Sentinel Lymph Node Biopsy in Early Stages of Oral Squamous Cell Carcinoma Using the Receptor-Targeted Radiotracer 99mTc-Tilmanocept.

Neck management in patients with early-stage, clinically node-negative oral squamous cell carcinoma (OSCC) remains a matter of discussion. Sentinel lymph node biopsy (SLNB) represents a treatment alternative to avoid elective neck dissection (END) in this cohort and different protocols and tracers exist. Here we present the clinical outcome of SLNB using 99mTc-tilmanocept in a two-day protocol in patients suffering from early-stage OSCC. A total of 13 patients (males: 6; females: 7; mean age: 65.7 years, ranging from 47 to 89 years) were included in this study. Most of the patients suffered from an OSCC of the floor of mouth (n = 6), followed by tongue (n = 5) and upper alveolar crest/hard palate (n = 2). Sentinel lymph nodes (SLNs) were successfully identified in all cases (range: 1-7). The average length of hospital stay was 4.7 days (range: 3-8 days) and mean duration of surgical intervention was 121 min (range: 74-233 min). One patient who suffered from an OSCC of the tongue was sentinel lymph node positive (SLN+). The mean follow-up for all sentinel lymph node negative (SLN-) patients (n = 12) was 20.3 months (range: 10-28 months). No local or nodal recurrences were observed within the observation period. In our patient cohort, SLNB using 99mTc-tilmanocept in a two-day protocol proved to be a reliable and safe staging method for patients suffering from early-stage, clinically node-negative OSCC. These results and their possible superiority to colloid tracers have to be confirmed in a prospective randomized controlled study.

Imaging foreign bodies in head and neck trauma: a pictorial review.

Open injuries bear the risk of foreign body contamination. Commonly encountered materials include gravel debris, glass fragments, wooden splinters or metal particles. While foreign body incorporation is obvious in some injury patterns, other injuries may not display hints of being contaminated with foreign body materials. Foreign objects that have not been detected and removed bear the risk of leading to severe wound infections and chronic wound healing disorders. Besides these severe health issues, medicolegal consequences should be considered. While an accurate clinical examination is the first step for the detection of foreign body materials, choosing the appropriate radiological imaging is decisive for the detection or non-detection of the foreign material. Especially in cases of impaired wound healing over time, the existence of an undetected foreign object needs to be considered.Here, we would like to give a practical radiological guide for the assessment of foreign objects in head and neck injuries by a special selection of patients with different injury patterns and various foreign body materials with regard to the present literature.

Detectability of foreign body materials using X-ray, computed tomography and magnetic resonance imaging: A phantom study.

PURPOSE: To evaluate the effectiveness of plain radiography (X-ray. XR), computed tomography (CT) and magnetic resonance imaging (MR) in visualising commonly seen foreign bodies. A special focus was put on objects relevant to head and neck surgery. METHOD: Thirty-four commonly encountered objects of different compositions including wood, plastic, and glass were embedded in a gelatin gel phantom and imaged using XR, CT and MR. The success rates of radiologists in detecting and correctly identifying the foreign objects were evaluated. Subjective visibility was rated on a 4-point Likert scale. Objective visibility was analysed using region of interest-based contrast for CT. RESULTS: Sensitivity in foreign bodies detection was highest in MR (97.1 %) followed by CT (86.0 %) and x-ray (61.8 %). Success rates for the correct identification of the objects and material types were highest in MR (33.3 % and 39.2 %, respectively) followed by CT (25.5 % for both) and XR (16.7 % and 15.7 %). Overall, subjective visibility was rated higher in CT and MR imaging ("good visibility"), as compared to XR ("poor visibility"). Interreader agreement was high across modalities (Kendall's W = 0.935, 0.834 and 0.794 for XR, MR and CT, respectively). CONCLUSIONS: Detection and identification of non-ferromagnetic objects was most successful in MR followed by CT imaging in this experimental setup.

Incidence and survival of HNSCC patients living with HIV compared with HIV-negative HNSCC patients.

PURPOSE: The aim was to analyze the incidence and survival of patients living with HIV (PLWH) with head and neck squamous cell carcinoma (HNSCC) and to compare with a control group of HIV-negative HNSCC patients. METHODS: Clinicopathological data and predictors for overall survival (OS) and disease-free survival (DFS) were investigated (2009-2019). RESULTS: 50 of 5151 HNSCC patients (0.97%) were PLWH, and 76% were smokers. Age ≤ 60 years, HIV-PCR ≤ 50 copies, CD4 cells ≤ 200/mm3, cART treatment, T and UICC classification, oral cavity and nasal/paranasal sinuses, and therapy were significantly associated with OS in univariate analysis. In the multivariate analysis, only age and HIV-PCR independently predicted OS. The OS of the 50 PLWH was not significantly altered compared with the 5101 HIV-negative controls. However, OS and DFS were significantly inferior in advanced tumor stages of PLWH compared with an age-matched control group of 150 HIV-negative patients. CONCLUSIONS: PLWH were diagnosed with HNSCC at a significantly younger age compared to HIV-negative patients. Taking into account patient age at initial diagnosis, both OS and DFS rates in PLWH are significantly worse compared with a matched control group of HIV-negative patients in advanced tumor stages UICC III/IV. The prognosis (OS) is improved when taking cART treatment, the HIV viral load is undetectable and CD4 count is high.

Submillisievert chest CT in patients with COVID-19 - experiences of a German Level-I center.

PURPOSE: Computed tomography (CT) is used for initial diagnosis and therapy monitoring of patients with coronavirus disease 2019 (COVID-19). As patients of all ages are affected, radiation dose is a concern. While follow-up CT examinations lead to high cumulative radiation doses, the ALARA principle states that the applied dose should be as low as possible while maintaining adequate image quality. The aim of this study was to evaluate parameter settings for two commonly used CT scanners to ensure sufficient image quality/diagnostic confidence at a submillisievert dose. MATERIALS AND METHODS: We retrospectively analyzed 36 proven COVID-19 cases examined on two different scanners. Image quality was evaluated objectively as signal-to-noise ratio (SNR)/contrast-to-noise ratio (CNR) measurement and subjectively by two experienced, independent readers using 3-point Likert scales. CT dose index volume (CTDIvol) and dose-length product (DLP) were extracted from dose reports, and effective dose was calculated. RESULTS: With the tested parameter settings we achieved effective doses below 1 mSv (median 0.5 mSv, IQR: 0.2 mSv, range: 0.3-0.9 mSv) in all 36 patients. Thirty-four patients had typical COVID-19 findings. Both readers were confident regarding the typical COVID-19 CT-characteristics in all cases (3 ± 0). Objective image quality parameters were: SNRnormal lung: 17.0 ± 5.9, CNRGGO/normal lung: 7.5 ± 5.0, and CNRconsolidation/normal lung: 15.3 ± 6.1. CONCLUSION: With the tested parameters, we achieved applied doses in the submillisievert range, on two different CT scanners without sacrificing diagnostic confidence regarding COVID-19 findings.

Presentation of cervical metastases and pathological mandibular fracture due to pulmonal adenocarcinoma: A case report.

INTRODUCTION: Oral metastatic tumors due to malignancies at distant locations are very rare. There are only few cases in the literature reporting about mandible/cervical metastases. Sometimes the oral finding is the manifestation of the disease. PRESENTATION OF CASE: We report on a 50-year-old patient who was diagnosed with a pathological mandibular fracture and cervical lymph node metastases due to an adenocarcinoma of the lung without other peripheral metastases. Following the interdisciplinary tumor board decision, resection and ipsilateral neck dissection including a mandible reconstruction using a microvascular fibula transplant was performed. The patient received an adjuvant chemotherapy with carboplatin/pemetrexed. DISCUSSION: The combination of cervical metastases and a pathological mandibular fracture has not been reported before. Distinction between oligometastatic and polymetastatic disease may be difficult. Bone lesions and a high number of metastases are associated with a negative outcome. In cases of limited oligometastatic diseases, metastasectomy might sometimes be indicated. Due to the absence of other peripheral metastases decision of metastasectomy was made. CONCLUSION: Due to rare occurrence of cervical metastases special attention should be paid to the incidence of possible metastases of distant malignancies at uncommon regions.

Advantages of a T1-Weighted Gradient-Recalled Echo (GRE) Sequence With a Radial 3D Sampling Approach Versus 2D Turbo Spin-Echo and Cartesian 3D GRE Sequences in Head and Neck MRI.

OBJECTIVE. The purpose of this study is to compare the image quality, including artifacts, of a T1-weighted gradient-recalled echo (GRE) MRI sequence with a radial sampling approach to that of both 2D turbo spin-echo (TSE) and cartesian 3D GRE MRI sequences performed in the head and neck region. MATERIALS AND METHODS. The retrospective study included 26 datasets of patients who underwent MRI examination for inflammatory or neoplastic diseases of the head and neck region performed using a 1.5-T system. All examination protocols comprised three fat-saturated T1-weighted sequences performed in the axial plane after contrast agent administration. Axial FOV and spatial resolution in plane and along the z-axis were recorded. Sequences were evaluated independently by two readers for qualitative and quantitative parameters, including homogeneity of fat saturation and discrimination of pharyngeal wall structures. Qualitative parameters were evaluated using a 5-point Likert scale. RESULTS. For comparison, mean values of Likert scale scores were generated from the two readers' data. Fat saturation was significantly better on the radial GRE sequences (1.942) than on the TSE (2.346; p = 0.002) and cartesian GRE (2.365; p = 0.008) sequences. The overall impact of foreign material artifacts was comparable among sequences (radial GRE, 1.731; TSE, 1.731 [p = 1.000]; cartesian GRE, 1.769 [p = 0.414]); however, on direct comparison, the mean area that was not evaluable because of susceptibility was smaller on radial GRE sequences (53.8 mm) than on TSE sequences (59.8 mm; p = 0.062) and cartesian GRE sequences (59.6 mm; p = 0.079). Overall image quality was 1.635 with the use of radial GRE, 2.423 with TSE (p = 0.000), and 2.500 with cartesian GRE (p = 0.000). CONCLUSION. For imaging of the head and neck region, radial GRE has several advantages, including improved fat saturation and reduced extent of susceptibility artifacts, compared with TSE and cartesian GRE, leading to improved overall image quality.

Primary oral manifestation of Langerhans cell histiocytosis refractory to conventional therapy but susceptible to BRAF-specific treatment: a case report and review of the literature.

Langerhans cell histiocytosis (LCH) is a diagnostic and therapeutic challenge. We report on a rare case of its primary oral manifestation that was treated successfully with the BRAF-specific agent, vemurafenib, after insufficient standard LCH treatment. This case underlines the importance of proper diagnosis and the evaluation of targeted therapy as a valuable tool in LCH treatment. Furthermore, the close collaboration of surgeons, oncologists, and dentists is mandatory to ensure adequate treatment, restore the stomatognathic system in debilitating post-treatment situations, improve quality of life, and ensure effective disease control in infants and young patients.

[Frequency and management of complex facial fractures-an oral and maxillofacial surgical assessment]. / Häufigkeit und Management von Gesichtsschädelfrakturen ­ eine MKG-chirurgische Einschätzung.

INTRODUCTION: The treatment of facial fractures is an integral part of the oral and maxillofacial surgical treatment spectrum. In the case of complex fractures that involve multiple levels of the facial skeleton associated with severe concomitant injuries, an individual and interdisciplinary treatment approach is needed, which requires the infrastructure of a national trauma center. OBJECTIVE: The aim of this study was to analyze the incidence and management of patients with complex facial fractures and considering the concomitant injury pattern. MATERIAL AND METHODS: A retrospective analysis of patients with complex facial fractures during the years 2009-2015 admitted to the emergency surgical department of a national trauma center was carried out. The identification of appropriate patient cases was based on the International Statistical Classification of Diseases and Related Health Problems (ICD) coding of electronic patient data. Only patients with at least a combination of mandibular and midfacial fractures (2-level fractures) were considered. Patients with mainly dentoalveolar fractures and simple nasal bone fractures were not included. The evaluation of the electronic medical records included the etiology, fracture pattern, associated severe injuries on the basis of the injury severity score (ISS), treatment regimen as well as the length of the hospital stay. RESULTS: In the 7­year study period, 3382 patients were identified with facial fractures. Of these, 128 patients (3.78%) presented with a complex fracture pattern with a combination of mandibular fractures and fractures of the midface. The majority of these patients (n = 92) had less severe concomitant injuries (ISS ≤ 16), while 36 patients showed severe concomitant injuries (ISS > 16). The incidence of a 3-level fracture involving the mandible, midface and anterior skull base was only 0.47% and could be detected in 16 patients, of which 10 were classified as polytrauma (ISS > 16). CONCLUSION: The incidence of complex fractures of the facial skeleton was comparatively low with almost 4%. More than one in four patients with complex injury patterns of the facial skeleton exhibited severe concomitant life-threatening injuries, necessitating an interdisciplinary management with the specialized infrastructure of a nationwide trauma center.

Sublingual cysts of different entities in an infant - A case report and literature review.

BACKGROUND: Congenital cysts and fistulas of the neck are common in children, often located in the head and neck area. Belonging to the group of tumor-like conditions, dermoid and epidermoid cysts are dysontogenetic lesions with seldom multiple co-occurrences in infants. CASE REPORT: We report on a nine-month-old female with a persisting congenital fistula of the tongue. The patient was admitted with acute poor feeding and hypersalivation, which started within the last 24 h. Magnetic resonance imaging detected a fistula of the tongue connected to sublingual cystic lesions. Intraoral surgical removal of three cystic lesions and the fistula was performed under general anesthesia. Histopathological analysis confirmed the coexistence of an epidermoid cyst and two dermoid cysts. CONCLUSION: Sudden feeding difficulties in combination with dysphagia and tongue displacement in pediatric patients pose an emergency situation that requires prompt diagnostic clarification. A persisting congenital fistula of the tongue is a clear indication of dysontogenetic lesions, including malformations, tumors, and tumor-like lesions. Congenital sublingual cysts are rare in infants, but can be life threatening when present. Surgical excision with histopathological analysis is essential to exclude any form of malignancy and malignant transformation.

Penetrating Foreign Bodies in Head and Neck Trauma: A Surgical Challenge.

Penetrating foreign bodies of different origins in the head and neck are rare and potentially dangerous injuries, which might pose problems for their detection, primary care, and final treatment. Depending on the severity of the underlying trauma, some injuries present a higher risk for the presence of foreign bodies. Minor wounds, including common lacerations, are likely to be contaminated with loose gravel debris or dental fragments, and need to be distinguished from severe wounds caused by impalement, shootings, stabbings, and explosions. Blast injuries resulting from terror attacks are challenging recent therapeutic concepts. Even though these injury patterns are uncommon, they carry the risk of impacted objects with dramatic consequences. Despite improving medical imaging techniques, detection remains a challenge as it is dependent on the material of the foreign body, the affected anatomical site, and the injury severity. Therefore, a detailed history of the circumstances leading to trauma is essential when foreign objects are not visible during clinical examination. Precise detection of the foreign body, its anatomical position, and the affected surrounding structures are vital, especially for impalement injuries of the head and neck area. Therefore, an interdisciplinary planning approach is essential prior to removal of the foreign object. Finally, tension-free anatomical adaptation of the corresponding structures is crucial for maintaining and restoring aesthetic and function. Here, we give an overview of the diagnosis and treatment of cases of foreign body injuries encountered in our department.

Enhanced radiographic visualization of resorbable foils for orbital floor reconstruction: A proof of principle.

PURPOSE: Despite the advantages and broad applications of alloplastic resorbable implants, postoperative radiological control is challenging due to its radiolucency. The aim of the present study was to evaluate the radiographic visibility of newly developed materials for orbital floor reconstruction. MATERIALS AND METHODS: The radiographic visibility of four different material combinations consisting of poly-(L-lactic acid)/poly-glycolic acid (PLLA/PGA) or poly(D,L-lactic acid) (PDLLA) enriched with magnesium (Mg), hydroxyapatite (HA) or ß-tricalcium phosphate (ß-TCP) with various layers of thicknesses (0.3, 0.6, and 1 mm), surgically placed above the orbital floor of a human head specimen, was evaluated using computed tomography (CT) and cone beam computed tomography (CBCT). The visibility was rated on a scale of 0-10 in CT/CBCT and by Hounsfield Units in CT for each subject. RESULTS: All of the materials were clearly detectable in CT scans. Visibility was significantly higher (p < 0.001) in the standard soft tissue window (mean score: 7.3, ranging from 2 to 10) in comparison to the standard bone window (mean score: 5.2, ranging from 1 to 10). In CBCT (mean score: 3.3, ranging from 0 to 7), there was significantly lower but still sufficient visibility of the materials compared to the CT soft tissue window (p < 0.001) and CT bone window (p < 0.001). Comparing the different materials' visibility among the group of same layer thicknesses with each other, in the majority of cases, PDLLA enriched with ß-TCP appeared to be most visible in both CT and CBCT. CONCLUSION: The incorporation of radiopaque elements to PLLA/PGA and PDLLA polymers is a promising strategy to improve their visibility in CT and CBCT. Our data suggest that the reconstruction of the orbital floor with these new materials could provide an advantageous postoperative radiographic control.

A novel classification scheme for advanced laryngeal cancer midline involvement: implications for the contralateral neck.

PURPOSE: There are insufficient data concerning risk factors for contralateral regional metastases in laryngeal cancer. The aim of this study was to investigate the frequency and risk factors for contralateral lymph node metastases and their dependence on midline involvement of the primary tumor in patients with advanced laryngeal squamous cell carcinoma. METHODS: 58 consecutive patients (8 females, 50 males; mean age 64.2 ± 9.8 years; AJCC stage III disease in 43.1%, IVA disease in 54.4%) undergoing primary total laryngectomy with bilateral neck dissection between 2002 and 2016 have been retrospectively investigated at one of the largest university medical centers in Europe. Preoperative staging computed tomography (CT) scans were analyzed for midline involvement of the primary laryngeal cancer. As a result, a classification scheme has been established (type A: clear, type B: involved, type C: exceeded, and type D: bilateral/origin side indeterminable). RESULTS: Contralateral lymph node metastases (pN2c necks) were found in six cases (10.3%), from which four were diagnosed with type D (23.5% of type D cases), and one each with type B and type C midline involvement. In cases with no midline involvement (type A), a risk ratio reduction of 100% was seen. CT-based midline typing resulted in fourfold increased sensitivity for predicting contralateral metastases compared to conventional staging. Positive nodal status (pN+) significantly reduced overall and disease-free survival (HR 2.706, p < 0.05). CONCLUSIONS: As a consequence, for type A category, a contralateral neck dissection might be avoidable accompanied by a reduction in surgical complications and operating time.

Computed tomography-based virtual fracture reduction techniques in bimandibular fractures.

PURPOSE: Computer-assisted preoperative planning (CAPP) usually relies on computed tomography (CT) or cone beam CT (CBCT) and has already become an established technique in craniomaxillofacial surgery. The purpose of this study was to implement CT-based virtual fracture reduction as a key planning feature in patients with bimandibular fractures. MATERIAL AND METHODS: Nine routine preoperative CT scans of patients with bilateral mandibular fractures were acquired and post-processed using a mean model of the mandible and Amira software extended by custom-made scripting and programming modules. RESULTS: A computerized technique was developed that allowed three-dimensional modeling, separation of the mandible from the cranium, distinction of the fracture fragments, and virtual fracture reduction. User interaction was required to label the mandibular fragments by landmarks. Virtual fracture reduction was achieved by optionally using the landmarks or the contralateral unaffected side as anatomical references. CONCLUSION: We successfully elaborated an effective technique for virtual fracture reduction of the mandible using a standard CT protocol. It offers expanded planning options for osteosynthesis construction or the manufacturing of personalized rapid prototyping guides in fracture reduction procedures. CAPP is justified in complex mandibular fractures and may be adopted in addition to routine preoperative CT assessment.

Patient and treatment-related risk factors for osteoradionecrosis of the jaw in patients with head and neck cancer.

OBJECTIVE: The purpose of this study was to evaluate risk factors for and the incidence of osteoradionecrosis (ORN) of the jaw in patients with head and neck cancer. STUDY DESIGN: This study was a retrospective analysis of the risk for ORN and outcome for 149 of 540 patients with head and neck cancer of the oral cavity (65%), oropharynx (26%), or other head and neck sites (9%) treated with radiotherapy between 2004 and 2009. ORN was graded according to Late Effects of Normal Tissues/Somatic Objective Management Analytic Scale (LENT/SOMA) criteria. RESULTS: Within a median follow-up of 41 months (95% confidence interval: 27.4-54.6), 38 patients (25.5%) had developed ORN, 37 patients (25%) had a local recurrence, and 53 patients (36%) had died. The median time to diagnosis of ORN was 14.5 months (range: 3-80), and 79% were diagnosed within 2 years of RT. Eleven of these patients had undergone previous mandibular surgery. Univariate significant risk factors for ORN were any comorbidity, poor oral hygiene, pre-radiotherapy osteotomy, close tumor-to-bone proximity, post-radiotherapy dentoalveolar surgery (DAS), DAS without sufficient wound closure, alcohol consumption, and denture pressure sores. In multivariate analysis, comorbidities, pre-radiotherapy mandibular surgery, poor oral hygiene, and insufficient DAS remained significant. CONCLUSIONS: Reducing the risk of ORN calls for maintaining optimal oral hygiene, ensuring good denture fit, receiving proper training in DAS, and helping patients to stop drinking and smoking.

Three-dimensional imaging of the inner ear by volume-rendered reconstructions of magnetic resonance data.

OBJECTIVE: To evaluate 3-dimensional inner ear visualization by volume rendering of high-resolution magnetic resonance data in patients with clinically suspected inner ear abnormality. DESIGN: Prospective comparative study of different postprocessing techniques, based on blinded film readings. SETTING: Tertiary referral hospital. SUBJECTS: Fifty patients (17 females and 33 males) aged 1 to 77 years (average age, 42 years) with sensorineural hearing loss, vertigo, and/or tinnitus. INTERVENTION: Postprocessing of magnetic resonance data to inner ear reconstructions by the use of volume rendering as well as maximum-intensity projection; caloric testing by electronystagmography. MAIN OUTCOME MEASURES: Film was read blindly by 4 radiologists using a 5-point parameter scale for image quality and diagnostic value. The assessibility of inner ear subsegments was evaluated. The specificity of volume-rendered reconstructions for detecting semicircular canal obliterations was assessed in a subgroup of 9 patients by caloric testing. The time required for data postprocessing as well as film reading was recorded by means of a stopwatch. RESULTS: Volume-rendered inner ear reconstructions were superior in image quality (P<.001), diagnostic value (P<.001), subsegment inner ear assessment (P<.01 to P<.001), and film reading time (P<.001) compared with maximum-intensity projections. The data postprocessing time was comparable for both techniques. Caloric weakness was noted in all patients assessed by electronystagmography. CONCLUSION: Volume rendering is the postprocessing technique of choice for 3-dimensional inner ear visualization, performing better than maximum-intensity projections with respect to various parameters.