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Management of cutaneous SCC of the face and scalp in Dorset
Abstracts / British Journal of Oral and Maxillofacial Surgery 47 (2009) e35–e69
Results: Non conventional injuries require non conventional treatment planning. Cases treated at the MMU show how multi-team resuscitation and operating improves the clinical outcome of these patients. Basic principles of wound management and an appreciation of the complexity of ballistics are the basic tenets of treatment. The use of modern imaging techniques allows detailed surgical planning for every patient. Keeping management simple gives predictable results that can be used as a steppingstone to further care. Conclusions: A ballistic injury to the head and neck gives unique challenges from the first moment the patient presents to a medical facility. Using basic principles to treat wounds and techniques that are no longer commonly used in conventional maxillofacial practice gives a more favourable result. doi:10.1016/j.bjoms.2009.06.078 52 Incidence of cervical metastasis in maxillary oral squamous cell carcinoma: a retrospective review Angela Boodhooa ∗ , Dimitrios Nikolarakos, Brang Lin, Graham Smith, Nicholas Hyde, Phil Wilson St Georges Hospital Current management of squamous cell carcinoma (SCC) originating in the oral mucosa of the maxilla with no evidence of cervical node metastasis (cN0) involves no elective therapy to the neck, unless the neck is to be entered for vascular access. There is emerging concern amongst head and neck surgeons, that studies have underestimated the rates of cervical metastasis from maxillary SCC. Aims: 1. To determine the rate of cervical lymph node metastasis of oral SCC of the maxilla. 2. To develop appropriate protocols for the management of the N0 neck in this disease. Methods: The records of all patients having undergone treatment for SCC of the maxilla by the Maxillofacial Head and Neck Oncology Surgeons at St George’s Hospital between 2001 and 2009 were reviewed. Data gathered includes, patient demographics, tumour pathology, treatment modalities and outcomes. (Disease free survival, local recurrence, cervical metastasis, salvage therapy.) Results: Preliminary analysis of the data collected indicates a similar incidence of cervical metastasis detected at the time of initial diagnosis to that documented in the past. The incidence of cervical metastasis following definitive management of the maxillary SCC with a clinically N0 neck appears to be higher than has been previously reported. Conclusions: The rate of metastasis in the neck following definitive treatment of maxillary mucosal SCC is higher than previously recognised. Further research is required to confirm this. If this conclusion is validated, it would further support
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the argument for more aggressive surgical management of the cN0 neck in SCCs of the maxilla. doi:10.1016/j.bjoms.2009.06.079 53 Military maxillofacial injuries treated at the Royal Centre for Defence Medicine: June 2001 to December 2007 John Breeze ∗ , A.J. Gibbons, N.J. Opie, A.M. Monaghan University Hospital Birmingham, United Kingdom Introduction: Since its formation in June 2001, the Royal Centre for Defence Medicine (RCDM) in Birmingham has treated the majority of significant maxillofacial injuries sustained by British military personnel while serving abroad. Method: This paper retrospectively analyses all recorded maxillofacial injuries evacuated to RCDM between June 2001 and December 2007. Results: During this period 119 military personnel with maxillofacial injuries were evacuated to RCDM for treatment. Eighty-three percent of personnel were injured in Iraq or Afghanistan. In total 61% (72/119) of patients had injuries caused by Improvised Explosive Devices and 9% (11/119) from Gun Shot Wounds and 1% from Aircraft incidents. Non-battle injuries accounted for a further 29% (35/119) of patients. Facial lacerations were the most common injury treated (106/119). There were 54 facial fractures. These fractures primarily affected the maxilla (17/54) and mandible (15/54). There were associated brain injuries in 24%, torso in 26%, upper limb in 39% and lower limb in 31% of the 119 patients. Conclusions: The numbers of maxillofacial injuries have risen over the last seven years, and have also increased proportionally to the total number of injured soldiers evacuated between 2005 and 2007. The types of injuries seen and changes over the last seven years will be discussed. doi:10.1016/j.bjoms.2009.06.080 54 Management of cutaneous SCC of the face and scalp in Dorset Niall McLeod Poole General Hospital, United Kingdom Aim: To review the management of patients who were diagnosed with new cutaneous squamous cell carcinoma (SCC) of the face and scalp within Dorset, comparing outcomes depending on different treatment modalities. Method: Patients identified from regional cancer database. Pathology records and electronic patient records interrogated for the period January 2003 and December 2006. Results: Three hundred and ten tumours were treated in 288 patients with a mean follow of 36 months. Tumour size,
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Abstracts / British Journal of Oral and Maxillofacial Surgery 47 (2009) e35–e69
location and differentiation was recorded, as was the development of local recurrence or regional metastases. Treatment modalities included curette and cautery, surgical excision and radiotherapy, with no significant difference found between treatment modality used and rates of recurrence or risk of metastases. The completeness of original excision also did not significantly affect risk of metastases. Discussion: We will discuss current guidelines for the management of cutaneous SCC with specific emphasis on SCC of the face and scalp. Local results for the treatment of cutaneous SCC of the face and scalp are in keeping with
damage may be increased by using an extraoral approach. Further, larger studies would be able to detect such small differences. An equal level of patient satisfaction, a possible reduced risk of facial nerve damage and salivary fistula formation, along with avoidance of a visible extraoral surgical scar indicate that intraoral ORIF may be the superior treatment option compared to extraoral ORIF. Table showing the difference in mean scores for the five variables between patients who underwent intraoral open reduction and those who underwent extraoral open reduction (CI: confidence interval).
Variables
Total score
TMJ dysfunction
Facial nerve damage
Effect on activities
Difference (95% CI)
1.25 (−10.64, 13.12)
0.83 (−11.47, 13.13)
0.75 (−2.72, 4.22)
0.03 (−1.30, 1.35)
national and international data for rates of completeness of excision, recurrence and metastases.
social
Duration of recovery
0.47 (−0.19, 1.14)
doi:10.1016/j.bjoms.2009.06.082 56
doi:10.1016/j.bjoms.2009.06.081 55 Open reduction of fractured mandibular condyles: an audit comparing an intraoral and extraoral approach Joanna Pararajasingham ∗ , Christoph Huppa, Kathleen Fan King’s College London, United Kingdom Introduction: Mandibular condylar fractures can be treated by closed reduction with intermaxillary fixation or open reduction with plate and screw fixation (ORIF). Plate and screw fixation can be performed either through an intraoral or extraoral approach. Aim: To test the hypothesis that there is no difference in patient satisfaction between patients who undergo ORIF via intraoral approach (Group I) and those who undergo ORIF via extraoral approach (Group II). Method: A retrospective study was carried out using a structured questionnaire to conduct telephone interviews of patients who had undergone ORIF of a condylar fractured at King’s College Hospital at least 6 months previously. Twentyone patients were included: 9 in Group I and 12 in Group II. Results: The means of five variables (TMJ Dysfunction Score, Facial Nerve Injury Score, Adverse Effects on Social Activities Score, Duration of Recovery Score, Total Score) were not found to be different between the two treatment groups (see table). Mean acceptability of the external surgical scar in Group II was 0.4 out of 5 (0 = best outcome). Conclusions: While the samples in this study were not large enough to detect small differences between the treatment groups, others have suggested that risk of facial nerve
Do guidelines for skin cancer excision margins correlate with clinical practice? Are we removing too much or too little? Roger Currie ∗ , V. McTaggart, E.R. Nairn, W.S. Hislop Oral and Maxillofacial Surgery and Pathology, Crosshouse Hospital, Kilmarnock, United Kingdom Abstract: In Non Melanotic Skin Cancer (NMSC) the assessment of surgical clearance is relevant to the risk of recurrence. The aim of this prospective study of 61 patients was to investigate the assessment, and accuracy of macroscopic surgical margins in NMSC’s at time of excision and compare this with the histological margins following laboratory processing using digital photography to record and measure these margins. Results: Each surgical margin was found to have a unique response to excision and laboratory processing, reacting independently to the tumour attached. There was no direct correlation between the fresh specimen and the microscopic measurements with less shrinkage at the 3’o clock margin, and more shrinkage with thinner tumours; whilst the microscopic margin remains the gold standard for assessing the status of excision margins the full results and clinical relevance in terms of tissue preservation will be presented and discussed. doi:10.1016/j.bjoms.2009.06.083
Results: Non conventional injuries require non conventional treatment planning. Cases treated at the MMU show how multi-team resuscitation and operating improves the clinical outcome of these patients. Basic principles of wound management and an appreciation of the complexity of ballistics are the basic tenets of treatment. The use of modern imaging techniques allows detailed surgical planning for every patient. Keeping management simple gives predictable results that can be used as a steppingstone to further care. Conclusions: A ballistic injury to the head and neck gives unique challenges from the first moment the patient presents to a medical facility. Using basic principles to treat wounds and techniques that are no longer commonly used in conventional maxillofacial practice gives a more favourable result. doi:10.1016/j.bjoms.2009.06.078 52 Incidence of cervical metastasis in maxillary oral squamous cell carcinoma: a retrospective review Angela Boodhooa ∗ , Dimitrios Nikolarakos, Brang Lin, Graham Smith, Nicholas Hyde, Phil Wilson St Georges Hospital Current management of squamous cell carcinoma (SCC) originating in the oral mucosa of the maxilla with no evidence of cervical node metastasis (cN0) involves no elective therapy to the neck, unless the neck is to be entered for vascular access. There is emerging concern amongst head and neck surgeons, that studies have underestimated the rates of cervical metastasis from maxillary SCC. Aims: 1. To determine the rate of cervical lymph node metastasis of oral SCC of the maxilla. 2. To develop appropriate protocols for the management of the N0 neck in this disease. Methods: The records of all patients having undergone treatment for SCC of the maxilla by the Maxillofacial Head and Neck Oncology Surgeons at St George’s Hospital between 2001 and 2009 were reviewed. Data gathered includes, patient demographics, tumour pathology, treatment modalities and outcomes. (Disease free survival, local recurrence, cervical metastasis, salvage therapy.) Results: Preliminary analysis of the data collected indicates a similar incidence of cervical metastasis detected at the time of initial diagnosis to that documented in the past. The incidence of cervical metastasis following definitive management of the maxillary SCC with a clinically N0 neck appears to be higher than has been previously reported. Conclusions: The rate of metastasis in the neck following definitive treatment of maxillary mucosal SCC is higher than previously recognised. Further research is required to confirm this. If this conclusion is validated, it would further support
e53
the argument for more aggressive surgical management of the cN0 neck in SCCs of the maxilla. doi:10.1016/j.bjoms.2009.06.079 53 Military maxillofacial injuries treated at the Royal Centre for Defence Medicine: June 2001 to December 2007 John Breeze ∗ , A.J. Gibbons, N.J. Opie, A.M. Monaghan University Hospital Birmingham, United Kingdom Introduction: Since its formation in June 2001, the Royal Centre for Defence Medicine (RCDM) in Birmingham has treated the majority of significant maxillofacial injuries sustained by British military personnel while serving abroad. Method: This paper retrospectively analyses all recorded maxillofacial injuries evacuated to RCDM between June 2001 and December 2007. Results: During this period 119 military personnel with maxillofacial injuries were evacuated to RCDM for treatment. Eighty-three percent of personnel were injured in Iraq or Afghanistan. In total 61% (72/119) of patients had injuries caused by Improvised Explosive Devices and 9% (11/119) from Gun Shot Wounds and 1% from Aircraft incidents. Non-battle injuries accounted for a further 29% (35/119) of patients. Facial lacerations were the most common injury treated (106/119). There were 54 facial fractures. These fractures primarily affected the maxilla (17/54) and mandible (15/54). There were associated brain injuries in 24%, torso in 26%, upper limb in 39% and lower limb in 31% of the 119 patients. Conclusions: The numbers of maxillofacial injuries have risen over the last seven years, and have also increased proportionally to the total number of injured soldiers evacuated between 2005 and 2007. The types of injuries seen and changes over the last seven years will be discussed. doi:10.1016/j.bjoms.2009.06.080 54 Management of cutaneous SCC of the face and scalp in Dorset Niall McLeod Poole General Hospital, United Kingdom Aim: To review the management of patients who were diagnosed with new cutaneous squamous cell carcinoma (SCC) of the face and scalp within Dorset, comparing outcomes depending on different treatment modalities. Method: Patients identified from regional cancer database. Pathology records and electronic patient records interrogated for the period January 2003 and December 2006. Results: Three hundred and ten tumours were treated in 288 patients with a mean follow of 36 months. Tumour size,
e54
Abstracts / British Journal of Oral and Maxillofacial Surgery 47 (2009) e35–e69
location and differentiation was recorded, as was the development of local recurrence or regional metastases. Treatment modalities included curette and cautery, surgical excision and radiotherapy, with no significant difference found between treatment modality used and rates of recurrence or risk of metastases. The completeness of original excision also did not significantly affect risk of metastases. Discussion: We will discuss current guidelines for the management of cutaneous SCC with specific emphasis on SCC of the face and scalp. Local results for the treatment of cutaneous SCC of the face and scalp are in keeping with
damage may be increased by using an extraoral approach. Further, larger studies would be able to detect such small differences. An equal level of patient satisfaction, a possible reduced risk of facial nerve damage and salivary fistula formation, along with avoidance of a visible extraoral surgical scar indicate that intraoral ORIF may be the superior treatment option compared to extraoral ORIF. Table showing the difference in mean scores for the five variables between patients who underwent intraoral open reduction and those who underwent extraoral open reduction (CI: confidence interval).
Variables
Total score
TMJ dysfunction
Facial nerve damage
Effect on activities
Difference (95% CI)
1.25 (−10.64, 13.12)
0.83 (−11.47, 13.13)
0.75 (−2.72, 4.22)
0.03 (−1.30, 1.35)
national and international data for rates of completeness of excision, recurrence and metastases.
social
Duration of recovery
0.47 (−0.19, 1.14)
doi:10.1016/j.bjoms.2009.06.082 56
doi:10.1016/j.bjoms.2009.06.081 55 Open reduction of fractured mandibular condyles: an audit comparing an intraoral and extraoral approach Joanna Pararajasingham ∗ , Christoph Huppa, Kathleen Fan King’s College London, United Kingdom Introduction: Mandibular condylar fractures can be treated by closed reduction with intermaxillary fixation or open reduction with plate and screw fixation (ORIF). Plate and screw fixation can be performed either through an intraoral or extraoral approach. Aim: To test the hypothesis that there is no difference in patient satisfaction between patients who undergo ORIF via intraoral approach (Group I) and those who undergo ORIF via extraoral approach (Group II). Method: A retrospective study was carried out using a structured questionnaire to conduct telephone interviews of patients who had undergone ORIF of a condylar fractured at King’s College Hospital at least 6 months previously. Twentyone patients were included: 9 in Group I and 12 in Group II. Results: The means of five variables (TMJ Dysfunction Score, Facial Nerve Injury Score, Adverse Effects on Social Activities Score, Duration of Recovery Score, Total Score) were not found to be different between the two treatment groups (see table). Mean acceptability of the external surgical scar in Group II was 0.4 out of 5 (0 = best outcome). Conclusions: While the samples in this study were not large enough to detect small differences between the treatment groups, others have suggested that risk of facial nerve
Do guidelines for skin cancer excision margins correlate with clinical practice? Are we removing too much or too little? Roger Currie ∗ , V. McTaggart, E.R. Nairn, W.S. Hislop Oral and Maxillofacial Surgery and Pathology, Crosshouse Hospital, Kilmarnock, United Kingdom Abstract: In Non Melanotic Skin Cancer (NMSC) the assessment of surgical clearance is relevant to the risk of recurrence. The aim of this prospective study of 61 patients was to investigate the assessment, and accuracy of macroscopic surgical margins in NMSC’s at time of excision and compare this with the histological margins following laboratory processing using digital photography to record and measure these margins. Results: Each surgical margin was found to have a unique response to excision and laboratory processing, reacting independently to the tumour attached. There was no direct correlation between the fresh specimen and the microscopic measurements with less shrinkage at the 3’o clock margin, and more shrinkage with thinner tumours; whilst the microscopic margin remains the gold standard for assessing the status of excision margins the full results and clinical relevance in terms of tissue preservation will be presented and discussed. doi:10.1016/j.bjoms.2009.06.083