Treatment Outcomes With Conservative Management of Frontal Sinus Outflow Tract Fractures.

OBJECTIVE: Historically, early surgical management of frontal sinus outflow tract (FSOT) fractures has been standard practice. There has been a paradigm shift toward nonsurgical or delayed management. Unfortunately, clinical indications and treatment outcomes for this approach are poorly understood. This study evaluates radiologic indicators, as well as sinus reaeration and complication rates for FSOT injuries treated nonsurgically. STUDY DESIGN: A retrospective cohort study of FSOT injuries between 2005 and 2019. SETTING: Academic, tertiary care medical center. METHODS: Radiographic fracture patterns of the frontal ostia (FO) and frontal recess (FR) were recorded as either patent, disrupted, or obstructed. Sinus reaeration, surgical rescue, and complication rates were documented. Patients with follow-up imaging >42 days were included. Patients undergoing immediate surgical intervention were excluded. RESULTS: One hundred patients were identified and 44 met the criteria (88 sinuses). Among nonobstructed FSOT injuries (ie, patent or disrupted), reaeration occurred in 91% of the FO and 98% of FR injuries. Two sinuses required surgical rescue including 1 Draf IIB (1%), and 1 obliteration (1%). Two sinuses had complications including 1 mucocele (1%) and 1 cerebrospinal fluid leak (1%). FO and FR fracture patterns had no identifiable correlation with long-term reaeration rates or the need for surgical intervention. CONCLUSION: Among nonobstructive injuries to the FSOT, average reaeration rates in observed patients were high (91%-98%). Rescue surgery (2%) and complication rates (2%) were low, suggesting that nonsurgical management of nonobstructed FSOT is a viable strategy. No radiographic features were clearly identified to be predictive of sinus reaeration.

Pediatric Mandible Fractures: Mechanism, Pattern of Injury, Fracture Characteristics, and Management by Age.

Background: Development of the craniofacial skeleton and different mechanisms of injury warrant different treatment paradigms for younger children versus those at skeletal maturity. Objective: To characterize the mechanism, fracture patterns, and management of mandible fractures across the pediatric age spectrum. Methods: A 10-year retrospective review of <18-year-old children with mandible fractures at a level 1 trauma center. Characteristics were compared by age subgroup analysis. Results: Of 220 patients meeting inclusion criteria, motor vehicle collision (n = 53, 40.8%), falls (n = 48, 36.9%), and assault (n = 19, 14.6%) were the most common mechanisms with more falls in younger children and more injury by assault in teenagers. Condylar fractures were most common in the 0- to <9-year-old children (n = 27, 38.4%); angle/ramus fractures (56, 62.6%) were most common in 15- to <18-year-old children (p < 0.001). Nonsurgical management was associated with younger age (p < 0.001). Fourteen of 125 patients (8.0%) undergoing surgical intervention experienced complications. Being uninsured was associated with shorter median (interquartile range) follow-up of 5.6 (1.4-10.7) weeks, compared with private [11.9 (4.3-49.0) weeks] and public insurance [11.7 (3.7-218.0) weeks] (p < 0.001). Conclusion: The mechanism, fracture sites, and treatment differed by age with the youngest frequently managed nonoperatively and teenagers treated with adult algorithms. Complications were rare overall within 6-12 weeks after injury, with or without surgical management.

Surgeon education through a surgical cost feedback system reduces supply cost in endoscopic skull base surgery.

OBJECTIVE: A large proportion of healthcare expense is operating room (OR) costs. As a means of cost mitigation, several institutions have implemented surgeon education programs to bring awareness about supply costs. This study evaluates the impact of a surgical cost feedback system (surgical receipt) on the supply costs of endoscopic skull base surgery (ESBS) procedures. METHODS: The supply costs of each ESBS surgical case were prospectively collected and analyzed before and after the implementation of a nonincentivized, automated, and itemized weekly surgical receipt system between January 2017 and December 2019. Supply cost data collected 15 months prior to intervention were compared with cost data 21 months after implementation of the surgical receipt system. Demographics, surgical details, and OR time were collected retrospectively. RESULTS: Of 105 ESBS procedures analyzed, 36 preceded and 69 followed implementation of cost feedback. There were no significant differences in patient age (p = 0.064), sex (p = 0.489), surgical indication (p = 0.389), or OR anesthesia time (p = 0.51) for patients treated before and after implementation. The mean surgical supply cost decreased from $3824.41 to $3010.35 (p = 0.002) after implementation of receipt feedback. Usage of dural sealants (p = 0.043), microfibrillar collagen hemostat (p = 0.007), and oxidized regenerated cellulose hemostat (p < 0.0001) and reconstructive technique (p = 0.031) significantly affected cost. Mediation analysis confirmed that the overall cost reduction was predominantly driven by reduced use of dural sealant; this cost saving exceeded the incremental cost of greater use of packing materials such as microfibrillar collagen hemostat. CONCLUSIONS: Education of surgeons regarding surgical supply costs by a surgical receipt feedback system can reduce the supply cost per case of ESBS operations.

The Impact of Medical Comorbidities on Patient Satisfaction in Chronic Rhinosinusitis.

BACKGROUND: Patient satisfaction has a significant bearing on medical therapy compliance and patient outcomes. The purpose of this study was to (1) describe patient satisfaction, as characterized by the Patient Satisfaction Questionnaire-18 (PSQ-18), in the care of patients with chronic rhinosinusitis (CRS) and (2) analyze the impact of comorbidities on satisfaction using the functional comorbidity index (FCI). METHODS: Patient demographics, disease severity measures, and PSQ-18 scores for patients with CRS presenting to a tertiary rhinology clinic between November 2019 and April 2020 were collected and analyzed. FCI was calculated retrospectively using the electronic medical record; individual comorbidities were tabulated. Spearman's correlations followed by multivariate regression was used to assess the relationship between medical comorbidities and PSQ-18. RESULTS: Sixty-nine patients met criteria for analysis. There were no significant differences in age, gender, and Sinonasal Outcomes Test-22 scores between CRS patients with (CRSwNP) and without (CRSsNP) nasal polyps. There was no significant difference in the mean FCI for patients with CRSwNP versus CRSsNP (5.1 and 4.3, respectively) (P = .843). Similarly, there was no significant difference in the mean sum PSQ-18 score (78/100 in both) between these cohorts (P = .148). The mean sum PSQ-18 score was not significantly associated with anxiety (P = .728), depression (P = .624), or FCI (P = .282), but was significantly associated with hearing impairment (P < .001). CONCLUSION: Patient satisfaction in the care of CRS is generally high with a diagnosis of comorbid hearing impairment demonstrating a negative association with satisfaction in this cohort.

Preoperative Gabapentin Administration and Its Impact on Postoperative Opioid Requirement and Pain in Sinonasal Surgery.

OBJECTIVE: To determine the efficacy of preoperative gabapentin on patient-reported pain levels and postoperative opioid requirements following sinonasal surgery. STUDY DESIGN: Retrospective review. SETTING: Academic institution. METHODS: Patients undergoing sinonasal surgery between July 2019 and January 2020 were followed. Groups were divided into those that received 600 mg of oral gabapentin 1 hour preoperatively (gabapentin) and those that did not (control). Postoperatively, each patient was counseled to use acetaminophen, ibuprofen, and oxycodone as needed for pain control. Patients completed a daily postoperative pain and medication log. Pain was measured by the visual analog scale (VAS) and opioid use by morphine equivalent dose (MED). Chi-square test and Wilcoxon test were used for data analysis. RESULTS: Fifty-seven patients were included (control, n = 28; gabapentin, n = 29). There was no significant difference in age, sex, or baseline Sinonasal Outcome Test-22 scores between the groups. The total MED, postoperative day (POD) 1-2 MED, POD 3-4 MED, and POD 5-6 MED did not differ significantly between the control (17.9, 12.2, 4.6, 1.5) and gabapentin (19.0, 8.9, 7.2, 3.5) groups (P = .98, .25, .16, .44). The mean daily VAS score did not differ significantly between the control (3.1) and gabapentin (2.8) groups (P = .81). The mean daily VAS score decreased significantly in both groups with each successive POD (P = .004). CONCLUSION: Preoperative gabapentin did not significantly reduce postoperative pain or opioid use. Postoperative discomfort following sinonasal surgery is mild, and opioid intake is minimal.

Oncocytic Cysts of the Nasopharynx: A Case Report.

BACKGROUND: Nasopharyngeal oncocytic lesions are a spectrum of benign lesions that represent a reactive or hyperplastic response to chronic inflammation. Though oncocytic lesions are typically asymptomatic, unilateral, and benign, this article discusses a rare case of large, bilateral oncocytic cysts and downstream otologic sequelae with a focus on identifying and discussing similar disease processes. METHODS: Case report and literature review.Case Presentation: A 67-year-old patient with 57 pack year smoking history presented for one year of left sided hearing loss and aural fullness. Clinic endoscopic exam demonstrated severe inflammatory and cystic changes lining the bilateral tori. Imaging and tissue sampling confirmed the cause was minor salivary gland cysts with papillary projections lined by oncocytic cells within bilateral tori tubarius. He was successfully treated with myringotomy with pressure equalizing tube, counseling on tobacco cessation, and surveillance with serial nasopharyngoscopy. CONCLUSIONS: Chronic eustachian tube dysfunction is a possible rare presentation and sequelae of large oncocytic cysts of the nasopharynx. Oncocytic cysts should be considered on the differential diagnosis for nasopharyngeal masses causing such dysfunction.

Preoperative multimodal analgesia decreases 24-hour postoperative narcotic consumption in elective spinal fusion patients.

BACKGROUND CONTEXT: Effective postoperative pain management in patients undergoing elective spinal fusion surgery has been associated with shorter hospital stays, reduced rates of hospital readmissions due to pain, and decreased cost of care. Furthermore, preoperative multimodal analgesia regimens have been shown to decrease postoperative subjective pain measurements and narcotic consumption in patients undergoing spinal fusion and total arthroplasty surgeries. PURPOSE: Compare the difference in effects on 24-hour postoperative narcotic consumption, reported pain, and early mobility with administration of preoperative celecoxib plus gabapentin, gabapentin alone, and a nonstandardized analgesia regimen in patients undergoing elective spinal fusion surgery involving ≤5 levels. STUDY DESIGN: Retrospective review, Level of Evidence III. PATIENT SAMPLE: A total of 185 adult patients undergoing elective spinal fusion surgery involving ≤5 levels from 2013 to 2017 at one academic institution. Patients were excluded if the surgery was nonelective, for oncological purposes, or the patient was younger than 17 years old. OUTCOME MEASURES: Twenty-four-hour postoperative morphine equivalent consumption, 24-hour postoperative visual analogue scale (VAS) pain scores, postoperative day to ambulate, and postoperative day to clear physical therapy. METHODS: A single-institution retrospective chart review was conducted. Patients meeting inclusion criteria were grouped by whether they had received preoperative celecoxib plus gabapentin, gabapentin alone, or neither of these medications. Opioid medication intake for the first 24 hours after the surgery end time was tabulated and converted to morphine equivalents. Visual analogue scale (VAS) pain scores were also averaged over the first 24 hours. Finally, physical therapy notes were reviewed to determine the time taken for the patient to first ambulate and to clear physical therapy. No external funding was procured for this research and the authors' conflicts of interest are not pertinent to the present work. RESULTS: Twenty-four-hour postoperative morphine equivalent consumption was significantly lower in the celecoxib plus gabapentin group compared with control (p=.004). Patients in the celecoxib plus gabapentin group had significantly lower mean VAS scores (p=.002) and had earlier mobility postoperatively (p=.012) than those in the control group. Early mobility and time to physical therapy clearance did differ between the celecoxib + gabapentin group compared with the gabapentin alone group. The gabapentin group had a significantly higher 24-hour morphine dose equivalent (p=.013) and a significantly higher VAS average (p=.009) compared with the celecoxib + gabapentin group. Gabapentin given alone compared with control did not show statistically significant improved outcomes in postoperative morphine equivalent consumption, pain scores or physical therapy goals. CONCLUSIONS: This study demonstrates that administering a selective COX-2 inhibitor and GABA-analogue preoperatively can significantly decrease 24-hour postoperative opioid consumption, VAS pain scores, and elapsed time to postoperative mobility in patients undergoing elective spine fusion surgery of ≤5 levels. Optimal standardized dosing and drug combination for preoperative multimodal analgesia remains to be elucidated.

Contrast volume use in manual vs automated contrast injection systems for diagnostic coronary angiography and percutaneous coronary interventions.

BACKGROUND: Contrast-induced nephropathy (CIN) is an important cause of iatrogenic morbidity and mortality. The amount of contrast delivered has a major effect on CIN and is operator-dependent. A few studies suggested that the use of automated contrast injection systems is associated with reduced contrast volume. It is unknown whether this is true when smaller amounts of contrast are used and how this is affected by training. METHODS: Volume of contrast media was measured in 1358 consecutive patients undergoing diagnostic catheterization and percutaneous coronary intervention (PCI) from January 31 to May 31, 2011. Patients were allocated to manual stopcock-manifold contrast injection (1052 patients) or automated contrast injection (306 patients). RESULTS: No significant difference in contrast volume use was found between manual and automated contrast injection systems, respectively: diagnostic catheterization, 72 ± 40 mL vs 96 ± 63 mL (P = 0.08); diagnostic catheterization with left ventricular angiography, 98 ± 40 mL vs 95 ± 35 mL (P = 0.51); PCI, 206 ± 82 mL vs 205 ± 90 mL (P = 0.84); diagnostic catheterization and PCI, 264 ± 83 mL vs 253 ± 93 mL (P = 0.51). No significant difference in CIN incidence, according to contrast injection systems, was found among patients receiving PCI (manual 9.8% vs automated 7.4%, P = 0.43). Using smaller sized catheters during diagnostic procedures was associated with injection of smaller amounts of contrast (P < 0.0001). CONCLUSIONS: The use of automated contrast injection for diagnostic catheterization and PCI is not associated with reduced contrast volume as compared with manual injection. The use of smaller calibre catheters might reduce contrast volume.