Anterior Border Research Articles

One burr-hole craniotomy: Enough lateral approach to foramen magnum in helsinki neurosurgery.

Background:In this video-abstract, we present a one burr-hole craniotomy for the enough lateral approach (ELA) to the foramen magnum developed in Helsinki Neurosurgery, a less invasive variant of the classical far lateral approach. ELA does not require the resection of the occipital condyle nor the exposure of the extracranial/intraosseal course of the lower cranial nerves. The vertebral artery is not transposed and the sigmoid sinus is not skeletonized. ELA allow us to access lesions that are close to the level of the foramen magnum (less than 10 mm). In this regard, low-lying vertebral aneurysms, foramen magnum meningiomas, or low brainstem cavernomas and intrinsic tumors are our common indications for this approach.Case Description:The patient with a foramen magnum meningioma is placed in park bench position with slight backward rotation and elevation of the upper body to maintain the head around 20 cm above the cardiac level. The correct positioning of the head requires slight forward flexion, contralateral rotation, and contralateral tilt to open the angle with the upper shoulder. Under microscopic vision, a straight incision is made behind the mastoid process running between the zygomatic line and 4–5 cm below to the level of the mastoid process. The suboccipital muscles are split with electrocoagulation while the vertebral artery is recognized by digital palpation. Blunt dissection with cotton balls is performed at the occipitocervical junction. Strong retraction maintains a clean space for the craniotomy. A single burr-hole is placed at the posterior border of the craniotomy, and a small 3 × 4 cm craniotomy is performed over the anterior border of the intradural origin of the vertebral artery. The anterior lateral border of the craniotomy is reached under visual control using a diamond drill. In this regard, one more burr hole opposite to the first one would be a tiring and difficult procedure deep inside the lateral margin of the craniotomy. The dura is opened based on the sigmoid sinus and cerebrospinal fluid is released. Finally, under high microscopic magnification, the lesion is properly removed.Conclusion:The described procedure may represent a more efficient lateral approach to the foramen magnum.Videolink:http://surgicalneurologyint.com/videogallery/enough-lateral-approach-for-the-foramen-magnum/

A Bilateral, Non-syndromic, Type III Second Branchial Arch Sinus in a Neonate: a Case Report

- in cases of a bilateral second branchial arch sinus, the branchio-oto-renal (BOR) or branchio-otic (BO) syndromes must be excluded; - ultrasound scan can be used for the thorough evaluation of the sinus anatomic course and the relationship with the adjacent anatomic structures; - rompt diagnosis and early therapeutic intervention, even during neonatal period, ensures an uneventful post-operation course.

Radiobiological doses, tumor, and treatment features influence on outcomes after epiescleral brachytherapy. A 20-year retrospective analysis from a single-institution: part II.

PurposeTo assess the influence of the radiobiological doses, tumor, and treatment features on retinopathy, cataracts, retinal detachment, optic neuropathy, vitreous hemorrhage, and neovascular glaucoma at the authors’ institution after brachytherapy for posterior uveal melanoma.Material and methodsMedical records of 243 eyes with uveal melanoma, treated by iodine brachytherapy between 1996 and 2016 at a single center were analyzed. Clinical and radiotherapy data were extracted from a dedicated database. Biologically effective dose (BED) was included in survival analysis performed using Kaplan-Meier and Cox regressions. Relative survival rates were estimated, and univariate/multivariate regression models were constructed for predictive factors of each item. Hazard ratio and confidence interval at 95% were determined. Variables statistically significant were analyzed and compared by log-rank tests.ResultsThe median follow-up was 73.9 months (range, 3-202 months). Cumulative probabilities of survival by Kaplan-Meier analysis at 3 and 5 years, respectively, were: 59% and 48% for retinopathy; 71% and 55% for cataracts; 63% and 57% for retinal detachment; 88% and 79% for optic neuropathy; 87% and 83% for vitreous hemorrhage; 92% and 89% for neovascular glaucoma, respectively. Using multivariate analysis, statistically significant risk factors were: age, tumor apical height, dose to foveola, and location of anterior border for retinopathy; age, dose to lens, type of plaque, and tumor shape, for cataracts; age, tumor apical height, and size of the plaque for retinal detachment; age, plaque shape, longest basal dimension, and BED to optic nerve for optic neuropathy; age, tumor apical height, and tumor shape for vitreous hemorrhage; tumor apical height and BED to foveola for neovascular glaucoma.ConclusionsTumor factors in addition to radiation treatment may contribute to secondary effects. Enhanced clinical optimization should evaluate radiobiological doses delivered to the tumor volume and surrounding normal ocular structures.

Kliničke karakteristike u pacijenata sa infarktom mozga u graničnoj oblasti arterije cerebri medije

Introduction: Clinical features of the ischemic neurovascular syndromes is constant and dependable from vascular territory of the affected blood vessel. Best examples are sensory and motor hemisyndromes and vision disturbances. Aim: To define motor, sensory and visual disturbances' in patients with ischemic stroke in the border zone of the middle cerebral artery. Material and methods: Border zone ischemic stroke diagnosis was based on clinical and neurological examination and confirmed with brain computerized tomography. Estimation of the symptoms was obtained by history, and degree of functional (neurological) deficit was estimated based on NIH-NINDS scale. Results: In total 30 patients were included in the study, 12 (40%) were females 47-79 years of age (±62.3 years) and 18 (60%) males 43-79 years of age (± 58.7 years). Neurological features were clearly different based on the side of the infarct. In the group with (ACA+ACM) + (ACM+ACM) infarct localization hemiparesis is significantly more frequent. In the group with ACM+ACP infarct localization homonymous hemianopia is significantly more frequent. Initial symptom of the reversible loss of consciousness in duration of several minutes was observed in 14 (46.6%) patients. Focal seizures (clonic seizures of the face, arm and leg) were detected in 4 (13.3%) patients (all with infarcts in the anterior border zone ACA-ACM). Headache was rare manifestation seen in 5 (16.6%) patients with 4 having posterior border zone infarcts. Conclusion: Supratentorial border zone infarcts have high specificity in clinical manifestations. The implicates therapeutical approaches which are prone to specific procedures.

One burr-hole craniotomy: Upper retrosigmoid approach in helsinki neurosurgery.

Background:In this video-abstract, we present a one burr-hole craniotomy for the upper retrosigmoid approach developed in Helsinki Neurosurgery to access the lateral cerebellar hemisphere, the cerebellopontine angle, and lateral skull base (e.g. including the posterior petrous bone). This approach may be utilized to manage tumors of the lateral posterior fossa and to perform microvascular cranial nerve decompression of the V or VII cranial nerves. The upper portion of the vertebral-posterior cerebral artery complex, and the anterior inferior cerebellar artery may also be accessed with this technique. Even though the specific location and size of the lesion may vary, this approach accesses all mentioned structures with a very minimal variation.Case Description:The patient with an unsuspected right cerebellopontine angle metastasis from a lung cancer is placed in the park bench position. Spinal drainage is inserted to release 50–100 ml of cerebrospinal fluid. The head and upper torso are elevated so that the head is about 20 cm above the heart level. A single-layer skin incision is made about one inch behind the mastoid process; the exact cranial to caudal location of the incision varies depending on how high or low one has to be from the foramen magnum and locus of pathology. The junction of the sigmoid and the transverse sinus is usually located just caudal to the zygomatic line, between the zygoma and the external occipital protuberance, and posterior to the mastoid line that is running caudally through the tip of the mastoid process. Dissection with curved retractors creates a clean space for the craniotomy. First, a burr-hole is made at the posterior border of the bone flap. Two curved cuts are made towards the mastoid process, allowing the sigmoid sinus to be partially exposed. The bone is cracked after thinning the anterior border of the craniotomy. A few drill holes are then made for tacking-up sutures. Finally, a sinus-based dura opening is performed under the microscope.Conclusion:Here, we described a one burr-hole craniotomy that provides an excellent approach to retrosigmoid lesions.Videolink:http://surgicalneurologyint.com/videogallery/retrosigmoid-approach

Assessing the variation in course and position of inferior alveolar nerve among south Indian population: A cone beam computed tomographic study.

Trauma to the inferior alveolar nerve (IAN) is one of the complications during surgical procedures in the posterior mandible. Most of the time, this is due to inaccurate assessment of an operator from conventional radiographs. Lately, with the availability of advanced imaging techniques such as cone beam computed tomography (CBCT), precise location of anatomic structures has become a reality. This study was designed to evaluate the course and position of IAN in relation to the alveolar crest, buccal cortical bone, lingual cortical bone, and inferior border of the mandible using CBCT in South Indian population. A total of 139 CBCT scans were assessed using sagittal section done at every 5-mm interval beginning 1 mm posterior to the mental foramen extending till the anterior border of the ramus. Measurements were made on sectional images as CN - alveolar crest to the nerve, BN - buccal cortex to the nerve, LN -lingual cortex to the nerve, and IN - inferior border to the nerve. IAN showed a wavy pattern from posterior to anterior in relation to the alveolar crest and was positioned inferiorly in males when compared to females at Section one of CN1 (P = 0.004). IAN was more away from the lingual cortex in dentulous compared to partially dentulous group (P = 0.003). Females showed more bone present lingual to nerve near the first molar region. Gender and presence or absence of dentition had an influence on overall results. There is a considerable variation in the position of IAN throughout its course in the mandible. Henceforth, advanced diagnostic images such as CBCT should be strongly recommended in evaluating the position of IAN preoperatively before advanced implant surgical techniques, nerve repositioning, and any other surgical procedures.

One burr-hole craniotomy: Posterior interhemispheric approach in Helsinki Neurosurgery.

Background:In this video abstract, we present a one burr-hole craniotomy for the posterior interhemispheric approach developed in Helsinki Neurosurgery to access posteriorly the medial surface of cerebral hemispheres, falx cerebri, and deep midline cerebrovascular structures. Therefore, preoperative imaging is essential to achieve an optimal operative corridor for a safest and more effcient approach.Case Description:The patient with a papillary tumor of the pineal region is placed in sitting position. A midline single-layer skin incision is made in front of the superior sagittal sinus. Strong retraction maintains a clean space for craniotomy. Aiming to reduce the risk of sinus transgression or cortical veins damaging in the eloquent frontal–parietal area, a burr-hole is made over the superior sagittal sinus at the anterior border of the bone flap and the bone is detached from the dura posteriorly with blunt dissectors. Thus, proximal detachment of the dura under some visual control remains safe. A long blunt flexible dissector is used during this stage in case of elderly patients with an adherent dura. Craniotomy around the superior sagittal sinus is performed to expose 2–3 cm of the dura lateral to the sagittal sinus according to the exact location of the lesion. Moreover, craniotomy extends slightly over the contralateral side to allow some retraction of the sagittal sinus. Two cuts, from both sites of the burr-hole, are joined along the posterior midline. A few drill holes are made for tack-up sutures. Finally, a hemostatic agent covers the sagittal sinus and a sinus-based dura opening is performed under the microscope.Conclusion:The described one burr-hole craniotomy may represent a more efficient manner for performing a posterior interhemispheric approach.Videolink:http://surgicalneurologyint.com/videogallery/posterior-interhemispheric-approach

Correlation of Mandibular Foramen to Occlusal Plane as a Clinical Guide for Inferior Alveolar Nerve Block in Children: A Digital Panoramic Radiographic Study.

Aim:The study aimed to correlate the position of mandibular foramen with occlusal plane as a clinical guide for inferior alveolar nerve block (IANB) injection in children from 3 to 13 years of age.Materials and Methods:The study was carried out on 180 children visiting our department and required orthopantomogram as a routine diagnostic aid. Mandibular casts were obtained and radiographs were digitally analyzed to obtain linear and angular measurements.Statistical Analysis:The measurements were correlated with the position of mandibular foramen with Karl Pearson's correlation test.Results:The results of the study suggest that the needle for IANB should be placed below the occlusal plane in 3–4-year-old children (1.26 mm approximately), almost at the level of occlusal plane in 5–7 years (0.33 mm), above the occlusal plane in 7–9 years (1.54 mm), 9–12 years (1.64 mm), 11–12 years (1.98 mm), and 12–13 years (2.9 mm), respectively. The distance of the mandibular foramen from anterior border of mandible was greater than that from posterior border. The gonial angle values decrease with increasing age.Conclusion:The bony landmarks within the jaws keep changing their relative positions along with the skeletal growth. It is therefore necessary to modify the placement of needle during local anesthesia techniques with advancing age.

Course of buccal nerve on the anterior border of mandibular ramus related to temporalis tendon

The purpose of this study was to examine the course of the buccal nerve on the anterior border of mandibular ramus in relation to superficial and deep tendons of the temporalis muscle. Distance was measured from the lingula level to each of the two points where the buccal nerve crosses over the deep tendon on the lingual side and the superficial tendon on the buccal side. The buccal nerve crossed over the deep tendon at approximately 2.4 cm above the lingula level and descended infero-laterally over the superficial tendon at approximately 0.2 cm above the lingula level towards the buccal side. In a dentulous adult, lingula is located approximately 1 cm above the occlusal plane. Therefore, when making incisions on the mandibular ramus beyond the occlusal plane, clinicians must be careful because the buccal nerve and temporalis tendons can be damaged.

Redescription of Nerocila exocoeti Pillai, 1954 (Crustacea: Isopoda: Cymothoidae) parasitic on beloniform (Exocoetidae and Hemiramphidae) hosts with Nerocila madrasensis Ramakrishna Ramaniah, 1978 placed into synonymy.

Nerocila exocoeti Pillai, 1954 is re-described based on the neotype and additional material from exocoetid hosts. Nerocila madrasensis Ramakrishna Ramaniah, 1978 (from Madras) is placed into synonymy with N. exocoeti. Nerocila exocoeti is characterized by the presence of short coxae, postero-lateral angles of the first five pereonites not backwardly produced, pereonites 6-7 are reduced, cephalon sub-quadrate with anterior border straight; first antenna composed of eight articles and endopod of uropod half the size of exopod. Nerocila exocoeti is only known from beloniform hosts; Parexocoetus brachypterus and Exocoetus volitans (Exocoetidae); Hemiramphus sp. and Rhynchorhamphus malabaricus (Hemiramphidae) are the identified hosts for the species.

Radiographic Analysis of Psoas Morphology and its Association With Neurovascular Structures at L4-5 With Reference to Lateral Approaches.

Retrospective imaging review. Utilize magnetic resonance imaging (MRI) to expand the anatomical description of psoas morphology and its association with neurovascular structures at L4-5. Anatomical psoas muscle variants may present a greater risk of neurovascular injury at the L4-5 level during lateral transpsoas approaches. Axial L4-5 sections of consecutive patients who obtained lumbar MRIs were analyzed. Teardrop psoas morphology was assessed qualitatively. MRI described psoas morphology and proximity of neurovascular structures, whereas plain radiographs were evaluated for lumbosacral transitional vertebrae (LSTV). Teardrop morphology was tested for associations with radiographic measurements using t tests and χ analysis. Fifty teardrop and 476 nonteardrop psoas muscles were identified. Teardrop morphology was associated with greater longitudinal length (53.1 vs. 49.3 mm, P = 0.012), and shorter transverse length (34.9 vs. 44.8 mm, P < 0.001) compared with nonteardrop. Teardrop morphology was associated with anterior and lateral migration of the psoas with greater distance between the anterior borders of the psoas and disc (13.5 vs. 6.3 mm, P < 0.001), and greater distance between the medial border of the psoas to the lateral disc border (1.6 vs. 0.5 mm, P < 0.001). Teardrop morphology was associated with a higher incidence of the lumbar plexus migrating anteriorly adjacent to the middle-third of the disc (43.4% vs. 17.6%, P < 0.001) and the iliac vasculature being more laterally and posteriorly located, adjacent to the anterior-third of the disc (43.4% vs. 30.0%, P = 0.047). Teardrop morphology was not associated with presence of LSTV (3.8% vs. 7.6%, P = 0.306). The current study provides detailed metrics of teardrop psoas muscles and surrounding structures. The study confirms that the presence of teardrop anatomy on L4-5 axial imaging is associated with anterior migration of the lumbar plexus and posterolateral migration of the iliac vasculature which may increase the risk of neurovascular injury during direct and oblique-lateral lumbar spine procedures. 3.

A new method to locate the radial head "safe zone" on computed tomography axial views.

Direct location of the "safe zone" on a CT axial view is impossible because the radial head is circular in shape. Previous "safe zone" location methods are not appropriate if the physician is unable to visualize the actual radial head. This study aims to introduce a new method to locate the "safe zone" on CT. CT scans were performed on 20 intact cadaveric upper limbs from 20 different corpses in full pronation and supination. The DICOM-format raw data were then re-sliced and analyzed in Mimics 17.0 (Materialise, Belgium). The radial interosseous border (IB) is shaped like a droplet on the axial view; its axis was selected as our reference line (RL). A parallel line in the radial head axial slice was created, and its position relative to the "safe zone" was studied. Deviation in RL direction was evaluated. Safe-zone scope was 114.41°±11.99. The rotation angle from the RL to the safe-zone's anterior and posterior border was 215.03°±5.99 and 100.62°±8.12, respectively. Rotation direction (clockwise or anti-clockwise) depended on relative radius-ulna position. The safe zone was located by determining these two borders. The reference line's direction was stable in the upper half of the IB; its distance to the radial head fovea was 77.33° mm±6.24. The radial head "safe zone" can be located on CT axial view based on the upper half of the IB using this new method. The method is clinically applicable to determine whether postoperative elbow malrotation results from plate impingement.

Morphological alterations in the position of the mandibular foramen in dentate and edentate mandibles.

The technique of inferior alveolar nerve (IAN) block must be based on precise anatomical knowledge regarding the correct position of the mandibular foramen (MF). The aim of the investigation reported here was to determine the anatomic and topographic localization of the MF according to mandibular ramus anatomic landmarks and to identify morphological alterations in the position of the MF and size and shape of the ramus in terms of the impact of tooth socket loss in the molar and premolar region. Seventy-three dry human adult mandibles were divided into two groups according to dental status. These were measured to determine the distances from the anterior and posterior ramus border (AB, PB) to the midpoint of the MF fossa, and from the mandibular notch (MN) and inferior ramus border (IB) to the MF entering point. A number of relevant ramus anatomic features were analyzed, such as ramus width (RW), height (RH), and thickness (RT). The MF was closer to the PB and IB in edentate mandibles (right/left mean PB-MF 10.66±1.84/11.06±2.05mm; right/left mean IB-MF 21.77±3.23/21.8±2.27mm) compared to dentate mandibles (right/left mean PB-MF 11.87±2.08/12.04±1.94mm; right/left mean IB-MF 22.94±3.09/22.74±3.74mm). Edentate mandibles demonstrated reduced RW (right/left mean RW 26.03±3.53/26.49±3.90mm), significantly reduced (p=0.03) right RH (right/left mean RH 43.56±4.74/45.43±4.86mm), and significantly reduced (p<0.05) RT in the area of the MF fossa depression (right/left mean RT 5.52±1.21/5.21±0.91mm) compared to dentate mandibles (right/left mean RW 27.34±3.84/27.48±3.80mm; right/left mean RH 46.33±4.52/47.40±4.20mm; right/left mean RT 7.86±1.98/8.10±1.92mm). Alterations in MF position and mandibular ramus anatomic features in edentate mandibles increase the potential risk of complications and failure of IAN block.

Postoperative Regression of Retro-odontoid Pseudotumor After Atlantoaxial Posterior Fixation: 11 Years of Experience in Patients With Atlantoaxial Instability.

Case series study. The aim was to investigate the incidence of retro-odontoid pseudotumor in patients with atlantoaxial instability (AAI) and evaluate pseudotumor regression after posterior fixation. The incidence of retro-odontoid pseudotumor in atlantoaxial instability patients remains uncertain. Moreover, the regression of retro-odontoid pseudotumor after posterior fixation in patients with various underlying diseases needs to be further investigated. From July 2004 to August 2015, 175 patients with AAI underwent posterior fixation operations at our institution. After excluding 11 patients (previous operation, n = 4; history of tumor, n = 7), the final study population comprised 164 patients. The final study population was categorized according to their underlying diseases (rheumatoid arthritis [RA], os odontoideum, atlanto-occipital assimilation, dens fracture, AAI of unknown cause, etc.) and age (adult and pediatric groups). The incidence of retro-odontoid pseudotumor in each group was analyzed. Pre- and postoperative magnetic resonance or computed tomography images were reviewed to assess its regression following surgery. Of the 164 patients included, 38 had retro-odontoid pseudotumor (23.2%). Three were diagnosed with RA and the rest were non-RA patients including os odontoideum (n = 12), dens fracture (n = 6), atlanto-occipital assimilation (n = 4), Morquio syndrome (n = 1), and AAI of unknown cause (n = 12). Pseudotumor size regressed in all 38 patients after atlantoaxial posterior fixation. There was a statistically significant decrease in pseudotumor size (the length between the anterior border of the odontoid process to the posterior border of the pseudotumor) from a mean length of 17.7 to 14.9 mm (P < 0.001). The patients had various underlying diseases and the overall incidence of retro-odontoid pseudotumor in patients with symptomatic AAI was 23.2% at our institution during the past 11 years. All patients who underwent posterior fixation for AAI showed a statistically significant decrease in pseudotumor size. 4.

Unilateral Duplication Of Parotid Duct. A Rare Anatomical Variation

Background: The paired parotid glands are the largest of the major salivary glands and produces mainly serous secretions. The secretion of this gland reaches the oral cavity through single parotid duct (Stensen’s duct). The parotid duct begins at the anterior border of the gland, crosses the masseter muscle, and then pierces the buccinator muscle to reach the mucosa lining the mouth at the level of the cheek. The purpose of this study is determine the morphologic features of the parotid duct and describe an anatomical variation until now unreported.&#x0D; Methods and Findings: A total of 17 cadavers were used for this study in the Morphology Laboratory at the University of Pamplona. In a cadaver were findings: The main parotid duct originated two conducts: Left superior parotid duct and Left inferior parotid duct, is observed the criss-cross of the ducts, and then perforated the buccinator muscle and entered the oral cavity at a double parotid papilla containing a double opening, separated from each other in 0,98 mm. In the remaining 33 parotid regions (97.06%) the parotid duct is conformed to the classical descriptions given in anatomical textbooks.&#x0D; Conclusions: The parotid duct anatomy is important for duct endoscopy, lithotripsy, sialography and trans-ductal facial nerve stimulation in the early stage of facial palsy in some cases. The anatomical variations also has clinical importance for parotid gland surgery and facial cosmetic surgery. To keep in mind the parotid duct variation will reduce iatrogenic injury risks and improve diagnosis of parotid duct injury.

Rainure périnéale congénitale : à propos d’un cas

Perineal groove is a rare anoperineal congenital malformation, usually occurring in girls, unknown to many pediatricians. We report the case of a 17-day-old girl admitted for urinary infection, who presented a wet sulcus with mucous membrane, extending from the vaginal fourchette to the anterior border of the anus. The diagnosis of perineal groove was clinically confirmed, after elimination of misdiagnosis such as infection or trauma. This benign malformation tends to be self-epithelialized in the 1st year of life, and no surgical treatment is recommended, except for cosmetic reasons or for recurrent infections. This diagnosis must be known so as to avoid unnecessary explorations and anxiogenic misdiagnosis.

Lingual tonsillolith: prevalence and imaging characteristics evaluated on 2244 pairs of panoramic radiographs and CT images.

Lingual tonsilloliths are not as well-known to radiologists than palatine tonsilloliths, although they might be common in clinical practice. The aim of this investigation was to clarify the prevalence and imaging characteristics of lingual tonsilloliths using panoramic radiographs and CT images. This study included 2244 patients without pathology at the base of tongue who had undergone panoramic radiography and CT of the maxillofacial region. The size, number and position of lingual tonsilloliths relative to the mandible and tongue were evaluated. Lingual tonsilloliths were observed in 33 (1.5%) and 108 (4.8%) of all patients on panoramic radiographs and CT images, respectively. The prevalence was higher in patients aged ≥40 years than in those aged < 40 years (χ2, p < 0.01). They appeared as small, round- or rod-shaped calcified bodies, and they always located closely anterior (1-17 mm) to the anterior border of oropharyngeal airway on panoramic radiographs. Lingual tonsilloliths were superimposed over the surrounding soft tissue inferior to the body of the mandible, posteroinferior to the angle of the mandible and posterior to the mandible in 16 (48.5%), 15 (45.5%) and 1 (3.0%) individual, respectively. A significant correlation was observed between the detectability on panoramic radiographs and size (Spearman's r = 0.961, p < 0.01) of tonsilloliths, as revealed by CT images. Lingual tonsilloliths commonly appear on CT. They also appear on panoramic radiography and may superimpose the surrounding soft tissue of the mandible. Although lingual tonsilloliths may resemble other pathological calcifications including submandibular sialoliths and lingual osseous cholistoma, they can be differentiated by carefully observing panoramic radiographs. When clinicians detect calcified bodies near the base of tongue, lingual tonsilloliths should be included in the differential diagnoses.

Cadaveric Study for Intraoral Needle Access to the Infratemporal Fossa: Application to Posterior Superior Alveolar Nerve Block Technique.

The posterior superior alveolar (PSA) nerve block is, from an anatomical perspective, challenging because the mandibular ramus and the zygomatic process of the maxilla can interfere with the course of the needle. Dentists empirically know that shifting the patient’s mandible to the ipsilateral side can improve visibility and accessibility for such blocks. This cadaveric study aimed to establish anatomical evidence for the ipsilateral mandible shifting used in the PSA. The distance between the lateral most bulging point of the alveolar part of the maxilla and ipsilateral anterior border of the ramus of the mandible ranged from 1.4 to 6.9 mm with a mean of 4.3 ± 1.6 mm. This result supports the empirical technique of shifting the mandible ipsilaterally for PSA nerve block.

Sternoclavicular Joint (SCJ) Septic Arthritis Presenting as Excruciating Cervical and Chest Pain With Intractable Hiccups

SESSION TITLE: Bacterial Infections 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: The SCJ is an unusual site of septic arthritis. It is involved in 0.5-1.0% of all joint infections and <0.5% of joint infections in healthy patients. The clinical signs of SCJ septic arthritis are chest pain localizing to SCJ (78%), fever (65%), and shoulder pain (24%). Here we present a case of SCJ septic arthritis with chest pain and intractable hiccup. CASE PRESENTATION: A 72-yo man, fell 1 month ago, was admitted for bacteremia. He was recently treated for pneumonia (PNA). Patient endorsed 3-day right-sided chest pain radiating from distal sternal border toward neck, with 2-day intractable hiccups. Patient had tender cervical/supraclavicular fullness with limited range of glenohumeral joint movement. WBC 17,300/uL with left shift. CXR showed right lower lobe (RLL) opacity. Rocephin and doxycycline were started. Given recent fall, chest pain, intractable hiccup, neck fullness, CT neck/soft tissue was order to evaluate for fracture, dislocation, subcutaneous emphysema, infection, or referred pain from diaphragmatic/pericardial pleural irritation in setting of RLL PNA. CT showed soft tissue infiltration centered in the right sternoclavicular region which extends inferiorly into the anterior mediastinum. There is superior extension along the right lateral anterior border of the thyroid, deep to the sternocleidomastoid. Infiltrated/inflamed fat interdigitates between the carotid artery and the thyroid on the right. The findings were most consistent with septic right SCJ, cellulitis/myositis of the right sternocleidomastoid, and phlegmon extending into the anterior mediastinum. ESR 72 mm/hr, CRP 248.3 mg/L. Blood cultures grew S. aureus. He was treated with 6-week rocephin. There was no indication for acute surgical intervention. On follow up, WBC 5500/uL, ESR 51 mm/hr, CRP 40.6 mg/L. DISCUSSION: Common risk factors for SCJ septic arthritis include IVDU (21%), infection at distant site (15%), diabetes mellitus (13%), trauma (12%), and infected central venous line (9%). No risk factors were found in 23% of patients with SCJ septic arthritis. The route of infection is often unknown. Management of SCJ septic arthritis consists of surgical debridement and IV antibiotics. The rate of positive cultures with needle aspiration is 77%, surgical debridement 36%, and blood cultures 13%. Typical causative organisms: S. aureus (49%), P. aeruginosa (10%), Brucella melitenis (7%), E. coli (5%), less frequently M. tuberculosis. CONCLUSIONS: SCJ septic arthritis may lead to serious complications such as osteomyelitis, chest wall abscess, mediastinitis, myositis, with irreversible tissue damage. Prompt diagnosis and appropriate surgical and antibacterial treatments are required. Clinical signs/symptoms and physical exam remain the core components to help in diagnosis with the support of imaging. Reference #1: Yoshihito Tanaka et al. Sternoclavicular joint septic arthritis with chest wall abscess in a healthy adult: a case report. Journal of Medical Case Reports (2016) 10:69. DISCLOSURE: The following authors have nothing to disclose: Kim Phung Nguyen, Vandana Pai No Product/Research Disclosure Information

EVALUATION OF THE RETENTION IN THE THERMOPLASTIC ACETAL RESIN DISTAL EXTENSION PARTIAL DENTURE PROSTHESIS WITH DIFFERENT DENTURE BASE EXTENSIONS

Objectives: The present study was conducted to investigate the retention and the patient satisfaction of the Thermoplastic Acetal resin distal extension partial denture prosthesis with different denture base extension length either extended to covered the retro molar pad or extended just at the anterior border of the retro molar pad in unmodified Kennedy class II mandibular cases. Thermoplastic Acetal resin partial denture is more comfortable and can replace any number of teeth in a dental arch.Methods: Total number of ten healthy patients with unmodified Kennedy class II mandibular cases were selected and received extra coronal attachment on the experimental side , and received unilateral partial denture with thermoplastic Acetal resin framework. The patients were grouped into two groups. Group I received mandibular unilateral distal(without denture base extension) just end at the anterior border of the retro molar padand group II received mandibular unilateral distal(with denture base extension ) covered the retromolar pad. Then the retention evaluation and patient satisfaction was done at insertion of dentures , six months and after 12 month from the insertion.Results: For both groups regarding the retention evaluation, there was insignificant difference between both groups as P-value > 0.05. Regarding the patient satisfaction Group I (without denture base extension) showed statistically significantly higher mean satisfaction score than Group II.Conclusions: The patients were received mandibular unilateral distal(without denture base extension) more satisfied by the prosthesis. and regarding the retention there was non significant difference between both groups so theunilateral partial denture with thermoplastic Acetal resin framework without denture base extension more preferable .