The estimation of physiologic ability and surgical stress (E-PASS) is a predictive postoperative complication scoring system. Recently, its relevance to postoperative delirium has also been shown. The E-PASS system comprises the preoperative risk score (PRS), surgical stress score (SSS), and comprehensive risk score (CRS), the latter of which is determined by the PRS and SSS. This study was carried out to determine the risk factors and predictive factors of postoperative delirium in oral cancer surgery. In total, 164 patients who underwent treatment for oral cancer between 2001 and 2017 were studied retrospectively. Postoperative delirium developed in 14 of the 164 patients (8.5%). Benzodiazepine administration, diabetes mellitus, blood loss at surgery, operation time (>7 hours), tracheotomy, continuous-suction drain, postoperative serum albumin, PRS, SSS, and CRS significantly correlated with the incidence of postoperative delirium on univariate analysis. No significant differences were found in flap reconstruction. Multivariate analysis showed that benzodiazepine administration (odds ratio: 11.7, 95% confidence interval: 2.62− 62.5) and CRS (odds ratio: 11.5, 95% confidence interval: 1.89 − 96.2) were independent risk factors for increasing the incidence of delirium. Significant differences were found in benzodiazepine administration (odds ratio: 7.00, 95% confidence interval: 1.9 − 25.9) and PRS (odds ratio: 3.92, 95% confidence interval: 1.1 − 14.6) among the preoperative predictors. It was suggested that the E-PASS system can be used to evaluate factors predicting the preoperative and postoperative risks of the development of delirium in patients with oral cancer.
Palmoplantar pustulosis (PPP) is a refractory skin disorder exhibiting numerous sterile pustules on the palms and soles of the patients. PPP is related to dental focal infection and metal allergy, and the experts in dermatology and dentistry have worked together to arrive at a consensus regarding the diagnosis and treatment of PPP. However, the obvious cause of PPP remains unknown, and a standard treatment has yet to be established. In this study, we aimed to clarify the relation of PPP to dental focal infection and dental metal allergy. We evaluated 29 patients with PPP who underwent oral examination and patch testing in the Department of Oral Medicine at Hokkaido University Hospital from July 2010 through May 2014. In total, 22 of the 29 patients had positive patch test results, and flare-up was observed in one patient. Metallic component analysis revealed that the oral cavity was metal-positive in 14 of 22 patch test-positive patients. In contrast, odontogenic foci were found in 25 of 29 patients.
Among 14 patients who had positive patch-test results for metal in the oral cavity, the course after metal removal could be confirmed in nine patients, and skin symptoms improved in all patients. Among 15 patients who did not have patch-test results for metal in the oral cavity, the course after treatment of odontogenic foci could be confirmed in eight patients, and symptoms improved in only one patient.
This study resulted in a higher rate of improvement after removal of dental metals versus treatment of odontogenic foci, suggesting that PPP strongly correlates with dental metal allergy. However, because odontogenic foci may be treated concurrently with metal removal, an association between PPP and dental focal infection cannot be denied. In addition to the time and cost burden of metal removal, symptoms may improve naturally in some cases. Therefore, we suggest that it is necessary to consider the suitability of metal removal on a case-by-case basis.
Neuroendocrine carcinomas occur mainly in the lung and digestive tract and rarely arise in the oral cavity. We report a case of neuroendocrine carcinoma arising in the floor of the mouth. A 77-year-old man was referred to our department because of contact pain in the left side floor of the mouth in April 2013. We performed a biopsy and diagnosed a carcinoma of floor of the mouth (suspected to be neuroendocrine carcinoma). Tumor resection, split-thickness skin grafting, and bilateral submandibular duct relocation were performed in May 2013. Histologically, the tumor was composed of polygonal cells. The tumor cells showed nuclei with dark-stained-chromatin and slightly rosette-like growth patterns in the subepithelium. Immunohistochemically, the tumor cells were positive for CD56, chromogranin, and TTF-1, partially positive for CD99, and negative for synaptophysin, CK20, and CD117. The mitotic rate of the tumor cells was 22/10HPFs, and the Ki-67 index exceeded 90%. The pathological diagnosis was neuroendocrine carcinoma. Ten months after operation, left cervical lymph node metastases and the right iliac metastases were found, and the patient died of multiple organ metastases after 11 months.
Salivary gland adenocarcinoma, not otherwise specified (NOS), is an epithelial carcinoma forming ductal or glandular structures that lack sufficient histologic features of the currently recognized categories of salivary gland carcinoma. We report an extremely rare case of adenocarcinoma, NOS, with calcification and bone formation in the submandibular gland.
A 44-year-old man who was referred to our department had been given a diagnosis of sialolithiasis of the right submandibular gland at a referral hospital a few years ago. CT and MR images revealed a 15-mm calcified substance in the right submandibular gland, and FDG-PET images revealed multiple abnormal uptakes in the cervical lymph nodes. We diagnosed a malignant submandibular gland tumor with multiple lymph node metastases of the neck and performed radical surgery with the patient under general anesthesia. Histological analysis of the surgical specimen revealed that the tumor was a high-grade adenocarcinoma, NOS, with dystrophic calcification and bone formation; moreover, multiple cervical metastatic nodes were detected with extracapsular invasion. Therefore, he underwent cetuximab-based bioradiotherapy as an adjuvant therapy. He has been followed up closely, and no recurrence has been noted.
We report a rare case of septic pulmonary embolism (SPE) and subdural abscess caused by odontogenic infection. A 59-year-old woman was admitted to our hospital because of fever and swelling of the left cheek, which was caused by severe periodontitis of the left maxillary molars. A CT scan at presentation revealed resorption of alveolar bone at the left maxillary molars and SPE in the lung field. On the 8th disease day, dysarthria occurred, and CT and MRI scans revealed a subdural abscess. The patient was transferred to the Department of Neurosurgery, and drainage by craniotomy was performed to remove the abscess. Streptococcus constellatus was detected in the blood culture, first molar tooth extraction cavity, and subdural abscess. On the basis of these results, the patient was given a diagnosis of PSE and brain abscess caused by odontogenic infection. Subsequently, she recovered well without any sequelae.
Congenital commissural lip fistula is caused by non-fusion in the embryonic phase. Cases accompanied by inflammatory symptoms or requiring surgery are rare. Van der Woude Syndrome (VWS) has been reported to be a syndrome where commissural lip fistula is present and autosomal dominant.
The patient was a 1-year 7-month-old boy who was examined in our department upon request for further evaluation of a mass in the left cheek. Initial examination showed a quail-egg-sized elastic, soft mass. Five months later, infection was found in the mass. Inflammation was treated, and excision through the oral cavity was planned. During surgery, a continual fistula-like structure was found in the left corner of the mouth. The structure was confirmed to be a commissural lip fistula and was removed. Currently, 1 year 6 months after surgery, the patient has made favorable progress, with no abnormal findings.
Commissural lip fistula should be included in the differential diagnosis when the cause of lesions near the corners of the mouth cannot be determined.
Dermoid cysts are classified into three types based on pathological cellular components: dermoid, epidermoid, and teratoid cysts. Teratoid cysts have skin appendages such as sweat glands, sebaceous glands and hair follicles, and additionally have cartilage, muscle, vascular, respiratory tissues and gastrointestinal tissues derived from mesoderm or endoderm. We describe an extremely rare case of a teratoid cyst around the mandibular angle. A 17-year-old woman was referred to our hospital because of a swelling around the left mandibular angle. Initial clinical examinations revealed a soft elastic mass that measured 45 × 45 mm. The lesion was preoperatively diagnosed as dermoid cysts or lipoma around the mandibular angle on computed tomography (CT) and magnetic resonance imaging (MRI). The lesion was removed and the histopathological diagnosis was a teratoid cyst containing squamous epithelium, sebaceous glands, hair follicles, sweat glands, arrector pili muscle, and cartilage. Recurrence has not occurred as of 6 years 6 months after surgery.
There are many reports on cases of vestibular schwannoma arising in the cerebellopontine angle that were detected because of hearing loss or sudden deafness. We herein report a case of a vestibular schwannoma in the cerebellopontine angle that was associated with the initial symptoms of hypoesthesia of the lower lip and skin on the chin.
A 55-year-old woman presented to our department with hypoesthesia of the lower lip and the skin of her chin. Intraoral X-ray film and CT revealed a radiolucent image close to the mandibular canal in the apical area of the left mandibular second molar, and apical periodontitis of the left mandibular second molar was diagnosed. Root canal treatment was performed; however, 7 days after treatment, hypoesthesia spread to the skin on the left half of her face and tongue. An intracranial lesion was suspected, and MRI was performed. A 40-mm long well-circumscribed lesion was found on the left side of the cerebellopontine angle. The patient was referred to the neurosurgery department of a local hospital, and a brain tumor was diagnosed. The tumor was resected with the patient under general anesthesia, and histopathological examination confirmed a schwannoma. Postoperatively, the hypoesthesia resolved. There has been no recurrence as of 3 years postoperatively; the patient is making good progress.
Juvenile ossifying fibroma (JOF) is a rare disease that develops before 15 years of age and grows relatively rapidly. JOF is classified into juvenile trabecular ossifying fibroma (JTOF) and juvenile psammomatoid ossifying fibroma (JPOF) according to the pathological variants. We report an extremely rare case of JOF with conglomeration of trabecular and psammomatoid variants in the maxilla. The patient was an 11-year-old boy who presented to our hospital with prolonged retention of the right maxillary first deciduous molar. Intraoral examination at presentation showed prolonged retention of the right maxillary first and second deciduous molars, buccal dislocation of the right maxillary first premolar, and buccolingual swelling of the right maxillary bone in the molar region. Radiological examination showed a well-circumscribed radiolucent quail-egg-size lesion, extending from the right maxillary first premolar to the apex of the first molar. The right maxillary first premolar had rotated, and the second premolar was impacted in the upper distal portion of the lesion. A biopsy was performed, and JOF was diagnosed. Tumor enucleation and curettage were performed with the patient under general anesthesia. No recurrence occurred during the 6-year follow-up period.