A patient with primary Burkitt's lymphoma of the postnasal space: case report.

INTRODUCTION: Burkitt's lymphoma is a highly aggressive lymphoma. The endemic form is present with Epstein - Barr virus. The most common sites are the mandible, facial bones, kidneys, gastrointestinal tract, ovaries, breast and extra-nodal sites. We present the first reported case of a primary Burkitt's lymphoma of the postnasal space occurring in an elderly Caucasian male. CASE PRESENTATION: A 72-year-old Caucasian male farmer presented with a 6-week history of a productive cough and a painless left sided cervical swelling. Examination of the neck revealed a 5 cm by 5 cm hard mass in the left anterior triangle. A CT scan of the head and neck showed a soft tissue swelling in the postnasal space. Histology of the postnasal space mass showed squamous mucosa infiltrated by a high grade lymphoma. Immunohistochemical staining and in situ hybridisation confirmed the tumour to be Epstein - Barr virus Ribonucleic acid negative suggesting this was a rare sporadic form of the tumour presenting in a location that is atypical for the clinical subtype and age of the patient. CONCLUSION: This is the first reported case of sporadic Burkitt's lymphoma of the postnasal space of an elderly Caucasian male in the absence of Epstein - Barr virus or human immunodeficiency virus infection and further serves to illustrate the diversity of histological subtypes of malignancies that may develop at this concealed site.

Branchial cysts within the parotid salivary gland.

Cystic lesions within the parotid gland are uncommon and clinically they are frequently misdiagnosed as tumours. Many theories have been proposed as to their embryological origin. A 20-year retrospective review was undertaken of all pathological codes (SNOMED) of all of patients presenting with any parotid lesions requiring surgery. After analysis seven subjects were found to have histopathologically proven parotid branchial cysts in the absence of HIV infection and those patients are the aim of this review. Four of the most common embryological theories are also discussed with regard to these cases, as are their management.

A patient with ulcerated calcifying epithelioma of Malherbe in the pinna: case report.

INTRODUCTION: Although pilomatrixomas are frequently encountered by dermatologists and pathologists in the differential diagnosis of head and neck lesions, this is not usually the case among head and neck surgeons. A pilomatrixoma (calcifying epithelioma of Malherbe) is a benign tumour of the hair matrix cells. Histologically it is characterised by the presence of ghost cells, basophilic cells and foreign body cells. It may sometimes be difficult to histologically distinguish it from its malignant counterpart, the pilomatrix carcinoma. We report an interesting case of an ulcerated pilomatrixoma of the pinna in a middle-aged Caucasian female. CASE PRESENTATION: A 46-year-old Caucasian female presented with a one-month history of tender brownish lump on the pinna. Initially it was thought to represent a pyogenic granuloma. The lesion was treated by wide circular excision. Histopathological evaluation reported a benign calcifying epithelioma of Malherbe. CONCLUSION: A search of the world's literature has led us to believe that this is a rare case of a calcifying epithelioma of Malherbe of the pinna. The rapid growth and ulcerative nature of this tumour makes this case even more unique.

Delay in pathological tissue processing time vs. mortality in oral cancer: short communication.

Several factors have been identified to affect morbidity and mortality in oral cancer patients. The time taken to process a resected cancer specimen in a patient presenting with primary or recurrent disease can be of interest as delay can affect earlier interventions post-surgery. We looked at this variable in a group of 168 consecutive oral cancer patients and assessed its relationship to mortality from the disease at 3 and 5 years. It is expected that delay in pathological processing time of surgical specimens acquired from patients with recurrent disease may increase or contribute to the increased rate of mortality. Further high evidence-based studies are required to confirm this.

The effect of tobacco and alcohol and their reduction/cessation on mortality in oral cancer patients: short communication.

BACKGROUND: The use of tobacco is known to increase the incidence of developing oral cancer by 6 times, while the additive effect of drinking alcohol further increases the risk leading to higher rate of morbidity and mortality. In this short communication, we prospectively assessed the effect of tobacco smoking and alcohol drinking in oral cancer patients on the overall mortality from the disease, as well as the effect of smoking and drinking reduction/cessation at time of diagnosis on mortality in the same group. MATERIALS AND METHODS: A cohort, involved 67 male patients who were diagnosed with oral squamous cell carcinoma, was included in this study. The smoking and drinking habits of this group were recorded, in addition to reduction/cessation after diagnosis with the disease. Comparisons were made to disease mortality at 3 and 5 years. RESULTS: Follow-up resulted in a 3-year survival of 46.8% and a 5-year survival of 40.4%. Reduction of tobacco smoking and smoking cessation led to a significant reduction in mortality at 3 (P < 0.001) and 5 (P < 0.001) years. Reduction in drinking alcohol and drinking cessation led to a significant reduction in mortality at 3 (P < 0.001) and 5 (P < 0.001) years. CONCLUSION: Chronic smoking and drinking does have an adverse effect on patients with oral cancer leading to increased mortality from cancer-related causes. Reduction/cessation of these habits tends to significantly reduce mortality in this group of patients. Smoking and drinking cessation counseling should be provided to all newly diagnosed oral cancer patients.

cTNM vs. pTNM: the effect of not applying ultrasonography in the identification of cervical nodal disease.

Accurate clinical staging of oral squamous cell cancer can be quite difficult to achieve especially if nodal involvement is identified. Radiologically-assisted clinical staging is more accurate and informs the clinician of loco-regional and distant metastasis.In this study, we compared clinical TNM (cTNM) staging (not including ultrasonography) to pathological TNM (pTNM) staging in 245 patients presenting with carcinoma of the oral cavity and the oro-pharyngeal region. Tumour size differences and nodal involvement were highlighted. US reports of the neck were then added to the clinical staging and results compared.Tumour size was clinically underestimated in 4 T1, 2 T2 and 2 T3 oral diseases. Also 20 patients that were reported as nodal disease free had histological proven N1 or N2 nodal involvement; while 3 patients with cTNM showing N1 disease had histologically proven N2 disease.Overall the agreement between the 2 systems per 1 site was 86.6% (Kappa agreement = 0.80), per 2 sites 90.0% (Kappa agreement = 0.68) and per 3 sites 90.5% (Kappa agreement 0.62).An accurate clinical staging is of an utmost importance. It is the corner stone in which the surgical team build the surgical treatment plan and decide whether an adjuvant therapy is required to deal with any possible problem that might arise. The failure to achieve an accurate staging may lead to incomplete surgical planning and hence unforeseen problems that may adversely affect the patient's survival.

Vascular mimicry in cultured head and neck tumour cell lines.

INTRODUCTION: Vascuologenesis is the de novo establishment of blood vessels and vascular networks from mesoderm-derived endothelial cell precursors (angioblasts). Recently a novel mechanism, by which some genetically deregulated and aggressive tumour cells generate "micro-vascular" channels without the participation of endothelial cells and independent of angiogenesis, has been proposed. This has been termed "vasculogenic mimicry" and has implications beyond angiogenesis and adds another layer of complexity to the current concept for the generation of tumour micro-circulation. We suggest this is common phenomenon in head and neck squamous cell carcinoma (HNSCC) cell lines and other aggressive tumour cell lines. We present experimental evidence of vasculogenic mimicry in HNSCC cell lines and compare them with other tumours and a positive control vascular cell line. MATERIALS AND METHODS: The cell lines used were HUVEC, HN 2a, 2b (primary and metastatic tongue base squamous carcinoma cell line), HCT116 (colonic carcinoma cell line) and DU145 (prostate carcinoma cell line).Pilot experiments were undertaken to assess growth of a bank of tumour cell lines on (growth factor reduced) matrigel (Sigma) with standard media (DMEM with 10% Fetal Calf Serum).A functional growth assay was performed by preparing the appropriate cell suspension in serum free medium plated onto either bare plastic or a well pre-coated with growth factor reduced type 4 collagen analogues.Phase contrast photomicrographs were taken at 4 hours and 24 hours. Image analysis was performed; particular features of interest were two dimensional area (surrogate of growth and migration), branch points and end point measurements (surrogate of intercellular complexity). RESULTS: There were observable differences in growth of the cells on laboratory plastic and collagen matrix. Tumour cells formed capillary like networks similar to HUVEC cells. Metastatic HNSCC cells lines were found to have vasculogenic properties similar to HUVEC cell lines when compared to cell lines from their corresponding primary tumour. The endothelial growth factor antibodies used did not inhibit or stimulate cell growth when compared to control but did discourage vascular mimicry. Other tumour cell lines also displayed this property. DISCUSSION: Tumour "vasculogenic mimicry" must still be regarded as a controversial issue whose existence is not proven. The clinical importance of this phenomenon however, is that it does explain the lack of complete efficacy of current anti-angiogenic treatments due to the added layer of complexity. It provides a feasible mechanism of early tumour vascular supply which can co-exist and incorporate with later angiogenic mechanisms. We suggest that "vasculogenic mimicry" maybe a common neoplastic phenomena which appears to also be dictated by the cells micro-environment. Its existence also suggests a further process that of the development of tumour mosaic vessels as the neo-vasculature integrates with the existing endothelial lined systems.

Dermatofibrosarcoma protuberans with fibrosarcomatous transformation of the head and neck.

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous neoplasm associated with a high cure rate. We present a case of aggressive DFSP with fibrosarcomatous areas in the head and neck. A 28-year-old Mediterranean female presented with a 45-day history of rapidly growing cutaneous lesion of the face. Surgical biopsy confirmed the diagnosis of DFSP. Subsequently, the patient underwent wide local surgical resection, followed by reconstruction. Histopathology report revealed fibrosarcomatous transformation and the patient underwent adjuvant radiotherapy. The patient continues to be disease free at the 35-month follow-up.Although DFSP behave as non-aggressive malignancy, surgery with complete removal of the affected area is the intervention of choice. Moreover, adjuvant treatment and follow-up of the patient is essential in order to prevent recurrence.

Mucogingival overgrowth in a geriatric patient.

Epulis fissuratum is a pathological condition caused by an ill-fitting denture. The mucogingival hyperplasia may be considered as a reactive condition of the oral mucosa to excessive mechanical pressure on the mucosa. Epulis fissuratum excision is a procedure usually done for prosthodontic reasons. The treatment of this benign entity is essential mainly for masticatory reasons. The use of diode laser for epulis removal without infiltrated anesthesia in a conscious geriatric patient is currently under investigation.

Risk factors associated with injury to the inferior alveolar and lingual nerves following third molar surgery-revisited.

OBJECTIVE: Earlier reports, including a preliminary study within our unit, have shown that the surgeon's experience is one of the most influential factors in determining the likelihood of both permanent inferior alveolar nerve (IAN) and lingual nerve (LN) paresthesia, following third molar surgery. The effect of this and other factors influencing such prevalence are assessed in this study. STUDY DESIGN: This prospective study involved 3236 patients who underwent surgical removal of impacted third molars. Patients' demographics and radiological parameters were recorded along with the grade of the treating surgeon. The prevalence of inferior alveolar and lingual nerves paresthesia at 1 month, 6 months, and 18 to 24 months postoperatively were also traced. RESULTS: At 1 month postoperatively, the incidence of IAN paresthesia was 1.5% and the LN was 1.8%. These figures decreased over time and 18 to 24 months postoperatively, the incidence of permanent dysfunction of the IAN was 0.6% and LN was 1.1%. With regard to inferior alveolar nerve paresthesia, risk factors included the patient's age (26-30 years), horizontally impacted teeth, close radiographic proximity to the inferior alveolar canal (IAC), and treatment by trainee surgeons. With regard to the lingual nerve, risk factors included male patients, distoangular impactions, close radiographic proximity to the IAC, and treatment by trainee surgeons. CONCLUSION: One of the main risk factors of developing permanent sensory dysfunction in the distribution of these nerves is related to the surgical skills/experience of the operator. Other factors are associated with the type of impaction and the radiographic proximity of the tooth to the inferior alveolar nerve. Such long-term complications can affect the patient's quality of life; the impact on profession, education, and research is unknown.

Dysaesthesia in the mental nerve distribution triggered by a foreign body: a case report.

INTRODUCTION: Foreign bodies' entrapments in the mandibular and submandibular regions are quite common. CASE PRESENTATION: We report an unusual case of foreign body (amalgam filling) entrapment over the mental foramen causing dysaesthesia in the distribution of the mental nerve. An interesting sign was blue discoloration of the overlaying oral mucosa which was interpreted as amalgam tattooing. CONCLUSION: Surgical removal of the foreign object eliminated the reported symptoms.

Third molar surgery: the patient's and the clinician's perspective.

BACKGROUND: In this report, the problems of third molar surgery have been reviewed from the perspective of both patient and clinician; additionally an overall analysis of preoperative imaging investigations was carried out.Specifically, three main areas of interest were investigated: the prediction of surgical difficulty and potential complications; the assessment of stress and anxiety and finally the assessment of postoperative complications and the surgeon's experience. FINDINGS: In the first study, the prediction of surgical difficulty and potential injury to the inferior alveolar nerve was assessed. This was achieved by examining the patient's orthopantomograms and by using the Pederson Difficulty Index (PDI). Several radiological signs were identified and a classification tree was created to help predict the incidence of such event.In the second study, a prospective assessment addressing the patient's stress and anxiety pre-, intra- and postoperatively was employed. Midazolam was the active drug used against placebo. Objective and subjective parameters were assessed, including measuring the cortisol level in saliva. Midazolam was found to significantly reduce anxiety levels and salivary cortisol was identified as an accurate anxiety marker.In the third study, postoperative complications and the surgeon's experience were examined. Few patients in this study suffered permanent nerve dysfunction. Junior surgeons reported a higher complication rate particularly in trismus, alveolar osteitis, infection and paraesthesia over the distributions of the inferior alveolar and lingual nerves. In apparent contrast, senior surgeons reported higher incidence of postoperative bleeding. DISCUSSION: These studies if well employed can lead to favourable alteration in patient management and might have a positive impact on future healthcare service.

Unilateral versus bilateral thyroarytenoid Botulinum toxin injections in adductor spasmodic dysphonia: a prospective study.

OBJECTIVES: In this preliminary prospective study, we compared unilateral and bilateral thyroarytenoid muscle injections of Botulinum toxin (Dysport) in 31 patients with adductor spasmodic dysphonia, who had undergone more than 5 consecutive Dysport injections (either unilateral or bilateral) and had completed 5 concomitant self-rated efficacy and complication scores questionnaires related to the previous injections. We also developed a Neurophysiological Scoring (NPS) system which has utility in the treatment administration. METHOD AND MATERIALS: Data were gathered prospectively on voice improvement (self-rated 6 point scale), length of response and duration of complications (breathiness, cough, dysphagia and total voice loss). Injections were performed under electromyography (EMG) guidance. NPS scale was used to describe the EMG response. Dose and unilateral/bilateral injections were determined by clinical judgment based on previous response. Time intervals between injections were patient driven. RESULTS: Low dose unilateral Dysport injection was associated with no significant difference in the patient's outcome in terms of duration of action, voice score (VS) and complication rate when compared to bilateral injections. Unilateral injections were not associated with any post treatment total voice loss unlike the bilateral injections. CONCLUSION: Unilateral low dose Dysport injections are recommended in the treatment of adductor spasmodic dysphonia.

Upper-lip laser frenectomy without infiltrated anaesthesia in a paediatric patient: a case report.

Labial frenectomy is a common surgical procedure in the field of oral surgery. Labial frenectomy is a procedure usually done for orthodontic reasons. The role of laser surgery in the oral cavity is well established. The use of diode laser frenectomy without infiltrated anaesthesia is currently under investigation. Needle-less oral surgery, without infiltrated anaesthesia, is a novel situation in paediatrics with paramount importance.

The stylomastoid artery as an anatomical landmark to the facial nerve during parotid surgery: a clinico-anatomic study.

BACKGROUND: The identification of the facial nerve can be difficult in a bloody operative field or by an incision that limits exposure; hence anatomical landmarks and adequate operative exposure can aid such identification and preservation. In this clinico-anatomic study, we examined the stylomastoid artery (SMA) and its relation to the facial nerve trunk; the origin of the artery was identified on cadavers and its nature was confirmed histologically. METHODS: The clinical component of the study included prospective reviewing of 100 consecutive routine parotidectomies; while, the anatomical component of the study involved dissecting 50 cadaveric hemifaces. RESULTS: We could consistently identify a supplying vessel, stylomastoid artery, which tends to vary less in position than the facial nerve. Following this vessel, a few millimetres inferiorly and medially, we have gone on to identify the facial nerve trunk, which it supplies, with relative ease. The origin of the stylomastoid artery, in our study, was either from the occipital artery or the posterior auricular artery. CONCLUSION: This anatomical aid, the stylomastoid artery, when supplemented by the other more commonly known anatomical landmarks and intra-operative facial nerve monitoring further reduces the risk of iatrogenic facial nerve damage and operative time.

Disease phobia in patients with temporomandibular joint pain assessed by the Illness Attitude Scale.

UNLABELLED: Disease phobia refers to a psychological state when the person continuously thinks that he/she is sick and improvement from the condition is impossible. Disease phobia in patients suffering from pain, secondary to temporomandibular disorders (TMDs), is usually the consequence of long-term problems; diagnosis and treatment of this group is a real challenge for healthcare professionals. AIM: The purpose of this prospective study was to objectively evaluate the role of Illness Attitude Scale (Kellner or IAS) in measuring cancerophobia and heart disease phobia in patients suffering from pain, as a consequence of TMDs. SUBJECTS AND METHODS: The cohort included 22 patients with TMDs who underwent evaluation of these phobias; pain was acute in 7 and chronic in 15. The patients were asked to complete the "Kellner" questionnaire, and this was followed by full clinical examination of the temporomandibular region. RESULTS: When measuring the correlation between the cancerophobia and heart disease phobia patients, the outcome was found significant in the total cohort, p < 0.01. Comparisons were carried out in the chronic group (n = 15) and was significant (p = 0.034 and r = 0.549); while in the acute group no significance was identified. CONCLUSION: Cancerophobia and heart disease phobia in TMD patients are factors that need to be taken in consideration when managing chronic pain in this group.

Ethical and technical considerations for the creation of cell lines in the head & neck and tissue harvesting for research and drug development (Part I): techniques of tissue harvesting and propagation.

BACKGROUND: Although much has been published for the development of cell lines, these were lab based and developed for scientific technical staff. OBJECTIVE OF REVIEW: We present a simple and successful protocol for the development of cell lines and tissue harvesting for the clinical scientist. We also discuss the ethical implications of tissue retention and present a generic consent form. CONCLUSION: The advantages of hospital-based cell line creation are numerous. We can be more certain that cell lines are developed from the particular tissues of interest and accurate anatomical and appropriate clinico-pathological control tissues are also harvested. We can also be certain of less cell line cross contamination.

Ethical and technical considerations for the creation of cell lines in the head & neck and tissue harvesting for research and drug development (Part II): ethical aspects of obtaining tissue specimens.

BACKGROUND: Although much has been published for the development of cell lines, these were lab based and developed for scientific technical staff. OBJECTIVE OF REVIEW: We discuss the ethical implications of tissue retention and present a generic consent form (Part II). We also present a simple and successful protocol for the development of cell lines and tissue harvesting for the clinical scientist (Part I). CONCLUSION: Consent is also more proximate and assurance can be given of appropriate usage. Ethical questions concerning tissue ownership are in many institutions raised during the current consenting procedure. We provide a robust ethical framework, based on the current legislation, which allows clinicians to be directly involved in cell and tissue harvesting.

Salivary VEGF: a non-invasive angiogenic and lymphangiogenic proxy in head and neck cancer prognostication.

BACKGROUND: Saliva is an enriched milieu containing biologically active proteins, including growth factors and cytokines. The endothelial growth factor family of proteins is important for the development of blood and lymphatic vessels in a healthy individual but also can aide tumour growth.The aim of this study is to develop an independent normative database of values of salivary VEGF in a healthy population and to test the hypothesis that values would be raised in the saliva of patients with oral cancer. METHODS: Twenty-one participants (12 males and 9 females) of whom 14 were healthy and 7 had oral squamous cell carcinoma took part in this study.An immunoassay was employed to quantify a range of specific vascular endothelial and lymphatic endothelial growth factors in various body fluid compartments (blood, saliva). This was correlated to tumour factors and patient outcomes. RESULTS: The mean salivary levels and serum VEGF A165 levels were significantly correlated in the sample as a whole. Additionally, both saliva and serum VEGF A165 levels were significantly correlated with age. There were significant differences in the salivary and serum levels of the control group and the cancer group. CONCLUSION: We present independent normative data on the levels of endothelial growth factor in the saliva of a healthy control population. We also suggest the use of simple non-invasive tests in helping to predict head and neck tumour biology and outcomes.

A forensic aspect of age characteristics of dentine using transversal microradiography: a case report.

BACKGROUND: Translucency of dentine is the result of occlusion of the corresponding dentinal tubules by a mineral substance which has a refractive index similar to that of the rest of the dentine. CASE PRESENTATION: This case report describes the microradiographic features of an upper cadaveric canine. Transverse microradiograph is one of the methods assessing apical dentine translucency for various dental and medical reasons. CONCLUSION: Estimation of age using teeth structures may be of primary value in forensic dentistry, especially when soft tissues are severely destructed.