The application of distally based fascial pedicled island flap to rapair wound of the extremities]

In order to preserve the major vessels of the extremities in the repair and reconstruction of wounds of the extremities, the distally based fascial pedicled island flap was applied clinically. Its axis and rotatary point were designed along orientation of the major arteries, and the blood supply was from the abundant vascular networks in the deep fascia. Twenty-two cases with exposure of tendon and bone including 10 upper limbs and 12 lower limbs were treated. The flap area of forearm ranged from 7 cm x 8 cm to 12 cm x 9 cm and the ratio of the length to width of the pedicle was 1: 1-2. The flap area of the calf ranged from 10 cm x 6 cm to 16.5 cm x 12 cm and the ratio of the length to width of the pedicle was 2:1. The rotatary angle was 130 degrees-170 degrees. After operation, 18 flaps were survived completely, 2 cases had partial necrosis on the margin, 2 failures received cross-leg flap in the second operation. The patients were followed up with an average of 13.5 months (ranged from 3 months to 2 years). The conclusions were as follows: 1. the blood supply of this type of flap was reliable and the major arteries of the extremities needed not to be sacrificed; 2. the preparation of the flap was easy and the survival rate was satisfactory; 3. the shortcomings of this flap were unsightly incision scar and the limited size of flap and; 4. during the operation, the compression of the pedicle must be avoided.     

Anatomy of the frontotemporal branch of the facial nerve and indications for interfascial dissection

INTRODUCTION: Many studies have been conducted of the surgical anatomy of the frontotemporal branch of the facial nerve (FTBFN). However, very few have addressed the indications for interfascial dissection. When the zygomatic arch needs to be exposed, the interfascial approach is recommended to protect the FTBFN. With the transbasal or subfrontal approaches, however, when a bicoronal skin incision is used, the need for the interfascial approach is not clear. METHODS: We studied 10 temporal regions (5 cadaveric heads). We dissected the recognized fascial layers of the temporal region and the FTBFN. We performed a histological study in a sixth specimen. RESULTS: We observed the following. 1) The galea and the superficial layer of the deep temporal fascia become fused in a curved line from the lateral orbital border 2.8 cm above the zygomatic arch to a point 3 cm posterior to the inferolateral angle of the orbit. 2) After this transitional area of adherence, the subgaleal loose cellular layer is lost and is replaced by a fibrofatty tissue. 3) The FTBFN in its course above the zygomatic arch runs in this tissue layer without being protected by the galea. 4) Over the superolateral angle of the orbital rim, the galea protects FTBFN, and there are no subgaleal adhesions in that area. CONCLUSION: Ahove the zygomatic arch, the FTBFN is not protected by the galea. During bicoronal approaches, if only the superolateral angle of the orbital rim needs to be exposed and not the zygomatic arch, there is no need to protect the FTBFN using an interfascial approach.     

A comparative study on coronary angiography and exercise ECG testing

42 patients with chronic urinary retention caused by BPH were treated by means of Mesh-like tubular stent placing from August 1993 to August 1994. The mesh-like tubular stent was made of nickel titanium alloy in sizes of 2.0 x 1.5 cm, 2.5 x 1.5 cm, 3.0 x 1.5 cm respectively. Under direct vision the stent was placed with the deployment tool. The desirable position of the stent is 0.3-0.5 cm proximal to the internal urethral orifice, 0.5 cm distal to the verumontanum. In 38 patients followed up for 1-6 months, 34 were succesful with an effective rate of 80%. IPSS, PUFR, RUV after 1, 3, 6 months of placement were 8.5 +/- 4.4, 6.8 +/- 3.5, 7.1 +/- 5.2; 12.5 +/- 6.0 ml/s, 14.0 +/- 5.2 ml/s, 14.4 +/- 8.1 ml/s; 43 +/- 11.5 ml, 47.4 +/- 13.3 ml, 44.5 +/- 15.7 ml respectively. Four stents were taken away transurethrally in the unsuccessful cases. The results indicat that there are no serious complications except for shorttime hematuria, fever, and bladder irritation. The success depends chiefly upon exactly meassuring the length of prostatic urethra, selecting the rational size of the stent, and correctly placing the stent.     

Eyelid crease incision for lateral orbitotomy

PURPOSE: The authors describe a surgical incision and technique for lateral orbitotomy that is intended to minimize visible scarring and deformity. METHODS: This is a noncomparative, interventional, retrospective case series. Other surgical approaches for lateral orbitotomy are briefly reviewed. The authors' technique includes incision placement within the natural upper eyelid crease, with minimal extension in a relaxed skin tension line; dissection to the superior and lateral orbital rims in the submuscular plane; and wide dissection within the subperiosteal space. Criteria are described for inclusion of a bone flap in the technique. RESULTS: The eyelid crease incision has been used for exposure of the superolateral diagonal half of the orbit in approximately 600 cases. A variety of pathologic conditions affecting the orbital bones or the subperiosteal, extraconal, or intraconal spaces have been treated. Surgical exposure has been adequate to achieve the goals of surgery in individual cases, and the cosmetic results have been preferable to those the authors achieved using other surgical incisions. CONCLUSIONS: The eyelid crease incision for lateral orbitotomy allows dissection in relatively avascular planes, involves minimal transection of orbicularis muscle and lymphatic channels, and results in negligible postoperative scarring. Depending on the size and location of the lesion and the goal of surgery, the eyelid crease incision may be used without a bone flap. However, when a bone flap is needed, the incision does not restrict its size.     

Maximal, three-wall, orbital decompression through a coronal approach

BACKGROUND AND OBJECTIVE: Only limited volume expansion is offered by traditional lateral orbital decompressions in which the anterior segment of the lateral wall is removed to allow lateral soft tissue prolapse. A great deal of additional soft tissue expansion can be obtained, not only laterally, but also posteriorly by removing the deep portion of the sphenoid wing. The authors report their experience in removing this bone through a coronal approach. PATIENTS AND METHODS: The authors performed maximal, three-wall, orbital decompressions through a coronal approach for 20 patients with thyroid-related orbitopathy. A disfiguring proptosis resulting from stable Graves' disease orbitopathy was the indication for surgery in all cases. Through a coronal approach, the lateral rim was left in place and thinned, augmented with specialized orbital rim onlay implants, or repositioned with osteosynthesis systems. The bone over the lacrimal fossa was sculpted to form a "keyhole" for the lacrimal gland, thereby providing additional orbital expansion. Once the medial canthal tendon and lacrimal sac had been elevated from their periosteal attachment, excellent exposure was obtained for medial and inferior orbital decompression. RESULTS: The authors report the results of 20 coronal orbital decompressions during a period of 44 months. Seven cases included lateral rim advancement. Up to 6 mm of retrodisplacement was achieved without rim augmentation, 9 mm with rim augmentation. DISCUSSION: The deep lateral orbital wall can provide significant room for volume expansion. The authors found that up to 6 mm of proptosis reduction can be obtained using the lateral wall alone. The coronal approach provides access to all four orbital walls for deep orbital decompression. The authors' philosophy of treatment in cases without compressive optic neuropathy is evolving toward the use of the lateral wall as the first approach with the incorporation of additional walls as needed.     

Eye movement in amyotrophic lateral sclerosis: a longitudinal study

Conservative therapy in cases of severe dysthyroid ophthalmopathy (DO) has not given satisfactory results. Since 1986, 51 patients (99 orbits) with marked DO have been treated by surgical decompression of the orbits. The procedure begins within the upper eyelid. The excision of the excessive skin and subcutaneous tissue is performed and eyelid fat is removed. In order to obtain the correction of the upper eyelid retraction, the levator aponeurosis is divided by 2-3 transverse incisions in its central part and Muller's muscle is sectioned at the level of its tarsal insertion. Through an incision in the lower eyelid, the posterior part of the orbital floor, the lateral orbit wall, as well as the periorbital and intraorbital fat are removed. Through an incision made over the medial margin of the orbit, the ethmoidal part of the medial orbital wall and the retrobulbar fat are removed. The periorbital periosteum should be incised at several sites. After operation all patients showed a significant reduction of exophthalmos (5-11 mm, 7.16 mm on average), significant reduction of intraocular pressure, marked improvement in ocular muscle function, as well as considerable reduction or disappearance of subjective symptoms. There was an improvement in vision in 68% patients who had impaired vision before the operation. There were no cases of subsequent impairment of vision or ocular motility. Mild relapse was recorded in three cases only and only one patient required unilateral reoperation. Strabismus surgery had to be performed in five patients due to unsatisfactory correction of double vision. It can be concluded that this method of orbital decompression gives very good functional and aesthetical long-term results.     

Experience with the Ultrex and Ultrex Plus inflatable penile prosthesis: new implantation techniques and surgical outcome

OBJECTIVE: To construct nomograms of the size of the fetal orbit and lens during gestation. SUBJECTS: The study group included 349 normal pregnant women at 14-36 weeks' gestation. METHODS: Routine biometric measurements were obtained in all the participants; these included biparietal diameter, head and abdominal circumferences, measurements of the long bones and the diameters of the fetal orbit and lens. The orbital and lens circumference measurements were also related to gestational ages. RESULTS: A linear growth function was observed between gestational age (GA) and orbital diameter (r = 0.94; p < 0.00001; y = -0.66 + 0.5 x GA), orbital circumference (r = 0.94; p < 0.00001; y = -2.1 + 1.5 x GA) and orbital area (r = 0.94; p < 0.00001; y = -98.1 + 8.3 x GA). Significant correlation was also found between femoral length (FL) and orbital diameter (r = 0.95; p < 0.00001; y = 3.3 + 1.9 x FL), orbital circumference (r = 0.95; p < 0.00001; y = 10.3 + 5.9 x FL) and orbital area (r = 0.93; p < 0.00001; y = -28.2 + 32.2 x FL). A linear growth function was observed between orbital circumference and biparietal diameter (r = 0.94; p < 0.00001) and head circumference (r = 0.95; p < 0.00001). A linear growth function was also observed between gestational age and the diameter of the lens (r = 0.89; p < 0.00001; y = 0.88 + 1.4 x GA) the circumference of the lens (r = 0.89; p < 0.00001; y = 2.78 + 0.4 x GA) and the area of the lens (r = 0.89; p < 0.00001; y = -7.95 + 1.0 x GA). The correlation was found between the ratios of the diameters, circumferences and areas of the lens and the orbit. CONCLUSIONS: These results provide normative data of the growth of the fetal orbit and lens and may aid future studies relating to fetal eye anomalies.     

The diagnostic value of discography

BACKGROUND: Conjunctival cyst formation following enucleation may occur in 3% to 7% of patients receiving orbital implants, especially secondary implants. We present a patient with a giant epithelial inclusion cyst of the anophthalmic orbit 50 years after enucleation without orbital implant. PATIENT: A 54-year-old male presented with increasing proptosis of the ocular prosthesis, shallowing of the inferior fornix, a palpable orbital mass, and difficulty in retaining the ocular prosthesis. At the age of 1 year enucleation of the right eye without orbital implant was performed following perforating ocular trauma. Results of examination of the other eye were unremarkable. Transillumination of the orbital mass was possible. The clinical diagnosis of an epithelial inclusion cyst was confirmed using ultrasonography and CT scan. An incision of conjunctiva and cyst wall and subsequent marsupialization were performed. Nine months postoperatively there was no evidence of recurrence of the cyst. The ocular prosthesis was well in place. CONCLUSION: Conjunctival cyst formation following enucleation may rarely occur in patients receiving orbital implants, especially secondary implants. The presentation of a conjunctival cyst formation following enucleation without orbital implant 50 years after surgery is noteworthy in comparison to implantation cysts which are known to occur more commonly within the first two years following secondary orbital implants.     

Reoperations of total hip prosthesis with acetabular reconstruction using bone allografts]

Detachment of the acetabular segment is the most important long-term problem with total hip prostheses. We analyzed long-term outcome in our first 48 acetabular reconstructions with cryopreserved allografts. Among the 48 hips operated on with this technique, 38 were reassessed after a mean follow-up of 7 years 3 months (range 5 years-9 years 6 months). Mean age of the population at surgery was 63 years. There were two predominant etiologies: sequelae of chronic hip luxation and primary osteoarthrosis of the hip. In 10 cases with massive destruction, the Müller ring was used to stabilize the allograft. Results were assessed at 6 months, 2 years, 4 years and at longest follow-up using the Merle d'Aubigné clinical assessment scale. For the radiographic assessment, the Ranawat criteria were used to evaluate the alignment of the reconstruction. Clinically, patient comfort was improved in all cases with significant pain relief. Radiologically, mean acetabular ascention was 5 mm and mean medialization was 3.5 mm. A rim was observed in 24 cases including 19 measuring less than 2 cm. Acetabular loosening was evidenced in the 5 other cases where the rim measured more than 2 mm. In 4 of these 5 cases, the acetabulum had migrated to a new setting. The radiographic image then remained unchanged. Analysis of our 38 first cases showed that bone allografts with cimented acetabulum, sometimes with a stabilizing ring, is one of the possible solutions for difficult acetabular reconstructions. However, after a 7 years 3 months follow-up, we have had five (13%) aseptic displacements including one case requiring reoperation. In the 33 stable joints (87%) with good results reconstruction has achieved a nearly perfect anatomic position, similar to first intention arthroplasty with the use of perfectly stabilized bone grafts with a maximal acetabular surface. Our follow-up is longer than most published in the literature. However, the migration rate of 13% it is still too short to draw any conclusion concerning the long-term outcome in our patients, despite their older age and reduced physical activity compared with primary hip arthroplasty patients.     

Orbital exenteration and placement of a prosthesis in fish

OBJECTIVE: To develop a procedure for orbital exenteration and prosthesis placement in fish. DESIGN: Prospective study. ANIMALS: 5 cultured hybrid striped bass (Morone saxatilis x M chrysops) ranging from 30 to 50 cm in length. PROCEDURE: Exenteration was performed, using a dorsal approach in which blunt dissection was performed in the circumorbital sulcus. The orbit was then dried, and simple interrupted sutures were placed, leaving 2 suture loops within the orbit. The orbit was filled with polyvinylsiloxane, and a prosthetic glass eye was seated in the polyvinylsiloxane. RESULTS: All fish retained the prosthesis and had satisfactory cosmetic results at the end of the 8-week study period. CLINICAL IMPLICATIONS: The increase in popularity of pet fish and abundance of valuable aquarium and show fish have led to heightened awareness of piscine ocular disease. Aquarium fish are often euthanatized because of disfiguring ocular problems. The technique described here for surgical exenteration and cosmetic orbital prosthesis placement in fish may extend the captive life of public display fish.     

Mesenchymal chondrosarcoma of the orbit. Report of three new cases and review of the literature

BACKGROUND: Extraskeletal mesenchymal chondrosarcoma is a rare tumor characterized by undifferentiated mesenchymal cells with islands of mature hyaline cartilage. Considering all sites, long-term survival is approximately 30%. Only seven cases of orbital mesenchymal chondrosarcoma have been reported. METHODS: The records of three cases of orbital mesenchymal chondrosarcoma treated at the Columbia-Presbyterian Medical Center, and the seven previously reported cases of this tumor were reviewed to determine clinical characteristics and appropriate therapy. RESULTS: Nine of the 10 patients were female; age of onset ranged from 10 to 35 years. Of eight patients with at least 2 years of observation, five survived 5 or more years after resection, or after resection plus adjuvant therapy. Two patients died of metastatic disease 2 and 5 years, respectively, after the initial treatment, and one died of pneumonia 6 months after surgery. Review of the histology of the three cases treated at Columbia-Presbyterian Medical Center did not identify distinct histologic types that might guide therapy. Presenting symptoms were typical of symptoms of an orbital mass: proptosis, pain, diplopia, change in visual acuity, ptosis, and tearing. CONCLUSION: The small number of reported cases of mesenchymal chondrosarcoma of the orbit prevents definitive conclusions, but it appears that resection is adequate therapy in some cases. Extraskeletal mesenchymal chondrosarcoma of the orbit may have a better prognosis than tumors in other sites.     

Reconstruction of total maxillectomy defects with preservation of the orbital contents

Reconstruction after total maxillectomy with preservation of the orbital contents is technically more challenging than when the maxillectomy is combined with orbital exenteration. Reconstruction of such defects should (1) provide support to the orbital contents, (2) obliterate any communication between the orbit and nasopharynx, (3) reconstruct the palatal surface, and (4) achieve facial symmetry and a good aesthetic result. We report our experience in performing reconstructive surgery on 14 patients who had a total maxillectomy and preservation of the orbital contents using nonvascularized bone grafts for reconstruction of the orbital floor and maxilla, in conjunction with a soft-tissue free flap or pedicled muscle flap. The orbital floor was reconstructed using split ribs in six cases (42.9 percent), split calvaria in six cases (42.9 percent), and iliac crest graft in two cases (14.3 percent). A myocutaneous rectus abdominis free flap was used for soft-tissue reconstruction and resurfacing of the palatal mucosa in twelve patients (85.7 percent), and a temporalis muscle transposition was used in two elderly patients (14.3 percent). One patient died 2 days after surgery. Mean follow-up and aesthetic and functional results were assessed in the remaining 13 patients a minimum of 6 months postoperatively. In 9 of these 13 patients (69.2 percent), postoperative radiotherapy was administered. No reexplorations or free flap failures were observed. One rectus flap developed partial necrosis of the skin island intraorally without affecting the final result. All patients had adequate functional vision. One patient had a mild vertical dystopia; there were no cases of enophthalmos. Ectropion was the most common undesirable result and was present in 10 of 13 cases (76.9 percent). It was graded as mild in four cases (40.0 percent), moderate in four cases (40.0 percent), and severe in the remaining two cases (20.0 percent). Speech was considered normal in six cases (46.2 percent), near normal in six cases (46.2 percent), and intelligible in one case (7.7 percent). Chewing function was considered good (soft to unrestricted diet) in all cases except for one patient who was only able to eat a pureed diet. Aesthetic results after immediate reconstruction were considered good in nine cases (69.2 percent) and fair in four cases (30.8 percent). Primary reconstruction of total maxillectomy defects with orbital content preservation remains a complex problem without a perfect solution. The combination of nonvascularized bone grafts for orbital/maxillary reconstruction with a soft-tissue free flap is a safe, reliable, and effective method of maximizing postoperative functional and aesthetic results.     

Invasive squamous cell carcinoma arising from asymptomatic choristomatous cysts of the orbit. Two cases and a review of the literature

BACKGROUND: Epithelial choristomatous cysts are common orbital lesions, the most frequent of which are dermoid or epidermoid tumors. Massive enlargement or extraorbital extension of these benign lesions may occur. Malignant transformation of the epithelial lining of epidermoid cysts is rarely reported. METHODS: Two patients are presented in whom the epithelial lining of a previously asymptomatic choristomatous cyst of the orbit underwent malignant transformation to produce invasive squamous cell carcinoma. The unusual origin and clinical presentation of the lesions caused a delay in the diagnosis and therapy in both patients. Metastatic workup was negative in both patients, who underwent resection of their tumors via orbital exenteration with craniofacial resection. Reported cases of malignant transformation in analogous choristomatous cysts elsewhere in the cranium are reviewed. RESULTS: One patient is alive and well without recurrent disease 40 months postoperatively. The second patient died of a pulmonary embolus 2 months postoperatively. Autopsy showed no residual tumor. Overall, only 3 of 18 reported patients with epidermoid choristoma of the head and orbit with malignant transformation were alive when reported. CONCLUSIONS: Malignant squamous metaplasia is believed to be a rare complication of orbital dermoid or epidermoid cysts, with only two previously reported cases. However, malignant transformation is relatively frequent in analogous epidermoid cysts found elsewhere in the cranial vault, especially after incomplete excision. These reports encourage the complete removal of epithelial choristomas of the orbit.     

Malar augmentation by osteotomy and advancement

We developed a modification of Tessier's zygoma plasty to increase anterior and lateral projection of the malar eminences in 8 patients with malar hypoplasia. The four steps of our modification are: (1) access solely through an intraoral upper sulcus incision; (2) osteotomy of the inferior orbital rim at a more medial site and of the lateral orbital rim more cephalad; (3) careful preservation of both the zygomaticomaxillary buttress and the zygomatic arch; and (4) use of a cranial bone graft alone, as a wedge, to stabilize the rotated zygoma, without the need for plate or screw fixation. Eight patients have undergone this procedure. Follow-up ranged from 4 to 15 months. There have been no complications. All 8 patients have achieved excellent accentuation of their malar eminences, with maintenance of symmetry. The increase in malar eminence projection has improved overall facial form in these patients. The modified Tessier zygoma plasty offers a stable and predictable technique for improving facial form. It provides a very natural correction for deficient malar projection, without introducing visible scars.     

KLT-based quality controlled compression of single-lead ECG

We report a rare case of orbital metastasis from hepatocellular carcinoma and review previously documented cases of this condition. The clinical, histopathological, and immunohistochemical characteristics of hepatocellular carcinoma metastatic to the orbit are described. Results from histopathological examination and histochemical findings of the orbital mass established the diagnosis. A review of 10 cases of metastatic hepatocellular carcinoma to the eye and orbit disclosed painful proptosis as the most common clinical sign of hepatocellular carcinoma metastatic to the orbit. In 5 (56%) of the 9 cases that had orbital metastasis (including the present case), the diagnosis was made after the patient first was examined with symptoms from the orbital mass. Metastatic hepatocellular carcinoma should be considered as a rare cause of painful proptosis. While patients usually are seen with signs and symptoms of widespread metastatic carcinoma, patients with hepatocellular carcinoma with orbital involvement may be first examined by the ophthalmologist because of the clinical manifestations of the disease, proptosis and pain. Other orbital lesions associated with painful proptosis are discussed briefly.     

The use of high-density polyethylene implants in facial deformities

OBJECTIVE: To determine the usefulness of porous high-density polyethylene implants (Medpor) in a variety of facial skeletal deformities and subcutaneous defects, excluding those associated with acute maxillofacial trauma. DESIGN: Case series. SETTING: Academic tertiary care referral center in Baltimore, Md. PATIENTS: Thirty-four patients (age range, 20-74 years) with facial deformities requiring skeletal defect reconstruction or augmentation (38 cases), treated between January 1, 1992, and January 1, 1997. Follow-up ranged from 6 months to 40 months. MAIN OUTCOME MEASURES: Age, type and origin of the deformity treated, type of treatment, and complications. RESULTS: Types of deformities and defects treated include 7 patients with orbital defects (secondary traumatic or oncologic deformities), 8 with temporal fossa defects, 8 with frontocranial defects, 4 with maxillary or malar defects, 7 with calvarial bone graft donor site defects, 2 with microtia, and 2 with chin deficiency. Forty implants were placed. Complications included implant exposure in 4 patients and inappropriate augmentation in 1 patient (chin implantation). CONCLUSIONS: High-density polyethylene implants offer an excellent alternative to autogenous and other alloplastic materials in reconstruction of many facial defects and deformities. Advantages include its versatility and relatively ideal pore size that allows for excellent soft tissue ingrowth and coverage. Disadvantages include its rigid nature and difficulty in contouring to the surface of complex skeletal structures.     

Penile circular fasciocutaneous skin flap in 1-stage reconstruction of complex anterior urethral strictures

PURPOSE: We review the applications and outcomes of penile circular fasciocutaneous flap urethroplasty in 66 patients at our institution. MATERIALS AND METHODS: We used a circular distal penile skin flap for urethral reconstruction in 66 men with complex urethral strictures. Average stricture length in this series was 9.08 cm. and mean followup was 41 months (range 1 to 7 years). RESULTS: The initial overall success rate was 79% (52 of 66 cases). Recurrent stenosis was noted in 7 of the 54 onlay (13%) and 7 of the 12 tubularized repairs (58%). Most recurrent strictures were successfully treated with a single subsequent procedure, including repeat urethroplasty in 5 cases and optical urethrotomy or dilation in 6. Two patients required perineal urethrostomy and 1 awaits further reconstruction. Including subsequent procedures, the overall long-term followup success rate was 95%. Neurovascular lower extremity complications developed in 4 patients after prolonged high lithotomy positioning. CONCLUSIONS: Circular fasciocutaneous flap urethroplasty is a highly effective 1-stage method of reconstructing complex urethral strictures. Onlay repairs appear to be more successful than those involving flap tubularization. Limiting the time that the patient spends in the high lithotomy position appears to prevent neurovascular extremity complications.     

Esthetic incisions in traumatology involving the mid-face region

For exposure of the facial bones and orbital floor, various types of incisions can be employed. For exposing the orbital rim, a subciliary incision may have the disadvantage of producing chronic edema and shortening of the lower lid. The transconjunctival approach combined with lateral canthotomy avoids an external scar and allows sufficient exposure of orbital floor and zygomatico-frontal suture line. The placements of implants and osteosynthesis are then possible. In severe midfacial trauma the authors prefer temporo-temporal incision combined with a conjunctival approach, lateral canthotomy and intraoral access to the zygomatico-maxillary area.     

Re: The use of selective serotonin reuptake inhibitors in the elderly

A case of small cell carcinoma of the prostate without a primary lesion in the lung was reported. The cancer was diagnosed after the patient complained of lumbago caused by bone metastasis. The tumor was 5.9 x 5.0 x 4.6 cm. The patient was treated with 4 courses of chemotherapy using cisplatin and etoposide. The tumor diminished to 4.0 x 4.0 x 3.5 cm after completion of the 4 courses of treatment. Prostatic antigen levels were less than 1.0 ng/mL during the therapy. Neuron-specific enolase levels were 35.9 ng/mL at the beginning of therapy, and decreased to 7.4 ng/mL after completion of 4 courses of treatment. The patient died 3 months after the completion of treatment. This regimen had some value for inhibiting the growth of small cell carcinoma.     

Orbitocranial penetration by a fern: case report

OBJECTIVE AND IMPORTANCE: Cranial and orbitocranial penetration by organic foreign material is not infrequent. It is important to identify whether penetration has occurred and to localize and remove the organic foreign material. CLINICAL PRESENTATION: We report a 15-month-old patient who suffered orbitocranial penetration with the stem of a fern. The stem passed through the orbit, exiting via the superior orbital fissure. It continued through the middle cranial fossa to end in the posterior cranial fossa. INTERVENTION: The patient underwent surgery, and a modified Dolenc procedure was performed. The foreign body was identified in the prepontine cistern and was removed. An extradural approach was performed to the cavernous sinus and superior orbital fissure, and the remaining foreign body was removed. CONCLUSION: Retained intracranial wood should be removed. The radiological diagnosis can be difficult, and magnetic resonance imaging is the investigation of choice. Magnetic resonance imaging may not detect some cases of organic foreign material penetration.