Diplopia—an unheralded consequence of neck dissection: case report

Introduction

Neck dissection is a part of the standard surgical procedure in the management of head and neck malignancy. Diplopia following neck dissection is a rare entity; hence, its diagnosis and management strategies needed to be discussed for prevention of its grave consequences.

Case report

A 30-year-old male patient presented with binocular horizontal diplopia following total thyroidectomy and neck dissection. On evaluation, there was internal jugular vein (IJV) thrombosis followed by cerebral venous sinus thrombosis (CVST). After meticulous medical management with diuretics and antiplatelet drugs, diplopia resolved completely and normal vision was restored.

Conclusion

Therapeutic ligation of internal jugular vein during neck dissection may result in IJV thrombosis followed by CVST leading to raised intracranial tension (ICT). It has to be anticipated and addressed as early as possible to prevent its grave consequences like blindness and death.

     

A Giant Plunging Sublingual Dermoid Cyst Excised by Intraoral Approach

Objective

Dermoid and epidermoid cysts are rare cysts of the head and neck region, which should be considered in differential diagnosis of sublingual mass, constituting 0.01 % of all oral cavity cysts. There are suspected theories regarding the basis of the pathology.

Case Report

30-year-old male referred to our clinic with a chief complaint of sublingual mass which had been present for many years but the lesion enlarged over the past 3 years. MRI examination revealed a giant cystic mass which was 3.6 × 3.9 mm in diameter and medially located at sublingual region.

Treatment and Prognosis

Intraoral approach was preferred for surgery and no recurrence or complaints were detected during follow-up period.

Conclusion

When a cystic mass is detected on the floor of oral cavity, we must consider dermoid cysts for differential diagnosis. Surgery is the only treatment. If possible, intraoral approach should be preferred because of its perfect cosmetic results.

     

Hemophilic pseudotumor of the mandible in a patient with hemophilia B

Introduction

Hemophilic pseudotumor is a rare complication occurring in patients with hemophilia, frequently seen in the femur, tibia, pelvic bones, iliac bones, or rarely in the maxillofacial region.

Case report

A 7-year-old male reported with a spontaneous extra-oral swelling that was managed with pre-operative transfusion of factor IX along with curettage of the lesion. Our report presents only the fourth case in literature wherein this tumor presented in a patient with hemophilia B.

Finding

Hemophilic pseudotumor is a rare entity in the maxillofacial region. High degree of suspicion is required for diagnosis, and close coordination between the medical and surgical teams aids in management.

     

Utility of intraoperative nerve monitoring in thyroid surgery: 20-year experience with 1418 cases

Purpose

The efficacy of intraoperative nerve monitoring is controversial in the literature. This study of a single surgeon’s experience seeks to determine if the use of intraoperative nerve monitoring influences recurrent laryngeal nerve injury during thyroid surgery.

Methods

Six hundred fifty-seven patients with normal pre-operative vocal fold function underwent thyroid surgery without the use of intraoperative nerve monitoring from September 1997 to January 2007, while 761 patients underwent thyroid surgery from February 2007 to February 2016 with routine use of nerve monitoring. Patients were followed for a minimum of 6 months after surgery, and postoperative nerve function was determined by fiberoptic laryngoscopy. A Fisher test was used to determine if nerve injury was statistically different between both groups.

Results

In patients operated on without nerve monitoring, 21 patients were found to have postoperative vocal fold paralysis with nine regaining functioning. In patients operated on with nerve monitoring, 27 were found to have vocal fold dysfunction with 17 regaining function. Fisher test analysis, both with and without patients regaining function, showed no difference in nerve injury between groups (p > 0.05, p > 0.05).

Conclusion

Intraoperative monitoring during thyroidectomy may not prevent injury to the recurrent laryngeal nerve.

     

Complicated Giant Pilomatrixoma of the Parotid Region

Objective

Pilomatrixoma (calcifying epithelioma of Malherbe) is a benign soft tissue tumour arising from dermis or subcutaneous tissue which should be considered in differential diagnosis of preauricular lesions especially when skin fixation is present.

Case Report

Twenty-three year old male referred to our clinic with complaint of left preauricular swelling over 18 months which enlarged and became painful in the last 2 months. Because the lesion showed signs of infection, surgery was planned after medical therapy was completed. FNAB suggest pleomorphic adenoma as preliminary diagnosis. US or MRI showed no specific feature.

Treatment and Prognosis

Total excision, superficial parotidectomy with facial nerve sparing was performed after regression of infectious signs. Postoperatively no recurrence was detected.

Conclusion

Pilomatrixomas are benign tumours but have diagnostic difficulties according to clinical and cytologic findings. This rare lesion should be kept in mind to avoid misdiagnosis as malign parotid tumours, particularly in the presence of skin change.

     

Estimation of Serum Beta 2-Microglobulin Levels in Individuals Exposed to Carcinogens: Clinical Study in Indian Population

Aim

The aim of the study is to evaluate the prognostic value of β2-m as a biochemical parameter for the diagnosis and prognosis of oral squamous cell carcinoma (SCC).

Materials and Methods

The study included 60 patients (15 oral SCC, 15 leukoplakia, 15 individuals exposed to various carcinogens and without oral cancerous or precancerous lesions, 15 healthy individuals). The levels of β2-m were estimated using chemi-luminescent immunometric assay on Immulite fully automated machine. Statistical analysis of the data was done using Tuckey’s test, ANOVA and independent sample t test.

Results

Results showed that β2-m was increased in individuals exposed to carcinogens without precancerous and cancerous lesion.

Conclusion

Serum β2-m can be used as a better indicator and can give an early indication of malignant change and therefore malignancy can be detected at an early and treatable stage.

     

First case of bilateral coronoid hyperplasia in monozygotic twin sisters—a new aetiological perspective?

Background

Mandibular coronoid hyperplasia is a rare condition associated with gradual reduction in mouth opening. Its aetiology is unknown but increased temporalis activity, endocrine stimulus, trauma and familial causes have been proposed.

Case report

In this article, we present a case of bilateral coronoid hyperplasia presenting with limited mouth opening in 16-year-old Caucasian twin sisters.

Discussion

This report gives a new perspective to the aetiology of coronoid hyperplasia since it describes its occurrence in monozygotic twins and hence provides a strong argument in support of a genetic aetiology.

     

The Jugaad Technique for Jaw Reconstruction: Denture Based Inverse Planning

Aim

The aim of this clinical paper is to introduce a technique to plan for functional maxillofacial reconstructions.

Materials and Methods

Preoperative dental casts were made of the patient and mock surgery performed on the casts. A fibula analogue was then placed in an ideal functional reconstruction position. New dentures were fabricated on the fibula analogue and drill holes for the placement of implants were placed through the denture. This denture formed as a guide to position the fibula transplant during surgery.

Results

This technique was useful in producing functional and rehabilitative outcomes in cases of both maxillary and mandibular reconstructive surgeries.

Conclusion

The Jugaad technique—denture based inverse planning—is a cost effective method for planning and executing maxillofacial reconstructions using mock surgery on casts and interim dentures.

     

Solitary Fibrous Tumor of the Tongue: An Uncommon Cause of Obstructive Sleep Apnea

Introduction

Solitary fibrous tumor is an uncommon mesenchymal neoplasm that may be found in any location. To date, only a few cases of solitary fibrous tumor involving the tongue have been reported.

Case Summary

We present the case of a 31-year-old man with a history of progressively worsening snoring and daytime sleepiness. Polysomnography revealed severe obstructive sleep apnea. An attempt to treat sleep apnea by continuous positive airway pressure and oral appliance led to a poor clinical response. CT and MRI scans findings revealed a large mass in the tongue base partially obstructing the airway. After the excision of the mass all symptoms, included daytime somnolence, disappeared and a polysomnographic examination showed the normalization of the somnographic parameters.

Discussion

Although OSA is rarely caused by tumors, each patient with sleep disorders breathing should be examined carefully for the potential presence of an upper aero-digestive tract neoplasm that may contribute to obstruction.

     

A Self-Retaining Lingual Flap Guarding Device During Surgical Removal of Impacted Mandibular Third Molar

Introduction

Lingual nerve damage is one of the common complications following mandibular third molar surgery. On considering the impact of lingual nerve damage on the patient’s quality of life, it is necessary to exercise caution to minimize its occurrence.

Material and methods

Although many lingual retractors are available, in this article we describe an indigenously designed lingual retractor for use in mandibular third molar surgery.

Conclusion

The indigenous lingual retractor described in this article provides advantages like clear access and excellent retention unlike conventional retractors.

     

Abducens palsy after temporomandibular joint arthroscopy: a rare complication

Background

Arthroscopy of the temporomandibular joint (TMJ) is a minimally invasive and safe procedure; nevertheless, some accidents and complications have been described in the literature.

Case report

The purpose of this article is to describe a case report of a patient that progressed to paralysis of the abducens nerve after a TMJ arthroscopy procedure.

     

Cutaneous squamous cell carcinoma of the scalp in the immunocompromised patient: review of 53 cases

Objective

We analyzed outcomes from immunocompromised patients with scalp squamous cell carcinoma (SCC) treated with surgical excision with and without radiation in order to explore 3-year disease-free survival and overall survival.

Study design

The study design was a retrospective chart review.

Setting

This study was conducted in a private practice setting.

Subjects and methods

The study included 53 immunocompromised patients with an average age of 63.2 years, with scalp squamous cell carcinoma. Pre-operative imaging dictated the extent of resection. Patients with bony involvement received wide local excision including full-thickness craniectomy and cranioplasty. Patients without bony involvement underwent wide local excision and outer-table calvarial resection. All patients were recommended to have post-operative radiation. Patients were followed for a minimum of 3 years.

Results

A total of 53 patients were included in the study. Six patients had pre-operative CT showing bone involvement and were treated with full-thickness craniectomy along with post-operative radiation. Fourteen patients without bone involvement on pre-operative CT were found to have positive bone involvement on final pathology. Forty-five patients underwent post-operative radiation. Patients treated with adjuvant radiation demonstrated a 3-year survival of 80 % and the overall survival was 62 %. In the surgery-only group, the 3-year survival was 62.5 % and the overall survival was 32.5 %.

Conclusions

Immunocompromised patients with scalp SCC have a poor prognosis. Early detection and treatment are crucial. Based on our results, we recommend wide local excision with at least outer-table calvarial resection, and post-operative radiation. Despite aggressive therapy, patients may still have distant, local, or regional recurrence.Level of evidence: level 2b (retrospective cohort)

     

Bone and Skin-Supported Stereolithographic Surgical Guides for Cranio-Facial Implant Placement

Purpose

Osseointegrated skin-penetrating implants enhance the retention and stability of the craniofacial prostheses and provide the long-term comfort. However, to determine the implant locations is a great challenge facing the surgeon. Implants may either be located in conventional manner or by STL generated surgical guides.

Materials and Methods

Present study reports the CT based 3D virtual modeling, preoperative virtual planning and the implant placement by using a STL surgical guide, in an anotia case.

Results

Employed materials and the methods facilitated the implant surgery while improving the operational security.

Conclusions

CT based 3D virtual modeling of the surgical site, determining the implant locations virtually and the STL guided placement of the craniofacial implants, were found useful applications in order to facilitating the surgical intervention and providing prevention from complications.

     

Is conservative surgery a better choice for the solid/multicystic ameloblastoma than radical surgery regarding recurrence? A systematic review

Purpose

Determine if conservative surgery of primary solid/multicystic ameloblastoma (SMA) is capable of decreasing the recurrence rate as effectively as radical surgery.

Methods

We searched in MEDLINE, Web of Science, Scopus and Cochrane Library for original studies reporting on the conservative or radical treatment of primary SMA and the related recurrence rate. All selected data were independently assessed. Meta-analysis was performed and the Relative Risk (RR) of recurrence with a confidence interval of 95% was the effect measure. P value for the summary effect of <?0.05 was considered statistically significant.

Results

The 2647 records retrieved were reduced to 7 studies to be qualitatively assessed and 4 studies were included in the meta-analysis. RR of 1.88 [0.59, 5.95] of the pooled values pointed that recurrence rate after the conservative surgery is neither comparable nor lower than the radical surgery (P?=?0.28).

Conclusions

Conservative surgery does not reduce the recurrence rate as efficiently as radical surgery for primary SMA. However, there is not enough evidence to support this statement.

     

Treatment of medication-related osteonecrosis of the jaws (MRONJ) with ultrasonic piezoelectric bone surgery. A case series of 20 treated sites

Purpose

There is no consensus on how to successfully treat medication-related osteonecrosis of the jaws (MRONJ). We report here on the application of piezoelectric bone surgery to treat MRONJ in combination with antibiotherapy and on its possible benefit.

Materiel and methods

A cohort of 18 consecutive patients has been treated for MRONJ; they involved 20 sites, 15 in the mandible, and five in the maxilla. Surgical removal of the necrotic areas and debridement was performed with a powerful piezoelectric surgery device (max 90 W) in combination with antibiotherapy.

Results

All patients healed and obtained a complete soft tissue closure within 1 month. No recurrence of the symptoms was observed during the present follow-up (10–54 months).

Conclusion

We hypothesize that healing of all treated sites might have resulted from the synergic effect of bone ablation, biofilm alteration, and antibiotic administration. Biofilm alteration might have permitted a better access of antibiotics to the involved germs. These encouraging results warrant further studies on the use of ultrasonic surgery to treat MRONJ patients in order to confirm or refute the hypothesized effect.

     

Patterns and surgical significance of facial nerve branching within the parotid gland in 43 cases

Purpose

Different patterns of facial nerve branching within the parotid gland were detected, and these anatomical variations may affect the treatment approaches and outcomes of surgery. The aim of this study was to identify the patterns of facial nerve branching with the parotid gland and their importance in surgical procedures.

Materials and methods

A total of 43 patients undergoing surgical treatments of parotid lesions were included in this study. Each patient’s demographic data and type of operation were recorded. In addition, the courses of the facial nerve within the gland were classified into six types according to their branching patterns and communication.

Results

In all of the patients, the facial nerve consisted of one trunk separated into two divisions. Branching type III was the most common variety found (30.2 %) followed by type II (23.2 %), while type V represented the least frequent pattern (4.6 %).

Conclusion

It is essential for surgeons to become familiar with the different types of nerve morphologies in order to avoid morbidity and preserve the facial nerve during surgery. Variations and anastomosis can explain the different consequences of facial nerve injury that may occur after parotid surgery.

     

A Protocol for Management of the Hairs Problem in Oral Cavity Reconstruction by Submental Flap

Background

Submental flap is a useful aid in maxillofacial reconstruction. For intraoral usage the hairs in male patients will create some problems.

Materials and Methods

In a retrospective study, patients in whom submental flap had been used for reconstruction of orofacial region between 2007 and 2013, in the Mashhad University, Ghaem Hospital, were included. The ways in which the problem of hairs was solved in male patients were evaluated.

Results

There were 42 patients in whom submental flap was used for orofacial reconstruction. Sixty percent were males. Three ways had been used for management of intraoral hairs: radiotherapy (9 patients), second surgery (2 patients) and flap de-epithelialization (13 patients).

Conclusion

Deepithelialized variant of submental flap is the best option when submental flap is used for oral cavity reconstruction in male patients. Flap thickness, age, race and postoperative radiotherapy can have strong influence on this strategy.

     

The role of elective superficial parotidectomy in the treatment of temporal region squamous cell carcinoma

Objective

In order to determine rates of metastasis and efficacy of elective superficial parotidectomy, we examine parotid specimens in patients with temporal region cutaneous squamous cell carcinoma treated with local excision and ipsilateral parotidectomy.

Study design

This paper is a retrospective review.

Setting

This study was conducted at a private tertiary referral practice in Fort Worth, Texas, from 1998 to 2013.

Subjects and methods

Ninety-three patients between ages 27 and 98 with primary squamous cell carcinoma of the temporal region greater than or equal to 2 cm were included in this study. Subjects had no evidence of adenopathy or parotid involvement on exam or imaging. Patients were treated with local excision and ipsilateral parotidectomy. The primary tumor was studied for vascular involvement and perineural invasion while the parotid specimen was analyzed for occult cancer. Patients were post-operatively followed for a minimum of three years.

Results

Twenty-three (24.7 %) parotid samples were found to harbor occult malignancy. Of these, nine (39.1 %) patients had vascular involvement of the primary tumor and 14 (60.8 %) had perineural invasion. Thirteen out of 58 affected males and 10 out of 35 affected females were found to have intraparotid node positivity. Vascular involvement (p?=?0.0004) and perineural invasion (p?=?0.0001) in the primary malignancy were found to be greater in patients with positive specimen. Sex was not statistically significant.

Conclusions

In patients with cutaneous squamous cell carcinoma of the temporal region at least 2 cm in size, elective superficial parotidectomy may be a beneficial part of treatment, especially in primary tumors showing perineural and/or vascular involvement.

Level of evidence

Level 2b (retrospective cohort)

     

A literature review of perioperative antibiotic administration in surgery for medication-related osteonecrosis of the jaw

Purpose

Few studies exist that focus on the details of perioperative antibiotic administration for surgery to treat medication-related osteonecrosis of the jaw (MRONJ). The regime and duration of perioperative antibiotics applied in published studies were reviewed to clarify appropriate perioperative antibiotic use in MRONJ surgery.

Methods

A literature search was conducted using the MEDLINE database via PubMed.

Results

The search resulted in 453 hits on PubMed. After reading the downloaded full-text articles, 17 articles met the inclusion and exclusion criteria. The most common perioperative antibiotic used for MRONJ surgery was a combination of penicillin-based antibiotics and β-lactamase inhibitor (52.9%), and the second most common regime was penicillin-based antibiotics with metronidazole (17.6%). The duration of administration was 2 weeks postoperatively in nine studies, whereas four studies applied long-term administration (2–6 weeks postoperatively).

Conclusions

Oral and maxillofacial surgeons mostly prefer penicillin-based antibiotics plus β-lactamase inhibitor or metronidazole for MRONJ surgery. The duration of administration of these medications may be based on empirical experience.

     

Recent Advances in Face Lift to Achieve Facial Balance

Introduction

Facial balance is achieved by correction of facial proportions and the facial contour. Ageing affects this balance in addition to other factors. We have strived to inform all the recent advances in providing this balance.

Method

The anatomy of ageing including various changed in clinical features are described. The procedures are explained on the basis of the upper, middle and lower face.

Results

Different face lift, neck lift procedures with innovative techniques are demonstrated.

Conclusion

The aim is to provide an unoperated balanced facial proportion with zero complication.