Does Positioning During Oral and Maxillofacial Surgery Operations Influence the Development of Upper Extremity Peripheral Neuropathy?

BACKGROUND: Controversy exists regarding the role of specific etiology and mitigating factors in perioperative upper extremity peripheral neuropathy (PUN) development during oral and maxillofacial surgery (OMS) procedures. PURPOSE: The purpose of this study was to measure the association between upper extremity (UE) positioning and developing PUN in OMS operations. STUDY DESIGN, SETTING, SAMPLE: The investigators implemented a retrospective cohort study. Patients referred to the Department of Oral and Maxillofacial Surgery at Jefferson Health who underwent orthognathic, telegnathic, or free flap surgery from April 2017 through December 2021 were identified. Exclusion criteria were age less than 13, revision surgery, ablative case without free flap reconstruction, incomplete medical record, pre-existing neuropathy, and UE position other than tucked or abducted. PREDICTOR VARIABLE: The predictor variable was UE position during surgery, which had 2 levels-tucked or abducted. MAIN OUTCOME VARIABLE: The outcome variable was self-reported development of PUN, defined as new sensory and/or motor deficit in a nonoperated extremity diagnosed within 48 hours of surgery. COVARIATES: Demographic covariates included age, gender, and race. Perioperative covariates included American Society of Anesthesiologists physical status and body mass index (BMI). The operative covariate was general anesthesia (GA) duration. ANALYSES: Descriptive statistics were calculated. Shapiro-Wilk test was used to assess normality of the sample. Categorical variables were analyzed with Fisher's exact test. Continuous variables were analyzed with Mann-Whitney U test. Significance was defined at P < .05. RESULTS: Of the 432 patients identified, 342 met inclusion criteria. Median (interquartile range) ages for the abducted and tucked cohorts were 40 (31) and 34 (28) years, respectively (P < .01). Males comprised 55.4% (n = 41) and 54.1% (n = 145) of abducted and tucked groups, respectively (P = .9). PUN frequency was 6.8% (n = 5) for abducted subjects and 3.7% (n = 10) for tucked subjects (relative risk 1.8, 95% confidence interval [0.7, 5.1]; P = .33). PUN was associated with gender (P = .01), American Society of Anesthesiologists status (P = .03), BMI (P = .01), and GA duration (P < .01) on bivariate analysis. When adjusting for covariates, only GA duration (P < .01) and BMI (P = .03) were associated with PUN development. CONCLUSION AND RELEVANCE: The findings suggest that PUN development during OMS procedures was not associated with UE position.

Negative pressure wound therapy for complex oral wounds.

Negative pressure wound therapy provides a nonsurgical treatment option for many types of complex wounds. This therapy utilizes the vacuum-assisted closure device, which decreases air pressure, removes fluid that accumulates within the wound, and aids to facilitate changes that promote healing. Despite the increased use of negative pressure wound therapy in the head and neck region, there is substantially less data available on the management of transoral vacuum-assisted wound closure. Herein, we present a case of a novel approach for the creation and use of a transoral wound vac for a patient with a refractory orocutaneous wound in the setting of multiple previous free flaps and surgeries. A watertight seal was able to be maintained and the patient was compliant with treatment, resulting in successful management of the wound. We promote the consideration of this novel technique's use for similar difficult-to-treat oral wounds.

Patient Referral and Acceptance of Maxillomandibular Advancement for Obstructive Sleep Apnea.

OBJECTIVE: Maxillomandibular advancement (MMA) is an effective surgical treatment for obstructive sleep apnea (OSA); however, it is unclear how many patients who are referred for MMA actually undergo surgery. This study aims to determine follow-up rates for patients referred for MMA and the reasons behind their choices. METHODS: Via retrospective review, we assessed consecutive patients with OSA intolerant to continuous positive airway pressure (CPAP) who underwent drug induced sleep endoscopy (DISE) between 2018 and 2020 at our institution. Patients recommended for MMA based on DISE and other findings were included. Patients were then contacted and administered an IRB-approved survey in present time. RESULTS: One hundred and fifty nine patients were referred to oral maxillofacial surgery (OMFS) for MMA consult. Seventy seven patients (48%) followed up with OMFS and 29 (18%) underwent MMA. Sixty two (40%) patients resumed CPAP. Fifty eight patients (36.5%) were lost to follow up. Seventy three patients (46%) completed our survey. Of those patients, 37 (51%) followed up with OMFS and 17 (23%) underwent MMA. Patients who did not follow up with OMFS cited the invasiveness of the surgery (39%), recovery time (17%), or both (31%) as reasons. Those who pursued consultation cited inability to tolerate CPAP (73%), not being a candidate for inspire (14%), and desire to learn about alternative treatments (14%) as reasons. Of those who did not undergo MMA, 28.6% are not using OSA treatment. CONCLUSION: Less than half of patients referred for MMA followed up, and less than half of those patients underwent MMA. Most patients cited concerns about the invasiveness of the surgery and recovery process. LEVEL OF EVIDENCE: 4 Laryngoscope, 2023.

Profound trigeminocardiac reflex from lingual nerve stimulation: a case report.

Trigeminocardiac reflex (TCR) is a well-known brainstem reflex that manifests as hypotension, bradycardia, dysrhythmia, and asystole when stimulation is applied to a branch of the trigeminal nerve. Most commonly associated with ophthalmic, orbital, and neurologic surgeries, mandibular division and oral cavity variants occur far less frequently. Here, we describe a case of asystolic TCR elicited by lingual nerve stimulation. This case highlights the role of specific anesthetic medications in modulating this phenomenon and reinforces the need for early recognition and clear communication in case of its occurrence. Anesthesia providers must consider discontinuing or avoiding certain medications when clinically appropriate, even during low TCR-risk procedures.

Carcinomatous Transformation of Odontogenic Keratocyst and Primary Intraosseous Carcinoma: A Systematic Review and Report of a Case.

PURPOSE: To assess the prognostic findings of the carcinomatous transformation of odontogenic keratocyst (OKC). METHODS: A systematic review of all cases of carcinomatous transformation of OKC was completed, and a case report was included. RESULTS: A total of 679 publications were screened, and 37 cases met inclusion criteria. The mean age for patients with malignant transformation of OKC was 45.1 years. Pain (67.5%) and swelling (78.3%) were the most common symptoms. The malignant transformation occurred with increased frequency in the posterior mandible and larger lesions that span greater than 2 subunits of the involved jaw. Resection was the definitive treatment in all cases and 14 cases (46%) utilized adjuvant treatment. CONCLUSIONS: Patient outcomes and follow-up was variable in our study such that overall survival was difficult to determine. However, overall survival in malignant transformation of odontogenic cysts of all kinds ranges from 62 to 85% and 30 to 8% for 2 and 5 years, respectively.

Controlled Substance Disposal Practices of Oral and Maxillofacial Surgeons.

PURPOSE: The goal of this study was to examine the medication wasting and disposal practices of oral and maxillofacial surgeons (OMSs) who deliver outpatient anesthesia using controlled substances, and to determine what factors, if any, influence those practices. METHODS: The investigators composed an anonymous online survey that was emailed to OMSs currently practicing in the United States. Participants were questioned about their length of practice experience, drug disposal training, specific methods employed for medication disposal, and the use of a witness during the disposal process. Descriptive and bivariate statistics were computed. The P value was set at 0.05. RESULTS: A total of 5,551 surveys were sent, yielding 719 responses (13%) and 656 completed surveys. The most common disposal methods reported were pouring the unused medications into an absorbent (n = 207, 32.4%), pouring into the sink (n = 196, 30.7%), placing into the sharps container (n = 141, 22.1%), and pouring into the trash (n = 32, 5%). Most respondents (n = 543, 84.7%) utilize a witness during the drug inactivation process. There was a statistically significant negative relationship between years of practice experience and receiving formal training in guidelines for the disposal of controlled substances during residency (P < .001). Those OMSs who received formal training regarding drug inactivation were more likely to standardize medication disposal methods (P < .001) and to utilize witnesses during the process (P = .013). OMSs who employed a standard method for drug disposal were more likely to involve witness confirmation during the process (P < .001). CONCLUSIONS: Medication disposal practices vary widely among OMSs who deliver outpatient anesthesia using controlled substances. Formal training in this area is associated with a greater likelihood of maintaining a standardized disposal method that utilizes a witness during drug disposal but is not associated with rendering the medications nonretrievable during the process. Further educational opportunities among OMSs and residents may help to improve compliance with drug disposal regulations.

Sclerotherapy for atypical oral manifestation of Cowden syndrome.

Cowden syndrome is an autosomal dominant disorder characterized by hamartomas, as well as benign and malignant neoplasms that may present in organ systems throughout the body. It also poses an increased lifetime cancer risk in those with the disorder. Its clinical presentation is often variable, and diagnosis can be challenging. In the head and neck region, it can present as thyroid enlargement or mass formation, cutaneous and mucocutaneous lesions of the skin and the oral cavity. The most typical oral manifestations of Cowden syndrome are oral papillomatosis and a cobblestone appearance of the mucosa. We present a case of vascular malformation of the tongue in a patient with Cowden syndrome. This lesion was similar in appearance to a cutaneous hamartoma on the patient's upper extremity. He had received prior surgical intervention for this tongue mass, and complete resection was recommended subsequently. However, in search of a less invasive treatment to minimize impact on speech and oral function, sclerotherapy was performed, resulting in resolution of the lesion. Sclerotherapy is a well-documented treatment for head and neck vascular malformations, but it is not universally employed. In our patient with atypical oral manifestation of Cowden syndrome, bleomycin sclerotherapy was employed, resulting in resolution of the lesion, as well as preservation of speech articulation and oral function.

Orbital hemorrhage and compressive optic neuropathy in patients with midfacial fractures receiving low-molecular weight heparin therapy.

While the implementation of deep vein thrombosis (DVT) prophylaxis in the hospital setting is a major concern, the use of antithrombotic agents is fraught with a variety of hemorrhagic complications. Due to increasing reports of adverse reactions to unfractionated heparin (UFH), several manufacturers have initiated product recalls. As a result, the use of low-molecular weight heparins (LMWHs) such as enoxaparin has risen substantially. In this paper, 2 orbital hemorrhagic complications in patients receiving enoxaparin therapy will be presented. The incidence of DVT in the OMS patient, recent prophylactic strategies, and their effectiveness will be reviewed.