Sensory recovery of noninnervated free flap in oral and oropharyngeal reconstruction.

The sensory recovery of noninnervated free flaps used in oral and oropharyngeal reconstruction is analysed retrospectively to evaluate the degree of sensory recovery in different free flaps; and to assess the influence of various clinical and surgical factors on the recovery. A total of 40 patients who underwent oral and oropharyngeal reconstruction with noninnervated radial forearm (24), jejunal (10) or gastro-omental (6) free flaps were studied for at least 12 months postoperatively. The modalities examined were light touch, sharp prick, hot and cold temperature and static two-point discrimination. All the modalities showed statistically significant recovery in all flaps (p<0.05). The degree of sensory recovery for each modality is highest in the radial forearm followed by gastro-omental and lastly jejunal flaps. The differences between radial forearm and gastro-omental/jejunal flaps are statistically significant (p<0.05) except for light touch. The differences between the later two groups of flaps did not show statistical significance (p>0.05). Sensory recovery for all modalities in all flaps was not dependent on sex, age, smoking, flap size, postoperative radiotherapy or follow-up period (p>0.05).

Metastasising pleomorphic adenoma of the parotid gland.

A 33-year-old man had a left superficial parotidectomy for a pleomorphic adenoma. He remained well, but 28 years later developed a metastasis in a lymph node in the left supraclavicular fossa.

Herpes zoster associated with tooth resorption and periapical lesions.

A 72-year-old woman presented with multiple periapical lesions and resorption of teeth in a single quadrant 17 years after an attack of herpes zoster (shingles) of the maxillary division of the trigeminal nerve. It is possible that cases of tooth resorption that were previously classified as idiopathic may have a viral aetiology and we suggest that these patients should be asked about a previous attack of shingles.

Laugier-Hunziker syndrome: a rare cause of mucocutaneous pigmentation.

An 80-year-old white woman presented with brown pigmentation on both sides of the buccal mucosa and lower lip and patchy freckling in her nails, which was diagnosed as Laugier-Hunziker syndrome.

Angiolymphoid hyperplasia with eosinophilia masquerading as Kimura disease.

Angiolymphoid hyperplasia with eosinophilia is a rare benign vasoproliferative disease of unknown cause, which can present as tumour-like nodules in the head and neck. We treated a patient who showed some of the features of Kimura disease (KD), which is an important differential diagnosis, because of the latter's association with renal disease.

Post-traumatic eye observations.

Retrobulbar haemorrhage after facial trauma or surgery is an uncommon but well-documented complication. The assessment and management of this condition is variable. We asked 288 maxillofacial surgeons in the UK about the signs and symptoms, incidence, and management of retrobulbar haemorrhage. We also enquired about the regimen that they used for eye observations, the patients who, in their opinion, required observation, and the method of communication of instructions to the nursing staff. A total of 185 responded (64%). Each surgeon had seen a mean of 1.3 cases of retrobulbar haemorrhage, of which most, n=190 (91%) were treated by surgery. There were 96 different eye observations regimens documented. There was a general consensus about the signs and symptoms, and 82 (44%) of respondents used a proforma for recording eye observations. On the basis of this study we recommend a standard regimen for eye observations, and have a designed a facial injury advice sheet to be given to patients who attend the accident and emergency department and are to be discharged home and followed up at a later date.

Another use of the Foley catheter: retraction for operations on the floor of mouth and ventral aspect of the tongue.

A Foley catheter that is passed through the nose and sutured to the tip of the tongue can be used to facilitate retraction for operations on lesions on the ventral aspect of the tongue and the floor of the mouth. It provides excellent access and is simple, inexpensive, atraumatic, minimises frustration, reduces the operating time, and eliminates some of the difficulties associated with the use of metal retractors.

Intraosseous vascular anomaly (haemangioma) of the zygoma.

Intraosseous vascular anomalies are rare, and although they have been described in the facial skeleton, those occurring in the zygomatic bone are extremely rare. We report the case of a 38-year-old woman who presented with a painless hard swelling in the left zygomatic prominence, which was diagnosed as a cavernous haemangioma after a bone biopsy. The further management of this lesion in discussed, with particular reference to surgical resection and reconstruction.

Subdural empyema and herpes zoster syndrome (Hunt syndrome) complicating removal of third molars.

We report a case of subdural empyema and herpes zoster syndrome (Hunt syndrome) complicating routine removal of third molars. Subdural empyema is an extremely rare but life-threatening complication of dental sepsis arising spontaneously or after dental surgery. The clinician should be familiar with its presentation and have a high index of suspicion, because late recognition and delay in its treatment can increase the associated morbidity and mortality. Surgical procedures and in particular maxillofacial surgery have also been known to trigger varicella zoster reactivation resulting in Hunt syndrome. Some patients develop the characteristic rash several days after the onset of facial weakness, so that Hunt syndrome may initially be misdiagnosed as Bell's palsy. We highlight the difficulties in diagnosing Hunt syndrome and argue the case for early treatment of all patients with Hunt syndrome and Bell's palsy with a combination of systemic steroids and antiviral drugs.

Power modulation contrast enhanced ultrasound for postoperative perfusion monitoring following free tissue transfer in head and neck surgery.

This feasibility study evaluated whether contrast enhanced ultrasound (CEU) was able to assess free flap perfusion following free tissue transfer in the head and neck region. Thirty-six patients underwent standard clinical monitoring (SCM) and CEU postoperatively. The time taken for each technique to detect flap failure was recorded. Qualitative CEU analysis by visual assessment predicted survival in 30/30 (100%) and failure in 5/6 (83%) flaps with sensitivity, specificity, positive (PPV) and negative (NPV) predictive values of 100, 86, 97 and 100%, respectively. Quantitative CEU measurement of blood volume (α) values within healthy perfused flaps was over 60 times higher than in failing flaps (8.25±2.82dB vs. 0.12±0.17dB, respectively, P<0.0001). If a cut-off α value of <1.5dB was used to predict future flap failure, the accuracy of the test was 100% (sensitivity, specificity, PPV, NPV). If a cut-off α value of >1.9dB indicated flap success, the PPV and NPV are 100%. Following surgery, SCM took 76 (±15) h to detect flap failure compared with 18 (±38) h with CEU (P<0.05). CEU is highly accurate in its ability to distinguish between perfused and failing flaps. The technique is quick (<10min) and capable of imaging all flap types.

An orbital apex fracture resulting in multiple cranial neuropathies.

Fractures of the orbital apex are rare after trauma, but can be devastating if associated with indirect traumatic optic neuropathy and a permanent visual defect. Computed tomography plays an important role in the diagnosis and classification of these fractures, but optimal treatment is controversial. We describe an isolated fracture of the orbital apex in a 15-year-old boy resulting in indirect traumatic optic neuropathy and palsies of cranial nerves III, IV and VI after a blunt injury to the face.

Incidence of sarcoidosis in head and neck cancer.

Sarcoidosis and sarcoid-like reactions have been reported to be associated with malignancies, particularly testicular cancer and lymphoma. They occur either synchronously or metachronously, and may also occur after chemotherapy. We know of only two other case reports of granulomatous reactions in head and neck cancer. The present case highlights the association of sarcoidosis with head and neck cancer, and the importance of considering the diagnosis in patients who may have metastatic disease.