Postoperative Opioid-Prescribing Practices in Nasal Surgery: A Prospective Study.

Importance: There has been a greater awareness of the opioid epidemic. Studies are needed to better characterize opioid usage after outpatient nasal surgery. Objective: Provide data to guide prescription management for nasal procedures and investigate opioid prescription and subsequent consumption, with the aim of offering analysis to build evidence-based guidelines for postoperative pain management. Design, Setting, and Participants: In this prospective single-center study, morphine milligram equivalents (MME) consumption and pain scores were collected in 69 patients who underwent nasal surgery. Main Measures and Outcomes: Patient demographics, MME use, and pain scores were examined. MME use was compared with patient demographics, surgical procedure type, and postoperative pain scores. Results: In total, 3302 MME were prescribed: 2012 MME (61%) were used, leaving 1290 MME (39%). Patients were prescribed a total average of 47.8 ± 24.0 MME. Four (6%) patients required a second prescription. History of opioid use, benzodiazepine use, and obesity were negative predictors of opioid consumption (p ≤ 0.001). Conclusion and Relevance: Assessing opioid consumption for nasal procedures will guide prescribing practices. Our results indicate that prescription practices can likely be down titrated in patients with a history of certain medication consumption.

Maxillectomy Reconstruction Revision Using Virtual Surgical Planning and Intraoperative Navigation.

Secondary revision of osseous flap reconstructions of the maxilla can enhance facial symmetry, but can be challenging due to the absence of normal anatomy and landmarks. We report four cases of maxillectomy reconstruction with scapula tip flap employing a novel combined approach with preoperative virtual surgical planning (VSP) and intraoperative navigation (ION) for secondary revision. VSP was employed to superimpose mirrored normal anatomy upon the reconstructed anatomy, and ION used for real-time intraoperative anatomical mapping. VSP and ION can be used to optimize maxillary bony revisions and recontouring, thereby improving anatomic symmetry and funtionality. Laryngoscope, 131:E2655-E2659, 2021.

Design and Printing of a Low-Cost 3D-Printed Nasal Osteotomy Training Model: Development and Feasibility Study.

BACKGROUND: Nasal osteotomy is a commonly performed procedure during rhinoplasty for both functional and cosmetic reasons. Teaching and learning this procedure proves difficult due to the reliance on nuanced tactile feedback. For surgical simulation, trainees are traditionally limited to cadaveric bones, which can be costly and difficult to obtain. OBJECTIVE: This study aimed to design and print a low-cost midface model for nasal osteotomy simulation. METHODS: A 3D reconstruction of the midface was modified using the free open-source design software Meshmixer (Autodesk Inc). The pyriform aperture was smoothed, and support rods were added to hold the fragments generated from the simulation in place. Several models with various infill densities were printed using a desktop 3D printer to determine which model best mimicked human facial bone. RESULTS: A midface simulation set was designed using a desktop 3D printer, polylactic acid filament, and easily accessible tools. A nasal osteotomy procedure was successfully simulated using the model. CONCLUSIONS: 3D printing is a low-cost, accessible technology that can be used to create simulation models. With growing restrictions on trainee duty hours, the simulation set can be used by programs to augment surgical training.

Mutation signature analysis identifies increased mutation caused by tobacco smoke associated DNA adducts in larynx squamous cell carcinoma compared with oral cavity and oropharynx.

Squamous cell carcinomas of the head and neck (HNSCC) arise from mucosal keratinocytes of the upper aero-digestive tract. Despite a common cell of origin and similar driver-gene mutations which divert cell fate from differentiation to proliferation, HNSCC are considered a heterogeneous group of tumors categorized by site of origin within the aero-digestive mucosa, and the presence or absence of HPV infection. Tobacco use is a major driver of carcinogenesis in HNSCC and is a poor prognosticator that has previously been associated with poor immune cell infiltration and higher mutation numbers. Here, we study patterns of mutations in HNSCC that are derived from the specific nucleotide changes and their surrounding nucleotide context (also known as mutation signatures). We identify that mutations linked to DNA adducts associated with tobacco smoke exposure are predominantly found in the larynx. Presence of this class of mutation, termed COSMIC signature 4, is responsible for the increased burden of mutation in this anatomical sub-site. In addition, we show that another mutation pattern, COSMIC signature 5, is positively associated with age in HNSCC from non-smokers and that larynx SCC from non-smokers have a greater number of signature 5 mutations compared with other HNSCC sub-sites. Immunohistochemistry demonstrates a significantly lower Ki-67 proliferation index in size matched larynx SCC compared with oral cavity SCC and oropharynx SCC. Collectively, these observations support a model where larynx SCC are characterized by slower growth and increased susceptibility to mutations from tobacco carcinogen DNA adducts.

Should All Status 1A Patients Be Prioritized Over High MELD Patients? Concept of Risk Stratification in Extremely Ill Liver Transplant Recipients.

BACKGROUND: Status 1A patients are prioritized over liver disease patients regardless of Model for End-stage Liver Disease (MELD) score. We aimed to identify groups with high waitlist mortality in Status 1A and MELD ≥40 patients to determine who would most benefit from transplantation. METHODS: Data on patients listed as Status 1A (n = 4447) and MELD ≥40 (n = 3663) over 15 years (2002-2017) was obtained from United Network for Organ Sharing/Organ Procurement and Transplant Network registry. They were divided into 2-derivation and validation groups. Risk factors associated with 28-day waitlist mortality were identified in derivation group and provided risk scores to divide patients into risk groups. Score system was applied to validation group to check its applicability. RESULTS: Risk factors for waitlist mortality in Status 1A included life support, performance status, severe coagulopathy, severe hypo or hypernatremia, and grade 3-4 encephalopathy. Risk factors in MELD ≥40 included higher MELD scores (≥45), age, sex, race, life support, and encephalopathy. On comparing 7- and 28-day mortality, both were higher in Status 1A and MELD ≥40 high-risk groups compared with low-risk groups in the derivation group (P < 0.001). Probability of transplantation was lowest for high-risk MELD ≥40 patients compared with all other groups (P < 0.001). These findings were reproduced in the validation set. Our proposed risk stratification system also showed acceptable 1-year graft and patient survival in high-risk groups. CONCLUSIONS: Our risk scoring system for extremely ill liver transplant candidates successfully stratified risk of waitlist mortality. Waitlist outcomes might be improved by modifications involving categorization of patients based on the presence/absence of risk factors.