V. Ilankovan

An audit of 405 temporomandibular joint arthrocentesis with intra-articular morphine infusion

The management of refractory pain in the temporomandibular joint (TMJ) is both challenging and controversial. Arthrocentesis is a simple technique that can be used instead of more invasive procedures in patients with pain that fails to respond to conventional conservative measures. We undertook an audit of 405 arthrocenteses in 298 patients over a 10-year period who had refractory pain in the TMJ. The pain was assessed subjectively by a visual analogue scale, both before arthrocentesis and at 1 and 6 months, and 1 year afterwards. A significant reduction in pain score was found after arthrocentesis (P < 0.001) and 269 patients (90%) found the procedure beneficial. We recommend arthrocentesis as an effective, minimally invasive technique in patients with continuing pain in the TMJ that is unresponsive to conservative management.

Morphometric analysis of orbital, buccal and subcutaneous fats: their potential in the treatment of enophthalmos

Retro-orbital fat volume reduction has been reported in patients with enophthalmos but could be restored by a suitable fat autograft. Buccal and subcutaneous adipose tissues were identified as possible donor sites. Samples of these and of orbital fat were obtained from fresh cadavers, and the relative volumes of collagen and of endothelial cells and the numerical density of mast cells were compared since these might influence graft survival. The results demonstrated strong similarities between orbital and buccal fat which were significantly different from subcutaneous fat. It was concluded that the buccal fat pad would be a more suitable donor site than subcutaneous adipose tissue to replace orbital fat loss and that its use merits further investigation.

Management and outcome of cervical lymph node metastases of unknown primary sites: a retrospective study

Analysis of the case records of 114 patients with cervical lymph node metastases from unknown primary sites showed that management should be adapted according to the site of nodal disease and the histopathology. Poorly differentiated carcinoma was best treated with radiotherapy, squamous cell carcinoma with radiotherapy and excision, and non-papillary adenocarcinoma by radical thyroidectomy and neck dissection. The 5-year survival for each regimen alone, was 15/40 (38%), 7/13 (54%) and 5/8 (63%), respectively. For metastatic masses in the supraclavicular region, chemotherapy was the preferred treatment. The overall survival for the 107 patients who completed the follow up was 36%.

Gold weight implants in the management of paralytic lagophthalmos

Lagophthalmos secondary to facial nerve damage can lead to corneal exposure and eventually blindness. Appropriate management depends on the severity and likely duration of recovery. Upper eyelid gold implants play an important role in the medium and long term management of this condition. The authors report their experience with 16 consecutive patients who underwent gold weight implantation of the upper eyelids for correction of paralytic lagophthalmos and describe their surgical technique. The mean age of the patients was 70 years with a male predominance (M:F=3.2:1). Radical parotidectomy (69%) was the most common reason for the intervention. The mean weight of the implant was 0.95 g. There were no intraoperative or immediate postoperative complications. One implant (6%) was extruded and one patient (6%) had residual lagophthalmos and required a heavier implant. 15 of the 16 patients were satisfied with the outcome and all had adequate lid closure at last follow up.

Reconstruction of maxillary defects with serratus anterior muscle and angle of the scapula

Large maxillary defects ideally require reconstruction with a free flap. Varied classifications have been reported to describe maxillary/orbital defects. We describe our experience of free flaps in large maxillary defects using composite tissue of serratus anterior muscle and the angle of the scapula. Eleven patients (6 men and 5 women, age range 42-69 years) were studied retrospectively and the outcome was recorded. We conclude that the composite flap is versatile enough to reconstruct maxillary defects of various sizes.

Sensory recovery of noninnervated free flap in oral and oropharyngeal reconstruction

The sensory recovery of noninnervated free flaps used in oral and oropharyngeal reconstruction is analysed retrospectively to evaluate the degree of sensory recovery in different free flaps; and to assess the influence of various clinical and surgical factors on the recovery. A total of 40 patients who underwent oral and oropharyngeal reconstruction with noninnervated radial forearm (24), jejunal (10) or gastro-omental (6) free flaps were studied for at least 12 months postoperatively. The modalities examined were light touch, sharp prick, hot and cold temperature and static two-point discrimination. All the modalities showed statistically significant recovery in all flaps (p<0.05). The degree of sensory recovery for each modality is highest in the radial forearm followed by gastro-omental and lastly jejunal flaps. The differences between radial forearm and gastro-omental/jejunal flaps are statistically significant (p<0.05) except for light touch. The differences between the later two groups of flaps did not show statistical significance (p>0.05). Sensory recovery for all modalities in all flaps was not dependent on sex, age, smoking, flap size, postoperative radiotherapy or follow-up period (p>0.05).

Atypical Fibroxanthoma—A Retrospective Immunohistochemical Study of 42 Cases

PURPOSE Atypical fibroxanthoma is a cutaneous dermal malignancy that presents on the sun-damaged skin of elderly people. It requires a definitive diagnosis, from a high-grade sarcoma to a nonmesenchymal neoplasm. The recommended treatment protocol differs from similar histologically related tumors; thus, a diagnosis of atypical fibroxanthoma should fulfill strict histologic and immunohistochemical stain criteria. The use of these standards will exclude other skin malignancies, including malignant fibrous histiocytoma, angiosarcoma, malignant melanoma, and squamous cell carcinoma. This study was performed with the aim of identifying key immunostains to develop diagnostic criteria. MATERIALS AND METHODS Forty-two cases were studied retrospectively over a 10-year period using a panel of immunostains. RESULTS The average age at presentation was 78 years, with a male predominance. The scalp was found to be the most common site of occurrence, although other investigators have found the forehead, cheeks, nose, and ears as the prevailing sites of presentation. CONCLUSIONS An extensive panel of immunohistochemical stains can be used to prove a diagnosis of atypical fibroxanthoma.

Retrospective study on the cutaneous head and neck melanoma in Dorset (UK)

Trends in the incidence and the sites of primary malignant melanoma on the skin of head and neck in Dorset as well as the outcome of treated cases were overviewed for the first time. Increase in incidence rate of cutaneous head and neck melanoma from 1.3 per 100,000 in 2004 to 3.1 per 100,000 in 2007 was recorded. The most prevalent histogenetic type of cutaneous malignant melanoma on head and neck in our study was melanoma of superficial spreading type 35.1% (n=20) of all registered cases. Superficial spreading melanoma apart from being the most common type of malignant melanoma of the head and neck in Dorset also showed increase in the number of diagnosed cases of the reviewed years. It increased from 2 (22.2%) of all head and neck melanoma cases in 2004 to 7 (30.4%) in 2007. The average age at the time of diagnosis the cutaneous malignant melanoma of head and neck for both men and women was 73.5 years. Breslow thickness, Clarks level of invasion, tumour ulceration and anatomical site remained the most important prognostic factors. Correlation between Breslow thickness and Clarks level of invasion found to be stronger in men.

Malignant peripheral nerve sheath tumour of the parapharyngeal space in a patient with neurofibromatosis type 1

A malignant peripheral nerve sheath tumour, the sarcoma most common in patients with neurofibromatosis type 1, arising in the parapharyngeal space is rare. They usually arise from pre-existing neurofibromas, particularly the plexiform type. The most common presenting symptoms are an enlarging neck mass, pain, and a neurological deficit. They are aggressive tumours that carry a poor prognosis despite wide excision and adjuvant radiochemotherapy. Patients with neurofibromatosis type 1 should be investigated, including deep biopsy, if pain and enlargement of the neurofibromas or any neurological deficit develop.

An audit of oral and dental health regimens practised in the management of oropharyngeal cancer

The purpose of the present study was to find out what preventive care was offered to patients after radiotherapy, particularly if they were dentate. As the mean age of the population increases and the number of people who retain at least some of their teeth into old age also rises, it is likely that more and more people with a diagnosis of oral cancer will be dentate. The incidence of oropharyngeal cancer has also started to increase recently and is affecting more young and dentate people. It is of paramount importance to provide comprehensive management for these patients, not only to remove the disease and reconstruct the defect, but also to provide the patient with the opportunity of experiencing a good quality of life by having a comfortable mouth after treatment. A questionnaire was sent to all senior fellows of the British Association of Oral and Maxillofacial Surgeons (BAOMS) and the results analyzed. The results of this survey show that improvements could be made if some simple preventive measures were instigated in the early stages of treatment.