Excessive Granulation Research Articles

The role of different materials for prevention of synechiae following endoscopic sinus surgery

BackgroundEndoscopic sinus surgery (ESS) has become the treatment of choice for nasal polyposis and chronic rhinosinusitis that cannot be adequately managed with medical therapy. Nasal packing is usually placed after ESS to prevent synechiae formation and postoperative bleeding and to support wound healing. ObjectivesThis study was done to evaluate the effect of different materials on the formation of synechiae and excessive granulation tissue in the middle meatus in patients who had undergone ESS. MethodsA total of 90 patients who had undergone ESS were studied prospectively. At the end of ESS each patient was packed with one of the three different materials randomly. The outcome variable was the formation of synechiae and excessive granulation tissue in the middle meatus, which was identified from endoscopic evaluations performed 3–4weeks and 10–12weeks after surgery. ResultsWe observed significant intergroup differences in the effect on the formation of synechiae in the middle meatus. The nasopore group was superior to the other two groups and there is a significant reduction in synechiae formation in the nasopore group than both other groups. ConclusionAmong patients who had undergone ESS for rhinosinusitis with or without polyps, the incidence of synechiae and excessive granulation tissue in the middle meatus in the patients who received nasopore packing was less to that of synechiae in the patients who received merocel and mitomycin C.

Enrichment of FLI1 and RUNX1 mutations in families with excessive bleeding and platelet dense granule secretion defects

AbstractWe analyzed candidate platelet function disorder genes in 13 index cases with a history of excessive bleeding in association with a significant reduction in dense granule secretion and impaired aggregation to a panel of platelet agonists. Five of the index cases also had mild thrombocytopenia. Heterozygous alterations in FLI1 and RUNX1, encoding Friend leukemia integration 1 and RUNT-related transcription factor 1, respectively, which have a fundamental role in megakaryocytopoeisis, were identified in 6 patients, 4 of whom had mild thrombocytopenia. Two FLI1 alterations predicting p.Arg337Trp and p.Tyr343Cys substitutions in the FLI1 DNA-binding domain abolished transcriptional activity of FLI1. A 4-bp deletion in FLI1, and 2 splicing alterations and a nonsense variation in RUNX1, which were predicted to cause haploinsufficiency of either FLI1 or RUNX1, were also identified. Our findings suggest that alterations in FLI1 and RUNX1 may be common in patients with platelet dense granule secretion defects and mild thrombocytopenia.Key Points

Topical application of mitomycin-C as an adjuvant treatment to bronchoscopic procedures in post-intubation tracheal stenosis

IntroductionPost-intubation tracheal stenosis (PITS) continues to be challenging in terms of diagnosis, management and prevention. Recurrence is common because of excessive granulation tissue formation and an insidious process of scar contracture. Topical application of mitomycin-C (MMC) as an adjuvant treatment for endoscopic management of stenosis has shown good results. The authors aimed to evaluate the results of MMC topical application following bronchoscopic dilatation as an adjuvant in PITS treatment. MethodsRetrospectively selected patients with PITS who had had rigid bronchoscopy (RB) dilatation followed by MMC application as adjuvant to endoscopic treatment. MMC in a concentration of 0.4mg/ml was applied with a cotton stiletto around the stenotic lesion and granulation tissue for 3min. ResultsEleven patients with PITS, with a median initial tracheal stenosis of 75% of the lumen, underwent RB/MMC treatment. Mean MMC sessions performed/patient was 3.5, with good response and prolonged decrease in granulation tissue formation in 55% of cases, moderate in 18% and relapse in 27%. Mean stenosis improvement was 34%. ConclusionsTopical MMC application at 0.4mg/ml concentration seems to be associated with good results as adjuvant in PITS management with decrease in granulation tissue and sustained improvement in lumen diameter.

Crinophagy in Neuroblastoma: A Case Report and Review of the Literature

Crinophagy is a well-described ultraphysiological phenomenon encountered in a variety of cells and tissues. This process reflects a form of autophagy in which degradation of excess or nonfunctional cellular constituents occurs, specifically of neuroendocrine granules. The diagnostic ultrastructural features are the identification of neuroendocrine granules within lysosomes, often encased in or accompanied by myelin bodies. An impressive variety of neuroendocrine/secretory cells and tumors have demonstrated crinophagy from the neuroendocrine cells of the pancreas, small bowel, prostate, and urinary tract. To our knowledge, however, crinophagy has not been previously described in neuroblastoma, despite the fact that these tumors characteristically produce neuroendocrine granules in abundance. This case further supports the idea that crinophagy represents a common ultrastructural mechanism for the disposal and degradation of excess neuroendocrine granules.

Aplicação tópica de mitomicina-C como adjuvante no tratamento broncoscópico da estenose traqueal pós-entubação

IntroductionPost-intubation tracheal stenosis (PITS) continues to be challenging in terms of diagnosis, management and prevention. Recurrence is common because of excessive granulation tissue formation and an insidious process of scar contracture. Topical application of mitomycin-C (MMC) as an adjuvant treatment for endoscopic management of stenosis has shown good results. The authors aimed to evaluate the results of MMC topical application following bronchoscopic dilatation as an adjuvant in PITS treatment. MethodsRetrospectively selected patients with PITS who had had rigid bronchoscopy (RB) dilatation followed by MMC application as adjuvant to endoscopic treatment. MMC in a concentration of 0.4mg/ml was applied with a cotton stiletto around the stenotic lesion and granulation tissue for 3minutes. ResultsEleven patients with PITS, with a median initial tracheal stenosis of 75% of the lumen, underwent RB/MMC treatment. Mean MMC sessions performed/patient was 3.5, with good response and prolonged decrease in granulation tissue formation in 55% of cases, moderate in 18% and relapse in 27%. Mean stenosis improvement was 34%. ConclusionsTopical MMC application at 0.4mg/ml concentration seems to be associated with good results as adjuvant in PITS management with decrease in granulation tissue and sustained improvement in lumen diameter.

Equine exuberant granulation tissue and human keloids: A comparative histopathologic study

To compare histopathologic features of a fibroproliferative disorder in horses (exuberant granulation tissue-EGT) and people (keloid). Archival tissue samples of EGT (n = 8) and keloid (12). After automated hematoxylin and eosin, histochemical (Gomori trichrome, Verhoeff-van Gieson elastin) and immunohistochemical (vimentin, α-smooth muscle actin, CD34, CD68, CD117) stainings, tissue sections were evaluated using a semi-quantitative grading scale for presence or absence of ulceration, keloidal collagen, myofibroblasts, and elastic fibers as well as degree of inflammation, fibrosis, vascularity, and orientation of collagen fibers. Superficial dermis and deep dermis of both horses and people had increased numbers of haphazardly oriented thickened collagen fibers; however, only keloids contained "keloidal" collagen. Fibroblast numbers were markedly increased in both groups but only EGT had myofibroblasts. Minimal vascularity was observed in the deep dermis of both groups. The superficial dermis in EGT was characterized by small vessels within immature granulation tissue. Macrophages and mast cells were infrequently found in both groups but polymorphonuclear cells were markedly increased in EGT. Humans and horses are the only mammals known to naturally develop excessive granulation during wound healing; however, similarities and differences between fibroblast populations and associated collagen have not been reported. Inflammatory response may contribute to observed differences in the cellular populations, with EGT possessing markedly increased myofibroblasts, small vessels, and acute inflammatory cells compared with keloids. Further work is warranted to develop common treatment strategies for these fibroproliferative conditions.

Temporary removal of the posterior bony canal wall with reconstruction using microplate osteosynthesis in cholesteatoma surgery: a case series and description of the technique

We describe the surgical technique of temporary removal of the posterior auditory canal wall with reconstruction and report the outcome of using this technique as a treatment method for cholesteatoma in a case series. In 32 cases of cholesteatoma surgery a technique of temporary removal of the posterior bony wall was applied. During primary surgery the posterior auditory canal wall was removed using an oscillating saw. For the purpose of reconstruction, the canal wall was repositioned and fixed using two titanium microplates (n = 26). In case the canal wall could not be reconstructed with osteosynthesis, either glass-ionomeric cement (BioCem™) was used for fixation (n = 4) or fibrin glue (Tissucol™) (n = 2) to support the posterior wall. The outcome includes the healing process in the first postoperative month, the absence of residual or recurrent disease and the successful reconstruction of the posterior auditory canal wall as evaluated during second-look surgery. When microplates where used, we saw healing problems of the canal skin in about 4% of patients. Recurrent cholesteatoma was found in 4 cases (14%), residual cholesteatoma in 8 ears (25%). In the osteosynthesis group, successful reconstruction was achieved in 25 patients (96%). In 3 out of 4 patients of the glass-ionomeric cement group (75%) excessive granulation tissue developed with extensive bony lysis. Temporary removal of the posterior auditory canal wall offers potential for the control of cholesteatoma. Our first results suggest that osteosynthesis allows for a good anatomical and functional reconstruction.

Comparison of the novel Medtentia double helix mitral annuloplasty system with the Carpentier-Edwards Physio annuloplasty ring: morphological and functional long-term outcome in a mitral valve insufficiency sheep model

BackgroundThe prevalence of mitral regurgitation in cardiac diseases requires annuloplasty systems that can be implanted without excessive patient burden. This study was designed to examine the morphological and functional outcome of a new double helix mitral annuloplasty ring in an ovine model in comparison to the classical Carpentier-Edwards (CE) annuloplasty ring as measured by reduction of mitral regurgitation and tissue integration. The Medtentia annuloplasty ring (MAR) is a helical device that is rotated into the annulus self-restoring the valve geometry, enabling a faster fixation without the need of elaborate repair of the valve geometry. The ventricular part of the helical ring encircles the valve chords.MethodsTwenty adult sheep were overpaced until 2+ level mitral valve regurgitation was achieved. Seven animals per group received either the MAR or the CE ring. Implantation was performed on-pump in a beating heart through the left atrial appendix. The animals were sacrificed 3.6 ± 0.3 months after surgery following an echocardiography for assessing mitral regurgitation as primary endpoint. The annuloplasty rings with surrounding tissue were harvested for histological analyses as secondary endpoints. The remaining six sheep received the MAR system and were sampled seven, nine or 12 months after surgery.ResultsImplantation time (p < 0.01) and perfusion time (p < 0.001) as clinical secondary endpoints were significantly shorter in the MAR group. Echocardiography follow-ups showed sufficient valve function repair in nearly all animals with a normalization of the ventricle diameters in both groups (group difference: p = 0.147). The weights of the hearts did not differ significantly. Histology revealed adequately covered atrial annuloplasty rings with functional endothelium and lack of excessive granulation tissue or fibrosis in all specimens. The ventricular projections of the MAR systems encircling the chordae tendineae were not completely covered with neointimal tissue, although in no case were microthrombi detected and no thromboembolic events were recorded.ConclusionsThe new MAR system is an easy to use annuloplasty system with a functional outcome comparable to that of the well–proven CE ring. Mitral valve regurgitation is effectively stopped both by restricting the pathological expansion of the annulus and by gathering the chords without thrombus formation.

Ingrown Toenail in Children: A New Surgical Approach

Onychocryptosis (ingrown toenail) is a common nail disorder that arises from a combination of factors: genetic predisposition, infection, repeated trauma, ill-fitting shoes, and deep trimming of the nails. It can lead to pain, inflammation, infection, and excessive periungual granulation tissue. Wedge excision of the nail with surgical or chemical matricectomy is traditionally used to treat the condition in adults; however, high recurrence rates …

Tracheal Wall Thickening Is Associated with the Granulation Tissue Formation Around Silicone Stents in Patients with Post-Tuberculosis Tracheal Stenosis

PurposeTracheal restenosis due to excessive granulation tissue around a silicone stent requires repeated bronchoscopic interventions in patients with post-tuberculosis tracheal stenosis (PTTS). The current study was conducted to identify the risk factors for granulation tissue formation after silicone stenting in PTTS patients.Materials and MethodsA retrospective study was conducted between January 1998 and December 2010. Forty-two PTTS patients with silicone stenting were selected. Clinical and radiological variables were retrospectively collected and analyzed.ResultsTracheal restenosis due to granulation tissue formation were found in 20 patients (47.6%), and repeated bronchoscopic interventions were conducted. In multivariate analysis, tracheal wall thickness, measured on axial computed tomography scan, was independently associated with granulation tissue formation after silicone stenting. Furthermore, the degree of tracheal wall thickness was well correlated with the degree of granulation tissue formation.ConclusionTracheal wall thickening was associated with granulation tissue formation around silicone stents in patients with post-tuberculosis tracheal stenosis.

Neonatal Umbilical Mass

A 41-day-old girl presented to the emergency department with a new dark red mass protruding from the umbilicus noted 3.5 hours prior to presentation. The patient’s mother reported the umbilical stump fell off at 4 days of life, but the patient continued to have intermittent clear green drainage from a small mass at the base of the umbilicus. The patient was born full-term with an otherwise unremarkable medical history. Physical exam revealed a small, moist, erythematous mass protruding from the umbilicus (Figure). The mass was removed with minimal bleeding and no pain while attempting silk ligation. The specimen was sent for pathology, which returned 3 days later with the diagnosis of umbilical granuloma. Figure. View from above (A) and from the side (B) with umbilicus retracted to demonstrate pedunculated stump of the umbilical granuloma. An umbilical granuloma is a common benign abnormality in neonates that form from excess granulation tissue remaining at the base of the umbilicus after cord separation. It forms during the first few weeks of life and should not be present at birth. They typically are associated with persistent drainage involving the umbilicus after cord separation.1 It is a soft, round, moist, usually pink, friable, pedunculated mass, typically 3–10 mm in diameter. Umbilical polyps, urachal tract, and omphalomesenteric duct remnants must be considered.1,2 Multiple techniques are available to treat umbilical granulomas. Application of topical antibiotics, elimination of friction, air drying with alcohol wipes, and application of common table salt are conservative measures that may allow for epithelialization.3–5 Cauterization with silver nitrate is the most common treatment and generally requires multiple applications.1,6 Ligature, electrocautery, and cryosurgery are other treatment options. Further evaluation for other pathology is warranted if the lesion fails to resolve with silver nitrate and/or ligation.1,5,7

Zinc sulfate treatment of vocal process granuloma

I would like to make several comments on a manuscript by Sun et al. [1]. There is a mismatch between the abstract, text, and Table 1. According to the abstract, 11 patients had history of laryngeal trauma and 5 were idiopathic; 11 patients were operated before and recurred, 5 did not receive any treatment. According to the ‘‘Materials and methods’’, all 16 patients were traumatic; all were operated and recurred. Table 1 is the same as abstract. I accepted the text as correct. The authors reported 16 patients with vocal process granuloma, which developed after intubation or external trauma to larynx. All patients were operated and all lesions recurred postoperatively. The authors prescribed 200 mg zinc sulfate orally after meals, making a total daily dose of 600 mg, including 242 mg zinc. All vocal process granulomas disappeared within 4–12 weeks after the treatment. Zinc is an essential mineral that plays vital role in many biochemical reactions. Daily requirement for an adult is around 11 mg. Its deficiency leads to many diseases. In head and neck surgery, we use zinc oxide cream to decrease skin inflammation around tracheotomy or tracheostoma and to decrease excess granulation tissue reaction in open wound care. Because of its anti-inflammatory effect in local use, it is pleasing to learn that it is helpful in the treatment of vocal process granuloma. In medicine, there is a general rule saying that if there is no indication for a specific test or treatment, there is already a contraindication. If a mineral is to cure a disorder, it must be deficient in the body. For example, if anemia is to respond to iron treatment, iron must be really deficient in the body. Furthermore, iron supplementation does not cure other forms of anemia and is even contraindicated. If zinc is expected to cure vocal process granuloma, those patients must be deficient in zinc. If those patients have normal blood and tissue levels of zinc, zinc supplementation, even in excessive doses (the authors are giving 22 times the daily requirement), is not expected to cure the problem. Were their patients deficient in zinc? Did the authors measure blood or tissue levels of zinc before starting treatment with zinc sulfate? If no, do they think that their results are evidence-based? I do not expect their patients to be deficient in zinc; because, they are in such a social level that they could reach medical services easily and were even operated. What do they think the mechanism of action of zinc is in curing vocal process granuloma, if it is not deficient in body? In vocal process granuloma there is no perfect cure using many conservative and invasive methods available. How can zinc sulfate give perfect cure of vocal process granuloma without any recurrence even 1 year after treatment?

Nail-Fold Excision for the Treatment of Ingrown Toenail in Children

To evaluate the effectiveness of the nail-fold excision procedure in children. Prospectively collected data on patients less than 18 years of age who underwent a nail-fold excision for symptomatic ingrown toenail were analyzed. Patients were seen in 2 centers and data collected included demographics, site of ingrown toenail, complications (including recurrence), patient satisfaction, and duration of follow-up. Overall, 67 procedures were performed on 50 patients between June 2009 and July 2011 at the 2 institutions. The mean age was 14 years (range, 9-18 years) and 30 were male patients. No recurrences were seen after a follow-up for a median of 14 months (range 6-28 months). Patients were very satisfied with the cosmetic outcomes. Six minor complications occurred, including 3 patients with bleeding requiring dressing change, 2 with excessive granulation tissue, and 1 with nail growth abnormality. The nail-fold excision technique is highly effective in the pediatric population, with no recurrence, excellent cosmesis, and very high patient satisfaction.

Corn starch granules with enhanced load-carrying capacity via citric acid treatment

This research investigated conditions by which maize starch granule porosity and load-carrying capacity (LCC) might be enhanced via treatment with varying citric acid concentrations (0.5–1.5M), temperatures (40–60°C), and lengths of treatment (1–8h). At the lowest temperatures (40 and 50°C), citric acid treatment induced minimal physicochemical changes to granules. In contrast, both aqueous and oil LCCs of starches treated at 60°C (0.5M citric acid, 2h) were almost doubled (15.69 and 14.48mL/10g starch, respectively), recovering 92% of the granular starch after treatment. Such treatment increased starch hydration capacity (0.97–1.91) and reduced gelatinization enthalpy (10.6–7.4J/g). More severe treatment conditions adversely impacted aqueous LCC (due to excessive granule swelling), but improved oil absorption. The basis for LCC enhancement by citric acid treatment was ascribed to leaching of starch material from granules and partial disruption of the granule crystalline structure, as opposed to starch hydrolysis or chemical substitution.

Malignancy and Chronic Leg Ulcers

To determine the frequency of skin cancers associated with chronic leg ulcers (CLUs) presumably of vascular origin and failing to heal (ie, increased wound area or depth) despite 3 months or more of appropriate treatment. Prospective cross-sectional study. Ambulatory or hospitalized patients from 17 dermatology departments. Between January 1, 2006, and May 31, 2008, a total of 144 patients consulted for CLUs, attributed to venous and/or peripheral arterial disease(s), increasing in wound size, that is, larger area and/or depth, despite appropriate standard treatment for at least 3 months. At inclusion, at least two 6-mm punch biopsies, 1 at the wound edge and 1 in the wound bed, in the most clinically suspicious areas, were systematically performed. The primary end point was the skin cancer frequency diagnosed in at least 1 wound biopsy specimen obtained at inclusion. The 144 patients included had 154 CLUs. The overall skin cancer frequency in the CLUs was 10.4%: 9 squamous cell and 5 basal cell carcinomas, 1 melanoma, and 1 leiomyosarcoma; 56.3% had persisted for at least 3 years. Univariate analyses retained older age, abnormal excessive granulation tissue at wound edges, high clinical suspicion of cancer, and number of biopsies, but not wound area or duration, as being significantly associated with skin cancer in 1 or more biopsy specimens. The combined primary ulcerated cancer or malignant transformation frequency was sufficiently high in CLUs referred to tertiary care centers to consider systematic biopsy of a wound refractory to 3 months or more of appropriate treatment.

Outcomes of revision external dacryocystorhinostomy and nasal intubation by bicanalicular silicone tubing under endonasal endoscopic guidance.

To evaluate the long-term treatment outcomes in patients who underwent revision of external dacryocystorhinostomy (DCR) and nasal intubation by bicanalicular silicone tubing (BSTI) under endonasal endoscopic guidance. Data from 28 patients with recurrent dacryocystitis were retrospectively reviewed. Revision external DCR and bicanalicular nasal intubation by silicone tubing under endonasal endoscopic guidance was performed in 28 eyes of 28 patients. The patients were evaluated with respect to the reason of recurrence, time to recurrence, time to revision, duration of follow-up and surgical success. Endoscopic endonasal examination detected an osteotomy-side obstruction by the excessive granulation tissue in 24 patients (86%), nasal septal deviation in three patients (10%) and nasal polyp in one patient (4%). Recurrence occurred after a mean duration of 5.3±3.7 months following the first operation. The mean time between the first DCR operation and the revision DCR was 11.5 ± 9.3 months. After a mean follow-up of 14.9±7.8 months, the rate of anatomic success alone was 85% (24/28); the rate of subjective success was 78% (22/28). Revision external DCR and bicanalicular nasal intubation by silicone tubing under endonasal endoscopic guidance can be recommended in patients with recurrent dacryocystitis as a surgical approach that achieves satisfactory objective and subjective success rates.

Treatment of Recalcitrant Excessive Granulation Tissue with Photodynamic Therapy in an Eight-Year-Old Patient with Focal Dermal Hypoplasia Syndrome

We report a pediatric patient with focal dermal hypoplasia syndrome who developed painful excessive granulation tissue refractory to traditional medical and surgical therapies. Complete response was achieved rapidly with a combination of photodynamic therapy and intralesional steroid injections. The patient has remained in remission for longer than a year.

Complications des gastrostomies percutanées (hors complications immédiates)

The most frequent complications following percutaneous gastrostomies are those occurring around the tube insertion site (leakage, purulent secretions and excessive granulation tissue) or those involving deterioration of the gastrostomy tube. These complications are usually benign; rarely, peristomial wound infection can present as a necrotizing fasciitis. In most cases, local antiseptic care and antibiotherapy are sufficient to control peristomial wound infection. In case of systemic signs of infection, parenteral antibiotherapy is indicated.

Computed Tomography or Magnetic Resonance Imaging‐Assisted Partial Hoof Wall Resection for Keratoma Removal

To (1) describe the computed tomography (CT) and magnetic resonance imaging (MRI) appearance of keratomas; (2) describe a CT- or MRI-assisted partial hoof wall resection technique for removal of keratomas; and (3) evaluate the morbidity and postoperative outcome of these horses. Case series. Horses (n=10) with keratoma. Data retrieved from medical records included signalment, lameness duration and grade, physical and diagnostic evaluation findings, CT and MRI technique and findings, surgical details, histopathologic diagnosis, postoperative treatment, and complications experienced. Long-term outcome was obtained by telephone interviews of owners. Complications including excessive granulation tissue formation and infection were seen in 2 horses (20%). No keratoma recurrence occurred. Follow-up information was available for 8 horses; 7 were sound and had resumed work. Mean time until they became sound was 2.7 months, and mean time until work resumed was 3.6 months. CT and MRI can be used to accurately identify the location of keratomas. Postoperative complications may be decreased by creating smaller hoof wall defects, filling the defects with antimicrobial-impregnated polymethylmethacrylate, and placing a shoe early in the postoperative period.

595 nm long pulsed dye laser with a hydrocolloid dressing for the treatment of hypergranulation tissue on the scalp in postsurgical defects

The formation of hypergranulation tissue is an aberrant process that interferes with normal wound healing. Excessive granulation tissue results in the persistence of open wounds. It is resistant to currently available treatment modalities. We report a case series of patients with hypergranulation tissue on the scalp who were successfully treated with a 595 nm pulsed dye laser and hydrocolloid dressing.