Mauro Pau

Intraoperative control of resection margins in advanced head and neck cancer using a 3D-navigation system based on PET/CT image fusion

Local recurrent of disease in advanced carcinomas of the head and neck is strongly correlated with the presence of positive or close resection margins after operative treatment. The purpose of this study is to present a new method of assessing resection margins intraoperatively using image-guided surgery based on positron emission tomography/computed tomography (PET/CT) image fusion. In 6 patients who underwent surgical treatment of head and neck stage for T4a-T4b carcinomas PET/CT image fusion was done on the workstation of a 3D-navigation system. Intraoperative image-guided navigation of the defect following surgical ablation of the tumour was performed in every patient. Intraoperative navigation of the ablative defect showed an unsafe resection margin in 4 patients. In three of these patients additional image-guided resection allowed local control of the tumour to be achieved. In one patient additional resection was not possible due to skull base invasion. The histopathological exam of the four tumour specimens confirmed positive or close resection margins. The current results suggest that intraoperative control of the surgical margins using a 3D-navigation system based on PET/CT image fusion can be a useful tool to assess and improve local control in advanced cancer of the head and neck.

Surgical treatment of synovial chondromatosis of the temporomandibular joint with erosion of the skull base: a case report and review of the literature.

Synovial chondromatosis (SC) is a rare metaplastic disease of the larger joints. It is rarely observed in smaller joints, especially in the temporomandibular joint (TMJ). This disease is considered to be metaplastic and shows no malignant tendencies, but can become locally aggressive, erode the cranial base, and even spread intracranially. To date, nine cases of spread into the intracranial space have been reported in the literature; however, the disease remained extradural in all cases. The authors present a review of the literature and report the case of a 70-year-old man with SC of the right TMJ that had eroded the cranial base, reaching the dura mater; a large intracranial mass was not present. The disease was considered to be stage 3 according to Milgrams classification. The patient was treated surgically, the tumour mass was removed, reconstruction of the cranial base was performed using titanium mesh, and the joint was reconstructed with a temporal muscle interposition flap. Diagnostic images and intraoperative photographs are also presented.

Trans-tragal incision for improved exposure of diacapitular and condylar neck fractures

The authors present a modification of the preauricular approach that improves the exposure of the condyle whilst reducing diacapitular and condylar neck fractures. The incision is a combination of the hockey-stick and endaural incisions. Its inferior part runs within the ear on the posterior face of the tragus; the tragal cartilage is transected together with the retrotragal skin and included in the anterior skin flap. Between May 2009 and December 2010, 16 patients with diacapitular or condylar neck fractures were treated with this approach. All patients showed good occlusion postoperatively and satisfactory aesthetic results. No infection or cartilage necrosis was observed in this series. This approach improves the exposure of the condylar head during the reduction of diacapitular and condylar neck fractures, ensuring easier internal fixation and good cosmetic results.

Surgical treatment of macroglossia caused by systemic primary amyloidosis

Amyloidosis is a heterogeneous group of disorders caused by the extracellular deposition of a fibrillar protein called amyloid. Amyloid involvement of the tongue is almost universally secondary to systemic disease. The clinical manifestations result from the progressive extracellular deposition of amyloid within the suprahyoid muscles. In the late stages, the progressive enlargement of the tongue causes hypo- and oropharyngeal blockage, with obstruction of the upper airways. Conservative excision is a satisfactory treatment for local amyloid masses; the role of surgery in systemic forms is controversial. The authors present a case of systemic primary amyloidosis of the tongue treated surgically by a partial glossectomy via a pull-through approach and discuss the indications and rationale for surgical intervention.

Three dimensional comparative measurement of polyurethane milled skull models based on CT and MRI data sets.

OBJECTIVE Due to the increase in the number and complexity of surgical procedures, available to craniomaxillofacial surgeons, allied to the rapid progress of technological developments, the use and production of 3D models has become important, especially for planning complex cases. The radiation exposure of additional CT based examinations is always subject to debate, so the feasibility of producing 3D models for surgical planning based on MRI imaging has been raised. MATERIAL AND METHODS 12 male and 3 female patients (n=15) between 47 and 84 years of age (mean age=65) were selected in a prospective study. Both magnetic resonance and computed tomography data sets of the facial bones were collected. Two milled models per patient were prepared: one based on the MRI scan and one based on the CT scan. The milled models were compared in a coordinative surveying procedure within 7 representative distances using a tentative measurement method. RESULTS Difference values between CT and MRI based models ranged from 0.1mm to 5.9 mm. On average MRI based models were smaller by 0.381 mm (SD 1.176 mm) than those on CT based. The accuracy of models based on MRI data was similar to those based on CT data. MRI based three dimensional milled models provide precise structure accuracy.

Primary osteomyelitis of the mandibular condyle—a rare case

Osteomyelitis is an inflammatory process involving cortical and cancellous bone. In the maxillofacial region, the mandible is the most frequently affected bone. In the vast majority, a bacterial focus can be identified as the origin of the disease. Chronic progress of the disease may lead to destruction of mandibular bony structures, resulting in mild or severe loss of function if no adequate treatment is applied. In some cases, the etiology of osteomyelitis remains unclear. Review of literature revealed two cases of necrosis of the mandibular condyle caused by primary osteomyelitis. We report a case of primary osteomyelitis of the mandibular condyle in a 51-year-old woman. Radiography revealed an almost complete destruction of the right mandibular condyle, resulting in malocclusion. The patient was treated with long-term antibiotics. No surgical intervention had been performed. After remission of the symptoms, the malocclusion had been corrected prosthetically. After a 4-year follow up period, the occlusion is stabile and there are no signs of progression of the disease.

Intraorbital Schwannoma of the Abducens Nerve: Case Report

A 53-year-old woman with modest protrusion of the right eye was referred to our outpatient department from the ophthalmology department. She had been noticing blurred vision for the previous 2 years and was referred by her ophthalmologist because of optic nerve atrophy. The patient’s vision at the time was 20/20, and she reported moderate double vision. On examination, a loss of red/ green perception, decreased contrast sensitivity, and a small central scotoma in the visual field were observed. Magnetic resonance imaging (MRI) showed a 4.5 1.5 –cm intraconal mass medial to the lateral rectus muscle nd dorsal to the orbit, with extension to the superior rbital fissure (Fig 1). The optic nerve was displaced medilly but showed no morphologic alteration. However, intraranial changes could not be excluded. Computed tomogaphy was used to plan an interdisciplinary approach with he neurosurgeon. After a lateral orbitotomy was performed with a piezolectric osteotome, the Tenon capsule was opened through sharp incision. A firm elastic mass, which could be shifted ownward by blunt dissection, was palpated directly under he lateral rectus muscle. Directly beneath it, a vascularized, ncapsulated expansion surrounded by fat was seen (Fig 2). mmediate fresh-frozen sections were taken to confirm the enign nature of the lesion. Microscopic examination of the urgical specimens after hematoxylin-eosin staining showed ntoni A and B areas (Fig 3). The mass was dissected arefully along the enveloping tissue, up to the superior rbital fissure. To avoid further trauma to the abducens erve, the capsule was left in place. Immediately after the intervention, there was no amelioation of the ocular symptoms. Visual acuity remained at 0/20, the double vision was unchanged, the loss of color ision and decreased contrast sensitivity were still present, nd the scotoma in the visual field remained stable. For the ight eye, abduction was only possible 10° before the pri-

Use of a modified high submandibular approach to treat condylar base fractures: Experience with 44 consecutive cases treated in a single institution

PURPOSE The aim of this article is to present our experience treating fractures of the condylar base with a modification of the high submandibular approach (HSA). MATERIALS AND METHODS Between June 2012 and April 2015, 44 fractures of the condylar base were treated in the Department of Oral and Maxillofacial Surgery of the Medical Hospital of Graz using the modified HSA. RESULTS We did not observe any damage (even transient) to the facial nerve or any complication related to violation of the parotid capsule (such as a salivary fistula, Frey syndrome, or a sialocele). CONCLUSIONS This approach provides good access to the condylar base, ensuring easier internal fixation, excellent protection of the facial nerve and parotid gland, and good cosmetic results.

Surgically assisted rapid maxillary expansion: feasibility of not releasing the nasal septum

Surgically assisted rapid maxillary expansion (SARME) is commonly used to correct maxillary transverse deficiency. The aim of this study was to analyse the need for intraoperative liberation of the nasal septum during the procedure. SARME was performed in 25 patients by combining a lateral osteotomy with an inter-radicular maxillary osteotomy. The deviation of the nasal septum after SARME was evaluated by comparing measurements between radiologically defined landmarks on pre- and postoperative computed tomographic images. Two defined angles (angle I, between crista galli-symphysis mandibulae and crista galli-septum nasi; angle II, between maxillary plane and septum nasi) were measured based on four representative planes and septal movement was analysed. The mean changes in angles I (0.03° ± 0.78°) and II (0.25° ± 1.04°) did not differ significantly from zero (p=0.87 and p=0.24, respectively). Observed variations and displacements were considered to be acceptable because they were insignificant in every respect. Intranasal airway function was also examined pre- and postoperatively to evaluate any loss of ventilation. The described surgical technique is a successful method of maxillary segment distraction. The authors found no compelling reason to release the nasal septum in the context of SARME.

The mandibular symphysis as a starting point for the occlusal-level reconstruction of panfacial fractures with bicondylar fractures and interruption of the maxillary and mandibular arches: Report of two cases

Panfacial fractures represent a challenge, even for experienced maxillofacial surgeons, because all references for reconstructing the facial skeleton are missing. Logical reconstructive sequencing based on a clear understanding of the correlation between projection and the widths and lengths of facial subunits should enable the surgeon to achieve correct realignment of the bony framework of the face and to prevent late deformity and functional impairment. Reconstruction is particularly challenging in patients presenting with concomitant fractures at the Le Fort I level and affecting the palate, condyles, and mandibular symphysis. In cases without bony loss and sufficient dentition, we believe that accurate fixation of the mandibular symphysis can represent the starting point of a reconstructive sequence that allows successful reconstruction at the Le Fort I level. Two patients were treated in our department by reconstruction starting in the occlusal area through repair of the mandibular symphysis. Both patients considered the postoperative facial shape and profile to be satisfactory and comparable to the pre-injury situation.