Arthroscopy of the Inferior Compartment of the Temporomandibular Joint: A New Perspective.

OBJECTIVE: Arthroscopy of the temporomandibular joint (TMJ) has become a well-standardized non-invasive procedure for the treatment of TMJ internal derangement (ID). Since the last 1980s, no clinical application for arthroscopy of the inferior compartment has been established because of the intrinsic difficulty of the technique and the believing of the absence of clinical relevance for treatment of ID. METHODS: We report on a particular case in which arthroscopy of the inferior joint compartment together with the examination of the upper joint space was performed in a patient with ID of the TMJ. A 1.9 mm scope was used, while the technique for entering the inferior compartment is presented. RESULTS: The presence of intense synovitis, fibrous adhesion, and pseudowall were observed in the inferior joint compartment, thus leading to the hypothesis of the more than likely influence of the status of the synovial lining within this space in the persistence of symptoms in recalcitrant patients with ID. CONCLUSION: We believe that this new insight could lead surgeons to a more complete use of this non-invasive procedure for the treatment of this entity. LEVEL OF EVIDENCE: 4/5.

Straightforward Method for Coverage of Major Vessels After Modified Radical Neck Dissection.

A new method for covering the internal jugular vein and carotid artery after exposure of the cervical vascular axis subsequent to neck dissection is presented. To cover the most caudal part of the vascular axis, a platysma coli muscle flap is harvested from its most medial and inferior part of the neck in a caudally based fashion and is slightly rotated posteriorly up to 45°. In addition, a superiorly based sternocleidomastoid muscle flap involving the posterior half of the muscle after detachment of the clavicle head is harvested and rotated 45° anteriorly to cover the upper two thirds of the vascular axis. This technique seems to be a good alternative to the pectoralis major myocutaneous flap for covering cervical major vessels, if no classical radical neck dissection is performed, especially in those oncologic malnourished patients who will undergo adjuvant radiotherapy after surgical treatment.

Lateral rhinotomy combined with anterior transantral approach for the treatment of large malignant melanoma of the nasal cavity involving the nasopharynx.

The authors report a case of nasal malignant melanoma involving the septum, nasal turbinates and nasopharynx which was approached by lateral rhinotomy combined with an anterior transantral approach with excision of the septum and the lateral wall of the nasal cavity for wide exposure of the tumour. Using this technique complete surgical resection of a large nasal malignant melanoma was achieved with minimal morbidity and good aesthetics.

Cholesterol granuloma of the orbit. Report of cases and analysis of controversial treatment.

Cholesterol granuloma of the orbit is a rare entity originated from a foreign body reaction against cholesterol crystal. Its pathogenesis still remains unclear, while controversy is still present concerning its management. In the present report, two new cases of cholesterol granuloma of the orbit are presented and the authors focus on treatment considerations.

Descending necrotizing mediastinitis following dental extraction. Radiological features and surgical treatment considerations.

Descending necrotizing mediastinitis (DNM) following dental extraction is an extremely serious infection with a high mortality rate. Oral infection may rapidly descend into the mediastinum across the retropharyngeal and retrovisceral spaces. Once established, mediastinitis is rapidly followed by sepsis and death. If DNM is suspected cervical and thoracic CT must be carried out urgently. After this, prompt control of the upper airway with tracheostomy, aggressive surgical debridement of the deep cervical spaces and mediastinum, and intravenous broad spectrum antibiotic therapy are mandatory. The present paper reports two new cases of DNM following dental extraction, and focuses on radiological features of abscess progression through the cervical spaces down into the mediastinum.

Influence of the upper joint surface and synovial lining in the outcome of chronic closed lock of the temporomandibular joint treated with arthroscopy.

PURPOSE: Temporomandibular joint (TMJ) arthroscopy has been reported to be an effective and reliable technique for the treatment of chronic closed lock (CCL) of the TMJ. The purpose of the present study was to evaluate whether the status of the joint surface and the synovial lining directly visualized with arthroscopy could determine postoperative results in patients with CCL of the TMJ. MATERIALS AND METHODS: In all, 257 of 500 patients (344 joints) fulfilled the inclusion criteria for CCL of the TMJ. Of these patients, 172 with unilateral TMJ involvement were finally selected for the study. Synovitis and chondromalacia were chosen as the main features for evaluation of the joint surface and synovial lining. Two groups of patients were established: 1) patients with scarce affectation (synovitis grades I-II and chondromalacia grades I-II); and 2) patients with severe affectation (synovitis grades III-IV and/or chondromalacia grades III-IV). Pain and maximal interincisal opening were chosen as dependent variables. All patients were assessed at 1, 3, 6, 12, and 24 months postoperatively. The paired-samples Student's t test was used to compare mean values for pain (using a visual analog scale) and maximal interincisal opening (MIO) both pre- and postoperatively. The Student's t test for unpaired data was applied for the statistical analysis. A P value less than .05 was considered statistically significant. RESULTS: Synovitis grades I-II were arthroscopically observed in 87 (50.58%) patients, whereas synovitis grades III-IV were present in 72 (41.86%) patients. Chondromalacia grades I-II were arthroscopically observed in 66 (38.37%) patients, whereas chondromalacia grades III-IV were present in 54 (31.39%) patients. A statistically significant decrease in pain (P < .001) with a parallel increase in mouth opening (P < .001) after arthroscopy was observed for patients with synovitis I-II, synovitis III-IV, chondromalacia I-II, and chondromalacia III-IV during the whole follow-up period. A significant difference (P = .01) in relation to VAS score was observed between patients with synovitis I-II and patients with synovitis III-IV at month 6 postoperatively. However, this difference did not persist during the rest of the follow-up period, as was the case in relation to mouth opening. No significant differences were observed in relation to decrease of pain and increase of MIO between patients with chondromalacia I-II and patients with chondromalacia III-IV at any time during the follow-up period. Although mean values for pain were lower in patients with synovitis I-II plus chondromalacia I-II in comparison to patients with synovitis III-IV plus chondromalacia III-IV for the whole follow-up period, no statistical significant differences were observed. In relation to the increase in mouth opening, slightly higher values were observed for patients with synovitis I-II plus chondromalacia I-II, although no statistical differences were observed with regard to patients presenting with synovitis III-IV plus chondromalacia III-IV. CONCLUSION: A significant decrease in pain with a parallel increase in MIO was achieved from month 1 postoperatively in patients with any grade of synovitis and/or chondromalacia. No statistical difference in pain or function was observed between patients with scarce involvement of the joint surface and the synovial lining and patients with severe involvement after arthroscopy.

Reconstruction of oromandibular defects by vascularized free flaps: the radial forearm free flap and fibular free flap as major donor sites.

PURPOSE: Since the advent of the modern microvascular techniques, the radial forearm free flap (RFFF) and the vascularized fibular free flap (VFFF) have become reliable methods for reconstructing oromandibular defects. The purpose of this study is to evaluate our experience with the use of both free flaps in the reconstruction of oral cavity defects after tumoral ablation. PATIENTS AND METHODS: Over a 9-year period, 103 consecutive patients were treated in our department for the reconstruction of oral defects after tumor ablation by means of microvascularized free flaps. A total of 55 patients underwent reconstruction using RFFFs; 42 patients underwent reconstruction using VFFFs with or without skin paddles. Patients were treated for benign (n = 15) and malignant (n = 82) entities. All but 7 patients received donor site covering with abdominal full-thickness skin grafts. RESULTS: Of the 55 patients who received RFFFs, 5 (9.09%) developed necrosis at the end of the postsurgical period, and 7 patients developed complications of the donor site. Of the 42 patients who received VFFFs, an overall flap survival rate of 92.85% was achieved, and complications at the donor site occurred in 5 patients. For both free flaps, anesthesia time lasted from 6 to 15 hours (mean, 9.57 hours), whereas the mean flap ischemic time was 82.86 minutes. CONCLUSIONS: Our results reveal that the RFFF is a reliable method for reconstructing a wide range of oral cavity defects with an acceptably low morbidity rate. It provides adequate bulk and pliability, enabling the reconstruction of a wide variety of locations within the oral cavity. The VFFF allows good reconstruction of composite mandibular defects and provides adequate support for dental implants.

Local recurrences and second primary tumors from squamous cell carcinoma of the oral cavity: a retrospective analytic study of 500 patients.

BACKGROUND: The purpose of this study was to evaluate the incidence of local recurrences (LRs) and second primary tumors (SPTs) from squamous cell carcinoma (SCC) of the oral cavity primarily treated with surgery and to further study their relationship with several primary tumor clinical and pathological features. METHODS: Five hundred of 522 patients with SCC of the oral cavity primarily treated with surgery were retrospectively analyzed for the appearance of LRs and SPTs within the oral cavity. All patients with SPTs fulfilled the Warren & Gates criteria. Several clinical features were analyzed. Histological study included TNM classification, tumor size, tumor thickness, surgical margins, perineural infiltration, peritumoral inflammation, and bone involvement. In the univariant analysis, the possible association between different clinical and pathological features and the presence of LRs or SPTs was analyzed by means of the chi-square test for categorical data and the Student's t test for parametric data. The appearance of LRs and SPTs was also studied by binary logistic regression as time-dependant phenomena, in the univariant analysis. Logistic regression was also used for the multivariant analysis between the selected variables. The Kaplan-Meier method was used to estimate the probability of SPT- or LR-free survival. RESULTS: The mean duration of the follow-up period was 52.27 +/- 49.52 months. At the end of this time, 53.82% of the patients were alive without evidence of disease, whereas 31.48% had specifically died of disease. Twenty-eight (5.6%) patients developed an SPT within the oral cavity, whereas 95 (19%) patients developed an LR during the whole follow-up period. The 5-year disease-specific survival rate for the whole series was 67.2%, in contrast to 34.9% in the group of patients with SPT and/or LR. In relation to the univariant analysis, T classification, TNM staging, pT classification, surgical margins, bone involvement, and postoperative radiotherapy (RT) were found to be predictive for LR. In relation to the multivariant analysis, only postoperative RT and bone involvement were predictive for the development of LR. CONCLUSION: The identification of preoperative and postoperative clinical and pathological features that prelude a higher risk for the appearance of LRs and/or SPTs may be of potential interest in determining which patients should benefit of a closer regular follow-up. When considering together the whole clinical and pathological features, only postoperative RT and bone involvement were predictive for the development of LRs. Because of the poor survival rate of the affected patients, we strongly recommend aggressive surgical treatment following the appearance of an SPT or LR.

Solitary cystic lymph neck node metastasis of occult thyroid papillary carcinoma.

The appearance of a solitary lateral cervical cystic mass as the only initial presenting symptom of occult thyroid carcinoma is uncommon. Its presence is often misdiagnosed due to the more frequent branchial cyst in young people. Although oronasopharyngeal squamous cell carcinoma has been reported as the main cause of lymph neck node metastasis, thyroid papillary carcinoma may be responsible for solitary cervical cystic masses as the initial manifestation of the disease. This situation has been rarely reported, although solid masses are much more frequent. In most of these cases all such lesions may initially be considered as metastatic foci from a primary thyroid lesion. However, an alternative explanation by means of which ectopic thyroid tissue is associated with a branchial cyst has to be considered, especially if no primary tumour is observed in the histological examination of the thyroid gland. We present a rare case of solitary cystic lymph node metastasis of occult papillary carcinoma of the thyroid. We also discuss possible etiology for thyroid papillary carcinoma in lateral neck cysts.

Solitary cystic lymph neck node metastasis of occult thyroid papillary carcinoma

The appearance of a solitary lateral cervical cystic mass as the only initial presenting symptom of occult thyroidcarcinoma is uncommon. Its presence is often misdiagnosed due to the more frequent branchial cyst in young people.Although oronasopharyngeal squamous cell carcinoma has been reported as the main cause of lymph neck node metastasis,thyroid papillary carcinoma may be responsible for solitary cervical cystic masses as the initial manifestationof the disease. This situation has been rarely reported, although solid masses are much more frequent. In most ofthese cases all such lesions may initially be considered as metastatic foci from a primary thyroid lesion. However, analternative explanation by means of which ectopic thyroid tissue is associated with a branchial cyst has to be considered,especially if no primary tumour is observed in the histological examination of the thyroid gland. We presenta rare case of solitary cystic lymph node metastasis of occult papillary carcinoma of the thyroid. We also discusspossible ethiology for thyroid papillary carcinoma in lateral neck cysts (AU)

Migration of aluminum silicate from the oral cavity to the submandibular region, with foreign body granuloma formation: report of a case.

We present the first case of foreign body granuloma in the cervical (submandibular) region as a result of migration of noninjected aluminium silicate particles from the oral mucosa. This migration can be explained by macrophage phagocytosis and transport through the local lymphatic network and surgical disruption of fascial layers. The appearance of foreign body granulomas in distant sites may appear several weeks after the local event in a specific disposition according with the migration route. This entity must be born in mind in differential diagnosis of multiple nodules, pigmentation, or persistent swelling in the cervical-orofacial region.