Cervical lymph node metastasis is an important prognostic factor in oral squamous cell carcinoma (OSCC), and preoperative evaluation of cervical lymph nodes requires high diagnostic accuracy. We investigated the usefulness of FDG-PET/contrast-enhanced CT for diagnosing cervical lymph node metastasis in OSCC and determined which procedures could be additionally performed to improve diagnostic accuracy. Between April 2005 and March 2013, a total of 115 patients with OSCC who were treated in the Department of Oral and Maxillofacial Surgery, Dokkyo Medical University Hospital participated in this study. The primary sites of OSCC were the tongue (n = 66), mandibular gingiva (n = 27), maxillary gingiva (n = 10), floor of the mouth (n = 6), and buccal mucosa (n = 6). The clinical stage of the disease was stage I in 10 cases, stage II in 35 cases, stage III in 17 cases, and stage IV in 53 cases. Uptake of FDG was elevated in the cervical lymph nodes of 48 patients, among whom 45 had cervical metastasis (true-positive) and three did not (false-positive). Among 67 patients who did not have elevated FDG uptake, 8 patients had cervical metastasis (false-negative) and 59 patients did not (true-negative). The sensitivity, specificity, and accuracy of FDG-PET at a threshold SUVmax of 2.0 were 84.9%, 95.2%, and 90.4%, respectively. A re-evaluation of patients with negative FDG-PET/contrast-enhanced CT findings together with palpation and MRI increased the diagnostic performance to 93.6%, the sensitivity to 94.5%, and the specificity to 94.1% accuracy.
In conclusion, FDG-PET/contrast-enhanced CT was very useful for diagnosing cervical lymph node metastasis in OSCC. Furthermore, palpation and MRI combined with FDG-PET/contrast-enhanced CT is recommended to reduce the rate of false-negative findings.
Glandular odontogenic cysts are odontogenic developmental cysts that commonly arise in the mandible. Their frequency of onset in the maxilla is low. We report a glandular odontogenic cyst arising in the maxillary premolar region. The patient was a 36-year-old man who was examined at our department because of swelling of the gum as the main complaint. At the first examination, swelling with pulsation was observed in the maxillary canine and first premolar gum regions. However, the maxillary canine and first premolar showed vital reactions when an electric pulp tester was used. Computed tomography revealed bone absorption with buccal cortical bone loss in a well-defined area, 10 mm in diameter, including the maxillary canine and first premolar regions. However, there was no communication between the region of bone loss and the apex. As a maxillary bone cyst was suspected, cystectomy was performed with the patient under local anesthesia. During surgery, detachment of the cyst was achieved easily, and after the excision, the surrounding bone surface was smoothened. A hemostatic splint was placed on the open wound. The patient was given a diagnosis of a glandular odontogenic cyst based on the histopathological findings of the excised specimen. The patient’s progress continues to be positive, with no recurrence as of 2 years 3 months after surgery.
Ankylosing spondylitis (AS) is a chronic inflammatory disease characterized by inflammation and ankylosis of the axial skeleton. Initial symptoms often include lumbosacral pain with limited range of motion. Temporomandibular joint (TMJ) disorders are found in 3.0% to 20.5% of all cases of AS. However, cases of AS associated with TMJ ankylosis are rarely reported.
This report describes a 66-year-old male patient who was given a diagnosis of AS accompanied by bilateral TMJ ankylosis. The patient had a medical history of AS for approximately 30 years. The patient was referred for examination because he could only open his mouth a maximum of 5 mm. Computed tomographic images showed no TMJ space and revealed a bony mass causing ankylosis of the osseous components of both temporomandibular joints. Magnetic resonance imaging revealed sclerosis of the bone marrow in the condyles, and the articular disk was not visible. Bone scintigraphy revealed involvement of the spine, sacroiliac joints, right knee, bilateral elbows, and both acromioclavicular joints.
This report describes the clinical treatment and management of TMJ ankylosis in a patient with AS. The postoperative course has been uneventful for 3 years, and the maximum mouth opening has increased to 40 mm without any complications.
We report the case of a patient who was given a diagnosis of acquired factor XIII deficiency because of abnormal bleeding during bilateral sagittal split ramus osteotomy. He was referred to our hospital by a local dental clinic at the age of 16 years for surgical correction. Bleeding occurred during the extraction of a horizontally impacted third molar and bone drilling, but was stopped without difficulty. Bilateral sagittal split ramus osteotomy was planned 4 years after the first consultation. There was no history of bleeding in the patient or his family. A preoperative blood examination did not produce any abnormal findings. However, during the operation 1,220 cc of intraoperative blood loss was caused by difficulty in controlling bleeding. The bleeding was eventually controlled by applying pressure after the intravenous injection of tranexamic acid (1 g/10 mL). Five days after the operation, a close examination at our hospital’s Department of Hematology revealed a low factor XIII level (38%), which was indicative of factor XIII deficiency. Gradual osseous healing without wound healing failure or infection was observed. The subsequent measurement of the patient’s factor XIII level showed that it had slightly recovered, but was still low (56%). A diagnosis of congenital factor XIII deficiency was made, but the presence of inhibitory factors was excluded. When the bone-connecting material was removed with the patient under general anesthesia 1 year after the operation, continuous bleeding from the entire wound occurred, as was observed previously. The bleeding was difficult to control by applying pressure after the intravenous injection of tranexamic acid (1 g/10 mL), but was stopped by administering 480 IU of a freeze-dried human blood coagulation factor XIII concentrate (Fibrogammin® P).
Pemphigus vulgaris (PV) is a rare autoimmune disease that causes blistering of the skin and mucous membranes. The condition commonly develops in middle-aged adults, and childhood onset is extremely rare. The present case was a 9-year-old girl who suffered from intractable blisters and erosions in the oral cavity. No skin lesioning was observed. Serological ELISA testing was positive against desmoglein (Dsg) 3, and direct immunofluorescence study revealed IgG and C3 deposits in the epidermal intercellular space. From the above results, we diagnosed pemphigus vulgaris. The clinical phenotype was mucosal dominant, consistent with the ELISA results. The patient’s oral mucosal lesions improved after treatment with prednisolone followed by high-dose intravenous immunoglobulin. The antibody titer to Dsg-3 decreased as symptoms improved.
We report a case of posterior superior alveolar artery damage caused by local anesthesia in which hemostasis was achieved by transcatheter arterial embolization. The patient was a 50-year-old woman who received local anesthesia for extraction of the maxillary left third molar at a dental clinic. Immediately after delivery of the local anesthetic, a swelling developed on the left side of her face, and the extraction procedure was cancelled. However, the swelling and pain increased; therefore, she was referred to our department. Swelling with dark-colored petechiae were observed from the left periorbital region to the submandibular region, associated with severe pain. Contrast-enhanced computed tomography (CT) and three-dimensional CT angiography suggested bleeding from the posterior superior alveolar artery. The swelling progressed despite pressure hemostasis at the site of arterial injury. Therefore, angiography was performed after consultation with a radiologist. Leakage of the contrast agent from the posterior superior alveolar artery was confirmed, and embolization of the artery using a gelatin sponge was performed. After the procedure, hemostasis was achieved, and bleeding did not recur. The swelling improved within a few days without any complications. Clinicians should consider the possibility of arterial injury caused by local anesthesia for dental procedures and take the necessary precautions.
VACTERL syndrome is defined by the presence of the following specific anomalies: vertebral anomalies, anal atresia, cardiac abnormalities, tracheo-esophageal fistula, renal anomalies, and limb abnormalities. VACTERL-H is a syndrome with at least three of the aforementioned features plus hydrocephalus, and the prognosis is poor. We describe the case of a girl who was suspected to have VACTERL-H syndrome. The patient had microglossia and jaw deformity with bilateral hyperplasia of the mandibular coronoid process. Because bilateral coronoid hyperplasia is a rare condition in the pediatric age, it may be an unrecognized cause of limited mouth opening.
We report on a 9-year-old girl who clinically met the diagnostic criteria for VACTERL-H syndrome. She was referred to our department because of limited mandibular movement. CT imaging confirmed the presence of jaw deformity with bilateral coronoid process hyperplasia. Bilateral coronoidotomy was performed through an intraoral approach to improve limited mandibular movement. Mouth opening exercises were started 3 days after surgery, and after 1 year, mouth opening was preserved at an adequate level.
Basaloid squamous cell carcinoma (BSCC) is a rare aggressive malignant tumor. The prognosis is very poor because of its high risk of regional lymph node and distant metastases. We present a case of BSCC that was successfully treated by superselective intra-arterial chemotherapy with radiotherapy. A 55 year-old man was referred to our department because of a swelling of the maxilla. He had an endophytic tumor measuring 36 × 35 mm on the right side of the maxilla with histologic findings of BSCC. Superselective intra-arterial chemotherapy with radiotherapy was performed. He was in complete remission for 24 months after chemoradiotherapy.
Fibrous dysplasia (FD) is a bone lesion characterized by replacement of the normal bone structure with fibro-osseous connective tissue. Maxillofacial FD causes facial asymmetry. However, reduction surgery via an intraoral approach is very challenging and can provide insufficient results. We report navigation-guided bone reduction surgery for maxillary FD and obtained favorable results. A 23-year-old man with FD of the maxilla underwent bone reduction surgery using a navigation system after preoperative planning including the mirroring method. The patient could obtain facial symmetry after surgery, and there was no facial asymmetry 9 years 3 months after surgery.
In panfacial fractures, reduction is difficult when the damage extends to the zygomatic suture, forming the outer facial frame, owing to loss of reference form on the other side. We report a case of panfacial fracture with zygomatico-maxillary complex treated using this navigation system.
A 46-year-old man was injured in a motorcycle accident, and panfacial fracture was diagnosed. His left zygoma was intact, but the right zygomatico-maxillary complex sustained a comminuted fracture and thus lost its anatomical form. In preoperative planning, the form of the left zygomatico-maxillary complex was mirrored to the right side.
We performed open reduction and internal fixation using a navigation system that captured the mirrored images. After general anesthesia, the reference marker was secured to the scalp using a head band. During surgery, the navigation system was used to fix the right zygomatico-maxillary complex. The navigation system was used to intraoperatively visualize the proper height, width, and anteroposterior projection of the face, which led to simultaneous confirmation of good facial reduction. The navigation system was very useful for surgery of the unilateral zygomatico-maxillary complex or comminuted fracture.