Evaluating the Efficacy of Liposomal Bupivacaine in Postoperative Pain Management for Rhinoplasty: A Retrospective Study.

BACKGROUND: Rhinoplasty, a leading cosmetic surgical procedure, often involves the use of opioids for postoperative pain management. This raises concerns due to potential opioid side effects and overprescription. Liposomal bupivacaine offers a promising alternative, but its efficacy in rhinoplasty remains under-investigated. This study assesses the impact of liposomal bupivacaine on postoperative pain and opioid consumption following rhinoplasty. METHODS: A retrospective study was conducted on patients undergoing rhinoplasty between January 2014 and September 2020. Postoperative pain scores were assessed at intervals up to 16 h, and opioid consumption was monitored. Patients were stratified into two groups: those receiving postoperative liposomal bupivacaine (Group 1) and those who did not (Group 2). RESULTS: No significant disparities in demographics or surgical specifics were identified between groups. Group 1 consistently reported lower pain scores, notably at 30 min (1.4 vs. 3.7, p = 0.0006) and 2 h (2.2 vs. 3.38, p = 0.0417). Cumulatively, Group 1's average pain score was 2.4, significantly lower than Group 2's 3.4 (p = 0.0023). Group 1 also demonstrated reduced opioid consumption, with oxycodone and oral morphine equivalent (OME) intake being notably lower (p = 0.005 and p = 0.0428, respectively). CONCLUSION: Liposomal bupivacaine presents as an efficacious alternative for post-rhinoplasty pain management, reducing both perceived pain and opioid consumption. While promising, the findings necessitate validation through larger, prospective studies considering the inherent limitations of this preliminary investigation. This study evaluates the efficacy of liposomal bupivacaine as a pain management strategy in postoperative care for rhinoplasty and septorhinoplasty procedures, with the potential to reduce reliance on opioids. The findings indicate that patients receiving liposomal bupivacaine experienced significantly lower pain scores postoperatively and less overall opioid consumption, thereby enhancing patient comfort and safety. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparing Open Versus Rigid Endoscopic and Flexible Endoscopic Techniques for the Treatment of Zenker's Diverticulum.

OBJECTIVE: To describe the outcomes of patients undergoing open stapler versus transoral rigid and flexible endoscopic therapies for symptomatic Zenker's diverticulum. STUDY DESIGN: Single institution retrospective review. SETTING: Tertiary care academic hospital. METHODS: We retrospectively evaluated the outcomes of 424 consecutive patients who underwent Zenker's diverticulotomy via an open stapler, rigid endoscopic CO2 laser, rigid endoscopic stapler, rigid endoscopic harmonic scalpel, or flexible endoscopic technique from January 2006 to December 2020. RESULTS: A total of 424 patients (173 females, mean age 73.1 ± 11.2 years) from a single institution were included. A total of 142 patients (33%) underwent endoscopic laser treatment, 33 (8%) underwent endoscopic harmonic scalpel, 92 (22%) underwent endoscopic stapler, 70 (17%) underwent flexible endoscopic, and 87 (20%) underwent open stapler. All open and rigid endoscopic procedures and most of the flexible endoscopic procedures (65%) were performed under general anesthesia. The flexible endoscopic group had a higher percentage of procedure-related perforation, defined as subcutaneous emphysema or contrast leak on imaging (14.3%). The recurrence rates were higher in the harmonic stapler, flexible endoscopic, and endoscopic stapler groups at 18.2%, 17.1%, and 17.4%, respectively, and lower in the open group (1.1%). Length of hospital stay and return to oral intake were similar among groups. CONCLUSION: The flexible endoscopic technique was associated with the highest rate of procedure-related perforation, while the endoscopic stapler had the lowest number of procedural complications. Recurrence rates were higher among the harmonic stapler, flexible endoscopic, and endoscopic stapler groups and lower in the endoscopic laser and open groups. Prospective comparative studies with long-term follow-up are needed.

Flexible endoscopic Zenker's diverticulotomy - A retrospective review of outcomes in 75 patients.

OBJECTIVE: Flexible endoscopic Zenker's diverticulotomy (FEZD) is a procedure performed primarily by gastroenterologists for treatment of symptomatic Zenker's diverticulum (ZD). Given the lack of prior investigations with large sample sizes, we report on one of the largest series of patients who underwent FEZD. METHODS: A review of patients who underwent FEZD at our institution from 2006 to 2021 was performed. Data were abstracted for patient demographics, clinical features, procedural characteristics, adverse events, and outcomes. RESULTS: A total of 75 patients (37 women) with mean age of 77.9 (33-102) years and mean (range) follow-up of 1.1 (0-13.2) years were identified. 67.9 % of FEZD cases were performed under general anesthesia. The mean procedure time was 37.1 min. Same day discharge and resumption of oral intake was seen in 56.4 % and 57.1 % of cases, respectively. Adverse events included intraprocedural bleeding (15.7 %) controlled with endoscopic means, infection (4.8 %) exclusively managed with antibiotics in all but one case, subcutaneous emphysema (2.4 %), and perforation (10.7 %) conservatively managed in all but one case. 97.6 % of patients had sustained subjective improvement in symptoms following their procedure. Fifteen patients (20 %) experienced recurrence after undergoing initial FEZD-26.7 % percent of whom were sufficiently treated with repeat FEZDs. Younger age was associated with recurrence (p < 0.01). CONCLUSION: FEZD is an effective, safe procedure for the management of symptomatic ZD. It is a viable alternative for patients in whom otorhinolaryngological procedures via rigid endoscopy are not an option.

Intraoperative Parathyroid Hormone Monitoring Is of Limited Usefulness in Guiding Autotransplantation in Reoperative or Subtotal Parathyroidectomy for Primary Hyperparathyroidism.

INTRODUCTION: Patients with primary hyperparathyroidism (1HPT) undergoing reoperative or subtotal parathyroidectomy (PTX) may undergo autotransplantation (ATX) when the viability of remaining tissue is unknown. This study aims to identify whether intraoperative parathyroid hormone levels (IOPTH) can determine ATX candidacy. METHODS: Patients with 1HPT who underwent PTX with ATX at our institution were identified. IOPTH and PTH values within 24 h, 2-4 weeks, and >1 month postoperative were analyzed. Patients were classified as either a candidate for ATX (low PTH after 2-4 weeks) or not a candidate based on postoperative PTH (normal PTH after 2-4 weeks). Associations of ATX candidate status with demographic and clinical attributes were studied. RESULTS: 268 had a reoperative (49%) or subtotal PTX with ATX. 151 had data for PTH analysis, and 21 (14%) were identified as candidates for ATX. The mean % decline in IOPTH from baseline to 20 min post-excision was 51% in noncandidates vs 73% in candidates (P = .002). The mean change in IOPTH from baseline to final was 52% in noncandidates and 83% in candidates (P = .009). A decrease in IOPTH from baseline to 20 min post-excision of 23.4% or greater or a final PTH of 52 pg/mL or less would be an indication for ATX. Of the 21 who needed an ATX, it failed in 10. CONCLUSION: Parathyroid ATX is frequently unnecessary, and the viability is less than expected. While candidates for ATX have a greater IOPTH % decline at all points during surgery and a lower final IOPTH, the clinical practicality of using IOPTH to determine ATX candidacy is limited.

Proximal Scar Progression in Idiopathic Subglottic Stenosis After Wedge Excision: Does it Happen?

OBJECTIVE: To compare the incidence of glottic stenosis in idiopathic subglottic stenosis (iSGS) patients with no prior surgical intervention to those with a history of endoscopic dilation and characterize the incidence of glottic involvement, changes in scar length, and progression of scar toward glottis following laser wedge excision (LWE). METHODS: A retrospective review of iSGS patients who underwent LWE between 2002 and 2021 was performed. Patients without prior airway surgery were labeled LWE primary (LWEP) and operative findings for LWEP patients were reviewed for glottic involvement, scar length (DL ), and distance from the glottis to superior-most aspect of scar (DGS ). Rates (in mm/procedure) of DΔL , reflecting an increase in length, and D-ΔGS , reflecting proximal migration, were calculated by dividing DΔL and D-ΔGS by the number of LWE procedures. RESULTS: 213 iSGS patients underwent LWE, with 132 being LWEP patients. LWEP had a lower incidence of baseline glottic involvement (n = 6, 4.5%) than LWE secondary (LWES; n = 6, 7.5%). Four new cases of glottic involvement were noted in LWEP patients following LWE, with only one being clinically significant resulting in permanently decreased vocal fold mobility. With each procedure, scar length increased by 1.0 mm and DGS decreased by 0.7 mm, reflecting a migration or decrease in DGS of 9.5% with each procedure with respect to initial DGS . Overall rates of glottic stenosis following operations were similar between LWEP and LWES cohorts, 7.6% and 7.5% respectively. CONCLUSION: There appears to be a low risk of glottic involvement resulting from the LWE procedure in iSGS patients. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:875-882, 2023.

Meeting Dermatologic Needs in an Uninsured Population: Lessons Learned from a Referrals Cohort at a Student-Run Free Clinic.

Unmet dermatologic needs of the uninsured patient population are important to identify and address, especially as the COVID-19 pandemic has introduced additional barriers of access to care. We describe the successful collaboration between a student-run free clinic and dermatology practice since 2012, highlighting excellent time to appointment intervals and resolution rates as well as the associated modest financial cost. We believe that the information provided in our report may serve as a proof of concept and facilitate the implementation of such collaborations throughout the United States.

Significant postoperative refractive errors in vivo with the Mentor Memorylens intraocular lens.

PURPOSE: To determine the difference between the predicted and postoperative refraction in eyes after implantation of the Mentor MemoryLens intraocular lens (IOL) and compare these results with those of 2 other types of foldable IOLs implanted by the same surgeons. SETTING: Community-based group practice ophthalmology clinic. METHODS: All operated eyes (341) of all patients who had routine phacoemulsification with implantation of a MemoryLens IOL performed by 1 of 2 surgeons were evaluated retrospectively. The predicted refractive error and actual postoperative refractive error were compared in each eye in the MemoryLens group and in 2 smaller control groups with an AcrySof acrylic (Alcon) or SI-40 silicone (Allergan Medical Optics) IOL implanted by the same surgeons using identical technique and IOL calculation parameters. Patients in whom the difference between the predicted and actual postoperative refraction fell significantly outside expected parameters were rechecked with repeat axial length and keratometric readings, and these measurements were used to back-calculate the effective in vivo IOL power. RESULTS: The MemoryLens group had significantly greater variability in postoperative refractive results from those predicted by the Hoffer program than the 2 control groups. The postoperative refractive error in the MemoryLens group differed from +1.50 to -5.50 diopters (D) from that predicted by the IOL calculation formulas. When the outlier groups (ie, greater than +0.50 D or less than -1.00 D from predicted refractive error) were evaluated and compared to the rest of the MemoryLens group and the 2 control groups, no significant difference in axial length, keratometric measurements, operative surgeon, surgical technique, or patient age was found. Repeat axial length and keratometric measurements in the outlier group were not significantly different from those in the same eyes preoperatively. Back-calculation using postoperative axial length and keratometric measurements in the highly myopic outlier group showed that the mean difference between the labeled IOL power and actual in vivo IOL power in the outlier group was -3.08 D (range -1.98 to -7.54 D). The best corrected visual acuity was not affected in patients in the outlier groups despite the refractive variability. CONCLUSION: The variation in postoperative refractive results in the MemoryLens group was significantly greater than in the 2 other foldable IOL groups.