Misdiagnosis of anterior cutaneous nerve entrapment syndrome as a somatization disorder

Introduction

Anterior cutaneous nerve entrapment syndrome (ACNES) is a frequently overlooked disease, causing chronic abdominal wall pain due to entrapment of an anterior cutaneous branch of one or more thoracic intercostal nerves. It is often misdiagnosed as a psychiatric condition, particularly under the heading of a somatization disorder.

Objectives

We describe the case of a patient who developed depressive symptoms after months of suffering from chronic abdominal wall pain.

Aims

To report a case-study, describing ACNES as a cause of persistent depressive symptoms.

Methods

A case-study is presented and discussed, followed by a literature review.

Results

A 35-year-female was referred to a psychiatrist for her depressive symptoms and persistent cutaneous abdominal pain for months. There she was diagnosed with a depression and possible somatization disorder and she received psychotherapy. Through Internet search, the patient found ACNES as a possible cause for her persistent abdominal pain. Since administration of anesthetic agents only shortly relieved her symptoms, a surgeon decided to remove the nerve end twigs. After surgery, her somatic problems and depressive mood disappeared.

Conclusion

The awareness of ACNES is still very limited in medicine. This may lead to incorrect diagnoses, including psychiatric disorders such as somatization disorder.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

[Orbital congenital nevi: Principles of treatment about 51 cases]

INTRODUCTION

The incidence of congenital nevi is one over 20,000 newborns per year, 14 % of them are located in the head and neck area. Nevi of the orbital region are particularly difficult to handle on the aesthetic and functional side. The objectives of this study were to conduct an analysis of different clinical presentations of congenital nevi of the eyelid orbital region in children to establish a treatment algorithm.

MATERIEL AND METHODS

We realised a bi-centric retrospective study including 51 children with orbito-palpebral congenital nevi. We analysed the different clinical presentations, their treatments and their results.

RESULTS

Nineteen underwent direct suture excision; three a total skin graft; 15 a combination of treatments, among them four underwent tissular expansion and 14 patients were not operated and clinically followed-up. The average follow-up time was 6.6 years. In 33 cases residual nevic area was still present. The postoperative sequelae were: dyschromia (n=17), anatomical deformation of the eye (n=10), nevi outbreaks (n=8), internal canthus deformation (n=5) and ectropion (n=1).

CONCLUSION

The results of our study show that therapeutic abstention is preferred when the aesthetic wrong is accepted by the patient and when there is not a higher risk of malignant degeneration. In order to minimise the risk of postoperative sequelae, we propose a therapeutic algorithm for the management of congenital orbital nevi.

[Childhood septic temporomandibular arthritis]

OBJECTIVE

To report a clinical case of acute otitis media in a child, complicated by septic temporomandibular arthritis and to present a review of the literature.

PATIENT AND METHODS

We report a case of a 7-year-old boy who presented an altered general condition, major hyperthermia, associated with a left temporozygomatic mass in a context of recurrent bilateral acute otitis media lasting for 2 months. Emergency computed tomodensitometry (CT scan) showed left temporomandibular joint arthritis. Treatment consisted of a parenteral double antibiotic therapy and prevention of temporomandibula (TM) ankylosis.

RESULTS

After 20 months of follow-up, the child showed a normal ORL examination with no maxillofacial sequelae.

CONCLUSION

All temporozygomatic masses presenting in a septic context should suggest the diagnosis of TM arthritis; computed tomodensitometry should be done immediately.

Flector tissugel used to treat capsular contracture after breast augmentation surgery

Capsular contracture constitutes the main postoperative complication after breast augmentation by implant placement. To date, no systemic treatment known allows for improvement that does not simultaneously put the patient at risk for secondary complications of a more general nature. Flector Tissugel is the sole locally active antiinflammatory patch. Its durable local antiinflammatory effect is associated only with a risk for rare and highly limited side effects. After approximately 3 weeks of treatment, a high frequency of change from capsular contracture Baker 2 or 3 to Baker 1 occurs, provided the application was started no later than 3 months after the onset of capsular contracture.

Le relissage fractionné par laser Fraxel®: un traitement complémentaire possible pour la chirurgie du rajeunissement facial

The fractional resurfacing (Fraxel laser) is a new procedure for facial and extrafacial rejuvenation. His claim is obtain a great efficacy on wrinkles, close to those of the CO(2) and erbium lasers, but without their risks and long lasting down time. We use a scanner, able to create multiple (around 2000 to 3000/cm(2)) 70-150 microns diameter microthermal zones surrounded by islands of viable tissue. The reepithelialization is complete in a day, but there is a collagen denaturization in the dermis, between 300-750 microns like after a traditional resurfacing. At each session, around 25% of the dermis are treated. 4 treatments are performed with a 1 to 2 weeks interval. We report our comprehensive results since we began in December 2004. At the time of the abstract, 600 sessions were performed (150 Patients). A visible reduction of wrinkles is observed anytime, with improvement of the texture of the skin, and in the same time, a dramatic improvement of the pigmented lesions. About tolerance, no severe side effects or dyschromia were noticed. We observed two case of limited erosion, (one of the first patients) due to a practical problem (bulk heating). The average erythema duration is 2 days. On the face, a 2-4 days edema occurs in many of the patients. Fraxel laser treatment is not designed as a substitute for surgical skin tightening such as facelift. Therefore, the fractional resurfacing is safe and effective for a visible reduction of wrinkles and appears as a very interesting treatment in association with face lift to rejuvenate the face.

Rajeunissement facial et lifting malaire concentrique : le concept du FACE RECURVE®

Cell ageing is responsible for the increasingly creased appearance of our skin. The ageing of the structures of the face is attributed primarily to the effect of gravity on the tissues. The theory expounded below sets out to prove that the main and initial cause of this ageing is the repeated contractions of the mimic muscles. This concept attributes only a secondary role to gravity in the ageing process, which is initially brought about by muscular contractions. An MRI study recently made it possible to demonstrate the anterior convexity curve of the mimic muscles in the young subject. This curve is due to the existence at the back of these muscles of a deep fat pad. In the young subject, the extent of its convexity and its location give a specific, youthful character to the movements, in terms of direction and amplitude, of the facial muscles. With age, the muscle gradually straightens and shortens due to the repeated contractions that expel the underlying fat and increase the tonus at rest. The application of these new findings to the ageing of the face gives rise to new technical possibilities both in the field of medicine and aesthetic surgery. These new techniques have the same targets: segments of the mimic muscles (maintain over time a good muscular curve and a low tonus at rest) and the underlying fatty convexities. As far as medicine is concerned, the combination of botulinum toxin and filling has proved its worth. But two technical elements are new: the filling products must, at several points, be injected primarily behind the muscle to treat the depressions naturally and restore the initial curve of the overlying muscle. A very low number of units (a quarter to one unit) of botulinum toxin must be injected into certain muscles to diminish the tonus at rest of these muscles without diminishing their strength in maximum contraction. In surgery, new possibilities to treat premature ageing include procedures that combine segmentary muscular weakening, micro liposuctions and retromuscular reinjections. The advantage with regard to the medical procedures is greater stability over time and the greater precision of these muscular actions (one third of a muscle can be weakened for example) and the fat reinjections can be more stable. These procedures can be performed under local anesthesia. In cases of more advanced ageing, surgery offers new treatment possibilities that include, for the midface region, the concentric malar lift. It replaces, on the orbital rim, the sub-orbicularis oculi fat that has descended eccentrically as a result of the contractions of the orbicularis oculi muscle. The procedure, using the subperiosteal detachment plane, is therefore stable over time. At the same time, specific muscles are weakened. The aims of restoring fatty volumes and muscular tonuses are thus achieved. Similarly, in the neck, the platysma muscle is specifically weakened. Each area is studied in line with its specificities. For the first time, the skin tension of the facelift has no more to be maximum to treat the relief of the jawl line, of the palpebro malar groove and so on. The skin tension becomes moderate, just to remove the excess of skin. The relief is faded with the specific muscular and fatty action. The name of this new concept is Face Recurve.

La chirurgie du cuir chevelu de l’enfant : principes et particularités thérapeutiques

Surgical treatment of the lesions of the scalp in children has specific objectives: excision of an extensive lesion using minimum operative procedures, hiding scar in the hair, correcting a wide and ungraceful scar. We reviewed our experience of 450 cases (1990-2000), and found that most common lesions in childhood were: sebaceous hamartoma, pigmentary naevus, post traumatic alopecia, aplasia cutis congenita and complicated hemangiomas. Different surgical procedures are discussed: excision, tissue expansion, hair grafts. Large excision can be performed before three months of life because of the good laxity of the scalp. Tissue expansion is particularly suited to the scalp. Aplasia cutis congenita is a special condition, with local vascular abnormalities: local flaps are prohibited. Hemangiomas may require early surgical treatment in the event of complications.

[Early surgery of immature hemangiomas with the aid of an ultrasonic scalpel. Apropos of 81 cases]

BACKGROUND

The natural course of immature hemangiomas in infants is well-known. A rapid phase of growth from 6 to 8 months is followed by a period of stability then regression. Since approximately 70% of these immature hemangiomas resolve spontaneously, abstention is generally the rule. The volume or localization of certain lesions may nevertheless have a serious functional or morphological impact.

MATERIAL AND METHODS

This retrospective study included 81 children who underwent surgery between October 1994 and March 2000. The children were aged 2 to 38 months at the time of surgery. Orbital localizations predominated (33 children). The indication for surgery was based on two criteria: risk of a functional impairment or risk of morphological sequela. All children with orbital hemangiomas with a functional risk of amblyopia were initially treated with corticosteroids. Surgery was performed in case of failure. The CAVITRON was used for 77 children and DISSECTRON for 4. These two ultrasound devices allowed easy dissection with little hemorrhage.

RESULTS

There were no peroperative hemorrhagic complications. Few postoperative complications were observed. After resection of the orbital hemangiomas there was little functional impact and the postoperative ophthalmologic examinations were normal within several weeks. Mean follow-up was 12 months after surgery. Use of an ultrasound dissector allowed early and safe treatment of immature hemangiomas.

DISCUSSION

Certain voluminous or poorly localized hemangiomas, particularly on the face, can have a serious function, morphological or psychological impact. Medical treatment is not always active and surgical resection may be required before the development of definitive sequelae. Ultrasound dissection, not previously used in this indication, can contribute significantly to the surgical outcome as demonstrated in these children operated on early. This technique is safe and shortens operative time. In light of these results, we believe early resection of immature hemangiomas should be reevaluated. It should not be considered as a last resort but rather as a complementary treatment.

"Distraction" of grafted alveolar bone in cleft case using endosseous implant

OBJECTIVE

Presentation of a specific surgical technique of vertical alveolar ridge distraction performed on an alveolar bone graft 1 year after the primary grafting procedure designed to correct a labioalveolar cleft. The graft had not obtained the results desired and presented heavily scarred mucosal tissue.

TECHNIQUE

A dental implant placed within the graft once it has been entirely freed by osteotomies functions as an endless screw. To avoid vascular risk, the alveolar bone graft is detached as a whole along its total height. Consequently, no bone remains above it to provide support for a conventional alveolar distractor. An osteosynthetic miniplate, fastened in a horizontal position beneath the nasal mucosae above the graft, is used to replace the missing bony support and to stabilize the implant, which activates the distraction process.

PATIENT

This study is based on our first clinical case with a follow-up of 18 months at present.

RESULT

A vertical displacement of the entire graft was achieved, including its attached mucosal layer, which repositioned both bone and mucosa on a far better level in the cleft area. Thus, a normal length of abutment was obtained permitting prosthetic rehabilitation based on the same endosseous implant, which was left in place within the graft.

CONCLUSION

This technique may prove particularly helpful in certain cases in which a primary alveolar bone grafting procedure has produced borderline results. In such cases, on the one hand, neither the reasonably satisfactory volume of the bone graft itself nor the poor quality of its scarred mucosal tissue argue in favor of a secondary grafting procedure. On the other hand, it is impossible to resort to currently available alveolar distracters since our choice of techniques leaves no bone support above the graft.

[Circumscribed mandibular osteitis in children due to hematogenous dissemination. Apropos of 5 clinical cases]

In children, mandibular swelling associated with an X-ray bone osteolysis may correspond to tumoral or infection diseases. Circumscribed osteitis of a child's mandibula, with no dental etiology occurs around 7-years of age, adjacent to a healthy first molar. Five cases reports were analyzed. Clinically, it is a bone swelling of the mandibula's lateral cortical associated with a soft tissue swelling. X-ray signs were not specific but all cases showed a bone lacuna with sharp outlines. Such clinical and X-ray signs strongly suggest diagnosis of osteitis which has a higher incidence than malignant tumors. The lack of dental pathology suggests bloodstream dissemination from another localized sepsis. Surgical removal of pathologic bone in addition to antibiotics (6 or 8 weeks) appears to be an effective treatment.

Immunity induced by primary human cytomegalovirus infection protects against secondary infection among women of childbearing age

To determine if immunity to human cytomegalovirus (HCMV) protects women from acquiring HCMV from their children, a blinded, randomized protocol was used to monitor seronegative women who received placebo or Towne vaccine (approximately 500 pfu) and seropositive women. Each group was similar for mean maternal (33 years) and child age (18 months) and duration of viral shedding by the child (15 months). Among 19 placebo recipients, 9 developed primary infection; 8 of 19 vaccines but only 3 of 42 naturally seropositive subjects had evidence of acquiring HCMV from their child. Wild type infection and Towne vaccine induced similar mean lymphoproliferative responses to HCMV antigens, but one dose of Towne vaccine produced mean neutralizing titers 10- to 20-fold lower than those after wild type infection. Thus, a vaccine that induces immune responses equal to those induced by wild type virus may protect healthy women from acquiring HCMV from their children.

Amputation of penis after circumcision--penoplasty using expandable prosthesis

A two-year-old boy was referred for correction of an amputation of penis following ritual circumcision. The reconstruction involved mobilization of the profound part of corpora cavernosa and coverage by a vascularised flap taken from the hypogastric area through the use of a sub-cutaneous expandable prosthesis. After two years, appearance of the neo-penis is satisfactory considering the initial lesions.