely to be any significant benefit from the use of a double gloving technique or perforation indication system during the routine dental treatment of HIV-positive patients.

Dental Care for Chronically Ill↗
PubMed2000

Photoelastic stress analysis in perforated (Rochette) resin bonded bridge design.

Rochette described the perforated cast metal bonded design for splinting periodontally compromised teeth. The design was later used for replacing missing teeth. The main causes of failure of the perforated (Rochette) type design were attributed to inappropriate case selection and erosion of the composite from perforations. The aim of this study was to analyse the effect of stress magnitude and direction on failure of perforated resin bonded bridges (RBBs). The objective was to compare stress magnitudes in this design with those reported on the non-perforated RBBs. Photoelastic modelling materials were selected to represent the relative stiffnesses of a posterior mandibular and an anterior maxillary perforated (Rochette) type design. The sizes of the models were scaled to x 2.5 in order to enhance visual analysis of the stress patterns. Stress magnitudes were quantified from isochromatic fringes and stress directions were evaluated from stress trajectories. These revealed a high-stress concentration around the perforations, particularly for those at the proximo-lingual/palatal (connector) areas. This experimental study revealed that the main reason for failure of Rochette designs is deformation at the perforations.

Birefringence↗
PubMed2002

Perforation rates for nonsterile examination gloves in routine dermatologic procedures.

BACKGROUND: Low cost, nonsterile examination gloves are used routinely to perform various dermatologic procedures. OBJECTIVE: To evaluate the perforation rate of nonsterile examination gloves in routine dermatologic procedures. METHODS: Three hundred fifty nonsterile latex examination gloves used to perform shave biopsies were evaluated for perforations using an air inflation/water submersion method. Ninety gloves, which were intentionally perforated with a 30-gauge needle, were used as controls to assess our evaluation method. RESULTS: Eight of the 350 gloves were found to have a perforation, which corresponds to a 2.3% perforation rate. Seven of the eight perforations were found in the web space between the second and third finger sleeves, with one being an obvious manufacturing error. All 90 perforations of the control group were correctly identified. CONCLUSION: There appears to be a very low risk of glove perforation when nonsterile examination gloves are used in routine dermatologic procedures.

Biopsy↗
PubMed2000

Two-stage radical gastrectomy for perforated gastric cancer.

INTRODUCTION: Perforation represents a severe complication of gastric cancer. Because it is rare, only few data are available regarding treatment and prognosis. METHODS: Patients with perforated gastric cancer were identified from two prospective registers of gastric cancer and of gastroduodenal ulcer. RESULTS: Between February 1982 and June 1999 23 patients with perforated gastric cancer were treated surgically. This corresponds to only 1.8% of 1273 patients presenting with gastric cancer, but to 14% of 161 patients presenting with gastric perforation during this time period. Overall, post-operative mortality was 13% (3/23). Initially, 21 patients had palliative operations. Two patients had a potentially curative procedure at the emergency operation and one of the two died post-operatively. Another six patients had potentially curative gastrectomy at a second stage and no patient died post-operatively. The 5-year overall survival was estimated at 50% for all eight curatively-treated patients. Median survival of palliatively treated patients was 6 months. CONCLUSIONS: Perforation of the stomach should raise suspicion of malignancy, particularly in elderly patients. At the time of perforation radical gastrectomy with lymphadenectomy is mostly not advised, either because a diagnosis of gastric cancer is not confirmed or because the patient's condition does not allow extended surgery. In this situation it is suggested to consider a two-stage procedure and direct the primary operation at the treatment of perforation and peritonitis. Tumour staging can be completed when the patient has recovered and a radical operation with curative intent can be planned without compromising long-term prognosis. Our observations and a review of the literature confirm that perforation of gastric cancer does not preclude long-term survival per se in a substantial number of patients.

Adult↗
PubMed2000

The management of nasoseptal perforation.

The most recent comprehensive review of the literature on repair of nasoseptal perforations dates back to 1985, since then there have been developments in the repair of very large perforations, previously thought to have been untreatable by surgical methods. The purpose of this article is to review the various methods which have been used to repair perforations, and their reported efficacies, with particular reference to the problem of large perforations. The article reviews the methods in use for providing mucosal cover for perforations; the options for a supporting layer; and the more recent solutions to mending perforations greater than 4 cm diameter. In conclusion, nasoseptal perforations of up to 4 cm diameter have been reported to be closed reliably with bilateral mucoperichondrial flaps and a connective tissue autograft. However, for larger perforations the only methods successfully used have been a three stage, composite graft and intranasal tissue expanders.

Connective Tissue↗
PubMed2000

Histological changes in the rabbit condyle following posterolateral disk perforation.

PURPOSE: To examine changes in condylar cartilage following perforation in the posterolateral region of the articular disk of the craniomandibular joint of a rabbit. MATERIAL AND METHODS: The circular perforation in the left joint of 25 female Japanese white rabbits measured precisely one-sixteenth of a disk. Histological examination, including the immunohistochemical proliferating cell nuclear antigen (PCNA) procedure, was performed on separate sets of five rabbits each 2, 4, 8, 12, and 24 weeks postoperatively. RESULTS: Microscopic examination revealed hypertrophy of the condylar cartilage with osteophyte formation up to 8 weeks after perforation. Proliferative activity then decreased near the condylar surface as the perforation flattened. Twenty-four weeks postoperatively, the condylar surface was found to be fibrous and flattened. Positive PCNA results in cartilage cells indicated proliferation following disk perforation which peaked in the 4th week and then decreased. CONCLUSION: Disk perforation was followed initially by hypertrophy of condylar cartilage, and later by degeneration of the condylar surface. Although osteoarthritic cartilage was found 24 weeks after perforation, degeneration decreased over time. This suggests that remodelling took place after the perforation.

Animals↗
PubMed2001

[Comparison of iodinated and barium-containing contrast media of different viscosity in the detection of pharyngeal perforation].

PURPOSE: In contrast to esophageal perforations, the more radiopaque barium-suspensions are not as important as iodinated aqueous contrast agents for the detection of pharyngeal perforations. This study was performed to find out whether the highly different viscosities (of iodinated and barium-containing contrast agents with comparable radiopacities) are a reason for this. METHODS: Viscosity, subjective difference in contrast, and CT-density of an iodinated aqueous (Telebrix) and a 50 wt/vol% barium-containing contrast agent (Micropaque) were determined. Moreover, to exclude postoperative perforation, 104 patients were prospectively examined by pharyngography using both contrast media. Pharyngographies of patients with perforation were later compared by two independent readers. All patients with perforation were followed up clinically to exclude complications due to barium administration. RESULTS: In-vitro comparison showed comparable radiopacity but the 50 wt/vol% barium-suspension was much more viscous than the iodinated contrast agent. During pharyngography, totally, 14 perforations were clearly delineated with the iodinated aqueous contrast agent. However, two of them were not detected with the barium-suspension. All the other perforations presented equally. CONCLUSIONS: Given a sufficient radiopacity, a low viscosity appears to be essential for a contrast agent to detect especially pharyngeal perforations. Thus, we recommend the sole use of an iodinated contrast agent (at suspicion of aspiration as isoosmolar variant) for this purpose.

Adult↗
PubMed2002

[First findings about the nasal airflow in noses with septal perforation].

BACKGROUND: A nasal septum perforation often leads to considerable complaints like nasal obstruction, crusting, epistaxis or whistling. Up to now there is no certain knowledge about the airflow pattern in noses with septal perforations. METHOD: We performed fluid dynamic experiments on functional nasal models (so-called modified Mink boxes). We investigated the flow pattern in models with septal perforations, different in size and location and in combination with and without septal deviations. RESULTS AND CONCLUSIONS: We have found no essential influence of the location of perforation on the airflow pattern. With increasing size of perforation the streamlines bump toward the posterior border of the perforation, causing turbulence. The whistling during inspiration is based on the principle of a lip whistle. The required flow velocity for vibration of the air depends on the dimension of the perforation. For large perforations it is impossible to get the required high flow velocity to cause a whistle.

Diagnosis, Differential↗
PubMed2002

[Fasciocutaneous radial artery perforator vessels - an anatomic study].

PURPOSE/BACKGROUND: Distal and proximal pedicled forearm flaps that are nourished by radial perforator vessels have been described. These flaps spare the radial artery during flap harvest. The question is, whether it is possible to raise individual free fasciocutaneous radial perforator flaps. METHOD AND MATERIAL: The number, external vessel diameter, and distribution of fasciocutaneous radial perforator vessels were investigated on 20 fresh cadaver arms. All specimen were then treated with the Spalteholz technique to demonstrate the arborizing of the perforator vessels. RESULTS: There was an average of 12 (range 9 to 16) fasciocutaneous perforator vessels per radial artery. The most proximal perforator vessel had an external diameter of 0.8 (range 0.5 to 1.0) mm, the others were measured smaller then 0.5 mm. There was a rich network of anastomoses at the level of the fascia up to the level of the subdermal plexus. CONCLUSIONS: The anatomic basis of the proximally and distally based radial perforator flaps was confirmed. Free flaps based exclusively on fasciocutaneous radial perforators would require supra-microsurgical skills due to the small vessel diameter. For practical reason it seems to be advisable to include parts of the radial artery into such a flap design.

Humans↗
PubMed2003

Vasculature of the peroneal artery: an anatomic study focused on the perforator vessels.

Based on the dissection of 20 fresh cadaver legs, the authors have further defined the vascular anatomy of the peroneal artery and its cutaneous perforator vessels. They identified a total of 95 cutaneous perforators of the peroneal artery greater then 0.3 mm in 20 legs. The average number of cutaneous perforators was 4.8 (range: three to seven) per leg. The cutaneous perforators were either musculocutaneous (34 percent) or septocutaneous (66 percent). The musculocutaneous perforators were found predominantly in the upper two-thirds of the lower leg; the septocutaneous perforators were located in the lower two-thirds of the leg. The external diameter of the cutaneous perforators at the posterior border of the fibula was 0.6 (range: 0.3 to 1.5) mm. The blood supply of the proximal fibula epiphysis and fibula head was found not to be in the vascular territory of the peroneal artery. These results are the basis of the established osteoseptocutaneous fibula transfer, the peroneal fasciocutaneous free flap, and the double-paddle peroneal tissue transfer that all require dissection of highly vascularized tissue adjacent to the fibula, in order to reach the peroneal vessels. These constant anatomic findings should encourage the surgeon to harvest skin flaps just to the level of the posterior border of the fibula, thereby creating perforator flaps based on the peroneal system.

Arteries↗
PubMed2006

[Therapy and course of disease in spontaneous esophageal perforations].

INTRODUCTION: Esophageal perforations occur spontaneously or as a complication of endoscopic procedures. Especially in spontaneous perforation there is ongoing debate regarding the best treatment options. METHODS: 24 patients that were treated at two surgical centers (University Halle, City-hospital Bielefeld) after spontaneous esophageal perforations between 1996 and 2005 were analysed retrospectively. RESULTS: All patients but one underwent surgical treatment with in 2 cases additional stent implantation. Average stay in hospital was 53 days. In-hospital-lethality was 25% (overall lethality 37.5%). Concerning the therapeutic outcome there was no link between patients' age, localization or size of the perforation and the time interval between perforation and treatment. In 22 patients diagnosis was made > 12hrs after the event. CONCLUSIONS: Main problem of the Boerhaave-syndrome is the septic-toxic disease. Prognostic criteria are the patients' health-state and not factors like size of perforation, time of delay or localization of the perforation. Since in case of survival esophageal resection shows good long-term-results, in doubt a radical surgical procedure should be recommended as primary option. Implanting an esophageal stent might become a useful mean of treating patients with spontaneous perforations.

Adult↗
PubMed2000

The relationship between the number, competence, and diameter of medial calf perforating veins and the clinical status in healthy subjects and patients with lower-limb venous disease.

PURPOSE: The role of medial calf perforating veins in the pathogenesis of the skin changes of chronic venous insufficiency (CVI) remains controversial. This study examined the relationship between abnormal medial calf perforating vein structure and function and the clinical severity of CVI. METHODS: Duplex ultrasound was used as a means of determining the number, flow characteristics, and diameter of medial calf perforating veins, and the presence of deep and superficial main stem reflux or occlusion in 50 limbs with no clinical or duplex evidence of venous disease (clinical, etiological, anatomical, and pathological grade [CEAP] 0), 95 limbs with varicose veins only (CEAP 2/3), 58 limbs affected by lipodermatosclerosis but not ulcer (CEAP 4), and 108 limbs affected by healed or open venous ulcer (CEAP 5/6). RESULTS: The proportion of limbs in which any perforating veins and incompetent perforating veins (IPVs) were demonstrated increased significantly with deteriorating clinical status (CEAP 0, 88% and 6%; CEAP 2/3, 95% and 52%; CEAP 4, 98% and 83%; and CEAP 5/6, 98% and 90%, respectively). The total number of perforators, the total number of IPVs, and the median diameters of perforators increased with deteriorating grade (CEAP 0 median diameter, 2 mm [interquartile range, 1 to 3 mm]; CEAP 2/3 median diameter, 3 mm [interquartile range, 2 to 4 mm]; CEAP 4 median diameter, 4 mm [interquartile range, 3 to 5 mm]; and CEAP 5/6 median diameter, 4 mm [interquartile range, 3 to 5 mm]). CONCLUSION: The deteriorating CEAP grade of CVI is associated with an increase in the number and diameter of medial calf perforating veins, particularly those permitting bidirectional flow.

Adult↗
PubMed2004

Scleral perforations in strabismus surgery: incidence and role of prophylactic cryotherapy--a clinical and experimental study.

PURPOSE: To determine the incidence of scleral perforations in strabismus surgery in a tertiary centre setting in India and to evaluate the risk or benefit, if any, of prophylactic cryotherapy following experimental scleral perforations in rabbits. METHODS: Seven hundred eyes of patients that had undergone strabismus surgery (1121 procedures) were examined postoperatively by indirect ophthalmoscopy. In the experimental component, 20 rabbit eyes were perforated with a 6-0 polyglactin suture. In each rabbit, one eye acted as a control while the other eye received a 20 seconds application of prophylactic cryo at the perforation site. They were then monitored for 6 weeks before subjecting some to histopathological examination by light and electron microscopy. RESULTS: Ten scleral perforations were detected in 9 of the patients (incidence of 1.42% of the eyes and 0.89% of the strabismus procedures). In the rabbits, a chorioretinal scar was seen in all perforated eyes. A mild cryo reaction was observed in the cryoed eyes. No other sequelae were seen. Histopathologic studies showed changes consistent with the normal healing process. CONCLUSIONS: Of the human eyes screened, 1.42% showed evidence of scleral perforation following strabismus surgery. In no case were sequelae leading to visual loss observed. In the rabbits no sequelae were observed at 6 weeks of follow-up apart from a chorioretinal scar and a cryoreaction in those eyes in which cryoprophylaxis had been given. Mild cryoprophylaxis did not exert any positive or negative influence on the natural course of scleral perforation in our short-term animal study.

Adolescent↗
PubMed2006

Inadvertent scleral perforation in eye muscle versus retinal detachment buckle surgery.

PURPOSE: Inadvertent scleral perforation is a recognized complication of eye muscle and retinal detachment buckle surgery. If these operations are performed by the same surgeon, it is unknown which of these procedures has a higher risk of scleral perforation. METHODS: In the period from 1999 until 2004, 427 eyes of 317 patients were operated using eye muscle surgery and 81 eyes of 80 patients with retinal detachment buckle surgery. All operations were performed by the same surgeon (JK). In a retrospective, single-center, comparative, observational study, the records of these patients were assessed to determine the number of scleral perforations with retinal damage or drainage of subretinal fluid. RESULTS: In the group receiving retinal detachment buckle surgery there were two cases of scleral perforation. In one case, scleral perforation occurred during buckle installation and in the other case during placement of a cerclage. The rate of scleral perforation was 2.5 % per patient and per eye in this group. In the group receiving eye muscle surgery no scleral perforations occurred. CONCLUSION: The number of scleral perforations was higher in retinal detachment buckle surgery than in eye muscle surgery, with all procedures having been performed by the same surgeon.

Adult↗
PubMed1998

Fibronectin and the extracellular matrix in the perforating disorders of the skin.

Despite detailed microscopic descriptions and clinical observation, little is known regarding the pathogenesis of the perforating disorders of skin, which have traditionally been subdivided into numerous microscopic entities associated with various clinical settings. An increasing body of evidence now suggests that the perforating disorders of skin are akin, and may constitute an expanded single pathologic entity. Each of the classic perforating disorders of skin, including elastosis perforans serpiginosa, perforating folliculitis, reactive perforating collagenosis, Kyrle's disease, and perforating disorder of uremia, have been shown to extrude collagen, elastin, and related extracellular matrix components through the epidermis. Considering a shared pathogenic mechanism among these entities, we explored the possible role of the extracellular matrix, in particular fibronectin, in perforating disorders of skin. Using immunohistochemical and serum determinations of extracellular matrix constituents, including fibronectin, collagen type IV, laminin, and tenascin, we showed consistent serum elevation and/or deposition of fibronectin, in each case, without a commensurate increase in laminin, collagen type IV, and tenascin. We propose that elevated serum and tissue concentrations of fibronectin may be responsible for inciting, in a physiologically aberrant manner, increased epithelial migration and proliferation culminating in perforation.

Adolescent↗