Poorly controlled diabetes mellitus is strongly associated with descending necrotizing mediastinitis of odontogenic origin.

OBJECTIVE: We hypothesized that poorly controlled diabetic status may be a negative prognostic factor for acute mediastinitis of odontogenic origin, and we conducted a cohort study to verify this hypothesis. STUDY DESIGN: Data were collected on all consecutive patients diagnosed with maxillofacial infections of odontogenic origin who received surgical treatment in the Oral and Maxillofacial Surgery Department. All patients included in the study were divided into 4 groups based on the presence or absence of diabetes and mediastinitis. Poorly controlled diabetic status constituted our primary predictor variable, and the occurrence of descending necrotizing mediastinitis was the outcome variable. RESULTS: All 7 patients with poorly controlled diabetes mellitus were complicated with descending necrotizing mediastinitis. An exact Fischer test was conducted to investigate the association of poorly controlled diabetes mellitus with descending necrotizing mediastinitis in patients admitted for surgical treatment of their maxillofacial collection. The result was significant at P < .01. CONCLUSION: This study represents the first scientific attempt to associate poorly controlled diabetes mellitus with descending necrotizing mediastinitis of odontogenic origin. Our results show evidently that these patients are more susceptible to deep space infections, which subsequently spread faster and are much more difficult to control.

Fine-Needle Aspiration Cytology in the Diagnosis of Salivary Gland Tumors Before the Milan System: A Ten-Year Experience From a Tertiary Care Center in Greece.

Objective The objective of this study was to determine the diagnostic value of fine-needle aspiration cytology (FNAC) for salivary gland tumors. Methodology A retrospective file analysis of patients with salivary gland pathology, attending the Department of Oral and Maxillofacial Surgery of a tertiary care center in Athens, Greece, over a 10-year-long period, was conducted. Sensitivity, specificity, accuracy, positive prognostic value (PPV), and negative prognostic value (NPV) of FNAC for benign and malignant tumors separately were assessed and compared with histology. Results A total of 82 patients (46 male and 36 female) with salivary gland tumors, submitted to both FNAC and histology, were included. The mean age was 55 years. A total of 73 tumors were histologically diagnosed as benign and nine as malignant. FNAC identified 62 benign and seven malignant tumors but was inconclusive in 13 cases. The most common diagnosis of both histology and FNAC was pleomorphic adenoma. FNAC sensitivity, specificity, accuracy, PPV, and NPV were 98.3% and 100%, 87.5% and 100%, 97.1% and 100%, 98.3% and 100%, and 87.5% and 100% for benign and malignant tumors, respectively. Conclusions FNAC is highly sensitive but moderately specific for the preoperative identification of benign salivary gland tumors. Its use as an initial diagnostic modality is warranted, thanks to its safeness, rapidity, and lack of pain.

Significant rise in neck infections progressing to descending necrotizing mediastinitis during the COVID-19 pandemic quarantine.

To present five patients with DNM, who were treated during the first quarantine for Coronavirus disease 2019 (Covid-19). Five patients with DNM were treated in our department during the first lockdown. The mean age of the patients was 42,2 years and four were male. Two patients were immunocompromised. Repeated surgical drainage was performed in all patients, whereas four were also subjected to elective tracheostomy during their first operation. The mean hospitalization duration was 55,4 days and mortality was 40%. During the first lockdown for the Covid-19, a rise in the ratio of DNM cases to the overall incidence of cervicofacial infections was observed in our department. All patients with DNM were operated on an emergency basis and were subsequently admitted to the ICU. We consider the effect of the quarantine as a decisive factor for this escalation, because according to the department archives, there had not been any cases of DNM originating from a dental infection, for the past 5 years. Additionally, past studies from the same department reported no more than 6 cases over a 10 year period.

Microsurgical reconstruction of complex oromandibular defects: An update.

Free flaps are the gold standard for reconstruction of the mandible, tongue and floor of the mouth. Free fibular flaps are the most preferable option for reconstruction of complex mandibular defects, as well as for tongue and mouth floor reconstruction, since they are harvested easily, present excellent sculptability and good functional outcomes. Alternative options for bone reconstruction include the fibular and iliac crest free flap, and for soft tissue reconstruction include the anterolateral thigh, the radial forearm free flap, and the nasolabial island flap. The principles of the surgical approach include resection of the mandibular segment, intraoperative evaluation of the defect, and various surgical manipulations of the flap on site to reconstruct the defect. Advances in computerized preoperative planning have allowed virtual simulation of the defect and fabrication of an individualized stereolithic mandibular model. This short review discusses the current trends of bone and soft tissue flaps for complex oromandibular reconstructions aiming to present a comprehensive review that the readers would find interesting and informative.

Blindness after facial trauma: epidemiology, incidence and risk factors: a 27-year cohort study of 5708 patients.

OBJECTIVES: This was a 27-year study of a cohort of 5708 patients who had sustained maxillofacial fractures. Our purpose was to present the etiology, mechanism of trauma, site, and concomitant injuries that led to visual loss. We hypothesize that fractures caused by high-energy impact of the midface may be associated with blindness. A discussion of the treatment approaches is also included. STUDY DESIGN: The study included 5708 patients who had sustained a maxillofacial fracture during the years 1985-2012. Patients' records were reviewed for gender, age, fracture site, etiology of trauma, concomitant injuries, method of treatment, length of hospital stay, and cause of blindness. The relationship of the above variables to blindness was investigated. RESULTS: The incidence of loss of vision was 0.34%. A very strong association between firearm injuries and blindness was observed (P < .001). These patients spent much longer time in hospital (P < .01) and suffered serious concomitant injuries involving the brain. CONCLUSIONS: Retrobullbar hemorrhage should be treated with lateral canthotomy, whereas in traumatic optic neuropathy, observation seems to be the safest thing to do. In patients with penetrating injuries of the globe, the immediate involvement of an ophthalmic surgeon is of paramount importance.

Fractures of the Nasal Bones: Is External Splinting Really Warranted?

BACKGROUND: It has been advocated that reduction of nasal bone fractures should be followed by internal packing and/or external splinting. Despite the ample literature concerning the advantages and limitations of various splint types, the necessity and effectiveness of external splinting has not been well documented. OBJECTIVE: To present the authors' experience and review the literature on treatment of nasal bone fractures, focusing on the indications and effectiveness of external splinting following closed reduction. STUDY DESIGN: Retrospective analysis and literature review. PATIENTS AND METHODS: Medical records of all patients, treated at the Department of Oral and Maxillofacial Surgery of the "KAT" General Hospital of Attica between January 2010 and December 2016 for facial trauma including nasal bone fractures, were retrospectively reviewed. Patient demographic data, fracture type, applied treatment, complications, and final outcome were registered. RESULTS: A total of 77 patients (58 males; 19 females) were included in the study. The age range was 18 to 65 years (mean, 37.8). Closed reduction without external splinting was performed in 63 patients and open reduction with internal fixation in 6; 8 severely comminuted fractures were treated with closed reduction and external splinting. The mean follow-up was 4.8 months. All severely comminuted fractures presented complications. CONCLUSIONS: External splinting following closed reduction of nasal bone fractures should not be used routinely but only in selected patients with severe comminution. Since the pertinent literature is inconclusive on the indications and effectiveness of external splinting, randomized controlled studies are warranted to fully elucidate the issue.

Determination of clozapine, and five antidepressants in human plasma, serum and whole blood by gas chromatography-mass spectrometry: A simple tool for clinical and postmortem toxicological analysis.

In this study, we describe a simple and rapid method for the determination of the antipsychotic drug clozapine and five commonly co-administered antidepressants - bupropion, mirtazapine, sertraline, clomipramine and citalopram - in serum, plasma and whole blood. Sample preparation includes solid phase extraction of analytes and determination of drug concentrations by gas chromatography-mass spectrometry without any derivatization steps. The method was fully validated according to international criteria and can be successfully applied for routine analyses. Correlation coefficients of calibration curves for the tested drugs in the three specimens were in the range 0.9977-0.9999. Intra-day and inter-day precisions ranged from 0.81-7.85% and 3.60-12.91% respectively for the studied analytes and matrices. Recoveries were satisfactory for different concentrations of each drug in each specimen allowing accurate determinations in the range from sub-therapeutic to toxic levels. The presented method shows acceptable sensitivity, linearity in wide concentration ranges (sub-therapeutic, therapeutic, supra-therapeutic/toxic levels), it is simple and rapid and it is applicable for qualitative and quantitative routine toxicological analyses of clinical and postmortem cases.

Hypericum perforatum L. treatment restored bone mass changes in swimming stressed rats.

UNLABELLED: Stress, via corticosteroids release, influences bone mass density. Hypericum perforatum (Hp) a traditional remedy possess antidepressive activity (serotonin reuptake inhibitor) and wound healing properties. Hp preparation contains mainly hypericin, hyperforin, hyperoside and flavonoids exerting oestrogen-mimetic effect. Cold swimming represents an experimental model of stress associating mental strain and corporal exhaustion. OBJECTIVES: This study investigates the Hp effect on femur and mandible bone mass changes in rats under cold forced swimming procedure. METHODS: 30 male Wistar rats were randomized into three groups. Group A was treated with Methanolic extract of Hp (Jarsin®) via gastroesophageal catheter, and was submitted to cold swimming stress for 10 min/daily. Group B was submitted to cold stress, since group C served as control. Experiment duration was 10 days. Haematocrite and serum free fatty acids (FFA) were estimated. Furthermore volume and specific weight of each bone as well as bone mass density via dual energy X-Ray absorptiometry (DEXA) were measured. Statistic analysis by t-test. RESULTS: Hp treatment restores the stress injuries. Adrenals and bone mass density regain their normal values. CONCLUSIONS: Injuries occurring by forced swimming stress in the rats are significantly improved by Hp treatment. Estrogen-like effects of Hp flavonoids eventually may act favorable in bone remodeling.

Osteo-cementum Producing Odontogenic Myxomas. A Literature Review of a Distinctive Variant.

INTRODUCTION: Odontogenic myxoma (OM) is a benign neoplasm of mesenchymal origin with growth characteristics, clinical behaviour and radiographic presentation similar to those of ameloblastoma. It is an intraosseous neoplasm characterized by stellate and spindleshaped cells embedded in loose myxoid or mucoid extracellular matrix. Although sometimes bony islands that represent residual trabeculae are found throughout the lesion, the formation of osteocement-like calcified spherules within the tumour is an extremely rare phenomenon. REVIEW: We report a very rare case of an OM of the left maxilla exhibiting osteo-cementous metaplasia within the substance of the tumour and beyond the facial skeleton, in the nasopharynx. A review of all four similar cases previously reported in the literature is also presented. CONCLUSION: Whether or not this property to produce significant amounts of bone can be associated with a different biological behavior for this specific variant of OM remains to be proved with the study of more similar cases.

Effect of Causative Tooth Extraction on Clinical and Biological Parameters of Odontogenic Infection: A Prospective Clinical Trial.

PURPOSE: To prospectively compare changes of body temperature, white blood cell count, fibrinogen, and C-reactive protein between odontogenic infections in which the responsible tooth was removed and odontogenic infections in which the treatment included no extraction. MATERIALS AND METHODS: The sample was composed of patients admitted to the authors' maxillofacial unit for odontogenic infection from 2010 through 2013. One hundred seventy-nine patients were categorized into an extraction or a non-extraction group based on whether the causative tooth was non-restorable or restorable, respectively. Non-restorable teeth were extracted at admission of the patient. Otherwise, the treatment protocol, including incision of the involved space in conjunction with intravenous antibiotics, was the same for the 2 groups. The parameters were measured and recorded at admission and 2 days later. Data records were statistically analyzed by comparing the change of the parameters studied between the extraction and non-extraction groups. P values less than .05 were regarded as statistically significant. RESULTS: One hundred seventy-nine patients fulfilled the inclusion criteria and were enrolled in the study. The mean age of the patients was 39.1 years (minimum, 14 yr; maximum, 81 yr; standard deviation, 15.4 yr). One hundred nine patients (60.9%) were male, and 70 (39.1%) were female. Differences in the mean decrease of axillary temperature, white blood cell count, fibrinogven, and C-reactive protein between the 2 groups were 0.178, 2,300, 1.01, and 0.64, respectively. All these differences were statistically significant (P =.02, .001, .001, and .001, respectively). Also, the mean hospital stay in the extraction group was 1.05 days shorter than in the non-extraction group, with the difference being statistically significant (P = .006). CONCLUSIONS: In odontogenic maxillofacial infections, extraction of the causative tooth is associated with a faster clinical and biological resolution of the infection.

Hemiatrophy of the tongue caused by an extensive vagus nerve schwannoma masquerading as a carotid chemodectoma.

BACKGROUND: Carotid chemodectomas or carotid body tumors are rare neoplasms, generally benign and frequently asymptomatic, which represent 0.6 % of all head and neck tumours. Schwannomas or neurilemmomas are benign, slow growing tumours that derive from the sheath of peripheral and cranial nerves. Of all neurilemmomas, 25-45 % originate from the head and neck region, with the vagus nerve being one the most encountered sites of occurrence. CASE REPORT: We describe a schwannoma originating from the vagus nerve mimicking a carotid body tumour and compromising the function of the hypoglossal nerve. DISCUSSION: Patients with lateral neck masses near the bifurcation of the carotid artery are often referred to the maxillofacial surgeon. The differential diagnosis of these lesions includes a variety of tumours among which carotid chemodectomas and vagus nerve schwannomas have a significant incidence. Both lesions may appear as completely asymptomatic, thus it is very difficult to identify the origin of the tumour based on physical examination. In making a differential diagnosis of the cervical tumours imaging studies play a key role. PURPOSE: A diagnostic algorithm based on contemporary imaging modalities, which can be useful in order to distinguish between these two pathological entities is presented.

Treating maxillofacial trauma for over half a century: how can we interpret the changing patterns in etiology and management?

OBJECTIVE: The aim of this study was to reveal the changes in the etiology and treatment of maxillofacial fractures in Greece over the period of the last 53 years. STUDY DESIGN: A patient-oriented retrospective review of clinical and epidemiologic data was performed to include all patients with maxillofacial fractures treated in the Oral and Maxillofacial Surgery Department of KAT General Hospital of Athens. We reviewed the causes of these injuries, their sites, and treatments (outcome variables) over the last 28 years and compared the results with those of a similar study from the same Department from 1960 to 1984 (predictor variable). RESULTS: The zygomatic complex was the most frequent fracture site in the recent years, whereas the condyle and symphysis were the most common ones in the early period. We observed a remarkable increase of injuries from interpersonal violence (P < .0001) and a divergence from conservative treatment (P < .001) with time. CONCLUSIONS: Universal agreement exists on the rapidly rising prevalence of facial fractures in the developed countries as a result of physical violence, and the present study confirmed this conclusion. Throughout the last 50 years, there has been a constant tendency of surgeons to adopt the concept of open reduction and internal fixation.

Facial trauma in the Trojan War.

PURPOSE: The Iliad and Odyssey of Homer represent the cornerstones of classical Greek literature and subsequently the foundations of literature of the Western civilization. The Iliad, particularly, is the most famous and influential epic poem ever conceived and is considered to be the most prominent and representative work of the ancient Greek epic poetry. We present the injuries that involve the face, mentioned so vividly in the Iliad, and discuss the aetiology of their extraordinary mortality rate. METHODS: We recorded the references of the injuries, the attacker and defender involved, the weapons that were used, the site and the result of the injury. RESULTS: The face was involved in 21 trauma cases. The frontal area was traumatized in 7 cases; the oral cavity in 6; the auricular area in 4; the orbits and the retromandibular area in 3; the mandible and the nose in 2; and the maxilla, the submental and the buccal area in 1, respectively. The mortality rate concerning the facial injuries reaches 100%. CONCLUSION: Homer's literate dexterity, charisma and his unique aptitude in the narration of the events of the Trojan War have established him as the greatest epic poet. We consider the study of these vibrantly described events to be recreational and entertaining for everyone but especially for a surgeon.

Impact of the economic recession on the etiology of maxillofacial fractures in Greece.

OBJECTIVE: The global economic crisis and the subsequent austerity measures taken in Greece in 2010 have moved the country to the epicenter of a financial storm with negative effects on the national health sector and all aspects of social life. METHODS: Records of patients admitted for treatment of maxillofacial fractures in two different periods of time were used in this study. Data concerning the etiology of fractures from 2006 to 2009 were compared with data from 2010 to 2013 to investigate whether the economic recession has significantly influenced the causality of trauma. RESULTS AND CONCLUSION: Our study demonstrates that the rate of facial fractures caused by motor vehicle accidents before the worsening of the crisis was significantly reduced in the period after 2010 but that the incidence of fractures due to interpersonal violence increased during the period of the severe economic crisis. We discuss the reasons that may have led to these changing patterns of trauma.

Visual loss due to paranasal sinus invasive aspergillosis in a diabetic patient.

Aspergillus species are commonly found in the soil and decaying organic matter. The spores can be typically inhaled or ingested, yet disease due to tissue invasion is rarely seen in the immunocompetent host. In the immunocompromised patient, there has been an increased incidence of invasive aspergillosis in the last 20 years. Invasive aspergillosis of the maxillary sinus with orbital and cranial spread can be lethal, therefore, necessitates early diagnosis and prompt treatment. The predilection of Aspergillus for infiltration of blood vessels can result in serious ocular complications which can lead to loss of vision. We present the case of an uncontrolled diabetic patient with invasive maxillary sinus aspergillosis and extension to the orbital contents. Our purpose was to emphasize the need of early recognition and prompt initiation of combined antifungal treatment and surgical intervention with the intent to preserve the involved vital structures.

Severe odontogenic infections: causes of spread and their management.

BACKGROUND: We conducted a study designed to investigate the clinical factors correlated with the spread of an odontogenic infection to the deep spaces of the head and neck. We also analyzed the treatment modalities for this and their outcomes. METHODS: The study retrospectively examined all patients admitted in 2009 and 2010 to the General Hospital of Attica "KAT" with maxillofacial infections of odontogenic origin. The patients' case records were reviewed according to predefined inclusion and exclusion criteria and the relevant data were collected. The data were analyzed statistically. RESULTS: The study involved 212 patients with a mean age of 40.8 y. Of these, 59.9% reported using oral antibiotics, usually (35.4%) without prescription. Moderate or poor oral hygiene was present in 78.3% of the study patients. The percentage of incompatible use of antibiotics due to non-compliance was 13.4%. Non-compliance indicates that these patients failed to follow the daily dosage or the dosing intervals of a prescribed antibiotic or they stopped an antibiotic due to an adverse reaction. Incision and drainage was required in 63.2% of the study patients, and 46.2% required extraction of the tooth responsible for their infection. A statistically significant association was documented between fever on admission and a prolonged hospital stay. No major complications were encountered among the study patients. CONCLUSIONS: Odontogenic infections remain a common cause of morbidity. Poor oral hygiene, self-medication, inadequate utilization of antibiotics, lack of treatment of the causative tooth, delayed presentation at the hospital, and bacterial resistance to empirically administered antibiotics appear to correlate with the spread of odontogenic infections. Incision and the evacuation of pus when indicated, intravenous antibiotic therapy, modification of the antibiotic regimen according to the results of sensitivity tests, and early treatment of the causative tooth constitute a successful management protocol for odontogenic infections.

An epidemiologic analysis of 1,142 maxillofacial fractures and concomitant injuries.

OBJECTIVE: The aim of this study was to evaluate the incidence and etiology of maxillofacial fractures in the Greek population over the past 5 years. A comparison of findings with 2 earlier studies from the same department was also performed. STUDY DESIGN: Seven hundred twenty-seven patients treated for a total of 1,142 facial fractures in the period from 2005 to 2009 were included in a retrospective, clinical, and epidemiologic study. Cause, type, site of injury, gender, age, and nationality of the patient were the parameters evaluated. RESULTS: Road traffic accidents remained the most common cause of injury (50.8%) followed by assaults (26.3%), falls (13.8%), work-related injuries (3.2%), and sport injuries (3%). CONCLUSIONS: Road traffic accidents remain the most frequent etiology of maxillofacial fractures. Fractures of the facial skeleton caused by assault increased significantly in the period assessed. Concomitant injuries were most frequently associated with motorcycle accidents.

Acute osteomyelitis of the mandible caused by Rhodococcus equi in an immunocompromised patient: a case report and literature review.

We present the first case of acute osteomyelitis of the mandible caused by Rhodococcus equi in an immunocompromised patient. A 53-year-old Caucasian man was referred to the outpatient clinic, because of a swelling of the left submental and submandibular spaces. The patient was immunocompromised owing to medication against myasthenia gravis and type II diabetes mellitus. The patient underwent surgical debridement under local anesthesia. Histologic examination showed acute osteomyelitis and both blood and pus cultures isolated Rhodococcus equi. The patient was discharged on linezolid 600 mg orally twice a day for 6 months and remains free of the disease 2 years postoperatively. Most patients with Rhodococcus infection are immunocompromised. Infection with this organism is rare and usually causes a distinct clinical syndrome resembling pulmonary tuberculosis. Diagnosis is frequently missed or delayed. Not only clinicians but also laboratory specialists should be aware of this organism, so as to contribute to prompt diagnosis and treatment of such infections.

Combined craniofacial approach for the removal of a large trigeminal schwannoma invading the infratemporal fossa.

BACKGROUND: Trigeminal schwannomas are rare tumours accounting for 0.07-0.36% of all intracranial tumours and 0.8-8% of intracranial schwannomas. Symptoms and signs of these lesions depend on the site of the tumour, which may compress the nerve of origin or adjacent nerves. CASE REPORT: We describe a case of a 69-year-old woman with a history of progressively worsening hypoesthesia involving the third division of the trigeminal nerve. A tumour of 5-cm diameter was revealed within the right cranial middle fossa, extending to the lateral wall of the cavernous sinus, the infratemporal fossa and the posterior wall of the maxillary sinus. A combined craniofacial approach was undertaken. A right extended subtemporal craniotomy was performed. The intracranial component of the tumour, originating from the third division of the trigeminal nerve and compressing the cavernous sinus, was removed in total. We proceeded with a Weber-Ferguson approach through which the extracranial component of the tumour was also totally resected. The postoperative computed tomography of the head has shown complete tumour removal. The histopathologic examination revealed a cellular neurinoma. Postoperatively, the patient expressed a transitory palsy of the oculomotor nerve, which resolved within a few weeks. The patient remains free of recurrence with mild hypoesthesia of the third trigeminal branch 5 years after treatment. DISCUSSION: Surgery of trigeminal schwannomas may be a very challenging task. Various surgical approaches for trigeminal schwannomas excision have been described. With this combined approach, the tumour was freed from the surrounding tissues and was easily and totally removed.

Iatrogenic oculocardiac reflex in a patient with head injury.

A 16-year-old girl with a history of a recent fall from the third floor was transferred to the emergency room. On presentation, the patient, who had sustained multiple facial fractures, was in clinical shock with a blood pressure 80/40 mm Hg, heart rate 130/min, tachypnea (>30/min), Po2 50 mm Hg, and So2 82%, and she was intubated for airway protection. Severe nasal hemorrhage was detected (hematocrit: 22%), therefore a bilateral anteroposterior balloon nasal catheter was inserted and inflated with air. Bleeding was controlled. A few minutes later, her heart rate dropped to 40/min. Atropine was administered intravenously and the rate increased to 60/min. Computed tomography of the head revealed brain and subarachnoid hemorrhage, multiple fractures of the facial skeleton, and a round foreign body, full of air, compressing the left eye. The medial wall and the floor of the ipsilateral orbit were also fractured, establishing a naso-orbital communication. The left catheter was immediately removed. Heart rate was restored to normal. Facial fractures were addressed surgically. Patient's vision is intact.