Kazuhide Matsunaga

Treatment of orbital floor fracture using a periosteum—polymer complex

Various materials for the reconstruction of bone defects in orbital floor fractures have been developed and applied clinically. Recently, reconstruction using polymers, in place of autologous bone and artificial materials, has been actively introduced, but there are problems, such as the size of reconstructable bone defects and the decomposition rate of polymers. A basic study was performed on bone regeneration using a periosteum-polymer complex produced by attaching periosteum to a biodegradable polymer sheet. In this study, patients with orbital floor fractures were evaluated clinically who had undergone reconstruction of orbital floor defects of the using a periosteum-polymer complex produced by applying periosteum to an Hydroxyapatite-[poly (l-lactide-epsilon-caprolactone)](HA-P (CL/LA)) sheet and the ilium in the previous 3 years. A bone defect of less than 2.5cm(2) area was defined as small, that of 2.5-4cm(2) as intermediate, and that of more than 4cm(2) as a large bone defect. For small bone defects, hypoaesthesia in the infraorbital nerve was observed in one patient each of the periosteum-polymer complex and ilium groups. Regarding intermediate bone defects, diplopia and hypoaesthesia in the infraorbital nerve were observed in one patient in each of the two groups. For large bone defects, diplopia was observed in one patient each for the periosteum-polymer complex and ilium groups, and hypoaesthesia of the infraorbital nerve was only detected in one patient of the former group. Not more than 2mm of enophthalmos was detected in any patient. The anatomical eyeball position and eyeball movement were normal after surgical treatment using the periosteum-polymer complex, just as in reconstruction using autologous bone.

Molecular mechanisms of cleft lip formation in CL/Fr mice

CL/Fr mice have a high incidence of cleft lip and the cleft lip is the result of incomplete fusion between the medial and lateral nasal prominences and the maxillary prominence at about day 11.5 of gestation. However, little is known about the molecular mechanisms that are responsible for the incomplete fusion. We made a molecular pathological investigation using 11.5-day CL/Fr embryos. Five embryos were each examined for real-time polymerase chain reaction (PCR) analysis. During the first palatal formation in normal development, an epithelial seam is formed when the medial and lateral nasal prominences first make contact. Some epithelial cells of the epithelial seam then undergo apoptosis, with remaining cells transforming into a mesenchymal phenotype (epithelial-mesenchymal transition, EMT). Mesenchymal cells of the medial and lateral nasal prominences then merge across the previous boundary of separation. In CL/Fr mice with cleft lip, neither apoptosis nor EMT occurs in the epithelial cells. Increased expression of claudin 6 mRNA is seen in epithelial cells of epithelial seam in cleft lip compared with that in normal embryos. Slug mRNA expression was also significantly reduced whereas noggin was increased in CL/Fr embryos with cleft lip. We suggest that EMT is prevented in CL/Fr mice with cleft lip by increased expression of claudin 6 and coexistent downregulation of slug in cells of the epithelial seam, and these altered concentrations of transcription factors/repressors prevent fusion of the medial and lateral nasal prominences, leading to clefts of the lip.

Novel strategy for orbital tumor resection: surgical "displacement" into the maxillary cavity.

Surgical intervention consisting of lateral orbitotomy, the indication of which is extremely wide for orbital tumor surgery, has been applied in cases of large, retrobulbar cavernous hemangioma. However, no method exists involving displacement of the tumor from the crowded orbital contents, with the exception of tumor traction toward the outer side. The impact of traction force on the fragile hemangioma is extremely traumatic and dangerous. The authors examined how a tumor might be displaced in the absence of traction force effect, into an appropriate cavity neighboring the orbit. The maxillary sinus may afford the most suitable space to shift the laterally situated orbital tumor. Thus, the osteotomy level was extended to the lateral half of the inferior orbital floor and orbital rim in order to displace the tumor through an escape window of sufficient size between the orbit and maxilla. This report describes the treatment of two cases with long histories of progressive proptosis associated with retrobulbar large cavernous hemangiomas. This novel procedure resulted in a successful outcome. The current approach and management, which involves displacement of the tumor into the maxillary sinus through the orbital floor escape window, is a novel procedure for orbital tumor surgery.

Serial changes in swallowing function in a case of dysphagia after jejunal reconstruction of the cervical esophagus: a case report

The patient was a 56-year-old woman. Cervical esophagectomy for cervical esophageal cancer with preservation of the larynx, bilateral neck dissection, and free jejunum reconstruction were performed in our hospital. The oral and anal sides of the free jejunum were reconstructed by end-to-side anastomosis. The oral-side blind pouch of the free jejunum was long, and the jejunum was atonic. We performed serial swallowing video fluorographic imaging 1 month and 6 months after surgery to quantitatively analyze (1) oral transit and pharyngeal transit time, (2) emptying times of the test diet in the free jejunum, (3) regurgitation of test diet, and (4) the minimal diameter of the free jejunum. At 1 month and 6 months after surgery, oral and pharyngeal transit time were evaluated as normal. Six months after surgery, emptying time of the test diet in the free jejunum was reduced compared with that 1 month after surgery. Six months after surgery, regurgitation of test diet from the blind pouch had decreased by approximately 36% compared with that at 1 month after surgery. Furthermore, 6 months after surgery, motility of the transferred jejunum had improved compared with that 1 month after surgery. These findings suggested that the food-transporting activity of the free jejunum recovered over time; however, the blind pouch length should be made as short as possible, and the jejunum should be anastomosed in a stretched position from the perspective of swallowing function.

Effectiveness of an Interdisciplinary Medical Hospital Admission Center: The Role of the Dental Section in the Interdisciplinary System for Perioperative Management of Patients Awaiting Surgery

Perioperative oral functional management (POFM) involves total oral management of a patient before surgery. Considerable benefits have been reported, but POFM remains scarce in medical settings. An interdisciplinary Medical Hospital Admission Center (MHAC) opened in our hospital in December 2014, and has since provided unified perioperative management for patients. This study reports on the clinical system and contributions of the systematized, standardized POFM applied through the MHAC. Patients awaiting surgery undergo oral screening before admission, with patients classified into three groups: red, needing surgical oral management (tooth extraction or other oral surgery) before surgery; yellow, needing non-surgical oral management before surgery, due to the planned surgery or the risk of tooth injury in connection with general anesthesia; or green, patients with good oral hygiene considered capable of suitable oral self-management. Patients categorized as red or yellow undergo POFM in the dental section of the MHAC before surgery. Almost all patients (88.8%) awaiting surgery now undergo preoperative oral screening, excluding emergent surgeries. In addition, oral screening is important for preventing tooth injury during endotracheal intubation for general anesthesia, and a need for preventive measures was identified in 6.1% of patients. No traumatic injuries of the teeth in connection with general anesthesia have occurred since the opening of the MHAC. Standardized POFM through an interdisciplinary MHAC thus seems extremely useful.

Long-term treatment of a girl with severe facial injury caused by a car accident

We report the outcome of treatment of severe facial degloving resulting from a car injury. The patient was a 3-year-old girl. In 1992, her mother moved a car without noticing that the girl was in front of it. The girl’s face was caught under the front wheel and dragged for about 5 m, and the facial skin was severely excoriated. On initial examination at our department, the skin was excoriated from the right forehead over the upper lip region and left cheek beyond the paramedian line. The upper and lower tarsal plates were also excoriated with the palpebral conjunctiva, and the levator muscle was completely ruptured. The cheek and zygomatic branches of the facial nerve were partially exposed, but their continuity was retained. The eyes