- Email: [email protected]
OMFS referral: an audit of standard practice and pilot of a novel web-based referral system
Oral presentation / British Journal of Oral and Maxillofacial Surgery 49S (2011) S1–S25
effects of infections to healing time or final outcomes, prophylactic antibiotics are not indicated for any elective skin cancer surgery. doi:10.1016/j.bjoms.2011.04.058 58 Facial lacerations—what makes for less painful local anaesthetic infiltration? N. Vig∗ , A. Ujam, J. Haq, S. Holmes Barts and The London, United Kingdom Introduction: This paper asks whether administration of local anaesthetic infiltration within a wound is more comfortable than administration dermally (through intact skin) in the treatment of facial lacerations. The vast majority of lacerations presenting in the emergency setting are sutured under local anaesthetic and infiltration can be very uncomfortable. Currently, no evidence exists to support this as in-wound infiltration as less painful than through-skin for facial wounds, and so practice varies. Methods: A prospective, single-blind, randomised study was conducted at a busy London teaching hospital. Exclusions included patients aged below 16, and patients with heavily contaminated wounds. Subjects received local anaesthetic within the wound on one side, and dermally on the other, and visual analogue pain scale was used to measure pain after each injection. They were also asked to report which was more painful. Results: Preliminary results of the study are based on 36 patients to date (total dataset to include 70 patients). Median pain scores were higher in those infiltrated dermally versus inwound (40 mm vs 16 mm; p < 0.001). Order of infiltration has no bearing on the result. There was also significant difference in patients reporting the dermal injection as more painful than the subcutaneous (p < 0.001). Conclusion: Early results of this study demonstrate inwound infiltration as a more comfortable option in achieving anaesthesia for facial lacerations and should be used where clinically indicated. doi:10.1016/j.bjoms.2011.04.059 59 Mortality and morbidity from combat neck injury J. Breeze∗ , L.S. Allanson-Bailey, N.C. Hunt, R.J. Delaney, A.E. Hepper, J. Clasper Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, United Kingdom Introduction: Neck injury represents 11% of battle injuries in UK forces in comparison to 2–5% in US forces. The aim of this study was to determine the causes of death and long-term morbidity from combat neck injury in
S23
an attempt to recommend new methods of protecting the neck. Method: Hospital and post mortem records for all UK servicemen sustaining battle injuries to the face or eye between 01 January 2006 and 31 October 2010 were analysed. Results: Neck wounds were found in 152/1528 (10%) of battle injured service personnel. 79% of neck wounds were due to explosions and were associated with a mortality rate of 41% compared to 78% from gunshot wounds. Current UK neck collars can potentially protect zone I from explosive fragments but all service personnel in this series chose not to wear them. The most common cause of death from explosive fragments was vascular injury (85%). 14% of survivors sustained permanent complications from their neck wound. Zone II was the most commonly affected area overall by explosive fragments (57%) but Zone I was associated with the highest morbidity in survivors. Conclusions: Nape protectors, that cover zone III of the neck posteriorly, would only have potentially prevented 3% of injuries and therefore this study does not support their use. Had current neck collars been worn, potentially 22% of wounds could have been prevented. Modifications to neck collar design have been implemented that maintain existing surface area coverage but will reduce load and thermal burden. doi:10.1016/j.bjoms.2011.04.060 60 OMFS referral: an audit of standard practice and pilot of a novel web-based referral system N. Cronin∗ , S. Dev, J. Coombes, K. Fan Kings College Hospital, London, United Kingdom Introduction: Oral and Maxillofacial surgery (OMFS) telephone referrals can be a protracted process. As King’s moves to electronic records, a web referral system may improve delivery of maxillofacial services. Aim: To review the traditional inter-hospital telephone referral pathway, implement a web-based referral pathway, and compare their effectiveness. Methods: Both pathways were audited using a proforma by the referring and receiving teams. The ease and speed of referral, availability of information, accessibility of OMFS on-call and educational value were assessed. Results: The appraisal of the telephone pathway demonstrated a good service by the OMFS on-call team: speed and accessibility of referrals were very satisfactory, as evidence by respective average scores of 7.5/10 and 9/10 on Likert scales of user satisfaction. However, the traditional telephone referral pathway was of limited educational value (3.1/10). The OMFS team scored the traditional telephone referral 4.6/10 for adequacy of information provided by the referrer, improving to 9/10 with web-referrals.
S24
Oral presentation / British Journal of Oral and Maxillofacial Surgery 49S (2011) S1–S25
Conclusions: Computer referrals ensures all data is collated and presented in a logical, standardized form, prompts ensure no essential information is missing prior to referral, particularly useful to junior rotating ED teams. Defined response timelines gives busy referring doctors an opportunity to continue working, and benefit accepting doctors who have time to review data and images. Patient data is secure, available prior to transfer, linked to patients’ notes, and when coupled to a login based audit trail results in less miscommunication. Web referral can improve delivery of maxillofacial services, which may lead to an improved patient experience. doi:10.1016/j.bjoms.2011.04.061 61 How reliable is the fibula skin paddle? E. Dodson∗ , Z. Al-Asaadi, T. Martin, S. Parmar University Hospitals Birmingham NHS Foundation Trust, United Kingdom The fibula is the bone of choice for many reconstructive surgeons for head and neck defects. However, many of the defects being reconstructed are not limited to bone and often involve the intraoral mucosa or external facial skin. Many authors have questioned the reliability of the fibula skin paddle and routinely use a radial forearm flap in conjunction with the fibula. Aims: To assess the reliability of the fibula skin paddle in our series of 57 composite fibula flaps. Materials and methods: A retrospective analysis was carried out in our unit of all composite fibula flaps. Results: 57 fibula flaps were raised for reconstruction of complex head and neck defects between 2005 and 2010. All the fibulas were raised without a tourniquet. All the skin paddles were raised with a large cuff of flexor hallucis. The soleus was never taken. The fibula donor site healed well and never required further surgery. 2 of the flaps failed in our fibula series (3.5%). Only 1 of the surviving 55 fibula flaps was the skin paddle lost (1.8%). Conclusions: The fibula skin paddle is extremely reliable if raised carefully, from the correct location on the leg, with preoperative Doppler markings and with a good cuff of flexor hallucis. A separate soft tissue flap is rarely required. doi:10.1016/j.bjoms.2011.04.062
62 Listening to head and neck cancer patients—the Bradford experience A. Pick∗ , A. Liu, J. McCaul Bradford Institute of Health Research, United Kingdom Introduction: Public/patient involvement is repeatedly trumpeted and heralded in research. Significantly, it has been assisted by the recent Department of Health policy document ‘Best Research for Best Health’ making generous and glowing references to the benefits of public involvement in health and social research. The experience of both INVOLVE and UKCRC is that increasing engagement with patients and public has positive benefits to clinical research. Methods: We outline our experience in Bradford’s Head and Neck patients Involvement Forum. We will describe our evolving methods of patient interaction from initial approach of survivors of head and neck cancers to targeted techniques such as focus group meetings. Interactions and meaningful dialogue between patients, CNS, Consultant Surgeons and Research Nurses from the outset are pivotal to successful application. Results: Not only are barriers to research in the NHS effectively removed, but future research can be tailored to the needs of patients, placing them at the centre of the clinician’s work. Developing effective patient and public engagement requires commitment, dedication and skills on part of the health professionals. We conclude with evidence that patient involvement is essential not just for successful grant application but that what they shared with health professionals is enlightening and useful in clinical research. doi:10.1016/j.bjoms.2011.04.063 63 Accuracy of MRI in prediction of tumour thickness and nodal stage in oral carcinoma C.T.-T.J.W. Lwin∗ , R. Hanlon, D. Lowe, R.J. Shaw, S.N. Rogers, J.S. Brown, F. Bekiroglu Univeristy Hospital Aintree, Liverpool, United Kingdom Aims: Tumour thickness is important in helping to predict local recurrence, nodal metastasis and patient survival. An accurate preoperative assessment of tumour thickness is desirable for optimal treatment planning. The aim of our study is to evaluate the correlation and accuracy of MRI measured depth of invasion and histological tumour thickness for various sub-sites of OSCC and determine its predictive accuracy for nodal metastases. Methods: Retrospective histological review of 102 consecutive patients with OSCC who underwent primary surgical treatment was completed. MRI STIR sequence in axial plane and T2-weighted images in coronal plane were used to
effects of infections to healing time or final outcomes, prophylactic antibiotics are not indicated for any elective skin cancer surgery. doi:10.1016/j.bjoms.2011.04.058 58 Facial lacerations—what makes for less painful local anaesthetic infiltration? N. Vig∗ , A. Ujam, J. Haq, S. Holmes Barts and The London, United Kingdom Introduction: This paper asks whether administration of local anaesthetic infiltration within a wound is more comfortable than administration dermally (through intact skin) in the treatment of facial lacerations. The vast majority of lacerations presenting in the emergency setting are sutured under local anaesthetic and infiltration can be very uncomfortable. Currently, no evidence exists to support this as in-wound infiltration as less painful than through-skin for facial wounds, and so practice varies. Methods: A prospective, single-blind, randomised study was conducted at a busy London teaching hospital. Exclusions included patients aged below 16, and patients with heavily contaminated wounds. Subjects received local anaesthetic within the wound on one side, and dermally on the other, and visual analogue pain scale was used to measure pain after each injection. They were also asked to report which was more painful. Results: Preliminary results of the study are based on 36 patients to date (total dataset to include 70 patients). Median pain scores were higher in those infiltrated dermally versus inwound (40 mm vs 16 mm; p < 0.001). Order of infiltration has no bearing on the result. There was also significant difference in patients reporting the dermal injection as more painful than the subcutaneous (p < 0.001). Conclusion: Early results of this study demonstrate inwound infiltration as a more comfortable option in achieving anaesthesia for facial lacerations and should be used where clinically indicated. doi:10.1016/j.bjoms.2011.04.059 59 Mortality and morbidity from combat neck injury J. Breeze∗ , L.S. Allanson-Bailey, N.C. Hunt, R.J. Delaney, A.E. Hepper, J. Clasper Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, United Kingdom Introduction: Neck injury represents 11% of battle injuries in UK forces in comparison to 2–5% in US forces. The aim of this study was to determine the causes of death and long-term morbidity from combat neck injury in
S23
an attempt to recommend new methods of protecting the neck. Method: Hospital and post mortem records for all UK servicemen sustaining battle injuries to the face or eye between 01 January 2006 and 31 October 2010 were analysed. Results: Neck wounds were found in 152/1528 (10%) of battle injured service personnel. 79% of neck wounds were due to explosions and were associated with a mortality rate of 41% compared to 78% from gunshot wounds. Current UK neck collars can potentially protect zone I from explosive fragments but all service personnel in this series chose not to wear them. The most common cause of death from explosive fragments was vascular injury (85%). 14% of survivors sustained permanent complications from their neck wound. Zone II was the most commonly affected area overall by explosive fragments (57%) but Zone I was associated with the highest morbidity in survivors. Conclusions: Nape protectors, that cover zone III of the neck posteriorly, would only have potentially prevented 3% of injuries and therefore this study does not support their use. Had current neck collars been worn, potentially 22% of wounds could have been prevented. Modifications to neck collar design have been implemented that maintain existing surface area coverage but will reduce load and thermal burden. doi:10.1016/j.bjoms.2011.04.060 60 OMFS referral: an audit of standard practice and pilot of a novel web-based referral system N. Cronin∗ , S. Dev, J. Coombes, K. Fan Kings College Hospital, London, United Kingdom Introduction: Oral and Maxillofacial surgery (OMFS) telephone referrals can be a protracted process. As King’s moves to electronic records, a web referral system may improve delivery of maxillofacial services. Aim: To review the traditional inter-hospital telephone referral pathway, implement a web-based referral pathway, and compare their effectiveness. Methods: Both pathways were audited using a proforma by the referring and receiving teams. The ease and speed of referral, availability of information, accessibility of OMFS on-call and educational value were assessed. Results: The appraisal of the telephone pathway demonstrated a good service by the OMFS on-call team: speed and accessibility of referrals were very satisfactory, as evidence by respective average scores of 7.5/10 and 9/10 on Likert scales of user satisfaction. However, the traditional telephone referral pathway was of limited educational value (3.1/10). The OMFS team scored the traditional telephone referral 4.6/10 for adequacy of information provided by the referrer, improving to 9/10 with web-referrals.
S24
Oral presentation / British Journal of Oral and Maxillofacial Surgery 49S (2011) S1–S25
Conclusions: Computer referrals ensures all data is collated and presented in a logical, standardized form, prompts ensure no essential information is missing prior to referral, particularly useful to junior rotating ED teams. Defined response timelines gives busy referring doctors an opportunity to continue working, and benefit accepting doctors who have time to review data and images. Patient data is secure, available prior to transfer, linked to patients’ notes, and when coupled to a login based audit trail results in less miscommunication. Web referral can improve delivery of maxillofacial services, which may lead to an improved patient experience. doi:10.1016/j.bjoms.2011.04.061 61 How reliable is the fibula skin paddle? E. Dodson∗ , Z. Al-Asaadi, T. Martin, S. Parmar University Hospitals Birmingham NHS Foundation Trust, United Kingdom The fibula is the bone of choice for many reconstructive surgeons for head and neck defects. However, many of the defects being reconstructed are not limited to bone and often involve the intraoral mucosa or external facial skin. Many authors have questioned the reliability of the fibula skin paddle and routinely use a radial forearm flap in conjunction with the fibula. Aims: To assess the reliability of the fibula skin paddle in our series of 57 composite fibula flaps. Materials and methods: A retrospective analysis was carried out in our unit of all composite fibula flaps. Results: 57 fibula flaps were raised for reconstruction of complex head and neck defects between 2005 and 2010. All the fibulas were raised without a tourniquet. All the skin paddles were raised with a large cuff of flexor hallucis. The soleus was never taken. The fibula donor site healed well and never required further surgery. 2 of the flaps failed in our fibula series (3.5%). Only 1 of the surviving 55 fibula flaps was the skin paddle lost (1.8%). Conclusions: The fibula skin paddle is extremely reliable if raised carefully, from the correct location on the leg, with preoperative Doppler markings and with a good cuff of flexor hallucis. A separate soft tissue flap is rarely required. doi:10.1016/j.bjoms.2011.04.062
62 Listening to head and neck cancer patients—the Bradford experience A. Pick∗ , A. Liu, J. McCaul Bradford Institute of Health Research, United Kingdom Introduction: Public/patient involvement is repeatedly trumpeted and heralded in research. Significantly, it has been assisted by the recent Department of Health policy document ‘Best Research for Best Health’ making generous and glowing references to the benefits of public involvement in health and social research. The experience of both INVOLVE and UKCRC is that increasing engagement with patients and public has positive benefits to clinical research. Methods: We outline our experience in Bradford’s Head and Neck patients Involvement Forum. We will describe our evolving methods of patient interaction from initial approach of survivors of head and neck cancers to targeted techniques such as focus group meetings. Interactions and meaningful dialogue between patients, CNS, Consultant Surgeons and Research Nurses from the outset are pivotal to successful application. Results: Not only are barriers to research in the NHS effectively removed, but future research can be tailored to the needs of patients, placing them at the centre of the clinician’s work. Developing effective patient and public engagement requires commitment, dedication and skills on part of the health professionals. We conclude with evidence that patient involvement is essential not just for successful grant application but that what they shared with health professionals is enlightening and useful in clinical research. doi:10.1016/j.bjoms.2011.04.063 63 Accuracy of MRI in prediction of tumour thickness and nodal stage in oral carcinoma C.T.-T.J.W. Lwin∗ , R. Hanlon, D. Lowe, R.J. Shaw, S.N. Rogers, J.S. Brown, F. Bekiroglu Univeristy Hospital Aintree, Liverpool, United Kingdom Aims: Tumour thickness is important in helping to predict local recurrence, nodal metastasis and patient survival. An accurate preoperative assessment of tumour thickness is desirable for optimal treatment planning. The aim of our study is to evaluate the correlation and accuracy of MRI measured depth of invasion and histological tumour thickness for various sub-sites of OSCC and determine its predictive accuracy for nodal metastases. Methods: Retrospective histological review of 102 consecutive patients with OSCC who underwent primary surgical treatment was completed. MRI STIR sequence in axial plane and T2-weighted images in coronal plane were used to