Axillary lymph node metastasis in second oropharyngeal cancer.

BACKGROUND: The risk of metastasizing in axillary lymph node is occasional in the head and neck cancers. This pattern of spread is difficult to explain and totally unpredictable even for these lymphophilic cancers. OBSERVATION: A 72-year-old patient benefited, 11 years ago, of surgical oncology care associated with adjuvant radiotherapy for squamous cell carcinoma of the left floor of the mouth (pT4 pN2b M0). He presented a second primary malignancy at the right oropharyngeal level. Pet CT revealed a right infraclinic axillary metastasis. The metastatic origin was confirmed by pathological analysis. DISCUSSION: The current management of head and neck cancers is based on the histological pattern of infiltration, the size of the primary tumor and the pattern of metastasizing lymph nodes and potential distant spreading. Current tests allow us to diagnose most distant metastases even outside the usual area of lymphatic drainage. Involvement of axillary lymph node, probably through retrograde lymphatic spreading is not so rare in recurrences of oropharyngeal cancer (T3-T4, N2…) as we have observed in the literature. In this review, we raise some degree of similarity between such oncological progression and factors related to this aberrant spreading.

Anthropometric and aesthetic outcomes for the nasolabial region in 101 consecutive African children with unilateral cleft lip one year after repair using the anatomical subunit approximation technique.

One hundred and one patients with complete or incomplete cleft lip underwent the anatomical subunit approximation technique for repair. The patients were followed up prospectively for 1year. The objective of this study was to determine the outcomes for the nasolabial area through anthropometric measurements and assessment of the Asher-McDade Aesthetic Index and Steffensen's criteria at 1year after surgery. Six assessors (three cleft surgeons and three non-surgeon medical professionals) examined cropped images; reliability was assessed using Cronbach's alpha. The difference in lip length between the healthy and operated sides was 0.61mm and the difference in nostril diameter was 0.37mm (differences not significant). The average scar width was 2.78±1.35mm. Hypertrophic scars were observed in 9.9% of cases. The average Asher-McDade Aesthetic Index rating varied between 1.35 and 1.98 for all parameters. Cronbach's alpha coefficient was 0.83, 0.89, 0.98, and 0.89 for nasal form, nasal symmetry, vermilion border, and nasolabial profile, respectively. Steffensen's criteria rated appearance as 'good' in 69.3% to 91.1% of cases. The anatomical subunit approximation technique can be performed in Sub-Saharan Africans for all types of unilateral cleft lip. It significantly improves the length of the medial and lateral lips, leaving an acceptable scar. A study with a larger sample size and longer follow-up is warranted.

Reproducibility of three-dimensional posterior cranial base angles using low-dose computed tomography.

OBJECTIVES: One of the key aspects of three-dimensional (3D) craniofacial cephalometry is the measurement of posterior cranial base angle as this area is deeply involved in craniofacial development. The purpose of our retrospective study was to define the best reproducible 3D posterior cranial base angles among five 3D angles transposed from 2D cephalometry (Cousin, BL1 of Ross and Ravosa, Bjork, Delaire, CBA4 of Liberman) and seven 3D angles based on physical anthropology studies and on new concepts (R1 to R7). The null hypothesis was that all 3D posterior cranial base angles were equally reproducible. MATERIAL AND METHODS: We used a preoperative low-dose computed tomography (CT) data from 20 adult patients undergoing orthognathic surgery after approval by local ethical committee. Two independent observers performed two series of 23 3D landmark identifications on 3D CT surface rendering of each patient using Maxilim software. Then, the same observers performed twice 3D cephalometric analyses (23 landmarks, 4 midpoints, 19 planes) that provided the automatic measurement of 12 posterior cranial base angles. RESULTS: Inter-observer correlation coefficient varied from 0.545 (Cousin) to 0.695 (CBA4 of Liberman) and from -0.177 (R2) to 0.827 (R4). CONCLUSIONS: The null hypothesis was rejected. The most reproducible angle was 3D angle R4 based on "basion," "superior optic" (right, left), and "crista galli inferior" landmarks. CLINICAL RELEVANCE: R4 angle might be used as reference 3D posterior cranial base angle in further clinical studies involving 3D cephalometry as a diagnostic tool for orthodontics and for orthognathic surgery.

[Etiologic diagnosis of jaw osteonecrosis, other than bisphosphonate and radiotherapy related osteitis]. / Diagnostic étiologique des ostéonécroses maxillomandibulaires, ostéites à bisphosphonates et ostéoradionécroses exceptées.

Our purpose was to highlight the various etiologies of maxillo-mandibular osteonecrosis, other than radiotherapy and biphosphonate related osteitis that have been abundantly reported. We performed a PubMed search from August 1, 1972 to August 1, 2012 using the following MeSH terms: "osteonecrosis", "bone", "necrosis", "jaw", "maxilla", "mandible", "palate", "oral", "avascular necrosis", NOT "bisphosphonate" NOT "osteoradionecrosis". Most cases of osteonecrosis were iatrogenic. Viral, mycotic, or bacterial infections were less frequent causes. Cocaine abuse, Wegener's granulomatosis, and N/K lymphoma were other etiologies. It is important to identify the various etiologies rapidly to manage this sometimes very mutilating condition adequately.

Etiologic diagnosis of jaw osteonecrosis, other than bisphosphonate and radiotherapy related osteonecrosis.

Our purpose was to highlight the various etiologies of maxillo-mandibular osteonecrosis, other than radiotherapy and biphosphonate related osteitis that have been abundantly reported. We performed a PubMed search from August 1, 1972 to August 1, 2012 using the following MeSH terms: "osteonecrosis", "bone", "necrosis", "jaw", "maxilla", "mandible", "palate", "oral", "avascular necrosis", NOT "bisphosphonate" NOT "osteoradionecrosis". Most cases of osteonecrosis were iatrogenic. Viral, mycotic, or bacterial infections were less frequent causes. Cocaine abuse, Wegener's granulomatosis, and N/K lymphoma were other etiologies. It is important to identify the various etiologies rapidly to manage this sometimes very mutilating condition adequately.

Cortical activation resulting from the stimulation of periodontal mechanoreceptors measured by functional magnetic resonance imaging (fMRI).

OBJECTIVE: To describe the normal cortical projections of periodontal mechanoreceptors. MATERIAL AND METHODS: A device using von Frey filaments delivered 1-Hz punctate tactile stimuli to the teeth during fMRI. In a block design paradigm, tooth (T) 11 and T13 were stimulated in ten volunteers and T21 and T23 in ten other subjects. Random-effect group analyses were performed for each tooth, and differences between teeth were examined using ANOVA. RESULTS: The parietal operculum (S2) was activated bilaterally for all teeth; the postcentral gyrus (S1) was activated bilaterally for T21 and T23 and contralaterally for T11 and T13. In the second-level analysis including the four teeth, we found five clusters: bilateral S1 and S2, and left inferior frontal gyrus, with no difference between teeth in somatosensory areas. However, the ANOVA performed on the S1 clusters found separately in each tooth showed that S1 activation was more contralateral for the canines. CONCLUSION: One-hertz mechanical stimulation activates periodontal mechanoreceptors and elicits bilateral cortical activity in S1 and S2, with a double representation in S2, namely in OP1 and OP4. CLINICAL RELEVANCE: The cortical somatotopy of periodontal mechanoreceptors is poorly described. These findings may serve as normal reference to further explore the cortical plasticity induced by periodontal or neurological diseases.

Tumour response and safety of cetuximab in a window pre-operative study in patients with squamous cell carcinoma of the head and neck.

BACKGROUND: To investigate the safety and activity of cetuximab in the pre-operative treatment of squamous cell carcinoma of the head and neck (SCCHN). PATIENTS AND METHODS: Cetuximab was administered for 2 weeks before surgery to 33 treatment-naïve patients selected for primary surgical treatment. Tumour biopsies, 2-[fluorine-18]-fluoro-2-deoxy-d-glucose positron emission tomography ((18)FDG-PET) and imaging were carried out at baseline and before surgery. The primary aim of the study was safety and the secondary aims included metabolical, radiological and pathological tumour response. Five untreated patients were included as controls. RESULTS: Cetuximab given 24 h before surgery was safe. Ninety percent of patients had (18)FDG-PET partial response (EORTC guideline) in the cetuximab group versus 0% in the control group. Delta maximal standardized uptake values (ΔSUVmax) were correlated with tumour cellularity on the surgical specimens (P < 0.0001). For patients with ΔSUVmax less than -25% or less than -50%, Ki67 was significantly decreased by cetuximab (P = 0.01 and 0.003). Cetuximab induced down-regulation of pEGFR (P = 0.0004) and pERK (P = 0.003). CONCLUSIONS: Short-course pre-operative administration of cetuximab is safe and shows a high rate of (18)FDG-PET response. (18)FDG-PET response was correlated with residual tumour cellularity suggesting that (18)FDG-PET deserves further investigation as a potential early marker of cetuximab activity in SCCHN.

Aerosol delivery to the lung is more efficient using an extension with a standard jet nebulizer than an open-vent jet nebulizer.

BACKGROUND: Open-vent jet nebulizers are frequently used to promote drug deposition in the lung, but their clinical efficacy and indications are not clear. Our study compared lung deposition of amikacin using two different configurations of a jet nebulizer (Sidestream(®)): one vented (N1) and one unvented with a corrugated piece of tubing (N2). METHODS: In vitro nebulizer performance was assessed by laser diffraction and filtering. Lung delivery was evaluated by scintigraphy in baboons as a child model, and by amikacin urinary drug concentration in seven healthy spontaneously breathing volunteers. Subjects were randomly assigned to the two nebulizer systems (N1 and N2). RESULTS AND CONCLUSIONS: In vitro results showed a higher efficiency of N2 than N1 in terms of lung deposition prediction (95±3 mg vs. 70±0 mg; p<0.0001). Radioactivity deposition in the baboons' lungs was lower with N1 than with N2 (1.8% vs. 4.7% of nebulizer charge; p<0.05). The total daily amount of amikacin urinary excretion was lower with N1 than with N2 (29.5 mg vs. 40.1 mg; p<0.01). Conversely, in vivo drug output rate was higher with N1 than with N2 (3.1 mg/min vs. 2.2 mg/min; p<0.05). Using a corrugated piece of tubing with standard jet nebulizers delivers higher doses to the lungs than open-vent jet nebulizers. The open-vent jet nebulizer might be recommended for rapid administration of a lower dose to the lungs and the standard jet nebulizer with corrugated piece of tubing for a higher dose in the lungs.

Aerosol delivery through tracheostomy tubes: an in vitro study.

BACKGROUND: Our study investigated the influence of the cannula's inner diameter (ID) and of its removal on the expected respiratory dose of amikacin, using three different jet nebulizer configurations (Sidestream(®)): vented (N1), unvented with a piece of corrugated tubing attached to the expiratory limb of the T attachment (N2), and unvented alone (N3). METHODS: The jet nebulizer was filled with amikacin (500 mg/4 mL) and was attached to the tracheostomy tube. A lung model simulating spontaneous breathing was connected to the tracheostomy tube. A filter was connected between the nebulizer and the tracheostomy tube to measure the inhaled dose, and between the tracheostomy tube and the lung model to measure the respiratory dose. Different cannula IDs were tested (6.5, 8, 8.5, and 10 mm), and aerosol lost in the cannulas was determined. RESULTS AND CONCLUSIONS: Respiratory dose varied between 96±1 mg and 44±3 mg, with higher values observed with N2. The aerosol lost in the cannula was significant and represented up to 63% of the inhaled dose. There was a negative correlation between the cannula's ID and the aerosol lost in the cannula. After removal of the internal cannula, an increase in the respiratory dose of up to 31.3% was observed. We recommend removing the inner tracheostomy cannula to nebulize a larger amount of drug through a tracheostomy tube. Among the three jet nebulizer configurations studied, we recommend the unvented one with a piece of corrugated tubing attached to the expiratory limb of the T attachment.

Reproducibility of three-dimensional cephalometric landmarks in cone-beam and low-dose computed tomography.

OBJECTIVES: The purpose of this study is to compare the reproducibility of three-dimensional cephalometric landmarks on three-dimensional computed tomography (3D-CT) surface rendering using clinical protocols based on low-dose (35-mAs) spiral CT and cone-beam CT (I-CAT). The absorbed dose levels for radiosensitive organs in the maxillofacial region during exposure in both 3D-CT protocols were also assessed. MATERIALS AND METHODS: The study population consisted of ten human dry skulls examined with low-dose CT and cone-beam CT. Two independent observers identified 24 cephalometric anatomic landmarks at 13 sites on the 3D-CT surface renderings using both protocols, with each observer repeating the identification 1 month later. A total of 1,920 imaging measurements were performed. Thermoluminescent dosimeters were placed at six sites around the thyroid gland, the submandibular glands, and the eyes in an Alderson phantom to measure the absorbed dose levels. RESULTS: When comparing low-dose CT and cone-beam CT protocols, the cone-beam CT protocol proved to be significantly more reproducible for four of the 13 anatomical sites. There was no significant difference between the protocols for the other nine anatomical sites. Both low-dose and cone-beam CT protocols were equivalent in dose absorption to the eyes and submandibular glands. However, thyroid glands were more irradiated with low-dose CT. CONCLUSIONS: Cone-beam CT was more reproducible and procured less irradiation to the thyroid gland than low-dose CT. CLINICAL RELEVANCE: Cone-beam CT should be preferred over low-dose CT for developing three-dimensional bony cephalometric analyses.

Osteosarcomas of the mandible: multidisciplinary management of a rare tumor of the young adult a cooperative study of the GSF-GETO, Rare Cancer Network, GETTEC/REFCOR and SFCE.

BACKGROUND: Mandibular osteosarcomas (MOS) mostly affect young adults. Their treatment is extrapolated from that of extragnathic osteosarcomas. MATERIAL AND METHODS: A retrospective multicooperative group study was conducted to determine the impact of chemotherapy, adjuvant radiation therapy and surgery on outcomes and to identify prognostic factors. This ethical committee-approved study included a centralized review of histology slides and operative reports. RESULTS: Of 111 patients, 58.6% were male, median age 35 years (13%, ≤18 years). Histology was osteoblastic, chondroblastic, fibroblastic, conventional not otherwise specified and others in 39.6%, 30.6%, 8.1%, 12.6% and 8.0%, respectively. Pathological World Health Organisation grades were low, intermediate and high grade in 6.4%, 11.8% and 81.8%, respectively. Surgery was carried out for 94.5% of patients. Neoadjuvant chemotherapy (mixed protocols) was carried out in 93.1% of patients. Postoperative chemotherapy and radiotherapy were carried out in 54.7% and 23.8%, respectively. Median follow-up was 59.6 months (range). Five-year local control, metastasis-free, disease-free and overall survival rates were 64.6%, 68.9%, 53.2% and 69.2%, respectively. Survival was significantly associated with age, tumor size and surgery. Wide surgery with clear margins and free flap reconstruction was the strongest prognostic factor. Neoadjuvant chemotherapy improved disease-free and metastatic-free survival and increased clear margins rates from 50% to 68%. Intermediate grades behaved like high grades in terms of metastatic-free and disease-free survival. CONCLUSION: This homogeneous series is the largest to date and emphasizes the major impact of clear margins and multidisciplinary management. Neoadjuvant chemotherapy improves disease-free survival and should be recommended for both high and intermediate grade MOS.

Intraparotid facial nerve schwannoma: case report and literature review.

A 68-year-old female presented with a right parotid mass and partial frontal peripheral facial nerve palsy. Pre-operatively, the mass was thought to be benign. Surgical intervention consisted of parotidectomy with sacrifice of the facial nerve due to the nerve's involvement in the tumoural process and its intrapetrosal course. Immediate nerve reconstruction was performed by an interposition graft of the great auricular nerve. Pathological examination revealed a schwannoma of the facial nerve. Review of the literature on this rare parotid gland tumour is reported.

Isolated marginal facial nerve paresis after TMJ discopexy: a case report.

Isolated marginal facial nerve paresis after TMJ discopexy: a case report. This is the first report of a transient, isolated marginal facial nerve paresis after temporomandibular joint arthrotomy. The paresis seems to have resulted from a crush lesion by Backhaus forceps, placed transcutaneously during the operation to distract the intra-articular space.

[Screening and diagnosis of precancerous oral mucosa lesions]. / Dépistage et diagnostic des lésions précancéreuses de la muqueuse orale.

The screening and early diagnosis of cancerous oral mucosa lesions are still key elements for a better prognosis. Therefore, it is of tremendous importance to try to determine how and when to diagnose precancerous oral mucosa lesions. Usually, clinical examination data must be completed by a pathological examination. This study, based on an exhaustive literature review, has for purpose to determine the sensitivity and specificity of complementary diagnostic tools currently available.

Innovative procedure for computer-assisted genioplasty: three-dimensional cephalometry, rapid-prototyping model and surgical splint.

The authors present a new procedure of computer-assisted genioplasty. They determined the anterior, posterior and inferior limits of the chin in relation to the skull and face with the newly developed and validated three-dimensional cephalometric planar analysis (ACRO 3D). Virtual planning of the osteotomy lines was carried out with Mimics (Materialize) software. The authors built a three-dimensional rapid-prototyping multi-position model of the chin area from a medical low-dose CT scan. The transfer of virtual information to the operating room consisted of two elements. First, the titanium plates on the 3D RP model were pre-bent. Second, a surgical guide for the transfer of the osteotomy lines and the positions of the screws to the operating room was manufactured. The authors present the first case of the use of this model on a patient. The postoperative results are promising, and the technique is fast and easy-to-use. More patients are needed for a definitive clinical validation of this procedure.

Assessment of changes in the oral tactile function of the soft tissues by implant placement in the anterior maxilla: a prospective study.

The aim of the present study was to assess the somatosensory function in the peri-implant soft tissues in the anterior jaw bone by means of two psychophysical tests. Light-touch sensation (LTS) and two-point discrimination (2PD) were performed before, and at planned intervals until 18 months after the placement of one or two implants in the anterior maxilla. The same tests were used on the contralateral control sites. The psychophysical threshold was determined by performing the staircase method. The mean values and standard deviation of LTS and 2PD, pooled over the four sessions at each test area, were calculated. Despite a large intersubject variation in both the LTS and 2PD, significantly high intra-individual correlations were found (P < 0.005). For LTS, the thresholds were not significantly affected over time (P > 0.05) on both implant and control sites. The 2PD increased significantly after surgery and maintained the higher discriminatory sense for 1 year (P-value 0.005). The control sites remained stable over time. However, no correlation was revealed between LTS and 2PD perception (Pearson correlation test). In this prospective study, no major differences between the different sites and testing sessions were reported; except for the 2PD thresholds which were lowered after implant surgery. These findings suggest that the regenerated nerves may be responsible for the increased 2PD sensitivity in the peri-implant soft tissue. The unchanged LTS thresholds did not allow confirming this hypothesis.

Three-dimensional appearance of the lips muscles with three-dimensional isotropic MRI: in vivo study.

INTRODUCTION: Our knowledge of facial muscles is based primarily on atlases and cadaveric studies. This study describes a non-invasive in vivo method (3D MRI) for segmenting and reconstructing facial muscles in a three-dimensional fashion. METHODS: Three-dimensional (3D), T1-weighted, 3 Tesla, isotropic MRI was applied to a subject. One observer performed semi-automatic segmentation using the Editor module from the 3D Slicer software (Harvard Medical School, Boston, MA, USA), version 3.2. RESULTS: We were able to successfully outline and three-dimensionally reconstruct the following facial muscles: pars labialis orbicularis oris, m. levatro labii superioris alaeque nasi, m. levator labii superioris, m. zygomaticus major and minor, m. depressor anguli oris, m. depressor labii inferioris, m. mentalis, m. buccinator, and m. orbicularis oculi. CONCLUSIONS: 3D reconstruction of the lip muscles should be taken into consideration in order to improve the accuracy and individualization of existing 3D facial soft tissue models. More studies are needed to further develop efficient methods for segmentation in this field.

Küttner's tumour: a case report.

Küttner's tumour (chronic sclerosing sialadenitis) is a chronic inflammatory disease of the salivary glands. It is a totally benign lesion. However, because of its clinical features, the clinical diagnosis is often that of a salivary gland neoplasm. We present a case of unilateral Küttner's tumour in the left submandibular salivary gland and discuss clinical, imaging and histological features.