A missed scalp laceration causing avoidable sequelae

Introduction: We present the case of an overlooked scalp laceration in an 81-year-old lady who presented with polytrauma following a fall down stairs. Complications that developed required more extensive treatment compared to what would have sufficed with early identification. Presentation of case: Imaging on admission to hospital showed multiple vertebrae and rib fractures as well as a large cranial subcutaneous haematoma with no intracerebral bleed. Before the laceration was identified, the patient developed acute anaemia requiring transfusion. Continued reduction in haemoglobin levels called for a more thorough examination of the scalp. Investigation, following copious irrigation, revealed a large laceration. The presence of infection and necrotic tissue necessitated a general anaesthetic for debridement and closure. Disscussion: Diagnostic errors are more common in patients presenting with multiple or severe injuries. Initial management in trauma cases should focus on more evident or life threatening injuries However, it is important that reflections and recommendations are continually made to reduce diagnostic errors, which are higher in polytraumatised patients. Various factors including haemodynamic instability and patient positioning added to the elusive nature of this wound. Adequate examination of lacerations requires thorough cleaning as coagulated blood and other material may obscure findings. This is particularly important in scalp lacerations where the overlying hair can form a barrier that is effective at hiding the wound edges. Conclusion: This case highlights the importance of a thorough secondary survey; an effective examination technique would have avoided the need for extensive treatment to manage the sequelae of the missed scalp laceration

Study of anatomical variance of the zygomaticofacial foramen and determination of reliable reference points for surgery

Background: Dissection onto the facial aspect of the zygoma is necessary in several maxillofacial procedures. This carries inherent risk of damage to the vessels exiting the zygomaticofacial foramen (ZFF) on the facial aspect of the zygoma. Objectives: The aim was to compare ZFF anatomy between ethnic groups and sexes, and to determine reliable reference points for surgery. Methods: 858 zygomatic bones on dry adult skulls were used in the study. Skulls were selected from nine different geographic regions for a comparison between ethnic groups, and a comparison of anatomy between sexes was completed. Each zygoma was examined for the number of ZFF, after which a cross-line laser was used to create two consistent lines from which the ZFF was measured and mapped. Findings: There were significant differences in number and location of ZFF between ethnic groups, but not between sexes. Of all 858 sides, 1 ZFF was most commonly identified (49.8%). However, foramina number ranged from 0 to 4 per zygoma. Despite this variability over 80% of ZFF bilaterally were found within a 15 mm diameter circle centred at 5 mm anterior to the intersection of lines discussed above. Moreover, over 90% of ZFF fell beyond an arc of 5 mm from the orbital margin. Conclusion: We present a novel method of identifying a ‘ZFF zone’ within which the majority of foramina lie. This simple technique can be of use in directing osteotomy sites, local nerve blocks, and in preventing iatrogenic damage to the ZFF neurovascular bundle

Preliminary Study on Genetic Variation in Vulnerable Species of Johannesteijsmannia Altifrons in Sikundur Forest, North Sumatra

Johannesteijmannia altifrons is vulnerable species according to Red Data Book from IUCN. This species may have two sub populations namely sang minyak and sang gajah. For conservation strategy, study on the genetic variation of this species was needed. The study aimed to examine the genetic variation of J. altifrons in Sikundur Forest, Gunung Leuser National Park, North Sumatera, using Isozymes marker. From three enzyme systems used (ACP, MDH, and PGD), two polymorphic loci were detected. Highest estimate of genetic variation parameters i.e. observed and expected heterozygosity were found in sang gajah, whereas sang minyak showed lower genetic diversity. This preliminary result suggested that this species had low average of polymorphic (40 %). Based on polymorphic level and expected heterozygosity, both sub populations genetically closed to each other. The differences of both sub populations lay on the wide leaf. Understanding of genetic variation suggested the importance of conservation effort of this species to increase number of populations

Sexual dimorphism and geographical variance: their impact on the reliability of the antilingula as a landmark in human mandibular surgery.

The intraoral vertical ramus osteotomy (IVRO) is an orthognathic procedure that is used to correct dentofacial abnormalities, and is performed by approaching the lateral aspect of the mandibular ramus. This approach, however, precludes visualisation of the inferior alveolar nerve (IAN) on the medial side, thereby placing it at risk of iatrogenic damage. The antilingula, a bony prominence on the lateral mandibular ramus, has been proposed as a landmark for prediction of the IAN's location during IVRO. The current study aimed to evaluate the variation in incidence and position of the antilingula, and therefore to determine its suitability as a surgical landmark during IVRO. The study included 480 dry hemimandibles from eight geographical populations from the Duckworth Collection in Cambridge. Skulls were sexed by visual analysis of dimorphic traits. Positional relations were determined through the digitisation of nine anatomical landmarks. The antilingula was identified in all specimens. No significant difference was identified in the positional relation between the antilingula and mandibular foramen between sexes, but multiple differences were identified in this relation between geographical populations. Our data showed that, irrespective of geographical variation, an osteotomy performed 8mm posterior to the antilingula would avoid the mandibular foramen in 98.8% of cases

Oral surgery: Mandibular fracture risk

Sir, a 28-year-old male patient presented to our maxillofacial department with an iatrogenic mandibular fracture, confirmed by imaging, following removal of an impacted lower right third molar tooth

Academic training in oral and maxillofacial surgery - when and how to enter the pathway

Entering into surgical academia can seem a daunting prospect for an oral and maxillofacial surgery (OMFS) trainee. However, the streamlining of academic training by the NIHR to create the integrated academic training (IAT) pathway has simplified academic training and more clearly defined academic positions and entry points for trainees. In this article we review the current NIHR IAT pathway and the various grades and entry points available to OMF surgeons, both pre- and post-doctoral. We highlight the unique challenges facing OMF trainees and provide advice and insight from both junior and senior OMFS academics. Finally, we focus on the planning and application for a doctoral research fellowship - discussing funding streams available to OMF surgeons

Clinical features and presentation of cervicofacial infection : a maxillofacial trainee research collaborative (MTReC) study

Introduction Cervicofacial infection (CFI) is a common presentation to the Oral and Maxillofacial (OMFS) department and accounts for significant emergency activity. The current study aims to understand the aetiology, management and clinical features of patients hospitalised with CFI. Methods Our study included all patients admitted for management of CFI from May to October 2017 at 25 OMFS units across 17 UK regions. Data were collected prospectively and included age, comorbidities, prior treatment received, markers of sepsis and presenting clinical features. Results One thousand and two (1002) admissions were recorded; 546 (54.5%) were male. Median age was 34 years (1-94 years). The most common presenting complaints were trismus (46%) and dysphagia (27%). Airway compromise was present in 1.7% of cases. Odontogenic infection accounted for 822/1002 (82%) admissions. Of those with an infection of odontogenic origin, 453/822 (55.1%) had received previous treatment. Two-thirds of those who had received treatment were managed by antibiotics alone (300/453, 66.2%) Patients met criteria for sepsis in 437/1002 (43.6%) of CFI, and in 374/822 (45.5%) of odontogenic infections. Conclusion This is the largest study worldwide of patients requiring inpatient management for CFI. Infection due to odontogenic origin is the most frequent reason for admission and nearly half do not seek treatment before presentation. Patients with CFI often present late in their disease and frequently meet criteria for sepsis, requiring timely and aggressive treatment to ensure optimum outcomes. Trismus is an emerging dominant feature with all the implications related to the anaesthetic management of these patients. Knowledge of these factors has implications for the referrer, triage, the emergency department, the anaesthetic team and members of the OMFS team