Henrik Holtmann

Oral cancer malnutrition impacts weight and quality of life.

Diet is important for both quality of life (QoL) and survival of patients with oral cancer. Their intake of food is impeded by functional restrictions in chewing and swallowing. In the DÖSAK REHAB STUDY 1652 patients from 38 hospitals within the German-language area of Germany; Austria and Switzerland were examined with regard to functional and psychological variables having an impact on diet. Chewing and swallowing are correlated with mobility of the tongue and the mandible as well as opening of the mouth. Thirty five percent of the patients lost weight; 41% maintained their weight and 24% gained weight. The QoL of patients who were able to maintain their weight and of those who gained weight was significantly better than that of patients who lost weight. A normal diet was important for maintaining weight. Mashed food; liquid food and loss of appetite were closely associated with loss of weight; although it was possible for nutritional counseling and dietary support to be implemented particularly favorably in this respect. Due to problems with eating patients’ strength deteriorated; thus restricting activity. Radiotherapy had a negative impact on diet and weight. It influenced sense of taste; dryness of the mouth; swelling and discomfort when ingesting food. Pain and scars in the region of the operation also cause patients to dislike hard; spicy and sour food. Support from a nutritional counselor in implementing a calorie-rich diet remedied this and such support needs to be integrated into patient management. The fact that a poor nutritional status is of such great importance is well-known; but what is often lacking is the systematic implementation of continued professional nutritional counseling over a long period of time; weight control and psycho-social support of the operated patients; particularly those who also have had radiotherapy.

TB or not TB? Diagnostic difficulties in HIV-positive versus HIV-negative tuberculosis patients with an immigration background in Germany

Patients immigrated or born to immigrated parents constitute an increasing proportion of TB in Germany. This study aimed to assess the clinical presentation and outcome of immigrated TB-monoinfected (TB/HIV–) patients versus TB patients with an HIV coinfection (TB/HIV+). Ninety-three patients (36 boys/men, 57 girls/women; age range, 2–59 years) were investigated of whom 47 were TB/HIV+ and 46 TB/HIV–. TB/HIV+ patients more frequently had an African background (76.6% [36/47], P <0.001), TB/HIV– patients (63.0% [29/46]) more often had an East-European or Asian background (P <0.001). Most common symptoms included lymphadenopathy (37.6% [35/93]) and weight loss (35.5% [33/93]). In TB/HIV+ patients acute presentation was more frequent including fever (57.4% [27/47]), gastrointestinal (44.7% [21/47]), and respiratory symptoms (36.2% [17/47]). TB skin test was highly positive in all performed cases (20/20), IGRA was positive in 98.2% (55/56) cases applied. Pulmonary involvement was relatively rare (51/93 [54.8%]), especially in TB/HIV– patients (36.10% [17/46]) vs. TB/HIV+ (70.23% [36/47]; P <0.001). An infectious etiology was suspected in only 43.5% (20/46) TB/HIV– vs. 72.3% (34/47) TB/HIV+ patients (P ⩽0.005); a malignancy was suspected in (21/46 [45.7%] TB/HIV– patients vs. 12/47 [25.5%] TB/HIV+; P ⩽0.043). The diagnostic delay between first presentation to a doctor and TB diagnosis was long in all cases, especially in TB/HIV– patients (range, 0–336 weeks; median, 8 weeks vs. TB/HIV+ patients; range, 0–288 weeks; median, 0 weeks; P <0.05). TB, especially in young immigrated HIV– patients frequently presents as an atypic extrapulmonary disease, which may end up in a delayed diagnosis of up to several years.

Pathogenesis of medication-related osteonecrosis of the jaw: a comparative study of in vivo and in vitro trials

Objective This study was performed to determine whether the results of prevailing in vivo and in vitro studies offer a reliable model for investigation of medication-related osteonecrosis of the jaw (MRONJ). Methods Embase, Medline, and the Cochrane Library were searched for articles published from September 2003 to June 2017 involving experimental approaches to the pathogenesis of MRONJ. In vivo and in vitro trials were analyzed with respect to the scientific question, study design, methodology, and results. Results Of 139 studies, 87, 46, and 6 conducted in vivo, in vitro, and both in vivo and in vitro experiments, respectively. Rats, mice, dogs, minipigs, sheep, and rabbits were the preferred animal models used. Osteoblasts, osteoclasts, fibroblasts, keratinocytes, macrophages, and human umbilical vein endothelial cells were the preferred cell types. Zoledronate, alendronate, ibandronate, and risedronate were the most frequent bisphosphonates used. MRONJ was most reliably induced in minipigs because of the close relationship with human bone physiology. In vitro studies showed that reduced viability, growth, and migration of cells in the bone and soft tissues were causative for MRONJ. Other than exposed jawbone after tooth extraction, no reliable cofactors were found. Conclusion The minipig is the most suitable animal model for MRONJ.

Trajectory-guided biopsy of orbital tumor – Technology, principal considerations and clinical implementation

Intraorbital space-occupying lesions always pose a challenge, both in terms of definite surgical removal as well as preoperative sampling for histopathological examination. Despite the use of modern high-resolution imaging techniques, the dignity of orbital lesions can often not be determined with sufficient certainty preoperatively. As the amount and complexity of treatment possibilities continue to increase, detailed diagnostics in advance of treatment choice are essential. Histological classification of orbital lesions can still be considered the gold standard for reliable diagnoses, leading to appropriate treatment. Over recent years minimally invasive surgical approaches have gained more importance in the treatment and diagnosis of cranio-maxillo-facial tumor and trauma. The aim of our study was to adapt and establish a precise procedure for orbital biopsies. 23 patients suffering from space-occupying lesions of unknown dignity were included. Trajectory-guided procedures were pre-planned for all cases. In most cases minimally invasive procedures were suitable for taking biopsies of the orbit. For only two patients a conventional, non-minimally invasive, lateral orbitotomy had to be performed. Further evaluation of the presented procedure demonstrates clearly that trajectory-guided biopsies of the orbit can be performed correctly and effectively, regardless of the suspected lesions size.

Extraskeletal chondroma walling the temporomandibular joint: Report of a rare case and review of the literature

Highlights • Extraskeletal or soft-tissue chondroma is a rare cartilaginous benign neoplasm.• Affects usually hands and feet, preauricular region is extremely rare.• Diagnosis is challenging since even histological features may be misleading to other pathologies.• Report describes a rare case of extraskeletal chondroma surrounding the temporomandibular joint in a 55-year-old woman.

Secondary Bleedings in Oral Surgery Emergency Service: A Cross-Sectional Study

Introduction Bleeding after dental surgery is still a common cause for emergency presentation in patients using anticoagulants. Our aim was to analyze pertinent characteristic features on the one hand and to bare existing problems in handling on the other. Materials and Methods The study included 76 patients. We documented basic data, anticoagulant medication, type of surgery, and tooth socket sutures in respective patients. Results The vast majority of patients took a coumarin derivative (41) and acetylsalicylic acid (27). Nine (12%) of the patients had to be hospitalized due to ongoing bleeding despite local haemostyptic steps and/or circulatory dysregulation. Most patients could be successfully treated in outpatient settings. No statistically significant correlation between bleeding, level of INR value, number of extracted teeth, and sewed alveoli could be shown. Sixty-five percent of cases with tooth extractions did not have suture of tooth sockets. Eighty-seven percent of the patients denied being informed about possible self-treatment options by their surgeon/dentist, and none of the patients got presurgical-fabricated bandage plate(s). Conclusions Patients taking coumarin derivative currently, furthermore, represent the biggest anticoagulant after-bleeding group in dentoalveolar surgery. The major part of after-bleedings (90%) can be handled in an outpatient setting with simplest surgical interventions. Unfortunately, the biggest part of the patient collective got no suture, no prefabricated dental bandage plate(s), and no explanation by their dentist how to handle in case of after-bleeding. Therefore, dental practitioners should furthermore get enlightenment on how to prevent after-bleeding situations.

Extensive Craniocervical Abscess after Transoral Ganglionic Local Opioid Analgesia at the Superior Cervical Ganglion for Atypical Trigeminal Neuralgia: Report of a Severely Complicated Case

Ganglionic local opioid analgesia (GLOA) describes the application of low-dose opioids close to sympathetic as, for example, to the superior cervical ganglion. GLOA can be effective in different pain syndromes affecting the head and face region and has been considered to be a safe technique with few complications reported so far. We present the case of a patient who received a single, transoral GLOA for a refractory trigeminal neuralgia. The patient subsequently developed an extensive epidural abscess at the craniocervical junction, requiring ultimately transoral odontoid resection and dorsal stabilisation. This severe complication challenges the role of transoral infiltration therapies in analgetic medicine.

A female traveler returning from Peru with an erythematous infraorbital swelling: A diagnostic challenge

After a vacation trip to tropical Peru a 54-year-old Caucasian woman presented at our clinic with sensations of pressure, irritation and pain located at a skin area with close proximity to her right infraorbital foramen. Clinical inspection of the said region showed a papular erythematous swelling with a diameter of approximately 2 cm. A little nodule in the center of the lesion appeared to be the opening of a fistula. In the case history we elicited that these symptoms already began in Peru and reached a maximum after she had returned home. The patient could not recall any traumas or infections in the facial region. At first, a general practitioner was consulted and prescribed a 7-day treatment with antibiotics (amoxicillin + clavulanic acid). These therapeutic measures did not have any positive effects on the lesion. In cooperation with the department for tropical medicine our clinic further investigated the case. We conducted an ultrasound examination displaying a space-occupying mass underneath the skin (see picture below). In analogy with the patients travel history an infestation with fly larvae was deemed most likely. In a surgical procedure under general anesthesia a superficial incision was made to carefully prepare the underlying tissue. Here a live insect larva was found which was extracted from the wound (Fig. 1). In a subsequent morphometric analysis the genus of the larva was categorized as dermatobia hominis. This species is indigenous to tropical and subtropical regions with a hot and humid local climate causing a disease termed myasis. Myasis is characterized by destructive processes of skin and other tissues infested by fly larvae just as described in our patient. We conclude that for a fast diagnosis of myasis early clinical examinations must be supported by sonographic imaging in patients with signs of persistent skin inflammation especially with a history of tropical travel destinations.

Regular Dental Visits: Influence on Health-Related Quality of Life in 1,607 Patients with Oral Squamous Cell Carcinoma

Background The incidence of oral squamous cell carcinoma (OSCC) is in the top 10 of all cancer entities. Regular oral examinations by dentists play an important role in oral cancer prevention. Methods Patients with OSCC (n = 1,607) and physicians (n = 1,489) completed questionnaires during the DÖSAK Rehab Study. The psychosocial and functional factors collected in these questionnaires were assessed in the present study. We compared patients who visited their dentist at least once a year (group A) with those who visited their dentist less than once a year (group B). Results Patients in group A had significantly better health-related quality of life after tumor treatment than patients in group B. Patients in group A also had a smaller tumor size and less lymph node metastasis and lost fewer teeth during the treatment. This resulted in better prosthetic rehabilitation and better psychological status after tumor treatment. Conclusions Dentists play an important role in the early recognition of oral cancer. This study should encourage dentists to take a more active role in oral cancer prevention.