Shahrokh C. Bagheri

Use of botulinum toxin A for drug-refractory trigeminal neuralgia: preliminary report.

OBJECTIVE Botulinum toxin type A (BTX-A) has been used to treat migraine and occipital neuralgia. We report preliminary results of an ongoing study that assesses the efficacy of BTX-A on trigeminal neuralgia (TN) patients refractory to medical treatment. STUDY DESIGN We treated 15 patients (8 men and 7 women) between 28 and 67 years of age who were suffering from drug-refractory TN from February 2008 to January 2010. Symptoms, including pain duration, provoking factors, affected nerve branch, frequency of TN attacks, and severity of pain just before injections, were evaluated 1 week, 1 month, and 6 months after injection. We injected 50 U reconstituted BTX-A solution at the trigger zones. The overall response to treatment was assessed via a 9-point patient global assessment scale and compared with values at baseline. Statistical analysis was performed by the analysis of variance (ANOVA) test for frequency of TN attacks, the Friedman test for severity of pain, and the Wilcoxon signed-rank test for PGA, and all with the use of SPSS software. RESULTS Eight men and 7 women aged 28-67 years (mean 48.9 y) suffering from TN from 6 months to 24 years all improved regarding frequency and severity of pain attacks; in 7 patients, pain was completely eradicated and there was no need for further medication. In 5 patients, nonsteroidal antiinflammatory drugs were enough to alleviate pain attacks, and 3 patients again responded to anticonvulsive drugs after injection. All patients developed higher pain thresholds after injections. The ANOVA test showed a significant difference in frequency of attacks before injection and at 1 week, 1 month, and 6 months after injection (P < .001). Friedman test and pair comparison of pain severity scores with Bonferroni correction adjustment showed a significant difference (P < .001) between severity of pain before and after injection. Wilcoxon signed-rank test showed significant improvement in all patients up to 6 months after injection (P < .001). Complications included transient paresis of the buccal branch of the facial nerve in 3 patients. CONCLUSION This study supports other similar studies and shows that BTX-A is a minimally invasive method that can play a role in treating TN before other more invasive therapies, i.e., radiofrequency and surgery.

Penetrating neck injuries.

The modern approach to patients presenting with penetrating injuries to the neck requires the cautious integration of clinical findings and appropriate imaging studies for formulation of an effective, safe, and minimally invasive modality of treatment. The optimal management of these injuries has undergone considerable debate regarding surgical versus nonsurgical treatment approaches. More recent advances in imaging technology continue to evolve, providing more accurate and timely information for the management of these patients. In this article the authors review both historic and recent articles that have formulated the current management of penetrating injuries to the neck.

Microsurgical Repair of the Inferior Alveolar Nerve: Success Rate and Factors That Adversely Affect Outcome

PURPOSE The objectives of this study were to determine the likelihood of regaining functional sensory recovery (FSR) after microsurgical repair of the inferior alveolar nerve (IAN), and which variables significantly affected the outcome of that surgery in a large series of patients. MATERIALS AND METHODS This was a retrospective cohort study that evaluated all patients who had undergone microsurgical repair of the IAN by 1 of the senior surgeons (R.A.M.) from March 1986 through December 2005. The requirements for inclusion of a patient in the study included the availability of a complete chart record and a final follow-up visit at least 12 months after surgery. All other patients were excluded. The predictor variables were categorized as demographic, etiologic, and operative. The final outcome variable was the level of recovery of sensory function as determined by standardized neurosensory testing at the last postoperative visit of each patient and based on guidelines established by the Medical Research Council Scale. Risk factors for surgical failure to achieve useful sensory function were determined from analysis of descriptive statistics, including patient age, patient gender, etiology of nerve injury, chief sensory complaint (numbness, pain, or both), time from injury to surgical intervention (in months), intraoperative findings, and surgical procedure. Logistic regression methods and associated odds ratios were used to quantify the association between the risk factors and improvement. Receiver operator characteristic curve analysis was used to find the threshold of those variables that significantly affected patient outcome. RESULTS In total, 167 patients (41 male and 126 female patients; mean age, 38.7 years [range, 15-75 years]) underwent 186 IAN repairs (19 patients sustained bilateral IAN injuries). The mean time from injury until surgery was 10.7 months (range, 0-72 months). Successful recovery from neurosensory dysfunction (FSR, defined by the Medical Research Council Scale as ranging from useful sensory function to complete sensory recovery) was observed in 152 repaired IANs (81.7%). With increasing duration from date of injury to IAN repair, the likelihood of FSR decreased (odds ratio, 0.898; P < .001). The odds of achieving FSR exhibited a linear decline between the date of nerve injury and its repair, with a significant drop in rate of successful outcome (FSR) occurring beginning at 12 months after injury. There was also a significant negative relationship between increasing patient age and improvement (odds ratio, 0.97; P = .015), with a threshold drop of achieving FSR at 51 years of age. The cause of the injury, the operative findings, and the type of operation performed to repair the nerve had no significant effect on the likelihood of the patient regaining FSR. The presence of pain after nerve injury did not affect the likelihood of achieving FSR after repair in a statistically significant manner (P = .08). In those patients who did not have pain as a major complaint before nerve repair, pain did not develop after microneurosurgery. CONCLUSIONS Microsurgical repair of an IAN injury resulted in successful restoration of an acceptable level of neurosensory function (FSR) in most patients (152 of 186 repairs [81.7%]) in this study. The likelihood of regaining FSR was inversely related to both time between the injury and its repair and increasing patient age, with significant threshold drops at 12 months after nerve injury and at 51 years of age, respectively.

Management of Mandibular Nerve Injuries from Dental Implants

Treatment of the patient who has sustained a nerve injury from dental implant procedures involves prompt recognition of this complication, evaluation of sensory dysfunction, the position of the nerve vis-à-vis the implant, and timely management of the injured nerve. In some patients, removal or repositioning of the implant and surgical exploration and repair of the injured nerve will maximize the implant patients potential for a successful recovery from nerve injury.

An Analysis of 101 Primary Cosmetic Rhinoplasties

PURPOSE Primary cosmetic rhinoplasty is one of the most complex of cosmetic surgical procedures in the maxillofacial area that requires precise consideration to both form and function. The complex and variable anatomy, highly visible position of the nose, and distinct patient desires contribute to the complexity of this procedure. This study reports the combined results of 101 consecutive primary cosmetic rhinoplasties at 2 centers. PATIENTS AND METHODS A retrospective chart review was completed on all patients who had primary cosmetic rhinoplasty with or without septoplasty and who were operated on by the senior authors (S.C.B. and H.M.) from June 2006 through December 2008. A standard physical examination, including photo documentation, was completed on each patient preoperatively. All patients were followed periodically after surgery for at least 12 months. Outcome was measured by both subjective and objective measures of cosmetic and functional (breathing) outcome. The following data were collected and analyzed: age of patient, gender, chief cosmetic and functional complaint, details of surgical procedure (including septoplasty, grafts, and donor sites), complications, and report of subjective outcome at final evaluation. RESULTS One hundred one patients (n = 101, average age 24.4 ± 6.8 years old) were enrolled in the study. Most patients presented for consultation regarding cosmetic rhinoplasty (80%) versus septorhinoplasty (20%). Although most of the patients (63%) were treated with septorhinoplasty, the open rhinoplasty (transcollumellar) incision was used in 61% of patients versus the closed rhinoplasty (39%) technique. The most commonly performed combination of techniques used was the combination of nasal tip modification, with dorsal reduction and nasal osetotomies (54%), followed by tip modification with dorsal reduction (19%), and dorsal reduction with osteotomies (18%) and no tip modification. In the 50 patients who required a graft, in 80% the donor site was the nasal septum. Spreader grafts were used in 14% of patients, and a combination of shield/tip graft was used in 52%. The following complications were observed: unhappy patient 16%, dehiscence at incision 5%, asymmetry requiring revision 6%, and infection 1%. In the 63 patients that had septoplasty, 6 (9.5%) reported that their breathing was not improved. In this series 11 patients (11%) received a revision rhinoplasty. CONCLUSIONS Primary cosmetic rhinoplasty is 1 of the more complex facial cosmetic procedures. The vast majority of complications can be avoided with careful and extensive treatment planning. In this series we found a complication and revision rate similar to that reported in the literature.

Lateral Crural Suspension Flap: A Novel Technique to Modify and Stabilize the Nasolabial Angle

The proper nasolabial angle is a determinant factor in achieving a pleasant result in esthetic rhinoplasty surgery. Nasal tip position depends on various interrelated elements. Its rotation should be analyzed by assessing the nasolabial angle. An increase in this angle results in an upward tilt of the base of the nose with a concomitant decrease in nasal length. Several methods have been advocated to improve this angle; unfortunately, these techniques have considerable limitations in modifying and stabilizing nasal tip rotation. The general principles for rotating the nasal tip include removing the factors that resist the rotation of the lower lateral cartilages, creating space to accommodate them, rotating the lower lateral cartilages into the desired position, and stabilizing the cartilages in the desired position. Resection of the cephalic margin of the lateral crura fulfills these goals. This report describes a straightforward and stable method that uses cephalic portions of the lower lateral crural cartilages as 2 flaps to suspend the nasal tip to the septum to modify and stabilize the nasolabial angle.

Nerve Injuries from Mandibular Third Molar Removal

Injuries to peripheral branches (IAN, LN, LBN) of the trigeminal nerve during the removal of M3s are known and accepted risks in oral and maxillofacial surgery practice. These risks might be reduced by modifications of evaluation or surgical techniques, depending on the surgeons judgment in individual patients. If a nerve injury does occur, prompt recognition, subjective and objective evaluation,and development of a treatment plan, if the sensory deficit fails to resolve in a reasonable period and is unacceptable to the patient, give the patient the best chance of achieving improvement or recovery of sensory function in the distribution of the injured nerve. Microneurosurgery may produce return of useful sensory function or complete sensory recovery, if done in a timely fashion by an experienced microsurgeon, in greater than 80% of patients who sustain nerve injuries during the removal of M3s.

Esophageal Rupture With the Use of the Combitube : Report of a Case and Review of the Literature

The Combitube (Tyco-Kendall, Mansfield, MA) is a supraglottic airway device that has been used as an adjunct in the management of a difficult airway after failed attempts at endotracheal intubation both during cardiopulmonary arrest and in the setting of acute trauma (Fig 1). This device has replaced the previous esophageal obturator airway due to several reports of esophageal rupture. It has been successfully used in emergent airway management and probably presents a lower risk of esophageal rupture than the esophageal obturator. An analogous device is the pharyngeo-tracheal lumen airway which has been previously studied successfully for emergent airway control. The Combitube is inserted blindly through the mouth and can adequately ventilate the patient whether it is placed in the trachea or more commonly, in the esophagus. If the patient is intubated through the trachea the Combitube can be used similar to an endotracheal tube with the distal cuff volume titrated to air leak. With esophageal intubation the proximal cuff is inflated and should also be titrated to air leak. The correct insertion of this device requires some degree of training and skill. To our knowledge there are 2 previous reports of soft tissue injury with the use of the Combitube. The incidence of esophageal injury with the use of this equipment has not been fully evaluated. Klein et al reported a case of esophageal rupture associated with the use of the Combitube. In this study they performed successful placement of this device in 8 patients in a controlled operating room setting by the same anesthesiologist. The ninth patient was reported to suffer an esophageal rupture that was confirmed by a contrast swallow study. They attributed this complication to increased intraluminal pressure distal to the tube and also to poor patient selection. Richards in 1998 reported a case of piriform sinus perforation during esophageal-tracheal Combitube placement in a 71-year-old female in the prehospital setting. He recommends caution when using this device even in the controlled setting. We present a case of esophageal rupture associated with the insertion of the Combitube in the prehospital setting.

Clinical Evaluation of Peripheral Trigeminal Nerve Injuries

This article presents a standardized method of clinical evaluation of the patient with a peripheral trigeminal nerve injury that provides both subjective and objective information. This evaluation scheme has been used by 1 author for more than 30 years (RAM) and by the other author (SCB) for 10 years. The information is easily obtained and recorded in the patients record, and it can be used by any clinician who performs subsequent evaluations on the same patient. The NST methods have been used successfully by specialists in other surgical disciplines for many years, and the various test results have been found to be closely correlated with the injuries found when the responsible nerve was surgically explored.Alternate testing methods or equipment are available that are used primarily in clinical and laboratory research rather than clinical practice. The reader who is interested in more information is encouraged to consult (Further Readings).

Etiology and Prevention of Nerve Injuries

Routine dental treatment procedures, surgical operations, and traumatic injuries to the oral and maxillofacial region often occur in close proximity to peripheral branches of the fifth (trigeminal) cranial nerve. Such clinical situations include local anesthetic injection, removal of teeth, placement of dental implants, ablative and reconstructive procedures, and fractures of facial bones, among many others, including endodontic therapy and orthognathic surgery. Such clinical situations include, among others, local anesthetic injections, removal of teeth, endodontic treatment, placement of dental implants, ablative, reconstructive and cosmetic operations, traumatic facial injuries, and orthognathic/craniomaxillofacial surgery. Despite the best of care, some nerve injuries are unavoidable; however, with careful planning, an excellent knowledge of regional anatomy and its possible variations, and modifications of surgical technique, the risk of injury to adjacent nerve structures may be reduced. In this chapter, the types of clinical scenarios that are associated with injuries to the peripheral branches of the trigeminal nerve will be presented, and measures that might be helpful in reducing these risks are discussed.