The K9-Teen Pandemic: When Good Boy Goes Bad. The Epidemiology, Management and Public Health Ramifications of Facial Dog Bite Injuries: Newcastle, Australia, Experience.

The purpose of this study was to investigate the epidemiology, pattern of injury and management of facial dog bite injuries. Methods: The authors conducted a retrospective cohort study over a 5-year period of patients who sustained a facial dog bite injury. The study setting was an Oral and Maxillofacial Surgery Department at a level 1 trauma centre, servicing an estimated catchment population in excess of 950,000 people. Results: In total, 171 patients were managed in the designated period from January 2017 to January 2022. The median age was 9 years (range 11 months to 77 years), with the highest incidence of a single age 4 years. The frequency was slightly greater amongst males (n = 93) than females (n = 78). The most common responsible breed were Pitbull types (n = 26). Overall, bites most often resulted from the family dog (n = 87), in the victim's own home (n = 84) and whilst playing with the dog (n = 64). The primary sites involved were the lips (n = 70), cheek (n = 53) and nose, representing the so called 'target area'. In 53 cases, the injuries were classified as severe. 138 patients required hospital admission, and of these, 130 required surgical management under general anaesthesia. Conclusions: Facial dog bite injuries present a significant burden on the healthcare system and result in physical, functional and/or emotional distress for the patient. As the rates of dog ownership continue to rise, a consequential increase in these injuries is also likely. Further, public health intervention is essential, particularly as the most susceptible demographic remains young male children.

Falls From Height, Facial Injuries and Fatalities: An Institutional Review.

Study Design: Retrospective cohort review. Objective: To investigate the relationship between falls from height and facial injuries. Methods: This is a retrospective cohort study, conducted over a 7-year period, of the medical records of all patients who presented to hospital for a maxillofacial injury following a fall from height. Fall heights were classified as low falls (1-3 m), high falls (3-10 m) and very high falls (≥10 m). Results: A total of 111 patients with 218 facial bone fractures were identified (78 men, 33 women and mean age 50.3 years). High falls were the most common (n = 58, 52.3%). Multiple fractures were identified in 51 (46.0%) patients. Orbital and middle third fractures were the most prevalent. Nasal, mandible, bilateral and fractures involving more than one facial third, increased as fall height increased, as did the requirement for operative fixation. The majority of patients had an associated injury (n = 100, 90.1%) and overall mortality was 6.3%. Conclusions: Falls from height are prevalent and there is a trend towards increased severity of facial injury, surgical intervention and associated morbidity as fall height increases. Falls from height are a significant public health concern and an important facet of maxillofacial trauma to recognise, as is the requirement for an interdisciplinary approach as they present to hospital.

The Implementation of COVID-19 Social Distancing Measures Changed the Frequency and the Characteristics of Facial Injury: The Newcastle (Australia) Experience.

STUDY DESIGN: A retrospective study was undertaken of a cohort of facially injured patients using matched 8-week periods: non-COVID (2019) and COVID (2020). OBJECTIVE: To determine whether there were any changes to the frequency and characteristics of facial injury due to the imposition of COVID-19 social distancing measures. METHODS: The primary predictor variable was an 8-week period of COVID-19 social distancing. The primary outcome variable was the sustaining of a facial injury. Demographic (age/gender) and injury characteristics (mechanism, site, and treatment) were also studied. Descriptive statistical analysis was undertaken and comparison made using Pearson χ2 and Fisher's exact tests. RESULTS: The number of facial injuries decreased from 103 (2019) to 73 (2020). There were statistically significant differences in changes over time for the 8-week periods. There were some clinically apparent differences seen in the characteristics of facial injuries. CONCLUSIONS: The imposition of COVID-19 social distancing changed the frequency and characteristics of facial injury.

To What Extent Does Illicit Drug Use Predispose to Facial Injury? An Institutional Investigation for an Emergent Problem.

STUDY DESIGN: There are potential substantive linkages between illicit drug use and the occurrence of injury. OBJECTIVE: The purpose of our study was to determine the prevalence, class of illicit drugs abused, and demographics in relation to a cohort of patients who sustained facial injury. METHODS: The authors undertook a retrospective observational study of a prospectively accessioned cohort of patients who had sustained a facial injury and presented to the John Hunter Hospital (Newcastle, NSW, Australia). The primary predictor variable was the presentation of a facial injury and the secondary outcome variables included illicit drug use, alcohol use, and socioeconomic factors. The study was carried out over a 12-month period. A descriptive analysis was undertaken on the assembled data. RESULTS: Of the 465 patient medical records that were accessed for the study, 348 were male and 117 were female. Their average age was 42.6 years: 5.8% (n = 27) were under the influence of illicit drugs at the time of their presentation and 13.1% (n = 61) admitted to an intercurrent illicit drug habit. Those who were under the combined influence of alcohol and drugs comprised of 2.8% (n = 13). CONCLUSIONS: Our study found that illicit drug use plays a small, but nonetheless, demonstrable role in the presentation of maxillofacial trauma patients to an urban level I trauma center. Illicit drug users are an emergent sociodemographic group of patients who can sustain facial trauma and their presentation needs to be appropriately considered, assessed, and managed collectively.

Postoperative Delirium is Associated With Prolonged Head and Neck Resection and Reconstruction Surgery: An Institutional Study.

PURPOSE: Delirium is a recognized complication of surgery. It has a deleterious effect on a patient's postoperative recovery and well-being. The purpose of this study was to estimate the frequency and identify the risk factors for the development of postoperative delirium (POD) in a cohort of patients who underwent extensive head and neck surgery (HNS) of greater than five hours duration. MATERIALS AND METHODS: The authors undertook a retrospective cohort study of patients who underwent HNS of greater than five hours duration. The primary predictor variables comprised a set of risk factors (sociodemographic, disease-specific, duration of surgery, and duration of inpatient stay) that were thought to be associated with the development of POD. The primary outcome variable was the development of POD. Descriptive, bivariate, and multivariate statistical analysis was undertaken, and significance was set at P < .05. RESULTS: One hundred and seventy patients were included in the study. There were 124 males and 46 females. Forty patients (23.53%) developed POD: 30 documented and 10 inferred. The mean age of the POD cohort was 65 years (SD 13), with a median age of 69 years. The occurrence of POD was statistically related to increased age, mental health status, American Society of Anesthesiologists (ASA) score, and drug dependence (either illicit or prescription). POD and operative duration were statistically associated. POD and length of stay were not statistically associated. CONCLUSION: Delirium did occur postoperatively in 23.53% of our patients who underwent extensive and prolonged HNS. POD may go unrecognized by treating teams. As POD has a deleterious effect on the cognitive function, it is important to identify and aggressively treat episodes of POD that occur during a patient's postoperative recovery.

Improving screening for physical impairments and access to early physiotherapy after neck dissection surgery: a translational controlled trial.

PURPOSE: Lack of routine screening for a range of physical impairments that can result after neck dissection (ND) may hinder physiotherapy referral and treatment. The purpose of this study was to implement an intervention that targeted both physiotherapists and surgeons to increase their post-operative physical screening of ND patients and in turn improve physiotherapy referral rates. METHODS: The authors undertook a translational controlled pilot study, conducted over a 12-month period that utilised three tertiary hospital sites. The target groups were physiotherapists at one intervention site and surgeons at the other intervention site, with the third hospital acting as a control site and receiving usual care. The intervention included a physiotherapy brochure and a clinical pathway for screening, to promote early identification and prompt referral of patients with a physical impairment. The primary outcome variables were screening and referral rates between sites at the study end-point. RESULTS: Logistic regression analyses were conducted on n = 174 to assess differences in screening and referral rates between sites. Patients at the intervention site that targeted physiotherapists had four times the odds of being screened for shoulder dysfunction compared to the control site (p = 0.0002), and three times the odds of being referred to physiotherapy (0.0039). There were no statistically significant differences in the odds of patients being screened for shoulder dysfunction or referred to physiotherapy at the intervention site that targeted surgeons. CONCLUSION: The translational intervention undertaken by physiotherapists resulted in significantly greater screening and referral rates of post-operative ND patients for physiotherapy.

Outcome of Head and Neck Cancer Patients Who Did Not Receive Curative-Intent Treatment.

PURPOSE: There exists a subgroup of patients with head and neck cancer (HNC) who neither warrant nor request curative-intent treatment and who progress to a terminal-care paradigm. The purpose of this study was to determine the frequency of and reasons for an HNC terminal-care referral and the time to and place of death for such patients. MATERIALS AND METHODS: The authors undertook a retrospective cohort study of all attendees with HNC who had undergone multidisciplinary team (MDT) assessment at the Calvary Mater Hospital (Newcastle, Australia) from January 2013 through December 2014. The primary predictor variables were a heterogeneous set of factors grouped together into logical demographic (age and gender) and clinicopathologic (tumor histology, site, and stage) categories and the reason for referral to terminal care. The secondary outcome variables were survival and place of death. A descriptive statistical analysis was undertaken and survival data were graphically displayed as Kaplan-Meier estimates. RESULTS: Of the 412 attendees with HNC who underwent MDT assessment, 74 (18%) were identified as having been immediately referred for terminal care. Their median survival was 6 months (95% confidence interval, 4.75-7.50). The most common reason for referral for terminal care was tumor extent. The most common place of death recorded for the group was a hospice facility. CONCLUSION: This study serves as a timely reminder that when curative-intent HNC treatment options have been exhausted, dialog and action need to be directed to transitioning the patient to a terminal-care management paradigm.

Maximizing shoulder function after accessory nerve injury and neck dissection surgery: A multicenter randomized controlled trial.

BACKGROUND: Shoulder pain and dysfunction after neck dissection may result from injury to the accessory nerve. The effect of early physical therapy in the form of intensive scapular strengthening exercises is unknown. METHODS: A total of 59 neck dissection participants were prospectively recruited for this study. Participants were randomly assigned to either the intervention group (n = 32), consisting of progressive scapular strengthening exercises for 12 weeks, or the control group (n = 29). Blinded assessment occurred at baseline, and at 3, 6, and 12 months. RESULTS: Three-month data were collected on 52 participants/53 shoulders. Per-protocol analysis demonstrated that the intervention group had statistically significantly higher active shoulder abduction at 3 months compared to the control group (+26.6°; 95% confidence interval [CI] 7.28-45.95; p = .007). CONCLUSION: The intervention is a favorable treatment for maximizing shoulder abduction in the short term. The effect of the intervention compared to usual care is uncertain in the longer term.

Pressure injury can occur in patients undergoing prolonged head and neck surgery.

PURPOSE: The aim of this study was to estimate the frequency of and identify the risks factors associated with the development of pressure injuries (PIs) in a sample of patients who underwent operative treatment of a head and neck malignancy. MATERIALS AND METHODS: The sample was composed of patients admitted under the care of the Combined Head and Neck Service, John Hunter Hospital from 2010 to 2012 and whose operation was a minimum of 5 hours duration. The predictor variables included a range of demographic, comorbidity, and operative factors. The outcome variable was the development of a PI. A multivariate logistic regression model was conducted to assess the association between predictor variables and the outcome variable (PI). RESULTS: Eighty-eight patients (62 male and 26 female) were included in the study. PIs were identified in 13 patients (14%). These injuries were typically located over bony prominences, in keeping with findings identified in the relevant literature. Specifically, an increased risk of PI was seen with decreasing patient age (54.5 ± 11.6 yr for PI vs 63.1 + 10.8 yr for no PI; P = .01) and increasing operative duration (729 ± 79 minutes for PI vs 625 ± 158 minutes for no PI; P = .02). CONCLUSIONS: PIs can occur in patients who undergo prolonged head and neck resective and reconstructive surgery. In particular, decreasing age and increasing operative duration were shown to be statistically significant factors in the development of PIs in this group of patients.

Equine-associated maxillofacial injuries: retrospective 5-year analysis.

We explored the relation between the causes of facial injuries in equestrians and the presence or absence of associated injuries. Over a 5-year period we retrospectively reviewed all patients who presented to the John Hunter Hospital, New South Wales, with facial injuries that had resulted from activity with horses. We analysed the rates of hard and soft tissue injuries, and of associated injuries by sex and mechanism. A total of 85 patients were included (50 female and 35 male) with an age range of 2-88 years. There was a significant difference in the rate of maxillofacial and associated injuries when groups were analysed for sex and mechanism of injury. Facial injuries caused by falling from a horse were more often associated with other injuries in men than in women (p<0.05), and men were 4 times more likely to present with associated injuries than women (OR 3.9; 95% CI 1.1 to 14) We also found significant differences in the rates of facial fracture. Women who had been kicked by a horse were more likely to sustain bony injuries than men (p<0.05). Our data confirm the association between kicks and facial fracture, and this may provide an impetus for the development of appropriate protective equipment. Patients who sustain facial injuries when falling from a horse often present with associated injuries and this has practical implications for clinicians involved in their management.

Malignant transformation of metachronous bilateral Schneiderian inverted papilloma of the lacrimal sac: management considerations and the contentious issue of orbital exenteration.

The authors present an unusual case of malignant transformation of metachronous bilateral Schneiderian inverted papilloma (IP) of the lacrimal sac. Such pathology has been sparingly covered in prior published literature, in particular with little formal discussion surrounding its optimal management. We describe the clinical presentation, course and management in a 35-year-old male with histopathological diagnosis of Squamous cell carcinoma (SCC) arising within IP. He underwent radical surgery, including orbital exenteration and medial maxillectomy. Our patient re-presented with IP in the contralateral side and subsequent malignant transformation to SCC with disseminated disease. Unfortunately he succumbed to disease approximately 20 months following initial surgery. This case raises several important questions with regard to appropriate treatment. In particular, we discuss the various management options with special consideration given to the contentious topic of orbital exenteration in such patients. We emphasise two particular controversial issues, namely, oncological efficacy of orbital preservation and the functional compromise that may result in the preserved eye.

Scapular muscle exercises following neck dissection surgery for head and neck cancer: a comparative electromyographic study.

BACKGROUND: Shoulder pain and dysfunction can occur following neck dissection surgery for cancer. These conditions often are due to accessory nerve injury. Such an injury leads to trapezius muscle weakness, which, in turn, alters scapular biomechanics. OBJECTIVE: The aim of this study was to assess which strengthening exercises incur the highest dynamic activity of affected trapezius and accessory scapular muscles in patients with accessory nerve dysfunction compared with their unaffected side. DESIGN: A comparative design was utilized for this study. METHODS: The study was conducted in a physical therapy department. Ten participants who had undergone neck dissection surgery for cancer and whose operated side demonstrated clinical signs of accessory nerve injury were recruited. Surface electromyographic activity of the upper trapezius, middle trapezius, rhomboid major, and serratus anterior muscles on the affected side was compared dynamically with that of the unaffected side during 7 scapular strengthening exercises. RESULTS: Electromyographic activity of the upper and middle trapezius muscles of the affected side was lower than that of the unaffected side. The neck dissection side affected by surgery demonstrated higher levels of upper and middle trapezius muscle activity during exercises involving overhead movement. The rhomboid and serratus anterior muscles of the affected side demonstrated higher levels of activity compared with the unaffected side. LIMITATIONS: Exercises were repeated 3 times on one occasion. Muscle activation under conditions of increased exercise dosage should be inferred with caution. CONCLUSIONS: Overhead exercises are associated with higher levels of trapezius muscle activity in patients with accessory nerve injury following neck dissection surgery. However, pain and correct scapular form must be carefully monitored in this patient group during exercises. Rhomboid and serratus anterior accessory muscles may have a compensatory role, and this role should be considered during rehabilitation.

Facial trauma patients with a preexisting psychiatric illness: a 5-year study.

OBJECTIVES: The aim of this study was to identify and assess the demographics and presence of preexisting psychiatric disorders in an adult patient cohort admitted for the management of a facial injury. STUDY DESIGN: The analysis included demographics, type of facial injury, length of hospital stay, and psychiatric diagnosis according to criteria as set out in the DSM-IV-TR-2000. RESULTS: We identified 71 patients who had confirmed psychiatric comorbidity. A range of intentional, unintentional, and recidivist injuries were identified. We found a significant association between length of hospital stay and the number of diagnostic categories of preexisting psychopathology (P < .05). CONCLUSIONS: This study further confirms that there is a subgroup of facially injured patients with preexisting psychiatric illness which often goes unrecognized and untreated. Early recognition, together with appropriate referral to and management by liaison psychiatry may play an important role in reducing the rate of facial trauma recidivism.

Impact of neck dissection on scapular muscle function: a case-controlled electromyographic study.

OBJECTIVE: To assess the dynamic activity of scapular muscles in patients with accessory nerve dysfunction after neck dissection surgery, compared with both their unaffected side and with age- and sex-matched controls. DESIGN: A case-control investigation. SETTING: Physiotherapy department of a hospital. PARTICIPANTS: Two groups of 10 participants were recruited. One group consisted of neck dissection patients with demonstrated clinical signs of accessory nerve injury. The second group was composed of matched healthy individuals. INTERVENTIONS: Surface electromyographic activity of the upper trapezius, middle trapezius, rhomboid major, and serratus anterior muscles was compared dynamically during scapular strengthening exercises. MAIN OUTCOME MEASURES: Electromyographic activity comparisons were made between the neck dissection affected side, the neck dissection unaffected side, and the matched healthy control side. Raw data and data expressed as a percentage of maximal voluntary isometric contraction were compared. RESULTS: The neck dissection affected side demonstrated significantly less upper trapezius and middle trapezius muscle activity compared with the neck dissection unaffected side and matched control group. The neck dissection unaffected side had significantly less upper trapezius muscle activity than the matched control group. CONCLUSIONS: Trapezius muscle activity is significantly reduced in accessory nerve shoulder dysfunction as a result of neck dissection, both in the affected and unaffected sides. This needs to be considered in the rehabilitation of this patient group.

Psychiatric outcomes in operatively compared with non-operatively managed patients with facial trauma: Is there a difference?

Patients who sustain facial injury and who require an operation may be at greater risk for developing psychological distress and maladaptive coping. The purpose of this study was to examine psychological responses in adult victims of facial trauma after operation. A consecutive group of adult patients attending specialist outpatient clinics after facial trauma were evaluated for psychological distress. The subjects were divided into two groups based on whether their facial injuries were managed operatively or conservatively. The primary predictor variable in this study was surgical intervention. The main outcome variable was Hospital Anxiety and Depression Scale (HADS) scores. Chi-squared, Mann Whitney U-test, and multiple regression analysis were used to analyse data. The sample consisted of 102 subjects; 71 patients had been managed operatively and 31 patients treated non-operatively. Psychometric scores suggestive of anxiety were present in 21% (n = 15) of the operatively managed group compared with 13% (n = 4) of the non-operatively managed group of patients. The prevalence of depression was comparable between both groups (14% compared with 13%). The median anxiety subscale scores for the operatively managed group when compared with the conservatively managed group of patients were significantly higher (6.6 compared with 4.4, p = 0.02); however, differences in the depression subscale scores did not reach statistical significance (6.2 compared with 4.6, p = 0.06). This study shows an association between anxiety disorders and operative interventions in patients with facial trauma (HADS-A, ß = 2.2, p = 0.04). Similar rates of depression were found in the surgically and conservatively managed patients.

Microvascular reconstruction of the mouth, jaws, and face: experience of an Australian oral and maxillofacial surgery unit.

PURPOSE: Microvascular reconstruction of oncologic surgical and traumatic defects has been globally practiced by plastic and orthopedic surgical disciplines since the early 1970s. During the past 20 years, reconstructive techniques have been progressively incorporated into the purview of oral and maxillofacial and otolaryngology-head and neck surgeons, particularly those practicing in Europe, the United Kingdom, and China. There has also been a steady increase in the adoption of these techniques in North America, South America, and Japan. MATERIALS AND METHODS: We reviewed our experience (during a 5-year period) with microvascular reconstruction of postablative defects in the oral and maxillofacial region. To our knowledge, resection and neck dissection (or neck exploration in benign free tissue transfer); undertaken by an oral and maxillofacial surgeon), and free tissue transfer reconstruction (undertaken by otolaryngology head and neck and oral and maxillofacial surgeons) of ablative defects of the mouth, jaws, and face (managed within an Australian head and neck cancer multidisciplinary care team) have not been previously reported. RESULTS: The study cohort comprised 107 patients who underwent 109 microvascularly anastomosed free tissue transfers. Of the 107 patients, 79 were males and 38 were females. The median age was 62 years (range 15 to 87). The clinicodemographic analyses and the range of complications observed in this patient cohort are reported. The overall flap success rate in our study was 97%. CONCLUSIONS: The surgical outcomes of our study compare favorably with those previously reported.

The prevalence of psychological distress in a sample of facial trauma victims. A comparative cross-sectional study between UK and Australia.

AIM: The potential psycho-social sequelae of traumatic facial injury have received increasing attention in recent years, however there remains paucity of cross-national comparative data on the prevalence of psychological distress following such trauma. The aim of the present study was to investigate and compare the prevalence of anxiety and depression in an adult patient group who have been treated for maxillofacial trauma, and who attend a follow-up clinic in either the West Midlands, UK or New South Wales (NSW), Australia. By using an identical methodological and statistical approach, we hoped to add to the available information on the incidence of early psychological distress in patients following facial trauma. METHOD: This was a comparative cross-sectional study. A sample of fifty consecutive adult victims of facial trauma in the West Midlands UK, was compared to a group of fifty-two facially injured patients in NSW, Australia. Demographic data was collected, following which the Hospital Depression and Anxiety Scale (HADS) were applied to both groups of patients. RESULTS: Psychometric scores suggestive of anxiety and depressive state were common in both groups of patients. The mean HADS depression subscale score for UK patients compared to Australian patients was not significantly different (5.94 versus 5.54 p=0.62). This was also the case for the HADS anxiety subscale (5.96 versus 5.94 p=0.98). Although the number of patients achieving scores suggestive of a 'caseness' for co-morbid psychological state was higher within the UK sample when compared to the Australian group (20% versus 11.5% for HADS depression subscale, and 20% versus 15% for HADS anxiety subscales respectively); these differences did not reach statistical significance. CONCLUSION: This cross-national comparative study has shown that anxiety and depression in facial trauma victims were comparable in both settings.

Surgical management of transitional cell carcinoma of the lacrimal sac: Is it time for a new treatment algorithm?

Transitional cell carcinoma (TCC) arising in the lacrimal sac is a rare neoplasm. Despite radical surgery and radiotherapy, these tumors generally have a poor prognosis due to an often late diagnosis, high rate of loco-regional recurrence and mortality. There are only a relatively small number of documented cases of TCC when compared to other epithelial malignancies of the lacrimal drainage system. As would be anticipated, there are currently no evidence-based clinical practice guidelines for the treatment of these lesions. We present an illustrative case and consider the literature in relation to current surgical management of these tumors. We propose an alternate management consideration for these tumors.

Does attribution of blame influence psychological outcomes in facial trauma victims?

PURPOSE: The relative importance of different variables and specific post-traumatic psychological reactions after facial injuries is poorly understood. The aim of the present study was to assess the association between the subjective attribution of blame and anxiety and depression in facial trauma victims. MATERIALS AND METHODS: We undertook a comparative cross-sectional study of psychological outcomes in a cohort of adult patients who have sustained a facial injury. The primary predictor variable was the attribution of blame (self-blame vs blame-others). The main outcome variable was the Hospital Anxiety and Depression Scale (HADS) scores. We also considered several demographic and other clinical variables to assess their relationship with the nature of blame attribution. Cochran-Mantel-Haenszel statistics were used to assess the relationship between the primary predictor and outcome variables, adjusted for age, gender, and confounding factors. RESULTS: The sample consisted of 102 facial trauma victims (77 men and 25 women). Of the 77 patients, 63 attributed blame for their injuries to someone else and 39 patients attributed blame to themselves. Psychometric scores suggestive of anxiety and the depressive state were significantly greater in the "blame-others" group than in the "self-blame" group (HADS-Anxiety 22% vs 13%, HADS-Depression 17% vs 8%). The prevalence of psychomorbidity in the blame-others group was approximately twice that found in the self-blame group (odds ratio 2.2). Facial trauma patients who blamed others for their injury were predominantly younger men (P = .01) and typically victims of intentional trauma (P < .001). CONCLUSIONS: The results of the present study suggest that external attribution of blame for facial injury is associated with poor postinjury psychiatric outcomes.