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Editorial Board/Reviewing Committee
doi : 10.1016/S0901-5027(22)00018-2
Volume 51, Issue 3, March 2022, Page i
Characterization and clinicopathological significance of circulating tumour cells in patients with oral squamous cell carcinoma
J.Curtin1S.-W.Choi2P.J.Thomson2A.K.-y.Lam1
doi : 10.1016/j.ijom.2021.05.020
Volume 51, Issue 3, March 2022, Pages 289-299
Circulating tumour cells (CTCs) are cancer cells released by cancer into the peripheral circulation. Haematogenous tumour spread is a hallmark of metastatic malignancy and a key factor in cancer recurrence and prognosis. CTCs have diagnostic and prognostic significance for a number of adenocarcinomas and melanoma. A review of the published peer-reviewed literature was performed to determine the clinical relevance of CTCs as a biomarker in the management of oral squamous cell carcinoma (OSCC). Fourteen studies met the eligibility criteria. With regard to patients with OSCC, this review found the following: (1) CTCs have been detected using multiple techniques; (2) the presence of CTCs does not appear to be related to tumour differentiation or size; (3) CTCs may be detected without lymph node involvement; (4) the detection of CTCs may be prognostic for both disease-free survival and overall survival; (5) quantification of CTCs may reflect the efficacy of therapy; (6) CTCs may be of value for ongoing patient monitoring. Preliminary evidence suggests that CTCs have diagnostic and prognostic potential as a biomarker for oral cancer management and warrant further investigation to determine their appropriate place in the management of OSCC patients.
The combined coronal–transconjunctival approach: an innovative surgical access for orbital exenteration in craniofacial resection
.AceroaP.de LeyvaaF.AlmeidaJ.NúñezM.Picón
doi : 10.1016/j.ijom.2021.07.007
Volume 51, Issue 3, March 2022, Pages 300-306
Malignant tumours arising in the paranasal sinuses or maxilla usually spread to the surrounding regions. The skull base and the anterior cranial fossa are frequently affected as well. When the resection of a tumour involves an orbital exenteration, a transconjunctival-perilimbic incision can be added to a coronal approach in order to preserve the eyelids and the conjunctiva, avoiding cutaneous midfacial incisions. Patients with a diagnosis of malignant tumour affecting the orbit, upper jaw, paranasal sinuses, and/or anterior skull base were eligible for this technique. Tumoural invasion of the eyelids, conjunctiva, lacrimal system, or surrounding skin was considered a contraindication for this technique. A retrospective study of the clinical records was performed and age, type of tumour, location, and reconstructive technique were evaluated. Eight patients referred to the study department between 2015 and 2019 were selected. All patients underwent craniofacial surgery and orbital exenteration. The transconjunctival-perilimbic approach was combined with a coronal incision in all cases. In our experience, the transconjunctival-perilimbic approach to orbital exenteration proposed in this paper can be used successfully in skull base surgery. Combined with a coronal and transmandibular approach, it allows wide access to the facial skeleton/anterior skull base while avoiding skin incisions in the midface.
Prognostic significance of lymph node ratio in patients with squamous cell carcinoma of the floor of the mouth
X.C.Liu13S.R.Ma23S.Shi2Y.F.Zhao12J.Jia12
doi : 10.1016/j.ijom.2021.07.001
Volume 51, Issue 3, March 2022, Pages 307-313
The lymph node ratio (LNR) has been proposed as an independent prognostic factor for survival in patients with oral squamous cell carcinoma (OSCC). However, little attention has been paid to its role in the specific subsite of the floor of the mouth (FOM). The purpose of this study was to evaluate the prognostic significance of the LNR in patients with FOM SCC. A retrospective analysis of 92 patients with FOM SCC who were treated with primary curative resection and neck dissection was conducted. Overall survival (OS) and disease-free survival (DFS) were used to evaluate the prognostic significance of the LNR. Both of these parameters were significantly worse (P
A SEER analysis of survival and prognostic factors in merkel cell carcinoma of the head and neck region
C.C.Go1D.H.Kim12C.A.Briceño12
doi : 10.1016/j.ijom.2021.05.014
Volume 51, Issue 3, March 2022, Pages 314-322
While Merkel cell carcinoma (MCC) of the head and neck is highly malignant, it remains poorly characterized due to its rarity. The purpose of this study was to examine prognostic factors for overall survival (OS) and disease-specific survival (DSS) in patients with MCC of the head and neck region. The Surveillance, Epidemiology and End Results registry was reviewed for patients diagnosed between 1984 and 2016 with histologically confirmed, primary MCC of the head and neck region. A total of 2818 patients met the inclusion criteria, with a median age at diagnosis of 77 years. At five and 10 years, respectively, the OS was 42.4% and 25.1% and the DSS was 67.9% and 64.1%. Multivariate Cox analysis indicated that predictors of decreased DSS included age at diagnosis ≥75 years, white race, increasing tumor spread, lymph node involvement and either the lip or the scalp/neck as a primary site. When adjusting for the aforementioned factors, tumor depth was not found to be a prognostic factor for DSS. We anticipate these results will help clinicians to counsel patients regarding expectations and potential prognosis.
Patients’ views of physical activity whilst living with and beyond head and neck cancer
S.N.Rogers12D.Lowe3A.W.Midgley4
doi : 10.1016/j.ijom.2021.05.006
Volume 51, Issue 3, March 2022, Pages 323-331
Exercise is an important component of recovery following cancer. Head and neck cancer (HNC) patients typically report low levels of engagement in exercise initiatives. The aim of this study was to give insight into HNC patients’ reflections on how and why they would be interested in participating in an exercise programme. A stratified sample of 51 patients based on age, gender and initial interest in an exercise programme was selected from 430 postal survey respondents. Twenty-five took part in a semi-structured telephone interview. There was responder bias with females, younger patients, and those already participating in or interested in an exercise programme being over-represented. The responders in this study highlighted issues related to physical activity levels, perceived ability to meet physical activity guidelines for cancer survivors, perceived exercise benefits, perceived exercise barriers, and advice to others diagnosed with cancer. The findings support the premise of personalized interventions tailored towards the specific needs of the patient, supported by patient peers to emphasize the benefits and help motivate patients to take part. In order to promote engagement in exercise there needs to be collaborative, culturally sensitive and individualized approaches, in order to address the specific barriers experienced by HNC patients.
Association between habitual snoring, middle ear disease, and speech problems in young children with non-syndromic cleft palate anomalies
M.Moraleda-Cibrián13S.P.Edwards2S.J.Kasten4S.A.Warschausky5S.R.Buchman4L.M.O’Brien126
doi : 10.1016/j.ijom.2021.07.003
Volume 51, Issue 3, March 2022, Pages 332-337
The purpose of this study was to investigate the association between habitual snoring (HS), middle ear disease (MED), and speech problems in children with cleft palate. This cross-sectional study included children aged 2.0–7.9 years with non-syndromic cleft palate anomalies. Parents completed the Pediatric Sleep Questionnaire and a questionnaire about MED. Audiograms and speech assessment were also conducted. Ninety-five children were enrolled; 15.2% of families reported HS, 97.6% MED, and 17.1% speech problems. HS (37.5% vs 10.3%, P = 0.007) and early episodes of MED (92.3% vs 58.2%, P = 0.021) were more likely to be reported for children with isolated cleft palate when compared to those with cleft lip and palate. Children with cleft lip and palate had a higher frequency of MED with effusion compared to those with Robin sequence (86.4% vs 57.1%, P = 0.049). The odds ratio for HS in children with ≥1 episode of MED in the last year was 7.37 (95% confidence interval 1.55–35.15, P = 0.012). There was a trend for children with speech problems reported by parents to have HS (30.8% vs 11.5%, P= 0.076). Anatomical factors play a role in the frequency of upper airway symptoms in children with cleft palate. A recent history of at least one episode of MED was associated with an increased frequency of HS.
Does different cranial suture synostosis influence orbit volume and morphology in Apert syndrome?
X.Lu1A.J.Forte2M.Alperovich1N.Alonso3J.A.Persing1
doi : 10.1016/j.ijom.2021.07.019
Volume 51, Issue 3, March 2022, Pages 338-346
This study was performed to compare the orbital and peri-orbital morphological variations in Apert syndrome patients with different cranial vault suture synostosis, so as to provide an anatomic basis for individualized surgical planning. Computed tomography scans of 57 unoperated Apert syndrome patients and 59 controls were subgrouped as follows: type I, bilateral coronal synostosis; type II, pansynostosis; type III, perpendicular combinations of cranial vault suture synostoses. Orbit bony cavity volume was significantly reduced in type I and type II, by 19% (P < 0.001) and 24% (P < 0.001), respectively. However, the reduction of orbital cavity volume in type III did not reach statistical significance. Globe volume projection beyond the orbital rim, however, increased by 76% (P < 0.001) in type III, versus an increase of 54% (P < 0.001) in type I and 53% (P < 0.001) in type II, due to different ethmoid and sphenoid bone malformations. Maxillary bone volume was only significantly reduced in type I bicoronal synostosis (by 24%, P = 0.048). Both type I and type II developed relatively less zygoma and sphenoid bone volume. Different cranial vault suture synostoses have varied influence on peri-orbital development in Apert syndrome. Instead of mitigating the abnormalities resulting from bicoronal synostosis in type I, additional midline suture synostosis worsens the exorbitism due to a more misshaped ethmoid.
Cleft palate lateral synechia syndrome in two patients and literature review
S.Plantin1M.Fabre23V.Soupre14A.Guimier5V.Agostini36C.T.Gordon36E.Galliani14A.Picard134A.Morice134
doi : 10.1016/j.ijom.2021.07.012
Volume 51, Issue 3, March 2022, Pages 347-354
Cleft palate lateral synechia (CPLS) syndrome is an extremely rare congenital malformation syndrome of unknown origin, characterized by the association of cleft palate and one or more intraoral lateral synechiae (OMIM # 119550). Fewer than 20 cases have been described to date. The clinical and histological findings and results of genetic investigations for two additional cases of CPLS are presented herein, in order to better delineate this syndrome, within the context of the relevant literature. The first case presented with a U-shaped cleft palate, bilateral synechiae, and Pierre Robin sequence, requiring early sectioning of the synechiae because of severe feeding problems. The second case presented with a V-shaped cleft palate and a single synechia, running from the left border of the cleft to the floor of the mouth, and was without feeding difficulties. In both cases, histopathological examination of the synechiae revealed an aspect of mucous membranes macroscopically, while staining of sections indicated lymphocyte infiltrates and parakeratosis with stratified squamous epithelium, associated with vessel and connective tissue abnormalities. Sequencing of candidate genes did not identify a genetic cause. Accurate clinical descriptions, histopathological diagnosis, and genetic investigations of patients with synechiae are lacking in the literature. Better characterization of future cases of CPLS will give new insights into its developmental causes.
Does the use of low-level light therapy postoperatively reduce pain, oedema, and neurosensory disorders following orthognathic surgery? A systematic review
L.M.Barbosa1J.M.de Luna Gomes2J.R.Laureano Filho1B.C.do Egito Vasconcelos1S.L.Dantas Moraes3E.P.Pellizzer2
doi : 10.1016/j.ijom.2021.06.006
Volume 51, Issue 3, March 2022, Pages 355-365
The aim of this study was to evaluate the efficacy of low-level light therapy (LLLT) in improving pain, oedema, and neurosensory disorders of the inferior alveolar nerve (IAN) after orthognathic surgery. This systematic review was performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Searches were conducted in the PubMed, Embase, and Web of Science databases for randomized clinical trials (RCTs) published up to September 2020. After evaluating eligibility, 15 RCTs were selected. None of the studies reported an evaluation of all of the outcomes within the same publication. It was possible to determine the effect of LLLT in controlling pain following orthognathic surgery. Of the three studies evaluating this outcome, all observed a positive effect. Of the four studies that evaluated oedema, two found a positive effect. Of the 11 studies that evaluated neurosensory disorders of the IAN, all of them observed a positive effect, at least in one of the sensory evaluation tests. A meta-analysis was not possible due to the heterogeneity across studies. Considering the limitations of this review, but given the fact that LLLT is a minimally invasive intervention, its use merits consideration in immediate postoperative orthognathic surgery.
Do oropharyngeal throat packs prevent fluid ingestion during orthognathic surgery?
K.Powell1D.Amin12R.Sesanto1A.Bryant3P.Kukreja3P.Waite1
doi : 10.1016/j.ijom.2021.07.011
Volume 51, Issue 3, March 2022, Pages 366-370
The oropharyngeal throat pack is commonly used in oral and maxillofacial surgery despite debated evidence regarding its barrier function. The study objectives were to investigate whether the oropharyngeal pack reduces blood ingestion and to evaluate its relationship with postoperative nausea and vomiting (PONV) and throat pain. This was a single-center, parallel group, single-blind randomized controlled trial. Participants undergoing orthognathic surgery, age ≥16 years, were included in the study. After intubation and prior to surgery start, the treatment group received oropharyngeal packing; the control group received no packing. Outcome variables were the quality of gastric contents aspirated by nasogastric tube (bloody or not bloody), PONV, and throat pain (visual analog scale). Thirty patients (treatment n = 15; control n = 15) were randomized and analyzed. There was no difference between the groups in quality of gastric contents (P = 1.00) or incidence of PONV at 2 hours and 24 hours (P = 1.00). Throat pain incidence and severity at 2 hours were both higher in the treatment group, but this was not statistically significant (P = 0.128, P = 0.223). The results indicate that the oropharyngeal pack is not an effective barrier against blood ingestion. Oropharyngeal packs do not improve or worsen PONV, but may increase throat pain.
Does the use of a piezoelectric saw improve neurosensory recovery following sagittal split osteotomy?
D.L.Sobol12J.S.Hopper1R.E.Ettinger12T.B.Dodson3S.M.Susarla123
doi : 10.1016/j.ijom.2021.07.002
Volume 51, Issue 3, March 2022, Pages 371-375
Neurosensory disturbance of the inferior alveolar nerve (IAN) is an adverse effect associated with sagittal split osteotomies (SSO). The purpose of this work was to evaluate neurosensory recovery of the IAN when SSOs were performed with piezoelectric (PZ) versus reciprocating (RP) saws. This was a prospective split-mouth study of patients undergoing bilateral SSO using a PZ saw on one side and an RP saw on the other. The primary outcome of interest was neurosensory recovery, as assessed using the functional sensory recovery (FSR) scale defined by the UK Medical Research Council. Descriptive, bivariate, and regression statistics were computed. Twenty patients (40 SSOs) with a mean age of 19.9 ± 3.2 years were included. The mean mandibular movement did not differ significantly (P = 0.50) between the PZ and RP groups. All patients achieved FSR within 1 year of surgery (range 34–249 days). The median time to FSR overall was comparable between the PZ and RP groups (94.5 days and 101.5 days, respectively; P = 0.20). However, at the time FSR was achieved, PZ SSO sites were more likely to have higher neurosensory scores when compared to RP SSO sites (hazard ratio 2.3, 95% confidence interval 1.1–4.9, P = 0.04).
A novel instrument for the prevention of condylar torque in bilateral sagittal ramus osteotomy when using bicortical screw fixation
C.Van den Borre1E.Van de Casteele234P.Boeckx1N.Nadjmi1234
doi : 10.1016/j.ijom.2021.06.007
Volume 51, Issue 3, March 2022, Pages 376-379
When using the bilateral sagittal split osteotomy (BSSO) technique, rigid internal fixation (RIF) remains the standard method to accurately fix the distal and proximal osteotomy fragments. A concern with the use of RIF, especially with bicortical screws, is the increased risk of condylar torque and its functional consequences. This technical note introduces a new method for preventing torque of the mandibular condyles after BSSO, using a sagittal split space maintainer.
Dental implant procedures in immunosuppressed organ transplant patients: a systematic review
D.Burtscher1D.Dalla Torre2
doi : 10.1016/j.ijom.2021.06.008
Volume 51, Issue 3, March 2022, Pages 380-387
During the last decades, the number of immunosuppressed organ transplant patients has increased consistently. Nevertheless, immunosuppression has been discussed as a contraindication for dental implant procedures for many years. Hence, the purpose of this systematic review was to assess the survival rate and outcomes of dental implants after solid organ transplantation. An electronic and manual literature search was conducted up to March 2021. Publications describing dental implants placed in patients after organ transplantation were included without any limitations regarding study design or date of publication. Ten articles met the inclusion criteria, leading to a sample of 93 patients with 249 implants. Implant survival rates were 100% over a mean follow-up of 60 months. In every case, implant surgery was performed under antibiotic coverage. No major medication-related complications were reported. Despite the limited amount of evidence in the literature, implant procedures seem to be a safe treatment option in immunosuppressed organ transplant patients. The observance of appropriate treatment protocols including a strict maintenance programme seems to be crucial for the long-term success of such treatments. However, stringent data regarding various influencing factors such as the prevalence of peri-implantitis are still missing.
The correlation of different methods for the assessment of bone quality in vivo: an observational study
M.R.OliveiraaA.GonçalvesaM.A.C.GabrielliaC.R.de AndradebC.R.ScardueliaV.A.Pereira Filhoa
doi : 10.1016/j.ijom.2021.05.019
Volume 51, Issue 3, March 2022, Pages 388-397
Different methods for the assessment of bone quality were evaluated in this study. Sixty alveolar bone areas were investigated. Peri-apical and panoramic radiographs were obtained with an aluminium scale to assess optical density. The Lekholm and Zarb (L&Z) classification was determined through radiographic analysis and the surgeon’s tactile perception. A trephine was used to obtain a bone biopsy for assessment by micro-computed tomography (micro-CT) and histomorphometry. Primary stability of the implants was assessed using insertion torque (IT) and the implant stability quotient (ISQ). The optical density on peri-apical radiographs was correlated with IT, ISQ, and micro-CT (BV, BV/BT, Tb.Th, Tb.N, BS/BV, Tb.Pf, and SMI) (rho ≤ 0.471, P ≤ 0.028). Panoramic radiography showed a correlation only with bone surface (BS) and bone surface/volume ratio (BS/TV) (rho ≤ 0.290, P ≤ 0.031). IT showed a correlation with ISQ, histometry, and micro-CT (BV, BS/TV, Tb.Th, Tb.N, BS/BV, Tb.Pf, Tb.Sp, BV/BT) (rho ≤ 0.550, P ≤ 0.022). ISQ did not show any correlation with micro-CT. The L&Z classification showed correlations with the optical density obtained in the peri-apical radiographs, histometry, osteocyte count, IT, and micro-CT (BS/BV, Tb.Sp, Tb.Pf, BV, BS/TV, Tb.Th, Tb.N) (rho ≤ 0.344, P ≤ 0.042). The L&Z bone classification and IT are reliable methods, peri-apical radiographs and ISQ are acceptable, and panoramic radiography is not a reliable method for the assessment of bone quality.
Tomographic evaluation of the mandibular nerve in the mental region and its surgical implications: a cross-sectional study
C.M.L.Tejada1M.Claudino2L.R.Azevedo Alanis3J.P.L.Manfrinato1S.R.Bernardes1G.Thomé1F.N.G.K.Fontão1
doi : 10.1016/j.ijom.2021.05.018
Volume 51, Issue 3, March 2022, Pages 398-404
The aim of this study was to evaluate the prevalence and length of the anterior loop (AL) of the inferior alveolar nerve, nerve emergence from the mental foramen, and prevalence of sensory disorders after implant placement in the interforaminal region. Four hundred and fifty hemimandibles (225 patients) were evaluated using cone beam computed tomography and panoramic radiographs. Information on the presence of sensory disorders was obtained from the medical records. AL prevalence was 13.6% and mean AL length was 1.25 mm. The false-negative rate for the identification of the AL using panoramic radiography was 58.6%. Straight nerve emergence from the mental foramen was the most prevalent (62.7%), followed by anterior (21.8%) and posterior (15.6%) emergence. The incidence of sensory disorders was 4.4%, and 1.1% were related to the presence of the AL. When implants were placed within the planned distance of the mental foramen or further, 1.2% had sensory problems associated with the presence of the mandibular incisive canal. In cases of distances smaller than planned, 12.9% had sensory alterations. Only five (1.1%) had the AL, with a length between 0 and 4.5 mm. However, in four cases, the planned distance was respected and, even so, there was a sensory disorder. Posterior nerve emergence from the mental foramen was associated with a higher prevalence of AL.
Mechanical evaluation of a patient-specific additively manufactured subperiosteal jaw implant (AMSJI) using finite-element analysis
E.De Moor1S.E.F.Huys1G.H.van Lenthe1M.Y.Mommaerts2J.Vander Sloten1
doi : 10.1016/j.ijom.2021.05.011
Volume 51, Issue 3, March 2022, Pages 405-411
Edentulism with associated severe bone loss is a widespread condition that hinders the use of common dental implants. An additively manufactured subperiosteal jaw implant (AMSJI) was designed as an alternative solution for edentulous patients with Cawood and Howell class V–VIII bone atrophy. A biomechanical evaluation of this AMSJI for the maxilla in a Cawood and Howell class V patient was performed via finite-element analysis. Occlusal and bruxism forces were incorporated to assess the loading conditions in the mouth during daily activities. The results revealed a safe performance of the implant structure during the foreseen implantation period of 15 years when exerting average occlusion forces of 200 N. For the deteriorated state of class VIII bone atrophy, increased stresses on the AMSJI were evaluated, which predicted implant fatigue. In addition, excessive bruxism and maximal occlusion forces might induce implant failure due to fatigue. The models predicted bone ingrowth at the implant scaffolds, resulting in extra stability and secondary fixation. For all considered loading conditions, the maximal stresses were located at the AMSJI arms. This area is most sensitive to bending forces and, hence, allows for further design optimization. Finally, the implant is considered safe for normal daily occlusion activities.
Does the use of topical anesthetics reduce the perception of pain during needle puncture and anesthetic infiltration? Systematic review and meta-analysis of randomized controlled trials
F.P.A.Maia1C.A.Araujo Lemos2E.S.de Souza Andrade1S.L.D.de Morais3B.C.do Egito Vasconcelos1E.P.Pellizzer4
doi : 10.1016/j.ijom.2021.06.005
Volume 51, Issue 3, March 2022, Pages 412-425
The objective of this systematic review was to assess whether the use of topical anesthetics reduces the perception of pain during puncture and anesthetic infiltration. Twenty-two randomized controlled clinical trials, published in English on or before August 6, 2020, were found in the PubMed/MEDLINE, Scopus, and Cochrane Library databases. Risk of bias was determined for randomization and other issues. A total of 1029 patients were evaluated using parameters such as type of topical anesthetic, application site, and pain (measured on a scale). Some studies assessed more than one topical anesthetic. Seventeen of them showed a reduction in pain from needle puncture and four from infiltration. Meta-analyses for some results showed considerable statistical heterogeneity. Regarding pain during needle puncture of the maxilla, statistically significant differences were observed in the topical anesthetics group, in both the vestibular (P = 0.0002) and palatal (P = 0.005) region. This was different from the mandible, for which there was no statistically significant difference (P = 0.07). With regard to pain caused by anesthetic infiltration in the maxilla, there was no difference in the use of anesthetic in relation to the control group (P = 0.11). Given these findings, using topical anesthetics only relieves pain during needle puncture and in the maxilla. PROSPERO 2020: CRD42020206362.
Prospective study examining the use of thrombin–gelatin matrix (Floseal) to prevent post dental extraction haemorrhage in patients with inherited bleeding disorders
T.Ali1J.Keenan1J.Mason23J.-T.Hseih1M.Batstone13
doi : 10.1016/j.ijom.2021.07.018
Volume 51, Issue 3, March 2022, Pages 426-430
The bleeding risk in individuals with inherited bleeding disorders (IBDs) during exodontia is traditionally managed with perioperative coagulation factors and/or desmopressin, in conjunction with systemic and topical perioperative tranexamic acid and meticulous primary closure. Factor replacement is costly, requires specialist input, and carries a risk of developing factor VIII (FVIII) inhibitors. This prospective study was performed to determine whether the use of a standardized Floseal and anti-fibrinolytic protocol could reduce postoperative bleeding in patients with IBDs undergoing dental extraction, as compared to factor replacement. All patients >18 years old attending Queensland Haemophilia Centre between November 2014 and July 2019 who required dental extractions were referred to the Oral and Maxillofacial Unit. Patients were consented for intraoperative Floseal administration instead of factor replacement. All other operative measures remained the same. The bleed rate was assessed against a historical control cohort. There were 34 extraction events in 32 patients. Four of the patients reported postoperative bleeding requiring factor supplementation or desmopressin; the bleeding rate was 11.8%. While not statistically significant, this was a reduction in the bleed rate compared to the traditional protocol (P = 0.35). Third molar extractions were 10.33 times more likely to cause postoperative bleeding (P = 0.018). The Floseal protocol was equipotent to the traditional perioperative factor replacement protocol. Floseal use is more economical, eliminates the risk of peri-procedural FVIII inhibitor development, and provides a haemostatic option for patients with very rare factor deficiencies, pre-existing clotting factor inhibitors, and those with anaphylaxis to clotting concentrates.
