Is Maxillofacial Gunshot Wound Location Associated With Operative Intervention?

PURPOSE: Gunshot wound (GSW) injuries are an important public health concern in the United States. The study purpose was to measure the association between GSW location and need for operative treatment. METHODS: This was a retrospective cohort study. Sample consisted of all patients treated for maxillofacial gunshot wound injuries at Cook County Health from 2008 to 2018. The sample data were collected through a retrospective charts review and review of computed tomography imaging. The predictor variable was the region of the face involved with the GSW and it was divided into 3 levels, upper face (UF), middle face (MF), and lower face (LF). The outcome variable was whether operative intervention was rendered or not (operative vs no intervention). Other variables of interest collected included patient demographics, the type of surgical intervention, disposition (home vs rehab/morgue), rate of intracranial injury, and need for blood transfusion. Data analysis was performed using Chi-square for proportions and relative risk (RR) with 95% confidence interval (CI). RESULTS: A total of 180 patients were identified to have sustained GSW injuries to the face during abovementioned time frame. Of those, 120 patients had isolated GSW injuries with no other organs involvement. The median age was 25 years. Majority of the patients were males (94%). The involved facial region appeared to influence the need for operative management and this reached statistical significance (Chi-square 22.703, P < .001). GSW injuries to LF were 2.94 times more likely to require operative intervention than injuries to the MF (RR = 2.94, 95% CI = 1.625-5.327). Injuries of the UF were 2 times more likely to require operative intervention than injuries of the MF (RR = 2.03, 95% CI 1.023-4.008). Injuries to the UF were more likely to be associated with intracranial injuries (Chi-square = 20.522, P < .001). CONCLUSIONS: In patients with facial GSW injuries, there is an association between injury location and the need for operative intervention. Injuries to the LF were most likely to require surgical intervention followed by the UF and MF, respectively.

Is Head and Neck Free Flap Reconstruction Feasible in Jehovah's Witness Patients?

BACKGROUND: Jehovah's Witnesses (JW) population are members of a religious group that refuses blood transfusion. This presents a dilemma for surgical teams when performing major surgical procedures on these patients. PURPOSE: This study aimed to assess the safety and feasibility of undergoing microvascular free flaps for maxillofacial reconstruction in JW patients and whether the type of underlying pathology impacts outcomes. STUDY DESIGN, SETTING, AND SAMPLE: This was a multi-institutional retrospective cohort study. The sample consisted of all JW patients who have undergone microvascular free tissue transfer for maxillofacial pathology between January 2016 and January 2021. PREDICTOR VARIABLE: The primary predictor variable was the underlying pathology for which patients underwent head and neck free flap reconstruction; this was benign versus malignant disease. MAIN OUTCOME VARIABLES: The primary outcome variables were safety, defined as discharge from the hospital with no mortality, and feasibility defined as successful free flap reconstruction. COVARIATES: Other variables included age, race, sex, length of surgery, length of hospital stay, and intraoperative use of vasopressors. ANALYSIS: Data analysis was performed utilizing t-tests for means and χ2 for proportions. Alpha was set at < 0.05. RESULTS: A total of 12 participants from 7 participating sites met the inclusion criteria. There were 9 males and 3 females with a mean age of 58.3 ± 8.3 years. There were no deaths in this cohort and all patients were discharged from the hospital. All 12 free flap reconstructions were successful with no incidents of free flap loss; none of the patients received any blood transfusions or any other blood products. Subgroup analysis showed that patients treated for malignant disease versus benign disease had longer operations (11.2 ± 2.9 vs 6.3 ± 0.2 hours, P < .01) and a longer hospital length of stay (11.8 ± 4.9 vs 5.3 ± 0.5 days, P = .04). CONCLUSION AND RELEVANCE: Our series supports the safety and feasibility of maxillofacial free flap reconstruction in this challenging subset of patients. Microvascular reconstructive surgeries for malignant diseases often result in longer operative times and hospital stays.

Detection of partial and/or complete Y chromosome microdeletions of azoospermia factor a (AZFa) sub-region in infertile Iraqi patients with azoospermia and severe oligozoospermia.

BACKGROUND: This study aimed to analyze the incidence of azoospermia factor a (AZFa) microdeletions in the Y chromosome and their association with male infertility in a population with azoospermia and severe oligozoospermia from Iraq. METHODS: A total of 75 infertile Iraqi males and 25 healthy controls were included in this study. The semen analysis was performed to determine the azoospermia, severe oligozoospermia, or normal cases. The AZFa microdeletions were investigated using the real-time polymerase chain reaction (real-time PCR). Then, AZFa sub-region deletions were investigated by a conventional PCR. RESULTS: In total, 40 men with azoospermia and 35 men with severe oligozoospermia were selected. Out of 75 infertile males, 46 (61.3%) individuals had AZFa microdeletions, of whom 32 (69.6%) had partial deletion, while 14 (30.4%) males had complete deletion using real-time PCR. The frequency of microdeletions was significantly different between the infertile and control group (p-value < 0.00001). The proportion of AZFa microdeletions appeared higher in azoospermia men (72.5%, n = 29/40) than severe oligozoospermia men (48.6%, n = 17/35), but based on the conventional PCR results, only one azoospermia patient (2.2%) was shown to have complete AZFa deletion, while the other 45 patients (97.8%) had partial AZFa deletions. CONCLUSION: In this study, the partial AZFa microdeletions were more numerous than complete AZFa deletion. According to our results, the AZFa microdeletions might be associated with male infertility and spermatogenic failure. It is recommended to investigate the AZFa sub-region microdeletions in patients that shown AZFa microdeletions in primary screening.

The Predictive Hole Technique: A Technical Note.

We describe a novel technique in which predictive holes, normally unique to patient-specific plates, may be utilized with off the shelf stock plates. This allows for the numerous benefits of predictive holes in mandibular reconstruction while negating the added cost of a custom milled plate. Three case examples are presented for technique illustration.

Fibula Jaw in a Day: State of the Art in Maxillofacial Reconstruction.

Microvascular free tissue transfer has been one of the greatest milestones in reconstruction of the mandible and maxilla after tumor ablative surgery. Although fibula free flap reconstruction allows for immediate bony reconstruction, dental rehabilitation usually requires 6 to 12 months before it is completed. This can have a serious psychological impact on patients because they go without teeth during this timeframe. The "jaw-in-a-day" procedure was previously described by a group at New York University Medical Center. It allowed for tumor removal and full jaw reconstruction and dental rehabilitation in 1 surgery. This report describes 3 patients treated with this novel technique and adds to the 4 cases previously reported in the literature. To their knowledge, the authors are the second group to report on this technique. A series of photographs and videos are referenced in this article to illustrate the different steps used in this procedure.

Multiple primary squamous cell carcinomas of the oral cavity.

PURPOSE: There is a subset of patients who develop multiple primary squamous cell carcinomas (SCCs) of the oral cavity. The aim of this study was to better characterize this group of patients and determine whether there are any associated risk factors. MATERIALS AND METHODS: This is a retrospective review of all patients treated for oral SCCs at the University of Maryland Department of Oral and Maxillofacial Surgery from November 1989 to February 2013. The inclusion criteria were patients who developed at least 3 primary oral cancers. Lesions were considered separate primaries if they involved different anatomic regions within the oral cavity and were more than 2 cm apart or if they occurred more than 5 years apart. RESULTS: Of 1,478 patients treated during this time frame, 20 met the inclusion criteria. There were 14 women and 6 men (female-to-male ratio, 2.3:1). Nineteen were Caucasian and 1 was of Indian ethnicity. The average number of primaries per patient was 3.9 (range, 3 to 6 primaries). The mean age at first diagnosis was 63.3 years (44 to 86 yr). The mean interval between the different primaries was 32 months (0 to 228 months). The most common site involved was the gingiva (45% of cases), followed by the tongue, buccal mucosa, retromolar fossa, and soft or hard palate. The mean follow-up was 118 months (22 to 342 months). Eleven patients developed nodal disease. Of those 11 patients, 9 died of the disease (<20% survival). The average time to neck involvement was 66.4 months. The average time from last neck involvement to death was 11.5 months. More than half the patients were nonsmokers or had quit more than 10 years before the first diagnosis. All patients quit smoking during the course of their treatment yet continued to develop multiple primaries. Three patients had proliferative verrucous leukoplakia (PVL), and 4 patients had biopsy-proved lichen planus. CONCLUSION: The incidence of multiple primary SCCs within the oral cavity appears to more commonly involve Caucasian women without risk factors, although lichen planus and PVL might play a role. The gingiva appears to be the most commonly involved primary site, and subsequent primaries tend to be restricted to the oral cavity. Close observation and early expectant treatment appear to improve prognosis and survival in these patients. Cervical nodal metastases adversely affected survival (P = .02) as did the development of more than 4 primary carcinomas (P = .04).

Osteo-cutaneous microvascular free-flaps are a viable option for reconstructing the temporomandibular joint.

Background: There are multiple reconstructive options after mandibular resection and disarticulation of the condyle. The purpose of this study was to assess the clinical outcomes and functionality of osteocutaneous free flaps in the reconstruction of mandibular defects that involve the Temporo-Mandibular Joint (TMJ). Methods: Our study is a retrospective cohort study involving subjects who underwent mandibular resection and needed TMJ reconstruction with vascularized bony-free flaps from February 2016 to June 2018. Data gathered included patient demographics, post-operative function, maximum interincisal opening (MIO), occlusion status, deviation on opening, and TMJ symptoms. Data points collected from postoperative CT imaging included the following: position of the flap in relation to the glenoid fossa and articular eminence, and closest point of contact. Results: Eight out of the nine patients who underwent free flap reconstruction of mandibular defects involving the TMJ qualified for the study. The mean age was 39.7 years old. In all 8 cases, virtual surgical planning (VSP) was used. The mean follow-up time was 18.75 months. The flap success rate was 100%. The mean MIO was 37.37 mm. Six patients resumed their premorbid diet, and one patient developed dysphagia and was peg tube dependent. In seven cases the occlusion was intact and reproducible, one case was without sufficient teeth for occlusion. On imaging, the mean distance from the neo-condyle to the glenoid fossa was 14 mm and to the articular eminence 8.68 mm. The point of closest contact in all cases appeared to be the articular eminence. Conclusion: Vascularized Osteocutaneous-flaps such as FFFs and DCIA flaps provide a good option for the reconstruction of mandibular defects that involve the TMJ. Ipsilateral deviation on opening does not negatively affect clinical outcomes or function. Placing patients in Maxillomandibular fixation for 4-6 weeks may help to prevent condylar sag and provide stable post-operative occlusion.

Treatment challenges of persistent ghost cell odontogenic carcinoma: a case report and literature review.

The aim of this case report is to review and compare the clinical, radiologic, histopathologic, and immunohistochemical features, along with the treatment of a case of ghost cell odontogenic carcinoma. In addition, a report of the existing published literature with an emphasis on treatment will be described to provide information on this rare but aggressive tumor. The family of odontogenic ghost cell tumors comprises a spectrum of lesions characterized by odontogenic epithelium with ghost cell keratinization and calcifications. It appears that early detection is vital in proper treatment due to the high possibility of malignant transformation.

Otologic complications of temporomandibular joint arthrocentesis due to arteriovenous fistula.

Arteriovenous fistula (AVF) is a rare sequela following arthrocentesis of the temporomandibular joint. This case report discusses a constellation of symptoms, findings, and appropriate management of a patient with a superficial temporal AVF. Several findings in this case, including vertigo, nystagmus, and hearing loss, have not been previously documented in the literature.

Management of Human and Animal Bites.

Dogs are the animal most frequently implicated in causing bite injuries to the human face. Dog bite injuries are most prevalent in younger patients. Pasteurella species are commensals of the oral microbiome of dogs and cats and are frequently implicated in infections resulting from dog and cat bite injuries. HIV, hepatitis B, and hepatitis C need to be considered in bites inflicted by humans. All animal bite wounds should be washed out. Most animal bite injuries can be managed in an outpatient setting. Given the cosmetically sensitive nature of the face, bite wounds generally merit suturing, even in delayed presentations.

Vascularized Free Tissue Transfer in a Patient with Hemophilia B: Case Report and Literature Review.

Hemophilia is a blood disorder characterized by impairment of the coagulation cascade leading to an increased bleeding risk (Kauffman, 2014). As such, surgical management of these patients can become difficult and well-defined surgical guidelines are not yet in place (Assoumane et al., 2017). Close monitoring of perioperative factor levels may be even more crucial for those undergoing microvascular free tissue transfer. This is because either a hypercoagulable or hypocoagulable bleeding state has the potential to further increase the risk of vascular compromise to the flap. We report a successful case of mandibular reconstruction using a free fibular flap in a patient with severe hemophilia B and the protocols we used, as well as a review of the literature of similar cases. In the literature, we identified 6 cases of microvascular free tissue transfer in patients with hemophilia; two of these cases had complications which were both related to excess bleeding. It is crucial that these cases be managed in a multidisciplinary fashion in close consultation with a hematologist. The role of venothromboembolism (VTE) prophylaxis in the hemophilic patient undergoing free tissue transfer is discussed.

Mammary Analogue Secretory Carcinoma of the Palate: Case Report and Review of the Literature.

Mammary analogue secretory carcinoma (MASC) is a recently described salivary gland tumor, with a limited number of published reports. Less than three hundred cases have been reported in the literature and only 18 of these cases have been reported in minor palatal salivary glands, though publication bias is likely a factor. We present a case of a 57-year-old male who was diagnosed with MASC tumor presenting in a minor salivary gland and briefly review the current literature. MASC has a variety of histological features and different range of clinical behaviors. The histopathological diagnosis of MASC can be difficult, and the immunohistochemical profile of MASC is still being updated. The gold standard for MASC diagnosis is cytogenetics, with the majority having a translocation t(12;15)(p133;q25). Presently, there is no conclusive evidence that MASC should be treated differently than any other low-grade malignant salivary gland tumors, though high-grade transformation has been described.

Reconstruction for Complex Oromandibular Facial Defects: The Fibula Free Flap and Pectoralis Major Flap Combination.

BACKGROUND: Extensive through-and-through oromandibular defects after advanced oral carcinoma excision pose a reconstructive challenge for the head and neck surgeon. These complex oromandibular wounds often involve the mandible, oral and/or aerodigestive mucosa, and the external skin. As a result, these defects are often not amenable to reconstruction with a single flap due to the volume of soft tissue needed and the three-dimensional reconstructive requirement. The use of two free flaps has often been suggested to overcome this reconstructive challenge. A simpler and less technically demanding way to deal with this may involve the use of a free flap in combination with a pedicled regional flap. We present our experience of the use of a simultaneous microvascular fibula free flap (FFF) with a pectoralis major myocutaneous flap (PMMC) for addressing these defects. METHODS: A retrospective chart review was performed of patients treated with a FFF and PMMC combination for the reconstruction of oromandibular defects at the University of Mississippi Medical Center (Jackson, MS) between October 2013 and February 2016. A minimum follow-up of 12 months was required. Data collected included the extent and location of tumor involvement, size of the postablative defect, tumor histology, clinical and pathological staging, length of follow-up, functional outcomes, and associated complications. RESULTS: A total of three patients were identified to have been treated with the above technique. Defects repaired involved through-and-through mandibular defects with associated oral mucosa and external skin defects. In all cases, the FFF was used for restoring bony continuity with the skin paddle used to reconstruct the intraoral lining. The PMMC was used for reconstruction of the external skin defect and for providing soft tissue bulk. The average size of the fibula skin paddle used for intraoral reconstruction was 7.7 cm × 11.7 cm. The average size of the PMMC paddle was 7.3 × 9 cm. The mean follow-up was 21.7 months. Both the FFF and PMMC survived in all cases, although postoperative wound healing complications occurred in two of the three patients. There was one partial flap loss. Two patients regained good oral intake while one patient tolerated oral intake but was PEG tube-dependent. CONCLUSIONS: The combination of pectoralis major myocutaneous flap and a vascularized free fibular flap is a viable option for the reconstruction of complex through-and-through oromandibular defects. This technique may be useful when a single microvascular free flap is not sufficient for reconstruction of such defects.

Bone Margin Analysis for Osteonecrosis and Osteomyelitis of the Jaws.

Bone margin analysis in cases of osteomyelitis, osteoradionecrosis, and medication-related osteonecrosis of the jaw is a controversial topic. There is little evidence to guide treatment and the interpretation of bone margin results. This article examines the significance of margin status and any possible effect on progression of the disease process. A review of various treatment adjuncts used for intraoperative margin analysis during removal of affected tissue is provided. Literature on the role of imaging is also discussed with regards to treatment planning for surgical resection. The histology of the three separate entities including the approach to surgical and pathologic evaluation of margins is also discussed.

Pediatric Head and Neck Malignancies.

Head and neck malignancies are rare in pediatric patients, and represent 12% of all pediatric malignancies. The incidence for these head and neck tumors is 1.49 cases per 1,000,000 person-years. Among the most common pediatric head and neck malignancies are lymphomas (27%), neural tumors including primitive neurectodermal tumors (23%), thyroid malignancies (21%), soft tissue sarcomas including rhabdomyosarcoma (12%), nasopharyngeal carcinoma, skeletal and odontogenic malignancies including osteosarcoma, Ewing sarcoma, and ameloblastic carcinoma. This article presents an overview of pediatric head and neck malignancies with emphasis on diagnosis and management.

Denosumab Related Osteonecrosis of the Jaw with Spontaneous Necrosis of the Soft Palate: Report of a Life Threatening Case.

Bisphosphonates have been used for years in the treatment of patients with distant bony metastasis and in the prevention of osteoporosis. One of main side effects of these medications is the development of bisphosphonate related osteonecrosis of the jaw (BRONJ) in a small subset of patients. A new class of medications with a shorter half-life, known as receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitors, was introduced with the hopes of avoiding this side effect. However, reports of osteonecrosis of the jaw after the use of RANKL inhibitors have also been documented. We report on a patient who developed a life threatening osteonecrosis of the jaw with sepsis shortly after switching from a bisphosphonate to a RANKL inhibitor for osteoporosis treatment. This patient developed several soft tissue defects including spontaneous necrosis of the soft palate. To our knowledge this is the first time this presentation has been described.

Adenoid cystic carcinoma of the minor salivary glands: a retrospective series of 29 cases and review of the literature.

OBJECTIVE: Approximately 78% of minor salivary gland tumors are malignant, of which adenoid cystic carcinoma (ACC) represents 15% in our series. ACC is an uncommon tumor characterized by slow growth and a high potential for recurrence. This series of 29 consecutive patients examines clincopathologic features, management, and survival outcomes. MATERIALS AND METHODS: This study is a retrospective chart review of 29 patients with ACC of the minor salivary glands in a period of 23 years (1989 and 2012). RESULTS: The mean age was 61.2 years (16-89 years), with no gender predilection. The majority occurred in the palate/maxilla (66%) and initial presentation was stage IV. Mean follow-up was 42.6 months. Recurrence rate was 10% local, 14% distant over the observation period. CONCLUSIONS: The palate/maxilla is the preferred location for occurrence, and initial presentation at stage IV is common. Postoperative radiation remains a common strategy to prevent local recurrence in lesions with adverse features.

Mandibular Brown Tumor of Secondary Hyperparathyroidism Requiring Extensive Resection: A Forgotten Entity in the Developed World?

Brown tumor of hyperparathyroidism (BTHPT) is rare in the United States and not frequently seen in clinical practice. This is likely because early diagnosis and prompt treatment of this disease process prevent the progression and development of BTHPT. Conversely, BTHPT is more common in underdeveloped countries where fewer patients have access to health care and hyperparathyroidism (HPT) goes untreated. It has been reported that the incidence of BTHPT in underdeveloped countries can be as high as 58 to 69 percent in patients with primary HPT. We present a case report of a patient in the United States with a large mandibular BTHPT requiring an extensive resection in the setting of secondary HPT. Despite being rare in this country, it is important for nephrologists, primary care physicians, and oral health care providers to be able to recognize this entity, so that intervention may be rendered early.