Is Penicillin Allergy a Risk Factor for Surgical Site Infection After Oral and Maxillofacial Surgery?

PURPOSE: The selection of perioperative antibiotics for prevention of surgical site infection (SSI) is often limited by the presence of a reported penicillin allergy. The purpose of this study was to determine if oral and maxillofacial surgery patients who report allergy to penicillin are at an increased risk of developing SSI. METHODS: A retrospective cohort study was performed of patients who underwent oral and maxillofacial surgical procedures in the operating room setting at a single institution between 2011 and 2018. The following categories of procedures were investigated: dentoalveolar, orthognathic, orthognathic with third molar extraction, pathology and reconstruction, and temporomandibular joint. The primary predictor and outcome variables were reported penicillin allergy and surgical site infection, respectively. Bivariate and multiple logistic regression analysis were performed. P < .05 was considered to be significant. RESULTS: The cohort was composed of 2,058 patients of which 318 (15.5%) reported allergy to penicillin. Beta-lactam antibiotics were administered less frequently to penicillin allergic patients perioperatively compared with those without penicillin allergy (7.9 vs 97.1%, P < .001), while clindamycin was more commonly administered (76.4 vs 2.5%, P < .001). Clindamycin was associated with a higher SSI rate compared with beta-lactam antibiotics (5.6 vs 1.4%, P < .001). Penicillin allergy was significantly associated with SSI at an adjusted odds ratio of 2.61 (95% CI 1.51 to 4.49, P = .001). After holding perioperative antibiotic usage equal between the 2 groups, penicillin allergy per se was no longer associated with SSI (P = .901), suggesting that the outcome was mediated by antibiotic selection. CONCLUSIONS: Penicillin allergy was associated with development of SSI due to receipt of non-beta-lactam antibiotics as perioperative prophylaxis. Formal allergy evaluation should be considered for patients with putative penicillin allergy.

Cricothyroid Membrane Puncture-Guided Tracheostomy: A New Technique for Emergency Airway Access.

PURPOSE: We sought to compare cricothyroid membrane puncture-guided tracheostomy (CMPGT) with surgical cricothyroidotomy (SC) and percutaneous tracheostomy with Griggs' guidewire dilating forceps (GWDF) for establishing an emergency airway in a porcine model. We hypothesized that CMPGT would be associated with a shorter time to ventilation and more rapid restoration of oxygenation. MATERIALS AND METHODS: We implemented a small pilot animal study. Eighteen miniature pigs were randomly assigned to undergo CMPGT, SC, or GWDF. The predictor variable was the technique used. The primary outcome variable was time to ventilation. Other outcome variables were efficiency of oxygenation restoration, procedure duration, and procedure-related complications. The data were assessed using 1-way analysis of variance and Bonferroni correction. The oxygen saturation (SpO2) changes over time were graphed using a time-series line plot. Statistical significance was set at P < .05. RESULTS: Airways were successfully established in all 18 pigs. SC (68 ± 4 seconds) showed the shortest procedure duration compared with GWDF (95 ± 3 seconds) and CMPGT (96 ± 4 seconds); however, the time to ventilation using CMPGT (21 ± 2 seconds) was significantly shorter than that with SC (68 ± 4 seconds) and GWDF (95 ± 3 seconds) (P < .01). Spo2 in each group increased postoperatively, reaching 95% at 120 seconds, 131 seconds, and 144 seconds in the CMPGT, SC, and GWDF groups, respectively. The slope of the ascending phase of the Spo2 curve was 0.38 for CMPGT, 0.42 for SC, and 0.53 for GWDF (P < .05). Two pigs in each group had minor intraoperative bleeding, and 1 pig in the SC group had moderate bleeding. CONCLUSIONS: The results of this animal study suggest that CMPGT is a time-efficient and safe technique for emergency airway access that allows for a more rapid return of ventilation and obviates conversion to definitive tracheostomy. Further cadaveric study is ongoing.

Vascularized fibular graft for pediatric mandibular reconstruction.

BACKGROUND: Although vascularized bone grafts have become well accepted in adults, especially following ablative head and neck procedures, there are few long-term reports of their use in pediatric patients. METHODS: In this study, the authors analyzed the outcomes of 18 free fibula grafts in 16 patients aged 10 months to 21 years (mean, 12 years) with an average follow-up of 5 years. Eleven patients had cancer-related defects, four had craniofacial anomalies, and one had a posttraumatic deformity. All patients with congenital malformations had been followed since birth, and the others had been followed from the time of their original cancer diagnosis or injury. RESULTS: Of the 16 patients, seven underwent irradiation and seven underwent chemotherapy. The most severe deformities were seen in those with cancer resection and radiation therapy. Most defects were hemimandibular; there was one total mandibular defect (a child with Ewing sarcoma). Ten patients had had previous failed nonvascularized bone grafts. Eleven flaps were osteocutaneous with either intraoral or extraoral components; most had multisegmental osteotomy and had one arterial and two venous anastomoses. All free fibula transfers were successful; there were no vascular problems and only two minor complications. CONCLUSION: A number of lessons are learned from careful analysis of this unique group of patients, and an algorithm of pediatric mandibular reconstruction is proposed.

Lymphatic malformation of the lingual base and oral floor.

BACKGROUND: Lymphatic malformation of the tongue and floor of the mouth is associated with chronic airway problems, recurrent infection, and functional issues related to speech, oral hygiene, and malocclusion. There are no accepted anatomic guidelines or treatment protocols. METHODS: This retrospective review focused on anatomic extent, treatment, complications, and airway management in 31 patients with lymphatic malformation of the lingual base and oral floor. RESULTS: Involved adjacent structures included the neck (77 percent), mandible (41 percent), face (42 percent), lips (10 percent), pharynx (45 percent), and larynx (26 percent). Fifty-eight percent of patients required tracheostomy during infancy; decannulation was possible in two-thirds of these patients. Management included resection alone (42 percent), resection and sclerotherapy (26 percent), resection and laser coagulation (16 percent), sclerotherapy and laser coagulation (16 percent), and resection and radiofrequency ablation (3 percent). Resection involved the neck (58 percent), floor of the mouth (52 percent), and tongue (42 percent); there were often multiple procedures. Aspiration was tried with little success in 10 percent of patients. Virtually all patients had residual abnormal lymphatic tissue. Complications and posttherapeutic problems included infection (81 percent), neural damage (27 percent), difficulty in speech (23 percent), feeding problems (10 percent), and seroma or hematoma (6 percent). Associated dental/orthognathic conditions, particularly prognathism and anterior open bite, were documented in one-third of patients. CONCLUSIONS: The initial step in the protocol is control of the neonatal airway. Staged cervical resection is undertaken in late infancy to early childhood; resection should also include abnormal tissue in the oral floor. Sclerotherapy is primarily for macrocystic disease or secondarily for recurrent cysts following partial extirpation. Vesicles of the mucous membranes and dorsal tongue are treated either by sclerotherapy, laser (carbon dioxide, yttrium-aluminum-garnet, or potassium-titanyl-phosphate), or radiofrequency ablation. Reduction for macroglossia is indicated for persistent protrusion or to allow correction of malocclusion. Embolization controls lingual bleeding. Orthognathic procedures are undertaken at the appropriate age, only after lingual size and position are acceptable.