The use of intra-articular opioids and bupivacaine for analgesia following temporomandibular joint arthroscopy: a prospective, randomized trial.

PURPOSE: This investigation evaluated the efficacy of using intra-articular morphine, bupivacaine, or a combination of both in the management of postarthroscopy temporomandibular joint (TMJ) pain. MATERIALS AND METHODS: Thirty-two consecutive patients with internal derangements of the TMJ and persistent pain underwent TMJ arthroscopy. The patients were randomized equally into 4 groups. Group 1 received a sterile saline solution (control), group 2 received bupivacaine alone, group 3 received only a morphine solution, and group 4 received morphine mixed with bupivacaine. The patients recorded postarthroscopy pain using a visual analog scale (VAS), as well as analgesic consumption for 24 hours. The VAS and analgesic consumption were compared in the 4 groups. RESULTS: Group 3 (bupivacaine alone) consumed, on average, 5.1 fewer analgesic equivalents than did group 1 (control) over the 24-hour period of study (P <.05). Otherwise, there was no significant difference in the number of analgesic equivalents consumed by the 4 groups. Patients treated with bupivacaine alone and those with morphine alone had significantly lower pain scores than the controls. However, there was no significant difference between the pain scores of the morphine and bupivacaine groups at any time. Patients treated with the mixture of morphine and bupivacaine showed no significant difference from controls at any time. CONCLUSIONS: Bupivacaine alone provides a better analgesic effect than morphine alone or the combination of morphine and bupivacaine. Morphine alone has a longer time of onset, with less effect on the pain scores during the 24-hour observation period.

A rare complication of tooth abscess--Ludwig's angina and mediastinitis.

Deep neck infections are a rare but potentially fatal complication of pulpal abscess of the teeth. If an infection can progress rapidly from a toothache to a life-threatening infection, then it is critical that dentists be able to recognize the danger signs and identify the patients who are at risk. This article reviews a case of a seemingly innocuous toothache which rapidly progressed to Ludwig's angina and mediastinitis, and discusses how to recognize and manage these life-threatening infections.

The use of computed tomography to define zygomatic complex position.

PURPOSE: The purpose of this study was to analyze the use of midline references and landmarks to assess the position of the zygomatic complex relative to the cranial base, and to test the reliability of these measurements in assessing facial symmetry. METHODS: Direct skull measurements were compared with measurements made on computed tomography (CT) images. The effect of CT scanner error, technologist error, gantry angle error, error of skull inclination, and error due to the presence of titanium rigid fixation hardware were assessed. To test observer variation and the effect of each level of error, 4 blinded bilateral measurements were repeated 3 times by 5 observers on both dry skull and CT scans. A mixed effect analysis of variance model then assessed for effect of method of measurement (dry skull vs CT), observer, CT scanner, technologist, gantry angle, skull inclination, and rigid fixation. RESULTS: A total of 2,040 measurements were made. Measurements for zygomatic complex posterior and anterior width and height were reliable and had an interobserver variations of 0.02 +/- 0.03 mm, 0.5 +/- 0.4 mm, and 0.37 +/- 0.3 mm, respectively. The difference between dry skull and CT assessment for the 3 reliable measurements was 1.2 +/- 0.3 mm, 0.44 +/- 0.4 mm, and 1.1 +/- 0.5 mm, respectively. The errors produced by the CT scanner, technologist, and rigid internal fixation hardware were not clinically significant. The measurements were not sensitive to gantry angle and skull inclination changes of 10 degrees or less. A fourth measurement assessing zygomatic complex projection was found not to be accurate or reliable. CONCLUSIONS: These findings suggest that the 3 CT scan measurements describing the position of the zygomatic complex relative to the cranial base are clinically useful.

Systematic review of the treatment and prognosis of the odontogenic keratocyst.

OBJECTIVES: To clarify the natural history of the odontogenic keratocyst (OKC) and to evaluate treatments with respect to the likelihood of recurrence. STUDY DESIGN: A systematic review of the literature was completed pertaining to the treatment and prognosis of the OKC. Each investigation was evaluated based on 4 inclusion criteria. Each study that met the 4 inclusion criteria was then evaluated based on 8 standards. RESULTS: Of 2290 citations reviewed pertaining to the OKC, 14 investigations were found to meet the 4 inclusion criteria. Resection was found to have the lowest recurrence rate (0%) but the highest morbidity rate. Simple enucleation was reported to have a recurrence rate of 17% to 56%. Simple enucleation combined with adjunctive therapy, such as the application of Carnoy's solution or decompression before enucleation, was reported to have recurrence rates of 1% to 8.7%. CONCLUSIONS: Although the existing literature consists of retrospective consecutive case series, it appears that resection or enucleation with adjunctive therapy is associated with recurrence rates that are lower than those associated with enucleation alone.

A prospective, blinded comparison of clinical examination and computed tomography in deep neck infections.

OBJECTIVES/HYPOTHESIS: To determine whether there is a scientific basis for the routine use of contrast-enhanced computed tomography (CECT) in the evaluation of suspected deep neck infection (DNI). STUDY DESIGN: We conducted a prospective, blinded comparison of clinical examination and CECT in DNI. METHODS: Thirty-five consecutive patients with suspected DNI were prospectively assessed by clinical examination and CECT for the presence and extent of surgically drainable purulent collections. Before CECT a surgeon recorded clinical data and predicted the extent of infection. A head and neck neuroradiologist, blinded to the clinical evaluation, predicted the extent of infection based on CECT. Final outcome (the presence of a purulent collection) was determined at surgery or in long-term follow-up. The clinical and CECT findings were compared with the final outcome to determine the sensitivity, specificity, and accuracy of each modality. RESULTS: Twenty patients had purulent drainable collections. The accuracy of clinical examination alone in identifying a drainable collection was 63%, the sensitivity was 55%, and the specificity was 73%. The accuracy of CECT alone was 77%, the sensitivity was 95%, and the specificity 53%. When CECT and clinical examination were combined, the accuracy in identifying a drainable collection was 89%, the sensitivity was 95%, and the specificity 80%. If fluid collections with volumes of 2 mL or greater on CECT were considered, the accuracy of CECT would have been 85%, the sensitivity 89%, and the specificity 80%. CONCLUSION: CECT and clinical examination are both critical components in the evaluation of suspected DNI.