Higher overall survival rates of oral squamous cell carcinoma treated with metronomic neoadjuvant chemotherapy.

Distant metastasis is an important prognostic factor for oral squamous cell carcinoma (OSCC). It involves the direct spread of tumor cells through blood vessels or via lymph nodes; however, there are currently no well-established treatments for its prevention in patients with OSCC. To investigate the impact of metronomic neoadjuvant chemotherapy on OSCC, we conducted a retrospective analysis of the efficacy of neoadjuvant chemotherapy with S-1 alone. Fifty-four patients underwent up-front surgery, while 106 received neoadjuvant chemotherapy with S-1 alone. A serious adverse event occurred in one of patient treated with neoadjuvant chemotherapy (1%); however, all patients underwent resection. The 5-year overall survival rate was higher with S-1 than with up-front surgery (96% vs. 81%, P = 0.002). Moreover, neoadjuvant chemotherapy significantly increased the overall survival rate of patients with poorly or moderately differentiated tumors, but not those with well-differentiated tumors. By analyzing a cohort of 523 head and neck squamous cell carcinoma (HNSCC) patients in the Cancer Genome Atlas, we identified genetic variants associated with histological differentiation. The frequency of pathogenic/likely pathogenic variants or deletions in 5 genes associated with HNSCC correlated with histological differentiation, some of which indicated the activation of the Wnt/ß-catenin pathway in well-differentiated HNSCC. The vessel marker CD31 was highly expressed in poorly differentiated OSCC, whereas the anti-angiogenic molecule, LCN2, which is induced by the activation of the Wnt pathway, was highly expressed in well-differentiated OSCC. The present study showed that overall survival rates were higher in patients with poorly or moderately differentiated OSCC who received metronomic neoadjuvant chemotherapy, which was attributed to a difference in angiogenesis based on the characteristic landscape of pathogenic mutations according to histological differentiation.

Tertiary lymphoid structures in tongue cancer: Association with clinicopathological parameters, preoperative S-1 chemotherapy response, and prognosis.

BACKGROUND: Tertiary lymphoid structures (TLSs) are observed in cancer-invasive sites of various organs, and show evidence of tumor-specific B and/or T cells, suggesting an active humoral antitumor response. The aim of this study was to evaluate the relationship between TLSs and prognosis in patients with tongue squamous cell carcinoma (TSCC) after preoperative S-1 chemotherapy. METHODS: Among 196 TSCC cases, 111 patients who received preoperative S-1 chemotherapy were compared to 85 patients who did not receive chemotherapy. We investigated the incidence of TLSs in both preoperative biopsy and resected specimens. RESULTS: TLSs were present in 24 (12%) biopsy specimens and 31 (16%) resected specimens. TLSs were associated with clinicopathologically advanced cases and positivity for lymphatic invasion. None of the cases with pStage 0 (i.e., noninvasive cancer) showed TLSs. In preoperative S-1 chemotherapy cases, TLSs were significantly more common in those treated with S-1 for more than 21 days and in those with treatment effects 0, Ia, and Ib. TLSs may not be a favorable prognostic factor by themselves but maybe a prognostic factor when combined with preoperative S-1 treatment. CONCLUSION: The presence of TLSs was suggested to be a factor indicating a favorable prognosis when considering the indication for preoperative S-1 chemotherapy. The synergistic effect of S-1 by activating antitumor immunity may be associated with a better prognosis in TSCC patients with TLSs.

Criteria for Treatment of Intranasal Supernumerary Teeth: A Comprehensive Literature Analysis.

Objectives: Among oral surgical conditions, supernumerary teeth of the dental arch is quite common. However, supernumerary teeth in the nasal cavity is a rarity and their diagnosis and treatment have not yet been systematized. We therefore examined the literature on intranasal supernumerary teeth to establish systematic methods for their diagnosis and treatment. Methods: Using the PubMed database, we searched for literature on intranasal supernumerary teeth, published from 1990 to 2019. We combined 131 cases identified in the literature with 1 case that we experienced and summarized the characteristics of 132 cases. We recorded data on sex, age, reason for consultation (chief complaint), reporting department, impact classification, surgical approach, and anesthesia. Results: Males outnumbered females in all decades evaluated. The median age of patients was 10 years. The characteristics of these cases resembled those of maxillary anterior supernumerary teeth. The most common reason for consultation in earlier years was nasal symptoms; however, over time, an increasing number of patients sought consultation due to indications in diagnostic imaging. The most common reporting department in all decades was Otolaryngology. However, reports from Departments of Oral Surgery became increasingly common over time. General anesthesia was applicable for all impaction positions and surgical methods used. Local anesthesia was performed only with the nasal method. Of the 132 patients, 4 experienced no effect from local anesthesia, which was then changed to general anesthesia. Intranasal supernumerary teeth were found to possess the same characteristics as impacted maxillary central supernumerary teeth. Conclusions: The increased use of computed tomography has enabled early detection in asymptomatic cases. Classifying intranasal supernumerary teeth by their vertical and horizontal impaction positions provides an accurate grasp of supernumerary tooth impact classification and the selection of suitable methods of surgery and anesthesia, thus enabling systematic diagnosis and treatment of intranasal supernumerary teeth.

Relationship between histopathological therapeutic effect and prognosis in oral cancer patients after preoperative S-1 chemotherapy followed by surgery.

OBJECTIVES: Preoperative S-1 chemotherapy is administered to prevent tumor proliferation before surgery in oral squamous cell carcinoma (OSCC). The aim of this study was to investigate the relationship between the histological therapeutic effect and prognosis in patients with OSCC after pre-operative S-1 chemotherapy. MATERIALS AND METHODS: Among 461 OSCC cases, 281 patients who received preoperative S-1 chemotherapy were compared with 180 patients that did not receive chemotherapy to determine the histological therapeutic effect in the resected specimens and the differences in relapse-free survival. RESULTS: The histological chemotherapeutic effect was well correlated with the subsequent prognosis. In an examination of the combined effect of treatment and ypStage, the groups with good S-1 treatment effects had extremely good prognoses, even if the postoperative resection specimens were within the same ypStage. In a stratified search of patients who received S-1 for more than 7 days and who had a significantly better prognosis than those who did not receive S-1, it was found that the prognosis was significantly better for patients with tongue cancer according to site; furthermore, tongue cancer, age under 70 years of age, male sex, and clinical stage I were factors associated with a significantly better prognosis. CONCLUSIONS: Even if the postoperative resection specimens were within the same ypStage, the groups that responded to S-1 treatment were considered to have extremely good prognoses. CLINICAL RELEVANCE: A good adaptation for S-1 was tongue cancer, and especially tongue cancer with cStage I, male sex, and age less than 70 years old.

Radiotherapy Plus Cetuximab for Squamous Cell Carcinoma of the Oral Cavity: A Multicenter Retrospective Study of 79 Patients in Japan.

There are a few reports that focus on radiotherapy (RT) and cetuximab (CET) therapy exclusively for oral cancer. This retrospective study aimed to investigate the efficacy and safety of RT and CET therapy for locally advanced (LA) or recurrent/metastatic (R/M) oral squamous cell carcinoma (OSCC). Seventy-nine patients from 13 hospitals who underwent RT and CET therapy for LA or R/M OSCC between January 2013 and May 2015 were enrolled in the study. Response, overall survival (OS), disease-specific survival (DSS), and adverse events were investigated. The completion rate was 62/79 (78.5%). The response rates in patients with LA and R/M OSCC were 69% and 37.8%, respectively. When only completed cases were examined, the response rates were 72.2% and 62.9%, respectively. The 1- and 2-year OS were 51.5% and 27.8%, respectively (median, 14 months), for patients with LA OSCC, and 41.5% and 11.9% (median, 10 months) for patients with R/M OSCC. The 1- and 2-year DSS were 61.8% and 33.4%, respectively (median, 17 months), for patients with LA OSCC, and 76.6% and 20.4% (median, 12 months) for patients with R/M OSCC. The most common adverse event was oral mucositis (60.8%), followed by dermatitis, acneiform rash, and paronychia. The completion rate was 85.7% in LA patients and 70.3% in R/M patients. The most common reason for noncompletion was an inadequate radiation dose due to worsening general conditions in R/M patients. Although the standard treatment for LA or R/M oral cancer is concomitant RT with high-dose cisplatin (CCRT) and the efficacy of RT and CET therapy for oral cancer is not considered to be as high as that for other head and neck cancers, it was thought that RT and CET therapy could be possible treatments for patients who cannot use high-dose cisplatin.

Medial maxillary (nasomaxillary buttress) fracture: Two case reports.

RATIONALE: Medial maxillary fractures are defined as fractures of the medial aspect of the maxilla, that is, fractures of the nasomaxillary buttress. The diagnosis of medial maxillary (nasomaxillary buttress) fractures is challenging because of its similarities with nasal, and naso-orbito-ethmoidal (NOE) fractures. PATIENT CONCERN: The patients included a 17-year-old Japanese man and a 37-year-old Japanese woman with facial injuries. Swelling of the affected cheek, nasal hemorrhage, periorbital ecchymosis, and C-shaped deviation of the nasal dorsum with normal nasal tip and root position were observed. Mild hypesthesia was noted in the affected region innervated by the left infraorbital nerve. Telecanthus, double vision, eye movement disorder, epiphora, trismus, tooth fracture, and malocclusion were absent in both cases. DIAGNOSIS: Based on clinical signs and imaging findings, the patients were diagnosed with medial maxillary (nasomaxillary buttress) fracture. INTERVENTION: The 17-year-old man underwent a reduction of the medial aspect of the maxillary bone with the treatment of concomitant fractures, and the 37-year-old woman did not request treatment. LESSONS: Medial maxillary (nasomaxillary buttress) fractures are not included in any current classification of the maxillary fracture patterns. As medial maxillary (nasomaxillary buttress) fractures are similar to nasal, and NOE fractures, careful differential diagnosis is required before selecting the surgical procedure to be performed because the treatment of concomitant fractures is also necessary.

Novel Management for Severe Odontogenic Maxillary Sinusitis Based on Pathophysiology.

Endoscopic sinus surgery is commonly performed to treat odontogenic maxillary sinusitis. However, recurrence and natural ostium reclosure often occur due to the inadequate patency of the excretory route. Furthermore, classical maxillary sinus radical surgery is still performed for odontogenic maxillary sinusitis even though it can cause postoperative maxillary sinus deformation, loss of function, and a postoperative maxillary cyst. A management that addresses these issues has not yet been identified. This study reported a conservative maxillary sinus management, wherein a nasoantral window is prepared and the thickened maxillary sinus mucosa is preserved, using the Caldwell-Luc approach. This study presents a case of severe odontogenic maxillary sinusitis that spread to the frontal sinus. This novel management facilitated complete recovery from severe odontogenic maxillary sinusitis in this case.

Ghost cell odontogenic carcinoma arising in dentinogenic ghost cell tumor with next-generation sequencing cancer panel analysis: A case report.

OBJECTIVE: Ghost cell odontogenic carcinoma (GCOC) is a rare tumor that can sometimes occur from dentinogenic ghost cell tumor (DGCT). STUDY DESIGN: We report a case of GCOC arising from DGCT that underwent long-term follow-up with multiple biopsies. The biopsy specimens were analyzed using a next-generation sequencing cancer panel. RESULTS: Histopathology of the resected tumor revealed that the boundary between benign and malignant components was clear. In immunohistochemistry, the nuclei of malignant tumor cells were positive for ß-catenin and LEF-1. CTNNBI mutation was detected in all 4 biopsy specimens, and all of these mutations were identical (c.98C>G (p.Ser33Cys)). No other gene mutations that could definitively cause malignant transformation were detected. CONCLUSIONS: This case suggested that GCOC and DGCT are ghost cell neoplasms caused by a common mutation of CTNNB1 and that the malignant cells of GCOC are derived from cells that specifically differentiate into ghost cells.

Ossifying fibrous epulis as an IgG4-related disease of the oral cavity: a case report and literature review.

BACKGROUND: Fibrous sclerosing tumours and hypertrophic lesions in IgG4-related disease (IgG4-RD) are formed in various organs throughout the body, but disease in the oral region is not included among individual organ manifestations. We report a case of ossifying fibrous epulis that developed from the gingiva, as an instance of IgG4-RD. CASE PRESENTATION: A 60-year-old Japanese man visited the Department of Oral and Maxillofacial Surgery, Gunma University Hospital, with a chief complaint of swelling of the left mandibular gingiva. A 65 mm × 45 mm pedunculated tumour was observed. The bilateral submandibular lymph nodes were enlarged. The intraoperative pathological diagnosis of the enlarged cervical lymph nodes was inflammation. Based on this diagnosis, surgical excision was limited to the intraoral tumour, which was subsequently pathologically diagnosed as ossifying fibrous epulis. Histopathologically, the ossifying fibrous epulis exhibited increased levels of fibroblasts and collagen fibres, as well as infiltration by numerous plasma cells. The IgG4/IgG cell ratio was > 40%. Serologic analysis revealed hyper-IgG4-emia (> 135 mg/dL). The patient met the comprehensive clinical diagnosis criteria and the American College of Rheumatology and European League Against Rheumatism classification criteria for IgG4-RD. Based on these criteria, we diagnosed the ossifying fibrous epulis in our patient as an IgG4-related disease. A pathological diagnosis of IgG4-related lymphadenopathy was established for the cervical lymph nodes. Concomitant clinical findings were consistent with type II IgG4-related lymphadenopathy. CONCLUSIONS: A routine serological test may be needed in cases with marked fibrous changes (such as epulis) in the oral cavity and plasma cells, accompanied by tumour formation, to determine the possibility of individual-organ manifestations of IgG4-related disease.

Predictive factors for refractory stage I and II anti-resorptive agent-related osteonecrosis of the jaw.

OBJECTIVES: We aimed to predict the possibility of patients with stage I and II anti-resorptive agent-related osteonecrosis of the jaw (ARONJ) developing resistance to our treatment protocol by evaluating their clinical and imaging factors. MATERIALS AND METHODS: We enrolled 58 patients with ARONJ who underwent imaging modality. As objective variables, we considered the healing, stage-down, and stable stages as successful outcomes, and the stage-up stage as resistant-to-treatment. As explanatory variables, we investigated the clinical and imaging factors. Furthermore, we examined stage-down as an improvement outcome to compare with the stable and stage-up stages, which were considered as no-improvement outcomes. We conducted unpaired between-group comparisons on all explanatory variables using χ2 tests for independence. RESULTS: Among 58 patients, the treatment was successful in 53 (91.4%); however, the disease was resistant in five (8.6%). Among the clinical factors, the resistant patients had a longer duration of administration of bone-modifying agents (BMAs) (cut-off: 1251 days, p = 0.032, odds ratio = 11.2, 95% confidence interval 1.115-122.518). In addition, the target disease that was being treated bone metastasis of malignant tumor was the only significant refractory factor (p = 0.024, OR: 3.667 95% CI 1.159-11.603) CONCLUSIONS: A combination of metabolic and morphological imaging modalities may be useful for oral surgeons to evaluate the disease activity and predict course of refractory ARONJ.

Determination of diagnostic and predictive parameters for vertical mandibular invasion in patients with lower gingival squamous cell carcinoma: A retrospective study.

Vertical mandibular invasion of lower gingival squamous cell carcinoma (LGSCC) determines the method of resection, which significantly affects the patient's quality of life. Therefore, in mandibular invasion by LGSCC, it is extremely important to monitor progression, specifically whether invasion is limited to the cortical bone or has progressed to the bone marrow. This retrospective study aimed to identify the diagnostic and predictive parameters for mandibular invasion, particularly vertical invasion, to enable appropriate selection of the method of mandibular resection. Of the patients who underwent surgery for LGSCC between 2009 and 2017, 64 were eligible for participation in the study based on tissue microarrays (TMA) from surgical specimens. This study analyzed morphological features using computed tomography (CT), and metabolic characteristics using maximum standardized uptake value (SUVmax), peak value of SUV (SUVpeak), metabolic tumor volume (MTV), and total lesion glycolysis (TLG). Moreover, immunohistochemical analysis of proteins, including parathyroid hormone-related protein (PTHrP), interleukin-6 (IL-6), E-cadherin, and programmed cell death-1 ligand 1 (PD-L1), was performed. Statistical analysis was performed using univariate logistic regression analysis with the forward selection method. The present study showed that MTV (≥2.9 cm3) was an independent diagnostic and predictive factor for positivity of mandibular invasion. Additionally, TLG (≥53.9 bw/cm3) was an independent diagnostic and predictive factor for progression to bone marrow invasion. This study demonstrated that in addition to morphological imaging by CT, the volume-based parameters of MTV and TLG on fluorine-18 fluorodeoxyglucose positron emission tomography were important for predicting pathological mandibular invasion in patients with LGSCC. A more accurate preoperative diagnosis of vertical mandibular invasion would enable the selection of appropriate surgical procedure for mandibular resection.

Diagnosis and treatment of secretory carcinoma arising from the oral minor salivary gland: Two case reports.

INTRODUCTION: Secretory carcinoma (SC) is a malignancy of the salivary glands, which is similar to SC of the breast regarding its association with neurotrophic tyrosine receptor kinase fusion-positive gene. SC is a recently described salivary gland tumor, and there are a few reports describing oral minor salivary gland-derived SC. We reported two cases of SC in the oral cavity and reviewed the literature. PATIENT CONCERNS: The patients included a 65-year-old Japanese woman who presented with a mass of the upper lip and an 84-year-old Japanese man who presented with a mass on the buccal mucosa. DIAGNOSIS: Diagnosis was based on histomorphological and immunohistochemical findings and identification of a specific translocation of the ETS variant 6-neurotrophic receptor tyrosine kinase 3 gene fusion. Case 1 was finally diagnosed using reverse transcription-polymerase chain reaction with formalin-fixed paraffin-embedded tissue samples, while case 2 was diagnosed using fluorescence in situ hybridization analysis. INTERVENTIONS AND OUTCOMES: In case 1, excisional biopsy was done and there was no recurrence observed in five-year follow-up. In case 2, tumor resection was done and there was no recurrence observed in two-year follow-up. CONCLUSION: It is highly likely for many cases of SC to be initially diagnosed as acinic cell carcinoma (AciCC) owing to their similar histological findings. The treatment strategy for minor salivary gland-originated SC is similar to that of AciCC; however, SC is often highly malignant and involves a high risk of cervical lymph node metastasis. Thus, establishing an accurate diagnosis together with pathologists and confirming the presence of the ETS variant 6-neurotrophic receptor tyrosine kinase 3 fusion gene using genetic analysis is important.

Texture analysis of [18F]-fluorodeoxyglucose-positron emission tomography/computed tomography for predicting the treatment response of postoperative recurrent or metastatic oral squamous cell carcinoma treated with cetuximab.

OBJECTIVE: To assess the value of the texture analysis of fluorine-18F-fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG-PET/CT) in predicting the treatment response of postoperative recurrent or metastatic oral squamous cell carcinoma (POR/M-OSCC) treated with cetuximab. METHODS: A total of 14 patients undergoing 18F-FDG-PET/CT with POR/M-OSCC were divided into the responder and non-responder groups according to cetuximab response by Response Evaluation Criteria in Solid Tumors (RECIST). The regions of interest (ROI) were set at the POR/M-OSCC lesions with the highest uptake of 18F-FDG, and the volumetric and texture features were analyzed. The features with correlation coefficient of 0.6 or more were further evaluated using the logistic regression analysis to create a model. RESULTS: The SHAPEVolume(vx), SHAPEVolume(mL), metabolic tumor volume (MTV), and gray-level run-length matrix run-length nonuniformity (GLRLMRLNU) were significantly different between the responder (n = 6) and non-responder (n = 8) groups (p = 0.044, 0.042, 0.047, and 0.012, respectively). The model's area under the curve (AUC) was found to be 0.83, 0.83, 0.79, and 0.92, respectively. The heatmap with PET feature dendrogram showed four distinct clusters including them in patient's responder and non-responder groups. CONCLUSIONS: Higher MTV, GLRLMRLNU, SHAPEVolume(vx), and SHAPEVolume(mL) in 18F-FDG-PET images may have the prediction values for treatment response with POR/M-OSCC treated with cetuximab.

CD15+ tumor infiltrating granulocytic cells can predict recurrence and their depletion is accompanied by good responses to S-1 with oral cancer.

BACKGROUND: It has been reported in oral squamous cell carcinoma (OSCC) that myeloid-derived suppressor cells infiltrate tumor tissues. This study examined whether S-1 chemotherapy changes immune cell populations in the tumor microenvironment. METHODS: We examined 71 patients with of OSCC, including 51 patients who received preoperative S-1 chemotherapy. Immunohistochemistry for PD-L1, CD8, forkhead box protein 3 (FOXP3), and CD15 was performed using biopsy and resected specimens. RESULTS: The numbers of CD8+ , FOXP3+ , and CD15+ cells in resected specimens were significantly decreased by S-1 chemotherapy. The reduction of the proportion of CD15+ cells significantly differed between responders and nonresponders. Most responders were distributed into the group with low PD-L1 expression and a low density of CD8+ cells before chemotherapy. Furthermore, many patients with recurrence exhibited a high density of CD15+ cells in biopsy specimens. CONCLUSION: Preoperative S-1 chemotherapy can potentially improve prognosis by reducing CD15+ cells in the tumor microenvironment.

Predictive factors for dental inflammation with exacerbation during cancer therapy with FDG-PET/CT imaging.

PURPOSE: Oral adverse events, such as dental inflammation with exacerbation, are stressful and lead to poor nutrition in patients undergoing cancer therapy. Thus, the prediction of risk factors for dental inflammation with exacerbation is important before cancer therapy is initiated. We hypothesized that, during cancer therapy (DIECT), fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) imaging could be useful to predict dental inflammation with exacerbation. METHODS: We enrolled 124 patients who underwent FDG-PET/CT for diagnostic staging before cancer treatment. We then assessed DIECT outcomes after basic perioperative oral treatment. Moreover, we evaluated clinical parameters, therapeutic strategies, periodontal examination (probing depth (PD) and bleeding on probing (BOP)), dental imaging, and FDG-PET/CT imaging results of patients with and without DIECT. Furthermore, PET/CT images were assessed as per the FDG accumulation of the dental lesion (PAD) grading system. RESULTS: Univariate analysis demonstrated significant differences in age, periodontal examination (PD and BOP), and PAD grade between patients with and without DIECT. Furthermore, multivariate logistic regression analysis identified independent predictive factors for a positive periodontal examination (PD) (odds ratio (OR) 5.9, 95% confidence interval (CI) 1.8-19.7; P = 0.004) and PAD grade (OR 11.6, 95% CI 3.2-41.2; P = 0.0002). In patients with cancer, PAD grade using FDG-PET/CT imaging was an independent and informative risk factor for DIECT. CONCLUSION: Our results suggested that, for patients with DIECT, periodontal examination and PAD grade were independent predictive factors. Hence, regardless of the presence or absence of any lesion on dental imaging, PAD grade might be an additional tool, in addition to periodontal examination that potentially improves oral care management.

Image screening for maxillo-mandibular actinomycosis with CT, 18F-FDG-PET/CT, and 18F-α-methyl tyrosine PET/CT.

OBJECTIVES: Clinical features and imaging findings of maxillo-mandibular actinomycosis are similar to those of intraosseous carcinoma. The purpose of this study is to clarify the characteristics of the imaging findings for screening of maxillo-mandibular actinomycosis using CT and PET. METHODS: Reports on maxillo-mandibular actinomycosis published between 1997 and 2016 were searched in PubMed using "actinomycosis," "maxilla," and "mandibular" as keywords. Ten cases suspected to have malignant tumors on diagnostic imaging findings were selected. In addition, three patients who visited Gunma University Hospital were also included. The 13 total cases were subjected to a pooled analysis of diagnostic screening of maxillo-mandibular actinomycosis using CT, 18F-FDG-PET/CT (FDG-PET/CT) and 18F-α-methyl tyrosine PET/CT (FAMT-PET/CT). Additionally, cases of intraosseous carcinoma were analyzed as comparative controls to investigate the difference between maxillo-mandibular actinomycosis and intraosseous carcinoma on CT imaging. RESULTS: CT images of the 13 cases with maxillo-mandibular actinomycosis were investigated; spotty-type bone resorption was observed in 66.7% (8/12). Moreover, FDG-PET/CT showed abnormal accumulation, but FAMT-PET/CT showed no apparent abnormal accumulation. CONCLUSIONS: Clinical and imaging findings of maxillo-mandibular actinomycosis are similar to those of intraosseous carcinoma. Differential diagnostic screening can confirm spotty-type bone resorption in cortical bone with CT and specific accumulation in malignant tumors with FAMT-PET/CT. This screening facilitates the rapid implementation of therapeutic interventions.

Elongated Styloid Process With Skeletal Mandibular Protrusion.

ABSTRACT: An elongated styloid process (ESP) causes symptoms such as pharyngeal pain, swallowing pain, and discomfort during mouth opening. The main treatment is surgical resection of the ESP. The authors present a case of ESP with skeletal mandibular protrusion. Because mandibular setback by sagittal splitting ramus osteotomy (SSRO) may lead to deterioration of symptoms of ESP, resection of ESP and bilateral SSRO were performed simultaneously. The patient was a 50-year-old man who visited our department with chief complaints of mandibular protrusion and pain in the left pharynx on mouth opening and swallowing. A lateral cephalogram helped in diagnosis of skeletal mandibular protrusion. In addition, an approximately 42-mm left styloid process elongated inferomedially was observed. Left styloidectomy was first performed via the cervical approach, followed by SSRO. Occlusion, facial appearance, and preoperative symptoms due to the ESP improved after surgery. The cervical appearance was esthetically satisfactory. In a case of ESP with skeletal mandibular protrusion with potential aggravation of symptoms because of mandibular setback of the ESP, resection of the styloid process is necessary together with orthognathic surgery.

Impact of skeletal muscle mass on postoperative delirium in patients undergoing free flap repair after oral cancer resection.

Postoperative delirium (POD) is a major risk factor for an extended hospital stay and higher costs, and is associated with increased mortality. The incidence of POD is high in free flap procedures, and POD may also be a risk factor for flap loss and complications. Sarcopenia is a condition characterized by skeletal muscle mass (SMM) depletion and a decrease in muscle power or physical activity. The aim of this study was to investigate risk factors for postoperative delirium (POD), including SMM, in 122 patients undergoing free flap repair after oral cancer resection. All patients underwent preoperative abdominal-lumbar CT or PET-CT. Cross-sectional areas (cm2) of skeletal muscles at the third lumbar vertebra were measured on preoperative CT, normalized for height, and defined as the skeletal muscle index (SMI, cm2/m2). Risk factors for POD were investigated, including the value of SMI and taking the type of POD into consideration. POD occurred in 45 patients (36.9%), and was hyperactive in 28 (62.2%), mixed in 13 (28.9%), and hypoactive in 4 (8.9%). In multivariate analysis, high preoperative albumin (p = 0.046, adjusted odds ratio [OR] = 3.69) and postoperative insomnia (p < 0.001, OR = 6.79) were significant risk factors for POD. In a sub-analysis evaluating risk factors restricted to POD including the hypoactive type, lower SMI (p = 0.035, OR = 2.52 per 10-unit decrease) and postoperative insomnia (p = 0.003, OR = 6.37) were significant. We conclude that lower SMM increases the hypoactive and mixed types of POD. Increasing SMM by exercise and nutritional therapy preoperatively may prevent such POD in free flap repair for oral cancer.

Laboratory Risk Indicator for Necrotizing Fasciitis of the Oro-Cervical Region (LRINEC-OC): A Possible Diagnostic Tool for Emergencies of the Oro-Cervical Region.

AIM: Oro-cervical necrotizing fasciitis (OCNF) treatment requires early surgical debridement and opening of the wound, and therefore, early diagnosis is very important. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score based on blood test data has recently been proposed as an auxiliary diagnostic tool. However, in some cases, it is difficult to diagnose OCNF. We performed a pooled analysis of patients with OCNF at Gunma University Hospital and literature cases, with the goal of designing a new auxiliary diagnostic tool for OCNF by adding physical characteristics of the oro-cervical region to blood test data in the first examination. METHODS: Univariate and multivariate logistic regression was used to select predictors of OCNF. The LRINEC-Oro-Cervical (OC) score was then designed using correlation coefficients of items selected in logistic regression analysis. A cutoff value for the LRINEC-OC score was determined using receiver operating characteristic (ROC) curve analysis. RESULTS: CRP, WBC, Cr, and skin flare in the cervical and precordial regions were extracted as independent factors (p < 0.05) and evaluated as predictors of OCNF. The LRINEC-OC score for the prediction of OCNF was designed using the regression coefficients in logistic analysis. The cutoff value for the LRINEC-OC score was 6 points with a sensitivity of 88.5% and a specificity of 93.4%, and the AUC was 0.909. CONCLUSION: Delays in diagnosis and surgical treatment for OCNF led to a fatal prognosis, and the potential utility of the LRINEC-OC score for improving the prognosis was shown in this study.