Facial Soft Tissue Injuries in Pediatric Patients.

Soft tissue injuries of the head and neck are a common reason for medical evaluation and treatment in pediatric populations with some unique and important considerations when compared with adults. The incidence and type of injuries continue to evolve with the adoption of new safety measures, technology advancements, and education of the general population. The goal of this article is to provide the reader with a thorough understanding of the evaluation and management of pediatric soft tissue trauma including the initial workup, physical examination, appropriateness of antimicrobial therapy, and setting for surgical repair. Additionally, the pediatric anesthetic considerations for evaluation and repair in regard to local anesthesia, sedation, and general anesthesia are described in detail. There is a focus on dog bites, perinatal injuries, and child abuse as these entities are distinctive to a pediatric population and have particular management recommendations. Lastly, application of the reconstructive ladder as it applies to children is supported with specific case examples and figures. Although there are many parallels to the management of soft tissue injury in adults, we will highlight the special situations that occur in pediatric populations, which are imperative for the facial plastic and reconstructive surgeon to understand.

Patterns of Orofacial Clefting in New York City From 1983 to 2010: Trends by Racial Background, Birthplace, and Public Health Strategies.

OBJECTIVE: To determine the role of racial background, public health initiatives, and residence on the prevalence of orofacial clefts (OFCs) in New York City (NYC). DESIGN/METHODS: Retrospective review of OFC cases from the New York State Congenital Malformations Registry. PATIENTS/PARTICIPANTS: Patients born with an OFC and all live births to mothers residing in NYC between 1983 and 2010. MAIN OUTCOME MEASURES: Orofacial cleft birth prevalence by cleft type, race, and borough of maternal residence for each year and by time period around the implementation of public health interventions including folate supplementation. RESULTS: A total of 3557 cases were reviewed. The prevalence remained stable for cleft palate and cleft lip with or without cleft palate (CL ± P) in sequential time periods of the study. Among CL ± P cases, cleft lip prevalence decreased early in the study compared to increases in cleft lip and palate prevalence. For most years, the prevalence of OFCs was lower among African Americans than whites. A total of 12% to 26% of mothers in 4 of the NYC boroughs deliver outside of their borough of residence, choosing to give birth in Manhattan most often. No difference in OFC prevalence was shown in any of the 5 NYC boroughs. CONCLUSIONS: The period prevalence remained relatively stable during the time periods before and after the implementation of folate supplementation for OFCs in NYC. Prevalence of OFC subtypes was lower for most time periods during this study among African Americans compared to whites. Several factors may explain the choice of birthplace outside of the mother's borough of residence.

Nasal Surgery in the Younger Patient.

Nasal surgery can be carried out safely in the younger patient. In cases of trauma, it is recommended that corrective surgery be carried out in a short time frame before scar contracture, aberrant remodeling, and malunion of structures occurs. In the less common situation of performing cosmetic surgery on the younger patient there are several principles and guidelines to be considered.

Nasal Lining Reconstruction with Loco-regional Flaps.

The reliability of local intranasal flaps speaks to the robust vascularity of the nose, which these flaps are based on. The goals for lining replacement, as in any other area of head and neck reconstruction, is to use tissue that best matches the qualities of what is being replaced. The goal of this review is to describe the extent to which local tissues can be used and when to consider regional flaps when the extent of a local flap will not provide enough coverage.

Ear Molding in Children-Timing, Technique, and Follow-up: A Systematic Review.

Background: Nonsurgical management of congenital ear anomalies using molding devices shows efficacy but lacks standardization of treatment protocols and outcome measures. Learning Objective: To compare ear molding techniques and identify factors related to treatment outcomes. Design Type: Systematic review of the literature (1990-2021). Methods: Studies reporting molding for congenital ear anomalies were assessed. PRISMA guidelines were used. Data extracted included: age at treatment initiation, treatment duration, correction rates, and complications. Data analysis included descriptive statistics and outcomes were compared using the Student t-test. Results: In total, 37 studies with 3,341 patients (mean patients per study, 95; range, 5-488) were included. Infants in whom treatment was initiated at 4.8 weeks (median, 3.7; range, 0.9-8.8 weeks) were treated for 5.1 weeks (median 4.7, range 2.6-7.6 weeks) with 11.0 months follow-up (median 11.4, range 1.4-21.0 months). Individualized devices (physician-customized) were used more (62.2% of studies) than commercial devices. No difference in correction (p = 0.44) or complication rates (p = 0.19) was identified between devices. Totally, 70.3% of studies reported complications and 40.5% of studies included long-term follow-up data. Conclusions: The available evidence supports initiating ear molding in the first weeks of life to be most effective, yet outcome data should be standardized in future studies to improve evidence quality.

Reporting nasal pressure injuries in neonates receiving non-invasive ventilation: a scoping review.

BACKGROUND/OBJECTIVES: Although neonates receiving Non-Invasive Ventilation (NIV) for respiratory support are at risk for nasal pressure injuries, efforts to standardize reporting are limited. A scoping review was conducted to identify the reporting systems used for describing these injuries. SUBJECTS/METHODS: PubMed, Embase, and Web of Science were queried for papers reporting nasal injury with NIV usage in neonates. The primary outcome was reporting system usage. RESULTS: 705 titles and abstracts were screened. 40 papers met inclusion criteria. Most studies were Randomized Clinical Trials (37.5%) or cohort studies (37.5%). Most commonly, nasal injuries were reported using a unique, descriptive scale developed by the authors (10 studies, 25%). The Fischer et al 2010 scale, a three-stage reporting system, was used in 8 studies (20%). While 15 studies (38.0%) reported on specific anatomic subsite injury, only 2 studies (5.0%) employed endoscopy for assessment. CONCLUSIONS: Wide heterogeneity in pressure injury reporting secondary to NIV exists across specialties, institutions, and literature.

Perioperative Management of Patients with Craniomaxillofacial Trauma.

Successful surgical management of patients with facial fractures requires a detailed preoperative evaluation and postoperative management that differs from elective surgical patients. This review presents evidence-based recommendations from the surgical and anesthesiology literature that address many of the clinical questions that arise during the perioperative management of this group of patients. Surgeons and anesthesiologists must work together at numerous points and make joint decisions, especially where airway and pain management challenges may arise. The multidisciplinary nature of the decision-making process is emphasized.

Traumatic Injuries of the Parotid Gland and Duct.

This review will focus on the key steps in the recognition of parotid gland and duct injuries focusing on the important steps needed at the initial assessment. Management planning is presented in the way that trauma surgeons interact with patients, highlighting the important parts of the informed consent conversation followed by the key information that must be communicated to the anesthesia and operating room teams, which ensures proper monitoring and equipment needs are in place. Short-term and long-term outcomes for patients with persistent sequelae of the trauma and their management are reviewed.

Excision of forehead and malar lesions using endoscopic techniques.

The use of endoscopes via limited incisions to access areas of the forehead and cheek has allowed facial rejuvenation procedures to be performed in a way that minimizes some of the morbidities associated with more traditional approaches. The possibility of expanding the indications for these approaches arises when endoscopic, minimally invasive techniques can be applied to the excision of lesions of the upper part of the face and the midface. Such methods offer several advantages without compromising therapeutic outcome. The specific techniques used will be illustrated as they were applied in several cases.

Mandibular Condylar Fractures.

Mandibular condyle fractures can result in short-term and long-term morbidity. As a weak area of the mandible, the condyle is vulnerable to injury by a direct impact or an indirect force. Current treatment recommendations aim to better match the severity of the fracture with the choice of closed or open approach. Long-term follow-up of patients provides the best opportunity to monitor the degree of functional restoration after treatment. There is a growing consensus regarding the use of standardized fracture classification methods and outcomes measures that will allow better assessment of treatment results and strengthen the quality of outcomes research.

Perceptual Assessment of Velopharyngeal Dysfunction by Otolaryngology Residents.

OBJECTIVE: To assess the ability of otolaryngology residents to rate the hypernasal resonance of patients with velopharyngeal dysfunction. We hypothesize that experience (postgraduate year [PGY] level) and training will result in improved ratings of speech samples. STUDY DESIGN: Prospective cohort study. SETTING: Otolaryngology training programs at 2 academic medical centers. SUBJECTS AND METHODS: Thirty otolaryngology residents (PGY 1-5) were enrolled in the study. All residents rated 30 speech samples at 2 separate times. Half the residents completed a training module between the rating exercises, with the other half serving as a control group. Percentage agreement with the expert rating of each speech sample and intrarater reliability were calculated for each resident. Analysis of covariance was used to model accuracy at session 2. RESULTS: The median percentage agreement at session 1 was 53.3% for all residents. At the second session, the median scores were 53.3% for the control group and 60% for the training group, but this difference was not statistically significant. Intrarater reliability was moderate for both groups. Residents were more accurate in their ratings of normal and severely hypernasal speech. There was no correlation between rating accuracy and PGY level. Score at session 1 positively correlated with score at session 2. CONCLUSION: Perceptual training of otolaryngology residents has the potential to improve their ratings of hypernasal speech. Length of time in residency may not be best predictor of perceptual skill. Training modalities incorporating practice with hypernasal speech samples could improve rater skills and should be studied more extensively.

Velo-cardio-facial syndrome: the pediatric otolaryngologist's perspective.

PURPOSE OF REVIEW: The understanding of velo-cardio-facial syndrome has grown markedly since the initial descriptions of this common genetic disorder nearly 30 years ago. Our knowledge of the syndrome has advanced in part from opportunities to monitor many patients into adulthood because of advances in the fields of cardiothoracic surgery and immunology. Longitudinal study has brought to light psychiatric and behavioral features of the syndrome that are often not apparent until late adolescence or the early adult years. Certain endocrine and immunologic features of the syndrome thought to be resolved in childhood are now witnessed in older patients. Variable expression and lack of disease awareness are two major factors that contribute to the delays in diagnosis in many cases. To address this, there has been a call to delineate screening parameters for patients at risk of carrying the deletion. RECENT FINDINGS: Several areas are highlighted in this review, reflecting the focus of scholarly work on velo-cardio-facial syndrome in the past year. Molecular genetics has shown smaller deletions in many families with the syndrome. The gene TBX1 has been found to be important to the phenotype. Surgical outcomes data reveal the greater challenges involved in correcting velopharyngeal insufficiency. SUMMARY: Defining the genetic basis of velo-cardio-facial syndrome will allow clinicians and basic scientists to make further inroads into understanding the variable expressivity of this syndrome. It is also important to be aware of the continued diagnostic challenges encountered by clinicians in attempts to improve the detection of patients with this syndrome.

Reporting of Postoperative Pain Management Protocols in Randomized Clinical Trials of Mandibular Fracture Repair: A Systematic Review.

IMPORTANCE: The control of pain associated with mandibular fractures is an important treatment outcome that affects function, adherence to treatment regimens, and patient comfort and satisfaction. OBJECTIVE: To explore the pain management protocols reported in studies of mandibular fractures, including the reporting of quality-of-life measures. EVIDENCE REVIEW: PubMed/MEDLINE, EMBASE, Cochrane CENTRAL, and clinicaltrials.gov were searched for randomized clinical trials published from 1970 to July 2014. We followed PRISMA reporting standards to assess study eligibility and extract data. Studies of patients older than 16 years who underwent operative mandibular fracture management were included. The primary data collected included the type of analgesic prescribed, associated adverse effects of the analgesic, method of pain assessment, and use of quality-of-life measures. A pain attentiveness score was assigned to studies based on the comprehensiveness of the information reported. Several variables were reviewed to determine the factors that predict reporting of pain-related data. Assessments of risk for bias were performed using the Cochrane Collaboration's domain-based evaluation method. FINDINGS: The initial search identified 111 articles, of which 38 met inclusion criteria. Among the 38 reviewed articles, there were 38 trials and 1808 unique patients represented. Among the 38 articles, the procedures reported included maxillomandibular fixation only in 6 (16%), open reduction with internal fixation only in 20 (53%), and both in 12 (32%). Specific analgesics prescribed were reported in only 5 of the 38 studies (13%), and 3 of these used a combination of nonsteroidal anti-inflammatory drugs and acetaminophen (paracetamol). Thirteen studies (34%) reported pain assessments and 5 (13%) included quality-of-life measures. Geographic region was the only variable that predicted pain attentiveness, with studies from Europe (3 of 11 studies [27%]) and Asia (6 of 16 studies [38%]) most likely to have a high pain attentiveness score. A low rating was least common in the United States (2 of 5 studies [40%]) (P = .047, Fisher exact test). Most of the studies had unclear (n = 27) or high (n = 6) risks for bias in the key domains assessed. CONCLUSIONS AND RELEVANCE: Pain management is a neglected outcome in randomized clinical trials of mandibular trauma; most studies did not describe the specific analgesics used. Many randomized clinical trials (13 [34%]) assessed pain levels among patients without providing information about the agents prescribed. The incorporation of validated pain measures and quality-of-life scores in future studies of mandibular trauma would focus attention on this key outcome measure.

Update on mandibular distraction osteogenesis.

PURPOSE OF REVIEW: Mandibular distraction osteogenesis has become one of the most powerful reconstructive tools for addressing congenital lower jaw deformities. This review will focus on clinical and basic science contributions to the literature in the last year, which have shown innovations in mandibular distraction osteogenesis techniques and advances in outcomes. RECENT FINDINGS: The longest phase of distraction is consolidation, when newly formed bone must fully heal. If consolidation could be accelerated, the length of time required for fixation would be less and complications associated with fixation devices would decline. In the last year, animal studies were conducted reporting the application of growth factors directly to distraction gaps to accelerate bone formation. Additional research in animal models showed success with the addition of bone marrow-derived mesenchymal stem cells to the distraction gap. Distraction devices are being piloted with automated, continuous formats compared with current devices that require manual activation. The use of surgical planning software programs to determine the location of osteotomies was another focus of current studies. SUMMARY: Rates of activation can be accelerated with the addition of stem cells and growth factors to distraction sites, as could time to full consolidation. The addition of mesenchymal stem cells and deferoxamine and the use of low-intensity ultrasound during distraction are three of the most promising approaches reported in recent studies with potential for future translation from animal models. Computer-assisted presurgical planning offers added accuracy and potential time savings. Newer distraction devices using computer automation are still in preliminary phases, but show promise.

Starting a cleft team: a primer.

Facial plastic surgeons have a comprehensive understanding of the challenges that patients with cleft lip and palate encounter in form and function. Because there are areas in the United States where access to cleft care is limited, opportunities exist for facial plastic surgeons to develop cleft teams to provide greater availability of services to patients. A consensus statement has been developed by the Cleft and Craniofacial Subcommittee of the Specialty Surgery Committee of the American Academy of Facial Plastic and Reconstructive Surgery that outlines strategies for facial plastic surgeons who are prepared to assume leadership roles in domestic multidisciplinary cleft team initiatives.