The impact of frailty on facial nerve recovery following Bell's palsy.

OBJECTIVES: Patients with Bell's palsy, the sudden onset of facial paralysis, have variable recovery. Frailty has been recognized as an important factor in predicting recovery. This study investigated the relationship between frailty and facial nerve recovery in Bell's palsy patients. METHODS: A retrospective review was conducted on 95 Bell's palsy patients at a single institution's Department of Otolaryngology from 2014 to 2023. A clinically relevant facial nerve recovery was defined as a House-Brackmann (HB) score decrease>1 between the initial and most recent visit. Patients without follow-up visits or initial HB scores <3 were excluded. Frailty was measured by modified frailty index-5 (mFI-5) at the time of Bell's palsy diagnosis. Elderly patients were those over 65 years at presentation (n = 29). Frail patients had mFI-5 > 1 (n = 8). Chi-squared analyses, Fisher's exact tests, and logistic regression models were conducted in SPSS. RESULTS: The analytic sample included 95 patients (median age = 56.8 years, IQR = 24.1) presenting with an initial HB score > 2. 36 % of patients' HB scores decreased by ≥2 within the follow-up period. Frailty (unadjusted Odds Ratio (OR) = 6.3, 95 % CI = [1.2, 33.1], p = .023) was associated with facial nerve recovery while age was not (unadjusted OR = 1.07, 95 % CI = [0.44, 2.59], p = .889). The mFI-5 adjusted OR was 8.43 (95 % CI = [1.38, 51.4], p = .021) when adjusting for age, gender, treatment modality, access to care, and follow-up duration in a logistic regression. CONCLUSIONS: Frailty correlated with enhanced facial nerve recovery after Bell's palsy in this cohort; age was not significantly associated. Further investigation into factors associated with frailty, including increased surveillance and treatment frequency, is warranted.

Cost and value of office-based facial plastic and reconstructive surgery procedures.

Introduction: This chapter will provide an overview of factors affecting the cost of office-based procedures in Facial Plastics and Reconstructive Surgery (FPRS), and will discuss the value of office-based interventions. Material and Methods: An in-depth literature review was conducted using multiple primary and secondary sources. Literature from multiple disciplines was included in the review, including otolaryngology, anesthesiology, surgery, public health, and economics. Discussion/Conclusions: A wide variety of procedures can be performed in an FPRS office. Large upfront costs to the office include laser, electrocautery and surgical equipment. These investments will yield an initial negative cost margin until sufficient case volume is achieved. It is often in the best interest of the patient to perform a procedure in-office and avoid the facility and anesthesia fees associated with a surgical center or hospital. Costs and reimbursements vary greatly across regions and facilities. Additionally, overall cost depends on payer mix, procedures performed, and productivity of the practice. The scarcity of literature on this topic as it applies specifically to FPRS indicates that further research is needed to elucidate the value of common facial plastics procedures in an office-based setting.

Primary diffuse large B-cell lymphoma of the nasal bone and palate: An unusual clinical presentation.

Primary bone lymphomas account for 3-5% of extranodal non-Hodgkin lymphomas in adults and are typically present in the axial skeleton and weight-bearing bones. We present a unique case of primary bone diffuse large B-cell lymphoma (DLBCL) of the nasal bone and palate. We discuss the pathologic and radiologic findings and review the current literature and clinical management to highlight how this unusual clinical entity should be considered in differential diagnoses of head and neck bone masses.

Resurgence of regional flaps for head and neck reconstruction.

PURPOSE OF REVIEW: The strain on healthcare resources in light of the COVID-19 pandemic has forced many head and neck surgeons to explore reconstructive options that may decrease length of stay. Here, we review three common and versatile regional flaps used in head and neck reconstruction that are comparable alternatives to free tissue transfer. RECENT FINDINGS: Initial anatomic descriptions of the facial artery musculocutaneous (FAMM) flap, the supraclavicular artery island flap and the submental artery island flap were published decades ago. Since then, many have proposed modifications to these descriptions to improve technical ease and patient outcomes. Benefits of regional flaps include ease of harvest, comparable outcomes to free tissue microvascular flaps, shorter operative time and hospital length of stay. Drawbacks to regional flaps include limitations to size and reach, partial necrosis, wound dehiscence and surgeon experience. The integrity of the vascular pedicle is also contingent upon vessel preservation during the cancer ablation. SUMMARY: Although a resurgence of regional flaps began well before the COVID-19 pandemic, many institutions began looking for alternatives to free flap reconstruction to conserve healthcare resources and minimize patient hospitalization time in the past year. There has been a revival of regional flaps such as the FAMM, supraclavicular and submental flaps that are valuable reconstructive options for many defects of the head and neck.

Dermal Filler Presenting as Parotid Mass: A Case Report.

Dermal filler injections are common cosmetic procedures and are growing in popularity. While frequently performed, dermal filler injections carry a risk of adverse events including vascular compromise and foreign body granulomas. Here, we discuss an unusual case of a patient with a history of dermal filler injections presenting with a parotid mass and an eyebrow mass requiring surgical resection. This case demonstrates the risk of delayed granuloma formation many years after dermal filler injection and highlights the importance of awareness and management of these potential long-term complications.

Using Lean to Improve Patient Safety and Resource Utilization After Pediatric Adenotonsillectomy.

OBJECTIVE: The objective of this quality improvement project was to decrease the rate of nonemergent use of emergency department (ED) resources in children undergoing adenotonsillectomy by 50% and/or reach a future state of 5% or less overall ED visits among all postoperative patients within 1 year. A secondary objective was to standardize the preoperative, intraoperative, and postoperative management of these patients. METHODS: The study was a quality improvement project using Lean. The target population was children younger than 18 years undergoing tonsillectomy with or without adenoidectomy. A retrospective review of adenotonsillectomy was performed for a 12-month period. Lean tools including A3 Thinking, Ishikawa "fishbone" diagram, and value stream mapping were used to analyze the problem and identify interventions. Postintervention data were collected for a 10-month period. RESULTS: Compared with the baseline period, the ED visit rate after adenotonsillectomy decreased from 36.2% to 15.5% (P = 0.0095). The rate of ED visits for nonbleeding complaints decreased from 30.4% to 12.1% (P = 0.01748). There was no significant change in rate of ED visits for bleeding (decreased from 5.8% to 3.5% [P = 0.6873]). There was no significant change in the use of intraoperative dexamethasone and acetaminophen. CONCLUSIONS: Postadenotonsillectomy patients often use emergency resources better reserved for other patients. Addressing this problem with Lean principles significantly decreased postoperative ED visit rates by more than 50%. IMPLICATIONS FOR PRACTICE: To our knowledge, this is the first reported use of Lean principles to decrease utilization of emergency resources in the postoperative period. Lean can be applied to other processes in our field to eliminate waste and add value to improve patient outcomes. LEVEL OF EVIDENCE: NA.

Virtual Reality as Distraction Analgesia for Office-Based Procedures: A Randomized Crossover-Controlled Trial.

OBJECTIVE: The purpose of this study was to explore the use of immersive and interactive virtual reality (VR) for analgesia, anxiety reduction, and overall satisfaction in patients undergoing outpatient postoperative debridements. STUDY DESIGN: Randomized crossover-controlled trial. SETTING: Academic outpatient clinic. SUBJECTS AND METHODS: Adult patients who had functional endoscopic sinus surgery and skull base surgery and were undergoing office-based postoperative nasal endoscopy and debridement were recruited and followed for 2 consecutive office visits. Participants were randomized to receive either the control or experimental analgesia for the first postoperative visit (PO1) and crossed over into the opposite treatment arm during the second postoperative visit (PO2). Outcomes included procedural pain, anxiety and satisfaction scores, procedural time, and reflexive head movements per minute (RHM). RESULTS: Eighty-two participants were recruited. At PO1, 39 received standard analgesia, and 43 received an immersive VR experience. At PO1, the VR group experienced significantly less anxiety (P = .043) and fewer RHM (P = .00016) than the control group. At PO2, the VR group experienced significantly fewer RHM (P = .0002). At PO2, patients who received the experimental treatment after initially receiving the control treatment had significantly decreased pain, anxiety, and RHM. This effect was not seen in the second group. Overall, 69.51% of patients felt that the VR treatment was better; 19.51% thought that it was the same; and 9.76% found it to be worse. CONCLUSION: VR technology holds promise as a nonpharmacologic analgesic and anxiolytic intervention for otolaryngology office-based procedures. Further study of VR use in other procedures is warranted. LEVEL OF EVIDENCE: 1, randomized controlled trial.

Efficiency of microvascular free flap reconstructive surgery: An observational study.

OBJECTIVE: We aimed to assess operative workflow and efficiency in microvascular free flaps via a direct observational study based on Lean principles of quality improvement (QI). METHODS: Observers monitored the workflow of twenty-three free flaps. Pre-operative preparation and surgical duration was recorded with supplemental data provided from our institution's surgical tracking database. Traffic patterns of operating room (OR) staff were documented as "entries" and "exits" from the OR and classified by role and the reason that the entry or exit was required. Patient data was obtained via chart review. RESULTS: The mean surgical time was 9.0 h. Approximately 20% of OR time was dedicated to the pre-incision process, averaging 1.6 h per case. One third of entries and exits occurred during this period. In total, 180.2 surgical hours were observed during which 6215 "entries" and "exits" occurred. The mean number of entries and exits per case was 270; the most common reasons were supplies and communication. No association was observed between elapsed surgical time or total number of entries and exits with post-operative infection rates. CONCLUSION: Comprehensive observational workflow studies of free flaps are challenging to execute due to lengthy procedure times. At our high-volume institution, a significant portion of OR time is devoted to the pre-incision period, largely due to inadequate supply availability and pre-operative communication. These findings will serve as a foundation for QI interventions at our institution, while our observational model provides a broadly applicable framework for assessing surgical efficiency.

Thermal imaging for microvascular free tissue transfer monitoring: Feasibility study using a low cost, commercially available mobile phone imaging system.

BACKGROUND: The use of infrared thermography to evaluate the perfusion of tissue flaps have been studied. This study aims to evaluate the utility of thermal imaging for flap monitoring with a low-cost, readily available smartphone imaging device. METHODS: Adult subjects who underwent head and neck reconstruction using a microvascular free flap with a cutaneous paddle were recruited. Thermal images were taken of the free flap before, during and after anastomosis. Thermal images were analyzed by measuring the average flap temperature minus the average surrounding tissue temperature (dT). RESULTS: Twenty-one patients were enrolled. The mean dT for flaps intraoperatively prior to anastomosis was -11.47 °F. For 20 patients, dT averaged between -0.30 to 0.12 °F. One flap was inadequately perfused and dT was found to be -4.35 °F. CONCLUSIONS: Low cost, mobile smartphone devices such as the thermal camera may provide an objective method of monitoring microvascular free flaps. LEVEL OF EVIDENCE: 2 Prospective Cohort Study.

Hospital Charge Variability across New York State: Sociodemographic Factors in Pituitary Surgery.

Introduction Significant charge disparities exist across New York State (NYS). Race and income are associated with increased charges. To determine risk factor, we correlate hospital charges for pituitary surgery with socioeconomic factors. Additionally, we identify patients at risk for increased hospital charges and provide insight into cost-effective practices. Methods Retrospective cohort study of the Statewide Planning and Research Cooperative System (SPARCS) database from the NYS Department of Health was conducted. The SPARCS database was reviewed. Patients who underwent transsphenoidal pituitary surgery from 1995 to 2015 were identified. Income and urban status were referenced from U.S. census data. Linear regression was performed to analyze the effect of sociodemographic factors, comorbidities, and complications on hospital charges while controlling for length of stay. Results A total of 9,373 patients were identified. Black (10.8%, p < 0.001) and Asian (14.5%, p < 0.001) had higher hospital charges. Patients from nonurban cities (13.4%, p < 0.001), Medicaid (13.8%, p < 0.001), and those from the 0 to 25th (9.1%, p < 0.001) and 25 to 50th (11.7%, p < 0.001) income quartile had lower hospital charges. Patients with postoperative cerebrospinal fluid leak (24.0%, p < 0.001), diabetes insipidus (22.1%, p < 0.001), smoking history (11.8%, p < 0.001), hypertension (7.4%, p < 0.001), and hypothyroidism (6.9%, p < 0.001) had higher hospital charges. Conclusion Patients incurring higher chargers were more likely to have a smoking history, hypertension, hypothyroidism, and comorbidities. The determinants of this analysis may provide insight into barriers to patient access and cost improvement strategies. In addition, this emphasizes the need for future studies to create a risk stratification model, similar to those in other fields.

Endoscopic Versus Microscopic Middle Ear Surgery: A Meta-analysis of Outcomes Following Tympanoplasty and Stapes Surgery.

OBJECTIVE: This meta-analysis compares the efficacy and safety of endoscopic and microscopic approaches to tympanoplasty and stapes surgery, two common middle ear procedures. DATA SOURCES: A comprehensive electronic search of PubMed/MEDLINE, Scopus, Web of Science, and Cochrane Library was conducted for studies published from the year 1960 through June 2018. Article selection and screening proceeded according to the strategies outlined in the standard Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. METHODS: Studies were assessed for quality using the Newcastle-Ottawa Scale and the Jadad scale depending on the presence of randomization. Bias was analyzed using funnel plots. For each outcome measure, a forest plot was generated and a pooled relative risk or risk difference was calculated to assess significance. RESULTS: Twenty-one studies met the inclusion criteria, 16 tympanoplasty (1,323 ears) and 5 stapes surgery (283 ears). The nonrandomized studies scored moderately well but the randomized studies were of low quality with respect to the Newcastle-Ottawa Scale and the Jadad Scale, respectively. With respect to tympanoplasty, statistical analysis demonstrated that the endoscopic approach had significantly lower canalplasty rates, better cosmetic outcomes, and shorter operative times. Furthermore, endoscopic compared to microscopic methods were similar in terms of audiological outcome, graft success rate, and complication rate. Among stapes surgeries, the endoscopic approach demonstrated a significantly decreased incidence of postoperative pain and chorda tympani injury but was similar to the microscopic approach with respect to audiological outcome, postoperative dizziness, and operative time. CONCLUSIONS: Though the merits of endoscopic techniques are becoming more well known, there are still concerns regarding their efficacy and safety. An analysis of the current literature suggests that audiological, functional, and safety outcomes are similar, if not superior, for the endoscopic approach to both tympanoplasty and stapes surgery compared to the microscopic approach. With respect to tympanoplasty, patients undergoing the endoscopic approach had lower canalplasty rates, better cosmetic outcomes, and shorter operative times. Among stapes surgeries, patients in the endoscopic group had a lower incidence of postoperative pain and injury to the chorda tympani. This meta-analysis of the current evidence supports the use of endoscopic techniques for tympanoplasty and stapes surgery.

Management of an Unusual Intranasal Foreign Body Abutting the Cribriform Plate: A Case Report and Review of Literature.

A 35-year-old man with history of schizophrenia presented 3 weeks after placing a screw in his right nostril. Initial imaging showed a screw in the right ethmoid sinus with the tip penetrating the right cribriform plate. On exam, the patient was hemodynamically stable with purulent drainage in the right nasal cavity but no visible foreign body. While most nasal foreign bodies occur in children and are generally removed at the bedside, intranasal foreign bodies in adults tend to require further assessment. The foreign body in this case was concerning for skull base involvement and the patient was brought to the operating room (OR) with neurosurgery for endoscopic sinus surgery (ESS) and removal of foreign body. The screw was removed and the patient recovered with no signs of cerebrospinal fluid (CSF) leak postoperatively. Any concern for skull base or intracranial involvement should call for a full evaluation of the mechanism of injury and intervention in a controlled environment.

Transgender Voice and Communication.

Voice is a complex marker for gender and pivotal to the gender reassignment process. The goal of the transgender patient is to achieve a voice and communication style that is congruent with their gender identity. Voice and speech therapy are fundamental for successful transition. Phonosurgery, to adjust pitch, can be an important adjunct to relieve the patient from active pitch elevation of voice to free them to focus on the other adjustments needed and learned through behavioral training with speech and voice therapy. The authors review current management options for transgender patients with difficulties in voice and communication style.

Percutaneous versus surgical tracheostomy: timing, outcomes, and charges.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to compare timing of procedure, patient characteristics, outcomes, and charges for patients who underwent percutaneous versus surgical tracheostomy. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective analysis was performed for all patients who underwent tracheostomy in 2015 to 2016 in New York State. Patients were identified using International Classification of Diseases, 10th Revision, Clinical Modification codes and stratified to the type of tracheostomy performed. The primary outcome of interest was mortality at index stay. Secondary outcomes of interest included length of stay and total hospitalization charges. RESULTS: Of the 8,682 patients, 2,488 (28.7%) underwent percutaneous and 6,194 (71.3%) underwent surgical tracheostomy. At hospitals where both procedures were performed, percutaneous tracheostomy patients were older, had more comorbidities, and had lower income (P < .05). Timing of the tracheostomy relative to admission did not affect the type of tracheostomy performed. While controlling for patient characteristics and complications during the visit, percutaneous tracheostomy was associated with increased mortality (odds ratio [OR]: 1.17, 95% confidence interval [CI]: 1.03-1.33, P = .0153) and increased hospital charges (OR: + 7.76%, 95% CI: 5.4-10.11, P < .0001). Length of stay was not affected by procedure type. CONCLUSIONS: Surgical tracheostomies are more commonly performed than percutaneous tracheostomies across New York State. Older, lower-income, and sicker patients have a higher chance of receiving percutaneous tracheostomies. Percutaneous approaches were associated with statistically significant increased mortality and higher charges despite no difference in length of stay. Further studies are needed to determine if these differences in outcomes are clinically significant. LEVEL OF EVIDENCE: NA Laryngoscope, 128:2844-2851, 2018.

Postoperative pain management after sinus surgery: a survey of the American Rhinologic Society.

BACKGROUND: Postoperative pain management is controversial as there are no current guidelines to direct clinical practice. The purpose of this study was to demonstrate prescribing patterns for pain management after functional endoscopic sinus surgery (FESS). METHODS: A 15-item web-based survey was electronically distributed to 1770 members of the American Rhinologic Society (ARS). Linear regression analysis was used to determine associations between providers and prescribing patterns. RESULTS: The survey was completed by 168 members (9.49%), representing all regions of the United States. The most commonly prescribed medications were opioid/non-opioid combination pills. One hundred fifty-seven of 168 members (94.05%) prescribed at least one kind of opioid after FESS, with an average of 27.38 pills. The majority of surveyed members worked in private or academic settings. Academic physicians were less likely to prescribe ibuprofen (p = 0.0407), and nonsteroidal anti-inflammatory drugs (NSAIDs) in general (p = 0.032). Physicians in private practice were less likely to refer patients to pain management (p = 0.0117), but more likely to refer patients to nontraditional forms of pain management (p = 0.0164). Academic physicians were more likely to refer patients to pain management (p = 0.00121). There was no association between perception of pain control and the prescription of NSAIDs or with number of opioid pills prescribed. CONCLUSION: Most providers prescribed opioids after FESS. There was no significant difference in the number of opioids prescribed based on geography or practice setting. There was significant heterogeneity in the adjuvant pain management strategy between academic and private practitioners. Most members provided patient education and few reported poor pain control. However, there was a gap in understanding of appropriate medication disposal and evidence-based postoperative pain management.