Surgical Fires Involving Alcohol-Based Preparation Solution, 1991-2020.

BACKGROUND: Alcohol-based skin preparations were first approved for surgical use in 1998 and have since become standard in most surgical fields. The purpose of this report is to examine incidence of surgical fires because of alcohol-based skin preparation and to understand how approval and regulation of alcohol-based skin preparations impacted trends in fires over time. METHODS: We identified all reported surgical fires resulting in patient or staff harm from 1991 through 2020 reported to the Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database. We examined incidence of fires because of these preparations, trends after approval and regulation, and common causes. RESULTS: We identified 674 reports of surgical fires resulting in harm to patients and surgical personnel, in which 84 involved an alcohol-based preparation. The time-adjusted model shows that from 1996 through 2006, there was a 26.4% increase in fires followed by a 9.7% decrease from 2007 to 2020. The decrease in fires was most rapid for head and neck and upper aerodigestive tract surgeries. Qualitative content analysis revealed improper surgical site preparation as well as close proximity of surgical sites to an oxygen source as the most common causes of fires. CONCLUSION: Since FDA approval, alcohol-based preparation solutions have been associated with a significant percentage of surgical fires. Warning label updates from 2006 to 2012 coupled with increased awareness efforts of associated risks of alcohol-based surgical solutions likely contributed to the decrease in fires. Improper surgical site preparation technique and close proximity of surgical sites to oxygen continue to be risk factors for fires. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:607-613, 2024.

Unilateral Minimally Invasive Across-Midline Vertebral Column Resection Partially Corrects Thoracolumbar Kyphosis - A Case Series.

OBJECTIVE: The goal of this study was to describe the indirect and partial correction of spine kyphotic deformities (secondary to various pathologies) achieved by minimally invasive posterolateral extracavitary approach (MIS PLECA) for corpectomy. METHODS: The authors retrospectively reviewed a consecutive case series of 12 patients undergoing MIS PLECA in a single institution. Perioperative data were collected and follow-up computed tomographies and radiographs were reviewed to assess for interbody arthrodesis. RESULTS: The mean age was 60.7 ± 20.8 years (58.4% males). The etiologies of deformity included pathological fracture (41.6%), acute trauma (30%), and infection. An expandable cage was used in 66.7% of patients for anterior reconstruction. The mean total estimated blood loss was 764.1 ± 332.9 ml. The mean operative time was 413.3 ± 98.8 minutes. The average length of hospital stay was 5.8 ± 2.5 days. A consistent degree of focal correction of sagittal alignment was seen in all patients with a mean correction of sagittal angle of 7.4 ± 4.3° (P < 0.0001). The mean duration of rehabilitation was 8.5 ± 6.7 days. All patients remained neurologically stable at the last follow-up with a mean follow-up period of 20.1 ± 12.8 months. Successful fusion was achieved in 91.7% at the last follow-up. CONCLUSIONS: MIS PLECA for corpectomy appears to be a feasible, safe, and effective MIS technique for select patients, particularly those who cannot tolerate the traditional open approach. Additionally, a focal sagittal deformity correction can be achieved using MIS corpectomy.

Surgical salvage of human papillomavirus-positive oropharyngeal cancer: Secondary analysis of a randomized controlled trial.

BACKGROUND: Survival outcomes are generally better for human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV+ OPSCC) than other forms of head and neck cancer. However, less is known about oncologic outcomes, late adverse events, and gastrostomy tube dependence associated with salvage surgery after the failure of definitive chemoradiation in patients with HPV+ OPSCC. METHODS: A secondary analysis of the Radiation Therapy Oncology Group 1016 randomized trial, which compared radiotherapy plus cetuximab to radiotherapy plus cisplatin in patients with HPV+ OPSCC, was performed. The oncologic and adverse event outcomes for patients who underwent salvage surgery were examined. RESULTS: Among the 805 patients who were assigned to treatment and were eligible for analysis, 198 developed treatment failure. Salvage surgery was required for 61 patients (7.6%), with 33 patients undergoing salvage surgery after locoregional failure (LRF) and 28 patients undergoing salvage neck dissection within the 20 weeks after treatment. Patients with LRF who underwent salvage surgery experienced improved overall survival in comparison with patients with LRF who did not undergo surgery (45% vs. 17% at 5 years after treatment; hazard ratio, 0.41; 95% confidence interval [CI], 0.23-0.74). Surgical salvage after LRF was associated with similar frequencies of late grade 3/4 dysphagia in comparison with LRF without surgery (24% [95% CI, 13%-41%] vs. 20% [95% CI, 12%-32%]; p = .64) and with similar gastrostomy tube dependence at 2 years (29% [95% CI, 15%-49%] vs. 13% [95% CI, 5%-28%]; p = .12). CONCLUSIONS: Salvage surgery in patients with HPV+ OPSCC is associated with favorable survival and adverse event outcomes.

Surgical Fire in the United States: 2000-2020.

BACKGROUND: Despite fire prevention protocols and perioperative staff training, surgical fires continue to cause patient harm, disability, and death. METHODS: We identified surgical fires that were reported to the Food and Drug Administration's Manufacturer and User Facility Device Experience database between 2000 and 2020 that resulted in patient or surgical personnel harm. Quantitative and descriptive content analyses were performed on free-text responses to identify contributing factors of surgical fire patient and personnel harm events. RESULTS: We identified 565 surgical fire events resulting in patient or surgical personnel harm over a 20-year study period (median 25 events/year; range, 8-53). Surgical fires were significantly more likely to occur during upper aerodigestive tract (unadjusted odds ratio 15.96; 95% confidence interval, 11.93-21.34) and head and neck (unadjusted odds ratio 5.47; confidence interval 4.14-7.22) procedures compared with abdomen and pelvis procedures. Upper aerodigestive tract and head and neck procedures had the highest incidence of life-threatening injury (41% and 21%, respectively). An electrosurgical device was the ignition source in 82% of events. Content analysis revealed 7 common categories identified as root causes of surgical fires: preparation of surgical site (n = 55, 29%); device malfunction (n = 51, 26%), surgical accident (n = 47, 24%), medical judgement (n = 44 reports, 23%), equipment care and handling (n = 18, 9%), patient factors (n = 10, 5%), and communication (n = 3, 2%). CONCLUSION: Surgical fires resulting in harm to patient and surgical personnel continue to occur. The common themes identified in this study will prepare and empower surgeons and surgical personnel to prevent surgical fires in the future.

Association of State-Imposed Restrictions on Gabapentin with Changes in Prescribing in Medicare.

BACKGROUND: Between August 2016 and July 2018, three states classified gabapentin as a Schedule V drug and nine states implemented prescription drug monitoring program (PDMP) regulation for gabapentin. It is highly unusual for states to take drug regulation into their own hands. The impact of these changes on gabapentin prescribing is unclear. OBJECTIVE: To determine the effect of state-imposed regulation on gabapentin prescribing for Medicare Part D enrollees from 2013 to 2018. DESIGN: Population-based difference-in-difference(DID) analysis study utilizing the Medicare Part D Prescriber Public Use File. PARTICIPANTS: All eligible Medicare Part D prescribers excluding those outside of the fifty states and the District of Columbia were included in our analysis. Prescriber data and key sociodemographic variables were organized by state and year. States with a gabapentin schedule change or PDMP regulation enacted before 2019 were included in the intervention group. For the Schedule V DID analysis, a control group of the ten highest opioid-prescribing states was used. INTERVENTIONS: States with gabapentin schedule changes or PDMP regulation before January 1, 2019, were included and compared to control states that did not implement these policies. MAIN MEASURES: Total days' supply of gabapentin per enrollee per year was the primary outcome variable. KEY RESULTS: The mean total days' supply of gabapentin per enrollee increased 41% from 19.71 to 27.81 total days' supply per enrollee per year between 2013 and 2018. After adjustment, Schedule V gabapentin regulation resulted in a reduction of 8.37 total days of gabapentin prescribed per enrollee (95% confidence interval of - 10.34 to - 6.39). In contrast, PDMP regulation resulted in a reduction of 1.01 total days of gabapentin prescribed per enrollee (95% confidence interval of - 1.74 to - 0.29). CONCLUSIONS: Classifying gabapentin as a Schedule V drug results in substantial reduction in total days prescribed whereas PDMP regulation results in modest reduction.

Incidence of Head and Neck Cancer With Lung Cancer Screening: Secondary Analysis of a Randomized Controlled Trial.

OBJECTIVES/HYPOTHESIS: To evaluate the incidence of head and neck cancers (HNC) in high-risk current and/or former smokers with screening low-dose computed tomography (LDCT) chest versus chest x-ray (CXR). STUDY DESIGN: Second analysis of randomized clinical trial. METHODS: We performed a secondary analysis examining the incidence of HNC in the National Lung Screening Trial. This was a randomized trial comparing LDCT versus CXR screening for lung cancer detection in high-risk individuals (30 pack-year smokers who currently smoke or quit within the last 15 years, aged 55-74). We compared the incidence of HNC in participants screened with LDCT versus CXR. We performed subgroup analyses in participants with mucosal HNC (oral cavity, oropharynx, larynx, hypopharynx, nasal/sinus cavity, or nasopharynx) or nonmucosal HNC (thyroid or salivary gland) and examined survival in the two screening arms. RESULTS: This trial enrolled 53,452 participants with a median follow-up of 6.2 years after randomization. The incidence of HNC was 111.8 cases per 100,000 person-years in the LDCT group versus 87.1 cases per 100,000 person-years in the CXR group (rate ratio 1.30, 95% confidence interval [CI] 1.05-1.61). There were 11.7 deaths from HNC per 100,000 person-years in the LDCT group and 12.9 deaths per 100,000 person-years in the CXR group (hazard ratio 0.80, 95% CI 0.42-1.52). CONCLUSIONS: Participants screened with LDCT had a modestly higher incidence of HNC. As uptake and adherence of lung cancer screening guidelines improve, clinicians should recognize that incidental findings from screening may lead to increased detection of HNC. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1609-1614, 2022.

Modeling oral cancer screening in the United States population.

OBJECTIVES: To evaluate the impact of oral cancer screening if applied to the United States (US) population or various high-risk populations in the US. METHODS: We modeled the effects of applying an oral cancer screening program to the US population assuming a similar mortality reduction as seen in the randomized Kerala trial. We combined data on the incidence of oral cancer in the Surveillance, End Results, and Epidemiology database, data on the relative risk in various high-risk groups from the Prostate, Lung, Cervical, and Ovarian screening trial, and the National Lung Screening Trial and data on the prevalence of cigarette use from the National Health Interview Survey. RESULTS: When extrapolating to the US population we predict the number needed to screen to prevent one oral cancer death (NNS) = 9,845 in all individuals aged 35 + . Screening efficiency would increase if applied to higher-risk populations. If oral cancer screening were applied to male ≥ 60 pack-year current smokers or former smokers who have quit within 15 years aged 50-79 we predict a 4.6% reduction in oral cancer mortality with an NNS = 1,485. CONCLUSIONS: Targeted screening of individuals at high risk for oral cancer has the potential to maximize the efficiency of screening and meaningfully impact oral cancer mortality. We suggest a future screening trial in high-risk individuals be considered to clarify the role of oral cancer screening in the US.

Incidence of Second Primary Lung Cancer After Low-Dose Computed Tomography vs Chest Radiography Screening in Survivors of Head and Neck Cancer: A Secondary Analysis of a Randomized Clinical Trial.

Importance: In head and neck cancer survivors, lung cancer screening may aid in detecting a second primary lung cancer or metastatic head and neck cancer earlier in the course of disease, which may improve treatment outcomes. However, no randomized data exist to assess the value of lung cancer screening in this population. Objective: To evaluate the incidence of second primary lung cancer in survivors of head and neck cancer survivors with screening low-dose computed tomography (CT) vs chest radiography (CXR). Design, Setting and Participants: For this ad hoc secondary analysis of a randomized clinical trial, head and neck cancer survivors were identified from the National Lung Screening Trial, which enrolled participants from August 2002 to April 2004. This randomized clinical trial compared screening using low-dose CT chest vs CXR in patients aged 55 to 74 years with at least a 30 pack-year history of cigarette smoking and who were current smokers or had quit within the past 15 years and who were at high risk for lung cancer. The incidences of second primary lung cancer and second primary head and neck cancer were compared with screening using low-dose CT vs CXR. Data were analyzed from December 1, 2020, to June 30, 2021. Interventions: Screening low-dose CT of the chest vs CXR. Main Outcomes and Measures: The primary outcome was the incidence of a second primary lung cancer. Results: Among 53 452 enrolled participants, we identified 171 survivors of head and neck cancer, of whom 82 were screened with low-dose CT of the chest and 89 with CXR. Participants' mean (SD) age was 61 (5) years, and 132 were men (77.2%). The incidence of lung cancer was higher among head and neck cancer survivors compared with participants without head and neck cancer (2080 per 100 000 person-years [2.1%] vs 609 per 100 000 person-years [0.6%]; adjusted rate ratio, 2.54; 95% CI, 1.63-3.95). In head and neck cancer survivors, the incidence of second primary lung cancer was 2610 cases per 100 000 person-years in the low-dose CT group vs 1594 cases per 100 000 person-years in the CXR group (rate ratio, 1.55; 95% CI, 0.59-3.63). In head and neck cancer survivors, overall survival was 7.07 years with low-dose CT vs 6.66 years with CXR (log-rank P = .48). Conclusions and Relevance: The results of this ad hoc secondary analysis of a randomized clinical trial suggest that head and neck cancer survivors are at especially high risk for a second primary lung cancer. These findings underscore the importance of low-dose CT screening in head and neck cancer survivors with significant cigarette smoking history who are fit to undergo treatment with curative intent.

Development of a self-directed sinonasal surgical anatomy video curriculum: Phase 1 validation.

BACKGROUND: Sinusitis is a common outpatient diagnosis made by physicians and is a reason for referral to otolaryngologists. A foundation in basic sinonasal anatomy is critical in understanding sinus pathophysiology and avoiding complications. Our objective in this study was to develop and to validate a self-directed surgical anatomy video for medical students. METHODS: Two multimedia videos were developed highlighting sinonasal anatomy. In Video 1 we included audio narration and radiologic imaging. Video 2 incorporated highlighted images from a sinus surgery video. An assessment was developed to test sinonasal anatomy landmarks, spatial recognition of structures, and their clinical relevance. An expert panel of rhinologists scored face and content validity of the curriculum videos and assessment. Factor analysis was used to separate questions into face and content validity domains, and a one-sample t test was performed. RESULTS: The panel scored face validity (Videos 1 and 2: 4.4/5) and content validity (Video 1: 4.5/5, 0.83; Video 2: 4.3/5, 0.75) significantly higher than a neutral response. There were no statistical differences for face or content validity between videos. The assessment was rated suitable (29%) or very suitable (57%) for testing basic sinonasal surgical anatomy, and the majority (71%) of respondents agreed (14%) or strongly agreed (57%) that the assessment thoroughly covered the sinus anatomy content with which medical students should be familiar. CONCLUSION: We have developed two videos and an assessment that highlight and test sinonasal anatomy. Future studies will aim to identify whether the use of a self-directed video curriculum improves sinonasal anatomy awareness and whether incorporation of surgical endoscopic videos augments training.

Optimizing the Virtual Otolaryngology Residency Information Sessions: A Survey of Applicants.

The 2020-2021 otolaryngology residency application cycle has been immensely distorted by travel restrictions mandated in response to coronavirus disease 2019, limiting opportunities for applicants to meet and rotate with programs of interest. The purpose of this study was to evaluate otolaryngology applicants' preferences toward the content and format of virtual residency information sessions. An anonymous online survey was developed to gauge applicants' virtual exposure to otolaryngology programs and investigate their preferences during virtual sessions. Almost all respondents attended at least 1 virtual information session (89%). Respondents felt that the most important aspects of these sessions were meeting residents, learning about operative volume, and meeting faculty. The majority (85%) preferred these sessions last no longer than 2 hours. Participants preferred virtual sessions to include breakout sessions with participant video/microphone on. These findings have implications for future virtual resident recruitment strategies.

Value in Scoliosis Surgery: Coordinated Surgical and Anesthetic Techniques Avoid Blood Transfusion without Fibrinolytic Medications or Red Blood Cell Salvage.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: The aim of this study was to document the impact of coordinated surgical and anesthetic techniques on estimated blood loss (EBL) and subsequent need for transfusion. SUMMARY OF BACKGROUND DATA: Scoliosis surgery is typically associated with large quantities of blood loss, and consequently blood transfusion may be necessary. Many strategies have been employed to minimize blood loss, including blood collection with reinfusion ("cell-saver") and the use of antifibrinolytic drugs. We reviewed our experience with methods to minimize blood loss to show that transfusion should be a rare event. METHODS: One hundred and thirty consecutive cases of spine fusion for adolescent idiopathic scoliosis utilizing pedicle screw fixation were reviewed from March 2013 to October 2019. The senior author was the primary surgeon for all cases. Data were collected from the electronic medical record, including age, sex, weight, number of instrumented levels, EBL, total fluids administered during surgery, pre- and postoperative hemoglobin, and procedure duration. RESULTS: The average EBL was 232 ±â€Š152 mL (range 37-740 mL). The average preoperative hemoglobin was 13.4 ±â€Š1.2 g/dL and the average postoperative hemoglobin (last measured before discharge) was 9.0 ±â€Š1.2 g/dL. One patient received a transfusion of 270 mL homologous blood. Blood salvage and reinfusion ("cell-saver") was not used. No patient was managed with antifibrinolytic drugs. CONCLUSION: Minimizing blood loss using a combination of surgical and anesthesia techniques can effectively eliminate the need for blood transfusion. The elimination of costly adjuncts increases the value of a complex orthopedic procedure.Level of Evidence: 5.

Predictors and prescribing patterns of opioid medications surrounding reverse shoulder arthroplasty.

BACKGROUND: Opioid analgesics play an essential role in postoperative pain management; however, they are also associated with high rates of abuse and decreased patient outcomes. With the declaration of the recent opioid crisis, more scrutiny has been placed on physicians and their prescribing habits, and orthopedic surgeons have been shown to be the third-largest providers of opioids. Many patients undergoing reverse shoulder arthroplasty (RSA) have acute and chronic pain and may be prescribed opioids. The purpose of this study was to understand opioid-prescribing patterns across all specialties for patients undergoing RSA. METHODS: A retrospective review of preoperative and postoperative opioid use in 407 patients who underwent RSA from 2012 to 2015 was performed. Demographic data including age, sex, race, ethnicity, body mass index, American Society of Anesthesiologists class, and smoking status were recorded. Opioid prescriptions within 90 days before and after surgery were collected using state-mandated prescription drug-monitoring databases. Prescriber specialty was recorded, and prescriptions were categorized as follows: orthopedic surgery, primary care or internal medicine, pain management and anesthesia, dentistry, and emergency medicine. RESULTS: The cohort was composed of 236 women (58.0%) and 171 men (42.0%). The average age was 71 years. Forty-six percent of patients received preoperative prescriptions, of which 24.7% were written by orthopedic surgeons and 60.0% were written by internal medicine specialists. Preoperatively, 20% of patients received >3 prescriptions for opioids, and postoperatively, 36.4% of patients received >3 opioid prescriptions. Fifty-nine percent of all postoperative prescriptions were written by orthopedists, and 35.2% were written by internal medicine specialists. CONCLUSION: Not surprisingly, orthopedic surgeons prescribed the majority of postoperative prescriptions. Increased awareness, however, of preoperative prescribing habits by other specialty providers may be needed, with communication of their prescriptions to orthopedists, as preoperative use is the strongest predictor of postoperative dependence on opioids. Physicians should be aware of the number of patients receiving multiple prescriptions and their contribution to dependence with continued refills postoperatively. Therefore, surgeons must be more meticulous in assessing opioid consumption before surgery, as well as which providers are writing prescriptions after surgery, to limit opioid dispensation.

Cochlear Implantation and Facial Nerve Synkinesis in an Infant with Hypoplastic Internal Auditory Canals - A Case Report.

Sensorineural hearing loss (SNHL) is a common finding in cases of the congenital internal acoustic canal (IAC) stenosis. Previous reports reveal a relationship between IAC stenosis and facial palsy as well as vestibular dysfunction. This case identifies a patient with bilateral profound SNHL, bilateral IAC stenosis, and temporary unilateral facial palsy who went on to receive bilateral cochlear implants (CI). The facial nerve synkinesis that was found in this patient with hypoplastic IACs occurred after a cochlear implant activation. The synkinesis was ipsilateral to prior transient facial palsy after salmonella infection. Patients with IAC stenosis and cochlear nerve hypoplasia may respond well to cochlear implantation, but caution should be used when considering CI with an emphasis on counseling for possible facial nerve complications.

How to Prevent K-Wire Bounce in Oblique Supracondylar Humerus Fractures.

Supracondylar humerus fractures with an obliquely oriented fracture pattern can pose a clinical challenge in obtaining adequate fixation. Traditionally, 1.6-mm Kirchner wires are used for fracture fixation when pinning pediatric supracondylar humerus fractures. However, when pinning across obliquely oriented fractures, the angle of pin inclination may increase to the point where the 1.6-mm k-wire cannot penetrate the far cortex. We have found that, when pinning oblique supracondylar humerus fractures, utilization of a 2.0-mm k-wire can assist the surgeon in obtaining bicortical purchase. We present a cadaveric study demonstrating the maximal angles at which both 1.6-mm and 2.0-mm k-wires will penetrate the far cortex. This technical trick can give surgeons a relatively simple solution to treat these difficult fractures.