Extraocular surgery for implantation of an active subretinal visual prosthesis with external connections: feasibility and outcome in seven patients.

BACKGROUND: Due to low energy levels in microphotodiode-based subretinal visual prostheses, an external power supply is mandatory. We report on the surgical feasibility and the functional outcome of the extraocular part of an approach to connect a subretinal prosthesis to an extracorporeal connector in the retro-auricular space via a trans-scleral, transchoroidal cable. METHODS: Seven volunteers with retinitis pigmentosa received an active subretinal implant; energy was supplied by gold wires on a trans-sclerally, transchoroidally implanted polyimide foil leading to the lateral orbital rim where it was fixated and connected to a silicone cable. The cable was implanted subperiostally beneath the temporal muscle using a trocar to the retro-auricular space where it penetrated the skin for connection to a stimulator. To avoid subretinal movement of the implant, three tension relief points have been introduced. RESULTS: All implantations were performed as planned without complications, and no serious adverse events occurred in the postoperative period. Fixation of the implants was stable throughout the entire study duration of 4 weeks; permanent skin penetration proved to be uncomplicated. Motility was minimally restricted in downgaze and ab-/adduction. Explantation was uneventful. CONCLUSION: The above-described procedure provides a method for stable fixation of a subretinal device with a trans-scleral, transchoroidal cable connection to an extracorporeal connector.

The role of intraoperative ultrasonography in zygomatic complex fracture repair.

Intraoperative assessment of the zygomatic arch is very important in achieving adequate repositioning. The correct alignment of the zygomatic arch indicates the proper position of the zygomatic bone and ensures adequate prominence of the lateral midfacial aspect. The aim of this study was to estimate the value of ultrasonography as an intraoperative repositioning control. In a clinical study of 25 patients, ultrasonography was employed for intraoperative visualization of the zygomatic arch before and after fracture repositioning. Twelve patients presented with isolated zygomatic arch fractures and 13 with combined fractures of the zygomatic bone and arch. The ultrasonographic findings were compared to the radiological and clinical findings. Ultrasonography was able to detect all fractures and dislocations of the zygomatic arch. It was possible to assess the repositioning in 24 out of 25 cases using ultrasonography. The ultrasound images were concordant with the radiographs. Clinical assessment by palpation only succeeded in isolated zygomatic arch fractures with an m-shaped impression, whereas it remained uncertain in nearly all cases with a different dislocation pattern. Ultrasonography was rapid and easy to perform, and is recommended as an intraoperative visualizing tool in all midfacial fractures with displacement of the zygomatic arch.

[Epitheloid leiomyosarcoma of the mouth in childhood]. / Epitheloides Leiomyosarkom der Mundhöhle.

A six-year-old girl is presented with an increasing mass involving the anterior vestibule and the floor of the mouth. Histologic and immunohistochemical examination revealed a poorly differentiated epitheloid leiomyosarcoma with destruction of the mandible. According to the CWS-96-study the patient underwent preoperative chemotherapy followed by complete resection of the mandibular body with the surrounding soft tissues. Recurrent tumor became evident only three months later on. The further treatment consisted of tumor resection, oral chemotherapy and irradiation. Nevertheless tumor control could not be achieved. The patient died of progressive disease 16 months after diagnosis. Leiomyosarcoma is extremely uncommon in childhood, especially with localisation in the oral cavity. Diagnosis is based on histologic examination and immunohistochemistry. In the presented case the lack of smooth muscle actin expression made diagnosis difficult. The preoperative chemotherapy could not achieve reduction of tumor size, so that extensive surgery became necessary. Estimation of the prognosis of the oral leiomyosarcomas in childhood is difficult. High grade tumours and involvement of bone seem to be associated with bad clinical outcome. The presented case is confirming that.

[Value of color-coded duplex sonography in preoperative visualization of lower leg arteries for microsurgical fibula transfer]. / Stellenwert der farbkodierten Duplexsonographie zur präoperativen Darstellung der Unterschenkelarterien bei mikrochirurgischem Fibulatransfer.

BACKGROUND: In patients being considered for a microsurgical fibular transfer, thorough examination of the vascular supply to the lower leg is indisputably necessary. The aim of this study was to evaluate the validity of color-coded duplex sonography (CCDS) in the assessment of the arteries of the lower leg. PATIENTS AND METHODS: In 13 patients needing bony reconstruction of the jaw 22 legs were examined using CCDS. The three arteries of the lower leg were visualized and traced from the ankle to the popliteal fossa. At every arterial segment Doppler sonographic examination was also performed. All 13 patients underwent digital subtraction arteriography (DSA) of the lower extremities, additionally. RESULTS: We were able to visualize and to assess all but one of the arteries using CCDS. In 13 extremities of 9 patients CCDS exhibited a normal vascular supply to the lower leg provided by three regular arteries. DSA confirmed this and the patients underwent fibular transfer. In the other 4 patients a regular vascular situation could not be shown by CCDS because of nonvisualization of arterial segments or pathological findings. Two of these patients received alternative bony transplants. In the remaining two patients angiography exhibited one leg to have a normal three vessel supply, respectively. Fibular transplants could be raised from this leg. In all patients CCDS was able to localize between 3 and 7 perforators branching off the peroneal artery. Their position determined the placement of the skin paddle to be raised with the bone. Further advantages of CCDS were the universal applicability to all patients and the possibility of performing it at our own department. The time required for the examination and the necessity of having adequate technical equipment were the disadvantages. CONCLUSION: In patients being considered for a microsurgical fibular transplantation, we recommend CCDS of the lower leg as a screening tool for the vascular supply of the lower leg. DSA and MRA are predominantly advocated for those patients, in whom CCDS reveals pathological or uncertain findings.

Significance of biodegradable implants in case of midfacial fractures.

The purpose of this prospective clinical study was to evaluate new resorbable implants for bone fixation. The plates and screws are made of poly (D, L)lactide (PDLLA). Bioresorbable osteosynthesis and fixation (ResorbX) has been applied in 22 patients. Indications for operations were craniofacial trauma (malar, orbital-floor or frontal bone fractures) or orthognathic procedures (Le Fort-I-osteotomies) as well as the surgical correction in case of craniofacial syndromes. In the initial follow up, the first patients showed clinically and radiologically uneventful fixation and healing of the bone. There were no implant material related complications. Overall, the advantages of PDLLA-implants appear to be their ease of use, radiolucency and resorption, although further experience is needed to determine the longterm benefits of biodegradable implants.

[Intraoperative computer tomography control within the scope of maxillofacial traumatology using a mobile scanner]. / Intraoperative computertomographische Kontrolle im Rahmen der maxillofazialen Traumatologie unter Verwendung eines fahrbaren Scanners.

Advances in intra-operative imaging and the development of new minimally invasive techniques are having an ever greater impact on modern surgery. Mobile CT scanners in the operating room is a new technique that permits image-guided surgery, and helps minimize postoperative complications. We report on our initial experience with intraoperative CT scanning during surgery on patients suffering lateral midface trauma. A mobile CT unit, the Tomoscan M (Philips, Utrecht, Netherlands) set up in the operating room, was evaluated in 6 patients with zygomatic bone fractures. The patients were placed on the CT scanner table, which is detachable from the gantry. The unit is powered by batteries charged from an ordinary ring mains supply via a conventional plug. The CT images obtained were of good quality in all cases. No technical problems were observed during surgery. Using repeat CT scans, the procedure also permits accurate intraoperative monitoring of the anatomical repositioning of the bone fragments, and accurate implantation. No intraoperative or early postoperative complications were observed. This new technical aid ensures highly accurate reduction of the bone fragments, and minimizes the need for reoperation. High-quality intraoperative imaging with surgical navigation increase surgical outcome, and expand the spectrum of minimally invasive surgery.

[Cystic neck lymph node metastases as an indication of occult tonsillar carcinoma]. / Zystische Halslymphknotenmetastasen als Hinweis auf ein okkultes Tonsillenkarzinom.

BACKGROUND: Cystic carcinomas of the neck without evidence of a primary tumor are diagnostically challenging lesions. Differentiation between a cystic lymph node metastasis of an occult primary tumor and a carcinoma arising in a branchiogenic cyst is frequently not possible even with histological examination. In order to clarify the diagnosis, an intensive search for a primary lesion in the upper aerodigestive tract must be carried out. DIAGNOSIS: An occult carcinoma might be situated in Waldeyer's ring, especially in the tonsillar crypts. These tumors tend to produce cystic metastases in the jugulodigastric region. Therefore, multiple biopsies have to be taken from the tissue of Waldeyer's ring. In the case of a positive histological result, adequate therapy of both the primary and the metastasis can be carried out. The diagnosis of a malignant branchiogenic cyst is only permissible after a primary lesion has been thoroughly excluded.

Sensory impairment of the lingual and inferior alveolar nerves following removal of impacted mandibular third molars.

In a prospective study 1,106 impacted mandibular third molars were removed from 687 patients. Clinical, radiographic, and surgical factors were recorded. Postoperatively, we examined the modalities of common sensation in order to assess sensory deficit. The patients were followed up, until complete restitution occurred, or, if the sensibility failed to recover, for at least 6 months. A total of 3.6% of the operated sides demonstrated impairment of labial sensation, and 2.1% of lingual sensation. The vast majority of these disturbances subsided completely during the follow-up period. The incidence of persisting sensory diminution after 6 months was 0.91% for the inferior alveolar, and 0.37% for the lingual nerve. However, the degree of the persisting deficit was slight in most instances. The relationship between the recorded factors and the alteration of sensation was analysed by using the chi2 test. For the inferior alveolar nerve we found the patient's age, the development of the roots, the degree of impaction, and the radiographic position of the nerve canal to be significantly correlated to sensory deficit, as well as the surgical procedures in the depth of the socket and the intraoperative opening of the mandibular canal. As far as the lingual nerve is concerned, general anaesthesia and the individual operator were the main factors predictive of nerve damage.

Failed closed reduction of a bifocal mandibular fracture because of dislocation of the mandibular ramus behind the styloid: case report.

We present an unusual dislocation of the mandibular ramus after a low condylar fracture associated with a fracture of the opposite body of mandible. As closed reduction failed, both fracture sites were exposed. The mandibular ramus was dislocated behind the styloid process, which was not shown on the preoperative radiographs. The intermediate fragment was freed and the fractures treated by miniplate osteosynthesis. The patient made an uneventful recovery with no residual deformity.

[Incidence, risk factors and follow-up of sensation disorders after surgical wisdom tooth removal. Study of 1,106 cases]. / Inzidenz, Risikofaktoren und Verlauf von Sensibilitätsstörungen nach operativer Weisheitszahnentfernung. Untersuchung an 1106 Fällen.

A study was carried out to determine the risk of dysesthesia of the inferior alveolar and of the lingual nerve after molar surgery. A total of 1103 impacted lower wisdom teeth and 3 impacted lower second molars were removed in 687 patients, all of whom with unaltered sensibility preoperatively. Clinical, radiological, and surgical factors of each case were recorded. Postoperative disturbances in the sensibility of the lip and tongue were evaluated by neurological examination. Follow-up was carried out for a maximum of 35 weeks. Dysesthesia of the inferior alveolar nerve occurred with an incidence of 3.57%. The lingual nerve was injured in 2.1% of patients. Most of the initially reported alterations in sensation resolved within the follow-up period. Dysesthesia of the inferior alveolar nerve persisted in 0.91%, and of the lingual nerve in 0.37%. However, the extent of the prolonged impairment was slight in general. The effect of the documented factors on the incidence of dysesthesia was analyzed. For the inferior alveolar nerve, analysis revealed significant effects in older patients, for completely developed roots, for deeply impacted teeth, in the radiological relationship of the roots and the inferior alveolar canal, for difficult surgery, and for intraoperative exposure of the nerve. The surgeon and the anesthesia had a significant influence on lingual dysesthesia.

Sequential therapy with azelastine in seasonal allergic rhinitis. Deutsche Rhinitis Studiengruppe (German Rhinitis Study Group).

A sequential therapy treatment with azelastine (Allergodil) in seasonal allergic rhinitis is introduced. In the critical early stage, treatment begins with a combination of azelastine tablets (azelastine hydrochloride, CAS 79307-93-0) and azelastine nasal spray (azelastine, CAS 58581-89-8), and after five days only the nasal spray is administered. This sequential therapy model aims at achieving the quickest and most complete effect without reducing the tolerability. The investigation was carried out as a randomized, controlled double-blind phase IV study of parallel group design with 300 patients during 14 days. In the first five days, one group was given one puff (0.14 mg) of azelastine nasal spray twice daily and one 2 mg tablet of azelastine at night. The other group received nasal spray and a placebo tablet. Beginning on day six, both groups received nasal spray only. Both treatments proved to be effective; the combination therapy, however, was significantly more effective beginning as early as the first treatment. The superiority of the combination therapy increased until day five. Thereafter, the two curves grew closer together; however, the superiority of the combination treatment remained. The tolerability of both treatments was similar.

Secretion of TFF-peptides by human salivary glands.

TFF-peptides (formerly P-domain peptides, trefoil factors) are typical secretory products of mucin-producing cells and seem to influence the rheological properties of mucous gels. Here, localization studies of TFF-peptides in human salivary glands are presented. Expression studies (polymerase chain reaction) revealed mainly TFF3 transcripts in submandibular and sublingual glands and trace amounts in parotid glands. Only low levels of expression of TFF1 could be monitored in submandibular and sublingual glands, and TFF2 transcripts were hardly detectable in all three major salivary glands. This result was partly confirmed by Western blot analysis, which only detected TFF3 in submandibular glands, but not in sublingual and parotid glands. TFF3 was also shown to be a constituent of human saliva. Immunofluorescence localized TFF3 solely in the secretory granules of serous cells of submandibular glands but not in mucous cells. This localization is remarkably similar to that of the unique low-molecular-weight mucin MUC7, which interacts with a number of oral microorganisms.