Management of patients at risk of osteoradionecrosis: results of survey of dentists and oral & maxillofacial surgery units in the United Kingdom, and suggestions for best practice.

We aimed to find out whether dental practitioners take specific measures to identify patients who are at risk of osteoradionecrosis (ORN) of the jawbones; how oral and maxillofacial surgery units in the United Kingdom manage patients who have had radiotherapy and require dental extractions, and the evidence behind current practice. We sent postal questionnaires to 60 dentists and 117 maxillofacial units. Dentists were questioned about measures used to identify radiotherapy patients, and use of antibiotic prophylaxis. Maxillofacial units were questioned about the existence of written protocols and the measures used to minimise the risk of ORN. Thirty-five percent of dentists questioned ask specifically about head and neck cancer or radiotherapy as part of their medical history, and 5% of maxillofacial units questioned had written protocols for the management of patients who had had radiotherapy or had previously been diagnosed with ORN. Prophylactic antibiotics are recommended for patients at risk of ORN by 16% of dentists and 81% of maxillofacial units. Preoperative mouthwash is recommended by 59% of maxillofacial units. Identification of patients at risk of ORN is the first step in prevention but it is not done efficiently at present. Recommendations include the use of preoperative mouthwash and prophylactic antibiotics. Operations should be atraumatic and should be done by experienced clinicians.

CT and duplex scanning: a comparison of imaging techniques for evaluation of the carotid tree in head and neck cancer patients.

Carotid artery disease is a common condition which, like head and neck cancer, is primarily smoking related. Internal carotid stenosis may result in cerebro-vascular complications, while severe stenosis of the external carotid can potentially compromise microvascular free tissue transfer reconstruction. We were interested to see whether any co-existing carotid artery disease could be assessed on the neck CT scan by comparing it to definitive duplex scanning in head and neck cancer patients. CT and duplex scanning of the common, internal and external carotid arteries was compared in 30 patients (180 vessels). The arterial phase of the neck CT scans were reviewed by two radiologists and all duplex scans were performed by one vascular technician to minimise inter-operator variability. The respective findings were blinded. Significant correlations were found between CT and duplex in confirming stenosis of the common and internal carotid arteries (P<0.001). There was a weak correlation between CT and duplex in the assessment of the external carotid system (P=0.02 and P=0.08), with CT under-estimating the true extent of stenosis in this vessel. The sensitivity and specificity of CT compared to duplex was 77% and 94% respectively. CT is useful not only for imaging the neck of head and neck cancer patients, but also in screening for carotid stenosis. Duplex scanning is more accurate than CT in assessing the external artery, and is useful for evaluating patients with significant stenosis of the carotid tree.

High division of the accessory nerve: a rare anatomical variation as a possible pitfall during neck dissection surgery.

A rare clinical variant found during neck dissection surgery is reported in which the spinal accessory nerve divided at a high level in the neck, before entering the sternocleidomastoid muscle. This case documents the need for meticulous technique in identification and dissection of the spinal accessory nerve in order to reduce the risk of postoperative morbidity.