Not by the Red on My Chinny Chin Chin: A Case of Mandibular Osteomyelitis in a 5-Year-Old Girl.

BACKGROUND: Osteomyelitis is not an uncommon emergency department diagnosis in pediatric patients, and most cases are in the lower extremities. Children can present with acute, subacute, or chronic erythema, pain, swelling, or decreased use of the extremity; some patients will also have fever or elevated serum inflammatory markers, or both. CASE REPORT: We present the case of a healthy 5-year-old girl who presented to the emergency department with 3 weeks of painless chin swelling and 2 days of erythema and pain. While laboratory testing was normal, magnetic resonance imaging demonstrated osteomyelitis of the mandible, later confirmed by biopsy. After 4 weeks of intravenous antibiotics and an additional 2 weeks of oral antibiotics, the patient recovered completely without any residual findings. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case demonstrates that osteomyelitis can develop in previously healthy, fully vaccinated children with competent immune systems. Systemic findings (ie, fever and elevated serum inflammatory markers) may be absent, and osteomyelitis should always be considered in the differential diagnosis for a child presenting with subacute to chronic cutaneous findings without other clear explanation.

Quantitative EMG criteria for diagnosing idiopathic REM sleep behavior disorder.

PURPOSE: The purpose of this study is to determine the diagnostic cutoff for the proportion of rapid eye movement (REM) sleep with tonic and phasic activities of the submentalis muscle activity that can be used to diagnose REM sleep behavior disorder (RBD). METHODS: Seventeen patients clinically diagnosed as idiopathic RBD and 15 age- and gender-matched controls were studied. Surface electromyography was recorded from the submentalis muscle, and two sleep technologists manually identified epochs with tonic and phasic activities during REM sleep. Receiver operating characteristic (ROC) curves were constructed to find the optimal cutoff values for diagnosing RBD using the proportion of REM sleep with tonic and phasic activities of the submentalis muscle. Cohen's kappa coefficient was calculated to evaluate interrater reliability. RESULTS: The cutoff value with the optimal sensitivity and specificity was 6.5% for the proportion of REM sleep with tonic activity (sensitivity, 94.1%; specificity, 93.3%; area under the ROC curve, 0.976) and 9.5% for the proportion of REM sleep with phasic activity (sensitivity, 94.1%; specificity, 93.3%; area under the ROC curve, 0.992). The cutoff value required to achieve a specificity of 100% was 8.9% for tonic activity and 11.1% for phasic activity. Cohen's kappa coefficient between two scorers was 0.96 (95% confidence interval, 0.95-0.97) and 0.95 (95% confidence interval, 0.94-0.95) for tonic and phasic activities, respectively (both p < 0.001). CONCLUSIONS: Identifying periods of tonic and phasic activities of the submentalis muscle during REM sleep is useful to discriminate patients with idiopathic RBD from controls.

Chin fasciculations in Madras motor neuron disease: a new clinical feature.

The characteristic features of Madras motor neuron disease (MMND) are onset in the young in the first two decades, sporadic occurrence, facial and bulbar paralysis, sensorineural hearing impairment, asymmetrical weakness of limbs and pyramidal signs with a slow progression. The majority of the cases reported are from South India. MMND variant has the additional features of optic atrophy and cerebellar signs. We are reporting a 48 year old female of MMND who had persistent fasciculations of chin, with electromyographic features of fasciculations and fibrillations in mentalis muscle. Chin fasciculations, a rare clinical feature, is now described for the first time in Madras motor neuron disease adding a new feature to the clinical constellation of symptoms.

Thermal sensory and pain thresholds in the tongue and chin change with age, but are not altered in burning mouth syndrome.

BACKGROUND: Burning mouth syndrome (BMS) is a chronic orofacial pain syndrome that occurs in middle-aged and postmenopausal women and poses a therapeutic challenge to dermatologists and dentists. It has been suggested previously that BMS is a small-fiber neuropathy. AIMS: This study was designed to examine thermal sensory and pain thresholds in the oral mucosa and chin, both innervated by the trigeminal nerve, in patients with BMS, as well as in healthy controls. In addition, the study proposed to examine whether there are any differences in oral thermal and pain sensations between the advanced age group, where BMS is prevalent and a younger group. RESULTS: Thermal and pain thresholds of BMS patients did not differ significantly from those of healthy subjects. An increased threshold to thermal warmth and a decreased threshold for cold sensation for the tongue and chin were noted in the group over 50 years in comparison with younger subjects, indicating a decreased sensitivity to thermal stimuli. The group over 50 years of age displayed an increased sensitivity to cold pain and a decreased sensitivity to hot pain in the tongue (compared with the chin). CONCLUSION: BMS patients do not demonstrate alterations in thermal and pain detection, thus failing to support a true small nerve neuropathy in this condition.

Safety and surgical outcomes of transoral endoscopic thyroidectomy vestibular approach for papillary thyroid cancer: A two-centre study.

OBJECTIVE: The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been increasingly used to treat patients with papillary thyroid cancer (PTC) with improved cosmetic outcomes. This study aimed to explore the safety and efficacy of TOETVA in patients with PTC. MATERIALS AND METHODS: This retrospective study included TOETVA patients from Yantai Yuhuangding and Xiamen Zhongshan Hospitals. Among the 297 patients studied, 84 had benign nodules (28.3%), 208 had PTC (70.0%), and five had follicular thyroid cancer (1.7%). RESULTS: The incidence of transient and permanent recurrent laryngeal nerve injury was 1.3%, while that of transient hypoparathyroidism was 1.0%. Mental nerve paraesthesia was observed in 241 cases (81.1%), while permanent mental nerve paraesthesia was noted in seven cases (2.4%). Abnormal motor function of the lower lip and chin was observed in 12 cases (4.0%). Ten of the 208 patients with PTC (4.8%) underwent total thyroidectomy (TT) and bilateral central neck dissection (CND). A mean 6.6 ± 4.1 and 10.9 ± 4.0 lymph nodes were removed in the unilateral and bilateral surgeries, respectively, with a metastasis rate of 49.0%; a mean 2.7 ± 2.3 and 3.2 ± 2.6 lymph nodes were metastatic, respectively. The parathyroid gland was inadvertently removed in 6.6% and auto-transplanted in 10.6% of patients with unilateral PTC. The non-stimulated thyroglobulin level in the TT and bilateral CND patients was below 1 ng/mL at the 6-month follow-up. CONCLUSION: TOETVA is safe in well-selected patients with unilateral PTC. However, its safety remains unclear in patients treated with TT and bilateral CND.

The implication of nigrostriatal dopaminergic degeneration in the pathogenesis of REM sleep behavior disorder.

BACKGROUND AND PURPOSE: The pathogenesis of rapid eye movement (REM) sleep behavior disorder (RBD) is not clear despite its frequent association with Parkinson's disease (PD). We investigated whether the nigrostriatal dopaminergic system is involved in the development of idiopathic RBD. METHODS: Fourteen patients with RBD, 14 patients with PD and 12 normal controls were included in the study. The diagnosis of RBD was confirmed on polysomnography. All the participants performed single-photon emission computed tomography imaging 3 h after injection of [(123)I]FP-CIT. During REM sleep of the RBD patients, each 30-s epoch was rated as 'tonic' when there was at least 50% of tonically maintained chin electromyography (EMG) activity in the epoch. Phasic EMG activities were calculated as the percentage of 3-s mini-epoch containing phasic EMG events (leg and chin, separately). RESULTS: The RBD patients showed a trend of lower binding in the striatum than the normal controls (P = 0.07), and the significance was revealed in the putamen (P = 0.02). However, in 11 individual cases of the 14 RBD patients, the dopamine transporter (DAT) densities in the putamen still remained within the normal range. In the RBD patients, there was no correlation between EMG activities and DAT densities. CONCLUSIONS: Nigrostriatal dopaminergic degeneration could be a part of the pathogenesis of RBD, but not essential for the development of RBD. The lack of correlation between RBD severity and DAT densities suggests that another pathogenic process not related to nigrostriatal dopaminergic transmission may be implicated in RBD.

Diagnostic Challenges and Treatment Options for Cutaneous T Cell Pseudolymphoma: A Case Study with Rituximab Treatment.

BACKGROUND Pseudolymphoma is a rare disorder that can mimic lymphoma both clinically and histologically. It usually affects middle-aged females. Since pseudolymphoma is a rare disorder not only is diagnosing the condition difficult, but there is also a lack of standardized treatment guidelines. In the literature, anti-CD20 monoclonal antibody rituximab is described as an effective treatment option. CASE REPORT 46-year-old female fell ill suddenly with swelling and enlargement of her chin. Multiple skin biopsies were done, which were re-evaluated multiple times as well. Each ended with a new diagnosis for the patient. Finally, in the last revision of biopsy material, pseudolymphoma was confirmed. The patient received multiple courses of corticosteroid treatments - locally and systemically - without long lasting effect. After diagnosis of pseudolymphoma, the patient was started on intravenous rituximab and this treatment was effective. CONCLUSIONS Cutaneous pseudolymphoma is a diagnostic challenge. Rituximab is a treatment option for refractory pseudolymphoma. Since there are no treatment guidelines for pseudolymphoma, more clinical studies are needed to establish best treatment options for these patients. Therefore, each reported clinical case is important.

Effects of ventral intermediate nucleus deep brain stimulation across multiple effectors in essential tremor.

OBJECTIVE: Essential tremor (ET) prominently affects the upper-limbs during voluntary movements, but can also affect the lower-limbs, head, and chin. Although deep brain stimulation (DBS) of the ventral intermediate nucleus (VIM) of thalamus improves both clinical ratings and quantitative measures of tremor, no study has quantified effects of DBS on tremor across multiple body parts. Our objective was to quantify therapeutic effects of DBS across multiple body parts in ET. METHODS: We performed quantitative assessment of tremor in ET patients who had DBS for at least one year. We assessed tremor on and off VIM-stimulation using triaxial accelerometers on the upper-limbs, lower-limbs, head and chin during seated and standing tasks. RESULTS: VIM-DBS significantly reduced tremor, but there was no statistical difference in degree of tremor reduction across the measured effectors. Compared to healthy controls, ET patients treated with DBS showed significantly greater tremor power (4-8 Hz) across all effectors during seated and standing tasks. CONCLUSIONS: VIM-DBS reduced tremor in ET patients. There was no significant difference in the degree of tremor reduction across the measured effectors. SIGNIFICANCE: This study provides new quantitative evidence that VIM-DBS is effective at reducing tremor across multiple parts of the body.

Hard and soft tissue stability of orthognathic surgery.

OBJECTIVE: To test the hypothesis that there is no difference in the stability of the hard and soft tissue changes following a surgical mandibular setback using a sagittal split ramus osteotomy or an intraoral vertical ramus osteotomy. MATERIALS AND METHODS: The samples consisted of 45 female patients with mandibular prognathism, who were divided into two groups. Twenty-three underwent a sagittal split ramus osteotomy (SSRO) with rigid fixation by titanium mini-screws and maxillomandibular fixation (MMF) for 14.0 +/- 0.7 days. Twenty-two underwent intraoral vertical ramus osteotomy (IVRO) without rigid fixation, and MMF was released 21.5 +/- 3.3 days after surgery. Data were collected from standardized cephalometric radiographs taken at the start of preoperative orthodontic treatment (T1), immediately after surgery (MMF, T2), and the completion of postoperative treatment (T3). Angular measurements were compared on each of T1, T2, and T3. RESULTS: There were no significant differences in the pretreatment hard and soft tissue morphology between the SSRO and IVRO. However, when fixation was released, the mandible was posteriorly positioned in the IVRO group. In the soft tissue profile, the mental region was located backward in the IVRO group at postoperative stage (T3). CONCLUSIONS: The hypothesis is rejected. The soft tissue profile of the IVRO group especially showed a retromandibular position after postoperative treatment in comparison with the SSRO group. This tendency of the IVRO group would contribute to the database for treatment planning and prediction.

A biomechanical evaluation of plating techniques used for reconstructing mandibular symphysis/parasymphysis fractures.

PURPOSE: The purpose of this investigation was to evaluate and compare the biomechanical behavior of 5 different methods used to repair mandibular symphysis/parasymphysis fractures. MATERIALS AND METHODS: Sixty synthetic polyurethane mandible replicas (Synbone, Laudquart, Switzerland) were used in this investigation. Ten controls and 10 each of the experimental groups were tested by subjecting 5 constructs in each group to vertical loading at the incisal edge and 5 constructs to torsional loading at the molar region by an Instron 1331 (Instron, Canton, MA) servohydraulic mechanical testing unit. The 5 methods of reconstruction include: arch bars using 18-gauge stainless steel wire with an acrylic lingual splint, 2 2.4-mm lag screw technique, 2 2.0-mm 4-hole locking miniplates, 2 2.0-mm 6-hole nonlocking miniplates, and 2 2.4-mm 6-hole limited-contact dynamic-compression plates. Mechanical deformation data within a 0 to 900 N range were recorded. Yield load, displacement at yield load, and stiffness were determined. Means and standard deviations were derived and compared for statistical significance using a Fisher's protected least significant differences test with a confidence level of 95% (P < .05). Third-order polynomial best-fit curves also were created for each group to further evaluate and compare the mechanical behavior. RESULTS: For incisal edge loading, statistically significant differences were noted between the lag screw technique and the arch bar, limited-contact dynamic-compression plate and locking miniplate; and between the nonlocking miniplate and the arch bar, limited-contact dynamic-compression plate and locking miniplate for stiffness. Additionally, statistically significant differences were noted between the lag screw technique and arch bar; and between the nonlocking miniplate and the arch bar, dynamic-compression plate and locking miniplate for yield load. For molar loading, statistically significant differences were noted between the lag screw technique and all other groups for both yield load and stiffness; as well as the arch bar and locking miniplate for stiffness. No statistically significant differences were noted between any groups for displacement at yield, for either incisal edge or molar loading. CONCLUSIONS: Although statistically significant differences were noted between each of the fixation systems in their abilities to resist loads under the conditions tested, when placed in the context of functional parameters, all systems met the requirements for incisal edge loading. When molar loading was considered, the lag screw technique performed more favorably than the other systems.

Influence of extraoral lateral force loading on the mandible in the mandibular development of growing rats.

INTRODUCTION: The objective of this study was to elucidate the influence of extraoral lateral force loading of the mandible on mandibular development. METHODS: Thirty growing Wistar rats were divided into 3 groups: control, sham, and experimental. To determine longitudinal developmental changes, each animal was placed under anesthesia and immobilized in a custom-built body retainer to allow microcomputed tomography to be performed before and after the experiment. In the experimental group, a fixing device of aluminum was fitted to the zygomatic arch. Lateral force was then applied to the mandible with an open coil for 2 weeks. Stereoscopic images were constructed from 3-dimensional microcomputed tomography images. Absolute lengths and perpendicular heights from the baseline of the lower border of the mandible were measured. The images were superimposed at the baseline planes in each animal. After the final observation, the rats were killed, and the bilateral condyles excised. The condyles were decalcified by the standard method, stained with hematoxylin and eosin and toluidine blue, and observed under a microscope. RESULTS: Lateral force induced the mandible to shift toward the nonloaded side; absolute mandibular length at menton-condylion on the side where the load was applied was greater than that in the control group. No difference from the control group was noted on the nonloaded side, and there were no significant differences in perpendicular heights. Lateral loading on the mandible resulted in histopathologic changes: (1) on the side where the load was applied, the cartilaginous zone hypertrophied in the highest margin of the condylar head, the erosive zone expanded, and the width of the mandibular neck decreased; (2) the chondrocyte layer shifted to the medial side on the nonloaded side, and cartilaginous ossification occurred in the lateral direction immediately below the chondrocyte layer, which deformed the mandibular neck toward the medial side and caused asymmetric development of the mandible. CONCLUSIONS: These results demonstrate that extraoral lateral force loading during the growth stage causes asymmetrical mandibular development.

Effect of chin tuck against resistance exercise on patients with dysphagia following stroke: A randomized pilot study.

BACKGROUND: Recently, chin tuck against resistance exercise (CTAR) has been reported as a remedial treatment for pharyngeal dysphagia. However, the clinical evidence of the effect is still lacking. OBJECTIVE: This study investigated the effect of CTAR on the swallowing function in patients with dysphagia following subacute stroke. METHODS: The patients were randomly assigned to an experimental (n = 11) or a control group (n = 11). The experimental group performed CTAR using the CTAR device. The control group received only conventional dysphagia treatment. Both groups received training on five days a week, for four weeks. The swallowing function was measured using functional dysphagia scale (FDS) and penetration-aspiration scale (PAS), based on a videofluoroscopic swallowing study (VFSS). RESULTS: The experimental group showed more improvements in the oral cavity, laryngeal elevation/epiglottic closure, residue in valleculae, and residue in pyriform sinuses of FDS and PAS compared to the control group (p < 0.05, all). CONCLUSIONS: This study demonstrated that CTAR is effective in improving the pharyngeal swallowing function in patients with dysphagia after stroke. Therefore, we recommend CTAR as a new remedial training alternative to HLE.

Complicated untreated apical periodontitis causing paraesthesia: A case report.

The purpose of this article was to report a case of untreated apical periodontitis resulting in severe late complications. A patient with an asymptomatic crowned root canal-treated mandibular molar revealing a radiographic substandard endodontic treatment and a slight periapical radiolucency was made aware of the treatment options and opted for no treatment. The lesion slightly increased in size after 6 years, but the tooth remained asymptomatic and endodontic retreatment was again refused. After 4 more years, the patient presented with an abscess and severe pain, complicated by paraesthesia of the left chin and lip. Radiographic examination revealed that the lesion had increased considerably to involve the mandibular canal. The treatment protocol included long-term intracanal medication with calcium hydroxide and follow-ups revealed complete resolution of the periapical radiolucency and the paraesthesia had completely subsided.

Simulation study comparing the helmet-chin PET with a cylindrical PET of the same number of detectors.

There is a growing interest in developing brain PET scanners with high sensitivity and high spatial resolution for early diagnosis of neurodegenerative diseases and studies of brain functions. Sensitivity of the PET scanner can be improved by increasing the solid angle. However, conventional PET scanners are designed based on a cylindrical geometry, which may not be the most efficient design for brain imaging in terms of the balance between sensitivity and cost. We proposed a dedicated brain PET scanner based on a hemispheric shape detector and a chin detector (referred to as the helmet-chin PET), which is designed to maximize the solid angle by increasing the number of lines-of-response in the hemisphere. The parallax error, which PET scanners with a large solid angle tend to have, can be suppressed by the use of depth-of-interaction detectors. In this study, we carry out a realistic evaluation of the helmet-chin PET using Monte Carlo simulation based on the 4-layer GSO detector which consists of a 16 × 16 × 4 array of crystals with dimensions of 2.8 × 2.8 × 7.5 mm3. The purpose of this simulation is to show the gain in imaging performance of the helmet-chin PET compared with the cylindrical PET using the same number of detectors in each configuration. The sensitivity of the helmet-chin PET evaluated with a cylindrical phantom has a significant increase, especially at the top of the (field-of-view) FOV. The peak-NECR of the helmet-chin PET is 1.4 times higher compared to the cylindrical PET. The helmet-chin PET provides relatively low noise images throughout the FOV compared to the cylindrical PET which exhibits enhanced noise at the peripheral regions. The results show the helmet-chin PET can significantly improve the sensitivity and reduce the noise in the reconstructed images.

Orthodontic treatment changes of chin position in Class II Division 1 patients.

INTRODUCTION: Because most patients with skeletal Class II malocclusions also have mandibular deficiencies, treatment plans should include improvement in chin projection. On that basis, the purposes of this study were to (1) determine how Class II treatment affects anteroposterior (AP) chin position in growing subjects and (2) ascertain the most important determinants of AP chin position. METHODS: Pretreatment and posttreatment lateral cephalograms of 67 treated patients (25 extraction headgear and Class II elastics, 23 nonextraction headgear, and 19 Herbst) were collected, traced, and digitized. The average pretreatment age was 12.2 years (range, 9-14 years), and the average treatment duration was 30.2 months (range, 17-65 months). Cephalometric changes were compared with 29 matched untreated Class II controls. Mandibular superimpositions were used to evaluate condylar growth and true mandibular rotation. RESULTS: All 3 treatment methods produced normal dental relationships and restricted or inhibited AP maxillary growth, with no significant improvement of AP chin position. Differences between changes in vertical position of the maxilla, maxillary and mandibular molars, and condylar growth could not reliably predict changes in chin position. Analyses demonstrated that true mandibular rotation was the primary determinant of AP chin position. Stepwise multiple regression showed that, combined with true mandibular rotation, condylar growth and movements of the glenoid fossa accounted for 81% of the variation in AP changes of pogonion. CONCLUSIONS: Contemporary treatments do not adequately address mandibular deficiencies. Future treatments must incorporate true mandibular rotation into Class II skeletal correction.

Taking it on the chin: recognizing and accounting for lower face asymmetry in chin augmentation and genioplasty.

During the course of thousands of preoperative facial analyses, it has become apparent that the chin, in most individuals, appears weaker on the left than on the right. This previously unreported disparity spans age, sex, and ethnicity. To document this finding, frontal and lateral photographs of 20 random patients from the senior author's practice were subjected to a battery of soft-tissue measurements. Analysis of four celebrities further demonstrated the ubiquity of relative left chin weakness. Precedent for asymmetry in human anatomy is abundant (e.g., handedness). Asymmetry, moreover, often is conserved throughout the population (e.g., sidedness of visceral orientation). Left-sided chin weakness appears to be another example of well-preserved anatomical asymmetry. The presence of this asymmetry should be considered in planning chin augmentation and genioplasty.