Ken Stewart

A randomised controlled trial of the use of aciclovir and/or prednisolone for the early treatment of Bell’s palsy: the BELLS study

OBJECTIVE To determine whether oral prednisolone or aciclovir, used separately or in combination, early in the course of Bells palsy, improves the chances of recovery at 3 and 9 months. DESIGN A 2 x 2 factorial randomised double-blind trial. Patients were randomly assigned to treatment by an automated telephone service using a permuted block randomisation technique with block sizes of four or eight, and no stratification. SETTING Mainland Scotland, with referrals mainly from general practice to 17 hospital trial sites. PARTICIPANTS Adults (aged 16 years or older) with unilateral facial nerve weakness of no identifiable cause presenting to primary care, the emergency department or NHS24 within 72 hours of symptom onset. INTERVENTIONS Patients were randomised to receive active preparations or placebo for 10 days: (1) prednisolone (50 mg per day, 2 x 25-mg capsules) and aciclovir (2000 mg per day, 5 x 400-mg capsules); (2) prednisolone and placebo (lactose, indistinguishable); (3) aciclovir and placebo; and (4) placebo and placebo. OUTCOME MEASURES The primary outcome was recovery of facial function assessed by the House-Brackmann scale. Secondary outcomes included health status, pain, self-perceived appearance and cost-effectiveness. RESULTS Final outcomes were available for 496 patients, balanced for gender; mean age 44 years; initial facial paralysis moderate to severe. One half of patients initiated treatment within 24 hours of onset of symptoms, one-third within 24-48 hours and the remainder within 48-72 hours. Of the completed patients, 357 had recovered by 3 months and 80 at 9 months, leaving 59 with a residual deficit. There were significant differences in complete recovery at 3 months between the prednisolone comparison groups (83.0% for prednisolone, 63.6% for no prednisolone, a difference of + 19.4%; 95% confidence interval (CI): + 11.7% to + 27.1%, p < 0.001). The number needed to treat (NNT) in order to achieve one additional complete recovery was 6 (95% CI: 4 to 9). There was no significant difference between the aciclovir comparison groups (71.2% for aciclovir and 75.7% for no aciclovir). Nine-month assessments of patients recovered were 94.4% for prednisolone compared with 81.6% for no prednisolone, a difference of + 12.8% (95% CI: + 7.2% to + 18.4%, p < 0.001); the NNT was 8 (95% CI: 6 to 14). Proportions recovered at 9 months were 85.4% for aciclovir and 90.8% for no aciclovir, a difference of -5.3%. There was no significant prednisolone-aciclovir interaction at 3 months or at 9 months. Outcome differences by individual treatment (the four-arm model) showed significant differences. At 3 months the recovery rate was 86.3% in the prednisolone treatment group, 79.7% in the aciclovir-prednisolone group, 64.7% in the placebo group and 62.5% in the aciclovir group. At 9 months the recovery rates were respectively 96.1%, 92.7%, 85.3% and 78.1%. The increase in recovery rate conferred by the addition of prednisolone (both for prednisolone over placebo and for aciclovir-prednisolone over aciclovir) is highly statistically significant (p < 0.001). There were no significant differences in secondary measures apart from Health Utilities Index Mark 3 (HUI3) at 9 months in those treated with prednisolone. CONCLUSIONS This study provided robust evidence to support the early use of oral prednisolone in Bells palsy as an effective treatment which may be considered cost-effective. Treatment with aciclovir, either alone or with steroids, had no effect on outcome.

Mandibular distraction osteogenesis: a comparison of distraction rates in the rabbit model

The rabbit model has been used to study the effects of different rates of distraction upon mandibular bone. Bilateral distraction was performed at two different rates anterior to the molar teeth. Both experimental groups were significantly inferior to sham operated controls in terms of bone density (DEXA) and mechanical testing. No difference in new bone formation between the two distraction rates was detected by these modalities. However, histological examination revealed non-union to be more common in the rapidly distracted group. This suggests that attempts to shorten the duration of external fixation in clinical mandibular distraction osteogenesis should be by methods other than more rapid distraction.

Distraction osteogenesis in craniofacial surgery : A review

Distraction osteogenesis is a technique of new bone formation by the gradual separation of bony fragments. The method, although initially developed for limb lengthening, is now being applied in the treatment of craniofacial deformities. A number of principles have been established through careful scientific study to guide clinical practice, such as the ideal rate and rhythm of distraction, the need for periosteal preservation during bone division, a “latent period” of neutral fixation before, and a “consolidation period” after distraction. The technique is being applied in craniofacial surgery particularly for mandibular deformities and offers considerable advantages over previous methods such as osteotomy and inlay bone grafting. Donor site morbidity is avoided, the investing soft tissue envelope is concurrently expanded, and the magnitude of the procedure is less. However, the technique is still in its infancy and requires further modification and refinement before widespread acceptance as a treatment in mainstream craniofacial surgery. Problems with cutaneous scarring and socially undesirable external hardware, particularly in the pediatric population, have led to the emergence of intraoral miniature devices, with the ultimate goal of development of a multiplanar internal autodistractor. Furthermore, many principles well established in leg lengthening, such as the rate and rhythm of distraction, need to be reexamined and the parameters redefined with particular reference to the craniofacial skeleton. Distraction osteogenesis has an expanding role in craniofacial surgery.

Long-term results of posterior suturing with postauricular fascial flap otoplasty

BACKGROUND Posterior suturing with postauricular fascial flap otoplasty has previously been shown to be associated with a significantly reduced rate of complications and better aesthetic outcome when compared with the anterior scoring and posterior suturing techniques. This study evaluates the long-term results of this technique. MATERIAL AND METHODS A retrospective casenote analysis of all paediatric patients who underwent otoplasty within a four-year period were retrieved. Sixty patients (112 ears) met the inclusion criteria (mean age 8.5 years; range 4 to 14). The perpendicular distance from the mastoid to the helical rim at the Frankfort line was recorded preoperatively and immediately postoperatively. Patients were invited to a follow up clinic where further measurements were taken by two observers. Photographs were evaluated by an independent blinded observer. RESULTS The clinical recurrence rate was 4.5%. Thirty patients (57 ears) attended the follow-up clinic (mean 3.9 years since surgery). Mean loss of medialisation was 0.7 mm (6.2%), with loss of medialisation of > or =1 mm seen in 26 ears (46%), and improvement in medialisation of > or =1 mm in 15 ears (26%). Mean visual analogue scores for overall appearance and symmetry were higher at follow-up than at six weeks postoperatively. There was no relationship between measurements or visual analogue scores and duration since surgery. CONCLUSIONS In conclusion posterior suturing with braided polyester permanent sutures covered with a postauricular fascial flap results in longevity of postoperative appearance and symmetry with low clinical recurrence rates and with excellent patient and parent satisfaction.

Treatment of infantile hemangiomas with propranolol: clinical guidelines.

Background: Infantile hemangioma is a vascular tumor and requires treatment in lesions manifested by potentially dangerous symptoms. Several publications have reported that involution of infantile hemangioma could be accelerated by propranolol but have used only invalidated subjective measures of assessment. The authors aimed to objectively validate the aesthetic results after propranolol treatment for infantile hemangioma, and to produce a therapy protocol, including optimal timing for introduction, pretreatment preparation, dosage, frequency of visits, duration, and patient safety. Methods: For the nonrandomized comparative cohort study, the authors enrolled 60 patients treated with propranolol. Medical two-dimensional photographs, taken before and after treatment, were subjectively analyzed by three plastic surgery consultants and objectively analyzed with a computer program. Aesthetic results were analyzed using the following parameters: subjective overall outcome, subjective color fading, and objective color fading. Reliability of subjective and objective methods was quantified and compared, as described with accuracy and repeatability. Volumetric parameters were obtained from three-dimensional scans taken before and after treatment and objectively analyzed with a computer program. Numerous patients’ data were recorded from the medical notes. Results: This study proved high efficiency of propranolol in treatment of infantile hemangioma, as assessed with the objective measures for the first time. The authors outlined an optimal treatment protocol, including introduction, dosage, duration, and cessation of therapy. Conclusions: Propranolol is an effective, well-tolerated, and safe first-line treatment for proliferative hemangioma. Therapy should begin early, continue with the target dosage of 2 mg/kg/day in three divided doses through the proliferative phase of infantile hemangioma, and be stopped gradually. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Activation of the masseter muscle during normal smile production and the implications for dynamic reanimation surgery for facial paralysis

INTRODUCTION In cases of unilateral facial paralysis, free muscle transfer with coaptation to the motor nerve of the Masseter is gaining popularity as a primary alternative to cross-facial nerve grafting. Despite initial expectations, a majority of these subjects can achieve a spontaneous smile. The mechanism behind this spontaneity is unclear. Plasticity of the cerebral cortex as well as the relative proximity of the motor centres of the mimetic and Masseter muscles has been used in explanation. This study demonstrates the involvement of the Masseter muscle during normal smile production, suggesting a more direct explanation for the spontaneous smile seen following reanimation procedures innervated by the Masseter nerve. METHODS Twenty healthy volunteers were subjected to electromyography of the Masseter muscle bilaterally to demonstrate whether contraction of the Masseter muscle occurred during voluntary and involuntary smile production. RESULTS Patient age ranged from 20 to 61 years (mean 41.6 years) with an equal male to female ratio. Activation of the Masseter occurred in 40 percent of individual muscles during smile production, occurring bilaterally in six participants, and unilaterally in four. There was no correlation between muscle activation and patient age or gender. CONCLUSIONS Natural contraction of the Masseter muscle during normal smile production helps to explain the high rate of spontaneous smile development in subjects with facial paralysis who have undergone a free muscle reanimation procedure powered by the nerve to the Masseter muscle.

The tip of the iceberg: a giant pelvic atypical lipoma presenting as a sciatic hernia

BackgroundThis case report highlights two unusual surgical phenomena: lipoma-like well-differentiated liposarcomas and sciatic hernias. It illustrates the need to be aware that hernias may not always simply contain intra-abdominal viscera.Case presentationA 36 year old woman presented with an expanding, yet reducible, right gluteal mass, indicative of a sciatic hernia. However, magnetic resonance imaging demonstrated a large intra- and extra-pelvic fatty mass traversing the greater sciatic foramen. The tumour was surgically removed through an abdomino-perineal approach. Subsequent pathological examination revealed an atypical lipomatous tumour (synonym: lipoma-like well-differentiated liposarcoma). The patient remains free from recurrence two years following her surgery.ConclusionThe presence of a gluteal mass should always suggest the possibility of a sciatic hernia. However, in this case, the hernia consisted of an atypical lipoma spanning the greater sciatic foramen. Although lipoma-like well-differentiated liposarcomas have only a low potential for recurrence, the variable nature of fatty tumours demands that patients require regular clinical and radiological review.

Early and late complications of polyalkylimide gel (Bio-Alcamid)®

This case report summarises early and late of complications that have developed inpatients treated with Bio-Alcamid for HIV-associated facial lipoatrophy and describes the management strategy employed to treat the most serious of these cases.

International trends in the treatment of microtia.

Background:Microtia is a well-known craniofacial malformation treatable with numerous different treatment strategies and techniques. The purpose of this study was to analyze the current international trends in microtia repair. Methods:All surgeons attending the fourth International Ear Reconstruction Congress in Edinburgh received a questionnaire by e-mail about their current surgical practice in microtia care. Results:Thirty-one questionnaires were received. Most primary reconstructions are performed at ages 8 to 10 years using autologous cartilage from the ipsilateral sixth to eighth ribs. Most surgeons make a multilayer framework, leaving a subcutaneous pedicle. Suction drainage was used in all patients. On average, the second stage was performed more than 6 months later using a mastoid flap. Most surgeons do not reconstruct the middle ear. Conclusions:Microtia reconstruction is performed in many different ways, with numerous treatment and postoperative possibilities.

The osmotic tissue expander: A 5-year experience

Tissue expansion is a valuable technique in soft tissue reconstruction. Osmotic expanders are self-inflating and obviate the need for repeated injections. In doing so, they eliminate port site problems and may reduce the potential to introduce infection. The use of such expanders has become more common in recent years. We report on our experience with the Osmed™ osmotic expanders over the last 5-years.