Uses of cryosurgery

Cryosurgery can be used in a number of conditions and in several is the treatment of choice (Table 38.1). Freezing can be used to treat surface lesions such as warts or small tumours. It is particularly suitable for Ablation of warts and small tumours Ablation of tiaemangiomas Treatment of bony cavities Blocking of nerves haemangiomas around the mouth. Several applications may be required but cryosurgery has the advantage that there is no haemorrhage and the surface may be left intact. Viral...

Patient management

The management of clefts of the lip and palate is multidisciplinary and requires the involvement of several specialities, which constitute a cleft team. In most centres, the minimum complement of a cleft team involved in the primary management would consist of a surgeon, orthodontist, speech and language therapist, ENT surgeon and audiologist. The participation of several other disciplines is also crucial in the management of the child with a cleft deformity, including paediatricians,...

Aetiology of oral cancer

The aetiology of oral squamous cancer is complex. The main factors associated with this disease are tobacco and alcohol consumption. Each of these factors increases the likelihood of oral cancer and both show a strong dose-related increase in incidence. It would seem that heavy smoking and heavy drinking have a synergistic effect, leading to an exponential rise in relative risk (Fig. 17.1). Tobacco is the main aetiological agent associated with oral cancer. The risk of oral cancer is related to...

Oral cancer morbidity

The number of deaths from oral cancer has been rising over the last 30 years. The death to registration ratio is 0.4, which is higher than many other cancers and similar to cancer of the uterine cervix and breast. The site in the mouth is an important prognostic indicator, with the tongue having the poorest prognosis and highest mortality (Table 17.2). Table 17.2 Registration and deaths by site in Scotland 1991-1996 Survival rates have not improved over the past 50 years, mainly due to late...

Management of scars

Scars in the head and neck are not only disfiguring and noticeable but often have a social stigma attached. Initial wounds can look quite satisfactory but, as healing progresses, scar formation develops. This appears as reddening and increasing size of the scar as it tends to become wider and raised from the skin surface. The scar becomes hard and can be associated with itch and pain. As the scar matures it should become softer paler and flatter. The final scar should look paler than the...

Vestibular dentureinduced hyperplasia

Several forms of denture-related hyperplastic soft-tissue lesions are recognised but they all arise as a result of loss of denture fit and are therefore more often seen in the 'old denture' wearer, who is often the satisfied denture wearer. The most common form is the result of alveolar resorption over a considerable number of years. This causes the periphery of the flange of the denture to impinge on the sulcus depth or adjacent lip or cheek tissue. As this is a very gradual process, the...

Osteorad ionecrosis

Irradiation to the jaws may occur as a result of radiotherapy for malignant disease of the mouth, pharynx or salivary gland regions. Damage to the cells within the bone, the osteocytes, and to the nutrient blood vessels within bone, renders the bone less vital and hence more open to infection. In the blood vessels there is an endarteritis and periarteritis that significantly reduces the blood supply to the bone and this particularly affects mandibular bone, which has a less profuse vascular...

Factors affecting healing

A number of local and systemic factors affect wound healing (Table 3.1) these are discussed in turn. Removal of hair allows better visualisation of the wound. It also facilitates application of adhesive dressings and suture removal. However, evidence has shown that shaving of skin at an early stage preoperatively increases bacterial counts in the area, and shaving more than 12 h before incision can significantly increase the rate of wound infection. Hair removal should therefore be performed...

Surgical management

Arthrocentesis is a method of flushing out the TMJ by placing a needle into the upper joint compartment using local or general anaesthesia. Ringer's lactate (see Ch. 5) is injected into the joint. This compartment will take up to 5 mL of fluid. By filling under pressure, any minor adhesions are broken down or lysed. A second needle placed into the same joint compartment allows through-flow of fluid to be achieved. This allows thorough washing or lavage of the joint. The process is referred to...

Classification of wound healing

A fundamental distinction in wound healing is between clean, incised wound edges that are closely apposed to each other, and wounds where the edges are separated. The former undergo healing by 'primary intention', the latter by 'secondary intention'. Where the edges are clean and held together with ligatures, there is little gap to bridge. Healing, when uncomplicated, occurs quickly with rapid ingrowth of wound healing cells (macrophages, fibroblasts, etc.) and restoration of the gap by a small...

Normal sequence of wound healing

Despite the differences in time taken and amount of scar tissue produced, the sequence of events in wound healing by primary and secondary intention is similar Skin trauma results in damage to superficial blood vessels and haemorrhage. Blood clotting results in fibrin clot formation, and this is stabilised by a number of factors, including fibronectin. Within 24 h neutrophils have migrated to the area, and epidermal cells have extended out in a single layer from the wound edges in an attempt to...

Criteria for removal of wisdom teeth

Over recent years there has been debate over the advisability of removing symptom-free wisdom teeth or leaving them in place. The trend in recent years has been to be conservative in the management of these teeth and this has been driven, to some extent, by the incidence of complications associated with their surgical removal, and particularly the small, but measurable, risk of damage to the inferior dental nerve or the lingual nerve. The controversy surrounding wisdom teeth has led to the...

Earlystage complications

Early-stage complications (Table 4.1) will be considered in turn. All but a few patients undergoing a surgical procedure require some form of anaesthetic, be this local, regional or general. The principles and adverse effects of general anaesthesia are described in detail in Chapter 10 and local anaesthetics are considered in Chapter 24. However, it is important to give some consideration to these because a significant proportion of complications from surgery are related to anaesthesia (Table...

Neurosurgical investigations and procedures

The purpose of neurosurgical history taking and examination is to determine anatomical localisation and, if possible, general pathology. This in turn guides the investigations that are most likely to assist in further diagnosis (of special pathology) and management. This is used to diagnose infection of the CSF, in which case the white cell count will be raised. Bleeding into the CSF (from, for example, a ruptured intracranial aneurysm) is diagnosed by frank blood-staining of the CSF and or...

Types of laser

Several types of laser are available (Table 38.5). These will be discussed below. The C02 laser has ideal properties for soft tissue surgery. It removes lesions with minimal damage to underlying tissue. There is less inflammation and oedema and little scarring, so that wide areas can be treated without the need for skin or mucosal grafts. Small blood vessels (< 0.5 mm) are coagulated so that haemostasis is rarely Type (and mode ) Excimer (pulsed) Argon (continuous wave) Wavelength and colour...

Complications of wound healing

A number of complications of wound healing can occur these are listed in Table 3.2. Table 3.2 Complications of wound healing Infection Dehiscence Incisional hernia Hypertrophic scarring Keloid scarring Contractures Wound infection is dealt with further in Chapter 8. As outlined in Table 8.2 (p. 54), several local and systemic factors predispose to wound sepsis. Total breakdown of all the layers of the surgical repair of a wound is called 'dehiscence'. The mortality of abdominal wound dehiscence...

Neurosurgical conditions

No head injury is so trivial thai it can he ignored, or so serious Ih.it it should be despaired of. These words are as true today as when written by Hippocrates. Head injuries are common and the majority are minor and do not require investigation or hospital admission. Nevertheless, the potential for complications is always present. Head injuries can be classified anatomically according to the structure(s) affected (scalp, skull, dura, brain), pathologically, depending on the type of brain...

The pharynx

Anatomy and physiology of the pharynx The pharynx is a fibromuscular tube that constitutes the upper aerodigestive tract. It is formed by the buccopharyngeal fascia and the overlapping pharyngeal constrictor muscles, which extend from the level of the base of the skull to a lower limit at the sixth cervical vertebra (C6). At C6 the cricopharyngeus fibres of the inferior constrictor form the upper oesophageal sphincter. The pharynx is usually divided into three regions the nasopharynx,...

Abnormal clotting increased bleeding tendency

Careful history taking is fundamental in the diagnosis of bleeding disorders and is essential before surgery. In patients who express a past history of bleeding problems, the site and type of bleeding (e.g. spontaneous Vs induced by trauma) needs to be determined accurately. This can give clues to the type of bleeding disorder. A history of excess bleeding at the time of previous surgery is very important to note. A detailed family history can suggest if such a disorder is inherited or...

Pericoronitis

This condition is characterised by inflammation around the crown of a tooth and only occurs when there is communication between the tooth and the oral cavity. The tooth is normally partially erupted, and hence visible, but occasionally there may be little evidence of communication between it and the oral cavity and careful probing of the gingiva immediately distal to the second molar may be necessary to demonstrate some communication, however small. The patient's main complaint will be pain,...

Immediate extraction complications

These occur at the time of the extraction and are listed in Table 26.1. This may be unavoidable if the tooth is weakened either by caries or a large restoration. However, the forceps may have been applied improperly to the crown instead of to the root mass, or the long axis of the beaks of the forceps may not have been along that of the tooth. Sometimes, crown fracture arises from the use of forceps whose beaks are too broad (see Ch. 25) or as a result of the operator trying to 'hurry' the...

Salivary gland swellings

Parotid Gland Alcoholic

Most surgical pathology of the salivary gland presents as a swelling in the associated gland and it is helpful clinically to characterise the swelling as one that affects the whole of the gland or as a discrete swelling that affects only part of the gland. Most discrete swellings are caused by a tumour, whereas swellings affecting the whole of the gland are usually caused by sialolithiasis, sialadenitis or sialadenosis (Table 14.1). There is obviously some overlap in this classification but it...

Intermediatestage complications

Intermediate-stage complications are listed in Table 4.6 and are considered in turn. Venous thromboembolism is a leading cause of preventable postoperative mortality. Clots form in the veins of the lower leg or in the pelvic veins during surgery. Classically, the patient presents with symptoms of a deep vein thrombosis (DVT) between postoperative days 5 and 7, although it can occur at any stage. A number of factors predispose patients to DVT in the postoperative period (Table 4.7). The degree...