Spontaneous sensory recovery in non-innervated radial forearm flaps used for head and neck reconstruction.

Although several studies have reported the use of reinnervated microvascular free flaps for oro-pharyngeal reconstruction, it has been known for some time that non-innervated flaps demonstrate spontaneous sensory recovery. This study sought to evaluate the degree of such spontaneous recovery in 50 radial forearm flaps used for mucosal reconstruction of head and neck ablative defects. The recovery of sensation to pinprick, light touch and temperature was tested a mean of 38 months (range 15-71) after surgical insetting. Two-point discrimination was also sought. Although 18 flaps (36%) remained anaesthetic, partial recovery in one or more modalities was present in 28 patients (56%). A recovery in all modalities of sensation in at least two-thirds of the flap area was recorded in 4 patients (8%). The mean 2-point static discrimination for fascio-cutaneous flaps was 18.9mm.

Sensory deficit in the donor hand after harvest of radial forearm free flaps.

Fifty patients undergoing radial forearm free flap reconstruction of head and neck defects were examined to find out the extent of sensory defect at the donor site. Flaps (mean length 6 cm, range 4-9) and mean width 4.7 cm (range 3.5-7) were raised. Of the 50 patients 38 (76%) were aware of some sensory loss over the radial distribution in the donor hand. There was objective evidence of a reduction in at least one sensory function in 32 of these patients (84%). The mean affected area was 44.3 cm(2) (range 6-125). The mean length of the affected area was 11.3 cm (range 4.3-12.1) and the mean width 5.1cm (range 2.1-8.4). Of the 12 patients (24%) who reported no feeling of sensory loss all modalities of sensation were preserved in 11 (92%).

Effects of repeated drill use on temperature of bone during preparation for osteosynthesis self-tapping screws.

Drills used during preparation for osteosynthesis with self-tapping screws are often used repeatedly until they become blunt and ineffective. Because the sharpness of the drill is one of the most important factors in its cutting efficiency, blunt drills may require the application of extra force, which in turn may contribute to excessive frictional heat produced during preparation of screw holes. Large rises in temperature can impair bony regeneration around screws and contribute to failure of internal fixation. In an attempt to quantify the potential increase in temperature produced by blunt drills, we devised an in vitro experiment to simulate preparation for osteosynthesis by using drills with different degrees of wear. Three drills were used: one was new, one had drilled 600 holes, and the third drill had been in use in theatre for several months. The mean (range) rise in temperature for the three drills were: new drill 7.5 degrees C (0.6-20.5 degrees C); drill after 600 holes 13.4 degrees C (5.7-28.3 degrees C); and drill from theatre 25.4 degrees C (12.4-41.3 degrees C). There was a highly significant difference in the temperatures generated by the three drills, and the changes in temperature were related to the amount of wear. The cost of drills is low, and as their repeated use can compromise the results of the operation they must be discarded after single use.

Management of drooling by transposition of the submandibular ducts and excision of the sublingual glands.

STATEMENT OF THE PROBLEM: Persistent drooling is common in patients with neurological impairments such as cerebral palsy. Although it may be induced by an excess of saliva, it usually results from incontinence secondary to impaired cerebral control of orofacial function. Various techniques, both medical and surgical, exist to combat the problem. The patient should have a course of conservative management initially (head position, education and training, suction aids, bio-feedback and support). Non-surgical managements and medical treatment should start as early as possible. Surgery has a place, when conservative and medical treatments (drugs/botulinum toxin) have failed. PURPOSE OF THE STUDY: Patients subjected to some of the more radical surgical methods may develop complications of the procedures themselves, it is important therefore that any intervention is based on sound principles. Physiology predicts that the most benefit would be derived from diversion of submandibular rather than parotid salivary flow (Fig. 1). MATERIALS AND METHODS: To assess the effect of bilateral transposition of the submandibular ducts combined with excision of the sublingual glands as a treatment for drooling, a retrospective survey of 21 patients was undertaken by contacting their carers and reviewing the clinical notes. RESULTS: Sixteen out of 21 patients had good to excellent control of their drooling with minimal side-effects and low morbidity. CONCLUSION: Drooling should be managed with a team approach using non-surgical management in the first instance. Surgery has a place and can be beneficial with few long-term side effects. Patients require long-term paedontic/dental follow up to maintain a healthy oral cavity.

The role of thorax imaging in staging head and neck squamous cell carcinoma.

The overall survival rate for patients with head neck squamous cell carcinoma remains disappointingly static despite improved locoregional control. This has been attributed to the development of distant metastases and second primary malignancies in these patients, a large proportion of which occur in the thorax. We retrospectively analysed the incidence of thoracic malignancies in 138 patients presenting with newly diagnosed (n = 107) or recurrent (n = 31) cancer of the head and neck over a 4-year period. All 138 patients had undergone both computerised tomography of the thorax (CT) and conventional chest radiography within one month of presenting with biopsy proven squamous cell carcinoma. Seventeen percent of these were found to have simultaneous thoracic malignancies. CT thorax was more sensitive in detecting simultaneous thoracic malignancies compared with standard chest X-ray (24/138 versus 9/138, odds ratio of 3:1 in favour of CT). All thoracic malignancies detected by chest X-ray were also detected by CT thorax. Patients presenting with recurrent tumors were significantly more likely to have simultaneous thoracic malignancies than those with newly diagnosed cancer (11/31 versus 13/107, chi2 test with Yates correction, chi2 = 4.66, p = 0.03). The primary site (laryngeal, oral or pharyngeal) or presence of nodal disease did not have an effect on the incidence of simultaneous thoracic malignancies. The presence of distant metastases and second primary malignancies has major implications in the management and prognosis of patients presenting with head and neck squamous cell carcinoma, with a large proportion of such patients succumbing to their disease within one year of diagnosis. As CT scanning of the thorax was a more effective screening investigation than standard chest X-ray in the detection of simultaneous thoracic malignancy, we recommend it for use in the staging of patients presenting with cancer of the head and neck.

The role of vital tissue staining in the marginal control of oral squamous cell carcinoma.

Since vital staining has been advocated as a sensitive method of displaying epithelial atypia, 14 oral squamous cell carcinomas were stained immediately preoperatively with toluidine blue and then resected 1 cm outside clinically abnormal or positively staining tissue. The integrity of the entire tissue margin was histologically examined in each case. Whilst vital staining delineated all 14 invasive carcinomas at the centre of each resected specimen, 10 foci of carcinoma-in-situ or severe dysplasia were identified not to have stained at the resection margins. Toluidine blue may, therefore, be an adjunct in identifying invasive tumour at mucosal resection margins. However, it would appear to be of no benefit in delineating positive resection margins due to carcinoma-in-situ or severe dysplasia, and hence it may be of little value in reducing the incidence of local recurrences.

The application of toluidine blue as a diagnostic adjunct in the detection of epithelial dysplasia.

The detection of premalignant lesions of the oral mucosa allows for treatment that may be sufficiently early to prevent their progression to invasive carcinoma. Although a number of techniques for supplementing clinical examination have been described, on the whole they rely on laboratory-based investigations with variable false-negative rates. Toluidine blue vital staining, on the other hand, has been advocated as a simple, inexpensive, and sensitive chairside test. Most of the clinical series investigating its efficacy, however, have relied on clinically abnormal mucosa or tissue that stained. For the purpose of quantifying the true sensitivity of toluidine blue, the present study involved the examination of clinically normal mucosa as well as abnormal tissue and compared it with the presence or absence of staining. With this technique the false-negative rates of 42% and 58% obtained for carcinoma-in-situ and mild-to-moderate dysplasia, respectively, suggest restricting the use of vital staining to selective cases.

The effects of operator technique and bur design on temperature during osseous preparation for osteosynthesis self-tapping screws.

OBJECTIVE: Although the importance of atraumatic preparation of bone before the placement of osseointegrated implants has long been emphasized, the situation during placement of self-tapping screws has received little attention. Because the production of excessively high temperatures during osseous drilling is known to impair bony regeneration, the strict thermal criteria that are set for implant placement should theoretically be extended to trauma and orthognathic internal fixation. STUDY DESIGN: Temperatures achieved during the drilling of thawed human cadaveric bone before the insertion of osteosynthesis self-tapping screws were measured in vivo with thermocouples. Combinations of 2 drilling systems and 2 bur designs were studied. Variations in surgical technique were incorporated by altering both the force applied by the operator and the application of irrigant. Statistical significance was examined through use of a Student t test. RESULTS: One of the 2 bur designs and careful operator technique were associated with significantly smaller increases in temperature. Irrigation had the greatest effect on temperature recorded, the absence of irrigant resulting in temperatures in excess of 70 degrees C. CONCLUSIONS: These findings emphasize the importance of careful surgical technique and constant irrigation during osseous preparation if the potential for bone regeneration around osteosynthesis self-tapping screws is to be maximized.

Oral cancer, smoking and alcohol: the patients' perspective.

Although the roles of smoking and drinking alcohol in the aetiology of oral cancer are common knowledge among the medical community, those who have the disease are often less well informed. To quantify this potential lack of knowledge, 152 patients being reviewed after treatment for oral cancer were questioned about their smoking habits, alcohol consumption, and their understanding of the part these factors play in the development of malignancy. At least six months after the diagnosis of their malignancy, 72 (47%) still smoked and 55 (36%) drank alcohol to excess. Only one-third were aware that these habits were important in the development of oral cancer. These results indicate widespread ignorance and suggest that education about the causes of oral cancer is required in the population as a whole and particularly among those with the disease.

New surgical technique for the correction of congenital muscular torticollis (wry neck).

Congenital muscular torticollis (wry neck) results from shortening of the sternocleidomastoid muscle and may lead to limitation of neck movement and craniofacial deformity. If conservative treatment is started early, with a regimen of passive stretching exercises and active strengthening of the contralateral muscle, about 95% of patients achieve an acceptable range of neck movement. The surgical management of patients who do not respond to physiotherapy remains controversial. Its aim is to provide a long-term, cosmetic restoration of neck mobility while minimizing the development of craniofacial deformity and upper cervical scoliosis; few previously advocated techniques achieve both these goals. We describe a technique that combines subperiosteal lengthening of the sternocleidomastoid muscle at its mastoid insertion, and division of lower fibrotic bands with minimal postoperative fibrosis. As the sternomastoid muscle is reattached lower down on the mastoid process, the lengthening of the muscle is stable, because the tendency to fibrosis and shortening is minimized. Comparison of the results with previous series shows that this technique provides immediate benefit and good long-term results.

Palmar arch backflow following radial forearm free flap harvest.

BACKGROUND: Most surgeons advocate an Allen test (for occlusion of the radial or ulnar artery) and Doppler ultrasound examination before harvesting a forearm flap. In this study we attempted to correlate the results of these tests with intraoperative measurement of backflow pressure in the radial artery stump. METHOD: Stump pressures were measured in 30 patients after the flap had been harvested and were compared with preoperative assessment and intraoperative measurements of mean arterial pressure (MAP). RESULTS: Mean arterial backflow pressure (MABP) in the arterial stump varied from 27 to 55mm Hg (mean 40.5). The ratio of this value to the mean arterial pressure ranged from 0.39 to 0.89 (mean 0.59) and exceeding 0.5 in 21 patients (70%). There was no correlation between this ratio and the preoperative assessment. CONCLUSIONS: These findings suggest that in the presence of a satisfactory Allen test and Doppler examination, there is adequate pressure in the palmar system to maintain vascular integrity of the donor hand after sacrifice of the radial artery. Despite the possibility of anatomical variants, the routine use of more invasive imaging is unnecessary.

Provision and quality assurance for head and neck cancer care.

In 1998, the British Association of Head and Neck Oncologists (BAHNO) published a report entitled 'Provision and quality assurance for head and neck cancer care in the United Kingdom. A nationally co-ordinated multidisciplinary approach'. This document considered, amongst other issues, operational policies for patient care. We audited three aspects of the care of 73 patients with head and neck cancer from initial referral to definitive treatment against standards set out in this report.Fifty-nine patients (81%) were seen within two weeks of initial referral, the maximum interval proposed by the BAHNO report. In 41 patients (56%), the diagnosis was confirmed and their treatment plan determined within the further two-week period suggested in the report. Of the 25 patients who required adjuvant radiotherapy, only 11 (44%) began treatment within six weeks of their surgical phase; this represented the greatest variance from the BAHNO recommendations. These findings highlight the need for units active in the treatment of specific diseases to audit their activity against available minimum standards in an attempt to improve the quality of patient care.

Can monocortical miniplates provide bony compression?. An experimental model.

Some maxillofacial surgeons advocate that screws in monocortical plate systems be placed eccentrically in an attempt to provide compression between bony ends. We sought to quantify the degree of displacement and compressive forces made possible by such eccentric placement in an experimental model using five miniplates and Perspex blocks to simulate mandibular fractures. The maximum displacement obtained was 0.67 mm and the maximal compressive force 5.2N (SEM=0.9, range=2.7-7.1). This demonstrates that eccentric placement of screws can achieve some compression and displacement at the fracture interface and that the forces obtained are close to those predictable from the dimensions of the burr, screw, and miniplate.

Prospective randomised trial of the benefits of a sternocleidomastoid flap after superficial parotidectomy.

Parotid surgery can cause postoperative facial nerve dysfunction, cosmetic impairment, and Frey's syndrome. Thirty-six patients listed for superficial parotidectomy were entered into a prospective randomised trial to find out if the use of a sternocleidomastoid flap could reduce the incidence of these complications. Partial facial nerve paresis was seen at 3 months in five patients in whom flaps were raised compared with six among those who did not have flaps (P=0.025). There was no difference between the two groups at 1 year. The flap was not associated with an improvement in either subjective (P=0.13) or objective (P=0.12) appearance measured on visual analogue scales. Eight patients in whom flaps were raised described symptoms suggestive of Frey's syndrome, compared with nine patients in whom a flap was not raised (P=0.31). Overall 19 of those who had a flap and 11 of those who did not had a positive starch-iodine test (P=0.21).

Influence of routine bone grafting on the stability of the non-cleft Le Fort 1 osteotomy.

Although bone grafting is known to improve stability after midface cleft osteotomy, it is advocated only rarely for people without clefts. To assess the influence of routine bone grafting on stability in such patients we analysed radiographic data of 112 patients retrospectively. All patients had had Le Fort 1 osteotomy with autogenous bone grafts harvested by trephine from the iliac crest, and 76 had had concurrent mandibular procedures. Rigid internal fixation was adopted throughout. Impaction proved to be the most stable move. While there was little postoperative relapse of the anterior maxilla (0.9%), the posterior maxilla tended to move further upwards with time (2.3%). Overall relapse after advancement and inferior repositioning was low (3.5% and 5%, respectively). The only complication noted at the iliac crest donor site was spread of the scar, which affected three patients. When we compared these results with previously published data, they suggested that in patients without clefts rigid internal fixation combined with bone grafting may improve stability after selected Le Fort 1 osteotomy moves.

The bicoronal flap (craniofacial access): an audit of morbidity and a proposed surgical modification in male pattern baldness.

Maxillofacial surgeons have used the bicoronal flap for nearly three decades to gain access to the craniofacial skeleton. A retrospective analysis of 68 bicoronal flaps done over a five-year period showed that our incidence of permanent morbidity was low. Although 24 patients (35%) experienced some form of sensory abnormality immediately after the operation, this persisted for longer than two years in only one. Complete motor recovery occurred by one year in all 15 patients (22%) who developed postoperative frontalis weakness. Three patients developed male pattern baldness postoperatively, which resulted in exposure of the scar and poor cosmesis. This prompted a cadaveric study in which we assessed the feasibility of modifying the position of the standard bicoronal incision in people who are prone to hair loss. The pivotal point of the bicoronal flap was found to lie at its most inferior aspect. By extending the incision into the skin crease in front of the lobe of the ear it was possible to adjust the anteroposterior position of the bicoronal incision without limiting access to the facial skeleton. We therefore advocate occipitally placed incisions with preauricular extensions in patients who are prone to male pattern baldness.

Atypical cervico-facial mycobacterial infections in childhood.

We describe three patients who presented with atypical mycobacterial infection. Although antituberculous drugs are ineffective, combination treatment with clarithromycin or amikacin and ciprofloxacin (with or without cotrimoxazole) leads to eventual resolution of the lesions. The treatment of choice, however, remains complete excision of the affected area which obviates the need for prolonged chemotherapy and minimizes the scarring which may otherwise develop after conservative treatment.

Complications of head and neck cancer surgery - prevention and management.

Surgery continues to retain a pivotal role in head and neck cancer in terms of the management of both the index tumour and potential or proven cervical disease. This review considers the specific complications of surgery in this anatomical region and, on the basis of the available evidence, describes both their management and prevention.