Surgical Tips for the Management of the Wide Nasal Base.

Alar base reduction (ABR) was first described by Weir in 1892, but continues to be a controversial topic in rhinoplasty in terms of optimal techniques. The authors describe the techniques for ABR including internal, external and combined ABR, flare excisions, and alar hooding reductions. The techniques described have resulted in consistent outcomes with acceptable scarring and high patient satisfaction.

Traumatic Tympanic Membrane Perforations Diagnosed in Emergency Departments.

Importance: Tympanic membrane perforations (TMPs) are frequent events leading to evaluation in the primary care and otolaryngology offices or the emergency department (ED). Despite specific warning labels on packaging of cotton-tipped applicators regarding the risk of injury to the ear canal with personal use, these products are commonly used to remove ear cerumen. Objective: To analyze the mechanism of injury for traumatic TMPs among patients presenting to the ED. Design, Setting, and Participants: Cross-sectional analysis of cases from 100 emergency departments in the United States. The National Electronic Injury Surveillance System was searched on April 3, 2015, for ear-related injuries with analysis information regarding patient age, patient sex, time and date of injury, specific injury diagnoses, and specific injury mechanisms that occurred across 5 years, from January 1, 2010, through December 31, 2014. Main Outcomes and Measures: Diagnoses of traumatic TMP documented in the ED visit record as well as patient demographics, diagnoses, and other aspects of the injury, including mechanism of injury. Results: There were 949 case entries in the database for traumatic TMP, which extrapolates to 4852 ED visits nationally. Of 949 patients evaluated, 568 (59.8%) were men and 381 (40.2%) were women resulting in a male to female ratio of 1.49:1. Most injuries occurred in patients 18 years or younger (602 of 949 [63.4%]) with children younger than 6 years most at risk (331 of 949 [34.9%]). Ear canal instrumentation including foreign bodies was noted in 581 of 949 cases (61.2%), with cotton-tipped applicators noted in 261 (44.9%) of these cases. While foreign body instrumentation represented the leading cause of traumatic TMP in patients aged 0 to 5 years (284 of 331 cases [85.8%]), 6 to 12 years (108 of 158 [68.4%]), 19 to 36 years (85 of 223 [38.1%]), 37 to 54 years (48 of 91 [52.7%]), and 55 years or older (22 of 33 [66.7%]), water trauma was the leading cause of TMP in patients aged 13 to 18 years (43 of 113 cases [38.1%]). Conclusions and Relevance: Traumatic TMP represents a common reason for evaluation in the ED. Despite common warnings regarding risk of injury to the tympanic membrane with use of a cotton-tipped applicator, it is still a major cause of traumatic TMPs. Other injury mechanisms also play an important role in the teenage and young adult populations.

Utility of intraoperative flexible endoscopy in frontal sinus surgery.

BACKGROUND: Surgical management of the frontal sinus can be challenging. Extensive frontal sinus pneumatization may form a far lateral or supraorbital recess that can be difficult to reach by conventional endoscopic surgical techniques, requiring extended approaches such as the Draf III (or endoscopic modified Lothrop) procedure. Rigid endoscopes may not allow visualization of these lateral limits to ensure full evacuation of the disease process. METHODS: Here we describe the utility of intraoperative flexible endoscopy in two patients with far lateral frontal sinus disease. RESULTS: In both cases, flexible endoscopy allowed confirmation of complete evacuation of pathologic material, thereby obviating more extensive surgical dissection. CONCLUSION: In cases where visualization of the far lateral frontal sinus is inadequate with rigid endoscopes, flexible endoscopy can be used to determine the need for more extensive dissection.

A 10-Year Analysis of Head and Neck Injuries Involving Nonpowder Firearms.

Objectives Firearms have an enduring and visible presence within American culture. However, the public health impact of nonpowder firearms and other "toy" guns has not been fully studied. These guns-including BB guns (ie, ball bearing), paintball guns, and pellet guns-are typically marketed to a younger audience. The objective of this study is to analyze head and neck injuries related to nonpowder firearms. Study Design Cross-sectional analysis of a national database. Setting Academic medical center. Subjects and Methods The National Electronic Injury Surveillance System was queried for head and neck injuries involving nonpowder guns, including air, BB, and pellet guns, and associated ammunition. Analysis of age, sex, incidence, injury location, and diagnosis was performed. Results From 2005 to 2014, there were 1695 cases recorded, or 55,060 estimated emergency room visits, due to injuries related to nonpowder guns and fired ammunition. The majority of patients were male (80.9%). These injuries were most common in children 6 to 12 years of age (37.9%), followed by those 13 to 18 years old (27.1%) and adults (≥19 years old; 17.8%), while preschool children (0-5 years) represented 17.2%. The most common injury diagnosis was penetrating foreign body (34.9%), followed by lacerations (24.3%) and contusions/abrasions (13.7%). Conclusion Nonpowder and other nonlethal firearm-related injuries to the head and neck region are a frequent source of emergency room visits nationally. Safety measures and public education on a mainstream level are required.

An Analysis of Patients Treated for Cerebrospinal Fluid Rhinorrhea in the United States from 2002 to 2010.

Background The Nationwide Inpatient Sample (NIS) database was used to analyze the demographic features and concomitant diagnoses in patients admitted with cerebrospinal fluid (CSF) rhinorrhea. Methods We analyzed the NIS database for all hospital admissions of CSF rhinorrhea between 2002 and 2010. Patient demographics, length of stay, hospital charges, concomitant diagnoses, hospital level characteristics, and complications were analyzed for patients undergoing surgical repair (group I) and for those treated without surgical repair (group II). Results Patients in group I were significantly older, the majority were female (67.5%), and were more likely to be obese (12.9%), have diabetes mellitus (15.7%), and hypertension (41.6%). Lengths of stay were similar between the two groups, but group I patients incurred higher hospital charges (p < 0.001). Group I patients were more likely classified as an elective admission (59.8 vs. 38.6%), and were more frequently admitted to a teaching hospital (83.6%) with a large bed size (79.0%). Acute medical complications and concomitant diagnosis of meningitis were similar in both groups. Conclusion Rates of meningitis did not differ between the two groups. Patients who underwent surgical repair were more likely to be an elective admission and admitted to a teaching hospital. Hospital charges were higher in patients undergoing repair.

Head and neck microvascular free flap reconstruction: An analysis of unplanned readmissions.

OBJECTIVES/HYPOTHESIS: Unplanned readmissions within 30 days of surgery represent a significant marker for healthcare quality. Small institutional studies have described rates of readmission for patients undergoing head and neck free flap reconstruction. However, large, multi-institutional analyses have not previously been described. STUDY DESIGN: Retrospective study of cases from the American College of Surgeons National Surgical Quality Improvement Program database. METHODS: Patients who underwent free flap reconstruction of the head and neck from 2011 to 2013 were identified. Univariate and multivariate analyses of unplanned readmission based on patient, laboratory, and hospital course characteristics were conducted. RESULTS: In total, 1,238 patients who underwent head and neck microvascular free flap reconstruction were included within the database, of which 1,204 patients had information pertaining to readmission. Overall 30-day readmission rate was 9.6%. A multivariate analysis of preoperative variables demonstrated that leukocytosis, diabetes mellitus, and hyponatremia were all associated with increased rates of readmission (odds ratio 2.224, 1.843, and 1.7423, respectively). A similar analysis of postoperative variables demonstrated that wound-related complications (surgical site infections and wound disruption), perioperative blood transfusion, and sepsis were associated with an increased rate of readmission. CONCLUSION: In patients with microvascular free flap reconstruction of the head and neck, the 30-day readmission rate was 9.6%. Preoperative diabetes mellitus, hyponatremia, and leukocytosis were associated with an increased rate of 30-day readmissions. Postoperative complications, particularly wound infections, perioperative blood transfusions, and sepsis, were found to be significant contributors to readmission. LEVEL OF EVIDENCE: 4. Laryngoscope, 2016 127:325-330, 2017.

Sinonasal fibrosarcoma: analysis of the Surveillance, Epidemiology, and End Results database.

BACKGROUND: Primary fibrosarcoma of the sinonasal region is an infrequently occurring malignant neoplasm. Fibrosarcomas are most commonly found in the extremities, with only 1% of fibrosarcomas reported in the head and neck region. This study analyzes the demographic, clinicopathologic, and survival characteristics of sinonasal fibrosarcoma (SNFS). METHODS: The Surveillance, Epidemiology, and End Results (SEER) database (1973 to 2012) was queried for SNFS cases. Data were analyzed with respect to various demographic and clinicopathologic factors. Survival was analyzed using the Kaplan-Meier model. RESULTS: Fifty-one cases of fibrosarcoma were identified in the sinonasal region. The mean age at diagnosis was 54.5 years and the mean survival was 119.7 months. There was no gender predilection with a male-to-female ratio of 1.04:1. The maxillary sinus was the most common site of involvement (54.9%), followed by the nasal cavity (23.5%). Five-year survival analysis revealed an overall survival rate of 71.7%, disease-specific survival rate of 77.8%, and relative survival (RS) rate of 78.8%. Disease-specific survival was better among those treated with surgery (with [76.2%] or without [87.5%] adjuvant radiotherapy) than those treated with primary radiotherapy alone (33.3%) (p = 0.0069). CONCLUSION: SNFS is a rare entity. This study represents the largest series of SNFS to date. The mainstay of treatment for this tumor is surgical resection with or without radiotherapy.

Characteristics of patients treated for orbital cellulitis: An analysis of inpatient data.

OBJECTIVES/HYPOTHESIS: Orbital cellulitis represents a spectrum of diseases, some of which may progress to potentially serious complications. The authors used the Nationwide Inpatient Sample (NIS) database to analyze the epidemiologic features of pediatric and adult patients admitted for the treatment of orbital cellulitis and to examine associations with surgical management. METHODS: The NIS was queried for patients admitted for treatment of orbital cellulitis from 2002 to 2010. Patient demographics, length of stay, hospital charges, and concomitant diagnoses were analyzed. RESULTS: There were 14,149 cases of orbital cellulitis identified with 1,717 (12.1%) having undergone surgical management. Surgical patients were older (29.6 ± 23.4) and more commonly male (62.0%) (P = 0.004 and < 0.001, respectively). Patients who had surgical intervention had longer length of stay and higher hospital charges than nonsurgical patients (P < 0.001). Our study showed that the proportion of pediatric patients age 10 to 19 years (22.1%) undergoing surgery was four times that of patients < 5 years of age (5.1%) (P < 0.001). Patients with concomitant diagnoses of acute and chronic sinusitis, acute osteomyelitis, exophthalmos, diplopia, and conjunctival edema had significantly increased odds ratio of surgical intervention. Frontal sinusitis was the site most commonly associated with surgical intervention among sinusitis patients. CONCLUSION: This study describes the characteristics of pediatric and adult patients admitted for orbital cellulitis from a national perspective. Patients 10 to 19 years of age were most likely to undergo surgical management. Acute and chronic sinusitis, acute osteomyelitis, exophthalmos, diplopia, and conjunctival edema were concomitant diagnoses associated with significantly increased odds ratio of surgical intervention. LEVEL OF EVIDENCE: 2C. Laryngoscope, 126:554-559, 2016.

Incidence of Suicide in Patients With Head and Neck Cancer.

IMPORTANCE: Suicide rates among patients with cancer in the US are significantly higher than those of the general population. To our knowledge, large cohort studies examining suicide rates among patients with head and neck cancer have not been performed. OBJECTIVE: To identify incidence rate, trends, and risk factors of suicide in patients with cancer of the head and neck. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study of geographic areas served by the Surveillance, Epidemiology, and End Results (SEER) program. In total, 350,413 cases of patients with head and neck cancer were recorded within the SEER registry between 1973 and 2011. Data analyses were performed in 2014. Incidence data were calculated from the subset of that population that had the cause of death category coded as "suicide and self-inflicted injury." EXPOSURES: Patients diagnosed as having a primary cancer of the head and neck region. MAIN OUTCOMES AND MEASURES: Influence of demographic factors, anatomic site of tumor, disease stage, and time since diagnosis on risk for suicide. RESULTS: Among 350,413 SEER registry patients with head and neck cancer, observed for 2,263,376 person-years, 857 suicides were identified with an age-, sex-, and race-adjusted suicide rate of 37.9/100,000 person-years. In contrast, the US general population suicide rate was 11.8 per 100,000 person-years. Suicide rates were higher in those treated with radiation alone (standardized mortality ratio [SMR], 5.12; 95% CI, 3.83-6.41) compared with those treated with surgery alone (SMR, 2.57; 95% CI, 1.66-3.49). The highest suicide risk was seen in patients with cancers of the hypopharynx (SMR, 13.91; 95% CI, 11.78-16.03) and larynx (SMR, 5.48; 95% CI, 4.14-6.81). CONCLUSIONS AND RELEVANCE: Patients with head and neck cancer have more than 3 times the incidence of suicide compared with the general US population. Furthermore, suicide rates were highest among those with cancers of the larynx and hypopharynx.

"Beaned": A 5-Year Analysis of Baseball-Related Injuries of the Face.

OBJECTIVES: Baseball remains one of the most popular and safest games played by children and adults in America and worldwide. Rules and equipment changes have continued to make the game safer. For youth leagues, pitching restrictions, safety balls, helmets, and face mask equipment continue to make the game safer. With increased utilization of safety equipment, the objective was to analyze recent trends in baseball-related facial injuries. STUDY DESIGN: Cross-sectional analysis of a national database. METHODS: The National Electronic Injury Surveillance System was searched for baseball-related facial injuries with analysis of incidence, age, and sex and specific injury diagnoses, mechanisms, and facial locations. RESULTS: From 2009 to 2013, there were 5270 cases entries, or 187,533 estimated emergency department (ED) visits, due to baseball-related facial injuries. During this time, there was a significant decline in the incidence of ED visits (P = .014). Inclusion criteria were met by 3208 visits. The majority of injuries occurred in patients ≤18 years old (81.5%). The most common injury was laceration (33.2%), followed by contusion (29.7%) and fracture (26.9%), while the most common injury site on the face was the nose (24.9%). The injuries were most commonly due to impact from a baseball (70%) or a bat (12.5%). CONCLUSION: The overall incidence of ED visits due to baseball-related facial injuries has decreased over the past 5 years, concurrent with increased societal use of protective equipment. Nonetheless, these injuries remain a common source for ED visits, and a continued effort to utilize safety measures should be made, particularly in youth leagues.

Current Status of Fractional Laser Resurfacing.

Fractional lasers were first developed based on observations of lasers designed for hair transplantation. In 2007, ablative fractional laser resurfacing was introduced. The fractionation allowed deeper tissue penetration, leading to greater tissue contraction, collagen production and tissue remodeling. Since then, fractional erbium:YAG resurfacing lasers have also been introduced. These lasers have yielded excellent results in treating photoaging, acne scarring, and dyschromia. With the adjustment of microspot density, pulse duration, number of passes, and fluence, the surgeon can adjust the treatment effects. These lasers have allowed surgeons to treat patients with higher Fitzpatrick skin types (types IV to VI) and greater individualize treatments to various facial subunits. Immunohistochemical analysis has demonstrated remodeling effects of the tissues for several months, producing longer lasting results. Adjuvant treatments are also under investigation, including concomitant face-lift, product deposition, and platelet-rich plasma. Finally, there is a short recovery time from treatment with these lasers, allowing patients to resume regular activities more quickly. Although there is a relatively high safety profile for ablative fractionated lasers, surgeons should be aware of the limitations of specific treatments and the associated risks and complications.

Malpractice in otology.

OBJECTIVE: (1) Analyze otologic procedural malpractice litigation in the United States of America. (2) Discuss ways to prevent future malpractice litigation. STUDY DESIGN AND SETTING: Case series with record review. METHODS: The study is a case series with review of court records pertaining to otologic procedures using the Westlaw legal database. The phrase medical malpractice was searched with terms related to otology and neurotology obtained from the AAO-HNS website. RESULTS: Of the 47 claims that met inclusion criteria, 63.8% were decided in the physician's favor, 25.5% were decided in the plaintiff's favor (average payment $446,697), and 10.6% were settled out of court (average payment $372,607). Cerumen removal was the most common procedure leading to complaint (21.3%) and the most likely procedure to lead to payment (50.0%). Hearing loss was the most common injury claimed among all cases (53.2%) and resulted in a high proportion of cases that led to payment (40.0%). Other common alleged injuries were facial nerve injury (27.7%), tympanic membrane perforation (23.4%), need for additional surgery (42.6%), and lack of informed consent (31.9%). In addition, cases resulting from acoustic neuroma or stapedectomy resulted in higher payments to the plaintiffs (average $3,498,597 and $2,733,000, respectively). CONCLUSIONS: Malpractice trials were resolved in the defendant's favor in the majority of cases. Cerumen removal was the most common procedure leading to complaint and the procedure most likely to result in payment. Hearing loss was the most common injury cited. Payment was highest in acoustic neuroma and stapedectomy cases.

Laser treatment of facial scars.

Laser treatment of facial scars cannot substitute for optimal initial repair. Nonetheless, laser treatments may serve as valuable adjunct interventions after initial wound healing. Proper classification of scars into atrophic, hypertrophic, and keloid categories enables the appropriate selection of laser modality.

Facial skin tightening with an 1100-1800 nm infrared device.

BACKGROUND/OBJECTIVES: To determine the efficacy of the 1100-1800 nm infrared device for facial and cervical skin tightening. METHODS: Ten female patients, with a mean age of 56.5 years, received two treatments 1 month apart with a chilled tip infrared device (Titan; Cutera, Brisbane, CA, USA). Individuals were examined and photographed prior to treatment and at 1 and 3 months post-treatment. Three treatment-independent evaluators compared the photographs and graded them on a standardized scale applied to seven regions subdividing the face and neck. After evaluating the photographs, the difference in pretreatment and post-treatment scores was expressed as a percentage. The patients also rated their results. RESULTS/CONCLUSION: The greatest tightening was achieved over the malar region, the upper neck and the body of the mandible. In these areas the average tightening was 10%, 10%, and 12% respectively. The patients reported a 32% improvement in the appearance of their cheeks and a 20% visible improvement in their necks. Overall, they were pleased with the result of this non-surgical skin tightening.