Trismus in patients with head and neck cancer: etiopathogenesis, diagnosis and management.

BACKGROUND: Trismus indicates severely restricted mouth opening of any aetiology. A mouth opening of 35 mm or less should be regarded as trismus. Aim of this study was to review the etiopathogenesis, incidence, treatment and prevention of trismus in patients with head and neck cancer. OBJECTIVE OF REVIEW: Trismus is frequently seen in patients suffering from malignant tumours of the head and neck. The reported prevalence of trismus in those patients varies considerably in the literature and ranges from 0 to 100% depending on the tumour site and extension. Trismus may worsen or remain the same over time, or the symptoms may reduce, even in the absence of treatment. When a patient presents with trismus after tumour treatment, it is important to determine whether the trismus is the result of the treatment, or is the first sign of a recurrence. Restricted mouth opening may impede inspection of the oral cavity as needed for dental care, and particularly for oncologic follow-up. CONCLUSIONS: Mouth opening after radiotherapy (RT) decreases on average by approximately 20% compared to mouth opening prior to RT. The prevalence of trismus increases with increasing doses of RT to mastication structures. The use of intensity-modulated RT seems to lower the percentage and severity of RT-induced trismus. Treatment of trismus can be conservative (with either medical or physical therapy) or surgical. Exercise therapy is the mainstay of treatment and exercise should start as soon as possible after treatment. The prevention of trismus, rather than its treatment, is the most important objective.

Orbitomaxillary mucormycosis (zygomycosis) and the surgical approach to treatment: perspectives from a maxillofacial surgeon.

Rhinocerebral or rhino-orbitocerebral (mucormycosis) zygomycosis (ROCZ) usually occurs among patients with poorly controlled diabetes mellitus (especially those with ketoacidosis), solid malignancies, iron overload or extensive burns, in patients undergoing treatment with glucocorticosteroid agents, or in patients with neutropenia related to haematologic malignancies. The disease process starts with inhalation of the fungus into the paranasal sinuses. The fungus may spread to invade the palate, sphenoid sinus, cavernous sinus, orbits or cranially to invade the brain. Pain and swelling precede oral ulceration and the resulting tissue necrosis can result in palatal perforation. Infection can sometimes extend from the sinuses into the mouth and produce painful, necrotic ulcerations of the hard palate. If untreated, infection usually spreads from the ethmoid sinus to the orbit, resulting in the loss of extraocular muscle function and proptosis. Surgical treatment includes the resection of involved tissues of the face, including skin and muscle, any skin of the nose that is involved, maxillary and ethmoid sinuses, necrotic tissue of the temporal area and infratemporal fossa, and orbital exenteration. The keys to successful therapy include suspicion of the diagnosis and early recognition of the signs and symptoms, correction of underlying medical disorders such as ketoacidosis, and aggressive medical and surgical intervention.

Evaluation of caspase-3 and caspase-8 deregulation in tongue squamous cell carcinoma, based on immunohistochemistry and computerised image analysis.

AIMS: To investigate the potential role of caspase-3 and caspase-8 protein expression in the biological behaviour of tongue squamous cell carcinoma. MATERIALS AND METHODS: We conducted immunohistochemical analyses of 87 specimens of primary tongue squamous cell carcinoma, using monoclonal anti-caspase-3 and anti-caspase-8 antibodies. A digital image analysis assay was also performed in order to evaluate the results. RESULTS: Reduced expression of caspase-8 and -3 proteins was observed in 30/87 (34.5 per cent) and 79/87 (90.5 per cent) cases, respectively. Cox regression analysis showed no prognostic significance for the association between overall protein expression of either marker and survival probability (p = 0.174 for caspase-3; p = 0.608 for caspase-8). Interestingly, the size of the examined tumours was strongly correlated with survival status (p = 0.024). CONCLUSIONS: Simultaneous deregulation of caspase-8 and -3 is a frequent event in tongue squamous cell carcinoma. Activation of caspase-3, which is predominantly down-regulated, may be a crucial process for induction of apoptosis and response to therapeutic strategies.

Sarcomas of the head and neck. Results from the treatment of 25 patients.

AIMS: Head and neck sarcomas comprise a heterogenous and biologically diverse group of rare neoplasms. In an effort to clarify some of the obscure clinical behavior of head and neck sarcomas, we present our experience and review the relevant literature. METHODS: Retrospective analysis of patients with histologically proven head and neck sarcomas treated in a tertiary Hospital Department between 1992 and 2002. RESULTS: During this period, 25 patients with head and neck sarcomas were registered. Follow-up ranged from 8 to 144 months. Twenty-three patients were treated with surgery as the primary modality; 14 were treated by surgery alone. Clear margins were obtained in all of them and local control was achieved in 12/13. The 2- and 5-year survival rates for the entire group were 80 and 40%, respectively. Mean overall survival time of our patients was 62 months (median 52 months). CONCLUSIONS: Surgical treatment remains the cornerstone of therapeutic management of head and neck sarcomas.

Ameloblastomas of the jaws: clinico-pathological review of 11 patients.

AIMS: The ameloblastoma is an uncommon benign odontogenic neoplasm of the maxillofacial region constituting less than 1% of tumours of the oral cavity. The purpose of this paper is to discuss and evaluate the surgical treatment and the outcome from a series of 11 patients with ameloblastomas. METHODS: Between the years 1995 and 2003, 11 patients (eight female and three male) aged 17-86 years (mean 52.7) suffering from ameloblastomas of the jaws were seen in our Department. RESULTS: Ten patients were treated surgically. In eight of those radical surgery was applied. Patients with maxillary tumours were subjected to hemimaxillectomy and local excision. Radical treatment with segmental resection of the mandible was performed in six patients with multilocular (solid) mandibular ameloblastomas, with immediate reconstruction of the defect. Follow-up ranged from 3 months to 7.5 years. CONCLUSION: Multilocular (solid) type of tumours should be approached with radical surgical treatment. Enucleation and rarely marsupialization can be applied selectively to unilocular ameloblastomas.

Presence of human herpes virus-8 in saliva and non-lesional oral mucosa in HIV-infected and oncologic immunocompromised patients.

BACKGROUND/AIM: Human Herpes Virus-8 (HHV-8) is a recently identified virus etiologically associated with Kaposi's sarcoma. Studies regarding its presence in the oral cavity have given variable results. This study attempted to determine the oral presence of HHV-8 in an area where classic Kaposi's sarcoma is primarily found such as Greece. METHODS: Three groups of patients were studied: 10 immunocompromised with hematologic malignancies, 10 immunocompromised with HIV infection and 20 immunocompetent as controls. Whole unstimulated saliva and scrapes from the lingual and the buccal mucosa were collected and polymerase chain reaction was applied to amplify HHV-8 DNA. RESULTS: None of the patients in any group had oral lesions. In the control group, all samples tested negative (0/60). HHV-8 DNA was detected in 5/30 (17%) of all samples from HIV-positive patients (the mean value of their CD4+ T-lymphocytes being 385/mm3) and in 13/30 (43%) of all samples from oncologic patients (mean CD4+ T-lymphocytes 51/mm3). HHV-8 DNA was found in 10% of saliva samples and 40% of lingual and buccal scrapes both of HIV-infected and of oncologic patients. CONCLUSION: HHV-8 is present in the saliva and the non-lesional oral mucosa (not simultaneously) of patients with impaired immunity, with or without HIV co-infection. The oral epithelium seems to represent an independent location of viral residency and may be of viral replication; the clinical implications need further clarification.

Functional and aesthetic results of various lip-splitting incisions: A clinical analysis of 60 cases.

PURPOSE: This study retrospectively evaluated the functional and aesthetic results of various types of lip-splitting incisions in a group of patients in whom this approach was used to treat intraoral tumors. PATIENTS AND METHODS: Between 1992 and 1998, 87 consecutive patients were subjected to either mandibulotomy or mandibulectomy using a lip-splitting incision. During this period, 4 types of incisions were sequentially used: straight midline incision, lateral lip-splitting incision, midline splitting with extension around the contour of the chin, and the chevron chin-contour incision. Sixty patients with a follow-up of at least 6 months were included in the study. The patients were asked to answer a questionnaire regarding the degree of satisfaction with the cosmetic result of the procedure and were clinically assessed for sensory and functional impairment resulting from the incision. The remaining 27 patients were lost to follow-up or had died of their disease. RESULTS: The lateral lip-splitting incision caused the fewest postoperative problems in patients subjected to either mandibulotomy or mandibulectomy. The best overall results were achieved by the chevron-chin contour incision. The incision that followed the contour of the chin and the straight midline incision showed less satisfactory results. CONCLUSION: The chevron chin-contour incision, along with meticulous soft tissue closure, produces the best aesthetic and functional results.

The diagnostic value of fine needle aspiration cytology in Waldeyer's ring lymphomas.

Fine needle aspiration cytology (FNAC) is a well-established diagnostic technique for tumours in the head and neck area. In recent years FNAC has been established as an accurate and useful method for the diagnosis of nodal malignant lymphoproliferative disease. The purpose of the present study was to determine and evaluate the accuracy of FNAC in the diagnosis of primary malignant lymphoma of Waldeyer's ring. The cases of 29 patients suffering from tumours of the oro- and nasopharynx, in which the diagnosis of lymphoma was established by FNAC during the years 1991-1998, were collected and analysed. Twelve of the patients had a previous history of lymphoma, and FNAC was used to establish the diagnosis of recurrent disease. In 17 patients with no previous history of malignancy FNAC was used to diagnose primary extranodal non-Hodgkin's lymphomas (NHLs). In two patients FNAC failed to diagnose NHL. In all patients cytological findings were complemented and compared with those of a histopathological examination after open biopsy. In two cases a difference in the specific histological type of the lymphoma was noted. The findings from the present study (sensitivity 93.10% and positive predictive value 100%) indicated that FNAC is a useful and accurate method in establishing diagnosis of Waldeyer's ring lymphomas.

Secondary orbital melanomas: analysis of 15 cases.

Orbital melanomas comprise a heterogeneous group of pigmented tumours originating from melanocytes of the ophthalmic tissues, or represent distant metastases of cutaneous melanomas to the orbit. They can be classified into primary and secondary orbital melanomas. Whereas primary orbital melanomas are extremely rare, secondary orbital melanomas are seen more often and usually represent massive extrascleral extensions of uveal melanomas. Their diagnosis is difficult and controversy exists both about the treatment policy and regarding the prognosis. In an effort to clarify some of the aspects of the biological behaviour of these intriguing lesions, we retrospectively reviewed all orbital melanomas treated in our departments during the last eight years. The records of 15 patients with massive secondary orbital melanomas treated surgically were reviewed and analysed. Eleven of the patients were female and four were male. The mean age at the time of surgery was 68 years. Presenting features included unilateral orbital mass, often with painless proptosis, conjuctival bleeding, acute glaucoma crisis, decreased visual acuity and intermittent diplopia. The site of origin was the uveal tract in nine cases, the conjunctiva in three, the eyelids in two and the skin of the lower extremity in one patient. All patients were treated surgically with various types of orbital exenteration. Additional treatment included radiotherapy and chemotherapy. Two patients died from intracranial extension of the disease and 10 died from distant metastases. Three patients are alive with no evidence of disease. The longest survival was 33 months and the mean survival was 16.6 months. Early diagnosis and proper management of ocular melanoma prevents orbital extension and prolongs patient survival. Surgical treatment of secondary orbital melanoma with or without adjuvant radiotherapy and/or chemotherapy does not seem to improve patient survival when compared with conservative treatment used in other reports. However, orbital exenteration is effective for local control of the disease.

The use of the buccal fat pad for reconstruction of oral defects: review of the literature and report of 15 cases.

PURPOSE: Although the buccal fat pad (BFP) was originally used as an alternative method for the closure of small to medium-sized oroantral and oronasal communications, its use has now been extended to use after excision of oral malignancies. This report describes experience with this technique. PATIENTS AND METHODS: The BFP was used as a pedicled graft to reconstruct medium-sized surgical defects of the oral soft and hard tissues in 15 patients suffering from oral malignant tumors. Six of the defects were in the maxilla, 3 in the retromandibular area, and 6 in the cheek and oral commissure. The BFP was left uncovered to epithelialize in 14 patients, and in one it was covered with lyophilized dura. RESULTS: The BFP healed without complications within 3 to 4 weeks in 13 patients, whereas in 2 patients with maxillary defects there was partial loss of the graft, requiring the additional use of an obturator in 1 case and a tongue flap in another to prevent oronasal leakage. Harvesting the graft proved to be extremely easy, and care was only necessary to avoid severing the supporting vascular plexus and the thin capsule covering the BFP. CONCLUSIONS: The findings support the view that the BFP is a useful, easy, and uncomplicated alternative method for the reconstruction of small to medium-sized surgical defects of the oral hard and soft tissues.

Tumours of the head and neck in the elderly: analysis of 190 patients.

Tumours of the head and neck represent approximately 5% of human neoplasms. More than 50% of the patients are above 65 years of age. During the years 1991-1996, 190 patients aged 65 or more and suffering from oro-facial neoplasms were treated in our department. They represent 48.6% of the total number of hospitalized tumour patients. One hundred and ten were male and 80 female. Benign tumours were found in 42 patients whereas 148 patients presented with malignant tumours. Of the malignant tumours, squamous cell carcinoma occurred in 103 patients and salivary gland tumours were the most frequently encountered benign tumours (12 patients). All patients with benign tumours were treated surgically. Of the 148 patients with malignant neoplasms, 116 were treated by surgery alone or in combination with radiotherapy and/or chemotherapy, and the remaining 32 with radiotherapy. Mortality from cancer was 28.1% and mortality from other causes was 5.8%. Postoperative morbidity in the benign tumour group of patients was minimal. In the malignant tumour group of patients, where the magnitude of surgical treatment was greater, there were no intraoperative or immediate postoperative deaths. Five patients died postoperatively whilst in hospital. Deaths were attributed to pre-existing medical problems. It is concluded that the age of the patient is not an important factor in determining the extent of surgical treatment in patients with tumours of the head and neck.

Fine-needle aspiration cytology in tumors and tumor-like conditions of the oral and maxillofacial region: diagnostic reliability and limitations.

BACKGROUND: Fine-needle aspiration cytology (FNAC) is a well established diagnostic technique. The purpose of the current study was to evaluate its diagnostic accuracy, sensitivity, and specificity in tumors and tumor-like conditions in the oral and maxillofacial region. METHODS: The results of 1022 cases of FNAC performed over a 7-year period (1990-1996) were retrospectively reviewed and analyzed. The material was collected from 228 major salivary glands, 67 perioral soft tissues and facial bones, 139 tumors of the oral cavity, 18 paranasal tumors, 41 oropharyngeal lesions, and 21 nasopharyngeal lesions, whereas 508 cases represented cervical lymph nodes. RESULTS: In 804 cases FNAC established or documented the initial diagnosis whereas in 198 cases it confirmed suspected recurrences. Definitive histologic diagnosis was established in 809 of the 1022 cases after surgical treatment and the histologic diagnoses were compared with preoperative FNAC results. In 20 cases the cytologic material was considered unsatisfactory and therefore the cytologic diagnosis was impossible to establish. In 12 of these cases diagnosis was made based on histologic examination after surgery. Malignancy was found in three of the latter cases. In the total number of 1022 cases there were 18 false-negative and 2 false-positive cytologic results. In another 19 cases a difference in the histologic type of the lesion was found. The diagnostic accuracy of the method was 98.2% with a sensitivity of 96.2% and a specificity of 99.4%. CONCLUSIONS: Four major causes of error were identified: material adequacy criteria, sampling technique, cytologic interpretation, and limitations of the procedure. FNAC proved to be a safe, accurate, inexpensive, and patient-friendly in the effort to establish preoperative diagnosis in tumors and tumor-like conditions of the oral and maxillofacial region. The authors have proposed modification in the mathematic computation of diagnostic accuracy, adding the parameter of nonconcordance with histologic typing of FNAC.

Chondrosarcomas of the skull base: review of the literature and report of two cases.

Chondrosarcomas are malignant mesenchymal tumours occurring only rarely in the bones of the cranium. Less than 5% of all chondrosarcomas are located in the head and neck area and their commonest location is the ethmoids and the sphenoid sinus. They are slow-growing tumours with low malignancy rate and unclear histopathogenesis. The prevailing hypothesis is that they arise from cartilaginous remnants in the petro-clival, spheno-occipital and fronto-nasal synchondroses. Diagnosis is only made after biopsy since clinical signs and symptoms and radiological findings are not pathognomonic. Symptomatology mainly derives from tumour encroachment and infiltration of adjacent intracranial structures. Surgery is the treatment of choice, while radiotherapy has an adjunctive role. Chemotherapy is not effective. Partial tumour excision to alleviate symptoms is an acceptable surgical technique since diagnosis is usually late, but treatment can be repeated when recurrence occurs. During the last year, two cases of chondrosarcoma of the skull base were treated in our institution. Both patients were female, aged 62 and 73, respectively. Computerized Tomography and Magnetic Resonance Imaging were inconclusive and diagnosis was established after biopsy. Treatment for both cases was surgical, with partial excision due to intracranial involvement of the internal carotid artery. In one case, a temporal approach was used, whereas the other patient was operated on via a naso-orbital approach. One patient received postoperative radiotherapy. The postoperative course was uneventful in both patients and marked clinical improvement was noted 18 months and 1 year after surgery. We support the view that partial resection of chondrosarcomas of the base of the skull to alleviate symptoms is an acceptable surgical treatment.

Cystadenolymphoma of the parotid gland an immunohistochemical study of the epithelial component of twenty cases.

Carcinoembryonic antigen, epithelial membrane antigen, Keratin, Desmin, Vimentin, CD30, lysozyme, alpha 1-antitrypsin, alpha 1-antichymotrypsin, S-100 protein, somatostatin and glucagon were looked for using immunohistochemical methods in the epithelial component of 20 parotid gland cystadenolymphomas and 20 normal parotid glands. Carcino-embryonic antigen, ephithelial membrane antigen, S-100 protein, and somatostatin were found in the epithelial cells of most of the cystadenolymphomas. In normal parotid tissue, carcinoembryonic antigen, epithelial membrane antigen, Keratin, alpha 1-antitrypsin, alpha 1-antichymotrypsin, and S-100 protein were found in all three types of ductal cells, somatostatin only in intercalated and striated ductal cells, and lysozyme only in acinar and intercalated ductal cells. Desmin and CD30 were found in the epithelial component of seven of the 20 tumors versus none of the 20 normal parotid glands. Glucagon and Vimentin were negative both in tumor epithelial cells and in normal parotid ductal cells. Our results support the theory that cystadenolymphomas arise from epithelial cells. The presence of lysozyme in the epithelial tumor cells and in the intercalated ductal cells of normal parotid tissue suggest that cystadenolymphomas may arise from the intercalated ducts. The presence of S-100 and somatostatin may indicate that the tumor derives from neuroendocrine structures, but further studies are needed to clarify this point.

Tumours of the head and neck in children. A clinico-pathological analysis of 1,007 cases.

Tumours of the head and neck in children are uncommon, representing only 2-3% of all head and neck tumours. During the twenty year period 1964-1983, 12,876 childhood tumours were submitted for pathological diagnosis. Of these 1,007 (7.8%) were in the head and neck region, and it is this group that has been analysed. 30.6% (308 cases) were malignant neoplasms, 27.8% (280 cases) were benign neoplasms, 24.2% (244 cases) presented as tumour-like conditions and 17.4 (175 cases) were dysplasias arising from embryonal remnants. The overall sex ratio was 1.5:1 in favour of males. Lymphomas accounted for 15.9% overall (52.3% of the malignant neoplasms). Of benign tumours, haemangiomas were the most frequent (38.5%) and of the tumour-like conditions, dermoid and epidermoid cysts accounted for 36.1%. Of the embryonal remnant dysplasias, thyroglossal duct cysts accounted for 71.4%.

Chondroid syringoma of the upper lip: report of a case.

The case of a 38-year-old white man with a chondroid syringoma in the left side of the upper lip is reported. Histochemical study of the lesion showed that the morphologic distributions of the neutral mucosubstances, sulfated acid mucopolysaccharides, and elastic fibers in the reported case were similar to those of mixed salivary gland tumor. The recently reported ultrastructural and immunohistochemical features of chondroid syringoma are also discussed in an effort to clarify its histogenesis.

Fractures of the coronoid process of the mandible. An analysis of 52 cases.

Fractures of the coronoid process occur infrequently. In the present study, 52 cases of fracture of the coronoid process are presented and analysed and the relevant literature is reviewed. Coronoid fractures constituted 2.9% of all facial fractures. Of the 52 cases, 12 were isolated coronoid fractures (23%), whereas in the remaining 40 cases, coronoid fractures coexisted with other maxillofacial injuries. The clinical picture, diagnosis and therapeutic modalities of coronoid fractures are discussed.

Fractures of the facial skeleton in the edentulous patient.

An evaluation was made of 112 fractures that occurred in 66 edentulous patients in a 10 year period. There was an average of 1.7 fractures per person. 104 fractures occurred in the mandible and 75% of these were treated without intermaxillary fixation or were not treated at all. In 28.5% of the cases no treatment was provided other than soft or liquid diet and appropriate instructions. As a group, the condylar fractures were those that were left with no treatment to a greater extent than any other group, apart from the Le Fort type of fracture; the latter being very few in absolute numbers. The age group associated with the edentulous state quite often suffers from conditions that may prohibit aggressive treatment. These conditions may be aggravated by the accident and, by the time the patient is ready for maxillofacial surgery, one has to contemplate (and discuss with the patient) the advantages and disadvantages of a procedure. It appears that aesthetics are of minor importance (to a certain degree) for elderly patients and small deviations from the normal (both in appearance and function) are acceptable to them, considering the prospect of an operation or of the prolonged discomfort, such as that associated with intermaxillary fixation. The advisability of the latter should be assessed carefully in view of the respiratory impairment that it may cause in patients whose airway may already be compromised.(ABSTRACT TRUNCATED AT 250 WORDS)