Increased local recurrence in advanced parotid malignancy treated with mastoidectomy without lateral temporal bone resection

Objective

We analyzed patients with advanced parotid malignancy requiring proximal facial nerve exposure undergoing mastoidectomy versus lateral temporal bone resection to determine differences in local and distant recurrence.

Study design

The study design is a case series with chart review.

Setting

The setting is in Tertiary care practice in Fort Worth, Texas from January1998 to January 2014.

Subjects and methods

The study included 120 patients with advanced parotid malignancy, 82 males between 19 and 87 years, and 38 females between 26 and 83 years. Patients with no overt bone involvement were treated with parotidectomy and mastoidectomy for exposure of the proximal facial nerve, and patients with clinically suspected (radiographic imaging or clinical fixation) bone involvement were treated with parotidectomy and lateral temporal bone resection. Follow up ranged from a minimum of 18 months to 11 years following surgery.

Results

Sixty patients were treated with mastoidectomy and 60 were treated with lateral temporal bone resection. In patients treated with mastoidectomy, 13 had local recurrence and 7 had distal recurrence. In patients treated with lateral temporal bone resection, 2 had local recurrence while 9 had distant recurrence. Statistical analysis revealed that patients treated with mastoidectomy developed local recurrence (p = 0.0022) more commonly than those treated with lateral temporal bone resection. There was no significant difference in distant recurrence between both groups (p = 0.5949).

Conclusions

Patients with advanced parotid malignancy should be treated aggressively with parotidectomy and lateral temporal bone resection regardless of bone involvement due to increased risk of local recurrence in those treated with mastoidectomy alone.

Level of evidence

Level of evidence is a 4 case series.

     

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.

     

Anatomical relation between nasal septum deviation and oropharynx volume in different facial patterns evaluated through cone beam computed tomography

Introduction

The objective of this study was to establish the anatomical relation between nasal septum deviation (NSD) and oropharynx volume in different facial patterns using cone beam computed tomography (CBCT).

Methods

Ninety CBCT examinations were analyzed. InVivoDental software was used to evaluate cephalometric image reconstructions in terms of facial type, determined from cephalometric measurements indicative of growth direction; the presence of NSD was also evaluated. ITK-SNAP software was employed for delimitation of the oropharynx. Intra-examiner error methods were recorded. The results were subjected to parametric and non-parametric tests using Bioestat 5.0.

Results

A comparison of facial types revealed a significantly lower prevalence of NSD in the dolichofacial group compared with the brachyfacial and mesofacial groups (P = 0.0101 and 0.0149, respectively). In the total sample, there was a very strong positive relation between the presence of NSD and oropharynx space volume (P = 0.0162). The oropharynx volume was larger in all facial patterns in the presence of NSD.

Conclusion

The presence of NSD was not associated with facial type, although the oropharynx volume in patients with NSD increased. Therefore, deviation of the septum influences oropharynx volume.

     

An intra-oral approach to facial skin lumps—a move towards scarless surgery

Introduction

The aim of surgical management of benign facial skin lumps is to remove the lesion in its entirety, with minimal damage to adjacent tissue structures, while maintaining facial aesthetics. A method to achieve these goals is to remove peri-oral lesions in the labial and buccal zones via an intra-oral approach. We report an extended cases series of facial skin lumps that were excised using an intra-oral approach.

Methods

A retrospective analysis was performed on all patients who underwent excisions of benign cutaneous lesions on the face via an intra-oral approach. Patient demographics, indication for surgery and complications were noted.

Results

Forty-seven lesions were excised over a 15-year period. Indications for surgery included benign lesion with minimal skin involvement, risks of keloid/scar hypertrophy and cosmetic factors. Lesions were predominantly epidermoid cysts and lipomas. Mean follow-up was 2.9 years with a 6.4% recurrence rate and 2.1% rate of haematoma and transient facial nerve weakness.

Discussion

There are established techniques to remove facial skin lumps. We believe that in selected cases, an intra-oral approach to such lesions, particularly in cases with high risk of scar pathology or where there is strong patient preference, may be an important tool in the oral and maxillofacial surgeon’s armamentarium.

     

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.

     

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.

     

Facial fractures caused by less-lethal rubber bullet weapons: case series report and literature review

Purpose

The present study aims to describe three cases of patients inflicted by rubber bullets with severe facial fractures.

Methods

In addition, a review of English-language literature involving facial fractures by rubber bullets from 1975 to 2016 was performed.

Results

This current study demonstrated that the use of the LLRBW is unsafety even when applied by police enforcements exclusively.

Conclusions

Management of facial fractures caused by LLRBW is done in a usual manner with closed or open reduction associated with bone mini-plates or reconstruction plates when indicated. Special initial wound care should be done to avoid secondary infection and additional procedures.

     

Behavior of C-reactive protein in association with surgery of facial fracture and the influence of dexamethasone

Purpose

To clarify pre- and postoperative C-reactive protein (CRP) levels in patients with facial fractures and to investigate the influence of perioperatively administered dexamethasone on postoperative CRP levels.

Patients and methods

Facial fracture patients were randomized to receive perioperatively a total dose of 30 mg of dexamethasone (Oradexon®), whereas patients in the control group received no glucocorticoid. The analysis included patients who had CRP measured pre- and postoperatively.

Results

A total of 73 adult patients with facial fractures were included in the final analysis. Mean CRP level was elevated preoperatively and the level increased further after surgery. However, postoperative CRP rise was significantly impeded by dexamethasone (p?<?0.001), regardless of gender, age, treatment delay, site of fracture, surgical approach, and duration of surgery. CRP rise halved on the 1st postoperative day when dexamethasone was used. In addition, dexamethasone resulted in a CRP decrease on the 2nd postoperative day, whereas the CRP rise continued in the control group.

Conclusions

CRP rise is a normal body response after facial fracture and surgery that can be markedly reduced with dexamethasone. CRP changes should be considered with caution if perioperative dexamethasone is used.

     

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)

     

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.

     

Extracranial Trigeminal Schwannomas: A Retrospective Analysis

Objective

To analyse the clinic-radiological features and treatment outcome of extracranial trigeminal schwannomas.

Method

Medical records and radiographs of patients treated, from January 2011 to December 2013, for neurogenic tumors were retrospectively reviewed. Extracranial schwannomas other than those of trigeminal nerve were also excluded. A number of parameters, including the patient’s age, gender, site, clinical features, radiographic features, histologic variants and treatment provided as well as any associated complications were recorded and analysed.

Result

A total of 5 patients met the inclusion criteria. The patients were males, aged 16–56 years. All the schwannomas appear to originate from the terminal branches of trigeminal nerve.

Conclusion

Long standing asymptomatic swelling of cheek should include trigeminal schwannomas as the differential diagnosis. The diagnosis though confirmed by the histologic examination but can also be made on the basis of MRI finding. Neural function can be preserved by meticulous surgery.

     

Bilateral Parotid Sialadenosis Associated with Long-Standing Bulimia: A Case Report and Literature Review

Purpose

Bulimia is a common cause of sialadenosis. This paper presents a case of bilateral parotid sialadenosis associated with long-standing bulimia, and reviews the relevant literature and current treatment options.

Methods and Results

A 32-year-old woman had severe bilateral parotid sialomegaly for the last 6 years, which had occurred secondary to bulimia nervosa, which she had since 14 years. Treatment with pilocarpine was unsuccessful, so she underwent bilateral conservative parotidectomy. This procedure not only improved the aesthetic appearance of the patient but also improved her social and work life and overall quality of life.

Conclusions

Sialomegaly secondary to bulimia results in a major alteration of the aesthetics of a patient’s face. Conservative measures are not enough in many cases, and parotidectomy may be the only viable option, as it can also significantly improve adherence to psychiatric treatment for bulimia, in addition to correcting the facial aesthetics.

     

Sialoendoscopy as a diagnostic and therapeutic option for obstructive diseases of the large salivary glands—a retrospective analysis

Objectives

The diagnosis and therapy of obstructive inflammatory disorders of the salivary glands have changed in the past decades following the introduction of sialoendoscopy. The aims of the present study were to analyze the relevance of sialoendoscopy using our own data and to compare the results to those of other studies.

Patients and methods

A retrospective analysis of 70 patients was performed, who were treated for obstructive disorders of the parotid and/or submandibular gland in whom sialoendoscopy was indicated. Two categories of interventions were considered: diagnostic interventional sialoendoscopy and endoscope-assisted interventions. Interventional sialoendoscopy procedures requiring extirpation of the gland were included in the analysis, as were abnormal intraductal processes that were detected during endoscopy.

Results

Treatment was successful in 58 of 67 (86.6 %) procedures (sialoendoscopy without surgical intervention n?=?59; endoscope-assisted surgical intervention n?=?8). Based on the underlying disease, the success rate was 88.6 % (n?=?39) in patients with obstructive sialadenitis without sialolithiasis and 86.6 % (n?=?19) in patients with sialolithiasis. It was not possible to draw definitive conclusions on the underlying disease from the observed pathological intraductal changes.

Conclusions

Sialoendoscopy is an effective and safe diagnostic and therapeutic option with low complication rate. However, limiting factors such as the size or the position of potentially removable obstacles must be taken into consideration.

Clinical relevance

The rate of gland extirpations can be reduced using sialoendoscopy.

     

Presto lift—a facelift that preserves the retaining ligaments and SMAS tethering

Background

Producing youthful facial appearance by face-lifting often comes along with an undesired loss of patient’s individual phenotype. This may result from insufficient preservation of retaining ligaments, the “guardians of facial identify,” and from severance of the intersegmental connections of the superficial musculo-aponeurotic system (SMAS), which tether, structure, and compartmentalize facial soft tissue into defined, relevant anatomical zones.

Methods

The technique reported here preserves most retaining ligaments. They serve to fix the facial soft tissue mass in loco. With the possible exception of the zygomatic-cutaneous ligament, they are only carefully distended. The SMAS intersegmental connections and the zygomatic SMAS border are preserved to retain effective points of facial tissue fixture. Aging-associated thinning and lengthening of the lower eyelid are reduced by midfacial-submalar preparation (Aston 1996). Subplatysmal preparation and disconnection of the cranial-platysmal border permits optimal modeling of neck structure.

Results

The combination of preservation of retaining ligaments and SMAS tethering (“PRESTO facelift”) introduced here as a novel face-lifting technique conserves the individual esthetics of the patient by approaching her/his individual phenotype from decades ago. In addition, undesired outcomes of facelift surgery and common risks of facelift surgery are circumvented.

Conclusions

The PRESTO facelift technique generates optimal esthetic results that conserve a patient’s personal facial identity, besides restoring a more youthful appearance and being rapid and safe.

     

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.

     

Complications after orthognathic surgery: our experience on 423 cases

Introduction

Orthognathic surgery is widely used to correct dentofacial discrepancies. However, this procedure presents numerous possible complications. The aim of our study is to review intraoperative and postoperative complications related to orthognathic surgery based upon a 10-year period in the Maxillofacial Surgery Department of Federico II University of Naples.

Materials and methods

Medical records of 423 patients who undergone orthognathic surgery in a 10-year period were retrospectively analyzed and complications was noted. Statistical analysis was conduced in order to understand if the type of surgical procedure influenced complications rate.

Results

One hundred eighty-five complications in 143 (33.8%) of the 423 treated patients were reported. Complications detected were nerve injury (49 cases, 11.9%), infections (10 cases, 2.4%), complications related to fixation plates or screws (30 cases, 7.1%), bad split osteotomy (8 cases, 1.9%), secondary temporo-mandibular joint disorders (36 cases, 8.5%), dental injuries (21 cases, 5%), condilar resorption (2 cases, 0.5%), and necessity of a second-time surgery (24 cases, 5.7%).

Conclusions

Serious complications seem to be quite rare in orthognathic surgery. Some of the surgical complications found are related to the surgeon experience and not strictly to the risks of the operation itself. Understanding potential complications allows the surgeon to guarantee safe care through early intervention and correctly inform the patient in the preoperative colloquy.

     

Massive internal jugular vein tumor thrombus derived from squamous cell carcinoma of the head and neck: two case reports

Purpose

Tumor thrombosis of the internal jugular vein (IJV) is an extremely rare disease, and the reported cases have been exclusively associated with differentiated thyroid cancer. In the present study, we describe two cases of IJV tumor thrombosis originated from squamous cell carcinoma (SCC), which is the first case report.

Methods

Case 1 was a 67-year-old man diagnosed with advanced supraglottic SCC with a massive tumor thrombus in the IJV. He was treated with bio-radiotherapy followed by radical surgery. Case 2 was a 65-year-old woman who underwent radical surgery for SCC of thyroid with tumor thrombosis in the IJV.

Results

These cases rapidly developed local recurrences and distant metastases and died within 10 months after surgery.

Conclusions

IJV tumor thrombosis originated from SCC apparently reflects extremely aggressive state of the tumor. Recognition and precaution to this condition is essential for the development of a clinically effective treatment strategy.

     

A preliminary study on plasma concentration achieved following intrapterygomandibular space injection of dexamethasone as a route of drug delivery with lignocaine inferior alveolar nerve block–correlation of clinical effects

Purpose

To determine the quantity of dexamethasone plasma concentration achieved following intrapterygomandibular space injection of dexamethasone when co-administered with inferior alveolar nerve block correlating with the clinical effects in the postoperative phase.

Objective

A preliminary prospective study to evaluate the dexamethasone plasma concentration achieved following intrapterygomandibular space injection of dexamethasone with 2% lignocaine inferior alveolar nerve block to achieve hemi-mandibular anesthesia for minor oral surgical procedures and derive clinical correlations.

Background

Dexamethasone is a glucocorticoid, chiefly used for the management of postsurgical sequelae like trismus and swelling in maxillofacial surgical practice. Conventionally, parenteral dexamethasone is administered via intravenous or intramuscular route. Intrapterygomandibular space injection is a novel route of steroid delivery described in literature. For minor oral surgical procedures in maxillofacial surgical practice requiring inferior alveolar nerve block, dexamethasone can be administered along with local anesthetic through a single injection as a mixture (twin mix).

Methods

Prospective double-blind randomized clinical trial was designed to evaluative plasma concentration of dexamethasone achieved following injection of a freshly prepared mixture of 1.8 ml of 2% lignocaine with adrenaline (1:200000) and 1 ml (4 mg) dexamethasone [2.8 ml solution of twin mix] in the pterygomandibular space. The 30 candidates included for the trial were randomly split into three study groups (ten each)—(1) control group (C); (2) intramuscular group (IM); (3) intraspace group (IS).

Results

The mean plasma dexamethasone concentration at 30 min postinjection in group IM was 226.41?±?48.67 ng/ml and for IS group it was 209.67?±?88.13 ng/ml. Post hoc (Bonferroni-Holm test) intergroup comparison for plasma dexamethasone concentration (IM and IS) was found statistically insignificant (P?=?0.605).

Conclusion

Intraspace route of drug administration can be utilized to deliver dexamethasonized local anesthetics safely with predictable clinical effects in the patients requiring mandibular minor oral surgery under local anesthesia.

     

Incidence and patterns of maxillofacial trauma—a retrospective analysis of 3611 patients—an update

Background

Maxillofacial fractures occur in a significant proportion worldwide and can occur as an isolated injury or in combination with other severe injuries including cranial, spinal, and upper and lower body injuries requiring prompt diagnosis with possible emergency interventions. The epidemiology of facial fractures varies with regard to injury type, severity, and cause and depends on the population studied. Hence, understanding of these factors can aid in establishing clinical and research priorities for effective treatment and prevention of these injuries.

Materials and methods

In this present retrospective study, we provide a comprehensive overview regarding cranio-maxillofacial trauma on 3611 patients to assist the clinician in assessment and management of this unique highly specialized area of traumatology. A preformed pro forma was used to analyze the medical records of patients treated for facial trauma in The Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College and Hospital, Chennai. The distribution according to age, gender, etiology, type of injury, time interval between accident and treatment, loss of consciousness, facial bones involved, pattern of fracture lines, treatment offered, and postoperative complications were recorded and evaluated.

Results

We inferred male patients sustained more injuries mostly in the third decade of age. Road traffic accidents were the most common cause of injury. Mandible was the most commonly fractured bone in the facial skeleton. Soft tissue injuries occurred more in road traffic accidents and upper lip was the commonest site of injury.

Conclusion

Our study provides insights into the epidemiology of facial injuries and associated factors and can be useful not only in developing prevention strategies but also for grading the existing legal regulations and also for framing a more effective treatment protocol.

     

Trigemino-Cardiac Reflex: A Phenomenon Neglected in Maxillofacial Surgery?

Background

Trigemino-cardiac reflex is a physiologic response of the body to pressure effects in the region of distribution of the trigeminal nerve. Oral and maxillofacial surgical procedures can induce the development of this reflex, which leads to significant changes in the heart rate and sinus rhythms. This study intends to evaluate the effects of this reflex in patients with facial fractures and its subsequent management.

Patients and Methods

A total of thirty-seven patients with facial fractures who reported to the Department of Oral and Maxillofacial Surgery at Basaveswar Teaching and General Hospital, Gulbarga during a period from July 2015–March 2016 were considered for the study.

Results

A male preponderance is observed with the most susceptible age group being 21–30 years. Twenty-three patients sustained mid-facial fractures alone, nine patients had isolated mandible fractures and five patients had fractures of both the mid-face and mandible. A relative bradycardia was observed in the patients with mid-facial trauma, both at the time of presentation and also during the surgical reduction of midfacial fractures which improved after completion of procedure in most of the patients. However, in two patients, the bradycardia progressed to a cardiac asystole during midface manipulation which required immediate halt of the procedure and intravenous administration of atropine.

Conclusion

Trigeminocardiac reflex though physiologic, which usually tends to subside without complications is not to be neglected in the surgeries of the maxillofacial skeleton. A propensity for unforeseen complications due to this reflex has to be avoided by meticulous monitoring of the ECG.