Surgical treatment for heart myxomas.

According to unselected autopsy data, primary cardiac tumours are a rare entity. About 80% of the tumours are benign and nearly half of these are myxomas. In clinical practice, when diagnosis of this pathological entity is ascertained, decision for surgical treatment is made in order to prevent thromboembolism and obstruction of the valvular apparatus. Surgical resection including total tumour removal is accompanied by low perioperative mortality. The recidive rate is low in sporadic cases. However, in familial syndrome groups, such as the Swiss-Carney syndrome, the recurrence rate is higher.

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Long recognized as the standard general reference in the field, this completely revised edition of Grainger and Allison's Diagnostic Radiology provides all the information that a trainee needs to master to successfully take their professional certification examinations as well as providing the practicing radiologist with a refresher on topics that may have been forgotten. Organized along an organ and systems basis, this resource covers all diagnostic imaging modalities in an integrated, correlative fashion and focuses on those topics that really matter to a trainee radiologist in the initial years of training

Resultate und ausser- gewöhnliche Komplikationen der Chirurgie der Gehörgangexostosen [Results and extraordinary complications of surgery for exostoses of the external auditory canal].

We present a retrospective study on 22 operations of exostosis of the external auditory canal in 20 patients. 8 patients were passionated by water sports. The most frequent indication for surgery (13 operations) was recurrent external otitis or ceruminal obstruction. In 7 cases the need for a wider access to the middle ear indicated surgery. Surgery was usually performed as an outpatient procedure, maximum hospitalization was 3 days. The mean healing period was 6 (3-10) weeks. Mean follow up was 43 (3-110) months. There were no severe intraoperative complications such as facial paresis, lesions of the ossicles or of the inner ear. As intraoperative complications we found 2 perforations of the tympanic membrane, 2 expositions of the capsule of the mandibular joint, one of which was followed by chronic pain. As postoperative complications we found an early soft tissue stenosis of the external auditory canal and one late soft tissue stenosis which recurred after revision surgery. No recurrence of exostosis was seen. We describe an up to now unknown complication: the appearance of bilateral petrositis caused by staphylococcus epidermidis after bilateral surgery in an otherwise healthy patient. This study confirms that severe complications are rare, minor ones however relatively common. And that also minor complications may have a troublesome follow. Therefore and because of the potential of severe complications indication for surgery must be made cautiously and risks of the operation must not be underestimated.

Multidetector-row computed tomography in the preoperative diagnosis of intestinal complications caused by clinically unsuspected ingested dietary foreign bodies: a case series emphasizing the use of volume rendering techniques

Objective The present study was aimed at describing a case series where a preoperative diagnosis of intestinal complications secondary to accidentally ingested dietary foreign bodies was made by multidetector-row computed tomography (MDCT), with emphasis on complementary findings yielded by volume rendering techniques (VRT) and curved multiplanar reconstructions (MPR). Materials and Methods The authors retrospectively assessed five patients with surgically confirmed intestinal complications (perforation and /or obstruction) secondary to unsuspected ingested dietary foreign bodies, consecutively assisted in their institution between 2010 and 2012. Demographic, clinical, laboratory and radiological data were analyzed. VRT and curved MPR were subsequently performed. Results Preoperative diagnosis of intestinal complications was originally performed in all cases. In one case the presence of a foreign body was not initially identified as the causal factor, and the use of complementary techniques facilitated its retrospective identification. In all cases these tools allowed a better depiction of the entire foreign bodies on a single image section, contributing to the assessment of their morphology. Conclusion Although the use of complementary techniques has not had a direct impact on diagnostic performance in most cases of this series, they may provide a better depiction of foreign bodies' morphology on a single image section.

Typical and atypical presentations of paranasal sinus mucocele at computed tomography

Mucoceles are cystic masses that generally affect the sinuses. It occurs as a result from obstruction of the ostium of a sinus and consequential accumulation of mucus. Frontal and ethmoid sinuses are mostly affected. Usually, the clinical symptoms are insidious, varying with the extent of the affected region. The treatment is surgical and endoscopic surgery is the method of choice in most cases. The present study is aimed at describing the main characteristics of paranasal sinuses mucoceles, demonstrating and illustrating a series of atypical presentations with emphasis on imaging findings.

Radiographic adenoid evaluation: proposal of an objective parameter

Objective The objective of the present study was to evaluate current radiographic parameters designed to investigate adenoid hypertrophy and nasopharyngeal obstruction, and to present an alternative radiographic assessment method. Materials and Methods In order to do so, children (4 to14 years old) who presented with nasal obstruction or oral breathing complaints were submitted to cavum radiographic examination. One hundred and twenty records were evaluated according to quantitative radiographic parameters, and data were correlated with a gold-standard videonasopharyngoscopic study, in relation to the percentage of choanal obstruction. Subsequently, a regression analysis was performed in order to create an original model so the percentage of the choanal obstruction could be predicted. Results The quantitative parameters demonstrated moderate, if not weak correlation with the real percentage of choanal obstruction. The regression model (110.119*A/N) demonstrated a satisfactory ability to “predict” the actual percentage of choanal obstruction. Conclusion Since current adenoid quantitative radiographic parameters present limitations, the model presented by the present study might be considered as an alternative assessment method in cases where videonasopharyngoscopic evaluation is unavailable.

Evolution à long term du syndrom de Widal après chirurgie endoscopique endonasale

Ce travail de recherche a été effectué dans le cadre d'une formation post-graduée à l'Hôpital de La Chaux-de-Fonds, dans lequel le service ORL bénéficie d'un recrutement significatif pour les pathologies naso-sinusiennes, en particulier les polyposes. Ces pathologies sont grevées d'un handicap fonctionnel considérable, de par l'obstruction nasale, la limitation des efforts physiques et les troubles olfactifs comme principales répercussions. J'ai ainsi répertorié 303 interventions endonasales pour ablation de polypes et drainage des cavités sinusales. effectuées entre 1987 et 2006. L'étude s'est focalisée sur les 33 patients atteints d'une polypose nasale mais également d'un asthme et d'une intolérance à l'aspirine, réalisant la triade de Widal. La prévalence en Europe pour la polypose nasale est de 1 à 2 %, dont 10 à 20 % de syndromes de Widal. Cette entité est grevée d'une morbidité plus sévère en raison des mécanismes métaboliques induisant des récidives de polypes précoces, rendant la maladie plus difficile à contrôler. Ces patients ont été évalués d'une part subjectivement par une échelle visuelle analogique pour les symptômes rhinologiques et généraux, et d'autre part via une analyse objective du status endonasal de la polypose à la fin du suivi. Pour chaque patient, les troubles fonctionnels résiduels (obstruction nasale, rhinorrhée, troubles olfactifs, céphalées, éternuements, larmoiement) ainsi que le status endonasal à la fin du suivi ont été analysés pour détecter d'éventuelles associations significatives avec les caractéristiques pré-opératoires (âge, sexe, allergies, antécédants de chirurgie endonasale, données scanographiques, status endonasal). Deux groupes ont été identifiés selon la sévérité de l'atteinte fonctionnelle résiduelle. La valeur moyenne de la gêne à la fin du suivi pour l'ensemble du collectif est de 3.9/10 sur l'échelle visuelle analogique (0= absence de gêne, 10= gêne maximale). Les facteurs de mauvais pronostic qui ont été identifiés sont le sexe féminin et la présence de polyallergies, mais sans relation statistiquement significative. La seule différence statistiquement significative est le stade avancé de polypose nasale à la fin du suivi dans le groupe présentant l'atteinte fonctionnelle la plus importante (groupe 2). Malgré la combinaison des traitements chirurgicaux et médicamenteux par corticoïdes et anti-leucotriènes, la maladie de Widal est grevée d'une gêne fonctionnelle résiduelle non négligeable dans notre suivi moyen de 11,6 ans. Ceci relativise les résultats parfois trop optimistes des études avec un suivi plus court, sachant que les délais avant une deuxième intervention chirurgicale dans notre série ont été de 6,5 ans. L'évolution des traitements immuno-modulateurs topiques et systémiques combinés aux interventions chirurgicales ponctuelles renforce l'arsenal thérapeutique dans la prise en charge des patients atteints de la maladie de Widal. Cette étude pourra être élargie au collectif entier des ethmoïdectomies répertoriées (n=303) dans le service ORL et actualisées, afin de rechercher et mettre en évidence d'autres associations en comparant le groupe des polyposes simples au groupe des triades de Widal.

Sclerosing encapsulating peritonitis: a case report

Sclerosing encapsulating peritonitis, a rare cause of bowel obstruction, was described as a complication associated with peritoneal dialysis which is much feared because of its severity. The authors report a case where radiological findings in association with clinical symptoms have allowed for a noninvasive diagnosis of sclerosing encapsulating peritonitis, emphasizing the high sensitivity and specificity of computed tomography to demonstrate the characteristic findings of such a condition.

Etude de l'évolution des patients porteurs d'une cardiomyopathie hypertrophique obstructive (CMHO) après alcoolisation septale

La cardiomyopathie hypertrophique (CMH) est la maladie cardiaque monogénique la plus fréquente, touchant environ 1 individu sur 500 dans la population (1,2). L'étiologie est familiale dans la majorité des cas avec une transmission de type autosomal dominant à pénétrance variable. Deux gènes principaux sont à l'origine de la maladie chez 70% des patients avec un test génétique positif. Il s'agit des gènes qui codent pour la chaine lourde β de la myosine (MYH7) et la protéine C liant la myosine (MYBPC3) (1-3). La CMH est définie par la présence d'une hypertrophie myocardique « inadéquate » car se développant en l'absence d'une cause d'augmentation de la post-charge (HTA, sténose aortique, membrane sous-aortique), d'une pathologie infiltrative ou d'un entrainement physique (4,5). Le plus souvent asymétrique et affectant préférentiellement le septum, cette hypertrophie s'accompagne dans près de deux tiers des cas d'une obstruction dynamique sous-aortique de la chambre de chasse du ventricule gauche par la valve mitrale (systolic anterior motion ou SAM). Cette obstruction est à la fois la conséquence du rétrécissement de la chambre de chasse par l'hypertrophie septale mais également d'un malpositionnement de la valve mitrale (6-8). On parle alors de Cardiomyopathie Hypertrophique et Obstructive (CMHO). L'obstruction - présente au repos dans 50% des cas et uniquement après manoeuvres de provocation dans l'autre moitié des cas (manoeuvre de Valsalva, test de vasodilatation par nitrite d'amyle) est à l'origine d'un gradient de pression entre le ventricule gauche et l'aorte, et donc d'une surcharge de pression pour le ventricule gauche. Cette surcharge de pression est à l'origine des symptômes classiquement rencontrés soit dyspnée et angor d'effort, présyncope voire syncopes à l'effort. Un gradient sous-aortique de plus de 50 mmHg (mesuré au repos ou après provocation) est considéré comme un gradient à valeur pronostique (6-8) et justifiant un traitement si associé à des symptômes. Le traitement médical des formes obstructives repose sur l'administration de substances inotropes négatives et/ou susceptibles de favoriser la relaxation myocardique tels que les béta-bloqueurs, les antagonistes du calcium et le disopyramide - pris isolément ou en association. Pour les nombreux patients qui deviennent réfractaires ou intolérants à ces traitements, deux interventions peuvent leur être proposées pour lever l'obstruction : une myotomie-myectomie chirurgicale du septum (9,10) ou une alcoolisation du septum par voie percutanée (7,8). Les indications à ces interventions sont les suivantes (7,8,11) : 1. Symptômes (dyspnée de classe fonctionnelle NYHA III ou IV, angor de classe fonctionnelle CCS III ou IV, syncope, ou présyncope) réfractaires au traitement médical ou intolérance du patient au traitement. Une dyspnée de classe II est considérée suffisante dans le cas de jeunes patients. 2. Obstruction sous-aortique avec gradient supérieur ou égal à 50 mmHg, au repos ou après manoeuvre de provocation, associée à une hypertrophie septale et à un mouvement systolique antérieur de la valve mitrale (effet SAM) 3. Anatomiecardiaquefavorableàuntraitementinvasif(épaisseurduseptumde plus de 16 mm) Si la myectomie chirurgicale reste la méthode de référence (12-18), l'alcoolisation septale du myocarde par voie percutanée est devenue un des traitements de choix dans la thérapie de la Cardiomyopathie Hypertrophique Obstructive réfractaire. Elle consiste à repérer par coronarographie l'artère septale nourrissant le septum basal hypertrophié, puis à y introduire un petit ballon pour isoler ce territoire du reste du lit coronaire avant d'y injecter une dose d'alcool à 95% comprise entre 1 et 5 cc. On crée ainsi un infarctus chimique, technique qui fut dans le passé utilisée pour le traitement de certaines tumeurs. Les effets ne sont pas immédiats et nécessitent généralement 2-3 semaines avant de se manifester. On assiste alors à une diminution progressive de l'épaisseur du myocarde nécrosé (7), à la disparition progressive de l'obstruction et à l'amélioration / disparition des symptômes. La question de savoir qui de la chirurgie ou de l'alcoolisation est le plus efficace a été source de nombreux débats (7,11-13,18). Par rapport à la chirurgie, les avantages de la méthode percutanée sont les suivants (11,14,15,18,19) : - Efficacités hémodynamique et fonctionnelle jugées comparable à la chirurgie selon les études - Taux de morbidité et de mortalité très faible et non supérieure à la chirurgie - Absence de sternotomie - Diminution de la durée de l'hospitalisation et surtout de la période de convalescence, le patient pouvant reprendre une activité dès son retour à domicile Certains experts émettent néanmoins des doutes quant à l'innocuité à long terme de la méthode, les zones nécrotiques pouvant servir de terrain arythmogène. Pour ces raisons, la méthode n'est pas recommandée chez les patients de moins de 40 ans (6,8). Le risque majeur de l'alcoolisation du septum proximal réside dans l'induction d'un bloc atrio-ventriculaire complet chimique, le noeud atrio-ventriculaire étant justement situé dans cette région. Ce risque augmente avec la quantité d'alcool administrée et nécessite, si persistance après trois jours, l'implantation d'un pacemaker à demeure. Selon les centres, le taux d'implantation d'un stimulateur varie ainsi entre 7% et 20% (7,14,20). L'efficacité clinique et l'incidence des complications est donc en partie liée à la compétence technique et à l'expérience de l'opérateur (7,14), mais aussi aux choix des patients. Il peut donc varier grandement selon les centres médicaux. L'étude proposée vise à analyser les résultats de l'alcoolisation obtenus à Lausanne, jusqu'à présent pas encore été étudiés, et à les comparer à ceux de la littérature.

Sleep-Disordered Breathing in Women

Sleep-disordered breathing (SDB) is underdiagnosed in women, probably due to the different gender-related manifestation. We investigated the differences in presentation, symptoms and co-morbidities of SDB in men and in pre- and postmenopausal women by a clinical, retrospective, cross-sectional study of 601 consecutively referred women and 233 age- and BMI-matched male-female pairs studied with the static-chargesensitive bed (SCSB) and an oximeter. Data on the use of nasal CPAP were gathered from the Paimio hospital database, and the co-morbidity information was based on reimbursed medication data from the National Agency for Medicines and the Social Insurance institution. The abnormal breathing episodes at night were more frequent in men than in women, and in postmenopausal women compared to premenopausal ones. Partial upper airway obstruction was the most common type of SDB in both genders but especially in females. BMI and the major symptoms of SDB were similar in pre- and postmenopausal women, and a menopause effect on symptoms was not found. CPAP adherence did not differ between symptomatic patients with partial upper airway obstruction and those presenting with conventional obstructive sleep apnea. Comorbidities were more frequent in SDB patients than in the general Finnish population. Compared to sleep apnea, partial upper airway obstruction was associated with a threefold prevalence of asthma and/or COPD in both genders, and with a 60% reduced prevalence of hypertension in females matched for age and BMI. Our results emphasize that partial upper airway obstruction is not a milder form of SDB but a different entity, the severity of which is underestimated when using the conventional apnea-hypopnea index. It seems clinically relevant to diagnose and treat the co-morbidities and SDB also in patients with partial upper airway obstruction, especially in elderly and symptomatic women.

Peutz-Jeghers syndrome: a systematic review and recommendations for management

Peutz¿Jeghers syndrome (PJS, MIM175200) is an autosomal dominant condition defined by the development of characteristic polyps throughout the gastrointestinal tract and mucocutaneous pigmentation. The majority of patients that meet the clinical diagnostic criteria have a causative mutation in the STK11 gene, which is located at 19p13.3. The cancer risks in this condition are substantial, particularly for breast and gastrointestinal cancer, although ascertainment and publication bias may have led to overestimates in some publications. Current surveillance protocols are controversial and not evidence-based, due to the relative rarity of the condition. Initially, endoscopies are more likely to be done to detect polyps that may be a risk for future intussusception or obstruction rather than cancers, but surveillance for the various cancers for which these patients are susceptible is an important part of their later management. This review assesses the current literature on the clinical features and management of the condition, genotype¿phenotype studies, and suggested guidelines for surveillance and management of individuals with PJS. The proposed guidelines contained in this article have been produced as a consensus statement on behalf of a group of European experts who met in Mallorca in 2007 and who have produced guidelines on the clinical management of Lynch syndrome and familial adenomatous polyposis.

Free Flap Monitoring. Using Tissue Oxygen Measurement and Positron Emission Tomography

Aims:This study was carried out to evaluate the feasibility of two different methods to determine free flap perfusion in cancer patients undergoing major reconstructive surgery. The hypotheses was that low perfusion in the flap is associated with flap complications. Patients and methods: Between August 2002 and June 2008 at the Department of Otorhinolaryngology – Head and Neck Surgery, Department of Surgery, and at the PET Centre, Turku, 30 consecutive patients with 32 free flaps were included in this study. The perfusion of the free microvascular flaps was assessed with positron emission tomography (PET) and radioactive water ([¹⁵O] H₂O) in 40 radiowater injections in 33 PET studies. Furthermore, 24 free flaps were monitored with a continuous tissue oxygen measurement using flexible polarographic catheters for an average of three postoperative days. Results: Of the 17 patients operated on for head and neck (HN) cancer and reconstructed with 18 free flaps, three re-operations were carried out due to poor tissue oxygenation as indicated by p_tiO₂ monitoring results and three other patients were reoperated on for postoperative hematomas in the operated area. Blood perfusion assessed with PET (BF_PET) was above 2.0 mL / min / 100 g in all flaps and a low flap-to-muscle BFPET ratio appeared to correlate with poor survival of the flap. Survival in this group of HN cancer patients was 9.0 months (median, range 2.4-34.2) after a median follow-up of 11.9 months (range 1.0-61.0 months). Seven HN patients of this group are alive without any sign of recurrence and one patient has died of other causes. All of the 13 breast reconstruction patients included in the study are alive and free of disease at a median follow-up time of 27.4 months (range 13.9-35.7 months). Re-explorations were carried out in three patients due data provided by p_tiO₂ monitoring and one re-exploration was avoided on the basis of adequate blood perfusion assessed with PET. Two patients had donorsite morbidity and 3 patients had partial flap necrosis or fat necrosis. There were no total flap losses. Conclusions: P_tiO₂ monitoring is a feasible method of free flap monitoring when flap temperature is monitored and maintained close to the core temperature. When other monitoring methods give controversial results or are unavailable, [₁₅O] H₂O PET technique is feasible in the evaluation of the perfusion of the newly reconstructed free flaps.

Vascular Function in Chronic Kidney Disease and in Renovascular Disease

Cardiovascular mortality is 15 to 30 times higher in patients with chronic kidney disease than in the age-adjusted general population. Even minor renal dysfunction predicts cardiovascular events and death in the general population. In patients with atherosclerotic renovascular disease the annual cardiovascular event and death rate is even higher. The abnormalities in coronary and peripheral artery function in the different stages of chronic kidney disease and in renovascular disease are still poorly understood, nor have the cardiac effects of renal artery revascularization been well characterized, although considered to be beneficial. This study was conducted to characterize myocardial perfusion and peripheral endothelial function in patients with chronic kidney disease and in patients with atherosclerotic renovascular disease. Myocardial perfusion was measured with positron emission tomography (PET) and peripheral endothelial function with brachial artery flow-mediated dilatation. It has been suggested that the poor renal outcomes after the renal artery revascularization could be due to damage in the stenotic kidney parenchyma; especially the reduction in the microvascular density, changes mainly evident at the cortical level which controls almost 80% of the total renal blood flow. This study was also performed to measure the effect of renal artery stenosis revascularization on renal perfusion in patients with renovascular disease. In order to do that a PET-based method for quantification of renal perfusion was developed. The coronary flow reserve of patients with chronic kidney disease was similar to the coronary flow reserve of healthy controls. In renovascular disease the coronary flow reserve was, however, markedly reduced. Flow-mediated dilatation of brachial artery was decreased in patients with chronic kidney disease compared to healthy controls, and even more so in patients with renovascular disease. After renal artery stenosis revascularization, coronary vascular function and renal perfusion did not improve in patients with atherosclerotic renovascular disease, but in patients with bilateral renal artery stenosis, flow-mediated dilatation improved. Chronic kidney disease does not significantly affect coronary vascular function. On the contrary, coronary vascular function was severely deteriorated in patients with atherosclerotic renovascular disease, possibly because of diffuse coronary artery disease and/or diffuse microvascular disease. The peripheral endothelial function was disturbed in patients with chronic kidney disease and even more so in patient with atherosclerotic renovascular disease. Renal artery stenosis dilatation does not seem to offer any benefits over medical treatment in patients with renovascular disease, since revascularization does not improve coronary vascular function or renal perfusion.

Objective Evaluation of Nasal Dimensions in Children with Acoustic Rhinometry

Aims: This study was carried out to investigate the usefulness of acoustic rhinometry in the evaluation of intranasal dimensions in children. The aim was to define reference values for school children. In addition, the role of the VAS scale in the subjective evaluation of nasal obstruction in children was studied. Materials and methods: Measurements were done with Acoustic Rhinometry A1. The values of special interest were the minimal cross-sectional area (MCA) and the anterior volume of the nose (VOL). The data for reference values included 124 voluntary school children with no permanent nasal symptoms, aged between 7 and 14 years. Data were collected at baseline and after decongestion of the nose; the VAS scale was filled in before measurements. The subjects in the follow-up study (n=74, age between 1 and 12 years) were receiving intranasal spray of insulin or placebo. The nasal symptoms were recorded and acoustic rhinometry was measured at each control visit. Results: In school children, the mean total MCA was 0.752 cm2 (SD 0.165), and the mean total VOL was 4.00 cm3 (SD 0.63) at baseline. After decongestion, a significant increase in the mean TMCA and in the mean TVOL was found. A correlation was found between TMCA and age, and between TVOL and height of a child. There was no difference between boys and girls. A correlation was found between unilateral acoustic values and VAS at baseline, but not after decongestion. No difference wasfound in acoustic values or symptoms between the insulin and placebo group in the follow-up study of two years. Conclusions: Acoustic rhinometry is a suitable objective method to examine intranasal dimensions in children. It is easy to perform and well tolerated. Reference values for children between 7 and 14 years were established.

Early detection of injuries in leaves of Clusia hilariana Schltdl. (Clusiaceae) caused by particulate deposition of iron

This study aims to evaluate the prognostic value of microscopic parameters of asymptomatic leaves of Clusia hilariana Schltdl. subjected to particulate deposition of iron (2.14 mg cm-2 day-1) for 45 consecutive days. Samples of young and expanded leaves without symptoms were collected and subjected to light and scanning electron microscopy techniques. The height of the epidermal cells on both surfaces of the leaf and the thickness of the hypodermis, the chlorophyll parenchyma, and the leaf blade were measured. Micromorphological injury occurred in the abaxial surface of young leaves and on both surfaces of expanded leaves. Erosion of the epicuticular wax and cuticle rupture were frequent on the adaxial surface, while on the abaxial surface of both leaves there was a loss of sinuosity on the anticlinal wall of the epidermal cells, stomatal deformity and obstruction. Micromorphometric alterations were seen in all leaf tissues except in the height of epidermic cells, probably due to the thick cuticle and prominent cuticular flanges. The highest difference in thickness of the leaf blade was seen in young leaves of plants subjected to SPMFe, indicating greater sensibility to particulate iron in comparison to the expanded leaves. The micromorphological and micromorphometric alterations in the leaf blade of Clusia hilariana Schltdl. showed the prognostic potential of these tools on the evaluation of impacts caused by the deposition of particulate matter, especially in the 'Restinga' natural vegetation, where the exposure is increasing due to the presence of iron ore industry in their surroundings.