Jaw osteonecrosis in patients treated with bisphosphonates: an ultrastructural study

Osteonecrosis of the jaw is a severe bone disorder traditionally associated with periodontal disease, local malignancy, chemotherapy, glucocorticoid therapy, or trauma. Recently a growing number of publications reported the occurrence of osteonecrosis of the jaw in patients undergoing treatment with bisphosphonates. The mechanism by which bisphosphonates might contribute to the development of osteonecrosis of the jaw is far from being fully elucidated. Suppression of bone turnover, infection, tissue hypoxia and cellular toxicity were proposed as possible mechanisms by which bisphosphonates may exert adverse effects on bone metabolism. Here, we studied 25 consecutive patients treated with bisphosphonates for osteoporosis or tumoral pathologies. We provide good evidence of hyperactive osteoclastic bone resorption and suggest a direct cytotoxic effect of bisphosphonates on bone tissue through induction of osteocyte cell death. We also demonstrate that bisphosphonates only have limited adverse effects on bone vascular network.

Endoscopic dacryocystorhinostomy: personal experience

Data are reported on a series of 52 endoscopic procedures of dacryocystorhinostomy, performed in the Department of Otorhinolaryngology of the Hospital of Varese, between May 1999 and February 2003. The study population comprised 42 patients (32 female, 10 male. mean age 57 and 51 years, respectively) with naso-lacrimal obstruction. In all cases, pre-operative diagnosis consisted in irrigation of the lacrimal pathways, confirmed on dacryocystography; in selected cases, an additional computed tomography examination was carried out. All procedures were performed under general anaesthesia and surgical times were recorded; mean time for primary dacryocystorhinostomy was 30 minutes. A silicone tube was inserted in all patients for a period of 3 months. The procedure was successful in 81% of primary dacryocystorhinostomy cases and in 75% of revision dacryocystorhinostomy cases. Personal clinical and surgical experience, focusing on surgical techniques used in dacryocystorhinostomy, is described.

An unusual tonsillolithiasis in a patient with chronic obstructive sialoadenitis

Concretions in the tonsil or peritonsillar area are an infrequent entity in clinical practice. Some patients have no symptoms or they can present with fetor oris or odynophagia. The lesions are often detected incidentally during radiographic examination. This pathology can be related to lithiasis in other regions of body. The authors describe a tonsillolith accidentally detected in a patient with a lithiasis of left submandibular gland. We review published cases of tonsilloliths and analyse the causes of stone formation in peritonsillar and tonsil regions.

[Hurthle cell neoplasm: our experience]

Hurthle cell neoplasm is a rare form of thyroid tumors, comprising from 1.5% to 10% of all tumors. Hurthle cell nodules are clinically indistinguishable from other nodular thyroid diseases. The histologic features of Hurthle cell neoplasm don't allow us to exactly distinguish benign nodules from malignant ones. Accurate histologic valutation is possible and necessary for a correct diagnosis and therapy of Hurthle cell tumors. The adenomas usually exhibit a follicular pattern; the carcinomas include a subset of Hurthle cell tumors with different biological behavior, including malignant follicular variants and papillary ones. The authors are in favour of total thyroidectomy for carcinomas and lobectomy plus isthectomy for adenomas; in case of carcinomas, the lymphadenectomy reduces the incidence of local relapse and is necessary in case of lymphnode involvement. Adjuvant radiation therapy is successful in preventing recurrences, in symptomatic metastates as palliative therapy and control recurrence of advanced resected tumors.

Atypical carcinoid tumour of the larynx treated with CO2 laser excision: case report

A case of atypical laryngeal carcinoid tumour of the right aryepiglottic fold is described in a 56-year-old female. The patient presented a 4-year history of dysphagia, occasional dyspnoea and pain originating in the right tonsillar fossa and radiating to the ear. A sessile, submucosal neoplasm of about 1 cm in diameter and apparently benign appearance was detected endoscopically in the supraglottic region. An excisional biopsy was collected by CO2 laser during direct microlaryngoscopy from which a diagnosis of atypical carcinoid tumour of the larynx was made, and later confirmed by histochemical and immunohistochemical staining. Post-operative course was uneventful, with return to a normal diet per os on the first post-operative day. Histopathological evaluation of the excised specimen revealed the presence of a neoplasm in proximity of the surgical margins, which were not, however, directly involved by the tumour. The close endoscopic follow-up was, nonetheless, implemented in order to promptly detect any evidence of relapse of the disease. After 18 months, a lesion, suspected of being a recurrence, was found, in the site of the original tumour. CO2 laser excision was again carried out, this time allowing for wider margins on the surgical resection. The post-operative diagnosis confirmed the clinical hypothesis of recurrence of atypical carcinoid tumour. The patient is presently alive and free from disease 7 years after the second endoscopic procedure. The difficult aspects of clinical and histopathological diagnoses, the surgical treatment as well as endoscopic and instrumental follow-up of this rare condition are discussed.

[Cyst and pseudocyst of oral maxillo-facial region. Clinical and therapeutical considerations]

Oral and maxillo-facial cysts are very common lesions that show different clinical and pathological aspects. The surgical treatment of these lesions is conditioned by many factors such as the lesion dimension, the involvement of vascular and neurological structures, the presence of recoverable teeth into the cyctic area, the conditions of the patient. For these reasons surgical treatment guidelines may greatly diverge in the various cases. There are three different kinds of treatment: cystotomy (Partsch I), cystectomy (Partsch II) and a combination of the two reported surgical treatments: at first Partsch I and in a second time Partsch II. The authors present two cases of maxillo-facial cysts that are characterized by different clinical aspects: a follicular cyst in a male, nine years old, and a retention cyst located in the tongue of a young female. Follicular cyst is a very common lesion of maxillary bones related to an impacted tooth; retention cyst is a rare soft tissue pathology. The analysis of these so different cases permits to formulate many interesting observations about the main aspects of diagnosis, treatment and management of patients affected by maxillo-facial cysts.

[Laryngeal carcinoma associated with congenital tracheobronchomegaly (Mounier-Kuhn syndrome): a case report]

Congenital tracheobronchomegaly or Mounier-Kuhn Syndrome is a rare disorder of controversial etiology. It is characterized by an abnormal enlargement of the trachea and primary bronchi, because of atrophy or absence of their elastic fibers and smooth muscles. Such alterations lead to the collapse of the respiratory tract during forced exhalation, making expectoration by coughing of little use. Subjects with this disorder are, therefore, predisposed to the development of phlogistic bronchopulmonary pathologies such as bronchitis, emphysema, bronchiectasis and pulmonary fibrosis. The present work reports the case of a 65-year-old man suffering from asymptomatic congenital tracheobronchomegaly which was unknown until preoperative testing was performed (standard chest x-ray, tracheobronchoscopy) following a diagnosis of squamous cell carcinoma of the larynx. The patient underwent total laryngectomy and bilateral neck dissection without any intra- and postoperative complication. This is the first case reported in the literature of an association between laryngeal carcinoma and Mounier-Kuhn Syndrome, although a cause-effect relationship between the two pathologies cannot be advanced at this time. This paper also reports how the patient was managed in terms of anesthesiology and surgical technique, both conditioned by the marked tendency for anteroposterior tracheal wall collapse and its high reactivity to mechanical insults.

[False mass in the left atrium... or better: true mass in false atrium]

We report the case of a 59-year-old man who underwent transesophageal echocardiography following a cryptogenic minor stroke. An image of a solid mass of the left atrial appendage, highly suggestive of a thrombus, was observed. The patient was treated for 10 weeks with oral anticoagulants. Because of the absence of changes in the echocardiographic appearance of the mass at follow-up, the patient was submitted to surgery. At surgical exploration no endocavitary thrombus was found, but the left atrial appendage appeared hypoplastic and dysmorphic. A biopsy was taken and the left atrial appendage was plicated. To our knowledge, this is the first report of a case of dysmorphism of the left atrial appendage mimicking a left atrial thrombus in a patient with cryptogenic minor stroke.

[Unusual case of hypercondensing malignant osteodysplasty: osteopetrosis]

Osteopetrosis, known also as Albers-Schonberg disease, is a genetic disorder causing a generalized sclerosis of the bones and the reduction of the marrow. The diagnosis is often secondary to pathologic processes and its usually observed through specific X-ray researches. The principal cause of osteopetrosis is to attribute to a deficit of bone resorption and remodelling. Osteomyelitis is a complication of osteopetrosis. The purpose of this article is based on several point: 1) to know the cause of osteopetrosis, then to classify and check it; 2) to present the case who did not respond to of a patient with osteopetrosis complicated by maxillary and phalanx osteomyelitis common therapies and give an accurate analysis.

[Functional results after type I thyroplasty with the Montgomery's prosthesis]

Between January 1999 and October 2000, 16 patients with glottic insufficiency of varying etiologies underwent Montgomery type I thyroplasty at the E.N.T. Department of the University of Brescia, Italy. In 2 cases revision surgery was required for the onset of delayed complication (cutaneous and endolaryngeal exposure of the prosthesis). All subjects underwent a battery of clinical-instrumental tests pre- and postoperatively as well as 2, 6 and 12 months after surgery. These tests included videolaryngostroboscopy, subjective perception analysis using the GRBAS scale proposed by Hirano on vowels, statements and songs, and, using the Multi-Dimensional Voice Program (MDVP), acoustic measurement of the following parameters: jitter (J), shimmer (S), noise to harmonic ratio (NHR) and maximum phonation time (MPT). The patients also filled out a self-evaluation questionnaire to judge the postoperative voice and this was used to calculate the "voice handicap index" (VHI). In order to make the study sample as homogeneous as possible, detailed pre- and postoperative functional data were studied only for the 11 patients with glottic insufficiency subsequent to monolateral vagal or recurrent paralysis. Analysis of these data revealed that, in these patients, postoperative perceptive and subjective evaluation was similar to that found in normal subjects. Videolaryngostroboscopy showed that the glottis closed completely in most cases and objective acoustic analysis parameters were significantly improved after surgery. Despite the small sample, our functional results confirm the validity of the cord medialization technique through an external approach in laryngeal hemiplegia. In cases of glottic insufficiency of various etiologies (trauma, scarring subsequent to external and/or endoscopic surgery and radiotherapy), more accurate selection of the patients is required to reduce the incidence of complications and to improve vocal results.

[Pleomorphic adenoma of the parotid gland in childhood]

BACKGROUND

The authors report the results of ten years' activity at the Pedodontic Surgery Unit in the Institute of Maxillofacial Surgery at the Second University of Naples and analyse the possibility of conservative treatment of pleomorphic adenoma in childhood.

METHODS

The study includes 614 cases of salivary gland pathology. The authors illustrate the epidemiological, clinical and therapeutic characteristics of this type of lesion in childhood, emphasising that the data emerging from this study do not differ from the clinical and therapeutic management of pleomorphic adenoma in young patients reported in the literature.

RESULTS

In particular, they emphasise that satisfactory therapeutic results can be achieved using conservative techniques, like conservative superficial parotidectomy.

CONCLUSIONS

Conservative superficial parotidectomy has the advantage of being less radical and traumatic for a young patient, without provoking a significant increase in recidivation.

[Laryngeal-tracheal resection in the treatment of thyroid malignancies: description of a case and review of literature]

Well-differentiated thyroid carcinomas infiltrate into the respiratory tract in between 0.9 and 7% of the cases. Laryngeal-tracheal involvement--most often discovered intra-operatively--can substantially modify the surgical approach. It should be evaluated pre-operatively through laryngo-tracheoscopy with a flexible fibroscope and, in some selected cases, using CT or NMR. Thyroidectomy, associated with laryngeal-tracheal resection and termino-terminal anastomosis, ensures good oncological results without any negative effect on the incidence of post-operative complications. The present work reports the case of a 64-year-old patient who, for 5 months, had presented a swelling of increasing consistency in the left hemithyroid, fixed on the deep planes. Echography showed a 5 cm mass in the left lobe and thyroid isthmus, without suspected lymphadenopathy for metastasis. Fine needle cytology was compatible with papillary carcinoma. CT using a contrast medium revealed an infiltration into the left antero-lateral wall of the I and II tracheal ring, with submucosal extension with no significant signs of stenosis of the airway. Esophagogastroscopy was normal while tracheobroncoscopy confirmed the radiological picture and made it possible to perform a tracheal biopsy which proved positive for papillary carcinoma. The patient underwent total thyroidectomy associated with anterior compartment lymphadenectomy and crico-tracheal resection of the cricoid arch and the first 5 tracheal rings. When surgery was completed, the patient was extubated without complications. Post-operative recovery was uneventful and the patient was discharged on the 9th day after surgery. Histopathological examination confirmed the pre-operative diagnosis and made it possible to stage the lesion as pT4N1bM0 because of the presence of one prelaryngeal lymph node metastasis and another one at the right paratracheal space. Complementary I131 therapy was scheduled along with periodic laryngo-tracheoscopic controls. 16 months after surgery the anastomotic line is perfectly healed and the patient is clinically disease free. A review of the literature on the surgical treatment of well-differentiated malignant thyroid neoplasms with respiratory tract involvement through resection and laryngo-tracheal anastomosis has made it possible to trace the indications, limits and results of this type of therapeutic approach.

[The complications and outcomes of fractures of the orbital-maxillary-zygomatic complex]

Thirty-three cases of complicated zygomatic-maxillary complex fractures and their complications and sequelae are analysed. Permanent alterations in infraorbital nerve sensitivity (4 cases), amaurosis caused by enucleation of globus (2 cases), diplopia recovered in sixteen cases without treatment and after operation in two cases, ectropion (1 case), subcutaneous emphysema (1 case), scars (3 cases) have been surveyed.

[The clinical applications of biomaterials]

The more and more availability of new alloplastic materials in oral and maxillo-facial reconstructions causes the necessity of judging if the biomaterials satisfy the surgical needs. The authors re-examine the main chemical, physical and biological characteristics of following materials: hydroxylapatite, polytetrafluoroethylene, polyglactin 910, polyfluorocarbons, polypropylene and report their experiences.

[Hypertrophy of the masseter: a rare case associated with hypertrophic cardiomyopathy]

Masseteric hypertrophy is a rare, monolateral or bilateral lesion. The aetiology is often unknown and both congenital and acquired forms are reported in the literature. The authors report a case of masseteric hypertrophy associated with hypertrophic cardiomyopathy. Family history shows two brothers suffering from the same cardiac disease. Echography, computed tomography, EMG test and aspiration biopsy of masseteric muscle were performed. Echocardiography and HLA, B and C antigens of 16 relatives were also performed. In the report case the authors hypothesized a multifactorial background on a genetic basis.

[The therapy of carcinomas in the oromaxillofacial area. IV. Carcinomas of the buccal mucosa]

The authors describe the therapeutic modalities for the care of epidermoid carcinoma of the buccal mucosa. Surgery and radiotherapy are equally effective in the early lesions, while for the advanced disease the therapy should always be combined.

[Therapy of carcinoma of the oro-maxillo-facial region. 3. Hard palate and upper gums]

The Authors describe the therapeutic modalities for the care of epidermoid carcinoma of the hard palate and superior gingiva. Surgery and radiotherapy are equally effective for the early stages, while in the advanced disease therapy should be always combined.

[Tooth heterotopy with endosinus localization]

Among the various cases of etherotophy, the only and multiple, that has observed, the Authors consider only a few among the significant ones and with endosinusal localization-after examining the probable mechanism patogenetic we pay attention to the necessity of an exact diagnostic judgement and on the opportunity of a precocious and exact treatment.

Prevention of neoplasms of the oral-maxillo-facial region: operative proposals

The authors, with their experience in the field of dépistage of maxillofacial cancer, propose the establishment of a health education program for prevention and early diagnosis.