Extrasinus Complications From Odontogenic Sinusitis: A Systematic Review.

OBJECTIVE: Odontogenic sinusitis (ODS) can cause infectious orbital, intracranial, and osseous complications. Diagnosis and management of complicated ODS have not been discussed in recent sinusitis guidelines. The purpose of this systematic review was to describe epidemiological and clinical features, as well as management strategies of complicated ODS. DATA SOURCES: PubMed, EMBASE, and Cochrane Library. REVIEW METHODS: A systematic review was performed to describe various features of complicated ODS. All complicated ODS studies were included in qualitative analysis, but studies were only included in quantitative analysis if they reported specific patient-level data. RESULTS: Of 1126 studies identified, 75 studies with 110 complicated ODS cases were included in qualitative analysis, and 47 studies with 62 orbital and intracranial complications were included in quantitative analyses. About 70% of complicated ODS cases were orbital complications. Only 23% of complicated ODS studies were published in otolaryngology journals. Regarding ODS-related orbital and intracranial complications, about 80% occurred in adults, and 75% were male. Complicated ODS occurred most commonly from apical periodontitis of maxillary molars. There were no relationships between sinusitis extent and orbital or intracranial complications. High rates of anaerobic and α-hemolytic streptococcal bacteria were identified in complicated ODS. Management generally included systemic antibiotics covering aerobic and anaerobic bacteria, and surgical interventions were generally performed to address both the complications (orbital and/or intracranial) and possible infectious sources (dentition and sinuses). CONCLUSION: ODS should be considered in all patients with infectious extrasinus complications. Multidisciplinary management between otolaryngologists, dental specialists, ophthalmologists, and neurosurgeons should be considered to optimize outcomes.

Upper Eyelid and Pupillary Effects of Topical Dilute Epinephrine.

PURPOSE: Adrenergic medications may elevate the upper eyelid and dilate the pupil. The effects of topical phenylephrine on Müller's muscle have been well described. Dilute epinephrine (DE) is a sympathomimetic agent commonly administered in blepharoptosis surgery, and has been shown to elevate the upper eyelid margin when injected subcutaneously. The effects of DE applied topically to the eye, whether intentional or inadvertent during surgery have not been characterized. The purpose of this investigation was to quantify and compare the effects of topical DE and phenylephrine on upper eyelid position and pupil size. METHODS: Prospective, nonrandomized trial of 41 adults without (n = 25, 25 eyes) and with ptosis (n = 16, 16 eyes). Upper eyelid margin reflex distance (MRD1) and pupil diameter were primary measures and pupil reactivity to light was a secondary measure. MRD1 and pupil diameter were recorded at baseline and at 30-second intervals for 5 minutes after administration of topical 1% lidocaine with epinephrine 1:100,000 (DE). After a washout period of >24 hours, the same measurements were recorded after administration of topical phenylephrine 2.5%. RESULTS: No statistically significant difference was observed between mean baseline and postexposure MRD1 after application of topical DE (p = 0.181). In contrast, a mean increase in MRD1 of 0.51 ± 0.09 mm (effect size 0.33) was observed after exposure to phenylephrine 2.5% (p < 0.001). Baseline-adjusted postexposure mean MRD1 was significantly greater for phenylephrine compared with DE (p < 0.001, analysis of covariance). Mean pupil diameter increased 0.29 ± 0.09 mm (effect size 0.48) in response to DE and 0.27 ± 0.11 mm (effect size 0.41) after application of phenylephrine (p = 0.004 and p = 0.001, respectively). All pupils maintained a constrictive response to light. CONCLUSIONS: Although DE is similar to topical phenylephrine in causing mydriasis, it did not have a similar effect on elevating the upper eyelid. These findings may have implications on intraoperative assessment during eyelid surgery. The pupillary changes due to DE offer one explanation for cases of transient pupil dilation during orbitofacial surgery.

Correcting myogenic ptosis accompanying extraocular muscle weakness: The "Bobby Pin" procedure.

This article evaluates the "Bobby Pin" procedure in the correction of myogenic ptosis accompanying extraocular muscle weakness. We retrospectively reviewed 26 eyelids of 13 patients who underwent "Bobby Pin" procedure for myogenic ptosis accompanying extraocular muscle weakness. We evaluated the patients' clinical features such as age, etiology of ptosis, symptoms, standard ptosis measurements, associated systemic diseases, additional ophthalmic conditions, complications, and recurrence. Etiology of myogenic ptosis and extraocular muscle weakness was oculopharyngeal dystrophy in 4 (31%) patients, chronic progressive external ophthalmoplegia in 4 (31%) patients, myotonic dystrophy in 2 (23%) patients, and idiopathic in 3 (15%) patients. The mean levator function was approximately 5 mm pre- and post-operatively (range 1 to 12 mm). The mean margin-to-reflex distance 1 increased from -1.1 mm (below the light reflex) pre-operatively to +0.4 mm (above the light reflex) post-operatively. After a mean follow-up of 40 months, only 1 (8%) patient experienced ptosis recurrence. Upper eyelids were symmetric in both contour and height in all patients. Mild superficial keratopathy involving less than 10% of cornea was observed in 4 (31%) patients. The "Bobby Pin" procedure is an effective and long-lasting treatment option for correcting acquired ptosis accompanying extraocular muscle weakness. The procedure is safe, simple, easily learned, time- and cost-effective, and does not require any expensive equipment.

Small incision removal of nylon foil orbital implants.

PURPOSE: To describe a small incision technique for the removal of a nylon foil orbital wall implant. METHODS: The authors retrospectively reviewed the charts of 9 patients who underwent a minimally invasive anterior orbitotomy for nylon foil explantation. Indications for removal and surgical technique, including size of orbitotomy incision and extent of orbital dissection, were recorded. Motility, globe position, strabismus pre- and post procedure, and complications were also assessed. Photographs, videos, and postoperative imaging were included, when available. RESULTS: The indications for removal were adjacent sinusitis (4 cases), undesirable implant position (3), orbital abscess (1), and adjacent orbital emphysema (1). The removal technique was associated with no changes in motility, globe position, or strabismus postprocedure. The average incision size was 1.1 cm, and the procedure was rapid, usually seconds once the anterior aspect of the implant was exposed and grasped with a hemostat. The dissection in all cases was to the anterior aspect of the implant without a need for deep orbital manipulation. The authors demonstrate through video that the implant folds to exit through a small incision. No adverse events were noted. Nasal endoscopy and radiography demonstrated a fibrous capsule that maintained orbital structure and support. CONCLUSIONS: Thin nylon foil implant can be explanted safely and efficiently through a very small incision. The orbit maintains structure and configuration postexplantation in this series.

Lateral tarsoconjunctival onlay flap lower eyelid suspension in facial nerve paresis.

PURPOSE: To evaluate the efficacy of a lateral tarsoconjunctival flap suspension procedure to improve paralytic eyelid malposition. METHODS: Retrospective chart review (with photograph and videographic data) of consecutive patients between 2008 and 2013 with permanent unilateral paralytic eyelid malposition treated with a far lateral tarsoconjunctival flap lower eyelid suspension alone or in conjunction with lateral canthoplasty. Upper and lower eyelid position, lagophthalmos, ocular surface disease, patient satisfaction, and cosmesis were recorded before and after intervention. Postoperative complications and subsequent management were also recorded. RESULTS: A total of 110 patients were identified. Lagophthalmos, ocular surface exposure, exposure keratopathy, and eyelid retraction (both upper and lower) improved in all cases. All patients described an improvement in eye irritation, epiphora, and cosmesis. Patients with a good Bell's reflex exhibited some dynamic function to the lower eyelid on videography. Three (2.7%) eyelids had flap dehiscence that was successfully treated with repeat suturing. Seven (6.4%) patients had symptomatic temporal peripheral vision requiring partial flap takedown. Five (4.5%) patients had pyogenic granulomas excised. Seven (6.4%) patients later had a supplemental medial tarsorrhaphy for medial lagophthalmos. CONCLUSIONS: The lateral tarsoconjunctival flap suspension was highly effective in this series of patients with paralytic eyelid malposition. Improved eyelid position and cosmesis were universal although some patients benefitted from an additional medial tarsorrhaphy. Return of natural upward lower eyelid movement upon eyelid closure was a further benefit in some patients. Temporal vision obstruction was an infrequent side effect and flap dehiscence and granulomas were rare complications.

Prevalence of low dietary calcium intake in patients with epilepsy: a study from South India.

BACKGROUND: The effects of antiepileptic drugs (AED) on bone health are well documented. Inadequate dietary intake of calcium and vitamin D plays a vital role and further compromises the bone health. OBJECTIVE: To assess the dietary pattern with special reference to calcium and related minerals in people with epilepsy (PWE) on AED. MATERIALS AND METHODS: The dietary assessment in PWE was documented by dietary recall method. Patients were categorized according to age: group I: <14 years; group II: between 15-20 years; group III: between 21-45 years; group IV: >46 years. From the raw weights, total energy, dietary calcium, dietary phosphorous intake and phytate calcium ratio was calculated using a food composition table by Indian Council of Medical Research (ICMR) and analyzed statistically. RESULTS: A total of 362 patients with mean age of 29 + 15 years were studied. There were 190 women. The mean duration of AED treatment was 4 + 3 yrs, 64% on monotherapy 64% and 36% on polytherapy. The mean dietary intake of the total chohort was 2,007 + 211 Kcal/day, carbohydrate 335 + 33 gm/day; protein 31 + 7 gm/day; fat 18+2 gm/day; calcium 294 + 40 mg/day; phosphorus 557 + 102; phytates 179 + 30 mg/day; and phytate/calcium ratio 0.56+0.2. Milk and milk products were consumed by 42% of the total cohort. The daily dietary calcium (301 + 40 mg/day) intake of men was significantly higher than women (287 + 39 mg/day) (P < 0.001). This was more evident in group II (P < 0.01) and group III (P < 0.03). There was a positive correlation between dietary calcium and dietary phytates (P < 0.001), dietary proteins (P < 0.001), dietary fat (P < 0.001), and total energy (P < 0.001). CONCLUSIONS: The dietary consumption of calcium of all the patients was far below the recommended daily dietary allowance (RDA) by Indian Council of Medical Research (ICMR). Low dietary calcium could have a confounding effect on PWE on AED in all age groups. There is a need to formulate consensus guidelines to supplement dietary calcium to PWE.