Christopher F. Viozzi

Mayo clinic consensus statement for the use of bisphosphonates in multiple myeloma.

Bisphosphonates are effective in the prevention and treatment of bone disease in multiple myeloma (MM). Osteonecrosis of the jaw is Increasingly recognized as a serious complication of long-term bisphosphonate therapy. Issues such as the choice of bisphosphonate and duration of therapy have become the subject of intense debate given patient safety concerns. We reviewed available data concerning the use of bisphosphonates in MM. Guidelines for the use of bisphosphonates in MM were developed by a multidisciplinary panel consisting of hematologists, dental specialists, and nurses specializing in the treatment of MM. We conclude that intravenous pamidronate and intravenous zoledronic acid are equally effective and superior to placebo in reducing skeletal complications. Pamidronate is favored over zoledronic acid until more data are available on the risk of complications (osteonecrosis of the jaw). We recommend discontinuing bisphosphonates after 2 years of therapy for patients who achieve complete response and/or plateau phase. For patients whose disease is active, who have not achieved a response, or who have threatening bone disease beyond 2 years, therapy can be decreased to every 3 months. These guidelines were developed in the Interest of patient safety and will be reexamined as new data emerge regarding risks and benefits.

Temporal Bone Fractures : A Review for the Oral and Maxillofacial Surgeon

Fracture of the temporal bone is, by definition, a fracture of the skull base. Even though the oral and maxillofacial surgeon (OMS) may not provide definitive management of temporal bone fractures or their sequelae, a working knowledge of this area is important for any surgeon participating in the care of patients with craniomaxillofacial trauma, because temporal bone fractures are often associated with injuries to other areas of the craniomaxillofacial skeleton and because these fractures are relatively frequent. In many centers, particularly community hospitals, the OMS may be the primary provider of care for facial trauma and will treat patients with clinical or radiographic evidence of temporal bone fractures. Immediate access to other specialists to manage or observe these injuries may not be possible, making the OMS responsible for early evaluation and management. This article briefly reviews the epidemiology of temporal bone injuries, as well as the pertinent anatomy, radiographic imaging findings, and ancillary testing maneuvers. It then presents a more detailed description of the various clinical findings and the associated management strategies. It concludes with a discussion of the subset of temporal bone fractures involving the temporomandibular joint.

Morbidity and Mortality Associated With Dental Extraction Before Cardiac Operation

BACKGROUND Dental extraction of abscessed or infected teeth before cardiac operation is often performed to decrease perioperative infection and late endocarditis. Literature to support dental extraction before cardiac operation is limited. The goal of this study was to evaluate the risk of major adverse outcomes in patients undergoing dental extraction before cardiovascular surgical procedures. METHODS A retrospective review was performed to identify patients who underwent dental extraction before planned cardiac operation. Major adverse outcomes within 30 days after dental extraction or until time of cardiac operation were recorded and defined as death, acute coronary syndrome, stroke, renal failure requiring dialysis, and need for postoperative mechanical ventilation. RESULTS Two hundred five patients underwent 208 dental extractions before 206 planned cardiac operations. Major adverse outcomes occurred in 16 of 205 patients (8%). Twelve patients (6%) died within 30 days after dental extraction, of which 6 (3%) occurred before cardiac operation, and 6 (3%) occurred after cardiac operation. CONCLUSIONS Patients with planned dental extraction before cardiac operation are at risk for major adverse outcomes, including a 3% risk of death before cardiac operation and an 8% risk of a major adverse outcome. The prevalence of major adverse outcomes should advise physicians to evaluate individualized risk of anesthesia and surgical procedures in this patient population.

Long-term results of radiation prophylaxis for heterotopic ossification in the temporomandibular joint.

PURPOSE To assess the long-term efficacy and toxicity of radiation therapy (RT) for postoperative prophylaxis of recurrent heterotopic ossification (HO) in the temporomandibular joint (TMJ). PATIENTS AND METHODS Twelve patients (18 joints) with bony ankylosis of the TMJ from HO were referred to undergo RT after arthrotomy with osseous recontouring, gap arthroplasty, or costochondral grafting. Treatment consisted of 10 Gy in 5 daily fractions to a field encompassing the TMJ with an adequate margin. RT was initiated 1 to 3 days postoperatively. Response to therapy was assessed by routine x-ray films obtained preoperatively, immediately postoperatively, and at follow-up by use of the Turlington-Durr grading system. Treatment efficacy was defined as freedom from HO re-formation requiring further surgical intervention. Efficacy and toxicity data were obtained from review of the medical records and were augmented by telephone interview of patients when possible (6 patients, all with follow-up >16 years). Efficacy rates by patient were estimated by the Kaplan-Meier method. RESULTS The median follow-up after RT was 16.4 years (range, 2.5-19.2 years). Symptomatic re-formation of HO requiring further surgery occurred in 5 patients (7 joints). Treatment efficacy rates were 71% (95% confidence interval [CI], 44-99) at 5 years and 48% (95% CI, 15-80) at 10 years. Of the 6 patients contacted regarding late toxicity, 2 had clinical xerostomia (grade 1, CTCAE v3.0) attributable to RT; no other late RT-related toxicities were noted. None of the 12 patients had malignancy attributable to RT. CONCLUSIONS Postoperative RT prevented re-formation of TMJ HO in 50% of treated patients long term. Late toxicities from RT were mild and infrequent.

Large Symptomatic Carotid Body Tumor Resection Aided by Preoperative Embolization and Mandibular Subluxation

Carotid body tumors (CBT) are rare and usually benign neoplasms (60%-90%), originating from the mesoderm and neural ectoderm. In view of the extensive and unrelenting growth of unresected CBT, encasing vital neurovascular structures, and the significant incidence of malignancy (> or = 10%), surgical excision is the standard treatment of choice. Despite progress in CBT imaging and surgical technique, cranial nerve deficit, stroke, and death continue to affect 10% to 40% of patients undergoing curative surgical resection, particularly in large tumors proximal to the skull base. In such cases, CBT shrinkage by preoperative embolization, improved surgical access utilizing mandibular subluxation, and electroencephalographic monitoring combined with meticulous surgical technique may enable curative tumor resection, without prohibitive morbidity. In light of associated disability, preoperative acknowledgment of the ever-present substantial risk of cranial nerve injury cannot be overemphasized. We report on a patient with a large symptomatic CBT treated surgically with the aid of mandibular subluxation and preoperative embolization.

Auriculotemporal neuralgia secondary to TMJ synovial cyst: a rare presentation of a rare entity.

Synovial cysts of the temporomandibular joint are rare, and to our knowledge, only 14 cases have been reported. The most common presentation is local pain and swelling. We present a case of a synovial cyst presenting with neuralgia in the distribution of the auriculotemporal nerve, initially misdiagnosed as trigeminal neuralgia.

Lower Extremity Compartment Syndrome Associated With Hypotensive General Anesthesia for Orthognathic Surgery: A Case Report and Review of the Disease

d p i t t h s d ompartment syndrome (CS) is a process that occurs hen pressure increases within closed, inelastic musulofascial compartments. A vicious cycle begins as eperfusion follows ischemia, leading to edema. dema in a fixed space can result in pressures elevatng above capillary pressure; arterial inflow and veous outflow are thus diminished. This process is rogressive, with worsening ischemia, further presure increase, halted outflow, and eventually, when he metabolic demands of the tissue are no longer et, rhabdomyolysis and necrosis. This rapidly progressive complication is especially evastating to the muscles and nerves of the lower xtremity involved with ambulation. Several etiologies or CS have been described in the literature. These nclude trauma, exercise, drug abuse, peripheral vascuar disease, snake bites, obesity, vasocompressive mediation, muscular physique, anesthesia-induced hypotenion, long-duration surgeries, and surgical positioning long-term compression and pedal dorsiflexion). Although trauma is the most common cause of CS, ong-duration surgeries in lithotomy position are recgnized causes of CS. There are very few reports on

Impact of Intraoperative Fluid Administration on Length of Postoperative Hospital Stay Following Orthognathic Surgery

PURPOSE The purpose of this study was to evaluate whether the volume of intraoperative fluids administered to patients during routine orthognathic surgery is associated with increased length of hospital stay for postoperative convalescence. MATERIALS AND METHODS A retrospective cohort study design was used to identify 168 patients undergoing routine orthognathic surgery at Mayo Clinic from 2010 through 2014. The primary predictor variable was total volume of intravenous fluids administered during orthognathic surgery. The primary outcome variable was the length of hospital stay in hours as measured from the completion of the procedure to patient dismissal from the hospital. Additional covariates were collected including patient demographic data, preoperative American Society of Anesthesiologists (ASA) score, type of intravenous fluid administered, complexity of surgical procedure, and duration of anesthesia. RESULTS On univariate analysis, total fluid was significantly associated with increased length of stay (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.42 to 2.33; P < .001). After adjustment for surgical complexity and duration of anesthesia on multivariable regression analysis, the association of fluid level with length of hospital stay was no longer statistically significant (OR, 0.86; 95% CI, 0.61 to 1.22; P = .39). Duration of anesthesia remained the only covariate that was significantly associated with increased length of hospital stay in the multivariable regression model (OR, 2.21; 95% CI, 1.56 to 3.13; P < .001). CONCLUSIONS Among surgical complexity, duration of anesthesia, and total volume of intraoperative intravenous fluids administered for routine orthognathic surgery, the duration of anesthesia has the strongest predictive value for patients requiring prolonged hospital stay for postoperative convalescence.

Impact of Perioperative Fluid Administration on Postoperative Morbidity and Length of Hospital Stay Following Maxillomandibular Advancement for Obstructive Sleep Apnea

PURPOSE The purpose of this study was to evaluate whether the volume of perioperative fluids administered to patients undergoing maxillomandibular advancement (MMA) for treatment of obstructive sleep apnea (OSA) is associated with an increased incidence of postoperative complications and prolonged length of hospital stay. MATERIALS AND METHODS A retrospective cohort study design was implemented and patients undergoing MMA for OSA at the Mayo Clinic were identified from 2001 through 2014. The primary predictor variable was the total volume of intravenous fluids administered during MMA. The primary outcome variable was length of hospital stay in hours. Secondary outcome variables included the presence of complications incurred during postoperative hospitalization. Additional covariates abstracted included basic demographic data, preoperative body mass index, preoperative apnea-hypopnea index, preoperative Charlson comorbidity index, preoperative American Society of Anesthesiologists score, type of intravenous fluid administered, surgical complexity score, duration of anesthesia, duration of surgery, and the use of planned intensive care unit admission. Univariate and multivariable models were developed to assess associations between the primary predictor variable and covariates relative to the primary and secondary outcome variables. RESULTS Eighty-eight patients undergoing MMA for OSA were identified. Total fluid volume was significantly associated with increased length of stay (odds ratio [OR] = 1.34, 95% confidence interval [CI], 1.05-1.71; P = .020) in univariate analysis. Total fluid volume did not remain significantly associated with increased length of hospital stay in stepwise multivariable modeling. Total fluid volume was significantly associated with the presence of postoperative complications (OR = 1.69; 95% CI, 1.08-2.63; P = .021) in univariate logistic regression. CONCLUSION Fluid administration was not found to be significantly associated with increased length of hospital stay after MMA for OSA. Increased fluid administration might be associated with the presence of postoperative complications after MMA; however, future large multicenter studies will be required to more comprehensively assess this association.

Relationship of Number of Missing Teeth to Hip Fracture in Elderly Patients: A Cohort Pilot Study: Relationship of Tooth Count to Hip Fracture

PURPOSE To determine the relationship between the number of missing natural teeth or remaining natural teeth and osteoporotic hip fracture in elderly patients and to determine the relationship between the number of missing teeth or remaining teeth and osteoporotic fracture risk assessment (FRAX) probability. MATERIALS AND METHODS Number of missing teeth was determined by clinical oral exam on a total of 100 subjects, 50 with hip fractures and 50 without. Ten-year fracture risk and hip fracture risk probabilities were calculated using the FRAX tool. Statistical analyses were performed to determine strength of associations between number of missing natural teeth and likelihood of experiencing a fracture. Degree of correlation between number of missing natural teeth and FRAX probabilities were calculated. RESULTS There appears to be an association between the number of missing natural teeth and hip fractures. For every 5-tooth increase in the number of missing teeth, the likelihood of being a subject in the hip fracture group increased by 26%. Number of missing natural teeth was positively correlated with FRAX overall fracture and hip fracture probability. CONCLUSIONS Number of missing natural teeth may be a valuable tool to assist members of medical and dental teams in identifying patients with higher FRAX scores and higher likelihood of experiencing a hip fracture. Additional research is necessary to validate these findings.