Does Segmental Mandibulectomy Involving Critical Functional Sites Affect Quality of Life?

PURPOSE: Segmental mandibulectomy (SM) is a morbid procedure, often indicated in the treatment of oral cavity pathology; however, the effect on quality of life resulting from resection of specific mandibular subsites has not previously been investigated. This study's primary aim was to evaluate differences in Health-Related Quality of Life (HRQoL) among patients who underwent segmental mandibulectomy with condylectomy (SMc+) or not (SMc-), and secondarily among patients who underwent SM with symphyseal resection (SMs+) or not (SMs-). METHODS: A single-centre cross-sectional study was performed, identifying adults who had undergone SM over a 5-year period. Patients who had disease recurrence, further major head and neck surgery, or any surgery 3 months prior to participating were excluded. Demographic, disease and treatment data were obtained via chart review. Participants completed the European Organisation for Treatment of Cancer 'General' and 'Head and Neck Specific' HRQoL modules. Condylectomy and midline-crossing resection were the primary and secondary predictor variables, while the primary outcome was HRQoL. Study variables were cross tabulated against predictor and outcome variables to identify potential confounders. The association between condylectomy and symphyseal resection on HRQoL was modelled using linear regression and subsequently with identified confounding factors. RESULTS: Forty-five enrolled participants completed questionnaires, of which 20 had undergone condylectomy and 14 symphyseal resection. Participants were majority male (68.9%) and on average 60.2 ± 18 years old, having undergone surgery 3.8 ± 1.8 years prior to participation. Prior to adjustment, Condylectomy patients reported significantly worse 'Emotional Function' (mean ± standard deviation) (47.7 ± 25.5 vs 68.4 ± 26.6, P = .02), 'Social Function' (46.3 ± 33.6 vs 61.4 ± 28.9, P = .04) and 'Mouth Opening' (61.1 ± 36.7 vs 29.8 ± 38.3, P = .04) compared to the SMC- group. SMs + patients reported significantly worse scores in 'Social Function' (43.9 ± 30.1 vs 48.3 ± 32,1, P = .03), 'Dry Saliva' (65.1 ± 35.3 vs 38.5 ± 33.9, P < .01) and 'Social Eating' (48.5 ± 45.6 vs 30.8 ± 36.4, P < .01) compared to the SMs-group. Following adjustment only 'emotional function' in the SMc comparison retained significance (P = .04). CONCLUSIONS: SM causes anatomical distortion resulting in functional deficit. While the condyle and symphysis are theoretically functionally important, our findings suggest that morbidity associated with their resection may be the result of associated surgical and adjuvant treatment burden.

Does the evidence justify routine transfer of residents of aged care facilities for CT scan after minor head trauma?

BACKGROUND: In 2014, the South Australian coroner recommended that residents of residential aged care facilities (RACF) who had sustained a head injury should be transported to emergency departments (ED) for assessment and a head CT scan, with the view to preventing mortality. The evidence base for the recommendation is unclear. AIMS: To determine the rate of emergent intervention (neurosurgery, transfusion of blood products or reversal of anti-coagulation) in residents transferred to ED with minor head trauma who had their usual cognitive function on ED assessment. METHODS: This was a retrospective cohort study by medical records review at two university-affiliated community ED. Participants were patients from RACF attending ED who had suffered minor head trauma and had their usual cognitive function. Exclusions were altered conscious state, new neurological findings or associated orthopaedic injury requiring hospital admission. The primary outcome was rate of emergent intervention in residents transferred to ED with minor head trauma who had their usual cognitive function on ED assessment. RESULTS: A total of 366 patients was studied; median age 86 years, 45% taking anti-coagulant/anti-platelet medication. Eighty per cent underwent head CT. Six per cent had intracranial haemorrhage (ICH; 95% CI 4-8.9%). No patient underwent neurosurgery. One had emergent intervention, reversal of anti-coagulation (0.3%, 95% CI 0.05-1.5%). CONCLUSION: The rate of emergent intervention for ICH in patients from RACF who sustained a minor head trauma but had their normal cognitive function was <1%. None underwent neurosurgical intervention. The low rate of intervention seriously challenges the appropriateness of routine transfer and CT for this patient group.

Accuracy of after-hours trauma cervical spine CT reporting by radiology trainees: Experiences from two Australian teaching hospitals.

INTRODUCTION: Like many teaching hospitals in Australia, after-hours computed tomography (CT) reporting at our institution is undertaken by the on-call radiology registrar. The accuracy of these reports is important as management is often initiated based on the interim findings, prior to review by the consultant radiologist. A common exception to this approach is cervical CT (CCT), as many hospital protocols recommend patients to remain in spinal precautions until the report is finalised by a consultant, although there are very few studies to support this practice. METHODS: The interim registrar reports for all CCTs performed after-hours over a 12-month period were retrospectively reviewed. The final consultant report was used as the gold standard to establish accuracy of the registrar report. The primary outcome was discrepancy between the provisional and final reports. Any discrepancy was classified as either an 'overcall' or 'miss'. Discrepancies were graded by the RADPEER scoring system. RESULTS: A total of 1084 after-hours CCT studies were reviewed. The number of cases positive for injury was 37 (3.4%). The total number of discrepancies was 14 (discrepancy rate 1.3%), including 4 overcalls (0.3%) and 10 misses (0.9%). The discrepancy rates for junior and senior registrars were 1.7% and 0.7% respectively. Only 5 misses (0.5%) were considered clinically significant. CONCLUSION: Registrars reporting after-hours CCT have low rates of discrepancy with very few clinically significant misses. However, the reduced registrar sensitivity for detection of cervical injury highlights the ongoing importance of consultant review in the process of cervical spine clearance pathways.

Factors associated with blunt internal carotid artery injury in petrous temporal bone fractures.

INTRODUCTION: Traumatic internal carotid artery (ICA) injuries are an uncommon complication of petrous temporal bone (PTB) fractures that can have devastating consequences of stroke, haemorrhage and death. Current guidelines suggest that all PTB fractures should be screened for blunt cerebrovascular injury, however clinical practice varies. The purpose of this study was to identify features associated with PTB fractures that increase the likelihood of ICA injury. METHODS: A retrospective cohort study was performed on all patients with PTB fractures who were investigated with computed-tomography angiography (CTA) scan admitted to a Level One Trauma Service in Melbourne, Australia from 2015-2020. Patient demographic and injury data were obtained from The Royal Melbourne Hospital Trauma Registry and medical records. Multivariate binomial logistic regression was performed to identify features associated with ICA injury. RESULTS: Out of 377 patients with 419 PTB fractures, 205 received a CTA scan and were included, identifying 22 ICA injuries (9.4%). The median age of ICA injuries was 33 (IQR 23-61), median Abbreviated Injury Scale (AIS) score for the head region was 5 (IQR 5-5) and the in-hospital mortality rate was 45.5%, mainly due to unsurvivable brain injury. Five patients (22.7%) developed ICA-specific complications of stroke or carotid-cavernous fistula. We identified five factors that were significantly associated with ICA injury. These included PTB fractures involving the carotid canal (OR 6.7, 95% CI 1.9-23.9, p=0.003), presenting with an initial GCS less than nine (OR 5.7, 95% CI 1.2-26.5, p=0.025) and increasing head AIS (OR 2.4, 95% CI 1.2-4.6, p=0.009). Mechanisms of injury that were associated with ICA injury were motor vehicle crash (OR 4.4, 95% CI 1.4-14.2, p=0.012) and motorbike crash (OR 4.6, 95% CI 1.2-18, p=0.029). CONCLUSION: Patients with PTB fractures and an additional feature of carotid canal involvement, presenting GCS less than nine, increasing head AIS indicative of severe head trauma or mechanism of injury by motor vehicle or motorbike crash, are at an increased risk of ICA injury and should be screened with a CTA scan.