Considering the Interaction between Surgical Approach and Timing on Complication Rates of Complex Orbital Fracture Repair.

OBJECTIVE: The optimal approach and timing of complex orbital fracture repair is an unresolved issue that is complicated by unique clinical presentations and patient-specific considerations. Early surgical repair in less than 14 days is associated with fewer complications; however, there are no guidelines addressing the optimal timing for surgical repair. This study assesses the time of surgical repair and surgical outcomes of complex orbital fractures. METHODS: Retrospective chart review from 2010 to 2022. Adult patients with orbital fractures are treated with surgical repair. RESULTS: In all, 94 patients presented with orbital fractures and were treated with 108 surgeries. Postoperative complications: vision disturbance 33/108 (30.6%), gaze restriction 12/108 (11.1%), lid malposition 10/108 (9.3%), globe complication 13/108 (12.0%), and hardware issues 14/108 (13.0%). Postoperative complications were not significantly associated with the surgical approach used for fracture repair or the time of surgical repair. CONCLUSION: Postoperative complications following surgical repair of orbital fractures are not associated with surgical approach or time of repair following the initial injury.

Superiorly-based turnover skin flap: Pediatric tracheocutaneous fistula closure.

OBJECTIVE: To present a novel superiorly-based turnover skin flap for the primary repair of pediatric tracheocutaneous fistula closure, and to determine the efficacy and safety of this tracheocutaneous fistula turnover flap primary closure technique. SUBJECT AND METHODS: This retrospective review analyzed one surgeon's (DJK) pediatric tracheostomy decannulation methods and results, specifically relating to the development of tracheocutaneous fistulas, over a fourteen-year period, from October 2002 through June 2016. The review furthermore examined a turnover flap technique for the primary closure of tracheocutaneous fistulas described herein. RESULTS: Over the period of study, 57 patients were decannulated, of whom 31 (54%) developed a tracheocutaneous fistula. Mean duration of tracheostomy in patients who developed a tracheocutaneous fistula following decannulation was forty-two months compared to thirteen months in patients who did not. Duration of decannulation was an independently significant variable (P < .001) in tracheocutaneous fistula development while gender, age at tracheostomy and age at decannulation were not (P > .05). Of the 31 patients who developed a tracheocutaneous fistula, 30 (97%) elected to pursue tracheocutaneous fistula closure using the turnover flap technique described in this study. Mean time from decannulation to tracheocutaneous fistula repair was 132 days. All tracheocutaneous fistulas were successfully closed. There were no perioperative or postoperative complications and no patient required subsequent hospitalization or surgical revision. CONCLUSIONS: The turnover technique presented is simple, straightforward, reliable, safe, and effective with excellent cosmetic results.

Considerations for the successful decannulation of the pediatric patient: A single surgeon's experience.

OBJECTIVE: To characterize the steps and interventions necessary for successful decannulation of the chronic pediatric tracheostomy patient. METHODS: This retrospective review analyzed one surgeon's (DJK) pediatric tracheostomy decannulation methods and results at a tertiary academic medical center over a thirteen-year period, from October 2002 through November 2015. It also examined which tests and procedures were conducted on patients prior to their successful decannulation. RESULTS: Over the period of study, 46 patients met inclusion criteria for analysis and underwent decannulation after being followed in the clinic or the hospital. One of these patients had to have the tracheostomy tube replaced. In nearly all cases, these patients underwent a systematic progression from tolerance of daytime tracheostomy capping to a capped sleep study, and endoscopic airway evaluation. In recent years, a subset of patients also underwent sleep endoscopy. In nearly all cases, patients spent a single night in the hospital in a non-acute bed at the time of decannulation. Ninety-eight percent (n = 45) of patients were successfully and safely decannulated after having met the milestones that we employ at our institution. CONCLUSIONS: This study serves as a safe, efficient, and resource-prudent protocol for otolaryngologists to follow when considering tracheostomy decannulation in the pediatric population. Sleep endoscopy can play a helpful role in guiding decannulation decisions. Since it is impossible to employ a single rigid protocol of testing prior to decannulating all patients, clinical judgment must always be exercised in individual circumstances.