The Association of Body Mass Index and Early Outcomes Following Orthognathic Surgery.

BACKGROUND: The existing data on the link between body mass index (BMI), operative characteristics, and surgical outcomes across orthognathic surgery are limited. PURPOSE: The purpose was to measure the association between BMI and early postoperative outcomes in orthognathic surgery. STUDY DESIGN, SETTING, AND SAMPLE: This is a retrospective cohort study of patients (n = 118) aged > 14 years undergoing bimaxillary orthognathic surgery between 2015 and 2018 by a single surgeon within the Kaiser Permanente Northern California-integrated healthcare system. Patients undergoing unilateral or additional procedures, history of prior orthognathic surgery, or pre-existing pain conditions were excluded. PREDICTOR VARIABLE: The predictor variable was BMI measured as a continuous (kg/m2) and categorical variable (underweight/normal, overweight, obese). MAIN OUTCOME VARIABLE(S): The primary outcome variables were additional postoperative antibiotics, increased postoperative visits, wound dehiscence, and wound infection. The secondary outcome variables were total operative and anesthesia time. COVARIATES: The demographic covariates included age, sex, and race/ethnicity. The clinical covariates included history of obstructive sleep apnea, Mallampati score, tobacco use, American Society of Anesthesia classification, thyromental distance, history of difficult intubation, and Angle's classification. ANALYSES: Bivariate and multivariate analyses were performed to measure the associations between BMI and the primary and secondary outcomes. Multivariable logistic regression analyses were used to measure associations between BMI and the postoperative outcomes. Statistical significance was defined as P < .05. RESULTS: The study sample was composed of 118 subjects with a mean age of 26.91 years (standard deviation 9.43). Forty-seven percent (n = 55) were male, and the mean BMI was 25.13 (standard deviation 5.19). BMI category was significantly associated with age, with increasing age associated with higher BMI category (P = .02). According to the bivariate and multivariable logistic regression analyses, controlling for age, race/ethnicity, BMI, and total operative time, increased total operative time was associated with additional postoperative antibiotics (odds ratio = 1.03, 95% confidence interval: 1.01, 1.05), and increased postoperative appointments (odds ratio = 1.02, 95% confidence interval: 1.01, 1.04). No significant association between BMI and other clinical or operative characteristics was seen aside from American Society of Anesthesia classification. CONCLUSION AND RELEVANCE: Elevated BMI was not associated with worsened operative characteristics or postoperative outcomes. This supports the suitability of orthognathic surgery in a BMI-diverse population.

Providing Evidence for Dogma: Risk of Epistaxis After COVID-19 Nasal-Screening Swab.

OBJECTIVE: There is anecdotal evidence SARS-CoV-2 (COVID) RT-PCR screening nasal swabs confer an elevated epistaxis risk. We aimed to assess the association between epistaxis and exposure to a COVID nasal swab. STUDY DESIGN: A matched pairs design was used. SETTING: The study was performed in a single, integrated health care system. METHODS: All patients who received a single COVID nasal swab at our institution between April 2020 and March 2021 were included. McNemar's test was used to compare rates of epistaxis between the 7 days following the index COVID swab (hazard period), and the 7 days preceding the index COVID swab (control period). Conditional logistic regression was used to evaluate sociodemographic and clinical risk factors for epistaxis. RESULTS: A total of 827,987 participants were included, with 1047 epistaxis encounters. The prevalence of epistaxis during the hazard and control periods were 0.08% and 0.04%, respectively. Swab exposure was associated with 1.92-fold odds of epistaxis during the hazard period (95% confidence interval [1.73, 2.12]). Older age, Asian/Pacific Islander (PI) (compared to white), male sex, hypertension, prior facial trauma, and warfarin or direct-acting oral anticoagulant use were also associated with significantly increased odds of epistaxis (p ≦ 0.01). CONCLUSION: COVID nasal swabs are associated with increased odds of epistaxis. Physicians should counsel patients, particularly those at the highest risk, including a history of prior facial trauma, anticoagulants/antiplatelets, or hypertension.

Association of Pain Disorder and Psychiatric Disease With Surgical Management of Obstructive Sleep Apnea.

OBJECTIVE: Patients undergoing surgical management for obstructive sleep apnea (OSA) are likely medically distinct from their counterparts not treated surgically. This study examined the associations between psychiatric and pain comorbidities and the likelihood of undergoing sleep surgery. STUDY DESIGN: A retrospective cohort study of adults with OSA. SETTING: Large integrated healthcare system. METHODS: The primary outcome was nonnasal, nonbariatric sleep surgery. The associations of baseline demographic and comorbid conditions with surgery to treat underlying OSA were examined using bivariable and multivariable analyses. RESULTS: Among 172,854 adults with OSA, 2456 received sleep surgery. Comorbid pain disorder and/or pain medication treatment was associated with 41% higher odds of surgery (95% confidence interval: 1.29-1.54). In bivariable analyses, those with a history of headache (p = .004), particularly migraine (p = .003), disorders of adult personality or behavior (p = .025), or behavioral/emotional disorder (p < .001) were more likely to undergo surgery. Younger adults were also more likely to undergo surgery (mean age at diagnosis 39.8 ± 12.6 vs 54.7 ± 14 years), as were men, Asian/Pacific Islander or Hispanic adults, those with lower body mass index (32 ± 7 vs 34.3 ± 8.1 kg/m2 ), or those with Charlson Comorbidity Index of zero (p < .001). CONCLUSION: Our study suggests a history of pain disorder (including receipt of pain medication), migraine, or certain behavioral and personality disorders are associated with an increased likelihood of undergoing sleep surgery. The findings may better characterize comorbid predictors of sleep surgery and potentially help clinicians tailor expectations, postoperative pain management, and overall sleep outcomes.

Characteristics of Adults Undergoing Soft Tissue and Orthognathic Surgery for Obstructive Sleep Apnea.

OBJECTIVE: To identify clinical and demographic characteristics of adults with obstructive sleep apnea (OSA) undergoing soft tissue and orthognathic sleep surgery, assess temporal trends in surgery type and proportion of women undergoing surgery, and provide clinical perspective before wide-spread implementation of hypoglossal nerve stimulation (HGNS). METHODS: In a retrospective cohort study, adults diagnosed with OSA from 2009 to 2016 were identified in a large integrated healthcare system. Characteristics between cohort members who did and did not undergo sleep surgeries were compared. Multivariable logistic regression models examined associations of different characteristics with whether surgery was performed. RESULTS: Of 172,216 adults with OSA, 2,262 (1.3%) underwent sleep surgery during 2009-2017. The most common sleep surgery was palate surgery (56.9%), which decreased proportionately over time. In multivariable analysis, older age and obesity were associated with lower odds of undergoing surgery. Those who underwent tonsillectomy and adenoidectomy were more likely to have larger tonsils and not require additional surgery, whereas tongue reduction recipients were more likely to have severe OSA and require multiple surgery types. The proportion of women undergoing surgery increased over time (p < 0.001 from trend test). CONCLUSION: Clinical and demographic characteristics associated with soft tissue and orthognathic sleep surgery were identified in a large adult cohort prior to widespread implementation of HGNS. An increase in sleep surgery among women and a decrease in palate surgery over time were observed. The findings provide clinical perspective on sleep surgery performed prior to implementation of HGNS and may inform future studies examining its associations with patient characteristics. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1262-1270, 2023.

Representation of Race and Sex in Sleep Surgery Studies.

OBJECTIVE: Obstructive sleep apnea (OSA) is a highly prevalent disorder with many treatment modalities, including surgical intervention. While OSA is known to be more prevalent in males and Black Americans, the representation of race and sex in sleep surgery studies is unknown. The aim of this systematic review is to assess the race and sex demographics represented in sleep surgery studies relative to known OSA demographics. DATA SOURCES: PubMed, MEDLINE, and OVID databases. REVIEW METHODS: A systematic review was conducted to identify studies published between 2016 and 2020 that investigated sleep outcomes following nonnasal surgical intervention for OSA in adults. Pooled racial, ethnic, and sex data of the enrolled subjects in selected studies were analyzed. RESULTS: The 148 included studies comprised 13,078 patients. Of the 137 studies that reported sex, 84.0% of participants were male, exceeding the population prevalence of OSA in males, which is estimated at 66%. Only 13 studies reported racial/ethnic demographic data. Of these, 87.8% of patients were White. Out of 30 studies of primarily American patients, only 4 reported race demographic data, with an average of 82.8% White participants. CONCLUSION: There is a racial/ethnic and sex inclusion bias among sleep surgery studies. Future studies should better document the demographics of enrolled participants as well as recruit participants who better represent the demographics of adults with OSA in the general population.

Postoperative Pain and Opioid Use after Facial Feminization Surgery.

The objective of this study is to characterize surgical pain after facial feminization surgery (FFS) and delineate postoperative opioid usage. It is a retrospective cohort study. It was performed in a multicenter integrated health care system. Electronic medical records were reviewed for patient demographic characteristics, medical history, pain medication prescriptions, and responses to a postoperative pain survey. Student's t-test and the Mann-Whitney U-test were used for bivariate analysis. Fisher's exact tests were used for categorical data. Seventy-four patients who underwent FFS were included. The mean (standard deviation) reported "average" postoperative pain score was 4.3 (2.3) out of 10. A total of 58% of patients reported pain lasting 5 or fewer days after surgery. The severity and duration of postoperative pain was similar between patients who underwent partial-FFS or full-FFS. A total of 68% of patients required fewer than 15 opioid tablets. There were no significant differences in the quantity of opioids prescribed or used between patients who underwent partial-FFS or full-FFS. Older age and premorbid mood disorder did not correlate with greater severity/duration of pain or number of opioids used after surgery. Most patients required fewer than 15 opioid tablets after surgery and experienced less than a week of postoperative pain. Patients undergoing full-FFS did not appear to experience significantly greater pain than those undergoing fewer procedures. Older age and premorbid mood disorder were not predictors of worse pain outcomes or greater opioid utilization.

Postoperative Pain After Endoscopic vs Microscopic Otologic Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: Equivalent outcomes, such as procedural safety and audiometry, have been reported between endoscopic ear surgery (EES) and microscopic ear surgery (MES). This study aims to determine if EES leads to decreased postoperative pain when compared with MES. DATA SOURCES: PubMed, OVID MEDLINE, Scopus, Web of Science, and Cochrane Central from 2000 to 2020. REVIEW METHODS: A systematic review in accordance with the PRISMA guidelines and standardized bias assessment was performed. Studies containing original data on postoperative pain following EES and MES were included. RESULTS: Fourteen studies fulfilled eligibility: 7 retrospective studies, 6 randomized controlled trials, and 1 case series. Studies included surgery for cholesteatoma (n = 3), tympanoplasty/myringoplasty (n = 6), and stapedotomy (n = 5), pooling data from 974 patients. Postoperative pain was quantitatively described through a variety of numeric pain scores. Meta-analysis was performed on 11 studies. Among the 7 studies utilizing the numeric rating scale or visual analog scale, postoperative pain in the EES cohort was significantly lower than that of the MES cohort (standardized mean difference = -1.45 [95% CI, -2.05 to -0.85], P < .001). Similarly, pain scores were lower in the EES cohort among the 4 studies utilizing the Three Grades Pain Scale (odds ratio = 0.2 [95% CI, 0.09-0.45], P < .001). Additional qualitative strengths identified in EES included significant improvements in visualization, operative time, postoperative complications, and decreased need for canalplasty. Quality assessment indicated low to moderate risk of bias for all studies. CONCLUSION: Meta-analysis confirms that EES results in significantly less postoperative pain when compared with MES. This surgical approach should be considered in the armamentarium of otologic surgeons, allowing for improved outcomes.

Psychological Effect of the COVID-19 Pandemic Among Facial Feminization Surgery Patients.

BACKGROUND: The COVID-19 pandemic has disproportionately impacted mental health among the lesbian, gay, bisexual, transgender, queer community, with the delay of medical services as a factor. The pandemic's psychological effect on the transfeminine community pursuing facial feminization surgery remains unstudied. METHODS: Patients at our institution whose facial feminization surgeries were delayed due to the COVID-19 pandemic were included. A chart review collected validated, self-reported depression and psychological distress measures, as well as perceived facial femininity and desire for feminizing facial surgery prior to the pandemic. The data were compared to repeat measures during the pandemic (March-April 2020). RESULTS: Thirty patients were included in the study, 11 of whom had repeat data. Respondents during the pandemic (compared to prepandemic) felt their face was more feminine (p = 0.026) and more likely to be perceived as feminine by others (p = 0.026). They indicated a lower desire to alter their appearance with surgery (p = 0.041). Depression and distress indices were greater during the pandemic (p = 0.0018 and p = 0.026, respectively). CONCLUSION: This study is consistent with increasing depression and psychological distress among transfeminine individuals pursuing facial feminization surgery during the pandemic. The study revealed greater perceived facial femininity and a lower desire for surgery during the pandemic.