[Noma. Proposal for a surgical treatment]. / Noma. Proposition d'un schéma thérapeutique.

The authors present their experience of surgical treatment of noma in situation of surgical camp. The strategy is focused on two objectives: treatment of tissue loss itself and treatment of the trismus. After having presented the means at disposal, going from local flaps, quickly exceeded, to distant flaps, they decided upon the indications by taking in account the NOILTULP classification. Thus, the authors present their experience of fascia temporalis skin grafted for oral lining in combination with the submental or Backamjian flap for external coverage. The treatment of the trismus is less codified requiring osteotomies in stages 3 and 4. They finally insist first on the prevention of this disease, very accessible to antibiotics at the initial stage of stomatitis and second on simple means very efficient to prevent the trismus which impairs heavily the functional outcome of the reconstructions.

Cancrum oris and noma: some etymological and historical remarks.

Necrotising ulcerative stomatitis is used in the International Statistical Classification of the WHO for orofacial gangrene in children, that is known in medical literature as cancrum oris or noma. The many historical synonyms for this disease together with other historical data indicate that orofacial gangrene in children was a common affection in Europe in previous centuries. The etymological and historical backgrounds of the names "noma" and "cancrum oris" indicate that "cancrum oris" is based on the incorrect use of the Latin term "cancer oris" and maybe on tradition, for which reasons the use of "noma" as medical term for necrotising ulcerative stomatitis should be preferred.

Clinical experience in the treatment of noma sequelae.

We report a cohort of 148 African children operated on between 1985 and 2000 for noma sequelae. A total of 440 operations were performed. Lesions included mouth constriction in 70 of 148 cases, and severe bone destruction in 69 of 148 cases. A large proportion of children was transferred to Switzerland for surgical treatment, whereas the others were operated on in local hospitals in Africa. Vascularized calvarium flap was mostly used for bone reconstruction (n = 36). Pedicled latissimus dorsi myocutaneous flap was the preferred strategy for cheek reconstruction (n = 40). Expanded frontal flap was used for nasal reconstruction (n = 18), and pedicled heterolabial flap for lip construction (n = 37). Given the elevated level of recurrence of mouth constriction (extraarticular ankylosis), a minimum of 2 years' follow-up after surgical treatment was considered mandatory. Follow-up was conducted by field nurses from the humanitarian organizations, and a third of the patients were seen directly by our surgical team during special missions to Africa.

[Reconstruction of severe facial defects due to noma]. / Die Rekonstruktion schwerer Gesichtsdefekte nach Noma-Erkrankung.

Noma is an ulcerative-necrotizing gingivo-stomatitis eventually leading to severe destruction of the midface, including lips and cheek, maxilla/mandible, nose and rarely the orbit. The defects are usually unilateral. Children from economically underdeveloped countries are predominantly affected. Medically untreated the disease has a high mortality rate, which can be dramatically lowered by adequate antibiotic therapy started in time. Predisposing factors include malnourishment, immunosuppression, and poor oral hygiene. Forty-eight noma patients were surgically treated in Sokoto, Nigeria during October 1997 by an Interplast Germany team sponsored by AWD Stiftung Kinderhilfe. Interdisciplinary surgical strategies and results, e.g. ankylosis release, local flap coverage and 12 pedicled musculocutaneous latissimus dorsi island flaps, as well as a noma classification (NOMAC), are presented.

Necrotising infection of the orofacial tissues in neonates (noma neonatorum). Case report.

Noma neonatorum should be differentiated from noma, in that it is typically a disease of seriously ill premature infants whose birth weight was low, and is caused by Pseudomonas aerugenosa septicaemia. We know of only two case reports of noma neonatorum involving newborn infants born at full term, so we report here another case of noma neonatorum in a neonate born at full term. In addition we describe the differences between noma neonatorum and noma (cancrum oris), a clinically related entity.

[Noma or cancrum oris: etiopathogenic and nosologic aspects]. / Noma ou cancrum oris: aspects étiopathogeniques et nosologiques.

Noma is a gangrenous disease that usually begins in the mouth and is characterized by rapid necrotizing destruction of soft tissue and underlying bone. The disease, which is associated with a strong putrid odor suggestive of mixed bacterial infection, develops only in predisposed persons, especially children whose natural defenses have been weakened by poor socio-economic living conditions. However a few atypical cases have recently been reported in adults in whom the main risk factor seemed to be immunodepression. The increasing number of wars in the Third World and the AIDS epidemic raise the likelihood that the number of cases of this disease will rise sharply particularly since the incidence has been grossly underestimated for many years. It now seems clear that a combination of local and systemic risk factors are implicated in the etiopathogenesis of noma with the common denominator being a weakened immune system. This would account for the fulminating course of the infectious process due to one or more opportunistic microbial or cytopathogenic agents or even to a still undetermined immunopathologic reaction that lead to massive tissue destruction. Poor understanding of the etiopathogenesis of noma is a major factor perpetuating the nosologic problems posed by this disease. Some authors add to the confusion by including a range of gangrenous diseases under the heading of noma. It is important that the term noma be applied only to necrotizing processes that begin in the mouth and present the characteristic features and course.

The surgical treatment of noma.

Noma is a gangrenous stomatitis affecting children from developing countries. It may leave dreadful mutilations around the mouth, with amputation of the lips, cheek, nose, lids, maxilla, palate, or mandibula. Reconstruction should take into account the size of the defect, the presence of trismus or constriction of the mandible, the age of the child, and the child's general condition. During the last 3 years, eight patients were treated at the Unit of Plastic and Reconstructive Surgery of the Hôpital Cantonal Universitaire. Except in one case, tracheostomy was avoided, thanks to intranasal intubation by fibroscopy. These children, aged 2 to 9 years, underwent 31 general anesthesias and complex reconstructive procedures, including latissimus dorsi musculocutaneous pedunculated and free flaps, cranial flaps with galea, cranial bone and skin grafts, and retroauricular temporal skin flaps. All patients were able to return to Africa with dramatic functional and cosmetic improvements. However, satisfactory mouth opening and mandibular function were not always obtained.