British Journal of Oral and Maxillofacial Surgery - Articles in Press

Supraclavicular metastases from distant primaries: what is the role of the head and neck surgeon? - Corrected Proof

Tom Aldridge, Atul Kusanale, Serryth Colbert, Peter A. Brennan — 2012-05-16

Abstract: Suspicious malignant supraclavicular lymphadenopathy provides a challenge for diagnosis and treatment. The wide variety of primary tumours that metastasise to this region should alert the clinician to look beyond the head and neck, particularly if it is the only site in the neck with suspected disease. As metastatic spread to these nodes from primaries not in the head and neck often indicates wide spread disease, neck dissection is controversial. In this article we review the lymphatic anatomy and discuss the investigation of supraclavicular lymphadenopathy. We discuss the evidence for the management of the neck in patients with subclavicular primary cancers (excluding lymphoma and melanoma) and the role of neck dissection.

The surgical management of severe macroglossia in systemic AL amyloidosis - Corrected Proof

2012-05-16

Abstract: Amyloidosis is a disease characterised by the deposition in body tissues of amyloid: abnormal protein in a beta pleated sheet formation. It is a systemic disorder and macroglossia may be seen in all forms. Changes to the normal architecture of the tissues and systemic features of the disease and its underlying cause can complicate the surgical management of the enlarged tongue.

First report of elective selective neck dissection in the management of squamous cell carcinoma of the maxillary sinus - Corrected Proof

2012-05-14

Abstract: Controversy remains about management of the neck in squamous cell carcinoma (SCC) of the maxillary sinus and we know of no reports of the use of elective selective neck dissection for management in this site. We retrospectively reviewed 18 consecutive patients with SCC of the maxillary sinus who were managed by primary operation with curative intent. A total of 13 patients had an elective selective neck dissection, which was invaded in one case 8%. Four patients had regional metastases, two with positive nodal disease confirmed after elective selective neck dissection, and two who developed regional recurrence (both after elective selective neck dissections which were negative (pN0)). A review of other published articles in the English language showed no cases of elective selective neck dissections reported. The mean regional recurrence rate was 12% (range 0–26%) and total mean regional metastases rate 21% (range 5–36%). Elective selective neck dissection did not contribute to an improved rate of neck control with regional recurrence of 11% (2/18) compared with 12% in the review. There is no evidence in this report to indicate that elective selective neck dissections for maxillary sinus SCC will result in better disease control. Future research may indicate fewer radiotherapy fields for necks with pathologically clear nodes after elective selective neck dissection.

Simultaneous custom-made replacement of the temporomandibular joint and cranioplasty - Corrected Proof

S. Kirchheimer, S. Sainuddin, S. Bojanic, N.R. Saeed — 2012-05-14

Abstract: A 23-year-old man presented with a history of fibrous ankylosis of the left temporomandibular joint (TMJ), scarring and shortening of the left temporalis muscle secondary to transection, and surgically-induced neuropathic pain after previous decompression of the temporal bone. There was evident hollowing of the left temporal fossa, and mouth opening was limited to 5mm. The aims of the operation were to treat the ankylosis, improve cosmesis, and reduce his medication. His left TMJ was reconstructed with a custom-made alloplastic joint, and a simultaneous custom-made cranioplasty. At follow-up after 2 years he was free of pain and taking no drugs. He had no obvious cranial deformity, and his mouth opening had increased to 35mm. To our knowledge this is the first reported case of simultaneous custom-made cranioplasty and reconstruction of the TMJ.

Use of a dial tension gauge to assess quantitatively the intraoperative improvement of ocular movement after endoscopic transantral repair of fracture of the orbital floor - Corrected Proof

Toshinori Iwai, Kazunori Yasumura, Taro Mikami, Jiro Maegawa — 2012-05-14

Fractures of the orbital floor are common midfacial fractures. Although conventional approaches such as the subciliary or transconjunctival approach are usually used for such fractures, the endoscopic transantral approach is safe and reliable in suitably selected patients and has recently been used as minimally invasive treatment.

Swallowing of tonsillar pack in recovery following general anaesthesia - Corrected Proof

P. Dhanrajani — 2012-05-14

Abstract: A patient swallowed a tonsillar pack in the recovery room after a procedure under general anaesthesia. This is a first reported case to our knowledge. We describe the incident to try to avoid it happening again.

Spontaneous mandibular regeneration: another option for mandibular reconstruction in children? - Corrected Proof

Praveen Sharma, Rhodri Williams, Andrew Monaghan — 2012-05-11

Abstract: Treatment for conditions of the mandible may require resection of the affected segment, and this may need reconstruction. There are case reports of spontaneous regeneration of segments of excised mandibles that resulted in reduced or no need for reconstruction, and we present four such cases. The age at presentation ranged from 6 to 12 years. In all cases the periosteum was preserved during resection. All patients showed evidence of spontaneous regeneration, both clinically and radiographically, between 3 and 5 months after resection. The planned delayed reconstruction meant that these patients either did not need any bony reconstruction, or needed less than had originally been anticipated. Such regeneration is mostly reported in children, and is thought to be the result of an intact periosteal layer. In patients having planned mandibular resections, where the periosteum is preserved, some spontaneous regeneration should be anticipated and final reconstruction delayed until this is complete.

Improving DAHNO data collection using a uniform modelling tool for patient care pathways - Corrected Proof

2012-05-09

The DAHNO (data for head and neck oncology) project has provided a continuous electronic comparative audit of the management of head and neck cancer since its introduction in 2004. Anonymised data on patients are collected and analysed, which allows outcomes to be assessed nationally, and provides a tool for improving standards of care. All NHS trusts that treat head and neck cancer in England and Wales have agreed to submit their information.

Chromosomal aberrations in adenomatoid hyperplasia of palatal minor salivary gland - Corrected Proof

Esther Manor, Igor Sinelnikov, Peter A. Brennan, Lipa Bodner — 2012-05-09

Abstract: Adenomatoid hyperplasia of minor salivary glands is rare, idiopathic, and benign, and typically presents as a tumour-like mass in the hard or soft palate. Its exact nature is not clear and histological examination usually shows an excess of normal-appearing minor salivary glands. To our knowledge, cytogenetic analysis of it in a minor salivary gland of the palate has not previously been reported. We present the cytogenetic analysis of adenomatoid hyperplasia in the hard palate of a 52-year-old woman.

Long-term results of maxillomandibular advancement surgery in patients with obstructive sleep apnoea syndrome - Corrected Proof

G.W. Jaspers, A. Booij, J. de Graaf, J. de Lange — 2012-05-07

Abstract: This article describes the eight-year follow-up results of maxillomandibular advancement (MMA) in a cohort of patients with obstructive sleep apnea syndrome (OSAS). Results are promising by means of Apnoea Hypopnoea Index (AHI) and Epworth Sleepiness Scale (ESS).

Magnetic resonance imaging assessment of temporomandibular joint soft tissue injuries of intracapsular condylar fracture - Corrected Proof

2012-05-07

Abstract: We evaluated the soft tissue of the temporomandibular joint (TMJ) with magnetic resonance imaging (MRI) after intracapsular condylar fracture. Eighteen consecutive patients (19 TMJ) were diagnosed between 1 January 2010 and 30 October 2011. They were examined using bilateral sagittal and coronal MRI, which were obtained immediately after injury to assess the displacement of the disc, whether there was a tear in capsule or the retrodiscal tissue, and whether there was an effusion in the joint. On the affected side MRI showed disc displacement in 15 of 19, tears in the capsule in 9, and tears in the retrodiscal tissue in 16. All 19 had joint effusions. It also showed 2 joints with abnormalities on the unaffected side. We conclude that MRI is useful for diagnosis and for estimating the amount of damage to the TMJ, and is helpful in planning treatment.

Exploiting the perforator concept to minimise donor site morbidity in harvesting the radial forearm free flap - Corrected Proof

Marc-James Hallam, David A. Butt, Marc D. Pacifico, Darryl M. Coombes — 2012-05-07

The radial forearm free flap (RFF) is a highly versatile and reliable workhorse flap but its harvest often leaves a significant donor site requiring soft tissue coverage. Most often this is achieved through the use of a skin graft, which aside from being unaesthetic has been reported to fail (full or partial) due to the poor “take” observed over the exposed flexor carpi radialis tendon. Even if the skin graft does not fail it may still cause adhesions with the underlying musculo-tendinous structures. We describe the use of a propeller flap based on an ulnar artery perforating vessel to avoid these problems.

Yolk sac tumour involving floor of mouth: case report - Corrected Proof

Q. Zhang, Y. Huang, C.Y. Bao, L.J. Li — 2012-05-07

Abstract: Yolk sac tumour is a rare malignant tumour of germ cell origin that usually arises from the gonads. It is extremely rare in the head and neck. We present a case of a yolk sac tumour that involved the floor of the mouth in a 14-month-old Chinese girl. The diagnosis was confirmed by histological examination that showed characteristic Schiller–Duval bodies, and immunohistochemical examination that showed α-fetoprotein being expressed within the cytoplasm of the neoplastic cells. The patient died 4 months postoperatively. To our knowledge, this is the first case of a yolk sac tumour of the floor of mouth that has been reported in an English journal.

Simple way of fixing a Gunning-type splint to the bone using intermaxillary fixation screws: technical note - Corrected Proof

Vilas Newaskar, Deepak Agrawal, Faisal Idrees, Poornima Patel — 2012-05-07

Undisplaced or minimally displaced fractures of the mandible in elderly patients are usually treated by closed reduction. Gunning-type splints or the patient's old dentures are commonly used to achieve intraoral reduction of fractured bony fragments. Skeletal wiring is usually used to fix these splints to the bone. However, this carries the risk of injury to the facial artery, the lingual nerve, the submandibular duct, and other vital structures. We describe a simple technique for fixing these splints to bone with the help of intermaxillary (IMF) screws.

Safe method of extraction to prevent a deeply-impacted maxillary third molar being displaced into the maxillary sinus - Corrected Proof

Toshinori Iwai, Hiroshi Chikumaru, Maiko Shibasaki, Tohnai Iwai — 2012-05-07

Removal of impacted maxillary third molars is a common operation, usually for orthodontic indications. Displacement of the molar into the maxillary sinus or infratemporal fossa is a rare complication. However, there is the possibility of accidental displacement when the third molar is deeply impacted, particularly if its roots are not developed and it lies along the maxillary sinus, or if its roots are developed but it is close to or in the maxillary sinus. We report a safe method of extraction to prevent its displacement into the maxillary sinus.

Extended nasolabial flap compared with the platysma myocutaneous muscle flap for reconstruction of intraoral defects after release of oral submucous fibrosis: a comparative study - Corrected Proof

Chandrashekhar R. Bande, Abhay Datarkar, Neeraj Khare — 2012-05-03

Abstract: We compared extended nasolabial flaps and coronoidectomy with platysma myocutaneous muscle flaps in the management of 20 randomly selected patients with histologically confirmed oral submucous fibrosis. Ten patients were treated by release of fibrous bands, bilateral coronoidectomy, and reconstruction with an extended nasolabial flap (nasolabial group), and the other 10 by bilateral release of fibrous bands, coronoidectomy, and reconstruction with a platysma myocutaneous muscle flap (platysma group). In the nasolabial group the mean preoperative interincisal mouth opening was 12(range 3–14)mm, and in the platysma group it was 11 (3–13). All 20 patients were given vigorous postoperative physiotherapy, and were followed up for 3 years. The interincisal mouth opening improved to 47(35–45)mm in the nasolabial group and 48(41–52)mm in the platysma group. The procedures were equally effective in the management of the oral submucous fibrosis, except that the extraoral scar was not aesthetically acceptable in the nasolabial group.

Lingual cyst lined by respiratory and gastric epithelium in a neonate - Corrected Proof

Rajnish Joshi, Alistair R.M. Cobb, Philip Wilson, B.M.W. Bailey — 2012-05-03

Abstract: Congenital oral cysts of foregut origin include bronchogenic, enteric, and oesophageal cysts, and they are much rarer than the well described dermoid, epidermoid, and thyroglossal cysts. The exact aetiology is poorly understood, but they are thought to arise from misplaced embryonic rests of the primitive foregut.The presentation of cysts lined by respiratory or gastrointestinal epithelium in the oral cavity is unusual. There have been previous reports of bronchogenic or gastrointestinal epithelium-lined lingual cysts, but few report both features occurring within the same cyst. In view of the scarcity of such reports, we present the case of a lesion on the ventral surface of the tongue of a newborn boy. On removal it was found to be a cyst lined by immature squamous, respiratory, and gastric body epithelium.

One-stage cleft repair outcome at age 6- to 18-years – a comparison to the Eurocleft study data - Corrected Proof

2012-05-01

Abstract: The optimisation of the relation between quality of outcome and burden of care is difficult in the treatment of cleft lip and palate. We analysed long-term outcome after one-stage repair of clefts to assess the benefits and limitations of this form of treatment. Thirty-three patients aged 6–18 years who had had lip repair, two-flap palatoplasty, and corticocancellous alveolar bone grafts at 6 months of age were divided into three age groups (6–11, 12–14, and 15–18 years) and compared with mean outcome data from the Eurocleft centres and with cephalometric standards of healthy people. Fifteen of the 33 patients were assessed for nasalance. Maxillary protrusion (SNA) and intermaxillary relation (ANB) in the one-stage groups differed significantly from those of healthy people, but not from corresponding means in the Eurocleft study. In 61% the Bergland score for alveolar ossification was grade I or II, and in 15% it was grade III; 24% had secondary alveolar bone grafting. No palatal fistulas occurred and nasalance did not differ significantly from that of healthy controls. As each patient generally had a primary operation and one secondary procedure, they benefited from half the number of surgical steps of multistage procedures. However, one-stage procedures led to significant disturbance in growth, but the degree of this was similar to mean values of multistage procedures in the Eurocleft study. Primary alveolar bone grafting led to inconsistent alveolar ossification and was suspected to interfere with anterior maxillary growth so it has been abandoned.

Use of a polyvinyl acetyl sponge (Merocel®) nasal pack to prevent kinking of the endotracheal tube used during laser excision - Corrected Proof

Tom Aldridge, Peter A. Brennan, Adam Crosby-Jones, Matthew Turner — 2012-05-01

Intraoral laser excision requires use of an endotracheal tube that can safely be used with a laser. A recognised complication when using these tubes is that they kink at the proximal end where the tube leaves the nose at an acute angle, which can cause it to narrow with resultant delays (). This can be particularly inconvenient when the face has been suitably draped.

Journal Oracle - Corrected Proof

2012-05-01

Physiotherapy in the management of disorders of the temporomandibular joint—perceived effectiveness and access to services: a national United Kingdom survey - Corrected Proof

Arif Rashid, Nigel Shaun Matthews, Helen Cowgill — 2012-04-30

Abstract: Up to a quarter of the general population has experienced temporomandibular joint disorder (TMD) at some point in time. Physiotherapy has been used in the management of TMD for many years, but evidence supporting its clinical effectiveness is limited. We investigated the perceived effectiveness of physiotherapy for patients with TMD among consultants in oral and maxillofacial surgery (OMFS) and the accessibility of these services in the United Kingdom (UK). Information was gathered from a postal or electronic questionnaire sent to the 356 OMFS consultants listed on the British Association of Oral and Maxillofacial Surgeons’ website. A total of 208 responded (58%) and 72% considered physiotherapy to be effective. Amongst these respondents, jaw exercises (79%), ultrasound (52%), manual therapy (48%), acupuncture (41%) and laser therapy (15%) were considered to be effective. Twenty-eight percent of respondents did not consider physiotherapy to be effective. Reasons for this included lack of knowledge or expertise of the physiotherapist (41%) and lack of awareness of the benefits of physiotherapy (28%). In relation to access to physiotherapy services, 10% of respondents had a designated physiotherapist for patients with TMD, 89% could refer directly to physiotherapy and 7% worked in an environment that provided training for physiotherapists. Patients were prescribed jaw exercises by 69% of respondents. Despite limited evidence to support its effectiveness, approximately three-quarters of OMFS consultants in the UK regard physiotherapy to be beneficial in the management of TMD.

Computer-assisted preoperative simulation for screw fixation of fractures of the condylar head - Corrected Proof

Toshinori Iwai, Yasuharu Yajima, Yoshiro Matsui, Iwai Tohnai — 2012-04-30

Fractures of the condylar head are generally treated conservatively because exposure and fixation are difficult without damaging the facial nerve. Conservative treatment is also recommended for children or for patients whose condylar head is in several fragments. The conservative approach requires long-term treatment, whereas open surgery can provide early recovery of occlusion and movement of the jaw for adults who have a condylar fracture with a large segment and loss of the vertical height of the mandibular ramus. Preoperative evaluation by three-dimensional computed tomography (CT) with computerised simulation can help the surgeon to decide whether open treatment is possible to fix the fracture. We have used three-dimensional simulation to assist in the planning and treatment of fractures of the condylar head.

Computer-assisted virtual technology in intracapsular condylar fracture with two resorbable long-screws - Corrected Proof

W.H. Wang, J.Y. Deng, J. Zhu, M. Li, B. Xia, B. Xu — 2012-04-30

Abstract: Our aim was to fix intracapsular condylar fractures (ICF) with two resorbable long screws using preoperative computer-assisted virtual technology. From February 2008 to July 2011, 19 patients with ICF were treated with two resorbable long screws. Preoperatively we took panoramic radiographs and spiral computed tomography (CT). Depending on their digital imaging and communications in medicine (DICOM) data, the dislocated condylar segments were restored using the SimPlant Pro™ software, version 11.04. The mean (SD) widths of the condylar head and neck from lateral to medial were 19.01 (1.28)mm and 13.84 (1.13)mm, respectively. In all patients, the mandibles and the ICF seen intraoperatively corresponded with the preoperative three-dimensional and virtual reposition. All patients were followed up for 6–46 months (mean 21). Occlusion and mouth opening had been restored completely in all but one patient, and absolute anatomical reduction was also achieved in most cases. Computer-assisted virtual technology plays an important part in the diagnosis of ICF, as well as in its preoperative design. Fixation with only two resorbable long screws is an effective and reliable method for fixing ICF.

Microdialysis: characterisation of haematomas in myocutaneous flaps by use of biochemical agents - Corrected Proof

2012-04-23

Abstract: Metabolic markers are measured by microdialysis to detect postoperative ischaemia after reconstructive surgery with myocutaneous flaps. If a haematoma develops around the microdialysis catheter, it can result in misinterpretation of the measurements. The aim of the present study was to investigate whether a haematoma in a flap can be identified and dissociated from ischaemia, or a well-perfused flap, by a characteristic chemical profile.In 7 pigs, the pedicled rectus abdominal muscle flap was mobilised on both sides. A haematoma was made in each flap and two microdialysis catheters were placed, one in the haematoma, and the other in normal tissue. One flap was made ischaemic by ligation of the pedicle. For 6 hours, the metabolism was monitored by measurement every half-an-hour of the concentrations of glucose, lactate, pyruvate, and glycerol from all 4 catheters. After 3 hours of monitoring, intravenous glucose was given as a challenge test to identify ischaemia.The non-ischaemic flap could be differentiated from the ischaemic flap by low glucose, and high lactate, concentrations. It was possible to identify a catheter surrounded by a haematoma in ischaemic as well as non-ischaemic muscle from a low or decreasing concentration of glucose together with a low concentration of lactate. All four sites could be completely dissociated when the concentrations of glucose and lactate were evaluated and combined with the lactate:glucose ratio and a flow chart. The challenge test was useful for differentiating between haematomas in ischaemic and non-ischaemic tissue.

E-cadherin and β-catenin expression in well-differentiated and moderately-differentiated oral squamous cell carcinoma: relations with clinical variables - Corrected Proof

2012-04-23

Abstract: The aim of this study was to establish the expression and localisation of E-cadherin and β-catenin in oral squamous cell carcinomas (SCC) so that we could correlate the findings with prognostically-relevant clinicopathological variables. E-cadherin and β-catenin expression in normal oral mucosa and in oral squamous cell carcinomas were examined immunohistochemically, and their association with clinicopathological factors and prognosis were then analysed in 69 patients who had been operated on for oral SCC. E-cadherin expression was found in all 69 cases: in 11 cases (16%) it was weak; in 21 (30%) moderate, and in 37 (54%) high. β-Catenin expression was found in 64 cases (93%): in 18 cases (26%) cell-membrane expression was weak; in 26 (38%) it was moderate; in 19 (28%) it was high, and in one case (1%) there was cytoplasmic staining. No nuclear staining was detected. E-cadherin was significantly associated with histological grade (p=0.002) and alcohol consumption (p=0.05), and β-catenin was significantly associated with nodal stage (p=0.02), TNM stage (p=0.009), and E-cadherin expression (p=0.01). However, none of them were independent prognostic factors in the disease-specific survival analysis. E-cadherin is closely linked to β-catenin expression in oral SCC and to tumour differentiation. Alcohol consumption could increase the aggressiveness of SCC, leading to reduced expression of E-cadherin. β-catenin could be an early marker for the identification of occult metastases in patients with oral SCC.

The use of Piezosurgery™ for external dacryocystorhinostomy - Corrected Proof

Amélie Rougeot, Matthieu Koppe, Arnaud Gleizal — 2012-04-19

Dacryocystorhinostomy aims to restore the flow of tears from the lacrimal sac into the nose when the function of the nasolacrimal duct has been altered. External dacryocystorhinostomy is one of the techniques used in the treatment of obstruction. This is the surgical creation of a communication between the lacrimal sac and the nasal cavity, which can also be made endoscopically. It consists in an anastomosis between the nasolacrimal duct and the nasal cavity, adjacent to the top of the obstacle, by ostectomy of the maxillary ramus. The main difficulty is to preserve the nasal mucosa while the bony window is being made to avoid postoperative stenosis. This is usually achieved using mechanical devices, which tend to damage the underlying nasal mucosa. The development of piezoelectric instruments (), capable of cutting bone while sparing the soft tissues, modified our technique. We describe the procedure and the benefits.

Physiological method of corneal protection during periocular surgery - Corrected Proof

M.A. Kittur, R. Isaac, I.R. Parkin — 2012-04-16

The incidence of injury to the eye after non-ocular surgery has been reported as between 3% and 8%. Corneal abrasions are the most common, but other injuries include conjunctivitis, blurred vision, red eye, chemical injury, direct trauma, and blindness. Injury to the eye during general anaesthesia is usually a result of incomplete closure of the eyelid, reduced formation of tears and drying of the cornea, and exposure to irritant chemicals used in surgical preparation. Such injuries usually heal without consequence, but occasionally can lead to corneal or scleral ulceration and can be painful in the postoperative period.

Delays in head and neck surgery—managers, theatre usage and suboptimal efficiency - Corrected Proof

A.N. Kanatas, A.B. Smith, C. Mannion, T.K. Ong, D.A. Mitchell — 2012-04-13

Achieving maximum efficiency means that there are daily pressures from managers, towards optimal theatre utilisation. In an attempt to improve team efficiency 41 consecutive reconstructions with radial free forearm flaps – a flap commonly used in head and neck surgery – were recorded and analysed prospectively.

Re: Use of carbon dioxide laser in lingual frenectomy. Is the light sabre greater than the sword? - Corrected Proof

A. Atwal, H. Cottom, G.C.S. Cousin, J.R. Gallagher — 2012-04-13

As clinicians currently undertaking a multi centre audit on the efficacy of outpatient lingual frenulotomy (division) in neonates and infants, we read the paper by Puthussery et al. using carbon dioxide laser in lingual frenectomy (excision) with interest.

Orbital fractures in children - Corrected Proof

Alistair R.M. Cobb, N. Owase Jeelani, Peter R. Ayliffe — 2012-04-12

Abstract: In children, differences in the properties and proportions of bone in the craniofacial skeleton and the lack of development of the paranasal sinuses result in orbital fractures that present differently from those in adults. Facial growth may be disturbed by such injuries and also by surgical intervention, which should therefore be as conservative as possible. However, urgent operation is needed to prevent irreversible changes when fractures of the orbital floor involve entrapped muscle. We present an approach to such injuries.

Incidence of oral cancer among South Asians and those of other ethnic groups by sex in West Yorkshire and England, 2001–2006 - Corrected Proof

Julia Csikar, Ariadni Aravani, Jenny Godson, Matthew Day, John Wilkinson — 2012-04-11

Abstract: In 2008 there were 11682 cases of oral cancer in the United Kingdom; this is 16.41/100000 population, and 3.7% of all cancers. Ethnic coding of these data is poor, and so databases were combined to report rates for the incidence of oral cancer in South Asians compared with those among other ethnic groups in West Yorkshire, 2001–2006. A total of 2157 patients with oral cancer were identified in West Yorkshire, 138 of whom were South Asian (6.4%). We analysed them by ethnicity, sex, area in which they lived, and site of cancer. Oral cancer was significantly more common among South Asian women than those from other ethnic groups in England and West Yorkshire, and in England alone it was significantly more common in men of other ethnic groups than those from South Asia. Patients from South Asia were at higher risk of being diagnosed with oral cancer than those of other ethnic groups within West Yorkshire, when data were adjusted for age at diagnosis and sex. In England and in West Yorkshire there was a significantly higher rate of oral cancer among Southern Asian women than among those of other ethnic groups, and men in other ethnic groups had a higher incidence than those from South Asia (England only). The excess of oral cancers gives further weight to the association between smokeless tobacco, smoking, alcohol, and dietary intake by ethnic group. This information is particularly pertinent in areas such as West Yorkshire where there are large groups of Asian people.

Combined second metatarsophalangeal joint and extended dorsalis pedis flap for reconstruction of temporomandibular joint and oral mucosa - Corrected Proof

Farzad Borumandi, Heinz Bürger, Alexander Gaggl — 2012-04-11

In cancerous temporomandibular joint (TMJ), the TMJ may have to be disarticulated avoiding further spread of the malignant tumour towards the skull base. In oncologic patients after radical excision of the TMJ with subtotal mandibular defects, in an irradiated or soon to be irradiated region, large tissue quantities and improved vascularity are favourable. The vascularized second metatarsophalangeal joint (MTPJ) transfer for the reconstruction of TMJ is a well known technique.

Re: Impact of coding errors on departmental income: an audit of coding of microvascular free transfer cases using OPCS-4 in UK - Corrected Proof

Geoff A. Chiu — 2012-04-09

I read with interest the paper by Moar and Rogers. Accuracy of coding is important not only for financial reasons but also for indicators of quality. The two main elements that can affect it are the quality of the source of the documentation (the operation note) and the coding of comorbidities. I have developed SurgiNote™, which is an operation note database (). Using a series of drop-down boxes and a filtration system, the surgeon is able to select the surgical specialty, individual surgical procedures, and the OPCS code. The American Society of Anesthesiologists’ (ASA) grade along with relevant comorbidities can also be entered. The indication, findings, operation, and postoperative and discharge instructions are entered as free text.

Effects of soft tissue injury to the temporomandibular joint: report of 8 cases - Corrected Proof

Dongmei He, Chi Yang, Minjie Chen, Xiujuan Yang, Lingzhi Li — 2012-04-05

Abstract: Our aim was to describe the effects of soft tissue injury to the temporomandibular joint (TMJ), to analyse possible reasons for it, and to evaluate the results of treatment. Eight patients (12 joints) who developed disorders of the TMJ after trauma to the mandible without fracture of the condyle were treated in our department from 2009 to 2010. Magnetic resonance imaging (MRI) and computed tomography (CT) were used to check the condition of the joint. Five patients had their joints explored to relieve pain and improve mouth opening. MRI showed all 12 joints had displaced discs. CT showed that the surface of the condylar bone was “intact” immediately after injury but destroyed later in 8 joints. Exploration showed fibrous ankylosis in 5, osteoarthritis with intra-articular adhesions in 2, and internal derangement in 1. Four were treated by costochondral graft (CCG) with 7 symptomatic joints. The disc was repositioned in 1 case with 1 affected joint. The mean maximal incision opening at follow-up were significantly better than the one before treatment (mean 34 compared with 23mm, p=0.02). Pain in the TMJ was relieved by operation in all patients so treated. The other 3 patients (4 joints) had no treatment because their symptoms were minor and mouth opening was not restricted. Soft tissue injuries of the TMJ can potentially lead to internal derangement, osteoarthrosis, and possibly fibrous ankylosis, which should be considered during follow-up. Displacement of the disc and damage to the condylar cartilage seem to be the causes of these complications. Surgical management is effective in the short term.

Response to “Tuberculosis of the temporomandibular joint: part of a bigger picture” - Corrected Proof

Meera Patel, Neil Scott, Carrie Newlands — 2012-04-05

Thank you for your letter and the points you raise regarding our case report about tuberculosis of the temporomandibular joint. Management of the tuberculosis infection was undertaken by a consultant respiratory physician according to the local guidelines in place at the time. This consisted of rifampicin, isoniazid, and pyrazinamide 5 times daily, and ethambutol 750mg daily for 8weeks. We accept that this is not in line with present recommendations.

Surgical and prosthetic treatment for microphthalmia syndromes - Corrected Proof

2012-04-05

Abstract: Our aim was to evaluate the long-term outcomes of prosthetic treatment and orbital expansion in the management of microphthalmia syndromes. We did a retrospective single-centre study of all cases of microphthalmia treated between 1989 and 2010. The patients were divided into three groups: isolated microphthalmia, microphthalmia associated with micro-orbitism, and complex microphthalmia syndrome. To evaluate the results a score was computed for each patient by assessing the length of the palpebral fissure, the depth of the conjunctival fornix, and local complications together with an evaluation of the satisfaction of patients and their families.Forty-four children were included (27 boys and 17 girls). Twenty-seven had unilateral microphthalmia (61%) and 17 bilateral microphthalmia (39%). Twelve patients were lost to follow up. The mean duration of follow-up was 12years (range 4–21). Management involved an ocular conformer in only 31 patients (71%). The treatment was deemed satisfactory in all except 10 children. Surgical treatment with orbital expansion permitted good symmetry of the orbital cavities with a final mean difference of 9% (range 3–17) compared with the initial 16.8% (range 13.6–20.3). The prosthetic treatment gives satisfactory results. Despite limited indications and difficult follow-up, our experience emphasises the value of surgical treatment for severe micro-orbitism.

Tuberculosis of the temporomandibular joint: part of a bigger picture - Corrected Proof

Chaudhry Kirti, Naveen Dutt, Meenakshi Awana — 2012-04-04

Patel et al. discussed a case of tuberculosis of the temporomandibular joint that progressed to ankylosis even after treatment. We wish to make several points. First, primary tuberculous infection usually originates in the lungs and in the case of a patient with tuberculosis of any other region, it is essential to rule out pulmonary tuberculosis by taking a radiograph of the chest and examining the sputum for acid fast bacilli. The authors have not mentioned any such investigation in this case report.

Up-regulation of interleukin-6 and vascular endothelial growth factor-A in the synovial fluid of temporomandibular joints affected by synovial chondromatosis - Corrected Proof

2012-04-04

Abstract: Our aim was to explore important inflammatory mediators for synovial chondromatosis in the temporomandibular joints (TMJs) by analysing synovial fluid. Samples were collected from 10 patients with unilateral synovial chondromatosis of the TMJ. Control samples were obtained from 11 subjects with no symptoms in the TMJ. Concentrations of aggrecan, interleukin (IL)-2, IL-4, IL-5, IL-6, IL-8 (CXCL8), IL-10, interferon (IFN)-γ, tumour necrosis factor (TNF)-α and vascular endothelial growth factor (VEGF)-A were measured in the samples of synovial fluid, and the results in the two groups compared. The tissues from the affected TMJ were examined histologically and immunohistochemically. Of the proteins evaluated, the concentrations of aggrecan, IL-6, and VEGF-A were significantly higher in the group with synovial chondromatosis. The immunohistochemical analysis showed that the synovial cells around the osteocartilaginous nodules were vigorously expressing VEGF-A.IL-6 and VEGF-A are thought to have important roles in the pathology of synovial chondromatosis of the TMJ.

Minimally-invasive open reduction of intracapsular condylar fractures with preoperative simulation using computer-aided design - Corrected Proof

Ming-liang Yang, Bin Zhang, Qing Zhou, Xiao-bo Gao, Qiang Liu, Li Lu — 2012-04-04

Abstract: Reduction of intracapsular condylar fractures is difficult, so we have based our technique on preoperative simulation using computer-aided design (CAD), which has proved useful in other surgical specialties. We have treated 11 patients with intracapsular condylar fractures. Before the operation the procedure was shown on the computer using a three-dimensional simulation system. The relation between the stump and the fragment of the condyle, and assessment of the position and the size of the screw, were made preoperatively to obtain a perfect fit. The displaced fragment was reduced by elevators, and fixed with a bicortical screw through a minimised preauricular incision under general anaesthesia. The fragments and the location of the screws were similar on the preoperative simulation and on the postoperative computed tomographic (CT) scan. The reduction and fixation of the fracture showed a perfect fit on the same view in the preoperative CAD simulation in the Mimics 10.01 software and postoperatively. Postoperative clinical examinations showed good occlusion and satisfactory mouth opening. Two patients had temporary paralysis of the occipitofrontalis muscle that recovered within 3 months. All patients regained normal mandibular movements and had short and invisible scars at 6 months’ follow up. The technique of CAD simulation could help to improve the accuracy during open treatment for intracapsular condylar fractures.

Current practice in management of the neck after chemoradiotherapy for patients with locally advanced oropharyngeal squamous cell carcinoma - Corrected Proof

Brian Bisase, Cyrus Kerawala, Christopher Skilbeck, Cheka Spencer — 2012-03-30

Abstract: Patients whose necks respond completely to chemoradiation are unlikely to have residual viable tumour, which questions the need for planned neck dissection. Partial responders often need further assessment. Positron emission tomography/computed tomography (PET/CT) is becoming the standard method of assessing the response of both the primary site and neck to chemoradiation. There is debate, however, about the timing of assessment, the best imaging technique, and the extent of neck dissection, and emerging evidence supports more selective procedures with their attendant reductions in morbidity. Various trials have tried to settle these controversies, but we hypothesised that current practice varies across the United Kingdom (UK), so we set out to establish what it is. A total of 219 questionnaires were sent to head and neck surgeons of varying disciplines and their oncology counterparts, which outlined a clinical picture of a patient with persistent nodal disease after chemoradiotherapy, and requested information about the respondents’ preferred choice and timing of investigations in addition to the type of neck dissection, if indicated. There were noticeable variations in practice, with a tendency towards personal choice rather than a multidisciplinary approach. Although there were some items of broad agreement, there was disparity about the timing of imaging and operation. There is inconsistency in the management of the neck in these patients in the UK, which may reflect an absence of guidelines and paucity of evidence-based information. We need to unify practice to improve the care of patients.

Developmental framework to validate future designs of ballistic neck protection - Corrected Proof

J. Breeze, M.J. Midwinter, D. Pope, K. Porter, A.E. Hepper, J. Clasper — 2012-03-29

Abstract: The number of neck injuries has increased during the war in Afghanistan, and they have become an appreciable source of mortality and long-term morbidity for UK servicemen. A three-dimensional numerical model of the neck is necessary to allow simulation of penetrating injury from explosive fragments so that the design of body armour can be optimal, and a framework is required to validate and describe the individual components of this program. An interdisciplinary consensus group consisting of military maxillofacial surgeons, and biomedical, physical, and material scientists was convened to generate the components of the framework, and as a result it incorporates the following components: analysis of deaths and long-term morbidity, assessment of critical cervical structures for incorporation into the model, characterisation of explosive fragments, evaluation of the material of which the body armour is made, and mapping of the entry sites of fragments. The resulting numerical model will simulate the wound tract produced by fragments of differing masses and velocities, and illustrate the effects of temporary cavities on cervical neurovascular structures. Using this framework, a new shirt to be worn under body armour that incorporates ballistic cervical protection has been developed for use in Afghanistan. New designs of the collar validated by human factors and assessment of coverage are currently being incorporated into early versions of the numerical model. The aim of this paper is to describe this developmental framework and provide an update on the current progress of its individual components.

Sentinel lymph node biopsy using a new indocyanine green fluorescence imaging system with a colour charged couple device camera for oral cancer - Corrected Proof

Toshinori Iwai, Jiro Maegawa, Makoto Hirota, Iwai Tohnai — 2012-03-28

Whether management of N0 neck in patients with oral cancer should be by observation or prophylactic neck dissection is controversial, as 20–30% of patients have occult cervical lymph node metastases. Accurate diagnosis of any metastasis is difficult despite the various imaging methods available, and consequently sentinel lymph node biopsy using blue dye, or a radioisotope, or both, has been used for these patients. However, biopsy is associated with several problems, including poor transcutaneous identification of the sentinel lymph nodes, high cost, the shine-through phenomenon, and exposure to radiation. Cost-effective indocyanine green (ICG) without radiation exposure has recently been used to detect sentinel nodes in patients with various cancers. Although ICG fluorescence imaging systems have advantages over conventional methods, identifying soft tissues such as muscles or nerves around the nodes is challenging on the monochromatic images produced. This requires surgeons to biopsy sentinel nodes under direct visualisation while also referring to the monochromatic images on the monitor. We report the use of a new ICG fluorescence imaging system that uses a colour charged couple device (CCD) camera for sentinel node biopsy in patients with oral cancer and will overcome these problems.

Simultaneous actinomycosis with aspergillosis in maxillary sinus - Corrected Proof

Ho-Ryun Won, Jae Hong Park, Kyung Soo Kim — 2012-03-27

Abstract: We report a case with review of literature of actinomycosis accompanied with aspergillosis arising in unilateral maxillary sinus, in which it was completely cured after endoscopic sinus surgery and short term antibiotic therapy. To the best of our knowledge, this is the first case report in literature reporting actinomycosis in combination with aspergillosis in the paranasal sinus. Also, we suggest short term antibiotic therapy within one month may be sufficient if the surgical opening of paranasal sinus involved by actinomycosis could be well preserved.

Is it necessary to resect bone for low-grade mucoepidermoid carcinoma of the palate? - Corrected Proof

Robert A. Ord, Andrew R. Salama — 2012-03-26

Abstract: Minor intraoral tumours of the salivary glands are relatively uncommon. Most are histologically low grade and display no aggressive clinical features such as bony invasion or regional metastases. The aim of this study was to investigate retrospectively a bone-sparing approach to resection of low grade mucoepidermoid carcinoma of the hard palate in 18 patients. Only one had radiographic evidence of bony invasion and was treated by composite resection of the hard palate. Sixteen patients were treated by wide local excision with 1cm margins of soft tissue using the periosteum of the hard palate as the deep margin. The mean (SD) follow-up time was 44 months, (range 2–140). Among patients who had only soft tissue resection the histological margins were clear in 11 patients, and 5 had close or invaded margins that were all localised to the deep margin. There were no local recurrences during the follow-up period. We suggest that a bone-sparing approach to such tumours gives adequate local control, and composite resections should be reserved for tumours that have obviously invaded the hard palate.

Cephalometric outcome of two types of palatoplasty in complete unilateral cleft lip and palate - Corrected Proof

2012-03-26

Abstract: In complete unilateral cleft lip and palate (CLP), a vomerplasty is assumed to improve midfacial growth because of the reduction in scarring in the growth-sensitive areas of the palate. Our aim, therefore, was to evaluate maxillofacial morphology after a modified Langenbeck technique or a vomerplasty in children with complete unilateral CLP who were operated on by a single surgeon. As part of a one-stage closure of complete unilateral CLP done during the first year of life, the technique for repair of the hard palate repair differed between the two groups. In the modified group (n=37, mean age 11 years) a modified von Langenbeck technique was used that resulted in denudation of the bony surface on the non-cleft side only. In the vomerplasty group (n=37, mean age 11 years) a vomerplasty was used to cover the palatal bone. Lateral cephalograms from both groups were compared using the Eurocleft protocol. Fourteen angular variables were measured and 2 ratios calculated. Skeletal morphology in the groups was comparable. Maxillary incisor inclination (ILs/NL angle) and interincisal angle (ILs/ILi) were better after vomerplasty (p=0.001 and 0.04, respectively) but soft tissue facial convexity (gs-prn-pgs) was less good after vomerplasty (p=0.009). However, there was no difference between the groups in the other variable that reflected facial convexity (gs-sn-pgs) (p=0.22). Modification of the palatoplasty had a limited effect on skeletal morphology in preadolescent children, but it resulted in better inclination of the maxillary incisors.

Head and neck cancer in the south west of England, Hampshire, and the Isle of Wight: trends in survival 1996–2008 - Corrected Proof

2012-03-26

Abstract: There are reasons why survival may have improved in people with head and neck cancer, but few studies have reported on trends in the UK, and results are not consistent. We examined recent trends in survival for people diagnosed with head and neck cancer in the south west of England. Patients were identified over four one-year audits in a population (roughly 6.5 million) served by five cancer networks, and the work was collated by the South West Public Health Observatory (SWPHO) tumour panel. The SWPHO cancer registry provided data on death. Prognostic data, including stage, time to treatment, and deprivation index were extracted or derived from clinical records. A total of 2164 cases of oral, laryngeal, and pharyngeal squamous cell carcinomas (SCC) were diagnosed. Crude total 5-year mortality decreased from 55% (95% CI 50.3–59.4) in people diagnosed in 1996 to 44% (95% CI 37.9–46.4) in those diagnosed in 2003 (p<0.001). Adjusted hazard ratios (HRs) for death within five years of diagnosis for surveys 2, 3, and 4 (compared with survey 1), respectively, were reduced in subsequent groups: HR 0.79 (95% CI 0.64–0.98), HR 0.70 (95% CI 0.56–0.87), and HR 0.72 (95% CI 0.58–0.90) (chi square for trend, p<0.001). Improvements over time were most pronounced among those with late-stage disease and with pharyngeal tumours. We have shown that survival has improved for people with head and neck cancer. Further large prospective studies are required to understand how quality of care, treatment, aetiology of tumour, individual risk, and behaviour contribute to survival.

De-escalation of surgery for early oral cancer – is it oncologically safe? - Corrected Proof

2012-03-26

Abstract: This study is a review of practice for patients with T1 or T2 squamous cell carcinoma (SCC) of the anterior tongue and floor of the mouth who presented to the regional maxillofacial unit in Liverpool between 1992 and 2007. We examined trends in management and analysed their effects on resection margins, recurrence, and survival. The Liverpool head and neck oncology database was used to identify patients, and to retrieve their clinical, surgical, and pathological data. When data were missing the case notes and pathology records were reviewed. Follow up was taken to January 2011. A total of 382 patients were included. Despite more conservative treatment with closer resection margins (27% in 1992–1995 and 60% in 2004–2007), fewer free flaps (79% in 1992–1995 and 38% in 2004–2007), and less adjuvant radiotherapy (37% in 1992–1995 and 22% in 2004–2007), there has been no significant increase in local recurrence (14% in 1992–1996 and 8% in 2004–2007), and overall survival has not been adversely affected. This is most striking when T1 tumours are considered in isolation with a consistent trend towards fewer clear margins (95% in 1992–1995 and 28% in 2004–2007) and fewer free flaps (53% in 1992–1995 and 11% in 2004–2007). The case mix was similar over the study period. These data support a more conservative approach to the management of early oral cancer.

West of Ireland facial injury study. Part 2 - Corrected Proof

2012-03-19

Abstract: The pattern, presentation, and volume of facial injury in the west of Ireland are subjectively different from those in the United Kingdom. We know of no prospective regional study of facial injury in Ireland to date, and nationally there is no system in place to collect data on injury. The epidemiology of facial trauma has important implications for the development of health services, the education and training of clinicians, workforce planning, prevention of injury, and promotion of health. Over 1 week we did a multicentre prospective data collection study involving all emergency departments in the west of Ireland. All patients who attended with facial injuries were included (n=325), and those with injuries solely of the scalp and neck were excluded. The proforma recorded a patient's characteristics, details of injury and presentation, treatment and follow-up. It also included relation with sport, alcohol, assault, and animals. Eighty-two fractures were suspected, of which 46% were nasal. Accidents caused 75% of injuries and sport caused 27%. Fractures were sustained by 63% (n=5) of those wearing helmets while playing hurling, but by only 22% of those who were not. Helmets did, however, reduce the total number of injuries. Injuries were associated with alcohol (23%), assault (14%), falls (38%), and motor vehicle crashes (11%). Because of the differences in aetiology, different avenues and methods are required to prevent injury. Staff in emergency departments will need training in this area, given the large proportion of facial trauma in the region.

Intraoral external oblique ridge compared with transbuccal lateral cortical plate fixation for the treatment of fractures of the mandibular angle: prospective randomised trial - Corrected Proof

S. Laverick, P. Siddappa, H. Wong, P. Patel, D.C. Jones — 2012-03-16

Abstract: Since the initial description by Michelet et al. and research by Champy et al. the placement of a single, four-hole, monocortical, osteosynthesis plate has been considered an acceptable method of fixation for a fracture of the mandibular angle. We investigated the null hypothesis that there is no difference in the incidence of postoperative removal of an infected plate between miniplates placed on the mandibular external oblique ridge and those placed on the buccal surface of the mandible through a transbuccal approach to treat a fracture of the angle of the mandible. Patients were randomised to having their angle fractures treated with a ridge plate placed intraorally or transbucally. Other variables were investigated including the effect of smoking, drinking alcohol, oral hygiene, and the method of holding the reduction on removal of the plate, occlusal outcome, and degree of preoperative anatomical displacement and postoperative reduction. We also studied the operating time required for the two techniques, the effect of the presence and consequent removal of a wisdom tooth in the line of the fracture, and the effect of delay in taking the patient to theatre for subsequent removal of the plate for infection. Of the 261 angle fractures 34 (13%) plates were removed because of infection, and 6 of these (18%) required a further period of fixation, such as intermaxillary fixation, to treat non-union. The transbuccal plate had a significantly lower postoperative infection rate (6/124, 5%) than the ridge plate (28/137, 20%) (p=0.001). Smoking adversely affected the healing of angle fractures (p=0.000). Displacement of fractures is related to the infection rate (p=0.003), and there are no significant relations between delay in going to theatre or the presence and potential removal of a wisdom tooth in the line of the fracture and infection rate. There was a highly significant difference between the rate of removal of plates placed intraorally on the external oblique ridge, and plates placed transbucally (p=0.000). Transbuccal plates were far less likely to need removal for infection than ridge plates, odds ratio 5.05.

Anatomical surgical planning for oral and oropharyngeal primary carcinoma combined with adjuvant treatment where indicated is associated with improved local control - Corrected Proof

2012-03-16

Abstract: We aimed to find out whether surgical tactics that lead to a reduction in tumour-involved surgical margins also improve local control. We retrospectively reviewed a consecutive case series (n=162) of previously untreated patients who had operations for squamous cell carcinoma (SCC) of the oral cavity or oropharynx. Extensive use was made of computed tomographic multiplanar imaging to plan primary resections. Nine patients (6%) had tumour at the resection margin. Local control at 36 months was 96%, disease-specific survival (DSS) was 86%, and overall survival (OS) was 77%. Carefully planned primary operation for SCC of the oral cavity and oropharynx to minimise tumour-involved margins combined with conventional adjuvant treatment where indicated, is associated with a high probability of local control and disease-specific survival.