Changes in Opioid Prescribing Habits for Patients Undergoing Rhinoplasty and Septoplasty.

IMPORTANCE: Opioid prescriptions have increased substantially over the last 2 decades, contributing to the opioid epidemic. Physician practices and legislative changes play a key role in decreasing prescription opioid use. OBJECTIVE: To evaluate changes in opioid prescribing habits for patients undergoing rhinoplasty and/or septoplasty before and after the adoption of new opioid legislation. DESIGN, SETTING, AND PARTICIPANTS: This single-institution case-control study examined opioid prescribing habits for 80 patients who were undergoing rhinoplasty and septoplasty with or without turbinate reduction at the University of Vermont between March 2016 and May 2018. Patients were excluded if they underwent concomitant endoscopic sinus surgery or were younger than 14 years. Patients were divided by surgery date before or after legislative changes on July 1, 2017. EXPOSURES: Rhinoplasty and septoplasty with or without turbinate reduction. MAIN OUTCOMES AND MEASURES: Patient demographics and opioid prescriptions were recorded. Patients were evaluated if they reported pain during follow-up, called the office, or received a second prescription. The Vermont Prescription Monitoring System was queried to determine if opioid prescriptions were filled within 30 days of the procedure. The 2 groups were compared to test the hypothesis that opioid prescriptions had decreased after legislative changes. RESULTS: Of a total of 80 participants, the mean (SD) age in the before (15 women [37.5%]) and after (16 women [40.0%]) groups were 41.4 years and 40.6 years, respectively. There was a statistically significant decrease in the number of pills prescribed to the after group (17.5 to 9.7; P < .001) as well as a decrease in the morphine milligram equivalents that were prescribed (130.9 to 73.2; P < .001). There was no statistical difference in the number of postoperative telephone calls for pain, second prescriptions, or increased complaints of pain at the postoperative visit. CONCLUSIONS AND RELEVANCE: Recent laws in Vermont regarding opioid prescribing were implemented in 2017 to curb the ongoing opioid epidemic. Our observations of patients undergoing septoplasties and rhinoplasties found a significant reduction in opioid prescriptions. This was not associated with an increase in patient complaints about postoperative pain or the need for a second prescription after surgery. This shows that we may safely be able to decrease the number of narcotic medications that we prescribe. LEVEL OF EVIDENCE: 3.

SMARCB1-Deficient Sinonasal Carcinoma: A Case Report and Discussion of the Clinical Implications.

OBJECTIVE: SMARCB1-deficient sinonasal tract carcinomas are an emerging subset of rare tumors recently described in the literature, with less than 100 reported cases. Given the aggressive nature of this tumor, timely diagnosis is especially important. We present a case report of a SMARCB1-deficient carcinoma of the sinonasal tract. METHODS: Case report with review of the literature. RESULTS: The patient was a 53-year-old male with computed tomography (CT)-proven mass of the right ethmoid and sphenoid sinuses. Rigid nasal endoscopy revealed a purple mass completely obstructing the right nasal cavity that extended inferiorly from the posterior ethmoids and sphenoid sinuses. Initial biopsy in the emergency room was nondiagnostic due to extensive tumor necrosis. Magnetic resonance imaging (MRI) revealed T2 hypointense enhancing mass centered in the right posterior ethmoids with invasion into the right orbital apex, classifying it as a T4b tumor. The patient underwent repeat biopsy with frozen section and tumor debulking. Immunohistochemical analysis of subsequent biopsy revealed complete loss of INI-1 and negative staining for other pertinent markers, alluding to the diagnosis of SMARCB1-deficient sinonasal tract carcinoma. CONCLUSION: Tumor necrosis may be problematic in obtaining a diagnosis for SMARCB1-deficient sinonasal carcinomas. Thus, sampling various regions of the tumor during initial biopsy can prevent delays in diagnosis and treatment.

Surgical management of an atypical presentation of a thyroid storm.

INTRODUCTION: Thyroid storm is a rare complication of Graves' disease that can carry a poor prognosis. In order to prevent major complications, thyroid storm must be quickly identified in patients and treatment must be promptly implemented. Medical treatment is usually initiated with antithyroid medications, such as propylthiouracil (PTU), methimazole, and beta-blockers. However, some patients may experience adverse reactions to these medications and alternate treatment options must be explored. CASE PRESENTATION: We report a case of a 30-year-old female initiated on PTU after diagnosis with Graves' disease that later presented an acute thyroid storm. DISCUSSION: Therapy was changed to methimazole, yet the patient subsequently developed angioedema and dyspnea. Medical management was discontinued and emergent thyroidectomy was performed without complication.

A case of heroin induced sensorineural hearing loss.

A case of a 31-year-old male who developed profound sensorineural hearing loss following a heroin overdose is presented. The patient subsequently had a full recovery of his hearing. Other cases of this rare phenomenon are reviewed and management options are discussed.