Reusable respirators as personal protective equipment during ENT surgery.

BACKGROUND: Robust personal protective equipment is essential in preventing the transmission of coronavirus disease 2019 to head and neck surgeons who are routinely involved in aerosol generating procedures. OBJECTIVE: This paper describes the collective experience, across 3 institutes, of using a reusable half-face respirator in 72 head and neck surgery cases. METHOD: Cost analysis was performed to demonstrate the financial implications of using a reusable respirator compared to single-use filtering facepiece code 3 masks. CONCLUSION: The reusable respirator is a cost-effective alternative to disposable filtering facepiece code 3 respirators. Supplying reusable respirators to individual staff members may increase the likelihood of them having appropriate personal protective equipment during their clinical duties.

Can head and neck cancer patients be discharged after three years?

BACKGROUND: Follow-up surveillance of head and neck cancer patients varies throughout the UK. The heterogeneity of these patients limits the applicability of a standardised protocol. Improvements in our understanding of the natural history of the disease may assist in the tailoring of resources to patients. METHOD: Prospective data collected at the Cumberland Infirmary over a 13-year period were analysed, primarily focusing upon recurrence rates and time to recurrence. RESULTS: In keeping with other studies, recurrence of head and neck squamous cell carcinoma was found to be maximal within the first three years of treatment, regardless of subsite. CONCLUSION: Hospital-based surveillance may be safely discontinued after three years for some patients. Laryngeal carcinoma may require further surveillance due to possible delayed recurrence of a second primary formation. Emphasis must be placed on patient education, accessibility to head and neck services, and the existence of a robust system to facilitate urgent referrals.

The sumatriptan/naratriptan aggregated patient (SNAP) database: aggregation, validation and application.

Pooled data from multiple clinical trials can provide information for medical decision-making that typically cannot be derived from a single clinical trial. By increasing the sample size beyond that achievable in a single clinical trial, pooling individual-patient data from multiple trials provides additional statistical power to detect possible effects of study medication, confers the ability to detect rare outcomes, and facilitates evaluation of effects among subsets of patients. Data from pharmaceutical company-sponsored clinical trials lend themselves to data-pooling, meta-analysis, and data mining initiatives. Pharmaceutical company-sponsored clinical trials are arguably among the most rigorously designed and conducted of studies involving human subjects as a result of multidisciplinary collaboration involving clinical, academic and/or governmental investigators as well as the input and review of medical institutional bodies and regulatory authorities. This paper describes the aggregation, validation and initial analysis of data from the sumatriptan/naratriptan aggregate patient (SNAP) database, which to date comprises pooled individual-patient data from 128 clinical trials conducted from 1987 to 1998 with the migraine medications sumatriptan and naratriptan. With an extremely large sample size (>28000 migraineurs, >140000 treated migraine attacks), the SNAP database allows exploration of questions about migraine and the efficacy and safety of migraine medications that cannot be answered in single clinical trials enrolling smaller numbers of patients. Besides providing the adequate sample size to address specific questions, the SNAP database allows for subgroup analyses that are not possible in individual trial analyses due to small sample size. The SNAP database exemplifies how the wealth of data from pharmaceutical company-sponsored clinical trials can be re-used to continue to provide benefit.

Role of computerized tomography (CT) scan of the chest in patients with newly diagnosed head and neck cancers.

Chest metastases and second primaries are not uncommon in patients with head and neck cancer. Early detection of a second site of malignant disease may alter prognosis and management. This study assessed the diagnostic yield of chest radiographs compared with computerized tomography (CT) in a series of patients with head and neck cancer. Forty-four consecutive patients with a head and neck squamous cell carcinoma (SCC) attending the head and neck surgery department of Cumberland Infirmary, Carlisle, between January 2000 and December 2000 were included in this prospective study. Patients with lymphomas and localized cancers of the skin and lip were excluded. Thirty men and 14 women, with a mean age of 67 years, were assessed. All had chest radiographs and chest CT at the same time as the CT scan of the primary site. Only one patient had a true positive finding on chest radiograph. Five patients had an abnormal chest CT. Of these, two had multiple lung metastases, and another patient had biopsy-proved bronchogenic carcinoma and underwent surgical excision. The sensitivity and specificity of CT scan was 100% and 95%, as opposed to 33% and 97% for chest radiograph.

Sumatriptan nasal spray and cognitive function during migraine: results of an open-label study.

OBJECTIVE: To examine measures of cognitive function during acute migraine, before and after treatment with sumatriptan nasal spray, 20 mg. BACKGROUND: Migraineurs frequently report symptoms of cognitive impairment during migraine. The efficacy of sumatriptan for treatment of migraine-related cognitive impairment is undocumented. METHODS: This open-label, single-attack study of 28 subjects used the Headache Care Center-Automated Neuropsychological Assessment Metrics, a computerized neuropsychological assessment battery, to measure cognitive function under three patient conditions: migraine-free, untreated migraine, and following sumatriptan (primary outcome). Headache response and pain-free response, percent effectiveness, and clinical disability were measured. RESULTS: Cognitive function (simple reaction time, sustained attention/concentration, working memory, visual-spatial processing) and alertness/fatigue were adversely affected during migraine compared with migraine-free performance (P<.05), and rapidly restored following sumatriptan nasal spray, 20 mg (P<.05). Headache and pain-free response were 86% and 68%, respectively, at 135 minutes postdose. Changes in migraine pain severity, clinical disability, and percent effectiveness following treatment with sumatriptan nasal spray, 20 mg, were significantly correlated with cognitive function measures across all subtests (P<.001). CONCLUSIONS: Sumatriptan nasal spray, 20 mg, restored migraine-related cognitive function and clinical disability.

Treatment of squamous cell carcinoma of the lip using Foscan-mediated photodynamic therapy.

Carcinoma of the lip is a common cancer of the head and neck area; its incidence is approximately one-quarter that for oral cavity cancers. It occurs most frequently on the lower lip of elderly males. This non-randomized Phase II study aimed to estimate the complete response (CR) rate to Foscan-mediated photodynamic therapy (Foscan-PDT) in patients with primary cancer of the lip, duration of CR, and the tolerability and safety of Foscan-PDT. Twenty-five patients with squamous cell carcinoma (SCC) of the lip (Tis, T1, T2/N0/M0) and Karnofsky status > or = 70 received 0.15 mg/kg Foscan intravenously, followed 4 days later by a single non-thermal illumination of the tumour (light dose 20 J/cm2, irradiance 100 mW/cm2, lambda=652 nm). Response was determined after 12 weeks and mean follow up is 424 days so far. After 12 weeks, 96% of cases (24/25) showed CR, and all CRs were confirmed by biopsy. The most common adverse event was swelling and local pain at the treatment site. Tumour recurrence was observed in two patients 4 and 18 months after PDT. One patient developed a single lymph node metastasis 7 months after therapy. Photosensitivity reactions occurred in five patients. The functional results were excellent in all patients without any signs of limited mouth opening or impaired lip closure. The cosmetic outcome was better than after surgical therapy. Foscan-PDT is an effective treatment modality for small primary tumours of the lips. Foscan-PDT yields complete response rates comparable to those published for surgery or radiotherapy without causing major toxicity. It allows preservation of form and function and does not compromise future treatment options for recurrent, residual or second primary disease.

Naratriptan efficacy in migraineurs who respond poorly to oral sumatriptan.

OBJECTIVES: To determine whether 347 patients would respond to a 50-mg oral dose of sumatriptan, even though they considered themselves poor responders to this acute therapy for migraine, and to investigate whether oral naratriptan can be an effective acute therapy for migraine in the subset of patients who did not respond to sumatriptan under double-blind, well-controlled conditions. BACKGROUND: Although most migraineurs respond to sumatriptan, there remains a need for an effective alternative for those who do not respond. Naratriptan is a more potent and more lipophilic member of this class of agent and could prove beneficial in such patients. This is the first well-controlled study to assess the value of another 5-HT1B/1D agonist in this difficult patient subset. METHODS: This study comprised two migraine attacks. The first (attack 1) was a single-blind assessment of the efficacy of sumatriptan (50 mg orally) in patients with a history of poor response to the drug. The second (attack 2) was a randomized, parallel group, double-blind, placebo-controlled trial of naratriptan (2.5 mg orally) in nonresponders to oral sumatriptan. RESULTS: Attack 1: About two thirds of this selected migraine population did not respond to sumatriptan. Attack 2: Naratriptan was statistically superior to placebo for headache relief at 2 hours and 4 hours, as well as for most other features of migraine attacks. These data suggest an intrinsic efficacy of naratriptan in this patient subset and not a coincidental response. No unexpected tolerability issues arose. CONCLUSIONS: Naratriptan is an alternative therapy for migraineurs who respond poorly to oral sumatriptan. No response to one "triptan" does not necessarily predict no response to them all.

Migraine polypharmacy and the tolerability of sumatriptan: a large-scale, prospective study.

Polypharmacy (the prescription of more than one therapy for a single patient) and subcutaneous (s.c.) sumatriptan tolerability were prospectively studied in 12,339 migraineurs, each followed for up to 1 year. Inclusion/exclusion criteria were minimal and mirrored United States Imitrex labeling. Drug usage and compliance monitoring were automatically interfaced with prescription refill. Concomitant drugs were used by 79% of patients, with analgesics, antidepressants, and sedatives used most commonly. No adverse interactions between sumatriptan and neurological drugs were found, possibly reflecting relative inability of the former to cross the blood-brain barrier. No difference in cardiovascular adverse events was associated with oral contraceptive use, which was more common than expected. No other drug class influenced adverse event probability, although sample sizes for these comparisons was sometimes <400 patients. This study confirms the prevalence of polypharmacy in migraine, identifies the drugs used, and concludes that, on a population basis, the tolerability of s.c. sumatriptan, when used according to labeled instructions, is unaffected by these concomitant drugs.

Craniosynostosis in babies: complications and management of 40 cases.

Forty consecutive craniofacial cases in babies operated on in a district general hospital by a craniofacial team consisting of maxillofacial and neurosurgeons are reviewed with regard to diagnosis, surgical treatment, complications and outcome. Surgery achieved the release of craniosynostosis and the treatment protocol, and perioperative complications are discussed. Dural breaches occurred on four occasions with no postoperative sequelae. Blood transfusion was required in all cases with an average replacement of 36 percent estimated blood volume (EBV). No central nervous system complications occurred but in one case a brachial plexus haematoma resulted in a temporary neuropraxia to the shoulder. No major infections or deaths occurred in this series.

Screw fixation following bilateral sagittal ramus osteotomy for mandibular advancement--complications in 700 consecutive cases.

The use of transbuccal positional screws for stabilisation of bony segments following bilateral sagittal split osteotomy for mandibular advancement was assessed in 700 consecutive cases. In 19 patients (2.7% of cases) screw fixation was not used as the method of fixation. Screw removal was performed in 20 patients (2.8% of cases), in 15 cases due to infection and 5 cases for diverse reasons. The incidence of inferior alveolar nerve damage was increased when compared to a group of patients managed with intermaxillary fixation following advancement BSSO treated in the same unit. In 4 patients (0.6%) a lingual nerve dysaesthesia occurred. Screw loosening in the first postoperative week occurred in 4 patients and in 3 of these re-operation was necessary. Extra oral scar formation did not give rise to any significant problems.

Columella reconstruction in midline facial cleft: a case report.

Columella reconstruction in a case of midline cleft of lip alveolus and palate with nasomaxillary hypoplasia is described. The use of an Abbe flap to provide locally available tissue for reconstruction is discussed.

Facial scoliosis--a diagnostic dilemma.

Facial scoliosis may be caused by frontal plagiocephaly or muscular torticollis. Determining the correct cause has implications for patient management. Past confusion in the literature has led to difficulty in determining appropriate treatment plans. The correct diagnosis may be readily obtained by using a series of clinical and radiological features peculiar to each condition. Four cases are shown demonstrating these diagnostic features.

Stability of the osteotomy site following bilateral sagittal split osteotomy: screw fixation v IMF.

In a group of patients with mandibular deficiency with a low to normal mandibular plane angle (mean 20.7 degrees, range 10-28 degrees) and deep bite, the position of the condylar segment relative to the mandibular body, following bilateral sagittal split osteotomy (BSSO) for mandibular advancement was assessed. Ten patients in whom intermaxillary fixation (IMF) was used for a 5-week period were compared to 10 patients where 2 mm diameter Wurzburg positional screws were used as internal fixation. Six patients who were known bruxists and underwent BSSO were also reviewed. No clinically significant changes were seen in any patient group and no significant differences were found in the relationship with time between the condylar and body segments, irrespective of the fixation method used.

Therapeutic arterial embolisation of vascular lesions in the maxillofacial region.

The technique of therapeutic arterial embolisation involves the introduction of a thrombus-inducing material into the lumen of a blood vessel to occlude the vessel and reduce the blood supply to a lesion or to a specific part of the body. It is particularly useful in the maxillofacial region in the management of vascular lesions where marked diminution in blood flow can be achieved. This paper reviews the procedure and the materials for embolisation, and describes four patients for whom it was of considerable assistance.