- Email: [email protected]
Anatomic location of the tongue base neurovascular bundle
CURRENT LITERATURE deaths in the United Kingdom and five in the United States. The usual toxicology screening tests may fail to detect MDMA unless large doses have been ingested. The drug will show up as a positive test for amphetamines, but at a 50% less sensitivity level. Emergency treatment consists of rapid rehydration and core cooling. Some patients may require short-acting benzo-diazepines, such as lorazepam.-RocER E. ALEXANDER No reprints available Exfoliative Cheilitis (EC) in AIDS: Association With Candida infection. Reichart P, Weigel D, SchmidtWesthausen A, et al. J Oral Path01 Med 26:290, 1997 Exfoliative cheilitis is a chronic surface inflammatory disturbance of the vermilion border of the lower lip, predominantly alfecting females of a young age group who may or may not have emotional sensitivity. This disease entity is characterized by the surface production of keratin scales. In addition to the characteristic scaling, some other pertinent characteristics of exfoliative cheilitis are, peeling, cracking, and fissuring of the lower lip. Exfoliative cheilitis can either resolve spontaneously or can be present for years without resolution. The exact etiologic and pathological backgrounds are unknown. Recent studies have made a correlation between the presence of exfoliative cheilitis and AIDS. The following is a summary of this study and the tindings associated with the above correlation. The experimental group of this study included 165 patients with AIDS. There were two control groups, twenty patients with AIDS but without clinical or histological evidence of exfoliative cheilitis (Cl), and twenty staff members that were negative for, human immunodeficiency virus (HIV) antibodies (C2). These two groups were inspected for any type of oral candidiasis. This study found that of 165 patients with AIDS, 28.5% had the presence of exfoliative cheilitis. Histologic examination showed that 23 of the 47 cases had the presence of hyphae. In 27 patients there was evidence of oral candidiasis, 14 patients had pseudomembranous candidiasis alone, 3 patients had a combination of pseudomembranous and erythematous candidiasis and 10 patients with only erythematous. Twenty patients of 35 that had received antifungal prophylaxis/therapy, presented with some evidence of oral candidiasis. Histological and microbiological evidence of intra-oral pseudomembranous candidiasis was found in 8 out of 14 cases, seven of which received antifungal prophylaxis or therapy. In Cl, Candida albicans was present in three samples and C albicans plus Cglabrata in one other case. In three cases there was evidence of oral pseudomembranous candidiasis, in six cases there was evidence of erythematous candidiasis and in four cases there was a combination of the two forms. In C2, not one case had the presence of Candida from the specimens collected from the vermilion borders. Several conclusions are made from this clinical trial. This particular study when compared with previous studies shows that a larger percentage of exfoliative cheilitis can be associated with AIDS. The two control groups used Cl and C2 also lend some information to the relationship of C albicans and AIDS. In C 1, there were 20% that had positive smears for C albicans, and those patients in C2, were all negative. What is indicated here is that 13 of the 20 patients that have oral candidiasis, can eventually spread it onto their lips from frequent moistening with the tongue. Looking at the later stages of AIDS, it can be noted that the therapy or prophylaxis with antifungal
525 agents is not successful. Of the 35 patients, 20 had residual candidiasis. There can be an increasing resistance or species shift that occurs as the disease process of AIDS advances. In immunocompromised patients, the etiologic and pathological development of exfoliative cheilitis can sometimes be associated with the infection of Candida. It presently remains questionable if there are other causes of exfoliative cheilitis associated with HIV and AIDS. It has been determined that exfoliative cheilitis should now be incorporated into the clinical spectrum of immunocompromised states of AIDS patients.-T.J. FELDMAN Reprint requests to Dr Reichart: Medizinische Fakultgt der HumboltUniversitiit zu Berlin, Zentmm Rir Zahnmedzin, Abteilung fiir Oralchirurgie und zahnPrzliche Rijntgenologie, Fijhrer Strape 15, 13353 Berlin, Germany. Secondary Craniofacial Management Following Skeletal Correction in Facial Asymmetry Application of Microsurgical Techniques. Siebert JW, Longacre MT. Clin Plast Surg 24:447, 1997 Deficiencies of both the facial skeleton as well as overlying soft tissues must be addressed when correcting facial asymmetry. Microvascular free tissue transfer is helpful in the camouflage of hemifacial microsomia, hemifacial atrophy, selected congenital anomalies such as complex orbital clefts, Treacher Collins syndrome and severe micrognathia; sequelae of adjuvant radiation treatment; facial and arteriovenous malformations; facial palsy; and deformities resulting from collagen vascular disorders, such as systemic lupus erythematosis and scleroderma. Fascia-cutaneous flaps appear to yield the best long-term correction of facial contour. The use of superficial temporal vessels or accessible deeper veins avoid an incision on the neck. An inframammary extended circumflex scapular (IMECS) flap allows a donor site scar that falls into the inframammary fold. Surgical planning includes marking irregularities directly on the face. An ipsilateral donor site is used so that microvascular free tissue transfer can be performed without turning the patient. Facial dissection is preferred through a standard preauricular facelift incision. The dissection is carried out 1.O cm beyond the limits of the deformity. After IMECS flap harvest, bony fixation is performed, venous followed by arterial end-to-end microvascular anastomosis carried out, and then skin and facial extensions modified. Final revision and closure is then performed. A state of the art approach for reconstruction of facial deformities should include standard craniofacial techniques, with or without bone expansion followed by soft tissue microvascular reconstruction.-R.H. HAUG Reprint requests to Dr Siebert: 799 Park Ave, New York, NY 10021. Anatomic Location of the Tongue Base Neurovascular Bundle. Lauretano AM, Li KK, Carandonna DS, et al. Laryngoscope 107:1057, 1997 Knowledge of the location of the hypoglossal/lingual artery neurovascular bundle (HLNVB) is essential in performing tongue base resections for neoplasm and for obstructive sleep apnea. This study presents a range of measurements to be considered as a guideline to the position of this bundle with respect to soft tissue and bony landmarks. Ten fresh cadaver heads were dissected to determine the location of the HLNVB. The lingual vessels and hypoglossal nerve were identified in the neck and followed into the tongue base
526
CURRENT LITERATURE
preserving surrounding soft tissue and bone. Measurements were taken in centimeters to assess tongue length, width, depth, and distance from foramen cecum to NVB in transverse, vertical, and diagonal distances. The distance from the NVB to hyoid bone, lateral margin of tongue, mandible, and retromolar trigone were also examined. Significant findings show the position of the tongue base and HLNVB is significantly inferior and lateral, that is 2.7 cm inferior and 1.6 cm lateral to foramen cecum, 0.9 cm superior to the hyoid bone, and 2.2 cm medial to the mandible. This inferolateral location allows the potential for aggressive tongue base resection without neurovascular compromisc.-J. BROKLOFF Reprint requests to Dr Lauretano: Joint Center of Otolamgology, 333 Longwood Ave, Boston, MA 02115. Unifocal Heliod Choroiditis. Hong PH, Jampol Dodwell DG, et al. Arch Ophthalmol 115: 1107,1997
LM,
Six patients observed by the authors exhibited a previously undescribed clinical syndrome of choroiditis. Choroiditis, the inflammation of the pigmented vascular tunic of the eye is thought to be secondary to microbial infection, an idiopathic granulomatous disease, an autoimmune disease, or various other systemic or ocular diseases. Six healthy patients ranging in age from 9 to 25 years (four males and two females), all exhibited an acute appearance of a single, round, discrete, yellow-white active focus of choroiditis approximately 1 disc diameter in size. All lesions were unilateral and unifocal. Their symptoms included loss of central vision and metamorphopsia. The lesion showed minimal growth, then gradual resolution of the infkuumation with only minimal thinning of the lesion. Decrease of visual acuity was highly variable, and was related to the location of the lesion and overlying subretinal fluid. Relapses were common and visual loss was permanent in one reported case. The authors were uncertain if the cause of this lesion was microbial infection, an immunologic reaction, or some other process. Systemic evaluations showed no definitive cause. This clinical entity, separable from previously established choroidal disorders, was called ’ ‘unifocal heliod choroiditis” due to the characteristic sun-like appearance of the lesions at initial presentation.-A.J. LJHJNAO Reprint requests to Dr Jampol: Northwestern University Medical 440, Chicago, IL 60611.
Department of Ophthalmology, School, 645 N Michigan Ave, Suite
The Craniofacial Dysostosis Syndromes: Staging of Reconstruction and Management of Secondary Deformities. Posnick JC. Clin Plast Surg 24:429, 1997 Crouzon syndrome, the most common form of craniofacial dysostosis, typically presents with premature synostosis of coronal, cranial base, and upper face sutures, as well as midface hypoplasia. The initial treatment is crania-orbital decompression with bicoronal suture release and osteotomies of the anterior cranial vault and upper orbits at 9 to 11 months of age. If signs of increased intracranial pressure develop in childhood the procedure is repeated. In childhood, monobloc, facial bipartition, and LeFort III procedure address the total midface deformity. Malocclusion and jaw deformity is addressed by osteotomy at 13 to 16 years of age. Patients with Apert syndrome possess misshapenness of the skull, mitten hand and feet deformities, mental retardation, and blindness. Cartilage dysplasia of the cranial base; fusion
of the coronal sutures, anterior cranial base, and midface; and failure of metopic and sagittal suture formation, are responsible for some of the craniofacial deformities. Primary crania-orbital decompression-reshaping is performed at 9 to 11 months of age. A repeat procedure may be carried out in childhood if signs of increased intracranial pressure develops. Total midface deformity managed with LeFort III or monobloc procedures are preferred in mid-childhood. Malocclusion and jaw deformity management in adolescence is generally performed with a maxillary osteotomy and genioplasty, as the mandible has a normal growth potential. Carpenter syndrome is characterized by craniosynostosis often associated with preaxial polysyndactyly of the feet, short lingers with clinodactyly, and variable soft tissue syndactyly. In Pfeiffer syndrome, craniosynostosis, broad thumbs, broad great toes, and occasionally soft tissue syndactyly of the hands are noted. Saethre-Chotzen syndrome contains craniosynostosis, low set frontal hairline, ptosis of the upper eyelids, facial asymmetry, brachydactyly, partial cutaneous syndactyly, and other skeletal deformities. Kleeblatschadel anomaly is a complete craniosynostosis resulting in a trilobular-shaped skull.-R.H. HMJG Reprint requests to Dr Posnick: Division of Plastic Georgetown Craniofacial Center, Georgetown University Center, 3800 Reservoir Rd NW, Washington, DC 20007.
Surgery, Medical
Uveal Melanoma, Growth Rate and Prognosis. DH, Kroll S, Phillips TL. Arch 0phthalmo1115:1014,1997
Char
The objective of this retrospective study was to investigate in vivo tumor growth rate, doubling time, and the association of these parameters with local tumor control and melanoma-related mortality. One hundred forty-five patients with history of choroidal or ciliary body melanoma who underwent serial observations were studied. Tumor growth rate was defined as the relative change in tumor size per time unit. Treatments after documented tumor growth were iodine 125 (1251) brachtherapy, helium ion irradiation, enucleation, laser proton irradiation, and resection. Only tumor width was documented to have increased in 12% of melanomas, only tumor thickness in 28%, and increase in both in 60%. The mean follow-up after initial evaluation was 8.6 years. The mean follow-up after treatment was 6.5 years. Melanoma-associated metastases developed in 13 patients. Eleven of the 13 metastatic tumors had doubling-time estimates of less than 1 year. Eight of the 117 patients undergoing irradiation had local treatment failures which occurred when lz51 brachtherapy was applied to tumors located in the macula. More rapidly growing tumors were associated with higher risk for local recurrence. Seven of the eight tumors had doubling time estimates of less than 0.8 years and growth rates in the highest third of irradiated melanomas. Possible explanation of the altered radiation response include an alteration in levels of mandanese superoxide dismutase and various oncogenes. Also, in sarcomas, more rapidly dividing cells could be more colonogenie, with lower percentage killed by radiation. The authors concluded that the growth rate of uveal melanomas predicts tumor-related mortality. Rapidly growing melanomas are associated with more rapid metastatic development. More malignant, rapidly growing melanomas may also be associated with higher risk for local recurrence after radiation-I.E. SHAMI Reprint requests to Dr Char: Department of Ophthalmology, Kirkham St, PO Box 073, University of California, San Francisco, Francisco, CA 94143.
10 San
525 agents is not successful. Of the 35 patients, 20 had residual candidiasis. There can be an increasing resistance or species shift that occurs as the disease process of AIDS advances. In immunocompromised patients, the etiologic and pathological development of exfoliative cheilitis can sometimes be associated with the infection of Candida. It presently remains questionable if there are other causes of exfoliative cheilitis associated with HIV and AIDS. It has been determined that exfoliative cheilitis should now be incorporated into the clinical spectrum of immunocompromised states of AIDS patients.-T.J. FELDMAN Reprint requests to Dr Reichart: Medizinische Fakultgt der HumboltUniversitiit zu Berlin, Zentmm Rir Zahnmedzin, Abteilung fiir Oralchirurgie und zahnPrzliche Rijntgenologie, Fijhrer Strape 15, 13353 Berlin, Germany. Secondary Craniofacial Management Following Skeletal Correction in Facial Asymmetry Application of Microsurgical Techniques. Siebert JW, Longacre MT. Clin Plast Surg 24:447, 1997 Deficiencies of both the facial skeleton as well as overlying soft tissues must be addressed when correcting facial asymmetry. Microvascular free tissue transfer is helpful in the camouflage of hemifacial microsomia, hemifacial atrophy, selected congenital anomalies such as complex orbital clefts, Treacher Collins syndrome and severe micrognathia; sequelae of adjuvant radiation treatment; facial and arteriovenous malformations; facial palsy; and deformities resulting from collagen vascular disorders, such as systemic lupus erythematosis and scleroderma. Fascia-cutaneous flaps appear to yield the best long-term correction of facial contour. The use of superficial temporal vessels or accessible deeper veins avoid an incision on the neck. An inframammary extended circumflex scapular (IMECS) flap allows a donor site scar that falls into the inframammary fold. Surgical planning includes marking irregularities directly on the face. An ipsilateral donor site is used so that microvascular free tissue transfer can be performed without turning the patient. Facial dissection is preferred through a standard preauricular facelift incision. The dissection is carried out 1.O cm beyond the limits of the deformity. After IMECS flap harvest, bony fixation is performed, venous followed by arterial end-to-end microvascular anastomosis carried out, and then skin and facial extensions modified. Final revision and closure is then performed. A state of the art approach for reconstruction of facial deformities should include standard craniofacial techniques, with or without bone expansion followed by soft tissue microvascular reconstruction.-R.H. HAUG Reprint requests to Dr Siebert: 799 Park Ave, New York, NY 10021. Anatomic Location of the Tongue Base Neurovascular Bundle. Lauretano AM, Li KK, Carandonna DS, et al. Laryngoscope 107:1057, 1997 Knowledge of the location of the hypoglossal/lingual artery neurovascular bundle (HLNVB) is essential in performing tongue base resections for neoplasm and for obstructive sleep apnea. This study presents a range of measurements to be considered as a guideline to the position of this bundle with respect to soft tissue and bony landmarks. Ten fresh cadaver heads were dissected to determine the location of the HLNVB. The lingual vessels and hypoglossal nerve were identified in the neck and followed into the tongue base
526
CURRENT LITERATURE
preserving surrounding soft tissue and bone. Measurements were taken in centimeters to assess tongue length, width, depth, and distance from foramen cecum to NVB in transverse, vertical, and diagonal distances. The distance from the NVB to hyoid bone, lateral margin of tongue, mandible, and retromolar trigone were also examined. Significant findings show the position of the tongue base and HLNVB is significantly inferior and lateral, that is 2.7 cm inferior and 1.6 cm lateral to foramen cecum, 0.9 cm superior to the hyoid bone, and 2.2 cm medial to the mandible. This inferolateral location allows the potential for aggressive tongue base resection without neurovascular compromisc.-J. BROKLOFF Reprint requests to Dr Lauretano: Joint Center of Otolamgology, 333 Longwood Ave, Boston, MA 02115. Unifocal Heliod Choroiditis. Hong PH, Jampol Dodwell DG, et al. Arch Ophthalmol 115: 1107,1997
LM,
Six patients observed by the authors exhibited a previously undescribed clinical syndrome of choroiditis. Choroiditis, the inflammation of the pigmented vascular tunic of the eye is thought to be secondary to microbial infection, an idiopathic granulomatous disease, an autoimmune disease, or various other systemic or ocular diseases. Six healthy patients ranging in age from 9 to 25 years (four males and two females), all exhibited an acute appearance of a single, round, discrete, yellow-white active focus of choroiditis approximately 1 disc diameter in size. All lesions were unilateral and unifocal. Their symptoms included loss of central vision and metamorphopsia. The lesion showed minimal growth, then gradual resolution of the infkuumation with only minimal thinning of the lesion. Decrease of visual acuity was highly variable, and was related to the location of the lesion and overlying subretinal fluid. Relapses were common and visual loss was permanent in one reported case. The authors were uncertain if the cause of this lesion was microbial infection, an immunologic reaction, or some other process. Systemic evaluations showed no definitive cause. This clinical entity, separable from previously established choroidal disorders, was called ’ ‘unifocal heliod choroiditis” due to the characteristic sun-like appearance of the lesions at initial presentation.-A.J. LJHJNAO Reprint requests to Dr Jampol: Northwestern University Medical 440, Chicago, IL 60611.
Department of Ophthalmology, School, 645 N Michigan Ave, Suite
The Craniofacial Dysostosis Syndromes: Staging of Reconstruction and Management of Secondary Deformities. Posnick JC. Clin Plast Surg 24:429, 1997 Crouzon syndrome, the most common form of craniofacial dysostosis, typically presents with premature synostosis of coronal, cranial base, and upper face sutures, as well as midface hypoplasia. The initial treatment is crania-orbital decompression with bicoronal suture release and osteotomies of the anterior cranial vault and upper orbits at 9 to 11 months of age. If signs of increased intracranial pressure develop in childhood the procedure is repeated. In childhood, monobloc, facial bipartition, and LeFort III procedure address the total midface deformity. Malocclusion and jaw deformity is addressed by osteotomy at 13 to 16 years of age. Patients with Apert syndrome possess misshapenness of the skull, mitten hand and feet deformities, mental retardation, and blindness. Cartilage dysplasia of the cranial base; fusion
of the coronal sutures, anterior cranial base, and midface; and failure of metopic and sagittal suture formation, are responsible for some of the craniofacial deformities. Primary crania-orbital decompression-reshaping is performed at 9 to 11 months of age. A repeat procedure may be carried out in childhood if signs of increased intracranial pressure develops. Total midface deformity managed with LeFort III or monobloc procedures are preferred in mid-childhood. Malocclusion and jaw deformity management in adolescence is generally performed with a maxillary osteotomy and genioplasty, as the mandible has a normal growth potential. Carpenter syndrome is characterized by craniosynostosis often associated with preaxial polysyndactyly of the feet, short lingers with clinodactyly, and variable soft tissue syndactyly. In Pfeiffer syndrome, craniosynostosis, broad thumbs, broad great toes, and occasionally soft tissue syndactyly of the hands are noted. Saethre-Chotzen syndrome contains craniosynostosis, low set frontal hairline, ptosis of the upper eyelids, facial asymmetry, brachydactyly, partial cutaneous syndactyly, and other skeletal deformities. Kleeblatschadel anomaly is a complete craniosynostosis resulting in a trilobular-shaped skull.-R.H. HMJG Reprint requests to Dr Posnick: Division of Plastic Georgetown Craniofacial Center, Georgetown University Center, 3800 Reservoir Rd NW, Washington, DC 20007.
Surgery, Medical
Uveal Melanoma, Growth Rate and Prognosis. DH, Kroll S, Phillips TL. Arch 0phthalmo1115:1014,1997
Char
The objective of this retrospective study was to investigate in vivo tumor growth rate, doubling time, and the association of these parameters with local tumor control and melanoma-related mortality. One hundred forty-five patients with history of choroidal or ciliary body melanoma who underwent serial observations were studied. Tumor growth rate was defined as the relative change in tumor size per time unit. Treatments after documented tumor growth were iodine 125 (1251) brachtherapy, helium ion irradiation, enucleation, laser proton irradiation, and resection. Only tumor width was documented to have increased in 12% of melanomas, only tumor thickness in 28%, and increase in both in 60%. The mean follow-up after initial evaluation was 8.6 years. The mean follow-up after treatment was 6.5 years. Melanoma-associated metastases developed in 13 patients. Eleven of the 13 metastatic tumors had doubling-time estimates of less than 1 year. Eight of the 117 patients undergoing irradiation had local treatment failures which occurred when lz51 brachtherapy was applied to tumors located in the macula. More rapidly growing tumors were associated with higher risk for local recurrence. Seven of the eight tumors had doubling time estimates of less than 0.8 years and growth rates in the highest third of irradiated melanomas. Possible explanation of the altered radiation response include an alteration in levels of mandanese superoxide dismutase and various oncogenes. Also, in sarcomas, more rapidly dividing cells could be more colonogenie, with lower percentage killed by radiation. The authors concluded that the growth rate of uveal melanomas predicts tumor-related mortality. Rapidly growing melanomas are associated with more rapid metastatic development. More malignant, rapidly growing melanomas may also be associated with higher risk for local recurrence after radiation-I.E. SHAMI Reprint requests to Dr Char: Department of Ophthalmology, Kirkham St, PO Box 073, University of California, San Francisco, Francisco, CA 94143.
10 San