New method to evaluate sequelae of static facial asymmetry in patients with facial palsy using three-dimensional scanning analysis.

OBJECTIVE: During the process of neural recovery after facial palsy, distressing sequelae of static and dynamic facial asymmetry develop in patients with facial palsy. A pronounced nasolabial fold is mainly responsible for static facial asymmetry, which leads to many psychological and social problems in patients. Objective and qualitative assessment of facial appearance is critical to determine the severity of sequelae of static facial asymmetry and whether an intervention is effective for treatment. In the present study, an attempt was made to develop three-dimensional analysis method to assess sequelae of static facial asymmetry after facial palsy. METHODS: Eight patients with sequelae of facial asymmetry after facial palsy and ten healthy volunteers were enrolled. We used three-dimensional scanning analysis with a portable non-contact optical scanner to obtain three-dimensional surface data from a patient's face and produced a three-dimensional digital model of the face. We then identified a reference plane fixed with the patient's face, and measured the depth of the nasolabial fold of the face. RESULTS: The nasolabial fold of the face on the affected side was significantly deeper than that on the unaffected side in patients with sequelae of static facial asymmetry after facial palsy. However, the depth of the facial nasolabial fold on the right side was not different from that on the left side in healthy volunteers. Affected-unaffected side differences in the depth of the nasolabial fold in patients with sequelae of static facial asymmetry after facial palsy were significantly larger than left-right differences in the depth of the nasolabial fold in healthy volunteers. Two weeks after treatment with botulinum toxin injection to the affected zygomaticus muscles, affected-unaffected side differences in the depth of the nasolabial fold were significantly decreased in the patients. In the patients who received botulinum toxin, the absolute values of affected-unaffected side differences in the depth of the nasolabial fold measured using the three-dimensional scanning analysis showed a significant positive correlation with the visual analog scale scores of facial asymmetry marked by independent doctors. CONCLUSION: The present findings suggest that affected-unaffected side differences in the depth of the nasolabial fold of the measured using three-dimensional scanning analysis can be used as an index of sequelae of static facial asymmetry. It is also suggested that the index can evaluate whether interventions are effective for the treatment of sequelae.

Vestibular and cochlear nerve enhancement on MRI and its correlation with vestibulocochlear functional deficits in patients with Ramsay Hunt syndrome.

OBJECTIVE: The correlation between enhancement of the vestibulocochlear nerves on gadolinium-enhanced magnetic resonance imaging (MRI) and vestibulocochlear functional deficits was examined in patients with Ramsay Hunt syndrome (RHS). METHODS: Nineteen patients with RHS who showed herpes zoster oticus, peripheral facial palsy, and vertigo were enrolled. Canal paresis (CP) in the caloric test, abnormal response to ocular and cervical vestibular myogenic potentials (oVEMP and cVEMP), and refractory sensorineural hearing loss were evaluated. MRI images perpendicular to the internal auditory canal were reconstructed to identify the superior (SVN) and inferior vestibular nerves (IVN) and the cochlear nerve (CV). The signal intensity increase (SIinc) of the four-nerve enhancement was calculated as an index. RESULTS: Among RHS patients, 79%, 53%, 17% and 26% showed CP in the caloric test, abnormal responses to oVEMP and cVEMP, and refractory sensorineural hearing loss, respectively. SIinc rates of the SVN were significantly increased in RHS patients with CP in the caloric test, and with abnormal responses to oVEMP and cVEMP. SIinc rates of the SVN tended to increase in RHS patients with refractory sensorineural hearing loss (p = 0.052). SIinc rates of the IVN were significantly increased in RHS patients with abnormal responses to oVEMP and cVEMP, and refractory sensorineural hearing loss, but not in those with CP in the caloric test. SIinc rates of the CN were significantly increased in RHS patients with CP in the caloric test, abnormal response to oVEMP and refractory sensorineural hearing loss, but not in those with abnormal response to cVEMP. CONCLUSION: In patients with RHS, the origin of vertigo may be superior vestibular neuritis, which is affected by reactive varicella-zoster virus from the geniculate ganglion of the facial nerve through the faciovestibular anastomosis. The results also suggested that in some RHS patients, inferior vestibular neuritis contributes to the development of vertigo and that the origin of refractory sensorineural hearing loss is cochlear neuritis.

Electroneurography cannot predict when facial synkinesis develops in patients with facial palsy.

The objective of this study is to clarify when facial palsy patients with lower value of Electroneurography (ENoG) should begin the rehabilitation to prevent the development of facial synkinesis. For this purpose, we examined the relationship between the value of ENoG measured 10-14 days after facial palsy onset and the onset day of the development of oral-ocular synkinesis. Sixteen patients with facial palsy including 11 with Bell's palsy and 5 with Ramsay Hunt syndrome (7 men and 9 women ; 15-73 years old ; mean age, 41.6 years) were enrolled in this study. There was no correlation between ENoG value and the onset day of the development of oral-ocular synkinesis (ρ = .09, p = .73). Oral-ocular synkinesis began to develop in 4.0 ±â€…0.7 months (mean ±â€…SD ; range : 3.1-5.0 months) after facial palsy onset regardless of ENoG value. In conclusion, ENoG value cannot predict when facial synkinesis develops in patients with facial palsy. We recommend that facial palsy patients with a high risk for the development of synkinesis begin the biofeedback rehabilitation with mirror to prevent the development of facial synkinesis 3 months after facial palsy onset. J. Med. Invest. 67 : 87-89, February, 2020.

Remission of Palmoplantar Pustulosis after On-Pump Coronary Artery Bypass Grafting in a Patient with Titanium Allergy.

Metal allergy is an uncommon problem during surgery. Among them, titanium allergy is said to be rare, but can lead to serious complications, such as palmoplantar pustulosis (PPP). A 69-year-old woman was admitted to our hospital with a chief complaint of chest pain. Coronary angiography showed severe coronary artery disease that required coronary artery bypass grafting (CABG). The patient had a history of orthopedic surgery for left distal radius fracture 2 years previously, which resulted in inflammation on the left arm and PPP. We suspected titanium allergy based on results of skin patch tests and use of titanium alloy in the previous orthopedic operation. The patient underwent CABG without use of permanent metallic material. As a result, her PPP disappeared. In this rare case, it is difficult to identify the exact cause of the improvement in PPP; thus, further studies are required to clarify the mechanism of remission.

Edge-to-edge repair for mitral regurgitation associated with isolated double-orifice mitral valve.

We report the case of a patient with severe mitral regurgitation who was diagnosed with double-orifice mitral valve by preoperative transthoracic and transoesophageal echocardiography. During surgery, it was revealed that the mitral valve was divided into 2 orifices, anterolateral and posteromedial, by a fibrous bridging tissue that was supported by the chordae tendineae originating from an accessory middle papillary muscle. The posterior scallop of the anterolateral orifice was prolapsed due to chordal elongation. Six interrupted sutures were made between the anterior leaflet and the posterior leaflet at the prolapsed site. Additional interrupted sutures were made at the sites of 2 clefts, and a ring annuloplasty was added. Residual mitral regurgitation was trivial, and the mean postoperative pressure gradient through each orifice was approximately 6 mmHg. To the best of our knowledge, this is the first case report of an edge-to-edge mitral repair for mitral regurgitation associated with a double-orifice mitral valve.

Electroneurography in the acute stage of facial palsy as a predictive factor for the development of facial synkinesis sequela.

OBJECTIVE: We investigated whether the value of ENoG is a predictive factor for the development of facial synkinesis in patients with facial palsy. METHODS: The degree of oral-ocular synkinesis was evaluated quantitatively by an asymmetry of the interpalpebral space width during the mouth movement (% eye opening). Twenty healthy volunteers without a history of facial palsy (12 men and 8 women; 25-65 years old; mean age: 42.3±9.7years) were included in the study to examine the normal range of % eye opening. Fifty-one patients with facial palsy including 38 with Bell palsy and 15 with herpes zoster oticus (28 men and 25 women; 11-86 years old; mean age: 54±19years) were enrolled to examine the relationship between the ENoG value 10-14days after the onset of facial palsy, and the % eye opening 12 months later. Receiver operating characteristic (ROC) curve for the ENoG value was then used to decide the optimum cut-off value as a predictor of the development of oral-ocular synkinesis. RESULTS: We defined a % eye opening inferior to 85% as an index of the development of oral-ocular synkinesis. There was a significant correlation between the values of ENoG 10-14days after the onset of facial palsy and those of % eye opening 12 months later (ρ=0.81, p<0.001). The area under the ROC curve for the ENoG value was the predictor for the development of oral-ocular synkinesis at 0.913 (95%CI: 0.831-0.996, p<0.001). The optimum cut-off value of ENoG 10-14days after the onset of facial palsy was 46.5% to predict the development of oral-ocular synkinesis 12 months after the onset of facial palsy (sensitivity 97.1% and specificity 77.5%). CONCLUSION: The value of ENoG 10-14days after the onset of facial palsy is a predictive factor for the development of facial synkinesis 12 months later. Since facial palsy patients with a ENoG value inferior to 46.5% have a high risk of developing synkinesis, they should receive the facial biofeedback rehabilitation with a mirror as a preventive therapy.

Surgical Repair of Subacute Right Ventricular Perforation after Pacemaker Implantation.

We report an 84-year-old woman who presented with right ventricular perforation 4 days after pacemaker implantation for syncope due to sick sinus syndrome. Median sternotomy revealed no pericardial effusion, but the pacing lead had penetrated the right ventricle and pericardium. When the pleura was opened, the tip of the lead was seen in the visceral pleura. The lead was cut in the pericardial cavity and extracted from the left subclavian wound together with the generator. The right ventricular perforation was sutured and a temporary pacing lead was placed on the right ventricular wall intraoperatively. Ten days after the surgery, a new pacemaker lead was placed in the ventricular septum via the right axillary vein. Right ventricular perforation is a rare complication after pacemaker implantation. Typically, it occurs at the time of implantation or within 24 hours after implantation. In the present case, the perforation of the right ventricle which needed urgent surgery occurred 4 days after implanting the pacing lead at the right ventricular apex. Great care should have been taken not to overlook this life-threatening complication even more than 24 hours after pacemaker implantation.

A case of a quadricuspid aortic valve identified preoperatively using transthoracic echocardiography.

Quadricuspid aortic valve is an extremely rare congenital heart anomaly that often causes valve incompetence, requiring surgical intervention. Care must be taken to avoid surgical complications in patients with quadricuspid aortic valve; thus, preoperative diagnosis is important. A 76-year-old man presented with exertional dyspnea due to aortic regurgitation. Transthoracic and transesophageal echocardiography revealed severe aortic regurgitation caused by quadricuspid aortic valve. To avoid interference with the cardiac conduction system, we performed aortic valve replacement using an ingenious technique, in which pledgeted sutures on the accessory leaflet were placed from outside the sinus of Valsalva to above the aortic annulus. The patient recovered uneventfully and was discharged from the hospital without any complications. While preoperative diagnosis of quadricuspid aortic valve is considered difficult, we identified it preoperatively using transthoracic echocardiography; we were, thus, able to properly prepare for complete atrioventricular block.

Simultaneous aortic valve replacement and pectus excavatum correction in a 76-year-old man.

A 76-year-old man was admitted to our department to undergo surgical treatment for aortic valve regurgitation. On physical examination, a bowl-shaped concavity was noted. Chest computed tomography revealed left-sided heart displacement by severe pectus excavatum with a Haller index of 6.40. Considering the postoperative cardiopulmonary complications that may result from mechanical compression due to uncorrected sternal deformities, we decided to perform a simultaneous aortic valve replacement and pectus excavatum correction. The operation time was long (570 min) and involved a high-volume transfusion due to excessive bleeding caused by resection of the deformed costal cartilages and sternal osteotomy under the use of heparin. The endotracheal tube was removed on the fifth postoperative day, but reintubation was required because of hypercapnea and difficulty in sputum discharge. With the aid of tube feeding for nutritional management, his cardiopulmonary function gradually ameliorated and his general condition improved. Consequently, he was weaned from mechanical ventilation on the 14th postoperative day. The patient is doing well 1 year after surgery. We report on the surgical management for pectus excavatum in adult patients.

Aortic valve replacement after previous coronary artery bypass grafting: a case report.

We experienced a case of aortic valve replacement after previous coronary artery bypass grafting with patent bypass grafts. Based on the retrosternal anatomy assessed by preoperative angiography and thoracic computed tomography, aortic valve replacement was performed through a median resternotomy. After careful dissection of the right side of the heart and the ascending aorta, cardiopulmonary bypass was established with cannulation of the ascending aorta and bicaval venous cannulation. The patent bypass grafts were dissected only as required for clamping and were clamped during cardiac arrest. After aortic valve replacement, the patient was uneventfully weaned from cardiopulmonary bypass and had a good postoperative recovery. It is important that surgeons have a meticulous strategy for reducing the risks associated with operating on patients with patent bypass grafts. We report on the surgical management of patients undergoing aortic valve replacement after previous coronary artery bypass grafting, including careful planning during the first operation.

Vestibular and cochlear neuritis in patients with Ramsay Hunt syndrome: a Gd-enhanced MRI study.

CONCLUSION: It is suggested that vertigo in patients with Ramsay Hunt syndrome is mostly induced by superior vestibular neuritis consecutive to the reactivation of varicella-zoster virus (VZV) infection from the geniculate ganglion through the faciovestibular anastomosis. Refractory hearing loss in patients with Ramsay Hunt syndrome may be due to cochlear neuritis following the spread of VZV. OBJECTIVES: An attempt was made to selectively identify vestibulocochlear nerves in the internal auditory canal (IAC) on gadolinium (Gd)-enhanced MRI in patients with Ramsay Hunt syndrome. METHODS: Fourteen patients with Ramsay Hunt syndrome presenting with facial palsy, herpes zoster oticus, vertigo, and/or sensorineural hearing loss were scanned on 1.5 T MRI enhanced with Gd. Perpendicular section images of the IAC were reconstructed to identify the facial, superior, and inferior vestibular nerves and the cochlear nerves separately. RESULTS: All except one of the patients with Ramsay Hunt syndrome with vertigo showed both canal paresis on the caloric test and Gd enhancement of the superior vestibular nerve in the IAC on MRI. Among 10 patients with hearing loss, 3 patients with severe to moderate sensorineural hearing loss showed Gd enhancement of the cochlear nerve in the IAC on MRI.

Gum chewing enhances early recovery of bowel function following transperitoneal abdominal aortic surgery.

BACKGROUND AND PURPOSE: Postoperative bowel dysfunction is still a major unsolved problem following transperitoneal abdominal aortic surgery. We conducted this study to establish if gum chewing during the postoperative period promotes recovery of bowel function following abdominal aortic surgery. METHODS: The subjects were 44 patients who underwent elective abdominal aortic surgery. The patients were allocated to a control group (n = 21), who received standard postoperative care, or a "gum group" (n = 23), who received standard postoperative care and were also given gum to chew three times a day from postoperative day (POD) 0-5. RESULTS: The patient characteristics, intraoperative, and postoperative care were equivalent in both groups. Flatus was passed on POD 1.49 in the gum group and on POD 2.35 in the control group (P = .0004) and the time to oral intake was 3.09 days in the gum group and 3.86 days in the control group (P = .023). The number of days to full mobilization in the hospital room was 3.35 versus 5.59 for the gum and control groups, respectively (P < .0001). CONCLUSIONS: Gum chewing enhances early recovery of bowel function following transperitoneal abdominal aortic surgery. Moreover, it is a physiologically sound, safe, and an inexpensive part of the postoperative care.

Mirror biofeedback rehabilitation after administration of single-dose botulinum toxin for treatment of facial synkinesis.

OBJECTIVE: The efficacy of facial biofeedback rehabilitation with a mirror after administration of a single dose of botulinum A toxin on facial synkinesis was examined in patients with chronic facial palsy. STUDY DESIGN: Prospective clinical study. SETTING: University hospital. SUBJECTS AND METHODS: The present study includes 8 patients with Bell palsy and 5 with herpes zoster oticus showing facial synkinesis. A single dose of botulinum A toxin was used as the initial process of facial rehabilitation. Patients then continued a daily facial biofeedback rehabilitation with a mirror at home. They were instructed to keep their eyes symmetrically open using a mirror during mouth movements. The degree of oral-ocular synkinesis was evaluated by the degree of asymmetry of eye opening width during mouth movements (% eye opening). RESULTS: After administration of a single dose of botulinum A toxin, temporary relief of facial synkinesis was observed in all patients. Patients were then instructed to continue the facial biofeedback rehabilitation with a mirror for 10 months. The mean values of the percent of eye opening during 3 designated mouth movements that included lip pursing /u:/, teeth baring /i:/, and cheek puffing /pu:/ increased significantly after 10 months when the effects of botulinum A toxin had completely disappeared. CONCLUSION: These findings demonstrate that facial biofeedback rehabilitation with a mirror after administration of a single dose of botulinum A toxin is a long-lasting treatment of established facial synkinesis in patients with chronic facial palsy.

Coronary artery bypass grafting in patients with pulmonary aspergillosis.

Cardiovascular surgery in patients with pulmonary aspergillosis has been rarely reported. Coronary artery bypass grafting (CABG) for three cases of angina pectoris with pulmonary aspergillosis was successfully performed. Patients were discharged from our hospital without any complications of invasive Aspergillus cardiovascular infection. Careful perioperative management for preventing pulmonary complications is important.

A new hydrocolloid dressing prevents surgical site infection of median sternotomy wounds.

PURPOSE: This prospective and semi-randomized study was conducted to clarify the effectiveness of a new hydrocolloid dressing placed over median sternotomy wounds using an occlusive dressing technique. METHODS: The subjects were 253 patients undergoing coronary artery bypass grafting (CABG), who were randomized to receive either the new hydrocolloid dressing (Karayahesive, n = 117) or a polyurethane foam dressing (Tegaderm plus Pad, n = 136) immediately after sternal wound closure. Karayahesive was left in place for 7 days, whereas the Tegaderm plus Pad was removed on postoperative day (POD) 2 and replaced with an adhesive wound dressing until POD 7. RESULTS: In the Karayahesive group, complete integrity of the wound was achieved in 91% of the patients, with an infection developing in 3.4%: as a superficial surgical site infection (SSI) in three and as a deep SSI in one. On the other hand, in the Tegaderm plus Pad group, an infection developed in 10.3% (14 patients) of the patients: as a superficial SSI in nine and as a deep SSI in five (P < 0.05). The total treatment costs from the application of the dressing until completion of treatment was 699 yen for the Karayahesive and 910 yen for the Tegaderm plus Pad (P < 0.001). CONCLUSIONS: The new hydrocolloid dressing, applied with an occlusive dressing technique to median sternotomy wounds, prevented SSI and was cost effective.

[Successful anesthetic management of two high-risk elderly patients using propofol-remifentanil].

This report deals with anesthetic management using remifentanil in high-risk elderly patients with many complications such as arteriosclerosis and obstructive lung disease other than the disease which was the object of operation. Case 1; an 87-year-old woman with complete left bundle branch block and aortic valve stenosis was scheduled for cholecystectomy, intestinal tract incision and gallstone extraction. Case 2; a 79-year-old woman with obstructive lung disease was scheduled for sigmoidectomy and cholecystectomy. The use of remifentanil in anesthetic management to control the blood pressure and the pulse, was useful. They were extubated within 30 minutes after the operation. They received epidural anesthesia 30 minutes before the remifentanil discontinuance. After remifentanil is discontinued, they had little pain. Elderly patients considered at high-risk were treated under total intravenous anesthesia with remifentanil and propofol.

[The combined use of laryngoscope and Trachlight: another option for endotracheal intubation in patients with large epiglottic cysts].

Epiglottic cysts often cause difficulty in airway management. A 71-year-old man had extraction for an epiglottic cyst of 4 cm in diameter. Anesthesia was induced with small divided doses of propofol. After verifying that mask ventilation was possible under light anesthesia, vecuronium was used for muscle relaxation. Because of the size of the cyst, it was impossible to observe directly the larynx using a laryngoscope. Therefore, while moving the tongue to the left with the laryngoscope, an endotracheal tube was inserted into the trachea using the Trachlight. The operation was finished in 55-min and the patient was extubated 15 min after the end of the operation. His postoperative course was uneventful and he was discharged from the hospital three days after the operation. The authors conclude that the combined use of the laryngoscope and Trachlight is helpful for endotracheal intubation in patients with large epiglottic cysts.

Blink reflex R2 recovery curves in patients with facial palsy within ten days after onset.

The purpose of this study was to investigate the acute changes in blink reflex responses in patients with facial palsy. We used the blink reflex R2 recovery curves as an index of the excitability of the blink reflex neural circuit and evaluated the excitability of the blink reflex within 10 days after onset. Twelve patients with peripheral facial palsy were selected on condition that the degree of facial palsy was so mild that R2 responses of the blink reflex were measurable on the affected side, and they were compared with 12 healthy volunteers. Conditioning and test electrical stimuli were delivered on the affected side of the supraorbital nerve. Ipsilateral R2 response (iR2) of the blink reflex in patients was significantly enhanced at interstimulus intervals (ISIs) between conditioning and test stimuli from 100 to 1,000 ms, in comparison with the control subjects. These findings suggested hyperexcitability of the blink reflex neural circuit in patients with facial palsy. In addition to iR2, contralateral R2 response (cR2) in the patients was also significantly increased at ISIs of 100-1,000 ms to the same extent as the enhancement of iR2. All these findings suggested that the hyperexcitable changes developed in a common pathway of iR2 and cR2, but not in the ipsilateral facial motor neurons. It is suggested that the hyperexcitability of the neural circuit of the blink reflex during an acute period of facial palsy is an adaptive response to compensate for impaired facial motor function.

Commissural dehiscence and pannus formation of porcine heart valve bioprostheses.

From May 1976 to June 2001, 95 porcine heart valve bioprostheses (BPs) were explanted. Among them, 85 prostheses were available for an analysis of structural valve deterioration (SVD). There were 32 Hancock (H) BPs and 53 Carpentier-Edwards (CE) BPs, with a mean implantation duration of 12 +/- 3.5 and 11.0 +/- 4 years, respectively. There were two extraordinary complications. One was commissural dehiscence (CD) of the CEBPs in 10/53 cases (18.9%), with a mean duration of 12.7 +/- 2.7 years. This was not observed in the HBPs. The other was pannus formation in both BPs. In the mitral position, it was 25/32 (78.1%) in HBPs and 37/53 (69.8%) in CEBPs. In the aortic position, it was 4/32 (1.3%) in the HBPs and 11/53 (20.8%) in the CEBPs. We conclude that CD could not be diagnosed preoperatively and anticoagulation is therefore indicated to prevent pannus formation of such prostheses, particularly in those located in the mitral position.