A. Nastri

Maxillary ameloblastoma: a retrospective study of 13 cases.

Ameloblastoma is uncommon in the maxilla, comprising about 15% of all reported ameloblastomas. Ameloblastomas are locally aggressive and, when involving the maxilla, potentially lethal. The long term outcome of 13 patients with ameloblastoma in the maxilla for whom surgery was the primary treatment between 1951-1990 was studied. Patient records from both private and public practices in Melbourne, Australia were examined as were those cases reported to the Bone Tumour Registry at the University of Bristol, England. The study showed that control of disease was achieved in all patients where the tumour was limited to the confines of the maxilla (10 cases). The mean follow-up period in this group was 7 years (range 2-20 years). In the three cases that recurred all had preoperative radiological evidence of posterior maxillary sinus wall destruction and/or pterygoid plate erosion. Two patients died of extensive local recurrence and one has persistence of the disease. Histopathological examination confirmed the diagnosis of ameloblastoma in each case with a variety of histological patterns being noted. It is concluded that notwithstanding histological type, the extent of the tumour at presentation and the adequacy of the surgical approach and removal were the main factors in successfully managing the disease.

Selected midfacial access procedures to the skull base.

The indications and operative technique of various procedures commonly used to provide or increase access to the central skull base, anterior and middle cranial fossae, nasopharynx, infratemporal fossa and retromaxillary space are discussed with illustrative cases.

Review article: Maxillofacial emergencies: Oral pain and odontogenic infections

Oral pain and odontogenic infections are common reasons for patients to present to EDs and general medical practice in Australia. Although most odontogenic infections can be managed on an outpatient basis, because of their proximity to the airway, infections in this region can be life threatening, requiring urgent surgical intervention and ICU management. This article focuses on the emergency assessment, triage and non‐specialist management of oral pain and odontogenic infections.

Review article: Maxillofacial emergencies: Maxillofacial trauma

Fractures of the facial skeleton are a common reason for patients to present to EDs and general medical practice in Australia. Trauma to the maxillofacial region can lead to airway obstruction, intracranial injuries, loss of vision or long term cosmetic and functional deficits. This article focuses on the emergency assessment, triage and non‐specialist management of traumatic injuries of the orbit and facial skeleton.

Survey of Australasian oral and maxillofacial surgeons 2011--scope and workforce issues.

This study examined the qualifications, training, and practice patterns of oral and maxillofacial surgeons in Australia in 2011. This information was compared to similar studies performed in 1986 and 1995. It was found that dentoalveolar surgery comprised the greatest proportion of practice. There had been major growth in dental implantology, orthognathic surgery, and management of pathology. These increases were directly related to the standardization and increase in qualifications and training. The workforce had increased at the highest rate predicted, but was only just keeping up with the increases in population and the number of general health practitioners.

Ameloblastoma: demographic data and treatment outcomes from Melbourne, Australia

BACKGROUND There is a lack of published data on the demographics and treatment outcomes of ameloblastomas treated in Australia. Our objective was to collect this data and compare the findings to other international studies. METHODS A retrospective study of 42 patients with ameloblastoma was conducted at The Royal Melbourne Hospital, Australia. Data on the demographic features, management techniques (ablative and reconstructive), and outcomes were collected and analysed. RESULTS The majority of tumours were solid/multicystic (81%) and occurred most commonly in the mandible (80.5%). Unicystic ameloblastomas affected a younger age group, with Type 3 being the most common subtype. Overall, the recurrence rate for solid/multicystic ameloblastomas was 14.7%; however, radical surgery was found to have a significantly lower recurrence rate when compared to conservative management (p=0.015), with a mean of 51 months follow-up. Results indicated that vascularized free-flaps had fewer postoperative complications than non-vascularized bone grafts; however, the differences did not reach statistical significance. CONCLUSIONS This is the largest clinicopathological study regarding ameloblastoma management from Australia, and our results support the current literature in recommending radical surgery for the treatment of solid/multicystic and Type 3 unicystic tumours.

Infratemporal inflammatory myofibroblastic tumour with orbital extension.

Inflammatory myofibroblastic tumour (IMT) is a rare distinctive neoplasm of intermediate biological potential with a predilection for the abdominopelvic region and lung of children and young adults. It is histologically composed of spindle cells (myofibroblasts) in a myxoid to collagenous stroma with a prominent inflammatory infiltrate composed primarily of plasma cells and lymphocytes. Its pathogenesis is controversial. Arising most commonly in the lungs, only two cases of histopathologically confirmed IMT originating from the infratemporal and pterygopalatine fossae have been documented in the literature. Neither had orbital involvement. We now report the first case of IMT originating from the infratemporal fossa with orbital extension in a previously well 31‐year‐old woman. The patient presented with a 5‐month history of intermittent right‐sided headaches, progressive trismus and right lower lid swelling. She then developed right proptosis, diplopia and paraesthesia in the ophthalmic and maxillary divisions of her trigeminal nerve. Magnetic resonance imaging showed a soft tissue mass occupying most of the right infratemporal fossa with extension into pterygopalatine fossa and orbit. Provisional diagnosis from an open biopsy was nodular fasciitis. She underwent surgical debulking of the infratemporal fossa and lateral orbit through a coronal and trans‐oral approach with trans‐zygomatic access via total zygomatic osteotomy. Review of intraoperative specimens revised the diagnosis to IMT. Further management included systemic corticosteroids and adjuvant radiotherapy.Inflammatory myofibroblastic tumour (IMT) is a rare distinctive neoplasm of intermediate biological potential with a predilection for the abdominopelvic region and lung of children and young adults. It is histologically composed of spindle cells (myofibroblasts) in a myxoid to collagenous stroma with a prominent inflammatory infiltrate composed primarily of plasma cells and lymphocytes. Its pathogenesis is controversial. Arising most commonly in the lungs, only two cases of histopathologically confirmed IMT originating from the infratemporal and pterygopalatine fossae have been documented in the literature. Neither had orbital involvement. We now report the first case of IMT originating from the infratemporal fossa with orbital extension in a previously well 31-year-old woman. The patient presented with a 5-month history of intermittent right-sided headaches, progressive trismus and right lower lid swelling. She then developed right proptosis, diplopia and paraesthesia in the ophthalmic and maxillary divisions of her trigeminal nerve. Magnetic resonance imaging showed a soft tissue mass occupying most of the right infratemporal fossa with extension into pterygopalatine fossa and orbit. Provisional diagnosis from an open biopsy was nodular fasciitis. She underwent surgical debulking of the infratemporal fossa and lateral orbit through a coronal and trans-oral approach with trans-zygomatic access via total zygomatic osteotomy. Review of intraoperative specimens revised the diagnosis to IMT. Further management included systemic corticosteroids and adjuvant radiotherapy.

Endoscopic resection of the pterygoid plates following incomplete transoral resection of an odontogenic myxoma

Odontogenic myxoma is a rare, benign, odontogenic tumour of mesenchymal origin with variable clinical behaviour and rates of recurrence. It has an incidence of about 0.07/million, and accounts for 0.5% – 20% of odontogenic tumours. 1,2–4 Maxillary and mandibular lesions occur in similar proportions. 5 Maxillary lesions are of particular concern because they are close to vital structures, are difficult to follow up, and access is difficult and transcutaneous procedures may be required. We describe the case of a 41-year-old man who presented to the Royal Melbourne Hospital with an incidentally-found cystic lesion that was associated with teeth 27 and 28. Biopsy examination showed that it was an odontogenic myxoma. Initial computed tomography (CT) showed a 10 × 10 × 20 mm, expansile lesion in the left posterior maxilla, with no perforation through the pterygoid plates. We attempted transoral resection twice with immediate reconstruction utilising buccal fat pad however the margins showed odontogenic myxoma within the bone at the posteriorsuperior aspect (Fig. 1). After discussion with the multidisciplinary tumour board, we decided to undertake an endoscopic resection of the residual pterygoid plates transnasally. The head and neck and neurosurgical units completed this as an alternative to a lateral “Obwegeser” approach. 6 Under a general anaesthetic, with the aid of Brainlab software (Brainlab AG, Munich, Germany), we used stereotactic instruments to do a left

Referral Patterns for Oral Squamous Cell Carcinoma in Australia: 20 years progress.

BACKGROUND The aim of this study was to identify changes in referral patterns and delays in diagnosis and treatment of oral squamous cell carcinoma (OSCC), managed at a tertiary institution in Victoria, Australia. METHODS The hospital records of all patients with newly diagnosed OSCC, managed by The Royal Melbourne Hospital (RMH) Head and Neck Tumour Stream between January 2008 and December 2010, were retrospectively reviewed. RESULTS Of the 101 patients, 52% first sought help from general medical practitioners (GMP) while 43% initially attended a general dental practitioner (GDP). The most common site of OSCC was oral tongue (42%). The most common presentation was ulceration (31%). Seventy per cent of patients presented with T1 (39%) or T2 (31%) tumours. The diagnostic delay ranged from 0 to 8 years with an average of 4.5 months. Patient delay ranged from 0 to 1.4 years with an average of 1.8 months. Professional delay ranged from 0 to 8 years with an average of 2 months. CONCLUSIONS Delays in patients seeking advice have decreased compared to previous studies, while delays in professionals making a diagnosis have not improved considerably. There has been a significant shift towards initial presentation to GMP rather than GDP. Further decrease in delays is possible by improving both population awareness and clinician education.

Kimura's disease: an uncommon cause of head and neck masses with potentially serious sequelae

Kimuras disease (KD) typically presents as a mass in the head and neck region in association with eosinophilia and elevated serum IgE. Excisional biopsy is often required in order to obtain an adequate sample for histological diagnosis and exclude malignancy. If suspected, patients should also be investigated for renal involvement as this may complicate KD. Treatment options include surgical excision and medical therapies such as corticosteroids depending on the extent and severity of disease.