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Mesenchymal cystic hamartoma (MCH) of the lung is a rare disease, with an indolent course in the majority of cases. It can be single or multifocal and it is composed of primitive mesenchymal cells admixed with cystic spaces. Only few cases have been reported in the literature, with variable clinical presentation. We describe the case of a huge MCH, presenting with spontaneous pneumothorax in a 65-year-old man. Further, we provide a brief overview of the literature and discuss the differential diagnosis with other entities, and the possible diagnostic pitfalls.

Purpose To review and summarize the clinical features, presentations, diagnostic modalities and management of dacryolithiasis. Methods A comprehensive PubMed search of all English articles on dacryolithiasis was reviewed. Although this review primarily relied on articles written in English, non-English-language articles that had abstracts translated into English were also reviewed. Data reviewed included epidemiology, pathogenesis, appearance and composition, clinical features, presentations, diagnostic modalities, management of dacryolithiasis and the implications of incidental dacryoliths found during lacrimal surgery. Results Although an unknown proportion of dacryolithiasis cases may remain asymptomatic; epiphora, acute and/or recurrent dacryocystitis, punctal discharge, and localized swelling are the most common presenting features of dacryolithiasis. It may also present as partial nasolacrimal duct obstruction. Dacryoliths exhibit a variety in external appearances. While some minimally invasive techniques for the removal of dacryoliths have been described, dacryocystorhinostomy with removal of the dacryoliths remain the most effective treatment in cases of symptomatic dacryolithiasis. The expression and production of certain proteins and peptides, namely those of the trifoil factor family play a significant role in the pathogenesis of dacryoliths. Conclusions The management of dacryolithiasis is driven by the goal of resolution of secondary obstruction and/or inflammation. Although a large number of dacryoliths are incidentally found during dacryocystorhinostomy, certain clinical features such as unilateral sac distension, particularly those with a palpable firm medial canthal mass, might lead one to have a high index of suspicion. It remains unclear if the incidental finding of a dacryolith during a dacryocystorhinostomy has a favorable prognostic value.

The purpose of this study was to evaluate the long-term outcome and patterns of failure in patients treated with primary radiotherapy (RT) for orbital lymphoma (OL). Seventy-nine patients diagnosed with stage IE OL between 1995 and 2012 were included. Fifty-nine patients (75%) had mucosa-associated lymphoid tissue lymphoma and 20 patients (25%) had follicular lymphoma subtype. The median follow-up was 49.7 months. Major tumor sites were conjunctiva (29%), orbit (47%) and lacrimal gland (24%). After treatment to a median dose of 30.6 Gy, there were a total of no local, one contralateral orbital, two regional and two distant recurrences, all outside of the treatment fields. The 10-year local relapse-free, distant metastasis-free and overall survival rates were 100%, 94.2% and 98.2%, respectively. Definitive RT to 30 Gy was shown to be highly effective for indolent OL, and this study represents one of the largest single-institution studies using primary RT for stage IE OL.

Objective To develop a new oculoplastic curriculum that incorporates learning theory of skill acquisition. To develop and evaluate the effectiveness of instructional videos for an oculoplastic surgical wet laboratory. Design Proof of concept, randomized controlled trial. Setting New York Eye and Ear Infirmary of Mount Sinai—tertiary care academic institution. Participants and Methods In total, 16 ophthalmology residents were randomly assigned to 1 of 2 groups and given either video and text or text instructions alone for the following 2 procedures: blepharoplasty and eyelid laceration repair. Operating time and esthetic result were measured, and the groups were statistically compared. A brief survey was administered. Results We developed a new 6 component oculoplastics curriculum that incorporates concepts of the Fitts and Posner skill acquisition model and mental imagery. In the wet laboratory pilot study, the group that watched the video of the laceration repair showed better esthetic grades than the group that received text alone (p = 0.038). This difference was not found for the blepharoplasty (p = 0.492). There was no difference between groups in operating time for the laceration repair (p = 0.722), but the group that watched the blepharoplasty video required more time to complete the task than those that reviewed text only (p = 0.023). In total, 100% of residents reported the videos augmented their learning. Conclusions Methods to optimize surgical education are important given limited operating room time in oculoplastics, a subspecialty in which the number of surgeries performed during residency is relatively low. We developed a curriculum based on learning theory and sought to formally test one important aspect, surgical video for wet laboratories. Our pilot study, despite its limitations, showed that wet laboratory surgical videos can be effective tools in improving motor skill acquisition for oculoplastic surgery.

The aim of the study was to evaluate the histopathological changes that occur in the tendon and subacromial bursal tissue in patients with rotator cuff tear trying to correlate these changes to their healing capability.Eighty-four patients were clinically evaluated with the Constant Scale. Radiographs and MRI were performed preoperatively and ultrasound were performed postoperatively. For each patient, a biopsy of the supraspinatus tendon and subacromial bursa was performed, and the specimens were histopathologically analyzed.Tendons histopathological features consisted of loss of structural organization, poor or absent neoangiogenesis, chondral metaplasia, and fibrosis. Bursal features consisted of neoangiogenesis, absence of chondral metaplasia, hyperplasia/hypertrophy, and absence of necrosis. Direct correlation was seen between tendon and bursal hyperplasia and time of the onset of symptoms; between tendon chondral metaplasia, fibrosis, bursal neoangiogenesis, inflammation, and patient age; between tendon neoangiogenesis, hyperplasia, necrosis, fibrosis, bursal necrosis, inflammation, and lesion size; on the contrary, tendon fibrosis, necrosis, and bursal tissue inflammation decrease as time passes from the onset of symptoms. Tendon fibers disarray, neoangiogenesis, and inflammation decreases as the patient's age increases. Bursal tissue fibrosis decreases as lesion size increases.Simple histopathological techniques should be employed routinely to assess the tissue quality, with the aim to predict future clinical evolution (repair or non-repair). Comparing the histopathological data with the demographical information and the descriptive statistics, it is possible to define the RCT repair at risk and identify which RCT will be able to heal.

Blepharoptosis (ptosis) is one of the most common eyelid disorders encountered in ophthalmology. A detailed history and exam are crucial in the evaluation of a patient presenting with ptosis. This provides the correct guidelines for surgical planning. The appropriate surgical technique is usually determined by the degree of ptosis and levator function. The surgeon should have an armamentarium of several different techniques for the management of ptosis. This article will detail a modified approach to the traditional tarsomyectomy (Fasenalla-Servat procedure) and also discuss the levator advancement. Despite the proper preoperative evaluation and meticulous attention to technique, the ptosis surgeon may still encounter postoperative complications. The ability to manage the array of possible complications truly distinguishes the ptosis surgeon.

Objective To evaluate the efficacy and safety of a combined endoscopic and transconjunctival orbital decompression in patients with thyroid-related orbitopathy with orbital apex compression. Study Design Retrospective review. Methods A sequential series of patients with thyroid-related orbitopathy presenting with orbital apex compressive myopathy with and without optic neuropathy who were undergoing combined endoscopic and transconjunctival decompression by the same surgeons from 1992 to 2001 was reviewed. Patients were regularly evaluated preoperatively and postoperatively over a 3- to 55-month period to record the effects of this approach on visual acuity, Hertel exophthalmometry, and diplopia. Complications and secondary ophthalmological procedures were reviewed. Results Between 1992 and 2001, 72 combined endoscopic and transconjunctival decompressions were performed on 41 patients with orbital apex compression. Visual acuity improved in 89.3% of the patients with compressive optic neuropathy (P

The purpose of this study was to determine whether orbital volume assessment by computerized tomography (CT) could provide additional information for the initial evaluation of orbital blowout fractures and guide optimal treatment. The medical records of 30 patients with orbital blowout fractures, either surgically or conservatively managed, were retrospectively reviewed. Orbital volumetric analysis was then determined from digitized CT scans. Fracture-related volume expansion relative to the unaffected fellow orbit was correlated with motility deficits and location and degree of enophthalmos. Early Hertel's measurements (4 weeks) were available in 21 patients and did not correlate with the computer volumetric values or with subsequent late enophthalmos. Late Hertel's measurements (4 weeks) were obtained in 13 of 15 nonrepaired fractures and in 5 of 15 surgically repaired patients (late presentation; 18 patients). When seen at more than 4 weeks, 11 (92%) of 12 patients withor = 13% orbital volume expansion manifested significant enophthalmos (2 mm) compared with 1 (17%) of 6 patients with13% orbital expansion (p = 0.004). Fractures presenting with enophthalmos on initial examination had extensive medial wall involvement in addition to the floor fracture (p = 0.003). CT measurements of orbital volume can predict the final degree of late enophthalmos and may facilitate the planning of surgical intervention.

Pigmented villonodular synovitis (PVNS) is a rare condition. Our purpose is to describe the largest series of patients with shoulder PVNS, massive irreparable rotator cuff tear, and glenohumeral osteoarthritis treated with arthroscopic debridement and synovectomy. We treated 9 patients with PVNS of the shoulder, irreparable rotator cuff tear, and slight glenohumeral arthropathy (group I). Patients underwent arthroscopic synovectomy and debridement. Results [constant score (CS) and subjective shoulder value (SSV)] were compared to those obtained from a control group (group II) of 20 consecutive patients undergoing arthroscopic debridement for irreparable cuff tear associated with hemorrhagic synovitis with no or slight glenohumeral arthropathy. Histologic examination was obtained in all cases to obtain the correct diagnosis. The preoperative shoulder function in group I was reduced with respect to group II. Upon follow-up, CS and SSV were lower in group I. Preoperatively, the differences relating to the CS value and to each item of the score were always statistically significant; instead, at follow-up, significant differences emerged in the CS, ADL, and ROM. At follow-up, significant differences emerged between CS of group I and of group II without glenohumeral arthropathy. Differences using the SSV were always statistically significant. The poor functional outcome of patients affected by PVNS can be attributed to the coexistence of the irreparable cuff tear and to the glenohumeral arthropathy. All patients with PVNS had shoulder osteoarthritis; it cannot be simply attributed to natural history of massive irreparable cuff tears, but to the pigmented villonodular synovitis.

Objective To report our experience with 200 cases of basal cell carcinoma (BCC) in 192 patients treated with an enhanced frozen-section control (FSC) technique using stereoscopic microdissection of surgical margins. Methods Retrospective series of 192 patients with 200 lesions diagnosed as BCC of the periocular region. All were excised en bloc with 1-mm margins beyond the clinically apparent tumor and examined using an enhanced FSC technique with stereoscopic microdissection of the surgical margins. Results Of 200 malignant BCCs, 93.0% represented primary tumors. The overall recurrence rate was 1.0%, with a mean follow-up of 4 years. In patients with primary lesions, the overall recurrence rate was 1.1%, with a mean follow-up of 3.9 years. There were no recurrences in the secondary tumor group after a mean follow-up of 4.8 years. Of the 200 lesions, 66.0% lesions required a single en bloc resection to achieve tumor-free margins. Conclusions An enhanced FSC technique using stereoscopic microdissection of the surgical margins permits greater conservation of healthy tissue and yields cure rates comparable to those of the standard FSC technique and Mohs micrographic surgery. We believe that this enhanced FSC technique is a highly effective method for resection of periocular BCC.

Injury and disruption of the canaliculi of the lacrimal excretory system commonly occur from laceration or shearing trauma. This type of injury will likely lead to dysfunction of tear flow from the palpebral sulcus and chronic epiphora. The goal of this article is to give a step-by-step review of canalicular repair.

Parosteal osteosarcoma is a rare low-grade malignant neoplasm. A case localized at the distal ulna is reported, and the tumour's radiological and histological features are described. Wide enbloc resection without postoperative adjuvant chemotherapy was the treatment. Good clinical function without signs of local recurrence was observed at the 3-year follow-up.

There is still considerable controversy as to whether or not the inflamed margins of a cuff tear should be excised during surgical suture. We have tried to discover whether anti-inflammatory drugs used before surgical treatment could resolve this issue. Thirty-eight patients were randomly either treated with an anti-inflammatory drug for 2 weeks or not. During the subsequent arthroscopic repair, a few fragments of supraspinatus edge were excised and examined microscopically. No significant differences emerged among samples belonging to the two groups. In all cases, we observed inflammatory infiltrate-lined tear edges. Fibrocytes and newly formed vessels were detected near the margin. Dystrophic calcifications were observed in both groups. Away from the edge, the tendon appeared hypocellular; containing areas with myxoid or fatty degeneration. Our study demonstrates that an anti-inflammatory drug is unable to resolve the inflammatory infiltrate. This failure is probably related to the poor blood supply to the cuff, which, in cases of rupture, is deprived of vessels coming from the humeral periosteum. Further studies are needed to understand how to eliminate the inflammatory process and clarify whether it might inhibit cuff healing and give rise to re-tearing of the sutured cuff.

Aternatives to autogenous bone graft for spinal fusion have been investigated for many years. It has been shown that osteoconductive materials alone do not give a rate of fusion which is comparable to that of autogenous bone graft. We analysed the effectiveness of porous ceramic loaded with cultured mesenchymal stem cells as a new graft material for spinal fusion in an animal model. Posterolateral fusion was carried out at the L4/L5 level in 40 White New Zealand rabbits using one of the following graft materials: porous ceramic granules plus cultured mesenchymal stem cells (group I); ceramic granules plus fresh autogenous bone marrow (group II); ceramic granules alone (group III); and autogenous bone graft (group IV). The animals were killed eight weeks after surgery and the spines were evaluated radiographically, by a manual palpation test and by histological analysis. The rate of fusion was significantly higher in group I compared with group III and higher, but not significantly, in group I compared with groups II and IV. In group I histological analysis showed newly formed bone in contact with the implanted granules and highly cellular bone marrow between the newly formed trabecular bone. In group II, thin trabeculae of newly formed bone were present in the peripheral portion of the fusion mass. In group III, there was a reduced mount of newly formed bone and abundant fibrous tissue. In group IV, there were thin trabeculae of newly formed bone close to the decorticated transverse processes and dead trabecular bone in the central portion of the fusion mass. In vitro cultured mesenchymal stem cells may be loaded into porous ceramic to make a graft material for spinal fusion which appears to be more effective than porous ceramic alone. Further studies are needed to investigate the medium- to long-term results of this procedure, its feasibility in the clinical setting and the most appropriate carrier for mesenchymal stem cells.

Avascular necrosis of bone can be an important complication of many bone diseases [1–6] or it can be idiopathic [7–13]. Despite its possible multifactorial etiopathogenesis, the pattern of development of avascular necrosis is fairly predictable [14–21] and the major problem concerning its outcome is the possibility of dead bone rehabitation [22–27].

The histological features are reported of osteo-odonto-acrylic laminae removed from three patients who for differing underlying causes received Strampelli's osteo-odonto-keratoprostheses (OOK) 20, 16, and 12 years previously. It appears that preservation of the alveolar-dental ligament plays a definitive role in the maintenance of the prosthesis. If this tissue undergoes necrosis as a consequence of an inflammatory disease the implanted material is eventually lost. However when no such event occurs the OOK is well preserved and well tolerated even 20 years after implantation.

A case in which a post-traumatic shoulder impairment revealed the presence of the joint involvement by a metastatic localization of lung adenocarcinoma is presented. The patient was a 60-year-old white man, a smoker, in apparent healthy condition complaining of pain and stiffness from a 1-year-old traumatic accident to the right shoulder sustained during a tennis match. He had been unsuccessfully treated for 6 months with physical therapy. Because of the negativity of the usual imaging studies, a diagnostic arthroscopy was performed. It revealed the presence of a traumatic rupture of the glenoid labrum and of an atypical gelatinous synovial formation in the medial wall of the joint; it was histologically and immunohistochemically diagnosed as adenocarcinoma, probably originating in the lung or in the gastrointestinal tract. The pulmonary origin of the neoplasm was confirmed by computed tomography. The patient underwent chemotherapy and eventually died with contralateral lung and femur metastases 8 months after the diagnosis. The clinical importance of this rare observation is discussed.

Dysfunction of the excretory part of the nasolacrimal system may be congenital in otherwise normal infants or associated with congenital facial anomalies. It may also occur as a result of soft-tissue trauma to the face and naso-orbital fractures. Dacryocystorhinostomy and conjunctivodacryocystorhinostomy are discussed as treatment techniques.

Bilateral lung transplantation is actually considered a valuable option for patients with endstage lung disease related to cystic fibrosis. Timing is crucial to transplant successfully as many patients as possible and it is mainly based on the progressive worsening of pulmonary function tests and quality of life. We reviewed the charts of all patients accepted for lung transplantation at our institution, in order to assess the role of several functional and demographic parameters; we compared the group of patients able to successfully wait for transplantation (Group A) with patients dying on the waiting list (Group B). Twenty-eight patients were accepted: 15 were successfully transplanted (2 at other institutions) (mean waiting time: 117 days), 7 died waiting (mean waiting time: 108 days) and 6 are still on the list. We recorded FEV-1, FVC, PaO2, PaCO2, supplemental O2 requirement, 6-minute walking test, right ventricular ejection fraction (RVEF) and cardio-pulmonary hemodynamics measured at right heart catheterization; we recorded also age at time of diagnosis and at time of evaluation, sex, weight and Schwachman score. These parameters were compared between Group A and B. Age at time of evaluation, sex, weight and Schwachman score did not present any difference between the two groups, as well as pulmonary function tests, PaO2, 6-minute walk test and RVEF. A statistically significant difference was found in terms of PaCO2 (43.9 +/- 9.3 in Group A vs 69.1 +/- 32.4 in Group B, heart rate at rest (102 +/- 21 vs 131 +/- 12) mean pulmonary artery pressure (20.6 +/- 2.9 vs 36 +/- 15.7), pulmonary vascular resistances (350 +/- 96 vs 460 +/- 119.4), cardiac index (3.2 +/- 0.6 vs 5.4 +/- 0.9). On the base of our initial experience we conclude that a careful evaluation of CF candidates for lung transplantation is recommended. A deterioration of pulmonary function tests and quality of life are useful parameters to accept patients in the waiting list; however priority should be attributed also on the base of cardio-pulmonary hemodynamics. A larger series of patients is required to draw definitive conclusions.