Trends in Management and Cost Burden of Facial Fractures: A 14-Year Analysis.

OBJECTIVE: To discuss patient demographics and management and better understand the economic impact associated with the treatment of facial fractures at a major metropolitan level 1 trauma center. STUDY DESIGN: Retrospective chart review. METHODS: We identified 5088 facial fractures in 2479 patients who presented from 2008 to 2022. Patient demographics, mechanism of injury, associated injuries, treatment information, and hospital charges were collected and analyzed to determine factors associated with surgical management and increased cost burden. RESULTS: Our 14-year experience identified 1628 males and 851 females with a mean age of 45.7 years. Orbital fractures were most common (41.2%), followed by maxilla fractures (20.8%). The most common mechanism was fall (43.0%). Surgical management was recommended for 41% of patients. The odds of surgical management was significantly lower in female patients, patients age 65 and older, and patients who presented after the onset of the COVID-19 pandemic. The odds of surgical management was significantly higher for patients who had a mandible fracture or greater than 1 fracture. The average cost of management was highest for naso-orbito-ethmoidal fractures ($37,997.74 ± 52,850.88), followed by LeFort and frontal fractures ($29.814.41 ± 42,155.73 and $27,613.44 ± 39.178.53, respectively). The highest contributor to the total average cost of management was intensive care unit-related costs for every fracture type, except for mandible fractures for which the highest contributor was operating room (OR)-related costs. CONCLUSIONS: This study represents one of the largest comprehensive databases of facial fractures and one of the first to provide a descriptive cost analysis of facial trauma management. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:3120-3126, 2024.

Augmented Virtual Examination for Cosmetic and Functional Rhinoplasty.

Background: Few studies have critically evaluated the quality of data obtained during telemedical evaluations of patients with nasal complaints. Objective: To compare the quality of data provided by remote endoscopic and external nasal examination with those by in-person evaluations for rhinoplasty and functional nasal surgery, measured by detectability of anatomic features, and to assess associated patient experience measured by reported ease, discomfort, and likelihood of peer recommendation. Materials and Methods: Twenty healthy subjects performed a nasal self-examination using an endoscope and webcam under remote videoconferencing service (VCS) guidance. They subsequently underwent in-person examination and were surveyed about their experience. Inter-rater reliability was calculated using kappa coefficients. Detectability of anatomic features by in-person versus virtual examination was compared using Wilcoxon and chi-square tests. Results: Median subject age was 27.5 years (range 23-77). Kappa coefficients were 0.78 for in-person and 0.66 for virtual evaluations. Only the internal nasal valve and inferior turbinate were better visualized in person. There were no differences between detectability of external features on in-person versus virtual examinations. Subjects' average likelihood of recommending this technology (1-10) was 8.65 (SD 1.4). Conclusions: Intranasal examination by physician-guided remote endoscopy and webcam-based facial analysis demonstrate nasal anatomy comparable with in-person evaluation and anterior rhinoscopy.

Augmented otorhinologic evaluation in telemedical visits.

PURPOSE: To determine if an endoscopic otologic and rhinologic examination performed by a patient and interpreted remotely by an otolaryngologist is non-inferior to in-person examination, and to assess the feasibility of this system for telemedical visits. MATERIALS AND METHODS: Twenty healthy subjects performed a self-examination of their ears and nose using a commercially available endoscope under remote guidance by an otolaryngology provider over Zoom. This same provider and another otolaryngologist also performed separate, in-person examinations of each subject and rated their findings. Finally, both providers blindly reviewed a video recording of each virtual exam four weeks later and rated their findings. Subjects were surveyed about their experience. Interrater reliability was calculated using Cohen's kappa coefficients and the ability to detect different anatomic structures and features by in-person vs. virtual examination was compared using Wilcoxon tests and Chi-squared proportion tests. RESULTS: The subjects' average age was 30 (SD 11.5) years. Interrater reliability was excellent; kappa coefficients were 0.72 and 0.81 (p < 0.001) for virtual and in-person exams, respectively. Of the 3 anatomic structures within the ear exam, none showed a difference in detectability between virtual and in-person exams. Of the 12 structures in the nasal exam, 3 were better visualized in-person and 9 showed no difference. Subject satisfaction was excellent; the average likelihood of recommending this virtual technology to peers (1-10) was 8.65 (SD 1.4). CONCLUSIONS: Patient self-examination of the ears and nose using a portable endoscope may be an effective strategy for obtaining valuable data during telemedical otolaryngology visits.

Critical Degree of Orbital Floor Displacement Drives Operative Repair of Zygomaticomaxillary Complex Fractures: Findings from a 10-Year Retrospective Study.

Among zygomaticomaxillary complex (ZMC) fractures presenting to a tertiary urban academic center, the authors hypothesized the presence of both clinical and radiographic predictors of operative management. The investigators conducted a retrospective cohort study of 1,914 patients with facial fractures managed at an academic medical center in New York City between 2008 and 2017. The predictor variables were based on both clinical data and features of pertinent imaging studies, and the outcome variable was an operative intervention. Descriptive and bivariate statistics were computed and the p-value was set at 0.05. In total, 196 patients sustained ZMC fractures (5.0%) and 121 (61.7%) ZMC fractures were treated surgically. All patients who presented with globe injury, blindness, retrobulbar injury, restricted gaze, or enophthalmos and a concurrent ZMC fracture were managed surgically. The most common surgical approach was the gingivobuccal corridor (31.9% of all approaches), and there were no significant immediate postoperative complications. Younger patients (38.9 ± 18 years vs. 56.1 ± 23.5 years, p < 0.0001) and patients with greater than or equal to 4 mm of orbital floor displacement were more likely to receive surgical treatment than observation (82 vs. 56%, p = 0.045), as were patients with comminuted orbital floor fractures (52 vs. 26%, p = 0.011). In this cohort, patients more likely to undergo surgical reduction were young patients with ophthalmologic symptoms on presentation and at least 4 mm displacement of the orbital floor. Low kinetic energy ZMC fractures may warrant surgical management as often as high-energy ZMC fractures. While orbital floor comminution has been shown to be a predictor for operative reduction, in this study we also demonstrated a difference in the rate of reduction based on the severity of orbital floor displacement. This may have significant implications in both the triage and selection of patients most suitable for operative repair.

Applying Occam's Razor and Descending the Reconstructive Ladder: The Modified Cheek Advancement Flap for Reconstruction of Nasal Defects.

Nasal reconstruction has important functional and cosmetic considerations, as proper repair of nasal defects is necessary to maintain function of the nasal airway and to recreate the normal appearance of this central facial structure. Cheek advancement flaps provide matched, mobile, and highly vascularized tissue for the reconstruction of nasal defects, allowing for the concealment of incisions within natural creases in a one-stage approach. However, cheek advancement flaps are often underutilized for nasal reconstruction because of their difficulty in restoring nasal contour. We describe reconstruction of 19 nasal dorsal and sidewall defects 0.8 to 3 cm in size. We incorporated a periosteal anchoring suture to maintain/restore nasal contour and additionally removed a half standing cone inferior to the defect to prevent encroachment of the nasal ala or alar crease. All patients were evaluated at least 3 months postoperatively. In all patients, we were able to restore concavity of the nasofacial sulcus, preserve the biconvex nasal tips, prevent alar flaring and retraction, and conserve the alar groove. All patients had excellent functional and cosmetic outcomes. We believe this modified cheek advancement flap provides functionally and aesthetically superior results and can be considered as a first-line approach for repair of nasal dorsal and sidewall defects in subselected patients.

Essential inpatient otolaryngology: what COVID-19 has revealed.

PURPOSE: To identify areas of critical otolaryngology contributions to inpatient care resistant to disruption by the COVID-19 pandemic. METHODS: Medical records of 614 otolaryngology consults seen between January and June of 2019 and 602 seen between January and June of 2020 were reviewed. Extracted data included patient demographics, SARS-CoV-2 status, medical comorbidities, consult location, consult category, reason for consult, procedures performed, and overall outcome. Prevalence of data items was compared using t tests and Chi-squared tests. RESULTS: The number of monthly consults to the otolaryngology service remained approximately stable after the onset of the COVID-19 pandemic. However, there was a substantial increase in ICU consults and a decrease in ER and floor consults. The proportion of otology, rhinology, and head and neck consults decreased while that of airway consults-most of which were tracheostomy-related-greatly increased. While the top ten reasons for consult remained essentially the same, they dramatically increased as a percentage of consults during COVID-19 (55-92%), whereas there was a dramatic decrease in the proportion of less frequent consults. CONCLUSION: The changes in otolaryngology consultation patterns seen after the onset of the pandemic are multifactorial, but may be attributed to novel pathologies, attitudes, and policies. Nonetheless, these patterns reveal that a set of core otolaryngologic issues, including acute airway issues, head and neck lesions, severe sinusitis and epistaxis, are essential and need to be addressed in the inpatient setting, whereas the significant drop in other consults suggests that they may be appropriately managed on an outpatient basis.

Patient-Reported Pain and Opioid Use After Ambulatory Head and Neck Surgery.

OBJECTIVE: The main objective of this study was to quantify daily pain and opioid use in patients after hemithyroidectomy and cervical lymph node biopsy (CLNB). The secondary objective was to identify factors associated with decreased pain and opioid use. STUDY DESIGN: Prospective cohort study from June 2017 to February 2019. Patients were given paper surveys to record daily postoperative opioid use and maximal pain on a visual analog scale. SETTING: Single institution (NewYork-Presbyterian/Weill Cornell Medical Center). METHODS: All adult patients undergoing hemithyroidectomy and CLNB by a single surgeon were consecutively selected for participation. Patients recorded daily pain and opioid analgesic use over a 2-week postoperative period. RESULTS: Of 33 patients enrolled, 29 (87.9%) returned a survey. Thirteen underwent CLNB, and 16 underwent hemithyroidectomy. Pain resolved after both procedures by the end of the 2-week period. CLNB patients used a median (interquartile range) of 15.0 (0-41.2) morphine milligram equivalents (MME), and 95% used 70 or fewer MME. Hemithyroidectomy patients used a median of 8.2 (4.5-13.9) MME, and 95% used 30 or fewer MME. Use of nonopioid analgesics was associated with a statistically significant decrease in pain (56.1 vs 171 visual analog scale, 95% confidence interval [CI] of Δ = [12.0 to 217.8]) and opioid use (12.2 vs 48.8 MME, 95% CI of Δ = [5.0 to 68.1 MME]) in CLNB but not in hemithyroidectomy. CONCLUSION: Patients have low pain and opioid requirements after hemithyroidectomy and CLNB. Head and neck surgeons should evaluate their opioid-prescribing patterns for opportunities to safely decrease postoperative prescriptions.

Injury Patterns in Pediatric Facial Fractures Unique to an Urban Environment.

This study aimed to define better the clinical presentation, fracture patterns, and features predictive of associated injuries and need for surgery in pediatric facial trauma patients in an urban setting. Charts of patients 18 years or younger with International Classification of Disease 9th and 10th revision (ICD-9/ICD-10) codes specific for facial fractures (excluding isolated nasal fractures) at NY-Presbyterian/Weill Cornell Medical Center between 2008 and 2017 were retrospectively reviewed. Of 204 patients, most were referred to the emergency department by a physician's office or self-presented. Children (age 0-6 years) were most likely to have been injured by falls, while more patients 7 to 12 years and 13 to 18 years were injured during sporting activities (p < 0.0001). Roughly half (50.5%) of the patients had a single fracture, and the likelihood of surgery increased with greater numbers of fractures. Older patients with either orbital or mandibular fractures were more likely to undergo surgery than younger ones (p = 0.0048 and p = 0.0053, respectively). Cranial bone fractures, CSF leaks, and intracranial injuries were more common in younger patients (p < 0.0001) than older patients and were more likely after high energy injuries; however, 16.2% of patients sustaining low energy injuries also sustained cranial bone, CSF leak, or intracranial injury. In an urban environment, significant pediatric facial fractures and associated injuries may occur after nonclassic low kinetic energy traumatic events. The age of the patient impacts both the injuries sustained and the treatment rendered. It is essential to maintain a high index of suspicion for associated injuries in all pediatric facial trauma patients.