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Fixation of mandibular fractures: A comparative analysis of rigid internal fixation and standard fixation techniques
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ABSTRACTS thors have reported patients with “multiple adenomas” resulting in hyperparathyroidism without chief cell hyperplasia. This paper reports the treatment of nine patients with primary HPT associated with double parathyroid gland enlargement. In four patients, marked asymmetry of two glands was noted, and the failure to recognize a second enlarged gland resulted in persistent or current hyperparathyroidism following the first surgery. In one of these patients, the second gland was enlarged in the mediastinal region. In five patients, initial excision of two enlarged glands resulted in normocalcemia with no recurrence. Only three patients fulfilled the histologic criteria of true double adenomas. The remainder showed multiglandular hypercellularity. The experience described in this article highlights the need for an increased awareness of hyperplasia or neoplasia affecting all parathyroid glands. This paper also addresses the importance of identifying all four glands in parathyroid explorations even if initial morphologic examination reveals a single adenoma. Relying solely on radiologic identification of an enlarged parathyroid gland may lead to a small but significant number of patients requiring re-exploration. Fixation of Mandibular Fractures: A Comparative Analysis of Rigid Internal Fixation and Standard Fixation Techniques. TB Dodson, DH Perrott, LB Ka-
ban, et al. J Oral Maxillofac
Surg 1990; 48:362-366
During the past 15 years, rigid internal fixation (RIF) has become a commonly used technique in the treatment of mandibular fractures. This procedure promotes rapid bone healing without the need for extended intermaxillary fixation (IMF). Some studies have suggested that RIF results in a lower complication rate in the treatment of mandible fractures. Despite these reputed advantages, there are few studies in the literature directly comparing the results of RIF with standard fixation using IMF plus wire osteosynthesis. This study is a prospective comparative study with nonrandomized controls. It compares the results of standard therapy (closed or open reduction) with 4 weeks of IMF to RIF. Ninety-two patients with 143 fractures were evaluated and treated. At the end of the study, the results were statistically analyzed to see whether there was any difference between the two groups. In this study, 83% of patients had a clinically successful outcome. There were no significant differences in postoperative complications between standard therapy and RIF. Patients with RIF had a higher frequency of malocclusion and facial nerve paralysis, but these may have been due to technical errors in the early part of the study. Two possible conclusions could be drawn from the fact that no significant differences were detected by these investigators: one is that there is truly no difference between the two treatment modalities; alternatively, the investigators had a small sample size. Statistically, at least 400 patients would have been necessary to detect a 10% difference in complication rates between the two groups. Although the two treatment modalities appear to be equivalent regarding outcome and complications, RIF offers significant advantages for some patients because IMF is not needed. Rigid internal fixation also
does not require significant postoperative patient cooperation or supervision. It is particularly appropriate in patients who require early mobilization or who have special nutritional requirements, such as alcoholics or patients with seizure disorders. Future studies comparing standard therapy and RIF are needed to see if this is a cost-effective treatment modality. Tracheostomy.
NJ Freezer, SW Beasley, CF Roberson. Arch Dis Child 1990; 65:123-126
This paper reviews 142 consecutive tracheostomies performed at a children’s hospital over a lo-year period to identify the current indication and morbidity associated with infant and pediatric tracheostomies. Trauma, subglottic stenosis, and craniofacial disorders were the most common reasons for which tracheostomies were performed. In patients successfully decannulated, the median period for a tracheostomy was 104 days. Sixty percent of patients were discharged from the hospital with their tracheostomies in place, and no patient was kept in the hospital because of a tracheostomy beyond 4 weeks. There were no tracheostomy-related deaths at home. Complications noted included tracheal granulomas and polyps, and tracheocutaneous fistulas. The authors concluded that tracheostomy is well tolerated in small children, with few significant complications. Although this article does not contain any new information for head and neck surgeons, its appearance in the pediatric literature should allay some of the fears of our colleagues as to the safety of this procedure. Caustic Injury of the Upper Gastrointestinal Tract in Adults: A Clinical and Endoscopic Study. C Sugawa,
CE Lucas. Surgery 1989; 106:802-807 Caustic injury of the upper gastrointestinal tract is multifactorial and varies with the extent of the injury. The authors evaluated 34 adult patients who had ingested caustic material over 8.5 years. Nineteen had accidental injury and 15 were attempted suicides. Ingested agents included hydrochloric acid, sulfuric acid, and strong alkali. All patients underwent early fiberoptic endoscopic evaluation. The severity and extent of injury varied according to the ingested agent. Three of the five patients with acid ingestion had esophageal injury, including superficial erythema and extended ulcers. Acid ingestion also produced full-thickness gastric ulcers in some patients. All 15 patients with strong alkali ingestion had esophageal injury. Most of these were confined to the esophagus. Superficial injuries healed uneventfully, whereas deeper ulcers resulted in stricture formation or the need for further gastrointestinal surgery (colon interposition, dilatation, etc). Lye tends to be odorless and tasteless and causes many pediatric caustic injuries. Solid alkaline substances may cause deeper injury, but tend to stick to the upper airway, causing oral and hypopharyngeal rather than esophageal injuries. Less concentrated but more easily swallowed liquid drain cleaners cause severe stomach and esophageal injuries. In contrast to lye, acids have offensive odors and bitter taste, and result in rapid vomiting if taken accidentally. This kind of fluid is found in
ABSTRACTS thors have reported patients with “multiple adenomas” resulting in hyperparathyroidism without chief cell hyperplasia. This paper reports the treatment of nine patients with primary HPT associated with double parathyroid gland enlargement. In four patients, marked asymmetry of two glands was noted, and the failure to recognize a second enlarged gland resulted in persistent or current hyperparathyroidism following the first surgery. In one of these patients, the second gland was enlarged in the mediastinal region. In five patients, initial excision of two enlarged glands resulted in normocalcemia with no recurrence. Only three patients fulfilled the histologic criteria of true double adenomas. The remainder showed multiglandular hypercellularity. The experience described in this article highlights the need for an increased awareness of hyperplasia or neoplasia affecting all parathyroid glands. This paper also addresses the importance of identifying all four glands in parathyroid explorations even if initial morphologic examination reveals a single adenoma. Relying solely on radiologic identification of an enlarged parathyroid gland may lead to a small but significant number of patients requiring re-exploration. Fixation of Mandibular Fractures: A Comparative Analysis of Rigid Internal Fixation and Standard Fixation Techniques. TB Dodson, DH Perrott, LB Ka-
ban, et al. J Oral Maxillofac
Surg 1990; 48:362-366
During the past 15 years, rigid internal fixation (RIF) has become a commonly used technique in the treatment of mandibular fractures. This procedure promotes rapid bone healing without the need for extended intermaxillary fixation (IMF). Some studies have suggested that RIF results in a lower complication rate in the treatment of mandible fractures. Despite these reputed advantages, there are few studies in the literature directly comparing the results of RIF with standard fixation using IMF plus wire osteosynthesis. This study is a prospective comparative study with nonrandomized controls. It compares the results of standard therapy (closed or open reduction) with 4 weeks of IMF to RIF. Ninety-two patients with 143 fractures were evaluated and treated. At the end of the study, the results were statistically analyzed to see whether there was any difference between the two groups. In this study, 83% of patients had a clinically successful outcome. There were no significant differences in postoperative complications between standard therapy and RIF. Patients with RIF had a higher frequency of malocclusion and facial nerve paralysis, but these may have been due to technical errors in the early part of the study. Two possible conclusions could be drawn from the fact that no significant differences were detected by these investigators: one is that there is truly no difference between the two treatment modalities; alternatively, the investigators had a small sample size. Statistically, at least 400 patients would have been necessary to detect a 10% difference in complication rates between the two groups. Although the two treatment modalities appear to be equivalent regarding outcome and complications, RIF offers significant advantages for some patients because IMF is not needed. Rigid internal fixation also
does not require significant postoperative patient cooperation or supervision. It is particularly appropriate in patients who require early mobilization or who have special nutritional requirements, such as alcoholics or patients with seizure disorders. Future studies comparing standard therapy and RIF are needed to see if this is a cost-effective treatment modality. Tracheostomy.
NJ Freezer, SW Beasley, CF Roberson. Arch Dis Child 1990; 65:123-126
This paper reviews 142 consecutive tracheostomies performed at a children’s hospital over a lo-year period to identify the current indication and morbidity associated with infant and pediatric tracheostomies. Trauma, subglottic stenosis, and craniofacial disorders were the most common reasons for which tracheostomies were performed. In patients successfully decannulated, the median period for a tracheostomy was 104 days. Sixty percent of patients were discharged from the hospital with their tracheostomies in place, and no patient was kept in the hospital because of a tracheostomy beyond 4 weeks. There were no tracheostomy-related deaths at home. Complications noted included tracheal granulomas and polyps, and tracheocutaneous fistulas. The authors concluded that tracheostomy is well tolerated in small children, with few significant complications. Although this article does not contain any new information for head and neck surgeons, its appearance in the pediatric literature should allay some of the fears of our colleagues as to the safety of this procedure. Caustic Injury of the Upper Gastrointestinal Tract in Adults: A Clinical and Endoscopic Study. C Sugawa,
CE Lucas. Surgery 1989; 106:802-807 Caustic injury of the upper gastrointestinal tract is multifactorial and varies with the extent of the injury. The authors evaluated 34 adult patients who had ingested caustic material over 8.5 years. Nineteen had accidental injury and 15 were attempted suicides. Ingested agents included hydrochloric acid, sulfuric acid, and strong alkali. All patients underwent early fiberoptic endoscopic evaluation. The severity and extent of injury varied according to the ingested agent. Three of the five patients with acid ingestion had esophageal injury, including superficial erythema and extended ulcers. Acid ingestion also produced full-thickness gastric ulcers in some patients. All 15 patients with strong alkali ingestion had esophageal injury. Most of these were confined to the esophagus. Superficial injuries healed uneventfully, whereas deeper ulcers resulted in stricture formation or the need for further gastrointestinal surgery (colon interposition, dilatation, etc). Lye tends to be odorless and tasteless and causes many pediatric caustic injuries. Solid alkaline substances may cause deeper injury, but tend to stick to the upper airway, causing oral and hypopharyngeal rather than esophageal injuries. Less concentrated but more easily swallowed liquid drain cleaners cause severe stomach and esophageal injuries. In contrast to lye, acids have offensive odors and bitter taste, and result in rapid vomiting if taken accidentally. This kind of fluid is found in