Odontogenic rhinosinusitis and sinonasal complications of dental disease or treatment: prospective validation of a classification and treatment protocol

Purpose

Odontogenic sinusitis and sinonasal complications of dental disease or treatment (SCDDT) represent a heterogeneous group of conditions that often require multidisciplinary care. The present study aims to prospectively validate a classification and treatment protocol for SCDDT patients.

Methods

One hundred twenty-eight consecutive patients (73 females and 45 males, mean age 52.4 years) affected by SCDDT not responding to dental and medical therapy were classified and surgically treated according to the proposed protocol. The protocol classified patients into three aetiology-based groups (preimplantologic, implantologic, and related to traditional dental diseases and procedures, respectively). The groups were further divided into classes according to the presence of oro-antral communications and/or dislocated dental hardware. Each condition was treated according to the class-related, protocol-defined treatment, by either a transnasal or combined transnasal/transoral approach. All patients were successfully classified according to our protocol. None of the proposed classes were redundant, and no condition fell outside the definitions.

Results

The surgical treatment protocol proved to be adequate and effective, in that 125 of the 128 patients completely recovered after surgical treatment.

Conclusions

The term SCDDT and the consequent classification proposed by the authors appear, therefore, to be nosologically correct. Furthermore, the protocol-related proposed treatment appears to be clinically sound, with a success rate nearing 98%.

Use of the masseteric nerve to treat segmental midface paresis

Segmental midface paresis with or without synkinesis reflects incomplete recovery from Bell's palsy, operations on the cranial base or parotid, or trauma, in 25%-30% of cases. To correct the deficit, the masseteric nerve was used to deliver a powerful stimulus to the zygomatic muscle complex, with the addition of a cross-face sural nerve graft to ensure more spontaneous smiling. By doing this, the orbicularis oculi muscle continues to have an appropriate stimulus from the facial nerve, and the zygomatic muscle complex is separately innervated, which considerably reduces synkinesis between the two muscle compartments. For those patients with muscular contractures of the midface, the new healthy neural stimulus relaxes muscles at rest. From January 2011 to March 2017, 20 patients presented with segmental facial paresis of the midface and were operated on using this new technique. All patients were evaluated before and after operation using Clinician-Graded Electronic Facial Paralysis Assessment (eFACE), and they showed considerable postoperative improvements in static, dynamic, and synkinetic variables. Our proposed use of the masseteric nerve to treat segmental facial paresis produces favourable results, but our initial data require confirmation by further studies.

Mixed facial reanimation technique to treat paralysis in medium-term cases

Recent facial paralyses, in which fibrillations of the mimetic muscles are still detectable by electromyography (EMG), allow facial reanimation based on giving new neural stimuli to musculature. However, if more time has elapsed, mimetic muscles can undergo irreversible atrophy, and providing a new neural stimulus is simply not effective. In these cases function is provided by transferring free flaps into the face or transposing masticatory muscles to reinstitute major movements, such as eyelid closure and smiling. In a small number of cases, patients affected by paralysis are referred late - more than 18 months after onset. In these cases, reinnervating the musculature carries a high risk of failure because some or all of the mimetic muscles may atrophy irreversibly while axonal ingrowth is taking place. A mixed reanimation technique to address this involves a neurorrhaphy between the masseteric nerve and a facial nerve branch for the orbicularis oculi, to ensure a stronger innervation to that muscle, associated with the transposition of the temporalis muscle to the nasiolabial sulcus. This gives good symmetry in the rest of the midface, while smiling movement is achievable, but not guaranteed. This one-time facial reanimation is particularly indicated for those who refuse major free-flap surgery or when that may be risky, as in previously operated and irradiated fields. More extensive procedures based on utilizing a free flap to recover smiling, while adding a cross-face nerve graft to restore blinking, may be proposed for motivated patients. Between 2010 and 2015, five patients affected by complete unilateral facial palsy underwent this technique in the Maxillofacial Surgery Department, San Paolo Hospital (Milan, Italy). Symmetry of the middle-third of the face at rest and recovery of smiling was quite good. Complete voluntary eyelid closure was obtained in all cases. Combining temporalis flap rotation and a masseteric-to-orbicularis-oculi-facial-nerve branch neurorrhaphy seems to be a valid solution for those medium-term referred patients.

Three-dimensional superimposition for patients with facial palsy: an innovative method for assessing the success of facial reanimation procedures

Facial palsy is a severe condition that may be ameliorated by facial reanimation, but there is no consensus about how to judge its success. In this study we aimed to test a new method for assessing facial movements based on 3-dimensional analysis of the facial surfaces. Eleven patients aged between 42 and 77 years who had recently been affected by facial palsy (onset between 6 and 18 months) were treated by an operation based on triple innervation: the masseteric to temporofacial nerve branch, 30% of the hypoglossal fibres to the cervicofacial nerve branch, and the contralateral facial nerve through two cross-face sural nerve grafts. Each patient had five stereophotogrammetric scans: at rest, smiling on the healthy side (facial stimulus), biting (masseteric stimulus), moving the tongue (hypoglossal stimulus), and corner-of-the-mouth smile (Mona Lisa). Each scan was superimposed onto the facial model of the "rest" position, and the point-to-point root mean square (RMS) value was automatically calculated on both the paralysed and the healthy side, together with an index of asymmetry. One-way and two-way ANOVA tests, respectively, were applied to verify the significance of possible differences in the RMS and asymmetry index according to the type of stimulus (p=0.0329) and side (p<0.0001). RMS differed significantly according to side between the facial stimulus and the masseteric one on the paralysed side (p=0.0316). Facial stimulus evoked the most asymmetrical movement, whereas the masseteric produced the most symmetrical expression. The method can be used for assessing facial movements after facial reanimation.

Surgical treatment of painful inferior alveolar nerve injuries following endodontic treatment: a consecutive case series of seven patients

PURPOSE

Injuries of the inferior alveolar nerve (IAN) related to endodontic treatment are being increasingly reported. However, consensus on the preferred intervention and the timing of and indications for surgical treatment is lacking. Here, we describe our experience with painful IAN injuries arising from endodontic treatment and requiring prompt microsurgical treatment.

METHODS

Seven consecutive patients with painful IAN injuries were referred to the Maxillofacial Surgery Unit of San Paolo Hospital in Milan. All patients had undergone root canals endodontic treatment in the mandibular molar or premolar between 2007 and 2014. The time elapsed between injury and referral for surgical treatment ranged from 10 days to 20 months. Each patient was treated by one of several different microsurgical procedures, described herein.

RESULTS

Overall, neurosensory status and IAN-related pain improved in all seven patients. The best results were obtained by IAN replacement with a sural nerve graft. However, complete sensory recovery was not achieved in any of the patients.

CONCLUSIONS

Although our sample includes only seven patients, early surgical treatment with an interpositional sural nerve graft seems to allow neurosensory recovery. Less satisfactory results are achieved in patients with IAN injuries of > 12 months duration.

Surgical treatment of synkinesis between smiling and eyelid closure

Synkinetic movements are common among patients with incomplete recovery from facial palsy, with reported rates ranging from 9.1% to almost 100%. The authors propose the separation of the neural stimulus of the orbicularis oculi from that of the zygomatic muscular complex to treat eyelid closure/smiling synkinesis. This technique, associated with an anastomosis between the masseteric nerve and a central branch of the facial nerve, as well as with the use of a cross-facial nerve graft, resolves most of the spasms of the midface musculature, leading to a more relaxed tone when the mimic muscle is at rest and enhancing muscle excursion during voluntary and spontaneous smiling. Between 2011 and 2016, 18 patients affected by segmental paresis of the middle of the face underwent surgical treatment at the Maxillofacial Surgery Department of the San Paolo Hospital (Milan, Italy). Of these patients, 72.22% of cases with hypertone obtained partial to complete relaxation. Synkinesis was completely resolved in 83.33% of cases, and a significant improvement in facial movement was achieved in all patients. Neurorrhaphy of the masseteric nerve and the central branch of the facial nerve appears to produce favorable results. These initial data should be confirmed by further studies.

Cross-tongue procedure: a new treatment for long-standing numbness of the tongue

The lingual nerve may be injured during oral procedures, usually during extraction of lower third molars. Patients often complain of numbness of the hemitongue postoperatively. If this persists for 3 months or more, microsurgical exploration and reconstruction of the lingual nerve is required, and better outcomes are achieved after early repair. After 18-24 months the production of axoplasmic fluid through the axons of the proximal stump is reduced, and neurorrhaphy between the proximal and distal stumps is not recommended. In such cases we suggest that a portion of the opposite lingual nerve should be used as an additional nerve source.

Two typical cases of pseudoankylosis of the jaw: same treatment, different outcome

Pseudoankylosis of the temporomandibular joint is a rare, extra-articular form of ankylosis of the jaw. It is characterised by limited mandibular movement caused by an extrinsic condition of the joint leading to fusion between the coronoid process and temporal, zygomatic or maxillary bone. Pseudoankylosis is less frequent than the intracapsular form. Extracapsular ankylosis can be congenital or acquired; approximately 70% of cases are associated with trauma. A CT scan is usually requested to achieve a diagnosis. CT can detect bony fusion, thus differentiating pseudoankylosis from true ankylosis. Once symptomatic bone ankylosis is diagnosed, surgery with postoperative physiotherapy is the recommended treatment. The ankylotic bone is removed together with the coronoid process and the mouth is forced open under general anaesthesia. Two cases of post-traumatic pseudoankylosis of the jaw treated with bilateral coronoidectomy and postoperative physiotherapy are described.

Double-bellied latissimus dorsi free flap to correct full dental smile palsy

A 45-year-old woman with left facial palsy presented to our department. She developed the condition after radical resection of a neurinoma of the homolateral VIII cranial nerve 2 years prior. On physical examination, a complete palsy of the lower third of the face was reported. Electromyographic examination showed no fibrillation potentials in mimic muscles. A latissimus dorsi muscle free flap (6 cm × 3 cm), split into two bellies linked by their own neurovascular pedicle, was used to restore full-mouth smile. Ten years after surgery, the patient showed a near-natural smile without need of any ancillary procedure.

Squamous carcinoma arising in a parotid Warthin's tumour

Warthin's tumour is the second most common benign neoplasm to affect the salivary glands. It virtually affects the sole parotid gland. A sudden increase in a tumour's size is usually due to a malignant transformation of the tumour. The transformation of the lymphoid stroma into malignant lymphoma is relatively common, while an epithelial malignancy is extremely rare. In this paper, the authors present a case of squamous cell carcinoma arising in Warthin's tumour. The patient underwent enucleoresection of the tumour. Intraoperative frozen section revealed the presence of a cystic component associated with the squamous cell carcinoma areas. In consideration of the result of the intraoperative consultation, the surgeons decided to enlarge the previous resection by removal of a 30×25 mm cuff from the surrounding parotid tissue. Close follow-up was carried out and 12 months after surgery there was no evidence of recurrence or metastatic neoplasm.

Paradoxical embolism following intralesional sclerotherapy for cervical venous malformation

We present a rare case of a 47-year-old woman admitted to our maxillofacial surgery department for a large cervicofacial venous malformation. The patient underwent fluoroscopy-guided intralesional foam sclerotherapy with sodium tetradecyl sulfate and air under general anaesthesia. On awakening, after 48 h of endotracheal intubation, she displayed dysarthria and dysmetria. Her brain CT scan showed no haemorrhagic lesions. A chest CT scan ruled out a potential pulmonary embolism. Suspicion for a paradoxical embolism was high and echocardiography confirmed a patent foramen ovale, which acted as a passageway for the embolus. Transcranial ultrasound showed mild right-to-left heart shunting. The dysarthria and dysmetria disappeared gradually over 48 h, thus confirming a reversible ischaemic neurological deficit. A brain MRI performed 1 week later showed no ischaemic or haemorrhagic lesions. The patient recovered completely. She was advised cardiosurgical follow-up and discharged.

Technical refinements in mandibular reconstruction with free fibula flaps: outcome-oriented retrospective review of 99 cases

Congenital disease, major trauma, tumour resection and biphosphonate-related osteonecrosis can lead to partial, subtotal, or total loss of the mandibular bone. Minor defects can be easily reconstructed using bone grafts, whereas microvascular free tissue transfer may be unavoidable in the case of major bone loss or poor quality of soft tissue. Simple bone or composite osteocutaneous fibula free flaps have proven invaluable and remain the workhorse for microvascular mandibular reconstruction in daily practice. Our experience with 99 consecutive fibular free flaps confirms the available data in terms of high success rate. In these cases, 90% had total success, while 7 had complete flap failures. Three of our patients showed skin paddle necrosis with bony conservation. This report focuses on the technical refinements used by the authors that can prove valuable in obtaining predictable and precise results: in particular, we discuss surgical techniques that avoid vascular pedicle ossification by removing the fibular periosteum from the vascular pedicle itself and reduce donor site morbidity and aid in management of the position in the new condylar fossa. Finally, new technologies such as intraoperative CT and custom premodelled fixation plates may also increase the predictability of morpho-functional results.

Eyelid reanimation, neurotisation, and transplantation of the cornea in a patient with facial palsy

Patients affected by facial palsy suffer from failure to fully close the eyelids; the resulting eye exposure can lead to dry eye syndrome, loss of epithelial integrity, corneal ulceration and infections. Corneal anaesthesia exacerbates risk of corneal damage in these patients. Eyelid paralysis-associated corneal lesions may induce severe visual impairment, for which the ideal treatment is corneal transplantation, a procedure contraindicated in patients with corneal sensitivity and inadequate eyelid closure. We present the case of a patient affected by unilateral facial palsy associated with corneal anaesthesia, due to seventh and fifth cranial nerve damage following homolateral eighth cranial nerve surgery. The patient underwent surgery to re-establish eyelid and corneal competence, and then received a corneal graft with consequent amelioration of visual acuity. This is the first case of associated corneal anaesthesia and facial palsy that was comprehensively treated with a set of surgical procedures, including a corneal transplant.

Mesenchymal phosphaturic tumour: early detection of recurrence

The case of a recurrent phosphaturic mesenchymal tumour of the maxillary sinus 10 years after the first surgical excision is reported. The neoplasm first presented with paraneoplastic osteomalacia causing a pathological femur fracture. A right maxillary sinus tumour was identified and treated thereafter. The patient had no local symptoms and serum electrolytes returned to normal after surgical removal of the tumour. However, 10 years later, the patient's urine Ca and P levels increased and an octreoscan detected a new tumour in the right maxillary sinus. Early diagnosis prevented the effects of the paraneoplastic activity of the neoplasm. This case emphasises the importance of specific, close follow-up, because the neoplasm rarely produces local signs indicating its position. To our knowledge, this is the first reported case of a late relapse presenting without relevant symptoms (local pain or swelling or pathological fractures).

Lipofilling of the atrophied lip in facial palsy patients

AIM

Patients affected by unilateral facial palsy often show partial or complete atrophy of the orbicularis oris. The lower hemilip on the affected side may have partial functional recover due to direct reinnervation stemming from the unaffected side. This explains why atrophy of the paralysed side is sometimes limited. Negative esthetic and functional findings include partial invisibility of the vermillion border due to lip inversion resulting from muscle flaccidity, asymmetry of the lower lip, oral incompetence, and speech and nutrition impairments of variable degree. In this study, we used Coleman lipofilling as a secondary and ancillary procedure to consolidate the results already obtained with dynamic reanimation, specifically aiming to reduce the volumetric loss due to atrophy of the orbicularis oris muscle.

METHODS

Eight patients underwent lipofilling to restore volumetric loss due to muscular denervation atrophy. Six of our patients were affected by inveterate facial palsy and one by an acute form of facial palsy. The last patient presented with high-grade bilateral upper lip atrophy due to Moebius syndrome. Two patients underwent a second lipofilling intervention.

RESULTS

The esthetic volume increase and the ameliorated lip competence were immediately noticeable after the first lipofilling, to great patient satisfaction. As a result of the variable rate of resorption over time of the grafted fat, it may be advisable to repeat the procedure in some patients to maximize results.

CONCLUSION

Lipofilling represents a useful and safe ancillary technique for camouflage of lower lip atrophy in paralysed patients.