Chronic rhinosinusitis risk after maxillectomy with microvascular reconstruction.

Objectives Chronic rhinosinusitis (CRS) can be associated with tumors involving the maxillary sinus, but outcomes after undergoing maxillectomy with free flap reconstruction remain unclear. Methods A retrospective analysis of medical records was performed to evaluate evidence of CRS in patients who underwent maxillectomy with free flap reconstruction at a single tertiary care academic institution from 2013 through 2020. Results Eighty-four patients were assessed. Nineteen (22.6%) patients were diagnosed with CRS after surgery, 23 (27.4%) patients were treated for sinus symptoms, and 49 (58.3%) had radiographic evidence of sinus inflammation for more than 6 months. Risk factors for requiring sinus treatment included adjuvant or neoadjuvant chemotherapy (p=0.002) and pre-operative use of sinus medication (p<0.001). Radiographic evidence of sinusitis 6 months after surgery is also closely associated with sinusitis treatment (p=0.051). Conclusions CRS may be underdiagnosed in patients undergoing maxillectomy with microvascular reconstruction. Further evaluation into patient sinus disease and symptoms following neoplastic surgery may lead to a higher quality of life in some long-term survivors.

Telehealth Utilization in Oral Medicine and Oral and Maxillofacial Surgery.

Objectives: The objectives of this retrospective study were to analyze telehealth utilization for two specialty care practices: oral medicine (OM) and oral and maxillofacial surgery (OMFS) during the first 2 years of the pandemic, its impact as a new treatment modality and on participating providers, as well as identify the type of patient visit that most readily adopted telehealth. Methods: Retrospective study of patients who sought specialty services, OM and OMFS, at an outpatient clinic in a university health system setting between March 1, 2019, and February 28, 2022. Source data were obtained from Epic, an electronic medical record application. Data were graphed using Tableau and Microsoft Excel software. Statistical analysis was performed utilizing chi-squared test and analysis of variance (ANOVA). Results: OMFS utilized telehealth 12% of the time, and OM 8% of the time. The majority (87%) of telehealth visits were for return patients (RPs). Compared with the first year of the pandemic, there was a decrease in the number of telehealth visits in the second year (p = 0.0001). As of August 2022, new patient (NP) telehealth encounters have largely returned to prepandemic levels (0-1.5%), whereas RP telehealth visits remained at an average level of 11.4% (9.4-12.4%). Surveyed providers consider telehealth as an effective complement to in-person care and will continue its use (4.2/5 Likert scale). Conclusions: Telehealth has become a viable pathway of care for OM and OMFS who previously did not utilize the remote platform to deliver healthcare. As a new treatment modality, telehealth is perceived as impactful in increasing access to specialty care by participating providers. NP visits are now almost completely in person, but telehealth continues for RPs. Ongoing demand for telehealth highlights urgency to develop appropriate standards and effective remote diagnostic/monitoring tools to maximize telehealth's capability to leverage finite health care resources and increase access to specialty care.

Nodal Metastasis in Surgically Treated Oral Cavity Squamous Cell Carcinoma.

INTRODUCTION: Management of the neck in oral cavity squamous cell carcinoma (OCSCC) is essential to oncologic control and survival. The rates of lymph node metastasis (LNM) vary based on oral cavity tumor site and stage and influence treatment decisions. The aim of this paper was to describe clinical LNM for different tumor subsites and stages of surgically managed OCSCC. METHODS: We conducted a retrospective analysis of 25,846 surgically managed OCSCC patients from the National Cancer Database (NCDB) stratified by tumor subsite and clinical T-stage. For cN + patients, rates of pathologic LNM and absence of pathologic LNM were determined. For cN0 patients, outcomes included the rates of elective neck dissection (END) and occult LNM and predictors of occult LNM determined by a multivariable logistic regression model. RESULTS: A total of 25,846 patients (59.1% male, mean age 61.9 years) met inclusion criteria with primary tumor sites including oral tongue (50.8%), floor of mouth (21.2%), lower alveolus (7.6%), buccal mucosa (6.7%), retromolar area (4.9%), upper alveolus (3.6%), hard palate (2.7%), and mucosal lip (2.5%). Among all sites, clinical N+ rates increased with T-stage (8.9% T1, 28.0% T2, 51.6% T3, 52.5% T4); these trends were preserved across subsites. Among patients with cN + disease, the overall rate of concordant positive pathologic LNM was 80.1% and the rate of discordant negative pathologic LNM was 19.6%, which varied based on tumor site and stage. In the overall cohort of cN0 patients, 59.9% received END, and the percentage of patients receiving END increased with higher tumor stage. Occult LNM among those cN0 was found in 25.1% of END cases, with the highest rates in retromolar (28.8%) and oral tongue (27.5%) tumors. Multivariable regression demonstrated significantly increased rates of occult LNM for higher T stage (T2 OR: 2.1 [1.9-2.4]; T3 OR: 3.0 [2.5-3.7]; T4 OR: 2.7 [2.2-3.2]), positive margins (OR: 1.4 [1.2-1.7]), and positive lymphovascular invasion (OR: 5.1 [4.4-5.8]). CONCLUSIONS: Management of the neck in OCSCC should be tailored based on primary tumor factors and considered for early-stage tumors.

Influence of topical corticosteroids on malignant transformation of oral lichen planus.

BACKGROUND: Oral lichen planus (OLP) is considered an oral potentially malignant disorder. While OLP has been associated with the development of oral squamous cell carcinoma (OSCC), little is known about the role of topical corticosteroids therapy (TCT) in the promotion of carcinogenesis. The study aimed to determine if TCT influences the time of malignant transformation of OLP to OSCC. The study also investigates this correlation in the presence or absence of Candida overgrowth, and in the context of conventional OSCC risk factors such as smoking, alcohol use, and male gender. METHODS: A retrospective analysis of electronic health records at a tertiary care academic medical center was performed. Patients with OLP and OSCC were considered for inclusion. The diagnosis of OLP required both clinical and histological documentation. RESULTS: Eighty-two patients met inclusion criteria, consisting of 48 women (58.25%) and 34 men (41.5%) and the mean patient age was 65.9 years (SD = 13.25). Forty-five patients (54.9%) received TCT for OLP before they developed OSCC. The time between the OLP and OSCC diagnoses increased by four years in patients who received topical steroid therapy for OLP (p < 0.001) and decreased by three years (p = 0.010) in those with Candida overgrowth. Gender, smoking, and alcohol use did not have a statistically significant influence on the time between OLP and OSCC. CONCLUSION: The management of OLP using TCT potentially delayed cancer development in our study. Conversely, it appears that Candida may play a role in the field cancerization of OLP patients.

Enlargement of Inferior Alveolar Nerve Canal and Mental Neuropathy Associated With B-Cell Lymphoma: A Case Report and Literature Review.

Enlargement of an inferior alveolar nerve canal (IANC) on radiographic imaging can indicate the presence of a wide variety of pathologic entities. Oral and maxillofacial surgeons have the unique opportunity to regularly examine panoramic radiographs and must exercise proficient clinical judgment when noting abnormal findings on imaging. While malignant processes associated with IANC enlargement are uncommon, these pathologies do occur and may be associated with significant sequelae, especially when accompanied by a delay in diagnosis and in treatment. The purpose of this case report is to describe a case in which a patient presented with mental nerve neuropathy associated with unilateral IANC enlargement on radiography, which was found to be a B-cell lymphoma on biopsy. More importantly, we aim to remind oral and maxillofacial surgeons of this rare presentation of a malignant process so as to promote prompt recognition and referral for appropriate treatment.

Are Bacteria Just Bystanders in the Pathogenesis of Inflammatory Jaw Conditions?

PURPOSE: It is unclear whether certain bacteria initiate the development of inflammatory jaw conditions, or whether these diseases create a milieu for dysbiosis and secondary colonization of indigenous flora. At present, there are no comparative studies on the types of bacteria that colonize different inflammatory jaw conditions. Accordingly, this study aims to identify and compare the types of bacteria isolated in osteomyelitis, osteoradionecrosis, and MRONJ. METHODS: This is a retrospective cohort study of patients diagnosed with inflammatory jaw conditions. The predictor variables were classification of bacteria as oral flora, categorized herein as resident bacteria, non-resident bacteria, or opportunistic organisms. The outcome variables were a diagnosis of osteomyelitis, osteoradionecrosis, and MRONJ. Covariates were age, sex, penicillin allergy, a diagnosis of diabetes and a history of smoking. Data analysis was performed using ANOVA and chi-squared tests. RESULTS: A total of 105 patients with inflammatory jaw conditions were enrolled. The final sample size was 69 subjects of which 16 were diagnosed with osteomyelitis, 20 with osteoradionecrosis, and 33 with MRONJ. There was no difference in the frequency that resident bacteria were isolated. Non-resident bacteria, which included Staphylococcus and Enterococcus among others, were isolated more frequently at 75% in osteomyelitis compared to 60% in osteoradionecrosis and 48% in MRONJ cases. There is weak evidence of significant difference when comparing osteomyelitis and MRONJ cases (P = .08). Opportunistic organisms, which included Mycobacterium and Candida, were isolated more frequently in osteoradionecrosis at 30% compared to 12.5% in osteomyelitis and 12.12% in MRONJ cases. There is weak evidence of significant difference when comparing osteoradionecrosis and MRONJ cases (P = .1). CONCLUSION: Non-resident bacteria including Staphylococcus and Enterococcus may be more frequently isolated in patients with osteomyelitis, while opportunistic organisms like Mycobacterium and Candida may be more frequently found in patients diagnosed with osteoradionecrosis.

Anterolateral thigh osteomyocutaneous flap in head and neck: Lessons learned.

BACKGROUND: Concerns regarding iatrogenic femur fracture may deter adoption of the anterolateral thigh osteomyocutaneous (ALTO) flap as an alternative reconstructive technique for large composite defects of the head and neck. We describe the evolution of our experience with this flap and the lessons learned in femur management. METHODS: Records from a prospective database (July 2009-January 2020) were reviewed to identify patients with composite osseous free tissue reconstructions. Venous thromboembolic events (VTE), femur fracture, estimated blood loss (EBL), procedure time, blood transfusions, and length of stay (days) were compared for ALTO flaps prior to and after the adoption of intramedullary fixation protocol. RESULTS: ALTO represented 10.5% (n = 23) of total osseus (n = 219) flaps. For large composite reconstructions with either ALTO flap, double flap (n = 2), or subscapular mega flaps (n = 14), ALTO flaps were most frequently used (59%, n = 23/59). There were no differences in operative time prior to and after implementation of prophylactic fixation [median (range): 5.4 (1.7-19.2) vs. 5.8 (1.7-15.0), p = .574]. Additionally, there were no differences in VTE, femur fracture, EBL, blood transfusion, or length of stay (p > .05) with adoption of prophylactic intramedullary fixation. CONCLUSIONS: The ALTO flap represents a useful tool to consider in the armamentarium of reconstructive options for large through and through defects of the head and neck. In our experience, the ALTO flap is a reasonable alternative to subscapular or double flap reconstructions and especially in the setting of unusable fibular flaps or when bone need exceeds that available from the scapula.

Comprehensive Oromandibular Reconstruction Utilizing an Anterolateral Thigh Free Tissue Transfer Flap and Tissue Engineering: Technical and Timing Considerations.

The present report describes the technical nuances involved in oromandibular reconstruction utilizing a soft tissue free flap and tissue engineering in a step wise fashion for complete oral rehabilitation.

Role of elective neck dissection and adjuvant radiation therapy in patients with polymorphous adenocarcinoma.

PURPOSE: To evaluate the role of elective neck dissection (END) and of adjuvant radiation (aRT) in polymorphous adenocarcinoma (PAC), previously known as polymorphous low-grade adenocarcinoma (PLGA). METHODS: Retrospective cohort study of patients in the National Cancer Database with a histology of PAC (coded as PLGA) at a head and neck site diagnosed between 2004 and 2015. Multivariable Cox proportional hazard modeling was used to assess overall survival in the overall population, and in sub-analyses of clinically N0 disease, positive resection margins, and late stage disease. RESULTS: A total of 922 patients [66.8% female; mean (SD) age, 60.9 (13.9) years] met inclusion criteria. 74.7% of patients received surgery alone, and 18.0% received surgery and aRT. Only 7.6% of patients with clinically N0 disease received an END, with 10.6% of these having at least one positive node. END did not have a survival benefit compared to no END [HR 1.28 (0.61-2.68)]. Compared to surgery alone, aRT did not have significantly increased survival in the overall population or in late stage [HR 0.68 (0.39-1.19) and HR 0.46 (0.18-1.22), respectively]. On sub-analysis of patients with positive resection margins, aRT had a significant survival benefit compared to surgery alone [HR 0.37 (0.14-0.99)]. CONCLUSION: PAC is a rare, slow-growing malignant tumor typically treated with surgical excision, with undefined indications for END or aRT. Our findings show END to not have a benefit to overall survival. In patients with positive resection margins, there was a survival benefit for aRT.

SMARCB1 (Integrase Interactor 1)-Deficient Sinonasal Carcinoma of the Maxillary Sinus: A Newly Described Sinonasal Neoplasm.

SMARCB1 (integrase interactor 1) is a tumor suppressor gene encoded on chromosome 22q11.2 that encodes a core subunit of SWI/SNF chromatin remodeling complexes and plays a critical role in regulating gene expression and chromatin structure. We describe a case of SMARCB1 (integrase interactor 1)-deficient sinonasal carcinoma of the left maxillary sinus in a 63-year-old woman with an initial presentation of numbness of the maxillary teeth and facial swelling.

Reconstruction of Through-and-Through Composite Segmental Mandibulectomy Defect in a Patient With a Dominant Peroneal Artery Using an Anterior Lateral Thigh Osteomyocutaneous Free Flap: A Case Report and Description of Flap.

The anterior lateral thigh osteomyocutaneous (ALTO) free flap represents a unique reconstructive option for patients who are otherwise not good candidates for traditional free flaps to repair a through-and-through defect of the head and neck. We report the case of a patient with squamous cell carcinoma of the oral cavity who had undergone composite segmental mandibulectomy with a resultant through-and-through defect. The patient was not a candidate for fibula free flap (FFF) reconstruction owing to the presence of bilaterally dominant peroneal arteries. The patient underwent reconstruction with a single free tissue ALTO flap, with a good viable flap postoperatively. The patient did not experience any major or minor surgical complications and has been living with no evidence of disease. The ALTO free flap could be an effective flap in the reconstruction of through-and-through defects of the mandible for patients who are not candidates for FFF-based reconstruction.

Pectoralis major muscle flap use in a modern head and neck free flap practice.

PURPOSE: Pectoralis major muscle flaps (PMMF) are a commonly used reconstructive modality to repair head and neck defects. As the use of free flap reconstruction is increasingly practiced in the head and neck, the role of the PMMF may be changing as well. This study sought to analyze indications and outcomes for PMMF following head and neck resections from one surgeon's experience. MATERIALS AND METHODS: Retrospective review from December 1, 2013 through September 30, 2017 at a tertiary care academic medical center. Indications for the PMMF were examined as well as surgical outcomes. Basic demographic data, patient head and neck cancer history, history of radiation and/or chemotherapy, and history of previous reconstructive procedures were obtained and compared across all subjects. RESULTS: Forty patients underwent a PMMF within the designated time frame. The majority of patients were male (83%) and the average age was 65 years (range 55.4-74.6 years). Of the 40 cases, 9 of the PMMFs were performed as primary reconstruction of the defect. In the remaining 31 cases, these flaps were utilized as a secondary reconstructive option following fistula formation (13), dehiscence (6), need for an additional flap for recurrent disease (6) infection (4), or major bleeding (2). In every case that it was utilized, the PMMF was the definitive reconstruction. Within the same time frame, 429 free flaps were performed by the same surgeon, with an average of 125 free flaps performed yearly. The rate of total flap failure overall was 3.9%. The other failed free flap reconstructive options used besides a PMMF were secondary free flaps (11), local wound care (4), or obturator placement (2). The secondary pectoralis flaps occurred following 7.2% of free flaps with total or partial failure that were performed within the same time range. The indications for the PMMF did not change or evolve during the time frame of the study. CONCLUSIONS: Although free flaps were performed with far greater frequency than PMMFs at our institution, the PMMF demonstrated continued utility as a secondary reconstructive option. For a surgeon who performs a high volume of free flaps, preservation of the pectoralis muscle and associated vasculature for possible later secondary reconstruction should be considered due to its strong efficacy.

Trainee Contribution Is Not Associated With Citation Frequency: A Retrospective Study.

PURPOSE: Publication citation frequency is a measure of scientific influence. The purpose of this study was to measure the association between trainee involvement in publications and citation frequency. MATERIALS AND METHODS: A retrospective cohort study of the Journal of Oral and Maxillofacial Surgery from January to December 2010 was conducted. For each included publication, the study topic and design were recorded. The primary predictor variable was trainee involvement (yes or no). For the purpose of our study, the term "trainee" encompassed dental students, graduate (non-dental) students, oral and maxillofacial surgery residents, and non-oral and maxillofacial surgery residents, as indicated by author affiliations listed in each article. The outcome variable was the number of citations accumulated between 2010 and 2017. Descriptive statistics were computed. Analyses of variance were performed to compare citation distribution among study types and designs. Student t tests and χ2 tests were performed. RESULTS: The sample consisted of 111 publications, of which 85 (76.6%) had at least 1 trainee author. Among all publications, the mean number of citations was significantly different across study designs (P = .03), with case reports earning the lowest number of citations on average (mean, 14.9 citations). Trainee publications had significantly different distributions of study topics (P = .02) and designs (P < .01). Among publications with a trainee author, the most common topic was pathology (37%) and the most common study design was a case report (45%). Despite the higher proportion of case reports, the mean number of citations between trainee (mean, 30.4 citations) and non-trainee (mean, 30.5 citations) publications was not significantly different (P = .99). CONCLUSIONS: Including trainees does not alter the citation frequency of the articles published in the Journal of Oral and Maxillofacial Surgery. This finding is encouraging to both academic surgeons and their trainees, as a higher volume of students and residents can be engaged in research while preserving the influence of the published works.

A 15-Year Review of Trainee Contributions to the Journal of Oral and Maxillofacial Surgery.

PURPOSE: The purpose of this study was to quantify trainee contributions to the Journal of Oral and Maxillofacial Surgery (JOMS). MATERIALS AND METHODS: This was retrospective cohort study of research articles published in the JOMS from 2002 to 2016. Predictor variables were the presence and type of trainee author. Outcomes were study topic and design. Comparisons were performed using χ2 tests. To quantify trainee contributions, the 1) number and 2) proportion of articles with a trainee author and 3) the proportion of trainee authors per publication were calculated. The association between time and the number and proportion of trainee articles was determined using simple correlations. The association between time and percentage of trainee authors per publication was determined using analysis of variance. RESULTS: Of the 1,455 articles included in this study, 72.0% had at least 1 trainee author and trainees composed 27.6% of all authorships. The number and proportion of trainee articles slowly increased with time, and there was a strong correlation between percentage of trainee articles and publication year (r = 0.86; P < .01). Compared with articles without a trainee, a larger proportion of trainee articles were on orthognathic procedures (P < .01). Trainee articles also had a larger proportion of case reports and series (P = .03) and retrospective cohort studies (P < .01) and a smaller proportion of prospective cohort studies (P = .02), literature reviews and meta-analysis (P < .01), and randomized controlled trials (P = .02). CONCLUSIONS: Trainee authors contributed to most JOMS articles, and an increasing percentage of articles included trainee authors. Efforts should be made to include trainees in studies with higher levels of evidence.

Anatomical Variations of the Superficial Radial Nerve Encountered during Radial Forearm Free Flap Elevation.

A frequently encountered anatomical structure in the elevation of a radial forearm free flap is the superficial branch of the radial nerve. This structure has a relatively consistent anatomic location, but variations do occur. We present a case where the superficial branch of the radial nerve was in an usual position but remained superficial to the brachioradialis throughout its course. Two previous reports also describe the superficial branch of the radial nerve remaining superficial to the brachioradialis, although, in these reports, the nerve was more medial than is typical. We postulate that one of the most common anatomic variations of the superficial branch of the radial nerve is for it to remain superficial to the brachioradialis. As this variation could potentially be confused with the medial or lateral antebrachial cutaneous nerves, it is important for the reconstructive surgeon to be aware of this to prevent inadvertent injury.

Mesenchymal Stromal Cell-Derived Interleukin-6 Promotes Epithelial-Mesenchymal Transition and Acquisition of Epithelial Stem-Like Cell Properties in Ameloblastoma Epithelial Cells.

Epithelial-mesenchymal transition (EMT), a biological process associated with cancer stem-like or cancer-initiating cell formation, contributes to the invasiveness, metastasis, drug resistance, and recurrence of the malignant tumors; it remains to be determined whether similar processes contribute to the pathogenesis and progression of ameloblastoma (AM), a benign but locally invasive odontogenic neoplasm. Here, we demonstrated that EMT- and stem cell-related genes were expressed in the epithelial islands of the most common histologic variant subtype, the follicular AM. Our results revealed elevated interleukin (IL)-6 signals that were differentially expressed in the stromal compartment of the follicular AM. To explore the stromal effect on tumor pathogenesis, we isolated and characterized both mesenchymal stromal cells (AM-MSCs) and epithelial cells (AM-EpiCs) from follicular AM and demonstrated that, in in vitro culture, AM-MSCs secreted a significantly higher level of IL-6 as compared to the counterpart AM-EpiCs. Furthermore, both in vitro and in vivo studies revealed that exogenous and AM-MSC-derived IL-6 induced the expression of EMT- and stem cell-related genes in AM-EpiCs, whereas such effects were significantly abrogated either by a specific inhibitor of STAT3 or ERK1/2, or by knockdown of Slug gene expression. These findings suggest that AM-MSC-derived IL-6 promotes tumor-stem like cell formation by inducing EMT process in AM-EpiCs through STAT3 and ERK1/2-mediated signaling pathways, implying a role in the etiology and progression of the benign but locally invasive neoplasm. Stem Cells 2017;35:2083-2094.

A Case of a Methicillin-Resistant Staphylococcus Aureus Retropharyngeal Abscess With Mediastinal Extension in an 11-Month-Old Girl.

We present the case of an 11-month-old girl with Mycoplasma pneumoniae-associated pneumonia who was subsequently diagnosed with a methicillin-resistant Staphylococcus aureus retropharyngeal abscess with mediastinal extension.