Color Doppler Ultrasound Indices as Predictors of Propranolol Response in Infantile Hemangioma: A Prospective Study

OBJECTIVE

To evaluate the utility of color Doppler ultrasonography in assessing infantile hemangioma response to treatment with oral propranolol.

METHODS

A prospective study was conducted between January, 2016 and December, 2022, wherein children with symptomatic (ulceration, bleeding, pain and scarring) infantile hemangioma were given oral propranol (2 mg/kg per day in three divided doses) as outpatient therapy. The clinical response was assessed three months post-initiation of treatment (intermediate clinical response) and three months post-completion of treatment (final clinical response, FCR). The primary outcome measurement was a clinical and radiological response (resistivity index (RI), pulsatility index (PI) and peak systolic velocity) to treatment. The secondary outcomes assessed were the complications related to treatment.

RESULTS

Out of 601 patients who were started on propranolol, 99 developed severe adverse effects and were excluded from analysis. At FCR assessment, out of 502 participants, 64.3% (n = 323) showed excellent response, 17.7% (n = 89) showed partial, and 17.9% (n = 90) were non-responders. A significant increase in RI and PI values was noted in all children following propranolol treatment for six months. An increase > 7.5% in RI could identify responders with 92% sensitivity, 91% specificity and area under the curve (AUC) of 0.963. An increase of > 11.5% in PI could identify responders with 86% sensitivity, 91% specificity and AUC of 0.896. Patients initially showing no response but later becoming excellent responders had significantly higher RI and PI values.

CONCLUSIONS

Color Doppler ultrasonography is a valuable tool in predicting the treatment outcome of infantile hemangioma using propranolol.

Locally Advanced oral Squamous cell Carcinomas: Auditing and Outcome Appraisal

Introduction: Patients with OSCC in India (oral squamous cell carcinoma) presents at a later stage with approximately 28% presenting at stage III and 64% at stage IV disease. In this retrospective study we have reviewed the treatment modalities rendered and outcomes associated for the management of locally advanced oral squamous cell carcinoma in our Institute. We evaluated the survival data and the factors effecting survival. Methods: Kaplan Meir method was used to evaluate OS and DFS rate and log rank test was used to compare the survival amongst groups. Cox regression analysis (univariate and multivariate) was used to evaluate the hazard ratio to find out the possible factors influencing risk of death and disease. Results: The median OS and DFS in our study were 32 and 24 months respectively. On a subset analysis of only T4b patients who underwent either upfront surgery or induction chemotherapy followed by surgery there was no significant difference in OS and DFS. All patients with TURD had partial response after induction chemotherapy and were subjected to surgical resection followed by adjuvant therapy. Conclusion: Extracapsular spread, bone involvement, skin infiltration, treatments, surgical margins and Lymph node size are the prime predictors of survival.Upfront surgery remains the standard of care for resectable LAOSCC. Induction chemotherapy might improve the resectability in technically unresectable OSCC. There is no difference in survival between concurrent chemoradiation, sequential chemoradiation and radical radiotherapy in the management of unresectable disease.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04168-4.

Comparative Evaluation of Nasolabial Flap, Buccal Fat Pad and Platysma Myocutaneous Flap for Reconstruction of Oral Sub Mucous Fibrosis Defects

Moderately advanced (stage III) and advanced (stage IV a & b) OSMF requires surgical intervention for management A number of options are available for reconstruction of post OSMF oral cavity defects. In our study we retrospectively compared buccal fat pad, nasolabial flap and platysma flap for reconstruction of the buccal mucosal defects. Patient records were obtained from the medical records section of the Institute and divided into three groups; group A (buccal fat pad), group B (nasolabial group) and group C (platysma flap). Maximal mouth opening and intercommisural distance were the primary outcomes. Kruskal Wallis test was used to test the mean difference between three groups. Mann-Whitney test was used for intergroup comparisons. Wilcoxon signed rank test was used to evaluate the mean difference in outcomes at each follow up interval. A p value of < 0.05 was considered as statistically significant at 95% confidence interval. After 1 year follow up patients in platysma group had significantly better mouth opening (39.84 ± 1.65 mm) compared to both buccal fat pad (36.69 ± 3.41 mm) and nasolabial groups (37.94 ± 0.43 mm). Inter commisural distance was significantly better in patients reconstructed with platysma flap (59.21 ± 0.99 mm) compared to both buccal fat pad (54.11 ± 1 mm) and nasolabial flap (56.84 ± 1.48 mm). Platysma flap lead to significantly better maximal mouth opening compared to both nasolabial and buccal fat pad. Both buccal fat pad and nasolabial lead to comparable mouth opening. Inter commissural distance is maximum with platysma flap followed by nasolabial flap and buccal fat pad.

Kite String (Manjha) Injuries Among Children: Single Center Experience Over Four Years

We reviewed hospital records for kite-string injuries among children over four years (2017-2022). Of 42 affected children, mortality was 9.5%. The mean (SD) Pediatric Trauma Score (PTS) was 8.02 (2.66), with passively involved children facing greater severity [mean (SD) PTS, 5.58 (2.23)]. Kite-string injuries, alarmingly, endanger even bystanders, urging stricter preventive strategies.

Survival Outcomes and Factors Affecting Survival in Resectable Locally Advanced Oral Squamous Cell Carcinoma

Management of locally advanced OSCC include primary surgery followed by adjuvant radiotherapy or chemo radiation, concurrent chemo radiation, induction chemotherapy followed by surgery or non surgical methods. In resectable disease the role of induction chemotherapy is questionable and surgery remains the first choice. In this study we aimed at evaluating the survival and factors effecting survival in locally advanced oral cancer. retrospective review of patient records was made. Kaplan Meir method was used to evaluate OS and DFS rate and log rank test was used to compare the survival amongst groups. Cox regression analysis (univariate and multivariate) was used to evaluate the hazard ratio to find out the possible factors influencing risk of death and disease. The 3 year OS of the entire cohort was 56.80% and 3 year DFS was 52.4%. ECS, surgical margin, PNI, LVI and LN size were independent risk factors for poor overall and disease free survival. We identified ECS, positive margin, LVI, PNI and LN size as independent risk factors effecting survival. These factors justify the use of adjuvant radiotherapy or chemo radiation according to the already available guidelines.

Outcome of Mandibular Reconstruction with Fibula free Flaps: Retrospective Analysis of Complications

Rationale: Fibula free flap has become the workhorse for head and neck reconstruction. In this retrospective study we aimed at determining the outcomes of mandibular reconstruction with fibula free flaps. Methods: Any patient who underwent a mandibulectomy and reconstructed with vascularised fibula flap was included in the study. The predictor variables were age, sex, type of lesion, tobacco and alcohol use, tracheostomy, neck dissection, post operative radio and chemotherapy. Flap failure, fistulas, dehiscence, bone exposure and hardware complications were the outcomes. A P value of < 0.05 was considered statistically significant. Results: 242 patient records were selected for evaluation. PORT, CRT, neck dissection, no. of segments were the factors significantly associated with every complication. Malignant lesion was significantly associated with every complication except for plate fracture. Plate fracture although occurred more frequently with malignant diseases, the association was insignificant. Tobacco consumption was significantly associated with increased incidence of post -operative complications. Alcohol consumption was significantly associated with plate fracture, screw loosening, fistulas, bone exposure and flap failure. Conclusion: Overall the fibula free flap has a success rate of 90.0% with fistulas being the most significant complication.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-022-03344-2.

Efficacy of Arthrocentesis and Stabilization Splints in Treatment of Temporomandibular Joint Disc Displacement Disorder Without Reduction: A Systematic Review and Meta-analysis

Background

Temporomandibular joint disc displacement disorders are a group of temporomandibular disorders beside from other inflammatory disorders and growth related disorders of joint. The purpose of this analysis was to evaluate the efficacy of arthrocentesis procedure in comparison with stabilization splints used for disc displacement disorders without reduction.

Materials and Methods

A systematic search was done in electronic databases (PubMed, Cochrane Central, Web of Science). In addition to this hand search of references and grey literatures was done. Qualities of randomized controlled clinical trials were assessed by Cochrane's tool for Systematic Reviews of Interventions and the Newcastle-Ottawa Scale was followed to assess the prospective and retrospective studies. Outcome variables pain (VAS) and maximum mouth opening were assessed by the software review manager 5.03.

Results

A total of five studies were included in the review. Three studies showed greater improvement of symptoms in patients of arthrocentesis group in terms of maximum mouth opening, pain (VAS) value. Two other studies found no significant advantage of arthrocentesis over the other treatment protocol. The meta-analysis resulted in statistically significant difference between outcome variables favouring arthrocentesis group (VAS 1-10) (Mean Difference: 3.10; 95% CI 1.74, 4.45; P ≤ .00001, Mean difference: 2.00; 95% CI 0.29, 3.71; P = 0.02).

Conclusion

Arthrocentesis showed effective result in terms of increase in mouth opening and reduction of pain level compared to stabilization splint and other non-invasive approaches in patients with disc displacement disorders without reduction. Overall, results supported the rationale of using arthrocentesis in patients with disc displacement disorders without reduction.

Bleomycin-triamcinolone sclerotherapy in the management of propranolol resistant infantile hemangioma of the maxillofacial region: A single arm prospective evaluation of clinical outcome and Doppler ultrasound parameters

INTRODUCTION

Propranolol has emerged as a first line agent in the management of hemangiomas. With increased use of propranolol, studies have also focused on relapses following propranolol therapy. Our current study evaluates the role of bleomycin triamcinolone sclerotherapy for the management of propranolol resistant Infantile Hemangioma (IH). We also evaluated the role color Doppler USG for response assessment of sclerotherapy.

METHODS

Patients with Propranolol resistant (Non- responders/ Partial responders) IHs were included in the study. Patients received intralesional bleomycin at a dose of 0.5 IU/kg followed by intralesional injection of triamcinolone at a dose of 2mg/kg body weight. Clinically patients were grouped into excellent, partial and non responders. Doppler parameters; Resistivity index (RI), Pulsatility index(PI) and Peak systolic velocity (PSV) were used to evaluate the response to sclerotherapy. These parameters were evaluated prior to sclerotherapy and 3 months following completion of therapy. The clinical responses of the patients were compared with the change in Doppler parameters before and after treatment.

RESULTS

A total of 115 participants were considered for analysis; 60.86% had excellent response, 32.17% had partial response and 6.95% had poor response. There was a significant change in terms of RI, PI and PSV in patients who were either excellent or partial responders. Poor responders did not have a significant change in Doppler parameters.

CONCLUSION

Combined bleomycin- triamcinolone sclerotherapy is an effective therapy for the management of propranolol resistant IHs. Doppler parameters RI, PI and PSV are reliable indicators of response in the management of IH.

Influence of Site, Size, Depth of Invasion and Histologic Grading on the Occurrence of Cervical Level IIb Metastasis and Extranodal Extension in Clinically N0 Neck of Patients with OSCC: A Single Center Retrospective Analysis

Background

Depth of Invasion ≥ 4 mm, T stage and primary site with more than 20% chances for occult metastasis are currently the accepted indications for elective neck dissection. Nodal metastasis decreases survival by 50%. ENE further reduces the prognosis. Dissection of level IIb lymph nodes in clinically N0 neck does not improve survival.

Methods

A total of 320 patients were evaluated. Binary and multiple logistic regression and chi-square test were used for data analysis. ROC curve with Youden's J index was used to set up a cutoff value for DOI. The predictor variables were site, size, grading and depth of invasion of primary tumor. Incidence of level IIb metastasis and ENE were the outcomes.

Results

The study revealed a significant association and risk stratification between primary tumor characteristics with the occurrence of ENE. The cutoff value for DOI predicting ENE was 12.5 mm. Tumors of the oral tongue were an independent risk factor for level IIb metastasis.

Discussion

Size of primary tumor, DOI, tumors of the mandibular alveolus and poor grading are independent risk factors for ENE. Isolated metastasis to level IIb rarely occurs in the absence of concomitant level IIa metastasis. Size, DOI and grading were significantly associated with level IIb metastasis. However, only tumors of the oral tongue were independent risk factor.

Sandwich therapy in the management of propranolol resistant infantile hemangioma of the lip

RATIONALE

Propranolol has evolved as a first line management of infantile haemangiomas. Nevertheless, the resistance to propranolol has warranted alternative treatment modalities. We hypothesize that combination of medical and surgical therapy (sandwich therapy) to be beneficial in the management.

METHODS

Patients were divided into three groups (total=31), Group A (bleomycin sclerotherapy), Group B (surgical group), Group C (sandwich therapy). A p value &lt;0.05 was taken as significant.

RESULTS

In Group A 54.5% of patients had excellent response, 27.3% partial response and 18.2% had no response. Comparing cosmetic outcome, 25% of patients in Group B and 16.7% of patients in Group C had excellent upshot. On the contrary 18.2% of patients in bleomycin had unsatisfactory and 18.2% had poor cosmetic outcome. Sandwich therapy was cosmetically more acceptable than Bleomycin sclerotherapy (p- value = 0.049). In terms of recurrence, sandwich therapy differed significantly from surgical therapy with fewer recurrences (p-value= 0.049).

CONCLUSION

Sandwich therapy is superior to bleomycin sclerotherapy in terms of cosmetic outcome and has fewer recurrences compared to surgical group and requires single stage resection. However, further studies with the help of Doppler ultrasound are required in this regard.

Sandwich osteotomy with interpositional grafts for vertical augmentation of the mandible: A meta-analysis

Sandwich osteotomy is a technique for vertical augmentation based on the principle of a graft being placed between two pedicled native bones. The inherent vascularization helps in graft consolidation. The aim is to review the bone height gained, implant survival and pitfalls with sandwich osteotomy. The PICO model was used to identify the suitable studies for the review. Oxford level of evidence, Newcastle Ottawa Scale and Cochrane's tool for Systematic Reviews of Interventions was applied for identifying study quality. Meta-analysis was performed with the help of RevMan. Funnel plot was used to evaluate publication bias and bias during article selection. Difference in means was used as principal summary measure. Fixed effects model with inverse variance statistics was used. I2test statistics was applied to identify study heterogeneity. Forest plots were produced for the outcome variables with 95% confidence interval (CI) and overall treatment effects and subgroup effects at a significance level of 0.05. The overall implant survival rate ranged from 90%-100% and prosthetic survival rate from 87%-95%. An overall 6-10mm of bone can be gained in the anterior mandible and 4-8mm in the posterior mandible. A total of 1030 implants were placed of which 988 implants survived after the mean follow up periods (odds ratio: 0.77, 95% CI: 0.49-1.21). Implant survival is independent of the graft being used. Vertical augmentation in the posterior mandible is limited compared to anterior owing to the presence of inferior alveolar nerve and the keratinized tissue deficiency.

How far we have come with the Management of Condylar Fractures? A Meta-Analysis of Closed Versus Open Versus Endoscopic Management

Background

The treatment approaches for condylar fractures of the mandible include functional, closed reduction and open reduction-internal fixation. Recently endoscopic management of condylar fractures has been emphasized in the literature. We systematically review the studies comparing closed versus open versus endoscopic-assisted condyle fracture management with regard to the indications, effectiveness and complications of each modality.

Methods

A total of 11 articles were selected based on the inclusion and exclusion criteria from PubMed, Cochrane and clinical trials.gov. Differences in means and risk ratios were used as principal summary measures with p value < 0.05 as significant. For detection of any possible biases in sample sizes, the OR and its 95% CI for each study were plotted against the number of participants. Chi-square test, I2 test and the Cochrane bias tool were used to assess the bias in and across studies.

Results

Except for deviation on opening there was no significant difference between open versus closed treatment of condylar fractures. Endoscopic approach and open surgical approaches differed only in terms of operating time and TMJ pain. There was no significant difference in facial nerve injury among the two groups.

Discussion

Closed reduction is particularly indicated for minimally displaced fractures; for moderate to severe displacement, open reduction is preferred. Open reduction can also be preferred over endoscopic approaches as there is no significant advantage of using latter. Limitations of the study included specific treatment according to the site of fracture not addressed, limited data regarding pediatric condylar fracture, lack of homogenous classification schemes, etc.

Assessing the optimal imaging modality in the diagnosis of jaw osteomyelitis. A meta-analysis

Osteomyelitis is an inflammatory infectious disease that affects bone and bone marrow. Histopathology remains the gold standard method for diagnosis, but imaging modalities also play an important role. We systematically reviewed five articles with comparative studies on plain films, computed tomography (CT) scan, magnetic resonance imaging (MRI), cone beam computed tomography (CBCT), positron emission tomography (PET), single photon-emission computed tomography (SPECT), scintigraphy, and SPECT/CT. Scintigraphy and SPECT/CT has the highest sensitivity of 100%. PET is only to be used in cases of follow up. Orthopantomography (OPG) is the most common initial diagnostic tool despite its low sensitivity. CT provides the necessary specificity needed for radionuclide imaging, which has the highest negative predictive value of 100% and a positive predictive value >95%. SPECT/CT with 100% sensitivity and 85% specificity can be considered as the imaging modality of choice for initial diagnosis and follow up.

Evaluation of Arthrocentesis with and Without Platelet-Rich Plasma in the Management of Internal Derangement of Temporomandibular Joint: A Randomized Controlled Trial

PURPOSE

The purpose of this study was to compare the efficacy of intra-articular injection of platelet-rich plasma after arthrocentesis versus arthrocentesis alone as a treatment modality in patients with internal derangement of temporomandibular joint.

METHODS

Twenty-four patients suffering from internal derangement of temporomandibular joint were included in the study. The patients were randomly divided into two groups as follows-twelve patients underwent arthrocentesis followed by intra-articular injection of platelet-rich plasma (study group) and the other twelve were treated by arthrocentesis alone (control group). Pain intensity was recorded on visual analogue scale (VAS); maximum mouth opening and joint sound were measured before and after intervention. The patients were clinically evaluated at the intervals of 1 month, 3 and 6 months subsequently.

RESULTS

There was no statistically significant difference in all the parameters between the groups. Intra-group analysis showed statistically significant improvement in all the parameters.

CONCLUSION

In both groups, improvement of pain, maximum mouth opening and TMJ sound were observed at all intervals, but there was no statistically significant improvement in arthrocentesis with PRP group when compared with arthrocentesis alone.

Implant survival in patients with neuropsychiatric, neurocognitive, and neurodegenerative disorders: A meta-analysis

Neurologic disorders impede oral hygiene measures and routine clinical follow-up, along with the various drugs used may jeopardise oral health and the peri- implant tissue health. A total of 7 studies were considered eligible for the current systematic review. The overall estimated effect was categorized as significant where P < 0.05. Funnel plot was used to assess the publication bias within the studies. Difference in means was used as principal summary measure. P value <0.05 was considered as statistically significant. 1069 implants survived in test group and 4677 implants survived in control group (odds ratio: 2.58, 95% CI: 1.93-3.43) indicating significant success in patient without any disorders or taking medications for these disorders. Subgroup analysis was done to check the implant survival rate in patients taking selective serotonin reuptake inhibitors (SSRI) compared with SSRI non-users. Subgroup analysis showed that SSRI non-users had higher implant survival rate than patients taking SSRI (odds ratio: 2.45, 95% CI: 1.82-3.31). Serotonin significantly inhibits bone mineralization and osteoblast differentiation. The presence of any form of neuropsychiatric or neuromuscular disorders precludes proper oral hygiene and may contribute towards implant failure.

Do medial sural artery perforator flaps have better clinical outcomes compared to the rectus abdominis perforator (DIEAP) flap in reconstruction of glossectomy defects? A Prisma guided meta-analysis

BACKGROUND

There is an increasing evidence for the use of thin flaps based on vascular perforators for reconstructive surgeries. The medial sural and deep inferior epigastric artery flaps offer versatility for the reconstruction of major defects of the head and neck.

OBJECTIVES

"Whether medial sural artery perforator (MSAP) flap or rectus abdominis perforator flap is better for the reconstruction of glossectomy defects in terms of functional outcome?"

DATA SOURCES

PubMed, Cochrane Library, clinicaltrials.gov and hand searches.

PARTICIPANTS AND INTERVENTIONS

Patients who underwent tongue reconstruction with either MSAP flap or deep inferior epigastric artery perforator (DIEAP) flap.

STUDY APPRAISAL AND SYNTHESIS METHODS

Based on defined study criteria 6 studies were selected according to Prisma Guidelines. The overall estimated effect was categorized as significant where P < 0.05.

RESULTS

There was no significant difference between both flaps in terms of receptor site complications (P = 0.223). Overall odds ratio (OR) for complications was 1.35 (95% confidence interval [CI]: 0.412-0.736) and the test for overall effect t value was 2.836, P < 0.05. Overall OR was 6.01 (95% CI 0.5-7.45) and the test for overall effect t value was 1.41, P < 0.05 indicating there was a statistical difference in the intelligibility of speech.

LIMITATIONS

Anatomical variations, under-reporting of studies and lack of universal tool for speech intelligibility.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Both the flaps are comparable in terms of functional outcome. Medium-sized defects can be reconstructed with MSAP and composite larger defects would benefit from DIEAP. In females, anterolateral thigh flap still remains the choice for composite reconstructions.

Magnitude of Gonial Angle Influence on the Commonness of Mandibular Angle Fractures

Background:

The aim of the study was to review the literature on the influence of gonial angle on mandibular angle fracture. The present systematic review addresses the following focus question: Does the magnitude of gonial angle influence the incidence of mandibular angle fractures?

Materials and Methods:

Electronic and manual literature searches were conducted on databases: PubMed/MEDLINE, Embase, Science direct, the Cochrane Library, and clinicaltrials.gov for studies published up to August 2019 to collect information about the effect of gonial angle, a skeletal morphological parameter with an incidence of fracture of the angle of the mandibular arch. Systematic literature review was performed to identify studies evaluating the effect of gonial angle in patients suffering from mandible fractures. Large retrospective studies were included and case reports were excluded.

Results:

Fifteen hundred articles published before August 2019 were identified. One hundred and sixteen articles met the inclusion criteria. Two articles remained when exclusion criteria were applied. As measured in the two included studies containing 280 panoramic radiographs of mandibular fractures, the mean gonial angle of patients in the angle fracture group ranged from 126.8° ± 7.9° to 128.5° ± 5.4°. The mean gonial angle of patients in the nonangle fracture group ranged from 118.5° ± 4.4° to 122.3° ± 4.9°. The mean gonial angle of patients in the angle fracture group displayed a range from 118.9° to 134.7° (confidence interval [CI] 95% 5.89–8.05), whereas the mean gonial angle of patients in nonangle fracture group displayed a range from 114.1° to 127.2° (CI 95% 3.89–4.95).

Conclusion:

A high gonial angle is an important factor influencing the occurrence of mandibular angle fractures owing to the poorer quality of bone and reduced height at the ramus angle region, all of which necessitate a modification of osteosynthesis techniques.