Management of Traumatic Nasal Avulsion Injuries

Soft tissue injuries to the midface (and nose) are common causes for seeking trauma care. As trauma patients, observing advanced trauma life support protocols is warranted given the risk of concomitant injuries. Here, options for optimizing tissue preservation, microvascular replantation, non-microvascular tissue replacement, and wound stabilization are discussed. Included in this discussion are data-driven predictors for successful replantation as well as technique descriptions with anatomic references to guide surgeons in choosing optimal donor vessels. In both partial and complete avulsion injuries, venous congestion is common. Several postoperative wound care protocols to maximize tissue perfusion and long-term viability are discussed.

Tenants of Mandibular Reconstruction in Segmental Defects

The premises of mandibular reconstruction are the restoration of occlusion and mandibular contour for the purpose of preserving the facial identity, oral airway, and effective speech and mastication. Establishing functional occlusion is the primary tenant in all mandibular reconstruction. In cases of segmental defects, particularly in dentate regions of the mandible, there has been a paradigm shift over the past two decades in how surgeons are approaching the restoration of load-bearing mandibular continuity with capacity for dental implantation. Here we discuss considerations for deciding the most effective method of reconstruction in segmental defects.

Complications Following Orbital Floor Repair: Impact of Intraoperative Computed Tomography Scan and Implant Material

Importance: Orbital floor fracture repair is complex and postoperative complications are common. A variety of applicable surgical techniques and technologies are available to surgeons, so data about which of these may decrease postoperative complication rates can help better guide clinical decision making. Objectives: To characterize the patient demographics and surgical techniques utilized in orbital floor fracture repairs at San Antonio Military Medical Center and their relationship with rates of postoperative complications. Design, Setting, and Participants: Retrospective chart review of patients who underwent orbital floor fracture repairs from March 2014 to March 2019 with a mean follow-up time of 1.86 months at a tertiary care academic military hospital and level 1 trauma center. Main Outcomes and Measures: Demographic data, indication for surgical repair, fracture severity, orbital floor approach, implant material, and use of intraoperative computed tomography (CT) scan were recorded. Chi-square analysis was performed to determine the relationship between these factors and postoperative diplopia, hypoglobus, enophthalmos, and infection. Results: A total of 124 procedures were performed during the study period: 71.8% of patients were male and 74% were civilian. Mean age was 39 years (range 19-81). Thirty-one patients were lost to follow-up. The most common approach was transconjunctival (83%), which was most frequently used exclusively (68.5%), but was also combined with cantholysis, transcaruncular, or transantral approach. Postoperative diplopia at follow-up was common (53.8%), resolved after an average of 36.3 days, and was significantly associated with surgical indication of entrapment or revision (p = 0.01) and nonutilization of intraoperative CT (p = 0.04). From 2014 to 2016, intraoperative CT was utilized in 21% of cases and revision rate was 10.5%. From 2017 to 2019, 50% of cases utilized intraoperative CT and revision rate was 2% (p = 0.15). Three cases were revisions performed for abnormal plate position noted on postoperative CT scan. Conclusions and Relevance: A statistically significant association was found between postoperative diplopia, surgical indication of entrapment or revision, and nonutilization of intraoperative CT. Revision rates decreased when use of intraoperative CT increased. Three revision cases may have been prevented by use of an intraoperative CT scan. Patients with entrapment should be counseled regarding the increased risk of postoperative diplopia.

Postoperative Nasal Septal Abscess Following Use of 2-Octylcyanoacrylate and Polydioxanone Plate in Open Septorhinoplasty: A Case Series

BACKGROUND

The employment of 2-octylcyanoacrylate adhesive (Dermabond) to assist graft placement in open septorhinoplasty has been increasingly used to stabilize cartilage grafts. Literature regarding this application has been mixed, with some showing the possibility of increased rates of inflammation, if not infection. We present an original comparative case series involving postoperative septal abscess formation adjacent to caudal strut grafting where both Dermabond and an absorbable polydioxanone (PDS) plate were used.

OBJECTIVE

To report an original comparative case series of patients who developed a postoperative septal abscess following open septorhinoplasty in the context of Dermabond application to affix cartilage to a PDS plate to facilitate caudal septal strut grafting.

DESIGN

Retrospective comparative series with relevant clinical photographs, culture studies, and surgical figures.

SETTING

Tertiary medical treatment facility.

RESULTS

Two patients underwent primary open septorhinoplasty with placement of an autologous caudal septal extension graft, which was stabilized using a PDS plate and secured into position using both Dermabond and PDS suture. Postoperatively, both patients presented a nasal septal abscess at an average of 8 weeks that required serial drainage and subsequent removal of the PDS plate in 1 of the patients. Cultures demonstrated mixed flora as well as Proteus mirabilis, previously unreported in the nasal septal abscess literature. In comparison to 8 patients who underwent reconstruction with PDS plate alone (without Dermabond application), this represents a relative risk of 15 ( P value = .053) for a septal abscess complication when Dermabond is employed .

CONCLUSIONS

We present an original case series on our limited, though impactful experience with PDS plate reconstruction using Dermabond to facilitate caudal septal graft placement in open septorhinoplasty. In conjunction with previously reported case series, which demonstrated elevated risk of prolonged inflammation and infection, we would recommend avoidance of subcutaneous Dermabond as an adjunct, particularly in combination with PDS plate utilization.

Navigation Guidance During Free Flap Mandibular Reconstruction: A Cadaveric Trial

Importance

Segmental mandibulectomy for tumors that distort the buccal surface of the mandible present a reconstructive challenge.

Objective

To determine whether mandible alignment after navigation-guided mandible reconstruction is better than alignment after non-template-assisted freehand reconstruction and as good as template-assisted reconstruction in a cadaveric trial.

Design, Setting, and Participants

A cadaveric trial using 10 specimens was conducted at a tertiary academic center. Fiducials were created on the ramus to compare alignment with each intervention. Segmental mandibulectomy was performed on each cadaver. Each cadaver underwent navigation-guided reconstruction, template-assisted reconstruction using a manually shaped plate, and non-template-assisted freehand reconstruction with plate contouring performed after mandibulectomy. The study was conducted from October 1, 2015, to January 1, 2016; data analysis was performed from February 1, 2016, to March 1, 2016.

Interventions

Segmental mandibulectomy, navigation-guided reconstruction, template-assisted reconstruction using a manually shaped plate, and non-template-assisted freehand reconstruction.

Main Outcomes and Measures

Ramus fiducial coordinates were recorded at baseline and after each intervention. Mandible dimensions were measured using cephalometric landmarks. Postintervention and baseline differences in ramus and mandible position were calculated.

Results

Ramus alignment was not significantly different between navigation-guided and template-assisted reconstruction, differing by 0.54 mm (98.3% CI, -0.38 to 1.47 mm). Non-template-assisted freehand reconstruction was associated with a 3.14-mm difference in alignment compared with template-assisted reconstruction (98.3% CI, 1.09 to 5.19 mm). Navigation-guided alignment resulted in a 3.69-mm improvement in alignment compared with non-template-assisted freehand reconstruction (98.3% CI, 1.79 to 5.58 mm). There was some improvement in the gonion-gonion and lingula mandibulae-lingula mandibulae (Lm-Lm) alignment for navigation-assisted compared with non-template-assisted freehand reconstruction by 1.97 mm (98.3% CI, -0.65 to 4.58 mm) and 1.39 mm (98.3% CI, -0.17 to 2.95 mm), respectively. There was marginal evidence of better Lm-Lm alignment for navigation-guided than template-assisted reconstruction (0.44 mm; 98.3% CI, -0.06 to 0.95 mm).

Conclusions and Relevance

Mandible alignment following navigation-guided reconstruction is similar to template-assisted reconstruction. Navigation-guided alignment is likely better than non-template-assisted freehand reconstruction, and navigation guidance offers a reliable technique for real-time adjustment when reconstructing complex surgical defects, such as tumors effacing the buccal cortex of the mandible.

Review of videolaryngoscopy pharyngeal wall injuries

OBJECTIVES

Reports of patient injuries associated with videolaryngoscopy are increasing in the literature. There are a wide variety of opinions regarding both safe use of the device and patient care following aerodigestive tract injury. We have seen an increase in videolaryngoscopy-associated injuries in recent years at our institution. Because of this, we wanted to determine if video-assisted laryngoscopy presents a greater risk of injury compared with direct laryngoscopy. Furthermore, we wanted to determine if there were patient and/or surgical factors that could contribute to patient injuries following videolaryngoscopy.

DATA SOURCES

MAMC anesthesia records, PubMed, Ovid.

REVIEW METHODS

We compared rates of injury between videolaryngoscopy to direct laryngoscopy at our institution by searching anesthesia records to identify laryngoscopy procedures that resulted in injury to the soft palate or oropharynx. We also identified 19 published cases in the literature, in addition to our cases, that we reviewed for patient characteristics (e.g., body mass index, age and sex, Mallampati grade), type of videolaryngoscope, location of injury, and type of repair (if any) required.

RESULTS

At our institution, we have a statistically higher rate of injury using videolaryngoscopy compared to direct laryngoscopy. Our data also indicate that women are more commonly injured during videolaryngoscope intubation than men. The right tonsillar pillars and soft palate are the most frequently injured, with through-and-through perforation of the soft tissues being the most common type of injury. The most common repair of injuries required simple closures, and long-term harm was very rare.

CONCLUSION

Our data suggests that using video-assisted laryngoscopy for intubation puts a patient at significantly greater risk for injury compared to direct laryngoscopy. Laryngoscope, 2016 127:349-353, 2017.

Multimedia approach to preoperative adenotonsillectomy counseling

OBJECTIVE

The primary objective was to compare retention of knowledge of surgical risks in parents of children having an adenotonsillectomy who received a preoperative handout or watched a video, in addition to standard counseling. A secondary objective was to determine whether time from counseling to day of surgery affects risk retention.

STUDY DESIGN

Prospective randomized control study.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

The study, conducted March 2010 through April 2011, included participants who had children undergoing adenotonsillectomy. The preoperative and postoperative test scores of those undergoing verbal counseling, counseling with handout, or counseling with video were compared.

RESULTS

Forty-five participants were tasked to identify 9 risks of adenotonsillectomy. Preoperatively, participants identified an average of 6.8 (95% confidence interval [CI], 6.2-7.3) in the counseling group, 7.3 (95% CI, 6.4-8.3) in the counseling and handout group, and 6.6 (95% CI, 5.9-7.3) in the counseling and video group (P = .32). Postoperatively, participants identified an average of 5.8 (95% CI, 4.9-6.7) in the counseling group, 6.5 (95% CI, 5.3-7.6) in the counseling and handout group, and 5.2 (95% CI, 4.1-6.3) in the counseling and video group (P = .19). Time between preoperative counseling and day of surgery was inversely correlated with postoperative score (β -.34, P = .02).

CONCLUSION

Participants were not able to identify all of the risks associated with adenotonsillectomy. There was no difference in identification of risks associated with adenotonsillectomy among different modalities of counseling. Participants retained more information when there was less time between the preoperative counseling and day of surgery.

Multimedia Approach to Adentonsillectomy Preoperative Counseling

Objective: 1) Compare surgical risk retention in participants who received a handout or watched a video in addition to standard verbal preoperative counseling. 2) Determine if time from counseling to day of surgery affects risk retention.

Method: We performed a prospective randomized control study in March 2010 through February 2011 in participants who had children undergoing adenotonsillectomy. Those unable to perform pre- and postoperative testing were excluded. We compared the preoperative and postoperative test scores of those undergoing verbal counseling, counseling with handout, or counseling with video.

Results: A total of 27 participants were tasked to identify 9 risks of adenotonsillectomy. Preoperatively, participants identified an average of 6.5 (SD 1.08) in the counseling group, 7.1 (SD 1.9) in the counseling and handout group, and 6.77 (SD 1.5) in the counseling and video group; P = .54. Postoperatively, participants identified an average of 5.3 (SD 1.4) in the counseling group, 6.5 (SD 2) in the counseling and handout group, and 5.3 (SD 2.1) in the counseling and video group; P = .29. Time between preoperative counseling and day of surgery were inversely correlated with postoperative score, correlation coefficient -0.36; P = .07.

Conclusion: Participants were not able to identify all of the risks associated with adenotonsillectomy. There was no difference in identification of risks associated with adenotonsillectomy among different modalities of counseling. Participants retained more information when there were fewer days between preoperative counseling and day of surgery.