Otorhinolaryngology, Head and Neck Diseases

Prestin autoantibodies screening in idiopathic sudden sensorineural hearing loss Publication date: April 2019 Source: European Annals of Otorhinolaryngology, Head and Neck Diseases, Volume 136, Issue 2 Author(s): H. Tovi, H. Ovadia, R. Eliashar, M.A. de Jong, M. Gross Abstract Objectives To define the clinical association of serum prestin autoantibodies and their impact on prognosis, as specific serum diagnostic markers in patients with idiopathic sudden sensorineural hearing loss (ISSNHL). Design Sera from 63 patients with ISSNHL were screened prospectively for the presence of prestin autoantibodies by an enzyme-linked immunosorbent assay (Elisa) test. Serum was assayed for anti-prestin IgG antibodies using recombinant human prestin (SLC26 A5). Demographic, clinical, and audiometric variables were analyzed. Results Two patients (3.17%) had demonstrable anti-prestin antibodies in serum (exact 95% CI: −1.16% to 7.5%). No statistically significant association was found between prestin autoantibodies and demographic or audiologic parameters. Conclusions This preliminary and novel study does not support the presence of an active humoral immune reaction against prestin in ISSNHL.

A submucosal tumor at the base of the tongue Publication date: April 2019 Source: European Annals of Otorhinolaryngology, Head and Neck Diseases, Volume 136, Issue 2 Author(s): A. Ko, C.L. Hyun, G.C. Lim

Endoscopic transnasal transseptal pituitary surgery Publication date: April 2019 Source: European Annals of Otorhinolaryngology, Head and Neck Diseases, Volume 136, Issue 2 Author(s): V. Favier, J. Boetto, C. Cartier, F. Segnarbieux, L. Crampette Abstract Pituitary surgery is performed via a transsphenoidal approach in the vast majority of cases according to various methods that have changed over the years. A microscopic transseptal approach via a sublabial mucosal incision or a nasal mucosal incision has also been extensively used. An endoscopic transnasal approach was first described in the 1990's, followed by the concept of a microscopic transseptal approach and an endoscopic strictly endonasal approach. We use an entirely endoscopic transseptal transsphenoidal approach via an incision in the nasal mucosa for both access and tumour resection. This procedure has a number of advantages: strictly midline approach to the sella turcica, large operative field, no interference between instruments and a low rate of nasal complications.

Symptomatic head and neck lipomas Publication date: April 2019 Source: European Annals of Otorhinolaryngology, Head and Neck Diseases, Volume 136, Issue 2 Author(s): Y. Najaf, C. Cartier, V. Favier, R. Garrel Abstract Introduction Lipomas are very common benign lumps that could be encountered in any part of the body but with limited proportion being present in the head and neck region. Case summary In this article, three different cases of symptomatic cervical lipomas were illustrated, with their different diagnostic as well as therapeutic approaches and will be discussed in light of medical literature. Discussion These cervical tumors tend to grow slowly giving variable signs that include dysphagia, dyspnea, dysphonia due to the mass effect of surrounding structures or can be present as simple as a cosmetic concern. Clinicians must bear in mind the malignant transformation of lipomas, which can be challenging to diagnose. With this article, authors will try to highlight the importance of maintaining a good communication between surgeons, pathologists and radiologists as an essential part of the medical management.

Hypertrophic recurring lichen planus of the external auditory canal Publication date: April 2019 Source: European Annals of Otorhinolaryngology, Head and Neck Diseases, Volume 136, Issue 2 Author(s): A. Košec, M. Kostić, J. Ajduk, M. Ries Abstract Introduction We report a case of unilateral progressive primary hypertrophic lichen planus of the external auditory canal requiring several surgical interventions to deal with constant pruritus, otorrhoea, stenosis and conductive hearing loss. Case summary A 58-year-old woman was initially treated with meatoplasty for suspected chronic obliterating otitis externa. She remained symptom-free for 5 years, before the disease recurred, affecting other body surfaces as well. Otorrhoea, conductive hearing loss and pruritus worsened, and a canal wall down tympanomastoidectomy was performed, removing the skin of the external auditory canal and the tympanic membrane completely. Lichen planus was confirmed histopathologically. Discussion Very few surgical results have been published on stenosis of the external auditory canal caused by lichen planus. Complete medial external auditory canal skin elevation and removal with postoperative split-skin grafting is advised for initial treatment. We discuss treatment options and surgical outcome after initial surgical failure.

Scedosporium apiospermum invasive sinusitis presenting as extradural abscess Publication date: April 2019 Source: European Annals of Otorhinolaryngology, Head and Neck Diseases, Volume 136, Issue 2 Author(s): N. Khoueir, B. Verillaud, P. Herman Abstract Introduction Chronic invasive fungal rhinosinusitis (CIFR) is a rare entity generally observed in immunodepressed subjects. The pathogen most frequently identified is Aspergillus spp. Imaging generally reveals invasive pseudoneoplastic features. We report a case of Scedosporium apiospermum (S. apiospermum) CIFR with an atypical clinical and radiological presentation. Case report A 72-year-old immunocompetent man presented with chronic headache, neck pain and bilateral limitation of lateral gaze. Imaging revealed an isolated left sphenoidal lesion with marked bone changes and an extradural abscess over the clivus. Large endoscopic sphenoidotomy with type II rhinopharyngectomy was performed and the diagnosis of S. apiospermum CIFR was based on histological examination and fungal culture. The patient refused all medical treatment and did not present any signs of recurrence after 1 year of follow-up. Discussion S. apiospermum is a fungal species rarely isolated in CIFR. The present case was revealed by an atypical clinical presentation including isolated sphenoidal infection complicated by bilateral abducens nerve paralysis and extradural abscess. Imaging was also unusual, revealing features of fibrous dysplasia or bacterial osteomyelitis rather than the typical pseudoneoplastic appearance. The patient was successfully treated by surgery alone, which may therefore be sufficient treatment in immunocompetent subjects.

Epiglottopexy by external puncture for epiglottic prolapse in severe laryngomalacia. A novel technique Publication date: April 2019 Source: European Annals of Otorhinolaryngology, Head and Neck Diseases, Volume 136, Issue 2 Author(s): H. Álvarez-Neri, P. Villamor, E. Ortiz Hernandez, J. Penchyna Grub Abstract Introduction Laryngomalacia (LM) is the first cause of stridor in infants. 10 to 20% of patients with LM may require surgery due to the development of severe symptoms. Supraglottoplasty is the most commonly performed surgery for severe LM. However, it is insufficient for the rostrocaudal displacement of the epiglottis against the posterior pharyngeal wall. Case summary We report a case of a 2-month-old infant with severe laryngomalacia with a remarkable collapse of the epiglottis towards the glottis with secondary obstruction of the airway, alteration in swallowing and failure to thrive. The patient was treated satisfactorily through epiglottopexy by an external puncture. During a follow-up of 2 years, the patient has been asymptomatic, without any adverse event. Discussion Glottic obstruction from posterior epiglottic collapse is the most severe type of laryngomalacia, generating severe respiratory symptoms and failure to thrive. Epiglottopexy by external puncture is a new technique, certainly affordable since it does not require special instruments and it can be performed in medical centers through suspension laryngoscopy. It can be achieved alone or in combination with traditional supraglottoplasty.

MERRF syndrome (Myoclonic Epilepsy with Ragged Red Fibres) presenting with cervicothoracic lipomatosis Publication date: April 2019 Source: European Annals of Otorhinolaryngology, Head and Neck Diseases, Volume 136, Issue 2 Author(s): F. Carré, R. Hervochon, C. Foirest, F. Tankéré Abstract Introduction Patients with MERRF syndrome (Myoclonic Epilepsy with Ragged Red Fibres) usually present with encephalomyopathy. However, progressive, recurrent cervicothoracic lipomatosis may be rarely observed. Case report The authors report 4 cases of MERRF syndrome associated with lipomatosis. In 3 patients, the diagnosis of MERRF syndrome was established on the basis of the clinical features of the lipomas and clinical interview revealing a personal or family history of lipomas and myopathy. Discussion In the presence of extensive spinal lipomatosis, the presence of other clinical signs of MERRF syndrome in the patient or the patient's family must be investigated. A diagnosis of MERRF syndrome can guide appropriate genetic counselling.

Guidelines (short version) of the French Society of Otorhinolaryngology (SFORL) on cervical lymphatic malformation in adults and children: Diagnosis Publication date: April 2019 Source: European Annals of Otorhinolaryngology, Head and Neck Diseases, Volume 136, Issue 2 Author(s): J. Lerat, A. Bisdorff-Bresson, M. Borsic, C. Chopinet, V. Couloignier, N. Fakhry, P. Fayoux, F. Jegoux, A. Larralde, N. Leboulanger, R. Nicollas, S. Pondaven Letourmy, SFORL work group Abstract Objectives The authors present the guidelines of the French Society of Otorhinolaryngology (SFORL) for the diagnosis of cervical lymphatic malformation in adults and children. Methods A multidisciplinary work group was entrusted with a review of the scientific literature on the above topic. Guidelines were drawn up, based on the articles retrieved and the group members' individual experience. They were then read over by an editorial group independent of the work group, and finalized in a coordination meeting. Guidelines were graded A, B, C or expert opinion, by decreasing level of evidence. Results The SFORL recommends that complete ENT examination should be performed to identify lesions at high risk of complication or associated with poor prognosis. In case of diagnostic doubt, especially in latero-cervical or oral floor lesions, fine-needle aspiration cytology should be performed before therapeutic decision-making. One or more validated classifications should be used to assess treatment efficacy and monitor progression. The reliability of antenatal diagnosis should be ensured by associating MRI to ultrasound. In antenatal diagnosis, the locoregional extension of the cervical lymphatic malformation should be evaluated accurately for prognosis, and associated malformations should be screened for, to guide treatment options.

Regulatory aspects of prospective and retrospective clinical research in France in 2018 Publication date: April 2019 Source: European Annals of Otorhinolaryngology, Head and Neck Diseases, Volume 136, Issue 2 Author(s): P. Gorphe, C. Jannin Abstract In France, the so-called "Jardé law" (named for its proposer) on human research, implemented since 2016, defines the regulatory and legal framework for "prospective" studies, formerly known as "biomedical research" or "common care". Three categories are distinguished: type 1 is at-risk drug or non-drug interventional research, type 2 is low-risk, low-burden interventional research, and type 3 is non-interventional research. The decrees of April 12, 2018 precisely define a list of research categories for types 2 and 3, thereby clarifying the regulatory procedures. The Sponsor registers the trial on the database of the National Drug Safety Agency (ANSM), or the European EudraCT database for drug studies, to obtain an identification number. Regulatory procedures are undertaken with the IRB and ANSM and then the Data Protection Commission (CNIL). Retrospective research on previously collected data (other than genetic) does not come under the Jardé law, and is governed by the 1978 data protection law, updated by the application decree of December 2016 and the law No. 2018-493 of June 20, 2018 on protection of personal data. This article presents a clarification of the key methodologic and regulatory steps.

Cranio-Maxillofacial Surgery

Comprehensive assessment of tranexamic acid during orthognathic surgery: A systematic review and meta-analysis of randomized, controlled trials Publication date: April 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 4 Author(s): Haoming Zhao, Shaopeng Liu, Zuping Wu, Huaqiang Zhao, Chuan Ma Abstract The objective of this study was to comprehensively assess the use of tranexamic acid (TXA) during orthognathic surgery. A systematic review and meta-analysis of randomized controlled trials addressing these issues were carried out. Three electronic databases, included PubMed, Web of Science, and Cochrane Library, were searched until April 30, 2018. Eligible studies were restricted to randomized, controlled trials (RCTs). Weighted mean differences (WMD) for blood loss, operation time, haematocrit, quality of surgical field, and odds ratio (OR) for transfusion rates were pooled for the included studies. Eight randomized, controlled trials were included for analysis. Compared with the control group, the TXA group showed a reduction in intraoperative blood loss of 165.03 ml (p < 0.00001; 95% CI, −200.93 to −129.13 ml), a reduction in the drop of haematocrit of 2.32 g/dl (p < 0.00001; 95% CI, −3.38 to −1.26 g/dl), and an improved quality of surgical field (p < 0.00001; MD, −1.01; 95% CI, −1.23 to −0.80). Tranexamic acid has a limited effect on reducing operative time (p < 0.00001; MD, −16.18 min; 95% CI, −19.60 to −12.75 min) and on decreasing the transfusion rates (p = 0.02; OR = 0.33; 95% CI, 0.13 to 0.83).

Announcements Publication date: April 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 4 Author(s):

Cartilage regeneration using decellularized cartilage matrix: Long-term comparison of subcutaneous and intranasal placement in a rabbit model Publication date: April 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 4 Author(s): Achim von Bomhard, Alexander Elsaesser, Ricarda Riepl, Katharina Pippich, Joseph Faust, Silke Schwarz, Ludwig Koerber, Roman Breiter, Nicole Rotter Abstract Autologous cartilage as donor tissue for various surgical reconstructions such as nasal septum regeneration is limited and associated with donor site morbidity. Our goal was to evaluate a new resorbable chondroconductive biomaterial made of decellularized porcine nasal septum cartilage compared with autologous native auricular cartilage as the gold standard. In order to examine the material and determine its long-term outcome further, we used subcutaneous implantation and septal implantation in an orthotopic rabbit model. In addition to non-seeded decellularized xenogenic cartilage, chondrocyte-seeded decellularized xenogenic cartilage was implanted as a septal replacement. After a three- or six-month period, the formation of newly synthesized cartilage extracellular matrix was evaluated immunohistochemically, whereas septal integrity and biocompatibility were evaluated histologically. The formation of the implanted neoseptum and form stability was analyzed by using 7-Tesla Magnetic Resonance Imaging. Good biocompatibility with no excessive rejection was demonstrated in all groups. Long-term stable and reliable septal reconstruction could be achieved in the study groups with or without cell seeding with autologous auricular chondrocytes. Autologous cell seeding was advantageous only with regard to septal perforations. Thus, cell seeding provides a benefit regarding long-term stability. However, because of slightly better biocompatibility, less pronounced septum deviation and the markedly lower effort involved, the non-seeded scaffold is favoured for possible clinical application.

Evaluation of Cd8+ and natural killer cells defense in oral and oropharyngeal squamous cell carcinoma Publication date: April 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 4 Author(s): Edilmar Moura Santos, Felipe Rodrigues de Matos, Everton Freitas de Morais, Hébel Cavalcanti Galvão, Roseana de Almeida Freitas Abstract Purpose The aim of this study was to evaluate the population of CD8+ and natural killer (NK) cells in samples of oral (OSCC) and oropharyngeal (OPSCC) squamous cell carcinoma. Patients and methods Fifty-four cases squamous cell carcinoma (42 OSCC and 12 OPSCC) were immunohistochemically treated by CD8 and CD57 monoclonal antibodies. It was evaluated the relationship of CD8+ and NK cells with tumor size, lymph node metastasis (LNM), clinical staging (CS), overall survival (OS) and disease-free survival (DFS). Results Only CD8 was higher expressed in both tumors T1 and T2 than T3 and T4, as well as in tumours without LNM and with CS II or III (P < 0.05). There was no association with OS and DFS of both biomarkers. Conclusions These findings suggest that the differential CD8+ cells infiltration in OSCC and OPSCC might reflect a distinctive tumor microenvironment with a favorable local cytotoxic immune response against neoplastic cells.

An in vitro long-term study of cryopreserved umbilical cord blood-derived platelet-rich plasma containing growth factors—PDGF-BB, TGF-β, and VEGF Publication date: April 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 4 Author(s): Kyoko Baba, Yasuharu Yamazaki, Yumiko Sone, Yoshika Sugimoto, Kazuno Moriyama, Takayuki Sugimoto, Kennichi Kumazawa, Yasuhito Shimakura, Akira Takeda Abstract Purpose Umbilical cord blood-derived platelet-rich plasma (UCB-PRP) containing growth factors has attracted attention as a biomaterial useful for regenerative medicine. The osteoblastic differentiation of umbilical cord-derived mesenchymal stromal cells (UC-MSCs) can be induced by UCB-PRP. Materials and methods Nine samples of UC and UCB were used to conduct an in vitro study that determined the contents of three growth factors (i.e., platelet-derived growth factor, transforming growth factor β-1, and vascular endothelial growth factor) and that examined, by staining with Alizarin red, their ability to induce the osteoblastic differentiation of UC-MSCs at the baseline, 3 months, and 3 years of cryopreservation. Results The contents of growth factors in cryopreserved UCB-PRP were markedly elevated compared to those found in UCB at baseline. The samples of UCB that were added with cryopreserved UCB-PRP and those with bone morphogenetic protein-2 were stained granularly with Alizarin red, thus indicating the presence of calcium. The samples of UCB that were not added with UCB-PRP were not stained with Alizarin red. The above-mentioned contents and ability were maintained at 3 years of cryopreservation. Cryopreserved UCB-PRP possibly and advantageously induced the osteoblastic differentiation of UC-MSCs. Conclusion The potential clinical application of cryopreserved UCB-PRP to regenerative medicine was suggested.

Enhancing adhesion and alignment of human gingival fibroblasts on dental implants Publication date: April 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 4 Author(s): Oral Cenk Aktas, Wolfgang Metzger, Ayman Haidar, Yahya Açil, Aydin Gülses, Jörg Wiltfang, Catharina Marques Sacramento, Frank Philipp Nothdurft Abstract Background Promoting the directional attachment of gingiva to the dental implant leads to the formation of tight connective tissue which acts as a seal against the penetration of oral bacteria. Such a directional growth is mostly governed by the surface texture. Material and methods In this study, three different methods, mechanical structuring, chemical etching and laser treatment, have been explored for their applicability in promoting cellular attachment and alignment of human primary gingival fibroblasts (HGFIBs). Results The effectiveness of mechanical structuring was shown as a simple and a cost-effective method to create patterns to align HGIFIBs. Conclusion Combining mechanical structuring with chemical etching enhanced both cellular attachment and the cellular alignment.

Clinical outcomes of pterygoid implants: Systematic review and meta-analysis Publication date: April 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 4 Author(s): Rafael Zetehaku Araujo, Joel Ferreira Santiago Júnior, Camila Lopes Cardoso, Anthony Froy Benites Condezo, Rosenvaldo Moreira Júnior, Marcos Martins Curi Abstract The aim of this systematic literature review was to analyze clinical outcomes of pterygoid implant for the treatment of patients with atrophic posterior maxillae and to provide clinical recommendations for this dental implant technique. An extensive search of electronic databases (PubMed/Medline, Science Direct, Lilacs, Embase, and Cochrane Library) was conducted, for articles published between January 1995 and January 2018, to identify literature presenting clinical outcomes of pterygoid implants in the treatment of patients with atrophic posterior maxillae. The systematic review was performed in accordance with PRISMA/PICO statement guidelines, and the risk of bias was assessed (Australian National Health and Medical Research Council scale). The relative risk of implant failure was analyzed within a 95% confidence interval (95% CI). After screening 331 abstracts from the electronic databases, 36 full-text articles were accessed for eligibility, and a total of 6 studies were included in this systematic review (after applying the inclusion and exclusion criteria). All studies were retrospective in nature and were classified with a poor level of evidence. A total of 634 patients received 1.893 pterygoid implants, with a mean implant survival rate of 94.87%. The mean prevalence of implant failure was 0.056 with a 95% CI of 0.04–0.077. This study demonstrates that pterygoid implants can be successfully used in patients with atrophic posterior maxilla. However, the results should be interpreted with caution, given the presence of uncontrolled confounding factors in the included studies.

A rare odontogenic cyst: Gingival cyst of the adult. A series of 20 new cases from a single center Publication date: April 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 4 Author(s): Stephanie Kenig Viveiros, Rodrigo Finger de Carvalho Pinho, Marcos Custódio, Suzana Cantanhede Orsini Machado de Sousa, Decio dos Santos Pinto Abstract Gingival cyst of the adult (GCA) is a rare entity and comprises around 0.3% of all odontogenic cysts. Due to its rarity, there are a few retrospective studies on it. Therefore, the aim of this study was to present casuistic data of a 20-year retrospective study performed in a Brazilian oral pathology reference center. All cases diagnosed as gingival cyst of the adult in the last 20 years were retrieved from the files of the Oral Pathology Service. Data from the lesions and patients were tabulated and presented descriptively. From a total of 68,229 oral biopsies, 7,023 were odontogenic cysts, and among these only 20 cases were diagnosed as gingival cyst of the adult, resulting in the largest series of gingival cyst of the adult, from a single center, in the last 15 years. Most cases occurred in women, and although 53% affected the anterior mandible, 40% occurred in the anterior maxilla, which contrasts with the previous literature. Despite being a rare lesion GCA should be considered in the clinical differential diagnosis of gingival lesions presenting either in the maxilla or mandible.

Temporary tracheotomy in microvascular reconstruction in maxillofacial surgery: Benefit or threat? Publication date: April 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 4 Author(s): Carolin Goetz, Nora-Maria Burian, Jochen Weitz, Klaus-Dietrich Wolff, Oliver Bissinger Abstract Background Temporary tracheotomies are often used in oral microvascular flap reconstruction surgery to secure postoperative airway management and avoid emergency tracheotomies. Even when planned electively, a tracheotomy can cause severe and life-threatening complications. The aim of this study was to evaluate the complications of tracheotomies performed on oral cancer patients with microvascular flap reconstructions and differentiated patterns, which could lead to postoperative complications. Methods 150 patients, treated in the Department of Oral and Maxillofacial Surgery from March 2017 to August 2018, were included in this study. Patient records and perioperative data were analysed and the following specific items were evaluated: time after surgery until removal of the tracheal cannula, complications, cause and point of time of reinsertion of the cannula, anticoagulative treatment, ASA grade (American Society of Anaesthesiologists), TNM stage, and patient-specific data. Results 30 patients (20%) developed tracheotomy-associated complications, most commonly pneumonia (50%). There was a significant correlation between the time period until removal of the cannula and the occurrence of complications such as pneumonia and bleeding. Conclusion The results of our study lead us to recommend continuing to perform temporary tracheotomies in oral cancer surgery with microvascular flap reconstruction. The overall complication rate is low and postoperative airway management can be performed in a safe and controlled manner. Nevertheless, the time period for the inserted cannula should be kept as short as possible.

The use of vascularized fibula flap in mandibular reconstruction; A comprehensive systematic review and meta-analysis of the observational studies Publication date: April 2019 Source: Journal of Cranio-Maxillofacial Surgery, Volume 47, Issue 4 Author(s): Mohamed E. Awad, Amara Altman, Radwa Elrefai, Peter Shipman, Stephen Looney, Mohammed Elsalanty Abstract Background Vascularized fibular flaps are considered the gold standard for the reconstruction of segmental defects in the mandible. This review compares the complication and success rates of these techniques between primary and secondary reconstruction, as well as between lateral and antero-lateral defects. Type of studies reviewed A systematic review and meta-analysis were conducted according to PRISMA protocol and the Cochrane Handbook for Systematic Reviews of Interventions. The authors performed an independent comprehensive search using PubMed, Ovid MEDLINE, Web of Science, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and COS Conference Papers Index according to established inclusion and exclusion criteria. The methodological index for nonrandomized studies (MINORS) was used to assess the quality of the included studies. Meta-analysis was conducted to compare the type of reconstruction and location of the defect. Results Seventy-eight studies, involving 2461 patients, were eligible. 83.7% of the included patient received primary reconstruction with vascularized fibular flap. The overall flap success rate was 93%. There was improvement in MINORS quality score over time with positive correlation with the publication year (r = 0.5549, P < 0.0001, CI 0.3693 to 0.6979). Meta-analysis indicated no significant association in flap success between primary and secondary reconstruction, or lateral and antero-lateral defects. Conclusion Based on the available studies, this review found no evidence of difference in success or complication rates between primary and secondary reconstruction or between lateral and anterolateral defects. High-quality clinical studies are required to analyze the outcome of these techniques, especially regarding the impact of chemotherapy, radiation therapy, implant-supported dental prostheses, and preoperative planning, on the outcome of reconstruction.

Neuroradiology

Intracranial aneurysms in Sickle Cell Disease: Aneurysms characteristics and modalities of endovascular approach to treat these patients Publication date: Available online 20 March 2019 Source: Journal of Neuroradiology Author(s): Sophie Gallas, Titien Tuilier, Vahid Ebrahiminia, Pablo Bartoluci, Jérôme Hodel, André Gaston Abstract Introduction:The neurological complications of Sickle Cell Disease (SCD) include cerebral infarction and haemorrhage with rarely subarachnoid haemorrhage due to cerebral aneurysms. Materials and methods: In our interventional department, working with SCD referral department, we reported our experience concerning management of adult's patients with cerebral aneurysms. We identified 26 adults with 48 intracranial aneurysms documented by imaging. Results:18 patients, with 26 cerebral aneurysms were treated by endovascular approach for their aneurysms. No patient was treated by surgical way in our institution. 50% of patients had multiple aneurysms. Locations of aneurysms treated were typical with 70 % of cerebral anterior artery and 30 % of posterior artery. Three patients suffered from subarachnoid haemorrhage. Two procedure-related complications occurred during the treatment: one thrombo-embolic event with good recovery after medical treatment and one aneurismal perforation leading to the death of patient. Hypercoagulability is a major specific risk in SCD and use of permanent device as stent of flow diverter should be discussed to prevent complications. Conclusion: Endovascular management of these aneurysms seems to be a good alternative to treat these patients, with stability of occlusion at follow-up.

Safety and efficacy of balloon angioplasty in symptomatic intracranial stenosis: A systematic review and meta-analysis Publication date: Available online 9 March 2019 Source: Journal of Neuroradiology Author(s): Keisuke Kadooka, Niels Hagenbuch, Vania Anagnostakou, Anton Valavanis, Zsolt Kulcsár Abstract Background and purpose Endovascular treatment is offered for symptomatic intracranial stenosis (ICS) when medical therapy fails. The purpose of this meta-analysis is to evaluate the risks and effectiveness of balloon angioplasty (BA) alone. Materials and methods Systematic review and meta-analysis of all available articles on BA for symptomatic ICS was conducted. Data was analyzed separately for > 70% (Group 1) and > 50% (Group 2) stenosis. The results of the Group 1 were compared with those of SAMMPRIS study to the extent possible. Results A total of 25 studies comprising 674 patients were included. The cumulative incidence of periprocedural (within 30 days) stroke and death were 16.3% (Group 1), 7.6% (Group 2) and 11.5% (all studies). Incidence rates of ischemic stroke in the qualifying artery territory during follow-up (per 100 patient-years) were 2.0, 2.4 and 2.3, any stroke and death during follow-up were 4.4, 7.4 and 6.9, restenosis rates were 4.9, 11.5 and 8.9 respectively. While comparison of cumulative incidences of periprocedural ischemic stroke between Group 1 (13.0%) and the medical arm from SAMMPRIS study(4.4%) showed a significant difference (P = 0.008), there was no significant difference between the Group 1 and the stenting arm from SAMMPRIS study(10.7%) in the same variable. Conclusion Balloon angioplasty for stenosis of more than 70% is likely to have similar outcome comparable to the stenting arm in the SAMMPRIS study, however it presents lower rates of late ischemic events and restenosis. These data may help deciding on the endovascular method of choice in case of medical therapy failure.

Comparison of automated and visual DWI ASPECTS in acute ischemic stroke Publication date: Available online 9 March 2019 Source: Journal of Neuroradiology Author(s): E. Kellner, M. Reisert, V.G. Kiselev, C.J. Maurer, H. Urbach, K. Egger Abstract Background and purpose To assess intra-and inter-rater agreement of the ASPECTS (Alberta Stroke Program Early CT Score) based on diffusion-weighted MRI and to compare it with fully – automated methods (eASPECTS). Methods DWI-ASPECTS of scans of 96 patients with acute ischemic stroke was rated by 2 experts. Automated methods based on thresholding the affected volumes of a coregistered atlas, and a regression tree learning method were established. Intra-rater, inter-rater and human-rater vs. automated methods agreements were investigated based on the intraclass correlation coefficients (ICC) and Bland Altman plots. Results Intra-rater agreement was good for both raters (ICC of 0.91 and 0.93). Inter-rater agreement was worse (ICC = 0.86) indicating a slight bias between both raters. Agreement with automated methods ranged from 0.81 to 0.87. Root-mean-squared deviation was 0.89 and 0.69 for the human raters and ranged from 0.95 to 1.24 for the automated methods. Conclusions Agreement values are on the same order or higher compared to a literature review of CT-based ASPECTS. Automated methods perform slightly worse than human expert ratings, but they still have enough power to determine the DWI-ASPECTS with good precision in a clinical setting.

Comparative analysis of methods of volume adjustment in hippocampal volumetry for the diagnosis of Alzheimer disease Publication date: Available online 8 March 2019 Source: Journal of Neuroradiology Author(s): Susana Estévez-Santé, Adolfo Jiménez-Huete, for the ADNI group Abstract Introduction: Hippocampal volumetry can discriminate normal subjects from patients with amnestic mild cognitive impairment (MCI) or Alzheimer disease (AD). We have analyzed the effects of different methods of hippocampal volume (HV) adjustment on the diagnostic accuracy of this technique. Methods: Cross-sectional analysis of 148 subjects of the ADNI database (48 normal, 66 MCI, 34 AD). Brain volumes were calculated from 3T MRI scans with gm extractor, a fully automated script based on FSL. A series of logistic regression models was obtained using 9 volumes of reference and 3 methods of adjustment (normalization, covariance, bilinear regression). Diagnostic accuracy was evaluated with the receiver operating characteristic curve method. External validity was assessed with 10-fold cross-validation. Results: The models with the highest area under the curve (AUC) were those including the HV normalized by total intracranial volume (TIV). The differences with bilinear regression and the covariance method adjusted by TIV were minor and not statistically significant. The lowest AUCs corresponded to the models based on raw (unadjusted) HVs. The results were qualitatively similar in two clinical settings (normal versus MCI, and normal versus AD), but the differences were higher in the normal versus MCI context. Conclusion: The accuracy of hippocampal volumetry for the differential diagnosis between normal subjects and patients with MCI or AD was maximized by normalizing the HV by the TIV. Our results do not exclude the potential superiority of non-linear models.

Impact of aneurysm morphology on safety and effectiveness of flow diverter treatment of vertebrobasilar aneurysms Publication date: Available online 8 March 2019 Source: Journal of Neuroradiology Author(s): Adam N. Wallace, Travis S. CreveCoeur, Jonathan A. Grossberg, Mudassar Kamran, Joshua W. Osbun, Josser E. Delgado Almandoz, DeWitte T. Cross, Christopher J. Moran

Cerebral amyloidoma: A mimicker of granulomatous disease on brain MRI Publication date: Available online 7 March 2019 Source: Journal of Neuroradiology Author(s): Alireza Radmanesh, Matthew D. Wood, Andrew W. Bollen

Congenital Zika syndrome and cerebellar cortical problem Publication date: Available online 7 March 2019 Source: Journal of Neuroradiology Author(s): Beuy Joob, Viroj Wiwanitkit

Improved detection and characterization of arterial occlusion in acute ischemic stroke using contrast enhanced MRA Publication date: Available online 7 March 2019 Source: Journal of Neuroradiology Author(s): Sarah Dhundass, Julien Savatovsky, Loïc Duron, R. Fahed, Simon Escalard, Michael Obadia, Kevin Zuber, Marie Astrid Metten, Mehdi Mejdoubi, Raphaël Blanc, Jean-Claude Sadik, Adrien Collin, Augustin Lecler Abstract Background and purpose To compare the accuracy and utility of contrast enhanced magnetic resonance angiography (MRA) (CEMRA) to Time of Flight MRA (TOF MRA) during detection and evaluation of occlusions on patients diagnosed with acute ischemic stroke (AIS). Methods This single-center study was approved by our local institutional research ethics board. From August 2014 to July 2016, 131 consecutive adult patients with confirmed AIS were included. Detection of an arterial occlusion and its characterization were evaluated independently with CEMRA or TOF MRA by two blinded neuroradiologists, then by consensus using all available MR sequences. A Cohen's Kappa coefficient (κ) and intra-class correlation coefficients (ICC) were used to compare the two techniques. Results There was substantial concordance in the detection of arterial occlusion between CEMRA and TOF MRA (κ = 0.75). TOF MRA was more likely to show an arterial occlusion than CEMRA (63 versus 52 patients respectively). There were 13 and 1 false positive arterial occlusion with TOF MRA and CEMRA respectively, and 1 false negative with TOF MRA. There was excellent concordance between the location of arterial occlusions and CEMRA and TOF MRA [κ = 0.89 (0.72–0.97)]. CEMRA was significantly more likely to allow measurement of the thrombus than was TOF MRA [38 (75%) versus 14 (22%)] (P < 0.0001). Conclusions Our study showed that CEMRA imaging detected arterial occlusions better than TOF MRA in AIS patients and more precisely such that thrombus length and location could be known, which improves the patient's management and care.

Review of synthetic MRI in pediatric brains: Basic principle of MR quantification, its features, clinical applications, and limitations Publication date: Available online 7 March 2019 Source: Journal of Neuroradiology Author(s): Christina Andica, Akifumi Hagiwara, Masaaki Hori, Koji Kamagata, Saori Koshino, Tomoko Maekawa, Michimasa Suzuki, Hirokazu Fujiwara, Mitsuru Ikeno, Toshiaki Shimizu, Hiroharu Suzuki, Hidenori Sugano, Hajime Arai, Shigeki Aoki Abstract Quantitative magnetic resonance imaging (MRI) with multislice, multi-echo, and multi-delay acquisition enables simultaneous quantification of R1 and R2 relaxation rates, proton density, and the B1 field in a single acquisition, and requires only about 6 minutes for full-head coverage. Using dedicated SyMRI software, radiologists can generate any contrast-weighted image by manipulating the acquisition parameters, including repetition time, echo time, and inversion time. Moreover, automatic brain tissue segmentation, volumetry, and myelin measurement can also be performed. Using the SyMRI approach, a shorter scan time, an objective examination, and personalized MR imaging parameters can be obtained in daily clinical pediatric imaging. Here we summarize and review the use of SyMRI in imaging of the pediatric brain, including the basic principles of MR quantification along with its features, clinical applications, and limitations.

Quantitative evaluation of WEB shape modification: A five-year follow-up study Publication date: Available online 7 March 2019 Source: Journal of Neuroradiology Author(s): Kevin Janot, Denis Herbreteau, Aymeric Amelot, Guillaume Charbonnier, Fakhreddine Boustia, Ana Paula Narata, Basile Kerleroux, Richard Bibi, Chrysanthi Papagiannaki, Aymeric Rouchaud, Laurent Pierot Abstract Background and purpose Web shape modification (WSM) has previously been associated with aneurysm recurrence. We report here our five-year experience of WEB device use with a quantitative approach of the WSM phenomenon. Methods From July 2012 to July 2017, 50 patients with 51 unruptured aneurysms treated with the WEB device have been prospectively enrolled in our data base and retrospectively analyzed. An independent "core lab" evaluated anatomical results and potential WSM in DSA follow-up. We defined the WSM ratio (WSMr) as a relative index between the height and the width of the device in working projections which gave an evaluation of the device deformation over the time. Results During the total follow-up period, WSM was observed in 35/48 aneurysms (72.9%). Adequate occlusion rates were 87.0% and 92.6% with and without WSM respectively (P = 0.65). 30 out the 35 (85.7%) shape modifications were already noticed at short-term follow-up (6-month DSA). 33 patients had 2 DSA controls and WSMr measurements were available in 24 patients: 18 (75%) with WSM and 6 (25%) without WSM. In the group with WSM, WSMr values were 0.80 in post-embolization, 0.52 at the first DSA angiogram and 0.42 at the second DSA angiogram. Conclusion WEB shape modification was observed in more than half of cases but with no influence regarding adequate occlusion rate. This quantitative approach of WSM highlights that this phenomenon appears to be early and progressive over time. This supports the hypothesis that WSM could be more probably related to aneurysm healing rather than external compression.

Oral Oncology

Machine learning to predict occult nodal metastasis in early oral squamous cell carcinoma Publication date: May 2019 Source: Oral Oncology, Volume 92 Author(s): Andrés M. Bur, Andrew Holcomb, Sara Goodwin, Janet Woodroof, Omar Karadaghy, Yelizaveta Shnayder, Kiran Kakarala, Jason Brant, Matthew Shew Abstract Objectives To develop and validate an algorithm to predict occult nodal metastasis in clinically node negative oral cavity squamous cell carcinoma (OCSCC) using machine learning. To compare algorithm performance to a model based on tumor depth of invasion (DOI). Materials and methods Patients who underwent primary tumor extirpation and elective neck dissection from 2007 to 2013 for clinical T1-2N0 OCSCC were identified from the National Cancer Database (NCDB). Multiple machine learning algorithms were developed to predict pathologic nodal metastasis using clinicopathologic data from 782 patients. The algorithm was internally validated using test data from 654 patients in NCDB and was then externally validated using data from 71 patients treated at a single academic institution. Performance was measured using area under the receiver operating characteristic (ROC) curve (AUC). Machine learning and DOI model performance were compared using Delong's test for two correlated ROC curves. Results The best classification performance was achieved with a decision forest algorithm (AUC = 0.840). When applied to the single-institution data, the predictive performance of machine learning exceeded that of the DOI model (AUC = 0.657, p = 0.007). Compared to the DOI model, machine learning reduced the number of neck dissections recommended while simultaneously improving sensitivity and specificity. Conclusion Machine learning improves prediction of pathologic nodal metastasis in patients with clinical T1-2N0 OCSCC compared to methods based on DOI. Improved predictive algorithms are needed to ensure that patients with occult nodal disease are adequately treated while avoiding the cost and morbidity of neck dissection in patients without pathologic nodal disease.

Electrochemotherapy as palliative treatment in patients with advanced head and neck tumours: Outcome analysis in 93 patients treated in a single institution Publication date: May 2019 Source: Oral Oncology, Volume 92 Author(s): Francesco Longo, Francesco Perri, Ettore Pavone, Corrado Aversa, Maria Grazia Maglione, Agostino Guida, Massimo Montano, Salvatore Villano, Antonio Daponte, Francesco Caponigro, Franco Ionna Abstract Purpose To describe outcomes of Electrochemotherapy as palliative treatment in patients with advanced head and neck (H&N) tumours. Methods Ninety-three patients (120 treatment sessions) with H&N recurrent and/or metastatic neoplasm were treated. Treatment response was assessed 4 weeks after ECT with clinical examination and two months after the first evaluation with a CT scan of the H&N for deep lesions evaluation. The grade of bleeding and pain before, at the end of treatment and one week after ECT were evaluated. Results Five percent of complete responses, 40% of partial responses were registered. Disease progression was seen in 20% of patients after the first ECT procedure, the remaining 34% of patients experienced stable disease. A good control of pain and bleeding was obtained, especially in patients with moderate symptoms before the treatment. No toxicities related to ECT were seen. Conclusions ECT is an interesting antitumoral therapy in advanced chemo and radio-refractory H&N neoplasms. ECT is able to reduce frequent symptoms, such as pain and bleeding, improving quality of life without damage to healthy tissue and with limited side effects. Moreover, ECT reduces hospitalization time and may contribute to an overall reduction in healthcare costs associated with advanced H&N cancers care.

Reducing radiotherapy target volume expansion for patients with HPV-associated oropharyngeal cancer Publication date: May 2019 Source: Oral Oncology, Volume 92 Author(s): Adam R. Burr, Paul M. Harari, Huaising C. Ko, Justine Y. Bruce, Randall J. Kimple, Matthew E. Witek Abstract Purpose To evaluate clinical outcomes and patterns of failure using a direct gross tumor volume to planning target volume expansion in patients with p16-positive oropharyngeal squamous cell carcinoma. Methods and materials We performed a retrospective review of patients with p16-positive oropharyngeal squamous cell carcinomas treated between 2002 and 2017 with primary radiotherapy with or without concurrent systemic therapy. Patient and disease characteristics associated with disease control and clinical outcomes were analyzed by Cox proportional hazards regression and Kaplan-Meier analyses. Imaging at the time of first failure was used to categorize failure patterns. Results We identified 134 patients with a median follow-up of 56.2 months (range 8.2–160.2 months). Local and regional control at 5 years was 91.5% (95% CI: 86.8–96.4%), and 90.8% (95% CI: 85.6–96.2%), respectively. Of the 14 locoregional failures, there were 10 in-field (Type A), 3 marginal (Type B), and 1 geographic (Type E). Age >70 years (HR 5.42; 95% CI: 1.87–15.68) and T4 versus T1-3 (HR 4.09; 95% CI: 1.01–2.65) were associated with increased rates of locoregional failure on multivariate analysis. The rate of gastrostomy tube retention at one year was 6.0% (range 2.8–12.7%). Conclusions Management of patients with p16-positive oropharyngeal squamous cell carcinoma using definitive radiotherapy and a high-dose planning target volume created without a gross tumor volume to clinical tumor volume expansion resulted in high locoregional control with the vast majority of failures occurring within the high-dose field. These data warrant prospective evaluation of this technique as a therapy de-intensification approach.

FDG PET/CT for metastatic squamous cell carcinoma of unknown primary of the head and neck Publication date: May 2019 Source: Oral Oncology, Volume 92 Author(s): Yiyan Liu Abstract Objective The role of FDG PET/CT is uncertain in squamous cell carcinoma of unknown primary (SCCUP). Published data are limited by heterogeneity of pathology, varied diagnostic criteria, and small sample size. Materials/methods This retrospective study was conducted in 40 patients who had FDG PET/CT for SCCUP. Prior to PET/CT, patients had underwent standard clinical evaluations including flexible rhinolaryngoscopy. The majority of the patients had anatomic imaging. All subjects had histopathological investigations, and follow-up data after PET/CT. Results FDG PET/CT detected the primary in 16 of 40 patients (40%), and the most common locations of the primary were in the base of the tongue, palatine tonsil, and hypopharynx. There were 10 false positive and 6 false negative PET/CT scans. There was no difference in the mean SUVs of the suspected primary lesions between true and false positive groups. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy of FDG PET/CT for SCCUP in this patient cohort were 72.7% (16/22), 44.4% (8/18), 61.5% (16/26), 57.1% (8/14), and 60% (24/40), respectively. The tonsil was the site with the most false positive and false negative findings. Conclusions FDG PET/CT might be an effective single shot of whole-body imaging for detection of the primary in SCCUP. Low specificity remained the most notable weakness of FDG-PET in work-up for SCCUP. In addition to varied physiologic uptake or inflammatory related uptake in the common locations of the primary, the image indication bias might be another significant contributor of high false positive rate.

Effect of local treatment for metastasis and its sequence with chemotherapy on prognosis of post-treatment metastatic nasopharyngeal carcinoma patients Publication date: May 2019 Source: Oral Oncology, Volume 92 Author(s): Yu-Jing Liang, Xue-Song Sun, Zhen-Chong Yang, Qing-Nan Tang, Shan-Shan Guo, Li-Ting Liu, Hao-Jun Xie, Sai-Lan Liu, Jin-Jie Yan, Xiao-Yun Li, Qiu-Yan Chen, Hai-Qiang Mai Abstract Background Distant metastasis after chemoradiotherapy remains the leading cause of death in NPC patients. But the effect of local treatment for metastatic sites and its sequence with chemotherapy on prognosis of them are poorly documented. Methods 448 post-treatment metastatic NPC patients were included in our retrospective study. And Cox regression and log-rank tests were applied to investigate the association between topical treatment and its sequence with chemotherapy and survival using the propensity score method (PSM) to adjust for gender, age, Tumor stage, Node stage, metastatic sites, diabetes and smoking with a 1:2 matching protocol. Results The 3-year OS was significantly higher in patients who received local treatment of distant metastasis compared with patients who did not (48.8% vs 33.8%, P = 0.001) in primary cohort. PSM identified 120 patients in the cohort with local treatment and 240 in that without and similar survival benefits were observed for the local treatment (3-year OS: 36.2% versus 48.8%, P = 0.011). Subgroup analyses indicated that there was no significant survival difference in patients with different treatment sequence. Conclusions In conclusion, post-treatment metastatic NPC patients could be beneficial from local treatment for metastasis but its sequence with palliative chemotherapy does not affect overall survival.

Significant association of PD-L1 expression with human papillomavirus positivity and its prognostic impact in oropharyngeal cancer Publication date: May 2019 Source: Oral Oncology, Volume 92 Author(s): Angela M. Hong, Peter Ferguson, Tristan Dodds, Deanna Jones, Mengbo Li, Jean Yang, Richard A Scolyer Abstract Background The programmed death pathway plays a role in persistent human papillomavirus (HPV) infection as well as in resistance to immune elimination during malignant progression. In this study, we examined PD-L1 expression by immunohistochemistry and tumour infiltrating lymphocytes (TIL) in 214 patients with oropharyngeal squamous cell cancer (OPSCC) to assess its clinical significance. Results HPV-positive OPSCC were significantly more likely to express PD-L1 than HPV-negative OPSCC (85.2% vs 57.1%, p < 0.05). PD-L1 staining was more likely to be associated with TILs in HPV-positive OPSCC (67.9% vs 49.6%, p = 0.01). Relative to those patients with HPV-positive/PD-L1-positive OPSCC, patients with HPV negative/PD-L1 negative OPSCC were 6.4 times more likely to develop a local recurrence, 5.8 times more likely to develop an event and 6.5 times more likely to die. Within the HPV positive cases, PD-L1 expression also significantly impacted on the outcomes with PD-L1 negative cases more likely to develop a locoregional recurrence (HR 4.16), to have an event (HR 2.5) and to die (HR 3.16). Evidence of an interaction between HPV status and PD-L1 expression was found for overall survival (p < 0.005). Conclusion Our findings suggested that different immune profiles in oropharyngeal cancer by HPV status and the effect of HPV on the outcomes is modified by PD-L1 expression.

Prognostic factors associated with achieving total oral diet after glossectomy with microvascular free tissue transfer reconstruction Publication date: May 2019 Source: Oral Oncology, Volume 92 Author(s): Diane W. Chen, Tao Wang, Jonathan Shey-Sen Ni, Vlad C. Sandulache, Evan M. Graboyes, Mitchell Worley, Joshua D. Hornig, Judith M. Skoner, Terry A. Day, Andrew T. Huang Abstract Objective Primary surgery followed by adjuvant therapy is the current standard of care in the multidisciplinary management of squamous cell carcinoma (SCC) of the oral tongue. Additionally, salvage glossectomy is used to treat recurrent base of tongue SCC. Microvascular free tissue transfer reconstruction (MVFTT) is utilized to maximize functional outcomes such as swallowing. We sought to identify prognostic factors related to achievement of a total oral diet in patients that underwent glossectomy with MVFTT. Methods Retrospective review at a tertiary care center from 2010 to 2015. Results 200 patients (69% male, mean age 60 years) met inclusion criteria. Extent of glossectomy was categorized as partial or hemiglossectomy (39%), tongue base resection with or without hemi-oral glossectomy (23%), composite resection with mandibulectomy (18%), and subtotal or total glossectomy (21%). Flap success rate was 96%. Median follow-up time was 14  months. A total oral diet was achieved by 49% of patients with median time to achievement of 31  days (IQR 9-209). Multivariate analysis identified body mass index  < 25 kg/m2, prior radiation therapy, adjuvant chemoradiation, and resection requiring subtotal or total glossectomy or concurrent mandibulectomy as independent risk factors for worse total oral diet achievement. Conclusion Swallowing dysfunction represents a significant morbidity following glossectomy in the treatment of SCC. High BMI, smaller resection fields, and absence of prior radiation therapy or adjuvant chemoradiotherapy correlated with improved likelihood of obtaining a total oral diet. Patients should be appropriately counseled of this risk with emphasis placed on aggressive swallow rehabilitation in the post- treatment setting.

Intra-operative point-of-procedure delineation of oral cancer margins using optical coherence tomography Publication date: May 2019 Source: Oral Oncology, Volume 92 Author(s): Sumsum P. Sunny, Sagar Agarwal, Bonney Lee James, Emon Heidari, Anjana Muralidharan, Vishal Yadav, Vijay Pillai, Vivek Shetty, Zhongping Chen, Naveen Hedne, Petra Wilder-Smith, Amritha Suresh, Moni Abraham Kuriakose Abstract Objectives Surgical margin status is a significant determinant of treatment outcome in oral cancer. Negative surgical margins can decrease the loco-regional recurrence by five-fold. The current standard of care of intraoperative clinical examination supplemented by histological frozen section, can result in a risk of positive margins from 5 to 17 percent. In this study, we attempted to assess the utility of intraoperative optical coherence tomography (OCT) imaging with automated diagnostic algorithm to improve on the current method of clinical evaluation of surgical margin in oral cancer. Materials and methods We have used a modified handheld OCT device with automated algorithm based diagnostic platform for imaging. Intraoperatively, images of 125 sites were captured from multiple zones around the tumor of oral cancer patients (n = 14) and compared with the clinical and pathologic diagnosis. Results OCT showed sensitivity and specificity of 100%, equivalent to histological diagnosis (kappa, ĸ = 0.922), in detection of malignancy within tumor and tumor margin areas. In comparison, for dysplastic lesions, OCT-based detection showed a sensitivity of 92.5% and specificity of 68.8% and a moderate concordance with histopathology diagnosis (ĸ = 0.59). Additionally, the OCT scores could significantly differentiate squamous cell carcinoma (SCC) from dysplastic lesions (mild/moderate/severe; p ≤ 0.005) as well as the latter from the non-dysplastic lesions (p ≤ 0.05). Conclusion The current challenges associated with clinical examination-based margin assessment could be improved with intra-operative OCT imaging. OCT is capable of identifying microscopic tumor at the surgical margins and demonstrated the feasibility of mapping of field cancerization around the tumor.

Development of a cytology-based multivariate analytical risk index for oral cancer Publication date: May 2019 Source: Oral Oncology, Volume 92 Author(s): Timothy J. Abram, Pierre N. Floriano, Robert James, A. Ross Kerr, Martin H. Thornhill, Spencer W. Redding, Nadarajah Vigneswaran, Rameez Raja, Michael P. McRae, John T. McDevitt Abstract Objectives The diagnosis and management of oral cavity cancers are often complicated by the uncertainty of which patients will undergo malignant transformation, obligating close surveillance over time. However, serial biopsies are undesirable, highly invasive, and subject to inherent issues with poor inter-pathologist agreement and unpredictability as a surrogate for malignant transformation and clinical outcomes. The goal of this study was to develop and evaluate a Multivariate Analytical Risk Index for Oral Cancer (MARIO) with potential to provide non-invasive, sensitive, and quantitative risk assessments for monitoring lesion progression. Materials and methods A series of predictive models were developed and validated using previously recorded single-cell data from oral cytology samples resulting in a "continuous risk score". Model development consisted of: (1) training base classification models for each diagnostic class pair, (2) pairwise coupling to obtain diagnostic class probabilities, and (3) a weighted aggregation resulting in a continuous MARIO. Results and conclusions Diagnostic accuracy based on optimized cut-points for the test dataset ranged from 76.0% for Benign, to 82.4% for Dysplastic, 89.6% for Malignant, and 97.6% for Normal controls for an overall MARIO accuracy of 72.8%. Furthermore, a strong positive relationship with diagnostic severity was demonstrated (Pearson's coefficient = 0.805 for test dataset) as well as the ability of the MARIO to respond to subtle changes in cell composition. The development of a continuous MARIO for PMOL is presented, resulting in a sensitive, accurate, and non-invasive method with potential for enabling monitoring disease progression, recurrence, and the need for therapeutic intervention of these lesions.

Risk of prolonged opioid use among cancer patients undergoing curative intent radiation therapy for head and neck malignancies Publication date: May 2019 Source: Oral Oncology, Volume 92 Author(s): William H. Smith, Ian Luskin, Lucas Resende Salgado, Bethann M. Scarborough, Jung-Yi Lin, Umut Özbek, Brett A. Miles, Vishal Gupta, Richard L. Bakst Abstract Objective Patients undergoing radiation treatment (RT) for head and neck malignancies often suffer significant disease- and treatment-related pain requiring opioids for effective management. However, the prevalence and associated risk factors of prolonged opioid use in this population remain poorly characterized. We sought to quantify the rate of prolonged opioid use among opioid naïve patients receiving curative-intent RT for head and neck malignancies and to identify associated risk factors. Methods We retrospectively identified patients who had undergone RT for head and neck malignancies at our institution between Jan 2011 and Sept 2017. Our primary endpoint was persistent opioid use 6-months following completion of RT. Patients were included if they were opioid-naïve, underwent curative intent RT, had adequate follow-up, and did not have residual or recurrent disease within our follow-up period. Univariable and multivariable logistic regression was utilized to identify risk factors for prolonged opioid use. Results We identified 311 patients meeting our inclusion criteria; 40 (12.9%) continued to use opioids 6-months following RT. Univariable analysis found current smoking, alcohol abuse, RT dose, treatment to the bilateral necks, induction chemotherapy, concurrent chemotherapy, PEG tube, daily milligram morphine equivalents, and adjuvant analgesic medication use to be positively associated with prolonged opioid use; prior surgery was negatively associated with prolonged opioid use. Delivery of induction chemotherapy (OR 2.86, CI (95%) 1.32–6.21) and alcohol abuse (OR 3.75, CI (95%) 1.66–8.47) remained statistically significant on multivariable analysis. Conclusion The prevalence of prolonged opioid use in previously opioid naïve patients undergoing curative intent head and neck RT was just under 13%. Patients with history of alcohol abuse and those who undergo induction chemotherapy were most at risk.

Anaesthesia , Intensive Care Medicine

Practical aspects of ultrasound-guided regional anaesthesia Publication date: April 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 4 Author(s): Pavan Kumar BC. Raju, Calum RK. Grant Abstract Ultrasound-guided regional anaesthesia is increasingly popular, offering the user a number of advantages over alternative methods of nerve localization (neurostimulation or paraesthesia). These include a more accurate understanding of individual patient anatomy, identification of needle tip position and the ability to assess local anaesthetic spread in relation to a target nerve. An understanding of the basic principles and commonly used terminologies of ultrasound scanning is a fundamental requirement when using this technology. The aim of this article is to outline these basic principles and explain the practical aspects of performing nerve blocks, using ultrasound, in order to achieve quick, safe and effective block performance with minimal procedural discomfort for the patient.

Self-assessment Publication date: April 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 4 Author(s): Viyayanand Nadella

Nerve cell function and synaptic mechanisms Publication date: April 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 4 Author(s): Allan Fletcher Abstract Nerve cells (neurones) are 'excitable' cells that can transduce a variety of stimuli into electrical signals, continuously sending information about the external and internal environment (in the form of sequences of action potentials) to the central nervous system (CNS). Interneurones in the CNS integrate this information and send signals along output (efferent) neurones to various parts of the body for the appropriate actions to be taken in response to environmental changes. Networks of neurones have been arbitrarily classified into various nervous systems that gather and transmit sensory information and control skeletal muscle function and autonomic function, etc. The junctions between neurones (synapses) are either electrical or chemical. The former permit the direct transfer of electrical current between cells, whereas the latter utilize chemical signalling molecules (neurotransmitters) to transfer information between cells. Neurotransmitters are mainly amino acids, amines or peptides (although other molecules such as purines and nitric oxide are utilized by some cells), and can be excitatory or inhibitory. Individual neurones within the CNS may receive synaptic inputs from thousands of other neurones. Therefore, each neurone 'integrates' this vast complexity of inputs and responds accordingly (either by remaining silent or firing action potentials to other neurones). Adaptations in the function and structure of chemical synapses in particular (synaptic plasticity) are thought to underlie the mechanisms mediating cognitive functions (learning and memory).

Insertion of a chest drain for pneumothorax Publication date: April 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 4 Author(s): Bilal Kirmani, Joseph Zacharias Abstract The insertion of a chest drain, either using the Seldinger technique or as a cut-down for a wide bore tube, is common and relatively straightforward. An appreciation of the anatomy, procedural technique and potential complications is important. The process is outlined here.

Peripheral nerve catheter techniques Publication date: April 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 4 Author(s): Ayman H.M. Mustafa Abstract Peripheral nerve catheters (PNC) or perineural catheters are used synonymously to describe placing a catheter in close proximity to nerve plexuses or individual nerves for the provision of continuous pain relief. The indications of PNCs extend beyond upper and lower extremity orthopaedic surgery to perioperative analgesia in patients undergoing a wide range of surgical procedures (e.g. abdominal, vascular, thoracic, breast and trauma surgeries). PNC use can facilitate early mobilization after surgery by providing high quality analgesia that in turn leads to reduced opioid consumption and associated opioid related side effects. Perioperative PNC analgesia can result in reduced length of in-hospital stay and improved rates of patient satisfaction. Insertion of peripheral nerve catheters can be done by either anaesthetist or surgeon. Long term benefits are still to be ascertained. Risks are similar to peripheral nerve block although catheter dislodgement remains a specific problem.

Intravenous regional anaesthesia Publication date: April 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 4 Author(s): Alastair J.M. Baird, Colin B. Donald Abstract Intravenous regional anaesthesia, or Bier's block, is a useful and safe technique for anaesthetizing distal limbs for short surgical procedures. It is most commonly used for reduction of forearm fractures within the emergency department and can be a useful method of providing anaesthesia in patients who may be unsuitable for a general anaesthetic, or when skills or equipment for other forms of regional anaesthesia are unavailable. When performed as recommended it has a proven safety record.

Upper limb nerve blocks Publication date: April 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 4 Author(s): Pavan Kumar B.C. Raju, James S. Bowness Abstract Brachial plexus blockade is used for a variety of upper limb surgical procedures. Ultrasound guidance is generally considered to be the gold-standard technique, although large-scale studies examining efficacy and complications of ultrasound-guided techniques compared with nerve stimulation are still needed. Interscalene block remains the approach of choice for shoulder surgery, although phrenic nerve blockade is common even using low volumes of local anaesthetic. Of the currently available studies comparing the other approaches, there seems to be little difference in efficacy between axillary, supraclavicular and infraclavicular approaches for elbow, forearm and hand surgery when equivalent levels of expertise are used. The major features influencing block choice and performance are discussed.

Lower limb nerve blocks Publication date: April 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 4 Author(s): Calum R.K. Grant Abstract The proliferation of ultrasound use is changing the approach to regional anaesthesia of the lower limb. Techniques are being developed that provide high-quality postoperative analgesia while minimizing associated motor block that may impair mobilization. Regional anaesthetic techniques also provide significant opioid-sparing benefits (e.g. less sedation, nausea and urinary retention) that are key principles of current enhanced recovery protocols. Ultrasound-guided nerve localization offers several potential advantages when performing femoral, adductor canal, sciatic and ankle blocks; however, neurostimulation remains a useful and widely used aid to lower limb regional anaesthesia practice.

Systemic toxic effects of local anaesthetics Publication date: April 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 4 Author(s): Heather N. Sheppard, Ravi Anandampillai Abstract Local anaesthetics are widely used in the provision of local/regional anaesthesia and the management of acute and chronic pain. Their mechanism of action temporarily inhibits voltage gated sodium channels in neuronal plasma membranes. Local anaesthetic systemic toxicity (LAST) is a serious yet largely preventable complication that can occur by any of the multiple routes of administration. LAST predominantly affects the central nervous and cardiovascular systems. Awareness of LAST and vigilance during administration of local anaesthetics may help in early recognition and successful management of the toxicity. Intralipid emulsion (ILE) infusions have been successfully used in reversing local anaesthetic-induced cardiotoxicity. Since 2007 in the UK, ILE infusion has been incorporated into the safety guidelines for management of LAST.

Complications of regional anaesthesia Publication date: April 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 4 Author(s): Alasdair Taylor, Calum R.K. Grant Abstract Complications of regional anaesthesia can be divided into those specific to central neuraxial blockade, those specific to peripheral nerve blockade, and those that pertain to both. Fortunately, severe complications, namely spinal cord damage, vertebral cord haematoma and epidural abscess are rare. Here we have given an overview of these complications, with reference to incidences available following the 3rd National Audit Project of the Royal College of Anaesthetists. A thorough knowledge of anatomy and pharmacology, and a meticulous, unhurried technique are key to reducing the risk of such complications. When considering the use of a regional anaesthetic technique, the risks and benefits for the individual patient should be assessed on a case-by-case basis, and set against the risks and benefits of alternatives.

Orthodontics and Dentofacial Orthopedics

Directory: AAO Officers and Organizations Publication date: April 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 4 Author(s):

Raymond George Sr, 1939-2018 Publication date: April 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 4 Author(s): Perry Opin

Eldon Dean Bills, 1931-2018 Publication date: April 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 4 Author(s): James L. Vaden, Michael L. Riolo

April 2019:155(4) Publication date: April 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 4 Author(s): Allen H. Moffitt

Searching the literature for studies for a systematic review. Part 3: Using controlled vocabulary Publication date: April 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 4 Author(s): Anne Littlewood, Dimitrios Kloukos

Doctors yes, assistants no Publication date: April 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 4 Author(s): Laurance Jerrold

Evaluation of fit for 3D-printed retainers compared with thermoform retainers Publication date: April 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 4 Author(s): David Cole, Sompop Bencharit, Caroline K. Carrico, Andrew Arias, Eser Tüfekçi Introduction In the literature, there is little information available on 3D-printed orthodontic retainers. This study examined the accuracy of 3D-printed retainers compared with conventional vacuum-formed and commercially available vacuum-formed retainers. Methods Three reference models (models 1, 2, and 3) were used to fabricate traditional vacuum-formed, commercially available vacuum-formed, and 3D-printed retainers. For each model, retainers were made using the 3 methods (a total of 27 retainers). To determine the trueness, ie, closeness of a model to a true model, the distance between the retainer and its digital model at reference points were calculated with the use of engineering software. The measurements were reported as average absolute observed values and compared with those of the conventional vacuum-formed retainers. Results Average differences of the conventional vacuum-formed retainers ranged from 0.10 to 0.20 mm. The commercially available and 3D-printed retainers had ranges of 0.10 to 0.30 mm and 0.10 to 0.40 mm, respectively. Conclusions The conventional vacuum-formed retainers showed the least amount of deviation from the original reference models and the 3D-printed retainers showed the greatest deviation. However, all 3 methods yielded measurements within 0.5 mm, which has previously been accepted to be clinically sufficient.

A novel 3D-printed computer-assisted piezocision guide for surgically facilitated orthodontics Publication date: April 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 4 Author(s): Hsin-Yu Hou, Chung-Hsing Li, Min-Chia Chen, Pei-Yi Lin, Wei-Chung Liu, Yi-Wen Cathy Tsai, Ren-Yeong Huang Surgical interventions on the alveolar ridges aimed at facilitating orthodontic tooth movement have been extensively reported. However, unexpected events or complications still occur in daily practice. The purpose of this report was to present a novel 3-dimensional (3D) computer-assisted piezocision guide (CAPG) designed to be translucent for increased visibility, rigid for enhanced support during guidance, and porous for profuse irrigation during procedure. Such a design can function to minimize the risk of surgical complications. In this case, we present a novel 3D-printed CAPG to facilitate a minimally invasive periodontal accelerated osteogenic orthodontics (PAOO) procedure with a guide that provides accuracy, adequate visibility, and greater access for the coolant to reach the surgery site. By navigating the cone-beam computed tomography data, we precisely know the cortical bone thickness, root direction, and interrelations between anatomic structures in an individual situation, which allows us to design our cutting slot for the required length and depth according to the operator's knowledge. Finally, 3D printing was applied, transferring our surgical plan to fabricate the CAPG. Moreover, the well designed pores on the CAPG allow effective irrigation during the piezocision procedure. This minimally invasive procedure was uneventful, and no devitalized tooth or alveolar bone was found.

Treatment of a severe Class II Division 1 malocclusion combined with surgical miniscrew anchorage Publication date: April 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 4 Author(s): Poonsak Pisek, Montian Manosudprasit, Tasanee Wangsrimongkol, Chutimaporn Keinprasit, Raweewan Wongpetch This article reports the camouflage treatment of a female patient, aged 15 years 2 months, who had a Class II Division 1 malocclusion with severe anterior protrusion and deep incisor overbite. The camouflage treatment plan included bilateral extraction of the maxillary first premolars combined with the use of temporary anchorage devices (TADs) and tension coil springs to retract canines into the extraction spaces and then the 4 incisors. The treatment included use of a mandibular fixed labial arch with minimal use of Class II elastics to correct mild mandibular spacing and level the curve of Spee. Ideal overjet and overbite relationships were established, and the final result was well balanced and esthetically pleasing. The molars were finished in a Class II relationship. Total treatment time was 2 years 6 months. Cephalometric superimpositions revealed that mandibular molars were not disturbed by the limited use of Class II elastics. Surgical miniscrews in canine and incisor retraction in Class II Division 1 malocclusion are an alternate type of temporary anchorage that reduce or remove reliance on conventional intermaxillary anchorage.

A comprehensive treatment approach for idiopathic condylar resorption and anterior open bite with 3D virtual surgical planning and self-ligated customized lingual appliance Publication date: April 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 4 Author(s): Farhana Rahman, Ahmet Arif Celebi, Patrick J. Louis, Chung How Kau Introduction We report the successful treatment of a 38-year-old woman with bilateral idiopathic condylar resorption and anterior open bite. She had incompetent lips, a gummy smile, increased lower facial height, high mandibular plane angle, skeletal and dental Class II malocclusion with mild mandibular crowding, increased overjet, and mandibular midline deviation to the right. Methods The treatment plan included: (1) presurgical alignment and leveling of the teeth in both arches; (2) jaw motion tracking (JMT) to detect mandibular movement; (3) 3-piece maxillary osteotomies with mandibular reconstruction and bilateral coronoidectomies; and (4) postsurgical correction of the malocclusion. The orthodontic treatment was performed with the use of custom lingual braces and clear brackets and the orthognathic surgery was planned with the use of virtual surgical planning. Results The idiopathic condylar resorption and anterior open bite were treated, crowding was eliminated in the lower anterior segment, correction of skeletal and dental Class II malocclusion was obtained, mandibular plane angle was reduced, and facial profile improved. Conclusions The results suggest that esthetic and functional results can be achieved with the cooperation of 2 specialties and with the use of state-of-the-art technology.