K.-D. Wolff

Incidence of maxillary sinusitis and oro-antral fistulae in bisphosphonate-related osteonecrosis of the jaw.

OBJECTIVE Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a serious side-effect of bisphosphonate therapy. In the majority of cases BRONJ occurs in the mandible. As a consequence a detailed investigation of BRONJ of the maxilla and in particular of involvement of the maxillary sinus has largely so far been neglected. The aim of this study was to analyse the frequency of maxillary sinusitis and oro-antral fistulae in BRONJ of the maxilla. SUBJECTS AND METHODS A retrospective multicentre analysis was carried out in three Departments of Oral and Maxillofacial Surgery focussing on patients suffering from BRONJ in the maxilla. The role of involvement of the maxillary sinus, in particular sinusitis and oro-antral fistula, was analysed. RESULTS Out of a total of 170 patients suffering from BRONJ 53 cases (31.2%) with involvement of the maxilla were identified. At least one sign of maxillary sinusitis was present in 43.6% (23/53) and an oro-antral fistula in the course of the disease was detected in 35.8% (19/53) of those patients. The mean length of time of bisphosphonate intake was 36.16±16.32 months. Zoledronate was most frequently associated (60.4%) with symptoms, followed by the combination of Zoledronate/Ibandronate (13.2%), and Zoledronate/Pamidronate or Pamidronate alone (both 7.5%). CONCLUSION Maxillary sinusitis and oro-antral fistulae are associated with a BRONJ manifestation in the upper jaw in approximately 44%. The involvement of the maxillary sinus should be given special attention and three-dimensional imaging modalities might be necessary, not only to evaluate the extent of necrosis, but also to exclude involvement of the maxillary sinus.

Changes in acoustic airway profiles and nasal airway resistance after Le Fort I osteotomy and functional rhinosurgery: A prospective study

The aim of this study was to investigate the changes in nasal airways after Le Fort I osteotomy and functional rhinosurgery. 49 patients were included in this study to assess intranasal anatomical and functional changes resulting from a Le Fort I osteotomy. The data were classified according to the three-dimensional positioning of the maxilla: in group I the maxilla was impacted; in group II the maxilla was inferior; and in group III only sagittal maxillary movement was performed. Presurgical and 5 months postsurgical rhinological inspection, anterior rhinomanometry and acoustic rhinometry were carried out. Additional rhinosurgery, such as resection of the inferior concha or septoplastic intervention, was performed to avoid functional problems in nasal breathing, particularly when the maxilla was impacted. Rhinomanometric assessment showed a significant improvement in nasal breathing in the whole group and each single group. Acoustic rhinometry revealed an increase in typical cross-sectional intranasal areas. The authors conclude that concerns about the respiratory consequences of this surgical procedure appear unwarranted when functional rhinosurgery is undertaken concomitantly, particularly in patients with increased preoperative nasal airway resistance.

Attenuation of leukocyte sequestration by selective blockade of PECAM-1 or VCAM-1 in murine endotoxemia

Background: Molecular mechanisms regulating leukocyte sequestration into the tissue during endotoxemia and/or sepsis are still poorly understood. This in vivo study investigates the biological role of murine PECAM-1 and VCAM-1 for leukocyte sequestration into the lung, liver and striated skin muscle. Methods: Male BALB/c mice were injected intravenously with murine PECAM-1 IgG chimera or monoclonal antibody (mAb) to VCAM-1 (3 mg/kg body weight); controls received equivalent doses of IgG2a (n = 6 per group). Fifteen minutes thereafter, 2 mg/kg body weight of Salmonella abortus equi endotoxin was injected intravenously. At 24 h after the endotoxin challenge, lungs, livers and striated muscle of skin were analyzed for their myeloperoxidase activity. To monitor intravital leukocyte-endothelial cell interactions, fluorescence videomicroscopy was performed in the skin fold chamber model of the BALB/c mouse at 3, 8 and 24 h after injection of endotoxin. Results: Myeloperoxidase activity at 24 h after the endotoxin challenge in lungs (12,171 ± 2,357 mU/g tissue), livers (2,204 ± 238 mU/g) and striated muscle of the skin (1,161 ± 110 mU/g) was significantly reduced in both treatment groups as compared to controls, with strongest attenuation in the PECAM-1 IgG treatment group. Arteriolar leukocyte sticking at 3 h after endotoxin (230 ± 46 cells × mm–2) was significantly reduced in both treatment groups. Leukocyte sticking in postcapillary venules at 8 h after endotoxin (343 ± 69 cells/mm2) was found reduced only in the VCAM-1-mAb-treated animals (215 ± 53 cells/mm2), while it was enhanced in animals treated with PECAM-1 IgG (572 ± 126 cells/mm2). Conclusion: These data show that both PECAM-1 and VCAM-1 are involved in endotoxin-induced leukocyte sequestration in the lung, liver and muscle, presumably through interference with arteriolar and/or venular leukocyte sticking.

Tumour budding activity and cell nest size determine patient outcome in oral squamous cell carcinoma: proposal for an adjusted grading system

Oral squamous cell carcinoma (OSCC) is a common malignancy with a variable clinical course. One of the established survival predictors in carcinomas in general is tumour grade; in OSCC, however, grading according to the World Health Organization (WHO) has no independent prognostic impact. Recently, a novel grading scheme associated with high impact on patient outcome has been proposed for squamous cell carcinoma of the lung.

Evaluation der Unterschenkelarterien vor mikrochirurgischem Fibulatransfer

Nach Einführung des mikrochirurgischen Fibulatransplantats im Jahr 1975 durch Taylor und erstem Einsatz im Kieferbereich 1989 durch Hidalgo hat sich dieses Transplantat zu einem Grundpfeiler für die Rekonstruktion des Unterkiefers bei ausgedehnten oromandibularen Defekten etabliert. Voraussetzung für die Anwendung dieses Transplantats ist allerdings der Nachweis einer intakten 3-Gefäß-Versorgung des Unterschenkels, um insbesondere bei Rauchern die Gefahr einer später auftretenden Mangeldurchblutung des Fußes zu minimieren. Dieser Nachweis wurde bisher mit der invasiven DSA-Technik erbracht. Die Fortschritte auf dem Gebiet der Magnetresonanzangiographie (MRA) ermöglichen jedoch zunehmend eine primäre Gefäßdiagnostik mit nichtinvasiven Untersuchungsverfahren. Ziel der vorliegenden prospektiven Untersuchung war, die Frage zu beantworten, ob die MRA normvariante Gefäßverläufe und pathologische Gefäßstenosen der Unterschenkelarterien zuverlässig darstellen und damit die konventionelle digitale Subtraktionsangiographie (DSA) ersetzen kann. In einer prospektiven Studie wurden bei 15 Patienten vor Entnahme eines Fibulatransplantats eine konventionellen DSA und postoperativ eine MRA der Unterschenkel mit i. v. Kontrastmittelgabe angefertigt. Alle Aufnahmen wurden verblindet und einer Auswertung durch 3 Radiologen zugeführt. Die Beurteilung des Gefäßstatus erfolgte in Bezug auf atherosklerotische Veränderungen, Stenosen, hypoplastische Gefäße, Gefäßokklusionen und allgemeine Gefäßanatomie. Die hohe Auflösung der MRA ermöglichte eine sichere Beurteilung aller 3 Hauptgefäße des Unterschenkels. Fehlende und hypoplastische Gefäße, Stenosen und atherosklerotische Veränderungen konnten eindeutig dargestellt werden und deckten sich mit den Befunden der DSA. Die MRA der Unterschenkel ermöglicht eine sichere Beurteilung des Gefäßstatus und ist aufgrund des geringeren Untersuchungsrisikos, der ambulanten Durchführbarkeit und der fehlenden Strahlenexposition der DSA in dieser Fragestellung vorzuziehen. Since the introduction of the fibula flap by Taylor in 1975, and its first application in the lower jaw by Hidalgo in 1989, it has become an option of first choice in mandibular reconstruction of large oromandibular defects. Perfusion of the osteomyocutaneous fibula transplant is based on the peroneal artery. To avoid postoperative ischaemia of the lower leg after sacrificing this artery, especially in smokers, adequate perfusion must be guaranteed preoperatively by radiological evaluation. Progress in the field of magnetic resonance angiography (MRA) enables an increasing number of primary non-invasive evaluations of vessels. The aim of this prospective study was to answer the question of whether MRA enables a accurate representation of anatomical variation and pathological stenoses of the lower leg vessels and can therefore replace conventional digital subtraction angiography (DSA). We carried out conventional DSA of the lower leg before raising a fibula transplant and postoperative MRA with contrast medium in a prospective study with 15 patients. Vessels were assessed for atherosclerotic, occlusive or hypoplastic changes and anatomical variations by three radiologists. High resolution of MRA enables a reliable judgement of the lower leg vessels. Hypoplastic vessels, stenoses, occlusion or atherosclerotic changes of the vessels could definitely be detected by MRA just as by DSA. Thus, all patients without these diagnosed contraindications could be operated successfully. MRA of the lower leg enables a definitive determination of the vessel quality and the site of preference for harvesting the flap. Because MRA is a low risk procedure, can be carried out on an outpatient basis and causes no radiation load, it should be preferred to conventional DSA.

Indikationen zur primären operativen Therapie von Gefäßanomalien im Säuglingsalter

Lasertherapie. Seit Einführung der Lasertherapie für die Behandlung von Hämangiomen und vaskulären Malformationen hat die operative Therapie in der Primärbehandlung immer mehr an Bedeutung verloren. Besonders Hämangiome, aber auch venöse Malformationen und Lymphangiome werden heute in der Regel einer primären Lasertherapie zugeführt, wobei besonders der Nd:YAG-Laser mit perkutaner oder transkutaner Applikationstechnik oft zu guten Ergebnissen führt. Chirurgische Verfahren. Chirurgische Verfahren kommen meist nach mehrmaliger Laserbehandlung erst sekundär im späten Kindes- oder Erwachsenenalter zur Anwendung und bestehen aus der Exzision von Restbefunden oder plastischen Korrekturoperationen. Besonders bei subkutan gelegenen Gefäßanomalien und bei erfolgloser Lasertherapie mit weiterhin schnell wachsenden Hämangiomen besteht jedoch auch heute noch eine klare Indikation zur chirurgischen Therapie, die selbst bei ausgedehnten Befunden eine blutungsarme und sichere Tumorentfernung ermöglicht. Fallberichte. Anhand von 3 Kasuistiken soll auf die Notwendigkeit einer operativen Intervention hingewiesen werden, durch die drohende Komplikationen wie Erblindung, Läsion des N. facialis oder letaler Ausgang bei massiver Einblutung verhindert werden konnten. Laser therapy. Since the introduction of laser therapy for treatment of hemangiomas and vascular malformations, primary surgical therapy has gradually lost importance. Particularly hemangiomas, but also venous malformations and lymphangiomas, are nowadays primarily treated by different types of lasers. Especially the Nd:YAG laser with a percutaneous or transcutaneous application technique often leads to satisfying results. Surgical therapy. Surgical therapy is mostly used secondarily in late childhood or in adults after several laser applications for excision of residual scars or other corrective procedures. Despite these improvements in laser therapy, there is still an indication for primary surgical treatment in subcutaneous vascular malformations and in rapidly growing hemangiomas after unsuccessful laser therapy. Even in large vascular anomalies, safe excision with only a little blood loss is possible if the tumors are encapsulated. Case reports. In this paper we want to point out the necessity of primary surgery in three children in whom complications such as loss of sight, facial nerve palsy, and a lethal outcome due to massive hemorrhage in a cystic lymphangioma could be avoided.

Sealing Maneuver for Microvascular Anastomoses in Rats

Microsurgical skills and techniques are the bases for numerous research studies involving rats. Moreover, these animals are widely used for microsurgical training in surgical disciplines. To reduce the number of rats used during research and microsurgical training, we developed the sealing maneuver. This technique helps to reduce bleeding especially in arterial anastomoses after opening of the vascular clamps. In 32 rats we performed 62 microanastomoses using the sealing maneuver. The distal clamp is shortly opened to let a small amount of blood into the anastomotic area. The clamp is then closed and the blood is left for about 1 minute for sealing. Finally, the bloodstream is reestablished and blood loss is kept to a minimum. We describe the use of this technique for end-to-end and end-to-side microanastomoses. The sealing maneuver is simple and reliable. This technique is especially useful in rats because of their physiological high fluid volume turnover.

[The leishmaniasis - a parasitel infection as differential diagnosis of malignant tumours of oral mucosa. A case report and review of literature].

Although parasitel infections in northern Europe are rare, it must be considered as differential diagnosis of malignant tumours of mucous membrane. With increasing tourisms in endemic areas, infections with parasite pathogen are spreading in non-endemic areas as well. In this case a mucous membrane malignancy with clinical feature of ulcer on unusual location was imitated. In this reported case the patient suffers with hepatitis c, causing cirrhosis of the liver and making a liver transplantation necessary. In this patient a history of a leishmaniosis which had been treated successful by the tropical institute is reported, but because of a new actually leishmaniosis-infection a liver transplantation is contraindicated. Under oral therapy with Miltefosin (IMPADIVO) a remission was successful. The leishmaniosis is a classical tropical disease. WHO reported a morbidity of nearly 12 million people in 88 countries around the world especially in tropical areas. Repeatedly infections in northern Europe caused by the phlebotonus-sandflies are described. Therefore leishmaniosis must be considered as differential diagnosis in suspect lesions of mucous membrane.

Hebung des Radialislappens mit primärem Wundverschluß durch Präfabrikation von Spalthautfaszienlappen

A disadvantage of the radial forearm flap is the removal of skin from a functionally important and aesthetically exposed region. To minimize the donor site morbidity with this flap, we have thus far used a two-phase procedure for intraoral defect coverage in 15 patients: In a first step, a 0.5-mm split thickness skin graft is transplanted to the forearm fascia and settles there over a period of 2 weeks. In step two, the prefabricated fascial-split thickness skin graft can be raised with complete preservation of the forearm skin and microsurgically transferred like a conventional radial forearm flap. We have obtained the following results with this procedure: (1) All skin grafts took completely on the forearm fascia. (2) Prefabricated fascial-split thickness skin flaps could be raised like conventional radial forearm flaps. (3) The very thin and moldable flaps were excellently suited for intraoral lining and showed complication-free healing. We conclude that tension-free, primary closure of the donor site can be achieved with minimal aesthetic and functional impairment.Ein wesentlicher Nachteil des Radialislappens besteht in der Entfernung der Haut aus einer funktionell bedeutsamen und kosmetisch exponierten Region des Unterams. Um die Problematik des Entnahmedefekts zu verringern, haben wir zur Deckung intraoraler Defekte an bisher 5 Patienten ein 2phasiges Vorgehen angewendet: In einem 1. Schritt wird 0.5 mm dicke Spalthaut auf die Unterarmfaszie transplantiert, welche dort über einen Zeitraum von 2 Wochen einheilt. Im 2 Schritt kann der vorgefertigte Spalthautfaszienlappen unter vollständiger Schonung der Haut des Unterarm gehoben und wie ein konventioneller Radialislappen mikrochirurgisch transplantiert werden. Mit diesem Verfahren haben wir folgende Erfahrungen gemacht: 1. Die Hauttransplantate sind in allen Fällen vollständig auf der Unterarmfaszie eingeheilt. 2. Die vorgefertigten Faszienspalthautlappen ließen sich wie konventionalle Radialislappen problemlos heben. 3. Alle Lappen eigneten sich als sehr dünne und formbare Transplantate hervorragend für die Defektdeckung in der Mundhöhle und heilten komplikationslos ein. 4. Alle Entrahmestellen am Unterarm konnten spannungsfrei primär verschlossen werden, und die kosmetischen und funktionellen Beeinträchtigungen waren gering. A disadvantage of the radial forearm flap is the removal of skin from a functionally important and aesthetically exposed region. To minimize the donor site morbidity with this flap, we have thus far used a two-phase procedure for intraoral defect coverage in 15 patients: In a first step, a 0.5-mm split thickness skin graft is transplanted to the forearm fascia and settles there over a period of 2 weeks. In step two, the prefabricated fascialsplit thickness skin graft can be raised with complete preservation of the foream skin and microsurgically transferred like a conventional radial forearm flap. We have obtained the following results with this procedure: (1) All skin grafts took completely on the forearm fascia. (2) Prefabricated fascialsplit thickness skin flaps could be raised like conventional radial forearm flaps. (3) The very thin and moldable flaps were excellently suited for intraoral lining and showed complication-free healing. We conclude that tension-free, primary closure of the donor site can be achieved with minimal aesthetic and functional impairment.

Immunohistochemical expression of CD44 in oral squamous cell carcinoma in relation to histomorphological parameters and clinicopathological factors

Oral squamous cell carcinoma (OSCC) is characterised by its variable clinical course. In addition to the routinely used TNM and Union for International Cancer Control systems, patient‐specific prognostic/predictive biomarkers are needed. Promising biomarkers include the determination of the cancer stem cell compartment, which can be identified by CD44 expression (among other things). The aim of this study was to evaluate the impact of CD44 in OSCC in terms of correlation with histomorphology, especially targeting features of EMT, and its influence on patient prognosis.