S. Laverick

[18F]-fluoride positron emission tomography for imaging condylar hyperplasia

The management of condylar hyperplasia depends on the diagnosis of continued growth in the affected condyle, and there is currently no satisfactory way of imaging it. [(18)F]-fluoride positron emission tomography (PET) was included in the investigation of 5 patients who were suspected of having condylar hyperplasia, and the results were correlated with the operative findings. The technique correctly identified condylar hyperplasia in all patients. Our results suggest that [(18)F]-fluoride PET is a valid way of assessing patients with condylar hyperplasia.

Treatment of actinic cheilitis with imiquimod 5% and a retractor on the lower lip: clinical and histological outcomes in 5 patients

Imiquimod 5% (Aldara, 3M Healthcare Ltd.) is a topically applied immune response modifier used in the treatment of superficial basal cell carcinoma, actinic keratosis, and genital warts. We reviewed the casenotes of 5 patients with histologically confirmed dysplastic lower lips who had been treated with topical imiquimod. Each patient was provided with a specially designed lower lip retractor to prevent spread of the cream. Treatment was stopped after 6 weeks or if an acute inflammatory reaction developed. The lower lip was biopsied 4 weeks later, and histologically the dysplastic changes had been reversed in all 5 patients. The lip retractor was well-tolerated, and prevented spread of the cream. Imiquimod 5% cream offers an alternative method to manage dysplastic lips. Our lip retractor is a simple and cost-effective method of isolating the lower lip and allowing application of topical agents. The method could equally well be used for agents other than imiquimod.

Intraoral external oblique ridge compared with transbuccal lateral cortical plate fixation for the treatment of fractures of the mandibular angle: prospective randomised trial

Since the initial description by Michelet et al. and research by Champy et al. the placement of a single, four-hole, monocortical, osteosynthesis plate has been considered an acceptable method of fixation for a fracture of the mandibular angle. We investigated the null hypothesis that there is no difference in the incidence of postoperative removal of an infected plate between miniplates placed on the mandibular external oblique ridge and those placed on the buccal surface of the mandible through a transbuccal approach to treat a fracture of the angle of the mandible. Patients were randomised to having their angle fractures treated with a ridge plate placed intraorally or transbucally. Other variables were investigated including the effect of smoking, drinking alcohol, oral hygiene, and the method of holding the reduction on removal of the plate, occlusal outcome, and degree of preoperative anatomical displacement and postoperative reduction. We also studied the operating time required for the two techniques, the effect of the presence and consequent removal of a wisdom tooth in the line of the fracture, and the effect of delay in taking the patient to theatre for subsequent removal of the plate for infection. Of the 261 angle fractures 34 (13%) plates were removed because of infection, and 6 of these (18%) required a further period of fixation, such as intermaxillary fixation, to treat non-union. The transbuccal plate had a significantly lower postoperative infection rate (6/124, 5%) than the ridge plate (28/137, 20%) (p=0.001). Smoking adversely affected the healing of angle fractures (p=0.000). Displacement of fractures is related to the infection rate (p=0.003), and there are no significant relations between delay in going to theatre or the presence and potential removal of a wisdom tooth in the line of the fracture and infection rate. There was a highly significant difference between the rate of removal of plates placed intraorally on the external oblique ridge, and plates placed transbucally (p=0.000). Transbuccal plates were far less likely to need removal for infection than ridge plates, odds ratio 5.05.

Toxicology screening in oral and maxillofacial trauma patients

The role of alcohol in facial trauma is recognised but we know of no research on the possible contribution made by the use of illicit drugs in patients with facial injuries, or the interactions that may occur during anaesthesia. We aimed to find out whether illegal drugs were identified in the urine of patients with maxillofacial injuries, what substances were present, and whether patients were willing to disclose use of drugs at the time of injury. Over a 12-month period we prospectively studied consecutive patients with facial injuries who were referred by accident and emergency (A&E) to the department of oral and maxillofacial surgery (OMFS) for inpatient assessment and treatment within 24 h of injury. Anonymised data on patients were obtained from questionnaires that were linked to a urine sample provided on admission. Results were obtained using immunoassay and gas chromatography with mass spectrometry. A total of 105 patients with facial injuries were eligible and 95 (90%) provided a urine sample and completed the questionnaire; 2 samples were of insufficient volume and were discarded before analysis. Twelve patients (13%) admitted using drugs at the time of injury but 44 (47%) samples tested positive for illegal drugs; fewer showed the presence of alcohol (n=37; 40%). Use of drugs, although often denied, is widespread among patients with facial injuries. It is important to consider the role that drugs have in patients who present with traumatic injuries, the interactions misused drugs may have with anaesthesia, and any possible benefits that targeted prevention strategies would have in this group.

Patterns of emergency maxillofacial referrals and provision of services

The rising number of maxillofacial injuries in the UK requires a reappraisal of emergency services within our specialty. Although the impact of a dedicated trauma list has been reported, it has not been widely embraced, and we know of few data that help to plan the number or timing of such lists. We designed a minimum dataset to collect information about referral, cause of emergency, assessment of patients, and outcome during 2003 and 2004. Theatre data were examined retrospectively to analyse operations during the same period. We conclude that to serve a population of 2.6 million a minimum of 8 emergency lists are required each week to deal with non-complex cases; this equates to 3 lists/million population. The lists should be concentrated at weekends and early in the week.

Postoperative management of the airway with a Ravussin cricothyroid cannula in head and neck surgery

p c i i ostoperative loss of the airway is a serious concern with axillofacial patients. Oedema or haematoma in the head nd neck region can impinge upon and threaten the upper irway. In “high risk” patients, a formal tracheostomy is ommonly done pre-emptively. This procedure has an assoiated morbidity1 and hence performing a tracheostomy on atients with less of a risk to the airway is often a difficult ecision. We present a technique that is established,2,3 but arely used within maxillofacial surgery. In patients where it s perceived that there is less risk of compromising the airay postoperatively, a Ravussin cricothyroid cannula3 can be sed in preference to a pre-emptive tracheostomy. This allows or transtracheal rescue of the airway if it is compromised ostoperatively. The cannula is placed (usually by the anaesthetist) at nduction and can be removed once the airway is under no otential threat, usually after 24 h. In an emergency it can be onnected to high frequency jet ventilation to provide immeiate oxygenation, and provided that the upper airway is not ompletely obstructed to exhalation, then ventilation is posible. Manoeuvres to open the airway such as a jaw thrust ay be required to ensure upper airway exhalation. Whether entilation or oxygenation is achieved, we still recommend ubsequent conversion to a tracheostomy. The latter can be ompleted as a “controlled” procedure.

Conservative management of a large keratocystic odontogenic tumour

Since the term odontogenic keratocyst first appeared in the literature, controversy has surrounded its terminology and surgical management. Recent articles would suggest that surgical opinion is still divided between aggressive radical resection and a more conservative approach. We present an interesting case of a large keratocystic odontogenic tumour shown to have eroded through bony cortices and present within soft tissues that was satisfactorily managed conservatively by decompression and secondary enucleation.

A presentation of facial necrotizing fasciitis with orbital involvement

Necrotizing fasciitis is a rare, severe, life-threatening soft tissue infection. Rapid progression and systemic illness are recognized features of the condition in which a high index of suspicion is essential to prompt early diagnosis and ensure a favourable outcome. Management necessitates immediate and aggressive surgical and antimicrobial treatment. This case report describes the rare presentation of facial necrotizing fasciitis with orbital involvement that required initial and subsequent widespread surgical resection within the first 24 h of admission, including unilateral enucleation of infected orbital contents.

‘White-eyed’ blowout fracture: a case series of five children

The ‘white-eyed’ blowout fracture is an orbital injury in children that is commonly initially misdiagnosed as a head injury because of predominant autonomic features and lack of soft-tissue signs. We present five patients who presented with nausea and vomiting following an apparent mild head or facial injury. None of the five had any external evidence of injury. Despite each case describing diplopia, there was a delayed diagnosis of at least 24 h. CT examination demonstrated an inferior orbital wall fracture in all cases with entrapment of the inferior rectus muscle. Each patient underwent surgical repair, two within 48 h of their injury, both of whom achieved complete recovery of ocular movements, while three were delayed beyond 48 h, with a resulting residual limitation of upgaze in all. It is, therefore, important for clinicians to be aware of this condition, so that it can be diagnosed early in order for early surgical release to be performed, which is associated with an excellent prognosis.

Excision of a submandibular gland: a safe day case procedure?

There are considerable benefits, both for patients and hospitals, if operations are done as day case procedures. Excision of a submandibular gland is a relatively common operation and it is usual practice for surgeons to be cautious, admit the patient for an overnight stay, and leave a drain in place. To assess the amount of postoperative bleeding into the wound (and hence potential risk to the airway) we have studied prospectively the amount of drainage that occurs. Sixty consecutive patients admitted for overnight postoperative monitoring after excision of a submandibular gland had a suction drain placed as part of the procedure. Drainage was measured by departmental staff at regular intervals during the following 24h. Nearly all the patients drained 40ml or less (mean 18ml) and in all cases there was a clear decrease in the volumes drained over the first 6-8h postoperatively. Drainage then became negligible. The plateau in drainage was evident regardless of the initial volume drained. Surgeons should be confident that drainage will cease after 6-8h in most patients, and residual drainage is negligible.