T.K. Mellor

Pentoxifylline and tocopherol in the management of patients with osteoradionecrosis, the Portsmouth experience

Osteoradionecrosis of the jaw remains the most problematic consequence of radiotherapy for the management of head and neck cancer. Treatment is often complex and multimodal. New theories on its pathophysiology have allowed the development of potential treatment modalities, including the use of pentoxifylline and tocopherol. In this retrospective case series we examined the outcomes of patients with ORN prescribed pentoxifylline and tocopherol.

Management of early stage cutaneous Merkel cell carcinoma of the head and neck

Merkel cell carcinoma (MCC) is a rare but aggressive skin cancer of neuroendocrine origin. As a result, few large studies have been published, and we know of even fewer on disease of the head and neck alone. The most appropriate way to manage patients with early local disease and no sign of metastases neck is controversial. We reviewed management of early cutaneous MCC of the head and neck in 8 hospitals in the United Kingdom over 12 years between 1999 and 2011 (the largest head and neck series in Europe to date), and identified 39 patients (19 men and 20 women) with early disease according to a well recognised classification. A total of 24 patients had stage Ia disease, 11 had stage Ib disease, and 4 were unclassified. Five of those with stage Ia disease developed regional metastases and 7 with stage Ib disease developed regional recurrence. The 2-year overall survival for stage Ia and Ib disease was 62% and 27%, respectively. Our study shows that prognosis is poor after conservative surgical management of stage I disease. Management of the neck is still controversial, and a meta-analysis of all the published data is needed to establish best practice statistically.

Skin necrosis of a pectoralis major myocutaneous flap, caused by methicillin-resistant Staphylococcus aureus

A case of MRSA-induced skin necrosis of part of a pectoralis muscle flap is described. It highlights the importance of recognising potential MRSA infection following surgery and treating it early and aggressively.

Acute vasculitis resulting in free flap failure: The importance of early recognition and options for management

Unusual or unexpected medical causes for free flap failure do occur but are uncommon. We present a rare case of a fibula free flap failure due to an acute vasculitis which was undiagnosed until after the flap had failed. In addition to two successful flap salvages and intravenous heparin, an epoprostenol infusion was commenced but a third salvage was not successful. The vasculitis resulted in marked blood vessel wall thickening, and cutaneous manifestations which presented as late signs. High peri-nuclear anti nuclear cytoplasmic antibody (pANCA) and myeloperoxidase (MOP) titres were subsequently found and histology from several blood vessels showed marked inflammation throughout the wall. A diagnosis of microscopic polyangiitis was made and high dose steroids were subsequently commenced. Interestingly, he had vasculitis several years previously treated with oral steroids but had been discharged from the rheumatology clinic. This rare case illustrates the potential hazards of free flap surgery in the vasculitides and discusses the warning signs and various management options to reduce the likelihood of flap failure in these patients.