The osteocutaneous radial forearm free flap: A pictorial essay.

The osteocutaneous radial forearm free flap (OCRFFF) is a versatile flap with the ability to reconstruct complex defects. We detail the techniques necessary to harvest an OCRFFF, including an outline on making 90-degree osteotomies to maximize bone harvest. In this pictorial essay, we provide illustrations of the anatomy and surgical techniques necessary for OCRFFF harvest. Detailed discussion is provided on how to protect the perforators to the bone and the approach to making osteotomies in a 90-degree fashion. The approach for prophylactic plating of the radius to prevent radius fractures is outlined. A case presentation on the real-life utilization of this flap is included. The OCRFFF is an excellent head and neck reconstructive option. While there are limitations to its use for patients requiring dental rehabilitation or long/anterior mandibular defects, for the right patient and indication it has shown great success in reconstructive efforts.

Early ambulation after fibular free flap surgery is associated with reduced length of stay, increased mobility independence, and discharge to home.

BACKGROUND: Fibula free flaps (FFF) are one of the most common bony flaps utilized. This paper describes a quality improvement project aimed at increasing early ambulation. METHODS: A review of FFF patients at an academic hospital was completed (2014-2023). In 2018, an institutional change to encourage early ambulation without placement of a boot was made. Changes in hospital disposition and physical therapy outcomes were evaluated. RESULTS: A total of 168 patients underwent FFF reconstruction. There was a statistically significant lower length of stay in Group 2 (early ambulation, no boot) (8.1 vs. 9.4; p = 0.04). A higher rate of discharge to a skilled nursing facility was noted in Group 1 (delayed ambulation with boot) (21.3% vs. 11.9%; p = 0.009). A higher proportion of patients in Group 2 demonstrated independence during bed mobility, transfers, and gait (p < 0.05). CONCLUSIONS: Early ambulation without boot placement after FFF is associated with decreased length of hospital stay, improved disposition to home and physical therapy outcomes.

Four-Dimensional Computed Tomography for Parathyroid Adenoma Localization: A Pre-Operative Imaging Protocol.

OBJECTIVE: Primary hyperparathyroidism (PHPT) affects approximately 0.86% of the population, with surgical resection as the treatment of choice. A 4D computed tomography (CT) is a highly effective tool in localizing parathyroid adenomas; however, there is currently no defined role for 4D CT when stratified against ultrasonography (USG) and nuclear medicine Technetium Sestamibi SPECT/CT (SES) imaging. STUDY DESIGN: Retrospective Study. SETTING: University Hospital. METHODS: All patients who underwent parathyroidectomy for PHPT between 2014 and 2019 at a single institution were reviewed. Patients who had a 4D CT were included. We compared outcomes of 4D CT as a second line imaging modality to those of USG and SES as first line modalities. An imaging algorithm was proposed based on these findings. RESULTS: There were 84 patients identified who had a 4D CT after unsuccessful first line imaging. A 4D CT localized parathyroid adenoma to the correct quadrant in 64% of cases, and to the correct laterality in 75% of cases. Obese patients had significantly lower rates of adenoma localization with USG (33.4%), compared to non-obese patients (67.5%; P = .006). In determining multigland disease the sensitivity of 4D CT was 86%, while the specificity was 87%. CONCLUSIONS: A 4D CT has impressive rates of accurate localization of parathyroid adenomas; however due to the radiation exposure involved, it should remain a second line imaging modality. PHPT patients should first be evaluated with USG, with 4D CT used if this is unsuccessful and patients are greater than 40 years old, have a high BMI, or are having revision surgery.

Pedicled osteomyocutaneous pectoralis major flap with osseous rib harvest for salvage mandibular reconstruction: Case and technique.

In the era of free flap reconstruction, mandibular defects are routinely reconstructed with osseous free flaps, and non-free flap bony reconstruction options are limited. A patient with T4N0 mandibular squamous cell carcinoma underwent resection with fibula free flap reconstruction of a parasymphyseal to angle defect. After free flap failure due to venous congestion, the flap was explanted. He declined additional free flap reconstruction and elected to proceed with pedicled osteomyocutaneous pectoralis major with rib. In this case presentation, we discuss the technical details of harvest of this flap using the 6th rib. The pedicled osteomyocutaneous pectoralis major flap with osseous rib harvest, which is infrequently described in the literature, remains a viable option for bony reconstruction, particularly in the salvage setting.

National Trends in 30-Day Readmission Following Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma.

Importance: As the incidence of oropharyngeal squamous cell carcinoma (OPSCC) continues to rise in the US, an increasing number of patients are being treated with transoral robotic surgery (TORS). Readmission following surgery can potentially delay initiation of adjuvant treatment and affect survival outcomes. Objective: To identify risk factors for 30-day postoperative readmission in patients undergoing TORS for OPSCC. Design, Setting, and Participants: This retrospective, population-based cohort study used data from the Nationwide Readmissions Database from 2010 to 2017. All patients undergoing TORS for OPSCC were identified using International Classification of Diseases codes and included. Exclusion criteria were age younger than 18 years or incomplete information regarding index admission or readmission. The analysis was performed from April to October 2023. Exposure: TORS for OPSCC. Main Outcomes and Measures: Univariate and multivariate analyses were performed to determine factors associated with 30-day readmission. Covariates included demographics and medical comorbidities, socioeconomic factors, hospital characteristics, and surgical details. Trends in readmission over time, reasons for readmission, and characteristics of the readmission were also examined. Results: A weighted total of 5544 patients (mean [SD] age, 60.7 [0.25] years; 4475 [80.7%] male) underwent TORS for OPSCC. The overall readmission rate was 17.5% (n = 971), and these rates decreased over the study period (50 of 211 patients [23.7%] in 2010 vs 58 of 633 patients [9.1%] in 2017). Risk factors associated with readmission included male sex (adjusted odds ratio [AOR], 1.54; 95% CI, 1.07-2.20) and a diagnosis of congestive heart failure (AOR, 2.42; 95% CI, 1.28-4.58). Factors associated with decreased rate of readmission included undergoing concurrent selective neck dissection (AOR, 0.30; 95% CI, 0.22-0.41). Among the 971 readmissions, the most common readmission diagnoses were bleeding (151 [15.6%]), electrolyte and digestive problems (44 [4.5%]), pneumonia (44 [4.5%]), and sepsis (26 [2.7%]). Conclusions and Relevance: In this cohort study, readmission rates following TORS for oropharynx cancer decreased over time; however, a subset of patients required readmission most commonly related to bleeding, infection, and electrolyte imbalance. Concurrent neck dissection may be protective against readmission. Elucidation of risk factors for readmission after TORS for OPSCC offers opportunities for evidence-based shared decision-making, quality improvement initiatives, and improved patient counseling.

Neoadjuvant dabrafenib and trametinib for functional organ preservation in recurrent BRAF V600E-mutated papillary thyroid cancer.

OBJECTIVES: To describe the first reported use of neoadjuvant dabrafenib and trametinib specifically to permit organ conservation surgery in locally advanced recurrent differentiated thyroid carcinoma. PATIENTS AND METHODS: A patient presented with locally recurrent, radioiodide-resistant DTC with a BRAF V600E mutation invading the laryngotrachea. Definitive treatment would require a total laryngectomy. She was offered neoadjuvant dabrafenib and trametinib prior to surgery. RESULTS: A significant radiographic response permitted partial laryngectomy, enabling preservation of voice, early resumption of oral feeding, and avoidance of permanent tracheostomy. At 9 months, she remained free of disease. CONCLUSION: Neoadjuvant tyrosine kinase inhibitor treatment prior to definitive surgery for locally-invasive recurrent DTC is a potential approach that may limit the degree of surgery and associated morbidity.

Demographic and Academic Productivity Trends Among American Head & Neck Society Fellows Over a 20-Year Period.

Importance: Historical data reveal that, compared with women, men are more likely to pursue a head and neck surgical oncology fellowship, but little is known about possible gender differences in academic productivity. Objective: To assess demographic trends and academic productivity among American Head & Neck Society (AHNS) fellowship graduates. Design, Setting, and Participants: This cross-sectional study used electronically published data from the AHNS on fellowship graduates in the US and Canada from July 1, 1997, to June 30, 2022. Scopus was used to extract h-indices for each graduate. Exposure: Scholarly activity. Main Outcomes and Measures: Main outcomes were changes in demographic characteristics and academic productivity among AHNS graduates over time. Data analysis included effect size, η2, and 95% CIs. Results: A total of 691 AHNS fellowship graduates (525 men [76%] and 166 women [24%]) were included. Over the study period, there was an increase in the number of programs offering a fellowship (η2, 0.84; 95% CI, 0.68-0.89) and an increase in the absolute number of women who completed training (η2, 0.66; 95% CI, 0.38-0.78). Among early-career graduates pursuing an academic career, there was a small difference in the median h-index scores between men and women (median difference, 1.0; 95% CI, -1.1 to 3.1); however, among midcareer and late-career graduates, there was a large difference in the median h-index scores (midcareer graduates: median difference, 4.0; 95% CI, 1.2-6.8; late-career graduates: median difference, 6.0; 95% CI, 1.0-10.9). A higher percentage of women pursued academic positions compared with men (106 of 162 [65.4%] vs 293 of 525 [55.8%]; difference, 9.6%; 95% CI, -5.3% to 12.3%). Conclusions and Relevance: This cross-sectional study suggests that women in head and neck surgery begin their careers with high levels of academic productivity. However, over time, a divergence in academic productivity between men and women begins to develop. These data argue for research to identify possible reasons for this observed divergence in academic productivity and, where possible, develop enhanced early faculty development opportunities for women to promote their academic productivity, promotion, and advancement into leadership positions.

Internal jugular vein reconstruction: An algorithm for reconstructive surgeons.

OBJECTIVES: The internal jugular vein (IJV) provides critical drainage from the brain, skull, and deep regions of the face and neck. Compromise to the bilateral IJVs has severe sequelae, but even unilateral IJV sacrifice or thrombosis after treatment can have sequelae. Despite the potential role of IJV reconstruction for head and neck surgeons, information about the indications, technique, and outcomes of the procedure are sparse. PATIENTS AND METHODS: We present a woman who had IJV sacrifice for an oral cavity cancer along with a contralateral selective neck dissection and adjuvant chemoradiation who developed occlusion of the contralateral IJV after her treatment, resulting in unacceptable cervical lymphedema and extensive neck varicosities. An end-to-side bypass from the superior IJV to the ipsilateral external jugular vein was performed. RESULTS: There were no complications from the procedure, which resulted in dissipation of her preoperative symptoms. We describe the literature surrounding IJV reconstruction, considerations for its use, the technique itself, and advice for perioperative management. CONCLUSION: IJV reconstruction is a valuable but underutilized technique for the head and neck microvascular surgeon in cases of bilateral threatened IJV outflow.

History, Innovation, Pearls, and Pitfalls in Complex Midface Reconstruction.

Midface reconstruction in head and neck cancer or individuals with extensive trauma to the face has evolved significantly over the past few decades with the introduction of free flap reconstruction and virtual surgical planning enabling surgeons to obtain optimal cosmetic and functional outcomes. Traditional methods such as the use of obturators or local flaps still have a role in select situations, but complex defects have been replaced by the advent of microvascular free tissue transfer and virtual planning, which can commonly provide a single-stage reconstruction of the midface with excellent aesthetic and functional results. This article provides an overview of the history and evolution of midface reconstruction, a discussion of how to integrate virtual surgical planning into a surgical practice, an example of a complex midface reconstruction case, and pearls and pitfalls that have been experienced by an experienced reconstructive team.

Expanding Understanding of Electrocochleography in Cochlear Implantation: Auditory Neuropathy Spectrum Disorder With Normal Pure Tone Average.

Objective: Describe the preoperative decision-making, intraoperative electrocochleographic (ECoG) findings, and outcome of cochlear implantation (CI) in a patient with auditory neuropathy spectrum disorder (ANSD) and normal pure-tone thresholds. Patients: A 19-year-old with a history of hypoxic ischemic encephalopathy and seizures was referred for hearing rehabilitation in the setting of typical hearing by pure tone audiometry but poor speech understanding. A diagnosis of ANSD was made based on acoustic brainstem response (ABR), distortion product otoacoustic emission, and acoustic reflex testing. Imaging revealed no central cause of hearing impairment. Interventions: Right-sided CI. Main Outcome Measures: Preoperative and postoperative audiometric data. Intraoperative ECoG. Results: Preoperatively the patient underwent comprehensive audiologic testing with behavioral audiometry, ABR testing, and CI candidacy evaluation. In the right ear, the pure tone average (PTA) was 15 dB and word recognition score was 36%. ABR confirmed ANSD. Preoperative CNC and AzBio in quiet were 8% and 0%, respectively. Intraoperative ECoG amplitudes and audiometry showed responses in the 100 uV range and estimated PTA of 42 dB HL. Postoperative testing at 1-month post-initial activation revealed PTA of 45 dB HL and unchanged word and sentence scores. However, the patient cites an improved ability to communicate and increased confidence and averages over 14 hours of device use daily. Conclusions: To our knowledge, this is the first reported case of CI in an ear with normal PTA. Given that nearly all presently available ECoG data comes from patients with greater degrees of hearing loss, this unique case adds to our understanding of hearing preservation in CI.

Mutation based approaches to the treatment of anaplastic thyroid cancer.

OBJECTIVE: The treatment of anaplastic thyroid cancer (ATC) has continued to rapidly evolve over time. Increased utilization of novel, personalized therapies based upon the tumour's somatic mutation status has recently been integrated. The aim of this case series is to describe a series of patients that underwent rapid genomic testing upon their diagnosis of ATC, allowing for the early integration of novel therapies. DESIGN: A fast track pathway for genomic tumour analysis of patients with ATC was implemented at a single academic cancer hospital in January of 2020. PATIENTS: All patients were evaluated by head and neck surgery, endocrinology, and medical oncology upon diagnosis of ATC. MEASUREMENTS: Genetic work-up was completed, which prompted a recommendation for dual BRAF/MEK inhibition with dabrafenib and trametinib for tumours with BRAF V600E mutation. For patients whose tumours were BRAF V600E wild-type, pembrolizumab with lenvatinib was offered. RESULTS: A total of four patients were included in this series. Two patients (50%) had tumours that were BRAF V600E positive. Among patients that were BRAF V600E positive, both patients initiated urgent dabrafenib and trametinib dual tyrosine kinase inhibitor (TKI) therapy; with one patient demonstrating near-complete clinical response allowing for posttreatment surgery, while the other demonstrated decreased tumour burden. Among patients who were BRAF V600E wild-type, lenvatinib and pembrolizumab were recommended off-label; one patient demonstrated decreased tumour burden, but developed severe pure red cell aplasia, while the other patient is demonstrating an early clinical response. CONCLUSIONS: The integration of early genomic analysis and personalized neoadjuvant TKI therapy into the treatment of ATC can greatly benefit patient care outcomes and optimize tumour control.

Graduating Otolaryngology Residents' Ideal Practice Expectations: A Longitudinal Analysis.

OBJECTIVE: Prior literature has indicated that the number of trained otolaryngologists required to meet the need of our growing population may be insufficient. Therefore, identifying trends in the subspecialty composition of future otolaryngology practices will elucidate workforce needs. STUDY DESIGN: One-page anonymous questionnaire. SETTING: The survey was completed by examinees at the conclusion of their American Board of Otolaryngology-Head and Neck Surgery oral examination from 2011 to 2019. METHODS: Data included age, gender, fellowship, practice type, and ideal future practice components. RESULTS: A total of 2286 examinees were included: 58.1% were male and 57.2% completed a fellowship. Ideal practice specialties included general otolaryngology (19%), rhinology (15%), head and neck (13%), and pediatrics (11%). General and pediatric otolaryngology had a negative correlation over time (r = -0.81, P = .01, and r = -0.75, P = .03, respectively). An overall 45% of graduates reported 1 ideal practice area (r = 0.61, P = .10), with a statistically significant decline in the number of ideal practice areas over time (r = -0.79, P = .018). Men more commonly reported allergy, head and neck, otology, rhinology, and sleep medicine as part of their ideal practice (P < .05), while women more commonly reported pediatric otolaryngology (P < .05). There was a higher mean number of ideal practice areas among men than women (2.58 vs 2.1, P < .001). CONCLUSION: There is a growing trend for more specialized otolaryngology practices. The data demonstrate a decline in considering general and pediatrics otolaryngology as part of practices, which portends a gap in access to comprehensive otolaryngology in the future.

Superior Semicircular Canal Dehiscence Syndrome Following Head Trauma: A Multi-institutional Review.

OBJECTIVE: To evaluate patients who become symptomatic from superior semicircular canal dehiscence (SSCD) following head trauma. STUDY DESIGN: Case series assessing patients presenting with SSCD after a trauma. METHODS: A case series was completed assessing patients presenting with SSCD after trauma. Data from three academic medical centers were evaluated, including the following: imaging, videonystagmography (VNG)/vestibular evoked myogenic potential (VEMP) testing, audiometric assessment, and surgical repair. Outcome measures included the following: 1) Description of audio-vestibular symptoms, 2) mean pre- and post-operative pure tone average (PTA), word recognition score (WRS), and air bone gap (ABG). RESULTS: A total of 14 patients were included; 86% were male. Approximately 43% were found to have bilateral SSCD on imaging, with 57% of patients pursuing surgical management. The most common presenting symptoms included pulsatile tinnitus (93%), autophony (79%), and hearing loss (64%). Approximately 36% of patients underwent VNG/VEMP testing, with 83.3% of those demonstrating abnormal results. The mean audiometric findings on the symptomatic side included an air-conduction PTA of 38.0 dB, bone-conduction PTA of 24.3 dB, WRS of 81%, and ABG of 17.9 dB. Among patients who underwent surgery (57%), there was no significant change in the air-conduction PTA, bone-conduction PTA, or WRS (P > .05). However, there was an improvement in the ABG (preoperative = 22.8 dB versus postoperative = 9.7 dB; P = .005). CONCLUSION: Head trauma may be a potentiating event for SSCD syndrome. This study advances the hypothesis that these patients likely have underlying radiographic SSCD prior to their trauma, and a traumatic event increases in intra-vestibular or intracranial pressures, unmasking SSCD syndrome. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2810-E2818, 2021.

Medical student attitudes and actions that encourage teaching on surgery clerkships.

INTRODUCTION: Surgical faculty and residents are responsible for the clinical education of medical students during their core surgical clerkship, sub-internships, and clinical electives. Much attention has been paid to faculty development in teaching, as well as residents-as-teachers programs, to enhance student learning in the surgical environment. This focus to "train the trainers" has not addressed what medical students can do to take ownership of and improve their own learning, as partners in educational interactions. The purpose of this exploratory study was to investigate how medical students' attitudes and actions can enhance clinical teaching interactions during surgical rotations. METHODS: Previously collected data from a multiple case study that explored the learning environment at a single academic medical center was analyzed to understand the roles that students play in their learning. The data includes transcriptions from semi-structured interviews with four 4th year mediacl students, three general surgery residents, and four surgery attendings, and focus groups with two sets of 3rd year medical students. Two authors employed thematic analysis to code the data. RESULTS: Findings were organized into five themes: eagerness, humility, confidence, team player, and adaptability. Each attitudinal theme was associated with specific actions that students adopted to encourage teaching behaviors from resident and faculty surgeons during their surgery rotations. Participants discussed the importance of students "seek[ing] out opportunities" for learning (eagerness) and being "willing to be wrong" (humility). Student expressions of confidence in their knowledge and skills were marked by following "steps that I know," which signaled to teachers that they could be entrusted to participate in patient care. Students categorized as team players "follow[ed] up on information without specifically being told." Finally, students categorized as adaptable responded to "immediate feedback" by making "adjustments." CONCLUSIONS: Medical students are important stakeholders and contributors to teaching interactions and are likely to impact their own learning experience through the adoption of key attitudes and associated actions.

A Systematic Review of the Relationship Between In-Training Examination Scores and Specialty Board Examination Scores.

BACKGROUND: In-training examinations (ITEs) are intended for low-stakes, formative assessment of residents' knowledge, but are increasingly used for high-stake purposes, such as to predict board examination failures. OBJECTIVE: The aim of this review was to investigate the relationship between performance on ITEs and board examination performance across medical specialties. METHODS: A search of the literature for studies assessing the strength of the relationship between ITE and board examination performance from January 2000 to March 2019 was completed. Results were categorized based on the type of statistical analysis used to determine the relationship between ITE performance and board examination performance. RESULTS: Of 1407 articles initially identified, 89 articles underwent full-text review, and 32 articles were included in this review. There was a moderate-strong relationship between ITE and board examination performance, and ITE scores significantly predict board examination scores for the majority of studies. Performing well on an ITE predicts a passing outcome for the board examination, but there is less evidence that performing poorly on an ITE will result in failing the associated specialty board examination. CONCLUSIONS: There is a moderate to strong correlation between ITE performance and subsequent performance on board examinations. That the predictive value for passing the board examination is stronger than the predictive value for failing calls into question the "common wisdom" that ITE scores can be used to identify "at risk" residents. The graduate medical education community should continue to exercise caution and restraint in using ITE scores for moderate to high-stakes decisions.

Penetrating Trauma Rapid Estimated Disability Scale: Assessing Facial Self-Inflicted Gunshot Wounds.

Objectives: Self-inflicted facial gunshot wounds (GSWs) result in complex but consistent injuries that are often survivable. We suggest a novel method for rapid stratification into groups that may be associated with hospital course and cost after self-inflicted facial GSWs. Methods: This is retrospective review of self-inflicted facial GSWs between January 1, 2009, and December 31, 2018, at a tertiary academic center. Patients were given a penetrating trauma rapid estimated disablity (PRED) score (1-4) based solely on radiologic imaging injury patterns. Clinicopathologic factors were then compared between groups. Results: There were 2 PRED 1 patients (15.1%), 8 PRED 2 patients (29.6%), 5 PRED 3 patients (18.5%), and 12 PRED 4 patients (44.4%). An increased PRED score was statistically associated with increasing mean days in intensive care unit (2.5 PRED 1, 4.2 PRED 2, 6 PRED 3, 11.6 PRED 4, p = 0.001), mean length of hospitalization (5.5 PRED 1, 13.1 PRED 2, 25.6 PRED 3, 39.8 PRED 4, p = 0.007), and mean cost ($) of hospitalization (22,000 PRED 1, 29,000 PRED 2, 37,000 PRED 3, 63,000 PRED 4, p = 0.01). Conclusions and Relevance: The PRED score for self-inflicted GSWs to the face is strongly associated with length of hospital stay and cost of hospitalization.

A National Survey of Robotic Surgery Training Among Otolaryngology-Head and Neck Surgery Residents.

OBJECTIVE: The aim of this study is to describe the current state of robotic surgery training among Otolaryngology-Head and Neck Surgery (OHNS) residency programs in the United States. METHODS: This is a national survey study among OHNS residents. All OHNS residency programs were identified via the Accreditation Council for Graduate Medical Education website. A total of 64/127 (50.3%) of OHNS programs were selected based on a random number generator. The main outcome measure was the number of OHNS residents with access to robotic surgery training and assessment of operative experience in robotic surgery among those residents. RESULTS: A total of 140 OHNS residents participated in the survey, of which 59.3% (n = 83) were male. Response rate was 40.2%. Respondents came from middle 50.0% (n = 70), southern 17.8% (n = 25), western 17.8% (n = 25), and eastern sections 14.3% (n = 20). Most respondents (94.3%, n = 132) reported that their institution utilized a robot for head and neck surgery. Resident experience at the bedside increased in the junior years of training and console experience increased across the years particularly for more senior residents. However, 63.4% of residents reported no operative experience at the console. Only 11.4% of programs have a structured robotics training program. CONCLUSION: This survey indicated that nearly all OHNS residencies utilize robotic surgery in their clinical practice with residents receiving little formal education in robotics or experience at the console. OHNS residencies should aim to increase access to training opportunities in order to increase resident competency. LEVEL OF EVIDENCE: IV.

Are Opioids Necessary in Middle Ear Surgery? Comparing the Transcanal and Postauricular Approach.

OBJECTIVE: Understand opioid-prescribing patterns in otologic surgery and the difference in opioid use between transcanal and postauricular surgery. STUDY DESIGN: Prospective survey. SETTING: Multihospital network. PATIENTS: All patients undergoing otologic surgery from March 2017 to January 2019. INTERVENTION: Patients undergoing otologic surgery were surveyed regarding postoperative opioid use and their level of pain control. Patients were divided by surgical approach (transcanal vs. postauricular). Those who underwent mastoid drilling were excluded. Narcotic amounts were converted to milligram morphine equivalents (MME) for analysis. MAIN OUTCOME MEASURES: Amount of opioid was calculated and compared between the two groups. Mann-Whitney U test and Chi-square testing were used for analysis. RESULTS: Fifty-five patients were included in the analysis; of these 18 (33%) had a postauricular incision. There was no difference in age (p = 0.85) or gender (p = 0.5) between the two groups. The mean amount of opioid prescribed (MME) in the postauricular and transcanal groups was 206.4 and 143 (p = 0.038) while the mean amount used was 37.7 and 37.5 (p = 0.29) respectively. There was no difference in percentage of opioid used (p = 0.44) or in patient-reported level of pain control (p = 0.49) between the two groups. CONCLUSION: Patients in both the transcanal and postauricular groups used only a small portion of their prescribed opioid. There was no difference in the amount of opioid used or the patient's reported level of pain control based on the approach. Otologic surgeons should be aware of these factors to reduce narcotic diversion after ear surgery.

Evaluation of opioid prescription patterns among patients undergoing thyroid surgery.

BACKGROUND: There is variability in opioid prescription patterns among surgeons performing thyroidectomy. Thus, the aim of this study is to evaluate opioid prescription rates and opioid use among hemithyroidectomy (HT) and total thyroidectomy (TT) patients. DESIGN/METHOD: An electronic postoperative survey was distributed to assess opiate use among patients undergoing HT/TT. Groups were compared using t-tests, chi-square tests, and analysis of variance. RESULTS: A total of 142 opiate naïve patients were included, of which 75 (52.8%) underwent HT and 67 (47.1%) underwent TT. The mean number of tablets prescribed was 21.3 (HT = 22.1, TT = 20.4; P = 0.3), with a mean of 14.1 tablets unused after surgery (HT = 13.2 tablets, TT = 15.0 tablets; P = 0.44). The mean morphine milligram equivalent (MME) prescribed was 150.1 mg (HT = 159.0 mg, TT = 140.2 mg; P = 0.3), with a mean of 98.2 MME unused after surgery (HT = 93.7 mg, TT = 103.2 mg; P = 0.6). CONCLUSIONS: Opioids are overprescribed after thyroid surgery. Avoidance of overprescribing is vital in mitigating the current opioid crisis.

Increasing Frailty, Not Increasing Age, Results in Increased Length of Stay Following Vestibular Schwannoma Surgery.

OBJECTIVE: Understand the frailty of vestibular schwannoma surgical patients and how frailty impacts clinical course. STUDY DESIGN: Retrospective Cohort. SETTING: Single-tertiary academic hospital. PATIENTS: All patients undergoing vestibular schwannoma surgery. INTERVENTION: The modified frailty index (mFI) was calculated for all patients undergoing surgery for vestibular schwannoma between 2011 and 2018. Patient demographics and medical history, perioperative course, and postoperative complications were obtained from the medical record. MAIN OUTCOME MEASURES: The primary endpoint was hospital length of stay (LOS). Secondary endpoint was postoperative complications. Basic statistical analysis was performed including multivariate linear regressions to determine independent predictors of LOS. RESULTS: There were 218 patients included and the mean age was 48.1 ±â€Š0.9 (range 12-77). One-hundred ten patients were male (50.5%). The mean ICU LOS was 1.6 ±â€Š0.1 days while mean total hospital LOS was 4.3 ±â€Š0.2. There were 145 patients (66.5%) who were robust (nonfrail) with an mFI of 0, while 73 (33.5%) had an mFI of ≥1. Frailty (mFI≥2) was associated with longer hospital LOS compared with the prefrail (p = 0.0014) and robust (p = 0.0004) groups, but was not associated with increased complications (OR = 1.3; 95% CI: 0.5-3.7; p = 0.5925) or ICU LOS (p > 0.05). In multivariate analysis, increased mFI, and NOT increased age, was an independent risk factor for increased hospital LOS (p = 0.027). CONCLUSION: Increasing frailty, and not increasing age, is an independent risk factor for longer hospital LOS, but not for increased postoperative complications. Patients' frailty status may be useful preoperatively in counselling patients about postoperative expectations and frail vestibular schwannoma patients may require increased health spending costs given their increased hospital LOS.