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.

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.

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.

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.

The significance of tracheostomy in the management of fractures of the facial skeleton.

Although tracheostomy in relation to maxillofacial injuries has been performed for a long time, opinions differ about the necessity and indications for this procedure. In the present study 44 cases of tracheostomy in patients with maxillofacial trauma are reported and the results analysed. The case for tracheostomy, the indications and contra-indications are presented and discussed.

Cranioplasty: a review of 10 cases.

Cranial defects can be the result of trauma or neoplasia. The need for repair of these defects has led to the development of many reconstructive techniques. Ten cases of cranial defects treated by various methods of cranioplasty are reported. Of the ten cases, four were treated by bone grafts, three by silastic plates, two by acrylic plates and one by a metal plate. The indications for and contra-indications to each technique are discussed.

Median cysts of the jaws--not a true clinical entity.

The so-called median cysts of the jaws (median mandibular and median palatine) are currently classified as fissural cysts. Their existence as distinct clinical and histological entities has been the cause of debate. It is the purpose of this paper to point out that from present evidence in published case reports and reviews of the literature, the presence of these cysts in the midline of the jaws is a random finding. It is suggested that the title median mandibular and median palatine cysts should be discontinued and that cysts at these sites should be labelled according to their particular histopathology.