Pediatric Trauma During COVID-19: What Have We Learned?

BACKGROUND: In December 2019, an outbreak of a novel pneumonia-like illness, COVID-19 (C-19), emerged in Wuhan, China. In March 2020, as the incidence of C-19 rose, the Israeli government, like that of other nations, declared a national state of emergency, and a full, general lockdown was announced. PURPOSE: The purpose of this study is to determine the incidence and characteristics of pediatric maxillofacial trauma presentation during the 2020 C-19 lockdown restrictions and compare them to periods outside lockdown between 2019 and 2020 (pre-C-19). STUDY DESIGN, SETTING, SAMPLE: A retrospective cohort study was conducted and included all pediatric patients (0-18 years) referred to the emergency department (ED) at Tzafon Medical Center, Israel, and diagnosed with maxillofacial injuries. Patients with missing demographic data and patients who did not complete the medical examination were excluded. PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE: The exposure variable is the date of injury-2020 C-19 lockdown period compared to the previous year (pre-C-19). MAIN OUTCOME VARIABLE(S): The main outcome variable was the number of pediatric maxillofacial trauma ED arrivals out of total pediatric ED arrivals and out of total maxillofacial ED arrivals. COVARIATES: Covariates included patient demographics, etiology, and place of injury. ANALYSES: The association between categorical variables was tested using the Fisher exact test or χ2 test for binary variables with relative risk when appropriate, logistic regression model used to predict outcome variable. P values were 2-tailed and statistical significance was defined as P < .05. RESULTS: The study sample comprised 1174 patients. Relative risk of presenting with oral and maxillofacial trauma out of all pediatric ED patients was 1.85 comparing C-19 period to pre-C-19 period (confidence interval [1.65; 2.073], P < .0001). Most of the injuries recorded during the C-19 restrictions occurred in the domestic environment (56.1% compared to 47.5% in pre-C-19, P < .001). Incidences necessitating treatment increased from 45.8 to 55% during C-19 (P = .002). CONCLUSION AND RELEVANCE: During C-19, there was a higher rate of pediatric injuries compared to pre-C-19. The incidence of domestic oral and maxillofacial injuries increased despite the considered home safety.

TMJ arthroscopic level 1 vs arthrocentesis in the management of internal derangement of the temporomandibular joint.

OBJECTIVES: The technique of lysis and lavage has shown excellent success rates in treating internal derangement of the temporomandibular joint (TMJ). This procedure has been shown to reduce pain and improve joint mobility, sometimes even in patients suffering from advanced stages of degenerative joint disease (Wilkes IV to V). There are two different approaches to lavage and arthrolysis: arthrocentesis and TMJ arthroscopy. The objective was to assess both approaches' efficacy in managing internal derangement of TMJ. METHOD AND MATERIALS: In total, 92 patients with clinical and radiographic documentation of internal derangement of the TMJ unresponsive to nonsurgical therapy were randomized to one of two surgical groups: arthroscopic lysis and lavage level 1 (64 patients) and arthrocentesis (28 patients). Radiologic changes in the joint, pain (visual analog scale), interincisal distance, lateral and protrusive movements, and clicks and sounds of the joints were recorded. Data were compared presurgically (T0) and in postoperative periods of 1 week (T1), and 1 (T2), 3 (T3), and 6 (T4) months. RESULTS: Both surgical modalities achieved a similar outcome. A gradual improvement was demonstrated during the follow-up periods with no reliance on radiologic changes to the joint or the TMJ diagnosis. More than that, significant differences were encountered in all parameters but protrusion between T0 and T4. Pain decreased from 7.16 ± 2.48 to 1.75 ± 1.98 for the arthroscopic group and from 7.53 ± 2.69 to 1.00 ± 1.86 for the arthrocentesis group (P = .000). CONCLUSION: Both the approaches of arthrocentesis and arthroscopic level 1 reduced pain and improved mouth opening and lateral and protrusive movements over time.

Unique challenges in naval military dentistry.

Divers are regularly exposed to a unique and changing environment that dentists must consider when treating such patients. This review focuses around two case studies encountered in naval dentistry: (i) diving barotrauma (pressure-induced injury related to an air space); and (ii) scuba diving mouthpiece-related oral conditions. Each condition is described by its effect on the oral cavity and in particular the teeth. Then we generally review the latest literature on the different effects of scuba diving on the diver's head, face and oral regions and emphasize methods of dental disease prevention, diagnostic tools and treatment guidelines.

A robust and interpretable gene signature for predicting the lymph node status of primary T1/T2 oral cavity squamous cell carcinoma.

Oral cavity squamous cell carcinoma (OSCC) affects more than 30 000 individuals in the United States annually, with smoking and alcohol consumption being the main risk factors. Management of early-stage tumors usually includes surgical resection followed by postoperative radiotherapy in certain cases. The cervical lymph nodes (LNs) are the most common site for local metastasis, and elective neck dissection is usually performed if the primary tumor thickness is greater than 3.5 mm. However, postoperative histological examination often reveals that many patients with early-stage disease are negative for neck nodal metastasis, posing a pressing need for improved risk stratification to either avoid overtreatment or prevent the disease progression. To this end, we aimed to identify a primary tumor gene signature that can accurately predict cervical LN metastasis in patients with early-stage OSCC. Using gene expression profiles from 189 samples, we trained K-top scoring pairs models and identified six gene pairs that can distinguish primary tumors with nodal metastasis from those without metastasis. The signature was further validated on an independent cohort of 35 patients using real-time polymerase chain reaction (PCR) in which it achieved an area under the receiver operating characteristic (ROC) curve and accuracy of 90% and 91%, respectively. These results indicate that such signature holds promise as a quick and cost effective method for detecting patients at high risk of developing cervical LN metastasis, and may be potentially used to guide the neck treatment regimen in early-stage OSCC.

Factors associated with prolonged hospitalizations from odontogenic infections in children.

OBJECTIVE: Oro-facial infections are common pathologies comprising a substantial health concern in the pediatric population. Incorrect or late treatment may lead to serious and possibly life-threatening complications. The aim of this study is to analyze variables associated with prolonged length of hospital stays (LOS) due to odontogenic infections in children. STUDY DESIGN: Data was collected from the records of patients (age <15 years) hospitalized due to odontogenic infections at Poriya Medical Center during the period of 1/2010-12/2015. Patients with oro-facial infections originating from other organs were excluded from the study as well as children with underlying systemic medical conditions that may affect recovery. RESULTS: A total of 411 patients (mean age 6.5 ± 2 years) were included in this study, with 58.4% being male. There were significantly higher (p < 0.05) values of white blood cell (WBC) counts in patients with >3 days LOS. Patients with >3 days LOS were also significantly older (8.4 vs. 6.3 years). There were no significant differences in sex distribution or other clinical or laboratory parameters between the groups. CONCLUSION: Older child age and higher WBC counts on admission are indicators for prolonged LOS.

Systems genetics analysis of oral squamous cell carcinoma susceptibility using the mouse model: current position and new perspective.

Oral squamous cell carcinoma (OSCC) is one of the most common human malignancies with complex etiology and poor prognosis. Although environmental carcinogens and carcinogenic viruses are still considered the main etiologic factors for OSCC development, genetic factors obviously play a key role in the initiation and progression of this neoplasm, given that not all individuals exposed to carcinogens develop the same severity of the disease, if any. Identifying genetic loci modulating OSCC risk may have several important clinical implications, including early detection, prevention and developing new treatment strategies. Due to limitations in controlled and standardized genetic studies in humans, genetic components underlying susceptibility of OSCC development remain largely unknown. A combination of quantitative trait loci mapping in mice, with complementary association studies in humans, has the potential to discover novel cancer risk loci. As of today, a limited number of genetic analyses were applied on rodent models to locate novel genetic loci associated with human OSCC. Here, we discuss the current status of the mouse models use for dissecting the genetic basis of OSCC and highlight how systems genetics analysis using mouse models, may increase our understanding of human OSCC susceptibility.

Mucoadhesive Hybrid Polymer/Liposome Pastes Based on Modified Polysaccharides.

Mucoadhesive hybrid polymer/liposome paste is a new drug delivery system presenting controllable and tailorable delivery mechanism. By using mucoadhesive material, the delivery can be more specific and local. Here, we present a study investigating the effect of polymer type, concentration, functional end group, and cross-linking on the release profile of nanoliposomes from polymer pastes. Polymer pastes can be expected to combine the mucoadhesion mechanisms of dry and wet dosage forms but have not been studied extensively. To better understand the mucoadhesion of pastes, we investigated a series of pastes based on the same polymer and used different chemical modifications that can produce interactions at different levels. Native and thiolated polymers presented enhanced mucoadhesion in a wet environment in comparison to acrylated polymers which dissolved rapidly because of the enhanced solubility of PEG chains in water. Paste cross-linking resulted in a sustained release profile compared to non-cross-linked pastes. Pectin-SH pastes, especially 3% (w/v), showed a linear liposomal release profile which is ascribed to the combination of ionic cross-linking and disulfide bridging. By configuring the polymer type or concentration, we can control the release mechanisms and achieve distinct inherent properties which can be applied for diverse medical applications.

The efficiency of extended postoperative antibiotic prophylaxis in orthognathic surgery: A prospective, randomized, double-blind, placebo-controlled clinical trial.

Postoperative antibiotics are commonly administered in orthognathic surgery, despite the fact that there is no consensus regarding their efficacy. The objective of this study was to investigate the effectiveness of postoperative antibiotics in orthognathic surgery by conducting a prospective, randomized, double-blind, placebo-controlled trial. Patients were randomly allocated into one of two study groups: the intervention group (treated with 1 g of intravenous (IV) amoxicillin-clavulanate TID) or the placebo group (treated with 50 mL of IV 0.9% NaCl TID). The infection rate was assessed using clinical and laboratory parameters. The intervention group included 38 patients, with 40 patients in the placebo group. Baseline and surgical characteristics were comparable between both groups. Mean postoperative C-reactive protein (CRP) and temperature were similar for both groups. Serous discharge was observed in two patients (both in the placebo group), and one of them required surgical intervention. Overall, infection rate was similar in both groups (p-value > 0.1). To conclude, administration of postoperative antibiotics in healthy, young patients undergoing orthognathic surgery did not show a significant advantage in reducing surgical infection rate.

Clinical significance of preoperative imaging in oral squamous cell carcinoma compared with lymph node status: a comparative retrospective study.

OBJECTIVE: The accuracy and sensitivity of commonly used imaging modalities in evaluating oral cavity cancer was evaluated by comparing the preoperative radiologic findings and the postoperative pathology report. STUDY DESIGN: Patients with oral squamous cell carcinoma, who had undergone at least 1 imaging test 2 weeks before surgery were included. Radiologic findings were compared with the dissected neck findings to assess the lymph node status. Sensitivity and specificity of the imaging modalities were calculated by using the χ2 test. RESULTS: Sensitivities for detecting metastatic neck lymph nodes at a threshold of 1 cm were 48% (P = .02) and 43.8% (P = .3) for computed tomography (CT) and magnetic resonance imaging respectively. Specificities were 76.3% and 70%, respectively. As for the 1.5 cm threshold, sensitivities were 36% (P = .002) and 31.3% (P = .5), respectively, and specificities were 91.5% and 76.7%, respectively. PET-CT was the most sensitive modality in the present study, with a P value of .02. CONCLUSIONS: The different studied imaging modalities used for preoperative neck staging are not sensitive enough and would lead to underdiagnoses of a significant proportion of patients. Thus, prophylactic neck dissection for occult neck disease is of extreme importance and remains the gold standard for oral cancer treatment.

Level IIB Neck Dissection in Oral Squamous Cell Carcinoma: Science or Myth?

Selective neck dissection enables us to reduce the morbidity of neck dissection while maintaining the same oncological results, mainly in clinically negative neck N0. The most common morbidity associated with selective neck dissection is spinal accessory nerve dysfunction and related shoulder disability, which are encountered during dissection of level IIB.The aim of authors' study is to evaluate the incidence of sublevel IIB lymphatic metastasis in clinically N0 oral squamous cell carcinoma (OSCC) patients.The study group comprised 48 men (68%) and 22 women (32%). The median number of the lymph nodes removed from level IIB was 6.5. All the investigated necks were clinically classified as N0, of which 14 (20%) turned out to have an occult nodal metastasis, including only 1 patient (1.42%) of level IIB occult metastasis, which originated from the primary tumor located in the tongue and also metastasized to level IIA. The most associated morbidity was shoulder pain and dysfunction, which presented in 60% of the patients.Also, an electronic search was conducted to find relevant studies investigating the prevalence of level IIB metastasis in OSCC. Ten studies were included for full text review, including the current study. The overall incidence of level IIB metastasis is 4% (17 patients); of these 17 patients, only 4 patients had isolated level IIB nodal metastases (2%).To conclude, neck dissecting, including dissecting level IIB, remains the keystone of treating OSCC. Its prognostic and therapeutic value exceeds its associated morbidity; therefore, dissecting level IIB is recommended in treating OSCC in clinically N0 patients.

Lymphoepithelial carcinoma--review of the treatment modalities and report of a rare case in the sublingual gland.

Controversies exist in the current literature regarding the treatment of lymphoepithelial carcinoma (LEC). The presented study summaries the literature controversies in the treatment of LEC and present a case of a rare LEC diagnosed in the sublingual gland of an otherwise healthy 21-year-old Arab woman. The patient was admitted for swelling in the sublingual area. A biopsy indicated a diagnosis of LEC of the sublingual gland. Treatment included a wide resection with safe margins, marginal mandibulectomy, functional neck dissection, and a radial forearm free flap for reconstruction. The patient received concomitant radiotherapy and has remained disease free since her last follow-up. The recommended primary treatment, based on the literature review, is primary surgical excision with neck dissection and optional adjuvant radiotherapy to the gland area. Chemotherapy was not found to be beneficial according to the literature.

Does long-term treatment with Doxil® predispose patients to oral cancer?

We present a possible adverse reaction related to long-term use of Doxil(®) in female patients. We believe that long-term use of Doxil(®) may predispose female patients to oral squamous cell carcinoma. The patients in this report were not exposed to the common risk factors related to oral cancer formation such as smoking or alcohol consumption. Both patients were 59-year-old females. The first patient was diagnosed in 2001 with stage IIIC ovarian cancer. Seven years following treatment with Doxil(®), she was diagnosed with stage III squamous cell carcinoma of the right maxilla. The second patient was diagnosed with Kaposi's sarcoma with evidence of spread to the lungs. Four years following treatment with Doxil(®) she was diagnosed with stage I squamous cell carcinoma of the left maxilla. A literature review did not reveal any report on Doxil(®) and predisposition to oral cancer; however, we found an abstract that was presented at the last annual meeting of the American Society of Clinical Oncology (ASCO) by Cannon et al. When we combine the data from Cannon et al. and the data presented here, a total of six female patients developed an epithelial carcinoma of the oral cavity following long-term treatment with Doxil(®). We believe that a large-scale study should be initiated on patients that were treated with Doxil(®) for more than 3 years, since these patients might be at risk for developing secondary cancer of the oral cavity.

Incidence of oral cancer occult metastasis and survival of T1-T2N0 oral cancer patients.

PURPOSE: In head and neck cancer, the most important prognostic factor is the presence or absence of neck metastasis. Although still debated in the published data regarding the "wait and see" policy for Stage T1-T2 oral cancer, a large number of clinicians support the necessity of neck dissection, especially in cases of oral tongue carcinoma, because of the poor prognosis and high risk of recurrence. The aim of the present study was to summarize and quantify the incidence of occult metastasis in oral cancer treatment at the oral and maxillofacial surgery department, Rambam Medical Center, in the past 10 years. PATIENTS AND METHODS: A total of 142 neck dissections performed at our department in the past 10 years (1998 to 2009) and a series of 68 patients (44 men and 22 women) treated for Stage T1N0 or T2N0 oral cancer were included in the present retrospective study. All patients underwent surgical resection of the oral cancer and selective neck dissection of the ipsilateral side. RESULTS: Occult lymph node metastases were detected in 11 patients (16% overall, 9 in the tongue, 1 in the buccal mucosa, and 1 in the gingiva of the mandible). The frequency of occult metastasis from tongue carcinoma was 34% (9 of 26 cases). The 5-year survival rate in the present study was 78.9%. In patients who underwent chemotherapy, radiotherapy, brachytherapy, or a combination of the 3 after surgical management, the overall survival rate decreased significantly to 22.5% (P = .006, log-rank test). CONCLUSION: The incidence of occult metastasis in patients with oral cancer in the present study was 16% overall. In those with tongue carcinoma, a much greater incidence (34%) of occult metastasis was detected. Furthermore, the need for chemoradiotherapy after initial surgical management, mainly because of occult metastasis, was a significant negative predictor of patient outcome. The results of the present study emphasize the need for prophylactic neck dissection in patients with oral cancer diagnosed with Stage T1N0 or T2N0 disease, especially when the primary lesion is localized in the tongue.

Superficial parotidectomy versus retrograde partial superficial parotidectomy in treating benign salivary gland tumor (pleomorphic adenoma).

PURPOSE: Of all benign salivary gland tumors of the parotid gland, pleomorphic adenoma (mixed tumor) is the most common. It accounts for 60% to 70% of all benign tumors of the parotid gland. This neoplasm arises in patients in the fourth to sixth decade of life, with a female predominance. The surgical excision of this lesion continues to be the subject of major debate. The goal is to avoid facial disability yet attain complete resection without perforation of the capsule/pseudocapsule. The purpose of our study is to compare 2 surgical techniques performed at the Ear, Nose, and Throat and Maxillofacial Departments, Rambam Medical Center, Haifa, Israel, and determine which is preferable in treating this lesion. PATIENTS AND METHODS: We reviewed 48 patients who underwent excision of pleomorphic adenoma of the parotid gland between 1996 and 2005 at Rambam Medical Center: 18 were treated surgically with the classical superficial parotidectomy (SP) technique, using an anterograde approach, and 30 were treated with retrograde partial superficial parotidectomy (PSP). We compared the 2 surgical techniques in terms of surgical time, histopathologic size of the lesion, amount of excised healthy parotid tissue, histologic margin, and the preservation of the capsule/pseudocapsule. We also made clinical records of temporary or definitive injury to the facial nerve, which branches of the facial nerve were temporarily or definitively injured, the occurrence of Frey syndrome, esthetic satisfaction, and the amount of recurrence or infection after surgery. RESULTS: Of the 48 patients, 19 (39.6%) were male and 29 (60.4%) were female, with a mean age (+/- SD) of 43.8 +/- 16.97 years (median, 50 years; range, 12-79 years). We found a significant difference (P = .029) in mean surgical time (+/- SD): 171 +/- 49.7 minutes (median, 165 minutes) when performing the classical SP and 145 +/- 42.7 minutes (median, 130 minutes) when performing the retrograde PSP. Much more healthy parotid tissue was taken out with the classical procedure (mean, 51.4 +/- 13.6 mm; median, 50 mm) than with the retrograde PSP technique (mean, 39.2 +/- 11.8; median, 35 mm) (P = .01). There was a significant difference (P = .0003) in facial nerve injuries: 39% of patients did not report any facial deficit in the SP group compared with 90% in the PSP group. In the SP group, only 3 patients reported a permanent deficit, and in the PSP group, only 3 patients had a temporary deficit (compared with 8 in the SP group). The main injuries occurred in the mandibular branch with both techniques: 6 SP and 2 PSP. There was no difference in esthetic satisfaction: 72.2% of patients in the SP group and 80% in the PSP group had no esthetic complaints. In the SP group, patients mainly complained about swelling (3 patients), and in the retrograde PSP group, the main complaint was depression (4 patients). Frey syndrome was found in 9 patients in the retrograde PSP group and 4 in the classical SP group (with an overall rate of 27.7%). The lesion recurred in only 2 patients--1 in each group. CONCLUSION: With both of the techniques, we found satisfactory results. In the majority of cases, retrograde PSP is a superior technique to the classical SP, although Frey syndrome is more often observed with the former.

Maxillofacial trauma patient: coping with the difficult airway.

Establishing a secure airway in a trauma patient is one of the primary essentials of treatment. Any flaw in airway management may lead to grave morbidity and mortality. Maxillofacial trauma presents a complex problem with regard to the patient's airway. By definition, the injury compromises the patient's airway and it is, therefore, must be protected. In most cases, the patient undergoes surgery for maxillofacial trauma or for other, more severe, life-threatening injuries, and securing the airway is the first step in the introduction of general anaesthesia. In such patients, we anticipate difficult endotracheal intubation and, often, also difficult mask ventilation. In addition, the patient is usually regarded as having a "full stomach" and has not been cleared of a C-spine injury, which may complicate airway management furthermore. The time available to accomplish the task is short and the patient's condition may deteriorate rapidly. Both decision-making and performance are impaired in such circumstances. In this review, we discuss the complexity of the situation and present a treatment approach.