Pseudomembranous colitis is mainly caused by microbial substitution due to antibacterial medication. We encountered a case of mandibular fracture complicated by septic shock due to pseudomembranous colitis, which followed a fatal course. The patient was a 78-year-old woman who was receiving medication for Parkinson's disease. The patient fell and sustained laceration of the mental region and a mandibular fracture. She was treated by our department and underwent suturing and maxillo-mandibular fixation. A hematoma developed in the floor of the mouth, and the CRP level was 5.0mg/dl. Although the antibiotic cefcapene pivoxil hydrochloride (CFPNPI) was prescribed, both the CRP level and peripheral WBC count increased 1 week later. Therefore, the antibiotic was switched to panipenem/betamipron (PAPM/BP), and the response was monitored. The patient complained of severe diarrhea 2 days after changing the antibiotic. Then, septic shock developed suddenly. Intensive medical treatment was performed, but the disease could not be controlled. The patient died the day after the onset of diarrhea.
In Japan, where medical treatment and welfare are highly developed, it is rare that cleft palate is left untreated for long periods. We recently encountered four patients with cleft palate, which did not undergo palatoplasty for a long period of 50 years. We performed palatoplasty by the Wardill method. We describe the patients and the main intraoperative points because good results were obtained.
Kniest dysplasia is a rare heritable chondrodysplasia. Its etiology is thought to involve mutations in COL2A1, the gene for collagen type II. Characteristic clinical features include short-trunk dwarfism, joint contracture, flat nose, kyphoscoliosis, myopia, and deafness. Cleft palate is frequently associated with this disease. Radiographically, platyspondyly and coronal cleft are seen in the vertebral bodies of newborns and young infants. The tubular bones are short and their ends are wide. A 5-month-old boy with Kniest dysplasia was referred to Hokkaido University Hospital because of poor suckling and cleft palate. A Hotz type plate was applied to improve feeding problems. The patient was weaned, and a gastric feeding tube was removed 5 months after plate application. Because speech development was delayed, he underwent palatoplasty at the age of 2 years 8 months. After surgery, there were no maladaptative speech patterns due to poor nasopharyngeal function. As for development of the facial skeleton, growth of the anterior cranial base was severely lmited. The cranial base angle was flattened, and the maxilla and mandible were retropositioned relative to the anterior cranial base. However, the antero-posterior relation of the jaws was normal.
A case of parotid pleomorphic adenoma with marked cystic changes is presented. A 70-year-old woman was referred to our hospital because of a painless swelling in the left parotid area. Ultrasonography demonstrated a well-demarcated apparently benign lesion in the parotid gland. MRI showed high signal intensities on Ti-, T2-, and fat-suppressed Tl-weighted images. Under a tentative diagnosis of parotid cyst, the lesion was excised with the patient under general anesthesia. The excised material was a cystic lesion with focal thickening of the wall. Pathological examination showed that a large cyst had formed in the tumor parenchyma of a pleomorphic adenoma. There has been no evidence of recurrence as of 5 years 3 months after the operation.
Adenoid squamous cell carcinoma has been accepted to be an uncommon variant of squamous cell carcinoma and a definite entity. Adenoid squamous cell carcinoma is characterized by a mixture of squamous components with adenocarcinomatous elements, which result from acantholytic phenomena in the tumor. We describe an extremely rare case of synchronous double cancer involving adenoid squamous cell carcinoma of the lower gingiva and squamous cell carcinoma of the esophagus in a 75-year-old man. Intraoral examination revealed a tumor measuring 30×25×7mm in the lower gingiva near the left second molar and the buccal mucosa. Biopsy revealed adenoid squamous cell carcinoma. On preoperative endoscopic examination, esophageal cancer was detected and histologically diagnosed as squamous cell carcinoma. The patient died of uncontrolled adenoid squamous cell carcinoma.
Ten cases of terminal oral squamous cell carcinoma with hypercalcemia are presented to provide a perspective on palliative medicine. The initial primary site was the tongue in 6 patients and the gingiva in 4, including one case with delayed occurrence of multiple oral cancers (lower gingiva, tongue, and palate). There were 6 men and 4 women, with a mean age of 57.4 years (29-80 years). Serum calcium levels ranged from 10.8 to 17.1mg/dl (mean 13.05±2.07mg/dl). The serum parathyroid hormone-related protein level was above the normal range in 9 of the patients. Mean survival from the onset of hypercalcemia was 68.6 days (13-209 days), except for 1 patient who died on the day of diagnosis. The causes of death were respiratory failure in 8 patients and hemorrhage in 2 both of which are common causes of death in patients with oral cancer. There were no deaths due to kidney failure caused by hypercalcemia. For treatment, excluding the patient who died on the day of diagnosis, bisphosphonates were given at 2-week intervals. In patients who received palliative therapy against recurrence, delayed lymph node metastasis, or both bisphosphonate treatment improved the main symptoms, including nausea, vomiting, and anorexia. Furthermore, oral ingestion of food, feeding-tube nutrition, or both could be continued longer in the 7 patients (maximal survival: 209 days) who received palliative therapy than in the 3 who underwent aggressive treatment (radical neck dissection combined with high-dose radiation therapy. These latter patients had large areas of necrosis in the neck extending to the soft tissue or orofacial-neck lymphedema.)(mean survival: 13.7 days). Our findings in this series suggest that the survival time of patients with oral squamous cell carcinoma who have hypercalcemia depends on the aggressiveness of treatment, which is considered a cause of malnutrition, before the onset of hypercalcemia.
Arteriovenous malformation (AVM) in the maxillofacial region is a rare, but potentially life-thereatening vascular lesion. Although AVM is usually diagnosed on angiography, the procedure is very invasive. We report the identification of AVM and feeding vessels on three-dimensional CT angiography (3D-CTA), which is minimally invasive. A 21-year-old man with a right buccal swelling was referred to our hospital. AVM was diagnosed on the basis of clinical signs and examinations such as ultrasonography, MR imaging, MR angiography, and CT. Angiography was not done. The vascular lesion was fed by two arteries (facial artery and infraorbital artery) in the right buccal region, clearly demonstrated on 3D-CTA. The patient underwent resection of the lesion and simultaneous reconstruction with a local flap. There was no evidence of recurrence 6 months after surgery. Three-dimensional CTA can identify feeding vessels and assess the extent of AVM. This method is useful for surgical planning, as well as preoperative diagnosis.