Severe odontogenic infections with septic progress - a constant and increasing challenge: a retrospective analysis.

BACKGROUND: More than 90% of all infections in the head and neck region can be traced back to an odontogenic origin. In rare cases they can lead to sepsis, which may pose a vital threat to the patient. The purpose of this study was to analyse characteristics concerning etiology and progress of severe odontogenic infections with a fulminant development. METHODS: All patients with odontogenic infections requiring hospital admission were included in a retrospective analysis conducted from 02/2012 to 09/2017. Of 483 patients 16 patients (13 male, 3 female) showed severe exacerbation with septic progress. The average age was 52.8 years. All patients underwent at least one surgical procedure that involved an extraoral incision and drainage as well as high volume irrigation intraoperatively. At least one revision was required for four of the patients. Three patients showed an exceedingly severe disease progression with multiorgan dysfunction syndrome (MODS) and circulatory arrest. Antibiotic treatment was adjusted according to the results of an antibiogram and resistogram. Irrigation with saline was done several times a day. RESULTS: Sixteen patients showed odontogenic infections that spread over multiple maxillo-facial and cervical regions accompanied by septic laboratory signs. All these patients needed intensive care and a tracheostomy. The hospitalization period was 27.8 days on average. In 16 cases risk factors for the development of odontogenic abscesses like diabetes mellitus, obesity, chronic alcohol and nicotine abuse, rheumatism and poor oral hygiene were present. Intraoperative swabs showed a typical polymicrobial aerobic and anaerobic spectrum of oral bacteria, especially anaerobes and streptococci, mainly Streptocococcus viridans. CONCLUSION: Odontogenic infections with fulminant progression should be treated based on clinical and imaging data with immediate surgical incision and drainage including elimination of odontogenic foci as well as intensified intra- and postoperative irrigation. If needed, repeat imaging followed by further incisions should be performed. Immediate antibiotic treatment adapted to the antibiogram is of utmost importance. A combination of tazobactam and piperacillin has proven to be a good first choice and can be recommended for abscesses that spread over multiple levels with initial signs of severe infections.

Monitoring a 'metabolic shift' after surgical resection of oral squamous cell carcinomas by serum lactate dehydrogenase.

OBJECTIVES: Monitoring surgical removal of oral squamous cell carcinomas (OSCC) is being routinely performed through clinical and imaging follow-up. We analyzed the potential use of serum lactate, lactate dehydrogenase (LDH), and LDH isoenzymes (LDH 1-5) as biomarkers in blood for the monitoring of surgical removal of OSCC. MATERIALS AND METHODS: Serum lactate, LDH, and LDH isoenzymes (LDH 1-5) have been prospectively assessed in healthy individuals (n = 19), patients with OSCC (n = 34: primary OSCC, n = 32 and recurrent OSCC, n = 2) before surgery and after curative tumor resection (n = 26). LDHA and LDHB expressions were analyzed by immunohistochemistry (IHC) in the same OSCC tumor specimen. RESULTS: Positive LDHA tumor tissue expression measured by IHC (n = 34/34, 100%) was significantly associated with increased serum LDH-5 (n = 24/34, 71%, P = 0.0258) but weak significantly associated with increased total serum LDH (n = 23/34, 68%, P = 0.0592). Positive LDHB tumor tissue expression measured by IHC (n = 25/34, 74%) was significantly associated with increased total serum LDH (P = 0.0172). After surgery, serum LDH and LDH-5 isoenzyme significantly decreased and LDH-1 significantly increased in the aftercare. A significantly inverse correlation of LDHA with LDHB IHC scores was found (P < 0.0001). CONCLUSIONS: The association of LDHA and LDHB measured by IHC with serum LDH indicates that analyzing this enzyme could serve as a favorable 'liquid biopsy' (non-invasive diagnostic tool) for OSCC.

Estrogen and Progesterone hormone receptor expression in oral cavity cancer.

BACKGROUND: Recent studies have shown an increase in the incidence of oral squamous cell carcinoma (OSCC) in younger patients. The hypothesis that tumors could be hormonally induced during pregnancy or in young female patients without the well-known risk factors alcohol or tobacco abuse seems to be plausible. MATERIAL AND METHODS: Estrogen Receptor alpha (ERα) and Progesterone Receptor (PR) expression were analyzed in normal oral mucosa (n=5), oral precursor lesions (simple hyperplasia, n=11; squamous intraepithelial neoplasia, SIN I-III, n=35), and OSCC specimen. OSCCs were stratified in a young female (n=7) study cohort and older patients (n=46). In the young female study cohort three patients (n=3/7) developed OSCC during or shortly after pregnancy. Breast cancer tissues were used as positive control for ERα and PR expression. RESULTS: ERα expression was found in four oral precursor lesions (squamous intraepithelial neoplasia, SIN I-III, n=4/35, 11%) and in five OSCC specimen (n=5/46, 11%). The five ERα positive OSCC samples were older male patients. All patients within the young female study cohort were negatively stained for both ERα and PR. CONCLUSIONS: ER expression could be regarded as a seldom risk factor for OSCC. PR expression seems to be not relevant for the development of OSCC.

Reimbursement for tissue reconstruction by pedicled and free flaps across five European countries. The importance of autologous breast reconstruction.

AIM: Case payment mechanisms have become the principle means of remunerating hospitals in many countries. We analysed the reimbursement for different types of autologous tissue transfer in five European countries. METHODS: We looked at common surgical options for breast reconstruction and flaps at other body regions. The principle diagnosis was systematically modified and processed with national grouper software to identify the relevant Diagnosis-Related Groups. RESULTS: The mean difference in payment was 4509 € in breast reconstruction versus only 2599 € in other locations. According to the underlying diagnosis for reconstruction, procedures after resection of malignant breast cancer showed higher reimbursement (mean 8319 €) than of other body parts (mean 6454 €). Sweden had the highest mean reimbursement (9589 €) followed by Austria (8032 €), Germany (7259 €), Italy (6667 €) and the UK (6037 €). Austria, Italy and the UK showed significant differences of reimbursement between pedicled flaps of the breast and other parts of the body. CONCLUSION: International data for the benchmarking and refinement of a national compensation system can be a useful instrument in identifying ways of improving each system. Across a spectrum of European countries, reimbursement for the reconstruction of the breast and other body parts was analysed and characteristics were identified. As rationalisation of healthcare becomes widespread in European countries, the need for individualised reimbursement which correlates accordingly is becoming ever more important.

Multiple osteolytic lesions of intraosseous adenoid cystic carcinoma in the mandible mimicking apical periodontitis.

AIM: Adenoid cystic carcinoma (ACC) is a relatively rare epithelial tumour of the salivary glands in the maxillofacial region. About 40-60% of the patients develop distant metastases, which have been documented most commonly in the lung but also in brain, bone, liver, thyroid, spleen and pancreatic gland. SUMMARY: A 55-year-old women with intraosseous ACC in the mandible mimicking apical periodontitis following curative resection and radiotherapy is presented. Three years later, multiple lung metastases were observed followed by chemotherapy. Five years after curative resection, the patient presented simultaneously with new expansive soft tissue in the pancreas and mammary gland as well as in the kidney found to be metastatic ACC. No case has been reported to date on the manifestation of distant metastases of intraosseous ACC in the breast and the kidney as described by these observations. Metastatic mammary gland ACC stained positive for epithelial growth factor receptor (EGFR) but was negative for HER-2/neu and Cyclooxygenase-2 (COX-2) expression.

[Analysis of Diagnosis Related Groups and their Impact on Health Care in Post Massive Weight Loss Surgery]. / Analyse von Fallpauschalen und deren versorgungsrelevante Effekte in der postbariatrischen Wiederherstellungschirurgie.

BACKGROUND: Diagnosis Related Groups (DRG) were introduced in Germany as a medico-economic classification system in 2004. In this analysis, we looked at restorative surgery after massive weight loss, focusing on reimbursement of this fee-per-case system in comparison to costs to deduce possible effects on health care over time. MATERIAL AND METHODS: First we analysed the algorithms for the relevant DRGs including data about length of stay and reimbursement. Furthermore, we integrated cost data from German reference hospitals of the last 5 years as well as single-centre data from a university hospital. RESULTS: Due to a diagnosis-related algorithm, coding will constantly lead to DRG K07Z. In 2016, a new diagnosis code specific to massive weight loss was introduced, which now leads to DRG J10B. As a result, reimbursement is reduced by more than half. In the cost matrix, staff, general ward, operation theatre and anaesthesia were identified as the main cost drivers. As expected, there was a statistically significant correlation between general ward costs and time of stay in hospital as well as operation theatre costs and incision-suture time. Considering the cost data of the reference hospitals, there was an average excess of EUR 781 per case whereas our own cost data revealed a deficit of EUR 1 700 to 2 700 per case. This is mainly due to the fact that approximately one third of our patient cohort underwent highly elaborate circular body lifts. CONCLUSION: It has to be questioned whether a newly introduced main diagnosis code can be applied as such without any underlying cost data having been collected in previous years. Given unchanged treatment measures, the main cost drivers identified by us remain the same, which means that there is no rationale for a drop in revenue. In addition to providing incentives for an efficient use of resources and quality optimisation, this system should offer medical service providers a sustainable and realistic possibility to break even.

[Development of DRGs in reconstructive breast surgery]. / Fallpauschalenentwicklung in der rekonstruktiven Mammachirurgie.

Diagnosis-Related Groups (DRG) were introduced in Germany in 2004 as a medico-economic classification system. In this analysis, we looked at reconstructive surgery after breast cancer, focusing on changes of the fee-per-case system in the last 6 years. Immediate, delayed, pedicle and free flaps as well as alloplastic reconstructive methods were analysed using data from German reference hospitals. We analysed the length of stay, reimbursements, costs and profits. The biggest profit margin was found in free perforator flaps. These were up to 3 times higher than in alloplastic reconstruction and pedicle flaps. Due to the fact that the underlying costs for the calculation of reimbursement are always retrospective, we accounted for the rate of price increase. In spite of increasing mean profits, foregone profits of up to €574 per case due to inflation were not taken into consideration. Contrary to actual guidelines, neither the immediate reconstruction of the breast by autologous tissue, nor the bilateral reconstruction is taken into account economically. Although a more differentiated reimbursement of breast reconstruction by DRG has taken place in the last years, the subject still remains a classical example for insufficient mapping of new medical standards in our DRG system. As the choice of surgical therapy is increasingly influenced by free market mechanisms, the risk for economic selection in contradiction to clinical recommendations becomes a real problem. Even 9 years after its introduction, the German DRG system is far from being a learning or quick adapting system.

[Necrosis of the jaws under bisphosphonate therapy]. / Nekrosen der Kieferknochen unter Bisphosphonattherapie.

Bisphosphonates are widely used in the treatment of cancer patients with hypercalcemia and bone metastases or in osteoporosis therapy. Current reports have focused on therapy-resistant osteonecrosis of the jaws as a possible side effect of bisphosphonates. Official German drug committees have recently warned about the possibility of these side effects. So far we have experience with 12 patients showing therapy-resistant osteonecrosis of the mandible under bisphosphonate medication, three of whom received oral bisphosphonates for osteoporosis treatment. Presentation of these three cases provides more information on this clinically important side effect of oral bisphosphonate medication, also in osteoporosis therapy.

[Rare entity of a macroscopically visible tumor cone of squamous cell carcinoma in the greater veins of the head and neck]. / Seltene Entität eines makroskopisch sichtbaren Tumorzapfens eines Plattenepithelkarzinoms in den grossen Kopf-Hals-Venen.

Cones of malignant tumors are commonly known but only a few descriptions of cones in the head and neck area exist - as seen in a 91-year-old patient under our care. Cones of thymic and thyroid cancers are described in the literature. There are no descriptions of cones of head and neck squamous cell carcinomas. Metastases of squamous cell carcinoma in the head and neck area are very aggressive and have a high potential for vascular neogenesis. A vascular cone might be possible by vascular formation or by mechanical intrusion as described elsewhere.

[Osteonecrosis of the jaws as a possible adverse effect of the use of bisphosphonates]. / Kieferknochennekrosen als mögliche unerwünschte Wirkung von Bisphosphonaten.

BACKGROUND: Bisphosphonates are widely used in the treatment of cancer patients with hypercalcemia and bone metastases or in osteoporosis therapy. Current reports have focused on therapy-resistant osteonecrosis of the jaws as a possible side effect of bisphosphonates. Official German drug committees have recently warned about the possibility of these side effects in the publication organs Deutsches Arzteblatt and Deutsche Apotheker Zeitung. CASE REPORTS: So far we have had experience with seven patients showing therapy-resistant osteonecrosis of the mandible under bisphosphonate medication. The presentation of these cases is intended to call attention to this clinically important side effect of bisphosphonate medication.

[Amyloidosis of the tongue as a possible diagnostic manifestation of plasmacytoma]. / Amyloidose der Zunge als diagnostisch richtungsweisende Manifestation des Plasmozytoms.

Plasmocytic non-Hodgkin's lymphoma is the most common tumor of bone and bone marrow, typically diagnosed by symptoms such as monoclonal paraproteinemia, proteinuria, anemia and hypercalcemia. In its progress, deposits of amyloids in almost all organs can be observed. However, plasmacytomas which are diagnosed by macroglossia of primarily unknown etiology are rare. This case report presents a 61-year-old woman who suffered from a persistent swelling of the tongue with painful ulcerations. A biopsy led to the diagnosis of primary systemic amyloidosis of the light-chain type, which subsequently proved to be a plasmacytoma with lambda light-chains stage II after Durie and Salmon. In the course of the disease the patient developed further deposits of amyloids in the whole gastro-enteric system. Macroglossia as a primary manifestation of plasmacytoma is rarely described in medical literature. However, reports on deposits of amyloid in the tongue in advanced stages of disease are well known.