Prediction of post-treatment trismus in head and neck cancer patients.

Our aim was to establish the incidence of trismus over time, together with risk factors (including quality of life (QoL)) for the prediction of trismus after treatment in patients with cancer of the head and neck. It was a longitudinal study of 152 patients accepted for primary operation who attended the head and neck cancer clinic of a tertiary referral cancer centre in the United Kingdom. A total of 87 patients was studied prospectively. Our results showed that 41/87 (47%) of patients presented with trismus, 57/80 (71%) had postoperative trismus, and 41/52 (79%) had trismus 6 months after operation or radiotherapy (trismus defined as a maximum mouth opening of ≤ 35 mm). Men and those who drank a lot of alcohol were less likely to have trismus after treatment. QoL variables showed that pain, eating, chewing, taste, saliva, social functioning, social contact, and dry mouth were significantly more impaired in the trismus group than among those without trismus. Postoperative differences in QoL between the two groups highlighted problems with social function and role-playing, fatigue, activity, recreation, and overall reduction in QoL. Women, and those who do not drink alcohol, are at particularly high risk of developing trismus, and, to prevent it and treat it, patients may benefit from multidisciplinary management at an early stage during treatment.

The impact of lymphovascular invasion on survival in oral carcinoma.

Data was retrospectively analysed on 72 consecutive patients treated primarily with resection and concomitant neck dissection for intraoral carcinomas. Twenty prognostic variables were assessed by univariate analysis to assess their influence on survival. Seven variables were significant at the 5% level. Survival was negatively influenced by six tumour related factors, increasing T stage (P=0.039), increasing N stage (P=0.004), greater than two nodes histologically positive nodal disease (P=0.017), tumour size > 4 cm (P=0.022), residual disease at the primary site (P=0.012), extracapsular nodal spread (P=0.01) and the one treatment related factor analysed, adjuvant radiotherapy (P=0.039). Subsequent multivariate analysis was performed via the cox stepwise regression method to assess the influence on survival of all factors which achieved significance at the 20% level. There were only two variables which made a significant difference (P<0.05) to the multivariate model. The presence of lymphovascular invasion (P=0.015) and histological evidence of mandibular invasion (P=0.047). Lymphovascular invasion appeared in the final model despite not achieving statistical significance at the 5% level on univariate analysis. A final cox survival model was constructed. The relative risk of death for those with cervical metastases (N2 and above) at diagnosis was 3.74 (P=0.005). The addition of lymphovascular invasion to the cox model revealed an increase in the relative risk of death in the presence of lymphovascular invasion of 2.99 (P=0.015). Patients with nodal negative disease and one single node positive provided the baseline risk as there was no significant difference between these two groups. The presence of histological evidence of lymphovascular invasion in oral carcinoma surgical specimens has a significant impact on survival outcome in oral carcinoma patients.

Clinical and biological factors affecting response to radiotherapy in patients with head and neck cancer: a review.

OBJECTIVE: The main aim of this article was to review the clinical and biological factors that have been shown to influence the response of the head and neck squamous cell carcinoma (HNSCC) to primary radiotherapy and briefly discuss how some of these factors could be exploited to improve outcome. DESIGN: Medline based search covering 1982-2006 to identify the HNSCC literature where the effect of clinical and biological factors on locoregional control and overall survival were investigated. RESULTS: Clinical factors are routinely used in management decisions. Nevertheless, identically staged tumours receiving the same treatment may have different outcomes. Biological factors such as hypoxia, proliferation and radio-sensitivity play an important role in radiation response. However, these are not currently used in practise because tests that are clinically reliable and feasible are not available. CONCLUSION: High-quality translational research will allow us to develop biological tests that can be used in routine clinical practise to tailor individual treatment, with the ability to improve patient outcome further by modifying the underlying tumour biology.

Functional status of patients with oral cancer and its relation to style of coping, social support and psychological status.

Sixty-eight patients were evaluated 6 months to 6 years after treatment for oral cancer using standardized questionnaires to explore the influence of age, sex, site and stage of tumour, and primary treatment on their functional status measured by the University of Washington Quality of Life Questionnaire (UW-QoL), and the association between functional status and psychological outcome measured by the Hospital Anxiety and Depression Scale (HADS), style of coping measured by the Mental Adjustment to Cancer Questionnaire (MAC-Q), and social support measured by the Short-Form Social Support Questionnaire (SSQ-6). Young patients, women, patients with advanced tumours, those with oropharyngeal tumours and those who had been treated with both surgery and radiotherapy reported worse function. The worse the functional domain, the more likely it was to be associated with anxiety, depression and ineffective coping style, and better functional scores were weakly associated with fighting spirit, level of social support and satisfaction with that support. We have identified patients at need and highlighted their problems. Dealing with these problems may ultimately improve the perception of function after treatment of oral cancer.

Preoperative vascular assessment: an aid to radial forearm surgery.

Twenty-three patients undergoing oral reconstructive surgery with radial forearm free flaps had a vascular assessment of the forearm preoperatively. Segmental upper limb pressures were measured and colour flow duplex visualization of forearm vessels and blood flow done. In 18 the blood pressure and flow were within normal limits, but five (22%) showed either unilateral or bilateral arteriopathy or aberrant vascular anatomy. Identification of pre-existing vascular disease helps to rationalize the selection of donor vessels, reduces the risk of ischaemic damage to the hand after disruption of the radial artery and may be of benefit in reducing the incidence of failure of free flaps.

Deafness and cholesteatoma complicating fracture of the mandibular condyle.

A case of posterior fracture-dislocation of the mandibular condyle which resulted in conductive deafness and cholesteatoma is presented. Initial management by condylectomy improved auditory canal patency but failed to prevent the development of cholesteatoma, necessitating mastoid surgery. Although major complications following fractures of the condyle are not common the need to consider the possibility of damage to the ear in such fractures is emphasised.

Closure of palatal defect with full-thickness skin graft via Le Fort 1 maxillary access osteotomy.

A technique for resection of a palatal tumour via a Le Fort 1 maxillary access osteotomy is described. Access via the osteotomy allows intra-operative examination of the superior aspect of the palate and resection of the tumour without gross destruction of the nasal mucosa. The nasal mucosa provides a bed for a full-thickness skin graft to effect closure of the palatal defect.

Fine needle cutting biopsy of lesions of the head and neck.

One hundred and twenty-four fine needle cutting biopsies of lesions of the head and neck have been carried out over the last 7 years. While the overall accuracy of diagnosis was 79%, the accuracy of the 43 biopsies carried out during the last 2 years was 93%. These results compare very favourably with published results of the accuracy of fine needle aspiration cytology.

Senior registrars' views on training in oral and maxillofacial surgery.

Fifty-three British senior registrars in oral and maxillofacial surgery (OMS) were sent a questionnaire designed to determine their views on some of the main aspects of training in the specialty. Thirty-seven returns were received (70%), 36 completed. This paper reports and discusses the results of the survey.

Skeletal reconstruction in cleft palate patients.

Improved management techniques of secondary cleft palate deformities are steadily evolving. The year's literature under review focuses mostly on the various methods available for establishing a complete and stable dental arch. Bone from the mandibular symphysis seems to offer a more reliable source of autogenous bone than do other sites, although if the residual cleft is large, this site may not provide sufficient bone. The optimum time to graft the alveolus appears to be after the incisors have erupted, but before the canine root has fully formed and the crown broken through the mucosa. Mucoperiosteal flaps give better long-term results than do mucosal flaps. Long-term stability of the alveolar segments may be achieved with extended bridges, and the use of rigid internal fixation may offer better three dimensional stability of the maxilla following advancement and inferior repositioning. Pharyngeal flaps have a detrimental effect on stability of the maxilla after advancement, although they may have a beneficial effect on velopharyngeal function after maxillary surgery.

Synovial chondromatosis of the temporomandibular joint.

A case report of synovial chondromatosis of the temporomandibular joint is presented in which the limitations of clinical findings, needle biopsy, standard radiography and computer assisted tomography were exposed and the importance of clinico-pathology consultation reaffirmed.

Central neurilemma of the mandible.

A rare case of symptomless central neurilemmoma of the mandible is reported. Post-operative recovery was uneventful and, in particular, post-surgical paraesthesia was followed by a return to normal sensation.

Mediastinitis and pericarditis caused by dental infection.

A case of dental infection with spread to the mediastinum causing pericarditis and cardiac tamponade is described. The clinical course of the disease, the investigations undertaken and the treatment given are outlined.

Dislocation of the mandibular condyle into the middle cranial fossa.

A case is reported of a 7 year-old girl who suffered a central luxation of the mandibular condyle into the middle cranial fossa. The management and previously reported cases are discussed.