Soft tissue morphology of the naso-maxillary complex following surgical correction of maxillary hypoplasia

Orthognathic surgery is undergone to improve facial and dental aesthetics and to improve function. Three dimensional (3D) soft tissue analysis based on stereophotogrammetry provides a realistic measurement of facial morphology. There is a need for objective assessment of surgery outcomes. The study aim was to evaluate the 3D naso-maxillary complex soft tissue morphology following Le Fort I maxillary advancement and compare the findings with a local reference group. 3D images of 112 volunteers were captured using stereophotogrammetry and viewed by 8 lay people; 40 images (16 males and 24 females) were chosen as the reference group to have harmonious facial appearance. The linear and angular measurements of this group were compared with 35 patients (19 female and 16 male) who had maxillary advancement in the post-surgical group. Facial morphology post-surgery was similar to the reference group, except the nasal base width which was wider by 2.3mm in males and 2.6mm in females. In the orthognathic group, the females had a smaller nasolabial angle by 9.7° than the reference group. In conclusion, 3D imaging is a sensitive tool for analysing facial appearance. Compared with a control group, statistical differences were identified in soft tissue morphology which should be considered in surgical planning and patient consent.

[Flexible bronchoscopy as it is lived by the patient]

INTRODUCTION

Flexible bronchoscopy is an indispensable complementary exam in respiratory medicine for both diagnosis of many pulmonary diseases and their treatment. Only a few studies in literature have been conducted to evaluate the safety and acceptability of this act.

PATIENTS AND METHODS

Prospective, mono-center, non-comparative study involving 120 patients who underwent a flexible bronchoscopy for diagnostic.

RESULTS

During the study, flexible bronchoscopy has caused neither deaths nor major complications. However, minor incidents have been deplored: hemoptysis (13.3%), epistaxis (3.3%), desaturation less than 90% (4.2%), laryngospasm (3.3%) and vagal discomfort (1.7%). 56.7% of patients were anxious before the exam and 24% of patients preferred to have general anesthesia. The patients reported cough in 78.3% of cases, difficulty in breathing in 55% of cases and pain in 13.3% of cases. The occurrence of nausea, noted in 15.8% of cases, was correlated with the pathway of the bronchoscope (P=0.002). At the end of the endoscopy, 67.5% of patients agreed to repeat the examination, if necessary, under the same conditions.

CONCLUSION

The results of our study confirm that many complications during a flexible bronchoscopy are rare and generally mild failing in life-threatening. However, the occurrence of discomfort (cough, pain, vomiting, dyspnea) or incidents (asphyxia, vagal discomfort, laryngeal spasm) are likely to alter patient comfort during the exam.

[Muscle metastasis revealing bronchial adenocarcinoma]

INTRODUCTION

The diagnosis of nonsmall cell lung cancer is made at a metastatic stage in 25% of cases. The most frequent sites are the lung, liver, bone, the adrenal glands and the central nervous system. Skeletal muscle metastases are uncommon and are rarely the first manifestation of a neoplastic process.

CASE REPORT

We report the case of 55 years old man presenting with a hard painless swelling of the left arm. A scan guided biopsy revealed infiltration of the muscle by a thyroid transcription factor 1 (TTF1) positive adenocarcinoma. A CT scan of the chest showed a partially necrotic tissue mass with moderate uptake of contrast. The patient was treated by chemotherapy with gemcitabine and carboplatine. The progress was unfavourable with the appearance of a second muscular metastasis in the thigh and the patient died 3 months after diagnosis.

CONCLUSION

Skeletal muscle metastases are rarely described in lung cancer and they are an exceptional presentation of the tumour. Their symptoms can be misleading and delay diagnosis.

[Intra-alveolar hemorrhage: rare presentation of fat pulmonary embolism]

INTRODUCTION

Fat embolism syndrome is a severe complication of long bone fractures, corresponding to the obstruction of small vessels by microdroplets of fat, originating from medulla ossium. Pulmonary involvement, present in 90% cases, makes the severity of the disease.

CASE REPORT

We report the case of a 22-year-old man who presented, two days after industrial accident causing an opened tibial fracture, acute dyspnea with hemoptysis. Angio-CT-scan didn't show any proximal vascular obstruction, but parenchymal sections showed diffuse, bilateral and multifocal hyperdensities predominating at the periphery. Broncho-alveolar lavage brought a hemorrhagic liquid, with a high macrophage content and lipid inclusions in macrophages. Exams for the etiologic diagnosis of intra-alveolar hemorrhage were negative: renal function, 24-hour proteinuria, antinuclear antibodies, antineutrophil cytoplasmic antibodies. The diagnosis of intra-alveolar hemorrhage secondary to fat embolism was established. The outcome was spontaneously favorable.

CONCLUSION

The occurrence of intra-alveolar hemorrhage in the course fat embolism is rarely reported. Its pathogenic mechanisms are not understood. It is mandatory to eliminate the other causes of alveolar hemorrhage before holding the diagnosis of fat embolism. Treatment is only symptomatic, based on respiratory reanimation.

[Pulmonary fibrosis as a presentation of Wegener's granulomatosis]

INTRODUCTION

Pulmonary fibrosis secondary to antineutrophil cytoplasmic antibodypositive vasculitis is rarely reported. Most cases have occurred in association with microscopic polyangiitis.

CASE REPORT

We report the case of an 82-year-old man presenting with pulmonary fibrosis. The CT scan showed honeycombing and traction bronchiectasis with peripheral and basal predominance. The diagnosis of Wegener's granulomatosis was based on the association of positive antineutrophil cytoplasmic antibodies, urinary sediment abnormalities and renal biopsy findings.

CONCLUSION

We emphasize, through this case, the rarity of interstitial fibrosis as a pulmonary manifestation of vasculitis and we discuss the pathogenesis of this association.

[A new case of pleural small cell carcinoma]

Small cell carcinoma (SCC) is commonly of pulmonary origin. Pleural small cell carcinoma is a very uncommon feature. We report here a case of small cell carcinoma of the pleura in a 36 year old man. The diagnosis of primary disease SCC of the pleura was established by transparietal pleural biopsy in absence of any mediastino-pulmonary or extrathoracic other lesions that could be the primary tumor. The treatment was based on chemotherapy with cisplatin and etoposide. The patient died four months in spite of cytotoxic chemotherapy. Extrapulmonary small cell carcinoma is a rare entity. Immunohistochemistry study is very useful for the diagnosis. The prognosis seems to be worse than the small cell lung cancer.

[Postpartum pericardic tamponade revealing systemic lupus erythematosus]

Pericarditis is the most common manifestation of systemic lupus erythematosus and is clinically found in 62% of the autopsies. Cardiac tamponade is a deadly but rare complication found in less than 1% of all lupus cases. It is highly revealing. The authors report the case of a 29-year old woman presenting postpartum cardiac tamponade. The diagnosis of systemic lupus erythematosus was based on the association of haematological disorders (anaemia and leukopenia), pericarditis, pleurisy and positive anti-nuclear and anti-native DNA antibodies. The patient was treated with pericardiac drainage and cortisone therapy. The evolution was favourable after 22 months. Using this case study, the authors note the rarity of cardiac tamponade as a manifestation inaugurating lupus and discuss the relationship between pregnancy and lupus disease.

[Primary pulmonary leiomyosarcoma revealed by spontaneous pneumothorax]

We report the case of a 57-year-old patient admitted for dyspnea and dry cough. Thoracic radiograph showed a right pneumothorax and right paracardiac opacity. Thoracic drainage was carried out allowing the return of the lung at the wall. Chest CT-scan revealed right upper mediastinopulmonary mass taking contrast material associated with a nodular thickening of the pleura. CT-guided biopsy of the mass and the pleural nodules concluded to pulmonary leiomyosarcoma. Death occurred one month after diagnosis confirmation. Pneumothorax is a usual mode of revealing sarcoma's pulmonary metastases; however, it is exceptionally associated with primitive pulmonary sarcomas. Our case is the second published case, to our knowledge, of primitive pulmonary leiomyosarcoma presenting with pneumothorax.

[A rare localization of solitary plasmocytoma]

INTRODUCTION

Solitary bone plasmocytoma is rare, characterized by malignant plasmocyte proliferation, derived from a sole B lymphocyte clone located on a bony segment without medullar invasion. It, above all, affects the thoracolumbar spine. Costal involvement is rarely described.

CASE REPORT

The authors report the case of a 60-year-old man who complained of dyspnea, dry cough, and thoracic pain four months before admission. Thoracic imaging revealed a left apical tissue mass with osteolysis of the first rib. A transparietal biopsy of the mass was not helpful. Surgical biopsy concluded as to the diagnosis of costal plasmocytoma. All of the examinations carried out to search for other localizations were negative confirming the solitary nature of the tumor. The treatment consisted of complementary radiotherapy at a dose of 45Gy. The patient was in remission after eight months.

CONCLUSION

Solitary costal plasmocytoma should be called to mind when confronted with a lytic tumor of the rib. The treatment is based on surgery and radiotherapy. The prognosis is dominated by the risk of progression to multiple myeloma.

[An anterior mediastinal mass of rare etiology]

Hydatid cyst of the mediastinum is very uncommon. The diagnosis, usually evident in endemic regions in the case of a typical clinical-radiological presentation, is rather more difficult in certain atypical forms. We report a case of a 19-year-old man who presented with a mass of tumour like appearance in the anterior mediastinum. The diagnosis of mediastinal hydatid cyst was established by transthoracic needle biopsy and endoscopic bronchial aspiration revealed hydatid membranous debris. The diagnosis was confirmed when the mediastinal cyst ruptured into a bronchus. Thoracotomy was carried out with an uneventful post-operative recovery. This observation illustrates the diagnostic difficulties when a mediastinal hydatid cyst presents the appearances of a tumour. This possibility must be included in the differential diagnosis of every mediastinal mass, particularly in endemic regions.

How accurate is model planning for orthognathic surgery?

The purpose of this study was to evaluate the accuracy of model surgery prediction after orthognathic surgery and to identify possible errors associated with the prediction process. The study included 46 patients who had undergone orthognathic surgical procedures; 22 in Group A who had had a Le Fort I osteotomy; and 24 in Group B who had had a Le Fort I osteotomy and mandibular setback surgery. The immediate postoperative and preoperative lateral cephalograms were analysed to calculate surgical changes; these were compared with those obtained from model surgery prediction and a statistical analysis was undertaken. The maxilla was more under-advanced and over-impacted anteriorly than predicted by model surgery. The amount of mandibular setback was more than that predicted by model surgery. None of the differences between prediction planning and actual surgical changes was statistically significant at p<0.05. Inaccuracy with the face bow recording, the intermediate wafer, and auto-rotation of the mandible in the supine or anaesthetized patient would appear to be the principal reasons for errors. Inaccuracies are associated with the transfer of prediction planning to model surgery planning and prediction, which should be eliminated to improve the accuracy and predictability of orthognathic surgery.

[A rare primary tumor of the mediastinum: pleomorphic liposarcoma]

Liposarcoma of the mediastinum is a rare tumor with various histologic features. We report a case of mediatinal pleomorphic liposarcoma in a 37-year-old man who complained of chest pain. Computed tomography showed an anterior expansive process within the mediastinum. Histological diagnosis was established by a trans-thoracic computed tomography guided core-needle biopsy. Despite a first cure of chemotherapy with gemcitabin/cisplatin, disease progression led to death 3 months after diagnosis. Mediastinal pleomorphic liposarcoma is an exceptional invading tumor affecting the middle-aged adult. This tumor, usually giant, becomes symptomatic by compression of mediastinal structures. Surgery is the best treatment when possible. The role of radiotherapy and chemotherapy are discussed. Prognosis depends both on the quality of resection and the grade malignancy.