Immediate lengthening temporalis myoplasty for facial palsy reconstruction following facial nerve inclusive total parotidectomy.

Immediate lengthening temporalis myoplasty (Labbé procedure) for immediate dynamic facial reanimation after nerve-inclusive parotidectomy in the elderly population is undocumented in the literature. The aim of this work was to determine whether the Labbé approach could achieve immediate, good functional and static results in elderly patients with acquired facial palsy. A retrospective analysis of five patients with parotid malignancies involving the facial nerve who underwent parotidectomy and an immediate Labbé procedure was performed. The House-Brackmann and Sunnybrook scores for facial palsy were used as objective measurements of the functional outcome. All patients underwent total parotidectomy, neck dissection, Labbé procedure, immediate temporary tarsorrhaphy, brow lift, and postoperative radiotherapy. Mean patient age was 83 (range 73-87) years. The average resected tumour size was 3.54 cm. The mean duration of surgery was 324 min and length of hospital stay 4 days. All patients experienced an improvement in House-Brackmann of one grade postoperative (grade V to IV in four, grade VI to V in one); the Sunnybrook score improved by 31 points on average (mean preoperative 3.8 vs postoperative 34.8). An immediate Labbé procedure following ablative parotid malignancy resection is a reliable and safe reconstructive procedure in a carefully selected elderly population, providing acceptable immediate static and dynamic hemifacial mimetic function and eliminating an additional facial palsy correction procedure.

OMFS moving into the recovery phase of the COVID-19 pandemic - a survey on general practice for elective local anaesthetic procedures.

The COVID-19 pandemic has meant a halt to elective oral and maxillofacial procedures under local anaesthetic. As oral and maxillofacial departments enter the recovery phase of the COVID-19 pandemic there are many considerations to make regarding standard operating procedures. Thus, this survey was conducted to identify areas of consensus and divergence in practice during the recovery phase of the pandemic for local anaesthetic procedures in oral and maxillofacial units. Our findings show there are some areas of inconsistency of practice particularly in preoperative risk management and self-isolation as well as fallow time between patients for aerosol generated procedures and non-aerosol generated procedures.

Single-stage nasal reconstruction with the islanded forehead flap.

BACKGROUND AND PURPOSES: Multi-staged forehead flaps are a well-recognised reconstructive workhorse for subtotal and total nasal defects. It carries the disadvantage of repeated trips to theatre for revisional surgery, which is not suited to all patient cohorts. The single-stage islanded forehead flap eliminates this need. We detail our indications and outcomes of using this flap to highlight the maintained versatility of the technique without significant compromise on reconstructive and patient outcome. SUBJECTS STUDIED AND METHODS: A prospective surgical database was collated where patients were categorised as partial or total reconstruction. We detail surgical technique and review of rationale of patient selection. Patient demographics, perioperative data and follow-up course were recorded. MAIN FINDINGS: A total of 22 patients were recorded from both the U.K. and Ethiopia via working with the charity Facing Africa. Defects occurred from a mixture of trauma, Noma and cancer resections. Thirteen were total nasal reconstructions and nine partial. The mean follow-up period was 2.25 years. We experienced two major complications which required minor revision in the theatre and two minor complications, all resolved satisfactorily. CONCLUSIONS: We demonstrate good outcomes and safety of the procedure in this first report of a varied cohort of nasal reconstructions in a heterogenous cohort of patients. We advocate the use of this flap in the multi-morbid patient where recovery can be expedited or those who have limitations from economical restraints.

Effect of Dexamethasone on Resting Blood Lactate Concentrations in Horses.

BACKGROUND: Blood lactate concentration is a marker of tissue perfusion and helps guide therapeutic interventions in critically ill horses. In both humans and dogs, administration of corticosteroids can increase blood lactate concentration, leading to type B hyperlactatemia. This effect could be a consequence of the impact of corticosteroids on glucose metabolism. OBJECTIVES: To investigate the effects of daily IM dexamethasone administration on blood lactate and glucose concentrations in horses. ANIMALS: Nine healthy adult horses. METHODS: A randomized, blinded, controlled, cross-over study design was used. Horses were randomly assigned to 1 of 2 groups, either receiving 0.05 mg/kg of dexamethasone IM or an equivalent volume of saline, daily for 7 days. Blood was collected to determine lactate and glucose concentrations at baseline, 2 hours after the daily injections and 24 hours after the last injection. RESULTS: Dexamethasone treatment had a statistically significant effect on lactate (P = .006) and glucose (P = .033) concentrations. The least squares mean lactate concentration was 0.93 mmol/L (95% CI: 0.87-0.99) in the dexamethasone group compared to 0.71 mmol/L (95% CI: 0.70-0.73) for the saline group. A positive relationship between blood lactate and glucose concentrations was identified, with a 0.07 mmol/L (95% CI: 0.05-0.09) increase in lactate concentration per unit increase in glucose (P < .0001) concentration. CONCLUSIONS AND CLINICAL IMPORTANCE: Dexamethasone induces statistically significant increases in blood lactate and glucose concentrations in healthy horses. Awareness of the potential for corticosteroids to induce type B hyperlactatemia might be important in the management of critically ill horses receiving dexamethasone.

Microvascular reconstruction of facial defects in settings where resources are limited.

The surgical treatment of defects caused by noma is challenging for the surgeon and the patient. Local flaps are preferred, but sometimes, because of the nature of the disease, there is not enough local tissue available. We describe our experience of free tissue transfer in Ethiopia. Between 2008 and 2014, 34 microsurgical procedures were done over 11 missions with the charity Facing Africa, predominantly for the treatment of defects caused by noma (n=32). The mean duration of operation was 442 minutes (range 200 - 720). Six minor wound infections were treated conservatively and did not affect outcome, a return to theatre was required in 4 patients with wound infections and one with a haemorrhage; 2 flaps failed and 2 partially failed, one patient developed an oronasal fistula, and one had an infection at the donor site that required a repeat graft. In settings where resources are limited, free flaps can be used when local tissue is not available and they cause less morbidity than pedicled tissue transfer.

Reconstruction of complex oro-facial defects using the myocutaneous sub-mental artery flap.

Oro-facial defects require reconstruction that provides suitable colour match and texture. Moreover inner and outer cheek lining and bulk are key considerations. In cases of severe oro-facial infections concomitant mandibular abnormality, for example trismus, can mandate the need for tissue to obturate mandibular defects. We assessed the use of the myocutaneous sub-mental artery flap (MSA) in non-oncological patients with such defects. Twenty two consecutive patients were included in this case series. All patients were survivors of Cancrum Oris (NOMA). Demographic details, nutritional status and co-morbidities were recorded. Defects were classified according to the tissues destroyed; cheek, mandible, oral cavity, lip(s), nose and eye(s). Simultaneous procedures carried out were recorded. The surgical anatomy of the MSA is described. All patients had composite defects of the cheek and oral cavity plus another local anatomical structure. Adjunct procedures such as trismus release were carried out in 18/22 patients. Four patients required a return to theatre. There was no trismus recurrence observed. No flap losses were incurred. The MSA is a robust flap with minimal incidence of major complications. The MSA negates the need for microsurgical tissue transfer. Furthermore the MSA provides adequate bulk to obturate these defects. Future applications of the MSA may include complex oro-facial oncological defects.

Isolated fracture of the superior orbital fissure.

We report a case of a patient with an isolated fracture of the superior orbital fissure and development of superior orbital fissure syndrome.

Osteonecrosis of the jaws induced by anti-RANK ligand therapy.

Since the introduction of bisphosphonates to treat diseases that affect remodelling of bone, increasing numbers of patients with bisphosphonate-related osteonecrosis of the jaws have been reported; the number is currently unknown. Recently anti-RANKL agents (receptor activator of nuclear factor-kappaB ligand) such as denosumab (Prolia, Amgen Inc., California, USA) that have a similar mode of action to bisphosphonates have been introduced to treat such diseases. We report a case of osteonecrosis that was induced by anti-RANKL therapy. To our knowledge this is the first case to have been induced by these agents.

Anatomical variability of omohyoid and its relevance in oropharyngeal cancer.

AIMS: To define the reproducibility of the position of omohyoid muscle. SETTING: A regional Maxillofacial surgical oncological service. MATERIAL AND PATIENTS: Thirty dissections of cadavers and consecutive series of 88 patients who had had neck dissections, either prophylactic or therapeutic, as part of their oncological management. METHOD: Measurement of the upper border of omohyoid muscle relative to the clavicle and the internal jugular vein (mm). RESULTS: The position of omohyoid muscle in relation to the clavicle and internal jugular vein varied considerably and by inference the nodal yield at level IV is also likely to vary. CONCLUSION: The wide variability of the position of omohyoid muscle is likely to have implications for the surgical management of oral and oropharyngeal cancer.

Transalveolar screws and the incidence of dental damage: a prospective study.

The incidence of screw/tooth contact in the placement of transalveolar screws was prospectively studied. The clinical significance of such contact when it occurred was assessed. Patients with fractures of the mandible requiring intra- or post-operative control of their occlusion with transalveolar screws were entered into the study. Following screw removal, contact was assessed radiographically and all teeth adjacent to screws were tested for vitality. Any contacts were judged to be minor if less than 50% of the diameter of the screw hole impinged on a tooth root or major if this was more than 50%. Fifty-four male and one female patients completed the study. There were 232 screws placed in these patients adjacent to 440 teeth. Twenty-six screws (11.2%) had major contacts and 37 (15.9%) had minor contacts. Seventeen teeth tested as non-vital with electronic pulp testing but of these only 6 showed any impingement by screws. Two screws were associated with complications in two patients. Screw/tooth contact does occur using transalveolar screws, however, the incidence of clinically significant damage appears to be very low.

Lack of tooth eruption following maxillary fracture: case report.

Aberrant tooth development following facial fractures is unusual. It is commonly reported that tooth buds involved in the line of a mandibular fracture will continue to develop normally and erupt sequentially. Few cases have been cited regarding developing teeth in the line of maxillary fractures. In the case reported, the normal growth and position of a maxillary third molar can be seen to be retarded at the position of a maxillary fracture, sustained by a child in the mixed dentition phase of dental development.

Ditylenchus dipsaci Infestation of Trifolium repens. I. Temperature Effects, Seedling Invasion, and a Field Survey.

Rates of development of stem nematode (Ditylenchus dipsaci) in white clover (Trifolium repens) seedlings were found to be linearly related to temperature. Basal developmental temperature (T(b)) was 3 degrees C, and the thermal constant (S) for development of gravid adult females from freshly laid eggs was 270 accumulated day-degrees above the T(b). Only 12% at 20 degrees C and 4% at 4 degrees C of the gravid female nematodes inoculated into seedling axils successfully penetrated seedling epidermis. These nematodes slowly migrated within the seedling and after a lag of 5 days at 20 degrees C started to lay eggs. The maximal rate of egg production was temperature-dependent, being 0.8 and 3.1 eggs female(1) day(1) at 10 and 20 degrees C, respectively. Nematodes emigrated rapidly from infested stolons when they were immersed in water, with rates being highest at 25 degrees C and lowest at 4 degrees C. The sensitivity to temperature of many of the parameters that govern nematode population dynamics indicates that climatic changes will have a marked effect upon this host-parasite system. A study of infested stolons from the field indicated that nematode numbers increased up to 3,000 or more before tissue senesence, triggered by nematode damage, caused a mass emigration of nematodes from the stolon.

Ditylenchus dipsaci Infestation of Trifolium repens. II. Dynamics of Infestation Development.

Trifolium repens (white clover) stolons were inoculated with Ditylenchus dipsaci (stem nematode), and the development of resulting infestations was monitored. Nematodes initially remained confined to superficial locations, concentrating in petiole axils near inoculation points. They were able to migrate slowly from the inidal inoculation points and infest adjacent axils, especially in regions near the stolon tip. As time progressed, in some axils, nematodes migrated through the stolon epidermis and colonized slowly expanding subepidermal pockets of host tissue (ca. 0.2-mm length of stolon/day). In these loci nematodes established exponentially increasing populations, but the rates of locus expansion remained constant, indicating that locus expansion was limited by unidentified host-dependent factors. As a result of increasing population pressure within subepidermal loci, J4 entered a "diapause" state and the rate of egg production by adults declined, thereby reducing rate of population growth to more sustainable levels. Typically, these populations peaked at ca. 10,000 individuals in ca. 160 days occupying 3-cm lengths of stolon. Thereafter, heavily infested regions of stolons started to die, leading to the formation of longitudinal splits in their epidermis. In other axils, nematodes did not migrate into the stolons but remained confined to axils. Some of these populations increased a hundred-fold in 95 days, with population growth ending when petioles started to die. Host plant stolon morphology was affected only when subepidermal stolon populations developed high population levels (>100 nematodes) within close proximity (<2 cm) to active terminal meristems. This occurred either when axillary buds became active on previously infested nodes or when nematodes established endoparasitic populations at locations near the stolon tip during winter and spring, when the rate of stolon extension was limited by low light intensity. Affected stolon tips could "escape" from the influence of such infestations when light intensity and temperature increased. Nematode activity was limited by low temperature rather than light intensity. Global warming is likely to lead to greater damage to infested plants during the winter and early spring because the predicted milder winter temperatures will enhance nematode activity but not necessarily promote stolon growth.