Risk Factors for Missed Follow-up Appointments among Facial Trauma Patients.

A retrospective case-control study was performed to characterize the rate of missed follow-up appointments after facial trauma and identify associated risk factors.Follow-up appointments for facial trauma over a 3-month period at a single, safety net hospital were analyzed. Appointment-specific, sociodemographic, trauma, and management data were compared between cases (missed appointments) and controls (attended appointments). Univariate testing and multivariable logistic regression were employed.A total of 116 cases and 259 controls were identified, yielding a missed appointment rate of 30.9% (116/375). Missed appointments were significantly associated with initial clinic appointments compared to return visits (odds ratio [OR] 2.21 [1.38-3.54]), afternoon visits compared to morning (OR 3.14 [1.94-5.07]), lack of private health insurance (OR 2.91 [1.68-5.18]), and presence of midface fractures (OR 2.04 [1.28-3.27]). Missed appointments were negatively associated with mandible fractures (OR 0.56 [0.35-0.89]), surgical management (OR 0.48 [0.30-0.77]), and the presence of nonremovable hardware (OR 0.39 [0.23-0.64]). Upon multivariable logistic regression, missed appointments remained independently associated with afternoon visits (adjusted OR [aOR] 1.95 [1.12-3.4]), lack of private health insurance (aOR 2.73 [1.55-4.8]), and midface fractures (aOR 2.09 [1.21-3.59]).Nearly one-third of facial trauma patients missed follow-up appointments, with the greatest risk among those with afternoon appointments, lacking private health insurance, and with midface fractures.

Balloon Sinuplasty and Stenting in the Management of Complex Frontal Sinus Outflow Tract Fractures.

OBJECTIVE: Classical management of complex fractures involving the frontal sinus outflow tract (FSOT) favors obliteration or cranialization to avoid delayed complications. We aim to exhibit success with a novel application of balloon sinuplasty and frontal stenting in the management of complex injuries disrupting the FSOT, which might have otherwise required more invasive interventions. STUDY DESIGN: Retrospective review. SETTING: Single institution, level 1 trauma center. METHODS: Retrospective review of patients presenting to a level 1 trauma center with fractures involving the FSOT. Outcomes include patency of the FSOT on imaging and endoscopy, rate of complications, degree of residual tabular displacement, and need for revision surgery. RESULTS: Twenty-five patients met inclusion criteria, with complete FSOT obstruction seen in all cases on computed tomography. All patients underwent balloon sinuplasty with frontal sinus stenting; 48% underwent concurrent anterior table repair, and 36% open repair of nasoorbitoethmoid complex fractures. The mean follow-up length was 13.9 months, at which time 91.3% of patients demonstrated radiographic and endoscopic FSOT patency. No residual sinus opacification or pneumocephalus was observed. CONCLUSION: Balloon sinuplasty with frontal sinus stenting is a straightforward and minimally invasive technique that can create a safe sinus in complex fractures disrupting the FSOT while avoiding the need for more invasive procedures.

Septal Perforation Repair Using a Temporoparietal Fascia and Polydioxanone Plate Construct: A Multi-Institutional Analysis.

Background: Nasal septal perforations (NSPs) are notoriously difficult to fix and closure can paradoxically lead to worsening of symptoms, prompting numerous techniques for repair including temporoparietal fascia (TPF)-polydioxanone (PDS) plate interposition grafting. Objectives: To compare rates of NSP closure with TPF-PDS interposition grafting among a variety of institutions with diverse environmental influences and patient-specific factors. Methods: Retrospective review of patients undergoing TPF-PDS interposition grafting at seven different U.S. institutions over 5 years. Outcomes include closure rate, self-reported symptom improvement, change in Nasal Obstruction Symptomatic Evaluation (NOSE) score, and postoperative complications. Results: Sixty-two patients (39 female) with a mean age of 41.5 years were included. Most common perforation location was anterior (53%), and average size was 1.70 cm2. NSP closure with symptomatic improvement was achieved in 95% of participants. Postoperative NOSE scores decreased on average by 42 points. Residual crusting occurred in 29% of patients, independent of external factors. Conclusions: TPF-PDS interposition grafting is highly effective for NSP repair in a wide variety of settings, and NOSE scores correspond well with patient-reported outcomes.

Optimizing Flap Harvest in Auricular Reconstruction.

INTRODUCTION: The temporoparietal fascial (TPF) and occipital cranial fascial (OCP) flaps are the mainstay of implant coverage in alloplastic auricular reconstruction. Their optimal design is critical for elevating a robust flap that ultimately leads to favorable outcomes. MATERIALS AND METHODS: Sixteen TPF and OCP dissections were performed on 8 cadaveric specimens. Vascular anatomy and key landmarks were documented. The minimum flap size that incorporated ideal vasculature and would appropriately cover a porous polyethylene implant was measured. RESULTS: The minimum flap dimensions (length × width × base width) to cover a standard PPE auricular implants were on average 11×8.3×6.4 cm for TPF and 13.1×8.6×6.5 cm for OCP. The average axial length of the superficial temporal artery and occipital artery were 12.51 and 13.2 cm, respectively. An "occipital elbow" was located on average 8.2 cm posterior to the external acoustic canal. The postauricular fascia contained additional contributions from the occipital artery and mastoid emissary vein, which was located on average 5.9 cm posterior to the superficial temporal artery. CONCLUSIONS: This study highlights the anatomic features behind optimal TPF and OCP flap design for auricular reconstruction. Contributions to axial length and anatomic relationships of their primary arterial supply, significance of the occipital elbow as a reliable landmark for fascial dissection, and importance of the postauricular fascia and its vascular supply for flap viability are emphasized. Ultimately, the authors provide minimal dimensions for both TPF and OCP flaps to obtain adequate alloplastic implant coverage.

Augmented Skin Grafting: A New Rung in the Reconstructive Ladder.

Importance: A gap in the reconstructive ladder exists in which complex defects may benefit from skin grafting but are not amenable due to their anatomic limitations. Similarly, some patients are intolerant of more invasive techniques in cosmetically sensitive areas. In these scenarios, augmented skin grafts may represent a unique alternative to traditional reconstructive options. Observations: This report is a clinical overview of skin grafting in complex nasal defects. We describe three types of augmented skin grafts, with examples of each. These include preliminarily augmented grafts with a dermal biomatrix, simultaneous augmentation with a perichondrocutaneous pseudo-composite graft, and delayed augmentation with staged structural grafting. Conclusions and Relevance: Augmented skin grafts represent unique methods of reconstruction for complex wounds in cosmetically sensitive areas. We propose these techniques as an evolving unique rung in the reconstructive ladder.

Frontal Sinus Fractures: A Contemporary Approach in the Endoscopic Era.

Although frontal sinus fractures are relatively uncommon, the potential for long-term morbidity is significant. Management strategies remain controversial due to a lack of strong clinical evidence. Despite a paucity of strong literature, a logical treatment algorithm is presented based on the structural integrity of three anatomic parameters: anterior table, frontal sinus outflow tract, and the posterior table/dura. The literature supports a paradigm shift from open surgical management to a more conservative treatment algorithm emphasizing observation and minimally invasive endoscopic techniques. Long-term follow-up for complex frontal sinus injuries is critical.

Traumatic Optic Neuropathy Management: A Survey Assessment of Current Practice Patterns.

INTRODUCTION: The treatment of traumatic optic neuropathy (TON) is highly controversial with a lack of substantiated evidence to support the use of corticosteroids or surgical decompression of the optic nerve. The aim of the study was to determine if there was a general consensus in the management of TON despite controversy in the literature. METHODS: An anonymous survey of members of the American Society of Ophthalmic Plastic and Reconstructive Surgery and the North American Neuro-Ophthalmology Society regarding their practice patterns in the management of patients with TON was performed. RESULTS: The majority of 165 respondents indicated that they treated TON with corticosteroids (60%) while a significant minority (23%) performed surgical interventions (P < 0.0001). Subgroup analysis comparing rates of treatment with steroids among oculoplastic surgeons and neuro-ophthalmologists (67% vs. 47%) was not significant (Fisher's Exact test [FET], P =0.11) while results did suggest that a higher proportion of oculoplastic surgeons (33%) than neuro-ophthalmologists (11%) recommended surgical intervention (FET, P =0.004). In cases where visual acuity exhibited a downward trend treatment with steroids was the most commonly employed management. In general, neuro-ophthalmologists trended toward observation over treatment in TON patients with stable visual acuity while oculoplastic surgeons favored treatment with corticosteroids. CONCLUSIONS: In spite of the lack of class I evidence supporting intervention of TON, the majority of respondents were inclined to offer corticosteroid treatment to patients whose visual acuity showed progressive decline following injury.

Eyelid Coupling Using a Modified Tarsoconjunctival Flap in Facial Paralysis.

Eyelid coupling using the modified tarsoconjunctival flap is an effective treatment for paralytic ectropion. Eyelid position and quality of life can be improved in patients with flaccid facial paralysis using these eyelid coupling procedures. The modified tarsoconjunctival flap can obscure the lateral visual field by coupling the eyelids, but without distortion of the canthal angle and eyelid margin. The procedure is often coupled with a lateral canthoplasty or canthopexy to address horizontal laxity of the lower eyelid. Collecting standardized outcome measures will help establish the ideal treatment paradigm of paralytic eyelid malposition.

Septal Perfoplasty for Management of Symptomatic Nasal Septal Perforation: An Alternative to Surgical Closure.

Importance: Symptomatic septal perforations are often difficult to manage and can have a significant impact on patient quality of life. Available surgical techniques for repair have demonstrated a varying rate of success, presenting a need for reliable interventions targeting symptom control. Objectives: To describe the modified surgical technique here termed septal perfoplasty. To demonstrate that creation of favorable septal perforation characteristics is effective in managing symptoms and improving patient quality of life. Design, Setting, and Participants: A retrospective review of the medical record was performed of patients who underwent the procedure of interest between July 1, 2006 and October 1, 2019 at Vanderbilt University Medical Center. All patients with symptomatic septal perforation who underwent septal perfoplasty within the timeframe reviewed were included. Septal perfoplasty was standardly performed in combination with turbinate reduction in all cases. This was combined with other indicated procedures for chronic sinusitis, repair of vestibular stenosis or nasal deformity. Main Outcomes and Measures: Creation of a well-mucosalized septal perforation, combined with patient-reported acceptable symptom control, was the primary outcome. Secondary outcomes include time to resolution, duration of follow-up, postsurgical complications, and need for further intervention. Results: Twenty patients (70% female; mean [range] age, 45.8 [15-72] years) underwent septal perfoplasty over the course of 13 years. The most common etiology of perforation was trauma (40%), presenting symptom was crusting (95%), and size of perforation repaired was large (60%). Mean follow-up was 37.6 months (range, 1-153 months). Overall, favorable perforation characteristics were created in 95% of cases by the first postoperative appointment. Acceptable symptomatic control was achieved in 18 out of 20 patients (90%), with a median time to improvement of 66 days. Eight patients required additional surgery to address chronic sinusitis or vestibular stenosis. Two patients experienced postoperative infections, treated conservatively with antibiotics. Conclusion and Relevance: Septal perfoplasty is a safe, simple, and effective method for management of symptomatic nasal septal perforation, which provides an alternative to more complicated interventions with comparable rates of symptomatic resolution. This procedure should particularly be considered for patients in which difficult repair is anticipated.

Predicting complications of pediatric temporal bone fractures.

OBJECTIVE: Our aim is to characterize complications of pediatric temporal bone fractures and identify predictive risk factors associated with fracture complications. METHODS: A retrospective review was conducted of all temporal bone fractures diagnosed in children (age less than or equal to 18 years) from a single academic institution between 2003 and 2017. Demographics, mechanism of injury, fracture characteristics, computed tomography evaluation and follow-up duration were recorded on each patient. Outcomes measured include facial nerve injury (FNI), cerebrospinal fluid (CSF) leak, sensorineural hearing loss (SNHL), and conductive hearing loss (CHL). RESULTS: One-hundred-seventeen patients with 129 temporal bone fractures were included in the study. Most fractures were otic capsule sparing (OCS) (96%, n = 124) and longitudinal (71%, n = 91). Otic capsule violating (OCV) fractures were associated with higher CSF leak rates (20% versus 2%, p = 0.14) and FNI rates (60% versus 5%, p = 0.002) compared to OCS fractures. Audiograms were available in 37 patients (34%). Patients with Glasgow coma scale (GCS) consistent with a mild traumatic brain injury (TBI) (GCS > 13) had significantly fewer complications (FNI and CSF leaks) compared to the group with moderate and severe TBI (GCS < 13), 5% versus 23% (p = 0.03). CONCLUSIONS: Higher complication rates are seen with OCV fractures and transverse fractures. Moderate and severe TBI as measured by GCS is predictive of FNI and CSF complications in pediatric temporal bone fractures.

Oncocytic Cysts of the Nasopharynx: A Case Report.

BACKGROUND: Nasopharyngeal oncocytic lesions are a spectrum of benign lesions that represent a reactive or hyperplastic response to chronic inflammation. Though oncocytic lesions are typically asymptomatic, unilateral, and benign, this article discusses a rare case of large, bilateral oncocytic cysts and downstream otologic sequelae with a focus on identifying and discussing similar disease processes. METHODS: Case report and literature review.Case Presentation: A 67-year-old patient with 57 pack year smoking history presented for one year of left sided hearing loss and aural fullness. Clinic endoscopic exam demonstrated severe inflammatory and cystic changes lining the bilateral tori. Imaging and tissue sampling confirmed the cause was minor salivary gland cysts with papillary projections lined by oncocytic cells within bilateral tori tubarius. He was successfully treated with myringotomy with pressure equalizing tube, counseling on tobacco cessation, and surveillance with serial nasopharyngoscopy. CONCLUSIONS: Chronic eustachian tube dysfunction is a possible rare presentation and sequelae of large oncocytic cysts of the nasopharynx. Oncocytic cysts should be considered on the differential diagnosis for nasopharyngeal masses causing such dysfunction.

Optimizing septal perforation repair techniques.

PURPOSE OF REVIEW: Multiple successful techniques and approaches for nasal septal perforation repair have been described, yet consistency in perforation and outcome metrics is required to identify the optimal approach to repair. The present article will review the recent literature. RECENT FINDINGS: Computational fluid dynamic studies continue to expand our understanding of the airflow dynamics in nasal septal perforation and after repair. Combining rhinoplasty and nasal septal perforation repair in appropriately selected patients can be safely done with excellent results. There has been a rise in utilization of a temporoparietal fascia with polydiaxonone plate construct for septal perforation repair with excellent outcomes. SUMMARY: The present review provides the reconstructive surgeon with an update on nasal septal perforation repair and describes a recently popularized technique of temporoparietal fascia-polydiaxonone plate for perforation reconstruction.

A Guide to Facial Trauma Triage and Precautions in the COVID-19 Pandemic.

COVID-19 is an emerging viral illness that has rapidly transmitted throughout the world. Its impact on society and the health care system has compelled hospitals to quickly adapt and innovate as new information about the disease is uncovered. During this pandemic, essential medical and surgical services must be carried out while minimizing the risk of disease transmission to health care workers. There is an elevated risk of COVID-19 viral transmission to health care workers during surgical procedures of the head and neck due to potential aerosolization of viral particles from the oral cavity/naso-oropharynx mucosa. Thus, patients with facial fractures pose unique challenges to the variety of injuries and special considerations, including triaging injuries and protective measures against infection. The proximity to the oral cavity/naso-oropharyngeal mucosa, and potential for aerosolization of secretions containing viral particles during surgical procedures make most patients undergoing operative interventions for facial fractures high risk for COVID-19 transmission. Our proposed algorithm aims to balance patient care with patient/medical personnel protection as well as judicious health care utilization. It stratifies facial trauma procedures by urgency and assigns a recommended level of personal protective equipment, extreme or enhanced, incorporating current best practices and existing data on viral transmission. As this pandemic continues to evolve and more information is obtained, the protocol can be further refined and individualized to each institution.

Assessment of the Learning Curve for Virtual Surgical Planning in Orbital Fractures.

Virtual surgical planning (VSP) is becoming more widely used in maxillofacial reconstruction and can be surgeon-based or industry-based. Surgeon-based models require software training but allow surgeon autonomy. We evaluate the learning curve for VSP through a prospective cohort study in which planning times and accuracy of 7 otolaryngology residents with no prior VSP experience were compared to that of a proficient user after a single training protocol and 6 planning sessions for orbital fractures. The average planning time for the first session was 21 minutes 41 seconds ± 6 minutes 11 seconds with an average maximum deviation of 2.5 ± 0.8 mm in the lateral orbit and 2.3 ± 0.6 mm in the superior orbit. The average planning time for the last session was 13 minutes 5 seconds ± 10 minutes and 7 seconds with an average maximum deviation of 1.4 ± 0.5 mm in the lateral orbit and 1.3 ± 0.4 mm in the superior orbit. Novice users reduced planning time by 40% and decreased maximum deviation of plans by 44% and 43% in the lateral and superior orbits, respectively, approaching that of the proficient user. Virtual surgical planning has a quick learning curve and may be incorporated into surgical training.

Contemporary management of frontal sinus fractures.

PURPOSE OF REVIEW: Frontal sinus fracture management is evolving. This article will highlight recent literature and provide an evidence-based algorithm in the contemporary management of frontal sinus fractures. RECENT FINDINGS: The role of transnasal endoscopic treatment of frontal sinus fractures has expanded to include fracture reduction and posterior table reconstruction. Evidence continues to support the safety of nonoperative management in select frontal sinus outflow tract fractures. SUMMARY: The management of frontal sinus fractures with frontal sinus outflow tract injury continues to evolve with a trend toward observation and minimally invasive approaches. Restoration of the frontal sinus outflow tracts with transnasal endoscopic techniques is being used increasingly in the acute and delayed setting. For severe fractures, the role of conservative treatment paradigms requires further research.

Posterior Maxillary Sinus Wall: A Landmark for Identifying the Sphenoid Sinus Ostium.

IMPORTANCE: Safe entry into sphenoid sinus is critical in endoscopic sinus and skull base surgery. A number of surgical landmarks have been used to identify the sphenoid sinus ostium during endoscopic endonasal surgery with variable reliability and intraoperative feasibility. OBJECTIVE: To determine if the posterior wall of the maxillary sinus is a reliable landmark to determine the depth of the sphenoid sinus ostium during anterior to posterior dissection. DESIGN, SETTING, AND PARTICIPANTS: Prospective study of adult patients undergoing endoscopic sinus surgery between August 2016 and September 2017. Measurements were made intraoperatively between the depth of the posterior maxillary sinus wall and sphenoid sinus ostium. MAIN OUTCOMES AND MEASURES: The primary measurement is the distance between the depth of the posterior maxillary sinus wall and sphenoid sinus ostium. Additional data points included age, gender, surgical indication, and primary versus revision endoscopic sinus surgery. RESULTS: Forty-five patients (38% male, 62% female) with an average age of 56 were enrolled, resulting in 88 operated sides. The average distance between the depth of the posterior wall of the maxillary sinus and the sphenoid ostium was 1.5 mm ± 1.4 mm. The most common position of the sphenoid sinus ostium was posterior to the level of the posterior maxillary sinus wall (54%), followed by same level (23%) and anterior (23%). There was no significant difference between different disease states (P = .75) and between primary and revision cases (P = .13). CONCLUSIONS AND RELEVANCE: The posterior wall of the maxillary sinus serves as an adjunctive intraoperative landmark to determine the depth of the sphenoid sinus ostium. While the posterior wall of the maxillary sinus approximates the depth of the sphenoid sinus ostium, the relative position is variable and can be anterior or posterior.