Bipedicled SIEA Flap with Deep Inferior Epigastric Artery and Vein Grafts for Breast Reconstruction.

A superficial inferior epigastric artery (SIEA) flap can be an alternative to a deep inferior epigastric artery perforator (DIEAP) flap in cases where SIEAs are relatively well developed. Although an SIEA flap is less invasive than a DIEAP flap, the pedicles of the former are anatomically shorter, making it more difficult to choose recipient vessels when bilateral SIEAs are necessary. A 45-year-old female diagnosed with cancer of the left breast underwent mastectomy (specimen weight: 750 g) and immediate two-stage breast reconstruction using a free abdominal flap with bilateral pedicles was planned. Preoperative computed tomographic angiography showed that the bilateral DIEAPs in the flap were less than one millimeter in diameter, whereas the bilateral SIEAs were well developed enough for us to opt for a double-pedicled stacked SIEA flap. After the double-pedicled SIEA flap was elevated, folded, and temporarily placed in the subcutaneous pocket, the pedicle length on one side was found to be insufficient. Therefore, portions of the right composite deep inferior epigastric artery (DIEA) and vein (DIEV) grafts (roughly 7 cm) were collected from a short fasciotomy and anastomosed to the peripheral ends of the right SIEA and SIEV, respectively. Following this, the left SIEA and SIEV were antegradely anastomosed to the internal mammary artery and vein (IMA/IMV), while the DIEA/DIEV grafts were retrogradely anastomosed to the IMA/IMV, respectively. We recommend the proactive use of this method, as pedicle extension using the DIEA/DIEV grafts enables a higher degree of freedom in unilateral breast reconstruction using bilateral SIEA flaps.

Efficacy of three-dimensional endoscopy in endonasal surgery.

OBJECTIVE: To examine the efficacy of a three-dimensional (3D) endoscope for endoscopic sinus and skull base surgery. METHODS: The study design was a retrospective case series and qualitative research. The clinical efficacy of 3D endoscopes was examined on five cadavers. We performed conventional endoscopic sinus surgery (ESS) in five cases and hypophysectomy in two cases using a 3D endoscope. The educational advantages of the 3D endoscope were assessed using questionnaires given to the participants of cadaver dissection courses. RESULTS: In the posterior portion of the nasal cavity, images captured via 3D endoscopy provided a superior perception of depth of information than those via two-dimensional (2D) endoscopy. All endonasal surgeries were completed in clinical settings using a 3D endoscope without perioperative complications. In terms of the operative time and amount of bleeding, the results of 3D endoscopic surgeries were not inferior to those of 2D endoscopic surgeries. Fatigue from 3D viewing through polarized glasses did not adversely affect performance of the surgery. Moreover, questionnaires for the evaluation of educational efficacy were completed by 73 surgeons. Of the respondents, 89% agreed that 3D endoscopy provided a better understanding of the surgical anatomy than did 2D endoscopy. As for the site where 3D endoscopy would be the most useful for understanding surgical anatomy, 40% of the respondents named the skull base; 29%, the posterior ethmoid sinuses; and 26%, the sphenoid sinus; and 9%, the ethmoid bulla and middle turbinate. CONCLUSION: The 3D endoscope contributes to a more precise anatomical understanding of the posterior structures of the sinuses and skull base and ensures a more precise operation of the instruments. Thus, 3D endoscopes will likely become a standard device for endonasal surgery in the near future.

Systemic steroid application caused sudden death of a patient with sudden deafness.

A 63-year-old man, who was diagnosed with sudden sensorineural hearing loss (SSHL), showed severe hypertension 10 hours after prednisolone administration. Subsequently, the patient suddenly died due to pulmonary edema. The autopsy indicated a pheochromocytoma in the right adrenal gland, and the cause of death was determined to be a pheochromocytoma crisis induced by systemic administration of prednisolone. Pheochromocytoma crisis is a life-threatening condition and can result from the use of corticosteroids. Physicians should consider the risk of a pheochromocytoma crisis due to systemic corticosteroids in the treatment of patients with sudden sensorineural hearing loss.

Audiometric outcomes of topical IGF1 treatment for sudden deafness refractory to systemic steroids.

OBJECTIVE: To examine the effects of topically applied recombinant human insulin-like growth factor 1 (IGF1) via gelatin hydrogels on alterations in pure-tone audiometry (PTA) in patients with sudden sensorineural hearing loss (SSHL) refractory to systemic steroids. STUDY DESIGN: Retrospective chart review. SETTING: A single university hospital. PATIENTS: Twenty-five patients with SSHL refractory to systemic steroids who received topical IGF1 treatment. INTERVENTION: Single topical application of IGF1 to the round window niche using gelatin hydrogels. MAIN OUTCOME MEASURES: The primary outcome was alterations in PTA thresholds at frequencies of 0.25, 0.5, 1, 2, and 4 kHz after topical IGF1 application. Secondary outcomes included differences in final improvements in PTA thresholds among frequencies tested and cumulative numbers of patients showing 10- or 20-dB recovery in PTA during the observation period. RESULTS: Topical IGF1 application via gelatin hydrogels significantly altered PTA thresholds at each frequency tested and at the average frequency. The numbers of patients with a 10-dB recovery in PTA increased until 4 weeks after treatment and then stabilized, whereas those patients showing 20-dB recovery gradually increased during the observation period. CONCLUSION: Topical IGF1 application via gelatin hydrogels contributes to the recovery of PTA levels in patients with SSHL refractory to systemic steroids. Major recovery of PTA levels occurs within 4 weeks after treatment.

Olfactory ensheathing cell tumor arising from the olfactory mucosa.

We report a rare case of olfactory ensheathing cell tumor. A female presented a large soft mass extending medially to the olfactory cleft and laterally to the middle meatus in the left nasal cavity. Imaging studies confirmed a cystic mass extending superiorly into the frontal lobe, indicating that the tumor arouse from the olfactory mucosa. A subtotal resection was achieved through an endoscopic endonasal approach without operative complications. Immunohistochemically constituent cells were diffusely positive for S-100 protein, but olfactory ensheathing cell tumor was diagnosed by negative staining for Leu7 (CD57). This case indicates that olfactory ensheathing cell tumor should be included in differential diagnoses for the olfactory cleft tumors.

Effect of cisplatin on distortion product otoacoustic emissions in Japanese patients.

OBJECTIVES/HYPOTHESIS: Although it is well known that cisplatin is associated with ototoxicity, there is still a lack of knowledge concerning the ototoxicity of cisplatin, especially in Japanese head and neck cancer patients. The objectives of this study were to determine the incidence rate of cisplatin ototoxicity and to determine the threshold dose causing ototoxicity in the Japanese population. STUDY DESIGN: Before-and-after study in a tertiary referral hospital. METHODS: The distortion product otoacoustic emission (DPOAE) was measured 1 week after each administration of cisplatin in 44 Japanese head and neck cancer patients treated at Kyoto University Hospital. We determined the incidence and threshold dose of cisplatin ototoxicity according to DPOAE data. RESULTS: The incidence of ototoxicity detected by DPOAE was 77.3%. The average DPOAE value was significantly lower in patients who received more than 200 mg/m(2) cisplatin than the baseline DPOAE value. The threshold dose for cisplatin ototoxicity was lower in Japanese patients than in European patients. CONCLUSIONS: Our data suggest that Japanese patients are more susceptible to cisplatin-induced ototoxicity. This is presumably caused by a genetic difference.

Argon plasma coagulation for intractable nasal obstruction occurring in patients with allergic rhinitis.

New surgical treatment for the intractable nasal obstruction in patients with nasal allergy by using Argon Plasma Coagulator (APC) was introduced. Of patients with allergic rhinitis treated at our institute, 28 patients complaining nasal obstruction were treated APC surgery. Epithelization of the mucosa of inferior turbinate was almost completely accomplished at 4 weeks after surgery, at which time mucosal swelling was reduced, and nasal obstruction was ameliorated in all cases, though a crust and fibrin membrane adhered to the mucosa between 2 to 4 weeks after surgery, resulting in temporary exacerbation of nasal obstruction. Nasal obstruction was again aggravated in only one patient about 6 months after surgery, but such symptom could be ameliorated by re-coagulation. No bleeding and no smoke occurred in the operation. No morbidity was also noticed after operation. APC is easy to perform safely and effectively compared with another laser surgeries, and is useful for intractable nasal obstruction occurring in patients with allergic rhinitis.

Successful treatment of an extra-abdominal fibromatosis (desmoid tumor) arising from the prevertebral fascia of the neck.

We describe the successful treatment of a fibromatosis (desmoid tumor) arising from the prevertebral fascia of the neck. Total resection with wide margins is reportedly the best treatment for this kind of tumor. However, the anatomy of the head and neck makes such resection difficult. In this case, we were unable to completely remove the tumor because it was large and located close to the cervical vertebrae, common carotid artery and internal jugular vein. Incomplete resection is known to result in higher tumor recurrence than complete resection. In addition, the recurrence or progression of a tumor in the head or neck region is known to cause mortality by compression of the airway or major blood vessels. On the basis of reports that irradiation is effective treatment for this kind of tumor, we administered 30-Gy irradiation to the affected area. This therapy was very effective and no sign of recurrence was seen for 2 years after irradiation. We found that function-sparing resection plus postoperative radiotherapy is an effective treatment for advanced fibromatosis in the head and neck regions with proximity to or involvement with vital structures.