Otolaryngology-Head and Neck Surgery, Vol 143, No 2S2, August 2010
surgical treatment, which is only available in certain military facilities. If a strong association exists between massive facial trauma and eye and brain injuries, then providers could use this information to assist in triaging patients for medical evacuation to the appropriate higher level facility. Additionally, massive facial trauma has not previously been defined, and understanding this injury pattern will allow providers to manage massive facial injuries more efficiently. METHOD: This study is a retrospective review of American military members who sustained traumatic facial injuries from improvised explosive devices and were treated at the 332nd Air Force Theater Hospital in Iraq from October 1, 2004, through September 30, 2007. Facial trauma was defined as any injury to the facial soft tissue and/or skeleton. Massive facial trauma was defined as any injury to the face involving three or more facial aesthetic units. The anatomic injury patterns, injury severity scores and the blood product transfusion rates of simple and massive facial trauma were compared. Statistical analysis was performed using 2 tests and the Mann-Whitney test. Statistical significance was set at p ⬍ 0.05. RESULTS: One hundred and four representative patients who sustained facial trauma from improvised explosive device blasts were reviewed, including seventy-five patients with facial trauma and twenty-nine patients meeting the criteria for massive facial trauma. The forehead, cheeks and nose were the most commonly injured facial units in the massive facial trauma group. The average injury severity score was 13.9 in the simple facial trauma group and 21.7 in the massive facial trauma group (p ⬍ 0.004). Sixteen (55%) of the patients in the massive facial trauma group received blood product transfusion compared with only twenty-one (28%) in the simple facial trauma group (p ⬍ 0.009). The rate of associated eye injury was 55% in the massive facial trauma group and 27% in the simple facial trauma group (p ⬍ 0.006). Brain injuries were described in 48% of the patients with massive facial trauma and 28% of the patients with simple facial trauma (p ⬍ 0.05). Patients with massive facial trauma were noted to have both eye and brain injuries 14% of the time, while patients with simple facial trauma sustained both eye and brain injuries 5% of the time (p ⬍ 0.0008). CONCLUSION: For the first time, massive facial trauma is defined as soft tissue injury to three or more facial aesthetic units with or without associated facial fractures. Applying this definition to patients with facial injury from improvised explosive devices effectively identifies patients who are more likely to have higher injury severity scores and an increased risk for eye and brain injuries requiring urgent evaluation by surgical subspecialists. Additionally, individuals with massive facial trauma from improvised explosive devices have a statistically higher rate of receiving blood product transfusions in the combat theater. Initial rapid facial trauma assessment by first responders may be useful in expediting evacuation or allocating appropriate medical resources for patients with massive facial trauma.
The Alar Sliding Graft for Better Alar Base Narrowing Ahmed Ismail, PhD (presenter) OBJECTIVE: 1) Demonstrates the efficacy of the alar sliding graft in getting better alar contour results in cases of alar base narrowing. 2) Illustrates the different surgical techniques for alar base reduction and the success rates of each technique. METHOD: This is a retrospective study of the alar sliding graft technique in cases of alar base narrowing. This technique was applied on 59 patients needing alar base reduction, either separately or in combination with different rhinoplasty techniques. The alar sliding graft is harvested from the nasal septal cartilage during septoplasty (36 cases, 61%) or from a separate incision in patients who are only undergoing alar base reduction (12 cases, 20.3%), or rhinoplasty surgery alone (11 cases, 11.7%). Introduction of the alar sliding graft is performed through a lateral incision at the nasofacial groove after creating a tunnel through the alar margin to a point just lateral to the lateral edge of nasal dome. Evaluation of the surgical outcome was performed 1, 6, and 12 months post-operatively using doctor and patient assessment scores, together with measuring the degree of alar flare. RESULTS: Patient satisfaction was excellent to good in 54 patients (91.5%). Two patients (3.4%) recorded fair results, while 3 patients (5.1%) recorded poor results. Doctor satisfaction was 56 (94.9%) as excellent to good, one patient (1.7%) as fair, and two patients (3.4%) as poor results. CONCLUSION: The alar sliding graft had been used for many years for correcting alar collapse and expanding the nasal tip, in hard cases of retracted alar margin, in revision rhinoplasty. To my knowledge, this is the first study to discuss the use of the alar sliding graft in patients undergoing alar base reduction for better alar contour. The patient and doctor satisfaction is encouraging. Compared to previous results from the literature, this technique gives better cosmetic results and is easy to apply and learn. Tissue Expansion of Radial Forearm Free Flap Donor Sites Martin Corsten, MD, FRCSC (presenter); Murray Allen, MD OBJECTIVE: Determine the long term cosmetic and functional outcomes of radial forearm free flap donor sites after pre-operative tissue expansion. METHOD: A randomized controlled trial was conducted over a 2-year period from May 2008 until Feb 2010. 24 patients with head and neck cancer requiring reconstruction with a radial forearm free-flap (RFFF) were randomly assigned to either the treatment (pre-operative tissue expansion) or control group. The Patient and Observer Scar Assessment Scale (PAOSAS) was used to assess the patients’ and expert observers’ assessment of forearm cosmetics while The Michigan
Ultrasonic Shears in the Harvest of Microvascular Free Flaps Cody Koch, MD, PhD (presenter); Steven Olsen, MD; Eric Moore, MD OBJECTIVE: The purpose of this study was to determine whether the use of ultrasonic shears in the harvest of microvascular free-flaps reduces operative time while maintaining acceptable outcomes. METHOD: Prospective non-randomized trial of the use of ultrasonic shears in the harvest of fibula and anterolateral thigh microvascular free-flaps used in head and neck reconstruction from October 2005 through December 2009 at a tertiary referral center. RESULTS: There were 108 fibula and anterolateral thigh free-flaps enrolled in the study. Ultrasonic shears were used in 53 fibula and 26 anterolateral thigh free-flaps while the traditional clamp-cut-tie method of harvesting was used in 16 fibula and 13 anterolateral thigh free-flaps. The average time of fibula free-flap harvest with ultrasonic shears was significantly reduced at 48.2 ⫹/- 4.3 minutes compared to controls at 62.7 ⫹/9.0 minutes (p0.05). CONCLUSION: The use of ultrasonic shears for the harvest of microvascular free-flaps for head and neck reconstruction significantly increases the efficiency by reducing operative time without an increased risk of complications. The reduced operating room time leads to significantly reduced costs.
General Otolaryngology Celecoxib and Pregabalin for Tonsillectomy Pain Patrick Murphy, MD, FRCSC (presenter) OBJECTIVE: To test the hypothesis that the combination of celecoxib and pregabalin does not increase the incidence of
secondary post-tonsillectomy bleeding by more than 5% compared to the use of opioids alone. METHOD: Based on a sample size calculation, a total of 305 charts of patients undergoing tonsillectomy using the electrocautery technique were retrospectively reviewed. Primary and secondary post-tonsillectomy bleeding was identified as was presentation to the emergency department for pain or dehydration. Non-inferiority testing was used with an equivalence margin of 5%. RESULTS: 176 patients received opioids while 129 received the new routine. The secondary bleeding rate was 9.1% for the New Routine and 13.7% for opioids. The 95% confidence interval comparing the bleeding rate of the New Routine to Opioids was -10.4% to ⫹1.4% (p⫽0.004). Significantly more patients receiving Opioids presented to the emergency department for pain or dehydration (8.8% vs 0.8%, P⬍0.002). CONCLUSION: Although overall secondary bleeding rates were higher than expected, there is no evidence that the combination of celecoxib, pregabalin and tramadol increases in the incidence of post-operative bleeding by more than 5%. Interestingly, the combination of celecoxib and pregabalin resulted in a lower bleeding rate. All patients also used a topical NSAID mouth wash (benzydamine) post-op, which may have contributed to the high bleeding rates. Future prospective studies are required. Comparing Sleep Endoscopy to Mallampati and Mu¨ller Maneuver Ismet Emre, MD (presenter); Senol Civelek, MD; Muge Ozcelik, MD; Suat Turgut, MD; Birsen Eksioglu Karaci, MD OBJECTIVE: Our main objective was to evaluate if sleep endoscopy findings were in correlation with the Mu¨ller maneuver findings in accordance with the site of obstruction and whether the Mallampati score is an actual indicator of the level of obstruction as seen on sleep endoscopy. An additional result was obtained in the comparison of the Mallampati score with the Mu¨ller maneuver. METHOD: The study was a prospective randomized clinical trial. The study was carried out in 9 months. 40 Patients with OSAS were included in the study. All patients were examined for the Mallampati score, then underwent flexible nasoendoscopy for the Mu¨ller maneuver and finally were sedated in the operating theater where sleep endoscopy was performed. The T-test was used to determine the average of basic data-independent variables (Age, EUS, BMI, AHI, and Neck Circumference Measurement). The McNemar test, used to assess the results of dependent groups, was used to compare the results of the examinations. The compatibility of the findings of the Mallampati test and sleep endoscopy was assessed via the kappa test, and for values lower then 0.50 it was accepted that the two methods were not similar in terms of their distinctive marks.
Hand Questionnaire was used to assess patients’ hand function at 10 months post-op. An ANOVA was used for each dependent variable with significance defined as a p-value less than 0.015. RESULTS: Pre-operative tissue expansion decreased the use of a distant split-thickness skin graft (STSG) for closure of a RFFF defect by 93%. Expert observers noted improved scar cosmetics in the treatment group (p equals 0.003) with primary closure having the best cosmetic outcome (p less than 0.001). There were no significant differences between treatment groups with respect to cosmetics as assessed by patients (p equals 0.7), wrist ROM (p greater than 0.4) or hand function (p greater than 0.3). CONCLUSION: Although expert observers noted improvements in forearm scar cosmetics when using tissue expansion, there were no significant improvements noted by patients’ assessments. Nevertheless, the use of a new, inexpensive and non-traumatic tissue expansion device is a safe method to reduce the need for a STSG when closing RFFF donor sites.