[Long-term results following mandibular resection in newborns with autogeneous rib graft for reconstruction of mandibular defects]

The authors report on the clinical course of two children, in whom benign tumors with destruction of the mandible were diagnosed at the age of 4 and 6 months respectively. Following mandibular continuity resection the lateral mandible was reconstructed with autogenous rib grafts. In both children craniofacial and mandibular growth was assessed during yearly clinical and radiological follow-up visits. A slight vertical overgrowth and transversal growth inhibition could be detected.

[Selective cervical lymph node dissection for primary, node-negative, oral squamous cell carcinoma: oncologic assessment and clinical relevance of prognostic factors for secondary local metastasis]

BACKGROUND

The aim of this retrospective study was to evaluate prognostic factors for the development of secondary local lymph node metastases in patients with oral squamous cell carcinoma who had undergone selective neck dissection for primary node-negative disease.

PATIENTS AND METHODS

The study included 331 patients with primary squamous cell carcinoma of the oral cavity who underwent 431 selective neck dissections between January 1986 and December 2002 in Germany at the Hannover Medical School's Department of Oral and Maxillofacial Surgery. Several potential prognostic factors were evaluated for their influence on the development of secondary metastases following primary neck dissection.

RESULTS

No statistically significant relationship to the appearance of secondary local metastasis following selective neck dissection was detected concerning: patient age or sex, histopathologic tumor stage, primary tumor grade, or adjuvant therapies such as pre- or postoperative radiotherapy and radiochemotherapy. The only study factor with a statistically significant influence was the extent of lymphadenectomy, in which particularly the region of the carotid bifurcation played a decisive role.

CONCLUSION

Significantly fewer secondary metastases occurred following neck dissections that included the carotid trigone. In light of these results, we recommend that neck dissection for primary oral squamous cell cancer always include the region of the carotid bifurcation, regardless of the above mentioned associated patient and tumor factors.

[Interdisciplinary treatment of carotid cavernous fistulas via the superior ophthalmic vein]

BACKGROUND

The endovascular occlusion of symptomatic carotid cavernous fistulae (CCF) via the transfemoral approach is safe and effective. Due to anatomical variations or after unsuccessful transarterial therapy, a direct surgical approach to the superior ophthalmic vein (SOV) may be necessary.

CASE REPORTS

In two patients with acute ophthalmologic symptoms coil occlusion of the CCF was performed after palpebral incision and cannulation of the SOV.

RESULTS

In both patients preparation of the SOV was performed successfully and without complications. After coil embolization of the CCF both patients had complete resolution of symptoms within several weeks. During a follow-up of 12 months there were no recurrences, but both patients exhibited moderate blepharoptosis.

CONCLUSION

Embolization of CCF via a surgically created approach is an effective procedure in selected cases when standard interventional treatment is not possible.

Das autologe Rippentransplantat zur �berbr�ckung von Kontinuit�tsdefekten des Unterkiefers

BACKGROUND

Reconstruction of mandibular defects following tumor resection in infants is a particular challenge. Although autologous rib grafts have no relevance nowadays for restoration of mandibular bone defects following ablative tumor surgery due to limited bone stock and the availability of other donor areas, they are a useful surgical alternative following tumor surgery in infants.

PATIENTS AND METHOD

We here report on the 5- and 10-year follow-up of two children who were diagnosed with benign tumors of the mandible with osseous destruction at the age of 4 and 6 months, respectively. Histological diagnoses were melanotic neuroectodermal tumor and hemangioendothelioma of the mandible. Following continuity resection of the mandible lateral mandibular bone defects were restored using autologous rib grafts. Yearly clinical and radiological follow-up visits in both children were performed to assess growth of the facial skeleton as well as mandibular growth.

RESULT

Cephalometric measurements on panorex films as well as 3D CT scans revealed slight vertical growth excess and transversal growth inhibition of the reconstructed mandible in comparison with the non-operated side.

DISCUSSION

Although further growth of rib grafts is difficult to predict and occlusal disharmony may occur due to physiologic maxillary growth and growth of the unaffected mandible, we believe that autologous rib grafts can be ideally used for restoration of mandibular continuity defects in newborns. Clinical follow-up visits on a yearly basis and orthodontic controls are useful for early orthodontic treatment of growth deficits. Further corrective surgery with bone augmentation or osseous distraction is required following completion of growth of the facial skeleton.

Epithelial malignancies of the salivary glands: clinical experience of a single institution—a review

In this retrospective study we give a clinical review of our experience with different subtypes of salivary gland cancer. Between January 1983 and December 2002, a total of 155 patients with carcinomas of the salivary glands received initial treatment at the Department of Oral and Maxillofacial Surgery, Hanover Medical School. There were 79 (51.0%) adenoid cystic carcinomas, 42 (27.1%) mucoepidermoid carcinomas, 12 (7.7%) adenocarcinomas, 10 (6.5%) polymorphous adenocarcinomas and 12 (7.7%) other tumor entities of smaller number. Complete resection was reached for 63.5% of patients with high grade carcinomas and for 80.0% of patients with low grade carcinomas. 26.2% of patients with high grade carcinomas and 13.3% of patients with low grade carcinomas received postoperative radiation. Overall survival rates at 5, 10 and 15 years were 65.9, 48.0 and 39.8% with significant difference for patients with high grade and low grade carcinomas. Histopathologic subtype, tumor stage and margin status significantly influenced prognosis. Statistically, we were not able to demonstrate a positive effect for postoperative radiation. In the future, patients with salivary gland carcinomas should be randomised for prospective multicentric clinical trials, which could provide reliable information about adjuvant treatment modalities and their results even for rare subtypes of salivary gland cancer.

[Malignant epithelial salivary gland tumors. Clinical review of 2 decades]

PURPOSE

In this retrospective study we give a clinical review of our experience with different tumor entities of salivary gland cancer.

PATIENTS

Between January 1983 and December 2002, a total of 155 patients with carcinomas of the salivary glands received initial treatment at the Department of Oral and Maxillofacial Surgery, Hanover Medical School.

RESULTS

There were 51.0% adenoid cystic carcinomas, 27.1% mucoepidermoid carcinomas, 7.7% adenocarcinomas, 6.5% polymorphous adenocarcinomas, and altogether 7.7% other less frequent tumor entities. Complete resection was achieved for 63.5% of patients with high-grade carcinomas and for 80.0% of patients with low-grade carcinomas. Postoperative radiation was administered to 26.2% of patients with high-grade carcinomas and 13.3% of patients with low-grade carcinomas. Overall local control rates at 5, 10, and 15 years were 77.5%, 66.2%, and 59.0%. Overall regional control rates at 5, 10, and 15 years were 93.5%, 87.6%, and 85,4%. Overall distant control rates at 5, 10, and 15 years were 85.9%, 77,2%, and 73,6%. Overall survival rates at 5, 10, and 15 years were 65,9%, 48,0%, and 39,8%. There was a significant difference between patients with low-grade and high-grade carcinomas. Polymorphous adenocarcinomas showed the best prognosis, followed by low-grade mucoepidermoid carcinomas, adenoid cystic carcinomas, adenocarcinomas, and high-grade mucoepidermoid carcinomas. The number of the remaining tumor entities was too small to be divided into independent subgroups for statistical analysis. Tumor entity, tumor stage, and margin status significantly influenced prognosis. Statistically, we were not able to demonstrate a positive effect for postoperative radiation.

CONCLUSION

Grading is important, but should be considered in the context of stage. In the future, patients with salivary gland carcinomas should be randomized for prospective multicenter clinical trials, which could provide reliable information about adjuvant treatment modalities and their results even for rare subtypes of salivary gland cancer.

Adenoid cystic carcinoma of the head and neck—a 20 years experience

In this retrospective study we give a clinical review of our experience with adenoid cystic carcinoma (ACC) and compare our results with those reported in the literature. Between 1981 and 2000, 74 patients with this disease were treated at our department. Complete resection was reached in 45 cases. Fourteen patients received postoperative radiation. Local control rates at 5, 10 and 15 years were 64%, 56% and 52% with a mean local control time of 11.1 years. Tumour size (P<or= 0.001), perineural invasion (P<or= 0.001) and margin status (P<or= 0.001) showed significant influence on local control. Statistically, we were not able to demonstrate a positive effect for postoperative radiation. Distant control rates at 5, 10 and 15 years were 72%, 62% and 59% with a mean distant control time of 14.4 years. Distant failure was diagnosed in lungs and bones and occurred independently of local treatment outcome. Overall survival rates at 5, 10 and 15 years were 71%, 54% and 37% with a mean overall survival of 11.2 years. Recurrence-free survival rates at 5, 10 and 15 years were 57%, 45% and 37% with a mean recurrence-free survival of 9.1 years. The survival rates at 5, 10 and 15 years after diagnosis of tumour progression were 35%, 15% and 0% with a mean survival time of 4.7 years. Our results provide insights to the unusual nature of ACC, which may be useful for making clinical decisions. However, prospective randomized multicentric studies are needed to define the optimal treatment for ACC with special regard to adjuvant treatment modalities.

[Congenital teratoma of the skull base: case report of an interdisciplinary treatment]

Teratomas of the oropharynx are quite rare congenital tumors. Even more rare than oropharyngeal teratomas are those with additional intracranial extension. Reviewing the literature the prognosis of these cases has been poor. In the majority stillbirth or immediate postpartum death following respiratory obstruction is reported. We present a case of a congenital teratoma of the oral cavity with intracranial extension in a female neonate. After several intraoral tumor resections to establish secure airway in the postpartum period the total tumor resection had to be performed at the age of 6 month via a lateral transmandibular approach to the skull base. By using extraoral distaction devices the operation related microsomia of the mandible could be corrected at the age of 5 years. At 7 years follow-up the girl presented free of recurrence and without any neurological or functional deficits.

[Adenoid cystic carcinoma of the major and minor salivary glands. Retrospective analysis of 74 patients]

PURPOSE

In this study we give a clinical review of our experience with adenoid cystic carcinoma (ACC) and compare our results with those reported in the literature.

PATIENTS

Between 1981 and 2000, 74 patients with ACC of the head and neck were treated at the Department of Oral and Maxillofacial Surgery, Hannover Medical School.

RESULTS

The average age at diagnosis was 58 years. There were 38 men and 36 women. The primary site was the parotid gland in 4 cases, the submandibular and sublingual gland in 21 cases, the lacrimal gland in 1 case, the minor salivary glands of the oral cavity and oropharynx in 44 cases, and the nasal cavity and maxillary sinus in 4 cases. There were 19 T1, 15 T2, 9 T3, and 31 T4 tumors with perineural invasion of 32 tumors. R0 resection was performed in 45 cases. Fourteen patients received postoperative radiation. There were only five N1 and two N2b necks. All patients were staged M0 at presentation. Local control rates at 5, 10, and 15 years were 64%, 56%, and 52% with a mean local control time of 11.1 years. Tumor size ( p< or =0.001), margin status ( p< or =0.001), and perineural invasion ( p</=0.001) showed significant influence on local control. However, we were not able to demonstrate a positive effect of postoperative radiation. Distant control rates at 5, 10, and 15 years were 72%, 62%, and 59% with a mean distant control time of 14.4 years. Distant failure was diagnosed in lungs and bones and occurred independently of local treatment outcome. Overall survival rates at 5, 10, and 15 years were 71%, 54%, and 37% with a mean overall survival of 11.2 years. Recurrence-free survival rates at 5, 10, and 15 years were 57%, 45%, and 37% with a mean recurrence-free survival of 9.1 years. The survival rates at 5, 10, and 15 years after diagnosis of tumor progression were 35%, 15%, and 0% with a mean survival time of 4.7 years.

CONCLUSION

Our results provide insights on the unusual nature of these tumors, which may be useful for making clinical decisions. However, prospective randomized studies are needed to define the optimal treatment for patients with ACC with special regard to adjuvant treatment modalities.

Neck dissection in oral cancer--clinical review and analysis of prognostic factors

The purpose of this study was to evaluate the oncologic effectiveness of radical and different types of modified neck dissections with preservation of the spinal accessory nerve, internal jugular vein and sternocleidomastoid muscle and to identify prognostic factors for regional control and survival in univariate and multivariate analysis. This retrospective study included 373 patients with squamous cell carcinoma of the oral cavity who underwent 401 neck dissections between January 1986 and December 1997 at the Department for Oral and Maxillofacial Surgery, Hanover Medical School. The actuarial neck control rate after 5 years was estimated with 87%. Neck failure occured only within the first 2 years after neck dissection. The number of positive nodes, macroscopic extracapsular spread, peeling off metastases from carotid artery and cranial base and preoperative radiochemotherapy were significant prognostic factors. Grade of metastases, microscopic extracapsular spread, lymphangiosis carcinomatosa and postoperative radiation showed no prognostic significance. The comparison of neck failures after radical and modified neck dissection demonstrated a tendency to improved regional control after radical neck dissection with increasing extent of neck disease.

[Effectiveness of neck dissection in metastasizing mouth carcinoma. Uni- and multivariate analysis of factors of influence]

BACKGROUND

The purpose of this study was to evaluate the oncologic effectiveness of radical and different types of modified neck dissections with preservation of n. accessorius, v. jugularis interna, and m. sternocleidomastoideus and to identify prognostic factors for regional control and survival in univariate and multivariate analysis.

METHODS

This retrospective study included 373 patients with squamous cell carcinoma of the oral cavity who underwent 401 neck dissections between January 1986 and December 1995 at the Department for Oral and Maxillofacial Surgery, Hanover Medical School.

RESULTS

The 5-year regional control was estimated at 87%. Relapse occurred only within the first 2 years after neck dissection. The number of positive nodes, metastases without lymphatic tissue, preparation of metastases from the carotid artery and cranial base, and preoperative radiochemotherapy were analyzed as prognostic factors with significant influence. The grade of metastases, extracapsular spread, lymphangiosis carcinomatosa, and postoperative radiation showed no prognostic significance.

DISCUSSION

The comparison of recurrent metastases after radical and modified neck dissection demonstrated that as the extent of neck disease increased there was a tendency toward improved regional control after radical neck dissection.

[The possibilities for surgical correction of dentoalveolar adaptations within skeletal repositioning osteotomy]

In the combined surgical orthodontic treatment the essential task is to eliminate the dentoalveolar adaptations of maxillofacial disorders. Additional segmental osteotomies can be considered if these adaptations are excessive or if complications are to be expected during the orthodontic treatment. Possibilities and indications as well as complications and limits of this approach are described.

[Maxillary osteotomy by the Le Fort I technic--a wide spectrum of indications for correcting different skeletal dysgnathias]

The osteotomy of the maxilla using the Le Fort I technique, today routinely performed in the down-fracture-technique, has changed surgical corrections of dentofacial deformities fundamentally. It offers a three-dimensional correction of the maxilla and also of the whole facial skull. Furthermore the upper dental arch can be expanded, intruded and shortened using a sagittal or transversal osteotomy in addition to a complete transposition of the maxilla. Planning of a maxillary osteotomy is performed under consideration of the clinical situation, the casts and the lateral cephalogram. The mandible must be considered at an early stage of the preoperative planning, since the mandible will follow all transpositions of the maxilla by rotating with the TMJ. Only by performing a simultaneous osteotomy of the mandible, a broad spectrum of indications for maxillary osteotomy will result and practically every desired profile of the lower third of the face can be achieved using combined maxillary and mandibular osteotomies.