Quality of recovery and safety of deep intravenous sedation compared to general anesthesia in facial plastic surgery: A prospective cohort study.

BACKGROUND: Facial plastic surgical procedures are performed under either general anesthesia (GA) or sedation. GA is often associated with post-operative nausea and longer recovery, while deep sedation is thought to greatly facilitate perioperative patient comfort and expedite recovery. The objective of this study was to compare these two anesthetic techniques in a relatively healthy patient population undergoing facial plastic surgery and to discuss optimizing patient safety with a deep sedation technique. METHODS: A non-randomized, prospective cohort study was conducted to evaluate patients undergoing facial plastic surgery with a focus on rhinoplasty under either deep intravenous sedation (DIVS) in an ambulatory surgery center or under GA in a community hospital. Patients were between ages 18-65 and agreed to participate in the study and complete a quality of recovery (QoR-40) survey. Two-tailed Student's t-test was done for numerical data and Chi-squared test for categorical data. RESULTS: Twenty-three patients and 16 patients had surgery under DIVS and GA, respectively. Compared to the GA group, the DIVS group had less post-operative nausea and vomiting (21.7% vs 50%, P = 0.04; 4.3% vs 37.5%; P = 0.004, respectively), shorter emergence time (4 vs 13 min, P < 0.001), and higher QoR-40 scores for almost all the categories except for physical independence. There were no post-operative medical or surgical complications. CONCLUSION: DIVS appeared to be safe in the office-based setting and provided a higher quality recovery after a predominantly rhinoplasty-based practice compared to the GA group. Vigilant monitoring of the patient is crucial for careful titration of sedation to avoid respiratory depression and possible compromise of the surgical result from having to rescue the airway.

Does Subglottic Squamous Cell Carcinoma Warrant a Different Strategy Than Other Laryngeal Subsites?

OBJECTIVES/HYPOTHESIS: Subglottic squamous cell carcinoma (SSCC) is a rare cancer with limited evidence-based treatment guidelines. This study aimed to describe the treatment patterns for SSCC and to determine which treatments provide the best overall survival. STUDY DESIGN: Retrospective database review. METHODS: The National Cancer Database (NCDB) was queried for patients treated for SSCC from 2004 through 2014. Overall survival (OS) rates were determined by the Kaplan-Meier method. Clinicopathologic characteristics were assessed by univariable and multivariable Cox proportional hazards models, which corrected for age, sex, race, insurance status, income quartile, residence, Charlson-Deyo comorbidity score, facility type providing treatment, tumor grade, and clinical N and T category. RESULTS: In this cohort of 549 patients with SSCC, the 5-year OS was 48.2%. SSCC presented at an advanced stage (American Joint Committee on Cancer stage III or IV) in 60.1% of cases; 78.3% of cases had no nodal metastases. Among only stage IV cases, multivariable analysis showed that radiotherapy (RT) (hazard ratio [HR] = 5.944; 95% confidence interval [CI]: 2.76-12.8; P < .001) and chemoradiotherapy (CRT) (HR = 2.321; 95% CI: 1.36-3.97; P = .002) were both associated with decreased 5-year OS compared to a group consisting of all surgeries. When this analysis was repeated for only stage III cases, RT (HR = 1.134; 95% CI: 0.38-3.37; P = .821) and CRT (HR = 1.784; 95% CI: 0.78-4.08; P = .170) were equivalent to surgery. CONCLUSIONS: Using the NCDB to study the largest cohort of SSCC with known staging and treatment, primary surgery may provide a better 5-year OS in advanced-stage SSCC. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1117-E1124, 2021.

Prognostic significance of surgical margins after transoral laser microsurgery for early-stage glottic squamous cell carcinoma.

OBJECTIVES: The impact of positive tumor margin status and other clinicopathological factors on prognosis in early stage glottic squamous cell carcinoma (SCC) treated with transoral laser microsurgery (TLM) remains unclear. This study examined overall survival (OS) rates of patients with positive tumor margin status compared to negative tumor margin status after TLM in clinical T1-2 glottic SCC. MATERIALS AND METHODS: The National Cancer Data Base (NCDB) was queried for patients who underwent resection of T1-2 glottic SCC by TLM. Patients were treated from 2004 to 2013. Overall survival was assessed with Kaplan-Meier curve analysis, and univariate and multivariate Cox proportional hazards analysis. Differences in clinicopathologic factors between positive and negative margin groups were compared using Pearson Chi-squared analysis. RESULTS: Of 747 patients meeting inclusion criteria, 598 (80.1%) had negative margins. Median follow-up time was 48.0 months. Unadjusted 5-year OS for positive margins (80.0%) was lower compared to that of negative tumor margins (82.9%), but this was not statistically significant (P = 0.265). This persisted after multivariate analysis (P = 0.960). When tumors were stratified by T stage (647 T1, 100 T2), unadjusted 5-year OS based on margin status remained statistically insignificant for both T1 (P = 0.933) and T2 tumors (P = 0.350). CONCLUSION: Positive margins did not negatively impact overall survival among patients with TLM-treated early-stage glottic cancer. This finding might be useful clinically in deciding treatment modality for early stage glottic SCC.

Basaloid Squamous Cell Carcinoma of the Larynx: A National Cancer Database Analysis.

OBJECTIVE: Basaloid squamous cell histology is a rare variant that accounts for about 2% of all head and neck squamous cell laryngeal carcinomas. The purpose of this study was to examine overall survival rates of patients according to treatment, stage, and laryngeal subsite. STUDY DESIGN: Retrospective analysis. SETTING: National Cancer Database (NCDB). SUBJECTS AND METHODS: The NCDB was queried for patients with basaloid squamous cell carcinoma (BSCC) who were treated from 2004 to 2014. Five-year overall survival rates were determined by the Kaplan-Meier method. Univariate and multivariate analysis was used to identify factors correlated with 5-year overall survival. RESULTS: The NCDB identified 440 patients meeting inclusion criteria. Median follow-up time was 31.2 months. On univariate analysis, the treatment modalities assessed (surgery alone, surgery with radiotherapy, surgery with chemoradiotherapy, radiotherapy, chemoradiotherapy) did not differ in their survival benefit. On multivariate analysis, only chemoradiotherapy (hazard ratio, 0.587; 95% CI, 0.37-0.93; P = .022) was associated with improved survival. All treatment modalities performed similarly between stage I and II tumors ( P = .340) and stage III and IV tumors ( P = .154). CONCLUSION: This study represents the largest laryngeal BSCC series to date. We found that chemoradiotherapy was associated with improved 5-year overall survival of laryngeal BSCC on multivariate analysis.

Stereotactic radiotherapy in three weekly fractions for the management of vestibular schwannomas.

PURPOSE: This study evaluates the rates of tumor control, hearing preservation and cranial nerve toxicity with the use of CyberKnife stereotactic radiotherapy consisting of 2100 cGy to the 80% isodose line delivered in three weekly fractions to treat vestibular schwannomas. MATERIALS AND METHODS: Retrospective chart review of vestibular schwannoma patients treated with CyberKnife stereotactic radiotherapy or undergoing watchful waiting between 2006 and 2017 was performed. For inclusion, patients receiving CyberKnife stereotactic radiotherapy must have had pretreatment magnetic resonance imaging and audiography, and 2 follow-up magnetic resonance imaging and audiograms. Watchful waiting patients must have had a minimum of 2 magnetic resonance imaging and 2 audiograms. RESULTS: Forty patients met inclusion criteria. Twenty-two underwent CyberKnife stereotactic radiotherapy. Eighteen remain in watchful waiting. Crude tumor control was 86.4% at mean radiographic follow-up of 52.3 months. Kaplan-Meier progression-free survival was 76.9% at 5 years. Kaplan-Meier survival from radiographic growth was 61.5% at 5 years. Kaplan-Meier hearing preservation was 17.5% at 5 years. All patients undergoing watchful waiting presenting with serviceable hearing maintained serviceable hearing. Serviceable hearing among CyberKnife stereotactic radiotherapy patients was 42.9% prior to treatment and 14.2% through mean follow-up of 53.7 months. One patient experienced trigeminal nerve toxicity 45 months after SRT. 95.5% of CyberKnife stereotactic radiotherapy patients were complication-free. CONCLUSIONS: Our fractionation regimen provides tumor control consistent with current literature. Hearing outcomes, however, should be discussed with patients prior to CyberKnife stereotactic radiotherapy.

Diagnostic dilemmas of mechanical restriction of the medial rectus: A case report.

BACKGROUND: Due to the proximity of the maxillary sinus and ethmoid sinuses to the orbit, inflammatory processes that originate in the sinonasal region have the potential to extend into the orbit. OBJECTIVE: We presented a case of ptosis and restrictive strabismus of the medial rectus muscle. METHODS: A case report with a literature review of possible diagnoses. RESULTS: Biopsy, imaging, and laboratory evaluation by otolaryngology, ophthalmology, and rheumatology services were unable to identify the cause of the fibrosis after 22 months of follow-up. A response to oral steroids indicated an inflammatory process. CONCLUSION: Unilateral mechanical restriction of the medial rectus muscle is a rare complication of nasal disease. Inflammatory processes and iatrogenic injury are known to cause fibrosis of surrounding tissue. We presented a unique case of medial rectus fibrosis that did not meet the diagnostic criteria of recognized etiologies.

Butterfly cartilage tympanoplasty outcomes: A single-institution experience and literature review.

PURPOSE: In 1998, Dr. Eavey described the trans-canal inlay butterfly cartilage tympanoplasty technique, also known as cartilage button tympanoplasty. Many retrospective studies have since demonstrated its efficacy and decreased operative time when compared to underlay and overlay tympanoplasty techniques. The butterfly cartilage tympanoplasty approach uses only a cartilage graft to repair tympanic membrane perforations. The aim of this study was to review the literature for studies that examined butterfly cartilage tympanoplasty success rates and outcomes and compare them to outcomes from our cohort. MATERIALS AND METHODS: Butterfly cartilage tympanoplasties were performed in 23 pediatric patients and 7 adult patients. We evaluated the tympanic membrane perforation closure rate and hearing results measured by closure of the air-bone gap. RESULTS: The reviewed studies evaluating butterfly cartilage tympanoplasties demonstrated perforation closure rates between 71%-100%. The hearing outcomes in the reviewed literature varied, although the majority reported improved hearing. In our cohort, 21 of the 32 repaired tympanic membrane perforations demonstrated complete perforation closure. The mean follow-up length was 13.4 months. The mean air-bone gap decreased from 13.4 dB to 6.9 dB. CONCLUSIONS: The butterfly cartilage/cartilage button technique is effective in closing tympanic membrane perforations and decreasing the air-bone gap in both adults and children.

Intratympanic Triamcinolone and Dexamethasone in the Treatment of Ménière's Syndrome.

OBJECTIVE: To describe the safety and potential efficacy of intratympanic administration of triamcinolone (40 mg/mL) in the treatment of unilateral Ménière's syndrome. STUDY DESIGN: Single-institution retrospective analysis. SETTING: Tertiary referral neurotology clinic. PATIENTS: Eighteen patients diagnosed with unilateral Ménière's syndrome with vertigo refractory to medical management. INTERVENTION(S): Intratympanic injection of triamcinolone or dexamethasone. OUTCOME MEASURE(S): Kaplan-Meier analysis was implemented to determine the rate of successful vertigo control. Responders were defined as patients who achieved sufficient vertigo control to decline ablative therapy. Nonresponders were defined as those who did not achieve satisfactory vertigo control and required ablative or surgical therapy. Pre- and posttreatment audiogram data was used to evaluate changes in hearing. Patient follow-up data was assessed for complications potentially resulting from intratympanic therapy. RESULTS: No patient experienced profound hearing loss or other serious adverse events as a result of intratympanic triamcinolone therapy. Tympanic membrane perforation occurred in three (18%) patients, all of whom had received three or more previous intratympanic injections. Satisfactory vertigo control with intratympanic triamcinolone therapy was achieved in 14 (78%) of 18 subjects. CONCLUSION: Our results suggest that intratympanic triamcinolone therapy on an as-needed basis is a safe and potentially effective procedure for vertigo control in patients with Ménière's syndrome. These findings warrant the implementation of prospective, controlled trials to investigate its safety and efficacy further.