Cervical lymphadenopathy in the dental patient: a review of clinical approach.

Lymph node enlargement may be an incidental finding on examination, or may be associated with a patient complaint. It is likely that over half of all patients examined each day may have enlarged lymph nodes in the head and neck region. There are no written guidelines specifying when further evaluation of lymphadenopathy is necessary. With such a high frequency of occurrence, oral health care providers need to be able to determine when lymphadenopathy should be investigated further. Although most cervical lymphadenopathy is the result of a benign infectious etiology, clinicians should search for a precipitating cause and examine other nodal locations to exclude generalized lymphadenopathy. Lymph nodes larger than 1 cm in diameter are generally considered abnormal. Malignancy should be considered when palpable lymph nodes are identified in the supraclavicular region, or when nodes are rock hard, rubbery, or fixed in consistency. Patients with unexplained localized cervical lymphadenopathy presenting with a benign clinical picture should be observed for a 2- to 4-week period. Generalized lymphadenopathy should prompt further clinical investigation. This article reviews common causes of lymphadenopathy, and presents a methodical clinical approach to a patient with cervical lymphadenopathy.     

Exacerbation of occult femoral hernia during laparoscopic prostatectomy.

Laparoscopic prostatectomy has been accepted as an appropriate treatment for prostate cancer because of the shorter hospital stay and quicker recovery. We present a rare complication of groin hernia with incarceration and necrosis of small bowel following laparoscopic prostatectomy. Occult hernias and small fascia defects may not always be apparent pre-operatively, but extension of pneumoperitoneal insufflation to extraperitoneal compartments should alert the surgeon to the possible presence of such a defect.     

Five Percent Lidocaine Cream Applied Simultaneously to the Skin and Mucosa of the Lips Creates Excellent Anesthesia for Filler Injections

Background. Injection of filler substances into the lips is painful, and many patients also find the injection of local or regional anesthesia into the lips painful.
Objective. To develop a highly effective and painless form of anesthesia to facilitate injection of filler substances into the lips.
Methods. Five percent lidocaine cream was applied simultaneously to the skin, vermilion, and mucosa of the lips (with the use of a barrier to keep the cream in contact with the mucosa and out of the rest of the mouth) for 20 to 30 minutes.
Results. Profound anesthesia of the lips was reliably produced, with no complications.
Conclusions. This "anesthetic cream block" is easier to perform and better tolerated than injectable anesthetics. Use of this technique is likely to expand the range of physicians who perform filler injections on the lips and will probably also expand the range of patients who wish to have filler injections done on their lips and who (because they had little or no discomfort) are willing to return for additional filler injections in the future.     

Mid- to long-term outcome of disc excision in adolescent disc herniation.

BACKGROUND CONTEXT: Adolescent disc herniation and its surgical treatment have been the subjects of many published clinical series. The majority of these series were heterogeneous; the number of adolescent patients (12-17 years) as opposed to young adults (18-20 years) was generally small and the length of follow-up varied greatly. Although the short-term outcome of disc excision in adolescents was mostly favorable, their long-term outcome is unknown. OBJECTIVES: To evaluate the mid- and long-term results of discectomy in patients younger than 17 years of age. STUDY DESIGN: Retrospective examination of a series of adolescent patients under the age of 17 years who underwent surgery for lumbar intervertebral disc herniation. PATIENT SAMPLE: The medical records of 26 patients (15 males, 11 females, 12-17 years old [average 14.6]) who were operated for lumbar intervertebral disc herniation in three spine centers between 1984 and 2002 were reviewed. These subjects represented the total number of patients meeting the criteria of adolescents undergoing discectomy for lumbar disc herniation in these institutions during the study period. All patients were located and contacted by an independent observer not involved in the care of these patients. Low back pain associated with leg pain was the main clinical symptom in 20 patients (77%), leg pain in 4 (15%), and back pain in 2 (8%). They all underwent posterior disc excision: 23 (88%) patients had one level discectomy, and 3 (12%) had simultaneous discectomy at two levels. The L4-L5 interspace was involved 19 times, and the L5-S1 interspace 10 times. Slipped vertebral apophysis was diagnosed in 4 patients (15%). Twelve of the 26 patients (46%) had a first-degree relative with a history of lumbar disc herniation. OUTCOME MEASURES: Telephone interviews provided follow-up data for 26 patients. Results were classified as excellent, good, moderate, or poor according to current symptom status, the need for additional surgery, the Oswestry Disability Index, and back and leg pain scores. RESULTS: The average time from surgery to follow-up was 8.9 years (range 3-21 years). At follow-up, the clinical results were excellent in 13 patients (50%), good in 4 (15%), moderate in 8 (31%), and poor in 1 (4%). Four subjects (15%) underwent a subsequent disc excision in the lumbar region, and one of them later underwent fusion. CONCLUSIONS: Discectomy provides satisfactory clinical results in young patients with disc herniation. The rate of reintervention (15%) is comparable to that in adults, indicating that discectomy for young patients should be approached similarly to that in adults.     

Lymphedema: How Do We Diagnose and Reduce the Risk of This Dreaded Complication of Breast Cancer Treatment?

Lymphedema is an under-recognized, progressive, life-long condition estimated to impact 2-3 million people in the United States. The incidence of breast cancer related lymphedema varies greatly in the literature largely due to different measurement techniques, competing thresholds for defining lymphedema, and variation in length of follow-up. Multiple imaging techniques have become useful for diagnosis. Lymphoscintigraphy is one of the most commonly used, as it can identify pathways of lymphatic drainage, quantify extent of dermal backflow, and help determine functional and morphologic changes in the lymphatic system. Early detection and intervention hold the greatest promise of reducing the incidence of lymphedema. Health care providers involved with cancer patients need to become more educated about lymphedema, aware of current risk-reduction practices, and familiar with methods of diagnosis and assessment, so that patients with early swelling can be referred to lymphedema treatment specialists at a time when treatment is more effective.     

Surgical epicardial left ventricular lead versus coronary sinus lead placement in biventricular pacing.

OBJECTIVE: Biventricular pacing has demonstrated improvement in cardiac function in treating congestive heart failure (CHF). Two different operative strategies (coronary sinus vs. epicardial stimulation) for left ventricular (LV) pacing were compared. METHODS: Since April 1999, a total of 86 patients (pts, age: 63+/-10 years) with depressed systolic LV function (mean ejection fraction 24+/-9%), left bundle-branch-block (mean QRS 182+/-22 ms) and congestive heart failure NYHA III or higher were enrolled. For biventricular stimulation coronary sinus (CS) leads were placed in 79 pts. Nine of these devices were converted to surgical epicardial LV-leads, because of CS-lead failure. In 7 patients epicardial LV-leads were initially implanted surgically, accounting for a total of 16 pts with surgical placed epicardial steroid-eluting LV-leads. For these, a limited left-lateral thoracotomy (7+/-4 cm) was used. Thirty-three (38%) pts had an indication for a defibrillator. The mean follow-up time was 16.4+/-15.4 months (0.1-45 months), representing 107.1 patient-years. RESULTS: In the biventricular pacing mode, QRS duration decreased to 143+/-16 ms (P<0.001). Threshold capture of the CS-leads increased significantly compared to surgically placed epicardial leads (18 month control: 2.2+/-1.4V/0.5 ms vs. 0.7+/-0.3V/0.5 ms), which had no increase in threshold (P<0.001). At the 18 month follow-up 7 CS-leads had a threshold of >4V/0.5 ms vs. epicardial leads which were under 1.1V/0.5 ms, except for one (1.8V/0.5 ms). After CS-lead implantation 25 LV-lead related complications occurred, (failed implantation, CS-dissection, loss of pacing capture, diaphragm stimulation or lead dislodgment), vs. one dislodgement after surgical epicardial lead placement (P<0.05). Correct lead positioning (obtuse marginal branch area) was achieved in all surgical epicardial placements but only in 70% with CS-leads (P<0.03). In the follow up period, 9 pts died (4 cardiac related). Heart transplantation was necessary in 4 pts due to deterioration of the cardiomyopathy. CONCLUSIONS: Surgical epicardial lead placement revealed excellent long-term results and a lower LV-related complication rate compared to CS-leads. Although, the approach via limited thoracotomy for biventricular pacing is associated with 'more surgery', it is a safe and reliable technique and should be considered as an equal alternative.