Accuracy of Salivary Circulating Tumor Human Papillomavirus DNA in Detecting Oropharyngeal Cancer: A Systematic Review and Meta-analysis.

Importance: Circulating tumor human papillomavirus DNA (ctHPV DNA) has shown potential as a biomarker capable of improving outcomes in patients with HPV-related oropharyngeal (OP) cancer. It can be isolated from plasma or saliva, with the latter offering reduced invasiveness and theoretic reduction of lead time. Objective: To perform a systematic review and meta-analysis on the accuracy of salivary ctHPV DNA for detecting HPV-associated OP cancer. Data Sources: Cochrane Library, Embase, PubMed, and Web of Science databases were searched from inception through October 2023. Study Selection: All patients who underwent salivary ctHPV DNA testing at presentation for possible or diagnosed HPV-related OP cancer were included. Non-English and review publications were excluded. Two authors independently voted on article inclusion with a third resolving conflicting votes. Data Extraction and Synthesis: Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines, multiple authors independently abstracted data and assessed bias of included articles. Bivariate random-effects meta-analysis was performed with I2 to assess for study heterogeneity. Main Outcomes and Measures: Sensitivities, specificities, positive likelihood ratios (PLR), negative likelihood ratios (NLR), and diagnostic odds ratios (DOR) with 95% CIs alongside area under the curve (AUC) of a summary receiver operating characteristic (SROC) curve were calculated. The initial analysis took place throughout December 2023. Results: Of 440 initially identified articles, 6 met inclusion criteria and demonstrated moderate heterogeneity (I2 = 36%) with low risk of bias and low applicability concerns. Overall, 263 total patients were included with a median (range) age of 58 (39-86) years, and 228 (87%) were male patients. Per updated prognostic staging criteria, localized tumors (ie, stages 1 or 2) comprised most cancers at 139 (77%), whereas advanced ones (ie, stages 3 or 4) comprised the remaining 41 (23%). Pooled sensitivity, specificity, PLR, NLR, and DOR values were 64% (95% CI, 36%-85%), 89% (95% CI, 46%-99%), 11.70 (95% CI, 0.37-77.00), 1.21 (95% CI, 0.08-7.00), and 139.00 (95% CI, 0.05-837.00), respectively. The AUC of the SROC curve was 0.80. Conclusions and Relevance: This study supports salivary ctHPV DNA as an acceptably specific test in detecting HPV-associated OP cancer that would benefit from testing in clinical trials prior to real-time implementation.

Reassessing the Utility of Surgical Intervention for Skull Base Osteomyelitis: A 16-Year Experience.

OBJECTIVE: The role of surgery in lateral skull base osteomyelitis (SBO) is controversial. Surgical intervention is often requested by consulting services in the interest of additional culture data to inform medical management. However, whether surgery alters subsequent antibiotic treatment or modifies disease outcome remains unknown. The aim of this study was to investigate the role of surgical intervention in the treatment of SBO by (1) comparing nonsurgical and surgical culture data and (2) assessing clinical outcomes and treatment course following surgical intervention. STUDY DESIGN: Retrospective. SETTING: Tertiary care center. METHODS: The electronic record was queried for all patients with SBO who presented to a single institution over a 16-year period (2007-2023). Information recorded included history and exam, bedside and intraoperative culture data, antibiotic course, and disease outcomes. Primary outcome measures included change in medical management based on intraoperative cultures, recurrence rates, and mortality rates. RESULTS: Forty patients (41 ears, average age 73 ± 13 years) met inclusion criteria. Out of 13 (32%) patients who underwent surgical intervention, one intraoperative culture changed the antibiotic course due to identification of resistance to the original antibiotic used. Surgery did not demonstrate a benefit in overall mortality (23% vs 18%, P = 0.36) or facial nerve function (33% vs 50%, P = 0.56) compared to medical management, and was associated with increased recurrence rates (54% vs 11%, P = 0.05). CONCLUSION: Surgical cultures rarely changed antibiotic selection. Surgical debridement in treatment-refractory SBO was also not associated with improvement in recurrence or mortality rates, though this may reflect underlying differences in disease severity.

The fragility index: how robust are the outcomes of head and neck cancer randomised, controlled trials?

BACKGROUND: The fragility index represents the minimum number of patients required to convert an outcome from statistically significant to insignificant. This report assesses the fragility index of head and neck cancer randomised, controlled trials. METHODS: Studies were extracted from PubMed/Medline, Scopus, Embase and Cochrane databases. RESULTS: Overall, 123 randomised, controlled trials were included. The sample size and fragility index medians (interquartile ranges) were 103 (56-213) and 2 (0-5), respectively. The fragility index exceeded the number of patients lost to follow up in 42.3 per cent (n = 52) of studies. A higher fragility index correlated with higher sample size (r = 0.514, p < 0.001), number of events (r = 0.449, p < 0.001) and statistical significance via p-value (r = -0.367, p < 0.001). CONCLUSION: Head and neck cancer randomised, controlled trials demonstrated low fragility index values, in which statistically significant results could be nullified by altering the outcomes of just two patients, on average. Future head and neck oncology randomised, controlled trials should report the fragility index in order to provide insight into statistical robustness.

Home Sleep Testing versus Traditional Polysomnography: Pros and Cons.

Obstructive sleep apnea (OSA) is associated with long-term cardiovascular and respiratory comorbidities and increased burden on the health-care system. Early and accurate diagnosis is essential to reduce physical and financial implications of the disease. Polysomnography uses neurophysiologic channels as well as basic respiratory and sleep parameters to best estimate the presence and/or severity of OSA. Although home sleep testing may have the potential for more variable results, it is a viable alternative to increase access to diagnosis of OSA and facilitate initiation of positive airway pressure.

Using injectable fillers for chin and jawline rejuvenation.

Objective: As the population ages, facial plastic providers must remain aware of the treatments to prevent and reverse the external signs of aging. In the mandibular region, skin laxity and soft tissue sagging in the jawline may lead to jowling and chin ptosis along with reduced chin projection. While surgical procedures, including chin implantation, may be performed, nonsurgical procedures are becoming increasingly popular due to their temporary, noninvasive, yet effective methods. This review covers the use of hyaluronic acid, calcium hydroxylapatite, poly-l-lactic acid, and polymethyl methacrylate in the jawline. Methods: PubMed was searched for data on the mechanism of action, pertinent anatomy, indications, contraindications, technique, and evidence supporting the safety and efficacy of the fillers. Results: There are a wide variety of fillers available for use in the lower face with unique characteristics and application methods. While the advantages of injectable fillers include relatively affordable cost, minimal patient discomfort, and limited recovery times, taking measures to prevent short- and long-term complications is necessary for optimal results. Conclusions: Understanding the benefits and limitations of injectable fillers in the jawline can help providers appropriately counsel and treat patients.

A quiet place: The impact of the word "quiet" on clinical workload.

Purpose: This study aimed to determine the impact of uttering the word "quiet" on clinical workload during the overnight otolaryngology call shift and understand the factors contributing to resident busyness. Materials and Methods: A multicenter, single-blind, randomized-controlled trial was conducted. A total of 80 overnight call shifts covered by a pool of 10 residents were randomized to the quiet or to the control group. At the start of shift, residents were asked to state aloud, "Today will be a quiet night" (quiet group) or "Today will be a good night" (control group). Clinical workload, as measured by number of consults, was the primary outcome. Secondary measures included number of sign-out tasks, unplanned inpatient and operating room visits, number of phone calls and hours of sleep, and self-perceived busyness. Results: There was no difference in the number of total (P = 0.23), nonurgent (P = 0.18), and urgent (P = 0.18) consults. Tasks at signout, total phone calls, unplanned inpatient visits, and unplanned operating room visits did not differ between the control and quiet groups. While there were more unplanned operating room visits in the quiet group (29, 80.6%) compared to the control group (34, 94.4%), this was not found to be significant (P = 0.07). The majority of residents reported feeling "not busy" during control nights (18, 50.0%) compared to feeling "somewhat busy" during quiet nights (17, 47.2%; P = 0.42). Conclusion: Contrary to popular belief, there is no clear evidence that uttering the word "quiet" significantly increases clinical workload.

The Use of Endonasal Spreader Grafts in Preservation Rhinoplasty.

SUMMARY: Rhinoplasty is a complicated procedure that requires surgical finesse and precision to sculpt a framework that suits each patient's unique anatomical needs. Extensive resection may lead to nasal valve incompetence, causing obstructive symptoms associated with reduced quality of life. Numerous techniques have been described to help preserve and open the nasal airway, thereby mitigating valvular obstructive problems. In particular, the endonasal spreader graft is a common technique used to widen the internal nasal valve cross-sectional area while limiting external incisions and preserving local nasal structures. Preservation rhinoplasty is a variation of the traditional rhinoplasty that can lower the nasal dorsum without causing major disruption to the nasal keystone area, the junction between the middle and upper thirds of the nose. This study describes the successful and safe combination of these two surgical operations, demonstrating three case examples in which all patients reported improved postoperative nasal obstruction symptoms. Using endonasal spreader grafts in preservation rhinoplasty allows providers to manage the nasal valve and nasal dorsum similarly to the external approach without extensive deconstruction and reconstruction.

Systematic Review: Evaluating the Efficacy of Intrathecal Fluorescein for Localizing Cerebrospinal Fluid Rhinorrhea.

OBJECTIVES: A defect in the skull base can result in leakage of cerebrospinal fluid (CSF) out of the subarachnoid space into the sinonasal cavities, termed CSF rhinorrhea. Patients presenting with CSF rhinorrhea often require surgical repair, typically performed endoscopically. Successful surgical intervention is highly reliant on accurate identification of the leak site. Identification can be enhanced by the administration of intrathecal fluorescein (IF) via a lumbar drain before surgery. The objective of this systematic review is to better characterize the benefits and limitations of IF administration. METHODS: A systematic search was conducted for literature documenting the use of IF for CSF leak localization. The results of this search were subjected to initial review, followed by full-text evaluation of selected texts, and final inclusion based on predetermined selection criteria. Primary outcomes were specificity and sensitivity of IF administration in identifying CSF leak sites. Secondary outcomes included administration technique and safety data. RESULTS: A total of 25 studies representing 3801 instances of IF administration met inclusion criteria. When injected slowly for up to 30 minutes at doses of <50 mg, IF administration results in minimal complications. A total of 25 mg doses (92.36%) of IF appear more sensitive than 10 mg (71.88%) doses of IF while maintaining a similar safety profile. Mixing fluorescein with double distilled water instead of CSF or saline may decrease waiting times before fluorescein can be identified and increase its safety profile. CONCLUSIONS: Intrathecal fluorescein may play an important role in the identification of CSF leak site during endoscopic repair.

Nonopioid perioperative analgesia in head and neck cancer surgery: A systematic review.

Objective: Management of postoperative pain after head and neck cancer surgery is a complex issue, requiring a careful balance of analgesic properties and side effects. The objective of this review is to discuss the efficacy and safety of multimodal analgesia (MMA) for these patients. Methods: Pubmed, Cochrane, Embase, Scopus, and clinicaltrials.gov were systematically searched for all comparative studies of patients receiving MMA (nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, anticonvulsants, local anesthetics, and corticosteroids) for head and neck cancer surgeries. The primary outcome was additional postoperative opioid usage, and secondary outcomes included subjective pain scores, complications, adverse effects, and 30-day outcomes. Results: A total of five studies representing 592 patients (MMA, n = 275; non-MMA, n = 317) met inclusion criteria. The most commonly used agents were gabapentin, NSAIDs, and acetaminophen (n = 221), NSAIDs (n = 221), followed by corticosteroids (n = 35), dextromethorphan (n = 40), and local nerve block (n = 19). Four studies described a significant decrease in overall postoperative narcotic usage with two studies reporting a significant decrease in hospital time. Subjective pain scores widely varied with two studies reporting reduced pain at postoperative day 3. There were no differences in surgical outcomes, medical complications, adverse effects, or 30-day mortality and readmission rates. Conclusion: MMA is an increasingly popular strategy that may reduce dependence on opioids for the treatment of postoperative pain. A variety of regimens and protocols are available for providers to utilize in the appropriate head and neck cancer patient.

The Fragility Index of Total Hip Arthroplasty Randomized Control Trials: A Systematic Review.

INTRODUCTION: Although randomized controlled trials (RCTs) are considered the benchmark study design, a change of outcomes for a few patients can lead to a reversal of study conclusions. As such, examination of the fragility index (FI) of RCTs has become an increasingly popular method to provide further information regarding the relative robustness of RCT results. The purpose of this study was to systematically characterize and assess the predictors of the FI RCTs in total hip arthroplasty literature. METHODS: PubMed/MEDLINE, Embase, and Cochrane were systematically searched for all total hip arthroplasty RCTs published between January 2015 and December 2020, which had an equal assignment of participants to a two parallel-arm study design, examined a surgical intervention, and reported on at least one statistically significant dichotomous outcome in the abstract. Potential factors associated with the FI were examined using the Spearman correlation and Mann-Whitney U test. RESULTS: Thirty-four RCTs were selected, with a median number of study participants of 111 (interquartile range [IQR] 72-171] and a median total number of events of 15 (IQR 9.5 to 29). The median FI was 2 (IQR 1 to 6), while six studies had a FI of 0. In 18 cases (52.9%), the number of patients needed to change from no event to event was less than that loss to follow-up. Larger sample size was found to predictive of a higher FI (rs = 0.367, P = 0.033), but the year of publication, journal impact factor, the calculated power analysis size, and loss to follow-up were not associated with FI. CONCLUSION: The FI serves as a useful addition to other more commonly used approaches of quantitative analyses, such as P values, effect sizes, and confidence intervals, and widespread reporting the FI may provide clinicians with further information about RCT results. LEVEL OF EVIDENCE: Level I, systematic review of Level I studies.

Multimodal Analgesia in Head and Neck Free Flap Reconstruction: A Systematic Review.

OBJECTIVE: Postoperative pain after head and neck cancer surgery is commonly treated with opioids, which are associated with considerable side effects. The objective of this study is to analyze the safety and efficacy of using multimodal analgesia (MMA) for patients undergoing head and neck cancer surgery with free flap reconstruction. DATA SOURCES: A systematic search was conducted in PubMed, Cochrane, Embase, Scopus, and clinicaltrials.gov. REVIEW METHODS: All studies comparing patients receiving MMA (gabapentin, corticosteroids, local anesthetic, acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]) vs patients receiving opioids for head and neck cancer surgery with free flap reconstruction were screened. The primary outcome was postoperative opioid usage. Secondary outcomes included length of stay, subjective pain scores, surgical/medical complications, adverse effects, and 30-day outcomes. RESULTS: A total of 10 studies representing 1253 patients (MMA, n = 594; non-MMA, n = 659) met inclusion criteria. Gabapentinoids were the most commonly used intervention (72.9%) followed by NSAIDs (44.6%), acetaminophen (44.3%), corticosteroids (25.1%), ketamine (7.2%), and nerve block (3.4%). Eight studies reported a significant decrease in postoperative opioid usage in the MMA groups. Subjective pain had wider variation, with most studies citing significant pain improvement. There were no differences in surgical outcomes, medical complications, adverse effects, or 30-day mortality and readmission rates. CONCLUSION: With the rise of the opioid epidemic, MMA may play an important role in the treatment of postoperative pain after head and neck cancer surgery. A growing body of literature demonstrates a variety of effective perioperative regimens.

Clinicopathologic Characteristics and Prognostic Factors Impacting Survival in Melanoma of the Eyelid.

PURPOSE: To examine prognostic factors for survival in patients with melanoma of the eyelid. DESIGN: Retrospective cohort study. METHODS: This population-based study reviewed patients with primary melanoma of the eyelid diagnosed in the Surveillance, Epidemiology and End Results database between 1975 and 2016. The primary outcomes included survival rates estimated by Kaplan-Meier analysis and mortality hazard ratios (HRs) for overall survival and disease-specific survival (DSS). RESULTS: The cohort consisted of 2257 patients with cutaneous melanoma of the eyelid, representing 1380 cases of melanoma in situ and 877 cases of invasive melanoma. For melanoma in situ and invasive melanoma respectively, at 5 years, the overall survival rates were 88.6% and 77.1%, while DSS rates were 99.4% and 91.0%. Cox regression analysis for eyelid melanoma indicated that for invasive melanoma, age at diagnosis ≥75 years (HR 2.17 [95% confidence interval {CI} 1.02-4.60]; P = .04), T4 staging (HR 8.45 [95% CI 2.96-25.31]; P < .001), lymph node involvement (HR 3.61 [95% CI 1.12-11.60]; P = .03), and nodular melanoma (HR 3.31 [95% CI 1.50-7.32]; P = .003) histologic subtype were associated with decreased rates of survival. Sex and tumor ulceration did not impact survival. CONCLUSIONS: This study is the largest analysis to date that focuses on DSS for cutaneous melanoma of the eyelid. The most significant predictors for invasive melanoma survival are age ≥75 years at diagnosis, T4 staging, lymph node involvement, and the nodular melanoma histologic subtype. Patients with these attributes are at higher risk and should be counseled regarding prognosis.

ERAS Protocols for Thyroid and Parathyroid Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: Enhanced recovery after surgery (ERAS) protocols are evidenced-based multidisciplinary programs implemented in the perioperative setting to improve postoperative recovery and attenuate the surgical stress response. However, evidence on their effectiveness in thyroid and parathyroid surgery remains sparse. Therefore, our goal was to investigate the clinical benefits and cost-effectiveness of ERAS protocols for the perioperative management of thyroidectomy and parathyroidectomy. DATA SOURCE: A systematic review of Medline, Scopus, Embase, and gray literature was performed to identify studies of ERAS or clinical care protocols for thyroidectomy and parathyroidectomy. REVIEW METHODS: Two reviewers screened studies using predetermined inclusion criteria. Our primary outcomes included hospital length of stay and hospital costs. Readmission and postoperative complication rates composed our secondary outcomes. Meta-analysis was performed to compare outcomes for patients enrolled in the ERAS protocol versus standard of care. RESULTS: A total of 450 articles were identified; 7 (1.6%) met inclusion criteria with a total of 3082 patients. Perioperative components in ERAS protocols varied across the studies. Nevertheless, patients enrolled in ERAS protocols had reduced hospital length of stay (mean difference, -0.64 days [95% CI, -0.92 to -0.37]) and hospital costs (in US dollars; mean difference, -307.70 [95% CI, -346.49 to -268.90]), without an increase in readmission (odds ratio, 0.75 [95% CI, 0.29-1.94]) or complication rates (odds ratio, 1.14 [95% CI, 0.82-1.57]). CONCLUSION: There is growing literature supporting the role of ERAS protocols for the perioperative management of thyroidectomy and parathyroidectomy. These protocols significantly reduce hospital length of stay and costs without increasing complications or readmission rates.

Addressing the Nasal Valves: The Endonasal Approach.

The external and internal nasal valves are directly implicated in nasal valve collapse. A variety of endonasal techniques have been developed to address nasal dysfunction while maintaining or improving aesthetic appearance. This review discusses the biomechanics, surgical approach, indications, and evidence of functional and aesthetic results for each maneuver. While the endonasal approach is safe and effective, a thorough understanding of the advantages and limitations is fundamental to selecting the most appropriate surgery for the individual patient.

Physiologic Timeline of Cranial-Base Suture and Synchondrosis Closure.

BACKGROUND: Fusion of cranial-base sutures/synchondroses presents a clinical conundrum, given their often unclear "normal" timing of closure. This study investigates the physiologic fusion timelines of cranial-base sutures/synchondroses. METHODS: Twenty-three age intervals were analyzed in subjects aged 0 to 18 years. For each age interval, 10 head computed tomographic scans of healthy subjects were assessed. Thirteen cranial-base sutures/synchondroses were evaluated for patency. Partial closure in greater than or equal to 50 percent of subjects and complete bilateral closure in less than 50 percent of subjects defined the fusion "midpoint." Factor analysis identified clusters of related fusion patterns. RESULTS: Two hundred thirty scans met inclusion criteria. The sutures' fusion midpoints and completion ages, respectively, were as follows: frontoethmoidal, 0 to 2 months and 4 years; frontosphenoidal, 6 to 8 months and 12 years; and sphenoparietal, 6 to 8 months and 4 years. Sphenosquamosal, sphenopetrosal, parietosquamosal, and parietomastoid sutures reached the midpoint at 6 to 8 months, 8 years, 9 to 11 months, and 12 years, respectively, but rarely completed fusion. The occipitomastoid suture partially closed in less than or equal to 30 percent of subjects. The synchondroses' fusion midpoints and completion ages, respectively, were as follows: sphenoethmoidal, 3 to 5 months and 5 years; spheno-occipital, 9 years and 17 years; anterior intraoccipital, 4 years and 10 years; and posterior intraoccipital, 18 to 23 months and 4 years. The petro-occipital synchondrosis reached the midpoint at 11 years and completely fused in less than 50 percent of subjects. Order of fusion of the sutures, but not the synchondroses, followed the anterior-to-posterior direction. Factor analysis suggested three separate fusion patterns. CONCLUSIONS: The fusion timelines of cranial-base sutures/synchondroses may help providers interpret computed tomographic data of patients with head-shape abnormalities. Future work should elucidate the mechanisms and sequelae of cranial-base suture fusion that deviates from normal timelines.

Endocrine Surgical Procedures During COVID-19: Patient Prioritization and Time to Surgery.

BACKGROUND: We tracked endocrine surgery patients with treatment delays due to COVID-19 to investigate the relationship between physician assigned priority scoring (PAPS), the Medically Necessary, Time Sensitive (MeNTS) scoring system and delay to surgery. MATERIAL & METHODS: Patients scheduled for endocrine surgery or clinically evaluated during COVID-19-related elective surgery hold at our institution (2/26/20-5/1/20) were prospectively enrolled. PAPS was assigned based on categories of high, moderate, or low risk, consistent with the American College of Surgeons' priority system. MeNTS scores were calculated. The primary outcome was delay to surgery. Descriptive statistics were performed, and receiver operator characteristic (ROC) curves and area under the curve (AUC) values were calculated for PAPS and MeNTS. RESULTS: Of 146 patients included, 68% (n = 100) were female; the median age was 60 years (IQR:43,67). Mean delay to surgery was significantly shorter (P = 0.01) in patients with high PAPS (35 d), compared with moderate (61 d) and low (79 d) PAPS groups. MeNTS scores were provided for 105 patients and were analyzed by diagnosis. Patients with benign thyroid disease (n = 17) had a significantly higher MeNTS score than patients with thyroid disease which was malignant/suspicious for malignancy (n = 44) patients (51.5 versus 47.6, P = 0.034). Higher PAPS correlated well with a delay to surgery of <30 d (AUC: 0.72). MeNTS score did not correlate well with delay to surgery <30 d (AUC: 0.52). CONCLUSION: PAPS better predicted delay to surgery than MeNTS scores. PAPS may incorporate more complex components of clinical decision-making which are not captured in the MeNTS score.

Perioperative Nimodipine to Improve Cranial Nerve Function: A Systematic Review and Meta-Analysis.

OBJECTIVE: Nimodipine has emerged as a promising strategy for protection of cranial nerves following vestibular schwannoma (VS) resections. Our goal was to conduct a comprehensive analysis of clinical studies to determine the therapeutic efficacy of nimodipine in improving facial nerve and cochlear nerve function. DATABASE REVIEWED: We searched PubMed, Scopus, Cochrane Clinical Trial Registry, Clinicaltrials.gov, World Health Organization's International Clinical Trials Registry Platform, and EU Clinical Trials Registry to identify clinical studies up to May 11, 2020. METHODS: We included studies evaluating perioperative administration of nimodipine as a strategy to prevent or treat facial nerve or cochlear nerve dysfunction following VS resections. Primary outcomes included preservation or recovery of House-Brackman scale for facial nerve function and Hearing and Equilibrium Guidelines for cochlear nerve function at the latest follow-up visit. Secondary outcomes included adverse events and administration strategies of nimodipine. RESULTS: Nine studies (603 patients) met inclusion, of which seven studies (559 patients) were included in the quantitative analysis. Overall, nimodipine significantly increased the odds of cranial nerve recovery compared with controls (odds ratio [OR] 2.87, 95% confidence intervals [CI] [2.08, 3.95]; I2 = 0%). Subgroup analysis demonstrated that nimodipine was only effective for cochlear nerve preservation (OR 2.78, 95% CI [1.74, 4.45]; I2 = 0%), but not for facial nerve function (OR 4.54, 95% CI [0.25, 82.42]; I2 = 33%). CONCLUSION: Although there is evidence supporting the perioperative role of nimodipine for VS resections, more studies are warranted to help clarify the effects of nimodipine therapy on cranial nerve preservation.

Intensive Care Versus Nonintensive Care Ward for Postoperative Management of Head and Neck Free Flaps: A Meta-Analysis.

Introduction: Although advances in surgical technique and medical management have drastically improved outcomes of free flap reconstructive surgery in head and neck patients, there is no clear consensus on appropriate level of postoperative care. Methods: The literature was searched systematically for all comparative studies of intensive care unit (ICU) and non-ICU admissions for head and neck patients. The primary outcomes were flap failure rate, flap complications, and hospital length of stay (LOS). Secondary outcomes included cost implications, medical complications, and rates of revision surgery, readmission, and mortality. Results: Nine articles (2510 patients) were included. Patients admitted to non-ICU wards were not significantly at increased risk for free flap failure, flap-related complications, or longer LOS. Total medical complications were found to have a pooled relative risk (RR) of 0.57 [95% confidence interval (CI) 0.40 to 0.83], favoring the non-ICU cohort. In particular, the non-ICU cohort was less likely to develop neuropsychiatric complications (RR 0.34 [95% CI 0.24 to 0.48]) and sepsis (RR 0.18 [95% CI 0.05 to 0.68]) with no difference in cardiovascular or pulmonary complications. Discussion: Patients admitted to non-ICU wards did not experience higher rates of adverse flap-related outcomes and had decreased risk of developing medical complications in the studies included in this meta-analysis.

A critical appraisal of surgical outcomes following orbital hypertelorism correction: what is the incidence of true bony relapse versus soft tissue telecanthus?

BACKGROUND: Orbital hypertelorism (OHT) represents a congenital condition defined by lateralization of the bony orbit, unlike soft tissue telecanthus in which there is an increase in intercanthal distance without true bony lateralization. Existing literature remains very limited in its postoperative assessment of bony versus soft tissue relapse, which may both clinically present as telecanthus. We performed a critical appraisal of the literature to determine the postoperative incidence of bony versus soft tissue relapse following OHT repair. METHODS: The PubMed, MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, and clinicaltrials.org were searched systematically for all English studies published in any time frame reporting relapse rates following primary OHT repair. The primary outcome was incidence of bony and soft tissue relapse defined as orbital lateralization and medial canthal drift, respectively. The secondary outcome measures include postoperative complications, predictors of postoperative complications, timing and type of surgery, and revision rates. RESULTS: Eleven articles were included. A total of 84 (35.3%) patients experienced bony relapse while 43 (27.2%) patients experienced soft tissue relapse. Age at time of intervention (p < 0.92), severity at presentation (p < 0.90), and surgical technique (p < 0.09) were not found be significantly associated with relapse rate. Methods for long-term follow-up were not standardized, and there was no consistent measure to objectively assess telecanthus. CONCLUSIONS: There is no general consensus on predictive factors of long-term relapse following OHT repair in the form of box osteotomy or facial bipartition. These findings call for cross-sectional outcome standardization to better understand long-term outcomes across institutional, provider, and patient differences.