Flap Extension Technique Using Intrasocket Granulation Tissue in Peri-Implant Osseous Defect: Case Series

A compromised extraction socket is characterized by severe bone resorption around neighboring teeth and is often occupied with thick intrasocket granulation tissue (IGT). Guided bone regeneration (GBR) is a procedure that can preserve the bone volume around extraction sockets, and it can also be combined with immediate implant placement. However, an early exposure of GBR sites is a possible complication because it increases the risk of infection and can inhibit successful bone regeneration. The purpose of these case series is to introduce a novel, surgical procedure that can prevent the exposure of GBR sites by using IGT for flap extension during immediate implant placement in compromised extraction sockets. The technique was successfully performed in six patients. For successful flap closure, the inner portion of the IGT was dissected so that the flap was properly extended with the base of IGT attached to the flap for blood supply. Periosteal releasing incisions were not performed. The IGT was first sutured to the palatal flap with resorbable sutures, and then the overlying flap was closed with additional sutures. There was no post-operative exposure of the surgical GBR site in any of the patients, and the location of the mucogingival junction remained unchanged. All grafted sites also achieved sufficient bone regeneration. Within the limitations, this case series demonstrates the potential use of IGT, a concept which was previously obsolete.

Epistaxis, mass in right nostril · Dx?

A 49-year-old woman visited our family medicine clinic because she'd had 3 episodes of epistaxis during the previous month. She'd already visited the emergency department, and the doctor there had treated her symptomatically and referred her to our clinic.

A novel approach to excision of distal tracheal granulation tissue in tracheostomy patients with difficult anatomy

Tracheostomy predisposes patients to various complications. The most common late complication is granuloma formation; others include tracheal stenosis, bleeding, infection, and fistula development. Small granulomas may not require treatment, but large ones necessitate removal to prevent bleeding, obstruction, respiratory distress and, in rare cases, death. Various treatment options have been described, but no single modality has proved to be superior. We describe a novel approach to treating substomal tracheal granulation by using trans-stomal Coblation for patients whose granulation is difficult to visualize. This procedure offers several advantages over other means, including better hemostasis, less risk of distal tissue loss, ease of use, and potentially less operative time.

Powered Instrumentation in the Treatment of Tracheal Granulation Tissue for Decannulation

OBJECTIVE: To evaluate the outcomes of powered instrumentation tracheal surgery (PITS) in patients with tracheal granulation tissue following tracheostomy that caused or exacerbated airway obstruction and impeded decannulation.

STUDY DESIGN: Retrospective case review.

METHODS: Sixteen patients that accepted PITS for decannulation from tracheal granulation tissue were reviewed. The surgical procedure was performed with the assistance telescope connected to a television monitoring system. The success of PITS was defined as a decannulation for 3 months without a recurrence of airway obstruction.

RESULTS: The average operation time was 34 minutes. No complication was met in the perioperative period. Fourteen cases (87.5%) were successfully decannulated within 3 days following PITS. The 2 cases that failed successful decannulation had undergone insertion of a tracheal stent for their hindered tracheal stenosis.

CONCLUSIONS: The preliminary results reveal that the new operation modality, PITS, is a safe and simple method for the treatment of tracheal granulation tissue and could be a useful alternative for benign tracheal lesions.

[The treatment principles of frontal sinus tract after the frontal approach craniotomy]

OBJECTIVE

To investigate the causes, clinical manifestation and treatment principles of frontal sinus tract after the frontal approach craniotomy.

METHOD

The clinic data of 13 patients with frontal skin sinus tract after the frontal approach craniotomy were retrospectively analyzed. All of them were described in the clinical record to have undergone frontal sinus mucosa pushing down or shaving and bone wax filling in the frontal sinus during the surgery, of whom 3 cases had history of frontal abscess incision drainage. All patients were performed endoscopic frontal sinus surgery and forehead skin sinus tract excision and suture.

RESULT

All of the patients successfully recovered after one-stage operation, and the frontal skin sinus tract was healed.

CONCLUSION

The frontal approach craniotomy with postoperative frontal sinus tract was related with the improper use of bone wax tamponade and sealing of frontal sinus. The treatment principles were to remove bone wax, remove inflammatory granulation tissue around the sinus tract, and to open frontal sinus and promote frontal sinus drainage.

[OBJECTIVE CRITERIA OF PATIENT'S READINESS TO FREE AUTOPLASTY IN CASE OF GRANULATING WOUNDS (CRITERIA OF READINESS OF GRANULATING WOUNDS TO OPERATION)]

The article based on the analysis of 84 follow-up of the patients. The authors suggested using the indices of microbiological and immunological investigations and data of laser Doppler ultrasonography to determine the readiness of granulating wound to free autoplasty. The data obtained allowed developing an algorithm of treatment, patient's preparation to surgery and determination of operation terms.

Successful conservative treatment of dentigerous cyst following intrusion of lower primary incisors

This paper reports on the development of a dentigerous cyst associated with a lower permanent incisor following intrusion of two lower primary incisors. The small root remnant of one of the traumatized primary incisors was associated with granulation tissue, while the second incisor was discolored and suspected of being non-vital. The associated permanent incisor and other adjacent incisors were apically and laterally dislocated from their natural site of eruption. The conservative treatment included extraction of the involved primary discolored incisor, as well as the root remnant, followed by removal of the granulation tissue. After 18 months of follow-up, the permanent incisors were erupting in normal position, without pathological signs of the dentigerous cyst. Following severe traumatic injury to a primary tooth, periodic radiographic follow-up, until eruption of the correspondent permanent tooth, is recommended.

Endoscopic management of a rare granulation polyp in a colonic diverticulum

There are many case reports on colon diverticula that cause irritable bowel syndrome, constipation, bleeding, diverticulitis, stricture due to multiple recurrences of diverticulitis, and perforation. However, few articles have examined neoplasms that arise from a diverticulum, such as adenoma and adenocarcinoma, and there have been no reports of granulation polyps that arise from a colon diverticulum after recurrent diverticulitis. We observed a rare granulation polyp that arose from a diverticulum as a result of repeated episodes of local diverticulitis. Narrow band imaging magnified colonoscopy was very useful to diagnose the polyp as a granulation polyp because of the absence of a pit pattern on the surface of the polyp. We successfully resected the polyp using endoscopic mucosal resection. We inverted the diverticulum, and the resected stalk of the polyp was used to close the diverticulum with an over-the-scope clip. If a granulomatous polyp could arise from a diverticulum, differential diagnosis between a colon neoplasm and a granulomatous polyp would not only be difficult but also necessary for suitable endoscopic treatment.

Adjunctive procedures after pediatric single-stage laryngotracheoplasty

OBJECTIVES

We report the frequency and success rates of adjunctive airway procedures after pediatric single-stage laryngotracheoplasty (LTP) and review different adjunctive techniques in a prospectively enrolled and retrospectively reviewed case series.

METHODS

Of 31 LTP procedures performed from 2008 to 2011 at an academic tertiary care children's hospital, 10 were single-stage LTP procedures. These 10 cases were analyzed to determine the number and type, if any, of adjunctive procedures required after LTP, as well as the subglottic response and decannulation rates.

RESULTS

Of the 10 patients with single-stage LTP procedures, 6 patients required a total of 16 postoperative adjunctive airway procedures. The adjunctive procedures included granulation tissue removal with forceps or a carbon dioxide laser, stent placement, mitomycin C application, and triamcinolone acetonide injection. One patient also required tracheotomy placement and, eventually, cricotracheal resection. All 6 patients had significant improvement of subglottic and/ or tracheal stenosis on their most recent endoscopic examination. With a minimum follow-up of 12 months, all 6 patients were decannulated.

CONCLUSIONS

In this series, more than half of our pediatric patients who underwent single-stage LTP required 1 or more postoperative adjunctive procedures, and all had successful outcomes.

[Modified surgical repair of severe ingrown toenail]

OBJECTIVE

To summarize the effectiveness of modified surgical repair for severe ingrown toenail.

METHODS

Between January 2005 and December 2010, 13 patients with severe ingrown toenail (16 toes) were treated. There were 12 males (15 toes) and 1 female (1 toe), aged 18-32 years with an average of 20 years. The disease duration was 1-15 years (mean, 2 years and 9 months). All affected toes were great toes. Ingrown toenail occurred bilaterally in 3 cases and unilaterally in 10 cases. Granulation tissue surrounding nail-edge, embedded toenail, and necrotic nail bed were completely removed; tension glue was used to make wound edge close to nail bed.

RESULTS

At 3-5 days after operation, wound congestion, swelling, and exudation were improved; at 7 days, new nail bed formed; at 2 weeks, all wounds healed, and nail bed was epitheliogenic, wound edge healed well close to nail plate, and patients returned to normal life. At 6 months after nail extraction, new toenail grew and nail groove formed. No recurrent sign was found during 24-month follow-up.

CONCLUSION

Modified surgical repair is one of effective methods to treat severe ingrown toenail with the advantages of good appearance and low recurrent rate.

Segmental phenolization for the treatment of ingrown toenails: technique report, follow up of 146 patients, and review of the literature

BACKGROUND

Ingrown toenail is a common problem causing significant morbidity. Various procedures used for treating this painful condition were discussed in the literature. OBJETCTIVE: Through a prospective study we aimed to evaluate in a long-term follow-up the efficacy of partial nail plate avulsion combined with phenolic chemical matricectomy for the treatment of Ingrown toenails.

METHODS

We recruited outpatient from January 2006 to December 2009; all treated by phenol matricectomy and assured a regular follow up.

RESULTS

Consecutive 146 patients with a total of 171 Ingrown toenails were enrolled. There was no significant morbidity and the procedure was tolerated well by all patients. The short-term results were excellent. No severe complications occurred during the 21-month follow-up period. The overall recurrence was 2.7 %.

CONCLUSION

Phenol cauterization compared with other surgical ablation techniques may be the treatment of choice of Ingrown toenails. It's an effective technique for the treatment of Ingrown toenails accompanied by less morbidity and lower recurrence rates.

Infected periodontal granulation tissue contains cells expressing embryonic stem cell markers. A pilot study

The commonly practiced removal of granulation tissue during periodontal surgery, aiming to eliminate infection and optimize healing conditions, may also remove progenitor stem cells that could otherwise support periodontal regeneration. The present study aimed to investigate if cells with embryonic stem cell properties are present in periodontal granulation tissue. During the course of flap surgery inflammatory granulation tissue was obtained from four patients and five periodontal defects. Tissues were processed in a collagenase/dispase solution to release the cells. Part of the resulting suspension was processed for bacteriological analysis (IAI PadoTest 4.5), whereas the remaining cell suspension was cultured and passaged once. Upon reaching confluence, total RNA was extracted, followed by cDNA synthesis. PCR was then performed (SYBR Green-based protocols) to measure gene expression levels of Collagen type I, and embryonic stem cell markers Nanog, Oct4, Rex-1 and Sox2. Results are expressed as 2⁻Δ(Ct) values of the target gene, calibrated against a house-keeping gene (GAPDH). A high total bacterial load up to 20.6 ± 11.0×10(6) counts/mg of tissue was found. Collagen type I was strongly expressed, confirming the predominance of mesenchymal/fibroblastic cells. Among the studied embryonic stem cells markers, Nanog was most highly expressed (2.3 ± 1.2), followed by Oct4 (1.1 ± 0.5), Rex-1 (0.6 ± 0.2) and Sox2 (0.3 ± 0.2). This is the first study that demonstrates the presence of cells expressing embryonic stem cell markers among infected granulation tissue. This knowledge needs to be considered when devising future strategies to improve periodontal wound healing and regeneration.

Comparison of modified widman and coronally advanced flap surgery combined with Co2 laser root irradiation in periodontal therapy: a 15-year follow-up

The aim of this study was to compare modified Widman flap surgery (MW) to coronally advanced flap surgery combined with carbon dioxide laser root conditioning (CAF + CO2) from baseline to 15 years of follow-up. Each of 25 patients participating in this study were treated using a split-mouth design: In one quadrant, the teeth received MW surgery (control), and on the other side, after a full-thickness flap was raised, a CO2 laser was used and the full-thickness flap was repositioned coronally and sutured (CAF + CO2, test). Plaque Index, Gingival Index, probing depth, and clinical attachment level were monitored from baseline to 15 years. For probing depths ⋝ 7 mm, CAF + CO2 sites provided greater pocket reduction (P < .01), and data on clinical attachment level showed a significant difference between control and test sites at 5 to 6 mm (P < .001) and ⋝ 7 mm (P < .001). This study showed that CAF + CO2 therapy resulted in significantly higher improvements than MW surgery.

595 nm long pulsed dye laser with a hydrocolloid dressing for the treatment of hypergranulation tissue on the scalp in postsurgical defects

The formation of hypergranulation tissue is an aberrant process that interferes with normal wound healing. Excessive granulation tissue results in the persistence of open wounds. It is resistant to currently available treatment modalities. We report a case series of patients with hypergranulation tissue on the scalp who were successfully treated with a 595 nm pulsed dye laser and hydrocolloid dressing.

Surgical anti-infective mechanical therapy for peri-implantitis: a clinical report with a 12-month follow-up

According to previous studies, bacterial infection plays the most important role in the late failures of dental implants. Peri-implantitis has been described as a site-specific infection that causes soft tissue inflammation and bone loss around osseointegrated implants that have performed masticatory functions. To reduce the number of pathogenic species and improve the clinical parameters (that is, probing depth, bleeding on probing, and suppuration) around dental implants, several anti-infective therapies have been developed for peri-implantitis. However, recent reviews have not identified sufficient evidence to support an ideal anti-infective protocol for this disease. This article presents a case of advanced peri-implantitis that was treated with a single surgical anti-infective mechanical therapy. A follow-up visit 12 months post-treatment showed improved clinical features.

Pulsed dye laser for the treatment of hypergranulation tissue with chronic ulcer in postsurgical defects

BACKGROUND AND OBJECTIVE

Hypergranulation tissue may complicate postoperative wounds, causing them to become chronic nonhealing ulcers. There is no reliably effective treatment. We report the use of the 595-nm pulsed-dye laser (PDL) for the treatment of wounds healing by second intention and complicated by hypergranulation tissue after Mohs micrographic surgery.

METHODS

In a retrospective case review, 9 patients with slow-healing or nonhealing postoperative wounds with hypergranulation tissue were treated with the 595-nm PDL. The majority of the wounds were located on the scalp, forehead, and temple.

RESULTS

All of the patients demonstrated dramatic improvement after one treatment. Most patients achieved complete or near complete re-epithelialization of the ulcers after 1 to 2 treatments. The PDL treatment required no local anesthesia, and there were no postlaser treatment complications reported.

CONCLUSIONS

The 595-nm PDL is an effective, safe, and reliable treatment to promote second intention healing in postsurgical wounds complicated by the formation of hypergranulation tissue.

Comparative study of skin grafting with and without surgical removal of granulation tissue in chronic burn wounds

A prospective comparative study of skin grafting of chronic wounds with and without surgical removal of granulation tissue was done on 51 patients with an objective of finding a better method of skin grafting objectively in the chronic burns wounds. Comparative study was done on those patients who had wounds on both the sides of their body. Wounds present on the right side of the body labeled as Group A were skin grafted after removal of granulation tissue and wounds present on left side of the body labeled as Group B were skin grafted without removal of granulation tissue. There was no significant difference in the comparative bacteriology, graft uptake and cosmetic appearance of the grafts. We found no effect of bacteriology and chronicity of the wounds on the uptake of grafts in the two groups. Serum albumin levels <4 g% was found to be associated with statistically significant decreased graft uptake only in Group A wounds. It was further observed that Group A wounds were associated with more blood loss, less secure haemostasis, prolonged surgical duration and thus more cost of surgery as compared to Group B wounds.

Immediate bone augmentation after infected tooth extraction using titanium membranes

Infectious process frequently results in extensive bone resorption and defect, periradicular or periapical lesions, or vertical fracture with infected sinus tract. When tooth extraction is mandated it typically results in additional bone loss in the buccal or lingual cortical plate. Immediate guided bone regeneration (GBR) and implant fixation at an infected site is frequently complicated by soft-tissue dehiscence, membrane exposure, and implant failure. The objective of this research is to assess the feasibility of immediate bone augmentation (IBA) after purulent tooth extraction, employing a dedicated titanium membrane. An intrasulcular incision was made around the tooth to be extracted and extended to 2 adjacent teeth while maintaining the papillae. Vertical releasing incisions were made to mobilize the mucoperiosteal flap. Cautious tooth extraction was executed utilizing conventional measures and was followed by meticulous curettage of the infected and granulated tissue in the socket. Titanium membranes were applied to the socket walls followed by socket filling with autologous platelet-rich fibrin and primary closure. Eight or more weeks later membrane removal and implant placement were performed. Of the 15 patients who underwent this procedure, 7 patients (47%) had early membrane exposure (between weeks 2 and 6), which was treated conservatively. No infection or early membrane removal was reported. All patients achieved sufficient bone augmentation, and 8 patients received implants without any additional GBR. IBA after infected tooth extraction, using titanium membrane application was feasible and safe and yielded adequate bone filling to support implant fixation at > or =8 weeks. Further studies need to evaluate if the titanium membrane helped in any way to inhibit plaque accumulation or resist infection in cases of early membrane exposure.

[Experience with laryngotracheal reconstruction in subglottic stenosis in a 30 years time period]

BACKGROUND

Severe subglottic stenosis is a difficult condition to manage. It can be treated by laryngotracheal reconstruction or cricotracheal resection.

PATIENTS AND METHODS

In this retrospective study the experiences for treatment of isolated subglottic stenosis in 37 patients (age: 3-78 years; stenosis grading: 20 x grade II, 13 x grade III, and 4 x grade IV) by laryngotracheal reconstruction in a 30-years experience are presented.

RESULTS

In 33 out of 37 patients (89.2 %) a sufficient subglottic patency (postoperative endoscopic finding: stenosis less than 30 %) was achieved by laryngotracheal reconstruction. However, 5 patients of this series had required revision of laryngotracheal recontruction and in 22 patients endoscopic removal of granulation tissue had been performed. Sufficient widening of the subglottic space had been possible in all grade II stenosis (20/20), in 11 out of 13 patients with grade III stenosis, and in 3 out of 4 patients with grade IV stenosis. In one child an accidental decannulation occurred and due to asphyxia an apallic syndrome developed.

CONCLUSIONS

Even through laryngotracheal reconstruction is a demanding surgical technique requiring great experience it is an effective option for treatment of subglottic stenosis less than 90 %. For severe subglottic stenosis (> 90 %) treatment by laryngotracheal reconstruction is possible and should be considered if mobilisation of the trachea by scar tissue is suited to be worse or to extended cricotracheal stenosis is present, both being not good candidates for cricotracheal resection.

Er:YAG laser therapy for peri-implant infection: a histological study

The purpose of this study was to evaluate the effects of Er:YAG laser on degranulation and implant surface debridement in peri-implant infection. The peri-implant infection was experimentally induced in dogs, and the treatment was performed using an Er:YAG laser or a plastic curet. Animals were sacrificed after 24 weeks, and undecalcified histological sections were prepared and analyzed. Degranulation and implant surface debridement were obtained effectively and safely by Er:YAG laser. Histologically, a favorable formation of new bone was observed on the laser-treated implant surface, and the laser group showed a tendency to produce greater bone-to-implant contact than the curet group. These results indicate that the Er:YAG laser therapy has promise in the treatment of peri-implantitis.

A simple, pain-free treatment for ingrown toenails complicated with granulation tissue

BACKGROUND

The treatment of ingrown toenail complicated with granulation tissue is usually partial or total nail avulsion with or without matricectomy. It costs loss of occupational power, however, because most patients cannot go to work or school for some time after surgery, and it is a costly and uncomfortable procedure for most patients.

OBJECTIVE

This study aimed to find an easy, painless, and inexpensive alternative.

MATERIALS AND METHODS

Seven patients with ingrown toenails complicated with granulation tissue are included. A small apparatus was applied on the nails, granulation tissue was chemically cauterized, and a foot bath was recommended twice daily. They were followed on a weekly basis or every other week until recovery. None of the patients received systemic treatment.

RESULTS

All seven patients were completely cured without requiring surgery and/or systemic treatment. The procedure did not have any effect on their daily life. The follow-up examination of the patients at 6 months revealed that they were totally cured, and there were no recurrences.

CONCLUSION

Patients with ingrown toenails complicated by granulation tissue might have an inexpensive and pain-free treatment alternative, although new studies with more patients are required.

Two cases of spinal epidural abscess with granulation tissue associated with epidural catheterization

Two cases of spinal epidural abscess are reported whose abscesses became granulated after epidural catheterization. Although emergency surgical intervention was performed almost within 24 h after the diagnosis of epidural abscess in case 1, the patient revealed a poor outcome. After laminoplasty, case 2 received lumbar epidural catheterization, and he had a complete recovery. The abscesses were recognized to spread around the catheter insertion site of the operative procedure in both cases, and MRI in case 2 showed the connection between the epidural abscess and the interspinous space where the catheter had been inserted. Methicillin-sensitive Staphylococcus aureus (MSSA) was identified at the operative field in both cases. Also, MSSA was identified at the subcutaneous abscess around the catheter in case 1 and at the catheter tip in case 2. Those findings suggest the midpoint of the abscess is the puncture site and that MSSA is found in or around the catheter. Infection at epidural catheterization seems to be caused by catheter insertion or skin contamination after catheterization. As those catheterizations were completed in the outpatient theater, we conclude that epidural catheterization should be performed in the operating room or with a restricted aseptic technique.

Clinical Application of Microskin Grafting to Repair Granulation or Decrustation Wounds

One hundred seven granulating or decrustation wounds in 58 patients were grafted with microskin grafts of different sizes. The modified procedure has been used successfully for different wound sites, such as limb, chest, abdomen, and the back, with satisfactory results. Signs of epithelialization were shown within 5 to 22 days in 40 patients. The wound healing rate was 94.4%, including 71.9% total healing rate and 22.4% improved healing rate. We think that this method could be applied to either granulation or decrustation wounds in addition to excision wounds.

Expandable tracheal stenting for benign disease: worth the complications?

OBJECTIVES

To characterize the limitations of self-expandable stents in the management of benign tracheal stenosis, we performed a retrospective review at a tertiary care medical center.

METHODS

Patients who underwent tracheal stenting were assessed for the cause and severity of tracheal stenosis, comorbidities, stent-related complications, and follow-up airway procedures.

RESULTS

Sixteen adults (12 women, 4 men; mean age, 47 years) had a total of 26 stents placed for benign disease. Intubation-related stenoses were most frequent (81%). The average follow-up time was 20 months (range, 1 to 40 months). Each stent remained functional for an average of 12.4 months. In the study group, 87% had a complication that required surgical intervention to maintain a patent airway. The most common problem was granulation tissue formation at the ends of the stent causing airway restenosis (81%), and 5 patients (31%) required tracheotomy as a result of restenosis around the stent. Fourteen of the stents (56%) were removed or expelled from the patients.

CONCLUSIONS

The implantation of self-expandable stents is a minimally invasive method of managing benign tracheal stenosis. Although a small subset of patients may benefit from placement, the majority of patients have complications that require intervention to maintain a patent airway. Thoughtful discretion is critical in selecting patients for this intervention.

Periodontal tissue healing following flap surgery using an Er:YAG laser in dogs

BACKGROUND AND OBJECTIVES

The purpose of this study was to compare periodontal tissue healing following flap surgery using an Er:YAG laser with that of conventional surgery.

STUDY DESIGN/MATERIALS AND METHODS

Bilateral premolars with experimentally induced periodontitis in six dogs were treated by periodontal flap surgery. Degranulation and root debridement in the furcation were performed using an Er:YAG laser or curet. At 3 months postsurgery, animals were sacrificed and decalcified specimens were prepared for histological and histometric analysis.

RESULTS

Degranulation and root debridement were effectively performed with an Er:YAG laser without major thermal damage and significantly faster than with a curet. Histologically, the amount of newly formed bone was significantly greater in the laser group than in the curet group, although both groups showed similar amounts of cementum formation and connective tissue attachment.

CONCLUSIONS

The Er:YAG laser irradiation can be safely and effectively utilized in periodontal flap surgery, and has the potential to promote new bone formation.

Follow up of patients with ocular scarring secondary to LOC syndrome treated by amniotic membrane transplantation

AIMS

To document and discuss the long term outcome of a new ophthalmic treatment for laryngo-onycho-cutaneous (LOC) syndrome.

METHODS

Two children were treated by excision of ocular granulation tissue and ocular surface rehabilitation with frozen amniotic membrane (AM). The clinical course of both patients was followed and documented at 2 years and 4 years following the surgery.

RESULTS

Patient 1 demonstrated limited recurrence of granulation tissue at 10 months. After 36 months, re-growth of granulation and scar tissue required a further three subsequent operations to the right eye in an attempt to keep the optical axis clear. 4 years postoperatively, neither eye has a clear visual axis. In contrast similar surgery for the right eye of patient 2 has been highly successful, with only very limited non-progressive recurrence after 2 years of follow up. The operation to the left eye has been similarly effective although the follow up is only 6 months.

CONCLUSIONS

Ocular surface rehabilitation with AM is the first partially effective treatment for the eye complications of LOC syndrome. The surprising benefit from AM may stem from the primary pathology of the condition. LOC syndrome is caused by a genetic defect resulting in an unusual N-terminal deletion of the alpha3a chain of the basement membrane protein laminin 5. One mechanism through which AM transplantation may act to reduce ocular scarring in this disease is to supplement the abnormal secreted laminin 5 with healthy transplanted laminin. Despite its initial efficacy one episode of AM treatment does not guarantee long term control of the scarring process and variations in AM graft efficacy may be related to other complicating factors such as limbal stem cell deficiency or severity of the initial scarring process.

Pseudosarcomatous fibrovascular proliferative tissue masquerading as a primary subglottic angiosarcoma

A unique case of pseudosarcomatous fibrovascular proliferative tissue causing biphasic stridor and simulating a primary subglottic angiosarcoma is reported. The patient presented with a wheeze and was diagnosed initially with asthma. He subsequently developed worsening biphasic stridor. Flexible nasendoscopy revealed a subglottic mass obstructing the airway. The mass was removed with a carbon dioxide laser and the patient's condition improved dramatically. The specimen was difficult to interpret histologically and was thought at first to be a novel case of a primary subglottic angiosarcoma. However, the slides were reviewed by expert soft tissue pathologists in the UK and USA, and a final diagnosis of a pseudosarcomatous fibrovascular proliferative lesion was made. This case highlights the important principle of seeking additional opinions before making a malignant diagnosis in an atypical site. Our report also emphasizes the importance of good clinico-pathological liaison, especially in difficult cases.

Spinal epidural abscess: prognostic factors and comparison of different surgical treatment strategies

BACKGROUND

Spinal epidural abscess (SEA) is a rare but potentially devastating disease requiring immediate surgical intervention and appropriate antibiotic treatment. The standard approach to decompress SEA is laminectomy. No report covers comprehensively the indications for the less invasive interlaminar approach, the usefulness of intra-operative ultrasonography and the suspected benefit of inserting a suction-irrigation drainage.

METHOD

A retrospective evaluation of the medical and radiological data was undertaken in 27 consecutive patients with SEA operated on during a period of 10 years by a dorsal approach. Factors influencing outcome were evaluated with special regard to different surgical strategies concerning the invasiveness of the operative approach, the use of intra-operative ultrasound and the use of different drainage systems.

FINDINGS

Outcome was mainly determined by the pre-operative neurological condition and the localization of the abscess. Recurrence rate was dependent on the longitudinal extent of the mass and the intra-operative finding of granulation tissue, but not on the administration of a postoperative suction-irrigation drainage. An interlaminar approach was equally matched to a decompression by laminectomy in lumbar SEA concerning the incidence of residual/recurrent abscess formation. In concomitant spondylodiscitis, laminectomy bore the risk of the formation of a postoperative kyphotic deformity. The use of intra-operative ultrasound allowed the visualization of hidden inflammatory masses and, thus, reduced the rate of residual abscess formation.

CONCLUSION

An interlaminar approach should be considered instead of laminectomy in lumbar SEA and in impending anterior column instability due to spondylitis. Intra-operative ultrasound is a beneficial aid for the determination of the extent of decompression during surgery and is practicable even through a narrow interlaminar bony window. The insertion of postoperative suction-irrigation drainage had no beneficial effect on outcome but bore the risk of epidural fluid congestion.

[Experimental-clinical grounds for the treatment of granulating soft tissue wounds by the wound edge approximating stapler]

Factors of risk of the appearance of wound complications were studied in experiment on a model of granulating wounds in 18 mongrel dogs. A traditional method (control group) and an apparatus method (main group) were used for suturing the wounds. In the main group of animals suturing the wounds was performed after bringing together the wound edges by specially designed devices. Morphological and microbiological investigations have shown that the leading role in the appearance of complications belongs to the morphological substrate of the wound with the main component including the degree of traumatizing the paravulnerable tissue with a suture thread when connecting the wound edges by a traditional method, ischemia of the paravulnerable tissues under conditions of microbial dissemination. The introduction of the developed method of closing the soft tissue granulating wounds into clinical practice resulted in a statistically significant reduction of pyo-inflammatory complications in the main group of patients. A conclusion is made on a more favorable course of the wound process when using the apparatus method of closing the wounds.

[Effect of autoskin grafting in fault hypodermis wound of granulation excision on full-thickness burn healing]

OBJECTIVE

To explore the mechanism of full-thickness burn wound healing with autoskin grafting in fault hypodermis wound of granulation excision and to evaluate its effect.

METHODS

By the techniques of clinical observation, histopathology, immunohistochemistry, TEM and FCM, we observed changes of the activity and structure of grafted skin and the granulation tissue, collagnous fiber,microvessels,the ultramicrostructure of fibroblasts and the expression of basic fibroblast growth factor (bFGF) in the base of autoskin grafting in fault hypodermis wound in burned adult minipigs (Group A), and compared with traditional method of autoskin grafting on the basilar fibrous tissue wound of scraped partly granulation being (Group B) and control group (Group C, without treatment except de-fur).

RESULTS

The grafted skin survived after 3 days of operation, and it had less injury and higher proliferative index (PI) in group A than in group B. The hyperplasia of granulation tissue and vascular endothelial and the expression of bFGF were more evident in group A. After 5 days, the proliferation of endothelial cells and granulation and the protein synthesis of fibroblasts were more active in group A, and at this moment, fresh collagen appeared and proliferated more actively in group B. After 7-14 days, epidermic structure and dermic microvascular density became normal gradually, the granulation on grafting base matured and transformed into fibrous connective tissue in group A. The same change deferred about 2 days in group B. After 21 days, the above pathologic change in group A was less than that in group B. After 30-60 days of operation, Group A achieved much less contraction and transfiguration than Group B, and the grafted skin was tender and movable.

CONCLUSION

Autoskin grafting in fault hypodermis wound of granulation excision has a better effect than traditional operation.

Cap polyposis: further experience and review

PURPOSE

Cap polyposis is characterized by the presence of inflammatory polyps with a "cap" of granulation tissue. It may represent one end of a spectrum of conditions caused by chronic straining. This experience represents the second largest reported series of cap polyposis.

METHODS

The case notes of all patients with histologically proven cap polyposis were reviewed retrospectively and clinicopathologic features identified. A MEDLINE search was performed from 1985 to 2002 using cap polyps, polyposis, and inflammatory polyp as key words and further hand search was undertaken of key references.

RESULTS

Eleven cases (9 males; median age, 20 (range, 15-54 years) of cap polyposis were diagnosed between 1993 and 2002. The commonest presenting symptoms were rectal bleeding (82 percent) and mucous diarrhea (46 percent). Chronic straining at stool and constipation were noted in seven of these patients (64 percent). Digital rectal examinations revealed polypoidal masses in the rectum in four patients (36 percent). All patients underwent colonoscopy. The commonest site of involvement was in the lower rectum (82 percent). One patient had polyps in the sigmoid colon and one patient in the transverse colon. Of 11 patients, 2 defaulted follow-up after colonoscopy. Three patients with solitary polyps had complete resolution of symptoms after polypectomy and remained symptom-free at three-month follow-up. The remaining six patients had persistent symptoms and required surgical intervention. Four underwent anterior resection and were all symptom-free at median of 48 (range, 18-72) months after surgery. One patient had transanal excision of rectal polyps and had recurrence at three months after surgery. This patient refused further treatment and remains symptomatic to date. One patient presented with recurrence of polyps at the coloanal anastomosis soon after a pull-through procedure. Total colectomy and ileal pouch-anal anastomosis was performed and the patient was free of symptoms at four months after surgery.

CONCLUSIONS

Cap polyposis is eminently treatable with good long-term prognosis and function. Patients with solitary cap polyp respond well to endoscopic polypectomy. However, patients with multiple polyps and concurrent anorectal pathology require surgical resection.

Extraction site bone grafting in general dentistry. Review of applications and principles

The clinician can successfully graft dental extraction sites to improve the aesthetics and function of the final restoration. When an extraction site receives a graft, ridge preservation is enhanced, pontic form can improve, dental implants can be placed in the correct position, and the prosthetic outcome will be enhanced.

The formation and management of middle ear granulation tissue in chronic ear disease

Granulation tissue is an important pathogenic feature of all types of chronic ear disease, and it can be controlled and treated with good aural toilet, appropriate antibiotic therapy, topical steroids, and chemical cautery or surgical debridement.

Deroofing Surgical Treatment for Pseudocyst of the Auricle

OBJECTIVES

Pseudocyst of the auricle is characterized by asymptomatic swelling caused by an intracartilaginous accumulation of fluid. If left untreated, permanent deformity of the pinna may occur. Many modalities of treatment have been reported, but problems regarding recurrence and appearance remain. The purpose of this study was to introduce more reliable treatment for pseudocyst of the auricle.

DESIGN

Retrospective chart review.

SETTING

Department of Otolaryngology, Kaohsiung Medical University, Kaohsiung, Taiwan.

METHODS

The population used for the present report consisted of 10 patients with auricular pseudocyst that was unresponsive to aspiration followed by intralesional steroid injection or who declined conservative treatment. All patients were treated surgically with the deroofing method under local anaesthesia.

MAIN OUTCOME MEASURES

Postoperative clinical outcome and recurrence of the lesion.

RESULTS

All patients had excellent cosmetic outcomes, and no recurrence or complication occurred.

CONCLUSIONS

Deroofing surgery for pseudocyst of the auricle is a safe, easy, and reliable procedure. If conservative measures fail or are declined by the patient, removal of the anterior cartilaginous leaflet of the lesion is an alternative method that can yield excellent results.

Vertical alveolar distraction osteogenesis with complications in a reconstructed mandible

We report here a case of vertical alveolar distraction osteogenesis with many complications that required further surgical interventions. A 54-year-old man underwent mandibular resection followed by iliac bone grafting as the result of large mandibular odontogenic keratocyst. Eleven months later, alveolar vertical distraction osteogenesis was applied to the patient for prosthetic rehabilitation. Fracture of the basal bone occurred in the consolidation period, and the fracture was fixed by the titanium miniplate system. Radiographic examination after completion of distraction osteogenesis confirmed a radiolucent area in half of the distracted area between the basal bone and the transport segment, and when the distractor was removed the radiolucent area was filled with fibrous granulation tissue. The granulation tissue was removed and endosteal implants were inserted together with a bone graft. Ultimately, all implants were osseointegrated, and adequate esthetics and function of the implant-supported prosthesis were achieved.

Squamous cell carcinoma in recessive dystrophic epidermolysis bullosa, presenting as an ulcer that appears to be filled with granulation tissue

BACKGROUND

Cutaneous squamous cell carcinoma (SCCA) is an important cause of death in patients with the severe form of recessive dystrophic epidermolysis bullosa (RDEB). These cancers often present with features that are different from those of actinically induced SCCA.

OBJECTIVE

To emphasize the unusual features with which SCCA can present in RDEB and discuss early recognition of such cancers.

METHODS

We present the case of a patient with RDEB who developed a cutaneous ulcer that appeared to be filled with heaped-up granulation tissue. Biopsy, however, showed moderately differentiated squamous cell carcinoma.

RESULTS

The patient underwent wide surgical excision of the cancer, with split-thickness skin graft. She has remained disease-free three years later.

CONCLUSION

In patients with RDEB, any ulcer that appears to be filled with heaped-up granulation tissue should be biopsied to rule out SCCA.

Effects of topical application of antimicrobials and bandaging on healing and granulation tissue formation in wounds of the distal aspect of the limbs in horses

OBJECTIVE

To determine whether povidone iodine ointment or 2 forms of silver sulfadiazine applied topically to wounds of the distal aspect of the limbs in horses affect the rate of second intention healing and to evaluate the additional influence of bandaging with these antimicrobials on granulation tissue formation.

ANIMALS

6 healthy adult horses.

PROCEDURE

Six standardized 2.5-cm2 skin wounds/horse were distributed between the dorsomedial surfaces of the metacarpi and metatarsi. One of the following 6 treatments was applied to each wound: 1% silver sulfadiazine cream with bandage, 1% silver sulfadiazine slow-release matrix with bandage, 1% silver sulfadiazine slow-release matrix without bandage, povidone-iodine ointment with bandage, untreated control with bandage, and untreated control without bandage. Wound area, granulation tissue area, and perimeter were measured by use of planimetry software applied to digital images. Exuberant granulation tissue was excised when present. Days until healing, rate of healing parameter, rate of contraction, and epithelialization were compared among wound treatment groups.

RESULTS

Healing parameters and mean days to healing did not differ significantly among any of the wound treatment groups. Percentage wound contraction and rate of epithelialization were similar among wound treatments. All bandaged wounds produced exuberant granulation tissue, which was surgically excised; none of the unbandaged wounds produced exuberant granulation tissue.

CONCLUSIONS AND CLINICAL RELEVANCE

When exuberant granulation tissue is removed, rates of epithelialization and wound contraction were not different among wound treatment groups, whether bandaged or unbandaged. Topical application of 1% silver sulfadiazine slow-release matrix on unbandaged wounds induced the same result as medications applied beneath bandages, but without exuberant granulation tissue formation.

KTP laser treatment of suprastomal obstruction prior to decannulation in paediatric tracheostomy

OBJECTIVE

Decannulation following tracheostomy in the paediatric patient is often complicated by the development of secondary suprastomal obstruction. We describe the technique of bronchoscopic KTP laser therapy in the management of such conditions, and have audited the results of this treatment with 12 children treated with this modality before attempted decannulation over the last 2 years at Great Ormond Street Hospital for Children (GOSH).

METHOD

Via a retrospective record review.

RESULTS

Eight (67%) were successfully decannulated, with four being unsuccessful. All children with less than 50% suprastomal obstruction were successfully decannulated following bronchoscopic KTP laser treatment.

CONCLUSIONS

Bronchoscopic KTP laser therapy is a useful tool in the abolition of suprastomal obstruction prior to decannulation following paediatric tracheostomy. Children with greater than 50% obstruction are likely to require an open procedure.

Titanium deposition after peri-implant care with the carbon dioxide laser

PURPOSE

Titanium endosseous implants are becoming increasingly important in dentistry because of their excellent long-term results. However, it has been reported that these implants may lead to higher concentrations of titanium, especially in the lungs and kidneys. The purpose of this study, therefore, was to determine whether CO2 laser-assisted decontamination of exposed implant surfaces is associated with an increase in titanium release.

MATERIALS AND METHODS

In 6 beagle dogs, a total of 60 implants were placed. After osseointegration and second-stage surgery, peri-implantitis was induced by cotton floss ligatures for 12 weeks. Surgical treatment consisted of granulation tissue removal, including decontamination of the implant surface with 3 different methods. Twenty implants were decontaminated conventionally by an air-powder abrasive for 60 seconds. Another 20 implants were decontaminated by laser treatment alone. The last 20 implants were treated conventionally by air-powder abrasive and then lased. Four months later, fresh tissue samples of various tissues were evaluated by histologic and chemical analysis.

RESULTS

Quantitative analysis indicated that titanium accumulation could be detected, especially in the spleen, liver, oral mucosa, regional lymph nodes, lung, and kidney in the beagle dog model.

DISCUSSION

The concentrations found did not exceed those previously reported in the literature.

CONCLUSION

These results support the hypothesis that CO2 laser-assisted therapy of ailing implants will not result in excessive titanium concentrations in tissues. Accordingly, CO2 lasers appear suitable and safe for peri-implant gingival surgery.

Use of a neodymium:yttrium-aluminum-garnet laser to remove exuberant granulation tissue from the esophagus of a horse

Use of a neodymium:yttrium-aluminum-garnet laser to remove exuberant granulation tissue from the esophagus of a horse A 4-year-old Quarter Horse mare was evaluated because of recurrent esophageal obstruction. Endoscopic examination revealed a proliferative mass in the esophagus approximately 55 cm aborad to the nares. Histologic examination of biopsy specimens revealed diffuse suppurative esophagitis and granulation tissue with no evidence of neoplasia. The mass was excisedand ablated transendoscopically with a neodymium:yttrium-aluminum-garnet laser. During a follow-up examination 2 weeks after the final laser procedure, the mass was no longer apparent, and the esophagus appeared healed. Six months after the final examination, there had been no recurrence of the mass. In this horse, transendoscopic laser excision was efficacious and avoided problems associated with an esophagotomy.

Enamel matrix proteins in the treatment of deep intrabony defects

BACKGROUND

The present study evaluated the healing of enamel matrix derivative (EMD) proteins in the treatment of periodontal lesions with deep intrabony defects.

METHODS

Ten deep intrabony defects in 7 periodontal patients were treated and followed for 1 year. The sites had a probing depth (PD) > or = 8 mm; clinical attachment level (CAL) > or = 9 mm, and intrabony component depth > or = 5 mm. All subjects received therapy prior to surgery and had a plaque score (PI) < or = 10%. Full thickness flaps were elevated buccally and lingually, granulation tissue was removed from the defects, and the root surfaces were planed. A 24% EDTA gel was applied followed by the enamel matrix protein preparation. The flaps were closed with interrupted sutures. The patients rinsed with a chlorhexidine solution twice a day for 6 weeks. They were recalled every 2 weeks for 6 months for professional tooth cleaning and then every 4 weeks for an additional 6 months. The experimental sites were re-examined 6 and 12 months after regenerative surgery.

RESULTS

At the 1-year examination, the mean CAL gain was 6.5 mm, the mean PD was 3.2 mm, and mean radiographic bone fill was 4.7 mm.

CONCLUSIONS

The application of enamel matrix proteins in combination with open flap curettage and root planing resulted in a gain of CAL and bone fill in deep intrabony defects.