Biomedical subjects
P Magennis
Publications and source records attributed to P Magennis.
Timing and presentation of recurrent oral and oropharyngeal squamous cell carcinoma and awareness in the outpatient clinic.
The aim of this study was to assess the timing of outpatient review appointments in relation to tumour recurrence. A retrospective review of 278 consecutive previously untreated patients with oral and oropharyngeal squamous cell carcinoma (SCC) between 1995 and 1999 was performed. Information on the time of recurrence, site, presentation, treatment and outcome was collected. There were 54 (19%) patients who developed recurrent disease. Recurrence occurred at a median time of 8 months after the initial operation and most (49/54) within 2 years. Thirty-five patients (65%) presented with a new lump (7 local, 22 regional and 5 locoregional). Our policy is to review patients once a month for the first year and every other month for the second year. Patients were seen less frequently than expected, and one in five patients attended half or less than half as frequently as intended in the first year. Although 20 patients were aware of new symptoms from their recurrent disease fewer than half (9) brought their appointment forward. This study has emphasised the need for close clinical follow-up of patients previously treated for oral/oropharyngeal SCC if recurrent tumours are to be discovered and treated at the earliest opportunity.
Trends in head and neck microvascular reconstructive surgery in Liverpool (1992-2001).
Microvascular reconstructive techniques in head and neck surgery are well established, but we are now entering an era of modification exemplified by perforator and free style free flaps. We present a review of the database introduced into the unit in 1992 over a 10-year period, during which time 977 patients with malignant disease were operated on and 620 defects were reconstructed with free flaps. There were 358 radial forearm flaps, 78 composite radial forearm flaps, 84 iliac crest flaps, 43 fibular flaps, 24 from the scapula, 26 from the latissimus dorsi, 4 from the rectus abdominis, and 3 from the lateral arm. The main changes over this time have been the use of more bulky flaps for larger resections of the tongue and the preference for iliac crest flaps over those from the fibula and forearm for composite reconstructions. Improving reliability of tissue transfer remains an important aim, and further development of reliable objective methods of monitoring of flaps is required.
The correlation between indices of deprivation and health-related quality of life in patients with oral and oropharyngeal squamous cell carcinoma.
Deprivation influences the incidence and outcome of patients with cancer. Health-related quality of life (HR-QoL) is an important measure of outcome but there is little on this subject and its correlation with deprivation in patients with oral and oropharyngeal cancer. Our aim was to ascertain the extent of deprivation in a cohort of patients who had operations for primary oral and oropharyngeal cancer and how deprivation affected HR-QoL in these patients during and after their treatment. A total of 278 consecutive patients who were operated on for oral and oropharyngeal cancer were included in this study. Validated measures of deprivation scores (Townsend, Carstairs, Jarman and Index of Multiple Deprivation 2000) were calculated, as well as patient-based indicators of social circumstances (marital status, smoking habit, alcohol intake). Comparison was made with the University of Washington-Quality of Life (UW-QoL) scores before and after treatment (6, 12, and 24 months).
Factors that influence the outcome of salvage in free tissue transfer.
INTRODUCTION: The success of salvage techniques for free tissue transfer is well documented. The aim of this study was to identify factors that influenced the results of salvage operations in a group of patients who required early exploration. METHODS: From a database survey of 408 patients who had a total of 427 free tissue transfer reconstructions, 65 (16%) returned to the operating theatre within 7 days. A retrospective analysis of their progress was made from the case records. RESULTS: The flap chart was found to be highly accurate for the 65 patients who had returned to the operating theatre, reporting two false positives and one false negative. Forty patients had compromised flaps and 25 had haematomas that required evacuation. The commonest problem with flaps was venous congestion (33/40, 83%), and 29 flaps were successfully salvaged (73%). Most successful salvage attempts were made within 24 hours of the end of the initial operation. The salvage rate was higher for the radial fasciocutaneous flaps (25/30, 83%), than for composite flaps (2/7, 29%). A total of 24/427 flaps failed (6%). CONCLUSIONS: We now recommend hourly observations of the flap for 24 hours followed by 4-hourly monitoring for 48 hours. Improved monitoring techniques for composite grafts may result in more being salvaged and a better overall survival.
Factors that influence the method of mandibular resection in the management of oral squamous cell carcinoma.
The method of conservative (rim) resection of the mandible is now well established and provides good control of disease in the primary site. There are few audits of this technique in terms of margins of resection for both rim and segmental resection of the mandible. Consecutive previously untreated patients managed with resection of the mandible as part of their treatment for oral and oropharyngeal squamous cell carcinoma were recruited for the study. The presence and extent of tumour invasion of the mandible was recorded and a retrospective analysis made to establish the incidence of unnecessary segmental resections. The invasion rate was 33% (8/35) for rims and 83% (54/65) in segmental resections of the mandible, which compares favourably with previous studies and indicates a reasonable accuracy of resection. In between 6 and 11 of the 62 cases (10-17%) a rim resection could have achieved a satisfactory resection margin and retained a functioning lower border of the mandible. The accuracy of resection in terms of margins was greater for mandibular resections (94% clear margins) than soft tissues (62% clear margins). The number of compromised margins was significantly greater in the invaded rim resection group (P=0.018). This study indicates that a more conservative mandibular resection was possible in a few cases. This is unlikely to have an adverse effect on the close or involved margin rate, which depends mainly on the accuracy of the soft tissue resection. Angling the horizontal rim resection to take into account tumour entry at the point of contact will help to ensure a clear bone margin if a conservative approach to mandibular resection is an option.
Update on dental graduates entering medicine 1986-1991.
In a previous publication we reviewed the future career plans of 169 dental graduates who entered medical school from 1986 to 1991 inclusive. The aim of the present study was to find out what happened to this group after qualification from medical school. The 169 individuals were traced and a questionnaire was sent to them by mail. A reminder was sent and some data for non-respondents were obtained from public sources such as registers and directories. In the original study, 120 of the 154 respondents (78%) intended to become oral and maxillofacial surgeons. We found in this follow up survey that the overall return rate to oral and maxillofacial surgery (OMFS) had dropped to 66%. For those not returning to the speciality, a wide range of alternative specialities had been chosen, with general medical practice (n=9) and oral medicine (n=8) being the most popular. Amongst those returning to OMFS, most undertook basic surgical training in general surgery and trauma. Two thirds of those eligible possessed the FRCS, with 43 (83%) holding the FRCS (Clinical Surgery in General) and six (12%) having the FRCS Ed (oral and maxillofacial surgery). Within the group, opinions were mixed about the changes caused by 'Hospital doctors: training for the future' (Calman Report) [Working Group on Specialist Medical Training. Hospital doctors: training for the future. London: Department of Health, 1993]. Concerns were voiced about the potential reduction in clinical experience, comparatively longer training for OMFS, and particularly the abrupt end of training with no protection whilst seeking a consultant appointment. Half thought that OMFS will become concentrated in supraregional centres, or head and neck units with related specialities.
Death certification in patients whose primary treatment for oral and oropharyngeal carcinoma was operation: 1992-1997.
The aim of this study was to report the cause and place of death of patients with oral cancer as recorded by death certification and their survival with regard to comorbidity and age. From the departmental head and neck oncology database, 322 patients were identified with previously untreated oral and oropharyngeal squamous cell carcinoma diagnosed between 1992 and 1997 inclusive. Three-hundred were matched with the Office for National Statistics (ONS) and copies of death certificates generated on 6 March 1999. Of the 286 patients primarily treated by operation, 203 were alive and 83 had died. In 56 (68%), oral cancer was a contributory factor to the patient's death. Patients with a medical history recorded on their admission for operation had similar survival curves compared to those having no problems recorded. Although most patients (n= 46 55%) died in hospital, only 13 (16%) died in the Regional Maxillofacial Unit. Almost half of those patients who died were not recorded as dead on the departmental oncology database. This study shows that it is useful to link with the ONS to obtain accurate data on date and place of death. The death certificate also gives a useful indication of the cause of death and this seems unrelated to preoperative comorbidity.
Flap monitoring after head and neck reconstruction: evaluating an observation protocol.
This study evaluated the postoperative free-flap monitoring frequency protocol used in a maxillofacial unit for patients receiving free-tissue transfer for reconstruction following orofacial cancer. All free-tissue transfers undertaken in the unit between January 1992 and October 1998 were reviewed retrospectively. Of the 370 patients evaluated, 46 returned to theatre with compromised free flaps. The compromise was purely venous in origin in 37 of these cases, arterial in three and due to a combination of arterial and venous problems in six. Thirty-five of the flaps were successfully salvaged. On average, the clinical manifestation of the problem occurred 25.5 hours postoperatively. However, there was a significant time difference between flaps that were salvaged successfully and those that were not: in the salvaged group the compromise was identified 17.5 hours postsurgery compared with 51 hours for the unsuccessful group. The timing of the return to theatre following the identification of the compromise was a significant factor in the success rate: 71 minutes for those salvaged and 103 minutes for those not salvaged. It is recommended that flaps are monitored hourly for the first 72 postoperative hours and observations recorded on a chart.
Three years' experience of collaborative care pathways on a maxillofacial ward.
Collaborative care pathways (CCPs) provide a framework for multidisciplinary patient care. They provide guidelines and a mechanism for audit, and were first introduced at the Regional Unit, Walton Hospital, Liverpool, in November 1994. They have been designed for many surgical groups. Between August 1996 and 31 July 1997, 955 patients were admitted on to the nine established pathways: fractured mandible (n=213), fractured zygoma (n=117), minor oral surgery (n=244), abscess (n=18), examination under anaesthesia (n=73), nasal surgery (n=73), osteotomy (n=80), salivary (n=63), and temporomandibular joint (n=74). The purpose of this article is to report the introduction of CCP in a maxillofacial ward and give results from a one-year audit. CCP have proved to be an extremely useful tool and have several advantages over traditional documentation. They are more accurate, easily computerized, and facilitate audit. They promote the development of guidelines and standardized perioperative care, and this in turn facilitates training and raises standards of care.
Swallowing rehabilitation after oro-pharyngeal resection for squamous cell carcinoma.
The resection of even relatively small tumours that involve the base of tongue can lead to problems with swallowing. Free tissue transfer has improved the functional results and reduced the complications of head and neck surgery. The outcome after ablative operations depends on the site and extent of the resection, and in cases where the tongue base is involved, swallowing can be severely impaired. Aspiration in a patient with swallowing difficulties is of particular concern, however, there is a range of techniques that can be introduced during videofluoroscopy to reduce or eliminate aspiration. It is during the rehabilitation phase that procedures and techniques to improve swallowing and prevent aspiration should be incorporated. The efficacy of adaptive manoeuvres needs further evaluation, and in this study we aim to assess the effectiveness of compensatory procedures and therapy techniques (chin tuck and supraglottic swallow) in eliminating aspiration. We report on a study of the swallow function of 13 patients following surgical resection of the oropharynx including the base of tongue. Postoperative assessment by videofluoroscopy was carried out at 2 weeks, 1 month, 3 months, and 6 months according to a standard protocol. Subjects were analysed in two groups depending on the degree of resection of the tongue base resection (less than 1/4,1/4 or more).Patients' swallowing disorders were related to the extent of the resection and the consistency of the bolus. Those with involvement of a quarter of the tongue base or more generally had greater impairment, and radiotherapy tended to exacerbate these problems. Compensatory procedures and therapy techniques were effective in 50% of patients who aspirated, and tended to be more effective between the one month and 6 month follow-up in patients with smaller resections.
Pre-operative evaluation of the lower extremity prior to microvascular free fibula flap harvest.
The microvascular free fibula flap, is currently one of the preferred methods for reconstruction of the oromandibular defect. The patency of the major vessels in the donor limb should be evaluated before the fibula is harvested because the blood supply can be inadequate to safely utilise this flap. The best method of evaluating, pre-operatively, the lower limb vasculature is controversial. Femoral angiography has been considered as the gold standard, however, the current literature advocates less invasive methods of assessment such as magnetic resonance angiography and colour flow Doppler. A postal questionnaire was sent to all members of The British Association of Head and Neck Oncologists asking details of the preferred method of lower limb vascular assessment prior to fibula flap harvest. Of 137 responses, 48 performed free fibula flaps. Of these 48 surgeons, the preferred method for evaluation was palpation of pulses combined with either angiography (40%) or Doppler on the ward (38%). None of this subgroup of surgeons utilised colour flow Doppler as a first line investigation despite this being available to 67% of responders. This survey highlights the diversity in pre-operative assessment amongst surgeons performing fibula flaps for head and neck malignancy. Few relied on clinical examination alone; however, the less invasive methods of vascular imaging were seldom utilised.
Repair of the radial free flap donor site with full or partial thickness skin grafts. A prospective randomised controlled trial.
The radial forearm free flap has become the mainstay in the reconstruction of soft tissue defects following ablative resection in the oral cavity. The method of repair of the associated forearm tissue defect has been the subject of considerable debate. The options range from direct closure, to local soft tissue flaps or skin graft repair. Larger defects usually require a skin graft and we have routinely used partial thickness skin. An audit of our complication rate led to the consideration of whether a full thickness repair would reduce the morbidity. We randomly allocated successive patients to receive full or partial thickness skin graft repair of the radial donor site in a consecutive series of 68 patients over an 18-month period. Sixty-four patients completed the initial assessment period of wound healing. Thirty seven patients completed a questionnaire at one year to subjectively assess the aesthetic appearance of the forearm wound and the skin graft donor site. They were also assessed for pain at both sites. The partial thickness donor site required significantly more re-dressings. There was no significant difference between the two groups in graft take or number of re-dressings at the recipient site. There was no significant difference in patient assessment of aesthetic appearance or pain in either the forearm recipient site or the skin graft donor site. Provided that an adequate graft is taken, full thickness and partial thickness skin grafts have the same short-term and long-term outcomes in the repair of the radial free flap donor site.
Quality of life 5-10 years after primary surgery for oral and oro-pharyngeal cancer.
This study reports the quality of life in long-term survivors of oral cancer treated by primary surgery. Two hundred and twenty patients were treated at the Regional Maxillofacial Unit between the years 1987 and 1992, of which 48 were alive and disease free in July 1997. Thirty-eight patients self-completed the following questionnaires: University of Washington Quality of Life Scale (UW-QOL), the European Organisation for Research and Treatment of Cancer (EORTC) core QOQ-C30 (v2) and the EORTC Head and Neck (H&N35). Results for this group were compared with the one year findings of a similar prospective cohort treated in 1995. Long-term survivors tended to report a good or excellent quality of life. Quality of life deficits in the long-term survivors were similar to those at one year. However, a larger longitudinal study is required to test this relationship more rigorously. The similarity of domain scores suggests that quality of life evaluation at one year is a useful marker of long-term outcome.
Cerebral radionecrosis following the treatment of parotid tumours: a case report and review of the literature.
Radiotherapy is an accepted part of the treatment of malignant tumours of the parotid gland. The use of radiotherapy in benign parotid tumours, where spillage of tumour cells has occurred at operation, is more controversial. Radiotherapy to the parotid bed is not without morbidity. Complications may arise as a result of radiation damage to neighbouring structures and there is also potential to induce malignant disease. A patient, whose postoperative radiotherapy following resection of a pleomorphic salivary gland adenoma was complicated by cerebral necrosis, is discussed. The literature pertaining to morbidity of radiotherapy for parotid tumours is reviewed.
Trends in facial injury.
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Carotoid artery thrombosis following a penetrating oro-pharyngeal injury of unusual aetiology.
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The BAOMS United Kingdom survey of facial injuries part 1: aetiology and the association with alcohol consumption. British Association of Oral and Maxillofacial Surgeons.
OBJECTIVE: To determine the age and sex distribution, timing, causes, geographical location, and nature of facial injuries in the UK and to determine the association of these factors with alcohol consumption by the patient or any other involved person. DESIGN: A 12-section proforma was completed on all patients with facial injuries covering their age and sex, time and day of injury and presentation, the cause and type of injury and where it occurred, the treatment the patient received, any other injuries, and alcohol consumption by the patient and any other involved person. The total attendances for the study week and the catchment population for each A&E department were recorded. SETTING: 163 of the A&E departments in the UK served by 137 of the UK's oral and maxillofacial departments. SUBJECTS: All patients who presented with facial injuries to these 163 A&E departments in England, Scotland, Wales and Northern Ireland over the study week from 09.00 hours on Friday 12 September 1997 to 08.59 hours on Friday 19th September 1997. RESULTS: 6114 patients with facial injuries presented over the week, out of a total of 152,692 A&E attendances. The male:female ratio was 68:32. This rose to 79:21 in assault cases. The mean age of all patients was 25.3 years, of males 23.2 years, and of females 29.8 years. Forty per cent of the facial injuries were caused by falls. A large proportion of these happened to the under-5 age group in the home. Eleven per cent of all falls were associated with alcohol consumption. Twenty-four per cent of the facial injuries were caused by assault. The commonest sites for assault were the street followed by public drinking establishments. More women than men were assaulted at home. Fifty-five per cent of assaults were related to alcohol consumption. Eight per cent of assaults were with bottles or glasses. Five per cent of the facial injuries occurred in road traffic accidents (RTAs). Fifteen per cent of RTA victims had consumed alcohol. The 15-25 age group suffered the greatest number of facial injuries caused by assault and RTAs and had the highest number associated with alcohol consumption. At least 22% of all the facial injuries in all age groups were related to alcohol consumption within 4 hours of the injury. In the over 15 age groups, alcohol consumption was associated with 90% of facial injuries occurring in bars, 45% on the street, and 25% in the home. Assault, RTA and alcohol consumption conveyed an increased risk of serious facial injury. CONCLUSIONS: Campaigns should be instituted to educate young people about the link between excessive alcohol consumption, assault, road traffic accidents and serious facial injury.