CURRENT LITERATURE

Abstracts

Acute Respiratory Distress Syndrome (ARDS): The Pro- phylactic Effect of Neurodepressant Agents. de Oliveira GG, Shimano LT, de Oliveira Antonio MP. J Trauma 26:451, 1986

It has been suggested that the pathophysiologic mecha- nism responsible for the development of ARDS is a cen- tral nervous system (CNS) derangement secondary to the alarm reaction (AR). Previously, it was postulated that the AR induces vasoconstriction, endothelial damage, and hypercoagulation that may lead to disseminated in- travascular coagulation and resultant tissue ischemia. The outcome of this in the CNS is cybernetic derange- ment of the functional aspects of the stress-adaptation centers. Cybernetic derangement may be the basis for some of the clinical findings in ARDS. 1) The Syndromic Development Lag: Following traumatic insult there is usually a lag time of 3-5 days before ARDS is clinically manifested. Although the time lag is a common observa- tion, it has yet to be conclusively explained. As the pe- ripheral nervous system is unable to produce a slow reac- tion response, it is postulated that a CNS disturbance is responsible. 2) The Etiologic Nonspecificity of Trauma in ARDS: There has been no correlation between modality of trauma or affected organ, and ARDS. 3) The Sec- ondary Multiorganic Damage: Concominant post-trau- matic pathology existing with ARDS, such as stress ulcers. acute tubular necrosis (ATN) or hepatic insuffi- ciency, is common. This observation supports the exis- tence of a CNS disturbance.

The study goal was to reduce the intensity and duration of the AR, thereby reducing self-induced brain lesions. Wistar rats were submitted to CNS (anterior hypotha- lamic electrolytic lesions) and peripheral nervous system (scald burns) trauma as models to simulate the ARDS- like syndrome. Prior to inducing the lesions, neurode- pressant agents were administered. The use of morphine, pentobarbital sodium, haloperidol, diazepam, chloropro- mazine, and urethane, resulted in significant attenuation of the onset of the ARDS-like syndrome. These results support the CNS derangement based theory of ARDS. and may be of important value in the prophylactis of ARDS in humans.-K. H. MAY

Reprint requests to Dr. de Oliveira: Clinical Pharmacology Divi- sion, Department of Preventive Family and Rehabilitation Medi- cine. University of Rochester Medical Center, 601 Elmwood Av- enue. Rochester, NY 14642.

Complex Maxillary Fractures: Role of Buttress Reconstruc- tion and Immediate Bone Grafts. Gruss JS, Mackinnon SE. Plast Reconstr Surg 78:9, 1986

A series of 171 patients treated for complex LeForte type fractures and their basis for treatment are presented. The key to repair is reconstruction of the anatomic pillars or buttresses. By anatomic reconstruction of the four an- terior buttresses, exact positioning of the maxilla in its correct A-P relation and restoration of vertical height is achieved. Direct exposure and fixation of all fracture sites are essential to repair. The methods of fixation range from wires and miniplates to immediate bone grafts. When concomitant mandibular fractures are present rigid internal fixation is utilized. The authors cite

improved intraoperative and postoperative airway man- agement as the major advantage to this type of mandib- ular fixation; tracheostomy is rarely needed. Minimal complications are reported: infection occurred in IO pa- tients and dehiscense of tissue to expose grafts in two.- WILLIAM R. WHITLOW

Reprint requests to Dr. Gruss: Sunnybrook Medical Center. 2075 Bayview Avenue. HG 948. Toronto. Ontario, Canada M4N 3M5.

Panendoscopy with Arteriography versus Mandatory Ex- ploration of Penetrating Wounds of the Neck. Noyes LD, McSwain NE Jr, Markowitz IP. et al. Ann Surg 204:21. 1986

The evaluation and management of penetrating wounds to the neck remains a controversial subject. Many au- thors advocate routine surgical exploration of all injuries that penetrate the platysma while others recommend pas- sive observation of carefully selected patients based on their signs and symptoms. Two hundred thirteen patients with a diagnosis of penetrating wound of the neck were evaluated at Charity Hospital in New Orleans. The pa- tients were divided into two groups. one surgical and the other non-surgical, based on clinical examination. The non-surgical group underwent tests that included arteri- ography and panendoscopy, (laryngoscopy, bronchos- copy and esophagoscopy). Common indications given to justify surgery included shock and expanding hematoma. The structure frequently injured was the internal jugular vein. Fifty per cent of the non-surgical group had positive findings requiring a surgical exploration. The overall neg- ative surgical exploration rate was 50%: the overall mor- tality rate was 13%‘. This study demonstrated the inade- quacies of signs and symptoms as a predicting factor for the presence and degree of injury. It is important to avoid the complications of missed injuries and, therefore, many authors advocate mandatory surgical exploration. The authors do support the use of arteriography with panen- doscopy as a safe method of initial exploration for stable patients with penetrating wounds to the neck. Its accu- racy is almost equal to surgery, with less morbidity and a decreased length of hospital stay, although at a slightly higher financial COSt.-JEFFREY H. KOOTMAN

Reprint requests to Dr. McSwain. Jr: Department of Surgery, Tulane University School of Medicine. 1430 Tulane Avenue. New Orleans, LA 70112.

Bacteria1 Infections of the Orbital And Periorbital Soft- Tissue In Children. Spires S. Smith R. Laryngoscope 96:763, 1986

Periorbital soft-tissue bacterial infections are common during childhood and, with appropriate antibiotic therapy, usually resolve quickly. In contrast, orbital soft- tissue infections are rare and frequently cause serious morbidity. This article presents a retrospective review of 241 children with orbital or periorbital infection. These infections ranged in severity from relatively minor pre- septal cellulitis to life-threatening cavernous sinus throm- bosis. Periorbital infections were more frequent. ac- counting for 226 of the cases reviewed. The majority of

90

CURRENT LITERATURE 91

these patients were under two years of age. Common predisposing factors included trauma and upper respira- tory infection with Haemophilus influenza, Strepto- coccus, and Staphylococcus as the most common caus- ative organisms. Response to antibacterial therapy with a semisynthetic penicillin and chloramphenicol was prompt and the incidence of complications low. True orbital soft- tissue infections occurred in the remaining 15 children; these children tended to be much older, with only three less than six years of age. Concomitant sinusitis was present in most of these patients and, despite aggressive medical and surgical therapy, significant complications developed. Computerized tomographic scanning proved to be an indispensible diagnostic aid in assessing the full extent of the infectious process. Initial therapy should in- clude the prompt administration of broad spectrum anti- biotics with adjustments dependent upon culture results. Surgical intervention should be performed early if the re- sponse to medical therapy is suboptimal-MONROE HARRIS

Reprint requests to Dr. Smith: Department of Otolaryngology and Communicative Science, Baylor College of Medicine, 1 Baylor Plaza. Houston, TX 77030.

Primary Mandibular Reconstruction Using the A0 Recon- struction Plate. Chow JM, Hill JH. Laryngoscope 96:768. 1986

The use of A0 synthes plates for primary reconstruc- tion of the mandible following tumor resection is re- ported. Squamous cell carcinoma of the oral or oropha- ryngeal cavity (stage III or IV) was reported in all six patients. Recurrence of tumor occurred in two patients following radiation therapy only; they subsequently un- derwent composite resection and primary mandibular re- construction. Radiation therapy was performed in all pa- tients postoperatively with plates in place, and they were followed for approximately six months. The most common postoperative complications (four of six pa- tients) were A0 plate exposure (extraoral and intraoral) and bony segment exposure (intraoral). One patient de- veloped a draining sinus tract secondary to a residual silk suture, and mobility of one plate was noted to require a second extraoral procedure for plate reattachment. The authors noted that A0 plates provide absolute stable fix- ation of mandibular segments without need for maxillo- mandibular or external fixation. The plates also provide greater graft surface area for revascularization than mesh trays and better functional and cosmetic results postoper- atively. However, the amount of soft tissue available and the degree of vascularization must be considered prior to placement of the A0 synthes plates.---BRENTON W. BURGER

Reprint requests to Dr. Chow: University of Illinois. Eye and Ear Infirmary. 185.5 West Taylor Street, Suite 2.42, Chicago, IL 60612.

Clinical Evaluation of Ceramic Hydroxylapatite in Oral and Maxillofacial Surgery-A Multiclinic Study. Taka- hashi S, Saito C, Ohhata H, et al. Jpn J Oral Maxillofac Surg. 32:92. 1986 (author’s translation)

Ceramic hydroxylapatite used for augmentation of 36 alveolar ridge deficiencies, reconstruction of bony de- fects resulting from extirpation of 104 jaw bone cysts and apical granulomas, and placement in 36 dental extraction

sockets was evaluated clinically and radiographically in six oral and maxillofacial surgery clinics. Patients ranged in age from the teens to the seventies, with an equal male to female ratio. The patients were followed periodically for a maximum period of one year.

Although postoperative swelling and redness were noted in approximately 90% and pain in 50% of the pa- tients at one week, they subsided gradually. The degree of inflammatory reaction did not differ significantly from that seen in comparable operations without hydroxylapa- tite implantation. Exfoliation of the implant material oc- curred in 25%, of ridge augmentations, 15% of cyst, granuloma defects, and 14% of dental extraction sockets. Dehiscence of the incision occurred in 14%, 12% and 22% of cases, respectively. Postoperative infection, did not develop in any case of ridge augmentation, but oc- curred in 23% and 8%, respectively, of the latter two pro- cedures. Surgical reentry, which included resuturing of a dehiscence (seven cases), incision of an abscess (four cases), refilling with hydroxylapatite (three cases), re- moval of a part or all of the implant (eight and four cases, respectively) and dental extraction (one case) was per- formed in 15% of the cases. Adverse effects due to the implant material were not encountered in any case. Par- esthesia or anesthesia of the mental nerve occurred in six patients, but normal sensation returned in all of them. Radiographically the particulate form of the implant was discernible immediately after the operation, but bony re- generation was indicated by an increase in radiodensity between the hydroxylapatite particles in a few months. The radiolucency separating the hydroxylapatite from the underlying or surrounding bone also gradually disap- peared. The mean augmentation was 27% of the original height as measured from the inferior border in the man- dible. In summary, the hydroxylapatite particulate was found to be useful as a bone substitute or an extender by more than 90% of doctors engaged in this study.-TAM10 NAKAJIMA

Reprint requests to Dr. Takahashi: Second Department of Oral and Maxillofacial Surgery. Tokyo Dental College, 1-2-7. Ma- sago, Chiba City 260. Japan.

Sarcomas and Sarcomatous Neoplasms of the Major Sali- vary Gland Regions. A Clinicopathologic and Immunohis- tochemical Study of 67 Cases and Review of the Literature. Auclair PL, Langloss JM, Weiss SN. et al. Cancer 58: 1305. 1986

Sarcomas of the major salivary glands are rare neo- plasms. Many authors feel that these tumors are not true connective tissue lesions but rather represent “sarcoma- toid” tumors of epithelial origin, similar to the sarco- matous component of the mixed tumor. This study re- viewed 67 cases diagnosed as sarcomas of the major sali- vary glands. Histochemical studies were performed on 27 specimens for which paraffin-embedded blocks of tissue were available. Cases were obtained from records of Armed Forces Institute of Pathology. Follow-up data were obtained in 48 cases. The cases were divided into three groups: Group I consisted of tumors arising entirely from the gland and without extension into paraglandular areas: Group II consisted of those tumors that arose in the area of the major salivary gland, but were not clearly of glandular or paraglandular origin: and Group III tumors arose in paraglandular tissues and involved the gland secondarily. Results of the study revealed a mean