Constantinos Mourouzis

Cutaneous head and neck SCCs and risk of nodal metastasis – UK experience

AIM To identify the risk of developing metastases to regional nodes in patients with cutaneous squamous cell carcinomas (CSCCs) of the head and neck. METHODS A retrospective study of patients with CSCC treated with surgical excision alone between 2000 and 2002 was performed. Demographic details of the patients, the site, size, differentiation, depth of invasion, clearance of surgical margins, and the presence of perineural or lymphovascular invasion of the lesion were documented. During the follow up period, patients with regional metastases were identified. The site of the metastasis and the time after the primary resection were documented and statistical analysis was performed using Chi-square and logistic regression analysis. RESULTS One hundered and ninety-four patients were included and 218 CSCCs were excised in total during the period of 3 years. The scalp was the most common site of skin lesion, followed by the ear. The incidence of regional metastatic disease was found to be 5.15%. The parotid gland was the most common area of regional metastasis. No metastases occurred after the first 2 years of follow up. The pinna, the poor differentiation and incomplete excision margins were found to be associated with regional metastasis independently, with odds ratio of 16, 21, and 2 respectively. CONCLUSIONS The rate of regional metastasis from CSCC remains low. The parotid gland was the most favoured metastatic site. Patients with poorly differentiated squamous cell carcinoma (SCC) located on the ear and incomplete excision margins were at the greatest risk for developing regional lymph node metastasis and require close follow up.

Squamous cell carcinoma of the maxillary gingiva, alveolus, and hard palate: is there a need for elective neck dissection?

We retrospectively studied 17 patients with squamous cell carcinoma (SCC) of the maxillary gingiva, alveolus, and hard palate who were treated over a 7-year period (2000-2007) to investigate whether selective neck dissection is justified at an early stage. Four patients presented with metastases in the neck, and all developed early recurrence in the neck, with poor prognosis. Of the 13 patients who initially had no sign of metastases, two developed regional metastases within the first 18 months of initial treatment. Squamous cancers of the maxillary gingiva, alveolus, and hard palate should be treated aggressively, and elective neck dissection should be considered because of the high risk of occult metastases. Prospective studies are difficult because of the rarity of the tumour.

Maxillofacial injuries sustained during soccer: incidence, severity and risk factors.

A very popular sport worldwide, soccer generates a great number of maxillofacial injuries, mainly fractures, resulting in esthetic or functional problems. The aim of this retrospective study was to contribute to the knowledge of soccer-related maxillofacial injuries, and call attention to the risk factors that favor these injuries. A total of 108 patients, who attended hospital because of maxillofacial injuries during soccer within a period of 8 years, were included in this study. The relationship of the patients with soccer, the type, the site, the severity, the mechanism of the injuries and the applied treatment were analyzed. The injured were all males, and were principally amateurs. Around 89.8% of the patients suffered maxillofacial fractures while 10.2% presented only soft tissue injuries; 13.9% had multiple fractures; 50% of the maxillofacial fractures concerned the zygomatic complex and 38.2% the mandible where the majority occurred at the angle. The prevailing mechanism was the direct impact of players. Head to head impact outnumbered. Elbow to head impact caused contusions of the temporomandibular joint. Kick to head impact was the main cause of multiple fractures. The treatment of fractures was mainly surgical (68.2%). These findings support the fact that maxillofacial injuries sustained during soccer tend to be severe, demanding surgical treatment. The mandibular angle is in danger due to the usual existence of impacted and semi-impacted third molars. There should be a preventive intervention on the above contributors, and mainly coaches and sports physicians should be properly informed about the specificity of the maxillofacial injuries.

Treating maxillofacial trauma for over half a century: how can we interpret the changing patterns in etiology and management?

OBJECTIVE The aim of this study was to reveal the changes in the etiology and treatment of maxillofacial fractures in Greece over the period of the last 53 years. STUDY DESIGN A patient-oriented retrospective review of clinical and epidemiologic data was performed to include all patients with maxillofacial fractures treated in the Oral and Maxillofacial Surgery Department of KAT General Hospital of Athens. We reviewed the causes of these injuries, their sites, and treatments (outcome variables) over the last 28 years and compared the results with those of a similar study from the same Department from 1960 to 1984 (predictor variable). RESULTS The zygomatic complex was the most frequent fracture site in the recent years, whereas the condyle and symphysis were the most common ones in the early period. We observed a remarkable increase of injuries from interpersonal violence (P < .0001) and a divergence from conservative treatment (P < .001) with time. CONCLUSIONS Universal agreement exists on the rapidly rising prevalence of facial fractures in the developed countries as a result of physical violence, and the present study confirmed this conclusion. Throughout the last 50 years, there has been a constant tendency of surgeons to adopt the concept of open reduction and internal fixation.

Ketamine-induced changes in metabolic and endocrine parameters of normal and 2-kidney 1-clip rats.

Background and objective: The aim of this study was to investigate the effect of ketamine on the endocrine and lipid metabolic status of the renal‐banded animals. Methods: Forty male rats were randomly divided into four groups. Group A served as control, Group B animals received ketamine intraperitoneally at a dose of 100 mg kg−1, Group C was submitted to 2‐kidney 1‐clip experimental hypertension and Group D received ketamine as above, as well as being submitted to renal artery clipping. Atrial natriuretic peptide, angiotensin II and free fatty acid concentrations were measured in serum. In addition, adipose tissue lipoprotein lipase activity and angiotensin II content were determined, while the left ventricular weight relative to body weight was used as a cardiac hypertrophy index. Results: In renal‐banded rats (Groups C and D) serum atrial natriuretic peptide, free fatty acid and angiotensin II concentrations as well as ventricular weight were increased, while adipose tissue lipoprotein lipase activity was lower than in control animals (Groups A and B). Ketamine administration did not influence angiotensin II concentrations either in normal (Group B) or banded rats (Group D). Ketamine increased serum atrial natriuretic peptide and free fatty acid concentrations only in normal animals (Group B). It had no influence on adipose tissue lipoprotein lipase activity either in normal (Group B) or banded animals (Group D). Adipose angiotensin II content did not differ between the four groups. Conclusion: Ketamine increased the atrial natriuretic peptide and free fatty acid concentration in normal rats. In 2‐kidney 1‐clip animals, ketamine did not elicit an additional response of serum atrial natriuretic peptide or free fatty acids levels. Its contribution to these factors was not significant.

Acute osteomyelitis of the mandible caused by Rhodococcus equi in an immunocompromised patient: a case report and literature review

We present the first case of acute osteomyelitis of the mandible caused by Rhodococcus equi in an immunocompromised patient. A 53-year-old Caucasian man was referred to the outpatient clinic, because of a swelling of the left submental and submandibular spaces. The patient was immunocompromised owing to medication against myasthenia gravis and type II diabetes mellitus. The patient underwent surgical debridement under local anesthesia. Histologic examination showed acute osteomyelitis and both blood and pus cultures isolated Rhodococcus equi. The patient was discharged on linezolid 600 mg orally twice a day for 6 months and remains free of the disease 2 years postoperatively. Most patients with Rhodococcus infection are immunocompromised. Infection with this organism is rare and usually causes a distinct clinical syndrome resembling pulmonary tuberculosis. Diagnosis is frequently missed or delayed. Not only clinicians but also laboratory specialists should be aware of this organism, so as to contribute to prompt diagnosis and treatment of such infections.

Effect of titanium maxillofacial implants and osteosynthesis materials on platelet function

The use of titanium implants and osteosynthesis materials in orthopaedics, neurosurgery, and maxillofacial surgery has increased considerably, and they may be retained in patients for a long time. We could find no papers in English that provided data about the effect of titanium osteosynthesis materials on platelet function, and the purpose of this study was to evaluate those effects. Platelet function was tested in 33 patients with titanium maxillofacial implants using the PFA-100 (platelet function analyser) system and these results were compared with those of a control group of 34 healthy volunteer blood donors. Platelet function was measured in each group using collagen/adrenaline and collagen/adenosine diphosphate (ADP) as agonists for assessment of platelet function. There were no significant differences between the groups (collagen/adrenaline p=0.1, collagen/ADP p=0.09). Titanium maxillofacial osteosynthesis materials have no significant effect on platelet function as assessed by the PFA-100 system.

The significance of orbital floor exploration during open reduction of zygomaticomaxillary complex fractures

Zygomaticomaxillary complex (ZMC) fractures represent one of the most common facial fractures. Their high vulnerability of the ZMC to injury is attributed to its intrinsically prominent convexity. Not only highbut also lowenergy ZMC fractures may result in posteriomedial displacement of the fractured bony fragments, thus corrupting the anatomy of the orbit and especially the orbital floor. The anatomy of the delicate orbital floor is intricate and crucial for surgeons involved in the treatment of orbital pathology. It is formed by the maxilla (medially to the infraorbital groove), the zygomatic bone (anterolaterally) and a small portion of the palatine bone (posteriorly). The infraorbital neurovascular bundle courses on the orbital floor along the infraorbital groove and infraorbital canal immediately above the maxillary sinus, thus thinning the orbital floor at its junction with the medial wall, before it exits at the infraorbital foramen. Therefore, most fractures tend to occur along the infraorbital groove, between the posterior and medial part of the orbital floor. Fractures of the orbital floor occur in one of the following three patterns: a) the fractured fragment(s) collapse(s) into the maxillary sinus, thus producing a defect of the orbital floor; b) the orbital floor gets comminuted and the multiple bony fragments produce a multi-folded appearance; c) the fractured fragments overlap telescopically, i.e. one inside the other. Thus, the only orbital floor fracture pattern associated with orbital floor defects is the first. Moreover, the orbital floor is by definition affected in ‘blowout’ orbital fractures, designated as fractures or defects of one or more internal orbital wall(s); since these Abstract Objective: Zygomaticomaxillary complex (ZMC) fractures represent a common type of facial fractures, sometimes associated with defects of the orbital floor that may escape diagnosis, unless investigated intraoperatively following open reduction. The aim of the study was to determine the frequency of orbital floor defects among cases of ZMC fractures treated with open reduction in our Department and to share our experience in the diagnostic and therapeutic approach of such defects. Patients and methods: The files of all patients, treated in our Department for ZMC fractures from January 2010 to October 2014 were retrieved and reviewed retrospectively. Specific related data were registered and submitted to thorough analysis. Results: Based on our findings a considerable percentage (34.1%) of the patients with ZMC fractures demonstrated considerable defects of the orbital floor; these were diagnosed through intraoperative exploration of the orbital floor following open reduction of the fractures and appropriately treated. Conclusions: Orbital floor defects associated with ZMC fractures may remain undiagnosed and therefore untreated, unless routine exploration of the orbital floor is performed following open reduction of the fractures. This could result in severe morbidity, including enofthalmos, restricted ocular mobility and impaired visual acuity.

An incidentally discovered radiolucency in the posterior maxilla

CLINICAL PRESENTATION An 18-year-old woman was referred to the maxillofacial outpatient clinic by a dentist owing to a radiolucent lesion discovered incidentally on a routine panoramic radiograph. The oral examination found swelling at the area of the left maxillary premolars. The swelling was bony-hard, nontender, and approximately 1 cm in size, and the overlying mucosa was normal. The adjacent teeth tested vital, and no evidence of periodontal disease or caries was detected. There was no tooth mobility, and the occlusion remained unchanged. The patient was asymptomatic, was otherwise healthy, and reported a noncontributory medical and dental history. No history of trauma was recorded. The panoramic radiograph of the patient showed a wellcircumscribed, unilocular, radiolucent lesion, interspersed with opaque formations, at the area of the left maxillary premolars (Figure 1). The unusual opacity in the area of the maxillary midline was a piece of nose-piercing jewelry. The lesion was further investigated with a computed tomography (CT) scan, which found a well-demarcated lesion, measuring 3 2.8 2.5 cm. The lesion had caused expansion of the buccal cortex, in conjunction with elevation of the floor of the maxillary sinus. No bony erosion was identified. The lesion was not homogeneous, with an average density of 190 Hounsfield units, and also contained multiple hyperdense spots, representing calcified structures (Figure 2).

Mycosis of the Maxillary Sinus as an Occupational Disease: Report of Two Cases

Fungal infections of the paranasal sinuses may occur in patients with chronic sinusitis, who usually have a predisposing cause such as neutropenia, prolonged use of corticosteroids, uncontrolled diabetes mellitus, HIV infection. Occasionally it may also be seen in immunocompetent patients. The patient’s medical report and occupation seem to be very important information. The duration of the symptoms and the negative response to other medical treatment for sinusitis, show the fungal infection as the more likely diagnosis.