Lori K. Howell

Current Status of Surgical Planning for Orthognathic Surgery: Traditional Methods versus 3D Surgical Planning

Background: Orthognathic surgery has traditionally been performed using stone model surgery. This involves translating desired clinical movements of the maxilla and mandible into stone models that are then cut and repositioned into class I occlusion from which a splint is generated. Model surgery is an accurate and reproducible method of surgical correction of the dentofacial skeleton in cleft and noncleft patients, albeit considerably time-consuming. With the advent of computed tomography scanning, 3D imaging and virtual surgical planning (VSP) have gained a foothold in orthognathic surgery with VSP rapidly replacing traditional model surgery in many parts of the country and the world. What has yet to be determined is whether the application and feasibility of virtual model surgery is at a point where it will eliminate the need for traditional model surgery in both the private and academic setting. Methods: Traditional model surgery was compared with VSP splint fabrication to determine the feasibility of use and accuracy of application in orthognathic surgery within our institution. Results: VSP was found to generate acrylic splints of equal quality to model surgery splints in a fraction of the time. Drawbacks of VSP splint fabrication are the increased cost of production and certain limitations as it relates to complex craniofacial patients. Conclusions: It is our opinion that virtual model surgery will displace and replace traditional model surgery as it will become cost and time effective in both the private and academic setting for practitioners providing orthognathic surgical care in cleft and noncleft patients.

Local response to chemoradiation in T4 larynx cancer with cartilage invasion

Patients with cartilage invasion were excluded from organ preservation protocols treating laryngeal and hypopharyngeal cancer. Treatment choice between chemoradiotherapy (CRT) and total laryngectomy (TL) remains controversial for these patients.

Management of pediatric intramuscular venous malformations

BACKGROUND Intramuscular venous malformations (VMs) are rare, but can be highly symptomatic. There are few reports on outcomes, particularly pain, functional limitations, and muscle contractures. We aimed to compare results of medical management, sclerotherapy, and surgical resection. METHODS We retrospectively reviewed 45 patients with an extremity or truncal intramuscular VM between June 2005 and June 2015 at a single institution. Outcomes were compared between treatment modalities with ANOVA and χ2 tests. RESULTS Six patients (13%) were treated with medical management, 4 (9%) with surgical resection, 23 (51%) with sclerotherapy, and 12 (27%) with both surgery and sclerotherapy. Sclerotherapy alone decreased pain in 72%. Only 20% of patients presented with muscle contracture. For these patients, 33% resolved with sclerotherapy, physical therapy, and aspirin; 22% resolved with surgery, and 45% had persistent contracture. 40% of patients treated with sclerotherapy then surgery developed new muscle contractures, compared to 4% of sclerotherapy only patients and 0% of surgery only patients (p=0.04). CONCLUSIONS Medical management, surgery and sclerotherapy are effective treatments for intramuscular VMs. Observation and supportive care can be a primary treatment for patients with minimal symptomatology and no functional limitations. Sclerotherapy is more effective for treating pain than contractures and when used alone, rarely causes a new muscle contracture.

Doxycycline Sclerotherapy Is Superior in the Treatment of Pediatric Lymphatic Malformations

PURPOSE To evaluate efficacy of sclerotherapy with doxycycline versus sodium tetradecyl sulfate (STS) for treatment of macrocystic and mixed lymphatic malformations (LMs). MATERIALS AND METHODS This single-center retrospective review identified 41 children (17 boys; 24 girls; age range, 1 month to 15.4 y) who underwent sclerotherapy with doxycycline (n = 32) or STS (n = 9) for macrocystic (n = 31) or mixed (n = 10) LMs. There were 114 treatments performed, averaging 2.8 treatments (range, 1-8 treatments) per patient. Average follow-up time was 10 months (range, 1-59 months). Clinical response was deemed excellent or moderate if > 90% or > 50% of LMs resolved based on visual estimate. RESULTS With doxycycline, 87% of patients (28 of 32) had excellent or moderate response with an average of 2.8 treatments (range, 1-7 treatments); 13% required subsequent resection. With 3% STS monotherapy, only 55% of patients (5 of 9) had excellent or moderate response with an average of 2.8 treatments (range, 1-8 treatments), and 33% required subsequent resection. Significantly fewer patients treated with STS responded well compared with patients treated with doxycycline (P = .03). Patients treated with STS had significantly longer follow-up than patients treated with doxycycline (27 months vs 6 months, P = .0001). CONCLUSIONS Doxycycline monotherapy resulted in a high rate of excellent clinical outcomes after a few treatments without increased need for subsequent operative resection. These results support use of doxycycline sclerotherapy as primary treatment for macrocystic and mixed LMs in children.

Defining pediatric orbital roof fractures: Patterns, sequelae, and indications for operation

Background: There are few published data addressing pediatric orbital roof fractures, particularly regarding long-term outcomes and indications for operative intervention. To provide evidence-based guidelines for the management of these injuries, the authors examined a large cohort of patients with this injury pattern. Methods: Institutional review board approval was obtained to review pediatric patients presenting to Johns Hopkins Hospital from 1991 to 2011. All patients with a diagnosis indicating orbital or skull base fractures were reviewed to determine orbital roof involvement. Patients with roof fractures were assessed for demographics, management, and outcomes. Results: A total of 1484 pediatric patients carried the diagnoses of orbital fracture or anterior skull base fracture. After review, 159 patients (11 percent) were found to have true orbital roof fractures, with 36 percent being comminuted. One hundred five patients returned after discharge (average follow-up, 19 months). One patient developed vertical dystopia 10 months after being lost to follow-up with a large, comminuted fracture. Ten patients underwent surgery to repair the orbital roof. Inferior displacement correlated with need for surgical repair (p < 0.001). Conclusions: In the largest study to date analyzing pediatric orbital roof fractures, the authors found that most can be managed conservatively with good long-term outcomes. Vertical dystopia occurred in less than 1 percent of patients and was associated with large, comminuted fractures. Inferiorly displaced and fractures with a surface area over 2 cm2 represent higher risk fractures that should be followed closely for possible intervention based on the development of sequelae such as vertical dystopia or encephalocele. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Ameloblastic Carcinoma In Situ: Review of Literature and a Case Presentation in a Pediatric Patient

Ameloblastic carcinomas are rare malignant lesions with 3 mandibular pediatric cases reported in the literature. We present a case of ameloblastic carcinoma in situ in a 15-year-old male with a right mandibular cystic lesion on computed tomography. The incisional biopsy revealed plexiform ameloblastoma. Due to the infiltrating and aggressive nature of the tumor, the patient underwent hemimandibulectomy and immediate reconstruction with a vascularized osteocutaneous fibula free flap. The final pathology was read as ameloblastic carcinoma in situ. Given the rarity of this disease in the pediatric population, this case report may be a valuable addition to the current literature.