[Medium- to long-term follow-up after anterior cruciate ligament rupture and repair in healing response technique]. / Mittel- bis langfristige Ergebnisse nach vorderer Kreuzbandruptur und Versorgung in Healing-Response-Technik.

BACKGROUND: Healing response (HR) is an all-arthroscopic technique for treatment of acute proximal anterior cruciate ligament (ACL) tears within 6 weeks after injury. By means of arthroscopically controlled microfracture holes in the native femoral attachment and perforations of the ACL itself the exit of stem cells and growth factors is induced and the ligament can heal into its native attachment zone. The purpose of the study was to document medium- to long-term results after 5 years or longer following the healing response (HR) procedure. The aim of our study was to show that HR is a treatment option for acute proximal ACL tears. MATERIAL AND METHODS: Between 2004 and 2007 126 patients were treated in healing response technique in our hospital. Patients with a complete proximal ACL tear and operation within 6 weeks of initial injury were included in this study. Patients who had complex knee injuries with multidirectional instability, ACL rerupture, contralateral ACL reconstruction, contralateral ACL rupture or knee replacement and cartilage repair procedures (AMIC, MACT, OATS) were excluded. 43 (23 women/20 men; mean age at time of surgery 36.6 years ± 11.6; range: 16 to 66 years) of 89 eligible patients received clinical follow-up up to 8 years after surgery (mean: 6.3 years). Lysholm score, Tegner activity score, a modified IKDC-2000 knee examination form and an individually created questionnaire were used for evaluation. Furthermore, range of motion, muscle circumference of the lower limb and the anterior tibial translation were measured with a KT-1000 arthrometer™ (MEDmetric® Corporation, San Diego, USA). RESULTS: 15.1 % of all patients showed a primary insufficiency after HR. 24.6 % of the 126 patients required subsequent ACL reconstruction up to the time of data collection. The 43 patients who received clinical follow-up showed a mean Lysholm score of 92 ± 8.9 points. 72 % reached their original level of activity in the Tegner activity score. According to the IKDC evaluation system 90.7 % of all patients were grade A. 93 % did not show muscles atrophies of the lower limb. There were no limitations in range of motion. Mean side-to-side difference in the KT-1000 manual-maximum displacement test measurements was 1.3 mm ± 1.6 mm. 97.7 % patients had a normal or nearly normal knee function and 86 % rated the overall treatment as good to very good. CONCLUSION: Patients with good clinical results 6 to 12 weeks after HR show even in the medium- to long-term follow-up good clinical outcomes as well as objective stability. In selected cases HR is an alternative treatment option for acute, proximal ACL ruptures. When indicating an HR procedure, it should be taken into consideration that up to 15 % of all patients could have a primary insufficiency.

Mucosal swabs detect HPV in laryngeal papillomatosis patients but not family members.

Seven patients, aged 2-7 years, with active recurrent respiratory papillomatosis (RRP) attending the University of Michigan Pediatric Otolaryngology Clinic were studied to determine if human papillomavirus (HPV) is harbored in sites of the upper aerodigestive tract other than in the laryngeal papilloma itself. We also determined if close family members had detectable virus in their oral cavities. Noninvasive swabs of buccal mucosa, posterior pharynx, nasal vestibule, and tonsillar pillar of patients, as well as buccal mucosa and posterior pharyngeal swabs of family members were studied. Swabs of the patients' papillomas served as the positive controls. HPV was detected using polymerase chain reaction (PCR) amplification and Southern hybridization techniques. Six of seven patients had detectable HPV in papilloma and endolaryngeal swabs. Four were HPV type 6, and two were HPV type 11. The patient whose swab was negative for HPV was found to be biopsy negative for papilloma 3 weeks after a single laser excision which was performed 6 months prior to the endolaryngeal swab. HPV types 16, 18 and 31 were not found in any of the patients. No swabs from other sites in patients or family members were HPV positive despite the presence of adequate DNA in the swabbed material for successful amplification of beta-actin sequences. The absence of HPV (other than in the papilloma itself) in the upper aerodigestive tract of patients and caregivers is consistent with the absence of reported cases of horizontal transmission to siblings or other family members. The findings are also consistent with the conventional view that juvenile respiratory HPV is transmitted vertically from vaginal condylomas in the mother.

High-risk human papillomavirus types and squamous cell carcinoma in patients with respiratory papillomas.

Respiratory papillomas (RPs) are benign, virally induced tumors of the larynx and respiratory epithelium that may obstruct the airway and tend to recur frequently. RPs are thought to be the result of infection with the human papillomaviruses (HPVs) types 6 and 11. We surveyed archival RP specimens to determine whether there were correlations of HPV type with patient characteristics or clinical course. Paraffin-embedded papilloma specimens of 45 different patients were analyzed. We assessed HPV types using the polymerase chain reaction with E6 consensus primers, hybrid capture assays (high or low risk), and dot blot hybridization of generic E6 PCR products with E6 type-specific oligonucleotide probes. The presence and type of HPV were correlated with patient data from a retrospective chart review. We found that RPs may have either low- or high-risk HPV types and some contain multiple HPV types. Respiratory infection with high-risk HPV apparently introduces a long-term risk of squamous cell carcinoma development, even in the absence of conventional cofactors. Low-risk HPV infection may also act in association with these cofactors to promote carcinogenesis. Our data also show a racial imbalance in RP that may indicate a difference in genetic resistance and/or susceptibility to HPV infection and the development of RP.

Pediatric myofibromatosis of the head and neck.

OBJECTIVES: To examine the clinical and pathological features of pediatric myofibroma of the head and neck and to discuss the challenges in diagnosis and treatment. DESIGN: A retrospective search of pathology department and clinical records to identify patients with myofibroma and a retrospective review of English-language medical publications. SETTING: Academic medical center. PATIENTS: Thirteen pediatric patients (aged from birth to 8 years old) diagnosed as having myofibroma of the head and neck. RESULTS: Nine of 13 patients were cured with conservative surgical excision. Four patients (31%) had recurrence, requiring multiple surgical procedures. One third showed spontaneous regression clinically or by histological examination. The clinical course did not parallel the histological appearance, as high cellularity and mitotic figures were commonplace among the specimens. A misdiagnosis of malignancy was not unusual in this series, as 3 patients had an initial diagnosis of fibrosarcoma, which on review was revised to myofibroma. CONCLUSIONS: Myofibromatosis is a distinct disorder among the great number of fibrous proliferations occurring in infants and children, with a particular predilection for the head and neck region. These lesions should be clearly distinguished from conventional adult-type fibromatoses (desmoid tumors), which are more aggressive. Most patients have solitary lesions that respond well to conservative surgical excision, whereas a few of these lesions behave more aggressively, requiring several surgical procedures for the management of recurrent or persistent tumor. Many of these lesions show spontaneous regression, suggesting that lesions not affecting vital functions, resulting in growth anomalies, or demonstrating rapid aggressive growth may be managed conservatively.

Neonatal choristoma of the tongue containing glial tissue: diagnosis and surgical considerations.

There are only six case reports documenting the presence of glial tissue in the tongue. Because of the small number of cases, the presentation and biologic behavior of these lesions is poorly characterized. We present the case of a 10-day-old male infant who arrived at the University of Michigan Medical Center with a history of positional dyspnea, with resultant cyanosis and bradycardia, dysphagia, and a mass at the base of the tongue. Histopathologically, this lesion was initially labeled as a hamartoma, but was ultimately defined as a choristoma based on the exclusive presentation of glial tissue in the specimen. This paper will discuss the presentation, diagnostic evaluation, and therapeutic management of this case. In addition, the role of intraoperative electrodiagnostic monitoring to preserve neuromuscular function will be addressed.

Cutaneous wound healing. An overview.

This article is a general discussion of the mechanisms of soft-tissue wound healing with an emphasis on tissue. The overall phases of cutaneous wound healing and their influencing factors are described as are concepts for managing skin incisions to achieve a more optimal scar appearance.

Chronic otitis media requiring ventilation tubes in tracheotomized ventilator dependent children.

The occurrence of sinusitis and middle ear effusions has frequently been attributed to the obstruction of the sinus ostia and/or eustachian tube. In the intensive care unit setting, edema caused by the irritation from nasogastric, nasotracheal and orotracheal tubes has been associated with this pathology and has been responsible for occult sepsis in this population. Our investigation was performed to determine the risk of chronic otitis media with effusion necessitating myringotomy with tympanostomy tubes among tracheotomized, ventilator dependent children in a consecutive series of children admitted to our recently created stable ventilator unit. We retrospectively reviewed the medical records of all tracheotomized, chronically ventilator dependent children < 48 months of age who had been hospitalized in this unit from the initial opening in September 1990 to January 1993. Data collected consisted of patient demographics, gestational age, cognitive abilities, age at onset of mechanical ventilation, age at tracheostomy, age at myringotomy, presence of nasogastric and gastroenterostomy tubes and evidence of gastric-esophageal reflux. All children underwent a tracheostomy procedure subsequent to the onset of mechanical ventilation. Of these patients, 9/12 (75%) later required myringotomy with tympanostomy tube placement following the occurrence of chronic otitis media with effusion. Ventilation tubes for chronic otitis media with effusion were not required in 3 patients. Using a case control study design, we examined the need of myringotomy tubes for children requiring continuous mechanical ventilation versus those requiring night-time only ventilation. The risk of myringotomy tubes in the continuously ventilated group (9/9) was significantly greater than the risk in the intermittently ventilated group (0/3) P < 0.01.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiation therapy as an alternative to surgery in the management of intracranial juvenile nasopharyngeal angiofibroma.

Juvenile nasopharyngeal angiofibroma is a benign, vascular tumor which typically presents in adolescent males. Although surgical resection is usually recommended for the management of this tumor, external beam radiation therapy has also been advocated in the literature. We report three cases of large juvenile nasopharyngeal angiofibromas with extensive intracranial extension primarily managed with external beam radiation therapy. Although there was not complete resolution of the tumors, there was significant alleviation of symptomatology with no serious side effects from the radiation therapy. Based on these cases, we feel that external beam radiation therapy in the management of extensive juvenile nasopharyngeal angiofibromas with intracranial extension is warranted in certain select cases.

Flutamide-induced regression of angiofibroma.

Juvenile nasopharyngeal angiofibroma (JNA) appears to be an endocrine-responsive tumor. This concept was tested in five young men with JNA by treating them with a testosterone receptor blocker (flutamide) for 6 weeks preoperatively. Tumor size was evaluated by axial computed tomography both before and after flutamide therapy. Four of the five patients had an average tumor shrinkage of 44%. The patients tolerated the drug well, and the serum testosterone levels 2 or more years posttherapy were normal. This pilot study demonstrate that preoperative hormonal pharmacoreduction of JNA is a feasible adjunct to surgical therapy that offers the possibility of reduced blood loss. However, the authors believe that a formal clinical trial of this treatment approach is warranted and should be done before widespread adoption of this agent.

Otolaryngologic (head and neck) problems in the elderly.

This article is designed to give the reader an appreciation of some of the more common or important facets of the management of head and neck disorders in the elderly patient. Readers are referred to the references for more detailed descriptions of the topics.

Intracranial complications of paranasal sinusitis: a combined institutional review.

Intracranial complications of paranasal sinusitis constitute true surgical and medical emergencies. The charts of all patients (n = 649) admitted for acute or chronic sinusitis to the University of Minnesota Hospital and to the University of Michigan Medical Center during a 13-year period (1975 to 1988) were retrospectively reviewed to determine the incidence of complications. The clinical presentation, bacteriology, involved sinuses, influencing host factors, white blood cell count on presentation, length of hospitalization, and postinterventional complications are presented. Twenty-four patients with intracranial complications from paranasal sinusitis are studied for an incidence of 3.7%. Aggressive medical and semi-emergent surgical intervention are required to prevent excessive morbidity and/or mortality. Intracranial complications included subdural empyema, frontal lobe abscesses, intrahemispheric abscesses, cavernous and superior sagittal sinus thrombosis, and osteomyelitis.

The use of biopsy in the evaluation of pediatric nasopharyngeal masses.

Pediatric nasopharyngeal tumors are rare, and few clinicians possess more than anecdotal experience. The differential diagnosis includes a diverse group of benign and malignant tumors, but can be narrowed further based on the clinical and radiographic appearance of the mass. Nasopharyngeal angiofibroma has such characteristic angiographic and CT imaging that many authors suggest biopsy is not essential in the evaluation of this lesion. We present a case of a pediatric nasopharyngeal neoplasm with angiographic, CT, and clinical findings consistent with angiofibroma. We then discuss the preoperative evaluation of, operative approach to, and postoperative staging and treatment of the biopsy-proven embryonal rhabdomyosarcoma. A review of the literature pertinent to this case is presented, and recommendations made concerning biopsy of lesions resembling juvenile nasopharyngeal angiofibroma. We believe this report reaffirms the use of histologic study whenever possible, in addition to radiographic imaging, in the diagnosis of pediatric nasopharyngeal masses.

Sleep apnea--an historical perspective.

In this article the authors have attempted to give the reader a brief overview of some of the development of recognition of obstructive sleep disorders and early aspects of their surgical therapy. They have avoided detailed descriptions of radiographic and other diagnostic measures, since many of these are summarized in other articles.

Surgical management of obstructive sleep apnea.

The authors have reviewed the surgical management of patients with OSA. They have emphasized not only surgical techniques but also the method of preoperative evaluation of the patients and have presented some considerations in the postoperative management of patients in an attempt to avoid catastrophic results. As our diagnostic techniques improve, we should have fewer problems with the determination of the amount of tissue to remove and also the selection of the appropriate procedure. The advent of flexible laryngoscopy, cineradiography, and cine CT may indeed improve our diagnostic and therapeutic capabilities.

Facial nerve paresis as the presenting symptom of leukemia.

Leukemic involvement of the temporal bone is not uncommon and may present in a variety of ways including auricular or external canal skin lesions, red or thick tympanic membrane, middle ear effusions, otitis media, hearing loss or mastoiditis. Symptomatic facial nerve involvement, on the other hand, is extremely unusual. We discuss a pediatric patient whose sudden onset facial nerve paresis was the presenting symptom that led to her diagnosis of leukemia. At the time of mastoidectomy, a granulocytic sarcoma or chloroma was noted to be overlying the VIIth nerve.

Juvenile myasthenia gravis: an unusual presentation.

Myasthenia gravis is a disease characterized by muscular weakness and fatigability which afflicts 2-10 patients per 100,000 with 20% of cases presenting in childhood. Muscles innervated by cranial nerves are frequently involved with ptosis and diplopia being the most frequent presenting complaints. We review the literature and report a case of a 20-month-old infant presenting with inspiratory stridor and cyanosis, resembling foreign body aspiration.