Emily Spataro

Etiology and Time to Presentation of Unilateral Vocal Fold Paralysis

Objective To determine the etiology, laterality, and time to presentation of unilateral vocal fold paralysis (UVFP) at a tertiary care institution over 10 years. Study Design Case series with chart review. Setting Academic medical center. Subjects and Methods All patients seen between 2002 and 2012 by the Department of Otolaryngology at the Washington University School of Medicine (WUSM), with a diagnosis of unilateral vocal fold paralysis, were included. Medical records were reviewed for symptom onset date, presentation date(s), and etiology of UVFP. Results Of the patients, 938 met inclusion criteria and were included. In total, 522 patients (55.6%) had UVFP due to surgery; 158 (16.8%) were associated with thyroid/parathyroid surgery, while 364 (38.8%) were due to nonthyroid surgery. Of the patients, 416 (44.4%) had nonsurgical etiologies, 124 (13.2%) had idiopathic UVFP, and 621 (66.2%) had left-sided UVFP. The diagnosis was more common on the left side in cases of intrathoracic surgeries and malignancies, as expected, but also in idiopathic, carotid endarterectomy, intubation, and skull base tumors. In total, 9.8% of patients presented first to an outside otolaryngologist at a median time of 2.1 months after onset, but these patients presented to WUSM at a median time of 9.5 months. Overall, 70.6% of patients presented to a WUSM otolaryngologist within 3 months of onset. Conclusion Iatrogenic injury remains the most common cause of UVFP. Thyroidectomy remains the leading cause of surgery-related UVFP. Patients are typically seen within 3-4 months of onset; however, a significant delay exists for those referred to WUSM.

Revision Rates and Risk Factors of 175 842 Patients Undergoing Septorhinoplasty

IMPORTANCE Estimates of the rate of revision septorhinoplasty and the risk factors associated with revision are unknown because the current published literature is limited to small, retrospective, single-surgeon studies with limited follow-up time. OBJECTIVES To determine the rate of revision for septorhinoplasty surgery and to determine the risk factors associated with revision. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort analysis of 175 842 patients undergoing septorhinoplasty between January 1, 2005, and December 31, 2009, from the Healthcare Cost and Utilization Projects State Inpatient Databases, State Ambulatory Surgery and Services Databases, and State Emergency Department Databases from California, Florida, and New York. Revisit information for these patients was then collected from the 3 databases between January 1, 2005, and December 31, 2012, with a minimal follow-up time of 3 years; and study analysis done January 1, 2005, to December 31, 2012. MAIN OUTCOMES AND MEASURES Revision surgery after an index septorhinoplasty was the main outcome measure, and the rate of revision was calculated within subgroups of patients based on different demographic and clinical characteristics. A multivariable model was then used to determine independent risk factors for the performance of revision surgery. RESULTS The study cohort comprised 175 842 participants who underwent septorhinoplasty procedures; mean (SD) age was 41.0 (15.3) years, and 57.0% were male. The overall revision rate for any septorhinoplasty procedure was 3.3% (5775 of 175 842) (99% CI, 3.2%-3.4%). After separating the patients into primary septorhinoplasty and secondary septorhinoplasty groups, the primary group had an overall revision rate of 3.1% (5389 of 172 324), while the secondary group had an overall revision rate of 11.0% (386 of 3518). Patient characteristics associated with an increased rate of revision include younger age (5.9% [633 of 10 727]), female sex (3.8% [2536 of 67 397]), a history of anxiety (3.9% [168 of 4350]) or autoimmune disease (4.4% [57 of 1286]), and surgery for cosmetic (7.9% [340 of 4289]) or congenital nasal deformities (8.9% [208 of 2334]). CONCLUSIONS AND RELEVANCE The study results, derived from a large cohort of patients with long follow-up time, suggest that the rate of revision septorhinoplasty is low, but certain patient characteristics are associated with higher revision rates. These data provide valuable preoperative counseling information for patients and physicians. This study also provides robust data for third-party payers or government agencies in an era in which physician performance metrics require valid risk adjustment before being used for reimbursement and quality initiatives. LEVEL OF EVIDENCE 3.

Complications and 30-day hospital readmission rates of patients undergoing tracheostomy: A prospective analysis

To determine inpatient and outpatient tracheostomy complication rates and 30‐day hospital readmission rates, and to assess patient and procedural risk factors associated with complications and readmissions.

Thirty-Day Hospital Revisit Rates and Factors Associated With Revisits in Patients Undergoing Septorhinoplasty.

Importance Estimates of the 30-day hospital revisit rate following septorhinoplasty and the risk factors associated with revisits are unknown in the current literature. Surgical 30-day readmission rates are important to establish, as they are increasingly used as a quality care metric and can incur future financial penalties from third-party payers and government agencies. Objective To determine the rate of 30-day hospital revisits following septorhinoplasty and the risk factors associated with revisits. Design, Setting, and Participants A retrospective cohort analysis was conducted of 175 842 patients undergoing septorhinoplasty between January 1, 2005, and December 31, 2009, using data from the Healthcare Cost and Utilization Project state inpatient database, state ambulatory surgery database, and state emergency department database from California, Florida, and New York. Information on revisits for these patients was collected from the 3 databases between January 1, 2005, and December 31, 2012. Data analysis was conducted from September 1, 2014, to May 1, 2015. Main Outcomes and Measures Hospital revisits within 30 days after an index septorhinoplasty and the primary diagnosis at the time of the revisit were the main outcome measures. The revisit rate was calculated within subgroups of patients based on different demographic and clinical characteristics. A multivariable model was then used to determine independent risk factors for the occurrence of a hospital revisit within 30 days of the septorhinoplasty procedure. Results In total, 11 456 of 175 842 patients (6.5%) who underwent septorhinoplasty procedures revisited the hospital within 30 days of the procedure. Most of these revisits (6353 [55.5%]) were to the emergency department. The most common primary diagnosis was bleeding or epistaxis, occurring in 2150 patients (1.2%). Multivariable logistic regression showed that patients aged 41 to 65 years (adjusted odds ratio [aOR], 1.09; 99% CI, 1.02-1.16) or older than 65 years (aOR, 1.23; 99% CI, 1.06-1.43) had an increased revisit rate, as did black patients (aOR, 1.39; 99% CI, 1.16-1.66); those with Medicare (aOR, 1.55; 99% CI, 1.32-1.81) and Medicaid (aOR, 1.63; 99% CI, 1.33-2.01); those with diagnoses of autoimmune disorders or immunodeficiency (aOR, 2.69; 99% CI, 1.20-6.03), coagulopathy (aOR, 2.06; 99% CI, 1.33-3.20), anxiety (aOR, 1.79; 99% CI, 1.55-2.07), and alcohol use (aOR, 1.70; 99% CI, 1.35-2.14); and those who had a conchal cartilage graft (aOR, 2.01; 99% CI, 1.29-3.14). Conclusions and Relevance The study results suggest that patients with more medical comorbidities and lower socioeconomic status most commonly returned to the emergency department for surgical complications, such as bleeding or epistaxis, in the 30-day period after the procedure. These data provide valuable preoperative counseling information for patients and physicians. In addition, this study provides data to third-party payers or government agencies in which postprocedure readmissions in the 30-day period are used as a quality care metric affecting reimbursements and financial penalties. Level of Evidence 3.

Repair of the Lateral Nasal Wall in Nasal Airway Obstruction: A Systematic Review and Meta-analysis

Importance While functional rhinoplasty has been broadly studied, to our knowledge no systematic review and meta-analysis of lateral wall repair has been done previously. Objective To evaluate the effectiveness of repair of the lateral nasal wall in adult patients with nasal airway obstruction. Data Sources Medline, Embase, Cinahl, Central, Scopus, and Web of Science databases and reference lists were searched for clinical and observational studies. Study Selection The selection criteria were defined according to the PICO (population, intervention, comparison, and outcome) framework. The relevant studies were selected by 2 independent reviewers based on the studies’ abstracts and full texts. Data Extraction and Synthesis Data were extracted using standardized lists chosen by the authors according to Cochrane Collaboration guidelines. The effect sizes were first calculated for each study and then pooled together using random effects synthesis. Heterogeneity was assessed using the I2 statistic, and publication bias was evaluated by the Egger test. Main Outcomes and Measures The results were reported as pooled row mean differences in changes from preoperative to postoperative Nasal Obstruction Symptom Evaluation scores at different times of follow-up (⩽3 months, >3 to 6 months, and >6 months). Results Of 1522 initial records, 10 studies were considered relevant—all of them observational. The pooled study sample included 324 participants. When combining all the repeated measures together, the pooled effect size for functional rhinoplasty was −47.7 (95% CI, −53.4 to 42.1) points on the Nasal Obstruction Symptom Evaluation scale with high heterogeneity of 72%. The pooled effect size outcomes were similar in short- (−45.0 points [95% CI, −47.8 to −42.2 points]), mid- (−48.4 points [95% CI, −52.5 to −44.4 points]), and long-term (−49.0 points [95% CI, −62.1 to −35.8 points]) follow-ups. Conclusions and Relevance The pooled effect size of 10 observational studies supported the effectiveness of functional rhinoplasty for the treatment of nasal airway obstruction caused by lateral nasal wall insufficiency. To improve the level of evidence, randomized clinical trials are needed. Level of Evidence NA.

Measuring Nasal Obstruction Outcomes

Methods of measuring nasal obstruction outcomes include both objective anatomic and physiologic measurements, as well as subjective patient-reported measures. Anatomic measurements include acoustic rhinometry, imaging studies, and clinician-derived examination findings. Physiologic measures include rhinomanometry, nasal peak inspiratory flow, and computational fluid dynamics. Patient-reported outcome measures (PROMs) are self-reported assessments of disease-specific quality-of-life outcomes. Several studies attempted correlation of these outcome measures; however, few show strong correlation. Expert opinion favors determining successful surgical outcomes using PROMs. This review provides a summary of current nasal obstruction outcome measures.

Psychometric Properties of the Standardized Cosmesis and Health Nasal Outcomes Survey: Item Response Theory Analysis

hypoplastic LLC), and their association with the tip shape was evaluated (Figure). We measured the nasal tip angle of the nose of 29 patients using the lateral view of the domal and columellar junctions of the LLC. The study was conducted from May 1, 2016, to February 28, 2017. It was approved by the institutional review board of Asan Medical Center, Seoul, Korea. Patients provided written informed consent; there was no financial compensation.

Risk Factors for Corrective Septorhinoplasty Associated With Initial Treatment of Isolated Nasal Fracture

Importance Initial treatment of nasal fractures can result in long-standing cosmetic or functional defects, but the risk factors for subsequent septorhinoplasty have not been explored. Objective To assess the risk factors for septorhinoplasty after the initial treatment of isolated nasal fracture. Design, Setting, and Participants This retrospective population-based analysis of US patients diagnosed with nasal fracture between January 1, 2007, and December 31, 2015, used insurance claims data from the Commercial and Medicare Supplemental categories of the Truven Health MarketScan database. Of the 340 715 patients diagnosed with nasal fracture, 78 474 were included in the final study cohort, excluding those who did not meet enrollment criteria or were diagnosed with concomitant facial fracture. Patients were classified into 1 of 4 groups according to the type and timing of treatment. Main Outcomes and Measures Septorhinoplasty between 6 and 24 months after nasal fracture diagnosis. Explanatory variables included initial fracture treatment, demographics, comorbidities, and diagnoses associated with a preexisting nasal obstruction or defect. Results Most of the 78 474 patients were under 65 years of age (66 770 [85.1%]) and male (41 997 [53.5%]) and lived in an urban area (67 938 [86.6%]). Among patients with no preexisting diagnosis of nasal obstruction or defect, open treatment within 3 weeks (adjusted odds ratio [aOR], 1.76; 95% CI, 1.33-2.32) of nasal fracture and between 3 weeks and 6 months (aOR, 1.52; 95% CI, 1.14-2.04) after fracture were associated with increased risk of subsequent septorhinoplasty. In patients with a diagnosis of preexisting nasal obstruction or defect, observation (aOR, 3.56; 95% CI, 2.80-4.53), closed reduction treatment (aOR, 3.10; 95% CI, 1.93-4.96), and open treatment within 3 weeks (aOR, 2.02; 95% CI, 1.48-2.77) of fracture were all associated with increased risk of subsequent septorhinoplasty, with observation having the highest risk. Patients were also more likely to undergo subsequent septorhinoplasty if they were younger than 65 years, with the greatest risk seen in patients 18 to 34 years of age (aOR, 6.02; 95% CI, 4.26-8.50), lived in an urban area (aOR, 1.21; 95% CI, 1.01-1.44), or had a history of anxiety (aOR, 1.45; 95% CI, 1.18-1.78), but less likely if they were male (aOR, 0.82; 95% CI, 0.73-0.91). Conclusions and Relevance This study suggests that a preexisting diagnosis of nasal obstruction or defect and other aspects of a patient’s history are factors to consider when assessing the likelihood of surgical revision of initial treatment of nasal fracture. Level of Evidence NA.

Nuances of the Tongue-in-Groove Technique for Controlling Tip Projection and Rotation

A central component ofsuccessful rhinoplasty surgery is maintaining or increasing tip support, as well as addressing tip projection and rotation. The tongue-in-groove (TIG) technique is a method to achieve this goal and has been most extensively described by Kridel and colleagues in 1999.1 This method uses sutures to create a strong connection between the septum and medial crura to control tip rotation and projection. In our practice, TIG is routinely used during anterior septal reconstruction (a modified extracorporeal septoplasty technique), as well as in primary and revision aesthetic and functional rhinoplasties.2,3 Criticisms of this method include that it may cause stiffness of the nasal tip and columellar retraction. We describe how these obstacles can be overcome, as well as the biomechanics and geometry of the tip/ tripod complex in relation to the TIG technique.

Tongue-in-Groove Technique for Rhinoplasty: Technical Refinements and Considerations

&NA; A key concept in successful rhinoplasty surgery is maintaining or increasing tip support, and addressing tip projection and rotation. The tongue‐in‐groove (TIG) technique is a method to achieve this goal using sutures to create a strong connection between the septum and medial crura to change tip rotation and projection. Criticisms of this method include that it may cause stiffness of the nasal tip and columellar retraction. TIG is routinely used by the authors during anterior septal reconstructions (a modified extracorporeal septoplasty technique), as well as in primary and revision aesthetic and functional rhinoplasties. Through this review, technical aspects of the TIG technique are discussed, as well as how pitfalls of the technique can be avoided, as illustrated by several rhinoplasty patient examples.