Immediate dental rehabilitation in fibula free flaps for malignancy: Is it feasible?

BACKGROUND: Fibula free flap reconstruction has revolutionized maxillofacial reconstruction. While immediate dental rehabilitation with dental implants and teeth has shown benefits, it remains uncommon, especially for patients with malignancy. METHODS: A retrospective cohort study at a single institution explored immediate dental rehabilitation in fibula flaps for patients with malignant disease. Thirteen patients with malignancies that underwent immediate fibula free flap reconstruction with dental implants and dental prosthesis were included with a minimum of 3-month follow-up. RESULTS: Forty eight implants replaced 90 teeth in 13 patients. All implants were integrated at 3 months, with an overall success rate of 87.5%. Two patients experienced delayed (>3 months postoperatively) implant loss due to osteoradionecrosis and infection. Peri-mucositis occurred in three patients which resolved with treatment. Skin paddles were used in 11 patients and radiation therapy was not delayed for any patient. CONCLUSION: With proper patient selection, diagnosis of malignancy and the need for osteocutaneous flap reconstruction does not exclude the ability to place immediate implants and deliver an immediate dental prosthesis in head and neck reconstruction.

A rare incidence of mandibular metastasis of papillary thyroid carcinoma: A case report and review of literature.

Papillary Thyroid Carcinoma (PTC) primarily metastasizes via regional lymphatics making its spread to the oral cavity exceedingly rare. Although this disease remains the most common endocrine malignancy, comprising roughly 85%-90% of all thyroid cancers, its occurrence within the oral cavity happens in less than 1% of oral malignancies. This study identifies a case involving a 77-year-old male with a history of well-differentiated PTC that was initially treated with a total thyroidectomy and adjuvant radioactive iodine. Five years after his initial treatment, surveillance imaging demonstrated a 3 cm expansile mass of the left mandible. An incisional biopsy then confirmed the diagnosis of metastatic PTC. A segmental resection of his mandible was completed with final reconstruction utilizing a fibula free flap. Given the limited number of cases involving metastatic spread of PTC to the oral cavity, a standardized treatment algorithm does not exist. Thus, this case serves to provide a documented report of this rare occurrence and to review literature that may help other clinicians treat patients with this malignancy type. There remains a need for future studies to create risk stratification models for patients with metastatic PTC that consider margin analysis, genetic characteristics, and risk factors to tailor individual treatment plans.

1,25-Dihydroxyvitamin D3 and 20-Hydroxyvitamin D3 Upregulate LAIR-1 and Attenuate Collagen Induced Arthritis.

Vitamin D plays a crucial role in regulation of the immune response. However, treatment of autoimmune diseases with 1,25-dihydroxyvitamin D3 [1,25(OH)2D3] doses sufficient to be effective is prohibitive due to its calcemic and toxic effects. We use the collagen-induced arthritis (CIA) model to analyze the efficacy of the noncalcemic analog of vitamin D, 20S-hydroxyvitamin D3 [20S(OH)D3], as well as 1,25(OH)2D3, to attenuate arthritis and explore a potential mechanism of action. Mice fed a diet deficient in vitamin D developed a more severe arthritis characterized by enhanced secretion of T cell inflammatory cytokines, compared to mice fed a normal diet. The T cell inflammatory cytokines were effectively suppressed, however, by culture of the cells with 20S(OH)D3. Interestingly, one of the consequences of culture with 1,25(OH)2D3 or 20S(OH)D3, was upregulation of the natural inhibitory receptor leukocyte associated immunoglobulin-like receptor-1 (LAIR-1 or CD305). Polyclonal antibodies which activate LAIR-1 were also capable of attenuating arthritis. Moreover, oral therapy with active forms of vitamin D suppressed arthritis in LAIR-1 sufficient DR1 mice, but were ineffective in LAIR-1-/- deficient mice. Taken together, these data show that the effect of vitamin D on inflammation is at least, in part, mediated by LAIR-1 and that non-calcemic 20S(OH)D3 may be a promising therapeutic agent for the treatment of autoimmune diseases such as Rheumatoid Arthritis.

Tracheotomies in COVID-19 Patients: Protocols and Outcomes.

PURPOSE: Approximately 3-15% of COVID-19 patients will require prolonged mechanical ventilation thereby requiring consideration for tracheotomy. Guidelines for tracheotomy in this cohort of patients are therefore required with assessed outcomes of tracheotomies. PATIENTS AND METHODS: A retrospective chart review was performed of COVID-19 patients undergoing tracheotomy. Inclusion criteria were the performance of a tracheotomy in COVID-19 positive patients between March 11 and December 31, 2020. Exclusion criteria were lack of consent, extubation prior to the performance of a tracheotomy, death prior to the performance of the tracheotomy, and COVID-19 patients undergoing tracheotomy who tested negative twice after medical treatment. The primary predictor variable was the performance of a tracheotomy in COVID-19 positive patients and the primary outcome variable was the time to cessation of mechanical ventilation with the institution of supplemental oxygen via trach mask. RESULTS: Seventeen tracheotomies were performed between 4-25 days following intubation (mean = 17 days). Seven patients died between 4 and 16 days (mean = 8.7 days) following tracheotomy and 10 living patients realized cessation of mechanical ventilation from 4 hours to 61 days following tracheotomy (mean = 19.3 days). These patients underwent tracheotomy between 4 and 22 days following intubation (mean = 14 days). The 7 patients who died following tracheotomy underwent the procedure between 7 and 25 days following intubation (mean = 18.2 days). Seven patients underwent tracheotomy on or after 20 days of intubation and 3 survived (43%). Ten patients underwent tracheotomy before 20 days of intubation and 7 patients survived (70%). Significant differences between the mortality groups were detected for age (P = .006), and for P/F ratio at time of consult (P = .047) and the time of tracheotomy (P = .03). CONCLUSIONS: Tracheotomies are safely performed in COVID-19 patients with a standardized protocol. The timing of tracheotomy in COVID-19 patients is based on ventilator parameters, P/F ratio, patient prognosis, patient advanced directives, and family wishes.

Fall-Related Facial Trauma: A Retrospective Review of Fracture Patterns and Medical Comorbidity.

PURPOSE: Medical comorbidities may contribute to falls and thus require identification for education and prevention. We hypothesized that the epidemiology and injuries seen will be similar to the literature, with most falls that result in injury occurring in the elderly, to prominent facial structures, and are associated with specific comorbidities. METHODS: A retrospective review was performed of patients evaluated by the Trauma and Oral and Maxillofacial Surgery services after sustaining traumatic facial injury from July 2015 to June 2016 as a result of a fall. Associations between injury patterns, previous falls, and medical comorbidities were analyzed, and descriptive and bivariate statistics were reported. RESULTS: Of 152 patients included, 53.3% were females with a mean age of 61.2 years. Soft tissue laceration was seen in 59.9% of patients. The 3 most common fracture patterns seen were nasal fracture in 30.9%, orbital fracture in 30.3%, and zygoma fracture in 20.4%. Cardiovascular disease (53.3%) was the most common comorbidity. No major comorbidity was seen in 32.9% of patients. There was a significant association between orbital fracture and neurologic disease (P = .04). Patients with neurologic disease had a significantly longer length of stay (P < .001), and those without any major comorbidities had a significantly shorter length of stay (P = .02). Patients with previous emergency department visits for falls were significantly older (P = .03), had more comorbidities (P = .005), and were more likely to have cardiovascular disease and associated comorbidities (P = .001). CONCLUSIONS: The results are consistent with the literature, with the most fall-related trauma occurring in the elderly with injury to prominent facial structures. The most common comorbidity was cardiovascular disease, which was associated with previous falls. There is a significant association between neurologic disease and orbital fractures. Future studies should focus on recurrent falls after receiving appropriate education to reduce risk based on their specific comorbidities.

Two-stage Reconstruction of the Scalp with Facial AV Loop.

We present the case of a 65-year-old woman with extensive osteoradionecrosis of the scalp and calvaria after external beam radiation therapy for follicular lymphoma. Due to the compromise of her adjacent vasculature including the superficial temporal vessels, she underwent two-stage reconstruction with the creation of an AVL (arteriovenous loop) graft utilizing her great saphenous vein. This was anastomosed to her right facial artery and vein, which was then matured. She underwent resection of the necrotic portions of calvaria and soft tissue of approximately 180 cm2, and a vascularized free latissimus dorsi muscle flap was harvested and anastomosed to her new conduit. This free muscle flap was then covered with a split-thickness skin graft harvested from her thigh. She achieved satisfactory functional and cosmetic results with minimal morbidity and without complication despite her age, multiple co-morbidities, and extensive and complex disease process.

Are Tracheotomies Required for Patients Undergoing Composite Mandibular Resections for Oral Cancer?

PURPOSE: Prophylactic tracheotomy has traditionally been performed during composite mandibular resection of oral cavity cancer to avoid postoperative airway compromise. The purpose of the present study was to measure the frequency and identify the factors associated with an increased or a decreased risk of an adverse airway event (AAE) within 30 days postoperatively. PATIENTS AND METHODS: A retrospective cohort study of patients who had undergone composite mandibular resection for oral cancer from 2006 to 2018 was conducted at the University of Tennessee Medical Center. The primary predictor variable was composite resection with or without immediate flap reconstruction. The primary outcome variable was realization of a 30-day AAE, defined as the requirement for tracheotomy for any reason, emergent endotracheal reintubation at any time during the postoperative admission, or prolonged (>48 hours) postoperative endotracheal intubation. The secondary outcome variable was the inpatient length of stay. Descriptive and bivariate statistics were used to compare the patients with and without an AAE for demographic, confounding, and clinical characteristics. RESULTS: A total of 114 patients were identified through retrospective medical record review. The prevalence of AAEs in the sample was 8.8% (10 of 114). None of the 49 patients without immediate flap reconstruction developed an AAE. Of the 65 patients who had undergone flap reconstruction, 10 (15.4%) developed an AAE. The χ2 analysis revealed a significantly greater rate of AAEs when flap reconstruction was implemented (P < .05). Also, a significantly greater rate of AAEs was found in the group requiring resection of the floor of the mouth with bilateral neck dissections and immediate flap reconstruction compared with all other flap reconstruction groups (P < .05). CONCLUSIONS: A composite resection involving the floor of the mouth with bilateral neck dissection and flap reconstruction should receive strong consideration for prophylactic tracheotomy to avoid an AAE.

Encephaloduroarteriosynangiosis (EDAS) in young patients with cerebrovascular complications of sickle cell disease: Single-institution experience.

Moyamoya syndrome occurs in sickle cell disease (SCD) as a secondary complication of large-artery stenosis. Moyamoya increases the risk of stroke, but its optimal management in SCD is not established. Encephaloduroarteriosynangiosis (EDAS) is a neurosurgical revascularization procedure for moyamoya whose use has been reported in SCD patients. We report the outcomes of 11 patients with SCD systematically evaluated for EDAS by a multidisciplinary team and compare the rate of stroke in patients who received EDAS to those who did not. Moyamoya syndrome was diagnosed by flow abnormalities on magnetic resonance angiography at median age of 8.2 years. Four patients deferred surgery. Seven patients underwent EDAS at median age of 19 years. There were no intraoperative complications, perioperative strokes, or deaths. Transient postoperative complications occurred in six cases (86%). On follow-up, three patients (43%) had no evidence of flow in their EDAS grafts, and one later developed a hemorrhagic stroke. Five EDAS patients (71%) had radiographically stable vasculopathy. Compared to the four patients who deferred surgery, the incidence of stroke in EDAS group was no different. The optimal use of EDAS in patients with SCD-associated moyamoya syndrome requires further investigation by a prospective, controlled clinical trial.

Disseminated Lichtheimia ramosa Infection After Hematopoietic Stem Cell Transplantation in a Child With Chronic Granulomatous Disease.

Mucormycosis is uncommon in patients with chronic granulomatous disease (CGD). We report a 7-year-old boy with X-linked CGD and absent oxidative burst who developed fatal Lichtheimia ramosa infection with fungal thrombosis of the kidneys, spleen and other organs after hematopoietic stem cell transplantation. Lichtheimia infection is rarely reported in patients with CGD and could be related to iatrogenic immunosuppression.