Congenital anomalies associated with cleft lip and palate-an analysis of 1623 consecutive patients.

OBJECTIVE: To document the frequency and nature of associated anomalies in cleft lip and/or palate patients from a craniofacial center in India. SETTING: Craniofacial Surgery & Research Centre, SDM College of Dental Sciences & Hospital, Dharwad, India. PATIENTS/PARTICIPANTS: A total of 1623 consecutive patients with cleft lip and/or cleft palate treated in a 40-month period. MAIN OUTCOME MEASURE: Frequency and nature of associated anomalies, analyzed according to the cleft type and principal organ system and/or area affected. RESULTS: The overall male to female ratio was 1.8∶1. Unilateral cleft lip with cleft palate (41%) was the most frequent cleft subtype, followed by cleft lip and/or cleft alveolus (33%); isolated submucous cleft palate (1%) was the least frequent. A total of 240 (14.8%) patients had associated anomalies, and these were more frequent in males (M∶F  =  1.4∶1). Per patient, anomalies were most frequent in the submucous cleft group (mean, 0.53) and least common in the cleft lip with or without cleft alveolus (mean, 0.14). Anomalies were most frequent in the facial region (21%), followed by the ocular (17%), central nervous (15%), gastrointestinal (3%), and urogenital (2%) systems. Thirty-four patients (2%) had recognized nonchromosomal syndromes; this was more common in the cleft palate group. CONCLUSIONS: Associated anomalies are not uncommon in patients with cleft lip and/or palate, though the frequency varies with the cleft type and organ system affected.

Split zygomaticus major muscle sling reconstruction for significant lower lip defects.

Defects to the lower lip remain surgically challenging to reconstruct. Restoration of aesthetics and function are crucial, of which the aims include restoring the tissues of the lower lip, maintaining oral competence, speech articulation, and restoring lip height and the vermillion. Further surgical techniques continue to be explored, with local flap surgery being the generally preferred method. However, many reconstructions leave the patient with pronounced deformity and morbidity. In this case report, we describe a new technique for the reconstruction of an 80% lower lip defect with an ipsilateral split zygomaticus major muscle sling, nasolabial flap, and facial artery musculomucosal flap. The reconstruction provided good oral competence, speech articulation and aesthetics, in addition to maintaining the oral commissure and lower lip height/length. Iatrogenic microstomia was avoided and zygomaticus functioning was normal. We are confident this technique will be useful to reconstructive surgeons in select cases of significant lip defects.

Outcomes of free flap reconstructive surgery in head and neck cancer patients over 80-years old.

An increasing elderly population in the United Kingdom has led to an increasing number of older patients with head and neck cancer, resulting in a greater demand for complex head and neck reconstructive surgery in this potentially high-risk age group. A possible perceived poorer tolerance to such major treatment risks under-treating some of these patients. The purpose of this study was to assess the outcomes in the elderly population (older than 80 years) who had undergone free flap reconstruction following head and neck cancer resection. A retrospective review of 127 patients was performed. Eighteen patients were 80 or older (14.2%) and 109 under 80 (85.8%). The elderly group experienced increased number of postoperative medical complications (p=0.01), but the surgical complications were not significantly different in the two groups (p=0.4). The average length of hospital stay was significantly longer in the older group (p=0.01). There was one flap failure during the study period, which belonged to the younger group of patients. Elderly patients undergoing free flap reconstruction experience an increased rate of postoperative medical complications resulting in an increased length of hospital stay. However, good surgical outcomes can still be achieved in this age group, and therefore age alone should not be considered as a primary factor in head and neck cancer management.

Spontaneous oral ulceration with bone sequestration: its relevance in current clinical practice.

Oral ulceration associated with bony exposure and sequestration is uncommon and often related to well-recognised conditions. In a small group of patients no obvious aetiological factors can be elucidated, and various terminologies have been utilised to describe these lesions. We report six cases of spontaneous oral ulceration with bone sequestration as a specific entity and review the pertinent literature. We retrospectively reviewed patients presenting in the period 2013-2018. Data collected included demographic details, relevant medical, drug, and radiotherapy history; presentation, investigations, management, and outcome. Six patients with an age range of 49-65 years were identified with spontaneous oral ulceration with bone sequestration in the study period. All were males, and none had any relevant history. Five lesions occurred over the mylohyoid ridge and one was related to a lingual mandibular torus. The most common presentation was a painful ulcer with exposed bone, which had been present for 6 - 12 weeks. Occlusal radiographs demonstrated focal rarefaction in two patients. All were managed conservatively and by removal of the loose sequestrum. Healing occurred successfully in all cases, and this was earlier when the loose sequestrum was removed. Spontaneous oral ulceration with bone sequestration is a distinct lesion that most often presents over the prominence of the mylohyoid ridge. It is currently an uncommon entity (0.02%), but this could well be due to a lack of recognition and under-reporting. It should be considered as a diagnosis only when other causes have been excluded. Lesions heal successfully with conservative management and surgical intervention, and this occurs earlier following removal of the loose sequestrum.

Intraosseous venous malformation of the craniofacial region: diagnosis and management.

Vascular lesions mainly affect soft tissues, and less than 1% affect bone. In 1982, they were categorised by Mulliken and Glowacki as haemangiomas or vascular malformations, and an updated classification was subsequently published by the International Society for the Study of Vascular Anomalies. These lesions, however, continue to be termed haemangiomas and there is little attempt to differentiate between them. We report eight cases of intraosseous venous malformation that were inappropriately labelled as haemangioma by clinicians, pathologists, and radiologists. We highlight tailored management, and describe the clinical features, results of investigations to aid accurate designation (histological and immunohistochemical, including GLUT1 staining and cross-sectional imaging), and outcomes.

RETRACTED: Management of seborrhoeic keratosis and actinic keratosis with an erbium:YAG laser-experience with 547 patients.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Editors because the photograph in Figure 1b was a duplicate image of Figure 1a, but with the keratosis removed, and did not represent the surgery that was described in the article. The authors apologise for this error.

'Elephant' graft to assist implant-retained nasal prosthesis.

Large rhinectomy defects can be reconstructed with endosseous craniofacial implants and an alloplastic implant-retained prosthesis. The survival of the implants and prosthesis is aided by the placement of split skin grafts. A simple and effective technique is described to enable accurate placement of a split skin graft in a single piece, by shaping it 'like an elephant'.

Factors influencing the occurrence of multicentric and 'recurrent' Warthin's tumour: a cross sectional study.

The multicentric nature of Warthin's tumour has been well recognised, though the factors predicting its occurrence and its influence on management remain speculative. In this cross sectional study, the authors analysed the presentation, management and outcome of solitary and multicentric Warthin's tumour, treated in the maxillofacial unit and investigated factors that could influence the occurrence of multicentric and recurrent tumours. Warthin's tumour was found in 24% (150/628) of patients presenting with parotid neoplasms and multicentric tumours were found in 13% (21/ 161) of parotidectomy specimens. Age, sex, side, site and smoking history were not predictors of multicentricity (P>0.40). Clinical examination (19%), imaging investigations (28%) and intra-operative palpation (33%) were poor at detecting multicentric tumours. Superficial parotidectomy was the most commonly performed operation. The recurrence rate was 0% in the solitary and 10% in the multicentric tumour group. Intra-operative rupture was not uncommon (11%), but was not associated with tumour recurrence (P= or >0.999). Incomplete excision (P=0.007) and multicentricity (P=0.026) were predictors of recurrence.

Primary oral leiomyosarcoma: a clinico-pathologic study and analysis of prognostic factors.

This clinico-pathologic study of primary oral leiomyosarcomas and analysis of potential prognostic factors involved a literature review of 64 cases and a report of four cases treated in the authors' unit. The demographic details, clinical presentation, diagnosis, treatment and outcome were documented for the whole group and clinico-pathologic variables analysed to detect potential prognostic factors. The most common presentation was that of a painless mass, with peak incidence in the 6th decade and a slight male predeliction (M:F=1.3:1). The maxilla was the most frequently involved site, followed by the mandible and tongue. Surgical excision was most commonly employed with radiotherapy and chemotherapy being reserved for recurrent and metastatic tumours. Local recurrence (34%) and metastasis (35%) were not uncommon and occurred most frequently to the lungs and regional lymph nodes (15%). Age, sex, size and mitotic index were not statistically related to recurrence or metastasis. Site (P=0.0125) was a predictor of metastasis. Metastasis (P=0.010) and lesions involving the maxilla and mandible (P=0.019) were associated with decreased survival. The estimated 5 year survival was 55% for the whole group and 43% and 19% for patients with bony involvement and metastasis respectively.

Corlett loop for microvascular reconstruction in a neck depleted of vessels.

Free tissue transfer has revolutionised reconstruction of the head and neck and there are currently few local factors that preclude its use. These include a lack of suitable recipient vessels in the area for microvascular anastomosis. We describe the use of a Corlett loop in which a temporary arteriovenous fistula (AVF) is created with a transposed cephalic vein to enable reconstruction of a mandibular defect with a fibular free flap.

Sudden transient complete loss of vision caused by nose blowing after a fracture of the orbital floor.

A 52-year-old man was being attended to in a hospital for a fracture of the right zygoma and orbital floor, after being struck on the right upper face. After blowing his nose, he immediately lost vision in the right eye, and an urgent CT scan showed extensive retrobulbar air. Vision was regained within an hour. The management of this rare condition is discussed.

Ectomesenchymal chondromyxoid tumour of the tongue: Unlikely to originate from myoepithelial cells.

Ectomesenchymal chondromyxoid tumour is a recently described rare entity found almost exclusively in the anterior dorsum of the tongue. We report an additional case, review the pertinent literature and explore the histogenesis of the lesion. The lesion has no discriminating clinical features and diagnosis is only established following histopathological examination including immunohistochemical assessment. The histogenesis of the lesion remains speculative and our study seems to discount myoepithelial cells as a potential source.

Atypical features in pleomorphic adenoma--a clinicopathologic study and implications for management.

Pleomorphic adenoma is the most common salivary gland neoplasm and infrequently undergoes malignant transformation. Carcinoma ex pleomorphic adenoma is typically an infiltrative neoplasm with features of cellular pleomorphism, high mitotic activity, peri-neural and vascular invasion. More recently, sub-groups of pleomorphic adenoma have been described exhibiting vascular invasion and features of malignancy without evidence of extra-capsular extension. There is little information in the literature regarding how these different histological variants influence clinical presentation and outcome following primary treatment. Following a review of 100 consecutive pleomorphic adenomas removed from the major salivary glands, 4 cases with atypical histological features were found. Three tumours exhibited features of dysplasia/carcinoma without evidence of extra-capsular invasion and a further case demonstrated benign vascular invasion. There were no clinical features suggestive of the atypical nature of these neoplasms, though fine needle aspiration cytology (FNAC) was suspicious of a malignancy in 2 cases and CT scan in 1 case. Patients underwent a superficial parotidectomy or submandibular gland excision based on the location of the lesion. All lesions were completely excised and there were no recurrences in this series.

Haemangiomas and vascular malformations of the maxillofacial region--a review.

Congenital vascular anomalies have been and remain poorly understood. Since 1982 haemangiomas and vascular malformations have been recognised as distinct entities that exhibit unique characteristics and demand appropriately tailored treatment plans. However, "haemangioma" still continues to be used as a clinical and pathological description of many different types of vascular anomalies, which complicates both the care of patients and the interpretation of reports in journals. In this review we summarise the current classification, terminology, and the pathological basis of these lesions and discuss their management. The various therapeutic options available and their outcome will be discussed in addition to the recent advances in the psychosocial aspects of care, interventional radiology, laser and pharmacological therapy.

Multiple synchronous and metachronous neoplasms of the parotid gland: the Chichester experience.

Parotid neoplasms are usually solitary and multiple tumours occurring in an individual are uncommon. The incidence and implications of multiple synchronous and metachronous tumours remains relatively unknown. We reviewed the case notes of 606 patients who had parotidectomies for neoplastic lesions over a 30 year period and identified 30 patients (5%) with multiple primary tumours. There were 24 patients with synchronous tumours and 6 with metachronous tumours. Sixteen of the synchronous tumours (67%) were ipsilateral, whereas all six metachronous tumours were contralateral. Preoperative examination was effective at detecting bilateral tumours but poor at detecting multiple ipsilateral tumours. Multiple tumours were likely to be of the same histology (n=24, 80%) and Warthin's was by far the most common multiple tumour. Ipsilateral tumours of differing histological types and identical tumours other than Wartin's were uncommon. All but one patient had superficial parotidectomies and there were no recurrences.

Recurrent nodal metastases in the posterior triangle: implications for treatment of the atypical tumour.

We studied the incidence of recurrent nodal metastases in level V (posterior triangle) in patients who had previously had a staging or therapeutic dissection of the neck, with or without postoperative radiotherapy. Of 160 patients studied (177 neck dissections), 41 (26%) developed recurrent metastases in the neck. Four patients (3%) developed ipsilateral recurrent disease in level V. In these four patients, level III or IV lymph nodes were shown histologically to have extracapsular spread at the time of the original dissection. All four metastases were located at or just beyond the anatomical boundaries of the posterior triangle. None of the metastases at level V were from oral or oropharyngeal primary tumours.

Addison's disease as a presentation of metastatic malignant melanoma.

Melanoma accounts for 5% of all skin cancers. The risk of metastasis is related to the thickness of the tumour, and can affect local, regional and distant sites. Adrenal metastasis from melanoma of the head and neck is uncommon and often asymptomatic. Addison's disease as a presentation of metastatic melanoma is extremely rare and we are unaware of previous reports in the world literature. We report a case of a patient with metastatic melanoma presenting with signs and symptoms of Addison's disease.

Transmasseteric antero-parotid approach for open reduction and internal fixation of condylar fractures.

The morbidity that results from surgical approaches to the condylar neck, and the time-consuming nature of the operation inhibits many surgeons from using open reduction and internal fixation for the treatment of condylar fractures. The many approaches that have been described stand testimony to the disadvantages of the individual techniques. The most common problems are limited access and injury to the facial nerve. We describe the transmasseteric antero-parotid (TMAP) technique, which offers swift access to the condylar neck while substantially reducing the risk to the facial nerve and eliminating the complications associated with transparotid approaches.

Dystroglycan complex in cancer.

Abnormalities in the interactions between tumour cells, adhesion molecules and extracellular matrix proteins are often implicated in the behaviour of carcinoma cells. The alpha- and beta-dystroglycan (DG) proteins form part of the large dystrophin-associated protein (DAP) complex. They are involved in epithelial cell development, formation of the basement membrane and maintenance of tissue integrity. Specific changes and reduction or loss of DG expression have been reported in human breast, colon, head and neck, and prostate cancers, implicating it in tumour invasion and dissemination. Degradation of beta-DG by matrix metalloproteinase (MMP) enzymes may assist tumour dissemination. We report the present knowledge of the DG interactions in solid tumour biology.