Rapp-Hodgkin syndrome with palmoplantar keratoderma, glossy tongue, congenital absence of lingual frenum and of sublingual caruncles: Newly recognized findings

Anatomical Characterization of the Nasolacrimal Canal Based on Computed Tomography in Children With Complex Congenital Nasolacrimal Duct Obstruction

PURPOSE

To characterize anatomical variations of the nasolacrimal canal in patients with complex congenital nasolacrimal duct obstruction.

METHODS

Retrospective case series of 25 children with congenital nasolacrimal duct obstruction. All children had failed probings and were examined by computed tomography. An analysis of imaging data is presented.

RESULTS

Anomalous development of the nasolacrimal canal was confirmed on computed tomography. Two main types of malformations were observed: fundamental (20 patients) and special (5 patients). In the fundamental type, the upper portion of the nasolacrimal canal was relatively normal and became significantly stenotic, or even atretic, at the middle and terminal segments. In the special type, the upper portion of the nasolacrimal duct was malformed. Only the special type showed an association with systemic abnormalities. In patients with unilateral fundamental type malformation (11 patients), the transverse and anteroposterior diameters of the upper segment of the nasolacrimal canal on the affected side were significantly larger than that of the normal side (P = .000). The height of the nasolacrimal canal on the normal side was significantly larger than that of the affected side (P = .000).

CONCLUSION

Computed tomography is useful for delineation of anatomical characteristics of the nasolacrimal canal and to diagnose nasolacrimal canal malformation. Malformed nasolacrimal canals are of two main types: fundamental and special. Hydrostatic pressure in the lacrimal duct appears to the underlying mechanism as enlargement of the nasolacrimal canal in the unilateral fundamental type. [J Pediatr Ophthalmol Strabismus. 2017;54(4):238-243.].

Orodental manifestations in ectodermal dysplasia-a review

Oral signs and symptoms are present in most ectodermal dysplasias (EDs). The aim of this article is to summarize some of the literature on current knowledge of oral manifestations and orofacial function in EDs. The review will focus on the most common forms where dental manifestations can be crucial for a differential diagnosis of ED among individuals with hypodontia and oligodontia, and preferably where the investigations included persons who had a genetically verified diagnosis. Disturbances in tooth development are common and can appear as tooth agenesis, variations in size and shape of teeth, defects in the mineralized tissues, and problems in tooth eruption. Abnormalities in number, size, and shape of teeth, and reduced salivary secretion, present in isolated oligodontia as well as in hypohidrotic ED and incontinentia pigmenti. In some more rare EDs these symptoms appear in combination with clefts of lip and/or palate in some affected individuals. Leukokeratosis in the oral mucosa presents in 70% of genetically confirmed cases of pachyonychia congenita. Also, orofacial function is often affected in ED, due to malformations, an incomplete dentition, and low salivary secretion which can compromise chewing, swallowing, and speech. In conclusion, there is a clinical overlap in oral signs and symptoms between isolated oligodontia and the most common EDs. Studies with genetically confirmed diagnoses and larger cohorts, as well as multicenter collaboration and the establishing of international registries, would create a basis for refined diagnostics, where oral examinations should be an integrated part of clinical assessment.

Split hand-split foot-ectodermal dysplasia and amelogenesis imperfecta with a TP63 mutation

We report on a mother and son who were affected with split hand-split foot (formerly described as ectrodactyly), ectodermal dysplasia, hyperpigmentation of skin, and dystrophic nails. Their hair was wiry, brownish, and slow-growing. Scanning electron micrography of their scalp hair showed hypoplastic hair bulbs, partial loss of hair cuticles, and frayed hair shafts. The son was affected with amelogenesis Imperfecta (hypocalcification, hypoplasia, and hypomaturation types), in the primary and permanent dentition. An unerupted supernumerary maxillary second premolar and fusion of mandibular incisors were observed in the primary dentition and their permanent successors. Mutation analysis showed a c.588-2A > C mutation in TP63 in the mother and her son. It is predicted that an alternative splice site was used, specifically the AG located just three nucleotides upstream. Use of this site is predicted to include three extra nucleotides in the transcript and thus incorporation of a single extra amino acid (p.Thr195_Tyr196insPro). This is the first time that amelogenesis imperfecta, fusion of teeth, and a supernumerary premolar have been shown to be associated with a TP63 mutation.

Unsuccessful probing and nasolacrimal canal agenesis in congenital epiphora

PURPOSE

To present 3 cases with nasolacrimal canal agenesis who underwent repetitive unsuccessful probing for treatment of congenital epiphora.

MATERIALS AND METHODS

Three patients who had undergone topical antibiotic therapy, lacrimal sac massage and repetitive probing in Ondokuz Mayis University, Medical School, Ophthalmology Department between June 2006 and March 2007 were included in the study. Thin-section computerized tomography (CT) scan was performed in all cases since nasolacrimal duct could not be detected during repetitive probing.

RESULTS

Among the patients 2 were males and 1 was a female. They were within the age range 5-7. Since it was not possible to cannulate the nasolacrimal canal during probing, CT scans were performed and nasolacrimal duct agenesis was detected in 3 patients. One of the patients had additional upper punctum agenesis, who also had no right frontal sinus and left sphenoid sinus. All tomographic images revealed a rudimentary upper nasolacrimal canal ending blindly and a lower canal leading into the maxillary sinus, which was very typical for the duct agenesis. In all patients, lacrimal fossas were shallow and irregular.

CONCLUSION

Nasolacrimal duct agenesis should be considered in patients with congenital nasolacrimal duct obstruction and unsuccessful repetitive probing, especially if it is difficult to cannulate nasolacrimal canal during probing. Although assessing whether dacryocystorhinostomy is in favor of the patient, the lacrimal sac and fossa should be examined with imaging in details.

Absence of inferior labial and lingual frenula in Ehlers-Danlos syndrome: a minor diagnostic criterion in French patients

BACKGROUND

Ehlers-Danlos syndrome (EDS) is a heterogenous group of diseases that can be potentially life threatening in the vascular form. The diagnosis is mainly based on a clinical score including many items that demonstrate skin, mucosa, joint, and vessel involvement. The score is particularly helpful in hypermobile and classical forms but can be normal in the vascular type. The absence of the lingual and inferior labial frenula was reported to be a useful diagnostic tool in a series of 12 patients with classical and hypermobile EDS. However, two further reports have contested the value of this sign.

OBJECTIVE

To determine the diagnostic value of the absence of inferior labial or lingual frenula in EDS.

METHODS

Patients with EDS were prospectively recruited from November 2006 to April 2007 in a French tertiary center. Each patient was examined to check for the presence or absence of the oral frenula and matched with two controls seen from February to May 2007.

RESULTS

Forty-three patients (ratio female/male of 2.07 : 1, mean age 31 years, range 4-63 years), 4 with classical EDS, 19 with hypermobile EDS, and 20 with vascular-type EDS, were included and matched with 86 controls. The sensitivity of the absence of the inferior labial frenulum was 42% (95% CI 27, 58) and for the lingual frenulum was 53.5% (95% CI 38, 69). The specificity was 99% (95% CI 94, 100) and 98% (95% CI 92, 100), respectively. In the vascular group, 13 of 20 patients were affected (sensitivity = 65% [95% CI 41, 85]; specificity = 97% [95% CI 87, 100]; odds ratio = 72 [95% CI 8, 645]). Inter-observer agreement was excellent (kappa value 0.91).

CONCLUSION

The absence of the inferior labial frenulum or lingual frenulum is a specific sign of EDS that can be easily checked by a physician. It can be helpful in the early diagnosis of the disease, including the vascular type, in affected families. It can also be helpful to distinguish between joint hypermobility syndrome and the hypermobile type of EDS in patients with joint hypermobility.

Pili Trianguli et Canaliculi Is a Defect of Inner Root Sheath Keratinization

A 4-year-old Caucasian girl with pili trianguli et canaliculi had distinctive findings. These included unique ultrastructural alterations consisting of tonofilament-desmosomal detachment and tonofilament clumping within inner root sheath cells. We believe that the hair anomaly in this condition may be due to a compromised cytoskeleton with subsequent configurational changes of the inner root sheath. Despite these configurational changes keratinization of the inner root sheath occurs. As inner root sheath keratinization typically precedes keratinization of the hair shaft, the abnormally configured inner root sheath determines the surface characteristics of the hair shaft in pili trianguli et canaliculi.

Heterozygous mutation in the SAM domain of p63 underlies Rapp-Hodgkin ectodermal dysplasia

Several ectodermal dysplasia syndromes, including Ectrodactyly-Ectodermal dysplasia-Clefting (EEC) and Ankyloblepharon-Ectodermal Dysplasia-Clefting (AEC) syndromes, are known to result from mutations in the p63 gene. We investigated whether Rapp-Hodgkin syndrome (RHS) is also caused by mutations in the p63 gene. We identified a heterozygous de novo germline missense mutation, S545P, in the sterile-alpha-motif (SAM) domain of p63, in a Thai patient affected with RHS. This is the first genetic abnormality to be described in RHS. The amino acid substitution is the most downstream missense mutation in p63 reported thus far. Histological assessment of a skin biopsy from the patient's palm showed hyperkeratosis and keratinocyte cell-cell detachment in the upper layers of the epidermis, along with numerous apoptotic keratinocytes. Collectively, these investigations demonstrate that RHS is also caused by mutations in p63 and that the clinical similarities to AEC syndrome are paralleled by the nature of the inherent mutation.

A newly recognized syndrome of skeletal dysplasia with opalescent and rootless teeth

A Thai girl with skeletal dysplasia and dental anomalies was seen. Her anomalies consisted of disproportionately short stature, short neck, broad and depressed nasal bridge, broad chest in the anteroposterior dimension, kyphosis, widely spaced nipples, and protruded abdomen. Radiographic testing indicated that she had a large sella turcica, platyspondyly, hypoplastic acetabulum, and a small body of mandible. Both her deciduous and permanent teeth were equally opalescent, and most were rootless, with root development of the mandibular teeth more severely affected. Some maxillary roots were extremely short and tapered. Hypodontia was also observed. These findings represent a unique and hitherto undescribed syndrome of skeletal dysplasia with concomitant dental anomalies.