The Use of Endonasal Spreader Grafts in Preservation Rhinoplasty.

SUMMARY: Rhinoplasty is a complicated procedure that requires surgical finesse and precision to sculpt a framework that suits each patient's unique anatomical needs. Extensive resection may lead to nasal valve incompetence, causing obstructive symptoms associated with reduced quality of life. Numerous techniques have been described to help preserve and open the nasal airway, thereby mitigating valvular obstructive problems. In particular, the endonasal spreader graft is a common technique used to widen the internal nasal valve cross-sectional area while limiting external incisions and preserving local nasal structures. Preservation rhinoplasty is a variation of the traditional rhinoplasty that can lower the nasal dorsum without causing major disruption to the nasal keystone area, the junction between the middle and upper thirds of the nose. This study describes the successful and safe combination of these two surgical operations, demonstrating three case examples in which all patients reported improved postoperative nasal obstruction symptoms. Using endonasal spreader grafts in preservation rhinoplasty allows providers to manage the nasal valve and nasal dorsum similarly to the external approach without extensive deconstruction and reconstruction.

Advances in Facial Reanimation.

Facial nerve paralysis is a debilitating clinical entity that presents as a complete or incomplete loss of facial nerve function. The etiology of facial nerve palsy and sequelae varies tremendously. The most common cause of facial paralysis is Bell's palsy, followed by malignant or benign tumors, iatrogenic insults, trauma, virus-associated paralysis, and congenital etiologies.

Using injectable fillers for chin and jawline rejuvenation.

Objective: As the population ages, facial plastic providers must remain aware of the treatments to prevent and reverse the external signs of aging. In the mandibular region, skin laxity and soft tissue sagging in the jawline may lead to jowling and chin ptosis along with reduced chin projection. While surgical procedures, including chin implantation, may be performed, nonsurgical procedures are becoming increasingly popular due to their temporary, noninvasive, yet effective methods. This review covers the use of hyaluronic acid, calcium hydroxylapatite, poly-l-lactic acid, and polymethyl methacrylate in the jawline. Methods: PubMed was searched for data on the mechanism of action, pertinent anatomy, indications, contraindications, technique, and evidence supporting the safety and efficacy of the fillers. Results: There are a wide variety of fillers available for use in the lower face with unique characteristics and application methods. While the advantages of injectable fillers include relatively affordable cost, minimal patient discomfort, and limited recovery times, taking measures to prevent short- and long-term complications is necessary for optimal results. Conclusions: Understanding the benefits and limitations of injectable fillers in the jawline can help providers appropriately counsel and treat patients.

Flipping the Otolaryngology Didactics Curriculum: Results of a Novel Resident Course Structure.

OBJECTIVE: To assess the impact of a novel flipped-classroom (FC) otolaryngology resident didactic curriculum on resident learning. METHODS: Based on the preferences elicited in a survey of preferred learning styles of residents, a hybrid web-based and in-person FC otolaryngology didactic curriculum was implemented over a 6-month period in 2020-2021. Resident reactions to the new curriculum were assessed via a second survey. Kruskal Wallis tests were used to compare mean stanine scores on the Otolaryngology Training Examination (OTE) exam for topics taught in the new format with topics delivered in the old format. RESULTS: After instituting the curriculum reform, engagement in at least a moderate amount of the pre-didactic work and synchronous case discussions was reported by 67% and 88% of the residents, respectively. After the curriculum change, residents in years PGY2 and above reported statistically significant increases in self-reported ability to retain information from didactics, to feel prepared for the OTE, and to feel confident in fund of knowledge (p < 0.001, p = 0.004, and p = 0.004, respectively). Compared to the prior year, mean stanine increased on OTE scores for residents in years PGY2-PGY5 to a statistically significant degree (5.45 vs. 4.41, p = 0.001) for the topics delivered in the new format compared to topics delivered in the traditional format (5.13 vs. 4.70, p = 0.07). CONCLUSION: By organizing a didactic curriculum through online modules that incorporate pre-recorded lectures and external resources, residents reported and demonstrated improved knowledge retention. LEVEL OF EVIDENCE: NA Laryngoscope, 133:2129-2134, 2023.

Changes in otolaryngology application requirements and match outcomes: Are we doing any better?

Objectives: Otolaryngology-specific requirements were piloted to minimize applicant and program burdens. We investigated the impact of introducing and then removing these requirements on Match outcomes. Methods: 2014-2021 National Resident Matching Program® data were examined. The primary outcome was the impact of Otolaryngology Resident Talent Assessment (ORTA; prematch 2017, postmatch 2019) and Program-Specific Paragraph (PSP; implemented 2016, optional 2018) on applicant numbers and match rates. Secondary survey analysis assessed candidate perceptions of PSP/ORTA. Results: Applicant numbers declined significantly during PSP/ORTA (18.9%; p = 0.001). With the optional PSP and postmatch ORTA, applicant numbers increased significantly (39.0%; p = 0.002). Examined individually, mandatory PSP was associated with a significant decline in applicants (p = 0.007), whereas postmatch ORTA was associated with significant increases in applicants (p = 0.010). ORTA and PSP negatively impacted the decision to apply to otolaryngology in 59.8% and 51.3% of applicants, respectively. Conversely, match rate success improved significantly from 74.8% to 91.2% during PSP/ORTA (p = 0.014), followed by a significant decline to 73.1% after PSP was made optional and ORTA moved to postmatch (p = 0.002). Conclusions: ORTA and PSP correlated with decreased applicant numbers and increased match rate success. As programs seek ways to remove barriers to applying to otolaryngology, the potential consequences of an increasing pool of unmatched candidates must also be considered.

Gender Differences Among Head and Neck Microvascular Reconstructive Surgeons.

OBJECTIVE: To determine whether gender differences exist in the training history, practice patterns, and home lives of surgeons who perform microvascular reconstruction of the head and neck. STUDY DESIGN: Cross-sectional survey. SETTING: Medical facilities that employ surgeons who practice head and neck microvascular reconstruction in the United States. METHODS: A survey was created using the Research Electronic Data Capture Framework and was distributed via email to microvascular reconstructive surgeons. Descriptive statistics were performed using Stata software. RESULTS: No significant differences were found in training or current practice patterns between microvascular surgeons who identify as men versus those who identify as women. Women had fewer children (p = .020) and were more likely to be childless (p = .002). Whereas men were more likely to report a spouse/partner as primary caretaker, women were more likely to hire a professional caretaker or cite themselves as a primary caretaker (p < .001). Women were more likely to have finished residency (p = .015) and fellowship (p = .014) more recently and to practice in the Southeast (p = .006). Of the microvascular surgeons who reported practice setting switches, men more commonly changed positions for career advancement, whereas women were more likely to switch due to burnout (p = .002). CONCLUSION: This study found no gender-based differences in training or practice patterns. However, significant differences were identified in childbearing, family structure, geographic practice location, and motives for switching practice.

Transcervical styloidectomy for Eagle syndrome.

We demonstrate a safe and effective surgical technique for the operative management of Eagle syndrome, also known as stylohyoid syndrome, via transcervical styloidectomy. Fifteen patients who presented to our institution for surgical management of Eagle syndrome were included. A detailed video shows the operative techniques used to perform styloidectomy via a transcervical approach. The procedure was well tolerated without complications, and all patients were discharged on postoperative day one. Thirteen patients (87%) endorsed significant improvement or complete resolution of their presenting complaint(s), most commonly throat and neck pain/discomfort (53%), otalgia (47%), and/or tinnitus (40%). The transcervical approach for styloidectomy provides an alternative for operative access that overcomes the limitations associated with the transoral approach. It enables better exposure of the operative field, a more efficient procedure, and, in the senior author's experience, results in decreased postoperative pain, trismus, and length of hospital stay.

Intensive Care Versus Nonintensive Care Ward for Postoperative Management of Head and Neck Free Flaps: A Meta-Analysis.

Introduction: Although advances in surgical technique and medical management have drastically improved outcomes of free flap reconstructive surgery in head and neck patients, there is no clear consensus on appropriate level of postoperative care. Methods: The literature was searched systematically for all comparative studies of intensive care unit (ICU) and non-ICU admissions for head and neck patients. The primary outcomes were flap failure rate, flap complications, and hospital length of stay (LOS). Secondary outcomes included cost implications, medical complications, and rates of revision surgery, readmission, and mortality. Results: Nine articles (2510 patients) were included. Patients admitted to non-ICU wards were not significantly at increased risk for free flap failure, flap-related complications, or longer LOS. Total medical complications were found to have a pooled relative risk (RR) of 0.57 [95% confidence interval (CI) 0.40 to 0.83], favoring the non-ICU cohort. In particular, the non-ICU cohort was less likely to develop neuropsychiatric complications (RR 0.34 [95% CI 0.24 to 0.48]) and sepsis (RR 0.18 [95% CI 0.05 to 0.68]) with no difference in cardiovascular or pulmonary complications. Discussion: Patients admitted to non-ICU wards did not experience higher rates of adverse flap-related outcomes and had decreased risk of developing medical complications in the studies included in this meta-analysis.

Evaluation of an interactive virtual surgical rotation during the COVID-19 pandemic.

OBJECTIVE: To evaluate medical student and attending surgeon experiences with a novel interactive virtual Otolaryngology - Head and Neck Surgery (OHNS) medical student elective during the COVID-19 pandemic. STUDY DESIGN: A virtual OHNS elective was created, with three components: (1) interactive virtual operating room (OR) experience using live-stream video-conferencing, (2) telehealth clinic, (3) virtual didactics. SETTING: OHNS Department at the University of Pennsylvania (May 2020 to June 2020). METHODS: Six medical students from the University of Pennsylvania; five attending otolaryngologists. Two surveys were designed and distributed to participating medical students and attending surgeons. Surveys included 5-point Likert scale items, with 1 indicating "not at all" and 5 indicating "very much so". RESULTS: Response rate was 100% for both surveys. Students on average rated the educational value of the telehealth experience as 4.2 ± 1.2, and the virtual OR experience as 4.0 ± 0.6. Most students (n = 5, 83%) indicated that they had enough exposure to faculty they met on this rotation to ask for a letter of recommendation (LOR) for residency if needed, while attending surgeons had an average response of 3.0 ± 1.0 when asked how comfortable they would feel writing a LOR for a student they met through the rotation. A majority of students (n = 4, 67%) felt they connected enough with faculty during the rotation to ask for mentorship. Half the students (n = 5, 50%) indicated that the rotation allowed them to evaluate the department's culture either "extremely well" or "somewhat well". CONCLUSIONS: Overall, participating students described this innovative virtual surgical rotation as an educationally and professionally valuable experience. With the continued suspension of visiting student rotations due to the COVID-19 pandemic, this virtual model may have continued relevance to medical education.

Creation of an Interactive Virtual Surgical Rotation for Undergraduate Medical Education During the COVID-19 Pandemic.

OBJECTIVE: During the coronavirus 2019 pandemic, medical student involvement in direct patient care has been severely limited. Rotations mandatory not only for core curricula but also for informing decisions regarding specialty choice have been postponed during a critical window in the application cycle. Existing virtual rotations are largely observational or lack patient-facing components. SETTING: A virtual Otolaryngology - Head and Neck Surgery rotation at the University of Pennsylvania (Philadelphia, Pennsylvania) was implemented for medical students, comprising interactive live-streamed surgeries, outpatient telehealth visits, and virtual small group didactics. RESULTS: Medical students enrolled in the virtual surgical rotation were able to engage with attending surgeons and operating room staff while remotely viewing surgical procedures captured with first-person audiovisual technology. Students participated in several different aspects of care delivery in both the inpatient and outpatient setting, similar to their typical responsibilities of an in-person rotation. CONCLUSIONS: The authors will continue to develop the virtual surgical education methodology to further disseminate an interactive video-based medical student elective to other procedural specialties and institutions.

Consensus of free flap complications: Using a nomenclature paradigm in microvascular head and neck reconstruction.

BACKGROUND: We aim to define a set of terms for common free flap complications with evidence-based descriptions. METHODS: Clinical consensus surveys were conducted among a panel of head and neck/reconstructive surgeons (N = 11). A content validity index for relevancy and clarity for each item was computed and adjusted for chance agreement (modified kappa, K). Items with K < 0.74 for relevancy (i.e., ratings of "good" or "fair") were eliminated. RESULTS: Five out of nineteen terms scored K < 0.74. Eliminated terms included "vascular compromise"; "cellulitis"; "surgical site abscess"; "malocclusion"; and "non- or mal-union." Terms that achieved consensus were "total/partial free flap failure"; "free flap takeback"; "arterial thrombosis"; "venous thrombosis"; "revision of microvascular anastomosis"; "fistula"; "wound dehiscence"; "hematoma"; "seroma"; "partial skin graft failure"; "total skin graft failure"; "exposed hardware or bone"; and "hardware failure." CONCLUSION: Standardized reporting would encourage multi-institutional research collaboration, larger scale quality improvement initiatives, the ability to set risk-adjusted benchmarks, and enhance education and communication.

Single-port transoral robotic combined approach with sialendoscopy for sialolithiasis: Case report and review of the literature.

BACKGROUND: The da Vinci single-port (SP) is utilized in transoral robotic surgery (TORS) procedures for malignant oropharyngeal tumors. We report a case utilizing the da Vinci SP in TORS for sialolith removal. METHODS AND RESULTS: A 75-year-old male with chronic right submandibular gland (SMG) sialadenitis underwent combined da Vinci SP TORS approach with sialendoscopy for multiple SMG sialoliths. We were unable to find a previous report of using the da Vinci SP in TORS for SMG sialolith removal. CONCLUSION: The da Vinci SP has been utilized in a combined TORS approach with sialendoscopy for SMG sialolith removal. The da Vinci SP's additional arm provides improved retraction, enabling optimal visualization, dissection, and preservation of important structures such as the lingual nerve.