Metastases in the cervical spine from primary head and neck cancers: current concepts of diagnosis and management.

Vertebral metastases from primary head and neck cancers are uncommon, and so there are no clear guidelines about management. The spinal cord can be compressed by a vertebral fracture or invasion of a tumour, and may present as an oncological and spinal emergency. The goals of treatment are to relieve pain and maintain neurological function. However, surgical treatments in this group of patients have not been defined, and primary operative treatment of spinal metastases remains controversial. Here we discuss their contemporary management. Surgical options should be considered for treatment to achieve stability of the spine, relieve pain, and preserve neurological function in certain cases.

Tattoos: could they be used to advantage as a medical alert in oral and maxillofacial surgery?

Many publications have addressed the medical complications of tattoos, but to our knowledge there are no reports of their use to alert people in our field of potentially dangerous conditions. We present a new way to inform oral and maxillofacial colleagues about patients with a history of malignant hyperthermia (or any other life-threatening medical problem) and discuss the potential advantages and disadvantages of medical alert tattoos.

Contemporary management of cleft lip and palate in the United Kingdom. Have we reached the turning point?

Babies born with clefts of the lip, and the alveolus or palate, or both, require multidisciplinary, highly specialised treatment from birth to early adulthood. We review the contemporary management of clefts and outline the current treatment protocol adopted by cleft networks in the United Kingdom. We also look at the level of evidence and the restructuring of services that has defined current practice. In light of the recent Cleft Care UK study, we ask whether it is now time to adopt a new philosophy towards the surgical techniques that are used.

Woody hardness - a novel classification for the radiotherapy-treated neck.

The term 'woody neck' is widely used by surgeons and oncologists to describe the fibrosis that can occur following radiotherapy for head and neck malignancy. These soft tissue and skin changes can be compounded by neck dissection, either before or after radiotherapy. To our knowledge, there is no classification published in the literature to describe the degree of woody hardness following treatment. We propose a simple ABC classification for varying degrees of indurated oedema and neck fibrosis secondary to radiotherapy or long-standing pathology, using the hardness of different woods to enable a suitable description to be made of severity.

Does the great auricular nerve predict the size of the main trunk of the facial nerve? A clinical and cadaveric study.

There seems to be only individual clinical experience and some anecdotal evidence about a relation between the width of the great auricular nerve (GAN) and the size of the main trunk of the facial nerve during parotidectomy. To our knowledge no anatomical studies have been published. In this cadaveric and clinical study we measured the widest point of the GAN as it crosses the sternomastoid muscle before it divides, and the main trunk of the facial nerve before it bifurcates. Measurements were obtained from 16 patients who required formal superficial parotidectomies with identification of the facial nerve, and from 21 cadavers (16 formalin-fixed and 5 fresh frozen) where both sides were dissected. We recorded the results and the side of dissection. The mean (SD) width of the GAN and facial nerve from all the dissections was 2.75 (0.53)mm and 2.83 (0.54)mm, respectively. There was a strong correlation between the width of the nerves from both sides (left: r=0.934, p<0.001; right: r=0.940, p<0.001). The nerves did not differ significantly in size in patients or cadavers (GAN: right, p=0.873; left, p=0.486; facial nerve: right, p=0.931; left, p=0.691). We have found that the GAN accurately predicts the width of the main trunk of the facial nerve. This is particularly useful surgically as a narrow GAN can alert the surgeon to expect a small facial nerve.

Perils of dermal fillers.

With the increasing use of hyaluronic acid-based injectable fillers for cosmetic enhancement a variety of adverse reactions are being reported in the literature. Although most adverse outcomes occur early we describe an interesting case study of a female presenting with granulomatous complications ten years postoperatively. To our knowledge this is one of the longest reported delayed reactions. For the general dental practitioner offering such treatments it is important to be fully aware of the potential risks and how they may be managed in order to consent appropriately for cosmetic procedures.

Surgical management of metastases that involve the carotid artery in cases of primary squamous cell carcinoma of the head and neck.

The surgical management of advanced cervical metastases with carotid artery involvement in patients with primary squamous cell carcinoma of the head and neck can be difficult. The authors retrospectively reviewed 73 patients over a 15-year period comparing the outcomes of carotid artery resection versus peeling the tumour off the carotid artery. Based on these findings, the authors suggest that in the absence of carotid wall involvement, nodal metastatic tumour should be peeled off the carotid artery where possible. This practice appears to have a lower morbidity than that associated with arterial reconstruction. Steps to minimize cerebrovascular injury are discussed.

Odontogenic skin sinus: a commonly overlooked skin presentation.

Facial skin lesions present routinely to clinic and are largely dermatological in origin. Odontogenic infections are an unusual cause of facial lesion and are well-described in the dental literature; however they are regularly overlooked and mismanaged, often to considerable aesthetic detriment. We present such a case and highlight important avoidable pitfalls.

Short communications published online in the British Journal of Oral and Maxillofacial Surgery during 2010-2011.

The British Journal of Oral and Maxillofacial Surgery (BJOMS) publishes many types of papers including original articles, review articles, and short communications. Many of the latter are isolated case reports of rare or interesting diseases or of difficult or unexpected complications. While case reports are sometimes considered to be of little educational or clinical value, and as such do little to advance medical knowledge, they do have an important role, and many trainees begin their publishing careers writing such papers. There is increasing pressure for space in paper medical journals and, for this reason, some journals either limit or do not publish short publications in print copy but instead put them online. Using established criteria, we previously evaluated all 142 short communications published in the BJOMS during 2008-2009 and found that 48% of them had little or no educational value. As a result, the editorial board of BJOMS took the decision to publish most short communications online only. We have now analysed 48 short communications that were published online only during 2010-2011. Most (80%) were single case reports that covered virtually the whole remit of the specialty, and over half (56%) were published by authors based in the UK. While many of these papers did not add important new information to existing knowledge, these types of article are clearly of value both for trainees and for experienced surgeons. We think that these should continue to be supported as, in addition to their educational value, they are an excellent way for trainees to start to write.

Acute vasculitis resulting in free flap failure: the importance of early recognition and options for management.

Unusual or unexpected medical causes for free flap failure do occur but are uncommon. We present a rare case of a fibula free flap failure due to an acute vasculitis which was undiagnosed until after the flap had failed. In addition to two successful flap salvages and intravenous heparin, an epoprostenol infusion was commenced but a third salvage was not successful. The vasculitis resulted in marked blood vessel wall thickening, and cutaneous manifestations which presented as late signs. High peri-nuclear anti nuclear cytoplasmic antibody (pANCA) and myeloperoxidase (MOP) titres were subsequently found and histology from several blood vessels showed marked inflammation throughout the wall. A diagnosis of microscopic polyangiitis was made and high dose steroids were subsequently commenced. Interestingly, he had vasculitis several years previously treated with oral steroids but had been discharged from the rheumatology clinic. This rare case illustrates the potential hazards of free flap surgery in the vasculitides and discusses the warning signs and various management options to reduce the likelihood of flap failure in these patients.

Amaurosis, ophthalmoplegia, ptosis, mydriasis and periorbital blanching following inferior alveolar nerve anaesthesia.

BACKGROUND: Ophthalmic complications following inferior alveolar nerve anaesthesia are rare. They include transient blindness (amaurosis), ophthalmoplegia, ptosis, mydriasis and diplopia. These events may occur following the intravascular administration of anaesthetic solution and are distressing to both patient and operator alike. CASE REPORT: We report the unusual case of a young patient who experienced amaurosis, total ophthalmoplegia, complete upper eyelid ptosis, mydriasis and periorbital blanching following inferior alveolar nerve anaesthesia. Similar but less profound signs were observed in the same patient on a subsequent occasion. This was following general anaesthesia, during which she had received local anaesthetic prior to mandibular wisdom tooth removal. CONCLUSIONS: Ophthalmic complications following inferior alveolar nerve anaesthesia are rare but distressing events. In particular, amaurosis is an extremely rare event and usually heralds a more sinister pathology such as stroke. Clinicians should be aware of these complications to minimise anxiety and reassure their patients appropriately.

Timing of pre-emptive tenoxicam is important for postoperative analgesia.

PURPOSE: In this prospective randomized study, a comparison was made between the efficacy of 20 mg tenoxicam, administered either, 30 min preoperatively or at induction of anesthesia, for the relief of postoperative pain in patients undergoing ambulatory breast biopsy. METHODS: Seventy-three patients were recruited and all received a standard anesthetic consisting of induction with 2 mg x kg(-1) propofol followed by 5 microg x kg(-1) alfentanyl. No premedication was administered and at the end of the procedure the wounds were infiltrated with 10 ml of bupivacaine (0.5%). Patients were randomized to receive 20 mg tenoxicam intraveneously either 30 min before surgery or at induction of anesthesia. RESULTS: Demographic criteria were similar in both groups. There were differences in pain scores at 30, 60, 120 and 240 min postoperatively (VAS at 30 min 3.2 +/- 1.2 vs 5.5 +/- 1.8; P < 0.001: VAS at 60 min 1.8 +/- 1.2 vs 3.7 +/- 1.9; P < 0.001: VAS at 120 min 0.9 +/- 0.9 vs 1.7 +/- 1.0; P = 0.003: VAS at 240 min 0.5 +/- 0.5 vs 1.1 +/- 0.8; P < 0.001: Expressed as mean +/- SD). There was a difference in the number of patients requiring additional analgesia, in the first four hours postoperatively (12 (33%) vs 27 (73%); P = 0.001) and a difference in the time to additional analgesia in these patients (87.5 +/- 32.5 vs 55.0 +/- 26.8 min; P = 0.002). CONCLUSION: Early administration of pre-emptive tenoxicam 30 min before induction of anesthesia improves postoperative analgesia in patients undergoing ambulatory breast biopsy.

Preemptive bupivacaine offers no advantages to postoperative wound infiltration in analgesia for outpatient breast biopsy.

BACKGROUND: Adequate analgesia is important after surgery and in particular after ambulatory surgery. Preemptive administration of analgesics, ie, prior to commencing surgery, has many theoretical advantages. METHODS: In this prospective randomized study, the use of preincisional bupivacaine was compared with a postincision dose for the relief of postoperative pain, in 74 patients undergoing day-case breast biopsy. RESULTS: Demographic criteria were similar in both groups. There were no differences in pain scores postoperatively on the visual analog scale (VAS): VAS at 30 minutes 4.5 ([SD] 2.4) versus 4.7 (1.9); P = not significant (NS); VAS at 60 minutes 3.3 (2. 3) versus 3.6 (2.2); P = NS; VAS at 120 minutes 1.9 (1.7) versus 2.5 (2.0); P = NS; VAS at 240 minutes 0.9 (1.0) versus 1.3 (1.4); P = NS. There was no difference in the number of patients requiring additional analgesia: 13 (36%) versus 18 (47%); P = NS. Nor was there a difference in the time to additional analgesia: 55.0 (37.8) versus 55.3 (39.2) minutes; P = NS. CONCLUSIONS: The administration of local anaesthesia prior to starting surgery does not appear to have any advantage over its postoperative administration in patients undergoing ambulatory breast biopsy.

An assessment of the value of intraperitoneal meperidine for analgesia postlaparoscopic tubal ligation.

UNLABELLED: Patients undergoing laparoscopic procedures may experience postoperative pain. The intraperitoneal (IP) administration of drugs is controversial but has proven effective in some studies for the relief of postoperative pain. However, some investigators have not been able to confirm the analgesic efficacy of IP local anesthetics. The administration of IP opioids for the relief of postoperative pain has received little attention. At the end of laparoscopic tubal ligation, 100 patients received 80 mL of 0.125% bupivacaine with 1:200,000 epinephrine IP and 50 mg of meperidine either IP or IM. Postoperative pain scores were measured at rest and with movement. Pain scores were significantly lower in the group receiving the IP meperidine both at rest (P: < 0.01) and with movement (P: < 0.05). We conclude that the combination of intraperitoneal bupivacaine and intraperitoneal meperidine was better than the combination of IP bupivacaine and IM meperidine for postoperative analgesia in patients undergoing laparoscopic tubal ligation. IMPLICATIONS: The combination of bupivacaine and meperidine delivered to the intraperitoneal cavity proved superior to equivalent doses of intraperitoneal bupivacaine and IM meperidine for postoperative pain relief in patients undergoing laparoscopic tubal ligation. Intraperitoneal delivery of analgesia proved effective in this study and merits further study and more widespread use.