Psychiatric aspects of head and neck surgery. Part II: Body image and psychiatric intervention

Investigating Predictors of Decannulation Through Endoscopic Approach in Patients With Tracheostomy and Peristomal Subglottic Stenosis

Objective

Peristomal subglottic stenosis (SGS) is a common sequela after tracheostomy, with severe cases precluding decannulation. Predictors of decannulation success in these patients following endoscopic intervention are not well studied. The aim of this study is to investigate predictors of successful decannulation and inform treatment decisions.

Study Design

This study is a retrospective case series of 22 adult patients presenting to the senior author with a tracheostomy and peristomal SGS precluding decannulation between 2018 and 2023.

Setting

Department of Otolaryngology-Head & Neck Surgery, University of Arizona College of Medicine-Tucson.

Methods

Patient demographics, relevant clinical factors, stenosis characteristics, and the number of endoscopic procedures performed were analyzed to identify predictors of successful decannulation. Endoscopic interventions were generally performed 3 months apart with CO2 laser debridement, balloon dilation, and intralesional injection of steroid, all done with a laser-safe endotracheal tube in place through the stoma.

Results

Out of the 22 patients in the study, 9 (40.9%) achieved decannulation, all through an endoscopic approach. Body mass index (BMI) and age were identified as significant negative predictors of decannulation success (P = .02; P = .05, respectively). Stenosis characteristics, such as the presence of tracheomalacia, excessive dynamic airway collapse, multilevel stenosis, posterior glottic stenosis, and anterior granulation tissue shelf did not significantly impact decannulation success.

Conclusion

A 40.9% decannulation rate was achieved in our cohort. BMI and age were identified as negative predictors of decannulation success. Stenosis characteristics did not significantly affect decannulation outcomes. Further investigation is warranted to establish reliable predictors of decannulation.

Brace compliance process in adolescents with spinal deformities: A qualitative study

BACKGROUND

Adolescent idiopathic scoliosis affects 2-4% of adolescents aged 10-16, while Scheuermann's kyphosis affects 0.4-10% of adolescents aged 11 to 16. Over the past 50 years, brace treatment has been recommended as the most common non-surgical intervention for treating these spinal deformities. The effectiveness of brace treatment depends on the duration of brace wearing. This study aimed to understand the brace compliance process for adolescents with spinal deformities through a qualitative approach.

METHOD

This study applied multicenter exploratory qualitative research with an interpretative framework and enlisted the participation of as many individuals as possible involved in brace-wearing in adolescents with spinal deformities. Semi-structured, in-depth, and face-to-face interviews and telephone conversations from September 2020 to May 2021 were conducted. The recorded audio of each interview was typed into Word software with each personal code. The content analysis method was used to analyze the data.

RESULTS

Seventy-four participants were interviewed, including 32 adolescents treated with braces and their parents (27 mothers, five fathers), six orthotists, two physiotherapists, and two spine surgeons. Following data analysis, four main categories, 14 categories, and 69 subcategories of 2403 related codes were discovered.

CONCLUSION

Based on the analysis of the current qualitative research, adolescents with spinal deformities experience extensive challenges in the treatment process, which can affect the results and brace intervention efficacy. The current research findings showed that every adolescent goes through similar but unique conditions during the treatment. The importance of considering each adolescent's specific conditions and characteristics and providing functional solutions and support was understood to help them navigate critical situations more quickly and achieve effective treatment outcomes.

An Amputated Tongue—The Consequences of a Human Bite

Drug-related hospital admissions are common, and up to 25% of patients presenting to emergency departments with injuries test positive for alcohol and drug use. This case reports on a 55-year-old male who attended the emergency department (ED) at the Royal United Hospital, Bath, UK. He presented after sustaining significant soft tissue trauma to his tongue, following recreational drug use of an unknown substance. His injuries included the amputation and loss of the anterior third of his tongue, having suffered a bite from another individual. This unusual case describes the patient’s injuries and subsequent management, both in the emergency department and during follow-up. This case will be of benefit to clinicians from many disciplines including dentists, oral and maxillofacial surgeons, ENT surgeons and speech and language therapists.

Frontal sinus augmentation: Preliminary results of a new approach in prosthetic orbital reconstruction

PURPOSE

Reliable application of endosseous implants for prosthetic facial reconstruction depends on the bone volume available at the defect site. Regarding the orbit, sufficient bone presentation in the medial superior orbital rim is limited due to the frontal sinus. The aim of this article is to report for the first time on the augmentation of the frontal sinus for gaining bone volume for supraorbital implant placement.

MATERIALS AND METHODS

Between 2007 and 2014, five patients with orbital exenteration were treated by frontal sinus augmentation using autogenous cancellous bone graft from the ilium. Extraoral implants for prosthetic orbit reconstruction were placed 4-7 months later. In advance, cadaver surgery was performed to prove the feasibility of the method. Surgical technique is described, and intraoperative images are provided.

RESULTS

The frontal sinus was successfully augmented in all five patients. No major complications related to the procedure were observed. A total of nine orbital implants were inserted in the augmented bone, thereof one sleeping implant. Six implants were restored prosthetically, two implants were lost at exposure. The observation period ranged from 6 to 97 months (mean: 52.8 months). Mean time for patient rehabilitation was 13 months. High patient satisfaction was achieved with the implant-retained orbital prosthesis.

CONCLUSION

The augmentation of the frontal sinus allows implant placement by providing sufficient bone volume in the medial supraorbital rim. Considering the surgical success of this method and patient satisfaction, this new approach is concluded to be a viable option in a unique subset of patients.

Reporting of Cosmesis in Head and Neck Reconstruction: A Systematic Review

OBJECTIVE

To identify the method and rate at which cosmesis is reported after reconstruction from head and neck surgery among adults.

DATA SOURCES

A medical librarian implemented search strategies in multiple databases for head and neck reconstruction, outcome assessment/patient satisfaction, and cosmesis/appearance.

REVIEW METHODS

Inclusion and exclusion criteria were designed to capture studies examining adults undergoing reconstruction after head and neck cancer surgery with assessment of postoperative cosmesis. The primary outcome was the method to assess cosmesis. Secondary outcomes were types of instruments used and the rate at which results were reported. Validated instruments used in these studies were compared and critically assessed.

RESULTS

The search identified 4405 abstracts, and 239 studies met inclusion and exclusion criteria. Of these, 43% (n = 103) used a scale or questionnaire to quantify the cosmetic outcome: 28% (n = 66), a visual analog, Likert, or other scale; 13% (n = 30), a patient questionnaire; and 3% (n = 7), both. Of the 103 studies that used an instrument, 14% (n = 14, 6% overall) used a validated instrument. The most common validated instrument was the University of Washington Quality of Life (UWQOL) questionnaire (4%, n = 9). The most highly rated instruments were the UWQOL and the Derriford Appearance Scale.

CONCLUSIONS

Reporting of cosmetic outcomes after head and neck cancer reconstruction is heterogeneous. Most studies did not report patient feedback, and a minority used a validated instrument to quantify outcomes. To reduce bias, improve reliability, and decrease heterogeneity, we recommend the UWQOL to study cosmetic outcomes after head and neck reconstruction.

Patients' satisfaction with facial prostheses

We assessed the "impact on wellbeing" and "satisfaction" of patients who had a facial prosthesis (of the ear, nose, or orbit) fitted in The Netherlands Cancer Institute. Patients had either an adhesive-retained or an implant-retained facial prosthesis between 1951 and 2011. We did a cross-sectional survey of 104 patients, then gave a questionnaire to the final study group of 71 (68%), a year or more later. All were satisfied with their prostheses (visual analogue scale (VAS): mean (SD) 8.1(1.5). The implant-retained group were the most satisfied (p=0.022), and the adhesive-retained group felt more self-conscious (p=0.013). Three-quarters of all patients said that the prosthesis was not painful and there were no problems with the way it functioned. A well-designed facial prosthesis has obvious benefits, but there were no appreciable differences between the two groups. Each patient must make a careful decision about which type of prosthesis to choose, taking into account the quality of their remaining tissue, the site of the defect, and their general health.

Dental demineralization and caries in patients with head and neck cancer

Concurrent chemoradiation (CCR) therapy is a standard treatment for patients with locally advanced head and neck cancer (HNC). It is well documented that CCR causes profound acute and late toxicities. Xerostomia (the symptom of dry mouth) and hyposalivation (decreased salivary flow) are among the most common treatment side effects in this cohort of patients during and following treatment. They are the result of radiation-induced damage to the salivary glands. Patients with chronic hyposalivation are at risk for demineralization and dental cavitation (dental caries), often presenting as a severe form of rapidly developing decay that results in loss of dentition. Usual post-radiation oral care which includes the use of fluoride, may decrease, but does not eliminate dental caries associated with radiation-induced hyposalivation. The authors conducted a narrative literature review regarding dental caries in HNC population based on MEDLINE, PubMed, CLNAHL, Cochrane database, EMBASE, and PsycINFO from 1985 to 2014. Primary search terms included head and/or neck cancer, dental caries, dental decay, risk factor, physical symptom, physical sequellea, body image, quality of life, measurement, assessment, cost, prevention, and treatment. The authors also reviewed information from National Institute of Dental and Craniofacial Research (NIDCR), American Dental Association (ADA), and other related healthcare professional association web sites. This literature review focuses on critical issues related to dental caries in patients with HNC: potential mechanisms and contributing factors, clinical assessment, physical sequellea, negative impact on body image and quality of life, potential preventative strategies, and recommendations for practice and research in this area.

Anaplastology in times of facial transplantation: Still a reasonable treatment option?

Optimum functional and aesthetic facial reconstruction is still a challenge in patients who suffer from inborn or acquired facial deformity. It is known that functional and aesthetic impairment can result in significant psychosocial strain, leading to the social isolation of patients who are affected by major facial deformities. Microvascular techniques and increasing experience in facial transplantation certainly contribute to better restorative outcomes. However, these technologies also have some drawbacks, limitations and unsolved problems. Extensive facial defects which include several aesthetic units and dentition can be restored by combining dental prostheses and anaplastology, thus providing an adequate functional and aesthetic outcome in selected patients without the drawbacks of major surgical procedures. Referring to some representative patient cases, it is shown how extreme facial disfigurement after oncological surgery can be palliated by combining intraoral dentures with extraoral facial prostheses using individualized treatment and without the need for major reconstructive surgery.

Psychiatric assessment of children with nonsyndromic cleft lip and palate

OBJECTIVE

The aim of the study was to determine whether children with nonsyndromic cleft lip and palate (NSCLP) are more likely to be diagnosed with psychiatric disorders and whether cleft-related factors are related to psychopathology.

METHOD

Twenty children from 6 to 16 years of age with NSCLP, attending the Plastic, Reconstructive and Aesthetic Surgery Department of Cerrahpasa Medical Faculty between January and October 2010, were included as the case group. Forty healthy children who were matched on age and sex with the case group served as controls. Children were assessed by psychiatric interviews and scales.

RESULTS

Social anxiety disorder (SAD) (P=.003) and major depressive disorder (MDD) (P=.010) were more prevalent in children with NSCLP. The severity of dentofacial (P=.035) and cleft lip nose deformities (P=.002), appearance and competence of the lip (P=.008), dental alignment (P=.002), feeding (P=.044) and articulation problems (P<.001) were associated with clinical global functioning.

CONCLUSIONS

Children with NSCLP are at risk of developing psychopathology, especially SAD and MDD. The above cleft-related factors and articulation problems may be the target of interventions to prevent and treat psychiatric disorders in these children.

Clinical and psychological characteristics of TMD patients with trauma history

OBJECTIVE

The purpose of this study was to investigate clinical and psychological characteristics of temporomandibular disorders (TMD) patients with trauma history.

MATERIALS AND METHODS

The clinical and psychological characteristics of 34 TMD patients with trauma history were compared with those of 340 TMD patients without trauma history. Craniomandibular index (CMI) was used for clinical characteristics of TMD patients. Symptom severity index (SSI) was used to assess the multiple dimensions of pain. Symptom checklist-90-revision (SCL-90-R) was used for psychological evaluation.

RESULTS

Temporomandibular disorders patients with trauma history displayed significantly higher CMI and palpation index. TMD patients with trauma history also exhibited higher values in duration, sensory intensity, affective intensity, tolerability, scope of symptom, and total SSI score. In addition, these patients showed significantly higher values in symptom dimensions of somatization, depression, anxiety, phobic anxiety, and paranoid ideation. Among the symptom dimensions of SCL-90-R, somatization showed the most significant correlations with CMI and SSI.

CONCLUSIONS

Temporomandibular disorders patients with trauma history displayed more severe subjective, objective, and psychological dysfunction than those without trauma history. Pain of myogenous origin, history of physical trauma, and psychosocial dysfunction were all closely related.

Evaluation of body image and self-concept and their correlation with depressive symptoms in Parkinson's disease

OBJECTIVE: To identify characteristics of body image and self-concept in individuals over fifty years of age with Parkinson's disease (PD). The secondary objectives are to analyze whether body image and self-concept are influenced by the severity of PD and to verify if there is correlation between depression, self-concept and body image in cases of PD. METHOD: Participating in the study were 48 individuals, being 26 with PD and 22 Controls. The instruments used were: The Mini Exam of Mental State, The My Body Image Test, The Factorial Self-concept Test, The Beck Depression Inventory, the motor section of The Unified Parkinson's Disease Rating Scale and The Modified Hoehn and Yahr Scale. RESULTS: In PD the perception of body image and self-concept demonstrated significantly reduced values p<0.001 and p=0.012 respectively, and the presence of depression symptomatology was significantly more (p=0.002). CONCLUSION: Individuals with PD present alteration of body image and self-concept and also present lower personal confidence and lower social receptivity, correlated with depressive symptoms.

Substance use in vulnerable patients with orofacial injury: prevalence, correlates, and unmet service needs

BACKGROUND

A large portion of the injuries treated at urban trauma centers are preventable with alcohol and substance use presenting as common antecedent risk factors.

METHODS

Alcohol and drug use characteristics of vulnerable adults treated for intentional orofacial injury at a regional trauma center were investigated. Patients (N = 154) presenting with intentional facial injury were recruited. Patients were considered eligible for recruitment if they were adults, recently used alcohol or drugs, and had a fracture within the 30 days preceding recruitment that involved the jaw, orbit, nose, or cheekbone as determined by clinical history, examination, and radiographic findings and that injury was due to interpersonal violence.

RESULTS

This patient cohort evidenced significant levels of alcohol use, with 58% of our patient cohort meeting the criteria for problem drinking. Although lower than alcohol use rates, the reported use of illicit drugs was substantial. Almost half of the sample reported other substance use in the previous month, with 24% meeting the criteria for problem drug use.

CONCLUSIONS

Despite the very high percentage of individuals needing alcohol or drug treatment, only a small proportion of the patient sample reported having seen a professional for alcohol or drug treatment. Integrating substance use services into trauma care is discussed.

Measuring attentional bias to peripheral facial deformities

OBJECTIVES

Introduce a novel method for objectively evaluating attentional bias to peripheral facial deformities using an established metric of attention.

METHODS

The SMI eye-tracker system (SensoMotoric Inc., Boston, MA) was used to record the eye movement patterns, called scanpaths, of eight naïve observers gazing at pictures of faces with or without peripheral surgical deformities. The scanpaths of observers gazing on those novel faces were compared, and the fixation durations for different facial regions were compared between faces.

RESULTS

There were statistically significant differences in the mean fixation times between the faces considered normal and those considered abnormal (those with an obvious defect). When multivariate analysis of variance was performed with dependent variables total fixation time, fixation time in central triangle, and fixation time in the defect region and the independent variable face, all four tests were highly statistically significant. When univariate analysis of variance was performed to test the hypothesis that defect fixation times varied by face, the results were highly statistically significant (F = 8.79, P = .0003).

CONCLUSIONS

Observers gazing on faces typically focus their attention on discriminating features, such as eyes, nose, and mouth. The well-established method of eye movement recordings was applied in a novel way to provide quantitative data showing changes in observer gaze patterns to focus on deformities. These gaze patterns are a direct reflection of observer attention. This is the first objective method to quantify the amount of distraction caused by peripheral facial deformities and may provide insight into the perception of facial deformity.

Scar flap for extension of the nasal and lip soft tissue shell in secondary cleft deformities: final aesthetic touches in clefts-part iii

A scar flap is formed with the pedicle at the lateral part of the columella base at the cleft side, that is, in the center of the affected region. It enables flap placement according to individual need. A prospective evaluation was performed in a group of 76 patients with cleft lip and palate, all operated on by the same plastic surgeon. The flap was used to improve the height of the columella and the extent of nasal mucosa on the frontal septum and on the nostril base in the vestibule. In the lip, the flap raised its height and improved proportionality. The average area of flap used in a unilateral deformity was 42 mm. Both flaps in a bilateral deformity were 77 mm. The average follow-up was 22.4 months. Neither local nor general complications were noted apart from a recurrence of the deformity of the nasal septum in 7.9% of patients. The nasal passage was improved in 59.9% of patients and normalized in 19.6% upon follow-up rhinomanometry, but nevertheless, only one third of patients overcame their dynamic stereotype of breathing by the mouth. Anthropometric measurements showed an absence of statistically significant differences between patients after surgery and healthy individuals in crucial parameters (nasal tip projection, length of columella, nasolabial angle, nasal angle, and lip angle). The loss of the stigmatizing deformity is based on rotation of the nasolabial angle in relation to the aesthetic axis of the face. Direct examination proved aesthetic and functional improvement as statistically significant in 92.1% of patients.

Moustache Reconstruction in Patients With Cleft Lip

Men with clefts often have limited or even missing moustache growth in scar areas or in the upper lip prolabium. However the histological testing showed the absence or at least the inactive form of androgenic receptor in hair follicle of cleft site, transplantation of autologous grafts harvested from hair was successful in all six cases either into scars or the prolabium. A more natural effect was achieved by using micrografts. The positive reaction of patients proved there is a need for detailed treatment in highly outgoing individuals.

The experience of brace treatment in children/adolescents with scoliosis

BACKGROUND

Idiopathic scoliosis is a chronic illness with several different braces used for its treatment. Brace treatment during childhood/adolescence can produce stress. There are studies supporting that it can decrease body-image perception while other studies support that it has no such effect.The purpose of this study was to explore the experience of brace treatment in children/adolescents with scoliosis. The aim was to investigate which feelings are created by the bracing experience in children/adolescents with scoliosis and what are the children/adolescents' with scoliosis opinions of the support provided to them by health-care professionals and by their families.

METHODS

We conducted interviews with the help of a semi-structured interview guide in order to address the topic of the experience of brace treatment. A convenient sample of twelve children and adolescents with scoliosis was selected from patients attending follow-up appointments at the Outpatient Scoliosis Clinics of two Greek hospitals. The data was analysed using the method of content analysis.

RESULTS

Patients in the sample were 10-16 years old and they were mainly females (71%). Almost all of the participants reported having to deal with stress, denial, fear, anger, and shame. They were satisfied with the information they received regarding their condition and therapy. However, the information was not accompanied by support from the health care professionals. They reported that they were receiving support mainly from their families, friends, and classmates.

CONCLUSION

The present study is contributing to the development of a better understanding of significant issues related to the experience of bracing therapy. It is clear that scoliosis children/adolescents have to be provided with support during the long period of bracing. It is apparent that those children/adolescents have unmet needs for care and health professionals and policy makers should try to find a way to address those needs.

[Analysis of quality of life in patients with a facial prosthesis]

OBJECTIVE

This clinical study examined the quality of life of face-disabled patients who had received a facial prosthesis.

PATIENTS AND METHODS

The examination of the 58 patients was performed using different questionnaires. For the evaluation of the subjective health-related quality of life an instrument constructed by the WHO was used (WHOQOQL-Bref). The Frankfurter Scales of Body Concepts (FKKS) was chosen to measure the self-assessment of the patient's own body perception. For the assessment of the present general quality of life a visual analogue scale was used (Anamnestic Comparative Self-Assessment, ACSA). Additionally an ad hoc questionnaire was used, which registers the post-therapeutic epithetic rehabilitation. The health-related quality of life of this sample was compared to a healthy one of the normal population.

RESULTS

The examinations showed that the quality of life of the patients is reduced in contrast to the healthy group when the acquired defects were located in the region of the eye and the nose. The evaluation of the scales of body concepts showed that the patient's own body image was significantly altered. Body contact with other persons and their own sexual attraction was perceived as remarkably diminished. The patients believed that they spread an unpleasant odor. It is surprising that the wearers of a facial prosthesis indicated that they did not notice a restriction in the acceptance of their body by others. The influence of the application of camouflage did not have an impact on the quality of life.

CONCLUSION

To improve the restricted quality of life, to the raise the reduced well-being and to strengthen the altered body experience, psychological care should be provided besides further optimization of the surgical-epithetic therapy and the camouflage technique.

Effects of tracheostomy on well-being and body-image perceptions

OBJECTIVE

Quality of life after tracheostomy was addressed by measuring its impact on well being and body image perceptions.

STUDY DESIGN AND SETTING

A controlled study in a laryngotracheal clinic of a tertiary referral center. Three groups were studied: 24 cannulated, 19 decannulated, and 20 noncannulated patients. They filled up 3 conventional questionnaires.

RESULTS

(1) Satisfaction-with-life scale: reduced scores were detected between cannulated and noncannulated patients. (2) Personality traits: neuroticism and extroversion: no differences were noted. (3) Body cathexis scale: both cannulated and decannulated patients scored less than noncannulated. In tracheostomy-specific issues, decannulated patients scored better than cannulated patients.

CONCLUSIONS

Reduced scores after tracheostomy indicate an overall diminished quality of life. These changes correlate with personality traits. Decannulated patients exhibited only slight improvement indicating an incomplete psychosocial recovery.

SIGNIFICANCE

This is the first report on tracheostomy related quality of life in noncancer patients conducted with specific psychological questionnaires.

Psychosocial sequelae and correlates of orofacial injury

Orofacial injury is a condition that disproportionately affects disadvantaged minorities--particularly young men--with great personal and health care consequences. Beyond the overt physical injury, a large proportion of the presenting patients manifest acute psychological sequelae. Although many patients may recover, in a sizeable proportion the symptoms may persist for extended periods of time and prove to be an obstacle to rehabilitation and reintegration. Health care givers should pay equal attention to evolving psychological sequelae of facial injuries. Strategic questions and screening for risk indicators can help with timely posttrauma identification of individuals most vulnerable to the development of acute and chronic symptomatology.

Adult patients looking at their burn injuries for the first time

A total of 222 burn nurses from 30 burn centers completed a questionnaire about how and when a burn patient looks at their burn wound for the first time. The registered nurse is most frequently with the patient when the patient sees the wound for the first time (n = 187; 84%). Looking at the wound is not usually a planned event, and it is not documented in the patient record. Nurses use verbal and nonverbal patient cues to determine when it is appropriate for the patient to look initially at the wound and combine this initial look with an opportunity to teach wound healing. The patient asks the nurse for an opinion about the way the wound looks (n = 181; 81.5%). The nurse uses silence, presence-of-self, and gentle encouragement with the patient while remaining positive and honest. Respondents reported that the patient wants the truth but also needs reassurance and some degree of optimism when viewing the wound for the first time.

Perceptions of body image, happiness and satisfaction in adolescents wearing a Boston brace for scoliosis treatment

AIMS

To explore the impact of bracing on the perceptions of body image, happiness and satisfaction of adolescents with scoliosis.

DESIGN

The study was designed as compare of 134 girls and 16 boys who wore a Boston type brace for scoliosis treatment and a control group of 99 healthy girls and 51 healthy boys. All them were secondary school pupils living in Athens Greece and were interviewed. A semi-structured schedule included general questions, and the Piers-Harris scale was used. Data were analysed using the SPSS/PC+ software, and descriptive statistics, factor analysis and the non-parametric Mann-Whitney U-test. Statistical significance was set at P=0.05 or less.

RESULTS

The scoliosis group had a poorer perception of body image in comparison to the control group (P=0.048), while boys with scoliosis (P=0.030) had a better perception of body image than girls with scoliosis. Girls with scoliosis had a statistically significant difference (P=0.0388) in perception of happiness and satisfaction, in comparison with girls in the control group. Cohabitation with the mother seemed to be negatively correlated with body image, happiness and satisfaction perceptions because adolescents with scoliosis who were not living with their mother had a better body image perception (P=0.027) as well as better perceptions of happiness and satisfaction (P=0.047). Nevertheless, only 5% of those with scoliosis declared that they had opportunities to discuss their feelings and problems with health professionals, while 90% of them declared that they wanted to have more opportunities to do this.

CONCLUSION

Adolescents with scoliosis face problems during bracing and they need to be supported by health care professionals.

Reliability and validity of an observer-rated disfigurement scale for head and neck cancer patients

BACKGROUND

Facial disfigurement is considered to be one of the most distressing aspects of head and neck cancer and its treatment, but it has been the focus of little systematic study. Existing studies have yielded conflicting results about the psychosocial impact of disfigurement. No studies to date have examined disfigurement using a valid and reliable observer-rated measure. The purpose of the current study was to examine the validity (convergent and discriminant) and the inter-rater reliability of a novel nine-point observer-rated disfigurement scale.

METHODS

The sample consisted of 74 ambulatory head and neck cancer patients more than 6 months post treatment. Ratings of disfigurement were assigned independently by surgical and nonsurgical raters. Validity was assessed by comparing the association between disfigurement ratings and sociodemographic and illness treatment variables. Reliability was assessed by examining the concordance between the surgical and nonsurgical ratings.

RESULTS

Disfigurement ratings were not associated with several sociodemographic variables, supporting the discriminant validity of the scale. Disfigurement was significantly related to a diagnosis of oral cancer, a history of adjunctive radiation, the type of surgical procedure performed, the degree of physical dysfunction, and the presence of postoperative complications. Observer ratings of disfigurement were significantly related to patient ratings of disfigurement. These findings support the convergent validity of the disfigurement scale. Inter-rater reliability of the scale was high (intraclass correlation coefficient =.91).

CONCLUSION

The study provides preliminary evidence for the validity and inter-rater reliability of a novel nine point observer-rated disfigurement scale that may be useful in evaluating the impact of disfigurement on quality of life in head and neck cancer.

Immediate maxillofacial prosthodontic rehabilitation after radical mid-face tumor resection

Mid-facial surgical defects can adversely affect a patient's esthetics and psychological well-being. Fabrication of a definitive mid-facial prosthesis can be a time-consuming procedure. It is crucial to minimize the time between the tumor resection and initial prosthetic rehabilitation. This article describes a method for rapid fabrication of a transitional facial prosthesis for mid-facial defects.

Self-esteem and cancer: theory and research

OBJECTIVE

To examine the relationship between self-esteem and the psychosocial response to cancer.

METHODS

The authors review methodological issues associated with measuring self-esteem in patients with cancer and examine existing empirical studies in light of these issues.

RESULTS

Self-esteem in cancer has been variously viewed as an outcome variable, a mediator of other psychosocial outcomes, and as a personal resource that facilitates coping. Unidimensional measures of global self-esteem have been most often employed in research studies, despite increasing recognition that self-esteem is multidimensional. Evaluation of global self-esteem has generally revealed no differences between cancer patients and controls. Aspects of multidimensional self-esteem, particularly body self-esteem, appears to be disturbed in many patients with cancer.

CONCLUSIONS

The clinical and theoretical literature have emphasized the importance of self-esteem to the psychosocial response to cancer. Empirical study of self-esteem in cancer has been limited by conceptual and methodological issues. Strategies for future research are discussed.

Treating the patient who is disfigured by head and neck cancer

A 46-year-old man with laryngeal carcinoma was admitted to the medical service for lethargy. The medical team requested a psychiatric consultation to assist with the patient's depression, substance abuse, and noncompliance. The case is presented and discussed with reference to the issues of depression, disfigurement, dysfunction, and substance abuse in the patient with head and neck cancer.

Changes in body image secondary to disease and injury

This article describes the relationship between body image and self-concept, discusses responses to changes in body image secondary to disease and injury, and explores strategies for adjustment to alterations in body image. Sociopsychological aspects of body image form a complex framework by which an individual understands the self and perceives how he or she is understood by others. As body image, self-concept, identity, and ego are closely associated, a loss of or alteration in any one of these factors can have deleterious effects on the entire self. Rehabilitation professionals assume an important role in helping people adjust to and accept alterations in body image by facilitating the grieving process; addressing loss, anxiety, and depression; and empowering individuals to emphasize and use their assets.