Evaluating the Role of the Self-Assembling Topical Haemostat PuraBond in Periorbital Ecchymosis Associated with Osteotomies in Septorhinoplasty.

To investigate the benefit of preoperative neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) in predicting early postoperative periorbital edema and ecchymosis in patients undergoing primary septorhinoplasty. Sixty patients in ASA-I (American Society of Anesthesiologists) who were scheduled for elective primary septorhinoplasty were prospectively included in the study. Periorbital edema and ecchymosis levels of the patients were scored on the postoperative second day. The relationship between early postoperative periorbital edema and ecchymosis levels and preoperative neutrophil, lymphocyte, platelet, NLR, and PLR values were investigated. The mean age of the 60 patients was 24.05 ± 6.83 years. The patients were divided into 2 groups according to the total periorbital edema scores in both eyes on the second day after surgery. There was no significant difference between the two groups in terms of neutrophil, platelet, and NLR ( P > 0.05). In addition, the lymphocyte count was found to be statistically significantly lower and PLR significantly higher in the group with high edema scores ( P < 0.05). When the patients were divided into groups according to their periorbital ecchymosis scores, no significant correlation was found between any blood values and periorbital ecchymosis ( P > 0.05). Preoperative PLR may be used to predict early postoperative periorbital edema in patients undergoing primary rhinoplasty. However, a blood value that can predict periorbital ecchymosis has not been determined yet.

Retrobulbar hemorrhage is a rare complication of blunt orbital trauma or periorbital, including cosmetic, surgery. Although all plastic surgeons are well aware of this complication, few have the unfortunate opportunity to experience this disaster in their practice. We present a case of a patient who developed retrobulbar hematoma after surgical treatment of left zygomatic fracture and blowout fracture of the orbital floor. Initial symptoms and signs of facial asymmetry, periorbital ecchymosis with upward gaze diplopia due to the fractures were noted and he was admitted for surgical treatment. Twenty hours after the surgery, the patient developed severe left eye pain and tenderness, massive swelling of left periorbital tissue with proptosis. Palpation revealed a stony hard left eyeball and his visual acuity bad also deteriorated. Retrobulbar hematoma was suspected and emergent surgical and medical treatments were instituted. The patient recovered well from the incident and developed no other sequelae after 4 months of follow up. A review of literature on the etiologies, diagnosis, surgical and medical modalities in treating this complication are also presented.

BackgroundPeriorbital edema and ecchymosis following rhinoplasty is disturbing for both the patients and their surgeons. The study aim was to determine whether nasal packing after lateral osteotomies in rhinoplasty surgery increases the risk of periorbital ecchymosis post-operatively.MethodsThis was a prospective self-controlled single-blinded study. Seventy four patients who underwent rhinoplasty with bilateral lateral osteotomies by a single surgeon were enrolled in the study. Nasal cavity packing for one side was done while the other side was left unpacked. Periorbital ecchymosis was evaluated by the operating surgeon and a separate surgeon who is unaware of the packing side separately on the first, fourth and seventh day post-operatively. A 4-grade scale was utilized to assess the ecchymosis with grade 4 being the most severe.ResultsNasal packing was found to significantly increase the severity and duration of periorbital ecchymosis post rhinoplasty. While no difference was observed between the packed and unpacked sides on the first post-operative day, significant difference was noted on the 4th day (mean score 2.36 and 1.15 for the packed and unpacked sides, respectively) and on the 7th day after surgery in favor of the unpacked side (score 1.24 and 0.61 for the packed and unpacked sides, respectively).ConclusionWe advise against the routine use of nasal packing in rhinoplasty unless necessary as it contributes to worsen the periorbital ecchymosis from lateral osteotomies and thereby increases the patients’ “down time” after surgery.

Endoscopic retrograde cholangiopancreatography (ERCP) is a conventional technique for diagnosis and treatment of pancratobiliary diseases, which is associated with various complications, including pancreatitis, hemorrhage, cholangitis, perforation, and mortality. In our case, a 69-year-old woman with positive hepatobiliary symptoms underwent ERCP, at the end of which a rare complication (raccoon eye) occurred, which was hypothesized to be due to amyloidosis, but the patient refused to complete the diagnostic procedure and became symptom free after 3 weeks. Racoon eye or periorbital ecchymosis is caused by blood tracking into periorbital tissues, which is frequently observed after head trauma but is also observed in systemic diseases, such as amyloidosis, neuroblastoma, and surgical interventions. To the best of our knowledge, this is the first report of raccoon eye after ERCP; further reports will help to confirm that this complication should also be considered before performing ERCP and that complete diagnostic tests for the predisposing diseases prior to ERCP are necessary.

Trauma is an inevitable phenomenon in paediatric population, be it mild, moderate or severe. Homoeopathic, a form of alternative system, is known for long standing chronic diseases but often slighted in acute medical conditions. As being the case, we would like to see how homoeopathy would respond to a traumatic case. Raccoon eye sign (RES) or Periorbital Ecchymosis (PE) is caused by blood tracking into periorbital tissues, which is frequently observed after head trauma but is also observed in systemic diseases, such as amyloidosis, neuroblastoma, and surgical interventions. A 7 year old boy presented with unilateral periorbital ecchymosis due to trauma and homoeopathic treatment brought out remarkable change in the ecchymosis and subconjunctival hemorrhage and clinical resolution of the hemorrhagic lesions.

The aim of this study was to determine the predictive value of 4 clinical signs (periorbital ecchymosis, periorbital emphysema, diplopia, and inferior orbital nerve hypoesthesia) for the diagnosis of orbital fractures (OFs) and the need for surgical treatment in patients with orbital trauma. The investigators designed and implemented a retrospective cohort study composed of patients with orbital trauma. The primary and secondary outcomes were respectively the diagnosis of OFs and the need for surgical treatment. Multivariable logistic regressions including the clinical signs, age, and causes of injury were used to determine the independent contribution of each clinical sign to the prediction of the outcomes and to obtain weights to compute OF and surgery scores. The outcomes were assessed by receiver-operating characteristic (ROC) curves, sensitivity, specificity, and positive and negative predictive values. A total of 912 patients were included. All clinical signs except periorbital ecchymosis were significantly associated with OFs and the need for surgical treatment (P < 0.001). The predictive power of each clinical sign taken separately was moderate for the 2 outcomes (area under ROC curve [AUC] <0.7). A better predictive value was found when all clinical signs were used together (AUC >0.7). Patients with an OF score >3 were likely to have an OF and patients with a surgery score ≤2 were unlikely to have surgery.The present study demonstrated that our OF and surgery scores resulted in an effective model that allowed the stratification of patients with orbital trauma based on their risk of having OFs and risk of needing a surgical treatment.

Study DesignRetrospective case series.PurposeTo determine the incidence of cervical radiculopathy requiring operative intervention by level and to report on the methods of treatment.Overview of LiteratureCervical radiculopathy is a common cause of pain and can result in progressive neurological deficits. Although the pathology is well understood, the actual incidence of cervical radiculopathy at particular spinal levels ultimately requiring operative intervention is unknown.MethodsA large consecutive series of patients operated on by a single surgeon were retrospectively analyzed. The incidence of cervical radiculopathy at each level was defined for every patient. Procedures used for operative treatment were noted. Health related quality of life (HRQL) scores were collected both pre-operatively and postoperatively.ResultsThere were 1305 primary and 115 revision operations performed. The most common primary procedures performed were anterior cervical discectomy and fusion (ACDF, 50%) and anterior cervical corpectomy and fusion (ACCF, 28%). The most commonly affected levels were C6 (66%) and C7 (62%). Reasons for revision were pseudarthrosis (27%), clinical adjacent segment pathology (CASP, 63%), persistent radiculopathy (11%), and hardware-related (2.6%). The most common procedures performed in the revision group were posterior cervical decompression and fusion (PCDF, 42%) and ACDF (40%). The most commonly affected levels were C7 (43%) and C5 (30%). Among patients that had their index surgery at our institution, the revision rate was 6.4%. In both primary and revision cases there was a significant improvement in Neck Disability Index and visual analogue scale scores postoperatively. Postoperative HRQL scores in the revision cases were significantly worse than those in the primary cases (p <0.01).ConclusionsThis study provides the largest description of the incidence of cervical radiculopathy by level and operative outcomes in patients undergoing cervical decompression. The incidence of CASP was 4.2% in 3.3 years in this single institution series.

Chylous ascites: a case of child abuse and an overview of a rare condition.

Coronavirus disease 2019 (COVID-19) could be complicated by venous or arterial stroke. However, to the best of our knowledge, there is a limited number of cases reported to develop cavernous sinus thrombosis (CST) after COVID-19. Herein, we present a 61-year-old diabetic male with persistent pain in his right forehead and periorbital region after COVID-19 pneumonia and diagnosed with CST after developing diplopia and periorbital ecchymosis. Magnetic resonance imaging revealed right maxillary sinusitis, inflammatory changes extending through the medial wall of the orbit and medial rectus muscle. CST was diagnosed. The mucormycosis was diagnosed by examining the extracted material with surgical thrombectomy. Appropriate surgical intervention, anticoagulant, and antifungal treatment yielded in a significant improvement in pain and orbital movements. In conclusion, in the presence of prothrombotic risk factors, like uncontrolled diabetes or recent COVID-19 infection, the physicians should consider the probability of CST in the differential diagnosis of persistent periorbital headache.

Superior orbital cleft syndrome is a complex of signs and symptoms developed from damage to noble vascular and neurological structures that are found in the orbital cavity, more precisely in the region of the superior orbital fissure. The objective of this study is to report a case of superior orbital cleft syndrome after facial trauma, detailing and discussing the therapy adopted, as well as the challenges of surgical treatment. A 31-year-old male patient, melanoderma, victim of physical aggression, presented to the emergency room of the General Hospital of the State of Bahia, with facial trauma caused by physical aggression. Oral and maxillofacial physical examination revealed preserved facial contours in the upper and lower thirds of the face, bone steps in frontozygomatic and infraorbital rim regions, facial flattening in the malar region on the left, visual acuity preserved bilaterally, extrinsic orbicularis motricity preserved in the right eye and presence of total ophthalmoplegia in the left eye, exophthalmosis, periorbital ecchymosis and upper eyelid ptosis in the left eye, pupil in the left eye was not photoreactive, nasal bones and maxillae were stable, there was no mobility atypical to the manipulation of the mandible, partial edentulism in both arches, and stable dental occlusion. hypoesthesia in the frontal and infraorbital regions, both on the left. Facial computed tomography showed fractures of the orbitozygomatic-maxillary complex (MCOC), roof and floor of the orbit, all on the left, as well as the presence of bone synthesis material in an appropriate position in the region of the left mandibular angle resulting from previous facial trauma treatment. The proposed surgical treatment was osteosynthesis of the orbitozygomatic-maxillary complex and conservative treatment of roof and floor fractures of the orbit, which was successfully performed by the oral and maxillofacial surgery and traumatology team. In the postoperative period, the patient had a good evolution without significant clinical complications, and remains under clinical follow-up to the present day. Thus, the present study highlights the importance of accurate diagnosis and appropriate treatment of this syndrome, emphasizing the need for an individualized therapeutic approach, considering the signs and symptoms and the risks involved. Therefore, it is essential for the professional to know about the clinical presentation and etiological factors of this condition to avoid possible diagnostic errors and the use of inappropriate forms of treatment so that health, function and aesthetics can be returned to these patients.

Introduction. Septorhinoplasty is one of the most commonly performed cosmetic surgical procedures, used both to enhance the aesthetic appearance of the nose and to restore its function. Traditionally, the bony vault and lateral walls are reshaped using mechanical instruments such as saws, chisels, osteotomes, and rasps. Additionally, electrically powered rasps, burs, and files have been specifically developed for rhinoplasty to improve surgical outcomes. However, these conventional methods have certain limitations, including prolonged surgical time, an increased risk of soft tissue damage, greater mechanical impact, and challenges in performing lateral osteotomies. In response to these challenges, surgeons have increasingly adopted ultrasonic instruments with a piezoelectric drive for bony vault modification and lateral osteotomy, offering greater precision and reduced trauma to surrounding tissues. Objective: to analyze the main results of piezoelectric and traditional osteotomy when performing septorhinoplasty. Materials and methods. This study was conducted on 44 patients, who were divided into two groups. The first group (control) consisted of 22 patients who underwent septorhinoplasty using traditional methods. The second group (research) also included 22 patients, in whom the piezoelectric technique was utilized to achieve surgical outcomes in septorhinoplasty. All patients underwent primary septorhinoplasty using either the closed or open approach. Piezoelectric surgery was performed with the VarioSurg3 NSK piezotome (Japan), ensuring precise bone modification with minimal soft tissue trauma. Results. The study was conducted on the first, third and seventh days after surgery. The study was conducted on the first, third, and seventh days after surgery, evaluating the following parameters: intraoperative complications (mucosal damage) and postoperative complications, including eyelid swelling, periorbital ecchymoses, nasal secretion activity, inflammatory reaction of the nasal cavity, and postoperative pain. In the second group, where septorhinoplasty was performed using a piezotome, significantly fewer cases of mucosal damage were observed compared to the first group. Additionally, the severity of postoperative complications in the second group was statistically significantly lower than in the control group (p&lt;0.05). An assessment of the effectiveness of the piezotome in septorhinoplasty demonstrated a reduced incidence of both intraoperative and postoperative complications, including eyelid swelling, periorbital ecchymoses, nasal discharge, inflammatory reactions in the nasal cavity, and postoperative pain. The reduced occurrence of intraoperative mucosal damage contributed to improved postoperative recovery, overall well-being, and higher patient satisfaction. Conclusions. The use of a piezotome enables precise, programmed remodeling of the external nasal skeleton. Piezoelectric surgery offers several advantages over traditional osteotomy methods, including selective action on soft tissues and greater precision in bone modification. The application of piezotomy in rhinoplasty has led to improved surgical techniques and a statistically significant reduction in both intraoperative and postoperative complications.

Success and satisfactory results in rhinoplasty are established not only with flawless surgery but also with meticulous perioperative care. Pain stays at the centre of these circumstances. Besides, several contributing perioperative factors such as periorbital edema and ecchymosis play key role on the patients' comfort. Septorhinoplasty was carried out in 50 patients between February and May 2014 under general anesthesia. Local anesthesia with lidocaine and adrenaline combination was done prior to incision. Following the procedure, silicone gel packs were applied. One periorbital region was cooled after surgery whereas the opposite site was left uncooled. Periorbital edema-ecchmosis and pain intensity were graded and noted 1 hour, 1 day, 3 days, 1 week and 1 month after surgery. Cold application seriously reduced postoperative edema and ecchymosis at the first week (p=0.001 for the first 3 days and p=0.006 at first week). Pain was reduced with cooling not on the first hour (p&gt;0.05), but on the forthcoming days throughout the first week (p<0.005). Operation time revealed that primary cases were carried out quicker than revisional surgery. Moreover, pain scores were found lower in primary cases than revisions, especially in the first 3 days. These finding were approved statistically. Cooling of the periorbital region reduces edema and ecchymosis as well as pain; however 3 days of use is enough after rhinoplasty. One hour after surgery, cooling does not affect the pain but reduce edema and ecchymosis.

Success and satisfactory results in rhinoplasty are established not only with flawless surgery but also with meticulous perioperative care. Pain stays at the centre of these circumstances. Besides, several contributing perioperative factors such as periorbital edema and ecchymosis play key role on the patients' comfort. Septorhinoplasty was carried out in 50 patients between February and May 2014 under general anesthesia. Local anesthesia with lidocaine and adrenaline combination was done prior to incision. Following the procedure, silicone gel packs were applied. One periorbital region was cooled after surgery whereas the opposite site was left uncooled. Periorbital edema-ecchmosis and pain intensity were graded and noted 1 hour, 1 day, 3 days, 1 week and 1 month after surgery. Cold application seriously reduced postoperative edema and ecchymosis at the first week (p=0.001 for the first 3 days and p=0.006 at first week). Pain was reduced with cooling not on the first hour (p&gt;0.05), but on the forthcoming days throughout the first week (p<0.005). Operation time revealed that primary cases were carried out quicker than revisional surgery. Moreover, pain scores were found lower in primary cases than revisions, especially in the first 3 days. These finding were approved statistically. Cooling of the periorbital region reduces edema and ecchymosis as well as pain; however 3 days of use is enough after rhinoplasty. One hour after surgery, cooling does not affect the pain but reduce edema and ecchymosis.

Pediatric Head Injury

Tubularized incised plate urethroplasty with dorsal inlay graft prevents meatal/neourethral stenosis: a single surgeon's experience