Purpose To determine the success rate of initial probing in children with congenital nasolacrimal duct obstruction (CNLDO) at different ages using nasal endoscopy, and to identify the anatomical sites of blockage within the drainage system. Methods A total of 87 eyes from 67 consecutive children with CNLDO underwent endoscopic nasolacrimal duct (NLD) probing under general anaesthetic. Patients who had had previous probings were excluded from the study. Diagnosis was based on history of epiphora since birth or shortly after, and fluorescein dye disappearance test (FDDT). Cure was judged as complete or near-complete remission of symptoms and signs and a normal FDDT. Results The age range was 12-91 months (mean 32.3 months). The success rates of probing were: 100% (58/58) for atresia and stenosis at the lower NLD, 100% (13/13) for punctal stenosis, 55.6% (5/9) for functional epiphora, and 0% (0/7) for canalicular and upper NLD obstruction. Age was not found to significantly affect the outcome of probing, whereas site did. Obstruction at canalicular or upper NLD level became more common with increasing age. Conclusion Probing of the nasolacrimal system using the endoscopic approach allows direct visualisation of the distal nasolacrimal duct, which facilitates diagnosis of the anomaly at this site. More complex proximal anomalies became increasingly prevalent in older children, which accounted for the poorer results with increasing age. Site of obstruction has a greater bearing on outcome than patient age.
Objective: To examine the relationship between the use of restraining devices and the incidence of specific facial fractures in motor vehicle crashes.Design: Retrospective analysis of patients with facial fractures following a motor vehicle crash.Setting: University of Alabama at Birmingham Hospital level I trauma center from 1996 to 2000. Patients:Of 3731 patients involved in motor vehicle crashes, a total of 497 patients were found to have facial fractures as determined by International Classification of Diseases, Ninth Revision (ICD-9) codes. Facial fractures were categorized as mandibular, orbital, zygomaticomaxillary complex (ZMC), and nasal.Results: Use of seat belts alone was more effective in decreasing the chance of facial fractures in this population (from 17% to 8%) compared with the use of air bags alone (17% to 11%). The use of seat belts and air bags together decreased the incidence of facial fractures from 17% to 5%.Conclusions: Use of restraining devices in vehicles significantly reduces the chance of incurring facial fractures in a severe motor vehicle crash. However, use of air bags and seat belts does not change the pattern of facial fractures greatly except for ZMC fractures. Air bags are least effective in preventing ZMC fractures. Improving the mechanics of restraining devices might be needed to minimize facial fractures.
Obliteration of the sphenoid sinus using fat is often used after transsphenoidal hypophysectomy. The morbidity of this approach includes donor site complications, fat necrosis, and delayed mucocele formation. As obliteration with fat is intended to prevent cerebrospinal fluid (CSF) leakage, an alternative for this technique would be techniques used for CSF rhinorrhea repair. Instead of sinus obliteration, these defects are repaired with fascial autografts, which are unfortunately associated with donor site complications. To avoid sinus obliteration and donor site complications, we have reconstructed the sella with acellular dermal allograft in lieu of sinus obliteration. Transsphenoidal hypophysectomy was performed under combined microscopic and endoscopic visualization. For closure, the sellar anterior wall was reconstructed with acellular dermal allograft, septal cartilage/bone autograft, and fibrin glue. The sinus mucosa was then draped over the reconstruction and held in place with microfibrillar collagen hemostat slurry. The sphenoid sinus was not obliterated. Postoperatively, all patients underwent serial nasal endoscopy. Thirteen patients underwent the procedure as described for removal of pituitary adenoma. Postoperative discomfort and pain were minimal. Intraoperative CSF leaks were identified in five patients; none of these patients experienced a postoperative CSF leak. The microfibrillar collagen hemostat was cleared by sphenoid mucociliary clearance. One patient developed acute sphenoid sinusitis several weeks after surgery; this patient did not develop meningitis. One postoperative CSF leak occurred in an obese patient, in whom an intraoperative CSF leak was not identified; this leak resolved with bedrest and delayed lumbar drainage alone. Sellar reconstruction with acellular dermal allograft may eliminate the need for sphenoid sinus obliteration after transsphenoidal hypophysectomy. Acellular dermal allograft sellar reconstruction ultimately provides for an aerated, functioning sphenoid sinus without increased CSF leak risk or potential donor site morbidity.
Hair relaxer, a commercially available alkaline product, is commonly the offending agent in caustic ingestion. These patients often experience oral cavity and facial burns; however, no clinically significant esophageal injuries have been reported. Therefore, we questioned the therapeutic and economic efficacy of the "standard treatment protocol" that includes hospitalization and endoscopic evaluation. Twenty-six patients over a 7-year period presented to our institution having ingested hair relaxer. Presenting signs and symptoms, esophageal findings, and cost of the standard treatment protocol were reviewed. Also, we analyzed the caustic potential and current packaging of hair relaxer. Our findings support modifications in the standard treatment protocol for hair relaxer ingestion including elimination of hospitalization and endoscopy in most patients. We also question compliance with childproof packaging laws and suggest avenues for prevention of hair relaxer ingestion.
The objective of this study was to create a standardized regimen for preoperative and postoperative analgesic prescribing patterns in rhinoplasty. A prospective study including patients (n = 35) undergoing rhinoplasty by a single surgeon at a tertiary hospital was conducted. Patients were enrolled in this study from August 2018 to November 2019. Patients then completed a diary documenting pain scores and analgesic use for 14 days postoperatively. Patient demographics, complications, rhinoplasty technique performed, and medical history were noted. At the second postoperative clinic visit, the diaries were submitted and pill counts were conducted to ensure accuracy. A total of 23 patients completed this study. The average age of the cohort was 39.07 ± 15.01 years, and 48% were females. The mean number of opioids consumed was 6.15 ± 4.85 pills (range: 0–18). Females consumed an average of 7.2 ± 5.2 pills and males consumed 4.5 ± 3.96 pills. The mean number of acetaminophen and ibuprofen tablets consumed were 7.48 ± 8.52 pills (range: 0–36) and 10.83 ± 10.99 pills (range 0–39), respectively. No postoperative nosebleeds were reported. Males had significantly higher pain scores than females on postoperative days 1 to 8. The mean pain score for postoperative days 8 to 14 was less than 1. Linear regression analysis showed that there was no association between the rhinoplasty technique used and the number of opioids consumed. Rhinoplasty is typically associated with mild pain even when osteotomies are included with the procedure. Our results suggest that surgeons can limit rhinoplasty opioid prescriptions to around seven pills and achieve sufficient pain control in most patients. Preoperative counseling suggesting a low postoperative pain level and the encouragement of nonsteroidal anti-inflammatory drug use will help reduce the risk and misuse of opioid prescriptions.
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