Three-dimensional superimposition for patients with facial palsy: an innovative method for assessing the success of facial reanimation procedures

Facial palsy is a severe condition that may be ameliorated by facial reanimation, but there is no consensus about how to judge its success. In this study we aimed to test a new method for assessing facial movements based on 3-dimensional analysis of the facial surfaces. Eleven patients aged between 42 and 77 years who had recently been affected by facial palsy (onset between 6 and 18 months) were treated by an operation based on triple innervation: the masseteric to temporofacial nerve branch, 30% of the hypoglossal fibres to the cervicofacial nerve branch, and the contralateral facial nerve through two cross-face sural nerve grafts. Each patient had five stereophotogrammetric scans: at rest, smiling on the healthy side (facial stimulus), biting (masseteric stimulus), moving the tongue (hypoglossal stimulus), and corner-of-the-mouth smile (Mona Lisa). Each scan was superimposed onto the facial model of the "rest" position, and the point-to-point root mean square (RMS) value was automatically calculated on both the paralysed and the healthy side, together with an index of asymmetry. One-way and two-way ANOVA tests, respectively, were applied to verify the significance of possible differences in the RMS and asymmetry index according to the type of stimulus (p = 0.0329) and side (p < 0.0001). RMS differed significantly according to side between the facial stimulus and the masseteric one on the paralysed side (p = 0.0316). Facial stimulus evoked the most asymmetrical movement, whereas the masseteric produced the most symmetrical expression. The method can be used for assessing facial movements after facial reanimation

Orbital medial wall fractures: Purely endoscopic endonasal repair with polyethylene implants

Our technique couples the stronger support granted by non-resorbable materials and the minimal invasiveness of the endoscopic approach without the need for long-term nasal packing

Role and Management of a Head and Neck Department during the COVID-19 Outbreak in Lombardy

The recent Italian outbreak of coronavirus disease 2019 led to an unprecedented burden on our health care system. Despite head and neck\u2013otolaryngology not being a front-line specialty in dealing with this disease, our department had to face several specific issues. Despite a massive reallocation of resources in the hospital, we managed to keep the service active, improving safety measures for our personnel, specifically during common otolaryngologic maneuvers known to produce aerosols. Furthermore, we strived to maintain our teaching role, giving residents an inclusive role in managing the response to the emergency state, and we progressively integrated our inactive specialists into other service rotations to relieve front-line colleagues\u2019 burden. Specific issues and management decisions are discussed in detail in the article

Masseteric-facial nerve neurorrhaphy: results of a case series

OBJECTIVE: Facial palsy is a well-known functional and esthetic problem that bothers most patients and affects their social relationships. When the time between the onset of paralysis and patient presentation is less than 18 months and the proximal stump of the injured facial nerve is not available, another nerve must be anastomosed to the facial nerve to reactivate its function. The masseteric nerve has recently gained popularity over the classic hypoglossus nerve as a new motor source because of its lower associated morbidity rate and the relative ease with which the patient can activate it. The aim of this work was to evaluate the effectiveness of masseteric-facial nerve neurorrhaphy for early facial reanimation. METHODS: Thirty-four consecutive patients (21 females, 13 males) with early unilateral facial paralysis underwent masseteric-facial nerve neurorrhaphy in which an interpositional nerve graft of the great auricular or sural nerve was placed. The time between the onset of paralysis and surgery ranged from 2 to 18 months (mean 13.3 months). Electromyography revealed mimetic muscle fibrillations in all the patients. Before surgery, all patients had House-Brackmann Grade VI facial nerve dysfunction. Twelve months after the onset of postoperative facial nerve reactivation, each patient underwent a clinical examination using the modified House-Brackmann grading scale as a guide. RESULTS: Overall, 91.2% of the patients experienced facial nerve function reactivation. Facial recovery began within 2-12 months (mean 6.3 months) with the restoration of facial symmetry at rest. According to the modified House-Brackmann grading scale, 5.9% of the patients had Grade I function, 61.8% Grade II, 20.6% Grade III, 2.9% Grade V, and 8.8% Grade VI. The morbidity rate was low; none of the patients could feel the loss of masseteric nerve function. There were only a few complications, including 1 case of postoperative bleeding (2.9%) and 2 local infections (5.9%), and a few patients complained about partial loss of sensitivity of the earlobe or a small area of the ankle and foot, depending on whether great auricular or sural nerves were harvested. CONCLUSIONS: The surgical technique described here seems to be efficient for the early treatment of facial paralysis and results in very little morbidity

Prevenzione delle fratture mandibolari conseguenti alla necrosi ossea da difosfonati

La frattura della mandibola rappresenta solitamente l'evento finale nei pazienti che presentano una progressione della necrosi ossea derivante dall'impiego dei difosfonati. Si tratta di una grave complicanza molto dolorosa che impedisce ai pazienti di alimentarsi correttamente, essendo pertanto un fattore che peggiora notevolmente la loro qualità di vita. L'obiettivo del trattamento dei pazienti che presentano la necrosi ossea legata ai difosfonati (BRONJ) dovrebbe essere rallentare la progressione della malattia. Presentiamo una soluzione tecnica per il trattamento dei pazienti che presentano necrosi mandibolare in stadio 3 ad alto rischio di sviluppare una frattura, avendo un'altezza mandibolare residua di osso sano inferiore a 6 mm. Il trattamento consiste nel posizionamento di una placca ricostruttiva mandibolare per via extra-orale in un piano superficiale al muscolo platisma per tenere i mezzi di sintesi separati dal sito infettivo e non farli contaminare con conseguente necessità di doverli rimuovere, seguito dal courettage per via endorale della necrosi mandibolare. Il rispetto della vascolarizzazione mandibolare e l'assenza di contatto diretto tra il sito di osteonecrosi e la placca ricostruttiva rappresentano alcuni dei vantaggi di questa metodica. La placca ricostruttiva rinforza la mandibola e consente di aggredire energicamente l'area di necrosi mandibolare, senza esporre il paziente a rischio di frattura iatrogena. Questo garantisce al paziente un rallentamento della progressione della malattia e impedisce la frattura patologica della mandibola, inevitabile epilogo delle necrosi ossee mandibolari

Prevention of bisphosphonate-related mandibular fractures = Prevenzione delle fratture mandibolari conseguenti alla necrosi ossea da difosfonati

La frattura della mandibola rappresenta solitamente l\u2019evento finale nei pazienti che presentano una progressione della necrosi ossea derivante dall\u2019impiego dei difosfonati. Si tratta di una grave complicanza molto dolorosa che impedisce ai pazienti di alimentarsi correttamente, essendo pertanto un fattore che peggiora notevolmente la loro qualit\ue0 di vita. L\u2019obiettivo del trattamento dei pazienti che presentano la necrosi ossea legata ai difosfonati (BRONJ) dovrebbe essere rallentare la progressione della malattia. Presentiamo una soluzione tecnica per il trattamento dei pazienti che presentano necrosi mandibolare in stadio 3 ad alto rischio di sviluppare una frattura, avendo un\u2019altezza mandibolare residua di osso sano inferiore a 6 mm. Il trattamento consiste nel posizionamento di una placca ricostruttiva mandibolare per via extra-orale in un piano superficiale al muscolo platisma per tenere i mezzi di sintesi separati dal sito infettivo e non farli contaminare con conseguente necessit\ue0 di doverli rimuovere, seguito dal courettage per via endorale della necrosi mandibolare. Il rispetto della vascolarizzazione mandibolare e l\u2019assenza di contatto diretto tra il sito di osteonecrosi e la placca ricostruttiva rappresentano alcuni dei vantaggi di questa metodica. La placca ricostruttiva rinforza la mandibola e consente di aggredire energicamente l\u2019area di necrosi mandibolare, senza esporre il paziente a rischio di frattura iatrogena. Questo garantisce al paziente un rallentamento della progressione della malattia e impedisce la frattura patologica della mandibola, inevitabile epilogo delle necrosi ossee mandibolari.Mandibular fracture is usually the clinical end of bisphosphonate-related osteonecrosis of the jaw. This is a painful complication and patients cannot feed as usual, with a worsening of their quality of life. The goal of treatment in bisphosphonate related osteonecrosis of jaw (BRONJ) patients is to slow progression of bone necrosis. We present a novel technique for treatment of severe mandibular BRONJ in stage 3 patients that present with a high risk to develop fracture, since they have a residual unaffected mandibular bone height less than 6 mm. We treated 10 patients in this clinical situation with an extra-oral application of a reconstructive plate superficial to the platysma, to keep the plate separated from the infected site to avoid contamination and consequent need of removal, followed by an intraoral approach for active curettage of mandibular necrosis. The preservation of blood supply to the mandible and avoidance of direct contact of the infected site with the reconstructive plate are some advantages of this technique. This plate allows enhancement of mandibular strength, allowing proper treatment of the BRONJ site on the oral side without fear of causing a mandibular fracture when the residual mandible is thin. This technical solution guarantees these patients an extended disease-free period since it is effective in preventing mandibular fractures in patients with low mandibular residual height left after the BRONJ onset

Insights on the Choice and Preparation of the Donor Nerve in Corneal Neurotization for Neurotrophic Keratopathy: A Narrative Review

The article introduces neurotrophic keratopathy (NK), a condition resulting from corneal denervation due to various causes of trigeminal nerve dysfunctions. Surgical techniques for corneal neurotization (CN) have evolved, aiming to restore corneal sensitivity. Initially proposed in 1972, modern approaches offer less invasive options. CN can be performed through a direct approach (DCN) directly suturing a sensitive nerve to the affected cornea or indirectly (ICN) through a nerve auto/allograft. Surgical success relies on meticulous donor nerve selection and preparation, often involving multidisciplinary teams. A PubMed research and review of the relevant literature was conducted regarding the surgical approach, emphasizing surgical techniques and the choice of the donor nerve. The latter considers factors like sensory integrity and proximity to the cornea. The most used are the contralateral or ipsilateral supratrochlear (STN), and the supraorbital (SON) and great auricular (GAN) nerves. Regarding the choice of grafts, the most used in the literature are the sural (SN), the lateral antebrachial cutaneous nerve (LABCN), and the GAN nerves. Another promising option is represented by allografts (acellularized nerves from cadavers). The significance of sensory recovery and factors influencing surgical outcomes, including nerve caliber matching and axonal regeneration, are discussed. Future directions emphasize less invasive techniques and the potential of acellular nerve allografts. In conclusion, CN represents a promising avenue in the treatment of NK, offering tailored approaches based on patient history and surgical expertise, with new emerging techniques warranting further exploration through basic science refinements and clinical trials

Pleomorphic Parotid Adenoma in a Child Affected with Cri du Chat Syndrome: Clinical, Cytogenetic, and Molecular Analysis

Salivary gland pleomorphic adenoma (SGPA) is the most common type of benign epithelial tumor; it is observed more commonly in females (with a female-to-male ratio of 1.43:1), and the age at diagnosis ranges between 40 and 59 years, with only 2% of cases diagnosed before age 18. Cri du Chat (CdC) is a rare syndrome caused by deletions of various sizes in the short arm of chromosome 5. Tumors in CdC patients are extremely rare: in Danish, Spanish, Australian, and Japanese groups of cases, no tumors have been reported, while a few cases have been described among 321 CdC patients collected in Italy and Germany. These cases all involve tumors that appear at a young age. We here report the case of a parotid pleomorphic adenoma in an 8-year-old boy with CdC. Exome analysis did not identify variants certainly significant for the development of SGPA. A CGH array, analyzed both in peripheral blood and tumor samples, failed to recognize anomalies previously associated with SGPA but identified a de novo duplication in 7p15.2, which contains part of a gene, SKAP2, in which the increased copy number is associated with the development of a different type of tumor such as pancreatic duct adenocarcinoma. The assumption that the duplication in 7p15.2 is relevant for the development of SGPA in our patient implies that CGH array studies must be included early in life in routine work-ups of CdC to identify CNVs with possible pathogenic roles for tumor development. This is particularly also relevant in relation to the severely impaired possibility for patients with CdC to report discomfort or pain related to tumor development. Constitutional CNVs in addition to the deletion in 5p should also be extensively studied to verify if their presence in some patients could explain why, in these cases, tumors develop at an age younger than expected