Platysma myocutaneous flap for intraoral reconstruction: An option in the compromised patient

CURRENT LITERATLJRE

461

laparotomy Were the only independent factors associated with abnormal findings on ACT scan, The sensitivity and specificity of the test were 97.5?i1 and 61.5’;;. respectively. Overall, 59 patients (69%) benetited from treatment changes after an ACT scan. Twelve patients (li”b) developed mild adverse events during transportation from the intensive care unit to the radiology suite. Patient age and incidence of hollow visceral injuries were the 2 variables significantly different between survivors and nonsurvivors. The authors concluded that abdominal computed tomographic scans reliably identify intro-abdominal foci of infection in patients with major trauma evaluated for sepsis of unknown origin.AJ. LIHIIN,\O Reprint requests to Dr Vrlmahos: Los Angcks iMedical

Center.

Bedside Embolism

1200 N State St. Rm 9900.

Noninvasive in Critically

JT, Owings JT, Goodnight

Detection of Ill Surgical

Count + IM: Los Angcks. CA WOj. Acute Patients.

Pulmonary

Anderson JE. Arch Surg 134:869, 1999

A readily available and portable screening tool for the bedside examination of patients with suspected pulmonary embolism (PE) is desperately needed. Although PE is relatively uncommon after trauma, its prompt diagnosis is a formidable task for the clinician. Physical findings are varied and nonspecific. Furthermore, assessment of arterial blood gases, calculation of alveolar arterial oxygen gradients, and evaluation of the chest radiograph or electrocardiogram are neither sensitive nor specific. The authors undertook this study to evaluate late pulmonary dead space fraction (Fd,,,,), calculated from the carbon dioxide (COl) expirognm. as a screening tool to detect PE in surgical patients, including those who required mechanical ventilation or had adult respiratory distress syndrome. The Fd,,,, was prospectively calculated in 12 patients with suspected PE who underwent pulmonary angiography at a university-based level I trauma center. Eleven of the 12 patients enrolled in the study were victims of trauma, and the remaining patient required emergency operation for a perforated ileum resulting from cocaine intoxication. The Fd,,,,, was calculated by means of the formula, Fd,,,, = (FaCOL - Fl j%TLCco2)/Faco2. Face, is the arterial fractional CO1 and Fl i%TLCco? is the fmctional CO2 value at an exhaled volume of 1% of the TLC. Results showed the Fdl,,, was 0.12 or above in all 5 patients who had PE confumed with angiogram; 4 required mechanical ventilation. The Fd,,,, values were below 0.12 in 8 of 9 patients without PE. One patient had an Fd,,,, greater than 0.12 but a negative angiogram. Four of the 9 patients with Fdl,,, below 0.12 had adult respiratory distress syndrome and negative angiogmms. The Fd,,,, had 100% sensitivity and 89”U specihcity for the detection of PE with the use of a cutoff of 0.12. Since the authors were able to accurately detect all PEs, the) concluded that the Fd,,,, is a valuable tool for bedside screening of PE In surgical patients.-AJ. LIHL:NAO Reprint requests to Dr Anderson: Department of Surgev. -1301 S St. Sacramento, CA 95817-2211. Exposures School-Based

to

Blood Dental

and Body Fluids Among Health Care Workers.

preventing exposure as well as dealing with exposures immediately. This study was undertaken to determine the incidence of reported exposures to blood and other body fluids by dental school-based dental health care workers (DHCW). It was also to compare exposure between dental school-based personnel and other dental workers, and to assess unreported exposures and reasons for not reporting exposures in the dental school. This study was conducted by a survey and a response rate of 5 1.9% was obtained from US dental schools. Six hundred fifty-two exposures were reported and 629 of these occurred in dental school clinics. An average of 23 exposures occurred per dental school with an annual mte of -i/lO,OOO patient visits and 1.3/10,000 per faculty pmctice. There was 62.5% of reported exposures accounted for by dental students with a rate of 106.3/1,000 students a year. A second survey directed to DHCW received 8.3% response from the IO.433 DHCW. Of this population, 31% acknowledged exposure and reported it. Reasons for not reporting exposure ranged from a judgment that the injury was not serious. time needed to report, and that the patient was believed to be healthy. The authors suggest that the results are to provide dental schools with a baseline to compare their reported exposures and to develop progmms intended to prevent and manage exposures.-SC. OLTLW Reprint IlCH<:. The eral

requests IO Dr knncdy: Department of Periodontology. 263 Farmington Ave. Farmington. CT 06030. Effects Nerve

of Cisplatinum Regeneration.

and

Vincristine

on

Periph-

Bmndt K. Evans GRD. Johnson M, et al. Plast Reconstr Surg 104:464. 1999

The authors have examined the effects of cisplatinum and vincristine on peripheral nerve regeneration. This arose from the current practice of treating extremity sarcoma by extirpating the tumor followed by adjuvant chemotherapy, particularly in view of the limb-sparing surgery currently pmcticed with the subsequent need for reconstruction of resultant nerve defects. The well-documented neurotoxic effects of chemotherapeutic agents raise concerns over the effects of such thempy on nerve regeneration. The authors took a cohort of rats and performed posterior tibia1 nerve isografts followed by cisplatinum and vincristine chemotherapy. Nerve regeneration was assessed using parameters such as walking track analysis and histomorphology. Animals were randomly allocated into groups and each underwent a 15 mm reversed interpositional nerve isograft. Groups were then created in which rats received cisplatin alone, vincris tine alone, or no further therapy. After analysis the authors could show no statistically significant difference in print length between control and case rats. Histomorphology showed no statistically significant difference between the number of axons per square millimeter and nerve fiber densiT in the chemotherapy versus the nonchemotherapy groups. They concluded that in the rodent model, using the posterior tibia1 nerve, postoperative adjuvant chemotherapy does not significantly alter the outcome of peripheral nerve regeneration and they contend that the practice of immediate nerve grafting after tumor extirpation is acceptable even if postsurgical chemotherapy is to be used.-C.G. PAGNI

Dental

Hasler J. J Dent Educ 63:464, 1999

Platysma tion: An

There is a risk of infection to all individuals who directly or indirectly come in contact with blood or other body fluids. Federal and state governmental agencies have attempted to educate and protect health care workers in

Two cases were presented showing the utility of the platysma myocutaneous flap in the reconstruction of intra-

Kennedy

J,

Myocutaneous Option in

the

Flap for Intraoral Compromised

Reconstnw Patient. Beren-

hnlz L. Kessler A. Segal S. Int J Oral Maxillofac 1999

Surg 28:285,

462

CLIRRENT

oral defects. One flap was based superiorly and lateral to the mandible and sutured to the defect after squamous cell carcinoma to the superior surface of the right horizontal ramus with extension to the right submucosa. The other was a superiorly based flap rotated superiorly to fill the oral cavity defect after squamous cell carcinoma to the floor of the mouth. Both patients were discharged after 1 week, appeared to have normal speech, and tolerated a regular diet. The donor sites were closed primarily without an) complications. Planning the incision preoperatively is critical and upper-cervical incisions should be avoided. Apron or utility incisions, which are based superiorly, are preferred. The submental artery should be preserved as not to jeopardize the arterial supply to the flap. The venous drainage is critical to the flap and therefore, tension and kinking should be avoided. The platysma myocutaneous flap should be considered for intraoral reconstruction, especially for selected small and medium-sized defects. It is thin, pliable. and generally hairless and already in the field. Relative contraindications include previous radiation, ligation of the facial artery, and neck dissection.-L.N. KARA~I Reprint requests to Drs Berenholz. Kessler, or Se@: Albert Einstein Medical Center. Philadelphia. PA: Department of 0tolayngology. Assaf Harof Medical Centrc. ticliatrd to Sackler Faculty of Mrdicinc, Tel Aviv Llnivcrsi~. Isncl. Antioxidant Levels in

Status Smokers

of Oral Mucosal and Non-Smokers.

Tissue

and

Plasma

Cowan CG, Calwell EIL, Young IS. et al. J Oral Pathol Med 28:360. 1999 Epidemiological data gathered over many years has highlighted the role of tobacco in the pathogenesis of potentiall) malignant oral lesions and oral squamous cell carcinoma. It is believed that antioxidant levels of individuals are an important factor in the occurrence of cancer. However. veq little information on the levels of mucosal antioxidants and their importance in oral malignancy is available. In Northern Ireland, 60 individuals (41 non-smokers and 19 smokers) consented to participate in a study where a buccal mucosal biopsy and a simultaneous fasting venous blood sampling were taken. Antioxidant level in tissue and plasma were measured using high-performance liquid chromatography. Because diet also plays an important role in antioxidant levels, the individuals also had their dietary intake assessed. When all the numbers were compared, it was found that the smokers had significantly lower levels of plasma P-carotene and significantly lower levels of tissue a-carotene. Dietar) intake correlated with plasma levels of a-carotene and P-carotene but not with tissue levels. The only correlation with plasma and tissue levels was with decreased a-carotene in both levels in the smokers. The study also measured a-tocopherol, retinal. and lycopene, but the numbers showed no significant diEference in plasma or tissue levels. The significance of these findings is unclear; however, studies have proven that increased levels of antioxidants have shown therapeutic value in oral potentially malignant lesions. For example, oral leukoplakia studies have shown a therapeutic effect of p-carotene, with clinical improvement ranging from 14.8% to 71%. Based on this study, malignancies can not be based on dietary in serum analysis alone, the level of antioxidants in the mucosa may play an important role in the occurrence and severity of oral malignanties.-D. PHILLIPS Reprint requests to Dr Cohen: School of Dentistry and Department of Clinical Biochemistry. The Queens Llnivrrsity of Belfast. Royal Victoria Hospital. JWfast. Northern Ireland.

Balloon Intractable

Compression Post-Traumatic

of

the

LITEKr\TlUtE

Intramaxillary Bleeding From

Sinus for the Maxil-

lary Artery. Hashim AA, Atiyeh BS. Kayle DI. et aI. J Plast Reconstr Hand Surg 33:32l, 1999 Intrdctable bleeding is a rare condition associated with severe facial fractures. In the midface, the bleeding usually originates from the sphenopalatine vessels which cannot he adequately controlled with posterior nasal packing. Repeated transfusions are necessary to maintain hemoglobin levels. This type of bleeding occurs secondary to a partial tear in the vessel wall of one of the lateral branches of the maxillary artery. Arteries located at the Ievel of the later;11 ptevgoid muscle or lateral to it can br approached onI1 through the maxillary sinus. For this type of bleeding, embolization is considered to be the first line of treatment with a failure rate of 12%. In this case report, the patient was a ZS-year-old man with complex Le Fort II and 111fractures with uncontrollable bleeding secondary to an injury to the descending palatine artery. Initially the patient had profuse oronasal bleeding along with bleeding from a ruptured ileocolic artery. After the ileocolic artery repair, significant oronasal bleeding persisted. In intensive care, the patient required continuous sedation to avoid his agitation. which exacerbated the bleeding. One week later. open reduction with internal fixation was perfommed. One week postopem tively. bleeding recurred. At this time. an angiography was performed and showed hemorrhaging from the descending palatine of the right internal maxillary artery. Embolization was performed with metallic coils. One week after embolization. bleeding recurred and a ~12 Foley catheter was inserted through a traumatic defect in the palate and inflated with 20 mL of saline. This immediately stopped the bleeding. A second angiogrdm with an inflated balloon showed no bleeding. During the angiogrdm. the balloon was deflated and bleeding was identified from the same descending palatine artery supplied by collaterals from the right facial artery. These collaterals were embolized and the inflated balloon kept in place for a total of 10 days after which the patient had no recurrence. In other cases, 10 days should allow enough time for the injured vessel to completel) thrombose and collapse. If no defect is present, the device can be introduced into the maxillary sinus using a Caldwell Luc approach or through a trdnsnasal approach. Balloon compression of the maxillas artery appears to be a quick and pnctical approach to control intrdctable bleeding. At the same time, no special instruments or expertise is required. Finally this procedure may be easily performed in the emergency room.-B. GREGOH’I Reprint requests to Dr Atiyeh: Division of Plastic and Rcconstructivc Surgq’, AnlcXicdn University New York. NY 10022.

of Beirut.

850 Third

Avc- 18th Floor.

New Book Annotations Ix&a-Arterial cer4urrent

Chemotherapy Results and

in Future

Head and Perspectives.

Neck

A (ed) with 20 contributors. Reinbek/Germany, Presse Verlag, 1999. 201 pages, illustrdted, $132.00

Can-

Eckardt. Einhom-

This book gives a comprehensive overview of the experimental and clinical work in the field of regional chemotherapy in head and neck cancer. Historic developments in this area are outlined and significant technical advances during