Orbital Wall Fractures and Ocular Injury: Impact on Management.

Background: Orbital wall fractures are often associated with concomitant ocular injury. In some cases, detection and treatment of such injuries requires ophthalmology evaluation. Study Objective: To identify a change in ocular management as a result of ophthalmology evaluation in patients with orbital wall fractures. Materials and Methods: Retrospective cohort, patients >18 years of age with orbital wall fracture, and prompt evaluation by an ophthalmologist from 2012 to 2020 in a tertiary Level 1 trauma center. Results: Fifty percent of patients had a moderate and/or severe ocular injury. Ophthalmology evaluation led to an ocular management change in 27% of patients. Patients with eyelid laceration, extra-ocular motion (EOM) abnormality, and pupillary defect were more likely to have a change in management. There was no delay of surgical bony fracture management. Conclusion: In patients with midface trauma including orbital wall fractures those with eyelid laceration, EOM abnormality, and pupillary defect were likely to undergo ocular management change as a result of ophthalmology consultation.

Clinical Diagnosis and Management of Mucosal Leishmaniasis in the Context of a Global Pandemic: A Case Report.

Mucosal leishmaniasis (ML) is a rare metastatic complication of Leishmania infection. It has a high potential for destructive and disfiguring complications, namely destruction of nasal architecture and airway compromise. ML is difficult to treat for a variety of reasons, including variable antimicrobial resistance rates between species, as well as between endemic areas geographically. There are several treatment options available, which are discussed here. In the majority of cases, a nuanced approach to treatment is required based on speciation and geography. Importantly, the treatment of ML requires a multi-disciplinary approach. We present a patient with a history of cutaneous leishmaniasis who presented with signs and symptoms concerning ML, but due to the COVID-19 global pandemic diagnostic testing was not possible, was treated empirically under clinical suspicion of ML with good results.

Recurrent Retrobulbar Hemorrhage Associated With CPAP Use After Orbital Fracture Repair.

We present a patient who underwent orbital fracture repair complicated by retrobulbar hemorrhages twice within the first postoperative week. The suspected cause is continuous positive airway pressure (CPAP) use with inappropriate patient-modified settings. The most likely mechanism of action was venous congestion from the extrinsic positive pressure, similar to Valsalva maneuvers increasing orbital vasculature pressure. In our patient, because his orbital blood vessels had recently been cauterized, they were too fragile to handle the engorgement and bled, leading to a retrobulbar hemorrhage. It is possible that at a lower CPAP setting, the vascular congestion would not have been as severe and caused bleeding. We recommend routinely asking patients about CPAP use before orbital surgeries and instructing patients to stop CPAP usage for 1 week after any orbital surgeries if medically cleared.

Use of Functional Rhinoplasty in the Aging Nose: Medicare Database Analysis.

Introduction: Nasal obstruction is a common clinical problem. It has become more recognized that the internal and external nasal valves are the areas of greatest resistance. There are changes with aging that can contribute to nasal valve compromise. This study sought to evaluate the utilization of functional rhinoplasty, septoplasty, and inferior turbinate reduction procedures in the Medicare population. Methods: The annual procedure data were obtained from the Part B National Summary Data File from 2000 to 2019. Functional rhinoplasty procedures using current procedural terminology (CPT) for rhinoplasty (30400, 30410, 30420, 30465), septoplasty (30520), and inferior turbinate reduction (30801, 30802, 30130, 30140, 30930) procedures were analyzed. Results: There was increased use of CPT codes 30465, 30410, and 30420 with a decrease in 30400. There was an overall increase in codes 30520 and 30140. When adjusting for the Medicare population per 100,000 enrollees, there was increased use of 30465 and 30140 and decrease in 30520. The charges and payment trends were similar to the overall use of CPT codes. Discussion: There is an overall increase in use of nasal airway procedures including functional rhinoplasty in the aging population.

Practice Characteristics of Pediatric Otolaryngology Same-Day Appointments.

OBJECTIVES: This study aims to assess characteristics of same-day clinic appointments in a pediatric population at an academic otolaryngology practice. METHODS: Retrospective chart review of patients aged 18 or younger who had same-day clinic appointments between January 1, 2016, and December 31, 2018, at a single academic institution. Demographic data, diagnosis(es), procedures, and operations completed were included in the analysis. RESULTS: There were 363 same-day visits by 322 patients in the 3-year study period. Two hundred sixty-nine (269) of these visits were from new patients. Otitis media and rhinosinusitis were the most frequently coded diagnoses. One hundred forty-four (144) procedures were completed the day of the visit and 169 operations were performed as a result of the same-day visit. If the patient had a procedure or operation performed, they were more likely to have been referred by another provider. CONCLUSIONS: Providing same-day appointments can help provide timely and appropriate otolaryngology specialty care to pediatric patients. Further evaluation is needed to determine the effects on patient satisfaction as well as no-show rates.

Assessing the Practice Characteristics of Otolaryngology Same-Day Appointments in an Academic Center.

OBJECTIVES: to Examine the practice characteristics of same-day clinic appointments and the use of same-day appointment scheduling to provide access to care in an otolaryngology-head and neck surgery clinic. METHODS: Retrospective chart review of same-day clinic appointments from January 1, 2016, to December 31, 2018, in patients aged >19 years at a single academic center. Demographic data, diagnoses, procedures completed, and operations completed were analyzed. RESULTS: There were 2696 visits by 2324 patients during the 3-year study period. More men than women (57% vs 43%) made same-day appointments. The mean age was 50.7 years (range, 19-99 years). Sinonasal and otologic diagnoses were the most frequently coded. A total of 1452 procedures were completed on the day of the visit, and 239 operations were completed as a result of the visit. Overall, a broad spectrum of otolaryngology care was delivered within the organizational new patient access goals. DISCUSSION: Access to otolaryngology-head and neck surgery care can be challenging. Many patients will seek care when they feel they need it, and patient conditions can change unexpectedly. Offering same-day scheduling can allow patients timely health care and appropriate care. IMPLICATIONS FOR PRACTICE: Same-day appointment scheduling can provide access to care and urgent care for patients. The department of otolaryngology-head and neck surgery has been able to maintain a high rate of providing new patient appointments within 10 days with this method. Further considerations for the impact of same-day scheduling on no-show rates and patient satisfaction can be evaluated.

Teaching nasal analysis to otolaryngology residents.

PURPOSE: This prospective cohort study was completed to evaluate a systematic approach for teaching nasal analysis to otolaryngology-head and neck surgery residents. METHODS: Residents from each post graduate year (PGY) were randomized to the control group or study group. Residents in the study group were given a 10-slide PowerPoint (Microsoft Corp) instruction on nasal analysis using the standard sequence of photographs and anatomic elements to describe in each view. All residents were given the standard sequence of photographs of 3 patients for assessment on nasal analysis. Then 12-14 weeks later all residents were re-evaluated using photographs of 3 new patients. The results were blinded and graded using an 18 point scale modified from a previous publication [1]. RESULTS: Twenty otolaryngology-head and neck surgery residents completed the study. Analysis was performed with and without multivariate regression modeling to adjust for PGY, sex, and number of rhinoplasties performed. The study group had overall higher scores in both the initial and follow up assessment, specifically with subsite-specific dorsal deviation, tip projection, and nostril symmetry. Neither group obtained high scores in facial symmetry, skin thickness, tip shape and contour, and radix position at initial or re-assessment. CONCLUSION: Nasal analysis is a complex task. A lecture on a systemic approach to facial analysis given to a group of residents, who performed significantly better on facial analysis cases than controls. Further research in providing feedback, periods of rehearsal or testing, or focused selected elements with serial exposure can be considered.

Reconstruction of Defects Involving the Lip and Chin.

Successful perioral reconstruction is the result of consideration of both functional and esthetic goals. The lips are complex esthetic units with multiple tissue layers and distinct anatomic landmarks. Reconstruction can be difficult due to variables affecting the defect, such as size, depth, location, and involvement of adjacent subunits. There are many local flaps that can be used to match the complex tissue layers and anatomic landmarks. Use of the same reconstructive principles can be applied to secondary reconstruction to attain a successful outcome. This article focuses on local reconstructive options for defects of the lip and chin.

Burnout in Otolaryngology-Head and Neck Surgery: A Single Academic Center Experience.

Burnout in modern medicine is becoming more recognized and researched. The objective in this study is to evaluate burnout in a tertiary care academic institution and compare results among faculty, trainees, and advanced practice practitioners (APPs) in a cross-sectional survey using the Maslach Burnout Inventory. Fifty-two surveys were distributed; 44 participants completed the survey (85%): 25 staff physicians (57%), 14 resident physicians (32%), and 5 nurse practitioners (11%). Staff physicians had low emotional exhaustion, moderate depersonalization, and low result for reduced personal accomplishments; trainees reported low emotional exhaustion, high depersonalization, and moderate reduced personal accomplishment; and nurse practitioners reported moderate on all 3 dimensions. There is overall low burnout in this tertiary care academic center of otolaryngologist providers and no difference in rates among the different groups (trainees, APPs, staff). Measures addressing specific deficiencies among dimensions of burnout would be helpful to prevent disintegration of physician satisfaction into burnout.

Role of adenoidectomy in chronic nasal obstruction after nasal steroid therapy failure.

OBJECTIVE: To identify clinical characteristics of pediatric patients that failed nasal steroid therapy for management of chronic nasal obstruction and to evaluate the efficacy of adenoidectomy in this subset of patients. DESIGN: Retrospective chart review. SETTING: Tertiary care academic center. SUBJECTS: Analysis was performed on children that underwent adenoidectomy between 2011 and 2015 for chronic nasal obstruction refractory to nasal steroids. RESULTS: Seventy-four cases were identified. Average age of presentation was 3.6years. Pre-operatively, 25.7% of patients had known asthma, 16.2% reported respiratory allergies, and 20.3% reported use of systemic antihistamines. The most common pre-operative symptoms included mouth breathing (82.4%), nasal congestion (81.1%), snoring (71.6%), and rhinorrhea (37.8%). Average adenoid size was 68% pre-operatively. Ninety-eight percent of patients experienced improvement or resolution of their symptoms following adenoidectomy. CONCLUSIONS: This study demonstrates average rates of respiratory allergies, but high rates of asthma among patients that fail nasal steroid therapy for chronic nasal obstruction. Adenoidectomy is a highly efficacious intervention in this subset of patients.

Is routine audiometric testing necessary for children with isolated preauricular lesions?

INTRODUCTION: Preauricular lesions, including tags, pits, sinuses, and cysts are commonly seen. Some studies have shown increased incidence of hearing loss in these patients but other studies have failed to corroborate this finding. The purpose of this study is to evaluate the incidence of hearing loss in patients with isolated preauricular lesions. METHODS: Retrospective chart review of all pediatric otolaryngology patients seen at a tertiary academic center between 2008 and 2014. All patients with the diagnosis code of 744.1 or 701.9 (preauricular skin tag) or 744.46, 744.47, or 744.89 (preauricular pit/fistula/cyst) were included in this study. Medical records were reviewed for clinical, demographic, and audiologic data. RESULTS: Ninety-nine patients, 46 males, 53 females, with preauricular lesions were identified. Twelve were found to have abnormal hearing. Five patients had conductive hearing loss due to underlying Eustachian tube dysfunction. Four patients had sensorineural hearing loss; three of these patients had an enlarged vestibular aqueduct and one patient did not have an identified cause. Three patients had sound field testing or abnormal otoacoustic emissions that suggested hearing loss with no further follow up. CONCLUSION: Children with isolated preauricular lesions with no history of otologic surgery or risk factors for hearing loss may not need audiologic evaluation outside of regular hearing screening. However, there does appear to be a higher association with Eustachian tube dysfunction in these children. Further studies will need to be done to determine whether or not there is an embryological correlation for this finding.

A Charge Comparison of Audiometric Testing in the Pediatric Population.

OBJECTIVE: To determine the charges associated with performing combined tympanometry and otoacoustic emissions vs a comprehensive audiogram in the pediatric population and to analyze its implications for future practice. STUDY DESIGN: Retrospective charge analysis. SETTING: Tertiary care academic center. SUBJECTS AND METHODS: Analysis was performed on 538 pediatric patients who underwent audiometric hearing testing from May through October 2014. RESULTS: In total, 401 patients had combined tympanometry and otoacoustic emissions testing and 91 patients underwent a comprehensive audiogram, while 46 patients underwent all 3 tests. The technical and professional charges for combined tympanometry and otoacoustic emissions were $139 and $116, respectively, with an overall charge of $255. The technical and professional charges for an audiogram were $124 and $198, respectively, with an overall charge of $322. CONCLUSION: Objective testing with a combination of tympanometry and otoacoustic emissions charges insurers $67 less than an audiogram. Given the questionable reliability of behavioral audiometry in very young children, this is a factor to consider when choosing the appropriate test. With a large number of pediatric auditory hearing tests performed each year, the cost savings within the health care system could be substantial.

Otolaryngologic manifestations of Noonan syndrome.

Noonan syndrome is an autosomal dominant disorder with associated anomalies that include short stature, congenital heart defects, developmental delay, and characteristic facial features among other abnormalities. Articulation deficiency and language delay are often present and require speech therapy. Otitis media and hearing loss have been reported to be common in these patients. We performed a retrospective chart review of pediatric patients who were diagnosed with Noonan syndrome at our tertiary care center from January 1979 through December 2009. We found 19 such patients. Of these, 8 had received single-specialty care at our hospital; it is not known if they had received otolaryngologic care from an outside provider. These 8 patients were not included in our study. The remaining 11 patients-6 boys and 5 girls, aged 1 to 19 years (mean: 9.2)-had all received multidisciplinary care at our institution; 9 of them had received care from an otolaryngologist at our center. Of this group, 7 had history of feeding difficulty, 6 had experienced speech delay that required speech therapy, 6 had undergone placement of a pressure equalization tube, 4 had undergone adenoidectomy with or without tonsillectomy, and 1 had been treated with endoscopic sinus surgery. Although this study is limited by our small number of patients, our results suggest that early otolaryngologist involvement must be considered in the care of children with Noonan syndrome because many have evidence of eustachian tube dysfunction, hearing loss, and speech delay.

Complete bronchial stricture and airway management challenges.

OBJECTIVE: The purpose of this report is to demonstrate a unique case of severe bronchial stricture and discuss the associated diagnostic and airway management challenges. STUDY DESIGN: The design was that of a case report. METHODS: A review of the literature was made. RESULTS: A 15-year-old adolescent boy with a history of renal transplantation 1 year prior presented with a 10-day history of progressive cough and shortness of breath necessitating ventilator support. Chest radiograph and computed tomography showed complete whiteout of the left lung with some areas of hyperinflation of the left upper lobe. Subsequent flexible and rigid bronchoscopy noted a narrowed left mainstem bronchus with no evidence of an intact lumen. After failed attempts at medical treatment and dilation, the patient underwent a left pneumonectomy. He was ultimately discharged home in good condition. DISCUSSION: Bronchial strictures are rare phenomenon with oftentimes unclear etiologies. Atresia of bronchi is even rarer, usually occurring in young males, and may go undiagnosed for 30 years until clinical symptoms occur. Treatment of narrowed segments may involve medical treatment of infectious agents, stent placement, dilation, and sleeve resection. Treatment of atresia or severe stricture may necessitate resection of the lung distal to the affected region. CONCLUSION: Bronchial strictures and atresias may go undiagnosed for years before pulmonary symptoms occur. Computed tomography and bronchoscopy with biopsies represent the mainstays of diagnosis. Regional lung hyperinflation and peribronchial translucency may hint at bronchial atresia. Treatment paradigms vary from dilation and stent placement to resection of the affected areas. In the absence of a clear etiology for lung whiteout, severe bronchial stricture or atresia should be considered as a possibility.