Revisiting King Appliance Space Regainer in Children: A Case Report with 1-Year Follow-Up

In recent times, for successful resolution of space discrepancies, a plethora of interceptive measures involving nonextraction approaches have been employed judiciously. Immaculate diagnosis and treatment planning help to prevent failure in diagnosing a case of space discrepancy and space regaining. This article describes a case in which space loss in the posterior quadrant of mandibular arch was successfully regained by employing King Appliance space regainer in an adolescent male, following which successful eruption of unerupted tooth took place. Additionally, after 1 year of follow-up, no marked reduction in arch dimension was seen.

Posterior Quadrant Disconnection for Childhood Onset Sub-Hemispheric Posterior Head Region Epilepsy: Indications in an Indian Cohort and Outcome

<b><i>Background:</i></b> Posterior quadrant disconnection (PQD) is an under-utilized surgical technique in the management of refractory epilepsy. There is a dearth of data pertinent to post-PQD seizure outcomes. <b><i>Methods:</i></b> This retrospective study analyzed patients with drug-resistant childhood-onset epilepsy who underwent PQD at our center from 2009 to 2018. The clinical, imaging, and electrophysiological data were reviewed. The seizure outcome was noted from the latest follow-up in all patients. <b><i>Results:</i></b> Fifteen patients underwent PQD, with a mean age at onset of epilepsy of 3.3 ± 4.6 years. All patients had seizure onset in childhood with focal onset of seizures, and in addition, 5 had multiple seizure types. All cases underwent presurgical workup with MRI, video-EEG, psychometry, while PET/MEG was done if required. Engel Ia and ILAE I outcomes were considered to be favorable. The histology of the specimen showed 9 patients (60%) had gliosis, 4 (26.7%) had focal cortical dysplasia (FCD), while 1 patient had nodular heterotopia and another had polymicrogyria-pachygyria complex. Postoperative follow-up was available in 14 cases. One patient was lost to follow-up. Mean follow-up duration for the cohort was 45 + 24 months. At last, follow-up (<i>n</i> = 14), 66.7% (10 cases) had favorable outcome (Engel Ia). At the end of 1-year follow-up, up to 73% (<i>n</i> = 11) of the patients were seizure-free. Four patients developed transient hemiparesis after surgery which improved completely by 3–6 months. <b><i>Conclusions:</i></b> Gliosis was more common etiology requiring PQD in our series than Western series, where FCD was more common. PQD is a safe and effective surgical modality in childhood-onset epilepsy with posterior head region epileptogenic focus.

Completion Posterior Quadrant Disconnection After Failed Temporal Lobectomy: 2-Dimensional Operative Video

Epilepsy is a chronic seizure disorder that affects about 1% of the global population.1 When seizure freedom cannot be obtained solely through antiseizure medicines (ASMs), the condition is termed medically refractory epilepsy (MRE).2,3 Though posterior quadrant disconnection (PQD) is underutilized in our experience, it is a highly effective surgical procedure for MRE restricted to the temporal, parietal, and/or occipital lobes.4-12 In this operative video, we demonstrate a right-sided completion PQD following failed temporal lobectomy in an 8-yr-old female with focal MRE. We review technical nuances, including (1) extension/revision of prior scalp incision, (2) placement of subdural strip for the identification of phase reversal and central sulcus, (3) disconnection of parietal and occipital lobes, (4) extension of the corticectomy to the pia overlying the falcotentorial junction and into the prior temporal lobectomy defect, and (5) posterior disconnection of the corpus callosum. Postoperatively, the patient experienced subtle left-arm weakness and central fever, both of which resolved. An external ventricular drain (EVD) was placed in the ventricle/operative cavity and left for 3 to 4 d until the draining cerebrospinal fluid (CSF) cleared. As of 3-mo follow-up, she has been seizure-free without complications. In summary, PQD is a safe and effective treatment option for MRE that can be utilized not only as an initial operation but also after failed surgery. Appropriate patient consent was obtained to perform this procedure and present this clinical case and surgical video for academic purposes. Image at 4:00 licensed under CC BY-2.5, 2006, modified from http://upload.wikimedia.org/wikipedia/commons/7/70/Lateral_head_skull.jpg (flipped and rotated). Image at 4:42, Public Domain: Gray H. Anatomy of the Human Body. 1918. Bartleby.com, https://commons.wikimedia.org/wiki/File:Lobes_of_the_brain_NL.svg; flipped, modified. Image at 6:42, Public Domain: House EL, Pansky B. A Functional Approach to Neuroanatomy. 1960. McGraw-Hill Book Company; https://upload.wikimedia.wikipedia.commons/5/52/Lawrence_1960_2.3.png; modified.

A STUDY ON CORRELATION OF SIZE AND SITE OF TYMPANIC MEMBRANE PERFORATION WITH DEGREE OF CONDUCTIVE HEARING LOSS IN CHRONIC OTITIS MEDIA

Background: Tympanic membrane perforations are common cause of hearing loss. This study was designed to analyze the relation between tympanic membrane perforation and conductive hearing loss. Materials and Methods: In this prospective study, patients with dry tympanic membrane perforations of safe type were included. The patients were divided into groups in according to size, site and duration of perforation. Based on the inclusion and exclusion criteria a total of 100 patients were included in this study. All the patients clinical data was analyzed statistically using paired t-test. Results:Hearing loss increased as the size of perforation increased. Posterior quadrant perforations were associated with more hearing loss as compared to anterior quadrant perforations. Also duration of disease was in linear relation with mean hearingloss. Conclusions: The degree of conductive hearing loss as a result of tympanic membrane perforation would be expected with the size, site and duration of perforation. Keywords: Tympanic membrane, Conductive hearing loss, Perforation, hearing loss, posterior quadrant, ear.

Phase-amplitude coupling of interictal fast activities modulated by slow waves on scalp EEG and its correlation with seizure outcomes of disconnection surgery in children with intractable nonlesional epileptic spasms

OBJECTIVEEpileptic spasms (ESs) are classified as focal, generalized, or unknown onset ESs. The classification of ESs and surgery in patients without lesions apparent on MRI is challenging. Total corpus callosotomy (TCC) is a surgical option for diagnosis of the lateralization and possible treatment for ESs. This study investigated phase-amplitude coupling (PAC) of fast activity modulated by slow waves on scalp electroencephalography (EEG) to evaluate the strength of the modulation index (MI) before and after disconnection surgery in children with intractable nonlesional ESs. The authors hypothesize that a decreased MI due to surgery correlates with good seizure outcomes.METHODSThe authors studied 10 children with ESs without lesions on MRI who underwent disconnection surgeries. Scalp EEG was obtained before and after surgery. The authors collected 20 epochs of 3 minutes each during non–rapid eye movement sleep. The MI of the gamma (30–70 Hz) amplitude and delta (0.5–4 Hz) phase was obtained in each electrode. MIs for each electrode were averaged in 4 brain areas (left/right, anterior/posterior quadrants) and evaluated to determine the correlation with seizure outcomes.RESULTSThe median age at first surgery was 2.3 years (range 10 months–9.1 years). Two patients with focal onset ESs underwent anterior quadrant disconnection (AQD). TCC alone was performed in 5 patients with generalized or unknown onset ESs. Two patients achieved seizure freedom. Three patients had residual generalized onset ESs. Disconnection surgeries in addition to TCC consisted of TCC + posterior quadrant disconnection (PQD) (1 patient); TCC + AQD + PQD (1 patient); and TCC + AQD + hemispherotomy (1 patient). Seven patients became seizure free with a mean follow-up period of 28 months (range 5–54 months). After TCC, MIs in 4 quadrants were significantly lower in the 2 seizure-free patients than in the 6 patients with residual ESs (p < 0.001). After all 15 disconnection surgeries in 10 patients, MIs in the 13 target quadrants for each disconnection surgery that resulted in freedom from seizures were significantly lower than in the 26 target quadrants in patients with residual ESs (p < 0.001).CONCLUSIONSIn children with nonlesional ESs, PAC for scalp EEG before and after disconnection surgery may be a surrogate marker for control of ESs. The MI may indicate epileptogenic neuronal modulation of the interhemispheric corpus callosum and intrahemispheric subcortical network for ESs. TCC may be a therapeutic option to disconnect the interhemispheric modulation of epileptic networks.

Endoscope-assisted posterior quadrant disconnection plus corpus callosotomy: case report

Intractable epilepsy impacts many children. Surgically resective and palliative treatments have developed to increase seizure freedom or palliate the seizure burden in those with medically refractory epilepsy. However, surgical epilepsy treatment can confer significant morbidity and death. Endoscope-assisted surgical approaches may be helpful in reducing the morbidity related to traditional open surgical approaches while allowing for good visualization of surgical targets. Here, the authors report a case utilizing an endoscope-assisted keyhole approach to perform a posterior quadrantectomy and corpus callosotomy, achieving the surgical goals of disconnection and reducing the need for large craniotomy exposure. They present the case of a 17-year-old male with medically refractory epilepsy treated with endoscope-assisted posterior quadrantectomy and corpus callosotomy through two mini-craniotomies to achieve a functional disconnection. To the authors’ knowledge, this is the first reported case of an endoscope-assisted approach for a posterior quadrantectomy for surgical epilepsy treatment in an adult or a pediatric patient. The case is reported to highlight the technical nuances and benefits of this approach in select patients as well as the expansion of applications of endoscope-assisted epilepsy surgery.