Not all facial swellings are angioedemas

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Paediatric traffic accident and obstructive sleep apnoea by antrochoanal polyps: case report and literature review.

Antrochoanal polyps are hyperplasias of the nasal mucosa, which have their origin in the maxillary sinus and extend through the nasal cavity and the choanae into the naso- and oropharynx. In children antrochoanal polyps represent one of the more frequent manifestations of paediatric nasal polyposis. Most studies on antrochoanal polyps in children report only on nasal obstruction, hyponasal speech and snoring, which are also encountered in the most common cause of obstructive sleep apnoea syndrome; i.e. adenoid or tonsillar hyperplasia. Only very few studies report on additional health hazards by antrochoanal polyps ranging from obstructive sleep apnoea syndrome to swallowing disorders and cachexia. We present the case of an 8 year old girl with a bicycle accident caused by excessive daytime sleepiness and obstructive sleep apnoea syndrome due to an extensive antrochoanal polyp. After a transnasal polypectomy and meatotomy type II the obstructive sleep apnoea and day time sleepiness resolved completely. Awareness of this additional health hazard is important and correct evaluation and timely diagnosis of a potential antrochoanal polyp is mandatory because minimally invasive rhinosurgery is highly curative in preventing further impending problems.

Assessment of speech perception and communication skills in adolescents with cochlear implants for pre- and peri-lingual deafness.

OBJECTIVE: This study aimed to assess speech perception and communication skills in adolescents between ages 8 and 18 that received cochlear implants for pre- and peri-lingual deafness. METHODS: We studied 15 adolescents, aged 12 to 23 years, with late cochlear implantation. Speech perception was assessed with the Bishop sentences test and a memory number sequence test at 3-9 years after cochlear implantation. A questionnaire completed retrospectively was used to investigate communication skills pre- and post implantation. RESULTS: Six individuals achieved grammar comprehension scores comparable to children 8-10 years old with normal hearing; only 3 individuals achieved a percentile rank higher than 50% in the memory number sequence test. The self-reported communication skills improved after cochlear implantation in all adolescents. CONCLUSIONS: Speech perception skills of adolescents with late implantation for pre- and peri-lingual deafness are typically inferior to those of children with normal hearing at the age of 10. However, when the evaluation of the cochlear implant outcome was broadened with the use of a questionnaire, many individuals reported that they participated more actively in conversations, spoke more actively to unknown individuals, and were more easily understood by others.

Radiation dose reduction in computer assisted navigation for functional endoscopic sinus surgery--cadaver head experiments and clinical implementation.

OBJECTIVES: Computed tomography based navigation for endoscopic sinus surgery is inflationary used despite of major public concern about iatrogenic radiation induced cancer risk. Studies on dose reduction for CAS-CT are almost nonexistent. We validate the use of radiation dose reduced CAS-CT for clinically applied surface registration. METHODS: Dose reduced CAS-CT of mineral salt fixed, human cadaver heads with 9.6, 6, 4, 2 and 1.1 mGy were compared with the reference dose at 65 mGy CTDI (CT-Dose Index). For each CT dose with different surface resolution, the precision of the soft touch registration was measured with target registration error (TRE). In a practical step, dose reduced protocols were tested for 12 months. RESULTS: Using surface registration at highest and lowest doses, TRE did not differ significantly for registration accuracy. Protocols tested preserved technical registration accuracy and the pragmatics of dose reduction was limited only by different needs for picture quality of the individual surgeon, use for uncomplicated or revision surgery, and reserve for other unexpected factors (movement artifacts). CONCLUSIONS: The accuracy of today's surface registration technology was not the limit for dose reduction. It is the amount of diminished picture quality tolerated by the individual surgeon and the question of how much of the ever refined radiological picture resolution is necessary at all. For the majority of operations, consensus for a significant 6-fold radiation dose reduction from 65 mGy to 9.6 mGy CTDI could be realized illustrating a big potential for similar approaches in other institutions.

Hydrodissection for subperichondrial septoplasty - an experimental anatomical study.

OBJECTIVES: The effect of hydrostatic infiltrations for subperichondrial dissection is controversial. Classical textbooks promote it as the "key step in elevating the flaps" or consider its practicability "a mere fable". Moreover, case reports describe fatal side effects. Up to now, experimental tests are missing. DESIGN: Experimental study. MATERIALS AND METHODS: Three surgeons simulated subperichondrial hydrodissection with 20 mineral salt fixed human cadaver heads. One ml lidocaine 5% with 1:105 adrenaline and India ink was infiltrated. Each septum was examined histologically using serial 3 microm sections in 150 microm intervals. Tissue cleavage containing the ink deposits with minimal distance to the proposed subperichondrial zone, intravasal spread and tissue deposition were analyzed. RESULTS: Every injection produced a physical dissection (n = 20). However, dissected planes were localized mostly in the supra-perichondrial connective tissue (n = 8) or within the perichondrium (n = 4). Only five cases showed the propagated correct dissection in a subperichondrial zone. Three anomalous septa were excluded from quantitative analysis. Infiltrated matter did not only accumulate within the dissection plane but also penetrated the surrounding vessels of the septal intumescentia (n = 8). CONCLUSION: Hydrostatic infiltrations represent an unreliable surgical technique for dissection of an anatomical correct subperichondrial plane but can be useful for anesthesia and hemostasis, however, using high pressure and high volume infiltrations might foster serious side effects.

[Spontaneous dural arterio-venous fistula at the cavernous sinus: detected by decompensation following endoscopic sinus surgery]. / Spontane durale arteriovenöse Fistel am Sinus cavernosus: Demaskierung nach endoskopischer Nasennebenhöhlen-Operation.

Spontaneous dural arterio-venous fistulas can imperceptibly develop over a long time period before they suddenly develop symptoms like bruit, loss of vision, exophthalmos and conjunctival injection. We present the rare case of an occult, para-infectious, dural arterio-venous fistula which became symptomatic after endoscopic sinus surgery. Conjunctival injection and slight exophthalmos developed due to decompensation of venous drainage probably by intraoperative positioning of the patient, positive pressure ventilation and nasal packing.

CT radiation dose for computer-assisted endoscopic sinus surgery: dose survey and determination of dose-reduction limits.

BACKGROUND AND PURPOSE: Computer-assisted navigation is increasingly used in functional endoscopic sinus surgery (FESS) to prevent injury to vital structures, necessitating preparative CT and, thus, radiation exposure. The purpose of our study was to investigate currently used radiation doses for CT in computer-assisted navigation in sinus surgery (CAS-CT) and to assess minimal doses required. MATERIALS AND METHODS: A questionnaire inquiring about dose parameters used for CAS-CT was sent to 30 radiologic institutions. The feasibility of low-dose registration was tested with a phantom. The influence of CAS-CT dose on technical accuracy and on the practical performance of 5 ear, nose, and throat (ENT) surgeons was evaluated with cadaver heads. RESULTS: The questionnaire response rate was 63%. Variation between minimal and maximal dose used for CAS-CT was 18-fold. Phantom registration was possible with doses as low as 1.1 mGy. No dose dependence on technical accuracy was found. ENT surgeons were able to identify anatomic landmarks on scans with a dose as low as 3.1 mGy. CONCLUSIONS: The vast dose difference between institutions mirrors different attitudes toward image quality and radiation-protection issues rather than being technically founded, and many patients undergo CAS-CT at higher doses than necessary. The only limit for dose reduction in CT for computer-assisted endoscopic sinus surgery is the ENT surgeon's ability to cope with impaired image quality, whereas there is no technically justified lower dose limit. We recommend, generally, doses used for the typical diagnostic low-dose sinus CT (120 kV/20-50 mAs). When no diagnostic image quality is needed, even a reduction down to a third is possible.

Exercise training in chronic heart failure: why, when and how.

The management of patients with chronic congestive heart failure has changed considerably during the last decade. Until recently, restriction of physical activity was recommended for patients with chronic heart failure. However, the knowledge that training influences largely the periphery rather than the heart itself has led to a dramatic change in the approach toward training in patients with chronic heart failure. Why to train patients with chronic heart failure: Training increases exercise tolerance by an average of 20% in chronic heart failure regardless of etiology (ischemic or non-ischemic cardiomyopathy) or severity of left ventricular dysfunction. Available data, while limited, demonstrate that increases in exercise capacity are paralleled by an improvement in quality of life. Studies have consistently demonstrated that training has no deleterious effect on central haemodynamics, left ventricular remodeling, systolic or diastolic function, or myocardial metabolism. At present, there are insufficient data to determine the effect of training on prognosis, but trials are currently underway to address this. When to train patients with chronic heart failure: Exercise training should be performed only with the patients that have been in a stable clinical condition for a period of at least 3-4 weeks. Clinical stability is defined as no change in symptoms, weight, drug regimen, or NYHA class over this period. How to train patients with chronic heart failure: Initially, the program should be supervised for a period of 2 to 4 weeks; home-based programs are usually appropriate thereafter. Activities that can be maintained for a lifetime should be encouraged, and the focus should be on aerobic-type activities. The intensity level should be targeted to about 50%-70% of peak VO2 and/or Borg ratings of 12-14 ("walk and talk").

Motor evoked potentials from masseter muscle induced by transcranial magnetic stimulation of the pyramidal tract: the importance of coil orientation.

BACKGROUND: Reliable recording of motor evoked potentials (MEPs) of the masseter muscle by transcranial magnetic stimulation (TMS) has proved more difficult than from facial or intrinsic hand muscles. Up to now it was unclear whether this difficulty was due to methodological and/or anatomical reasons. METHODS: The mechanism of pyramidal cell activation in masseter MEPs was investigated by using magnetic and electric transcranial stimulation. Analysing the effect of magnetic coil positioning and orientation over the scalp, and scrutinizing the masseter recording technique to avoid compound motor action potential (CMAP) contamination from facial muscles, an optimized method of masseter MEPs was developed. RESULTS: In particular, an antero-lateral inducing current orientation in the stimulating coil, approximately paralleling the central sulcus, proved clearly more effective for the masseter muscles than the postero-lateral orientation (P=0.005) found optimal for intrinsic hand muscles. The thus evoked masseter MEPs by transcranial magnetic stimulation (TMS) were found to be identical in shape, amplitude and latency as those evoked by transcranial electric stimulation (TES), evidencing a direct rather than trans-synaptic activation of the pyramidal cells. CONCLUSIONS: We conclude that in TMS evoked MEPs of masseter muscles, the direct stimulation of the pyramidal tract is more easily achieved than the trans-synaptic activation, which is in contrast to the intrinsic hand muscles. We hypothesize that the presynaptic projections to pyramidal cells of the masticatory muscles are less abundant than in hand muscles, and are therefore less accessible to trans-synaptic stimulation.

Effect of exercise training on postexercise oxygen uptake kinetics in patients with reduced ventricular function.

BACKGROUND: The time required for oxygen uptake (O(2)) to return to baseline level (recovery kinetics) is prolonged in patients with reduced ventricular function, and the degree to which it is prolonged is related to the severity of heart failure, markers of abnormal ventilation, and prognosis. In the present study, we sought to determine the effect of exercise training on O(2) recovery kinetics in patients with reduced ventricular function. METHODS: Twenty-four male patients with reduced ventricular function after a myocardial infarction were randomized to either a 2-month high-intensity residential exercise training program or to a control group. O(2) kinetics in recovery from maximal exercise were calculated before and after the study period and expressed as the slope of a single exponential relation between O(2) and time during the first 3 min of recovery. RESULTS: Peak O(2) increased significantly in the exercise group (19.4 +/- 3.0 mL/kg/min vs 25.1 +/- 4.7 mL/kg/min, p < 0.05), whereas no change was observed in control subjects. The O(2) half-time in recovery was reduced slightly after the study period in both groups (108.7 +/- 33.1 to 102.1 +/- 50.5 s in the exercise group and 122.3 +/- 68.7 to 107.5 +/- 36.0 s in the control group); neither the change within or between groups was significant. The degree to which O(2) was prolonged in recovery was inversely related to measures of exercise capacity (peak O(2), watts achieved, and exercise time; r = - 0.48 to - 0.57; p < 0.01) and directly related to the peak ventilatory equivalents for oxygen (r = 0.59, p < 0.01) and carbon dioxide (r = 0.57, p < 0.01). CONCLUSION: Two months of high-intensity training did not result in a faster recovery of O(2) in patients with reduced ventricular function. This suggests that adaptations to exercise training manifest themselves only during, but not in, recovery from exercise.

Symptomatic mechanical heart valve thrombosis: high morbidity and mortality despite successful treatment options.

BACKGROUND: Recommendations for treatment of mechanical prosthetic heart valve thrombosis (PVT) include systemic thrombolysis and/or reoperation. Data on complications and outcome are limited. METHODS: Clinical and echocardiographic findings of 17 patients with mechanical PVT were reviewed. Complications and outcome of surgery and/or thrombolysis were analysed. Prospective follow-up was obtained. RESULTS: Symptomatic PVT occurred 8.4 +/- 7.2 years after mechanical valve replacement at mean age 55 +/- 15 years. Thrombosis involved the mitral valve in 12 patients (71%), the aortic valve in 4 (24%) and the tricuspid valve in one (6%). The reason for PVT was inadequate anticoagulation in 11 patients (65%), endomyocardial fibrosis in 2 (12%) and unknown in 4 (24%). Prior to diagnosis, systemic emboli occurred in 6 patients (35%). Thirteen patients (76%) presented in functional class NYHA IV. Haemodynamic valve obstruction was documented by echocardiography in 15 patients (88%). Treatment included primary reoperation in 12 patients (71%), thrombolysis with urokinase in 3 (18%) (with reoperation in 1), reinstitution of adequate anticoagulation in one (6%); death occurred before treatment in one (6%). Intraoperatively, both pannus and thrombus were found in 5 of 13 patients (38%). Treatment-related emboli occurred in 5 patients (29%), to the brain in 3, to the legs in one and to a coronary artery in one. Five patients died (mortality 29%) within 30 days due to multiorgan failure/septicaemia (3 patients), congestive heart failure (1), or cerebral emboli (1). Follow-up after 28 +/- 28 months in the 12 surviving patients was unremarkable. CONCLUSIONS: The most common aetiology for obstructive PVT is thrombus formation due to inadequate anticoagulation. PVT remains a serious complication with high morbidity and mortality despite aggressive treatment by thrombolysis and/or surgery. Surgery is often needed due to the frequent presence of pannus and/or large thrombi. However, long-term prognosis after successful treatment of PVT is excellent.

Effect of exercise training on heart rate variability in patients with new-onset left ventricular dysfunction after myocardial infarction.

BACKGROUND: Cardiac rehabilitation with exercise training alters sympathovagal control of heart rate variability (HRV) toward parasympathetic dominance in patients after acute myocardial infarction (MI). However, its effects on HRV in patients after MI with new-onset left ventricular dysfunction are yet unknown. We aimed to investigate the effects of 8 weeks of supervised, high-intensity exercise training on time- and frequency-domain measures of HRV in this selected patient population. METHODS AND RESULTS: Twenty-five men with an acute MI and a low ejection fraction were randomly assigned to enter or not to enter a training program in a regional rehabilitation center. HRV was evaluated before and after 1 and 2 months of training and at 12 months. Maximal exercise testing with respiratory gas exchange was performed at baseline and after training. Resting heart rate decreased (P <. 01) and the percentage of R-R intervals differing >50 ms from the preceding one (pNN50) increased (P <.05) after training. The standard deviation of R-R intervals (SDRR) tended to increase, but frequency-domain indexes remained unchanged. There was a significant decrease in SDRR (P <.05) and high-frequency power (P <.01) at 12 months in untrained patients. Exercise time increased by 38% and maximal oxygen uptake increased by 29% in the training group (P <. 01). CONCLUSIONS: Despite beneficial effects on clinical variables, exercise training did not markedly alter HRV indexes. A significant decrease in SDRR and high-frequency power in the control group suggests an ongoing process of sympathovagal imbalance in favor of sympathetic dominance in untrained patients after MI with new-onset left ventricular dysfunction.

Exercise training and myocardial remodeling in patients with reduced ventricular function: one-year follow-up with magnetic resonance imaging.

BACKGROUND: Exercise training is now an accepted therapeutic intervention in patients with reduced ventricular function after a myocardial infarction. However, there are conflicting reports on the effects of training on the remodeling process of the heart, and previous studies have only assessed short-term effects of training. METHODS AND RESULTS: Twenty-five patients with reduced ventricular function after myocardial infarction were randomly assigned to an intensive 2-month exercise training program or to a control group (control group: n = 13, aged 55 +/- 7 years, ejection fraction 33.3% +/- 6%; exercise group: n = 12, aged 56 +/- 5 years, ejection fraction 31.5% +/- 7%) and followed up for 1 year. Measures of left ventricular size, function, and wall thickness in the infarct and noninfarct areas were made by magnetic resonance imaging at baseline, after the 2-month training period, and 1 year later. Maximal oxygen uptake increased in the trained group, from 19.7 +/- 3 mL/kg per minute at baseline to 25.1 +/- 5 and 24.2 +/- 5 mL/kg per minute after 2 months and 1 year, respectively (P <.05 vs baseline for both), whereas the control group did not change significantly. Ejection fraction, end-diastolic volumes, and end-systolic volumes did not change at any measurement point throughout the study period in either the trained or control groups. Myocardial wall thickness measurements at end-diastole and end-systole and their differences determined by magnetic resonance imaging yielded no significant interactions between groups. When myocardial wall thickness measurements were classified by infarct or noninfarct areas, no differences were observed between groups over the study period. CONCLUSIONS: Intensive exercise training in patients with reduced ventricular function resulted in a significant improvement in exercise capacity after 2 months, and this improvement was sustained over 1 year. In contrast to some recent reports, training had no deleterious effects on left ventricular volume, function, or wall thickness regardless of infarct area.

Influence of high-intensity exercise training on the ventilatory response to exercise in patients with reduced ventricular function.

BACKGROUND: Exercise training increases exercise capacity in patients with reduced ventricular function in part through improved skeletal muscle metabolism, but the effect training might have on abnormal ventilatory and gas exchange responses to exercise has not been clearly defined. METHODS: Twenty-five male patients with reduced ventricular function after a myocardial infarction were randomized to either a 2-month high-intensity residential exercise training program or to a control group. Before and after the study period, upright exercise testing was performed with measurements of ventilatory gas exchange, lactate, arterial blood gases, cardiac output, and pulmonary artery and wedge pressures. RESULTS: In the exercise group, peak VO2 and VO2 at the lactate threshold increased 29 and 39%, respectively, whereas no increases were observed among controls. Maximal cardiac output increased only in the exercise group (1.7 L x min(-1), P < 0.05), and no changes in rest or peak exercise pulmonary pressures were observed in either group. At baseline, modest inverse relationships were observed between pulmonary wedge pressure and peak VO2 both at rest (r = -0.56, P < 0.05) and peak exercise (r = -0.43, P < 0.05). Maximal VE/VCO2 was inversely related to maximal cardiac output (r = -0.72, P < 0.001). Training did not have a significant effect on these relationships. Training lowered VE/VO2, heart rate, and blood lactate levels at matched work rates throughout exercise and tended to lower maximal Vd/Vt. The slope of the relationship between VE and VCO2 was reduced after training in the exercise group (0.33 pre vs 0.27 post, P < 0.01), whereas control patients did not differ. CONCLUSIONS: Exercise training among patients with reduced left ventricular function results in a systematic improvement in the ventilatory response to exercise. Training increased maximal cardiac output, tended to lower Vd/Vt, and markedly improved the efficiency of ventilation. Peak VO2 and ventilatory responses to exercise were only modestly related to pulmonary vascular pressures, and training had no effect on the relationships between exercise capacity, ventilatory responses, and pulmonary pressures.

[Cardiovascular diseases and sports]. / Kardiovaskuläre Erkrankungen und Sport.

Regular physical activity has been found helpful--contrary to previous belief--in heart disease and has a positive effect on the wellbeing of the patient. A positive effect on the mortality rate from coronary heart disease with normal left ventricular function has been found. The physical performance of the patient with impaired left ventricular function increases via reduction of peripheral vascular resistance, increased blood flow and more efficient muscle metabolism. Patients with arterial hypertension profit equally from a regular workout. But in the presence of end organ damage high intensity sports should be avoided. In cases of congenital valvular disease with heart failure and right and left ventricular congestion the activity level should be adapted to the symptoms. Hypertrophic cardiomyopathy is the most common reason for sudden death in young athletes. If diagnosed, all high intensity sports are strictly forbidden. Threatening ventricular arrhythmias are seldom found in young adults. Symptomatic arrhythmias should be investigated for organic causes.

Influence of intensive physical training on urinary nitrate elimination and plasma endothelin-1 levels in patients with congestive heart failure.

BACKGROUND: Congestive heart failure (CHF) is associated with increased peripheral vascular resistance. Exercise-induced shear stress may release endothelial relaxing factors, such as nitric oxide (NO), and inhibit the production of vasoconstrictors such as endothelin-1 (ET-1) thereby modulating vascular tone. We examined the effect of intensive training on ET-1 plasma concentrations and NO-metabolite elimination in patients with CHF after acute myocardial infarction. METHODS: Seventeen patients with CHF after a myocardial infarction were randomized to an exercise group (n = 9), who performed physical training for 8 weeks, or a control group (n = 8) who received usual care. A physical examination, pulmonary function test, and a maximum exercise test were performed, and 24-hour urinary nitrate elimination and ET-1 in plasma were determined before and at the end of the study period. RESULTS: Maximal oxygen uptake remained unchanged in controls (17.9 +/- 1.4 to 18.1 +/- 1.5 mL/(kg min) but increased in the exercise group (from 20.4 +/- 0.75 to 26.7 +/- 1.4 mL/(kg min). After 8 weeks the urinary nitrate elimination in controls was significantly decreased (1.25 +/- 0.20 to 1.03 +/- 0.22 mmol/24 hours; P < 0.001), while it was unchanged in the exercise group (1.26 +/- 0.23 to 1.39 +/- 0.28; P = 0.71). Plasma ET-1 levels did not change after 8 weeks (7.87 +/- 0.62 versus 7.57 +/- 0.75 and 7.13 +/- 0.6 versus 7.35 +/- 0.7 pg/mL for control and exercise groups, respectively). CONCLUSION: In patients with CHF after acute myocardial infarction nitrate elimination decreases over the subsequent 2 months. This trend was reversed by training. Because nitrate elimination mirrors endogenous NO production, these results suggest that training may positively influence endothelial vasodilator function.

Optimal timing of phase II rehabilitation after cardiac surgery. The cardiologist's view.

Structured programmes of rehabilitation have been shown to be effective in restoring functional capacity, increasing return to work and improving the psychosocial status of patients following open heart surgery. However, uncertainty still exists about the optimal timing of rehabilitation after cardiac surgery. Data in the literature suggest that phase II rehabilitation can begin as early as one week after open heart surgery without having a negative influence on infections, mortality or readmissions. Early rehabilitation can even improve graft patency after CABG. However, age, operative complications and co-morbidities must be considered individually for each patient when determining the beginning of phase II rehabilitation.