The authors' recommendations for minimizing fistulas and stricture rate, following free jejunal reconstruction, include the gastrointestinal stapler for bowel anastomosis whenever possible, and the use of a prophylactic pedicled pectoralis major muscle flap for patients exposed to previous radiotherapy.
Non-echoplanar diffusion weighted magnetic resonance imaging (DWI) has established itself as the modality of choice in detecting and localising post-operative middle ear cleft cholesteatoma. Despite its good diagnostic performance, there are recognised pitfalls in its radiological interpretation which both the radiologist and otologist should be aware of. Our article highlights the various pitfalls and provides guidance for improving radiological interpretation and navigating beyond many of the pitfalls. It is recommended radiological practice to interpret the diffusion weighted images together with the ADC map and supplement with the corresponding T1 weighted and T2 weighted images, all of which can contribute to and enhance lesion localisation and characterisation. ADC values are also helpful in improving specificity and confidence levels. Given the limitation in sensitivity in detecting small cholesteatoma less than 3 mm, serial monitoring with DWI over time is recommended to allow any small residual cholesteatoma pearls to grow and become large enough to be detected on DWI. Optimising image acquisition and discussing at a joint clinico-radiological meeting both foster good radiological interpretation to navigate beyond the pitfalls and ultimately good patient care.Teaching Points• Non-echoplanar DWI is the imaging of choice in detecting post-operative cholesteatoma.• There are recognised pitfalls which may hinder accurate radiological interpretation.• Interpret with the ADC map /values and T1W and T2W images.• Serial DWI monitoring is of value in detection and characterisation.• Optimising image acquisition and discussing at clinico-radiological meetings enhance radiological interpretation.
The role of the cytokine leukemia inhibitory factor (LIF) in axotomy‐induced sprouting of postganglionic sympathetic fibres into the dorsal root ganglia was examined in the adult rat.
Immunocytochemistry was used to study the distribution and density of tyrosine hydroxylase‐immunoreactive (TH‐IR) fibres within the lumbar dorsal root ganglia and lumbar spinal nerves 14 days following continuous intrathecal infusion of LIF (0.33 mg ml−1), or 14 days following unilateral peripheral nerve axotomy.
In LIF‐treated animals, numerous pericellular TH‐IR basket‐like structures were observed surrounding sensory neurones, which were absent from controls.
The number of TH‐IR fibres within the L3, L4 and L5 spinal nerves was significantly higher in LIF‐treated animals than in control or saline‐treated animals (P < 0.01, Student's t test).
Unilateral ligation of the L4 spinal nerve or unilateral sciatic nerve ligation was also associated with the formation of TH‐IR baskets around sensory neurones and a significant increase in the number of TH‐IR fibres within the lumbar spinal nerves (P < 0.01, Student's t test).
The percentage of neurones surrounded by TH‐IR baskets within the L3 and L4 dorsal root ganglia following sciatic axotomy was significantly reduced in animals treated continuously for 2 weeks with a monoclonal antibody against the LIF receptor motif, gp130 (0.833 mg ml−1) (P < 0.05, Mann‐Whitney U test). Antibody treatment did not reduce the axotomy‐induced increase in TH‐IR fibres within lumbar spinal nerves.
These results demonstrate that exogenous application of the axotomy‐associated cytokine LIF is associated with sprouting of uninjured postganglionic sympathetic neurones around sensory neurones within the dorsal root ganglion. It is likely that increased LIF expression following peripheral axotomy plays an important role in the novel sympathetic sprouting observed within sensory ganglia following peripheral nerve injury.
Iatrogenic injury to the spinal accessory nerve (SAN) during neck dissection may result in significant and avoidable morbidity in the form of 'shoulder syndrome'. The authors describe a simple method, based on the anatomy of the sternocleidomastoid muscle (SCM), which allows consistent and rapid identification of the SAN in the upper neck during dissection, thereby facilitating its preservation.
The aetiology of unilateral paralysis of the hemilarynx must be fully investigated, as the innervating system has a protracted course, particularly on the left side. Degenerative cervical spine disease, although rare, should be considered as part of the differential diagnosis.
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