The surgical management of extra-articular ankylosis in noma patients.

Extraarticular ankylosis occurs frequently in children suffering from noma sequelae. Over 20years of operating on these patients, we observed high recurrence of mouth opening limitation. We therefore progressively changed our surgical strategy. This retrospective study compares the impact of different parameters (types of surgery, noma type, physiotherapy compliance, age and sex) on immediate and long-term mouth opening. It includes a series of 121 patients with extraarticular ankylosis operated on between 1990 and 2015. Soft tissue reconstruction evolved from local and pedicled flaps to large free flaps. Mouth opening was performed by bone-bridge excision, sometimes associated to contralateral coronoidectomy. Mouth opening technique including bilateral coronoidectomy with free flap reconstruction was the only independent factor for significantly better immediate mouth opening with a mean increase of 8.7mm [95% confidence interval (CI) 4.3-13.1, P<0.001) and this effect was maintained in the 3years of follow-up. Another positive factor related to long-term results was excellent physiotherapy, while noma type 4 was a negative factor. Recurrence remains problematic in the management of noma sequelae. If physiotherapy and long-term follow-up cannot be offered, patients should not be operated on, because if limitation of mouth opening recurs, oral feeding may become impossible when a facial defect has been reconstructed.

[GESNOMA (Geneva Study Group on Noma): state-of-the-art medical research for humanitarian purposes]. / GESNOMA (Geneva Study group on Noma): une recherche médicale de pointe à but humanitaire.

Noma is a devastating gangrenous disease that leads to severe tissue destructions in the face. It is seen almost exclusively in children living in less developed countries. The exact prevalence of the disease is unknown and the cause remains unknown too. Risk factors are: malnutrition, a compromised immune system, poor oral hygiene and a lesion of the gingival mucosal barrier, as well as an unidentified bacterial factor. Herpes viruses might also contribute. Studies of the buccal flora in acute phases of noma and comparison with control children do not exist. Our study takes place in Niger. For each child (cases and controls) we take samples of gingival fluid, saliva, blood and mouth mucosal swabs. The samples are analysed in Geneva in different laboratories. We control the serologies for Herpes viruses and measles. We also perform a nutritional assessment and the mucosal swabs are cultivated for the presence of viruses. The gingival flora is investigated by microarrays. These microarrays are instrumental to test for the presence of thousands of different bacteria in each clinical sample. This method allows a qualitative and quantitative description of the oral flora in noma-children and control cases. This is the first large scale study on the etiology of noma which uses new technical approaches for humanitarian purposes.