Preoperative underweight is associated with adverse postoperative events in patients undergoing microvascular reconstruction surgery for oral and maxillofacial cancer

We aimed to describe the prevalence of postoperative complications and evaluate its relationship with underweight, obesity, preoperative nutritional status, and systemic inflammation status in patients undergoing microvascular reconstruction for oral and maxillofacial cancer. Patients who were ≥20 years old and underwent microvascular reconstruction surgery between January 2009 to June 2019 were investigated. Patient demographics including body mass index, prognostic nutritional status, and neutrophil-lymphocyte ratio were collected. Logistic regression analysis was applied to evaluate these impacts on postoperative complications. A postoperative complication was defined as a Clavien–Dindo classification more than or equal to II. Of the 145 patients included in the analysis, 83 patients (57.2%) experienced postoperative complications, belonging to a Clavien–Dindo classification Ⅱ (n = 71), Ⅲb (n = 11), and Ⅳa (n = 1). Multiple logistic regression revealed that a body mass index less than 18.5 kg/m² (odds ratio 6.19, 95% confidential interval 1.34–28.6, P = 0.02) was related to postoperative complications. Another multiple logistic regression model including all explanatory factors found that underweight (P = 0.03) was related to postoperative complications. This retrospective study showed that preoperative underweight was associated with postoperative complications as evaluated by the Clavien–Dindo classification.     

First bite syndrome after parotidectomy: a single-centre experience

The aim of this study was to investigate the prevalence of first bite syndrome (FBS) among post-parotidectomy patients and to analyse the risk factors for its occurrence. The study involved 111 adult patients operated for benign parotid tumours. After surgery, the participants were asked to assess the presence of food-related pain and the nature of the pain. Participants also answered questions on complications after parotidectomy. FBS was found in seven patients (6.3%). Sex (P = 0.036) and age (P = 0.002) differed significantly between patients with and without FBS. Female patients were found to be at higher risk of FBS, and the lower the patient’s age, the more likely FBS was to occur after surgery. Tumour location (P = 0.002) and the occurrence of disturbing symptoms before surgery (P = 0.009) had a statistically significant effect on the occurrence of FBS. A tendency towards significance for paresis of cranial nerve VII after surgery (P = 0.051) was found; this complication was more frequent in the FBS patients. FBS is a rare pain syndrome that can occur after parotidectomy and should be distinguished from postoperative pain. Proper diagnosis and implementation of the appropriate treatment can significantly improve patient quality of life.     

Lateral wall orbital decompression in Graves’ orbitopathy

Orbital decompression can be carried out, for rehabilitative reasons, using various techniques, but a general consensus on the ideal surgical approach has not been reached. Postoperative diplopia is the most common side effect of decompression surgery. The authors report 39 patients (72 orbits) who underwent lateral wall orbital decompression. Mean preoperative and postoperative Hertel exophthalmometry were 22.8 ± 2.2 mm (mean ± SD; range 16–26 mm) and 18.2 ± 2.1 mm (range 15–22 mm), respectively. Mean proptosis reduction was 4.5 ± 1.9 mm. A new appearance of diplopia postoperatively in the extreme gaze direction was observed in three patients (8%). The complication rate in this series was low, making the procedure safe and well tolerated. In the authors’ opinion, when a single-wall approach is feasible, lateral wall decompression should be the first choice because of its effectiveness in terms of proptosis reduction and safeness in terms of postoperative diplopia.     

Perioperative evaluation of glycaemic status in neck dissection: a retrospective analysis at a single hospital centre

Diabetes mellitus is generally considered a risk factor for impaired wound healing. This study aimed to evaluate the glycaemic status of patients undergoing neck dissection and describe its impact on postoperative outcomes, especially wound healing. A retrospective analysis was performed of the preoperative, intraoperative, and postoperative glycaemic data obtained from the medical charts of 60 adult patients who had undergone 64 neck dissections. Nine of the 64 procedures were performed in diabetic patients (14.1%). The average glucose values were: preoperative 5.99 ± 1.25 mmol/l, intraoperative 8.90 ± 2.62 mmol/l, and postoperative 10.01 ± 2.49 mmol/l. All registered preoperative hyperglycaemia cases (eight cases) were diabetic. Postoperative insulin therapy was done in 14 procedures (21.9%). Wound healing complications were found in five patients (7.8%); there was no wound infection. There was no association of wound healing complications with preoperative diabetic status (P = 1.000), preoperative glucose control (P = 1.000), preoperative (P = 0.469), intraoperative (P = 0.248), and postoperative (P = 0.158) glucose values, or with postoperative glucose control (P = 0.577). These data do not support the association of stress-induced hyperglycaemia or diabetes mellitus with postoperative wound healing problems in neck dissection.     

Airway changes and prevalence of obstructive sleep apnoea after bimaxillary orthognathic surgery with large mandibular setback

This study used three-dimensional computed tomography and polysomnography to evaluate the effect of a large mandibular setback on the postoperative pharyngeal airway space and obstructive sleep apnoea (OSA). Twelve patients who underwent bimaxillary surgery for a mandibular setback movement of >9 mm were included in this study. Changes in the pharyngeal airway space and polysomnography parameters based on the surgical movements were analyzed. The median mandibular setback movement was 11.08 mm. The total pharyngeal, oropharyngeal, and hypopharyngeal volumes, and the retroglossal cross-sectional area were significantly decreased postoperatively (P = 0.006; P = 0.005; P = 0.012; P = 0.005, respectively). The apnoea–hypopnoea index (AHI) increased significantly after surgery (P = 0.021). There were significant positive correlations between the preoperative inferiorly located hyoid bone and both AHI and respiratory disturbance index (RDI) postoperative (P = 0.008 and P = 0.027) and between the postoperative inferiorly dislocated retropalatal level and both AHI and RDI postoperative (P = 0.002 and P = 0.014). Four patients (33.3%) developed new onset OSA postoperatively. Large mandibular setback movements significantly reduced the pharyngeal airway space in the setting of bimaxillary surgery (P = 0.006).     

The impact of smoking on surgical complications after head and neck reconstructive surgery with a free vascularised tissue flap: a systematic review and meta-analysis

Reconstructive surgery with a free vascularised tissue flap is indicated in large defects in the head and neck region, which arise mostly because of head and neck cancer. Tobacco smoking is a major risk factor for head and neck cancer, and many patients undergoing reconstructive surgery in the head and neck have a history of smoking. The objective of this meta-analysis was to determine the impact of smoking on surgical complications after head and neck reconstructive surgery with a free vascularised tissue flap. A systematic review was undertaken for articles reporting and comparing the incidence of overall surgical complications after reconstructive surgery with a free vascularised tissue flap between smokers and nonsmokers. Relevant articles were searched using PubMed, Cochrane, and Embase databases, and screened for eligibility according to the PRISMA guidelines. The risk of bias analysis was conducted using the Newcastle-Ottawa quality assessment scale. A meta-analysis was performed to quantitatively compare the incidence rate of overall surgical complications, flap failure, surgical site infection, fistula, and haematoma between smokers and nonsmokers using OpenMetaAnalyst (open source) software. Only qualitative analysis was performed for wound dehiscence, bleeding, nerve injury, and impaired wound healing. Forty-six articles were screened for eligibility; 30 full texts were reviewed, and 19 studies were included in the quantitative meta-analysis. From the 19 studies, 18 were retrospective and 1 was a prospective study. In total, 2155 smokers and 3124 nonsmokers were included in the meta-analysis. Smoking was associated with a significantly increased risk of 19.12% for haematoma (95% Confidence Interval (CI): 4.75–33.49; p < 0.01), and of 4.57% for overall surgical complications (95% CI: 1.97–7.15; p < 0.01). No significant difference in risk was found for flap failure (95% CI: ?4.33–9.90; p = 0.44), surgical site infection (95% CI: ?0.88–2.60; p = 0.33) and fistula formation (95% CI: ?3.81–3.71; p = 0.98) between smokers and nonsmokers. Only for flap failure was a significant heterogeneity found (I² = 63.02%; p = 0.03). Smoking tobacco was significantly associated with an increased risk of overall surgical complications and haematoma, but did not seem to affect other postoperative complications. Encouraging smoking cessation in patients who need reconstructive head and neck surgery remains important, but delaying surgery to create a non-smoking interval is not needed to prevent the investigated complications. More high-quality retrospective or prospective studies with a standardised protocol are needed to allow for definitive conclusions.     

Surgical mission planning in the developing world

Surgical missions to the developing world have been criticized for their lack of outcome analysis. Reported studies indicate a high rate of postoperative complications. An integrated pathway developed for surgical missions and a report of its performance in action is presented herein. Patients were optimized for surgery by a medical team from the UK for a minimum of 14 days preoperatively. They were then transferred to hospital for surgery and returned when stable. At the completion of the mission a junior doctor remained behind for 3 weeks to chart the patients’ progress. Thirty case patients were treated over a 2-week period. The complication rate at 3 weeks postoperatively was 7/30. Twenty-two operations were classified as complex (over 1 h with more than one flap) and eight as simple (under 1 h with minimal flaps). Of those undergoing the simple operations, 2/8 encountered complications at an average of 5 days postoperatively (range 3–7 days). Many medical teams depart in an elevated atmosphere of accomplishment, which without an outcome analysis gives a false impression of their positive impact. Outcome analysis is essential to honestly appraise the effect of surgical missions.     

Effects of postoperative chemotherapy and radiotherapy on patients with squamous cell carcinoma of the oral cavity and multiple regional lymph node metastases

Nodal metastasis in oral squamous cell carcinoma (OSCC) is considered to be a predictor of a poor prognosis. The aim of this study was to investigate the relationship between the number of positive lymph nodes and the prognosis in OSCC patients with nodal metastases and to assess the effects of postoperative radiotherapy (RT) or concurrent chemoradiotherapy (CCRT) on this patient group. A retrospective investigation of 98 patients with OSCC who underwent radical neck dissection and had at least three pathologically positive lymph nodes was performed. The 5-year disease-specific survival rate was 66.7% for patients with 3 positive nodes, while it was significantly lower for those with 4 positive nodes and those with ≥5 positive nodes (21.5% and 46.1%, respectively; P < 0.01). The loco-regional control and disease-specific survival rates for the surgery alone, surgery plus RT, and surgery plus CCRT groups were 46.2% and 40.5%, 66.3% and 54.4%, and 81.7% and 52.4%, respectively. For patients with ≥4 positive nodes, the loco-regional control rate after surgery plus CCRT was better than that observed after surgery alone (77.5% vs. 32.6%, P = 0.01). Postoperative RT and CCRT have positive impacts on the prognosis of OSCC patients with advanced stage neck disease.     

Hand perfusion following radial or ulnar forearm free flap harvest for oral cavity reconstruction: A prospective study

The radial forearm free flap (RFFF) and ulnar forearm free flap (UFFF) are used in head and neck reconstruction because they provide a thin and pliable skin paddle as well as a long vascular pedicle. However, in spite of several studies showing the safety of the UFFF, the RFFF is more popular among reconstructive surgeons based on concerns about hand ischaemia. A prospective study was designed in which 10 UFFF and 11 RFFF surgeries were performed in 20 patients undergoing oral cavity reconstruction between January 2017 and July 2018. Hand vascular parameters were evaluated preoperatively and postoperatively using Doppler ultrasound and plethysmography. The preoperative and postoperative diameters of the radial and ulnar arteries, and the flow velocities through the remainder of the forearm artery were measured preoperatively and at 3 months postoperative. Additionally, a comparison was performed between the preoperative and postoperative fingertip perfusion values according to impedance plethysmography. The preoperative mean diameter of the radial artery (2.89 ± 0.47 mm) was significantly greater than that of the ulnar artery (2.35 ± 0.48 mm) at the level of the wrist; however, 3 months after the surgery, the mean diameters of the two arteries did not differ significantly. There were no differences in digital perfusion when a UFFF was used compared with an RFFF.     

Outcomes of free flap reconstructive surgery in head and neck cancer patients over 80-years old

An increasing elderly population in the United Kingdom has led to an increasing number of older patients with head and neck cancer, resulting in a greater demand for complex head and neck reconstructive surgery in this potentially high-risk age group. A possible perceived poorer tolerance to such major treatment risks under-treating some of these patients. The purpose of this study was to assess the outcomes in the elderly population (older than 80 years) who had undergone free flap reconstruction following head and neck cancer resection. A retrospective review of 127 patients was performed. Eighteen patients were 80 or older (14.2%) and 109 under 80 (85.8%). The elderly group experienced increased number of postoperative medical complications (p = 0.01), but the surgical complications were not significantly different in the two groups (p = 0.4). The average length of hospital stay was significantly longer in the older group (p = 0.01). There was one flap failure during the study period, which belonged to the younger group of patients. Elderly patients undergoing free flap reconstruction experience an increased rate of postoperative medical complications resulting in an increased length of hospital stay. However, good surgical outcomes can still be achieved in this age group, and therefore age alone should not be considered as a primary factor in head and neck cancer management.     

Evaluation of airflow characteristics before and after septoplasty in unilateral cleft patients with a deviated nasal septum: a computational fluid dynamics study

The aim of this study was to evaluate changes in airflow characteristics before and after septoplasty in unilateral cleft lip and palate (UCLP) patients using computational fluid dynamics (CFD) models. The study was designed as a prospective cohort study involving pre- and postoperative computed tomography data from 12 UCLP patients with a deviated nasal septum who underwent septoplasty. CFD analysis of nasal airflow was conducted to study changes in velocity, pressure, volume, nasal resistance, and wall shear stress of the nasal domain before and after surgery. The study results demonstrated a statistically significant difference in pressure drop after septoplasty: median 116.10 Pa (interquartile range (IQR) 749.02 Pa) preoperative compared with 43.39 Pa (IQR 349.01 Pa) postoperative (P =  0.004). Maximum wall shear stress was found to be approximately three times lower after septoplasty: median 6.15 Pa (IQR 1908.62 Pa) preoperative versus median 2.51 Pa (IQR 540.06 Pa) postoperative (P = 0.002). Changes in nasal resistance were also found to be statistically significant: median 460.59 Pa·s/l (IQR 1946.99 Pa·s/l) preoperative versus median 166.61 Pa·s/l (IQR 694.08 Pa·s/l) postoperative (P = 0.04). These values demonstrate significant changes in flow dynamics after surgery indicative of a more uniform airflow pattern and stabilization of the nasal mucosa.     

Thyroid surgery outcomes analysis in an oral and maxillofacial surgery department

The purpose of this study was to identify complication rates of thyroidectomies performed within the Department of Oral and Maxillofacial Surgery, University of Florida Health – Jacksonville, and to compare these with quantified data regarding complications of thyroidectomies performed by other specialties. A retrospective cohort analysis was implemented to determine complication rates amongst patients treated in the department between January 2012 and December 2017. Data variables included demographics, ASA status, social history, and preoperative signs and symptoms. The primary outcome variables were length of hospital length, secondary procedures in the same admission, and postoperative complications including hypocalcemia, hematoma, and voice changes. A total of 402 patients were identified, of whom six were excluded for insufficient data. The mean age of the 396 patients included was 47.9 years and 84.6% were female. Of the patients included, 338 experienced no complications; 86 patients spent more than one postoperative day in the hospital. A statistically significant (P = 0.033) correlation was found between higher ASA status (III, IV, V) and increased length of stay. The results indicated safe and efficient thyroid surgery within a department of oral and maxillofacial surgery by current prevailing standards.     

Clinical comparison of a xenogeneic collagen matrix versus subepithelial autogenous connective tissue graft for augmentation of soft tissue around implants

Dental implant placement is a predictable therapy for replacing teeth. Nevertheless, mechanical, biological, and aesthetic complications frequently occur. The aim of this study was to compare the clinical outcomes of a xenogeneic collagen matrix (XCM) used at the time of implant placement as an alternative to a subepithelial connective tissue graft (SCTG), for soft tissue augmentation. This was a prospective clinical trial with 12 months of follow-up. In the control group, soft tissue augmentation at the time of implant placement was performed with a SCTG, while in the test group, a XCM was employed. At 12 months postoperative, all xenografts showed no postoperative complications. In both groups, a significantly greater thickness was observed on the buccal and occlusal sides from preoperative to 3 months postoperative (P < 0.05). No statistically significant difference in pink aesthetic score (P = 0.379, 6 months postoperative) or marginal bone loss (P = 0.449 at 3 months postoperative, P = 0.778 at 6 months postoperative) was observed between the groups. Statistically significant differences in pain perceived by the patients (P < 0.0001) and the time to complete the surgical procedure (P = 0.0008) were detected. At 12 months after surgery, XCM provided similar clinical results in terms of soft tissue augmentation on the buccal and occlusal sides as compared with the SCTG.     

Head and neck surgery is a risk factor for atrial fibrillation: incidence and outcomes

Atrial fibrillation (AF) is the most common postoperative arrhythmia and can cause increased length of stay, costs, morbidity, and mortality. Little information exists about postoperative AF after major head and neck surgery, but it is thought to occur more frequently than after surgery at other extra-thoracic sites. A retrospective cohort study was implemented, including patients who had undergone major head and neck surgery and who had follow-up records covering a minimum of 60 days postoperative. The main outcome was the incidence of new onset postoperative AF after major head and neck surgery; secondary outcomes were the incidence of any AF, the role of cardiology, predictors of AF postoperatively, and clinical outcomes. A total 337 patients were included. Twenty-four patients experienced AF postoperatively (7.1%), of whom 12 (3.6%) had new onset AF. New onset AF was associated with advanced age of ≥65 years (odds ratio 11.6, P = 0.027) and having a laryngectomy (odds ratio 9.9, P = 0.003). Postoperative AF following major head and neck surgery is not a rare phenomenon and can be associated with considerable morbidity and costs due to the need for intensive care, specialty consultations, additional testing and laboratory studies, and cardiology follow-up.     

Non-randomized controlled prospective study on perioperative levels of stress and dysautonomia during dental implant surgery

PurposeThe purpose of this study was to compare pre- and postoperative autonomic activities and changes in salivary stress biomarkers between patients who received only local anesthesia and those who received local anesthesia together with intravenous sedation in dental implant surgery.MethodsA total of 21 patients were enrolled in this non-randomized controlled prospective study; 7 subjects underwent implant surgery under local anesthesia with intravenous sedation and 14 subjects underwent surgery under only local anesthesia. Stress was evaluated by measuring salivary levels of chromogranin A (CgA) and a spectral analysis of heart rate variability (HRV) at baseline (on a day other than the day of surgery), 1 h preoperatively, and 1 h postoperatively. HRV analysis yields low- (LF) and high-frequency (HF) components, the LF/HF ratio, and the component coefficient of variance (CCV[HF]), which provide indices of sympathetic and parasympathetic regulatory activity.ResultsCgA levels were significantly higher (p < 0.05) at baseline in patients who received sedation than those who did not, but CgA levels did not differ prior to surgery. Also, the values of most parameters, including LF, HF, LF/HF (L/H), and CCV(HF), did not significantly differ between groups or among the three time points. Only ΔL/H and ΔCCV(HF) were significantly lower (p < 0.05) at 1 h preoperatively in patients who received sedation than those who received only local anesthesia.ConclusionsCgA levels were high in both groups immediately before surgery, and thus CgA values immediately before surgery may not be a reliable indicator of the need for intravenous sedation. Also, spectral analysis of HRV, especially ΔL/H and ΔCCV(HF), could be useful for assessing tension and anxiety.     

Changes in border movement of the mandible in skeletal Class III before and after orthognathic surgery

The purpose of this study was to examine the changes in border movement of the mandible before and after mandibular ramus osteotomy in patients with prognathism. The subjects were 73 patients with mandibular prognathism who underwent sagittal split ramus osteotomy (SSRO) with and without Le Fort I osteotomy. Border movement of the mandible was recorded with a mandibular movement measure system (K7) preoperatively and at 6 months postoperatively. Of the 73 patients, 21 had measurements taken at 1.5 years postoperative. Data were compared between the pre- and postoperative states, and the differences analyzed statistically. There was no significant difference between SSRO alone and SSRO with Le Fort I osteotomy in the time-course change. The values at 6 months postoperative were significantly lower than the preoperative values for maximum vertical opening (P = 0.0066), maximum antero-posterior movement from the centric occlusion (P = 0.0425), and centric occlusion to maximum opening (P = 0.0300). However, there were no significant differences between the preoperative and 1.5 years postoperative measurements. This study suggests that a postoperative temporary reduction in the border movement of the mandible could recover by 1.5 years postoperative, and the additional procedure of a Le Fort I osteotomy does not affect the recovery of mandibular motion after SSRO.     

Submental intubation in oral and maxillofacial surgery: a systematic review 1986–2018

Submental intubation is a low-risk alternative to tracheostomy when nasotracheal or orotracheal intubation is not appropriate. To improve the selection of patients and clinical outcomes we have explored published papers on submental intubation in oral and maxillofacial surgery, and included a proposal for a decision pathway. Systematic searches of PubMed, Scopus, and Cochrane databases for papers published between 1986 and 2018 yielded 116 eligible articles (one randomised controlled trial, 61 case series, 40 case reports, six surgical techniques, and eight letters) that included 2 229 patients. Measured outcomes were the indications, techniques, devices used, time taken to complete the procedure, and complications. Indications were trauma (81%), orthognathic surgery (15%), disease (2%), and cosmetic surgery (1%). Technical preferences were for a one-tube (84%) over a two-tube technique (6%), and a paramedian (52%) over a median incision (33%). The preferred device was a reinforced endotracheal tube (85%). The mean (range) intubation time was 10 (2–37) minutes. The complication rate was 7% (n = 152), the most common being superficial skin infection (n = 54), hypertrophic scarring (n = 18), and damage to the tube apparatus (n = 15). Submental intubation has minimal complications, takes a short time to do, and it is a useful alternative to tracheostomy in some oral and maxillofacial operations. More robust evidence regarding the selection of patients, modifications to the technique, and a comparison of risk with that of tracheostomy, are needed for further evaluation of its feasibility.     

Factors contributing to delayed decannulation of temporary tracheostomies following free tissue reconstructive surgery for head and neck cancer

Temporary tracheostomies (TT) are performed to secure the airway perioperatively and postoperatively in head and neck cancer patients undergoing tumour resection and free tissue reconstructive surgery. Patients report that having a TT is unpleasant and they appreciate its removal at the earliest opportunity. Early removal not only improves patient satisfaction but should allow for a more rapid recovery. The aim of this prospective study was to assess factors that contribute to delays in decannulation following TT and hence to provide an insight into the factors that will support earlier decannulation when it is safe to do so. Consecutive patients who had TT over a six-month period were included. Delayed decannulation was defined as that after day seven postoperatively. There were 42 patients with a median (IQR) age of 70 (60-74) years, 26 of whom were men. The tracheostomy was surgical in 29 and percutaneous in 13. The median (IQR) time to decannulation was 4 (3-5) days (range 1-11 days). Seven patients had delayed removal (7-11 days), the reasons being hospital-acquired pneumonia (HAP) (n = 4), prolonged stay in the high dependency unit (HDU) following postoperative myocardial infarction and cardiac arrest (n = 1), failure to tolerate TT occlusion (n = 1), and not stated (n = 1). There were early postoperative complications in 14 patients but despite this seven decannulations were still performed within two and six days. Additional multiprofessional assessment over weekends is likely to facilitate earlier decannulation. As some TTs are removed after a few days there is a need for better selection to avoid their use in certain patients.     

Pharyngeal airway space changes after maxillomandibular advancement: a five-year retrospective study

The aim of this study was to compare the alterations in three regions of the airway—nasopharynx, oropharynx, and hypopharynx—in relation to the area of the midsagittal plane, volume, and minimal axial area after maxillomandibular advancement (MMA) surgery. Thirty patients who had undergone MMA surgery were evaluated at four time points: preoperative (T0), immediately postoperative (T1), 1 year postoperative (T2), and ≥5 years postoperative (T3). All measurements were performed using computed tomography, analyzed in Dolphin Imaging 11.0 Premium 3D software. The area in the midsagittal plane presented a mean increase of 22.0% between T0 and T3 (P < 0.001), with the highest increase in the oropharynx (24.1%, P < 0.001). The total volumetric increase at T3 was 16.7% (P < 0.001), with the highest increase in the nasopharynx (15.7%; P < 0.001). The lowest minimal axial area was found for the oropharynx at all time points, and the highest increase in minimal axial area was found for the nasopharynx (114.9%; P < 0.001). MMA surgery showed the highest increase in upper posterior airway between T0 and T1, and this was followed by a progressive reduction until T3, but with a statistically significant increase at T3 compared with T0 in all cases.