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Pain and dysphagia in patients with squamous carcinomas of the head and neck: the role of perineural spread medicine 94 purchase levaquin 750 mg with visa. Sucralfate in the treatment of chemotherapy-induced stomatitis: a double-blind medications pain pills buy 500mg levaquin with visa, placebo-controlled pilot study symptoms crohns disease buy levaquin 250 mg with amex. Relationship between salivary flow rates and Candida counts in subjects with xerostomia medications during pregnancy chart levaquin 750 mg with mastercard. Outbreak of systemic candida albicans in intensive care unit caused by cross-infection medications known to cause pill-induced esophagitis purchase generic levaquin pills. New polyethylene glycol laxative for treatment of constipation in adults: a randomized medicine expiration dates cheap 750mg levaquin, double-blind, placebo-controlled study. Ionized calcium in isolation may not detect all cases of symptomatic hypercalcaemia. Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus. A randomized trial of risperidone, placebo, and haloperidol for behavioral symptoms of dementia. Olanzapine treatment of psychotic and behavioral symptoms in patients with Alzheimer disease in nursing care facilities: a double-blind, randomized, placebo-controlled trial. In 1997, in the so-called Bristol case, three doctors, two cardiac surgeons and a manager were found guilty of serious professional misconduct by virtue of having performed below their expected standard. Two years later, public mistrust of the medical profession was heightened when Harold Shipman was jailed for the murder of several of his patients. The problem for doctors now is that they face several levels of jeopardy that they would not have previously expected. Formerly, an unsatisfactory outcome from an operation may at worst have resulted in an action being raised in the civil courts for alleged medical negligence. While the new regulations relating to the provision of legal aid have made this more difficult to obtain, it has nevertheless not halted the process because many legal firms are now taking cases on a contingency basis. Doctors now also face disciplinary action under clinical governance; a three-stage enquiry if the Wilson Complaint Procedure is invoked; inspection by Royal College Inspection Teams; independent review panels; and possible referral to the National Clinical Assessment Authority. Independent hospitals are also required to set up a complaints procedure, which would be handled internally by the Medical Advisory Committee and externally by the National Commission for Care Standards. If there is a death, or a series of deaths, the police may be alerted by the coroner or may decide to investigate on their own. In the last few years the Crown Prosecution Service has brought many more charges of manslaughter against doctors who have had fatalities where recklessness has been alleged. If standards of performance are involved in the complaint, the case examiner may invite the doctor to undergo a performance review. If the allegation is serious, then the doctor may well have his registration suspended pending the hearing. In recent years, the thresholds of judgements have been slightly altered so that if someone does have their name erased, then there is virtually no likelihood of being reinstated on appeal. It remains to be seen if this will result in more doctors losing their right to practise or if it will raise the threshold for the level of sanction imposed. Many doctors are concerned that a single unfortunate clinical incident might affect their registration. Their lordships found this case to be `a borderline case of serious professional misconduct based on a single incident. Clinical situations Perhaps the two main clinical problems that obfuscate any case of negligence are communication and note keeping. Many cases begin because the patient or his relatives are unhappy at the way that they have been treated after what they perceive as a bad result. Local policies will differ depending on the Trust Risk Assessment policy but, in general, it is better to spend time talking to a patient and his relatives explaining what might have gone wrong, the implications and what you are going to do about it, rather than hide the fact and unrealistically think and hope that the problem will go away. An apology or an expression of sympathy at the plight of the patient is not an admission of liability and, while it may not make an allegation go away, it makes for a more convincing defence. This is very true and no matter how pressed you are, you must always go the extra mile to write a note while thinking about how you would answer in a court of law. When writing up an operation, take care to address what you did with the vital structures. In the clinic, it is often easier to write very full letters after each consultation but the secretarial back up may not allow that. In that instance you should take care to make some note of important negative findings as well as positive ones. There are times when it may be important to add to a note that has already been written. There is nothing wrong with this provided that it is clearly indicated that the entry was added at a later date. It is much more precise and clear than previous editions and constitutes a good foundation for a safe medical practice. Since many cases of alleged negligence in head and neck surgery have common principles, it may be of use to address these principles from within the context of this publication. Chapter 203 Medical negligence in head and neck surgery] 2805 has been supplanted by a newer and more acclaimed procedure. In this instance you must be very careful that when you consent the patient for the procedure that you are accustomed to doing that you make it clear that there is the option of referral to a colleague for the more up-todate procedure. Again, this might seem overprotective but is preferable to being accused of an unsatisfactory surgical outcome when it transpires that this was the first time that you had attempted the procedure, and the patient did not know this. This does not of course apply to an incremental step performed in an operation in which you are experienced. However, what was omitted was detailing clearly what steps a surgeon had to take when he learned a new procedure, which is an integral part of lifelong learning! The primary causes of failure to refer to a colleague are trust policy (if the colleague is in another Trust), private practice jealousies and dysfunctional relationships. There is nothing wrong in talking to the media about any of these situations, but patient identity must never be compromised. Health issues Like any other medical practitioner, an otolaryngologist must take care to avoid drug or alcohol abuse. There are many agencies that supply confidential help to those unfortunate enough to have these problems. It is more preferable to avail oneself of these procedures prior to any untoward event occurring. It should be borne in mind that a conviction and disqualification for driving due to an excess level of alcohol will result in an interview with two psychiatrists and a public hearing. Major scientific fraud relates to either fabrication or falsification of data or events. The author is reminded of the plethora of neoglottis operations that apparently could only achieve good results in the hands of the original author! In other words, a doctor is not negligent if he is acting in accordance with such a practice merely because there is a body of opinion that takes a contrary view. Bolitho the modification of Bolam took place in the House of Lords in the case of Bolitho v. Later he referred to a `standard of practice Relationships Otolaryngologists are no less prone than any other group to getting into problems with patients because of indecency or sexual advances. In particular, in cases often involving the weighing of risk against benefits, before accepting a body of opinion as being responsible, reasonable or respectable, the judge will need to be satisfied that, in forming their views, the experts have directed their minds to the comparative risks and benefits and have reached a defensible conclusion on the matter. Consent Until recently, informed consent could be thought of under four categories. The patient should be informed of: information that will vary according to the complexity and risks of the procedure in question; the details of the diagnosis and likely prognosis if the condition is left untreated; the details of uncertainties about the diagnosis including options for further investigation prior to treatment; the options for treatment including the option not to treat; the common and serious side effects of any investigation; the benefits and risks and the likely change in life style should any of the explained risks occur; whether or not the treatment is new, novel or experimental; whether doctors in training will be involved. Thus, if nodes are found in the neck during a laryngectomy, you cannot go ahead and carry out a neck dissection unless this has been discussed with the patient. You should not withhold information necessary for decision-making unless you judge that disclosure will cause the patient serious harm. In this context, harm does not mean that the patient would become upset or decide to refuse treatment. Although some patients refuse endoscopic sinus surgery when confronted with the possibility of intracranial complications that could lead to death, the information should never be withheld. The doctor who gives consent must be suitably trained and qualified and must know all about the procedure. Although still to be tested in otolaryngology, this would seem to suggest that if someone whose primary practice was in otology were to give an opinion on a complication of endoscopic sinus surgery, then he might be challenged on his claim to be a specialist. Recklessness With the Crown Prosecution Service becoming increasingly involved with fatalities within medical practice, another definition has assumed some importance. It may be defined as identifying a particular risk, realizing the consequences of proceeding in the light of that risk, and a fatality occurring. Human Rights Act this is becoming a common defence, especially Article 6, which concerns the right to a fair trial. A signed consent form is not sufficient evidence that the patient gives or still gives consent for the procedure if it is more than three months since it was signed. Similarly, some hospitals run an enormous backlog of nonurgent ultrasound investigations. The principle that the otolaryngologist should follow has to be the same as outlined above. Attempts should be made to draw the service deficiency to the attention of managers and colleagues. Endoscopy Endoscopy is a very responsible procedure both in the clinic and the day surgery unit. Although it is an easy surgical procedure, the consultant in charge must make sure that, if indeed he delegates it, that he is confident to act on the findings of his specialist registrar because he, the consultant, is ultimately responsible. If a doctor works to a defined protocol in the use of these investigations then he has a stronger defence than if it appears that he is quite random in their use. Operative problems In the preceding sections we have dealt with consent issues and the performance of the correct operation on the correct patient by a surgeon competent to carry out that procedure. In this section, we will consider specific and frequent head and neck complications highlighting any negligence issues. The surgeon should attempt to take steps with the managers and with the department prior to reverting to a haphazard and episodic use of the technique. Imaging In regard to imaging, the problem is the shortage of both radiologists and equipment in some hospitals. When the wait for scans for nonurgent cases, such as parotids, is a matter of months, then the surgeon may well have to operate without a scan and if there is a subsequent the accessory nerve may be damaged in two main situations. However, patients must be made aware of the severe restriction on life style that an accessory nerve palsy causes. There will be limitations in regard to putting on clothes, to power in the arm, to cosmesis, to sporting activities and, most importantly, it may prevent future employment, thus making it a very expensive claim to settle. Damage to the nerve in cancer surgery has a certain logic in the mind of patients provided that the explanations have been clear enough. Damage to the nerve in procedures involving gland biopsy in the posterior triangle are a different issue. Small glands in that area seldom need to be biopsied because, unless they are multiple and tuberculosis or lymphoma is suspected, there are alternative means of rationalizing the situation. If the accessory nerve is damaged in such a procedure then that damage must be recognized, either at the time of surgery or in the immediate postoperative period. If the nerve is traumatized and it is not just a neuropraxia, then the earlier the repair is carried out the better. When the only operation for the removal of metastatic neck nodes was the classical radical neck dissection, removal of the accessory nerve formed an integral part of every operation and while the majority of patients had problems, some did not. With the advent of various subtypes of neck dissection, the surgeon should always make a note of what the patient was told about shoulder function after the operation and the reasons for the surgeon to include the accessory nerve in the removed specimen. When modified neck dissection was included in everyday practice, perceived wisdom was that the accessory nerve should not be preserved in the N1 neck if the nodes were in levels 2 or 3. There has been some slippage from this by some head and neck surgeons in the last few years and so there may be genuine disagreement between experts when reports are exchanged that will not be helpful to the court. Provided consent has been obtained for this, and also consent for an immediate medialization of the vocal cord, then no charges should arise. If the carotid artery is breached in the removal of a chemodectoma, then questions may be asked as to why a vascular surgeon was not either present or at least available for call if required. If accidental breach occurs during the removal of malignant glands that may be attached to the artery, then it is unlikely that any charges would flow from any complication of the breach. Not so, however, if the artery is holed during a laser procedure in the tonsil/tongue base as occurred recently. The brachiocephalic artery may rupture with fatal results if a tracheostomy tube displaces from the trachea and erodes it. If the nerve is damaged during thyroidectomy and the surgeon is regularly carrying out the operation, then he is at no more risk than any endocrine surgeon who creates the same problem. Thus, to attempt tracheostomy (a difficult and complex operation) when simpler procedures would suffice until the arrival of more skilled help, might be considered negligent in the advent of an unfortunate result. Charges of negligence may arise from recognizing an airway problem too late, from not recognizing that a tube had displaced or from performing a tracheostomy that resulted in a tracheal stenosis. In each region or Trust there should be someone who carries out the majority of the parotidectomies. Before any parotid surgery, every step should be taken to establish both the position and the nature of the parotid lump. If there is any suggestion of malignancy, then the consenting procedure should be specific in the explanation of a possible sacrifice of the facial nerve or one of its branches. If a branch of the facial nerve is permanently damaged without reason, then the resulting defect in the face is nowadays almost unacceptable. The injury happens even in the best of hands, but, unless preceded by clearly documented informed consent, then an allegation of negligence will be difficult to defend.

Diseases

Ruvalcaba syndrome
Tarsal tunnel syndrome
Incisors fused
Meige syndrome
Marfanoid craniosynostosis syndrome
Facial dysmorphism shawl scrotum joint laxity syndrome
Dyssegmental dysplasia Silverman Handmaker type
Spine rigid cardiomyopathy

The exception is extensive mandibulotomy schedule 6 medications order levaquin on line amex, either median or lateral symptoms 7dp5dt discount 750 mg levaquin with mastercard, which provides a useful exposure of the lateral skull base medicine expiration order levaquin 250mg free shipping. The technique can also be modified to allow good exposure of the anterior skull base symptoms zinc deficiency adults order genuine levaquin line. The mylohyoid muscle is divided and an anterior mandibulotomy performed treatment tinea versicolor order genuine levaquin, and the lateral floor of the mouth incised as far as the anterior tonsillar pillar medicine and health order levaquin mastercard. The contents of the carotid sheath can then be exposed when the incision is continued to the maxillary tuberosity. In exceptional circumstances, a palatal flap can be elevated, allowing better exposure of the internal carotid artery as it enters the skull base and giving access to the nasopharynx. Other exposures of the skull base Wide field access to the skull base is required in three surgical situations. The first is when access to the most superior part of the internal carotid artery is necessary. The second is when high benign, usually nerve, tumours are invading the foramina of the base of the skull, and the final indication is for resection of malignant tumours in this area. In our experience it is unlikely that such tumours will be cured and the morbidity is usually extremely high. Very careful consideration should therefore be given before contemplating such surgery for malignancy. Transmandibular surgery, which gives good access, particularly anteriorly, has already been discussed. Various new approaches have been described including combined infratemporal fossa and transfacial approaches. This provides excellent control of the internal carotid artery without leaving facial scars; regrettably, the approach requires that hearing be sacrificed on that side and there is a high risk of facial nerve palsy. The Fisch type D approach, which uses an infratemporal preauricular incision, provides more limited access but preserves hearing. A recent description95 combines the Fisch type D with a transfacial transmaxillary approach. Procedures incorporating a Le Fort 1 osteotomy may be useful, in particular for medial and anterior skull base lesions involving the clivus. Until recently the usual approach for such a tumour was laterally, with accompanying unacceptable morbidity. A recent description96 combines a segmented Le Fort 1 osteotomy with a transmandibular approach. The oncological and functional outcome is said to be good but no one unit is likely to gain much experience of such a technique. Another recently described approach, this time for a massive schwannoma, involved creating orbital frontal ethmoidal osteotomies combined with an extended frontal approach. In that series, a number of patients had vagal tumours, and permanent vocal cord palsies occurred in 13; however, 10 patients had facial nerve palsy, which fortunately usually recovered. Finally, in a paper from North Carolina103 dealing with management of the carotid artery at the skull base in patients undergoing tumour resection, the authors recommended that the carotid artery be preserved, which was fortunately usually the case. They suggest that if carotid artery resection should prove necessary then vascular bypass and reconstruction be performed. Nasopharyngeal carcinoma is also highly radiocurable, with the diseasefree survival at three years varying between 60 and 86 percent. Techniques such as hyperfractionated regimens, intensity modulated regimens and stereotactic radio surgery have offered exciting advances in this field. It is perhaps not well appreciated that conventional radiotherapy can control vagal paragangliomas including the glomus jugulare tumour, with very few side effects. Radiotherapy is also effective in controlling the growth of the carotid body paraganglioma. For deep lobe parotid tumours that have recurred, all patients seen in our unit have received radiotherapy. We also now use this adjuvant modality in new cases of deep lobe parotid tumours, even though the recurrence rate is small, mainly because of anatomical considerations. A recurrent pleomorphic adenoma in the deep lobe of the parotid usually involves quite extensive and difficult surgery for its excision. In addition, it is our view that almost all patients with extensive malignant tumours of the head and neck requiring surgery should also be offered postoperative irradiation. With the advent of high-resolution scanning techniques with or without angiography, if necessary, accurate localization of tumours is almost invariably possible. A practical note, both from that study and from our own experience, is that the balloon occlusion test so commonly used, is not infallible. Over the years, our department has witnessed two deaths from cerebral insufficiency when the balloon occlusion test was normal. Further, we have experience that occluding the internal carotid artery on a long-term basis using a balloon technique in therapeutic angiography can cause death from a propagated clot, developing over a period of days, causing cerebrovascular insufficiency. As long as local control has been achieved, the neck should be treated as appropriate for the histological type, and according to the protocols given in Chapter 199, Metastatic neck disease. Our practice is to reduce the risk of neck node metastasis happening by employing postoperative irradiation to the primary site and the regional nodes. Apart from squamous cell carcinomas arising from the oral cavity, oropharynx and post-nasal space, elective neck dissection is not usually considered. A final difficulty is in dealing with patients with bilateral vagal paragangliomas or neurofibromas. For successful removal of these tumours the vagus nerve will, almost certainly, have to be sacrificed. Therefore, it is best to operate on the side with the most advanced lesion and to administer radiotherapy to the opposite side. In the case of oral and oropharyngeal cancers invading this region the cure rate, at best, is 10 percent at five years, and thus it is unlikely to be therapeutically rewarding to treat a recurrence. In the poststyloid compartment, further cranial nerve palsies may develop, and for lesions compressing the internal carotid artery, cerebrovascular insufficiency may become manifest. The only way of detecting early recurrences of benign tumours would be by serial scanning, which we consider unnecessary, as the only reason for revision surgery would be for the treatment of symptoms. A specific problem, very rarely, arises when a benign tumour undergoes malignant transformation. Almost all parapharyngeal salivary tumours arise in the deep lobe of the parotid gland and nearly all are pleomorphic adenomas. There is no consensus as to the risk of malignant change in a pleomorphic adenoma, but a figure of approximately 10 percent over a lifetime is probably reasonable. For a full discussion on this topic the reader is referred Chapter 190, Malignant tumours of the salivary glands. The risk of malignancy in a deep lobe parotid tumour and, indeed, risk of recurrence is probably lower than for superficial parotid pleomorphic adenomas. However, I am personally convinced with regards to the above discussion that there is no scientific literature to support one line of management or another. The Liverpool head and neck database of some 7000 patients includes only 34 deep lobe pleomorphic adenomas. Survival calculations for malignant tumours must not be overinterpreted as the numbers (particularly of malignant tumours) were small. There were two lymphomas; one patient was cured but the other died at six years after recurrence. There was one bilateral malignant vagal paraganglioma which was treated by surgery and irradiation on the side of the largest tumour and radical radiotherapy on the side of the small tumour. Of those with malignant tumours, three had regional neck node metastases and these all occurred in patients with malignant salivary gland neoplasms. This is partly because all series are relatively small, the overwhelming majority of tumours are benign and individual series contain relatively small numbers of malignant tumours. While these patients succumb to their disease, the majority of those with malignant paragangliomas do not, but have a locally progressive behaviour which can be cured, or at least controlled, by radical surgery and radiotherapy. Owing to the small numbers of malignant salivary cancers of this region, the reader is referred to Chapter 190, Malignant tumours of the salivary glands. The prognosis of the tumour then depends on two factors: the first is death from treatment or its complications and the second is death from the tumour itself, dependent on its histology. Deaths from treatment will be dealt with under complications (see later under the complications of treatment) and deaths from type of tumour in our series apply almost entirely to malignant tumours, with the outcome described above. Other very rare causes of death include intracranial spread of a benign tumour, and fatal syncopal attacks, usually ascribed to pressure on the glossopharyngeal nerve. Spread of oral or oropharyngeal cancer to this region is again associated with a T4 stage and frequently renders the tumour inoperable. It is largely because of this that complications associated with surgery are high (vide infra). As regards temporary unwanted effects of surgery, nerve palsies were the most common, affecting over 60 percent of patients. The commonest was injury to the marginal mandibular nerve and the next in frequency was injury to the hypoglossal nerve. Vascular morbidity happened in 13 percent and temporary cerebrovascular accident in 4 percent. There were haematomas in almost 10 percent of patients and the same number had problems, usually respiratory infection or heart failure. Extrapolation can be made from irradiation of cancers of the adjacent post-nasal space. The greatest problem is the significant risk of temporal lobe necrosis, in particular with hyperfractionated schedules in which the incidence may be as high as 14 percent after 71 Gy in 40 fractions over 35 days. On the other hand, the five-year actuarial incidence of temporal lobe necrosis for those receiving 66 Gy in 33 fractions over 44 days was nil. This is essentially related to the radiation dose delivered to the parotid gland, and for each gland independently, salivary flow is reduced exponentially at a rate of approximately 4 percent per gray of mean parotid dose. Techniques to spare the parotid are discussed in Chapter 198, Management of the patient presenting with neck lymphadenopathy and an unknown primary carcinoma. It should be remembered that xerostomia is permanent and, significantly, adversely affects quality of life scores. Not infrequently, cranial nerve palsy will be noted on examination or may be the presenting feature. Procedures involving the internal carotid artery can be the cause of a disastrous cerebrovascular accident, albeit infrequently. Cytological and imaging techniques have revolutionized diagnosis and management in this difficult area. Tumours such as this are very much an area where the treatment decision must be reached between the doctor and the patient. We have a number of young patients with carotid paragangliomas who did not wish to have surgery once the risks were explained to them and this is obviously entirely reasonable. As in oncology, in general, the simple rules of increasing tumour size, pain, involvement of other structures (such as cranial nerves or muscles of mastication) or imaging evidence of invasion, suggest that prompt investigation followed by appropriate treatment is required. This, of course, would suggest that excision and histological assessment should be advised. It should also be noted that even with histopathology it is not always possible to assess whether a tumour is malignant or not. Assuming there is a cytological diagnosis and imaging, together with clinical assessment, leading to a reasonably certain diagnosis, it should not be forgotten that irradiation is effective at inhibiting further growth of a number of benign lesions and, on occasion, causing shrinkage of the tumour. This is true for all paragangliomas and is, perhaps, the treatment of choice for paragangliomas of the jugular foramen and jugular bulb. It is probably also the treatment of choice in an elderly patient with symptoms from a carotid paraganglioma, in whom surgery is likely to carry a high risk, particularly of cerebrovascular accident. Considering malignant tumours, combined treatment protocols are usually indicated with surgery followed by chemoradiation. Owing to problems with access and associated quite devastating aesthetic sequela, these tumours may not, in practice, prove amenable to total surgical excision. In the rare patient with unilateral or bilateral malignant paragangliomas, our experience is that they are only diagnosed at operation, where obvious malignant behaviour is seen, most notably as invasion of surrounding tissues. In these cases a radical excision on the side of the largest lesion should be carried out, almost always with the sacrifice of the vagus nerve, and irradiation offered for the other side. The embryology is a little irrelevant as these lesions form cysts, usually requiring surgical excision. Base of the skull invasion and spread means that skills in lateral skull base surgery must be available. The head and neck surgeon must have a full working knowledge of reconstructive techniques and, in particular, microvascular composite graft reconstruction. More than 80 percent of tumours are benign and if treatment is required it is almost always surgical. The main problem is one of access followed by problems related to adjacent structures. Some benign tumours, notably paragangliomas, may in fact be malignant but can only be diagnosed surgically not histologically. Best clinical practice [Initial assessment should consist of a thorough clinical examination that documents all cranial nerve deficits, followed by a scan and fine needle aspiration biopsy (if appropriate). The parapharyngeal space: Anatomy and pathologic conditions with emphasis on neurogenous tumours, 2nd edn. Familiar non-chromaffinic paragangliomas (glomus tumours): Clinical and genetic aspects (abridged). Synovial sarcoma in the parapharyngeal space: case report and review of the literature. Metastasis of maxillary carcinoma to the parapharyngeal space: rationale and technique for concomitant en bloc parapharyngeal dissection. The prognostic significance of parapharyngeal tumour involvement in nasopharyngeal carcinoma. Occult medullary carcinoma of the thyroid presenting as neck and parapharyngeal metastasis. The pathological anatomy and treatment of parotid tumours with retropharyngeal extension (dumb-bell tumours): with a report of 4 personal cases.

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It does require a laparotomy which can be a problem in patients with significant co-morbidity or poor performance status symptoms 5 days post embryo transfer levaquin 750 mg with amex. A large segment of greater omentum is harvested which can be reduced in volume after insetting medications gout purchase 250mg levaquin with visa. It is critical that the stomach be stretched out to length before stapling to ensure that enough functional stomach remains treatment tracker order levaquin 500 mg amex. A jejunal feeding tube is placed for patients undergoing laryngopharyngeal reconstruction treatment 5ths disease purchase levaquin 500 mg on-line. The gastro-omental flap is largely used for conduit reconstruction following laryngopharyngetomy medications 1800 purchase levaquin 750mg without prescription. Numerous authors have reviewed functional outcomes following oral cavity reconstruction and have all come to similar conclusions medications zetia order 250mg levaquin otc. Any reconstruction used in the oral cavity should have the goal of replacing the volume resected but must maintain and not limit the mobility of the tongue remnant. Highly sensate flaps such as the free forearm flap have been widely used in oral cavity reconstruction, clearly providing two-point, touch and temperature sensation for the reconstructed oral cavity. In posteriorly placed defects in the oropharynx, specifically the tongue base and palate, two additional issues are of importance. In tongue base resection, appropriate but not excessive volume replacement appears to improve swallowing results. In soft palate reconstruction, recreating appropriate palate closure is particularly important to avoid nasal regurgitation. The reconstruction would be of low morbidity in terms of its donor site and relatively easy to harvest and revascularize. It is thin and pliable and certainly functions well at maintaining the mobility of the residual tongue. This flap is probably the best sensate flap available and if one believes sensation is important this would be the preferred flap. The anterolateral thigh flap in patients with the appropriate body habitus is probably a very close option to the forearm in producing high quality functional results. The other flaps available all suffer from providing too much bulk and, potentially, can limit the residual movement of the oral and oropharyngeal structures. The current options for reconstruction of this defect are the enteric reconstructions; the jejunum or gastroomental flap or tubed skin flaps. There is extensive experience world-wide with the jejunal flap and it has proven efficacy in the reconstruction of this defect. Swallowing and speech results with the jejunum are less than perfect which has led some centres to consider the free gastro-omental flap. The gastro-omental flap appears to produce improved swallowing and voice results with the benefit of a large segment of greater omentum. There have been numerous reports of cutaneous skin tubes for oral reconstruction, in particular the free forearm flap and anterolateral thigh flap. Both these reconstructions have excellent swallowing and voice results, with low donor site morbidity, but have been problematic in the development of distal anastomotic strictures. A number of authors now advocate the use of silastic stents with cutaneous flaps, an approach which appears to have dramatically reduced the rate of distal anastomotic stricture. The use of the submandibular gland transfer moving the gland out of the field of radiation is probably a technique that will be more widely used in the future. Prospective studies evaluating the long-term functional outcomes of these various reconstructions will help elucidate the best approach for this complex group of patients. The ideal pharyngeal reconstruction would provide a mucosalized conduit that has Reconstruction of composite defects, including oral lining and the mandible, continue to challenge reconstructive Chapter 207 Free flaps in head and neck reconstruction Table 207. In mandibular reconstruction the key issue is the length of bone required, whether the transferred bone is amenable to secondary osseointegration and the morbidity associated with the donor site of the bone flap. Secondary issues are the correction of disparities in bone height between the native mandible and condylar reconstruction. The mandibular resection that extends to include the condylar head continues to be a problem in terms of recreating a functional joint that will allow an appropriate range of movement for mouth opening and mastication. In addition, there are remarkable variations in the colour of the various skin flaps based on the race and genetic background of the patient. When balancing donor site morbidity with skin colour, amount of available skin and the ability to adjust the volume of the reconstruction, the scapular system of flaps and the anterolateral thigh appear to offer the greatest potential. Currently, the flap of choice in most centres is the free fibular transfer based on the quality of the available skin island and the length of available bone with limited donor site morbidity. The scapular bone flap is probably an excellent alternative where the fibula is not an option because of peripheral vascular disease and is particularly useful in the elderly. The osseocutaneous radius transfer has a limited bone stock and significant potential donor site problems making it a poor choice for mandibular reconstruction. As experience develops with the aforementioned reconstructions, the indications and efficacy of the various techniques will be further delineated. The developments over the next decade in tissue engineering and in the management of the immune response to allogeneic transplants will certainly offer further opportunities for better and more functional reconstructions for head and neck patients. The available options for mandible reconstruction largely achieve the goals of reconstruction of this defect. Recreation of a functional nonprosthetic condyle continues to be a problem and simple surgical techniques to augment the vertical height of the existing mandibular reconstructions would be helpful. There has been recent interest in the terminology and concept of perforator flaps. There is a need for specialized nursing units for monitoring free tissue transfer to facilitate rapid return to the operating theatre for vessel occlusion. Its advantages are ease of harvest, long pedicle length and potential for sensation. The lateral arm flap offers limited donor site morbidity with the disadvantage of a short vascular pedicle and small donor vessels. The rectus abdominus flap has consistent anatomy and is excellent for large cutaneous, oral or skull base defects. The anterolateral thigh flap is a recently popularized flap, particularly in patients with thin thighs. The fibular flap is the current standard of care for extensive mandibular defects. Care needs to be taken in using this flap in patients with peripheral vascular disease. The swallowing results are good but not excellent and speech rehabilitation with this flap is problematic. The gastro-omental flap has seen limited use for pharyngeal reconstruction over the past 20 years. It has become more popular based on the opportunity to transfer large segments of omentum which may be an advantage in the chemoradiation failure patient. Deficiencies in current knowledge and areas for future research $ $ Best clinical practice [Free tissue transfers are best performed in centres with high clinical and surgical volumes with specialized nursing units for postoperative management and monitoring. Prospective outcome studies evaluating the efficacy of the various reconstructive techniques in terms of speech and swallowing. Research and creative opportunities in prefabrication of reconstruction and evaluating the utility of allotransplantation. Mandibular reconstruction, deficiencies in prospective evaluations of functional outcomes (swallowing and deglutition). Further definition of the role of osseointegration technology in oral rehabilitation. Prefabrication of mandibular components and evaluating the utility of allotransplantation. Maxillary reconstruction, deficiencies in prospective studies evaluating outcome and quality of life in patients treated with reconstructive procedures or maxillofacial prosthedontics. The vascular territories (angiosomes) of the body: experimental study and clinical applications. A triple-blinded randomized trial comparing the hemostatic effects of large-dose 10% hydroxyethyl starch 264/0. Dextran-related complications in head and neck microsurgery: do the benefits outweigh the risks Usefulness of color Doppler sonography for assessing hemodynamics of free flaps for head and neck reconstruction. The Cook-Swartz venous Doppler probe for the post-operative monitoring of free tissue transfers in the United Kingdom: a preliminary report. Variations in the postoperative management of free tissue transfers to the head and neck in the United Kingdom. Clinical experience in end-to-side venous anastomoses with a microvascular anastomotic coupling device in head and neck reconstruction. Reinnervated lateral antebrachial cutaneous neurosome flaps in oral reconstruction: are we making sense The necessity of internal fixation of the donor-site defect to prevent pathological fracture. Colorimetric evaluation of facial skin and free flap donor sites in various ethnic populations. The inframammary extended circumflex scapular flap: an aesthetic improvement of the parascapular flap. Refinements in free flap breast reconstruction: the free bilateral deep inferior epigastric perforator flap anastomosed to the internal mammary artery. The internal oblique-iliac crest osseomyocutaneous microvascular free flap in head and neck reconstruction. The free vascularised iliac crest tissue transfer: donor site complications associated with eighty-two cases. Immediate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment. Reconstruction of cervical esophagus, hypopharynx and oral cavity using free jejunal transfer. Morbidity and functional outcome of free jejunal transfer reconstruction for circumferential defects of the pharynx and cervical esophagus. Functional results of primary closure vs flaps in oropharyngeal reconstruction: a prospective study of speech and swallowing. Predictors of speech and swallowing function following primary surgery for oral and oropharyngeal cancer. Long-term outcomes of submandibular gland transfer for prevention of postradiation xerostomia. With superficial injuries, most facial wounds will heal with little to no scar formation. However, once the reticular dermis has been violated, some amount of residual scarring is bound to occur. Successful application of various treatments requires an understanding of which techniques are best indicated when performing scar revision or treating hypertrophic and keloid scars. When there is an excessive local tissue response to injury, a dysregulated deposition of extracellular matrix and collagen occurs resulting in either a hypertrophic scar or keloid. Both keloids and hypertrophic scars have a tendency to persist at the site of injury and recur after surgical excision. The distinction of what differentiates a hypertrophic scar from a keloid has been debated. A more broadly accepted distinction in that only keloids grow beyond the boundaries of the original scar. Clinically, one may think in terms of a wound-healing spectrum with normal thin scars at one end, hypertrophied scars in the middle and keloids at the other end of the spectrum. Review of the literature is made more difficult by a lack of outcome standardizations. Most authors combine keloids from all body sites making the study of only head and neck keloids more difficult. Many papers also combine the treatment of both hypertrophic scars and keloids together, further making the elucidation of meaningful comparable results more difficult. The complete resolution of a keloid provides a clear endpoint from which to compare various treatment regimens. Short follow-up times are also problematic as previous studies have demonstrated that 90 percent of keloids will recur in the first 12 months and 100 percent will recur in the first 24 months. When possible, attempts have been made to reference only those articles with follow up beyond 12 months and those with a substantial number of head and neck keloids. Until recently, completely satisfactory epidemiological data on the genetics of familial keloids have been lacking. Recently, a comprehensive study of the pedigrees of 14 families of various ethnicities was undertaken to try and determine the mode of familial keloids expression. The study data represent the most comprehensive collection of keloid families to date and include the pedigrees of up to four generations, including 341 family members of whom 96 displayed keloids. The findings support the familial transmission of keloids occurring via an autosomal dominant mode of incomplete clinical penetrance and variable expression. Taken together, these data suggest that single gene mutations can predispose family members to keloids. A review of the medical literature from 1965 to date reveals over 1000 articles describing the treatment of keloids with multiple the topical application of silicone gel sheets to the surface of keloids has been shown to be beneficial in the management of these lesions.

Rose Apple (Jambolan). Levaquin.