Brian Bisase

Use of cone beam computed tomography in the management of glass injuries to the face

Fig. 1. Axial cone beam computed tomogram showing two fragments of glass embedded in a patient’s face (fragments denoted by arrows). one beam computed tomography (CBCT) is an emerging ethod of imaging in maxillofacial surgery. Its advantages nclude short scanning time and a lower radiation dose than onventional CT, and it produces images with isotropic subillimetre spatial resolution and a high diagnostic quality.1 o date it has been used for dental implant planning, evalution of temporomandibular joints, and trauma of the facial keleton.2,3 We describe a new approach that uses CBCT to aid locaion of glass fragments in facial wounds. Currently this is ased on clinical examination and plain film radiographic iews that use the principle of parallax to locate the fragents. Identification of such fragments can be difficult articularly when they are small to medium in size. Stanard radiography can give an approximation of their position ut falls short of providing three-dimensional images that llow precise mapping of all fragments in the wound. The se of CBCT gives a three-dimensional image that can be eproduced to aid retrieval of even small fragments without nterference from artefacts.4 We have used CBCT to locate and assist in the removal of lass fragments from the face of a patient who was allegedly glassed” in the periorbital region on the right side of his face. NewTom 3G CBCT scanner (AFP Imaging Corporation, ew York, USA) was used to obtain images of the maxillofaial region to ascertain whether any glass fragments had been mbedded. Two fragments were identified and subsequently emoved under general anaesthetic (Figs. 1 and 2).

Current surgical management of metastases in the neck from mucosal squamous cell carcinoma of the head and neck.

Neck dissection, which is an important method of treatment for metastases from mucosal (and other) squamous cell carcinomas (SCC) of the head and neck, is also useful for staging disease. Since its inception it has changed from a radical to a more conservative procedure, and vital structures are preserved wherever possible. Refinements in methods of imaging to assess involvement in the neck have encouraged alternative approaches that can improve outcomes and reduce morbidity. We look at the reported evidence for the surgical management of metastases in the neck from mucosal SCC.

Facial trauma: a case of potentially life-threatening distracting injuries.

We report the case of a 60-year-old cyclist with multiple facial lacerations. Reassessment of the mechanism of injury and presenting clinical features of a change in voice, odynophagia, and a graze in the anterior neck triggered concern. Fibreoptic nasoendoscopy showed a large haematoma of the supraglottic airway. Scans confirmed laryngeal injuries, which were managed conservatively as an inpatient without prophylactic tracheostomy. This report emphasises the importance of a high index of suspicion in patients with such facial injuries and other subtle signs, and highlights the need for careful clinical assessment.

Dentigerous Cyst and Ameloblastoma of the Jaws: Correlating the Histopathological and Clinicoradiological Features Avoids a Diagnostic Pitfall.

Aim. To determine how many ameloblastomas were misdiagnosed as dentigerous cysts (DCs) by correlating the radiological and histopathological features of a series of both entities. Methods and results. Histopathology reports and radiological imaging of 135 DCs and 43 ameloblastomas were reviewed. Any clinical or radiological feature that suggested that the diagnosis of DC was wrong—for example, absence of an unerupted tooth—prompted review of the original histology. A total of 34 cases coded as DC at diagnosis were excluded; in the remaining 101 patients, the clinicoradiological and histopathological features were consistent with DC in 96 (95.0%). Review of the histology revealed that 4 patients had actually had odontogenic keratocysts (OKCs) and one a luminal/simple unicystic ameloblastoma (UA). One other OKC and 3 other ameloblastomas (1 luminal UA, 2 solid/multicystic) had originally been diagnosed as DC; these had been identified prior to the study. Of the 9 misdiagnosed patients, 6 were ≤20 years old. Clinically, DC had been the only, or one of the differential, diagnoses in 7 patients; in the other 2, the clinical diagnosis was radicular cyst. In none of the 4 misdiagnosed ameloblastomas was the radiology compatible with a diagnosis of DC. Incorrect terminology had been used on the histopathology request form in 5 of the 34 excluded cases where the clinical diagnosis was DC, despite the cyst being periapical to an erupted carious or root-filled tooth. Conclusions. The entire clinical team must ensure that a histopathological diagnosis of DC is consistent with the clinicoradiological scenario, particularly in younger patients.

Staging of squamous cell carcinoma of the tongue: extrinsic lingual muscles and the 8th editions of the American Joint Committee on Cancer/Union for International Cancer Control staging manuals

Our aim was to find out first whether the extrinsic muscles of the tongue are histologically identifiable, and secondly to what degree the use of the new criteria in the 8th editions of the American Joint Committee on Cancer(AJCC)/Union for International Cancer Control (UICC) manuals (which have recognised the importance of depth of invasion of tumour, rather than invasion of the extrinsic muscles of the tongue and extranodal extension), will alter staging of lingual squamous cell carcinoma (SCC). The histological sections from 165 patients who had had primary resection of lingual SCC were reviewed, and one or more extrinsic muscles of the tongue was identified in 100 patients (61%), with the genioglossus seen the most often (in 96). By contrast, the hyoglossus was identified in only eight patients, the styloglossus in two, and the palatoglossus in none. Identification was straightforward only in extensive resections. Applying the criteria from the 8th edition increased the number of pT3 SCC with a simultaneous reduction in pT4a tumours. The number of pN2b SCC was also reduced, but the new category of pN3b meant that overall 53% of tumours were upstaged. The kappa scores for agreement between the two sets of criteria were 0.221 (weighted 0.410) for the pT values, 0.508 (0.713) for pN values (but 0.227, weighted 0.386, if the pN0 values were removed before calculation), and 0.243 (0.514) for overall stage, indicating poor to fair agreement. We conclude that the removal of invasion of extrinsic muscles of the tongue as a criterion for a pT4a SCC is justified, and that many SCC of the tongue will be upstaged as a result of implementation of the 8th editions.