Intraoperative findings during temporal artery biopsy: keys to optimise the diagnosis of giant cell arteritis

The objective of this study was to describe the perioperative findings during temporal artery biopsy (TAB) and the characteristics associated with a diagnosis of giant cell arteritis (GCA). Perioperative findings were prospectively described by a single operator blinded to the clinical and laboratory characteristics of the patients on 40 consecutive TABs, of which 21 were positive (53%) for GCA. Patients with a TAB positive for GCA (TAB+) more frequently had abnormalities on palpation of the temporal artery than negative TAB (TAB-) patients (mainly pulse abolition (p=0.007), indurated artery (p=0.002), and painful artery (p=0.021)). The appearance of a big artery (p<0.001), a thickened artery (p<0.001), and an indurated artery at incision (p<0.001) was significantly associated with a positive TAB. A multivariate model identified a big artery, no local bleeding, and pain during artery traction as being associated with TAB positivity (sensitivity 71.4% and specificity 89.5%). The appearance of the temporal artery during TAB is important in predicting the positivity of the biopsy. Whether this should influence the optimal length of the TAB warrants a prospective study.     

Giant cell arteritis--an incidental finding

Giant cell arteritis is a systemic, inflammatory, and vascular syndrome that requires early diagnosis and immediate management because of the risk of loss of vision. Local symptoms include headache, scalp tenderness, jaw claudication, visual disturbances, and scalp necrosis. Systemic symptoms include weight loss, fever, malaise, fatigue, and polymyalgia rheumatica. We describe a case that was identified histologically as an incidental finding after excision of a basal cell carcinoma from the parietal area of the scalp. A search of PubMed and Medline using the keywords "giant cell arteritis", and "incidental histopathological diagnosis" returned no similar previously published cases in the head and neck. We present this as an unusual and interesting case.     

Langerhans cell histiocytosis in childhood – Review,symptoms in the oral cavity,differential diagnosis and report of two cases

BackgroundLangerhans cell histiocytosis is a rare disease characterized by monoclonal proliferation and migration of special dendritic cells. This disease primarily affects bones, but occurs less frequently in other organ systems or may manifest as a multisystem disease.Case reportsExtraoral and intraoral symptoms of Langerhans cell histiocytosis are described in a 13-month-old female and a 5-month-old male infant.Dermatitis was found on the scalp, abdomen, flexures and in intertrigineous areas in both patients. The intraoral examination of the 13-month-old infant showed premature eruption of all maxillary deciduous molars, loosening and significant damage of periodontal tissues (gingivitis with bleeding, swelling of palatal mucosa, periodontal pockets) resembling severe periodontitis.In the oral cavity of the 5-month-old predentate infant bilateral swellings of maxillary alveolar mucosa with deep ulcerations were seen.The oral and skin symptoms in both infants were indications for biopsy. Langerhans cell histiocytosis was confirmed histologically and immunohistochemically.ConclusionOral findings in Langerhans cell histiocytosis may be the only clinical symptom of the disease; therefore the role of dentists in establishing diagnosis is very important.     

Gingival cyst of the adult. Case report of a bilateral presentation

The gingival cyst of the adult (GCA) constitutes a pathologic developmental process that the dentist must be prepared to diagnose and treat. The GCA has been infrequently reported in the past as a unilateral phenomenon, but this case constitutes the first known report of synchronously occurring, bilateral GCA in the dental literature.     

Giant Hemangioma Presenting as a Scalp Mass Leading to a Craniofacial Deformity

Hemangioma is the most common vascular tumor during childhood. However, cases of giant hemangiomas determining deformities in the craniofacial region are not reported frequently. Craniofacial giant hemangiomas are challenging for surgeons since they cause aesthetic and/or functional problems and may be associated with important complications such as ulcerations, infections and bleedings. The present report is aimed at describing a rare case of craniofacial asymmetry in a 30-year-old patient, secondary to an extensive mass whose growth deformed the scalp in the frontal-parietal-temporal region. The lesion was completely surgically removed with good aesthetic results, and the anatomopathological examination revealed that it was a cavernous hemangioma.     

Surgical treatment of aplasia cutis congenita of the scalp associated with bilateral coronal synostosis

Aplasia cutis congenita is a rare condition characterized by the congenital absence of skin. The authors report a case of aplasia cutis congenita of the scalp associated with bilateral coronal synostosis. Simultaneous fronto-orbital advancement and skull reconstruction for large defect at the fontanelle were performed in the initial operation. A tissue expander made it possible to resect most of the hairless scar and totally cover the reconstructed defect and skull. During the second stage, the residual hairless scar was completely covered with hair-bearing scalp by tissue expansion and the residual skull defects were successfully reconstructed with split calvarial bone grafting.     

Erythema multiforme following cardizem therapy: report of a case

A 63-year-old male developed severe, painful ulcerations shortly after beginning therapy for angina with diltiazem (Cardizem). Erythema multiforme is a common adverse reaction to medications. The case report, as well as the role of the dentist in diagnosis and management of these clinical presentations, is discussed.     

Anatomical restrictions in the surgical excision of scalp squamous cell carcinomas: does this affect local recurrence and regional nodal metastases?

Squamous cell carcinomas (SCCs) of the skin of the scalp have the potential for regional metastases. Microscopically, clearance may be less than the optimal dimensions. We report 101 SCCs of the scalp treated surgically under the care of a single oral and maxillofacial surgeon. Forty-two of the study patients had deep margins that were clear by less than 2 mm, of whom five had margins that involved pericranium ± skull. Our study demonstrated a local recurrence rate of 6% and a regional recurrence rate of 7%. All patients presented with relapse of the disease within 18 months of primary surgery. The evidence presented in this study suggests that in SCCs of the scalp, less than ideal surgical margin clearance, entirely due to anatomical restrictions, does not appear to substantially affect regional recurrence, but increases the risk of local recurrence.     

Large granular lymphocyte leukemia and its association with oral neutropenic ulcerations: a case report

Large granular lymphocyte leukemia is a rare chronic indolent disorder commonly associated with severe neutropenia. The pathogenesis of the neutropenia is unclear. A case is presented of a 74-year-old man who had recurrent oral ulcerations for over a year before a diagnosis was made. These recurrent oral ulcers cleared with treatment and have not returned. The differential diagnosis of persistent oral ulcerations includes trauma; viral, fungal, and bacterial infections; systemic disease; or various malignant conditions. The oral ulcers in this man were likely infectious in nature and related to the severe chronic neutropenia. This case serves to illustrate the potentially complex nature of oral ulcers.     

Bicoronal flap approach to the temporomandibular joints

The bicoronal scalp flap provides an excellent approach to the temporomandibular joint, particularly in cases where bilateral operation is required. It is also indicated when wide exposure is required and when previous surgery may make more conventional techniques difficult. In this report, the anatomy and indications for this approach are reviewed, the operative technique is described and complications are discussed.     

Masticatory muscle pain: An important indicator of giant cell arteritis

Giant cell arteritis (GCA) is a poly symptomatic disease which constitutes an ophthalmic emergency because early recognition and management can prevent blindness. There is conflicting information in the literature on the validity, sensitivity, and specificity of various systemic symptoms and signs of GCA. This paper presents a review of our prospective studies on the subject, and our findings are particularly relevant to dentists. We investigated 363 patients in a prospective study. Positive temporal artery biopsy was seen in 106 patients and negative in 257 referred for diagnosis of GCA. Systemic symptoms and signs of GCA and erythrocyte sedimentation rate (Westergren-ESR) and C-reactive protein (CRP) levels were compared in these two groups of patients. The odds of having a positive temporal artery biopsy ( i. e., GCA) were 9.1 times greater with jaw claudication (pain in masticatory muscles on eating), 3.4 times with neck pain, 3.2 times with CRP > 2.45 mg/dL, 2.0 times with ESR 47–107 mm/hr, 2.7 times with ESR > 107 mm/hr, and 2.0 times when the patients were aged ≥ 75 years. Other signs and symptoms did not show a significant association with a positive biopsy. Our study showed that "normal" ESR values do not rule out GCA but that CRP is a more useful test than ESR. Since jaw claudication is one of the most important symptoms of GCA, dentists should keep this possibility in mind when older patients come complaining of jaw pain while eating .     

Oral mucosal involvement in Langerhans' cell histiocytosis: long-term follow-up of a rare case

Langerhans' cell histiocytosis (LCH) is a rare disease where different organs and systems may be affected. Oral involvement generally consists of mucosal ulceration associated with lesions of the underlying bone. Many reports exist about the misdiagnosis of this disease. Various symptoms may lead the clinician to an incorrect diagnosis, especially with multiple organ involvement. Oral manifestations are common, and dentists should be aware of this disease and evaluate intraoral findings accordingly. This study presents an LCH case characterized by oral mucosal ulcerations with no involvement of the underlying bone. A definitive diagnosis was made by open biopsy from the oral mucosa.     

Eosinophilic ulcer of oral mucosa: a case report

Eosinophilic Ulcer (EU) is a rare self-limiting chronic benign lesion of the oral mucosa with pathogenesis still unclear, however it may resemble malignancies, traumatic ulcerations and some infections such as deep fungal infections, tuberculosis and primary syphilis. This is a case report of a patient with EU in the lateral border of the tongue with no history of associated trauma and refractory to treatment with drugs. The ulcer rapidly healed after an incisional biopsy and the definite diagnosis was achieved only combining histologic findings and the clinical follow-up.     

Oral ulcerations as the first sign of a foramen magnum meningioma

We report the case of a patient with oral ulcerations that were likely traumatic in origin caused by biting of the tongue. Physical examination showed only deviation, fasciculations, and hemiatrophy of the right side of the tongue. Neurologic examination disclosed an isolated XII nerve palsy. A magnetic resonance image showed a lesion in the posterior fossa displacing the brain stem at a bulbar level. This was consistent with the diagnosis of a meningioma, later confirmed by the histopathologic study. It is very unusual that a meningioma produces a selective involvement of the XII nerve. Early diagnosis of a foramen magnum meningioma is important, both to improve prognosis and to avoid neurologic sequelae.     

Painful chewing and blindness: signs and symptoms of temporal arteritis

BACKGROUND: This case report illustrates the need to consider temporal arteritis in the differential diagnosis of jaw or tooth pain. This disease affects the cranial arteries, more frequently in women and usually in those older than age 60 years, causing jaw pain, visual symptoms, headache, scalp pain and sometimes blindness. CASE DESCRIPTION: A 71-year-old man had jaw pain that increased with chewing and speaking, scalp tenderness and dimming vision. A temporal artery biopsy confirmed the diagnosis of temporal arteritis. Treatment with decreasing amounts of oral steroids over 23 months was successful in relieving his signs and symptoms and in saving his vision. CLINICAL IMPLICATIONS: Patients with this disease may seek care from their dentist first. Jaw or tooth pain is the most reliable clinical symptom in the diagnosis of temporal arteritis. Diagnosis and timely referral for treatment with oral steroids can prevent blindness.     

Gingival cyst of the adult,lateral periodontal cyst,and botryoid odontogenic cyst: An updated systematic review

The aim of the present review was to integrate the available data published on gingival cyst of the adult (GCA), lateral periodontal cyst (LPC), and botryoid odontogenic cyst (BOC) into a comprehensive analysis of their clinical/radiological features. An electronic search was undertaken in July/2017. Eligibility criteria included publications having enough clinical/radiological/histological information to confirm the diagnosis. A total of 146 publications (157 GCAs, 213 LPCs, 96 BOCs) were included. GCA and LPC presented highest prevalence in the sixth/fifth decades; BOC in the sixth/seventh decades. LPCs were larger lesions than GCAs and GCAs appeared at an older age than LPC. There was no statistically significant difference between them for other factors (location, symptoms, recurrence, follow‐up time). In comparison with LPC, BOC lesions were larger, appeared more often in mandible and in older subjects, had more often a multilocular appearance, and presented a higher recurrence rate. Recurrence rates: GCA (3.2%), LPC (2.4%), BOC (21.7%). No factor seems to influence the recurrence rate of GCA or LPC. Multilocular radiological appearance seems to affect the recurrence rate of BOCs. Conservative surgical approaches seem to be enough for GCA/LPC. BOC presents a more aggressive behavior than GCA/LPC. Therefore, treatment of this lesion might involve some kind of adjunctive therapy after enucleation.     

Oral ulcerations

Ulcerations are common occurrences in the mouth. Causes include physical trauma, radiation, chemical injury, and microbial infection (bacterial, viral, and fungal). Some ulcerations, such as recurrent aphthous stomatitis, Beh?et's syndrome, and erythema multiforme, are of uncertain etiology, whereas others (eg, pemphigus, pemphigoid) are apparently of immunologic origin. Malignant neoplasms also may present as ulcerations. Because the natural history and treatment varies with the diagnosis, the practitioner should become familiar with the clinical appearance of the various types of ulcerations so that appropriate treatment can be instituted.     

A case study of amnion rupture sequence with acalvaria, blindness, and clefting: clinical and psychological profiles

The purpose of this article is to report the case of a 10-year-old girl born with anophthalmia, bilateral oblique facial clefts, and missing scalp and bones over the temporal and parietal areas of the cranial vault bilaterally. Early amnion rupture seems to be the most probable cause of this rare combination of anomalies. Because no similar case has been reported in the literature so far, we describe here the clinical and psychosocial history of this unusual patient, who has been able to live the intellectually and socially normal life of a blind child in spite of the major craniofacial deformities. The already completed and possible future therapeutic strategies are discussed.     

Bilateral central giant cell granulomas of the mandible in an 8-year-old girl with Noonan syndrome (Noonan-like/multiple giant cell lesion syndrome)

We report a case of an 8-year-old girl who presented with bilateral central giant cell granulomas of the posterior mandible. Characteristic facial features and a history of pulmonary stenosis led us to suspect a diagnosis of Noonan syndrome. A medical geneticist confirmed this. This case report will discuss the salient features of this diagnosis.     

Case of recurrent paracoccidioidomycosis in female. 10 years after initial treatment

This report describes a case of recurrence of chronic paracoccidioidomycosis 10 years following the initial diagnosis. A 56-year-old female was admitted to the Dental Clinic of the Pontifical Catholic University of Paraná complaining of oral soreness. Mulberry-like ulcerations were observed on the gingiva, right labial comissura, and vermillion of the lip. The patient reported persistent chronic cough, weight loss, appetite loss and fever. The anamnesis revealed that the patient had developed and been treated for paracoccidioidomycosis 10 years earlier. A biopsy was performed and microscopic examination revealed microabscesses, collections of macrophages organized into granulomas, multinucleated giant cells and Paracoccidioides brasiliensis. The patient was treated with Itraconazole and, the oral lesions disappeared within 3 months. Persistent follow-up examination in patients with a history of paracoccidioidomycosis is essential in the management of this disease.