A case report of Lemierre's Syndrome associated with dental sepsis.

INTRODUCTION: Lemierre's syndrome is a potentially fatal condition characterised by spread of an oropharyngeal infection, resulting in thrombosis of the internal jugular vein. This leads to septicaemia and possible metastatic abscesses. CASE PRESENTATION: We discuss the case of a previously healthy 17-year-old male who developed Lemierre's syndrome following dental sepsis. He presented with bilateral submandibular and submental swelling extending into the neck and chest. His management included a tracheostomy; incision and drainage of the abscesses; drainage of a pleural effusion and prolonged anticoagulant therapy. CONCLUSION: The incidence of Lemierre's disease appears to be increasing and early diagnosis is essential. A high index of suspicion is needed in cases of oropharyngeal infection followed by fever, tender swelling of the neck and dysphagia - especially in young patients.

Influence of condition of surgical margins on local recurrence and disease-specific survival in oral and oropharyngeal cancer.

BACKGROUND: The clearance of surgical margins at the primary site is widely thought to influence the subsequent course of the disease in patients operated on for oral and oropharyngeal carcinoma. In some reports the adverse impact of close or involved margins was not negated by postoperative radiotherapy. These findings, in addition to descriptive histopathological studies, have led some authors to recommend margins of more than a macroscopic clearance of 1cm at certain subsites. We have therefore examined the relation between the condition of surgical margins and local recurrence and disease-specific survival. METHODS: Identical treatment protocols were used to treat two independent groups of patients (Sydney, Australia, n=237; Lanarkshire, n=95) who presented with previously untreated carcinoma of the mouth or oropharynx. All patients were operated on with the primary objective of achieving a macroscopic clearance of 1cm. Postoperative radiotherapy was used according to a protocol. Data about patients were entered into comprehensive computerised databases prospectively. Known clinical and pathological prognostic indicators, in addition to the condition of surgical margins, were analysed to find out if they were predictive of local recurrence and disease-specific survival using the Cox proportional hazard model. RESULTS: Local recurrence was predicted by the presence of perineural invasion at the primary site in both groups. Disease-specific survival was predicted by the presence and extent of regional lymph node metastases in both groups. The condition of surgical margins (clear, close, or involved) did not predict local recurrence, or disease-specific survival on multivariate analysis. CONCLUSIONS: A macroscopic margin of 1cm seems adequate in the surgical management of oral and oropharyngeal carcinoma. For most patients who have close or involved margins the biology of the disease influences the subsequent course irrespective of the width of clearance of tumour.

Early closure of a randomized trial: surgery and postoperative radiotherapy versus radiotherapy in the management of intra-oral tumours.

Tumours of the oral cavity/oropharynx occur relatively infrequently in the UK. The management of such lesions, especially the squamous cell carcinomas, is still a little controversial. Some centres advocate radiotherapy while others adopt surgery and radiotherapy. In an attempt to resolve the question of which approach gives the better results, a multicentre randomized trial was established to compare surgery plus postoperative radiotherapy with radical radiotherapy alone. It was anticipated that 350 patients would be required to give a statistically significant result, but, after 35 patients had been entered, the trial was closed prematurely with a marked difference in overall survival in favour of the combination arm (P = 0.0006). At this analysis, carried out 23 months after trial closure, the survival difference between the two arms remains statistically significant for all causes of mortality (P = 0.001; relative death rate = 0.24; 95% CI 0.10-0.59).

The compressible silicone rubber prosthesis in temporomandibular joint disease.

An alternative technique for temporomandibular joint arthroplasty is described, in which the mandibular condyle is replaced by a soft compressible silicone rubber prosthesis. A modified Nicolle-Calnan metacarpo-phalangeal joint prosthesis was used to reconstruct 31 joints in 24 patients. Results suggest that in those patients where there has been no loss of the prosthesis, function continues to be markedly improved when compared with the pre-operative condition. Painful symptoms were relieved in cases of specific joint pathology but the technique was of little value in the management of dysfunctional pain when radiographic evidence of joint pathology was absent. A specifically designed TMJ prosthesis of this type may be a useful addition to the surgeon's armamentarium.

Mylohyoid nerve damage due to excision of the submandibular salivary gland.

Two cases of damage to the mylohyoid nerve following the excision of submandibular salivary glands are presented. The distribution of analgesia over the chin, accompanied by normal sensation to the lip, indicated that the mylohyoid nerve was damaged.

Chronic bilateral dislocation of the temporomandibular joint.

Reports of long standing bilateral dislocation of the temporomandibular joint are infrequent in the literature. Three cases are described, one of which was dislocated for 4 years prior to surgery; different methods of treatment were used in each case.

Primary amyloidosis causing macroglossia and respiratory symptoms.

Amyloidosis may involve the tongue, causing macroglossia. Such a case is described which resulted in airway obstruction. The subsequent management was by permanent tracheostomy.

Topical bleomycin in the treatment of oral leukoplakia: a pilot study.

Six patients with oral leukoplakia were treated by the daily application of a 0.5 per cent (w/v) solution of bleomycin sulphate in dimethyl sulphoxide. After 12 to 15 applications, the white patch peeled off and the resultant raw surface epithelialised over the following 14 days. Repeat biopsies showed a significant improvement in the histology, with reduced dysplasia and keratinisation.

The treatment of erosive lichen planus with a retinoid--etretinate.

The synthetic retinoid, etretinate, has been used to treat ten patients with erosive lichen planus of the oral mucosa. Beneficial effects were minimal, with only a slight decrease in the areas of ulceration being recorded after 8 weeks of therapy. Side effects were common and troublesome, however, outweighing the marginal improvement.

Mandibular infarction occurring during a sickle cell crisis.

The genetic abnormality and clinical problems associated with sickle cell disease are described and exemplified by a report of a patient who presented during a crisis with facial pain and sensory changes in the distribution of the inferior dental nerve; investigations revealed that these were due to infarction of part of the mandible. Although similar cases have been described, it is believed that the radionuclide scan of the mandible in the investigation of this patient uniquely demonstrated the position and extent of the infarcted area. The management of patients with sickle cell disease in the field of oral and maxillofacial surgery is discussed.