Prospective comparison of panoramic tomography (zonography) and helical computed tomography in the diagnosis and operative management of mandibular fractures.

This prospective study compared the sensitivity of panoramic tomography (zonography) and helical computed tomography (CT) in diagnosing 73 mandibular fractures in 42 consecutive patients and correlated the results with known surgical findings. The purpose of the study was to determine the optimal radiologic examination for the diagnosis and operative management of mandibular fractures. The attending surgeons' interpretations of panoramic tomograms and helical CT images in the axial plane were compared with the patients' known surgical findings. A series of questions assessed the relative contribution of these two radiologic examinations in formulating an optimal operative plan for each patient. In the 42 patients studied, the sensitivity of helical CT was 100 percent in diagnosing mandibular fractures; this compared with 86 percent (36 of 42) for panoramic tomography, in which significantly more fractures were missed (p = 0.0412). In the six patients with fractures not visualized, the operative management was altered because of the new fracture visualized on helical CT. Of the seven missed fractures, six were in the posterior portion of the mandible. Comparing fracture detection by region, seven fractures found on helical CT were not visualized on panoramic tomography. Helical CT improved the understanding of the nature of mandibular fractures by providing additional information regarding fracture displacement and comminution and by locating injuries missed using panoramic tomography. This study suggests that helical CT alone may be more diagnostic than panoramic tomography alone in evaluating mandibular fractures. Helical CT sufficiently demonstrated details of fractures in 41 of 42 patients; in one patient, the nature of a dental root fracture was better delineated by panoramic tomography.

Resorbable plate fixation in pediatric craniofacial surgery: long-term outcome.

OBJECTIVE: To determine the long-term efficacy of resorbable plate fixation in pediatric patients undergoing craniofacial surgery for congenital anomalies, traumatic deformities, or skull base tumors. DESIGN: Retrospective case review. MATERIALS AND METHODS: Medical records of 57 consecutive cases using resorbable plates and screws for craniofacial fixation in patients younger than 18 years were analyzed. MAIN OUTCOME MEASURES: The status of bone healing postoperatively (anatomical union, malunion, delayed union, or nonunion) and any complications or adverse effects (hardware visibility or palpability, plate extrusion, or infection) were noted. RESULTS: In midfacial and upper face procedures (54 patients) anatomical union and uncomplicated bone healing occurred in 52 (96%) of the patients. In this same group, complications (plate extrusion) occurred in 2 patients (3.7%) and were resolved using conservative treatment without untoward sequelae. These outcomes are comparable to results using metal osteosynthesis in similar situations. Costs of resorbable hardware are similar to existing metal fixation systems. CONCLUSIONS: Our data support the use of bioresorbable plate fixation in pediatric craniofacial surgery as a means of avoiding the potential and well-documented problems with rigid metal fixation. Indications include fractures and segmental repositioning in low-stress non-load-bearing areas of the middle and upper craniofacial skeleton. Although there is an initial learning curve in using this technology, we believe the benefits are well worth the effort and represent a major advance in pediatric craniofacial surgery.

Fine-needle aspiration diagnosis of unusual cutaneous neoplasms of the scalp in HIV-infected patients: a report of two cases and review of the literature.

We report on two unusual, non-AIDS-defining scalp neoplasms, Merkel-cell carcinoma (MCC) and malignant melanoma, in 2 men with acquired immunodeficiency syndrome (AIDS). In the first patient, metastatic MCC was initially diagnosed by fine-needle aspiration (FNA) of a posterior cervical lymph node, based on the cytomorphology and the characteristic immunohistochemical and ultrastructural features. No skin lesion was initially apparent, but a 0.3-mm scalp primary was found during the ensuing neck dissection. In the second patient, recurrent and metastatic malignant melanoma from a Breslow 1.3-mm scalp primary was diagnosed by FNA. Both patients developed generalized disease in a relatively short time, despite their small primaries. These cases illustrate the occurrence of Merkel-cell carcinoma and melanoma in AIDS patients, and stress the need to consider these unusual cutaneous neoplasms when evaluating lymph node FNA samples from HIV-positive patients, especially since both may present as metastases from clinically occult primaries.

Carotid stenting and "extarterectomy" in the management of head and neck cancer involving the internal carotid artery: technical case report.

OBJECTIVE AND IMPORTANCE: Head and neck cancer that invades the internal carotid artery (ICA) represents a significant management challenge. We describe a novel technique that allows for aggressive tumor removal without disrupting blood flow through the affected ICA. CLINICAL PRESENTATION: A 62-year-old man was referred to our institution for management of a neck malignancy involving the ICA. Cerebral angiography suggested that there was good collateral flow from the opposite hemisphere, but the patient reported visual loss in the ipsilateral eye during balloon test occlusion of the ICA. INTERVENTION: A self-expanding stent was deployed in the ICA; it spanned the entire length of the artery involved by tumor. One month later, the patient underwent tumor resection. During surgery, a long ICA arteriotomy was performed directly down to the mesh of the stent. A neoendothelium had formed within the stent, which prevented arterial bleeding. The carotid wall was dissected from the stent without difficulty and removed en bloc with the surrounding tumor. The exposed stent was wrapped circumferentially with a synthetic patch material. The patient tolerated the procedure well, and postoperative angiography demonstrated normal filling of the ICA. CONCLUSION: We describe a novel approach to a patient with head and neck cancer involving the cervical ICA. Preliminary stenting, which allows time for endothelialization before surgery, may permit aggressive tumor resection without interrupting flow through the ICA. This technique obviates the need for complicated carotid reconstruction procedures and avoids the risk of delayed ischemia from carotid sacrifice.

Contribution of conventional axial computed tomography (nonhelical), in conjunction with panoramic tomography (zonography), in evaluating mandibular fractures.

Previous studies comparing the sensitivity between different radiological exams have concluded that conventional axial computed tomography (CT; nonhelical) is unsuitable in the assessment of mandibular fractures. Axial CT was shown to have a reduced sensitivity compared with plain radiographs and panoramic tomography because it missed nondisplaced fractures in the posterior portion of the mandible. Because the resolution of CT has improved from the time of these previous studies, the authors were interested in assessing whether axial CT (nonhelical) could now provide additional clinically useful information and enhance our understanding of mandibular fractures, beyond that obtained from panoramic tomography alone. In their study, 5 staff surgeons initially evaluated the panoramic tomograms and then the CT scans of 39 patients with 66 fractures. A series of four questions assessed the relative contribution of these two radiological exams in formulating an optimal operative plan for each patient. The authors found that axial CT provided supplementary information regarding missed fractures, comminution, and the exact size and degree of displacement of fracture fragments. This additional data could have changed the operative plan in a substantial proportion of patients (17 of 39). Axial CT demonstrated two missed parasymphyseal fractures (2 of 39 patients) that were not seen on these patients' panoramic tomograms. Axial CT also revealed undiscovered comminution or demonstrated fracture displacement more precisely in 39% of patients (15 of 39) and 24% of fractures (16 of 66). This study demonstrates that axial CT was clinically useful as an additional investigation to panoramic tomography. Axial CT helped elucidate further the nature of suspected mandibular fractures.

Mandibular distraction osteogenesis in a neonate.

Children with craniofacial anomalies are predisposed to airway obstruction and frequently require airway intervention. Tracheotomy is performed when the airway obstruction is severe and refractory to other less invasive interventions. Tracheotomy is associated with significant morbidity, and there is a trend noted in the literature toward achieving earlier decannulation by the institution of definitive structural changes to the mandible. Mandibular distraction osteogenesis has been shown to alleviate airway obstruction in the pediatric population. We report a case in which mandibular distraction osteogenesis was successfully carried out in a neonate with acute airway obstruction at birth as a result of combined Pierre Robin sequence and Klippel-Feil syndrome. After 1 year, the patient still had an adequate airway with tolerable scarring and no neurologic sequelae.

Determination of the efficacy of topical oral pilocarpine for postirradiation xerostomia in patients with head and neck carcinoma.

Pilocarpine hydrochloride suspended in a candy-like pastille was evaluated as a topical treatment for radiation-induced xerostomia in head and neck cancer patients. This local delivery system, which differs from systemically administered pilocarpine preparations, was developed to hopefully maximize the local response and minimize the systemic side effects. A prospective, randomized, double-blind, placebo-controlled trial was undertaken to determine objective and subjective efficacy in reversing the decrease in salivation. Forty previously irradiated patients received increasingly higher pilocarpine dosages in pastilles for 5 successive weeks. At each successive dose of pilocarpine, no significant increased salivation was noted. However, 25 (74%) of 34 patients reported that pilocarpine alleviated their subjective xerostomia. Topical pilocarpine administration has shown similar results to previous systemic delivery methods for radiation-induced xerostomia, but with improved patient tolerance.