The importance of in-hospital mortality for patients requiring free tissue transfer for head and neck oncology

Mortality is a rare but disastrous complication of microvascular head and neck reconstruction. The investigators attempt to identify the procedure-related mortality cases and analyse the causes of death. A retrospective analysis of 804 consecutive free flap procedures during a 19-year period was performed and fatal cases were identified (n=42 deaths). Multivariate logistic regression was employed to determine the association of in-hospital mortality with patient-related characteristics. The 30-day post-operative mortality rate was 1% (8 out of 804 patients), and the in-hospital mortality rate (post-operative deaths in-hospital before or after the 30th post-operative day without discharge) was 5.2% (42 out of 804 patients). Cancer recurrence and metastases related pneumonia were the most common causes of death (n=26, 62%), followed by cardiac, pulmonary, infectious and hepatic/renal aetiologies. Logistic regression analysis revealed that patients with stage IV disease and an operation time of >9h were significantly associated with post-operative mortality. Malignancy-related conditions were the most common causes of death following free flap transfer for head and neck reconstruction. For patients with stage IV head and neck cancer, this aggressive surgical approach should be cautiously justified due to its association with post-operative mortality. To shorten the operation time, experienced microsurgical operation teams are necessary.

Clinical indication for intraoperative 3D imaging during open reduction of fractures of the mandibular angle

PURPOSE

This retrospective study investigated 3-dimensional (3D) imaging with intraoperative Cone-Beam Computed Tomography (CBCT) in Mandibular Angle Fractures (MAF) treated by open reduction. The aim of this study was to demonstrate the image quality of intraoperative CBCT in this region and the benefit for the patients.

METHODS

83 patients with 86 MAF were included in this study. 8 patients were female and 75 male. Patient age ranged from 11 to 68 years (average age 26.8 years). All patients were examined with the mobile CBCT scanner ARCADIS Orbic 3D (Siemens Medical Solutions, Erlangen, Germany) directly after surgical treatment of the MAF.

RESULTS

As a direct result of intraoperative CBCT four patients (5%) underwent intraoperative revision. The intraoperative acquisition of the data sets was uncomplicated and in all cases it was possible to effectively visualise and assess the MAF in 3D quality.

CONCLUSION

The results showed that intraoperative CBCT is a reliable imaging technique for real-time intraoperative assessment of treated MAF. Use of the mobile 3D CBCT scanner is easy to integrate into routine practice and offers the advantage that immediate revision surgery can be performed.

A hematogenous spread brain abscess invading the right damaged temporomandibular joint

We report a rare case of a brain abscess which drained spontaneously in a temporomandibular joint damaged by osteoarthritis. The female patient presented to our hospital with a severe headache and pain in the temporomandibular joint. She showed elevated inflammatory parameters with unknown cause. Magnetic resonance imaging of her whole body revealed a large temporal brain abscess extending into the glenoid fossa of the temporomandibular joint. The brain abscess was incised and drained by neurosurgeons in our hospital and in the same operation we resected the articular disc and the affected part of the right temporomandibular joint. Histological examination confirmed a chronic arthrosis in the resected bone of the temporomandibular joint and an inflammatory abscess in the resected brain tissue. The patient recovered well and the inflammation resolved as seen in postoperative investigations. Magnetic resonance imaging a month later confirmed local consolidation in the brain with no sign of residual inflammation.

Organisationsstrukturen moderner Wundversorgung

Die Heilung chronischer Wunden stellt in mehrfacher Hinsicht eine Herausforderung dar. Sie erfordert eine differenzierte Abklä-rung der Ulkusentität und eine enge Koope-ration verschiedener Berufsgruppen. Erschwerend im Management chronischer Wun-den ist das Fehlen konsentierter interdisziplinärer Leitlinien. Dagegen steht dem Therapeuten im Rahmen der modernen Wundbehandlung ein reichhaltiges Armamentarium an Wundauflagen und Verbandsstoffen zur Verfügung, die einen differenzierten Einsatz erfordern. Daneben ist eine Vernetzung stationärer und ambulanter Strukturen für eine erfolgreiche Wundbehandlung unabdingbar. Am Universitätsklinikum Hamburg-Eppendorf wurde 2010 das Comprehensive Wound Center gegründet. Neben einer kompetenten, fachübergreifenden und patientengerechten Diagnostik ist insbesondere die interdisziplinäre Zusammenarbeit verschiedener ärztlicher und pflegerischer Professionen angestrebt. Durch Vernetzung der internen Strukturen erfolgten im ambulanten als auch im stationären Management eine Umstrukturie-rung und eine sektorenübergreifende Wund-versorgung. Da bis zu 80 % chronischer Wun-den angiologischer Ursache sind, erfolgte zudem die Anbindung an die Klinik für Gefäß-medizin, die nach dem Konzept einer Organklinik konzipiert ist und bereits interdisziplinäre Zentrumsstrukturen aufweist. Durch eine zen-trale Koordinierung ist eine enge Kooperation zwischen niedergelassenen Ärzten und Pflegedienste innerhalb des Wundnetzes möglich. Neben der Patientenbetreuung hat das Comprehensive Wound Center einen weiteren Schwerpunkt in der Grundlagenforschung so-wie in der klinischen und versorgungswissenschaftlichen Forschung.

Clinical indication for intraoperative 3D imaging during open reduction of fractures of the neck and head of the mandibular condyle

PURPOSE

This study aimed to evaluate the use of intraoperative cone-beam computed tomography (CBCT) in monitoring the results of repositioning and osteosynthesis of condylar process and head (capitulum) fractures of the mandible to see if CBCT is beneficial for these patients.

PATIENTS AND METHODS

Sixty patients (22 females and 38 males, age range 16-79 years, average 36.5 years) with condylar process and head fractures according to the classification of Spiessl and Schroll were treated during the study period. Thirty-four of the 60 patients received a CBCT scan immediately after surgical treatment under aseptic conditions.

RESULTS

In all 34 cases, intraoperative CBCT provided high-quality imaging of the condylar process in all three planes. In four patients (11.8%), unsatisfactory reposition or unexpected complications were detected which could immediately be corrected with a surgical revision.

CONCLUSION

Intraoperative use of CBCT enables optimization of the surgical outcome for fractures of the condylar process and head of the mandible, reduces postoperative complications, and spares patients from repeated intervention. In addition, intraoperative CBCT enables safer treatment with minimally invasive approaches.

Diagnostic and therapeutic aspects in the treatment of gunshot wounds of the viscerocranium

Gunshot wounds of the viscerocranium are a rare occurrence during times of peace in Europe. The removal of projectiles is recommended; in some cases, however, this is controversial. The material properties of projectiles and destruction of anatomical landmarks make it difficult to determine their precise location. Therefore, navigation systems and cone-beam computed tomography (CT) provide the surgeon with continuous intraoperative orientation in real-time. The aim of this study was to report our experiences for image-guided removal of projectiles, the use of cone-beam computed tomography and the resulting intra- and postoperative complications. We investigated 50 patients with gunshot wounds of the facial skeleton retrospectively, 32 had image-guided surgical removal of projectiles in the oral and maxillofacial region, 18 had surgical removal of projectiles without navigation assistance and in 28 cases we used cone-beam CT in the case of dislocated projectiles and fractured bones. There was a significant correlation (p = 0.0136) between the navigated versus not navigated surgery and complication rate (8 vs. 32%, p = 0.0132) including major bleeding, soft tissue infections and nerve damage. Furthermore, we could reduce operating time while using a navigation system and cone-beam CT (p = 0.038). A high tendency between operating time and navigated surgery (p = 0.1103) was found. In conclusion, there is a significant correlation between reduced intra- and postoperative complications including wound infections, nerve damage and major bleeding and the appropriate use of a navigation system. In all these cases we were able to present reduced operating time. Cone-beam CT plays a key role as a useful diagnostic tool in detecting projectiles or metallic foreign bodies intraoperatively.

Single nucleotide polymorphism in esophageal cancer related gene 1: an analysis in resected oral squamous cell carcinoma patients

Esophageal cancer related gene 1 (ECRG1) is a novel candidate tumor suppressor gene in human esophageal squamous cells. Overexpression of ECRG1 protein inhibits tumor cell proliferation. Genetic polymorphisms in coding sequences of the gene may cause functional alterations of the gene product and be associated with higher cancer risk and disease phenotypes. A single nucleotide polymorphism (SNP) (Arg290Gln) found in the coding region of ECRG1 might play a role in susceptibility to esophageal squamous cell carcinoma. This study examined SNPs in ECRG1 in a similar tumor type (oral squamous cell carcinoma; OSCC) and investigated the relationship between SNPs in ECRG1 and the clinical outcome of patients with OSCC. DNA samples of 137 OSCC patients were analyzed for SNP genotypes Arg/Arg, Arg/Gln and Gln/Gln in the coding region (exon 8) of ECRG1. SNP genotypes Arg/Arg were found in 70 (51%), Arg/Gln in 60 (43%) and Gln/Gln in 7 (5%) patients. There was no significant association between genotypes and survival (p=0.77) or relapse free survival (p=0.32). The Gln/Gln genotype had the best survival (not significant) probably due to rare cases of SNP Gln/Gln genotype. Genotype Arg/Arg might be a potential negative prognostic marker in OSCC, but more studies with higher patient numbers are required.

Navigated implantation after microsurgical bone transfer using intraoperatively acquired cone-beam computed tomography data sets

The use of a combination of intraoperative cone-beam computed tomography (CBCT) and a navigation system via a spinal software platform for the navigated implantation of oral implants after microsurgical bone transfer is described. Intraoperative data sets were generated using Arcadis Orbic 3D (Siemens, Medical Solutions, Erlangen, Germany) and immediately transferred to the VectorVision(2) navigation system (BrainLAB, Feldkirchen, Germany) via the NaviLink interface. In two patients who underwent microsurgical bone transfer for midfacial reconstruction, implants were placed using intraoperatively acquired CBCT data sets for planning and navigated insertion. In both cases, successful realization of the planned implant sites was achieved by the guidance of the drill, leading to rehabilitation of both patients. CBCT data generated by mobile systems are sufficient for the planning of implant position, and can be used for navigated insertion using tools originally developed for spinal surgery.

Validation of a new training tool for ultrasound as a diagnostic modality in suspected midfacial fractures

The aim of this study was to test a previously described training tool for ultrasound for use as a first-line imaging modality. Navigated sonography was performed in 10 patients with midfacial fractures diagnosed using computed tomography (CT). One examiner ranked his sonographic findings regarding the presence of a fracture on six predefined anatomic landmarks on a scale from 1 to 5. These results were correlated with CT findings by displaying fused images. In all but three patients fractures were correctly identified using sonography. In the remaining three patients the examiner was unable to determine whether a fracture was present or not. Normally, these patients would have been subjected to conventional radiographs. Ultrasound proved to be a reliable first-line imaging modality for the investigation of suspected midfacial fractures in daily clinical practice, resulting in decreased radiation exposure since conventional radiographs are omitted. According to this algorithm, patients with sonographically confirmed midfacial fractures are examined for surgical planning using cone-beam CT.

[The eruption times of permanent teeth in boys and girls in the Stormarn District, Schleswig-Holstein (Germany)]

In a longitudinal study in two small towns in southern Schleswig-Holstein (Ammersbek and Ahrensburg, District Stormarn; 9155 inhabitants) we investigated 2832 oral findings of 1396 patients (711 males, 685 females). The minimum age was 1.51 years, and the maximum age was 25.50 years. The dental findings were collected over a period of about 20 years (1982-2002). The oral findings per child were assessed between one and eight times. The eruption times of teeth in females are earlier than those for the same teeth in males. Further, the permanent dentition in females is completed earlier than in males. In both sexes the tooth eruption occurs symmetrically in both jaws. The comparison of both jaws revealed a slightly advanced eruption of the lower jaw teeth in both sexes. There is a noteworthy change in the eruption sequence of the teeth. In contrast to other reports we observed that the eruption of the canine proceeds the eruption of the second molar. We found no acceleration of the dentition when compared with other reports and could confirm the rules of tooth eruption in man.

CONCLUSION

Oral examination of teeth is a simple tool to calculate tooth eruption intervals. This first investigation on a population of Schleswig-Holstein revealed a change in the eruption sequence of permanent teeth. These findings are relevant for dental treatment planning and should be reconfirmed at certain intervals.

Intraoperative imaging of zygomaticomaxillary complex fractures using a 3D C-arm system

After preclinical studies and evaluation of radiation exposures, intraoperative three-dimensional (3D) C-arm based imaging is now available for the facial skeleton. Fourteen patients admitted for surgical treatment of zygomaticomaxillary complex (ZMC) fractures were included in the study. Preoperative diagnostics and surgical treatment were performed as usual. Intraoperatively, after open reduction, a cone-beam computed tomography (CBCT) dataset was generated using the SIREMOBIL Iso-C3D (Siemens Medical Solutions, Erlangen, Germany). After DICOM-import in eFilm Workstation axial, coronal and sagittal reconstructions were evaluated by five examiners with the help of six defined criteria. In our study, secondary reconstructions were available after 6 min, excluding the time needed for the evaluation of the images. Especially the positioning of the isocentre of the SIREMOBIL Iso-C3D proved to be uncomplicated. Because of the size of the datasets, assessment of the symmetry of the malar projection proved difficult. Best scoring results were found regarding the visualization of the fragment position, bony anchorage of the screws and the fitting of the plates. Remarkable was the low level of metal artefacts in primary and secondary reconstructions. In conclusion, our results demonstrate intraoperative CBCT using the SIREMOBIL Iso-C3D suitable for assessment of postoperative results following ZMC reduction.

Diagnosis, treatment and follow-up control in 124 patients with basal cell carcinoma of the maxillofacial region treated from 1992 to 1997

AIM

The aim of this study was to analyze diagnostic and therapeutic procedures and the outcome of patients treated for the most common malignant tumor of the facial skin, basal cell carcinoma.

PATIENTS AND METHODS

The files of patients with basal cell carcinoma (BCC) treated over a period of 6 years were evaluated. Emphasis was placed on the frequency of second interventions, local recurrences and histological subtyping of tumors.

RESULTS

One-hundred and twenty-four patients were treated for 216 basal cell carcinomas (solitary: 67%, multiple: 33%). The tumors were predominantly located in the skin covering the middle third of the face. The tumors were 30 mm or less in diameter in 86%. Treatment was exclusively surgical. Histopathological subtyping revealed solid (83%), sclerodermiform (10%), metatypical (4%) and multicentric (3%) tumors. Resection of adjacent bone was mandatory in 12 patients and orbital exenteration in 2. Further local resections were necessary after thorough histological investigation in 71% of patients. Local recurrences occurred in 14 patients, predominantly within the first year after ablative surgery. Relative to the small number of sclerodermiform BCC, this subtype was the most frequent tumor that developed local recurrences.

CONCLUSION

Basal cell carcinoma is a malignant tumor, slowly growing and often showing wide extension to macroscopically non-affected sites. Resection of tumors is delicate in the maxillofacial region due to the predilection for sites of origin adjacent to structures of eminent importance for facial appearance. The sclerodermiform subtype is prone to local recurrence and these patients should be followed up carefully.

Eruption times of permanent teeth in children and young adolescents in Athens (Greece)

In a study in Athens, Greece, during the summer of 2003, 2,304 patients (1,168 boys and 1,176 girls) were examined by a young dentistry. The examination occurred within the framework of a routine dental check-up performed at the National and Kapodistrian University of Athens. The age span ranged from 3.00 to 24.93 years of age. Sex, age and present permanent teeth were recorded. Wisdom teeth were excluded. The sequence of tooth eruption differs significantly in the lower and upper jaw, whereas no significant differences existed when comparing the sides of each jaw. The tooth eruption in the lower and upper jaw of male and female probands is symmetrical. In comparing the upper and the lower jaw of both genders, it becomes evident that there is a tendency for earlier tooth eruptions in the lower jaw. In respect to the tooth eruption sequence, a change was noted in the upper jaw. Contrary to the reports of other authors, the second premolar has changed places with the canine and erupts prior to this tooth. This could also be demonstrated in recent studies from New York and Bremen (Germany). Otherwise no major differences concerning the sequence of tooth eruptions were observed, when compared with the results gained from other populations. Concerning the entire dentition, no acceleration of the tooth eruption could be noted. The computed differences of teeth eruption as a mean value calculated over all teeth was +/-1 year at maximum, compared with studies from different continents. Oral examination of teeth is a simple tool to calculate tooth eruption intervals. This first investigation in a population of Athens revealed a change in the eruption sequence of permanent teeth. These findings are relevant for dental treatment planning and should be reconfirmed at certain intervals.

Eruption times of permanent teeth in teenage boys and girls in Izmir (Turkey)

In a study in the Aegean city of Izmir, Turkey, during the summer of 2002, 2101 patients (1046 boys and 1055 girls) were examined. The examination occurred within the framework of a dental check-up performed at two schools and one pre-school unit. The age span ranged from 3.98 to 24.91 years. Sex, age and present permanent teeth were recorded. Wisdom teeth were excluded. The sequence of tooth eruptions differs significantly in the lower and upper jaw, whereas no significant differences existed when comparing the sides of each jaw. The times of tooth eruption is earlier in females than in males. The entire tooth eruption process of the second dentition occurs in females earlier than in males. The tooth eruption in the lower and upper jaw of male and female probands is symmetrical. In comparing the upper and the lower jaw of both genders, it becomes evident that there is a tendency for earlier tooth eruptions in the lower jaw. In respect to the tooth eruption sequence, a change was noted in the upper jaw. Contrary to the reports of other authors, the second premolar has changed places with the canine and erupts prior to this tooth. Otherwise no major differences concerning the sequence of tooth eruptions, when compared to the results gained from other populations, were observed. Concerning the entire dentition, no acceleration of the tooth eruption could be noted. The computed differences of teeth eruption as a mean value calculated over all teeth, was +/- 1 year at maximum, compared to studies from different continents. Oral examination of teeth is a simple tool to calculate tooth eruption intervals. This first investigation on a population of Izmir revealed a change in the eruption sequence of permanent teeth. These findings are relevant for dental treatment planning and forensic odontology and should be reconfirmed at certain intervals.

[Experiences in the treatment of midfacial fractures using a fixed-angle osteosynthetic system. Biomechanical results]

AIM

Fixed-angle osteosynthetic systems are characterized by mechanical "locking" of the osteosynthetic screw and plate. These systems have found increasing acceptance and use for osteosynthetic fixation and temporary reconstruction of the mandible. The aim of this study was to investigate the applicability and performance of fixed-angle systems in the treatment of midfacial fractures.

MATERIAL AND METHOD

A newly developed fixed-angle osteosynthetic plate system (smart lock) was compared to a conventional system using fresh human skulls. The iatrogenically produced zygomatic fractures of the human skulls were treated by osteosynthesis and biomechanically tested. Furthermore, in a dynamic test series, an artificial bone was subjected to an alternating force of 15 N of up to 1,000,000 cycles. The new screws and plates were subjected to further biomechanical tests.

RESULTS

The tests using the fixed-angle implants revealed that an increase of stability of up to 40% can be expected after osteosynthetic fixation. Furthermore, the plates resisted 1,000,000 cycles of alternating forces, whereby the conventional systems failed after 170,000 cycles on the average.

CONCLUSION

Fixed-angle systems, due to their construction, provide a high degree of stability even in thin bones of the midface. They appear to be promising for the treatment of midfacial fractures.

[Sonography as a training tool for screening of dubious midfacial fractures]

BACKGROUND

In uncertain midfacial fractures, sonography is an alternative first-line imaging modality to conventional radiographs. Patients with sonographically confirmed fractures can then be directly admitted to three-dimensional imaging, resulting in decreased radiation exposure since the conventional radiographs are omitted.

MATERIAL AND METHODS

Using a high-frequency linear and curved array scanner in a healthy proband, images of the zygomatic arch, anterior maxillary sinus wall, infraorbital rim, and lateral orbital wall were obtained. For identification and anatomical allocation corresponding navigated ultrasound images of a reference skull were generated and fused with a segmented CT data set. Navigated sonography was reproduced in a patient with orbitozygomatical fracture of the left side. Therefore, the CT data set, performed during preoperative diagnostics, was fused with the ultrasound images.

RESULTS

Because of different coupling shapes, the high-frequency linear array scanner was subjectively found to be more suitable for sonography in the field of the zygomatic arch, anterior maxillary sinus wall, and infraorbital rim, and the curved array scanner was better suited for transbulbar sonography of the orbital walls. After coupling sonography with the navigation system and referencing the scanner, it was possible to verify ultrasound findings objectively by navigation of the scanner and fusion with the CT data set. Using the reference skull, ultrasound images corresponding to normal findings were obtained and with the fused CT data, providing colored segmentation of the facial bones, an anatomically correct identification was possible. Clinical application of this tool is described in a patient with left-sided orbitozygomatical fracture.

CONCLUSION

By fusion of ultrasound images and corresponding CT data with the help of a navigation system, a sonographic training tool for preliminary evaluation of midfacial fractures is available.

Intraoperative 3D imaging of the facial skeleton using the SIREMOBIL Iso-C3D

OBJECTIVES

With respect to high-contrast structures, cone beam computed tomography (CBCT) offers an alternative imaging modality to computed tomography (CT), requiring less radiation exposure. The C-arm system SIREMOBIL Iso-C3D for three-dimensional (3D) reconstruction has made this modality available for intraoperative use. This paper presents the first intraoperative images of the facial skeleton using the SIREMOBIL Iso-C3D.

METHODS

Cases of a zygomaticomaxillary complex fracture, a mandibular angle fracture and a bimaxillary repositioning osteotomy are described to demonstrate the application possibilities of this system in maxillofacial surgery.

RESULTS

In addition to the uncomplicated handling of the SIREMOBIL Iso-C3D, generally important was the low level of metal artefacts in its primary and secondary reconstructions, even in close proximity to the material. However, it has to be kept in mind that while soft tissues are visualized using CBCT, information about soft tissue quality cannot be obtained.

CONCLUSION

The SIREMOBIL Iso-C3D generates intraoperative data sets suitable for the visualization of the facial bones after open reduction of fractures.

Virtuelle Simulation dentoalveolärer Eingriffe in einem dreidimensionalen Computermodell mit Kraftrückkopplungssystem

BACKGROUND

Selective reduction of bone without injuring inner structures is an essential part of surgical techniques, especially during dental surgery. Virtual drilling is possible using a new simulator. The following illustrates simulation of an apicectomy.

MATERIAL AND METHODS

Using the VOXEL-MAN system, a virtual three-dimensional model of a skull was created based on CT data. Both inferior alveolar nerves and apical inflammations of teeth 23, 25, 36, and 35 were virtually simulated. To achieve a realistic drilling effect with the force feedback system, special tools were integrated into VOXEL-MAN to obtain a high resolution of collision recognition. Adding drilling noises further improved the simulation. Spatial 3D perception was possible with the help of shutter glasses.

RESULTS

The presented computer model enabled the visual and haptic observation of complex volume-based models and virtual interaction with them. The haptic feeling proved to be convincing because of collision recognition, consideration of drilling parameters, and addition of drilling noises. Via postoperative reconstructions, polydimensional verification of performed drilling routes is possible.

CONCLUSION

Using apicectomies as examples, realistic simulation of dental surgical procedures, even in complex anatomical models, is possible. Generally, it is possible to add virtual pathologies in data sets and/or to use anonymous patient data sets to extend the range of simulated surgical procedures.

Strahlenexposition und dreidimensionale Darstellungsm�glichkeiten des SIREMOBIL Iso-C3D zur Planung chirurgischer Zahnsanierungen

BACKGROUND

Preoperative dental X-ray diagnostics of multimorbid, non compliant patients requiring dental surgery are often insufficient. The SIREMOBIL Iso-C(3D) has made intraoperative 3D imaging available, even for the facial skeleton. This modality was used intraoperatively in two patients referred for surgical dental treatment. Furthermore, radiation exposure of the SIREMOBIL Iso-C(3D), an orthopantomography and a complete dental status was compared.

MATERIAL AND METHODS

An Alderson-Rando phantom was exposed to ten cycles of the SIREMOBIL Iso-C(3D) using the fast mode (50 projections). In comparison 28 panoramic views of an Orthophos and 10 sets of 14 dental images using the Oralix DC with a quadrate mask were applied. Twenty-five anatomically defined TLD positions were analyzed. Furthermore, SIREMOBIL Iso-C(3D) was used in one patient by performing 100 projections and in a second patient by performing 50 projections. After DICOM-import in eFilm, axial, coronal, and sagittal reconstructions were evaluated by five examiners regarding defined criteria.

RESULTS

The radiation exposure level of the SIREMOBIL Iso-C(3D) was lower than in the complete dental status and only slightly higher in comparison with the orthopantomography, although the system requires the highest number of single projections. Quantitative evaluation of the visualization and recognition of defined structures proved to be very good and good in most points. However, limitations of the system became obvious regarding apical processes.

CONCLUSION

Because of the dosimetry results and the visualization of the relevant structures, in patients for whom preoperative images cannot sufficiently be performed, the intraoperative use of the SIREMOBIL Iso-C(3D) as a base examination is justified.

Investigation about origin and spreading of neoendothelium in autologous arterial vessel replacement

INTRODUCTION

In many fields of surgery an autologous arterial vessel replacement is used. Because of trauma and insufficient nutrition, a loss of complete endothelium in the replaced vessel segment and at the anastomoses can be observed within a few hours. The origin and the spread of the neoendothelium are unknown. Our study uses Von-Willebrand-protein, a product of endothelium cells, as a marker to obtain new information about the origin and spread of the new endothelial cells.

MATERIALS AND METHODS

Seventy Wistar rats, seven groups of 10 animals each, were operated. A four-millimetre-long segment of the common carotid artery was isolated and reinserted. After a varying length of time (between directly after the operation and six months after), the common carotid artery including bifurcation was isolated after cardioperfusion. Carotid arteries were embedded and cross-sections were stained with hematoxylineosin, Verhoeff's tissue elastin stain and immunohistochemical anti-Von-Willebrand-factor-antibody. The complete vessel was divided into nine points of measurement on each side, three points at each anastomosis and three points in transplanted segment. There the number of positive endothelial cells was rated.

RESULTS

Twenty-four hours after the operation no further endothelium was detectable in autologous transplant. Stainings eight days after operation contained Von-Willebrand-factor-positive cells in luminal cell layers. Near to the anastomosis excessive myointimal hyperplasia was detectable. Also, eight days after operation, some positive endothelial cells in adventitia were seen near to the anastomosis in small vessel lumina. Four weeks after operation, the luminal endothelium was completely regenerated and the luminal endothelial layer was confluent. Eight days after the operation regeneration in lateral regions was faster than in the region of the transplant.

CONCLUSION

In our experiment regeneration in lateral regions was faster than in the region of the transplant. Early staining in adventitia and proof of newly formed vasa vasora in adventitia may be a sign of a possible migration from adventitia to luminal area.

Dreidimensionale Darstellungsmöglichkeiten des Mittelgesichts mithilfe der digitalen Volumentomographie anhand einer Kadaverstudie zur winkelstabilen Osteosynthese

BACKGROUND

Multidirectional angularly stable interlocking plate systems are now available for the surgical treatment of the midface. After first experiences in cases of mandibular fractures, application to the facial skeleton was investigated using a cadaver study. Furthermore, three-dimensional imaging by means of the digital volume tomograph NewTom DVT 9000 after reduction of orbitozygomatical fractures was performed and evaluated.

MATERIAL AND METHODS

After artificial osteotomy and reduction of both zygomatical complexes, osteosynthesis of the left side was performed with three 4-hole miniplates (2.0). On the right side, three angular stable 2-hole plates (2.3) were used. Thereafter, a three-dimensional data set was generated using the NewTom DVT 9000. After DICOM-import in eFilm reconstructions were evaluated by six examiners regarding defined criteria.

RESULTS

After adaptation and fixation of the angular stable interlocking plate system without complications, manual checking revealed that the primary stability did not seem inferior to the other side. Defined criteria were sufficiently evaluable, even close to the osteosynthetic material, using reconstructions of the digital volume tomography data set.

CONCLUSION

Surgical treatment of midfacial fractures using a multidirectional angularly stable interlocking plate system seems promising. The NewTom DVT 9000 proved to be suitable to visualize even fine osseous structures of the midface.

[Involvement of the maxillary sinus in Langerhans cell histiocytosis]

AIM

A clinical presentation of Langerhans cell histiocytosis (LCH) in the maxillary sinus of two patients is given. LCH in the maxillary sinus is a rare occurrence. Our aim was to compare the different treatment alternatives available and to suggest a classification as well as a therapeutic regime.

PATIENTS AND METHOD

Records and clinical data of two patients treated between 1994 and 2001 were retrospectively evaluated. Both patients suffered from LCH in the maxillary sinus and the maxilla regions. Only surgical treatment was used. After resection, a large defect of the maxillary sinus, which did not allowing coverage, was seen in both cases. After reconstructive operations, closure was finally achieved. Both patients underwent follow-ups, whereby one suffered from a relapse after 15 months.

RESULTS

Although one of the patients under investigation showed a recurrence of LCH, we are of the opinion that surgical treatment is very effective in the elimination of this condition. A proposal for a classification of LCH in the oral-maxillo-facial-region is made.

CONCLUSIONS

The evaluation of our clinical study suggests that LCH is a disease that should be treated surgically. Only in very severe cases should the surgical treatment be complimented by either radiotherapy or chemotherapy. In disseminated cases, especially chemotherapy seems to improve the outcome. Surgery offers the possibility of eliminating systemic side effects.

3D-imaging of the facial skeleton with an isocentric mobile C-arm system (Siremobil Iso-C3D)

OBJECTIVES

The purpose of this study was to compare three-dimensional (3D) imaging of the facial skeleton using an isocentric mobile C-arm system vs CT.

METHODS

A dried human skull was scanned using a Siremobil Iso-C3D and a multi-detector CT (SOMATOM Volume Zoom; Siemens Medical Solutions, Erlangen, Germany) to compare reconstructed data sets. For each group of scans a standard protocol and a high resolution protocol were used. Image quality was analysed using six anatomical and six virtual structures in the primary reconstructed axial images of both data sets of the Siremobil Iso-C3D compared with CT. A receiver operating characteristic (ROC) study was performed with six examiners.

RESULTS

The original categorical response data revealed no significant differences in sensitivity and specificity (P < 0.05). However, image quality of the reconstructed images of the Siremobil Iso-C3D was inferior to the CT images, with metal artefacts having a more prominent negative effect.

CONCLUSIONS

The Siremobil Iso-C3D produces 3D images of the facial skeleton suitable for imaging osseous structures. No significant differences were found in sensitivity or specificity between the two methods. Metal objects degrade the image from the Iso-C method to a greater extent than those from CT.

[Abnormalities of the maxillary sinus in type 1 neurofibromatosis]

AIM

The aim of this study was to determine the malformations of the maxillary sinus in neurofibromatosis type 1 patients (NF1).

MATERIAL AND METHODS

Twenty-two patients with NF1 were investigated clinically and radiologically: 11 had an unilateral trigeminal plexiform neurofibroma and 11 had multiple cutaneous neurofibromas. The histological type of NF was ascertained in all cases following tumor resections. The malformation of the maxillary sinus was assessed on plain radiographs and computed or magnetic resonance tomograms. Intraindividual side comparison was used to judge the size of the sinus and its position in the midface.

RESULTS

In patients with cutaneous neurofibromas the maxillary sinus appeared symmetrical in size and position. The pneumatization of the sinus had no abnormalities on the radiographs. Malformations of the maxillary sinus were restricted to plexiform neurofibromas. On the side affected by a plexiform NF, the sinus appeared hypoplastic and caudally displaced due to an enlarged ipsilateral orbit. The expansion of the sinus to the lateral side was impaired, obviously due to tumor masses. Consecutively, the alveolar process of the affected side was also displaced leading to a complex malocclusion.

DISCUSSION

Malformations of the face are frequently presented as case reports in the literature. Emphasis is given to the elephantiasis-like tumor growth of the face in certain patients with NF1. The underlying pathology has not yet been fully understood. This report provides evidence that in the midfacial region the overgrowth is predominantly caused by the plexiform neurofibroma itself and that the bones can even be hypoplastic and show scoliosis-like malformation compared to the nonaffected side. These findings are relevant when debulking procedures of the face are planned for NF1 patients.

[Clinical outcome of re-innervation of radial flaps and latissimus dorsi muscle transplants]

BACKGROUND

The necessity of nerve anastomosis in an attempt to regain cutaneous sensitivity following flap transfer has been the basis of many discussions. In our study, we investigated the degree of sensory recovery with emphasis on the different nerval qualities on the radial forearm and the latissimus dorsi flap. COLLECTIVE: Sixty-two patients with 66 latissimus dorsi flaps and 19 patients with a radial forearm free flap were examined.

RESULTS

Except for five latissimus dorsi and two radial forearm flaps, all flaps investigated showed clinical signs of sensory recovery, whereby the degree and quality of cutaneous reinnervation varied. In comparison, neural reconstruction did not lead to any clinical improvement.

CONCLUSION

Based on our clinical results, we consider nerve reconstruction during radial forearm and latissimus dorsi free flap transfer unnecessary. To what extent this can be said for other flaps requires further investigation.

Clinical and histological results of sensory recovery after radial foreann flap transfer

The necessity of nerve anastomosis in an attempt to regain dermal sensitivity following pedicled or free-flap transfer has been the basis of many discussions. In our study, we investigated the degree of sensory recovery with emphasis on the different nerval qualities, on the radial forearm flap and correlated it to the histological and immunohistological findings. Nineteen patients with radial forearm free flap--five of whom underwent nerve anastomosis--were examined. The follow-up interval was 20.3 months (average) after surgical intervention. Histological examinations were performed on 13 of the 19 patients, in eight cases on one occasion and in five on more than one occasion. Seventeen patients experienced sensory recovery, whereby the degree and quality of dermal innervation varied. In comparison, the nerval reconstruction did not lead to any significant improvement. Based on our clinical results, we regard the nerve reconstruction during the radial forearm free flap transfer as unnecessary. To what extent this can be said for other flaps demands further investigation.

[Experimental and histomorphologic studies of healing processes of anastomoses of the carotid artery in the Wistar rat animal model with immunohistochemical imaging of collagen IV]

INTRODUCTION

The main risk in free flap tissue transfer is posed by the microvascular anastomosis. The dangers confronting the anastomosis are thrombosis, aneurysm, and vascular insufficiency. Collagen IV is associated with the basement membrane complex. It plays an essential role in vascular tissue organization and supports mechanical properties of vessels. We used a long-term animal experiment to gain a new understanding of histomorphological apposition of anastomosis and distribution of collagen IV.

METHODS

Seventy Wistar rats, seven groups of ten animals each, were operated. A 4-mm long segment of the common carotid artery was isolated and reinserted. After a varying length of time (between directly after the operation and 6 months later), the common carotid arteries including bifurcation were isolated after cardiovascular perfusion. Carotid arteries were embedded, and cross-sections were stained with hematoxylin and eosin, Verhoeff's tissue elastin stain, and immunohistochemical anti-collagen IV antibody. By using the above-described technique in each section four anastomoses were examined. The histomorphology and intensity of the anti-collagen IV stainings were evaluated.

RESULTS

Compression, shift, and dehiscence as forms of vessel apposition were often seen. We observed an overexpression of collagen IV in the media in cases of compression and shift. The grade of expression of collagen IV in the anastomosis depends on the extent of the injury.

CONCLUSIONS

A well-performed microvascular anastomosis is clinically important not only for the acute phase after the operation, but also for the long-term course. The application of antibodies to identify the collagen IV distribution is valuable for studying vascular healing. Further applications could be used in follow-up studies of vascular prostheses.

Limitations of B-scan ultrasound for diagnosing fractures of the mandibular condyle and ramus

The aim of this study was to analyse the applications and limitations of B-scan ultrasonography for diagnosing fractures of the mandibular condyle and ramus. Thirty-two patients with 39 radiologically proven fractures of the mandibular condyle and ramus were included in the study. The patients were examined with a 7.5 MHz small-part applicator. Five patients without fractures of the facial skeleton acted as controls. Normal sonoanatomical findings had been obtained for patients without mandibular fractures. B-scan ultrasonography enabled the experienced examiner to identify dislocated fractures of the mandibular ramus and the articular process in 67% of the fractures. The main disadvantage of ultrasonography was the inability of this technique to identify non-dislocated fractures. Because of its low sensitivity and specificity, B-scan ultrasonography does not provide an alternative to X-ray diagnosis of mandibular condyle and ramus fractures.

[Acute temporomandibular joint arthritis after Lyme borreliosis]

CASE REPORT

This report is about a rare connection between Lyme disease and an inflammation of the left temporomandibular joint. In this case, an infection was documented in 1998, 5 years after contact with Borrelia burgdorferi. The patient, a 49-year-old female, first came to our department in 1999. She showed the symptoms of a left temporomandibular joint infection.

THERAPY

We suggested treatment with ceftriaxone 1 x 2 g/day i.v.

[Pneumatization of the zygomatic arch on pantomography]

BACKGROUND

The pneumatized spaces of the zygomatic arch (zygomatic air cell defect) are a clinically asymptomatic variation of the temporal bone. The empty spaces of the articular eminence and temporal bone of the zygomatic arch are depicted on radiographs as a sharply demarcated osteolytic lesion of round or oval shape. The aim of this study was to determine the prevalence and characteristics of the ZACD in our outpatients.

MATERIALS AND METHODS

We investigated the panoramic radiographs of 1,084 patients who were treated during 1 February and 31 July 2000. The mean age of the 1,084 patients was 41.9 years (SD: 17.2 years; range: 2-96): 628 patients were male (58%) and 456 female (42%). A ZACD was found in 20 of 1,084 patients (prevalence: 1.85%). The mean age of the patients with a ZACD was 43.2 years (SD: 18.4 years; range: 7-87): 11 were female (55%) and 9 male (45%).

RESULTS

A bilateral ZACD was found in 20% (four patients). Interestingly, one of these ZACD patients was a 7-year-old boy. Up to now, it had generally been accepted that pneumatization of the zygomatic arch takes place after puberty with the youngest persons with ZACD being 15 years of age. Our findings should prompt consecutive studies on the prevalence of ZACD in children. This finding can be relevant in patients treated for spreading otitis media or mastoiditis.

[Squamous epithelial carcinoma in a Zenker diverticulum]

Zenker's diverticulum is a common anomaly in the elderly patient. Carcinoma in such a diverticulum is a rare but recognized complication of a posterior pharyngeal pulsion diverticulum. We present a case of a 67-year-old patient with a long-standing symptomatic Zenker's diverticulum. The diagnosis of the neoplasm was only achieved intraoperatively. The patient underwent a proximal esophageal resection with lymphadenectomy. Reconstruction was done with a microvascular free jejunal transplant. The postoperative course was uneventful. Wide oncologic surgical resection is the therapy of choice in cases of carcinoma in a Zenker's diverticulum.

[Vascular and neural malformations]

The presentation of vascular and neural malformations in an understandable terminology permits accurate diagnosis, proper treatment, individualized prognosis, and also stimulates studies of pathogenesis. The descriptive classification includes: NF 1 and NF 2; hemangiomas, low- and high-flow vascular malformations, combined malformations, and hypertrophy; and syndromes such as, Parkes Weber, Klippel-Trénaunay, Maffuci's, and multiple dysplasia syndromes. Lymphatic malformations are abnormalities of lymphatic development. The list of treatment includes surgical and nonsurgical treatment. Not all vascular malformations can be successfully treated. Coping with NF is a challenge for both, affected individuals and health care professionals. NF is often associated with a myriad of anomalies that present a lot of problems for plastic surgery. In certain cases watchful waiting seems justified but not in cases of severe problems, giant growth, and local complications.

[Primary solitary malignant schwannoma of the trigeminal nerve, Report of a case and review of the literature]

We present the case of a primary solitary malignant schwannoma of the trigeminal nerve. A total of 55 cases have been described in the literature; however, in these cases two tumors were affecting the supraorbital branch. This nerve-sheath tumor usually affects men in the fifth decade of life. The main clinical sign of malignant schwannomas of the head and neck is an indolent swelling. Hematogenic or lymphogenic metastasis has not been described. Because of the pleomorphism of the tumor cells immunohistochemical study is important. The treatment of choice is radical resection, possibly with adjuvant radio- or chemotherapy. The 5-year survival rate of malignant schwannoma of the trigeminal nerve is 41.7%.

Interstitial high dose rate brachytherapy in locally progressive or recurrent head and neck cancer

In a retrospective study, 19 patients with progressive or recurrent head and neck cancer which had been treated with interstitial high dose rate brachytherapy were analysed. All of them had been previously treated with external radiation. Initial therapy further included surgery in 9 cases and chemotherapy in 3 patients. Staging according to the TNM system revealed advanced stage tumors in the majority of patients. Interstitial brachytherapy was carried out with the isotope Iridium-192. The applied total dose at the reference isodose varied between 10 and 30 Gy. Application was fractionated once a week. A complete tumor remission was achieved in 5 patients and partial remission in 10 patients. In 4 patients the tumor continued to grow despite brachytherapy. The mean follow-up in our collective was 21 months. The calculated local control rate was 34% at 24 months. The survival rate was 49% at 12 months and 35% at 24 months. Interstitial brachytherapy is recommended as a palliative treatment in preirradiated squamous cell carcinoma with local recurrence or progression.

[Titanium magnets on implants as an aid in rehabilitation after tumor treatment]

After the resection of a tumor, many patients need a reconstruction with hard and soft tissue and also with sufficient dentures. Often, only little space is available for the implantation. Implant length and diameter have to be reduced, and the result is a change in the biomechanics with a possible mechanical overloading of the implant. We examined 52 tumor patients undergoing reconstruction with 189 implants. A new concept involving attachment with the help of magnets is presented, offering a satisfactory solution in these difficult cases after tumor resection and reconstruction.

[Clear cell odontogenic carcinoma in connection with squamous epithelial carcinoma. Case report and review of the literature]

One case of a newly described, rare odontogenic tumor is reported. A literature review of 19 cases lends support to the odontogenic origin and metastatic capability, both regionally and distantly, of the clear cell odontogenic tumor. We conclude that this tumor is malignant, with a tendency to recur locally after surgery. It requires an aggressive surgical approach and should be referred to as a clear cell odontogenic carcinoma. In our patient we saw a clear cell odontogenic carcinoma and a squamous cell carcinoma, both with regional lymph node metastasis. The histological differentiation of this type of tumor from other clear cell tumors is difficult.