Vibration Versus Ice to Reduce Cosmetic Botulinum Toxin Injection Pain-A Randomized Controlled Trial.

Botulinum toxin is the most commonly performed facial cosmetic procedure and pain at the injection site is a frequent patient concern. While various topical interventions have been described for analgesia, there have not been any studies comparing different techniques. We compared the use of a vibratory stimulus, ice pack application, and no intervention on injection site pain for cosmetic botulinum toxin injection. A prospective-, randomized-, individual-controlled study was conducted using a visual analog scale to assess pain. Patients received bilateral glabellar injections, with randomization into unilateral vibration, unilateral ice application, or vibration and ice on either side. We analyzed 88 injections on 22 patients. Mean visual analog scores were 26.5 (standard deviation [SD]: 23.1) among injections with vibration, 24.4 (SD: 22.9) with ice, and 29.4 (SD: 27.1) without analgesia. There was no significant difference in pain scale scores with the use of vibration, ice, or no topical anesthesia (P = .737). Further, pain scale scores did not differ significantly between medial and lateral injections nor did patients have a reduction in pain on either side of the forehead regardless of which method was used. While there may be a role for topical interventions to improve injection site analgesia, we maintain that consistently proper technique plays a greater role in improving patient tolerance. Future studies will continue to investigate the role of topical anesthesia in cosmetic facial injections and address patient-specific factors contributing to discomfort.

Associations between population based voting trends during the 2016 US presidential election and adolescent vaccination rates.

BACKGROUND: Politics play a role in the dissemination of public health information, including immunization-related issues. We aim to describe relationships between HPV vaccination rates and state voting patterns during the 2016 US presidential election. METHODS: We classified each of the 50 states as either "Red" or "Blue," based on whether a higher proportion of the state's casted votes were for the Republican or Democratic nominee during the 2016 US presidential election. State-specific HPV, Tdap, and meningococcal vaccination rates were obtained from the 2016-National Immunization Survey-Teen. State socio-demographic factors and HPV vaccine legislation were obtained from the US Census Bureau and National Conference of State Legislatures. Vaccination rates and socio-demographic variables were compared using independent t-tests. Multiple linear regression compared vaccination rates between "Red" and "Blue" states, adjusting for percentage of both uninsured children and educational attainment. RESULTS: Compared to "Blue" states, "Red" states had significantly lower unadjusted HPV vaccine series initiation (56% vs 66%, p < 0.05) and completion (39% vs 50%, p < 0.05) rates; yet had similar rates of Tdap (88% vs 89%, p > 0.05) and meningococcal (79% vs 83%, p > 0.05) vaccinations. After adjusting for potential confounders, the regression-adjusted mean rate for HPV vaccine initiation and completion remained significantly lower for "Red" states compared to "Blue" states (57% vs 65%, p < 0.05, and 41% vs 48%, p < 0.05, respectively). CONCLUSION: HPV vaccination rates are associated with statewide-level voting patterns. Future interventions aimed at improving HPV vaccination rates should consider engaging local and national elected leaders to be proactive in disseminating accurate and authoritative immunization information.

Septal fractures predict poor outcomes after closed nasal reduction: Retrospective review and survey.

OBJECTIVES/HYPOTHESIS: To determine outcomes of patients with displaced nasal bone fractures after closed nasal reduction (CNR). STUDY DESIGN: Retrospective patient review. METHODS: Review of all patients presenting to the emergency department of a tertiary-care, level 1 trauma hospital with a nasal bone fracture over a 2-year period, followed by telephone survey after CNR. RESULTS: Six hundred seven patients presented to the emergency department in 2015 and 2016 with a diagnosis of nasal bone fracture. Of these, 134 patients met inclusion criteria and underwent CNR without septal reduction. Those with sports-related injuries and those with a septal fracture identified on computed tomography imaging were significantly more likely to undergo CNR. Ninety-one patients completed the post-CNR telephone survey. Over 90% of patients were satisfied with the procedure. However, patients with septal fractures reported worse outcomes, as 53.6% versus 24.1% (P = .0025) disagreed that CNR improved nasal breathing. Of all patients, 11 (2%) eventually underwent septorhinoplasty, with the presence of septal fracture on imaging a significant risk factor. CONCLUSIONS: Nasal bone fractures are a common injury, often managed initially with CNR. Patients with septal fractures should be counseled on the high risk of posttraumatic nasal deformity and obstruction despite CNR. In addition, addressing a septal fracture found on imaging may be warranted with either closed septal reduction or early aggressive management given the poorer outcomes seen in the present study. Although these patients are more likely to have definitive treatment, many forego later intervention despite persistent symptoms, emphasizing the need for early intervention or close follow-up. LEVEL OF EVIDENCE: 3 Laryngoscope, 129:1784-1790, 2019.

Audiovestibular symptoms as predictors of prolonged sports-related concussion among NCAA athletes.

OBJECTIVE: We looked to determine the rates of audiovestibular symptoms following sports-related concussions among collegiate athletes. Further, we assessed the correlation between these symptoms and the time to return to participation in athletic activity. STUDY DESIGN: Retrospective analysis of the National Collegiate Athletic Association Injury Surveillance System (NCAA-ISS). METHODS: The NCAA-ISS was queried from 2009 through 2014 for seven men's sports and eight women's sports across divisions 1, 2, and 3. Injuries resulting in concussions were analyzed for audiovestibular symptoms, duration of symptoms, and return to participation times. RESULTS: From 2009 to 2014, there were 1,647 recorded sports-related concussions, with athletes reporting dizziness (68.2%), imbalance (35.8%), disorientation (31.4%), noise sensitivity (29.9%), and tinnitus (8.5%). Concussion symptoms resolved within 1 day (17.1%), within 2 to 7 days (50.0%), within 8 to 30 days (25.9%), or persisted over 1 month (7.0%). Return to participation occurred within 1 week (38.3%), within 1 month (53.0%), or over 1 month (8.7%). Using Mann-Whitney U testing, overall symptom duration and return to competition time were significantly increased when any of these symptoms were present (P < 0.05). Duration of concussion symptom correlated with dizziness (P = 0.043) and noise sensitivity (P = 0.000), whereas return to participation times correlated with imbalance (P = 0.011) and noise sensitivity (P = 0.000). Dizziness and imbalance (odds ratio: 4.15, confidence interval: 3.20-5.38, P < 0.001) were the two symptoms with the strongest association. CONCLUSION: Audiovestibular symptoms are common complaints among collegiate athletes sustaining concussions. Dizziness and noise sensitivity correlated with the duration of concussive symptoms, whereas imbalance and noise sensitivity was correlated with prolonged return to competition time. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2850-2853, 2017.

Maxillofacial injuries among National Collegiate Athletic Association athletes: 2004-2014.

OBJECTIVE: Participation in National Collegiate Athletic Association (NCAA) sports increases annually, yet the risk of maxillofacial injuries among these athletes is unknown. We report the incidence and trends in maxillofacial injuries among NCAA athletes. STUDY DESIGN: Retrospective study of the NCAA Injury Surveillance System (ISS) representing athletes from seven men's and eight women's sports across Divisions 1, 2, and 3. Incidence of maxillofacial injuries by sport, gender, anatomic location, and injuries requiring surgery were measured. METHODS: Athlete exposure data from 2004 to 2005 through 2013 to 2014 were analyzed, along with maxillofacial injuries recorded in the NCAA-ISS. RESULTS: There were 2,017 injuries recorded, which projects to 41,204 injuries from 202,087,229 athlete events, or 2.04 injuries per 10,000 athlete events (95% confidence interval [CI], 1.68 to 2.40). Women had higher injury rates, 2.06 versus 2.03 (P = 0.016 [95% CI 0.22 to 2.09]). Highest rates were noted in men's wrestling 7.02 (95% CI, 2.84 to 11.19) and men's basketball 4.80 (95% CI, 3.57 to 6.02), and were lowest in women's ice hockey 0.61 (95% CI, 0.17 to 1.06) and women's volleyball 0.43 (95% CI, 0.20 to 0.66). No gender differences in fractures or need for surgery, but men sustained more operative fractures, 27.85% versus 17.04% (P = 0.035 [95% CI, 0.79 to 20.82]). Men's football, women's ice hockey, women's volleyball, and women's gymnastics had consistently low fracture rates. CONCLUSION: Maxillofacial injuries represent approximately 3.4% of all injuries sustained by NCAA athletes. Women had a higher injury rate, whereas men had a higher rate of operative facial fractures. Awareness and improved facial protection, especially among noncontact sports, will be crucial in reducing the incidence of these injuries. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1296-1301, 2017.

Decade review of mandible fractures and arch bar impact on outcomes of nonsubcondylar fractures.

OBJECTIVES/HYPOTHESIS: Review trends in mandible fracture management and outcomes in patients treated with and without intraoperative arch bar use. STUDY DESIGN: Retrospective chart review. METHODS: All patients with mandible fractures between October 1, 2001, and October 1, 2011, were reviewed. Excluded were those with concomitant midfacial fractures or inadequate follow-up. RESULTS: Overall, 734 patients sustained 1,312 mandible fractures. Assault was the most common etiology. The parasymphyseal, subcondylar, and angle regions were most likely fractured. In total, 85% of patients underwent open-reduction internal-fixation (ORIF). This overall number had no significant annual deviation. However, use of arch bars to achieve intraoperative maxillomandibular fixation (MMF) with ORIF decreased annually, whereas the use of manual reduction with ORIF increased annually. These trends held statistical significance. Outcomes were reviewed in patients with one or two nonsubcondylar fractures by assessing complications of malocclusion, infection, and malunion. In 228 patients meeting criteria, the incidence of complications was 12.9% in those treated using intraoperative arch bars with ORIF and 12.5% in those using manual reduction with ORIF. When assessing individual complications, there was no statistically significant difference. CONCLUSION: Our data suggest a shifting trend in mandible fracture management. Our techniques for achieving fracture reduction ideal for ORIF favors manual reduction over the use of arch bars in select cases. We found no statistical increase in the incidence of complications when using manual reduction with ORIF in patients with one and two nonsubcondylar fractures. In appropriately selected cases, manual stabilization of fractured segments is an alternative to using arch bars to achieve intraoperative MMF. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:596-601, 2016.

Update on approaches to the craniomaxillofacial skeleton.

PURPOSE OF REVIEW: A myriad of surgical approaches to the craniomaxillofacial skeleton exist. Depending on the purpose of the procedure and the anatomic area to be addressed, classically used approaches include coronal approach, midfacial degloving, eyelid incisions, and other cutaneous incisions. Over the last decade, endoscopic approaches have become more popular. Whether external, transoral, or endoscopic, a detailed knowledge of the indications, anatomy, limitations, and potential complications is critical to the successful employment of these approaches. This article reviews the recent literature on classic as well as novel advancements to the craniofacial skeleton. RECENT FINDINGS: Multiple studies in the last 5 years have investigated the approaches to the craniofacial skeleton. Most of these focus on trauma. Recent advances have concentrated on external versus endoscopic approaches to the mandibular condyle, an endoscopic approach to the midface and orbit, three-dimensional imaging of the facial skeleton, and improving upon the existing classic approaches and techniques. SUMMARY: Approaches to the craniomaxillofacial skeleton continue to evolve with the refinement of classic approaches and advent of new technologies and approaches. This study reviews the recent literature and provides a comprehensive review of options for craniofacial exposure and the most up-to-date surgical options.

Tissue conservation using circular defect with dog-ear deformities excision technique.

OBJECTIVES: Compare circular defect with dog-ear deformities excision (CDDE) technique to 3:1 fusiform excision technique when removing facial lesions to analyze which technique provides superior wound closure. METHODS: Identical 1-cm circular skin defects were created on bilateral cheek, forehead, and parietal scalp on three fresh cadavers. Similarly, using four fresh cadavers, identical 2-cm circular skin defects were created on bilateral cheek, forehead, and scalp. In both the 1-cm and 2-cm circular defects (n = 19), a 3:1 fusiform excision and closure was performed on one side of the cadaver head for control. On the opposite side, CDDE excision technique was performed. The following measurements were recorded: circumferential incision length after tissue excision, average of wound widening widths after an approximation suture was placed at the halfway point, and the final incision length after primary closure. Final incision length upon closure was divided by the original defect size to obtain a final incision length to defect ratio. A paired t-test was performed on all variables for analysis. RESULTS: When using the CDDE excision technique, there were statistically significant decreases in circumference, average wound widening, final incision length in both 1-cm and 2-cm circular defects (P < .01). The final incision length upon closure to defect ratio in CDDE excision was approximately 2.5:1, whereas 3:1 fusiform excision resulted in the final incision length to defect ratio of approximately 3.5:1. CONCLUSIONS: When compared to fusiform excision technique, CDDE excision technique appears to minimize tissue excision, decrease wound widening and the final incision length.

Reconstruction of eyelid defects.

Reconstruction of the eyelids is highly complex because of their function and critical role in appearance. Optimal restoration of their form and function depends on a firm understanding of normal eyelid position, the structural support system of the eyelids, and the forces that act to keep the eyelids in precise balance. With this knowledge, the surgeon can choose among numerous reconstructive techniques to correct a deficit, depending on its location, depth, and size, while restoring normal eyelid function and an esthetically pleasing form. This article reviews the pertinent eyelid anatomy, describes methods for analysis of eyelid position before and after surgery, and discusses the structural restoration options for commonly encountered eyelid defects.

The effects of sound conditioning on gentamicin-induced vestibulocochlear toxicity in gerbils.

OBJECTIVES/HYPOTHESIS: Recent studies in animal models have shown via physiologic and histologic measures that the administration of exogenous antioxidants is protective against gentamicin-induced oto-vestibulo toxicity. In addition, studies have also shown that sound conditioning increases cochlear antioxidants. The objective of this study is to determine whether sound conditioning provides protection against gentamicin in the cochlear and/or vestibular system. STUDY DESIGN: : Prospective animal study. METHODS: Three-month-old gerbils were divided into three groups (A, B, and C). The gerbils in group A were sound conditioned only (n = 2). In group B, the animals received gentamicin on the round window (n = 2). The gerbils in group C were sound conditioned first and later received gentamicin to the round window (n = 2). The animals were ultimately sacrificed and their right cochlea and posterior crista ampullaris were removed, processed, and sectioned. The specimens were analyzed for inner hair cell (IHC) and outer hair cell (OHC) loss and vestibular supporting and sensory hair cell nuclei per micrometer of vestibular epithelium. RESULTS: The sound-conditioned group (A) had no loss of cochlear hair cells. The gerbils treated with gentamicin only (B) had a 34% decrease of OHCs and 49% decrease of IHCs. The sound-conditioned plus gentamicin-treated group (C) had a 5.5% decrease in OHCs and 12% decrease in IHCs. There were no significant differences with regards to supporting cell nuclei within the posterior crista across all groups. When compared to group A, the gerbils in groups B and C did have a 23 to 42% decrease in the number of sensory cell nuclei per micrometer of vestibular epithelium. CONCLUSIONS: Sound conditioning does appear to attenuate the effects of gentamicin in the cochlea, although not significantly altering its vestibulotoxicity. An upregulation of cochlear-specific antioxidants is believed to be an important factor. As we had a small sample size, we can only note trends in the data, but future studies with more animals and measurements of antioxidant levels after sound conditioning would be useful to quantify this effect and determine if it can be exploited clinically. Laryngoscope, 2009.

Update on perioral cosmetic enhancement.

PURPOSE OF REVIEW: As our understanding of the perioral region advances and procedures available for its treatment increase, we are more able to successfully treat the aged perioral region with minimal risk. The aged perioral region has traditionally been rejuvenated by direct surgical excision, chemical peels, and laser resurfacing. Many minimally invasive techniques are now employed for this purpose, including chemodenervation, use of soft tissue fillers, and fat grafting. RECENT FINDINGS: Over the last couple of decades, rejuvenation techniques have evolved to include chemodenervation, soft tissue fillers, fat grafting, and dermabrasion. The present article will review the most recent literature regarding the use of these techniques for various perioral age-related changes, including rhytids, labiomental folds, nasolabial folds, lip-cheek grooves, and thinning lips. Often, these modalities are combined to give the most natural aesthetic result. SUMMARY: An increase in our armamentarium of techniques and general understanding of the complex perioral region allows us to treat the area quite effectively with minimal risk. Volume loss, a key component of perioral aging, is best addressed with soft tissue fillers and autologous fat. In addition, botulinum toxin helps rest some of the key muscles responsible for perioral rhytids. Facial resurfacing techniques are still crucial adjuncts in the rejuvenation of this area, and they may be the only treatment that adequately addresses multiple deeper perioral rhytids.

Day float: an alternative to the night float coverage system for residency programs.

OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) has mandated an 80-hour work week that has resulted in changes to many residency programs. In otolaryngology, most programs have switched to either home call or night float systems. Our department covers all of the maxillofacial trauma and backup airway calls, which has made it difficult to employ a home call system. Instead of a night float coverage system, our program implemented a day float coverage system that allows the residents to participate in a 24-hour call period. After call and sign-out, the residents go home; however, their clinical duties are covered by the day float resident. STUDY DESIGN: A brief review of the literature pertaining to call coverage systems followed by a description of our day float system. Residents who have participated in either night float, day float, or both systems were then surveyed regarding their experiences or perceptions of both systems. METHODS: A nine-question survey was handed out to our otolaryngology residents and their responses were recorded. RESULTS: The averaged responses strongly favored the day float over the night float coverage system regardless of the level of training and the systems in which the residents have participated. CONCLUSIONS: The day float coverage system is favored by residents in our program. It allows for a more attending-like 24-hour period of call, continuity of care, attendance at educational activities, and more time with family. In addition, it eliminates a prolonged period devoid of clinical activities.

The use of fibrin glue for fixation of acellular human dermal allograft in septal perforation repair.

OBJECTIVES: Acellular human dermal allograft used as an interpositional graft between mucoperichondrial flaps has been shown to be effective in the repair of septal perforations. The material is typically sutured to the septum, but this can be technically difficult. We describe a technique in which fibrin glue is used to secure the acellular human dermal allograft for septal perforation repair. STUDY DESIGN: A retrospective case series of 5 patients who underwent this procedure are reviewed. METHODS: Five patients with preexisting septal perforations underwent septal repair using fibrin glue to secure the interpositional acellular human dermal allograft. The graft was first placed between the mucoperichondrial flaps, and 1/3 cm(3) of fibrin glue was applied to both sides. One side was then covered with a bipedicled mucosal flap and compressed for 5 minutes to allow for fixation. RESULTS: The use of fibrin glue compared with conventional suturing decreased the length of the procedure by approximately 30 minutes. At the 3-month postoperative examination, all 5 patients were found to have successful outcomes. CONCLUSION: The use of fibrin glue for fixation of the acellular human dermal allograft in septal perforation repair is technically less difficult and reduces the length of the procedure, and we believe it reduces graft migration when compared with conventional suturing techniques.

Nontraumatic cerebrospinal fluid rhinorrhea as a result of pseudotumor cerebri.

OBJECTIVE: The purpose of this study is to demonstrate that pseudotumor cerebri, also known as benign intracranial hypertension, can be an overlooked cause of spontaneous, nontraumatic cerebrospinal fluid (CSF) rhinorrhea. STUDY DESIGN AND METHODS: This study presents a literature review and 2 case reports. The medical records of 2 patients who had nontraumatic CSF rhinorrhea were reviewed. RESULTS: The patients were diagnosed as having spontaneous, nontraumatic CSF rhinorrhea, believed to have been caused by pseudotumor cerebri, and were surgically treated. The patients are obese, middle-aged women. CONCLUSIONS: Cerebrospinal fluid rhinorrhea is most often the result of trauma, but it may also occur spontaneously because of nontraumatic causes in some patients. Pseudotumor cerebri can be an overlooked cause of spontaneous, nontraumatic CSF rhinorrhea. A patient with signs and symptoms of pseudotumor cerebri should be evaluated and treated, if the condition is present, to prevent complications that include irreversible visual loss and CSF rhinorrhea.

Floating the uvula: an intraoperative method for detecting bifidity.

A bifid uvula, midline diastasis of the palatal muscles, and notching of the posterior hard palate have classically formed a triad diagnosing submucosal clefts. The uvula has thus served as a tool for clinicians to detect the earliest signs of clefting. In this case report, we discuss how mucosal lining may be held together by mucous viscosity, making it difficult to detect notching or a grossly bifid uvula. We demonstrate a simple intraoperative technique to easily overcome this force. This paper involves a case report of an 8-year-old female undergoing an adenotonsillectomy. A previously undetected bifid uvula was found only after floating the uvula in normal saline solution. This changed our surgical approach from a complete to a partial adenoidectomy. A bifid uvula may be considered the earliest form of a cleft palate, and more importantly, it has been shown in the literature to be associated with other anomalies as submucosal cleft, hyoplastic eustachian tube orifice, and absence of the salpingopharyngeal folds. The intraoperative technique of floating the uvula helps to overcome mucous viscosity and identify an otherwise missed bifid uvula.