K.M. Lavery

Dental extractions in patients on warfarin: is alteration of anticoagulant regime necessary?

Various clinical protocols for the management of warfarinised patients needing dental extractions have been suggested. This study was designed to compare two approaches in the management of these patients. A control group of 32 patients had their warfarin treatment stopped for 2-3 days prior to having dental extractions, resulting in a reduction in the average preoperative international normalised ratio (INR) from 2.6 to 1.6. The study group of 33 patients did not have their anticoagulant treatment altered before extractions, and had an average preoperative INR of 2.7. All patients were treated under local analgesia on an outpatient basis, and local measures-consisting of Surgicel pack and sutures-were used in all cases to control postoperative bleeding from extraction sockets. None of the patients had any immediate postoperative bleeding, and only 1 patient from each group had mild delayed haemorrhage, which was easily controlled with local measures. It is proposed that, provided the INR is within the therapeutic range of 2.0 to 4.0 and local measures are used to control postoperative bleeding, there is no justification in altering warfarin treatment prior to dental extractions in these patients, and thereby exposing them to the risk of thromboembolism.

Combined radial forearm and pharyngeal flap for soft palate reconstruction

The use of a free vascularised fascio-cutaneous radial forearm flap in combination with a cranially based pharyngeal flap for soft palate reconstruction has not been previously reported. We present the technique and illustrate its use in two cases of total and one case of subtotal soft palate reconstruction. The functional outcome is discussed with particular reference to nasal airway patency, speech and swallowing.

Perivascular epithelioid cell tumor (PEComa) of the cheek

We present the unusual case of a perivascular epithelioid cell tumor (PEComa) occurring within the cheek of a 32-year-old woman. PEComa is a rare, recently described, family of tumors with diverse clinicopathologic expression and which express melanocytic and muscle markers. It mainly affects the abdominopelvic region and rarely occurs in somatic soft tissue or skin. To our knowledge, this is the first reported case of PEComa occurring in the facial cutaneous tissues. Other possible diagnoses considered included benign mesenchymal tumors of smooth muscle or neural origin. However, the cytomorphologic and immunohistochemical profile were most suggestive of PEComa. The tumor was completely excised, but in view of uncertainty as to how this entity would behave in an unusual location, lifelong follow up is recommended. After complete excision, there was no recurrence in 4 years.

Management of Jehovah's witness patients undergoing major head and neck surgery

Several diverse strategies have been recommended to manage Jehovahs Witness patients undergoing surgery when significant blood loss is expected. However, many of the proposed management strategies cannot be used when the urgent nature of the disease precludes adequate preoperative preparation of the patient. We present our experience of the management of two Jehovahs Witnesses with oral carcinoma requiring extensive resection, neck dissection, and reconstruction with free tissue transfer.

Wegener's granulomatosis of the parotid gland and surrounding tissues.

egener’s granulomatosis (WG) is an idiopathic inflammaory disease which produces a systemic vasculitis. The head nd neck is involved in nearly 90% of cases, but the site sually affected is the upper airway.1 The other organs most haracteristically involved are the lungs and kidneys. Howver, WG can also present as a swelling or abscess of the eck, often in the area of the major salivary glands, usually he parotid. One or both sides can be affected.2–4 There are solated reports of sublingual5 and the lacrimal6 gland disase. Symptoms may be vague or masquerade as malignancy, nd when disease of the major salivary glands is the index resentation of WG the cause may remain unknown until ore typical features arise, as we describe in this report.

The utility of molecular diagnostics to predict recurrence of head and neck carcinoma

Background:Locoregional recurrence is the major cause of treatment failure after surgery for oral squamous cell carcinoma. Molecular diagnostics have the potential to improve on clinicopathological parameters to predict this recurrence and plan adjuvant treatment. The test most frequently applied is based on detecting TP53 mutations, but alternative methodology is required for cases that harbour the wild-type gene.Methods:One hundred and two cases with tumour-adjacent margins, considered to be clear margins by microscopy, were examined using carefully optimised molecular diagnostics based on detection of the TP53 and Ly-6D markers. The markers were also combined to provide a dual approach.Results:The dual molecular diagnostic identified cases with a significant increase in the probablility of developing locoregional recurrence when tumour-adjacent positive and clear margins were compared (P=0.0001). These tests were most useful when the clearance at the resection margins was 5 mm or less. The TP53-based diagnostic was a better predictor of locoregional recurrence than established clinicopathological parameters.Conclusion:The optimised TP53-based diagnostic rapidly identifies an important subgroup of cases with close margins that will benefit from new treatment modalities to reduce the risk of recurrence.

New intravenous sedative combinations in oral surgery: A comparative study of nalbuphine or pentazocine with midazolam

A randomised, double blind study was conducted to compare the efficacy and safety of nalbuphine or pentazocine with midazolam in patients undergoing minor oral surgery under local analgesia. Forty patients, aged between 17 and 48 years and in American Society of Anesthesiologists A.S.A. Class I participated. The results confirmed that the use of either nalbuphine (0.2 mg/kg) or pentazocine (0.5 mg/kg) allowed for a significant reduction in the mean dosage of midazolam required to produce satisfactory sedation when compared with trials where midazolam was used alone. Thus a mean midazolam, 0.087 mg/kg (nalbuphine group) or 0.081 mg/kg (pentazocine group) was required compared with 0.17 mg/kg (Aun et al., 1984) and 0.19 mg/kg (Skelley et al., 1984). Inadvertent overdosage with midazolam is prevented as the onset of sedation and its end-point are more obvious. No adverse cardiovascular or respiratory side effects were noted. The recovery rate for both groups was similar. Ninety-five per cent (39 of 40) of patients were able to walk unaided at 2 h post operation. At this time significantly more patients in the nalbuphine group were pain free (p less than 0.001). Both combinations provided excellent operating conditions with a high degree of safety and high patient acceptability. As the nalbuphine group enjoyed a more comfortable post-operative period this combination is favoured.

Facial trauma: a case of potentially life-threatening distracting injuries.

We report the case of a 60-year-old cyclist with multiple facial lacerations. Reassessment of the mechanism of injury and presenting clinical features of a change in voice, odynophagia, and a graze in the anterior neck triggered concern. Fibreoptic nasoendoscopy showed a large haematoma of the supraglottic airway. Scans confirmed laryngeal injuries, which were managed conservatively as an inpatient without prophylactic tracheostomy. This report emphasises the importance of a high index of suspicion in patients with such facial injuries and other subtle signs, and highlights the need for careful clinical assessment.