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Clinics in
ORAL AND
MAXILLOFACIAL
SURGERY
SM Sharma MDS
Professor and Head
Department of Oral and Maxillofacial Surgery
AB Shetty Memorial Institute of Dental Sciences
Nitte University
Mangalore, Karnataka, India

Foreword
Rajendra Prasad

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Clinics in Oral and Maxillofacial Surgery

First Edition: 2013

ISBN 978-93-5090-615-6
Printed at: S. Narayan & Sons

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Dedicated to
Past, Present
and
Future Postgraduates

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Foreword

Dental and oral organs are the part of digestive system of human body. Since they are exposed to
various insults of environment and also exhibit their signs about systemic conditions, the science of
dentistry has developed into various specialties.
Oral and maxillofacial surgery has many facets of ailment pertaining to these organs. As surgery is
an important component and is most appealing as well as challenging for the dental students, the book
Clinics in Oral and Maxillofacial Surgery has been authored by Dr SM Sharma. It is very apt that the
practice of this science and controversies in modality of treatment and complications encountered are
discussed in detail with suitable illustrations.
The completion, reasoning, and also suitable relevant description make the students/practitioners
to understand and adopt this in their clinical works. The goal of any treatment is immediate relief
from agony and, secondly, conservation of tissue as much possible, with careful, clear-cut dissection,
controlling perioperative events, and promoting wound healing.
The contribution from basic medical sciences is defining anatomy, physiology, pathogenesis, and
microbiological implication on oral tissues. The diagonosis and treatment planning is complex process
of factual and reasonable judgment. The author has pointed out simple clues to arrive at diagnosis.
The postgraduate students can refer to this voulme for their applied knowledge in this specialty.
I hereby congratulate Dr SM Sharma for his contribution and wish him good success in his endeavor
and also wish more work of this kind is produced by him in future.

Rajendra Prasad
Principal
AB Shetty Memorial Institute of Dental Sciences
Nitte University
Mangalore, Karnataka, India

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Message

Professor Sharma has taken great efforts over several years to collect a very comprehensive volume of
case studies illustrating the entire gamut of maxillofacial surgery. It is highly commendable that he has
now decided to place this wealth of information at the disposal of postgraduates and faculty as a means
of enhancing interest and understanding of clinical methodology.
Today, we have an overwhelming amount of books, specialized journals, and scholarly papers
providing information about every facet of oral and maxillofacial surgery. Without knowledge and
understanding, there can be no pursuit of clinical excellence, and the value of books and Internet
searches cannot be underestimated. Nevertheless, only direct encounter with clinical situations and
visualization of clinical problems awaken the mind to relate what is stored in memory to reality. As
the process of logical decision making and adaptation of algorithms enable us to make choices with
regard to optimal management of disease, and as we acquire the skills needed to implement therapies,
our gradual transformation into maturity as clinicians takes place. Indeed, if we are sensitive enough,
possess discipline to constantly improve our innate talents and remain humble, our clinical practice
can truly have a transforming impact on our patients and also us.
The book Clinics in Oral and Maxillofacial Surgery places on record the considerable experience
of Professor Sharma as a teacher and the lessons learnt in oral and maxillofacial surgery practice over
several decades in the form of clinical cases. I am sure this book will be of immense value.

Paul C Salins
Vice-President/Medical Director
Chief, Craniofacial Surgery
Narayana Hrudayalaya Hospitals
Bengaluru, Karnataka, India

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Preface

For quite sometime, I was thinking of writing a book, but a question remained that when there are so
many books in the market, current trends, issues, contemporaries or advances, then what is the need
of another book. During many years of my clinical experience and as an examiner, I felt that post-
graduates should be thorough with the recent updates so that they can present and prepare themselves
for the clinical examination. They should know a good clinical case presentation method with relevant
questions normally an examiner asks and also specific examination cases, discussion, instruments, etc.
I feel that there is a need of the book Clinics of Oral and Maxillofacial Surgery that will help students
in the preparation for examination. The book will also be of immense value for students preparing for
national board examination and even the faculty.
We are living in an era of explosion of knowledge. Definitely, new things and new cases are coming
each day, and it is not the last word written here. Of course, postgraduates should also refer other
specific books for detailed theory knowledge. Ultimately, goal is to provide the best knowledge and,
thereby, a good care for our patients.
Listening to patient is more difficult and important rather just talking to him. Lord Platinom, one of
the greatest teachers at the University College of Medicine in London, was of the firm opinion that if
you listen to your patient long enough, he/she will fully guide you what is wrong with him/her.
Clinicians can learn many things from the patients either at bedside or chairside. Each patient is like
a book. No two patients are alike even with the same disease, as every disease presents itself through the
personality of the patient. The habit of learning books by heart does not work here. Books are necessary
to keep in touch with the basics of clinical practice. I assure Clinics in Oral and Maxillofacial Surgery
will bring vital information to enhance the knowledge of clinical aspects of the subject.

SM Sharma

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Contents

Section 1: Basic Surgical Principles and Perioperative Management


1. Clinical Approach to Oral and Maxillofacial Surgical Patients 3
Case History 4
Chief Complaint 4
History of the Present Illness 4
Medical History 4
Social History 5
Family History 5
Review of Systems 6
Examination of the PatientGeneral Procedure 6
Vital Signs 6
Craniofacial Region Examination 7
Facial Structures 8
Lips 8
Cheeks 8
Maxillary and Mandibular Mucobuccal Folds 8
Hard Palate and Soft Palate 8
Tongue 8
Floor of the Mouth 8
Gingivae 9
Teeth and Periodontium 9
Tonsils and Oropharynx 9
Salivary Glands 9
Neck and Lymph Nodes 10

2. Preoperative Care and Evaluation 12


Preoperative Evaluation 12
Systemic assessment 14

3. Principles of Postoperative Care 22


Postoperative Care 22

4. Postoperative Complications and Management 27


Pulmonary Complications 31
Ophthalmological Complications 35

5. Medically Compromised Patient Preparation for Maxillofacial Surgery 36


Cardiovascular System 36
Diabetes mellitus 38

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xiv Clinics in Oral and Maxillofacial Surgery
Hemophilia, Anticoagulation 39
Thyroid Disorders 40
Adrenal Diseases 41
Renal Disease 41
Hepatic Disease 41
Respiratory Disease 42
Immunocompromised Patient 42

Section 2: Examination of Maxillofacial Trauma Patient


6. Initial Assessment and Emergency Care of Maxillofacial Trauma Patient 45
Initial Assessment 45
Preparation 45
Triage 46
Trauma Scoring Systems 47
Primary Survey 49

7. Neurological Consequences Associated with Maxillofacial Injury 55


Pathophysiology 55
Classification of Head Injuries 55
Primary Assessment 57
Secondary Assessment 57
Neurological Examination 59
Cranial Nerves Examination 59
Examination of Motor System 60
Examination of Sensory System 60
Imaging 61
Unconscious Patient 61
Critical Care in Head Injury 61
Contribution of Neurosurgeon in Trauma Team 61

8. Maxillofacial Trauma: First 24 Hours in Intensive Care Unit 62


Intensive Care Unit 62
Prioritization 62
Case Presentation 68

9. Basic Principles for the Management of Maxillofacial Trauma 75


Approach to a suspected fracture 75
Reduction 78
Fixation 79
Titanium Miniplates 80
Newer Development in Osteosynthesis 82
Locking Plates 83

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Contents xv

10. Dentoalveolar Fractures 85


Etiology 85

11. Mid-facial Fractures 88


Surgical Anatomy 88
Classification 88
Maxillary Fracture Management 91
Zygomaticomaxillary Complex Fractures 95
Treatment Indications for Surgery 98
Timing of Surgery 98
Surgical Approaches 98
Open Reduction Techniques 99
Fixation V/S Nonfixation 99
Direct Fixation Techniques 99
Indirect Fixation 99
NasoEthmoidal Orbital fracture 99
Nasal Fractures 102
Orbital Blowout Fractures 103
Clinical Cases 109
Zygomatic Arch Fracture Right Side 113

12. Mandibular Fractures 114


Anatomical Considerations 114
Classification 114
Clinical Assessment and Diagnosis 116

13. Condylar Fractures 121


Etiology of Condylar Injuries 121
Classifications 121
Diagnosis of Condylar Injuries 122
Clinical Features 122
Radiography 123
Management Goals 123
Conservative and Functional Management 123
Closed Reduction 124
Open Reduction 124
Complications 128
Conclusion 128
Some more cases 128

14. Cerebrospinal Fluid Rhinorrhea 130


Classification of CSF Rhinorrhea 130
Differential Diagnosis 131
Management 133

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xvi Clinics in Oral and Maxillofacial Surgery

15. Maxillofacial Trauma: Case Presentation 135


Case number 1 135
Case Number 2 136
Case Number 3 139
Case Number 4 141
Case Number 5 142
Case Number 6 144
Case Number 7 144
Case Number 8 144
Case Number 9 145
Case Number 10 145

Section 3: Carcinomas of Oral Cavity


16. Examination of an Ulcer 149
Parts of an Ulcer 149
Classification 150
History 151
Differential Diagnosis 151
Causes of Oral Ulcers 152
Biopsy 153
Intraosseous or Hard Tissue Biopsy Technique and Surgical Principles 157

17. Cancer Biology 158


Modes of Tumor Spread 158
Process of Bone Metastasis 160
Biology of Invasion and Metastasis 161

18. Surgical Treatment Plan for Oral and Maxillofacial Cancers 166
Epidemiology 166
TNM Definitions 166
Management 167
Maxillary Approach 168

19. Management of Neck in Oral and Maxillofacial Carcinoma 179


History 179
Anatomical Divisions 179
Various Incisions for Neck Dissection 182
Sentinel Node Biopsy 184
Classification of Neck Dissections 184
Comprehensive Neck Dissection 184
Selective Neck Dissection (SND) 189

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Contents xvii

20. Role of Chemotherapy and Radiotherapy in Oral and Maxillofacial


Carcinoma 191
Biological Response Modifiers 194
General Principles in the Treatment of Cancers 194
Components of Chemotherapy 194
Case Study 197
Panoramic Radiograph 198
Etiology 200
Pathogenesis 200
Classification 200
Revised European-American Lymphoma [REAL] 201
Recommended Procedure for Staging 202
Spread of Oral Lymphoma 202
Treatment Options 202
Chemotherapy 202
Roles of Radiotherapy 202

21. Reconstructive Options in Oral and Maxillofacial Cancer 216


A Multidisciplinary Approach 217
Goals of Reconstruction 217
Timing of Reconstruction 217
Current Approach 217
Primary Closure 218
Skin Grafts 218
Flaps 218

22. Clinical Cases of Cancers of Oral Cavity 237


Case Number 1 237
Case Number 2 238
Case Number 3 240
Case Number 4 242
Clinical Case 5 243
Case Number 6 246
Case Number 7 249
Some More Clinical Cases 252

Section 4: Cysts and Tumors of Odontogenic Origin


23. Odontogenic Cysts 257
Classification 257

24. Keratocystic Odontogenic Tumors 275


Pathophysiology 275
Clinical Presentation 275

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xviii Clinics in Oral and Maxillofacial Surgery
Signs and Symptoms 276
Radiological Features 276
Histological Features 276
Treatment 277
Conclusion 278
Case Presentation 278
Discussion 281
Some More Cases 282

25. Odontogenic Tumors 285


Classification 286
Ameloblastoma 287
Unicystic Ameloblastoma 290
Ameloblastic Fibrosarcoma 297
Odontogenic Myxoma 301
Case Presentations 301
Cases of Odontogenic Myxoma 308

26. Clinical Cases of Odontogenic Cysts and Tumors 310


Case Number 1 310
Case Number 2 312
Case Number 3 313
Case Number 4 315
Case Number 5 316

Section 5: Maxillofacial and Cervical Swellings


27. Maxillofacial and Cervical Swellings: Differential Diagnosis 323
Embryology of Neck 323
Clinical Examination of Neck Swellings 325
Superficial Swellings 326
Investigations for Head and Neck Masses 326
Unknown Neck Mass 328
Branchial Cyst 328
Case Presentation 330

28. Salivary Gland Disorders 335


Parotid Gland 335
Clinical Case of Parotid Swellings 337
Clinical Case Presentation 339
Head and Neck Examination 340
Sublingual Glands 341
Minor Salivary Glands 341
Saliva 341

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Contents xix
Clinical Examination and Classification of Salivary Gland Diseases 342
Classification of Salivary Gland Disorders by Who 349
Clinical Case Presentation 362
Some More Cases 364
Cases 1 365

29. Fibro-osseous Lesions of Jaws 370


Classification 370
Fibrous Dysplasia 370
Osseous Dysplasias (OD) 374
Ossifying Fibroma 376
Juvenile Ossifying Fibroma 378
Case Number 1 380
Case Number 2 383

30. Vascular Anomalies 385


Hemangiomas of the Maxillofacial Region 385
Hemangioma 386
Role of b-Blockers in Management of Hemangiomas 389
Vascular Malformations 391
Venous Malformations 394
Arterial and Arteriovenous Malformations 396
Case Number 1 397
Case Number 2 402
Some more cases 404

Section 6: Examination of Temporomandibular Joint Disorders


31. Temporomandibular Joint Ankylosis 409
Classification 409

32. Temporomandibular Joint Dislocation, Subluxation, and Hypermobility 422


Etiology 422
Diagnosis 423
Treatment 424
Surgery for Subluxation and Dislocation 426

33. Internal Derangements of Temporomandibular Joint and Myofascial Pain


Dysfunction Syndrome 429
Derangements of the Condyle-Disk Complex 429
Structural Incompatibility of the Articular Surfaces 435
Inflammatory Disorders of the TMJ 437
Myofascial Pain Dysfunction Syndrome 438

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xx Clinics in Oral and Maxillofacial Surgery

34. Clinical Cases of Temporomandibular Joint Pathology 441


Case Number 1 441
Case Number 2 443
Case Number 3 444
Osteochondroma of the Coronoid Process 448

Section 7: Maxillofacial Infections


35. Fascial Spaces and Odontogenic Infections 451
Infections of the Orofacial Region 452
Types of Infection 454
Fascial Space Infections 457
Case of a Submandibular Space Infection 469
Case Reports 471

36. Osteomyelitis and Osteonecrosis 474


Classification 474
Etiology 476
Clinical Features 478
Investigations Prior to Management 482
Goals of Management 482
Osteonecrosis and Hyperbaric Oxygen Therapy 486
Definition 486
Etiology 486
Incidence 486
Pathogenesis 486
Histologic Features 487
Clinical Classification of ORN 487
Classification of ORN 487
Differential Diagnosis 488
Case Presentation 1 488
Hyperbaric Oxygen Therapy 491
Case Presentation 2 493
Case Presentation 3 495
Case 4 497

Section 8: Examination of Jaw Deformities


37. Diagnosis and Evaluation of Jaw Deformity 501
Dentofacial Deformity 501
Esthetic Surgical Procedures 507
Case Number 1 508
Case Number 2 512

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Contents xxi

38. Principles and Protocols of Bimaxillary Surgery 515


Case Series 515
Cephalometric Tracing and Osteotomy Lines 517
Planning 520

39. Maxillary Orthognathic Procedures 522


Anterior Maxillary Osteotomy 522
LeFort I Osteotomy 526
Case Series 528

40. Mandibular Orthognathic Procedures 535


Classification of Osteotomies of the Mandible 535
Technique 537
Cases 541

Section 9: Miscellaneous
41. Imaging in Maxillofacial Pathology 553
Diagnostic Importance 553
Imaging Modalities 553

42. Management of Soft Tissue Facial Wound 566


Healing 566
Case Series 573

43. Surgical Anatomy of Incisions in Maxillofacial Surgery 576


General Guidelines for Incision Placement 576
Incisions for Mandibular Area 577
Incisions Around the Temporomandibular Joint 582
Incisions for the Zygoma 584
Incisions Around the Orbit 586
Incisions Around the Nasal Complex 587
Summary and Conclusion 589

44. Fluid, Electrolyte, and AcidBase Balance 590


Sodium 592
Potassium 593
Magnesium 594
Calcium 595

45. Surgical Nutrition 600


Nutrition and Maxillofacial Cancer 603
Feeding Methods Enteral Nutrition 604
Postoperative Nutrition Requirements 608

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xxii Clinics in Oral and Maxillofacial Surgery

46. Power-driven Instruments Useful in Maxillofacial Surgery 610


Electrosurgery 610
Basics of Lasers and its Effects on Tissues 615
Laser Types 618
LaserTissue Interaction 620
Laser Hazards and Laser Safety 621
Harmonic Scalpel 622

47. Instruments and Postexposure Prophylaxis 623


Instruments to Transfer Sterile Instruments 624
Instruments for Preparing Surgical Field 624
Instruments to Hold Towels and Drapes in Position 625
Instruments to Incise Tissue 625
Instruments for Elevating Mucoperiosteum 627
Instruments for Controlling Hemorrhage 628
Procedure Specific Instruments of Oral and Oral and Maxillofacial Surgery 641
Diagnostic Instruments 641
For Opening the Mouth/Keeping the Mouth open 642
Soft Tissue Retractors 642
Instruments for Exodontia 644
Instruments for Trauma and Orthognathic Surgery 651
Instruments for Cleft Surgery 658
Use of Drains in Oral and Maxillofacial Surgery 660
Types of Drains 662
Postexposure Prophylaxis (PEP) Following Needle Stick Injury 667

Questions and Answers 671


Index 697

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1
Section
Basic Surgical Principles and
Perioperative Management
1. Clinical Approach to Oral and Maxillofacial
Surgical Patients
2. Preoperative Care and Evaluation
3. Principles of Postoperative Care
4. Postoperative Complications and
Management
5. Medically Compromised Patient Preparation
for Maxillofacial Surgery

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Clinical Approach to Oral and
Maxillofacial Surgical Patients
1
INTRODUCTION management in oral and maxillofacial surgery
should begin with the golden rule. Treat patients
Every patient is unique in the contemporary oral
the way you would treat your parents, spouse or
and maxillofacial surgery. The skills we bring to
children. The patients should receive the highest
bear in daily clinical work-up are so diverse that
quality of care and for this listening to symptoms
positive impact we have on our profession and the
and concerns of the patients and appropriate
health of our patient makes us proud to be known
evaluation through complete examination and
as Oral and Maxillofacial Surgeons.
diagnostic tests are the priorities.
Oral and maxillofacial surgery provide an
extensive surgical services including management Consider treatment options by joint clinics
of traumatic injuries of maxillofacial structure, or clinicopathological discussions so that the
pathology and eventual reconstruction, minor best possible treatment is chosen. This will help
oral surgery, placement of implant, orthognathic to understand the risks, benefits and possible
reconstruction of the facial deformity and complications of the various treatment options
distraction osteogenesis. Thus, the specialty including in some cases no treatment. The whole
is recognized for excellent ability and adapt to exercise should be legibly documented in records
changes in public need for prosperous health, and explained to the patient and the family.
setting the highest goals. The management of oral and maxillofacial
Oral and maxillofacial surgery is a unique disorders besides the application of technical
specialty that deals with the gentle structures of skills also requires training in basic sciences for
the facial skeleton, oral cavity and the neck and diagnosis and treatment and a genuine sympathy
that covers a broad spectrum extending from oral and love for the patient.
malignancies, facial injuries, facial deformities Maxillofacial surgeon must also maintain good
and facial reconstruction to impacted 3rd molars, cordial behavior to his/ her fellow colleagues and
dental implants and generally minor oral surgery. subordinates.
This legacy of greatness must pass on to the next This chapter addresses the rationale and
generation of oral and maxillofacial surgeons. method for gathering relevant medical and
As an oral and maxillofacial surgeon, we are dental information (including the examination
responsible for the diagnosis and treatment of the patient) and the use of this information for
of traumatic, congenital, developmental and treatment. This process can be divided into the
iatrogenic lesions in maxillofacial complex. Risk following four parts:

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4 Section 1: Basic Surgical Principles and Perioperative Management

When did this problem start?


What did you notice first?
Did you have any problems or symptoms related to
this?
What makes the problem worse or better?
Have the symptoms gotten better or worse at any
time?
Have any tests been performed to diagnose this
complaint?
Have you consulted other, oral and maxillofacial
surgeons, or anyone else related to this problem?
What have you done to treat these symptoms?

CASE HISTORY An appropriate interpretation of the information


collected through a medical history achieves
A detailed and concise compilation of all physical,
dental, and social, factors relative and essential to three important objectives:
diagnosis, prognosis, and treatment. It enables the monitoring of medical
conditions and the evaluation of underlying
systemic conditions of which the patient
CHIEF COMPLAINT
may or may not be aware
The chief complaint is established by asking the It provides a basis for determining whether
patient to describe the problem for which he or dental treatment might affect the systemic
she is seeking help or treatment. health of the patient, and
The chief complaint is recorded in the patients It provides an initial starting point for
own words as much as possible.
assessing the possible influence of the
patients systemic health on the patients
HISTORY OF THE PRESENT ILLNESS oral health and/or dental treatment.
The history of present illness is the course of the The components of a medical history may vary
patients chief complaint: when and how it began; slightly, but most medical histories contain
direct and specific questions are used to elicit this specific information under specific headings
information. Information on the health of the patient can be
arbitrarily divided into objective and subjective
MEDICAL HISTORY information
Obtaining a medical history is an information The objective information consists of an
gathering process for assessing a patients account of the patients past medical history,
health status. The medical history comprises as well as information gained by physical and
a systematic review of the patients chief or supplementary examination procedures (i.e.
primary complaint, a detailed history related signs)
to this complaint, information about past and The subjective information (i.e. symptoms) is a
present medical conditions, pertinent social report of the patients own sensory experience
and family histories, and a review of symptoms but can also be second hand, as in the case of
by organ system children or others unable to communicate for

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Chapter 1: Clinical Approach to Oral and Maxillofacial Surgical Patients 5
themselves. This second hand information or adverse drug reaction to medications, local
is often used to confirm and supplement a anesthetic agents, foods, or diagnostic procedures.
patients description of his or her complaint
The past medical history is usually organized Medications
into the following subdivisions: An essential component of a medication
history is a record of all the medications a
patient is taking
Serious or significant illnesses
Identification of medications helps in the
Hospitalizations recognition of drug induced (iatrogenic)
Transfusions disease and oral disorders associated with
different medications and in the avoidance of
Allergies
untoward drug interactions
Medications The types of medications, as well as changes in
Pregnancy dosages over time, often give an indication of the
status of underlying conditions and diseases.

Serious or Significant Illnesses Pregnancy


The patient is asked to enumerate illnesses Knowing whether or not a woman of childbearing
that required (or require) the attention of a age is pregnant is particularly important when
physician, that necessitated staying in bed for deciding to administer or prescribe any medication.
longer than 3 days, or for which the patient was
(or is being) routinely medicated SOCIAL HISTORY
Specific questions are asked about any Different social parameters should be recorded;
history of heart, liver, kidney, or lung diseases; occupation; tobacco use when obtaining the social
congenital conditions; infectious diseases; history, the clinician should take into account the
immunologic disorders; diabetes or hormonal patients chief complaint and past medical history
problems; radiation or cancer chemotherapy; in order to gather specific information pertinent
blood dyscrasias or treatment. to the patients oral and maxillofacial surgical
management.
Hospitalizations
A record of hospital admissions complements FAMILY HISTORY
the information collected on serious illnesses Serious medical problems in immediate family
and may reveal significant events such as members (including parents, siblings, spouse,
surgeries that were not previously reported and children) should be listed.
A history of blood transfusions, including the Disorders known to have a genetic or envi-
date of each transfusion and the number of ronmental basis (such as certain forms of cancer,
transfused blood units, may indicate a previous cardiovascular disease including hypertension,
serious medical or surgical problem that can allergies, asthma, renal disease, stomach ulcers,
be important in the evaluation of the patients diabetes mellitus, bleeding disorders, and sickle
medical status. cell anemia) should be addressed. Also noted are
whether parents, siblings, or offspring are alive or
Allergies dead; if dead, the age at death and cause of death
The patients record should document any history are recorded. This type of information will alert
of classic allergic reactions, such as urticaria, hay the clinician to the patients predisposition to
fever, asthma, or eczema, as well as any untoward develop serious medical conditions.

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6 Section 1: Basic Surgical Principles and Perioperative Management

REVIEW OF SYSTEMS surfaces, provided the examination is carried out


competently.
The review of systems is a comprehensive and
systematic review of subjective symptoms affecting
different bodily systems. It includes the following
Evaluation Protocol
categories:
General
Head, eyes, ears, nose, and throat
Cardiovascular
Respiratory
Dermatologic
Hematologic-lymphatic
Neuropsychiatric.

E XAMINATION OF THE PATIENT


GENERAL PROCEDURE
A thorough and systematic inspection of the
oral cavity and adnexal tissues minimizes the
possibility of overlooking previously undiscovered VITAL SIGNS
pathologies. The examination is most conveniently
carried out with the patient seated in a dental Vital signs (respiratory rate, temperature, pulse,
chair, with the head supported or examination and blood pressure) are routinely recorded as
table. Before seating the patient, the clinician part of the examination.
should observe the patients general appearance In addition to being useful as an indicator of
and gait and should note any physical deformities systemic disease, this information is essential as
or handicaps. a standard of reference should syncope or other
The routine oral examination should be untoward medical complications arise during
carried out. Laboratory studies and additional patient treatment.
special examination of other organ systems may
be required for the evaluation of patients with Respiratory Rate
orofacial pain or signs and symptoms suggestive of Normal respiratory rate during rest is 1420
salivary gland disorders or pathologies suggestive breaths per minute. Any more rapid breathing
of a systemic etiology. is called tachypnea and may be associated with
Examination carried out in oral and underlying disease and/or elevated temperature.
maxillofacial surgery clinic is restricted to that of
the superficial tissues of the oral cavity, head, and
neck and the exposed parts of the extremities. On Temperature
occasion, evaluation of an oral lesion logically The normal oral (sublingual) temperature is 37C
leads to an inquiry about similar lesions on other (98.6F), but oral temperatures <37.8C (100F)
skin or mucosal surfaces or about the enlargement are not usually considered to be significant.
of other regional groups of lymph nodes. Although Studies of sublingual, axillary, auditory canal and
these enquiries can usually be satisfied directly rectal temperatures in elderly patients indicate
by questioning the patient, the surgeon may also that these traditionally accepted values differ
quite appropriately request permission from the somewhat from statistically determined values.
patient to examine axillary nodes or other skin Recent drinking of hot or cold liquids or mouth

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Chapter 1: Clinical Approach to Oral and Maxillofacial Surgical Patients 7
breathing in very warm or cold air may alter the encourages increased use. Both blood pressure and
oral temperature. Also, severe oral infection may pulse are recorded, but irregular rhythms cannot be
alter the local temperature in the mouth without detected. To detect potential deviations, electronic
causing fever. devices should occasionally be calibrated against a
manual sphygmomanometer.
Pulse Rate and Rhythm If the cuff is applied too loosely, if it is not
completely deflated before applying, or if it is too
The normal resting pulse rate is between 60 and small for the patients arm, the pressure readings
100 beats per minute (bpm). A patient with a pulse
obtained will be erroneously high and will not
rate >100 bpm (tachycardia), even considering
represent the pressure in the artery at the time of
the stress of a surgery, should be allowed to rest
measurement.
quietly to allow the pulse to return to normal
before the start of treatment. If the patients pulse
rate remains persistently high, medical evaluation CRANIOFACIAL REGION EXAMINATION
of the tachycardia is appropriate because severe The ability to perform thorough physical
coronary artery disease or myocardial disease examination of superficial structures of head,
may be present. Note that the pulse rate normally neck and oral cavity is essential. To perform this
rises about 510 bpm with each degree of fever. examination procedure successfully oral and
Rates that are consistently < 60 bpm maxillofacial surgeon should have knowledge of:
(bradycardia) warrant medical evaluation Anatomy of craniofacial region
although sinus bradycardia, a common condition, He should know the technique for displaying
can be normal. mucosal surfaces and skin of craniofacial
Although a healthy person may have occasional region with minimum discomfort to the patient
irregularities or premature beats (especially He should have the knowledge of pathology of
when under stress) a grossly irregular pulse can oral and maxillofacial region
indicate severe myocardial disease (arrhythmia or He should have ability to record both normal
dysrhythmia), justifying further cardiac evaluation. and abnormal findings
Cardiac consultation is necessary for the accurate He should know the general appearance of the
interpretation of most pulse rate abnormalities. patient and general nutritional status
Pulse rate abnormalities may be regular or He should study the character of skin and the
irregular. Irregular rate abnormalities may be presence of petechiae and eruption
divided further into regularly irregular and He should be able to determine the reaction
irregularly irregular abnormalities. of pupil to light and accommodation especially
when neurological disorders are being
Blood Pressure investigated
Blood pressure should be measured with Superficial and deep lymph nodes of the neck
appropriate equipment and in a standardized are examined from behind the patient when
fashion. Although sphygmomanometers are the patient head is inclined forward
most accurate devices, validated electronic devices Inner surfaces of lips mucosa of the cheek
or aneroid sphygmomanometers with appropriately maxillary and mandibular mucobuccal fold
sized cuffs are sufficient for blood pressure the palate tongue sublingual space gingival
screening. Electronic devices are usually accurate to and supporting structures
within 3 percent of a manual sphygmomanometer. Examine tonsillar and pharyngeal areas
Their ease of use in comparison with manual Examine the tongue, sublingual space, oropharynx
sphygmomanometers is a great advantage and Examine the occlusion.

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8 Section 1: Basic Surgical Principles and Perioperative Management

FACIAL STRUCTURES ulcers, recent burns, leukoplakia, and asymmetry


of structure or function.
Observe the patients skin for color, blemishes,
Examine the orifices of minor salivary glands.
moles, and other pigmentation abnormalities;
Palpate the palate for swellings and tenderness.
vascular anomalies such as angiomas, telangi-
ectasias, nevi, and tortuous superficial vessels;
and asymmetry, ulcers, pustules, nodules, and TONGUE
swellings. Inspect the dorsum of the tongue (while it is at
Note the color of the conjunctivae. Palpate rest) for any swelling, ulcers, coating, or variation
the jaws and superficial masticatory muscles for in size, color, and texture.
tenderness or deformity. Note any scars or keloid Observe the margins of the tongue and note the
formation. distribution of various papillae. Note the frenal
attachment and any deviations as the patient
LIPS pushes out the tongue and attempts to move it to
the right and left up down to see ankyloglossia?
Note lip color, texture, and any surface abnormalities
Wrap a piece of gauze around the tip of the
as well as angular or vertical fissures, lip pits, cold
protruding tongue to steady it, and lightly press
sores and, ulcers.
a warm mirror against the uvula to observe the
base of the tongue and vallate papillae; note
CHEEKS any ulcers or significant swellings. Holding the
Note any changes in pigmentation of the tongue with the gauze, gently guide the tongue
mucosa, a pronounced linea alba, leukoedema, to the right and retract the left cheek to observe
hyperkeratotic patches, intraoral swellings, ulcers, the foliate papillae and the entire lateral border
nodules, scars, other red or white patches, and of the tongue for ulcers, keratotic areas, and red
Fordyces granules. Observe openings of Stensens patches. Repeat for the opposite side, and then
ducts and establish their patency by first drying have the patient touch the tip of the tongue to the
the mucosa with gauze and then observing the palate to display the ventral surface of the tongue
character and extent of salivary flow from duct and floor of the mouth; note any varicosities, tight
openings, with and without milking of the gland. frenal attachments, stones in Whartons ducts,
Palpate muscles of mastication. ulcers, swellings, and red or white patches. Gently
palpate the muscles of the tongue for nodules
 AXILLARY AND MANDIBULAR
M and tumors, extending the finger onto the base of
MUCOBUCCAL FOLDS the tongue and pressing forward if this has been
poorly visualized or if any ulcers or masses are
Observe color, texture, any swellings, and any suspected. Note tongue thrust on swallowing.
fistulae. Palpate for swellings and tenderness over
the roots of the teeth and for tenderness of the
FLOOR OF THE MOUTH
buccinator insertion by pressing laterally with a
finger inserted over the roots of the upper molar With the tongue still elevated, observe the
teeth. openings of Whartons ducts, the salivary pool, the
character and extent of right and left secretions,
HARD PALATE AND SOFT PALATE and any swellings, ulcers, or red or white patches.
Gently explore and display the extent of the
Illuminate the palate and inspect for discoloration, lateral sublingual space, again noting ulcers and
swellings, fistulae, papillary hyperplasia, tori, red or white patches.

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Chapter 1: Clinical Approach to Oral and Maxillofacial Surgical Patients 9

GINGIVAE When salivary flow is reduced, there may be


a brief flow of viscous or cloudy saliva, followed
Observe color, texture, contour, and frenal
by a small amount of apparently normal saliva;
attachments. Note any ulcers, marginal inflam-
this emphasizes the need for careful observation
mation, resorption, festooning, Stillmans clefts,
of the initial flow. Psychic stimuli (such as asking
hyperplasia, nodules, swellings, and fistulae.
the patient to think of a cold refreshing lemon
drink on a hot day) may also be used to increase
TEETH AND PERIODONTIUM the flow of parotid saliva during the examination.
Note missing or supernumerary teeth, mobile Palpate any suspected parotid swelling externally
or painful teeth, caries, defective restorations, at this time, recording texture and any tenderness
dental arch irregularities, orthodontic anomalies, or nodularity; distinguish parotid enlargement
abnormal jaw relationships, occlusal interferences, from hypertrophy and spasm of the masseter
the extent of plaque and calculus deposits, dental muscle.
hypoplasia, and discolored teeth. For the submandibular and sublingual glands,
use bimanual palpation (insert the gloved index
TONSILS AND OROPHARYNX finger beside the tongue in the floor of the mouth
and locate the two salivary glands and any
Note the color, size, and any surface abnormalities
enlarged submandibular lymph nodes, using a
of tonsils and ulcers, tonsilloliths, and inspissated
second finger placed externally over the gland);
secretion in tonsillar crypts. Palpate the tonsils for
note the location, texture, and size of each gland
discharge or tenderness, and note restriction of the
oropharyngeal airway. Examine the faucial pillars and any tenderness or nodules. Dry the orifices of
for bilateral symmetry, nodules, red and white both Whartons ducts and note the amount and
patches, lymphoid aggregates, and deformities. character of the excreted saliva as one and then
Examine the postpharyngeal wall for swellings, the other submandibular glands and ducts are
nodular lymphoid hyperplasia, hyperplastic milked.Palpate Whartons duct on each side
adenoids, postnasal discharge, mucus secretions. for any salivary calculi. When either the parotid
or the submandibular/sublingual salivary flow
appears minimal, flow may often be stimulated
SALIVARY GLANDS
by either gustatory stimuli (such as lemon juice
Note any external swelling that may represent swabbed on the tongue dorsum) or painful stimuli
enlargement of a major salivary gland. A (e.g. pricking the gingiva with an explorer). With
significantly enlarged parotid gland will alter the stimulation of the salivary flow, minor salivary
facial contour and may lift the ear lobe; an enlarged gland function can be demonstrated by the
submandibular salivary gland (or lymph node) appearance of multiple small beads of saliva on
may distend the skin over the submandibular the dried upper- and lower-lip mucosa.
triangle. With minimal manipulation of the
patients lips, tongue, and cheeks, note the Temporomandibular Joint
presence of any salivary pool, and note whether
the mucosa is moist, covered with scanty frothy Mandibular deviation while opening and closing the jaw
saliva, or dry. To evaluate parotid gland function, Range of vertical and lateral movements
dry the cheek mucosa around the orifice of each Palpate the joints, and listen for clicking and crepitus
parotid duct, and massage or milk the gland during opening and closing of the jaw
and duct externally, observing the amount and Note any tenderness over the joint or masticatory
character of any excreted material. With a normal muscles
gland, clear and freely flowing saliva will be Explore the anterior wall of external auditory meatus
for tenderness
readily apparent.

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10 Section 1: Basic Surgical Principles and Perioperative Management

NECK AND LYMPH NODES sit erect and to turn his or her head to one side to
relax the sternomastoid; use thumb and fingers to
Examination of the neck includes examination
palpate under the anterior and posterior borders
of the submandibular and cervical lymph nodes,
of the relaxed muscle, and repeat the procedure
the midline structures (hyoid bone, cricoids and
on the opposite side. Next, palpate the posterior
thyroid cartilages, trachea, and thyroid gland),
cervical nodes in the posterior triangle close
and carotid arteries and neck veins.
to the anterior border of the trapezius muscle.
With the patients neck extended, note the
Finally, check for supraclavicular nodes just
clavicle and the sternomastoid and trapezius
above the clavicle, lateral to the attachment of the
muscles, which define the anterior and posterior
sternomastoid muscle.
triangles of the neck. Palpate the hyoid bone, the
Normal lymph nodes may be difficult to
thyroid and cricoid cartilages, and the trachea,
palpate; enlarged lymph nodes (whether due to
noting any displacement or tenderness.
current infection, scarring from past inflammatory
Palpate around the lower half of the
processes, or neoplastic involvement) are usually
sternomastoid muscle, and identify and palpate
readily located. Many patients have isolated
the isthmus and wings of the thyroid gland below
enlarged and freely movable submandibular
and lateral to the thyroid cartilage, checking for
and cervical nodes from past oral or pharyngeal
any nodularity, masses, or tenderness. If local or infection. Nodes draining areas of active infection
generalized thyroid enlargement is suspected, are usually tender; the overlying skin may be
check to ascertain whether the mass moves up warm and red, and there may be a history of
and down with the trachea when the patient recent enlargement.
swallows. Observe the external jugular vein as it Nodes enlarged as the result of metastatic
crosses the sternomastoid muscle, and with the spread of a malignant tumor have no characteristic
patient at an angle of approximately 45 to the clinical appearance and may be small and
horizontal, note any distension and/or pulsation asymptomatic or grossly enlarged. Classically,
in the vein. Distension more than 2 cm above the nodes enlarged due to cancer are described as
sternal notch is abnormal; in severe right-sided fixed to underlying tissue (implying that the
heart failure, distension as far as the angle of tumor cells have broken through the capsule of
the mandible may be seen. Place the diaphragm the lymph node or that necrosis and inflammation
of the stethoscope over the point of the carotid have produced perinodular scarring and
pulse, and listen for bruits or other disturbances adhesions), but this feature will usually be absent
of rhythm that may indicate partial occlusion of except with the most aggressive or advanced
the carotid artery. tumors.
Palpate for lymph nodes in the neck Gradually enlarging groups of nodes in the
commencing with the most superior nodes and absence of local infection and inflammation
working down to the clavicle. Palpate anterior are a significant finding that suggests either
to the tragus of the ear for preauricular nodes; systemic disease [e.g. infectious mononucleosis
at the mastoid and base of the skull for posterior or generalized lymphadenopathy associated with
auricular and occipital nodes; under the chin human immunodeficiency virus (HIV) infection]
for the submental nodes; and further posterior or a lymphoid neoplasm (lymphoma or Hodgkins
for submandibular and lingual-notch nodes. disease); such a finding justifies examination
The superficial cervical nodes lie above the for (or inquiry about) lymphoid enlargement at
sternomastoid muscle; the deep cervical nodes lie distant sites, such as the axilla, inguinal region, and
between the sternomastoid muscle and cervical spleen, to confirm the generalized nature of the
fascia. To examine the latter, ask the patient to process. A successful outcome to cancer treatment

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Chapter 1: Clinical Approach to Oral and Maxillofacial Surgical Patients 11
is dependent on early detection and treatment, and cervical lymph node enlargement include
hence the need for rapid follow up investigation acute bacterial, viral, and rickettsial infections
whenever unexplained lymph node enlargement of the head and neck (e.g. acute abscesses,
is detected during examination of the neck. infectious mononucleosis, cat-scratch disease,
Enlargement of supraclavicular and cervical and mucocutaneous lymph node syndrome);
nodes may occur from lymphatic spread of chronic bacterial infections, such as syphilis and
tumor from the thorax, breast, and arm as well as tuberculosis; leukemia, lymphoma, metastatic
from tumors of the oral cavity and nasopharynx. carcinoma, collagen disease, and allergic
Conditions to be considered in a patient with reactions and sarcoidosis.

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Preoperative
Care and Evaluation
2
INTRODUCTION testing, echo study, imaging procedures, and
neurosurgical consultation. Preoperative patient
Preoperative care and evaluation of oral and
conditions are significant predictors of postop-
maxillofacial patient is the preparation and
erative complications.
management of a patient prior to surgery. It includes
both physical and psychological preparation.
Although importance of a thorough history and Aim
physical examination remains key element in the Patients who are physically and psychologically
preoperative evaluation of all patients. prepared for surgery tend to have better
Preoperative patient management period, surgical outcomes
maxillofacial pathology, defects and injuries are Preoperative teaching meets the patients
assessed and accurate decision is made for a surgical need for information regarding the surgical
intervention. Patient is appropriately apprised of the experience, which in turn may alleviate most
problems, procedure and the need for surgery as of patients fears. Patients who are more
well as options available and necessary preoperative knowledgeable about what to expect after
evaluation and preparation is completed. surgery, and who have an opportunity to
express their goals and opinions, often cope
DEFINITION better with postoperative pain and decreased
mobility
The patient management period during which
Preoperative care is extremely important
oral and maxillofacial pathology, defects and
prior to any invasive procedure, regardless of
injury are assessed and diagnosed, an accurate
whether the procedure is minimally invasive or
decision is made for a surgical intervention; the
patient and family are appropriately appraised of a form of major surgery
the condition; problem and need for surgery as Preoperative teaching must be individualized
well as options available. for each patient. Some people want as much
information as possible, while others prefer
only minimal information because too much
PREOPERATIVE EVALUATION knowledge may increase their anxiety
Preoperative evaluation of a patient before Patients have different abilities to comprehend
surgery for the purpose of detecting factors that medical procedures; It is important for the
could affect surgical outcome and may include in patient to ask questions during preoperative
addition to a thorough examination, laboratory teaching sessions.

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Chapter 2: Preoperative Care and Evaluation 13

Table 2.1: Modified American Society of Anesthesiologists (ASA) physical status may be more practical in
recent use for preoperative risk assessment
A normal healthy patient
A patient with mild systemic disease
A patient with severe systemic disease that limits activity but is not incapacitating
A patient with severe systemic disease that is a constant threat to life
A moribund patient who is not expected to survive 24 hours without the operation

Description Assessment (Table 2.1) medical supplies including general anesthesia


Preoperative care involves many components, masks, tubing, and multi-dose medication vials
and may be done the day before surgery in the The night before surgery, skin preparation
hospital, or during the weeks before surgery on is often ordered, which can take the form of
an outpatient basis scrubbing with a special soap or possibly scalp
Many surgical procedures are now performed or facial hair removal from the surgical area
in a day surgery setting. Shaving hair is no longer recommended
because studies show that this practice may
increase the chance of infection
Physical Preparation
Instead, adhesive barrier drapes can contain
Physical preparation may consist of a complete hair growth on the skin around the incision.
medical history and the patients surgical and
anesthesia background
The patient should inform the physician Psychological Preparation
and hospital staff if he or she has ever had Patients are often fearful or anxious about
an adverse reaction to anesthesia (such as having surgery. It is often helpful for them to
anaphylactic shock), or if there is a family express their concerns to health care workers.
history of malignant hyperthermia This can be especially beneficial for patients
Laboratory tests may include complete blood who are critically ill, or who are having a high-
count, electrolytes, prothrombin time, activated risk procedure
partial thromboplastin time, and urinalysis The family needs to be included in
The patient will most likely have an electro- psychological preoperative care
cardiogram (ECG) if he or she has a history of If the patient has a fear of dying during surgery,
cardiac disease, or is over 50 years of age this concern should be expressed, and the
A chest X-ray is done if the patient has a history surgeon notified. In some cases, the procedure
of respiratory disease may be postponed until the patient feels more
Part of the preparation includes assessment for secure
risk factors that might impair healing, such as Children may be especially fearful. They
nutritional deficiencies, steroid use, radiation should be allowed to have a parent with them
or chemotherapy, drug or alcohol abuse, or as much as possible, as long as the parent is
metabolic diseases such as diabetes not demonstrably fearful and contributing to
The patient should also provide a list of all the child's apprehension. Children should be
medications, vitamins, and herbal or food encouraged to bring a favorite toy or blanket to
supplements that he or she uses the hospital on the day of surgery
Latex allergy has become a public health Patients and families who are prepared
concern. Latex is found in most sterile surgical psychologically tend to cope better with the
gloves, and is a common component in other patients postoperative course. Preparation

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14 Section 1: Basic Surgical Principles and Perioperative Management

leads to superior outcomes since the goals Carotid pulse (Corrigans sign) associated with
of recovery are known ahead of time, and the large volume pulse as in anemia, thyrotoxicosis,
patient is able to manage postoperative pain or fever.
more effectively.
Jugular Venous Pressure
SYSTEMIC ASSESSMENT Is an indicator of the pressure in the right
atrium
Cardiovascular System Maybe elevated in heart failure, constrictive
A variety of problemsischemic heart disease pericarditis, cardiac tamponade, etc.
(IHD), congestive cardiac failure (CCF), Heart sounds and murmers
cardiac arrhythmias, valvular heart disease, S1 and S2 normal physiological heart sounds
cardiomyopathies, hypertension
S3abnormal if >40 years
Cardinal symptomsexercise intolerance and S4abnormal in young,indicative of
chest pain.
ventricular stiffness
To assess the cardiovascular status Murmers are caused by turbulent flow
Pulse (rate, rhythm, character) High velocity murmersmitral or aortic
BP regurgitation
Cardiac murmers, added heart sounds. Low velocity murmersmitral stenosis.
Other signs like Cardiac Investigations
Hepatomegaly Chest X-ray
Ankle edema Assess cardiomegaly
Basal crepitations in lung Atrial or ventricular hypertrophy
Neck vein distension. Calcifications
-- Pericardial
General Examination
-- Valvular
Clubbingassociated with congenital heart -- Myocardial or coronary artery
disease or subacute endocarditis
-- Lung field
Cyanosisseen when capillary oxygen satura-
ECGto record the electrical activity of heart
tion is less than 85 percent
ECHOinvolves use of ultrasound with
Central cyanosisseen in tongue and lips,
contrast agent to assess cardiac structure and
due to desaturation of central arterial blood
function, useful to determine
as in right to left heart shunt
Valve stenosis and regurgitation
Peripheral cyanosisnoticed in hand and
Vegetations >2 mm
feet, may be due to circulatory shock, CCF,
abnormalities of peripheral circulation, or Aortic aneurysms and dissections
exposure to cold. Cardiomyopathies, pericardial effusion.

Pulse Other Investigations


Ratephysiological variation Nuclear imaging (SPECT)
Pulse chart is valuable Radionuclide angiography (MUGA)
Rhythmirregularities are seen due to prema- Positron emission tomography (PET)
ture beats, intermittent heart block, ectopic Cardiac catheterization

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Chapter 2: Preoperative Care and Evaluation 15
Digital subtraction angiography Arrhythmias
Cardiovascular magnetic resonance (CMR). Ventricular tachycardia and ectopic should be
Risk of surgery in patients with cardiac treated preoperatively.
problems as described by Lee et al.

High-risk Surgery Respiratory System


History of IHD Physical Examination
CCF Observe for pattern of breathing and degree of
Previous stroke chest expansion
Diabetes mellitus Cyanosis and clubbing
Renal failure Dyspnea, cough, hemoptysis, wheeze, chest
Cardiovascular system. pain.

Management Asthma
Ischemic Heart Disease In well controlled asthmatics, salbutamol
inhalation or nebulization is done prior to
Patient maybe already on medications like anesthesia to prevent bronchospasm and
b-blockers, diuretics or nitrates and are laryngospasm
continued up to the time of premedication
Elective surgery is undertaken if PEFR is 250
Those with history of angina at rest transdermal 300 L/min
or IV nitrates are given preoperatively.
In severe asthma a short course steroid,
Hypertension prednisone 4080 mg/day can be used
Other drugs that are used are antileukotrienes
WHO defines hypertension as:
and theophylline
Systolic BP >160 mm Hg
Atelectasis and increased risk of pneumonia
Diastolic BP >95 mm Hg are seen in asthmatics postoperatively
Accordingly 4 groups of patients: Histamine releasing drugs like
Diastolic BP 95110 mm Hg d-tubocurarine, morphine, atracurium are
Diastolic BP 110120 mm Hg avoided.
Diastolic BP >120 mm Hg
Elevated systolic BP 200250 mm Hg Chronic Obstructive Pulmonary Disease
Assess end organ disease Chronic bronchitis
If treatment is required, then surgery can be Emphysema
postponed for 46 weeks to allow optimization of Smoking is the most common cause.
therapy.
Management
Congestive Cardiac Failure Hydration to mobilize mucus secretion
GA can cause cardiac muscle depression and Inhaled b agonists or inhaled ipratropium
hypokalemia, ionotropic agents like dopamine or Oral and parenteral steroids used if wheezing
dobutamine. is detected preoperatively
Production of mucopurulent sputum may
Valvular Heart Disease indicate need for antibiotics
Appropriate antibiotic prophylaxis against Nitrous oxide and narcotics are avoided in
endocarditis. anesthesia.

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16 Section 1: Basic Surgical Principles and Perioperative Management

Table 2.2: Management of difficult airway


Recognition of difficult airway
Preparation for difficult airway positioning of patient for airway manipulation
Awake intubation technique
Technique for anesthetized patient with difficult airway
Technique for patient who cannot be ventilated or intubated
Confirming the position of endotrachel tube
Extubation or tube exchange for a patient with known difficult airway

Upper airway, examination is carried out for Liver biochemistry


intubation (Table 2.2) Serum aspartate and alanine amino-
transferases-reflects hepatocellular damage
Mallampati Classification (Figs 2.1 to 2.4) Serum alkaline phosphatase-reflects
Depending on structures visible cholestasis
Class I: Hard palate, soft palate, uvula and Total protein
faucillapillors (Fig. 2.1) Viral markers
Class II: Hard palate, soft palate and uvula (Fig. Additional blood, immunological (AMA,
2.2) ANCA), genetic investigations
Urine tests for bilirubin and urobilinogen
Class III: Hard palate and soft palate (Fig. 2.3)
Imaging techniques for defining gross anatomy
Class IV: Hard palate only (Fig. 2.4).
Liver biopsy for histology
Liver diseases and anesthesia
Liver Diseases
Serum albumin is a valuable guide to assess
Important Functions of Liver severity of chronic liver disease
1. Metabolism of glucose, amino acids, fatty Prothrombin time is a sensitive indicator of
acids and cholesterol both acute and chronic liver disease.
2. Production of bile
3. Detoxification of drugs and waste products Liver Enzymes
4. Synthesis (albumin, coagulation factors) Aspartate aminotransferase (a mitochondrial
Each of these factors will influence the safe enzyme), also present in heart, muscle, kidney
conduct of anesthesia and brain. High levels in hepatic necrosis, MI,
While assessing liver disorders history of muscle disease and CCF
jaundice is recorded (indicates hepatitis,
Alanine aminotranferase (cytosol enzyme)
cholecystitis or gallstones)
specific for liver diseases
Assess evidence of clotting disorders.
International normalized ratio INR is the ratio
Investigations PT (patient)/PT (control sample)
Blood tests Normal value0.81.2
Liver function tests For patients on anticoagulants23
Serum albumin INR of 5bleeding tendencies
Prothrombin time < 0.5high chances of having a clot.

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Chapter 2: Preoperative Care and Evaluation 17

Fig. 2.1 Class I: Visualized intraoral anatomy: Soft Fig. 2.2 Class II: Visualized intraoral anatomy: Soft
palate, fauces, uvula, anterior and posterior pillars palate, fauces, uvula
Implications: Generally associated with an easy intubation Implications: Generally associated with an easy intubation

Fig. 2.3 Class III: Visualized intraoral anatomy: Fig. 2.4 Class IV: Visualized intraoral anatomy: The
Only soft plate, base of uvula hard palate but not the soft palate
Implications: Potential for intubation difficulty Implications: Potential for intubation difficulty

Imaging Techniques CT
Ultrasound examination Assess size, shape, density of liver and can
Splenomegaly/hepatomegaly determine focal diseases
Focal liver disease MRI
Parenchymal liver disease MRCP (MR Cholangiopancreatography)
Lymph node enlargement Radionucleide imaging

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18 Section 1: Basic Surgical Principles and Perioperative Management

PTC (percutaneous transhepatic cholangiog- Thyroid Disorders


raphy). The normal T3:T4 ratio is 15:1,are released in
response to TSH
Preparation
The most common lab tests to assess thyroid
During premedication, IM drugs are avoided function are measurement of total thyroid
due to preexisting bleeding tendency hormone levels by RIA,
Opiates are avoided, benzodiazepenes are Normal levels5012 pg/dL
given Higher valuehyperthyroidism
Vitamin K is administered when necessary to Lower valuehypothyroidism
the jaundiced patient T3 resin uptake
Central venous monitoring is advisable for Higher values of T3 resin uptake are associated
patients with cirrhosis with hypothyroidism and lower values with
In obstructive jaundice, oral bile salts are hyperthyroidism.
administered to avoid postoperative renal
failure and endotoxemia Hyperthyroidism
If factors II, VII, IX, and X are reduced they may Weight loss
respond to vitamin K Palpitations
In case factor V and X are reduced then infusion Restlessness
of fresh frozen plasma is given. Surgical riskcardiac failure
Thyroid crisis
Surgery in Diabetic Patients Elective surgery is deferred until hyper-
A diagnosis of diabetes is made if: thyroidism is controlled
Fasting venous blood glucose level >140 mg/dL If emergency surgery is required-IV sodium
(7.8 mmol/L) iodide is used to block hormone from the gland
An abnormal glucose tolerance test b antagonists used to control the effects of
Glucose concentration in excess of 200 mg/dL thyroid hormones.
after ingestion of 75 g of glucose.
Hypothyroidism
Preoperative Management Poses a lesser surgical and anesthetic risk when
Patients with diet controlled diabetes mellitus compared to hyperthyroidism
can be safely maintained without food or Weight gain
glucose infusion before surgery Muscle weakness
Patients on oral hypoglycemics should Bradycardia.
discontinue them the evening before surgery. In
case of long acting agents like chlorpropamide, Surgical Risk
they are discontinued 2 or 3 days prior to surgery Pretoperative heart failure
Patients on insulin require glucose and insulin Mental confusion postoperatively
preoperatively Delayed wound healing.
In patients undergoing major surgical
procedures one half of the morning dose of Chronic Renal Failure
insulin with 5 percent dextrose at 100125 Impaired renal function will show:
mL/hr subsequent insulin admin is guided by Acid base and electrolyte imbalance
frequent (46 hr) blood glucose determinations. Anemia

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Chapter 2: Preoperative Care and Evaluation 19
Hypertension and IHD Heparin Window
Coagulation disorders Describes the time before and after a surgical
Delayed gastric emptying, gastric reflux, etc. procedure when the patients warfarin therapy
is replaced with low molecular weight heparin.
Preoperative Management The standard protocol is to
Routine hemofilteration or dialysis is done for Discontinue warfarin 4 or 5 days before the
surgical patients scheduled procedure,
All intercurrent therapy should be continued Initiate unfractionated IV heparin or low
up to the day of surgery molecular weight heparin
Opioid premedication is avoided (bleeding After the International normalized ratio (INR)
tendencies) falls below the therapeutic range, and then
Doses of analgesics are titrated against effect discontinue heparin before surgery (45 hours
Enfluorane is avoided. before surgery when using unfractionated IV
heparin and 1224 hours before surgery when
Laboratory Investigations using LMWH)
The single most useful measure of renal health After surgery, when the risk of bleeding is
is GFR (normally, 100125 mL/min/1.73 sqm minimized, both heparin and warfarin are
of body surface area in an adult) restarted. Once the INR is within the therapeutic
Mild-to-moderate renal insufficiency2550 mL range, heparin therapy is stopped, while oral
anticoagulation using warfarin continues.
Severe renal deficiency1025 mL
Frank renal failure >10 mL Corticosteroid Therapy
GFR is measured clinically by determining the Normal secretion2530 mg/day
clearance of endogenous creatinine At the time of trauma or surgery300500 mg/
Other indicators of renal problems are day
proteinuria, hematuria, pyuria, all detectable In patients on steroid therapy, ACTH production
by urine analysis. is supressed.

Drug Therapy Management


Adrenal cortical function is assessed using
Patients on Anticoagulant Therapy
synthetic ACTH.
Warfarin (coumadin)
Heparin. Regimen
100 mg IV at the time of induction followed by
Indications 100 mg IV every 6 hours for 3 days
Deep venous thrombosis (DVT) 25 mg at induction followed by
Pulmonary embolism 25 mg q6h for 24 hours for intermediate surgery
Unstable angina 25 mg q6h for 48 hours for major surgeries.
Acute MI.
Oral anticoagulation therapy does not need Oral Contraceptives
to be changed for minor oral surgical procedures Oral contraceptives + surgery will reduce the
and exodontia if patients INR range is 23. action of antithrombin III

Ch-2.indd 19 15-04-2013 10:09:04


20 Section 1: Basic Surgical Principles and Perioperative Management

Before elective surgery, combined pill should Medications for lactating mothers include
be stopped 4 weeks prior paracetamol, cephalexin, erythromycin, ligno-
If surgery is an emergency, then prophylactic caine, pentazocine, antihistamines.
heparin should be considered.
NPO Status
Antiepileptic Therapy For all patients, abstain from any oral intake
Patients on chronic antiepileptic therapy have except for medications with sips of water for
hepatic microsomal enzyme induction 8 hours before elective surgery.
Higher than normal doses of hypnotics and
Aspiration Prophylaxis Regimen
analgesics will be required for anesthesia and
pain relief. For patients who are not considered at
increased risk for aspiration of gastric contents
Antihypertensives Solid food permitted until 6 hours before
Are maintained up to the time of surgery, which surgery
will maintain normal BP and blood volume. Clear liquids (not milk or juices containing
pulp) until 2 hours before surgery
Surgery in the Special Patient Obese, diabetic or patients on narcotic therapy
(delayed or incomplete gastric emptying)
Pediatric Patients Require longer fasting periods
The normal physiology of these patients makes Additional pretreatment with metoclopro-
them differ from adults in their response to drugs mide, H2 antagonists
and anesthesia Maintenance IV fluid should be started.
Children have
NPO Status and Antibiotic Prophylaxis
Large tongue
Antibiotic prophylaxis depends on:
Small nasal airway
Type of pathogens encountered during surgery
Small mandible The type of operative wound
Short neck Class I woundno antibiotic prophylaxis
All these makes airway very easily compromised Class II woundsingle dose of appropriate
Children have relatively large surface areas antibiotic prior to skin incision
that can allow excessive heat loss when they Class III woundparenteral antibiotic with
are left uncovered in operating room aerobic and anerobic activity
Dosing of drugs is usually best decided based Class IV woundsame as with Class III wound
on manufacturers recommendations. but should be continued postoperatively.

Pregnant and Lactating Patients Medicolegal Aspects


Are relative contraindications for elective oral Documented Informed consent which is
and maxillofacial surgical procedures legally valid
If surgery cannot be deferred then patients Patient awareness of various drugs used and
obstetrician is consulted with the procedure
When feasible surgery should be conducted Perioperative complications and deaths.
under LA
Drugs like aspirin, diazepam, steroids, pro- Informed Consent
methazine, and tetracycline are best avoided The patients or guardian's written consent for
in pregnancy the surgery is a vital portion of preoperative care

Ch-2.indd 20 15-04-2013 10:09:04


Chapter 2: Preoperative Care and Evaluation 21
By law, the physician who will perform the information, and how long it will be before
procedure must explain the risks and benefits of they can see the patient
the surgery, along with other treatment options Knowledge about what to expect during the
However, the nurse is often the person who postoperative period is one of the best ways
actually witnesses the patients signature on the to improve the patients outcome. Instruction
consent form. It is important that the patient about expected activities can also increase
understands everything he or she has been told. compliance and help prevent complications
Sometimes, patients are asked to explain what Additionally, the patient should be informed
they were told so that the health care professionals about intermaxillary ligation, early ambulation
can determine how much is understood (getting out of bed). The patient should also
Patients who are mentally impaired, heavily be taught that the respiratory interventions
sedated, or critically ill are not considered decrease the occurrence of pneumonia,
legally able to give consent. In this situation, the and that early leg exercises and ambulation
next of kin (spouse, adult child, adult sibling, decrease the risk of blood clots
or person with medical power of attorney) may Patients hospitalized postoperatively should
act as a surrogate and sign the consent form be informed about the tubes and equipment
Children under age 18 must have a parent or that they will have. These may include multiple
guardian sign. intravenous lines, drainage tubes, dressings,
and monitoring devices
Preoperative Teaching Pain management is the primary concern for
Preoperative teaching includes instruction many patients having surgery. Preoperative
instruction should include information about
about the preoperative period, the surgery
the pain management method that they will
itself, and the postoperative period
utilize postoperatively. Patients should be
Instruction about the preoperative period encouraged to ask for or take pain medication
deals primarily with the arrival time, where before the pain becomes unbearable, and
the patient should go on the day of surgery, should be taught how to rate their discomfort
and how to prepare for surgery. For example, on a pain scale. This instruction allows the
patients should be told how long they should be patients, and others who may be assessing
NPO (nothing by mouth), which medications them, to evaluate the pain consistently. If they
to take prior to surgery, and the medications will be using a patient-controlled analgesia
that should be brought with them pump, instruction should take place during the
Instruction about the surgery itself includes preoperative period.
informing the patient about what will be done
during the surgery, and how long the procedure Normal Results
is expected to take. The patient should be told The anticipated outcome of preoperative care
where the incision will be is a patient who is informed about the surgical
It is also important for family members (or course, and copes with it successfully
other concerned parties) to know where to wait The goal is to decrease complications and
during surgery, when they can expect progress promote recovery.

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Principles of
Postoperative Care
3
INTRODUCTION Main points in the postoperative treatment
plan includes:
Postoperative care of maxillofacial surgical patient
like orthognathic, trauma or cancer patients are
Prophylaxis
quite as important as their preoperative prepara- Monitoring problems contingency planning
tion; deficient care in either area may produce an for adverse events makes them easy to manage.
unsatisfactory outcome, irrespective of standard
of surgery. Recovery from Major Surgery
The recovery from major surgery can be divided
POSTOPERATIVE CARE into 3 phases:
1. An immediate or postanesthetic phase
Provides physiological support when patient is
2. An intermediate phase
temporarily incapacitated
Gives adequate pain relief 3. A convalescent phase
Anticipates and takes early action on During the first two phases, care is principally
complications directed at maintenance of homeostasis,
Maintains good team communication treatment of pain and prevention and early
Regularly reviews the treatment plan. detection of complications
The convalescent phase is a transition
Definition period from the time of hospital discharge
Postoperative care covers the period of time, to full recovery.
the surgery ends to the time patient regains
consciousness. Care includes correct positioning Immediate Postoperative Period
of the patient relative to surgery performed and Major causes of early complications and death
application of minimum pressure and strain on following major surgery are acute pulmonary,
operative site, maintenance of open airway, body cardiovascular and fluid derangements
temperature, fluid balance and monitoring sign of The patient can be discharged from the
developing shock. recovery room to postoperative ward when
cardiovascular, pulmonary and neurologic
Aim functions have returned to baseline
It is to enable the patient to return to pain-free Operating room to recovery room: The attending
and independent life quickly. surgeon and responsible assistant should

Ch-3.indd 22 15-04-2013 10:09:42


Chapter 3: Principles of Postoperative Care 23
accompany the patient to recovery room with Venous stasis may be minimized by intermittent
recovery room note and postoperative orders. compression of the calf by pneumatic stockings.
Many of the physiological disorders which are
easily recognized in fully awake, nonmedicated Diet Orders
patients are modified, abated or entirely elimi- Wright estimated that 50 percent of persons in
nated by residual anesthesia. In recovery room, surgical wards of private, public hospitals are at
this presents major difficulties in recognizing various stages of starvation.
problems such as hypoxia, hypoventilation and Orders should include
hypovolumia. Time to start clear fluids
Patients who require continuing ventilator
Aim of nutrition therapy is to achieve positive
or circulatory support or who have other
nitrogen balance and to provide adequate
conditions that require frequent monitoring
calories
are transferred to an ICU
Postoperative orders must be advised of the Nitrogen requirement: Nitrogen loss (urine
nature of the operation and patients condition. urea 0.028 + 2) approx = 3-6 g/d
It should cover. Energy requirements = 50 percent glucose + 30
percent fat
Monitoring Electrolytes + vitamins added to feeds.
Vital signs: Blood pressure, pulse and respiration
should be recorded until stable. When an arterial Administration of Fluids and Electrolytes
catheter is in place, blood pressure and pulse Based on maintenance needs and replacement
should be monitored continuously. of gastrointestinal losses from drains, fistulas or
stomas.
Central venous pressure: Indicated when opera-
tion has caused large blood losses/fluid shifts. Drainage Tubes
Fluid balance: Aids in hydration and helps to Drain carecharacter and quantity
guide intravenous fluid replacements. A bladder Suctintype and pressure
catheter can be placed for frequent measurement Irrigation fluids.
of urine output. In the absence of bladder catheter,
the surgeon should be notified if the patient is Medications
unable to void within 68 hours after operation. Antibiotics
Respiratory care: Patient may require mechanical Analgesics
ventilation, supplemental oxygen by mask or Gastric acid suppressants
nasal prongs. For intubated patients, tracheal Deep vein thrombosis prophylaxis
suctioning or other forms of respiratory therapy Corticosteroids
must be specified. For extubated patients, deep Antipyretics
breathing exercises frequently to avoid atelectasis. Laxatives
Stool softeners.
Position in Bed and Mobilization
Patient should be turned from side-to-side Laboratory Examinations and Imaging
every 30 minutes until conscious and then Daily chest radiograph
hourly for the first 812 hours to minimize
Blood counts
atelectasis
Early ambulation to reduce venous stasis Serum electrolytes
Upright position to increase diaphragmatic Liver function test, if needed
excursions Renal function test, if needed.

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24 Section 1: Basic Surgical Principles and Perioperative Management

Routine Daily Checks for all Surgery Patients Fluid and Electrolytes
Subjective Maintenance calculations
Greeting with general questions to assess his Calculate ongoing losses
mental state Blood loss
Postoperative patient who is hungry is usually Other parameters
a patient who is doing well. From practical standpoint most losses or gains
of body fluids are from ECF
Objective Improper fluid balance:
Look for pain reaction on face, pallor, cyanosis Preoperative: Causes prompt hypotension
Take patients hand for peripheral perfusion with induction of anesthesia
Look for temperature chart: Intraoperative: complete replacement of blood
Fever is common usually after major surgery loss + 45 mL/hr of RL up to total of 300 mL
If temperature persists, source of infection
may be: chest, urine, surgical wound (in Postoperative Fluid Management
order of occurrence) Based on vitals (blood loss + urine output)
Replacement includes loss + maintenance
Cardiovascular Status In postoperative period 1 lts of fluid is given
Check for BP, pulse, RR, oxygen saturation to replace urine volume necessary to handle
Blue jumpers and warm trousers excretion work load (900 mL urine + 600 mL
Urine output insensible loss)
Pressure areas IV fluid of choice 5 percent dextrose in normal
Wound. saline @ 100 mL/hr
Next day add 40 mEq of K+.
Intermediate Postoperative Period
Monitoring of Fluid Replacement
Starts with complete recovery from anesthesia
and lasts for the rest of hospital stay Pulse
In this period, patient recovers most basic BP
functions and become self-sufficient and able Urine output
to continue convalescence at home. CVP.

Wound Care Complications of Fluid Balance


Bulky dressings are not usually used for incised Hypotension and tachycardia earliest post-
wounds operative sign of circulatory instability
Area can be inspected daily for signs of Minimum urine output of 3050 mL/hr to be
infection maintained.
Skin sutures left in place until wound healed
soundly Clinical Features of Fluid Overload
Removal of the dressing and handling of the Weight gain
wound during first 24 hours should be done Heavy eyelids
with aseptic technique Dyspnea.
If wound becomes infected one or two sutures
removed prematurely to allow egress of Mathematics of Fluids
infected material Distribution of body fluids: rule of thirds
Wounds of head and neck sutures can be Colloid stays in vascular compartment
removed in 46 days checking apposition, Saline stays in extracellular compartment
swelling, gaping of wound edges. Dextrose eventually goes to all compartment.

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Chapter 3: Principles of Postoperative Care 25
Flowchart 3.1: pH control in body

Acid-base Balance Opioids for Severe Pain (Fig. 3.1)


This occurs from altered excretion of CO2, Morphine-like agonists: Morphine, hydrocodone
impaired excretion of H+ ions from kidney or Oxycodone, codeine
productions of lactic acid (Flowchart 3.1). Mixed agonist/antagonists: Butorphanol
Respiratory acidosis nalbuphine
Causes Dezocine
Atelectasis Partial agonist: Buprenorphine.
Pneumonia
Airway obstruction Multimodal Pain Control
treated by underlying cause, assist ventilation. Patient controlled IV analgesia by morphine. If
Respiratory alkalosis patient experiences pain, patient activates device,
Causes bolus dose of morphine is delivered.
Hyperventilation (apprehension, pain, brain
injury) Postoperative Edema
treated by reducing ventilatory rates. Edema of face and neck may be alarming in its
Metabolic acidosis appearance after maxillofacial surgeries
Causes However only edema causing respiratory arrest
Acute circulatory failure or renal damage is of significance to the patient
Chloride excess If this is anticipated then tracheostomy has to
Loss of GI fluids be performed specially in case of IMF.
Administration of unbalanced salt solutions
treated by sodium bicarbonate Management
Head up position
Metabolic alkalosis
Causes Hydrostatic pressure amounts to 2 mm Hg for
Loss of acids, every 2.5 cm of vertical height above heart and
Retention of bases gravity must be allowed to act for the patient
Hypokalemia. and not against him
treated by rehydration.K+, Cl Oxygen to be administered in case of stridor.

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26 Section 1: Basic Surgical Principles and Perioperative Management

Fig. 3.1: WHO pain relief ladder

Pulmonary Care Gastrointestinal Prophylaxis


Postoperative pulmonary complications can Maxillofacial trauma patients more prone to
be prevented by early mobilization stress ulcers
Proper meticulous NPO status Superficial erosions due to reduced blood flow
Frequent changes in position and not due to gastric acidity
Encouragement to cough Prevention is by early enteric feedings,
Incentive spirometer sucralfate, proton pump inhibitors.
Chest physiotherapy
Care of Drain and Catheter
Cardiovascular System Care Observance of aseptic methods during can-
Hemodynamic stability nulation
Control of heart rate with digitalis, beta- Frequent change of tubings, rotation of
blockers insertion sites
Treatment of hypokalemia if any Use of sialistic catheters
Ventricular dysarythmias prevented by oxygen, Drain is usually removed once it has stopped
analgesia, electrolyte balance. draining, or minimal drainage.

Ch-3.indd 26 15-04-2013 10:09:43


Postoperative Complications
and Management
4
INTRODUCTION The most frequent are bleeding, infection,
change in position of occlusion or protracted
Postoperative period is crucial because
pain.
consciousness and reflex may still be impaired.
It is critical since the first 2448 hours is most
Precautions
important to monitor basic physiological
parameters, such as CVS, respiratory, renal, and Avoid heavy preanesthetic sedation
laboratory tests to optimize and sustain recovery. Adequate preoperative starvation
Nasogastric tube to remove liquid from
DEFINITION stomach
Metoclopramide 10 mg prokinetic to hasten
Any expected or unexpected problem that arise gastric emptying
during postoperative period which includes
H2 antagonists to inhibit secretion of gastric
time the surgery ends to the time patient
acid.
regains consciousness.
Symptoms
Aspiration
Restlessness
Reduced consciousness Tachycardia
Neurologic deficits Occasionally cyanosis.
Mechanical disruption of normal anatomy
Local pharyngeal anesthesia Signs: Auscultation of breath sounds, chest X-ray
Recumbent position Investigations: Chest X-ray, sputum examination,
blood routine (Fig. 4.1).
Risk factors
Treatment
Age
Type of anesthesia Removal of foreign body
Type of surgery Use of steroids
Recent meal Broad-spectrum antibiotics.
Delayed gastric emptying
Decreased lower esophageal sphincter tone Sore Throat
Obesity Throat packFirst postoperative concern in
Neuromuscular disorders OMFS.

Ch-4.indd 27 15-04-2013 10:10:17


28 Section 1: Basic Surgical Principles and Perioperative Management

A B
Fig. 4.1: Chest X-rays

Etiology Surgical factors


Trauma during intubation Duration
Irritation of larynx Type of surgery
Trauma to pharynx. Anesthetic factors
Drugs used
Management Hypoxia
Tongue should be cleaned of blood Poor airway management.
Lozenges
Salt water gargling Management
Cup of tea. Stop all oral fluids until bowel sounds are
present
Nausea and Vomiting Phenothiazines
Dehydration, electrolyte imbalance, aspiration Gastric suction in case of protracted nausea
of vomitus raises intracranial pressure and vomiting
Emergency bedside tray consisting wire cutter, Antihistamines
wire twister should be kept ready in case
Dopamine antagonists
of intermaxillary wire removal or arch bar
adjustment or removal.
Anticholinergic drugs
Seratonin antagonists
Etiology Dexamethasone 28 mg IV.
Patient factors
Age Regurgitation
Weight Passive movement of gastric contents into the
Anxiety pharynx under the force of gravity
Sex Anesthesia reduces the barrier pressure
Past medical history Head down position

Ch-4.indd 28 15-04-2013 10:10:17


Chapter 4: Postoperative Complications and Management 29
Increased gastric pressure, pregnancy, full Good hemostasis
stomach, high intra-abdominal pressure, gas Judicious use of steroids
from face-mask ventilation Compression of area of surgery.
Incompetence of cardiac sphincter.
Stress Gastritis
Urinary Retention Seen in 2540 percent of ICU patients, clinically
Voluntary effort 812 hours postoperatively significant bleeding in 210 percent of patients.
Secondary to anesthesia, drugs and recumbency
Prerenal Risk Factors
Decreased cardiac output Mechanical ventilation for >48 hours
Volume depletion Coagulopathy
Renal Significant burns
Acute tubular necrosis Head injury.
Postrenal
Obstructive uropathies Treatment
Bladder atony secondary to medications Antacids
Urinary tract infections. Proton pump inhibitors
Sucralfate.
Treatment
Suprapubic hot packs Hyperthermia
Assisted ambulation Temperature >100F for more than 6 hours
1012 hours straight catheter. No more than warrant further investigations.
500700 ml should be removed or else bladder
spasm and syncope could result Immediate Fever
Correct volume depletion Medications
Fluid bolus Blood products
Diuretics. Trauma from surgery
Hypersensitivity reactions
Polyuria
Altered thermoregulatory mechanisms
Excessive volume administration
Idiosyncratic reactions.
Pharmacologic diuresis
Osmotic diuresis. Acute Fever
2472 hours
Edema Atelectasis
Etiology Aspiration pnuemonia.
Physical trauma
Infections Subacute Fever
Increased venous pressure Pulmonary embolism
Decreased lymphatic flow Urinary tract infections
Excessive sodium retention Surgical site infections
Cardiac failure, immobility. Intravascular catheters.

Management Management
Position site of surgery above the level of heart Care of IV line and catheter.

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30 Section 1: Basic Surgical Principles and Perioperative Management

Hypotension Fluid gains and loses


McLean defines it as inadequate blood flow to Confusion
vital organs or failure of cells of vital organs to Hypercapnia.
utilize oxygen.
Rare Causes
Etiology Renovascular hypertension
Hypoxia Cushings disease
Hypercarbia Hyperaldosteronism
Coronary insufficiency Hyperthyroidism
Arrhythmias Pheochromocytoma
Electrolyte imbalance Increased intracranial pressure.
Endotoxic shock
Pulmonary embolism Diagnosis
Transfusion reactions Signs
Fat embolism. Vital signs
Anxious patient
Diagnosis
Flushed skin
Healthy patient tolerates well Respiratory distress
Renal failure in prolonged hypotension Epistaxis
Hematocrit
Full bladder.
Orthostatic vital signs supine then sitting
or standing taken within 30 sec or 1 minute Symptoms
increase in heart rate of 20 or a decrease in Pain at operated site
systolic pressure of 20 indicates significant Headache
volume depletion. Nausea
Vomiting
Management
Visual changes.
300 ml of normal saline or ringer lactate IV over
10 minutes Management
Trendelenburg position
Antihypertensive regimen
Ephidrine 10 mg IV or phenylephrine drip
Myocardial ischemia Control of pain
Myocardial ischemia is an imbalance between Assess renal status.
myocardial oxygen supply and demand.
Hypertensive Emergencies
Hypertension Diazoxide300 mg IV or 150 mg followed by
50 mg increments
It causes wound hematomas and disruption of
suture lines. Hydralazine-propranolol 10 mg hydralazine
in 10 ml normal saline with 1 mg propranolol
Common Causes given in 2 ml aliquots
Compliance Frusemide 10 mg IV if the patient is in positive
Pain fluid balance
Bladder distension Morphine, if pain is the cause; 5 mg IV and 2
Drugs mg increments are added.

Ch-4.indd 30 15-04-2013 10:10:18


Chapter 4: Postoperative Complications and Management 31

Myocardial Ichemia Pleural effusion


Symptoms may be masked Tracheal lacerations or rupture
History and elevated cardiac specific blood Bronchospasm.
enzyme levels
ST segment depression on ECG. Risk Factors
Patient-related
Management Smoking
Increased FiO2 Lung conditions
Nitroglycerin infusion. General health status
Age
Cardiac Arrhythmias Obesity.
Ischemia
Procedure-related
Ectopy
Site of surgery
Acidbase imbalances
Type of surgery
Drugs
Duration of surgery
Preexisting cardiac problems
Type of anesthesia.
Hypercapnea
Pain
Fluid overload.
Pathophysiology
Lack of normal pattern of spontaneous breaths
Management Spontaneous deep breaths to maximal lung
Correct hypoxia inflation are eliminated from the pattern of
Adequate pain control breathing
Correct fluid and electrolyte imbalances. Alveolar collapse begins to produce
transpulmonary shunting.
Pulse Recumbent position
Superior lobes of lungs ventilated
Sinus Tachycardia Perfusion is preferential to dependent lobes
Unrelieved pain Shunting of blood
Hypoxia Lower lobe alveoli begin to collapse.
Hypercapnea
Hypovolemia Pulmonary Interstitium
Hydrostatic pressure increases
Sinus Bradycardia
Oncotic pressure decreases
Hypoxia Capillary permeability increases
Vagal stimulation Impaired mucociliary transport
Needs treatment only if it is causing symptoms. Normal cough reflex suppressed
Ventilatory response to hypercapnea and
PULMONARY COMPLICATIONS hypoxemia decreases.
Exacerbation of COPD or asthma
Hypoxemia Hypoxemia
Aspiration PaO2 <90 percent
Upper airway obstruction Anesthesia induced hypoventilation
Postobstructive pulmonary edema Loss of upper airway muscle tone
Pneumonia Volume overload

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32 Section 1: Basic Surgical Principles and Perioperative Management

Inability to clear secretions Mechanical etiology


Upper airway edema Life threatening
Aspiration Occurs in patients with severe trauma and
Pulmonary embolism preexisting lung disease
Exacerbation of COPD and asthma. 2. Late postoperative failure:
>48 hours
Treatment
Triggered by pulmonary embolism, opioid
Supplemental oxygen overdose.
Noninvasive positive pressure ventilation.
Clinical Features
Upper Airway Obstruction Tachypnea of 2530 breaths/min
Lack of adequate air movement Tidal volume < 4 mL/kg.
Intercoastal and suprasternal retractions
Discoordinate abdominal and chest wall Treatment
movements Emergency intubation
Complete obstruction is silent.
Adequate ventilation
Etiology Treat underlying cause.
Incomplete recovery
Laryngospasm, precipitated by irritation of Pneumothorax
glottis by secretions of blood or a foreign body. Autogenous rib grafts
Airway edema Subclavian central venous lines
Children are more susceptible to upper airway Neck dissections
edema because of small diameter of their Flaps.
upper airway
Tonsillar or adenoid hypertrophy. Signs
Tachypnea
Management Tachycardia
Warmed and humidified 100 percent oxygen Cyanosis
by mask Hyperresonance
Chin lift jaw thrust to relieve obstruction
Absent breath sounds.
Head elevation and fluid restriction
Dexamethasone Management
Reintubation.
Intermittent needle aspiration
Laryngeal Edema Chest tube placement.
Postnasal or oral intubation
Usually in infants and children due to narrow Aspiration Pneumonitis
anatomy of glottis. General anesthesia that tend to obtund reflexes
Can be prevented by use of glucocorticoids, Drug overdose with resultant CNS depression
ultrasonic nebulizers, tracheostomy. Seizure disorders
Previous history of CVAs
Respiratory Failure Tracheostomy
1. Early postoperative failure: Esophageal motility disorders
<48 hours, failure develops over minutes Bowel obstruction.

Ch-4.indd 32 15-04-2013 10:10:18


Chapter 4: Postoperative Complications and Management 33
Pathophysiology Cimetidine or an antacid in an effort to decrease
the acidity and amount of gastric secretions
Rapid-sequence intubation is recommended
in these patients
Extubated in an alert and fully awake condition
A suction source should be readily available at
the bedside at all times.

Bronchospasm
Reflex stimulation of airways
Hyperreactive airway (COPD, asthama, smokers).

Management
Beta2 sympathomimetic bronchodilators
Steroids.

Pulmonary Edema
Diagnostic Findings Pathophysiology
Dyspnea Disruption of pulmonary basement membrane
Cough by large negative intrapleural pressure
Wheezing Fulminant life-threatening pulmonary edema
Fever within minutes
Tachycardia Signs of respiratory obstruction, desaturation,
Hypotension distress
Shock Cardiac involvement leads to life-threatening
Cyanosis dysrhythmias.
Unilateral radiodense infiltrates, most
Management
commonly seen in the right upper lung if the
patient is supine at aspiration, or possibly 100 percent O2
bilateral diffuse infiltrates. Lasix 1 mg/kg
IPPV
Management Morphine-venodialator.
Trendelenburg position Management of postoperative pulmonary
Pharyngeal and endotracheal suction should complications:
be started immediately
Lung expansion maneuvers
Bronchoscopy for the removal of particulate Adequate pain control.
matter from the airway
Bronchodilators (aminophylline) Delayed Awakening
Hydrocortisone. Persistent effects of drugs
Prevention Decreased cerebral perfusion
Septicemia
This includes identification and appreciation
Hemorrhage
of patients who are at particular risk

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34 Section 1: Basic Surgical Principles and Perioperative Management

Fat embolism Long-term Effects


Air embolism Anxiety
Metabolic causes Post-traumatic stress disorder.
Electrolyte and acid-base imbalances
Hypothermia Convulsions
Hypoglycemia.
Etiology
Neurologic Damage Hyperthermia
Anoxia
Signs and Symptoms Hypocalcemic tetany
Slurred speech Toxemia.
Visual changes
Agitation Treatment
Confusion IV diazepam.
Numbness
Muscular weakness Jaundice
Paralysis. Halothane hepatitis
Etiology Hepatotoxic effects of drugs
Fat emboli Incompatible transfusions
Uncontrolled hypertension Large hematomas
Coagulopathies. Viral hepatitis.

Emergence Delirium Hemorrhage


Hypoxemia If large volumes of blood have been transfused,
Acidemia then hemorrhage may be exacerbated by
Hyponatremia consumption coagulopathy
Hypoglycemia May also be due to preoperative anticoagulants
Sepsis or unrecognized bleeding diathesis.
Pain
Alcohol withdrawal Thromboembolism
Drugs used preoperatively may precipitate Changes in composition of blood
delirium. Damage to blood vessel walls
Decreased blood flow.
Management
Risk Factors
Oxygen
Fluid and electrolyte replacement Extensive trauma
Adequate analgesia Infection
Diazepam 2.55 mg IV, if severe. Heart failure
Blood dyscrasias
Awareness and Recall Malignancy
Metabolic disorders.
Etiology
Pharmacodynamic variability Investigations
Faulty equipment Venography
Light anesthetic techniques. Radioactive fibrinogen uptake

Ch-4.indd 34 15-04-2013 10:10:18


Chapter 4: Postoperative Complications and Management 35
Ultrasonography
Impedance plethysmography.
Management
Elimination of stasis
Mechanical methods
Graded compression stockings
Intermittent pneumatic compression
Pharmacological management.

Wound Dehiscence
Poor blood supply
Excess suture tension
Long-term steroids
Immunosuppressive therapy
Radiotherapy.

OPHTHALMOLOGICAL COMPLICATIONS after 2nd postoperative week associated with


Loss of protective reflexes prolonged nasogastric intubation, dehydration,
Tear production, tear film stability reduced etc. pathology consist decrease secretion of
Chemical injuries parotid gland which gets infected by staphylococci
Direct trauma to eyes. or gram-negative bacteria from the oral cavity
resulting in inflammation, accumulation of cells
Management that obstruct the duct eventually resulting in
Occlusive dressings, viscous ointments or gels. formation of small abscess.

Wound Hematoma Clinical Feature


Neck wound hematomas cause pain pressure, First appears as pain or tenderness at the angle
dysphagia, respiratory distress of the jaw progressing with high temperature
Should be treated by emergency re-exploration Swelling and redness in the parotid area
and evacuation
Parotid feels firm
Vocal cord paralysis
Result of manipulation of recurrent laryngeal In laboratory investigation leukocytosis may
nerve be seen.
Primary concern is aspiration
Management
Bilateral vocal cord paralysis is a serious
complication. Adequate fluid intake
Avoid anticholinergics
Postoperative Parotitis Minimize trauma
It is a staphylococcal infection of parotid gland Improve oral hygine (mouthwash, irrigation,
limited to elderly, poor oral hygiene usually seen moisturizing measures, etc).

Ch-4.indd 35 15-04-2013 10:10:18


Medically Compromised
Patient Preparation for
Maxillofacial Surgery
5
INTRODUCTION Pulmonary dysfunction
Hypertension
Maxillofacial surgeon may come across various
Renal dysfunction
medical and systemic conditions that are
Hepatic dysfunction
challenging for various surgical procedures.
Endocrine dysfunction
Hence, thorough knowledge is a prerequisite
Thyroid dysfunction
before planning for surgical intervention.
Adrenal dysfunction and patients taking
Proper planning will help in minimizing
steroids
chances of adverse event; thus, protecting
Dysfunction of the immune system
patients from anxiety, injury, sleepless night
An arbitrary guideline for the patient selection
heartache or litigation
for treatment may be based on the classification
The initial contact with any new patient should
of physical status of the American Society of
be carefully orchestrated to achieve specific
Anesthesiology (ASA) (Table 5.1).
goals:
Assessment of patients surgical needs
Identification of potential management CARDIOVASCULAR SYSTEM
problems
Formulation of a treatment plan in light of
Examination
the patients oral and medical status Symptoms
Preparation of the patient for indicated Dyspnea
procedures. Wheezing
The disorders discussed are: Syncope
Cardiac dysfunction Angina

Table 5.1: The American Society of Anesthesiologists classification of physical status


ASA I ASA II ASA III ASA IV ASA V


Definition
A patient without Patient with Patient with severe Patient with incapacitating A moribund patient not
any systemic mild systemic systemic disease disease that is constant expected to survive 24 hours
disease disease limiting activity threat to life with or without surgery

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Chapter 5: Medically Compromised Patient Preparation for Maxillofacial Surgery 37
Orthopnea Moderate Risk
Pedal edema Acquired valvular dysfunction
Palpitations. Hypertrophic cardiomyopathy
Mitral valve prolapse with regurgitations.
Signs
Cyanosis Endocarditis Prophylaxis Not Recommended
Jugular venous distention Isolated atrial septal defect
Clubbing of the finger nails Surgical repair of ASD, VSD
Carotid bruits Prior coronary artery bypass graft
Alteration in pulses and abnormal cardiac Mitral valve prolapse without regurgitation
rhythms Previous rheumatic fever
Pedal edema Cardiac pacemaker.
Presence of third or fourth heart sound Standard regimens for antibiotic prophylaxis
Cardiac murmurs. to minimize risk of bacterial endocarditis due to
oral surgical procedures is described in Table 5.2.
Routine Preoperative Tests
Chest radiographsPA and Lateral views Hypertensive Patient
Electrocardiography Hypertension is the presence of elevated
Exercise stress test pressure that places patients at increased risk
Echocardiography of organ damage
Nuclear stress tests Degree of hypertension
Radionuclide ventriculography Emergencies
Ambulatory echocardiography. Urgencies
Mild uncomplicated
Cardiac Abnormalities Transient.
Ischemic heart disease
Angina pectoris Primary Agents for Use in
Myocardial ischemia Hypertensive Emergencies
Congestive heart failure Sodium nitroprusside 0.2510 g/kg/m IV
Cardiac valve abnormalities: infusion
Aortic stenosis Labetalol 10-80 g IV bolus every 10 min
Mitral stenosis Intravenous nitroglycerin 5100 g/min IV
Aortic regurgitation infusion.
Mitral valve regurgitation
Mitral valve prolapse Management of Hypertensive Urgencies
Prosthetic heart valves. Sublingual nifedipine 510 mg
Oral clonidine 0.2 mg initial then 0.1 mg/hr.
Endocarditis Prophylaxis Recommended
Preoperative Management of
High Risk Hypertensive Patient
Prosthetic heart valves Patients ideally should undergo elective surgery
Prior bacterial endocarditis only when in normotensive state
Cyanotic congenital heart disease Elective surgical procedures on patients with
Surgically constructed shunts. sustained preoperative diastolic blood pressure

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38 Section 1: Basic Surgical Principles and Perioperative Management

Table 5.2: Antibiotic prophylactic regimens


Adults, not allergic to Adults, allergic to Children, not allergic to Children, allergic to
penicillin penicillin penicillin penicillin
2 g amoxicillin 600 mg clindamycin 50 mg/kg amoxicillin 20 mg/kg clindamycin
1 hour before procedure 1 hour before procedure or 1 hour before procedure or 1 hour before procedure or
2 g ampicillin IM or IV 600 mg clindamycin IV 50 mg/kg ampicillin IM 20 mg/kg IV clindamycin
within 30 minutes before within 30 minutes before or IV within 30 minutes within 30 minutes prior to
procedure procedure or before procedure procedure or
2 g cephalexin 1 hour 50 mg/kg cephalexin or
before procedure or cefadroxil 1 hour before
procedure or
1 g cefazolin IM or IV 25 mg/kg IM or IV
within 30 minutes before cefazolin 30 minutes
procedure or before procedure or
500 mg azithromycin or 15 mg/kg azithromycin
clarithromycin 1 hour or clarithromycin 1 hour
before procedure before procedure

higher than 110 mm Hg especially in persons The morbidity and mortality of these procedures
with end organ damage should be delayed are enhanced greatly by the physiologic effects
until blood pressure is better controlled over a of hyperglycemic microangiopathies
course of several days Insulin-dependent diabetes mellitus (IDDM)
Mild-to-moderate hypertension often resolves applies to all forms of diabetes in which
after administration of anxiolytic agents such exogenous insulin is required to prevent
as midazolam. diabetic ketoacidosis (Type 1 DM)
Noninsulin-dependent diabetes mellitus
Choice of Anesthetic Agents (NIDDM) is used to denote any condition in
Ketamine is contraindicated which some endogenous insulin is present to
Barbiturates, benzodiazepines, opioids, pro- prevent ketoacidosis
pofol are equally safe in inducing anesthesia in Management of any patient begins with the
most hypertensive patients initial assessment that includes age of onset,
manifestation, requires exogenous insulin,
Postoperative Management susceptibility to ketoacidosis, blood glucose
concentration.
Hypertension in the postoperative is often
multifactorial and can be due to the volume Drug History
overload, pain, bladder distension
Exogenous insulin is used for patients who
If acute treatment is necessary IV nicardipine have no function of beta cells of the pancreas
or sublingual nifedipine. and require an exogenous source of insulin to
prevent ketoacidosis.
DIABETES MELLITUS
Patients with diabetes mellitus (DM) have 50 Preoperative Assessment
percent chance of undergoing surgery in their Cardiovascular
lifetime History (hypertension, angina, infarction)

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Chapter 5: Medically Compromised Patient Preparation for Maxillofacial Surgery 39
Blood pressure Traditionally the dose is one-fourth or one-half
ECG. of the actual dose
One of the protocols for control of the IDDM
Neurologic during the perioperative period is the split
Peripheral neuropathy dose technique
Autonomic examination. All long-acting preparation is changed to
short acting. A glucose infusion is begun and
Renal subcutaneous (SC) insulin is given according
Proteinuria to need demonstrated by hourly capillary
Serum creatinine levels glucose evaluations
Urinalysis. Mix 50 U of regular insulin in 500 ml of normal
saline (1U/h = 10 ml/hr)
Metabolic Initiate IV infusion at 0.51U/hour
Home glucose control Measure blood glucose concentration every
Glycosylated Hb hour and adjust infusion rates accordingly.
Electrolytes.
Postoperative Care
Preparation Continue the glucose infusion
Patients with IDDM Check the serum glucose and acetone levels
Stop administration of long-acting insulin After the patient has voided completely, start
checking urine fractional samples for glucose
Substitute intermediate acting insulin.
and acetone
Patients with NIDDM Write orders on a sliding; scale the amount of
insulin to be given for specific urine glucose levels
Stop administration of long-acting sulfonyl-
Units of CZI Urine sugar
ureas, stop administration of metformin, and
1020 4
reinforce dietary advice
1015 3
Minor surgical procedures, such as routine
510 2
extractions, biopsies and procedures that are
05 1
minimally stressful can be performed without
altering the patients usual regimen
Patient should have the usual morning meal HEMOPHILIA, ANTICOAGULATION
and oral medication One of the most important factors in successful
Patient should be treated early in the day surgery lies in the control of bleeding
and have the capillary blood glucose level Bleeding disorders may be either (Table 5.3):
evaluated. Intrinsic: Results from congenitally deficient
Moderate surgical procedure that induces or dysfunctional components of the
a certain amount of surgical stress, such as hemostatic system
removal of impacted tooth, administration of Acquired: because of an underlying condition
general anesthesia (GA) or disease
Medications stopped evening before surgery
Should be scheduled in the morning and not Laboratory Screening Tests
be subjected to prolonged fasting Bleeding time
Patients with IDDM should hold their dose Platelet count
of regular insulin and alter the dose of Partial thromboplastin time (PTT)
intermediate-acting insulin Prothrombin time (PT)

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40 Section 1: Basic Surgical Principles and Perioperative Management

Table 5.3: Intrinsic and acquired bleeding disorder therapy, liver disease and disseminated
intravascular coagulation (DIC)
Intrinsic bleeding Acquired bleeding
disorder disorder C
International normalized ratio (INR) = Patient PT
Hemophilia A Thrombocytopenia Control PT
Hemophilia B Decresed production of
platelets Management of Bleeding
von Willebrands Increased destruction of In case in which immediate anticoagulation
disease platelets is required the use of fresh frozen plasma is
Patients on anticoagulants management of choice
Liver disease
When bleeding is not severe the best therapeutic
approach is to stop warfarin and follow the
patient with a frequent PT/INR measurements
until the desired level is reached
Bleeding Time
For simple tooth extractions in a patient with
Von Willebrands disease an INR level 2.5 or lower, the use of local
Thrombocytopenia caused by drug antifibrinolytic agents should be adequate
Autoimmune thrombocytopenia Tranexamic acid: 10 ml of 4.8 percent aqueous
Pregnancy solution can be used
Hypersplenism Direct pressure at the extraction sites
Cirrhosis Full liquid diet followed by soft diet for 5 days
Drugs such as warfarin No aspirin postoperatively.
Vessel abnormality.

Platelet Count
Management of Hemophilia
Disorder is a sex-linked recessive trait
Normal:190000400000 per microliter
The successful management is the adequate
Thrombocytopenia ranges from 50000-100000
maintenance of the antihemophilic globulin
However, the minor surgical procedures, such
(AHG)
as tooth extraction and biopsy are usually
The normal AHG is 50100 percent.
tolerated
Factor VIII replacement can be provided
Placing Gelfoam or microfibrillar collagen in
through blood, plasma, fresh frozen plasma
the socket accelerates the formation of platelet
and cryoprecipitate.
plug.

Partial Thromboplastin Time THYROID DISORDERS


Normal: 2236 seconds Patients having thyroid disorders can be classified
Tests the factors involved in the intrinsic broadly into.
coagulation pathway, viz VIII, IX, XI, XII Hypothyroid
Hemophilia A Euthyroid
Hemophilia B. Hyperthyroid.
Prothrombin Time Investigations
The normal range is 1114 seconds Blood TSH, T3 and T4.
Examines the efficiency of the extrinsic and
common coagulation pathways, viz II, V, VII, X Imaging
Increase in PT could be due to vitamin K Ultrasonography (USG) (cysts)
deficiency, fat malabsorbtion, Coumadin Radioisotope scansgland uptake.

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Chapter 5: Medically Compromised Patient Preparation for Maxillofacial Surgery 41
Cytopathology in the body, sodium and potassium ion levels
Fine needle aspirate (FNA)/biopsy (FNB) and the blood pressure
Hyperthyroidism leads to hypermetabolic Patients with adrenal insufficiency should
state in the body resulting in catabolic state be supplemented with adequate exogenous
with tachycardia, diarrhea and heat tolerance steroids prior to procedure to help the patient
If the patient is subjected to stress, thyroid combat with stress.
storm occurs.
Intra- and Postoperative Management
Management Continuous monitoring of the vital signs
Monitor the hormone levels intra- and post- Adequate intravenous corticosteroid supple-
operatively ments to prevent adrenal crisis
Continuous monitoring of the vital parameters Maintain fluid and electrolyte balance.
Check for signs
If the patient is in a thyroid storm treat by RENAL DISEASE
cooling the patient, intravenous infusion of
glucose and IV fluids. Renal Failure and Acute Glomerulonephritis
Disturbances in the renal function leads to
changes in the acid-base balance, serum
ADRENAL DISEASES
calcium, and phosphorous levels
Common adrenal disorders that have to be dealt Postoperative infection
with during surgical procedure are: Associated hypertension secondary to fluid
retention and edema.
Cushings Syndrome
Signs Preoperative Investigations
Centripetal obesity Renal profile
Moon face Urinalysis
Buffalo hump Electrolytes
Hypertension USG of kidneys
Thin skin and purpura
Management
Muscle weakness
Osteoporotic changes and fractures. Monitoring of acid-base balance and electrolyte
Renal profile-tests intra- and postoperatively
Addisons Disease Potassium overload during fluid replacement
is to be avoided
Signs Patients should be covered with broad
Postural hypotension spectrum antibiotics.
Salt and water depletion
Weight loss and lethargy HEPATIC DISEASE
Hyperpigmentation A history of chronic alcohol intake, substance
Scars, mouth and skin creases due to pigmen- abuse, repeated blood transfusions and viral
tation effect of increased adrenocorticotropic hepatitis is indicative of probable silent liver
hormone secretion disease
Vitiligo The liver is the site for various drugs and
During surgery attention must be paid in anesthetic gases biotransformation and
maintaining optimum levels of carbohydrates synthesis of vitamin K

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42 Section 1: Basic Surgical Principles and Perioperative Management

A patient with viral hepatitis should be handled Pain: General/inspiratory


with care to avoid inadvertent transmission of Infections: Pneumonia
the disease Airflow obstruction
Asthma
Preoperative Investigations Chronic obstructive pulmonary disease
Liver enzymes: SGOT, SGPT Restrictive pulmonary change
Total bilirubin: Direct and indirect Gas exchange failure
Serum albumin Reduced surface area, fibrosis, fluid
Serum alkaline phosphatase Tumors.
Bleeding time and clotting time
Prothrombin time Preoperative Investigations
USG liver. Routine chest radiographs
Pulmonary function test
Management Blood investigations like arterial blood gases
Avoid anesthetic gases that are metabolized in Sputum AFB culture
the liver Bronchoscopy if required.
Correction of coagulation deficiency by IV The patient should be on bronchodilators
vitamin K, fresh frozen plasma transfusions pre-intra- and post- operatively.
Careful intra- and postoperative management Carry inhaler for use in case of emergency
of blood volume, urine volume
Appropriate precautions and sterilization IMMUNOCOMPROMISED PATIENT
techniques to prevent transmission of disease
in carrier of viral hepatitis. Common Causes of Immunosupression
Advanced age
RESPIRATORY DISEASE Malignancy
Cough: What? Malnutrition
Dry sputum (color?), blood Acquired/congenital immunodeficiency
Wheeze: Expiratory noise Trauma
Stridor: Inspiratory noise Burns
Dyspnea: Distress on effort Radiation.

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2
Section
Examination of Maxillofacial
Trauma Patient
6. Initial Assessment and Emergency Care of
Maxillofacial Trauma Patient
7. Neurological Consequences Associated with
Maxillofacial Injury
8. Maxillofacial Trauma: First 24 Hours in
Intensive Care Unit
9. Basic Principles for the Management of
Maxillofacial Trauma
10. Dentoalveolar Fractures
11. Mid-facial Fractures
12. Mandibular Fractures
13. Condylar Fractures
14. Cerebrospinal Fluid Rhinorrhea
15. Maxillofacial Trauma: Case Presentation

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Ch-6.indd 44 15-04-2013 10:11:40
Initial Assessment and
Emergency Care of
Maxillofacial Trauma Patient
6
INITIAL ASSESSMENT First peak: Nonsalvageable within minutes
Second peak: Salvageable within minutes to
Trauma is the leading cause of death in the first
hours
four decades of life. Trauma team can play a
Hemopneumothorax
major role in reducing the incidence of death in
Fractures, abdominal organ injuries, pelvic
such patients.
fractures, etc.
Advanced trauma life support protocol The concept of Golden hour emphasizes
Primary survey and resuscitation upon the urgency necessary for successful
Secondary survey management. It refers to a time period lasting
Continued postresuscitation monitoring & from a few minutes to first few hours following
re-evaluation traumatic injury being sustained by a casualty,
Definitive treatment during which there is the highest likelihood
that prompt medical treatment will prevent
Trimodal Death Distribution death
Trimodal death distribution is described in The first 10 minutes of prehospital care given
Figure 6.1. to patients at the site of injury is Platinum 10
minutes
Third peak: Days to weeks.
Patient dies because of sepsis during this
period.

PREPARATION
Prehospital
Stabilization of airway
Control of external bleeding
Immobilization and transport
Inhospital
Triaging the casualties
Identification of life-threatening injuries
Resuscitation and stabilization
Any other injury
Fig. 6.1: Trimodal death distribution Definitive care.

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46 Section 2: Examination of Maxillofacial Trauma Patient

TRIAGE A process of prioritizing patients based on the


severity of their condition
Triage is a protocol for immediate classification
of the seriousness of the accident (Fig. 6.2) This protocol must be uniform, understandable
The term comes from the French word trier, and universally accepted. The aim of
meaning to sort out or cull out wool into prehospital triage is the rapid and accurate on
various categories depending upon the quality, site identification of high-risk patients based
a term used by Napoleons surgeon on (Fig. 6.3):
It has been defined as doing the greatest good 1. Severity of the injury and its physiological
for the greatest number effectinjury anatomy.

Fig. 6.2: Triage categories

Fig. 6.3: Simple triage and rapid treatment

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Chapter 6: Initial Assessment and Emergency Care of Maxillofacial Trauma Patient 47
2. Likelihood of the survivalinjury bio
mechanics.
3. Urgency of medical and/or surgical care.
4. Urgency of evacuation to the trauma center.
5. Converse with a victim if conscious and
if the patient answers coherently and is
focused, it is obvious that airway, ventilation
and cerebral functions are normal provided
the victim is not in the lucid interval.
Accurate triage of patients on site is not easy.
It is further compounded by the fact that triage
can change minute to minute depending to a
large extent on the identification of concealed
hemorrhage or internal life-threatening injuries.
It is always wise to overtriage than undertriage. Fig. 6.4: Glasgow outcome scale
In general, it must be understood that
prehospital and hospital team management is
different from hospital medical or trauma team. Best Verbal (V) Response
1. No verbal response.
Protocol for Triage 2. Incomprehensible sounds
3. Inappropriate words
Initial evaluation
4. Disoriented, converses
Primary survey
5. Oriented, converses.
Resuscitation
Secondary survey Best Motor (M) Responses
Definitive treatment or transfer to an
1. No motor response
appropriate trauma center.
2. Extension to pain (decerebrate response)
Types of Triage 3. Abnormal flexion (decorticate response)
4. Withdraws to pain
Simple triage
5. Localizes pain
Continuous integrated triage
6. Follows commands.
Reverse triage
Individual triage.
Pediatric Glasgow Coma Scale
TRAUMA SCORING SYSTEMS Best Eye (E) Response
1. No eye opening.
Glasgow Coma Scale 2. Eye opening to pain.
Scored between 3 and 15, 3 being the worst, and 3. Eye opening to shout.
15 the best. It is composed of three para meters 4. Eyes opening spontaneously.
(Fig. 6.4).
Best Verbal (V) Response
Best Eye (E) Response 1. No verbal response.
1. No eye opening 2. Grunts, inconsolable, agitated.
2. Eye opening to pain 3. Inconsistently inconsolable, moaning.
3. Eye opening to speech 4. Cries but consolable, inappropriate inter actions.
4. Eyes opening spontaneously 5. Cries appropriately.

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48 Section 2: Examination of Maxillofacial Trauma Patient

Best Motor (M) Responses


1. No motor response.
2. Extension to pain (decerebrate response).
3. Abnormal flexion to pain for an infant

(decorticate response).
4. Infant withdraws from pain.
5. Localizes pain.
6. Infant moves spontaneously or purposefully.

Injury Severity Scoring


Injury severity scoring is a process by which
complex and variable patient data is reduced
to a single number Fig. 6.5: Abbreviated injury scale
This value is intended to accurately represent
the patient's degree of critical illness. In order
to accurately estimate patient outcome, we by a scaling committee of the Association for
need to be able to accurately quantify the the Advancement of Automotive Medicine
patient's anatomic injury, physiologic injury, (Fig. 6.5)
and any pre-existing medical problems, which Injuries are ranked on a scale of 1 to 6, with 1
negatively impact on the patient's physiologic being minor, 5 severe and 6 a nonsurvivable
reserve and ability to respond to the stress of injury (Fig. 6.5).
the injuries sustained.
Outcome = Anatomic injury + physiologic injury Injury Severity Score and New Injury
+ patient reserve Severity Score
The Injury Severity Score (ISS) is an anatomical
Organ Grading Scales scoring system that provides an overall score
The Organ Injury Scales were developed for patients with multiple injuries. Each injury
by Organ Injury Scaling Committee of the is assigned an AIS and is allocated to one of the
American Association for the Surgery of six body regions. Only the highest AIS score
Trauma (AAST). These scales provide a in each body region is used. The three most
common nomenclature by which clinicians severely injured body regions have their score
may describe injuries sustained and their squared and added together to produce the ISS
severity score
Each organ injury may be graded from 1 to 6. As multiple injuries within the same body region
1 is assigned to the least severe injury while are only assigned a single score, a proposed
a 5 is assigned to the most severe injury from modification of the ISS, the New Injury Severity
which the patient may survive. Grade 6 injuries Score (NISS), has been proposed. This is
are not salvageable and severe enough to claim calculated as the sum of the squares of the top
the patients life three scores regardless of body region (Table
Injuries may also be divided by mechanism 6.1).
penetrating or blunt or laceration or contusion.
Revised Trauma Score
Abbreviated Injury Scale The Revised Trauma Score (RTS) is a physio
The Abbreviated Injury Scale (AIS) is an logical scoring system, with high interrater
anatomical scoring system The AIS is monitored reliability and demonstrated accuracy in

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Chapter 6: Initial Assessment and Emergency Care of Maxillofacial Trauma Patient 49

Table 6.1: Injury severity score


Region Injury description AIS Square top three
Head and neck Cerebral contusion 3 9
Face No injury 0 0
Chest Flail chest 4 16
Abdomen Complex rupture spleen 5 25
Extremity Fractured femur 3 0
External No injury 0 0
Injury severity score 50

Table 6.2: Revised trauma score


Coded value Respiratory rate Systolic BP Glasgow coma score
4 1029 >89 1315
3 >20 7689 912
2 69 5075 68
1 15 149 45

predicting death. It is scored from the first set Airway Maintenance


of data obtained on the patient, and consists
Recognize Airway Obstruction
of Glasgow coma scale, systolic blood pressure
and respiratory rate. The conditions associated with airway obstruc-
RTS = 0.9368 GCS + 0.7326 SBP + 0.2908 RR tion in the acutely injured and stabilized trauma
Values for the RTS are in the range 0 to 7.8408. victim must be recognized by using following
The RTS is heavily weighted towards the algorithm.
Glasgow coma scale to compensate for major
Look Listen Feel
head injury without multisystem injury or
Signs of Any abnormal Any asymmetry
major physiological changes. A threshold of
obvious airway sounds during on inspiration
RTS <4 has been proposed to identify those obstructions respiration and expiration
patients who should be treated in a trauma
center, although this value may be somewhat
low (Table 6.2). Assess the Patency
Signs of respiratory distress
PRIMARY SURVEY i. Stridor
A = Airway and cervical spine ii. Cyanosis
B = Breathing iii. Anxiety
C = Circulation and hemorrhage control iv. Tachypnea rate >25/min
D = Dysfunction of the central nervous system v. Intercostals retraction
E = Exposure. vi. Use of accessory muscles.

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50 Section 2: Examination of Maxillofacial Trauma Patient

Causes of upper airway obstruction in trauma Clear the Airway and Reposition the Patient
patient Allow the patient to maintain an existing airway
Tongue position through self posturing than to jeopardize the
Aspiration of foreign bodies airway by forcing him or her to assume another
Regurgitation of stomach contents position.
Facial/tracheal/laryngeal fractures.
Airway Maneuvers and Adjuncts
Conditions that influence airway management
Chinlift/jaw thrust maneuver
1. Syndromes:
Oral and nasopharyngeal airways
i. Treacher Collins syndrome Bag-valve mask ventilation.
ii. Crouzon and Apert syndrome Perform endotracheal intubation (Fig. 6.6) or
iii. Pierre Robin syndrome surgical airway if unable to intubate.
iv. Hemifacial microsomia
v. Down syndrome Airway Maintenance Techniques
vi. Goldenhar syndrome 1. Chin lift
2. Infections: Epiglottitis, bronchitis, pneumonia, 2. Jaw thrust
abscess (submandibular, retropharyngeal, 3. Oropharyngeal airway
Ludwigs angina), papillomatosis, tetanus. 4. Nasopharyngeal airway
3. Trauma: Foreign body, cervical spine injury, The triple maneuver, head tilt/chin lift, jaw
fractures, soft tissue edema. thrust and open mouth done together is the
4. Neoplastic: Upper and lower airway tumors, most reliable method to maintain a patent upper
radiation therapy. airway.
5. Inflammatory: Rheumatoid arthritis, ankylos-
ing spondylitis, (TMJ) syndrome, scleroderma, Definitive Airway
sarcoidosis, angioedema. Indications
6. Endocrine/metabolic: Acromegaly, diabetes Unconscious
mellitus, myxedema, goiter, obesity. Severe maxillofacial fracture

Fig. 6.6: Endotracheal intubation equipment

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Chapter 6: Initial Assessment and Emergency Care of Maxillofacial Trauma Patient 51
Risk for aspiration: Bleeding/vomiting Invasive airway accesssurgical airway
Risk for obstruction Cricothyroidotomy
Neck hematoma/laryngeal, tracheal injury, Needle cricothyrotomy
stridor Percutaneous cricothyrotomy
Inadequate respiratory effort Tracheostomy.
Tachypnea/hypoxia/hypercapnia/cyanosis
Needle cricothyrotomy and transtracheal jet
Severe head injury: Need for hyperventilation. insufflations
Laryngoscopy First described by Sanders in 1969
Direct: Through a laryngoscope Indications
Indirect: Through a laryngeal mirror When edema of the glottis
One can inspect the base of tongue, valleculae, Fracture of the larynx
epiglottis, aryepiglottic folds, piriform fossa, Severe oropharyngeal hemorrhage obstructs
vestibular and vocal fold the airway and an endotracheal tube cannot
Anatomy of the visualization of the vocal cords be placed into the trachea
with a laryngoscope: Jet insufflation can provide up to 45 minutes
Alignment of 3 axes. of extratime before a definitive airway is
Curved blade is inserted into the vallecula. established
Straight blade is inserted directly into esophagus. It is performed by a large bore cannula 1214
Visualization of cord may be facilitated by gauge through the cricothyroid membrane
BURP maneuver. into the trachea
Cannula is connected to an oxygen source with
Airway adjuncts a Y connector or side hole
Guedel Intermittent sufflation 1 second on and 4
Laryngeal mask airway (LMA) (Fig. 6.7) seconds off is accomplished by occluding the
ETC/Combitube. Y connector.

Fig. 6.7: Laryngeal mask airway

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52 Section 2: Examination of Maxillofacial Trauma Patient

Cricothyroidotomy Indications
Indications Major laryngeal trauma.
i. Maxillofacial trauma Inability to intubate or perform needle
ii. Oropharyngeal obstruction cricothyrotomy.
iii. Condition in which oral and nasal intubation Laryngeal foreign body or pathology.
is contraindicated Prolonged ventilation.
iv. Spinal cord injury. Facilitation of management of cervical spine
injuries or oncological resections of the head
Contraindications
and neck.
Age; in children under the age of 1012 years
Crush injury to the larynx Contraindications
Pre-existing laryngeal or tracheal pathological When a cricothyrotomy may be performed
condition; obstruction secondary to tumor or more safely
subglottic stenosis. Expanding hematoma in the neck.
Procedure Procedure
The space between thyroid and cricoid Incisions: Both vertical and horizontal are
cartilage, i.e. cricothyroid membrane is the site advocated. In the emergency situation, the
of the cricothyrotomy vertical incision has been advocated. The
Usual width 2.73.2 cm and height 0.51.2 cm incision is made from the inferior to the cricoid
Once the anatomy is identified and marked, cartilage to the suprasternal notch
local or general anesthesia is administered For improved cosmetic results in an elective
The head and neck is placed in a slightly tracheostomy horizontal incision is advocated
extended position
Retraction and dissection exposes the pre
Unless contraindicated a horizontal incision is
tracheal fascia and the thyroid isthmus
made through skin and subcutaneous tissue
The incision is made superior to the cricoid Two principles must be adhered
cartilage Cricoid cartilage and the 1st tracheal ring
A Trousseau dilator is inserted and spread must not be cut or injured
vertically, to enlarge the opening of the The incision into the trachea must not be
membrane. extended below the 4th tracheal ring
A tracheostomy hook is placed between the 1st
Advantages and 2nd tracheal ring
More rapid Various entrance incision into the trachea is
Less complications advocated such as U incision-inverted U-T
Improved cosmetic result incision and cruciform
Less soft tissue thickness to pass through
The inverted incision advocated by Bjork and
Contraindicated in children, laryngeal infection.
Dukes is preferred.
Tracheostomy
Complications
Tracheotomy is a surgical procedure in which
an opening is made in the anterior wall of the Tracheal stenosis, bleeding, obstruction of tube,
mucosal ulceration, cartilaginous necrosis
trachea to establish airway
In contrast, tracheostomy is the surgical Hemorrhage, hypoxia, pneumothorax, sub
creation of and opening into the trachea cutaneous emphysema, tracheesophageal
through the neck, with the tracheal mucosa fistula, damage to recurrent laryngeal nerves
being contact with the skin. Hemorrhage, infection, aspiration.

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Chapter 6: Initial Assessment and Emergency Care of Maxillofacial Trauma Patient 53
Cervical spine injury Table 6.3: Effect of blood loss
Multisystem trauma, altered consciousness or
Blood loss <15% 1530% >40%
blunt trauma above the level of clavicle
Hyperextension to be avoided Heart rate <100 >120 >140
Neutral position by means of, spine board and SBP N N Highly low
bolstering device Cap refill N Delayed -do-
Semirigid cervical collar to be avoided RR 1420 2030 >35
stabilize only 50 percent of movements.
CNS Anxious ++ Lethargic

Breathing and Ventilation Abbreviations: SBP, systolic blood pressure; RR,


respiratory rate; CNS, central nervous system
Expose patients chest for chest wall excursions
Inspection of wounds
Palpation without spinal movement Changes in vital signs with percentage blood
Detect injuries to chest wall volume lost (Table 6.3).
Percussion for presence of air or blood
Auscultation to assure gas flow to lungs. Fluid Resuscitation
Crystalloid, colloid or blood.
Identify Crystalloid in the ratio of 3 ml of crystalloid to
Pnuemothorax 1 ml blood.
Open Colloids:
Closed Albumin 5%
Tension Gelatin
Massive hemothorax Hydroxyethyl starches
Flail chest with contusion. Dextran.
blood product replacement
Circulation Class III and IV hemorrhagepacked red
Hemorrhage is the most common cause of blood cells
early post-injury death. Thrombocytopenia (platelets <50,000)platelets
Ominous signs: PT/PTT >1.5 normalfresh frozen plasma
Altered level of consciousness Hemophilia A, von Willebrands disease, factor
Pale skin XIII deficiency, microvascular bleeding in
Rapid thready central pulse. transfused patients with fibrinogen concentra-
tions <80100 mg/dlcryoprecipitate.
Shock
Abnormality of the circulatory system that Acid-base balance
results in inadequate organ perfusion and Early hypovolemic shock tachypnea
tissue oxygenation. Any patient who is cold and respiratory alkalosis mild metabolic
tachycardic is in shock until proven otherwise acidosisdoes not require treatment
Shock in trauma patient is hypovolemic until Longstanding or severe shock tissue
perfusion anaerobic metabolism severe
proven otherwise
metabolic acidosis treat with fluids
Systolic BP maintained till 30 percent of loss
If pH <7.2 sodium bicarbonate.
Tachycardia occurs before drop in systolic BP
Tachycardia is present if rate is greater than Therapeutic decisions
160 in an infant, 140 in preschool child, 120 Rapid response to initial fluid administration:
from 5 years to puberty and 100 in adult Patient has lost <20 percent of blood volume. No

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54 Section 2: Examination of Maxillofacial Trauma Patient

further transfusion required but cross matched P: Responds to pain


blood should be kept available. U: Unresponsive
Changes in neurological examination may
Transient response
indicate intracranial pathology or reflect
Respond to fluid but once slowed perfusion
hypovolemia or decreased oxygenation of CNS.
indices will deteriorate. Have lost 2040 percent
of blood volume or still bleeding. Continue fluid Indications for CT
administration and initiate blood transfusion
Patients with seizure activity
Minimal or no response Unconsciousness lasting longer than a few
Usually require surgical intervention to control minutes
exsanguinating hemorrhage Abnormal mental status
Rarely due to pump failure secondary to cardiac Abnormal neurological evaluation
contusion or tamponade. CVP monitoring Clinical evidence of skull fracture
helps to differentiate between two. Also suggested for patients with blunt trauma
Evaluation of response to treatment and who have experienced loss of consciousness
Return of normal BP, pulse pressure and pulse or mild amnesia.
rate, are signs that circulation is stabilizing
Improved skin circulation and CNS status do Exposure
show enhanced perfusion Patient should be completely undressed to
Urinary output can be easily measured and is facilitate thorough examination and assessment
one of prime monitors Patient should be kept warm during this stage
CVP monitoring can be useful in complicated
cases Adjuncts to Primary Survey and Resuscitation
Urine output reflects renal blood flow ECG :
Adequate volume replacement should produce Dysrhythmias: Blunt cardiac injury
approximately PEA: Tamponade, pneumothorax, hypovolemia
50 ml/hr in adult
Bradycardia, VPCs: Hypoxia.
1 ml/kg/hr in children
Urinary catheter: Volume status, renal perfusion
2 ml/kg/hr in babies; 1yr.
Gastric catheter: Decompress stomach, reduce
Disability: Brief Neurological Examination risk of aspiration
Monitoring: BP, pulse oximeter, arterial blood
Detail neurological examination at the end of
gas level, RR
primary survey
Establishes level of consciousness, pupillary X-rays and diagnostic studies:
size and reaction Chest, CS, pelvis
A: Alert Diagnostic peritoneal lavage
V: Response to vocal stimuli USG abdomen.

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Neurological
Consequences Associated
with Maxillofacial Injury
7
INTRODUCTION enhance the likelihood of a intracranial
hemorrhage and have to be considered.
Maxillofacial region has all special structures
and centers for breathing, speech, vision,
hearing, mastication, and diglution and is highly PATHOPHYSIOLOGY
vulnerable to wide variety of injuries. These Brain receives about 1/5th of total cardiac
injuries can often be dramatic and for the patients output
are frequently disfiguring leading to considerable CPP = MAP ICP
psychological damage. This injuries often disrupt Intracranial pressure: 015 cm of H2O.
the appearance and ability to express emotion.
Hence it is crucial to establish an early, clear 1 liter per min at rest (cerebral blood flow) or 49
understanding of the mechanism of injury. mL/100 gm of brain/min
Patient sustaining maxillofacial injuries are at l Normal
a great risk of accompanying injuries. Localized
injury to the face resulting in fractures may also At 25-39 mL/100 gm/min
involve brain and meninges. In many cases l Confusion and sometimes loss of consciousness
maxillofacial injuries distract attention from more At 8 mL/100 gm/min
critical often life-threatening injuries.
l Neuronal death
Road traffic accidents accounts for 70 percent
of brain injuries
Brain injury is 10 times more common than
spinal injury CLASSIFICATION OF HEAD INJURIES
Twice more common in males than females 1. According to duration since impact:
Alcohol intoxication in at least 3050 percent of
Primary: Inertial brain injury (Figs 7.1 to 7.3)
head injuries
Contact brain injury
Correlation exists between midfacial injuries
a. Cerebral contusions (Figs 7.1A and B)
and central nervous system (CNS) trauma
b. Skull fractures (Figs 7.3A and B)
Intracranial hemorrhage cannot be excluded in
c. Concussions
patients with maxillofacial fractures even when
a GCS score of 15 and normal neurological Secondary: Hematoma formation
findings. Hence, accurate and systematic a. Extradural hematoma (Fig. 7.4)
assessment is essential b. Acute subdural hematoma (Figs 7.5A and B)
Predictors such as nausea, vomiting, seizures, c. Chronic subdural hematoma
skull base injuries and closed head injuries d. Intracerebral hematoma

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56 Section 2: Examination of Maxillofacial Trauma Patient

Primary Brain Injury (Figs 7.1 to 7.3)

A B
Figs 7.1A and B: Contusions

A B
Figs 7.2A and B: Multiple contusions

A B

Figs 7.3A and B: Skull fracture

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Chapter 7: Neurological Consequences Associated with Maxillofacial Injury 57
2. According to extent of involvement: Motor power
Focal Glassgow comma scale.
Diffuse Unilateral nonreactive pupillary dilatation in
3. According to severity of injury: head trauma commonly heralds uncal herniation
Mild secondary to an expanding supratentorial mass
Moderate lesion.
Severe Alarming findings
4. According to site of impact: Bradycardia and papillary dilatation
Coup injuries
Counter-coup injuries. SECONDARY ASSESSMENT
Three Ss:
PRIMARY ASSESSMENT Simple
Level of consciousness Systematic
Pupil Standardized
It is a complete head to toe detailed examination
Secondary Brain Injury (Figs 7.4 to 7.8) of the patient

Fig 7.4: Extradural hematoma

A B
Figs 7.5A and B: Acute subdural hematoma

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58 Section 2: Examination of Maxillofacial Trauma Patient

A B

C D

E F
Figs 7.6A to F: Subdural hematoma

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Chapter 7: Neurological Consequences Associated with Maxillofacial Injury 59

Fig 7.7: Multiple hemorrhages after trauma Fig 7.8: Intraventricular hemorrhage

Full history and reassessment of vital signs CRANIAL NERVES EXAMINATION


Complete neurological examination including
GCS CN I: Olfactory
Special investigations such as radiographs, lab Usually not tested
investigations Rash, deformity of nose
Facial grimace in response to pain above but Test each nostril with essence bottles of coffee,
not below the clavicles vanilla, peppermint.
Hypotension without evidence of hemorrhage.
CN II: Optic
Associated Trauma With patient wearing glasses, test each eye
Scalp separately on eye chart/card using an eye cover
Periauricular region Examine visual fields by confrontation by
Periorbital region wiggling fingers 1 foot from patients ears,
Face asking which they see move
Cervical spine. Keep examiners head level with patients head
If poor visual acuity, map fields using fingers
NEUROLOGICAL EXAMINATION and a quadrant-covering card
The neurological examination consists of the Look into fundi.
following components:
1. Higher cognitive function as assessed by the
CN III, IV, VI: Oculomotor, Trochlear,
mental status examination. Abducens
2. Cranial nerves. Look at pupils: Shape, relative size, ptosis.
3. Motor system. Shine light in from the side to asses pupils
4. Sensory systems. light reaction
5. Stance and gait. Assess both direct and consensual responses

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60 Section 2: Examination of Maxillofacial Trauma Patient

Assess afferent papillary defect by moving light Patient says Ah: Symmetrical soft palate
in arc from pupil to pupil. While doing arc test, movement
have patient block light so that light can only Gag reflex.
go into one eye at a time
Follow finger with eyes without moving head: CN XI: Accessory
test the 6 cardinal points in an H pattern From behind, examine for trapezius atrophy,
Look for failure of movement, nystagmus asymmetry
Convergence by moving finger towards bridge Patient shrugs shoulders
of patients nose Patient turns head against resistance: Watch,
Test accommodation by patient looking into palpate SCM on opposite side.
distance, then a hat pin 30 cm from nose.
CN XII: Hypoglossal
CN V: Trigeminal Listen to articulation.
Corneal reflex: Patient looks up and away Inspect tongue in mouth for wasting,
fasciculations.
Look for blink in both eyes, ask if can sense it
Protrude tongue: Unilateral deviates to affected
Facial sensation: Sterile sharp item on
side.
forehead, cheek, jaw
Repeat with dull object. Ask to report sharp or
dull EXAMINATION OF MOTOR SYSTEM
If abnormal, then temperature, light touch
Motor: Patient opens mouth, clenches teeth.
Components of the Motor Examination
Palpate temporalis and masseter muscles as Abnormal involuntary movements
they clench. Posture
Muscle bulk
CN VII: Facial Tone
Power
Inspect facial droop or asymmetry
Coordination
Facial expression muscles: Patient looks up and
Deep tendon reflexes.
wrinkles forehead
Examine wrinkling loss
Feel muscle strength by pushing down on each EXAMINATION OF SENSORY SYSTEM
side
Components of the Sensory Examination
Examine the facial expression.
Light touch
CN VIII: Vestibulocochlear Pain and temperature
Vibration sense
(Hearing, Vestibular Rarely) Position sense
Do specific tests like: 2 point discrimination
Webers test: Lateralization Double simultaneous stimuli (extinction).
Rinnes test: Air vs Bone conduction
Investigations Require in
CN IX, X: Glossopharyngeal, Vagus Head Injury Patients
Voice: Hoarse or nasal Hemogram
Patient swallows, coughs Blood chemistry
Examine palate for uvular displacement Coagulation profile

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Chapter 7: Neurological Consequences Associated with Maxillofacial Injury 61
Blood grouping and cross matching History (Specific Indicator Points)
Arterial blood gas analysis Subarachnoid hemorrhage: Coma of sudden
Wound swab. onset
Subdural hematoma: History of trauma with
IMAGING concussion, followed a few days later with
Plain skull X-ray fluctuating drowsiness and stupor
Extradural hematoma: Concussion followed by
CT scan
a brief lucid interval before rapidly deepening
MRI. coma
A history of headache before coma frequently
Indications present with intracranial space occupying
1. GCS <15 at 2 hours after injury lesion of any cause.
2. Vomiting >2 episodes
3. Age >65 years Pattern of Breathing
4. Confusion CheyneStokes respirationsubdural hematoma
5. Loss of consciousness Altered respiration patternRaised ICP.
6. Seizures
7. Deteriorating consciousness CRITICAL CARE IN HEAD INJURY
8. Confusion persisting after initial assessment The aim is prevent secondary injury to the
9. Resuscitation damaged neuron
10. Progressive headache Prevent hypoxia
11. Multiple trauma Prevent hypotension
12. Any sign of base of skull fracture, open skull Control hyperglycemia
fracture. Maintain normal serum Na+ level.

UNCONSCIOUS PATIENT CONTRIBUTION OF NEUROSURGEON IN


Always pause and observe an unconscious TRAUMA TEAM
or drowsy patient for a few moments before Treating associated head injury and spine
disturbing them injury, management of CSF leak, meningitis, and
Change in level of consciousness is the single whenever access and repair of anterior cranial
most important information. fossasingle stage repair is required.

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Basic Principles for
the Management of
Maxillofacial Trauma
9
INTRODUCTION Etiology
Primate evolution has made human face very 1. Typical causes:
vulnerable to frontal impacts. In other species, i. Direct violence
face is more protective. Most mammals like ii. Indirect violence
gorilla have prognathous jaws. In homo 2. Crush injuries:
sapiens, the sense of smell has become less i. Automobile accidents RTA
important and mastication less aggressive. ii. Aeroplane crash
Concurrently, the nose and jaws have receded iii. Mining accidents.
(Fig. 9.1) 3. High velocity missiles.
Injury has become a major public health 4. Predisposing causes like presence of cyst, tumors,
problem and education 1.2 million people die osteomyelitis, presence of 3rd molars, etc.
as a result of road traffic accidents each year.
Average 3,242 persons die each day around
Components of Trauma System
the world from RTA. By 2020, RTA will become
the 2nd leading cause of disability and the 3rd i. Prehospital care
leading cause of death ii. In hospital care
60% of patients with severe facial trauma have iii. Rehabilitation
multisystem trauma and the potential for iv. Prevention
airway compromise. v. Education
2050 percent concurrent brain injury. vi. Research.
14 percent cervical spine injuries.
Blindness occurs in 0.53 percent APPROACH TO A SUSPECTED FRACTURE
25 percent of women with facial trauma are 1 . History
victims of domestic violence 2. Symptoms
25 percent of patients with severe facial trauma 3. Physical examination
will develop Post-traumatic stress disorder. 4. Imaging.

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76 Section 2: Examination of Maxillofacial Trauma Patient

Fig. 9.1: Jaw pattern in different species

History 5. Are there areas of numbness or tingling on


your face?
Ample history.
6. Is the patient able to bite down without any
pain?
Specific Questions 7. Is there pain with moving the jaw?
1. Was there loss of consciousness? If so, how Obtain a history from the patient or witnesses
long? about:
2. How is your vision? Cause of fracture
3. Hearing problems? Degree of force
4. Is there pain with eye movement? Specific symptoms

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Chapter 9: Basic Principles for the Management of Maxillofacial Trauma 77
Time since injury 7. Palpate the zygoma along its arch and its
Allergies articulations with the maxilla, frontal and
Medications. temporal bone.
8. Check facial stability.
Physical Examination 9. Inspect the teeth for malocclusions, bleeding
1 . Symmetry/deformity and step-off.
2. Lacerations/abrasions/ecchymoses 10. Intraoral examination.
3. Palpable step deformities 11. Manipulation of each tooth.
a. Orbital rims 12. Check for lacerations.
b. Zygomatic arches 13. Stress the mandible.
c. Nose 14. Tongue blade test.
d. Frontal Bones 15. Palpate the mandible for tenderness, swelling
e. Mandibular borders and step-off.
4. Movement of dental arches
5. Fractured/avulsed/mobile teeth Radiographic Examination (Table 9.1)
6. Visual disturbances Basic Principles of Treatment of Severe
a. Diplopia Maxillofacial Injuries
b. Reflexes 1. Preservation of life.
c. Extraocular muscle function 2. Maintenance of function.
d. Acuity 3. Restoration of appearance (esthetics).
e. Fields.
7. Intranasal Inspection Preservation of Life
a. Hematoma ABC to be followed:
b. Airway obstruction 1. Airway management
c. CSF rhinorrhea. 2. Bleeding control
8. Facial movement (including jaw excursions) 3. Conscious restoration, circulation maintenance.
9. Facial sensation.

Clinical Examination Table 9.1: Structure and best view


Mandible
1. Inspection of the face for asymmetry.
Condyle/coronoid Lateral oblique
2. Inspect open wounds for foreign bodies.
Ramus/body Waters
3. Palpate the entire face.
Condyle and neck Reverse Towne's
a. Supraorbital and
Symphysis Occlusal
b. Infraorbital rim
Symphysis/body/ ramus Panoramic
c. Zygomatico/frontal suture
Maxilla and zygoma
d. Zygomatic arches.
Waters
4. Inspect the nose for asymmetry, telecanthus,
widening of the nasal bridge. Lateral
5. Inspect nasal septum for septal hematoma, Submentovertex view (jug handle)
cerebrospinal fluid or blood. Frontal and orbital floor
6. Palpate nose for crepitus, deformity and Caldwell
subcutaneous air. Waters

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78 Section 2: Examination of Maxillofacial Trauma Patient

Airway Management Close Reduction


i. Chin lift. Advantages
ii. Jaw thrust.
i. Conservative
iii. Oropharyngeal suctioning.
ii. Inexpensive
iv. Manually, move the tongue forward.
iii. Convenient
v. Maintain cervical immobilization.
vi. Oro or nasopharyngeal airways. iv. Short procedure, stable
vii. Endotracheal intubation. v. Secondary bone healing
viii. Be prepared for cricothyroidotomy. vi. No great operator skill needed
ix. In extensive injuries, tracheostomy may be vii. No foreign object left in the body.
indicated.
Disadvantages
Bleeding Control i. Absolute stability not possible
i. Maxillofacial bleeding: ii. Long period of IMF, difficult nutrition
a. Direct pressure. iii. Muscle atrophy and stiffness
b. Avoid blind clamping in wounds. iv. TMJ problems
ii. Nasal bleeding: v. Irreversible loss of bite force
a. Direct pressure. vi. Weight loss
b. Anterior and posterior packing. vii. Decrease range of motion of mandible.
iii. Pharyngeal bleeding:
a. Packing of the pharynx around endotra- Open Reduction
cheal tube.
Advantages
Principles of fracture management
i. Early return to normal jaw function
Reductionaligning of fragments to original anatomic
ii. Normal nutrition and oral hygiene
position
iii. Can get absolute stability
Fixation for re-establishment of form, function and
occlusion iv. Primary bone healing
Immobilization until bony union occurs v. Don not require patients compliance
Control of infection
vi. Less myoatrophy
vii. Helpful in epileptics, early work, etc.
Rehabilitation

Disadvantages
REDUCTION i. Need for an open procedure
ii. Prolonged anesthesia
Restoration of the fractured fragments to their
original anatomic position. Can be brought about iii. Expensive hardware
by iv. Some risk to neuromuscular structures
Close reduction (alignment without visualization of v. No manipulation is possible
fracture line) vi. Need much operator skill
Open reduction (alignment with visualization of vii. Higher frequency malocclusion, facial nerve
fracture line) damage and scarring.

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Chapter 9: Basic Principles for the Management of Maxillofacial Trauma 79

A B

Figs 9.2A and B: Intermaxillary fixation with help of Eric arch bar and elastics

FIXATION

Fixation

Nonrigid fixation

Semirigid fixation

Rigid fixation

Fig. 9.3: OPG showing Eric arch bar in place


(condylar fracture)
Nonrigid
Dental Wiring Cap splint
Direct wiring i. Used in adult patients with few firm teeth
available
Essigs wiring
ii. Expensive and construction is also time
Eyelet wiring
consuming.
Risdons wiring
Multiloop wiring. Rigid Fixation
Arch Bars Intraosseous wiring (semirigid)
Jelenko Plates and screws
Kirchener wire
Erich pattern (Figs 9.2 and 9.3)
Lag screws.
German silver notched.
Compression Plates (Fig. 9.4)
Gunnings splint
Noncompression osteosynthesis
i. Edentulous patient Monocortical miniplate osteosynthesis
ii. Rigid fixation is not possible Michilet et al developed the concept of miniplate
iii. To establish the occlusion. osteosynthesis in late 1960s.

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80 Section 2: Examination of Maxillofacial Trauma Patient

Goals Limitations
Perfect anatomical reduction Because of their smaller size, miniplates are not
Complete stable fixation as rigid and this decreased rigidity may lead to
Painless mobilization of injured region around torsional movements of the fracture segments
its articulation. under functional loading, resulting in infection
or nonunion or both. This also precludes their
Advantages use in comminuted fractures.
Smaller incisions and less soft tissue dissection Also because of reduced stability, reduced
are necessary for their placement function is recommended after fracture
fixation. A soft diet for 36 weeks and some
Because of smaller size and thinner profile of
surgeons also recommend 12 weeks of IMF.
the plates, these are less palpable and reduces
the necessity of plate removal. The smaller
size of the miniplate may decrease the stress TITANIUM MINIPLATES
shielding seen following rigid fixation
Lag Screws
The screws being monocortical can be placed
in areas of mandible adjacent to tooth roots Indications
with minimal risk of tooth injury (Figs 9.5 to It is ideal for wide sagittal fractures or lamel-
9.7). lar fractures that have large area of interfrag-

A B

Fig. 9.4A and B: (A) Compression plate; (B) OPG showing compression plate in situ

A B

Figs 9.5A and B: (A) Showing symphysis fracture; (B) Showing intraoperative miniplate fixation

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Chapter 9: Basic Principles for the Management of Maxillofacial Trauma 81

Fig. 9.6: Showing 2 hole and 4 hole miniplate in situ Fig. 9.7: Showing 4 hole plate and locking screw

mentary contact and friction between the Rotational stabilization by close interdigitation
lamellae of the fracture serration
Median fractures of the mandible with Interfragmentary mechanical rest and stability
bicondylar neck fractures Best condition of primary fracture healing
Comminuted fractures. Easy removal of screws.
Types
Technique
True lag screw
Cortical lag screw. A true lag screw has threads only on its
terminal end. When used the threads engage
Principle the distal cortex and the head seats agginat the
Length of the fracture should be at least equal proximal cortex, resulting in compression and
to the height of the mandible and twice the mechanical rest.
height of the atrophic mandible. The gliding hole is drilled first in the outer
At least two lag screws for functionally stable cortical plate. This is achieved with a 2.7 mm drill
fixation bit protected by a corresponding drill sleeve.
Insertion of lag screw along the bisector of the
angle formed by perpendiculars to the bone Reconstruction plates
surface and to the fracture line. It is a load bearing plate.
Advantages If the bone loss is severe or in a comminuted
fracture, reconstruction plate will provide
Minimal hardware requirement
stability and support the fracture segments
The need for few specialized instruement during healing.
Possibility of application with miniplate system At least sscrews should be placed in each
Direct central application of compression forces segment and if an osseous gap has to be bridged
An even distribution of forces on fragment atleast 4 screws in each segment should be
interface applied.

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82 Section 2: Examination of Maxillofacial Trauma Patient

NEWER DEVELOPMENT IN The principle is further based on the idea that


OSTEOSYNTHESIS (FIGS 9.8 TO 9.16) plate is not positioned along the trajectories
but over the weak structure lines
3-D Plates (Figs 9.8 and 9.9) The fixation points remain in the vicinity of the
Developed by Fermand M in 1995 fracture line
Differs from other miniplate system The connecting arms should be positioned
The basic concept of three dimensional mini rectangle to the fracture line.
plate fixation is geometrically closed quadran-
gular plate secured with screws creates create Advantages of 3-D Plates
stability in three-dimensions (Fig. 9.14) Stability is achieved by configuration not by
The smallest component is a cube or square thickness or length
stone Adjustment is easy because of thin connecting
The stability is gained over a defined surface arms of the plate
area Screws adapt to each part of the plate without
The maintenance of quadrangular position of any tension on the bone
the arms of the plate to each other is essential There is no need for the exact adaptation of
to optimal stability plate to the bone
Minimal dissection is required as compared to
the other plating system, hence blood supply is
not hampered.

Trapezoidal Condylar Plates


(Figs 9.10 and 9.11)
C Meyer specifically developed for osteosyn-
thesis of low subcondylar and high subcondylar
fractures.

Advantages
It respects the principle of functionally stable
Fig. 9.8: Showing 3-D plates osteosynthesis of Champy (1976)

A B

Fig. 9.9A and B: showing 3-D plates in situ intraoperative

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Chapter 9: Basic Principles for the Management of Maxillofacial Trauma 83

Fig. 9.10: Trapezoidal miniplate


Fig. 9.11: Trapezoidal miniplate in situ

It also take the advantage of 3-D characteristics bone and therefore plates provide fracture
of plates well stablished by Farmand (1990) stability without requiring direct contact with
Enhanced stability, less periosteal dissection the bone (Fig. 9.16).
and possible osteosynthesis of small fragments
(Fig. 9.15) Advantages of Locking Plate Over
Plates are available in various sizes 4 and 9 Compression Plate
holes with different bridges in order to allow Precise adaptation of the plate to the bone is
anatomical variations. not required as the screws lock into the plate
independent of the bone
Because the plate is not compressed against
LOCKING PLATES (FIG. 9.7 TO 9.12) the bone more periosteum remains viable to
These plates are designed with threaded hole aid in the fracture healing
through which the screws pass If a screw loosens in a compression plate, it is a
This provides two separate points of fixation mobile foriegn body that may become infected,
for each screw, one into the bone and second exposed, or painful
in the threads of screw hole in the plate. The In the locking plate, if the screw become loose
screw lock into the plate independent of the in the bone, it remain fixed to the plate.

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84 Section 2: Examination of Maxillofacial Trauma Patient

Fig. 9.12: Titanium locking plates

Fig. 9.13: Different plates in situ Fig. 9.14: Trapezoidal miniplate in use

Fig. 9.15: 3 D miniplate in use Fig. 9.16: Locking miniplate in use

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Dentoalveolar Fractures
10
DEFINITION Periodontal injury: Concussion, subluxation,
intrusion, extrusion, lateral luxation, avulsion.
Dentoalveolar fractures are those in which
Alveolar bone injury: Intrusion of teeth with
avulsion, subluxation or fracture of the teeth occurs
fracture of socket, alveolus or jaws.
in association with a fracture of the alveolus. Early
Gingival injury: Contusion, abrasion, laceration,
recognition and management can improve tooth
degloving
survival and functionality trauma to the teeth are
Combination of the above
not life-threatening however associated maxillo-
facial injuries can compromise the airway, mostly Dental Hard Tissue Injury
maxillary teeth are at higher risk than mandibular.
Fractures of this types are more common in Occurs as a result of direct trauma or by forcible
permanent teeth than deciduous teeth. impaction against the opposing dentition
It may occur as an isolated clinical entity or Anterior teeth damaged by direct impact while
in conjunction with any other soft tissue or facial posterior ones damaged by impaction between
bone fracture. the two jaws (Fig. 10.1)
Isolated dentoalveolar fracture seen among Upper teeth intrusion is more frequent and
children and adolescents and boys are three times impact against lower teeth may lead to vertical
at risk than girls. splitting
Meticulous clinical and radiographical exami-
ETIOLOGY nation are very essential to determine the
degree of dental damage and chest X-ray when
i. RTA (minor accidents)
ii. Collisions and falls missing or knocked out tooth is suspected
iii. Cycling accidents Early treatment is imperative to relieve pain
iv. Epileptic seizures and preserve tooth.
v. Iatrogenic damage during: Treatment objectives: Preservation of damaged
Extraction of teeth teeth
Endoscopy procedure
Endotreacheal intubation. Depends upon
Complexity of maxillofacial injury
Classification of Dentoalveolar Injuries Age of the patient
(Andreasen and Andreasen 1994) General dental condition
Dental hard tissue injury: Crown infracture and Site of injury
fracture with or without root fracture. Wishes of the patient.

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86 Section 2: Examination of Maxillofacial Trauma Patient

Fig. 10.1: Dentoalveolar fracture

Fig. 10.2: Disturbed occlusion as the result of fracture Fig. 10.3: Short-term IMF with elastics

Prognosis is influenced by Less displaced with no occlusal interference


Open root apices should be monitored since extraction carries
Intact gingival tissue risk to permanent one (Fig. 10.2).
Absence of root fracture
Periodontal-bone support. Management of Injuries to
Permanent Dentition (Fig. 10.3)
Injuries to the Primary Dentition Crown fracture
70% involve maxillary central incisors Dressing of exposed dentin, minimal pulpot-
Intrusion, lateral luxation and avulsion are the omy or pulp extirpation and restoration of
commonest damaged part of the tooth
Intruded teeth are likely to normally erupt
Root fracture
spontaneously
(Oblique, vertical or transverse)
Damage to developing permanent teeth by Inevitable extraction
displaced tooth are recognizable problem Saving the tooth by:
a. Rigid splinting for a minimum of 8 weeks
Management of Injuries to Primary Dentition b. Devitlaiztion (RCT) with eventful apico
Fractured, extruded or grossly displaced teeth surgery
are to be extracted c. Orthodontic extrusion or crown lengthening

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Chapter 10: Dentoalveolar Fractures 87
Injuries to periodontal tissues Midline split of palate with unilateral Le Fort I
Force distributed over several teeth or impact lead to large dentoalveolar fracture
cushioned by overlying soft tissue may result into: Fracture of tuberosity and fracture of antral
a. Concussion floor is a recognized complication of upper
b. Subluxation molars extraction.
c. Intrusion
Management of injuries to the alveolar bone
d. Displacement and avulsion
(Block or plate fracture)
e. Fracture of teeth structure
Looseness and displacement of teeth carries a Finger manipulation
high risk of subsequent pulp necrosis Reduction (closed) and fixation
As with root fracture, late complications can be Rigid wire and composite splint
resorption, canal obliteration, ankylosis and Elimination of premature contact and occlusal
loss of alveolar bone trauma
Short inter-maxillary fixation.
Management of injuries to the periodontal tissues
Loosened, laterally luxated and extruded teeth Management of tuberosity fracture
should be repositioned and splinted for 13 Removal of comminuted fracture of loss
weeks respectively by semi rigid splint: (Fig. 10.3). alveolar bone and teeth and repair of soft tissue
a. Acid-etch composite Delay of extraction of teeth in case of tuberosity
b. Arch bar fracture for (68 weeks)
c. Orthodontic wire Mandatory extraction of a tooth from a block
d. Soft stainless-steel wire-loop fracture should be carried out surgically.
e. Vacuum formed splint. Splinting of a tooth of fractured tuberosity in to
Avulsed teeth necessities immediate replanta- other standing teeth for one month.
tion and semirigid splinting for 1-2 weeks and Injuries to the gingival and soft tissues
prognosis is influenced by: Damage to the lip observed more with anterior
a. Stage of root development dento-alveolar fracture
b. Length of exposure Embedded of portion of a tooth or foreign
c. Medium storage bodies in soft tissues is very substantial
d. Handling and splinting Laceration of the gingiva is associated with
Alveolar fracture dento-alveolar fracture
Alveolar injury in mandible is associated with Degloving of the mental region is a common
complete fracture of tooth-bearing area and in injury to the lower anterior teeth.
maxilla is often isolated injury Management of soft tissue injuries
Teeth damage might be no existed but the Inspection of a full thickness perforating wound
potential devitilzation should be expected Debridement and copious lavage with chlo-
Alveolar fractures are often seen as two distinct rhexidine solution
fragment containing teeth but comminuted Removal of denuded piece of bone
fracture is possible Repair of soft tissue injury
Alveolar fracture in mandible my go along with Application of external support strapping to
mandible fracture and impacted fracture into help in tissue adaptation
the maxilla may appear to be immobile Antibiotic prescription.

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Mid-facial Fractures
11
INTRODUCTION SURGICAL ANATOMY
Mid-face fractures rarely occur in isolation and Physical characteristics of the mid-facial
are often a component of a panfacial or maxillary- skeleton
mandibular fracture pattern. The evolution of Articulation with the base of the skull
open reduction and internal fixation techniques Involvement of the brain and cranial nerves
in the treatment of facial fractures over the past Involvement of the orbit
2 decades has supplanted the need for prolonged Disturbance of the occlusion
periods of intermaxillary fixation and facilitated Paranasal sinuses
early functional rehabilitation. Important blood vessels
Appropriate application of the general Articulation with the base of the skull
principles can minimize morbidity and ensure Match box phenomenon
a return to premorbid facial appearance and Areas of weakness
occlusion. Improved diagnostic capabilities, use Buttress system
of open surgical techniques, advance rigid fixation Vertical buttress
devices, advances in techniques of resuscitation, Horizontal buttress.
and more focused surgical training have markedly
improved the care of the facial trauma patient. CLASSIFICATION (TABLE 11.1)
Mid-face fractures are defined as an area
A. Lefort I, II, III, IV
bounded superiorly by a line drawn across the
B. As per the direction of fracture line (Erich):
skull from frontozygomatic suture across the fronto
nasal and fronto maxillary sutures on the opposite Horizontal
side and inferiorly by the occlusal plane of the Pyramidal
upper teeth. Transverse
Causes: C. Depending on the relation of fracture line to
Road traffic accidents zygomatic bone:
Altercation Sub zygomatic
Sport Supra zygomatic
Falls D. Depending on the level of fracture:
Commonest site: Low level
Nasal 50% Mid level
Zygomatic 22% High level
Occular 12% E. Rowe and Williams classification:

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Chapter 11: Mid-facial Fractures 89

Table 11.1: Mid-face fracture b. Fractures involving the occlusion:


Lefort
1. Dentoalveolar fractures
I 2. Subzygomatic
II Lefort I (low level or Guerin)
III Lefort II (pyramidal)
IV 3. Suprazygomatic
As per the direction of fracture line (Erich) Lefort III (high level or craniofacial
Horizontal dysjunction)
Pyramidal
F. Modified Lefort classification:
Transverse
Lefort I Low maxillary fracture
Depending on the relation of fracture line to
zygomatic bone
Ia Low maxillary fracture/multiple
Subzygomatic segments
Suprazygomatic Lefort II Pyramidal fracture
Depending on the level of fracture IIa Pyramidal fracture and nasal fracture
Low level IIb Pyramidal fracture and NOE fracture
Mid level Lefort III Craniofacial dysjunction
High level IIIa Craniofacial dysjunction and nasal
Rowe and William's classification fracture
Fractures not involving the occlusion IIIb Craniofacial dysjunction and NOE
Fractures involving the occlusion
Lefort IV Lefort II or III and cranial base
Modified Lefort classification fracture
Lefort I, Ia
IVa Supraorbital rim fracture
Lefort II, IIa, IIb
Lefort III, IIIa, IIIb
IVb Anterior cranial fossa and orbital wall
Lefort IV, IVa, IVb fracture

LeFort I (Low Level, Subzygomatic,


a. fractures not involving the occlusion: Guerin's, Horizontal, Floating Fracture)
1. Central region (Fig. 11.1)
Fractures of the nasal bones and/or Horizontal fracture line above the level of floor
nasal septum of the nose involving lower third of septum
Lateral nasal injuries and the mobile fragment consists of the palate,
Anterior nasal injuries the maxillary alveolar process and lower third
Fractures of the frontal process of the of pterygoid plates and associated portion
maxilla of palatine bone. May occur as single or in
Fractures of types A and B which combination with II and III
extend into the ethmoid bone Allows motion of the maxilla while the nasal
Fractures of types A, B and C which bridge remains stable.
extend into the frontal bone. Radiographic findings:
2. Lateral region Fracture line which involves:
Fractures involving the zygomatic bone, Nasal aperture
arch and maxilla excluding the dentoal- Inferior maxilla
veolar component. Lateral wall of maxilla.

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90 Section 2: Examination of Maxillofacial Trauma Patient

Fig. 11.1: LeFort I fracture line Fig. 11.3: LeFort II fracture line

LeFort II (Pyramidal/Subzygomatic
Fracture) (Fig.11.3)
From the nasal bridge the fracture invariable
enters the medial wall of the orbit, involving the
lacrimal bone and then recrosses the orbital rim
at the junction of the middle third and the lateral
two third, medial to, or through infraorbital
foramen. The fracture line runs beneath the
zygomaticomaxillary suture, traversing the
lateral wall of the antrum to extend backward
Fig. 11.2: LeFort I fracture showing Guerin's sign horizontally through the pterygoid plate.

Clinical findings of LeFort (Fig. 11.2) Clinical findings of LeFort II


Facial edema Moon face
Ecchymosis in buccal, lingual and palatal (Guerin's Bilateral circumorbital ecchymosis
sign) Bilateral subconjunctival hemorrhage-medial half
Malocclusion of the teeth Step deformity at infraorbital margin
Motion of the maxilla while the nasal bridge remains Nasal flattening
stable-grating sound Traumatic Telecanthus
Cracked-pot sound and # of cusps Epistaxis or CSF rhinorrhea
Mid palatal split Movement of the upper jaw and the nose

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Chapter 11: Mid-facial Fractures 91
Radiographic imaging: Fracture through
Zygomaticofrontal suture
Zygoma
Medial orbital wall
Nasal bone.

MAXILLARY FRACTURE MANAGEMENT


General Considerations
Restoration of occlusion is must for correct
reduction
Fixation is maintained by external/internal
skeletal fixation until consolidation is achieved.
Immobilization for 68 weeks to stable segments
IMF for 34 weeks.

Methods of Reduction
1. Closed reduction.
2. Open reduction.
Fig. 11.4: LeFort III fracture line
Manual/Closed Reduction
Simple manipulation by hand
Radiographic findings: Fracture line which By dental impression compound
involves: By rubber dam sheet/ ribbon gauze/rubber
Nasal bones catheters
Medial orbit By using special instruments-Disimpaction
Maxillary sinus forceps.
Frontal process of the maxilla.
Rowes Maxillary Disimpaction Forceps and
LeFort III Fracture (Fig.11.4) Hayton Williams Forceps-I Fracture
Fracture extends through the zygomaticofrontal For II# -Asche`s/Walsham`s Septal Forceps.
suture and the nasofrontal suture and across the
floor of the orbits to effects a complete separation Fixation of LeFort Fractures
of the mid-facial structures from the cranium.
External Fixation
Clinical findings of LeFort III Craniomandibular
Gross edema of face-Panda facial within 24-48 hr Box frame
Bilateral circumorbital/periorbital ecchymosis and Halo frame
gross edema-Racoon eyes. Plaster of Paris head cap.
Tenderness and separation of frontozygomatic sutures Craniomaxillary
Dish faced deformity Supraorbital pins
Epistaxis and CSF rhinorrhea Zygomatic pins
Motion of the maxilla, nasal bones and zygoma
Halo frame
Suspension by cheek wires from Halo-frame or
Severe airway obstruction
head cap.

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92 Section 2: Examination of Maxillofacial Trauma Patient

Pin fixation (supraorbital pins) Indicated in rare cases of elongated middle 3rd
Simple method fractures
Wooden screw pattern pins Progressive tightening
Landmarks for pin placement Special head cap attachments via plaster of
Supraorbital pins linked with upper silver cap paris of head caps and halo frame.
splint Disadvantage
Great advantage without IMF Lack of stability.
Important to check occlusion in postoperative day
Transfixation of maxilla
Occasionally a discrepancy.
Rapid form of fixation
Box Frame Useful in the rare situation- profuse leak of CSF
and risk of aerocele
Combined middle 3rd and mandibular fracture Achieved by Steinmann pin or Stout Kirschner
Fractured mandible is reduced first wire
Middle 3rd fracture is mobilized and occlusion Transfixation pin is linked to head cap or
re-established haloframe.
Temporary IMF
Supraorbital pins inserted and craniomaxillary Internal Fixation (Figs 11.5 to 11.11)
fixation established 1. Direct osteosynthesis
IMF released. Transosseous wiring at fracture sites
-- High level (frontozygomatic and frontonasal)
Halo Frame -- Mid level (orbital rim/zygomatic buttress)
Plaster of Paris head cap and cheek wires -- Low level (alveolar /midpalatal)

Fig. 11.5: Lateral wiring Fig. 11.6: Frontozygomatic wiring

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Chapter 11: Mid-facial Fractures 93

Fig. 11.7: Infraorbital rim wire Fig. 11.8: Pyriform aperture wire

Fig. 11.9: Circumzygomatic wire Fig. 11.10: Buttress wiring

Miniplates Internal fixation


Transfixation with Kirschner wire or Suspension wires to mandible (Fig. 11.9)
Steinman pin: Frontal Central or lateral
-- Transfacial Circumzygomatic
-- Zygomaticseptal Zygomatic

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94 Section 2: Examination of Maxillofacial Trauma Patient

Pterygoid buttress was not operated


Posterior height of mid-face restore the ramus
Mid-face projection ORIF of the nasomaxillary
and zygomaticomaxillary buttresses
Upper mid-face Open reduction of zygomatic
and nasoethmoidal fracture was performed.

Open Reduction and Internal Fixation by


Miniplates, Microplates, and Screws
Champy et al 1976
Harle and Duker in 1975
Luhr in 1979.
Surgical approaches to maxillary fractures (Figs
11.12 to 11.17)
Fig. 11.11: Circumpalatal wire

Infraorbital
Pyriform aperture (Fig. 11.8).

Adams Wiring (1942)


Disadvantages of Fixation by Wire Suspension:
Lack of compensation of dislocating forces
direction posteriorly
Difficult to ensure a correct facial projection
Tooth borne appliances offer only direct
control the occlusal level of fractures
Lack of 3 dimensional stability. Fig. 11.12: Intraoral approach

Complications of Fixation by Wire Suspension


Mid-face shortening
Widening and retrusion of paranasal areas.

Sequence of Internal Fixation


Top to bottom Merville (1974)
Outer facial frame
Bottom to top to middleManson and Kelly
et al.

Open Reduction and Internal Fixation by


Interosseous Wiring
Introduced by Adams 1942
Later refined by Manson et al
Reconstruction of the sinus wall fragment
between the 2 anterior pillars was omitted Fig. 11.13: Lower eyelid approach

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Chapter 11: Mid-facial Fractures 95

Fig. 11.14: Transconjunctival lateral canthotomy


A

B
Fig. 11.15: Upper lid blepharoplasty Figs 11.17A and B: Showing postoperative radiograph

ZYGOMATICOMAXILLARY COMPLEX
FRACTURES (FIG. 11.18)
Introduction
Zygomatic fractures are common facial injuries
It is the most common facial fracture of the
second in frequency after nasal fractures
The high incidence of zygoma fractures
probably relates to the zygomas prominent
position within the facial skeleton.

Anatomy
It is the major buttress of facial skeleton and
Fig. 11.16: Coronal approach principal structure of the lateral mid-face

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96 Section 2: Examination of Maxillofacial Trauma Patient

Classification
Rowe and Killey (1968)
Type I: No significant displacement
Type II: Fracture fo the zygomatic arch
Type III: Rotation around vertical axis
Inward displacement of orbital rim
Outward displacement of orbital rim
Type IV: Rotation around longitudinal axis
Medial displacement of frontal process
Lateral displacement of frontal process
Fig. 11.18: Left zygomatic complex fracture involving
orbit showing subconjuctival echymosis Type V: Displacement of the complex enbloc
Medial
Inferior
It is a thick strong bone and is roughly Lateral (Rare)
quadrilateral in shape with an outer convex Type VI : Displacement of orbitoantral partition
surface and inner concave Inferiorly
Superiorly
It has temporal, orbital, maxillary and frontal
Type VII : Displacement of orbital rim segments
processes
Type VIII : Complex comminuted fractures
It articulates with four bones: the frontal,
sphenoid, maxilla and temporal.
Rowe (1985)
Terminology and Fracture Pattern 1. Group A: Stable fractureshowing minimal or
The malar bone represents a strong bone on no displacement and requires no intervention.
fragile supports and it is for this reason that, 2. Group B: Unstable fracturewith great
though the body of the bone is rarely broken, the displacement and distruption at the frontozy-
four processes fontal, maxillary and zygomatic gomatic suture and comminuted fracture.
are frequent sites of fracture. Requires reduction as well as fixation.
HD Gillies, TP Kilner, D Stone, 1927 3. Group C: Stable fractureother types of zygo-
Zygomatic or malar fractures are the terms matic fractures, which requires reduction, but
commonly used to describe fractures that involve no fixation.
the lateral one-third of the mid-face. Other names
Fractures of the Zygomatic Arch Alone
for this fracture are:
1. Minimum or no displacement.
Zygomaticomaxillary complex
2. V type in fracture.
Zygomaticomaxillary compound 3. Comminuted fracture.
Zygomatico-orbital
Zygomatic complex Diagnosis of ZMC Fracture
Malar (Figs 11.19 to 11.21)
Trimalar In a typical case diagnosis may be made at sight
Tripod. once the characteristic appearance has been

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Chapter 11: Mid-facial Fractures 97

Fig. 11.19: Clinical presentation of right side


zygomatic complex fracture Fig. 11.20: Flattening on left side of face

Signs and Symptoms


Periorbital ecchymosis and edema
Flattening over the zygomatic arch
Ecchymosis of the maxillary buccal sulcus
Deformity of the zygomatic buttress of the maxilla
Trismus
Abnormal nerve sensibility
Epistaxis
Subconjuctival ecchymosis
Crepitation from air emphysema
Displacement of the palperbral fissure
Unequal pupillary level
Diplopia
Fig. 11.21: Reduced mouth opening Enophthalmos

fully recognized. A peculiar facies is present, due The most useful method of evaluating the
chiefly to a certain flatness of contour and absence position of the body of the zygoma is from the
of expression on the affected side. superior view
HD Gillies, TP Kilner, D Stone, 1927 Intraoral examination to evaluate buccal
ecchymosis in the superior buccal sulcus
Inspection and Palpation Palpation of the infraorbital rim, frontozygo-
matico suture, body of the zygoma and arch.
It should be performed from the frontal, lateral,
superior and inferior vantages Radiological Evaluation (Figs 11.22 to 11.24)
Note symmetry, pupillary levels and presence of Plain film radiography
orbital edema and subconjuctival ecchymosis Waters view
and anterior and lateral projection of zygomatic Submentovertex
bodies CT scan.

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98 Section 2: Examination of Maxillofacial Trauma Patient

Fig. 11.22: Zygomatic arch fracture

Fig. 11.23: Zygoma fracture Fig. 11.24: Fracture of anterior wall of maxillary sinus

TREATMENT INDICATIONS FOR SURGERY If possible surgery should be performed within


714 days before significant healing has begun
Alteration in facial contour
Stable nondisplaced fractures may be observed
Globe displacementenophthalmus/exoph-
weekly for proper healing.
thalmus/ diplopia
Muscle/fat/nerve entrapment
SURGICAL APPROACHES
Mechanical restriction of mandibular movement.
Temporal Approach (Gillies Approach)
TIMING OF SURGERY Isolated arch fractures/minimally displaced
Early: Surgery performed prior to significant ZMC fracturesno direct visualization
swelling 23 cm incision in hairline below and parallel
Late: After resolution of significant edema to anterior branch of temporal artery

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Chapter 11: Mid-facial Fractures 99
Through and through superficial temporalis Complications
fascia
Infraorbital nerve disordres
Rows zygomatic elevator passed medial to
Persistent diplopia
arch for elevation in a sweeping upward and
outward direction. Enophthalmos
Blindness
Intraoral Keen Approach Infection
Incision in maxillary buccal suicus in region Maxillary sinusitis
of canine sulcus, periosteum is elevated and Ankylosis of zygoma to coronoid process
elevator passed deep to arch superiorly
Malunion of zygoma
Again no visual access for direct fixation.

OPEN REDUCTION TECHNIQUES NASOETHMOIDAL ORBITAL FRACTURE


Lateral brow incision Introduction
lnfracilliary (blepheroplasty) incision Naso-orbital ethmoid fractures involves central
Infraorbital crease incision mid-face nasal bone, frontal process of maxilla
Supratarsal fold and ethmoid bone
"Crows foot" incision These have variously been described as
Bicoronal/Hemicoronal flap. fracture of the ethmoids, naso-orbital fractures,
nasoethmoidal injuries and nasoethmoido-
FIXATION V/S NONFIXATION maxillofronto-orbital complex
Although nasal fractures are the most common
Nondisplaced fractures should be followed
facial fracture, they often go unnoticed by both
clinically without surgical intervention
surgeons and patients. Patients with nasal
One or two point fixation may be adequate for
fractures usually present with some combina-
stable, minimally displaced fractures
tion of deformity, tenderness, hemorrhage,
Direct fixation at the site of fracture techniques
edema, ecchymosis, instability, and crepitation;
for unstable, comminuted, and grossly displaced
however, these features may not be present or
fractures.
may be transient (Tremolet de Villers, 1975)
To further complicate the matter, edema can
DIRECT FIXATION TECHNIQUES
mask underlying nasal deformity, crepitation,
Wiring2430 gauge stainless steel wire and instability; thus, many surgeons and patients
Mini bone plates fail to pursue further diagnosis and appropriate
Steinmann pins. treatment. If untreated, nasal fractures can result
both in unfavorable appearance and in unfavorable
INDIRECT FIXATION function, especially when the underlying structural
Fixation away from the fracture site integrity of bone and cartilage is lost.
Steinmann pins / transfacial pin
Temporary packing with penrose drains, gauze, Pathophysiology
gelfoam, silastic, antral balloon The nasal bones and underlying cartilage are
Attachment of external framework susceptible to fractures because the nose maintains
Extent of fixation obviously dictated by a prominent position and central location on the
fractureminiplate fixation is generally the face and because it has a low breaking strength.
most common stabilization technique. Patterns of fracture are known to vary with the

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100 Section 2: Examination of Maxillofacial Trauma Patient
momentum of the striking object and the density
of the underlying bone (Murray, 1984). As with
other facial bones, younger patients tend to have
larger nasoseptal fracture segments, whereas older
patients are more likely to present with more-
comminuted fracture patterns (Cummings, 1998).

Causes
Road traffic accidents
Sports injuries
Fights
Work related accidents
Falls are a more common cause of nasal injury
in children.

Frequency
Fracture of nasal bones is the most common
site-specific bone injury of the facial skeleton.
Nasal fractures account for 3945 percent of all
facial fractures (Hussain, 1994) Fig. 11.25: Nasoethmoidal complex
Sex: The male-to-female ratio in nasal fractures
is greater than 2:1 each of which is formed by the thin lacrimal
Age: The incidence is increased in patients bone and the lamina papyracea (orbital plate)
aged 1530 years (Muraoka, 1991) of the ethmoid which overlie the ethmoid
A small but significant increase in the number sinuses
of nasal fractures is noted in the elderly This space contains the nasal septum,
population because of a higher rate of falls turbinates, ethmoid sinuses and is bridged
Most nasal bone fractures in young adults above by the cribriform plate of the ethmoid.
are related more to altercations and sporting
injuries and less to motor vehicle accidents; Classification of the Nasoethmoidal Injuries
however, these rates vary according to the Rowe and Williams Classification
location of the conducted study and the
1. Isolated nasoethmoid and frontal region

association with alcohol (Muraoka, 1991;
injuries without other fractures of the mid-face.
Hussain, 1994; Scherer, 1989; Logan, 1994).
Bilateral
Surgical Anatomy Unilateral
The skeletal foundation of nasoethmoidal 2. Combined nasoethmoidal and frontal region
complex consists of a strong triangular shaped injury with other fractures of mid-face
frame (Fig. 11.25) Bilateral
On each side the frontal process of maxillary Unilateral.
bone and the nasal process of the frontal bone
are united above at glabella. The triangle is Markowitz Classification
completed inferiorly by the premaxilla Depending on the velocity and point of impact
Behind the frame lies interorbital space Type I: Nasal-orbital-ethmoid fracture: Involves
situated between the medial walls of the orbit only one portion of the medial orbital rim with

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Chapter 11: Mid-facial Fractures 101
its attached medial canthal tendon, may occur angle becomes blunt with obliteration of the
unilateral or bilateral caruncle and may be displaced downwards
Type II: Nasal-orbital-ethmoid fracture: May and laterally particularly when there is
occur in bilateral or unilateral form and may associated comminution and displacement
be large segments or comminuted. Most of zygomatic complex
commonly the canthus remains attached to a Eyelids: These become lax and epicanthal
large central segment fold is more prominent. Flattening of the
bottom of the naso-orbital valley is the
Clinical Features earlier sign of traumatic disruption of the
Frontal depression canthal region
Nasal deformity Canthal ligament: Diminished tension of
Traumatic telecanthus the canthal ligament
CSF rhinorrhea
Eye: diplopia.
Diplopia
Hemorrhage (due to rupture of anterior and
Imaging
posteior branches of ethmoidal artery) Plain films are of almost no use in diagnosing
NOE fractures as most will be undetected
Type III: Nasal-orbital-ethmoid fracture: This CT is of greatest value and provides more
fracture includes comminution involving insight into NOE injuries. Thin axial slices
central fragment of bone where the medial provide the basic detail of the extent of the
canthal tendon attaches. The canthus is injury. Coronal sections are essential to reveal
rarely avulsed completely but on occasions the details of the fractures of the middle third
the fragments of bone are so small that the of the orbit.
reconstruction is not possible, in these cases
transnasal wiring of the canthus is required.
Treatment
Eight steps for the management of such injuries
Diagnosis of Telecanthus are presented:
An increased intercanthal distance may result i. Surgical exposure
from severance, avulsion or displacement ii. Identification of the medial canthal tendon/
laterally while still attached to the fragment tendon-bearing bone fragment
of bone. Traumatic telecanthus should be iii. Reduction/reconstruction of medial orbital
differentiated from hypertelorism where in rim
there is increased interpupillary distance iv. Reconstruction of medial orbital wall
The criteria for making diagnosis: v. Transnasal canthopexy
vi. Reduction of septal fractures
A high index of suspicion
vii. Nasal dorsum reconstruction/augmentation
Measurement: The intercanthal distance
viii. Soft tissue adaptation.
should be measured carefully with dividers
and particular attention should be paid to
Surgical exposure
the distance of the midpoint of the nose
Through Existing laceration
from each canthus to reveal the possibility
H-shaped incision
of the unilateral displacement. The normal
intercanthal distance is 3334 mm Vertical or horizontal nasal radix
Palpebral fissure: This should be scrutinized Bilateral Z
carefully since characteristically it becomes Open sky approach (w incision)
narrowed and almond shaped. Medial Bicoronal plus lower lid incision

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102 Section 2: Examination of Maxillofacial Trauma Patient
Identification of the Medial Canthal Tendon/ that occurs after NOE injuries. This procedure is
Tendon-bearing Bone Fragment mainly of esthetic importance.
The canthal tendon is almost never avulsed
from bone, but it is usually attached to a Soft Tissue Adaptation
bony fragment. The proper identification of A thermoplastic nasal stent may be used early
this fragment and its reduction produces an in the post surgical period to help to redrape the
esthetically acceptable result soft tissues deeply into the naso-orbital valley to
If the tendon is severed or avulsed one should prevent thickening of the soft tissue giving the
tag the thicker anterior component with appearance of an increased intercanthal distance
braided tendon wire or suture.
Conclusion
Reduction/Reconstruction of Medial Orbital Rim No other facial fracture is more challenging
Transnasal reduction of the canthal bearing to repair than an NOE fracture. The complex
bone fragment is the most important step in anatomy of the region and difficulty with the
preserving the intercanthal distance access makes the surgeons task more demanding.
In simple fractures simple repositioning and Fortunately, significant contributions made by a
fixation with a small bone plate or wire may host of surgeons and new instrumentation and
be all that is necessary. In more comminuted technology have culminated in a better under-
injuries transnasal wiring has advantages over standing of NOE injuries and their treatment.
plates
A hole is made through the unstable bone NASAL FRACTURES (FIGS 11.26 TO 11.29)
fragment as well as the bone on the contra
lateral side. A double 30 gauge wire is then
Most common of all facial fractures
threaded through 2 holes transnasally with a
Injuries may occur to other surrounding bony
structures.
awl and wire is tightened.
They are 3 types
Reconstruction of Medial Orbital Wall Depressed
Laterally displaced
Reconstruction of both bony orbital volume
Nondisplaced.
and shape is important to achieve normal eye
position
Clinical findings
Materials used: Autogenous bone (calvarial
bone). Nasal deformity
Edema and tenderness
Reduction of Septal Fractures Epistaxis
Most NOE fractures are associated with fracture Crepitus and mobility
of perpendicular plate of ethmoid bone. Simple
intranasal manipulation of the septum with Asch
forceps to place it in the midline is adequate using Diagnosis
upward and anterior force with the forceps. History and physical examination
Nasal Dorsum Reconstruction/Augmentation
Lateral or Waters view to confirm your diagnosis.
Nasal dorsum reconstruction with a cantilevered
Treatment
bone graft provides long lasting dorsal nasal
support and prevents the characteristic saddling Control epistaxis
Drain septal hematomas.

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Chapter 11: Mid-facial Fractures 103

Fig. 11.27: Nasal bone fracture


Fig. 11.26: Radiograph showing nasal fracture

Fig. 11.28: Nasal fracture Fig. 11.29: Radiograph showing nasal fracture

ORBITAL BLOWOUT FRACTURES Etiology and Epidemiology


(FIGS 11.30 TO 11.32) Males > females, 4:1.
Orbitozygomatic fractures second in frequency
Orbital Trauma of facial fractures.
Anatomy RTA, assaults, sport injuries.
Bones of the orbit Fracture Patterns
Fracture lines rupture of dura mater causes Type I: Nasal-orbital-ethmoid fractures
CSF to escape into orbit Involves only one portion of medial wall with
Medial wall, floor of the orbit. its attached medial canthal ligament.
Muscles of the eye May be unilateral or bilateral
Common tendinous ring Type II: Nasal-orbital-ethmoid fractures
Eyelids. Comminuted or large segments.

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104 Section 2: Examination of Maxillofacial Trauma Patient

Fig. 11.30: PNS view shows lateral rim fracture

Fig. 11.31: MRI showing nasal and orbital lateral rim Fig. 11.32: PNS showing infraorbital rim fracture
fracture postoperative

Medial canthal ligament attached to the large Orbital emphysema.


central segment.
The eyelids
Reduction is required.
Abnormality of the palpebral fissure.
Type III: Nasal-orbital-ethmoid fractures Height, width, inclination.
Comminution involving the large central fragments Mobility (ptosis, pseudoptosis)
where the medial canthal ligament attaches.
Integrity of the margins and tarsal plates.
Clinical Features The ligaments
The periorbital tissues Alteration in the canthal level.
Edema Alteration in the ocular level
Circumorbital ecchymosis Increased intercanthal distance (telecanthus)
Subconjunctival hemorrhage Alteration in the ocular level.

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Chapter 11: Mid-facial Fractures 105
The eye Intraorbital pressure
Preservation of vision Forced duction testing
Limitation of the ocular movements Jones test
Presence of diplopia Hess chart
Exopthalmos or enopthalmos Pictorial record of ocular movement of each
Pupilary reflexes eye
Ophthalmic injuries Dissociation test which shows ocular move-
Increased interpupilary distance. ment of non fixing eye in all positions of gaze.
The lacrimal apparatus Imaging
Wounds involving the puncta
Epiphora Plain radiography.
Wounds involving the passages. Waters view
Reverse waters view
Neurological defecits AP skull and PA skull view
Paraesthesia of the infraorbital, supraorbital or Computed tomography.
supratrochlear nerves. Radiographic interpretation
Paresis of extraocular muscles PA skull view
Paresis of facial nerve. Computed tomography
The orbit Coronal CT scan of orbits demonstrating loss
Pain on palpation and /or deformity at of orbital floor on the left in contrast to the
The superior margin normal orbital floor on the right.
The frontozygomatic suture Coronal view computed tomography scan of
The inferior margin patient showing left orbital floor fracture with
The nasomaxillary and nasofrontal suture. herniation of orbital contents
Zygomatic bone and/or arch. Medial wall fracture
The lateral antral wall. Orbital roof fracture.
The mandible
General Principles
Limited opening with deviation to the opposite
side. Classification for the purpose of treatment.
Restricted lateral excursion to the same side. a. No treatment
Limited opening with deviation to the opposite b. Indirect reduction with:
side. No fixation
Temporary support
Physical Examination Direct fixation
Difficult in traumatized patient Indirect fixation
ABCs (ATLS) c. Direct reduction and fixation
Palpation of superior, inferior, lateral, medial, d. Immediate reconstruction by grafting
zygoma, maxilla and mandible done in e. Delayed reconstruction by osteotomy and /or
sequential order grafting
Ophthalmologic evaluation f. Late restoration of contour by onlay grafts.
Visual acuities (subjective and objective)
Pupillary function Optimum time for surgery
Ocular motility (NL Rowe and JLL Williams)
Anterior chamber for hyphema Factors to be considered:
Fundoscopic examination 1. Ophthalmic injuries
Test for pupilary reflexes 2. Progressive proptosis

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106 Section 2: Examination of Maxillofacial Trauma Patient
3 . Deterioration in visual acuity Fracture of the orbital floor was consistently
4. The visual integrity on the unaffected side produced at and above a force of 2.08 J
5. The necessity for immediate operation for
Orbital floor fractures can occur at low
other facial or general injuries energies with direct ocular trauma only ("pure"
6. General condition of the patient hydraulic mechanism).
Distinct advantage in not operating for 57
Two main theories
days as the edema would resolve facilitating
Hydraulic Theory
ease of operation
510 days critical period. Buckling Theory
Early surgery necessary within 3 days in
children with diplopia and mainly within 7 Diagnosis
days in adults . 2 mm thick section CT scan. 100% accuracy.
(Hammerschalg et al)
Order of repairs
Forced duction test
Work from stable to unstable
Infraorbital nerve paresthesia.
Use occlusion as guide
Evaluation of ocular changes secondary to
Generally stabilize mandible, zygoma and
blowout fractures
palate before mid-face or before orbit and NOE
Assessment of diplopia
Skin incisions for orbital fractures
Measurement of globe position.
Bicoronal incision (Tessiers)
Used for the purpose of extensive orbital surgery Timing of surgery
especially when roof has to be visualized. Management of blowout fractures involving
Bicoronal incision the orbital floor has been controversial over
Hemicoronal approach the past several decades
Multiple eyelid incisions A 2-week waiting period has been found to be
Lateral brow incision of little benefit and possibly harmful to their
Blepharoplasty incision motility. Hence, it is advocated surgery within
Lynchs incision the first few days after injury as it may help to
Subciliary incisions avoid permanent motility restriction.
Transconjunctival incisions
Lateral canthotomy Orbital floor materials
Lateral brow incision. Titanium and Vitallium mesh
Gelatin film
Approaches to orbital rim
Polydiaxone
Transconjunctival approach
Polyamide mesh
Tessier for correction of congenital orbital
Polyglactin 910
deformities
Polyglactin 910
Converse posttraumatic orbital deformities.
Polypropelene
Advantage: no external scar.
Silicones
Blow-out fractures Bone-derived biomaterials
Smith and Regan Fresh-frozen bone
Freeze-dried bone
Pure and impure fracture. Demineralized bone
Deproteinated bone
Mechanism Non-bone substitutes
Force necessary to fracture the orbital floor Hydroxyapatite
Current theory on the pathophysiology of Tricalcium phosphate
orbital wall fractures postulates either a Marlex mesh
"Hydraulic" or a "Buckling" mechanism Medpor

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Chapter 11: Mid-facial Fractures 107
Complications of orbital trauma Acetazolamide 500 mg IV
Hemorrhage Dexamethasone 8 mg PO
Retrobulbar hemorrhage Papaverine 40 mg smooth muscle relaxant
Superior orbital fissure syndrome Dextran-40 500 ml IV improves perfusion.
Orbital apex syndrome
Caroticocavernous fistula Superior Orbital Fissure Syndrome
Canalicular injuries. Instructive example of precise anatomical
localization of a lesion by neurological signs.
Retrobulbar Hemorrhage
Signs and symptoms
Hot angry eye
Gross and persistent edema of the periorbital
This is a very rare condition that can result in
tissue
loss of vision
Proptosis and subconjuntival hemorrhage
Where bleeding into the orbital space can result
Ophthalmoplegia and ptosis
in compression of the optic nerve, leading to
Dilatation of pupil
ischemia and eventually blindness
Direct light reflex absent
It can follow both trauma and surgery to the
Consensual reflex preserved
orbital region
Corneal reflex lost
Trauma
Loss of sensation over forehead.
Infraorbital
Zygomatic Endoscopic repair of orbital blow-out fractures
Le Fort Fracture types can be evaluated and repaired
Postoperatively endoscopically without the need for an eyelid
Blepheroplasty incision.
Zygomatic reduction It offers improved visualization, anatomic
LeFort reduction. fracture repair, no risk of postoperative eyelid
complications, and good clinical results.
Symptoms
Orbital pain
Decreased visual acuity or blindness
Trigeminocardiac Reflex
Diplopia if vision preserved In the early 20th century, trigeminocardiac
reflex (TCR) has gained much clinical
Signs
attention, in the form of the oculocardiac reflex
Proptosis with globe that is very hard on palpation (OCR) which is the cardiac response (mainly
Increased intraocular pressure on tonometry bradycardia) associated with stimulation of
Marked subconjuctival edema and ecchymosis the ophthalmic division of the trigeminal nerve
Opthalmoplegia. during ocular surgeries
Treatment Schaller, for the first time, demonstrated that
Immediate action a similar reflex occurs with stimulation of the
Remove any sutures in the area, for pressure intracranial portion of the trigeminal nerve.
relief
Medication Trigeminocardiac reflex
Mannitol 1 g/kg as 20% infusion Defined as the sudden onset of parasympathetic dys-
-- Osmotic diuretic rhythmia, sympathetic hypotension, apnea or gastric
-- Contraindicated in congestive cardiac hypermotility during stimulation of any of the sensory
failure. branches of the trigeminal nerve

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108 Section 2: Examination of Maxillofacial Trauma Patient
Pathophysiology Risk factors
(Central Neurogenic Reflex )
Hypercapnia
Hypoxemia
Light general anesthesia
Age (more pronounced in children)
The nature of the provoking stimulus (stimulus

strength and duration)
Drugs

Drugs known to increase the trigeminocardiac


reflex include:
Potent narcotic agents (sufentanil and alfentanil)
Beta-blockers, and
Calcium channel blockers.
Narcotics may augment vagal tone through their
inhibitory action on the sympathetic nervous system.
Beta-blockers reduce the sympathetic response of
the heart and by so doing, augment the vagal cardiac
response resulting in bradycardia. Calcium channel
blockers result in peripheral arterial smooth muscle
relaxation and vasodilatation causing reduction in
blood pressure.
Clinically, the trigeminocardiac reflex has
been reported to occur during craniofacial Clinical significance of the trigeminocardiac reflex
surgery, balloon-compression rhizolysis of the and why it should be treated: Trigeminocardiac
trigeminal ganglion, and tumor resection in reflex is a transient response to the trigeminal nerve
manipulation in its extra or intracranial course
the cerebellopontine angle. Apart from the few
which subsides with cessation of the stimulus. But,
clinical reports, the physiological function of this
in the most serious forms of severe bradycardia
brainstem reflex has not yet been fully explored.
and asystole, administration of vagolytic agents is
From experimental findings, it may be suggested
warranted in addition to cessation of the stimulus.
that the trigeminocardiac reflex represents an The importance of the trigeminocardiac reflex
expression of a central neurogenic reflex leading which may range from mild bradycardia which
to rapid cerebro vascular vasodilatation generated responds to simple cessation of the stimulus
from excitation of oxygen sensitive neurons in the to asystole and severe bradycardia requiring
rostral ventrolateral medulla oblongata. By this additional intervention with vagolytics. In some
physiological response, the adjustments of the rare but serious cases, it may lead to death if not
systemic and cerebral circulations are initiated to detected early and appropriate measures taken.
divert blood to the brain or to increase blood flow Management of the trigeminocardiac reflex:
within it. As it is generally accepted that the diving The most important "management option" for
reflex and ischemic tolerance appear to involve at the trigeminocardiac reflex is to be aware of its
least partially similar physiological mechanisms, potential danger and minimize any mechanical
the existence of such endogenous neuroprotective stimulation of the nerve.
strategies may extend the actually known clinical
appearance of the trigeminocardiac reflex and Treatment
include the prevention of other potentially brain Cessation of the manipulation, and administration
injury states as well. of vagolytic agents or adrenaline.

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Chapter 11: Mid-facial Fractures 109

CLINICAL CASES (FIGS 11.33 TO 11.44)

Fig. 11.33: 3D CT showing nasal fracture

A B
Figs 11.34A and B: Intraoperative nasal fracture exposure and reduction with mini plates

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110 Section 2: Examination of Maxillofacial Trauma Patient

A B

Figs 11.35A and B: Intraoperative infraorbital rim fracture exposure and reduction with mini plates

Fig. 11.36: Showing soft tissue injuries and


periorbital edema

A B
Figs 11.37A and B: Preoperative left zygomatic arch fracture

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Chapter 11: Mid-facial Fractures 111

A B

Figs 11.38A and B: Intraoperative left zygomatic arch fracture reduction by Gillies temporal approach

B C
Figs 11.39A to C: 3D CT showing zygomatic arch fracture

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112 Section 2: Examination of Maxillofacial Trauma Patient

Fig. 11.40: CT showing zygomatic fracture Fig. 11.41: Left frontozygomatic fracture

Fig. 11.42: Intraoperative frontozygomatic fracture exposure Fig. 11.43: 3D CT Intrafrontozygomatic fracture

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Chapter 11: Mid-facial Fractures 113

ZYGOMATIC ARCH FRACTURE RIGHT SIDE (FIG. 11.44)

A B

C D
Figs 11.44A to D: Zygomatic arch fracture right side: (A) Preoperative clinical picture showing depression at
preauricular region. (B) Intraoral suturing. (C) Jug handle view showing fractured zygomatic arch. (D) Postoperative
clinical picture

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Mandibular Fractures
12
INTRODUCTION Medial and lateral pterygoid
Mylohyoid
Mandibular fracture is more common than
Geniohyoid and genioglosus
middle third fracture. It could be observed
Anterior belly of digastric.
either alone or in combination with other facial
fractures. Minor mandibular fracture may be
associated with head injury owing to the cranio-
Effects of Muscles on Displacement
mandibular articulation. Mandibular fracture Transverse midline fracture (symphysial)
may compromise the patency of the airway in stabilizes by the action of mylohyoid and
particular with loss of consciousness. Mandible geniohyoid
is more sensitive to lateral impact than frontal Oblique fracture (parasymphysial) tends to
one. Fracture of condyle regarded as a safety overlap under the influence of muscles action
mechanism to the patient. Bilateral parasymphysial fracture results in
Frontal force of 800900 lb (350400 N) is backward displacement associated with loss of
required to cause symphyseal fracture tongue control when the level of consciousness
Frontal impact is substantially cushioned by is depressed.
opening and retrusion of the jaw
Long canine tooth and partially erupted 3rd, Incidence of mandibular fractures
molar represent line of relative weakness. Body fractures 33.6%
Subcondylar fracture 33.4%
Factors influencing site of fracture and displacement Fractures at the angle 17.4%
Anatomy of the mandible and attached muscle (canine
Alveolar fractures 6.7%
and wisdoms)
Ramus fractures 5.4%
Weakening areas of mandible (resorption and
pathology) Midline fractures 2.9%
Direction of force of the blow Fracture of coronoid process 1.3%
Age of the patient

CLASSIFICATION
ANATOMICAL CONSIDERATIONS
Krugers General Classification
Attached Muscles Simple or closed
Masseter Compound or open
Temporalis Comminuted

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Chapter 12: Mandibular Fractures 115
Complicated or complex An adequate number of teeth of suitable shape
Impacted and stability.
Greenstick An adequate number of teeth whose shape or
Pathological. stability is unsuitable.
Lateral compression splint, arch bars or cast
Rowe and Killeys Anatomic Classification metal splints.
I. Fractures not involving the basal bone Class II: When the teeth are present only on one
Dentoalveolar fractures side of the fracture line
II. Fractures involving the basal bone a. Short edentulous posterior fragment
Single unilateral If favorable IMF
Double unilateral If unfavorable ORIF
Bilateral b. Long edentulous posterior fragment
Multiple. If favorable IMF
If unfavorable ORIF
Factors influencing site of fracture and displacement
Class III: When both the fragments are edentulous
Anatomy of the mandible and attached muscle (canine
and wisdoms) Simple fractures without much displacement
gunning type splints
Weakening areas of mandible (resorption and
pathology)
Simple fractures which are unfavorableORIF
Compound fracturessurgical intervention.
Direction of force of the blow
Age of the patient AO Classification
Relevant to Internal Fixation
Favorable or Unfavorable
F : No. of fracture
Aimed towards angle fractures.The direction
L : Location of the fracture
of fracture line is important for resisting the
O : Occlusion status
muscle pull
S : Soft tissue involvemrnt
They are influenced by the medial pterygoid-
A : Associated fractures of the facial skeleton
masseter sling
They can be vertically or horizontally in Fracture of the Angle and Body
direction
Pain, tenderness and trismus
Favorable fracture line makes the reduced
Extraoral swelling at the angle with obvious
fragment easier to stabilize
deformity
If the vertical direction of the fracture
Step deformity behind the molar teeth
favours the unopposed action of medial
Movement and crepitus at the fracture site
pterygoid muscle, the posterior fragment
Derangement of occlusion
will be pulled lingually
Intraoral buccal and lingual hematoma
If the horizontal direction of the fracture
Involvement of inferior alveolar nerve
favors the unopposed action of masseter and
Gingival tear if fracture in tooth area
pterygoid muscles in upward direction, the
Tooth involvement and possible longitudinal
posterior fragment will be pulled lingually.
split fracture.
Kazanjian and Converse Classification Midline Fracture
Class I: When the teeth are present on both sides The most common missed fracture
of the fracture line Typessymphysial or parasymphysial

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116 Section 2: Examination of Maxillofacial Trauma Patient
Commonly associated with one or both -- Lateral oblique
condylar fracture. -- PA mandible
Unilateral fracture leads to over-riding of the -- AP mandible (Reverse Towne)
fragments and bilateral may contribute in loss -- Lower occlusal
of voluntary tongue control. CT scan
Long canine tooth represent a weak area and 3D CT imaging
contributes to parasymphysial fracture. MRI.

CLINICAL ASSESSMENT AND DIAGNOSIS Principles of Treatment


(FIGS 12.1 TO 12.13) Similar to Elsewhere Fractures in the Body
1 . History of trauma Reduction of fragments in good position
2. Clinical Examination Immobilization until bony union occurs
Extaroral
These are achieved by
-- Inspectionassessment of asymmetry,
Close reduction and immobilization
swelling, ecchymosis, laceration and cut Open reduction and rigid fixation
wounds
-- Palpation for tenderness, pain, step Definitive Treatment
deformity and malfunction.
Intra- and paraoral Objective
-- bleeding, hematoma, gingival tear, Restoration of functional alignment of the bone
gagging of occlusion and step deformity fragments in anatomically precise position
and sensory and motor deficiency utilizing the present teeth for guidance.
3. Radiographs (Figs 12.3 to 12.5 and 12.7 to

Reduction and Fixation of the Jaw (Fig. 12.2)
12.10)
Plain radiograph Close reduction and IMF (traditional method
by means of manipulation).
-- OPG

Fig. 12.1: Showing intraoperative symphysis Fig. 12.2: Showing intraoperative symphysis
fracture exposure fracture plating

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Chapter 12: Mandibular Fractures 117

Fig. 12.3: Radiographic image of symphyseal fracture Fig. 12.4: Radiographic image of symphyseal
fracture with lingually displaced fracture

Fig. 12.5: PA skull showing bilateral Fig. 12.6: Clinical appearance of displaced
parasymphyseal fracture symphyseal fracture

Open reduction and semi-rigid fixation (using Cap splints


interossous wirings). IMF prior to rigid fixation
Open reduction and rigid fixation (using bone Bonded brackets
palates osteosynthesis).
IMF screws
Close Reduction Dental wiring:
Arch bars Direct wiring
Jelenko Eyelet wiring
Erich pattern Minimal displacement
German silver notched IMF for 6 weeks.

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118 Section 2: Examination of Maxillofacial Trauma Patient

Fig. 12.7: 3D CT showing parasymphyseal fracture Fig. 12.8: 3D CT showing parasymphyseal


(oblique view) fracture (frontal view)

Fig. 12.9: 3D CT showing parasymphyseal fracture Fig. 12.10: 3D CT showing parasymphyseal fracture
(basal view) (lateral view)

Fig. 12.11: OPG showing parasymphyseal Fig. 12.12: Clinical photograph of closed
fracture eduction

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Chapter 12: Mandibular Fractures 119

A B
Figs 12.13A and B: intraoperative symphyseal fracture exposure and fixation with 3D plate

Open Reduction and Fixation Relative Indications


Surgical approaches to the mandible Functional tooth that would be removed
Intraoral approach Advanced caries or periodontal diseases
Doubtful tooth which would be added to
a. Symphysis and parasymphysis region existing denture.
degloving incision Tooth in untreated fracture presenting more
b. Body, angle, ramus region transbuccal than 3 days after injury.
incision
Extraoral approach Management of Teeth
Submandibular Risdons incision Retained in Fracture Line
Postramal Hinds incision Good quality intraoral periapical radiograph
Intraosseous or transosseous wiring (Fig. 12.14)
Compression plates
Insinuation of appropriate systemic antibiotic
Mini plates
therapy
Lag screws.
Splinting of tooth if mobile
Teeth in the Fracture Line Endodontic therapy if pulp is exposed
Immediate extraction if fracture becomes
The fracture is compound into the mouth.
infected
The tooth may be damaged or lose its blood
supply. Follow up for 1 year and endodontic therapy if
The tooth may be affected by some preexisting there is a loss of vitality.
pathology.
Edentulous Body Fracture
Absolute Indications Bucket handle type of fracture
Longitudinal fracture Management of edentulous body fractures
Dislocation or subluxation from socket Gunning splint
Presence of periapical infection Old modality
Infected fracture line Rigid fixation is not possible
Acute pericoronitis. To establish the occlusion.

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120 Section 2: Examination of Maxillofacial Trauma Patient
Open reduction and fixation is usually not
necessary
Plating at the inferior border
Resorbable plates
Cap splints:
Open cap splints
Close cap splints.

Complications of Open Reduction and


Direct Fixation During Mandibular Fracture
Management
During primary treatment:
Infection
Fig. 12.14: Radiograph showing fracture line passing Damage to inferior alveolar, mental and
in the region of impacted tooth sometimes facial nerve.
Gingival and periodontal complications.
Fracture Mandible in Children Late complications
Malunion
Conservative therapy
Delayed union
Close reduction
Nonunion.

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Condylar Fractures
13
INTRODUCTION In adults, motor vehicle accidents account
for the majority of condylar fractures, while
Condylar injuries deserve special consideration
interpersonal violence, work-related incidents,
apart from those of the rest of the mandible
sporting accidents and falls play significant but
due to their anatomic differences, variations in
lesser roles.
clinical picture, unique management protocols
In children, falls and bicycle accidents are the
and distinct healing potential. The management
major causes, with motor vehicle accidents
of mandibular condylar injuries is one of the
also contributing significantly.
most controversial areas in the treatment of facial
Different still are in elderly, falls again
trauma. Fractures involving the mandibular
constitute the primary etiologic factor, followed
condyle are the only facial bone fractures which
by assaults and automobile accidents.
involve a synovial joint. Severe displcement
Other less obvious causes of injury to the
of fractured condyle can cause malocclusion.
temporomandibular joint (TMJ) include
abnormal mouth opening; and impaired function.
orotracheal intubation, whiplash injury,
childbirth and weight lifting.
Condyle 29.1%
Angle 24.5%
CLASSIFICATIONS
Symphyseal and parasymphyseal 22%
Wassmund (1934) described five types of condylar
Body 16%
fractures:
Dentoalveolar 3.1% Type I: Fracture of the neck of the condyle
Ramus 1.7% with relatively slight displacement of
Coronoid 1.3% the head.
Type II: Fractures which produce an angle of 45
to 90 degree, resulting in tearing of the
ETIOLOGY OF CONDYLAR INJURIES medial portion of the capsule.
Facial injuries are most commonly associated Type III: The fragments are not in contact, and the
with falls, motor vehicle accidents, sports- head is displaced mesially and forward
related trauma and interpersonal violence. owing to traction of the lateral pterygoid
Injury to the condyle may be caused by a variety muscle. The fragments confined to the
of mechanisms, which also vary according to glenoid fossa. The capsule is torn, and
the characteristics of the group studied. the head is outside the capsule.

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122 Section 2: Examination of Maxillofacial Trauma Patient
Type IV: Fractures where the condylar head Spiessl and Schroll (1972)
articulates in an anterior position to Nondisplaced fracture
the articular eminence. Low-neck fracture with displacement, mostly
Type V: Vertical or oblique fractures through with contact between fragments
the head of the condyle. High-neck fracture with displacement, mostly
without contact between fragments
MacLennan (1952) Classification Low-neck fracture with dislocation
Type I: Nondisplaced fracture. High-neck fracture with dislocation
Intracapsular fracture of condylar head.
Type II: Fracture deviation, where there is
simple angulation of the condylar Injuries of the TMJ other than fractures
process to the major fragment (e.g. Contusion
greenstick fracture). Effusion and Hemarthrosis
Type III: Fracture displacement, where there is TMJ Sprain
simple overlap of the condylar process Subluxation
and major mandibular fragments. Dislocation
Type IV: Fracture dislocation, where the head
of the condyle is completely disrupted DIAGNOSIS OF CONDYLAR INJURIES
from the articular fossa.
Diagnosis is based on a suggestive history, deter-
Lindahl in 1977 mination of the direction of force, clinical signs
and symptoms and radiographic visualization of
Proposed a classification based on radiographic the joint and subcondylar region.
views in two planes at right angles to each other.
He took into consideration three major aspects.
CLINICAL FEATURES
They are the anatomic location of the fracture,
relationship of condylar fragment to mandible An overall evaluation of the patient with
and relationship of condylar head to the glenoid traumatic injury should precede evaluation of the
fossa. maxillofacial region. Numerous symptoms point
Anatomic location of the fracture generally to traumatic damage in the joint region.
They include pain, tenderness and swelling in
Condylar head
the joint region, limitation of mouth opening and
Condylar neck malocclusion. Supplementing these suggestive
Subcondylar symptoms, different fracture types provide
Relationship of condylar fragment to mandible characteristic symptoms.
Nondisplaced Unilateral malocclusion
Deviated Premature tooth contact
Displacement with medial or lateral overlap Contralateral open bite
Displacement with anterior or posterior Deviation of midline to side of injury
overlap Swelling over the preauricular region
Restricted mouth opening
No contact between fractured segments
Bleeding from the ear
Relationship of condylar head to fossa Mandibular mid line shifted to the affected
Nondisplaced side
Displacement Ecchymosis over the mastoid occasionally
Dislocation [Battles sign].

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Chapter 13: Condylar Fractures 123

A B

Figs 13.1A and B: Occlusion in unilateral condylar injuries

Unilateral condylar fracture (Fig. 13.1) Goals


Deviation to the ipsilateral side Stable occlusion
Gagging of occlusion on ipsilateral molar teeth Restoration of interincisal opening
Painful limitation of protrusion and laterl excursion to Full range of mandibular excursive movements
the opposite side Minimize deviation
Relief from pain
Bilateral condylar fracture Avoid internal derangement of the TMJ
Undisplaced and intracapsular fractureocclusion not Avoid growth disturbance
disturbed
Displaced fractureanterior open bite
Pain and limitation of opening, protrusion and lateral
CONSERVATIVE AND FUNCTIONAL
excursion MANAGEMENT
Objective is either to allow bony union
RADIOGRAPHY (FIGS 13.2 TO 13.5) to occur where there is no significant
displacement of the condyle or in the case of
Conventional radiography fracture dislocation, to produce an acceptable
Orthopantomogram (OPG) functional pseudoarthrosis by re-education of
Lateral oblique view of mandible the neuromuscular pathways
Posteroanterior (PA) view of mandible The aims of conservative and functional treatment
Reverse Townes view are to encourage active movement of the jaw as
Transcranial views for TMJ early as possible provided that the patient can
CT scan bring his or her teeth into normal occlusion.
Magnetic resonance imaging (MRI). Excessive pain or persistent malocclusion will
require periods of intermaxillary fixation. Such
MANAGEMENT GOALS a period of fixation should not exceed 10 days if
The objective of the maxillofacial surgeon treating there is a risk of ankylosis. In the case of children
condylar fractures is primarily directed towards one must be aware of the remarkable remodelling
functional rehabilitation. capacity of the condyle which may persist.

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124 Section 2: Examination of Maxillofacial Trauma Patient

Fig. 13.2: Orthopantomogram (OPG) showing Fig. 13.3: Orthopantomogram (OPG) showing condylar
trapezoidal plate in place after condylar fracture fixation and parasymphysial fracture (fixed with mini plates)

B
Fig. 13.4: Radiographic image of mideally Figs 13.5A and B: Illustrating closed reduction treat-
displaced condyle ment given for a case of right subcondylar fracture (A)
Preoperative, (B) Postoperative

CLOSED REDUCTION (FIGS 13.5A AND B) removed and the patient is followed by functional
movements with elastics applied in the anterior
Placement of archbars or splints, immobilizing
region.
the jaws for 24 weeks has been the mainstay of
therapy for many decades.
Displaced fractures of the neck of the condyle, OPEN REDUCTION (FIGS 13.6 TO 13.11)
the joint must be relieved of stress by opening In open reduction, the objective is to perform a
the occlusion by 23 mm with an acrylic block in repositioning of the fractured condyle as near
the distal molar region in the side of the fracture. to its anatomical location as possible. This is
This therapy is known as extension by means of achieved by exposing the condylar fragment,
a fulcrum. The height of the fulcrum depends reducing it to a normal relationship with the
on the radiographically determined degree of mandibular fragment and then fixing it in that
ramus shortening. After 8 days, the fixation is position

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Chapter 13: Condylar Fractures 125

Fig. 13.7: Intraoperative incision marking

Fig. 13.8: Intraoperative incision

Figs 13.6A to C: Illustration of open reduction for a


case of right subcondylar fracture. (A) Preoperative,
(B) Intraoperative, (C) Postoperative

Surgical access in cases of fracture dislocations


tends to be difficult with a real risk to branches
of 7th cranial nerve and the maxillary artery.

Indications
Zide and Kent (1983) divided indications for open
reduction of a condylar fracture into absolute and
relative. Fig. 13.9: Intraoperative exposure of fracture line

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126 Section 2: Examination of Maxillofacial Trauma Patient

Fig. 13.10: Intraoperative fixation of fracture with Fig. 13.11: Traphezoidal plate fixed to condylar
traphezoidal plate stump

The absolute indications Various surgical approaches


Displacement of the condyle into the middle cranial Preauricular
fossa
Horizontal incision over the zygomatic arch
Inability to achieve occlusion with a closed reduction
Endaural
Lateral fracture-dislocation of the condyle and
Retroauricular
Invasion of the joint space with a foreign body
Submandibular
Retromandibular
Relative indications for open reduction
Intraoral
Bilateral condylar fractures where establishing vertical
facial height is important Rhytidectomy
Associated injuries that dictate early immediate Endoscopy
function
Associated medical conditions that indicate an open The advantages of all extraoral approaches are
reduction is preferable to maxillomandibular fixation
that a fracture is visualized and approached
and
more directly than from an intraoral approach.
Conditions in which treatment has been delayed and
early healing in a malaligned position has commenced
Each of the different approaches is designed to
prevent or minimize injury to the branches of
the facial nerve. The major disadvantages of
Surgical Approaches all extraoral approaches are visible scars and
The selection of surgical approach for open possible injury to the branches of the facial
reduction depends on a variety of factors, nerve
which include the level at which the fracture It is claimed that the intraoral technique
has occurred, the degree of displacement or obviates the known complications of external
dislocation and the planned method of fixation. open reduction such as the possibility of
Other factors are the quest for optimal access facial nerve injury, external scar, ischemic
for visualization and instrumentation, esthetic compromise to the proximal segment and
factors like scarring, minimizing injury to vital undoubted technical facilities. The main
structures like nerves, blood vessels and ducts disadvantage of this approach is that exposure
of salivary glands of the condylar segment is limited.

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Chapter 13: Condylar Fractures 127

Methods of Immobilization of the Condyle Treatment should be entirely functional where


Once the proximal segment is visualized and possible
the fracture reduced, the fragments can be Indirect immobilization by intermaxillary
immobilised in a number of ways. fixation is indicated for control of pain and
should be released after 710 days
Methods of immobilization of the condyle Where an intracapsular fracture has been
Simple soft tissue repair without fixation diagnosed careful follow-up and monitoring of
Transosseous wiring growth is required.
Bone pins
Adolescents
Glenoid fossa-condyle suture
Kirschner wire Ten to seventeen years of age
Intramedullary screws
Malocclusion is an indication for intermaxillary
Bone plating
fixation for 23 weeks. The dentition at this
stage is suitable for application of simple eyelet
Three useful plating techniques are described: wires.
i. Extraoral approach through the preauric-
ular route Adults
ii. Intraoral approach Unilateral intracapsular fractures: The occlusion
iii. OsteotomyExtracorporeal reduction is usually undisturbed and the fracture should be
technique through a submandibular inci- treated conservatively without immobilization of
sion. the mandible.

Specific Treatment of Condylar Fractures Unilateral condylar neck fractures


If the fracture is undisplaced the occlusion
The following factors should be considered will generally be undisturbed and no active
The age of the patient whether under 10 years of age, treatment is necessary
1017 years of age, adults A fracture dislocation will often induce
Whether the fracture is intracapsular or extracapsular significant malocclusion due to shortening of
(low condylar neck or high condylar neck)
ramus height and premature contact of molar
Site, whether unilateral or bilateral
teeth on that side
Whether the occlusion is undisturbed or whether there
is malocclusion
A low condylar neck fracture is probably
best treated by open reduction in these
Children under 10 Years of Age circumstances
This group has been shown to be more likely In the case of a high condylar neck fracture
with extensive displacement and malocclusion,
to develop growth disturbance or limitation of
intermaxillary fixation is applied and maintained
movement than other groups
until stable bony union has occurred, i.e. 34
If malocclusion is present entirely as a result
weeks.
of condylar injury it should be disregarded
because spontaneous correction will take Bilateral intracapsular fractures: The occlusion
place as the dentition develops is usually slightly damaged in these cases. The
Displaced condylar neck fractures will undergo degree of displacement of the two condyles may
functional restitution in most cases not be the same and it is best to immobilize the
Unilateral and bilateral fractures are treated mandible for the 34 weeks required for stable
the same union.

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128 Section 2: Examination of Maxillofacial Trauma Patient
Bilateral condylar neck fractures: These fractures followed by active functional therapy is indicated
present the major problem in treatment. There for most cases. Surgical management has
is usually considerable displacement of one specific indications, and can be accomplished
side and/or the other. Even if displacement is through a wide variety of techniques. In general,
not evident when first seen, the fractures are complications are not common following
inherently unstable and functional treatment is condylar trauma. Important among the possible
contraindicated. complications are ankylosis, growth disturbances
and internal derangement.
COMPLICATIONS
Complications that occur concurrent with SOME MORE CASES (FIGS 13.12 TO 13.15)
or early after treatment of condylar fractures
include the following:

Early complications
Fracture of the tympanic plate and middle ear
injury
Fracture of the glenoid fossa
Damage to cranial nerves
Vascular injury

The late complications of condylar injury


commonly include the following:

Late complications
Malocclusion
Growth alteration
Temporomandibular joint dysfunction (Internal Fig. 13.12: Preauricular incision for condylar exposure
derangement)
Ankylosis

CONCLUSION
Fractures of the mandibular condyle constitute
a significant portion of mandibular fractures.
A number of clinical signs and symptoms
are characteristic of injury to the condylar
apparatus. The use of plain radiographs in
multiple view, or CT scans discloses most
condylar fractures and displacements, if any. A
number of classification systems are available
to help in treatment planning and record
keeping.
Nonsurgical treatment is adequate for a majority Fig. 13.13: Exposure and fixation of condyl with help
of condylar fractures. A period of immobilization of two hole miniplate

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Chapter 13: Condylar Fractures 129

Fig. 13.14: Postopertive closure of preauricular incision

A B
Figs 13.15A and B: Pre- and postoperative radiograph after miniplate fixation

Ch-13.indd 129 15-04-2013 10:16:51


Cerebrospinal
Fluid Rhinorrhea
14
INTRODUCTION Nutrition
Removal of metabolic wastes.
Cerebrospinal fluid (CSF): Third circulation
Clear fluid bathing the cerebral hemispheres, Historical Perspective
cerebellum and layers of meninges that is
First reported in the 17th century
produced on a daily basis in the ventriculocisternal
Dandy in 20th century, reported first successful
portion of the nervous system, It is essentially an
repair utilizing a bifrontal craniotomy for
ultrafiltrate of plasma. It is 510% of intracranial
placement of a fascia lata graft
volume. Approximate amount 50160 mL, it
Extracranial approaches introduced mid-20th
forms at the rate of 2022 mL/hr or 500 mL/day
century
and renewed three times a day, mostly made in
Endoscopic approaches were introduced and
choroid plexus traverses, ventricles, convexities,
popularized in the 1980s and early 1990s.
uptaken by arachnoid villi, normal pressure
between 50180 mm H2O, but pressure is maintain Objectives
by relative balance between CSF secretion and
Understand the classification system for
CSF resorption, it surrounds and cushions
various causes of CSF rhinorrhea
brain, pathologic communication with outside
Understand the pathophysiology and diagnosis
world can lead to problem. The CSF circulates
of CSF rhinorrhea
from ventricles through foramina Luschka and
Review diagnostic testing techniques (chemical
Magendie to subarachnouid space.
markers and CSF tracers) as well as localization
studies
DEFINITION Review both medical and surgical strategies in
Cerebrospinal fluid (CSF) rhinorrhea results from a treatment of CSF rhinorrhea.
direct communication between the CSF-containing
subarachnoid space and the mucosalized space of CLASSIFICATION OF CSF RHINORRHEA
the paranasal sinuses.
Main site of formation: Choroid plexus around Based on established pathophysiology of CSF
the lateral ventricles. rhinorrhea
This has important clinical implications for the
Functions selection of treatment strategies and patient
Water Cushion counseling about prognosis
Protection Initial schemestraumatic leaks and nontrau-
Buoyancy matic leaks

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Chapter 14: Cerebrospinal Fluid Rhinorrhea 131
Accidental traumaEighty percent of all CSF CSF pressure maintained by relative balance
rhinorrhea between CSF secretion (choroid plexus) and
Non-traumaticFour percent of all CSF CSF resorption (arachnoid villi)
rhinorrhea CSF resorption rate plays major role in
Procedure-relatedSixteen percent of all CSF determining CSF pressure
rhinorrhea. CSF rhinorrhea requires disruption of
barriers that normally separate the contents
Traumatic of the subarachnoid space from the nose and
Accidental paranasal sinuses
Immediate Pressure gradient is also required to produce
Delayed flow of CSF.
Surgical
Complication of neurosurgical procedures Conditions with elevated intracranial pressure
i. Transsphenoidal hypophysectomy and associated CSF rhinorrhea
ii. Frontal craniotomy Nontraumatic CSF rhinorrhea
iii. Other skull-base procedures Benign intracranial hypertension (BIH)
Complication of rhinologic procedures Empty sella syndrome (ESS).
i. Sinus surgery
ii. Septoplasty DIFFERENTIAL DIAGNOSIS
iii. Other combined skull base procedures. CSF otorrhea presents as CSF rhinorrhea
Sinonasal saline irrigations
Nontraumatic
Seasonal and perennial allergic rhinitis
Elevated intracranial pressure Vasomotor rhinitis.
Intracranial neoplasm
Hydrocephalus Clinical Presentation (Fig. 14.1)
i. Noncommunicating Unilateral watery nasal discharge
ii. Obstructive Salty taste
Benign intracranial hypertension Positional variation
Normal intracranial pressure History trauma or surgery
Congenital anomaly Weight loss
Skull-base neoplasm Presence of inflammatory paranasal sinus
i. Nasopharyngeal carcinoma disease
ii. Sinonasal malignancy Headache
Skull-base erosive process History of single or multiple episodes bacterial
i. Sinus mucocele and osteomyelitis meningitis.
Idiopathic.
Physical Examination (Fig. 14.2)
Pathophysiology
Position testing
CSF produced by choroid plexus (20 mL/hr) Halo sign
CSF circulates from ventricles through foramina Glistening moist nasal mucosa on side of CSF
Luschka and Magendie to subarachnoid space leak
Total CSF volume is 140 mL = 20 mL (ventricles) Clear fluid stream
+ 50 mL (intracranial subarachnoid space) Papilledema
+70mL (paraspinal subarachnoid space) Abducens nerve palsy
CSF pressure ranges 40 mm H2O (infants) - Traumatic CSF rhinorrhea and physical stigmata
140 mm H2O (adults) of recent or distant maxillofacial trauma.

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132 Section 2: Examination of Maxillofacial Trauma Patient

Fig. 14.2: Diagrammatic presentation of classical


Fig. 14.1: CSF rhinorrhea in midfacial trauma case halo sign

Diagnostic Testing CSF Tracers


Two types of testing Visible dyes (Intrathecal fluorescin).
1. Identification substance serves as marker CSF. Radionuclide markers (Radioactive iodine
2. Agent administration that documents commu- (131I) serum albumen (RISA), technetium
nication (intradural and extradural space). (99Tc)-labeled serum albumin and diethylene
triamterine penta acetic acid (DTPA), and
Chemical Markers Indium (111In)-labeled DTPA).
GlucoseThe CSF has glucose concentration Radiopaque dyes (metrizamide).
equal to or greater than half the glucose Chemical markers CSF tracers
concentration of the serum5890 mg/100 mL
Glucose Visible dyes
Beta-2 transferrinA specific iron binding
protein found only in CSF, aqueous humor and Beta-2 transferrin Radionuclide markers
perilymph. It is a sensitive and specific method Radiopaque dyes
of detecting presence of CSF. It is not found in
blood, mucus and tears, thus, making it specific Localization Studies
marker of CSF at the time of maxillofacial injury Radionuclide cisternography
where this materials are inhibitor to provide Poor spatial resolution.
CSF leak diagnosis clinically. Beta 2 transferrin MR cisternography
is an isolated form. Long scan acquisition times required that
produce thick image slices that cannot
Method of testing-
identify small skull-base defects.
Sample requirement 0.5 mL of body fluid CT cisternography (Metrizamide)
Plain tubes no additive Difficult to reliably interpret, even with
Transport at room temperature slices of 1 mm.
If delayed more than 2 hours send at 4C All above studies assume presence active CSF
An additonal 1 mL serum is recommended if flow (intermittent or very small leaks may not
patient is suspected of alcohol intoxication. be identified)

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Chapter 14: Cerebrospinal Fluid Rhinorrhea 133
Nasal endoscopy after intrathecal fluorescin Graft material:
infusion. Temporalis fascia, fascia lata, muscle plugs,
pedicled middle turbinate flaps (mucosa
MANAGEMENT alone or mucosa and bone), autogenous fat,
free cartilage grafts (from the nasal septum
Multidisciplinary Approach or the cartilaginous auricle), and free bone
Maxillofacial surgeon grafts (from the nasal septum or calvarium)
Otolaryngologist Acellular dermal allograft
Neurosurgeon. Higher failure with pedicled intranasal
grafts versus free grafts
Conservative Treatment of CSF Rhinorrhea Underlay technique
Subarachnoid drainage through a lumbar Larger defects require layered reconstruc-
catheter tion less risk of delayed recurrence and
Strict bed rest meningoencephalocele formation
Head elevation Never place mucosal grafts intracranially
Stool softeners (intracranial mucocele after repair can
Patient advised to avoid coughing, sneezing, occur)
nose blowing, and straining. Surgical sealant (fibrin glue) may be used
to help hold the grafts in place
Transcranial Techniques Absorbable nasal packing is placed
After craniotomy, defect site identified, and adjacent to the grafts, and nonabsorbable
tissue graft placed to close the defect. packing used to support absorbable
Materials used: Fascia lata grafts, muscle plugs, packing.
and pedicled galeal flaps may be used. Pure endoscopic approaches provide excellent
A tissue sealant, such as fibrin glue, may be access to the ethmoid roof, cribriform plate, and
used to hold the grafts into position. most of the sphenoid sinus.
Access to the cribriform plate region and roof Lateral sphenoid leaks may require an extended
of the ethmoid requires a frontal craniotomy. approach, which incorporates endoscopic
Extended craniotomy and skull-base tech- dissection of the medial pterygomaxillary space.
niques with even greater brain compression Osteoplastic flap or a simple trephine might
provide access to the sphenoid sinus defects. be required for repair of defects through the
Potential morbidities include brain compres- posterior table of the frontal sinus.
sion, hematoma, seizures, and anosmia. Postoperative care includes:
High failure rates (25%) despite direct access.
Strict bed rest for several days and antistaphy-
lococcal antibiotics
Extracranial Techniques
Observation in ICU for first 24 hours
Endoscopic repair of CSF rhinorrhea provides Continue lumbar drain for 45 days
adequate visualization of defect.
Nasal packing removed after several days
Intrathecal fluorescin facilitates defect
identification. Operative site may be checked through serial
nasal endoscopy
Prepare defect site for grafting.
Mucosa within 5 mm of the margins of the Patients advised to avoid strenuous activity,
skull-base defect must be removed to facilitate sneezing, coughing for 6 weeks after repair.
mucosal grafting. Primary cases successful repair: 8590%

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134 Section 2: Examination of Maxillofacial Trauma Patient
Secondary endoscopic repair also has high Significant delay between time of surgery and
likelihood of success. CSF leak diagnosis-conservative measures
Endoscopic techniques offer several advantages. less successful, and early surgical intervention
Excellent visualization afforded by nasal warranted.
endoscopy facilitates identification of the defect
and graft placement. Nontraumatic Leaks
Endoscopic repair is also well-tolerated, Usually require surgical repair
especially compared with intracranial techniques. Can attempt conservative measures
Report outcomes are excellent for both primary Treat underlying etiology along with CSF
and secondary endoscopic repairs. rhinorrhea (neoplasm, hydrocephalus, etc.)
Always consider unrecognized elevation of ICP
Management Strategy (ESS or BIH) in cases of spontaneous CSF leaks
Indications Operative repair in ESS and BIH usually
Failed conservative management necessary.
Intraoperative recognition of a leak (during sinus
surgery, skull-base surgery, and craniotomy) CSF Fistula
Large defects/leaks (especially in association Fracture skull, dural, arachnoid tear
with pneumocephalus) Risk of meningitis and even the death
Idiopathic leaks (spontaneous leaks) Spontaneous cessation in 66% by 10th day
Open traumatic head wounds with CSF leakage. High index of suspicion of rhinorrhea,
otorrhea, pneumocephalusX-ray skull, CT
Traumatic (Nonsurgical) Etiology scan, MRI brain to rule out site of fistula.
Complications of CSF rhinorrhea:
Conservative measures (reduces ICP and
promotes spontaneous closure) Meningitis
Persistent rhinorrhea-explore and repair Tension pneumocephalous
Extracranial endoscopic techniques and open
transcranial procedures (massive head injury CONCLUSION
requiring urgent operative exploration) might 1. Categorize leaks
be warranted. 2. Beta-transferrin assay and several CSF tracer
studies available, but have limitations
Intraoperative Injury with Immediate 3. High-resolution CT provides detailed informa-
Recognition tion about the bony skull-base anatomy
The CSF leaks noted intraoperatively should 4. MRI assesses soft tissue issues, including
be repaired immediately during functional unrecognized tumors and coincidental
endoscopic sinus surgery (FESS) meningoencephaloceles
Intracranial and skull-base procedures include 5. Many CSF leaks respond to conservative
deliberate violations of the dura; provide a management (observation plus measures to
watertight seal at the end of the procedure. minimize ICP)
6. Traumatic CSF rhinorrhea tends to resolve
Operative Injury with Delayed Recognition with conservative measures alone
Conservative therapy for a few days warranted 7. Nontraumatic CSF rhinorrhea require opera-
since some leaks will close tive repair
Can pursue operative intervention for massive 8. Extracranial techniques are first line for CSF
leaks early rhinorrhea.

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Maxillofacial Trauma:
Case Presentation
15
CASE NUMBER 1 Personal History
A 20-year-male patient complains of headache, Sleep normal, bowel and bladder habits normal
inability to close his teeth and pain in front of ear No history of substance abuse.
on right side since 1 day.
Clinical Examination
History of Presenting Illness Systemic Examination
Gives history of fall from bike while driving Patient conscious, cooperative
yesterday near Someshwara and sustained Pupils bilateral equal in size and reacting to light.
injuries and contusion over lower jaw region
Patient was conscious whole time and gives Vitals
no history of any vomiting or ENT bleeding BP132/82 mm Hg
following accident Pulse74 b/min, regular
Gives history of bleeding from chin laceration RR22 cycles/min.
and mouth CNS
Patient was drowsy and was taken to nearby
Cranial nervesnormal
hospital where primary treatment was given. GCS15/15; E4,M6,V5
Patient had one episode of seizure and 3 Pupilsbilateral equal and reactive
episodes of vomiting following which CT scan No motor or neurosensory deficit noted
of head was done which showed cerebral No cerebellar signs noted
edema along with fracture of mandible at CVSS1 and S2 heard
parasymphysis region on left side and condyle RSbilateral equal air entry
on right side Per abdomenNAD.
Patient got discharge and came to hospital.
Head and Neck Examination
Past Medical History Face
No history of hypertension, diabetes mellitus, Facial asymmetry noted, chin deviated to left
epilepsy, asthma. side, and mild edema noted over right pre-
auricular area
Drug History A single laceration of about 2/0.5 cm size
Patient not on any medication, and does not give present over chin area not involving deep
history of allergy to any drug. muscles (Fig. 15.1)

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136 Section 2: Examination of Maxillofacial Trauma Patient

Fig. 15.1: Chin soft tissue injury Fig. 15.2: Intraoral soft tissue injuries and disturbed
occlusion

On palpation lower border continuity present CASE NUMBER 2


in left premolar region with a distinct step
A 24-year male patient with alleged RTA following
palpable
which he sustained injury to the face:
Bony crepitus felt over right TMJ area, condyle
could not be palpated on right side, tenderness Patient was pillion rider and was under the
present over right preauricular area. influence of alcohol
Ellis class 3 fracture of 11 and 21
Eyes Overriding of fracture segments noted
No abnormality detected. Ecchymosis present in left vestibule involving
lower lip mucosa on left side (Fig. 15.3).
Nose
No abnormality detected. Radiographic Findings
OPG suggestive of displaced condylar head
Ears fracture on right side and left body fracture
No abnormality detected. (Fig. 15.4)
No history of loss of consciousness
Inspection
History of giddiness for 24 minutes
Mouth opening restricted 25 mm
Deviation present on mouth opening towards No history of vomiting/seizures
right side. History of bleeding from both ears
Unable to open the jaw and bite properly
Palpation Medical history: No relevant history.
Tenderness severe in nature on right preauricular
region. General Examination
Conscious and oriented
Intraoral GCS 15/15
Deranged occlusion Vitals BP 140/100 mm Hg
Arch form disrupted between 34 and 35 with Pulse 78/min
displacement of anterior arch segment lingually Respiratory rate 24/min
(Fig. 15.2). CVS NAD

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Chapter 15: Maxillofacial Trauma: Case Presentation 137
CNS NAD Posterior open bite present
RS NAD Sublingual ecchymosis present (Fig. 15.3).
Local examination Palpation
Inspection E/O: Depression present in right condylar fossa
E/O Bony crepitation present
On examination facial asymmetry with swelling TMJ tenderness present
on right side of the face, bleeding from both ears I/O: No dentoalveolar fracture
(Fig. 15.5) No step deformity present
Difficulty in opening the mouth deviation of
jaw to right side (Fig. 15.6) Investigations
I/O PA Cephalometric (Open Mouth)
Deranged occlusion (Fig. 15.7) Medially displaced right condylar fracture (Fig. 15.8).

Fig. 15.3: Intraoral photograph showing mild Fig. 15.4: OPG showing fracture: Right condyl and
sublingual ecchymosis left parasymphysis

Fig. 15.5: Swelling of right side of face Fig. 15.6: Reduced mouth opening

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138 Section 2: Examination of Maxillofacial Trauma Patient

Fig. 15.7: Preoperative stabilization Fig. 15.8: PA skull showing medially displaced condyle

Fig. 15.9: OPG showing right parasymphysis and


condylar fracture Fig. 15.10: CT showing medially displaced condyl

OPG Diagnosis
OPG shows subcondylar fracture on right side Right subcondylar fracture.
and incomplete parasymphysis fracture on right
side (Fig. 15.9).
Treatment
CT Scan (Fig. 15.10) Open reduction internal fixation through subm-
Medially displaced right subcondylar fracture. andibular approach (Figs 15.11 and 15.12).

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Chapter 15: Maxillofacial Trauma: Case Presentation 139

A B

Figs 15.11A and B: (A) Intraoperative open reduction; (B) Intraoperative after closure

Fig. 15.12: Postoperative occlusion Fig. 15.13: Extraoral photograph

CASE NUMBER 3 Medical History


A 20 years female patient complains of pain over No relevant history.
the right side of the face while opening the mouth
since 1 week. Extraoral Examination (Fig. 15.13)
History of trauma to the symphysis region FaceAsymmetry was noted due to the
1week back-fall from the table swelling on the right side of face
Patient was unconsciousness for 15 minutes Nose, eyesNormal
following the trauma LipCompetent and laceration was noted on
History of giddiness for 24 minutes the lower lip
No history of vomiting/seizures Lymph nodesBilateral submandibular lymph
History of bleeding from both ears nodes were palpable.
Unable to open the jaw and bite properly. One in number

Ch-15.indd 139 15-04-2013 10:23:34


140 Section 2: Examination of Maxillofacial Trauma Patient
Nontender TMJ tenderness present.
Soft-in consistency Muscles of mastication was tender on palpation.
Mouth opening was reduced. I/O: Ellis class II facture of 11.
Ellis class I fracture of 21.
Local Examination Ellis class III fracture of 22.
Inspection
E/O: Facial asymmetry present Radiographs
Swelling on right side of face Diagnosis
Trismus present Bilateral subcondylar fracture (Fig. 15.15).
Deviation of jaw to right side
A 4 cm laceration which had been sutured was Treatment Given
seen over skin. Erich arch bar placement for maxillary and
I/O: Deranged occlusion (Fig. 15.14) mandibular arch (Fig. 15.16).
Posterior open bite present. Small piece of impression compound was
placed between the right occlusal surface of the
Palpation molar and premolar, red elastics was placed. After
E/O: Depression present in right condylar fossa. 12 hours, the impression compound was removed
and occlusion was achieved (Fig. 15.17).
Bony crepitation present.

Fig. 15.15: OPG shows bilateral subcondylar fracture


Radiolucent line running through left subcondylar region
Fig. 15.14: Preoperative occlusion and the fractured segment is displaced on the right side

Fig. 15.16: Postoperative photograph Fig. 15.17: Postoperative radiograph following


conservative management

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Chapter 15: Maxillofacial Trauma: Case Presentation 141

Fig. 15.19: Intraoral photograph showing sublingual


Fig. 15.18: Extraoral photographs ecchymosis

CASE NUMBER 4 of the nose, 1.5 cm over the right philtrum


region and over the skin of right zygomatic
A 25-year-male patient complains of laceration and
region (Fig 15.18)
abrasion of the face and inability to open the mouth
and bleeding from the oral cavity (Fig. 15.18). Laceration about 2.5 cm present at right side
angle of the mouth on the lower lip (Fig. 15.19)
History of Presenting Illness A 3.5 cm laceration present over the skin over
Patient complains of alleged RTA and sustained submental region with active bleeding
injury to the face and the lower jaw Slight edema noticed over the lower half of the
No history of loss of consciousness, vomiting, face.
seizures, bleed from the nose
History of alcohol intoxication Palpation
Patient was conscious, well-oriented to time place Step deformity present bilaterally in the left
Medical historyNothing significant and right parasymphysis region
Drug allergyNo history of drug allergy. No palpable step noticed in the maxilla,
zygomatic complex region.
General Physical Examination
GCS 15/15
Intraoral Examination
VITALS Inspection
BP 150/90 mm Hg Trismus present
Pulse 88/min Mouth opening decreased to 1
CVS, CNS, RS NAD Tenderness while opening the mouth
Pupils bilaterally reacting to light Occlusion was deranged
Extraocular muscles NAD Sublingual ecchymosis present
Totally avulsed tooth interim restorative treatment
Extraoral Examination (IRT) 33 and partially avulsed tooth IRT 43.
Inspection Palpation
Abrasion 2.5 cm 2.5 cm present over the right Step deformity in the right and left parasymphysis
forehead region, 2.5 cm 1.5 cm over the bridge region at the region of 33 and 43.

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142 Section 2: Examination of Maxillofacial Trauma Patient

A B

Figs 15.20A and B: Both the left and right lateral oblique views did not show any signs of condylar fracture

Provisional Diagnosis
Bilateral fracture of parasymphysis region
Bilateral subcondylar fractureNo (Figs 15.20A
and B).

Investigations
Diagnosis
Bilateral parasymphysis fracture at the region of
23 and 32 (Fig. 15.21)

Treatment Plan
Intermaxillary fixation using Erichs arch bar
Open reduction and internal fixation.
Intraoperative (Figs 15.22 and 15.23)
Skin prepared with povidone iodine Fig. 15.21: PA skull X-ray shows radiolucent lines
Extraoral submandibular incision placed, running bilaterally at the parasymphysis region
incision extended over the lacerated wound
Bilaterally fracture site identified and fracture
site reduced after securing IMF intraorally Dynaplast pressure dressing placed.
Two 4 hole plate with gap placed over the lower
border of mandible. 8 mm screw fixed bilaterally CASE NUMBER 5 (FIGS 15.24 TO 15.27)
Two 2 hole with gap plate fixed above the 4
hole plate and fixed with 6 mm screws Diagnosis
Muscle closed with 3-0 vicryl. Skin closed with Displaced fracture of condylar head fracture on
3-0 Ethilon, subcuticular suture right side and mandibular body on left side.

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Chapter 15: Maxillofacial Trauma: Case Presentation 143

Fig. 15.22: Intraoperative fracture site exposure Fig. 15.23: Intraopertive miniplate fixation

Fig. 15.24: Extraoral photograph Fig. 15.25: PA skull showing fracture parasymphysis
left side, and right condylar head fracture

Fig. 15.27: Postoperative radiograph showing


Fig. 15.26: Intraoperative miniplate fixation traphezoidal plate for condylar fracture

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144 Section 2: Examination of Maxillofacial Trauma Patient

Treatment Plan CASE NUMBER 7 (FIG. 15.30)


Open reduction and internal fixation of right
condylar head fracture with titanium TCP plates
and of left side body with conventional titanium
miniplates.

CASE NUMBER 6 (FIGS 15.28 AND 15.29)


Diagnosis
Malunited coronoid fracture of left side.

Fig. 15.30: OPG showing bicondylar with


parasymphysis fracture

CASE NUMBER 8 (FIGS 15.31 AND 15.32)

Fig. 15.28: OPG showing left coronoid fracture

Fig. 15.31: Intraoperative fracture of


parasymphysis region

Fig. 15.29: Lateral ramal view showing left coronoid Fig. 15.32: Open reduction and fixation with locking
fracture (L) plate and screw

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Chapter 15: Maxillofacial Trauma: Case Presentation 145

CASE NUMBER 9 (FIGS 15.33 TO 15.35) CASE NUMBER 10 (FIGS 15.36 TO 15.38)

Fig. 15.33: Intraoperative fracture of symphysis

Fig. 15.36: Intraoperative showing mandibular


angle fracture

Fig. 15.34: Intraoperative 4 hole locking plate

Fig. 15.37: Intraoperative showing angle fracture reduction


and fixation with 3D mini plate (Curtesy: Dr Muralee)

Fig. 15.35: 4 hole locking plate Fig. 15.38: 3D mini palte

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Ch-15.indd 146 15-04-2013 10:23:37
3
Section
Carcinomas of Oral Cavity
6. Examination of an Ulcer
1
17. Cancer Biology
18. Surgical Treatment Plan for Oral and
Maxillofacial Cancers
19. Management of Neck in Oral and
Maxillofacial Carcinoma
20. Role of Chemotherapy and Radiotherapy in
Oral and Maxillofacial Carcinoma
21. Reconstructive Options in Oral and
Maxillofacial Cancer
22. Clinical Cases of Cancers in Oral Cavity

Ch-16.indd 147 15-04-2013 10:24:50


Ch-16.indd 148 15-04-2013 10:24:50
Examination of an Ulcer
16
INTRODUCTION
An ulcer is a localized defect in the continuity of
an epithelial surface. It is usually associated with
an inflamed base of granulation tissue with or
without necrotic slough.The majority is chronically
inflamed; the slough at their base represents
inadequate drainage. Acutely inflamed ulcers may
have an outer rim of cellulitis. Weak ulcers are
those with low quality granulation tissue and hence
delayed healing; they are usually due to ischemia or
infections such as tuberculosis ulcers.
The incidence and prevalence varies across
the world.

Fig. 16.1: Ulcer on lateral surface of tongue


DEFINITION
An ulcer is a break in the continuity of the covering
epithelium, either skin or mucous membrane due
to molecular death of cells.
What causes oral ulcers? Oral ulcers may have
a great many causes, Although in some no cause
is identified oral ulcers (Fig. 16.1) are termed
acute if they persists for less than three weeks
duration, and chronic if they persists for longer Edge
than three weeks Lies between the floor and the margin.

Different Types of Edges


PARTS OF AN ULCER
Sloping edge
Margin Seen in a healing ulcer
It may be described as area between the edge and Inner part is red due to granulation tissue
the normal surrounding tissue. Middle part is white due to scar/fibrous tissue

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150 Section 3: Carcinomas of Oral Cavity
Outer most part has a bluish tinge due to a thin Bluish unhealthy granulation tissue seen in
layer of epithelial proliferation. tuberculosis ulcers
No granulation tissue is often present in
ischemic ulcersin this case structures such
as tendons may lie bear in the base of the ulcer
Solid brown or gray dead tissue suggests full-
Undermined edge thickness skin death
Characteristic of a tuberculous ulcer. Disease The redness of the granulation tissue is
process advances in a deeper plane (in the proportional to the underlying vascularity
subcutaneous tissue). Also seen in bedsore, of the ulcer site (and therefore of the ulcers
carbuncle, meleneys ulcer, tropical ulcer. ability to heal).

Base
Is the one on which the floor rests. It may be bone,
or soft tissue.

Depth
Punched out edges
Seen in gummatous, trophic ulcer, occurs due Is defined height: in millimeters
to end arteritis with rapid destruction of full Anatomically: which structures are visible.
thickness of the skin.
Relations
It is important to define the relation of the ulcer
with surrounding structures, especially those
deep to it. The examiner must try to ascertain
whether the ulcer is adherent to deep structures.
Raised and beaded edges (with a pearly white
color) Local Lymph Nodes
Is seen in a rodent ulcer (Basal cell carcinoma) Check for
Occurs due to a slow growth of tissue at the Enlargement
edge of the ulcer. Tenderness.

State of the local tissues to be assessed


Local blood supply
Local nerve supply
Everted Edges (Rolled out Edges) For evidence of previously healed ulcers
Seen in carcinomatous ulcer due to excessive
proliferation of malignant cells over the normal
skin. CLASSIFICATION
Floor Clinical
It is the one that is seen. Floor may contain Spreading ulcer: Here the edge is inflamed and
discharge, granulation tissue. edematous
Wash-leather appearance is seen in syphilitic Healing ulcer: Edge is sloping with healthy pink/
ulcers red granulation tissue with serous discharge

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Chapter 16: Examination of an Ulcer 151
Callous ulcer: Floor contains pale, unhealthy Infective Ulcer
granulation tissue. Bacterial (TB, ANUG, syphilis)
Viral (HSV, HZ, CMV, HIV, HHV8, coxsackie),
Pathological
Fungal (histoplasmosis, mucormycosis, cryp-
Specific ulcers tococosis, blastomycosis, candidiasis).
Malignant ulcer
Nonspecific ulcer. Neoplastic Ulcers
Squamous cell carcinoma
HISTORY
Kaposis sarcoma
A detailed history is an essential component of Non-Hodgkins lymphoma
the diagnosis. Malignant melanoma
Mode of onset Malignant salivary gland tumors.
Duration
Pain
Systemic Ulcers
Discharge
Associated disease Mucous membrane pemphigoid
Age of the patient Pemphigus
Erythema multiforme
Protocol for description of the ulcer Lichen planus
Position SLE
Color
Gastrointestinal disorders (Crohns disease,
ulcerative colitis)
Tenderness
Hematological disorders (anemias, neutrope-
Temperature nias, and leukemia)
Shape Radiation-induced necrotic ulcer (Fig. 16.2).
Size
Specific to the ulcer:
Base
Edge
Depth
Discharge
Relationship to other structures
Lymph nodes

DIFFERENTIAL DIAGNOSIS
Traumatic Ulcer
Sharp edge of a fractured tooth
Over extended denture
Thermal and chemical burns
Iatrogenicincluding radiotherapy/chemo-
therapy. Fig. 16.2: Necrotic ulcer postradiotherapy

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152 Section 3: Carcinomas of Oral Cavity

Miscellaneous Other factors important in the assessment of


Bechets syndrome the patient include lifestyle factors and stress,
smoking, the relationship with food and the
Necrotizing sialometaplasia
relationship with the menstrual cycle
Recurrent aphthous stomatitis (Fig. 16.3)
Evidence of immunodeficiency and granulocyto-
Drug-induced, e.g. gold injections for rheuma-
penia, is important as is family history. There are
toid arthritis.
suggested HLA associations including HLA-A2,
B12, and Aw-29.
CAUSES OF ORAL ULCERS
Neoplastic (Figs 16.4 to 16.6)
Traumatic
Oral squamous cell carcinoma often presents as an
Ill fitting dentures, poorly finished restorations
ulcer with a deep indurated crater and sometimes
and rough edges to teeth may all cause oral ulcers.
with associated cervical lymphadenopathy. The
variant leukemia, mycosis fungoides infiltrates
Chemical and Temperature submucosally and may cause epithelial ulceration.
Can lead to burn ulcers; aspirin and eugenol are
known to produce ulcers. Thermal burns and Connective Tissue Disease
cryotherapy have similar effects.
Systemic lupus erythematosus and rheumatoid
arthritis may have oral ulcers as part of the
Recurrent Oral Ulceration (Fig. 16.3) symptom complex
Most recurrent oral ulceration (ROU) is of Bechets syndrome has four described clinical
unknown etiology but in a few people there subtypes; mucocutaneous, arthritic, neurological
appears to be a related hematological disorder. and ocular. Oral ulceration is typically part of the
This is ill defined, however, and causal rela- mucocutaneous syndrome but may occur in any
tionships are difficult to establish of the other variants. Bechets syndrome is rare
ROU includes anemia, cyclic neutropenia, and affects males more frequently than females
suggested haematinic deficiencies including in a ratio of about 3:1. The diagnosis requires oral
iron, zinc, folate and vitamin B12 ulceration and at least two other lesions.

Fig. 16.3: Multiple aphthous ulcer Fig. 16.4: Carcinomatous ulcer

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Chapter 16: Examination of an Ulcer 153

Fig. 16.5: Carcinomatous ulcer Fig. 16.6: Carcinomatous ulcer

Iatrogenic Persistent hyperkeratotic changes in surface


Lasers, cryotherapy, diathermy, topical agents tissues
such as eugenol and drugs such as aspirin Any persistent tumescence, either visible or
palpable beneath relatively normal tissue
may all cause accidental oral mucosal breach,
Inflammatory changes of unknown cause that
subsequent ulceration and inflammation
persist for long periods
Nonsteroidal anti-inflammatory agents (NSAID) Lesion that interfere with local function
and cytotoxic drug therapy are potentially Bone lesions not specifically identified by
complicated by oral ulceration clinical and radiographic findings
Lichenoid reactions to antihypertensives and Any lesion that has the characteristics of
gold injections are also described malignancy.
Radiotherapy related mucositis and ulceration
is well documented. Characteristics of Lesions that Raise the
Suspicion of Malignancy
Factitious Erythroplasialesion is totally red or has
Occasionally, patients present with ulcers that defy speckled red appearance
diagnosis and by a process of careful exclusion, Ulcerationlesion is ulcerated or presents as
self inflicted ulceration may be diagnosed. an ulcer
Durationlesion has persisted more than 2
weeks
BIOPSY Growth ratelesion exhibits rapid growth
Bleedinglesion bleeds on gentle manipulation
Definition of Biopsy Indurationlesion and surrounding tissue is
Removal of tissue from a living individual for firm to the touch
diagnostic examination. Fixationlesion feels attached to adjacent
structures.
Indications for Biopsy
Any lesion that persists for more than 2 weeks Principles and Techniques of Biopsy
with no apparent etiologic basis It is important to develop a systematic approach
Any inflammatory lesion that does not respond in evaluating a patient with a lesion in the oral
to local treatment after 1014 days and maxillofacial region (Figs 16.7 to 16.10).

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154 Section 3: Carcinomas of Oral Cavity

Fig. 16.7: Excisional biopsy step I Fig. 16.8: Excisional biopsy step II

Fig. 16.9: Excisional biopsy step III Fig. 16.10: Excised specimen

These steps include: Up to 90 percent of systemic diseases can be


A detailed health history discovered through history taking
A history of the specific lesion The same can be true of oral lesions when one
A clinical examination is familiar with the natural progression of the
A radiographic examination more common disease processes.
Laboratory investigations
Surgical specimens for histopathologic Medical Conditions that
evaluation (Figs 16.10 to 16.12). Warrant Special Care
Congenital heart defects
Health History Coagulopathies
An accurate health history may disclose Hypertension
predisposing factors in the disease process or Poorly controlled diabetics
factors that affect the patients management Immunocompromised patients.

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Chapter 16: Examination of an Ulcer 155

Fig. 16.11: Lesion indicated for incisional biopsy Fig. 16.12: Excised portion of the lesion

Historical Reasons for the Lesions A radiolucency with sharp borders will often be
Trauma to the area a cyst
Recent toothache A ragged radiolucency will often be a more
Habits. aggressive lesion
Radiopaque dyes and instruments can help
Clinical Examination differentiate normal anatomy.
The clinical examination should always include
when possible:
Laboratory Investigation
Inspection Oral lesions may be manifestations of systemic
Palpation disease
Percussion If a systemic disease is suspected it should be
Auscultation. pursued.

Clinical Evaluation Types of biopsy


The anatomic location of the lesion/mass Oral cytology
The physical character of the lesion/mass
Aspiration biopsy
The size and shape of the lesion/mass
Single versus multiple lesions Incisional biopsy
The surface of the lesion Excisional biopsy
The color of the lesion
Needle biopsy
The sharpness of the boundaries of the lesion
The consistency of the lesion to palpation
Presence of pulsation
Lymph node examination. Oral Cytology
Developed as a diagnostic screening procedure
Radiographic Examination to monitor large tissue areas for dysplastic
The radiographic appearance may provide changes
clues that will help determine the nature of the Most frequently used to screen for uterine
lesion cervix malignancy

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156 Section 3: Carcinomas of Oral Cavity
May be helpful with monitoring postradiation Technique of Aspiration Biopsy
changes, herpes, pemphigus A 18-gauge needle is connected to a 5 or 10 mL
The disadvantage of oral cytological procedures syringe
include: The tip of needle may have to be repeatedly
Not very reliable with many false positives repositioned to locate a fluid center.
Expertise in oral cytology is not widely
available Excisional Biopsy
The lesion is repeatedly scraped with a Removal of the entire lesion
moistened tongue depressor or spatula type A perimeter of normal tissue surround the
instrument. The cells obtained are smeared lesion is also excised to ensure total removal
on a glass slide and immediately fixed with Constitute definitive treatment.
a fixative spray or solution.
Indication of Excisional Biopsy
Aspiration Biopsy Smaller lesions(<1 cm in diameter) that, on
clinical examination, appear to be benign.
Aspiration biopsy is the use of a needle and
syringe to penetrate a lesion for aspiration of its Principle of Excisional Biopsy
content (Fig. 16.13).
The entire lesion, along with 23 mm of normal
appearing surrounding tissue, is excised.
Indication of Aspiration Biopsy
Aspiration should be carried out on all lesions Incisional Biopsy
thought to contain fluid or any intraosseous Samples only a particular or representative
lesion before surgical exploration a fluctuant part of the lesion
mass in the soft tissues should also be aspirated Lesion is large
to determine its contents Lesion has different characteristics at different
Any radiolucency in the bone of the jaw should location.
be aspirated to rule out a vascular lesion that
can cause life threatening hemorrhage. Indication of Incisional Biopsy
Extensive size (>1 cm in diameter)
Hazardous location
A great suspicious of malignancy.

Principles of Incisional Biopsy


Representative areas of lesion should be
incised in wedge fashion
Selected in an area that shows complete tissue
changes (the lesion extends into normal tissue
at the base and/or margin of the lesion)
Necrotic tissue should be avoided
Taken from the edge of the lesion to include
some normal tissue
A deep, narrow biopsy rather than a broad,
Fig. 16.13: FNAC procedure shallow one.

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Chapter 16: Examination of an Ulcer 157

Anesthesia Care should be taken to be sure that the tissue


Block local anesthesia techniques are employed has not become lodged on the wall of the
when possible container above the level of the formalin.
The anesthesic solution should not be injected
within the tissue to be removed, because it can Surgical Closure
cause artificial distortion of the specimen Primary closure of the elliptic wound is usually
When blocks are not possible, infiltration of possible
local anesthesia may be used locally, but the Palatal biopsy: Best managed postoperatively
solution should be injected at least 1 cm away with the use of an acrylic splint
from the lesion. Dorsum or lateral border of the tongue: Sutures
to be placed deeply and at frequent intervals
Tissue Stabilization into the substance of the tongue to retain
Tongue or soft palate closure.
Heavy retractive sutures
Towel clips. INTRAOSSEOUS OR HARD TISSUE BIOPSY
Lip
Assistants finger pinching the lip on both
TECHNIQUE AND SURGICAL PRINCIPLES
sides of the biopsy area. Aspiration Biopsy of Radiolucent Lesion
Any radiolucent lesion that requires biopsy
Identification of Surgical Margins
should undergo aspiration biopsy before
Marked with a silk suture to orient the specimen surgical exploration, which provides valuable
for the pathologist diagnostic information regading the nature of
If the lesion is diagnosed as requiring additional the lesion
treatment, the pathologist can determine Brisk, pulsatingvascular lesion
which margin, if any had residual lesion Straw colored fluidcyst
Identification of surgical margins Airmaxillary sinus.
One must be certain to illustrate the orientation
of the lesion and the method with which the Mucoperiosteal Flaps
specimen was marked in the pathology data
Most hard tissue lesions approached
sheet.
Through mucoperiosteal flaps
Hemostasis Full thickness flaps, incision through mucosa,
submucosa and periosteum
Avoid suction device
Gauze wrapped over the tip of the low volume Dissection to expose bone is done sub
suction device periosteally.
Simple gauze compression.
Osseous Window
Specimen Care Lesions within jaws (central lesions) require the
Immediately placed in 10 percent formalin use of cortical window.
solution that is at least 20 times the volume of
surgical specimen Removal of Specimen
Totally immersed in the solution Most small lesions that have a connective tissue
capsule can be removed with their entiret.

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Cancer Biology
17
INTRODUCTION
Cancers are caused by abnormalities in the
genetic material of the transformed cells. These
abnormalities may be due to the effects of
carcinogens, such as tobacco smoke, radiation,
chemicals, or infectious agents. Abnormalities
found in cancer affect two general classes of
genes, cancer-promoting oncogenes and tumor
suppressor genes. The heritability of cancers
is usually affected by complex interactions
between carcinogens and the hosts genome.
In addition, histologic grading, the presence of
specific molecular markers can also be useful in
establishing prognosis, as well as in determining
individual treatments.

MODES OF TUMOR SPREAD


replace the tissue involved. Also added factor
Local infiltration which destroy muscle is local inflammatory
Lymphatics reaction sometimes with marked lymphocytic
Bloodstream infiltration, e.g. malignant melanoma.
Along the natural passages Local fibrotic response that is a stromal reaction
Through serous cavities induration and loss of mobility
By inoculation Bone involvement shows endosteal reactive
Perineural spread. bone formation characterized by lymphocytic
and macrophages and osteoclastic infiltration
Local Infiltration (moth-eaten appearance)
Local Infiltration in Soft Tissues is by Marrow fibrosis, fatty hematopoietic marrow
Centrifugal Manner replaced by loose connective tissue,
Microscopically connective tissue then In older mandible there may be avascular
muscle break-up and destroy and ultimately necrosis (atheroma of IA artery).

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Chapter 17: Cancer Biology 159

Spread by Natural Passages


In this tumor cells are implanted in epithelial
surface and forms new growth
For example, bronchus, bowel, ureter, also
upper lip to lower lip.

Spread through Serous Cavities


Transcelomic spread passive transfer in cranial cavity
(malignant glial tumor cells shed into ventricals and
sub arachnoid space throughout CSF).

Implantation/Inoculation
In course of the operation in surrounding tissues.

Spread by Lymphatics
Wall of lymphatic vessel is breached.

Lymphatic Permeation
Lymph vessel lamina, cancer cell grow within
vessel to reach regional lymph nodes.

Embolic Spread through Lymphatics


Cancer cells form emboli that is carried along
with lymph to reach regional lymph nodes
Remain attached to the site and obstruct lumen
May extend up to draining lymph node The Dissemination of Cancer from Metastasis
Spread along the whole group.

Growth of Cancer Cell in Lymph Nodes


Distribution of metastasis
Tongue has rich pattern of lymph vessels also
lymph flow is increased by muscular activity
Hard palate has relatively less lymph vessels and
absence of mobility hence low nodal metastasis
Towards front of the mouth sub mandibular
lymph nodes involve first
Back in the mouth spread is straight to deep
jugular chain, usually first to jugulo-digastric
Nodes of posterior triangle are almost never Examples
involved in primary intraoral tumor Carcinomas of glandular epithelium metastasize
Deep jugular chain mediastinal lymph nodes through both lymphatics and blood stream.
Internal jugular vein is in intimate contact with Carcinomas of breast metastasize early by
the nodes than the carotids and it becomes lymphatics and late by blood stream.
involved first by local infiltration, fixation and Epitheliomas of skin and oral mucosa spread
ultimate invasion of its lumen by tumor. through lymphatics.

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160 Section 3: Carcinomas of Oral Cavity

Retrograde Lymphatic Spread Retrograde Venous Spread


Due to peculiarities in blood flow on vertebral
venous plexus cancer in which pressure variation
in the thorax and abdomen cause temporary
reversal of blood flow.
Examples
Vertebral metastasis of thyroid carcinoma.
Carcinoma of nasopharynx from spine to base
of skull
Carcinoma prostate spine and pelvic bones.

Spread by Blood Perineural Spread


Willis (1930) showed incidence of systemic Sometimes tumor spread along the perineural
metastasis is not dependent on blood supply. space. Involved nerves are greater palatine and
Liver 41 percent inferior alveolar nerve in oral carcionomas and
Lung 30 percent also minor salivary gland tumors like adenoid
Skeletal muscles 1 percent cystic carcinoma.
Spread to blood from
Jugular chain via thoracic duct PROCESS OF BONE METASTASIS
Direct invasion of blood vessel. The spread of malignant neoplasms to bone is
Veins are invaded more than arteries because not a random process but rather a cascade of
they are thin walled. specific molecular events orchestrated through
Invasion of tumors of the major veins of the complex interactions between neoplastic cells and
neck in systemic metastasis. their environment. Certain malignancies exhibit
Thrombus formation in vessels for the nutrients osteotropism or anextraordinary affinity to target
for the tumor cells. and proliferate in bone.
Extravasation mechanically block the channels
attach to vascular endothelium survival and The cascade of events (bone metastasis)
growth of metastatic deposits depends on Tumor cell detachment
PDGF, FGF, TGF-b, VEGF factors. Tumor cell motility
Interaction with the extracellular matrix
Differences in Lymphatics and Interaction with endothelium
Hematogenous Spread Direct effect on bone
Lymphatics spread Hematogenous spread Osteolitic metastasis

Carcinomas more  arcomas more common


S Osteoblastic metastasis
common because because close proximity
epithelial cells are larger to blood vessels The primary sites of metastatic deposits to
Detected early Detected late jaw bones in females is the breast followed by the
adrenals, colorectum, female genital organs and
Less serious and More serious as it
localized involves multiple organs
thyroid. For males it is the lung, followed by the
prostate, kidney, bone, and adrenals. Blood flow has
Excision offers good Poor prognosis traditionally been accepted as the only determinant
prognosis
of the site of a metastasic deposit, solid tumors

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Chapter 17: Cancer Biology 161
metastasize most frequently to the vascular areas of Oncogenesis
the skeleton, and especially red bone marrow site. After the initial neoplastic transformation tumor
cells under go progressive proliferation that
BIOLOGY OF INVASION AND METASTASIS is accompanied by further genetic changes
and development of heterogeneous tumor cell
Clonal Evolution Theory
population with varying degree of metastatic
Nowell (1976) proposed clonal evolution theory potential.
This model is built on theory of natural
selection and posits of cancer cells to develop
strategies to survive hostile environment (tissue Angiogenic Switch
barriers, immune response, programmed cell As the tumor grows the central tumor becomes
death) and use host resource (e.g. oxygen and more hypoxic and the tumor initiates the recruits
nutrients) to grow and proliferate its own blood supply which involves secretion
Carcinogens bring about change usually at of various angiogenic factors and removal of
genetic or epigenetic level. angiogenesis inhibitors.

Molecular Progression Model Clonal Dominance and


Van der Riet and coworkers proposed Molecu- Invasive Phenotype
lar Progression Model Continued genetic alterations in tumor cell
It is the accumulation of genetic events and not population results in selection of tumor cell
the specific ordering of events that appears to
clones with distinct growth advantage and
be associated with phenotypic progression.
acquisition of an invasive phenotype.
Invasive tumor cells down regulate cell to
Field Carcinogenesis
cell adhesion, alter their attachment to extra
Slaughter (1953) hypothesized that because of
cellular matrix by changing integrin expression
constant carcinogenic pressure the multiple
profiles and proteolytically alter the matrix.
genetic events occurred through out the involved
These changes result in enhanced cell motility
mucosa, allowing the development of multiple
and the ability of the cells to separate from the
molecularly distinct lesions.
primary tumor mass.
Competing Theory
Survival in the Circulation
It states that rather than several molecularly
distinct lesions that arise independently, a single Once the tumor cells and tumor cell clumps
group of molecularly similar transformed progeni- (emboli) have reached the vascular or lymphatic
tor cells migrates to distant sites, thus explaining compartments, they must survive a variety of
the appearance of multiple primary lesions, second hemodynamic and immunological challenges.
primary lesions and recurrent lesions.
Tumor Cell Arrest
Genetic Basis for Cancer After the survival in circulation tumor cell must
arrest in distant organs or lymph nodes, by size
Genes have been classified as
trapping on the in flow side of the microcircu-
Oncogenes, e.g. RAS genes lation, or by Adherence of tumor cells through
Tumor-suppressor genes, e.g. RB gene, TP53 gene specific interaction with capillary or lymphatic
Various genes for tumor progression (angiogenesis, endothelial cells, or by binding to exposed base-
apoptosis, invasion, and metastases) ment membrane.

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162 Section 3: Carcinomas of Oral Cavity

Extravasation and Growth at Candidate suppressor genes include genes


the Secondary Site associated with:
Enhanced cell attachments
After exiting the vascular or lymphatic compart-
Phosphatase activity that regulate focal
ments metastatic tumors may proliferate in
adhesion assembly
response to paracrine growth factor or become
Angiogenesis inhibitors
dormant.
Factors that suppress cell migration and
growth.
Angiogenesis in Metastatic Foci
The development of neovascular network at the Angiogenesis: Balance of Positive and
metastatic site enhances the metastatic potential
of the cells just as it does for primary tumor.
Negative Effectors
Judah Folkman and colleagues in 1970s
Evasion of Immune Response demonstrate tumor cells release soluble factors
that induce angiogenic response. For example,
Metastatic foci of tumor cells must evade
it includes platelet factor-4, interferon-,
eradication by immune responses that may be
thrombospondin and protease inhibitors
non-specific or targeted directly against the tumor
Angiogenesis inhibitors is the identification
cells.
of cryptic inhibitors that are revealed by
proteolytic modification of ECM components,
Oncogenesis for example, 29 kD fragment of fibronectin, 16
Metastasis and tumorigenesis are under kD fragment of prolactin, angiostatin released
separate genetic control, genetic analysis of from plasminogen and endostatin.
different stages of tumor progression resulted
in the multistep theory of tumorigenesis, which Tumor Heterogeneity and Clonal
involves activation of oncogenes, inactivation
of tumor suppressor genes and identification Dominance
of host of tumor associated molecules (cancer Fidler et al first demonstrated the concept of
markers) heterogeneity of primary neoplasm
Thorgeirsson et al was first to demonstrate It suggested that not all tumor cells in the
that transfection of activated Ras oncogene primary tumor population share the same
sequences into the fetal mouse fibroblast results propensity to form metastases and the
in acquisition of a metastatic phenotype when formation of metastatic foci selects for an
these cells are implanted in the nude mouse aggressive subpopulation of tumor cells out of
In addition the adenovirus 2E1A gene was primary tumor
shown to suppress Ras gene induction of the This dominance arises secondary to a selective
metastatic phenotype without alteration in growth advantage in the metastatic cells
tumorigenecity or inhibition of soft agar colony responding to local growth factor.
formation
This demonstrates clear suppuration between Defining the Invasive Phenotype
tumorigenicity and metastatic phenotype Extensive changes occur in quantity,
Candidate effector genes include those associated organization and distribution of subepithelial
with: basement membrane
Cellular adhesion to ECM component as well Invasive carcinoma is characterized by loss
As proteases, motility factors, angiogenic of basement membrane around the invasive
factors, and growth regulation tumor cells in the stroma

Ch-17.indd 162 15-04-2013 10:25:21


Chapter 17: Cancer Biology 163
Quantity and location of tumor cells that have to the nucleus. The WNT-1 proto-oncogene
escaped the primary tumor once the basement initiated signaling pathway which includes
membrane barrier is compromised is difficult frizzled (FRZ) and disheved (DSH) gene
to determine. product, can block the activity of GSK3 b,which
also can result in accumulation of b catenin
Cell-cell Adhesion Suppresses or In nucleus free nonphosphorylated b catenin
Facilitates Metastasis Formation can bind to the members of TCF (tissue coding
Varieties of cell surface receptor that mediate factor)/ LEF-1 [lymphoid enhancer-binding
the interactions include cadherins, integrins, factor 1] family of transcription factor. Catenin
immunoglobulin superfamily CD44 activates transcription from the cyclin D1
Tumor cells must decrease the cell and matrix promoter and contributes to neoplastic trans-
adhesive interactions to escape from the formation by causing accumulation of cyclin
primary tumor, at later stages in the metastatic D1
cascade, however, tumor cells may need to Other type of molecules facilitate metastasis
increase adhesive interactions with cells and formation, i.e. during tumor cell arrest and
ECM extravasations immunoglobulin super family
E-cadherin is a transmembrane glycoprotein members-nerve adhesion molecule and vascu-
that has five extracellular homologous lar cell adhesion molecule-1
domains, single membrane spanning region Role of vascular cell adhesion molecule-1 is in
and a cytosolic domain endothelial cell is cytokine inducible counter
E-cadherins is physically anchored to the actin receptor for VLA-4 (very late antigen-4)
cytoskeleton by cytoplasmic proteins termed integrin
Catenins VLA-4 is expressed on leukocytes and in attach-
Any disruption of the intracellular E-cadherin- ment to endothelial cells VLA-4 is expressed on
catenin complex results in loss of adhesion tumor cells in malignant melanoma and meta-
This would include changes in E-cadherin static sarcoma but not in adhenocarcinomas.
expression or function, as well as genes other
than E-cadherins that are required for complex Cell-extracellular Interaction in Tumor
formation and function Progression
Lochter et al reported that E-cadherin function During the process of metastases the cell must
can be disrupted by degradation of E- cadherins interact with interact with ECM (subepithelial
extra cellular domains by stromelysin-1 a basement membrane of tissue origin, stromal
member of MMP elements of tissue origin, sub endothelial base-
In normal cells b catenin is sequestered in ment membranes during extravasations, stromal
the intracellular adhesion complex with and basement membrane of organs.
cytoplasmic domain of E-cadherin, catenin,
catenin and p120
Role of CD 44 in tumor invasion
Loss of cell-cell adhesion results in disruption
of adhesion complex and free b catenin. Free b A transmembrane glycoprotein with large ectodomain
catenin is bound adhenomatous polyposis coli and a small cytoplasmic domain
(APC) gene product Involved in cell adhesion to hyaluronan (HA)
In many cancer tumor suppressor gene APC is Gene encoding CD44 is on short arm of chromosome
nonfunctional 11 has constant and variable exons
This leads to high levels of cytoplasmic b
Differentially spliced forms of CD44 can be generated
catenin that can be subsequently trans located

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164 Section 3: Carcinomas of Oral Cavity

Role of Integrins in Tumor Invasion Proteases in Tumor Cell Invasion


Integrins are dimeric transmembrane proteins Matrix proteolysis is key part of tumor cell
that are formed by the noncovalent association invasion. Matrixins or MMPs matrixins and
of and b subunits. their specific inhibitors TIMPs
Integrins bind to individual matrix proteins, Twenty matrixins and 4 TIMPs have been
such as laminin, fibronectin, vitronectin and recognized
collagens These have signal peptide sequence, a pro
Direct integrin signaling starts after engage- peptide domain; a catalytic domain (zinc
ment of integrin with ECM ligands ion) and a hemopexinlike domain. TIMP
Lateral clustering of integrin receptors, and the also contain 12 absolutely conserved cysteine
interaction of the integrin cytoplasmic domain residue that are involved in intermolecular
to form complexes the proteins that link to disulphate bond
cytoskeleton. This results in organization of Amino-terminal domain for inhibitory site/
cell structure known as focal adhesions (FAK) carboxy terminal domain other binding
interaction
The decreased expression of alpha 5, beta 1
and alpha 2, beta 1 integrin is associated with Many matrixins are initial protease cleavage of
prodomain by another matrixins or serine, such
cellular transformation and tumorigenesis .
as plasmin or by urokinase type plasminogen
activator the bond brakes and prodomain
Cellular Migration: New Insight
released and active site for catalysis is freed. In
Assembly of cytoskeleton elements to form 1980, MMP secreted from a melanoma cell line
membrane ruffles, lamellipodia, filopodia and that was able to degrade basement membrane
pseudopodia accomplishes cell movement collagen
integrin connection to the ECM provides MMP have shown to degrade plasminogen to
adhesive traction and contraction of the actin angiostatin, the angiogenesis inhibitor.
filaments results in forward propulsion of cell
body Invasion, Extravasation, and
As the cell moves new projection occur at the Orthotopic Effect
leading edge and are anchored to new focal
adhesions. As the cell moves forward, the focal Tumor cell Extravasation
adhesions appear in the retrograde fashion on Tumor cell extravasation is quantitated by using
cell surface polymerase chain reaction amplication of human
When cell moves on the rigid surface more specific alu genomic DNA sequences of tumor
restraining force is exerted to prevent move- cells present in chorioallantoic membrane. These
ment of the focal adhesion demonstrate:
The last step in integrin mediated cell migration MMPs
is the release of the ECM integrin-cytoskeletal Urokinase type plasminogen activator
attachment at the trailing edge of the cell. Urokinase type plasminogen receptors are
Release of integrin from the cell surface involved in tumor cell intravasation.
(integrin release has been observed in fibro-
blast migration) Extravasation
Destabilization of the cytoskeletal linkages Eighty percent of the circulating tumor cells
intracellularly. remain viable in circulation and extravasate up to

Ch-17.indd 164 15-04-2013 10:25:21


Chapter 17: Cancer Biology 165
3 days after there introduction in the circulation Prognostic markers
and the process is not protease dependant. Clinical: Size, grade, vascular invasion, nodal
invasion
Local Environment of Target Organ Molecular: Expression of oncogene by cells,
Local environment of target organ may profoundly CD44 molecule, estrogen receptor, epidermal
influence the growth potential of extravasated growth factor receptor, angiogenic growth
tumor cells the importance tissue micro envi- factor and degree of neovascularization,
ronment (host) on the growth of primary tumor expression of metastases associated gene or
is well-known and is referred to as orthotopic nucleic acid in DNA.
effect
SUMMARY
Occult Metastases
Integrins are a family of heterodimeric, cation-
A proportion of patient with no evidence of
dependent cell membrane adhesion molecules
systemic dissemination will develop recurrent
which mediate cell-cell and cell-matrix
disease after primary therapy these patients
interaction. They play a fundamental role in
had occult systemic spread of disease that was
the maintenance of tissue integrity and in oral
undetectable by methods routinely employed.
squamous cell carcinomas there is variable
loss or reduced expression of beta 1 integrins
Methods used for detection of occult metastases
and of alpha 6 beta 4, which correlates to loss
Immunohistochemisty of basement membrane proteins and is most
Molecular methods extensive inpoorly differentiated lesions
Flow cytometry Integrins are also involved in regulating the
Prognostic markers activity of proteolytic enzymes that degrade
the basement membranethe intial barrier to
Immunohistochemistry: Monoclonal antibodies surrounding tissue
to detect occult metastatic cells are antibodies to Integrins are essential for cell migration
epithelial specific antigens. and invasion not only because they directly
mediate adhesion to the extracellular matrix
Molecular methods: Reverse transcriptase- Integrins not only send signals to the cell in
polymerase chain reaction (RT-PCR) which responce to the extracellular environment, but
differentiates gene expression between and also they respond to intracellular cues and alter
lymphoid cells to identify epithelial cancer cells. the way that they interact with the extracellular
Flow cytometry environment
To detect cancer cells in bone marrow and Integrin binding to legends in the extracellular
blood matrix initiates several proservival mechanisms
Extremely sensitive (1 in 1,000,000 cells). to prevent apoptosis.

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Surgical Treatment Plan for
Oral and Maxillofacial Cancers
18
INTRODUCTION Age: Over the age of 40 years: 95 percent of
patients Average age: 60 years
Surgery for oral cancer can be mutilating and
Sites: Lateral border of middle-third and
disfigurement is a problem for patient, as head
ventral surface of tongue: most common sites
and neck is an important component of body
of oral cancer
image. Patients must cope not only with loss of
Lower lip cancer: Significant reduction in
structure and function as a result of operation,
cancer incidence during the last few decades
many aspects of health related quality of life are
reflect the increased use of sun screens
affected. Failure to deal with issue of appearance
Tongue cancer: Greatest increase in frequency.
can lead to distress such as avoiding social
contacts, alcohol misuse aggression, etc.
Technique of reconstruction of head and TNM DEFINITIONS
neck and mid-face has remained a challenge in
the field of maxilla facial surgery microvascular
Primary Tumor (T)
reconstruction technique in head and neck cancer TX: Primary tumor cannot be assessed
surgery are well-established, reconstruction with T0: No evidence of primary tumor
free flap, radial fore arm flap, composite radial fore Tis: Carcinoma in situ
arm flap, iliac crest flap or fibular flap, latissimus T1: Tumor 2 cm or less in greatest dimension
dorsi flap are few to name available options. T2: Tumor more than 2 cm but not more than 4
cm in greatest dimension
The most important considerations T3: Tumor more than 4 cm in greatest
Suitability of the flap to replace excised tissue
dimension
T4: (lip) Tumor invades through cortical bone,
Mobility at the donor site
inferior alveolar nerve, floor of mouth, or skin
Facility and ability to operate as a teamwork of face, i.e. chin or nose.
Reliability of transfer tissue
Regional Lymph Nodes (N)
NX: Regional lymph nodes cannot be assessed
EPIDEMIOLOGY N0: No regional lymph node metastasis
Oral cancer: Sixth most common malignancy N1: Metastasis in a single ipsilateral lymph
in the world is 30 percent of all head and neck node, 3 cm or less in greatest dimension
cancers. Squamous cell carcinoma: 95 percent N2: Metastasis in a single ipsilateral lymph
of all oral cancers node, more than 3 cm but not more than 6 cm

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Chapter 18: Surgical Treatment Plan for Oral and Maxillofacial Cancers 167
in greatest dimension; or in multiple ipsilateral Table 18.1: TNM staging
lymph nodes, none more than 6 cm in greatest Stage Tumor (T) Node (N) Metastasis (M)
dimension; or in bilateral or contralateral
0 Tis N0 M0
lymph nodes, none more than 6 cm in greatest
dimension I T1 N0 M0
N2a: Metastasis in a single ipsilateral lymph II T2 N0 M0
node, more than 3 cm but not more than 6 cm
III T3 N0 M0
in dimension
T1 N1 M0
N2b: Metastasis in multiple ipsilateral lymph T2 N1 M0
nodes, none more than 6 cm in greatest T3 N1 M0
dimension
IV A T4 N0,N1 M0
N2c: Metastasis in bilateral or contralateral
Any T N2,N3 M0
lymph nodes, none more than 6 cm in greatest Any T Any N M1
dimension
N3: Metastasis in a lymph node more than 6 IV B Any T N3 M0
cm in greatest dimension. IV C Any T Any N M1

Distant Metastasis (M)


MX: Distant metastasis cannot be assessed Surgery ladder of reconstruction
M0: No distant metastasis Primary closure
M1: Distant metastasis. Free grafts
Skin
MANAGEMENT Bone

Prognostic Factors Flaps

Stage (Table 18.1)


Size of lesion Lip
Nodal involvement T1: WE + primary closure
Tumor thickness T2: External beam radiation (50 g in 15 fractions)
Perineural invasion T3: RT + prophylactic neck RT
Intralymphatic invasion T4: Surgery + postoperative RT.
Vascular invasion.
Anterior 2/3rd of Tongue
Selection of Initial Treatment T1 and T2: Interstitial implant
Surgical treatment of the regional lymph node Tip: Surgical excision
for CA oral cavity is based on understanding T3: Implant and external beam including
of the regional lymphatic, lymph nodes ipsilateral lymph node drainage
metastasis T4: Surgery along with postoperative RT.
When regional metastasis are clinically
palpable, comprehensive clearance of the Buccal Mucosa
lymph nodes should be done T1 and T2: External beam RT
Classical radical neck dissection remains gold T3 and T4: Surgery and postoperative RT
standard of surgical management of clinically Large lesions: Treated by surgery or radiation
apparent metastatic lymph nodes therapy or combination of these.

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168 Section 3: Carcinomas of Oral Cavity
Floor of Mouth Node Positive Neck
T1: Interstitial implants morbidity is rare as Surgery: Neck dissectionradical neck dissection
small volume of tissues is irradiated or modified radical neck dissection or selective
T2: Implant and external beam RT to include neck dissection.
ipsilateral lymph node drainage. Beam
arrangement uses anteroposterior oblique Ipsilateral Mobile Nodal Finding
field T1: Radiation
T3 and T4: Surgery and post RT. T2: Modified radical or radical neck dissection
Radiotherapy: Extracapsular rupture of tumor
Assessment of mandibular invasion
metastasis.
Tumor adjacent to but not fixed to the mandible-inner
table of the periosteum to be removed Bilateral Nodal Disease
Tumor fixed to the periosteummarginal mandibulectomy First neck dissection of side less involved
Bony infiltrationsegmental resection Attempt to preserve the IJV
Fixed nodal diseaseCT scan
Lower Alveolus
Indications for Classical Radical Neck
Because of proximity to mandible, invasion Dissection
occur at an early stage,
Detected by CT scan or MRI or OPG N3 disease
T1 and T2: external beam radiation Multiple gross metastasis involving multiple
Extensive bone involvementsurgery followed levels
by postoperative RT. Recurrent metastasis in previously irradiated
neck
Retromolar Triangle Extranodal spread
Tumor at this site spread along the mandibular Involvement of accessory chain lymph node.
ramus and tract superiorly into the pteryoid There are multitudes of surgical accesses
fossa. for the facial skeleton based on the concept of
T1 and T2: external beam RT modular osteotomies.
Advanced stagessurgery.
MAXILLARY APPROACH
Upper Gingiva and Hard Palate
Most small lesions are treated surgically as Transfacial Approach
invasion in the bone is common The term transfacial is used to describe any
Reconstructed with obturator. procedure that mobilizes the mid facial skeleton
through a facial (skin) incision, irrespective of the
Treatment Option for Lymph Nodes extent of midface disassembly used. One of the
most commonly used transfacial approaches to
Clinically Negative Node the midface for the resection of maxillary tumors is
T1: No dissection the Weber-Fergusson (WF) maxillectomy incision.
T2: Supraomohyoid or modified radical neck
dissection of carcinoma of floor of the mouth, Weber-Fergusson Incision (Figs 18.1 and 18.2)
tongue, buccal mocosa This approach was first described by Weber in
Radiotherapy if recurrence is less than 2 cm the German literature and was later modified by
outside the irradiated area. Fergusson in the English literature.

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Chapter 18: Surgical Treatment Plan for Oral and Maxillofacial Cancers 169
Modifications
Altemirs incisionstraight line incision in the
lip is moved from the midline and placed on the
philtrum.
Technique
This is accomplished by placing the incision
along the philtrum, carrying the lip extension
with a slight step away and with an option of
placing a chevron in the vermillion portion of
the incision
Fig. 18.1: Weber-Fergusson maxillectomy incision.
Modification marking
The superior extent of the lip incision should
be performed into the nasal sill and then
extend out along the base of the ala and in a
cephalad direction
The lateral nasal incision should be raised and
placed in the nasal side wall at the junction
of the nasal subunit. Once the medial canthal
region is approached, the incision may be
extended laterally inferior to the lower eyelid
in one of the creases (as in the Dieffenbach
modification) or extended superiorly into a
Lynch incision
A full-thickness flap is then elevated while
maintaining sound oncologic margins
The bony osteotomies are made as the tumor
dictates
At the conclusion of the resection and
reconstruction, the flap is reapproximated,
taking care to have correct anatomic closure so
as to minimize the postoperative scar.
Fig. 18.2: Weber-Fergusson maxillectomy incision
Mid-face Degloving Technique
This approach requires familiarity with
Advantages
closed rhinoplasty techniques. The technique
It allows for improved access to the maxilla and
incorporates the use of vestibular and intranasal
for unimpeded resection of tumors affecting
incisions to lift or deglove the facial skin from
the anterior and superior aspects of the maxilla
the facial skeleton, improving the access to the
It may also be used to aid in swinging the
maxillary tumor.
maxilla laterally while pedicled to the cheek
flap. The lateral maxillary swing is used Posterior Maxillary Approach
routinely in accessing the nasopharynx for the
resection of nasopharyngeal carcinomas.
Large tumor that extends anteriorly, superiorly,
and posteriorly with extension toward the
Drawback pterygoid plates or the infratemporal fossa, it
When the tumor involves the posterior aspect may be advantageous to use two approaches
of the maxilla and/or the pterygoid plates, the The Weber-Fergusson approach may be
approach does not improve the access. combined with a lip-splitting mandibulotomy

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170 Section 3: Carcinomas of Oral Cavity
approach so that the posterior aspect of the circumventing the chin along the chin and/
tumor can be resected in a more direct fashion. or labiomental groove
The combination of the two techniques was The Robson incision, which is placed on
first reported by Dingman and Conley using a a relaxed skin tension line medial to the
lateral mandibular osteotomy, and it was later commissure and descends down toward the
modified by Lawson and colleagues by moving neck to meet with the neck incision.
the osteotomy to a midline mandibulotomy Hayter and colleagues recently published a
Obwegesers approach to the posterior maxilla modification of the McGregor incision that
and the retromaxillary and/or infratemporal incorporates a chevron into the vermillion
space. margin and the midline lip incisions to
improve closure, thereby improving the final
Transmandibular Approach esthetics. The incision is marked in the midline
of the lower lip, with or without a chevron, and
Lip-split Mandibulotomy Approach extended to the labiomental crease. Once the
The mandibulotomy approach is typically used crease is reached, the incision is extended
in combination with a lip split to the ipsilateral side of the along the mental
The first description of a lip-split technique was crease toward the midline submental region;
by Roux in the middle of the nineteenth century. from there, the incision to the neck incision
Since then, there have been a multitude of The placement of the circum-mental incision on
variations to the lip-splitting incision the ipsilateral side rather than the contralateral
side of the neck dissection is to decrease the
The 3 classic incisions most often used are:
possibility of ischemic necrosis of the chin
The Roux incision, whereby a straight-line Once the flap is elevated, the osteotomy is
incision is made from the midline of the then marked anterior to the mental foramen
lower lip, extending through the chin and The osteotomy is completed first, taking care
connecting to the neck incision to elevate the lingual mucosa and protect it.
The McGregor incision (Figs 18.3 and The osteotomy is completed, and the mucosa
18.4), which extends in a vertical fashion incision is performed on the floor of the mouth
from the midline of the lip toward the chin, along the lingual mucosa. A cuff is left for later

Fig. 18.3: Hayter and colleagues modification of the Fig. 18.4: Hayter and colleagues modification of the
McGregor incision marking McGregor incision

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Chapter 18: Surgical Treatment Plan for Oral and Maxillofacial Cancers 171
closure if possible, or a gingivosulqular incision muscle is encountered, taking care to leave a
is placed to reflect a lingual mucoperiosteal flap. small cuff of muscle attached to the mandible
The mucosal incisions through the buccal and to aid in closure. Similarly, the genioglossus
lingual gingival mucosa should be stepped away and geniohyoid muscles are detached, and the
from the bone cuts so that the soft tissue closure contents of the oral cavity are then pulled into
does not lie directly over the osteotomy site the neck, allowing for a more direct resection
With the osteotomy and mucosal incision through unimpeded visual and tactile feel of
completed, the mandible is then able to be the tumor. Devine and colleagues compared
reflected laterally, providing a clear view of their experience between the lip-split
the tumor and allowing for uncompromised mandibulotomy and the mandibular lingual
resection. This lateral swinging of the releasing access and found that patients with
mandible is why this technique is at times lingual release reported more problems with
referred to as the mandibular swing approach. speech, swallowing, and chewing.
Once the resection and reconstruction are
completed, the fixation is reapplied and the Visor Flap
incisions are closed. When the incisions are An alternative to the pull-through technique
closed with attention to the careful alignment of is the visor flap. This flap is mostly used in the
tissues, the postoperative scar is imperceptible resection of tumors involving the anterior oral
The use of a non-lip-splitting mandibulotomy cavity; however, at times, it may also be used in
is most commonly employed to improve the resection of lateral tongue and floor of the
access to the parapharyngeal space and the mouth tumors
infratemporal fossa. In some circumstances, The incision for the flap is performed from the
however, it may be used to improve access to mastoid process on one side and is extended
the oral cavity. This approach incorporates two toward the contralateral mastoid or to the
osteotomies: one at the parasymphyseal area mandibular symphysis on the unaffected side
and another at the ramus region. The approach The flap is elevated as usual, taking care to
identify and preserve the marginal mandibular
of Attia and coworkers uses a parasymphyseal
branch of the facial nerve. Once the inferior
and horizontal ramus osteotomy above the
border of the mandible is encountered, a
lingula and swings the segment in a superior
periosteal incision is made along the exposed
direction. As described by Attia and coworkers,
mandible. An intraoral incision is made along
this procedure involves a lip-splitting incision
the gingivobuccal sulcus, and a mucoperiosteal
The concept of ill-continuity resection has
flap is elevated and reflected toward the inferior
been around for many years. The rationale
border of the mandible. The two dissections
for this approach lies in the possibility of a
are then connected
tumor focus in the lymphatics between the
The flap is tethered to the mandible only at
primary and the cervical nodes. To that end, the mental foramen region. The mental nerve
proponents of this theory advocate that the is incised, and the flap is then mobilized in a
resection should remove the primary, the cephalad direction with the aid of two rubber
intervening lymphatics, and the cervical nodes drains. With the drains secured, the surgeon
in one block specimen. The technique was first has an unimpeded view of the oral cavity to
described by Scheunemann in 1975 and was proceed with the tumor extirpation
later modified by Stanley. The pull-through One of the obvious drawbacks of this technique
operation is performed by making a releasing is the sacrifice of the mental nerve, leading to
incision on the lingual aspect of the gingival anesthesia of the lip and chin. The benefit is
and the elevation of a mucoperiosteal flap. The that the surgeon is able to remove the tumor
dissection is performed until the mylohyoid without the need for a lip-splitting incision.

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172 Section 3: Carcinomas of Oral Cavity

Some More Access Approach (Figs 18.5 to 18.10)


Surgical Procedure for Neck Dissection and Hemiglossectomy (Figs 18.10A to Z and 18.10AA to DD)

Fig. 18.5: Showing LeFort-l down fractureaccess Fig. 18.6: Showing LeFort-I down fracturelesion removal
surgery (Courtesy of Figures 18.1 to 18.6: Dr Vikram Shetty)

Fig. 18.7: Lip split access surgery marking Fig. 18.8: Lip split access surgery

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Chapter 18: Surgical Treatment Plan for Oral and Maxillofacial Cancers 173

Fig. 18.9: Lip split access surgerylesion removal

A B

C D
Figs 18.10A to D: (A) Incision marking, (B) Initial dissection, (C) Neural structure identification, (D) Vessel ligation

Ch-18.indd 173 15-04-2013 10:26:04


174 Section 3: Carcinomas of Oral Cavity

E F

G H

I J
Figs 18.10E to J: (E) Identification of vascular structure, (F) Dissection for lymph node, (G) Neural structure
identification, (H) Dissection (I) Identification of lymphatic channel, (J) Lymph node group dissection

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Chapter 18: Surgical Treatment Plan for Oral and Maxillofacial Cancers 175

K L

M N

O P

Figs 18.10K to P: (K and L) Dissected lymph nodes, (M) Dissection, (N) Identification of deeper lymph node,
(O and P) Dissection for deeper lymph node

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176 Section 3: Carcinomas of Oral Cavity

Q R

S T

U V

Figs 18.10Q to V: (Q and R) Dissection for deeper lymph node, (S) Dissected lymph node. (T) Ligated vascular
structure, (U) Hemostasis achieved after neck dissection, (V) Holding tie

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Chapter 18: Surgical Treatment Plan for Oral and Maxillofacial Cancers 177

W X

Y Z

AA BB

Figs 18.10W to BB: (W) Areas marked for dissection, (X) Glossectomy dissection, (Y) Excised lesion of the
part of tongue, (Z) Tongue after hemiglossectomy, (AA) Hemostasis achieved after glossectomy, (BB) Closure
after hemiglossectomy

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178 Section 3: Carcinomas of Oral Cavity

CC DD
Figs 18.10CC and DD: (CC) Closure after hemiglossectomy, (DD) Incision closure

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Management of Neck in Oral
and Maxillofacial Carcinoma
19
INTRODUCTION 1989, 1991, and 1994: Medina, Robbins, and
Byers classification of neck dissection.
Oral and maxillofacial surgeons frequently
encounter neck masses in adult patients When
adult patients presents with neck mass, malignancy ANATOMICAL DIVISIONS
is the greatest concern. Accurate diagnosis of neck
mass requires good medical history, knowledge
Fascial Layers of the Neck
of normal anatomy. Lymph nodes are located Superficial cervical fascia
throughout the head and neck, fixed, firm, or Deep cervical fascia
matted lymph nodes larger than 1.5 cm require Investing or outer layer
further evaluation, Biopsy should be considered Visceral or middle layer
for neck masses with progressive growth, location Internal layer.
within the supraclavicular fossa or size greater than
3 cm. Biopsy also should be considered if a patient Deep Cervical FasciaInvesting Layer
with neck mass develops symptoms. Frozen section Splits to contain 2 muscles and 2 glands
of the mass followed by neck dissection should Forms carotid sheath
be performed if the mass proves to be metastatic. Nerves embedded in the fascia
Hence, the single most important prognostic factor
Glossopharyngeal
in squamous carcinoma of the maxillofacial region
Accessory
is the status of the cervical lymph nodes.
Hypoglossal
Ansa hypoglossi.
HISTORY
20th Century Deep Cervical Fascia
Middle or Visceral Layer
1951: Martin advocates radical neck dissection
Forms pretracheal fascia
after analysis of 1450 cases
Surrounds pharynx, larynx, esophagus, and
Advocated RND for all cases
trachea.
Standardized the radical neck dissection
1952: Suarez describes a functional neck
dissection
Deep Cervical FasciaInternal Layer
Preservation of SCM, omohyoid, subman- Forms prevertebral fascia
dibular gland, IJV, XI. Nerves superficial to prevertebral fascia
Enables protection of carotid. Cervical sympathetic trunk

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180 Section 3: Carcinomas of Oral Cavity
Nerves deep to prevertebral fascia Level I
Cervical plexus
Phrenic nerve
Submental triangle (Ia)
Anterior digastric
Brachial plexus.
Hyoid
Mylohyoid.
Head and Neck Lymphatics
Submandibular triangle (Ib)
Waldeyers internal ring Anterior and posterior digastric
Collection of lymphoid aggregates in pharynx Mandible.
Superficial lymph node system
Occipital, post auricular, parotid, preauricular, Marginal Mandibular Nerve
facial nodes Most commonly injured in dissection of level
Deep system 1b
Junctional nodes Landmarks:
Upper cervical nodal group 1 cm anterior and inferior to angle of
Middle cervical nodal group mandible
Lower cervical nodal group Mandibular notch
Spinal accessory group Subplatysmal
Nuchal nodes Deep to fascia of the submandibular gland
Visceral nodes Superficial to facial vein.
Nodes in upper mediastinum.
Hypoglossal Nerve
Patterns of Cervical Lymph Node Lies deep to the IJV, ICA, CN IX, X, and XI
Metastases Curves 90 degrees and passes between the IJV
Predictable and sequential progression of and ICA
metastatic spread from each primary site Lateral to hyoglossus
Select group of regional lymph nodes Deep to mylohyoid.
are at risk for initial involvement
Skip metastases are rare. Level Ia
Chin
Lymph Node Levels in Neck Lower lip
Lymph node levels Anterior floor of mouth
Sloan Kettering nomenclature Mandibular incisors
Subgroups. Tip of tongue.
Common nodal drainage patterns.
Level Ib
Lymph Node Levels in Neck Oral cavity
Level Ia: Submental Floor of mouth
Level Ib: Submandibular
Oral tongue
Level II: Upper jugular Nasal cavity (anterior)
Level III: Middle jugular Face.
Level IV: Lower jugular
Level V: Posterior triangle Level II
Level VI: Anterior compartment/visceral/ Upper jugular nodes
central compartment Anterior: Lateral border of sternohyoid,
Level VII: Superior mediastinum (nodes in posterior digastric and stylohyoid
tracheo-esophageal groove). Posterior: Posterior border of SCM

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Chapter 19: Management of Neck in Oral and Maxillofacial Carcinoma 181
Cricoid cartilage lower border (clinical
landmark)
Omohyoid muscle (surgical landmark)
Junction with IJV.

Level III Range


Oral cavity
Nasopharynx
Oropharynx
Hypopharynx
Larynx.

Level IV
Lower Jugular Nodes
Anterior: Lateral border of sternohyoid
Fig. 19.1: Lateral neck swelling Posterior: Posterior border of SCM
Cricoid cartilage lower border (clinical landmark)
Omohyoid muscle (surgical landmark)
Skull base Junction with IJV
Hyoid bone (clinical landmark) Clavicle.
Carotid bifurcation (surgical landmark).
Level IIa anterior to XI Phrenic Nerve
Level IIb posterior to XI Sole nerve supply to the diaphragm
Submuscular recess C3-5
Oropharynx is greater than oral cavity and Anterior surface of anterior scalene
laryngeal meets (Fig. 19.1) Under prevertebral fascia
Posterolateral to carotid sheath.
Spinal accessory nerve relationship with the
IJV. Thoracic Duct
Level II Range Conveys lymph from the entire body back to
the blood
Oral cavity
Begins at the cisterna chyli
Nasal cavity
Enters posterior mediastinum between the
Nasopharynx azygous vein and thoracic aorta
Oropharynx Courses to the left into the neck anterior to the
Larynx vertebral artery and vein
Hypopharynx Enters the junction of the left subclavian and
Parotid. the IJV.

Level III Level IV Range


Middle jugular nodes Hypopharynx
Anterior: Lateral border of sternohyoid Larynx
Posterior: Posterior border of SCM Thyroid
Inferior border of level III Cervical esophagus.

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182 Section 3: Carcinomas of Oral Cavity

Level V Lymph node biopsy alter lymphatic drainage


for 1 year
Posterior Triangle of Neck
Extensive surgery and RT lead to shunting of
Posterior border of SCM lymph and opening of abnormal channel.
Clavicle
Anterior border of trapezius Prognostic nodal factors
Va Spinal accessory nodes Clinical status
Vb Transverse cervical artery nodes Size
Radiologic landmark Number
Inferior border of cricoid Extranodal spread
Supraclavicular nodes. Level of involvement
Tumor emboli
Spinal Accessory Nerve
Penetrates deep surface of the SCM Risk in "N 0" neck
Exits posterior surface of SCM deep to Erbs High tumor stage
point High grade tumor
Traverses the posterior triangle on the levator Local depth of infiltration
scapulae Site of lesion
Enters the trapezius about 5 cm above the
clavicle. Treatment options for N 0 neck
Elective neck dissection SOHND
Level V Range Sentinel node biopsy
Nasopharynx Elective neck radiotherapy in the event of clinically
Oropharynx evident cervical neck metastasis
Posterior neck and scalp. Wait and watch

Level VI VARIOUS INCISIONS FOR NECK


Anterior compartment DISSECTION (FIGS 19.2 TO 19.9)
Hyoid
Suprasternal notch
Medial border of carotid sheath.
Perithyroidal lymph nodes
Paratracheal lymph nodes
Precricoid (Delphian) lymph node.

Level VI Range
Thyroid
Larynx (glottic and subglottic)
Pyriform sinus apex
Cervical esophagus.

Natural History of Malignant Neck Disease


Drainage patterns apply in nonviolated neck,
hence, supraomohyoid neck dissection suitable
in previously untreated neck Fig. 19.2: Apron incision

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Chapter 19: Management of Neck in Oral and Maxillofacial Carcinoma 183

A
B
Figs 19.3A and B: Half apron incision

Fig. 19.4: Conley incision Fig. 19.5: H-incision

Fig. 19.6: MacFee incision Fig. 19.7: Y-incision

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184 Section 3: Carcinomas of Oral Cavity
Difficulties of lymphatic mapping in head and
neck.
It is difficult to visualize lymphatic channels
using lymphoscintigraphy because of
proximity to the injection site
The radiotracer travels fast in the lymphatic
vessels
If more than one node is visible, it can be
difficult to distinguish first-echelon nodes
from second-echelon nodes
The SLN may be small and not easily
accessible (e.g., in the parotid gland).
Sentinel nodes found in >90 percent of cases.
Experience matters
Fig. 19.8: Schobinger incision Surgeons with less than 10 cases56 percent
success in SLNB.
Lymphoscintigraphy revealed unexpected
bilateral or contralateral disease in about
14 percent of patients.

CLASSIFICATION OF NECK DISSECTIONS


Comprehensive neck dissection
Selective neck dissection.

COMPREHENSIVE NECK DISSECTION


All surgical procedures on the lateral neck which
comprehensively remove cervical lymph nodes
from level I to level V (Figs 19.10 to 19.31).

Fig. 19.9: Modified Schobinger incision

SENTINEL NODE BIOPSY


If the first draining lymph node had no evidence
of micro metastasis on histopathological examina-
tion, there was <5 % incidence of micrometastases
to the remaining lymph node basin

Sentinel Lymph Node Concept


Tumor spreads via lymphatics to a primary
node
Examination of primary echelon nodes for
tumor directs the need for surgical manage-
ment of the nodal basins Fig. 19.10: Incision for neck dissection

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Chapter 19: Management of Neck in Oral and Maxillofacial Carcinoma 185

Fig. 19.11: Electrosurgical dissection (I) Fig. 19.12: Electrosurgical dissection (II)

Fig. 19.13: Surgical dissection (I) Fig. 19.14: Electrocautery (I)

Fig. 19.15: Electrocautery (II) Fig. 19.16: Electrosurgical dissection (III)

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186 Section 3: Carcinomas of Oral Cavity

Fig. 19.17: Surgical dissection (II)

Fig. 19.18: Surgical dissection (III) Fig. 19.19: Surgical dissection (IV)

Fig. 19.20: Surgical dissection (V) Fig. 19.21: Surgical dissection (VI)

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Chapter 19: Management of Neck in Oral and Maxillofacial Carcinoma 187

Fig. 19.22: Identification of neural structure Fig. 19.23: Identification of vascular structure

Fig. 19.24: Carotid artery identification Fig. 19.25: Identification of neural structure

Fig. 19.26: Hemostasis achieved (I) Fig. 19.27: Hemostasis achieved (II)

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188 Section 3: Carcinomas of Oral Cavity

Fig. 19.28: Lymph node dissection (I) Fig. 19.29: Lymph node dissection (II)

Fig. 19.30: Modified lip split approach for Fig. 19.31: Modified lip split approach for
submandibular lymph node step I submandibular lymph node step II

Comprehensive neck dissection Radical Neck Dissection


Classical RND Removal of all ipsilateral cervical lymph node
 xtended RND (Additional regional lymph nodes/
E groups extending from the inferior border of
cranial nerves, muscles, skin) the mandible to the clavicle; medially, the
 RND type 1: Selectively preserves spinal accessory
M midline; and posteriorly, the anterior border of
nerve the trapezius muscle
 RND type 2: Preserves spinal accessory nerve and
M Included are all lymph nodes from levels I
SCM/IJV through V
 RND type 3: Preserves spinal accessory nerve, IJV,
M
and SCM
The SAN, IJV and SCM are also removed.

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Chapter 19: Management of Neck in Oral and Maxillofacial Carcinoma 189

Indications Modified RND


N3 disease MRND refers to the excision of all lymph
Recurrent metastatic disease in previously nodes routinely removed by the RND with
irradiated neck preservation of one or more nonlymphatic
Grossly apparent extranodal spread with structures (i.e. the SAN, IJV and SCM) (SAN =
invasion of spinal acc N/IJV at the base of skull Spinal accessory nerve; IJV = Internal jugular
Access prior to pedicled flap reconstruction. vein; SCM = Sternocleidomastoid muscle)
The structure(s) preserved should be specifically
Contraindications named.
Untreatable primary tumor
Unfit for major surgery SELECTIVE NECK DISSECTION (SND)
Distant metastasis (FIGS 19.32 TO 19.34)
Significant B/L neck disease Selective neck dissection refers to cervical
Inoperable neck disease lymphadenectomy in which there is preservation
RND Structures excised. of one or more of the lymph node groups that
are routinely removed in the radical neck dissection.
Extended RND
RND plus additional lymph node groups/non Supraomohyoid Neck Dissection (Level IIII)
lymphatic structures/both T1-T4, No
Retropharyngeal lymph nodes Oral cavity.
Parotid nodes
Lymph node levels 6,7. Extended SOHND (Level IIV)
Primary Ca lateral border of oral tongue
Nonlymphatic Structures Skin CA (SCC and melanoma) anterior to line
Mandible of tragus.
Parotid gland
Mastoid tip Lateral Neck Dissection (Level IIIV)
Prevertebral fascia T2T4 No
Musculature SCC larynx, oropharynx, hypopharynx.
Digastric muscle
Hypoglossal nerve Posterolateral (Level IIV)
ECA Postauricular, suboccipital nodes
Skin. Skin CA posterior to the line of tragus.
Indications SND for Primary Treatment of N+ Neck
Neck disease invades nonlymphatic structures Efficacy of leaving levels IIb and V undisturbed in
Primary tumor of parotid, pharynx oral carcinoma.

Retropharyngeal LN dissection SND for Salvage of Neck Persistence/
Transglottic and subglottic CA Early Recurrence
Carcinoma cervical esophagus-paratracheal, SND: Persistant stable adenopathy post-RT
pretracheal, anterior compartment nodes Progressive neck disease after RT: Compre-
Carcinoma thyroid. hensive neck dissection (lV)

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190 Section 3: Carcinomas of Oral Cavity

Fig. 19.34: Resected specimen Courtesy of Figures


19.10 to 19.34: Dr BR Prasad)
Fig. 19.32: Exposure for segmental mandibulectomy

Complication of neck dissection


Infection and festula formation
Shoulder dysfunction
Airleak through wound drain
Chylous fistula (12.5%)
Facial and cerebral edema
Bleeding and postoperative hematoma under the flap
Apnea
Jugular vein thrombosis
Blowout of carotid
Neuroma
Brachial plexus injury
Cervical plexus injury
Lingual nerve injury
Fig. 19.33: Excision of lesion Cervical symphathetic chain injury
Hypoglossal nerve injury
Fixed Nodes Phrenic nerve injury
Overall poor prognosis Vagus nerve injury
Extracapsular spread present
Resectability dependant on the anatomic
structure to which fixed, e.g. mandible, larynx, Preoperative radiotherapy with salvage
sternocleidomastoid muscle. surgeryno improvement in survival.
R+ resection common Skin fixitywide excision of skin with
5-year survival15 percent, if surgery + resurfacing and postoperative RTbetter
postoperative RT long-term survival.

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Role of Chemotherapy and
Radiotherapy in Oral and
Maxillofacial Carcinoma
20
INTRODUCTION Phases of Cell Cycle (Fig. 20.1)
The standard protocol in the treatment of Four phases of the cell cycle are G1, S, G2, and
oral malignancies is surgery, radiation and M
chemotherapy. Cancer is one of the major causes of G1 is the presynthetic phase and the duration
death. The treatment of cancers after so many years is variable
of research and experience is still unsatisfactory During the S phase the synthesis of DNA occurs
due to certain characteristics of the cancer cells- and hence the activity of replicating enzymes
like capacity for uncontrolled proliferation, like DNA and RNA polymerases, topoisomer-
invasiveness and metastasis. Recently targeted ases, thymidine kinases and dihydrofolate
treatment in form of monoclonal antibodies reductases are maximum at this phase of 12 to
with antiangiogenesis, epidermal growth factor 18 hours duration
inhibitors and tyrosin kinase inhibitor are use G2 is the postsynthetic phase (18 hr) and in
along with chemotherapy and radiation. The main the M phase (12 hr) the mitosis takes place.
aim of this is to eliminate the residual cells which
are resistant to the major modalities of treatment
like chemo therapy or radiation.

The newer monclonal antibodies are


Transtuzumab
Cetuximab
Bevacizumab
Gefitinib
Erlotinib Fig. 20.1 Phases of cell cycle

Cell cycle specific drugs Cell cycle nonspecific drugs


 phase: Antimetabolites, doxorubicin,
S Alkylating agents
epipodophyllotoxins, vinca alkaloids Anticancer antibodies
G2 and M phases: Bleomycin Cisplatin
M phase: Taxanes, vinca alkaloids Procarbazine, camptothecins

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192 Section 3: Carcinomas of Oral Cavity
The daughter cells may start dividing or may anticancer drugs but it is reversible and the hair
enter into a dormant phase called G0 grows after the chemotherapy is completed
The knowledge of cell cycle may be used for Reduced spermatogenesis in men and
staging and scheduling treatment because amenorrhea in women (due to damage to the
different drugs act at different stages of the cell germinal epithelium) can occur, for example,
cycle. However, some drugs are cell cycle non- men treated with mechlorethamine for 6
specific months can become infertile.

Common Adverse Immediate Adverse Effects


Effects to Anticancer Drugs Nausea and vomiting are very common with most
Since most anticancer drugs act on the rapidly cytotoxic drugs. They result from the stimulation
multiplying cells, they are also toxic to the normal of the CTZ and start about 46 hr after treatment
rapidly multiplying cells in the bone marrow, and may continue for 12 days. Prior treatment
epithelial cells of skin and mucous membranes, with powerful antiemetics is required.
lymphoid organs and gonads. Thus, the common
Hyperuricemia
adverse effects are:
Rapid tumor cell lysis can result in an increased
plasma uric acid levels and may precipitate gout.
Bone Marrow Depression
Results in leukopenia, anemia, thrombocytopenia Teratogenicity
and in higher dosesaplastic anemia. In such All cytotoxic drugs are teratogenic and are there-
patients, infections and bleeding are common. fore contraindicated in pregnancy.
Other Proliferating Cells Carcinogenicity
GITstomatitis, esophagitis, glossitis and Cytotoxic drugs themselves may cause secondary
proctitis can be painful. Diarrhea and ulcers cancers, e.g. leukemias may follow the treatment
along the gut are common of Hodgkins lymphoma.
Alopecia (loss of hair)partial to total Measures to prevent adverse effects to anti-
alopecia is seen following treatment with most cancer drugs (Table 20.1).

Table 20.1: Measures to prevent the adverse effects of anticancer drugs


Toxicity Measures
Naysea, vomiting Antiemetics: Ondansetron, granisetron, metoclopramide
Hyperuricemia Allopurinol
Methotrexate toxicity Folinic acid (10 mg)dose as per blood methotrexate levels
Cystitis due to cyclophosphamide and Ifosfamide Mesna IV; n-acetyl cysteinebladder wash
Myelosuppression
Anemia Iron, blood transfusion
Leukemia Erythropoietin
Thrombopoietin G-CSF, GM-CSF
Nephrotoxicity due to cisplatin Thrombocytopenia
Xerostomia due to radiation Amifostine

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Chapter 20: Role of Chemotherapy and Radiotherapy in Oral and Maxillofacial Carcinoma 193

Oral complications of chemotherapy


Due to chemotherapy, interference with cellular
mitosis decreases the regenerative ability of oral
Ulceration and mucositis mucosa
Xerostomia Common siteslabial mucosa, buccal mucosa,
Generalized oral pain
soft palate, floor of mouth and central surface of
tongue.
Lymphadenopathy
Necrotizing ulcerative gingivitis Treatment (Table 20.2)
Hemorrhage Elimination of mechanical irritants
Pain can be controlled by viscous xylocaine,
Oral mucositis
benadryl

Table 20.2: Classification of drugs used in cancers


Alkylating agents
Nitrogen mustards
Mechlorethamine, cyclophosphamide, Ifosfamide, chlorambucil, melphalan
Ethylenimines
Thiotepa
Alkyl sulfonate
Busulfan
Nitrosoureas
Carmustine, streptozotocin
Triazine
Dacarbazine
Antimetabolites
Folate antagonist
Methotrexate, pemetrexed
Purine Analogs
mercaptopurine, thioguanine, pentostatin, fludarabine, cladribine
Pyrimidine analogs
5-fluorouracil, fioxuridine, capecitabine, cytarabine (cytosine arabinoside) gemcitabine
Natural Products
Antibiotics
Actinomycin-d (dactinomycin), daunorubicin, doxorubicin, bleomycin, mitomycin-C, mithramycin
Epipodophyllotoxins
Etoposide, teniposide
Camptothecins
Topotecan, irinotecan
Taxanes
Paclitaxel, docetaxel
Vinca alkaloids
Vincristine, vinblastine, vinorelbine
Miscellaneous
Hydroxyurea, procarbazine, mitotane, 1-asparaginase, cisplatin, interferon alpha, imatinib
Hormones and their antagonists
Glucocorticoids, androgens, antiandrogens, estrogens, antiestrogens, progestins, aromatase inhibitors

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194 Section 3: Carcinomas of Oral Cavity
Systemic analgesicscodeine, morphine Tretinoin (alltransretinoic acid) induces
Antibiotics differentiation in leukemic cells and the
Xerostomia leukemic promyelocytes loose their ability to
Promotes the accumulation of oral bacteria proliferate. It is useful to induce remission in
which initiates dental caries acute promyelocytic leukemia
TreatmentSialagogs Amifostine has been designed to offer selective
Replacing lost secretionsrehydration. cytoprotection to normal tissues from the
effects of cytotoxic drugs. Amifostine activates
Radioactive Isotopes an enzyme in the normal tissues which can
Some radioactive isotopes can be used in the inactivate the active form of cisplatin and
treatment of certain specific cancers radiation. It has also been shown to stimulate the
Radiophosphorus P32 is used in polycythemia bone marrow in some bone marrow disorders.
vera. It is taken up by the bone where it emits Amifostine is used to prevent toxicity due to
rays and has a half-life of about 14 days cisplatin and radiation induced xerostomia
Strontium chloride emits rays and has a longer (Table 20.3).
half-life in the bony metastases. It is used to
alleviate pain in painful bony metastases GENERAL PRINCIPLES IN
Radio active iodine I131 is used in the treatment THE TREATMENT OF CANCERS
of thyroid cancers.
Chemotherapy in most cancers (except the
curable cancers) is generally palliative and
BIOLOGICAL RESPONSE MODIFIERS suppressive. Because of the ability of cancers
Several agents are used to beneficially for recurrence. To avoid this it is essential to
influence the patients response to treatment kill all the cells or as many cells as possible
and to overcome some adverse effects. These during treatmentto achieve what is known as
have also been termed biological response Total cell kill. Chemotherapy is just one of the
modifiers. They are as follows: modes in the treatment of cancer. Combination
Hematopoietic growth factors like eryth- of drugs is preferred for synergistic effect, to
ropoietin and myeloid growth factors like reduce adverse effects and to prevent rapid
GM-CSF, G-CSF, M-CSF and thrombopoietin development of resistance. Drugs which do not
are used to treat bone marrow suppression depress bone marrow are useful in combination
Interferons like interferon alpha are used in regimens to avoid overlapping of adverse effects.
hairy cell leukemia, Kaposis sarcoma and With appropriate treatment, cure can now be
condylomata acuminata achieved in a few cancers. Maintenance of good
Monoclonal antibodies are immuno- nutrition, treatment of anemia, protection against
globulins that react specifically with infections, adequate relief of pain and anxiety
antigens present on the cancer cells. Allergic and good emotional supportall go a long way
reactions are common. Trastuzumab also in the appropriate management of these dreaded
enhances host immune responses and is diseases.
useful in breast cancers. Rituximab attaches
to antigens on the B cells causing lysis of COMPONENTS OF CHEMOTHERAPY
these cells. It is used in B cell lymphomas
Aldesleukin is recombinant interleukin-2. Components of chemotherapy
It enhances cytotoxic activity of T-cells, Induction or Neo adjuvant chemotherapy
induces activity of natural killer cells and Adjuvant chemotherapy
also induces interferon production. Concurrent chemotherapy

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Chapter 20: Role of Chemotherapy and Radiotherapy in Oral and Maxillofacial Carcinoma 195

Table 20.3: Choice of drugs in malignancies


Malignancy Preferred drugs
Acute lymphatic leukemia Vincristine + prednisolone + L- asparaginase maintenance -
Mercaptopurine/methotrexate, cyclophosphamide
Acute myeloid leukemia Cytosine arabinoside + daunorubicin
Chronic lymphatic leukemia Fludarabine/chlorambucil + prednisolone
Chronic myeloid leukemia Hydroxyurea, busulfan Imatinib; interferons
Hodgkins disease MOPP ABVD
M-Mechlorethamine A-Adriamycin
O-Oncovin (vincristine) (doxorubicin)
P-Procarbazine B-Bleomycin
P-Prednisolone V-Vinblastin
D-Dacarbazine
Non-Hodgkin's lymphoma Cyclophosphamide + doxorubicin + vincristine (oncovin) +
Prednisolone (CHOP)*
Multiple myeloma Melphalan + prednisolone/vincristine + doxorubicin +
dexamethasone
Carcinoma of the head and neck Fluorouracil + cisplatin
*In; CHOP, H stands for doxorubicin formerly called hydroxydaunomycin

Induction or Neoadjuvant Chemotherapy Drugs Used


Use of chemotherapy in newly diagnosed patients Methotrexate, fluorouracil and leucovorin.
without metastatic disease before primary surgery
or radiotherapy. Adjuvant Chemotherapy
Chemotherapy given following definitive primary
Objectives treatment like surgery and radiotherapy.
Better drug delivery because of intact vascular
bed Objectives
Reduction of tumor bulk, to allow earlier To eradicate the sub clinical persistent disease
application of definitive radiation after surgery/radiotherapy and decrease the
Early eradiation of micrometastasis rate of loco-regions and distant relapse
Higher doses and improved tolerance of Has improved overall survival in locally
chemotherapy with possibility that chemo- advanced squamous cell carcinoma of head
therapy sensitive tumors may be cured with and neck but its role is unclear.
less aggressive surgery.

Disadvantage Concurrent Chemotherapy


Delays potential curative surgery/radiotherapy Chemotherapy given along with radiotherapy.
in tumors non responsive to chemotherapy
Noncompliance to surgery or radiation in Objectives
patients who respond initially to chemotherapy To prevent the emerging of radioresistant
and may loose the chance for cure colonies
Increased therapy related morbidity, cost and To inhibit the development of drug resistance
duration of treatment. To irradiate distant micrometastasis.

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196 Section 3: Carcinomas of Oral Cavity
Drugs Used Chemotherapy Both as Single Agent and
Fluorouracil, bleomycin, mitomycin, methotrex- Combination
ate, cisplatin, carboplatin, hydroxyurea.
Single Agent
Disadvantages Palliative
Administration of chemotherapy along Used mostly in head and neck cancer of
with radiation increases toxicity and often squamous cell carcinoma
necessitates interruption in radiotherapy Response is of short duration averaging 3
Prolongation of total treatment has been months
adversely affecting the success of radiotherapy Patients benefits from less pain, better ability
in squamous cell carcinoma of head and neck to swallow and having prolonged survival.
To overcome this problem, chemotherapy is Drugs used
administered in two different ways Methotrexate (standard single agent for oral
Chemotherapy + radiotherapy administered cancer)
at full or nearly full dosage (split course Dose: 40 mg/m2 and 3 g/m2 weekly for short
radiotherapy) treatment.
Chemotherapy and radiotherapy administered
in rapid alteration interrupting one modality at Other drugs
the time while administrating the other. Bleomycin, cisplatinum, fluorouracil, vinblastin.

Drugs Used Combination Therapy


Cisplatin (100 mg/m2 every 3 weeks for 3 doses) Used in recurrence of tumor after initial treatment
Carboplatin (45 mg/m2 for 5 days during weeks with surgery/radiotherapy (Figs 20.2 and 20.3)
1,3,5 and 7) Used for palliation of symptoms
Gemcitabine (150 mg/m2/ week infusion). Prolong life.

Fig. 20.2: Preoperative chemotherapy Fig. 20.3: Postchemotherapy

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Chapter 20: Role of Chemotherapy and Radiotherapy in Oral and Maxillofacial Carcinoma 197
Drugs used Vital signs within normal limits.
Combination of cisplatin + methotrexate +
bleomycin Extraoral Examination
Combination of cisplatin + fluorouracil. Gross facial asymmetry
Solitary diffuse swelling noted over the right
CASE STUDY side of the face (Fig. 20.5)
Female aged 33 years Measuring 15 15 cm.
Reported with painful swelling in right side of Periorbital edema (Fig. 20.6)
the face since 20 days Skin over the swelling appeared erythematous
Small painful swelling in right submandibular in areas.
region (Fig. 20.4)
After 10 days she consulted a local doctor Intraoral Examination
Incision and drainage was tried Restricted mouth opening
The swelling rapidly grew to present size No signs of swelling noted intraorally
No contributory medical and dental history Pericoronitis noted in relation to 48.
No history of drug allergy
Personal history: Occasional tobacco chewer. To summarize
A 33 years old female with a solitary, tender,
rapidly growing diffuse inflammatory swelling,
Clinical Examination soft to firm in consistency, on the right side of the
General Physical Examination face since 20 days.
Moderately built and nourished Provisional diagnosis: Fascial cellulitis?

Fig. 20.4: Diffuse swelling over right side: Front view Fig. 20.5: Diffuse swelling over right side: Lateral view

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198 Section 3: Carcinomas of Oral Cavity

PANORAMIC RADIOGRAPH
(FIGS 20.7 TO 20.14)

Fig. 20.6: Facial asymmetry with periorbital edema

Differential Diagnosis
Infected right fascial spaces?
Infected sarcoma? B
Metastasis from supraclavicular primary tumor? Fig. 20.7A and B: Chest X-ray
Thyroid
Salivary gland
Metastasis from infraclavicular primary tumor?
Lung
Esophageal.

Routine Blood Investigations


Raised neutrophil count.

Differential Diagnosis
Infected sarcoma
Malignant salivary gland tumor Fig. 20.8: USGcolor doppler showing increased soft
Culture results negative. tissue mass

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Chapter 20: Role of Chemotherapy and Radiotherapy in Oral and Maxillofacial Carcinoma 199

Fig. 20.9: MRI axial showing extensive homogenous hypotense mass

Fig. 20.10: Coronal View hypotense mass Fig. 20.11: ELISA HIV negative

Fig. 20.12: Incisional Biopsy Fig. 20.13: Histopathology (I)

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200 Section 3: Carcinomas of Oral Cavity
Lymphomas account for 45 percent of all
neoplasms
Non-Hodgkin's lymphoma accounts for 65
percent
Incidence is low in Asia.
Williams et al, Hematology 4th edition 1991
Shohat et al Oral Surg, Oral Med, Oral pathol
2004:97:328-31.

ETIOLOGY
Unknown.

Predisposing Factors
Fig. 20.14: Histopathology (II) Exposure to drugs or infectious agent
History of Sjgrens syndrome
Immunohistochemistry Immunosuppression
Previous irradiation
CD-20:Positive
Williams et al. Hematology 4th edition 1991
CD-3: Negative
Stenson et al. Am J of Otolar 1996;17(4);276-80.
Summary
Rapidly growing soft tissue swelling in 33 yr
PATHOGENESIS (FIG. 20.15)
female Clinical Presentation
Not responding to antibiotics
Males
No obvious odontogenic cause
5th7th decades
USG increased soft tissue mass
Tonsil- Waldeyers ring (34%) followed by
MRI extensive homogenous hypointense mass
salivary glands (15%)
Histopathology: immature lymphoblast.
Swelling or mass (59%)
Final Diagnosis Pain and dysphagia (7%)
Primary osseous lymphoma accounts for 4% of
Extranodal non-Hodgkin's lymphoma ANN-
all ENH
ARBOR stage II E.
Mandible is most common site presenting as
osteolytic lesion
Management
Hart et al. Clinical Oncology 2004;16;186-92
Chemotherapy Bryan et al. The Lancet Onc 2004:5:341-53
CHOP regimen: 4 drugs Gusenbauer et al. J O M S 1990;46;409-15.
1. Cyclophosphamide.
2. Doxorubicin.
CLASSIFICATION
3. Vincristine.
4. Prednisone. Working Formulation
Post-chemotherapy Low Grade
Lymphomas are a heterogenous group of Small lymphocytic
neoplastic disorders originating from the Follicular small cleaved cell
lymphoreticular system Follicular mixed cell

Ch-20.indd 200 15-04-2013 10:27:39


Chapter 20: Role of Chemotherapy and Radiotherapy in Oral and Maxillofacial Carcinoma 201

Fig. 20.15: Pathogenesis of cancer cell

Intermediate Grade Angioimmunoblastic T cell lymphoma


Follicular large cell Anaplastic large cell lymphoma.
Diffuse mixed cell
Diffuse large cell Hodgkins Disease
Harris, et al Blood 1994;84(5);1361-92.
High Grade
Immunoblastic Staging
Lymphoblastic ANN-ARBOR staging
Rosenberg et al Cancer 1982;49;2112-35. Stage I: Involvement of a single lymph node
region or of a single extranodal organ or site
REVISED EUROPEAN-AMERICAN (IE)
Stage II: Involvement of two or more lymph
LYMPHOMA [REAL] node regions on the same side of the diaphragm,
B-Cell Neoplasms or localized involvement of an extranodal site
or organ (IIE) and one or more lymph node
Precursor b-cell neoplasms
regions on the same side of the diaphragm
Peripheral B-cell neoplasms
Stage III: Involvement of lymph node regions
Mental cell lymphoma
on both sides of the diaphragm, which may
Follicle cell lymphoma
also be accompanied by localized involvement
Marginal zone b-cell lymphoma
of an extranodal organ or site (IIIE) or spleen
Hairy cell leukemia
(IIIS) or both (IIISE)
Lymphoplasmacytoid lymphoma
Stage IV: Diffuse or disseminated involvement
Diffuse large B-cell lymphoma
of one or more distant extranodal organs with or
Burkitts lymphoma.
without associated lymph node involvement.
T Cell and NK Cell Neoplasms
Systemic Symptoms
Precursor T cell neoplasms
A-No symptoms
Peripheral T cell neoplasms
B-Weight loss >10% in 6 months, fever, night
Mycosis fungoides
sweats
Peripheral T cell lymphoma
Carbone et al. Cancer Res 1971;31;1860.
Angiocentric lymphoma

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202 Section 3: Carcinomas of Oral Cavity

RECOMMENDED PROCEDURE FOR MOPP- Nitrogen mustard-6 mg/m2 IV


STAGING Oncovin-1.4 mg/m2 IV
Prednisone-40 mg/m2
General Procarbazine-100 mg/m2
1 . History and physical examination. Williams et al. Hematology 4th edition 1991.
2. Pathologic diagnosis from biopsy specimen with Monoclonal Antibodies - Bryan et al.
review by an experienced hematopathologist. Rituximab-anti CD-20 antibody
3. Laboratory studies: complete blood count,
Tositumomab-anti CD-20 antibody
blood chemistry, LDH ,beta-2 microglobulin, Alemtuzumab-anti CD-52 antibody.
uric acid, renal and liver function HIV testing.
4. Bone marrow aspiration and biopsy . ROLES OF RADIOTHERAPY
5. Chest X-ray, CT scan of chest, abdomen, and Madam Curie discovered radium in 1878. Same
pelvis. year it was used for treatment of cancer.
Alexander Grahambell wrote a letter to Dr Sowers
Additional in 1903 to try placing radium into very heart of
1. Ultrasonography and MRI to clarify CT scan tumor.
abnormalities.
2. Gallium scan in large masses. Introduction
3. Lumbar puncture. The main aim of delivering radiation in treating
4. Gastrointestinal studies. malignancies is to treat the tumor and spare
5. CT scan or MRI of brain. normal tissues. In this direction medical
6. MRI to detect bone marrow involvement. technology has revolutionized the way radiation
Swan et al. J Clin Oncol 1989;7:151827. was delivered using deep X-ray and the present
use of advanced medical linear accelerators with
SPREAD OF ORAL LYMPHOMA sophisticated computer software.
Radiation therapy may be used alone for the
Lymphatic spread via cervical lymph nodes to treatment for head and neck cancer, or it may
extranodal organs be used before/after surgery for the combined
Contiguous spread to adjacent organs modality treatment of patients with high-risk
Blood-borne distant metastases cancers
Takahashi et al. J Oral Max Surg 1990;46;409-15. Many advanced but resectable head and neck
cancers require both surgery and radiation
TREATMENT OPTIONS therapy for optimal control
For early to intermediate cancers, either
Radiotherapy radiation therapy or surgery alone may lead to
20002500 cGypalliative therapy equivalent control
45005000 cGycurative therapy. For most early oral cavity cancers, a functional
outcome is best achieved by resection and
CHEMOTHERAPY reconstruction, if needed
CHOP-Cyclophosphamide: 750 mg/m2 IV In contrast, small glottic tumors located near
Oncovin: 1.4 mg/m2 IV the commissures are more expediently treated
Adriamycin: 50 mg/m2 IV and have better functional outcomes with
Prednisone: 100 mg radiation therapy.

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Chapter 20: Role of Chemotherapy and Radiotherapy in Oral and Maxillofacial Carcinoma 203

Types of Radiation Definitive Radiotherapy alone for early larynx


X-rays produced electrically are the primary cancer
modality used in radiation therapy for head Preoperative Radiotherapy before neck dissection
and neck cancer. Other modalities for external for a fixed nodal mass
radiation therapy (teletherapy) are electrons, Postoperative Postoperative radiotherapy after
also produced electrically, and gamma rays, composite resection of oral cancer
which are derived from cobalt-60 sources Palliative Radiotherapy for massive incurable
Radioactive sources such as cesium 137, iodine head or neck cancer causing pain or
125, or iridium 192 also produce gamma rays bleeding
and can be placed directly into (interstitial Benign Radiotherapy for refractory keloids
brachytherapy) or next to (intracavitary of the skin
brachytherapy) a tumor
Less commonly used and highly specialized
external modalities The only difference is the origin. X-rays are
Gamma rays and X-rays behave identically made electronically from some type of X-ray
both physically and biologically once they are machine, whereas gamma rays are emitted
formed both are photons (packets of energy from the disintegration of unstable radioactive
without mass or charge). isotopes (radioactive decay)
The energies of all therapeutic radiations are
sufficient to break chemical bonds in critical
Pro-surgery Pro-radiotherapy
targets primarily DNA within tumor cells,
Relatively quick, Avoids prolonged general
leading to cellular death.
expeditious treatment anesthesia; few medical
contraindications
X-ray Energy: Orthovoltage and
Ability to assess Lower risk of systemic
prognosis through complications (e.g. Megavoltage
pathologic assessment sepsis, pneumonia, In diagnostic X-ray machines, the electrons
of specimen (e.g. pulmonary embolism, are accelerated toward the target by being
margins) and alter acute treatment mortality)
placed within a large potential difference, they
treatment accordingly
(e.g. add postoperative
are attracted to the positively charged anode
radiotherapy or additional and accelerate toward it proportionate to the
surgery) potential difference applied across the circuit.
Avoids risk of permanent Ability to more easily A target is placed at the anode
radiation xerostomia and treat a larger volume This is a highly inefficient process, as more
other late dental or oral of potential occult than 99 percent of energy is lost to heat
complications microscopic disease (e.g. This technique limits the maximal velocity
both sides of neck, base achievable by the electrons and thus limits the
of skull, supraclavicular maximal energy of the X-rays that are created.
fossa)
This energy range up to hundreds of kilovolts is
Preserves the ability to Ability to preserve normal sufficient for diagnostic imaging and was used
use radiotherapy in the anatomic structure,
historically for orthovoltage Xx-ray therapy; it
future, if needed cosmesis, and often
function
is now used only for selected skin cancers
X-rays for modern radiation therapy are made
Avoids the risk of Treatment can usually be
by a linear accelerator, which uses microwaves
radiation carcinogenesis given on an outpatient
(thyroid, sarcoma) in basis, and many patients for electron acceleration. Microwaves are
young patients can continue to work nonionizing electromagnetic radiations. The
during treatment electrons can be conceptualized as being
accelerated by riding the crests of the microwaves

Ch-20.indd 203 15-04-2013 10:27:39


204 Section 3: Carcinomas of Oral Cavity
Electron velocity approaches 90 percent of the Megavoltage radiation therapy is bone
speed of light. This is a much more efficient sparing. Megavoltage radiation is absorbed
process and leads to X-rays with energies differently in tissues owing to the Compton
measured in the millions of megavoltage effect, which is independent of atomic
radiation number. Therefore, bone and soft tissue
Lower-energy X-rays deposit their maximal within the irradiated volume absorb approx-
energy at or near the skin surface, leaving little imately the same doses.
energy for greater depths
This makes them efficient for use in the Steps Involved in clinical radiation therapy
treatment of cutaneous lesions but extremely Consultation, including decision to irradiate.
inefficient for the treatment of nodal or Preradiation work-up, including staging, dental
mucosal carcinomas at depths beyond 2 cm evaluation, nutritional assessment
from the skin surface
Simulation, including immobilization of the area to be
Higher-energy X-rays beams deposit their irradiated
maximal energy below the skin surface (skin
Dosimetry (calculation of radiation dose to tumor and
sparing) and penetrate more deeply normal structures)
An additional disadvantage of lower energy
Setup or final quality assurance planning session
X-rays is that they interact with tissues
dependent on the atomic number (number of Radiation treatments, including on-treatment visits by
the physician(s)
protons) of the tissue, raised to the third power
(photoelectric effect). Because the difference Conedown(s) if applicable: repeat of steps 3 through 6
between the atomic number of soft tissue and Postradiation follow-up visits
of bone is approximately two, this means that
diagnostic and orthovoltage X-ray energy, in Radiation Therapy Simulation, Treatment
principle, is absorbed up to eight times more
by bone than by soft tissue Planning, and Dosimetry
This is highly undesirable for treatment of Simulation process is designed to place the
mucosal head and neck cancers, however, radiation field and its dose where the tumor is,
because the surrounding bones of the jaw and while excluding as much of the surrounding
skull would absorb far more energy than the normal tissue as possible
tumor In order to aim the radiation beam, a diagnostic
There are three main advantages of megavoltage X-ray energy machine called a simulator
radiotherapy: is used. The simulator is mechanically and
The higher-energy X-rays deposit at greater optically identical to the treatment linear
depths, allowing for a more homogeneous accelerator, except that it allows for fluoroscopy
dose in the treatment of tumors at any head and uses diagnostic energy X-rays instead of a
and neck location and at any internal depth megavoltage X-ray. The resulting diagnostic-
The maximal energy is deposited approxi- quality images facilitate aiming of the beam by
mately 1 cm deep to the skin surface. Thus visualizing internal structures
megavoltage radiation therapy is skin The majority of treatment fields are set up
sparing. Even though patients may develop isocentrically. This means that the patient
bothersome skin reactions during mega- is positioned so that the center of the tumor
voltage radiation therapy, they are much target volume corresponds to a point in space
less severe than the reactions occurring with representing the intersection of the center of
orthovoltage treatment the radiation beam coming from the head of

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Chapter 20: Role of Chemotherapy and Radiotherapy in Oral and Maxillofacial Carcinoma 205
the machine and a line through the center of This requires reliance on the imaging and
the axis of the rotation of the gantry computerized planning system for both place-
Because the radiation gantry moves in a ment and verification of radiation ports. The
360-degree circle around the patient, the ability to use unusual field angles shaped by
isocentric technique guarantees that the center highly conformal shielding blocks represents
of the radiation field always corresponds to the three-dimensional or conformal, treatment
center of the tumor target volume. This allows planning
radiation to be delivered in multiple beams The main advantage of these techniques is the
from any angle; they intersect and deliver an potential for the delivery of higher radiation
additive dose to the tumor while traversing doses to the tumor with the goal of improving
different normal tissues, thereby minimizing control, while minimizing dose and toxicity to
their dose accumulation and consequent risk critical normal structures
for toxicity and injury. X-ray fields are rectangular, and the borders are
defined by collimators. These X-ray fields are set
Beam Angles and Fields up for individual patients at the time of simula-
Once a patient is immobilized, the radiation tion. Fluoroscopy allows for rapid placement of
oncologist determines the specific beam fields and verification with diagnostic-quality
angles to be used. Critical normal structures X-ray films, called simulation films
in the entry-exit path have a major impact on The radiation oncologist can further customize
beam selection the shape of the port within the rectangular
The entire neck from the lower limit of the radiation treatment field by the addition of
clavicle to the skull base requires treatment shielding blocks made of a lead alloy called
for most patients. Because opposed anterior cerrobend. This allows for the protection of
and posterior fields do not allow for selective sensitive normal structures not at cancer risk.
shielding of critical structures such as the eyes
or spinal cord, it is common to use right and Course of Radiation Therapy and
left lateral opposed fields its Toxicities Risks and Potential
Wedge pair for lateralized tumors confines Complications
radiation and its toxicities, especially mucositis A typical course of radiation therapy for head
and xerostomia, to one side with a wedge- and neck cancer is delivered 5 days per week,
shaped dose distribution Monday through Friday, over 7 weeks for 35
It is the role of radiation dosimetry to determine fractions. Each individual treatment takes a
the appropriate number of radiation pulses or few minutes
monitor units required to deliver the prescribed There are no immediate side effects for most
daily dose for a specifically sized and shaped patients. There is one exception: about 5 percent
radiation field for an individual patient, of patients develop a self-limited parotitis after
accounting for his or her size, shape, surface the first fraction that spontaneously resolves in
contour, thickness, and tissue homogeneity 1 to 2 days
As a result of this process, graphic representa- Toxicities that occur during or shortly after
tions of radiation dose distribution (dose range the completion of radiation therapy are called
and homogeneity) within a treatment volume, acute effects, and those that occur several
called isodose plots, are generated months or longer after completion of radiation
With segmental imaging techniques of CT and therapy are called late effects
MRI, radiation oncologists began using more The acute effects generally start after 23 weeks,
unusual beam angles and include dermatitis, swelling, mucositis,

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206 Section 3: Carcinomas of Oral Cavity
permanent xerostomia, and usually temporary mandible is defined as an area of gingival
loss of taste dehiscence lasting more than 6 months in
Irradiation does not appreciably affect tissue which nonvital bone is exposed and does not
temperature, but the acute skin reaction heal with local wound care
resembles a suntan or, if severe, a burn. The skin ORN occurs sporadically and spontaneously in
adnexa are also affected, leading to epilation half of cases but occurs more predictably as a
and dryness result of trauma
Mucositis is manifested by pain, odynophagia. If dental extraction or invasive surgery is
Weight loss required after radiotherapy, hyperbaric oxygen
Temporal bone radiation may lead to serous (HBO) therapy has been shown to decrease the
otitis media, which is generally self-limited but risk of ORN from about 305 percent
may require myringotomy The spinal cord is irradiated in many head
Nasal radiation leads to crusting. There will be and neck setups. If the dose exceeds the
temporary hoarseness if the larynx is irradiated tolerance a complication is possible. Acute
Xerostomia begins within the first week of transient radiation myelopahty (ATRM), or
radiotherapy, progresses, and is generally Lhermittes syndrome, is characterized by
permanent. Studies indicate a 35 percent to shock-like tingling paresthesias radiating to
50 percent decrease in stimulated salivary flow the extremities
at the end of the first week of radiotherapy. ATRM is thought to be a result of transient
This increases to an 80 percent to 90 percent demyelination of the posterior columns
decrement by the end of radiotherapy. Serous It usually starts 13 months following radiation
acini are more radiosensitive, so patients are and is thought to be self-limited, lasting 19
left with more scant and viscid secretions months
Excretion was maintained in all salivary Transverse myelopathy generally starts 618
glands exposed to 25 Gy or less, and in about months following radiotherapy and represents
50 percent of salivary glands at doses of 2545 irreversible lower motor neuron injury. This
Gy. Recent studies suggest that pilocarpine is probably the most feared of all radiation
and amifostinell may either palliate or reduce complications, as it may progress to the loss of
xerostomia. Dilute salt and baking soda oral all spinal cord function
irrigations help dissipate radiation-induced The generally accepted tolerance of the spinal
thick secretions cord is 4550 Gy
Expected late effects include chronic skin If the thyroid is irradiated, at least one-third of
changes such as mild altered pigmentation, patients will develop abnormally high thyroid-
epilation, telangiectasia, edema, and subcuta- stimulating hormone levels. Patients may not
neous induration become symptomatic for some time, but this
The severe form of bone damage is osteo- overstimulation may lead to the development
radionecrosis (ORN). Meticulous pretreatment of thyroid nodules and tumors. Screening for
evaluation is required so that patients with hypothyroidism is part of routine surveillance.
dental problems can have bad teeth restored
or extracted. All teeth maintained must receive Shrinking Field or Cone-down Technique
adequate lifetime dental prophylaxis, including
Radiation therapy is fractionated over many
daily fluoride treatment and a rigorous hygiene
weeks, and the beam angles, field sizes, and
program
techniques of delivery are altered to maximize
ORN can occur in any cancellous bone but is
a differential effect on the tumor while limiting
seen most often in the mandible. ORN of the
the effects on normal tissue

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Chapter 20: Role of Chemotherapy and Radiotherapy in Oral and Maxillofacial Carcinoma 207
The larger the deposit of tumor cells, the greater Brachytherapy
the dose of radiation therapy required for control. Brachytherapy represents an alternative
Grossly visible tumor requires at least the full technique for a final cone down boost. The
prescribed radiation dose, whereas microscopic radioactive source may be placed directly
disease several centimeters away may be into tumors, called interstitial brachytherapy
eradicated with a 1020 percent lower dose (e.g. for tongue or floor of the mouth tumors),
Other regions at risk even farther from the or adjacent to tumors, called intracavitary
gross and microscopic tumor may require brachytherapy (e.g. for nasopharynx tumors)
an even smaller dose because of an even
The advantage of brachytherapy is based on
smaller tumor cell infestation. This allows the
the inverse square effect described earlier, in
radiation oncologist to use a shrinking field or
which an extremely high dose of radiation is
conedown technique in which newer, smaller
delivered to the tumor while delivering a much
fields are used successively during the course
lower dose to the surrounding normal tissue.
of radiation therapy
Effective brachytherapy requires surgical skills
A constant radiation dose per fraction is
and appropriate resources
administered, but to progressively smaller
Brachytherapy is established and indicated
volumes. This technique allows for reducing the
as a boost for early nasopharynx cancers, is
volume of normal tissues, especially mucosa,
considered by most a requisite for definitive
exposed to the highest doses of radiation
treatment of early oral tongue and floor of the
therapy, thereby limiting toxicity
mouth cancers, and is used commonly for base
Additionally, changing beam angles to traverse
of the tongue cancers. Brachytherapy can, in
different areas of normal tissue. spreads out the
principle, be applied to any other head and
entry-exit path dose so that the same normal
neck site and is limited only by the imagination
tissue areas surrounding the treatment volume
of the therapist.
do not receive the cumulative dose
The reality of cure for an individual patient is
dependent on the elimination of the last tumor
Fractionation
cell. A constant proportion of tumor cells is Fractionation refers to the schedule on which
killed with each fraction of radiation therapy. the radiation dose is administered
This may vary from less than 4060 or more Standard radiotherapy is administered daily, 5
There is no absolute resistance to radiation days a week, with weekends off. In an effort to
therapy, unlike the potential for tumor cell maximize damage to the more rapidly dividing
survival with chemotherapy tumor cells while sparing normal tissues as
This is because whereas the cell membrane much as possible, fractionation schedules
may be an absolute barrier to the entry of, or have been altered
a mechanism for eliminating, chemotherapy It is now well recognized that there is a clinical
drugs, the cell membrane is not a barrier to advantage to multiple-exposure therapy.
ionizing radiation therapy Multiple fractions controlled tumors better
Clinically, there can be relative resistance than single larger doses, and, paradoxically,
to specific doses of radiation therapy for normal tissues tolerated repeated small doses
individual tumors, and in some cases, the total better than single large doses
dose required for cure exceeds that which the Accelerated fractionation refers to an overall
surrounding normal tissue can tolerate reduction in treatment time accomplished by
In principle, almost all tumors can be giving two or more daily dose fractions of close
controlled by radiation therapy if a sufficiently to conventional size.
high dose is delivered. It is the normal tissue Hyperfractionation implies that the overall
tolerance that limits the dose prescribed. treatment time is conventional or slightly

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208 Section 3: Carcinomas of Oral Cavity

Table 20.4: Site specific radiotherapy


Site Indication Technique
Oral tongue/floor of mouth Radiotherapy (mandatory boost) Interstitial: Implant via submental approach
Base of tongue Radiotherapy boost or for palliation As for oral tongue
after local failure
Nasopharynx Radiotherapy boost or for palliation Intracavitary: Insertion using nasogastric or
after local failure endoracheal tube
Neck Postoperative radiotherapy after Interstital: Temporary catheter implant or
incomplete resection permanent iodine 125 seed placement into
operative bed

reduced, but an increase in total dose is cells will be killed, and there will be relative
achieved by giving two or more small-dose sparing of hypoxic cells
fractions on each treatment day. Each of these Reoxygenation represents the process by
regimens is associated with varying degrees of which the oxygen gradient is restored to
early and late toxicities the remaining hypoxic cells in the interval
For example, some clinicians feel that long- between radiation therapy fractions, restoring
term effects such as osteoradionecrosis are the potential for further cell killing
increased with hyperfractionated schedules, It has also been suggested that more hypoxic
especially when combined with concomitant tumors would be more radioresistant. Recent
chemotherapy data on several human tumors suggest that
The radiobiologic principles explaining why oxygen measurements made by an interstitial
fractionation allows for tumor control without needle, the Eppendorf probe, may predict
local necrosis are the four Rs: tumor behavior and response to treatment
In general, more hypoxic tumors have lower
"Four R's" local control and a greater probability for the
Repair development of distant metastases, independent
Reoxygenation of whether treatment is with surgery or radiation
therapy
Repopulation, and
More recently, the hypoxic toxin tirapazamine
Redistribution
has been shown to augment radiation response
in experimental models by selectively killing
Repair is a series of enzymatic processes hypoxic cells not killed by radiation exposure
of intracellular mechanisms for healing Repopulation, which refers to the ability of
intracellular radiation damage. Patients who various cell populations to divide in the interval
lack enzymes that are important for DNA repair between radiation therapy fractions.
are extraordinarily sensitive to radiation injury Accelerated repopulation may occur in
Reoxygenation The sensitivity of tumor cells tumors during radiotherapy, so it is important
to the lethal effects of radiation varies with the to complete any planned course as quickly
local oxygen concentration. There may be as as possible (i.e. minimizing unscheduled
much as a 2.53-fold ranges of sensitivity to cell interruptions)
killing, depending on oxygen concentration Some fractionation schedules are designed to
There is a gradient of oxygenation and hypoxia get the total dose even more quickly (acceler-
within a tumor. When a fraction of radiation is ated fractionation) to minimize the effect of
applied, the more radiosensitive oxygenated tumor regrowth

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Chapter 20: Role of Chemotherapy and Radiotherapy in Oral and Maxillofacial Carcinoma 209

Redistribution this reflects the relative Although it is possible to achieve control of


variability of cell radiosensitivity throughout some tumors when a mass persists at the
the cell cycle. In some cell lines, relative end of radiation therapy, this is uncommon
radiosensitivity can vary threefold from one in practical terms. For carcinomas that are
part of the cell cycle to another. not cleared toward or by the end of radiation
In general, the cells are considered to be the therapy, durable control is uncommon
most radiosensitive during the mitotic phase Radiosensitizers are agents that enhance the
(late G2) and most radioresistant in late radiation effect without having any necessary
S-phase. direct antitumor effects
Clinical radiotherapy represents the balance The strongest radiation sensitizer ever
among the four Rs for tumor versus normal discovered is oxygen. Many early experiments
tissue. with radiosensitizers involved various modes
of oxygen delivery or the use of drugs that
Fractionation schedules can be defined by
mimicked the effect of oxygen.
Dose per fraction
Number of fractions per day Preoperative and Postoperative Radiation
Overall treatment time Therapy
Total cumulative radiation dose Many patients with stage III and IV head and
neck cancer are at high risk for local regional
recurrence even after gross total resection of
Radiosensitization and Radioresistance their cancers. The combination of surgery and
In clinical radiation therapy, it is noted that radiation therapy can improve local regional
some tumors shrink more rapidly than others control and perhaps survival
during a course of radiation therapy. The rate The most common approach involves the use
of relative tumor regression can be described of postoperative radiation therapy. This allows
as its Radioresponsiveness. The rate of tumor the surgeon to operate on tissues unaffected by
regression depends on the time to expression radiation therapy, it allows for surgical staging
of its lethal injury to identify areas at highest risk.
It is generally accepted that most irradiated
head and neck squamous cancer cells undergo The indications for postoperative radiation
therapy include
a mitotic death, or loss of clonogenicity. A
tumor cell with a lethal injury may live for Large infiltrating tumors
some time but must attempt to divide before Compromised margins of surgical resection
expressing that injury. In other words, a tumor Perineural spread
cell does not know it is dead, until it tries to Extension of the tumor into the deep soft tissues
divide or bone
Thus the underlying rate of tumor cell turnover Multiple lymph nodes
that determines the rate of tumor regression,
Large lymph nodes
or radioresponsiveness
There is no absolute relationship between the Extracapsular nodal spread
rate of tumor response and its ultimate control.
Radiation-induced cell killing may even Generally, postoperative radiation therapy is
persist for many weeks after the completion of initiated 46 weeks after surgery, or earlier if
radiation therapy practical.

Ch-20.indd 209 15-04-2013 10:27:40


210 Section 3: Carcinomas of Oral Cavity
This is based on several retrospective studies This technique has generally fallen out of favor
suggesting that further delays may compromise because it is now believed that if a tumor is
tumor control and survival. There is a suggestion initially unresectable, preoperative radiation
that the overall treatment package time from therapy will not make it so
the time of surgery until the completion of Radiation therapy may be helpful, however,
radiation therapy may also be an important for borderline resectable tumors, particularly
factor for tumor control and possibly survival. large neck nodes
This is based on the concept of accelerated Theoretical advantages of preoperative
repopulation of tumor clonogens radiation therapy are that blood supply may be
It is therefore important that patients undergo better than after surgery, leading to improved
oral medicine evaluation very early. If dental oxygenation, and that tumor seeding during
restorations or extractions are required, these surgery may be decreased
must be done at or close to the time of ablative Major disadvantages of preoperative radiation
surgery so that all surgical wounds can heal therapy are the loss of definitive tumor staging
during the same interval, avoiding a delay in and the lower doses given because of concern
starting radiation therapy about an increase in surgical morbidity
Planned preoperative radiation therapy has Many tumors will regress within 68 weeks
been used in the past for tumors thought to of RT. Preoperative RT has been limited to
be unresectable or at high-risk for incomplete 4550 Gy in total dose to avoid incidence of
resection postoperative complications (Figs 20.16A to C)

B C
Figs 20.16A to C: Postradiotherapy skin changes

Ch-20.indd 210 15-04-2013 10:27:41


Chapter 20: Role of Chemotherapy and Radiotherapy in Oral and Maxillofacial Carcinoma 211
therapy may control larger nodal masses, the
frequency and reliability of this control are lower
It is therefore accepted that when radiation
therapy is selected as the modality to control the
primary tumor, neck dissection may be added if
there is an initial gross lymph node independent
of the response to radiation therapy
Even with complete clinical tumor clearance,
studies have shown that up to 40 percent of
neck dissection specimens harbor tumor cells
thought to be viable.

Radiation Therapy: Sites and Subsites


(Fig. 20.18)
Carcinoma Oral Tongue
Exophytic T1 and T2 superficial lesions of
the anterior 3rd and tip without deep muscle
invasion best treated with wide local excision
T1 and T2 lesions of middle 3rd and which
require more extensive resection up to
Fig. 20.17: Radioprotective shield
hemiglossectomy are better treated by radical
RT
Planned preoperative radiation therapy usually Posteriorly seated tumors with infiltration into
involves a lower dose of radiation therapy tongue base are better treated EBRT or with
5060 Gy using a protective shield (Fig. 20.17) surgery and postop RT
and is followed by surgery in approximately Extension into gingiva or mandible is
48 weeks. contraindicated for RT alone as subsequent
There is a window of opportunity for surgery ORN may develop.
when the acute inflammation of radiation is
optimally resolving but the chronic sequelae Carcinoma Floor of Mouth
of fibrosis and vascular changes that impede For tumors more than 4 cm, brachytherapy
wound healing are not pronounced is a relative contraindication because an
Salvage surgery, in contrast, is performed on interstitial implant will result in local soft-
an unplanned basis generally months to years tissue ulceration and risk of ORN due to the
after the completion of full dose (6570 Gy) decreased distance between gingival mucosa
radiation therapy and bone (Fig. 29.19)
This is done for recurrent or persistent cancers Interstitial implant is suitable for small tumors
that are associated with poorer outcomes (T1 lesions with well-demarcated borders). For
with respect to tumor control and greater T3 or T4 lesions, combined EBRT (preoperative
normal tissue complications because of more or postoperative) and surgery is appropriate.
pronounced late effects
The main use of postradiation surgery involves Buccal Mucosa
management of the neck when there is initial In small superficial T1 tumors, surgery and RT
gross nodal disease. Lymph nodes less than 2 can be used. In lesions larger than 1 cm, neck
to 3 cm can generally be well controlled with dissection is preferred to EBRT with the primary
radiation therapy alone. Although radiation treated with brachytherapy.

Ch-20.indd 211 15-04-2013 10:27:41


212 Section 3: Carcinomas of Oral Cavity

B
A
Figs 20.18A and B: Cobalt radiotharapy unit

A B

Figs 20.19A and B: Case of osteoradionecrosis post-radiotherapy

Maxillary Tumors the contralateral sinus. The ethmoid sinuses


Tumors of the maxilla are generally first treated are also included.
with surgery postoperative RT is indicated
Management of Neck
in all except small lesions resected with wide
In large and less well differentiated. tumors of
margins. The retro maxillary prevertebral
the tongue, floor of the mouth, gingiva, buccal
space is generally included to cover lymphatic mucosa without clinical involvement of the
drainage lymph node, elective (adjuvant) RT is performed
In tumors of the antrum, the orbit is not Combined RT and neck dissection is the proce-
included in the treatment volume. Shielding of dure of choice in for N1 and N2 neck after the
the orbital contents is mandatory primary lesion is controlled. Postoperative RT
Tumors of the PNS need an extended irradia- is also indicated in patients with extracapsular
tion volume to include the medial border of extension in the histospecimen.

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Chapter 20: Role of Chemotherapy and Radiotherapy in Oral and Maxillofacial Carcinoma 213
Salivary Gland Tumors peak. This limits the ionization process to a
well-defined area near the terminal range of
Indication
the proton
Perineural invasion of tumor The biologic qualities LET and RBE of protons
Locoregional LN mets are very similar to those of photons. The major
Incomplete or marginal resection advantage of protons is this physical property.
High-grade malignancy The use of protons allows for the placement of
a tightly defined three dimensional volume of
Extraparotid extension of tumor
dose deposition while sparing the surrounding
Tumor cell spill during surgery
normal tissue. This is particularly helpful
Enucleation of tumor in central locations, for example, at or near
the optic apparatus and pituitary region.
Advances in Radiation Therapy Protons and electrons deposit their energies at
opposite ends of their paths: electrons earlier,
Other particles that can be used for the
and protons later
treatment of head and neck cancer include
protons and neutrons. Neutrons and protons
The main aim of delivering radiation in
treating malignancies is to treat the tumor
have equivalent masses of approximately 2000
and spare normal tissues. In this direction
times the mass of an electron. Neutrons have
medical technology has revolutionized the
no charge, and protons have a unit charge
way radiation was delivered using deep X-ray
of +1. The use of neutrons has been mainly
and Tele cobalt machines in 60s and 70s and
experimental, except in the treatment of
the present use of Advanced medical linear
unresectable salivary neoplasms
accelerators with sophisticated computer
The main advantage of neutrons is enhanced
software.
biologic efficiency. For any unit distance
traveled by a neutron, there is a higher degree
3D CRT
of ionization than with most other forms of
radiation therapy. Neutrons cause substantially Telecobalt machines, with Co-60 as the
more ionizing damage than X-rays, protons, source of radiation, were first installed in the
or electrons. This deposition of energy per early 1950s. They become highly popular
unit length or density of ionization is called and continued to dominate the radiotherapy
linear energy transfer (LET). The advantage scenario till the 70s when Medical Linear
of neutrons is based on their high LET accelerator was installed
characteristics. A given dose of neutrons thus The treatment was given two dimensionally
leads to greater tissue damage in both tumors where normal tissues and the tumor was
and normal tissue than does the same dose irradiated as a conventional treatment
of photons. The goal, as always in radiation But the main goal of radiotherapy is to deliver
therapy, is a therapeutic index. Neutrons are high radiation dose to the tumor with as less as
thus said to have a greater relative biologic possible dose to the normal tissues
effect (RBE) During the past two decades, advances in
Protons and other heavy charged particles have radiological imaging and computer technology
a unique way of depositing their doses. Toward have significantly enhanced our ability to
the end of their deceleration process deep achieve this goal through the development of
in tissue, protons stop abruptly and rapidly Three-dimensional -image based conformal
deposit their energy in what is called the, Bragg radiotherapy (3D CRT) (Figs 20.20 and 20.21)

Ch-20.indd 213 15-04-2013 10:27:42


214 Section 3: Carcinomas of Oral Cavity
data sets primarily CT more recently often
supplemented with Magnetic resonance
imaging (MRT). From these inputs the planned
dose distributions are then calculated and
displayed by advanced treatment planning
systems
In the delivery of 3D CRT Computer controlled
radiation machines with multileaf collimators
(MLC) and treatment verification with
electronic portal images, are increasingly used.

Intensity Modulated Radiation Therapy


Intensity modulated radiation therapy (IMRT)
is an advanced method of 3D CRT (super
Fig. 20.20: The ring gantry-based platform combines
integrated CT imaging with conformal radiation therapy
conformal therapy) that utilizes sophisticated
computer controlled radiation beam delivery
to improve the conformality of the dose
distribution to the shape of the tumor
The radiation beam can be made to bend
the way you want it treating the tumor and
sparing the normal tissue like spinal cord. This
is a medical revolution in technology. This is
achieved by the use of multileaf collimator
capable of dynamic beam delivery or multiple
static beams sequentially altered in shape by
the MLC
Both 3DCRT and IMRT utilizes sophisticated
strategies for patient immobilization and
positioning and computer enhanced treatment
verification
The treatment planning steps for IMRT are
similar to 3DCRT during initial and final
stages but the diverge in the middle. In IMRT
the treatment planner would not specify the
MLC settings as these would be calculated by
Fig. 20.21: linear accelerator radiotherapy machine
the computer. Once all relevant tissues have
been delineated and beam direction specified,
Three-dimensional conformal therapy is a the Radiation oncologist specifies the desired
method of irradiating target volume defined doses to tumor and normal tissues. From these
by a set of X-ray beams individually shaped to specifications treatment planning system
conform the two dimensional beams eye view adjust beam shapes and intensities so as to best
projection of the target meet these dose criteria. When the treatment
In 3D CRT the target and non-target structures plan has been accepted, all planning datas are
are delineated from patient specific 3-D image transferred to linear accelerator to deliver the

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Chapter 20: Role of Chemotherapy and Radiotherapy in Oral and Maxillofacial Carcinoma 215
Image-guided Radiotherapy
Image-guided radiotherapy (IGRT) is an
advanced method of IMRT. In modern RT
modalities the volume of the irradiated normal
tissue must be reduced in order to limit acute
and late injury
The reduction of safety margin around the
tumor plays a decisive role in limiting toxicity
The main limitation in margin reduction are
setup errors and organ motion issues. The
only way to reduce the safety margins is the
accurate daily localization of the target volume
with image guided techniques. For these two
couples of X-ray images and acquired for setup
Fig. 20.22: Post-radiotherapy cutaneous fistula and correction and verification in order to evaluate
dental caries
residual target localization errors and intra -
fraction motion. The process of target position
desired X-ray intensities The medical physicist correction and verification takes about 5
must perform dosimetric and QA tasks to verify minutes. The delivery of treatment will be there
that all equipments is functioning properly and while tumor tracking in the same position.
that of the dose prescription and treatment IMRT is an art of precise Treatment planning
plan are accurately delivered to the patient on and IGRT is an art of precise Treatment
a daily basis (Fig. 20.22). delivery.

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Reconstructive Options in
Oral and Maxillofacial Cancer
21
INTRODUCTION for reconstruction of defects. Function of
chewing, swallowing, articulation and lip
Reconstructive surgery has a leading role in the
competence must also be addressed. Ultimate
management of Maxillo-Facial Cancer. The
goal is to restore function, bony continuity,
role of free tissue transfer has revolutionized
tongue movement and restoration of sensation
the resection. The surgical challenge in the
reconstruction of the Face and jaws uniquely With the advent of newer modalities of
involves the restoration of the facial skeleton as treatment and multimodality approach it is
well as the soft tissues of the face and mouth. now possible to decrease morbidity and has
Stereo lithography has recently added a new given a wide scope of reconstructive surgeries
dimension in the planning of complex facial The soft tissue component of the radial forearm
and orbital defects after cancer resection flap is now the favored method of reconstructing
Oral and Maxillo-Facial region reconstruction the soft tissues of the mouth and pharynx. This
after tumor resection is most challenging prob- flap can be made sensate by incorporating
lem since mandible play a major role in airway the antebrachial nerve of the forearm and
protection, support of the tongue, muscles anastamosing this nerve to a donor nerve in
of floor of the mouth, dentition, mastication, the oral region. The improved sensation can
articulation, deglutition and respiration help initiate the swallow reflex and improve
During reconstruction, continuity and contour overall oral function. Reconstruction of the
of the lower third face should be kept in mind, mandible is necessary in about 30% of oral
otherwise it results in deviation of mandible cancer resections. Techniques include the use
towards the resected side due to unopposed of the fibula, iliac crest and scapula flaps and,
pull of remaining muscles of mastication, in selected cases, the immediate placement of
contraction of soft tissue and scar formation implants in the grafted bone enabling rapid
While undertaking reconstruction of deformity, rehabilitation of oral function
restoration of soft tissue, or bony continuity Maxillectomy defects, which may be so
should not be the only criteria. Maxillary extensive as to include evicerated eye, may be
defects are inherently complex because they treated by obturation with prosthesis to fill the
generally involve more than one component large defect which communicates between the
of mid-face and most of them are composite in eye socket and the oral cavity. a combination of
nature intraoral and extraoral implants (for example
A number of local flaps, pedicle flaps, and in the supraorbital rim) offer considerable
Microvascular free flaps have been employed advantages in these situations

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Chapter 21: Reconstructive Options in Oral and Maxillofacial Cancer 217
However, the restoration of the excised bone GOALS OF RECONSTRUCTION
and soft tissues with a vascularised graft
To replicate the function and appearance of
from the iliac crest, incorporating one of the the resected tissue
muscles that lie in the abdominal wall, may be Normal speech, mastication, swallowing, and
a better option for many patients. This allows oral continence
the patient to wear a denture which can be Replace with like tissue
supported by implants in the reconstructed Minimize donor site deformity.
maxilla and the eye can be restored with a
separate implant-retained orbital prosthesis TIMING OF RECONSTRUCTION
Maxillofacial reconstructive techniques are
not as yet able to restore the function of tissues Immediate Reconstruction
to normal that they replace with the exception Is ideal
of the mandible. For example, tissue to replace Prevents retraction and fibrosis of the defect
the tongue can never fulfill the functions of Allows adjuvant therapy
speech, taste and swallowing so important to a Minimizes number of surgical procedures
patients quality of life. Although it is technically Favors psychological rehabilitation.
possible to transplant a tongue with its nerve
and blood supply, further research will have Delayed Reconstruction
to be carried out to assess the function of such Easier identification of recurrence
techniques. On the other hand, we can replace Better appreciation of the defect by the patient.
the structure and function of the mandible
by transferring bone and soft tissue and then Types of defects
placing osseointegrated implants to which a Surface defects
Mucosa
prosthetic appliance can be attached to restore Skin
the function of chewing as well as restore a Full thickness defects
patients appearance and smile. Bony defects
Composite defects
Principles of reconstruction
Minimal morbidity of recipient and donor site Reconstruction options
Replace like with like Primary closure
Skin graft
Functional reconstruction
Local flaps
Esthetic consideration Regional flaps
Adequate vascularity Distant flaps
Free flaps

A MULTIDISCIPLINARY APPROACH
CURRENT APPROACH
Reconstructive surgery is part of the
multidisciplinary team Choose a reconstructive method which best
Adequate reconstruction is the first step in provides with the ideal reconstruction (Fig.
rehabilitation 21.1)
Maximize the quality of life for the patient Small defects does not necessarily require
Restoration of form and function of tissues. reconstruction.

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218 Section 3: Carcinomas of Oral Cavity
Donor siteHeals by epithelialization from
wound edges and from skin appendages.

Full Thickness
Includes epidermis and all dermis
Provides better coverage but is less likely to
take than a split skin graft because of greater
thickness and slower vascularization
Donor site is full thickness skin loss and must
be closed primarily or with a split thickness
skin graft.

Uses
Usually on the face for better color match
On the finger to avoid contractures
Fig. 21.1: Reconstruction ladder Anywhere that thick skin or less contraction of
the recipient site is desire.
Decision making in oral cavity reconstruction is
PRIMARY CLOSURE depicted in Flowchart 21.1.
Should be done without much distortion or
tension FLAPS
V- excision ideal for lip and eyelids.
The term flap originated in the 16th century
from the Dutch word flappe, meaning
SKIN GRAFTS something that hung broad and loose, fastened
Advantages only by one side
Useful for surface defects: mucosa, skin. The flap is a full thickness segment of tissue
Well vascularized bed is must that has its own blood supply.
Full thickness graft for small defects. Flaps differ from grafts in that they maintain
their blood supply as they are moved.
Disadvantages
Criteria for choosing a flap
Graft contraction
Adequate amount of skin or mucosa
Does not resemble original tissues.
Adequate bulk
Split Thickness Good location and color match
Includes epidermis and part of dermis Predictable blood supply
Thickness varies from thin to thick Distance from irradiated sites
A higher percentage of take (survival) is more Low donor morbidity
likely with a thinner graft
Recipient site wound contraction is less with a
Classification of flaps
thicker graft.
By the arrangement of their blood supply
Uses Configuration
Large areas of skin loss Location
Granulating tissue beds Tissue content
May be meshed to allow increased area of
Method of transferring the flap
coverage

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Chapter 21: Reconstructive Options in Oral and Maxillofacial Cancer 219
Flowchart 21.1: Decision making in oral cavity reconstruction

Definition
A flap is a unit of tissue that is transferred from Axial pattern flaps (Facial/faciocutaneous)
one site (donor site) to another (recipient site) Submental
while maintaining its own blood supply or from
Temperoperital
an anastomised vessel.
Deltopectoral
Arrangement of Blood Supply
These include random pattern, axial pattern, and Mathes and Nahai Classification
pedicle flaps. One vascular pedicle (e.g. tensor fascia lata)
Dominant pedicle(s) and minor pedicle(s)
Random Flaps (e.g. gracilis)
Are supplied by the dermal and subdermal plexus Two dominant pedicles (e.g. gluteus maximus)
alone and is the most common type of flap used Segmental vascular pedicles (e.g. sartorius)
for reconstructing facial defects. One dominant pedicle and secondary segmental
Has limited length to width ratio (1.52:1). pedicles (e.g. latissimus dorsi).

Axial Pattern Flaps Pedicle Flaps


Are supplied by more dominant superficial Are supplied by large named arteries that
vessels that are oriented longitudinally along supply the skin paddle through muscular
the flap axis perforating vessels.
Greater length possible than with random flap. Can be

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220 Section 3: Carcinomas of Oral Cavity
Peninsular skin and vessel intact in pedicle Fasciocutaneous Flaps
Island vessels intact, but no skin in pedicle. Fasciocutaneous flaps are tissue flaps that
include skin, subcutaneous tissue, and the
Free Flaps underlying fascia. Including the deep fascia
Refers to flaps that are harvested from a remote with its prefascial and subfascial plexus
region and have the vascular connection enhances the circulation of these flaps. They
reestablished at the recipient site. can be raised without skin and are then referred
to as fascial flaps
Location Use fasciocutaneous flaps to provide coverage
Classification by the region from which the tissue when a skin graft or random skin flap is
is mobilized. This includes local, regional, and insufficient for coverage (e.g., in coverage over
distant flaps: tendon or bones)
Local flaps make use of tissue adjacent to the They are simple to elevate, quick, and fairly
defect reliable in healthy patients
Regional flaps refer to those flaps recruited Because they are less bulky, fasciocutaneous
from different areas of the same part of the flaps are indicated when thinner flaps are
body required. Unlike with muscle flaps, no
Distant flaps are harvested from different parts functional loss occurs
of the body. Cormack and Lamberty classified fasciocuta-
neous flaps based on vascular anatomy.
Configuration Type A is supplied by multiple fasciocutaneous
Flaps are often referred to by their geometric perforators that enter at the base of the flap
configuration. Examples of these flaps include and extend throughout its longitudinal length.
bilobed, rhombic, and Z-plasty. The flap can be based proximally, distally, or as
an island.
Tissue Content Type B has a single fasciocutaneous perforator,
which is of moderate size and is fairly consist-
The layers of tissue contained within the flap can
ent. This flap may be isolated as an island flap
also be used to classify a flap.
or used as a free flap.
Cutaneous flap refers to those flaps that
Type C is based on multiple small perforators
contain the skin only
that run along a fascial septum. The supplying
Fasciocutaneous flap refers to those flaps that
artery is included with the flap. It may be based
contain the fascia and skin
proximally, distally, or as a free flap.
Myocutaneous flap refers to those flaps that
Type D is an osteomyocutaneous flap, similar
contain the skin, subcutaneous tissue, and
to Type C but including a portion of adjacent
muscle. Blood supply of skin and fat comes
muscle and bone. It may be based proximally
from blood vessels perforating the muscle.
or distally on a pedicle or used as a free flap.
Cormak and Lamberty also introduced a new
Muscle/Myocutaneous classification based on clinical applications.
Pectoralis major Type A has a fascial plexus,
Latismus dorsi Type B has a single perforator, and
Reapezius
Type C has multiple perforators and a
segmental source artery.
Masseter
Mathes and Nahai likewise classified
Platysmus fasciocutaneous flaps as Type A (with a direct
Infrahyoid cutaneous pedicle to the fascia), Type B (with a

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Chapter 21: Reconstructive Options in Oral and Maxillofacial Cancer 221
septocutaneous perforator), and Type C (with Method of Transfer
perforators from a musculocutaneous source The most common method of classifying flaps is
based on the method of transfer.
Myocutaneous/Muscle Flap
Advancement flaps are mobilized along a
Myocutaneous flap is a composite soft tissue linear axis toward the defect
flap in which skin portion provided wound
Rotation flaps pivot around a point at the base
closure while the muscle mass merely served
of the flap
as a carrier for the essential blood supply
Muscle flap contains only muscle with its Transposition flap refers to one that is
mobilized toward an adjacent defect over
blood supply, if required further covered with
an incomplete bridge of skin. Examples of
skin graft
transposition flaps include rhombic flaps and
bilobedflaps
Types of muscle flaps Interposition flaps differ from transposition
Type IOne vascular predicle flaps in that the incomplete bridge of adjacent
Type IIDominant vascular predicles and minor skin is also elevated and mobilized. An example
vascular pedicles of an interposition flap is a Z-plasty
Type IIITwo dominant pedicles Interpolated flaps are those flaps that are
Type IVSegmental vascular pedicles mobilized either over or beneath a complete
bridge of intact skin via a pedicle. These flaps often
Type VOne dominant vascular pedicle and
secondary segmental vascular pedicles require a secondary surgery for pedicle division
Microvascular free tissue transfer from a differ-
ent part of the body relies on reanastomosis of
Advantages the vascular pedicle.
Rich blood supply with distinct vascular
pedicle Advancement Flaps (Figs 21.2A and B)
Vascular pedicle is often located outside the Flap directly moves forward into a defect
surgical defect owing to the arc of rotation and without any lateral movement
length of the muscle Advancement flaps have a linear or rectangular
Muscle provides bulk for deep, extensive configuration. Advancement flaps are subclas-
defects and protective padding for exposed sified as simple, single pedicle, bipedicle, and
vital structures V-Y flaps.
Muscle is malleable and can be manipulated to
produce a desired shape or volume
VY Flap
Well vascularized muscle is resistant to
bacterial inoculation and infection This flap is unique among advancement flaps in
Reconstruction using muscle or musculocuta- that it is pushed rather than stretched into the
neous flap is often a one stage procedure. defect. The donor flap, which usually is triangular,
is advanced, and the resulting donor defect is
Disadvantages closed in a straight line. This approach results in a
Donor defect may lose some degree of function suture line with a Y configuration.
Donor defect may be esthetically unacceptable
to the patient Pivotal Flaps
Sometimes these flaps may provide excessive Pivotal flaps are moved about a pivotal point
bulk, leaving an esthetically unacceptable rersult from the donor site to the defect. Pivotal flaps
Flap may eventually atrophy and fail to provide include rotation, transposition, and interpolation
adequate coverage. flaps.

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222 Section 3: Carcinomas of Oral Cavity

A B

Figs 21.2A and B: Advancement (Courtesy: Dr Vikram Shetti)

A B

Figs 21.3A and B: Rotation and transposition (Courtesy: Dr Vikram Shetti)

Rotation Flaps (Figs 21.3A and B) Intraoperative


Rotation flap is a semicircular flap that rotates Technical errors
about a pivot point to fill the defect. Design errors
Poor choice of recipient vessels
Causes of Flap Complications Judgment errors.
Preoperative Postoperative
Poor flap design Extrinsic
Under estimation of recipient requirements Pedicle kinking/pressure
Premorbid condition of the patient. Infection

Ch-21.indd 222 15-04-2013 10:28:36


Chapter 21: Reconstructive Options in Oral and Maxillofacial Cancer 223
Vascular thromboses Regional Myocutaneous Flaps
Intrinsic Pectoralis major flap
Distal ischemia. Deltopectoralis flap
Sternocleidomastoid flap
Improving Skin Flap Survival Trapezius myocutaneous flap
Improve the blood flow to the flap Latissimus dorsi myocutaneous flap
By pharmacologically Temporalis flap
Changing the rheological properties of blood Masseter flap
Improve the flaps ability to tolerate ischemic Platysma flap .
insult
Avoidance of infection Free Flaps
Prevention of hematoma
Radial forearm
Avoidance of raw areas.
Iliac crest with rectus abdominalis muscle
Tests of skin flap circulation
Fibula
Scapula.
Subjective tests
Color
Capillary blanching Nasolabial Flap
Warmth Earliest description by Sushrutha in 700 BC
Bleeding from stab wound Dieffenbach 1830 superiorly based nasolabial
Objective tests flap for nasal alae rec
Metabolic tests Von Langenbeck 1864 Used nasolabial flap for
Photoelectric tests
Temperature tests
nasal recon
Vital dye Esser 1921 used inferiorly based nasolabial flap
Quantitative tests for palatal fistula closure
Clearance tests The nasolabial flap is an arterialised local flap
in the head and neck region
Local Flaps Axial blood supply provided either by the facial
artery (inferiorly based) or by the superficial
Forehead flap
temporal artery through its transverse facial
Nasolabial flap
branch and the infraorbital artery (superiorly
Cervical flap
based)
Submental flap
It is used in a variety of situations including
Tongue flap.
reconstruction of the lower eyelid and small
defects of the nose, lips and oral cavity
Tongue flap
In cancer treatment its major role is for
Advantages
reconstruction of the floor of the mouth, palate
Perforator from Ipsilateral lingual vessels and ala of the nose. The recent innovation of
Intraoral defects
folding the flap has further expanded its role,
Anterior and posterior based
Provide bulk as it is now able to provide lining and cover for
Disadvantages a full thickness commissural defect.
Two stages
May affect speech Forehead Flap
Field change First described in Indian literature
Decrease mobility of tongue Kazanjianin 1946 described the median
Limited arc of rotation forehead flap for nasal repair

Ch-21.indd 223 15-04-2013 10:28:36


224 Section 3: Carcinomas of Oral Cavity
This flap was based on supratrochlear vessels defects of lower and middle third of face,
and occasionally, the supraorbital artery cervical esophagus and laryngeal defects
Used to cover the defects below the level of the Axial pattern flap
eye. Based on submental branch of facial artery
Bridge segment is not tubed as they can cope Venous drainagesubmental vein which
up with raw surface without causing sepsis drains into the common facial vein
There is a depression if the frontalis muscle is 2 mm in diameter at its origin
involved it can be countered by beveling the Pedicle length8 cm
margin or grafting after 10 days so that some The maximum dimension that can be reliably
amount of granulation tissue is formed harvested is 15 7 cm, this must be individualized
Width to length is 5:1 to each patient based on the laxity that dictates
Esthetic deformity. the amount of skin that can be harvested without
compromising a primary closure.
Submental Flap (Figs 21.4 to 21.7)
First described by Martin et al Tongue Flap (Fig. 21.8)
Submental flap has been described for Described for use in intraoral reconstruction of
reconstruction of intraoral defects, cutaneous a soft palate defect (Kloop and Schurter 1956)

Fig. 21.4: Submental flap marking Fig. 21.5: Submental flap incision

Fig. 21.6: Submental flap transposition Fig. 21.7: Submental flap for tongue reconstruction
(Courtesy: Rajendra Prasad)

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Chapter 21: Reconstructive Options in Oral and Maxillofacial Cancer 225
Advantages
Excellent blood supply
Low morbidity
Reinnervation from the adjacent host tissue
Can provide 90100 cm of mucosal tissue
for rotation can be used in patients post
radiotherapy also.

Limitation
Size of flap and the defect.

Abbe Flap (Figs 21.9 to 21.11)


When more than 30 percent width of lip is
resected reconstruction requires mobilization
of flap from the opposite lip
When 2/3rd lip is excised reconstruction
done by borrowing tissue equivalent to half of
surgical defect
Fig. 21.8: Tongue flap (Courtesy: Vikram Shetty)
Popularised by Abbe for reconstruction of
upper lip and Estlander for lower lip
The upper lip defect is usually shaped as
Variants of flap design for temporary or an inverted V but if it is central and must
definitive coverage of small defects fit into the phitral area it may end up as an
Correction of lip deformities and reconstruction inverted W
for treatment of electrical burns
The flap is then designed on the lower lip to
Closure of palatal fistulas
correspond in shape through a flap initially cut
Anteriorly or posteriorly based
as a V-may be converted into a Way by splitting
Midline or lateral
the tip if the W is narrow one.
Useful for small intra-oral defects
Donor site closed primarily
Two stage procedure Karapandzic Flap
Base of flap should measure 2.53.0 cm wide The Karapandzic manuver depends on the
Length of flap should be sufficient to avoid creation of paired lip flaps based on branches
tension on the pedicle from the motion of the of the facial artery. The skin incisions parallel
tongue the lip margin at a distance equal to the depth
Length may be extended 56 cm of the defect
Vasculature. The principle is mobilization and utility of
Lingual artery from the external carotid gives skin, soft tissues, mucosa of lower portion of
4 branches nasolabial region, which are shifted medially
suprahyoid artery The superficial muscles of facial expression
dorsal lingual artery are divided but sensory and motor nerves
deep lingual artery which run in close proximity to main arterial
sublingual artery. channels are spared

Ch-21.indd 225 15-04-2013 10:28:37


226 Section 3: Carcinomas of Oral Cavity

Fig. 21.9: Abbe flap marking Fig. 21.10: Abbe flap transposition

Fig. 21.11: Abbe in position for upper lip construction Fig. 21.12: PMMC flap marking (Courtesy: Rajendra
(Courtesy: Rajendra Prasad) Prasad)

For reconstruction of defects of lower lip where


80 percent or more of lower lip is resected in
its central part leaving the lateral ends near
commisure intact.

Pectoralis Major Myocutaneous Flap


(Figs 21.12 to 21.15)
Workhorse for head and neck reconstruction
First described by Ariyan 1977
Broad, flat fan shaped muscle that covers
pectoralis minor, subclavius, serratus anterior
and intercostal muscles. Fig. 21.13: After incision

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Chapter 21: Reconstructive Options in Oral and Maxillofacial Cancer 227

Fig. 21.14: Buccal defect closed with flap Fig. 21.15: After suturing (Courtesy: Rajendra Prasad)

Based on Shoulder disability


Thoraco-acromial artery (axillary artery) Blood loss is more as compared to other
faciocutaneous flaps
Internal (thoracic) mammary artery
Avoid twisting, torsion and tension.
Lateral thoracic artery (subclavian artery)
Can be harvested Pectoralis Major Flap: Island Type
As a muscle paddle
Very reliable limited arch of rotation
As an island
As a bipedal. Entire muscle may be elevated or divided from
the lateral portion of the muscle
Advantages Tunnelized to defect and fixate
Non-delayed, one-stage procedure Primary closure of donor site.
Highly reliable success rate of more than 95%
Pectoralis Major Flap: Paddle Type
Technically easy and quick to perform
Island flap is not long enough to cover defect
Primary closure of the donor site
Skin of the flap is not directly attached to the
May be used along with other flaps
muscle
Change of position of patient not required
Increase arch of rotation
during surgery
Pectoralis major flap: gemini type
Skin coverage, muscle bulk and good blood
supply. Bilobular island flap
When defects require closure of the oral
Disadvantages mucosa and overlying skin
Excessive bulk and thickness may compromise Manipulate as a single island flap, after
its blood supply transposition: fold the muscle on itself so each
Hair bearing area island covers the appropriate defect.

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228 Section 3: Carcinomas of Oral Cavity
The vascularization from the occipital artery
is additionally supplied by preserving the
platysma during preparation of the SCM flap
Mainly used for intraoral and pharyngeal
reconstruction
Can be used for mandibular reconstruction if
taken along with clavicle
Limited rotational angle.

Latissimus Dorsi Flap


First described by Tansini in 1895
Not as versatile as pectoralis major myocutane-
Fig. 21.16: Deltopectoral flap ous flap but certain qualities such as the
hair free skin and donor site scar make it an
invaluable alternative
Deltopectoral Flap (Fig. 21.16) Indicated when large amount of tissue is
Outlined along the inferior border of the required
clavicle, medially the sternum extending to the Arterial supply based on thoracodorsal artery
lateral acromion process returning at the level Venous drainage from thoracodorsal vein
of 5th rib Motor nerve innervation potential with
Lateral to medial elevation beneath the level of thoracodorsal nerve.
the pectoralis muscle fascia
Base: 2 cm from the lateral sternal border Advantages
Axial pattern flap Large flap with long pedicle (artery 23 mm,
Perfused by intercostal perforating branches of vein 35 mm, length: 710 cm)
the internal mammary artery 2nd largest skin paddle
Useful for cheek, chin and neck defects Possibility for "axillary megaflap"
Two stage procedure Multiple skin paddles
Donor site requires split thickness skin graft Low donor site morbidity
Horizontal flap design with round tip Possibility of muscle reinnervation via
Excellent reliability in head and neck defects, thoracodorsal nerve.
but color match and texture not satisfactory.
Disadvantages
Sternocleidomastoid Flap Difficult positioning and two team harvest
First described by Owens in 1955 Postoperative seroma formation
Bulky flap
Blood supply
Unable to tube.
Superior : branches of occipital artery
Middle : branches of the superior thyroid artery Trapezius Flap
Inferiorly : Branches of the thyrocervical trunk Based on transverse cervical artery
Useful for floor of mouth, skull base.
Can be used as a muscle flap only, myocutane-
ous flap or as a composite flap Anterolateral Thigh Flap
Can be based superiorly or inferiorly First described by Song et al 1984
The superior thyroid vessels should be First used in head and neck by Koshima and
preserved at all times Kimata et al

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Chapter 21: Reconstructive Options in Oral and Maxillofacial Cancer 229
Fasciocutaneous/Myocutaneous/Chimeric Primary closure possible at donor site
Descending branch of Lateral circumflex femoral Relatively low morbidity
artery and its venae comitantes Esthetically compliant donor area
Musculocutaneous (60%)/septocutaneous (40%) Possible for 2 surgical teams operating
perforators simultaneously.
Fasciocutaneous flap
Soft tissue defects of head and neck region Disadvantages
Can be thinned to line the tongue Variability of vascular pedicle
Bi-paddled by excising skin bridge Transverse branch anomaly
(preserve subdermal venous plexus) Predominance of musculocutaneous/
Fascial flapfor intraoral mucosal defects septocutaneous perforators
Musculocutaneous flap Relation of perforators to vastus lateralis
Sensate flapin association with lateral Difficulty in identifying LCFA with doppler
femoral cutaneous nerve of thigh probe
Chimeric flapin association with other Skin color may not match
composite flaps. Hair growth in male patients.
Indications
Platysma Flap
Soft tissue defects
External defects in head and neck The cervical skin is supplied by a random
Oropharyngeal lining. anastomosing network located superficial to the
platysma
Vascular Anatomy Platysma-cutaneous branches from the facial, sub-
Transverse pedicle anomaly (10%) mental and submandibular arteries supply the an-
Descending branch still exists, but small <1.5 terosuperior aspects of the platysma muscle and
overlying skin
mm
Two to three muscular perforatorssuperior Branches from the occipital and posterior
to inferior from quadriceps artery auricular arteries supply the skin over the
Superior perforator runs on medial edge of posterosuperior aspect of the muscle. The
vastus lateralis muscle (15%) anterior midportion of the muscle and skin is
Arterial diameter 0.23.5 mm supplied by a branch of the superior thyroid
Two venae comitantes dia. 1.84.0 mm. artery
The venous drainage of the vertical flap
Advantages mainly passes through the anterior facial vein
Versatility or submental vein, and that of the transverse
Thickness is moderate and uniform design mainly through the external jugular
Can be thinned down/muscle can be added vein.
for bulk
Reliable pedicle Advantages
Large diameter pedicle (arterial/venous) Reconstruction of lingual defects, because it is
Long pedicle (when rectus femoris and not bulky and preserves motor innervation
transverse branches ligated) The relative simplicity of raising the flap
Sensate flap Lower postoperative morbidity
Large area of skin paddle (upto 15 cm wide and Proximity to the oral cavity and face, being
25 cm long) thin, pliable.

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230 Section 3: Carcinomas of Oral Cavity
Disadvantages
This flap has hair-bearing nature in males
Due to postoperative swelling in the sub
mandibular region flap necrosis can be seen
Post operative chemo/radio therapy can lead
to flap necrosis.

Temporalis Flap (Fig. 21.17)


Blood supply
Deep temporal fascia : middle temporal branch
(superficial temporal artery)
Anterior deep temporal artery
Posterior deep temporal artery

Orbital, skull base and small intraoral defects.


Small scar with minimal cosmetic deformity
Muscular flap only with a good rotational arch. Fig. 21.17: Temporalis flap
Facial nerve injury is seen in few cases.

Pedicle flaps: Disadvantages


Indications
Limited size and arc of rotation Bony defects >3 cm
Distal most flat: least vascular Defects that require considerable bulk and
Mobility limited by the pedicle tissue
Gravitational pull, hence dehiscence Defects that require thin skin flaps with sensation
Bulky
Composite floor of mouth and tongue defects
Defects that are not amenable to regional flaps.
Partial flap loss, complications up to 20%
Interfere with early lymph node detection Advantages
Two team approach
Improved vascularity and wound healing
Free Vascularised Flaps Low rate of resorption
Early 1900s Alexis Carrel-Free tissue transfer in Potential for sensory and motor innervation
animals (jejunum to neck) Permits use of osseointegrated implants
1950s Jacobsen and Suarezfirst anastomoses Wide variety of available tissue types tailored
in animal to match defect
1959 Seidenbergfree jejunum segments to Wide range of skin characteristics
repair pharyngoesophageal defects More efficient use of harvested tissue
1972 McLean and Bunckeomental flap to Immediate reconstruction.
cover a cranial defect
1973 Daniels and Taylorfirst free cutaneous Disadvantages
flap Technically demanding
1976 Baker and Panjefirst free flap in head Increased operating room time
and neck cancer reconstructiongroin Increased flap failure rate
pedicled on the circumflex iliac artery. Functional disability at donor site.

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Chapter 21: Reconstructive Options in Oral and Maxillofacial Cancer 231

Fig. 21.18: Radial forearm free flap Fig. 21.19: Lateral arm free flap

Contraindications Lateral Arm Free Flap (Fig. 21.19)


Severe medical illness who cannot withstand Arterial supplyposterior radial collateral
long surgery, artery from profunda brachii artery
Uncontrolled hypertension or diabetes, Venous supplyvena commitantes in spiral
Severe atherosclerosis with vessel wall groove of humerus.
calcification and
Advantages
Very aggressive pathology with doubtful of
resected margins. Low donor site morbidity (vertical scar)
Easy positioning
Radial Forearm Free Flap (Fig. 21.18) Potential for sensory innervation via posterior
cutaneous nerve.
Arterial source - radial artery
Venous Sourcepaired vena commitantes Disadvantages
and/or cephalic vein Short and smaller caliber artery (1.55 mm, up
Fasciocutaneous (type-C) to 8-10 cm)
Ideal for intraoral soft tissue defects. Longer dissection than RFFF
Thicker subcutaneous tissue
Advantages Pressure dressing
Thin, pliable skin with long, Risk to radial nerve.
Large pedicle
Easy positioning Lateral Thigh Free Flap
Potential for sensate flap Arterial supply is from third perforator of
profunda femoris artery
Potential for unusual shapes
Venous output from associated vena commitantes.
Potential for vascularized bone
Ease of preoperative evaluation. Advantages
Disadvantages
Large amount of thin, hairless skin
Low donor site morbidity (primary closure)
Poorly esthetic donor site requires skin graft Easy positioning
Potential for pathologic fractures Sensation potential with lateral femoral
Loss of hand function. cutaneous nerve.

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232 Section 3: Carcinomas of Oral Cavity
Disadvantages Multiple fasciocutaneous/musculocutaneous
Difficult dissection flaps available (scapular, parascapular,
Retraction of vastus lateralis latissimus dorsi, serratus anterior)
Short, variable pedicle 15 cm, 24 mm. Major drawback: patient positioning.

Rectus Abdominus Free Flap Fibular Free Flap (Figs 21.20 and 21.21)
Arterial supply based on deep inferior The fibula is a long thin bone that has close
epigastric artery proximity to the Peroneal artery and venae and
Venous supply form vena commitantes joining can therefore be harvested on a single large
external iliac vein. pedicle. The length of the bone, consistent
blood supply and relative ease of harvest make
Advantages this donor one of the most useful when osseous
Easy positioning and harvest reconstruction is required
Constant anatomy Consist of a large peroneal vessels and a long
Long (810 cm) and large caliber vessel pedicle
(average 3.4 mm) Approx 25 cm of bone can be harvested
Donor site closed primarily Arterial supplyperoneal artery
Large flap obtained Dual supplyendosteal and periosteal
Anterior rectus sheath durable. Venous supplyvena commitantes.

Disadvantages Advantages
Often bulky Longest and strongest bone stock (25 cm of
No sensation potential bone)
Potential for hernia formation if dissection Cortical boneweight bearing
below arcuate line. Straightlong bone defect
Triangular cross sectionresists angular and
Scapular Free Flap rotatory stress
Circumflex scapular artery and vein Can be a sensate flapLateral sural nerve
14 cm of bone available (lateral aspect) Multiple osteotomies-precise contouring
Allows osseointegrated implants Skin for soft tissue defects
Long pedicle to axillary artery Low donor site morbidity

Fig. 21.20: Fibula free flap graft marking Fig. 21.21: Harvested graft

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Chapter 21: Reconstructive Options in Oral and Maxillofacial Cancer 233
Easy positioning start at the bottom and work your way up, trying
Excellent periosteal blood supply (contoring) the simplest technique that will work.
Support osseointegrated implants Maxillofacial reconstruction is an extremely
Bone union rapid. demanding process that needs continous
improvements and refinements. Patients
Disadvantages clinical condition should be managed with
High incidence of peripheral vascular disease a team approach , including oncologists ,
Small cutaneous paddle radiotherapists , and reconstructive surgeon.
Decreased ankle strength and toe flexion Dispite the progress achieved in this field ,
Small risk chronic ankle pain challenges of maxillofacial reconstruction
Requires invasive study for operative still remains elusive , because of the inability
evaluation. to attain complete functional and cosmetic
recovery with current techniques.
Conclusion A competent maxillo-facial surgeon should be
familiar with free-flap which is the workhorse
Reconstruction is an integral part of treatment
in head and neck reconstruction. Of course
Should be done immediate every reconstruction has advantages and
Consider the safest and most reliable methods limitation with each technique knowing when
of reconstruction before embarking on more and where to adopt particular procedure.
complex and time-consuming options Conservative surgical options including Mohs
Local and regional flaps are safe and reliable technique for skin cancers, newer endoscopic
resources skull base tumor resection continue toward
The pectoralis major myocutaneous flap is a more organ sparing treatment plans.
time-proven method for reconstructing almost Transoral Robotic Surgery[TORS] for base
all defects of the oral cavity. But surpassed by of tongue neoplasm is a new emerging
microvascular free flaps modality of surgery that may pave the road to
The microvascular free flap has revolutionized more conservative surgeries. Reconstructive
the field of head and neck reconstruction in maxillo-facial surgeon should be aware
terms of preserved function and cosmesis. of new surgical techniques and advances.
Reconstruction of oromandibular defects Research is now progressing in the field of
using osteocutaneous free flaps gives patients stem cell and osteosynthesis.
new hope in the face of historically devastating The potential is that these research should
defects provide rapid de novo bone growth which
With all the tools available, a maxillofacial will eliminate the need for vascularized
surgeon should repair many defects and give bone graft.
the patient a good, functional, and cosmetic Gene theraphy and immune system targeting
outcome. These techniques include an increas- are the newer treatment modalities entering
ing element of risk as you move up the recon- in the battle against oral and maxillofacial
structive ladder. Therefore, it is always wise to cancer.

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234 Section 3: Carcinomas of Oral Cavity

Reconstruction with Reconstruction Plate (Figs 21.22A to F)

A B

C D

E F

Figs 21.22A to F: Reconstruction with reconstruction plate (A) Marking of incision; (B) Exposure of surgical
site; (C) Tumor mass detached from nearby tissues; (D) Excised tumor mass with portion of mandible;
(E) Reconstruction plate in situ; (F) Approximation of tissue

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Chapter 21: Reconstructive Options in Oral and Maxillofacial Cancer 235

Reconstruction with Free Fibula Graft (Figs 21.23A to J)

A B

C D

E F

Figs 21.23A to F: Reconstruction with free fibula graft: (A) Marking of incision at recipient site;
(B) Removal of pathology from recipient site; (C) Marking of incision at donor site; (D) Initial incision
using electrosurgery at donor site; (E) Deep dissection for harvesting fibula graft; (F) Harvested fibula
graft

Ch-21.indd 235 15-04-2013 10:28:40


236 Section 3: Carcinomas of Oral Cavity

G H

I J

Figs 21.23G to J: (G) Preparation of recipient site; (H) Contouring of graft; (I) Contoured graft; (J) Placement of graft

Reconstruction with Submental Flap (Figs 21.24A to C)

A B C
Figs 21.24A to C: Reconstruction with submental flap: (A) Marking of incision; (B) Flap in situ at recipient site;
(C) Primary closure of donor site

Ch-21.indd 236 15-04-2013 10:28:41


Clinical Cases of
Cancers of Oral Cavity
22
CASE NUMBER 1
A 50-year-old female patient complains of growth
at the angle of the mouth since 2 months duration.
Intermittent discomfort while talking and
chewing for 1.5 years.

History of Present Illness


Intermittent pain while chewing and talking
1.5 years
Small slowly progressive nodular growth in the
angle of the mouth2 months.

Medical
Patient is a known hypertensive for 4 years on
regular medications.

Personal History Fig. 22.1: Extraoral clinical picture

History of chewing betel (paan) leaf for 2 years for


intermittent pain.

Systemic Examination
Pallor +
BP = 140/80 mm Hg.

Lymph Nodes
Not palpable in levels IV.

Clinical Presentation: Extraoral


Examination (Figs 22.1 to 22.3)
1 cm 2 cm
Pale pink induration on the lip medially Fig. 22.2: Extraoral clinical picture frontal view

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238 Section 3: Carcinomas of Oral Cavity

Fig. 22.3: Intraoral clinical picture Fig. 22.4: Extraoral clinical picture postoperative

Brown colored nodular growth from commissure


= 1 cm
Firm
Indurated pyramidal shaped nodule
Alteration of color and consistency up to 7 mm
medial to the commissure.
T4a NO MX LESION Left buccal mucosa,
commissure of the lip and skin adjacent to the
vermillion border of the lip.

Treatment Done
Wide excision and primary closure with local
random rotational advancement flap under GA.

Postoperative
See Figures 22.4 and 22.5.
Fig. 22.5: Intraoral clinical picture postoperative
CASE NUMBER 2
60-year-old gentleman complains of ulcer on the Associated with pain
tongue since 1 year. Dull and intermittent
Burning sensation of mouth
History of Presenting Illness No difficulty in speech and tongue movements.
Ulcer at the lateral border of tongue
Since 1 year Medical History
Progressed to present size No relevant medical history.

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Chapter 22: Clinical Cases of Cancers of Oral Cavity 239

Personal History Examination


Consumes mixed diet Inspection
H/o paan chewing since 40 years 1012 paans No discharge noticed
per day Floor covered with slough.
Consumes alcohol daily since 20 years
Sleep normal Palpation
Bowel and bladder habits normal.
Inspectory findings confirmed.
General Physical Examination Ulcer
Tender
Conscious and cooperative
Edges are raised and indurated
Moderately built and moderately nourished
Base
Pallor present
Indurated
No signs of icterus, cyanosis, clubbing, edema
Fixed to underlying tissue.
Vital signsnormal.
Lymph Node Examination
Head and Neck Examination Submental lymph node
Eyesno clinically detectable abnormalities Palpable
Noseno clinically detectable abnormalities 1 in number
TMJno clinically detectable abnormalities Not fixed
Mouth opening34 mm. Nontender
Firm in consistency measuring approximately
Intraoral Examination 1 cm in the longest diameter.
Teeth present
Left submandibular lymph node
87654321 12345678
87654321 12345678 1 in number
Calculus and stains present Not fixed
Mucosa is pale Nontender
Depapillation of tongue is observed (Fig. 22.6). Firm in consistency measuring approximately
1 cm in the longest diameter.
Right submandibular lymph node
1 in number
Not fixed
Nontender
Firm in consistency measuring approximately
1 cm in the longest diameter.

Investigations
Routine blood investigations
Histopathology
FNAC of submental lymph node
USG neck
Fig. 22.6: Intraoral clinical picture of lesion on lateral Chest radiograph
border of tongue MRI contrast study.

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240 Section 3: Carcinomas of Oral Cavity
Adequate node resection
Reconstruction of defect
Radiotherapy
Chemotherapy.

Tumor Resection
Hemiglossectomy.

Neck nodes
Left radical neck dissection
Right extended supraomohyoid neck dissection.

Anterior Tongue Reconstruction


Very difficult to reconstruct
Complex intrinsic musculature and function
Redundancy is advantageous
Near hemiglossectomy does not significantly
Fig. 22.7: Histopathology: Showing early invasive SCC: alter function.
Deep elongation, branching off rete processses, and
narrowing of junction of branches
Oral (Mobile) Tongue
Speech and deglutition
Histopathology
Mobility allows for:
Articulation of speech
Suggestive of early invasive squamous cell Bolus manipulation in preparation for
carcinoma (Fig. 22.7). deglutition
FNAC
Sensory functions: proprioception, pain, taste
Assists in mastication and bolus processing
Submental lymph node Defects < 50% can be closed primarily +/- STSG
Nonspecific smear. Larger or composite defects require more bulk
(i.e. fasciocutaneous free flap)
USG Neck
Lateral arm free flap is good for defects
No evidence of significant lymph node enlarge- including posterior aspect of tongue/FOM.
ment bilaterally
Thyroid and Submandibular glands appear
normal CASE NUMBER 3
Neck vessels appear normal. A 72-year-old gentleman complains of ulcer on
the tongue since 3 months (Fig. 22.8).
Final Diagnosis
Squamous cell carcinoma of the tongue History of Presenting Illness
Grading and staging Ulcer on the left lateral posterior part of tongue
T2 N2C MX Since 3 months
Stage: IV A. Progressed to present size
Associated with pain
Management Severe and intermittent
Resection of primary Burning sensation of mouth
Adequate clearance No difficulty in speech and tongue movements.

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Chapter 22: Clinical Cases of Cancers of Oral Cavity 241

Fig. 22.8: Extraoral clinical picture Fig. 22.9: Intraoral clinical picture of lesion on lateral
border of tongue

Medical History Calculus and stains present


No relevant medical history. Mucosa is pale
Depapillation of tongue is observed.
Personal History
Consumes mixed diet Inspection
H/o paan chewing for 40 years 1012 paans per No discharge noticed
day Floor covered with slough
Habit of smoking cigarette and beedies 1015
daily for 30 years Palpation
Sleep normal Inspectory findings confirmed
Bowel and bladder habits normal. Ulcer
Tender
General Physical Examination
Edges are raised and indurated
Conscious and cooperative
Moderately built and moderately nourished Base
Pallor present Indurated
No signs of icterus, cyanosis, clubbing, edema Fixed to underlying tissue
Vital signsnormal. Floor
Covered with necrotic slough.
Head and Neck Examination
Eyesno clinically detectable abnormalities Histopathology
Noseno clinically detectable abnormalities Suggestive of squamous cell carcinoma.
TMJno clinically detectable abnormalities
No gross facial asymmetry present. Final Diagnosis
Squamous cell carcinoma of the tongue
Intraoral Examination (Fig. 22.9)
Grading and staging
Teeth present
T3 N0 MX
8754 321 12345
87654321 12345 Stage III.

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242 Section 3: Carcinomas of Oral Cavity

Management Biopsy taken by a local doctor, report not


Wide excision of primary lesion collected.
Ipsilateral mod type III neck dissection or
Left extended supraomohyoid neck dissection Personal History
Reconstruction of defect Paan chewing with tobacco 56 times a day for 30
Radiotherapy years.
Chemotherapy.
General Examination
CASE NUMBER 4 Moderately built and nourished
A 65-year-old female was referred to the Anemic
department with complains of mobility of teeth in Pallor present
lower left back region. Lymph nodes positive
Generalized skin lesions especially in bilateral
History of Presenting Illness legs.
Tooth mobility since 1 month
Pain since 1 month, severe in nature, throbbing Local Examination
in nature, radiating to temporal region Extraoral Examination
Mobility increased after tooth extraction Facial asymmetry present
Swelling in mandibular region for 15 days. Swelling present in left mandibular region (Fig.
22.10)
Past Medical History Size: 5 3 cm
Undergone surgery in neck 18 years back Extensions:
(details unknown) Anteriorly: commisure
Posteriorly: 2 cm anterior to angle of mandible
Known asthmatic on medication
Superiorly: 2 cm below the ala-tragal line
Skin lesions for 2 years, not on medications. Inferiorly: lower border of the mandible.
Past Dental History Intraoral Examination (Fig. 22.11)
Extraction of 45, 44 done, 1 month back, Poor oral hygiene, generalized tobacco stains
swelling increased since then Mouth opening: 38 mm.

Fig. 22.10: Extraoral clinical picture showing swelling Fig. 22.11: Intraoral picture of lesion

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Chapter 22: Clinical Cases of Cancers of Oral Cavity 243
Soft Tissue
Gingiva: Generalized chronic gingivitis
Ulceroproliferative growth in 34, 35 region
Size 3.5 4 cm
Extensions:
Anteriorly: 34 area
Posteriorly: Distal surface of 36
Inferiorly: Gingivobuccal sulcus
Superiorly: occlusal level of teeth on buccal
mucosa
Medially: involving the edentulous alveolar
crest 1 cm sup to lingual sulcus Fig. 22.12: OPG showing erosion of bone
Teeth present: 87654321 1234567
87 4321 123 67
Lymph nodes: high degree of efficacy. For resectable cancer,
Ipsilateral side: transoral laser microsurgery.
Multiple nodes: level 1b, single, 2 cm, firm,
fixed, tender
CLINICAL CASE 5
level 2a node: single, mobile, nontender
Level 3 node: 0.5 cm single, mobile, nontender A 17-year-old male presents with chief complaint
Level 5 node: single, mobile. of ulcer in the right retromolar region.

Contralateral Side History of Presenting Illness


Level 1b node: 1 1 cm mobile, nontender. Insidious in onset
Initially noticed a small swelling measuring
Provisional Diagnosis about 5 mm in size associated with pain and
Carcinoma lower alveolous/buccal mucosa discharge since 4 months
Traumatic ulcer. Gradually progressive in size and symptoms
Pain radiating to lower jaw and ear
Clinical Staging Associated with yellowish discharge and foul
smell
T4a N2c Mx, Stage IV A (operable disease).
Associated with difficulty in swallowing
Investigations Not associated with fever or any other systemic
symptoms.
OPG (Fig. 22.12)
Incision biopsy. Medical History
Management Hospitalized 2 months back for the same
complaint and biopsy was done
Multimodal Therapy Reportnonspecific ulcer.
Surgery: wide excision + hemimandibulectomy
+ MRND type 2 + reconstruction with PMMC Personal History
Postoperative radiotherapy. Oral hygiene practice
Mixed diet
Newer Trends No addictive habits
Newer tumor specific medical therapies are Normal bowel and bladder habits
anticipated to be less toxic while maintaining a Disturbed sleep.

Ch-22.indd 243 15-04-2013 10:29:29


244 Section 3: Carcinomas of Oral Cavity

General Physical Examination Involving right submandibular area


Conscious and cooperative Rt superficial cervical node palpablesingle,
Moderately built and moderately nourished firm, partially fixed, nontender, size1 1 cm.
pallor present
No signs of icterus, cyanosis, clubbing, edema Intraoral Examination
Vital signsnormal. Inspection
Ulceroproliferative growth noticed involving
Head and Neck Examination
right soft palate, faucial pillar, postpharyngeal
Eyesno clinically detectable abnormalities wall, floor of the mouth, posterior ventrolateral
Extraocular muscle movementsnormal surface of tongue, retromolar region (Figs
No proptosis, diplopia, blurring of vision 22.14 and 22.15)
Noseno clinically detectable abnormalities Size4 5 cm
TMJno clinically detectable abnormalities Extensions
Mouth openingrestricted Anteriordistal surface of right lower second
Lymph node examination. molar
Posteriorfaucial pillar, soft palate and
Inspection
extending posteriorly into oropharynx
Diffused swelling noticed below the angle of Linguallyright postventrolateral surface of
the mandible on right side (Fig. 22.13) tongue and floor of the mouth
Size2 2 cm Borders are ill-defined
Involving right submandibular area Surface appeared to be necrotic with erythe-
No secondary changes noted. matous areas.
Palpation Palpation
Well defined, firm, tender, fixed swelling Tender, ulceroproliferative growth noticed
noticed Size4 5 cm
Size 2 2 cm Borders ill-defined and indurated
Posterior extensions could not be made out
Yellowish white discharge noticed.
To summarize..
A 17-year-old male with the c/o ulceration
on the right posterior palatal region of 8
months duration associated with pain and pus
discharge
Extraoral examination revealed palpable
lymph nodes in submandibular and superficial
cervical region, two in no., firm, tender and
fixed.
Intraorally, ulceroproliferative growth noted on
posterior palatal, oropharyngeal and retromolar
region, postlateroventral surface of tongue floor
of the mouth with indurated ill defined borders,
with the surface being necrotic. Blood investigation
Fig 22.13: Clinical view showing swelling in not significant except ESR slight increase with no
submandibular region bony involvement in radiograph. CT shows soft

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Chapter 22: Clinical Cases of Cancers of Oral Cavity 245

Fig. 22.14: Intraoral lesion at palatal region Fig. 22.15: Intraoral lesion

Fig. 22.16: Soft tissue growth involving the right lateral Fig. 22.17: No bony involvement in OPG
oropharyngeal extending inferiorly up to C4 level with
no bony involvement

tissue growth involving right lateral oropharynx Routine blood investigations


and extending inferiorly upto C4 level with no bony Incisional biopsy
involvement (Figs 22.16 and 22.17). Microbial culture
CT imaging
Differential Diagnosis Ultrasonography.
Carcinoma of minor salivary gland?
Lymphoma? Routine Blood Investigations
Carcinoma of soft palate extending to the Hemoglobin12.6 g/dL
oropharynx? TLC7800/cumm
DLCneutrophils65%
Investigations Lymphocytes22%
Exfoliative cytology Eosinophils13%
Radiographs Monocytes5%

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246 Section 3: Carcinomas of Oral Cavity
Basophils0% and nonprogressive, but since last one week the
ESR20 mm/hr swelling showed a rapid progression in growth to
Platelet count3.62 lakhs/cumm present size.
RBC count4.44 millions/dL.
Medical History
CT Scan and Ultrasonography Known hypertensive and under regular
Revealed multiple enlarged lymph nodes in RT medication.
submandibular region and bilateral deep cervical Known asthmatic currently under medications
lymph node involvement.
Drug allergyNo relevant history
Major salivary glands appears to be normal.
Dental HistoryFirst dental visit
Final Diagnosis: Non-Hodgkins Family HistoryNo contributing factors.
Lymphoma
Personal Habits
Treatment Options for Lymphoma
Mixed diet
Radiotherapy Brushes teeth with coconut coir
20002500 cGypalliative therapy Smokes 15 bidis per day, stopped smoking
45005000 cGycurative therapy 2 years back
Chemotherapy Chewing paan with betel nut, araca-nut with
CHOPcyclophosphamide-750 mg/m2 IV slaked lime since 30 years for 1 hour
Oncovin1.4 mg/m2 IV Alcohol consumption daily for a period of
Adrimycin50 mg/m2 IV 20 years.
Prednisone100 mg
Physical Examination
MOPPnitrogen mustard-6 mg/m2 IV
Oncovin1.4 mg/m2 IV General Physical Examination
Prednisone40 mg/m2 Patient is moderately built and nourished
Procarbazine100 mg/m2 Cooperative
Monoclonal antibodies Waddling gait
Rituximabanti CD-20 antibody Pallorpresent
Tositumomabanti CD-20 antibody Afebrile.
Alemtuzumabanti CD-52 antibody.
Extraoral Examination (Figs 22.18 to 22.20)
Inspection
CASE NUMBER 6
Facial asymmetry on the left side of the face
A 58-year-male patient complains of swelling on the due to the presence of swelling
lower 1/3rd on the left side of face since one month.
Mouth opening-2 finger width (26 mm)
History of Present Illness Eyes, ear, noseNAD
Patient noticed a small swelling lateral to the angle LipsNAD
of the mouth on left side. It was asymptomatic SkinNAD.

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Chapter 22: Clinical Cases of Cancers of Oral Cavity 247

Fig. 22.18: Extraoral swelling: frontal view Fig. 22.19: Extraoral swelling: side view

Palpation
Swelling is firm in consistency, tender, skin
over the swelling is pinchable
Two left submandibular lymph nodes palpable,
tender 1.5 cm in diameter, partially fixed
Submental lymph node palpable, mobile,
nontender.

Intraoral Examination
Inspection
A fissural indurated growth is noticed arising
from the buccal mucosa approximately