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Jaw Deformity 27
https://t.me/med1917
FACIAL PAIN
Diagnostic Criteria for Trigeminal Neuralgia (Classic)
e following list highlights the criteria for diagnosis in patients
presenting with classic trigeminal neuralgia.
At least three attacks in trigeminal nerve distribution.
Three of the following:
●
Paroxysmal attacks < 2 min
●
Severe intensity
●
Electric shock–like shooting, stabbing or sharp in quality
●
Precipitation by innocuous stimuli
FIBROMYALGIA
ese criteria can be used to diagnose bromyalgia in adults.
●
Pain more than 3 months
●
All four quadrants
●
Nine pairs of tender points (need 11 of the 18 for positive
diagnosis)
●
Always depressed
Giant Cell Arteritis Royal College of
PhysiciansCriteria
e following list forms the criteria for the diagnosis of temporal
arteritis as highlighted by the UK Royal College of Physicians.
Three of the following (mnemonic=ANTRA):
●
Age >50
●
New headache
●
Temporal artery abnormal (hypoechoic halo on USS)
●
Raised ESR (>50)
●
Abnormal artery biopsy
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28 Classifications and Lists in Oral and Maxillofacial Surgery
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Idiopathic/Atypical Facial Pain
DiagnosticCriteria
e following list provides criteria for the diagnosis of atypical
facial pain.
●
Daily
●
>2hours per day
●
>3 months
●
Dull/nagging
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Poorly localised
●
No neurological decits allowed
Migraine without Aura
e following criteria can aid the diagnosis of migraine presenting without any warning signs of its onset.
●
Five attacks
●
Each attack lasting at least 4hours, max 72hours
●
Two of the following:
●
Unilateral
●
Pulsating
●
Moderate or worse pain
●
Aggravated by normal activity
Multiple Sclerosis Criteria
is list provides diagnostic criteria for multiple sclerosis.
●
Two episodes of neurological dysfunction
●
Two areas of central nervous system (CNS) involved
●
Separated in time and space
●
AND nausea OR photophobia/phonophobia
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Jaw Deformity 29
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Migraine with Aura
e following list provides diagnostic criteria for migraine presenting with warning signs of its onset.
●
Two attack s
●
One of the following:
●
Visual
●
Speech
●
Motor
●
Brainstem
●
Retinal symptoms
●
Aura for >5 min followed by headache >1hour
●
Chronic migraine is 15 days per month
●
Status migrainosus is more than 3 days’ duration
FURTHER READING
CKS NICE. https://cks.nice.org.uk/topics/trigeminal-neuralgia/
diagnosis/diagnosis/.
De Angelis F, Brownlee WJ, Chard DT, etal. New MSdiagnostic
criteria in practice. Pract Neurol. 2019;19:64–67.
Michael Cutrer F, Martin VT. Migraine: Clinical diagnostic criteria.
In: Aminoff MJ, Boller F, Swaab DF, eds. Handbook of clinical
neurology. Vol. 97. London: Elsevier; 2010: 295–302.
RCP London. Diagnosis and management of giant cell arteri-
tis. [online]. 2010. www.rcplondon.ac.uk/guidelines-policy/
diagnosis-and-management-giant-cell-arteritis.
RCP London. The diagnosis of fibromyalgia syndrome.
[online]. 2022. www.rcplondon.ac.uk/guidelines-policy/
diagnosis-fibromyalgia-syndrome.
Ziegeler C, Beikler T, Gosau M, May A. Idiopathic facial pain syn-
dromes–An overview and clinical implications. Dtsch Arztebl
Int. 2021;118(6):81–87.
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Head and Neck Oncology
ANNEROTH GRADING SCORE (CORRELATES
WITH LYMPH NODE INVOLVEMENT RISK)
is system describes the grading of malignant oral tumours
according to level of dierentiation, keratinisation, irregularities in shape and size of nuclei, abnormal mitosis and extent of
vascular invasion. Ahigh score in each subcategory corresponds
to an increased likelihood of lymph node metastasis.
1. 5–10
2. 11–15
3. 16–20
4. >20
Each of these are scored 1–4 in severity (top to bottom):
●
Keratinisation
●
Highly keratinised (>50% of cells)
●
Moderately keratinised (20–50% of cells)
●
Minimally keratinised (5–20% of cells)
●
Not keratinised (0–5% of cells)
●
Nuclear pleomorphism
●
Little
●
Moderately abundant
●
Abundant
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Extreme
DOI: 10.1201/9781003156895-4 31
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32 Classifications and Lists in Oral and Maxillofacial Surgery
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●
Mitosis
●
0–1
●
2–3
●
4–5
●
>5
●
Invasion pattern
●
Pushing well-delineated inltrating borders
●
Inltrating solid cord bands, strands
●
Small group of cords or inltrating cells
●
Marked widespread cellular dissociation in small groups of
cells (n < 15) and/or in single cells
●
Stage of invasion
●
Carcinoma in situ and/or questionable invasion
●
Distinct invasion but involving lamina propria only
●
Invasion below lamina propria adjacent to muscles, salivary gland tissues and periosteum
●
Extensive and deep invasion replacing most of the stromal
tissue and inltrating jaw bone
●
Lympho-plasmocytic invasion
●
Marked
●
Moderate
●
Slight
●
None
BROWN CLASSIFICATION OF MANDIBULAR
DEFECTS
is classication system describes mandibular defects following
oncological resections. Ahigher class of defect is associated with
larger sized defects, and the system can be used to inform mode of
reconstruction and improve functional and aesthetic outcomes.
●
I (angle) – lateral defect not including ipsilateral canine or condyle
●
Ic (angle and condyle) – lateral defect including condyle
●
II (angle and canine) – hemi-mandibulectomy including but
not contralateral canine or condyle
●
IIc (angle, canine, condyle) – hemi-mandibulectomy including condyle
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Head and Neck Oncology 33
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●
III (both canines) – anterior mandibulectomy including both
canines but neither angle
●
IV (both canines and at least one angle) – extensive anteriormandibulectomy including both canines and one or both condyles
●
IVc (both canines and at least one condyle) – extensive anterior mandibulectomy including both canines and one or
both condyles
BROWN CLASSIFICATION OF
MAXILLARYDEFECTS
is classication describes patterns of maxillectomy and
defects according to the vertical dimension of the maxilla.
1. Alveolus (no oro-antral communication)
2. Not involving orbital oor
ese can be oered an obturator. If more extensive 2c/d then
consider bula with implant.
3. Involving orbital oor
4. Orbital oor and walls (enucleation or exenteration defect)
5. Orbitomaxillary
6. Nasomaxillary
Alphabetical component correlates with increasing diculty of
obturation
a. Central palate (not including alveolus)
b. Posterior palate
c. Anterior palate
d. Posterior and anterior palate
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34 Classifications and Lists in Oral and Maxillofacial Surgery
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CHYLE LEAK MANAGEMENT
e following algorithm can be used to diagnose and manage
Chyle leaks peri-operatively and post-operatively.
●
Diagnosis by aspiration of 100 mg/dl triglycerides and milky
colour
●
Intraoperatively – ligate/clip/tie duct, cover with ap, topical
OK432 (group Astrep), tetracycline, tissue glue
●
Post-op low output (<500 mL/day) – medium chain triglycerides, aspiration, pressure dressing, topicals via drain
●
High output (>500 mL/day) – as in preceding plus somatostatin/octreotide ± TPN
●
Frequency: aects approximately 2% of neck dissections
CRITERIA FOR SUCCESSFUL NONVASCULARISED BLOCK BONE GRAFT
e following list describes criteria which can result in favourable outcomes of non-vascularised bone gras in the reconstruction of mandibular defects.
●
Lateral defect
●
Defect less than 6cm
●
So tissue coverage
●
No radiotherapy
FEATURES OF POSITIVE NODES ON IMAGING
e following list describes features whose presence can indicate
nodal involvement on imaging, for example, with computerised
tomography (CT).
●
Extra-capsular spread (loss of normal fat planes)
●
Diameter > 1cm
●
Spherical
●
More than three contiguous nodes with maximum diameter
of 1.5cm
●
Central necrosis
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Head and Neck Oncology 35
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GRADES OF CHONDROSARCOMA
e following list describes grades of chondrosarcoma. Ahigher
grade correlates to an increased risk of metastases.
III. 70% me tast ase s
GLOBAL STAGE GROUPING IN H&N
CANCER OVERALL
This system describes global stage grouping in head and
neck malignant tumours. A higher score correlates to a
larger tumour size, increased risk of nodal involvement and
metastases.
●
0=Tis
●
I=T1 (if HPV positive, can have a single ipsilateral positive
node; N1)
●
II=T2 (if HPV positive, can have N2a/b/c; if EBV positive,
CUP can have N1)
●
III=T3 or N1 (if HPV positive, can have N3; if EBV positive,
CUP can have N2)
●
IVA=T4a or N2
●
IVB=T4b or N3
●
IVC=M1
NB: For nasopharyngeal and young thyroid patients (<45years;
more recently <55years), we are more lenient on regional spread
(in nasopharyngeal, Stage II can include N1, in StageIII can have
N2; in thyroid <55years, metastases in Stage II only)
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36 Classifications and Lists in Oral and Maxillofacial Surgery
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HOW DOES TREATMENT OF OROPHARYNGEAL
CANCER DIFFER FROMORAL CANCER?
e following summary highlights the underlying dierence
between management strategies for oropharyngeal and oral
cancers.
●
Oral cancer – small and low grade are best treated with
surgery alone (excision +/- sentinel node biopsy); otherwise excision plus selective neck dissection (SND) of levels
1-3 in N0 cases but more extensive selective (levels 1-4)
or modified radical neck dissection (MRND) (or more) if
nodal disease. If N2 or T3 disease, or unfavourable tumour
pathology (e.g. perineural invasion) adjuvant radiotherapy is given as well. Radiotherapy can be used for small
tumours, but side effects often don't warrant it.
●
Oropharyngeal cancer – small tumours receive either radical
radiotherapy (to tumour AND neck) or transoral surgery
PLUS neck dissection (and radiotherapy if adverse pathology)
Advanced tumours (stage 3+) require either radical chemoradiotherapy or surgery (excision and neck dissection) PLUS
adjuvant (chemo)radiotherapy; if radical chemo-radiotherapy
alone, 12-week PET-CT; if any residual disease, neck dissection within the following 4 weeks
HYPOPHARYNX TNM
e following list outlines TNM staging for hypopharyngeal
tumours. Ahigher T stage corresponds to local as well as more
distant invasion.
●
T1 – single site up to 2cm
●
T2 – multiple sites OR up to 4cm
●
T3 – more than 4cm or xation of hemilarynx
●
T4a – local invasion (components of larynx, oesophagus,
thyroid, hyoid)
●
T4b – more distant invasion (mediastinum, prevertebral fascia, carotids)
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Head and Neck Oncology 37
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INDICATIONS FOR ADJUVANT EXTERNAL
BEAM RADIATION THERAPY (DXT) IN ORAL
CANCER
e following list describes common indications for use of radiotherapy in the management of oral malignancy.
●
T3+
●
N2+
●
Extra-capsular nodal spread (ECS) or use chemo-radiotherapy
●
OR high-grade, perineural invasion, close margins
●
Give AT LEAST 60 Gy within 6 weeks of surgery
INDICATIONS FOR ADJUVANT CHEMORADIOTHERAPY IN ORAL CANCER
e following list outlines common indications for use of chemoradiotherapy following primary cancer resection.
●
Positive margins
●
Extra-capsular spread (ECS)
NB: ey must be t and up to age 70 inclusive; not benecial aer
age 70.
INDICATIONS FOR RADICAL NECK DISSECTION
e following list outlines common indications for use of
radical neck dissection in the management of head and neck
tumours.
●
Large neck tumour
●
Involved structures
●
Posterior triangle involvement
●
Failed radiotherapy (DXT)
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