Osteomyelitis of the jaw: resistance to clindamycin in patients with prior antibiotics exposure.

The purpose of this paper was to review our clinical experience in patients with osteomyelitis (OM) of the jaw, focusing on aspects of antimicrobial resistance. A retrospective review of the medical records of adult patients with jaw OM was carried out. Among 46 cases of jaw OM, the cause was odontogenic in 32 (seven had recent dental implants and four bisphosphonate osteonecrosis), postoperative/post-traumatic in eight, and secondary to osteoradionecrosis in six. Clinical features were chronic in 91.3%. The infection was polymicrobial in 24/41 (65.9%). Viridans streptococci were the most commonly isolated agents. Among 26 viridans streptococci tested, 81% were susceptible to penicillin and 96% to fluorquinolones, but only 11.5% to clindamycin. Overall, 35/38 (92.1%) had at least one clindamycin-resistant isolate. Appropriate antibiotics were administered for a mean of 5.8 +/- 3.2 months. Beta-lactams were used in 19 cases and fluorquinolones in 14. Among 39 cases with long-term follow-up, only two relapsed. Currently, jaw OM is commonly related to osteoradionecrosis, dental implants, and bisphosphonates. In patients with prior antibiotics exposure, a high percentage of infections were caused by clindamycin-resistant microorganisms, thus, beta-lactams should be the antibiotic of choice. In penicillin-allergic cases, the new fluorquinolones, probably in combination with rifampin and/or clindamycin, could be a promising alternative.

Tolerancia al material de osteosíntesis en cirugía electiva del maxilar superior / Tolerance of the ostheosynthesis material in elective surgery of the superior maxilla

Se evaluaron retrospectivamente un total de 36 pacientes sometidos a osteotomía de LeFort I. En 21 de estos pacientes (8 hombres y 13 mujeres con edad media 20,8 años) se realizaron osteotomías estándar con corrección del defecto con miniplacas en forma de "L", usando en 11 casos miniplacas 2,0 y el resto 1,5. Se sometieron a los 15 pacientes restantes (8 hombres y 7 mujeres con edad media 39,6 años) a osteotomía segmentada sagital para el abordaje lesiones de la base del cráneo, colocando en todos ellos miniplacas de 2,0. Después de un seguimiento mínimo de 30 meses se llegaron a los siguientes resultados: De un total de 160 miniplacas colocadas ( 84 en grupo estándar y 76 en osteotomías de abordaje neuroquirurgico) se retiraron sólo 4 de estas miniplacas, 2 de ellas por palpación intraoral y 2 por exposición. Por todo lo expuesto y en comparación con otras series concluimos que la baja incidencia de complicaciones derivadas del material de osteosíntesis no justifica su retirada sistemática en las osteotomías de maxilar superior. (AU)

Rinoplastia abierta / Open rhynoplasty

La rinoplastia abierta frente a la cerrada ha sido objeto de discusión y uno de los tópicos más frecuentes de conferencias y publicaciones. El abordaje abierto ha ido ganando aceptación en la última década como resultado fundamentalmente de la amplia exposición y directa visualización de la estructura osteocartilaginosa del esqueleto nasal. Esta exposición ofrece ventajas especialmente en casos complejos de rinoplastia secundaria. El abordaje abierto proporciona mayores opciones y control de la técnica quirúrgica permitiendo el modelado del esqueleto nasal mientras se mantiene su integridad por lo que este abordaje es utilizado cada vez más frecuentemente en rinoplastia primaria (AU)

Malignant tumors of the minor salivary glands. Retrospective study on 59 cases.

Minor salivary glands cancer account for 2-4% of head and neck cancer, 10% of all oral cavity cancer and 15-23% of all salivary glands cancer (1). There is a remarkable variation in clinical presentation, behavior and histology of those neoplasms. The incidence of malignancy is around 52-60% (2-4) Several classifications of salivary gland tumors have been presented, but for the present study we have utilized the WHO classification of 1992 (5). We present the results of a review of our experience with those malignancies, considering prognostic factors as histopathology, tumor grade, clinical staging, age and sex, primary location, regional and distant metastasis.

Activated extracellular signal-regulated kinases: association with epidermal growth factor receptor/transforming growth factor alpha expression in head and neck squamous carcinoma and inhibition by anti-epidermal growth factor receptor treatments.

The expression of the activated mitogen-activated kinases/extracellular signal-regulated kinases (ERKs) ERK1 and ERK2 was characterized in 101 humanhead and neck squamous carcinoma specimens. Activated ERK1/2were detected at different levels in the majority of these tumors, as assayed by immunostaining with an antibody specific for the dually phosphorylated and activated ERK1 and ERK2. ERK1/2 activation levels were higher in tumors with advanced regional lymph node metastasis (P = 0.048) and in relapsed tumors (P = 0.021). The expression of epidermal growth factor (EGF) receptor (P = 0.037), transforming growth factor alpha (TGF-alpha; P < 0.001), and HER2 (P = 0.066; positive trend) correlated with activation of ERK1/2. In a multivariate analysis, both TGF-alpha (P < 0.0001) and HER2 (P = 0.045) were independently correlated with ERK1/2 activation. In turn, activation of ERK1/2 was associated with a higher Ki-67 proliferative index (P = 0.002). In EGF receptor-dependent model cells (A431 and DiFi), a specific EGF receptor tyrosine kinase inhibitor ("Iressa"; ZD1839) and a chimeric anti-EGF receptor antibody ("Cetuximab"; C225) inhibited ERK 1/2 activation at concentrations that inhibited autocrine cell proliferation. In patients on treatment with C225, the activation of ERK1/2 in skin, an EGF receptor-dependent tissue, was lower compared with control skin. Parallel changes were seen in keratinocyte Ki67 proliferation indexes in skin from C225-treated patients. Taken together, these studies provide support for a role of activation of ERK1/2 in head and neck squamous carcinoma and a correlation with EGF receptor/TGF-alpha expression. The inhibition of ERK1/2 activation in vitro and in vivo by compounds targeting the EGF receptor points to the interest of ERK1/2 as potential surrogate markers of EGF-receptor signaling in clinical therapeutic studies.

Tumores malignos de glándulas salivales menores. Estudio retrospectivo sobre 59 casos / Malignant tumors of the minor salivary glands, Retrospetive study on 59 cases

Los tumores malignos de las glándulas salivales menores suponen el 2-4 por ciento de todos los cánceres de cabeza y cuello, el 10 por ciento de todos los tumores malignos de la cavidad oral y el 1523 por ciento de todos los cánceres de glándulas salivales (1). La incidencia de malignidad está entre el 52 y el 60 por ciento (2-4). Se ha efectuado un estudio retrospectivo sobre 111 pacientes afectados por tumores de glándulas salivales menores atendidos en el Departamento de Cirugía Maxilofacial de Hospital Vall d'Hebron entre 1975 y 1997. Los pacientes se identificaron mediante una búsqueda en los archivos de Cirugía Oral y Maxilofacial, Oncología y Patología. Se recogieron datos referentes a edad, sexo, localización, estadio clínico, grado tumoral, metástasis a distancia y regionales, diagnóstico histológico, terapia y estado tras última revisión. Se recogieron un total de 56 tumores malignos que se clasificaron en cuatro estadios clínicos usando la clasificación de la OMS (5-7). Todos los pacientes que fueron controlados durante al menos 4 años se incluyeron en un análisis de factores pronósticos. Nuestra serie presenta una incidencia de malignidad del 66,3 por ciento, siendo la lesión más frecuente el carcinoma adenoide quístico (CAQ). El análisis de los factores permitió relacionar el peor pronóstico con la edad avanzada, los estadios III y IV, la presencia de metástasis en el diagnóstico y la invasión de márgenes (AU)

Fibrosis del músculo temporal tras la inyección de un agente esclerosante: a proposito de un caso / Fibrosis of the temporal muscle after injection of a sclerosant: report of a case

La miositis osificante localizada es una enfermedad reactiva; normalmente secundaria a traumatismos, que pueden ser únicos e importantes o inapreciables pero repetitivos. De la misma manera, las extracciones dentales pueden originar ya sea de manera directa o indirecta la miositis osificante localizada. Se presenta un caso de fibrosis y cicatrización del músculo temporal tras la inyección de un agente esclerosante de características desconocidas, simulando una miositis osificante localizada (MOL) del músculo temporal con anquilosis extraarticular de la articulación temporomandibular. Clínicamente, la paciente presentaba un trismo importante, con una apertura bucal de 10 mm. Para el diagnóstico se requirió una ortopantomografía, una radiografía de Waters y una tomografía computarizada, aportando el diagnóstico definitivo el estudio anatomopatológico de la pieza quirúrgica. Se intervino al paciente bajo anestesia general, realizándose la extirpación total del músculo temporal izquierdo junto con una coronoidectomía izquierda, y se utilizó un colgajo de mejilla para la reconstrucción del defecto. Durante los controles postoperatorios se objetivó una progresiva disminución del trismo, presentando en la actualidad una apertura interincisal de 35 mm (AU)

Preoperative induction chemotherapy followed by concurrent chemoradiotherapy in advanced carcinoma of the oral cavity and oropharynx.

BACKGROUND: Combined modality therapy plays a central role in the management of advanced head and neck tumors. The objective of our Phase II study was to determine the feasibility, toxicity, and clinical and pathologic response of preoperative induction chemotherapy, followed by concurrent chemoradiotherapy in patients with Stage III or IV squamous cell carcinoma according to the American Joint Committee on Cancer Staging of the oral cavity and oropharynx with no distant metastases. METHODS: After staging, 62 patients with locally advanced carcinoma of the oral cavity and oropharynx were treated preoperatively with chemotherapy (1 cycle of cisplatin and 5-fluorouracil [P-5FU]) followed by concurrent chemoradiotherapy (3 cycles of P-5FU combined with radiotherapy, 60 grays [Gy] given in 33 fractions of 1.8 Gy). After evaluation, patients underwent surgery either as a diagnostic (biopsy) or therapeutic procedure (resection of the primary tumor and/or the neck). Surgery was performed with the intent to spare organ function. RESULTS: Grade 3-4 mucositis was observed in 37 patients (59%). Overall clinical response was obtained in 87%, and the complete clinical response rate was 50%. Surgery was performed in 53 patients, 50 at the primary tumor site (11 biopsies, 14 marginal excisions, and 25 wide excision) and 46 patients had neck dissection. Pathologic complete remission was observed in 29 patients (46%). After a median follow-up of 39 months, locoregional control rate was 76%, estimated 3-year disease free survival rate was 73% (+/- 4%), and estimated 3-year overall survival rate was 76% (+/- 4%). CONCLUSIONS: This intensive multimodality treatment is feasible, and toxicity is significant but tolerable. The treatment results appear promising and durable. Organ-preserving surgery can be performed in many patients.

Adenopatías cervicales en Oncología. Clínica, diagnóstico y tratamiento / Cervical adenopathies in Oncology. Clinical presentation, diagnosis and treatment

Las adenopatías cervicales representan el síntoma de aparición del 12 por ciento de los tumores de cabeza y cuello. Ante una tumoración cervical se ha de establecer el diagnóstico diferencial entre tres etiologías: congénita, infecciosa y neoplásica. El diagnóstico de sospecha se debe confirmar mediante la realización de una punción aspiración con aguja fina (PAAF), que nos proporcionará el diagnóstico histológico en más del noventa por ciento de los casos. La correspondencia entre la localización de la adenopatía y sus territorios de drenaje linfático indica la localización probable del tumor primario. La localización del tumor primario, la estadificación, la histología, el grado de aneuploidía y el estado inmunológico del enfermo se han citado como factores que predisponen al tumor primario a metastatizar. La metástasis de origen desconocido constituyen el 5 por ciento de las adenopatías metastásicas, y su diagnóstico precisará la realización de biopsias aleatorias en las regiones donde las neoplasias de localización submucosa metastatizan de forma temprana. La localización, la histología, la estadificación y la aparición del tumor primario se han citado como factores pronósticos en esta entidad (AU)

Preoperative simultaneous chemoradiotherapy in locally advanced cancer of the oral cavity and oropharynx.

Combined chemoradiotherapy (CT/RT) treatments appear to yield better results for advanced tumours of the head and neck than do conventional therapies. In the present study, CT/RT was used preoperatively in unresectable tumors of the oral cavity and oropharynx. Forty patients were entered prospectively into a phase II study. Treatment consisted of three cycles of chemotherapy with cisplatin and 5-day infusion of fluorouracil (FU), and the addition of simultaneous radiotherapy (30 Gy) from the second to third cycles. Patients with resectable residual disease or complete clinical response underwent surgery. All patients later received a second phase of irradiation (30 Gy) and two cycles of chemotherapy only in responders. During the first phase of treatment, 22 (55%) patients presented mucositis grades III-IV. Mean weight loss was 7%. Twelve patients were admitted for parenteral nutrition. Thirty-six (90%) patients obtained clinical response, which was complete in 15 (37%). Thirty-two of the 40 underwent surgery. The percentage of pathologic complete responses (PCR) was 35% (14 patients). With a median follow-up of 21 months, the median survival of patients was 23 months, and 19 (47%) of them are disease-free. A high PCR rate was attained with this treatment regimen. Toxicity was significant, but tolerable with adequate support measures.

Management of the nasal tip by open rhinoplasty.

Open rhinoplasty has acquired widespread recognition in the surgical community in recent years. For many years, traditional closed rhinoplasty was the only possibility for correction of most deformities of the nose. Although it is not the only alternative to difficult nasal problems, the wide exposure achieved with the open technique, the excellent results obtained in the management of the tip and its use as a training procedure for residents, accounts for the new resurgence of the popularity of the technique.

Angiolymphoid hyperplasia with eosinophilia affecting the oral mucosa: report of a case and a review of the literature.

Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon disorder of unknown aetiology. Clinically, it is characterized by cutaneous papules or nodules on the head and neck, and extracutaneous involvement is rare. We report a 30-year-old woman who had an asymptomatic submucosal nodule on the upper lip, which histopathologically showed features of ALHE, and review the previously described 15 cases of oral ALHE.

An unusual case of intraparotid foreign body.

Foreign bodies in salivary glands are an unusual event; foreign bodies simulating parotid tumors are an exceptional finding. A posttraumatic case of intraparotid foreign body and a brief literature review are presented.