Chronic Granulation Research Articles

Diagnosis of urethral diverticula in women: value of MR imaging.

The purpose of this study was to determine the role of MR imaging in the diagnosis of urethral diverticula in women. In 20 patients (mean age, 47 years), MR imaging was performed (1.5-T); unenhanced T1-weighted and T2-weighted images and contrast-enhanced T1-weighted images were obtained. MR imaging findings were compared with findings on urethrograms (including voiding cystourethrograms or double balloon catheter studies) in 16 patients, urethroscopic findings in 18, and surgical findings in 13. MR images were assessed for the presence, size, number, and location (anterior or posterior to the urethral lumen and relationship to the neck of the bladder) of diverticula, visualization of ostia, and presence of any concomitant complications. Sixteen of 20 patients had urethral diverticula: uncomplicated (simple) urethral diverticula in 13 patients; a diverticulum with a stone in one; a diverticulum with chronic granulation in one; and a diverticulum with adenocarcinoma in one. In the remaining four patients, the diagnoses included Gartner's duct cyst (one) and paraurethral cyst (one); urethras were deemed to be normal in two. In 13 patients who had surgery, MR images correctly showed the presence or absence of diverticula, whereas urethrography was correct in nine (69%) and urethroscopy in 10 (77%). Compared with surgical findings (20 diverticula in 12 patients), MR images depicted 14 (70%) of 20 diverticula and urethrography and urethroscopy each depicted 11 (55%) of 20. The ostium of the diverticulum could not be identified on MR images. The use of MR contrast material did not contribute to lesion detection, but the enhanced images were superior to unenhanced images in showing granulation tissue and carcinoma, although they did not help in their differentiation. MR imaging is accurate for showing urethral diverticula, but owing to its high cost, it should be considered only when urethroscopic or urethrographic findings are equivocal or when patients are unable to undergo these procedures and clinical findings strongly suggest a urethral diverticulum.

Temporal changes during bone regeneration in the calvarium induced by osteogenin.

Repair of rat craniotomy defects, 8 mm in diameter, was compared with that of defects treated with either rat insoluble collagenous bone matrix (ICBM) or partially purified bovine osteogenin, a bone-inductive protein, reconstituted with ICBM (OG/ICBM). Repair of all defects was similar histologically throughout the first 3 days, characterized by acute, then chronic inflammation and granulation tissue formation. In defects treated with OG/ICBM, cartilage and osteoblasts were present at day 5. By day 9, cartilage and osteoid production were active. New bone showed hematopoietic tissue by day 11; a complete bone bridge was established by day 21. By day 42, fatty marrow was present. Defects treated with ICBM alone showed islands of cartilage and bone embedded in connective tissue at day 9, which reached peak maturity by day 14. In these and in untreated defects, significant osteoblastic and osteoclastic activity, located primarily at the margins of the defects, subsided by day 28. Untreated defects gradually filed in with fibrous connective tissue which matured throughout 156 days. Radiopacity, quantified by computerized image analysis, increased significantly between days 9 and 11 in OG/ICBM-treated defects, and remained greater (P < 0.05) than that of the ICBM-treated defects. There was a more gradual increase in radiopacity in ICBM-treated defects. The sequence of morphologic events during calvarial bone regeneration was very similar to that described previously for heterotopic bone formation induced by demineralized bone matrix.

Diagnosis and Management of Spinal Epidural Abscess

Twenty-five patients with spinal epidural abscess were treated at the University of Western Ontario hospitals between July 1980 and July 1990. There were eighteen males (72%) and seven females (28%), with a median age of 60 years. Concurrent illness resulting in immunocompromise was present in 60%. Eleven presented with complete myelopathy, thirteen had limb weakness, and one had no neurological deficit. In twenty cases the abscess consisted of frankly purulent material, while in five the epidural collection consisted of chronic granulation tissue. Staphylococcus aureus was isolated in 64% of the abscesses. Twenty-seven surgical procedures were performed on 21 patients. Ten cases occurred in the cervical spine (40%), seven in the thoracic spine (28%), three in both the cervical and thoracic spine (12%) and five in the lumbosacral spine (20%). Fourteen patients (56%) retained or recovered ambulation and there were five deaths (20%). The progression from back and radicular pain to weakness and eventual paralysis continues to be characteristic of spinal epidural infection. Morbidity and mortality remain unacceptably high because of delay in diagnosis and treatment. Magnetic resonance imaging is the radiological investigation of choice for the diagnosis of spinal epidural abscess. Prompt intervention, before the development of severe neurological deficits, can improve outcome. Immediate surgical drainage combined with antibiotics remains the treatment of choice.

Fibroblast growth factor reverses the bacterial retardation of wound contraction

Chronic granulating wounds were established in rats by excising burns inoculated with Escherichia coli. Recombinant human basic fibroblast growth factor was applied at dosages of 1, 10, and 100 μg/cm 2 to the wounds of three groups of 20 animals on days 5, 9, 12, 15, and 18 after injury. The rate of wound closure was compared with that of similarly wounded animals treated with saline vehicle alone. High levels of bacteria caused significant retardation of wound contraction. The addition of basic fibroblast growth factor at the 100 /μg/cm 2 dosage level markedly improved the rate of wound closure whereas inert vehicles applied alone were ineffective. Since bacterial counts did not decrease in the basic f ibroblast growth factor treated wounds, basic fibroblast growth factor was not inherently bactericidal. Histologic examination of the wounds treated with basic fibroblast growth factor showed increased cellularity with increased numbers of fibroblasts and round cells. These results suggest basic fibroblast growth factor can overcome the defect in healing created by bacterial infection, and this peptide may have efficacy in the management of the contaminated wound.

The Use of Cultured Autologous Epidermis in the Treatment of Extensive Burn Wounds

Seventeen patients with deep second- and third-degree burn wounds have been grafted with cultured autologous epidermis. These epidermal cell sheets were cultivated according to the feeder layer technique as described by Rheinwald and Green. After dispase treatment and detachment from the culture vessel, the cell sheets, mounted on a polyamide mesh, were ready for grafting. Patients with wounds excised at an early stage, prepared with human cadaver allografts or synthetic dressings, showed a significantly better graft take than nonexcised, chronic granulating wounds which were grafted at a later stage (47% versus 15%; p less than 0.002). Sandwich treatment of expanded mesh autografts and cultured autograft overlay did not improve the graft take, although in some cases wound healing was accelerated. The graft take was inversely correlated with the age of the patient (p = 0.01), and showed a weak inverse correlation with the day of first (and subsequent) culture grafting (p = 0.07). Wound infection was the main cause of graft failure. Up to 4 years after grafting, the grafted areas showed continued stability and the regenerated skin became supple, smooth, and pliable. Hypertrophic scar formation was less than observed in comparable areas treated with meshed grafts. Wound contraction occurred approximately to the same extent as in split-thickness skin grafts. We emphasize that by a better control of wound infection the graft take, also in secondary-stage procedures, can significantly improve.

Short- and long-term effects of transcatheter ablation of the coronary sinus by radiofrequency energy.

Catheter ablation of left-sided atrioventricular accessory pathways through the coronary sinus by direct-current shock may be complicated by rupture and thrombosis of the coronary sinus and injury to the coronary arteries. This study examined short and long-term effects of radiofrequency catheter ablation of the coronary sinus in 20 closed-chest dogs to determine whether this technique is feasible for potential interruption of left-sided accessory pathways. Single-pulsed radiofrequency energy (750 kHz, 85-293 J) was delivered to three sites in the distal and middle coronary sinus between the distal (1) or the proximal electrodes (2 or 3) of a standard 6 French quadripolar catheter and a chest-wall patch electrode. Single-pulsed radiofrequency energy (78-293 J) was also applied to two sites near the ostium of the coronary sinus with the proximal (4) or the distal (1) electrode of the same catheter. Coronary artery and levophase coronary sinus angiograms obtained before and immediately after ablation, as well as before killing, showed intact vascular structures in all dogs. Right atrial, pulmonary arterial, and aortic pressures measured in three dogs did not change significantly at the time of energy delivery. No significant changes were found in atrioventricular nodal refractoriness and conduction. None of the dogs had significant rhythm disturbances during and after ablation as evaluated by ambulatory electrocardiographic monitoring and periodic rhythm strips at follow-up. Ten dogs were killed 1-7 days after ablation, three dogs were killed at 4 weeks, three dogs at 6 weeks, two dogs at 8 weeks, and two dogs at 12 weeks. Discrete lesions ranging in size from 3 x 3 to 8 x 10 mm2 in surface area and 0.5-4.5 mm in depth were found in the coronary sinus with most of the lesions extending to the left atrial and left ventricular myocardium. There was neither rupture of the coronary sinus nor occlusion of the coronary arteries. Mural thrombus was found in the coronary sinus on five acute lesions in two dogs, but none was noted on the chronic lesions, which was characterized by chronic granulation tissue and fibrosis. Two dogs in the study during chronic conditions had damage to branches of the underlying coronary artery that showed necrotizing arteritis and arterial sclerosis. Conduction system studies in four dogs showed some chronic inflammatory and fibrotic changes. Similar discrete lesions were found in situ in the coronary sinus of four postmortem human hearts with radiofrequency catheter ablation.(ABSTRACT TRUNCATED AT 400 WORDS)

Bovine pododermatitis aseptica diffusa (laminitis) aetiology, pathogenesis, treatment and control.

Pododermatitis aseptica diffusa (laminitis) is a major cause of lameness and discomfort to cattle with resultant economic losses. The disease is a result of multifactorial aetiology most of which is not clearly understood. Feeding readily fermentable carbohydrates to unaccustomed cattle predisposes to the disease. Histamine, lactic acid and endotoxins are believed to be involved. Systemic acidosis, histaminosis and endotoxaemia are thought to produce the pathophysiological characteristics of laminitis. The diagnosis is primarily based on the observation of symmetrical and bilateral lesions in hooves and characteristic lameness affecting all feet. Gross lesions include concavity of the dorsal wall, discolorations in the sole and rotation of the pedal bone. Degenerative changes and arteriosclerosis are constant histological findings in the corium, with chronic thrombi and chronic granulation tissue. The disease may be treated conservatively and by application of cyclo-oxygenase inhibiting non-steroidal anti-inflammatory drugs and prevented or controlled by proper feeding and management practices.

Revision tympanoplasty.

The terms 'planned two-stage operations', 'planned second-look operations', 'previous surgery', and 'revision surgery' are discussed on the basis of our series of 2,303 ears operated upon from January 1965 to December 1980. We have not performed any planned two-stage operations. All operations prior to the first operation in our department are denoted 'previous surgery'. 'Revision surgery' denotes all reoperations performed either in this department or elsewhere during the observation period until the end of 1984, and the revision rate is analysed in patients with different pathological conditions. 'Revision surgery' was performed in 15.6 percent of 740 ears with cholesteatoma (in 13.9 per cent once, in 1.6 per cent twice, and in 0.1 per cent three times), and 'previous surgery' in 3 per cent. Among 229 ears with chronic granulating otitis, revision surgery had been performed in 12.2 per cent up to December 1982. By December 1984, this figure had risen to 16.1 per cent. 'Previous surgery' had been performed in 18.3 per cent. A total of 38.4 per cent had at least two operations. The revision rate in other conditions varied from 10 per cent (sequelae to chronic otitis) to 34 per cent (post-inflammatory acquired atresia). These rates are discussed and the functional results presented.

Long-term results of surgery for chronic granulating otitis

The late results of planned one-stage procedures in 229 ears with chronic granulating otitis were analyzed, and the justification for two-stage procedures is discussed. All ears were discharging despite intensive preoperative treatment, and all had severe mucosal pathology. The total re-perforation rate was 12%. Five per cent were closed at re-operation, so that at the last follow-up perforations were found in 7% of the ears. The average observation period was 11 years (range, three to 20 years). After one operation, 91% of the ears were dry, and after the re-operations, 98% of the ears were dry. The re-operation rate was 16%. Because of these results obtained by planned one-stage procedures, the authors do not recommend two-stage procedures in non-cholesteatomatous conditions. The authors furthermore conclude that canal-up mastoidectomy is preferable in non-cholesteatomatous granulating otitis.

An additional clinical observation in two cases of vertical root fracture

Cases involving vertical root fractures in endodontically treated teeth can present difficulties in diagnosis. There are clinical and radiographic signs that, when present, can make diagnosis easier. In the two cases presented here, displacement of portions of the root occurred long after obturation of the canal. This spreading apart or movement of the apical portions of the root could be a result of pressure from the proliferating chronic granulation tissue that was present. The radiographic finding of displacement of apical portions of the root can be an additional diagnostic sign that a vertical root fracture had occurred.

Pathology of Bovine Laminitis Especially As Regards Vascular Lesions

Macro- and microscopical changes in the hooves of 14 cattle having a clinically established diagnosis of laminitis are described, Deviation of the pedal bone was found in 10 of the animals. In acute laminitis, the microscopical changes in the corium were hyperaemia, oedema, thrombosis and haemorrhages. Degenerative changes were found in the epidermis especially in the vicinity of thromboses of vessels in the corium. In chronic laminitis, arteriolosclerosis and arteriosclerosis were constant findings in the corium. There was also a high frequency of chronic thrombi and chronic granulation tissue. Prominent features in the lamellae epidermales were hyper- and parakeratosis. As judged from changes in arterioles and arteries, hypertension is suggested to be a pathogenetic factor in bovine laminitis. cattle; laminitis; histology; arteriolosclerosis; arteriosclerosis.

Difficult Wounds: Radiation Wounds

In an era of modern radiotherapy, problems associated with the indiscriminate treatment of benign disease have largely disappeared. Skin sparing effects of super voltage radiation equipment make the problems previously seen with orthovoltage equipment less frequent. Vigilance on the part of the workers in the field, in general, protects from the disasters that befell Thomas Edison's laboratory assistant. Despite these modern advances, the reconstructive surgeon often faces problems of managing acute local radiation injury from accident following planned therapeutic radiation or the ulcerations and breakdowns seen months or years after radiation therapy. The single most serious hazard to surgery in radiated tissue is the lodgment of bacteria in this tissue rendered avascular by the radiation and secondary necrosis from the infection itself. The principles of management are no different from those used for other chronic granulating wounds: local wound care, appropriate topical antibacterial therapy, systemic antibiotics during the perioperative period and, most importantly, adequate soft tissue coverage.

Atelectasis and secretory otitis media.

That condition where the tympanic membrane is displaced toward the promontory is termed atelectasis. Thirty-seven patients (61 ears) showing various degrees of atelectasis graded from stage 1 to stage 4 were studied. Atelectatic drums are an inflammatory phenomenon occurring in underventilated ears. This conclusion is reached by considering the reversibility of the atelectasis upon ventilation; while the inflammatory factor can be deduced from the history and histopathology of the atelectatic drum, as well as the histology of the necrosed incus, the latter occurs in over a third of our cases. Also pneumatization of the mastoid is almost never present. Twelve (21%) of the ears treated did indeed develop a perforation at one time or another (two had cholesteatomas). Chronic granulating external otitis with specific features occurred in 15% of cases. The characteristics of these ears and their case histories lead us to view atelectatic ears as part of the otitis media syndrome, where their place is somehow transitional between secretory otitis media on the one hand and chronic otitis media on the other.

Density of mucous glands in various chronic middle ear diseases.

From 491 operated ears 5 180 pieces of mucosa from 16 different middle-ear sites were stained by the PAS-alcian blue whole-mount method and the density of glands in each piece determined. The mean density of glands was greatest in secretory otitis, 7.1 glands/mm2; in dry adhesive otitis, 4.3; in chronic, infected, adhesive otitis, 3.4; in chronic granulating otitis, 2.0; in cholesteatoma and sequelae to otitis, 1.3; in tympanosclerosis, 0.6; and in otosclerosis, 1.7. The differences in glandular density and the predominance of the various secretory types were found to be characteristic of the various middle-ear diseases.

Subungual Basal Cell Epithelioma

To the Editor.— Among the relatively large variety of primary skin tumors that may arise in the subungual region, basal cell epithelioma has not been previously described. In a written communication (May 1972), E. B. Helwig stated that he was unaware of the occurrence of this lesion in the nail bed. We have recently had the opportunity of observing such a lesion in this location, which appeared to develop after a prolonged period of treatment for a chronic subungual infection. Report of a Case A 51-year-old man first developed a hangnail of the fourth finger in 1953, which was treated by partial excision of Residual tumor 3 mm in size from ulnar border of ungual skin graft. the nail and topically applied ointments. During the following 19 years, a chronic granulating infection was present in this nail bed of the finger, which was treated on several occasions by partial nail

Results of tympanoplasty with modified radical mastoidectomy.

The results of tympanoplasty combined with modified radical mastoidectomy in the same stage on 266 discharging ears was assessed by various criteria. Prior to the operation 9% of the cases had social hearing, 3-9 months after 47%. The air-bone gap closed to within 0-15 dB in 37% of the cases, within 0-30 dB in 77%. A hearing gain exceeding 10 dB was obtained in 66%. Perforation recurred in 14% of the cases, and 8 ears could not be rendered dry. The results in cholesteatoma were found to be the same as in chronic granulating otitis. The results were identical in cases where the bridge was preserved and in cases where it was removed. There was no major difference between the various types of tympanoplasty with respect to the magnitude of the hearing gain, but the mean postoperative hearing was considerably better after type I—III than after type IV tympanoplasty. The most successful ossiculoplasty proved to be interposition of bone and incus, least successful with interposition of polyethylene. The results ...

Radiosensitivity of malignant roundcell rhabdomyosarcoma in the nasal fossa of a child.

Rhabdomyosarcomas of the nasal cavity in childhood are rare. Of the 167 rhabdomyosarcomas in children reported by Stout (4), only 3 were primary in the nasal cavity, the nasopharynx being the more common site. Fifteen cases of embryonal rhabdomyosarcoma arising in cervical, facial, and orbital musculature were reported from the New York Memorial Hospital by Stobbe and Dargeon (3), in patients ranging in age from sixteen months to sixteen years. In 1948 Cappell (1) described 3 such tumors in children, arising beneath the mucous membrane in the uvula and palate. Treatment consisted of local radium application and surgery but was of no avail. All patients had local recurrences and ultimately died with distant metastases in lymph nodes and lungs. Dargeon (2) has stated that rhabdomyosarcoma is radiosensitive but recurs after radiotherapy. Because of the rarity of this type of neoplasm and the paucity of knowledge of its radioresponsiveness, we are reporting a case in a young girl, arising in the nasal fossa, with histologically verified metastases in the cervical lymph nodes. This tumor, although unusually radiosensitive both at the primary and secondary sites, ultimately recurred and the patient died with pulmonary metastases. Case Report An 8-year-old Caucasian girl was admitted to the University of California Medical Center (San Francisco) on Jan. 6, 1960, with a history of recurrent episodes of right nasal bleeding since June 1959. In August 1959, there had been discovered a polypoid pink-gray mass on the right nasal fossa floor, extending along the nasal septum posteriorly to the entrance of, but not into, the nasopharynx. The tumor was removed surgically at that time and was histologically reported as “chronic granulation tissue.” Two months later a recurrence at the same site was removed (October 1959) by the same surgeon. The child was then referred to the University of California Medical Center for further treatment. On admission to this hospital, the right nostril was completely obstructed by a fleshy, red, polypoid tumor which extended through the right choana into the vault of the nasopharyngeal cavity. The left nasal fossa was not unusual. Otoscopic examination showed a fluid level on the right associated with diminished hearing on that side. Several enlarged, firm, tender lymph nodes were palpable in the right midcervical area under the sternocleidomastoid muscle. The left cervical lymph nodes were also slightly enlarged. The remainder of the physical examination was not significant. The child's birth, development, and past history were normal. The results of laboratory studies were normal. Roentgenograms showed a density in the right nasal fossa and nasopharynx (Fig. 1) and opacification of both maxillary antra. No bone destruction was seen. There was no abnormality apparent on the chest film.

A Microscopic Carcinoma of the Testis Concealed In Chronic Granulation Tissue 1

A Microscopic Carcinoma of the Testis Concealed In Chronic Granulation Tissue ¹

Central Tumors of the Lower Jaw

IN the X-ray diagnosis of bone tumors it is as important to realize the limitations of the X-ray as it is to recognize those diagnostic characteristics which the film reveals. With the aid of the X-ray the central bone-expansive tumors of the lower jaw can be differentiated from periosteal lesions and osteomyelitis. But central bone-destructive tumors of the jaw include (1) the root or alveolar abscess, (2) its derivatives—the granuloma and root cyst, (3) the dentigerous cyst, (4) the adamantine epithelioma, (5) the giant-cell tumor, (6) the fibroma and fibrosarcoma, and (7) rarer lesions such as carcinoma arising from the gums, and myxoma. After recognizing a lesion as central, further identification is sometimes difficult. This problem of differential diagnosis is the topic of the following pages, based on a study of the jaw tumors in the Surgical Pathological Laboratory of the Johns Hopkins Hospital. The root abscess.—The most frequent finding in a routine X-ray examination of the teeth is the presence of periapical areas of bone absorption about non-vital teeth whose apices may be more or less eroded (Figs. 1 and 2). This characteristic picture of a locally symptomless lesion is usually called a root or alveolar abscess. If, however, the tooth be extracted, no pus, but, rather, a granuloma or sometimes a root cyst will be found. The granuloma is the sequel of an acute apical peridontitis in which the intense inflammation has subsided, with the formation of a nodule of chronic granulation tissue. Strands of squamous epithelium, arising from the irritated epithelial rests remaining about the tooth root, are a frequent finding in microscopic sections of such a granuloma. When cystic degeneration occurs in these epithelial sprouts a dental cyst lined by stratified squamous epithelium is the result (Fig. 3). The granuloma is of small size, while the root cyst may grow by continuous desquamation of epithelial cells and expand the jaw bone to such an extent that parchment crepitation may be elicited on pressure. The recognition of the so-called root abscess is most important, not only because root abscesses may give rise to osteomyelitis or act as foci of infection in various chronic conditions but because early malignancy must be excluded. The roentgenogram of a root abscess is quite characteristic. When, however, the film shows an atypical area more films should be taken for further study, and, upon extraction of the tooth, sections should be made from tissue adherent to the tooth or from the root socket. It should be unnecessary to note that teeth should not be extracted without first taking X-ray films. This laboratory contains many cases of tooth extraction in early malignancy performed with the hope of relieving local symptoms in which either no X-ray has been made or else it has been incorrectly diagnosed as a root abscess. In these early cases the X-ray, supplemented by the microscope, performs an invaluable service.

PULMONARY BOTRYOMYCOSIS

Botryomycosis is known to veterinarians as a pedunculated fibrous granuloma of horses especially. The growth usually arises in connection with skin surfaces, and often in the cut spermatic cord following castration. However, in the first description of the condition by Bollinger 1 in 1870 an internal organ, the lung of a horse, was the seat of the disease. In 1897, Poncet and Dor 2 identified the infection in a woman in a small growth on the palmar surface of the hand. Although human cases have been reported from France, Italy and Switzerland, it has been observed most commonly in northern Africa and in Morocco where it is said to occur as commonly as actinomycosis. The gross lesions consist of abundant chronic granulation tissue which is not especially characteristic but which on microscopic examination reveals granules made up of coccus-like organisms embedded in and surrounded by a hyaline matrix. In the chronic inflammatory