Björn Petruson

Zygoma fixture in the management of advanced atrophy of the maxilla: technique and long-term results.

Despite refinements in surgical technique, including bone grafting and sophisticated prosthetic reconstructions, there are limitations to what can be achieved with bone‐anchored fixed prostheses in patients with advanced atrophy of the maxillae. A new approach was suggested by a long‐term study on onlay bone grafting and simultaneous placement of a fixture based on a new design: the zygoma fixture, and the aim of this study was to assess its potential. Twenty‐eight consecutive patients with severely resorbed edentulous maxillae were included, 13 of whom had previously had multiple fixture surgery in the jawbone that had failed. A total of 52 zygoma fixtures and 106 conventional fixtures were installed. Bone grafting was deemed necessary in 17 patients. All patients have been followed for at least five years, and nine for up to 10 years. All patients were followed up with clinical and radiographic examinations, and in some cases rhinoscopy and sinoscopy as well. Three zygoma fixtures failed; two at the time of connection of the abutment and the third after six years. Of the conventional fixtures placed at the time of the zygoma fixture, 29 (27%) were lost. The overall prosthetic rehabilitation rate was 96% after at least five years of function. There were no signs of inflammatory reaction in the surrounding antral mucosa. Four patients with recurrent sinusitis recovered after inferior meatal antrostomy. To conclude, the zygoma fixture seems to be a valuable addition to our repertoire in the management of the compromised maxilla.

Juvenile nasopharyngeal angiofibroma: long-term results in preoperative embolized and non-embolized patients.

A treatment and follow-up study of 32 patients with juvenile nasopharyngeal angiofibroma (JNA) was performed at our clinic between 1974 and 1998. The majority had undergone surgery either via an antral approach or with a lateral rhinotomy. In the 1970s, surgery was combined with ligature of the external carotid artery and, since 1981, it has been combined with preoperative embolization. Two patients received radiotherapy (45 Gy) as primary treatment and the 3 cases of multiple recurrence received radiotherapy (30-45 Gy) as secondary treatment. No recurrence was found in patients treated with radiotherapy. The overall recurrence rate was 25%; the recurrence rate in non-embolized patients was 8% and among embolized patients it was 41%. We found no statistically verified differences in recurrence rate between embolized and non-embolized patients. No statistically significant difference was found in either recurrence or peroperative bleeding when comparing preoperatively embolized patients with non-embolized patients. Regression analyses showed that the only factor affecting recurrence was age, i.e. the younger the patient was at diagnosis the greater the risk of developing recurrence. The development of imaging and embolization techniques will hopefully contribute in the future towards reducing the recurrence rate.

Juvenile Nasopharyngeal Angiofibroma: A Report of Eighteen Cases

Juvenile nasopharyngeal angiofibroma is a disease afflicting mainly adolescent males. The lesion is benign but characterized by local aggressive growth. In advanced cases the tumour may extend intracranially. In this study 18 cases of juvenile nasopharyngeal angiofibroma were investigated. Tumour extension was assessed with the use of angiograms and CT and the individual cases staged in four different categories on the basis of tumour extension. Two cases were staged as I (tumour confined to the nasopharynx), 7 cases as II (tumour extending into nasal cavity and/or sphenoid sinus), 8 as III (tumour extending into one or more of the following: antrum, ethmoid sinus, pterygomaxillary and infratemporal fossae, orbit and/or cheek) and one as IV (tumour extending into the cranial cavity). Preoperative arterial embolization was performed in 8 cases. All patients underwent surgery; none received irradiation. The follow-up period was 6 yrs 4 mo (6 months-17 years). In one case of intracranial extension, tumour recurrence occurred. It is concluded that with the aid of CT and arteriograms to evaluate the extension of the tumour and preoperative embolization, this lesion can be cured in the vast majority of cases, with surgery as the method of choice.

Sinuscopy in patients with titanium implants in the nose and sinuses.

Foreign bodies in the nose and sinuses can cause chronic infections. Long titanium fixtures through the maxilla to the zygomatic bone were followed up with a sinuscope in 14 patients after more than one year. There were no signs of infection or inflammation in the mucosa around the fixtures.

Survival after surgical treatment in maxillary neoplasms of epithelial origin

During 1968-1979, 55 cases of epithelial neoplasms originating from the maxillary antrum were diagnosed and treated within the referral area of 1.5 million inhabitants. A majority of the patients were operated upon after pre-operative irradiation therapy (40-50 Gy). No significant difference in survival rate was found between patients operated on by total maxillectomy, including orbital exenteration, and patients subjected to partial maxillectomy. Patients with tumours not completely removed during primary surgery and patients with glandular involvement had a poor prognosis despite additional surgery and radiotherapy. The prognosis for the remaining patients was considerably better, with a 5-year survival rate of 60 per cent.

Insulin-like growth factor I is a possible pathogenic mechanism in nasal polyps.

High concentrations of the trophic peptide insulin-like growth factor I (IGF-I; somatomedin C; SmC) were demonstrated immunocytochemically in all nasal polyps examined, except in areas with necrosis or tissue defects. Most epithelial cells, activated macrophages, and proliferating blood vessels, proved positive, contrasting with the low degree of cellular staining in adjacent normal nasal mucosa. It is proposed that nasal mucosal inflammatory reactions induce local formation and accumulation of IGF-I, which may eventually result in very high IGF-I concentrations in the paranasal sinuses due to the tendency these have to be enclosed, i.e. producing reduced drainage. Assuming that IGF-I constitutes the pathogenic factor, appropriate treatment should be given to reduce the inflammatory reactions and improve drainage.

Function and Structure of the Nasal Mucosa After 6 Weeks' Use of Nose-Drops

The nasal mucosa of 20 healthy subjects were examined before, during and after 6 weeks of regular use of xylometazoline nose-drops (1 mg/ml) 0.15 ml three times daily. The subjects, except those affected by common colds, did not suffer any diminished mucociliar function during or after the trial. The surface structures were not found to have changed when examined with scanning electron microscopy. No morphological changes were observed in the intercellular space, basal membrane or tunica propria when using transmission electron microscopy. During the test period 5 of the subjects developed upper respiratory infections which temporarily prolonged the mucociliar transport time tested with small particles of saccharin. In some of these subjects a reduction in the number of ciliated cells was observed as well as an inflammatory reaction close to the epithelial cells. It is concluded that the use of xylometazoline over a 6-week period does not provoke any major functional or structural changes in a normal nasal mucosa.

The Nasal Mucosa in Immunodeficiency: Surface Morphology, Mucociliary Function and Bacteriological Findings in Adult Patients with Common Variable Immunodeficiency or Selective IgA Deficiency

Twenty-two adult patients suffering from common variable immunodeficiency (CVID) and sixteen patients with selective IgA deficiency were examined with regard to the mucocilliary function of the nose. The surface structures of the nasal mucosa, e.g. cell distribution and degree of destruction and metaplasia, were judged from scanning electron microscopy of nasal biopsies. Bacteria were isolated from nasopharyngeal swabs. The results of the clinical and morphological investigations were analysed with regard to the duration of the disease and possible benefit of adequate prophylaxis with immunoglobulin. It was found that patients with CVID had a slower mucociliary transport rate and more extensive mucosal damages than patients with selective IgA deficiency. Most likely these alterations were due to repeated infections as patients who had had few infections or adequate immunoglobulin prophylaxis (CVID patients) had better mucociliary function and showed less extensive mucosal changes. Potentially pathogenic bacteria in the nasopharynx were found in equal numbers in both patient groups.

Haemostatic disorders in habitual nose-bleeders

Ninety-one habitual nose-bleeders were screened for haemostatic disorders. 46 screening results in 38 nose-bleeders were outside the normal range. After extended investigation, it was found that 25 (27 per cent) habitual nose-bleeders had haemostatic disorders, all except one in the primary haemostasis. The disorders found could be classified as mild bleeding disorders (MBD) and compared to the estimated frequency of MBD in the population there was an increased incidence of haemostatic disorders in the habitual nose-bleeders. Abnormal vessels in the nasal mucosa were present in 85 per cent of the investigated nose-bleeders, equally distributed between nose-bleeders with and without haemostatic disorders. This indicates that abnormal vessels and haemostatic disorders in habitual nose-bleeders, it is possible to detect previously unknown but clinically important disorders.

Reduced nocturnal asthma by improved nasal breathing.

The nose and not the mouth should be used for breathing as the nose has better air conditioning capacity. When air is inhaled through the mouth it may dry and cool the respiratory mucosa, which can lead to bronchoconstriction in sensitive patients with asthma. By dilating the nostrils you can increase nasal breathing in most subjects. The aim of this study was to investigate whether sleeping with dilated nostrils reduces nocturnal asthma. At the Asthma and Allergy Research Centre, Gothenburg, 15 out-patients with nocturnal asthma were selected. Every other night for 10 nights the test subjects slept with the nasal dilator Nozovent which has been shown to increase the nasal air-flow and decrease the need for mouthbreathing. Every morning the patients self-reported on a form whether they had woken with asthma during the night or if they had had to take asthma medication. When sleeping with the nasal dilator the patients woke up with asthma on 17 of 75 nights as compared with 32 of 75 when sleeping without the device (p < 0.01). Reduced nocturnal asthma was observed by 12 patients and less need for asthma medication at night by 7. None of the patients noted any side-effects due to the device. In conclusion, the easy-to-use and cheap medical device, Nozovent, which mechanically dilates the nostrils and improves nasal breathing, can reduce nocturnal asthma.