Intraoperative cytological examination of bone medullary. A useful technique to predict the extension of bone invasion in segmental mandibulectomy.

AIM: The main of the present report is to evaluate the utility of intraoperative cytological analysis of medullary bone to predict the extension of bone infiltration in segmental mandibulectomy. MATERIALS AND METHOD: Between the years 2016 and 2018, a total of 17 previously untreated patients with squamous cell carcinoma of the oral cavity underwent a segmental mandibular resection and intraoperative cytological analysis of the bone medullary at Virgen de las Nieves University Hospital (HUVN). The results of the intraoperative cytological analysis were compared with the result of the postoperative histopathological examination and sensitivity, specificity, positive predictive value, and negative predictive value of the test were calculated. RESULTS: Cytological analysis was positive in three patients and the bone resection was consequently extended. All the extensions of these bone margins were clean following the postoperative histological examination. However, two other patients previously classified as clean with intraoperative cytological analysis of bone medullary presented infiltration of bone margins postoperatively. The protocol demonstrated a high negative predictive value (85,7%). The positive predictive value, sensitivity, and specificity were 33,3%, 33,3%, and 85,7% respectively. CONCLUSION: Intraoperative cytological analysis of bone medullary could represent an easy, fast, reliable and inexpensive method to reduce the rate of r1 surgeries attributable to the infiltration of the bone margin. This may have a positive impact on overall survival without increasing the duration and the iatrogenicity of surgery.

Arthroscopic osteoplasty of the medial and anteromedial wall of temporomandibular joint: surgical technique and anatomical considerations.

The anterior displacement of the articular disc is the most frequent cause of pathological alterations in the TMJ. Although it is an extremely common pathology, there is no certainty about the aetiopathogenesis of this disease. The main aim of the present report is to describe new anatomical findings that could help clarifying the aetiopathogenesis of this disease and determine a typology of treatment based on the cause of the disease. All the operative records of patients who underwent arthroscopic osteoplasty of the medial TMJ wall in our centre from January 2021 to September 2021 were reviewed and analysed to identify specific anatomical features observed in every procedure. Fifty-two joints were included for analysis in this study. Twenty-two joints were classified as Wilkes stages II-III and 30 as Wilkes stages IV-V. The most common complication observed in our sample was the dysaesthesias found in the temporal and preauricular regions. Other complications observed were frontal branch paresis (n = 2), intraoperative bleeding (n = 1), and postoperative malocclusion (n = 1). The compression of the superior head of pterygoid lateral muscle (SPLM) on the medial bony wall and the consequent muscle atrophy could be key for the aetiology of the anterior TMJ disc displacement. Therapeutic actions on the osseous and muscular component in this anatomical area could improve the outcomes of patients affected by TMJ internal derangement. A meticulous dissection of the fascia of the superior fascicle of the lateral pterygoid muscle allows a remodelling of the bone surfaces with minimal complications.

Is a "watch and wait strategy" safe to manage clinically N0 squamous cell carcinoma of the upper jaw?

PURPOSE: The main aim of the present study is to analyze the behavior of squamous cell carcinoma (SCC) of maxillary gingiva, alveolus, and hard palate and to determine the utility of selective neck dissection in clinically N0 patients at early stages. MATERIAL AND METHOD: Twenty-nine previously untreated patients with SCC of maxillary gingiva, alveolus, and hard palate were diagnosed and treated with at least a tumorectomy and selective neck dissection at HUVN and included in the study. RESULTS: A total of 34.4% of patients (10/29) showed nodal involvement at postoperative histopathologic exam. Several pathologic features such as N involvement, N stage, T stage, and locoregional failure all have a negative impact on overall survival. DISCUSSION: SCC of maxillary gingiva, alveolus, and hard palate shows an aggressive behavior that is comparable with other oral cavity cancers. A more aggressive treatment is thus required for improving locoregional control and overall survival. Supraomohyoid neck dissection may be useful in cT2N0M0.

Behavior of Buccal Mucosal Squamous Cell Carcinoma: A Retrospective Study of 53 Carcinomas of This Anatomical Region.

The main aim of the present report is to study the pattern of distribution of cervical metastasis in buccal mucosa cancer and to discuss the various therapeutic options available. Fifty-three patients with squamous cell carcinoma of the buccal mucosa treated with tumorectomy and selective neck dissection were included in the study. We also studied the relationship between specific pathological features and overall survival. Level Ib was the most affected level, followed by level IIa. T stage, N stage, N involvement tumor thickness, extracapsular spread (ECS), and vascular invasion were associated with poorer outcomes regarding overall survival ( p < 0.001). Carcinoma of the buccal mucosa should be treated aggressively from the early stages. A large tumorectomy of the primary tumor is required to reduce the number of local recurrences. Moreover, we recommend performing a supraomohyoid neck dissection even in cT1N0 if there is a suspicion that the tumor thickness may be greater than 0.4 cm. The high risk of local recurrence obliges protection of the neck from a future cervical recurrence even in T1 small tumors. This could reduce the risk of cervical involvement during the follow-up and improve overall survival rates.

Behavior of squamous cell carcinoma of the floor of the mouth. Is supraomohyoid neck dissection sufficiently safe to manage clinically N0 patients?

AIM: The main aim of the present report is to study the behavior of SCC of the floor of the mouth. MATERIALS AND METHOD: A retrospective analysis was conducted using the records of patients diagnosed with squamous cell carcinoma of the floor of the mouth between 2000 and 2012 in the HUVN. Ninety-three patients with squamous cell carcinoma of the floor of the mouth treated with tumourectomy and selective neck dissection were included in the study. The pattern of distribution of cervical metastases and numerous histological features such as T-stage, N stage, surgical margins, tumor thickness, ECS (extracapsular spread) and vascular invasion were analyzed. RESULTS: Level I was the most affected level, followed by Level II. T stage, tumor thickness, and surgical margins showed a strong relationship with the risk of developing a local or cervical failure at follow-up. Overall survival was 52.7%. T stage, tumor thickness, N stage, recurrence, extracapsular spread, and vascular invasion were also associated with a poor prognosis. CONCLUSIONS: SCC of the floor of the mouth is an aggressive disease even at early stages. Due to the low rate of positive nodes observed at level IV and V in clinically N0 patients, supraomohyoid neck dissection might be considered sufficiently safe in this group.

Unfavorable outcomes in microsurgery: possibilities for improvement.

The main aim of the present report is to describe our learning curve in microsurgery and how we solved the problems that frequently occur during the first phases of this learning curve. We analyzed the medical records of 69 patients that underwent head and neck reconstruction with free flaps in our department. The patients were divided into two groups. Group 1 included the patients reconstructed between January 2011 and June 2017, whilst Group 2 included those reconstructed between July 2017 and August 2018. A χ2 test was used to compare the differences between the two groups in terms of flap failure (failure and partial failure) and eventual clinical errors. The p value was set at 0.05. Flap failure and clinical errors were most frequently observed in Group 1 (p < 0.05). Greater awareness of the need for proper functioning of the anastomosis during surgery, along with more exhaustive postoperative monitoring might explain the lower number of failures and signs of vascular compromise observed in Group 2. A number of variables may influence flap survival. Postoperative care, head position, kinking, body temperature, blood pressure and the ability to recognize the sign of vascular compromise all play a fundamental role following surgery. However, microsurgery is not just a routine type of surgery, and a properly trained team with several types of professionals must be adequately prepared to obtain acceptable results.

What is the real prognostic value of close margins in oral oncology?

AIM: The surgical margin is usually considered an important prognostic factor in oral oncology. However, the real value of a close surgical margin and its relationship with survival is still unclear. Thus, the present report sought to identify the relationship between close surgical margins and overall 3-year survival, whilst also analyzing the association between such margins and recurrence. MATERIALS AND METHODS: The medical records of 200 patients affected by oral squamous cell carcinoma were retrospectively reviewed. The patients were divided into three groups: positive margin (0-2 mm), close margin (2-5 mm), and negative margin (>5 mm). The relationship between surgical margins and overall survival and recurrence rate was analyzed. RESULTS: Surgical margins and reoperation were found to have no significant association with overall survival (P > 0.05). Overall survival was 63% in our sample. Specifically, this was 50%, 64.7% and 66.2% in patients with positive, close and free margins, respectively. Perineural invasion, pN, and locoregional or cervical recurrences were the factors most directly related to overall survival. DISCUSSION: The results of this study indicate that surgical margins are not directly related to overall survival and other factors might significantly influence patient outcomes. Advanced T stage, node involvement, perineural invasion, and ECS are strongly linked with patient survival (P < 0.05). These findings should be carefully evaluated in patients with close surgical margins. Our results indicate that an aggressive adjuvant treatment of patients with close surgical margins could help in obtaining a similar pattern of overall survival with patients with negative margins.

Distribution of cervical metastasis in tongue cancer: Are occult metastases predictable? A retrospective study of 117 oral tongue carcinomas.

PURPOSE: The aims of this study were to evaluate the pattern of distribution of cervical metastasis in tongue cancer and to analyze the various therapeutic options available. Moreover, numerous histological features were analyzed to assess the impact of each factor on overall survival. MATERIALS AND METHODS: A retrospective analysis was conducted using the records of patients diagnosed with oral tongue cancer between 2004 and 2010 in the Virgen de las Nieves University Hospital (HUVN). A total of 117 patients with squamous cell carcinoma of the tongue treated with glossectomy and selective neck dissection were included in the study. The pattern of distribution of cervical metastases and numerous histological features such as T-stage, N stage, surgical margins, tumor thickness, extracapsular spread (ECS) and vascular invasion were analyzed. RESULTS: Level IIA was the most affected, followed by level III. The rate of skip metastasis was 7,4%. T and N stage, tumor thickness, ECS, surgical margins and nerve and vascular invasion were associated with poorer outcomes in terms of overall survival (p < 0,001). CONCLUSION: Cervical nodal involvement represents the major prognostic factor in tongue cancer. A total of 51,2% of N+ patients presented T1 and T2 tumors in this series. We recommend performing neck dissection at the early stages in clinically N0 patients when a tumor thickness >0,4 cm is suspected. Level IV should be included in the neck dissection of clinically N0 tongue cancer.

Arthroscopic Eminoplasty of Temporomandibular Joint: Surgical Technique.

Temporomandibular joint (TMJ) is one of the most used joint of the body. Moreover, it is common knowledge that TMJ may show degenerative changes 10 years earlier than other joints. Recently, the use of arthroscopic surgery is revolutionizing the classic management of TMJ pathologies. In fact, the minimal invasiveness of this procedure allows faster results and fewer complications than other procedures. In this article, we present our arthroscopic technique. In this line, we would like to emphasize that we used this approach in different temporomandibular disorders such as anchored disk syndrome, habitual dislocation of TMJ, and internal derangement. Furthermore, we wish to underline that our efforts have been rewarded with great results.

Arthroscopic approach for treating a pigmented villonodular sinovitis of TMJ. A case report.

The present report describes the case of a 29-year-old man referred to our service for TMJ pain and progressive reduction of the mouth opening. Differential diagnostics included rheumatologic diseases, monoarthritis and intraarticular lumps. In this line, a face CT scan and a MRI of TMJ were carried out in order to ensure a proper diagnosis. These tests showed a solid lesion into the joint cavity. In view of that, we decided to perform a diagnostic and therapeutic arthroscopy of TMJ. Histopathological studies confirmed the diagnosis of pigmented villonodular synovitis. The main aim of this report is to describe this rare syndrome with the goal of proposing suitable treatments. Moreover, we highlight the benefits of using arthroscopic procedures in the cases which the tumor is still confined to the joint. As far as we are aware, scientific literature documents only a single case of pigmented villonodular synovitis of TMJ treated with arthroscopic approach. Key words:Arthroscopic approach, pigmented villonodular synovitis, TMJ, mouth opening.

Juxtacortical Mandibular Chondrosarcoma during pregnancy: A case report.

Chondrosarcoma is one of the most common malignant bone tumors in adults. It use to affect upper arm, pelvis and thigh bone. A wide surgical extirpation represent the gold standard to treat this disorder. In fact, radiotherapy and chemotherapy are no useful. Interestingly, chondrosarcoma is rare in head and neck (HNCS) and extremely uncommon during pregnancy. Thus, there is a lack of evidence about the proper treatment in these cases. A wide surgical extirpation is also considered the most effective procedure in HNCS. There are no consistent evidences about the he role of radiation and chemotherapy. In view of that, the present study describes a case of juxtacortical mandibular chondrosarcoma affecting a 28-year-old pregnant woman. After a multidisciplinary analysis of the case, we decided to treat the patient with a wide surgical resection and and immediately reconstruction. Key words:Mandibular chondrosarcoma, pregnancy, surgical extirpation, radiotherapy, chemoteraphy.

Arthroscopic eminoplasty: a new choice of treatment for TMJ internal derangement.

BACKGROUND: Temporomandibular joint (TMJ) internal derangement is a common disabling disorder that is often underestimated by society. The main goal of our study was to show the clinic improvement experienced by patients that underwent arthroscopic eminoplasty as a treatment for TMJ in our center. METHODS: Nineteen patients (1 male, 18 females) agreed to participate voluntarily in our study. These patients presented signs and symptoms of TMJ internal derangement and pathological MRI images, and underwent arthroscopic eminoplasty in our center. A patient database was created to record Wilkes stages, type of surgical intervention, complications, and preoperative and postoperative pain and mouth opening. RESULTS: Our data showed that TMJ pain (measured 6 months before surgery) was higher (M=7.44, SD=1.44; t(18)=8.37, P<0.01) than the pain registered eighteen months after surgery (M=3.10, SD=2.40). Moreover, postoperative mouth opening (M=33.6 SD=7.92) was greater than preoperative mouth opening. CONCLUSIONS: The results indicate that this technique is effective in reducing pain and increasing mouth opening with minimal postoperative morbidity. Specifically, this technique minimizes the stress suffered by the joint disc at the narrowest points of joint space and increases articular stability.

Cervical necrotizing fasciitis and acute mediastinitis of odontogenic origin: A case series.

Necrotising fasciitis (NF) is an uncommon infection. Early signs and symptoms include fever, severe pain and swelling, and redness at the wound site. Moreover, fulminant evolution and high mortality rate are typical of this pathology. In the present report we describes three cases of cervical necrotizing fasciitis complicated by acute mediastinitis. All patients were apparently immunocompetent adults. The main aim of the present report is to show the serious consequences that a dental infection might trigger. Furthermore, we highlight the importance of a multidisciplinary approach in these cases. The constant interaction between different medical specialties is essential for ensuring a proper management of each case. Key words:Cervical necrotizing fasciitis, acute mediastinitis, odontogenic origin , multidisciplinary approach.

Meningitis and subdural empyema as complication of pterygomandibular space abscess upon tooth extraction.

Complication of dental infections might be various and heterogeneous. The most common complications are represented by maxilar celulitis, canine space celulitis, infratemporal space celulitis, temporal celulitis and bacteremia. Among rarest complications we found: sepsis, bacterial endocarditis, mediastinitis, intracranial complications, osteomyelitis, etc. Although dental infections are often considered trivial entities, sometimes they can reach an impressive gravity. In this regard, the present study describes a case of dental infection complicated by meningitis, subdural empiema and cerebral vasculitis. Furthermore, we observed other neurological complications, like thalamic ischemic infarction, during the disease evolution. Noteworthy, these entities were not presented when the patient was admitted to hospital. Therefore, the main aim of this report is to highlight the serious consequences that an infection of dental origin could cause. Key words:Meningitis, subdural empyema, odontogenic infections.