Faculty Bibliography

Importance/UNASSIGNED:Decision-making in the timing of tracheostomy in patients with coronavirus disease 2019 (COVID-19) has centered on the intersection of long-standing debates on the benefits of early vs late tracheostomy, assumptions about timelines of infectivity of the novel coronavirus, and concern over risk to surgeons performing tracheostomy. Multiple consensus guidelines recommend avoiding or delaying tracheostomy, without evidence to indicate anticipated improvement in outcomes as a result. Objective/UNASSIGNED:To assess outcomes from early tracheostomy in the airway management of patients with COVID-19 requiring mechanical ventilation. Design, Setting, and Participants/UNASSIGNED:A retrospective medical record review was completed of 148 patients with reverse transcriptase-polymerase chain reaction-confirmed COVID-19 requiring mechanical ventilation at a single tertiary-care medical center in New York City from March 1 to May 7, 2020. Interventions/UNASSIGNED:Open or percutaneous tracheostomy. Main Outcomes and Measures/UNASSIGNED:The primary outcomes were time from symptom onset to (1) endotracheal intubation, (2) tracheostomy; time from endotracheal intubation to tracheostomy; time from tracheostomy to (1) tracheostomy tube downsizing, (2) decannulation; total time on mechanical ventilation; and total length of stay. Results/UNASSIGNED:Participants included 148 patients, 120 men and 28 women, with an overall mean (SD) age of 58.1 (15.8) years. Mean (SD; median) time from symptom onset to intubation was 10.57 (6.58; 9) days; from symptom onset to tracheostomy, 22.76 (8.84; 21) days; and from endotracheal intubation to tracheostomy, 12.23 (6.82; 12) days. The mean (SD; median) time to discontinuation of mechanical ventilation was 33.49 (18.82; 27) days; from tracheostomy to first downsize, 23.02 (13.76; 19) days; and from tracheostomy to decannulation, 30.16 (16.00; 26) days. The mean (SD; median) length of stay for all patients was 51.29 (23.66; 45) days. Timing of tracheostomy was significantly associated with length of stay: median length of stay was 40 days in those who underwent early tracheostomy (within 10 days of endotracheal intubation) and 49 days in those who underwent late tracheostomy (median difference, -8; 95% CI, -15 to -1). In a competing risks model with death as the competing risk, the late tracheostomy group was 16% less likely to discontinue mechanical ventilation (hazard ratio, 0.84; 95% CI, 0.55 to 1.28). Conclusions and Relevance/UNASSIGNED:This cohort study from the first 2 months of the pandemic in New York City provides an opportunity to reconsider guidelines for tracheostomy for patients with COVID-19. Findings demonstrated noninferiority of early tracheostomy and challenges recommendations to categorically delay or avoid tracheostomy in this patient population. When aligned with emerging evidence about the timeline of infectivity of the novel coronavirus, this approach may optimize outcomes from tracheostomy while keeping clinicians safe.

General and local anesthetics are generally well tolerated in the healthy population. Complications may arise affecting the surgical and anesthetic course. We present a case of severe bradycardia and hypotension, along with ST depressions which developed following general anesthesia and local injection of lidocaine with epinephrine to the nose in a healthy male during routine otolaryngological surgery. Symptoms improved with atropine, epinephrine and chest compressions. Subsequent electrocardiogram and Troponin were abnormal, and normalized within days. Reviewing the literature, several possible etiologies arise. These include the Trigeminocardiac Reflex, Takotsubo cardiomyopathy and others. These are discussed and the condition's immediate management recommended.

Since its introduction by Smith and Robinson, the anterior approach to the subaxial cervical spine has become one of the standard procedures for numerous cervical spine pathologies, including, but not limited to degenerative disease, trauma, tumor, deformity, and instability. Along with its increasing popularity and improvements in anterior instrumentation techniques, a comprehensive knowledge of the surgical anatomy during the anterior exposure is critical for trainees and experienced spine surgeons alike to minimize the infrequent but potentially devastating risks associated with this approach. Understanding the anatomy and techniques to minimize damage to relevant structures can reduce the risks of developing notable postoperative complications and morbidity.

OBJECTIVE:To report the outcomes on a large series of elderly patients who underwent cochlear implantation (CI) surgery under local anesthesia with conscious sedation (LA-CS). METHODS:Retrospective chart review on 100 consecutive elderly patients (> 65 years) who underwent CI with LA-CS at a tertiary care center between August 2013 and January 2020. An age-matched control group of 50 patients who underwent CI with general anesthesia (GA) are used for comparison. Outcomes measured included time in the operating room, time in the postanesthesia care unit (PACU), and rate of adverse events. RESULTS:Cochlear implant surgery under LA-CS was successfully performed in 99 (99%) patients. One patient requiring conversion to GA intraoperatively. No patients in the LA-CS group experienced cardiopulmonary adverse events; however, three patients (6%) in the GA group experienced minor events including atrial fibrillation and/or demand ischemia. Overnight observation in the hospital due to postoperative medical concerns or prolonged wake-up from anesthesia was required in one patient (1%) from the LA-CS cohort and 12 patients (24%) from the GA cohort. Perioperative adverse events exclusive to the LA-CS group included severe intraoperative vertigo (8%), temporary facial nerve paresis (3%), and wound infection (1%). The average amount of time spent in the operating room was 37 minutes less for procedures performed under LA-CS compared to GA (P < .05). The average amount of time in recovery was similar for both groups (P > .05). CONCLUSION/CONCLUSIONS:Cochlear implant surgery under LA-CS offers many benefits and is a safe, feasible, and cost-effective alternative to GA when performed by experienced CI surgeons. LEVEL OF EVIDENCE/METHODS:3 Laryngoscope, 2020.

OBJECTIVE:We sought to determine the time course of clinical and histologic differences between aspirated inorganic and organic foreign bodies. STUDY DESIGN/METHODS:In-vivo METHODS: Twenty Sinclair miniature swine (Sus scrofa domesticus) were divided into two groups-inorganic or organic foreign bodies. Either an organic (peanut) or an inorganic (Lego) foreign body was placed within a bronchus and left for 3, 5, 7, 14 or 21 days. The airway was reassessed at the predetermined endpoint at which time endoscopic, gross, and histopathological findings were documented. Specimens were scored with a pathologic scoring system to assess injury severity from the foreign body. RESULTS:Foreign bodies were successfully placed in all 20 swine. Two animals required early euthanasia due to respiratory compromise. The foreign body was identified grossly in eight (40%) animals. An additional three (15%) had microscopic evidence suggestive of a previous foreign body of an undetermined duration. There was no difference in injury severity between organic and inorganic foreign bodies. The 3-day group had injuries limited to the bronchial lining, whereas the longer duration groups had bronchial and adjacent lung parenchymal involvement. There was no difference in injury severity between days 5 and 21. CONCLUSIONS:Airway foreign bodies initially cause bronchial damage. After 5 days, the foreign body causes lung parenchymal changes. There was no difference in airway lesion severity between organic and inorganic foreign bodies. LEVEL OF EVIDENCE/METHODS:N/A Laryngoscope, 2020.

OBJECTIVE:Electric cortical stimulation (ECS) has been the gold standard for intraoperative functional mapping in neurosurgery, yet it carries the risk of induced seizures. We assess the safety of focal cortical cooling (CC) as a potential alternative to ECS. METHODS:We reviewed 40 patients (13 with tumor and 27 with mesial temporal lobe epilepsy) who underwent intraoperative CC at the University of Iowa Hospital and Clinics (CC group), of whom 38 underwent ECS preceding CC. Intraoperative and postoperative seizure incidence, postoperative neurologic deficits, and new postoperative radiographic findings were collected to assess CC safety. Fifty-five patients who underwent ECS mapping without CC (ECS-alone group) were reviewed as a control cohort. Another 25 patients who underwent anterior temporal lobectomy (ATL) without CC or ECS (no ECS/no CC-ATL group) were also reviewed to evaluate long-term effects of CC. RESULTS:Seventy-nine brain sites in the CC group were cooled, comprising inferior frontal gyrus (44%), precentral gyrus (39%), postcentral gyrus (6%), subcentral gyrus (4%), and superior temporal gyrus (6%). The incidence of intraoperative seizure(s) was 0% (CC group) and 3.6% (ECS-alone group). The incidence of seizure(s) within the first postoperative week did not significantly differ among CC (7.9%), ECS-alone (9.0%), and no ECS/no CC-ATL groups (12%). There was no significant difference in the incidence of postoperative radiographic change between CC (7.5%) and ECS-alone groups (5.5%). Long-term seizure outcome (Engel I+II) for mesial temporal epilepsy did not differ among CC (80%), ECS-alone (83.3%), and no ECS/no CC-ATL groups (83.3%). CONCLUSIONS:CC when used as an intraoperative mapping technique is safe and may complement ECS.

OBJECTIVES/OBJECTIVE:Our objective was to identify gender differences in work-life balance, professional advancement, workload, salary, and career satisfaction among facial plastic and reconstructive surgeons. STUDY DESIGN/METHODS:Cross-Sectional Survey METHODS: American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) members were invited by email to respond to a confidential 25-question online survey. The survey had a response rate of 12%. There were a total of 139 participants; 23 participants were in training and 116 were either board-eligible or board-certified facial plastic surgeons. Collected variables included general demographics, personal life, academic involvement, career development, workload, and career satisfaction. RESULTS:Forty percent of participants were female. Fifty-nine percent of female participants were 25-35 years old compared with 15% of male participants. The majority of male participants were over 45 years old (63%) while only 19% of female participants fell into this age category (P < .0001). Women were more likely to be in a relationship with a physician (35% vs. 19%) or non-physician full-time professional (55% vs. 31%). The vast majority of men had children (89%) while only half of women (52%) had children. On average, women with children had fewer children than men (P < .0001). No gender difference was seen with respect to working full versus part-time (P = .81). Participants were equally satisfied with a surgical career regardless of gender. CONCLUSION/CONCLUSIONS:Although significant progress has already been made towards closing the gender gap, gender disparities remain both professionally and personally for facial plastic surgeons. With an increasing number of women in medicine, we should continue to strive to close the gender gap. LEVEL OF EVIDENCE/METHODS:4 Laryngoscope, 2020.

OBJECTIVES:While abducens nerve palsy (ANP) is a known risk in the setting of some endoscopic endonasal skull base surgery (ESBS), frequency and prognosis of post-operative palsy remain unknown. Our goals were to determine the frequency and prognosis of ANP after high-risk ESBS, and identify factors associated with recovery. METHODS:Retrospective case series of all patients with pathology at highest risk for abducens nerve injury (pituitary adenoma, chordoma, meningioma, chondrosarcoma, cholesterol granuloma) generated a list of patients with abducens nerve palsy after ESBS performed from 2011-2016. A validated ophthalmologic clinical grading scale measuring lateral rectus duction from 0 to -5 (full motion to inability to reach midline) was measured at multiple time points to assess recovery of ANP. RESULTS:Of 655 patients who underwent ESBS with increased risk of abducens injury, 40 (6.1%) post-operative palsies were identified and 39 patients with dedicated examination at multiple time points were included in subsequent analysis. Complete resolution was noted in 25 patients (64%) within 12 months. While 19 of 23 (83%) with a partial palsy had complete resolution, only six of 16 (38%) with a complete palsy resolved entirely (P = .005; Fisher's exact test). All six patients with delayed onset of palsy resolved (P = .070; Fisher's exact test). Meningioma and chordoma had higher rates of both temporary and permanent post-operative ANP (P < .0001; Fisher's exact). CONCLUSIONS:The frequency of post-operative ANP following ESBS is low, even in high-risk tumors. While only a minority of complete abducens nerve palsies recover, patients with partial or delayed palsy post-operatively are likely to recover function without intervention. LEVEL OF EVIDENCE:IV Laryngoscope, 131:513-517, 2021.

Although significant advances have been made in measuring the outcomes of rehabilitation interventions, comparably less progress has been made in measuring the treatment processes that lead to improved outcomes. A recently developed framework called the Rehabilitation Treatment Specification System (RTSS) has potential to identify which clinician actions (i.e., ingredients) actively improve specific patient functions (i.e., targets). However, the RTSS does not provide methodology for standardly identifying specific, unique targets or ingredients. Without a method to evaluate the uniqueness of an individual target or ingredient, it is difficult to know whether variations in treatment descriptions are synonymous (i.e., different words describing the same treatment) or meaningfully different (e.g., different words describing different treatments or variations of the same treatment). A recent project used vocal rehabilitation ingredients and targets to create RTSS-based lists of unique overarching target and ingredient categories with underlying dimensions describing how individual ingredients and targets vary within those categories. The primary purpose of this manuscript is to describe the challenges encountered during the project and the methodology developed to address those challenges. Since the methodology was based on the RTSS's broadly applicable framework, it can be used across all of rehabilitation regardless of the discipline (speech-language pathology, physical therapy, occupational therapy, psychology, etc.) or impairment domain (language, cognition, ambulation, upper extremity training, etc.). The resulting standard, operationalized lists of targets and ingredients have high face and content validity. The lists may also facilitate implementation of the RTSS in research, education, interdisciplinary communication, and everyday treatment.

PURPOSE/OBJECTIVE:Malignant fungating wounds (MFWs) afflict up to 14% of patients with advanced cancer. The bacterial community structures of MFW may influence the development and severity of wound symptoms. The purpose of this systematic review was to evaluate existing evidence regarding the relationship between microbiome and symptoms of MFWs. METHODS:A systematic review of the published literature from January 1995 to January 2020 was conducted. An established quality assessment tool was used to assess the quality of the included studies. SEARCH STRATEGY/METHODS:We searched 4 major electronic databases and retrieved 724 articles; 7 met inclusion criteria. FINDINGS/CONCLUSIONS/CONCLUSIONS:Seven studies were included; the overall quality of the included 7 studies was ranked as adequate. Findings from the studies provided an incomplete characterization of the microbiome and metabolome of MFW; none included modern genomic technologies. Twenty different species of aerobes and 14 species of anaerobes were identified, with inconsistent identification of biofilms and multi-drug-resistant bacteria. Symptom occurrence increased with the number of bacteria species (P = .0003) and the presence of at least 1 anaerobe (P = .0006) in malignant wound beds. Cancer wound-derived odor was associated with dimethyl trisulfide and 4 fatty acid volatiles. Periwound and moisture-associated skin damage were associated with higher putrescine levels in exudates. IMPLICATIONS/CONCLUSIONS:Understanding the role of microbiota of MFW in developing or amplifying the severity of wound symptoms is the first step toward development of more precise and effective topical interventions.