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P72 Bilateral branchial cysts – a diagnostic dilemma
Posters / British Journal of Oral and Maxillofacial Surgery 48 (2010) S25–S55
P70 Oral and maxillofacial surgery training: vocation training vs hospital post S. Sah, S. Patel, F. Evans, A. McKechnie. United Lincolnshire Hospitals NHS Trust, UK Objectives: To determine the confidence of recent dental graduates in minor oral surgery and the benefit of vocation training (VT) vs OMFS post. Methods: An e-mail questionnaire was sent to 150 UK dental graduates at three stages of training; beginning of VT, beginning of first OMFS post and after six months of OMFS post. The questionnaire asked about confidence in five key aspects of minor oral surgery: raising a mucoperiosteal flap, bone removal, tooth sectioning, use of elevators and intra-oral suturing. Respondents were asked to rate confidence with respect to each domain as: “very confident”, “confident”, “not confident” or “not done before”. Results were tabulated and response frequencies compared using the Chi squared test. Results: Of 150 questionnaires, 91 were returned (61%). In terms of overall confidence in all five domains there was no significant difference between recent graduates and dentists who had completed VT. After six months hospital OMFS training, however, there was significant improvement in all domains (p < 0.01), with pooled data showing 89% of responses were “confident” or “very confident”. However, only 65% of respondents were confident or very confident in all five domains. Conclusions: This pilot study shows that post-graduate vocational training in a primary care setting is insufficient to improve confidence with minor oral surgery procedures. The best way to train dentists to perform oral surgery, confidently, is through a hospital-based programme. The duration of hospital OMFS training should be not less than six months. These results have implications for the delivery of Dental Foundation Training. P71 Management of patients with sickle cell haemoglobinopathy receiving oro-facial, head and neck surgery in a district general hospital S. Ratcliffe, E. Ali, L. Cheng, A. Ezsias, R. Amos, L. McCready, R. Quershi. Oral & Maxillofacial Surgery, Haematology and Anesthesia, Homerton Hospital, London, UK Introduction: Sickle cell haemoglobinopathy is not uncommon among immigrants from endemic area and their offspring born in the UK. They can present perioperative challenges in patients receiving surgery to mouth, head and neck and they are often complicated by the severity of the disease process and individual variation in clinical presentation. We present treatment protocols in conjunction with our haematologists and anaesthetists for our patients with sickle cell haemaglobinopathy. Non-complicated sickle cell patients treated under local anaesthetic: – Ensure patient is in a steady state and delay surgery if necessary. – Ensure increased fluid intake including temporary intravenous infusion. Non-complicated sickle cell patients treated under general anaesthetic: – Intravenous fluid replacement during nil by mouth period and beware of potential renal impairment. – Keep patient warm and provide supplementary oxygen to maintain good oxygen saturations during anaesthesia.
S43
– Cross match blood preoperatively and check full blood count regularly. – Keep patient under observation overnight. Complicated sickle cell patients treated under general anaesthetic: – Ensure good haemoglobin level by preoperative transfusion. – Hydration, oxygenation, warmth and pain control are paramount in perioperative care. – Subcutaneous diamorphine infusion for pain control in patients developing sickle cell crisis. Conclusion: It is important to minimize potential perioperative morbidity and mortality in the management of sickle cell patients. Multidisciplinary management is paramount in avoiding perioperative sickle cell crisis which is often precipitated by pain, hypoxia or dehydration. P72 Bilateral branchial cysts – a diagnostic dilemma R. Boyapati, C. Newlands. Royal Surrey County Hospital, Guildford, UK Confidently diagnosing bilateral branchial cysts in the neck can pose a problem to the clinician, as 98% of all branchial cysts present as a unilateral entity, usually in the second to third decades. Up to 80 per cent of so-called branchial cysts in the over 40s’ age group are subsequently shown to be malignant necrotic metastatic cervical lymphadenopathy from an unknown primary. We present a 56 yr old male smoker who presented with a 3 week history of bilateral Level II cystic neck swellings. Investigations showed a moderate neutrophilia and an ESR of 60. FNA yielded pus, containing atypical squamous cells. CT/MRI scans showed the presence of bilateral 3 cm cystic lesions extending towards the tonsillar fossae, and no other abnormalities. The differential diagnosis included cystic lymph node metastases arising from an occult primary, tuberculous lymphadenitis, and bilateral branchial cysts. EUA and panendoscopy were unremarkable and excisional biopsy of one of the cystic lesions was performed. Histology showed a classical branchial cyst, and the contralateral cyst was subsequently removed. Diagnosis of branchial cysts in this age group should be made with caution; this case demonstrates the diagnostic dilemmas and work up, where the final diagnosis turned out to be bilateral branchial cysts. P73 Extreme idiopathic osteonecrosis of the condylar head, coronoid process and angle of the mandible: presentation of fourteen cases in a West African population S. Khullar, D. Tvedt. Mercy Ships, UK Idiopathic Osteo Necrosis (ON) of the mandible has been reported in the medical literature related to dental implants or prosthesis which have caused localised ischaemic ON. Avascular ON, which most commonly affects the femoral head is well recognised. Avascular ON of the condylar head is a less frequent finding. Controversy exists as to the aetiology of ON in the edentulous regions of the mandible. The authors would like to present a series of 14 cases of severe idioipathic ON related to the condylar head, angle or coronoid process of the mandible in a West African population (Liberia, Benin). The patients had received very little or no previous dental treatment and did not have access to any type of medical care. They presented with extreme facial swelling in all cases – many of which were
P70 Oral and maxillofacial surgery training: vocation training vs hospital post S. Sah, S. Patel, F. Evans, A. McKechnie. United Lincolnshire Hospitals NHS Trust, UK Objectives: To determine the confidence of recent dental graduates in minor oral surgery and the benefit of vocation training (VT) vs OMFS post. Methods: An e-mail questionnaire was sent to 150 UK dental graduates at three stages of training; beginning of VT, beginning of first OMFS post and after six months of OMFS post. The questionnaire asked about confidence in five key aspects of minor oral surgery: raising a mucoperiosteal flap, bone removal, tooth sectioning, use of elevators and intra-oral suturing. Respondents were asked to rate confidence with respect to each domain as: “very confident”, “confident”, “not confident” or “not done before”. Results were tabulated and response frequencies compared using the Chi squared test. Results: Of 150 questionnaires, 91 were returned (61%). In terms of overall confidence in all five domains there was no significant difference between recent graduates and dentists who had completed VT. After six months hospital OMFS training, however, there was significant improvement in all domains (p < 0.01), with pooled data showing 89% of responses were “confident” or “very confident”. However, only 65% of respondents were confident or very confident in all five domains. Conclusions: This pilot study shows that post-graduate vocational training in a primary care setting is insufficient to improve confidence with minor oral surgery procedures. The best way to train dentists to perform oral surgery, confidently, is through a hospital-based programme. The duration of hospital OMFS training should be not less than six months. These results have implications for the delivery of Dental Foundation Training. P71 Management of patients with sickle cell haemoglobinopathy receiving oro-facial, head and neck surgery in a district general hospital S. Ratcliffe, E. Ali, L. Cheng, A. Ezsias, R. Amos, L. McCready, R. Quershi. Oral & Maxillofacial Surgery, Haematology and Anesthesia, Homerton Hospital, London, UK Introduction: Sickle cell haemoglobinopathy is not uncommon among immigrants from endemic area and their offspring born in the UK. They can present perioperative challenges in patients receiving surgery to mouth, head and neck and they are often complicated by the severity of the disease process and individual variation in clinical presentation. We present treatment protocols in conjunction with our haematologists and anaesthetists for our patients with sickle cell haemaglobinopathy. Non-complicated sickle cell patients treated under local anaesthetic: – Ensure patient is in a steady state and delay surgery if necessary. – Ensure increased fluid intake including temporary intravenous infusion. Non-complicated sickle cell patients treated under general anaesthetic: – Intravenous fluid replacement during nil by mouth period and beware of potential renal impairment. – Keep patient warm and provide supplementary oxygen to maintain good oxygen saturations during anaesthesia.
S43
– Cross match blood preoperatively and check full blood count regularly. – Keep patient under observation overnight. Complicated sickle cell patients treated under general anaesthetic: – Ensure good haemoglobin level by preoperative transfusion. – Hydration, oxygenation, warmth and pain control are paramount in perioperative care. – Subcutaneous diamorphine infusion for pain control in patients developing sickle cell crisis. Conclusion: It is important to minimize potential perioperative morbidity and mortality in the management of sickle cell patients. Multidisciplinary management is paramount in avoiding perioperative sickle cell crisis which is often precipitated by pain, hypoxia or dehydration. P72 Bilateral branchial cysts – a diagnostic dilemma R. Boyapati, C. Newlands. Royal Surrey County Hospital, Guildford, UK Confidently diagnosing bilateral branchial cysts in the neck can pose a problem to the clinician, as 98% of all branchial cysts present as a unilateral entity, usually in the second to third decades. Up to 80 per cent of so-called branchial cysts in the over 40s’ age group are subsequently shown to be malignant necrotic metastatic cervical lymphadenopathy from an unknown primary. We present a 56 yr old male smoker who presented with a 3 week history of bilateral Level II cystic neck swellings. Investigations showed a moderate neutrophilia and an ESR of 60. FNA yielded pus, containing atypical squamous cells. CT/MRI scans showed the presence of bilateral 3 cm cystic lesions extending towards the tonsillar fossae, and no other abnormalities. The differential diagnosis included cystic lymph node metastases arising from an occult primary, tuberculous lymphadenitis, and bilateral branchial cysts. EUA and panendoscopy were unremarkable and excisional biopsy of one of the cystic lesions was performed. Histology showed a classical branchial cyst, and the contralateral cyst was subsequently removed. Diagnosis of branchial cysts in this age group should be made with caution; this case demonstrates the diagnostic dilemmas and work up, where the final diagnosis turned out to be bilateral branchial cysts. P73 Extreme idiopathic osteonecrosis of the condylar head, coronoid process and angle of the mandible: presentation of fourteen cases in a West African population S. Khullar, D. Tvedt. Mercy Ships, UK Idiopathic Osteo Necrosis (ON) of the mandible has been reported in the medical literature related to dental implants or prosthesis which have caused localised ischaemic ON. Avascular ON, which most commonly affects the femoral head is well recognised. Avascular ON of the condylar head is a less frequent finding. Controversy exists as to the aetiology of ON in the edentulous regions of the mandible. The authors would like to present a series of 14 cases of severe idioipathic ON related to the condylar head, angle or coronoid process of the mandible in a West African population (Liberia, Benin). The patients had received very little or no previous dental treatment and did not have access to any type of medical care. They presented with extreme facial swelling in all cases – many of which were