Uvulopalatopharyngoplasty: Does Multilevel Surgery Increase Risk?

OBJECTIVES: (1) Determine the rate of postoperative complications, reoperation, readmission, and death after uvulopalatopharyngoplasty (UPPP) for sleep apnea through multi-institutional clinical data. (2) Compare outcomes of UPPP between multilevel and single-level procedures for the treatment of sleep apnea. STUDY DESIGN: Retrospective database analysis. METHODS: The American College of Surgeons National Surgical Quality Improvement Program-a nationally validated, prospective, multi-institutional database from 2005 to 2013-was analyzed for patients who underwent UPPP, per corresponding Current Procedural Terminology codes. Patients were categorized into 3 groups: UPPP alone, UPPP + nasal cavity (NC), and UPPP + base of tongue (BOT). Perioperative outcome measures of interest include surgical/medical complications, reoperation, readmission, and death. Comparisons were made among surgical groups through univariate cross-sectional analysis. RESULTS: A total of 1079 patients underwent UPPP; 413 patients had UPPP + NC; and 200 patients had UPPP + BOT procedures. One death was reported for the entire cohort of patients. Among all 3 groups (UPPP, UPPP + NC, and UPPP + BOT), no differences were noted in the rates of medical complications (P = .445), surgical complications (P = .396), reoperation (P = .332), and readmission (P = .447). However, the length of hospital stay in days was greatest for the UPPP + BOT group (UPPP, 0.81 ± 0.69; UPPP + NC, 0.87 ± 0.90; UPPP + BOT, 1.50 ± 2.70; P < .001). CONCLUSION: These national data demonstrate no significant increase in risk when UPPP is performed as a single- or multilevel procedure. When indicated, UPPP with multilevel procedures may be safely performed for treatment of sleep apnea. These data set a benchmark for perioperative risk in UPPP surgery and will prove useful for counseling patients.

Comparison of the rotation-advancement and philtral ridge techniques for unilateral cleft lip repair.

BACKGROUND: The Millard rotation-advancement flap has become the most widely used technique for unilateral cleft lip repair. The philtral ridge repair is a modified straight-line technique that was developed to further optimize the scar associated with the rotation-advancement flap. The purpose of this article is to introduce the philtral ridge repair and objectively compare the outcomes of these two techniques. METHODS: Two senior board-certified surgeons, who are active members of their respective craniofacial teams, use different surgical techniques for the unilateral cleft lip: the philtral ridge and rotation-advancement repairs. The authors retrospectively analyzed preoperative and postoperative photographs of consecutive patients who underwent repair performed by each surgeon between 2003 and 2009. Using Adobe Photoshop imaging software, facial points on the cleft and noncleft sides were measured, including height and symmetry of Cupid's bow, width and height of the nasal vestibule, height of the vermilion, and alar base position. Ratios of cleft side to noncleft side measurements were calculated to standardize comparisons between patients. In addition, the symmetry of each lip repair was graded subjectively by health care professionals and the general public. RESULTS: There were no differences in preoperative ratios between the two techniques with the exception of a wider cleft nasal vestibule in the rotation-advancement group (p = 0.04). There were no statistically significant differences in postoperative measures or subjective analysis of symmetry between the groups. CONCLUSION: Both the rotation-advancement and philtral ridge techniques produced outcomes with a high degree of facial symmetry and are excellent options for unilateral cleft lip repair.

Characterization of facial paresis in hemifacial microsomia.

OBJECTIVE: To provide an overview of the incidence, characteristics, and proposed etiologic mechanisms of facial paresis in patients with manifestations of hemifacial microsomia. DATA SOURCES: PubMed database for English-language studies with no date restrictions. REVIEW METHODS: A comprehensive literature review was performed identifying all studies that discussed incidence, characterization, or etiologic mechanisms for facial paresis in hemifacial microsomia/oculo-auriculo-vertebral spectrum. CONCLUSIONS: This review supports that the prevalence of facial weakness in the spectrum of hemifacial microsomia/oculo-auriculo-vertebral spectrum ranges from 10% to 45%. Most of these patients have involvement of all facial nerve branches or lower branches only. The most commonly involved single nerve branch has yet to be described. The 2 most common associated anomalies involve the mandible and auricle. Dysmorphogeneisis of the temporal bone and its effects on the facial nerve are most likely implicated in the cause of facial weakness. IMPLICATIONS FOR PRACTICE: There is a wide variety of facial nerve presentations seen within oculo-auriculo-vertebral spectrum for which the exact etiologic mechanism is unclear. Through a better understanding of the presentation and etiology surrounding facial paresis in hemifacial microsomia, improved treatment options may be offered in the management of the facial weakness.

Surveillance tracheal aspirate cultures do not reliably predict bacteria cultured at the time of an acute respiratory infection in children with tracheostomy tubes.

BACKGROUND: The aim of this study was to characterize the practice of routinely obtaining tracheal aspirate cultures in children with tracheostomy tubes and to analyze the appropriateness of using this information to guide antibiotic selection for treatment of subsequent lower respiratory infections. METHODS: Pediatric otolaryngologists and pulmonologists were surveyed regarding surveillance culture practices. Records of children with tracheostomy tubes from January 1, 2003, through December 31, 2007, were reviewed. Consecutive cultures were compared for similarity of bacteria and antibiotic sensitivity when a clinic culture preceded a culture from when the child was ill and received antibiotics and when a hospital culture preceded a hospital culture from a separate hospitalization. RESULTS: Seventy-nine of 146 pulmonologists and five of 33 otolaryngologists obtained routine surveillance tracheal aspirate cultures (P < .001); 97% of pulmonologists used these cultures to guide subsequent empiric therapy. There were 36 of 170 children with one or more eligible pairs of cultures. Nearly all children had a change in flora in their tracheal cultures. Limiting empiric antibiotic choices to those that would cover microbes isolated in the previous culture likely would not have been effective in covering one or more microbes isolated in the second culture in 56% of pairs with the first culture from hospitalization vs 30% with the first culture from an outpatient setting (P = .15). CONCLUSIONS: This study demonstrated that there are significant changes in bacteria or antibiotic sensitivity between consecutive tracheal cultures in children with tracheostomy tubes. Use of prior tracheal cultures from these children was of limited value for choosing empiric antibiotic therapy in treating acute lower respiratory exacerbations. Surveillance cultures, thus, are an unnecessary burden and expense of care.