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.

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.

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.

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.

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.

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.

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.

[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.

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.

[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.

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.

[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.

Anatomical and mesoscopic characterization of the dystrophic diaphragm: An in vivo nuclear magnetic resonance imaging study in the Golden retriever muscular dystrophy dog.

Because respiratory failure remains a major issue in Duchenne Muscular Dystrophy patients, respiratory muscles are a key target of systemic therapies. In the Golden Retriever Muscular Dystrophy (GRMD) dogs, the disease shows strong clinical and histological similarities with the human pathology, making it a valuable model for preclinical therapeutic trials. We report here the first nuclear magnetic resonance (NMR) imaging anatomical study of the diaphragm in GRMD dogs and healthy controls. Both T1- and T2-weighted images of the diaphragm of seven healthy and thirteen GRMD dogs, from 3 to 36 months of age, were acquired on a 3 tesla NMR scanner. Abnormalities of texture and shape were revealed and consisted of increases in signal intensity on T2-weighted images and in signal heterogeneity on both T1- and T2-weighted images of the dystrophic diaphragm. These abnormalities were associated with a significant thickening of the muscle and we identified a clear 8-mm-threshold distinguishing clinically preserved GRMD dogs from those more severely affected. In this study, we demonstrated the feasibility of NMR imaging of the diaphragm and depicted several anatomical and mesoscopic anomalies in the dystrophic diaphragm. NMR imaging of the diaphragm shows a promise as an outcome measure in preclinical trials using GRMD dogs.

[Exclusive radiotherapy for a facial basal cell carcinoma with trigeminal ganglion involvement]. / Radiothérapie exclusive d'un carcinome basocellulaire de la face avec atteinte du ganglion de Gasser.

Basal cell carcinomas with symptomatic perineural invasion are rare entities. We report the case of a 60year-old man (with a grafted kidney), surgically treated in 2007 for a sclerodermiform basal cell carcinoma infiltrating the left nostril. Five years later, a painful left hemifacial hypoesthesia associated with an ulcus rodens of the nasolabial fold appeared. A biopsy confirmed a recurrence. MRI showed an enhancement of the trigeminal ganglion. The patient had a trigeminal perineural invasion secondary to a cutaneous basal cell carcinoma. He received a local intensity-modulated radiotherapy alone (70Gy in 33 sessions), administered from the skin tumour to the skull base. Three years after the end of treatment, the patient is in radiological and clinical remission, with partial recovery of the hypoesthesia. Evolution was marked by iterative corneal ulcers and decreased visual acuity. Modalities of treatment by surgery and/or radiation therapy and complications are poorly described in the literature.

[Central giant cell granuloma in children: Presentation of different therapeutic options]. / Granulome central à cellules géantes de l'enfant : présentation des différentes options thérapeutiques.

Central giant cell granuloma (CGCG) is a benign tumor that may be subdivided in a non-aggressive form and an aggressive form. In aggressive forms, tumor size and high recurrence risk need large surgical resections. In order to minimize surgical morbidity, especially in children, medical treatments acting on the tumor proliferation are currently being assessed: steroids (triamcinolone), anti-osteoclastic drugs (calcitonine, alendronate, denosumab), anti-angiogenic drugs (interferon α). However to date, there is no evidence for any superiority of medical over surgical treatment. Complete response is rarely obtained and additional surgery is often necessary to remove the tumor in case of tumor progression, to remove a remnant or to remodel bone. Moreover, these drugs have frequent local or systemic side effects such as osteonecrosis and growth deficiencies.

[Retrospective study on bleeding and thromboembolic complications related to tooth extraction, in 93 patients usually treated by antithrombotic therapy]. / Étude rétrospective évaluant les risques hémorragiques et thromboemboliques lors d'avulsions dentaires chez 93 patients habituellement traités par AVK et/ou AAP.

INTRODUCTION: Tooth extraction for patients treated by AVK and/or platelet aggregation inhibitor is performed according to local habits rather than to a consensus. We had for objective to assess hemorrhagic and thromboembolic risks for patients for whom treatment with AVK and/or platelet aggregation inhibitor was modified before tooth extraction. MATERIALS AND METHODS: Ninety-three patient files were examined retrospectively. The following data was collected: epidemiological data, ASA score, nature and changes of antithrombotic therapy, preoperative INR, number teeth extracted, postoperative complications (bleeding and thromboembolic events). RESULTS: Thirty-seven patients were treated with oral anticoagulants, 41 by a platelet aggregation inhibitor, 10 by double platelet aggregation inhibitor therapy, and 5 by an AVK-platelet aggregation inhibitor combination. At D0, the mean INR was decreased to 1.4, 4 patients with high thromboembolic risk had received heparin relay treatment; the treatment was stopped for 9 of the 56 patients on monotherapy with antiplatelet therapy, 4 were switched from clopidogrel to lysine acetylate; clopidogrel was stopped for 7 patients under combination therapy. Seven hundred and twenty-six avulsions (mean 8.1 per patient) were performed, 41 patients presented with mild/moderate bleeding, easily resolved. A patient presented with delayed hemorrhage at D6 (AVK overdose). No thromboembolic complication was reported. DISCUSSION: The modification of antithrombotic treatment, as for surgery at high risk of bleeding, seems to limit the risk of bleeding without increasing thromboembolic risk.

[Comparison of two opioids with different kinetics for intravenous analgesia in outpatient multiple third molar avulsions]. / Comparaison de deux opioïdes de cinétique différente dans l'analgésie intraveineuse pour avulsion des dents de sagesse en ambulatoire.

INTRODUCTION: We had for aim to compare the effects of intra-operative opioid analgesia according to the drug kinetics. PATIENTS AND METHODS: We conducted a prospective, controlled, randomized, double-blinded trial including 60 patients scheduled for ambulatory multiple third molar avulsion. The general anesthesia, performed with propofol and analgesia was a target-controlled infusion of either remifentanil or sufentanil. The anesthesia was set to reach an optimal bispectral index and adjusted to a clinical target throughout the procedure. The main endpoints were: postoperative request for morphine and other opioids; postoperative pain; postoperative adverse effects of opioids. RESULTS: In the post-operative care unit (French acronym PACU), patients who received remifentanil were extubated earlier (17 vs. 26 min.), but had more pain and required twice more morphine for analgesia (6 vs. 3 mg), than those who had received sufentanil. However, the need for post-surgery oral opioid intake was greater in the sufentanil group, so the overall postoperative opioid consumption and patient satisfaction were identical in both groups. The time spent in the PACU was also identical for both groups. DISCUSSION: Using an ultra-short kinetic opioid such as remifentanil does not seem useful, since the shorter delay before extubation is compensated by a greater need for morphine in the PACU.