Giant submandibular sialolith: a case report.

Introduction: Salivary glands lithiasis (Sialolithiasis) is defined as calcified concretions in the salivary glands. Most common localization is in submandibular gland. Usually, submandibular stones are mainly located in Wharton's duct, whereas parotid stones are more often located in the gland parenchyma. Sialoliths are usually 5-10 mm in size, and stones more than 10 mm are unusual sizes. Exact etiology of sialolith formation is still unknown. Case Report: We discuss a case of a 70-year-old patient, presenting painful swelling and a giant submandibular gland sialolith successfully treated with open surgery. Conclusions: A careful anamnesis and physical examination of the patient are important in the diagnosis of sialolithiasis. In addition, several imaging techniques, such as panoramic X-rays and Ultrasound, can be applied. The management can be both medical and surgical.

Central odontogenic fibroma interesting the maxillary sinus. A case report and literature survey.

Odontogenic fibroma (OF) is a rare benign odontogenic tumor deriving from the dental mesenchymal tissue and accounting for less than 5% of all odontogenic tumors. This paper presents an aggressive histologically diagnosed central odontogenic fibroma (COF) in a 17-year-old girl characterized by asymptomatic rapid growth with massive replenishment of the left maxillary sinus. We carried out a review of the literature to retrieve all published cases of COF especially focused on radiographic aspects and surgical treatment of cases characterized by clinical aggressive behaviour, as we observed in our patient. Search strategy included retrieval of English language papers, published from 1966 to today, in dental journals on MEDLINE/PubMed and EMBASE, and hand-searching of the bibliography of retrieved papers. Sixty-nine cases of COF were identified from 1954 to 2003 and a new one was added. We have compared characteristics of COFs according to age, gender, location, clinical and radiographic findings of aggressive development, and histology. We discuss clinical and radiographic aspects of our case compared with COFs previously published. We give suggestions for surgical treatment of COF in case of aggression to important anatomical structures.

Effect of mirtazapine on thyroid hormones in adult patients with major depression.

Hypothalamic pituitary thyroid (HPT) axis abnormalities and alterations in major depression are reported in the literature. The aim of our study was to evaluate the effect of mirtazapine on thyroid hormones after 6 months of therapy in a sample of adult outpatients with Major Depression (MD). 17 adult outpatients (7 men, 10 women) with MD according to DSM-IV criteria, were included in the study. All participants had to have met criteria for a major depressive episode with a score of at least 15 on the Hamilton Depression Rating Scale (HAM-D). Fasting venous blood samples were obtained for determination of serum Thyroid Stimulating Hormone (TSH), Free T3 (FT3) and Free T4 (FT4) concentrations both at baseline and after 6 months of therapy. HAM-D scores decreased significantly from the first day of treatment to the end of the treatment period (P<0.001) and twelve patients (70.6%) were classified as responders. A significant increase in FT3 concentrations was found between baseline and the end of the treatment period (P=0.015), whereas FT4 concentrations decreased (P=0.046). No significant changes were found in TSH levels. Higher FT4 concentrations at baseline predicted higher HAM-D scorers both at baseline and at the end of the treatment period. Furthermore, higher FT3 concentrations at endpoint were found to be predictors of lower HAM-D scores. Long-term treatment with mirtazapine increases FT3 levels and decreases FT4 maybe involving the deiodination process of T4 into T3.

Comparative study on sensory recovery after oral cavity reconstruction by free flaps: preliminary results.

Anatomical restoration was once the only goal of reconstructive surgery, but now it represents only one step in the complete functional recovery process to allow resumption of physiological activity. Soft tissue and nerves play important roles in functional recovery, but the potential of these structures is not yet well known. Rehabilitation after oral cavity reconstruction by free flaps needs an interdisciplinary diagnostic and therapeutic approach, in which neurosensory recovery of transferred tissue is an important aspect. Previous studies have used clinical assessment to evaluate sensory recovery after oral reconstruction with free flaps, but these results have been subjective and not quantifiable. The aim of the present study is to evaluate the sensory recovery using objective and standardized electrophysiological data by recording the masseter inhibitory reflexes (MIR) following mental and lingual electrical stimulation. A group of 14 patients who underwent oral cavity reconstruction by transplantation of either forearm (9) or jejunal (5) noninnervated free flaps were investigated. We found that sensory recovery of fasciocutaneous radial forearm free flaps was better than that of jejunal free flaps. This could represent the starting point for further studies about sensory recovery of reconstructed anatomical structures based on standardized and objective electrophysiological data.

The surgical approaches to nasopharyngeal angiofibroma.

After a short summary of the aetiopathogenesis, the routes of extension and the diagnostic features of nasopharyngeal angiofibroma, the importance of early diagnosis and careful surgical planning is underlined. In particular the extension and topographic localization allows the choice of the best approach to optimize surgical radicality--the prime concern in the treatment of nasopharyngeal angiofibroma. Different surgical approaches are proposed for the tumour removal according to our experience in 17 patients.

[A primary pleomorphic adenoma of the parapharyngeal space]. / Adenoma pleomorfo primitivo dello spazio parafaringeo.

The rarity of benign primary neoformations in the parapharyngeal space associated with aspecific clinical symptomatology often leads to the identification of large size lesions with deformation of the lateral wall of the pharynx and homolateral hemiplate. The improved diagnostic specificity of radiological instruments like CT and NMR allows a precise topographical localisation of the mass and the diagnosis of its nature in 90% of cases. The deep position of the neoplasia makes it necessary to search for the most conservative surgical approach possible that enables a sufficiently broad operating field to be obtained for complete exeresis and the control of neck vessels. This paper describes the therapeutic protocol used and makes a critical revision of the surgical approaches in an exemplary case of primary pleomorphic adenoma in this region.

[Intraoral reconstruction with radial forearm flap]. / Ricostruzione del cavo orale mediante lembo libero radiale.

The intraoral region include structures that represent a functional matrix for the physiology of this region. The reconstructive problems of this area are centred around difficulties to obtain thin flaps that provide coverage without excessive bulk and uninhibited tongue motion. For this regions the radial forearm flap is particularly suited to intraoral reconstruction because it is thin, minimally hair bearing and with moderate donor site morbidity. The Authors report their experience in 6 cases of intraoral reconstruction with radial forearm flap and analyzes it's surgical, anatomical and anatomopathological features. The advantage, the svantage and the indications of this flap are discussed.

[Complications of reconstructive surgery using free flaps in the maxillofacial region]. / Complicanze della chirurgia ricostruttiva mediante lembi liberi del distretto maxillo-facciale.

The subject of our investigation was a group of twenty-nine patients with cervico-facial malignant neoplasms. The 29 patients, whose ages ranged from 12 to 68, with a mean age of 40, underwent surgery between January 1992 and January 1995. Cranial base and/or maxillo-facial defects were restored by free flap tissue transfer. Thirty-one micro-surgical free flaps were performed and post-operative monitoring was carried out for about 15-20 days. The aim of the present study is to show the importance of clinical semeiology which permits an early diagnosis of post-operative complications. Furthermore, post-operative monitoring of microsurgical free tissue transfer enables an etiological diagnosis and surgical vascular salvage of the flap to be made at the most opportune time. Many Authors report microsurgical transfer success at 95%-96% because timely detection and resolution of complication can minimize flap failure. We report our experience with 31 free flaps performed in 29 patients. Three of the patients needed a second transfer due to the failure of the first. Two underwent free flap transfers, while a pedicle flap was carried out on the other. In fourteen, latissimus dorsi free flaps were used (in 2 cases the procedure had to be performed twice), the forearm and the jejunum were employed in eight patients and the rectus abdominis in one.

[The use of the jejunum free flap in the reconstruction of the oral cavity]. / Il lembo rivascolarizzato di digiuno nella ricostruzione del cavo orale.

The rapid development of surgical techniques in the head and neck area has greatly assisted in enabling reconstructive surgery to bring about prompt positive results. Radical tumor excision alone is no longer an acceptable treatment. Through new reconstructive techniques, psychological and social isolation of the patients, due to difficulties in such vital functions as chewing, speech, swallowing and breathing, can be reduced remarkably. In the past numerous techniques which employed myocutaneous flaps in the reconstruction of the oropharynx have been described. During the last ten years, however, many Authors have proposed the use of free flaps for this reconstructive surgery. Our Department presents its personal experience in reconstruction of the oral cavity using the jejunal flap, which facilitates superior physiological and histological adaptation when compared to that had with other flaps. Our histological study shows metaplastic transformation of the columnar epithelium into squamous epithelium (similar to oral cavity epithelium), phenomenon already observed in "cervix uteri" and anorectal area. The primary reconstruction with a free revascularized jejunal loop associated with mandibular replacement offers certain significant advantages such as satisfactory reconstruction of large defects, high flexibility of the flap and a productions of mucous which cleans the surface of transplants. Furthermore, the mesenteric foot tissue serves as good transplant material for extended soft-tissue loss. In agreement with a Study begun by Carrel in 1906 and that of Reuther (1982), we believe that reconstruction of large defects in the oral cavity by means of transplantation of the mucosa is the ideal treatment.

[The indications for reconstruction of the oral cavity using a pedicled flap of the musculus pectoralis major]. / Indicazioni alla ricostruzione del cavo orale mediante lembo peduncolizzato di muscolo grande pettorale.

The reconstruction of postoperative or post-radiotherapeutic losses of substance in the oral cavity must respond to a number of basic requirements, such as lingual motility, the conservation of the labiogingival groove and adequate drainage of saliva towards the pharynx. This study reports the authors' experience of the reconstruction of the oral cavity using a pectoralis major myocutaneous flap. The identification of anatomic structures, such as the interpectoral compartment which separates the deep folium of the pectoralis major muscle from the clavi-coraco-axillary fascia covering the smaller pectoral muscle. Is indispensable for the correct preparation of the flap. Using an oblique incision along the lateral margin of the pectoralis major muscle the edge of the muscle is revealed and the muscle is separated from the pectoralis minor and from the costosternal structure. The cutaneous island is formed using the deep level of the muscle, and after tunnelling into the subcutaneous plane of the superficial fascia in the deltopectoral region, the flap is overturned to reach the part of the surgical reconstruction. The transposed tissue is sutured at various levels so as to reduce traction on a single component of the flap and to preserve the integrity of the perforating vessels. A total of 16 reconstructions of the oral cavity were performed by the authors using a pedunculated flap from the pectoralis major muscle. Fourteen of these cases were advanced stages of cancer and two were the outcome of radiotherapy. A myofascial flap was used in one case due to the excessive thickness of the subcutaneous panniculus of fat, whereas in the other cases it was not necessary to involve the cutaneous component which guarantees better functional adaptation. The following results were obtained: the metaplasia of the cutaneous surfaces of the flap into a multi-stratified non-keratinized epithelium and the contemporary reduction of cutaneous adnexa. The best functional recovery was observed using myocutaneous flaps compared to the case with the myofascial flap. Other results included: flap versatility in the reconstruction of the region of the retromolar trigonum and antero-lateral oral floor, and lastly the difficulty of performing a correct plastic surgery of the soft palate in those cases with damage in the tonsillar region and consequent rhinolalia. Complications observed, attributable to lesions of the perforating vessels, included two cases of total necrosis of the cutaneous component of the flap and four cases of partial necrosis which were resolved using local reclamation and medication.(ABSTRACT TRUNCATED AT 400 WORDS)

[Surgical removal of an osteotribe fractured during the extraction of an embedded third molar. Clinical case]. / Rimozione chirurgica di una fresa ossivora fratturata durante l'estrazione di un terzo molare incluso. Caso clinico.

Although rarely reported, the fracture of an osteotribe during the extraction of embedded lower third molars may have severe consequences on the surrounding anatomic structures possibly resulting in permanent damage to the patient. Operators must take special care when choosing instruments, which must comply with particular quality requisites, and during their use in order to avoid intraoperative accidents and subsequent complications. The authors describe a case that was brought to their attention in which the fragment of an osteotribe that had fractured during a previous operation was lodged in the submandibular fossa, penetrating the upper part of the homonymous gland. After the necessary clinical tests, the authors proceeded to remove the fragment thus leading to the resolution of the symptoms reported by the patient.

[Dissection of the cranial base en bloc with the infratemporal fossa]. / Dissezione della base cranica in monoblocco con la fossa infratemporale.

A high incidence of morbidity and mortality was related with skull-base neoplasm surgery. Several advances have permitted, in recent years, the total excision of such neoplasms with minimal patient morbidity. Due to an improved understanding of the surgical anatomy of the skull-base and to the collaboration of the neurosurgeon and maxillofacial surgeon and, moreover, to the improvements of imaging (CT and MR) in the past decades new combined approaches were planned and performed to allow en bloc resections of extensive lesions. Extensive exposure of the tumor, improved management of the internal carotid artery, preservation of cranial nerves not involved by tumors and improved cranial base reconstruction techniques (by free flaps) have resulted from this progress. The aim of the present work is to show the main anatomical landmarks of infratemporal fossa and medium skull base that help the surgeon to achieve an en bloc resection.

[Reconstruction of the oral cavity: the free radial forearm flap versus the free jejunal flap]. / Ricostruzione del cavo orale: lembo libero di radiale versus lembo libero di digiuno.

The concentration in a restricted area such as the oral cavity of the essential anatomic structures for mastication, deglutition, speech, salivary drainage and respiration makes it indispensable to ensure not only the structural reconstruction of the region but also, and above all, a functional reconstruction of the anatomic unit affected by resection. The use of revascularised flaps has extended both the quantity and quality of reconstructive methods available. In the context of the oral cavity the most widely used flaps are the radial forearm free flap and jejunum free flap. In this paper the authors report their personal experience in a group of 13 patients (6 radial forearm and 7 jejunum) undergoing oral cavity reconstruction using free flap. For each flap the authors describe the microsurgical procedure, the clinical characteristics of the post-operative period, the locoregional complications, the donor site and lastly the long-term clinical, anatomopathological and functional modifications 6-12 months after primary treatment. Moreover, they highlight the varying characteristics of the two flaps and make a critical assessment of the advantages and disadvantages of using one or other method. Lastly, in the light of their experience and a review of international literature, the authors underline the importance of making a careful choice and personalized reconstruction, and finally outline their own criteria of choice.

[Indications for mandibular periosteotomy in the treatment of cancer of the oral cavity]. / Indicazioni alla corticotomia nel trattamento del carcinoma del cavo orale.

Marginal mandibulectomy is a compromise between preserving the mandibular structure and radical oncological surgery. In order to evaluate the correctness of the indications for this operation, a group of 47 patients with oral carcinoma underwent direct surgery or associated chemoradiotherapy and surgery. Surgery was programmed on the basis of clinical and radiological examinations and the specific evaluation of the distance of the tumour mass from the mandibular surface. This approach was justified by the lack of correlation, in anatomic and clinical terms, between tumoral infiltration of the mandible and metastatic recurrence in the cervical lymph nodes. Lastly, the varying pattern of tumoral invasion of the various mandibular regions (thickness of cortical bone, presence of foramen) induced the authors to distinguish the indications for conservative treatment by segments. According to international literature and on the basis of the authors' past experience, marginal mandibulectomy represents an extremely interesting method since it associates a satisfactory aesthetic-functional level with a radical oncological approach, in particular with regard to the symphyseal and parasymphyseal region owing its structural characteristics and reconstructive importance. The indications for this type of surgery are therefore in theory based primarily on oncological aspects, and subsequently on the various anatomic and reconstructive aspects of the various mandibular segments.

[Surgical approach to benign primary tumors of the para-pharyngeal space]. / Approcci chirurgici per le neoplasie benigne primitive dello spazio parafaringeo.

Surgical access to tumors of the parapharyngeal space can be performed by transoral or trancervical approaches. Risk of intraoperative bleeding and difficulties in radical enucleation represent the disadvantages of transoral approach. This approach must be performed for small and inferomedial lesions, or for preoperative biopsy when necessary. Transcervical approaches can be distinguished in transparotid or transmandibular, or submandibular. Before the late '70s all parapharyngeal masses were approached by transparotid access, with facial nerve manipulation in all cases. CT and MR techniques now allow the right presumptive preoperative diagnosis in 90% of patients. To avoid the risk of injury of the facial nerve when possible, transparotid approach is now limited to the lesions with parotid origin. Transmandibular and submandibular approaches allow an adequate exposure and a direct access to the parapharyngeal space. Personal experience with 6 patients presenting primitive tumors of the parapharyngeal space is reported and surgical approaches proposed in the literature are reviewed.

[Differential diagnosis in a case of brown tumor caused by primary hyperparathyroidism]. / Diagnosi differenziale in un caso di tumore bruno da iperparatiroidismo primitivo.

Fibrous-cystic osteitis is a bone metabolic disorder related to hyperparathyroidism. This pathological condition shows a bone catabolism enhancement, due to increased level of PTH. Brown tumour is a uni- or multi-focal bone lesion, which represents the terminal stage of the hyperparathyroidism-dependent bone pathology. This focal lesion is not a real neoplasm showing itself as a cellular reparative process, mainly interesting the jaws, specially the mandible. Because of the similar radiological features (cyst-like radiolucency) showed by other lesions, the diagnosis can be difficult. Histology cannot guarantee a certain diagnosis, some lesions, such as giant cell tumour, giant cell granuloma, aneurysmal bone cyst and cherubism, show a similar macroscopical and microscopical features. Differential diagnosis is possible only by comparative evaluation of clinical, radiological and biochemical evidences. Personal experience with a patient affected by maxillary expansive lesion previously diagnosed as GCT is reported. Radiological examinations showed another cyst-like lesion involving the mandible. Clinical history and multifocality of lesions were suggestive for the presence of a systemic disease, laboratory data allowed a primary hyperparathyroidism diagnosis. Parathyroid scintigraphy was performed and detected a parathyroid adenoma. In first instance the patient underwent to surgical operation on the jaws in order to stop the rapid progression of bone lesions, and then another operation for the removal of parathyroid adenoma was performed.

[Gardner's syndrome. A case report]. / Sindrome di Gardner. Un caso clinico.

Gardner's syndrome is a congenital condition characterised by diffuse intestinal adenomatous polyposis (IAP) associated with maxillary osteomas, odontomas, hypertrophy of the retinal epithelium and skin tumours. It may affect subjects of all ages with equal frequency in males and females. The fact that diffuse adenomatous polyposis, the most serious clinical aspect of the syndrome, is treated surgically, has led to improved survival in patients and, consequently, an increased incidence in associated lesions, particularly maxillary osteomas. A personal case observed at the Odontostoma-tological Clinic of the University of Rome La Sapienza is reported.

[Perioperative drug management in surgery using revascularized flaps]. / Presidi farmacologici perioperatori nella chirurgia mediante lembi rivascolarizzati.

The success of free flap tissue transfer firstly depends on the correct surgical technique. Taking off from the donor site tissue for the reconstruction provokes a chain of physiopathological events that could evolve in truly pathological phenomena. The pharmacological treatment is aimed to miss and control the eventual local complication, and also to support the general conditions of the patient. Numerous pharmacological protocols have been proposed on experimental studies, and also on clinical practice to control local complications. It is necessary to eliminate the reactive vasospasm present in the vessels during anastomosis, and to reduce the risk of vascular pedicle thrombosis and to maintain rheological qualities of blood so to reactivate and sustain microcirculation functionality. Many authors have proposed anticoagulant and antiplatelet therapy, associated with vasodilatator drugs and drugs acting on blood viscosity and tissue metabolism, even if the latter have been primarily studied in experimental applications. The authors report their own experience on 29 patients that underwent 31 free flap tissue transfers from January 1992 to January 1995. The pharmacological therapy activated on the test can be divided into two different periods, one intraoperative and one postoperative. ASA is administered one hour before anastomosis, and vessels are irrigated with heparin or lidocaine solutions during the adventectomy and anastomosis. Antiplatelet therapy together with administration of low molecular dextran is performed in the first 3 to 4 postoperative days; afterwards, the dextran-40 administration is stopped while the ASA therapy is continued in smaller dose.

[A statistical study of 206 patients suffering from malignant neoplasms of the cervicofacial area]. / Studio statistico su 206 pazienti affetti da neoplasie maligne del distretto cervico-facciale.

This study focuses on the importance of early diagnosis in the oncological resolution of neoplasia of the cervico-facial district. In a sample of 206 patients suffering from neoplasia of the cervico-facial district, the authors found a greater incidence of pathology between the 6th and 7th decades of life, a finding that confirms the enhancement of etiopathogenetic factors over time. The oral cavity represents the site predominantly affected by this neoplasia with an incidence of 57.3%. Epidermoid carcinoma represents 61.7% of the histological types examined. The treatment protocol used in 167 patients depending on the clinical stage and the general conditions of the patient was as follows: multimodal in patients at stage 3 and 4 with a minimum survival rate at 12 months of 75% and 58% respectively, predominantly surgical in patients at stage 1 and 2 with a survival rate of 94.4 and 89.7% respectively.