A giant parapharyngeal lipoma causing obstructive sleep apnea.

Lipoma is the most common soft tissue mesenchymal neoplasm. Its occurrence is low in the oral cavity (1 to 4%) and in head and neck region (20 to 25%). Usually asymptomatic and slowly growing, lipoma can compress neighboring cervico-facial structures causing dysphagia, dyspnea, or obstructive sleep apnea. We describe an unusual case of giant cervico-parapharyngeal lipoma causing an obstructive sleep apnea in a 69-year-old man and with the complete remove of OSA after surgical procedure.

Costal graft as a support for bone regeneration after mandibular juvenile ossifying fibroma resection: An unusual case report.

Spontaneous regeneration of bone tissue after mandibular resection is rare in adults, although it does often take place in children. Periosteum conservation appears to play a major role in this healing process. We here report regarding a 5-year-old boy who exhibited a large mandibular trabecular juvenile ossifying fibroma. The lesion was treated by mandibulectomy, with careful preservation of the periosteal layer and immediate reconstruction with a costal graft by an intraoral approach. Monitoring over the course of a year revealed spontaneous mandibular regeneration, and it allowed for a series of measurements of the graft to be made. During this follow-up period, the mandibular height increased from 41.5% to 75.2% (P=0.0008) of the height of the unaffected mandibular height, while the width grew from 34.4% to 82.8% (P=0.0078) of the width of the healthy side, thus demonstrating the importance of a conservative approach regarding the periosteum in such situations. The costal graft acted as a support for bone regeneration by immobilizing the remaining bone fragments and by preventing soft-tissue prolapse.

[Asymmetric hypertrophy of the masticatory muscles]. / Hypertrophie asymétrique des muscles masticateurs.

INTRODUCTION: Hypertrophy of the masticatory muscles most commonly affects the masseter. Less common cases of isolated or associated temporalis hypertrophy are also reported. Parafunctional habits, and more precisely bruxism, can favor the onset of the hypertrophy. This condition is generally idiopathic and can require both medical and/or surgical management. OBSERVATION: A 29-year-old patient was referred to our department for an asymmetric swelling of the masticatory muscles. Physical examination revealed a bilateral hypertrophy of the masticatory muscles, predominantly affecting the right temporalis and the left masseter. Major bruxism was assessed by premature dental wearing. The additional examinations confirmed the isolated muscle hypertrophy. Benign asymmetric hypertrophy of the masticatory muscles promoted by bruxism was diagnosed. Treatment with injections of type A botulinum toxin was conducted in association with a splint and relaxation. Its effectiveness has been observed at six months. DISCUSSION: Few cases of unilateral or bilateral temporalis hypertrophy have been reported, added to the more common isolated masseter muscles hypertrophy. The diagnosis requires to rule out secondary hypertrophies and tumors using Magnetic Resonance Imaging. The condition is thought to be favoured by parafunctional habits such as bruxism. The conservative treatment consists in reducing the volume of the masticatory muscles using intramuscular injections of type A botulinum toxin. Other potential conservative treatments are wearing splints and muscle relaxant drugs. Surgical procedures aiming to reduce the muscle volume and/or the bone volume (mandibular gonioplasty) can be proposed.

[Long-term follow-up of cemento-osseous dysplasia: a contralateral recurrence before radiotherapy]. / Évolution à long terme de la dysplasie cémento-osseuse: une récidive controlatérale avant radiothérapie.

INTRODUCTION: Cemento-osseous dysplasia is a benign fibro-osseous lesion of the jaws. Its complications are very rare. OBSERVATION: A panoramic x-ray was made to complete the pre-radiotherapy oral assessment of a 71-year-old female patient presenting with lung adenocarcinoma. This revealed a periapical fibro-osseous lesion on tooth n° 46. She had presented with a similar lesion on tooth n° 36, 16 years before. This had been treated by extraction and alveolar curettage. No surgical treatment was suggested for this recurrence on tooth n° 46. DISCUSSION: The diagnosis of focal cemento-osseous dysplasia is usually made on radiological and clinical data. The risk for transition to a florid form is unknown. Exeresis surgery before radiotherapy is discussed.

Propofol versus sevoflurane for fiberoptic intubation under spontaneous breathing anesthesia in patients difficult to intubate.

BACKGROUND: The most recommended technique for the management of patients with a difficult airway is fiberoptic intubation (FOI). The aim of this study was to compare propofol and sevoflurane for FOI performance in patients who were difficult to intubate. METHODS: Seventy-eight patients scheduled for maxillo-facial surgery were included in this prospective, randomized study. The airway was topically anesthetized with lidocaine 5% before performance of FOI with propofol TCI (group P) or sevoflurane (group S). The following parameters were recorded: rate of success, duration of the induction and of the FOI, BIS and PETCO2 values. A visual analogic scale (VAS) was used to monitor the technical difficulties as well as the recall of patients and their satisfaction. The respiratory and hemodynamic complications were also evaluated. RESULTS: Induction and procedure duration were significantly shorter in group S compared with group P. The rate of successful FOI was not different: 38 cases (97%) in group P and 35 cases (90%) in group S. No significant differences were observed between groups regarding BIS values and VAS values for technical difficulties and for patient recall and satisfaction. The incidence of hypertension or tachycardia was significantly higher in group S compared with group P. The incidence of respiratory complications was not significantly different between the groups, but three patients experienced obstructive dyspnea with hypoxemia. CONCLUSION: Propofol and sevoflurane provide a high success rate for the performance of FOI in patients who are difficult to intubate.

[Very large mandibular keratocysts: review]. / Très grands kératokystes mandibulaires: mise au point.

The odontogenic keratocyst (OKC) is unique among odontogenic cysts of the jaws, especially because of the high risk of recurrence. Epidemiological studies demonstrate male predominance and the most common location in the mandible. We reviewed our own experience with eight patients and data in the literature, focusing on very large mandibular keratocysts. We reviewed the clinical, radiological, and histological elements required for the positive and differential diagnosis. CT scans should be performed for very large cysts due to their superiority over plain x-rays, both for treatment planning and follow-up. Surgical treatment is indicated. The choice remains controversial between radical and conservative approach. We prefer conservative treatment. Problems concerning bone healing, recurrence and follow-up are also discussed.

[Difficult surgical management of facial neurofibromatosis type I or von Recklinghausen disease in children]. / Difficultés de la prise en charge chirurgicale des manifestations faciales de la neurofibromatose de type I ou maladie de von Recklinghausen chez l'enfant.

We report a case of predominantly facial neurofibromatosis type I in a 7-year-old girl, exposing the difficulties encountered in surgical management. Infiltration of facial soft tissues by plexiform neurofibroma is difficult to control. Resection of large areas of facial skin is unconceivable, facial functions must be preserved. Orbitocranial surgery is reserved for orbital manifestations of neurofibromatosis with osseous sphenoid dysplasia and pulsatile exophthalmos. Despite progress in tumor imaging and surgery, facial neurofibromatosis remains a challenge for the surgeon. We discuss surgical technique and indications for surgery in these cases.

[Gross tumor volume and clinical target volume in radiotherapy. Tumors of the buccal cavity]. / Volume tumoral macroscopique et volume-cible anatomoclinique en radiothérapie. Tumeur de la cavité buccale.

Radiation therapy, either alone or combined with surgery is a cornerstone in the treatment of oral cavity tumors. Target volumes to be treated with external beam radiation must take under consideration the initial tumor location, providing information on satellites lymph nodes to be irradiated as well. Modern imaging, with emphasis on CT scan with injection, is now mandatory for a better analysis of initial lesions including both tumor location and invaded lymph nodes. Tumor volumes based on clinical examination and CT scan analysis might be divided in two groups. First, volumes susceptible to receive a prophylactic irradiation for an hypothetical microscopic spread (CTV) to be treated with a prophylactic dose; second, volumes including lesions visible clinically or on CT scan that should receive a higher radiation dose (GTV). Clinical tolerance will largely be depending upon radiation-induced mucositis, impairing food intake. Radiation techniques aiming at normal tissues preservation should be used, including devices allowing keeping an open mouth during radiation delivery.

Enhancement of delta aminolevulinic acid-photodynamic therapy in vivo by decreasing tumor pH with glucose and amiloride.

OBJECTIVES/HYPOTHESIS: Delta aminolevulinic acid (ALA)-induced protoporphyrin IX (PpIX) is a fluorescent sensitizer that permits detection and treatment of squamous cell carcinoma of the oral cavity. An exogenously induced decrease in tissue pH was evaluated for its effect in enhancing cellular uptake of ALA and facilitating its transformation into PpIX. STUDY DESIGN: Mice grafted with HT29 colonic cancers had been given glucose and amiloride to modify the pH of tissues. Influence of pH changes has been evaluated on ALA-induced PPIX fluorescence by optic fiber spectrofluorimetry as well as on tumor growth. RESULTS: The pH in HT 29 tumor decreased from 7.1 to 6.67 (P < .05) after intraperitoneal injection of glucose and amiloride. The PpIX fluorescence ratios in tumor or muscle before, between, and 2 hours after glucose and amiloride injection were not higher than control ratios. Aminolevulinic acid-photodynamic therapy was more efficient on HT 29 tumor-bearing mice when the pH value was decreased with glucose and amiloride, showing a difference in the tumor growth index ratio from the 1st to 14th day of 22% between amiloride-glucose aminolevulinic acid-photodynamic therapy and aminolevulinic acid-photodynamic therapy alone (P < .05). CONCLUSIONS: Glucose and amiloride did not change PpIX fluorescence in HT 29 tumor after intraperitoneal injection of aminolevulinic acid but enhanced aminolevulinic acid-photodynamic therapy efficacy. This was probably a result of mechanisms other than an increase in aminolevulinic acid cellular penetration and PpIX production, such as susceptibility to free radical toxicity or alteration of cellular repair enzymes under acidotic conditions. If a decrease of pH induces a more efficient photodynamic therapy as suggested by our results, an easier way to obtain this decrease than glucose and amiloride would be necessary for clinical applications.

[Ewing's sarcoma of the jaw. The value of multidisciplinary management. Apropos of 4 cases]. / Sarcome d'Ewing des maxillaires. Intérêt d'une prise en charge multidisciplinaire. A propos de 4 cas.

Ewing's sarcoma is the second most common malignant bone tumor of childhood, yet it is a rare tumor. Primary maxillary localization is unusual and occur in only 1-2% of cases, mostly in the mandible. The prognosis of Ewing's sarcoma has been improving considerably since the introduction of combined modality treatment. The estimated overall survival at 4 years is 75%. It is widely accepted that prompt chemotherapy is necessary to treat occult micrometastasis, present in over 80% of cases at time of diagnosis, and to reduce the tumor size. Prognostic factors correlated with a poor overall survival are large tumor size and poor histologic response to initial chemotherapy. Adequate local control of Ewing's sarcoma can be achieved after chemotherapy, with radical or conservative surgery and radiotherapy. Surgery was recommended whenever possible. Radiation dosage and fields are based upon the quality of surgery and histological response to chemotherapy. Concern has been raised, however, regarding deleterious late effects of radiation in this young population. Conservative surgery and reconstruction are often used to improve functional outcome. We report four cases of Ewing's sarcoma localized to jaw bone and mandible, successfully treated by combined modality treatment.

[Lingual osteoma. Apropos of a case]. / Ostéome lingual. A propos d'un cas.

The authors present a case of osteoma of the tongue. This tumor was discovered without any functional symptom. Surgical resection with histological examination gives the diagnostic. This choristoma is rare, benign and clinically poor. Osteoma of the tongue is a heterotopic bone tissue and his main differential diagnosis are lingual thyroid and thyroglossal cyst. There are several opinions concerning the histogenesis of this choristoma, but an embryological anomaly is probable. Surgical removal of the tumor is curative, without any reported local recurrence.

Advantages and limitations of the fibula free flap in mandibular reconstruction.

PURPOSE: The authors analyze the advantages and disadvantages of mandibular reconstruction with a fibula free flap in a retrospective study of 29 cases, and make comparisons with the iliac free flap and the lateral brachial free flap. MATERIAL AND METHODS: Twenty-nine patients (22 male, 7 female) aged 5 to 70 years were studied. Functional and esthetic evaluations were performed together with radiologic examination of the bony calluses. RESULTS: The fibula free flap has advantages for mandibular reconstruction, such as the length of bone available, low morbidity of the donor site, and the possibility of using a skin paddle. However, there is the disadvantage of not being able to reconstruct large soft tissue defects. In addition, bone vascularization is reduced when a large number of osteotomies are required. CONCLUSION: This reconstruction technique is satisfactory for mandibular defects measuring over 20 cm.

[Maxillofacial manifestations of Steinert's myotonic dystrophy. Clinical and therapeutic aspects]. / Manifestations maxillo-faciales de la dystrophie myotonique de Steinert. Aspects cliniques et thérapeutiques.

The craniofacial manifestations, together with teleradiographic and cephalometric findings, of Steinert's dystrophy were examined based on a review of the literature and the clinical features of several patients with myotonic dystrophy leading to the diagnosis of Steinert's disease. The prevalence of the functional impairments due to facial deformation varies with the severity of the disease, suggesting early interceptive treatment supported by orthopaedic care and rehabilitation therapy of orofacial functions. Surgery involves bimaxillary osteotomy which can improve mastication and facial morphology. Operative risks should be carefully identified with adequate explorations before surgery.

[Limited mouth opening due to muscular fibrosis after locoregional anesthesia. Apropos of a case]. / Limitation d'ouverture buccale par fibrose musculaire après anesthésie locorégionale. A propos d'un cas.

The amplitude of buccal opening was limited due to fibrosis of the middle pterygoideus muscle two months after a patient had undergone anaesthesia of the lower dental nerve trunk. Surgery was required. A physiological explanation was attempted based on other cases reported in the literature.

[Mandibular metastasis of hepatocellular carcinoma. Apropos of 3 cases]. / Métastases mandibulaires des carcinomes hépato-cellulaires. A propos de 3 observations.

Three cases of mandibular metastasis of hepatocellular cancer are reported. The specific characteristics are described: rarity, discovery, localization, haemorrhagic biopsies and histological criteria. Prognosis is poor.

[Saethre-Chötzen syndrome. A study apropos of 17 cases]. / Le syndrome de Saethre-Chötzen. Une étude à propos de 17 cas.

Case reports of seventeen patients with the Saethre-Chötzen syndrome treated at the Stomatology and Maxillofacial Surgery Clinic, Nantes, France are analyzed, together with clinical and paraclinical signs of this syndrome, included within the framework of the acrocephalosyndactylies. Results of cases reported in the published literature are reviewed and compared with those of the present series. The characteristic craniofacial equilibrium of the Saethre-Chötzen syndrome is discussed, together with findings of a teleradiographic study performed according to Delaire's analysis. A discussion on the differential diagnosis of this syndrome is enlarge to include all acrocephalosyndactylies.

[Our experience using free vascularized bone flaps in mandibular reconstruction. The external brachial flap, the fibular flap, the para-scapular flap]. / Notre expérience des lambeaux libres vascularisés osseux dans les reconstructions mandibulaires. Le lambeau brachial externe, le lambeau fibulaire, le lambeau parascapulaire.

New techniques developed over the last decade use vascularized bone flaps for maxillofacial reconstructive surgery. Indications for use of three recently described flaps (external brachial, fibular, parascapular) are discussed as a function of the regions to be reconstructed. Three clinical cases are presented, each patient having received one type of flap.

[Prognostic and therapeutic aspects of lympho-epithelial lesions of the parotid. Apropos of 8 cases]. / Aspects pronostiques et thérapeutiques des lésions lympho-épithéliales de la parotide. A propos de 8 observations.

The so-called benign lympho-epithelial lesion (BLEL) of the parotid is a rare condition. Its diagnosis is based on histology. For a long time there have been problems with its classification and prognosis: classification since certain cases may be classified as Sjögren's syndrome or as a precursor of the latter, prognosis there may be recurrence, contralateral involvement or progression to non-hodgkin's lymphoma. The authors discuss these factors in 8 cases and propose total parotidectomy with facial nerve preservation as the treatment of choice.