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Middle third injuries
Letters to the Editor CLEFT LIP AND PALATE SURGERY IN INDIA
MIDDLE
THIRD
Sir, May I, through your correspondence column, bring to the attention of higher trainees the exceptional training which can be obtained in Mangalore, India in cleft lip and palate surgery. I have just returned, having spent 2 weeks at a workshop there. In a total of 8 days operating we performed 42 operations, most of which were primary cleft repairs, I myself completing 15 primary lip repairs and 3 primary palate repairs. There are still over 140 cleft cases requiring primary surgery on the waiting list and the only limitation on the number of cases that can be treated, is the time taken to complete the surgery. Unlike other units in which it may be only possible to observe, or the report of a previous course in India’ in which there was said to be little teaching, this unit provides hands-on training which is closely supervised and instructed by a very experienced maxillofacial cleft surgeon, the surgery being performed to a very high standard using principles developed by Delaire.2-4 A fundamental understanding of these concepts is essential though, before visiting this unit if the trainee is to obtain the most from a visit. Further workshops can be arranged on an individual basis for interested trainees (or consultants) who wish to increase their experience. It would also be possible to arrange workshops in the management of oral.malignancy or aesthetic facial surgery, tailored to the training requirements of individual surgeons. If any trainees who are interested in travelling to Mangalore will contact me, I can initiate the arrangements for them.
Sir, As part of audit all the records and radigraphs of a 5-yearold child who was hit in face by a playground swing, and who subsequently died of neurosurgical injuries were reviewed. The CT scan revealed a complex, cornminuted maxillary fracture, which had been suspected clinically, but due to the severity of the neurosurgical injury had not been referred for specialist opinion. Further scrutiny of the cases transferred for neurosurgical care revealed a 9-year-old child with a complex middle third injury sustained as the result of a road traffic accident 4 months prior to this case. This finding of two cases of complex middle third injuries occurring in children in a hospital which has few cases of trauma in 4 months is surprising. This is because the reported incidence of these injuries in the UK is very low,’ and this confirms earlier studies in the USA2 and Australia.3 However, it is well recognised that when these complex middle third injuries are present in children, it is often in association with cranial, and more rarely, visceral injuries.’ This unexpected cluster of cases suggests that the true incidence of these injuries may be higher than the current published studies suggests, but because of the severity of the associated injuries they are not seen by maxillofacial surgeons. P. J. Anderson Fellow in Craniofacial
INJURIES
Surgery
W.J. Harkness F.R.C.S. Consultant Neurosurgeon Hospital for Sick Children Ormond Street London
Andrew Fordyce Senior Registrar Oral and Maxillofacial Unit Middlesbrough General Hospital Ayresome Green Lane Middlesbrough Cleveland TS5 5AZ
References 1. Anderson PJ. Fractures of the facial skeleton in Children. Injury 1995; 26: 47-50. 2. Kaban LB, Mulliken JB, Murray JB. Facial fractures in Children. Plas Reconstructr Surg 1977; 59: 15-21. 3. Hall RK. Injuries to the face and Jaws in Children. Int J Oral Surg 1972; 1: 65-82.
References 1. Smith WP. Clinical attachment to the Dharwad Cleft Unit, SCM College of Dental Sciences and Hospital, Dhanvad, India November-December 1993. Supplement to Ann R Co11 Surg Engll994; 76: 296-297. 2. Markus AF, Smith WP, Delaire J. Primary closure of cleft palate: a functional approach. Br J Oral Maxillofac Surg 1993; 31: 71-77. 3. Markus AF, Delaire J. Functional primary closure of cleft lip. Br J Oral Maxillofac Surg; 1993; 31: 281-291. 4. Smith WP, Markus AF, Delaire J. Primary closure of the cleft alveolus: a functional approach. Br J Oral Maxillofac Surg; 1995; 33: 156-165.
THIRD
MOLAR
SURGERY
Sir, In response to the letter in your journal of August 1995 by J V Townend concerning our paper on third molar surgery from earlier in the year, I would like to thank Mr Townend for his obvious careful appraisal of the paper. However, I feel he has failed to appreciate the key points of the publication. The thrust of this paper was to highlight the fact that 5 1% of patients who actually underwent third molar surgery had no clinical indication for this. The authors consider this to be the most important take home message from this paper, whereas the data relating to nerve injury probably only reflects a minor contribution to the already vast literature on this subject. 395
MIDDLE
THIRD
Sir, May I, through your correspondence column, bring to the attention of higher trainees the exceptional training which can be obtained in Mangalore, India in cleft lip and palate surgery. I have just returned, having spent 2 weeks at a workshop there. In a total of 8 days operating we performed 42 operations, most of which were primary cleft repairs, I myself completing 15 primary lip repairs and 3 primary palate repairs. There are still over 140 cleft cases requiring primary surgery on the waiting list and the only limitation on the number of cases that can be treated, is the time taken to complete the surgery. Unlike other units in which it may be only possible to observe, or the report of a previous course in India’ in which there was said to be little teaching, this unit provides hands-on training which is closely supervised and instructed by a very experienced maxillofacial cleft surgeon, the surgery being performed to a very high standard using principles developed by Delaire.2-4 A fundamental understanding of these concepts is essential though, before visiting this unit if the trainee is to obtain the most from a visit. Further workshops can be arranged on an individual basis for interested trainees (or consultants) who wish to increase their experience. It would also be possible to arrange workshops in the management of oral.malignancy or aesthetic facial surgery, tailored to the training requirements of individual surgeons. If any trainees who are interested in travelling to Mangalore will contact me, I can initiate the arrangements for them.
Sir, As part of audit all the records and radigraphs of a 5-yearold child who was hit in face by a playground swing, and who subsequently died of neurosurgical injuries were reviewed. The CT scan revealed a complex, cornminuted maxillary fracture, which had been suspected clinically, but due to the severity of the neurosurgical injury had not been referred for specialist opinion. Further scrutiny of the cases transferred for neurosurgical care revealed a 9-year-old child with a complex middle third injury sustained as the result of a road traffic accident 4 months prior to this case. This finding of two cases of complex middle third injuries occurring in children in a hospital which has few cases of trauma in 4 months is surprising. This is because the reported incidence of these injuries in the UK is very low,’ and this confirms earlier studies in the USA2 and Australia.3 However, it is well recognised that when these complex middle third injuries are present in children, it is often in association with cranial, and more rarely, visceral injuries.’ This unexpected cluster of cases suggests that the true incidence of these injuries may be higher than the current published studies suggests, but because of the severity of the associated injuries they are not seen by maxillofacial surgeons. P. J. Anderson Fellow in Craniofacial
INJURIES
Surgery
W.J. Harkness F.R.C.S. Consultant Neurosurgeon Hospital for Sick Children Ormond Street London
Andrew Fordyce Senior Registrar Oral and Maxillofacial Unit Middlesbrough General Hospital Ayresome Green Lane Middlesbrough Cleveland TS5 5AZ
References 1. Anderson PJ. Fractures of the facial skeleton in Children. Injury 1995; 26: 47-50. 2. Kaban LB, Mulliken JB, Murray JB. Facial fractures in Children. Plas Reconstructr Surg 1977; 59: 15-21. 3. Hall RK. Injuries to the face and Jaws in Children. Int J Oral Surg 1972; 1: 65-82.
References 1. Smith WP. Clinical attachment to the Dharwad Cleft Unit, SCM College of Dental Sciences and Hospital, Dhanvad, India November-December 1993. Supplement to Ann R Co11 Surg Engll994; 76: 296-297. 2. Markus AF, Smith WP, Delaire J. Primary closure of cleft palate: a functional approach. Br J Oral Maxillofac Surg 1993; 31: 71-77. 3. Markus AF, Delaire J. Functional primary closure of cleft lip. Br J Oral Maxillofac Surg; 1993; 31: 281-291. 4. Smith WP, Markus AF, Delaire J. Primary closure of the cleft alveolus: a functional approach. Br J Oral Maxillofac Surg; 1995; 33: 156-165.
THIRD
MOLAR
SURGERY
Sir, In response to the letter in your journal of August 1995 by J V Townend concerning our paper on third molar surgery from earlier in the year, I would like to thank Mr Townend for his obvious careful appraisal of the paper. However, I feel he has failed to appreciate the key points of the publication. The thrust of this paper was to highlight the fact that 5 1% of patients who actually underwent third molar surgery had no clinical indication for this. The authors consider this to be the most important take home message from this paper, whereas the data relating to nerve injury probably only reflects a minor contribution to the already vast literature on this subject. 395