Opioid Prescribing Practice and Needs in Thyroid and Parathyroid Surgery.

Importance: In recent years, the medical community's inadvertent contribution to opioid addiction has been recognized. Objective: To determine the opioid prescribing practices and opioid needs for patients undergoing thyroid and parathyroid surgery to help reduce postoperative opioid administration. Design, Setting, and Participants: This retrospective cohort study included 1788 opioid-naive patients who underwent thyroid and parathyroid surgery from January 1, 2012, through December 31, 2017, at the high-volume academic endocrine surgery center at Oregon Health and Sciences University. Patients with long-term opioid treatment and those who underwent other head and neck procedures or robotic thyroidectomy were excluded. For analysis, 1765 procedures were available (723 parathyroidectomy, 400 hemithyroidectomy, and 642 total thyroidectomy). Main Outcomes and Measures: The quantity of prescribed opioids was determined in morphine milligram equivalents (MME). Opioid refill data after discharge were also analyzed. Patients were then divided into past (1336 in group 1 [January 1, 2012, to September 30, 2016]) and current (429 in group 2 [October 31, 2016, to December 31, 2017]) prescribing practices. For each procedure, the mean quantity prescribed for each group, difference between the means, 95% CI for the difference, and effect size were calculated. Results: A total of 1702 patients (80.0% female [n = 1361]; mean age, 51.2 years [range, 7-97 years]) undergoing 1765 procedures were included in the analysis. For parathyroidectomy, the mean (SD) opioid quantity prescribed was 176.20 (86.66) MME in group 1 vs 80.08 (74.43) MME in group 2 (effect size, 1.139); for hemithyroidectomy, 204.65 (112.24) MME in group 1 vs 112.24 (102.31) MME in group 2 (effect size, 0.842); and for total thyroidectomy, 214.87 (161.09) MME for group 1 vs 102.29 (87.72) MME for group 2 (effect size, 0.754). In the last quarter of 2017, the numbers of patients discharged without any opioid prescription were 15 of 26 (57.5%) for parathyroidectomy, 12 of 32 (37.5%) for hemithyroidectomy, and 9 of 27 (33.3%) for total thyroidectomy. Patient calls requesting pain medications for group 2 were similar or fewer, depending on the procedure. Those who were prescribed less than 75.0 MME postoperatively did not call for additional opioid prescriptions. Conclusions and Relevance: Our study suggests that patients undergoing thyroid and parathyroid surgery need little, if any, postoperative opioids.

Effect of gentamicin and levels of ambient sound on hearing screening outcomes in the neonatal intensive care unit: A pilot study.

OBJECTIVE: Hearing loss rates in infants admitted to neonatal intensive care units (NICU) run at 2-15%, compared to 0.3% in full-term births. The etiology of this difference remains poorly understood. We examined whether the level of ambient sound and/or cumulative gentamicin (an aminoglycoside) exposure affect NICU hearing screening results, as either exposure can cause acquired, permanent hearing loss. We hypothesized that higher levels of ambient sound in the NICU, and/or gentamicin dosing, increase the risk of referral on the distortion product otoacoustic emission (DPOAE) assessments and/or automated auditory brainstem response (AABR) screens. METHODS: This was a prospective pilot outcomes study of 82 infants (<37 weeks gestational age) admitted to the NICU at Oregon Health & Science University. An ER-200D sound pressure level dosimeter was used to collect daily sound exposure in the NICU for each neonate. Gentamicin dosing was also calculated for each infant, including the total daily dose based on body mass (mg/kg/day), as well as the total number of treatment days. DPOAE and AABR assessments were conducted prior to discharge to evaluate hearing status. Exclusion criteria included congenital infections associated with hearing loss, and congenital craniofacial or otologic abnormalities. RESULTS: The mean level of ambient sound was 62.9 dBA (range 51.8-70.6 dBA), greatly exceeding American Academy of Pediatrics (AAP) recommendation of <45.0 dBA. More than 80% of subjects received gentamicin treatment. The referral rate for (i) AABRs, (frequency range: ∼1000-4000 Hz), was 5%; (ii) DPOAEs with a broad F2 frequency range (2063-10031 Hz) was 39%; (iii) DPOAEs with a low-frequency F2 range (<4172 Hz) was 29%, and (iv) DPOAEs with a high-frequency F2 range (>4172 Hz) was 44%. DPOAE referrals were significantly greater for infants receiving >2 days of gentamicin dosing compared to fewer doses (p = 0.004). The effect of sound exposure and gentamicin treatment on hearing could not be determined due to the low number of NICU infants without gentamicin exposure (for control comparisons). CONCLUSION: All infants were exposed to higher levels of ambient sound that substantially exceed AAP guidelines. More referrals were generated by DPOAE assessments than with AABR screens, with significantly more DPOAE referrals with a high-frequency F2 range, consistent with sound- and/or gentamicin-induced cochlear dysfunction. Adding higher frequency DPOAE assessments to existing NICU hearing screening protocols could better identify infants at-risk for ototoxicity.

Aesthetics of the Nasal Dorsum: Proportions, Light, and Shadow.

Due to its central location, the nose plays a prominent role in facial aesthetics. As tastes have shifted and techniques have advanced, the accepted "ideal" appearance and proportions of the nose have evolved over time. By assessing the aesthetics of the nasal dorsum through the use of lines and angles, one can more precisely elucidate a goal for the patient's postoperative nasal shape, which should, in turn, guide the surgeon to execute specific operative maneuvers needed to achieve that contour. In assessing the aesthetics of the nasal dorsum, practitioners calculate and observe aspects such as the paired dorsal aesthetic lines, the nasofrontal angle, and the nasofacial angle. There is also additional consideration given to nasal tip position as this must fit harmoniously with the shape of the dorsum. In contrast to the established aesthetic lines and angles, using nasal geometric polygons for the aesthetic evaluation and development of operative goals in rhinoplasty has recently been described in the literature. Constructed ideals, in the form of proportions, lines, and angles, should be used with caution, as there are many factors to consider in the aesthetic analysis of the nasal dorsum, including ethnic differences, and subjective and changing views of beauty.

Benign radiographic coronal synostosis after sagittal synostosis repair.

Whether cranial vault remodeling surgery for nonsyndromic, isolated sagittal suture synostosis affects the patency of initially normal, unaffected sutures is unknown. The influence of coronal and lambdoidal suture patency after cranial vault remodeling on the trajectory of subsequent cranial growth is also unknown. Disruption of normal sutural anatomy during cranial vault reconstruction could influence the incidence of secondary craniosynostosis and need for reoperation in a small proportion of these patients.We performed a retrospective review of patients younger than 1 year with nonsyndromic sagittal synostosis treated at a single tertiary referral pediatric hospital from September 2005 to January 2010 by an interdisciplinary team. Computed tomographic images obtained preoperatively, immediately postoperatively, and 2 years postoperatively were evaluated for the occurrence of secondary synostosis of initially nonsynostotic sutures. Craniofacial disorders clinic and ophthalmologic follow-up records were also analyzed for the occurrence of radiographic cranial restenosis, clinical or ophthalmologic signs of intracranial hypertension (ICH), and reoperation.Fifty-one patients younger than 1 year underwent primary surgical repair of isolated, nonsyndromic sagittal suture synostosis during the study period. Thirty-seven of these patients (71%) had completed 2-year clinical and radiographic follow-up by the time of analysis, constituting the study population. The average age at surgery was 5.4 months (range, 3.1-11.5 months). Thirty-three (89%) of the 37 study patients showed radiographic evidence of bilateral secondary coronal synostosis (SCS). Five patients (15%) additionally showed partial lambdoid synostosis. One patient with radiographic SCS (3%) required reoperation for radiographic cranial restenosis, clinical signs and symptoms of ICH, and papilledema first noted 1 year after primary cranial vault reconstruction.There is a high incidence of secondary coronal suture synostosis following cranial vault remodeling for isolated, nonsyndromic sagittal synostosis. Postoperative SCS was only rarely associated with secondary radiographic cranial stenosis, clinical or ophthalmologic signs of ICH, and the need for reoperation.