Preoperative autologous blood donation in orthognathic surgery]

AIM: To minimize the perioperative risk of transfusion-associated complications, preoperative autologous blood donation is routinely performed in orthognathic surgery. This study critically analyzed the necessity of this procedure with respect to clinical, economic, and juridical issues. MATERIAL AND METHODS: In the Department of Oral and Maxillofacial Surgery, Bonn Medical School, 178 orthognathic surgical procedures were performed from 1994 to 2002. All patients (women, n=101; men, n=77) were informed about the possibility of autologous blood donation. This procedure was carried out in 83%, for single jaw surgery two and for bimaxillary osteotomies three to four units of packed red blood cells were predeposited. Of the patients, 99 underwent monognathic surgery in the lower jaw, 27 patients in the upper jaw, and bimaxillary osteotomy was performed in 52 patients. RESULTS: The average blood loss for the monognathic procedure in the lower jaw was 756 ml, in the upper jaw 858 ml, and in double jaw surgery 1391 ml. In 13 patients the hemoglobin concentration fell below 7.5 g/dl and 12 patients received their predeposited autologous blood units. A total of 57.7% of all donated autologous blood units were discarded. CONCLUSION: Autologous blood donation should be performed from the medical point of view for double jaw surgery and considered in single cases with special risks in monomaxillary osteotomies.     

Transfusionsbedarf bei Dysgnathieoperationen

The use of deposited autologous blood instead of allogenic blood is recommended in cases of elective maxillofacial operations if the blood transfusion probability is more than 10%. As an alternative, the controlled intraoperative normovolemic hemodilution and the preoperative use of EPO (Erytropoetin) should be considered. In a retrospective study, we analyzed 438 patients who underwent orthognathic surgery. The perioperative blood loss was determined in order to calculate the transfusion probability in case of the acceptance of 7.5 g/dl hemoglobin as the critical value in patients without cardiac failures. Only four patients undergoing Le Fort I osteotomy (1.55%) or bimaxillary osteotomy (3.03%) had to be transfused. Therefore, the statistical transfusion need was clearly below 10%. Due to this, there was no general need for autologous blood donation. However, in individual cases with low hemoglobin and/or low blood volume, a transfusion need can be predicted. In those few cases, autologous blood donation may be indicated. However, in case of a more conservative indication to transfusion (hemoglobin 10 g/dl), more than 10% of the patients with bimaxillary osteotomies would have been transfused. Autologous blood donation is then indicated according to the German regulations for transfusion. If low hemoglobin values are accepted, the exact individual blood demand should be calculated, a blood saving operation technique should be used, adequate postoperative warding is necessary, and compatible allogenic red cell concentrates should be quickly available.     

Optimized hemodilution with hydroxyethyl starch. A blood saving method in malocclusion operations]

OPTIMIZED HEMODILUTION: To avoid blood transfusions, the method of optimized hemodilution (OHD) was developed. OHD consists of preoperative hypervolemic hemodilution with 500 ml hydroxyethyl starch (HES) and consecutive volume replacement with HES in the case of intraoperative intravasal fluid loss. This study verifies the efficacy of OHD. RESULTS: Mono- and bimaxillary operations (n = 213) performed between January 1995 and May 1999 were evaluated retrospectively with respect to reduction of blood transfusions due to application of OHD. The average blood loss in the OHD group (n = 127) was 593 ml, and no blood transfusion was required. In contrast, the control group (n = 86) showed an average blood loss of 738 ml, and 15% of these patients (n = 13) required transfusion of a total of 18 blood units. Based on our results, provision of autologous blood is only necessary for patients who do not receive OHD. The costs of fluid replacement and transfusion are increased by a factor of 5.7 when OHD is not used. DISCUSSION: OHD should be preferably used in cases of elective surgery on patients with good cardiopulmonary health. It is an easy to handle infusion regimen, which does not require additional monitoring, has no risk of infection, and results in a significant cost reduction.     

Complications of orthognathic surgery. Apropos of a series of 84 patients

BACKGROUND: Patients demand satisfactory functional and esthetic results from orthognatic surgery. The aim of this study as to assess adverse outcomes after orthognatic surgery. PATIENTS AND METHODS: We retrospectively reviewed 84 patients who underwent maxillary (22.6%), mandibular (29.8%) or bimaxillary (38.1%) osteotomy in 1997. We re-examined 76 of these patients at a mean 21 months follow-up. Data were recorded for the preoperative, early postoperative, secondary postoperative and late postoperative periods. RESULTS: Infectious complications occurred in 2% of the cases of maxillary surgery. For mandibular surgery there were 10.5% infectious complications including 83% that resolved spontaneously, 3.5% neurological complications and 1.7% temporomandibular joint complications. DISCUSSION: Maxillary osteotomy has proven reliable. Major adverse outcome is infrequent but serious. Adverse outcomes in mandibular surgery are more common but less problematic.     

Complications in surgical treatment of malocclusions. Report of 50 years experience]

BACKGROUND: During the past few decades, orthognathic surgery has become routine in oral and maxillofacial surgery. As these surgical interventions are elective, the goal is a low complication rate. The aim of this study was to analyze the intraoperative and postoperative complications after orthognathic surgery without considering orthodontic relapse. PATIENTS AND METHODS: The medical files of 507 patients were reviewed who had been treated in the department of oral maxillofacial surgery at the Martin-Luther-Universit?t in Halle-Wittenberg during a period of 51 years. The indication for orthognathic surgery was mandibular hyperplasia in 314 cases (61.9%), mandibular hypoplasia in 69 cases (13.6%), mandibular hyperplasia with a frontal open bite in 53 cases (10.5%), maxillary hyperplasia with a cleft in 30 cases (5.9%), maxillary hyperplasia in 22 cases (4.3%), severe laterognathia in 10 cases (2.1%), and isolated frontal open bite in 9 cases (1.5%). The surgical procedures were as follows: bilateral sagittal split osteotomy (n = 336, 66%), Le Fort I osteotomy (n = 29, 5.9%), bimaxillary osteotomy (n = 35, 6.3%), and segment osteotomy (n = 107, 21.1%). Rigid fixation was used in 147 patients. RESULTS: In 55% of the patients a postoperative neurosensory deficit of the inferior alveolar nerve was observed, which was only found in 28% after 1 year. Inflammatory wound healing was found in 5.3% of the patients. CONCLUSION: Due to antibiotic perioperative prophylaxis and modern rigid osteosynthesis devices, orthognathic surgery has become a routine method in maxillofacial surgery with predictable surgical results.     

Maxillary distraction complications in cleft patients

INTRODUCTION: Cleft lip and palate (CLP) patients often present with a class III malocclusion in connection with a three dimensional maxillary hypoplasia. Twenty-five to 60% of these patients require a maxillary advancement. Two solutions are possible: orthognathic surgery and maxillary distraction. The purpose of this study was to evaluate the complications of the maxillary distraction in CLP patients. MATERIALS AND METHODS: Data was collected from the records of patients treated at our Surgery Unit between 2000 and 2007. Among the eight patients (four male and four female), five presented a bilateral CLP, two a unilateral CLP and one a unilateral cleft lip associated to a soft palate cleft. The average age at surgery was 17 years old. All had a Le Fort I osteotomy with a pterygomaxillary disjunction. The first two patients had external distractors and the six following internal ones. After a seven-day latency, activation was led to the rate of 1mm per day twice. The period of consolidation was four months on average. The maxillary advancement varied between 7 and 19mm with an average of 12.6mm. The average follow-up was four years. RESULTS: We encountered difficulties and/or complications in seven patients: one intraoperatively haemorrhage, one avulsion of a tooth fixed at the pterygoid process during the osteotomy, three device failures, two cases of significant pains during activation, one dissociation of the dental anchorage of an external system, two labial ulcerations and one maxillary sinusitis by migration of the 18. DISCUSSION: Difficulties of maxillary distraction in CLP patients are very frequent. The majority is related to the distractors and did not interfere with the final result. But this frequency must be taken into account in the indication and in the choice of the material. Two types of complications can occur during distraction: those related to the osteotomy and those related to the material. The complications related to the osteotomy are in connection with the cicatricial ground of the CLP. They are not specific of the distraction. We especially managed complications related to the material. The social benefit of the internal distractors is undeniable, but the design of certain models must be reexamined to improve their tolerance.     

CT灌注成像评价烟雾病血管搭桥术后的评价

目的本研究旨在探讨大脑中动脉颞浅动脉吻合术联合颞肌敷贴术在缺血性烟雾病治疗中的效果情况。方法选取2018年8月至2019年10月间于我院眼耳鼻喉外科就诊缺血性烟雾病并行大脑中动脉颞浅动脉吻合术联合颞肌敷贴术的患者共计63人85侧病变,所有患者均于术前1周、术后2周行CTA、CTP检查,分别观察患者吻合血管情况、CTP参数及并发症发生率。结果63人85侧病变手术均成功完成,平均手术时间(4.27±1.35)h,平均出血量(138.58±34.47)ml;术后CTA显示81侧吻合桥通畅,通畅率为95.29%,CTP显示术后脑血流量(CBF)、脑血容量(CBV)明显高于术前1周;平均通过时间(MTT)及达峰时间(TTP)明显低于术前1周,差异均具有统计学意义(P<0.05);术后共出现并发症5例,其中桥动脉闭塞3例、高灌注综合征1例、吻合口动脉瘤1例,并发症发生率为7.94%。结论大脑中动脉颞浅动脉吻合术联合颞肌敷贴术在缺血性烟雾病治疗中的效果良好,并发症发生率也较低,值得于外科中推广使用。     

鼻内镜下电凝辅助等离子射频切除鼻咽血管纤维瘤

目的探讨鼻内镜下电凝辅助等离子射频切除鼻咽血管纤维瘤的应用。方法回顾性分析2008年1月～20011年12月诊治的5例鼻咽血管纤维瘤患者的临床资料,全部患者均在鼻内镜下行电凝辅助等离子射频切除术,观察术中平均出血量、术后恢复时间。结果本组病例肿瘤均一次性切除,平均出血量426 ml,无术后并发症,无残留;术后随访3个月,鼻内镜示术腔上皮化;随访1年,4例无复发,1例失访。结论鼻内镜下电凝辅助等离子射频切除局限于鼻腔鼻咽部的鼻咽血管纤维瘤是适宜的。     

鼻咽血管纤维瘤手术治疗51例分析

目的比较鼻咽血管纤维瘤的治疗方法。分析各手术方式及术前超选择性动脉栓塞对不同分期患者治疗的优缺点。方法回顾性分析1989年2月—2004年10月51例鼻咽血管纤维瘤手术方式,采用Fisch分期,Ⅰ、Ⅱ期患者33例,经腭进路22例,鼻内镜手术11例;Ⅲ、Ⅳ期患者18例,经鼻侧切开9例,面中掀翻+LefortⅠ或同侧上颌骨拆装4例,颅面联合进路5例。51例患者中23例术前行超选择性瘤体供血动脉栓塞,其中Ⅳ期7例,Ⅲ期8例,Ⅱ期5例,Ⅰ期3例。结果术中平均出血量为1010ml,23例选择性瘤体供血血管栓塞患者,术中出血量200~870ml,平均485ml(x-±s,485ml±202ml);未栓塞组出血量500~3500ml平均1600ml(1600±757)ml,栓塞组平均出血量低于未栓塞组平均出血量(t=7·48,P<0·05)。术后1次复发8例,2次复发2例。术后复发时间平均为26·4个月(9~48个月)。结论术前行血管造影及血管栓塞对减少术中出血量具有临床意义。对于Ⅰ、Ⅱ期的患者,选择鼻内镜手术,可以避免传统手术创伤对患者术后颅面部生长发育的影响。对于Ⅲ、Ⅳ期患者,采用面中掀翻、LefortⅠ或同侧上颌骨拆装不仅有利于肿物的根治性切除,而且能够达到术后咬合关系影响小和美容佳的目的。     

Bipolar diathermy tonsillectomy

Tonsillectomy is an operation performed by various techniques. We have developed a bipolar diathermy dissection technique that allows a low intra-operative blood loss without an increase in complications. The average blood loss was less than 4 ml in 100 patients. Most were able to drink and eat by 4 and 10 hours respectively. There was no increase in analgesic requirements. No primary haemorrhage was recorded; three patients had a secondary haemorrhage. The technique allows accurate coagulation of blood vessel and is an easy procedure to learn.     

Extensive endoscopic sinus surgery from the viewpoint of out-patients in a metropolitan area

Extensive functional endoscopic sinus surgery (FESS) was assessed retrospectively from the viewpoint of out-patients on the basis of their responses to a postal questionnaire, particularly in the Tokyo metropolitan area. Seventeen patients were included in this study (six females and 11 males) with an age range of 22-70 years. All the patients had at least ethmoid sinusitis. Additionally, some patients had maxillary or sphenoid sinusitis or polyps obstructing the nasal cavities. The average operation time and blood loss were 36 minutes and 31 ml, respectively. Four patients had to travel more than one hour to reach home. All of them used the train for travelling to and from the hospital. 'Doctors' advice' was the most common reason for the decision to undergo this ambulatory surgery. Nine (53 per cent) had some unexpected problems post-operatively. The establishment of a care pathway may improve the outcome of extensive FESS on an out-patient basis.     

经口内镜翼下颌皱襞内侧入路咽旁间隙良性肿瘤切除术

目的:探讨经口内镜翼下颌皱襞内侧入路切除咽旁间隙良性肿瘤的手术方法,并评估其临床效果。方法:回顾性分析2016年1月至2020年7月,于青岛大学附属医院耳鼻咽喉头颈外科接受经口内镜翼下颌皱襞内侧入路咽旁间隙良性肿瘤切除术的23例患者的临床资料,其中男14例,女9例,中位年龄43岁。肿瘤位于茎突前间隙者13例,位于茎突后...     

Kieferh?hlenuntersuchung nach Sinusbodenelevation kombiniert mit autologer Onlay-Osteoplastik

BACKGROUND: Complication rates after sinus floor augmentation of up to 10% are mentioned in literature, often when heterologous bone implants are used. The aim of our retrospective study was to determine the complication rate involving the maxillary sinus of patients treated with autologous spongiosa. PATIENTS AND METHODS: In 46 patients with an absolute maxillary atrophy (61% female, 39% male, mean age 49 years), a sinus floor augmentation, if necessary combined with an onlay bone graft of the iliac crest, was performed. Implants (Br?nemark) were placed in a two-stage procedure after 3-6 months. Prior to surgery, a panoramic film was made for diagnosis and treatment planning; in addition, a sinus X-ray was taken when disease of the maxillary sinus was suspected. panoramic radiography was routinely taken after surgery. A clinical and radiological follow-up examination was performed after 6-12 months, and the patients answered a questionnaire. This study also included evaluation of operation reports and case histories. Ultrasound as well as magnetic resonance imaging to prevent radiation exposure were performed additionally. RESULTS: In spite of perforation of the maxillary sinus mucosa in about 25%, removal of the bone graft due to inflammation was not necessary. A transient sinusitis developed in 2%. The implant loss rate (3 out of 154) may be called small. DISCUSSION: Even though alternative heterologous graft materials exist, maxillary sinus floor elevation with autologous bone graft is still a safe option. Changes of the maxillary sinus are detectable in a small percentage, relatively often due to preexisting unrecognized or subclinical diseases of the maxillary sinus. Magnetic resonance imaging is, in spite of the high financial and technical effort required, a serious alternative to computed tomography. The combination of autologous bone graft with calcium phosphate ceramics, platelet-rich plasma, or synthetic bone growth factors should be tested as an alternative treatment method.     

Postoperative pain in tonsillectomy: comparison of ultrasonic tonsillectomy versus blunt dissection tonsillectomy

Intraoperative blood loss, postoperative pain, and postoperative appetite were compared between 15 adult patients who underwent tonsillectomy using an ultrasonically activated scalpel (UT) and 15 adult patients who underwent blunt dissection tonsillectomy with cold steel instruments (BT). The average intraoperative blood loss of the UT group was 4.6 +/- 1.9 ml (mean +/- standard deviation), while that of BT group was 41.9 +/- 12.9 ml. This difference was highly statistically significant (p < 0.0001). In contrast, there were no significant differences in the VAS pain and appetite scores between patients who underwent UT and those who underwent BT on any day in the 6-day postoperative period. Our current results show that UT is a safe technique, and we believe that it should be considered a useful alternative for tonsil surgery.     

Severe Class III malocclusion: long-term stability. Retrospective analysis of 12 cases

PURPOSE: Long-term stability of severe class III is rarely evaluated in the literature. We present our findings with 12 patients who underwent surgery from June 1995 to December 1997 and analyze cephalometric superpositions. MATERIALS AND METHODS: Twelve operated patients were reviewed to analyze long-term results (follow-up 3 years 8 months). The sex ratio was well balanced. Mean age was 23 years. All patients were given pre- and postoperative orthodontic care and underwent bimaxillary surgery with Lefort 1 osteotomy and sagittal osteotomy of the rami. Delaire cephalometry on preoperative and early and late postoperative films was used to analyze outcome. Skeletal instability was defined as displacement greater than 4 mm. Recurrence was defined as secondary loss of the functional and esthetic result. RESULTS: Four patients (33%) developed skeletal instability. All patients achieved long-term stability. DISCUSSION: To detail the cause of skeletal instability, study of the principal factors of instability is presented together with a discussion of data in the literature.     

Usefulness of uvulopalatopharyngoplasty with genioglossus and hyoid advancement in the treatment of obstructive sleep apnea

OBJECTIVE: To evaluate the usefulness of uvulopalatopharyngoplasty plus mandibular osteotomy with genioglossus and hyoid advancement in the treatment of obstructive sleep apnea syndrome (OSAS). DESIGN: Prospective study of 20 consecutive patients with OSAS. SETTING: University medical center. PATIENTS AND INTERVENTIONS: Twenty OSAS patients with multilevel upper airway obstruction who refused continuous positive airway pressure treatment. All patients were evaluated before and 6 months after surgery by clinical history, the Epworth Sleepiness Scale, physical examination, fiberoptic nasopharyngoscopy combined with the Müller maneuver, cephalometric analysis, nocturnal polysomnography, and a second-night polysomnography with upper airway pressure recording during sleep. Surgery procedures were uvulopalatopharyngoplasty plus mandibular osteotomy with genioglossus and hyoid advancement. Surgical successful outcome was defined as an apnea-hypopnea index (AHI) lower than 20 plus subjective resolution of daytime symptoms. MAIN OUTCOME MEASURE: Surgical success rate. RESULTS: Mean +/- SD AHI decreased from 60.5 +/- 16.5 to 44.6 +/- 27(P =.007), and CT90 (percentage of time with oxyhemoglobin saturation below 90%) decreased from 39.5% +/- 26% to 25.1% +/- 26.4% (P =.002). The overall surgical success rate was 35% but increased to 57% in patients with moderate OSAS (AHI, 41-60) and to 100% in mild OSAS (AHI, 21-40). In the group of severe OSAS, the success rate was 9%. Predictors of surgical outcome success were the AHI, CT90, stages 2 and 3-4 sleep percentages, and the cephalometric ANB angle (angle formed from the deepest point on the maxillary outer contour to the nasion to the deepest point on the outer mandibular contour). CONCLUSION: Patients with mild and moderate OSAS and multilevel obstruction in the upper airway may benefit from uvulopalatopharyngoplasty plus genioglossus and hyoid advancement.     

Juvenile nasopharyngeal angiofibromas in Denmark 1981-2003: diagnosis, incidence, and treatment

CONCLUSIONS: Juvenile nasopharyngeal angiofibroma (JNA) is a rare tumor in young males, with a non-negligible potential for recurrence. Preoperative embolization is a safe procedure that diminishes the peroperative blood loss and the need for blood transfusion. The endoscopic approach was used with good results in JNA stage I and II (Chandler). OBJECTIVES: To estimate the incidence rate of JNA in the Danish population and to describe symptoms and treatment. PATIENTS AND METHODS: This was a national retrospective cohort study. All cases of JNA diagnosed in Denmark from 1981 to 2003 were identified. Data were extracted from medical records. RESULTS: Forty-five male (no female) JNA cases were identified. In 43 cases, clinical data were recovered. Median age was 15 years. The incidence rate in Denmark was 0.4 cases per million inhabitants per year and 3.7 cases per million males (aged 10-24) per year. All patients underwent surgery, and the endoscopic approach was increasingly being used. The embolization procedure proved to be safe and decreased the intraoperative blood loss statistically to 650 ml in the embolized group from an average of 1200 ml in the non-embolized group (p<0.05). Similarly, the need for peroperative blood transfusion was reduced (p<0.005). The primary recurrence rate was 23% and no patients died.     

术前IADSA和栓塞术在鼻咽纤维血管瘤治疗中的应用

目的：研究分析术前经动脉数字减影血管造影（ＩＡＤＳＡ）和栓塞术在鼻咽纤维血管瘤治疗中的价值。方法：分析本院２１例鼻咽纤维血管瘤患者的临床分析治疗资料，１主后１年复发，再次手术治疗。２２次手术中，术前行及未行ＩＡＤＳＡ和栓塞术的各１１次。 术前示行和行ＩＡＤＳＡ和栓塞术的要中平均出血量和输血量。结果：术前未行和行ＩＡＤＳＡ和栓塞术的术中出量量和输血量分别为１１３６ｍｌ、８３６ｍｌ、６７７ｍｌ、４００     

鼻内镜下低温等离子射频治疗鼻腔血管瘤

目的 探讨鼻内镜下低温等离子射频治疗鼻腔血管瘤的疗效.方法 回顾性分析2007年10月至2009年10月诊治的15例鼻腔血管瘤患者的临床资料,全部患者均于鼻内镜下实施低温等离子射频切除术,术后观察疗效.结果 所有患者肿瘤均1次完整切除,出血量为1～150 ml,平均约15 ml,术后鼻腔仅以明胶海绵保护创面,未另行其他填塞止血,术后无出血及并发症,患者痛苦小,恢复快.随访2个月至2年均无复发.结论 鼻内镜卜低温等离子射频切除术治疗鼻腔血管瘤具有简单、微创等优势,是治疗鼻腔血管瘤的一种有效方法 .     

鼻内镜下低温等离子射频切除术治疗鼻咽血管纤维瘤的初步观察

目的 探讨鼻内镜下低温等离子射频切除术治疗鼻咽血管纤维瘤(nasopharyngeal angiofibroma,NA)的可行性.方法 回顾性分析2005年12月至2009年8月诊治的4例NA患者的临床资料,其中1例为Ⅰ期患者,3例为Ⅱ期患者,4例患者术前均行选择性动脉栓塞,采用控制性低血压全身麻醉,在鼻内镜下采用低温等离子射频刀完成肿瘤切除手术,双极电凝辅助止血.结果 4例患者肿瘤均彻底切除,手术时间分别为60、80、110、90 min,术中出血量分别为250、250、320、280 ml,所有患者术中、术后均未输血.术后随访6个月至4年,无并发症发生,肿瘤无复发.结论 鼻内镜下低温等离子射频切除手术治疗Ⅰ期及Ⅱ期NA患者,具有出血量少、肿瘤切除彻底等优点,是一种微创的手术治疗方法.