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Maxillofacial injuries sustained playing sports are becoming increasingly common, and in the UK where football is the most popular team sport, associated maxillofacial injuries are a regular occurrence. This study retrospectively examined data on patients who were referred with facial injuries sustained playing football between 2007 and 2019 (n = 265). Demographics, mechanism of injury, diagnosis, and treatment received were analysed. The mean (SD) age was 25 (11.0) years (range 3-85) and there was a strong male predominance (n = 256, 97% male). Facial fractures were diagnosed in 143 (54%) patients. The most common injury was a midface fracture and the most common mechanism of injury was a clash of heads. Patients with a facial fracture were significantly more likely to have sustained a concurrent head injury (p = 0.006). Those who were elbowed or punched were significantly more likely to have a facial fracture than a soft tissue or dentoalveolar injury (p ≤ 0.05). Players who clashed heads were significantly more likely to have a midface fracture (p ≤ 0.001). In conclusion, football-related maxillofacial injuries predominantly affect young adult males following a clash of heads. An elbow or punch to the face carries a significant risk of facial fracture and concurrent head injury. Therefore, to reduce the percentage of maxillofacial injuries seen in this sport, observed intentional contact between players, using an elbow or fist to the face in particular, must continue to carry the highest sanction.

Merkel cell carcinoma (MCC) is a rare and highly aggressive neuroendocrine malignancy of the skin. Its incidence is increasing with half of cases involving the head and neck. To the best of our knowledge, few large studies have been published in the UK, and to date this is the largest reported series of head and neck MCC. We retrospectively reviewed the outcomes of patients with MCC in three hospitals in the south-east of England over a 12-year period (2008–2019). Diagnosis was based on histological data following biopsy. Overall survival and disease-specific survival were calculated using Kaplan–Meier and log-rank tests. Fifty-eight patients met the inclusion criteria (24 stage I, 22 stage II, 9 stage III, and 3 unclassified). Median disease-free survival was 36 months (95% CI 0 to 77.2) and median overall survival 50 months (95% CI 29.9 to 70). Overall five-year survival was 34.4% (95% CI 17% to 52%) with two-year survival at 62% (95% CI 48% to 76%). Five-year disease-free survival was 26.7% (95% CI 17 to 52%) with two-year disease-free survival at 54% (95% CI 40% to 68%). To date, this is the largest UK based study reporting overall and disease-free survival associated with MCC of the head and neck. Half the patients presented late, and surgery was the mainstay of treatment, augmented by adjuvant radiotherapy. There is a need to better stratify patients at risk of developing metastatic disease, with the use of sentinel lymph node biopsy and positron-emission tomography-computed tomography (PET-CT), as immunotherapy and targeted agents are now available to treat advanced disease.

Neutrophil to lymphocyte ratio (NLR) is a marker of infection and is used as a prognostic marker for cancer and cardiovascular disease. There is little application of NLR as a biomarker for odontogenic infection. C-reactive protein (CRP) is a commonly used marker for odontogenic infection that correlates with length of stay (LOS). The aim of this study was to assess the clinical utility of NLR as a prognostic marker of deep neck space infections secondary to odontogenic infection and to analyse its correlation with admission CRP and LOS. Data from January 2019 to December 2019 were retrospectively examined for patients admitted with a deep neck space infection of odontogenic cause. Data on admission CRP, NLR, sex, age, site of infection, LOS, treatment, ICU admission, and presence of comorbidities were analysed. A total of 161 patients were included, 89 (52.7%) of whom were male, and 72 (42.6%) female. Mean (SD) age was 38.4 (16.8) years (range: 5-86 years). Mean (SD) admission CRP and NLR were 105.9 (93.1) mg/L and 7.5 (7.7). Mean (SD) LOS was 2.9 (3.2) days (range: 0.5-35 days). Both admission CRP (p≤0.01) and admission NLR (p≤0.01). were significantly associated with LOS. Receiver operating characteristics analysis for LOS≥2 days produced an area under the curve for CRP and NLR of 0.666 and 0.639. The optimum cut-off value of NLR for LOS≥2 days was 4.65. In conclusion, NLR can be used as a prognostic marker for patients admitted with deep neck space infection secondary to odontogenic infection. Patients with NLR≥4.65 are likely to require LOS≥2 days.

Process mapping in industry is a well-established tool to improve efficiency. It is defined as a quality improvement technique that breaks down a process, or task, into its individual components, or steps, then analyses it. Lean principles are used to reduce waste and produce consistently good outcomes. Improving the operative efficiency of orthognathic surgery has many benefits. There is increasing demand for this complex surgery, and patients have appropriately high expectations with relation to their outcome. There are also increasing pressures for hospitals to reduce costs. In a recent paper by our group (Bowe et al, in press), we have published operating times for orthognathic procedures that are significantly shorter than in previously available series, with an average time for a bimaxillary osteotomy of 2 hours and 19 mins. Through observation of the senior authors' uniform technique, refined from experience of over 2,000 cases, a bimaxillary osteotomy was broken down into individual steps, all arranged in a process-mapped template with which to increase efficiency and results. We show here the multiple small operative efficiencies we have developed, and the Lean surgical principles which we use. This has enabled us to reduce the operative time of these common procedures, without compromising outcomes. This study presents an approach to process map bimaxillary orthognathic operations and shows how the application of Lean principles improves operative efficiency, and produces consistent results.

This study was undertaken with the aim to compare the T stages in a series of cutaneous squamous cell carcinoma (cSCC) patients using both the eighth edition of the Union for International Cancer Control (UICC) TNM Classification of Malignant Tumours (TNM8) and Brigham and Women's Hospital (BWH) staging systems. This would allow comparison of the two to determine suitability with regards to T stage and the effect on local recurrence and nodal disease. This was a six-year retrospective cohort study of patients with primary invasive cSCC of the head and neck who were diagnosed and treated at Western Sussex Hospitals Trust in the United Kingdom between 2007 and 2012. The TNM8 and BWH staging systems were applied to these primary cSCCs. A total of 695 invasive cSCCs treated in 604 patients over six years were identified. Most patients were male (76%), with a mean (range) age of 81 (50-103) years. The most common location for local recurrence was the scalp (n=26, 58%). Regional metastasis occurred most commonly in the parotid gland (n=20, 63%). All tumours were classified using both staging systems. Specifically, 432 tumours remained in the same T stage (61%), and 192 were downstaged (27%) and 71 upstaged using the BWH (10%). The median (SD) follow-up time was 23 (28) months (range 1-123). The BWH alternative staging system overlapped with the TNM8 in high-stage and low-stage tumour assignment. The highest percentage of local recurrence and regional metastasis occurred in T2b tumours.

Flow couplers for venous anastomosis, which enable the invasive monitoring of free flaps during the postoperative period with a continuous venous signal audible immediately after completion of the anastomosis, have been reported to be reliable, sensitive, and specific as anastomotic flap monitoring adjuncts. The purpose of this study was to evaluate the reliability, sensitivity, specificity, and outcomes of surgical exploration, and the impact on free-flap survival of the venous anastomotic flow coupler for microvascular head and neck reconstruction in a consecutive series of patients. This is a retrospective review of consecutive patients treated in the department of oral and maxillofacial surgery who underwent reconstruction of a head and neck defect using venous anastomosis with a flow coupler-vascularised free flap between October 2015 and December 2020. A total of 189 patients had free-flap reconstruction of head and neck defects. We compared the venous flow coupler group (n = 72) with patients who had free flaps with hand-sewn anastomoses over the same period (n = 117). There were no false positive/negatives associated with the flow coupler as an implantable flap monitor. The flow coupler cohort had a significantly higher flap salvage rate compared with free flaps that were monitored clinically (p = 0.04). The venous flow coupler has been shown to be a reliable microvascular anastomotic and invasive flap monitor that enables accurate and timely detection of flap compromise and prompt, successful free-flap salvage.

This is the third of three articles that give an overview of the current evidence for management of the neck and parotid in patients with cutaneous cancers of the head and neck. In this paper we discuss Merkel cell carcinoma (MCC) and review the latest evidence for management of the regional nodes.

UK national guidelines in 2016 recommended that sentinel lymph node biopsy (SLNB) should be offered to patients with early oral squamous cell carcinoma (OSCC). We review the establishment of an OSCC SLNB service with specific consideration to resources, service implications and patient outcomes. A review of processes was performed to identify key stages in establishing the service, and subsequently a retrospective cohort study consisting of 46 consecutive patients with T1/T2 N0 OSCC was undertaken. The key stages identified were: coordinating a nuclear medicine pathway and reliable cost-appropriate pathology service, constructing a Trust business case, and gaining approval of a new interventional service policy. A median (range) of 3.3 (1-8) sentinel nodes (SLN) were removed, with 17 patients having a positive SLN. The negative predictive value of SLNB was 100%, with 12 having a SLN outside the field if elective neck dissection (END) was planned. There was a significantly increased risk of a positive SLN with increasing depth of invasion (DOI) (p=0.007) and increased diameter (p=0.036). We also identified a longer-than-ideal time to completion neck dissection and inadequate ultrasound follow up of negative SLNB patients. Establishment of a service requires careful planning. Our results were in keeping with those reported in the literature, and showed that SLNB for OSCC has a high negative predictive value and can identify at-risk SLN outside the traditional END levels, even in well-lateralised tumours. Our findings show that DOI and size of SLN were significantly associated with a positive SLN, and also identified areas requiring improvement.

Lateral posterior segmental mandibular defects present a reconstructive challenge and an osseous flap would be the gold standard to reconstruct such a defect. However, combining a mandibular reconstruction plate (MRP) with a soft-tissue free flap (to restore mucosal integrity and provide durable coverage of the plate itself) offers an alternative option for posterior segmental mandibular defects in patients who are not suitable for osseous reconstruction, or do not choose it. We retrospectively reviewed 30 consecutive patients (19 male and 11 female) who underwent reconstruction of a segmental mandibulectomy defect using a bridging MRP and anterolateral thigh (ALT) free flap. The mean (range) age was 67 (31-87) years. The American Society of Anesthesiologists’ (ASA) status of the study population comprised Grade 1 (n = 10), Grade 2 (n = 18), and Grade 3 (n = 2). The majority of patients had oral cavity squamous cell carcinoma (n = 26) involving the mandible, two had osteoradionecrosis, and two mucoepidermoid carcinoma. Four patients had complications specific to the reconstruction, and flap loss occurred in one (96.7% success rate). Metalwork infection occurred in three, including one plate extrusion and one plate fracture. The median length of stay was 10 days, and mean (range) duration of follow up 23.3 (1-96) months. This technique is an alternative reconstructive option for the non-tooth-bearing mandible. Reconstructing a posterolateral segmental mandibulectomy defect with a bridging MRP and ALT free flap offers a robust reconstructive alternative with a favourable complication profile.

Developing and regenerated myelinated rat dorsal and ventral root fibers respond differently to the fast potassium channel blocking agent 4-aminopyridine (4-AP). To pursue this issue further, we made unilateral sciatic nerve crushes in adult rats. Sural (SN) and lateral gastrocnemius (LGN) nerve branches were collected 4-6 months later, for physiological and morphological examination. Regenerated and control nerves in Ringers solution showed generally similar compound action potential (CAP) waveforms, but CAPs of regenerated SNs and LGNs in 4-AP were markedly different. While regenerated SNs showed a prominent late CAP negativity with a "rippled" appearance and markedly compromised recovery properties, the CAP and recovery properties of regenerated LGNs were minimally changed. Light and electron microscopic examination of SN and LGN fibers failed to reveal any features obviously related to the observed physiological differences. We conclude, that the effect of 4-AP on regenerated cutaneous afferents differs from its action on regenerated muscular afferents and efferents. This physiological diversity lacks obvious structural correlates.