Sphenopalatine Ganglion Stimulation to Augment Cerebral Blood Flow

Background and Purpose—

Many patients with acute ischemic stroke are not eligible for thrombolysis or mechanical reperfusion therapies due to contraindications, inaccessible vascular occlusions, late presentation, or large infarct core. Sphenopalatine ganglion (SPG) stimulation to enhance collateral flow and stabilize the blood-brain barrier offers an alternative, potentially more widely deliverable, therapy.

Methods—

In a randomized, sham-controlled, double-masked trial at 41 centers in 7 countries, patients with anterior circulation ischemic stroke not treated with reperfusion therapies within 24 hours of onset were randomly allocated to active SPG stimulation or sham control. The primary efficacy outcome was improvement beyond expectations on the modified Rankin Scale of global disability at 90 days (sliding dichotomy), assessed in the modified intention-to-treat population. The initial planned sample size was 660 patients, but the trial was stopped early when technical improvements in device placement occurred, so that analysis of accumulated experience could be conducted to inform a successor trial.

Results—

Among 303 enrolled patients, 253 received at least one active SPG or sham stimulation, constituting the modified intention-to-treat population (153 SPG stimulation and 100 sham control). Age was median 73 years (interquartile range, 64–79), 52.6% were female, deficit severity on the National Institutes of Health Stroke Scale was median 11 (interquartile range, 9–15), and time from last known well median 18.6 hours (interquartile range, 14.5–22.5). For the primary outcome, improved 3-month disability beyond expectations, rates in the SPG versus sham treatment groups were 49.7% versus 40.0%; odds ratio, 1.48 (95% CI, 0.89–2.47); P =0.13. A significant treatment interaction with stroke location (cortical versus noncortical) was noted, P =0.04. In the 87 patients with confirmed cortical involvement, rates of improvement beyond expectations were 50.0% versus 27.0%; odds ratio, 2.70 (95% CI, 1.08–6.73); P =0.03. Similar response patterns were observed for all prespecified secondary efficacy outcomes. No differences in mortality or serious adverse event safety end points were observed.

Conclusions—

SPG stimulation within 24 hours of onset is safe in acute ischemic stroke. SPG stimulation was not shown to statistically significantly improve 3-month disability above expectations, though favorable outcomes were nominally higher with SPG stimulation. Beneficial effects may distinctively be conferred in patients with confirmed cortical involvement. The results of this study need to be confirmed in a larger pivotal study.

Clinical Trial Registration—

URL: https://www.clinicaltrials.gov . Unique identifier: NCT03767192.

Ex corpore linguae: A cohort analysis after a unique surgical technique in oral cancer resection

OBJECTIVE

Resection of posteriorly located oral squamous cell carcinomas (OSCCs) remains challenging for head and neck surgeons. However, several surgical techniques, such as lip and mandibular splitting, as well as submental "visor drop-down" of intraoral soft tissues, have been proposed for this purpose. Merrick et al. suggested that a pedicled genial drop-down surgical approach should be used to resect dorsally located OSCCs. Our study investigated patient outcomes following this surgical procedure, as no previous study has analyzed long-term follow-up data.

MATERIAL AND METHODS

All patients who underwent surgery using the pedicled genial "visor drop-down" approach at the Maxillofacial Department of the University Hospital Giessen in Germany between 1995 and 2010 were included in this study. In addition, our study required that patients diagnosed with OSCC had no history of other intraoral malignancy or any other form of malignancy. A preliminary questionnaire was completed for each patient based on retrospective analysis of available data from medical reports.

RESULTS

A total of 51 patients fulfilled all inclusion and exclusion criteria and were evaluated retrospectively. In total, 32 patients were excluded from the study due to OSCC recurrence or acquisition of a different type of malignancy. The male to female distribution of patients in our study was 30 to 21 (58.8%-41.2%), and the mean ages of female and male patients were 57.7 (SD 14.3) and 55.7 (SD 14.4) years, respectively. Approximately 76.5% of tumors were located along the dorsal aspect of the tongue, 17.6% were along the floor of the mouth, 3.9% were in the dorsal mandibular region, and 1.9% were in the dorsal palatal region. The mean overall operation time was 6.25 h, and 28 patients received microvascular flaps for reconstruction. Results of final histopathological examination suggested primary in-sano resection of the tumor in 84.3% of patients. Overall, the 5-year postoperative survival rate was 52.9%; 31.3% of the patient cohort was not followed up for the full 5-year period. In addition, 15.7% of the patients included in our study died during the study period. Unimpaired functional outcomes in terms of swallowing and speech were observed in 86.3% of patients.

CONCLUSION

The pedicled genial "visor drop-down" approach, also known as the ex corpore linguae, is a suitable method for the radical resection of dorsally located OSCCs, with a promising 5-year survival rate and satisfactory postoperative oral function.

Replantation of a displaced incisor in a boy with a cleft lip and alveolus: a case report

BACKGROUND

Tooth replantation after traumatic avulsion or transplantation is a challenge in oral surgery. A special method named auto-alloplastic replantation, in which a titanium post is used after extraoral endodontic treatment, combines several advantages. The treatment is performed in one step with no further endodontic intervention, no wide root canal instrumentation, no recontamination, and reduced endodontic infection. This is the first report on replantation of an ectopic tooth in a patient with a cleft lip and alveolus using this method.

CASE PRESENTATION

This case report presents the treatment of a 13-year-old white boy with a cleft lip and alveolus who had an ectopic incisor in the cleft region. His rehabilitation was performed by a tooth transposition using the auto-alloplastic replantation technique. After preparation of the displaced incisor from the vestibule, extraoral endodontic treatment followed using a titanium post prior to replantation in a newly formed socket. In the follow-up, the tooth is still in place and functioning after 2 years.

CONCLUSIONS

This method can be used to bridge the years while a patient is young and jaw growth is incomplete until bone augmentation and implantation can be performed. The tooth will preserve the remaining alveolar ridge and help the adolescent psychologically.

Comparison of miniplate versus lag-screw osteosynthesis for fractures of the mandibular angle

OBJECTIVES

Treating mandibular angle fractures is common in maxillofacial surgery. The aim of this study was to compare lag screw fixation and miniplates.

STUDY DESIGN

This retrospective investigation compared patients treated with miniplates (n = 24) and with lag screws (n = 21). Inclusion criteria were a solitary angle fracture without comminution or other reasons for load-bearing osteosynthesis. The main parameters for the outcome analysis were fracture gaps at 4 defined measuring points on postoperative radiography. Postsurgical complications were recorded.

RESULTS

Fracture gaps measured in panoramic radiographs differed significantly between the lag-screw (average 0.56 mm) group and the group using 1 miniplate (average 0.85 mm) and 2 miniplates (1.40 mm). Miniplate fixation resulted in a wider fracture gap, especially in the region of the lower margin of the mandible.

CONCLUSION

Lag-screw fixation demonstrated smaller fracture gaps compared with miniplate fixation.