Lymphoedema following treatment for head and neck cancer: impact on patients, and beliefs of health professionals.

Cervicofacial lymphoedema is a recognised side-effect that may result following treatment for head and neck cancer. This study aimed to investigate the perspectives of affected patients and the beliefs that treating health professionals hold about head and neck lymphoedema. Ten patients with head and neck lymphoedema and 10 health professionals experienced in the treatment of head and neck cancer patients agreed to participate in semi-structured face to face interviews. Interviews were recorded, audio files were transcribed and coded and then analysed for themes. Themes of experiences of patients with head and neck lymphoedema and the beliefs of health professionals largely overlapped. Given its visible deformity, the main effect of lymphoedema in head and neck cancer patients was on appearance. In some cases this lead to negative psychosocial sequelae such as reduced self-esteem, and poor socialisation. Clinicians need to be aware of those patients more likely to experience lymphoedema following treatment for head and neck cancer, and how they are affected. Understanding how patients with facial lymphoedema are affected psychologically and physically, and the importance of prompt referral for lymphoedema treatment, might ultimately improve outcomes and ensure optimal management.

COVID-19 social-distancing measures altered the epidemiology of facial injury: a United Kingdom-Australia comparative study.

The purpose of this study was to undertake a retrospective cross-sectional analysis to compare the frequency and characteristics of facial injury presentations at a UK and an Australian tertiary referral hospital during the implementation of COVID-19 social-distancing measures. The primary predictor variables were a heterogeneous set of factors grouped into logical categories: demographics, injury mechanisms and site, and management. The primary outcome variable was the presentation of a hard or soft tissue facial injury. A descriptive statistical analysis was undertaken on the assembled data. The study found a clinical and statistically significant reduction in the frequency (absolute number) of facial injuries at each study site. In addition, a striking similarity common in both countries was an increase in the number of facial injuries due to falls and a reduction in facial injuries due to interpersonal violence. Conservative (non-operative) management of facial injury increased at both sites. The implementation of COVID-19 social-distancing public health measures, which aimed to limit community transmission of the coronavirus, had a secondary serendipitous effect of reducing the frequency of facial injury presentations and altering their epidemiological characteristics at both a UK and Australian tertiary referral hospital.

Complaints of neuropathic pain, noxious cervical plexus neuropathy and neck tightness are reported by patients who undergo neck dissection: an institutional study and narrative review.

There exists a subgroup of patients who undergo neck dissection (ND) who postoperatively complain of either neuropathic pain, dysaesthesia and/or discomfort that is located within the dermatomal distribution of the cervical plexus. The purpose of our study was to determine the prevalence, characteristic, and demographics of these symptoms in our patient cohort. We undertook a retrospective randomised observational cohort study of 105 patients who had undergone ND. The primary predictor variable was the undertaking of a ND. The secondary outcome variable was the complaint of either neuropathic pain or a noxious neuropathy, at a minimum of twelve months after surgery. A recognised symptom questionnaire and a visual analogue score was employed for the purpose of the study. A descriptive and statistical analysis was applied to the assembled data. Twenty patients (19%) complained of either spontaneous (n=9) or evoked (n=11) neuropathic pain that occurred within the surgical site. In addition, 71 patients (68%) described an altered sensation in the dermatomal distribution of the great auricular or tranverse cervical nerves while 70 patients (67%) described the feeling of 'neck tightness'. There were no characteristics of the study cohort that underpinned these results. Neuropathic pain can occur following ND. This can cause distress to a small but defined group of patients. Despite its importance, we found a paucity of studies in the literature that have investigated neuropathic pain following ND. We believe this condition requires more research attention and clinical awareness.

Widespread oral and oropharyngeal mucosal oedema induced by ecstasy (MDMA): A case for concern.

We describe an unusual adverse reaction that was probably caused by taking ecstasy: the patient developed widespread oral and oropharyngeal mucosal oedema, which was triggered after he had taken ecstasy and alcohol. The reaction to this could have been fatal.

Liquor legislation, last drinks, and lockouts: the Newcastle (Australia) solution.

The aim of this study was to determine whether the regional implementation of prohibitive liquor legislation, introduced in order to limit the sale of and access to alcohol, can lead to a sustained reduction in the incidence of assault occasioning facial injury, as seen in patients presenting to a level 1 trauma hospital. A retrospective observational cohort study was conducted to document patients who were identified as an acute hospital presentation of assault occasioning facial injury. The period of study was 2003-2015; this ensured a similar period of time before and after the implementation of the legislation in 2008. A statistical analysis was undertaken to assess the rates of change in oral and maxillofacial (OMF) assault admissions pre and post legislation. The study found that pre-legislation numbers of OMF assaults increased at a rate of 14% per annum and then decreased at a rate of 21% per annum post legislation (31% relative rate ratio reduction). Similar trends were seen for all males, males aged 18-35 years, and males where alcohol was recorded at clinical presentation. The introduction of 'last drinks' and 'lock out' legislation has led to a significant and sustained reduction in assaultive alcohol-related facial injury in Newcastle.

Bilateral axillary metastasis from a primary ethmoidal squamous cell carcinoma.

The development of infra-clavicular lymph node metastasis from head and neck squamous cell carcinoma is an uncommon event. We present a rare case of bilateral axillary nodal metastasis that developed in a patient previously treated for a primary ethmoidal squamous cell carcinoma. To our knowledge, there have only been five case reports in the English literature, accounting for a total of 10 patients, which documented a clinically apparent metastasis to axillary lymph nodes from various head and neck malignancies. Significantly however, the simultaneous ipsilateral and contralateral lymphatic spread of disease from a tumour in the para-nasal sinus, so as to involve bi-axillary nodes, has not been previously reported. We discuss the possible pathogenesis and the prognostic significance of this manifestation.

Recurrent nodal metastases in the posterior triangle: implications for treatment of the atypical tumour.

We studied the incidence of recurrent nodal metastases in level V (posterior triangle) in patients who had previously had a staging or therapeutic dissection of the neck, with or without postoperative radiotherapy. Of 160 patients studied (177 neck dissections), 41 (26%) developed recurrent metastases in the neck. Four patients (3%) developed ipsilateral recurrent disease in level V. In these four patients, level III or IV lymph nodes were shown histologically to have extracapsular spread at the time of the original dissection. All four metastases were located at or just beyond the anatomical boundaries of the posterior triangle. None of the metastases at level V were from oral or oropharyngeal primary tumours.

Genetic duplications in bacteria and their relevance for genetic toxicology.

Tandem genetic duplications of various lengths occur at high frequency and at many chromosomal locations in bacteria. Most duplications are formed and lost by recombinational mechanisms. Since they readily give rise to haploid segregants, duplications are characteristically unstable. Various selection procedures permit measurements of duplication frequencies, and several mutagens have been shown to induce the formation of duplications in haploid bacteria and the loss of duplications from merodiploid bacteria. Although the data base is not extensive, it includes agents that interact with DNA by a variety of molecular mechanisms. Grounds on which the induction of genetic duplications in bacteria can be relevant for genetic toxicology are discussed.

Mutagenicity of acridines in a reversion assay based on tetracycline resistance in plasmid pBR322 in Escherichia coli.

The mutagenicity of a series of acridine compounds was studied in an assay based on the reversion of mutations in the tetracycline-resistance gene (tet) of plasmid pBR322 in Escherichia coli. Mutations that restore the tetracycline-resistant phenotype were detected in tetracycline-sensitive strains carrying mutant plasmids. Mutations that revert by +2, +1, -1 and -2 frameshift mutations and by base-pair substitutions were used to analyze the mutagenicity of two simple acridines, two acridine mustards, and a nitroacridine. The simple acridines (9-aminoacridine and quinacrine) effectively induced -1 frameshifts and weakly induced +1 frameshifts. The acridine mustards (quinacrine mustard and ICR-191) were more potent inducers of -1 and +1 frameshifts than the simple acridines. Reactive acridines, including both the mustards and the nitroacridine Entozon, were effective inducers of -2 frameshifts but the simple acridines were not. The two classes of reactive acridines differed from one another, in that the mustards were better inducers of +1 frameshifts than Entozon, whereas Entozon was a particularly potent inducer of -2 frameshifts. None of the compounds induced +2 frameshifts, and the induction of base-pair substitutions was negligible. These results confirm and extend studies showing that adduct-forming acridines are stronger frameshift mutagens than simple intercalating acridines and that the acridines differ from one another not only in overall mutagenic potency but also in the prevalence of different classes of frameshift mutations.

Cephalometric alterations following facial advancement surgery: 1. Statistical evaluation. A review of aesthetic evaluation of the face and an attempt to assess treatment validity.

Simultaneous maxillary and mandibular advancement surgery, with or without chin advancement, was performed to correct combined mid and lower dento-facial deficiency, the diagnosis of the deformity in this study being based purely on a clinical analysis. The purpose of this investigation was to test the validity of the diagnosis, surgical treatment objective, and subsequent surgical result, by comparing pre- and postoperative cephalometric data with 'Class I dento-skeletal parameters', derived from three different analyses. Lateral cephalometric radiographs were obtained from patients who had undergone 'facial advancement surgery'. The radiographs were subjected to cephalometric analysis in an attempt both to quantify and qualify the skeletal and dental changes that had taken place, following surgical correction of 'horizontal facial deficiency'. A statistical analysis was then used to assess postoperative change to normal, and how the proportion of patients so defined varied by method. All patients had optimal improvements in aesthetics, and in dental occlusion. Dento-skeletal changes remained stable at 12 months post surgery. In spite of these successes, the results of this investigation showed that no greater than 50% of preoperative abnormal measurements per patient were normalised by surgery.

Cephalometric alterations following facial advancement surgery. 2. Clinical and computerised evaluation.

Part 1 of this investigation identified an established patient cohort whose treatment is best suited to combined surgical-orthodontic correction of dento-facial deformity. This is as opposed to the attempted correction of the problem by an orthodontics-only or a surgery-only approach. Experienced surgeons will subjectively assess facial aesthetics and devise surgical treatment objectives in terms of the beneficial soft tissue improvements derived from dento-skeletal manipulation. None the less, traditional and soft tissue cephalometric parameters remain a guideline in the diagnostic phase of treatment. Part 2 of this investigation compared pre and postoperative clinical and computerised evaluations of patients diagnosed as having combined mid and lower dento-facial deficiency with Class 1 dento-skeletal parameters.

The stability of facial advancement surgery (in the management of combined mid and lower dento-facial deficiency).

The short-term (6 weeks postoperative) and long-term (12 months postoperative) skeletal stability of combined maxillary and mandibular advancement was evaluated by cephalometric analysis in 15 patients. The mean horizontal advancement of the maxilla was 5.84 mm. 6 weeks later a mean relapse of 0.03 mm (0.5%) was identified. The mean relapse at long-term follow-up was 0.59 mm (10.1%). The mean horizontal advancement of the mandible was 12.35 mm at menton and 12.65 mm at pogonion. At 6 weeks, mean horizontal relapse, respectively at the above landmarks, was 0.11 mm and 0.21 mm (1.3%). The mean relapse at long-term follow-up was respectively 2.19 mm and 1.98 mm (16.9%). Subjectively and objectively improvements were seen in facial aesthetics and dental occlusion. The results indicated that rigid fixation of osteotomies undertaken to correct 'horizontal facial deficiency' is a surgically predictable and relatively stable procedure when reviewed up to 12 months after surgery.

The stability of facial osteotomies. 3. Chin advancement.

Surgical repositioning of the chin can be used to improve function and aesthetics. The most commonly employed technique involves a sectioning of the lower border of the anterior mandible, thus allowing a sliding movement of the chin. It is generally accepted that the maintenance of a soft tissue attachment provides a clinically stable skeletal and predictable soft tissue change with minimal postoperative osseous resorption. Part 3 of this series of papers addresses the issues of treatment planning, surgical technique and clinical indications for undertaking advancement genioplasty. These, combined with the surgeon's artistic sense of facial harmony, are pre-conditions necessary for successful chin surgery.

The stability of facial osteotomies. 4. Maxillary and mandibular (with or without chin) advancement with rigid internal fixation.

The short-term (6 weeks postoperative) and long-term (12 months postoperative) horizontal skeletal stability of combined maxillary and mandibular advancement was evaluated by cephalometric analysis of 15 patients. The mean horizontal advancement of the maxilla was 5.84 mm. Six weeks later a mean horizontal relapse of 0.03 mm (0.05%) was identified. The mean horizontal relapse at long-term follow-up was 0.59 mm (10.1%). The mean horizontal advancement of the mandible was 12.35 mm at menton and 12.65 mm at pogonion. At 6 weeks, mean horizontal relapse, respectively at the above landmarks, was 0.11 mm and 0.21 mm (1.3%). The mean horizontal relapse at long-term follow-up was 2.19 mm and 1.98 mm (16.6%) respectively for the same landmarks. Subjectively and objectively, improvements were seen in facial aesthetics and dental occlusion. The results indicate that rigid fixation of osteotomies undertaken to correct 'horizontal facial deficiency' is a surgically predictable and relatively stable procedure when reviewed up to 12 months after surgery.

The stability of facial osteotomies. 1. The evolution of maxillary, mandibular and chin osteotomies.

Surgical repositioning of the dento-skeletal components of the face, combined with appropriate orthodontic treatment, can be used to improve function and aesthetics. An extensive number of osteotomies are performed within the maxillofacial region. The most common of these are the Le Fort I osteotomy of the maxilla, the bilateral sagittal split osteotomy of the mandibular ramus, and the horizontal osteotomy of the anterior mandible. The attainment of three dimensional stability following corrective jaw surgery continues to be a major problem in the post-surgical period, in spite of the widespread adoption of rigid internal osteosynthesis. The evolution of these osteotomies to advance dento-skeletal components is traced from their inception to the present day and the concept of stability is explained (Part I). This serves as a prelude to an investigation into the stability of these procedures, undertaken in isolation or combination, to advance selected segments of the mid- and lower face (Parts 2, 3, 4, 5).

The stability of facial osteotomies. 2. Mandibular advancement with bicortical screw fixation.

Surgical repositioning of the dento-skeletal components of the lower third of face, combined with appropriate orthodontic treatment, can be used to improve function and aesthetics. However, the attainment of three-dimensional stability following corrective jaw surgery continues to be a major problem in the post-surgical period. This paper examines the short-term (6 week post-operative) and long-term (12 months postoperative) horizontal skeletal stability of bilateral sagittal split mandibular advancement in 15 patients. The mean horizontal advancement of the mandible was 6.1 mm. Six weeks later, a mean continued forward movement of 0.16 mm was identified. The mean relapse at long-term follow-up was 0.46 mm (7.5%). Results indicate that rigid bicortical screw fixation of bilateral sagittal split osteotomies undertaken to correct horizontal lower dentofacial deficiency is both statistically and surgically predictable and stable when reviewed up to twelve months after surgery.

The stability of facial osteotomies. Part 5. Maxillary advancement with miniplate and screw fixation.

Surgical repositioning of the dento-skeletal components of the middle-third of the face, combined with appropriate orthodontic treatment, can be used to improve function and aesthetics. However, the attainment of three-dimensional stability following corrective jaw surgery continues to be a major problem in the postsurgical period. This paper examines the short-term (six weeks postoperative) and long-term (12 months postoperative) horizontal skeletal stability of Le Fort I maxillary advancement in 15 patients. The mean horizontal advancement of the maxilla was 8.76 +/- 0.99 mm. Six weeks later, a mean relapse of 0.22 +/- 0.19 mm was identified. The mean relapse at long-term follow-up was 0.61 +/- 0.26 mm (6.96%). These results indicate that rigid miniplate and screw fixation of Le Fort I osteotomy undertaken to correct horizontal mid-dentofacial deficiency is both statistically and surgically predictable and stable when reviewed up to twelve months after surgery.

The stability of facial osteotomies. Part 6. Chin setback.

Isolated horizontal osteotomy of the anterior mandible (genioplasty) to move the chin posteriorly can be used to improve facial profile. There has been an increasing tendency in practice to carry out this procedure in combination with maxillary and/or mandibular surgery. This is most appropriately undertaken when pre-operative prediction techniques indicate that chin prominence will remain excessive following maxillary and/or mandibular advancement surgery. This paper reviews surgical techniques applicable to posterior movement of the chin ("the setback genioplasty') and illustrates the clinical results achieved with its use.

The skeletal stability of one-piece Le Fort 1 osteotomy to advance the maxilla; Part 1. Stability resulting from non-bone grafted rigid fixation.

During the past decade, we have increasingly preferred to do a one-piece Le Fort 1 osteotomy to advance the maxilla, sometimes in isolation to treat patients with maxillary retrusive skeletal Class III patients or combined with mandibular advancement to treat bimaxillary retrusive skeletal Class II. Clinical impressions of rigid fixation techniques have indicated that there is improved stability when compared with wire fixation. There are few studies in the literature that have addressed relapse following one-piece Le Fort 1 osteotomy to advance the maxilla. Such surgery involves one single spatial movement and thereby eliminates other possible surgical variables, which may impact on the degree of stability achievable postoperatively. We studied 45 patients who had undergone a uniform one-piece maxillary advancement with elimination of controllable variables, apart from 15 patients who had simultaneous mandibular advancement. Rigid fixation was adopted throughout the study. The mean surgical change documented was 7.42 mm. The mean stability calculated at 12 months revealed a relapse of 0.72 mm (10%). This was not significant (P = 0.3). We conclude that the Le Fort 1 advancement osteotomy is a stable and surgically predictable procedure that gives only slight relapse at 12 months.

The skeletal stability of one-piece Le Fort 1 osteotomy to advance the maxilla; Part 2. The influence of uncontrollable clinical variables.

The stability of orthognathic surgery has been the subject of numerous publications over the last 20 years. It is now apparent that studies must pay attention to the homogeneity of the patients investigated and in particular, surgical techniques. In Part 2 of our study of 45 patients who had a uniform one-piece maxillary advancement with rigid fixation to advance the maxilla, we found that uncontrollable variables, including patients age, sex, the degree of advancement, and simultaneous mandibular advancement, had no effect on post-operative skeletal stability.