The purpose of this study was to analyze computer-aided surgical planning (CAS) and margin status following oncological reconstructive surgery of the jaws. A retrospective study was conducted on patients who underwent microvascular reconstructive surgery from 2014 to 2021. The predictor variable was the use of CAS. The primary and secondary outcomes were histopathological bone margin status, local recurrence, and disease-free survival (DFS). Covariates included demographic, operative, pathological, and clinical outcomes. Thirty-five CAS and fifty-two non-CAS subjects were included for analysis. Demographic characteristics such as age, sex, and comorbidities were comparable between the study groups, with all p-values > 0.05. For operative variables, the osteocutaneous radial forearm flap was more commonly used in the non-CAS group (34.6%) compared to the CAS group (2.9%) (p < 0.01). The mean follow-up period was shorter in the CAS group (31.9 months) than in the non-CAS group (42.6 months) (p < 0.01). CAS was not associated with margin status (p = 0.65) or local recurrence (p = 0.08). DFS was comparable between the study groups (p = 0.74). Bone margin involvement was not associated with any covariates. The use of CAS in oncological reconstructive jaw surgery was not associated with increased bone margin involvement.

Outcomes1. Participants will be able to analyze the current attitudes palliative care providers have toward psychedelic and psychedelic-assisted therapies and join in on the discussion of new modalities that show potential for treating existential distress.2. Utilizing an up-to-date review of psychedelic and psychedelic-assisted therapies as modalities for treating existential distress, participants will investigate the legal and ethical implications of treatments and determine whether they would potentially use them in their practiceKey MessageSince palliative care providers are at the forefront of addressing existential distress, their opinions surrounding the potential risks and benefits of psychedelics and psychedelic-assisted psychotherapy (PAP) are key to predicting whether they will ultimately prescribe these treatment modalities.AbstractExistential distress encompasses several psychological stressors that can lead to significant patient suffering at the end of life. As it stands, current medications and psychotherapy approaches are of limited benefit in addressing existential distress. Recent research has shown that psychedelics such as psilocybin have significant potential in alleviating existential distress1,2. However, there has not been widespread utilization of these modalities due to stigma and legal barriers. Since palliative care providers are at the forefront of addressing existential distress, their opinions surrounding the potential risks and benefits of psychedelics and psychedelic-assisted psychotherapy (PAP) are key to predicting whether they will ultimately prescribe these treatment modalities. There have been several prior studies assessing psychiatrists, addiction specialists, and medical students' attitudes toward psychedelics, but limited studies of the opinions of palliative care providers3,4. This prospective study utilizes an online survey to assess the current attitudes, knowledge, exposure, and acceptance of psychedelics and PAP among palliative care providers (physicians, nurses, chaplains, and social workers) working in both the outpatient and inpatient settings at several major Kaiser Permanente Medical Centers throughout Southern California. We hypothesize that palliative care providers with familiarity of scientific literature regarding psychedelics have greater belief that they show promise in treating existential distress and would be willing to use them in their practice.KeywordsManaging Suffering and Distress / Ethical / Legal Aspects of Care

Introduction: Head and Neck Cancer (HNC) ranks sixth among the most common men’s tumours. The prevalence of HNC in children has increased in several countries, and the prevalence varies worldwide. In several regions in Brazil and the world, a lack of epidemiological data records on childhood HNC is observed, demonstrating little knowledge about the demographic profile of these patients. Aim: To determine the prevalence of HNC in paediatric patients over the years at a reference centre in the North region of Brazil. Materials and Methods: A cross-sectional study was conducted with the objective of quantitatively and qualitatively analysing the prevalence of HNC in a reference oncology hospital. The electronic medical records of patients aged 0 to 19 years were reviewed at a referral centre in Northern Brazil from October 2015 to February 2022. Demographic variables, topographic location of tumours, city of origin, patient outcome, and histopathological diagnosis were collected. Results: A total of 4,113 medical records were analysed, and 126 met the criteria for analysis. Males had a higher incidence n=75 (59.52%) of HNC than females n=51 (40.47%). The age group with the highest percentage of HNC was > 4 to 9-year-old n=40 (31.74%). The most common diagnosis were lymphoma 78 (61.90%), sarcoma 22 (17.46%); carcinoma 14 (11.11%), and histiocytosis 10 (7.93%). Conclusion: In Northern Brazil, the most common tumour was Hodgkin’s lymphoma, and the most prevalent group affected were males aged > 4-9-year-old.

Le et al. provided a comprehensive commentary on perioperative management for head and neck oncologic patients undergoing microvascular reconstructive surgery. This commentary is based on a detailed review and consensus statements from the Society for Head and Neck Anesthesia (SHANA), an international organization dedicated to enhancing perioperative care for these patients. The consensus statement, published in 2021 by Healy et al., addressed preoperative, intraoperative, and postoperative considerations to optimize clinical outcomes. It included 14 statements from 16 SHANA members across 11 institutions, following two rounds of literature reviews. The commentary emphasized the importance of preoperative nutrition optimization, tobacco cessation, and early recognition of alcohol withdrawal symptoms. In the intraoperative phase, key aspects such as airway management in cases of extensive tumor burden (including awake fiberoptic intubation and tracheostomy), fluid management, hemodynamic monitoring, and multimodal analgesia were briefly discussed. Notably, vasopressors can be used to optimize hemodynamic management without compromising flap perfusion. Additionally, careful fluid resuscitation is crucial to avoid fluid overload, which could increase the risk of flap failure. Multimodal pain management strategies were highlighted, including inhalational anesthetics, anti-inflammatories, narcotics, and regional anesthesia. In the postoperative period, effective communication between healthcare provider teams is essential. Airway management was linked to three of the five consensus statements, underscoring the need for clear and concise communication between the anesthesia and surgical teams. This includes coordinating ventilatory support weaning, extubation planning, and preparation for reintubation if necessary. Such measures help reduce intensive care unit (ICU) utilization, minimize airway-related adverse events, and shorten the length of hospitalization. Overall, the commentary hopes to serve as a guide for multidisciplinary head and neck oncology units across all international centers in managing this complex patient population.

Background and Objective: Microvascular free tissue transfer (MFTT) for reconstruction of oral cavity defects are complex and extensive surgeries that entail long procedure times, substantial blood loss, and meticulous preoperative planning in order to decrease perioperative complications and improve clinical outcomes. Many factors are important and contribute to the success of these surgeries. The purpose of this paper is to demonstrate the factors involved in perioperative management of head and neck patients undergoing MFTT of the oral cavity. Methods: An online review of scientific articles was performed using PubMed and Google Scholar to gather data from controlled trials, cohort studies, systematic reviews and meta-analyses. The search involved several keywords and their combinations including: oral cavity, free flap transfer, microvascular reconstruction of oral cavity. Articles were evaluated in a 25-year period from 1999-2024. The inclusion criteria were studies in English, literature relevant to the expert consensus, and relevance to our study. Key Content and Findings: A variety of factors are important in the perioperative management of the MFTT patient. Advancements in surgical techniques and postoperative flap monitoring have improved the success rate of oral cavity MFTT reconstruction. Furthermore, nutrition and behavioral factors remain important keys to medical optimization before MFTT. Finally, nutritional intake and pain management in the postoperative course are also important in wound healing and early mobilization. Conclusions: MFTT for oral cavity reconstruction is a complex science and requires meticulous planning and monitoring in the perioperative period to ensure free flap success rates, minimize complications, and improve clinical outcomes.

Background Dexmedetomidine is a highly selective alpha-2-receptor agonist and its use has not been well studied in major microvascular reconstructive surgery of the head and neck. Purpose The purpose is to measure the association between dexmedetomidine and neck hematoma formation in subjects undergoing head and neck microvascular reconstructive surgery. Study design, setting, and sample The investigators implemented a retrospective cohort study on subjects undergoing microvascular head and neck reconstruction for benign and malignant pathology at the University of Alabama at Birmingham from 2014 to 2021. Patients with unresectable tumors were excluded. Predictor variable(s) The predictor variable was the intraoperative use of dexmedetomidine (DEX) upon emergence from general anesthesia. Subjects received standard anesthetic drugs and DEX while control subjects received only standard anesthetic drugs. Main outcome variable(s) The primary outcome was postoperative neck hematoma (PONH) formation necessitating a return to the operating theatre. The secondary outcome was the length of stay (LOS). Covariates The covariates were demographic, operative, and oral morphine equivalents (OME) of anesthesia drugs. Analyses Bivariate analyses were performed using Student’s t-test and chi-square test for continuous and categorical variables. Multivariate regression analyses were conducted to assess for associations between DEX and the outcomes adjusted for confounding variables when present. P values of < 0.05 were regarded as statistically significant. Results A total of 297 subjects (mean age, 59.6 years, and standard deviation (SD), 14.9) with 61.6% male received DEX, and 304 subjects (mean age, 58.9 years, and SD, 14.6) with 60.2% male served as controls (P > 0.5). A total of 11 PONH occurred in the control group when compared to 2 in the DEX (Relative risk (RR) = 5.4, 95% Confidence interval (CI), 1.2 to 24, P=0.02). The mean LOS was 7.7 (SD, 4.3) and 9.4 (SD, 8.1) for the DEX and control groups (95%CI, 0.7 to 2.8, P<0.01). After adjusting for tobacco history, tracheostomy, and neck dissection, DEX (Beta coefficient (B) = -1.7, 95%CI -2.7 to -0.7, P<0.01) and neck dissection (B = 2.2, 95%CI 1.0 to 3.4, P<0.01) were statistically associated with LOS. Conclusions The use of intraoperative DEX upon emergence from general anesthesia was associated with lower postoperative neck hematoma formation and shorter length of stay following microvascular head and neck reconstruction.

A 10-year-old Hispanic girl with no prior medical conditions or known allergies came to the oral and maxillofacial surgery clinic for evaluation of painless oral lesions of 6 months' duration. Before her appearance at the clinic, she was seen at an urgent care center with symptoms of sore throat, erythema, and painless swelling of the oral lesions. After administration of nonsteroidal anti-inflammatory drugs, her symptoms improved, and she was discharged home with outpatient follow-up at our clinic.

Background A tracheostomy is routinely performed following free tissue transfer (FTT) for oral cavity reconstruction; however, its avoidance whenever possible is advocated to enhance patient recovery and reduce hospital length of stay (LOS). Purpose This study aims to measure and compare clinically relevant outcomes for patients who have endotracheal intubation versus tracheostomy for FTT for oral cavity reconstruction. Study Design, Setting, Sample A retrospective cohort study was conducted to evaluate subjects undergoing FTT of the oral cavity for benign and malignant pathology at the University of Alabama at Birmingham from 2014 to 2021. Subjects with unresectable tumors or defects that were not primarily located in the oral cavity were excluded. Independent Variable The independent variable was perioperative airway management and was divided into 2 groups: 1) endotracheal intubation or 2) tracheostomy. Main Outcome Variable(s) The main outcome measure was defined as a postoperative airway-related complication and required escalation of care to an intensive care unit. LOS and surgical complications were also analyzed. Covariates The covariates were classified as demographic, medical, pathologic, and operative. Analyses Bivariate and multivariate statistical analyses were conducted to compare the outcomes between subjects who were immediately extubated and tracheotomized. Subject demographics and operative parameters were also analyzed. Results A total of 560 subjects met the inclusion criteria, with 122 subjects in the immediate extubation group and 438 subjects in the tracheostomy group. The mean age was 59.7 ± 16.3 years in the immediate extubation group and 59.3 ± 13.8 years in the tracheostomy group (P = .8). The proportion of males was 57.4% in the immediate extubation group and 60% in the tracheostomy group (P = .6). No postoperative airway-related complications occurred in the endotracheal intubation group. After controlling for confounding factors, tobacco use was associated with airway-related complications (odds ratio [OR]: 2.66; 95% confidence interval: 1.1-6.3; P = .03). LOS was shorter in the endotracheal intubation versus tracheostomy group (6.8 vs 9 days, P < .01). Conclusion and Relevance In subjects who underwent FTT for oral cavity reconstruction, postoperative airway-related complications were associated with a tracheostomy and tobacco use status.

Rosai-Dorfman disease (RDD) is a rare histiocytic disorder with an unclear aetiology, and commonly presents with painless, bilateral cervical lymphadenopathy. Extranodal presentation in the absence of nodal involvement has been reported to have a predilection for the head and neck with less than 20 cases involving the jaw bones and sinuses. We present an interesting case of unifocal RDD of the infratemporal space in the absence of nodal involvement in a 61-year-old female treated with surgical excision and adjuvant radiation therapy.

This study aims to identify the rate of occult nodal metastasis (ONM), risk factors associated with ONM, and compare regional recurrence (RR), 2-year disease-free survival (DFS) in patients treated with elective neck dissection (END) versus expectant management (OBS) for primary T1–T2 gingival squamous cell carcinoma (GSCC) of the maxilla and mandible. A retrospective analysis was conducted and included patients from 2014 to 2021 who were treated at a tertiary referral center. Twenty patients underwent END and 36 were managed expectantly, with a mean follow-up period of 28 months. ONM was observed in 26

A tracheostomy is commonly performed following major oral cavity ablative and microvascular reconstructive surgery to secure the airway postoperatively. An elective tracheostomy is often performed for these major surgeries to avoid postoperative upper airway complications that can require an emergent re-intubation or surgical airway (eg, cricothyrotomy or tracheostomy) which can cause iatrogenic trauma to the reconstruction site and increase patient morbidity. 1 Patients with a tracheostomy that necessitate a return to the operating room postoperatively under general anesthesia will have an atraumatic anesthetic induction compared to those who are not tracheostomized. However, performing a tracheostomy is not without risks, which can include tracheal stenosis, bleeding, fistula formation, and pneumonia.2 The purpose of this study is to determine whether immediate extubation versus elective tracheostomy following free flap reconstruction of the oral cavity was associated with postoperative respiratory-related complications.

Traumatic pseudoaneurysm (TPA) is an extremely rare complication following a tooth extraction. TPAs are vascular lesions that occur due to extravasated blood that is still contained by the adventitia or adjacent soft tissue. This sac of blood may continue to expand, leading to superimposed infection, severe hemorrhage, or thromboembolism. In the maxillofacial region, TPA is most often associated with penetrating trauma, condylar fractures, or orthognathic surgery and can present days to weeks following the inciting event. The purpose of this paper is to review the management of a rare facial artery TPA following routine mandibular third molar tooth extraction in a 19-year-old healthy male. A computed tomography angiography and color Doppler ultrasound were used for diagnosis of the TPA. The initial treatment involved endovascular embolization followed by surgical excision due to the delayed appearance of a large 3-cm upper neck mass. While TPA is a rare complication following third molar surgery, we report the first case presenting to the head and neck surgeon as a unilateral neck mass following definitive endovascular therapy.

Purpose: Regional anesthesia has been shown to effectively manage acute pain and reduce opioid uti-lization in the early postoperative period following colorectal, orthopedic, and thoracic surgeries. The same effect, however, has not been demonstrated in major head and neck surgery. The purpose of this study is to determine whether supplemental regional anesthesia reduces opioid utilization following microvascular free flap reconstruction of the oral cavity. Methods: A prospective, randomized clinical trial was conducted for patients undergoing oral cavity reconstruction using microvascular free tissue transfer between January 2020 and March 2022. The pre-dictor variable was a regional anesthetic nerve block, delivered preoperatively, at the flap donor site. The primary and secondary outcomes were opioid utilization, measured in oral morphine equivalent (OME), from postoperative day 1 to 5, and hospital length of stay (LOS), respectively. Covariates included age, sex, tobacco and alcohol history, prior radiation therapy, pathology, oral site, flap type, tracheostomy, and neck dissection. Student's t test, c2 test, and linear regression models were computed using correla-tions with 95% confidence intervals (CIs). For all statistical tests, P values of <.05 were regarded as statis-tically significant. Results: Ninety-eight participants completed the study. The mean age was 56 years with 55% male. Forty-eight patients received a presurgical regional anesthesia block, and 50 patients served as control sub-jects. Bivariate analysis demonstrated an even distribution of all study variables. Total OME utilization was significantly less in the treatment group compared to the control group, (166.32 vs 118.43 OME; 95% CI, 1.32 to 94.45; P = .04). The LOS was comparable (6.60 vs 6.48 days; 95% CI, -0.53 to 0.77; P = .71). To-bacco use had a positive effect (B = 0.28; 95% CI, 21.63 to 115.31; P = .005) while the block had a negative effect with total OME, (B = -0.19; 95% CI, -90.39 to -0.59; P = .047). The extent of the neck dissection (B = 0.207; 95% CI, 0.026 to 1.403; P = .042) was a positive predictor for LOS. Overall, there were no adverse events associated with the regional block throughout the study period. Conclusions: Supplemental regional anesthesia is safe and associated with reduced opioid utilization in patients undergoing vascularized free flap reconstruction of composite oral cavity defects and does not prolong the length of hospitalization. Published by Elsevier Inc. on behalf of the American Association of Oral and Maxillofacial Surgeons

The temporomandibular joint (TMJ) is a ginglymoarthrodial joint that allows translational or sliding movement in the superior compartment and rotational or hinging movements in the inferior compartment. The articulation of both mandibular condyles with the glenoid fossa of the temporal bone is separated by a cartilaginous articular disk that allows the joint to undergo the functional movements involved in speech and mastication. Any anatomic disequilibrium of the TMJ can produce mechanical dysfunction and orofacial pain. The complexity of the TMJ necessitates a thorough understanding of the anatomy and physiology to diagnose and treat its pathology properly. The authors present the second of a three-part educational series on the TMJ, focusing on the pathophysiology and assessment of joint disorders.

Study Design Case report. Objective To highlight the diagnostic and treatment dilemma associated with chronic invasive fungal sinusitis (CIFS) in the immunocompetent individual. Methods The patient was initially treated for chronic bacterial sinusitis with antibiotic therapy and multiple surgical debridement with no evidence of fungal organisms. Following the completion of the left partial maxillectomy, mucormycosis was finally identified on histopathology, and the appropriate antimicrobial therapy was initiated. During this time, the patient received an interim maxillary obturator for speech and oral function. Following the resolution of CIFS, a computed tomography (CT) of the face was obtained for computer-aided surgical planning for a vascularized fibula flap reconstruction with endosseous dental implants using patient-specific surgical cutting guides and a reconstruction plate. Results Optimal esthetic and functional outcomes were achieved following the placement of the definitive dental prosthesis. The patient remained free of disease and without pain 2 years postoperatively. Conclusions Chronic invasive fungal sinusitis in the immunocompetent patient remains rare; however, delayed diagnosis can lead to inadequate treatment and extensive soft and hard tissue necrosis. Obtaining sufficient tissue sampling is essential for a definitive diagnosis of CIFS. This report demonstrates the challenge in diagnosing CIFS and the importance of the multidisciplinary approach to treat CIFS associated with extensive involvement of the maxilla.

Background Advance care planning is an integral part of supporting patients through serious illness and end-of-life care. Problem Several components of advance care planning may be too inflexible to account for patients' changing disease and evolving goals as serious illness progresses. Health systems are starting to implement processes to address these barriers, though implementation has varied. Proposed Solution In 2017, Kaiser Permanente introduced Life Care Planning (LCP), incorporating advance care planning dynamically into concurrent disease management. LCP provides a framework for identifying surrogates, documenting goals, and eliciting patient values across disease progression. LCP provides standardized training to facilitate communication and utilizes a centralized section within the electronic health record for longitudinal documentation of goals. Outcomes More than 6000 physicians, nurses, and social workers have been trained in LCP. Over one million patients have engaged in LCP since its inception, with over 52% of patients age 55+ having a surrogate designated. There is evidence of high treatment concordance with patients' desired wishes (88.9%), with high rates of advance directive completion as well (84.1%).

PURPOSE:Data on timing of oral intake (PO) after free flap reconstruction of the oral cavity have been limited. Recent studies have shown that early PO after free flap reconstruction does not lead to increased morbidity and has resulted in decreased hospital stay. The objective of this study is to assess postoperative complications associated with timing of PO after free flap reconstruction of the oral cavity and to define clinical predictors of postoperative complications. METHODS:This was a retrospective comparative cohort study and comprised of patients who underwent free flap reconstruction of the oral cavity between January 2014 and December 2019 in the Department of Oral and Maxillofacial Surgery at the University of Alabama at Birmingham. The predictor variable was timing of PO grouped into early (<5 days) and late (>5 days), postoperatively. The primary and secondary outcomes were postoperative complications and hospital length of stay (LOS), respectively. Covariates included age, gender, pathology, reconstruction site, flap type, tracheostomy, neck dissection, defect volume (cm3), skin paddle size (cm2), and gastrostomy tube (g-tube). Student's t-test, Chi-squared test, and binary logistic regression models were computed using odds ratios (ORs) with 95% confidence intervals (CIs). For all statistical tests, P values of < .05 were regarded as statistically significant. RESULTS:The sample consisted of 415 patients (253 males and 162 females), with a mean age of 58.8 years (range, 14.4-88.2 years). The majority had malignant pathology (68.9%) with defects involving the mandible (52.3%) and reconstructed with a radial forearm (43.6%), followed by fibula (39%), and osteocutaneous radial forearm (13%). Seventy one "early PO" and 344 "late PO" patients were analyzed. Early PO was associated with lower postoperative complications compared with the late PO group (RR = 0.847, 95% CI 0.747-0.960, P = .031) and shorter hospital LOS (6 vs 9 days, 95% CI 2.2459-3.720, P < .001). A regression model showed a 2% increase for postoperative complications with each unit (cm3) increase of defect volume (OR = 1.002, 95% CI 1.000-1.004, P = .035) and 2.286 times higher odds for postoperative complication in patients with a g-tube (95% CI 1.271-4.110, P = .006). CONCLUSIONS:Early PO after free flap reconstruction of the oral cavity was not associated with increased postoperative outcomes or delayed hospital course. Variables such as defect location, defect volume, and tracheostomy may increase the risk for postoperative complications and can help guide surgeons in deciding the optimal timing for PO postoperatively.

Midface defects can be life-changing, both functionally and psychologically, for the affected patient. Additionally, restoration of form, function, and aesthetics can be challenging for the reconstructive surgeon. For defects affecting facial subunits such as the nose and orbit, a maxillofacial prosthetic can both obturate the defect and achieve aesthetically pleasing outcomes. Osseointegrated implants placed into sound bone at the defect site allows the maxillofacial prosthodontist to optimize prosthesis retention without the need for adhesive or a mechanical device. In this article, we will share our multidisciplinary treatment protocol and outcome for addressing large midface defects using osseointegrated implant-retained maxillofacial prosthetics. Finally, we will also share our experience and challenges in the incorporation of digital technology in the prosthetic processes of the treatment plan. In the evolving digital age, rapid prototyping technologies have provided the reconstructive surgeon and maxillofacial prosthodontist the ability to accurately plan and execute predictable and reproducible results for a complex array of maxillofacial defects.