Augmented Virtual Examination for Cosmetic and Functional Rhinoplasty.

Background: Few studies have critically evaluated the quality of data obtained during telemedical evaluations of patients with nasal complaints. Objective: To compare the quality of data provided by remote endoscopic and external nasal examination with those by in-person evaluations for rhinoplasty and functional nasal surgery, measured by detectability of anatomic features, and to assess associated patient experience measured by reported ease, discomfort, and likelihood of peer recommendation. Materials and Methods: Twenty healthy subjects performed a nasal self-examination using an endoscope and webcam under remote videoconferencing service (VCS) guidance. They subsequently underwent in-person examination and were surveyed about their experience. Inter-rater reliability was calculated using kappa coefficients. Detectability of anatomic features by in-person versus virtual examination was compared using Wilcoxon and chi-square tests. Results: Median subject age was 27.5 years (range 23-77). Kappa coefficients were 0.78 for in-person and 0.66 for virtual evaluations. Only the internal nasal valve and inferior turbinate were better visualized in person. There were no differences between detectability of external features on in-person versus virtual examinations. Subjects' average likelihood of recommending this technology (1-10) was 8.65 (SD 1.4). Conclusions: Intranasal examination by physician-guided remote endoscopy and webcam-based facial analysis demonstrate nasal anatomy comparable with in-person evaluation and anterior rhinoscopy.

Critical Degree of Orbital Floor Displacement Drives Operative Repair of Zygomaticomaxillary Complex Fractures: Findings from a 10-Year Retrospective Study.

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.

Applying Occam's Razor and Descending the Reconstructive Ladder: The Modified Cheek Advancement Flap for Reconstruction of Nasal Defects.

Nasal reconstruction has important functional and cosmetic considerations, as proper repair of nasal defects is necessary to maintain function of the nasal airway and to recreate the normal appearance of this central facial structure. Cheek advancement flaps provide matched, mobile, and highly vascularized tissue for the reconstruction of nasal defects, allowing for the concealment of incisions within natural creases in a one-stage approach. However, cheek advancement flaps are often underutilized for nasal reconstruction because of their difficulty in restoring nasal contour. We describe reconstruction of 19 nasal dorsal and sidewall defects 0.8 to 3 cm in size. We incorporated a periosteal anchoring suture to maintain/restore nasal contour and additionally removed a half standing cone inferior to the defect to prevent encroachment of the nasal ala or alar crease. All patients were evaluated at least 3 months postoperatively. In all patients, we were able to restore concavity of the nasofacial sulcus, preserve the biconvex nasal tips, prevent alar flaring and retraction, and conserve the alar groove. All patients had excellent functional and cosmetic outcomes. We believe this modified cheek advancement flap provides functionally and aesthetically superior results and can be considered as a first-line approach for repair of nasal dorsal and sidewall defects in subselected patients.

Essential inpatient otolaryngology: what COVID-19 has revealed.

PURPOSE: To identify areas of critical otolaryngology contributions to inpatient care resistant to disruption by the COVID-19 pandemic. METHODS: Medical records of 614 otolaryngology consults seen between January and June of 2019 and 602 seen between January and June of 2020 were reviewed. Extracted data included patient demographics, SARS-CoV-2 status, medical comorbidities, consult location, consult category, reason for consult, procedures performed, and overall outcome. Prevalence of data items was compared using t tests and Chi-squared tests. RESULTS: The number of monthly consults to the otolaryngology service remained approximately stable after the onset of the COVID-19 pandemic. However, there was a substantial increase in ICU consults and a decrease in ER and floor consults. The proportion of otology, rhinology, and head and neck consults decreased while that of airway consults-most of which were tracheostomy-related-greatly increased. While the top ten reasons for consult remained essentially the same, they dramatically increased as a percentage of consults during COVID-19 (55-92%), whereas there was a dramatic decrease in the proportion of less frequent consults. CONCLUSION: The changes in otolaryngology consultation patterns seen after the onset of the pandemic are multifactorial, but may be attributed to novel pathologies, attitudes, and policies. Nonetheless, these patterns reveal that a set of core otolaryngologic issues, including acute airway issues, head and neck lesions, severe sinusitis and epistaxis, are essential and need to be addressed in the inpatient setting, whereas the significant drop in other consults suggests that they may be appropriately managed on an outpatient basis.

Patient-Reported Pain and Opioid Use After Ambulatory Head and Neck Surgery.

OBJECTIVE: The main objective of this study was to quantify daily pain and opioid use in patients after hemithyroidectomy and cervical lymph node biopsy (CLNB). The secondary objective was to identify factors associated with decreased pain and opioid use. STUDY DESIGN: Prospective cohort study from June 2017 to February 2019. Patients were given paper surveys to record daily postoperative opioid use and maximal pain on a visual analog scale. SETTING: Single institution (NewYork-Presbyterian/Weill Cornell Medical Center). METHODS: All adult patients undergoing hemithyroidectomy and CLNB by a single surgeon were consecutively selected for participation. Patients recorded daily pain and opioid analgesic use over a 2-week postoperative period. RESULTS: Of 33 patients enrolled, 29 (87.9%) returned a survey. Thirteen underwent CLNB, and 16 underwent hemithyroidectomy. Pain resolved after both procedures by the end of the 2-week period. CLNB patients used a median (interquartile range) of 15.0 (0-41.2) morphine milligram equivalents (MME), and 95% used 70 or fewer MME. Hemithyroidectomy patients used a median of 8.2 (4.5-13.9) MME, and 95% used 30 or fewer MME. Use of nonopioid analgesics was associated with a statistically significant decrease in pain (56.1 vs 171 visual analog scale, 95% confidence interval [CI] of Δ = [12.0 to 217.8]) and opioid use (12.2 vs 48.8 MME, 95% CI of Δ = [5.0 to 68.1 MME]) in CLNB but not in hemithyroidectomy. CONCLUSION: Patients have low pain and opioid requirements after hemithyroidectomy and CLNB. Head and neck surgeons should evaluate their opioid-prescribing patterns for opportunities to safely decrease postoperative prescriptions.

Theory and Evidence for Platelet Therapy of the Aging Face.

Platelet preparations are autologous blood concentrates with supraphysiologic concentrations of platelets with or without leukocytes used in various clinical applications including regenerative medicine, wound healing, and facial rejuvenation. Their use harnesses the important role of platelets and their secretory products in immunoregulation, wound healing, angiogenesis, and tissue remodeling. The use of platelet preparations has been long documented in orthopaedic surgery, maxillofacial surgery, and other fields, but over the years research has increased in their application to facial plastic surgical techniques. Here we review the various formulations of platelet rich concentrates, their applications to facial skin rejuvenation, wound healing, scar reduction, and tissue fill as documented in the literature since 2018.

Injury Patterns in Pediatric Facial Fractures Unique to an Urban Environment.

This study aimed to define better the clinical presentation, fracture patterns, and features predictive of associated injuries and need for surgery in pediatric facial trauma patients in an urban setting. Charts of patients 18 years or younger with International Classification of Disease 9th and 10th revision (ICD-9/ICD-10) codes specific for facial fractures (excluding isolated nasal fractures) at NY-Presbyterian/Weill Cornell Medical Center between 2008 and 2017 were retrospectively reviewed. Of 204 patients, most were referred to the emergency department by a physician's office or self-presented. Children (age 0-6 years) were most likely to have been injured by falls, while more patients 7 to 12 years and 13 to 18 years were injured during sporting activities (p < 0.0001). Roughly half (50.5%) of the patients had a single fracture, and the likelihood of surgery increased with greater numbers of fractures. Older patients with either orbital or mandibular fractures were more likely to undergo surgery than younger ones (p = 0.0048 and p = 0.0053, respectively). Cranial bone fractures, CSF leaks, and intracranial injuries were more common in younger patients (p < 0.0001) than older patients and were more likely after high energy injuries; however, 16.2% of patients sustaining low energy injuries also sustained cranial bone, CSF leak, or intracranial injury. In an urban environment, significant pediatric facial fractures and associated injuries may occur after nonclassic low kinetic energy traumatic events. The age of the patient impacts both the injuries sustained and the treatment rendered. It is essential to maintain a high index of suspicion for associated injuries in all pediatric facial trauma patients.

Patterns of Facial Fractures in a Major Metropolitan Level 1 Trauma Center: A 10-year Experience.

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.

Patient, Defect, and Surgical Factors Influencing Use of Ancillary Procedures after Facial Mohs Repairs.

This article determines if patient, defect, and repair factors can be used to predict the use of additional treatments to achieve optimal aesthetic results after repair of facial Mohs defects. An electronic chart review of patients undergoing Mohs excision and reconstruction of facial neoplasms from November 2005 to April 2017 was performed, reviewing patient demographics and history, tumor size, defect size and location, method and service of reconstruction, time between resection and repair, complications, and subsequent treatments. A total of 1,500 cases with basal cell and squamous cell carcinoma were analyzed. The average defect size was 3.09 ± 8.06 cm2; 81.9% of defects were less than 4 cm2 in size. Advancement flaps were used to repair 44.3% of defects. Complications and undesired sequelae (CUS) were noted in 15.9% of cases; scar hypertrophy or keloid (10.8%) was most common. Postoperative ancillary procedures were performed in less than one-quarter (23.4%) of patients to enhance the postrepair appearance; the most common procedures were intralesional corticosteroid injections and pulse dye laser treatments. CUS were more likely in females (19.6%), defects on the lips (28.7%) and on the nose (27.3%) (p < 0.001 for each). Females (22.7% vs. 12.7%), lip repairs (40.2% vs. 18.3%), transposition flaps (39.2% vs. 14.8%), and repairs performed by a dermatologist (17.9% vs. 11.2%) (p < 0.001 for each) were more likely to be treated with postoperative corticosteroid injections. Females (14.5% vs. 7.4%), patients under the age of 60 years (13.9% vs. 8.8%), and patients whose repair was performed by a dermatologist (11.9% vs. 2.9%) (p < 0.001 for each) were more likely to receive postoperative pulsed dye laser treatments. CUS and ancillary procedures after repair of facial Mohs defects are uncommon. Awareness of individual risk factors and defect characteristics allows the surgeon to choose the most appropriate repair technique while anticipating the potential need for ancillary procedures.

Establishing an Office-Based Framework for Resuming Otolaryngology Care in Academic Practice During the COVID-19 Pandemic.

OBJECTIVE: The COVID-19 health crisis abruptly disrupted the practice of otolaryngology. This article aims to define the changes needed to operate an academic otolaryngology practice safely and efficiently from within the epicenter of the pandemic. We define the areas of normal patient workflow that have been affected by COVID-19, and we offer mitigation strategies with attention paid to the specific needs of subspecialties. DATA SOURCES: The article includes data specific to the office practice metrics of the Weill Cornell Medicine Department of Otolaryngology-Head and Neck Surgery, as well as publically available data from New York Presbyterian Hospital system and the New York Times. REVIEW METHODS: Expert opinion. CONCLUSIONS: Through careful planning and execution, it is possible to reestablish safe otolaryngologic patient care during the COVID-19 pandemic. It will require a significant change from prior practice models for successful implementation. Additionally, telemedicine can be positively integrated into the treatment of otolaryngology diseases for new and established patients. IMPLICATIONS FOR PRACTICE: The information conveyed in this review can be used as a guide by large and small otolaryngology groups to identify aspects of the patient visit that are "at risk" due to COVID-19, and it suggests sensible responses that can be made without a significant disruption to normal practice. The methods used to identify vulnerabilities with the patient visit process can be applied to future unforeseen crises, such as a resurgence of COVID-19 or a novel pandemic.