UHCW publication: Success rates and complications of eminectomies

Success rates and complications of eminectomies: a retrospective case series
Rahman, Z; Chand, M; Breeze, J; Stocker, J. Oral Surgery; Edinburgh Vol. 11, Iss. 1, (Feb 2018): 28-32.

Abstract
Introduction
Eminectomy is the physical removal of the articular eminence to enable free movement of the condyle. The primary indication is to treat recurrent dislocation, although in the past it has been used for non-reducing disc displacement without reduction (NDDR). The established contraindication to the procedure is pneumatisation of the articular eminence or tubercle. Determining the success rates of eminectomies from previous papers are hampered by the lack of baseline objective measures needed to improve assessment of treatment outcomes.

Methodology
A retrospective case series was conducted, in which written and computerised hospital records and images were analysed from 2007 to 2014, using a minimum data set developed by our unit to assess outcomes. These included indication for procedure, frequency of dislocation, interincisal distance, pre-operative imaging and objective pain scoring.

Results
Twenty of twenty-eight (71%) patients receiving an eminectomy conformed to the minimum data set. Pain improvement was demonstrated in 60% of patients with both recurrent dislocation and NDDR. Complications occurred in 24% of eminectomies, all of which were temporary.

Conclusions
Eminectomy is a safe and effective procedure for management of chronic temporomandibular joint dislocation in well-selected cases. However, the results were less predictable with NDDR. The recording of specific clinical information is required to improve comparing outcomes and we would recommend the use of a proforma such as one utilised in our study. There was no evidence that pneumatisation of the eminence was related to an adverse clinical outcome but further evidence is required to question this as a contraindication to eminectomy.

Cranio-Cervical Trauma Eidemiology, Classification, Diagnosis and Management

J Spine Neurosurg 2017, 6:5. DOI: 10.4172/2325-9701.1000284

Objective: To provide an overview of current knowledge of the management of Cranio-Cervical (Occipito-cervical) injuries.

Conclusion: Cranio-cervical injuries constitute a significant proportion of high velocity trauma and can be missed. There is a need for high index of suspicion in such patients. Recent trends seem to favour surgical management of these injuries even in the elderly. Aim should be early surgical fixation wherever possible even in elderly patients, if there is no significant co-morbidity or contraindication for surgery.

UHCW Research: Amar Saxena

Are patients satisfied with the head and neck skin cancer service? An evaluation of outpatient services with a review of published reports

British Journal of Oral and Maxillofacial Surgery December 2017 Volume 55, Issue 10, Pages 1018–1023 

Scientific publications place much emphasis on postoperative outcomes such as recurrence, but little attention to patients’ satisfaction. The purpose of this evaluation was to find out patients’ reported outcomes after their initial consultation, treatment, and follow-up appointments for non-melanoma skin cancer of the head and neck.

UHCW Research: V. Petrosyan

A service evaluation of surgical tracheostomies in the emergency theatre at University Hospital, Coventry: time for a dedicated tracheostomy team?

British Journal of Oral and Maxillofacial Surgery , Volume 55 , Issue 10 , e96 

The routine practice of surgical tracheostomy has been challenged by bedside percutaneous dilatational tracheostomy (PDT). Whilst PDT is cost-effective and time-efficient, there is still a place for the open technique in patients with unfavourable anatomy, unstable cervical spine injuries and/or coagulopathies. Complication rates of the open technique are often lower, but booking such cases into busy emergency theatres may prove difficult.

UHCW Research: Miesha Virdi, Priya Chohan, Ross Elledge, Roger Townsend and Gary Walton

Nivolumab for treating squamous cell carcinoma of the head and neck after platinum-based chemotherapy [TA490]

New technology appraisal guidance from NICE:

Evidence-based recommendations on nivolumab (Opdivo) for treating squamous cell carcinoma of the head and neck in adults who have had platinum-based chemotherapy.

Nivolumab is recommended for use within the Cancer Drugs Fund as an option for treating squamous cell carcinoma of the head and neck in adults whose disease has progressed on platinum-based chemotherapy, only if:

• the disease has progressed within 6 months of having chemotherapy
• nivolumab is stopped at 2 years of uninterrupted treatment, or earlier in the event of disease progression and
• the conditions in the managed access agreement are followed.

Should we consider devolution of “head and neck” surgery from the specialties of oral and maxillofacial surgery; ear, nose, and throat surgery; and plastic surgery?

Br J Oral Maxillofac Surg. 2017 Jun;55(5):566. doi: 10.1016/j.bjoms.2016.12.019. Epub 2017 Feb 14.
Editorial published in the British Journal of Oral and Maxillofacial Surgery

In the United Kingdom the practice of vascular surgery has now become recognised as the tenth independent surgical specialty by the Royal College of Surgeons of England and the General Medical Council (GMC). Traditionally, surgical trainees developed their subspecialty vascular interest within the parameters of obtaining a certificate of completion of training (CCT) in General Surgery. The process of devolution of areas of subspecialty may also apply to other surgical specialties.

 

UHCW Research: Elledge R, Walton G, Sandhu R, Prasad S, Howe D

NIHR Signal Pilocarpine improves dry mouth caused by radiotherapy

Out of several treatments tested, the drug pilocarpine gave the most significant improvement in dry mouth following radiotherapy for head and neck cancer. Less dry mouth and increased salivary flow were twice as likely after taking pilocarpine than after a dummy pill.

Dry mouth from radiotherapy impairs quality of life. Although people can try simple measures at home, such as sucking ice cubes, they may wish to discuss pilocarpine treatment with their GP. Side effects from this medication are usually short-lived but if they are troublesome other options are available, though not supported by such good evidence as pilocarpine.

from the NIHR Dissemination Centre

Pembrolizumab (KEYTRUDA®) for advanced, metastatic oesophageal cancer – second line

The most common treatment options for oesophageal cancer in the UK is surgery; alternative treatments are radiotherapy and chemotherapy. Pembrolizumab is a type of immunotherapy, which works targeting specific proteins that stimulates an immune response that targets the cancer cells. It increases the body’s natural ability to identify and attack cancer cells. If licenced, pembrolizumab will offer an additional treatment option for patients with oesophageal cancer and prolong the time without cancer progression.


From the NIHR Innovation Observatory

Nivolumab is recommended for use within the Cancer Drugs Fund (CDF) for some patients with head and neck cancer.

The immunotherapy drug, nivolumab, also known as Opdivo made by Bristol-Myers Squibb, will be available for patients with head and neck cancer who have not responded to chemotherapy within 6 months, and the cancer has spread to other parts of the body.

When NICE first reviewed nivolumab, it was found that the evidence for its effectiveness in treating head and neck cancer was uncertain. NICE invited Bristol-Myers Squibb to submit a CDF proposal to show how they would strengthen the evidence for nivolumab.

Patients can now have access to the drug via the NHS whilst it is within the CDF. During this time, further data will be collected from how well patients do who access the drug through the CDF and from a clinical trial to help address uncertainties in the evidence.

Cetuximab for treating recurrent or metastatic squamous cell cancer of the head and neck [TA473]

New Evidence-based recommendations on cetuximab (Erbitux) for treating recurrent or metastatic squamous cell cancer of the head and neck in adults.

Cetuximab in combination with platinum-based chemotherapy is recommended as an option for treating recurrent or metastatic squamous cell cancer of the head and neck in adults only:

• if the cancer started in the oral cavity and
• when the company provides the drug in line with the commercial access agreement with NHS England.

Use of buccal cortex as interpositional graft in mandibular setbacks

Br J Oral Maxillofac Surg.2017 Aug 14. pii: S0266-4356(17)30240-1. doi: 10.1016/j.bjoms.2017.07.009. [Epub ahead of print]

The most commonly used options for mandibular fixation after sagittal split ramus osteotomy (SSRO) are monocortical plates and bicortical screws, which have comparable stability.1 We have recently changed our practice to the routine use of bicortical screws where possible, particularly for mandibular setbacks. They are faster to place and need to be removed less often than miniplates.2


UHCW Research: Rohit Chandegra and Peter Stockton

Head injury: assessment and early management

Updated NICE guidance on the assessment and early management of head injury.

In June 2017, we updated recommendations 1.2.8 and 1.4.12 with cross-references to related NICE guidelines, and an outdated research recommendation was deleted.

Thyrolingual trunk: aberrant branches of the external carotid artery

British Journal of Oral and Maxillofacial Surgery May 2017 Volume 55, Issue 4, Pages 437–438 

We recently encountered an anatomical variation of the superior thyroid and lingual branches of the external carotid artery during a modified radical neck dissection. It was a common trunk, arising below the level of bifurcation of the common carotid artery, and we anecdotally named it the thyrolingual trunk (Fig. 1). This subsequently branched into the respective superior thyroid and lingual arteries.

UHCW Research: Al-Ali, S., Elledge, R., Esmil, T. and Walton, G.

PET-NECK: a multicentre randomised Phase III non-inferiority trial comparing a positron emission tomography-computerised tomography-guided watch-and-wait policy with planned neck dissection in the management of locally advanced (N2/N3) nodal metastases in patients with squamous cell head and neck cancer

Health Technol Assess. 2017 Apr;21(17):1-122. doi: 10.3310/hta21170.

PET-CT-guided active surveillance showed similar survival outcomes to ND but resulted in considerably fewer NDs, fewer complications and lower costs, supporting its use in routine practice.

UHCW Research: Fresco, L.

NICE says head and neck cancer drug is not cost effective

NICE has published draft guidance saying the cost of using nivolumab to treat head and neck cancer is too high for routine NHS use.

Re: Should we consider devolution of "head and neck" surgery from the specialties of oral and maxillofacial surgery; ear, nose and throat surgery; and plastic surgery?

Br J Oral Maxillofac Surg. 2017 Feb 14. pii: S0266-4356(17)30042-6. doi: 10.1016/j.bjoms.2016.12.019. [Epub ahead of print]

We were interested in Islam’s editorial regarding the devolution of head and neck surgery from the parent specialties that feed into it.1 We have had a devolved arrangement of practice at University Hospitals Coventry and Warwickshire Hospitals NHS Trust since 2003. To the best of our knowledge this is the only service in the country in which this is the case, and it is recognised as such within the clinical and management structure of the hospital. The service has a separate clinical lead, QIPS (Quality, Improvement, and Patient Safety), business, and departmental meetings

UHCW Research: Elledge R, Walton G, Sandhu R, Prasad S and Howe D.

Head and neck cancer drug is not cost-effective

NICE does not recommend head and neck cancer drug cetuximab in draft guidance out for consultation.

In 2009 when NICE originally looked at cetuximab it found it was not cost effective, and it was later made available through the Cancer Drugs Fund.

NICE has looked again at cetuximab as part of its programme to appraise drugs that are currently available on the CDF and found that despite new evidence and a drop in price it was still not cost effective

Nivolumab for Recurrent Squamous-Cell Carcinoma of the Head and Neck

NEJM October 9, 2016DOI: 10.1056/NEJMoa1602252

The recurrence and metastasis of squamous-cell carcinoma of the head and neck are facilitated by immune evasion,7 which is mediated in part by expression of the programmed death ligands (PD-L1 and PD-L2) of the T-cell–suppressive immune-checkpoint receptor programmed death 1 (PD-1).8-11Nivolumab, a fully human IgG4 anti–PD-1 monoclonal antibody, has shown antitumor efficacy in multiple tumor types.12,13 We designed a randomized trial to investigate whether overall survival would be longer with nivolumab therapy than with standard therapy, among patients with platinum-refractory squamous-cell carcinoma of the head and neck.

New draft quality standard to improve treatment of head and neck cancer.

NICE is consulting on a new draft quality standard to improve treatment of head and neck cancer.

Current practice, when scans can’t detect if cancer has spread to the lymph nodes in patients with early oral cavity cancer is to have major surgery to remove them in case it has.

The draft quality standard recommends those patients instead have a biopsy to remove the main lymph gland linked to the cancer to establish if it has spread and if further surgery is needed.

A scan may help decide if surgery is required as follow-on treatment for head and neck cancer

People with head and neck cancer in the UK usually receive chemotherapy and radiotherapy followed by surgery. Using a scan to assess cancer status after this first line chemoradiotherapy and only suggesting surgery to those with a clear indication led to similar survival rates, complications and fewer operations compared with planned cancer surgery for everyone.

After receiving similar initial treatment, this trial compared routine neck dissection surgery to surgery only if the scan showed residual cancer 12 weeks after chemoradiotherapy.

Head and neck surgery can be invasive and disfiguring, so doctors and patients alike want to minimise unnecessary operations, this potentially saves money.

The scanning tested was PET-CT scanning, a newer type of highly detailed CT scanning. This scan guided surveillance is not currently covered by NICE guidance. These findings suggest there may be a place for it and that by saving surgery for some people it could also save costs, compared to planning surgery for everyone without a surveillance scan.

From the NIHR Dissemination Centre