Pharmacotherapy of spasticity in children with cerebral palsy

Spasticity is one of the most common symptoms presented by neurologic patients. Apart from surgical management, drug therapy is an important treatment of children suffering from spasticity. In this review, recent advances in the pharmacologic armamentarium are reported in detail. In particular, there are oral medications (benzodiazepines, baclofen, dantrolene sodium, alpha 2 adrenergic agonists) and parenteral medications (botulinum toxin type A and B, alcohol). Moreover, there is also baclofen that can be administered intrathecally. There are some reports supporting the use of intramuscular alcohol (45% and/or 5-7% phenol) to reduce spasticity without the loss of voluntary movement or loss of sensation. Among these drugs, intrathecal baclofen is one of the most effective substances that can reduce spasticity significantly in the upper and lower extremities. Finally, the effectiveness of therapy with botulinum toxin type A in the management of spasticity is analyzed. Botulinum toxin type A reduces hypertonia in the injected muscles for a period of 2 to 4 months without important side effects. The purpose of this article is to provide an overview of available oral and parenteral drugs for treatment of spasticity in cerebral palsy and to outline indications and contraindications.     

Mini-invasive lateral oropharyngectomy for T3–T4a oropharyngeal cancer

Mandibular swing is the approach of choice for resection of advanced oropharyngeal carcinomas without bone involvement. This approach requires a mandibulotomy, which is associated with complications. A prospective outcome analysis was performed for 21 patients operated without mandibulotomy for T3–T4a oropharyngeal carcinoma. Tumour size was categorized as T3 in 14 patients (66.7 %) and as T4a (33.3 %) in 7 patients. Twelve patients were N0 (57.1 %), 2 (9.5 %) were N1, and 7 (33.3 %) were N2. Surgical margins were negative in 18 cases (85.7 %), positive in 1 (4.8 %), and close in 2 (9.5 %). Average hospital stay was 14.5 days (range 10–22). Adjuvant treatment (radiotherapy or concurrent chemoradiotherapy) was administered to all but three patients previously irradiated. In all cases radiotherapy started within 42 days of surgery. The 3-year overall survival was 85.7 %, and relapse-free survival was 71.4 %. Oropharyngectomy without mandibulotomy has the same indications as mandibular swing. It provides good access to achieve satisfactory clearance of tumours, sparing patients the morbidity associated with mandibulotomy.     

Surgical techniques in the treatment of pleomorphic adenoma of the parotid gland: our experience and review of literature.

This paper presents a retrospective study carried out on a sample of 100 patients affected by pleomorphic adenoma of the parotid gland and treated at the Department of Maxillofacial Surgery at the University of Rome "La Sapienza" between January 1, 1989 and December 31, 1997. For the diagnosis of this neoformation, cytological tests were performed on material taken from the neoformation using fine needle aspiration and ultrasound scan. In some selected cases, a CT examination of the head and neck with medium contrast or Nuclear Magnetic Resonance (NMR) was carried out. This study sets out to examine the most suitable treatment to be followed for the removal of the pleomorphic adenoma of the parotid gland. In 56 cases the patients underwent a superficial, conservative parotidectomy. Forty one patients had a total parotidectomy with the facial nerve left intact and one patient had a total parotidectomy where the marginal mandibular nerve of the facial nerve was damaged. The remaining two patients involved in the study were suffering from a recurrent pleomorphic adenoma and in these two cases a total parotidectomy was performed where the facial nerve was killed. The removal of the cranial nerve VII in these patients proved necessary because the nerve fibers had adhered to the surrounding scar tissue of the tumor, either after previous surgery or due to repeated chronic phlogosis of the gland.     

Cyclopia: a radiological and anatomical craniofacial post mortem study

Cyclopia is a rare foetal malformation characterized by a single palpebral fissure and a proboscis associated with severe brain malformation. Approximately 1.05 in 100 000 births including stillbirths are identified as cyclopian. Cyclopia is not compatible with life. The authors present an anatomical and histological study of the fronto-orbito-maxillary region carried out after 3-D CT reconstruction in a 21 week-old foetus with cyclopia. Anatomical and histological observations suggest that the integrity of the trigeminal nerves is very important for the normal development of the embryological structures of the face. Fusion of the facial processes in the midline takes place even if central prosencephalic structures are absent. For this reason the face in cyclopia, in both its positive and negative aspects, constitutes a model for the study of the normal development of this region. Copyright 2001 European Association for Cranio-Maxillofacial Surgery.     

Ethmoido-orbital tumors: our experience

No data in the literature report the specific invasion of the orbit from ethmoidal tumors, although such a pattern of involvement of the orbit frequently occurs because of the thin lamina papyracea separating the two structures. From January 1986 to January 2003, 38 patients with untreated primary ethmoidal malignancies were observed at the Unit of Maxillo-Facial Surgery of the University "La Sapienza" in Rome. Personal data were obtained from review of the personal clinical file of each. Orbital invasion was present in 24 patients with ethmoidal malignancy. Three stages of orbital invasion were identified. The average overall survival, with the Kaplan-Meyer method, was 61.4% after 1 year and 51.1% at 5 and 10 years. Intracranial involvement is the main element for short-term negative prognosis. Orbital exenteration is fundamental if grade III orbital invasion occurs because it ensures an improvement of the disease-free survival.     

Aetiological factors for oral manifestations of HIV

OBJECTIVES: Describe the oral diseases in HIV-infected individuals in London, UK and identify social and medical factors related to the presence of specific oral diseases.
DESIGN: Cross-sectional analytic study.
SETTING: Dental clinics.
SUBJECTS: Consecutive sample of 456 patients with HIV infection.
METHODS: Social and medical history and clinical examinations. Univariate and logistic regression analysis.
OUTCOMES: Presence of HIV-associated oral disease.
RESULTS: 80% of patients with AIDS and 50% of patients with HIV had a specific oral disease. The most common diseases were hairy leukoplakia (30%), erythematous candidiasis (24%), pseudomembranous candidiasis (14%), angular chielitis (6%), necrotising periodontal disease (8%) and non-recurrent ulceration (6%).
CONCLUSIONS: The presence of erythematous candidiasis was not related to advanced HIV disease. Pseudomembranous candidiasis, hairy leukoplakia and mucosal ulceration were significantly associated with advanced HIV disease. Smoking was also identified as a strong aetiological factor in oral diseases. Longitudinal studies are required to further explore the prognostic significance of oral diseases in HIV infection.     

Combined surgical therapy of temporomandibular joint ankylosis and secondary deformity using intraoral distraction

Temporomandibular joint (TMJ) ankylosis is a pathological process caused by damage of the mandibular condyle. When this event takes place in subjects during the developmental age, it results in an alteration of the entire maxillofacial complex. Therefore, surgical methods able to remove the temporomandibular ankylosis also include necessary operations to correct the secondary maxillofacial deformity. The distraction osteogenesis has induced our center to modify the surgical protocol for the therapy of patients who have developed TMJ ankylosis and secondary maxillomandibular deformity. We have treated four patients with monolateral ankylosis of the TMJ and serious deformities of the maxillomandibular complex secondary to functional limitation. During the same operation, arthroplasty was performed with the removal of the ankylotic block and the interposition of a temporal muscle flap in the new articular space; an intraoral osteodistractor was also positioned to lengthen the mandible. All patients showed recovery of the eurhythmy of the face and good re-establishment of the symmetry. An average 12-month follow-up showed the average opening of the mouth to be at least 35 mm. The combination of TMJ arthroplasty and intraoral osteodistraction provides good functional and aesthetic results in patients affected by ankylosis who have developed secondary maxillofacial deformities.