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Among zygomaticomaxillary complex (ZMC) fractures presenting to a tertiary urban academic center, the authors hypothesized the presence of both clinical and radiographic predictors of operative management. The investigators conducted a retrospective cohort study of 1,914 patients with facial fractures managed at an academic medical center in New York City between 2008 and 2017. The predictor variables were based on both clinical data and features of pertinent imaging studies, and the outcome variable was an operative intervention. Descriptive and bivariate statistics were computed and the p-value was set at 0.05. In total, 196 patients sustained ZMC fractures (5.0%) and 121 (61.7%) ZMC fractures were treated surgically. All patients who presented with globe injury, blindness, retrobulbar injury, restricted gaze, or enophthalmos and a concurrent ZMC fracture were managed surgically. The most common surgical approach was the gingivobuccal corridor (31.9% of all approaches), and there were no significant immediate postoperative complications. Younger patients (38.9 ± 18 years vs. 56.1 ± 23.5 years, p < 0.0001) and patients with greater than or equal to 4 mm of orbital floor displacement were more likely to receive surgical treatment than observation (82 vs. 56%, p = 0.045), as were patients with comminuted orbital floor fractures (52 vs. 26%, p = 0.011). In this cohort, patients more likely to undergo surgical reduction were young patients with ophthalmologic symptoms on presentation and at least 4 mm displacement of the orbital floor. Low kinetic energy ZMC fractures may warrant surgical management as often as high-energy ZMC fractures. While orbital floor comminution has been shown to be a predictor for operative reduction, in this study we also demonstrated a difference in the rate of reduction based on the severity of orbital floor displacement. This may have significant implications in both the triage and selection of patients most suitable for operative repair.
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Fracturas Conminutas , Fracturas Maxilares , Fracturas Orbitales , Fracturas Craneales , Fracturas Cigomáticas , Humanos , Estudios Retrospectivos , Fracturas Cigomáticas/cirugía , Fracturas Maxilares/cirugía , Fracturas Orbitales/complicaciones , Fracturas Conminutas/complicacionesRESUMEN
Nasal obstruction is a common presenting complaint in most otolaryngology practices. A reduction of nasal airflow can contribute to exercise intolerance, snoring, obstructive sleep apnea (OSA), and an overall decreased quality of life. When medical management for non-anatomical issues fails to resolve the obstruction, surgeries targeting nasal obstruction-namely septorhinoplasty and/or inferior turbinate reduction are often considered. A frequently overlooked alternative for these patients is the wide array of non-surgical and minimally invasive appliances available to address nasal obstruction. This article attempts to provide a basic overview of these devices, benefits, and limitations, and the evidence supporting their efficacy in alleviating nasal obstruction.
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Obstrucción Nasal , Apnea Obstructiva del Sueño , Humanos , Obstrucción Nasal/etiología , Obstrucción Nasal/cirugía , Calidad de Vida , Ronquido/cirugía , Apnea Obstructiva del Sueño/cirugía , Cornetes Nasales/cirugíaRESUMEN
Eustachian tube dilation (ETD) is a relatively new intervention for the treatment of eustachian tube dysfunction. Though it previously had no assigned billing code, the American Medical Association recently accepted a new Category I Current Procedural Terminology code application for ETD to be effective in January 2021. Reported complications are uncommon and usually minor. Herein, we present a rare case of massive pneumomediastinum following this procedure. Such major complications are critical to report as ETD becomes a more commonly practiced procedure.
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Enfermedades del Oído , Trompa Auditiva , Enfisema Mediastínico , Dilatación , Enfermedades del Oído/diagnóstico , Enfermedades del Oído/etiología , Humanos , Enfisema Mediastínico/diagnóstico por imagen , Enfisema Mediastínico/etiologíaRESUMEN
ABSTRACT: Frontal sinus fractures account for 5% to 15% of all facial fractures, and have traditionally been associated with high kinetic energy blunt injury. Surgical management is largely focused on minimizing potentially serious sequelae including frontal sinus dysfunction, CSF leak, and significant cosmetic deformity. An institutional database of 1944 patients presenting with maxillofacial fractures over a 10-year period was queried. Demographics, mechanism of injury, yearly trends, surgical approaches, and follow-up data were examined. A total of 160 (8.3%) patients presented with at least 1 fracture of the frontal sinus anterior table, posterior table, or frontal sinus outflow tract during the study period. The average annual number of cases was 15.9â±â5.7 per year with a peak of 21.5â±â4.0 cases during the 2014 to 2015 period and a decline to 8.5â±â1.5âcases/year from 2016 to 2017. Among those patients with falls, 61.5% (nâ=â40) were a result of tripping or fainting at a height of <6âft. 55.6% of fracture types were isolated to the anterior table, but fracture location was not significantly associated with operative intervention. Cases of operative fracture type had a higher rate of both displacement and comminution compared to nonoperative fractures (P < 0.00001). Of all patients presenting with frontal sinus fractures, 75% of cases were managed nonoperatively. However, many patients presented with falls and other seemingly low energy injuries which are not traditionally associated with frontal sinus trauma. These results highlight the need for continued follow-up even in otherwise low-risk urban populations in order to avoid long term sinus dysfunction.
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Seno Frontal , Fracturas Craneales , Seno Frontal/cirugía , Humanos , Fracturas Craneales/epidemiología , Fracturas Craneales/cirugía , Centros TraumatológicosRESUMEN
BACKGROUND: Cosmetic concerns following Mohs Micrographic surgery (MMS) are significant and may require adjunctive treatments for unsatisfactory appearance. OBJECTIVE: To determine factors associated with adjunctive cosmetic intervention for facial defects following MMS. METHODS AND MATERIALS: A retrospective review of 699 patients undergoing repair of facial defects after MMS from 2008-2018 was performed. Tumor types, defect sizes, patient demographics, repair methods, complications, and post-operative cosmetic interventions were examined. RESULTS: 666 Mohs cases and resultant defects were analyzed. The most common method of repair following MMS was primary closure (52.3%), and the most common post-operative intervention was steroid injection (18.3%). The lip subunit was more than twice as likely as other locations to be treated with steroid injections (P<.001). The lip subunit also had the highest frequency of scar revision (13%; P<0.001). Patients who had primary closure were less likely to require scar revision (P=0.003) or dermabrasion (P=0.042), and there was no significant association between skin graft repair and cosmetic intervention. CONCLUSIONS: Both defect subunit and closure type were independently associated with adjunctive cosmetic intervention following MMS. Defect size was not significantly associated with an adjunctive intervention in our study. Understanding the factors affecting the need for adjunctive cosmetic interventions may improve patient counseling prior to Mohs repair. J Drugs Dermatol. 2020;19(3): doi:10.36849/JDD.2020.4701.
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Cicatriz/cirugía , Cirugía de Mohs , Neoplasias Cutáneas/cirugía , Anciano , Cara , Femenino , Humanos , Masculino , Complicaciones Posoperatorias/cirugía , Procedimientos de Cirugía Plástica , Estudios RetrospectivosRESUMEN
BACKGROUND AND OBJECTIVES: The reported risk of nodal metastasis in hard palate and upper gingival squamous cell carcinoma (SCC) has been inconsistent with inadequate consensus regarding the utility of neck dissection in the clinically negative (cN0) neck. MATERIALS AND METHODS: Using the National Cancer Database, cN0 patients diagnosed with SCC of the head and neck with the subsites of the hard palate and upper gingiva were identified from 2004 to 2014. RESULTS: A total of 1830 patients were identified, and END was performed on 422 patients with cN0 tumors. Pathologically positive nodes occurred in 14% (59/422) of patients in this cohort. Higher tumor stage, academic hospital type, and large hospital volume (>28 cancer-specific cases/year) were associated with a higher likelihood of END both in univariate and multivariate analyses (P < .05). Patients >80 years of age were less likely to receive END on multivariate analysis (OR 0.52, 0.32-0.84). No variables, including advanced T stage, predicted occult metastases. Cox proportional hazards regression analysis showed that patients who underwent END demonstrated improved OS over an 11-year period (hazard ratio 0.75, P = .002). On subgroup analysis, this improvement was significant in patients with both stage T1 and T4 tumors. CONCLUSIONS: Tumor stage, hospital type, and hospital volume were associated with higher rates of END for patients with cN0 hard palate SCC and after controlling for clinical factors, END was associated with improved overall survival.
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Carcinoma de Células Escamosas/mortalidad , Procedimientos Quirúrgicos Electivos/mortalidad , Neoplasias Gingivales/mortalidad , Neoplasias Maxilares/mortalidad , Disección del Cuello/mortalidad , Paladar Duro/cirugía , Anciano , Anciano de 80 o más Años , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/cirugía , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Neoplasias Gingivales/patología , Neoplasias Gingivales/cirugía , Humanos , Masculino , Neoplasias Maxilares/patología , Neoplasias Maxilares/cirugía , Persona de Mediana Edad , Estadificación de Neoplasias , Paladar Duro/patología , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
Symptoms of depression can be induced in humans through blockade of acetylcholinesterase (AChE) whereas antidepressant-like effects can be produced in animal models and some clinical trials by limiting activity of acetylcholine (ACh) receptors. Thus, ACh signaling could contribute to the etiology of mood regulation. To test this hypothesis, we administered the AChE inhibitor physostigmine to mice and demonstrated an increase in anxiety- and depression-like behaviors that was reversed by administration of nicotinic or muscarinic antagonists. The behavioral effects of physostigmine were also reversed by administration of the selective serotonin reuptake inhibitor fluoxetine. Administration of fluoxetine also increased AChE activity throughout the brain, with the greatest change in the hippocampus. To determine whether cholinergic signaling in the hippocampus could contribute to the systemic effects of cholinergic drugs, we infused physostigmine or virally delivered shRNAs targeting AChE into the hippocampus. Both pharmacological and molecular genetic decreases in hippocampal AChE activity increased anxiety- and depression-like behaviors and decreased resilience to repeated stress in a social defeat paradigm. The behavioral changes due to shRNA-mediated knockdown of AChE were rescued by coinfusion of an shRNA-resistant AChE transgene into the hippocampus and reversed by systemic administration of fluoxetine. These data demonstrate that ACh signaling in the hippocampus promotes behaviors related to anxiety and depression. The sensitivity of these effects to fluoxetine suggests that shRNA-mediated knockdown of hippocampal AChE represents a model for anxiety- and depression-like phenotypes. Furthermore, abnormalities in the cholinergic system may be critical for the etiology of mood disorders and could represent an endophenotype of depression.
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Ansiedad/psicología , Neuronas Colinérgicas/metabolismo , Depresión/psicología , Hipocampo/metabolismo , Resiliencia Psicológica , Transducción de Señal , Estrés Psicológico/metabolismo , Acetilcolinesterasa/metabolismo , Animales , Antidepresivos/farmacología , Antidepresivos/uso terapéutico , Ansiedad/complicaciones , Ansiedad/tratamiento farmacológico , Ansiedad/metabolismo , Conducta Animal/efectos de los fármacos , Antagonistas Colinérgicos/farmacología , Antagonistas Colinérgicos/uso terapéutico , Neuronas Colinérgicas/efectos de los fármacos , Neuronas Colinérgicas/patología , Dependovirus/metabolismo , Depresión/complicaciones , Depresión/tratamiento farmacológico , Depresión/metabolismo , Fluoxetina/farmacología , Fluoxetina/uso terapéutico , Técnicas de Silenciamiento del Gen , Suspensión Trasera , Hipocampo/efectos de los fármacos , Hipocampo/patología , Humanos , Masculino , Ratones , Ratones Endogámicos C57BL , Fenotipo , Fisostigmina , ARN Interferente Pequeño/metabolismo , Receptores Colinérgicos/metabolismo , Transducción de Señal/efectos de los fármacos , Estrés Psicológico/complicaciones , Estrés Psicológico/tratamiento farmacológico , Factores de TiempoRESUMEN
PURPOSE OF REVIEW: Enhanced Recovery after Surgery (ERAS) refers to a patient centered, multidisciplinary team developed pathway aimed at reducing the surgical stress response and facilitating expedited patient postoperative recovery. These protocols have been largely developed in the general surgery literature and have led to vast improvements in the patient experience. With a growing shortage of hospital resources during the height of the COVID-19 pandemic there has been a growing push to apply these principles to a wide variety of specialties. RECENT FINDINGS: ERAS protocols are generally substantiated on three phases along the continuum of surgical care: preadmission optimization, intraoperative treatment, and postoperative management. In this article, the evidence for ERAS development in craniomaxillofacial surgery will be reviewed, and recommendations from prior studies for enhanced recovery will be outlined. SUMMARY: ERAS protocols have been proven effective in many surgical arenas, however, modification is needed for the craniomaxillofacial population. The implications for widespread implementation of ERAS protocols during these procedures are a potentially shortened length of stay, expedited early return to function, reduction in narcotic dependence, and reduction in postdischarge complications necessitating additional intervention.
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COVID-19 , Recuperación Mejorada Después de la Cirugía , Cuidados Posteriores , COVID-19/epidemiología , Humanos , Tiempo de Internación , Pandemias , Alta del Paciente , Complicaciones Posoperatorias , Literatura de Revisión como AsuntoRESUMEN
We present the case of a patient with a recent history of ischemic stroke who presented with clicking larynx syndrome, a condition in which clicking noises in the larynx can be provoked by movement of the head and neck. Diagnostic imaging revealed unusual development and posterior angulation of the superior horn of the thyroid cartilage that potentially was causing trauma to the left common carotid artery. We deduced that symptomatic impingement of the carotid artery by the thyroid cartilage was not only the cause of the patient's clicking larynx syndrome, but also suspected to be the cause of her prior strokes due to repetitive trauma resulting in thrombus. The patient was managed surgically with thyroplasty and transcervical resection of the left greater cornu of the thyroid cartilage with resolution of her symptoms. Anatomical displacement of the thyroid cartilage can manifest as clicking larynx syndrome as well as cause mechanical injury to the carotid artery, resulting in turbulent flow, possible thrombosis, and stroke. Laryngoscope, 132:1410-1413, 2022.
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Enfermedades de la Laringe , Laringoplastia , Laringe , Accidente Cerebrovascular , Trombosis , Arterias Carótidas/diagnóstico por imagen , Femenino , Humanos , Enfermedades de la Laringe/cirugía , Laringoplastia/métodos , Laringe/cirugía , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/cirugía , Cartílago Tiroides/cirugíaRESUMEN
Objective: This article introduces a dynamic neck brace to measure the full range of motion (RoM) of the head-neck. This easy-to-wear brace was used, along with surface electromyography (EMG), to study changes in movement characteristics after neck dissection (ND) in a clinical setting. Methods: The brace was inspired by the head-neck anatomy and was designed based on the head-neck movement of 10 healthy individuals. A 6 degrees-of-freedom open-chain structure was adopted to allow full RoM of the head-neck with respect to the shoulders. The physical model was realized by 3D printed materials and inexpensive sensors. Five subjects, who underwent unilateral selective ND, were assessed preoperative and postoperative using this prototype during the head-neck motions. Concurrent EMG measurements of their sternocleidomastoid, splenius capitis, and trapezius muscles were made. Results: Reduced RoM during lateral bending on both sides of the neck was observed after surgery, with a mean angle change of 8.03° on the dissected side (95% confidence intervals [CI], 3.11-12.94) and 9.29° on the nondissected side (95% CI, 4.88-13.69), where CI denotes the confidence interval. Axial rotation showed a reduction in the RoM by 5.37° (95% CI, 2.34-8.39) on the nondissection side. Neck extension showed a slight increase in the RoM by 3.15° (95% CI, 0.81-5.49) postoperatively. Conclusions: This brace may serve as a simple but useful tool in the clinic to document head-neck RoM changes in patients undergoing ND. Such a characterization may help clinicians evaluate the surgical procedure and guide the recovery of patients.
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OBJECTIVE/HYPOTHESIS: To report characteristics and management of facial fractures in a major metropolitan center within the United States. STUDY DESIGN: Retrospective chart review. METHODS: Retrospective review at a level 1 trauma academic medical center of 3,946 facial fractures in 1,914 patients who presented from 2008 to 2017. Demographics, injury mechanism, associated injuries, and treatment information were collected. Logistic regression analyses were performed to determine factors associated with management. RESULTS: There were 1,280 males and 630 females with a median age of 42 years. Orbital fractures were the most common (41.4%) followed by maxilla fractures (21.9%). The most common mechanism was fall (43.6%). Surgical management was recommended for 38% of patients. The odds of surgical management were less for females (OR 0.59, 95% CI 0.48-0.73). Patients over 70 years were significantly less likely to undergo surgery compared to other age groups (OR 0.15-0.36, P < .001). The odds of surgical management were 1.69 times greater for patients with more than three fractures than for a single fracture (95% CI 1.18-2.42) and 2.23 times greater for traffic injuries compared to injuries from activities of daily living (95% CI 1.42-3.5). CONCLUSIONS: This represents one of the largest comprehensive databases of facial fractures. Our patients were most frequently injured during activities of daily living, most commonly from falls. The majority of patients were managed conservatively. Gender, age, fracture number, and mechanism of injury were independently associated with the decision to treat surgically. Our data are in stark contrast to that from other populations in which assault or motor vehicle accidents predominate. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2176-E2180, 2021.
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Huesos Faciales/lesiones , Traumatismos Faciales/epidemiología , Pautas de la Práctica en Medicina/estadística & datos numéricos , Fracturas Craneales/epidemiología , Centros Traumatológicos/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Tratamiento Conservador/estadística & datos numéricos , Bases de Datos Factuales , Traumatismos Faciales/terapia , Femenino , Fijación de Fractura/estadística & datos numéricos , Humanos , Lactante , Masculino , Persona de Mediana Edad , Fracturas Orbitales/epidemiología , Fracturas Orbitales/terapia , Estudios Retrospectivos , Fracturas Craneales/terapia , Estados Unidos , Adulto JovenRESUMEN
STUDY DESIGN: Meta-analysis. OBJECTIVE: Despite the increasing importance of tracking clinical outcomes using valid patient-reported outcome measures, most providers do not routinely obtain baseline preoperative health-related quality of life (HRQoL) data in patients undergoing spine surgery, precluding objective outcomes analysis in individual practices. We conducted a meta-analysis of pre- and postoperative HRQoL data obtained from the most commonly published instruments to use as reference values. METHODS: We searched PubMed, EMBASE, and an institutional registry for studies reporting EQ-5D, SF-6D, and Short Form-36 Physical Component Summary scores in patients undergoing surgery for degenerative cervical and lumbar spinal conditions published between 2000 and 2014. Observational data was pooled meta-analytically using an inverse variance-weighted, random-effects model, and statistical comparisons were performed. RESULTS: Ninety-nine articles were included in the final analysis. Baseline HRQoL scores varied by diagnosis for each of the 3 instruments. On average, postoperative HRQoL scores significantly improved following surgical intervention for each diagnosis using each instrument. There were statistically significant differences in baseline utility values between the EQ-5D and SF-6D instruments for all lumbar diagnoses. CONCLUSIONS: The pooled HRQoL values presented in this study may be used by practitioners who would otherwise be precluded from quantifying their surgical outcomes due to a lack of baseline data. The results highlight differences in HRQoL between different degenerative spinal diagnoses, as well as the discrepancy between 2 common utility-based instruments. These findings emphasize the need to be cognizant of the specific instruments used when comparing the results of outcome studies.