Running a safe and effective Cleft Network Service in response to the COVID-19 pandemic.

Maintaining an excellent level of service in a network Cleft Lip and Palate service in the UK has been an added challenge for both clinicians and patients throughout the COVID-19 pandemic. We describe the changes to our service, and report a high level of patient satisfaction with the changes. Some of the enforced changes may last beyond the duration of this pandemic.

Submucous cleft palate: outcomes after primary repair with repositioning of the levator muscle in 51 consecutive patients.

I report the incidence of hypernasal resonance, nasal emission, and fistula after intravelar surgery with retropositioning of the levator muscle by a single surgeon in a consecutive series of 51 patients who presented with symptomatic submucous cleft palate. Intravelar veloplasty with repositioning of the levator muscle was highly effective in that 37/51 patients (73%) achieved either normal or mild and inconsistent resonance (p<0.0001), and 39 (77%) normal or mild and inconsistent nasal emissions (p<0.0001). The fistula rate was 6% (n=3). Both the clinical grade of submucous cleft palate and the presence of a syndrome correlated directly with changes in hypernasality, whereas the age of the patient and the degree of hypernasality at presentation did not. Non-syndromic patients with clinical grade III and II submucous cleft palates responded well to intravelar surgery with repositioning of the levator muscle, and routine preoperative videofluoroscopy is not recommended. I recommend intravelar surgery with repositioning of the levator muscle routinely for all non-syndromic patients who present with grade III or II submucous cleft palate and velopharyngeal insufficiency.

LIAD-fs scheme for studies of ultrafast laser interactions with gas phase biomolecules.

Laser induced acoustic desorption (LIAD) has been used for the first time to study the parent ion production and fragmentation mechanisms of a biological molecule in an intense femtosecond (fs) laser field. The photoacoustic shock wave generated in the analyte substrate (thin Ta foil) has been simulated using the hydrodynamic HYADES code, and the full LIAD process has been experimentally characterised as a function of the desorption UV-laser pulse parameters. Observed neutral plumes of densities >10(9) cm(-3) which are free from solvent or matrix contamination demonstrate the suitability and potential of the source for studying ultrafast dynamics in the gas phase using fs laser pulses. Results obtained with phenylalanine show that through manipulation of fundamental femtosecond laser parameters (such as pulse length, intensity and wavelength), energy deposition within the molecule can be controlled to allow enhancement of parent ion production or generation of characteristic fragmentation patterns. In particular by reducing the pulse length to a timescale equivalent to the fastest vibrational periods in the molecule, we demonstrate how fragmentation of the molecule can be minimised whilst maintaining a high ionisation efficiency.

Prophylactic antibiotics and surgery for primary clefts.

There are currently no evidence-based guidelines about the use of antibiotic prophylaxis in repair of cleft lip and palate. After the designation of regional cleft centres in the UK, a postal questionnaire was sent to cleft surgeons in 2004 to enquire about the use of routine antibiotic prophylaxis for primary repair of cleft lip and palate. The results showed a lack of consensus and wide disparity among centres. The findings show that there is a need for a random control clinical trial to establish national recommendations for the rational use of prophylactic antibiotics in primary cleft surgery.

A simple nasal splint to assist the stability of nasopharyngeal tubes in the Pierre Robin sequence associated airway obstruction: technical innovation.

Upper airway obstruction in association with the Pierre Robin sequence presents at or shortly after birth. The airway difficulty can be managed in a number of ways from postural nursing to surgical intervention with tracheostomy, however, each method has its disadvantages. A technique is described whereby the airway obstruction is relieved with the use of paediatric nasopharyngeal airways which are stabilized with an individually constructed acrylic nasal splint. This technique has been successfully applied in two cases of the Pierre Robin sequence presenting with airway obstruction.

Recurrent bilateral coronoid hyperplasia: an unusual case.

A case of bilateral coronoid hyperplasia is presented. The possible aetiology of this rare condition is discussed. This case is unusual in that true synovial joints were demonstrated bilaterally between the coronoid processes and the zygomatic bones and following a bilateral coronoidectomy, the coronoid hyperplasia with marked limitation of jaw opening fully recurred, which has not been described previously. After a further coronoidectomy with return of function to the temporomandibular joints, a change from a retrognathic mandibular relationship to a gross prognathic position occurred. The management problems encountered with this case are discussed along with a documented account of the treatment provided over a 12-year period.

Botulinum toxin treatment of bilateral masseteric hypertrophy.

Botulinum toxin is a new and innovative method of treating bilateral masseteric hypertrophy which offers many advantages over conventional surgical treatment. Experience gained through the successful use of this drug when given as an intramuscular injection is reported. No significant side-effects have occurred and this technique is recommended for the routine treatment of masseteric hypertrophy.

Malignant melanoma of the oral cavity--an increasing clinical diagnosis?

Oral malignant melanoma is fortunately a rare lesion. However the actual incidence in the population at present is unknown but may be increasing. The overall prognosis remains poor despite more radical surgery with adjuvant radiotherapy, chemotherapy and immunotherapy. The clinical presentation of oral malignant melanoma can vary widely from a typically pigmented macular or proliferative lesion to a non-pigmented soft vascular tumour; single or multiple, primary or metastatic. Our experience of five patients with malignant melanoma of the oral cavity is presented and the management of such lesions discussed.

An in-vitro study of the comparative viability on different swab types of simulated specimens of bacteria commonly present in oro-facial infections.

An in-vitro study was undertaken to investigate the survival on bacteriological swabs of three potentially pathogenic organisms found in oro-facial infections, by using simulated clinical specimens incubated in the presence or absence of Amies transport medium. Standard inocula of pure cultures of Streptococcus milleri, Prevotella melaninogenica and Peptostreptococcus anaerobius were soaked on to swabs and plated out on to solid media at various intervals up to 3 days, enabling an estimate of their viability to be made following further incubation. Differential survival of the three test organisms was observed, with Streptococcus milleri being generally the hardiest and Peptostreptococcus anaerobius the least hardy, whilst survival was consistently enhanced by the presence of a transport medium. Recovery of Prevotella melaninogenica was improved by incubation for 5 days. We conclude that transport swabs should be used in preference to plain swabs whenever immediate laboratory culture cannot be assured, to avoid loss of anaerobic bacteria.

Lympho-epithelial cysts: a maxillofacial surgeon's perspective.

Cervical swellings are referred to Oral and Maxillofacial Surgeons and may subsequently be diagnosed as lympho-epithelial cysts. The clinical presentation of such swellings appears to differ from that seen in other specialties also treating these cysts in that a larger proportion of lympho-epithelial cysts presenting to our specialty are infected, which complicates the diagnosis and also the subsequent management. We present our recent experience of 5 patients who underwent excision of a lympho-epithelial cyst, all of which were infected on initial presentation and four of which were associated with concurrent ipsilateral dento-alveolar infection. The fifth case presented with rapid development of a cervical swelling in the immediate post-natal period. As these cysts contain abundant lymphoid tissue as an integral part of the lymph drainage system of the head and neck, we propose that the management of an infected lympho-epithelial cyst should include a full clinical and radiographic examination of the oral cavity for a possible focus of infection and indeed any patient awaiting surgery for a non-infected cyst would benefit from an examination of the mouth and treatment of any sites of chronic infection.

Polycystic disease of the parotid glands: two familial cases.

Polycystic (dysgenetic) disease of the parotid glands is a rare disorder with only three fully documented reports in the literature containing a total of six cases. This developmental disorder of the distal ductal system appears limited to the parotid glands of female patients and is usually bilateral. We present two further cases with a confirmed familial background to add to the literature. This is the first documented report of familial polycystic disease of the parotid glands. The pathogenesis, mode of inheritance, clinical features, histological appearance and management of this interesting condition are discussed.

Obstructive sleep apnoea syndrome presenting as lingual ulceration.

Two patients with obstructive sleep apnoea syndrome are reported where the initial presenting complaint was of lingual ulceration. This unusual presentation has not been reported previously. Both patients experienced frequent apnoeic episodes during sleep with a profound fall in the arterial oxygen saturation. It is postulated that the lingual ulceration resulted from repeated trauma to the tongue by the teeth as the patient made violent inspiratory efforts at the termination of an apnoeic episode. The diagnosis of sleep apnoea syndrome was based upon suggestive symptoms of snoring, morning fatigue and day-time somnolence plus a minimum of 15 apnoeic episodes per hour of sleep. The first-line investigations of this condition are available in all district general hospitals and a diagnosis of sleep apnoea syndrome obtained. Referral to a regional sleep study centre may be appropriate prior to the commencement of therapy. Management is predominantly medical, consisting of weight loss and the administration of nocturnal nasal continuous positive airways pressure.

A prospective study of 134 consecutive patients requiring diagnosis, excision and repair of a facial cutaneous lesion.

A prospective study of 134 patients undergoing excision of a facial lesion was undertaken. Considerable clinical diagnostic difficulty was experienced, with 21% of clinical diagnoses being incorrect. A tendency towards a clinical over-diagnosis of basal cell carcinoma was noted and whilst this is not unreasonable, a number of benign lesions inevitably were diagnosed as malignant with unnecessary sacrifice of tissue. Incisional biopsy of lesions should be considered when sited close to important anatomical structures to enable accurate diagnosis prior to definitive surgery. Although a few definite indications for a particular reconstructive technique exist (Table 1), a choice is more often available. Repair of the excisional defect with a local flap as opposed to a skin graft resulted in a reduced length of hospital admission with fewer postoperative complications and better final cosmesis. As a consequence, a local flap is recommended as the method of repair where direct closure is not feasible.