Karen A. Eley

Functional fibrinogen to platelet ratio using thromboelastography as a predictive parameter for thrombotic complications following free tissue transfer surgery: a preliminary study.

Background: Microvascular free tissue transfer in head and neck surgery has become an indispensable tool. Anastomotic thrombosis is one of the leading causes of flap failure; however, there are no validated methods to accurately identify and quantify those patients most at risk of thrombotic complications. The aim of this study was to determine if functional fibrinogen to platelet ratio using thrombelastography could preoperatively identify patients at risk of thrombotic complications. Materials and Methods: Twenty nine patients undergoing free tissue transfer surgery for head and neck pathology underwent routine TEG® analysis, with calculation of functional fibrinogen to platelet ratio at induction of anesthesia. All perioperative thrombotic complications were recorded and crossreferenced with preoperative ratios. Data was further compared to results obtained from 42 healthy volunteers. Results: The mean functional fibrinogen to platelet ratio was significantly higher in the surgery group compared to healthy volunteers. Of the 29 patients studied, 31% (n = 9) had some form of thrombotic event, with all but one patient having a ratio ≥42% (mean 47% ± 7%). For those patients without thrombotic events, the mean ratio was 37% ± 5%. Conclusion: A functional fibrinogen to platelet ratio above 42% as measured by TEG® may be useful in identifying those patients likely to develop thrombotic complication.

Angioleiomyoma of the hard palate: report of a case and review of the literature and magnetic resonance imaging findings of this rare entity.

Angioleiomyomas are benign solitary smooth muscle tumors originating in the tunica media of vessels. They are rarely encountered within the oral cavity, and the number of reported cases specifically involving the hard palate remains small. A 39-year-old man presented with a 2-cm painless swelling on the left anterior hard palate. The mass had been present for ≈ 5 years before presentation, during which time it had slowly enlarged. Magnetic resonance imaging (MRI) showed a uniform signal pattern with T1 signal intensity slightly higher than surrounding soft tissues and marked hyperintensity on T2-weighted sequences. Although the MRI characteristics of angioleiomyomas affecting the extremities have previously been reported, this is the first reported case describing the MRI features of an oral-cavity angioleiomyoma. In view of the inability to differentiate angioleiomyoma from other pathologies with similar MRI features, simple local excision for definitive histopathologic diagnosis remains recommended.

A detailed anatomical assessment of the lateral tongue extrinsic musculature, and proximity to the tongue mucosal surface. Does this confirm the current TNM T4a muscular subclassification?

PurposeThe current T4a subclassification of the TNM staging system for oral malignancies has been criticised as based almost exclusively on anatomical data. The aim of this study was to provide anatomical confirmation of the muscular constraints of T4a classification of oral tongue tumours.MethodsA detailed anatomical study describing and measuring the adjacency of the named extrinsic tongue muscles to the lateral tongue surface was completed on the Visible Human Female (VHF). The distance of styloglossus and hyoglossus to the over lying mucosa were determined.ResultsThe appearance, position, orientation and anatomical relationships of the lateral tongue extrinsic muscles, with comparison to their classical descriptions are described. The right VHF styloglossus was 1.3xa0mm (0.33–1.48) and left 2.91xa0mm (0.66–7.68) from the mucosal surface in the axial plane. The right VHF hyoglossus was 2.93xa0mm (1.48–4.96) and left 4.33 (1.68–8.71) from the mucosal surface in the axial line.ConclusionsIn the lateral tongue, styloglossus and hyoglossus are very superficial. The inclusion criteria of hyoglossus and styloglossus in the T4a staging does not appear justified based upon their anatomical position.

A review of post-operative feeding in patients undergoing resection and reconstruction for oral malignancy and presentation of a pre-operative scoring system ☆

Percutaneous endoscopic gastrostomy (PEG) and nasogastric tubes (NGT) are routine after resection and reconstruction of oral cancer. The selection of the most appropriate method of feeding can be challenging, as both methods carry morbidity. This makes correct selection paramount. The objectives of this retrospective review were to identify the benefits and complications of feeding with PEG and NGT in patients with oral malignancy. We retrospectively reviewed 144 patients who had undergone oral cancer resection and reconstruction, to compare PEG and NGT feeding and to identify the key factors that aid selection of the most appropriate feeding method. We used these factors to develop the Key to Appropriate Replacement Enteral Nutrition (KAREN) scoring system. One hundred and twenty of the 144 patients were managed with PEG, and of these, 9 used it for less than 28 days. The mean (range) duration of use was 13 (5-63) days, and 1.9 (1-5) tubes/patient were used. The KAREN scoring system assigned the correct method of feeding in 92% of cases. The scoring system requires prospective validation but could provide clinicians with a tool to assist in a sometimes difficult decision.

The nasolabial approach: a potential alternative to the lip-splitting incision for maxillectomy

First described by Weber and later modified by Fergusson, the Weber-Fergusson incision has undergone numerous modifications, but the fundamental approach to maxillectomy has largely remained the same. We report the potential benefit of a nasolabial incision for partial maxillectomy. The incision is hidden within the nasolabial fold and obviates the need for division of the upper lip, which may undergo atrophy and shortening after radiotherapy.

Magnetic resonance imaging–based tumor volume measurements predict outcome in patients with squamous cell carcinoma of the mandible

OBJECTIVEnThe objectives of this study were to determine the benefit of pretreatment magnetic resonance imaging (MRI)-based tumor volume (Tv) measurements in patients presenting with squamous cell carcinomas (SCCs) involving the oral cavity subsites most frequently associated with mandibular bone invasion.nnnSTUDY DESIGNnA 10-year retrospective study of all patients undergoing surgical resection for primary SCC of the retromolar trigone, mandible, or floor of mouth (with bone involvement) was completed. In total, 62 patients met the inclusion criteria, and Tv measurements completed on their pretreatment MRI.nnnRESULTSnTumor volume was significant at predicting all-cause survival and disease-free survival at 5 years. Tv stratification to correlate with the TNM staging system resulted in down-staging in 40 of the 62 cases.nnnCONCLUSIONSnTumor volume was a more useful predictor of outcome than the current clinical or pathologic TNM staging, considering the automatic up-staging of tumors involving mandibular bone to T4 tumors.

A rapidly enlarging mandibular swelling

CASE PRESENTATION A 12-year-old boy presented to the Department of Oral and Maxillofacial Surgery with a 2-week history of a mass in the lower right molar region. Over that period it had rapidly enlarged, but was not associated with any discomfort. The first molar tooth had been extracted 18 months before presentation for unrestorable dental decay. There was no history of trauma or further dental symptomatology. His past medical history was unremarkable, he was systemically well, and there was no family history of note. Intraorally, there was a 4 2-cm nontender ulcerated mass centered at the first molar socket (Figure 1). The upper teeth occluded with the mass, and, extraorally, there was mild fullness in the region, but no erythema. There was no palpable lymphadenopathy, and systemic examination was normal. A full blood count, urea, electrolytes, liver function tests, and calcium were all within the normal range. Panoramic radiography (OPG) demonstrated developing dentition with absence of the lower right first molar tooth. There was evidence of a soft tissue mass arising from this region, with an apparent underlying lucency of the mandibular bone. A computed tomography (CT) scan of the region confirmed destruction of the lingual cortex of the mandible with some periosteal new bone formation. The soft tissue mass was poorly delineated, with evidence of calcification (Figure 2, A and B, Figure 3). A 6-mm right submandibular lymph node and several small submental nodes were evident.

The IKEA pencil: a surprising find in the NHS

IKEA, not Argos, is the preferred choice in surgery

An unusual mandibular mass in a child

A 2-year-old boy was referred to the oral and maxillofacial department with a 1-week history of swelling affecting the right mandible (Figure 1). Although this had been noted by his parents and the nurse at his nursery, he had remained asymptomatic and systemically well. There was no history of trauma or dental pain. He had been born at 36 weeks via Cesarean section, and his medical and surgical history was positive only for an uneventful left inguinal hernia repair at 3 months of age. He was meeting all of his developmental milestones, and his childhood immunizations were up to date. On clinical examination there was mild extraoral swelling noted around the right angle and body of the mandible. Intraorally, his dentition was within normal limits, with evidence of good oral hygiene. A 3 3 cm firm swelling was noted in the right retromolar region. Systemic examination was unremarkable. Magnetic resonance imaging (MRI) was arranged, and a review appointment made. However, over the course of the following week, there was rapid growth of the mass, which was now associated with pain, particularly when eating, resulting in an emergency hospital admission. Routine hematology and biochemistry results at this time demonstrated a normal full blood count, but elevated C-reactive protein (CRP) of 15 mg/L (normal 0-8 mg/L), and lactate dehydrogenase (LDH) of 408 IU/L (normal 90-235 IU/L). An ultrasound scan of the right mandibular region showed a 3 1.8 2.5 cm solid mass overlying the right mandible with some deep extension. It did not appear overtly vascular. A radiograph of the mandible was markedly abnormal, with bony destruction, and “sunray spiculation” suggesting a degree of osteogenesis.

A slowly enlarging cheek mass

A 32-year-old Kenyan male was referred to the Department of Oral and Maxillofacial Surgery with a 4-month history of a slowly enlarging mass in the region of the left cheek (Fig. 1). This was associated with some mild discomfort. There were no other features of note, and in particular no nasal, dental, or sinus symptomatology. On clinical examination there was a 3.0-cm very firm, nonfluctuant swelling over the anterior aspect of the left cheek, with normal appearance of the overlying skin. A 1.5-cm tender nonfixed lymph node was palpable in the ipsilateral submandibular region. Facial nerve function was unaffected, and there were no other features of note. Past medical history was positive for a recent diagnosis of type 1 diabetes mellitus (with poor glucose control), crystal arthropathy, and chronic renal impairment secondary to tuberculous autonephrectomy of the right kidney. He had arrived from Kenya 7 years before presentation, and was an ex-smoker of 2.5 pack years. Routine laboratory investigations demonstrated a normal full blood count, elevated urea (16.6 mmol/L [2.56.7 mmol/L]) and creatinine (232 mol/L [70-150 mol/L]), and a negative sickle cell screen. An orthopantogram was normal. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a