COVID-19 impact on facial trauma: Insights from Mississippi's only level 1 trauma center.

PURPOSE: Our primary aim was to understand and describe the impact of COVID-19 on the incidence and etiology of facial trauma in the state of Mississippi. METHODS: Retrospective review of facial trauma-related Emergency Department encounters in Mississippi from March 11, 2019 to March 10, 2021, divided into three time periods using the state of Mississippi's Governor's Office Executive Orders. Chi-square tests and segmented linear regressions were used for analysis. RESULTS: Patients presenting with facial trauma were typically male, 18-44 years old, and lived in urban zip codes. Insurance payors significantly differed across time periods. There were no significant differences in self-inflicted assault or accidental injury between the 3 time periods, with pre- and pandemic patients more likely to be self-pay while patients during recovery being more likely to have private insurance. During the pandemic, facial trauma from a family member, partner or spouse, or other person in the household significantly increased. CONCLUSION: Similar accidental facial trauma trends may reflect lower adherence to social distancing guidelines. The increase in facial trauma perpetrated by family members is consistent with reported increases in domestic violence during the pandemic. While overall facial trauma demographic patterns did not change significantly during the COVID-19 pandemic, there were notable changes in the etiology and insurance payor of facial trauma cases. LAY SUMMARY: The COVID-19 pandemic impacted healthcare systems worldwide, and our study seeks to understand how the pandemic affected incidence of facial trauma.

Rapidly Progressive Complicated Acute Bacterial Sinusitis in the Setting of Severe Pediatric SARS-CoV-2 Infection.

OBJECTIVE: This case report presents a case of a rapidly progressive complicated sinus infection in a child with the multisystem inflammatory syndrome in children. METHODS: Case report with literature review. RESULTS/CASE REPORT: We present a novel case of severe rapidly progressive complicated sinusitis in a 14-year-old African American male diagnosed with the multisystem inflammatory syndrome in children. Infection was caused by an aggressive pathogen, Streptococcus intermedius (anginosus), and within 48 hours progressed to orbital, subgaleal, and intracranial abscess, requiring multidisciplinary intervention by ophthalmology, neurosurgery, and otolaryngology. Following surgical intervention and a 4-week course of intravenous antibiotic therapy, the patient had resolution of the infection with no neurologic sequelae. CONCLUSION: Despite the low incidence of multisystem inflammatory syndrome in children, physicians should be aware that immunologic changes and the cytokine storm induced by severe acute respiratory syndrome coronavirus 2 can potentially predispose patients to severe bacterial or opportunistic infections. As more cases of MIS-C develop, associated complications can become evident. Similar cases of SARS-CoV-2 and severe bacterial sinusitis have been published in the literature, but it remains unclear if there is an association between SARS-CoV-2 disease and an increased risk of complicated sinusitis in children.

The effect of continuous positive airway pressure therapy on nasal patency.

BACKGROUND: Nasal congestion and obstruction are reported in the majority of continuous positive airway pressure (CPAP) users and are frequently cited as reasons for noncompliance. To our knowledge, no study has demonstrated a change in objective or subjective nasal patency in patients with obstructive sleep apnea (OSA) after a therapeutic trial of CPAP therapy. METHODS: This prospective nonrandomized trial tested the hypothesis that CPAP therapy would result in both objective and subjective improvements in nasal patency in patients with OSA. Prior to initiation of CPAP, acoustic rhinometry (AR) was used to determine nasal volume and minimum cross-sectional area in the upright and reclined positions. Subjective nasal patency was assessed with the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire. Both assessments were repeated at follow-up visits. RESULTS: AR data demonstrated a statistically significant increase in total nasal volume (TV) in the reclined position (p = 0.002) and minimum cross-sectional area (MCA) in both the sitting and reclined positions (p = 0.006, p = 0.021) in OSA patients after >30 days of CPAP therapy and with >70% compliance. NOSE scores decreased significantly (p = 0.038) representing an improvement in nasal patency. CONCLUSION: Objective and subjective measurements of TV and MCA increased after initiation of CPAP therapy in this prospective study.

Iatrogenic pneumothorax during hypoglossal nerve stimulator implantation.

Hypoglossal nerve stimulation is a promising new treatment for patients with obstructive sleep apnea. In the initial Stimulation Therapy for Apnea Reduction Trial, the overall rate of serious adverse events was <2% and no cases of pneumothorax were reported. We present the case of an iatrogenic pneumothorax during placement of the chest sensor lead between the intercostal muscles. Following clinical and radiological evaluation, surgery was continued and the patient was treated expectantly. In the following review, we discuss pathophysiology, diagnosis, and expected outcomes. Surgeons placing hypoglossal nerve stimulators should be aware of complications and prepared to manage a pneumothorax.

A cost-effectiveness analysis of the up-front use of balloon catheter dilation in the treatment of pediatric chronic rhinosinusitis.

BACKGROUND: The treatment of pediatric sinusitis continues to be a controversial topic. It has been recommended to treat pediatric chronic rhinosinusitis (CRS) with adenoidectomy before proceeding to more invasive techniques. There are concerns regarding side effects of endoscopic sinus surgery in pediatric patients. With the advent of balloon catheter dilation (BCD) as a minimally invasive technique, some authors are recommending up front adenoidectomy with BCD in order to maximize disease resolution while minimizing risk. PURPOSE: Our study examines the cost effectiveness of adenoidectomy alone versus adenoidectomy and upfront BCD for the management of pediatric CRS. METHODS: A decision tree analysis was created to determine the cost effectiveness of treating a pediatric patient who has failed medical management, using adenoidectomy versus adenoidectomy with up-front BCD. Three separate decision trees were made. The incremental cost effectiveness ratio (ICER) was calculated for each scenario and a sensitivity analysis was done to determine how different values impacted our results. RESULTS: Adenoidectomy as the sole first procedure was found to be more cost effective in all three decision trees. For tree 1, the adenoidectomy plus BCD arm was 0.03% more effective in the end, but with an $81, 431 incremental cost. CONCLUSIONS: Costs in addition to outcomes must be considered when comparing treatment modalities in our current health care environment. This study found that adenoidectomy as a first intervention before proceeding to more advanced techniques is nearly as effective and is a much more cost-effective algorithm for the treatment of pediatric CRS. However, the physician must advocate the best treatment for his or her own patients.

Resident fatigue in otolaryngology residents: a Web based survey.

IMPORTANCE: Resident fatigue has become a point of emphasis in medical education and its effects on otolaryngology residents and their patients require further study. OBJECTIVE: The purpose of our study was to evaluate the prevalence and nature of fatigue in otolaryngology residents, evaluate various quality of life measures, and investigate associations of increased fatigue with resident safety. STUDY DESIGN: Anonymous survey. SETTING: Internet based. PARTICIPANTS: United States allopathic otolaryngology residents. INTERVENTION: None. MAIN OUTCOME(S) AND MEASURES: The survey topics included demographics, residency structure, sleep habits and perceived stress. Responses were correlated with a concurrent Epworth Sleep Scale questionnaire to evaluate effects of fatigue on resident training and quality of life. RESULTS: 190 residents responded to the survey with 178 completing the Epworth Sleep Scale questionnaire. Results revealed a mean Epworth Sleep Scale score of 9.9±5.1 with a median of 10.0 indicating a significant number of otolaryngology residents are excessively sleepy. Statistically significant correlations between Epworth Sleep Scale and sex, region, hours of sleep, and work hours were found. Residents taking in-house call had significantly fewer hours of sleep compared to home call (p=0.01). Residents on "head and neck" (typically consisting of a large proportion of head and neck oncologic surgery) rotations tended to have higher Epworth Sleep Scale and had significantly fewer hours of sleep (p=.003) and greater work hours (p<.001). Additionally, residents who reported no needle stick type incidents or near motor vehicle accidents had significantly lower mean Epworth Sleep Scale scores. Only 37.6% of respondents approve of the most recent Accreditation Council for Graduate Medical Education work hour restrictions and 14% reported averaging greater than 80hours of work/week. CONCLUSION AND RELEVANCE: A substantial number of otolaryngology residents are excessively sleepy. Our data suggest that the effects of fatigue play a role in resident well-being and resident safety.

Congenital bilateral vocal fold paralysis and Charcot-Marie-Tooth disease.

We present the case of a patient with Charcot-Marie-Tooth disease (CMT) type 1 with congenital bilateral vocal fold paralysis in order to emphasize the treatment options and long-term outcome. The case is reviewed with regard to presentation, differential diagnosis, and treatment. We also reviewed the literature to determine the frequency of congenital and childhood presentations of bilateral vocal fold paralysis associated with CMT, most specifically CMT type 1. We found only 14 children reported to have bilateral vocal fold paralysis associated with CMT, and only 1 of these cases was associated with CMT type 1. None of these patients had congenital vocal fold paralysis. Because of the degenerative nature of the disease, our patient underwent endoscopic cordotomy to avoid tracheotomy. We conclude that CMT should be included in the differential diagnosis in evaluating neonates with bilateral vocal fold paralysis. If CMT is definitively diagnosed, it could alter the course of treatment.

Comparison of pull out strength of resorbable screws in human cadaveric laryngeal cartilage using different drill diameters.

BACKGROUND: In a previous study at our institution, it was determined that resorbable screws with untapped drill holes resulted in the highest resistance forces to linear load when compared with titanium screws. The 1.1-mm drill diameter/2.0-mm screw diameter and 1.5/2.0 drill/screw combinations were superior to the 1.1/1.5 combinations; however, there was no conclusion as to the best screw size to drill bit diameter. The aim of this prospective study was to compare the pull out strength of resorbable screws in fresh frozen cadaveric laryngeal cartilage. The importance of drill hole diameter will also be determined. METHODS: After debridement of connective tissue and perichondrium, 12 cartilage specimens were tested. Linear pull out strength of screws was measured using a load cell. Resorbable screws of size 2.0 mm were tested using drill hole diameters of 0.0 mm, 0.8 mm, and 1.5 mm. All tested screws were 6 mm in length or greater. RESULTS: We found no strong evidence that the means for the 0.8/2.0 and 1.5/2.0 differ or that the 0.0/2.0 and 0.8/2.0 means differ. There is evidence that the 0.0/2.0 and 1.5/2.0 means differ (adjusted p value .0108), with the 0.0/2.0 combination having a smaller mean. CONCLUSIONS: Resorbable screws without pre drilled holes result in less resistance to linear loads than either the resorbable screws with the 0.8/2.0 or the 1.5/2.0 drill/screw combinations. The 1.5/2.0 drill/screw combination had the strongest pull out force, though this was not statistically significant.

Postoperative carotid spasm in the setting of head and neck surgery.

Delayed arterial spasm is a clinical and angiographic condition frequently observed after subarachnoid hemorrhage. It has long been associated with a local myogenic reaction to prolonged arterial contact with fresh blood. Carotid spasm from direct manipulation of the petrous carotid during skull base procedures is also a rare but known response to longitudinal arterial traction. Uncomplicated cervical cases, although subject to similar conditions of arterial manipulation, have less commonly been associated with arterial spasm. Two cases of severe internal carotid spasm leading to stroke in patients undergoing removal of glomus tumors are presented to emphasize carotid spasm as a potential complication in head and neck surgery. The perioperative guidelines to prevent, recognize, and treat this complication are also reviewed as outlined in the literature.

Diagnostic evaluation of inhalant allergies: a cost-effectiveness analysis.

BACKGROUND: The purpose of this study was to compare the cost-effectiveness of modified quantitative testing (MQT), intradermal dilutional testing (IDT), and in vitro allergy testing as diagnostic methods used in the management of patients with suspected IgE-mediated inhalant allergies. METHODS: A systematic review was conducted to determine key statistics for analysis, such as prevalence of disease, and sensitivity and specificity of each diagnostic modality. Costs were calculated based on charges from distribution companies to providers. A deterministic cost-effectiveness analysis then was conducted using a decision tree model to evaluate the various diagnostic strategies. After identifying results at baseline, we performed a sensitivity and threshold analysis to assess the strength of recommendations. RESULTS: At an allergic rhinitis prevalence of 20%, MQT dominated IDT and in vitro testing, with 85 people correctly diagnosed at a baseline total cost of $6630 for the 100 patients tested. Although in vitro testing had the highest effectiveness, it had an incremental cost-effectiveness ratio of $3185. The results were sensitive to changes in the prevalence, costs, and sensitivities and specificities of the different modalities. CONCLUSION: The prevalence of allergic rhinitis is high and rising according to many studies, leading to a growing population of patients requiring allergy testing. Not only does today's medical community want effective health interventions, but also there is pressure to make health care cost efficient. This study looks at the cost-effectiveness of various diagnostic allergy tests. In our model, we found MQT to be the most cost-effective method of diagnosing allergic disease.

Synchronous reconstruction of the floor of mouth and chin with a single skin island fibular free flap.

OBJECTIVES: The goal this presentation is to: 1) Review the reconstructive options for anterior mandible through-and-through composite defects and 2) Instruct the audience in the application of the double-skin paddle fibular flap in selected patients. METHODS: Case presentation with review of the literature. RESULTS: A 70-year old male with an anterior floor of mouth squamous cell carcinoma underwent composite resection that included resection of a 5-cm ovoid component of overlying chin skin. The defect was reconstructed with a fibular osteocutaneous flap with a double skin paddle technique. CONCLUSIONS: Several reconstructive options have been described in the literature for extended oral cavity defects including the use of multiple free flaps, combinations of regional and distant flaps, and sequential reconstruction. This case report reviews the use of a single flap reconstruction of these defects for selected patients.