Timing and dosage of postoperative radiotherapy for squamous cell carcinoma of the upper aerodigestive tract

Surgeons

Journal Abstracts Use of a free conchal cartilage graft for closure of a palatal fistula: An experimental study and clinical application. N. Ohsumi, T. Onizuka, Y. Zto Plast Reconstr Surg 1993; 91: 433-440. Cleft palate repair particularly following pushback palatoplasty frequently results in the formation of a palatal fistula. However, fistula recurrences rates following surgical closure have been reported to be as high as 50% in some studies. This paper reports on the use of free conchal cartilage graft in the closure of palatal fistula. In the animal experiment, an oronasal fistula, 10 mm in diameter was created in the hard palate of 33 rabbits. One month later, the size of all the fistula decreased spontaneously to 2-3 mm in diameter. The animals were then divided into 2 groups. Group I (n = 8) served as a control in which surgical closure of the fistula was not performed. In Group 2 (n=25), the fistula was closed utilizing an autogenous free conchal cartilage graft. The cartilage with attached perichondrium was inserted into a surgically created mucosal pocket around the bony defect. In 75% (6 of 8) of the control group, the fistula persisted but in 96% (24 of 25) of the experimental group, the palatal fist&a was successfully closed. Histological examination demonstrated healing by local epithelial migration and complete replacement of the cartilaginous graft by fibrous scar tissue. In 24 cleft lip and palate patients, closure of a palatal fistula was performed using autogenous conchal cartilage. The mean age of the patients was 7.6 years and the mean follow up period 15.2 months. The size of the palatal fistula varied from a slit like hole to 8-11 mm in diameter. Patients were divided into 3 subgroups (8 patients per group) based on the size and location of the fistula in the hard palate. Very small fistulas (Type I<2 mm diameter) were closed by inserting the graft into a surgically created pocket as outlined in the animal experiment. Medium size fistulas (Type II 225 mm diameter) were closed with a local hinge flap and graft whereas larger fistulas (Type III z 5 mm diameter) required a large hinge flap, a conchal graft and a local mucosal flap. Vestibular flaps were used for anterior fistulas whilst a posterior fistula required a palatal mucosal flap. The overall success of this technique was 91.7% although the technique is only recommended for a fistula with a diameter less than 10 mm. Morbidity from the donor site was negligible. The technique results in a palate with near normal morphology in which complete closure of the nasal layer is not required. W. P. Smith Chichester UK

Electromyographic evaluation of continuous passive motion manual rehabilitation of the temporomandibular joint. R. R. J. Van Sickels. J Oral Maxillofac Surg 1993; 51: 1311-1314.

versus

Lemke,

A study to evaluate electromyographically (EMG) the degree of muscle activity that occurs with continuous passive motion (CPM) compared with traditional mandibular exercises with tongue depressors is reported by Drs Lemke and Van Sickels. Eight TMJ surgery candidates were prospectively evaluated with two modes of postoperative physiotherapy. All patients had failed traditional non-surgical therapy. Surgeries were five open arthrotomies and three arthroscopies. CPM began within 12 h of surgery on all patients. The electromyographic (EMG) activity measurements were done within 1 week of surgery. The project was well controlled for variables. The comparisons were done on suprahyoid (opening) muscles and masseter (closing) muscle groups. Measurements were made at rest, maximum opening and during the opening/closing cycle with the CPM machines (passive) and tongue blades (active) to achieve the same results. Statistical analysis showed the resting

and maximal opening EMG activity to be similar with CPM and tongue blades. The activity was significantly different when comparing the open/closing cycles with CPM to tongue blades. The significance level was set at P less than 0.05 and showed less activity with the CPM device. The authors believe that the similarity between resting and maximal opening between the two techniques suggests that the patients tolerated the CPM device and no increase in muscle activity was needed to tolerate the CPM device. The differences between active cycles with CPM and tongue blades does demonstrate less muscle activity with CPM. The authors believe this demonstrates the passive nature of CPM. The advantages of this are hypothesized by the authors. This is an interesting study which is worth reading. Reprint requests: Dr J. Van Sickels; Department of Oral and Maxillofacial Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 7828467908. D. E. Frost Chapel J3ill USA Rigid J. V.

fixation

of comminuted

Johnson. J Oral Maxillofac

mandibular fractures. B. R. Surg 1993; 51: 1320-1326.

Smith,

Comminuted mandibular fractures have traditionally been treated with closed reduction following the premise that minimal stripping of periosteum from small bony segments would avoid infections, loss of viability of segments and generally lead to better long term results. This time proven technique is being challenged by advocates of rigid internal fixation which lists comminution as an absolute indication for rigid fixation. This retrospective study evaluates results in a small (15 patients-16 fractures) group of comminuted mandibular fractures treated in a trauma center with open reduction and internal fixation with rigid internal fixation using A0 2.7 mm reconstruction plates in 13 cases and multiple 2.0 mm mini-plates in two cases. There were no controls nor a comparison population treated traditionally. The results showed a 13% infection rate which is certainly acceptable for this population group. The opening range, seventh and fifth nerve deficits are reported and seem reasonable, however, are essentially without meaning with no controls or comparison treatment group. The authors’ conclusion, that rigid fixation of comminuted mandible fractures with A0 reconstruction plates or, in the case of comminuted ramus fractures, 2.0 mm mini-plates as a viable treatment modality seems supported. However, one is cautioned to remember that comminution has a wide spectrum and the basic premise of maintaining as much periosteal coverage on small fragments as possible still is logical This basically is a report of a series of 15 patients with various degrees of comminuted mandibular fractures treated with rigid internal fixation. The results were acceptable. Reprint requests to: Dr B. R. Smith, Department of Oral and Maxillofacial Surgery, School of Medicine in Shreveport, Louisiana State University Medical Center, 1501 Kings Highway, PO Box 33932, Shreveport, Louisiana 71130-3932. D. E. Frost Chapel Dill USA Tin&g and dosage of postoperative radiotherapy cell carcinoma of the upper aerodigestive tract.

K. J. Buechter, L. E. Bairnsfeather, Maxillofac The (PI)

Surg

for

squamous

Z? L. Ampil, W. W. Shockley. J Oral

1993; 51: 119441197.

controversy over delay in elective postoperative and its effect on the local and regional recurrence

irradiation rate (LRR)

Journal was evaluated in this retrospective study. The authors looked at 70 patients treated over a 244year period. The patients were similar except for the timing of PI. Inclusion criteria were stage III or stage IV squamous cell carcinoma of the upper aerodigestive tract, the PI was delivered via parallel opposed lateral ports which included the primary tumour site, upper neck and anterior lower neck, no local or regional disease or distant metastasis at time of PI initiation and evaluable for LRR at time of death or after a minimum of 2 years follow-up. Surgical procedures were described as ‘curative’. In 40 patients, PI was given within 6 weeks of surgery, while in 30 patients, it was delivered greater than 6 weeks after surgery. Radiation techniques were similar for the two groups. An overall recurrence rate of 27% (19 of 70) was noted. The difference between LRR’s for timely PI (less than six weeks) and delayed (greater than 6 weeks) was not significant at the P less than or equal to 0.05 level. The absolute numbers showed a tendency in favor of timely PI. (S/40 = 20% for timely vs. 1 l/30 = 37% for delayed). Many complicating factors which are common to retrospective studies are noted by the authors. They contradict their data in the conclusions by stating that an ‘escalated total dose of PI may have to be considered when prolonged interval...is unavoidable’. The data they reported shows a tendency to higher LRR’s or no change in the LRR when increased doses are used in the prolonged delayed PI. Overall the article is interesting and should be used to direct future prospective evaluations of postoperative irradiation. Reprint requests should be directed to: Dr F. L. Ampil, Department of Radiology, Louisiana State University Medical Center, 1501 Kings Highway, PO Box 33932, Shreveport, Louisiana 71130-3932. D. E. Frost Chapel Hill USA

Temporomandibular joint clicking only on closure: report of a case and explanation of the cause. S. W: Wise, W. F. Conway, D. M Laskin. J Oral Maxillofac Surg 1993; 51: 127221273. An interesting case of clicking TMJ only on closure is reported. The patient had undergone previous conservative joint therapy as well as joint surgery in the form of ‘discoplasty and condylar shave’. She subsequently had pain and a loud click on closure. The interesting point in this case is an MRI confirmed translation of the condyle over the anterior band of the disc. The disc was surgically confirmed to have been adherent to the eminence and posterior aspect of the glenoid fossa. This adhesion was thought to be secondary to either previous trauma or the initial surgery. While not a totally unique case, the MRI’s were quite revealing and definitely showed the condyle translating over the anterior band in a fixed disc. This article will be interesting to those treating TMJ patients. Request for reprints to: Dr W. F. Conway, Department of Radiology, Box 615, MCV Station, Richmond, Virginia 23298-0615. D. E. Frost Chapel Hill USA

Tumor radiotherapy R. Wiichter. Dtsch 17: 224-229.

and defect bridging osteosynthesis? Z Mund-, Kieferund Gesichtschirurgie

The possibility for application therapy for malignancies while

R.

Stall, 1993;

of peri- or postoperative radiofixation material is in place is still

abstracts

195

subject of controversies. The increase of local dosage in the surrounding of the plate may cause damage to the adjacent tissue. The authors have carried out an animal experiment, and the osteogenetic activities at the bone/screw interface were assessed qualitatively and quantitatively under fractioned peri-and/or postoperative telecobalt irradiation. The same procedure was followed with human bone sections of 20 patients. Experimental and clinical results showed a reduction in the osteogenetic activity that appeared after a time interval varying with the mode and the dose of irradiation. The reduction could be correlated with the irradiation induced vascular lesions. In humans the radiation induced lesions of the bone reached the maximum value around 180 days after the end of the radiotherapy. A further recovery of the bone cannot be expected until at least 2 years, therefore, immediate plate - placement b’efore radiolesions of the bone occur seems not to be related with an increased risk for complications. Backscattering effects in front of a fixation plate and shadowing effects behind plates seem not to have any effect on the efficiency of the radiotherapy and on the rate of adverse effects in the surrounding tissue. R. Schmelzeisen Hannover Germany Evaluation of dexamethasone for reducing postoperative oedema and inflammatory response after orthognathic surgery. C. R. Weber, J. M. &z$n. J Oral Macillofac Surg 1994; 52: 35-39. Using a randomized, prospective, double-blind study design to evaluate efficacy of dosing schedules for intravenous dexamethasone in reducing postoperative oedema associated with sagittal split osteotomies, the authors found significant reduction in oedema in the first postoperative day and significant reduction in C-reactive proteins on postoperative days 1, 2 and 3. 23 patients were assigned to one of three groups. Group 1 (N= 7) was a control; group 2 (N = 8) received 16 mg of dexamethasone preoperatively and placebo postoperatively while group 3 (N = 8) received 16 mg of dexamethasone preoperatively and 8 mg every 6 h postoperatively for three doses. Exclusion criteria were acceptable. The groups were not different statistically but had a wide age range and sex difference (9 males and 14 females). Surgical time was statistically not different but there was a 9% difference between Group 1 at 186 min and Group 2 at 164 min. Group 3 was between the two at 175 min. No discussion of fixation type was given. It can be assumed that transoral rigid fixation, transcutaneous rigid fixation, and wire osteosynthesis all have varying degrees of soft tissue trauma. Advancement sagittal split osteotomies may be expected to have different patterns of oedema than set-backs. It was not mentioned whether these were all advancements or a mixed group. Also important in standardization is operator experience and consistency. The authors state ‘and/or several other surgeons’ performed the surgery. All of these factors may lead to substantial differences in oedema. The use of standardized frontal photographs and computer assistance for measuring oedema is not novel. The results showed improvement with steroids, but no significant difference between Groups2 and 3. The C-reactive protein measurement, which is less related to surgical trauma and more related to steroid injection, as expected, was significantly elevated in the non-dexamethasone group. In general, this article supports use of steroids for orthognathic surgery, but it could be improved from a scientific point with tighter control of the groups. No conclusions can be made about doses of dexamethasone postoperatively. Requests for reprints to Dr C. Weber, Slst Combat Support Hospital, Box 16, APO AE 09242. D. E. Frost Chapel Hill USA