Surgery in head and neck cancer: United Kingdom National Multidisciplinary Guidelines.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. Surgery is one of the key modalities used in head and neck cancer treatment. Recent advances and a greater awareness of the short- and long-term toxicities associated with non-surgical modalities and newer technologies that permit minimal access resections have led to a resurgence in surgery. This paper provides an overview of the role of surgery in head and neck cancer practice.

Persistent idiopathic unilateral isolated hypoglossal nerve palsy: a case report.

Isolated hypoglossal nerve palsy (IHNP) although a rare condition, has been previously reported. A literature review revealed that in most cases, IHNP indicates the presence of an intracranial or extracranial space occupying lesion, head and neck injury, vascular abnormality, infection, autoimmune disease or neuropathy. Reports of idiopathic cases are rare and the vast majority of IHNP are reversible. We report a case of persistent idiopathic unilateral hypoglossal nerve palsy, with an emphasis on the investigations necessary to be undertaken on presentation of such a lesion.

Topical adrenaline and cocaine gel for anaesthetising children's lacerations. An audit of acceptability and safety.

OBJECTIVES: (1) To assess the acceptability of a gel solution of adrenaline (epinephrine) (1 in 2000) and cocaine (5%) for anaesthetising children's facial lacerations to the child, parent, and operator. (2) To assess the safety of the current protocol. SETTING: The emergency unit of a large university hospital. METHODS: All patients who were treated with topical adrenaline and cocaine (topAC) gel over a six month period were entered into a prospective audit (n = 75). Patient details, the nature and cause of the injury, and any treatment carried out were all recorded. The acceptability to children over 3 years of age, was assessed by the use of the Wong Baker face scale, in which 0 represents "no hurt" and 5 represents "hurts worst". The acceptability to both the parent and the operator was assessed by the use of a 0 to 9 Likert scale, where 0 represented "very acceptable" and 9 represented "not at all" acceptable. RESULTS: (1) Children aged 3 years or older graded their pain during the procedure as having a mean value of 1.17 on the Wong Baker (0 to 5) scale. Parents graded acceptability on the Likert scale (0 to 9) with a mean score of 1.13. Operators using the same grading system, recorded a mean score of 1.75. (2) No toxic side effects were seen but the protocol was updated in line with evidence. CONCLUSIONS: Topical adrenaline and cocaine is an effective anaesthetic for suturing children's facial lacerations and is acceptable to child, parent, and operator alike.

Reduction of occult metastatic disease by extension of the supraomohyoid neck dissection to include level IV.

BACKGROUND: Patients with clinically N0 necks will undergo elective removal of lymphatic tissue from levels I, II, and III as part of their routine surgical management. Level IV is omitted on the basis that there is negligible chance of containing significant occult disease. Evidence to support this approach is minimal, and the aim of this study was to increase the yield of metastatically involved lymph nodes by simply extending the supraomohyoid neck dissection (SOHND) to include level IV. METHODS: The records of 49 patients with cancer of the oral cavity undergoing extended supraomohyoid neck dissection (ESOHND) during the period January 1996-March 1999 were reviewed. All patients were staged as having N0 disease. The follow-up period ranged from 12 to 36 months. RESULTS: Thirteen of 55 N0 stage necks showed occult metastasis (26.5%). Neck failure rate occurred in 4 of 49 patients (8.2%). Neck failure rate in the pN0 group was 5.4% and in the pN+ group was 16.6%. Complication rates of ESOHND were noted as 3.6%. No long-term morbidity arose. Occult metastasis in level IV occurred in 5 of 49 cases (10%). Two cases involved other surgical levels. CONCLUSIONS: ESOHND as performed in this study removed occult level IV metastatic regional disease from an extra 10% of patients that, if the patients had undergone SOHND, would have remained undiscovered. No long-term morbidity is associated with this procedure that the authors now recommend as a first-line treatment in all patients with N0 necks.

The effect of head rotation on the diameter of the internal jugular vein: implications for free tissue transfer.

PURPOSE: To determine the effects of medial (inwards) and lateral (outwards) rotation of the head on the transverse diameter of the internal jugular vein. MATERIAL: The original study sample included 26 patients. Duplex ultrasound was used to measure the transverse diameter of the internal jugular vein at a fixed point on either side of the neck. Measurements were taken with the head central (neutral position), rotated laterally and medially. RESULTS: Using Student's t-test we found that lateral rotation of the head produced a reduction in the mean of the transverse diameters of the left and right ipsilateral vein from 6.9 mm to 5.4 mm (p < 0.03) and 5.9 mm to 5.0 mm (p = 0.2173) respectively. One patient excluded from the study because of previous neck surgery showed complete occlusion of the ipsilateral internal jugular vein on lateral rotation of the head. CONCLUSION: There is a possibility that patency of the vein could be compromised if the head is turned laterally. This situation may arise immediately after surgery in the ventilated and paralysed patient when the head may be unsupported. It could be of particular importance if the vein has been used as a recipient vein for free tissue transfer.

Strain persistence of invasive Candida albicans in chronic hyperplastic candidosis that underwent malignant change.

OBJECTIVES: The aim of this study was to assess persistence and tissue invasion of Candida albicans strains isolated from a 65 year-old patient with chronic hyperplastic candidosis (CHC), that subsequently developed into squamous cell carcinoma (SCC). MATERIALS AND METHODS: C. albicans (n=7) were recovered from the oral cavity of the patient over seven years. Confirmation of CHC and SCC in this patient was achieved by histopathological examination of incisional biopsy tissue. DNA fingerprinting was performed on the seven isolates from the CHC patient together with a further eight isolates from patients with normal oral mucosa (n=2), chronic atrophic candidosis (n=1), SCC (n=1) and CHC (n=4). Genotyping involved the use of inter-repeat PCR using the eukaryotic repeat primer 1251. Characterisation of the tissue invasive abilities of the isolates was achieved by infecting a commercially available reconstituted human oral epithelium (RHE; SkinEthic, Nice, France). After 24 h, C. albicans tissue invasion was assessed by histopathological examination. RESULTS: DNA fingerprinting demonstrated strain persistence of C. albicans in the CHC patient over a seven year period despite provision of systemic antifungal therapy. The strain of C. albicans isolated from this patient was categorised as a high invader within the RHE compared to other isolates. CONCLUSIONS: Candidal strain persistence was evident in a patient with CHC over seven years. This persistence may be due to incomplete eradication from the oral cavity following antifungal therapy or subsequent recolonisation from other body sites or separate exogenous sources. The demonstration of enhanced in vitro tissue invasion by this particular strain may, in part, explain the progression to carcinoma.

Conservative approach in the management of mandibular fractures in the early dentition phase. A case report and review of the literature.

A case is described of the management of bilateral fractures of mandible as a result of being kicked by a horse, in a 2-year-old child. The fractures were treated without any surgical intervention and the child made a good recovery with good function and appearance. The fractured mandible in children under the age of 5 years provides us with difficult treatment options. By encompassing the anatomical and developmental potential of facial tissues, both hard and soft, the majority of these cases can be managed conservatively. This negates the disadvantages of attempting potentially growth disturbing interventional surgery.

Maxillectomy--to reconstruct or obturate? Results of a UK survey of oral and maxillofacial surgeons.

Post-maxillectomy defects may be restored either by surgical reconstruction or by prostheses and there is continuing controversy about the most appropriate method of rehabilitation in any particular case. A questionnaire was designed to assess the current practices of oral and maxillofacial surgeons in the UK after resection of the maxilla for malignant disease. Maxillectomies were carried out by 83% of surgeons; most surgeons do 1-5 cases a year; 38% of surgeons do reconstruct surgically, but only in 10% of cases. Only 65% of surgeons have access to the services of a restorative dentist; this did influence 19% of surgeons' decision about whether to reconstruct surgically or restore by prosthetic means.

Complications associated with peripheral alcohol injections in the management of trigeminal neuralgia.

A retrospective study was carried out on 82 patients whose symptoms of trigeminal neuralgia were controlled by repeated peripheral alcohol nerve blocks in order to assess the associated complications. Peripheral alcohol nerve blocks were invariably associated with swelling and discomfort lasting several days. Significant complications occurred in 3 out of 413 nerve blocks administered over a 20-year period.

Prosthodontic rehabilitation in the maxilla following treatment of oral cancer.

This is the second in a two-part series on oral cancer. Part 1 focused on the surgical aspects of treatment and morbidity associated with oral cancer. In this article aspects of prosthodontic management of patients with maxillary tumours are considered, with emphasis on promoting optimal rehabilitation.

Oral rehabilitation and quality of life following the treatment of oral cancer.

This is the first of two articles concerning the surgical and prosthodontic rehabilitation of patients who have undergone surgery for cancer of the mouth. This article discusses the morbidity associated with treatment and its effect on quality of life. The second article will consider aspects of the prosthodontic rehabilitation particularly with regard to obturator construction following maxillectomy.

Peripheral surgical techniques for the management of trigeminal neuralgia--alcohol and glycerol injections.

Trigeminal neuralgia remains a difficult condition to manage. Surgery aimed at peripheral nerve branches continues to be used extensively by oral and maxillofacial surgeons. The efficacy of 68 peripheral alcohol injections (retrospective study) and 22 peripheral glycerol injections (prospective study) were assessed in comparison with peripheral cryotherapy. The results indicate that the median time for total pain control after the first alcohol block was 13 months. When individual branches were assessed it was 13 months for the infra-orbital nerve and 19 months for the inferior alveolar nerve. These results compare with the published results on cryotherapy. The results for glycerol were disappointing with a mean time of pain relief of 7 months. The results suggest that peripheral alcohol nerve blocks do still have a role to play in the management of trigeminal neuralgia, particularly in the elderly, medically compromised and those unwilling to undergo more extensive surgery. They also provide a means of temporary relief.

Neurotic excoriations complicating superficial parotidectomy--a case report.

A case is described in which division of the great auricular nerve during parotidectomy was complicated by perichondritis of the ear cartilage following self-inflicted injury. The desirability of preserving the posterior branch of the nerve whenever possible is stressed.