Application of dual-frequency ultrasound for reduction of perilesional edema and ecchymosis after rhinoseptoplasty

OBJECTIVES

Biological aspect and clinical research demonstrated that dual-frequency ultrasound (local dynamic micro-massage, LDM) waves of very high frequency can significantly modify cellular signaling providing anti-inflammatory and anti-fibrotic effects. During the recent past, these waves were successfully applied for the treatment of various inflammatory skin conditions, hypertrophic scars, and chronical wounds. Since the main complications after rhinoseptoplasty are caused by excessive inflammatory reactions and development of fibrosis along nasal implants which can lead to a revision rhinoseptoplasty, in this retrospective multicenter blinded study we have evaluated the efficacy of LDM ultrasound for the treatment of the postoperative perilesional ecchymosis and edema in patients after rhinoseptoplasty.

METHODS

Twenty-four patients received daily LDM treatment (study group) for 5 days starting from the first day postoperative, whereas 24 patients (control group) were treated with conventional ice packs. Dynamic reduction of the postoperative perilesional ecchymosis and edema was followed up, and the total duration of these side effects was determined within specific paranasal anatomical areas.

RESULTS

Post-rhinoseptoplasty ecchymosis and edema were observed in the areas of anterior cheek, lower eyelids, and upper eyelids. Duration of the postoperative perilesional edema was significantly reduced in the group treated with LDM (1.9 ± 0.9 days) compared with control group (4.5 ± 2.1 days). Duration of the ecchymosis was also significantly reduced in LDM group (2.8 ± 1.4 days) compared with controls (7.4 ± 2.8 days). Postoperative patient satisfaction in LDM-treated and control groups was 3.1 ± 1.3 and 1.5 ± 0.7, respectively, demonstrating significantly higher satisfaction in LDM-treated group.

CONCLUSIONS

This study proved that the post-rhinoseptoplasty group treated with LDM ultrasound showed a significantly shorter duration of the postsurgical perilesional ecchymosis and edema, with no substantial adverse effects other than those observed in the control group. It can be suggested that ultrasound treatment can serve as an alternative option for the noninvasive management of postoperative perilesional ecchymosis and edema.

Dermatological Toxicities of Bruton's Tyrosine Kinase Inhibitors

The development of Bruton's tyrosine kinase (BTK) inhibitors represents a major breakthrough in the treatment of chronic lymphocytic leukemia and other B cell malignancies. The first-generation inhibitor ibrutinib works by covalent irreversible binding to BTK, a non-receptor tyrosine kinase of the TEC (transient erythroblastopenia of childhood) family that plays a critical role in the B-cell receptor signaling pathway. It also induces an 'off-target' inhibition of a range of other kinases including (but not limited to) epidermal growth factor receptor (EGFR), SRC, and other kinases of the TEC family (interleukin-2-inducible T-cell kinase [ITK], Tec, BMX). Dermatological toxicities are among the most common toxicities of ibrutinib, but remain of mild to moderate intensity in most cases and are readily manageable. Their incidence is highest during the first year of treatment and declines over time. In addition, it has been postulated that ibrutinib-related dermatologic adverse events are mediated by the direct binding to both BTK and other 'off-target' kinases. Bruising, ecchymoses, and petechiae represent the most characteristic dermatologic adverse events. Nail and hair changes are also common, as skin infections (opportunistic infections including herpes simplex and herpes zoster virus reactivations, and Staphylococcus aureus superinfection), folliculitis, and other types of rashes. Panniculitis, aphthous-like ulcerations with stomatitis, neutrophilic dermatosis, peripheral edema, and skin cracking can also occur. Next-generation BTK inhibitors, acalabrutinib and zanubrutinib, have been designed to optimize BTK inhibition and minimize off-target inhibition of alternative kinases (Tec, ITK, EGFR, SRC-family kinases). These drugs have been recently FDA-approved for relapsed or refractory mantle cell lymphoma. Although the overall incidence of their toxicities is expected to be more limited, acalubrutinib and zanubrutinib are associated with a range of dermatologic toxic effects that appear to be similar to those previously described with ibrutinib, including bruising and ecchymoses, panniculitis, human herpesvirus infections, cellulitis, and skin rash. In particular, both drugs induce skin bleeding events in more than 30% of patients treated. However, the available dermatological data are still rather limited and will have to be consolidated prospectively. This review article analyses the wide spectrum of dermatological toxicities that can be encountered with first- and second-generation BTK inhibitors. Finally, recommendations for appropriate treatment as well as a synthesis algorithm for management are also proposed.

Systemic Amyloidosis Caused by Monoclonal Immunoglobulins: Soft Tissue and Vascular Involvement

Clinical features of soft tissue amyloid light-chain (AL) amyloidosis include macroglossia, arthropathy, muscle pseudohypertrophy, skin plaques, and carpal tunnel syndrome. Vascular manifestations of AL amyloid include periorbital ecchymosis, jaw or limb claudication, and even myocardial infarction caused by occlusion of small vessel coronary arteries. Some of these features, such as macroglossia, periorbital ecchymosis, and the so-called shoulder-pad sign, are pathognomonic for AL amyloidosis. These findings may be the initial presenting features of the disease, and the recognition of these red flag symptoms is very important for the diagnosis and early intervention on the underlying plasma cell disease.

Effectiveness of tumescent solution combined with negative pressure wound therapy in traditional high ligation and stripping of the great saphenous vein

Traditional high ligation and stripping (THLS) is a routine operation for varicose veins. However, THLS is accompanied with postoperative subcutaneous ecchymosis and pain. In this current study, we aimed to explore the effect of tumescence solution (TS) combined with negative pressure wound therapy (NPWT) on the relief of subcutaneous ecchymosis and pain after THLS of great saphenous vein.A total of 180 patients receiving THLS were enrolled in group A, and 120 patients undergoing THLS and TS combined with NPWT were assigned into group B. The occurrences of subcutaneous ecchymosis and pain were recorded. Moreover, the total area of subcutaneous ecchymosis was estimated by the grid method. Visual analogue scale (VAS) score was used to assess the pain level of both groups.Preoperative characteristics were not significantly different between 2 groups. Postoperative ecchymosis occurred in 112 cases (62.2%) of group A and 41 cases (34.2%) of group B. The area of ecchymosis in group A (66.6 ± 44.5) cm was larger than that in group B (25.2 ± 19.9) cm. The number of patients without obvious pain in group A (57, 31.7%) was significantly less than that in group B (77, 64.2%) after operation. In addition, VAS score in group A (3.1 ± 2.6) was higher than that in group B (2.2 ± 1.9).In conclusion, the application of TS combined with NPWT in THLS can not only alleviate subcutaneous ecchymosis and pain, but also prevent the occurrence of subcutaneous ecchymosis and pain after operation. Therefore, it is conducive to postoperative recovery and is suitable for clinical application.

Post Filler Ecchymosis Resolution With Intense Pulsed Light

Bruising after dermal filler and neuromodulator injections is a common side effect and can have durations of 1 to 2 weeks. While it ultimately resolves, faster resolution can produce better outcomes for patients and also make patients more likely to return for future treatments. We report the successful reduction in bruising following injections of fillers with an intense pulsed light source. We also documented the onset of action of bruising resolution with serial photographs. Resolution started within the first hour of treatment and continued rapidly over 48 hours. This is the first-time reported study of resolution of bruising from injectables with intense pulsed light. Patient satisfaction is improved when such adverse events are minimized.

Periorbital ecchymoses and breathlessness

A 54-year-old man presented at our facility with a 3-month history of exertional breathlessness and purple blotches around his eyes. Examination revealed bilateral periorbital and perioral ecchymosis, purpuric spots along his waist, and waxy papules on his eyelids. In addition, the patient had macroglossia with nodular infiltration and irregular indentations at the lateral margin of his tongue. The patient also had a raised jugular venous pressure and prominent atrial and ventricular waves. Further examination revealed a fourth heart sound over the left ventricular apex, as well as bilateral basal rales. All other systems were normal except for mild hepatomegaly. Routine hematologic and biochemical lab work was unremarkable. X-rays of the spine and skull were normal, but a chest x-ray showed mild cardiomegaly. An electrocardiogram showed a QS complex from leads V1 to V4 (a pseudo-infarction pattern). An echocardiogram showed biatrial enlargement, left ventricular hypertrophy with a left ventricular ejection fraction of 48%, a speckled pattern on the myocardium, a thickened interatrial septum, and mild pericardial effusion. A color Doppler revealed mild mitral and tricuspid regurgitation with a restrictive pattern of mitral valve flow. Serum protein electrophoresis was normal. WHAT IS YOUR DIAGNOSIS? HOW WOULD YOU TREAT THIS PATIENT?

An Elderly Man with a Swollen Knee,Significant Ecchymosis, and Minimal Knee Pain

A 72-year-old man presents with left knee pain and swelling over several days. The pain and swelling started after he felt a "pop" when bending to pick up an object off the floor. His past medical history is significant for type 2 diabetes mellitus. Physical exam revealed significant ecchymosis on the anterolateral aspect of the thigh. There was a minimal amount pain upon knee flexion.

The dangers of bunk beds to the eye - a case report and preventive measures

This is to illustrate the case of a 14 year old male student of a secondary school who fell off the top of an unguarded bunk bed in his hostel while sleeping and sustained a fracture of the left orbital margin, severe periorbital echymosis and conjunctivitis. He was managed conservatively. Two weeks post injury; the swelling resolved. At 2 months post injury, he improved tremendously and his visual acuity in the affected eye was 6/6. The swelling resolved and his anterior and posterior segments were normal. The patient was lucky to have had an intact eyeball. If it had been a penetrating eye injury, it could have been disastrous. Blinding eye injuries may be irreversible.Unguarded bunk beds may be dangerous to the eye. A recommendation of minimal standard for bunk-beds for children or no bunks at all in schools is suggested.

Case report: scrotal ecchymosis after shockwave lithotripsy

Shockwave lithotripsy (SWL) is the treatment of choice for most renal calculi because it is highly effective and relatively noninvasive. Although complications of SWL are relatively few, one that occurs more frequently is perirenal hematoma, usually diagnosed by radiologic procedures. We present an interesting case of scrotal ecchymosis as an unusual presentation of perirenal hematoma causing ipsilateral spermatic-vein thrombosis after SWL for a left renal stone. To our knowledge, this condition has not been reported previously.

Widespread cutaneous involvement by invasive Apophysomyces elegans in a gravid patient following trauma

Invasive infections in humans with organisms from the fungal subclass Zygomycetes are most commonly seen in immunocompromised and diabetic patients. Rarely, such fungal infections may be seen in immunocompetent, nondiabetic individuals. In these cases, cutaneous trauma with direct implantation of fungal organisms into the wound from soil contamination is the frequent scenario. We present the case of a 31-year-old gravid woman involved in a single-vehicle automobile accident who presented to our institution with severe head trauma. On admission, a small ecchymotic area on her right forearm was noted. The lesion eventually expanded and ulcerated. Culture and histologic examination of tissue from the site revealed fungal organisms consistent with Zygomycetes. Subsequent studies confirmed the fungal organism as Apophysomyces elegans. Antifungal therapy was initiated, and multiple debridements were performed. Amputation of the right arm above the elbow was eventually necessary, but aggressive surgical intervention and antifungal therapy were unsuccessful in preventing the spread of the infection. The patient died 2 weeks after admission from polymicrobial sepsis. This case illustrates the dangerously invasive nature of A elegans, even in immunocompetent individuals.

Bruising following blood donation, its management and the response and subsequent return rates of affected donors

A study was undertaken to determine the incidence of bruising among blood donors and to analyse their response to the management of this complication. A total of 52 510 donors were bled at 476 consecutive donor sessions held by the Brentwood Centre during a 4-month period. Of these, 344 donors (0.66%) were found to have developed bruises following venepuncture. The incidence of bruising among males was 0. 35% and that among females was 0.98%. All bruised donors were managed by the Centre nursing and medical staff. One hundred and sixty-one donors informed the Centre that they were fully satisfied with the way their bruising was managed. Of 329 bruised donors who remained in the panel, 249 (75.7%) attended subsequent blood donor sessions in response to routine invitations, showing that the majority of bruised donors continued to donate blood. This response was compared with that of a control group of donors who did not develop any complications and there was no significant difference in the return rates between the two groups.

Horse bite injury

Bite wounds are relatively frequent, the order of frequency being, dogs, cats and humans. The clinical importance of other types of bites depends on the severity of the injury or any subsequent infection. We report on the case of a woman bitten on her thigh by a horse, producing severe haematoma, fat necrosis and muscle rupture, without an external wound. We emphasize the importance of the ultrasound examination in the evaluation of the extent of the crush injury.

The management of abrasions and bruises

An update on the treatment of soft tissue damage commonly resulting from accidental injuries and assaults.

Rodenticide-induced coagulopathy in a young child. A case of Munchausen syndrome by proxy

PURPOSE

To present the diagnosis and management of superwarfarin ingestion, a cause of serious and prolonged coagulopathy.

METHODS

Specific identification of the anticoagulant was made by high-pressure liquid chromatography.

RESULTS

A 24 month-old child developed bruises and a prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT) after receiving multiple doses of brodifacoum, a superwarfarin rodenticide. The coagulopathy was treated successfully with large doses of parenteral and oral vitamin K1; fresh frozen plasma was administered as a precautionary measure on two occasions. After the first 10 days of the child's hospitalization, the mother was identified as the source of brodifacoum, exemplifying the behavior described as Munchausen syndrome by proxy. Oral vitamin K1 was initiated and continued in an outpatient setting with tapering doses over nine months, using the PT as a guide for therapy.

CONCLUSIONS

This report emphasizes the necessity of recognizing rodenticide poisoning and investigating its source. Frequent monitoring of the PT is essential to prevent hemorrhagic complications due to repeat exposure, inadequate vitamin K1 therapy, or noncompliance.

Effects of heat and cold on the perineum after episiotomy/laceration

The Redness Edema Ecchymosis Discharge Approximation (REEDA) tool, devised to evaluate postpartum healing of the perineum following an episiotomy/laceration, was used to evaluate the effects of heat and cold on the perineum during the first 24 hours after delivery. Ninety patients were randomly assigned to one of three treatment groups. Treatment consisted of 30 subjects applying a warm perineal pack, 30 applying a cold perineal pack, and 30 taking a warm sitz bath. Analysis of variance indicated no difference in the REEDA score before or two hours after treatment. A Pearson r correlation indicated the REEDA score was associated with a laceration and not with infant weight. Although these findings do not support assumptions from the literature, this study provides baseline data and trends for future study.

[Ecchymotic patches of the fingers and Gardner-Diamond vascular purpura]

Ecchymotic patches on the fingers and vascular purpura in Gardner-Diamond syndrome are two benign but recurrent clinical disorders occurring chiefly in young women. They involve superficial cutaneous hemorrhagic signs. Both disorders testify to microvascular fragility without perturbation of general hemostasis. Diagnosis is easy for those familiar with the disorders. Ecchymotic episodes accompanied by sharp pain begin at the roots of the fingers. Microtraumatism is soon seen to be involved. Ecchymosis develops at the flexor muscles of the fingers but "capillary" resistance is only reduced in one third of cases. The pathogenic explanation involves rupture of a small post-capillary vein due to disorders in the control system of kinins and local metabolites. The autoerythrocyte sensitization syndrome described in 1955 by Gardner and Diamond is characterized by painful and febrile episodes followed by purpuric and ecchymotic lesions of the skin on various parts of the body, but not necessarily on the legs. Dysneurotonic effects are frequent but diagnosis is based upon promotion of the disorder by intradermal or subcutaneous injection of a minimal quantity of autologous blood. Immunological effects are considered but the ailment involves microvascular control disorders, notably of the capillary-vein segment, in particular at Copley's endo-endothelial fibrin film. Imbalance in fibrin formation and lysis is associated with perturbation of the kinin and serotonin systems. In addition to the use of certain bioflavonoids and calcium inhibitors, prevention and treatment should involve consideration of drugs which affect plasticity in the vascular wall and pericapillary interstitial conjunctiva and the rheological properties of blood flow and interstitial tissue.

Scrotal ecchymosis: sign of intraperitoneal hemorrhage in the newborn

Ecchymosis of the scrotum and lower abdominal wall occurred in four newborn boys. All were anemic. Three had coagulation abnormalities and evidence of sepsis. In two, group B streptococcal septicemia was documented. Intraperitoneal hemorrhage from a ruptured subcapsular hematoma of the liver was the source of blood in the scrotum in three, and most probably in the fourth as well. Two infants died in spite of antibiotics, vigorous blood replacement, including exchange transfusion, and desperation laparotomies for continued intraperitoneal hemorrhage. Newborns with scrotal ecchymosis should be examined for intraperitoneal hemorrhage, ruptured subcapsular hematoma of the liver being the most probable source. Their coagulation status should also be evaluated, and sepsis should be suspected, especially in those with a demonstrated coagulopathy. Group B Streptococcus is a likely primary etiologic agent in these critically ill neonates. Nonoperative treatment, as given the two survivors in this experience, is preferred.

Spontaneously acquired factor IX inhibitor in a nonhemophiliac child

A 2 1/2-year-old, previously healthy child developed progressive swelling of the left leg and a hematoma of the anterior chest wall associated with a falling hemoglobin concentration, as a result of a spontaneously acquired Factor IX inhibitor. Successful management of her condition required a four-volume exchange transfusion and immunosuppressive therapy consisting of cyclophosphamide for four days and prednisone for one month. A brief review of the literature regarding the occurrence and nature of acquired coagulation factor inhibitors and the role of immunosuppressive therapy is also presented.

Eye disorders: common ocular injuries: assessing the severity

Any eye injruy due to blunt trauma calls for a measurement of visual acuity as part of the initial examination. Blunt trauma may result in a black eye or in a far more serious injury such as blowout fracture, hyphema, or macular edema.