Comparison of provision of maxillofacial emergency service during the two COVID-19 national lockdowns in the United Kingdom.

We previously published a study on the provision of emergency maxillofacial services during the first UK COVID-19 pandemic national lockdown. We repeated the study during the second lockdown and now present our findings that highlight the main differences and learning issues as the services have evolved.

Provision of Emergency Maxillofacial Service During the COVID-19 Pandemic : A Collaborative Five Centre UK Study.

The global pandemic of Coronavirus disease (COVID-19) represents one of the greatest challenges to healthcare systems, and has forced medical specialties to rapidly adapt their approaches to patient care. Oral and Maxillofacial Surgery is considered particularly at risk of disease transmission due to aerosol generation during surgical interventions, patient proximity and operating environment. On day 2 (26th March, 2020) of when severe restrictions in population movement were instigated in the United Kingdom, we began a study to prospectively monitor the presentation and management of maxillofacial emergencies at five hospital trusts. Data was collected onto an online live database fed through a smartphone application. Of the total 529 patients over six weeks, 395 attended for face-to-face consultations and 134 patients received remote consultations via telephone or video link. There were 255 trauma related cases, 221 infection and 48 cases of postoperative complications. Most trauma cases were minor soft tissue injury related to slip, trip or fall at home. There were 44 cases of facial fractures with a tendency for conservative treatment. 19 cases were related to domestic violence or self-harm. Of the 216 dental related emergencies, 68% could have been managed in the primary care setting. A quarter of all emergency patients were satisfactorily managed by remote consultations. There was a significant change in the provision of emergency maxillofacial service during the pandemic lockdown. We discuss the study findings as well as the potential implications in relation to planning for possible further COVID- 19 spikes and future pandemics.

Concurrent Horner's and Harlequin syndromes.

Horner's syndrome and Harlequin syndrome are both caused by disruptions to the sympathetic supply to the face. They have a varied aetiology, including intraneural dysfunction, extra- or intraneural compression, and idiopathic as well as iatrogenic causes. Horner's syndrome can occur as a rare complication of thyroid surgery and the Harlequin sign has only been documented as a complication of cervical surgery in a handful of paediatric patients. We present a patient who developed both conditions subsequent to excision of a papillary carcinoma with a neck dissection. We illustrate the anatomical basis for this presentation and highlight the need for its appreciation. This is of particular interest as it impacts on several specialities operating in the cervical and thoracic fields.

'Elephant' graft to assist implant-retained nasal prosthesis.

Large rhinectomy defects can be reconstructed with endosseous craniofacial implants and an alloplastic implant-retained prosthesis. The survival of the implants and prosthesis is aided by the placement of split skin grafts. A simple and effective technique is described to enable accurate placement of a split skin graft in a single piece, by shaping it 'like an elephant'.

Upper lip blanching and diplopia associated with local anaesthesia of the inferior alveolar nerve.

A case of transient left lateral rectus nerve palsy, following an inferior alveolar nerve block to enable the surgical removal of a permanent mandibular left third molar tooth, is reported. The anatomy related to this case is considered together with suggestions for management of such patients.

Zygomaticus implants for retention of nasal prostheses after rhinectomy.

Malignant tumours of the nose occasionally require rhinectomy. Implant retained prostheses can give good aesthetic results. Predictable biomechanical retention of nasal prostheses can be achieved using osseointegrated implants and Brånemark intra-oral and craniofacial implants have been used previously. Zygomaticus implants are traditionally used for dental rehabilitation of the partially edentulous maxilla with severe bone resorption. We describe two patients in whom zygomaticus implants have been used to aid salvage in prosthetic reconstruction of the nose.

Do oral flora colonize the nasal floor of patients with oronasal fistulae?

OBJECTIVE: To determine if oral bacteria colonize the cleft nasal floor in patients with unilateral oronasal fistula when compared with the unaffected nasal floor and whether the results obtained would be of benefit in assessing oronasal fistulae in the clinic. DESIGN: Prospective study of 26 patients with cleft palate and unilateral oronasal fistula. Microbiological culture swabs were taken from the mouth and nasal floors of patients. The unaffected nasal floor was used as a control. Bacterial isolates were identified and compared in the laboratory by a senior microbiologist. MAIN OUTCOMES MEASURE: A significant growth of oral bacteria from the cleft nasal floor when compared with the unaffected nasal floor. RESULTS: Four patients were excluded because no growth was found on any culture plate. In the remaining 22 cases, a light growth of oral flora was found in the cleft nasal floor in only 3 patients. No statistical correlation between culture of oral bacteria and the cleft nasal floor could be found (p =.12). CONCLUSIONS: The relative lack of colonization of the cleft nasal floor by oral bacteria may reflect poor transmission of bacteria through the fistula, competition with commensal nasal flora, or an inability of oral bacteria to survive in a saliva-depleted area. The investigation is not helpful in the assessment of oronasal fistulae in the clinic.

Are myoepithelial cells responsible for the widespread expression of inducible nitric oxide synthase in pleomorphic adenoma? An immunohistochemical study.

Many of the actions of nitric oxide (NO) are still poorly understood. Recently, it has been shown that the inducible isoform of the enzyme nitric oxide synthase, iNOS, is expressed in both salivary ducts and pleomorphic adenoma. The current immunohistochemistry study determined whether or not this distribution correlated with smooth muscle actin (SMA) expression, thereby suggesting the expression by myoepithelial cells in both sites. Twenty cases of histologically confirmed pleomorphic adenoma, the sections of which contained adjacent normal salivary gland tissue, were stained for iNOS and smooth muscle actin (clone 1A4). The salivary ducts of all cases were stained intensely by both antibodies, with smooth muscle actin staining also being noted around acini in the normal gland parenchyma. Moderate or heavy staining for iNOS was found in all specimens of pleomorphic adenoma, with smooth muscle actin being distributed in a similar manner in 19 cases. Smooth muscle actin, but not iNOS, was also noted in blood vessels of both normal glands and tumours. The correlation between iNOS and SMA in pleomorphic adenoma was significant (P<0.001). The presence of iNOS in normal salivary ducts and pleomorphic adenoma is most likely due to expression by myoepithelial cells.

Allergy to local anaesthetic: the importance of thorough investigation.

A case report is presented which highlights the importance of a good history in arriving at the correct diagnosis in cases where allergy to local anaesthetic is suspected. Management of the patient is discussed and the topic of 'adverse reaction' briefly reviewed.

Emerging role of nitric oxide in cancer.

The small molecule nitric oxide has generated an exponential amount of research since its identification as a biological messenger in 1987. It is a free radical, the actions of which are diverse, and many are still poorly understood. An area of great interest is the role of nitric oxide in the growth and metastasis of solid tumours, where it seems to have a complex action including both inhibitory and tumour-promoting activity. Over 28,000 research papers have been written on nitric oxide, with only a minority concentrating on the head and neck. In this review, we give a brief history of this fascinating molecule, concentrating on its possible interest to oral and maxillofacial surgeons.

Perforating vessel(s) of the orbital floor: a cadaveric study.

Brisk haemorrhage is occasionally encountered in subperiosteal orbital floor exploration. Personal experience of the authors of a vessel perforating the orbital floor in a roughly similar position in a number of cases prompted further study. Twelve fresh cadavers (24 orbits) were dissected specifically to identify any vessel(s) perforating the orbital floor. In this study a vessel was identified in 83% of the dissections.