Post-traumatic Sinus Syndrome, Proposal for a New Clinical Entity (CDR Syndrome) as Variant of the Silent Sinus Syndrome: Systematic Review and Case Series

The diagnostic criteria for silent sinus syndrome (SSS) are still controversial, especially for the post-traumatic/surgery cases that are, nowadays, excluded from the diagnosis of SSS because lacking of spontaneously. We present a systematic review of the last 10 years and our case series of SSS associated to previous trauma/surgery, proposing a new interpretation of SSS. In this work, following the PRISMA guide lines for systematic reviews, we collected 86 articles published on PubMed, Cochrane Library and Medline Plus since 2013 to 2023 about SSS. We divided them in six groups forming the structure of the review: (1) epidemiology, (2) clinical presentation, (3) imaging, (4) etiopathogenesis, (5) sss and craniofacial trauma and (6) treatment. We reported two explicative clinical cases: two men of 34 and 37 years old, involved in motorcycle accident in 2020 and 2014, respectively, and underwent surgery. They came back in 2023 referring diplopia documented by Hess-Lancaster test. CT-scan reported two clear cases of SSS. Basing on what is reported in literature, and basing on our experience, the post-traumatic/surgery SSS are more frequent than the idiopathic ones. Our proposal is to considered them as two individual entities. We propose to adopt the name of Post-traumatic sinus syndrome, or CDR syndrome (Catalfamo-De Rinaldis), for all cases that respect four specific diagnostic criteria reported into the text.

Central Giant Cell Reparative Granuloma (CGCRG) of the Jaw in Children Treated with Neoadjuvant Bisposphonates: Review and a Case Report

Central giant cell reparative granuloma (CGCRG) of the jaw is a neoformation localized in the mandible or in the maxillary bone and characterized by fibrous tissue, osteoclast-like giant cells and reactive bone formation. The CGCRG is a less frequent benign tumor but sometimes it is characterized by an aggressive behavior with a very rapid growth. It affects the young adults mainly and the children occasionally. Nowadays no medication therapy is approved for CGCRG in pediatric cases. We present a case of an aggressive form of a mandibular CGCRG in a 5-year child with Arnold-Chiari syndrome. This case is unique for the use of bisphosphonates (BPs) as neoadjuvant therapy in pediatrics. The therapy were administrated with the purpose of arresting the rapid growth of the tumor in order to avoid a demolitive surgery to the young patient. The child was without symptoms and presented an unusual swelling in the left mandible developed in a few weeks. The lesion was diagnosed by a CT scan and it was confirmed by a biopsy performed for histopathological assessment a few days later. The drug therapy consisted of seven cycles iv of Zoledronate associated to Calcium Gluconate. The child was closely observed through clinical and serological evaluations during the following months. About five months after the last cycle of BPs the child underwent CT scan and a conservative surgical treatment, consisted in a deep curettage, was programmed. Seven months after surgery the aesthetic profile of the patient improved and CT scan reported a significant calcic neoapposition in the area of the previous bone lesion. After more than one year from surgery, no relapse was observed. This case report demonstrates that BPs can be used safely in pediatric patients with CGCRG. Especially BPs could have a role as neoadjuvant therapy: If administrated before surgical treatment BPs avoid the necessity of resective surgery and reduce the risk of recurrence in pediatric CGCRG after conservative curettage.

Styloid Jugular Nutcracker: The Possible Role of the Styloid Process Spatial Orientation-A Preliminary Morphometric Computed Study

Styloid Jugular Nutcracker (SJN, also known as Eagle Jugular Syndrome EJS) derives from a jugular stenosis caused by an abnormal styloid process, compressing the vessel in its superior portion (J3) against the C1 anterior arch. It could be considered a venous vascular variant of Eagle Syndrome (ES). Main clinical features of this ES variant are headache, pulsatile tinnitus and dizziness, possibly related to venous hypertension and impaired cerebral parenchyma drainage. In our opinion, conceptually, it is not the absolute length of the styloid bone that defines its abnormality, but its spatial direction. An elongated bone pointing outward far away from the midline could not compress the vein; vice versa, a short styloid process tightly adherent to the cervical spine could be pathological. To prove this hypothesis, we developed a semi-automatic software that processes CT-Angio images, giving quantitative information about distance and direction of the styloid process in three-dimensional space. We compared eight patients with SJN to a sample of healthy subjects homogeneous for sex and age. Our results suggest that SJN patients have a more vertically directed styloid, and this feature is more important than the absolute distance between the two bony structures. More studies are needed to expand our sample, including patients with the classic and carotid variants of Eagle Syndrome.

The C-S Approach for The Management of Median or Paramedian Frontal Sinus Lesion

The frontal sinus is one the most complex of the paranasal sinuses, its proximity to the cranial vault and the orbit cause that frontal sinus pathologies can progress to involve these structures and lead to significant morbidity, or even death. Surgical management of the frontal sinus is technically challenging, the most commonly used surgical approaches are coronal, butterfly, gullwing and suprabrow. The purpose of this article is to propose the C-S approach, an interesting alternative to the gullwing approach for the managing of median and paramedian frontal sinus lesions or isolated displaced fractures of the anterior wall. The main advantage of this technique is represented by the fact that it follows the new tension lines described in the literature, a curved vertical line that follows the glabellar frown.

The Utility of Capsicum annuum L. in Internal Medicine and In Dentistry: A Comprehensive Review

Capsaicin is a chili peppers extract, genus Capsicum, commonly used as a food spice. Since ancient times, Capsaicin has been used as a "homeopathic remedy" for treating a wild range of pathological conditions but without any scientific knowledge about its action. Several studies have demonstrated its potentiality in cardiovascular, nephrological, nutritional, and other medical fields. Capsaicin exerts its actions thanks to the bond with transient receptor potential vanilloid subtype 1 (TRPV1). TRPV1 is a nociceptive receptor, and its activation starts with a neurosensitive impulse, responsible for a burning pain sensation. However, constant local application of Capsaicin desensitized neuronal cells and leads to relief from neuropathic pain. In this review, we analyze the potential adjuvant role of Capsaicin in the treatment of different pathological conditions either in internal medicine or dentistry. Moreover, we present our experience in five patients affected by oro-facial pain consequent to post-traumatic trigeminal neuropathy, not responsive to any remedy, and successfully treated with topical application of Capsaicin. The topical application of Capsaicin is safe, effective, and quite tolerated by patients. For these reasons, in addition to the already-proven beneficial actions in the internal field, it represents a promising method for the treatment of neuropathic oral diseases.

How to Avoid and Manage Mental Nerve Injury in Transoral Thyroidectomy

Transoral endoscopic thyroidectomy by vestibular approach (TOETVA) represents an innovative and scarless technique for thyroid surgery. The procedure is conducted via a three-port technique at the oral vestibule using a 10mm port for the 30° endoscope and two additional 5mm ports for the dissecting and coagulating instruments. Patients meeting the following criteria can be considered as candidates for TOETVA: (a) an ultrasonographically (US) estimated thyroid diameter =10cm; (b) US-estimated gland volume =45mL; (c) nodule size =50mm; (d) presence of a benign tumor, such as a thyroid cyst or a single- or multinodular goiter; (e) Bethesda 3 and/or 4 categories, and (f) papillary microcar-cinoma without the evidence of metastasis. Beyond the classic complications of thyroid surgery, namely cervical hematoma, recurrent laryngeal nerve injury and hypoparathyroidism, novel consequences can occur as mental nerve (MN) injury. In this paper, leading experts in the field report on their current clinical experience with the TOETVA approach for thyroid gland surgery, with emphasis given to tips and tricks to avoid and manage MN injury.

Facial and Orbital Fractures: A Fifteen Years Retrospective Evaluation of North East Sicily Treated Patients

Background:

Orbital fractures are classified as diseases usually related to common midface trauma. It represents the most challenging treatment due to the complex anatomy, physiology, and aesthetic role. A midface trauma involves also the zygomatic complex and the nose, however the orbit fracture seems to be a more frequent disease due to its anatomical features.

Objective:

The purpose of this work is to retrospectively evaluate and record the frequency of the midfacial traumas and orbital fractures observed in the North Eastern Sicily. The results of the present data may be useful for the clinicians in order to recognize the kind of fracture just from the first general visit having a quick diagnosis and management.

Methods:

In the years between 2001 and 2016, about 1200 patients with midfacial trauma and about 100 patients involving the orbital floor have been evaluated. All those patients underwent the surgical fracture reduction and a CT scan follow up control at one month, three months, six months and one year.

Results:

Data showed high percentage of orbital floor, nose and mandibular body and ramus fractures; moreover the most frequent causes of fractures seem to be related to motor vehicle accident, followed by assaults, work and fall.

Conclusion:

The results have highlighted the changing trends in the causes of facial injuries, particularly the increasing incidence of assaults and the falling incidence of motor vehicle accidents in developed countries. The quick diagnosis and management proved fundamental for the successful treatment. Clinicians should be able to recognize the first symptoms in order to avoid possible complications.

Diffusion tensor imaging reveals morphological alterations of the lateral pterygoid muscle in patients with mandibular asymmetry

OBJECTIVES

To evaluate non-invasively the morphological features of both lateral pterygoid muscle (LPM) and masseter muscle by using diffusion tensor Imaging on two patients affected by mandibular asymmetry.

METHODS

Two female patients with mandibular excess and asymmetry who underwent Le Fort I osteotomy and bilateral sagittal split osteotomy were recruited for this study. Morphological (T₁ weighted) and diffusion weighted images were acquired with a 3T scanner 1 week before (T0) and 1 month after the surgery (T1). Probabilistic tensor-based tractography reconstruction of bilateral masseters and LPMs was performed and mean fractional anisotropy (FA) values for both muscles were extracted.

RESULTS

Diffusion tensor imaging was able to identify the muscle geometrical morphology and diffusion microstructural changes. Both at T0 and T1, mean FA values had no significant differences between the right and left side of masseter (at T0: p = 0.91; at T1: p = 0.54) and LPM (at T0: p = 0.92; at T1: p = 0.43), respectively. Both patients reported a significant improvement in FA mean values of the left LPM (p = 0.03) between T0 and T1, whereas no diffusion parameters' changes were observed for the bilateral masseter muscles and right LPM.

CONCLUSIONS

We found that after the surgery the LPM ipsilateral to the deviation side showed a significant increase of FA compared to the baseline. Although preliminary, our findings suggest that diffusion tensor imaging may represent a promising tool to investigate non-invasively the masticatory muscles in temporomandibular joint disorders.

Histomorhological and clinical evaluation of maxillary alveolar ridge reconstruction after craniofacial trauma by applying combination of allogeneic and autogenous bone graft

A variety of techniques and materials for the rehabilitation and reconstruction of traumatized maxillary ridges prior to dental implants placement have been described in literature. Autogenous bone grafting is considered ideal by many researchers and it still remains the most predictable and documented method. The aim of this report is to underline the effectiveness of using allogeneic bone graft for managing maxillofacial trauma. A case of a 30-year-old male with severely atrophic maxillary ridge as a consequence of complex craniofacial injury is presented here. Augmentation procedure in two stages was performed using allogeneic and autogenous bone grafts in different areas of the osseous defect. Four months after grafting, during the implants placement surgery, samples of both sectors were withdrawn and submitted to histological evaluation. On the examination of the specimens, treated by hematoxylin and eosin staining, the morphology of integrated allogeneic bone grafts was revealed to be similar to the autologous bone. Our clinical experience shows how the allogeneic bone graft presented normal bone tissue architecture and is highly vascularized, and it can be used for reconstruction of severe trauma of the maxilla.

Sarcoglycans and integrins in bisphosphonate treatment: immunohistochemical and scanning electron microscopy study

Osteonecrosis of the jaw is an adverse outcome associated with bisphosphonate treatment. Bisphosphonates are used in conjunction with antineoplastic chemotherapy for the treatment of hypercalcaemia associated with malignancy, lytic bone metastasis and multiple myeloma. However, it is not known if the osteonecrosis of the jaw lesion originates in the bone or whether it initiates in the gingival epithelium. Two bisphosphonates are commonly used in cancer treatment. One of these is pamidronate disodium, a second-generation bisphosphonate that differs from the first-generation drug because it inhibits bone resorption at a dose that does not affect bone mineralization. The other widely used BP, zoledronate, is a third-generation drug that is the most potent bisphosphonate in clinical use, showing strong anti-osteoclastic activity, similar to pamidronate. The aim of the present study was to evaluate the modifications of human oral mucosa and underlying bone in patients after treatment with these nitrogen-containing bisphosphonates for 24 and 36 months. We analyzed the structural damage of the oral mucosa and damage of the perilesional mandibular bone observing possible correlations from them. Our results allow to express two hypotheses about the mechanism responsible for these results relating to mandible matrix necrosis; first, an increased skeletal microdamage associated with turnover suppression occurred early in treatment and progress with longer treatment duration, second, opening damage in osteonecrosis of the jaw modifies structural morphology of gingival epithelium.

Five years follow-up of implant-prosthetic rehabilitation on a patient after mandibular ameloblastoma removal and ridge reconstruction by fibula graft and bone distraction

This case report presents a combination of surgical and prosthetic solutions applied to a case of oral implant rehabilitation in post-oncologic reconstructed mandible. Bone resection due to surgical treatment of large mandibular neoplasm can cause long-span defects. Currently, mandibular fibula free flap graft is widely considered as a reliable technique for restoring this kind of defect. It restores the continuity of removed segment and re-establishes the contour of the lower jaw. However, the limited height of grafted fibula does not allow the insertion of regular length implants, therefore favouring vertical distraction osteogenesis as an important treatment choice. This report presents a patient affected by extensive mandibular ameloblastoma who underwent surgical reconstruction by fibula free flap because of partial mandibular resection. Guided distraction osteoneogenesis technique was applied to grafted bone, in order to obtain adequate bone height and to realize a prosthetically guided placement of 8 fixtures. After osseointegration, the patient was rehabilitated with a full arch, screw-retained prosthetic restoration. At five-years follow up, excellent integration of grafted tissue, steady levels of bone around the fixtures and healthy peri-implant tissues were reported.

Sclerotherapy for cervical cystic lymphatic malformations in children. Our experience with computed tomography-guided 98% sterile ethanol insertion and a review of the literature

PURPOSE

The treatment of cystic lymphatic malformations of the neck and mediastinum is controversial. Surgical management may be limited by the invasiveness of the procedure, the complex anatomy of this region, and the high recurrence rate. An alternative therapeutic method is sclerotherapy. We report our experience in the treatment of cystic lymphatic malformations of the neck by computed tomography (CT)-guided instillation of 98% sterile ethanol in children.

METHODS

Eight children with clinical suspicion of cervical cystic lymphatic malformation were assessed by ultrasonography (US) and magnetic resonance imaging (MRI) to define the location, size, and number of cystic cavities. The CT-guided instillation of 98% sterile ethanol was performed. Cystic fluid was analyzed by fine-needle aspiration cytology. Clinical and US or MRI follow-up was performed after 1 and 3 months and at 1 and 2 years.

RESULTS

The results were excellent with complete disappearance of the lesion in 7 (87.5%) of 8 patients. One patient (12.5%) with satisfactory results required a second alcohol injection with an excellent outcome. No allergic reactions or complications were observed.

CONCLUSIONS

The CT-guided 98% sterile ethanol sclerotherapy is a good alternative to surgical therapy. This procedure seems accurate, minimally invasive, safe, low cost, and reliable without untoward complications. Moreover, it does not exclude later surgical treatment.

Immunohistochemial evaluation of sarcoglycans and integrins in gingival epithelium of multiple myeloma patients with bisphosphonate-induced osteonecrosis of the jaw

Osteonecrosis of the jaw (ONJ) is an adverse outcome associated to bisphosphonate treatment. However, it is not known whether the ONJ lesion originates in the bone, or whether it may initiate in the oral mucosa. The aim of our study was to evaluate the pattern of basal lamina of oral mucosa after bisphosphonate administration and to analyze the structural damage of the mucosa in ONJ patients, and in subjects treated with bisphosphonates without osteonecrosis. By immunohistochemistry, we evaluated changes in basement membrane by expression of signalling proteins, laminin, and type IV collagen. All tested proteins were almost absent in basal lamina and mucosa of subjects treated with bisphosphonates without osteonecrosis, whereas in mucosa of patients with ONJ, they showed a clearly detectable pattern of the same proteins, specifically in basal lamina, but less in comparison to control samples. Moreover, in pathological mucosa, the clearly detectable staining pattern for VEGF indicated a massive neoangiogenesis. Bisphosphonates induce changes in expression of proteins also in oral mucosa. The increase of these proteins in basal lamina, and the neo-angiogenesis, concomitant with formation of the lesion, could indicate a compensative behaviour in the remodelling of the gingival mucosa in order to restore the epithelial architecture.

Bisphosphonates induce apoptosis of circulating endothelial cells in multiple myeloma patients and in subjects with bisphosphonate-induced osteonecrosis of the jaws

Bisphosphonates (BPs) are the current standard of care for bone lesions in patients with multiple myeloma (MM) but they are associated with a number of side effects such as osteonecrosis of the jaw. The exact mechanisms of osteonecrosis are not elucidated, and its physiopathology is based on several hypotheses such as a decrease in bone remodeling or an inhibitory effect on angiogenesis. The aim of our study was to investigate the mechanism involved in the pathogenesis of osteonecrosis. We examined the apoptosis of circulating endothelial progenitor cells in MM subjects before and after BP treatment and in osteonecrosis patients using a flow-cytometric analysis. Our data showed an increase in endothelial cell apoptosis in MM patients after BP administration and in osteonecrosis subjects. Our study seems in agreement with the hypothesis that BPs can inhibit angiogenesis interfering with endothelial cell proliferation and survival, leading to loss of blood vessels and avascular necrosis.

Anterior Skull Base Reconstruction With a Galeal-Pericranial Flap

Excision of neoplasm and trauma involving the anterior cranial base may often result in communication between the intracranial and extracranial compartments. Many techniques have been proposed to obtain a watertight separation. We report our 5 years of experience in the management of anterior skull base defects using a galeal-pericranial flap. Between January 2001 and April 2006, 22 patients were treated for a cranial base reconstruction at the University of Messina. Five of them presented with persistent cerebrospinal fluid (CSF) leak after previous craniofacial trauma. Ten underwent a combined maxillofacial-neurosurgical approach for the removal of a benign tumor involving the anterior skull base. Seven had severe craniofacial trauma, which required an intervention of reconstruction of the anterior skull base. In the whole series, a galeal-pericranial flap was used to separate intra- and extracranial compartments. No patients developed postoperative brain contusions or subdural-epidural blood collections. Throughout the follow-up period, there was no evidence of flap failure. In all but one patient, no postoperative CSF leak was evident. In one patient, a mild transient postoperative CSF leakage was present. There has been no recurrent CSF leak or meningitis. The follow up average of 23 months shows no incidence of infection. Even if our series does not comprise malignancies and previously irradiated patients, our data confirm the validity of the galeal- pericranial flap for the surgical management of minimal and moderately sized defects of anterior cranial base.

Maxillofacial traumas

Craniofacial traumas often involve the orbital region. This report describes an unusual case of penetration of an object into the left upper oral vestibule up to the left medial-upper orbital wall. The object was an indicator switch. A multidisciplinary approach was necessary to make a correct diagnosis and to apply the best surgical treatment. The object was surgically removed, and rigid internal fixation was used to reconstruct the inferior and medial orbital walls. The aesthetic and functional results were good. One year later, the patient showed a slight enophthalmos with normal ocular motility.

Sublingual epidermoid cyst

Dermoid and epidermoid cysts are developmental pathologies that occur in the head and neck with an incidence ranging from 1.6 to 6.9%, and they represent less than 0.01% of all oral cavity cysts. Our purpose is to report a case of sublingual epidermoid cyst of the floor of the mouth. We studied and operated on an 18-year-old white male patient showing a large swelling of oral floor. His main symptoms were difficulty breathing, swallowing, and speaking. At his birth the patient's tongue was adherent to the floor of the mouth. His father had the same problem at birth. Both father and son underwent surgical separation of tongue, during the post-neonatal period. After the surgical removal of the swelling, under general anesthesia, all the patient's symptoms were missed. Histological examination of the mass confirmed the diagnosis of an epidermoid cyst. No relapse of the lesion was present in ten months of follow-up. Many theories are proposed on the etiology of the epidermoid and dermoid cyst. In this case a traumatic event can be found, such as an operation of the tongue in neonatal age. However a multifactorial origin must be assumed for justifying the fact that the patient's father did not develop a dermoid cyst although he had the same problem of an adherent tongue and was operated on.