Primary chronic osteomyelitis associated with synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO syndrome)

The Necessity of Antibiotics in the Management of Surgically Treated Mandibular Osteomyelitis: A Systematic Review

OBJECTIVES

Mandibular osteomyelitis remains an incompletely understood entity, and treatment of its various presentations remains diverse. The purpose of this study was to review the necessity of antibiotic therapy after surgical treatment of mandibular osteomyelitis.

STUDY DESIGN

A systematic review of published articles on surgical management of mandibular osteomyelitis with or without postoperative antibiotic therapy was performed to answer the question, "Does the use of postoperative antibiotics compared with surgery alone alter the success rate in treating mandibular osteomyelitis?" The most recent evidence was sought by searching PubMed, Embase, and Scopus databases. Article appraisal was performed by 2 reviewers.

RESULTS

Forty-five articles were found that met the inclusion criteria, with all studies being retrospective cohort or case series designs. Only 13 articles used Zurich classification designations of acute osteomyelitis, secondary chronic osteomyelitis, or primary chronic osteomyelitis, and the general heterogeneity of these articles made comparison difficult. No study made an intentional statistical assessment of various antibiotic protocols.

CONCLUSIONS

Limited evidence suggested that resection may have better success rates than other forms of surgical intervention, regardless of antibiotic therapy. This systematic review questions the perceived necessity of intermediate- or long-term antibiotic therapy in the management of mandibular osteomyelitis after surgical resection.

Axial skeletal lesions and disease duration in SAPHO syndrome: A retrospective review of computed tomography findings in 81 patients

AIMS

To explore the relevance of disease duration with axial skeletal lesions in synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome based on computed tomography (CT).

METHODS

Patients who had undergone whole-spine CT were included from a previously reported single-center cohort of SAPHO syndrome. Patients with previous treatments of bisphosphates, biological agents or surgeries were excluded. Sites of axial skeletal involvement were reviewed including the spine, sacroiliac joints, and anterior chest wall. Duration of osteoarticular involvement was defined as the interval between the onset of osteoarticular symptoms and the CT evaluation.

RESULTS

Eighty-one patients (54 female and 27 male) were included in the study. The mean disease duration was 26.9 ± 34.9 months. Fifty (63.0%) patients showed spinal lesions on CT. The average numbers of involved vertebral segments for corner and endplate lesions were 3.16 ± 3.51 and 0.73 ± 1.85 respectively. Sixty-eight (84.0%) patients exhibited abnormalities in the anterior chest wall. The number of involved vertebral segments showed poor correlation with disease duration for both corner lesions (r²  = 0.051, P = 0.043) and endplate lesions (r²  = 0.137, P = 0.001). Patients with costoclavicular involvement showed remarkably longer disease duration than those without (49.3 ± 47.7 months vs 18.0 ± 23.5 months, P = 0.006), while no significant difference was detected regarding other structures in the anterior chest wall.

CONCLUSION

Costoclavicular involvement is a hallmark of long disease duration in SAPHO syndrome. Corner and endplate lesions in the vertebrae and sacroiliac involvement may not relate to disease course.

Surgical Management of Primary Chronic Osteomyelitis of the Jaws: The Use of Computer-Aided-Design/Computer-Aided Manufacturing Technology for Segmental Mandibular Resection

The term osteomyelitis of the jaws identifies different pathological patterns characterized by the involvement of the cortical bone and bone marrow in osteoarticular infections.At the head and neck level, the segment most affected by osteomyelitis is the mandible and in most of the cases the cause of the infection is bacterial, as a result of pulp or periodontal infections, post-extraction alveolitis, foreign bodies and fractures. The mandibular PCO often presents with an insidious onset, without a striking acute phase, and it is characterized by recurrent episodes of pain, swelling, lockjaw, latero-cervical lymphadenopathy, without signs of suppuration.Three patients have been collected and recorded for the study.The authors believe that in the more advanced cases of PCO in adult patients, in which the mandibular bone appears almost entirely sclerotic and deformed, and that are not responsive to pharmacological therapy or to conservative surgical therapies such as decortication, it is necessary to perform a complete removal of the portion affected by osteomyelitis, with lower alveolar nerve preservation and contextual reconstruction with free microvascular bone flap.Our review aims to describe the clinico-pathological features of a rare pathological entity, propose a surgical treatment algorithm using computer-aided-design/computer-aided manufacturing technology and review the existing literature.

Swellings of the sternoclavicular joint: review of traumatic and non-traumatic pathologies

The sternoclavicular joint (SCJ) is an integral part of the shoulder girdle that connects the upper limb to the axial skeleton.

Swelling of the SCJ is commonly due to trauma, degeneration, infections and other disease processes that affect synovial joints.

This review also focuses on uncommon conditions that could affect the SCJ, including SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome, Friedrich’s disease and Tietze syndrome.

The scope of this review is limited to the analysis of the current evidence on the various conditions affecting the SCJ and also to provide an algorithm to manage these conditions.

Cite this article: EFORT Open Rev 2018;3:471-484. DOI: 10.1302/2058-5241.3.170078

Osteomyelitis of the jaw: time to rethink the bone sampling strategy?

This work aims at describing the diversity of osteomyelitis of the jaw (OJ) and at assessing the relevance of a new method designed to avoid salivary contamination during bone sampling in order to improve microbiological analysis and clinical decision-making. We reviewed medical and microbiological data of patients with a suspected OJ based on clinical and/or CT-scan signs and at least one bone sample made for microbiological analysis. During the study period, a new procedure for intraoral bone sampling was elaborated by surgeons and infectious diseases specialists authoring this article (based on stratified samples, cleaning of the surgical site and change of instruments between each sample). A comparison of the microbiological analyses between the two procedures was performed. From 2012 to 2017, 56 patients were included. Median age was 58 years (11-90), sex ratio: 1.24. Main risk factors were having a dental disease (n = 24) or cancer (n = 21). Nineteen patients with the new sample procedure were compared to 37 patients with standard procedure, especially non-cancer patients (n = 16 and 19, respectively). With the new procedure, a median of 3 (1-7) microorganisms per sample was recovered, vs. 7 (1-14) with the former (p < 0.001), a significant decrease of the microbial density was observed for all types of microbes, especially in deeper samples and cultures were more frequently sterile. The way sampling is managed deeply influences microbiological analysis. This strategy facilitates the distinction between pathogens and contaminants and should constitute the first step toward an evidence-based antimicrobial strategy for OJ.

Imaging for Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis (SAPHO) Syndrome

Multifocal osteomyelitis and synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome constitute a spectrum of disease that includes inflammatory bone lesions and dermatologic findings. Radiographic features resemble those of the spondyloarthropathies with anterior chest wall involvement. Early radiographic findings are osteodestructive with lytic lesions. Bone scintigraphy of the sternoclavicular region classically yields a 'bull's head' pattern of radionuclide uptake. Magnetic resonance imaging (MRI) can demonstrate corner lesions of vertebral bodies. Ultrasound often reveals peripheral enthesitis. Late radiographic features are usually osteoproliferative. PET/CT can identify chronic lesions. Differential diagnostic considerations include osteomyelitis and malignancy, which often prompt bone biopsy.

Juvenile Mandibular Chronic Osteomyelitis: Role of Surgical Debridement and Antibiotics

PURPOSE

To document outcomes of management of juvenile mandibular chronic osteomyelitis (JMCO) using a standardized treatment protocol including open biopsy, decortication, microbial culture, and long-term antibiotic therapy.

MATERIALS AND METHODS

This was a retrospective case study of pediatric patients with JMCO treated at Massachusetts General Hospital for Children from 1996 through 2014. Inclusion criteria included age younger than 18 years, diagnosis of JMCO, management by the protocol, adequate clinical and radiographic data in the record, and follow-up of at least 1 year after initial treatment. Inpatient and outpatient records were reviewed for demographics, clinical and radiographic findings, and histologic and laboratory evaluations. The predictor variable was the standardized treatment protocol and the primary outcome variables were disease status at end of treatment and complications of treatment.

RESULTS

Twenty patients (mean age at onset, 10.7 yr; range, 3 to 14 yr) were treated, 12 (11 girls) of whom met the inclusion criteria. Management of all patients consisted of biopsy (extraoral when feasible, n = 9; intraoral, n = 3), decortication, cultures, and long-term antibiotic therapy. Nonsteroidal anti-inflammatory drugs (NSAIDs) were administered only as needed for pain control. There was complete resolution of osteomyelitis with no recurrence in 7 of 12 patients (mean follow-up, 4.3 yr; range, 1 to 11 yr). Five patients had partial responses, with decreased frequency and severity of disease recurrence. These were well controlled with short courses of antibiotics (4 to 12 weeks) with NSAIDs only as needed for pain control (mean follow-up, 1.4 yr; range, 1 to 3 yr). There were no major complications related to antibiotic therapy. Minor complications included rash (n = 2), nausea and vomiting (n = 1), and vaginal candidiasis (n = 1).

CONCLUSION

The results of this study indicate that 58.3% of patients were cured and had no recurrent symptoms (mean follow-up, 4.3 yr). The remaining patients continue on intermittent treatment with antibiotics for recurrent episodes of swelling and pain. Favorable responses to antibiotic therapy support the hypothesis that JMCO is an infectious disease and that negative cultures might represent a failure of standard culture techniques to isolate the responsible organisms.

Primary Chronic Osteomyelitis of the Jaws in Children: An Update on Pathophysiology, Radiological Findings, Treatment Strategies, and Prospective Analysis of Two Cases

Objective. Primary chronic osteomyelitis (PCO) of the jaws in children is associated with pain, trismus, and swelling. In children, temporomandibular joint involvement is rare and few studies have been published due to the relatively low incidence. This paper presents two cases of mandibular PCO in children with the involvement of the collum mandibulae. In addition, a review of the literature regarding demographic data, histological, radiological, and laboratory findings, and treatment strategies of PCO was also performed. Material and Methods. Prospective analyses of two PCO cases. A PubMed search was used and the articles were sorted according to their corresponding key area of focus. Results. Review of the literature revealed twenty-four cases of PCO with two cases of mandibular condyle involvement. The mean age was 18 years; the male to female ratio was 1 : 3. Most of the patients were treated with anti-inflammatory drugs in combination with decortication. Clinical recurrence was seen in 7 cases. Conclusion. A combination of anti-inflammatory drugs and surgical intervention appears to be the first choice of treatment. However, surgical removal of necrotic tissue adjacent to collum mandibulae has its limitations in children. Further investigations are of utmost importance in order to increase our knowledge and understanding of this disease.

SAPHO (synovitis-acne-pustulosis-hyperostosis-osteitis): a multidisciplinary approach

OBJECTIVE

The aim of this study is to suggest a model for inquiry and treatment of patients with undiagnosed multiple inflammatory reactions.

STUDY DESIGN

A retrospective study was performed using 43 patient records from patients with chronic osteomyelitis of the jaw, treated at the Oral and Maxillofacial Clinic at Södersjukhuset, Stockholm, Sweden. The diagnoses primary chronic osteomyelitis (PCO) or secondary chronic osteomyelitis (SCO) were eventually made, according to symptoms and course of disease.

RESULTS

A total of 85% of the PCO patients fulfilled the criteria of the disorder SAPHO (synovitis-acne-pustulosis-hyperostosis-osteitis). The difficulty of settling on the diagnosis, as well as the length and diversity of treatment, was extreme. After treatments became multidisciplinary, time between diagnosis and cure was halved.

CONCLUSIONS

In order to improve diagnostics and treatment of patients with chronic inflammatory disease of the jaw, a structured plan for examination and treatment is proposed.

Radiological features of long bones in synovitis, acne, pustulosis, hyperostosis, osteitis syndrome and their correlation with pathological findings

Abstract The purpose of this study was to demonstrate the radiological features of long bones in synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome and to correlate these with the clinical findings. Eleven long bone lesions in seven cases of SAPHO syndrome were examined. The patients ranged in age from 6 to 63 years, with a mean of 47 years. In all seven cases, radiography, (99m)technetium bone scintigraphy, CT scan, and magnetic resonance imaging (MRI) were performed. In six of the cases, bone biopsy and bone culture were carried out for 7 long bones. Seven of the involved lesions were from the shaft of the femur, one each was from the neck and the shaft of the humerus, and one was from the proximal tibia. These lesions showed radiologically hyperostosis, osteolysis, and bone infarction-like lesion. Osteolysis was occasionally accompanied by sclerotic change. Hyperostosis usually showed diaphyseal involvement, presenting low signal intensity on T1- and T2-weighted MR images. Histologically, these findings corresponded to massive bone necrosis, new bone formation, fibrosis, or a mixture of these associated with mild inflammatory cell infiltration. Osteolysis involved dyaphysis, metaphysis, or epiphysis associated with arthritis, and presented low signal intensity on T1-weighted images, nonhomogeneous signal intensity lower than fat on T2-weighted images, and high signal intensity on fat suppression images. These findings corresponded to fibrosis, granulation, and inflammatory cell infiltration with lymphocyte aggregation. Bone infarction-like lesion was observed in the shaft or neck of the femur and the humerus and accompanied by calcification and cystic change. Bone cultures were negative in all cases in which bone biopsy was performed. Although hyperostosis is thought to be a characteristic bone lesion in SAPHO syndrome, the long bone lesion can occasionally show not only hyperostosis but also osteolytsis and bone infarction-like lesions.

The SAPHO syndrome

OBJECTIVE

To review the epidemiology, presentation, diagnosis, treatment, pathogenesis, and genetics of the syndrome known under the acronym of SAPHO for Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis to heighten awareness of this entity.

METHODS

We conducted a Medline search using SAPHO syndrome, chronic recurrent multifocal osteitis/osteomyelitis, and related terms as keywords and extracted further relevant articles from the retrieved references.

RESULTS

The SAHPO acronym identifies a syndrome encompassing a variety of osteoarticular disorders that are frequently accompanied by dermatoses characterized by neutrophilic pseudoabscesses, but can also occur in isolation. SAPHO syndrome is rare, although probably underrecognized because its diagnosis may be challenging because of the wide variability in its musculoskeletal and cutaneous manifestations. This is especially true when atypical sites are involved and when specific skin lesions are absent. There are no standardized treatment protocols available. Current treatments are empirical and have the objective of providing relief from the at times debilitating pain associated with SAPHO syndrome. They include nonsteroidal anti-inflammatory drugs and analgesics as first-line agents. Systemic corticosteroids, disease-modifying anti-rheumatic drugs, biologicals targeting tumor necrosis factor alpha and interleukin-1, and bisphosphonates have all been beneficial in some patients, but ineffective in others. This suggests that the pathogenesis of SAPHO syndrome is multifactorial, but this aspect remains poorly explored, although bacteria and immunological dysfunction are hypothesized to play a role.

CONCLUSIONS

The early recognition, diagnosis, and prompt treatment of SAPHO syndrome can prevent the unnecessary use of long-term antibiotics or invasive procedures, while rapidly alleviating pain in a majority of affected patients.

[Importance of SPECT/CT for resolving diseases of the jaw]

CLINICAL/METHODICAL ISSUE

Diseases of the jaw, such as osteomyelitis, condylar hyperactivity and tumors need adequate imaging to evaluate the extension and activity for therapy planning.

STANDARD RADIOLOGICAL METHODS

Conventional planar scintigraphy, orthopantomography, computed tomography (CT) and magnetic resonance imaging (MRI) can be used for the evaluation of jaw diseases.

METHODICAL INNOVATIONS

Single photon emission computed tomography/computed tomography (SPECT/CT) provides metabolic and morphologic information in one imaging step and is becoming increasingly more available in larger hospitals.

PERFORMANCE

The SPECT/CT is superior to planar scintigraphy alone, CT and orthopantomography in the evaluation of the extension and activity of osteomyelitis and jaw tumors.

ACHIEVEMENTS

In our hospital SPECT/CT has replaced the other imaging modalities in the evaluation of osteomyelitis and condylar hyperactivity.

PRACTICAL RECOMMENDATIONS

If available SPECT/CT should be performed for the evaluation of osteomyelitis of the jaw.

Chronic mandibular osteomyelitis with suspected underlying synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome: a case report

Chronic mandibular osteomyelitis is an intractable disease. In recent years, some case reports have related this disease process to synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome, which is chronic with frequent remissions and exacerbations. This report describes a case of chronic mandibular osteomyelitis suspected to be SAPHO syndrome. A 68-year-old woman presented with pain on the left side of the mandible. On the basis of clinical and radiological findings, chronic mandibular diffuse sclerosing osteomyelitis was initially diagnosed. We administrated oral clarithromycin (400 mg daily) and levofloxacin (500 mg daily), and her pain subsequently resolved. On (99m)Tc-labeled methylene diphosphonate scintigraphy, tracer uptake in the asymptomatic mandible was unchanged, but there was increasing tracer uptake in the sternocostal and sternoclavicular joints, compared with (99m)Tc-labeled methylene diphosphonate scintigraphic findings of the first visit. We diagnosed SAPHO syndrome and administrated oral sodium risedronate hydrate (2.5 mg daily). Although there has been no pain or swelling in the area of the left mandibular lesion, we have followed up on other skin and osteoarticular manifestations in conjunction with other medical departments.

Surgical management of primary chronic osteomyelitis of the jaws in children: a prospective analysis of five cases and review of the literature

INTRODUCTION

Primary chronic osteomyelitis (PCO) of the jaws is an uncommon non-suppurative inflammatory disease of unknown origin. Although the disease is not age-specific, only sparse cases with onset during childhood or adolescence have been reported in the literature.

PURPOSE

This study seeks to present five cases of maxillofacial PCO in children and to evaluate the effectiveness of the applied therapeutic protocol. A review of the literature concerning diagnosis and treatment of PCO with special emphasis on surgical therapy is also performed.

PATIENTS AND METHODS

Demographic data, clinical, radiographic and histopathologic findings, blood tests results, and the treatment protocol applied to five young patients suffering from PCO and referred to the Department of Oral and Maxillofacial Surgery at "A. & P. Kyriakou Children's Hospital" over the past 5 years are presented. Decortication and contouring of the affected bone were performed; antibiotics were administered for a short period of time and the patients remained under follow-up evaluation.

RESULTS

The posterior mandible was affected in four cases and the maxilla-zygomatic bone in one case. All patients showed remission of signs and symptoms after surgical treatment. The postsurgical clinical course was uneventful in all cases. However, recurrences have been noted, as reported in the literature.

CONCLUSION

PCO of the jaws is a complex clinical entity, presenting both a diagnostic and therapeutic challenge, especially in young patients. Surgical treatment in conjunction with antibiotics and non-steroid anti-inflammatory drugs proved to be beneficial and to improve considerably the patients' quality of life. Nevertheless, exacerbation of the disease may appear and regular follow-up of the patients is required.

SAPHO syndrome with affection of the mandible: diagnosis, treatment, and review of literature

The synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is a rare syndrome of unknown etiology. Involvement of the mandible is found in almost 10% of cases. In the literature, conservative treatment is recommended most often, because decortication and partial resection are found to be ineffective and of temporary profit. We report a case of SAPHO syndrome in a 44-year-old women with unilateral hyperostosis of the mandible and massive painful swelling of the surrounding soft tissues. Owing to facial disfiguration and pain, resection of the affected bone followed by immediate reconstruction with a microvascular iliac crest flap were performed. The aim of this paper was to present the necessity of surgical intervention in SAPHO syndrome of the mandible in cases of esthetic and functional limitation.

SAPHO Syndrome Diagnosis and Treatment: Report of Five Cases and Review of the Literature

Background:

The term “SAPHO (Synovitis, Acne, Pustulosis, Hyperostosis and Osteitis) syndrome” includes a variety of musculoskeletal disorders associated with skin conditions; Osteitis is the most prominent skeletal lesion, whereas palmoplantar pustulosis and acne are the main skin lesions. Diagnosing SAPHO syndrome is difficult, because this syndrome is often confused with suppurative osteomyelitis, which has similar clinical and pathologic findings. SAPHO diagnosis is even more difficult when atypical sites are involved and there are no skin lesions.

Patients and Methods:

This case series presents five patients (3 women, 2 men), ages 27 to 44 years, who came to the Orthopaedic Department outpatient clinic for evaluation of pain in the humerus, clavicle, sacroiliac joints, and/or distal radius, and were diagnosed with SAPHO syndrome. Clinical and radiologic findings, treatment and outcome data, with up to 4 years of follow-up are presented. An extensive discussion of the clinical presentation, published literature, treatment options and outcome of SAPHO syndrome is also included.

Results:

Once the diagnosis of SAPHO syndrome was established, treatment with antibiotics (clindamycin) and non steroid anti-inflammatory drugs (lornoxicam) was remarkably effective. All patients did well and remained symptom free for up to four years, after a 3-8 month course of treatment.

Interpretation:

SAPHO syndrome should be included in the differential diagnosis when evaluating patients with lytic, sclerotic, or hyperostotic bone lesions and pain. Prompt SAPHO syndrome recognition, followed by appropriate therapy with antibiotics and NSAIDs can produce rapid symptom resolution, while avoiding unnecessary procedures and longterm antibiotic therapy.

SAPHO syndrome with ankylosis of the temporomandibular joint

SAPHO syndrome is a rare combination of different symptoms with unknown aetiology. A complete ankylosis of the temporomandibular joint (TMJ) in a patient with SAPHO syndrome has not been described previously. The goal of this case report is to present the disease, give an overview about the frequency of mandibular involvement and describe different therapeutic strategies. The complication of an ankylosis of the TMJ is noted and the literature is reviewed. The authors report a 42-year-old patient with SAPHO syndrome and recurrent swelling of the right mandible and the soft tissue. The persisting involvement of the mandible resulted in a complete osseous ankylosis of the right TMJ and required resection with alloplastic replacement of the right condyle. SAPHO syndrome should be suspected in some cases of 'therapy resistant osteomyelitis' of the mandible. Smaller joints, such as the TMJ may also be affected. Treatment of SAPHO syndrome should include antibiotics and NSAIDs; corticosteroids may be helpful. Surgery is the ultimate treatment.

Case reports: aseptic femoral osteitis and sternocostal hyperostosis from SAPHO syndrome

Synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome are characterized by peculiar bone lesions that commonly involve the anterior chest wall. Osteitis typically is the most prominent skeletal lesion seen in synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome. We present a patient with aseptic femoral osteitis and sternocostal hyperostosis. The classic clinical, radiographic, and histologic features of this syndrome are described. Diagnosis is difficult in patients with only one symptomatic bone. The lesion often is confused with suppurative osteomyelitis because of similar clinicopathologic findings. Although the optimal treatment is unclear, it is important to consider synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome in the differential diagnosis of any lytic, sclerotic, or hyperostotic bone lesion to avoid unnecessary long-term antibiotic therapy.

Is primary chronic osteomyelitis a uniform disease? Proposal of a classification based on a retrospective analysis of patients treated in the past 30 years

INTRODUCTION

Primary chronic osteomyelitis of the jaw is a rare, non-suppurative, chronic inflammatory disease of unknown aetiology. To date, classification is confusing due to a non-uniform terminology. The aim of this study was to establish a simple (clinical) classification based on patient data from our clinic.

METHODS

Retrospective analysis revealed 30 cases of which clinical course, radiology, pathology, therapy and outcome were analysed.

RESULTS

Both sexes were equally represented. The mean age at onset of disease was 35 years (range 5-76 years). Onset of disease revealed two peaks of incidence, one in adolescence and one after age 50 years. While clinical symptoms were similar in all cases, an increased intensity of these symptoms was noted in younger individuals as well as in the early stages of the disease. Five adults and one adolescent presented with additional non facial bone, joint and skin manifestations consistent with the diagnosis of SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome, or chronic recurrent multifocal osteomyelitis. Radiology demonstrated sclerosis, osteolysis and periosteal reaction in variable stages in all cases. However, findings were more extensive in younger patients. Histology revealed different stages of chronic inflammation in all cases. Microabscess formation was noted in 11 cases, six of which were children/adolescents. Therapy consisted mainly of surgery, antibiotics and hyperbaric oxygen therapy. At the end of the follow up period, 11 patients demonstrated complete remission, while in 14 cases amelioration and in 5 no significant improvement was noted.

CONCLUSION

Based on differences in age at presentation, clinical appearance and course, radiology and histology, a subclassification into early and adult onset primary chronic osteomyelitis has been established. Cases with purely mandibular involvement should further be distinguished from cases associated with other syndromes.

Osteomyelitis of the mandible

Before application of any cross-sectional imaging modality, the orthopanoramic view is indispensable in assessing the status of dentition, in recognizing direct radiographic signs of osteomyelitis, or in determining the presence of predisposing conditions such as a fracture or systemic bone disease. The orthopanoramic view is the procedure of choice in follow-up examinations in patients who have osteomyelitis. In acute osteomyelitis, the higher sensitivity of MR imaging for detection of intramedullary inflammation advocates this imaging modality for confirmation of the clinical diagnosis. If surgical treatment is planned, high-resolution CT is required to specify the degree of cortical destruction, the presence of sequestra in particular, and to define the extent of osseous removal required. In chronic osteomyelitis, the higher sensitivity of MR imaging to detect periosteal inflammation and soft tissue involvement advocates this modality to reveal the presence, location, and extent of chronic inflammation. The assessment of persistence or recurrence of chronic inflammation after surgical treatment is by high-resolution CT for the first 6 months following surgery. Finally, scintigraphy is recommended when multi-focal systemic disease is suspected, such as in CRMO and SAPHO syndrome.

SAPHO: syndrome or concept? Imaging findings

The SAPHO syndrome was a term coined to include a variety of musculoskeletal disorders associated with skin conditions, mainly palmoplantar pustulosis and acne conglobata. It is more correctly a spectrum which includes the following: skin lesions, osteoarticular manifestations of synovitis hyperostosis and osteitis affecting particular target sites, and.a clinical course marked by relapses and remissions. The major sites of involvement are the anterior chest wall, the spine, long bones, flat bones, and large and small joints. The distribution and severity of involvement varies from the adult to the pediatric form of chronic recurrent multifocal osteomyelitis (CRMO). The diagnosis of SAPHO syndrome is not difficult when the typical osteoarticular lesions are located in characteristic target sites. The diagnosis is more difficult if atypical sites are involved and there is no skin disease.

Primary chronic osteomyelitis in childhood and adolescence: a retrospective analysis of 11 cases and review of the literature

PURPOSE

Primary chronic osteomyelitis (PCO) of the jaw is a rare, nonsuppurative, chronic inflammation of an unknown cause. The disease is not age specific. So far, only case reports of this disease with an onset in childhood or adolescence have been described.

PATIENTS AND METHODS

Review of the patient data of our department from the past 30 years revealed 11 patients with an early onset of PCO in childhood and during puberty.

RESULTS

Demographic data, clinical course, radiologic and histologic examinations, and treatment modalities are described and compared with the literature with special emphasis on the somewhat confusing terminology used for this pathology.

CONCLUSION

We present a group of 11 patients with an early onset of PCO of the mandible, which, to our knowledge, is the largest described series to date. The series shows the complexity of this disease in a young patient population, demanding a careful evaluation of each case before initiation of therapy.

Acne with chronic recurrent multifocal osteomyelitis involving the mandible as part of the SAPHO syndrome: case report

For 12 years, a 26-year-old man had acne conglobata and a non-suppurative diffuse sclerosing osteomyelitis of the mandible as part of a chronic recurrent multifocal osteomyelitis of the sternum, the pelvic bones, and the femoral head, and aseptic arthritis of the knee, the fibulotalar, and the sternoclavicular joints. This fulfills the formal criteria of the SAPHO syndrome. Repeated surgical and antibiotic treatment combined with hyperbaric oxygen caused partial improvement. Complete relief and partial disappearance of the scintigraphic lesions was achieved with long-term corticosteroids, non-steroidal anti-inflammatory drugs, minocycline, and isotretinoin.