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A 10-year-old female is brought to the emergency room by her grandparents after sustaining an unwitnessed fall while on the playground. The patient reports having been swinging on the monkey bars, slipping on the edge of the landing, and ultimately straddling the handrail of the landing. She had immediate onset of pain and was able to walk to her grandmother and describe her fall. They went to the bathroom to assess her injury and noted blood in her undergarments, prompting them to come immediately to the emergency room. She remains in pain currently. She and her grandmother report heavy bleeding from the injury. Prior to this event the child was in her usual health. She has not yet had menarche, though they have noted some breast development. She has not had prior genital trauma or vaginal bleeding. She has been in her grandparents’ custody for the last six months.
Retropharyngeal haematomas are most commonly associated with trauma and anti-coagulant use. This paper describes the first reported case of a spontaneous retropharyngeal haematoma suspected to be due to indomethacin use.
It is proposed that the combination of indomethacin affecting platelet aggregation, alongside the patient coughing, may have led to this retropharyngeal haematoma.
The complexities of management are discussed and the current literature reviewed. In the absence of airway compromise or a rapidly enlarging haematoma, patients can be managed conservatively with observation and close discussion with the haematology department. Follow-up imaging is not necessary if the patient's symptoms settle; however, any increase in parathyroid hormone levels must be investigated to exclude a parathyroid adenoma.
Although organised haematoma often induces bone thinning and destruction similar to malignant diseases, the aetiology of organised haematoma and the optimal treatment remain unclear. This paper presents the clinical features of individuals with organised haematoma, and describes cases in which a novel modified approach was successfully applied for resection of organised haematoma in the maxillary sinus.
Pre-operative examination data were evaluated retrospectively. Modified transnasal endoscopic medial maxillectomy was employed.
Fourteen patients with organised haematoma were treated. Contrast-enhanced computed tomography showed heterogeneous enhancement in all patients. Eight patients underwent modified transnasal endoscopic medial maxillectomy, without complications such as facial numbness, tooth numbness, facial tingling, lacrimation and eye discharge. Dissection of the apertura piriformis and anterior maxillary wall was not necessary for any of these eight patients. No recurrence was observed.
Pre-operative examinations can be helpful in determining the likelihood of organised haematoma. Modified transnasal endoscopic medial maxillectomy appears to be a safe and effective method for organised haematoma resection.
This paper presents our experience on delayed-onset haematoma formation after cochlear implantation, a topic which has not been well discussed in the literature.
Retrospective case review study.
Five children who had undergone cochlear implant surgery at 1.5 to 4 years of age (median, 2.5 years) were studied. The haematoma episodes occurred 2–12 years (median, 6 years) after cochlear implantation. Two patients had recurrent episodes. Two of the seven haematoma episodes were managed by needle aspiration alone, four by incision and drainage alone, and one by both needle aspiration and incision and drainage. Other than one patient with coagulopathy, there were no obvious predisposing factors, including trauma.
The majority of delayed-onset haematomas occurred without obvious predisposing factors. Needle aspiration can differentiate a haematoma from an abscess or cerebrospinal fluid leakage, and it provides an effective immediate therapeutic solution. However, aseptic techniques are emphasised to minimise the chances of an uncomplicated haematoma converting into a septic one.
Conchal cartilage is frequently used in rhinoplasty, but donor site morbidity data are seldom reported. This study aimed to investigate the complications of conchal cartilage harvesting in rhinoplasty.
A retrospective chart review of 372 patients who underwent conchal cartilage harvesting for rhinoplasty was conducted. Data regarding patient demographics, types of nasal deformities, graft usage and complications were analysed.
A total of 372 patients who underwent conchal cartilage harvesting for rhinoplasty were enrolled. The harvested conchal cartilage tissues were used in a variety of applications: tip graft, dorsal graft, septal reinforcement and correction of nostril asymmetry. Nine cases (2.4 per cent) with donor site morbidities were identified, including four cases (1.1 per cent) with keloids and five cases (1.3 per cent) with haematomas.
Conchal cartilage harvesting is a safe and useful technique for rhinoplasty, with a low complication rate. However, patients should be informed about the possibility of donor site morbidities such as keloids and haematomas.
To report a rare case of simultaneous bilateral cochlear implantation in a five-month-old child with Usher syndrome.
A five-month-old boy with Usher syndrome and congenital profound bilateral deafness underwent simultaneous bilateral cochlear implantation. The decision to perform implantation in such a young child was based on his having a supportive family and the desire to foster his audiological development before his vision deteriorated. The subject experienced easily resolvable intra- and post-operative adverse events, and was first fitted with an externally worn audio processor four weeks after implantation. At 14 months of age, his audiological development was age-appropriate.
Simultaneous bilateral cochlear implantation is possible, and even advisable, in children as young as five months old when performed by an experienced implantation team.
A large variety of techniques have been used for auricular haematoma management. The open surgical management of auricular haematoma involves incision, evacuation and the obliteration of dead space using biodegradable mattress sutures. Our goal was to describe open surgical management for primary, recurrent and spontaneous auricular haematoma.
Auricular haematoma patients who underwent open surgical management were prospectively audited (2010–2013). Information was collected on demographics, clinical presentation, aetiology, examination findings, previous interventions, details of open surgical management and post-operative follow up.
In all, 12 male and 3 female patients with a mean age of 33 years (range 16–86 years) were evaluated. Contact sport injury was the most common aetiology. Ten patients had undergone previous unsuccessful interventions to treat auricular haematoma before open surgical management was performed. All patients were managed successfully without significant recurrence. One patient had a minor local reaccumulation which required reinsertion of a mattress suture. One elderly patient developed localised cellulitis which responded well to antibiotics.
Open surgical management of auricular haematoma has been successful. The technique is simple and reliable, and can be accomplished in a clinical setting under local anaesthesia.
To present the utility of the recently introduced Maniceps septum stitch device for suturing of the nasal septum.
This paper describes nasal septum suturing techniques using the Maniceps septum stitch device following septoplasty to prevent post-operative complications such as haematoma and nasal septum perforation.
Nasal septum suturing using the Maniceps septum stitch device appears to be a safe and easy surgical procedure to help prevent post-operative complications and may reduce the incidence of nasal septum perforation following septoplasty.
This chapter discusses the diagnosis, evaluation and management of neck trauma. It presents special considerations with regard to immobilization and the safety of removing the cervical collar for penetrating neck trauma. High-resolution computed tomography angiography (CTA) is the initial diagnostic study of choice in the stable patient with penetrating neck trauma or blunt neck trauma when blunt cerebrovascular injury is suspected. CTA can be the initial diagnostic study of choice regardless of zone of injury. CTA is particularly useful for zone I and III penetrating injuries, which are more difficult to evaluate by physical examination. Unstable patients with penetrating injuries require immediate surgical consultation and exploration in the OR. Unstable patients include those patients with hard signs: clear airway injury (air bubbling through wound), hemodynamic instability despite resuscitation, uncontrolled bleeding (including expanding hematoma), or evolving neurological deficit.
To report a case of subdural haematoma occurring as an extremely rare and life-threatening complication of cochlear implantation, and to explore the causative association between intracranial haemorrhage and cochlear implantation surgical techniques. This association has not previously been reviewed in depth.
A three-year-old boy was diagnosed with a large subdural haematoma, one week after cochlear implantation. After emergency evacuation of the haematoma, the patient made an excellent recovery and was discharged from hospital without any neurological deficit.
Mechanisms of injury are discussed and the literature reviewed, focusing on the possible causes of intracranial haemorrhage identified after cochlear implantation. Notably, bone drilling had been used in all reported cases, and the probable causative injury had always occurred after such drilling.
The issue of bone drilling during cochlear implantation is raised, and alternative methods of implant housing suggested, in order to avoid intracranial haemorrhage.
Organised haematomas of the maxillary sinus are rare, non-neoplastic, haemorrhagic lesions which can extend into the nasal cavity and/or the other paranasal sinuses. This study aimed to investigate the pathology of maxillary sinus organised haematoma, and also proposes a new aetiological hypothesis based on the observed pathology.
Biopsies, computed tomography, magnetic resonance imaging and post-surgical histopathological examination of resected specimens were carried out.
Distinct pathological differences were observed between the basal and peripheral portions of organised haematomas. We propose that an organised haematoma originates from the exudation of blood components between vascular endothelial cells. As a result, the basal portion consists of aggregated, dilated vessels around the natural ostium of the maxillary sinus. In addition, pseudovessels, without endothelial cells, arise from endocapillary vessels within the haematoma. Exudation of additional blood components from the pseudovessels advances the growth of the organised haematoma.
To review the safety of thyroidectomy combined with cervical neck dissection without drainage, in patients with papillary thyroid carcinoma.
Materials and methods:
Two groups were defined depending on whether cervical neck dissection was or was not performed (groups one and two, respectively).
Group one included 153 patients with central neck dissection and 52 patients with central and lateral neck dissection. Group two included 121 patients. Post-operative drainage was not used in either group. Overall, 17 patients (5 per cent) developed post-operative haematoma and/or seroma: 12 patients (6 per cent) in group one and 5 patients (4 per cent) in group two. There were no major bleeding episodes; only minor bleeding or seroma was encountered, not requiring surgical intervention. Overall, 91 per cent of patients had a post-operative stay of 1 day. The number of peri-operative local complications and length of stay did not differ significantly between the two groups.
Thyroidectomy plus cervical neck dissection without drainage is safe and effective in the treatment of papillary thyroid carcinoma.
This chapter focuses on the epidemiology of oral anticoagulant therapy (OAT)-associated ICH, its pathophysiology, and treatment options based on the currently available data. One of the most common indications for OAT is to prevent stroke in patients with atrial fibrillation. Intracerebral hemorrhage is the deadliest form of stroke, with a mortality rate between 30% and 55%. The incidence and dynamics of hematoma expansion in OAT-ICH remain to be established. Current data suggest that the natural course of hematoma expansion in this group of patients is more prolonged as compared to spontaneous ICH. This may provide a longer time window for treatment of OAT-ICH. However, in OAT-ICH the underlying coagulopathy prolongs the time course of bleeding or rebleeding, and repeated dosing or a higher dose might be essential. The risk of thromboembolism that is associated with current hemostatic treatment strategies which aim to normalize coagulation is unknown.
Intracerebral hemorrhage (ICH) presents clinically in a variety of ways, depending primarily on the location and size of the hematoma. Several studies have correlated the anatomical location of putaminal hemorrhages with their clinical presentation. Caudate hemorrhage presents with sudden onset of headache, vomiting, and altered level of consciousness, resembling subarachnoid hemorrhage (SAH) from ruptured cerebral aneurysm. Behavioral and neuropsychological abnormalities can be a prominent part of the clinical picture of caudate hemorrhage. Lobar ICHs occur in any of the cerebral lobes, generally favoring the parietal and occipital areas although some series have reported a predominance of frontal or temporal locations. Primary hemorrhage into the medulla oblongata is the least common of all brain hemorrhages. The most consistent clinical profile in medullary hemorrhage has been with sudden onset of headache, vertigo, dysphagia, dysphonia or dysarthria, and limb incoordination.
Vasectomy is typically performed as an outpatient procedure using local anesthetics. The technique employed for occlusion of the vasal lumina may influence the incidence of recanalization. Suture ligature, still the common method employed worldwide, may result in necrosis and sloughing of the cut end distal to the ligature. Hematoma is the common complication of vasectomy, with an average incidence of 2%. Sperm granulomas form when sperm leak from the testicular end of the vas. Sperm are highly antigenic, and an intense inflammatory reaction occurs when sperm escape outside the reproductive epithelium. The concept of male hormonal manipulation for contraception predated the era of female hormonal contraception by 20 years. Progestins have been used in multiple small studies for suppression of spermatogenesis and testosterone production in men. Along with hormonal manipulation, immunocontraception appears to offer reasonable hope for a nonsurgical contraceptive option in men.
A patient with complete transposition and a ventricular septal defect was clinically improved by an atrial septectomy at nine years but continued sepsis in the thoracotomy scar resulted in blood-stream infection with Staphylococcus aureus at the age of 24 years. A deep nylon suture was found and removed at surgical exploration. Five months later she again became febrile and had a vasculitic skin rash which responded to antibiotic therapy. At that time she was cyanosed and had a restricted exercise tolerance and was found to have aneurysmal dilatation of the pulmonary trunk. A year later she had acute chest pain with increased breathlessness, fever, hepatomegaly and pulmonary regurgitation. The fever did not respond to antibiotic therapy and she died suddenly following removal of a Hickman line. At postmortem examination, there was found to be a false aneurysm in the mediastinum due to rupture of the aneurysmal pulmonary trunk. No evidence of infection was found and it was considered that the low grade pyrexia had been due to the large hematoma within the false aneurysm.