Surgical Treatment of Primary Parapharyngeal Space Tumors: A Single-Institution Review of 28 Cases.

PURPOSE: This study evaluated the surgical treatment of tumors arising from the parapharyngeal space (PPS) in a single-center setting. MATERIALS AND METHODS: This retrospective study was conducted with 28 patients who underwent surgery for primary PPS tumors from 2011 to 2018. Patient clinical features, histologic tumor type, surgical approach, complications, and follow-up data were evaluated. RESULTS: All patients underwent surgery in this series. The transmandibular approach was most frequently performed (35.7%), followed by the transcervical (28.6%), transparotid (17.9%), and transoral (17.9%) approaches. A surgical navigation system was applied to the surgery of 4 cases with superior PPS tumors. The mean surgical duration of these cases (205.0 minutes) was shorter than that of cases without surgical navigation, and the mean maximum size (MMS) of tumors (5.8 cm) was larger (P < .01). Eleven different tumor types were diagnosed after surgery (78.6% benign and 21.4% malignant). For postoperative complications, there were 10 cases of lower lip numbness, 4 of facial nerve dysfunction, 2 of trismus, and 1 each for the remaining types. During 4- to 81-month follow-up, 27 patients had no recurrence, metastasis, or death and 1 patient was lost to follow-up. CONCLUSION: The histopathologic diagnoses were consistent with those of previous reports. Surgical resection is the main treatment for PPS tumors, with relatively low rates of recurrence and death. For superior PPS tumors, the surgical navigation system can substantially shorten the operative duration and is more suitable for larger tumors.

The Safety and Accuracy of Surgical Navigation Technology in the Treatment of Lesions Involving the Skull Base.

OBJECTIVE: As compared with the normal anatomy, structures of the skull base and its surroundings have been dramatically altered of the lesion near the skull base. How to remove the lesion at the skull base was mainly depending on surgeon's personal experience during past years. In this study, the authors explored the safety and accuracy of the surgical navigation system in resecting lesions near the skull base. METHODS: The surgical cases consisted of 15 patients who underwent surgery involving the skull base with the using of surgical navigation technology. Five patients had adenoid cystic carcinoma at minor salivary glands of the palate extending to the skull base and 10 patients were suffered from bony ankylosis of temporomandibular joint. After the system converted patient's computed tomography scans into three-dimensional reconstructive images, preoperative planning and simulation of the operation process could be made by surgeons. During the operation, the virtual images were matched with the patient through individual registration. The system provided surgeon with feedback about the operation on the screen instantly with moving the navigated pointer. RESULTS: The application of surgical navigation system was safe and reliable for resecting the ankylotic bone and identifying the extent of tumors resection near the skull base. No complications including cerebrospinal fluid leak, cranial nerve injuries, severe bleeding happened to those patients. CONCLUSIONS: Given the safety and accuracy of the surgical navigation system, surgery near the skull base appeared to be an ideal field for using with its complex anatomy.

Functional assessment: Free thin anterolateral thigh flap versus free radial forearm reconstruction for hemiglossectomy defects

BACKGROUND: To compare free thin anterolateral thigh (ALT) flap with free radial forearm (FRF) flap in the reconstruction of hemiglossectomy defects, and to introduce our methods and experience in the tongue reconstruction with free thin ALT flap. MATERIAL AND METHODS: The clinicopathologic data of 46 tongue carcinoma cases hospitalized from December 2009 to April 2014 were obtained from Nangjing Stomatological Hospital, Medical School of Nanjing University. All the subjects were evaluated for the articulation and the swallowing function 3 months after the surgery. RESULTS: Among these 46 patients, 12 patients underwent tongue reconstruction after hemiglossectomy with ALT flap; 34 patients underwent tongue reconstruction with FRF flap. The differences in the incidence of vascular crisis, the speech and the swallowing function between two groups were not significant (P﹥0.05). CONCLUSIONS: Thin ALT flap could be one of the ideal flaps for hemiglossectomy defect reconstruction with its versatility in design, long pedicle with a suitable vessel diameter, and the neglectable donor site morbidity

Functional assessment: Free thin anterolateral thigh flap versus free radial forearm reconstruction for hemiglossectomy defects.

BACKGROUND: To compare free thin anterolateral thigh (ALT) flap with free radial forearm (FRF) flap in the reconstruction of hemiglossectomy defects, and to introduce our methods and experience in the tongue reconstruction with free thin ALT flap. MATERIAL AND METHODS: The clinicopathologic data of 46 tongue carcinoma cases hospitalized from December 2009 to April 2014 were obtained from Nangjing Stomatological Hospital, Medical School of Nanjing University. All the subjects were evaluated for the articulation and the swallowing function 3 months after the surgery. RESULTS: Among these 46 patients, 12 patients underwent tongue reconstruction after hemiglossectomy with ALT flap; 34 patients underwent tongue reconstruction with FRF flap. The differences in the incidence of vascular crisis, the speech and the swallowing function between two groups were not significant (P > 0.05). CONCLUSIONS: Thin ALT flap could be one of the ideal flaps for hemiglossectomy defect reconstruction with its versatility in design, long pedicle with a suitable vessel diameter, and the neglectable donor site morbidity.

[Surgical management of temporomandibular joint ankylosis under the guidance of navigation].

OBJECTIVE: To assess the safety and the accuracy of surgical navigation technology in the resection of severe ankylosis of the mandibular condyle with the middle cranial fossa. METHODS: The CT scan data was transferred to a Windows-based computer workstation, and the patient' s individual anatomy was assessed in multiplanar views at the workstation. In the operation, the patient and the virtual image were matched by individual registration with the reference points which were set on the skull bone surface and the teeth. Then the real time navigation can be performed. RESULTS: The acquisition of the data sets was uncomplicated, and image quality was sufficient to assess the operative result in three cases. The operations were performed successfully with the guidance of real-time navigation. The application of surgical navigation have enhanced the safety and the accuracy of the surgery for bony ankylosis of temporomandibular joint. CONCLUSIONS: The application of surgical navigation can improve the accuracy and safety of surgical excision of the ankylosed skull base tissue.

Gorham disease of the mandible.

Gorham disease, or massive osteolysis, is a rare condition of unknown etiology. The disease is characterized by spontaneous progressive osteolysis of 1 or more skeletal bones. The mandible is the most commonly involved bone in the maxillofacial region. This article reports a case of Gorham disease with mandibular involvement in a 46-year-old male patient with a 7-year follow-up. In this case, we performed lower right mandibular osteotomy and reconstruction with a phased titanium plate. Postoperative follow-up showed continued mandibular bone loss that was progressing to the contralateral mandible. Massive osteolysis of the mandible is a rare clinical condition that must be differentiated from mandibularosteomyelitis, benign and malignant tumors, as well as hyperparathyroidism. Improved differential diagnoses and disease follow-up are required to effectively manage massive osteolysis.

[Comparative study in reconstruction of tongue defect with thin anterolateral flap and forearm flap].

OBJECTIVE: To compare the thin anterolateral flap with forearm flap in tongue defect repairing, and to introduce our methods and experiences in the tongue reconstruction with the thin anterolateral flap. METHODS: The clinicopathologic data of 46 cases with tongue carcinoma were obtained from School of Stomatology, Nanjing University Medical Center, Nanjing University from December 2009 to December 2011. To compare two methods of incidence of vascular crisis, tongue shape, language and swallowing functional recovery. RESULTS: 46 patients with tongue carcinoma were performed the tongue reconstruction in 12 month, which 12 cases were used the thin anterolateral flap and 34 cases were used the forearm flap. In the thin anterolateral flap group, All cases were succeeded. 1 case occurs vascular crisis. In the forearm flap group, 33 cases were succeeded, and 1 case occurs necrosis. 3 cases occurs vascular crisis. The results of comparing two methods showed that: no obvious differences in the tongue shape, and no obvious differences in the function of language and swallowing. CONCLUSIONS: There no obvious differences in the reconstruction of tongue defect between the thin anterolateral flap and the forearm flap. The thin anterolateral flap have some advantages: little influence is on the donor site, the flap extent is abundant, the donor site is not spectacular. The thin anterolateral flap should be piror method for the tongue defect repairing.

Treatment of postoperative midfacial deformity of chilopalatognathus by distraction osteogenesis with a self-constructed tooth-borne distraction device.

OBJECTIVE: Distraction osteogenesis has recently evolved a challenging technique to overcome major drawbacks of the traditional orthodontic treatment modalities. The aim of this study was to evaluate the therapeutic efficacy of patients with chilopalatognathus who have premaxillary deficiency through distraction osteogenesis using a self-constructed tooth-borne distraction device. MATERIAL AND METHODS: Individual tooth-borne distraction devices were used for advancement of the maxillary anterior segment. Distraction was performed for 26 patients in accordance with the specific requirements of each individual. Cephalometric radiographs were taken before treatment (T1), after distraction (T2), and after consolidation for 8 weeks (T3). RESULTS: Cephalometric analysis revealed that the premaxilla was moved forward and that the length of palatal plane increased. In 2 cases, the distractor did not work during distraction and was removed. CONCLUSIONS: Distraction osteogenesis using individual tooth-borne distraction devices in patients with chilopalatognathus could effectively resolve soft tissue insufficiencies and hypoplasia of the maxilla.

Reconstruction of extensive through-and-through cheek defects with free anterolateral thigh flap.

OBJECTIVE: The purpose of this study was to assess the clinical features and therapeutic efficacy of extensive through-and-through cheek defects reconstruction with free anterolateral thigh flap. METHODS: A total of 11 patients underwent simultaneous tumor radical resection and through-and-through cheek defects reconstruction with free anterolateral thigh flap. RESULTS: In these 11 patients, 7 patients had undergone the reconstruction of through-and-through cheek defects with the folded anterolateral thigh flap (2 skin islands and an intervening de-epithelialized zone); 4 patients had undergone the reconstruction of through-and-through cheek defects with the 2 separate skin paddles anterolateral thigh flap in 1 single pedicle. All of these 11 flaps were free fasciocutaneous anterolateral thigh flaps. The subcutaneous fat thickness of the anterolateral thigh flap is less than 1.5 cm. CONCLUSIONS: The free anterolateral thigh flap was one of the versatile soft tissue flaps in the extensive through-and-through cheek defects reconstruction.

Cervical metastases from squamous cell carcinoma of hard palate and maxillary alveolus: a retrospective study of 10 years.

BACKGROUND: The purpose of this study was to investigate the incidence of cervical metastasis in squamous cell carcinoma (SCC) of hard palate and maxillary alveolus and to define its impact factors. METHODS: We conducted a retrospective study of patients surgically treated for SCC of hard palate and maxillary alveolus from 2002 to 2011. In situ hybridization was performed to detect high-risk human papillomavirus (HPV) infection. RESULTS: The incidences of cervical metastasis and occult metastasis were 17.2% (11/64) and 9.8% (5/51), respectively. The pT classification and vascular invasion were correlated with cervical metastasis. Occult metastatic risk was significantly higher among patients with pT4. Presence of positive nodes impaired prognosis significantly. CONCLUSION: SCC of hard palate and maxillary alveolus has nonnegligible incidences of both overall and occult metastasis, which were highly associated with pT classification. We recommend routine, synchronous elective neck dissection for T4 lesions, whereas observation is an alternative for T1 to T3 lesions.

GSTM1 null polymorphisms and oral cancer risk: a meta-analysis.

Many studies have examined the association between the GSTM1 null gene polymorphism and oral cancer risk in various populations, but their results have been inconsistent. To assess this relationship more precisely, a meta-analysis was performed. The PubMed and Embase databases were searched for case-control studies published up to May 2013. Data were extracted and pooled odds ratio (OR) with 95% confidence intervals (CI) were calculated. Ultimately, 39 studies, comprising of 4,704 oral cancer cases and 7,090 controls, were included. Overall, for null versus present, the pooled OR was 1.29 (95% CI = 1.20-1.40), and the heterogeneity was found in all studies. In the stratified analysis by ethnicity, significant risks were found among Asians (OR = 1.39, 95% CI = 1.27-1.53; P = 0.000 for heterogeneity), but not in Caucasians (OR = 0.99, 95% CI = 0.83-1.18; P = 0.677 for heterogeneity). In conclusion, this meta-analysis demonstrates that the GSTM1 null gene polymorphism may be an increased risk of oral cancer in Asians but not in Caucasians.

VEGF +936C/T and +460C/T gene polymorphisms and oral cancer risk: a meta-analysis.

Many studies have examined the association between the VEGF +936C/T (rs833061) and +460C/T (rs3025039) gene polymorphisms and oral cancer risk in various populations, but their results have been inconsistent. To assess this relationship more precisely, we performed a meta-analysis. The PubMed, Embase, Web of Science, and China National Knowledge Infrastructure databases were searched for case-control studies that were published up to January 2013. Data were extracted and pooled odds ratios (ORs) with 95 % confidence intervals (CIs) were calculated. Ultimately, six studies were included, comprising 1006 oral cancer cases and 1016 controls. Overall, the pooled OR for VEGF +936 T allele carriers (TC + TT) versus the wild-type homozygotes (CC) was 1.28 (95 % CI 1.04-1.58; P = 0.228 for heterogeneity), the pooled OR for TT versus CC was 1.64 (95 % CI 1.34-1.98; P = 0.315 for heterogeneity), and the pooled OR for the T allele versus the C allele was 1.42 (95 % CI 1.22-1.76; P = 0.286 for heterogeneity). In the stratified analysis by ethnicity, significant risks were found among Caucasians but not Asians. However, there were no associations between VEGF +460C/T and oral cancer risk in only two of the included studies. In conclusion, this meta-analysis demonstrates that the VEGF +936 T allele may be associated with an increased risk of oral cancer, especially among Caucasian populations.

Prognostic significance of VEGF immunohistochemical expression in oral cancer: a meta-analysis of the literature.

Vascular endothelial growth factor (VEGF) is considered as a prime mediator of angiogenesis and has been implicated in carcinogenesis and metastasis. Various studies examined the relationship between VEGF protein overexpression with the clinical outcome in patients with oral cancer, but yielded conflicting results. Electronic databases updated to March 2013 were searched to find relevant studies. A meta-analysis was conducted with eligible studies which quantitatively evaluated the relationship between VEGF overexpression and survival of patients with oral cancer. Survival data were aggregated and quantitatively analyzed. We performed a meta-analysis of 17 studies (n = 1,207 patients) that evaluated the correlation between VEGF overexpression detected by immunohistochemistry and survival in patients with oral cancer. Combined hazard ratios suggested that VEGF overexpression had an unfavorable impact on overall survival (hazard ratio [HR] = 1.89; 95 % confidence interval [CI], 1.24-2.55) and disease-free survival (HR = 2.08; 95 % CI, 1.14-3.02) in patients with oral cancer: 1.77 (1.09-1.44) in oral squamous cell carcinoma (SCC) patients and 4.28 (1.35-7.21) in adenoid cystic carcinoma (ACC) and mucoepidermoid carcinoma (MEC) of the salivary glands. No significant heterogeneity was observed among all studies. VEGF overexpression indicates a poor prognosis for patients with oral SCC, ACC, and MEC of the salivary glands.

Clinical application of thin anterolateral thigh flap in the reconstruction of intraoral defects.

OBJECTIVE: The purpose of this study was to assess the clinical features and therapeutic efficacy of intraoral defect reconstruction with thin anterolateral thigh flaps. METHODS: A total of 34 patients underwent simultaneous tumor resection and intraoral defect reconstruction with free thin anterolateral thigh flaps. RESULTS: There were 16 male and 18 female patients; the ratio of males to females was 0.9:1; the mean age was 55.4 years. In these 34 patients, 26 flaps were musculocutaneous perforators (76.5%) and 8 flaps were septocutaneous perforators (23.5%). Partial loss of flap occurred in 2 patients (5.9%). CONCLUSIONS: The free thin anterolateral thigh flap was the ideal soft tissue flap in intraoral defect reconstruction. This thin flap presents good functional results at the receiving site with the additional advantages of minimal donor-site morbidity and a high level of patient satisfaction.

[Clinical application of free thin anterolateral thigh flap in the reconstruction of intraoral defects].

OBJECTIVE: To assess the clinical features and therapeutic effect of free thin anterolateral thigh flap for the reconstruction of intraoral defects. METHODS: The clinicopathologic data of 34 cases with oral carcinoma were obtained from Institute and Hospital of Stomatology, Nanjing University Medical School, from December 2008 to December 2011. These 34 patients underwent the simultaneous tumor resection and intraoral defects reconstruction with free thin anterolateral thigh flaps. The defects were located at tongue, buccal, mouth floor, and so on. The subcutaneous fat thickness of the flap at the site of the perforator is usually measured by ultrasound before the operation. If the thickness of the subcutaneous fat at the site of the perforator exceeded 1.5 cm, the patient was excluded from the study. RESULTS: There were 16 male and 18 female patients. The mean age was 55.4 years. Among the 34 patients, 26 flaps with musculocutaneous perforators and 8 flaps with septo-cutaneous perforators were used. Partial flap necrosis occurred in 2 patients. CONCLUSIONS: The free thin anterolateral thigh flap is the ideal soft tissue flap for the intraoral defects reconstruction. Satisfactory functional results can he achieved at recipient area with minimal morbidity at the donor site area.

Salivary adenocarcinoma, not otherwise specified: a clinicopathological study of 28 cases.

OBJECTIVE: The objective of this study was to summarize the clinicopathologic features of salivary adenocarcinoma, not otherwise specified (ANOS) and to evaluate current treatments. STUDY DESIGN: Between 1992 and 2010, 28 patients with ANOS were diagnosed and treated. Clinical data of demographic features, resection margin, neck dissection status, recurrence, and mortality were reviewed. RESULTS: The parotid had the most frequent incidence of ANOS and the palate was second. The peak onset was between 40 and 60 years. The preferred management modality was surgical intervention in all cases. Neck dissection and postoperative radiotherapy were performed in 67.9% and 64.3%, respectively. The mean survival time was 97 months. The 5- and 10-year overall survival rates were 62.2% and 36.0%, respectively. CONCLUSIONS: The current data demonstrate that T, N, M, and Union for International Cancer Control staging, resection margin, and neck dissection status are the most powerful predictors of survival. Long-term follow-up is required to identify possible late recurrence.

Massive osteolysis of the mandible.

We describe a case of massive osteolysis (MO) of the mandible and review related literature. Massive osteolysis in the craniofacial region is a rare condition characterized by progressive absorption of involved bones leading to craniofacial deformities. Currently, the cause and pathophysiology of MO are unclear, and its management or treatment continues to be based on clinical experiences. In our institution, we treat MO of the mandible with surgery; however, this kind of therapeutic management has been unsuccessful.

Clinical application of free anterolateral thigh flap in the reconstruction of intraoral defects.

OBJECTIVE: The purpose of this study was to assess the clinical features and therapeutic efficacy of the intraoral defects reconstruction with 3 types of anterolateral thigh flaps. STUDY DESIGN: The clinicopathologic data of 39 cases with oral tumors were obtained from the School of Stomatology, Nanjing University Medical Center, from December 2008 to June 2010. These patients underwent the simultaneous tumor resection and intraoral defects reconstruction with free anterolateral thigh flaps. RESULTS: There were 22 male and 17 female patients; the ratio of male to female was 1.3:1; the mean age was 56.1 years. Twenty-two of the anterolateral thigh flaps were musculocutaneous flaps (56.4%), 8 were fasciocutaneous flaps (20.5%), and 9 were ultrathin flaps (23.1%). Five patients required operative exploration in the perioperative period. Three flaps were thrombotic events, 1 flap was hematoma, and 1 flap was twisting of perforator. After the salvages, 1 flap was partial failure, 1 flap was total failure, and the other 3 flaps were complete survival. CONCLUSIONS: The free anterolateral thigh flap was the ideal soft tissue flap in the intraoral defects reconstruction. This flap presents good functional results at the receiving site with the additional advantages of minimal donor-site morbidity and a high level of patient satisfaction.

[Reconstruction of oral soft tissue defects with free anterolateral thigh flap].

OBJECTIVE: To assess the clinical features and therapeutic efficacy of anterolateral thigh (ALT) flaps for the intraoral defects reconstruction. METHODS: The clinicopathologic data of 67 cases with oral tumors were obtained from School of Stomatology, Nanjing University Medical Center from Dec. 2008 to Dec. 2010. All the patients underwent the simultaneous tumor resection and intraoral defects reconstruction with free anterolateral thigh flaps. The defects included the tongue, buccal, gingival, mouth floor, and so on. The descending branch of lateral femoral circumflex artery was anastomosed to the external maxillary artery or superior thyroid artery; the vein was anastomosed to the common facial vein or external jugular vein. The flaps were divided into three types: musculocutaneous ALT flap, fasciocutaneous ALT flap and thinned ALT flap. RESULTS: There were 38 male patients and 29 female. The anterolateral thigh flaps included 35 musculocutaneous flaps, 17 fasciocutaneous flaps and 15 thinned flaps. The success rate was 98.5% (66/67). Partial necrosis happened in one case with diabetes, which healed after debridement and dressing. 1 flap was totally necrosis. Double venous anastomosis was performed in 41 flaps, and one venous anastomosis was performed in 26 flaps. 8 patients required operative exploration in the perioperative period including 6 flaps with thrombotic events (5 flaps were complete survival after the salvages, and 1 flap was failure) , 1 flap with hematoma, and 1 flap with twisting of perforator. The follow-up period ranged from 2 to 24 months( mean, 8.7 months). The result was satisfied. The donor sites were closed directly in all patients, and the wounds healed uneventfully. CONCLUSIONS: The free anterolateral thigh flap is an ideal soft tissue flap for the intraoral defects reconstruction with good functional result at recipient area and less morbidity at the donor site.

Ganglion cyst of the temporomandibular joint.

We describe a case of a ganglion cyst of the temporomandibular joint (TMJ) and review the literature of this rare entity. Because of the rarity of such cysts in the TMJ, an accurate diagnosis is not usually made preoperatively. Treatment is surgical but, if a diagnosis can be made, a period of conservative management is justified.