Long-term Conservative Treatment Research Articles

Long-term conservative treatment outcomes for midshaft clavicle fractures: a 10-to-30-year follow-up

BackgroundFew reports exist on the long-term outcomes of midshaft clavicle fracture conservative treatments. Therefore, this study investigated the long-term outcome of this treatment in patients with midshaft clavicle fractures.MethodsPatients were treated conservatively for midshaft clavicle fractures with a figure-of-eight bandage between 10 and 30 years ago. Subsequently, a telephone survey was used to follow-up these patients, and 38 were successfully evaluated. The mean term after trauma was 17.0 years. Afterward, the American Shoulder and Elbow Surgeons Shoulder (ASES) score and Shoulder pain and disability index (SPADI) on the affected and unaffected sides were calculated based on the filled questionnaires. We defined patients whose ASES and SPADI on the affected side were worse than the unaffected side as the symptomatic group. Furthermore, plain radiographs measured proportional changes in clavicular length and displacement.ResultsThe ASES scores of the affected side were significantly lower than those of the unaffected side, and the SPADI of the affected side was significantly higher than that of the unaffected side. Furthermore, the symptomatic group's proportional changes in clavicular length and displacement were significantly larger than the asymptomatic group.ConclusionThe affected shoulder side was more symptomatic than the unaffected side 10 to 30 years after the trauma when midshaft clavicle fractures were treated conservatively. Moreover, several patients became symptomatic for fractures with a larger proportional change in clavicular length or displacement.

A Case of Hypopharynx Perforation After Esophagogastroscopy

We report a case of endoscopic and open surgical treatment for iatrogenic perforation in the hypopharynx, a rare but potentially fatal complication of esophagogastroduodenoscopy. The patient was a 55-year-old female who exhibited strong resistance during passing through hypopharynx, leading to the suspicion of perforation, which was confirmed by CT scan and esophagography. Conservative management was attempted with antibiotics and prohibition of oral intake for 2 months, but she experienced worsening discomfort in the neck and was eventually readmitted for surgical treatment. The patient was treated with endoscopic mucosal repair and open surgery with regional flap. With the hypopharynx perforation healed, the patient was able to resume regular diet after a week and was discharged. Hypopharyngeal perforation that did not improve with long-term conservative treatment can be successfully treated through open surgery using a flap.

Early diagnosis and surgical treatment of craniosynostoses

Craniosynostosis is a craniofacial anomaly, characterized by premature fusion of one or more of the cranial sutures. Each suture and their combination correspond to a special type of deformation.Purpose. The study aimed at indicating the difficulties of early diagnostics of various forms of the craniosynostosis and evaluating the quality of treatment of patients with this disease depending on their age.Material and methods. A survey of parents with craniosynostosis who were treated at the Almazov National Medical Research Centre in 2018–2019 was conducted. The parents of 107 patients were surveyed. The main objectives of our research were: to evaluate the timeliness of diagnosis of craniosynostosis at primary health care at patient’s place of residence; to compare the methods of diagnosis verification and to present the results of the parents’ subjective assessment of the results of surgical treatment at the early and long-term postoperative period.Results. The median age of children when they were diagnosed with craniosystosis was 5 months, the median age of patients when they underwent a surgical treatment was 16 months. The median duration of the catamnesis was 6 months. We revealed that the preliminary diagnosis was established by a neurologist and pediatrician only in 21% of cases. Only at 28% of cases, children were directed to neurosurgeon, who confirm the diagnosis. In 38 (35.3%) cases, patient’s parents independently sought medical advice. The diagnosis was verified by the results of the computer tomography in 55% of patients. on because primary care specialists due to the lack of primary care specialists’ awareness about the diagnosis of craniosynostoses and attempts at long-term monitoring and conservative treatment. The timeliness of detection of craniosynostosis in the newborn period and in the|first month of life can significantly improve the cosmetic and functional outcomes of the disease.

Klebsiella invasive liver abscess syndrome presenting with a central nervous system manifestation secondary to latent cholecystitis: a case report

BackgroundBrain abscess is a life-threatening event. Moreover, when Klebsiella pneumoniae is the cause, rapid diagnosis and appropriate treatment are required. Klebsiella invasive liver abscess syndrome, a bloodstream metastatic infection of potentially aggressive nature, has been recognized to cause infection in the central nervous system, and concern for Klebsiella liver abscess syndrome is increasing globally.Case presentationA 73-year-old Japanese woman was admitted to the institution complaining of aggravated dysarthria and weakness in the right upper extremities with onset 5 days earlier. Magnetic resonance imaging revealed a brain abscess in the left basal ganglia, and abdominal computed tomography revealed a liver abscess in liver segment 7. The patient’s dysarthria symptoms became increasingly worse over the next few days, so surgical drainage via frontotemporal craniotomy was performed on admission day 3, and subsequent culture from the brain abscess showed growth of Klebsiella pneumoniae. On admission day 9, percutaneous transhepatic drainage of the liver segment 7 abscess was undertaken. The pus culture also showed growth of Klebsiella pneumoniae, thus associating the liver abscess with the brain abscess. Following long-term conservative treatment with antibiotics and abscess drainage, the liver abscess disappeared. However, the patient continuously presented with right upper quadrant pain, and abdominal computed tomography showed swelling of the gallbladder. Consequently, percutaneous transhepatic gallbladder drainage was initially administered, and the bile culture was also positive for Klebsiella pneumoniae. For radical treatment, a laparoscopic cholecystectomy was performed on admission day 99. The postoperative period was complicated by an intraabdominal abscess; however, conservative therapy was successful. She was subsequently discharged, and 12-month follow-up revealed no further sequelae.ConclusionsWe describe a rare case of Klebsiella liver abscess syndrome, which first presented with a central nervous system manifestation. Our patient was successfully treated via an early surgical intervention and subsequent antibiotic therapy. Although surgical drainage remains the cornerstone treatment for brain abscess, when a brain abscess is found, and there is a high index of suspicion for the existence of a liver abscess, Klebsiella liver abscess syndrome should be considered as a possible diagnosis.

Successful, Combined Long-term Treatment of Cerebral Candidiasis and Aspergillosis in a Liver Transplant Recipient: A Case Report

Invasive fungal infections, of which the most common are candidiasis and aspergillosis, are among the most important and fatal complications in solid organ transplantation. They continue to be a significant cause of morbidity and mortality in patients with involvement of the central nervous system (CNS) because of the poor CNS penetration of antifungal medications. Voriconazole yields fungicidal drug concentrations in the CNS, but its use is limited in solid organ transplant patients because of its metabolic interactions with immunosuppression. Here we report a case of invasive fungal infection in the CNS after an emergency liver transplantation due to hepatitis B virus-related acute liver failure. The patient was managed successfully with a long-term conservative medical treatment.

TREATMENT OF DIABETIC OSTEOARTHROPATHY WITH THE ILIZAROV METHOD

We present the clinical observation of 55-year-old female patient with diabetic osteoarthropathy (Wagner 3; Brodsky 2; 3a) complicated with chronic osteomyelitis treated in the purulent osteology clinic. Long-term conservative treatment in the hospital at place of residence was not successful, so the patient was found requiring limb amputation. On admission to the purulent osteology clinic, the patient complained of vast purulent wound of the right foot, numbness of the fingers of both feet and disturbed support ability of the limb. The patient underwent complex restorative treatment with the Ilizarov method. Primary treatment outcomes were obvious healing of the osteomyelitis and restoration of the limb function persisting already for three years after treatment. The clinical case presented illustrates the possibility of the Ilizarov method in complex regenerative treatment of patients with diabetic osteoarthropathy, which allows to suppress the necrotic process, eliminate the existing deformation to fill the bone defect and thus restore function of the limb.

New Simple 3-Dimensional Computed Tomogram Classification Leading to Successful Conservative Treatment in 51 Atlanto-Axial Rotatory Fixation Children

Objective: to present a new and easy classification of atlanto-axial rotatory fixation (AARF) and to investigate the efficiency of conservative treatment of AARF. Background: Although there is a precise definition and diagnostic classification of AARF, there is still significant difficulty in measuring the atlas and axis angles because all of the atlas or axis cannot be seen in a certain 2-dimensional computed tomogram image. In addition, some recent case reports showed that long-term conservative treatment can reduce pediatric AARFs, even that are severe or chronic. Methods: Fifty-one children with AARF were analyzed retrospectively with new 3-dimensional computed tomogram (3DCT)-based AARF classification; the mean age was 72.7 ± 35.2 months (19–139 months). In the new AARF classification, type 1 was defined as that when the C1C2 angle is not 0° on midline and type 2 as that when the C1C2 angle is 0° on the midline. Results: All 7 children with AARF type 1 were treated successfully only with Halter tractions. Twenty among 44 children with type 2 did not show any difference in improvement compared with not-treated 24 children with type 2. Conclusion: The first new AARF classification based on 3DCT appears to be easy to use and even the most severe children with AARF may be managed only with conservative treatment such as long-term Halter traction.

Modern dressings in treatment of patients with deep burns

Treatment of burns is a complex, multi-stage and financially costly process. Methods of treatment of patients with thermal trauma are currently continuing to improve: a multidisciplinary approach to treatment is being formed; burn centers have been established, where doctors of various specialties (surgeons, traumatologists, anesthesiologists, rehabilitologists, therapists, ophthalmologists and many others) participate in the treatment of patients. However, to date, the question of wound treatment in patients with deep burns at the stages of preparation for plastic closure and after autodermoplasty with a split perforated 1:4 graft remains open. It is known that extensive and deep burns are accompanied by the development of wound infection, which is one of the important factors that disrupt the epithelization of wounds. This results in lysis of the grafts and may require repeated surgery or long-term conservative treatment at the site of the operation.

Functional deficits in chronic mechanical ankle instability

BackgroundThe interaction of functional and mechanical deficits in chronic ankle instability remains a major issue in current research. After an index sprain, some patients develop sufficient coping strategies, while others require mechanical support. This study aimed to analyze persisting functional deficits in mechanically unstable ankles requiring operative stabilization.MethodsWe retrospectively analyzed the functional testing of 43 patients suffering from chronic, unilateral mechanical ankle instability (MAI) and in which long-term conservative treatment had failed. Manual testing and arthroscopy confirmed mechanical instability. The functional testing included balance test, gait analysis, and concentric-concentric, isokinetic strength measurements and was compared between the non-affected and the MAI ankles.ResultsPlantarflexion, supination, and pronation strength was significantly reduced in MAI ankles. A sub-analysis of the strength measurement revealed that in non-MAI ankles, the peak pronation torque was reached earlier during pronation (maximum peak torque angle at 20° vs. 14° of supination, p < 0.001). Furthermore, active range of motion was reduced in dorsiflexion and supination. In balance testing, patients exhibited a significant increased perimeter for the injured ankle (p < 0.02). During gait analysis, we observed an increased external rotation in MAI (8.7 vs. 6.8°, p<0.02).ConclusionsThis study assesses functional deficits existent in a well-defined population of patients suffering from chronic MAI. Impairments of postural sway, gait asymmetries, and asymmetric isokinetic strength can be observed despite long-term functional treatment. The finding that pronation strength is particularly reduced with the foot in a close-to-accident position indicates potential muscular dysfunction in MAI. Possibly, these deficits alongside the underlying mechanical instability characterize patients requiring mechanical stabilization.

Congenital hyperinsulinism: management and outcome, a single tertiary centre experience.

Hyperinsulinemic hypoglycaemia (HH) is the most frequent cause of persistent hypoglycaemia in neonates and infants. The most severe forms of HH are inherited and referred to as congenital hyperinsulinism (CHI). Diazoxide is the mainstay of treatment, with surgery being an option in appropriate cases. To describe the management and outcome of patients with CHI within our service. Children referred to or attending HH clinic between 2009 and 2017 were identified. Clinical course, genetics and interventions were documented. A total of 39 children were identified, and seven patients with secondary and syndromic HH were excluded. Most were born with an appropriate weight for gestational age (62.5%). Diazoxide was started in all patients; however, 7 did not respond and required octreotide/continuous feeding, with 6/7 requiring surgery. Genetic mutations were detected in 12/32 (37.5%). Hyperinsulinism resolved in conservatively treated patients within 12months in 11/32 (34.3%) compared to 14/32 (43.7%) requiring more than 12months of medication. A total of 7 patients underwent pancreatectomy.Conclusion: Although LGA and SGA are risk factors, most babies in our cohort are born AGA. A genetic mutation does not exclude medical remission; long-term conservative treatment of CHI is feasible as surgery does not guarantee complete remission.What is Known:•Congenital hyperinsulinism (CHI) is a clinically and genetically heterogeneous disorder that is the most common cause of permanent hypoglycaemia in infants and children.•Identification of genetic mutations and the use of 18F-DOPA PET scan when feasible lead to better outcomes.What is New:•The study describes clinical criteria, management and outcome of large number of patients with CHI in single tertiary centre.•Conservative treatment is feasible without the need for surgery, with HH resolving in over 30% within 12months, irrespective of genetic mutation.

A Case of Relapsed Mucosal Prolapse Syndrome after Low Anterior Resection that was Performed after Long-Term Conservative Treatment

A Case of Relapsed Mucosal Prolapse Syndrome after Low Anterior Resection that was Performed after Long-Term Conservative Treatment

Safety and Efficacy of Anterior Lumbar Interbody Fusion for Discogenic Chronic Low Back Pain in a Short-stay Setting: Data From a Prospective Registry.

IntroductionAs a possible treatment option for chronic lower back pain (CLBP) due to single-level degenerative disc disorder (DDD), the efficacy of anterior lumbar interbody fusion (ALIF) has been reviewed various times in the existing literature. Nevertheless, a scarcity of data exists pertaining to ALIF procedures carried out in a short-stay setting using an Enhanced Recovery after Surgery (ERAS) protocol, particularly concerning the safety.MethodsProspectively collected data are analyzed to study the efficacy and safety of short-stay ERAS ALIF in treatment of single-level DDD. Visual Analog Scale (VAS) in both back and leg pain along with the Oswestry Disability Index (ODI) were used to collect measure outcomes. The primary endpoint was a minimum clinically important difference (MCID) of ≥30% for the ODI at 12 months.ResultsForty-four patients underwent surgery after failed long-term conservative treatment. MCID was achieved in 78%. Age was the only significant factor in association with MCID (p = 0.03), while gender, Modic changes, results of prognostic tests, prior surgery and smoking status had no significant influence on either MCID or change scores for any outcome measure. One complication in the form of transient new radiculopathy occurred in one patient (2.3%).ConclusionWith overall positive outcomes in terms of both efficacy and safety, an ALIF procedure with subsequent implementation of an ERAS protocol in a short-stay setting can be an option for strictly selected patients with CLBP. Further study, however, possibly with a larger sample size, would be necessary to substantiate these findings.

Risk factors for conservative treatment failure in acute osteoporotic vertebral compression fractures (OVCFs)

This study aimed to identify risk factors for failure of conservative treatment of acute osteoporotic vertebral compression fractures (OVCFs). This is a retrospective study of patients presenting with acute OVCFs who were initiated on conservative treatment for 3weeks. Conservative treatment was considered to have failed if patients were not satisfied with pain relief or there were bed rest-related complications. These patients progressed to operation. Patients were divided into a conservative treatment failure group (group A) and a conservative treatment group (group B). X-ray, computed tomography and magnetic resonance imaging of two groups were performed on the first visit to our department due to OVCFs. Recorded data for comparison among groups included age, gender, fracture level, bone mineral density (BMD), body mass index (BMI), modified frailty index (mFI), whether the fractures were multiple (≥ 2 vertebral bodies was defined as multiple vertebral fractures) or combined with old fractures, and whether intervertebral cleft (IVC) was present. We collected data from 173 patients who underwent conservative treatment of acute OVCF in our hospital. Of these, 71 had conservative treatment failure, while 102 patients succeeded in long-term conservative treatment. After logistic regression analysis, age, BMD, BMI, mFI, and IVC were identified as high-risk factors for conservative treatment failure (P < 0.05). Age, BMD, BMI, and mFI were included in receiver operating characteristic curve analysis, the result showed that the cutoff value of age was 73.5years old, of BMI was 23.65kg/m2, of BMD was - 3.45, and mFI was 2.5. According to the results of this study, patients with high-risk factors should be actively observed during conservative treatment, especially for patients with all of the above risk factors, but further research would be required before considering early-stage treatment policy change.

Analyse der Lebensqualität von Patienten mit Osteoidosteom vor und nach Behandlung mittels Radiofrequenzablation

The aim of this study was to investigate the effectiveness of the treatment of osteoid osteomas (OO) by radiofrequency ablation (RFA). In particular, the recurrence rate and the improvement in the quality of life as assessed by the reduction of pain intensity were evaluated. Retrospective analysis of 26patients after RFA of an OO and prospective analysis of 14patients using aself-developed quality of life questionnaire. The questionnaire, the electronic patient file and the histopathological findings were processed. An average of 22months passed between the first onset of complaints and the causative treatment by RFA. After RFA, there was asignificant reduction in pain symptoms and thus an increase in the quality of life. These results confirm that RFA from OO is asafe and efficient treatment procedure. In order to avoid long-term conservative treatment attempts and to reduce effects on the musculoskeletal system, atimely RFA of OO should be performed after diagnosis.

A binational analysis of 252 pancreatic resections for chronic pancreatitis with regard to incidental carcinoma sequence and overall postoperative outcome

Introduction: Therapeutic treatment algorithms for patients with chronic pancreatitis remain to be debated controversially until today. Especially surgical therapy is often only considered after long-term conservative treatment. The aim of this study was a binational analysis of patients who underwent pancreatic resections for suspected chronic pancreatitis at an austrian and german high-volume center with regard to incidental carcinoma sequence and overall postoperative outcome. Patients and methods: An overall of 252 consecutive pancreatic resections for suspected chronic pancreatitis were performed at both institutions between 2005 and 2015. In a binational retrospective analysis both postoperative results as well as histopathological findings were analyzed. Results: Pancreatic resections were performed in 193 male (76.6%) and 59 female patients (23.4%) with a median age of 53.2 years. A total of 175 pancreatic head resections (69.4%), 37 distal pancreatectomies (14.7%), 23 total pancreatectomies (9.1%) and 18 other pancreatic resections (7.1%) were performed within our study period. Postoperative complications > Clavien II occurred in 94 patients (37.3%). 21 patients (8.3%) developed clinically relevant postoperative pancreatic fistula (grade B and C), while postoperative mortality occurred in 5 patients (2.0%). Final histological examination of the operation specimen revealed an incidental pancreatic adenocarcinoma in 18 out of the 252 patients (7.1%). Conclusion: The results of our study demonstrate that pancreatic resections for chronic pancreatitis may nowadays be considered as technically feasible and safe. Especially the high incidence of incidental pancreatic adenocarcinoma underlines the necessity for an early surgical therapy approach in these patients.

A Bi-national Analysis of 252 Pancreatic Resections for Chronic Pancreatitis with Regard to Incidental Carcinoma Sequence and Overall Postoperative Outcome.

Numerous treatment algorithms for patients with chronic pancreatitis are still debated. In particular, surgical therapy is often only considered after long-term conservative treatment. The aim of this study was the bi-national analysis of patients who underwent pancreatic resection for suspected chronic pancreatitis at an Austrian and a German high-volume center with regard to overall postoperative outcome and incidental carcinoma sequence. Overall, 252 consecutive pancreatic resections for suspected chronic pancreatitis were performed at the two institutions between 2005 and 2015. In a bi-national retrospective analysis, postoperative results as well as histopathological findings were analyzed. Pancreatic resections were performed in 193 male (76.6%) and 59 female patients (23.4%), with a median age of 53.2 years. A total of 175 resections of the pancreatic head (69.4%), 37 distal pancreatectomies (14.7%), 23 total pancreatectomies (9.1%) and 18 other pancreatic resections (7.1%) were performed within our study period. Postoperative complications Clavien-Dindo grade II or greater occurred in 94 patients (37.3%). Twenty-one patients (8.3%) developed clinically relevant postoperative pancreatic fistula (grade B and C), while postoperative mortality occurred in four patients (1.6%). Final histological examination of the operative specimen revealed incidental pancreatic adenocarcinoma in 18 out of the 252 patients (7.1%). The results of our study demonstrate that pancreatic resections for chronic pancreatitis may nowadays be considered technically feasible and safe. The high incidence of incidental pancreatic adenocarcinoma especially underlines the necessity for an early surgical therapeutic approach for these patients.

Chronic pudenal neuralgia treatment with method of pulsed radio frequency (PRF)

Pudendal neuralgia is a pronounced pain in pudendal nerve dermatomes, most often aggravated in the sitting position. This condition is characterized by such symptoms as pain in the perineum, genitals, anus. The onset of pudendal nerve neuralgia can occur after surgery, cycling, trauma or without a provocative factor. Today, there is no ideal method for treating pudendal neuralgia. Treatment includes medication, blockade, decompressive surgery, or radiofrequency intervention. The article presents the clinical case of a patient who received a stable positive result due to radiofrequency pulse ablation (PRF) of the pudendal nerves after unsuccessful long-term conservative treatment. 44 years age patient complained of a pronounced pulling and throbbing pain in the perineum from the anus to the pubis, which was strengthened in the sitting position. The manifestation of the disease occurred several years ago for no apparent reason. Over time, the pain acquired signs of neuropathic, that is, burning and baking, sometimes unbearable. Conservative treatment included non-steroidal, anti-inflammatory drugs, physiotherapy procedures, massage and antidepressants. But it turned out to be ineffective: the patient’s condition worsened, she was forced to resign from the work (office clerk). After a comprehensive examination (MRI, SCT, ultrasound, physical examination), a diagnosis was established: chronic neuropathy of the pudendal nerves. Under the fluoroscopic and ultrasound-guided treatment-diagnostic block of the pudendal nerves. Received a positive result – for the duration of the action of the anesthetic pain was stopped. After this a pulse radiofrequency ablation of the pudendal nerves was performed at a frequency of 2 Hz (20 millisecond pulses) at 42°C, duration 120 seconds. Observation for 2 months confirmed the correctness of the chosen strategy. The pain significantly decreased, reaching a level of temporary discomfort, the patient returned to professional activity. The success of the treatment in such way: from medical-diagnostic block under X-rays and ultrasound-control to destructive radio-frequency procedures.

National Athletic Trainers' Association Position Statement: Evaluation, Management, and Outcomes of and Return-to- Play Criteria for Overhead Athletes With Superior Labral Anterior-Posterior Injuries.

To present recommendations for the diagnosis, management, outcomes, and return to play of athletes with superior labral anterior-posterior (SLAP) injuries. In overhead athletes, SLAP tears are common as either acute or chronic injuries. The clinical guidelines presented here were developed based on a systematic review of the current evidence and the consensus of the writing panel. Clinicians can use these guidelines to inform decision making regarding the diagnosis, acute and long-term conservative and surgical treatment, and expected outcomes of and return-to-play guidelines for athletes with SLAP injuries. Physical examination tests may aid diagnosis; 6 tests are recommended for confirming and 1 test is recommended for ruling out a SLAP lesion. Combinations of tests may be helpful to diagnose SLAP lesions. Clinical trials directly comparing outcomes between surgical and nonoperative management are absent; however, in cohort trials, the reports of function and return-to-sport outcomes are similar for each management approach. Nonoperative management that includes rehabilitation, nonsteroidal anti-inflammatory drugs, and corticosteroid injections is recommended as the first line of treatment. Rehabilitation should address deficits in shoulder internal rotation, total arc of motion, and horizontal-adduction motion, as well as periscapular and glenohumeral muscle strength, endurance, and neuromuscular control. Most researchers have examined the outcomes of surgical management and found high levels of satisfaction and return of shoulder function, but the ability to return to sport varied widely, with 20% to 94% of patients returning to their sport after surgical or nonoperative management. On average, 55% of athletes returned to full participation in prior sports, but overhead athletes had a lower average return of 45%. Additional work is needed to define the criteria for diagnosing and guiding clinical decision making to optimize outcomes and return to play.

Optimal time of surgery for acute adhesive small bowel obstruction

To define optimal terms of surgery for acute adhesive non-strangulatory small bowel obstruction. The analysis included 703 publications from e-LIBRARI.RU (342 works) and NCBI (361 works) databases for acute adhesive intestinal obstruction. The vast majority of articles presented retrospective analysis of single-center experience. It has been established that short course of medication is predominantly used for acute adhesive intestinal obstruction in the Russian Federation. International studies point 2-5 days for conservative treatment. The advantages and disadvantages of short and long courses of medication were analyzed. Therefore, multicenter, prospective, randomized trial 'Comparison of early operative treatment (12-hour medication) and long-term conservative treatment (48 hours) for acute adhesive small bowel obstruction' (COTACSO) was planned and registered (Unique Protocol ID: 14121729). The study protocol involves clinical, laboratory and instrumental exclusion of strangulation, randomization and conservative treatment of 2 groups of patients for 12 and 48 hours. Patients will undergo surgical interventions if obstruction will be present by that date. The main endpoint is mortality rate in both groups. The end of the study is December 2020.

Management of congenital nasal pyriform aperture stenosis

Background: Upper nasal airway obstruction in neonates is a dangerous condition because infants are predominantly nasal breathers. Congenital stenosis of the nasal pyriform aperture (CNPAS) is a rare but important condition to consider. Treatment varies from conservative measures, to surgical intervention with widening of the pyriform aperture. Objectives: To present surgical management of CNPAS as an alternative to conservative treatment. Methods: Six patients with CNPAS were presented at the tertiary care Academic Medical Center, diagnosed with respiratory insufficiency, obstructive breathing pattern and/or feeding difficulties. All patients underwent computed tomography scan and nasal endoscopy. Distance measurements of the pyriform aperture were performed. Findings: The mean age on presentation was 12 days. The widest and smallest mean distances of the pyriform aperture were 6.4 mm (range, 5.6–7.8 mm) and 5.1 mm (range, 3.6–6.1 mm). One conservatively treated patient showed no improvement in aperture width after 7 months. Three patients received surgical widening of the pyriform aperture. All patients recovered successfully. No complications occurred. Conclusion: CNPAS is a rare disorder, which can be very well managed by surgical widening of the pyriform aperture. Considering the fact that recovery of the surgically treated patients was quickly and without complications, one might think that surgical widening could be a good alternative for long-term conservative treatment with unknown outcome. Standardised documentation of patients is necessary to get insight in the (dis)advantages of conservative treatment versus surgical treatment.