Bioactive Glass S53P4 in Mastoid Obliteration Surgery for Chronic Otitis Media and Cerebrospinal Fluid Leakage

Objectives:

We evaluated the results of cases of chronic otitis media treated with mastoid obliteration surgery using bioactive glass S53P4.

Methods:

Twenty-five patients with chronic otitis media and 1 patient with cerebrospinal fluid leakage without chronic infection were treated with bioactive glass S53P4. Twenty patients had had previous surgery because of chronic otitis media with or without cholesteatoma. A mastoid obliteration was performed with bioactive glass S53P4 granules and a musculoperiosteal flap with or without bone paté. In 2 patients with a bony dehiscence at the middle cranial fossa, a bioactive glass plate was used to support the protruding dura. In addition, in 3 patients, occlusion of a dural fistula was needed. The median follow-up period was 34.5 months (range, 1 to 182 months).

Results:

Excluding the 2 patients with only 1 month of follow-up at our department, 96% of the patients had a dry, safe ear or only intermittent otorrhea. In 92% of the patients, the objective of achieving a smaller or nonexistent cavity was achieved.

Conclusions:

Bioactive glass S53P4 is a noteworthy material in mastoid obliteration surgery.

Blood pressure and free flap oxygenation in head and neck cancer patients

CONCLUSION

This study suggests that although oxygen partial pressure in tissue (p(ti)O(2)) measurement is a feasible method for continuous postoperative monitoring of free flaps, low correlation between blood pressure (BP) and p(ti)O(2) might predict compromised overall outcome. Thus, it is of utmost importance to keep the BP optimal for adequate perfusion of re-anastomosed tissue transfers.

OBJECTIVE

Optimal BP is an important factor in assuring adequate blood flow in a free flap. Tissue oxygenation in free flaps as a postoperative monitoring target is in routine clinical use in some clinics. Correlation between p(ti)O(2) and systemic BP was investigated.

METHODS

Ten consecutive patients underwent resection of head and neck squamous cell carcinoma followed by microvascular reconstruction with a free microvascular flap. P(ti)O(2) of each flap was continuously monitored for 3 postoperative days with a polarographic measurement system. BP was measured invasively and continuously during the operation and during the first postoperative day at the intensive care unit. The correlation coefficient between p(ti)O(2) and BP was analysed.

RESULTS

The correlation coefficient between p(ti)O(2) and BP was relatively high in all patients with uneventful flap survival (r (mean) = 0.63, n = 5). In flaps with haemodynamic problems or compromised flap vitality the correlation appeared low (r(mean) = -0.02, n = 5).

A national series of 244 sinonasal cancers in Finland in 1990-2004

Sinonasal cancer is still a somewhat controversial entity because most series are single-center studies. The aim of this study was to give more accurate and generalisable information about treatment of the neck and prognosis of sinonasal cancer. Retrospective, population-based, multicentre study. Altogether 244 patients diagnosed in 1990-2004 were evaluated. The 3- and 5-year disease-specific survival (DSS) rates after treatment with curative intent were 68 and 57%, respectively. Regional status at the time of the diagnosis (P < 0.001, log rank) and local recurrence (P = 0.02, log rank) during the follow-up had a statistically significant effect on DSS. Initially 13% of the patients were diagnosed with neck metastasis. The proportion of regional recurrences during the follow-up was 9%, but it did not have a statistically significant impact on DSS (P = 0.68, log rank). Histopathology had no statistically significant impact on survival in this material of 244 patients. In conclusion, routine elective neck treatment of all sinonasal cancer patients is not recommended, but the importance of the treatment of the primary location is emphasised.

[Head and neck reconstructions]

Tissue reconstructions of the head and neck are required both in the repair of tissue defects following the surgical excision of malignant tumors and in the treatment of various other facial deformities. While it is usually possible to repair a damaged tissue or organ region, functional restoration is very difficult. The aim is radical excision of the tumor, and successful reconstruction will provide quality of life for the patient even after an extensive surgical procedure. The goal of the new reconstructive procedures is as natural outcome as possible, but the risk for postoperative complications must be taken into account.

Management and outcome of pediatric skull base fractures

OBJECTIVE

The management of skull base fractures in the pediatric age group continues to be a major challenge even for experienced multidisciplinary teams. This retrospective study was undertaken at a tertiary care academic hospital to evaluate the management and outcome of pediatric skull base fractures.

METHODS

Retrospective analysis covering a period of 13.5 years (from 1996 to 2009) and 63 patients (mean age 10.7 years; range 1-18 years) was performed.

RESULTS

A road traffic accident was the most frequent etiological factor (38%). The most common skull base fracture type was temporal bone fracture (64%). Longitudinal temporal fractures were observed in 45% and transversal in 23% of these patients; in 10 cases (25%) the fracture was comminuted or mixed type. A fracture involving the spheno-ethmoidal complex was the second most common type of basilar skull fracture (41%) followed by fracture through the orbital bone (35%). Forty-three percent of the patients had a concomitant intracranial injury. Early neurological deficits were diagnosed in 21 patients (33%) and 10 patients (16%) had permanent neurological deficits. One patient died after 1 week of intensive care treatment. Fifty-four patients (86%) were discharged home and 8 patients (13%) were discharged for further rehabilitation. Glasgow Coma Scale score of 8 or lower correlated with moderate to poor outcome.

CONCLUSIONS

We conclude that skull base fracture is a rare injury in childhood. Mortality is uncommon, but this trauma is commonly associated with intracranial injury. Early neurological deficits are caused by traumatic brain injury and were observed in one-third of the patients. However, only less than one-sixth suffered from permanent neurological or neuropsychiatric disorders.

Survey of current functional outcomes assessment practices in patients with head and neck cancer: initial project of the head and neck research network

BACKGROUND

Functional outcomes assessment has become increasingly important in informing treatment decisions in the area of head and neck cancer. However, consistency of assessment methods across studies has been lacking. For the literature to inform clinical decision making, consensus regarding outcomes measurements is necessary.

OBJECTIVE

The Head and Neck Research Network (HNRN) was founded in January 2008 to become a conduit for high-quality research in the area of functional outcomes in patients with head and neck defects. The present study surveyed experts in functional outcomes assessment to determine what are considered the most important tools for assessing speech and swallowing and what background patient characteristics are important to capture.

DESIGN, PARTICIPANTS, AND MEASURES

Respondents to the online survey included 54 participants with a background in speech-language pathology, with the majority of respondents from the United States, Canada, and the United Kingdom.

RESULTS AND CONCLUSIONS

The results from the survey indicated that clinicians consider both subjective and objective measures as important to use when assessing function. More advanced technical tools were often rated as less important; however, it also was noted that clinicians were most often not able to access these tools or were unfamiliar with them.

A review of 59 consecutive patients with lesions of the anterior cranial base operated on using the subcranial approach

INTRODUCTION

Lesions of the anterior cranial fossa are still a challenge for the surgeon. Since Joram Raveh introduced the concept of a subcranial approach in 1978 it has been used in the treatment of lesions extending into the anterior cranial fossa. Our experience with the subcranial approach during the past 8 years at Turku University Central Hospital is described.

PATIENTS

Fifty-nine consecutive patients underwent surgery using the subcranial approach for treating various benign and malignant neoplasms, for repair of frontobasal-midfacial fractures, and for repair of cerebrospinal fluid leaks.

METHODS

Patient records were retrospectively reviewed, with special focus on surgical technique, early outcome, and complications.

RESULTS

Nineteen of the patients were operated on because of combined fronto-naso-orbital and skull base fractures, 37 were tumour cases, and 3 patients required surgical repair for cerebrospinal fluid leakage. Significant complications consisted of two cases of meningitis. However, they were successfully treated with antibiotics. The most common late complaint was olfactory nerve dysfunction (44), other late complications such as diplopia (4), enophthalmos (2), scar tissue in the nasal cavity (2), and trigeminal nerve dysfunction (2) were also encountered.

CONCLUSION

The subcranial approach affords exposure to the orbital, sphenoethmoidal, and clivus regions, as well as to the nasal and paranasal cavities. On the basis of this review, it is concluded that it is a safe and effective approach for treating lesions involving the anterior skull base.

Preoperative hyperfractionated accelerated radiotherapy and radical surgery in advanced head and neck cancer: A prospective phase II study

BACKGROUND AND PURPOSE

To evaluate whether preoperative hyperfractionated accelerated radiotherapy (RT) combined with major radical surgery is feasible and successful in the treatment of advanced primary head and neck cancer.

PATIENTS AND METHODS

Ninety four patients with histologically confirmed head and neck squamous cell cancer (HNSCC) in the oral cavity (41/96; 43%), supraglottis (14/96; 15%), glottis (5/96; 5%), oropharynx (16/96; 17%), nasal cavity/paranasal sinuses (8/96; 8%), nasopharynx (3/96; 3%), hypopharynx (7/96; 7%) and two (2%) with unknown primary tumour and large cervical lymph nodes entered into the study. 21/96 patients (22%) had stage II, 17/96 (18%) stage III and 58/96 patients (60%) stage IV disease. The patients received preoperative hyperfractionated RT 1.6 Gy twice a day, 5 days a week to a median tumour dose of 63 Gy with a planned break for 11 days (median) after the median dose of 37 Gy. Then, after a median of 27 days the patients underwent major radical surgery of the primary tumour and metastatic lymph nodes including reconstructions with pedicled or microvascular free flaps when indicated as a part of the scheduled therapy. 12/96 patients had only ipsilateral or bilateral neck dissections.

RESULTS

After a median follow-up time of 37.2 mos 77/96 (80.2%) patients had complete locoregional control. All but 2 patients had complete histological remission after surgery. 40/96 pts were alive without disease, two of them after salvage surgery. 32/96 patients had relapsed; 15 had locoregional and 13 distant relapses, 4 patients relapsed both locoregionally and distantly. Fifty patients have died; 29 with locoregional and/or distant relapse, eight patients died of second malignancy, and 19 had intercurrent diseases. Disease-specific and overall survival at 3 years was 67.7 and 51%, respectively. Acute grade three mucosal reactions were common, but transient and tolerable. Late grade 3-4 adverse effects were few.

CONCLUSIONS

Preoperative hyperfractionated accelerated RT can be successfully combined with major radical surgery in the treatment of HNSCC. The amount of serious late adverse effects was not increased.

Bioactive glass S53P4 in frontal sinus obliteration: A long-term clinical experience

BACKGROUND

Synthetic, osteoconductive, and antimicrobial bioactive glass (BAG) has been used in many surgical applications.

METHODS

BAG was used as obliteration material in a series of osteoplastic frontal sinus operations on 42 patients suffering from chronic frontal sinusitis, which could not be cured with other means of treatment.

RESULTS

Accurate obliteration of sinuses was achieved in 39 patients. Uneventful recovery and clinical outcome were seen in 92% of the patients. Histopathologic samples harvested at 1, 5, and 10 years after obliteration revealed a healing process progressing from the fibrous tissue phase to bone formation with scattered fibrous tissue and bony obliteration maintaining BAG granule remnants. Fourier-transform infrared (FTIR) studies showed bone produced by BAG to be similar to natural frontal bone. Micorobiologic cultures obtained with histologic samples revealed no growth of bacteria.

CONCLUSIONS

BAG appears to be a reliable frontal sinus obliteration material, providing favorable conditions for total bony sinus obliteration.

Effect of age and repeated hyperbaric oxygen treatments on vagal tone

OBJECTIVES

To evaluate the influence of repeated hyperbaric oxygen (HBO2) exposures and age on vagal response to hyperbaric oxygenation, and to evaluate the timing of changes in vagal activity during the treatments.

STUDY DESIGN

Open, controlled, non-randomized study.

METHODS

Heart rate variability of 23 patients with chronic osteomyelitis or radionecrosis of the jaw or reconstructive surgery of the facial region was studied during repeated treatments. During each treatment, the patients were exposed to HBO2 at 2.5 ATA and heart rate variability was measured using power spectral analysis before compression, three times at 2.5 ATA and during and after decompression. The patients were grouped according to age (Cut-off point 50 years). Statistical analysis was carried out using analysis of variance for repeated measurements.

RESULTS

Repeated exposures did not change vagal response to hyperbaric oxygenation. Vagal activity measured by HF power increased significantly in both age groups during the HBO2 exposures but there were no significant difference between the groups in the response. However, the level of HF power was significantly higher in the subjects under 50 years old. Significant differences between consecutive measurements were related to pressure changes.

CONCLUSIONS

Repeated therapeutic HBO2exposures are not causing permanent changes in vagal control of the heart. Vagal responsiveness to hyperbaric hyperoxia is preserved in advanced age.

Fibrous dysplasia of the sphenoid sinus and skull base presents in an adult with localized temporal headache

Fibrous dysplasia (FD) of the sphenoidal sinus is a rare disease, especially during adulthood. We report a case of FD of the right sphenoidal sinus in an adult male patient who presented with nonspecific symptoms limited to headache localized to the right temporal area and to the inferior orbital rim of both sides. Magnetic resonance imaging revealed a dense mass that occupied the entire right sphenoidal sinus and skull base with typical ground-glass opacification and bony sclerosis of the whole sphenoidal wall. The diagnosis of FD was confirmed on pathological examination of a biopsy taken through sphenotomy. The patient underwent a subcranial craniotomy for tumor resection. After more than 4 years of follow-up, the patient was disease-free. On the basis of these clinical features, it is important to consider sphenoidal FD in both young and adult patients complaining of an unexplained headache, because it may present unusually with headache localized to the temporal region or the inferior orbital rim.

Permanent in vitro growth is associated with poor prognosis in head and neck cancer

OBJECTIVE

The propensity of head and neck carcinomas to grow in vitro and to form a permanent cell line varies. It is not known whether the outcome of patients whose cancer gives rise to permanent in vitro growth differs from that of patients whose cancer cells fail to grow in vitro. The purpose of this study was to find out whether tumor cell capability for in vitro growth is associated with prognosis in head and neck cancer.

MATERIAL AND METHODS

The study group consisted of 30 patients treated for head and neck cancer at the University Central Hospital of Turku between 1987 and 1994, and whose tumor samples had produced a permanent cell line in our laboratory. A control group was selected from patients treated during the same time period and with the same protocols in the same department. The controls were selected on the basis of similar tumor localization, TNM status, histological grade, age, gender and general condition. Tumor samples from 14 of the 30 control patients were also cultured, but did not result in a permanent cell line. The median follow-up time was 54 months in the study group and 52 months in the control group.

RESULTS

The 3-year survival rate of the patients whose cancer gave rise to in vitro growth was only 19%, compared to 68% among the controls (p = 0.001). In a multivariate analysis the propensity of cancer cells to grow in vitro had independent prognostic value, the relative risk of death (RR) being 1.95 (95% CI 1.11-3.42) when compared to cancers that did not produce a cell line. Of the other factors tested, only the primary tumor size (RR 1.75; 95% CI 0.97-3.16) and the blood hemoglobin level at diagnosis (RR 0.97; 95% CI 0.95-1.01) were possibly independently associated with survival.

CONCLUSIONS

The results suggest that the capability of cancer cells for in vitro growth has prognostic significance in head and neck cancer, and that cancer cells that are able to survive and grow in in vitro conditions behave aggressively in vivo. The independence of cancer cells from the paracrine signals produced by the neighboring host cells may enhance cancer cell survival and the metastatic potential in vivo.

Treatment of squamous cell carcinoma of the oral cavity, oropharynx and hypopharynx--an analysis of 174 patients in south western Finland

The purpose of this study was to determine the efficacy and feasibility of full-dose preoperative radiation therapy (RT) in head and neck cancer presenting in the oral cavity, oro- and hypopharynx, within a single university hospital district. During a seven-year period, 1989 to 1995, 174 patients with squamous cell carcinoma (SCC) of the oral cavity (OC, 70% of all patients), oropharynx (OP, 15%) and hypopharynx (HP, 15%) were referred to Turku University Central Hospital. All patients were seen by a tumor board consisting of an ENT (ear-nose-throat) head and neck surgeon, a radiation oncologist and a dentist. Potentially curative treatment was given to 142 patients. Of these, 88 (62%) had preoperative RT, 6 (4%) postoperative RT, 34 (24%) definitive RT and 14 patients (10%) were treated with surgery only. The radiation dose was > or = 50 Gy. averagely 64 Gy. The major endpoints of the study were local control, overall survival and major complications of the combined treatment. The 5-year relative survival rate (RSR) was 40% for all, and 43% for patients treated with curative intent. For these, the local control at 5 years was 60%; the disease-specific 5-year survival rate was 65% for the patients with lingual SCC, 45% for those with other oral tumor localizations. 64% for the oropharynx patients and 47% for those with tumor in their hypopharynx, while it was 55% for all patients. The preoperative radiotherapy was fairly well tolerated. Ten (7%) of the patients treated with curative intent suffered major complications, and four patients had evidence of osteoradionecrosis. With the exception of patients with early SCC the outcome remains rather poor in this group of cancer patients who often have marked co-morbidity. In our opinion, preoperative radiotherapy to a dose of 62-64 Gy can safely be given, and remains a feasible means to treat patients with oral, oropharyngeal or hypopharyngeal cancer.

Effect of postoperative irradiation on free skin flaps: an experimental study in rats

The modern treatment of musculoskeletal malignant tumours often requires different combinations of surgery, chemotherapy, and radiotherapy. Although combination treatments have allowed reconstruction of more complex defects, the risk of complications also rises. In clinical series the complication rate is influenced by the characteristics of the defect and the quality of the radiation used. The flap survival is high, but the overall complication rate is more than 25%. In this study we looked at the healing of microvascular free skin flaps exposed to postoperative irradiation in a rat model. Epigastric microvascular free skin flap were exposed to a single dose of 20 Gy radiation one week postoperatively (n = 8). A comparison was made with free epigastric skin flaps without postoperative radiation (n = 8). The healing was assessed histologically at four weeks and by measuring the tensile strength of the wound. Biochemical total nitrogen and hydroxyproline contents were also measured. Results showed that histologically the interfaces healed similarly with only minimal histomorphological changes. Neither the mechanical strength of the healing interface nor the biochemical markers altered significantly. Postoperative irradiation with a single dose of 20 Gy does not affect the survival of free skin flaps in rats. In the future the model described could be used to study the effects of combination therapy of surgery, radiotherapy, and chemotherapy more closely to find the optimal control of malignancies with limited damage to treated tissue.

Effect of hypothermia on blood-flow responses in pedicled groin flaps in rats

Cooling is widely used for preserving tissues such as kidneys before transplantation and for preserving extremities before replantation. Hypothermia has also been shown to be effective in the temporary storage of free flaps. However, in the intact living body, cooling can be damaging to tissue and the body system. We used a custom-designed clamping method (after flap elevation, occlusion and release of the flap-feeding artery) and continuous laser Doppler flowmetry to investigate the effects of hypothermia on blood flow and postocclusive reactive hyperaemia in the flaps. The animal model used was the partially elevated epigastric flap of adult Sprague-Dawley rats. In the hypothermia group (n=12), the core temperature and the flap temperature were allowed to fall during anaesthesia. At core temperatures of 34.58 degrees C and 338 degrees C and after rewarming of the rat, the feeding artery was occluded for 30 s and 120 s to observe the changes in blood flow and postocclusive reactive hyperaemia in the flap. In the control group (n=12), the core temperature was maintained at more than 378 degrees C throughout the experiment. To compare the flap blood-flow responses to occlusion of the femoral artery in the hypothermia group and the control group, the postocclusive reactive hyperaemia periods (i.e. blood flow above baseline after clamp release) were analysed. Statistical analysis of the responses showed that the magnitude (P=0.024), duration (P<0.001) and amplitude (i.e. peak flow) (P=0.037) of postocclusive reactive hyperaemia were significantly decreased in the hypothermia group. Our results suggest that hypothermia significantly decreases blood flow and postocclusive reactive hyperaemia in the rat epigastric flap. This may increase the risk of ischaemic flap complications unless rewarming is performed.

Effect of blood loss on vascular responsiveness in pedicled groin flaps in a rat model

Using the clamping method (closing and opening the flap feeding artery) and continuous laser Doppler flowmetry, the effects of blood withdrawals on flap blood flow and on active and passive mechanisms regulating it were investigated in 12 Sprague-Dawley rats. Measurements were made during stable normovolemic conditions, during hypovolemia (after 3 ml/kg and after 6 ml/kg blood withdrawal), and after retransfusion of the shed blood. The continuous blood flow responses during and after the clamping procedure were analyzed. After clamp release, the increase in blood flow, duration of overshoot, and peak flow of overshoot were significantly greater (the level of significance was set equal to 0.05) in the registrations performed after blood withdrawals than before them. The post-ischemic response curves indicating significantly increased flap hyperemia during reperfusion in the registrations after blood withdrawals may be associated with decreased vascular resistance in the flap. Thus, the authors conclude that a short-term decrease in blood pressure caused by blood loss may prepare the flap microcirculation for tolerating more ischemia.

Neodymium YAG contact laser in the treatment of cancer of the mobile tongue

The aim of this study was to evaluate the usefulness of a contact neodymium YAG laser for the treatment of squamous cell carcinoma (SCC) of the mobile tongue in 35 patients. The TNM stage and histologic grade were as follows: T1, n = 20; T2, n = 11; T3, n = 4; and N0, n = 33; N1, n = 2; G1, n = 20; G2, n = 10; and G3, n = 5. The surgical treatment consisted of a hemiglossectomy or resection with adequate margins in 28 cases, and an ipsilateral neck dissection was also performed in 7 patients. Radiotherapy to a mean tumor dose of 62-64 Gy and an elective dose of 50 Gy to the cervical lymph nodes was given to 14 patients. The radiotherapy was preoperative in 12 patients and postoperative in 2. Tongue resection was easily performed using the contact neodymium YAG laser, with a mean operation time of 31 min and intraoperative bleeding varying from negligible to 100 cm3. During postoperative follow-up no major complications occurred: cases with minor hemorrhage were easily controlled on the ward and 1 patient had a bleed on the 14th postoperative day necessitating hospitalization. The resection was histologically radical in all cases. During follow-up one patient had a local recurrence (T2N0, G3) and four failed in the neck (T1N0 G2, T1N0 G2, T1N0 G2, T2N0 G2), three of whom were successfully salvaged with a neck dissection and radiotherapy. One patient with osteoradionecrosis was diagnosed and treated curatively. Two patients died of their tongue cancer (T2N0 G3, T2N0 G2), 1 died from a second primary tumor (T2N0 G1) and 2 of intercurrent disease with no evidence of cancer; 30 patients (86%) are still alive with no evidence of disease. The function of the tongue in all patients in this sample was good to satisfactory. The major complaint was xerostomia in the irradiated patients. In conclusion, the contact neodymium YAG laser appears to be suitable for resection of T1-T2 SCCs of the oral tongue. In this limited patient sample T stage or grade did not predict failures in the neck. Biologic predictive markers need to be evaluated.

Effect of acute ischemic preconditioning on blood-flow response in the epigastric pedicled rat flap

Research in the field of microvascular surgery has shown that ischemic preconditioning (repeated brief episodes of feeding artery occlusions followed by reperfusion) improves flap survival. The authors used a custom-designed clamping method and laser Doppler flowmetry to investigate changes in blood flow (BF) responses, either with acute ischemic preconditioning or without it. The animal model used was the partially elevated epigastric flap of adult Sprague-Dawley rats. In the preconditioned group (n=12), the flaps underwent preconditioning with three cycles of 10-min of feeding artery clamping, followed by 10 min of reperfusion, for a total preconditioning period of 1 hr. In the control group (n=12), the flaps were perfused without clamping for 1 hr. All the flaps underwent occlusion of the feeding artery for 15, 30, 60, 120 and 180 sec to observe the changes in the BF responses, 60 min and 150 min after flap elevation. To compare the responses between preconditoned and control groups the BF responses were analyzed during the overshoot period (i.e., BF being above the baseline after different feeding artery occlusion periods). Statistical analysis of the responses showed that the magnitude of increase in BF after clamp release (p<0.001), the duration of overshoot (p=0.014), and the amplitude of overshoot after clamp release (p=0.002) were statistically significantly greater in the preconditioned group than in the control group. The results suggest that vessels and their responses to change in perfusion pressure are involved in the multifactorial process of the ischemia-protective effect caused by acute ischemic preconditioning. As far as is known, this is the first report showing changes in flap vascular responses after acute ischemic preconditioning.

Repair of orbital floor fractures with bioactive glass implants

PURPOSE

The ideal management of orbital floor fractures has been highly controversial. Many implants, both autogenous and alloplastic, have been used to span the defects. This study evaluated the use of bioactive glass implants (BAG-implant, S53P4; Abmin Technologies Ltd, Turku, Finland) for the repair of orbital floor defects caused by blunt facial trauma.

PATIENTS AND METHODS

This retrospective review of 36 patients was carried out from 1995 to 1999. All patients were diagnosed with an orbital floor fracture or a large orbital blowout fracture. The BAG-implant was placed over the defect, using a subciliary or transconjunctival approach. No screw fixation was used when the implant was the correct size. Follow-up examination was done at 1 and 3 months after surgery. Twenty-eight (82%) of the patients were also seen at one-year follow-up (21 men and 7 women).

RESULTS

The implants did not cause a foreign body reaction in the bone or soft tissue. There was no sign of resorption or infection, nor postoperative extrusion, hemorrhage, or displacement of the implant. Diplopia was seen preoperatively in 17 cases (61%) and postoperatively in 5 cases (18%). In 1 patient, the implant was removed 3 months after operation because of diplopia. Infraorbital nerve paresthesia was seen preoperatively in 9 patients (32%) and postoperatively in 5 patients (18%). The functional and cosmetic results were good at the 1-year follow-up.

CONCLUSION

The BAG-implant is a well-tolerated material in orbital floor reconstruction. It provides a favorable environment for an uncomplicated healing process because it is bioactive and biocompatible and because it causes new bone formation.

Changes in blood flow in the partially elevated epigastric pedicled flap in response to occlusion of the femoral artery in rats

In this study, the authors used a custom-designed clamping method and laser Doppler flowmetry to investigate the short-term autoregulatory patterns of blood flow (BF) in partially elevated pedicled epigastric flaps in rats (n=11). The femoral artery was clamped for 30, 60, 120 and 180 sec directly after flap elevation and 40 to 80 min after flap elevation. Changes during and after clamping indicate the functioning of autoregulatory factors in the vessels of the epigastric partially elevated flap. The longer the clamp ischemia is in a flap, the greater (p < 0.0001) is the need for a compensatory increase in BF and for a longer time (p < 0.0001) in the flap after clamp release. They compared the responses of BF directly after flap elevation with those 40 to 80 min after flap elevation. The results suggest a significant increase in the autoregulatory capacity of the pedicled partially elevated flap in measurements performed 40 to 80 min after flap elevation (p = 0.043). They conclude that the novel clamping method seems to be reliable when studying the short-term autoregulatory patterns of the epigastric partially elevated pedicled flap.

Experimental follow-up model for clinical frontal sinus obliteration with bioactive glass (S53P4)

Bioactive glass S53P4 (BG) is an osteoconductive allograft material. Since 1990, BG has been used in the obliteration of frontal sinuses in more than 30 consecutive patients. The patients have been monitored regularly with clinical examinations, computer tomography (CT) scans, laboratory tests and, in a few cases, biopsies have also been obtained. The material has been well tolerated and no loss of volume of obliteration material has been seen in the obliterated sinuses. However, in repeated CT monitoring and with Region of Interest (ROI) analysis, a decrease in the density of the obliteration material inside the frontal sinuses has been seen. In the present study, the clinical conditions after an obliteration operation were simulated and the behaviour of the BG in the obliterated area was observed. The aim was to study whether it is possible indirectly to estimate the resorption of a massive amount of BG with ROI analysis for monitoring the clinical success of the treatment. Thus two sizes of granules (0.63-0.8 mm and 0.8-1.0 mm) in eight separate BG amounts, weight 25 g, were tested in simulated body fluid (SBF) in standard conditions. The dissolution of silicon (Si) and phosphate (P) was detected with direct plasma atom emission spectroscopy (DCP-AES) monthly up to 6 months. The BG amounts were scanned with CT and the slices analysed using the ROI technique at 1, 3 and 6 months. The cumulative loss of Si and P in SBF was significant during the study (p < 0.0001) and it was stronger with smaller than with larger granules (p < 0.0001). This was shown correspondingly by the decrease of Hounsfield units (p < 0.0001) in ROI analysis. The method seems reliably to reveal the resorption of BG for clinical purposes.

Changes in blood flow in the epigastric free flap after microsurgical artery anastomoses in rats

A number of clinical disorders of free vascularized flap are presumed to reflect insufficient blood flow (BF) or an inadequate range of vascular responsiveness. We compared the changes in BF in a pedicled and free epigastric flap, directly after and 90 min after performing microsurgical artery anastomoses. We used the clamping method and laser Doppler flowmetry in six Sprague-Dawley rats. The BF response curves shortly after re-anastomosing of the artery differ markedly from those in a pedicled flap model and curves registered 90 min after performing the anastomosis. We conclude that the clamping method is reliable and reproducible when studying the short-term autoregulatory BF patterns of epigastric pedicled and free flaps.

Reconstruction of orbital floor fractures using bioactive glass

INTRODUCTION

The management of orbital floor fractures continues to be debated. Bioactive glasses and glass-ceramics are in the new group of materials developed for the repair of bone defects which are beyond any innate healing capacity due to their size.

OBJECTIVE

We compared the use of alloplastic implants (bioactive glass) with conventional autogenous grafts (cartilage--plus or minus Iyophilized dura) for the repair of orbital floor defects after trauma.

MATERIAL AND METHODS

Twenty-eight patients having orbital floor fractures with persistent diplopia, enophthalmos, and/or infraorbital nerve paraesthesia were operated on from 1991 to 1995 at Turku University Central Hospital. Reconstruction was either with bioactive glass (S93P4) or autogenous cartilage implants.

RESULTS

Postoperative tomograms in the 28 patients showed adequate maintenance of orbital and maxillary sinus volume without any evidence of resorption in either group. None of 14 patients in the study group had any evidence of dystopia or complications relating to implants follow-up. One had infraorbital nerve paraesthesia and another had entropion postoperatively. Among the 14 control subjects there were three cases of persistent diplopia, two of infraorbital nerve paraesthesia and one of enophthalmos.

CONCLUSION

Bioactive glass implants are well-tolerated and seem to be a promising repair material for orbital floor fractures. Their use leads to less morbidity as no donor site operation is needed. Also it provides favourable healing as it is bioactive, biocompatible and causes new bone formation.

Effect of carbogen inhalation on peripheral tissue perfusion and oxygenation in patients suffering from sudden hearing loss

The effects of repeated carbogen inhalation on peripheral tissue perfusion and oxygenation were assessed in 5 patients suffering from sudden hearing loss by means of continuously measured subcutaneous tissue oxygen and carbon dioxide tension, transcutaneous oxygen tension, laser Doppler red cell flux, and fingertip temperature. The subcutaneous oxygen tension increased clearly during the carbogen inhalation periods, and also, a smaller increase in subcutaneous carbon dioxide tension was simultaneously noticed. The changes in transcutaneous oxygen tension were even greater and the latency was shorter as compared with the subcutaneous gas tensions. The laser Doppler measurements showed no signs of vasoconstriction during the study. In conclusion, carbogen inhalation increases peripheral tissue oxygenation without microvascular vasoconstriction and with only a minor retention of carbon dioxide.

A modified protocol for early treatment of osteomyelitis and osteoradionecrosis of the mandible

BACKGROUND

The treatment of osteoradionecrosis (ORN) and early chronic osteomyelitis (COM) of the mandible and maxilla is controversial. Hyperbaric oxygen (HBO) at two to three times the atmospheric pressure at sea level can result in tissue oxygen tension of almost 400 mmHg. Herewith HBO increases oxygen supply in hypoxic tissue, thus inducing fibroblastic proliferation and capillary formation.

METHODS

From 1981 to 1991, we used a monoplace chamber and since 1992, we have also had a multiplace chamber for HBO treatment. Hyperbaric oxygen was given at 2.5-2.8 atmosphere absolute pressure (ATA) for 90-120 minutes, once per day. The patients had five to 10 preoperative and five to seven postoperative sessions. Surgical therapy consisted of decortication of the affected bone, subsequently covered with a free periosteal transplant from the tibia.

RESULTS

Thirty-six patients with ORN and 33 with COM of the mandible and maxilla was treated with this protocol. The median follow-up time in this material is 34 months, with a minimum of 10 months. Thirty-six ORN patients (92%) and 26 COM patients (79%) have remained symptom-free after the first treatment period. Three failed ORN patients were successfully treated with a free microvascular flap. The seven failed COM patients have been retreated, and five of them have occasional clinical symptoms.

CONCLUSIONS

Hyperbaric oxygen is a promising adjunct to surgery in the treatment of mandibular and maxillary ORN and COM. Using this protocol, the necessary HBO treatment sessions have been reduced from earlier protocols, without adverse effect on the outcome.

Obliteration of the frontal sinus cavity with bioactive glass

BACKGROUND

Bioactive glass (BG) is a glass ceramic material. It has been used as surgical bone replacement material in ear and oral surgery, orthopedics, and dentistry.

METHODS

Bioactive glass was used as obliteration material in a series of osteoplastic frontal sinus operations on 10 patients suffering from chronic frontal sinusitis, which other, more-conservative treatment modalities had failed to cure.

RESULTS

Bioactive glass is easy to handle, and complete obliteration of all sinusal recesses and excavations is easily achieved. No adverse effects of the implant material have been seen over a mean follow-up period of 5.0 years. One patient with a local recurrent infection in the outer table of the sinus was reoperated on 5 months after primary surgery. Repeated postoperative computed tomographic scans analyzed by digital region-of-interest (ROI) selection showed no remarkable changes in the frontal sinus cavities but a slight, yearly decrease in the density of the occlusion material. Laboratory monitoring of patients and histopathologic examination of two postoperative biopsy specimens indicated that the material is well tolerated and stable.

CONCLUSIONS

Bioactive glass is a promising and well-tolerated bone graft suitable for osteoplastic frontal sinus operations. Total accurate obliteration of the sinus is achieved with different sizes of granules and blocks. The results of the obliteration are maintained owing to the stability of the material.

The success rate of free flaps after preoperative irradiation in head and neck reconstruction

BACKGROUND AND AIMS

The reconstructive treatment of large head and neck tumours involves serious problems. Preoperative irradiation increases the risk of postoperative complications. Microvascular free flaps offer definite advantages over conventional reconstruction techniques and permit immediate preoperative high-dose radiation therapy.

MATERIAL AND METHODS

In 1985-1996, at the Turku University Central Hospital, 101 patients, 61 (60%) men and 40 (40%) women (age range 15-79 years, mean 61 years), with head and neck tumours, underwent microvascular reconstructions, and 90 of them were irradiated before surgery. All irradiated patients underwent primary reconstruction immediately after resection. The total irradiation dose was about 60 Gy, usual range 50 to 65 Gy. The patients were operated on 3 to 5 weeks after discontinuation of irradiation therapy.

RESULTS

Of the whole material of 101 free flaps, 89 (88%) were transferred successfully. The success rate in irradiated patients was 88% and in nonirradiated patients 91%. Reoperation had to be performed within twelve hours in three cases, with good results. Only two hernias occurred as donor complications (2%). Two of the patients died postoperatively (2%). Partial flap necrosis occurred in five patients and five patients underwent another reconstruction using a new free flap or with conventional reconstruction techniques.

CONCLUSIONS

Free flaps are often the only acceptable choice in extensive head and neck primary reconstructions after irradiation. Microvascular free tissue transfers to the head and neck after preoperative irradiation has become the accepted method of reconstruction as a result of increased success rates with superior aesthetic and functional results.

Microvascular free flaps in head and neck cancer surgery in Finland 1986-1995

Microvascular free tissue transfer has in many cases replaced classic flap techniques and is now an established workhorse for head and neck reconstructions. In this retrospective study the over 300 patients, who had microvascular free flap reconstructions in head and neck cancer surgery in Finland during a 10-year period (1986-1995) were reviewed. The operations were performed in the University Hospitals by plastic surgeons, ENT specialists or maxillofacial surgeons. The cases consisted of defects resulting from resection of oral cavity tumors (63%), mid- or upper-face and skullbase tumors (20%) and hypopharyngo-esophageal tumors (17%). The series includes a wide range of flap types and analyses flap outcome and complications. A total of 313 cases was reconstructed by 317 flaps (forearm flaps 47%, latissimus dorsi flaps 19%, free jejunum or colon transfers 15%, free iliaca crest flaps 8% and other flaps 11%). Thrombosis of one of the vessels and haematoma were the most frequent causes of failure in microvascular free tissue transfer. A total flap necrosis occurred in 27 (8.5%) and a partial necrosis in 12 (4%) patients. The most reliable flap in terms of survival was the radial forearm flap. The ever-improving success of microvascular free tissue transfer has made it a useful procedure for head and neck reconstructions. There is also a growing need for microvascular team surgery in the field of head and neck cancer therapy.

Microvascular free tissue transfers after preoperative irradiation in head and neck reconstructions

Surgical reconstruction of large head and neck tumors involves great problems. Preoperative irradiation increases the risk of postoperative complications. The use of microvascular free flaps has definitive advantages over conventional reconstruction techniques and permits immediate preoperative high-dose radiation therapy. Eighty-eight patients, 55 (62%) men and 33 (38%) women, with head and neck tumors underwent microvascular reconstruction at the Turku University Central Hospital in 1985-1995; 77 of them were irradiated before surgery. All irradiated patients underwent primary reconstruction. The preoperative radiation dose was 50-65 Gy. The free tissue transfer was successful in 77 (88%) of the 88 patients. The success rate was 87% in irradiated patients and 91% in nonirradiated patients. Free tissue transfers are suitable for one-stage reconstruction in selected patients such as those receiving high-dose preoperative irradiation. The transfer of microvascular free flaps to the head and neck has become the most common reconstruction method owing to its increasing success rates as well as its excellent esthetic and functional results.