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Spontaneous cerebrospinal fluid rhinorrhoea is a clinical entity that is difficult to both diagnose and treat. A case in a 56-year-old woman with a defect in the lateral wall of the sphenoid sinus and middle cranial fossa floor is presented. Pathogenesis and management of this rare condition are discussed. Copyright 1999 Harcourt Publishers Ltd.
Anomalies of the aortic arch can be deducted by embryology. Aortic ring anomalies (double aortic arch, Art. lusoria, right descending aorta with Lig. arteriosum) have to be opened if clinically indicated. Aortic arch stenosis has to be removed by resection of intraaortic membranes, end-to-end-anastomosis, patch enlargement, or prosthetic bypass graft. Aortic interruptions require a functionally sufficient bridging by end-to-end-anastomosis, prosthetic bypass graft, or interposition of an aortic arch vessel. In 1971 the left common carotid artery was used in a 14 years old boy which seems to be insufficient for bridging the aortic arch defect five years later.
Thirty cases of skin defects of the hand were treated with 32 venous flaps. Seven of the flaps used were flow-through venous flaps (V-V type), in which venous blood flows in and out. Of the arterialized venous flaps into which arterial blood flows, the outflow in nine cases was anastomosed to a vein (A-V type), that in 15 cases to an artery (A-A type), and one flap had inflow only. Twenty-one of the flaps were completely successful, but seven resulted in partial and four in complete necrosis. Indications for V-V flaps are skin defects of small dorsal areas of the fingers, but this type of flap can also be used for skin defects in the dorsal area of the hand, if the number of veins anastomosed is increased. The A-V flap is especially indicated for covering multiple digital skin defects, while the best indication for A-A flaps is a skin defect on the lateral or volar side of the digit which requires simultaneous reconstruction of blood circulation.
BACKGROUND: Nasal cerebral heterotopia is a congenital lesion that is mainly detected in early childhood. The rare cases of this disorder found in adult patients are located intranasally. A common symptom is compromised nasal air passage. Clinical findings include polypoid masses in either the nasal cavity or the paranasal sinuses. To our knowledge, primary cerebrospinal fluid (CSF) rhinorrhea has been reported only twice in these patients. PATIENT: A 64-year-old female patient presented with CSF rhinorrhea proven by beta 2-transferrin testing. Previous head injury or intranasal manipulation were excluded. Anterior rhinoscopy revealed a watery drainage from the right middle meatus. CT scan showed a defect in the lateral roof of the right ethmoid sinus, approximately 5 mm in diameter; MRI revealed a mass in the right ethmoid and frontal sinuses, penetrating the anterior skull base. The lesion was resected by an extranasal approach. It showed a fibrous connection to the frontal lobe. Histologically, the lesion consisted of neural tissue composed of gray and white matter, both with a normal structuring. Dura and skull base were reconstructed. There were no signs of a CSF leak postoperatively. RESULTS AND CONCLUSIONS: The differential diagnosis of CSF rhinorrhea includes traumatic events and neoplasms, elevated intracranial pressure, and connate lesions as encephaloceles and, in rare cases, nasal cerebral heterotopia.
The CST20 gene of Candida albicans was cloned by functional complementation of a deletion of the STE20 gene in Saccharomyces cerevisiae. CST20 encodes a homolog of the Ste20p/p65PAK family of protein kinases. Colonies of C. albicans cells deleted for CST20 revealed defects in the lateral formation of mycelia on synthetic solid "Spider" media. However, hyphal development was not impaired in some other media. A similar phenotype was caused by deletion of HST7, encoding a functional homolog of the S. cerevisiae Ste7p protein kinase. Overexpression of HST7 partially complemented the deletion of CST20. Cells deleted for CST20 were less virulent in a mouse model for systemic candidiasis. Our results suggest that more than one signaling pathway can trigger hyphal development in C. albicans, one of which has a protein kinase cascade that is analogous to the mating response pathway in S. cerevisiae and might have become adapted to the control of mycelial formation in asexual C. albicans.
A 54-year-old woman was referred with spontaneous cerebrospinal fluid (CSF) rhinorrhoea. CT cisternography revealed a defect in the lateral wall of the left sphenoid sinus, with an anteromedial temperosphenoidal encephalocele associated with contrast leakage into the sinus. Subsequent monitoring showed raised intracranial pressure. Transcranial intradural repair of the encephalocele followed by lumboperitoneal shunt for the high pressure abolished the leakage of cerebrospinal fluid.
Twelve members of a family with hereditary cerebellar ataxia of late onset were examined and, in 5, quantitative recording of eye movements were obtained. The initial and most severe symptom in all patients was ataxia of gait, followed by dysarthria and later by dysmetria of the limbs. Clinical examination did not reveal involvement of structures other than the cerebellum. Ocular motor examination showed: (1) inability to hold eccentric gaze resulting in gaze-paretic nystagmus; (2) downward beating nystagmus, accentuated on lateral gaze; (3) defective smooth pursuit, with relative preservation of optokinetic nystagmus induced by full-field stimulation; (4) rebound nystagmus; (5) enhanced gain (eye velocity/head velocity) of the vestibulo-ocular reflex during rotation in darkness; (6) decreased ability to suppress the vestibulo-ocular reflex during fixation of an object rotating with the patient; (7) saccadic dysmetria, especially downward overshoot; and (8) square wave-jerks. Although each of these signs can probably occur with lesions elsewhere in the brain, in combination they are highly suggestive of cerebellar involvement. With the reservation that we do not yet have pathological confirmation of the location of our patients' lesions, our results support the suggestion that the cerebellum specifically: (1) helps maintain eccentric gaze; (2) produces smooth pursuit eye movements; and (3) modulates the amplitude of saccadic eye movements. Many of the characteristics of the altered vestibulo-ocular responses and rebound nystagmus could be explained by the underlying anomaly in the smooth pursuit system.
Closure of large or cosmetically important surgical wounds is often a difficult problem. The utilization of contiguous island flaps--the double V to Y technique--is evaluated as a primary method of closure. The results obtained with this technique were of high cosmetic quality in all areas of the body in which surgery was performed. Use of the technique avoids tissue distortion, cosmetic defects, grafting, and later reconstructive surgery.
PURPOSE: To describe the upper eyelid island orbicularis oculi myocutaneous flap, medially or laterally based, for reconstruction of periorbital defects. METHODS: During the past three years we have used the island orbicularis oculi myocutaneous flap in 62 patients with tumors of the periorbital area, with the following indications: (a) anterior lamellar defects of the medial aspect of the upper eyelid, when the peripheral arcade is intact; (b) up to 2/3 anterior lamellar lower eyelid defects; (c) inner and outer canthus defects; and (d) defects of the peripalpebral area (the lateral half of the eyebrow, bridge of the nose and suprazygomatic areas). RESULTS: The flap proved to be flexible, safe, relatively simple, and provided good functional and aesthetic results. Complications were minimal. CONCLUSIONS: The upper eyelid island orbicularis oculi myocutaneous flap may be a useful tool for periorbital reconstruction.
PURPOSE: To report a 64-year-old woman's case of infectious crystalline keratopathy (ICK) that occurred 9 years after the penetrating keratoplasty (PKP). METHODS: This study includes clinical history and histopathologic findings of the case. RESULTS: As historic background, the patient underwent PKP for lattice dystrophy and later, persistent epithelial defect occurred on the graft. Topical steroid treatment and a therapeutic soft contact lens were applied; however, ICK developed and second PKP was performed. In the ICK region, yeasts were cultured and histologically, degenerated keratocytes containing yeast particles surrounded the intralamellar plaques of yeasts without accompanying inflammatory cells. CONCLUSION: This case is possibly the first to develop ICK long after PKP. Histologically, ICK presumably occurred based on the immunologically incompetent condition, and, by verifying the previous reports, the neurotrophic background after PKP may partially be involved in the development of ICK.
Unique treatment of a necrotizing infection of the abdominal wall, using a temporary closure with polyvinyl, led to survival in a patient with a stab wound, who developed extensive abdominal myofascial necrosis. A large abdominal wall defect was repaired later with polypropylene mesh and a split-thickness autograft.
Surgical removal of the soft palate in cases of neoplastic disease has a functionally detrimental effect on the patient, resulting in rhinolalia and nasal regurgitation. The authors describe their original surgical technique for repairing the lateral soft palate defect using a uvulopalatal flap. The flap is readily available and the procedure is single staged and without sequela. The aim of this reconstructive procedure is to obtain a diminished soft palate defect by primary surgery. In five patients who underwent a partial excision of the soft palate, the surgical defect was corrected at the time of initial surgery by a uvulopalatal flap. In this technique, the surface of the defect was diminished, postoperative rhinolalia and regurgitation were unremarkable, and sometimes an obturator was obviated. Using a local myomucosal flap, the procedure is simple, safe, and effective.
Complete oral rehabilitation after oromandibular resection is a goal that is frequently difficult to attain. Poor speech, inability to eat a solid diet, and cosmetic deformity are all potential problems. The introduction of osseointegrated implants and free vascularized bone grafting are two techniques that have permitted improved results of oromandibular reconstruction. When used together they provide the best possibility for providing oral continence, a stable denture, and minimal cosmetic deformity. The free vascularized iliac crest has been used widely to reconstruct mandibular defects with the placement of enosseus implants. However, the radius provides a good alternative to reconstruct the mandible. We report four cases of mandibular reconstruction with the use of the free vascularized radius with subsequent placement of osseointegrated implants. The results of these cases suggest that enosseus implants can be used successfully in the radius. The radius is ideal to reconstruct small to moderate-sized defects of the lateral mandible with loss of oral mucosa.
We have achieved functional reconstruction for a bilateral upper alveolar bone, gingival, and palatal defect that has various problems originating from instability of the prosthesis using the fibula osteocutaneous flap with osseointegrated implants. The flap had three bone segments and two skin paddles. The combined bone segments created the upper alveolar arch, and the skin paddles closed the palatal defect. Nine months later, prosthodontic treatment was performed successfully. Our procedure restored the patient to masticatory function of the upper jaw, intelligible speech, and natural facial appearance. As a result, quality of life of the patient was extremely improved.
Pectus excavatum occurs in two thirds of children with Marfan's syndrome. The characteristics of seven children with Marfan's syndrome and pectus excavatum were compared with those of 38 children who had pectus excavatum without Marfan's syndrome. The children with Marfan's syndrome presented later, had progressive defects, and were more likely to have wound problems; however, acceptable cosmetic and functional results after chest wall repair were obtained in the patients with Marfan's syndrome.
Neglected skin carcinomas are not very often in our days. It is known that skin is the most common site of malignancy Squamous cell carcinoma (SCC) is the second most common malignancy of the skin. We report a combined surgical treatment in an unusual case of a squamous cell carcinoma (T4 n0 m0) localized on scalp, presented primarily as a frontal ulcerative bloody mass, with no palpable lymph nodes and a whole body negative computed tomography. Three months after the first surgical procedure, the tumour reappeared presenting left frontal lobe invasion. A combined surgical management (neurosurgery and plastic surgery) was realized, in order to remove the tumour and to cover the defect. Three months later the tumour recrudesced invading the left antrum, infiltration of remained parotid gland and an ipsilateral mandible osteolysis, besides a 2 cm size distal metastasis at the right upper lobe of the lung was revealed. This article, through case report and a brief review of the literature, offers criteria for the surgical treatment of SCC that arise on the scalp.
Colour discrimination was assessed by means of the Farnsworth-Munsell 100-Hue test in 54 patients being treated for tuberculosis with ethambutol and 50 patients who were treated for tuberculosis by drugs other than ethambutol. The ethambutol group showed significantly more errors than controls along the deuteran axis. The sub-group of ethambutol treated patients who had been taking the drug for more than 2 months showed significantly more errors along the tritan axis. It is concluded that subclinical colour discrimination impairment is relatively common in patients receiving ethambutol and that a deuteran type of defect is an early and a tritan type of defect is a later manifestation of ethambutol toxicity.
Clinical and photobiological differences between Japanese patients belonging to xeroderma pigmentosum (XP) variant and complementation group A were studied, especially focussing on XP variants. All of the XP variant patients commonly manifested a delayed onset of pigmented freckles as the initial symptom around 5--7 years old without acute sun erythema, in contrast to the early manifestation of acute solar erythema during infancy in XP group A patients. Six XP variant patients tested showed normal and three showed low minimal erythema doses (MEDs), at the 24 h reaction peak after monochromatic u.v. (280--330 nm) irradiation, while XP group A patients had definitely low MEDs (280--350 nm) with abnormally delayed peaking of the erythema reaction at 72 h. In cell culture studies, all XP variant strains exhibited normal levels of 254 nm u.v.-induced, unscheduled DNA synthesis (UDS), 1.4--2 times more accumulation of excision DNA breaks by arabinofuranosyl cytosine and hydroxyurea due to a subtle defect in the later polymerization step of excision repair, and a slightly higher sensitivity to u.v. cell killing than did normal cells. With respect to the synergistic effect of caffeine on u.v. lethality, XP variant strains could be divided into caffeine-susceptible (eight cases) and caffeine-resistant (two cases) subgroups. The extent of excision-break accumulation was greater in the former subgroup than in the latter. All of eight XP variant patients whose cells showed caffeine potentiation of u.v. lethality had already had skin malignancies, but two sib patients whose cells were caffeine-resistant had as yet had no neoplasm. It is strongly suggested that in XP variant, caffeine-susceptibility may be related to the development of neoplasms.