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Shum JW, Dierks EJ. Fellowship Training in Oral and Maxillofacial Surgery: Opportunities and Outcomes. Oral Maxillofac Surg Clin North Am 2022; 34:545-554. [PMID: 36224071 DOI: 10.1016/j.coms.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The pursuit of fellowship training stems from one's desire to master a focused area of surgery. Successful applicants tend to have published articles and participated in other scholarly activities. They commonly have a mentor within the subspecialty of their interest. Selection of the program is generally based on the breadth of experience available followed by faculty reputation and location. Advantages to the successful fellowship graduate include the experience and confidence to provide specialized and efficient care to patients. Enhancements to an academic department with a fellowship program include mentorship for residents and guidance toward fellowship, as well as an increased level of scholarly activity.
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Affiliation(s)
- Jonathan W Shum
- Oral, Head and Neck Oncologic and Reconstructive Surgery Fellowship, Department of Oral and Maxillofacial Surgery, The University of Texas Health Science Center at Houston, 6560 Fannin Street Suite 1900#, Houston, TX 77054, USA.
| | - Eric J Dierks
- Department of Oral and Maxillofacial Surgery, Oregon and Health Sciences University, Head and Neck Surgical Associates, 1849 NW Kearney, Suite 300, Portland, OR 97209, USA
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Khatib B, Gelesko S, Amundson M, Cheng A, Patel A, Bui T, Dierks EJ, Bell RB. Updates in Management of Craniomaxillofacial Gunshot Wounds and Reconstruction of the Mandible. Oral Maxillofac Surg Clin North Am 2021; 33:359-372. [PMID: 34210400 DOI: 10.1016/j.coms.2021.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This article includes updates in the management of mandibular trauma and reconstruction as they relate to maxillomandibular fixation screws, custom hardware, virtual surgical planning, and protocols for use of computer-aided surgery and navigation when managing composite defects from gunshot injuries to the face.
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Affiliation(s)
- Baber Khatib
- Advanced Craniomaxillofacial and Trauma Surgery/Head and Neck Oncologic and Microvascular Reconstructive Surgery, Department of Surgery, Legacy Emanuel Medical Center, 2801 N Gantentenbein Avenue, Portland, OR 97227, USA; Providence Portland Hospital, 4805 NE Glisan Street, Portland, OR 97213, USA; Head & Neck Surgical Associates, 1849 NW Kearney Street #302, Portland, OR 97209, USA.
| | - Savannah Gelesko
- Head & Neck Surgical Associates, 1849 NW Kearney Street #302, Portland, OR 97209, USA
| | - Melissa Amundson
- Head & Neck Surgical Associates, 1849 NW Kearney Street #302, Portland, OR 97209, USA; Department of Surgery, Trauma Service, Legacy Emanuel Medical Center, 2801 N Gantentenbein Avenue, Portland, OR 97227, USA
| | - Allen Cheng
- Head & Neck Surgical Associates, 1849 NW Kearney Street #302, Portland, OR 97209, USA; Department of Surgery, Trauma Service, Legacy Emanuel Medical Center, 2801 N Gantentenbein Avenue, Portland, OR 97227, USA; Head and Neck Cancer Program, Legacy Good Samaritan Medical Center, 1015 NW 22nd Avenue, Portland, OR 97210, USA
| | - Ashish Patel
- Head & Neck Surgical Associates, 1849 NW Kearney Street #302, Portland, OR 97209, USA; Department of Surgery, Trauma Service, Legacy Emanuel Medical Center, 2801 N Gantentenbein Avenue, Portland, OR 97227, USA; Providence Oral, Head and Neck Cancer Program and Clinic, Providence Cancer Center, 4805 NE Glisan Street, Portland, OR 97213, USA
| | - Tuan Bui
- Oral and Maxillofacial Pathology, Sanford Health, E - 1717 S University Drive Fargo, ND 58103, USA
| | - Eric J Dierks
- Head & Neck Surgical Associates, 1849 NW Kearney Street #302, Portland, OR 97209, USA; Department of Surgery, Trauma Service, Legacy Emanuel Medical Center, 2801 N Gantentenbein Avenue, Portland, OR 97227, USA
| | - R Bryan Bell
- Head & Neck Surgical Associates, 1849 NW Kearney Street #302, Portland, OR 97209, USA; Department of Surgery, Trauma Service, Legacy Emanuel Medical Center, 2801 N Gantentenbein Avenue, Portland, OR 97227, USA; Providence Oral, Head and Neck Cancer Program and Clinic, Providence Cancer Center, 4805 NE Glisan Street, Portland, OR 97213, USA; Robert W. Franz Cancer Research Center, Earle A. Chiles Research Institute at Providence Cancer Center, 4805 NE Glisan Street, Portland, OR 97213, USA
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Abstract
This article presents an overview of the history of the buccal fat pad flap, its relevant anatomy, and its indications and contraindications. The surgical technique for its harvest is described, as are the postoperative care and possible complications.
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Affiliation(s)
- Fairouz Chouikh
- Clinique de Chirurgie Maxillo-faciale du Grand Montréal, 1055 Beaver Hall, Suite 301, Montréal, Québec H2Z 1S5, Canada
| | - Eric J Dierks
- Head and Neck Surgical Associates, 1849 Northwest Kearney Street, #300, Portland, OR 97209, USA.
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Cuddy K, Dierks EJ, Cheng A, Patel A, Amundson M, Bell RB. Management of Zygomaticomaxillary Complex Fractures Utilizing Intraoperative 3-Dimensional Imaging: The ZYGOMAS Protocol. J Oral Maxillofac Surg 2020; 79:177-182. [PMID: 32956619 DOI: 10.1016/j.joms.2020.08.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 08/03/2020] [Accepted: 08/21/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Utilization of technology to aid in the assessment, planning, and management of complex craniomaxillofacial injuries is increasingly common. Limited data exist regarding the implication of intraoperative CT/3-Dimensional imaging on decision making in the management of zygomaticomaxillary complex (ZMC) fractures. This study characterizes the utilization of the intraoperative CT scanner for ZMC fracture surgery and analyzes the impact of the intraoperative CT scanner on fracture management. Using these findings, we sought to propose an algorithm to guide the appropriate utilization of intraoperative 3-Dimensional imaging in ZMC fracture surgery. METHODS This retrospective case series evaluates the use of the intraoperative CT scanner for orbitozygomatic trauma surgery at a level 1 trauma center from February 2011 to September 2016. We evaluated the preoperative CT images assessing for the number of displaced sutures, the presence of adjacent fractures requiring fixation, the presence of comminution of the zygomaticomaxillary buttress or body of the zygoma, as well as the number of axes displaced ≥ 5 mm. This information was evaluated to provide guidance on the appropriate utilization of the intraoperative scanner in ZMC fracture management. RESULTS A total of 71 patients were identified to have intraoperative facial CT scans and surgery for ZMC fractures over the study time period. There was a 23.9% (17/71) CT directed revision rate. There was a significantly increased likelihood of CT directed revision for fractures with adjacent fractures requiring fixation, and those with ≥ 2 axes displaced ≥ 5 mm. Using these findings, we proposed the ZYGOMAS algorithm outlining the indications for use of intraoperative CT in management of ZMC fractures. CONCLUSIONS If available, intraoperative CT/3-Dimensional imaging should be utilized in the management of ZMC fractures with the requirement for orbital floor reconstruction, where adjacent fractures require fixation and/or when ≥ 2 axes are displaced ≥ 5 mm.
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Affiliation(s)
- Karl Cuddy
- Assistant Professor, Director of Education and Maxillofacial Trauma, Division of Oral and Maxillofacial Surgery, University of Toronto, Toronto, Ontario.
| | - Eric J Dierks
- Attending Oral and Maxillofacial Surgeon, Legacy Emanuel Medical Center, The Head and Neck Institute, Portland, OR; and Affiliate Professor, Oral and Maxillofacial Surgery, Oregon Health & Science University, Portland, OR
| | - Allen Cheng
- Attending Oral and Maxillofacial Surgeon, Legacy Emanuel Medical Center, The Head and Neck Institute, Portland, OR
| | - Ashish Patel
- Attending Oral and Maxillofacial Surgeon, Legacy Emanuel Medical Center, The Head and Neck Institute, Portland, OR
| | - Melissa Amundson
- Clinical Affiliate Assistant Professor of Surgery, Department of Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Clinical Assistant Professor, Department of Clinical Sciences, Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL
| | - R Bryan Bell
- Attending Oral and Maxillofacial Surgeon, Legacy Emanuel Medical Center, The Head and Neck Institute, Portland, OR; Affiliate Professor, Oral and Maxillofacial Surgery, Oregon Health & Science University; and Physician Executive and Director, Division of Surgical Oncology, Radiation Oncology and Clinical Programs; Director, Providence Head and Neck Cancer Program; Associate Member, Earle A. Chiles Research Institute at the Robert W. Franz Cancer Center, Providence Cancer Institute, Portland, OR
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Viet CT, Dierks EJ, Cheng AC, Patel AA, Chang SC, Couey MA, Watters AL, Hoang T, Xiao HD, Crittenden MR, Leidner RS, Seung SK, Young KH, Bell RB. Transoral robotic surgery and neck dissection for HPV-positive oropharyngeal carcinoma: Importance of nodal count in survival. Oral Oncol 2020; 109:104770. [PMID: 32599498 DOI: 10.1016/j.oraloncology.2020.104770] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 04/02/2020] [Accepted: 04/30/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND In this study we determine the survival in patients with HPV-positive oropharyngeal carcinoma treated with transoral robotic surgery (TORS), neck dissection and risk-adapted adjuvant therapy. METHODS We retrospectively identified 122 patients with HPV-positive oropharyngeal carcinoma treated with TORS and neck dissection between 2011 and 2018. Survival probability was calculated. We determined the effect of the type of neck dissection performed (modified radical neck dissection-MRND vs. selective neck dissection - SND), extranodal extension (ENE), margin status, and presence of ≥ 5 metastatic nodes on survival. RESULTS Our patient population had a five-year overall survival of 91.0% (95% C.I. 85-97%). The five-year probability of recurrence or cancer-associated death was 0.0977 (95% C.I. 0.0927-0.1027). The five-year probability of cancer-associated death was 0.0528 (95% C.I. 0.048-0.0570). All patients who died of their disease had distant metastasis. Our PEG dependence rate was 0%. Patients with ENE and positive margins who underwent adjuvant chemoradiation did not have worse survival. Presence of ≥ 5 metastatic nodes portended worse survival after controlling for age, positive ENE and margins. Low yield (<18 nodes) on neck dissection worsened DFS on multivariable analysis. Furthermore, patients who underwent SND did not have worse OS than those who underwent MRND. CONCLUSION Our study demonstrates that surgery could be simplified by performing TORS with SND rather than MRND. The one true poor prognostic factor in HPV-positive oropharyngeal carcinoma patients who undergo surgery is high nodal burden. Patients with high nodal burden are much more likely to die from their disease.
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Affiliation(s)
- Chi T Viet
- Oral and Maxillofacial Surgery Department, Loma Linda University School of Dentistry, Loma Linda, CA, United States; Head and Neck Cancer Program, Providence Cancer Institute, Portland, OR, United States; Head and Neck Cancer Program, Legacy Cancer Center, Portland, OR, United States
| | - Eric J Dierks
- Head and Neck Cancer Program, Providence Cancer Institute, Portland, OR, United States; Head and Neck Cancer Program, Legacy Cancer Center, Portland, OR, United States
| | - Allen C Cheng
- Head and Neck Cancer Program, Providence Cancer Institute, Portland, OR, United States; Head and Neck Cancer Program, Legacy Cancer Center, Portland, OR, United States
| | - Ashish A Patel
- Head and Neck Cancer Program, Providence Cancer Institute, Portland, OR, United States; Head and Neck Cancer Program, Legacy Cancer Center, Portland, OR, United States
| | - Shu-Ching Chang
- Medical Data Research Center, Providence St. Joseph Health, Portland, OR, United States
| | - Marcus A Couey
- Head and Neck Cancer Program, Providence Cancer Institute, Portland, OR, United States; Head and Neck Cancer Program, Legacy Cancer Center, Portland, OR, United States
| | - Amber L Watters
- Oral Oncology and Medicine, Providence Cancer Institute, Portland, OR, United States
| | - Thien Hoang
- Oral Oncology and Medicine, Providence Cancer Institute, Portland, OR, United States
| | - Hong D Xiao
- Head and Neck Cancer Program, Providence Cancer Institute, Portland, OR, United States
| | - Marka R Crittenden
- Head and Neck Cancer Program, Providence Cancer Institute, Portland, OR, United States; Earle A. Chiles Research Institute at Robert W. Franz Cancer Center, Providence Cancer Institute, Portland, OR, United States; The Oregon Clinic, Portland, OR, United States
| | - Rom S Leidner
- Head and Neck Cancer Program, Providence Cancer Institute, Portland, OR, United States; Earle A. Chiles Research Institute at Robert W. Franz Cancer Center, Providence Cancer Institute, Portland, OR, United States
| | - Steven K Seung
- Head and Neck Cancer Program, Providence Cancer Institute, Portland, OR, United States; The Oregon Clinic, Portland, OR, United States
| | - Kristina H Young
- Head and Neck Cancer Program, Providence Cancer Institute, Portland, OR, United States; Earle A. Chiles Research Institute at Robert W. Franz Cancer Center, Providence Cancer Institute, Portland, OR, United States; The Oregon Clinic, Portland, OR, United States
| | - R Bryan Bell
- Head and Neck Cancer Program, Providence Cancer Institute, Portland, OR, United States; Earle A. Chiles Research Institute at Robert W. Franz Cancer Center, Providence Cancer Institute, Portland, OR, United States.
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Fagin AP, Dierks EJ, Bell RB, Cheng AC, Patel AA, Amundson MS. Infection prevalence and patterns in self-inflicted gunshot wounds to the face. Oral Surg Oral Med Oral Pathol Oral Radiol 2019; 128:9-13. [PMID: 30987890 DOI: 10.1016/j.oooo.2019.02.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 02/03/2019] [Accepted: 02/25/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Self-inflicted gunshot wounds (SIGSWs) to the craniomaxillofacial region are uncommon injuries but are associated with a high mortality rate. Therefore, treating these patients is a rare occurrence even in the largest trauma centers. As with many rare conditions, data specifically addressing this injury pattern are scarce. Because of the proximity of the blast, even low-velocity injuries can be associated with significant avulsion of tissue, comminution of structures, and tissue die back. Previous case reports have recommended the use of prophylactic antibiotics, but no study has specifically investigated the postinjury infection rate or microbial patterns in this patient population. The purpose of this study was to answer the following clinical question: "Among patients with SIGW to the maxillofacial region, what is the prevalence of postinjury infection, and are there any microbial patterns that can guide empiric antibiotic selection?" STUDY DESIGN We designed retrospective cohort study at a level I trauma center in Portland, Oregon. Data on 17 patients who had sustained a SIGSW involving the maxilla or the mandible and survived their initial injury were collected from 2010 to 2017. RESULTS Patients who had a culture-positive infection within 30 days of their injury were defined to have a postinjury infection. Six of the 17 patients (35%) developed a postinjury infection, with an average time to infection of 11 days from initial injury (range 3-19 days). Of the 17 subjects, 15 (88%) received a course of prophylactic antibiotics, on average, for 14 days (range 3-24 days). Of the 6 cases of postinjury infection, culture grew gram-negative bacteria in 4 cases-anaerobic bacteria in 2 and polymicrobial organisms in 2. There was no clear pattern or prevalence of any specific bacterium, but cultures notably included Staphylococcus aureus, Enterobacter species, Bacteroides species, and Escherichia coli. CONCLUSIONS SIGSWs are associated with a high rate of postinjury infection (35%) despite prophylactic antibiotic usage in 88% of these cases. Given the antimicrobial patterns observed in this study, prophylactic antibiotics in this patient population should include empiric coverage for gram-negative and anaerobic bacteria.
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Affiliation(s)
- Adam P Fagin
- Oral and Maxillofacial Surgery Resident, Oregon Health and Science University, Portland, OR, USA.
| | - Eric J Dierks
- President and Medical Director of Head and Neck Surgical Associates; Senior Consultant of the Head and Neck Institute, Portland, OR, USA
| | - R Bryan Bell
- Medical Director, Providence Head and Neck Cancer Program, Head and Neck Institute, Portland, OR, USA
| | - Allen C Cheng
- Section Chair of Oral and Maxillofacial Surgery at Legacy Emanuel Hospital; Medical Director of the Legacy Good Samaritan Oral/Head and Neck Cancer Program; Head and Neck Institute, Portland, OR, USA
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Dillon JK, Villing AS, Jones RS, Futran ND, Brockhoff HC, Carlson ER, Schlieve T, Kademani D, Patel K, Claiborne ST, Dierks EJ, Ying YP, Ward BB. What Is the Role of Elective Neck Dissection in the Management of Patients With Buccal Squamous Cell Carcinoma and Clinically Negative Neck? J Oral Maxillofac Surg 2018; 77:641-647. [PMID: 30503978 DOI: 10.1016/j.joms.2018.10.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/06/2018] [Accepted: 10/27/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Buccal squamous cell carcinoma (BSCC) is rare in the United States. Given its location, few anatomic barriers to spread exist and it has been found to have a high locoregional recurrence rate. The role of elective neck dissection (END) in patients with clinically negative neck (N0) is not clear. This study aims to answer the following research question: Among patients with N0 BSCC, does END improve locoregional control rates, distant metastasis rates, and 2- and 5-year survival rates? MATERIALS AND METHODS A retrospective cohort study was conducted. The sample included patients who received a diagnosis of BSCC. The primary predictor variable was END status (yes or no). Five institutions participated between June 2001 and June 2011: University of Washington, University of Michigan, University of Tennessee, North Memorial Oral and Maxillofacial Surgery in Minnesota, and Head and Neck Surgical Associates (Portland, OR). The primary outcome variable was locoregional recurrence. Secondary outcome variables were distant metastasis and 2- and 5-year survival rates. Other variables collected were demographic characteristics, initial operation, adjuvant therapy, clinical and pathologic data, and staging. Kaplan-Meier and Cox proportional hazards statistics were computed. RESULTS The sample was composed of 98 patients with clinical N0 BSCC. The mean age was 66 years (range, 30-88 years), and 54% were men. Of the patients, 74 (76%) underwent END. The locoregional recurrence-free rate was 61% for END versus 38% for no END (P = .042). The distant metastasis rate was 4% for END versus 9% for no END. The 2- and 5-year disease-free survival rates were 91% and 75% (P = .042), respectively, for END and 85% and 63% (P = .019), respectively, for no END. CONCLUSIONS END had a therapeutic effect, as evidenced by a lower locoregional recurrence rate, lower distant metastasis rate, and improved 2- and 5-year survival rates.
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Affiliation(s)
- Jasjit K Dillon
- Clinical Associate Professor and Program Director, Department of Oral and Maxillofacial Surgery, University of Washington, Seattle, WA.
| | - Akashdeep S Villing
- Formerly, Chief Resident, Department of Oral and Maxillofacial Surgery, University of Washington, Seattle, WA. Currently, Private Practice, Surrey, British Columbia
| | - Richard S Jones
- Formerly, Chief Resident, Department of Oral and Maxillofacial Surgery, University of Washington, Seattle, WA. Currently, Private Practice, Spokane, WA
| | - Neal D Futran
- Professor and Chair, Department of Otolaryngology, Head and Neck Surgery, University of Washington, Seattle, WA
| | - Hans C Brockhoff
- Formerly Oral and Maxillofaical Oncology and Microvascular Reconstruction Fellow, Department of Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, MI. Currently, High Desert Oral and Facial Surgery, University Medical Center, El Paso, TX
| | - Eric R Carlson
- Professor and Chair, Department of Oral and Maxillofacial Surgery, University of Tennessee, Knoxville, TN
| | - Thomas Schlieve
- Formerly, Fellow, Department of Oral and Maxillofacial Surgery, University of Tennessee, Knoxville, TN. Currently, Assistant Professor and Program Director, Department of Oral and Maxillofacial Surgery, University of Texas Southwestern/Parkland Memorial Hospital, Dallas, TX
| | - Deepak Kademani
- Clinical Associate Professor, North Memorial Oral and Maxillofacial Surgery, Minneapolis, MN
| | - Ketan Patel
- Clinical Associate Professor, North Memorial Oral and Maxillofacial Surgery, Minneapolis, MN
| | - Scott T Claiborne
- Clinical Associate Professor, North Memorial Oral and Maxillofacial Surgery, Minneapolis, MN
| | - Eric J Dierks
- Affiliate Professor of Oral and Maxillofacial Surgery at Oregon Health and Science University Hospital, Portland, OR. Head and Neck Associates, Emmanuel Hospital, Portland, OR
| | - Yedeh P Ying
- Formerly, Fellow, Head and Neck Associates, Emanuel Hospital. Currently, Assistant Professor, Oral & Maxillofacial Surgery, University of Alabama, Birmingham, AL
| | - Brent B Ward
- Associate Professor and Chair, Department of Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, MI
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Fagin AP, Dierks EJ, Bell RB, Cheng AC, Patel AA, Amundson MS. Infection Prevalence and Patterns in Self Inflicted Gunshot Wounds to the FACE. Oral Surg Oral Med Oral Pathol Oral Radiol 2018. [DOI: 10.1016/j.oooo.2018.05.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Khatib B, Patel A, Dierks EJ, Bell RB, Cheng A. The Biaxial Double-Barrel Fibula Flap-A Simplified Technique for Fibula Maxillary Reconstruction. J Oral Maxillofac Surg 2018; 77:412-425. [PMID: 30347200 DOI: 10.1016/j.joms.2018.09.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/12/2018] [Accepted: 09/12/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE Previously described techniques for microvascular fibula reconstruction of Brown Class II to IV maxillectomy defects are complex, require multiple osteotomies, result in a short pedicle, and inadequately reconstruct the dental alveolus in preparation for endosseous implants. This report describes a simplified technique for Brown Class II to IV defects that re-creates facial support, allows for dental reconstruction with appropriately positioned implants, and maintains adequate pedicle length. MATERIALS AND METHODS A retrospective chart review was performed of all patients with Brown Class II to IV maxillectomy defects immediately reconstructed with a biaxial double-barrel fibula flap technique. The reconstructive surgeon evaluated each patient at least 1 month after reconstruction for enophthalmos, facial symmetry, nasal patency, satisfactory jaw position, deglutition, intelligible speech, and intraoperative need for vein grafting. RESULTS The sample was composed of 6 patients (mean age, 54 yr; range, 33 to 78 yr; 67% women) who underwent reconstruction with the biaxial double-barrel fibula flap technique for Brown Class II to IV defects. None of these patients required vein grafting. None of these patients had flap failure. Diagnoses for these patients were a hybrid odontogenic tumor (n = 1), squamous cell carcinoma (n = 3), adenoid cystic carcinoma (n = 1), and sinonasal melanoma (n = 1). All 6 patients had excellent facial contour and malar projection, regular oral intake, 100% intelligible speech, and a new maxillary skeletal Class I relation without need for intraoperative vein grafting. One patient developed enophthalmos related to inferior rectus sacrifice and removal of orbital fat. Complications included development of nasal synechia and occlusion of the maxillary sinus ostium (n = 1). CONCLUSIONS The biaxial double-barrel fibula flap technique achieves the goals of providing adequate facial support and an alveolar segment amenable to implant dentistry. It allows for intelligible speech, deglutition, orbital support, and separation of the oronasal, orbital, and sinus cavities. In addition, it minimizes the need for vein grafting.
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Affiliation(s)
- Baber Khatib
- Assistant Clinical Professor, Maxillofacial Microvascular Reconstructive Surgery, Department of Oral and Maxillofacial Surgery, Medical University of South Carolina, Charleston, SC; Previously, Fellow, Head and Neck Oncologic and Microvascular Reconstructive Surgery, Providence Cancer Center Head and Neck Institute, Portland, OR.
| | - Ashish Patel
- Attending Head and Neck/Microvascular Surgeon, Providence Oral, Head and Neck Cancer Program and Clinic, Providence Cancer Center, Portland; Consultant, Head and Neck Institute, Portland, OR
| | - Eric J Dierks
- Director of Maxillofacial Trauma, Trauma Service, Legacy Emanuel Medical Center, Portland; Consultant, Head and Neck Institute, Portland, OR
| | - R Bryan Bell
- Medical Director, Providence Oral, Head and Neck Cancer Program and Clinic, Earle A. Chiles Research Institute at the Robert W. Franz Cancer Center, Providence Cancer Institute, Portland; Director, Fellowship in Head and Neck Oncologic and Microvascular Reconstructive Surgery, Head and Neck Institute, Portland, OR
| | - Allen Cheng
- Director, Head and Neck Cancer Program, Legacy Good Samaritan Medical Center, Portland; Consultant, Head and Neck Institute, Portland, OR
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Khatib B, Cuddy K, Cheng A, Patel A, Sim F, Amundson M, Gelesko S, Bui T, Dierks EJ, Bell RB. Functional Anatomic Computer Engineered Surgery Protocol for the Management of Self-Inflicted Gunshot Wounds to the Maxillofacial Skeleton. J Oral Maxillofac Surg 2018; 76:580-594. [DOI: 10.1016/j.joms.2017.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Khatib B, Gelesko S, Amundson M, Cheng A, Patel A, Bui T, Dierks EJ, Bell RB. Updates in Management of Craniomaxillofacial Gunshot Wounds and Reconstruction of the Mandible. Facial Plast Surg Clin North Am 2018; 25:563-576. [PMID: 28941508 DOI: 10.1016/j.fsc.2017.06.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article includes updates in the management of mandibular trauma and reconstruction as they relate to maxillomandibular fixation screws, custom hardware, virtual surgical planning, and protocols for use of computer-aided surgery and navigation when managing composite defects from gunshot injuries to the face.
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Affiliation(s)
- Baber Khatib
- Advanced Craniomaxillofacial and Trauma Surgery/Head and Neck Oncologic and Microvascular Reconstructive Surgery, Department of Surgery, Legacy Emanuel Medical Center, 2801 N Gantentenbein Avenue, Portland, OR 97227, USA; Providence Portland Hospital, 4805 NE Glisan Street, Portland, OR 97213, USA; Head & Neck Surgical Associates, 1849 NW Kearney Street #302, Portland, OR 97209, USA.
| | - Savannah Gelesko
- Head & Neck Surgical Associates, 1849 NW Kearney Street #302, Portland, OR 97209, USA
| | - Melissa Amundson
- Head & Neck Surgical Associates, 1849 NW Kearney Street #302, Portland, OR 97209, USA; Department of Surgery, Trauma Service, Legacy Emanuel Medical Center, 2801 N Gantentenbein Avenue, Portland, OR 97227, USA
| | - Allen Cheng
- Head & Neck Surgical Associates, 1849 NW Kearney Street #302, Portland, OR 97209, USA; Department of Surgery, Trauma Service, Legacy Emanuel Medical Center, 2801 N Gantentenbein Avenue, Portland, OR 97227, USA; Head and Neck Cancer Program, Legacy Good Samaritan Medical Center, 1015 NW 22nd Avenue, Portland, OR 97210, USA
| | - Ashish Patel
- Head & Neck Surgical Associates, 1849 NW Kearney Street #302, Portland, OR 97209, USA; Department of Surgery, Trauma Service, Legacy Emanuel Medical Center, 2801 N Gantentenbein Avenue, Portland, OR 97227, USA; Providence Oral, Head and Neck Cancer Program and Clinic, Providence Cancer Center, 4805 NE Glisan Street, Portland, OR 97213, USA
| | - Tuan Bui
- Oral and Maxillofacial Pathology, Sanford Health, E - 1717 S University Drive Fargo, ND 58103, USA
| | - Eric J Dierks
- Head & Neck Surgical Associates, 1849 NW Kearney Street #302, Portland, OR 97209, USA; Department of Surgery, Trauma Service, Legacy Emanuel Medical Center, 2801 N Gantentenbein Avenue, Portland, OR 97227, USA
| | - R Bryan Bell
- Head & Neck Surgical Associates, 1849 NW Kearney Street #302, Portland, OR 97209, USA; Department of Surgery, Trauma Service, Legacy Emanuel Medical Center, 2801 N Gantentenbein Avenue, Portland, OR 97227, USA; Providence Oral, Head and Neck Cancer Program and Clinic, Providence Cancer Center, 4805 NE Glisan Street, Portland, OR 97213, USA; Robert W. Franz Cancer Research Center, Earle A. Chiles Research Institute at Providence Cancer Center, 4805 NE Glisan Street, Portland, OR 97213, USA
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Kupfer P, Cheng A, Patel A, Amundson M, Dierks EJ, Bell RB. Virtual Surgical Planning and Intraoperative Imaging in Management of Ballistic Facial and Mandibular Condylar Injuries. Atlas Oral Maxillofac Surg Clin North Am 2016; 25:17-23. [PMID: 28153179 DOI: 10.1016/j.cxom.2016.05.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Philipp Kupfer
- Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
| | - Allen Cheng
- Head and Neck Institute, 1849 Northwest Kearney, Suite 300, Portland, OR 97209, USA; Trauma Service, Legacy Emanuel Medical Center, 2801 North Gantenbein, Portland, OR 97227, USA; Oral/Head and Neck Cancer Program, Legacy Good Samaritan Medical Center, 1015 Northwest 22nd Avenue, Portland, OR 97210, USA
| | - Ashish Patel
- Head and Neck Institute, 1849 Northwest Kearney, Suite 300, Portland, OR 97209, USA; Trauma Service, Legacy Emanuel Medical Center, 2801 North Gantenbein, Portland, OR 97227, USA; Providence Oral, Head and Neck Cancer Program and Clinic, Providence Cancer Center, 4805 Northeast Glisan, Suite 2N35, Portland, OR 97213, USA
| | - Melissa Amundson
- Head and Neck Institute, 1849 Northwest Kearney, Suite 300, Portland, OR 97209, USA; Trauma Service, Legacy Emanuel Medical Center, 2801 North Gantenbein, Portland, OR 97227, USA
| | - Eric J Dierks
- Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA; Head and Neck Institute, 1849 Northwest Kearney, Suite 300, Portland, OR 97209, USA; Trauma Service, Legacy Emanuel Medical Center, 2801 North Gantenbein, Portland, OR 97227, USA
| | - R Bryan Bell
- Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA; Head and Neck Institute, 1849 Northwest Kearney, Suite 300, Portland, OR 97209, USA; Trauma Service, Legacy Emanuel Medical Center, 2801 North Gantenbein, Portland, OR 97227, USA; Providence Oral, Head and Neck Cancer Program and Clinic, Providence Cancer Center, 4805 Northeast Glisan, Suite 2N35, Portland, OR 97213, USA.
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Markiewicz MR, Bell RB, Bui TG, Dierks EJ, Ruiz R, Gelesko S, Pirgousis P, Fernandes R. Survival of microvascular free flaps in mandibular reconstruction: A systematic review and meta-analysis. Microsurgery 2015; 35:576-87. [DOI: 10.1002/micr.22471] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 07/26/2015] [Accepted: 08/03/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Michael R. Markiewicz
- Division of Head Neck Surgery, Department of Oral & Maxillofacial Surgery, Division of Surgical Oncology; University of Florida College of Medicine; Jacksonville FL
| | - R. Bryan Bell
- Oral, Head and Neck Cancer Program; Providence Cancer Center; Portland OR
- Department of Oral and Maxillofacial Surgery; Oregon Health and Science University; Portland OR
- Head and Neck Institute; Portland OR
| | - Tuan G. Bui
- Oral, Head and Neck Cancer Program; Providence Cancer Center; Portland OR
- Department of Oral and Maxillofacial Surgery; Oregon Health and Science University; Portland OR
- Head and Neck Institute; Portland OR
| | - Eric J. Dierks
- Oral, Head and Neck Cancer Program; Providence Cancer Center; Portland OR
- Department of Oral and Maxillofacial Surgery; Oregon Health and Science University; Portland OR
- Head and Neck Institute; Portland OR
| | - Ramon Ruiz
- Department of Pediatric Craniomaxillofacial Surgery; Arnold Palmer Hospital for Children University of Central Florida; Orlando FL
| | - Savannah Gelesko
- Department of Oral and Maxillofacial Surgery; Oregon Health and Science University; Portland OR
| | - Phillip Pirgousis
- Division of Head Neck Surgery, Department of Oral & Maxillofacial Surgery, Division of Surgical Oncology; University of Florida College of Medicine; Jacksonville FL
| | - Rui Fernandes
- Division of Head Neck Surgery, Department of Oral & Maxillofacial Surgery, Division of Surgical Oncology; University of Florida College of Medicine; Jacksonville FL
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Bui TG, Dierks EJ. Reconstruction of cervical defects. Atlas Oral Maxillofac Surg Clin North Am 2015; 23:105-115. [PMID: 25707569 DOI: 10.1016/j.cxom.2014.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Tuan G Bui
- Oral and Maxillofacial Surgery, Oregon Health and Sciences University, Portland, OR, USA; Head and Neck Surgical Institute, 1849 Northwest Kearney Street, #300, Portland, OR 97209, USA.
| | - Eric J Dierks
- Oral and Maxillofacial Surgery, Oregon Health and Sciences University, Portland, OR, USA; Head and Neck Surgical Institute, 1849 Northwest Kearney Street, #300, Portland, OR 97209, USA
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Abstract
Accurate assessment of surgical margins in the head and neck is a challenge. Multiple factors may lead to inaccurate margin assessment such as tissue shrinkage, nonstandardized nomenclature, anatomic constraints, and complex three dimensional specimen orientation. Excision method and standard histologic processing techniques may obscure distance measurements from the tumor front to the normal tissue edge. Arbitrary definitions of what constitutes a "close" margin do not consider the prognostic significance of resection dimensions. In this article we review some common pitfalls in determining margin status in head and neck resection specimens as well as highlight newer techniques of molecular margin assessment.
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Affiliation(s)
- Y Etan Weinstock
- Department of Otorhinolaryngology, University of Texas Health Science Center at Houston, 6431 Fannin Street MSB 5.031, Houston TX 77030, USA.
| | - Ibrahim Alava
- Department of Otorhinolaryngology, University of Texas Health Science Center at Houston, 6431 Fannin Street MSB 5.031, Houston TX 77030, USA
| | - Eric J Dierks
- Head and Neck Surgical Associates and Oregon Health & Science University, 1849 Northwest Kearney, Suite 300, Portland, OR 97209, USA
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Weeks AC, Bobek SL, Miles CM, Slavin RE, Dierks EJ. Ectopic eye in the maxilla: a report of melanotic neuroectodermal tumor of infancy with an unusual histologic finding and subsequent reconstruction. Oral Surg Oral Med Oral Pathol Oral Radiol 2014. [DOI: 10.1016/j.oooo.2014.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Bell RB, Markiewicz MR, Dierks EJ, Gregoire CE, Rader A. Thin Serial Step Sectioning of Sentinel Lymph Node Biopsy Specimen May Not Be Necessary to Accurately Stage the Neck in Oral Squamous Cell Carcinoma. J Oral Maxillofac Surg 2013; 71:1268-77. [DOI: 10.1016/j.joms.2012.12.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 12/30/2012] [Accepted: 12/30/2012] [Indexed: 11/26/2022]
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Liu G, Dierks EJ, Bell RB, Bui TG, Potter BE. Post-therapeutic surveillance schedule for oral cancer: is there agreement? Oral Maxillofac Surg 2012; 16:327-340. [PMID: 22941063 DOI: 10.1007/s10006-012-0356-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Accepted: 08/18/2012] [Indexed: 06/01/2023]
Abstract
INTRODUCTION Patients with oral cavity squamous cell carcinoma represent a diverse group, and the treatment these patients undergo also varies widely. Some patients undergo local excision alone while others require extensive surgery, often with adjuvant chemoradiotherapy. The post-therapeutic surveillance schedule for these patients tends to be a "one size fits all" formula for all head and neck squamous cell carcinoma patients, which has often been dictated by institutional doctrine or a senior surgeon's dogma. The post-therapeutic needs and risks of a T1 oral cancer patient treated with surgery alone differ from those of a patient with advanced laryngeal carcinoma, and the follow-up regimen should be tailored to the specific patient's risk of loco-regional recurrence, distant metastasis, and other related medical issues. RESOURCES AND MATERIALS A total of 65 papers were identified, 18 of which either focused on follow-up strategy for oral cavity squamous cell carcinoma or their tabular data allowed these cases to be extracted. Internationally recognized cancer entities were also queried. CONCLUSIONS No international consensus was achieved about the follow-up strategies. The value of post-therapeutic surveillance schedule following oral cancer treatment is generally not in dispute, although patient-initiated symptom-driven visits can be effective in identifying tumor recurrence for oral cancer patients. The range of appointment interval schemes tends to identify a progressive escalation of visit intervals such that there are more visits in the first year than in the second, and fewer yet during the third. Patients may fail to comply with their clinic visit structure. Most references agree that follow-up beyond the third year is unnecessary and may waste medical resources as well as the time of both patient and surgeon. There is no agreement as to the need for or interval of imaging studies.
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Affiliation(s)
- Guicai Liu
- Head and Neck Surgical Associates, 1849 NW Kearney, Suite #300, Portland, OR 97209, USA
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Affiliation(s)
- Tuan G Bui
- Head and Neck Surgical Associates, Portland, OR, USA.
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Markiewicz MR, Dierks EJ, Bell RB. Does intraoperative navigation restore orbital dimensions in traumatic and post-ablative defects? J Craniomaxillofac Surg 2012; 40:142-8. [DOI: 10.1016/j.jcms.2011.03.008] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2010] [Revised: 12/29/2010] [Accepted: 03/01/2011] [Indexed: 11/16/2022] Open
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Markiewicz MR, Dierks EJ, Potter BE, Bell RB. Reliability of Intraoperative Navigation in Restoring Normal Orbital Dimensions. J Oral Maxillofac Surg 2011; 69:2833-40. [DOI: 10.1016/j.joms.2010.12.043] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 11/21/2010] [Accepted: 12/27/2010] [Indexed: 10/18/2022]
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Clark PK, Markiewicz MR, Bell RB, Dierks EJ. Trends and attitudes regarding head and neck oncologic surgery: a survey of United States oral and maxillofacial surgery programs. J Oral Maxillofac Surg 2011; 70:717-29. [PMID: 21764201 DOI: 10.1016/j.joms.2011.02.113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 02/10/2011] [Accepted: 02/14/2011] [Indexed: 10/17/2022]
Abstract
PURPOSE The purposes of this study were to: 1) estimate the prevalence and trends of American oral and maxillofacial surgery (OMS) programs in recruiting head and neck oncologic surgery (HNOS) -trained faculty, performing HNOS oncologic procedures and microvascular reconstruction, and presenting HNOS research at academic meetings; 2) estimate whether HNOS and microvascular reconstruction involvement varies among programs with or without a program director or chair trained in HNOS; 3) estimate whether HNOS involvement varies among those OMS programs that regularly attend and do not attend tumor board; 4) estimate whether HNOS involvement varies among those programs that have and have not presented HNOS research at an academic meeting; 5) estimate whether HNOS involvement varies among doctor of medicine-integrated and 4-year OMS programs. MATERIALS AND METHODS Investigators developed and distributed a survey to all US OMS program directors and/or chair composed of questions regarding faculty prevalence and recruitment, frequency and trends in cases, and the priority of applicants for residency with regard to HNOS. There were 18 close-ended questions, and one open-ended question. Responses were recorded in categorical, Likert, ordinal, and numerical format. Bivariate associations were calculated using Fisher exact test and logistic regression. RESULTS Sixty-three of 101 surveys were returned (62.3%). Ten program directors or chair completed a fellowship in HNOS (15.9%). Programs with an HNOS-trained program director or chair were more likely to have another HNOS-trained faculty member (P = .01), performed more malignant tumor resections (P < .001), neck dissections (P < .001), and microvascular free-flap reconstructions (P = .02) than programs without program directors or chair trained in HNOS. Programs that regularly attended tumor board performed an increasing number of malignant tumor resections (P = .008); and neck dissections (P = .003) than programs that did not regularly attend their institution's tumor board. Presentations of HNOS-related research at national meetings did not differ between doctor of medicine-integrated and 4-year OMS programs (P = .7). There was no difference in the prevalence of HNOS-trained program directors and chair between doctor of medicine-integrated and 4-year programs (P = .7). CONCLUSIONS This study's data and comments suggest that programs involved in HNOS have a strong involvement in expanded scope OMS and related academic activities.
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Affiliation(s)
- Paul K Clark
- School of Dentistry, Oregon Health and Science University, Portland, OR 97239, USA
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Abstract
The temporomandibular joint is elegant in its design, which may make it difficult if not impossible to comprehensively reconstruct. Although a broad range of nonvascularized options exists for reconstruction of degenerative conditions of the temporomandibular joint, vascularized reconstructions such as the fibula or the second metatarsal phalangeal joint are more appropriate for defects resulting from oncologic resection or in patients with compromised soft tissue. An anatomically based classification system for these defects is presented.
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Bell RB, Weimer KA, Dierks EJ, Buehler M, Lubek JE. Computer Planning and Intraoperative Navigation for Palatomaxillary and Mandibular Reconstruction With Fibular Free Flaps. J Oral Maxillofac Surg 2011; 69:724-32. [DOI: 10.1016/j.joms.2009.12.040] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Revised: 11/24/2009] [Accepted: 12/29/2009] [Indexed: 10/19/2022]
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Sklenicka S, Dierks EJ, Jarmin J, Miles C. Pseudogout of the temporomandibular joint: an uncommon cause of temporomandibular joint pain and swelling. ACTA ACUST UNITED AC 2010; 111:709-14. [PMID: 21167760 DOI: 10.1016/j.tripleo.2010.07.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2010] [Accepted: 07/17/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pseudogout, or calcium pyrophosphate deposition, is a rare cause of pain, swelling, and trismus of the temporomandibular joint (TMJ). Diagnosis and management of the lesion are discussed. CASE DESCRIPTION A 58-year-old female had a 2-month history of progressive swelling of right TMJ associated with trismus and facial pain. Imaging of the TMJ revealed a mixed radiolucent and radiopaque lesion associated with the right TMJ joint space. Surgical excision was performed successfully via preauricular approach. Pathology was consistent with calcium pyrophosphate deposition of the TMJ, also known as pseudogout. Surgical excision successfully treated her symptoms as expected. She is now disease free without recurrence. CLINICAL IMPLICATIONS Pseudogout is a rare cause of TMJ pain, swelling, and trismus that should be included in the differential of joint pain and dysfunction. It can be treated successfully with surgery.
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Affiliation(s)
- Scott Sklenicka
- North Florida Oral and Facial Surgery, Oral and Maxillofacial Surgery, Oregon Health and Science University, Jacksonville, FL, USA
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Sklenicka S, Gardiner S, Dierks EJ, Potter BE, Bell RB. Survival Analysis and Risk Factors for Recurrence in Oral Squamous Cell Carcinoma: Does Surgical Salvage Affect Outcome? J Oral Maxillofac Surg 2010; 68:1270-5. [DOI: 10.1016/j.joms.2009.11.016] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Revised: 11/18/2009] [Accepted: 11/18/2009] [Indexed: 10/19/2022]
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Dierks EJ, Harper GA. The 4 Cardinal Bends of the Zygomatico-Maxillary Buttress: Technical Note. J Oral Maxillofac Surg 2009; 67:1149-51. [DOI: 10.1016/j.joms.2009.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2008] [Accepted: 01/02/2009] [Indexed: 10/20/2022]
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Spink MJ, Hirsch DL, Dierks EJ. Minimizing microstomia while maximizing esthetics in the reconstruction of acquired lip defects: the evolution of the bilateral paramedian cross-lip flap. J Oral Maxillofac Surg 2008; 66:2627-32. [PMID: 19022147 DOI: 10.1016/j.joms.2008.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2007] [Accepted: 06/06/2008] [Indexed: 10/21/2022]
Affiliation(s)
- Michael J Spink
- Department of Oral and Maxillofacial Surgery, Baystate Medical Center, Springfield, MA 01199, USA.
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Abstract
Congenital neck lesions reflect abnormal embryogenesis in head and neck development. A thorough knowledge of embryology and anatomy is critical in the diagnosis and treatment of these lesions. The appropriate diagnosis of these lesions is necessary to provide appropriate treatment and long-term follow up, because some of these lesions may undergo malignant transformation or be harbingers of malignant disease.
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Affiliation(s)
- Peter A Rosa
- Department of Oral and Maxillofacial Surgery, New York University College of Dentistry, New York, NY, USA
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Teenier TJ, Eyre JM, Dierks EJ. S314: Tracheotomy A-Z. J Oral Maxillofac Surg 2008. [DOI: 10.1016/j.joms.2008.05.319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Dierks EJ, Bell RB. Dedication. Oral Maxillofac Surg Clin North Am 2008. [DOI: 10.1016/j.coms.2008.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Dierks EJ. S433: Evaluation and Management of Nasal and Septal Injuries. J Oral Maxillofac Surg 2008. [DOI: 10.1016/j.joms.2008.05.348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bagheri SC, Stockmaster N, Delgado G, Kademani D, Carter TG, Ramzy A, Dierks EJ. Esophageal Rupture With the Use of the Combitube: Report of a Case and Review of the Literature. J Oral Maxillofac Surg 2008; 66:1041-4. [DOI: 10.1016/j.joms.2007.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2005] [Revised: 06/19/2007] [Accepted: 08/23/2007] [Indexed: 10/22/2022]
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Holmgren EP, Bagheri S, Bell RB, Bobek S, Dierks EJ. Utilization of tracheostomy in craniomaxillofacial trauma at a level-1 trauma center. J Oral Maxillofac Surg 2007; 65:2005-10. [PMID: 17884529 DOI: 10.1016/j.joms.2007.05.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2006] [Revised: 04/10/2007] [Accepted: 05/08/2007] [Indexed: 11/24/2022]
Abstract
PURPOSE The decision to perform a tracheostomy on patients with maxillofacial trauma is complex. There is little data exploring the role of tracheostomy in facial fracture management. We sought to profile the utilization of tracheostomy in the context of maxillofacial trauma at our institution by comparing patients who required tracheostomy with and without facial fractures versus those with facial fractures not requiring tracheostomy. MATERIALS AND METHODS All patients admitted to the Trauma Service at Legacy Emanuel Hospital and Health Center (LEHHC), Portland, OR, from 1993 to 2003 that sustained facial fractures or underwent tracheostomy were identified and data were retrospectively reviewed using patient charts and the trauma registry. Variables such as age, gender, death, injury severity score (ISS), facial injury severity score (FISS), Glasgow coma score (GCS), intensive care days (ICU), hospital length of stay (LOS), facial fracture profile, and oral and maxillofacial surgery (OMFS) operative intervention were tabulated and analyzed. Data were divided into 3 groups for comparison: group 1 (ffxT) consisted of patients who underwent a tracheostomy procedure and repair of their facial fracture during the SAME operation by the OMFS department (N = 125); group 2 (ffxNT) were those patients who had repair of their facial fractures by OMFS and did not require a tracheostomy (N = 224); and group 3 (NffxT) were patients who did not have facial fractures but received a tracheostomy during their hospitalization (N = 259). Ten-year data were used to analyze the ffxT and 5-year data were used to analyze the ffxNT and NffxT. Analysis of variance and chi2 testing was used for statistical analysis. RESULTS A total of 18,187 patients were admitted to the trauma LEHHC Trauma Service during the study period, of which 1,079 (5.9%) patients sustained facial fractures and 788 (4.3%) required a tracheostomy. One hundred twenty-five patients (0.69% of total; 11.6% of facial fracture) received a tracheostomy at the same time as the facial fracture repair. All patients had their facial fractures successfully managed, regardless of the type of method used to stabilize the airway. There were no known cases of tracheal stenosis, severe bleeding requiring a return to the operating room, airway obstruction, or loss of secured airway. Males were the predominate gender in all 3 groups. The NffxT group (mean, 44.9 years) was much older compared with the ffxT (mean, 36.2 years) and ffxNT (mean, 30.9 years) groups. The incidence of death was higher in the tracheostomy groups compared with 0% with the non-tracheostomy group. The ffxNT group had a statistically significant higher GCS with an average of 12.4 when compared with the tracheostomy groups (ffxT = 6.8; NffxT = 6.7). ISS was nearly the same in the tracheostomy group (ffxT = 28.45; NffxT = 30.04), but higher when compared with the ffxNT (ISS = 17.33). All 3 groups were much different in terms of LOS and ICU days, in which the NffxT group had an average hospital LOS and ICU days of 34.4 and 16.56, respectively. This was higher when compared with the ffxT (LOS = 19.71 days; ICU = 7.21 days) and ffxNT (LOS = 6.82 days; ICU = 1.33 days) groups. The FISS averaged 6.22 in the ffxT group and was higher compared with an FISS of 3.16 in the ffxNT group. Overall, the fracture profile was different between the tracheostomy and non-tracheostomy groups. There was a higher prevalence of mandibular fractures, multiple mandibular fractures, and Le Fort III fractures in the ffxT group compared with the ffxNT group. CONCLUSION Tracheostomy is commonly performed in the context of multisystem trauma and is a safe method for airway stabilization in patients with craniomaxillofacial trauma. Multi-institutional collaboration and a prospective, randomized trial measuring outcome, resource utilization, and length of ICU stay is necessary to determine if tracheostomy is indeed of measurable benefit to patients with complex injuries.
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Affiliation(s)
- Eric P Holmgren
- Department of Oral and Maxillofacial Surgery, Oregon Health & Science University, Portland, OR, USA
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Dierks EJ, Over LM, Schmidt BL, Bell RB, Buehler M. Fibula Onlay Reconstruction of the Severely Atrophic Mandible in a Patient With Chronic Lymphocytic Leukemia: Case Report. J Oral Maxillofac Surg 2007; 65:2367-71. [DOI: 10.1016/j.joms.2006.05.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2006] [Revised: 04/23/2006] [Accepted: 05/31/2006] [Indexed: 11/30/2022]
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Hirsch DL, Dierks EJ. Use of a Transbuccal Technique for Marginal Mandibulectomy: A Novel Approach. J Oral Maxillofac Surg 2007; 65:1849-51. [PMID: 17719411 DOI: 10.1016/j.joms.2005.10.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2005] [Accepted: 10/27/2005] [Indexed: 11/27/2022]
Affiliation(s)
- David L Hirsch
- Head and Neck Surgical Associates, Legacy Emanuel Hospital, Portland, OR, USA.
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Dierks EJ. S334: Evaluation and Management of Nasal and Septal Injuries. J Oral Maxillofac Surg 2007. [DOI: 10.1016/j.joms.2007.06.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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42
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Dierks EJ. Pediatric Maligniancies. J Oral Maxillofac Surg 2007. [DOI: 10.1016/j.joms.2007.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Teenier TJ, Eyre JM, Dierks EJ. S424: Tracheotomy from A-Z. J Oral Maxillofac Surg 2007. [DOI: 10.1016/j.joms.2007.06.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bell RB, Dierks EJ, Brar P, Potter JK, Potter BE. A Protocol for the Management of Frontal Sinus Fractures Emphasizing Sinus Preservation. J Oral Maxillofac Surg 2007; 65:825-39. [PMID: 17448829 DOI: 10.1016/j.joms.2006.05.058] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Revised: 05/23/2006] [Accepted: 05/24/2006] [Indexed: 11/22/2022]
Abstract
PURPOSE The purpose of this retrospective study is to review the incidence and etiology of frontal sinus fractures at an urban trauma center and validate a treatment protocol by assessing the outcome of a consecutive series of patients treated over a 10-year period. PATIENTS AND METHODS All patients with frontal sinus fractures admitted to our trauma service from 1995 to 2005 were managed by the same surgeons using similar treatment philosophies based on the amount of displacement or comminution of the anterior and/or posterior table, the integrity of the nasofrontal duct, and the neurologic status of the patient as determined by clinical and radiographic examination. Using information obtained from the Trauma Registry and from individual physician chart notes, a database was created for the purpose of assessing outcome, defined as complications, length of hospital stay, and death. Demographics, injury severity score, fracture pattern, mechanism of injury, length of hospital stay, the number of operations, concomitant maxillofacial injuries, treatment, follow-up, and complications were statistically described. Outcome measures were evaluated by Student's t test using continuous variables. RESULTS One thousand two hundred seventy-five patients with facial fractures were identified during the study period, of which 144 patients (11.3%) carried the diagnosis of frontal sinus fracture; 28 patients had inadequate records, leaving a study group of 116 patients. The majority of patients were male, had a mean age of 33.7 years, and presented with significant injuries demonstrated by a mean injury severity score of 23.7 and mean length of hospital stay of 8.9 days. The most common mechanisms of injury were blunt trauma resulting from a motor vehicle collision, fall, assault, or other accidents. Sixty-six patients presented with nondisplaced frontal sinus fractures that were managed nonoperatively; 50 patients had frontal sinus injuries that required surgical repair consisting of: 1) open reduction and internal fixation of the anterior table alone, with preservation of the sinus membrane (n = 29); 2) removal of all sinus mucosa, obliteration of the frontal sinus with autogenous abdominal fat, and reconstruction of the anterior table (n = 5); and 3) removal of all sinus mucosa, cranialization of the frontal sinus, and lining of the nasofrontal recess with a pericranial flap (n = 16). Six patients died of concomitant injuries. With follow-up ranging between 0 and 90 weeks, there were no known complications in the patients treated nonoperatively; 82% of the patients maintained normal sinus function and anatomy and the overall complication rate was 6.9%. Complications occurred in 16% of those patients treated surgically: including brain abscess, contour deformity, osteomyelitis, hematoma, meningitis, and mucocele. There was no statistically significant association between complications and other patient variables (P > .05), other than the test for injury severity score, which was different between survivors and nonsurvivors (P < .01). CONCLUSION Application of the management protocol described in this report results in functional sinus preservation for the majority of patients, with relatively few significant perioperative complications.
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Affiliation(s)
- R Bryan Bell
- Oral and Maxillofacial Surgery Service, Legacy Emanuel Hospital and Health Center, Department of Oral and Maxillofacial Surgery, Oregon Health & Science University, Portland, OR, USA.
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Bell RB, Osborn T, Dierks EJ, Potter BE, Long WB. Management of Penetrating Neck Injuries: A New Paradigm for Civilian Trauma. J Oral Maxillofac Surg 2007; 65:691-705. [PMID: 17368366 DOI: 10.1016/j.joms.2006.04.044] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2005] [Accepted: 04/18/2006] [Indexed: 11/15/2022]
Abstract
PURPOSE Improvements in imaging technology, particularly computed tomographic angiography (CTA), have altered the management of patients with penetrating neck injuries. Although some centers still advocate routine exploration for all zone 2 neck injuries penetrating the platysma, many civilian centers in the United States have adopted a policy of selective exploration based on clinical and radiographic examination. The purpose of this retrospective study is to evaluate our 5-year experience with the management of penetrating neck injuries, to further elucidate the role of CTA in clinical decision-making, and to assess treatment outcome. PATIENTS AND METHODS One hundred thirty-four consecutive patients were identified from the Legacy Emanuel Trauma Registry as having sustained penetrating neck injuries from 2000 to 2005. Using data collected from the Trauma Registry, as well as individual chart notes and electronic records, variables were collected and evaluated including age, gender, mechanism of injury, number of associated injuries, and the Injury Severity Score, Glasgow Coma Scale on admission, initial hematocrit, airway management techniques, diagnostic and therapeutic modalities, missed injuries, length of hospital stay, disposition, and outcome. Descriptive statistics were used to describe demographics, treatment, and outcome. RESULTS One hundred twenty patients met the inclusion criteria, 55 of which had only superficial injuries that did not penetrate the platysma. The primary study group consisted of 65 patients who sustained more significant injuries that violated the platysma including deep, complex, and/or avulsive wounds, vascular injuries, injuries to the aerodigestive tract, musculoskeletal system, cranial nerves, or thyroid gland. The overall mortality rate for the 65 patients with injuries penetrating the platysma was 3.0% (n = 2). Complications occurred in 7 of the surviving 63 patients (10.7%): 2 patients with zone 3 internal carotid artery injuries developed hemispheric ischemic infarcts and hemiplagia; as well as other complications including: infection (n = 2); deep venous thrombosis (n = 1); aspiration pneumonia (n = 1); and hematoma (n = 1). All surviving patients except the 2 stroke patients eventually healed uneventfully without significant functional deficit. The use of CTA as a guide to clinical decision-making led to a significant decrease in the number of neck explorations performed and a virtual elimination of negative neck explorations. CONCLUSION The management of stable patients with neck injuries that penetrate the platysma has evolved at our institution into selective surgical intervention based on clinical examination and CTA and has resulted in minimal morbidity and mortality.
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Affiliation(s)
- R Bryan Bell
- Department of Oral and Maxillofacial Surgery, Oregon Health & Sciences University, Portland, OR, USA.
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Bell RB, Kademani D, Homer L, Dierks EJ, Potter BE. Tongue Cancer: Is There a Difference in Survival Compared With Other Subsites in the Oral Cavity? J Oral Maxillofac Surg 2007; 65:229-36. [PMID: 17236926 DOI: 10.1016/j.joms.2005.11.094] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2005] [Accepted: 11/11/2005] [Indexed: 11/17/2022]
Abstract
PURPOSE Advances in the management of patients with oral squamous cell carcinoma (OSCC) have confounded the importance of site in predicting overall prognosis. The purpose of this retrospective study was to review the outcome of patients with OSCC and to determine if site is a significant predictor of survival or disease-free survival. PATIENTS AND METHODS The records of 233 patients that underwent surgery for resectable OSCC treated at a single institution from 1993 to 2003 were identified. Patients with positive surgical margins, high grade histology, aggressive biologic behavior, or advanced stage disease underwent adjuvant radiotherapy or chemoradiotherapy. The demographics, site, stage, pathologic, treatment, and survival data were collected and statistically analyzed in an attempt to identify predictors of loco-regional control and disease-free survival. Descriptive statistics were calculated for each variable and survival was calculated using the Kaplan-Meier method. For purposes of comparison, patients were divided into 2 groups: those with tongue lesions (n = 73) and all other sites (n = 152). The Cox proportional hazards model was used to distinguish different survival rates between the groups. RESULTS Two hundred fifteen patients consisting of 104 males (48%) and 111 females (52%) met the criteria for inclusion in the study. Overall and disease-free survival rates were 56% and 58%, respectively. Stage and grade were identified as having a statistically significant effect on survival (P = .0014, likelihood ratio chi2 = 0.04, 1 degree of freedom; and P = .026, chi2 = 5, 1 degree of freedom, respectively). There was no significant difference in survival between patients with tongue cancer and other sites in the oral cavity (P = .8, chi2 = .04, 1 degree of freedom). CONCLUSIONS Grade and stage are significant predictors of overall and disease-free survival for patients with OSCC. In this study, however, there was no survival difference between patients with tongue cancer and cancers located at other sites in the oral cavity.
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Affiliation(s)
- R Bryan Bell
- Oral and Maxillofacial Surgery Service, Legacy Emanuel Hospital and Health Center, Portland, OR, USA.
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Holmes JD, Dierks EJ. M645. J Oral Maxillofac Surg 2006. [DOI: 10.1016/j.joms.2006.06.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Carter TG, Bagheri S, Dierks EJ. Author’s response. J Oral Maxillofac Surg 2006. [DOI: 10.1016/j.joms.2006.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Bagheri SC, Dierks EJ, Kademani D, Holmgren E, Bell RB, Hommer L, Potter BE. Application of a Facial Injury Severity Scale in Craniomaxillofacial Trauma. J Oral Maxillofac Surg 2006; 64:408-14. [PMID: 16487802 DOI: 10.1016/j.joms.2005.11.013] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2004] [Indexed: 11/21/2022]
Abstract
PURPOSE To establish a Facial Injury Severity Scale (FISS) that correlates with patient outcome and provides a practical tool for communication between clinicians and healthcare personnel for management of facial trauma. PATIENTS AND METHODS All patients presenting to the Emergency Department (ED) at Legacy Emanuel Hospital (Level One Trauma Center) in Portland, Oregon between 01/1993 and 6/2003 with facial fractures with or without concomitant non-facial injuries where identified retrospectively. The diagnosis and treatment of all facial fractures were conducted by the Oral and Maxillofacial Surgery (OMFS) service. The following data were collected; age, gender, mechanism of injury, detailed diagnosis of facial fractures, disposition, and the length of hospital stay (LOS). The hospital operating room charges (ORC) for the treatment of each patient's facial fractures were also obtained. We designed the FISS to be a numeric value composed of the sum of the individual fractures and fracture patterns in a patient. Not all fractures of the face are weighted equally in the FISS because not all fracture patterns are equal in severity. Individual fracture points within the scale were optimized to result in the highest correlation. RESULTS A total of 1,115 patient admissions to the ED with blunt or penetrating maxillofacial injuries were identified and reviewed. Full information on operating room charges (ORC) was available for 247 patients (average age: 32, SD +/- 17; range, 2 to 84; male:female, 3:1; blunt:penetrating, 232:15). The FISS scores were calculated for each patient (average FISS: 4.4, SD +/- 2.7; range, 1 to 13). Hospital ORC for the treatment of each patient's maxillofacial injuries were obtained from the hospital financial services (average ORC: 4,135 dollars, SD +/- 2,832 dollars; range, 845 dollars to 18,974 dollars). A significant correlation was identified between the FISS and the ORC (R value = .82). The length of stay was significantly associated with the FISS (t = 4.7, 245 degrees of freedom, P = .000004). Although the association was statistically significant, FISS is not a very good predictor of length of stay. The correlation between the predicted and observed values was 0.38. There were 3 deaths among the 247 entries. Those 3 deaths had higher than average FISS scores, but the difference between the scores of survivors and non-survivors was not significant (P = .08). The number of deaths was small and a larger study would be required to resolve this question. CONCLUSIONS We introduce a FISS that is easily calculated and reliably predicts the severity of maxillofacial injuries as measured by the operating room charges required to treat the facial injury. The scale is also an indicator of hospital length of stay. We anticipate this to be a valuable tool for assessment and management of maxillofacial trauma.
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Affiliation(s)
- Shahrokh C Bagheri
- Craniomaxillofacial Trauma/Cosmetic Surgery, Head and Neck Surgical Associates, Atlanta, GA, USA.
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Verschueren DS, Bell RB, Bagheri SC, Dierks EJ, Potter BE. Management of laryngo-tracheal injuries associated with craniomaxillofacial trauma. J Oral Maxillofac Surg 2006; 64:203-14. [PMID: 16413891 DOI: 10.1016/j.joms.2005.10.034] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2005] [Indexed: 11/15/2022]
Abstract
PURPOSE Laryngeal fractures can occur in association with maxillofacial injuries and may lead to life-threatening airway obstruction. Because of a low incidence and a paucity of peer-reviewed information, there is no universally accepted treatment protocol and few clinicians have extensive experience with complex laryngo-tracheal trauma. The purpose of this retrospective analysis is to validate a treatment protocol for the management of laryngo-tracheal injuries occurring in severely injured patients by assessing the outcome of a consecutive series of patients who were treated by the same surgeons over a 12-year period. PATIENTS AND METHODS All patients with laryngeal fractures admitted to the trauma service at Legacy Emanuel Hospital and Health Center (LEHHC; Portland, OR) from 1992 to 2004 were managed by the same surgeons, using a standard protocol based on the stability of the airway, and were retrospectively identified using the LEHHC Trauma Registry. Using information from the Trauma Registry and individual physician chart notes, a database was created for the purpose of assessing outcome. The following data were collected: age, gender, mechanism of injury, number of associated injuries and the Injury Severity Score, Glasgow Coma Scale on admission, initial hematocrit, airway management techniques, length of hospital stay, LEHHC laryngeal injury classification, treatment modality, disposition, and any available follow-up. Descriptive statistics were used to describe demographics, treatment, and outcome. Outcome measures were defined as complications, airway patency, speech, and deglutition. RESULTS A total of 16,465 patients were identified from the Trauma Registry as having sustained head, neck, or facial injuries, of which 37 patients were diagnosed with laryngeal fractures. Complete patient records were available for 27 patients (mean age, 35.5 +/- 15.3 years; range, 8 to 80 years; 23 males, 4 females) who were classified according to the LEHHC laryngeal injury classification scheme. Most patients sustained injuries as the result of blunt trauma (n = 23; 85.1%) and almost all of them had concomitant maxillofacial injuries (n = 26; 96.3%). Twenty patients (74.1%) required advanced airway intervention (tracheostomy, 14; endotracheal intubation, 5; emergent cricothyrotomy, 1), of which 13 patients underwent neck exploration. Eight of these patients required open reduction and internal fixation with titanium plates and screws, and 2 patients required the addition of an endolaryngeal stent. There was a general trend toward poorer outcome with increased LEHHC laryngeal injury classification. However, all patients were successfully decannulated, maintained patent airways, and ate a normal diet. Hoarseness was common in patients who underwent surgical exploration; however, long-term perioperative complications were rare and included infection requiring hardware removal (n = 1), unilateral vocal cord paralysis (n = 1), and subjective dysphagia. CONCLUSION Fractures of the larynx are uncommon injuries that are frequently associated with maxillofacial trauma and are potentially associated with significant morbidity. Management of laryngo-tracheal injuries using a protocol based on airway status as described in this report results in airway patency, functional vocal quality, and normal deglutition for almost all patients.
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Affiliation(s)
- David S Verschueren
- Department of Oral and Maxillofacial Surgery, Oregon Health & Science University, Portland, OR 97209, USA
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