A predictive model for swallowing dysfunction after oral cancer resection

Aggressive therapy of oral cancers is associated with significant postoperative morbidity. Patients with feeding issues may require nutritional support. In our unit, patients identified as developing feeding issues are reactively referred for specialist input through a feeding issues multidisciplinary team meeting (FiMDT). Reactive feeding increases length of patient stay (LOS) and may contribute to patient morbidity. We aimed to develop a model to pre-emptively identify patients likely to develop feeding issues postoperatively, to facilitate the establishment of a preoperative referral pathway to increase patient flow. All referrals to a Head and Neck multidisciplinary team meeting over a five-year period were identified and preoperative factors were extracted. Linear regression was used to confirm that FiMDT was an independent predictor of LOS. Logistic regression was used to determine if referral to FiMDT could be predicted based on preoperative factors only. A total of 203 patients met inclusion criteria for analysis. Inpatient referral to FiMDT was an independent predictor of LOS. Significant predictors of inpatient FiMDT referral included tracheostomy, patient age, and alcohol intake. The resulting model was 90% sensitive and 93.8% specific with a threshold of 0.2. We have shown that inpatient FiMDT referral is an independent predictor of patient length of stay, and that the odds of referral can be robustly predicted. We aim to use this model in redirecting emphasis to a preoperative referral pathway for improved patient flow.

Sexual dimorphism and geographical variance: their impact on the reliability of the antilingula as a landmark in human mandibular surgery

The intraoral vertical ramus osteotomy (IVRO) is an orthognathic procedure that is used to correct dentofacial abnormalities, and is performed by approaching the lateral aspect of the mandibular ramus. This approach, however, precludes visualisation of the inferior alveolar nerve (IAN) on the medial side, thereby placing it at risk of iatrogenic damage. The antilingula, a bony prominence on the lateral mandibular ramus, has been proposed as a landmark for prediction of the IAN's location during IVRO. The current study aimed to evaluate the variation in incidence and position of the antilingula, and therefore to determine its suitability as a surgical landmark during IVRO. The study included 480 dry hemimandibles from eight geographical populations from the Duckworth Collection in Cambridge. Skulls were sexed by visual analysis of dimorphic traits. Positional relations were determined through the digitisation of nine anatomical landmarks. The antilingula was identified in all specimens. No significant difference was identified in the positional relation between the antilingula and mandibular foramen between sexes, but multiple differences were identified in this relation between geographical populations. Our data showed that, irrespective of geographical variation, an osteotomy performed 8mm posterior to the antilingula would avoid the mandibular foramen in 98.8% of cases.

361 An Epidemiological Study into The Incidence of Facial Fractures Presenting to Addenbrooke’s Emergency Department

Introduction

Our aim was to present the epidemiological estimates of facial fractures within East Anglia.

Method

We recorded all patients presenting with facial fractures to our Emergency Department between 2014-2019. All features relating to the patient profile and injury were recorded. We used the English Indices of Deprivation, along with the UK Census (2011), to assess for a correlation between factors such as deprivation status and age with specific causes of facial fractures.

Results

2022 cases were collected totalling 2551 fractures. Mean patient age was 39. The overall leading causes of fractures were falls, assaults and sporting incidents (29.9%, 27.3%, and 17.1% respectively). Towns such as Newmarket and Cambridge demonstrated a distinct leading cause as a result of town-specific recreational activities; horse-riding and cycling respectively. We discovered a positive correlation between deprivation status and fractures due to assault. There was also a relationship between an older population and incidence of fractures due to falls.

Conclusions

Facial fractures reflect a significant cost-burden on the NHS, as well as an emotional burden on patients, which can be reduced by public health interventions and liaison between healthcare professionals and local county authorities. Sharing of these findings with the relevant parties may allow the implementation of location-specific interventions.

Clinical features and presentation of cervicofacial infection: a Maxillofacial Trainee Research Collaborative (MTReC) study

Cervicofacial infection (CFI) is a common presentation to the Oral and Maxillofacial (OMFS) department and accounts for significant emergency activity. The current study aims to understand the aetiology, management, and clinical features of patients hospitalised with CFI. Our study included all patients admitted for management of CFI from May to October 2017 at 25 OMFS units across 17 UK regions. Data were collected prospectively and included age, comorbidities, prior treatment received, markers of sepsis, and presenting clinical features. One thousand and two (1002) admissions were recorded; 546 (54.5%) were male. Median (range) age was 34 (1-94) years. The most common presenting complaints were trismus (46%) and dysphagia (27%). Airway compromise was present in 1.7% of cases. Odontogenic infection accounted for 822/1002 (82%) admissions. Of those with an infection of odontogenic origin, 453/822 (55.1%) had received previous treatment. Two-thirds of those who had received treatment were managed by antibiotics alone (300/453, 66.2%). Patients met criteria for sepsis in 437/1002 (43.6%) of CFI, and in 374/822 (45.5%) of odontogenic infections. This is the largest study worldwide of patients requiring inpatient management for CFI. Infection due to odontogenic origin is the most frequent reason for admission and nearly half do not seek treatment before presentation. Patients with CFI often present late in their disease and frequently meet criteria for sepsis, requiring timely and aggressive treatment to ensure optimum outcomes. Trismus is an emerging dominant feature with all the implications related to the anaesthetic management of these patients. Knowledge of these factors has implications for the referrer, triage, the emergency department, the anaesthetic team, and members of the OMFS team.

Analysis of the frequency of bacteraemia of dental origin implicated in infective endocarditis in patients requiring valve surgery

Understanding the frequency of bacteraemia of dental origin that is implicated in severe infective endocarditis (IE) will further our understanding of the disease's pathoaetiology and help us take steps to reduce its prevalence. A total of 78 patients from the Royal Papworth Hospital, Cambridge, who had valve surgery due to IE (as confirmed by the Modified Duke Criteria) were included. Case notes were retrospectively reviewed for microorganisms that were implicated in the bacteraemia and IE. Associated factors were also recorded to determine whether they were different if a dental or non-dental pathogen was inoculated. A dental pathogen was implicated in 24 of the patients with IE; 20 had non-dental pathogens, and 30 were culture negative. This was not deemed statistically significant (p=0.54). Of the associated factors, only smoking was statistically significant with a greater proportion of non-smokers having bacteraemia of dental origin (p=0.03). No other associated factor was appreciably different based on the aetiology of the microorganism. Our results indicate that dental pathogens are not more likely to cause severe IE. We therefore advocate the stance adopted by the current national guidance on the judicious prescription of antibiotic prophylaxis for IE with regard to dental procedures.

Systematic scoping review of mandibular bone tissue engineering

Tissue engineering is a promising alternative that may facilitate bony regeneration in small defects in compromised host tissue as well as large mandibular defects. This scoping systematic review was therefore designed to assess in vivo research on its use in the reconstruction of mandibular defects in animal models. A total of 4524 articles were initially retrieved using the search algorithm. After screening of the titles and abstracts, 269 full texts were retrieved, and a total of 72 studies included. Just two of the included studies employed osteonecrosis as the model of mandibular injury. All the rest involved the creation of a critical defect. Calcium phosphates, especially tricalcium phosphate and hydroxyapatite, were the scaffolds most widely used. All the studies that used a scaffold reported increased formation of bone when compared with negative controls. When combined with scaffolds, mesenchymal stem cells (MSC) increased the formation of new bone and improved healing. Various growth factors have been studied for their potential use in the regeneration of the maxillofacial complex. Bone morphogenic proteins (BMP) were the most popular, and all subtypes promoted significant formation of bone compared with controls. Whilst the studies published to date suggest a promising future, our review has shown that several shortfalls must be addressed before the findings can be translated into clinical practice. A greater understanding of the underlying cellular and molecular mechanisms is required to identify the optimal combination of components that are needed for predictable and feasible reconstruction or regeneration of mandibular bone. In particular, a greater understanding of the biological aspects of the regenerative triad is needed before we can to work towards widespread translation into clinical practice.

Study of anatomical variations of the zygomaticofacial foramen and calculation of reliable reference points for operation

Dissection on to the facial aspect of the zygoma is common in procedures of the midface for trauma, craniofacial deformity, and cosmesis. These procedures carry the risk of injury to the neurovascular structures that exit from the zygomaticofacial foramen (ZFF). The purpose of this study was to map the ZFF, and to establish reliable reference points from which to identify it before and during operation. We also aimed to compare the anatomy of the ZFF between sexes and among geographical populations. A total of 429 adult skulls from nine geographical sites were used. A cross-line laser was superimposed on to each zygoma to generate consistent landmarks (lines 1 and 2) from which to measure the ZFF, and the number of ZFF on each zygoma was recorded. The site and incidence of ZFF differed significantly among geographical populations, but not between sexes. Of all 858 sides, no foramina were found in 16.3%, one foramen in 49.8%, two foramina in 29%, three in 3.4% and four in 1.4%. A total of 93% of foramina were within a 25mm diameter zone (ZFF zone) centred 5mm anterior to the intersection of lines 1 and 2 on the right zygoma, and 94% were within equivalent measurements on the left. Using these landmarks, we propose a new method of identifying a ZFF zone that is irrespective of sex or geographical population. This technique may be useful in the prevention of iatrogenic damage to the ZFF neurovascular bundle during procedures on the midface and in local nerve blocks.