The varieties of grief experience.

The bereavement literature has yet to show consensus on a clear definition of normal and abnormal or complicated grief reactions. According to DSM-IV, bereavement is a stressor event that warrants a clinical diagnosis only in extreme cases when other DSM categories of psychopathology (e.g., Major Depression) are evident. In contrast, bereavement theorists have proposed a number of different types of abnormal grief reactions, including those in which grief is masked or delayed. In this article, we review empirical evidence on the longitudinal course, phenomenological features, and possible diagnostic relevance of grief reactions. This evidence was generally consistent with the DSM-IV's view of bereavement and provided little support for more complicated taxonomies. Most bereaved individuals showed moderate disruptions in functioning during the first year after a loss, while more chronic symptoms were evidenced by a relatively small minority. Further, those individuals showing chronic grief reactions can be relatively easily accommodated by existing diagnostic categories. Finally, we found no evidence to support the proposed delayed grief category. We close by suggesting directions for subsequent research.

Toward an integrative perspective on bereavement.

For nearly a century, bereavement theorists have assumed that recovery from loss requires a period of grief work in which the ultimate goal is the severing of the attachment bond to the deceased. Reviews appearing in the 1980s noted a surprising absence of empirical support for this view, thus leaving the bereavement field without a guiding theoretical base. In this article, the authors consider alternative perspectives on bereavement that are based on cognitive stress theory, attachment theory, the social-functional account of emotion, and trauma theory. They then elaborate on the most promising features of each theory in an attempt to develop an integrative framework to guide future research. The authors elucidate 4 fundamental components of the grieving process--context, meaning, representations of the lost relationship, and coping and emotion-regulation processes--and suggest ways in which these components may interact over the course of bereavement.

Fatal necrotizing fasciitis following a mandibular fracture.

Necrotizing fasciitis of the head and neck is an uncommon, insidious infection that usually occurs secondarily to odontogenic infections, although blunt and penetrating trauma can be another cause. Of 65 total reported cases of necrotizing fasciitis, 10 (15.4%) have been fatal. This article presents a case of a mandibular fracture in a severely immunocompromised elderly patient in whom delayed treatment proved fatal. The clinician must remain suspicious of any infection refractory to antibiotic therapy alone, since necrotizing fasciitis is a rapidly progressing condition with high morbidity and potential for mortality. Rapid diagnosis, surgical treatment, antibiotic therapy, medical management, nutritional support, and early detection and treatment of complications are critical elements in the management of necrotizing fasciitis.

Craniofacial trauma and cerebrospinal fluid leakage: a retrospective clinical study.

PURPOSE: The study examines the efficacy of antibiotic treatment in patients with traumatic cerebrospinal fluid (CSF) leakage and identifies a consistent clinical approach for better management of these patients. PATIENTS AND METHODS: A retrospective study of traumatic CSF leakage in 88 patients with craniofacial fractures was performed. The mechanism of injury, etiology and source of leakage, decision to treat conservatively (without surgery) versus aggressively (with surgery), decision to use early versus late repair, and decision to provide prophylactic antibiotic coverage were recorded. Both timing of repair and the decision to use antibiotics were compared with the incidence of meningitis resulting from CSF leakage. RESULTS: Of 48 patients treated with antibiotics, 5(10.4%) developed meningitis. In the remaining 40 who were not treated with antibiotics, only one patient acquired meningitis. Five of 53 (9.4%) patients with conservative treatment developed meningitis versus 1 of 35 (2.9%) after aggressive treatment. CONCLUSION: There was no statistically significant difference in the rate of occurrence of meningitis between the conservative and the aggressive treatment group. However, the data suggest that there may be no benefit in treating these patients with antibiotics to prevent meningitis, whereas aggressive treatment and early repair of facial fractures may, in fact, be helpful.

Current concepts in the surgical management of traumatic auricular hematoma.

There has been considerable confusion in the literature regarding the proper treatment of auricular hematoma. This has stemmed from an inadequate understanding of the mechanisms involved in the formation and propagation of this condition. This article reviews the literature and give suggestions as to the proper surgical management of this problem.

Reconstruction of complex maxillectomy defects with the scapular-free flap.

The defect resulting from partial or complete maxillectomy can often be reconstructed with a skin graft and a prosthesis. In situations where this simple maneuver is unsatisfactory, a more complex reconstructive modality, providing the restoration of composite tissue, is required. The scapular microvascular-free flap was used in this series of 11 patients, as a cutaneous flap in 3 and as an osteocutaneous flap in 8, to meet the specific reconstructive needs of each patient. Excellent to satisfactory restoration of facial contour and palatal function was achieved in 10 patients. There was 1 flap failure. There were no donor site complications. Selected case histories are presented to demonstrate a spectrum of reconstructive problems. There are clear limitations to its applicability, such as the odd scapular bone contour, the thickness of the cutaneous paddle, the position change required for flap harvesting, and the risk of flap failure. The scapular flap has proven to be useful in restoring bony and soft tissue contour of the face, rigid support for the velum, oronasal separation, support for the orbit, and obliteration of the maxillary sinus. We found the scapular-free flap to be a useful tool for reconstructing complex and variable maxillectomy defects.

Prevention of sore throat after nasotracheal intubation.

The influence of tube size, cuff inflation, and pharyngeal packing on development of sore throat after nasotracheal intubation was studied. Pharyngeal packing was found to be the most significant factor, followed by tube size and inflation of the cuff.

Giant sialolithiasis appearing as odontogenic infection.

The dentist frequently is called on to diagnose pathoses of the head and neck region. Two reports of giant submandibular sialoliths that were originally diagnosed as submandibular space odontogenic infections are presented. Careful history, and physical and radiographic examinations are necessary to assure proper diagnosis and treatment of this condition.

Vascular malformation: report of a case with eight-year follow up.

An interesting example of a vascular malformation of the mandible has been presented. Early diagnosis made conservative treatment possible. Although the lesion was small, a considerable amount of hemorrhage was encountered during surgery. Adequate treatment was provided with ligation of external carotid arteries bilaterally in conjunction with curettage and packing. After an eight-year follow up, there has been no clinical or radiographic evidence of recurrence.

Current concepts of the adult respiratory distress syndrome.

The adult respiratory distress syndrome (ARDS) is a sequel to pulmonary injury that may be direct, closed chest trauma or indirect, through air or vascular passages, aspiration, or fat embolization. An understanding of this syndrome is essential for the oral surgeon who not only manages severe maxillofacial injuries but is also a member of a trauma team that manages multisystem injuries. Emphasis on pathophysiologic pathways resulting in ARDS is presented with a discussion on oxygenation and ventilation abnormalities. Application of these guidelines will assist the oral surgeon in understanding the management of patients with this acute progressive syndrome.