Brian S. Pan

Neonates with Tongue-Based Airway Obstruction A Systematic Review

Objective. In this systematic review, the authors summarize the current evidence in the literature regarding diagnosis, treatment, and long-term outcomes in neonates with tongue-based airway obstruction (TBAO) and assess the level of evidence of included studies. Data Sources. The terms Pierre Robin syndrome/sequence, micrognathia, retrognathia, and cleft palate were combined with airway obstruction, treatment, tongue-lip plication, and osteogenesis distraction to perform an Ovid literature search, yielding 341 references. The authors excluded references containing patients with isolated choanal/nasal obstruction, patients older than 12 months, and expert opinion papers, yielding 126 articles. Review Methods. The authors searched 3 electronic databases and reference lists of existing reviews from 1980 to October 2010 for articles pertaining to the diagnosis, treatment, and outcomes of TBAO. Reviewers assigned a level of evidence score based on Oxford’s Centre for Evidence Based Medicine scoring system and recorded relevant information. Results. Most studies were case studies and single-center findings. The lack of standardization of diagnostic and treatment protocols and the heterogeneity of cohorts both within and between studies precluded a meta-analysis. There was little evidence beyond expert opinion and single-center evaluation regarding diagnosis, treatment, and long-term outcomes of neonates with TBAO. Conclusions. The variability in the phenotype of the cohorts studied and the absence of standardized indications for intervention preclude deriving any definitive conclusions regarding diagnostic tools to evaluate this patient population, treatment choices, or long-term outcomes. A coordinated multicenter study with a standardized diagnostic and treatment algorithm is recommended to develop evidence for the diagnosis and treatment of neonates with TBAO.

Development of a Best Evidence Statement for the Use of Pressure Therapy for Management of Hypertrophic Scarring.

Pressure therapy has been considered standard, first-line intervention for the treatment of hypertrophic scars since its introduction in the 1960s. Although widely used, this scar management technique has historically been based on a wide array of anecdotal evidence as opposed to strong scientific support. Evidence has become more prevalent in recent years, necessitating a synthesis to develop an evidence-based clinical guideline. The clinical question was asked, “Among individuals with or at risk to develop active hypertrophic scars, does treatment with pressure therapy improve aesthetic and functional outcomes?” An evidence-based practice project was completed with aims to synthesize relevant literature to determine recommendations for the use of pressure therapy in individuals at risk for hypertrophic scars. A systematic search of the literature was conducted for the dates January 1950 to February 2014 of the following databases: MEDLINE, CINAHL, Cochrane Database for Systematic Reviews, Burntherapist.com, Cochrane Libraries, Ebsco, Google Scholar, OT Seeker, Ovid, MedLine, PEDro.org, Pubmed.gov, Pubmed Clinical Queries, and hand search of relevant articles through use of reference lists. Search terms included scar, hypertroph*, pressure therapy, compression therapy, pressure garment, burn, scald, trauma as well as MeSH terms cicatrix and hypertrophic. Articles were reviewed in terms of ability to answer the clinical question as well as strength of conclusions. A total of 45 articles were found and critiqued, 28 of which were relevant to the clinical question. Evidence strength ranged from level 1 to level 5. Results from the studies were synthesized to create clinical recommendations to guide treatment. Based on best available evidence, it is recommended that pressure therapy is utilized to decrease scar height and erythema that it is used for grafts and wounds requiring 14 to 21 days to heal, for 23 hours/day for 12 months, fit to achieve 20 to 30 mm Hg of pressure, fit by a skilled technician, and replaced every 2–3 months. In addition, it is not recommended that pressure therapy is used to treat abnormal pigmentation, nor used to hasten scar maturation. This literature search revealed insufficient evidence addressing the impact of pressure therapy on scar pliability. Among individuals with or at risk to develop active hypertrophic scars, treatment with pressure therapy does improve outcomes, particularly for aesthetic concerns including scar thickness and erythema. Applicability of research to practice: The practical treatment recommendations presented may improve consistency and efficacy of pressure therapy utilization at the point of care.

Management of the Acutely Burned Hand

Despite contributing a small percentage to the total body surface area, hands are the most commonly burned body part and are involved in over 90% of severe burns. Although the mortality of isolated hand burns is negligible, morbidity can be substantial given our need for functioning hands when performing activities of daily living. The greatest challenges of treating hand burns are 2-fold. First, determining the depth of injury can be difficult even for the most experienced surgeon, but despite many diagnostic options, clinical examination remains the gold standard. Second, appropriate postoperative hand therapy is crucial and requires a multidisciplinary approach with an experienced burn surgeon, hand surgeon, and hand therapist. Ultimately, the goals of treatment should include preservation of function and aesthetics. In this review, we present an approach to the management of the acutely burned hand with discussion of both conservative and surgical options. Regardless of the initial treatment decision, subsequent care for this subset of patients should be aimed at preventing debilitating postburn scar contractures that can severely limit hand function and ultimately require reconstructive surgery.

Face Masks for Noninvasive Ventilation: Fit, Excess Skin Hydration, and Pressure Ulcers

BACKGROUND: Pressure ulcers (stages III and IV) are serious safety events (ie, never events). Healthcare institutions are no longer reimbursed for costs to care for affected patients. Medical devices are the leading cause of pediatric pressure ulcers. Face masks for noninvasive ventilation were associated with a high percentage of pressure ulcers at our institution. METHODS: A prospective cohort study investigated factors contributing to pressure ulcer development in 50 subjects using face masks for noninvasive ventilation. Color imaging, 3-dimensional surface imaging, and skin hydration measurements were used to identify early skin compromise and evaluate 3 interventions to reduce trauma: (1) a silicone foam dressing, (2) a water/polyethylene oxide hydrogel dressing, and (3) a flexible cloth mask. A novel mask fit technique was used to examine the impact of fit on the potential for skin compromise. RESULTS: Fifty subjects age 10.4 ± 9.1 y participated with color images for 22, hydration for 34, and mask fit analysis for 16. Of these, 69% had diagnoses associated with craniofacial anomalies. Stage I pressure ulcers were the most common injury. Skin hydration difference was 317 ± 29 for sites with erythema versus 75 ± 28 for sites without erythema (P < .05) and smallest for the cloth mask (P < .05). Fit distance metrics differed for the nasal, oronasal, and face shield interfaces, with threshold distances being higher for the oronasal mask than the others (P < .05). Areas of high contact were associated with skin erythema and pressure ulcers. CONCLUSIONS: This fit method is currently being utilized to select best-fit masks from available options, to identify the potential areas of increased tissue pressure, and to prevent skin injuries and their complications. Improvement of mask fit is an important priority for improving respiratory outcomes. Strategies to maintain normal skin hydration are important for protecting tissue integrity.

Photodamage: Treatments and Topicals for Facial Skin

This article provides an overview of current therapies for photodamaged facial skin and their efficacy, with particular focus on studies that use the objective, quantitative evaluation methods discussed in the previous article. The role of topically applied agents including prescription drugs and cosmetics is discussed. From this information, a schema for the relative effectiveness of therapeutic modalities in reducing perceived age is presented. This information assists the facial plastic surgeon in evaluating patient expectations and selecting the most effective program.

Decision Making for Children with Obstructive Sleep Apnea without Tonsillar Hypertrophy

Objective Evidence-based medicine is the gold standard practice model for patient management. Our aim was to determine whether decisions made by pediatric subspecialists regarding management of obstructive sleep apnea in children without tonsillar hypertrophy adhered to this model or were based on clinical experiences. Study Design Single-institution prospective study. Setting Multidisciplinary upper airway center in an academic pediatric hospital. Subjects and Methods Twelve pediatric subspecialists representing 8 specialties participating in upper airway clinics and management conferences. Real-time decisions made in treatment conferences and upper airway clinics were collected. Physicians were queried regarding the basis of their decisions, and these decisions were then classified into 10 categories. Results Over 13 days (10 case conferences, 3 half-day clinics), 324 decisions were made for 58 patients (mean age = 8.9 ± 7.4 years, mean body mass index percentile = 75 ± 29); 34% (n = 108) of decisions were evidence based; 59% (n = 193) were nonevidence based; and 7% (n = 23) were based on parental preference. Providers were able to cite specific studies for <20% of these decisions. There was no significant increase in the proportion of evidence-based decisions made over time. Conclusions We deemed 34% of decisions regarding the management of obstructive sleep apnea in children without tonsillar hypertrophy to be evidence based and found that sharing the basis for decisions did not improve the percentage of evidence-based decisions over time. These findings reflect significant evidence gaps and highlight the need for a systematic literature evaluation to identify best practice in managing this population. We recommend that these evidence gaps be further characterized and incorporated into an agenda for future research.

Establishing a Reproducible Hypertrophic Scar following Thermal Injury: A Porcine Model

Background: Our complete understanding of hypertrophic scarring is still deficient, as portrayed by the poor clinical outcomes when treating them. To address the need for alternative treatment strategies, we assess the swine animal burn model as an initial approach for immature scar evaluation and therapeutic application. Methods: Thermal contact burns were created on the dorsum of 3 domestic swine with the use of a branding iron at 170°F for 20 seconds. Deep partial-thickness burns were cared for with absorptive dressings over 10 weeks and wounds evaluated with laser and negative pressure transduction, histology, photographic analysis, and RNA isolation. Results: Overall average stiffness (mm Hg/mm) increased and elasticity (mm) decreased in the scars from the initial burn injury to 8 weeks when compared with normal skin (P < 0.01). Scars were thicker, more erythematous, and uniform in the caudal dorsum. The percent change of erythema in wounds increased from weeks 6 to 10. Histology demonstrated loss of dermal papillae, increased myofibroblast presence, vertically oriented vessels, epidermal and dermal hypercellularity, and parallel-layered collagen deposition. Immature scars remained elevated at 10 weeks, and minimal RNA was able to be isolated from the tissue. Conclusions: Deep partial-thickness thermal injury to the back of domestic swine produces an immature hypertrophic scar by 10 weeks following burn with thickness appearing to coincide with the location along the dorsal axis. With minimal pig to pig variation, we describe our technique to provide a testable immature scar model.

Enzyme replacement therapy for congenital hypophosphatasia allows for surgical treatment of related complex craniosynostosis: a case series

Hypophosphatasia (HPP) is a rare inherited disorder of bone metabolism that results in the loss of function of the gene coding for tissue-nonspecific alkaline phosphatase (TNSALP). Patients with HPP have defective bone mineralization as well as craniosynostosis that can be seen in the infantile and childhood forms of this disease. Traditionally, HPP has had a poor prognosis, with few children surviving to exhibit the phenotype of clinical craniosynostosis that requires surgical intervention. Here, the authors report on new advancements in enzyme replacement therapy (ERT) for children affected by HPP, allowing these patients to survive and undergo surgery to address complex craniosynostosis. The authors discuss their case series of 4 HPP patients treated at their institution with ERT who have undergone successful surgical intervention for craniosynostosis. These children had no complications related to their surgeries and exhibited decreased neurological symptoms following cranial vault remodeling. This study reveals that ERT administered either pre- or post- operatively paired with cranial vault remodeling strategies can yield improved neurological outcomes in children affected by HPP.

Evolution in minimal-incision palatoplasty: surgical technique and outcomes in 67 consecutive cases.

Background: Conventional palatoplasty relies on extensive mucosal incisions and isolation of flaps on the palatine vessels to facilitate midline closure and velar reconstruction. This introduces substantial scarring, which has adverse effects on vascularity and growth. The authors have developed a minimally invasive palatoplasty technique that may have advantages over traditional techniques. The authors present their operative experience and outcomes when using the minimally invasive method paired with a novel cranial base maneuver for nasal mucosa closure. Methods: Based on cadaveric dissections, the authors developed a modified minimal-incision approach that permits anatomical reconstruction from a midline approach. From 2003 to 2010, a retrospective review was performed on 67 consecutive minimal-incision palatoplasties. Cases requiring relaxing incision and/or conversion to other palatoplasty techniques were compared with minimal incision alone. Results: Minimally invasive palatoplasty alone was able to be performed in 78 percent (n = 52) of all cases. Fistula rates were 7.6 percent (n = 4) in the minimally invasive palatoplasty group and 20 percent (n = 3) in the relaxing/conversion group (p = 0.04). Of patients requiring relaxing incisions/conversion, a higher percentage were syndromic (73 percent; p = 0.01). Eighty-nine percent of all Veau class I defects were able to be successfully closed with the minimally invasive palatoplasty approach (p = 0.01). Conclusions: Minimal-incision palatoplasty paired with a cranial base maneuver for nasal mucosa elevation results in adequate soft-tissue mobility and length to arrive at a tension-free closure. Fistula and velopharyngeal insufficiency rates are comparable to that of other techniques, and theoretical advantages of this technique will be borne out by longer term follow-up. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Reconstruction of the Isolated Columellar Defect: A Novel 2-Stage Technique and Review of the Literature

The importance of the nasal complex cannot be overstated from a functional, social, and psychological perspective. The goal of reconstruction is to restore the trilaminar composition of the nose. This is accomplished by recreating the nasal lining and providing a cartilaginous framework to simultaneously support a patent airway and project the defining features to the overlying soft tissue. The columella is one of the smallest subunits of the nose, but the loss of this structure has important esthetic and structural implications. The ideal operation for an isolated defect of the columella remains elusive. The ideal reconstruction would match the pigmentation and texture of the surrounding nasal skin and provide a convex contour with underlying structural support. In addition, the donor site would not create a secondary deformity by disrupting normal anatomy. This report describes a novel 2-stage technique for reconstruction of the columella and reviews the current literature.