Effects of Intravenous Tranexamic Acid During Rhytidectomy: A Randomized, Controlled, Double-Blind Pilot Study.

BACKGROUND: Tranexamic acid (TXA) is an antifibrinolytic agent shown to decrease intraoperative bleeding, reduce transfusions, and improve outcomes across multiple specialties. Within plastic surgery, initial reports are encouraging but formal studies are lacking. OBJECTIVES: The aim of this study was to determine whether intravenous (IV) TXA has any effect on intraoperative bleeding or postoperative sequelae in patients undergoing a deep-plane facelift. METHODS: This is a prospective, randomized, double-blind, case series in a private practice surgery center. The participants were 44 patients undergoing rhytidectomy with the senior authors (R.A.G. or M.J.G). The treatment group received a 1-g dose of IV TXA prior to skin incision and the same dose 4 hours later (vs saline). Bleeding was rated mild, moderate, or severe. Postoperative ecchymosis and edema were subjectively evaluated by patient and surgeon and scores were aggregated for analysis. RESULTS: The TXA group showed decreased intraoperative bleeding but this difference did not reach statistical significance. Postoperative ecchymosis/edema ratings were lower for patients who received TXA, including a statistically significant decrease in surgeon-rated bruising. TXA resulted in a statistically significant decrease in postoperative collections in this study and no major complications occurred. CONCLUSIONS: TXA is a safe, low-cost addition to any existing surgical protocol and may lead to fewer surgical sequelae and improved satisfaction. Although we did not observe a dramatically different intraoperative experience, postoperative bruising and collections were significantly reduced. TXA acid may have great value in the management of patients undergoing rhytidectomy and its use warrants further study.

Use of continuous positive airway pressure after rhinoplasty, septoplasty, and sinus surgery: A survey of current practice patterns.

OBJECTIVE: To explore current practice patterns in the use of continuous positive airway pressure (CPAP) following nasal or sinus surgery. STUDY DESIGN: Cross-sectional survey. METHODS: An electronic 24-question survey was created to evaluate surgeon practice patterns for restarting CPAP after nasal surgery. We also explored factors contributing to their decisions (1-5 Likert scale) and complications believed to be directly related to restarting CPAP. Factors with a median rating score greater than 3 out of 5 were deemed "important." Subgroup analyses were performed to assess the impact of practice setting and clinical experience. RESULTS: A total of 407 physicians completed the survey (27.4% response rate for those that opened the e-mail). The majority of surgeons temporarily stop CPAP after nasal surgery, generally for 1 to 2 weeks, although the range of time is wide. There are also many surgeons who do not stop CPAP after any of these procedures and who reported that complications were fairly minimal. Severity of obstructive sleep apnea (OSA) was deemed important for all procedures. There were additional patient and surgery-specific factors considered important for each individual surgery. Subgroup analysis revealed significant differences in physician practice setting and clinical experience. CONCLUSION: Regarding the use of CPAP after nasal surgery, considerable variation existed in the practice patterns of physicians. Severity of OSA was universally considered important, but the remaining factors were less consistent. A comparative study investigating the outcomes of various protocols is necessary. LEVEL OF EVIDENCE: N/A.

Safety of concurrent nasal and oropharyngeal surgery for obstructive sleep apnea.

OBJECTIVE: This study evaluated for increased complications or risk associated with concurrent nasal and oropharyngeal surgeries to treat patients with obstructive sleep apnea (OSA). STUDY DESIGN: Retrospective chart review. METHODS: We performed a retrospective chart review on consecutive patients between 2006 and 2011 who underwent either simultaneous nasal and pharyngeal surgery (group 1) or pharyngeal surgery alone (group 2) to treat OSA. We compared the length of hospitalization and the rate of complications in both groups. RESULTS: Group 1 consisted of 20 patients, all male, with ages ranging from 25 to 72 years (average, 35 years) and apnea-hypopnea index (AHI) from 2.6 to 119 (average, 52.2). Group 2 consisted of 20 patients, 1 female, with ages ranging from 23 to 71 years (average, 37 years) and AHI from 10 to 101 (average, 46.1). In group 1, 30% of patients were ambulatory compared to 25% of patients in group 2. In all cases, the nonambulatory patients were observed for only 1 night. The rate of complications in both groups was 10% (2 out of 20 in each group). Both complications in group 1 were post-tonsillectomy bleeds. In group 2, 1 patient had a post-tonsillectomy bleed and 1 patient was readmitted with dehydration due to poor pain control. There was no statistically significant difference in length of hospitalization or rate of complications in these 2 groups. CONCLUSION: Performing concurrent nasal and oropharyngeal surgery for OSA was safe when compared to oropharyngeal surgery alone in our cohort and, with careful selection criteria, can even be done in the ambulatory setting. Large, multi-institutional investigations are indicated.

Severe systemic reaction from calcium hydroxylapatite vocal fold filler.

We describe a severe systemic reaction that occurred following injection augmentation with calcium hydroxylapatite vocal fold filler. The reaction occurred within 30 minutes of the procedure and consisted of diffuse itching, hives, edematous face and eyelids, and voice changes indicating glottic edema. It is classified as a grade 3 systemic reaction. Consideration is given to possible etiologies and at risk patients are discussed. We recommend a postprocedure observation time of at least 30 minutes to monitor for such reactions.

Laryngeal fracture after coughing.

Nontraumatic laryngeal fractures are exceedingly rare disease entities. Only 3 prior instances have been described in the medical literature (Br Med J 1950;1:1052; Acta Otorrinolaringol Esp 2007;58:73-4; Otolaryngol Head Neck Surg 2012;147:801-2). We present a case of thyroid cartilage fracture and associated phlegmon formation after a vigorous coughing spell in a 47-year-old man. On presentation, the patient's symptoms included the triad of odynophagia, dysphagia, and dysphonia as well as diffuse swelling and tenderness over the thyroid cartilage. Computed tomography and magnetic resonance imaging revealed a mildly displaced anterior thyroid cartilage fracture as well as a phlegmon in the strap muscle compartment adjacent to the fracture (Figs. 1 and 2). Intravenous dexamethasone and antibiotics were initiated, and the patient was admitted to the medical intensive care unit. On fiberoptic examination with the flexible laryngoscope, the patient was found to have slightto-moderate watery edema of the right aryepiglottic fold and right greater than left arytenoid cartilages. After 48 hours, the patient's neck swelling and pain significantly improved. On hospital day 4, the patient was discharged with a course of oral antibiotics. One week later, the patient reported only mild odynophagia and persistent dysphonia. He otherwise felt well and was tolerating fluids and soft food without difficulty. A preexisting, congenital abnormality resulting in a focal weakness in the thyroid cartilage might predispose patients to nontraumatic fractures (Otolaryngol Head Neck Surg 2012;147:801-2). Patients in prior case reports of nontraumatic laryngeal fractures presented with similar symptoms (Table). The triad of odynophagia, dysphagia, and dysphonia after a severe coughing or sneezing episode should raise the clinician's suspicion of a thyroid cartilage fracture.

Mucosal brush biopsy of the oral cavity to detect local, peanut-specific immunoglobulin E.

BACKGROUND: This study compares the ability of mucosal brush biopsy (MBB) from 2 separate locations in the oral cavity to detect peanut-specific immunoglobulin E (IgE) in patients who report adverse oral cavity reactions when ingesting peanuts. METHODS: Twenty patients who reported a history of oral cavity itching or swelling when ingesting peanuts underwent either MBB of the dorsal tongue (n = 10) or the vestibule (n = 10). Serum testing for total and peanut-specific IgE, using standard immunofluorescent assay, was obtained for all patients. Total and specific IgE for each location were compared. Additionally, the correlation between MBB and peanut-specific IgE on serum was determined using Fisher's exact probability testing. RESULTS: Peanut-specific IgE was detected in 3 of 10 (30%) MBB specimens from the dorsal tongue and in 10 of 10 (100%) MBB specimens from the vestibule. The mean peanut-specific IgE on MBB (kU/L) in the dorsal tongue group was 0.03 vs 0.17 in the vestibule group (p = 0.0002). No significant association was noted for peanut-specific IgE between MBB and serum testing (p = 1.0). CONCLUSION: This study demonstrates for the first time that peanut-specific IgE can be detected using MBB in the oral cavity of patients who are symptomatic when consuming peanuts. The vestibule was a superior location compared to the dorsal tongue for oral cavity MBB, correlating very well with self-reported symptoms. Peanut-specific IgE on MBB overall did not correlate well with serum testing for peanut-specific IgE.

Axial computed tomography evaluation of the internal nasal valve correlates with clinical valve narrowing and patient complaint.

BACKGROUND: The objective of this work was to explore the utility of axial computed tomography (CT) imaging to objectively define a narrow internal nasal valve, and compare those findings with clinical examination and patient complaint. METHODS: Retrospective review from a single facial plastic surgery center. We reviewed 40 consecutive patients evaluated for either sinusitis or nasal airway obstruction for which a CT scan was obtained at a single radiology institution. Thirty-six complete office records were examined for the presence of clinical internal valve narrowing and complaints of nasal obstruction. In total, 72 internal nasal valves were analyzed using axial plane CT and measurements were compared to clinical findings and presence of airway obstruction. RESULTS: Measured valve areas for clinically normal internal nasal valves averaged 0.47 cm(2) vs 0.28 cm(2) for clinically narrow valves, a decrease of 40.4%. In unobstructed nasal airways the valve area averaged 0.51 cm(2) vs 0.38 cm(2) in obstructed airways, a difference of 25.5%. A radiographically measured valve area of <0.30 cm(2) suggests clinical narrowing with a sensitivity of 71.4%, specificity of 88.9%, positive predictive value of 62.5%, and negative predictive value of 92.3%. CONCLUSION: Using standard axial CT imaging we describe an objective method of radiographically evaluating the nasal valve, demonstrating strong correlation with physical examination and patient complaint. Additionally, radiographic valve areas can be used to screen for clinically narrow nasal valves with good sensitivity and specificity, providing a novel straightforward method for nasal valve assessment.

Radix grafts in cosmetic rhinoplasty: lessons from an 8-year review.

We describe our experience with radix augmentation during cosmetic rhinoplasty over an 8-year period using both autologous and synthetic grafts and provide insight into maximizing success. We discuss various surgical considerations, including patient selection, graft materials, and dealing with complications. We focus on our operative technique and provide patient examples.

Prevalence of over-the-counter and complementary medication use in the otolaryngology preoperative patient: a patient safety initiative.

OBJECTIVES/HYPOTHESIS: To determine the prevalence of over-the-counter and complementary and alternative medication use in the preoperative otolaryngology patient population. STUDY DESIGN: Cross-sectional survey. METHODS: Data were collected from preoperative surveys given to all patients undergoing surgery by a single physician with an academic practice over a 6-month period from March to September 2010. Responses were compiled and combined with demographic information obtained from the computer-based chart system. RESULTS: A total of 92 patients, with ages ranging from 5 to 84 years old (average, 41), completed the survey. Fifty-three (58%) patients were female, and 39 (42%) were male. Forty-two (46%) patients reported the use of nonprescription medications, and 48% reported the use of multiple medications. Of those who reported using medication, 11 (26%) were male and 31 (74%) were female. The average age of nonprescription medication users was 49 years. The most commonly reported over-the-counter medications were aspirin and ibuprofen. The most commonly reported complementary and alternative medications were green tea, fish oil, and vitamin E. CONCLUSIONS: The use of nonprescription medications in the otolaryngology preoperative population is very common, especially in the female patient. The most commonly reported medications are associated with serious potential complications, and awareness of their use is critical before the patient undergoes surgery.

Laryngeal mucous membrane pemphigoid: a systematic review and pooled-data analysis.

OBJECTIVES/HYPOTHESIS: To perform a systematic pooled-data analysis of literature data involving laryngeal mucous membrane pemphigoid (MMP). STUDY DESIGN: A systematic review and pooled-data analysis. METHODS: We conducted a systematic literature search of MEDLINE, EMBASE, Cochrane Central Register of Clinical Trials, Cochrane Database of Systematic Reviews, clinicaltrials.gov, and the National Guideline Clearinghouse databases without language restriction for studies including combinations of relevant terms. All authors independently screened the abstracts of the search results, identified articles eligible for review, and critically appraised the full-text studies. Pooled-data analyses and Kaplan-Meier survival analyses were conducted using SPSS version 16.0 software (SPSS Inc., Chicago, IL). RESULTS: Of the 2,524 citations reviewed, the included articles consisted of 63 case reports and 10 case series reporting on 141 patients with laryngeal MMP. No clinical trials or comparative trials were found. The overall calculated prevalence of laryngeal MMP was 12.2% (95% confidence interval [CI], 11.5-12.9%) of cases of MMP or one in 10 million persons in the general population. Mean age at laryngeal MMP onset was 59.7 years (95% CI, 57.9-61.1 years), and the supraglottis was the most commonly affected site (84.8%, 95% CI, 82.5-87.2%). Distribution among genders was equivalent (P = .655). The presence of antiepiligrin autoantibodies was associated with increased laryngeal involvement (Odds ratio 7.9, 95% CI, 3.9-16.0). The overall 5-year relative survival rate was 92.4% (standard error, 8.4) with a follow-up range of 1 to 221 months. Standard medical therapy alone occasionally improved the condition; however, relapses were frequent, and 10.5% eventually required tracheostomy. Laryngeal surgical interventions seemed to be effective in severe cases. CONCLUSIONS: Laryngeal MMP is a rare condition that can be life threatening without proper treatment and frequent follow-up.