Facial Involvement Research Articles

Tuberculous otitis media: rare cause of recurrent facial nerve palsy

<p class="abstract">Tuberculous otitis media (TOM) is a rare form of tuberculosis, due to tubercular otitis media, thick caseous material and granulation tissue gets deposited in middle ear cleft causing bone erosion, sequestration, ossicular destruction, heading loss which can be conductive or mixed and rarely facial paralysis. In this case report we discuss tubercular otitis media as a cause of recurrent facial nerve paralysis. 54 year old male patient with no known previous comorbidities presented to ENT OPD on 12 October 19 with complaints of scanty, mucopurulent foul smelling occasionally blood stained continuous otorrhoea (R)×02 years, painless progressive and persistent hearing loss ×1 year and recurrent (R) sided facial nerve palsy, 03 episodes in last 2 years which were spontaneous and sudden in onset, showed gradual recovery with oral medication. Tubercular otitis media is not a very common diagnosis with which an otolaryngologist comes across. It generally presents with otorrhea and hearing loss which mimics more commoner ear disease. Typical findings of multiple tympanic membrane perforations are not necessarily seen. There can be involvement of facial nerve and presence of refractory otorrhoea with atypical features may be considered indicative of tubercular pathology. A clinician should have high index of suspicion whenever there are signs which outlies symptoms in form of severity. This case highlights the diagnostic challenge and high index of clinical suspicion required for diagnosis. Combination of appropriate diagnostic modality along with good clinical vigilance will aid in early diagnosis and start of early medication which reduces chances of any subsequent complications.</p><p class="abstract"> </p>

A comparative study between micro needling with modified Kligman regimen versus micro needling with tranexamic acid in melasma patients

<p class="abstract"><strong>Background:</strong> Melasma is common, acquired disorder of hyperpigmentation, with female predominance and occurrence of facial involvement mostly. Various modalities of treatment are available including topical, oral and procedural therapies.</p><p class="abstract"><strong>Methods:</strong> Total 46 patients of melasma were studied. They were divided in two groups A and B. Micro needling with derma roller 1.5mm was done once in a month for 3 months. Group A patients received topical Modified Kligman regimen daily at night, while group B patients were advised topical tranexamic acid daily. Topical sunscreen was advised in both group patients. Patients were evaluated clinically and by Modified MASI score, and followed up for 3 more months after completion of treatment.<strong></strong></p><p class="abstract"><strong>Results:</strong> Female predominance was noted with most common age group being 25-40 years. Epidermal type of melasma was common. Centro-facial type of distribution was found mostly in patients. Significant decrease was noted in modified MASI score (p<0.05) which was more and rapid in group A patients.</p><p class="abstract"><strong>Conclusions:</strong> Modified Kligman regimen has better efficacy but tranexamic acid is safer with lesser side effects. Inspite of various treatment arms, melasma is still challenging.</p>

Clinical, microscopic and molecular presentation in pediatric versus adult old world cutaneous Leishmaniasis.

Cutaneous leishmaniasis (CL) is an emerging uncontrolled tropical parasitic disease in endemic and nonendemic areas with a high prevalence in the pediatric age group. A total of 382 individuals from Lebanon, Saudi Arabia, Pakistan, and Syria diagnosed with CL by punch biopsy/scrapings were grouped into adults (>18years) and pediatrics (≤18years). Data recorded included clinical features [number, location, type, size, and extensiveness (size larger than 3cm, more than 5 lesions per patient, lesion present for more than 12months, special types, disfiguring lesion or closeness to vital sensory organs) of lesions] and microscopic findings [Ridley's Parasitic Index and Ridley's Pattern]. In addition, molecular confirmation and speciation were performed. In comparison with adults, patients in the pediatric group (n=158, 41.4%) showed significantly higher number of lesions, more facial involvement, and more extensive disease (P<.05). Microscopically, a more advanced Ridley's pattern was observed. The other variables did not show statistical difference between the two groups. Historically, CL has been known to be a neglected tropical disease of poverty and pediatric predilection. In our pediatric group, CL manifests with more extensive disease clinically mirrored by more advanced lesions microscopically.

Nasal Floor Asymmetry Is Associated With Nasal Obstruction

The role of morphologic characteristics of the nasal cavity in nasal obstruction is not yet sufficiently understood. The aim of this study was to determine which morphometric parameters of the nasal cavity severely impair nasal breathing and when. In a hospital-based, computed tomography-morphometric cross-sectional study, we evaluated computed tomography coronal scans of patients with known nasal obstruction scheduled to undergo functional nasal surgical procedures (cases) and trauma patients without facial involvement or known nasal obstruction (controls). The primary predictor variable was case versus control. In both groups, we measured and compared the piriform aperture width; nasal floor canting; piriform aperture vertical height, height-width ratio, and total cross-sectional area; height difference between the right and left nasal floors; and nasal septal thickness; as well as age and gender differences. Metric data means, standard deviations, and 95% confidence intervals were calculated and analyzed. The sample was composed of 60 patients evenly divided between cases and controls. Of these, 30 were men. The average age of the cases and controls was 27.4±7.8years and 38.5±18.6years, respectively (P<.001). The differences in piriform aperture width were not statistically significant between cases and controls (23.3±1.9mm and 23.8±1.7mm, respectively; P>.2). In contrast, we noted statistically significant differences between cases and controls in nasal floor canting (5.4°±4.6° and 1.8°±1.5°, respectively; P<.001) and height difference between the right and left nasal floors (1.8±1.2 mm and 1.0±0.7mm, respectively; P=.002). Nasal floor canting of 3° or greater and a height difference between the right and left nasal floors of 1.5mm or greater may contribute to the etiology of clinically relevant nasal obstruction. A piriform aperture width of 22mm or less may be considered narrow. Future studies can determine when and how exactly to surgically address a clinically relevant narrow piriform aperture and nasal floor canting.

Efficacy of surgery combined with postoperative 125 I interstitial brachytherapy for treatment of acinic cell carcinoma of the parotid gland in children and adolescents.

Acinic cell carcinoma (AciCC) is rare in children; therefore, reaching a consensus on its management is challenging and radiotherapy is limited by concerns about long-term toxicity. The purpose of this study is to analyze the effectiveness and safety of surgery plus postoperative 125 I interstitial brachytherapy (IBT) for children and adolescents with AciCC of the parotid gland (PG) treated at a single institution. Sixteen patients ≤ 18 years old with AciCC of the PG treated with surgery plus 125 I IBT from 2007 to 2018 were included. Surgery was the primary treatment; ten patients underwent total gross excision and six subtotal gross excision. The matched peripheral dose was 60-120Gy. Overall survival, disease-free survival (DFS), local control rate, distant metastasis, and radiation-associated toxicities were analyzed, and factors influencing outcomes were evaluated. During follow-up (1.8-12.6 years; mean, 6.3 years), lymph node metastasis was observed in one case, 2.6 years after 125 I IBT treatment. The five-year overall and DFS rates were 100% and 91.7%, respectively. On univariate analysis, tumor size ≥ 3cm (100%vs 50%; P=0.025) and extraglandular extension (100%vs 50%; P=0.025) were significant prognostic indicators for DFS. No severe radiation-associated complications occurred. Children and adolescents with AciCC of the PG with high-risk features can be managed using surgery plus postoperative 125 I IBT with excellent local control. Radiation-related complications were minor. Patients with facial nerve involvement can have their facial nerves preserved. Residual tumors can be safely managed using adjuvant 125 I IBT.

Association of Comorbid Conditions with Six-month Survival and Disease Outcome in Patients of Necroinflammatory Otitis Externa.

To determine association of gender, causative organisms, control of diabetes, facial paralysis, infectious agent, and hearing loss with disease outcome, in terms of six-month improvement of symptoms, static condition or expiry of patients presenting with necroinflammatory otitis externa (NOE). Descriptive study. ENT Department in collaboration with Pathology Department, KEMU/Mayo Hospital, Lahore from 2016 to 2019. Methodology: Patients with NOE were inducted. Studied variables included age at presentation, gender, diabetes, glycated hemoglobin (HbA1c) levels, comorbid conditions, facial nerve involvement, hearing loss, CT and biopsy findings, and causative organisms; and their association with outcome was observed with significance at p<0.05. Out of 28 patients, there were 17 males (60.7%) and 11 females (39.3%). Association between gender and survival showed that 41.2% (7) males and 27.3% (3) females survived; and 23.5% (4) males and 1 (9.1%) female expired within six months of diagnosis. Thinning of temporal bone (2/5=40%) was common among the expired patients. Twenty percent (1/5) patients diagnosed with squamous cell carcinoma and 80% (4/5)with granulation tissue (GT) expired (p=0.543) All ten patients (100%) that improved had mild to moderate hearing loss (p <0.001). Among expired group, 80% (4/5) had HBA1c of more than 7 and 20% (1/5) had good control of diabetes. Aspergillus (2/5=40%) and Pseudomonas (1/5=20%) were the commonest among expired patients; Staphylococcus (6/10=60%) and Pseudomonas (3/10=30%) infections were more frequent among the survived (p=0.005). Previously pseudomonal infection was described as the only causative agent of NOE. This study showed a rising community-acquired disease with Staphylococcus aureus 6/10 (60%) and Pseudomonas 3/10 (30%) infection. Fungal infection is associated with poor survival and death, thus requiring aggressive management. Thinning of temporal bone on CT, uncontrolled diabetes, sever hearing loss and facial paralysis score V/VI were associated with poor outcome of disease. Key Words: Necroinflammatory otitis externa, Pseudomonas aeruginosa. Diabetes, Hearing loss, Facial paralysis, Temporal bone thinning, CT scan.

Facioscapulohumeral muscular dystrophy 1 patients participating in the UK FSHD registry can be subdivided into 4 patterns of self-reported symptoms

Facioscapulohumeral muscular dystrophy (FSHD) is an autosomal dominant incurable skeletal muscle disease. FSHD1 constitutes 95% of cases and is linked to truncation of the D4Z4 macrosatellite at 4q35. In most cases the condition initially presents with facial and proximal weakness of the upper limbs, but over the course of the disease involves lower limb and truncal muscles. Weakness is progressive and frequently asymmetric, which is a hallmark of the disease. Here we performed an analysis of 643 FSHD1 patients in the UK FSHD patient registry, investigating factors affecting rate of onset of 5 major FSHD symptoms: facial, periscapular, foot dorsiflexor, hip girdle weakness, and hearing loss. We found shorter D4Z4 repeat length associated with accelerated onset of each symptom. Furthermore, paternal inheritance of the pathogenic allele was associated with accelerated onset of foot dorsiflexor weakness, while pregnancy and carrying multiple children to term was associated with slower onset of all muscle symptoms. Lastly, we performed clustering analysis on age of onset of the 4 muscle symptoms across 222 patients. We identified 4 clinical presentations of FSHD1. A classical presentation (74%) and 3 facial sparing phenotypes: a mild presentation (5%) with later facial and periscapular involvement, an early shoulder presentation (10%) with accelerated periscapular weakness and an early foot presentation (9%) with accelerated foot dorsiflexor weakness. The mild presentation was associated with longer D4Z4 repeat lengths, while the early foot presentation had a female bias. We note, however that symptom progression differs significantly in these 4 clinical presentations independently of D4Z4 repeat length and gender, motivating investigation of further modifiers of FSHD1 severity.

Emotional expressions with minimal facial muscle actions. Report 2: Recognition of emotions

We tested the hypothesis that an emotion expressed by a still-face person keeping direct gaze can be adequately recognized. The prospective study involved 800 volunteers as judges (age 16–25). All the judges were presented with three 10-picture sets of still faces expressing angry, sad, and happy emotions by vivid gaze only. The first 10-picture set consisted of full faces, the second set consisted of the middle part of the face pictures, and the third set presented the eyes only. Half of the judges (Group 1, n = 400) were asked to label the pictures as Angry, Sad, or Happy. Another 400 judges (Group 2) were asked to label the same pictures as Angry, Sad, Surprised, Frightened, or Happy to validate the selected sets of pictures. Group 1 judges presented correct recognition of the emotion in 72% for full-face pictures, 73% agreement for middle parts, and 68% agreement for the eyes only, while in Group 2 the agreements were 63%, 68%, and 48.5% respectively. After Bonferroni correction for multiple comparisons, our results show that the gaze was the only emotional cue in all tests and the presented emotions were recognized with relatively equal degree of success. We confirm our initial statement (Report 1) that the expression of an emotion can be adequately achieved with minimal facial muscular involvement when predominantly the gaze expresses emotion. In most of the cases, an “emotional gaze” during a still-face or static face situation is adequately recognized by people but the emotion recognition skill has individual variations.

Exploring the impact of paediatric localized scleroderma on health-related quality of life: focus groups with youth and caregivers.

Paediatric localized scleroderma (LS) can negatively impact health-related quality of life (HRQoL) by causing skin fibrosis, abnormal limb development, disfigurement, and side-effects from immunosuppressive treatment. Studies to date have rarely included qualitative data gathered directly from paediatric patients with LS. To assess the impact of LS on HRQoL among affected youth and their caregivers using qualitative description. Youth with all subtypes of LS and their caregivers were purposively sampled to participate in age-appropriate focus groups (younger children, early adolescents, adolescents). Each group started with a drawing exercise followed by in-depth discussion of topics including skin symptoms (e.g. itch, pain, tightness), functional impairment, physical appearance, family and peer relationships, and treatment burden. Focus groups were transcribed verbatim and co-coded, with adjudication of differentially applied codes. The study findings were triangulated via comparison with adult reports and published literature. Eleven youth aged 9-16 years and 16 caregivers participated in three focus groups each. Major identified areas of impact included uncomfortable skin symptoms, physical functioning limitations, extracutaneous manifestations, body image, bullying and teasing, unwanted questioning from others, and treatment side-effects and burden. This is the first qualitative study of HRQoL in LS to include all major LS subtypes. We identified domains of HRQoL impacted by LS, some of which replicate earlier findings and some of which were novel. As impact also changed with developmental stage, our findings support the need for ongoing, formal evaluation of HRQoL in children and adolescents with LS. What is already known about this topic? Paediatric localized scleroderma (LS) negatively impacts health-related quality of life (HRQoL) via skin fibrosis, musculoskeletal and other extracutaneous manifestations from the disease process, and side-effects of systemic immunosuppression. The full impact of LS and its treatment on HRQoL is incompletely understood, with only one published qualitative study of youth with LS, which was limited to facial involvement. There are no qualitative studies of HRQoL in other LS subtypes to date. What does this study add? This is the first qualitative evaluation of HRQoL in youth with LS inclusive of all disease subtypes. Our study confirms that LS affects HRQoL across multiple distinct domains, including uncomfortable skin sensations, impacts on body image, bullying and teasing from peers, unwanted intrusive questioning, physical limitations, extracutaneous manifestations and high treatment burden. These results indicate the need for ongoing clinical assessment of paediatric patients in these domains. What are the clinical implications of the work? These results support the need to care for patients with LS holistically by synthesizing cutaneous, musculoskeletal and extracutaneous disease assessments with multidimensional evaluation of psychosocial impact and adverse effects of treatments. The development of an LS-specific HRQoL measure would advance such efforts.

Surgery for necrotizing otitis externa-indications and surgical findings.

Treatment for necrotizing otitis externa (NOE) includes long term antibiotic and surgery in selected cases. Indications and extent of surgery, however, are still not defined. The aims of this study were: (1) present our experience in surgery for NOE (2) compare high-resolution computer tomography and perioperative findings (3) suggest recommendations for indications and extent of surgery. A retrospective case series study was conducted in a tertiary referral center. Patients hospitalized due to NOE between the years 1990-2015 and underwent surgery were included. Twenty patients were included in the study. HRTBCT was performed in 17 patients. Most common radiological findings included mastoid fullness (n = 13, 76.4%) and edema of external ear canal (n = 12, 70.5%). Surgical indications included lack of response to treatment (n = 18) and facial nerve palsy (n = 2). Seven patients underwent local debridement. Most common operative findings included soft tissue necrosis (n = 4, 57.1%) and gross bony destruction of the external ear canal (n = 2, 28.5%). Thirteen patients underwent tympanomastoid surgery. Most common operative findings included granulation tissue in the mastoid (n = 7, 53.8%) and mastoid bony erosion (n = 4, 30.7%). Facial canal involvement was seen in four patients (30.7%). This is the first study to describe a large group of surgically treated NOE. Initial surgical approach should be based on clinical and HRTBCT findings. Minimal HRTBCT findings may be addressed with local debridement. Severe HRTBCT findings should be addressed with canal wall up mastoidectomy as the minimal surgical procedure. Further extent should be decided based on perioperative findings.

Review of treatment modalities and outcomes of patients with basal cell adenocarcinoma.

This study summarizes the treatment modalities of basal cell adenocarcinoma (BCAC) of the parotid gland and subsequent outcome at a single institution to better define the treatment of this rare tumor. A retrospective review of patients treated for BCAC of the parotid gland from 1/01/1996 to 08/1/2018 was performed. Patients were identified using our institution's Cancer Registry. A total of thirteen patients (46% female, median age of 56) treated for BCAC of the parotid gland were identified. Eight patients (57%) were staged as T1, four were staged as T2 (29%), and two were stage T4a (14%) due to tumor involvement of the facial nerve. None of the patients had nodal involvement or distant metastases. Three patients (21%) underwent radiation therapy ranging from 60-70Gy for positive margin or facial nerve involvement by tumor. Five patients (36%) underwent a neck dissection (ND) ranging from just a level IIb dissection up to levels IIa, IIb, and III with none of the nodes being positive for disease. The remainder of patients did not undergo a neck dissection. Follow-up was 8.1±6.2 (mean±SD) years with no local or regional recurrence at time of last follow-up in any patient cohort. Our review suggests that elective neck dissections are not necessary following resection of T1/T2N0M0 basal cell adenocarcinoma for the prevention of local or regional recurrence. No longer performing neck dissections for T1/T2N0M0 BCAC would reduce the morbidity associated with the treatment of this rare parotid tumor.

Infecciones del espacio orofacial, etiología, susceptibilidad microbiológica y manejo quirúrgico

Orofacial infections are considered as one of most common infections and need rapid and adequate treatment as they affect a very delicate region and are associated with serious life-threatening complications. Orofacial infections can be either odontogenic that is with an origin in teeth and associated structures or non-odontogenic, not associated with teeth, can affect facial spaces and spread from one space to another, so a good knowledge about diagnosis and treating these infections is of utmost importance, and can include both non-surgical and surgical treatment. The aim of our study was to determine the most common cause of orofacial infections, the most common bacterial microorganisms and their antibiotic susceptibility. Materials and Methods: A descriptive study was undertaken in the Department of Oral and Maxillofacial Surgery, Al-Shaheed Ghazi Al-Hariry Hospital, Baghdad, Iraq from 1st January to 30th September 2015. This study included 45 patients with different forms of orofacial infections; data regarding age, gender, underlying cause, facial space involvement, presenting signs were collected through history, clinical examination and radiographs, incision and drainage with swab sample for culture and sensitivity test was performed. Results: Patients with orofacial infections showed a female to male ratio of 1.25:1. The mean age was 32.8 years. Most of the patients were in their 4th decade of life (27%). Most infections were odontogenic in origin (62%), the most common facial space involved was submandibular (65%), the most common isolated microorganism was Streptococcus pyogenes (59%), and most patients were treated using an extra-oral surgical approach (78%). Antibiotics to which bacterial isolated showed the most sensitivity were netilmicin, cefoperazone and rifampicin (91%). Pain and limitation of mouth opening gradually decreased in most of patients during the two weeks follow up period. Conclusion: Orofacial infections were more common in females, in the third and fourth decade of life, were odontogenic in origin, were mostly caused by Streptococcus pyogenes, and most isolates were susceptible to netilmicin, cefoperazone and rifampicin. Pain and trismus decreased over two weeks post-treatment.

Rhino-orbito-cerebral mucormycosis in patients with uncontrolled diabetes: A case series

IntroductionMucormycosis is a rare, aggressive, and invasive disease with a fatal outcome. It most commonly affects patients with compromised immunity, particularly those with poorly controlled diabetes. We present a case series of patients with uncontrolled diabetes and mucormycosis. Presentation of caseWe present a series of three patients with uncontrolled diabetes, with main symptoms of paranasal sinusitis, nasal discharge, ophthalmic changes, and facial nerve involvement. Diagnoses of mucormycosis were made via microbiological testing and computed tomography. These cases were managed by combination therapy of tight glycemic control, urgent endoscopic sinus debridement, and antifungal therapy. DiscussionDiagnosing rhino-orbito-cerebral mucormycosis requires a high degree of suspicion and both microbiologic and microscopic evidence. Better clinical outcomes can be obtained by combining medical and surgical management. ConclusionWe describe our experience in handling three cases of poorly controlled diabetes with rhino-orbito-cerebral mucormycosis.

Spectrum of diagnosis of hereditary angioedema: Seven case reports

Hereditary angioedema (HAE) is a potentially life-threatening disorder, due to a mutation in complement one-inhibitor (C1-INH) gene, which blocks the activity of various components of complement – fibrinolytic and bradykinin control system. Our seven cases of HAE give different clinical presentations of TYPE I/II/III HAE as facial, abdominal, laryngeal, and genital involvement along with comorbidities (5 cases) such as hypothyroidism, rhinosinusitis, and hypothalamic–pituitary–adrenal suppression, and four cases have had history of recurrent abdominal attacks. Treatment with Pdc-INH concentrate and self-administrated Icatibant provides consistent and reliable efficacy in those who have had multiple successive HAE attacks, with the involvement of all body parts. However, if pdc-INH concentrate is not available, then fresh frozen plasma and androgens (Danazol) can be used in emergency. Our cases demonstrate the importance of diligent clinical and family history with special tests: C4, C1-INH quantitative, and C1-INH functional.

Cystic Vestibular Schwannomas and Post–Gamma Knife Radiosurgery-Induced Necrosis of Vestibular Schwannomas: Report of Two Cases and Review of Literature

AbstractCystic vestibular schwannomas (VS) form a rare subgroup that differs from the solid variant clinically and radiologically. Certain unique features reported in cystic VS are larger size, presentation with atypical initial symptoms such as dysgeusia, vertigo, facial pain and gait unsteadiness, short duration of symptoms, rapid progression of symptoms or sudden deterioration and frequent involvement of facial nerve. Gamma Knife radiosurgery (GKRS) is a safe and effective treatment for VS, achieving tumor control and resulting in a very low morbidity rate. Here, we described two cases of cystic vestibular schwannomas prior to GKRS and their radiological appearances post-GKRS.

Keratosis Pilaris Rubra Totalis: Clinical and Histopathological Study with New insights

Background: Keratosis pilaris rubra (KPR) is a common but unrecognized follicular keratinizatioin. It is a common skin problem among Iraqi population and most cases were misdiagnosed as dermatitis as there are few reports in medical literature. Objective: To do full clinical and histopathological evaluation of KPR in Iraqi population. Patients and Methods: This is case descriptive, clinico-histopathological outpatient based study. It was done in the Center of Dermatology and Venereology, Baghdad Teaching Hospital, Medical City, Iraq during the period from March 2016 to October 2017. Sixty patients were enrolled in this study. History and dermatological examination were carried out for all patients. Skin biopsy was done for 10 patients for histopathological study using Hematoxylin and Eosin stain. Results: A total of the 60 patients were diagnosed as KPR during the study period. Thirty nine (65%) males and 21 (35%) females. The age at onset of disease ranged from since birth to 8 (2.9± 2.17) years . Facial involvement included the cheeks in 60 (100%) patients. Other sites of involvement included the arms where the lateral aspects involved in 60 (100%) patients and the medial aspect 11 (18.3%), thighs including the buttocks in 51 (85%), trunk 25 (41.6%), legs 22 (36.6%) and the neck 15 (25%).The rash was erythematous all over but most obvious on the sides of face presenting as red, rough face. Histopathological evaluation showed follicular plugging in (100%) with dilatation of both superficial and deep vascular plexus in (75%) of cases. Limitation: The main limitation of this study was the lack of follow up data related to the subject of the study. Conclusion: KPR is a common condition among Iraqi population and this study is the largest study carried out all over the world. As most areas of body are involved, the name keratosis pilaris rubra totalis is suggested.

Feasibility study of stem-cell enriched autologous lipotransfer to treat oro-facial fibrosis in systemic sclerosis (Sys-Stem): Protocol for open-label randomised controlled trial

IntroductionOro-facial fibrosis is a common and disabling manifestation of systemic sclerosis (SSc), causing a plethora of functional, aesthetic and social compromise, yet is without effective treatment. Autologous lipotransfer is an established minimally invasive surgical procedure that is postulated to exert anti-fibrotic effects by adipose-derived stem cells, and presents a novel method in the treatment of fibrotic conditions. This study aims to assess the safety and efficacy of autologous lipotransfer for facial involvement in SSc. Methods and analysisThis is the first randomised controlled study with an open label design to assess autologous lipotransfer for oro-facial involvement in systemic sclerosis. The goals of this study are to assess the feasibility of using a range of quantitative and qualitative outcome measures to effectively measure disease severity and treatment outcome, and to assess patient acceptability for future multi-centre trials. A total of 50 participants will be randomised to a treatment or control group. The treatment group will receive autologous fat transfer to the peri-oral region by a single surgeon. Dermal fibroblasts and adipose-derived stem cells will be isolated from tissue samples. All outcome measures will be taken at baseline, then at 6 weeks, 3 months and 6 months from the time of intervention in the treatment arm, or from baseline in the control arm. Ethics and disseminationThe study has ethical approval (REC reference 19/LO/0718). Results will be available to patients, patient user groups, clinicians and the public through presentations at national and international rheumatology conferences and published in peer reviewed journals. Trial registrationRegistered on ISRCTN registry (ISRCTN17793055).

Descriptive study on malignant otitis externa in diabetic patients at a tertiary care hospital at Madurandhagam

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Malignant otitis external (MOE) is a destructive infection, principally affecting ageing diabetic patients. The present study directed for analysing various forms of clinical presentations, causative organisms and management of such diseases.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; We conducted a descriptive study of patients with MOE in the ENT Department of Karpaga Vinayaga Institute of Medical College and Hospital, Madurandhagam. Haematological, biochemical and epidemiological parameters were taken and result analysis was carried out. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; They affect both the soft tissue and bones of immunocompromised patient’s predominantly diabetic patients. Various forms of clinical presentations such as ear discharge which proved to be due to &lt;em&gt;Pseudomonas aeruginosa&lt;/em&gt;. Facial nerve involvement, osteonecrosis and bony erosion was noted in MOE patient.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; MOE or external otitis progressing necrosis is a serious infection of the subject often older and diabetic by &lt;em&gt;P. aeruginosa&lt;/em&gt;.&lt;/p&gt;

Airway Management in Case of Recurrence of Pleomorphic Adenoma of Right Submandibular Gland and Soft Palate

Objective: Pleomorphic adenoma is the most common type of all benign and malignant salivary gland tumours, involving more frequently the parotid gland. We present a case of a benign recurrent pleomorphic adenoma of the right submandibular gland and soft palate in a 42-year-old female without any signs of facial nerve involvement or damage. Methods: Case report. Findings: There was no evidence of the malignant transformation of the tumour confirmed on biopsy. It is 8x4cm oval in shape with diffuse border and was obstructing the upper airway and compression symptoms. The tumour was completely respected and reconstruction was done using pectoralis major myocutaneous (PMMC) flap. In this case, potential and predicted difficult airway is elaborated with excellent postoperative results. Applications/improvements: Though tumour of the submandibular gland is rare they require careful evaluation for the airway ventilation and intubation difficulties it poses.Keywords: Pleomorphic Adenoma, Submandibular Gland, Soft Palate, Difficult Airway

Ponto-medullary Junction Infarction Presenting as Ipsilateral Abducens Nerve Palsy and Contralateral Hemiparesis without Facial Involvement

Raymond syndrome is a pontine syndrome consisting of ipsilateral abducens nerve palsy, contralateral facial paralysis, and contralateral hemiparesis. However, subsequent clinical observations argued on the presentation of facial involvement. The only differentiating point between the facial including called classic type and the facial sparing Raymond syndrome is the location of the lesion. The classic type involves abducens nerve, corticofacial, and corticospinal tracts; while in the facial sparing type, corticofacial tracts, and peripheral facial nerves are spared. We experienced a 78-year-old man presented with sudden onset dizziness, binocular horizontal diplopia, and right-sided motor weakness. Neurological examination showed he had left abducens nerve palsy and right hemiparesis without facial involvement. Brain magnetic resonance imaging showed acute ischemic infarction in the left ponto-medullary junction. Regardless of the presence or absence of facial palsy, the combination of abducence nerve palsy and contralateral hemiparesis should direct the clinician’s attention towards the medial ventral caudal ponto-medullary junction. Keywords: Abducens nerve; Hemiparesis; Ponto-medullary junction; Raymond syndrome 중심 단어: ì™¸ì „ì‹ ê²½, ë°˜ì‹ ë§ˆë¹„, 교뇌연수이음부, ë ˆì´ëª¬ë“œì¦í›„êµ°