Management of benign parotid tumors. What can we learn from our experience?

AIM: Parotid gland is the most common location for salivary gland tumors, more commonly pleomorphic adenoma and Warthin's tumor. Types of parotid surgery include superficial parotidectomy (SP), partial superficial parotidectomy (PSP), total conservative parotidectomy (TCP), enucleation (E), extracapsular dissection (ECD), and are related to different incidence of complications. The choice depends on tumors localization, dimension and histology. The aim was to compare complications rate such as facial and great auricular nerve impairment and Frey syndrome according to type of surgery performed. MATERIALS AND METHODS: We retrospectively review the management of 116 benign tumors of the parotid gland treated between January 2004 and January 2020 at our Department. RESULTS: Most frequent complication observed was a GAN deficiency (22.41%), permanent in 13% of cases. Post-operative facial nerve impairment was observed in 19 patients (persistent only in 1 case). Only Frey syndrome (4,31% of cases) seemed to be related to type of surgery (p<0.05) resulting more frequent in the group of patients that underwent "classical" parotidectomy, while facial nerve impairment, even if more frequent in this cases, did not statistically correlated with operative technique (p=0.054). CONCLUSIONS: Once experience is gained, in order to reduce post-operative morbidity extracapsular dissection is a reliable technique in the management of these neoplasms, even if attention has to be paid particularly in the removal of superficial masses "emerging" from the parenchyma. PSP is an alternative to SP, while CTP has to be reserved to selected cases ot tumors arising in the deep lobe. KEY WORDS: Benign tumor, Extracapsular dissection, Enucleation, Facial nerve Parotid gland, Parotidectomy, Superficial parotidectomy.

Management and treatment of sinonasal inverted papilloma.

AIMS: The aim of this paper is to describe the surgical experience of 35 patients with Inverted Papilloma (IP) of paranasal sinuses and its recurrence rate after a year of follow-up. MATERIALS: A retrospective chart review was performed on patients presenting with IP of paranasal sinuses. Thirty-five patients comprised the focus of this study. For all patients was performed a pre-surgery TC, and for more 5 patients it was necessary to perform a Magnetic Resonance (MR) with gadolinium. RESULTS: Among 35 patients selected, 18 patients underwent to open surgery, 4 patients had a combined approach with endoscopy and open surgery, while 13 patients were managed only with an endoscopic approach, with a minimum of 1 year of follow-up. Our results highlighted that the global percentage of success 12 months after the treatment was 93% and it not vary according to the tipology of the approach used if a radical excision of the lesion is achieved. More in depth, among 35 cases, only 2 patients were found to have recurrences and were treated with coronal and endoscopic approach. CONCLUSION: It is fundamental to underline that surgery must be carried on in a radical manner to treat these tend to recur. A complete removal of the lesion and bone peripheral border filing are essential to perform a correct and definitive treatment. Also, endoscopic approach can be taken into account when tumors are localized median to a sagittal plan crossing the orbit median wall and when they did not massively compromised paranasal sinus walls.

Aesthetic restoration in maxillo-mandibular malformations: the role of genioplasty.

AIM: The aim of this study was to determinate how orthognatic surgery aids to cure many skull and face abnormalities and to help re-establishing the correct occlusive relation thanks to the repositioning of the maxillo-mandibular skeleton basis. METHODS: The study included 183 male patients and 338 female patients, with an average age of 23 years. The sample series was divided according to specific pathologies. All patients underwent surgical procedures and the therapeutic strategy was determined based on the anomalies presented. RESULTS: 113 patients had a II class dental skeletal occlusion, 180 patients had a III class dental-skeletal occlusion and 222 patients had skull-facial abnormalities. 5 patients underwent only a genioplasty, 82 patients underwent a genioplasty associated with BSSO, 175 patients underwent a genioplasty associated with Le Fort I osteotomy and the remaining 253 patients underwent a genioplasty associated with BSSO and Le Fort I osteotomy. CONCLUSION: The experience shows that genioplasty has been successfully introduced in orthognathic surgical therapeutic procedures, for dental-skeleton abnormalities and mandibular asymmetries treatment. In recent years, the evolution of computer systems has allowed an accurate assessment and programming, by means of the three-dimensional display, which are of great help in the course of diagnosis and evaluation of the displacements to be carried out, in order to obtain optimal aesthetic results.

Open reduction and internal fixation of extracapsular mandibular condyle fractures: a long-term clinical and radiological follow-up of 25 patients.

BACKGROUND: During the last 2 decades, many studies on the treatment of mandibular condyle fracture have been published. The incidence of mandibular condyle fractures is variable, ranging from 17.5% to 52% of all mandibular fractures. This retrospective study evaluated the long-term clinical and radiological outcomes after surgical treatment of 25 patients with a total of 26 extracapsular condyle fractures. METHODS: We used 2 types of surgical approaches, the retromandibular retroparotid or preauricular approach. Three kinds of rigid internal fixation plates were used-single plate, double plate, and trapezoidal plate. The following post-operative clinical parameters were evaluated: dental occlusion, facial nerve functionality, skin scarring, and temporomandibular joint functionality. All patients underwent post-operative orthopanoramic radiography and computed tomography. The patients were also monitored for complications such as Frey's syndrome, infection, salivary fistula, plate fracture, and permanent paralysis of the facial nerve; the patient's satisfaction was also recorded. RESULTS: Of the 25 patients, 80% showed occlusion recovery, 88% had no facial nerve injury, and 88% presented good surgical skin scarring. The patients showed early complete recovery of temporomandibular joint functionality and 72% of them were found to be asymptomatic. The postoperative radiographs of all patients indicated good recovery of the anatomical condylar region, and 80% of them had no postoperative complications. The average degree of patient satisfaction was 8.32 out of 10. Our results confirm that the technique of open reduction and internal fixation in association with postoperative functional rehabilitation therapy should be considered for treating patients with extracapsular condylar fractures. CONCLUSION: The topic of condylar injury has generated more discussion and controversy than any other topic in the field of maxillofacial trauma. We confirm that open reduction and internal fixation is the treatment of choice for patients with neck and sub-condylar mandibular fractures.

Bisphosphonate therapy and osteonecrosis of the jaw complicated with a temporal abscess in an elderly woman with rheumatoid arthritis: a case report.

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is an adverse drug reaction described as the progressive destruction and death of bone tissue of the mandible or maxilla, in the course of bisphosphonate therapy. Orally administered bisphosphonates, widely used for the treatment of osteoporosis, are rarely associated with BRONJ. Instead, the risk greatly increases whether the patient is concomitantly taking steroid and/or immunosuppressant agents. The aims of this paper are to briefly discuss the evidence of the associations between bisphosphonate therapy and BRONJ, and the effects of co-occurring factors such as the presence of rheumatoid arthritis, dental surgery, and concomitant corticosteroid therapy. In particular, we present the case of an elderly woman with BRONJ suffering from rheumatoid arthritis, with a recent dental extraction and with a very unusual complication: a temporal abscess, who was successfully treated.

Fronto-ethmoidal osteoma. Open treatment.

INTRODUCTION: Osteoma is a benign tumour, composed of mature compact or cancellous bone, which can arise in any facial bone. Among the paranasal sinuses, the frontal and ethmoid sinuses are most frequently involved. Osteoma grows very slowly and small lesions are often not symptomatic. On the other hand, sometimes patients present with symptoms such as sinusitis, headache or ophtalmologic manifestations. These findings are secondary to obstruction of the involved sinus cavity with secondary mucocele formation or occasionally an expansile lesion with distortion of the facial contour. MATERIALS AND METHODS: From 2005 to 2010, twenty-one (21) patients affected with non-syndromic fronto-ethmoidalosteomas were evaluated in our Department. Collected data include patients' age at the time of disorders, gender, presenting signs and symptoms, primary diagnosis, type and characteristics of the treatment performed, radiological findings and post-treatment results. All patients were investigated by CT scans in axial and coronal planes. The treatment and outcomes of this group were reviewed. RESULTS: All patients of the study underwent surgery and had a follow-up of at least 5 years. Surgical excision of the tumour was undertaken. Postoperative CT scans in axial and coronal planes showed complete removal of the tumour in all cases. No complications or recurrences were observed. DISCUSSION: Small, asymptomatic osteomas probably do not need to be treated but should be observed periodically. Surgical management remains the mainstay of treatment for these tumours. It requires total excision via an adequate approach, depending upon the site of presentation. CONCLUSION: A purely endoscopic endonasal approach has the risk of incomplete excision. In our experience open technique provides a wide exposure and better control. Even frontal osteomas can be safely removed by careful open surgery KEY WORDS: Ethmoidal sinus, Frontal sinus, Open treatment, Osteoma, Paranasal sinuses.

Variation of the upper airways in pediatric patients with OSAS and retrusion of the midface.

In pediatric patients, the incidence of Sleep-Disorder breathing (SDB) is 2% for OSAS and 7-8% for snoring. Snoring, sleep apnea and the development of neurocognitive and behavioral disorders represent the main symptoms. In these children, snoring is noisy and is present for the greater part of sleep. Accurate diagnosis and treatment protocol is critical for a child with OSAS as it is associated to complications as: pulmonary hypertension, chronic pulmonary heart disease, low height-weight development, behavioral problems, reduced school performance, bedwetting and daytime sleepiness or irritability. For this reason, over the years different surgical techniques were developed to solve the clinical symptoms evident on the polysomnographic test. In this paper, the authors report the experience at the Department of Cranio-Maxillo-Facial Surgery, Policlinico Umberto I, "Sapienza" Università di Roma, in the treatment of pediatric patients with OSAS and midface retrusion.

Endoscopic approach to maxillo-facial trauma.

AIM: This article reviews the application of endoscope-assisted techniques to the treatment of maxillofacial trauma and discusses some aspects of these techniques and reporting our experience. INTRODUCTION: In the last decades, diagnostical imaging, surgical techniques and surgical instrument development allowed a great progress in management of facial fractures. In recent years, to some Authors, endoscopic approach to maxillofacial trauma has become common for reducing zygomatic arch, orbital blow-out, medial orbital wall, frontal sinus and subcondylar mandibular fractures. The endoscopic reduction of facial fractures as an alternative to open reduction allowed to manage patients with less unwanted complications. In fact, endoscopic approach permit to decrease perisurgical morbidity and offers to surgeons to reach good results. DISCUSSION: Indications to endoscopic reduction are represented by dimension, extension and site of the fracture and to the surgeon's experience. CONCLUSIONS: The use of endoscopy in maxillo-facial surgery represents one of the main realities of modern medicine together with advanced sectors of biomedical engineering research. In this way, not only time of hospitalization will be reduced but also morbidity in maxillofacial surgery.

Pigmented villonodular synovitis of the temporomandibular joint.

Pigmented villonodular synovitis (PVNS) is a relatively rare disease affecting synovium-lined joints. PVNS was first fully described in 1941 by Jaffe et al, who considered it a benign inflammatory state of the synovium of uncertain etiology. Reports of this disease in the temporomandibular joint (TMJ) are extremely rare. This report describes a case of a 78-year-old man affected by PVNS of the right TMJ. Clinical examination revealed the presence of a right-sided preauricular mass; a magnetic resonance imaging scan showed a mass located lateral to the right mandibular condyle, close to the TMJ capsule. The clinical and pathologic features of the case are described.

Isolated sphenoid sinus mucocele: etiology and management.

Sphenoid isolated lesions are rare; they occur in 2% to 3% out of all paranasal sinus lesions. Diagnosis is based on the endoscopic examination and computed tomography scan or magnetic resonance imaging of the maxillofacial area. In this study, we present patients with sphenoid mucocele in the Maxillo-facial Surgery Department, University of Rome La Sapienza, treated with the endoscopic technique. Moreover, a literature review is performed, dealing with the evolution of approaches to the sphenoid sinus. From January 2001 to January 2007, we treated 75 patients affected by paranasal sinus mucocele. Out of this number, 8 patients (11%) presented an isolated localization in the sphenoid sinus. These patients were divided as follows: 5 involved the right sphenoid sinus and 3 involved the left sphenoid sinus. Isolated sphenoid sinus disease is a rare entity that can result in serious sequelae if diagnosis and treatment are inappropriately delayed. In our study, we highlighted how the endoscopic approach allows the removal of even large mucocele with the use of 45-degree angle optic and if it is possible to control and remove lateral walls of the sphenoid sinus. In our experience, we shifted from a traditional approach to the endoscopic approach. At the present time, the endoscopic approach represents the gold standard for sphenoid sinus mucocele treatment because it allows the best view of the sphenoid sinus and grants a better restoring of respiratory function and a higher compliance from the patient.

Ozone therapy in the treatment of avascular bisphosphonate-related jaw osteonecrosis.

Avascular osteonecrosis of the jaw (ONJ) may occur as a consequence of several conditions, even including chemotherapy treatment in patients affected by tumors or osteoporosis. We report our clinical experience in treating bisphosphonate-induced ONJ with a therapeutic methodology that includes ozone therapy as a new and original approach for the clinical management of maxillary necrotic lesions. Of 58 patients with ONJ observed at our department, 33 gave their informed consent to be part of the research and were treated according to a therapeutic approach, which included noninvasive surgery associated with pre- and postsurgical cycles of ozone therapy consisting of eight sessions lasting 3 minutes each besides antibiotic and antifungal therapies. Outcomes showed how ozone therapy increases the benefits of surgical and pharmacologic treatments, increasing the complete healing of the lesions with the disappearance of symptoms and brings cases of lesion progression down to zero. In conclusion, ozone therapy is a reliable presidium in treatment of ONJ; its benefits are remarkable and improve significantly the outcomes of the surgical approach.

Complex-type penetrating injuries of craniomaxillofacial region.

Craniofacial traumas are one of the most common clinical events of the 21st century. The possibility of associated injuries of the head and neck may also determine functional and cosmetic problems in these patients. The most frequent pathologic conditions observed are contusions, lacerations, abrasions, avulsions, and the inclusion of foreign bodies. In particular, penetrating injuries represent a rare but complex variety of craniofacial trauma. Generally, the penetrating material is stiff enough to cross through different anatomic structures during a particularly violent collision caused by a road or work accident or during an attack. The therapeutic strategy adopted for this type of patient depends mainly on diagnostic procedures such as skull radiograms in different projections, computerized tomography, magnetic resonance imaging, and, occasionally, echotomography. However, on arrival at the emergency department, the clinical conditions of the patient will determine the type of investigation to be carried out. Last, to prevent any postoperative infections, wide spectrum antibiotic therapy is advisable. Ideally, imaging should be repeated postoperatively to confirm resolution of the initial clinical condition. In this article, the authors describe three unusual clinical cases of patients with penetrating injuries of the head and face together with the protocol adopted for treatment of such complex craniofacial injuries. The three cases described demonstrate that, despite the initial appearance of penetrating wounds, a correct diagnostic assessment followed by a suitable therapeutic protocol can reduce cosmetic and functional defects to a minimum.

LeFort III advancement with and without osteogenesis distraction.

The LeFort III osteotomy is the surgical treatment performed in patients with mid-facial retrusions in craniofacial dysostoses such as Crouzon, Apert, Pfeiffer syndromes, etc. The first authors to report the accomplishment of this osteotomy were Gillies and Harrison in 1951, this technique was then resumed and improved by Tessier in 1967, who made five different variants mainly regarding the typology of the osteotomy concerning the lateral wall of the orbit. Recently, distraction techniques have been applied to the upper mid-face which foresees a gradual advancement of the mid-face through the osteogenetic distraction procedure. The purpose of this retrospective clinical outcome study is to evaluate and compare the two different surgical techniques through the experience acquired during the treatment of 15 cases of craniofacial dysostoses from 1990-2005, and through international literature. The standard surgery technique was performed in 5 of these patients, whereas the osteogenetic distraction technique was performed in the remaining 10. All patients were studied preoperatively through the acquisition of photographic images, cephalometric analysis of the skull, and the study on plaster models of the occlusion of the dental arches. The instrumental exams required before surgery are the following: telecranium X-rays in two projections, orthopanoramic X-rays, CT. The results of this study indicate that the osteodistraction technique represents the choice treatment in severe retrusions of the mid-face while the traditional surgical technique remains indicated in adult patients that are in need of moderate advancements.

Pigmented villonodular synovitis of the temporomandibular joint.

Pigmented villonodular synovitis (PVNS) is a relatively rare disease, affecting the synovial-lined joints. PVNS was first fully described by Jaffè in 1941, who considered it to be a benign inflammatory state of the synovium of an uncertain etiology. Reports of this disease in the temporomandibular joint (TMJ) are extremely rare. The authors report a case of a 38-year-old woman affected by pigmented villonodular synovitis of the TMJ. Clinical examination revealed the presence of a preauricular mass in the left side; a computed tomography scan showed a 3.0 x 2.0 cm preauricular mass in close continuity to the TMJ capsule. The purpose of this report is to describe the clinicopathological features of a case involving the TMJ. The previously reported cases in the literature are also reviewed.