Daryl Godden

How should we manage oral leukoplakia

The aim of this article is to review the management of oral leukoplakia. The topics of interest are clinical diagnosis, methods of management and their outcome, factors associated with malignant transformation, prognosis, and clinical follow-up. Global prevalence is estimated to range from 0.5 to 3.4%. The point prevalence is estimated to be 2.6% (95% CI 1.72-2.74) with a reported rate of malignant transformation ranging from 0.13 to 17.5%. Incisional biopsy with scalpel and histopathological examination of the suspicious tissue is still the gold standard for diagnosis. A number of factors such as age, type of lesion, site and size, dysplasia, and DNA content have been associated with increased risk of malignant transformation, but no single reliable biomarker has been shown to be predictive. Various non-surgical and surgical treatments have been reported, but currently there is no consensus on the most appropriate one. Randomised controlled trials for non-surgical treatment show no evidence of effective prevention of malignant transformation and recurrence. Conventional surgery has its own limitations with respect to the size and site of the lesion but laser surgery has shown some encouraging results. There is no universal consensus on the duration or interval of follow-up of patients with the condition.

Replacing tracheostomy with overnight intubation to manage the airway in head and neck oncology patients: towards an improved recovery.

In maxillofacial head and neck oncology, tracheostomy is often used to secure the airway, but not without risk. This study compared the existing practice of two units: one where tracheostomy was routinely done with one where overnight intubation was used. From both units we retrospectively analysed 50 consecutive patients who had intraoral resection, neck dissection, and microvascular reconstruction for head and neck cancer. When compared with tracheostomy, overnight intubation resulted in a shorter mean stay in the intensive therapy unit (ITU) (1.4 compared with 3.7 days), a shorter overall hospital stay (12.9 compared with 18.0 days), less time to first oral intake (8.9 compared with 12.8 days), and a lower rate of lower respiratory tract infection (LRTI) (10% compared with 38%). This study supports the discontinuation of routine tracheostomy and the adoption of a more selective practice to improve recovery.

First do no harm: should routine tracheostomy after oral and maxillofacial oncological operations be abandoned?

Tracheostomy is traditionally used to secure the airway after major oral and maxillofacial oncological operations. In our unit, as an alternative, patients are intubated overnight without tracheostomy. We reviewed the case notes of 55 patients who had had a major intraoral resection, neck dissection, and reconstruction with a free flap. All patients were extubated and fit for transfer to the ward the following morning. We conclude that overnight intubation is a safe alternative to tracheostomy, and that the routine use of tracheostomy for oral and maxillofacial oncological operations should be used only for a few selected cases.

Ethical issues of facial transplantation.

The transplantation of tissue from one human to another has always been contentious, and transplantation of facial tissue creates an additional ethical dimension that seems to give it special status. This paper reviews the ethical debate and concludes that it is the practical limitations of the procedure that should regulate its use, and not the special status of the face.

Recent advances in the management of salivary gland disease

The management of salivary gland disease forms a considerable part of the work done by oral and maxillofacial surgeons. Fast track and one-stop head and neck lump clinics allow for early diagnosis of salivary gland tumours in most units, the emphasis being on outcome after operation for benign disease. There have been limited advances in salivary gland surgery in recent years. Most recent publications have compared outcome of new methods of treatment with conventional techniques. This article reviews papers related to diseases of the salivary glands published in the British Journal of Oral and Maxillofacial Surgery (BJOMS) over a two-year period (2007-2008), and includes other relevant articles to bring readers up to date about salivary gland disease.

Update on melanoma: the present position

Cutaneous melanoma is becoming increasingly common among people with fair skins, and this has been blamed on exposure to ultraviolet radiation from sunbathing, the use of sun beds, and holidays abroad. The key to controlling the epidemic of melanoma is prevention, but also important are the organisation of the skin cancer service, surgical advances, and the development of neoadjuvant treatments. Because there are many of these tumours in the head and neck region, head and neck surgeons are increasingly involved in the management of such patients. We review the current philosophy in the management of melanoma.

Feasibility of a novel classification for parotid gland cytology: A retrospective review of 512 cytology reports taken from 4 United Kingdom general hospitals

A novel classification for parotid cytology has been previously proposed. The purpose of this study was to assess the feasibility and clinical relevance of this classification.Background A novel classification for parotid cytology has been previously proposed. The purpose of this study was to assess the feasibility and clinical relevance of this classification. Method Between 2010 and 2013, cytology reports from 4 United Kingdom general hospitals were retrospectively classified and compared to histological and clinical outcomes. Results Based on the cytology reports of 512 patients, we revised our previous “P” system to a “Sal” (salivary) classification to encompass all cytologic outcomes. The percentage of patients with a final diagnosis of malignancy according to each category heading were: Sal 1 (inadequate) 7.9%; Sal 2I (nonneoplastic) 10%; Sal 2N (benign neoplastic) 1.4%; Sal 3 (atypical) 20.4%; Sal 4 (suspicious) 52.6%; Sal 5P (primary salivary gland malignancy) 71.4%; Sal 5NOS (malignancy not otherwise specified) 100%; and Sal 5M (metastasis) 91.7%. Conclusion By stratifying the probability of encountering a malignant neoplasm, the classification could guide clinical management decisions. A future prospective study is warranted.

How do I manage an acute injury to the facial nerve

Paralysis of the facial nerve is a cause of considerable functional and aesthetic disfigurement. Damage to the upper trunk can result in eye complications with the risk of exposure keratitis. Numerous factors influence the therapeutic strategy: the cause of the injury, the time elapsed since injury, functional impairment, and the likelihood of recovery. We discuss the management of an acute injury to the facial nerve and focus on the surgical options.

Dynamic reanimation for facial palsy: an overview

Facial paralysis can have a profound effect on the patient from both an aesthetic and functional point of view. The symptoms depend on which branch of the nerve has been damaged and the severity of the injury. The purpose of this paper is to review currently available treatments for dynamic reanimation of a damaged facial nerve, and the goals are a symmetrical and coordinated smile. Careful selection of patients and use of the appropriate surgical technique can have excellent results.

Use of a dermal regeneration template and full-thickness skin grafts to reconstruct exposed bone in the head and neck

Soft tissue defects over bone are difficult to reconstruct and this is compounded when there is no periosteum. We present what is to our knowledge the first reported use of a dermal regeneration template (Integra®, Integra Life Sciences Corp, Plainsboro, NJ, USA) to assist in reconstruction over an exposed mandible.