Letters to Editor
obstruction in patients of liver abscess. The clinical picture depends on whether the compression is complete or incomplete. Patients having complete obstruction have a fulminant course with high mortality. In the present case, the course was not fulminant due to incomplete obstruction. However, our patient presented with shock that resulted from decreased preload (venous return) due to IVC obstruction due to large liver abscess. This is further evident by the fact that his blood pressure improved following drainage of the abscess resulting in increased venous return. Children with liver abscess are more prone to develop this complication as they have a relatively small liver tissue mass thus putting the IVC at a greater risk of being compressed by a large abscess. The location of the abscess on USG appears to be more important than its volume or size as a large abscess in the vicinity of IVC is more likely to compress it than the one away from it.[2] Diagnosis can be confirmed with Doppler (sensitivity of 85-95%[3]) by demonstrating the reduced IVC/hepatic vein caliber and flow. Since this condition is associated with a high mortality,[4] early intervention is mandatory and can be life saving. Percutaneous aspiration under USG guidance should be carried out complemented with broad spectrum antibiotic therapy. Open surgical drainage, as in this case, is indicated in the event of failure of percutaneous aspiration due to organized pus or inaccessibility, multiple abscess cavities, and ascites due to intraperitoneal rupture.[5] Recognizing
IVC obstruction as a cause of shock in patients with liver abscess is essential for effective management of this potentially life threatening condition. Debajyoti Mohanty, Pankaj Kumar Garg, Bhupendra Kumar Jain, Shuchi Bhatt1
Departments of Surgery, 1Radiology, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi ‑ 110 095, India E‑mail: [email protected]
REFERENCES 1. Schmid BD, Lalyre Y, Sigel B, Kiani R, Layden TJ. Inferior vena cava obstruction complicating amebic liver abscess. Dig Dis Sci 1982;27:565‑9. 2. Sharma MP, Sarin SK. Inferior vena caval obstruction due to amoebic liver abscess. J Assoc Phys India 1982;30:243‑4. 3. Valla DC. Hepatic vein thrombosis (Budd Chiari syndrome). Semin Liver Dis 2002;22:5‑14. 4. Zeitoun G, Escolano S, Hadengue A, Azar N, El Younsi M, Mallet A, et al. Outcome of Budd Chiari syndrome: A multivariate analysis of factors related to survival including surgical portosystemic shunting. Hepatology 1999;30:84‑9. 5. Strong RW. Pyogenic liver abscess. In: Blumgart LH, editor. Surgery of the liver, biliary tract and pancreas. Philadelphia: Saunders Elsevier; 2007. p. 927‑34. Access this article online Quick Response Code:
Website: www.jstcr.org
DOI: 10.4103/2006-8808.118635
Bimaxillary and Bilateral Dentigerous Cysts: A Rare and First Reported Case
T
he article ‘Bimaxillary and Bilateral Dentigerous Cysts ‑ A Rare and First Reported Case’[1] allows us, to reinforce the need for a systematic approach to clinical investigations.Without such an approach, the diagnosis of rare conditions may well remain undiscovered. The authors report a full clinical investigation that corresponds exactly to that required where buccal (or lingually) placed swellings are found; the unusualness being in the antero‑posterior extent of those swellings. The absence of syndromic clinical findings will restrict any tentative diagnosis. The second stage of investigation will normally be radiographic to allow the localisation of oral hard or soft tissue pathology. The initial radiographic investigation normally requires the use of two‑dimensional (2D)
radiographs. As a result, such radiographs can be referred to as a clinician’s main diagnostic aid.[2] In the context of this article, a main clinical indication for periapical and/or panoramic radiography includes assessment of the presence, and positionof unerupted teeth and of root and bone morphology prior and subsequent to extraction.[3] The panoramic radiograph comes into its own, in the realm of oral surgery diagnosis, allowing a full pictorial radiographic overview of the maxillae, although only 2‑dimensional. Such an aid will allow the justification of further 3D imaging:[4] The magnitude of the lesions certainly justifies the use of 3D imaging. The authors applied CT imagery, as their cross‑sectional imagery ‘of choice’. Today, it is questionable whether this should be the case ‑ the prime choice is suggested to be that of CBCT.[5] However, this
Journal of Surgical Technique and Case Report | Jan-Jun 2013 | Vol-5 | Issue-1
61
Letters to Editor
application will be dependant on the corresponding costs of change. Having established a radiographic diagnosis of the presence of dentigerous cysts, the authors established its validity via the histopathological examination of the obtained aspirates. Since it is reported that ameloblastomas[6] and squamous cell carcinomas[7] have occurred in the lining of dentigerous cysts, a histopathological examination is mandatory to eliminate these and other possible lesions in the locations. Further, since other malignant lesions can mimic the imaging appearances of dentigerous cysts,[8] it must be reinforced that a histological examination is carried out.[9] The treatment of choice for the dentigerous cyst is enucleation[10,11] along with the extraction of the impacted teeth.[9] However, the potential for proliferation of lining residue remains. Therefore, long‑term post‑operative follow‑up must be advocated. The authors show once again that the use of 2D panoramic imaging is the ‘modality of choice’, due to its ease of use and availability. However, in the aid of advancement of techniques, what is missing here is the lack of application of other, now accepted, adjunctive surgical techniques that bring traditional oral surgery techniques into the modern arena. These are extreme surgical defects left following such enucleations and extractions. The potential for intra‑wound healing infection and subsequent morphological anatomical anomalies is high, regardless of the surgical techniques employed. Today, some regard to the application of allografts or xenografts to the enormous wounds needs to be expressed in modern day oral surgery. Wound reduction decreases the potential for post‑operative infection and aids in the more rapid attainment of natural anatomical morphology.[9]
62
Shane J. J. McCrea
The Dental Implant and Gingival‑plastic Surgery Centre, Bournemouth, Dorset, UK. E‑mail: [email protected]
REFERENCES 1. 2. 3. 4. 5.
6. 7. 8. 9.
10. 11.
Aher V, Prasant MV, RajKumar GC, Mukaram F. Dentigerous Cyst in Four Quadrants‑A rare and First Reported Case. J Surg Tech Case Report 2013;5 [in press]. Whaites E. Essentials of dental radiography and radiology. 3rd ed. London: Churchill Livingstone; 2002. McCrea SJ. Commentary. J Cranio Max Dis 2012;1:57‑8. Horner K, Pendlebury ME. Selection criteria for dental radiography. 2nd ed. England, London: Faculty of General Dental Practitioners, Royal College of Surgeons; 2004. Loubele M, Bogaerts R, VanDijck E, Pauwels R, Vanheusden S, Suetens P, et al. Comparison between effective dose of CBCT and MSCT scanners for dentomaxillofacial applications. Eur J Radiol 2009;71:461‑8. Houston GD. Oral Pathology. Ameloblastoma arising in a dentigerous cyst. J Okla Dent Assoc 2007;98:28‑9. Maxvmiw WG, Wood RE. Carcinoma arising in a dentigerous cyst: A case report and review of the literature. J Oral Maxillofac Surg 1991;49:639‑43. Elo JA, Slater LJ, Herford AS, Tanaka WK, King BJ, Moretta CM. Squamous cell carcinoma radiographically resembling a dentigerous cyst: Report of a case. J Oral Maxillofac Surg 2007;65:2559‑62. McCrea S. Adjacent dentigerous cysts with the ectopic displacement of a third mandibular molar and supernumerary (forth) molar: A rare occurrence. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107: e15‑20. Damante JH, Guerra EN da S, Ferreira O Jr. Spontaneous resolution of simple bone cysts. Dentomaxillofac Radiol 2002;31:182‑6. Chiapasco M, Rossi A, Motta JJ, Crescentini M. Spontaneous bone regeneration after enucleation of large mandibular cysts: A radiographic computed analysis of 27 consecutive cases. J Oral Maxillofac Surg 2000;58:942‑8. Access this article online Quick Response Code:
Website: www.jstcr.org
DOI: 10.4103/2006-8808.118636
Journal of Surgical Technique and Case Report | Jan-Jun 2013 | Vol-5 | Issue-1
Copyright of Journal of Surgical Technique & Case Report is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
obstruction in patients of liver abscess. The clinical picture depends on whether the compression is complete or incomplete. Patients having complete obstruction have a fulminant course with high mortality. In the present case, the course was not fulminant due to incomplete obstruction. However, our patient presented with shock that resulted from decreased preload (venous return) due to IVC obstruction due to large liver abscess. This is further evident by the fact that his blood pressure improved following drainage of the abscess resulting in increased venous return. Children with liver abscess are more prone to develop this complication as they have a relatively small liver tissue mass thus putting the IVC at a greater risk of being compressed by a large abscess. The location of the abscess on USG appears to be more important than its volume or size as a large abscess in the vicinity of IVC is more likely to compress it than the one away from it.[2] Diagnosis can be confirmed with Doppler (sensitivity of 85-95%[3]) by demonstrating the reduced IVC/hepatic vein caliber and flow. Since this condition is associated with a high mortality,[4] early intervention is mandatory and can be life saving. Percutaneous aspiration under USG guidance should be carried out complemented with broad spectrum antibiotic therapy. Open surgical drainage, as in this case, is indicated in the event of failure of percutaneous aspiration due to organized pus or inaccessibility, multiple abscess cavities, and ascites due to intraperitoneal rupture.[5] Recognizing
IVC obstruction as a cause of shock in patients with liver abscess is essential for effective management of this potentially life threatening condition. Debajyoti Mohanty, Pankaj Kumar Garg, Bhupendra Kumar Jain, Shuchi Bhatt1
Departments of Surgery, 1Radiology, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi ‑ 110 095, India E‑mail: [email protected]
REFERENCES 1. Schmid BD, Lalyre Y, Sigel B, Kiani R, Layden TJ. Inferior vena cava obstruction complicating amebic liver abscess. Dig Dis Sci 1982;27:565‑9. 2. Sharma MP, Sarin SK. Inferior vena caval obstruction due to amoebic liver abscess. J Assoc Phys India 1982;30:243‑4. 3. Valla DC. Hepatic vein thrombosis (Budd Chiari syndrome). Semin Liver Dis 2002;22:5‑14. 4. Zeitoun G, Escolano S, Hadengue A, Azar N, El Younsi M, Mallet A, et al. Outcome of Budd Chiari syndrome: A multivariate analysis of factors related to survival including surgical portosystemic shunting. Hepatology 1999;30:84‑9. 5. Strong RW. Pyogenic liver abscess. In: Blumgart LH, editor. Surgery of the liver, biliary tract and pancreas. Philadelphia: Saunders Elsevier; 2007. p. 927‑34. Access this article online Quick Response Code:
Website: www.jstcr.org
DOI: 10.4103/2006-8808.118635
Bimaxillary and Bilateral Dentigerous Cysts: A Rare and First Reported Case
T
he article ‘Bimaxillary and Bilateral Dentigerous Cysts ‑ A Rare and First Reported Case’[1] allows us, to reinforce the need for a systematic approach to clinical investigations.Without such an approach, the diagnosis of rare conditions may well remain undiscovered. The authors report a full clinical investigation that corresponds exactly to that required where buccal (or lingually) placed swellings are found; the unusualness being in the antero‑posterior extent of those swellings. The absence of syndromic clinical findings will restrict any tentative diagnosis. The second stage of investigation will normally be radiographic to allow the localisation of oral hard or soft tissue pathology. The initial radiographic investigation normally requires the use of two‑dimensional (2D)
radiographs. As a result, such radiographs can be referred to as a clinician’s main diagnostic aid.[2] In the context of this article, a main clinical indication for periapical and/or panoramic radiography includes assessment of the presence, and positionof unerupted teeth and of root and bone morphology prior and subsequent to extraction.[3] The panoramic radiograph comes into its own, in the realm of oral surgery diagnosis, allowing a full pictorial radiographic overview of the maxillae, although only 2‑dimensional. Such an aid will allow the justification of further 3D imaging:[4] The magnitude of the lesions certainly justifies the use of 3D imaging. The authors applied CT imagery, as their cross‑sectional imagery ‘of choice’. Today, it is questionable whether this should be the case ‑ the prime choice is suggested to be that of CBCT.[5] However, this
Journal of Surgical Technique and Case Report | Jan-Jun 2013 | Vol-5 | Issue-1
61
Letters to Editor
application will be dependant on the corresponding costs of change. Having established a radiographic diagnosis of the presence of dentigerous cysts, the authors established its validity via the histopathological examination of the obtained aspirates. Since it is reported that ameloblastomas[6] and squamous cell carcinomas[7] have occurred in the lining of dentigerous cysts, a histopathological examination is mandatory to eliminate these and other possible lesions in the locations. Further, since other malignant lesions can mimic the imaging appearances of dentigerous cysts,[8] it must be reinforced that a histological examination is carried out.[9] The treatment of choice for the dentigerous cyst is enucleation[10,11] along with the extraction of the impacted teeth.[9] However, the potential for proliferation of lining residue remains. Therefore, long‑term post‑operative follow‑up must be advocated. The authors show once again that the use of 2D panoramic imaging is the ‘modality of choice’, due to its ease of use and availability. However, in the aid of advancement of techniques, what is missing here is the lack of application of other, now accepted, adjunctive surgical techniques that bring traditional oral surgery techniques into the modern arena. These are extreme surgical defects left following such enucleations and extractions. The potential for intra‑wound healing infection and subsequent morphological anatomical anomalies is high, regardless of the surgical techniques employed. Today, some regard to the application of allografts or xenografts to the enormous wounds needs to be expressed in modern day oral surgery. Wound reduction decreases the potential for post‑operative infection and aids in the more rapid attainment of natural anatomical morphology.[9]
62
Shane J. J. McCrea
The Dental Implant and Gingival‑plastic Surgery Centre, Bournemouth, Dorset, UK. E‑mail: [email protected]
REFERENCES 1. 2. 3. 4. 5.
6. 7. 8. 9.
10. 11.
Aher V, Prasant MV, RajKumar GC, Mukaram F. Dentigerous Cyst in Four Quadrants‑A rare and First Reported Case. J Surg Tech Case Report 2013;5 [in press]. Whaites E. Essentials of dental radiography and radiology. 3rd ed. London: Churchill Livingstone; 2002. McCrea SJ. Commentary. J Cranio Max Dis 2012;1:57‑8. Horner K, Pendlebury ME. Selection criteria for dental radiography. 2nd ed. England, London: Faculty of General Dental Practitioners, Royal College of Surgeons; 2004. Loubele M, Bogaerts R, VanDijck E, Pauwels R, Vanheusden S, Suetens P, et al. Comparison between effective dose of CBCT and MSCT scanners for dentomaxillofacial applications. Eur J Radiol 2009;71:461‑8. Houston GD. Oral Pathology. Ameloblastoma arising in a dentigerous cyst. J Okla Dent Assoc 2007;98:28‑9. Maxvmiw WG, Wood RE. Carcinoma arising in a dentigerous cyst: A case report and review of the literature. J Oral Maxillofac Surg 1991;49:639‑43. Elo JA, Slater LJ, Herford AS, Tanaka WK, King BJ, Moretta CM. Squamous cell carcinoma radiographically resembling a dentigerous cyst: Report of a case. J Oral Maxillofac Surg 2007;65:2559‑62. McCrea S. Adjacent dentigerous cysts with the ectopic displacement of a third mandibular molar and supernumerary (forth) molar: A rare occurrence. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107: e15‑20. Damante JH, Guerra EN da S, Ferreira O Jr. Spontaneous resolution of simple bone cysts. Dentomaxillofac Radiol 2002;31:182‑6. Chiapasco M, Rossi A, Motta JJ, Crescentini M. Spontaneous bone regeneration after enucleation of large mandibular cysts: A radiographic computed analysis of 27 consecutive cases. J Oral Maxillofac Surg 2000;58:942‑8. Access this article online Quick Response Code:
Website: www.jstcr.org
DOI: 10.4103/2006-8808.118636
Journal of Surgical Technique and Case Report | Jan-Jun 2013 | Vol-5 | Issue-1
Copyright of Journal of Surgical Technique & Case Report is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
