Does anti-inflammatory drugs modify the severe odontogenic infection prognosis? A 10-year's experience.

BACKGROUND: Numerous biochemical datas support the noxious role of anti-inflammatory drugs on immune response. Those observations are often put forward for unfavorable evolution of odontogenic infection but has never been really proven in clinic. The aim of this study is to try to clarify this role based on the collection of the clinical course of odontogenic infections over a 10-year analysis period. MATERIAL AND METHODS: The investigators implemented a prospective observational study. The sample was composed of patients managed between January 2004 and December 2014 for severe odontogenic infection based on three criteria: hospital admission, intravenous antibiotic therapy, tooth extraction and collections drainage under general anesthesia. Clinical and pharmacological data were collected at admission, during hospitalization until discharged home. The population was first separated into two groups patients with or without anti-inflammatory drugs on admission, then on four groups (non-steroidal anti-inflammatory drugs, corticosteroids drugs, both and none on admission). Analysis were performed each time by univariate analysis, multivariate analysis and propensity score matching. RESULTS: Six hundred and fifty-three patients were included in the study, 329 (50%) patients report orally anti-inflammatory treatment before presenting to hospital, 50 (7.6%) received corticosteroids, 242 (37%) received NSAIDs and 37 (5.6%) both. Evolution is worsening for patients under anti-inflammatory drugs in term of hospitalization in ICU (p=0.016), number of surgeries (p=0.003), risk of tracheotomy (p=0.036), duration of hospitalization (p=0.005) and spaces involved by the infection (p<0.001). When separating patients into 4 groups, dysphonia and odynophagia are more frequent for patients under corticosteroid and NSAID (35.14%, p<0.001), mediastinal erythema is more frequent for patients under corticosteroid (16%, p=0.004), fever is more frequent for patients under NSAID (35.5%, p=0.032), pain is higher for patients under corticosteroids (p=0.024). But, in order to reduce bias, linked to factors of gravity, a regression weighted by propensity scores was performed and any group of patients is different from the others. CONCLUSIONS: Patients under anti-inflammatory drugs have more severe dental infection on admission and their complex evolution seems to be linked to the severity of infection on admission.

[Therapeutic failure in skin carcinomas of the face]. / Chirurgie secondaire des tumeurs cutanées de la face.

Therapeutic failures in the management of skin carcinomas of the face are not rare, because of the very high frequency of these lesions. They come in 3 aspects: (a) tumor recurrence at the site of resection: reminders concerning the margins of excision in first surgery and in case of recurrence are made, as well as a focus on the behavior to take in case of incomplete margins; (b) Functional drawbacks related to surgery: abnormalities are addressed by anatomical location (eyelids and lips) through some examples and decisional algorithms. The nose and the ear are treated in other chapters of the book; (c) the aesthetic sequelae are finally presented thanks to new clinical cases.

[Nasal cavity mucosal melanoma with skin extension mimicking a malignant lentigo with mucosal extension]. / Mélanome muqueux des fosses nasales avec extension cutanée mimant un lentigo malin cutané d'extension muqueuse.

Mucosal melanoma is a rare malignant disease developed from melanocyte. We report the case of a patient with nasal cavity mucosal melanoma with a primary clinical and histological diagnosis of malignant lentigo with mucosal spreading. The presence of a c-Kit mutation, in a second lecture and the evolving nature of the lesion, reorientated the diagnosis of malignant lentigo to mucosal melanoma with skin extension. Extensive surgical resection and foramen free flap with costal graft reconstruction may have a local control of the disease. Yet, after one year, a regional evolution involving a parapharyngeal node was treated by stereotaxic radiotherapy. After 5 years, the patient was considered in clinical and radiological remission. Malignant lentigo with mucosal extension is a very rare situation, this diagnoses must be evoqued after setting mucosal melanoma diagnosis.

[Morel-Lavallée syndrome and post-traumatic nodular fat necrosis: Two post-traumatic complications mimicking cellulitis]. / Syndrome de Morel-Lavallée et cytostéatonécrose : deux complications post-traumatiques simulant une dermo-hypodermite infectieuse.

BACKGROUND: Dermal and subcutaneous inflammation following direct trauma is initially evocative of soft-tissue infection. However, two differential diagnoses must be considered: Morel-Lavallée syndrome and post-traumatic nodular fat necrosis. PATIENTS AND METHODS: Case 1: a 51-year-old woman fell off her motorbike and had dermabrasions on her right and left tibial ridges that rapidly developed into dermo-hypodermitis of the entire limb. There was no improvement after 3 weeks of antibiotics. The patient was apyretic. She had a soft, non-inflammatory tumefaction on the inner aspect of her left knee. Ultrasound revealed subcutaneous collection in both legs. The surgeons confirmed a diagnosis of Morel-Lavallée syndrome and drained the two collections. Progress was good and the patient healed without major consequences. Case 2: following a fall on her stairs, a 40-year-old woman presented dermabrasions and haematomas on her left leg. Antibiotic therapy failed to prevent the progression of dermo-hypodermitis. The patient remained apyretic and there was no inflammatory syndrome. A CT scan showed thickening of a subcutaneous fat and fluid collection, resulting in diagnosis of post-traumatic nodular fat necrosis. Management was surgical and the outcome was good. DISCUSSION: These two cases show two post-traumatic cutaneous complications: Morel-Lavallée syndrome and post-traumatic nodular fat necrosis. Morel-Lavallée syndrome occurs after tangential trauma next to richly vascularized tissue. Post-traumatic nodular fat necrosis is defined as necrosis of adipocytes. In both cases, diagnosis is confirmed by imagery (Ultrasonography, tomography). CONCLUSION: Our two case reports show that inflammatory presentation of both Morel-Lavallée syndrome and post-traumatic nodular fat necrosis can lead to diagnostic and therapeutic errors while a surgical procedure is necessary since tissue necrosis can occur.

Is BRAF a prognostic factor in stage III skin melanoma? A retrospective study of 72 patients after positive sentinel lymph node dissection.

BACKGROUND: BRAF was identified as an oncogene in skin melanoma in 2002, and since 2011 has been a therapeutic target in the treatment of metastatic melanoma. The role of BRAF mutation in tumour initiation and the disease course remains to be elucidated. OBJECTIVES: The main objective of our study was to determine whether there is a relationship between BRAF status and overall survival in patients with a melanoma and a positive sentinel lymph node. We also sought an association between BRAF status and the clinicopathological features of the melanoma. Finally, we looked for a potential heterogeneity of BRAF status in primary and metastatic tumours. METHODS: All patients (n = 72) treated for melanoma and with a positive sentinel lymph node at the University Hospital of Clermont-Ferrand, France, between January 2000 and January 2010 were enrolled in the study. We investigated BRAF status in primary melanoma and lymph node metastatic tissue in our molecular pathology laboratory and collected the clinical and survival data. RESULTS: Of the 72 patients, 32 had at least one BRAF mutation. There was a statistically significant difference in overall survival between the BRAF-mutated and wild-type populations. The only clinical feature related to BRAF status was metastatic burden. Of the 25 patients in whom we obtained the status in both locations, five had a discordant result. CONCLUSIONS: BRAF mutation is an indicator of poor prognosis in patients with stage III melanoma with a positive sentinel lymph node. BRAF status could be used in the staging of this population. BRAF has a role not only in cellular immortalization but also in metastatic spread.

Which centers should be authorized to treat craniosynostosis? A plea for quality and not for quantity.

BACKGROUND: In centers for craniosynostosis surgery, the volume of activity does not necessarily reflect the quality of the treatment. OBJECTIVE: Our aim was to analyze a retrospective series of patients over a period of 6 years in a low-volume craniosynostosis surgery center, and to study indicators that reflect the quality of treatment. PATIENTS AND METHODS: The analysis included all patients who underwent a craniofacial surgery for all forms of craniosynostosis during the period 2012-2017 (annual follow-up for 4 years). Data on the type of synostosis, sex, age, weight, type of surgery, duration of surgery, blood transfusion, postinterventional care, and total length of hospital stay were collected. Medical and surgical complications were recorded using the Leeds classification. RESULTS: Overall, 42 patients (33 male; 23 cases of scaphocephaly, 13 cases of trigonocephaly, 4 cases of coronal plagiocephaly, 1 case of lambdoid plagiocephaly, and 1 case of brachycephaly) underwent craniofacial surgery with a median age of 7.4 months [4.8; 10.4] and a mean weight of 8.40 ± 1.92 kg at surgery. The median hospital stay was 7 days [6;7] with 1 day in the postinterventional care unit for 83% of patients. The global complication rate was 12% (95% CI: 4%-26%) with three minor cutaneous and two major (cardiovascular and septic) complications. CONCLUSION: Complication rates reflect the quality of care in a center that treats craniosynostosis much more than do the number of procedures, mean hospital stay, and blood transfusion rates. It is essential to define new indicators capable of measuring the quality of life linked to surgical procedures and of using them to assess the competence of a center.

[Conservative surgery for a mandibular condyle osteochondroma]. / Chirurgie conservatrice d'un ostéochondrome du condyle mandibulaire.

INTRODUCTION: Osteochondroma is a rare benign bone tumor of the mandibular condyle (90 cases reported). The symptoms are similar to those of temporomandibular joint disorders: painful temporomandibular joint, joint sounds, and modification of dental occlusion. CASE REPORT: A 37-year-old female patient consulted for a wide left laterodeviation of the mandible. CT scan revealed a 27 mm long bony growth on the condyle. The condyle neck was osteotomized, then the tumor and condyle head were split, the condyle was then remodeled and osteosynthesized on the condyle neck. The functional and esthetic results were satisfactory at 12 months without any recurrence or relapse. DISCUSSION: The authors present a novel conservative technique, slightly different from those reported in the literature. There are several therapeutic alternatives. They can be classified in three groups: invasive, non-invasive, and conservative techniques. Nevertheless, osteochondroma is a benign tumor and its management should be as little invasive as possible.

Significant decrease of facial cellulitis admissions during COVID-19 lockdown in France: A multicentric comparative study.

During the 2020 coronavirus pandemic, a lockdown was imposed in France during the first wave. An apparent decrease in incidence of cellulitis of odontogenic origin was noticed then. This study aimed to compare the incidence of cellulitis during this extraordinary period with the same period in 2018 and 2019, based on retrospective multicentric data. All maxillofacial surgery departments in French public hospitals were contacted. Responders were asked to include all patients admitted for the surgical drainage of a head and neck abscess of odontogenic origin during the first 2020 lockdown period, and in a similar time frame in 2018 and 2019 (control group), based on screening the French diagnostic and therapeutic classification of medical acts. We report a 44% significant nationwide decrease in the incidence of admissions for cellulitis. There were 187 patients in 2020 for 334 and 333 patients in 2018/2019 respectively. The reasons to explain this finding are hypothetical (organizational reasons leading to earlier management, patients' fear to seek for medical management, usual excess in surgical indications or concomitant decrease of non-steroidal anti-inflammatory drugs delivery). Whatever the explanation, it would be of great interest to find it out in order to improve the prevention of cellulitis.

[Frontal sinusitis, mucocele and subperiosteal superolateral orbit abscess]. / Sinusite frontale, mucocèle et abcès orbitaire supérolatéral.

INTRODUCTION: Periorbital infection following pansinusitis is a rare complication which can lead to irreversible orbital and intracranial consequences. Chandler classified them in 1970. OBSERVATION: An eight-year-old child presented with a subperiosteal superolateral abscess. The initial flu-like syndrome developed into pansinusitis resisting to usual treatment. Palpebral edema and major exophthalmia then appeared requiring CT scan and MRI, which confirmed a subperiosteal abscess. DISCUSSION: A subperiosteal abscess is a serious condition requiring an early diagnosis and a medical or surgical treatment adapted to the severity. Chandler's classification gives the opportunity to adapt management to the infection's gravity. Ethmoiditis may be complicated by periorbital abscesses found usually in the superointernal quadrant. Medical imaging and surgical treatment confirmed a superolateral periorbital abscess and a frontal mucocele. This case illustrates the possibility of communication between frontal sinus and orbital cavity. During frontal sinus infection, pre-existing mucocele may become super-infected and induce a periorbital abscess.

Arthrogryposis multiplex congenita and limitation of mouth opening: Presentation of a case and review of the literature.

Arthrogryposis multiplex congenita (AMC) is a rare entity gathering many diseases, isolated or included in more global syndromes. It affects symmetrically joints of lower limbs, back and maxillofacial area with temporomandibular joint (TMJ) impairment leading to deterioration of oral functions and mouth opening resulting in poor quality of life. Therapeutic strategy varies according to type and severity of impairment and could involve physical therapy and/or surgery. This article reported a case of AMC followed in our unit and highlighting various maxillo-facial impairments, especially restricted mouth opening and its consequences due to fibrotic TMJ and hypertrophic coronoid processes. We described our therapeutic approach based on surgery and postoperative physical therapy. A stable improvement of mouth opening was obtained, and patient's quality of life was increased. We performed a review of the literature and suggested a therapeutic management of mouth opening limitation in AMC.

Virtual surgical planning and three-dimensional printing for the treatment of comminuted zygomaticomaxillary complex fracture.

OBJECTIVE: the objective of the study is to evaluate the interest of advanced computer technology, including virtual surgical planning, three-dimensional modeling and pre-bended titanium plate and mesh in the treatment of comminuted zygomaticomaxillary complex fractures. MATERIAL AND METHODS: A total of 19 patients were included. In the study group (n=6) surgery was combined with preoperative planning including mirroring and bending of the titanium plates and mesh on a 3D model. In the control group (n=13) plates and mesh were bended on the patient during the surgery. Patient characteristics, clinical outcomes, orbital volumes, zygoma projection and complications were recorded. RESULTS: After surgery, the orbital volume and the zygoma projection variations between injured side and unaffected side were compared. Orbital volume variation was 2.1mL [1.5; 4.0] in the control group and 0.4mL [0.1; 1.0] in the study group. Zygoma projection variation was 0.2cm in the control group and 0.1cm in the study group. Orbital volume restoration (P=0.004) and zygoma symmetrisation (P=0.04) were significantly better when titanium plates and meshes were pre-bent on a stereolithographic model. CONCLUSION: This study confirms the interest of surgical planification using 3D models to improve treatment of midface trauma.

Surgical approach of ectopic maxillary third molar avulsion: Systematic review and meta-analysis.

Ectopic maxillary third molars (EMTM) are extracted mainly by the Caldwell-Luc technique but also by nasal endoscopy. There is currently no consensus on the treatment of this eruption and its management is heterogeneous and multidisciplinary. Two literature searches were performed with no time restrictions via Pubmed. In the first, we used the keywords "ectopic AND third molar" and in the second the keywords "dentigerous cyst AND ectopic third molar". For both articles, epidemiological, symptomatic, radiological and surgical data were recorded. Overall, 33 eligible articles were identified involving 39 cases of EMTM. 79% of patients were symptomatic. 87% of the teeth were associated with a dental cyst. In only 13% of cases was the location of the tooth in the sinus specified in the three planes of the space. Surgery was performed in 77% of patients by the Caldwell-Luc technique, by nasal endoscopy in 10% and by the Le Fort I approach in 3%. The indications for avulsion of EMTM are symptomatic patients or asymptomatic patients with an associated cyst. The intra-sinusal location of the tooth is not a factor in the choice of technique used, which depends rather on the individual skills of the surgeon. Although for a trained operator the Le Fort I osteotomy is an easy procedure, its interest in the treatment of EMTM is limited owing to the rare but potentially severe complications involved.

[Acute dacryocystitis complicating primary mononucleosis infection]. / Dacryocystite aiguë sur une primo-infection mononucléosique.

INTRODUCTION: Infectious mononucleosis may lead to numerous complications. Tonsillar hyperplasia with risk of airway obstruction is well known. Dacryocystitis is a rare but potentially severe complication. OBSERVATION: A 6-year-old child with primary mononucleosis infectious diagnosed 8 days before, developed acute dacryocystitis, with rapid evolution to orbital cellulitis, despite adequate antibiotherapy. Emergency surgical drainage was required. DISCUSSION: Dacryocystitis is a rare and little documented complication of EBV infection. Its acute evolution to orbital cellulitis is possible and potentially severe. Its physiopathology is specific. Patients are initially free of chronic stenosis and epiphora, which express acute obstruction of the lachrymal sac due to general lymphoid hyperplasia.

Extracorporeal septorhinoplasty: Technical note.

Severe nasal septal deformities can be responsible for functional and aesthetic impairments. Correction of these deformities can be difficult and restoring perfect nasal shape and function is still challenging. Classical techniques can, sometimes, lead to disappointing results or relapse. In this article, the aim was to describe the different techniques of extracorporeal septorhinoplasty and fixation of the neoseptum. Three techniques are mainly used: "crisscross" suture, "U-shaped" suture and anterior septal reconstruction to fix the neoseptum after extracorporeal remodeling. All these techniques are technically demanding, especially concerning keystone area management; but, if well performed, could give satisfactory functional and aesthetic outcomes. We therefore think that extracorporeal septorhinoplasty should really improve our results concerning functional and aesthetic aspects in case of severe anterior or caudal septum deviation.

Mandible extensive intra osseous destructive lesion, a diagnostic challenge.

Intraosseous verrucous carcinoma of the mandible is a rare situation often confused with chronic osteomyelitis. Despite the low aggressively of the tumor, prognosis is poor because of delayed diagnosis. We report 3 cases, from three different hospitals, initially diagnosed with a chronic osteomyelitis of the mandible after wisdom extraction. Imaging, bacteriological and histological samples supported each time this interpretation. The 3 patients worsened with intraosseous extension of the lesions and outflow of whitish and purulent debris. Only extensive resection with mandibulectomy allow the pathologists to identify the tumor. Adjuvant radiotherapy or radiochemiotherapy followed the surgery. One patient is in clinical remission. In front of mandible lesion resistant to antibiotic therapy and sequestrum resection, atypical squamous cell carcinoma must be evoked. MRI and CT-scan are not able to distinguish osteomyelitis and intraosseous verrucous carcinoma. Presence of whitish lysed and debris of keratin must draw the attention. Firm evidence must be provided to the pathologist but samples should be wide and thick.

miR-379 links glucocorticoid treatment with mitochondrial response in Duchenne muscular dystrophy.

Duchenne Muscular Dystrophy (DMD) is a lethal muscle disorder, caused by mutations in the DMD gene and affects approximately 1:5000-6000 male births. In this report, we identified dysregulation of members of the Dlk1-Dio3 miRNA cluster in muscle biopsies of the GRMD dog model. Of these, we selected miR-379 for a detailed investigation because its expression is high in the muscle, and is known to be responsive to glucocorticoid, a class of anti-inflammatory drugs commonly used in DMD patients. Bioinformatics analysis predicts that miR-379 targets EIF4G2, a translational factor, which is involved in the control of mitochondrial metabolic maturation. We confirmed in myoblasts that EIF4G2 is a direct target of miR-379, and identified the DAPIT mitochondrial protein as a translational target of EIF4G2. Knocking down DAPIT in skeletal myotubes resulted in reduced ATP synthesis and myogenic differentiation. We also demonstrated that this pathway is GC-responsive since treating mice with dexamethasone resulted in reduced muscle expression of miR-379 and increased expression of EIF4G2 and DAPIT. Furthermore, miR-379 seric level, which is also elevated in the plasma of DMD patients in comparison with age-matched controls, is reduced by GC treatment. Thus, this newly identified pathway may link GC treatment to a mitochondrial response in DMD.

[Giant cell tumors and pseudogiant cell tumors of the jaws]. / Tumeurs et pseudotumeurs des maxillaires riches en cellules géantes.

Giant cell tumors and pseudogiant cell tumors of the jaws are divided into cherubism, central giant cell granuloma (CGCG), aneurysmal cyst, giant cell tumor, and hyperparathyroidism-jaw tumor. These tumors have variable clinical characteristics, such as bilateral tumors in cherubism, disseminated tumors in hyperparathyroidism, or focal tumors in other types. Their radiological presentation is quite similar with presence of well-delimitated uni- or multilocular radiolucency. The primary surgical treatment must be conservative. Anatomopathology gives the histologic diagnosis, with presence of giant cells. Some tumors are locally aggressive leading to larger bone exeresis. The nosology of these giant-cell tumors remains unclear, especially for giant cell central granuloma and giant cell tumors.

From rigid bone plate fixation to stable dynamic osteosynthesis in mandibular and craniomaxillo-facial surgery: Historical evolution of concepts and technical developments.

Historically, extensive observation of limb fracture healing led to a consensus that only complete rigid immobilization could guarantee recovery. This agreement was arrived at because for a long time progress in treatment was driven by clinicians and did not stem from the application of biological research. The clinical approach was based on immobilization of the fracture by rigid osteosynthesis plates and bicortical screws. Subsequently, after extrapolation of the ideas of Lane, the concept of rigid compressive osteosynthesis rapidly gained in acceptance. It was not until the second half of the 20th century that maxillofacial surgeons concluded that the principles of osteosynthesis should be based on biomechanical studies and not only on clinical observation. The concept of stable dynamic osteosynthesis stems from basic research. This paper traces the evolution of concepts in maxillofacial osteosynthesis.

Are routine microbiological samplings in acute dental infections justified? Our 10-year real-life experience.

PURPOSE: Most patients with severe odontogenic infections are successfully treated with large spectrum probabilistic antibioc therapy, drainage of the collections and tooth treatment or extraction and are discharged home before antibiotic sensitivity results were available. The investigators hypothesized whether bacteriological sampling should be systematically performed in the management of patients with severe odontogenic infections. METHODS: The investigators implemented a prospective observational study. The sample was composed of patients managed between January 2004 and December 2014 for severe odontogenic infection based on three criteria: hospital admission, intravenous antibiotic therapy, tooth extraction and collections drainage under general anesthesia. The predictor variable was the results of bacteriological sampling, culture and sensitivity. The outcome variable was antibiotic therapy adaptation according to antibiotic sensitivity results. RESULTS: The sample was composed of 653 patients; 386 (59%) were male and 267 (41%) female, with a mean age of 37 years (range 18-88); 378 (58%) patients had been receiving oral antibiotics before admission to hospital, for a mean duration of 4.1 days (range 1 - 30). About 535 (81.9%) patients had swabs taken during surgery. Microorganisms were observed in 477 (89.1%) patients but in 377 (70.5%) they were polymorphic oropharyngeal flora. After culture, at least one antibiogram was obtained for 91 (17%) patients and the results led to antibiotic therapy being adapted in 23 (4.3%) patients. CONCLUSION: The results suggest that bacteriological analysis had an impact on evolution in less than 5% of patients. Future studies will focus on the patients for whom the bacteriological analysis is essential.

Characterization of dystrophic muscle in golden retriever muscular dystrophy dogs by nuclear magnetic resonance imaging.

The Golden Retriever Muscular Dystrophy dog lacks dystrophin. Disease progression in this model shares many similarities with the Duchenne muscular dystrophy, both from anatomico pathological and clinical standpoints. The model is increasingly used in pre-clinical trials but needs to be further investigated, particularly with reference to the evaluation of therapies. The aim of this study was to identify quantitative indices that would help characterize the dystrophic dog non-invasively using NMR imaging. Two-month-old dystrophic dogs and healthy control animals were scanned at 4T. Standard T2- and T1-weighted images, fat-saturated T1-weighted images pre- and post-gadolinium chelate injection were acquired and kinetics of muscle enhancement were studied over a 2-h period. Several indices were found to be abnormally high in dystrophic dogs: the T2-weighted/T1-weighted signal ratio, T2-weighted image heterogeneity and maximal signal enhancement post-gadolinium. These may be proposed to evaluate muscle structural alterations non-invasively in this disease.