Conventional clinical signs and symptoms are poor predictors of postoperative cerebrospinal fluid leak: A single-centre cohort perspective.

BACKGROUND: Postoperative cerebrospinal fluid (CSF) leak remains a concerning complication of the endoscopic endonasal approach (EEA) for skull base pathology. Signs and symptoms suggesting CSF leak often trigger additional workup during the postoperative course. We systematically evaluate associations between subjectively reported clinical signs/symptoms noted during the immediate postoperative period and incidence of postoperative CSF leaks. METHODS: Retrospective chart review was conducted at a tertiary academic medical centre including 137 consecutive patients with intraoperative CSF leak during EEA with primary repair between July 2018 and August 2022. Postoperative CSF leak associations with clinical signs and symptoms were evaluated using positive (PPV) and negative predictive values (NPV), sensitivity, specificity and odds ratio (OR) via univariate logistic regression. RESULTS: Seventy-nine patients (57.7%) had high-flow leaks repaired and 5 (3.6%) developed CSF leaks postoperatively. Of reported symptoms, rhinorrhea was most common (n = 52, 38.0%; PPV [95% CI] = 7.6% [4.8%, 11.9%]), followed by severe headache (n = 47, 34.3%; 6.3% [3.1%, 12.5%]), dizziness (n = 43, 31.4%; 2.3% [0.4%, 12.1%]), salty or metallic taste (n = 20, 14.6%; 9.9% [3.3%, 25.8%]), and throat drainage (n = 10, 7.3%; 9.9% [1.7%, 41.4%]). Nausea or vomiting constituted the most reported sign concerning for CSF leak (n = 73, 53.3%; PPV [95% CI] = 4.1% [2.0%, 8.1%]). On univariate regression, no sign or symptom, including rhinorrhea (OR [95% CI] = 7.00 [0.76-64.44]), throat drainage (3.42 [0.35-33.86]), salty/metallic taste (4.22 [0.66-27.04]), severe headache (3.00 [0.48-18.62]), dizziness (0.54 [0.06-4.94]), fever (3.16 [0.50-19.99]), and nausea/vomiting (1.33 [0.22-8.21]), associated with postoperative CSF leak. CONCLUSIONS: A range of subjectively reported symptoms and signs failed to predict postoperative CSF leak. Further investigation is warranted to inform appropriate attention and response.

Medicare volume and reimbursement trends in lingual and hyoid procedures for obstructive sleep apnea.

OBJECTIVES: This study aims to analyze utilization and reimbursement trends in lingual and hyoid surgery for obstructive sleep apnea (OSA). METHODS: Annual retrospective data on lingual and hyoid OSA surgeries was obtained from the 2000-2021 Medicare Part B National Summary Datafiles. Current Procedural Terminology (CPT) codes utilized included 21,685 (hyoid myotomy and suspension [HMS]), 41,512 (tongue base suspension [TBS]), 41,530 (radiofrequency ablation of the tongue [RFT]) and 42,870 (lingual tonsillectomy [LT]). RESULTS: The number of lingual and hyoid OSA surgeries rose 2777 % from 121 in 2000 to 3481 in 2015, before falling 82.9 % to 594 in 2021. Accordingly, Medicare payments rose 17,899 % from an inflation-adjusted $46,958 in 2000 to $8.45 million in 2015, before falling drastically to $341,011 in 2021. As the number of HMSs (2000: 91; 2015: 84; 2021: 165), TBS (2009: 48; 2015: 31; 2021: 16), and LTs (2000: 121; 2015: 261; 2021: 234) only experienced modest changes in utilization, this change was largely driven by RFT (2009: 340; 2015: 3105; 2021: 179). Average Medicare payments for RFT rose from $1110 in 2009 to $2994 in 2015, before falling drastically to $737 in 2021. CONCLUSION: Lingual and hyoid surgery for OSA has overall fallen in utilization among the Medicare population from 2000 to 2021. However, there was a brief spike in usage, peaking in 2015, driven by the adoption (and then quick dismissal) of RFT. The rise and fall in RFT use coincide with the rise and fall in reimbursement.

How Variable are Patient Comorbidity Profiles Among Practicing Otolaryngologists?

OBJECTIVE: To determine whether certain groups of otolaryngologists (ORLs) are treating cohorts of patients with more comorbidities. STUDY DESIGN: Cross-sectional population-based analysis. SETTING: 2019 Medicare Provider Utilization and Payment Dataset. METHODS: Each ORL's average Medicare hierarchical condition category (HCC) risk score, a comorbidity index calculated from a patient's comorbidities, was collected. These were stratified and compared by various physician characteristics, including practice region and rurality, years in practice, gender, subspecialty, and setting (academic vs community). RESULTS: Among 8959 ORLs, the mean HCC risk score for Medicare patients was 1.35 ± 0.35. On univariate analysis, ORLs practicing in urban (compared to rural), ORLs in academic settings (compared to community), and early career ORLs all had a patient population with a higher HCC risk score (P < .001 for all). On multivariate analysis controlling for gender, rurality, graduation year, and region, rural setting was associated with decreased odds of having a high-risk patient population (odds ratio: 0.58 [95% confidence interval, CI: 0.48-0.71]; P < .001), while those more recently graduated has an increased risk (2000-2009: 1.41 [1.01-1.96], P = .046; 2010-2015: 2.30 [1.63-3.25], P < .001). In a separate subgroup analysis, subspecialty differences were seen and community setting was associated with decreased odds of having a high-risk patient population (0.36 [0.23-0.55]; P < .001). CONCLUSION: There is variability in patient comorbidity profiles among ORLs, with those in urban settings, those more recently graduated, and those in academic settings treating a group with more comorbidities. As the comorbidity burden may increase the cost of practice and complications, these findings may have important implications for health inequity.

Medicaid Acceptance Varies by Physician Seniority and Specialty in California.

Given varied insurance acceptances and differing pay between insurances, our objective was to examine the number of California physicians enrolled in Medicare and Medicaid (Medi-Cal), stratified by specialty and graduation year. Medi-Cal and Medicare providers were extracted from publicly available databases (Centers for Medicare & Medicaid Services and California Health and Human Services) and were subsequently merged into one dataset using National Provider Identifier. From there, we stratified physicians by specialty and graduation year. We found that emergency medicine, radiology, pathology, anesthesiology, general surgery, and internal medicine had the highest percent of Medi-Cal-accepting physicians, whereas dermatology, psychiatry, physical medicine & rehabilitation, and plastic & reconstructive surgery physicians had the lowest. There also appears to be an inverse relationship between acceptance of Medi-Cal and earlier year of graduation (P < 0.05). This study demonstrated striking variability in Medi-Cal acceptance based upon physician years in practice and specialty. Older, experienced physicians, as well as physicians of certain specialties, are less likely to accept Medi-Cal.

Tissue Sealant Impact on Skull Base Reconstruction Outcomes: A Systematic Review and Meta-Analysis.

OBJECTIVE: Despite significant advances in understanding of skull base reconstruction principles, the role of tissue sealants in modifying postoperative cerebrospinal fluid (CSF) leak outcomes remains controversial. We evaluate postoperative CSF leak incidence associated with tissue sealant use in skull base defect repair during endoscopic skull base surgery (ESBS). DATA SOURCES: Web of Science, PubMed/MEDLINE, Scopus, and Cochrane Library. REVIEW METHODS: Systematic review and meta-analysis of risk differences (RD). A search strategy identified original studies reporting CSF leakage following ESBS with disaggregation by tissue sealant use and/or type. RESULTS: 27 non-randomized studies (n = 2,403) were included for qualitative and meta-analysis. Reconstruction with a tissue sealant did not significantly reduce postoperative CSF leak risk compared with reconstruction without sealant (RD[95% CI] = 0.02[-0.01, 0.05]). Sub-analyses of dural sealant (-0.02[-0.11, 0.07]) and fibrin glue (0.00[-0.07, 0.07]) compared with no sealant were similarly unremarkable. Postoperative CSF leakage was not significantly modulated in further sub-analyses of DuraSeal (0.02[-0.02, 0.05]), Adherus (-0.03[-0.08, 0.03]), or Bioglue (-0.06[-0.23, 0.12]) versus no dural sealant use, or Tisseel/Tissucol versus fibrin glue nonuse (0.00[-0.05, 0.05]). No significant association was seen comparing dural sealant use versus fibrin glue use on pairwise (0.01[-0.03, 0.05]) or network meta-analysis (-0.01[-0.05, 0.04]). Limitations in source literature prevented sub-analyses stratified by leak characteristics, defect size and location, and accompanying reconstruction materials. CONCLUSION: Tissue sealant use did not appear to impact postoperative CSF leak incidence when compared with nonuse. Higher quality studies are warranted to thoroughly elucidate the clinical value of adjunct sealant use in endoscopic skull base reconstruction. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.

Boomerang Modification of the Septal Extension Graft: Graft Design and Functional Outcomes.

Background: A "boomerang" graft is an end-to-end caudal septal extension graft (SEG) that conforms to the geometry of the anterior septal angle, and avoids septal overlap, unlike a side-to-side SEG. Objective: To compare breathing improvements in rhinoplasty patients receiving boomerang SEGs and patients receiving side-to-side SEGs. Methods: Retrospective cohort analysis of patients undergoing rhinoplasty with either end-to-end boomerang SEG or a side-to-side SEG. Functional outcomes were assessed through the Nasal Obstruction Symptom Evaluation (NOSE) survey. Results: The boomerang SEG cohort had a mean age of 34 years and were 68% female compared with 38 years and 67% female in the side-to-side SEG cohort (p > 0.05). The cohorts did not differ in the proportion of the lateral crural tensioning, spreader graft placement, or history of rhinoplasty. The boomerang cohort demonstrated a 67% reduction in NOSE scores compared with a 70% reduction among the side-to-side SEG cohort (p = 0.14). Men undergoing boomerang graft placement reported significantly less postoperative functional improvement than men undergoing placement of a side-to-side SEG (62% vs. 77%, p = 0.01). Conclusion: Use of a boomerang graft is not likely to negatively affect rhinoplasty functional outcomes when compared with a side-to-side SEG.

The impact of nasal packing on skull base reconstruction and quality-of-life outcomes following endoscopic skull base surgery.

KEY POINTS: Nasal packing type was not associated with postoperative cerebrospinal fluid leaks Nondissolvable packing conferred an increased risk for postoperative sinonasal infections Nasal packing type did not influence short- and long-term quality-of-life scores.

Mutational landscape and predictors of survival in head and neck mucosal melanoma.

KEY POINTS: Head and neck mucosal melanomas have a diverse mutational landscape with low mutational burden. A molecular subset (∼13%) has ROS1 mutations, which is an actionable driver mutation. ROS1-mutated patients have improved overall survival likely due to high mutational burden.

Complications of Novel Radiofrequency Device Use in Rhinology: A MAUDE Analysis.

With the widespread adoption of intranasal radiofrequency (RF) devices, our objective was to report national adverse events (AEs) associated with their use. The Food and Drug Administration's Manufacturer and User Facility Device Experience was queried. A total of 24 device-related AEs were reported, 11 (45.8%) for Celon® (Olympus), 3 (12.5%) for Vivaer® (Aerin), 2 (8.3%) for Neuromark® (Neurent), and 8 (33.3%) for Rhinaer® (Aerin). Seven (63.6%) of the Celon®-related complications were related to tissue necrosis (largely user error-related), but 1 (9.1%) episode of pediatric ocular palsy was also reported. Vivaer® complications included synechiae formation, a mucosal perforation, and a case of empty nose syndrome. Of the posterior nasal nerve ablating devices, 9 of 10 AEs were epistaxes, of which 7 (77.8%) required operative intervention. Surgeons should exercise vigilance and tissue-appropriate device settings when utilizing RF devices. Epistaxis and tissue necrosis may occur, as well as more rare, but devastating, complications.

Factors Influencing Graduates of American Academy of Facial Plastic and Reconstructive Surgery Fellowships Career Choice of Academic or Private Practice: A 20-Year Review.

Background: Absence of published literature on facial plastic and reconstructive surgery (FPRS) fellows' pursuit of academic careers hampers informed decision making for those interested in the specialty, fellowship program directors, and leaders in the American Academy of Facial Plastic and Reconstructive Surgery. Objective: To examine career choices among FPRS fellows from 2000 to 2019 and identify factors linked to academic or private practice employment after fellowship. Methods: Data from 796 fellows were analyzed, including gender, medical school, residency program, fellowship program, fellowship year, and degrees, to categorize them based on academic or nonacademic career placement. Logistic regression analyses were conducted to explore the association between demographic factors and academic career placement. Results: Forty-three percent (n = 345) obtained academic positions, with significant associations found between academic placement and additional advanced degrees, completion of fellowship training in the northeast, and residency training at an institution offering FPRS fellowship. Conclusion: Although fellows in FPRS predominantly pursue private practice, the decision to pursue academia is influenced by complex and multifactorial factors among graduates in the field.

Second Harmonic Imaging of Nasal, Auricular, and Costal Cartilage.

OBJECTIVE: There is little knowledge about the histological organization of facial and costal cartilages in terms of matrix structure and cell morphology. Second harmonic generation (SHG) imaging is a nonlinear imaging technique that capitalizes on signal generation from highly ordered macromolecules such as collagen fibers. The purpose of this study was to use SHG microscopy to image collagen extracellular matrix (ECM) structure, chondrocyte size, and density of these cartilages. STUDY DESIGN: Experimental. METHODS: Surgical remnants of septal, lower lateral, rib, and auricular cartilages were collected following surgery, sectioned into 0.5-1 mm thick samples and fixed to facilitate batch process imaging. A Leica TCS SP8 MP Microscope and multiphoton laser were used to image the specimens. Images were analyzed for cell size, cell density, and collagen fiber directionality patterns using ImageJ. RESULTS: SHG images of septal specimens show mesh-like structure of the ECM. There appears to be a superficial layer, characterized by flattened lacunae and middle zone, marked by circular lacunae clusters, similar to what is observed in articular cartilage. The structure of the ECM depicts a visible orientation perpendicular to the surface of the perichondrium. Cell size and density analysis through ImageJ suggests variety across cartilage types. Directionality analysis indicates that the collagen in the ECM displays preferred direction. CONCLUSION: This study establishes clear extracellular models of facial and costal cartilages. Limitations include heterogeneous cartilage thickness due to processing difficulties. Further studies include automating the cutting process to increase uniformity of tissue thickness and increasing sample size to further validate results. LEVEL OF EVIDENCE: 2 Laryngoscope, 133:3370-3377, 2023.

Racial and ethnic disparities in the presentation size and timing of pituitary adenomas resected via endoscopic endonasal approach.

KEY POINTS: In a single-center cohort of pituitary adenoma patients, non-White race independently predicted larger tumor size at initial presentation. Uninsured patients suffered a significantly higher rate of pituitary apoplexy at initial presentation. Geographically distant care appeared to present a greater barrier for non-White and Hispanic patients relative to their White and non-Hispanic counterparts.

Frailty, Age, ASA Classification, and BMI on Postoperative Morbidity in Mandibular Fracture ORIF.

OBJECTIVE: To assess how traditional, simple markers of health independently affect postoperative morbidity of mandibular fracture open reduction-internal fixations (ORIFs). STUDY DESIGN: Cohort study. SETTING: National Surgical Quality Improvement Project (NSQIP) Database. METHODS: The 2005 to 2017 NSQIP database was queried for patients who underwent mandibular ORIF. To control for the severity of the trauma, an additional "concurrent surgery" variable was created. A modified 5-item frailty index was calculated based on the following: presurgery-dependent functional status, chronic hypertension, diabetes mellitus, history of chronic obstructive pulmonary disease, and history of congestive heart failure. RESULTS: Among 1806 patients with mandibular ORIFs (mean age 34.8 ± 15.4 years), modified frailty index (mFI) was associated with 30-day medical complications (p < .001), reoperation (p < .001), and readmission (p = .005) on univariate analysis. Increased age was associated with prolonged hospitalization (p < .001) and medical complications (p < .001). The increased American Society of Anesthesiologists (ASA) score was associated with all endpoints (p ≤ .003), while increased body mass index (BMI) was associated with none. On multivariate analysis, only increased ASA was associated with any adverse event (reference: ASA 1; ASA 2, odds ratio [OR]: 2.17 [95% confidence interval, CI: 2.17-3.71], p = .004; ASA 3-4, OR: 3.63 [95% CI: 1.91-6.91], p < .001). Similarly, mFI and BMI were not independently associated with prolonged hospitalization (≥2 days) (p ≥ .015), but 65+ age (reference: 18-49; OR: 2.33 [95% CI: 1.40-3.86], p = .001) and ASA 3 to 4 groups (reference: ASA 1; OR: 3.26 [95% CI: 2.06-5.14], p < .001) were. CONCLUSION: ASA status and age are more useful modalities than mFI or BMI in predicting poor postoperative morbidity in mandibular ORIF. These simple metrics can assist with managing surgeons' expectations for mandibular ORIF patients.

Diagnosis, Prognosticators, and Management of Acute Invasive Fungal Rhinosinusitis: Multidisciplinary Consensus Statement and Evidence-Based Review with Recommendations.

BACKGROUND: Acute invasive fungal sinusitis (AIFS) is an aggressive disease that requires prompt diagnosis and multidisciplinary treatment given its rapid progression. However, there is currently no consensus on diagnosis, prognosis, and management strategies for AIFS, with multiple modalities routinely employed. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on AIFS, summarize the existing evidence, and provide recommendations on the management of AIFS. METHODS: The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through January 2022. Studies evaluating management for orbital, non-sinonasal head and neck, and intracranial manifestations of AIFS were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on management principles for AIFS were generated. RESULTS: A review and evaluation of published literature was performed on 12 topics surrounding AIFS (signs and symptoms, laboratory and microbiology diagnostics, endoscopy, imaging, pathology, surgery, medical therapy, management of extrasinus extension, reversing immunosuppression, and outcomes and survival). The aggregate quality of evidence was varied across reviewed domains. CONCLUSION: Based on the currently available evidence, judicious utilization of a combination of history and physical examination, laboratory and histopathologic techniques, and endoscopy provide the cornerstone for accurate diagnosis of AIFS. In addition, AIFS is optimally managed by a multidisciplinary team via a combination of surgery (including resection whenever possible), antifungal therapy, and correcting sources of immunosuppression. Higher quality (i.e., prospective) studies are needed to better define the roles of each modality and determine diagnosis and treatment algorithms.

Developing the Optimal Osteotome Hand-Sharpening Method.

Background: Rhinoplasty osteotomes can be sharpened in various ways: professional sharpening or hand sharpening using whetstones or rotary powered devices. Objective: To compare the effectiveness of sharpening osteotomes using various sharpening methods with that of professional sharpening as measured by a custom edge tester. Materials and Methods: We performed repeated serial osteotome impacts on bovine femoral cortical bone. These dull osteotomes were sharpened using preidentified sharpening techniques. Edge morphology was evaluated. Sharpness was tested using a custom mechanical testing platform. Optimized sharpness was achieved with a whetstone sharpening method wherein the osteotome is flipped after every stroke. Results: Seven distinct sharpening methods were tested for sharpness five times each to determine the optimal sharpening method versus professional sharpening (control). The two sharpening methods, 5 (5.51 ± 0.32) and 6 (5.55 ± 0.32), that used this flipping technique were significantly sharper than other methods. Methods 5 (p = 1.0) and 6 (p = 1.0) were the only methods that were not significantly different from control. Conclusion: Single stroke with successively alternating surfaces created the sharpest blades that achieved results similar to professional sharpening.

Freshly Thawed Cryobanked Human Neural Stem Cells Engraft within Endogenous Neurogenic Niches and Restore Cognitive Function after Chronic Traumatic Brain Injury.

Human neural stem cells (hNSCs) have potential as a cell therapy after traumatic brain injury (TBI). While various studies have demonstrated the efficacy of NSCs from ongoing culture, there is a significant gap in our understanding of freshly thawed cells from cryobanked stocks-a more clinically relevant source. To address these shortfalls, the therapeutic potential of our previously validated Shef-6.0 human embryonic stem cell (hESC)-derived hNSC line was tested after long-term cryostorage and thawing before transplant. Immunodeficient athymic nude rats received a moderate unilateral controlled cortical impact (CCI) injury. At four weeks post-injury, 6 × 105 freshly thawed hNSCs were transplanted into six injection sites (two ipsi- and four contra-lateral) with 53.4% of cells surviving three months post-transplant. Interestingly, most hNSCs were engrafted in the meninges and the lining of lateral ventricles, associated with high CXCR4 expression and a chemotactic response to SDF1alpha (CXCL12). While some expressed markers of neuron, astrocyte, and oligodendrocyte lineages, the majority remained progenitors, identified through doublecortin expression (78.1%). Importantly, transplantation resulted in improved spatial learning and memory in Morris water maze navigation and reduced risk taking in an elevated plus maze. Investigating potential mechanisms of action, we identified an increase in ipsilateral host hippocampus cornu ammonis (CA) neuron survival, contralateral dentate gyrus (DG) volume, and DG neural progenitor morphology as well as a reduction in neuroinflammation. Together, these findings validate the potential of hNSCs to improve function after TBI and demonstrate that long-term biobanking of cells and thawing aliquots before use may be suitable for clinical deployment.