Treatment of Chronic Anal Fissure with Topical Nitroglycerin

PURPOSE: Lateral partial internal sphincterotomy is considered as the best surgical procedure of the idiopathic chronic anal fissure. Because the aim of surgery is to relieve sphincter spasm, and occasional minor incontinence following surgery has been reported, alternative chemical means of spasmolysis could be considered. Nitric oxide (NO) is known to be a major inhibitory neurotransmitter of the internal anal sphincter, so we investigated the effect of topical nitroglycerin for chronic anal fissure. METHODS: Twenty nine patients (19 women, mean age 36 years) with chronic anal fissure were treated with 0.2% nitroglycerin ointment. Pain score was quantitated with Visual Analog Scale (VAS) in regular time interval. Manometry was performed in five patients and maximum anal resting pressure (MARP) was measured before and 30 minutes after topical application of nitroglycerin ointment. All patients were re-examined and questioned regarding pain relief and side effects 2 years after cessation of treatment. RESULTS: All had appearances of chronicity and pain. There were 25 posterior and 12 anterior fissures. Pain was significantly abolished within 5 minutes after application of nitroglycerin ointment. Mean pain score (VAS) was 6.03 before, 0.69 30 min after, 0.58 1 week after, and 0.53 3 weeks after application of nitroglycerin ointment (P<0.001). MARP was markedly reduced 30 minutes after application of nitroglycerin from 166.2 15.1 cmH2O to 108.8 20.9 cmH2O (P<0.05). The 57% of patients (13/23) were effective for 2 years and 22% of patients (5/23) had recurred their symptom after cessation of nitroglycerin ointment. Two patients (9%), whose fissures had not healed completely within 3 weeks were requested for surgery and the other 2 patients (9%) had been operate due to the side effect of the ointment. Mild headache (7%) and dizziness (10%) were occured, but well tolerated when the dose was reduced. CONCLUSIONS: Topical application of nitroglycerin ointment seems to be an effective and safe alternative in the treatment of chronic anal fissure.

A Case of Orbital Pseudotumor

The orbital pseudotumor is non-specific inflammatory disease and is unrelated with specific local or systemic disease. The major symptoms are orbital pain, limitation of the ocular movement and exophthalmos. The inflammatory change can be diffuse within the orbit or may involve a specific structure such as an extraocular muscle or lacrimal gland. It occasionally occurs acutely, but chronically in some cases. It may bring about scarring accompanied by the intraorbital soft tissue including retroorbital fat or extraocular muscles. This can be detected by ultrasound, CT orMRI. The findings by imaging procedures are thickened extraocular muscles, diffuse inflammation of intraorbital soft tissue, enlarged lacrimal gland and enhanced periorbital tissue like "a ring". Sometimes, the focal masses may be seen around the optic nerve, within the retroorbital fat or near the opbital periosteum. The diagnosis of pseudotumor is made by excluding other causes or orbital mass lesions, such as neoplasm, and other causes of orbital inflammation such as Graves' disease and local infection. Treatments are usually used systemic high-dose steroids, additionally surgical excision and radiation. Authors experienced a 52-year old female with progressively enlarged tumor in right orbital area, exophthalmos and loss of sight was treated with surgical excision, and then the defect was reconstructed with the radial forearm free flap successfully.

ANALYSIS OF NASAL TIP PLASTY

Since the nose is the most prominent part in the face, the plastic surgeons are interested in the continued effort for rhinoplasty. Nasal tip projection is essential to optimal nasal for the patient's face. But, the nasal tips of Orientals are characterized by bulbous appearance due to thick and tense skin, flaring of nostril. and restriction of nasal tip projection due to underdevelopment of medial crus of alar cartilage and short columella. Most orientals want to correct their nasal tip as well as shape of nose. We present clinical cases of various nasal tip deformities which were corrected with various operative methods through either alar rim incision of open rhinoplasty incision depending upon the severity of tip deformity in order to achieve more natural tips and good nasal tip projection. And the clinical cases were categorized into causes of nasal tip deformity and methods of nasal tip augmentation. We are reporting these reporting these cases with review of literatures.

A case report of congenital epulis: Congenital gingival granular cell tumor

The congenital epulis is a rare benign lesion which has an uncertain histogenesis. But, recently it is suggested that it derives either from histiocytic/mesenchymal cells or myofibroblasts which based on many immunohistochemical study. Neumann first described congenital granular cell tumor which developed from the gingiva as congenital epulis in 1871. Epulis means "on the gum" or "gumboil" in Greek word. Congenital epulis is located exclusively on the anterior or lateral alveoiar ridge with marked predilection for female infants. The mass was covered with a nonpapillated stratified squamous epithelium of uniform thickness. There was no pseudoepitheliomatous hyperplasia. Granular cells have abundant cytoplasm with distinct borders and mitotic figures were rarely found. Six days old female neonate who had 2 x3 cm sized mass with 2 x2 cm neck in the gingival and anterior alveolar ridge of mandible was operated by simple excision and coverage by local mucosal flap. After two years she had normal teeth eruption and no recurrence.

ANALYSIS OF PLASTIC SURGERY IN ELDERLY

In modern society we have been gradually interested in the elderly and easily come into contact with many medical favors to enhance the quality of life, and the elderly are gradually increasing owing to the development of the basic science such as new diagnostic machinery, operative technique and development of the therapeutics. However, the variation of the environment has increased the possibility to be exposed to the dangerous factors, and it has given rise to the problems about the quality of the elderly life. It has also greatly enlarged in medical as well as social. Therefore, the frequency of the elderly reconstructive surgery to increase the quality of the elderly life by operation without life or death has increased in plastic surgery. So authors thought that the safe operative study is necessary. We reviewed the case of 102 elderly patients (65 years of age), who were operated during the period from 1988 to 1995, and analyzed the age & sex distribution, classification & distribution of diseases in elderly, operation of plastic & reconstructive surgery in elderly, anesthetic, methods, underlying diseases, and postoperative complications through the patient records. We also examined postoperative function, aesthetic improvement, progression of the quality of life by telephone and analyzed the elderly classification and elderly plastic & reconstructive surgery. The results are as follows : 1. There were benign neoplasm, facial bone fracture, aesthetic surgery, skin and soft tissue defect, complicated diabetic mellitus, malignant ulcer, malignant neoplasm, pressure sore in elderly diseases of plastic & reconstructive surgery. 2. We mainly performed skin graft, flap surgery, ORIF, aesthetic surgery. 3. The recovery rate after postoperative evaluation shows that ; 1) 52% of total interviewee feel that their QOL has improved. 2) 24% of total interviewee feel that their QOL has not changed. 3) 24% of total interviewee feel that their QOL has deteriorated. We report the point at issue and statistical examination with record investigation.