The Journal of Craniofacial Surgery

& Volume 25, Number 2, March 2014

Our article reports a case of a bulky PPS hemangioma (7  4.5 cm) compared with the reports of other authors. Previous studies of authors described nonsurgical management of PPS hemangiomas with steroids and radiotherapy or embolization and laser and reported good results with decrease in symptoms10: however, prolonged follow-up is mandatory in cases of nonsurgical treatment and decision-making between surgery and other treatments should be based on patient’s health history. Our multidisciplinary treatment provided good results with the aid of preoperative embolization, preventing intraoperative and postoperative complications, such as massive hemorrhages in PPS. Previous studies of authors reported a similar superselective embolization for the treatment of arteriovenous and capillary hemangiomas, to collapse the cutaneous angiomatous spaces.11 We differently described this approach as preoperative aid to surgery. In the current study, we performed a minimally invasive surgery of a bulky mass (7  4.5 cm) without mandibulotomy, with bleeding control because of the preoperative embolization. Mandibulotomy is a useful technique in this kind of surgery. However, in cases of nonmalignant masses, surgery may be performed without it to avoid all morbidities due to this procedure, such as prolonged hospitalization as well as reduced food intake and aesthetics.12 With this article, we report a case of a giant PPS capillary hemangioma. In the management of such neoformations, we suggest a multidisciplinary approach to evaluate the proper treatment on the basis of health history of the patient. Minimally invasive surgery with preoperative embolization leads to minor complications and better outcome.

REFERENCES 1. Gadre PK, Gadre KS, Halli RC, et al. Mandibular subsigmoid access osteotomy in the management of parapharyngeal space tumors. J Craniofac Surg 2013;24:579Y582 2. Cavallotti C, Giovannetti F, Cavallotti C, et al. Vascular wall of head-facial hemangioma. J Craniofac Surg 2011;22:1052Y1055 3. Greene AK. Current concepts of vascular anomalies. J Craniofac Surg 2012;23:220Y224 4. Acosta L, Montalva˜o P, Magalha˜es M, et al. Parapharyngeal space tumors. Our experience. I.P.O. Francisco Gentil, Lisbon [in Spanish]. Acta Otorrinolaringol Esp 2002;53:485Y490 5. Cassoni A, Terenzi V, Della Monaca M, et al. Parapharyngeal space benign tumours: Our experience. J Craniomaxillofac Surg [published ahead of print May 16, 2013] doi: 10.1016/j.jcms.2013.03.002 6. Dimitrijevic MV, Jesic SD, Mikic AA, et al. Parapharyngeal space tumors: 61 case reviews. Int J Oral Maxillofac Surg 2010;39:983Y989 7. Presutti L, Molteni G, Malve` L, et al. Parapharyngeal space tumors without mandibulotomy: our experience. Eur Arch Otorhinolaryngol 2012;269:265Y273 8. Cho JH, Joo YH, Kim MS, et al. Venous hemangioma of parapharyngeal space with calcification. Clin Exp Otorhinolaryngol 2011;4:207Y209 9. Kale US, Ruckley RW, Edge CJ. Cavernous haemangioma of the parapharyngeal space. Indian J Otolaryngol Head Neck Surg 2006;58:77Y80 10. Huang CM, Lee KW, Huang CJ. Radiation therapy for life-threatening huge laryngeal hemangioma involving pharynx and parapharyngeal space. Head Neck 2013;35:E98YE101 11. Weyer U, Freitag J, Russ C, et al. Association of arteriovenous and cavernous angioma of the head and neck area. Dtsch Med Wochenschr 1991;116:416Y420 12. Kolokythas A, Eisele DW, El-Sayed I, et al. Mandibular osteotomies for access to select parapharyngeal space neoplasms. Head Neck 2009;31:102Y110

Brief Clinical Studies

Compressive Optic Neuropathy Presenting With Psychiatric Symptoms Nurgu¨l O¨rnek, MD,* Nesrin Bu¨yu¨ktortop-Go¨k0inar, MD,* Ersel Da?, MD,Þ Kemal O¨rnek, MD* Abstract: We report a case of bilateral optic neuropathy presenting with psychiatric symptoms. A 50-year-old woman was admitted with blurry vision in both eyes. She had a 3 months’ history of depressed mood. Both optic discs had mild temporal pallor with visible spontaneous venous pulsations. Magnetic resonance imaging of the brain showed a large frontal mass compressing the optic nerves. The tumor was surgically resected, and tissue pathology demonstrated an olfactory groove meningioma. Key Words: Bilateral, compressive, optic neuropathy, psychiatric symptoms

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eoplasms involving the central nervous system, especially in the pituitary-hypothalamic region and frontal lobes, may cause visual loss associated with psychiatric features. Unrecognized tumors of the frontal lobes may result in papilledema and visual loss associated with apathy, depression, and personality changes.1

CLINICAL REPORT A 50-year-old woman was admitted to us with a complaint of blurry vision in both eyes. She had a 3 months’ history of depressed mood manifested by day time sleeping, feelings of hopelessness, and difficulties in concentrating. She did not receive any psychiatric evaluation and treatment at that time. On examination, visual acuities were 1/10 in both eyes. Pupils were equal and sluggishly reactive to light without relative afferent defects. The anterior segments of both eyes were unremarkable. Both optic discs had mild temporal pallor with visible spontaneous venous pulsations. Fundus fluorescein angiography did not show any abnormalities. The patient did not have symptoms such as headache, scalp tenderness, or other systemic discomfort. Humphrey visual field test showed altitudinal visual field defects in both eyes. In a few days, magnetic resonance imaging of the brain was performed, and a large frontal mass compressing the optic nerves was detected (Fig. 1). The tumor was surgically resected, and tissue pathology demonstrated an olfactory groove meningioma. Following the surgery, her vision improved to 3/10 in the right eye and 3/10 in the left eye.

DISCUSSION Meningiomas originating from the olfactory groove account for approximately 10% of all intracranial meningiomas. Most patients develop one or a combination of the following symptoms; mental changes in cognition or personality, headache, and visual deficits. From the Departments of *Ophthalmology and †Neurology, School of Medicine, Kirikkale University, Kirikkale, Turkey. Received August 9, 2013. Accepted for publication September 30, 2013. ¨ rnek, MD, 1465. Address correspondence and reprint requests to Kemal O sokak, 16/31, C ¸ ukurambar, C ¸ ankaya, Ankara, Turkey; E-mail: [email protected] No funding was received for this study. The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/01.SCS.0000436734.65879.00

* 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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Brief Clinical Studies

FIGURE 1. Magnetic resonance imaging of the brain showing a large frontal mass compressing the optic nerves.

Visual loss is usually limited to acuity or restriction of visual field. Personality changes may lead these patients to avoid ophthalmic care until their vision is extremely poor.2,3 In this report, because of bilateral visual loss with coexisting mental and behavioral changes in patient’s history, the patient was initially diagnosed as compressive optic neuropathy. Following the detection of visual field defects in both eyes, a brain magnetic resonance imaging scan was ordered, and it revealed a large olfactory meningioma compressing the optic nerves. After surgical excision of the tumor, the patient was well and seeing better. To conclude, this report underlines the importance of thorough ophthalmologic examination and neuroimaging studies in patients who have visual loss, personality changes, and cognitive impairment to avoid life-threatening complications.

REFERENCES 1. Binder RL. Neurologically silent brain tumors in psychiatric hospital admissions: three cases and a review. J Clin Psychiatry 1983;44:94Y97 2. Tsikoudas A, Martin-Hirsch DP. Olfactory groove meningiomas. Clin Otolaryngol Allied Sci 1999;24:507Y509 3. Gazzeri R, Galarza M, Gazzeri G. Giant olfactory groove meningioma: ophthalmological and cognitive outcome after bifrontal microsurgical approach. Acta Neurochir (Wien) 2008;150:1117Y1125

The Role of Temporalis Fascia for Free Mucosal Graft Survival in Small Nasal Septal Perforation Repair Eun-Ju Jeon, MD,* Jin Choi, MD,* Joo-Hyung Lee, MD,Þ Sung-Won Kim, MD,þ In-Chul Nam, MD,* Yong-Su Park, MD,* Sang-Gyun Jin, MD,Þ Byung-Jun Cheon, MDÞ From the *Department of OtolaryngologyYHead and Neck Surgery, College of Medicine, The Catholic University of Korea, Incheon St Mary’s Hospital, Incheon; †Department of OtolaryngologyYHead and Neck Surgery, College of Medicine, The Catholic University of Korea, Daejeon St Mary’s Hospital, Daejeon; and ‡Department of OtolaryngologyYHead and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul St Mary’s Hospital, Seoul, Republic of Korea. Received September 26, 2013. Accepted for publication October 22, 2013. Address correspondence and reprint requests to Jin Choi, MD, Department of OtolaryngologyYHead and Neck Surgery, College of Medicine, The Catholic University of Korea, Bupyeong 6-dong, Bupyeong-gu, Incheon, E-mail: [email protected] The authors report no conflicts of interest. Institution where the work was done: Department of OtolaryngologyYHead and Neck Surgery, College of Medicine, The Catholic University of Korea, Bupyeong 6-dong, Bupyeong-gu, Incheon, Republic of Korea. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000492

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& Volume 25, Number 2, March 2014

Abstract: Temporalis fascia has been used widely as a interposition graft for mucosal rotation flap in nasal septal perforation repair. However, the exact role of temporalis fascia in healing process has not yet been clarified. For the pedicle of rotation flap has been considered as a major vehicle for nutrition distribution, the role of temporalis fascia has been devaluated. In this study, we experienced small nasal septal perforation repairs using free mucosal graft not having pedicles but covered by temporalis fascia. Three patients with small nasal septal perforations not larger than 1  1 cm2 were included. In 2 patients, the perforations were repaired using free composite grafts from the inferior turbinate mucosa covered by continuous temporalis fascia not divided, and the surgical results were successful with complete healings. In 1 patient, however, the temporalis fascia was divided into 2 parts to better fit the shape of the perforation, and the graft failed to survive. These surgical results suggest that the temporalis fascia might have an important role in healing process of nasal septal defect and could be used as a beneficial options for small mucosal defect repair surgeries using free mucosal grafts. Key Words: Nasal septal perforation, temporalis fascia, nasal mucosa

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enerally, small nasal septal perforation has been repaired by mucosal rotation flap having pedicles with or without interposition graft. Temporalis fascia is the most widely used interposition graft with high success rates, but its exact role has not been known. In some literatures, its roles have been reported as a template for mucosal healing process and/or preventing mucosal flap shrinkage after rotation, although dispensable.1 In this study, we describe a new surgical technique for repair of septal perforations using free mucosal graft not having pedicles. Free mucosal grafts have been known to have high failure rates. We covered it with temporalis fascia to induce graft survival rates. We aimed to evaluate the efficacy of this technique based on the successful repair results of septal perforations and the role of temporalis fascia in healing process.

MATERIALS AND METHODS Description of Surgical Technique Preparation of the Nasal Septum All surgeries were performed under general anesthesia. The perforation was measured at its greatest diameter under a 0-degree endoscopic view. The perforation margin and inferior turbinate mucosa were infiltrated with 2% lidocaine with 1:100,000 epinephrine for hemostasis and hydrodissection. Under the endoscopic view, the margin of the perforation was trimmed with a sickle knife. Using the standard septoplasty approach, a hemitransfixion incision was performed at the caudal portion of the nasal septum. A unilateral mucoperichondrial flap was then elevated to expose the defect.

Preparation of the Composite Graft The mucosal graft obtained from the inferior turbinate, which was slightly larger than the perforation itself, was harvested with a sickle knife and scissors using an endoscope for visualization. The temporalis muscle fascia was harvested and flattened using a procedure similar to that used in tympanoplasty. The harvested temporalis fascia was used to cover the raw surface of the inferior turbinate mucosal graft and was secured using a simple suture technique (Fig. 1). During the preparation of the temporalis muscle fascia, the same techniques were applied in all * 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.