- Email: [email protected]
12 Aesthetic analysis of nose following rhinoplasty in cleft patients – a study of 30 cases
Oral presentations / British Journal of Oral and Maxillofacial Surgery 48 (2010) S1–S24
Results: From a total of 407 cases, 15 (4%) were admitted one day preoperatively. Postoperatively, 3 were day-cases, 343 (84%) stayed one night only, 48 (12%) stayed 2 nights and 12 (3%) stayed >2 nights. Poisson regression analysis shows there was no association between postoperative length of stay and age, estimated travel time, diagnosis and operation type. Patients stayed 2 or more nights postoperatively mostly for medical reasons. Patients with cleft palate compared to cleft lip operations had increased length of postoperative stay, with a p value of 0.002. Evidence shows the four readmissions were related to a longer original postoperative length of stay; odds ratio for an extra night’s stay was 2.20. Conclusion: Length of stay can in most cases be limited to one night postoperatively only. 9 What is normal? Validation of cancer biomarkers using saliva from a control group A.M. Matthews, H. Kaur, L. Liloglou, R. Shaw, J. Risk. School of Dental Sciences Liverpool University, UK Introduction: Oral squamous cell carcinoma is increasing in incidence in the UK. There has been an upsurge in those diagnosed at a young age without exposure to the common risk factors. HPV may play an aetiological role in this group. Reliable molecular biomarkers from readily available surrogate tissue, such as saliva, may prove a useful adjunct in the diagnosis and surveillance of early stage or recurrent disease, but to date there is a notable absence of validation of these biomarkers using normal controls. Methods: 140 saliva samples and mucosal scrapes were collected from a normal cohort of patients attending Liverpool University Dental Hospital. DNA was extracted and prepared for real-time quantitative methylation assays. A panel of genes, comprising p16, TMEFF2, ADAMTS9, cyclin A1, cytolobin and HPV, was selected for validation on this normal cohort on the basis of their tumour specificity identified in preliminary studies by this group. Results: Correlation of gene promoter methylation levels in matched saliva and mucosal scrapes was undertaken. Methylation of the gene promoters in matched tumour and normal tissue pairs from an OSCC cohort show tumour specificity for: Gene promoter
Tumours with methylation above 95% of normal tissue
P value
p16 TMEFF2 ADAMTS9 CyclinA1 Cytoglobin
28% 50% 33% 53% 65%
0.048 0.0001 0.045 0.001 0.002
(22/80) (12/24) (7/21) (42/78) (52/80)
Conclusion: Saliva is a valid surrogate tissue. The level of methylation in normal saliva samples has been determined, thereby validating the tumour specificity of a panel of cancer biomarkers and determining the baseline for future studies on cancer patient saliva. 10 Speech outcome after closure of oronasal fistula in cleft patients S. Reddy, A. Kamisetty, Gopalkrishnan. S D M College of Dental Sciences and Hospital, India Introduction: oronasal fistula formation is a common complication of palatoplasty in cleft patients. The acquisition of a speech is
S3
a complex process which is challenged in children with palatal fistula. Aim: To analyse speech outcome after closure of fistula. Material and Methods: A prospective study was done on 20 patients ranging from 5 to 15 years and speech was assessed preoperatively and postoperatively under parameters like intelligibility, audiologic assessment, nasal emission, articulation, nasalance and tonar percentage. The instruments used here GSI Tympstar- middle ear analyser, Grason stadler- GSi audiometer, Dual mike/nasometer, mouthmirror and Vaghmi software. Results: – All patients are intelligible preoperatively and postoperatively with no hearing impairment. – Nasal emission which was present with consonants like p t k s f sh decreased after closure of fistula. – Nasalance % which was high before closure of fistula decreased after closure of fistula. – Tonar % which was low before closure of fistula increased after closure of fistula which suggests escape of air through nose after closure is less. – Definitive increase in voice was noticed without any productive improvement in articulation. Conclusion: Skillful surgery along with experienced speech therapists and patient compliance leads to significant improvement in speech. 11 Future prospects for CT angio: computer simulation of the effects of surgery on head and neck circulation D.F. Campbell, V. Cook, M. Paul, P. Shiels. Southern General Hospital, Glasgow, UK Introduction: If, for example, an IJV is sacrificed, does it matter, does the cerebral venous pressure increase, is it more likely that future metastasis will be contralateral ? There is currently only a poor understanding of how surgery, such as IJV sacrifice effects flow in the head and neck. We can speculate based on lumen size of collateral drainage yet it would improve understanding if the dynamics of flow could be reviewed using new software techniques blended with exist CTA. Material and Methods: Engineers have developed advanced modeling systems for Computerized Flow Dynamics (CPD), and these tools have been used show dynamic flow on geometric models of circulation and CT images. Aims and Results: A new perspective on head and neck circulation. Images of H&N flow modeling will be shown. Clinical relevance: One possible medical future is an emphasis on the customization of treatment based on individual medical profiling. CFD will add to this planning by modeling the consequences of interventional procedures such as embolisation and other guided therapies. The effectiveness of various novel cancer therapies will be discuss along with the implication for vascular abnormalities. 12 Aesthetic analysis of nose following rhinoplasty in cleft patients – a study of 30 cases F. Puthussery, K. Shekar, T.R. Flood, N.A. Nasser. Salisbury NHS Foundation Trust, UK Objective: To assess the cosmesis of the nose following open rhinoplasty in cleft patients. Methods: 30 patients who had rhinoplasty as a part of their treatment in cleft management were included in the study. Pre and
S4
Oral presentations / British Journal of Oral and Maxillofacial Surgery 48 (2010) S1–S24
post operative photographs were analysed for symmetry, alar base width, nasal tip position and septal deviation in a frontal view and worms eye view. We also carried out VAS scoring amongst 5 clinicians to see if the residual asymmetry, if present was nil (0), mild (1) – severe (5). Results and Conclusions: We present the results for our study and discuss the pitfalls in treating this complex group of patients. 13 Nasogastric tube insertion: A novel approach for head and neck patients J. Blythe1 , N.J. Baker1 , C. Feres2 , A.A. Webb1 . 1 Department of Oral and Maxillofacial Surgery, Southampton General Hospital, 2 Dept of ENT, Southampton General Hospital, UK Introduction and Aims: Nasogastric tube insertion for feeding is common in secondary care management for head and neck oncology patients. Whilst this is often a simple task, it can be exceedingly difficult in patients with unfavourable pharyngeal and regional anatomy or dysphagia. Maxillofacial surgeons and Otolaryngologists may be called upon to provide expert assistance in NGT insertion. This often requires the nasendoscope to provide fibre-optic guidance, commonly passing the endoscope through one nostril, and the nasogastric tube through the other. Method: This article recommends a technique not previously reported in maxillofacial surgery literature to maximise efficiency and minimise patient distress. The ‘piggy back’ technique allows the nasogastric tube to be transported in unison with the endoscope into the upper oesophagus, through one nostril. Our experience of this technique at Southampton General Hospital is reviewed. Conclusion: This technique has a number of advantages. Firstly, the NGT and endoscope act as one unit improving operator technique. The approach reduces the need for assistance. Patient anxiety is less when only the single nostril is accessed. And finally there is a reduction in expense and radiation exposure associated with radiologically-guided techniques. 14 Determining molecular pathways using comparative genomic hybridisation in metastatic oral squamous cell carcinoma J. Dhanda, R. Shaw, B. Lloyd, D.R. Sibson, J.A. Woolgar, J.M. Risk. University of Liverpool, UK Background: Extracapsular spread (ECS) in metastatic oral squamous cell carcinoma (OSCC) represents the most significant adverse prognostic indicator. The aim of this study was to use comparative genome hybridisation (CGH) analysis in an initial exploratory study hypothesising that molecular pathways would be significantly enriched according to the presence of ECS. Methods: Macromolecules were purified from fresh frozen samples representing T2 and T4 stage disease with or without nodal disease or ECS (n = 43). CGH analysis was performed using 720,000 human genomic probes per array (Nimblegen). Genomic segmentation was used to identify regional copy number changes. Genes identified in the segments were mapped to canonical pathways to assess significance according to metadata defining the samples. Results: Significant copy number changes were found in node positive status affecting multiple pathways including cytoskeletal remodelling, apoptosis, transcription and immune response. Significantly affected networks included angiogenesis, protein
folding and proteasome proteolysis between disease free versus recurrence. Significant associations for ECS were not found. Discussion: This is the highest density CGH array study specifically on OSCC of which we are aware. The high resolution uniquely allowed significantly associated pathways to be determined. Samples associated with ECS could not be distinguished. This may be a result of their smaller numbers (n = 11) or due to underlying reduced host immune responses. Future work expanding the number of samples with regard to ECS cases and also including expression array studies is underway. These are planned to further test the significance and examine the possibility of expression changes associated with ECS. 15 Impact of nerve involvement in oral squamous cell carcinomas S. Bhatia, M.J. Fardy. University Dental Hospital and University Hospital of Wales, UK Perineural Invasion has been thought to be an important variable affecting the outcome of Oral squamous cell carcinomas. In an attempt to identify the impact of the nerve involvement on the recurrence and prognosis in such patients, we retrospectively looked at 100 consecutive cases of Oral squamous cell carcinomas treated surgically from 2000 to 2004 in our unit. An incidence of 22% of perineural invasion was found on histopathology. 50% of these patients were still alive at 5 years. 85% of perineural invasion cases had Well or moderately differentiated SCC as histology and only 15% as Poorly differentiated SCC. Nearly 50% of these patients had either T1–T2 lesions contrary to the belief that the lesions are usually larger. The depth the tumours ranged from 3.5 mm to 51 mm with a mean depth of the tumour of 21 mm. We discuss the relevance of Perineural index and review the results with literature. 16 Changes in resonance and articulation following midface advancement P. Bordbar, W. Blumenow, D. Richardson, C. Duncan. Alder Hey Children’s Hospital, UK Aims: To analyse changes in resonance and articulation following midface advancement in syndromic craniofacial patients, and to assess the influence of craniofacial diagnosis, and the presence or absence of cleft palate. Method: An audit of pre- and post-operative resonance and articulation assessment records in a cohort of fifteen craniofacial patients who underwent midface advancement between 2002 and 2009. Five patients had a concomitant diagnosis of cleft palate. All patients underwent perceptual assessment of articulation and resonance using GOS.SP.ASS. 98 revised. Nasoendoscopy and videofluroscopy were carried out only when clinically indicated. Results: Velopharyngeal function deteriorated in six out of fifteen patients (40%) post-operatively. Five of these patients had Apert Syndrome. The patients with Crouzon Syndrome did not display deterioration in their velopharyngeal function post-operatively. Four out of the six patients with deterioration in velopharyngeal function had a cleft palate. All had Apert Syndrome except one patient. The two patients without a cleft palate that deteriorated also had Apert Syndrome. Significant change in articulatory pattern occurred in only one patient. Conclusion: Our findings suggest 1. There is a high risk of deterioration in velopharyngeal function following midface advancement in patients with Apert
Results: From a total of 407 cases, 15 (4%) were admitted one day preoperatively. Postoperatively, 3 were day-cases, 343 (84%) stayed one night only, 48 (12%) stayed 2 nights and 12 (3%) stayed >2 nights. Poisson regression analysis shows there was no association between postoperative length of stay and age, estimated travel time, diagnosis and operation type. Patients stayed 2 or more nights postoperatively mostly for medical reasons. Patients with cleft palate compared to cleft lip operations had increased length of postoperative stay, with a p value of 0.002. Evidence shows the four readmissions were related to a longer original postoperative length of stay; odds ratio for an extra night’s stay was 2.20. Conclusion: Length of stay can in most cases be limited to one night postoperatively only. 9 What is normal? Validation of cancer biomarkers using saliva from a control group A.M. Matthews, H. Kaur, L. Liloglou, R. Shaw, J. Risk. School of Dental Sciences Liverpool University, UK Introduction: Oral squamous cell carcinoma is increasing in incidence in the UK. There has been an upsurge in those diagnosed at a young age without exposure to the common risk factors. HPV may play an aetiological role in this group. Reliable molecular biomarkers from readily available surrogate tissue, such as saliva, may prove a useful adjunct in the diagnosis and surveillance of early stage or recurrent disease, but to date there is a notable absence of validation of these biomarkers using normal controls. Methods: 140 saliva samples and mucosal scrapes were collected from a normal cohort of patients attending Liverpool University Dental Hospital. DNA was extracted and prepared for real-time quantitative methylation assays. A panel of genes, comprising p16, TMEFF2, ADAMTS9, cyclin A1, cytolobin and HPV, was selected for validation on this normal cohort on the basis of their tumour specificity identified in preliminary studies by this group. Results: Correlation of gene promoter methylation levels in matched saliva and mucosal scrapes was undertaken. Methylation of the gene promoters in matched tumour and normal tissue pairs from an OSCC cohort show tumour specificity for: Gene promoter
Tumours with methylation above 95% of normal tissue
P value
p16 TMEFF2 ADAMTS9 CyclinA1 Cytoglobin
28% 50% 33% 53% 65%
0.048 0.0001 0.045 0.001 0.002
(22/80) (12/24) (7/21) (42/78) (52/80)
Conclusion: Saliva is a valid surrogate tissue. The level of methylation in normal saliva samples has been determined, thereby validating the tumour specificity of a panel of cancer biomarkers and determining the baseline for future studies on cancer patient saliva. 10 Speech outcome after closure of oronasal fistula in cleft patients S. Reddy, A. Kamisetty, Gopalkrishnan. S D M College of Dental Sciences and Hospital, India Introduction: oronasal fistula formation is a common complication of palatoplasty in cleft patients. The acquisition of a speech is
S3
a complex process which is challenged in children with palatal fistula. Aim: To analyse speech outcome after closure of fistula. Material and Methods: A prospective study was done on 20 patients ranging from 5 to 15 years and speech was assessed preoperatively and postoperatively under parameters like intelligibility, audiologic assessment, nasal emission, articulation, nasalance and tonar percentage. The instruments used here GSI Tympstar- middle ear analyser, Grason stadler- GSi audiometer, Dual mike/nasometer, mouthmirror and Vaghmi software. Results: – All patients are intelligible preoperatively and postoperatively with no hearing impairment. – Nasal emission which was present with consonants like p t k s f sh decreased after closure of fistula. – Nasalance % which was high before closure of fistula decreased after closure of fistula. – Tonar % which was low before closure of fistula increased after closure of fistula which suggests escape of air through nose after closure is less. – Definitive increase in voice was noticed without any productive improvement in articulation. Conclusion: Skillful surgery along with experienced speech therapists and patient compliance leads to significant improvement in speech. 11 Future prospects for CT angio: computer simulation of the effects of surgery on head and neck circulation D.F. Campbell, V. Cook, M. Paul, P. Shiels. Southern General Hospital, Glasgow, UK Introduction: If, for example, an IJV is sacrificed, does it matter, does the cerebral venous pressure increase, is it more likely that future metastasis will be contralateral ? There is currently only a poor understanding of how surgery, such as IJV sacrifice effects flow in the head and neck. We can speculate based on lumen size of collateral drainage yet it would improve understanding if the dynamics of flow could be reviewed using new software techniques blended with exist CTA. Material and Methods: Engineers have developed advanced modeling systems for Computerized Flow Dynamics (CPD), and these tools have been used show dynamic flow on geometric models of circulation and CT images. Aims and Results: A new perspective on head and neck circulation. Images of H&N flow modeling will be shown. Clinical relevance: One possible medical future is an emphasis on the customization of treatment based on individual medical profiling. CFD will add to this planning by modeling the consequences of interventional procedures such as embolisation and other guided therapies. The effectiveness of various novel cancer therapies will be discuss along with the implication for vascular abnormalities. 12 Aesthetic analysis of nose following rhinoplasty in cleft patients – a study of 30 cases F. Puthussery, K. Shekar, T.R. Flood, N.A. Nasser. Salisbury NHS Foundation Trust, UK Objective: To assess the cosmesis of the nose following open rhinoplasty in cleft patients. Methods: 30 patients who had rhinoplasty as a part of their treatment in cleft management were included in the study. Pre and
S4
Oral presentations / British Journal of Oral and Maxillofacial Surgery 48 (2010) S1–S24
post operative photographs were analysed for symmetry, alar base width, nasal tip position and septal deviation in a frontal view and worms eye view. We also carried out VAS scoring amongst 5 clinicians to see if the residual asymmetry, if present was nil (0), mild (1) – severe (5). Results and Conclusions: We present the results for our study and discuss the pitfalls in treating this complex group of patients. 13 Nasogastric tube insertion: A novel approach for head and neck patients J. Blythe1 , N.J. Baker1 , C. Feres2 , A.A. Webb1 . 1 Department of Oral and Maxillofacial Surgery, Southampton General Hospital, 2 Dept of ENT, Southampton General Hospital, UK Introduction and Aims: Nasogastric tube insertion for feeding is common in secondary care management for head and neck oncology patients. Whilst this is often a simple task, it can be exceedingly difficult in patients with unfavourable pharyngeal and regional anatomy or dysphagia. Maxillofacial surgeons and Otolaryngologists may be called upon to provide expert assistance in NGT insertion. This often requires the nasendoscope to provide fibre-optic guidance, commonly passing the endoscope through one nostril, and the nasogastric tube through the other. Method: This article recommends a technique not previously reported in maxillofacial surgery literature to maximise efficiency and minimise patient distress. The ‘piggy back’ technique allows the nasogastric tube to be transported in unison with the endoscope into the upper oesophagus, through one nostril. Our experience of this technique at Southampton General Hospital is reviewed. Conclusion: This technique has a number of advantages. Firstly, the NGT and endoscope act as one unit improving operator technique. The approach reduces the need for assistance. Patient anxiety is less when only the single nostril is accessed. And finally there is a reduction in expense and radiation exposure associated with radiologically-guided techniques. 14 Determining molecular pathways using comparative genomic hybridisation in metastatic oral squamous cell carcinoma J. Dhanda, R. Shaw, B. Lloyd, D.R. Sibson, J.A. Woolgar, J.M. Risk. University of Liverpool, UK Background: Extracapsular spread (ECS) in metastatic oral squamous cell carcinoma (OSCC) represents the most significant adverse prognostic indicator. The aim of this study was to use comparative genome hybridisation (CGH) analysis in an initial exploratory study hypothesising that molecular pathways would be significantly enriched according to the presence of ECS. Methods: Macromolecules were purified from fresh frozen samples representing T2 and T4 stage disease with or without nodal disease or ECS (n = 43). CGH analysis was performed using 720,000 human genomic probes per array (Nimblegen). Genomic segmentation was used to identify regional copy number changes. Genes identified in the segments were mapped to canonical pathways to assess significance according to metadata defining the samples. Results: Significant copy number changes were found in node positive status affecting multiple pathways including cytoskeletal remodelling, apoptosis, transcription and immune response. Significantly affected networks included angiogenesis, protein
folding and proteasome proteolysis between disease free versus recurrence. Significant associations for ECS were not found. Discussion: This is the highest density CGH array study specifically on OSCC of which we are aware. The high resolution uniquely allowed significantly associated pathways to be determined. Samples associated with ECS could not be distinguished. This may be a result of their smaller numbers (n = 11) or due to underlying reduced host immune responses. Future work expanding the number of samples with regard to ECS cases and also including expression array studies is underway. These are planned to further test the significance and examine the possibility of expression changes associated with ECS. 15 Impact of nerve involvement in oral squamous cell carcinomas S. Bhatia, M.J. Fardy. University Dental Hospital and University Hospital of Wales, UK Perineural Invasion has been thought to be an important variable affecting the outcome of Oral squamous cell carcinomas. In an attempt to identify the impact of the nerve involvement on the recurrence and prognosis in such patients, we retrospectively looked at 100 consecutive cases of Oral squamous cell carcinomas treated surgically from 2000 to 2004 in our unit. An incidence of 22% of perineural invasion was found on histopathology. 50% of these patients were still alive at 5 years. 85% of perineural invasion cases had Well or moderately differentiated SCC as histology and only 15% as Poorly differentiated SCC. Nearly 50% of these patients had either T1–T2 lesions contrary to the belief that the lesions are usually larger. The depth the tumours ranged from 3.5 mm to 51 mm with a mean depth of the tumour of 21 mm. We discuss the relevance of Perineural index and review the results with literature. 16 Changes in resonance and articulation following midface advancement P. Bordbar, W. Blumenow, D. Richardson, C. Duncan. Alder Hey Children’s Hospital, UK Aims: To analyse changes in resonance and articulation following midface advancement in syndromic craniofacial patients, and to assess the influence of craniofacial diagnosis, and the presence or absence of cleft palate. Method: An audit of pre- and post-operative resonance and articulation assessment records in a cohort of fifteen craniofacial patients who underwent midface advancement between 2002 and 2009. Five patients had a concomitant diagnosis of cleft palate. All patients underwent perceptual assessment of articulation and resonance using GOS.SP.ASS. 98 revised. Nasoendoscopy and videofluroscopy were carried out only when clinically indicated. Results: Velopharyngeal function deteriorated in six out of fifteen patients (40%) post-operatively. Five of these patients had Apert Syndrome. The patients with Crouzon Syndrome did not display deterioration in their velopharyngeal function post-operatively. Four out of the six patients with deterioration in velopharyngeal function had a cleft palate. All had Apert Syndrome except one patient. The two patients without a cleft palate that deteriorated also had Apert Syndrome. Significant change in articulatory pattern occurred in only one patient. Conclusion: Our findings suggest 1. There is a high risk of deterioration in velopharyngeal function following midface advancement in patients with Apert