Evaluation of metastases and reactive lymph nodes in Doppler sonography using an ultrasound contrast enhancer.

RATIONALE AND OBJECTIVES: The authors conducted a prospective study in D-galactose signal-enhanced Doppler sonography of lymph nodes to investigate new aspects in differentiating malignant from reactive lymph nodes of patients with suspected malignancy of the neck. METHODS: Twenty-one patients with suspected squamous epithelial cell carcinoma metastases of the neck were examined by Doppler sonography before and after administration of an ultrasound signal-enhancing agent, consisting of D-galactose microbubbles. Qualitative sonomorphology, peak flow rates, and pulsatility and resistive indices were assessed. RESULTS: Compared with conventional Doppler, enhanced Doppler sonography gave detailed additional information about vascularization of metastases or reactive lymph nodes. Signal-enhanced Doppler of metastases showed a relatively characteristic pattern of vascularity, therefore facilitating differential diagnoses and allowing better discrimination from surrounding tissue, demonstrated by the infiltration of neighboring vessels in the neck. Concerning reactive lymph nodes, vascularization could be stated and measured in many cases only after signal enhancement. Evaluating peak velocities and pulsatility and resistive indices could not differentiate significantly malignant from reactive lymph nodes. CONCLUSIONS: Administration of a D-galactose-based signal-enhancer helps to differentiate malignant from reactive lymph nodes of the neck. It is superior to conventional Doppler by improving evaluation of the vascularity and could be of use for staging procedures.

Assessment of vascularity in reactive lymph nodes by means of D-galactose contrast-enhanced Doppler sonography.

RATIONALE AND OBJECTIVES: A prospective study in signal-enhanced Doppler sonography of lymph nodes that were assumed pretherapeutically to be benign was performed to investigate characteristic sonomorphologic features and vascularity of reactively enlarged lymph nodes. METHODS: Thirty-four patients with enlarged superficial lymph nodes of the neck were examined first by B-scan sonography then by Doppler sonography before and after administration of an ultrasound signal-enhancing agent. In B-scan sonography, lymph nodes were classified into three groups according to their sonomorphologic features: (1) homogeneous parenchyma, (2) a centrally located echogenoic line, and (3) a echogenoic "hilus reflex." In conventional and contrast-enhanced Doppler sonography, peak flow rate, pulsatility index, and resistive index were assessed. Sonomorphologic criteria were compared with histologic findings. RESULTS: Reactively enlarged lymph nodes showed characteristic sonomorphologic patterns correlating to their histologic features. Echogenicity of the hilus corresponded to fibrosis (centrally located echogenoic line in 13 nodes; 38.2%) or fatty involution of the hili (echogenoic hilus reflex in 15 nodes; 44.1%). Administration of the galactose-based ultrasound contrast enhancer facilitated the assessment of hilar vessels, which projected to the echogenoic hili, respectively, actually additionally visualized a hilar vascularity in 10 of the 34 lymph nodes compared with conventional Doppler. Measured Doppler indices gave not a significant clue for identifying reactive lymph nodes or for differential diagnosis. CONCLUSIONS: Qualitative sonomorphologic assessment of characteristic sonomorphologic features of reactive lymph nodes may serve as a valuable tool for examining reactively enlarged lymph nodes. Administration of an ultrasound echo enhancer allows the assessment of a characteristic nodal vascularity in reactive lymph nodes and were superior to conventional B-mode and conventional Doppler sonography.

Endovascular management of a bleeding mandibular arteriovenous malformation by transfemoral venous embolization with NBCA.

A 13-year-old boy presented with an arteriovenous malformation (AVM) involving the left mandible that bled after intraoral biopsy. The AVM was treated on an emergency basis by primary intravenous delivery of n-butyl cyanoacrylate after transfemoral catheterization, resulting in complete anatomic and clinical cure.

[Signal-enhanced color-coded duplex sonography of reactively and metastatically enlarged lymph nodes]. / Signalverstärkte farbkodierte Duplexsonographie reaktiv und metastatisch vergrösserter Lymphknoten.

PURPOSE: Prospective comparison of B-mode-, plain and signal-enhanced colour Doppler ultrasound to evaluate new criteria for assessment of the tumour status of enlarged cervical lymph nodes. METHODS: Colour Doppler sonography was performed before and after application of d-galactose in 35 patients with suspected lymph node metastases of the neck. Sonomorphology was analysed qualitatively, maximal flow rate, pulsatility index and resistance index were determined quantitatively. RESULTS: Signal enhanced Doppler revealed a typical vessel morphology of the lymph nodes facilitating differential diagnosis. In 23%, vascularisation of the lymph nodes was only visible after application of the signal-enhancing agent (benign: 44%, malignant: 5%). The measurement of flow velocity and the calculation of RI and PI did not lead to a reliable differentiation between malignant and benign lymph nodes whereas B-mode sonography yielded highly valid results. CONCLUSION: The application of d-galactose facilitates differentiation between malignant and benign lymph nodes.

B-scan sonography in maxillo-facial surgery.

Ultrasonography is a relatively new diagnostic aid in maxillo-facial surgery. The method is useful in examining tumours, swellings, cysts and similar processes in the soft tissues of the cervico-facial region. Some examples are given, and some details of the technique are outlined. The ultrasound examination may easily be repeated as often as necessary.

Lower lip carcinoma. Infiltration of the mandible along the mental nerve.

In general, carcinoma of the lower lip has a good prognosis after radical surgery. In rare cases, however, recurrences may be seen because of spread of the tumour along the mental nerve into the mandible. The earliest symptom of this is pain in the mandible and radiological evidence of widening of the mental foramen. Large resections and reconstructive procedures will be necessary. Three cases are presented.

Resorption of microsurgically vascularized bone grafts after augmentation of the mandible.

Vascularized bone grafts taken from the iliac crest to augment the extremely atrophied mandible are valued for their ability to maintain their contour. Reliable data on long-term performance, however, is not yet available. The purpose of this study was to investigate the long-term results of this method, evaluating the radiological documentation (lateral cephalograms, orthopantomograms) of six patients. The mean follow-up period was 7.3 years. Dental implants were not inserted into the bone grafts. The average increase in ridge height immediately after surgery was 17.8 mm in the symphyseal area, 17.1 mm above the mental foramen and 13.9 mm in the molar region. In the first postoperative year, the average vertical loss was 3.0 mm in the symphyseal, 2.0 mm in the premolar and 2.9 mm in the molar regions. After that the mean yearly rate of vertical resorption dropped to 0.24 mm in the symphyseal, 0.27 mm in the premolar and 0.34 mm in the molar regions, which corresponded to the physiological loss in ridge height due to aging. The fact that graft resorption was so slight portends a good long-term prognosis with this procedure. However, indication is restricted by the high operative burden for the patient and by the availability of alternative rehabilitation methods.

Experience with AO reconstruction plates after partial mandibular resection involving its continuity.

A report is presented on experience with the use of 54 plates, without primary bone grafts, after resections for malignant tumours involving the continuity of the mandible, in 52 patients. There were complications in 27 cases: postoperative infection or soft tissue dehiscence occurred 20 times, chronic soft tissue perforation once, screw loosening twice, and plate fracture four times. Adjuvant radiotherapy and/or chemotherapy had no effect on the incidence of the complications. Seventeen of the plates (a good 30%) had to be removed prematurely due to the complications. Major deformity did not always occur if relative stabilization had developed through cicatrix formation. Thirty-seven plates (barely 70%) remained: in 19 cases until the death of the patient, in 3 cases until recurrence, in 12 cases until bone grafting, and in 3 cases they were still in situ up to 65 months. In principle, reconstruction plates have proven themselves. However, application and soft tissue coverage need great care and a great deal of experience.

3D sonography.

A method of 3-dimensional (3D) sonography (US) is described in this paper. Special emphasis is laid upon the basic problem of generating well-orientated 3D visualizations on the basis of different evaluation techniques. Furthermore, some problems of data acquisition and data processing using US are presented. Alternative solutions thereto are briefly discussed.

Venous graft as temporary arteriovenous shunt in free tissue transfer.

A new method of interpositional venous graft in microvascular tissue transfer is described. The interpositional vein is transferred to the vessels of the recipient site primarily, forming an arteriovenous shunt. Later, when the microanastomosis to the flap is created, the shunt is divided into an arterial branch and a venous branch. This method reduces the ischemic time of the free flap and allows the use of interpositional grafts of optimal length.

A method for the bony and dental reconstruction of the maxilla in dentate patients.

Reconstruction was carried out on eleven patients using a vascularized full thickness calvarial bone flap following partial maxillectomy. The donor site was covered with a split calvarial bone graft. Intraorally a mucosal transposition flap was used to cover the graft. Six months later implants were inserted and were allowed to heal for three months before dental rehabilitation began. No serious complications were encountered.

Osteochondroma of the mandibular condyle: a case report.

A case of osteochondroma of the right mandibular condyle in a 47-year-old woman is presented. Instead of condylectomy, surgical resection was performed, resulting in fewer functional changes and less dysfunction of the temporomandibular joint but recurrence within 12 months after surgery.

Microsurgical and prosthetic reconstruction of patient with recurrent ameloblastoma extending into the skull base.

A patient with recurrent ameloblastoma extending into the skull base is presented. An interdisciplinary treatment strategy is described, which included proper diagnosis by computed tomography (CT) and magnetic resonance imaging (MRI) scans and radical resection of the tumor in cooperation with the neurosurgeon, followed by reconstruction with microsurgical methods, and prosthetic rehabilitation based on an implant-supported epithesis.

Computed tomographic study of bone availability for facial prosthesis-bearing endosteal implants.

In a computed tomographic study, 56 patients with facial defects were examined to assess the availability of bone for extraoral Brånemark implants (3 or 4 mm long, 3.75 mm diameter) to bear facial prostheses. Bone depths were determined in the auriculotemporal (2-8 mm), infraorbital (0-10 mm), lateroorbital (8-14 mm), supraorbital (1-14 mm) and medioorbital (1-6 mm) areas as well as at the base of the nasal skeleton (1-5 mm). The low values for the supraorbital and infraorbital areas were determined at the points closest to the frontal- and maxillary sinuses, respectively. Implantation in these areas would be permissible only under certain conditions. The very thin osseous structures of the nasal region also present problems for implants. In the auriculotemporal region, the bone width is always sufficient, but at the orbital margin it can vary from 3 to 8 mm. The three-year success rates for implant survival were found to be 100% and 85.8% respectively for auricular and orbital defects. No serious skin complications were seen. Six patients (10.7%) required secondary corrective surgery in a total of 13 implant areas.

The infrahyoid flap. A technique for defect closure in the floor of the mouth, the tongue, the buccal mucosa, and the lateral pharyngeal wall.

The surgical technique, indications, and results of the infrahyoid muscle flap are presented. This flap is fed by the superior thyroid vessels and innervated by the ansa cervicalis. The flap is indicated in case of medium-sized defects in the floor of the mouth, the tongue, the buccal mucosa, and the lateral pharyngeal wall. The advantages of the technique presented include the rapid flap elevation close to the original operating field, the ability to use the motor capability of the flap, and the ability to combine it with other local flaps--for example, the platysma flap. This technique appeared to render excellent function for swallowing and speech. Safe flap grafting is possible only if the internal jugular vein is preserved.

Three-dimensional ultrasonography in maxillofacial surgery. A new diagnostic tool.

Three-dimensional (3-D) ultrasonography is introduced as a new diagnostic method for soft-tissue lesions. This method is based on the production of absolutely parallel brightness (B)-scan tomographies with constant intervals. After adequate preparation, the sonographic primaries are processed into 3-D graphs by a specialized program called EUCLID-IS. This method promises to be useful in the evaluation of tumor patients as well as in the follow-up examination of these patients. The main advantages of the presented method are the capacity to measure accurately the volume of regions of interest and the excellent visualization of the structures examined.

Radioimmunoscintigraphy of squamous cell carcinoma in the head and neck region.

Radioimmunoscintigraphy (RIS) with a monoclonal antibody (SQ 174, Biomira, Inc, Canada) is introduced as a new diagnostic method for detection of squamous cell carcinoma in the head and neck region. RIS could detect eight of the 10 primary tumors. One patient had histopathologically proven nodal disease. This lymph node was seen in RIS. No false positive results were seen in RIS, whereas sonography, computed tomography, and magnetic resonance imaging showed several false positive results.

Immunocytologic detection of isolated tumor cells in bone marrow of patients with squamous cell carcinomas of the head and neck region.

The well-documented specificity of anticytokeratin monoclonal antibodies for detection of epithelial micrometastatic cancer cells in bone marrow as a prognostic indicator inspired us to apply this approach to patients with squamous cell carcinomas (SSC) of the head and neck region. The sensitivity of the broad-spectrum anticytokeratin monoclonal antibody (mAb) A45-B/B3 used for tumor cell detection was demonstrated by immunostaining of cryostat sections from the respective primary tumors. Analysis of 31 patients with SSC revealed A45-B/B3-positive cells in 10 cases (32.3%) at frequencies of 1-207 per 1 x 10(6) mononuclear cells. Most specimens displayed isolated tumor cells, while cell clusters were found in only two cases (6.5%). The present data suggest that hematogenous dissemination of cancer cells is more frequent than expected from clinicopathologic staging of patients with SSC of the head and neck region.

Otoplasty: a combined approach to different structures of the auricle.

A technique for otoplasty is presented, which combines the advantages of different methods. The procedure includes a dorsal skin excision, a cartilage incision at the border between the concha and scapha, scoring of the crus superior on the anterior side, and if necessary a reduction of the conchal height and modification of the position of the cauda helicis by cartilage excision. The results of the treatment of 526 ears in 312 patients are retrospectively analysed by a patient questionnaire and a chart review.

Camouflage in head and neck region--a non-invasive option for skin lesions.

The technique of camouflage, a non-invasive procedure to correct flaws in the texture and colour of the facial skin, is presented. The acceptance and use of camouflaging by 52 patients with different diagnoses are presented. The advantages of camouflaging are discussed in comparison to medical tattooing.