Mandibular central mucoepidermoid carcinoma with distant metastasis.

Mucoepidermoid carcinoma is the most common malignant salivary gland tumour. Central mucoepidermoid carcinomas (CMC) are an exceedingly rare subgroup, representing 2-4% of all cases. The authors report on a case of CMC in a patient who presented with trigeminal neuropathy, trismus and distant metastasis. The possible pathogenesis of CMC and criteria for diagnosis are discussed.

Serum testosterone levels in surgeons during major head and neck cancer surgery: a suppositional study.

Serum testosterone levels are known to have diurnal variation and to decrease by up to 2% per year after the age of 40. They can also be affected by stress and aggressive behaviour as well as various medical conditions. Although studies have investigated the role of mood and stress, none has specifically evaluated the effect of operative procedures on surgeons testosterone levels, particularly those in our own specialty, one that has historically been associated with perceived 'high testosterone' levels. We devised a suppositional study, particularly pertinent for publication at the beginning of April. This was a prospective randomised study of five male consultant maxillofacial surgeons (including two with male pattern baldness) and assayed serum testosterone levels at rest, during, and after a series of major ablative and reconstructive procedures. The resting testosterone levels were found to be similar in all surgeons (220 ± 120.9 mcg/ml). During major head and neck procedures, a statistically significant increase in serum testosterone was found (up to a maximum concentration of 1062.50 mcg/ml). Multivariate analysis revealed that the likely predictors of increasing serum testosterone were: size and extent of tumour and complexity, and type of microvascular reconstruction (all P<0.001). The long-term effects of chronically raised serum testosterone warrant further investigation but recent evidence has found that it may be cerebro-protective against conditions including Alzheimer's syndrome.

A chylous cyst at the right base of the neck.

A case is presented of a cystic lesion, which presented at the base of the right side of the neck. The lesion was more obvious on forced expiration. Aspiration revealed chylous fluid and a Magnetic Resonance Imaging (M.R.I.) scan revealed a well-circumscribed cystic lesion with no deeper extension. So far, this chylous cyst has not required treatment, but is being kept under regular review.

Novel diamond-coated tools for dental drilling applications.

The application of diamond coatings on cemented tungsten carbide (WC-Co) tools has been the subject of much attention in recent years in order to improve cutting performance and tool life in orthodontic applications. WC-Co tools containing 6% Co metal and 94% WC substrate with an average grain size of 1 - 3 microm were used in this study. In order to improve the adhesion between diamond and WC substrates it is necessary to etch cobalt from the surface and prepare it for subsequent diamond growth. Alternatively, a titanium nitride (TiN) interlayer can be used prior to diamond deposition. Hot filament chemical vapour deposition (HFCVD) with a modified vertical filament arrangement has been employed for the deposition of diamond films to TiN and etched WC substrates. Diamond film quality and purity has been characterized using scanning electron microscopy (SEM) and micro Raman spectroscopy. The performances of diamond-coated WC-Co tools, uncoated WC-Co tools, and diamond embedded (sintered) tools have been compared by drilling a series of holes into various materials such as human tooth, borosilicate glass, and acrylic tooth materials. Flank wear has been used to assess the wear rates of the tools when machining biomedical materials such as those described above. It is shown that using an interlayer such as TiN prior to diamond deposition provides the best surface preparation for producing dental tools.

Prognostic value of facilitative glucose transporter Glut-1 in oral squamous cell carcinomas treated by surgical resection; results of EORTC Translational Research Fund studies.

Hypoxia in tumours of the oral cavity has not been extensively investigated with regard to clinical outcome and prognosis. The expression of the facilitative glucose transporter, Glut-1, has been shown to be related to hypoxia in tumours at other sites. The aim of the present study was to investigate the relationship between Glut-1 expression and clinical outcome in a series of oral squamous cell carcinomas. A retrospective series of 54 cases of oral squamous cell carcinomas with known clinical outcome and treated by one surgeon over a period of 6 years was used in the study. A representative section from each case was stained immunohistochemically with an antibody against Glut-1. The stained sections were then assessed independently by two observers using a semi-quantitative method. The relationship between these results and the clinical outcomes of local recurrence, regional lymph-node metastasis and disease-free survival were examined. Glut-1 staining was observed in most of the tissue specimens and all of the few sections with demonstrably necrotic areas histologically. Some showed more prominent staining in the epithelial islands of the tumour than others. However, the intensity of staining was variable. There was a significant relationship between those tumours which demonstrated intense staining and recurrence overall (chi(2)=6.18, P=0.032). This relationship was strongest in relation to regional lymph-node recurrence (chi(2)=10.19, P=0.005). A significant relationship between disease-related death and intense Glut-1 staining was also observed (chi(2)=11.67, P=0.002). In conclusion, the results of this study indicate a relationship between Glut-1 expression and disease progression of oral cancer and could indicate a need for neoadjuvant chemoradiotherapy for those tumours demonstrating intense Glut-1 expression.

Do frozen sections help achieve adequate surgical margins in the resection of oral carcinoma?

This retrospective study examined the notes of 82 patients who underwent an attempted curative resection of oro-pharyngeal carcinoma, and who had frozen sections taken, over a four year period. Three hundred and fifty mucosal, 179 deep tissue, and 22 nerve frozen sections had been taken. Concordance between cryostat and paraffin sections was 99.5% although no false positives or negatives for invasive tumour were found. Nine (11%) patients who had frozen sections which were reported as dysplastic or positive for invasive tumour underwent further local resection; excision was then found to be complete in 8 (10%) of these patients with further frozen sections. In 15 patients the margins of the main resection specimen were judged to be close to the tumour (<5mm), 5 patients had squamous epithelial dysplasia and 12 patients had invasive tumour at a resection margin. Ten of the 12 patients with margins containing invasive tumour had negative cryostat sections intraoperatively, which demonstrated problems with sampling which is the major drawback. During follow up, 14 patients developed local recurrence. Only one of the patients who had frozen section guided further local resection, developed local recurrence. Frozen sections help achieve tumour clearance.

Lethal invasive mucormycosis: case report and recommendations for treatment.

A case of lethal invasive mucormycosis (IM), a rare fungal infection which predominantly affects immunocompromised patients, is reported in a 73-year-old female patient who presented with a cervical abscess. The patient had asthma treated with steroids and had previously undiagnosed diabetes mellitus. Despite surgical treatment and parenteral antibiotic therapy, there was fatal progression of the condition. The pathogenesis, histological appearances and treatment of mucormycosis are discussed, particularly the importance of urgent histological examination of debrided tissue to distinguish this condition from necrotizing fasciitis (NF) earlier than microbiological culture alone would allow, thus permitting the early introduction of appropriate antifungal therapy.

Catecholamine sensitivity in the rat femoral artery after microvascular anastomosis.

Tissue can demonstrate vasospastic instability after microvascular anastomosis. This study investigates the in vitro effect of increasing concentrations of phenylephrine on the rat femoral artery after microvascular anastomosis. Bilateral groin flaps based on the inferior epigastric artery were raised on 55 Wistar male rats. On the test side, a microvascular anastomosis was performed, but not on the control side. On days 2-12 postoperatively, the rats were sacrificed and the femoral arteries harvested and suspended in increasing concentrations of phenylephrine. The vascular tone on the test and control sides were recorded and compared. Increased sensitivity was found on the test side as compared with the control side (P = 0.000). This supersensitivity to phenylephrine was blocked by the addition of phentolamine and it is believed to be the result of sympathetic denervation, which occurs when the sympathetic fibers are cut during the harvesting of the flap. The resulting vascular instability is believed to contribute to flap failure.

Eagle's syndrome: an unusual cause of a clicking jaw.

Calcification of the stylohyoid ligament is a well recognised radiographic finding in dental practice. Fortunately, affected individuals seldom develop symptoms. We report a case of a patient whose main complaint was a loud click following jaw movement. This unusual presentation has not been described before and should be considered in the differential diagnosis of 'clicking jaw'.

Need for intensive care after operations for head and neck cancer surgery.

We compared the postoperative morbidity of 44 patients who had had major head and neck oncological resections and who were nursed postoperatively on a general ward with that of 33 who were nursed on an intensive care unit at North Manchester General Hospital and Withington Hospital, South Manchester, respectively. There was no difference in the general morbidity (9/44, 20% compared with 9/33, 27%, 95%, CI of difference -0.26 to 0.13). We conclude that it is safe to nurse the patients on a general ward provided that certain conditions are fulfilled.

Anatomy of a "black eye": a newly described fascial system of the lower eyelid.

The anatomy of a black eye is examined in a series of cadaver dissections in which a previously unreported fascial system of the lower eyelid is identified. This fascia originates at the orbital rim, and is in continuity with the orbital septum and with the periosteum of the orbital floor and anterior maxillary wall. This fascia contributes to the thickened area along the orbital rim called the arcus marginale. At the level of the orbicularis oculi muscle, this fascia was noted microscopically to fuse with a fibrous septa of the superficial cheek fat. This creates one long continuous membrane from the orbital rim above to the cheek skin below. Dye injection techniques show that this membrane is impermeable and traps injected dye in the same place where a black eye forms. After periorbital injury, extravasated hemoglobin pigment is confined to the area above the cutaneous insertion of this membrane. This fascial system has been named the septum malaris: malar describes its origin along the orbital rim of the cheek, and septum further describes the partitioning nature of this ultra-thin membrane.

Malignant melanoma of the parotid gland: a case report and literature review.

A case is reported of a malignant melanoma presenting in a parotid gland with no other primary lesion detectable. The pathological feasibility of primary malignant melanoma of the parotid is discussed together with a review of the literature.

A double-blind comparative study of soluble aspirin and diclofenac dispersible in the control of postextraction pain after removal of impacted third molars.

The analgesic efficacy and patient acceptability of soluble aspirin and diclofenac dispersible were compared in patients with postoperative pain after removal of impacted third molars. A total of 136 patients were randomly allocated to receive soluble aspirin 600 mg tds or diclofenac dispersible 50 mg tds after extraction under local anaesthesia of impacted third molars on one side of the mouth. The medication, which was both patient and operator blind, was reversed after extraction of the contralateral third molars 3 weeks later, the patients acting as their own controls in assessing postoperative pain, pain relief, and interincisal opening. Patients receiving diclofenac dispersible recorded significantly lower pain levels; pain relief was significantly greater and the patients' assessment significantly favoured diclofenac dispersible. Interincisal opening throughout the study period was significantly increased in the diclofenac dispersible group. The surgeons' postoperative assessment of extraction sites showed no significant difference between the two treatment groups in rate of healing. Two patients reported side-effects while taking soluble aspirin, and eight while taking diclofenac dispersible, two of whom discontinued treatment.

Remanipulation or external fixation after slipped Colles' fractures? An anatomical study.

A series of 50 consecutive patients with Colles' fractures which redisplaced after reduction underwent either remanipulation and a plaster cast or remanipulation and external fixation. The external fixator group achieved a significantly better anatomical result than simple remanipulation and replastering. Where plaster immobilization has failed, external fixation gives a better anatomical result than remanipulation and replastering.

Soft tissue abscess caused by Mycobacterium fortuitum.

Mycobacterium fortuitum is an environmental organism which rarely causes disease. We report the case of a young man in whom this organism caused a soft tissue abscess. The laboratory findings and subsequent management of the case are described.