Pediatric Midface Fractures: Outcomes and Complications of 218 Patients

Objective To analyze management, outcomes, and complications of pediatric midface fractures. Methods Retrospective cohort study at an urban, single‐institution, multispecialty surgical teams, at two level 1 pediatric trauma centers. Query included subjects aged 0–17 diagnosed with midface fractures between 2012 and 2016. Results A total of 218 pediatric patients presented with 410 total midface fractures. The most common etiologies included motor vehicle collisions (MVC) (n = 56, 25.7%), sport‐related (n = 35, 16.1%), and assault/battery (n = 32, 14.7%). Fracture site distribution included: 125 maxillary (34 with exclusively the nasal/frontal process), 109 nasal, 47 ethmoid, 40 sphenoid, 33 zygoma, 29 frontal sinus, 21 lacrimal, and 6 palatal. Among these, there were 105 orbital, 17 naso‐orbito‐ethmoid, and 12 Le Fort fractures. One‐quarter of patients received at least one midface‐related operation during the initial encounter. Operative intervention rates for specific midface fracture subsites were not significantly different (X2 = 6.827, P = .234). One hundred thirty‐five patients (63.4%) attended follow‐up, thus known complication rate was 14.6% (n = 31). Complication rates between midface fracture subsites were not significantly different (X2 = 5.629, P = .229). Complications included facial deformity (n = 18), nasal airway obstruction (n = 8), diplopia (n = 4), hardware‐related pain (n = 3), and paresthesias (n = 3). Conclusions The most common sites of pediatric midface fractures involved the maxilla, and nasal bones. Three quarters of pediatric midface fractures were treated conservatively, with low rates of complications. Facial deformity was the most common complication; as such, proper management and follow‐up are important to ensure normal growth and development of the pediatric facial skeleton. Level of Evidence

Cadaveric Simulation of Otologic Procedures: An Analysis of Droplet Splatter Patterns During the COIVD-19 Pandemic

Objective. The otolaryngology community has significant concerns regarding the spread of SARS-CoV-2 through droplet contamination and viral aerosolization during head and neck examinations and procedures. The objective of this study was to investigate the droplet and splatter contamination from common otologic procedures. Study Design. Cadaver simulation series. Setting. Dedicated surgical laboratory. Methods. Two cadaver heads were prepped via bilateral middle cranial fossa approaches to the tegmen (n = 4). Fluorescein was instilled through a 4-mm burr hole drilled into the middle cranial fossa floor, and presence in the middle ear was confirmed via microscopic ear examination. Myringotomy with ventilation tube placement and mastoidectomy were performed, and the distribution and distance of resulting droplet splatter patterns were systematically evaluated. Results. There were no fluorescein droplets or splatter contamination observed in the measured surgical field in any direction after myringotomy and insertion of ventilation tube. Gross contamination from the surgical site to 6 ft was noted after complete mastoidectomy, though, when performed in standard fashion. Conclusion. Our results show that there is no droplet generation during myringotomy with ventilation tube placement in an operating room setting. Mastoidectomy, however, showed gross contamination 3 to 6 ft away in all directions measured. Additionally, there was significantly more droplet and splatter generation to the left of the surgeon when measured at 1 and 3 ft as compared with all other measured directions

COVID-19 Status Differentially Affects Olfaction: A Prospective Case-Control Study

Objective The symptoms and long-term sequelae of SARS-CoV-2 infection have yet to be determined, and evaluating possible early signs is critical to determine which patients should be tested and treated. The objective of this ongoing study is to evaluate initial and short-term rhinologic symptoms, olfactory ability, and general quality of life in patients undergoing SARS-CoV-2 testing. Study Design Prospective case-control. Setting Academic institute. Methods Adult patients tested for SARS-CoV-2 were prospectively enrolled and separated into positive and negative groups. Each participant completed 4 validated patient-reported outcome measures. The UPSIT (University of Pennsylvania Smell Identification Test) was distributed to patients who were SARS-CoV-2 positive. Results The positive group reported significantly decreased sense of smell and taste on the 22-item Sinonasal Outcome Test (SNOT-22) as compared with the negative group (mean ± SD: 3.4 ± 1.7 vs 1.2 ± 1.4, P < .001). The positive group had a much higher probability of reporting a decrease in smell/taste as “severe” or “as bad as it can be” (63.3% vs 5.8%) with an odds ratio of 27.6 (95% CI, 5.9-128.8). There were no differences between groups for overall SNOT-22 domain scores, PHQ-4 depression/anxiety (Patient Health Questionnaire−4), and 5-Level EQ-5D quality-of-life scores. Mean Self-MOQ (Self-reported Mini Olfactory Questionnaire) scores were 7.0 ± 5.6 for the positive group and 1.8 ± 4.0 for the negative group (P < .001). The mean UPSIT score was 28.8 ± 7.2 in the positive group. Conclusion Symptomatic patients who are SARS-CoV-2 positive report severe olfactory and gustatory dysfunction via the Self-MOQ and SNOT-22 as compared with symptomatic patients testing negative

Mitigation of Aerosols Generated During Rhinologic Surgery: A Pandemic-Era Cadaveric Simulation

Objective: After significant restrictions initially due to the COVID-19 pandemic, otolaryngologists have begun resuming normal clinical practice. However, the risk of SARS-CoV2 transmission to health care workers through aerosolization and airborne transmission during rhinologic surgery remains incompletely characterized. The objective of this study was to quantify the number concentrations of aerosols generated during rhinologic surgery with and without interventions involving 3 passive suction devices. Study Design: Cadaver simulation. Setting: Dedicated surgical laboratory. Subjects and Methods: In a simulation of rhinologic procedures with and without different passive suction interventions, the concentrations of generated aerosols in the particle size range of 0.30 to 10.0 mm were quantified with an optical particle sizer. Results: Functional endoscopic sinus surgery with and without microdebrider, high-speed powered drilling, use of an ultrasonic aspirator, and electrocautery all produced statistically significant increases in concentrations of aerosols of various sizes (P \.05). Powered drilling, ultrasonic aspirator, and electrocautery generated the highest concentration of aerosols, predominantly submicroparticles \1 mm. All interventions with a suction device were effective in reducing aerosols, though the surgical smoke evacuation system was the most effective passive suction method in 2 of the 5 surgical conditions with statistical significance (P \.05). Conclusion. Significant aerosol concentrations were produced in the range of 0.30 to 10.0 mm during all rhinologic procedures in this cadaver simulation. Rhinologic surgery with a passive suction device results in significant mitigation of generated aerosols

Aerosol generation during cadaveric simulation of otologic surgery and live cochlear implantation

Objective The risk of SARS‐CoV‐2 transmission to healthcare workers through airborne aerosolization during otologic surgery has not been characterized. The objective of this study was to describe and quantify the aerosol generation during common otologic procedures in both cadaveric surgical simulation and live patient surgery. Methods The number concentrations of generated aerosols in the particle size range of 0.30 to 10.0 μm were quantified using an optical particle sizer during both a cadaveric simulation of routine otologic procedures as well as cochlear implant surgery on live patients in the operating room. Results In the cadaveric simulation, temporalis fascia graft harvest using cold techniques (without electrocautery) (n = 4) did not generate aerosols above baseline concentrations. Tympanoplasty (n = 3) and mastoidectomy (n = 3) both produced statistically significant increases in concentrations of aerosols (P < 0.05), predominantly submicron particles (< 1.0 μm). High‐speed, powered drilling of the temporal bone during mastoidectomy with a Multi Flute cutting burr resulted in higher peak concentrations and greater number of spikes in aerosols than with a diamond burr. In the operating room, spikes in aerosols occurred during both cochlear implant surgeries. Conclusion In the cadaveric simulation, temporalis fascia graft harvest without electrocautery did not generate aerosol levels above baseline, while significant aerosol levels were generated during mastoidectomy and to a much less degree during tympanoplasty. Aerosol spikes were appreciated during cochlear implantation surgery in live patients

Sarcopenia is associated with blood transfusions in head and neck cancer free flap surgery

Objective: To determine if sarcopenia is a predictor of blood transfusion requirements in head and neck cancer free flap reconstruction (HNCFFR). Methods: A single-institution, retrospective review was performed of HNCFFR patients with preoperative abdominal imaging from 2014 to 2019. Demographics, comorbidities (modified Charlson Comorbidity Index [mCCI]), skeletal muscle index (cm2/m2), oncologic history, intraoperative data, and 30-day postoperative complications (Clavien-Dindo score [CD]) were collected. Binary logistic regression was performed to determine predictors of transfusion. Results: Eighty (33.5%), 66 (27.6%), and 110 (46.0%) of n = 239 total patients received an intraoperative, postoperative, or any perioperative blood transfusion, respectively. Sixty-two (25.9%) patients had sarcopenia. Patients receiving intraoperative transfusions had older age (P = .035), more frequent alcoholism (P = .028) and sarcopenia (P < .001), greater mCCI (P < .001), lower preoperative hemoglobin (P < .001), reconstruction with flaps other than forearm (P = .003), and greater operative times (P = .001), intravenous fluids (P < .001), and estimated blood loss (EBL, P < .001). Postoperative transfusions were associated with major complications (CD ≥ 3; P < .001). Multivariate regression determined sarcopenia (P = .023), mCCI (P = .013), preoperative hemoglobin (P = .002), operative time (P = .036), and EBL (P < .001) as independent predictors of intraoperative transfusion requirements. Postoperative transfusions were predicted by preoperative hemoglobin (P = .007), osseous flap (P = .036), and CD ≥ 3 (P < .001). A perioperative transfusion was predicted by sarcopenia (P = .021), preoperative hemoglobin (P < .001), operative time (P = .008), and CD ≥ 3 (P = .018). Conclusion: Sarcopenia is associated with increased blood transfusions in HNCFFR. Patients should be counseled preoperatively on the associated risks, and the increased blood product requirement should be accounted in resource-limited scenarios

Aerosol generation during routine rhinologic surgeries and in-office procedures

Objective Cadaveric simulations have shown endonasal drilling and cautery generate aerosols, which is a significant concern for otolaryngologists during the COVID‐19 era. This study quantifies aerosol generation during routine rhinologic surgeries and in‐office procedures in live patients. Methods Aerosols ranging from 0.30 to 10.0 μm were measured in real‐time using an optical particle sizer during surgeries and in‐office procedures. Various mask conditions were tested during rigid nasal endoscopy (RNE) and postoperative debridement (POD). Results Higher aerosol concentrations (AC) ranging from 2.69 to 10.0 μm were measured during RNE (n = 9) with no mask vs two mask conditions (P = .002 and P = .017). Mean AC (0.30‐10.0 μm) were significantly higher during POD (n = 9) for no mask vs a mask covering the patient's mouth condition (mean difference = 0.16 ± 0.03 particles/cm3, 95% CI 0.10‐0.22, P < .001). There were no discernible spikes in aerosol levels during endoscopic septoplasty (n = 3). Aerosol spikes were measured in two of three functional endoscopic sinus surgeries (FESS) with microdebrider. Using suction mitigation, there were no discernible spikes during powered drilling in two anterior skull base surgeries (ASBS). Conclusion Use of a surgical mask over the patient's mouth during in‐office procedures or a mask with a slit for an endoscope during RNE significantly diminished aerosol generation. However, whether this reduction in aerosol generation is sufficient to prevent transmission of communicable diseases via aerosols was beyond the scope of this study. There were several spikes in aerosols during FESS and ASBS, though none were associated with endonasal drilling with the use of suction mitigation

Aerosol and droplet generation from mandible and midface fixation: Surgical risk in the pandemic era

This article is made available for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.Purpose The COVID-19 pandemic has led to concerns over transmission risk from healthcare procedures, especially when operating in the head and neck such as during surgical repair of facial fractures. This study aims to quantify aerosol and droplet generation from mandibular and midface open fixation and measure mitigation of airborne particles by a smoke evacuating electrocautery hand piece. Materials and methods The soft tissue of the bilateral mandible and midface of two fresh frozen cadaveric specimens was infiltrated using a 0.1% fluorescein solution. Surgical fixation via oral vestibular approach was performed on each of these sites. Droplet splatter on the surgeon's chest, facemask, and up to 198.12 cm (6.5 ft) away from each surgical site was measured against a blue background under ultraviolet-A (UV-A) light. Aerosol generation was measured using an optical particle sizer. Results No visible droplet contamination was observed for any trials of mandible or midface fixation. Total aerosolized particle counts from 0.300–10.000 μm were increased compared to baseline following each use of standard electrocautery (n = 4, p < 0.001) but not with use of a suction evacuating electrocautery hand piece (n = 4, p = 0.103). Total particle counts were also increased during use of the powered drill (n = 8, p < 0.001). Conclusions Risk from visible droplets during mandible and midface fixation is low. However, significant increases in aerosolized particles were measured after electrocautery use and during powered drilling. Aerosol dispersion is significantly decreased with the use of a smoke evacuating electrocautery hand piece

Aerosol and droplet generation from orbital repair: Surgical risk in the pandemic era

This article is made available for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.Introduction The highly contagious COVID-19 has resulted in millions of deaths worldwide. Physicians performing orbital procedures may be at increased risk of occupational exposure to the virus due to exposure to secretions. The goal of this study is to measure the droplet and aerosol production during repair of the inferior orbital rim and trial a smoke-evacuating electrocautery handpiece as a mitigation device. Material and methods The inferior rim of 6 cadaveric orbits was approached transconjunctivally using either standard or smoke-evacuator electrocautery and plated using a high-speed drill. Following fluorescein inoculation, droplet generation was measured by counting under ultraviolet-A (UV-A) light against a blue background. Aerosol generation from 0.300–10.000 μm was measured using an optical particle sizer. Droplet and aerosol generation was compared against retraction of the orbital soft tissue as a negative control. Results No droplets were observed following the orbital approach using electrocautery. Visible droplets were observed after plating with a high-speed drill for 3 of 6 orbits. Total aerosol generation was significantly higher than negative control following the use of standard electrocautery. Use of smoke-evacuator electrocautery was associated with significantly lower aerosol generation in 2 of 3 size groups and in total. There was no significant increase in total aerosols associated with high-speed drilling. Discussion and conclusions Droplet generation for orbital repair was present only following plating with high-speed drill. Aerosol generation during standard electrocautery was significantly reduced using a smoke-evacuating electrocautery handpiece. Aerosols were not significantly increased by high-speed drilling

Gastrokine-1, an anti-amyloidogenic protein secreted by the stomach, regulates diet-induced obesity

Obesity and its sequelae have a major impact on human health. The stomach contributes to obesity in ways that extend beyond its role in digestion, including through effects on the microbiome. Gastrokine-1 (GKN1) is an anti-amyloidogenic protein abundantly and specifically secreted into the stomach lumen. We examined whether GKN1 plays a role in the development of obesity and regulation of the gut microbiome. Gkn1−/− mice were resistant to diet-induced obesity and hepatic steatosis (high fat diet (HFD) fat mass (g) = 10.4 ± 3.0 (WT) versus 2.9 ± 2.3 (Gkn1−/−) p < 0.005; HFD liver mass (g) = 1.3 ± 0.11 (WT) versus 1.1 ± 0.07 (Gkn1−/−) p < 0.05). Gkn1−/− mice also exhibited increased expression of the lipid-regulating hormone ANGPTL4 in the small bowel. The microbiome of Gkn1−/− mice exhibited reduced populations of microbes implicated in obesity, namely Firmicutes of the class Erysipelotrichia. Altered metabolism consistent with use of fat as an energy source was evident in Gkn1−/− mice during the sleep period. GKN1 may contribute to the effects of the stomach on the microbiome and obesity. Inhibition of GKN1 may be a means to prevent obesity