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The contemporary management of chyle leak following cervical thoracic duct injury: a literature review
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Poster presentation / British Journal of Oral and Maxillofacial Surgery 49S (2011) S26–S116
P27 Eye wide shut on a small island: a case report on the early remote management of tension pneumo-orbit and review of the contemporary literature J. Blythe ∗ , S. Lagichetty, S. Walsh Queen Alexandra Hospital, Portsmouth/St Mary’s Hospital, IOW/St Richard’s Hospital Chichester, United Kingdom Introduction: An indirect optic nerve injury caused by tension pneumo-orbit (orbital compartment syndrome) is a rare complication of orbital fractures. The disrupted bony and soft tissues can adopt a one-way air valve mechanism with the paranasal sinuses. Post-trauma nose blowing may result in the rapid development of orbital emphysema. The resultant rise in intra-orbit pressure threatens the orbital neuro-vascular apparatus. Surgical decompression at the earliest opportunity is the gold standard for safeguarding vision in sight-threatening cases. Early intervention becomes a logistical challenge when midfacial fractures occur in remote geographic locations lacking expert experience or when delays in patient transfer risk irreversible morbidity. Method: This article presents a case of rapidly deteriorating vision secondary to indirect optic nerve injury out of hours, out at sea and out of reach of maxillofacial surgeons. Urgent canthotomy was performed by a novice surgeon in an emergency department under the telephone guidance of a maxillofacial surgeon. Followed by urgent helicopter transfer to mainland tertiary care. Result: Normal visual acuity returned within forty-eight hours of surgical intervention. Conclusion: The case highlights the rare and important role of telephone-based diagnosis and surgical guidance. The article describes the clinical features, initial surgical and medical management, and definitive care. In addition, the contemporary literature on tension pneumo-orbit is reviewed. doi:10.1016/j.bjoms.2011.03.036 P28 The contemporary management of chyle leak following cervical thoracic duct injury: a literature review J. Blythe ∗ , R.J.R. Smith, A. Gulati, A. Habib, K. Herd, R. Anand, P.A. Brennan Queen Alexandra Hospital, Portsmouth, United Kingdom Introduction: There have been significant medical and surgical advances in the management of iatrogenic cervical thoracic duct injury in recent years. Newer techniques have been shown to improve the effectiveness and efficiency of intra-operative management following ductal injury during neck dissection. This poster provides a concise review of the contemporary literature on the management of cervical thoracic duct injury and its sequelae.
Method: A MEDLINE search was undertaken to identify contemporary papers detailing medical and surgical management of chylous leaks. Results: Traditionally, identification of a cervical chylous leak intra-operatively has been managed surgically by duct ligation or oversewing with regional tissues. These techniques have their limitations. Contemporary authors have reported that fibrin glue or cyanoacrylate application over the breached area offers an efficient and conservative management alternative. If primary intervention is unsuccessful or if diagnosis of a chylous leak is delayed then medical management techniques should be initiated in the first instance. This is initially focussed on reversing hypovolaemia and protein and electrolyte deficiencies followed by a tailored approach to stem chyle flow and promote ductal healing. However, if the chyle leak is excessive or continues for 1–2 weeks either re-exploration of the site or ligation of the duct in the thoracic cavity (using either an open or video-assisted thoracic surgery) is recommended. Conclusion: A concise review of the contemporary literature reporting the management of iatrogenic chylous leaks is presented here along with a useful algorithm for reference. doi:10.1016/j.bjoms.2011.03.037 P29 The potential impact of the 2010 tuition fee policy on double qualification: a junior trainee perspective J. Blythe ∗ , D. Patel, A. Gulati, J.J. Scott, R.A. Anand, P.A. Brennan Queen Alexandra Hospital, Portsmouth, United Kingdom Introduction: In 2010 the government passed the controversial student tuition fee policy. From 2012 this will have a significant economic burden on junior trainees pursuing a career in oral and maxillofacial surgery. It is expected that most medical and dental courses will charge the maximum amount. The financial impact of fees up to £9000 per annum for two clinical degrees will potentially deter the most promising future maxillofacial surgeons. This may have grave consequences for the speciality and a ‘knee-jerk’ shift in undergraduate training may be required for future OMFS surgeons. By assessing the impact on future trainees the speciality can focus efforts to assist potential maxillofacial surgeons achieve their aspirations. The aim of this study was to evaluate the contemporary views of junior trainees undertaking or preparing to undertake their second clinical degree. Assessing the potential impact the change in legislation would have on trainees aspiring to a career in oral and maxillofacial surgery. Method: A questionnaire was completed by cohort of junior BAOMS trainees. Their attitudes towards the tuition fee legislation and impact on training assessed. In addition,
Poster presentation / British Journal of Oral and Maxillofacial Surgery 49S (2011) S26–S116
P27 Eye wide shut on a small island: a case report on the early remote management of tension pneumo-orbit and review of the contemporary literature J. Blythe ∗ , S. Lagichetty, S. Walsh Queen Alexandra Hospital, Portsmouth/St Mary’s Hospital, IOW/St Richard’s Hospital Chichester, United Kingdom Introduction: An indirect optic nerve injury caused by tension pneumo-orbit (orbital compartment syndrome) is a rare complication of orbital fractures. The disrupted bony and soft tissues can adopt a one-way air valve mechanism with the paranasal sinuses. Post-trauma nose blowing may result in the rapid development of orbital emphysema. The resultant rise in intra-orbit pressure threatens the orbital neuro-vascular apparatus. Surgical decompression at the earliest opportunity is the gold standard for safeguarding vision in sight-threatening cases. Early intervention becomes a logistical challenge when midfacial fractures occur in remote geographic locations lacking expert experience or when delays in patient transfer risk irreversible morbidity. Method: This article presents a case of rapidly deteriorating vision secondary to indirect optic nerve injury out of hours, out at sea and out of reach of maxillofacial surgeons. Urgent canthotomy was performed by a novice surgeon in an emergency department under the telephone guidance of a maxillofacial surgeon. Followed by urgent helicopter transfer to mainland tertiary care. Result: Normal visual acuity returned within forty-eight hours of surgical intervention. Conclusion: The case highlights the rare and important role of telephone-based diagnosis and surgical guidance. The article describes the clinical features, initial surgical and medical management, and definitive care. In addition, the contemporary literature on tension pneumo-orbit is reviewed. doi:10.1016/j.bjoms.2011.03.036 P28 The contemporary management of chyle leak following cervical thoracic duct injury: a literature review J. Blythe ∗ , R.J.R. Smith, A. Gulati, A. Habib, K. Herd, R. Anand, P.A. Brennan Queen Alexandra Hospital, Portsmouth, United Kingdom Introduction: There have been significant medical and surgical advances in the management of iatrogenic cervical thoracic duct injury in recent years. Newer techniques have been shown to improve the effectiveness and efficiency of intra-operative management following ductal injury during neck dissection. This poster provides a concise review of the contemporary literature on the management of cervical thoracic duct injury and its sequelae.
Method: A MEDLINE search was undertaken to identify contemporary papers detailing medical and surgical management of chylous leaks. Results: Traditionally, identification of a cervical chylous leak intra-operatively has been managed surgically by duct ligation or oversewing with regional tissues. These techniques have their limitations. Contemporary authors have reported that fibrin glue or cyanoacrylate application over the breached area offers an efficient and conservative management alternative. If primary intervention is unsuccessful or if diagnosis of a chylous leak is delayed then medical management techniques should be initiated in the first instance. This is initially focussed on reversing hypovolaemia and protein and electrolyte deficiencies followed by a tailored approach to stem chyle flow and promote ductal healing. However, if the chyle leak is excessive or continues for 1–2 weeks either re-exploration of the site or ligation of the duct in the thoracic cavity (using either an open or video-assisted thoracic surgery) is recommended. Conclusion: A concise review of the contemporary literature reporting the management of iatrogenic chylous leaks is presented here along with a useful algorithm for reference. doi:10.1016/j.bjoms.2011.03.037 P29 The potential impact of the 2010 tuition fee policy on double qualification: a junior trainee perspective J. Blythe ∗ , D. Patel, A. Gulati, J.J. Scott, R.A. Anand, P.A. Brennan Queen Alexandra Hospital, Portsmouth, United Kingdom Introduction: In 2010 the government passed the controversial student tuition fee policy. From 2012 this will have a significant economic burden on junior trainees pursuing a career in oral and maxillofacial surgery. It is expected that most medical and dental courses will charge the maximum amount. The financial impact of fees up to £9000 per annum for two clinical degrees will potentially deter the most promising future maxillofacial surgeons. This may have grave consequences for the speciality and a ‘knee-jerk’ shift in undergraduate training may be required for future OMFS surgeons. By assessing the impact on future trainees the speciality can focus efforts to assist potential maxillofacial surgeons achieve their aspirations. The aim of this study was to evaluate the contemporary views of junior trainees undertaking or preparing to undertake their second clinical degree. Assessing the potential impact the change in legislation would have on trainees aspiring to a career in oral and maxillofacial surgery. Method: A questionnaire was completed by cohort of junior BAOMS trainees. Their attitudes towards the tuition fee legislation and impact on training assessed. In addition,