Atypical Tongue Abscesses Mimicking Submucosal Malignancies: A Review of the Literature Focusing on Diagnostic Challenges.

Tongue abscesses are rare conditions that usually follow mucosal disruption due to mechanical trauma or foreign body impaction. They typically manifest abruptly as a rapidly growing, hard mass or swelling in the context of tongue muscles; the patient frequently complains of pain, difficulties in swallowing or speaking, and fever. Nonetheless, the features of its presentation, together with accurate clinical evaluation, blood tests, and appropriate imaging tests, are usually sufficient to easily discern a tongue abscess from a malignancy. However, in rare cases, they may occur with slowly progressing and subtle symptoms, nuanced objective and laboratory findings, and inconclusive radiological evidence, leading to difficult differential diagnosis with submucosal malignancy. Herein, we review the literature, available on Pubmed, Embase, and Scopus, on publications reporting tongue abscesses, with atypical presentation suggesting an oral tumor. Our review confirms that tongue abscesses may manifest as a slowly growing and moderately painful swelling without purulent discharge and minimal mucosal inflammation; in this case, they may constitute an actual diagnostic challenge with potentially severe impact on correct management. Atypical tongue abscesses must therefore be considered in the differential diagnosis of tongue malignancy with submucosal extension, even when other diagnostic elements suggest a neoplasia; in this case, a deep biopsy under general anesthesia is essential for differential diagnosis, and simultaneous drainage of the necrotic and abscessual material may resolve the condition.

Trimming of Facial Artery Myomucosal Flap (FAMM) using Indocyanine Green Fluorescence Video-Angiography: Operative Nuances.

BACKGROUND: Facial artery myomucosal flap (FAMM) is an intraoral flap pedicled on facial artery used for reconstruction of oral/oropharyngeal defects.1 Careful assessment of perfusion is essential to avoid flap necrosis, and several options are used for this purpose. Among these, indocyanine green (ICG) fluorescence video-angiography (ICG-VA) represents an innovative tool whose adoption in flap surgery is still at its early days.2 METHODS: In this multimedia article, we described the use of ICG-VA for perfusion assessment of a FAMM flap harvested for reconstruction of oral lining after ablation of a cT2cN0 floor-of-mouth (FOM) cancer. The use of ICG-VA was aimed at defining ischemic areas on the flap according to a flap-to-normal mucosa ICG ratio. RESULTS: After transoral excision of the FOM cancer and subsequent harvesting of a FAMM flap, we used ICG-VA to intraoperatively assess its perfusion. The degree of flap perfusion was expressed point-by-point through flap-to-normal mucosa ICG ratio (percentage); a value of 25-27% was considered as threshold for ischemia.3 Perfusion was documented both with white light modality with "overlay fluorescence" and "black and white SPY fluorescence mode" designed to increase the sensitivity of ICG detection. Small, ischemic areas were detected in the distal part of the flap and were trimmed. At the end of the procedure, an adequate perfusion was evident throughout the whole flap, allowing its safe insetting for left FOM reconstruction. Postoperative course was uneventful. CONCLUSIONS: ICG-VA represents a reliable tool for intraoperative detection-and trimming-of ischemic areas on reconstructive flaps.

An update on novel pharmacological agents for primary sclerosing cholangitis.

INTRODUCTION: Primary sclerosing cholangitis (PSC) is a rare chronic cholestatic disease with heterogeneous phenotypes that may lead to liver transplantation and/or end-stage liver disease. Its multifactorial etiopathogenesis remains uncertain, but gut-liver axis and bile composition and excretion are widely demonstrated to influence the immune-mediated fibrogenic reactive cascade. AREAS COVERED: Different experimental therapeutic options are under investigation, mainly aiming at modulating bile acids excretion, limiting inflammatory-cascade reactions, and changing intestinal microbiota composition; none of them yet demonstrated to prolong transplant-free survival.This review provides a comprehensive description of the experimental drugs recently tested and/or currently under investigation. A bibliographical search was performed in PubMed, MEDLINE, EMBASE, OVID, and clinicaltrial.gov until July 2021. EXPERT OPINION: The heterogeneity and poor prevalence of PSC, its uncertain pathophysiology, and the lack of surrogate endpoints are the major challenges in drug discovery. Strategies that synergistically target microbiota, bile acids, and liver fibrosis are needed. In parallel, we must enhance biomarkers discovery to develop surrogate endpoints, as biochemical markers' fluctuations over the time hamper their effectiveness. Magnetic resonance cholangiopancreatography tools that accurately measure bile duct changes represent a potential marker for disease monitoring. A collaboration between academia, research consortia, patient's associations, and industry is required.