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Cervicofacial Subcutaneous Emphysema after Oral Laser Surgery
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doi: 1054/bjom.2000.0336, available online at http://www.idealibrary.com on
CERVICOFACIAL SUBCUTANEOUS EMPHYSEMA AFTER ORAL LASER SURGERY
Fig. 1
examination revealed supra and infra-orbital rim discontinuities. Intra-orally a gingival tear was present between the first molar and second premolar, together with a vertical step in the upper dental arch resulting in premature molar contact and minimal open bite. Percussion of the right upper molars gave a ‘cracked cup’ note. A fracture was demonstrated on CT scan (Fig. 1) to run from the right frontal bone, through the orbit, and could be traced caudally to the right maxillary alveolus in the region of the step, 3D reformatting demonstrated the unusual fracture which appears to run in continuity from the cranium to the right upper molar region with the same vertical displacement at all levels. The scan also revealed an unstable cervical spine fracture which required operative stabilization. The patient had a cervical fusion from which she made an uneventful recovery. Her craniofacial fracture was managed conservatively and the occlusion improved dramatically as the fractured maxilla was ‘bitten up’ within 10 days of the original injury. As there was no indication to rescan the patient we were unable to monitor progress of the fracture radiographically.
Mr S. Holmes FDSRCS, FRCS Specialist Registrar Mr N. Ali FDS, FRCS Specialist Registrar Professor P.F. Bradley MD, BDS, FRCS, FDSRCS(Eng), FDSRCS(Edin) Head, Department of Oral and Maxillofacial Surgery Bart’s and The Royal London NHS Trust Whitechapel London E1 1BB, UK Tel: +44 (0)20 7377 7050 Fax: +44 (0)20 7377 7121
Sir, Subcutaneous emphysema is an uncommon complication of oral surgery, but it has been reported in association with various dental and oral procedures such as tooth extraction, restorative dentistry (amalgam restoration, cavity preparation, post and core, crown preparations), root canal therapy, periodontal treatment, osteotomy, and dental implant surgery.1–3 It has occurred in particular during removal of mandibular third molars as a result of the use of high-speed handpieces.1,2 A 19-year-old woman complained of an abscess of the right upper central incisor. A dental radiogram showed a small radiolucent area around the root apex of the right upper central incisor. This was incised and the slender tip of a carbon dioxide laser for dental use was inserted into the submucous tissue above the root apex to cauterize an apical lesion within three minutes. This laser had an air stream of 152 kPa directed towards the tip. Immediately after the procedure, the patient’s right cheek, periorbital region, temporal region and neck swelled up, without systemic symptoms. She was referred to the clinic of the Department of Oral Surgery of Kawasaki Medical School Hospital. She was alert without systemic symptoms or fever. Examination showed right facial and bilateral neck swelling with crepitus, and gas bubbles were confirmed by a computed tomogram of the head and neck (Fig. 1). No pneumothorax or pneumomediastinum was noted on chest radiographs. Oral cefditoren 300 mg/day was prescribed to prevent infection such as necrotizing fasciitis.4 The emphysema resolved completely
Fig. 1 Computed tomograms taken at the first consultation.
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in about 10 days. Carbon dioxide laser surgery has become the treatment of choice for outpatient dental and oral surgery. It has been reported to be safe, but 2 (0.9%) of 222 laser laryngoscopies developed emphysematous complications.5 This case may be the first report of iatrogenic subcutaneous emphysema after oral laser surgery. It should be kept in mind that emphysematous complications may occur during oral laser surgery, whenever compressed air is used inside the mouth. Tsuyoshi Hata, DDS, PhD Masaru Hosoda, DDS, PhD Department of Oral Surgery Kawasaki Medical School 577 Matsushima Kurashiki-shi Okayama 701-0192 Japan (Tel: +81 86 462 1111; Fax: +81 86 462 1199) REFERENCES 1. Heyman SN, Babayof I. Emphysematous complications in dentistry, 1960–1993: an illustrative case and review of the literature. Quintessence International 1995; 26; 535–543. 2. Monsour PA, Savage NW. Cervicofacial emphysema following dental procedures. Aust Dent J 1989; 34: 403–406. 3. Davies JM, Campbell LA. Fatal air embolism during dental implant surgery: a report of three cases. Can J Anaesth 1990; 37: 112–121. 4. Yamaoka M, Furusawa K, Uematsu T, Yasuda K. Early evaluation of necrotizing fasciitis with use of CT. J Craniomaxillofac Surg 1994; 22: 268–271. 5. Wetmore SJ, Key JM, Suen JY. Complications of laser surgery for laryngeal papillomatosis. Laryngoscope 1985; 95: 798–801.
doi: 1054/bjom.2000.0448, available online at http://www.idealibrary.com on
RE: McCreary CE, McCarten BE. Clinical management of oral lichen planus. Br J Oral Maxillofac Surg 1999; 37: 338–343 Sir, In relation to the article by McCreary and McCarten on oral lichen planus in the October issue of the Journal we think it is important that your readers are aware that since their article was accepted for publication of Cochrane systematic review has been completed on ‘interventions used in the treatment of lichen planus’.1 It is also important to note that the review is in electronic form and so is updated when new information becomes available. The aim of the Cochrane review was to evaluate the effectiveness and adverse effects of different therapies used in randomized controlled trials for the relief of symptomatic lichen planus by the use of meta analysis. Its other objective was to determine the quality of placebo-controlled clinical trial data available for the treatment of symptomatic lichen planus. Following extensive searching of the world literature and after requests to the pharmaceutical industry only nine randomized controlled trials were identified involving 192 patients. The results were reported as follows: ‘The nine interventions were grouped into four separate classes (cyclosporines,
retinoids, steroids and phototherapy) for comparison. No therapy was replicated exactly, the closest replication involved two trials using high and low dose cyclosporine mouthwash. Only trials recording the same outcomes in each therapeutic class were pooled. The largest number of pooled trials was three. Large odds ratios with very wide confidence intervals indicating a statistically significant treatment benefit were seen in all trials. However this has to be tempered by considerations of the small study sizes, the lack of replication, the difficulty in measuring outcome changes and the very high likelihood of publication bias. Only systemic agents were associated with treatment toxicities, all other side-effects were mild and mainly limited to local mucosal reactions. There is only weak evidence for the superiority of the assessed interventions over placebo for palliation of symptomatic oral lichen planus.’ Our review highlighted the need for larger placebo-controlled randomized trials in order to demonstrate an effective therapy. Clear diagnostic criteria as well as standardized outcome measures are essential if comparisons are to be made between treatments. It is therefore impossible at present to lay down evidence-based guidelines on the management of lichen planus. Dr. J. M. Zakrzewska M. Thornhill E. S.-Y. Chan Bart’s and The Royal London NHS Trust Department of Oral Medicine Turner Street London E1 2AD, UK REFERENCES 1. McCreary CE, McCarten BE. Clinical management of oral lichen planus. Br J Oral Maxillofac Surg 1999; 37: 338–343. 2. Chan ES-Y, Thornhill M, Zakrzewska J. Interventions for treating oral lichen planus (Cochrane Review). The Cochrane Library Oxford Update Software 1999 (Issue 2). doi: 1054/bjom.2000.0477, available online at http://www.idealibrary.com on
THE GREAT AURICULAR AND THE FACIAL NERVE: IS THERE A CORRELATION BETWEEN THE DIAMETER OF THESE NERVES? Sir, With a large parotid surgical practice in the Black Country, we have frequently been struck by an apparent correlation between the diameter of the great auricular nerve and the facial nerve. It appears that, on many occasions, finding a small and rather ‘delicate’ great auricular nerve correspons to subsequently finding a small and ‘delicate’ facial nerve, often with an atypical distribution of divisions or branches. It would appear the converse also holds true in that a robust great auricular nerve is correlated with a similarly robust facial nerve. It is difficult to explain these findings in view of the dissimilar nature of these two nerves. However, the correlation seems to be present more often than could be accounted for by chance alone. Our purpose in writing is to enquire as to whether any colleagues with large salivary gland practices have noticed this phenomenon.
3/16/01 5:33 PM
Page 161
Letters
161
doi: 1054/bjom.2000.0336, available online at http://www.idealibrary.com on
CERVICOFACIAL SUBCUTANEOUS EMPHYSEMA AFTER ORAL LASER SURGERY
Fig. 1
examination revealed supra and infra-orbital rim discontinuities. Intra-orally a gingival tear was present between the first molar and second premolar, together with a vertical step in the upper dental arch resulting in premature molar contact and minimal open bite. Percussion of the right upper molars gave a ‘cracked cup’ note. A fracture was demonstrated on CT scan (Fig. 1) to run from the right frontal bone, through the orbit, and could be traced caudally to the right maxillary alveolus in the region of the step, 3D reformatting demonstrated the unusual fracture which appears to run in continuity from the cranium to the right upper molar region with the same vertical displacement at all levels. The scan also revealed an unstable cervical spine fracture which required operative stabilization. The patient had a cervical fusion from which she made an uneventful recovery. Her craniofacial fracture was managed conservatively and the occlusion improved dramatically as the fractured maxilla was ‘bitten up’ within 10 days of the original injury. As there was no indication to rescan the patient we were unable to monitor progress of the fracture radiographically.
Mr S. Holmes FDSRCS, FRCS Specialist Registrar Mr N. Ali FDS, FRCS Specialist Registrar Professor P.F. Bradley MD, BDS, FRCS, FDSRCS(Eng), FDSRCS(Edin) Head, Department of Oral and Maxillofacial Surgery Bart’s and The Royal London NHS Trust Whitechapel London E1 1BB, UK Tel: +44 (0)20 7377 7050 Fax: +44 (0)20 7377 7121
Sir, Subcutaneous emphysema is an uncommon complication of oral surgery, but it has been reported in association with various dental and oral procedures such as tooth extraction, restorative dentistry (amalgam restoration, cavity preparation, post and core, crown preparations), root canal therapy, periodontal treatment, osteotomy, and dental implant surgery.1–3 It has occurred in particular during removal of mandibular third molars as a result of the use of high-speed handpieces.1,2 A 19-year-old woman complained of an abscess of the right upper central incisor. A dental radiogram showed a small radiolucent area around the root apex of the right upper central incisor. This was incised and the slender tip of a carbon dioxide laser for dental use was inserted into the submucous tissue above the root apex to cauterize an apical lesion within three minutes. This laser had an air stream of 152 kPa directed towards the tip. Immediately after the procedure, the patient’s right cheek, periorbital region, temporal region and neck swelled up, without systemic symptoms. She was referred to the clinic of the Department of Oral Surgery of Kawasaki Medical School Hospital. She was alert without systemic symptoms or fever. Examination showed right facial and bilateral neck swelling with crepitus, and gas bubbles were confirmed by a computed tomogram of the head and neck (Fig. 1). No pneumothorax or pneumomediastinum was noted on chest radiographs. Oral cefditoren 300 mg/day was prescribed to prevent infection such as necrotizing fasciitis.4 The emphysema resolved completely
Fig. 1 Computed tomograms taken at the first consultation.
BJOM-055.QXD
3/16/01 5:33 PM
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Page 162
British Journal of Oral and Maxillofacial Surgery
in about 10 days. Carbon dioxide laser surgery has become the treatment of choice for outpatient dental and oral surgery. It has been reported to be safe, but 2 (0.9%) of 222 laser laryngoscopies developed emphysematous complications.5 This case may be the first report of iatrogenic subcutaneous emphysema after oral laser surgery. It should be kept in mind that emphysematous complications may occur during oral laser surgery, whenever compressed air is used inside the mouth. Tsuyoshi Hata, DDS, PhD Masaru Hosoda, DDS, PhD Department of Oral Surgery Kawasaki Medical School 577 Matsushima Kurashiki-shi Okayama 701-0192 Japan (Tel: +81 86 462 1111; Fax: +81 86 462 1199) REFERENCES 1. Heyman SN, Babayof I. Emphysematous complications in dentistry, 1960–1993: an illustrative case and review of the literature. Quintessence International 1995; 26; 535–543. 2. Monsour PA, Savage NW. Cervicofacial emphysema following dental procedures. Aust Dent J 1989; 34: 403–406. 3. Davies JM, Campbell LA. Fatal air embolism during dental implant surgery: a report of three cases. Can J Anaesth 1990; 37: 112–121. 4. Yamaoka M, Furusawa K, Uematsu T, Yasuda K. Early evaluation of necrotizing fasciitis with use of CT. J Craniomaxillofac Surg 1994; 22: 268–271. 5. Wetmore SJ, Key JM, Suen JY. Complications of laser surgery for laryngeal papillomatosis. Laryngoscope 1985; 95: 798–801.
doi: 1054/bjom.2000.0448, available online at http://www.idealibrary.com on
RE: McCreary CE, McCarten BE. Clinical management of oral lichen planus. Br J Oral Maxillofac Surg 1999; 37: 338–343 Sir, In relation to the article by McCreary and McCarten on oral lichen planus in the October issue of the Journal we think it is important that your readers are aware that since their article was accepted for publication of Cochrane systematic review has been completed on ‘interventions used in the treatment of lichen planus’.1 It is also important to note that the review is in electronic form and so is updated when new information becomes available. The aim of the Cochrane review was to evaluate the effectiveness and adverse effects of different therapies used in randomized controlled trials for the relief of symptomatic lichen planus by the use of meta analysis. Its other objective was to determine the quality of placebo-controlled clinical trial data available for the treatment of symptomatic lichen planus. Following extensive searching of the world literature and after requests to the pharmaceutical industry only nine randomized controlled trials were identified involving 192 patients. The results were reported as follows: ‘The nine interventions were grouped into four separate classes (cyclosporines,
retinoids, steroids and phototherapy) for comparison. No therapy was replicated exactly, the closest replication involved two trials using high and low dose cyclosporine mouthwash. Only trials recording the same outcomes in each therapeutic class were pooled. The largest number of pooled trials was three. Large odds ratios with very wide confidence intervals indicating a statistically significant treatment benefit were seen in all trials. However this has to be tempered by considerations of the small study sizes, the lack of replication, the difficulty in measuring outcome changes and the very high likelihood of publication bias. Only systemic agents were associated with treatment toxicities, all other side-effects were mild and mainly limited to local mucosal reactions. There is only weak evidence for the superiority of the assessed interventions over placebo for palliation of symptomatic oral lichen planus.’ Our review highlighted the need for larger placebo-controlled randomized trials in order to demonstrate an effective therapy. Clear diagnostic criteria as well as standardized outcome measures are essential if comparisons are to be made between treatments. It is therefore impossible at present to lay down evidence-based guidelines on the management of lichen planus. Dr. J. M. Zakrzewska M. Thornhill E. S.-Y. Chan Bart’s and The Royal London NHS Trust Department of Oral Medicine Turner Street London E1 2AD, UK REFERENCES 1. McCreary CE, McCarten BE. Clinical management of oral lichen planus. Br J Oral Maxillofac Surg 1999; 37: 338–343. 2. Chan ES-Y, Thornhill M, Zakrzewska J. Interventions for treating oral lichen planus (Cochrane Review). The Cochrane Library Oxford Update Software 1999 (Issue 2). doi: 1054/bjom.2000.0477, available online at http://www.idealibrary.com on
THE GREAT AURICULAR AND THE FACIAL NERVE: IS THERE A CORRELATION BETWEEN THE DIAMETER OF THESE NERVES? Sir, With a large parotid surgical practice in the Black Country, we have frequently been struck by an apparent correlation between the diameter of the great auricular nerve and the facial nerve. It appears that, on many occasions, finding a small and rather ‘delicate’ great auricular nerve correspons to subsequently finding a small and ‘delicate’ facial nerve, often with an atypical distribution of divisions or branches. It would appear the converse also holds true in that a robust great auricular nerve is correlated with a similarly robust facial nerve. It is difficult to explain these findings in view of the dissimilar nature of these two nerves. However, the correlation seems to be present more often than could be accounted for by chance alone. Our purpose in writing is to enquire as to whether any colleagues with large salivary gland practices have noticed this phenomenon.