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Routes of entry of squamous cell carcinoma to the mandible
CURRENT LITERATURE ABSTRACTS The Scalp as a Donor Site in Bums. Zingaro E, Capozzi A, Pennisi V. Arch Surg 123:652, 1988
Carcinomas of the oral region that are in close proximity to the mandible are commonly resected with a full thickness of the adjacent mandible being included in the surgical specimen. This method of resection frequently creates a situation that makes functional and aesthetic reconstruction difficult. Some head and neck surgeons have tried to limit the extent of mandibular reconstructive problems by leaving the inferior border of the mandible intact when there is no gross evidence of involvement of that portion of the mandible. This philosophy is based on the frequent clinical observation that when carcinomas invade the mandible, the invasion is limited to residual alveolar bone. Sixty-two mandibles found histologically to be invaded by squamous cell carcinomas were studied for the sites of entry of the tumor. Forty-six of the mandibles had never been irradiated, and 36 of these were fully edentulous. The surfaces invaded in order of frequency were the alveolar crest, 31; lingual plate, nine; buccal plate, two; mental or mandibular foramen, one (each). In no case was the lower border penetrated by tumor in the absence of total replacement of the mandible by tumor. The prominence of involvement of the alveolar crest and lack of inferior border tumor was also seen in the ten partially edentulous mandibles. Sixteen mandibles that had been irradiated were also studied and the order of frequency of mandible surfaces penetrated was alveolar crest, 11; lingual plate, ten; buccal plate, six; inferior border, four; and mandibular foramen, one. The results help support the concept of avoiding full thickness mandibular resections when the clinical situation makes it unlikely that the carcinoma has spread widely into the nonirradiated mandible. But once a mandible has been irradiated, the likelihood of entry of tumor into the inferior border may rise, increasing the risk of undertaking only a rim resection.-J.R. HUPP
The scalp is presented as a donor site for skin grafting, particularly in the severely burned patient. The advantages include the availability of a large donor site that is well concealed and heals rapidly. A series of 21 patients on whom this procedure was performed is reviewed. The technique of harvesting the split thickness skin grafts in this area requires the use of a Pitkin’s syringe and Brown air dermatome. Based on the anatomy of the scalp, the need for subgaleal injections of fluid to stabilize the scalp is noted. The advantage of this procedure in the extensively burned child because of relative body surface area distributions is also noted. Excessive blood loss, hypertrophic scarring, and the need for hair transplantation have not been noted. Complete hair regrowth was observed in nearly all cases.-M. HARRIS Reprint requests to Dr. Zingaro: Bothin Bum Center, St. Francis Memorial Hospital, 900 Hyde St, San Francisco, CA 94109.
Endocrinology and Osteoporosis. Selby PL, Francis RM. J Endocrinol 117: 1, 1988 The association of osteoporosis with various endocrine disorders is discussed in this review article. A number of general factors contribute to age-related bone loss including menopause, smoking, decreased physical activity, and a decline in calcium absorption with age. Several conditions due to endocrine disturbance are associated with the development of osteoporosis. Despite general acceptance of the major role of estrogen in reducing bone resorption, there is no agreement as to the mechanism of action. Nonetheless, good evidence exists that estrogen treatment reduces bone resorption, decreases the loss of cortical and trabecular bone, and reduces the incidence of fracture in postmenopausal women. Thyrotoxicosis is another cause of osteoporosis due to a marked increase in bone resorption accompanied by an increase in bone formation which fails to keep pace with resorption. The rise in plasma calcium this process causes leads to the suppression of parathyroid hormone and malabsorption of calcium. These problems are reversed when a euthyroid state is reestablished. Corticosteroid therapy, through an effect on bowel mucosa, causes calcium malabsorption. Corticosteroids are also believed to enchance osteoclast attachment to bone thus stimulating resorption. In addition, the suppression of bone formation and collagen production by corticosteroids causes further skeletal compromise. Finally, many feel that diabetic osteopenia is a real entity. Various explanations have been given for how diabetes mellitus might affect bone metabolism but no consensus exists to help guide the management of diabetics with respect to their bone mass.-J. R. HUPP
Reprint requests to Dr. MacDonald: Glasgow Dental Hospital, 378 Sauchiehalol St, Glasgow, GZ 352, United Kingdom. Cocaine
Absorption
From the Nasal Mucosa. Bromley
Hayward A. Anaesthesia
L,
43:356, 1988
Thirty adults undergoing routine nasal surgery were divided randomly into two groups, receiving an equal volume of a cocaine topical anesthetic solution. The group 1 solution consisted of 2 mL of 10% cocaine, 2 mL of 1% sodium bicarbonate, and 16 mL of sterile water. The group 2 solution consisted of 2 mL of 10% cocaine, 2 mL of 1% sodium bicarbonate, 1 mL of 1:1,000 epinephrine, and 15 mL of sterile water. Serial arterial blood pressures were recorded and venous blood samples obtained at 10, 15,30, and 60 minutes following application of the topical anesthetic solution to the nasal mucosa. There was a statistically significant difference between the plasma levels of cocaine in the two groups, with lower levels in group 2. This effect was most marked at the 15minute sampling time, where there was a tenfold difference in mean plasma cocaine between the two groups. There were no significant differences in arterial blood pressure and heart rate between the two groups. Three patients in the cocaine plus epinephrine group developed bradycardia, one requiring administration of atropine. The authors state that a minority of conscious patients who receive cocaine
Reprint requests to Dr. Selby: Department of Medicine, University of Newcastle Upon Tyne, The Medical School, Framlington Place, Newcastle Upon Tyne, England, NE2 4HH.
Routes of Entry of Squamous Cell Carcinoma to the Mandible. McGregor AD, MacDonald DG. Head Neck Surg 10:294, 1988 911
Carcinomas of the oral region that are in close proximity to the mandible are commonly resected with a full thickness of the adjacent mandible being included in the surgical specimen. This method of resection frequently creates a situation that makes functional and aesthetic reconstruction difficult. Some head and neck surgeons have tried to limit the extent of mandibular reconstructive problems by leaving the inferior border of the mandible intact when there is no gross evidence of involvement of that portion of the mandible. This philosophy is based on the frequent clinical observation that when carcinomas invade the mandible, the invasion is limited to residual alveolar bone. Sixty-two mandibles found histologically to be invaded by squamous cell carcinomas were studied for the sites of entry of the tumor. Forty-six of the mandibles had never been irradiated, and 36 of these were fully edentulous. The surfaces invaded in order of frequency were the alveolar crest, 31; lingual plate, nine; buccal plate, two; mental or mandibular foramen, one (each). In no case was the lower border penetrated by tumor in the absence of total replacement of the mandible by tumor. The prominence of involvement of the alveolar crest and lack of inferior border tumor was also seen in the ten partially edentulous mandibles. Sixteen mandibles that had been irradiated were also studied and the order of frequency of mandible surfaces penetrated was alveolar crest, 11; lingual plate, ten; buccal plate, six; inferior border, four; and mandibular foramen, one. The results help support the concept of avoiding full thickness mandibular resections when the clinical situation makes it unlikely that the carcinoma has spread widely into the nonirradiated mandible. But once a mandible has been irradiated, the likelihood of entry of tumor into the inferior border may rise, increasing the risk of undertaking only a rim resection.-J.R. HUPP
The scalp is presented as a donor site for skin grafting, particularly in the severely burned patient. The advantages include the availability of a large donor site that is well concealed and heals rapidly. A series of 21 patients on whom this procedure was performed is reviewed. The technique of harvesting the split thickness skin grafts in this area requires the use of a Pitkin’s syringe and Brown air dermatome. Based on the anatomy of the scalp, the need for subgaleal injections of fluid to stabilize the scalp is noted. The advantage of this procedure in the extensively burned child because of relative body surface area distributions is also noted. Excessive blood loss, hypertrophic scarring, and the need for hair transplantation have not been noted. Complete hair regrowth was observed in nearly all cases.-M. HARRIS Reprint requests to Dr. Zingaro: Bothin Bum Center, St. Francis Memorial Hospital, 900 Hyde St, San Francisco, CA 94109.
Endocrinology and Osteoporosis. Selby PL, Francis RM. J Endocrinol 117: 1, 1988 The association of osteoporosis with various endocrine disorders is discussed in this review article. A number of general factors contribute to age-related bone loss including menopause, smoking, decreased physical activity, and a decline in calcium absorption with age. Several conditions due to endocrine disturbance are associated with the development of osteoporosis. Despite general acceptance of the major role of estrogen in reducing bone resorption, there is no agreement as to the mechanism of action. Nonetheless, good evidence exists that estrogen treatment reduces bone resorption, decreases the loss of cortical and trabecular bone, and reduces the incidence of fracture in postmenopausal women. Thyrotoxicosis is another cause of osteoporosis due to a marked increase in bone resorption accompanied by an increase in bone formation which fails to keep pace with resorption. The rise in plasma calcium this process causes leads to the suppression of parathyroid hormone and malabsorption of calcium. These problems are reversed when a euthyroid state is reestablished. Corticosteroid therapy, through an effect on bowel mucosa, causes calcium malabsorption. Corticosteroids are also believed to enchance osteoclast attachment to bone thus stimulating resorption. In addition, the suppression of bone formation and collagen production by corticosteroids causes further skeletal compromise. Finally, many feel that diabetic osteopenia is a real entity. Various explanations have been given for how diabetes mellitus might affect bone metabolism but no consensus exists to help guide the management of diabetics with respect to their bone mass.-J. R. HUPP
Reprint requests to Dr. MacDonald: Glasgow Dental Hospital, 378 Sauchiehalol St, Glasgow, GZ 352, United Kingdom. Cocaine
Absorption
From the Nasal Mucosa. Bromley
Hayward A. Anaesthesia
L,
43:356, 1988
Thirty adults undergoing routine nasal surgery were divided randomly into two groups, receiving an equal volume of a cocaine topical anesthetic solution. The group 1 solution consisted of 2 mL of 10% cocaine, 2 mL of 1% sodium bicarbonate, and 16 mL of sterile water. The group 2 solution consisted of 2 mL of 10% cocaine, 2 mL of 1% sodium bicarbonate, 1 mL of 1:1,000 epinephrine, and 15 mL of sterile water. Serial arterial blood pressures were recorded and venous blood samples obtained at 10, 15,30, and 60 minutes following application of the topical anesthetic solution to the nasal mucosa. There was a statistically significant difference between the plasma levels of cocaine in the two groups, with lower levels in group 2. This effect was most marked at the 15minute sampling time, where there was a tenfold difference in mean plasma cocaine between the two groups. There were no significant differences in arterial blood pressure and heart rate between the two groups. Three patients in the cocaine plus epinephrine group developed bradycardia, one requiring administration of atropine. The authors state that a minority of conscious patients who receive cocaine
Reprint requests to Dr. Selby: Department of Medicine, University of Newcastle Upon Tyne, The Medical School, Framlington Place, Newcastle Upon Tyne, England, NE2 4HH.
Routes of Entry of Squamous Cell Carcinoma to the Mandible. McGregor AD, MacDonald DG. Head Neck Surg 10:294, 1988 911