Inpatient Otolaryngology Consultations and COVID-19: The Surge and Lasting Effects at an Urban, Academic Institution.

Objective: This study aims to examine the lasting effects of the coronavirus disease 2019 (COVID-19) pandemic on inpatient otolaryngology consultations. Methods: In a retrospective analysis, inpatient otolaryngology consultations at an urban, academic tertiary care center were reviewed over the course of 2 years (Jun 2019-Jun 2021). The consultations were categorized by time period based on the local data for COVID-19 hospitalizations and deaths as follows: pre-COVID (Jun 2019-Feb 2020), Surge 1 (Mar 2020-May 2020), Surge 2 (Oct 2020-Jan 2021), and Post Surge (Mar 2021-Jun 2021). Results: A total of 897 patients undergoing an inpatient otolaryngology consultation across all 4 time periods were included for analysis. The average consultations per day was 1.67 ± 0.24 in pre-COVID times, and dropped acutely to 0.86 ± 0.33 consultations per day during Surge 1. The consultation volume was not statistically different from pre-COVID levels during Surge 2 (1.33 ± 0.35) and Post Surge (1.60 ± 0.20). Reason for consultation and procedures performed did not vary significantly between pre-COVID times and Post Surge, except that consultation for postoperative complaint was less frequent in Post Surge (4.8% vs 1.0%, P = .02). More patients had been screened with rapid antigen COVID testing in Post Surge versus Surge 1 (20.1% vs 7.6%, P = .04). Conclusions: Inpatient otolaryngology consultation volumes, indications, and procedures performed at an urban, academic institution returned to pre-COVID levels after being significantly impacted during Surge 1.

Quality-Based Evaluation of Patient-Facing Online Education Materials Regarding Facial Filler Procedures.

Injectable facial fillers have become tremendously more popular in recent years, and the Internet offers a proportional amount of consumer-facing educational material. This study sought to explore the quality of these online materials. The top 20 Web sites offering educational materials about facial filler were identified via Google search and sorted by source: Medical Professional Boards, Hospitals and Providers, Medical News and Reference, and Fashion. The materials were assessed for overall quality with the validated DISCERN instrument. The authors also assessed understandability and actionability (Patient Education Material Assessment Tool - PEMAT), accuracy, comprehensiveness, and readability (Flesch-Kincaid Grade Level and Flesch Reading Ease). The mean DISCERN score was 46.9 ± 7.6, which is considered "fair" quality educational material; above "poor," but below "good" and "excellent." Understandability and actionability scores were low, particularly with respect to visual aids. The materials were generally accurate (76-99%), but scored poorly in comprehensiveness, as 15% failed to mention any risks/adverse effects and only 35% mentioned cost. On average, readability was at an 11th grade level, far more complex than ideal (< 6th grade level). Information disseminated from seemingly reputable sources such as professional boards and hospitals/providers were not of higher quality or superior in any of the above studied domains. In conclusion, online educational materials related to injectable facial fillers are of subpar quality, including those from academic and professional organizations. Visual aids were particularly weak. The facial rejuvenation community should make a concerted effort to set a higher standard for disseminating such information.

Hypoglossal and Masseteric Nerve Transfer for Facial Reanimation: A Systematic Review and Meta-Analysis.

Background: Hypoglossal and masseteric nerve transfer are currently the most popular cranial nerve transfer techniques for patients with facial paralysis. The authors performed a systematic review and meta-analysis to compare functional outcomes and adverse effects of these procedures. Methods: A review of online databases was performed to include studies with four or more patients undergoing hypoglossal or masseter nerve transfer without muscle transfer or other cranial nerve transposition. Facial nerve outcomes, time to reinnervation, and adverse events were pooled and studied. Results: A total of 71 studies were included: 15 studies included 220 masseteric-facial transfers, and 60 studies included 1312 hypoglossal-facial transfers. Oral commissure symmetry at rest was better for hypoglossal transfer (2.22 ± 1.6 mm vs. 3.62 ± 2.7 mm, p = 0.047). The composite Sunnybrook Facial Nerve Grading Scale was better for masseteric transfer (47.7 ± 7.4 vs. 33.0 ± 6.4, p < 0.001). Time to first movement (in months) was significantly faster in masseteric transfer (4.6 ± 2.6 vs. 6.3 ± 1.3, p < 0.001). Adverse effects were rare (<5%) for both procedures. Conclusions: Both nerve transfer techniques are effective for facial reanimation, and the surgeon should consider the nuanced differences in selecting the correct procedure for each patient.

Evidence-Based Clinical Practice Guideline: Reconstruction after Skin Cancer Resection.

SUMMARY: A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

Evidence-based clinical practice guideline: Reconstruction after skin cancer resection.

A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

Evidence-Based Clinical Practice Guideline: Reconstruction after Skin Cancer Resection.

SUMMARY: A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

Cytopathologic assessment of gloves and instruments after major head and neck surgery.

PURPOSE: To investigate the potential for cancer cells to be transferred between anatomic sites via instruments and other materials. MATERIALS AND METHODS: Pilot prospective study from April 2018-January 2019 at Rush University Medical Center. Glove and instrument washings were collected from 18 high-risk head and neck cancer resection cases (36 samples total). Each case maintained at least one of the following features in addition to a diagnosis of squamous cell carcinoma or sarcoma: palliative/salvage surgery, positive margins, extensive tumor burden, and/or extra capsular extension (ECE). Surgical gloves and four main instruments were placed through washings for blind cytological assessment (2 samples/case). RESULTS: 18 patients undergoing surgical tumor resection for biopsy-proven squamous cell carcinoma with at least one of the aforementioned characteristics were included. 26.7% of cases had ECE, 40.0% had positive final margins and 46.7% had close final margins. Tumor locations included: oral cavity (10), neck (4), parotid gland (2), and skin (2). Malignant cells were isolated on glove washings in 1 case (5.5%). No malignant cells were isolated from instrument washings. The single case of malignant cells on glove washings occurred in a recurrent, invasive squamous cell carcinoma of the scalp with intracranial extension. Anucleated squamous cells likely from surgeon skin were isolated from 94.4% of washings. Squamous cells were differentiated from mature cells by the absence of nuclei. CONCLUSIONS: Malignant squamous cells can be isolated from surgical glove washings, supporting the practice of changing of gloves after gross tumor resection during major head and neck cancer resections.

Enhanced recovery after surgery for head and neck free flap reconstruction: A systematic review and meta-analysis.

INTRODUCTION: Head and neck free flap reconstruction requires multidisciplinary and coordinated care in the perioperative setting to ensure safe recovery and success. Several institutions have introduced enhanced recovery after surgery (ERAS) protocols to attenuate the surgical stress response and improve postoperative recovery. With multiple studies demonstrating mixed results, the success of these interventions on clinical outcomes has yet to be determined. OBJECTIVE: To evaluate the impact of ERAS protocols and clinical care pathways for head and neck free flap reconstruction. METHODS: We searched PubMed, SCOPUS, EMBASE, and grey literature up to September 1st, 2020 to identify studies comparing patients enrolled in an ERAS protocol and control group. Our primary outcomes included hospital length of stay (LOS) and readmission. Mortality, reoperations, wound complication and ICU (intensive care unit) LOS comprised our secondary outcomes. RESULTS: 18 studies met inclusion criteria, representing a total of 2630 patients. The specific components of ERAS protocols used by institutions varied. Nevertheless, patients enrolled in ERAS protocols had reduced hospital LOS (MD -4.36 days [-7.54, -1.18]), readmission rates (OR 0.64 [0.45;0.92]), and wound complications (RR 0.41 [0.21, 0.83]), without an increase in reoperations (RR 0.65 [0.41, 1.02]), mortality (RR 0.38 [0.05, 2.88]), or ICU LOS (MD -2.55 days [-5.84, 0.74]). CONCLUSION: There is growing body of evidence supporting the role of ERAS protocols for the perioperative management of head and neck free flap patients. Our findings reveal that structured clinical algorithms for perioperative interventions improve clinically-meaningful outcomes in patients undergoing complex ablation and microvascular reconstruction procedures.

Beauty is in the eye of the follower: Facial aesthetics in the age of social media.

BACKGROUND: The advent of social media has influenced the relationship between aesthetic surgeons and their patients, as well as the motivations of such patients to seek cosmetic surgery. AIMS & OBJECTIVES: To determine how the cephalometric proportions of modern social media models fit with historical canons of beauty. MATERIALS & METHODS: Frontal and lateral photographs of 20 high-influence female Instagram models were obtained and evaluated for cephalometric measures. The means of these measures were compared with previous reports in the literature. RESULTS: Cephalometric measurements of social media models were in agreement with historical ideals of beauty for Nostril axis (120.7°), Goode's ratio (0.6), Nasofacial angle (35.7°), Nasofrontal angle (130.9°), and the horizontal thirds. Results were discrepant from historical ideals for the Nasolabial angle (82.6°) and the vertical facial fifths. CONCLUSION: Cephalometric measurements of social media models in the digital age closely resemble the ideal values proposed by previous authors. Due to a preference for larger or altered lip profiles, nostril axis is a more reliable measure of nasal tip rotation than nasolabial angle.

Enhanced recovery protocol for transoral robotic surgery demonstrates improved analgesia and narcotic use reduction.

BACKGROUND: No study has evaluated the impact of the Enhanced Recovery After Surgery (ERAS) protocol on opioid usage among patients undergoing transoral robotic surgery (TORS). METHODS: In this retrospective study, patients undergoing TORS were enrolled in an ERAS protocol and compared to control patients. Primary outcome measures included postoperative mean morphine equivalent dose (MED), Defense and Veterans Pain Rating Scale (DVPRS) pain scores, and opioid prescriptions on discharge. RESULTS: The mean MED administered postoperatively was lower in the ERAS group (17.6 mg) than in the control group (65.0 mg) (p < .001). Average postoperative DVPRS scores were 2.9 in the ERAS group vs. 4.2 in the control group (p = .042). Fewer patients in the ERAS group received opioid prescriptions on discharge (31.6%) than controls (96.2%) (p < .001). CONCLUSION: The TORS ERAS protocol is associated with reduced postoperative opioid usage, lower pain scores, and reduced opioid requirements on discharge.

Rapid implementation of COVID-19 tracheostomy simulation training to increase surgeon safety and confidence.

OBJECTIVE: To determine if rapid implementation of simulation training for anticipated COVID-19 tracheostomy procedures can increase physician confidence regarding procedure competency and use of enhanced personal protective equipment (PPE). METHODS: A brief simulation training exercise was designed in conjunction with the development of a COVID-19 Tracheostomy Protocol. The simulation training focused primarily on provider safety, pre and post-surgical steps and the proper use of enhanced PPE. Simulation training was performed in the simulation lab at the institution over 2 days. Pre and post self-evaluations were measured using standardized clinical competency questionnaires on a 5-point Likert Scale ranging from "No knowledge, unable to perform" up to "Highly knowledgeable and confident, independent." RESULTS: Physicians self-reported a significant increase in knowledge and competency immediately after completing the training exercise. Resident physicians increased from a mean score of 3.00 to 4.67, p-value 0.0041, mean increase 1.67 (CI 95% 0.81 to 2.52). Attending physicians increased from a mean score of 2.89 to 4.67, p-value 0.0002, mean increase 1.78 (CI 95% 1.14 to 2.42). Overall, all participants increased from a mean score of 3.06 to 4.71, p-value 0.0001, mean increase 1.65 (CI 95% 1.24 to 2.05). DISCUSSION: Implementation of this simulation training at our institution resulted in a significant increase in physician confidence regarding the safe performance of tracheostomy surgery in COVID-19 patients. IMPLICATIONS FOR PRACTICE: Adoption of standardized COVID-19 tracheostomy simulation training at centers treating COVID-19 patients may result in improved physician safety and enhanced confidence in anticipation of performing these procedures in real-life scenarios.

Management of the Clinical and Academic Mission in an Urban Otolaryngology Department During the COVID-19 Global Crisis.

OBJECTIVE: The objective of this study was to assess the strategic changes implemented in the departmental mission to continue safe delivery of otolaryngology care and to support the broader institutional mission during the COVID-19 pandemic response. STUDY DESIGN: Retrospective assessment was performed to the response and management strategy developed to transform the clinical and academic enterprise. SETTING: Large urban tertiary care referral center. RESULTS: The departmental structure was reorganized along new clinical teams to effectively meet the system directives for provision of otolaryngology care and support for inpatient cases of COVID-19. A surge deployment schedule was developed to assist frontline colleagues with clinical support as needed. Outpatient otolaryngology was consolidated across the system with conversion of the majority of visits to telehealth. Operative procedures were prioritized to ensure throughput for emergent and time-critical urgent procedures. A tracheostomy protocol was developed to guide management of emergent and elective airways. Educational and research efforts were redirected to focus on otolaryngology care in the clinical context of the COVID-19 crisis. CONCLUSION: Emergence of the COVID-19 global health crisis has challenged delivery of otolaryngology care in an unparalleled manner. The concerns for preserving health of the workforce while ethically addressing patient career needs in a timely manner has created significant dilemmas. A proactive, thoughtful approach that reorganizes the overall departmental effort through provider and staff engagement can facilitate the ability to meet the needs of otolaryngology patients and to support the greater institutional mission to combat the pandemic.

Sexual Dimorphism of the Nasal Skin and Soft Tissue Envelope.

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Implementation of Preoperative Screening Protocols in Otolaryngology During the COVID-19 Pandemic.

OBJECTIVE: To highlight emerging preoperative screening protocols and document workflow challenges and successes during the early weeks of the COVID-19 pandemic. METHODS: This retrospective cohort study was conducted at a large urban tertiary care medical center. Thirty-two patients undergoing operative procedures during the COVID-19 pandemic were placed into 2 preoperative screening protocols. Early in the pandemic a "high-risk case protocol" was utilized to maximize available resources. As information and technology evolved, a "universal point-of-care protocol" was implemented. RESULTS: Of 32 patients, 25 were screened prior to surgery. Three (12%) tested positive for COVID-19. In all 3 cases, the procedure was delayed, and patients were admitted for treatment or discharged under home quarantine. During this period, 86% of operative procedures were indicated for treatment of oncologic disease. There was no significant delay in arrival to the operating room for patients undergoing point-of-care screening immediately prior to their procedure (P = .92). DISCUSSION: Currently, few studies address preoperative screening for COVID-19. A substantial proportion of individuals in this cohort tested positive, and both protocols identified positive cases. The major strengths of the point-of-care protocol are ease of administration, avoiding subsequent exposures after testing, and relieving strain on "COVID-19 clinics" or other community testing facilities. IMPLICATIONS FOR PRACTICE: Preoperative screening is a critical aspect of safe surgical practice in the midst of the widespread pandemic. Rapid implementation of universal point-of-care screening is possible without major workflow adjustments or operative delays.

Level of Evidence in Facial Plastic Surgery Research: A Procedure-Level Analysis.

BACKGROUND: As evidence-based medicine has taken hold across medical specialties, the level of evidence within the facial plastic surgery literature has risen, but remains weak in comparison. There has not yet been a systematic, critical appraisal of the relative strength of evidence among subsets of the practice of facial plastic surgery. METHODS: The current study is a systematic review, designed to evaluate the level of evidence observed in the facial plastic surgery literature. Five journals were queried using facial plastic surgery terms for four selected years over a 10-year period. Following screening, articles were assigned to a category regarding subject matter, assessed for the presence of various methodological traits, and evaluated for overall level of evidence. Comparisons were made in regard to level of evidence across the breadth of facial plastic surgery subject matter. RESULTS: A total of 826 articles were included for final review. Studies on operative facial rejuvenation and rhinoplasty had significantly fewer authors on average than studies on cancer reconstruction or craniofacial topics. Craniofacial studies demonstrated higher levels of evidence relative to all other categories, with the exception of facial paralysis and facial trauma studies, from which there was no significant difference. In general, reconstructive studies had significantly more authors and higher levels of evidence than did articles with an aesthetic focus. CONCLUSION: Level of evidence in facial plastic surgery remains relatively weak overall. Reconstructive and particularly craniofacial studies demonstrate higher mean level of evidence, relative to other subsets of facial plastic surgery. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.