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The relationship of TMJ clicking to palpable facial pain
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had been present for three weeks and was rapidly increasing in size. The lesion was 4.0 cm in its broadest dimension and was located along the mandibular attachment of the left masseter. The initial impression was of a malignant parotid salivary gland tumor. Surgical excision was performed and visible tumor remained. Nine months postoperatively, the patient appeared free of disease. Characteristically, the lesion has a sudden onset, with rapid expansive growth, and is usually diagnosed within eight weeks of the onset of symptoms. The most common sites of occurrence are the shoulders and upper extremities. Only five cases in the head and neck region have been described, most of them involving the sternocleidomastoid. This is the first known report of a case involving the muscles of either mastication or facial expression. It is important to distinguish PM from nodular fascitis, myositis ossificans, proliferative fascitis, and rhabdomyosarcoma. A prime feature of this lesion is that surgical excision shows it to occur entirely within muscle. It appears as a scarlike thickening of muscle, with considerable amounts of fibrous connective tissue. Often, necrosis is present. Histologically there is diffuse fibroblastic proliferation involving and separating the muscle fibers. Large basophilic giant cells, resembling rhabdomyoblasts or ganglion cells, are seen, which can lead to misdiagnosis of sarcoma. However, the cytoplasm of malignant cells is typically acidophilic staining. An improper diagnosis of this totally benign condition can lead to overtreatment. Histologically, PM appears aggressive, but it has never been reported to recur or metastasize following simple surgical excision. The suspected cause of PM is subclinical trauma involving cell types that are aberrant derivatives of myofibroblasts.-MARK W. OCHS Reprint requests to Dr. Orlowski: Department of Pathology, School of Dentistry, Farleigh Dickinson University, 110 Fuller Place, Hackensack, NJ 07601.
Rationale for Use of Antimicrobial Combinations. Moellering RC Jr: Am J Med 75~4, 1983 This article reviews and discusses the rationale for use of combinations of antibiotics. Combinations of antibiotics are used for these purposes: (1) to broaden the spectrum of coverage, (2) to prevent the emergence of resistant microbes, (3) to decrease toxicity by use of lower concentrations of drugs, and (4) to enhance antimicrobial activity via synergistic interaction. Three types of antimicrobial interaction or combinations that result in synergistic antimicrobial activity are listed. These types include (1) combinations of agents that inhibit bacterial cell wall synthesis with aminoglycosidic aminocyclitois, (2) the use of beta-lactam inhibitors in combination with beta-lactam antibiotics, and (3) the administration of agents that act on sequential steps in one of the bacterial metabolic or synthetic pathways. The differences in in vitro test models for each mechanism of action are reviewed. There is a complex interaction of antimicrobial agents, pharmacokinetics and metabolism, host defenses, and microbe in human infections, which is difficult to
CURRENT LITERATURE
reproduce in vitro. Therefore, clinical trials are the only reliable way to determine whether antimicrobial combinations are clinically useful. The challenge is to define precisely the nature of antimicrobial interactions and then to define critically the use of combinations in the clinical area. If this is done, the use of antimicrobial combinations can result in significant therapeutic benefit.-STEVE BUCKLEY Reprint requests to Dr. Moellering: Hospital, Boston, MA 02215.
New England Deaconess
A New Procedure in Nasal Packing to Stop Bleeding. Nassif ACN: Laryngoscope 93: 1983 The author presents a variation of a method utilizing a Foley catheter modified by the use of Gelfoam@ packing and a new fixation device for the control of severe posterior nasal bleeding. The procedure can be divided into three phases. First, the distal tip of the Foley catheter is sectioned, and the catheter is introduced through the bleeding fossa up to the choana. Five milliliters water is added to push the balloon into the nasopharynx, after which another IO- 15 ml water is added while tension is being placed on the catheter. This serves to block the choana, and bleeding will occur through the anterior nasal fossa. Second, Gelfoam@ covered with acromycin ointment is placed into the posterior and medial portions of the cavity while tension is still maintained on the catheter. This serves to minimize the chances of recurrent bleeding during removal of the tampon. The anterior nasal cavity is then packed tightly with petroleum jelly gauze. Third, the catheter is fixed at the level of the nostril by use of a small perforated piece of nylon sponge, and a Nassif lip designed
for this use is applied.-MARK
SILVERBERG
Reprint requests to Dr. Nassif: Av. Vicente Machado, 1171, 5.” andar, 501, Curitiba. Parana. Brazil 80.000.
The Relationship of TMJ Clicking to Palpable Facial Pain. Bush F, Butler J, Abbott D: J Craniomand Pratt Sept-Nov:43, 1983 The relationship between joint clicking and tenderness of the masticatory muscles is still very uncertain. This study was undertaken to determine whether a positive correlation does exist. A survey of 324 dental students showed that approximately one third had clicking in one or both TMJs. More students had clicking in both joints than in one (56% vs 45%). Tenderness to palpation was found in the masticatory muscles of 12% of the students. Tenderness of the TMJ upon palpation via the external auditory meatus occurred in approximately 1% and joint tenderness upon lateral palpation in nearly 3%. Statistical analysis showed that there was a significant relationship between TMJ clicking and tenderness of the masticatory muscles. The clinical significance will require further Study.-JEFFREY L. RAJCHEL Reprint requests to Dr. Bush: Department of General Dentistry, Medical College of Virginia, P.O. Box 566, Richmond, VA 23298.
had been present for three weeks and was rapidly increasing in size. The lesion was 4.0 cm in its broadest dimension and was located along the mandibular attachment of the left masseter. The initial impression was of a malignant parotid salivary gland tumor. Surgical excision was performed and visible tumor remained. Nine months postoperatively, the patient appeared free of disease. Characteristically, the lesion has a sudden onset, with rapid expansive growth, and is usually diagnosed within eight weeks of the onset of symptoms. The most common sites of occurrence are the shoulders and upper extremities. Only five cases in the head and neck region have been described, most of them involving the sternocleidomastoid. This is the first known report of a case involving the muscles of either mastication or facial expression. It is important to distinguish PM from nodular fascitis, myositis ossificans, proliferative fascitis, and rhabdomyosarcoma. A prime feature of this lesion is that surgical excision shows it to occur entirely within muscle. It appears as a scarlike thickening of muscle, with considerable amounts of fibrous connective tissue. Often, necrosis is present. Histologically there is diffuse fibroblastic proliferation involving and separating the muscle fibers. Large basophilic giant cells, resembling rhabdomyoblasts or ganglion cells, are seen, which can lead to misdiagnosis of sarcoma. However, the cytoplasm of malignant cells is typically acidophilic staining. An improper diagnosis of this totally benign condition can lead to overtreatment. Histologically, PM appears aggressive, but it has never been reported to recur or metastasize following simple surgical excision. The suspected cause of PM is subclinical trauma involving cell types that are aberrant derivatives of myofibroblasts.-MARK W. OCHS Reprint requests to Dr. Orlowski: Department of Pathology, School of Dentistry, Farleigh Dickinson University, 110 Fuller Place, Hackensack, NJ 07601.
Rationale for Use of Antimicrobial Combinations. Moellering RC Jr: Am J Med 75~4, 1983 This article reviews and discusses the rationale for use of combinations of antibiotics. Combinations of antibiotics are used for these purposes: (1) to broaden the spectrum of coverage, (2) to prevent the emergence of resistant microbes, (3) to decrease toxicity by use of lower concentrations of drugs, and (4) to enhance antimicrobial activity via synergistic interaction. Three types of antimicrobial interaction or combinations that result in synergistic antimicrobial activity are listed. These types include (1) combinations of agents that inhibit bacterial cell wall synthesis with aminoglycosidic aminocyclitois, (2) the use of beta-lactam inhibitors in combination with beta-lactam antibiotics, and (3) the administration of agents that act on sequential steps in one of the bacterial metabolic or synthetic pathways. The differences in in vitro test models for each mechanism of action are reviewed. There is a complex interaction of antimicrobial agents, pharmacokinetics and metabolism, host defenses, and microbe in human infections, which is difficult to
CURRENT LITERATURE
reproduce in vitro. Therefore, clinical trials are the only reliable way to determine whether antimicrobial combinations are clinically useful. The challenge is to define precisely the nature of antimicrobial interactions and then to define critically the use of combinations in the clinical area. If this is done, the use of antimicrobial combinations can result in significant therapeutic benefit.-STEVE BUCKLEY Reprint requests to Dr. Moellering: Hospital, Boston, MA 02215.
New England Deaconess
A New Procedure in Nasal Packing to Stop Bleeding. Nassif ACN: Laryngoscope 93: 1983 The author presents a variation of a method utilizing a Foley catheter modified by the use of Gelfoam@ packing and a new fixation device for the control of severe posterior nasal bleeding. The procedure can be divided into three phases. First, the distal tip of the Foley catheter is sectioned, and the catheter is introduced through the bleeding fossa up to the choana. Five milliliters water is added to push the balloon into the nasopharynx, after which another IO- 15 ml water is added while tension is being placed on the catheter. This serves to block the choana, and bleeding will occur through the anterior nasal fossa. Second, Gelfoam@ covered with acromycin ointment is placed into the posterior and medial portions of the cavity while tension is still maintained on the catheter. This serves to minimize the chances of recurrent bleeding during removal of the tampon. The anterior nasal cavity is then packed tightly with petroleum jelly gauze. Third, the catheter is fixed at the level of the nostril by use of a small perforated piece of nylon sponge, and a Nassif lip designed
for this use is applied.-MARK
SILVERBERG
Reprint requests to Dr. Nassif: Av. Vicente Machado, 1171, 5.” andar, 501, Curitiba. Parana. Brazil 80.000.
The Relationship of TMJ Clicking to Palpable Facial Pain. Bush F, Butler J, Abbott D: J Craniomand Pratt Sept-Nov:43, 1983 The relationship between joint clicking and tenderness of the masticatory muscles is still very uncertain. This study was undertaken to determine whether a positive correlation does exist. A survey of 324 dental students showed that approximately one third had clicking in one or both TMJs. More students had clicking in both joints than in one (56% vs 45%). Tenderness to palpation was found in the masticatory muscles of 12% of the students. Tenderness of the TMJ upon palpation via the external auditory meatus occurred in approximately 1% and joint tenderness upon lateral palpation in nearly 3%. Statistical analysis showed that there was a significant relationship between TMJ clicking and tenderness of the masticatory muscles. The clinical significance will require further Study.-JEFFREY L. RAJCHEL Reprint requests to Dr. Bush: Department of General Dentistry, Medical College of Virginia, P.O. Box 566, Richmond, VA 23298.