- Email: [email protected]
Long-term quality of life after ablative intraoral tumour surgery
532 fresh cadavers were injected systemically. The temporal region was then dissected and the layers examined both macroscopically and radiographically. It was determined that the vascular supply to the area was derived from multiple arteries including the superficial temporal, middle temporal, deep temporal, posterior auricular, transverse facial, zygomaticoorbital, zygomaticotemporal, zygomaticofacial, and middle meningeal. The temporal region was divided into four layers with the arterial supply. They are skin and superficial fascia-superficial temporal artery; loose areolar fascia-superficial temporal and middle meningeal arteries; deep temporal fascia-middle temporal, zygomaticotemporal, zygomaticofacial, and transverse facial arteries; and temporal muscle-deep and middle temporal arteries. The four layers have a network of anastomoses that are also described. Finally, based on this vascular anatomy, the authors review the various flaps that are derived from each layer and the proper elevation techniques based on this anatomy.-M.J. RISSER Reprint requests to Dr Nakajima: Associate Professor, Department of Plastic and Reconstructive Surgery, School of Medicine, Keio University, 35, Shinanomachi, Shinjuku-ku, Tokyo 160, Japan Increase in Length of Experimental Skin Flaps that Survive with Dibutyryl Cyclic AMP. Kusumoto K, Isshiki N, Suzuki S, et al. Stand J Plast Reconstr Hand Surg 29:97, 1995 In this study, the authors assess the effect of dibutyryl cyclic AMP (DB-CAMP) on extending the length of surviving experimental flaps in rabbits by examining its distribution after intravenous injection and measuring changes in the blood flow within the flap. Using high performance liquid chromatography and laser Doppler Aowmetry techniques, the authors show that DB-CAMP reached the critical area of circulation within the skin flap, increased the blood flow within this area, and extended the length of flap that survived. The mechanism of increasing the length of surviving flap by DB-CAMP is based on its ability to increase cardiac output and dilate peripheral vessels, thus improving blood flow to the flap.-C.E. PEOPLES Reprint requests to Dr Kusumoto: Department of Plastic and Reconstructive Surgery, School of Medicine, Kyoto University, Kyoto, Japan. Detection of Premalignant Oral Lesions: A 10 Year Retrospective Study in Alberta. Peters E, McGaw WT. J Canad Dent Ass 61:775, 1995 A comprehensive review of all oral premalignant lesions and squamous cell carcinomas (SCC) diagnosed and biopsied by the oral pathology diagnostic service at the University of Alberta over two sequential 5-year periods (1984 to 1988 and 1989 to 1993) was undertaken. A total of 6,089 and 9,284 lesions, respectively, were examined. There was virtually no change in SCCs, as a percentage of total lesions diagnosed, between the two periods (0.71% in 1984 to 1988 and 0.69% in 1989 to 1993). There was a global increase in premalignant lesions, from 0.94% of total lesions in the first 5-year period to 1.23% in the second. This disproportionate increase in the number of premalignant biopsies conducted in 1989 through 1993 relative to the number of SCC biopsies suggests an improvement in the detection of oral premalignancy by dentists.-G.H. SPERBER
CURRENT LITERATURE Reprints to Dr Peters: 5085 Dentistry Pharmacy Centre, University of Alberta, Edmonton, Alta, T6G 2N8, Canada. When Bleeding Complicates Oral Anticoagulant apy. Brigden ML. Postgrad Med 98:153, 1995.
Ther-
The risk-benefit ratio of oral anticoagulant therapy is a particular concern in the 1990s because the indications for use are rapidly expanding. This article reviews the use of anticoagulation, discusses monitoring the intensity of oral anticoagulant therapy by using the International Normalized Ratio (INR) as a tool of evaluation. A wide variety of thromboplastins have been introduced so prothrombin time (PT) ratios are no longer interchangable between laboratories. The INR overcomes this by relating the patient’s prothrombin time ratio to the International Sensitivity Index (ISI) of the particular product being used. The formula for calculation is INR = (Patient’s PT [seconds] + mean normal PT [seconds]) x ISI. The standard INR range for most indications is 2 to 3, and the therapeutic range will be identical from country to country and laboratory to laboratory. By keeping patients in this range, the incidence of bleeding can be reduced. The elderly (over 65 years of age) are more sensitive to the effects of warfarin and require lower doses. A major risk factor for unexpected oscillations in control is caused by patient noncompliance. A patient may miss one or two doses, which causes the INR to register low, causing the physician to increase the dosage. The authors discusses factors that increase the risk of bleeding complications, topics that need to be reviewed with patients before placing them on anticoagulant therapy, drugs that increase or decrease the effect of warfarin sodium products (especially aspirin and nonsteroidal antiinflammatory drugs), and a list of dietary items that contain high concentrations of Vitamin K. The author presents seven cases in which patient management lessons are highlighted.-R.E. ALEXANDER Reprint requests to Dr Brigden: Metro-McNair Clinical Laboratories, 4489 Viewmont Ave, Victoria, BC, Canada VSZ 5K8. Long-Term Quality of Life after Ablative Intraoral Tumour Surgery. Schliephake H, Neukam FW, Schmelzeisen R, et al. Journal of Cranio Maxillo-Facial Surgery 23:243, 1995. The authors have carried out a retrospective study to determine the long-term quality of life of patients who had undergone intraoral tumor resection. The group consisted of 135, who had malignant tumors in the floor of the mouth and adjacent areas. A standard questionnaire was used to determine the physical functional status, the psychological status and social functioning of cancer patients (Schipper et al, 1984). The results were related to the T stage, the size and the location of the intraoral soft tissue defect, the mode of reconstruction and the postoperative interval. There was a significant correlation of the Functional Living Index-Cancer (FLIC) score with the Karnowsky-Index. The FLIC was devised in 1984 by Schipper. It contained 22 questions referring to the physical functional status, the psychological status and the social functioning of cancer patients. Before evaluation the questionnaire was explained and patients were instructed to answer all questions by marking with a vertical line that point on a horizontal line of a linear visual analogue scale, that best represented their response. There was a scale ranging from 1-7, with higher numbers representing a higher quality of life. The values were significantly lower in the high T-stages. The factors that were found to be crucial for
CURRENT
533
LITERATURE
quality of life postoperatively were, the location of the soft tissue defect, the type of soft tissue reconstruction and discontinuous resections of the mandible. The bilateral defects with loss of mandibular continuity and myocutaneous flap reconstructions showed significantly lower FLIC values. There was no increase in the FLIC values following reconstruction of the mandibular defect. Dysphagia, reflux of food through the lips and nose during meals, decreased appetite, and persistent pain significantly decreased the FLIC scores. The authors conclude that the FLIC is suitable for the determination of life quality in cancer patients because the score has shown the potential to reflect the differences in postoperative life quality with regard to surgical procedures and functional sequelae.-St J CREAN
and 62% preferred to use an obturator. The most common method used was the temporalis flap (53%), microvascular flaps (26%) palatal rotation flap (11%) and other methods (10%) that included the buccal fat pad flap, the deltopectoral flap, pectoralis major, the masseter crossoverflap and tongue flaps. Only 65% of surgeons have access to the services of a restorative dentist, which seemed to influence the choice of 19% of surgeons as to whether to reconstruct surgically or by prosthetic means. A total of 43% use implant fixtures in maxillectomy casesof which the Branemark system (39%) was the most popular. The authors conclude that there appears to be little consensusabout the most effective method of oral rehabilitation after maxillectomy.-St J CREAN
Reprintrequeststo
Reprint requests to Dr Ali: Maxillofacial NHS Trust, Swansea, SA6 6NL, England.
Plunging Ranulas in Children. Tavill MA, Poje CP, Wetmore RF, et al. Ann Otol Rhino1 Laryngol 104:405, 1995.
Is Your Patient Using Cocaine?: Clinical Signs That Should Raise Suspicion. Warner EA. Postgrad Med 98: 173, 1995.
Dr Schliephake: Dept of Oral and Maxillofacial Surgery, University Medical School, Konstanty-Gutschow Strasse 8, d-30625 Hannover, Germany.
Ranulas are mucoceles originating from the sublingual gland. Two forms exist. They are the simple intraoral ranula, and the plunging (cervical or diving) ranula. The latter are much rarer than the former. Simple ranulas appear as bluish, superficial, slow-growing and nontender masses with true epithelial lining. It is usually unilateral. A plunging ranula is a soft, painless, ballottable cervical mass, representing a pseudocyst without an epithelial lining that is composed of compressed fibrous connective tissue. They arise secondary to trauma to the sublingual gland or duct leading to obstruction. They may arise in patients treated for simple ranulas in whom the sublingual gland was not removed. Magnetic resonance imaging (MRI) is extremely helpful in narrowing the differential diagnosis and delineating the extent of the lesion. Sialography and ultrasound provide minimal information. Multiple treatment approaches have had variable results. They include marsupialization, sublingual gland excision, ranula excision with or without sublingual gland excision, scleral therapy and irradiation. To prevent recurrence, the sublingual gland must be removed.-G.H. SPERBER Reprint requests to Dr Wetmore: Division gology, Children’s Hospital of Philadelphia Blvd, Philadelphia, PA 19104.4399.
of Pediatric Otolaryn34 St and Civic Center
Maxillectomy-To Reconstruct or Obturate? Results of a United Kingdom Survey of Oral and Maxillofacial Surgeons. Ali A, Fardy M, Patton DW. Br J of Oral and Maxillofacial Surgery 33:207, 1995 Postmaxillectomy defect reconstruction remains a controversial subject. The choice lies between primary surgical reconstruction or prosthetic rehabilitation with an obturator. Although various surgical techniques have been advocated for reconstruction including the temporalis flap, the osteocutaneous scapula flap, and vascularised free flaps many clinicians favour the use of obturators. A questionnaire was designed to assess the current practices of oral and maxillofacial surgeons in the UK, after resection of the maxilla for malignant disease.A total of 257 questionnaires were distributed of which 148 were completed (response rate of 58%). Maxillectomies were carried out by 83% of surgeons; most surgeons performed 1 to 5 cases per year; 38% of surgeons do reconstruct surgically, but only in 10% of cases
Unit,
Morriston
Hospital
The use of cocaine is on the rise and patients who seek care do not always report cocaine use. Primary care doctors need to be aware of the symptoms and signs of cocaine use. One third of trauma patients in urban hospitals have cocaine metabolites in their urine. Cocaine is used in several forms. Chewing the leaves has rarely been associatedwith any serious medical complications. The leaves can be processedinto a powder that can be absorbed through any mucous membrane, or injected (it cannot be smoked because it decomposes at high temperatures). Crack is made by mixing the powder with baking soda and water, then heating the mixture until the base precipitates into a soft mass. Freebase is prepared by mixing the powder with a solvent (eg ether) and a base (eg ammonia), then extracting the alkaloid base from the ether layer. Crack and freebase melt at a much lower temperature and thus can be smoked. Nasal “snorting” is the most common form of use (90% of users), about 33% smoke crack, and less than 10% inject the drug. Crack causes most hospitalizations. The delay in onset varies depending on the form of use (from 6 to 8 seconds when smoked to 30 to 60 minutes when snorted nasally). The serum half-life is about 1 hour. The drug does not show up in blood tests very long, but metabolites (especially Bezoylecgonine) show up in the urine for up to 48 hours. High level users may test positive for up to 3 weeks. Urine testing is generally reliable, with few false positives. Escalating dosages are required to achieve the same euphoric effects. Complications of use can include appetite suppression, weight loss, dysphoria, status epilepticus seizures, cardiac arrhythmias, hypertension, tachycardia, cerebral hemorrhage, myocardial infarction (possibly from coronary artery spasms), and psychiatric complications that include a depression-like state, aggravated thought patterns, and worsening of any attention-deficit hyperactivity disorder. Pulmonary complications can include worsening asthma, a chronic cough and black sputum. Spontaneous pneumothorax can occur in users who perform Valsalva’s maneuvers after inhaling cocaine. Management of addiction is mainly through group and individual counseling. No pharmacologic treatment has been found that significantly and consistently reduces the urge to use cocaine.-
Reprint requests to Dr Warner: of Medicine, Box 19, 12901 33612-4799.
University of South Florida College Bruce B. Downs Blvd, Tampa, FL
CURRENT LITERATURE Reprints to Dr Peters: 5085 Dentistry Pharmacy Centre, University of Alberta, Edmonton, Alta, T6G 2N8, Canada. When Bleeding Complicates Oral Anticoagulant apy. Brigden ML. Postgrad Med 98:153, 1995.
Ther-
The risk-benefit ratio of oral anticoagulant therapy is a particular concern in the 1990s because the indications for use are rapidly expanding. This article reviews the use of anticoagulation, discusses monitoring the intensity of oral anticoagulant therapy by using the International Normalized Ratio (INR) as a tool of evaluation. A wide variety of thromboplastins have been introduced so prothrombin time (PT) ratios are no longer interchangable between laboratories. The INR overcomes this by relating the patient’s prothrombin time ratio to the International Sensitivity Index (ISI) of the particular product being used. The formula for calculation is INR = (Patient’s PT [seconds] + mean normal PT [seconds]) x ISI. The standard INR range for most indications is 2 to 3, and the therapeutic range will be identical from country to country and laboratory to laboratory. By keeping patients in this range, the incidence of bleeding can be reduced. The elderly (over 65 years of age) are more sensitive to the effects of warfarin and require lower doses. A major risk factor for unexpected oscillations in control is caused by patient noncompliance. A patient may miss one or two doses, which causes the INR to register low, causing the physician to increase the dosage. The authors discusses factors that increase the risk of bleeding complications, topics that need to be reviewed with patients before placing them on anticoagulant therapy, drugs that increase or decrease the effect of warfarin sodium products (especially aspirin and nonsteroidal antiinflammatory drugs), and a list of dietary items that contain high concentrations of Vitamin K. The author presents seven cases in which patient management lessons are highlighted.-R.E. ALEXANDER Reprint requests to Dr Brigden: Metro-McNair Clinical Laboratories, 4489 Viewmont Ave, Victoria, BC, Canada VSZ 5K8. Long-Term Quality of Life after Ablative Intraoral Tumour Surgery. Schliephake H, Neukam FW, Schmelzeisen R, et al. Journal of Cranio Maxillo-Facial Surgery 23:243, 1995. The authors have carried out a retrospective study to determine the long-term quality of life of patients who had undergone intraoral tumor resection. The group consisted of 135, who had malignant tumors in the floor of the mouth and adjacent areas. A standard questionnaire was used to determine the physical functional status, the psychological status and social functioning of cancer patients (Schipper et al, 1984). The results were related to the T stage, the size and the location of the intraoral soft tissue defect, the mode of reconstruction and the postoperative interval. There was a significant correlation of the Functional Living Index-Cancer (FLIC) score with the Karnowsky-Index. The FLIC was devised in 1984 by Schipper. It contained 22 questions referring to the physical functional status, the psychological status and the social functioning of cancer patients. Before evaluation the questionnaire was explained and patients were instructed to answer all questions by marking with a vertical line that point on a horizontal line of a linear visual analogue scale, that best represented their response. There was a scale ranging from 1-7, with higher numbers representing a higher quality of life. The values were significantly lower in the high T-stages. The factors that were found to be crucial for
CURRENT
533
LITERATURE
quality of life postoperatively were, the location of the soft tissue defect, the type of soft tissue reconstruction and discontinuous resections of the mandible. The bilateral defects with loss of mandibular continuity and myocutaneous flap reconstructions showed significantly lower FLIC values. There was no increase in the FLIC values following reconstruction of the mandibular defect. Dysphagia, reflux of food through the lips and nose during meals, decreased appetite, and persistent pain significantly decreased the FLIC scores. The authors conclude that the FLIC is suitable for the determination of life quality in cancer patients because the score has shown the potential to reflect the differences in postoperative life quality with regard to surgical procedures and functional sequelae.-St J CREAN
and 62% preferred to use an obturator. The most common method used was the temporalis flap (53%), microvascular flaps (26%) palatal rotation flap (11%) and other methods (10%) that included the buccal fat pad flap, the deltopectoral flap, pectoralis major, the masseter crossoverflap and tongue flaps. Only 65% of surgeons have access to the services of a restorative dentist, which seemed to influence the choice of 19% of surgeons as to whether to reconstruct surgically or by prosthetic means. A total of 43% use implant fixtures in maxillectomy casesof which the Branemark system (39%) was the most popular. The authors conclude that there appears to be little consensusabout the most effective method of oral rehabilitation after maxillectomy.-St J CREAN
Reprintrequeststo
Reprint requests to Dr Ali: Maxillofacial NHS Trust, Swansea, SA6 6NL, England.
Plunging Ranulas in Children. Tavill MA, Poje CP, Wetmore RF, et al. Ann Otol Rhino1 Laryngol 104:405, 1995.
Is Your Patient Using Cocaine?: Clinical Signs That Should Raise Suspicion. Warner EA. Postgrad Med 98: 173, 1995.
Dr Schliephake: Dept of Oral and Maxillofacial Surgery, University Medical School, Konstanty-Gutschow Strasse 8, d-30625 Hannover, Germany.
Ranulas are mucoceles originating from the sublingual gland. Two forms exist. They are the simple intraoral ranula, and the plunging (cervical or diving) ranula. The latter are much rarer than the former. Simple ranulas appear as bluish, superficial, slow-growing and nontender masses with true epithelial lining. It is usually unilateral. A plunging ranula is a soft, painless, ballottable cervical mass, representing a pseudocyst without an epithelial lining that is composed of compressed fibrous connective tissue. They arise secondary to trauma to the sublingual gland or duct leading to obstruction. They may arise in patients treated for simple ranulas in whom the sublingual gland was not removed. Magnetic resonance imaging (MRI) is extremely helpful in narrowing the differential diagnosis and delineating the extent of the lesion. Sialography and ultrasound provide minimal information. Multiple treatment approaches have had variable results. They include marsupialization, sublingual gland excision, ranula excision with or without sublingual gland excision, scleral therapy and irradiation. To prevent recurrence, the sublingual gland must be removed.-G.H. SPERBER Reprint requests to Dr Wetmore: Division gology, Children’s Hospital of Philadelphia Blvd, Philadelphia, PA 19104.4399.
of Pediatric Otolaryn34 St and Civic Center
Maxillectomy-To Reconstruct or Obturate? Results of a United Kingdom Survey of Oral and Maxillofacial Surgeons. Ali A, Fardy M, Patton DW. Br J of Oral and Maxillofacial Surgery 33:207, 1995 Postmaxillectomy defect reconstruction remains a controversial subject. The choice lies between primary surgical reconstruction or prosthetic rehabilitation with an obturator. Although various surgical techniques have been advocated for reconstruction including the temporalis flap, the osteocutaneous scapula flap, and vascularised free flaps many clinicians favour the use of obturators. A questionnaire was designed to assess the current practices of oral and maxillofacial surgeons in the UK, after resection of the maxilla for malignant disease.A total of 257 questionnaires were distributed of which 148 were completed (response rate of 58%). Maxillectomies were carried out by 83% of surgeons; most surgeons performed 1 to 5 cases per year; 38% of surgeons do reconstruct surgically, but only in 10% of cases
Unit,
Morriston
Hospital
The use of cocaine is on the rise and patients who seek care do not always report cocaine use. Primary care doctors need to be aware of the symptoms and signs of cocaine use. One third of trauma patients in urban hospitals have cocaine metabolites in their urine. Cocaine is used in several forms. Chewing the leaves has rarely been associatedwith any serious medical complications. The leaves can be processedinto a powder that can be absorbed through any mucous membrane, or injected (it cannot be smoked because it decomposes at high temperatures). Crack is made by mixing the powder with baking soda and water, then heating the mixture until the base precipitates into a soft mass. Freebase is prepared by mixing the powder with a solvent (eg ether) and a base (eg ammonia), then extracting the alkaloid base from the ether layer. Crack and freebase melt at a much lower temperature and thus can be smoked. Nasal “snorting” is the most common form of use (90% of users), about 33% smoke crack, and less than 10% inject the drug. Crack causes most hospitalizations. The delay in onset varies depending on the form of use (from 6 to 8 seconds when smoked to 30 to 60 minutes when snorted nasally). The serum half-life is about 1 hour. The drug does not show up in blood tests very long, but metabolites (especially Bezoylecgonine) show up in the urine for up to 48 hours. High level users may test positive for up to 3 weeks. Urine testing is generally reliable, with few false positives. Escalating dosages are required to achieve the same euphoric effects. Complications of use can include appetite suppression, weight loss, dysphoria, status epilepticus seizures, cardiac arrhythmias, hypertension, tachycardia, cerebral hemorrhage, myocardial infarction (possibly from coronary artery spasms), and psychiatric complications that include a depression-like state, aggravated thought patterns, and worsening of any attention-deficit hyperactivity disorder. Pulmonary complications can include worsening asthma, a chronic cough and black sputum. Spontaneous pneumothorax can occur in users who perform Valsalva’s maneuvers after inhaling cocaine. Management of addiction is mainly through group and individual counseling. No pharmacologic treatment has been found that significantly and consistently reduces the urge to use cocaine.-
Reprint requests to Dr Warner: of Medicine, Box 19, 12901 33612-4799.
University of South Florida College Bruce B. Downs Blvd, Tampa, FL