J Oral Maxillofac
Surg
‘l&855-ml.1990
Use of the Ultrasonic Surgical Aspirator in the Treatment of a Solitary Eosinophilic Granuloma of the Mandible: A Case Report JOSE LANDRITO, DMD, KAZUHIRO SAKURAI, DDS,* AND KAZUHIKO OHSHIMA, DDS, PHDt
Solitary eosinophilic granuloma is the most common benign lesion in the spectrum of diseases called histiocytosis X. The disease primarily involves children and young adults, with some predilection for males. ‘7’ It is infrequently found in the mandible or maxilla, but when it does occur it causes expansion and erosion of the cortical plate with extension into adjacent soft tissues.3 The patients’ chief complaints are frequently bone pain and swelling. Pathologic fractures are not uncommon.iY4 The lesion is easily cured by simple surgical excision and/or appropriate radiotherapy.5 The purpose of this report is to describe the use of the ultrasonic surgical aspirator in the treatment of a patient with solitary eosinophilic granuloma of the mandible.
The ultrasonic surgical aspirator (Mochida Luketron Sonotec-MIC, Model MAA-2512; Sumito Bakelite Co, Ltd, Tokyo, Japan) essentially consists of a control and power console to which the surgical handpiece is connected (Fig 1). It requires only standard operating room connections. The gassterilizable, pencil-grip handpiece (26 x 260 mm, 230 g) contains a vibrating suction device of hollow titanium oscillating longitudinally along its axis at the ultrasonic frequency of 24 kHz. This oscillation or vibration is produced by a plumbeous zirconate titanate (PZT) electrostrictive transducer. At full power (100 W), the maximal stroke of the exposed tip is 300 pm. The vibration produced is imperceptible. Cooling is provided by irrigation with a physiologic saline solution over the tip (at 20 mL/min), which also helps with aspiration of fragmented tissue. There are two types of tips, the flat cut type and the angle cut type, which are easily interchangeable. On contact with the tissue surface, the vibrating tube causes fragmentation of the tissue through the action of the vibration energy of ultrasonic waves emitted from the tip. Fragmented and emulsified tissues are aspirated through the hollow tube in the tip and removed from the surgical field. Adjustment of the fragmentation rate (tip stroke) and aspiration are controlled by the console, The maximal vacuum available is 600 mm Hg.
Description of the Apparatus The ultrasonic surgical aspirator, sometimes referred to as an “ultrasonic scalpe1,“6*7 is an instrument that allows dissection of tissues by means of fragmentation.8 This device is selective in its fragmentation and allows dissection of soft tissues away from major blood vessels and nerves without damaging them. The selectivity of the fragmentation and the safety of the dissection in the vicinity of important structures inspired us to use this device in our case. Received from the Department of Oral and Maxillofacial Surgery, Hiroshima University, School of Dentistry, Hiroshima City, Japan. * Graduate student. t Assistant. Address correspondence and reprint requests to Dr Land&o: Department of Oral and Maxillofacial Surgery 1, Hiroshima University, School of Dentistry, Kasumi 1 chome, Minami-ku, Hiroshima City, 734 Japan. 0 1990 American geons
Association
of Oral and Maxillofacial
Report of a Case On February 27, 1988, a boy aged 4 years, 8 months was referred to the Hiroshima University Dental Hospital for evaluation of pain and swelling in the left mandibular molar area. The carious deciduous mandibular left second molar, which was believed to be the source of swelling and pain, previously had been endodontically treated and antibiotics had been prescribed. Because the pain and
Sur-
swelling continued, the patient’s parents consulted another dentist who discovered a large lesion on radio-
0278-2391/90/4808-0014$3.00/O
a55
856
ULTRASONIC ASPIRATOR & EOSINOPHILIC GRANULOMA
FIGURE 1. A, Control console for ultrasonic surgical aspirator. B, Surgical handpiece.
graphic examination. The patient was then referred to our department for further evaluation and treatment. Physical examination showed a well-developed, wellnourished patient. Extraoral and intraoral examination revealed a pronounced bony expansion on the buccal aspect and lower border of the mandible, and slight expansion on the lingual aspect. No significant lymphadenopathy was noted. The oral mucosa appeared normal. There was no clinical evidence of cutaneous or visceral involvement. The patient’s past medical and socioeconomic histories were noncontributory. Light microscopic examination of a small incisional biopsy specimen led to the diagnosis of eosinophilic granuloma. On the basis of electron microscopic examination, the diagnosis was further substantiated by the finding of cells with Birbeck (Langerhan’s cell) granules. Panoramic and posteroanterior radiographs, as well as
FIGURE 2. A, Panoramic radiograph showing soapbubble-like radiolucency below the crown of the permanent mandibular left first molar. B, Posteroanterior projection demonstrates marked expansion and thinning of buccal plate. C, Computed tomography showing affected buccal and lingual plates.
857
LANDRITO, SAKURAI, AND OHSHIMA
a computed tomography (CT) scan were taken (Fig 2). In
the panoramic examination, a large soap-bubble-like radiolucency immediately below the well-developed crown of the permanent mandibular left fist molar was seen. It extended to the area of the permanent mandibular left second premolar and second molar and to the inferior border of the mandible, causing it to deform (Fig 2A). In the posteroanterior view, a marked expansion of the buccal plate was readily observed (Fig 2B). In the CT scan, it was noted that the buccal and lingual cortical plates were affected (Fig 2C). Radiographic skeletal survey disclosed no other lesions. Anterior and posterior technetium 99m methylene diphosphonate and gallium 67 citrate whole body images supported the radiographic findings. The results of the admission laboratory studies (complete blood count, serum electrolytes, BUN, glucose, aspartate aminotransferase, bilirubin) were within normal limits. On March 23, the lesion was extirpated under general anesthesia. First, the involved teeth were extracted and a portion of the overlying bone was removed to gain access to the lesion. When this was accomplished, the ultrasonic surgical aspirator was used until the neurovascular bundle was seen. Lesional tissue adjacent to the vessels was removed using the ultrasonic surgical aspirator with the flat cut-type tip (Fig 3) at a dial setting of 70% to 80% of its maximal output. Irrigation was liberal to accomplish clear visualization and to prevent excessive heating of the tip, which could produce injury to the vessels. Lesional tissue distant to the vessels was removed with the use of conventional instruments. A sufficient amount of sound bone remained after thorough removal of the lesion, making mandibular fixation or splinting unnecessary. Twelve days after the surgical operation, the area of the lesion received 200 cGy/d for 5 consecutive days (for a total dose of 1,000 cGy) using cobalt teletherapy. There were no complications encountered during or after therapy. Physical examination did not reveal any sensory deficit in the lip and chin to light touch and pinprick. Follow-up was performed at monthly intervals, with bimonthly radiographic examination. A panoramic radiograph taken 1 year postoperatively (Fig 4) showed healing of the lesion, and the inferior border of the mandible had almost returned to its normal form.
FIGURE 4. treatment.
Panoramic radiograph of the mandible 1 year after
Discussion Thirteen years have passed since the ultrasonic surgical aspirator was introduced and yet there have been only three articles in the English literature dealing with surgical procedures involving the oral cavity using this device. One article8 dealt with extirpation of a carcinoma of the floor of the mouth; another’ reported its use for hemiglossectomy as a part of a composite resection; the third article” cited its use to remove a tumor in the floor of the mouth after partial resection of the body of the mandible. To our knowledge, our report is the first to describe the use of the ultrasonic surgical aspirator in the removal of a lesion in the jawbone. The usefulness of the ultrasonic surgical aspirator to remove lesions in the vicinity of the mandibular canal without damaging major nerves and vessels was substantiated by our experience in this case. The working area at the tip provided precise control of the amount of tissue removed; therefore, major nerves and vessels were selectively left intact. Good healing was evident and no complications due to the procedure were encountered. It was evident that the ultrasonic aspiration tip can directly fragment and aspirate lesional tissue in a controlled and rapid manner. On the other hand, this device is not devoid of disadvantages. To begin with, the handpiece is very bulky and the tip is straight, making it very difficult to place with ease in many intraoral locations. Furthermore, the cost is quite high.7 Finally, this device was designed to fragment soft tissue lesions. Thus, calcified lesions are totally unaffected. Acknowledgment The authors are grateful to Professor Kazuaki Takada and Assistant Professor Koji Yoshiga of our department for their collaboration and valuable advice in treating this patient.
References FIGURE 3. sion.
The ultrasonic surgical aspirator removing the le-
1. Sbarbaro JL, Francis KC: Eosinophilic granuloma of bone. JAMA 178:706. 1961
858
HEMORRHAGE
2. Hartman KS: Histiocytosis X: A review of 114 cases with oral involvement. Oral Surg 49:38, 1980 3. Green WT, Farber S: Eosinophilic or solitary granuloma of bone. J Bone Joint Surg 24:499, 1942 4. Lieberman PH, Jones CR, Dargeon HWK, et al: A reappraisal of eosinophilic granuloma of bone, HandSchilller-Christian syndrome and Letterer-Siwe syndrome. Medicine 48:375, 1%9 5. Schajowicz F, Slullitel J: Eosinophilic granuloma of bone and its relationship to Hand-Schilller-Christian and Letterer-Siwe syndromes. J Bone Joint Surg 55B:545, 1973 6. Hodgson WJB, DelGuercio LRM: Preliminary experience in
J Oral Maxillofac 48:858-861,
AFTER BIOPSY OF A PROSTATE TUMOR
liver surgery using the ultrasonic scalpel. Surgery 95:230, 1984 7. Mowry R, Hengerer AS: The ultrasonic scalpel in head and neck surgery. Otolaryngol Head Neck Surg 90:305, 1982 8. Hodgson WJB, Poddar PK, Mencer EJ, et al: Evaluation of ultrasonically powered instruments in the laboratory and in the clinical setting. Am J Gastroenterol 72:133, 1979 9. Weitz J, Hodgson WJB, Loscalzo LJ, et al: A bloodless technique for tongue surgery. Head Neck Surg 3:244, 1981 10. Ueda M, Kaneda T, Imaizumi M, et al: Mandibular ameloblastoma with metastasis to the lungs and lymph nodes. J Oral Maxillofac Surg 47:623, 1989
Surg
1960
Significant Postoperative Hemorrhage Following Biopsy of a Prostate Tumor Metastatic to the Mandibular Condyle: Report of a Case RICHARD J. CATRAMBONE,
DMD,* AND RICHARD C. PFEFFER, DDSt
Metastatic carcinoma is the most common malignant tumor of bone. Nevertheless, metastatic disease represents less than 1% of all the tumors of the maxillofacial area. ’ The mandibular body is the preferred site of these tumors2 Prostatic carcinoma metastatic to the mandibular condyle is extremely rare: only 13 cases of metastasis to the mandibular condyle have been reported in the literature. Most recently Thatcher and Dyer3 reported a case of carcinoma of the prostate metastatic to the condyle mimicking a parotid tumor. A review of the literature did not disclose any reports of severe postoperative bleeding following excision or biopsy of these rare metastatic tumors. This article reports an unusual case of postoperative hemorrhage following an incisional biopsy of tissue which was later diagnosed as metastatic adenocarcinoma of the * Chief Resident, Oral and Maxillofacial Surgery, Tufts University School of Dental Medicine, Boston, MA. t Director, Department of Dentistry, and Section Chief, Oral and Maxillofacial Surgery, Camey Hospital, Dorchester, MA. Address correspondence and reprint-requests to Dr Catrambone: Deuartment of Oral and Maxillofacial Surnerv, Tufts University School of Dental Medicine, 1 Kneeland &,-Boston, MA 02111. 0 1990 American
Association
geons 0278-2391/90/4808-0015$3.00/O
of Oral
and Maxillofacial
Sur-
prostate, and provides an explanation orrhagic event.
for the hem-
Report of a Case In February 1987, a 78-year-old white man was referred to the senior oral surgeon’s (R.C.F.) private office by an ENT group which had been following him for a right preauricular swelling of approximately 6 weeks’ duration. The 4 x 4 cm mass was firm, nontender, and immobile except during mandibular excursions. Panoramic and computerized tomographic (CT) surveys disclosed a large, destructive lesion of the right infratemporal fossa involving the condyle and superior aspect of the ramus (Fig 1). The condyle was pathologically fractured (Fig 2). The patient had no complaints of discomfort and gave no history of trauma. He had experienced occasional sensations of paresthesia along the distribution of the third division of the trigeminal nerve on the right side. AU other cranial nerves were grossly intact. A sialogram of the right parotid was unremarkable and, clinically, salivary flow was within normal limits. The overlying skin was intact. There was no obvious limitation of opening, and the patient did not realize his mandible was fractured. Plans were made for an intraoral biopsy in the office the following day. The patient’s past medical history was remarkable for rheumatic fever as a child, a right mastoidectomy, and disease of the prostate since the early 1970s. In 1976, he underwent a transurethral prostate resection when a diagnosis of stage A prostatic adenocarcinoma was made. Follow-up treatment included a bilateral inguinal lymphadenectomy and radical resection a month later. Lymph
Surg
‘l&855-ml.1990
Use of the Ultrasonic Surgical Aspirator in the Treatment of a Solitary Eosinophilic Granuloma of the Mandible: A Case Report JOSE LANDRITO, DMD, KAZUHIRO SAKURAI, DDS,* AND KAZUHIKO OHSHIMA, DDS, PHDt
Solitary eosinophilic granuloma is the most common benign lesion in the spectrum of diseases called histiocytosis X. The disease primarily involves children and young adults, with some predilection for males. ‘7’ It is infrequently found in the mandible or maxilla, but when it does occur it causes expansion and erosion of the cortical plate with extension into adjacent soft tissues.3 The patients’ chief complaints are frequently bone pain and swelling. Pathologic fractures are not uncommon.iY4 The lesion is easily cured by simple surgical excision and/or appropriate radiotherapy.5 The purpose of this report is to describe the use of the ultrasonic surgical aspirator in the treatment of a patient with solitary eosinophilic granuloma of the mandible.
The ultrasonic surgical aspirator (Mochida Luketron Sonotec-MIC, Model MAA-2512; Sumito Bakelite Co, Ltd, Tokyo, Japan) essentially consists of a control and power console to which the surgical handpiece is connected (Fig 1). It requires only standard operating room connections. The gassterilizable, pencil-grip handpiece (26 x 260 mm, 230 g) contains a vibrating suction device of hollow titanium oscillating longitudinally along its axis at the ultrasonic frequency of 24 kHz. This oscillation or vibration is produced by a plumbeous zirconate titanate (PZT) electrostrictive transducer. At full power (100 W), the maximal stroke of the exposed tip is 300 pm. The vibration produced is imperceptible. Cooling is provided by irrigation with a physiologic saline solution over the tip (at 20 mL/min), which also helps with aspiration of fragmented tissue. There are two types of tips, the flat cut type and the angle cut type, which are easily interchangeable. On contact with the tissue surface, the vibrating tube causes fragmentation of the tissue through the action of the vibration energy of ultrasonic waves emitted from the tip. Fragmented and emulsified tissues are aspirated through the hollow tube in the tip and removed from the surgical field. Adjustment of the fragmentation rate (tip stroke) and aspiration are controlled by the console, The maximal vacuum available is 600 mm Hg.
Description of the Apparatus The ultrasonic surgical aspirator, sometimes referred to as an “ultrasonic scalpe1,“6*7 is an instrument that allows dissection of tissues by means of fragmentation.8 This device is selective in its fragmentation and allows dissection of soft tissues away from major blood vessels and nerves without damaging them. The selectivity of the fragmentation and the safety of the dissection in the vicinity of important structures inspired us to use this device in our case. Received from the Department of Oral and Maxillofacial Surgery, Hiroshima University, School of Dentistry, Hiroshima City, Japan. * Graduate student. t Assistant. Address correspondence and reprint requests to Dr Land&o: Department of Oral and Maxillofacial Surgery 1, Hiroshima University, School of Dentistry, Kasumi 1 chome, Minami-ku, Hiroshima City, 734 Japan. 0 1990 American geons
Association
of Oral and Maxillofacial
Report of a Case On February 27, 1988, a boy aged 4 years, 8 months was referred to the Hiroshima University Dental Hospital for evaluation of pain and swelling in the left mandibular molar area. The carious deciduous mandibular left second molar, which was believed to be the source of swelling and pain, previously had been endodontically treated and antibiotics had been prescribed. Because the pain and
Sur-
swelling continued, the patient’s parents consulted another dentist who discovered a large lesion on radio-
0278-2391/90/4808-0014$3.00/O
a55
856
ULTRASONIC ASPIRATOR & EOSINOPHILIC GRANULOMA
FIGURE 1. A, Control console for ultrasonic surgical aspirator. B, Surgical handpiece.
graphic examination. The patient was then referred to our department for further evaluation and treatment. Physical examination showed a well-developed, wellnourished patient. Extraoral and intraoral examination revealed a pronounced bony expansion on the buccal aspect and lower border of the mandible, and slight expansion on the lingual aspect. No significant lymphadenopathy was noted. The oral mucosa appeared normal. There was no clinical evidence of cutaneous or visceral involvement. The patient’s past medical and socioeconomic histories were noncontributory. Light microscopic examination of a small incisional biopsy specimen led to the diagnosis of eosinophilic granuloma. On the basis of electron microscopic examination, the diagnosis was further substantiated by the finding of cells with Birbeck (Langerhan’s cell) granules. Panoramic and posteroanterior radiographs, as well as
FIGURE 2. A, Panoramic radiograph showing soapbubble-like radiolucency below the crown of the permanent mandibular left first molar. B, Posteroanterior projection demonstrates marked expansion and thinning of buccal plate. C, Computed tomography showing affected buccal and lingual plates.
857
LANDRITO, SAKURAI, AND OHSHIMA
a computed tomography (CT) scan were taken (Fig 2). In
the panoramic examination, a large soap-bubble-like radiolucency immediately below the well-developed crown of the permanent mandibular left fist molar was seen. It extended to the area of the permanent mandibular left second premolar and second molar and to the inferior border of the mandible, causing it to deform (Fig 2A). In the posteroanterior view, a marked expansion of the buccal plate was readily observed (Fig 2B). In the CT scan, it was noted that the buccal and lingual cortical plates were affected (Fig 2C). Radiographic skeletal survey disclosed no other lesions. Anterior and posterior technetium 99m methylene diphosphonate and gallium 67 citrate whole body images supported the radiographic findings. The results of the admission laboratory studies (complete blood count, serum electrolytes, BUN, glucose, aspartate aminotransferase, bilirubin) were within normal limits. On March 23, the lesion was extirpated under general anesthesia. First, the involved teeth were extracted and a portion of the overlying bone was removed to gain access to the lesion. When this was accomplished, the ultrasonic surgical aspirator was used until the neurovascular bundle was seen. Lesional tissue adjacent to the vessels was removed using the ultrasonic surgical aspirator with the flat cut-type tip (Fig 3) at a dial setting of 70% to 80% of its maximal output. Irrigation was liberal to accomplish clear visualization and to prevent excessive heating of the tip, which could produce injury to the vessels. Lesional tissue distant to the vessels was removed with the use of conventional instruments. A sufficient amount of sound bone remained after thorough removal of the lesion, making mandibular fixation or splinting unnecessary. Twelve days after the surgical operation, the area of the lesion received 200 cGy/d for 5 consecutive days (for a total dose of 1,000 cGy) using cobalt teletherapy. There were no complications encountered during or after therapy. Physical examination did not reveal any sensory deficit in the lip and chin to light touch and pinprick. Follow-up was performed at monthly intervals, with bimonthly radiographic examination. A panoramic radiograph taken 1 year postoperatively (Fig 4) showed healing of the lesion, and the inferior border of the mandible had almost returned to its normal form.
FIGURE 4. treatment.
Panoramic radiograph of the mandible 1 year after
Discussion Thirteen years have passed since the ultrasonic surgical aspirator was introduced and yet there have been only three articles in the English literature dealing with surgical procedures involving the oral cavity using this device. One article8 dealt with extirpation of a carcinoma of the floor of the mouth; another’ reported its use for hemiglossectomy as a part of a composite resection; the third article” cited its use to remove a tumor in the floor of the mouth after partial resection of the body of the mandible. To our knowledge, our report is the first to describe the use of the ultrasonic surgical aspirator in the removal of a lesion in the jawbone. The usefulness of the ultrasonic surgical aspirator to remove lesions in the vicinity of the mandibular canal without damaging major nerves and vessels was substantiated by our experience in this case. The working area at the tip provided precise control of the amount of tissue removed; therefore, major nerves and vessels were selectively left intact. Good healing was evident and no complications due to the procedure were encountered. It was evident that the ultrasonic aspiration tip can directly fragment and aspirate lesional tissue in a controlled and rapid manner. On the other hand, this device is not devoid of disadvantages. To begin with, the handpiece is very bulky and the tip is straight, making it very difficult to place with ease in many intraoral locations. Furthermore, the cost is quite high.7 Finally, this device was designed to fragment soft tissue lesions. Thus, calcified lesions are totally unaffected. Acknowledgment The authors are grateful to Professor Kazuaki Takada and Assistant Professor Koji Yoshiga of our department for their collaboration and valuable advice in treating this patient.
References FIGURE 3. sion.
The ultrasonic surgical aspirator removing the le-
1. Sbarbaro JL, Francis KC: Eosinophilic granuloma of bone. JAMA 178:706. 1961
858
HEMORRHAGE
2. Hartman KS: Histiocytosis X: A review of 114 cases with oral involvement. Oral Surg 49:38, 1980 3. Green WT, Farber S: Eosinophilic or solitary granuloma of bone. J Bone Joint Surg 24:499, 1942 4. Lieberman PH, Jones CR, Dargeon HWK, et al: A reappraisal of eosinophilic granuloma of bone, HandSchilller-Christian syndrome and Letterer-Siwe syndrome. Medicine 48:375, 1%9 5. Schajowicz F, Slullitel J: Eosinophilic granuloma of bone and its relationship to Hand-Schilller-Christian and Letterer-Siwe syndromes. J Bone Joint Surg 55B:545, 1973 6. Hodgson WJB, DelGuercio LRM: Preliminary experience in
J Oral Maxillofac 48:858-861,
AFTER BIOPSY OF A PROSTATE TUMOR
liver surgery using the ultrasonic scalpel. Surgery 95:230, 1984 7. Mowry R, Hengerer AS: The ultrasonic scalpel in head and neck surgery. Otolaryngol Head Neck Surg 90:305, 1982 8. Hodgson WJB, Poddar PK, Mencer EJ, et al: Evaluation of ultrasonically powered instruments in the laboratory and in the clinical setting. Am J Gastroenterol 72:133, 1979 9. Weitz J, Hodgson WJB, Loscalzo LJ, et al: A bloodless technique for tongue surgery. Head Neck Surg 3:244, 1981 10. Ueda M, Kaneda T, Imaizumi M, et al: Mandibular ameloblastoma with metastasis to the lungs and lymph nodes. J Oral Maxillofac Surg 47:623, 1989
Surg
1960
Significant Postoperative Hemorrhage Following Biopsy of a Prostate Tumor Metastatic to the Mandibular Condyle: Report of a Case RICHARD J. CATRAMBONE,
DMD,* AND RICHARD C. PFEFFER, DDSt
Metastatic carcinoma is the most common malignant tumor of bone. Nevertheless, metastatic disease represents less than 1% of all the tumors of the maxillofacial area. ’ The mandibular body is the preferred site of these tumors2 Prostatic carcinoma metastatic to the mandibular condyle is extremely rare: only 13 cases of metastasis to the mandibular condyle have been reported in the literature. Most recently Thatcher and Dyer3 reported a case of carcinoma of the prostate metastatic to the condyle mimicking a parotid tumor. A review of the literature did not disclose any reports of severe postoperative bleeding following excision or biopsy of these rare metastatic tumors. This article reports an unusual case of postoperative hemorrhage following an incisional biopsy of tissue which was later diagnosed as metastatic adenocarcinoma of the * Chief Resident, Oral and Maxillofacial Surgery, Tufts University School of Dental Medicine, Boston, MA. t Director, Department of Dentistry, and Section Chief, Oral and Maxillofacial Surgery, Camey Hospital, Dorchester, MA. Address correspondence and reprint-requests to Dr Catrambone: Deuartment of Oral and Maxillofacial Surnerv, Tufts University School of Dental Medicine, 1 Kneeland &,-Boston, MA 02111. 0 1990 American
Association
geons 0278-2391/90/4808-0015$3.00/O
of Oral
and Maxillofacial
Sur-
prostate, and provides an explanation orrhagic event.
for the hem-
Report of a Case In February 1987, a 78-year-old white man was referred to the senior oral surgeon’s (R.C.F.) private office by an ENT group which had been following him for a right preauricular swelling of approximately 6 weeks’ duration. The 4 x 4 cm mass was firm, nontender, and immobile except during mandibular excursions. Panoramic and computerized tomographic (CT) surveys disclosed a large, destructive lesion of the right infratemporal fossa involving the condyle and superior aspect of the ramus (Fig 1). The condyle was pathologically fractured (Fig 2). The patient had no complaints of discomfort and gave no history of trauma. He had experienced occasional sensations of paresthesia along the distribution of the third division of the trigeminal nerve on the right side. AU other cranial nerves were grossly intact. A sialogram of the right parotid was unremarkable and, clinically, salivary flow was within normal limits. The overlying skin was intact. There was no obvious limitation of opening, and the patient did not realize his mandible was fractured. Plans were made for an intraoral biopsy in the office the following day. The patient’s past medical history was remarkable for rheumatic fever as a child, a right mastoidectomy, and disease of the prostate since the early 1970s. In 1976, he underwent a transurethral prostate resection when a diagnosis of stage A prostatic adenocarcinoma was made. Follow-up treatment included a bilateral inguinal lymphadenectomy and radical resection a month later. Lymph
