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Lemierre's syndrome: suppurative thrombophlebitis of the internal jugular vein secondary to oropharyngeal infection – An overview and case report of surgical management
Free poster abstracts numbered P1 - P255 / British Journal of Oral and Maxillofacial Surgery 54 (2016) e66–e153
P191 Should dental assessments routinely be carried out on patients with brain abscesses? Cynthia Goziem Ikwueke ∗ , David McAnerney, Vijay Santhanam Addenbrookes Introduction: A brain abscess is a rare but serious and potentially a life threatening condition. Presenting symptoms range from headaches to hemiparesis.Common sources of microbial infection are from either direct or indirect spread from ear- nose and throat, cardiac or pulmonary origin. Therefore these areas are routinely screened using CT head,chest X-ray and transthoracic echo. A recent study found that odontogenic infections could be accountable for up to 32% of cases. The aim of this service evaluation was to establish whether dental screening should be routinely carried out on patients with brain abscesses for which a source has not been identified. Methods: The data was collated using a search of diagnostic codes on a computerised system. This created a list of patients with a ‘brain abscess’ as the primary diagnosis, over a 12 month period. Results: 12 patients were assessed, of which the source of infection was not identified in 8 patients. Of the cases of unknown origin 7 patients had a negative transthoracic echo and chest x-ray while 3 underwent a dental assessment for which one was positive in dental origin. Conclusions: Although the incidence of brain abscesses is low, literature has shown that late source diagnosis causes an increase in morbidity and mortality. Due to this, with our positive diagnosis in a third of the patients assessed, we would recommend a dental assessment is carried out to rule out odontogenic causes in patients presenting with a brain abscess where no other source of infection is found. http://dx.doi.org/10.1016/j.bjoms.2016.11.184 P192 Medication-Related Osteonecrosis of the Jaw; a Case Series and Review of Treatment Modalities Paayal Shah ∗ , Shrina Nathwani, Robert Bunyan Luton and Dunstable Hospital NHS Foundation Trust Introduction: Medication related osteonecrosis of the jaw (MRONJ) adversely affects quality of life, producing significant morbidity. MRONJ is reported in patients taking oral and intravenous bisphosphonates as potent inhibitors of bone resorption. Concomitant use with newer medications such as RANKL inhibitors and anti-angiogenic medications also predispose to the development of jaw osteonecrosis. Aims: There is currently no standardised protocol for the medical management of MRONJ established in the UK. We
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review the current literature and present a cohort of patients treated successfully using part of the Delanian regime of pentoxyfylline and alpha tocopherol, traditionally used in the treatment of radiation induced fibrosis. Method: Prevention of MRONJ comprises of dental screening prior to medication commencement and avoidance of dento-alveolar surgery, or surgery with precautions. Adjunct medical therapies include hyperbaric oxygen, laser, and recombinant parathyroid hormone as well as chlorhexedine mouth rinses. We present a series of patients with either spontaneous or surgery induced osteonecrosis, treated with a combination of pentoxifylline and alpha tocopherol until remission. We also describe the use of an alternative peripheral vasodilator, naftidrofuryl oxalate, in two patients intolerant to pentoxyfylline. To our knowledge this is the first reported case of this drug being effectively used in the treatment of MRONJ. Results: Results show an improvement in symptoms or complete resolution in all patients. Conclusion: The successful initial case series warrants further controlled trials to determine if this can be used as an effective therapy for patients, and supports the ongoing work of the Cochrane Collaboration. http://dx.doi.org/10.1016/j.bjoms.2016.11.185 P193 Lemierre’s syndrome: suppurative thrombophlebitis of the internal jugular vein secondary to oropharyngeal infection – An overview and case report of surgical management James Sloane ∗ , Clifton Wan, Peyman Alam St Richards Hospital, Chichester Lemierre’s syndrome is a rare condition caused by acute oropharyngeal infection with secondary septic thrombophlebitis of the internal jugular vein and is characterized by metastatic infections in over 90% of cases. It typically affects young, otherwise healthy, individuals and has a mortality rate of up to 18%. A 54-year-old, previously fit and well lady presented with acute pain and inflammation in the left cervical soft tissue with sepsis following a sore throat. Ultrasound and CT scans confirmed an extensively thrombosed left internal jugular vein and Group A streptococci were isolated fromblood cultures. Despite 9 days of IV antibiotics and treatment dose low molecular weight heparin, her condition deteriorated with evidence of septic pulmonary emboli, rising inflammatory markers, symptoms of septic arthritis and severe pyrexias. At this point she was referred to our maxillofacial team and underwent ligation and excision of the left internal jugular vein containing the septic thrombus. Her clinical response to this intervention was rapid and she went on to make a full recovery.
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Free poster abstracts numbered P1 - P255 / British Journal of Oral and Maxillofacial Surgery 54 (2016) e66–e153
A previously common condition, Lemierre’s syndrome is now a rare phenomenon in the antibiotic era but given its significant morbidity, mortality and need for prompt treatment, it is an important condition for the Oral and Maxillofacial surgeon to be aware of. We present a case report, discuss the diagnostic criteria, relevant investigations, surgical techniqueand evidenced based rationale for treatment of this important syndrome.
P195
http://dx.doi.org/10.1016/j.bjoms.2016.11.186
Introduction: Solitary fibrous tumours (SFT) are rare, spindle cell neoplasms that are generally associated with serosal surfaces especially the pleura. Extra-pleural cases have been reported at sites including the abdomen, orbit, upper respiratory tract and oral cavity. SFTs are derived from mesenchymal cells and can develop following inflammation or injury to an area since spindle cells are a naturally occurring part of the body’s response to insult. There is little evidence however to support SFTs arising post-radiotherapy. We present a case whereby we hypothesise that an oral SFT arose following childhood radiotherapy. Case: A 35-year-old male presented with a 3-week history of a right retromolar trigone mass which was increasing in size and occasionally bled. He had Craniospinal radiotherapy aged 5 years for treatment of a Pinealoma. Clinically, the lesion was fixed, pedunculated and measured 2.5x1.5cms. Incisional biopsy suggested an extra-pleural solitary fibrous tumour due to the presence of submucosal spindle cell stromal tumour and the tumour cells being CD99, BCL2 and CD34 positive. CT neck/chest showed a well-defined avidly enhancing right retromolar trigone mass. Wide local laser excision of the lesion with a 10 mm clinical margin was performed. Local excision was complete and final histopathology confirmed the diagnosis of a benign extra-pleural solitary fibrous tumour. Conclusion: Solitary fibrous tumours particularly extrapleural SFTs are a very rare entity and in this case we hypothesise that it was in fact radiotherapy induced. Evidence does support malignant SFTs arising following therapeutic radiotherapy. We present our findings, management and review of current literature.
P194 The Gillies Temporal Incision - An alternative approach for Superficial Temporal Artery Biopsy George Markose ∗ , Richard M Graham Pennine Acute NHS Trust Introduction: Superficial temporal artery biopsies are harvested by surgeons of various specialties. The main complications of the procedure include a scar on the face, weakness of the temporal branch of the facial nerve, and harvest of disease free arterial segment. Standard preauricular techniques described for a superficial temporal artery biopsy fail to adequately address either of these issues. Method: We describe a modification of the Gillies temporal approach for a superficial temporal artery biopsy. Results: There are many advantages to this approach. Placing the incision away from the frontal branch of the facial nerve reduces the risk of nerve injury. The incision is placed with specific measurements and palpation and does not rely on a Doppler reading to identify the position of the vessel. In patients with significant giant cellarter it is thickening of the arterial wall and subsequent narrowing of the lumen, lead to reduced blood flow, making it poorly identified using Doppler. With the incision being at the junction of the frontal and parietal branch, the approach can be easily modified to harvest the parietal branch required. In addition, this incision avoids any scarring to the face as it is hidden within the hairline. Clinical Relevance: This modification of a well-known approach may reduce the risks associated with a superficial temporal artery biopsy. In GCA it is the palpable, rather than the audible vessel that should be biopsied. Hence a procedure based on measurements and palpation is likely to yield better results than one based on a Doppler. http://dx.doi.org/10.1016/j.bjoms.2016.11.187
Extra-pleural Solitary Fibrous Tumour - A Rare Entity in the Oral Cavity Probably Induced by Childhood Radiotherapy Susan Murray ∗ , Anna Friel, Barry O’Regan, Ibrahim Nawroz Fife OMFS Unit, Victoria Hospital, Kirkcaldy, Fife
http://dx.doi.org/10.1016/j.bjoms.2016.11.188 P196 Vascular lesions- History, Diagnosis, Classification and management. A case series Badrinarayanan Srinivasan ∗ , Emily Chan, James Sloane, Parkash Ramchandani, Konrad Wolfe, Madanagopalan Ethunandan University Hospital Southampton Introduction/Aim: Vascular lesions mainly affect the soft tissues with less than 1% occurring in the bone. In 1982, Mulliken and Glowacki classified Vascular lesions into Haemangiomas and Vascular malformations (VM). Vascular
P191 Should dental assessments routinely be carried out on patients with brain abscesses? Cynthia Goziem Ikwueke ∗ , David McAnerney, Vijay Santhanam Addenbrookes Introduction: A brain abscess is a rare but serious and potentially a life threatening condition. Presenting symptoms range from headaches to hemiparesis.Common sources of microbial infection are from either direct or indirect spread from ear- nose and throat, cardiac or pulmonary origin. Therefore these areas are routinely screened using CT head,chest X-ray and transthoracic echo. A recent study found that odontogenic infections could be accountable for up to 32% of cases. The aim of this service evaluation was to establish whether dental screening should be routinely carried out on patients with brain abscesses for which a source has not been identified. Methods: The data was collated using a search of diagnostic codes on a computerised system. This created a list of patients with a ‘brain abscess’ as the primary diagnosis, over a 12 month period. Results: 12 patients were assessed, of which the source of infection was not identified in 8 patients. Of the cases of unknown origin 7 patients had a negative transthoracic echo and chest x-ray while 3 underwent a dental assessment for which one was positive in dental origin. Conclusions: Although the incidence of brain abscesses is low, literature has shown that late source diagnosis causes an increase in morbidity and mortality. Due to this, with our positive diagnosis in a third of the patients assessed, we would recommend a dental assessment is carried out to rule out odontogenic causes in patients presenting with a brain abscess where no other source of infection is found. http://dx.doi.org/10.1016/j.bjoms.2016.11.184 P192 Medication-Related Osteonecrosis of the Jaw; a Case Series and Review of Treatment Modalities Paayal Shah ∗ , Shrina Nathwani, Robert Bunyan Luton and Dunstable Hospital NHS Foundation Trust Introduction: Medication related osteonecrosis of the jaw (MRONJ) adversely affects quality of life, producing significant morbidity. MRONJ is reported in patients taking oral and intravenous bisphosphonates as potent inhibitors of bone resorption. Concomitant use with newer medications such as RANKL inhibitors and anti-angiogenic medications also predispose to the development of jaw osteonecrosis. Aims: There is currently no standardised protocol for the medical management of MRONJ established in the UK. We
e131
review the current literature and present a cohort of patients treated successfully using part of the Delanian regime of pentoxyfylline and alpha tocopherol, traditionally used in the treatment of radiation induced fibrosis. Method: Prevention of MRONJ comprises of dental screening prior to medication commencement and avoidance of dento-alveolar surgery, or surgery with precautions. Adjunct medical therapies include hyperbaric oxygen, laser, and recombinant parathyroid hormone as well as chlorhexedine mouth rinses. We present a series of patients with either spontaneous or surgery induced osteonecrosis, treated with a combination of pentoxifylline and alpha tocopherol until remission. We also describe the use of an alternative peripheral vasodilator, naftidrofuryl oxalate, in two patients intolerant to pentoxyfylline. To our knowledge this is the first reported case of this drug being effectively used in the treatment of MRONJ. Results: Results show an improvement in symptoms or complete resolution in all patients. Conclusion: The successful initial case series warrants further controlled trials to determine if this can be used as an effective therapy for patients, and supports the ongoing work of the Cochrane Collaboration. http://dx.doi.org/10.1016/j.bjoms.2016.11.185 P193 Lemierre’s syndrome: suppurative thrombophlebitis of the internal jugular vein secondary to oropharyngeal infection – An overview and case report of surgical management James Sloane ∗ , Clifton Wan, Peyman Alam St Richards Hospital, Chichester Lemierre’s syndrome is a rare condition caused by acute oropharyngeal infection with secondary septic thrombophlebitis of the internal jugular vein and is characterized by metastatic infections in over 90% of cases. It typically affects young, otherwise healthy, individuals and has a mortality rate of up to 18%. A 54-year-old, previously fit and well lady presented with acute pain and inflammation in the left cervical soft tissue with sepsis following a sore throat. Ultrasound and CT scans confirmed an extensively thrombosed left internal jugular vein and Group A streptococci were isolated fromblood cultures. Despite 9 days of IV antibiotics and treatment dose low molecular weight heparin, her condition deteriorated with evidence of septic pulmonary emboli, rising inflammatory markers, symptoms of septic arthritis and severe pyrexias. At this point she was referred to our maxillofacial team and underwent ligation and excision of the left internal jugular vein containing the septic thrombus. Her clinical response to this intervention was rapid and she went on to make a full recovery.
e132
Free poster abstracts numbered P1 - P255 / British Journal of Oral and Maxillofacial Surgery 54 (2016) e66–e153
A previously common condition, Lemierre’s syndrome is now a rare phenomenon in the antibiotic era but given its significant morbidity, mortality and need for prompt treatment, it is an important condition for the Oral and Maxillofacial surgeon to be aware of. We present a case report, discuss the diagnostic criteria, relevant investigations, surgical techniqueand evidenced based rationale for treatment of this important syndrome.
P195
http://dx.doi.org/10.1016/j.bjoms.2016.11.186
Introduction: Solitary fibrous tumours (SFT) are rare, spindle cell neoplasms that are generally associated with serosal surfaces especially the pleura. Extra-pleural cases have been reported at sites including the abdomen, orbit, upper respiratory tract and oral cavity. SFTs are derived from mesenchymal cells and can develop following inflammation or injury to an area since spindle cells are a naturally occurring part of the body’s response to insult. There is little evidence however to support SFTs arising post-radiotherapy. We present a case whereby we hypothesise that an oral SFT arose following childhood radiotherapy. Case: A 35-year-old male presented with a 3-week history of a right retromolar trigone mass which was increasing in size and occasionally bled. He had Craniospinal radiotherapy aged 5 years for treatment of a Pinealoma. Clinically, the lesion was fixed, pedunculated and measured 2.5x1.5cms. Incisional biopsy suggested an extra-pleural solitary fibrous tumour due to the presence of submucosal spindle cell stromal tumour and the tumour cells being CD99, BCL2 and CD34 positive. CT neck/chest showed a well-defined avidly enhancing right retromolar trigone mass. Wide local laser excision of the lesion with a 10 mm clinical margin was performed. Local excision was complete and final histopathology confirmed the diagnosis of a benign extra-pleural solitary fibrous tumour. Conclusion: Solitary fibrous tumours particularly extrapleural SFTs are a very rare entity and in this case we hypothesise that it was in fact radiotherapy induced. Evidence does support malignant SFTs arising following therapeutic radiotherapy. We present our findings, management and review of current literature.
P194 The Gillies Temporal Incision - An alternative approach for Superficial Temporal Artery Biopsy George Markose ∗ , Richard M Graham Pennine Acute NHS Trust Introduction: Superficial temporal artery biopsies are harvested by surgeons of various specialties. The main complications of the procedure include a scar on the face, weakness of the temporal branch of the facial nerve, and harvest of disease free arterial segment. Standard preauricular techniques described for a superficial temporal artery biopsy fail to adequately address either of these issues. Method: We describe a modification of the Gillies temporal approach for a superficial temporal artery biopsy. Results: There are many advantages to this approach. Placing the incision away from the frontal branch of the facial nerve reduces the risk of nerve injury. The incision is placed with specific measurements and palpation and does not rely on a Doppler reading to identify the position of the vessel. In patients with significant giant cellarter it is thickening of the arterial wall and subsequent narrowing of the lumen, lead to reduced blood flow, making it poorly identified using Doppler. With the incision being at the junction of the frontal and parietal branch, the approach can be easily modified to harvest the parietal branch required. In addition, this incision avoids any scarring to the face as it is hidden within the hairline. Clinical Relevance: This modification of a well-known approach may reduce the risks associated with a superficial temporal artery biopsy. In GCA it is the palpable, rather than the audible vessel that should be biopsied. Hence a procedure based on measurements and palpation is likely to yield better results than one based on a Doppler. http://dx.doi.org/10.1016/j.bjoms.2016.11.187
Extra-pleural Solitary Fibrous Tumour - A Rare Entity in the Oral Cavity Probably Induced by Childhood Radiotherapy Susan Murray ∗ , Anna Friel, Barry O’Regan, Ibrahim Nawroz Fife OMFS Unit, Victoria Hospital, Kirkcaldy, Fife
http://dx.doi.org/10.1016/j.bjoms.2016.11.188 P196 Vascular lesions- History, Diagnosis, Classification and management. A case series Badrinarayanan Srinivasan ∗ , Emily Chan, James Sloane, Parkash Ramchandani, Konrad Wolfe, Madanagopalan Ethunandan University Hospital Southampton Introduction/Aim: Vascular lesions mainly affect the soft tissues with less than 1% occurring in the bone. In 1982, Mulliken and Glowacki classified Vascular lesions into Haemangiomas and Vascular malformations (VM). Vascular