Internal jugular to internal jugular vein bypass of symptomatic central vein obstruction

Introduction: Central venous obstruction (CVO) often arises among hemodialysis patients with upper extremity access due to a varying number of risk factors. While the true incidence of CVO in hemodialysis patients is unknown, it been reported in the range of 20%–40% in dialysis patients undergoing venograms. In the non-hemodialysis population, chronic central vein obstruction has a compensatory mechanism comprised of numerous collaterals along the chest wall, neck, and mediastinum. However, the presence of an AVF or AVG ipsilateral to a central venous stenosis or occlusion can overwhelm the collateral network due to the significantly elevated blood flow. This may result in severe and debilitating upper extremity and fascial swelling. While ligation results in almost instantaneous symptomatic relief, it does not address the patient’s underlying pathologic process and necessitates an additional access. As these patients continue to live longer, our strategies to manage these failing accesses are becoming increasingly complex. The goal of preserving existing access while correcting any symptoms is paramount. Previous case reports have documented various surgical options for preserving an existing access. Case presentation: Our patient is a 49-year-old female with hypertension and end-stage renal disease, on hemodialysis through a right arm arteriovenous (AV) fistula. She had a history of multiple AV fistulae creations in the past, all of which previously thrombosed. Several years after the creation of her most recent fistula, she developed severe throbbing headaches, right arm and facial swelling, right eye lacrimation, and blurry vision. AV fistula angiogram demonstrated right brachiocephalic vein chronic occlusion and endovascular revascularization through both trans-AVF and transfemoral approaches were attempted, but unsuccessful. Discussion: This case illustrates the success of the creation of an internal jugular-jugular vein bypass to maintain a right arm arteriovenous fistula, while at the same time, correcting the symptoms of a right brachiocephalic vein occlusion.

A Case of Unrelenting Facial Swelling

Melkersson-Rosenthal syndrome (MRS) is an uncommon disorder with presenting symptoms that typically involve the face and orofacial structures. It is a difficult diagnosis to make, as it may present with a protracted course of seemingly unrelated dermatological, ocular, and neurological findings. This case report reviews the presentation, workup, and diagnosis of a 75-year-old woman who presented with orofacial swelling, facial palsy, and tongue fissuring that had intermittently recurred over 10 years without a unifying diagnosis. Extensive medical history, photography, laboratory workup, and radiographic imaging were performed to identify the diagnosis of MRS in this patient. Our case highlights the challenge and importance of critically evaluating and consolidating a patient’s history of their present illness, physical examination, and ancillary testing to successfully establish a unifying diagnosis, especially when the diagnosis is relatively rare and diverse in its range of affected populations and symptomatology.

Comparison of Two Different Doses of Dexamethasone to Control Swelling and Trismus following Mandibular Third Molar Surgery

Introduction: Third molar surgery is one of the most common procedures performed by dental surgeons in clinical practice, where postoperative sequelae like pain, trismus, and swelling are often encountered. Thus, in this study, we compared medications employed to reduce such complications. Objective: To compare the effect of two different doses (4 and 8 mg) of dexamethasone in the control of swelling and trismus after the surgical extraction of mandibular impacted third molars. Methods: An experimental study consisted of twenty-seven (27) healthy adult patients of both genders with bilateral impacted lower third molars, where surgical extraction was indicated, 4 mg and 8 mg of dexamethasone were given orally to the patients 1 hour before the surgical procedure at both the surgeries. The swelling was recorded by measuring the length of 3 facial planes using a measuring tape. Trismus was evaluated by measuring the maximum interincisal distance. Recording of facial swelling and maximum interincisal distance was done preoperatively and on the 1st and 2nd days postoperatively. Results: Based on statistical analysis (Independent T-test), the results showed a difference in the measurements of the degree of swelling and trismus of the treated sample. 8 mg of dexamethasone promoted a greater reduction of symptoms than 4mg of dexamethasone though there was no statistically significant (p-value >0.05) difference between the two doses. Conclusions: 8 milligrams of the dexamethasone had better effectiveness than 4 milligrams of the dexamethasone in reducing the degree of swelling and trismus. Keywords: Dexamethasone; impacted third molars; swelling; trismus.

Open surgical approach to management of rhino-orbito-cerebral mucormycosis

<p class="abstract"><strong>Background: </strong>Since December 2019, when novel corona virus (COVID 19) was reported, it has spread widely to cause a pandemic. Rhino-orbito-cerebral Mucormycosis (ROCM), an opportunistic fungal infection caused by the order Mucorales and class Zygomycetes has led to an epidemic in our country.</p><p class="abstract"><strong>Methods: </strong>This prospective cross sectional study was conducted at a 1200 bed tertiary care teaching hospital in Mysore. All patients of ROCM who presented to us for treatment were selected for the study after informed consent. Only those patients who were operated via open approach were included.</p><p class="abstract"><strong>Results:</strong> Median age of the patients was 50 years (SD±10). 49 were male patients (67.1%). Diabetes mellitus was the most common underlying co-morbidity seen in 71 patients (97.3%). Facial pain (100%) and facial swelling (90.4%) were the most common presenting complaint. KOH positivity from nasal swab for Mucormycosis was positive in only 37 patients (50.7%). Traditional inaccessible areas to endoscope like the premaxilla, lateral orbit cavity, infra temporal fossa and hard palate were tackled by the open surgical approach route. Advantages of open surgical approach being the access to areas which are traditionally difficult to approach via the endoscope, aggressive debridement is possible which might be challenging endoscopically. Complications like wound dehiscence, oro-antral fistula, osteomyelitis and abscess were noted in our study.</p><p class="abstract"><strong>Conclusions: </strong>Open surgical approach offers a very viable, affordable and a very effective means for aggressive surgical debridement of infection and reduce mortality associated with ROCM.</p><p> </p>

PATHOLOGICAL STUDY ON LARYNGOTRACHEITIS IN LAYERS

A clinical conditions resembling infectious laryngotracheitis were diagnosed amongst 20,000 , 18,000 , 16,000 and 17,500 respectively, 28-30 weeks old, ISA brown layers. The hens had nasal discharges, moist rales, coughing and gasping. Hemorrhagic mucous was ejected during sneezing, lacrirnation, conjunctivitis with facial swelling with eyes partially or completely" closed. Postmortum examination of dead and affected hens revealed hemorrhagic tracheitis with thin pseudomembrane formation. The larynx, congested with petechia on mucous membrane, Infraorbital sinus contained clear thick fluid. Histopathological examination of trachea showed hypertrophy, of epithelial pseudostratification of the mucosal cell surface, extensive hemorrhages and desquamative necrotizing tracheitis with mononuclear cells infiltration. Multinucleated gaint cells in theciliated epithelium containing round, oval shaped intranuclear A inclusion bodies. The lamina propiia shows edema, marked‘ congestion with lymphocytic infiltration.A presumptive diagnosis of laryngotracheitis was made.

A rare presentation of rhinosporidiosis on buccal mucosa − a case report

Introduction: Rhinosporidiosis is a chronic mucocutaneous infection caused by Rhinosporidium seeberi, which mainly affects the mucus membranes of the nose, oropharynx, skin, eyes, and genital mucosa. The purpose of this case report was to illustrate the importance of clinicians in understanding the unusual incidence of this fungal infection, clinical presentation, treatment modalities, and recurrence rate. Observations: A clinical case report showed rare occurrence of rhinosporidiosis in the lower third of the face. The lesion was surgically excised by electrocauterization at its base. Commentaries: The patient showed no signs of recurrence even after 3 years of follow-up. Further research should be carried out to analyze the role of genetic predisposition in causing zoonotic infection. Conclusion: Rhinosporidiosis should also be considered as the differential diagnosis when facial swelling is encountered.

Endodontic Management of a Maxillary Lateral Incisor with Dens Invagination and Periapical Lesion: A Case Report and Mini Review of the Literature

Dens invagination (DI) is a dental anomaly that can cause pulpal and periapical pathoses of the affected tooth. We describe the treatment of a healthy 18-year-old female with a chief complaint of recurrent facial swelling pertaining to a peg-shaped maxillary lateral incisor with DI. Examinations showed necrosis of the involved tooth with symptomatic apical periodontitis. Cone-beam computed tomography corresponded to Oehlers type II DI. Orthograde endodontic treatment was performed. To completely debride the canal and resolve the persistent purulent discharge, various methods and medicaments were used in separate sessions including passive ultrasonic activation of 5.25% sodium hypochlorite solution, calcium hydroxide mixed with 2% chlorhexidine, and double antibiotic paste as intracanal medicament. After resolution of the symptoms, the root canal and the invaginated space were filled by a mineral trioxide aggregate plug and backfilled with thermoplasticized gutta-percha. At the one-year follow-up, complete bone healing was noted in the affected periradicular area.