Oral Surgery Flashcards
(190 cards)
1
Q
What are the two treatment goals of zygomatic fracture management?
A
- Restore facial projection/symmetry
- Restoration of orbital volume/globe position/shape palpebral fissure
2
Q
What is meant by comminution?
A
Where bone fractures into multiple fragments
3
Q
What suture is the most reliable indicator of proper reduction & orientation in 3D with restoration of function and symmetry?
A
Zygomaticosphendoidal suture
4
Q
What treatment does a non-displaced zygomatic fracture require?
A
Very little, can be conservative. However, needs monitoring and potential reduction and internal fixation.
5
Q
What treatment does a displaced, minimally comminuted zygomatic fracture require?
A
Straightforward open reduction and internal fixation at minimally 2, or maybe 3 points.
6
Q
What treatment does a complex and comminuted, or isolated zygomatic fracture require?
A
Major reconstruction with larger flaps for exposure and reconstruction of facial buttresses to fix fracture.
7
Q
What are the 4 advantages of open reduction and internal fixation of a zygomatic fracture?
A
- Improved alignment
- Fixation of zygomaticomaxillary buttress provides vertical support
- Orbital rim exposure allows inspection of orbital floor
- Inspection of fracture sites prior to closure
8
Q
In what three scenarios is two-point fixation indicated?
A
- Minimally displaced fractures
- When zygomaticomaxillary complex fracture remains stable after initial reduction with no palpable step deformity at the infraorbital rim
- There are minimal changes on orbital volume and globe displacement is not evident on CT scan.
9
Q
In what two situations is three point fixation indicated?
A
Where there is instability of fragments and/or exploration of the orbital floor is required.
10
Q
Name 5 methods of fixation (includes historical techniques and present).
A
- Kirscher wires
- Lag screw fixation
- Wire osteosynthesis
- Titanium plates and screws
- Resorbable plates and screws
11
Q
What materials for fixation are most commonly used in current day?
A
Titanium plates and screws
12
Q
What are the 4 most likely sites for fixation of zygomatic fractures?
A
- Fronto-zygomatic area
- Infra-orbital margin region
- Zygomaticalmaxillary buttress
- Zygomatic arch
13
Q
What is the aim of reduction?
A
Provides force in the direction opposite to that which caused the fracture and to re-approximate the bone to the original position.
14
Q
What are the two main treatment goals of open fixation and internal reduction?
A
- Restore facial symmetry
- Restore globe volume position and function
15
Q
What is a common approach to reduction of a zygomatic arch fracture?
A
Gillies temporal approach
16
Q
Describe the gillies temporal approach in 4 steps.
A
- Identify incision site
- Skin incision and dissect/incise the temporalis fascia
- Introduce the instrument and navigate beneath the zygomatic arch
- Introduce elevator to reduce
17
Q
What instruments are used for the gillies temporal approach for reduction of zygomatic fractures?
A
Bristow elevator
Rowe elevator
18
Q
What are the two points of fixation of a zygomatic fracture for a two point fixation approach?
A
- Fronto-zygomatic buttress
- Zygomatico-maxillary buttress
19
Q
What are the three points of fixation of a zygomatic fracture for a three point fixation approach?
A
- Fronto-zygomatic buttress
- Zygomatico-maxillary buttress
- Infra-orbital margin
20
Q
What type of flap is required to access the zygomatic arch area in a comminuted high energy fracture to allow for four point fixation?
A
Bi-coronal flap
21
Q
What are the 7 general complications of orbital fracture?
A
- Decreased visual activity
- Ectropion/entropion/lid malposition
- Corneal exposure/abrasion
- Ptosis
- Epiphora
- Enophthalmos/orbital dystopia
- Diplopia
22
Q
What does “ectropion” mean?
A
eyelid turns upward/ becomes averted. eyelid exposed, watery eyes occur with excessive tearing, dryness and irritation.
23
Q
What does “entropion” mean?
A
eyelid turns inwards, eyelashes rub against inner surface of eye. Left with redness, irritation and sensitivity.
24
Q
What is meant by “ptosis”?
A
Eyelid droops
25
What is meant by “enopthalmos”?
Eyes sunken in
26
What is meant by “orbital dystopia”?
Eyes are not at same level
27
What are the three main/major complications of orbital fracture?
1. Blindness
2. Superior orbital fissure syndrome (SOFS)
3. Retrobulbar haemorrhage with compartment syndrome (RBH+OCS)
28
What is superior orbital fissure syndrome?
Complex impaired function of cranial nerves (III, IV, V and VI) that enter the orbit through superior orbital fissure. Trauma is a major precipitating factor.
29
What are symptoms of RBH +OCS?
Globe pain and diplopia (double vision)
30
What is retrobulbar haemorrhage with orbital compartment syndrome?
Bleeding from infra-orbital artery, blood accumulation in the retrobulbar space , an increase in intra-orbital pressure which may result in OCS presenting as proptosis of the eye.
31
What is the managment of SOFS?
Conservative with observation
32
What is the aim of non-surgical management of RBH +OCS?
Used as immediate management to reduce pressure in the eye until surgical management can be implicated.
33
What is the surgical management of RBH+OCS?
Lateral canthotomy- surgical decompression.
34
What are the 4 main causes of mandibular fracture?
1. Assault
2. Sporting injury
3. Road traffic accidents
4. Pathological
35
Give an example of pathological fracture.
If you have a cyst, tumour or some other osteolytic lesion affecting the mandible it will undermine the strength of the mandible a predispose it to fracture. The fracture can happen spontaneously or with a weak force (such as biting into toast.)
36
Define the type of fracture:
Undisplaced fracture, where overlying periosteum is intact. If you look at radiograph you can see a small crack running through cortical layer of bone, but the two parts haven’t moved apart.
Simple fracture
37
Define the type of fracture:
one that has perforated through the overlying periosteum.often it can perforate through the overlying skin and present externally. (Bone protruding through skin).
Compound fracture
38
What type of fracture is a fracture involving a tooth socket? What is the significance of this type of fracture?
Compound fracture,
the fracture line runs through the PDL into the oral cavity, exposing the fractured mandible to the oral microbiota which predisposes it to becoming infected
39
Which type of fracture has a higher potential for wound infection, simple or compound fracture?
Compound fracture
40
What type of fracture is described:
where the fracture pattern has multiple fracture lines, so it tends to be more high impact fractures. You often see these types of fractures with high velocity road traffic accidents or even bullet wounds, where the bone is broken into multiple small fragments. This is far more challenging to manage than a clean break.
Comminuted fracture
41
What type of fracture is described:
uncommon in mandible, associated with fractures in children. Where you get flexing of bone such that one of the outer cortex’s will fracture but the inner cortex will flex so there is no displacement.
Greenstick fracture
42
What type of fracture is described:
If you a cyst, tumour or some other osteolytic lesion affecting the mandible it will undermine the strength of the mandible a predispose it to fracture.
Pathological fracture
43
What are the three most common sites for fracture in the mandible?
1. Condyle
2. Angle of mandible
3. Parasymphysis
44
How do muscles attached to mandible cause displacement of fractures?
By either pulling the fracture together or pulling it apart
45
What 4 factors determine the amount of displacement of a fracture?
1. The pattern of fracture
2. The degree of comminution
3. Teeth in the fracture line
4. Muscle pull
46
What is meant by a ‘bucket handle’ fracture?
This is a bilateral parasymphyseal fracture, where muscles pull the anterior segment of mandible downwards and backwards.
47
In what patients do you most commonly see ‘bucket handle’ fractures?
Edentulous patients
48
What sign in the way teeth meet together might suggest a displaced fracture of the mandible?
Malocclusion
49
What are the extra-oral clinical feature suggestive of a mandibular fracture?
1. Pain
2. Swelling
3. Bruising
4. Trismus
5. Concurrent soft tissue injury
6. Otorrhoea (ear discharge)
7. Anaesthesia/paraesthesia of lip
50
What might otorrhoea (ear discharge) be a specific sign of? explain why.
Condylar fracture.
External auditory meatus can tear when condyle fractures, condylar neck driven backwards can breach bony wall of external auditory meatus and that can cause condylar head to be driven into muddle cranial fossa. So blood mixed with CSF can leak out of external auditory meatus.
51
If a patient suspects fracture and complains of numbness in lower lip, what does this suggest about the location of the fracture upon extra-oral examination?
The fracture is some point between the mental foramen and the lingula on the medial portion of the mandible.
(So anywhere between the last standing molar and the premolar region there is a fracture as this is exactly where IAN canal is situated)
52
What are the intra-oral clinical features of a fracture of the mandible?
1. Haematoma in FOM & buccal mucosa
2. Malocclusion
3. Tongue swelling
4. Step deformity in occlusion
5. Gingival laceration
6. Mobility or loss of teeth/ fractured teeth
53
What intra-oral sign is considered pathognomonic of a mandibular fracture?
Haematoma in the FOM (Coleman’s sign)
54
If a step deformity in occlusion is present what this suggest about a fracture?
There is quite a degree of displacement
55
What are the two ideal radiographic views to investigate a suspected mandibular fracture? Why are these views ideal to take?
DPT and PA mandible, ideal because they are 90 degrees to each other so allow fracture to be seen from different angles. Also, PA view allows you to determine if there is displacement in all three dimensions.
56
What is the time/window of treatment that would ideal for a patient to be treated within for a fracture?
Within a 72 hour window
57
Delay to presentation/ treatment of a fracture can cause increased risk of complications. Name these 4 complications.
1. Wound dehiscence 2. Infection 3. Exposure of hardware 4. Non-union or fibrous union
58
Delay to presentation/ treatment of a fracture can cause increased risk of complications. Name these 4 complications.
1. Wound dehiscence (breakdown)
2. Infection
3. Exposure of hardware
4. Non-union or fibrous union
59
Who should a patient be referred to if they have a fracture of the head?
Maxillofacial surgery
60
What treatment technique is used nowadays to fix fracture of the head?
Open techniques.
Specifically, Open Reduction and Internal Fixation.
61
Describe an open technique for treating a fracture of the head.
Fracture margins are directly visualised through an incision, and aligned with mini-plates to reduce the fracture.
62
Why are open techniques generally preferred over closed techniques for treating fractures of the head?
Because open techniques involve immobilisation of the fracture to allow for a period of healing. Whereas, closed techniques often leave the fracture site mobile which can have detrimental effects on healing.
63
What are the two aims of ‘reduction’ as part of open reduction and internal fixation treatment for a fracture?
1. Aligns the bone ends anatomically
2. Recreates the normal bone anatomy
64
What are the three aims of ‘fixation’ as part of open reduction and internal fixation treatment for a fracture?
1. Prevents movement of bone margins whilst healing occurs
2. Can be load-bearing so that 100% of the functional load is supported by the fixation e.g. two large plates.
3. Can be load sharing such that the load is distributed between the hardware and and the bone margins e.g. one upper boarder plate and arch bars.
65
What is more ideal, fixation being load bearing or load sharing?
Load-bearing fixation
66
What is the difference between mini-plates and reconstruction plates?
Mini-plates made of titanium placed to fix fracture. These are placed and not removed/there for life.
Reconstruction plates tend to be used within edentulous patients, they are thicker and longer which hold mandible very rigidly.
67
Why might you opt to use a closed technique of intermaxillary fixation if you have a bilateral condylar fracture?
To ensure you don’t loose condylar height in the process
68
What are the 5 advantages of open reduction and internal fixation?
1. Improved alignment and occlusion
2. Fracture immobilised
3. Avoid IMF
4. Low rate of non-union
5. Lower rate of infection
69
What are the three disadvantages of open reduction and internal fixation?
1. Morbidity of surgical procedure
2. Expensive hardware
3. Need for GA
70
According to champy’s principles, what line should plates be placed in within the mandibular angle region, and mental foramina region?
In the mandibular region, plates should be placed either along or just below the oblique line of the mandible.
Between the mental foramina, 2 plates are recommended below the apices of teeth.
71
Why are edentulous fractures more difficult to manage?
1. Atrophic
2. Poorly vascularised so poor healing capacity
3. Lack of anatomical landmarks
72
Name 8 complications of surgery for mandibular fractures.
1. Non-union, fibrous union, mal-union
2. Altered occlusion
3. Distracted TMJ
4. Scars
5. Infection
6. Necrosis
7. Numb lip
8. Exposed plate
73
What are the two types of condylar fracture?
1. Extra-capsular
2. Intra-capsular
74
How are condylar fractures often managed?
Conservatively with soft diet and NSAIDs
75
What is a main concern with intra capsular fracture of condyle?
You can get ankylosis of the joint if it is completely immobilised which can lead to problems with trismus and inability to move joint in the long term.
76
How are greenstick fractures in children usually managed?
With simple blow-down splint
77
Paediatric fractures are uncommon, but what is the most common type of fracture in a Child?
Condylar fracture
78
How are condylar fractures managed in children and why?
Managed conservatively with splints, open surgery is rarely done in children because of rusk to condylar growth plate, which could lead to asymmetry formation of the mandible, and the mandible could be deviated to one side as a result.
79
If a fracture patient does not want open reduction and internal fixation treatment, what 5 things would you tell them could happen if they decline?
1. The fracture will not heal off its own accord
2. They are likely to get wound infection that could cause cellulitis (life-threatening)
3. Persistent malocclusion
4. Chances are fibrous union will occur
5. Can have deep bone infection in long term
80
Who would you refer a displaced/mobile mandibular fracture to and in what time frame?
Max fax within a 24 hour period
81
If a patient with a fracture complains of numb teeth, what sort of fracture could this be a sign of?
Bony injury fracture
82
If metalwork is exposed through mucosa, what is the management?
Routine referral to max fax to remove screw and plate under LA
83
State what structures bound the middle third of the facial skeleton superiorly.
1. Frontozygomatic
2. Frontonasal
3. Frontomaxillary
84
State what structures bound the middle third of the facial skeleton inferiorly.
1. Occlusal plane upper teeth
2. Alveolar ridge
85
State what structures bound the middle third of the facial skeleton posteriorly.
Pterygoid plates of sphenoid bone
86
What areas of the middle third facial skeleton have the lowest tolerance to impact. State in order of least resistance.
1. Nasal bones
2. Zygomatic arch
3. Maxilla
87
Describe a le fort 1 fracture
Maxillary alveolus separated
88
Describe a le fort 2 fracture
Runs through the infra-orbital margins
89
Describe a le fort 3 fracture
Disarticulates nearly the entire lower facial skeleton from the skull base
90
When le fort fractures happen in combination, what is this described as?
Panfacial fracture
91
What is the Glasgow coma scale and what is it used for?
Scale ( from 3 (worst)-15 (highest)) used to measure head injury using three parameters:
1. Best eye response
2. Best verbal response
3. Best motor response
92
Define, ecchymosis.
Small bruise caused by bleeding
93
What 8 clinical findings would be representative of a potential le fort I fracture?
1. Mobility of tooth- bearing segment of the upper jaw
2. Crepitus in buccal sulcus
3. “Cracked-pot” percussion note from upper teeth
4. Intra-oral haematoma in buccal sulcus
5. Bruising of upper lip and lower mid-face
6. Occlusal discrepancy
7. Anterior open bite tendency
8. Dentures not fitting
94
What 9 clinical findings would be representative of a potential le fort II/III fracture?
1. Bilateral peri-orbital bruising
2. Subconjuctival haemorrhage
3. Lengthening of face
4. Malocclusion (anterior open bite)
5. Gross oedema of the face
6. Nasal deformity
7. Rhinorrhoea (CSF)
8. Mobility of upper jaw
9. Palatal haematoma
95
What is the primary imaging modality for suspected le fort fractures?
CT scan
96
What is the unique fracture line of a le fort 1 fracture?
Lateral piriform aperture
97
What are the unique fracture lines of a le fort II fracture?
Inferior orbital rim and zygomatic buttress
98
Why is management of le fort fractures usually delayed initially?
To allow for swelling to go down and patient to become stable
99
What is the best treatment for mid-face fractures?
Open reduction and internal fixation
100
Describe the use of Rowes disimpaction forceps
Forceps introduced into nose (either side) and palate to provide leverage to the fracture and allow manipulation of the lower face.
101
Name which buttresses are involved in ORIF of a le fort 1 fracture.
1. Nasomaxillary
2. Zygomaticomaxillary
102
Name which buttresses are involved in ORIF of a le fort II fracture.
1. Infra-orbital
2. Naso-frontal
3. Zygomaticomaxillary
103
Name which buttresses are involved in ORIF of a le fort III fracture.
1. Frontozygomatic
2. Naso-frontal
3. Zygomatic arches
104
What infectious disease is commonly associated with oropharyngeal cancer?
HPV
105
What infectious disease is commonly associated with nasopharyngeal cancer?
EBV
106
What cellular process causes fibrosis in submucous fibrosis?
Induced activist of TGF-beta and produces collagen, inhibits collagen degradation causing fibrosis
107
What pre-malignant disorder is described:
Progressive, multi focal, exophytic, persistent with no risk factors.
Proliferative Verrucous leukoplakia (PVL)
108
What are the 7 red flags that would suggest to you a lesion may be malignant?
1. Persisting ulcer >2-3 weeks
2. Rolled margins, central necrosis
3. Erythroleukoplakia appearance
4. Cervical lymphadenopathy
5. Worsening pain
6. Referred pain
7. Weight loss (systemic)
109
What lesions/conditions warrant referral to oral med?
- red/white patches
- erosions/ulcers
- vesiculobullous lesions
- burning mouth syndrome
- facial pain
- Xerostomia for salivary gland biopsy
110
Define, the removal of tissue for histopathological examination.
Biopsy
111
What are the 4 clinical applications of biopsy?
1. Benign lesions (therapeutic)
2. Bullous (type present), ulcerative, desquamative lesions
3. Differential diagnosis of white patches
4. Suspected malignancy
112
What are the two types of biopsy?
1. Excisional
2. Incisional
113
What are the three subtypes of incisional biopsy?
1. Exfoliative cytology
2. Aspirational (FNAC)
3. Labial gland biopsy
114
For what type of lesions would excisional biopsy be appropriate?
Small, benign lesions (e.g. Mucoceole)
115
When excising a mucoceole, what else must be excised to ensure that the lesion does not recur?
The affected salivary gland
116
What must you warn a patient about if undergoing excisional biopsy on the lower lip?
There is potential for:
- small scar
- numbness (usually temporary) in this area due to delicate network of sensory nerves in lower lip
117
What is a common cause of pyogenic granuloma?
Overhang/ irregular edge of filling material such as amalgam
118
What is the biggest advantage of cutting diathermy to remove tissue induced hyperplasia?
No bleeding post-operatively and no need for suturing
119
Define, removal of a representative portion of lesion.
Incisional biopsy
120
What are the two main advantages of using frozen section for biopsy?
1. Allow rapid diagnosis of malignancy
2. Results within 1 hour
121
What is exfoliative cytology? When is it most often used?
Removal of surface cells by scraping with a spatula or cytobrush
Widely used in cervical cancer screening
122
What is the purpose of fine needle aspiration cytology (FNAC)?
Determines whether a lesion is solid or cystic/fluid filled.
123
What is FNAC very useful for?
Lumps within the parotid glands and neck lumps to determine whether the lump is a tumour
124
What type of biopsy technique is used in diagnosis of Sjögren’s syndrome?
labial gland biopsy
125
Describe a labial gland biopsy.
Harvesting a small amount of salivary tissue from minor glands in the lower lip
126
What imaging modality can be used alongisde FNAC in parotid tumour diagnosis for greater accuracy?
Ultrasound
127
What is the most reliable indicator of malignancy?
Histopathological examination of tissue
128
A 47 year old male patient attends for a routine check up and you notice a 3cm red/white patch on the floor of the mouth which he was unaware of. He has a heavily restored dentition with many crowns and amalgam restorations. He is a smoker of 20/day since he was 16 years old and drunks a bottle of vodka per week.
Give 2 possible diagnosis for this lesion.
1. SCC
2. Lichenoid reaction
129
A 47 year old male patient attends for a routine check up and you notice a 3cm red/white patch on the floor of the mouth which he was unaware of. He has a heavily restored dentition with many crowns and amalgam restorations. He is a smoker of 20/day since he was 16 years old and drunks a bottle of vodka per week.
What concerns you about this lesion?
- Size
- clinical appearance being erythroplakia
- high risk site on FOM
130
A 47 year old male patient attends for a routine check up and you notice a 3cm red/white patch on the floor of the mouth which he was unaware of. He has a heavily restored dentition with many crowns and amalgam restorations. He is a smoker of 20/day since he was 16 years old and drunks a bottle of vodka per week.
As primary dentist what would you do?
Urgent 2 week referral for investigation of mouth cancer
131
A 47 year old male patient attends for a routine check up and you notice a 3cm red/white patch on the floor of the mouth which he was unaware of. He has a heavily restored dentition with many crowns and amalgam restorations. He is a smoker of 20/day since he was 16 years old and drunks a bottle of vodka per week.
How would this be investigated?
Incisional biopsies
132
A 47 year old male patient attends for a routine check up and you notice a 3cm red/white patch on the floor of the mouth which he was unaware of. He has a heavily restored dentition with many crowns and amalgam restorations. He is a smoker of 20/day since he was 16 years old and drunks a bottle of vodka per week.
What advice could you give your patient about the management of such lesions?
1. If it turns out be a potentially malignant lesion, depending on the severity it would be excised
2. If it turns out be cancer the management would be first line of treatment
133
A 47 year old male patient attends for a routine check up and you notice a 3cm red/white patch on the floor of the mouth which he was unaware of. He has a heavily restored dentition with many crowns and amalgam restorations. He is a smoker of 20/day since he was 16 years old and drunks a bottle of vodka per week.
What preventative advice would you give?
advocating smoking cessation and consumption of alcohol to <14 units per week.
134
What is the most common pathology to affect minor salivary glands?
Mucus extravasation cyst
135
What is the tx for mucus extravasation cyst?
Excision with overlying mucosa + underlying glandular tissue
136
Describe the function of major salivary glands.
Major salivary glands ONLY produce saliva when you sit down to eat. The rest of the time when you are fasting these are not producing saliva.
137
Why are major salivary glands fairly prone to infection?
You have a period where saliva is not passing down the ducts (when fasting), it is during this time that these glands are more prone to infection. Where bacteria from oral cavity can pass up into duct when there is no saliva to flush them out.
138
What is another name for the parotid duct?
Stenson’s duct
139
What 5 vessels could potentially be damaged in surgery of the parotid gland?
- branches of the facial nerve
- terminal branches of the external carotid artery
- superficial temporary artery
- maxillary artery
- greater auricular nerve
140
Via what duct does the submandibular gland drain?
Whartons duct in the FOM
141
Via what two ducts can the sublingual gland drain?
Via tiny ducts (Rivini’s ducts) on the plica sublingualaris
OR
A common duct which joins the submandibular duct (Bartholin’s duct)
142
Match the salivary gland to the type of mucous secretion:
1. Mucous gland
2. Mixed seromucous gland
3. Mixed seromucous gland but predominantly serous
1. Sublingual gland
2. Submandibular gland
3. Parotid gland
143
Sialadenitis can be viral or bacterial in nature.
What virus’s can cause viral sialadenitis?
1. Paramyxovirus (mumps)
2. Cytomegalovirus (CMV)
3. HIV
144
What is the key difference between viral and bacterial infection?
Viral are self-limiting, bacterial will likely require antibiotics
145
Why can’t major salivary glands be incised and drained where bacterial infection is present?
Because major glands are encapsulated, so the only thing that can drain pus is the duct itself.
146
What is bacterial sialadenitis secondary to (local and systemic)?
1. Stasis, so gland isn’t functioning properly (local)
2. Immunosuppression/medication/dehydration/irradiation (systemic)
147
What two things can cause stasis of a gland?
1. Lack of function
2. Obstruction of duct
148
What is the acute management of bacterial Sialadenitis?
Antibiotics
Fluids
Sialogogues
analgesics
149
In order of the salivary glands mainly affected by Sialadenitis, rate from most likely to least.
1. Submandibular gland
2. Parotid gland
3. Sublingual gland
150
A man presents with acute parotitis of the left parotid gland which appears bacterial in aetiology, causing a large swelling down the left side of his face with perio-orbital involvement. Why is it so important that this patient is referred to max fax for IV antibiotics ASAP?
Because there is risk of retrograde spread and cavernous sinus thrombosis
151
What is a sialolith?
Calcified mass formed within a salivary gland or Ductal system.
152
In what gland do 80% of sialoliths form?
Submandibular gland
153
What condition is described?
Recurrent episodes of transient prandial salivary gland swelling, no symptoms between attacks. Stasis of saliva along with worsening of symptoms can occur if the condition is severe.
Obstructive sialadenitis
154
What condition is described?
Stasis of salivary gland allows for ascending infection, painful swelling become worse over 24-72 hour duration, oral discharge and pus obvious and systemic manifestations.
Acute sialadenitis secondary to sialolithiasis (obstruction)
155
Different radiographic views are best at determining where a sialolith is located, whether it sits intraductal or intraglandular. What type of radiographs are best at determining each?
Occlusal view best for intra-Ductal
DPT best for intra-glandular
156
What is the tx for an intraglandular sialolith?
Removal alongside whole gland
157
What is the tx for an intra-Ductal sialolith?
Retrieval of stone under LA.
158
What are the treatment options for obstructive salivary disorders?
1. Sialogogues (conservative)
2. Surgical removal of intra-ductal stone
3. Removal of gland if intra-glandular Stone and severe symptoms
4. Lithotripsy (rare)
5. Basket retrieval
159
How does lithotripsy work?
Machine produces ultrasonic waves to breakdown the stone (particularly useful for large intra-glandular stones without need for whole gland removal)
160
What is the limitation of the basket retrieval technqiue for salivary stones?
Will only work with small stones
161
Define, a large mucus retention cyst in the FOM.
Ranula
162
What is the difference between a mucus extravasation cyst and a mucus retention cyst?
Extravasation cyst- results from a broken salivary duct with spillage of mucous into soft tissue.
Retention cyst - decrease or absence of glandular secretion produced due to blockage of salivary gland ducts, with a subsequent build up of mucous.
163
Define, a rare, benign, ulcerative, reactive inflammatory disorder of the minor salivary glands (often on the palate), which can mimic malignancy.
Necrotising sialometaplaisa
164
What is intermittent swelling of a salivary gland suggestive of?
Transient obstruction
165
What is persistent swelling of a salivary gland, with pain, suggestive of?
Complete obstruction
166
What is the differential diagnosis for unilateral, localised, diffuse swelling of salivary gland region?
1. Obstructive sialadenitis
2. Viral sialadenitis
3. Tumour
167
What is the diagnosis for a bilateral and localised swelling of salivary glands?
Whartons tumour (Benign cystic tumour of the salivary glands)
168
What is the differential diagnosis for a bilateral and diffuse swelling of salivary glands?
1. Sjögren’s syndrome
2. Sialadenosis (usually associated with underlying systemic disorder)
169
If a salivary gland is nodular and non-heterogenous, what does this suggest?
Tumour
170
Why is incison of major salivary glands contra-indicated?
Because by doing so you could cause seeding of tumour cells into the surrounding tissue and cause multiple recurrences
171
What is the investigation for a parotid tumour?
Fine needle aspiration with ultrasound guidance
172
Why is ultrasound very useful in investigating major salivary gland pathology?
It outlines the size, position, consistency and vascularity of lesion
173
What is the treatment for a ranula?
Marsupialise or complete removal
174
What are the three indications for surgery of salivary glands?
1. Chronic pain/symptoms
2. Repeated acute or chronic Sialadenitis
3. Benign/malignant tumours +/- nerve reconstruction
175
When doing surgery in the submandibular area, what vessels must be considred to avoid damage?
1. Marginal mandibular branch of facial nerve
2. Lingual nerve
3. Hypoglossal nerve
176
What can damage to the marginal mandibular branch of the facial nerve result in during surgery of submandibular gland?
Weakness of the lower lip
177
What can damage to the lingual nerve result in during surgery of submandibular gland?
Numbness of the tongue
178
What can damage to the hypoglossal nerve result in during surgery of submandibular gland?
Weakness of tongue movement
179
What post-op risks must you warn the patient of prior to removal of submandibular gland?
1. Pain, swelling, bruising, infection, bleeding
2. Scar
3. Numbness of the tongue
4. Weakness of the lower lip
5. Weakness of tongue movement
180
What are the 4 techniques used for parotid surgery?
1. Extracapsular dissection
2. Lobar resection
3. Superficial parotidectomy
4. Total parotidectomy
181
What is the parotid surgery technique of choice if indicated for symptomatic Sjögren’s syndrome?
Superficial parotidectomy
182
In what instance is total parotidectomy advocated for?
When there is a deep lobe Tumour, sitting in the 5th of the lobe beneath the facial nerve.
183
If a malignant tumour involves the facial nerve, what does this unfortunately mean for the pateint?
The part of the facial nerve involved will have to be resected so the patient will end up with palsy.
184
What are post-op complications for parotid surgery that you must make patients aware of?
1. Pain, bruising, swelling, infection
2. Facial nerve injury - weakness of muscles of facial expression
3. Gustatory sweating (Frey’s syndrome)
4. Numbness around earlobe (auricular temporal nerve damage)
5. Salivary fistula
6. Recurrence of tumour
185
How do sialoliths form?
Saliva is supersaturated with calcium and phosphate, so you get this deposited, forming a plug of mucus known as sialoliths.
186
Why do mucus extravasation cysts tend to fill up and burst in early stages?
Because overlying mucosa is so fragile, it is only when it has been there a long time that you can get some scarring and fibrosis and this no longer occurs.,
187
What are the risks of incising a mucus extravasation cyst in the lower lip?
1. Recurrence
2. Damage to adjacent minor salivary glands
3. Small area of numbness where network of nerves have been incised (can be transient or chronic)
188
If a patient with suspected pleomorphic adenoma in the parotid gland region has weakness of the CNVII, would this change your provisional diagnosis and how would this change the suggested treatment?
If at presentation patient has any nerve palsy this would suggest you are dealing with a malignant parotid tumour and Therfore tx is far more aggressive, with superficial parotidectomy and resection of superficial nerves.
189
What is the most commonly affected tooth by OAC?
Maxillary 2nd molar
190
What type of flap design is used to manage OAC’s?
Buccal advancement flap
