Patho-Anatomic Spectrum of Branchial Cleft Anomalies: Proposal of Novel Classification System.

PURPOSE: Histogenesis, nomenclature, and classification of branchial cleft anomalies (BCAs) have been subjects of controversy for decades. The purpose of this study was to investigate the accuracy of current developmental theories (congenital, lymph node, and hybrid branchial inclusion theories) in defining the anatomic and histopathological characteristics of BCAs. METHODS: Ninety consecutive patients with BCAs who underwent surgical excision were enrolled in this 2-center retrospective cohort study. RESULTS: The present study included 90 patients: 46 (51.11%) women and 44 (48.89%) men (P > .05). The mean age at presentation was 31.89±17.31 years. Altogether, 92 BCAs were identified within the study population including 49 (53.26%) on the left side and 43 (46.74%) on the right side (P > .05). The BCAs included 79 (85.87%) branchial cleft cysts, 11 (11.96%) branchial cleft sinuses, and 2 (2.17%) branchial cleft fistulae. Three (3.26%) BCAs were distributed in the head regions, 88 (95.65%) in the neck regions, and 1 (1.09%) in the thoracic cavity. Following surgery, lymphoepithelial tissue was detected in the histopathological examination in 83 (90.22%) BCAs. The hybrid branchial inclusion theory exhibited significantly higher accuracy in defining patho-anatomic characteristics of BCAs than the branchial apparatus, precervical sinus, thymopharyngeal, and inclusion theories (90.22, 9.78, 2.17, 0.00, and 0.00%; respectively) (P < .05). CONCLUSION: The novel branchial node (BN) classification system based on the hybrid branchial inclusion theory appears to be superior to other classification systems in determining the patho-anatomy of BCAs.

Branchial cleft anomalies: hybrid "Branchial Inclusion" theory.

PURPOSE: Branchial cleft anomalies (BCAs) are developmental malformations of the head and neck region. Their histogenesis has been the subject of controversy and is not fully understood. This study aimed to test all present developmental theories ("branchial apparatus," "precervical sinus," "thymopharyngeal," and "inclusion" theories) on a sample of 48 BCAs from a single institution. METHODS: We performed a retrospective analysis of clinical-epidemiological and anatomical-pathological characteristics of BCAs treated over a 12-year period in our hospital. RESULTS: Overall, 46 patients (24 [52.17%] women and 22 men [47.83%]) underwent surgical excision of 48 BCAs. The mean patient age at presentation was 31.65 ± 19.40 years. Branchial cleft cysts were found in 42 (87.50%) cases, and branchial cleft sinuses were found in six (12.50%) cases. Eight (16.67%) BCAs were distributed in the preauricular region, 34 (70.83%) at the anterior border of the sternocleidomastoid muscle (SCM), three (6.25%) at the posterior border of the SCM, two (4.17%) in the suprasternal notch, and one (2.08%) in the retrosternal space. Histopathologically, 39 (81.25%) BCAs had a lymphoepithelial structure and nine (18.75%) BCAs had solitary epithelial cells. Inflammation and infection were observed in 24 (50%) and 12 (25%) cases, respectively. CONCLUSION: None of the hypothesized developmental theories fully explain the embryonic origin of BCA in our study sample. A possible explanation of BCA histogenesis is through the hybrid "branchial inclusion" theory.

Congenital Neck Masses.

ABSTRACT: Congenital neck masses (CNMs) are developmental malformations that present with a wide spectrum of clinical symptoms and signs. They account for 21% to 45% of neck masses in children and 5% to 14% in adults. This study aimed to present the clinical manifestations and treatment of CNM from single-institution experiences. A retrospective analysis of patients surgically treated for CNM in a 12-year period was performed. Altogether, 117 patients (female/male ratio, 1:1.05) were diagnosed with CNM. The mean age at presentation was 26.91 years (range, 0.01-84 years). Within the study population, 120 CNMs were identified: 52 (43.33%) thyroglossal duct remnants, 48 (40.00%) branchial cleft anomalies, 7 (5.83%) epidermoid/dermoid cysts, 4 (3.33%) hemangiomas, 3 (2.50%) lymphangiomas, 1 (0.83%) hemangiolymphangioma, 1 (0.83%) hemangioendothelioma, 1 (0.83%) internal laryngocele, 1 (0.83%) external laryngocele, 1 (0.83%) ectopic thyroid gland, and 1 (0.83%) parathyroid cyst. The lateral neck region was the most frequently affected anatomical site, followed by the midline neck location and mediastinum (54%, 45%, and 1%, respectively). Surgical excision was performed in all cases. Recurrence was recorded in 5 (4.17%) patients. The results of this study provide comprehensive information regarding the clinical spectrum of CNM. Successful management of these lesions depends on a thorough understanding of neck embryology and anatomy. Misdiagnosis and improper treatment increase the morbidity and recurrence rate of CNM.

Cell proliferation and apoptosis in the fusion of human primary and secondary palates.

The markers of cell proliferation (Ki-67) and apoptosis [caspase-3, TdT-mediated biotin-dUTP nick-end labelling (TUNEL)] and the expression of syndecan-1 and heat shock protein 70 (Hsp70) were analyzed immunohistochemically in 11 developing human palates, from developmental weeks 6 to 10. During fusion of the primary palate, the proportion of proliferating cells decreased from 42 to 32% and the proportion of apoptotic cells decreased from 11 to 7% in the medial-edge epithelium. At later stages, the proportions of both types of cells decreased in the ectomesenchyme, except for proliferating cells in its non-condensing part. At developmental weeks 9-10, the epithelial seam in the secondary palate comprised 28% proliferative cells and 5% apoptotic cells. While condensing ectomesenchyme contained more apoptotic cells than proliferating cells, the opposite was observed for the non-condensing ectomesenchyme. Co-expression of syndecan-1 and Hsp70 was detected in cells budding from the epithelial seam. Our study indicates similar principles for human primary palate and secondary palate fusion, and parallel persistence of proliferation and apoptotic activity. While proliferation enables growth and fusion of different palatal primordia, apoptosis results in the removal of of large numbers epithelial cells at the fusion point. The disintegration of seam remnants seems to be executed through the processes of change in protein content and cell migration, probably leading to cell death as their final outcome.

Treatment cost of patients with maxillofacial fractures at the University Hospital in Mostar 2002-2006.

The aim of this study was to establish the costs structure of medical treatment for the patients with maxillofacial fractures, to perform a treatment cost evaluation, describe the factors which considerably influence the costs and discover the ways of achieving financial savings in treated patients. The study group consisted of patients with maxillofacial fractures who were admitted and treated at the Department of Maxillofacial Surgery of the University Hospital Mostar in the period from January 2002 until December 2006. Data for the study were collected from the patients' databases, case histories and data obtained on the basis of individual payments for the treatment that was collected by Finance Department of the University Hospital of Mostar Most patients in this study were men (83%), of average age 34 +/- 19 years. Zygomatic bone fracture was the commonest injury. Open surgical procedure was performed in 84.7% of treated cases. The costs for the open procedure were considerably higher than conservative treatment. Medication cost made up a total of 37.9% and cost of hospital accommodation 27.3% out of total hospital charge. Cost reduction in treated patients with maxillofacial fractures should be achieved through protocols of urgent treatment of maxillofacial trauma patients immediately after sustaining an injury and with earlier discharge of the patients when postoperative complications are not expected.

Expression of Ki-67, Oct-4, γ-tubulin and α-tubulin in human tooth development.

AIMS: To analyze factors controlling cell proliferation and differentiation, and appearance of primary cilia during the cap and bell stages of incisor or/and canine human enamel organs. MATERIALS AND METHODS: Qualitative and quantitative analysis of proliferating Ki-67 positive cells and expression of γ-tubulin, α-tubulin and Oct-4 was immunohistochemically analyzed in the cap an bell stages of 10 developing human incisor and canine germs, 8-21 weeks old. RESULTS: During the analyzed period, ratio of Ki-67 positive cells changed in outer enamel epithelium from 48.86% to 24.52%, in inner enamel epithelium increased from 56.11% to 60.06% and then dropped to 44.24%. While in dental papilla proliferation first increased from 46.26% to 55.45%, and then dropped to 22.08%, a constant decrease of proliferation characterized enamel reticulum (from 46.26% to 15.49%). Strong cytoplasmic Oct-4 expression characterized epithelial parts of enamel organ, particularly the differentiating ameloblasts. During further development, Oct-4 expression shifted to both nuclear and cytoplasmic expression in mesenchymal tooth components. Primary cilia characterized most of the cells in developing enamel organ. While non-ciliated (proliferating) cells mainly contained two centrioles (γ-tubulin), the primary cilia (α-tubulin) were arising from basal bodies (γ-tubulin) of non-proliferating cells. CONCLUSIONS: We suggest that increase in cell proliferation enables growth of enamel organ, while its selective decrease leads to disintegration of some tooth parts. Drop of proliferation coincided with initiation of ameloblast and odontoblast differentiation. Additionally, cell differentiation was accompanied by increased expression of Oct-4 and probably by signalling via primary cilia, both regulating processes of cell proliferation and differentiation.

Developmental patterns of Ki-67, bcl-2 and caspase-3 proteins expression in the human upper jaw.

The distribution of the Ki-67, bcl-2 and caspase-3 proteins was immunohistochemically analyzed in the developing human upper jaw (5th-10th gestational weeks). During this period, proliferative activity gradually decreased from higher levels at the earliest stages (50-52%) to lower levels, both in the jaw ectomesenchyme and in the epithelium. The highest expression of bcl-2 protein was found in the epithelium and ectomesenchyme of areas displaying lower rates of cell proliferation. High levels of caspase-3 protein were detected during the earliest stages of jaw development, indicating an important role for apoptosis in morphogenesis of early derivatives of the maxillary prominences. The number of Ki-67, bcl-2 and caspase-3 positive cells changed in a temporally and spatially restricted manner, coincidently with upper jaw differentiation. While apoptosis might control cell number, bcl-2 could act in suppression of apoptosis and enhancement of cell differentiation. A fine balance between cell proliferation (Ki-67), death (caspase-3) and cell survival (bcl-2) characterized early human upper jaw development. A rise in the number of apoptotic cells always temporally coincided with the decrease in number of surviving bcl-2 positive cells within the palatal region. Therefore, the upper jaw development seems to be controlled by the precisely defined expression of genes for proliferation, apoptosis and cell survival.