Bilateral Defects Research Articles

Role of periosteum in alveolar bone regeneration comparing with collagen membrane in a buccal dehiscence model of dogs

To investigate the role of periosteum on the treatment of buccal dehiscence defects comparing with collagen membrane in canine model. Bilateral dehiscence-type defects at the buccal side on the distal root of the lower 3rd/4th premolars were created in six beagle dogs with a total of 24 defects and assigned into three groups: Group A: blood clot in an untreated defect; Group B: deproteinized bovine bone material (DBBM) covered with an absorbable membrane; Group C: DBBM covered with the periosteum. The structural parameters for trabecular architecture and vertical bone regeneration were evaluated. Histological and histomorphometric evaluation were carried out to observe new bone formation and mineralization in the graft site. Immunohistochemical analysis was performed to identify the expression of osteopontin (OPN) and osteocalcin (OCN) at postoperative 3 months. Group C achieved greater vertical alveolar bone gain than that of group A and group B. The periosteum-covered group showed significantly greater new bone formation and accelerated mineralization. The greater immunolabeling for OPN and OCN was observed in group C than in group A. Periosteal coverage has explicit advantages over collagen membranes for the quality and quantity of new bone regeneration in dehiscence defects repairing.

Total extra-peritoneal inguinal hernia repair: experience in a tertiary care hospital of Bangladesh

Background: Open hernioplasty, a traditional procedure, is practiced for decades all over the world, for inguinal hernia repair and the newer procedure of total extraperitoneal (TEP) inguinal hernia repair is the current trend. Aim of this study was to share the experience of TEP inguinal hernia repair.
 Methods: This retrospective observational study was done from April, 2012 to March, 2021 at BIRDEM General Hospital, Dhaka, Bangladesh. Patients with inguinal hernia reporting to BIRDEM outpatient department (OPD) were counseled for TEP repair. Those who consented were treated electively with a TEP repair for a unilateral or bilateral hernia defect, either direct or indirect. All procedures were completed with patients under general anaesthesia. Polypropylene mesh was placed in preperitoneal space. Followed up records were noted at one week, one month, one and two years after surgery. Patients’ age, hernia types and locations, complications, length of stay in hospital, return to work and recurrence were noted.
 Results: Total patients were 118 including one female. Patients were between 22 and 72 years. All of them had primary hernias and 72% of them underwent unilateral repairs. One of the cases required conversion to transabdominal preperitoneal procedure. In five patients (4.2%) intraoperative complication occurred and postoperative courses were complicated in 8 patients (6.7%). Patients were able to resume their daily activities after a mean period of 7 days (3 to 10 days). There was no mortality.
 Conclusion: In patients with uncomplicated inguinal hernias, TEP is associated with a very low overall risk of serious complications and recurrence with a very good functional outcome. It is equally applicable with bilateral inguinal hernias without added risk.
 BIRDEM Med J 2023; 13(1): 44-48

Minimally Invasive Mandibular Microsurgery: A Systematic Review and Meta-analysis.

All known cases of MIMMR were identified following the Preferred Reporting Items for Systematic Reviews, Meta-Analyses guidelines, and our own surgical experience. Patient demographics, MIMMR type [submandibular (SM), modified facelift/retroauricular (MFL/RA), or intraoral (IO)], methodology, and clinical outcomes were analyzed with the Fisher exact and Kruskal-Wallis tests. Forty-seven patients underwent MIMMR. Ameloblastoma was the most common pathology treated using all approaches, and MFL/RA was the only approach used to treat squamous cell carcinoma (P = 0.0103). Reconstruction was reported for large, bilateral defects only via the SM or IO approach (P = 0.0216). The iliac crest or fibula was used as a donor site. The facial artery was the most common recipient vessel using the IO and SM approaches, whereas the superior thyroid and external carotid vessels were the most common in the MFL/RA approach (P < 0.0001). Virtual planning was used in all cases performed via an IO approach, 80.0% of cases using an SM approach, and no MFL/RA cases (P < 0.0001). Good aesthetic and functional outcomes were reported for every patient, and there was no difference in complication rates (P = 0.2880). Minimally invasive approaches are safe and effective treatment options for patients requiring mandibular microsurgery, usually in the setting of benign pathology. The IO and SM approaches usually rely on the facial vessels, whereas the MFL/RA approach permits access to the superior thyroid and external carotid vessels and cervical lymphadenectomy.

A Comparative Finite Element Analysis of ‘Hexa-Zygomatic’ Implants vs Conventional Quad Zygomatic Implants for The Rehabilitation of Bilateral Maxillectomy Defects

Restoration of bilateral maxillectomy defects is inherently challenging. Zygomatic implants are one of the non-bone grafting solutions for restoration of such defects which require minimum armamentarium and are widely available. The Quad Zygomatic Implants have a long track record in maxillectomy defects secondary to cancer ablative surgeries. In the current scenario, they are being used in COVID associated mucormycosis maxillectomy defects. Since there is a paucity in literature on the use of zygomatic implants in the above-mentioned malady, we have used finite element analysis to assess the longevity of the Quad Zygomatic Implants concept and the newer Hexa Zygomatic Implants concept for these types of cases. The finite element analysis showed similar results for both the concepts on simulation which leads to the conclusion whereas both are viable treatment modalities. The Quad Zygomatic Implants concept is the more economically favourable and practical solution. As this a finite element analysis study, clinical based studies with long follow-up may shed light on a more conclusive clinical outcomes.

Reconstruction of the mandible from partial inputs for virtual surgery planning.

Statistical Shape Models (SSMs) and Sparse Prediction Models (SPMs) based on regressions between cephalometric measurements were compared against standard practice in virtual surgery planning for reconstruction of mandibular defects. Emphasis was placed on the ability of the models to reproduce clinically relevant metrics. CT scans of 50 men and 50 women were collected and split into training and testing datasets according to an 80:20 ratio. The scans were segmented, and anatomical landmarks were identified. SPMs were constructed based on direct regressions between measurements derived from the anatomical landmarks. SSMs were developed by establishing correspondence between the segmented meshes, performing alignment, and principal component analysis. Anterior and bilateral defects were simulated by removing sections of the mandibles in the testing set. Measurement errors after reconstruction ranged from 1.07˚ to 2.2˚ and 0.66mm to 2.02mm for mirroring, from 0.45˚ to 3.67˚ and 0.66mm to 2.54mm for the SSMs, and from 1.74˚ to 5.01˚ and 0.64mm to 2.89mm for the SPMs. Surface-to-surface errors ranged from 1.01mm to 1.29mm and 1.06mm to 1.33mm for mirroring and SSMs, respectively. Based on the results, SSMs are recommended for VSP in the absence of normal patient anatomy.

Calcium Sulfate Alone or Associated with Chorion Membrane in Deep Narrow Periodontal Defect? A Clinical and Radiographic Study

Abstract Background: Soft-tissue intervention over bony defects may impede periodontal regeneration, the sole purpose of periodontal therapy. Human chorion membrane (CM) enhances guided tissue regeneration (GTR) and restores lost tissue. Consequently, calcium sulfate may represent a promising class of bone graft substitutes that helps in significant attachment gain without GTR membrane in deep narrow defects. Hence, this study was conducted to evaluate the efficacy of calcium sulfate graft in periodontal regeneration and to weigh the rationale of using CM for GTR in deep narrow defects. Methods: Thirteen patients with bilateral deep narrow defects clinically and radiographically (26 sites, ≥7 mm pocket depth [PD]) were selected and randomly allocated to Group I (open flap debridement and calcium sulfate placement) and Group II (open flap debridement and calcium sulfate with CM placement). Clinical parameters such as PD, clinical attachment level, and radiographical intrabony defect were recorded at baseline and 6 months postsurgery. Results: Significant attachment gain was found in both groups with nonsignificant intergroup differences. Conclusion: Calcium sulfate with or without CM is able to restore deep narrow bony defects efficiently. Deep narrow defects itself able to prevent soft-tissue collapse and ascertain excellent periodontal regeneration.

Comparative evaluation of regenerative potential of injectable platelet-rich fibrin and platelet-rich fibrin with demineralized freeze-dried bone allograft in the treatment of intrabony defects: A randomized controlled clinical study.

Injectable platelet-rich fibrin (i-PRF) being in liquid form keeps graft particles clumped together forming agglutinated steak of bone graft. It has been shown to contain more platelets and long-term deliverance of growth factors in comparison with platelet-rich fibrin (PRF). The aim of the present study was to assess regenerative potential of i-PRF and comparing it with PRF, along with demineralized freeze-dried bone allograft (DFDBA) in the treatment of intrabony alveolar defects. Thirty defect sites in 15 patients with bilateral intrabony defects were assigned randomly into two groups (Group I (Control group)- DFDBA + PRF and Group II (Test group)-DFDBA + i-PRF). Gingival index (GI), plaque index (PI), pocket probing depth (PPD), and relative attachment level (RAL) were recorded at baseline, 3 months, and 6 months. Linear bone growth (LBG) was recorded radiographically at baseline and 6 months. ANOVA test and post hoc Tukey test were used to assess intragroup comparison of clinical parameters. Paired t-test was used to assess intragroup comparison of the radiographic parameter. Unpaired t-test was used to assess intergroup variations in all the clinical as well as radiographic parameters. Statistically significant PPD reduction (P = 0.005) and RAL gain (P = 0.003) were found in Group II than in Group I, and no significant difference was found in other parameters. Percentage LBG was higher in Group II than Group I but the difference was not statistically significant. i-PRF with DFDBA showed more favorable results as compared to PRF with DFDBA in the management of intrabony periodontal defects.

Lumbar Radiological Pseudo-Bulging Patterns

Objective: The most interesting humanoid fracture is probably the pars interarticularis defect. The main aim of our study is to describe the pseudo-bulging patterns in sagittal images in magnetic resonance imaging (MRI). Thus, it aims to increase pars interarticularis defects recognizability with MRI. Radiation exposure in tomography may be eliminated. Materials and Methods: Our study is single-center, non-randomized, retrospective, and observational. Level of pars interarticularis defect, complete-incomplete formation, presence of pedicular involvement, and unilateral or bilateral pars interarticularis defect were observed and noted in lumbar tomography. Pseudobulging patterns were observed on lumbar magnetic resonance imaging. Adobe Photoshop® 2023 was used to filter the pseudo-bulging images. The shape and form of the pseudo-bulging patterns were observed and noted. Descriptive statistics were used in our study. Results: Various pars interarticularis defects were detected in 24 patients on computed tomography images. 14 were female and 10 were male. In our study, pseudo-bulging patterns revealed a distinctive appearance in 21 of 24 cases. We defined 4 different pseudo-bulging shapes and forms. Conclusion: We revealed four different pseudo-bulging patterns in sagittal MRI images of patients with confirmed pars interarticularis defects by tomography. Learning the pseudo-bulging patterns and shapes will facilitate the identification of the pars interarticularis defect on the MRI.

Prosthetic Rehabilitation of a Bilateral Cranial Defect with Modified Titanium Mesh - A Case Report

Elevated intracranial pressure following traumatic brain injury is treated by craniotomy. Cranioplasty is a surgical procedure used to rectify the cranial defects. A cranioplasty not only improves the patients appearance but also protects the brain and mitigates neurological symptoms. Titanium being the most biocompatible material can be used to treat these defects. However 3-D-printed titanium plates are very expensive for most of patients. Titanium mesh is another option but its cosmetic outcome is poor. In this case we got the cranial defect 3-D printed following which wax up was carried out in the desired cranial contour. It was then tried on patientrsquos skull and after making necessary changes was processed in PMMA polymethylmethacrylate material. Finally the stock titanium mesh was adapted to PMMA prostheses for achieving the planned cranial contour. Manually adapted titanium mesh customized titanium mesh has given far better results than stock titanium mesh. Customized titanium mesh could be a possible affordable alternative to the 3-D printed titanium plate.nbsp

Intrabony defect management with a bone graft (hydroxyapatite and β-tricalcium phosphate) alone and in combination with a diode laser: A randomized control trial.

The current research was conducted to evaluate the use of a diode laser and a bone graft (hydroxyapatite [HA] + β-tricalcium phosphate [β-TCP]) in healing of intrabony defects. In this split-mouth evaluation, 40 patients with bilateral intrabony defects were treated with, Group I (control) - bone graft alone (HA + β-TCP) and Group II, (test) - bone graft with a diode laser. The clinical and radiologic parameters of all patients, such as plaque index (PI), probing depth (PD), gingival index (GI), gingival recession (GR), and relative clinical attachment level (RCAL) were recorded at baseline, after 3 months and after 6 months. Reductions in PI, PD, GI, GR, and RCAL were found after 6 months. Furthermore, significant differences were displayed in the intra-group comparison while those of the inter-group evaluation (P > 0.05) were insignificant. In both groups, considerable decrease in intrabony pockets was discovered; however, the inter-group comparison was insignificant in relation to GR and RCAL.

Ocular toxicity among patients taking anti-tubercular treatment.

Tuberculosis remains a major public health problem in Nepal and anti-tubercular drugs used for the treatment of pulmonary and extrapulmonary tuberculosis can be associated with ocular toxicity. This prospective study aimed to evaluate the incidence of ocular toxicity among patients receiving anti-tubercular therapy and to assess the change in visual functions and ocular imaging before and after use of anti-tubercular therapy. A total of 89 eyes of 45 TB patients taking anti-tubercular therapy were enrolled. Detailed history and examination including best-corrected visual acuity (BCVA), colour vision (Farnsworth D-15t), contrast sensitivity (Pelli-Robson chart), Goldman visual field analysis and spectral domain optical coherence tomography for retinal nerve fibre layer (RNFL) analysis were assessed at baseline and at 6 months after starting anti-tubercular therapy. Visual evoked potential (VEP) was performed in suspected cases. The mean age of the patients was 29.13±14.00 years and 62.2% were males. The mean weight of the subjects was 54.37±10.36 kg, mean daily dosage of ethambutol was 17.91±1.74 mg/day/kg and mean administration duration was 2.71±1.54 months. The incidence of ocular toxicity was 2.24%. Bilateral retrobulbar optic neuropathy occurred in a 27-year female of 55 kg receiving ethambutol (20 mg/kg/day) for 6 months for Pott's spine. Her best-corrected visual acuity in both eyes was reduced to 6/36 from 6/6 and developed non-specific color vision defect, decreased contrast sensitivity, bilateral cecocentral visual field defect and mean decrease in retinal nerve fibre layer thickness compared to the baseline data. In rest cases, a statistically significant decrease in mean retinal nerve fibre layer thickness in both eyes suggested the evidence of subclinical toxicity. Though less common, ethambutol toxicity can occur in patients under anti-tubercular therapy in the form of retrobulbar optic neuritis. Decreased contrast sensitivity and thinning in the mean retinal nerve fibre layer thickness can be the indicator of subclinical toxicity.

Comparative Evaluation of Injectable Platelet Rich Fibrin (I-PRF) with DFDBA and Titatium Prepared Platelet Rich Fibrin (T-PRF) with DFDBA In The Treatment of Infrabony Defects In Chronic Periodontitis Patients - A Clinico-Radiographical Study

Objectives: The main objective of this study was to evaluate the efficacy of Titanium prepared platelet-rich Fibrin (T-PRF) and Injectable Platelet Rich Fibrin (I-PRF) with demineralized freeze-dried bone allograft (DFDBA) in order to improve the clinical and radiographic results obtained in treatment of periodontal infrabony defects.&#x0D; Materials and Methods: This split-mouth randomized controlled clinical trial was conducted on 30 subjects with two comparable bilateral infrabony defects. Plaque Index(PI), Gingival Index(GI) Clinical attachment level (CAL), Periodontal Pocket depth (PD), as well as radiographic parameters IOPA including the radiographic defect size, were measured at six months post-operatively.&#x0D; Results: The mean reductions in PD and CAL were 4.0±0.77 mm and 2.5±0.68 mm in sites treated with I-PRF+DFDBA, respectively (P&lt;0.05); these reductions were 4.2±0.86 mm and 3.1±0.62 mm, respectively in T-PRF+DFDBA group (P&lt;0.05). Radiographic evaluation revealed reduction in the radiographic defect size in the I-PRF+DFDBA and T-PRF+DFDBA sites. Statistically, there were no significant differences between the two treatment modalities.?&#x0D; Conclusion: This study showed that both treatments resulted in significant improvement in the probing depth reduction, clinical attachment level gain and radiographic size of the infrabony defect at six months after surgery. I-PRF with DFDBA membrane in treatment of infrabony osseous defect showed more defect fill followed by T- PRF along with DFDBA membrane.

Comparative evaluation of demineralized freeze-dried bone allograft with and without concentrated growth factor membrane in the treatment of periodontal intrabony defects: a randomized controlled clinical trial.

The current study's aim was to evaluate and compare demineralized freeze-dried bone allograft (DFDBA) with and without concentrated growth factor (CGF) membrane in the treatment of periodontal intrabony defects on both a clinical and radiographic level. 30 stage III grade B periodontitis patients with bilateral intrabony defects were involved in the split mouth randomized controlled trial, and they received either DFDBA alone (control group) or DFDBA plus CGF membrane treatment (test group). At baseline and 6 and 12months, the gingival index (GI), plaque index (PI), probing pocket depth (PPD), clinical attachment level (CAL), and gingival recession (GR) were assessed, whereas cone beam computed tomography was used to assess the bone defect height (BDH), vertical bone loss (VBL), bone defect depth (BDD), mesio-distal bone defect width (MDBDW), bucco-lingual bone defect width (BLBDW), and bone defect volume (CBCT) at baseline and 12months. The radiographic measures BDH, BDD, MDBDW, BLBDW, and BDV in the test group likewise showed a higher reduction in PPD and gain in CAL than the control group. The results of the intergroup comparison showed that the test group had statistically significant differences in BDH, BDD, and MDBDW. The data show that the test group achieved better results, with greater reductions in PPD, gains in CAL, and decreases in BDH, BDD, MDBDW, BLBDW, and BDV. The use of concentrated growth factor in conjunction with demineralized freeze-dried bone allograft may be suggested for the treatment of periodontal intrabony defects.

Enhanced osteogenesis by addition of cancellous bone chips at xenogenic bone augmentation: In vitro and in vivo experiments.

To investigate and compare the influence of deproteinized bovine bone mineral (DBBM) combined with autologous cortical (CorBC) or cancellous bone chips (CanBC) as bone grafts on guided bone regeneration (GBR) in vivo and in vitro. Defects were created in the mandibular buccal alveolar ridges in dogs and randomly filled with 3 groups of bone grafts: DBBM, DBBM + CorBC, or DBBM + CanBC. Osteogenesis was evaluated by sequential fluorescent labeling and histological analysis. Moreover, rat bilateral calvaria defects were randomly grafted with DBBM, DBBM + CorBC, or DBBM + CanBC. A blank group was included as control. Defect healing was assessed by histological staining, micro-CT, and quantitative polymerase chain reaction. In vitro migration, proliferation, and osteogenic differentiation assays were performed by stimulating rat bone marrow mesenchymal stem cells (rBMSCs) with cortical (CorBCM) or cancellous bone conditioned medium (CanBCM) to unveil the cellular mechanism. In the canine model, the augmented sites of DBBM + CanBC exhibited higher mineralized tissue proportion than the other two groups (DBBM: 0.61 ± 0.03 versus DBBM + CorBC: 0.69 ± 0.07 versus DBBM + CanBC: 0.86 ± 0.06; p < .05). In the rat model, the BV/TV value of DBBM + CanBC (0.51 ± 0.01) was higher than those of DBBM + CorBC (0.41 ± 0.02), DBBM (0.31 ± 0.01), and Control (0.10 ± 0.01; p < .01). Further radiological, histological and transcriptional results showed similar trends. In vitro experiments revealed that CorBCM and especially CanBCM could enhance rBMSCs migration, proliferation, and osteogenic differentiation. In vivo and in vitro experiments verified favorable synergistic effect of mixing autologous bone chips with DBBM on osteogenesis. Furthermore, CanBC presented more powerful osteogenic effect than CorBC.

Generative adversarial network-created brain SPECTs of cerebral ischemia are indistinguishable to scans from real patients

Deep convolutional generative adversarial networks (GAN) allow for creating images from existing databases. We applied a modified light-weight GAN (FastGAN) algorithm to cerebral blood flow SPECTs and aimed to evaluate whether this technology can generate created images close to real patients. Investigating three anatomical levels (cerebellum, CER; basal ganglia, BG; cortex, COR), 551 normal (248 CER, 174 BG, 129 COR) and 387 pathological brain SPECTs using N-isopropyl p-I-123-iodoamphetamine (123I-IMP) were included. For the latter scans, cerebral ischemic disease comprised 291 uni- (66 CER, 116 BG, 109 COR) and 96 bilateral defect patterns (44 BG, 52 COR). Our model was trained using a three-compartment anatomical input (dataset ‘A’; including CER, BG, and COR), while for dataset ‘B’, only one anatomical region (COR) was included. Quantitative analyses provided mean counts (MC) and left/right (LR) hemisphere ratios, which were then compared to quantification from real images. For MC, ‘B’ was significantly different for normal and bilateral defect patterns (P < 0.0001, respectively), but not for unilateral ischemia (P = 0.77). Comparable results were recorded for LR, as normal and ischemia scans were significantly different relative to images acquired from real patients (P ≤ 0.01, respectively). Images provided by ‘A’, however, revealed comparable quantitative results when compared to real images, including normal (P = 0.8) and pathological scans (unilateral, P = 0.99; bilateral, P = 0.68) for MC. For LR, only uni- (P = 0.03), but not normal or bilateral defect scans (P ≥ 0.08) reached significance relative to images of real patients. With a minimum of only three anatomical compartments serving as stimuli, created cerebral SPECTs are indistinguishable to images from real patients. The applied FastGAN algorithm may allow to provide sufficient scan numbers in various clinical scenarios, e.g., for “data-hungry” deep learning technologies or in the context of orphan diseases.

Straight-segment mandibulectomy: a reproducible porcine mandibular critical-size defect model

Porcine mandibular defect models are commonly used for the preclinical evaluation of reconstruction techniques. Existing studies vary in technique, complexity, and postoperative outcomes. The procedures are complex and often described without sufficient detail. We describe in detail a simple and reproducible method for creating a critical-size mandibular defect in a porcine model. Seven hemimandibular critical size defects were created in five male Yorkshire-Landrace pigs, three with unilateral defects and two with bilateral defects. A transverse incision was made over the mandibular body. Periosteum was incised and elevated to expose the mandibular body and a critical-size defect of 30 × 20 mm created using an oscillating saw. The implant was inserted and fixed with a titanium reconstruction plate and bicortical locking screws, and the wound closed in layers with resorbable sutures. Intraoral contamination was avoided. Dentition was retained and the mental nerve and its branches preserved. The marginal mandibular nerve was not encountered during dissection. All pigs retained normal masticatory function, and there were no cases of infection, wound breakdown, haematoma, salivary leak, or implant-related complications. The procedure can be performed bilaterally on both hemimandibles without affecting load-bearing function. All pigs survived until the end point of three months. Postoperative computed tomographic scans and histology showed new bone formation, and a three-point bend test showed the restoration of biomechanical strength. Straight-segment mandibulectomy is a simple and reproducible method for the creation of critical-size mandibular defects in a porcine model, simulating a load-bearing situation.

Bilateral congenital chest wall defects associated with microtia: First case report

Congenital chest wall defects are uncommon and present commonly at birth or later in infancy. The most common types are pectus excavatum, pectus carinatum, and sternal clefts. We present the first case report of multiple congenital anomalies that include bilateral chest wall defects with complete absence of the skin and muscular layer plus microtia that are associated with right facial nerve paralysis. The baby was managed conservatively with an application of a daily dressing. Both defects healed properly and closed after seven weeks of treatment without evidence of a hernia. On follow-up, after five years the boy was seen with good scars without complications.

Laparoscopic assisted repair of a giant bilateral congenital Morgagni hernia associated with malrotation in an infant

Morgagni hernia is a rare congenital malformation accounting for less than 5% of all congenital diaphragmatic hernias. Patients may be asymptomatic or present with non-specific respiratory or gastrointestinal symptoms, which can delay the diagnose. While it is highly associated with Down Syndrome, only a few series have reported association with malrotation. The defect can be unilateral or bilateral and colon is the most frequent herniated organ. Laparoscopic assisted repair seems to be the preferable approach for repairing the defect in the last years. We present a case of a 3-year-old Down Syndrome boy that was diagnosed with a giant Morgagni hernia while investigated for reflux disease. At the time of the surgery, he was found to have a bilateral defect with herniation of small bowel, omentum, cecum, appendix, ascending and transverse colon, as well as malrotation. The defects were successfully repaired with the laparoscopic assisted technique. Malrotation was corrected at the same time. Morgagni hernia is a rare congenital disease that can be associated with malrotation, which should always be investigated at the time of surgery. The laparoscopic assisted approach is an easy and safe way to repair the defect. Malrotation when present should be corrected at the same time.

RF01 | PMON77 Low Libido Despite High Testosterone Levels in a Man With FSH-Secreting Pituitary Macroadenoma

Abstract Background Up to 60% of non-functioning pituitary adenomas stain for gonadotrophins on immunocytochemistry but do not secrete excess gonadotrophins. Functioning gonadotroph adenomas with clinical manifestations are extremely rare and majority of these are FSH secreting macroadenomas. Diagnosis may be difficult in pre-menopausal women with high oestrogen and variable FSH levels but in men, the unusually high gonadotrophins give the clues for diagnosis. Clinical Case We present the case of a 37-year-old Caucasian male with clinical manifestations of an FSH-secreting pituitary macroadenoma. He had sexual dysfunction with loss of libido for a year followed by bilateral testicular pain and enlargement (right &amp;gt;left). He was initially investigated under urology and had repeated treatment for suspected epididymitis. The diagnosis came to light many months later when he presented to emergency department with headaches and visual disturbance. Brain imaging confirmed a pituitary macroadenoma (3×2.5×3cm) with optic chiasm compression. He had bilateral superior temporal visual field defects. Pituitary profile showed unusually high FSH 200 IU/L (0.7-11.1), normal LH 7.6 IU/L (0.8-7.6) and a high normal testosterone 27 nmol/L (8.5-29). Prolactin was slightly elevated at 474mIU/L (0-350), cortisol and TSH were in normal range. He had polycythaemia (Haemoglobin 181g/l and HCT 0.51 L/L) and old blood results indicate his haemoglobin was above the upper limit of normal for previous 10 years. This gentleman had a successful transsphenoidal hypophysectomy with near complete resection of pituitary adenoma. His vison improved immediately after surgery. Histology of the resected adenoma showed gonadotroph differentiation and immunoreactivity predominantly with FSH and also with LH and prolactin stains. A day after surgery, his FSH levels dropped to 18 IU/L and LH was undetectable. Symptoms of hypogonadism had gradually worsened post-surgery and 2 months later, his pituitary profile showed severe hypogonadotrophic hypogonadism (FSH 3.6 IU/L, undetectable LH and testosterone 0.9 nmol/L). He was started on testosterone replacement which he continues till date. He remains asymptomatic with no testicular pain and the last MR imaging, a year after his surgery showed no recurrence in the pituitary adenoma. Conclusion Testicular enlargement and hypogonadal symptoms with low testosterone levels are recognised features in FSH secreting pituitary adenomas. Our patient had testicular enlargement but consistently high testosterone levels prior to surgery and polycythaemia for many years prior to presentation. This may be due concomitant hypersecretion of both FSH and LH from his pituitary adenoma. The reason for low libido despite high androgen levels was not entirely clear. Symptoms of hypogonadism overlap with many non-gonadal illnesses. A normal testosterone level in most cases would not lead to further endocrine investigations. Our case highlights the need to suspect such rare underlying pituitary pathology when dealing with unusual combination of hypogonadal symptoms, testicular enlargement and normal or high normal testosterone levels. Presentation: Saturday, June 11, 2022 1:30 p.m. - 1:35 p.m., Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Modified Extraoral Retentive Technique for Retaining Obturator in Bilateral Maxillectomy Defects Secondary to Mucormycosis in Healing Phase

Modified Extraoral Retentive Technique for Retaining Obturator in Bilateral Maxillectomy Defects Secondary to Mucormycosis in Healing Phase