Barry O’Regan

Techniques for dissection of the facial nerve in benign parotid surgery: a cross specialty survey of oral and maxillofacial and ear nose and throat surgeons in the UK

We investigated techniques of dissection of the facial nerve currently being used in parotid surgery for benign disease in oral and maxillofacial (OMF) and ear, nose and throat (ENT) surgery. A postal questionnaire was sent to 300 OMF and 300 ENT consultants and 49% were returned(171(57%) OMF and 123 (41%) ENT. The antegrade technique was used routinely by 209 surgeons (87%), the retrograde technique by 9 (4%), and both techniques combined by 21 surgeons (9%). The antegrade technique was used by 135 surgeons (56%) for revision parotidectomy, by 193 (81%) for limited superficial parotidectomy, by 173 (72%) for obese patients with large tumours and by 75 (31%) for injury to the facial nerve. The retrograde technique was used by 21 surgeons (9%) for revision parotidectomy, by 22 (9%) for limited superficial parotidectomy, by 15 (6%) for obese patients with large tumours and by 29 surgeons (12%) for injury to the facial nerve. A combination of techniques was chosen by 83 surgeons (35%) in revision parotidectomy, by 24 surgeons (10%) in limited superficial parotidectomy, by 51 surgeons (21%) in obese patients with large tumours and by (56%) surgeons 135 for injury to the facial nerve.

Comparison of facial nerve injury and recovery rates after antegrade and retrograde nerve dissection in parotid surgery for benign disease: prospective study over 4 years

The facial nerve can be dissected using an antegrade or retrograde approach. Antegrade dissection is the established technique and retrograde dissection is used less often. Recent publications have drawn attention to the potential value of the retrograde technique particularly if direct identification of the nerve trunk is difficult, and in revision procedures. We prospectively studied 43 consecutive procedures in 40 patients who had parotidectomy over a 4-year period, and evaluated and compared rates of temporary and permanent nerve injury, and nerve recovery after antegrade and retrograde dissection in operations for benign parotid disease. Each patient was allocated randomly to the antegrade (n=20) or retrograde (n=20) groups. Three patients were excluded. All patients had peroperative nerve monitoring and were followed up at 1 week, 1 month, 3 months, or to full recovery of the nerve. The House-Brackmann (HB) grading system was used to assess the degree of injury to the nerve. A high rate of serious nerve injury (HBIII or above) was associated with retrograde dissection at 1 week. Serious nerve injuries (HBIII or above) were slow to recover after the antegrade technique at 3 months. There was no difference between groups in the rates of full nerve recovery at 6 months.

Incidence of hypertrophic and keloid scars after N-butyl 2-cyanoacrylate tissue adhesive had been used to close parotidectomy wounds: A prospective study of 100 consecutive patients

Suturing is the usual technique for cutaneous wound closure after parotidectomy and gives a satisfactory aesthetic appearance for most patients. Late complications include the development of hypertrophic and keloid scars, the incidence of which ranges from 5% to 16% in elective cases. We studied the use of N-butyl 2-cyanoacrylate (Indermil) for closure of parotid wounds in 100 consecutive patients over a period of 7 years, our main aim being to establish the incidence of hypertrophic and keloid scars after the use of Indermil. We also wanted to explore the potential advantages of this technique as an alternative method of wound closure. The incidence of hypertrophic and keloid scars was 8 and 9, respectively. The technique is simple and safe, and the incidence of hypertrophic and keloid scars within the accepted range for sutures.

Transmasseteric antero-parotid approach: a technique adaptation for ectopic subcondylar third molar removal and associated dentigerous cyst enucleation

by Wilson et al. in 2005 to manage condylarfractures. We adapted this approach to remove a subcondy-lar ectopic third molar and associated odontogenic cyst, andto the best of our knowledge this is the first report of thistechnique being used for this clinical problem. We chosethe TMAP approach to reduce the surgical morbidity antic-ipated with alternative approaches as it has a low risk ofiatrogenic injury to the facial nerve and reduces the riskof injury to the lingual nerve. An intraoral approach wouldrequire coronoidectomy and further lateral and medial ramuscortical bone removal, increasing the risk of condylar frac-ture. In contrast to an intraoral approach the TMAP approach

Provision of oral medicine in departments of oral and maxillofacial surgery in the UK: national postal questionnaire survey 2009

We investigated the current provision of oral medicine in oral and maxillofacial (OMF) departments in the UK. We examined the number of specialists in oral medicine in OMF departments, the training given to OMF consultants in oral medicine, and the estimated time dedicated to treating patients with oral medical conditions in outpatient clinics. We also examined the pattern and reasons for onward referrals to departments of oral medicine. A postal questionnaire was sent to 300 OMF consultants and was returned by 183 (61%). Sixteen (9%) of the responding consultants had a registered specialist qualification in oral medicine with the General Dental Council (GDC), 15 (8%) had a degree in oral medicine, and 4 (2%) had a diploma. One hundred and eighteen (64%) consultants had been given formal training in oral medicine during their training as registrars. Time dedicated to oral medicine in outpatient clinics varied between less than 20% and more than 40% of total outpatient time. Sixteen surgeons (9%) referred 1-2 patients/week to departments of oral medicine, and 19 (10%) referred 2-4/month. Reasons for referral included need for specialist expertise, failure of treatment, and lack of time in outpatients. The proposal for a dentally qualified consultant-led oral medicine service was supported by 70 responding surgeons (38%).

Tumour recurrence after surgical removal of parotid pleomorphic salivary adenoma using a retrograde facial nerve dissection technique.

Recurrence after surgical removal of parotid pleomorphic salivary adenoma using retrograde facial nerve dissection is not well researched. We adopted retrograde nerve dissection for parotid surgery for benign disease as a standard procedure in 1995. The objective of this study was to establish the rate of recurrence of primary tumours associated with the technique after removal of parotid pleomorphic salivary adenoma. We recruited 59 patients over a 16-year (1995-2011) period and collected the data prospectively. Eight patients were excluded as they had died or had been lost to follow up. Male:female ratio was 16:35 and age range was 15-69 years. The mean tumour size as measured on magnetic resonance imaging (MRI) was 27.4mm. Thirty-eight patients had superficial parotidectomy, 8 had total parotidectomy, and 5 had partial superficial parotidectomy. Mean follow up from the date of operation was 104 months (median 98, range 17-171). All patients were reviewed and examined in 2011 to establish whether the tumour had recurred. One patient had developed a solitary nodular recurrence 8 years after the initial procedure. Recurrence was 2%. The rate of clinically apparent recurrence after parotidectomy for pleomorphic salivary adenoma in this study is low and is comparable with others reported.

Screw-wire traction technique: aid to anatomical reduction of multi-segment mid-facial fractures

The screw-wiretractiondeviceisconstructedinasterileoper-ating environment. The free edges of a stainless steel tie wireare held with Lawson Tait artery forceps. The wire is twistedto form a loop that is reduced to a dimension of 3mm arounda straight Warwick James elevator or straight artery forcepsand then cut to a length of 5cm. The mounted screw is placedthrough the wire loop ready to be applied to the predrilledscrew hole (Fig. 1). The hole is drilled and the traction unitis applied as shown in Fig. 2.

Ipsilateral removal of sublingual gland after excision of submandibular gland for benign disease: 10-year prospective study and comprehensive review 1978–2008

The removal of the submandibular salivary gland for non-neoplastic disease is a common procedure that has well documented risks and postoperative complications. Persistent symptoms of pain and swelling in the floor of the mouth that can occur after excision of the submandibular gland may require removal of the sublingual gland, but a causative association between the two has not, to our knowledge, been comprehensively established. We prospectively studied 77 patients who had had excision of the submandibular gland for benign disease, six of whom (8%) returned to theatre for ipsilateral sublingual sialadenectomy within a 5-year period after the initial operation (mean 24 months). These findings suggest that the association is under-reported, and may need to be considered during the consent process for excision of the submandibular salivary gland.

Screw-wire osteo-traction (SWOT) in the reduction and fixation of frontonasal dysjunction in Le Fort II/III upper mid-facial fractures

a d t m a rontonasal dysjunction may occur as a component of Le ort II or III fractures. Frontonasal reduction and fixaion in upper midfacial fractures using a bicoronal flap for ccess is essential for effective management of the fracture,1 ut conventional anatomical reduction and stability can be ifficult to achieve before osteosynthesis. Screw-wire osteoraction (SWOT) is a useful adjunctive method to secure recise anatomical reduction and maintain stability during steosynthesis. A few published reports describe its use in the anagement of lower midfacial fractures,2–4 but we know of o reports of it being used in the management of frontonasal ysjunction in upper midfacial fractures.

MD by portfolio or published work in OMFS

Background: The Fanconi Anaemia (FA) pathway is responsible for homologous recombination repair of DNA interstrand crosslink damage. This checkpoint in S-phase of the cell cycle is mediated by ATR (Ataxia Telangiectasia Rad-3) and BRCA-1. The role of this tumour suppressor pathway in early oncogenesis is evaluated in oral dysplasia (OED) which transformed into oral squamous cell carcinoma (OSCC) by evaluating expression of FANC-D2 protein. Methods:Forty patients with OED (and documented clinical outcomes/parameters) were identified from a cohort of patients who were prospectively recruited into a molecular biomarker study (1996-2012). The OED in 23 patients transformed into OSCC while the remaining 17 patients were in remission. Archival formalin fixed paraffin embedded (FFPE) blocks from the first biopsy confirming the diagnosis of OED, immediately preceding malignant transformation and OSCC blocks, where applicable, were retrieved. 0.4 micron thickness sections were stained with FANC-D2, ATR and H2AX (control) antibodies. Immunohistochemistry (IHC) scoring was performed by two clinicians, assessing nuclear and cytoplasmic staining extent and intensity. Corresponding FFPE cores (0.5 mm diameter) were processed for protein and DNA extraction to validate the IHC findings. Results: Based on the FANC-D2 dysplasia scoring system devised: a score ≥4 was associated with stable nontransforming OED (16 non-transformers vs. 5 transformers) and a score of ≤3 was associated with malignant transformation of OED (7 non-transformers vs. 12 transformers) (Fisher exact test p = 0.02). ATR IHC showed staining patterns which correlate with FANC-D2 expression. The findings of IHC were validated with Western blots of protein extracts from the FFPE cores stained with FANC-D2 antibodies. Conclusion: Failure to activate the FA pathway (indicated by poor expression of FANC-D2 protein) due to defective DNA damage detection by ATR has been shown to be related to malignant transformation in OED. FANC-D2 IHC has the potential to influence the management of OED where equipoise exists.