Medial canal stenosis--chronic stenosing external otitis

Chronic stenosing external otitis is an indolent condition that is difficult to treat. Twelve cases that were operated on during a 3-year period were reviewed. The results of treatment are presented and the surgical methods are discussed. This involves excision of all fibrous tissue and if necessary the drum, a wide canalplasty, a meatoplasty, and then reconstruction with a fascial graft if necessary followed by split skin grafts, with emphasis on maintaining the anterior tympanomeatal angle.

Clinical symptoms caused by intra-articular fibrous plicae after knee replacement. Arthroscopic diagnosis and therapy

In 29 patients with persistent complaints after knee replacement we found intra-articular fibrous tissue in different areas of the joint. In 26 patients diagnostic arthroscopy was followed by arthroscopic resection of the tissue. The fibrous tissue was differentiated into five types. Type 1 represented a transverse fibrous band located at the superior margin of the femoral component of the prosthesis. A type 2 plica was a lateral plica extending from the superolateral border of the patella to the infrapatellar fat pad. The type 3 fibrous band reached from the inferior pole of the patella to the intercondylar area. The type 4 nodulus was located at the superior border of the patella, and the type 5 plica was a meniscoid-like tissue between the femoral and the tibial component. Arthroscopic resection resolved the symptoms in 25 of the patients. Different factors seem to contribute to the development of intra-articular plicae after knee alloarthroplasty.

Survival despite almost complete fibrous obstruction of a Sorin tilting disc mitral prosthesis

We report the case of a 40-year-old woman whose Sorin tilting disc mitral prosthesis was obstructed by fibrous overgrowth to the point of near occlusion. The unusual features of this case are that the patient survived reoperation and that her preoperative symptoms were mild despite an immobile disc and near occlusion of the valve. In most similar cases in the literature, preoperative symptoms have been acute and mortality has been high.

Sclerosing cervicitis: case report and literature review

Sclerosing cervicitis is an idiopathic fibrosis of the soft tissue compartments of the neck. Reported cases in the past have been characterized by both benign and malignant courses, but the histopathology of the lesion has been invariably benign.

Alteration of glutamine concentration in the vitreous humor in patients with proliferative vitreoretinopathy

Using sensitive high performance liquid chromatography (HPLC), we measured free amino acid concentrations in the undiluted vitreous samples of patients who underwent pars plana vitrectomy for treatment of idiopathic preretinal macular fibrosis (PMF, n = 8), proliferative diabetic retinopathy (PDR, n = 12), or proliferative vitreoretinopathy (PVR, n = 15) to investigate the effect of vitreoretinal diseases on the concentrations of free amino acids in human vitreous. The most abundant amino acid was glutamine in all of three groups. Other major amino acids commonly found in the human vitreous samples were serine, alanine, arginine, valine, and lysine. Patients with PDR and PVR showed significantly lower concentrations of glutamine in vitreous (PDR: 655 +/- 230 nmoles/ml, PVR: 683 +/- 302 nmoles/ml) than those with PMF (PMF: 975 +/- 247 nmoles/ml; significance level, PDR: p < 0.01, PVR: p < 0.05). In addition, patients with grade D PVR showed significantly lower concentration of glutamine (357 +/- 117 nmoles/ml) than those with grade C PVR (802 +/- 256 nmoles/ml, p < 0.005), or PMF (p < 0.005). These results suggest two possible mechanisms for the alteration of intravitreal glutamine in the pathologic conditions. The first possibility is a reduced amount of supply of glutamine that is normally transported or released from surrounding tissues into vitreous humor. The second possibility is an increased amount of uptake and utilization of glutamine by cells within vitreous and pathologic tissues.

Relaxing the fibrosed capsulorhexis rim to correct induced hyperopia after phacoemulsification

I present two cases in which hyperopia occurred after phacoemulsification through a capsulorhexis. In both eyes, the anterior capsule rim had become fibrosed and contracted. The patients were successfully treated with YAG laser relaxing incisions.

Management of nondilatable cavernous fibrosis with the use of a downsized inflatable penile prosthesis

The basic underlying cause of inability to implant a penile prosthesis is cavernous fibrosis resulting in unsatisfactory cavernous dilation. During the last 3 years, 20 patients with severe cavernous fibrosis underwent penile prosthetic implantation with a downsized inflatable penile prosthesis, obviating the need for additional cavernous reconstruction. After a mean followup of 20 months 19 of the 20 patients had a functional device with only 1 requiring explantation for infection. We believe that this downsized penile prosthesis is a valuable addition to the urological armamentarium when considering reimplantation or implantation in a patient with intracavernous fibrosis and scarring.

Facial cleft no. 30

Midline clefts of the lower lip, mandible, tongue, and neck are rare congenital deformities and are classified as facial cleft no. 30 by Tessier. This is a report of a patient who presented with congenital fibrotic neck cord but no lower lip cleft, which has been the most frequently observed pathognomonic sign of this anomaly. The patient was treated initially for thyroglossal remnant. In the patients who present with a fibrotic cord located at the cervical midline without a lower lip cleft, the diagnosis of facial cleft no. 30 should be kept in mind.

Intra-articular soft-tissue masses of the ankle. Meniscoid lesions and transarticular fibrous bands

Meniscoid lesions and fibrous bands are unique lesions, most likely of differing origin. Although they are similar in clinical presentation, their appearance at arthroscopy is clearly different. The meniscoid lesion is attached only at its origin at the inferolateral gutter on the anterior talofibular ligament. Fibrous bands are attached at two ends and may be found anywhere in the joint but are most common extending dramatically over the anterior joint line. Unexpected encountering of a fibrous band should alert the surgeon to carefully inspect the joint for other associated (occult) pathology. Because of the frequent association of bands with antecedent fracture, the observation of this lesion should lead the clinician to consider antecedent intra-articular fracture (transchondral fracture, malleolar fracture, and tibial pilon fracture) as a likely co-pathology. Careful examination of the ankle and review of the radiographs and other available images may be helpful in assessing the joint for these injuries when fibrous bands are encountered. The association of meniscoid lesion with prior soft tissue injury (sprain) is also important to understanding this lesion. Excision of both these abnormal lesions in concert with repair of coexistent pathology is associated with improvement of symptoms. Finally, both fibrous bands and meniscoid lesions are associated with symptoms that warrant closer inspection and observation. Whether the operative intervention is open or closed, the reader can benefit from the information presented.

A case of lymphocytic hypophysitis with massive fibrosis and the role of surgical intervention

Four weeks after a normal delivery, a 33-year-old woman was admitted to our hospital with visual disturbance, hypopituitarism, and diabetes insipidus. A homogeneously enhanced pituitary mass with suprasellar extension was observed. Presurgical steroid therapy was ineffective. A transsphenoidal approach revealed a firm white mass, which was histologically diagnosed as a lymphocytic hypophysitis with massive fibrosis. Lymphocytic hypophysitis shows a variety of clinical courses, and there are various problematic aspects concerning the histologic stage as well as the differential diagnosis. However, it is difficult to speculate concerning these without histologic studies. Cases with massive fibrosis, spontaneous resolution, or positive effects of steroids may be less likely.

The pulsed holmium: yttrium-aluminum-garnet laser. Applications to ankle arthroscopy

The holmium:YAG laser has many advantages over conventional surgical instrumentation and techniques in ankle arthroscopy. These include minimal mechanical damage to surrounding tissue structures, better access to tight recesses, and the ability to coagulate, smooth, ablate, and weld tissues. The laser also offers improved contouring of damaged articular surfaces, all with a single instrument. The holmium:YAG laser uses a wavelength of 2.1 microns, which is strongly absorbed by water, the major component of tissue. This wavelength allows the laser to deliver a consistent tissue effect to both pigmented and nonpigmented tissues. It currently may transmit up to 60 watts of power to tissue in high-energy, short-duration pulses. The holmium:YAG laser also operates in a fluid medium, which provides a near physiologic environment and maintains continual irrigation. The holmium:YAG laser beam is transmitted through a flexible fiberoptic handpiece, which greatly increases maneuverability. A variety of angled laser tips are available, depending on the pathology type and location. Different tissue effects can be created by varying the tip to target distance. All these qualities provide precise control without significant thermal damage and make the laser ideal for application to articular structures of the ankle joint. The holmium:YAG laser is a safe and effective arthroscopic instrument with a promising future. We have used it, along with traditional shavers and abraders, to effectively treat numerous pathologies of the ankle joint. The laser's versatility in cutting, ablation, and coagulation has been uniformly successful. Patients surveyed postoperatively have reported less overall symptoms and faster healing. They have reported a decrease in ecchymosis, edema, and postoperative pain. Patients' return to full activity has appeared to be quicker with the use of holmium:YAG laser therapy. Although our results have thus far been very encouraging, further research and clinical applications in the use of the holmium:YAG laser need to be continued.

Surgical removal of an extrafoveal fibrotic choroidal neovascular membrane with foveal serous detachment in age-related macular degeneration

BACKGROUND

Visual recovery after submacular surgery for age-related macular degeneration (AMD) has been very limited.

METHODS

A patient with an extrafoveal fibrotic choroidal neovascular membrane from AMD had an overlying serous foveal detachment with the fibrotic tissue elevating the foveal retina. Photocoagulation of the neovascular membrane was not recommended because of its nonpigmented, fibrotic nature. The membrane was surgically excised.

RESULTS

Preoperative and postoperative visual acuity and central 30 degrees visual fields were followed. Visual acuity improved from 20/200 to 20/25, and a preoperative central scotoma resolved completely 18 months after surgical excision of the extrafoveal fibrotic neovascular membrane. There were no intraoperative or postoperative complications.

CONCLUSION

This type of patient may represent a distinct subset of patients with AMD amenable to subretinal surgery who could potentially have good recovery of vision.

Intraocular lens encapsulation by shrinkage of the capsulorhexis opening

A 57-year-old man with retinitis pigmentosa and subcapsular cataract had phacoemulsification with a continuous curvilinear capsulorhexis and implantation of a poly(methyl methacrylate) intraocular lens. Six months later, the patient presented with blurred vision and severe anterior capsule fibrosis which led to complete posterior chamber lens encapsulation.

Popliteal entrapment syndrome: misdiagnosed as a compartment syndrome

We report a case of popliteal artery entrapment syndrome which was originally diagnosed as a chronic compartment syndrome. The relative occurrence of the two conditions and their very similar symptoms explain the misdiagnosis. The diagnostic methods and surgical treatment for both conditions are discussed and suggestions are made as to possible non-invasive screening methods.

[Mediastinal fibrosis]

Even tough the ultimate etiologic and pathogenic mechanisms of mediastinal fibrosis are not quite established, several causes have been mentioned as the more frequent inducers, such as histoplasmosis, tuberculosis and other granulomatous diseases. Generally the diagnosis is suggested by a hilar or mediastinal mass, which is seen in thorax radiography, because 40% of patients are asymptomatic. Exeresis of fibrotic Magma is difficult because usually there is no separation with trachea neither with superior cava vein. That is why many times we have to restricted ourselves to the surgical approach on the complications. The present work discusses three new cases of mediastinal fibrosis.

Medial meatal fibrosis: the University of Western Ontario experience

Medial meatal fibrosis is an uncommon but surgically treatable cause of conductive hearing loss. A review of 10 years experience with this entity at The University of Western Ontario revealed a total of 15 cases involving nine patients. Each of them was treated by one of four otologists. This disease may arise from either recurring or chronic infection or from chronic dermatitis, and it frequently presents with bilateral involvement. It may occur at virtually any age, and to our knowledge, this series includes the first cases of this disease to be described in children. The medical and surgical management of this condition is described in detail and the results are summarized.

[Arthroscopic therapy of arthrofibrosis of the knee joint]

Arthrofibrosis following ACL reconstruction is a well-recognized and disturbing complication. It may result in a greater functional deficit than the original ACL deficiency. The purposes of this retrospective study were to present our results of arthroscopic arthrolysis and gentle manipulation in 16 consecutive cases in the past almost 3 years, to determine and define the etiology and risk factors, to make recommendations regarding prevention and to develop a time-related management concept. All the 16 patients had previously undergone open ACL reconstruction and had developed arthrofibrosis. The average time from the index surgery to arthrolysis was 7.4 months (range 2.5-18.5 months) and the average follow-up was 17.6 months (range 6-38 months). After pathology-oriented arthroscopic debridement, notchplasty, cyclops resection etc., and following manipulation of the knee, range of motion was found to be improved in all cases at the final follow-up. The average of extension deficit was decreased from 20.0 degrees to 7.0 degrees and the flexion deficit from 34.4 degrees to 9.9 degrees. Only three patients regained normal range of motion compared to the other side. The only complication was an avulsion fracture of the fibula head which did not cause any lateral instability. No patient gained motion at the expense of joint stability. Patella baja was present in two and patellofemoral pain in seven cases at the final follow-up. Three patients underwent further surgery after the final follow-up. Arthrofibrosis, while having many causes, appears to be a preventable complication.(ABSTRACT TRUNCATED AT 250 WORDS)

Reversible achalasia-like motor pattern of esophageal body secondary to postoperative stricture of gastroesophageal junction

Two cases are presented of benign stenosis of the cardia secondary to fibrosis following antireflux surgery in which the patients developed a motor alteration in the esophageal body similar to that of achalasia of the cardia. There was a complete absence of contractions in one patient, which had developed over a long period of time, and a vigorous pattern in the other patient, which had evolved over a short period. In both cases, after surgical treatment of the stenosis, normal motility in the esophageal body returned.

Chronic fibrosing mediastinitis and superior vena caval obstruction from blastomycosis

Chronic fibrosing mediastinitis is most commonly a complication of granulomatous disease caused by histoplasmosis. We report a case of Blastomyces dermatitidis causing superior vena caval obstruction from fibrosing mediastinitis.

Desmoplastic malignant melanoma: rare and difficult to diagnose

BACKGROUND

We review our experience with a recent cluster of three cases of rare desmoplastic malignant melanoma (DMM).

OBJECTIVE

Our purpose is to alert clinicians to this rare tumor and the difficulty in clinical and histopathologic diagnosis.

METHODS

The clinical presentation and steps necessary to establish diagnosis are outlined. A literature review on diagnosis, treatment, and prognosis is presented.

RESULTS

Two thirds of DMM are amelanotic and may appear only as a dermal nodule or thickening. Diagnosis can be made with the combination of light microscopy and immunopathology. Treatment consists of surgical excision. Lymph node dissection should be considered only when histologically positive regional nodes are present.

CONCLUSION

The diagnosis of DMM may be difficult when based only on clinical expectation of melanoma and light microscopy findings. A strong clinical suspicion of DMM coupled with immunologic studies will establish the diagnosis.

Idiopathic preretinal fibrosis: a review of 237 cases

We reviewed the charts of 223 patients (236 eyes) with idiopathic preretinal fibrosis, dividing them into two groups: those who only had been observed, and those who, after an observation period, had the membranes surgically removed. All of the patients had been followed from 6 to 120 months (mean, 29 months). Vision in the nonsurgical group slowly deteriorated and was accompanied by metamorphopsia. More rapid visual deterioration occurred in 60 eyes (25%), of which 37 (16%) required surgery. Vision in 78% of the surgical group improved, with the greatest subjective benefit considered to be subsidence of metamorphosia. Vision spontaneously improved in 2.5% of the cases.

[Arthrolysis as a surgical treatment concept of post-traumatic stiffness of the knee joint]

In the period from 1977 to 1989 105 arthrolyses were performed in 102 patients. There were mainly posttraumatic fibroarthroses: 51 consecutive to fractures, 39 after ligamentous injuries, 13 post-infectious of which 11 were also post-traumatic and only 2 patients with rheumatological diseases. Remarkable is the increased number of fibroarthrosis after polytrauma (n = 26). The preoperative range of motion was under 30 degrees in 26 patients and 48 patients had a severely limited range of motions between 30 and 60 degrees. The follow-up examination performed in an average of 2 years after the operative mobilization showed that the initial mobility was more than doubled. These results are related to atiology, operative procedure and degree of severity of the preoperative stiffness. Fair to excellent results were obtained in almost 3/4 of the patients. We explain these results by an adapted extraarticular or combined procedure which were used in 63 cases. The open release is backed by an intensive rehabilitation program in which painlessness through PDA and an immediate postoperative continuous passive motion are of most importance.

Surgery for pre-macular fibrosis

We review 12 consecutive cases of pre-macular fibrosis (PMF) treated by vitreous surgical techniques. The causes of PMF included retinal detachment surgery in four patients, idiopathic in three patients, laser treatment in three patients, pars planitis in one patient and diabetic retinopathy in one patient. The membrane was successfully removed in all the patients. One patient developed a retinal detachment that was repaired successfully. All patients had improved visual acuity (VA) of two Snellen lines or more and six patients achieved VA of 6/12 or better. Patients with PMF following retinal detachment had poorer final VA.