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Over an 18-year period, 147 patients with malignant tumours involving the maxillary complex were treated in a combined head and neck clinic, of whom 50 underwent surgery. There were 33 males and 17 females, the mean age was 57 years (range 11-87 years). The most common clinical presentations were either painful facial swelling, infraorbital anaesthesia, palatal ulceration or nasal obstruction. Preoperative investigations included EUA, biopsy and either CT or MRI scans. Of the 50 tumours, 62% were squamous cell carcinomas. Surgery consisted of either partial or total maxillectomy including craniofacial resection in nine patients. Reconstruction was by either split skin grafting or by free tissue transfer when the cranial contents had been exposed. Adjuvant radiotherapy was given in 82% of the patients. The mean follow-up was 5 years and 59% of patients are alive and disease free. The 5-year local control rate was 67%; it was greatly influenced by histological evidence of nerve invasion, local recurrence being the major cause of death. It was concluded that adequate surgical clearance, followed by planned postoperative radiotherapy, is the most effective treatment for malignant disease of the maxillary complex.

Chronic non-specific sialadenitis of the parotid gland is an insidious inflammatory disorder which is characterised by intermittent, often painful, swelling of the gland. The disease tends to progress and may lead to the formation of a fibrous mass. The purpose of this paper is to review our experience in the surgical management of patients with chronic non-specific parotid sialadenitis. In a consecutive series of 100 patients treated for benign parotid disease, 19 were found to have chronic non-specific sialadenitis; 10 were male and 9 female. Mean age was 46 years and the mean duration of symptoms was 4.6 years. Sialography was performed in two-thirds of the patients and 17 patients were treated by superficial parotidectomy. Thirteen patients developed temporary facial nerve weakness and three Frey's syndrome. Three patients complained of temporary paraesthesia of the cheek, and two developed painful neuroma of the greater auricular nerve. Although there were two cases of infection of the parotid duct remnant, no recurrence of deep lobe sialadenitis or fistula formation was noted. Histologically, 3 lesions showed mild chronic sialadenitis, the rest had widespread involvement of the gland, and prolonged duration of symptoms was associated with extensive and severe involvement of the gland. Superficial parotidectomy has a very high success rate, with minimal long-term complications, and should be offered early in established cases, to reduce unnecessary morbidity.

Twenty patients (12 men and 8 women, median age 69 years) with metastatic tumours in the parotid gland who presented over a 12-year period were evaluated retrospectively. Preoperative investigations included fine needle aspiration cytology (n = 11) and computed tomography or magnetic resonance imaging (MRI) (n = 14). Most tumours originated from the head and neck region, the two main types being squamous cell carcinoma (n = 10) and malignant melanoma (n = 7). All 20 presented with a parotid mass and 11/20 (55%) had associated lymphadenopathy. Eleven patients (55%) underwent superficial, five total, and four radical, parotidectomy. Neck dissection was required in 16 patients (80%), and all 11 patients with clinically palpable lymph nodes had evidence of tumour in the neck dissection specimens. Half of all patients (n = 10) received adjuvant postoperative radiotherapy. Three-quarters of the patients (n = 15) were alive after a mean follow-up of 31 months and only one developed a marginal recurrence. The cumulative 5-year survival rate was 51%, and there was no significant difference (P = 0.48) in the 3-year survival rates of patients who had radical compared with those who had modified neck dissections. Patients who had superficial parotidectomy had a longer overall survival compared with those who had total or radical parotidectomy (P = 0.04) perhaps reflecting the advanced nature of tumours that required total or radical excision of the gland. We conclude that superficial parotidectomy is usually an adequate treatment for secondary parotid tumours (when disease is clinically limited to the superficial lobe), and we suggest that patients in whom metastatic disease of the parotid gland is suspected do not require neck dissection if they have no palpable lymph nodes and MRI shows no evidence of spread. There seems to be no survival advantage in radical over modified neck dissection.

Malignant tumours of the submandibular salivary gland are rare, difficult to distinguish clinically from benign disease and often only diagnosed after initial excision of the enlarged gland. In this study of 70 patients (46 male, 24 female) with a mean age of 64 years (range 17-94), and an average duration of symptoms of 3 months, a painless submandibular swelling was the most common presentation. Of the 69 primary tumours, the most frequent histological types were adenoid cystic carcinomas (26 patients, 37%) and carcinoma ex-PSA (18 patients, 26%). One tumour was metastatic in origin, arising from a parotid primary. A total of 65 patients were treated by primary excision of the gland while five patients who presented with advanced disease were treated by radiotherapy alone. Adjuvant postoperative radiotherapy was utilised in 53 (75%) of patients. After a mean follow-up of 5 years, 32 (46%) of patients are still alive. Metastatic disease accounted for 21 deaths (30%). The clinical stage at presentation was the most significant factor predicting survival.

Steroids are used outside the realm of competitive athletics in Australia among a wide variety of groups with different motivations and goals. This paper provides an overview of the reasons for use; rates of usage; physical and psychological side effects; and sources of steroids. Issues associated with injecting steroids; their current legal status; and drug education and prevention programmes are reviewed briefly. Research involving identified sub-populations is needed to determine user profiles and prevalence rates of users and potential users. Studies of Australian users are also needed to obtain baseline information on areas of potential harm associated with steroids use, e.g. aggressive behaviour, needle-sharing behaviour, physical side effects and potential for dependency. It is concluded that future deterrence strategies should focus more on demand reduction, rather than supply.

Malignant parotid tumours are uncommon and present a significant management challenge. Fifty-one such patients (25 male, 26 female, median age 64 years) operated on in the Newcastle Plastic Surgery Unit between 1983 and 1994 were retrospectively evaluated. Preoperative investigations included FNA cytology (n = 20), and for staging CT and/or MRI scans (n = 21). Of the 35 primary tumours 32 were epithelial and three lymphomatous. Metastatic tumours were squamous cell carcinoma (7), melanoma (6), renal cell carcinoma (2) and sebaceous carcinoma (1). FNA cytology correctly diagnosed malignancy with an 88% sensitivity (false negatives = 2). A total or radical parotidectomy was required in 60% of patients, the rest undergoing superficial parotidectomy. In continuity neck dissection was undertaken in 23 (45%) cases. Postparotidectomy reconstruction included 10 free, 3 myocutaneous, and 4 local transposition/rotation flaps. Thirty-seven patients (73%) received postoperative radiotherapy. Seventy-two per cent of patients are alive after a mean follow-up of 42 months. The crude 5- and 10-year survival rates were 68% and 49% respectively while the loco-regional control rate (Kaplan-Meier method) at 10 years was 79%. Fifteen patients (30%) have permanent facial palsy. It is concluded that radical surgery with appropriate reconstruction followed by planned postoperative adjuvant radiotherapy gives effective control of malignant parotid tumours.

Many large vault or skull base tumours are best treated by wide surgical excision and primary reconstruction using a microvascular free tissue transfer (free flap). We report 23 patients who were reconstructed using free flaps, eight having been previously treated surgically elsewhere and seven of whom had recurrent disease after radiotherapy. There was one flap failure and a local recurrence rate of 16% (3/19). The outcome at a mean follow-up period of 29 months, was 19 patients alive and four deaths.

Background: Increasing attention has been directed in recent years to the detection and treatment of psychiatric co-morbidity among depressed individuals. The overlap of social phobia (SP) and avoidant personality disorder (APD) has been well recognized and a relationship between these disorders and depression has been suggested., Methods: The pattern and clinical implications of co-morbidity of SP and APD with major depressive disorder (MDD), diagnosed by DSM-III-R criteria, were studied among 243 out-patients presenting with depression., Results: Overall, 26.7% of adults in our sample with MDD met criteria for SP and 28.4% for APD. Almost two-thirds of depressed adults meeting criteria for social phobia or avoidant personality disorder met criteria for both (SP+APD). Depressed adults who met criteria for both SP+APD exhibited a significantly higher proportion of atypical depression (54.8%) compared with those with neither SP nor APD (31.1%). Among depressed patients, the co-occurrence of SP with APD was also associated with an earlier age of onset of MDD, a greater number of comorbid Axis I diagnoses, and greater impairment of social adjustment and assertiveness., Conclusions: Results confirm the overlap of SP and APD in a depressed population and the high prevalence of these disorders in MDD. They suggest that depressed individuals with both SP and APD but not SP alone are at particularly high risk for atypical depression and for social dysfunction in excess of that caused by a current major depression.

We present an 8-year experience with the Würzburg noncompression titanium miniplate system for the rigid fixation of the mandible during elective head and neck cancer surgery in a consecutive series of 100 patients. One half of the miniplates were used to fix mandibulotomies undertaken for surgical access. The remaining half were in patients undergoing reconstruction of segmental mandibular defects, the vast majority (92%) with vascularised bone grafts. One to four variously shaped miniplates were used per patient (mean = 1.5), plate size ranging from 4 to 40 holes. Fifteen patients (15%) developed complications which included 3 mandibular osteoradionecrosis, 8 broken, 5 infected, and 4 exposed plates. Three of the eight fractured plates were associated with nonunion. In this study, the main advantages of titanium miniplate fixation, namely case of application, decreased fixation time and malleability, were accompanied by a level of morbidity which, while comparing well with alternatives, may necessitate a reappraisal of this technique of fixation.

A case of Frey's syndrome arising in a free radial forearm flap used to reconstruct a defect in the parotid region is reported. To our knowledge, Frey's syndrome, although common following parotidectomy, has not been reported in a free flap. It is possible that parasympathetic secretomotor fibres gained access to the fasciocutaneous flap via the cutaneous nerve stumps in its edge, resulting in gustatory sweating.

In this prospective study, eight consecutive patients underwent excision of oral cavity cancer and reconstruction with a microvascular free flap. Six patients had one pre- and two postoperative assessments of speech and swallowing at four to six weeks and four to six months respectively. One patient could not attend for the preoperative assessment and another for the first postoperative assessment. The speech assessment consisted of an intelligibility score and an articulation score. The swallowing assessment consisted of a videofluoroscopic examination. Five patients had an excellent postoperative speech assessment score, two had a moderate and one a poor result. Videofluoroscopy demonstrated minor swallowing problems preoperatively in one patient. Postoperatively, three patients had severe or moderate loss of control of bolus. Significant aspiration was detected in two and mild aspiration in one patient at the second postoperative assessment. The abnormalities of speech and swallowing were minor in the majority of the patients and the overall outlook was good. This information should be of value for preoperative counselling.

In reconstructive breast surgery, the permanent tissue expander has become popular because it avoids expander-implant exchange and gives the patient some control over the final breast size. It may, however, be associated with a number of complications. We therefore analysed the clinical notes of 111 consecutive recipients of Becker breast expanders with respect to complications and their possible predisposing factors. 120 prostheses were inserted in 111 consecutive patients with a mean age of 42.6 years. Median follow-up was 12 months (range 8 to 22). The commonest indication was postmastectomy breast reconstruction (81%) followed by congenital hypoplasia (14%) and acquired breast asymmetry following repeated biopsies (3%). Overexpansion before size adjustment was achieved after an average of 8 expander inflations. Complications included capsular contracture (9%), local tumour recurrence (8%), wound dehiscence (8%), filling port failure (6%), infected prostheses (4.5%) and ruptured implants (1.6%). The significant predisposing factors to wound dehiscence/infection were heavy smoking and radiotherapy (P < or = 0.05, chi 2 test). Expansion rate was not a factor. 89% of patients expressed satisfaction with the final aesthetic result. Despite the excellent results obtained with this technique, caution must be exercised in heavy smokers and the previously irradiated.

A case of poorly differentiated adenocarcinoma of adnexal origin in the upper lip of a man aged 75 is reported which on presentation and initial biopsy was thought to be a salivary neoplasm. He had been aware of the lesion for 10 years but had sought treatment because of recent increase in size of the tumour. He subsequently developed bilateral metastases in cervical nodes. The histopathologic features and relationship of the tumour to the orbicularis oris muscle were consistent with a poorly differentiated adnexal adenocarcinoma of sweat-gland origin. Although carcinomas of skin adnexae are rare they should be considered in the differential diagnosis of tumours in the orofacial region.

Brachytherapy delivered within the early post-operative period has been associated with delayed healing and wound breakdown. The objective of this study was to determine whether reconstruction with a microvascular free flap reduced the incidence of wound breakdown after early post-operative brachytherapy and wide excision of soft tissue sarcomas. Four patients with sarcomas underwent excision and free flap reconstruction. Brachytherapy was administered in the early post-operative period using Iridium-192 wires via tubes inserted intraoperatively. In three of the four patients the wounds healed uneventfully, demonstrating that brachytherapy can be delivered in the early post-operative period following free flap reconstruction without an increase in the frequency of wound breakdown. There has been no local recurrence to date in this group of patients.

Objective: The purpose of this study was to quantify the proportion of patients who show no response to a fixed dose of fluoxetine after 2, 4, and 6 weeks of treatment and then respond by week 8., Method: In an open trial, 143 outpatients who met DSM-III-R criteria for major depressive disorder were treated with a regimen of fluoxetine, 20 mg/day. The authors analyzed the proportion of patients who had less than a 20% decrease from baseline in their scores on the Hamilton Rating Scale for Depression after 2, 4, and 6 weeks and who went on to have a 50% or greater reduction by week 8. A last-observation-carried-forward strategy was used to calculate conditional probabilities of 8-week response. Kaplan-Meier survival analysis was used to estimate probabilities of response at week 8 given degrees of response at week 2., Results: Eighty-two subjects (57.3%) who started the trial responded by week 8. Of those subjects who showed no improvement at weeks 2, 4, and 6, the proportions of responders at week 8 were 36.4%, 18.9%, and 6.5%, respectively. The Kaplan-Meier estimate of 8-week response given nonresponse at week 2 was 0.45., Conclusions: The proportion of patients with no response to antidepressant treatment by 4 or 6 weeks who responded by week 8 was substantially less than that for subjects who had at least a partial response. Nonresponse as early as week 2 predicted 8-week outcome.

Sialadenosis (sialosis) is an uncommon, non-inflammatory condition which usually causes bilateral, diffuse enlargement of the salivary glands, particularly the parotid. We present a series of 7 patients with sialadenosis. Two had bilateral and 4 unilateral parotid involvement. One patient had unilateral submandibular gland sialadenosis. One patient had bilateral parotid and bilateral submandibular gland sialadenosis. The clinicopathological features and management of the condition are reviewed.

One hundred forty-eight patients, ages 18-65, with major depression were administered the Mini-Mental State Examination (MMSE) prior to 8 weeks of treatment with fluoxetine; 75 of these patients were readministered the MMSE following treatment. MMSE scores were not related to pretreatment severity of depression or to reported concentration problems and were not predictive of antidepressant response. Non- and partial responders had lower posttreatment MMSE scores than responders, men had lower posttreatment scores than women, and subjects over 50 had lower pretreatment scores than younger subjects, although in all cases, the magnitude of the differences was small and unlikely to be clinically important. Our results suggest that while the MMSE has been shown to be useful among geriatric and other depressed inpatients, it is not a sensitive indicator of depression severity, concentration problems, or likelihood of treatment response among otherwise healthy adults with major depression in an outpatient setting.

Two cases are described of ulnar nerve compression at the elbow due to an anomalous muscle--the epitrochleo-anconeus. In both cases the onset of symptoms may have been related to a period of excessive exercise of the upper limb. Both cases recovered rapidly and completely following medial epicondylectomy and excision of the abnormal muscle.

A case of reconstruction of a large mandibular defect is presented, in which a 17 cm free vascularised fibular bone graft was first anastomosed to a radial fasciocutaneous flap in situ in the forearm, and then the combined flap was transferred and revascularised in the neck.

The authors present a ten-year series of consecutive one-stage reconstructions of defects following excision of malignant disease and of traumatic defects, using the radial forearm flap. Of the 155 radial forearm flaps performed, 144 were free flaps and 11 were pedicled flaps; 55 of the 144 free flaps were osteofasciocutaneous. Microvascular reconstructions with this versatile flap had a 98 percent success rate in this series.

In a blind, prospective trial, 42 patients undergoing 51 cervical lymph node dissections for head and neck malignancies were investigated by a preoperative MRI scan. Histological examination of the dissection specimens recorded the distribution, size, percentage of neoplastic involvement and any extra-capsular spread of the sampled nodes. The MRI correctly diagnosed all 17 positive nodes (sensitivity 100%). However it could not differentiate between enlarged reactive and malignant nodes, so there was a significant false positive rate (specificity 53%). Routine use of MRI scans will allow an unnecessary neck dissection to be avoided in a patient with a clinically negative neck who also has a negative MRI scan.

DNA fingerprints generated by the Jeffreys' probes, 33.6 and 33.15, indicated the presence of minisatellite-like sequences in the red clover genome. The fingerprints generated by probe 33.6 gave less background and fewer but better defined bands than those obtained with probe 33.15. Assay of a regenerative somaclonal variant (F49R) by DNA fingerprinting with probe 33.6 detected mutation that was unlinked to the regenerative trait. The fingerprints obtained under the applied conditions also demonstrated genetic stability of consecutive generations of the regenerants in tissue culture. DNA fingerprints of F1 plants revealed that each polymorphic band was inherited from either one or the other parent. Both probes distinguished individual-specific genotypes in seven cultivars of red clover. Greater variability in DNA fingerprints was detected between (V=0.899) than within (0.417≤V≤0.548) cultivars.

A new medical instrument is presented that produces a doppler blood flow image from a laser beam in a raster pattern and the results of a pilot study which shows this technique to be highly accurate in assessing burn depth is described.

Management of large or recurrent basal cell carcinomas (BCCs) on the face can be difficult, especially where radiotherapy has been the primary treatment. Free tissue transfer using microvascular surgery permits wide excision margins ensuring clearance of the tumour without being compromised by concern over closure, since the free flap can be designed after the excision of the tumour and its size and composition can thus be custom made. Age alone should not be a contraindication to this major procedure.

Brachytherapy delivered within the early postoperative period has been associated with delayed wound healing and wound breakdown. The objective of this study was to determine whether reconstruction with a microvascular free flap reduced the incidence of wound breakdown in the presence of early postoperative brachytherapy following wide excision of soft tissue sarcomas and head and neck carcinomas. Ten patients with malignant tumours underwent wide excision and free flap reconstruction. Brachytherapy was administered using Iridium-192 wires in the early postoperative period via tubes inserted intra-operatively. In 9 of the 10 patients the wounds healed uneventfully, demonstrating that brachytherapy can be delivered in the early postoperative period following free flap reconstruction without an increase in the frequency of wound breakdown.

One hundred and eleven cases of free tissue transfer were reviewed to assess the indications for, and results of, such procedures. More than 90% of cases were seen after treatment of tumour or trauma, with the most utilized flaps being the radial forearm, jejunum and latissimus dorsi. Fifteen per cent of cases required re-exploration of the anastomosis, of which more than 75% were salvaged. Haematoma formation and venous thrombosis were the commonest problems and were more successfully treated than arterial occlusion. The overall success rate was 92%. Free microvascular tissue transfer is a useful and reliable technique, especially in the management of head and neck tumours and limb trauma. The most important factors relating to flap survival are the experience of the surgical team and the integrity of the anastomosis.

The intramuscular haemangioma is a relatively uncommon benign vascular tumour which accounts for less than 1% of all haemangiomas. It is a rare lesion in the orofacial muscles. A case is reported arising in the orbicularis oris muscle presenting in a 9-month-old child.

A case is presented demonstrating the value of magnetic resonance imaging (MRI) in the assessment of a midline sublingual epidermoid cyst in a 22-year-old female. The advantages of MRI compared with CT in the evaluation of soft-tissue lesions in the sublingual space are discussed.

Objective: To report the outcome of a multidisciplinary physically based program to treat sufferers of chronic low back pain who had not responded to previous treatment., Design: Prospective intervention study., Setting: The treatment program was conducted at the private practice of Brian C Edwards and Associates Rehabilitation Centre., Patients: A total of 54 patients participated in the treatment program. All patients were medically referred. No specific exclusion criteria were used; however, all were not working and had not responded to previous treatment., Intervention: The rehabilitation program consisted of mobilising physiotherapy, isokinetic testing, physical reconditioning, work hardening and psychological testing. This was carried out for seven hours a day, five days a week for four weeks., Results: Of the 54 patients taking part in this trial 30 (55%) were successfully rehabilitated (returned to work) and remained so at a follow-up session one year later., Conclusion: While selection criteria for successful rehabilitation have not been established, the results do indicate that such physical rehabilitation programs have an important part to play in the rehabilitation of sufferers of chronic low back pain.

A case of failure of a free radial forearm flap is presented. It is surmised that this was due to venous thrombosis in the cephalic vein which showed evidence of recanalization of an old thrombus. The patient had received intravenous erythromycin some months previously.

Although high-performance liquid chromatography has been used extensively to characterize the glycosaminoglycan chains of proteoglycans, very few researchers have reported the use of this technology for the separation of intact proteoglycan species. The high molarity denaturing buffers required for proteoglycan disaggregation and separation are often not compatible with the low back-pressure limitations imposed by many of the HPLC systems designed for the separation of biological macromolecules. In this study, heparan sulfate and dermatan sulfate proteoglycans, obtained by the metabolic labeling of cultured corneal endothelial cells, were rapidly and completely separated in less than an hour in a high-pressure liquid chromatography system. The separation, which used a Dionex BioLC system equipped with a Pharmacia Superloop and a ProPac PA1 column, also effected a greater than 10-fold concentration of the proteoglycans during the separation procedure. All buffers were 8 M in urea, and the back-pressures generated during the separation were well below the limit of the system. The pooled fractions from the ion-exchange column were subsequently analyzed for glycosaminoglycan composition and molecular size. The system was able to resolve dermatan sulfate-substituted species from heparan sulfate-substituted species in a single chromatographic step. The proteoglycan nature of the recovered products was established by Sepharose CL-4B chromatography and gel electrophoresis.

A 47-year-old man with a 15 year history of unilateral, idiopathic trigeminal anaesthesia presented with trophic ulceration of the right ala nasi and had a successful nasal reconstruction performed using an innervated left forehead flap. Three years later the cosmetic results is satisfactory and the flap retains normal sensation.

Although needle aspiration diagnosis was described over 50 years ago, many patients with neck swellings are still subjected to hazardous and unnecessary open diagnostic surgical biopsy. In a six-month period, over 200 fine needle aspirates were performed on tumours from the head and neck region, 44% of which were positive for cancer. The technique of aspiration, its advantage for the patient, clinician and cytopathologist, and the results of the study will be discussed. Close cooperation between the clinician and the cytopathologist is essential.

A colorimetric method is described for measuring glucose consumption by tissue culture cells. This procedure, which utilizes the coupled activities of glucose oxidase and horseradish peroxidase, is insensitive to the spectral interferences caused by the phenol red and sera present in most tissue culture media. The spectral properties (absorbance maxima and apparent absorption coefficients) and stability of a large number of chromogenic horseradish peroxidase substrates were surveyed for their ability to perform in an assay for glucose in the presence of phenol red and sera components. One of these chromophores, the product of an oxidative couple between 4-aminoantipyrine and N-ethyl-N-sulfopropyl-m-toluidine, was subsequently used to develop a fixed time assay for glucose in media samples. The assay required only 10 microliters of media in a 1-ml assay volume; reproducibility studies showed variabilities of less than 5% in the assay of a single sample, and values obtained in glucose analyses correlated well with those obtained using commercially available test kits. The assay was used to study the rate of glucose consumption in two different cell types, bovine corneal endothelial cells and human diploid fibroblasts.

Gastric mucus of the pig (Sus scrofa L.) has been separated into two distinct components in guanidine:urea:phosphate. The insoluble gelatinous phase has been solubilized by reduction in bicarbonate buffer. Gel filtration chromatography suggests the presence of a high molecular weight (1.92 X 10(6] and a low molecular weight (6.25 X 10(5] mucoprotein. Proteolytic digestion with trypsin, papain and pronase yielded glycopeptides whose molecular weights ranged from 2.6 X 10(5) to 6.25 X 10(5). Amino acid analysis of each mucoprotein fragment was determined. Notable differences when compared to soluble mucus glycoproteins lie in the conservation of those amino acids likely to be involved in the O-glycosyl linkage.

The incidence of a palmaris longus tendon in patients with Dupuytren's disease is significantly greater than in a control group with normal hands (p = 0.014). If a patient has a palmaris longus tendon, then there is a highly significant chance of Dupuytren's disease developing in that hand (p less than 0.001).