- Email: [email protected]
Inverted papilloma: An analysis of 87 cases
902
CURRENT LITERATURE
mucous or cutaneous ulcer with denuded bone, lasting for more than 3 months. The total study group comprised 43 1 patients, 68% men and 32% women. The mean age for men was 64.3 years, and for women 66 years. In this number treated for malignant tumors, 21 osteoradionecroses were diagnosed in 19 patients (4.4%). This latter group of patients was studied in more detail with another group of 30 patients who had tooth extractions in connection with radiation therapy without development of osteoradionecrosis (NORN group). The patients were irradiated according to either conventional or superfractionation schemes. Osteoradionecrosis developed on average 12 months after cessation of radiotherapy with a time variation from 2 weeks to 34 months. Osteoradionecrosis, after extraction as well as spontaneously, usually appeared after higher radiation doses. The intensive short duration scheme (superfractionation) is thought to have a more pronounced effect on tumor cells with high mitotic activity without decreasing the ability to replicate in normal cells in the target volume. However, the findings also indicate that this type of radiotherapy increased the risk for ORN. The investigation confirmed that extractions before as well as after radiotherapy can cause ORN. The importance of an atraumatic extraction technique is emphasized. The risk factors for the development of osteoradionecrosis of the jaws are high age, high radiation dose, superfractionation, and the combination of tumor surgery and chemotherapy with traumatic tooth extraction.-M. COLLINS Reprint requests to Dr Widmark: Department of Oral Surgery, University of Gateberg, Sweden. Preoperative Screening For HIV Infection. Arch Surg 124:9, 1989
Fournier
This report surveyed 202 surgeons working in the New York metropolitan area for occupational risk of human immunodeficiency virus (HIV). The study involved three types of hospitals: a 500-bed tertiary care suburban hospital; two municipal hospitals in New York City where many patients are known intravenous drug abusers; and several voluntary hospitals in both urban and suburban areas. Fifty-four general surgeons, 97 specialists, and 51 general surgical residents were surveyed. Eighty-six percent of the surgeons reported one or more previous puncture injuries associated with the care of surgical patients during the previous year. Only 12% of the injuries had been reported to hospital health services. Seventy-six percent of all injuries occurred during surgery. Seventythree percent of injuries were self-inflicted while performing surgery. The most common anatomic site of injury was the nondominant hand (71%). The true prevalence of HIV infection of the hospitals surveyed is unknown. The HIV infection rate ranges from 0.32% in midwestem hospitals to 54% for some New York City institutions. Assuming that the prevalence of HIV infection in surgical patients is 5%, the author then estimates the 30-year risk of HIV seroconversion is less than 1% for 50% of the group surveyed. One percent to 2% for 25% of the group, 2% to 6% for 15% of the group, and more than 6% to 10% for the remainder.-D.R. EDWARDS Reprint requests to Dr Lowenfels: Department of Surgery, New York Medical College, Valhalla, NY 10595.
AM.
The aim of this study was to see if there is a benefit of routine human immunodeficiency virus (HIV) screening in the surgery patient. The identification of HIV-positive patients may lead to more careful techniques by surgeons and surgical assistants. Arguments against routine screening are as follows: 1) There are no data to support the idea that knowing the patient is HIV positive will promote carefulness and lower incidence of exposure. 2) Patient care is being influenced by the results. 3) Falsepositives distort the infection rate even when highly accurate tests are applied to low-risk populations. 4) Autonomy and confidentiality are not always adhered to. The risk of HIV infection after percutaneous exposure has been estimated at 0.5% to 0.9% based on frequency of seroconversion among health care workers. The frequency of exposure from glove puncture has been estimated as 1 in every 40 cases. Prevalence of high HIVinfected population, such as in New York City, makes the chance of treating a HIV-positive patient 2 in 100. Currently, two tests are available for HIV, the enzyme-linked immunosorbent assay (ELISA), which has many falsepositives. The Western blot has a greater specificity than ELISA. The reason for false-positives is that quality assurance procedures are not adhered to. The author concludes that a surgeon must decide to use routine HIV screening preoperatively based on location and patient population.-D.R. EDWARDS Reprint requests to Dr Foumier:
Frequency of Puncture Injuries in Surgeons and Estimated Risk of HIV Infection. Lowenfels AB. Arch Surg 124:10, 1989
Department Of Medicine, PO Box 016960 (R-103), University Of Miami School Of Medicine, Miami, FL 33101.
Inverted PapilIoma: An Analysis of 87 Cases. Lawson W, LeBenger J, Som P, et al. Laryngoscope 99:1117, 1989 In this report 87 cases of inverted papilloma are retrospectively reviewed during a 15-year period. A review of the literature and a brief history of this lesion are also presented. Inverted papilloma is a benign but locally aggressive sinonasal tumor that has been associated with malignant change. In the present study, 6% (5 of 87) of cases were found to be associated with malignancy. Current literature reports the incidence of malignant change to be anywhere from 2% to 53%. Most malignant cases are detected simultaneously, whereas the incidence of actual malignant transformation of previously biopsied lesions is relatively low (1.1%). Ten patients were treated by conservative means: polypectomy, Caldwell-Luc procedure, or external ethmoidectomy. Recurrence rate was 10% (1 of 10) in these patients. Previous reports give recurrence rates from 41% to 78% in patients treated by this modality. Seventy-five patients were treated with lateral rhinotomy and medial maxillectomy. Recurrence in these patients was 9% (7 of 75). Current reports state recurrence rates from 6% to 29% with this method of exoneration. The locations most frequently associated with recurrence, in decreasing frequency, are the sphenoid sinus, the lateral recess of the antrum, the posterior and supraorbital ethmoids, the frontal sinus, and the cribriform plate. The size of the tumor appears to be the most important factor in the development of recurrent disease following lateral rhinotomy. In conclusion, the authors suggest that this lesion responds well to conservative therapy in a small number of patients with limited extension tumor.-C.T. POWELL
903
CURRENT LITERATURE
Reprint requests to Dr Lawson: Department of Otolaryngology, Mount Sinai Medical Center, 1 Gustave L. Levy Pl, New York, NY 10029. AIDS-Related Changes in Dental Practice. Neidle EA. J Dent Educ 53525. 1989 In 1978, the American Dental Association developed some simple infection control guidelines to help protect dental personnel and patients from the transmission of hepatitis B. These guidelines are also assumed to protect against the human immunodeficiency virus (HIV). This article reports on the behavioral changes that dentists have made in complying with these infection control guidelines over the past few years, by comparing dental surveys taken in 1986 and 1988. A comparison of these surveys concluded that there was an increase in the use of gloves, eyewear, and gowns. The most significant increase was found to be in the use of gloves. Dentists were also more willing to treat HIV- and HBV-infected patients in 1988 than in 1986. The surveys had similar findings concerning the best location for treatment of infected patients. Dentists overwhelmingly felt that AIDS patients should be treated in special public health clinics. There was a much greater willingness to treat hepatitis B than to treat HIV-infected patients. Despite the increased compliance with infection control guidelines, the dental profession’s response to the situation has been wary, resentful, and uneasy. A number of concerns have been expressed by dentists. For example, many feel that gloves hamper their performance and that infection control is time consuming and expensive. The author further discusses the attitudes of practicing dentists regarding treating infected patients. Five points were listed that may account for the apprehension regarding the treatment of these patients. First, the dental profession sees itself as being at very high risk of infection. Second, dentists have guarded their right to decide whom, how, and when to treat, and they have resented OSHA’s interference. Third, dentists did not choose their profession to treat sick patients. Fourth, dentists are afraid that patients and staff will desert if it becomes known that their office treats HIV-infected patients. Fifth, dentists are fearful for themselves, their families, their practices, and their staff. The author concludes that dental schools should provide moral, intellectual, and scientific leadership concerning the AIDS epidemic.-M.E. OSEAS Reprint requests to Dr Neidle: American Dental Association, 211 E Chicago Ave, Chicago, IL 6061 l-2678.
Topical Silicone Gel: A New Treatment for Hypertrophic Scars. Ahn ST, Monafo WW, Mustue TA. Surgery 106:781. 1989 The authors present an alternative method for treatment of hypertrophic scars during their moderate to late maturation phase. Prospective clinical trials of silicone gel application that measured 3.5 mm in thickness (Q79119 Silastic gel sheeting, Dow Corning Corporation, Midland, MI) were conducted. Fourteen treated scars in 10 adults received application of the gel over an 8consecutive-week period. Control scars were monitored on adjacent sites and both test and control scars underwent photography, biopsy, and elastometric examination. All treated scars had at least a 12-hour-a-day application
period and all showed clinical as well as elastometric improvement in comparison with test scars. Gains continued after 4 weeks’ discontinuance of therapy. The mechanism of action of the silicone gel has not been determined, but preliminary indications rule out pressure as well as histologic incorporation of the material into the skin as possible explanations. The theory that the gel was simply delaying hypertrophy of the scar rather than preventing it was also addressed. Indications on this matter show persistent gains after discontinuance and improvement of even fully mature scars. In summary, the article proposes a promising method of hypertrophic scar treatment with clinical and laboratory data supportive as initial and extended improvement in scar appearance and elasticity is evidenced by silicone gel application.-G.B. WONG Reprint requests to Dr Mustoe: Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, Suite 17424, 1 Barnes Hospital Plaza, Saint Louis, MO 63110.
Vitamin C and Oral Health. Rubinoff AB, Latner PA, Pasut LA. Can Dent Assoc J 55:705, 1989 Although this article concentrates on vitamin C and it’s relationship to periodontal disease and healing, it is important to the oral and maxillofacial surgeon as well. As surgeons, we are concerned with overall patient health which obviously includes healing. This article reviews vitamin C’s role in health and healing, and emphasizes its importance in areas such as the production of collagen and its relationship to the strength of bones, cartilage, muscles, and vascular tissues. It also reviews recommended nutrient intakes for vitamin C for different ages as well as amounts of vitamin C in some common foods and signs of vitamin C deficiency.-D.M. MONASEBIAN Reprint requests to Dr RubinofE c/o Canadian Dental Journal, 1815 Alta Vista Dr, Ottawa, Ontario, Canada KlG3Y6.
The Contribution of the Nasopalatine Nerve to Sensation of the Hard Palate. Langford RJ. Br J Oral Maxillofac Surg 27:379, 1989 The author reports on a two-part study investigating the area of innervation of the hard palate by the nasopalatine nerve and the effects on sensation of nasopalatine nerve division. In the first part of the study, the mucosa of the hard palate anterior to the first molar tooth was tested in 20 patients with no previous maxillary surgery for light touch using Von Frey hairs and pinprick using a calibrated algesimeter before and after bilateral anterior (greater) palatine nerve block using 3% plain mepivacaine administered adjacent to the first molar tooth. In the second part of the study, patients undergoing a GA day stay procedure involving division of the incisive bundle were assessed pre- and postoperatively for palatal sensation as in the first part of the study. The results of this study suggest considerable overlap in the receptive fields of the nasopalatine and anterior palatine nerves and that the anterior palatine nerves are capable of providing normal sensation to the entire hard palatal mucosa. Thus, for surgical procedures under local anesthesia involving the anterior hard palate including the extraction of anterior maxillary teeth, anesthesia of both the nasopalatine nerve
CURRENT LITERATURE
mucous or cutaneous ulcer with denuded bone, lasting for more than 3 months. The total study group comprised 43 1 patients, 68% men and 32% women. The mean age for men was 64.3 years, and for women 66 years. In this number treated for malignant tumors, 21 osteoradionecroses were diagnosed in 19 patients (4.4%). This latter group of patients was studied in more detail with another group of 30 patients who had tooth extractions in connection with radiation therapy without development of osteoradionecrosis (NORN group). The patients were irradiated according to either conventional or superfractionation schemes. Osteoradionecrosis developed on average 12 months after cessation of radiotherapy with a time variation from 2 weeks to 34 months. Osteoradionecrosis, after extraction as well as spontaneously, usually appeared after higher radiation doses. The intensive short duration scheme (superfractionation) is thought to have a more pronounced effect on tumor cells with high mitotic activity without decreasing the ability to replicate in normal cells in the target volume. However, the findings also indicate that this type of radiotherapy increased the risk for ORN. The investigation confirmed that extractions before as well as after radiotherapy can cause ORN. The importance of an atraumatic extraction technique is emphasized. The risk factors for the development of osteoradionecrosis of the jaws are high age, high radiation dose, superfractionation, and the combination of tumor surgery and chemotherapy with traumatic tooth extraction.-M. COLLINS Reprint requests to Dr Widmark: Department of Oral Surgery, University of Gateberg, Sweden. Preoperative Screening For HIV Infection. Arch Surg 124:9, 1989
Fournier
This report surveyed 202 surgeons working in the New York metropolitan area for occupational risk of human immunodeficiency virus (HIV). The study involved three types of hospitals: a 500-bed tertiary care suburban hospital; two municipal hospitals in New York City where many patients are known intravenous drug abusers; and several voluntary hospitals in both urban and suburban areas. Fifty-four general surgeons, 97 specialists, and 51 general surgical residents were surveyed. Eighty-six percent of the surgeons reported one or more previous puncture injuries associated with the care of surgical patients during the previous year. Only 12% of the injuries had been reported to hospital health services. Seventy-six percent of all injuries occurred during surgery. Seventythree percent of injuries were self-inflicted while performing surgery. The most common anatomic site of injury was the nondominant hand (71%). The true prevalence of HIV infection of the hospitals surveyed is unknown. The HIV infection rate ranges from 0.32% in midwestem hospitals to 54% for some New York City institutions. Assuming that the prevalence of HIV infection in surgical patients is 5%, the author then estimates the 30-year risk of HIV seroconversion is less than 1% for 50% of the group surveyed. One percent to 2% for 25% of the group, 2% to 6% for 15% of the group, and more than 6% to 10% for the remainder.-D.R. EDWARDS Reprint requests to Dr Lowenfels: Department of Surgery, New York Medical College, Valhalla, NY 10595.
AM.
The aim of this study was to see if there is a benefit of routine human immunodeficiency virus (HIV) screening in the surgery patient. The identification of HIV-positive patients may lead to more careful techniques by surgeons and surgical assistants. Arguments against routine screening are as follows: 1) There are no data to support the idea that knowing the patient is HIV positive will promote carefulness and lower incidence of exposure. 2) Patient care is being influenced by the results. 3) Falsepositives distort the infection rate even when highly accurate tests are applied to low-risk populations. 4) Autonomy and confidentiality are not always adhered to. The risk of HIV infection after percutaneous exposure has been estimated at 0.5% to 0.9% based on frequency of seroconversion among health care workers. The frequency of exposure from glove puncture has been estimated as 1 in every 40 cases. Prevalence of high HIVinfected population, such as in New York City, makes the chance of treating a HIV-positive patient 2 in 100. Currently, two tests are available for HIV, the enzyme-linked immunosorbent assay (ELISA), which has many falsepositives. The Western blot has a greater specificity than ELISA. The reason for false-positives is that quality assurance procedures are not adhered to. The author concludes that a surgeon must decide to use routine HIV screening preoperatively based on location and patient population.-D.R. EDWARDS Reprint requests to Dr Foumier:
Frequency of Puncture Injuries in Surgeons and Estimated Risk of HIV Infection. Lowenfels AB. Arch Surg 124:10, 1989
Department Of Medicine, PO Box 016960 (R-103), University Of Miami School Of Medicine, Miami, FL 33101.
Inverted PapilIoma: An Analysis of 87 Cases. Lawson W, LeBenger J, Som P, et al. Laryngoscope 99:1117, 1989 In this report 87 cases of inverted papilloma are retrospectively reviewed during a 15-year period. A review of the literature and a brief history of this lesion are also presented. Inverted papilloma is a benign but locally aggressive sinonasal tumor that has been associated with malignant change. In the present study, 6% (5 of 87) of cases were found to be associated with malignancy. Current literature reports the incidence of malignant change to be anywhere from 2% to 53%. Most malignant cases are detected simultaneously, whereas the incidence of actual malignant transformation of previously biopsied lesions is relatively low (1.1%). Ten patients were treated by conservative means: polypectomy, Caldwell-Luc procedure, or external ethmoidectomy. Recurrence rate was 10% (1 of 10) in these patients. Previous reports give recurrence rates from 41% to 78% in patients treated by this modality. Seventy-five patients were treated with lateral rhinotomy and medial maxillectomy. Recurrence in these patients was 9% (7 of 75). Current reports state recurrence rates from 6% to 29% with this method of exoneration. The locations most frequently associated with recurrence, in decreasing frequency, are the sphenoid sinus, the lateral recess of the antrum, the posterior and supraorbital ethmoids, the frontal sinus, and the cribriform plate. The size of the tumor appears to be the most important factor in the development of recurrent disease following lateral rhinotomy. In conclusion, the authors suggest that this lesion responds well to conservative therapy in a small number of patients with limited extension tumor.-C.T. POWELL
903
CURRENT LITERATURE
Reprint requests to Dr Lawson: Department of Otolaryngology, Mount Sinai Medical Center, 1 Gustave L. Levy Pl, New York, NY 10029. AIDS-Related Changes in Dental Practice. Neidle EA. J Dent Educ 53525. 1989 In 1978, the American Dental Association developed some simple infection control guidelines to help protect dental personnel and patients from the transmission of hepatitis B. These guidelines are also assumed to protect against the human immunodeficiency virus (HIV). This article reports on the behavioral changes that dentists have made in complying with these infection control guidelines over the past few years, by comparing dental surveys taken in 1986 and 1988. A comparison of these surveys concluded that there was an increase in the use of gloves, eyewear, and gowns. The most significant increase was found to be in the use of gloves. Dentists were also more willing to treat HIV- and HBV-infected patients in 1988 than in 1986. The surveys had similar findings concerning the best location for treatment of infected patients. Dentists overwhelmingly felt that AIDS patients should be treated in special public health clinics. There was a much greater willingness to treat hepatitis B than to treat HIV-infected patients. Despite the increased compliance with infection control guidelines, the dental profession’s response to the situation has been wary, resentful, and uneasy. A number of concerns have been expressed by dentists. For example, many feel that gloves hamper their performance and that infection control is time consuming and expensive. The author further discusses the attitudes of practicing dentists regarding treating infected patients. Five points were listed that may account for the apprehension regarding the treatment of these patients. First, the dental profession sees itself as being at very high risk of infection. Second, dentists have guarded their right to decide whom, how, and when to treat, and they have resented OSHA’s interference. Third, dentists did not choose their profession to treat sick patients. Fourth, dentists are afraid that patients and staff will desert if it becomes known that their office treats HIV-infected patients. Fifth, dentists are fearful for themselves, their families, their practices, and their staff. The author concludes that dental schools should provide moral, intellectual, and scientific leadership concerning the AIDS epidemic.-M.E. OSEAS Reprint requests to Dr Neidle: American Dental Association, 211 E Chicago Ave, Chicago, IL 6061 l-2678.
Topical Silicone Gel: A New Treatment for Hypertrophic Scars. Ahn ST, Monafo WW, Mustue TA. Surgery 106:781. 1989 The authors present an alternative method for treatment of hypertrophic scars during their moderate to late maturation phase. Prospective clinical trials of silicone gel application that measured 3.5 mm in thickness (Q79119 Silastic gel sheeting, Dow Corning Corporation, Midland, MI) were conducted. Fourteen treated scars in 10 adults received application of the gel over an 8consecutive-week period. Control scars were monitored on adjacent sites and both test and control scars underwent photography, biopsy, and elastometric examination. All treated scars had at least a 12-hour-a-day application
period and all showed clinical as well as elastometric improvement in comparison with test scars. Gains continued after 4 weeks’ discontinuance of therapy. The mechanism of action of the silicone gel has not been determined, but preliminary indications rule out pressure as well as histologic incorporation of the material into the skin as possible explanations. The theory that the gel was simply delaying hypertrophy of the scar rather than preventing it was also addressed. Indications on this matter show persistent gains after discontinuance and improvement of even fully mature scars. In summary, the article proposes a promising method of hypertrophic scar treatment with clinical and laboratory data supportive as initial and extended improvement in scar appearance and elasticity is evidenced by silicone gel application.-G.B. WONG Reprint requests to Dr Mustoe: Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, Suite 17424, 1 Barnes Hospital Plaza, Saint Louis, MO 63110.
Vitamin C and Oral Health. Rubinoff AB, Latner PA, Pasut LA. Can Dent Assoc J 55:705, 1989 Although this article concentrates on vitamin C and it’s relationship to periodontal disease and healing, it is important to the oral and maxillofacial surgeon as well. As surgeons, we are concerned with overall patient health which obviously includes healing. This article reviews vitamin C’s role in health and healing, and emphasizes its importance in areas such as the production of collagen and its relationship to the strength of bones, cartilage, muscles, and vascular tissues. It also reviews recommended nutrient intakes for vitamin C for different ages as well as amounts of vitamin C in some common foods and signs of vitamin C deficiency.-D.M. MONASEBIAN Reprint requests to Dr RubinofE c/o Canadian Dental Journal, 1815 Alta Vista Dr, Ottawa, Ontario, Canada KlG3Y6.
The Contribution of the Nasopalatine Nerve to Sensation of the Hard Palate. Langford RJ. Br J Oral Maxillofac Surg 27:379, 1989 The author reports on a two-part study investigating the area of innervation of the hard palate by the nasopalatine nerve and the effects on sensation of nasopalatine nerve division. In the first part of the study, the mucosa of the hard palate anterior to the first molar tooth was tested in 20 patients with no previous maxillary surgery for light touch using Von Frey hairs and pinprick using a calibrated algesimeter before and after bilateral anterior (greater) palatine nerve block using 3% plain mepivacaine administered adjacent to the first molar tooth. In the second part of the study, patients undergoing a GA day stay procedure involving division of the incisive bundle were assessed pre- and postoperatively for palatal sensation as in the first part of the study. The results of this study suggest considerable overlap in the receptive fields of the nasopalatine and anterior palatine nerves and that the anterior palatine nerves are capable of providing normal sensation to the entire hard palatal mucosa. Thus, for surgical procedures under local anesthesia involving the anterior hard palate including the extraction of anterior maxillary teeth, anesthesia of both the nasopalatine nerve