Persistent Drainage Research Articles

Failing transcervical thymectomy in myasthenia gravis. An evaluation of transsternal re-exploration.

Twenty cases of failing transcervical thymectomy are reported. They were selected for transsternal re-exploration from a series of 95 patients who had previously undergone transcervical thymectomy because of myasthenia gravis (MG). A specific method for pre-operative detection of remnants of the non-tumorous thymic gland is lacking, but the applied clinical selection criteria were so far reliable: generalized, disabling, fluctuating MG despite cholinesterase inhibitor and/or immunosuppressive treatment, and no or inconsistent improvement after transcervical thymectomy. At transsternal re-exploration the commonest findings were intact lower thymic lobes with persistent venous drainage into the brachiocephalic vein. Presence of thymic tissue was histologically confirmed in all the excised specimens (weight range 10-60, mean 23 g), and the examination showed thymic hyperplasia in 18 cases, fatty involution of the gland in two, and a lympho-epithelial thymoma in one case. The re-operation was followed by objectively registrable improvement in all but one of the 20 patients during observation periods of 8-75 (mean 21) months. There was statistically significant reduction in disability scores (means 8.2-4.9) and in need for anticholinesterase medication (to 67% of pretreatment dose). Immunosuppression became unnecessary in 6 of 11 patients and could be reduced in 4 patients. The incidence of failure in transcervical thymectomy was alarmingly high (27%), and more re-operations are anticipated. Since the transcervical approach involves a high risk of incomplete thymectomy, its use should be abandoned. However, in most of the patients with re-operation, subsequent progress has been sufficiently promising for advocacy of sternotomy whenever the clinical criteria of failure are fulfilled.

Open Fractures of the Tibia Treated by the Hoffmann External Fixator

In a prospective study 40 consecutive patients with open tibial fractures were treated by the Hoffmann external fixator; the follow-up period was 18 months. All fractures were irrigated, debrided, and fixed rigidly with the Vidal-Adrey modification of the Hoffmann device as soon as the patients' condition allowed. The wounds were left open, to be closed secondarily with skin grafts, muscle flaps, and other plastic surgical procedures. The 40 wounds were all classified as Gustilo's Type II or III in relation to soft tissue damage; 36 injuries were due to motor vehicle accidents and four to gunshot wounds. At the 18-month follow-up examination there had been five amputations and five nonunions had healed after bone grafting; in addition, five patients had persistent pin drainage. Pin site drainage (80%) was the most common problem, but most cleared after removal of the fixator and five after curettage of ring sequestra. There was a high number of associated surgical procedures (2.4% per patient) related to the open fracture. At the 18-month follow-up examination bony healing was noted in all patients.

Silver Anode Treatment of Chronic Osteomyelitis

Twenty-five patients with active, chronic osteomyelitis, resistant to conventional management, were treated with surgical debridement and daily application of electrically activated silver dressings. Sixteen (64%) cases resulted in closed, stable, pain-free wounds, with the remainder resulting in persistent drainage or amputation. Nine of 12 cases complicated by nonunion achieved union. In 13 patients an open-bone graft was performed and silver treatment continued: these tended to remain free of purulent drainage but fared no better than average in the long-term follow-up. The silver anode dressing seems to be an effective aid in the treatment of chronic bone infection when combined with adequate surgical debridement, thereby reducing the need for prolonged systemic antibiotics.

Screening the Nipple for Involvement in Breast Cancer

On the basis of independent clinical and pathological screens, mastectomy patients can be effectively classified into high-risk and low-risk groups for neoplastic involvement of the nipple-areolar complex. Clinical criteria included gross nipple signs, cutaneous signs, and tumor location, size, and bilaterality. Pathological criteria comprised subareolar involvement multicentricity, and nodal involvement. Fifty consecutive women undergoing mastectomy for cancer at the New York Hospital-Cornell University Medical Center underwent classification into high-risk and low-risk groups on the basis of these criteria. Fifty-four percent of the patients studied passed the screens and were included in the low-risk group. The incidence of nipple involvement in this group was 0. In the remaining 46%, failing either or both of the screens and constituting the high-risk group, the incidence of neoplastic involvement of the nipple was 35%. All involved nipples fell into this group.

Traumatic hemothorax: Is decortication necessary?

Recent recommended management of traumatic hemothorax has included early thoracotomy to evacuate clotted blood (“decortication”) and thereby to prevent early and late pleural sequelae. This report reviews the management and results in 452 patients with hemothorax caused by penetrating (338 cases) or blunt trauma (114 cases). The patients were placed into two groups: Group I consisted of 408 patients who had pleural drainage as the only operative treatment for hemothorax. Group II comprised 44 patients who also had thoracotomy. The primary indications for thoracotomy were massive or persistent pleural blood drainage, cardiac tamponade, vascular injury, pleural contamination, débridement of devitalized tissue, sucking chest wounds, and major bronchial air leak. Thoracotomy was not done just because there was chest roentgenographic evidence of residual hemothorax. Group I patients were divided into subgroups A or B determined by whether or not a chest roentgenogram taken after insertion of the tube showed adequate removal of pleural blood. Two hundred ninety patients were classified as Group IA with no residual hemothorax, and 118 patients were Group IB with residual hemothorax after chest tube drainage. In long-term follow-up, abnormal chest x-ray findings were observed in all groups but were frequent in the more severely injured patients of Group IB and Group II. Empyema occurred with equal frequency whether or not there was hemothorax. Development of empyema was related to shock on admission, pleural contamination, pneumonia, and prolonged duration of catheter drainage. We concluded that prompt adequate chest tube drainage is usually sufficient treatment for traumatic hemothorax. Residual hemothorax can be managed expectantly and need not be managed by early decortication.

The problem mastoid cavity: medical and surgical management.

The patient with persistent foul drainage from a previously operated-on mastoid cavity has a serious problem that requires aggressive attention from the otologic surgeon. The ear must be carefully evaluated in the office. Careful cleaning of the cavity and effective application of medication will dry up many of these cavities. Revision surgery of the ear requires a systematic approach using all the techniques of modern otologic surgery. This means the use of a post-auricular incision and wide bone removal combined with bone removal combined with obliteration techniques and grafting of the middle ear. This approach was used in 29 ears in 27 patients. Rapid healing and a trouble-free, dry ear was obtained in 26 patients or 90% of the operated-on cases.

Linear Limb Sinus Tract in a Child

CHRONIC draining sinus tracts and recurrent abscesses are usually associated with chronic inflammatory disorders (tuberculosis, fungal disorders), neoplasms, inflammatory bowel disease, and the presence of a foreign body. This report describes the case of a child who had recurrent gluteal and thigh abscess, with persistent draining sinus tracts that, in the final analysis, represented a subdermal linear limb sinus tract covering the entire length of the lower extremity. We believe this lesion is of congenital origin; review of the English literature did not reveal a similar case. Report of a Case A 5-year-old girl was admitted to the James Whitcomb Riley Hospital for Children on the Indiana University Medical Center campus on April 11, 1972, with the chief complaint of persistent purulent drainage from the right gluteal fold. The draining area had been present for two years and was initially thought to be related to an insect bite. A single

Malignant external otitis: A severe form of otitis in diabetic patients

Two cases of malignant external otitis are presented and the literature is reviewed. The disease seems to occur exclusively in elderly diabetic patients. Diagnosis is mostly a clinical one, and requires a high index of suspicion. The characteristic clinical manifestations are pain and severe tenderness of the tissues around the ear and mastoid, persistent drainage and the presence of granulation tissue at the junction of the osseus and cartilagenous portions of the external ear. Roentgenographic findings are not helpful in the early stages. The pathogenesis of this disease depends on the presence of clefts in the cartilage forming the floor of the external auditory canal at its junction with the osseus portion through which infection can spread from the external ear to the deep soft tissues. Serious and often fatal complications may ensue. The most common and earliest symptom to appear is facial nerve palsy. Pseudomonas aeruginosa has been isolated uniformly, in pure or mixed cultures. This entity, therefore, should be borne in mind whenever an elderly diabetic patient presents with external otitis not amenable to the usual methods of therapy. Ps. aeruginosa should be strongly suspected, and its isolation should prompt vigorous systemic treatment with gentamicin and carbenicillin before extensive necrosis of cartilage and bone takes place. Any delay in diagnosis and management will lead to serious and often fatal complications.

Osteomyelitis in infants and children. A review of 163 cases.

One hundred sixty-three cases of osteomyelitis in infants and children were seen at our hospital during the past 15 years. There were twice as many boys as girls. Staphylococcus aureus was the major etiologic agent, being identified in 61% of the cases. Gram-negative bacteria were responsible for only 14 cases (9%). The femur, the tibia, or the humerus were affected in 103 of the 152 patients with single bone involvement. Ostoemyelitis of more than one bone was seen in 11 cases (7%). Associated joint infectin was confirmed in 29 patients. There were no deaths. Surgical drainage was carried out in 81 cases (50%). Ten patients had recurrent or persistent drainage and one developed a Brodie abscess. Of the patients with S aureus osteomyelitis, chronic disease occurred in 19% of those receiving parenterally administered antibiotics for three weeks or less, but in only one patient (2%) of those who received parenteral antibiotics longer than three weeks.

The role of surgery and hyperalimentation in therapy of gastrointestinal-cutaneous fistulae.

Thirty-eight patients with external gastrointestinal fistulas arising from different levels of the gastrointestinal tract, observed and treated at the Massachusetts General Hospital, from December 1970 to April 1973, are analyzed. Surgical complications were the causes of fistulization in 77% of the cases. The treatment program included parenteral nutrition through a subclavian line in all cases. The 38 patients were fed parenterally for a total of 2311 days. Spontaneous fistula closure occurred in only 11 of the 38 patients. Surgical procedures were necessary in 71.05% of the cases to control fistula complications or persistent fistula drainage. Operative success rate was 70.4%. Parenteral nutrition effects on metabolic parameters, fistula secretion, nutritional status, morbidity and mortality of fistulas are discussed. Parenteral nutrition hazards are also presented. Overall mortality in this series was 21%. Roles of parenteral nutrition and surgery in the total management of external gastrointestinal fistulas are suggested.

Polymer Osteosynthesis

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Current concepts of chronic attic and middle ear disease; new surgical technique to preserve hearing.

• Chronic inflammatory disease in the middle ear sometimes leads to retraction and perforation of the pars flaccida of the tympanum. These attic perforations, marginal in location, are more difficult to remedy than perforations of the pars tensa. The latter are characteristic of acute otitis, generally central in location, and likely to heal spontaneously in a few weeks. Prophylaxis includes follow-up of all cases of acute otitis to make sure that treatment with sulfonamides and antibiotics is continued until the exudate in the middle ear is resolved completely. In cases of incomplete resolution or other longstanding disease resulting in marginal perforations, if there is persistent drainage with symptoms of extension to neighboring structures and evidence of cholesteatoma, surgery must be considered. In four cases of chronic otitis persisting from 3 to 20 years there were marginal perforations. All were successfully treated by modified radical mastoidectomy with special attention to the ossicular chain. Audiograms showed that the severe hearing losses that were almost inevitable with older types of radical mastoid surgery were avoided in these cases.

Radical mastoidectomy with primary split-thickness skin grafting; survey of fifty cases.

THIS SURVEY of 50 consecutive radical mastoidectomies is presented (1) to reveal certain features of the symptomatology and pathology connected with these chronic ear infections, (2) to emphasize certain parts of the skin-grafting technique, and (3) to present data on the healing time and the results obtained, with emphasis on the hearing before and after operation. Radical operations on these patients were performed only after careful consideration had been given to the possibilities of eliminating the pathology by some modified radical procedure. In several instances operations were started with a modified procedure planned only to discover pathology of a nature that required the more radical operation. <h3>SYMPTOMATOLOGY</h3> All 50 patients gave a history of longstanding pus discharge from the ear. Some patients had had the discharge for 40 years or more, and the persistent drainage, often with a foul odor, was usually the chief complaint. In many the hearing had

Experiences in treatment of traumatic cavitation in the upper tibia

Seven cases of compound fractures of the tibia and fibula are presented. All of the fractures involved the upper flare of the tibia, and all developed osteomyelitis with persistent drainage from a through-and-through cavity of the tibia. The treatments were long, persistent and varied, with each type given a thorough trial. Four of the cases are completely epithelialized. All are ambulatory and asymptomatic with some limitation of motion at the knee The treatment here outlined is conservative, with sequestrectomy, immobilization, systemic antibacterials and early weight bearing.

TRANSTUBAL INSTILLATION OF PENICILLIN IN ACUTE OTITIS MEDIA

Many reports substantiate the therapeutic value of the local application as a supplement to the administration of penicillin. It may be employed whenever the site of the suppurative process is accessible, as in the pleural, the peritoneal or the pericardial cavity, in joints, in wounds, fistulas, burns and compound fractures and within the cerebral ventricles, the spinal canal, the nasal accessory sinuses or other preformed body spaces.¹ A procedure for blowing penicillin into the tympanic cavity by the transtubal route will be presented in this report. It has been used in cases in which acute otitis media has not responded completely to the usual local measures plus systemic treatment with either penicillin or one of the sulfonamide compounds. It has been found to be of value when the suppuration of the middle ear has reached a subacute stage of decreased but persistent drainage without necrosis in the mastoid process. TECHNIC

The early diagnosis and surgical treatment of actinomycosis of the head and neck

In the treatment of actinomycosis, if possible, complete eradication of the diseased process by certain surgical procedures should constitute the chief therapeutic measure. Wangensteen has very adequately stated the problem, “It is highly important, therefore, that actinomycotic wounds be frequently and meticulously examined. When a pocket has been well curetted, persistent drainage usually means an adjacent focus. The main consideration of most consequence is whether all the actinomycotic debris has been curetted away.” For supportive measures, potassium iodide and irradiation therapy are of value, but they should be considered of secondary importance.