2017-18 HSC Section 3 Green Book

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Trauma and Critical Care Medicine

Home Study Course

Hsc Home Study Course

Section 3 February 2018

© 2018 American Academy of Otolaryngology—Head and Neck Surgery Foundation Empowering otolaryngologist-head and neck surgeons to deliver the best patient care

THE HOME STUDY COURSE IN OTOLARYNGOLOGY -- HEAD AND NECK SURGERY

SECTION 3

Trauma and Critical Care Medicine

February 2018

SECTION FACULTY:

James Cohen, MD, PhD * Philip E. Zapanta, MD * Cristina Cabrera-Muffly, MD Robert H. Chun, MD Marc Gibber, MD Brian Kellermeyer, MD Phillip S. LoSavio, MD, MS Jeffrey J. Stanley, MD

American Academy of Otolaryngology - Head and Neck Surgery Foundation

Section 3 suggested exam deadline: March 12, 2018 Expiration Date: August 7, 2018; CME credit not available after that date

Introduction The Home Study Course is designed to provide relevant and timely clinical information for physicians in training and current practitioners in otolaryngology - head and neck surgery. The course, spanning four sections, allows participants the opportunity to explore current and cutting-edge perspectives within each of the core specialty areas of otolaryngology. The Selected Recent Material represents primary fundamentals, evidence-based research, and state of the art technologies in trauma and critical care medicine. The scientific literature included in this activity forms the basis of the assessment examination. The number and length of articles selected are limited by editorial production schedules and copyright permission issues, and should not be considered an exhaustive compilation of knowledge on trauma and critical care medicine. The Additional Reference Material is provided as an educational supplement to guide individual learning. This material is not included in the course examination and reprints are not provided. Needs Assessment AAO-HNSF’s education activities are designed to improve healthcare provider competence through lifelong learning. The Foundation focuses its education activities on the needs of providers within the specialized scope of practice of otolaryngologists. Emphasis is placed on practice gaps and education needs identified within eight subspecialties. The Home Study Course selects content that addresses these gaps and needs within all subspecialties. Target Audience The primary audience for this activity is physicians and physicians-in-training who specialize in otolaryngology-head and neck surgery. 1. Compare and contrast the pros and cons of the different management approaches and surgery techniques to subcondylar fractures. 2. Describe the current management of laryngeal and tracheal injuries in the pediatric population. 3. Apply current principles of penetrating facial and neck trauma to adult and pediatric patients. 4. Discuss patient factors and CT findings in orbital fractures that will predict the need for surgical intervention and influence operative management. 5. Review clinical symptoms and signs and temporal bone imaging in temporal bone fractures in order to identify surgical candidates for facial nerve intervention. 6. Identify facial fracture patients who are most at risk for brain injury. 7. Apply evidence-based medicine in order to manage the airway in difficult airway patients and obstructive sleep apnea patients. 8. Review current management of medical and procedural intervention in select hematological otolaryngologic pathology. Outcomes Objectives The participant who has successfully completed this section should be able to:

9. Discuss the management principles of caustic ingestion. 10. Recall management principles in head and neck burns. 11. Discuss non-narcotic pain management in otolaryngologic surgery.

Medium Used The Home Study Course is available in electronic or print format. The activity includes a review of outcome objectives, selected scientific literature, and a self-assessment examination. Method of Physician Participation in the Learning Process The physician learner will read the selected scientific literature, reflect on what they have read, and complete the self-assessment exam. After completing this section, participants should have a greater understanding of trauma and critical care medicine as well as useful information for clinical application. Accreditation Statement The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Credit Designation The AAO-HNSF designates this enduring material for 40.0 AMA PRA Category 1 Credit(s) ™. Physicians should claim credit commensurate with the extent of their participation in the activity. ALL PARTICIPANTS must achieve a post-test score of 70% or higher for a passing completion to be recorded and a transcript to be produced. Residents’ results will be provided to the Training Program Director. PHYSICIANS ONLY : In order to receive Credit for this activity a post-test score of 70% or higher is required. Two retest opportunities will automatically be available if a minimum of 70% is not achieved. Disclosure The American Academy of Otolaryngology – Head and Neck Surgery/Foundation (AAO- HNS/F) supports fair and unbiased participation of our volunteers in Academy/Foundation activities. All individuals who may be in a position to control an activity’s content must disclose all relevant financial relationships or disclose that no relevant financial relationships exist. All relevant financial relationships with commercial interests 1 that directly impact and/or might conflict with Academy/Foundation activities must be disclosed. Any real or potential conflicts of interest 2 must be identified, managed, and disclosed to the learners. In addition, disclosure must be made of presentations on drugs or devices, or uses of drugs or devices that have not been approved by the Food and Drug Administration. This policy is intended to openly identify any potential conflict so that participants in an activity are able to form their own judgments about the presentation. [1] A “Commercial interest” is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. 2 “Conflict of interest” is defined as any real or potential situation that has competing professional or personal interests that would make it difficult to be unbiased. Conflicts of interest occur when an individual has an opportunity to affect education content about products or services of a commercial interest with which they have a financial relationship. A conflict of interest depends on the situation and not on the character of the individual. Estimated time to complete this activity: 40.0 hours

2018 Section 3 TRAUMA AND CRITICAL CARE MEDICINE FACULTY

* Co-Chairs: James Cohen, MD, PhD, Professor, Department of Otolaryngology/Head and Neck Surgery, Oregon Health Science University, Portland, OR. Disclosure: No relationships to disclose. Philip E. Zapanta, MD, FACS, Associate Professor of Surgery, Otolaryngology Residency Program Director, George Washington University School of Medicine and Health Sciences, Washington, D.C. Disclosure: No relationships to disclose. Faculty: Cristina Cabrera-Muffly, MD, Assistant Professor of Otolaryngology, Otolaryngology Residency Associate Program Director, University of Colorado School of Medicine, Aurora, CO. Disclosure: No relationships to disclose. Robert H. Chun, MD, Associate Professor, Department of Otolaryngology, Associate Residency Program Director, Medical College of Wisconsin, Milwaukee, WI. Disclosure: No relationships to disclose. Marc Gibber, MD, Assistant Professor, Director of General Otolaryngology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY. Disclosure: Intellectual Property Rights; Sigma Surgical. Brian Kellermeyer, MD, Assistant Professor, Department of Otolaryngology, West Virginia University, Morgantown, WV. Disclosure: No relationships to disclose. Phillip S. LoSavio, MD, MS, Assistant Professor, Director and Section Head of Sleep Surgery, Residency Program Director, Department of Otorhinolaryngology - Head and Neck Surgery, Rush University Medical Center, Chicago, IL Disclosure: Other Financial; Expert review of medical legal case material; Hinshaw and Culbertson. Jeffrey J. Stanley, MD, Assistant Professor, Department of Otolaryngology/Head and Neck Surgery and Neurology, University of Michigan Health System, Ann Arbor, MI. Disclosure: No relationships to disclose.

Planner(s): Linda Lee, AAO─HNSF Education Program Manager Stephanie Wilson, Stephanie Wilson Consulting, LLC; Production Manager Stacey L. Ishman, MD, MPH, AAO-HNSF General

No relationships to disclose No relationships to disclose

Consulting Fee: Medtronic;

Otolaryngology Education Committee Chair

Research Funding: National Institute of Health Research Funding: American Society of Pediatric Otolaryngology

Richard V. Smith, MD, chair, AAO-HNSF Education Steering

Expert Witness: various legal

Committee

firms

This 2017-18 Home Study Course Section 3 does not include discussion of any drugs and devices that have not been approved by the United States Food and Drug Administration.

Disclaimer The information contained in this activity represents the views of those who created it and does not necessarily represent the official view or recommendations of the American Academy of Otolaryngology – Head and Neck Surgery Foundation.

August 7, 2018: Deadline for all 2017-18 exams to be received; course closed August 8, 2018.

EVIDENCE BASED MEDICINE The AAO-HNSF Education Advisory Committee approved the assignment of the appropriate level of evidence to support each clinical and/or scientific journal reference used to authenticate a continuing medical education activity. Noted at the end of each reference, the level of evidence is displayed in this format: [EBM Level 3] .

Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001) Level 1

Randomized 1 controlled trials 2 or a systematic review 3 (meta-analysis 4 ) of randomized controlled trials 5 . Prospective (cohort 6 or outcomes) study 7 with an internal control group or a systematic review of prospective, controlled trials. Retrospective (case-control 8 ) study 9 with an internal control group or a systematic review of retrospective, controlled trials. Case series 10 without an internal control group (retrospective reviews; uncontrolled cohort or outcome studies).

Level 2

Level 3

Level 4

Expert opinion without explicit critical appraisal, or recommendation based on physiology/bench research.

Level 5

Two additional ratings to be used for articles that do not fall into the above scale. Articles that are informational only can be rated N/A , and articles that are a review of an article can be rated as Review. All definitions adapted from Glossary of Terms, Evidence Based Emergency Medicine at New York Academy of Medicine at www.ebem.org . 1 A technique which gives every patient an equal chance of being assigned to any particular arm of a controlled clinical trial. 2 Any study which compares two groups by virtue of different therapies or exposures fulfills this definition. 3 A formal review of a focused clinical question based on a comprehensive search strategy and structure critical appraisal. 4 A review of a focused clinical question following rigorous methodological criteria and employing statistical techniques to combine data from independently performed studies on that question. 5 A controlled clinical trial in which the study groups are created through randomizations. 6 This design follows a group of patients, called a “cohort”, over time to determine general outcomes as well as outcomes of different subgroups. 7 Any study done forward in time. This is particularly important in studies on therapy, prognosis or harm, where retrospective studies make hidden biases very likely. 8 This might be considered a randomized controlled trial played backwards. People who get sick or have a bad outcome are identified and “matched” with people who did better. Then, the effects of the therapy or harmful

exposure which might have been administered at the start of the trial are evaluated. 9 Any study in which the outcomes have already occurred before the study has begun. 10 This includes single case reports and published case series.

OUTLINE

February 2018 Section 3

TRAUMA AND CRITICAL CARE MEDICINE

I.

Trauma A. Contemporary management of mandible, midface, frontal (and panfacial) fractures

B. Management of laryngeal and tracheal injuries

C. Management of penetrating head and neck injuries

D. Orbital trauma

E. Temporal bone trauma

F. Neurological considerations in head and neck trauma

II.

Critical Care and Perioperative Care A. OSA considerations and airway management 1. Best practices for airway management 2. Best practices for perioperative management of OSA patients undergoing general anesthesia

B. Management of head and neck hemorrhage

C. Caustic ingestion

D. Management of burns to the head and neck

E. Perioperative pain control (narcotic and nonnarcotic therapies)

TABLE OF CONTENTS Selected Recent Materials - Reproduced in this Study Guide

2018 SECTION 3: TRAUMA AND CRITICAL CARE MEDICINE

ADDITIONAL REFERENCE MATERIAL.................................................................................i - iii

I.

Trauma A. Contemporary management of mandible, midface, frontal (and panfacial) fractures Hackenberg B, Lee C, Caterson EJ. Management of subcondylar mandible fractures in the adult patient. J Craniofac Surg . 2014; 25(1):166-171. EBM level 5.......................1-6 Summary : This review article discusses three main methods of surgical intervention used to treat subcondylar fractures, including closed reduction, open reduction with internal fixation, and endoscopic-assisted reduction with internal fixation. It also includes an algorithm for treatment of subcondylar fractures in the adult patient. Kendrick DE, Park CM, Fa JM, et al. Stryker SMARTLock Hybrid Maxillomandibular Fixation System: clinical application, complications, and radiographic findings. Plast Reconstr Surg . 2016; 137(1):142e-150e. EBM level 4................................................7-15 Summary : This article discussing a new maxillomandibular fixation technique is of interest from a practical educational standpoint to keep up to date on new surgical techniques. Kotrashetti SM, Lingaraj JB, Khurana V. A comparative study of closed versus open reduction and internal fixation (using retromandibular approach) in the management of subcondylar fracture. Oral Surg Oral Med Oral Pathol Oral Radiol . 2013; 115(4):e7- e11. EBM level 1.........................................................................................................16-20 Summary : This article compares clinical and radiologic outcomes of patients with subcondylar fractures randomized to receive treatment with either closed reduction or open reduction with rigid internal fixation (ORIF). ORIF was found to have better outcomes than closed reduction. Liao HT, Wang PF, Chen CT. Experience with the transparotid approach via a mini- preauricular incision for surgical management of condylar neck fractures. J Craniomaxillofac Surg . 2015; 43(8):1595-1601. EBM level 3..................................21-27 Summary : This article is a retrospective review of 58 patients with condylar neck fractures, half of which were treated with a transparotid approach open reduction and internal fixation, and half of which were treated with other surgical approaches. No facial nerve injury, infection, or hemorrhage was identified in the transparotid approach group.

B. Management of laryngeal and tracheal injuries Chatterjee D, Agarwal R, Bajaj L, et al. Airway management in laryngotracheal injuries from blunt neck trauma in children. Paediatr Anaesth . 2016; 26(2):132-138. EBM level 4...........................................................................................................................28-34 Summary : This article presents a case report and literature review. A review of the mechanisms of injury, clinical presentation, initial airway management, and anesthetic considerations in laryngotracheal injuries from blunt neck trauma in children is presented. Most helpful is a treatment algorithm for these patients. Strychowsky JE, Adil E, Licameli G, Rahbar R. Vocal fold avulsion in the pediatric population: presentation and management. Int J Pediatr Otorhinolaryngol . 2015; 79(7):959-964. EBM level 4........................................................................................35-40 Summary : This article presents a case report and literature review. The authors feel that accurate and timely diagnosis of pediatric vocal fold avulsion is important. CT imaging without sedation should be considered in stable patients. The endoscopic approach is the preferred method of repair when it is amenable to the extent of injury and availability of expertise from both surgeon and anesthesiologist. C. Management of penetrating head and neck injuries Ghadersohi S, Ference EH, Detwiller K, Kern RC. Presentation, workup, and management of penetrating transorbital and transnasal injuries: a case report and systematic review. Am J Rhinol Allergy . 2017; 31(2):29-34. EBM level 1..............41-46 Summary : This study reviews the presentation, workup, and management of transnasal or transorbital penetrating foreign body injury. This study emphasizes the importance of interdisciplinary management to prevent acute and delayed complications. Madsen AS, Oosthuizen G, Laing GL, et al. The role of computed tomography angiography in the detection of aerodigestive tract injury following penetrating neck injury. J Surg Res . 2016; 205(2):490-498. EBM level 4............................................47-55 Summary : Data from a 4-year trauma registry were reviewed. All findings of deep surgical emphysema were correlated for aerodigestive tract injury based on the results of clinical examination, surgical neck exploration, endoscopy, or contrasted swallow. This study found that CT angiography for penetrating neck injuries has a high sensitivity and specificity for demonstrating vascular injury. The absence of deep surgical emphysema in the deep cervical fascial planes virtually excludes surgically significant aerodigestive tract injury.

Shiroff AM, Gale SC, Martin ND, et al. Penetrating neck trauma: a review of management strategies and discussion of the “No Zone” approach. Am Surg . 2013; 79(1):23-29. EBM level 5............................................................................................56-62 Summary : Algorithms developed in the 1970s focused on anatomic neck “zones” to distinguish triage pathways resulting from the operative constraints associated with very high or very low penetrations. A “No Zone” paradigm eliminating “neck zone” differentiation during triage and management utilizes both physical examination and CT angiography to effectively identify vascular and aerodigestive injury after penetrating neck trauma. Tessler RA, Nguyen H, Newton C, Betts J. Pediatric penetrating neck trauma: hard signs of injury and selective neck exploration. J Trauma Acute Care Surg . 2017; 82(6):989- 994. EBM level 4.........................................................................................................63-68 Summary : This is a single institution, retrospective cohort of 44 pediatric patients with penetrating neck injuries. The study identified hard and soft clinical signs of injury which correlated to high sensitivity and specificity for vascular injury. The use of CT angiography in the evaluation was also investigated. Of the 44 patients, 90% were discharged home and two patients died. The management was similar to that of adult patients with penetrating neck injuries. D. Orbital trauma Aldekhayel S, Aljaaly H, Fouda-Neel O, et al. Evolving trends in the management of orbital floor fractures. J Craniofac Surg . 2014; 25(1):258-261. EBM level 3..........69-72 Summary : This article is a combined 10-year literature review and surgeon survey about management of orbital fractures. Factors identified that influence operative management included enophthalmos, hypophthalmos, positive forced duction, defect size, mobility restriction, and persistent diplopia. Approaches and implant types also are discussed. Andrews BT, Jackson AS, Nazir N, et al. Orbit fractures: identifying patient factors indicating high risk for ocular and periocular injury. Laryngoscope . 2016; 126 Suppl 4:S5-S11. EBM level 3................................................................................................73-79 Summary : This article is a retrospective review of 279 subjects with orbit fractures. Characteristics of their orbit fractures, including mechanism of injury, physical examination findings, and radiological findings were correlated with ocular injury to identify risk factors for concomitant ocular injury in patients with orbital trauma. Patients with penetrating trauma, visual acuity deficits, afferent pupillary defect, and fracture involvement of the posterior orbit were at the highest risk for vision loss.

Mansour TN, Rudolph M, Brown D, et al. Orbital blowout fractures: a novel CT measurement that can predict the likelihood of surgical management. Am J Emerg Med . 2017; 35(1):112-116. EBM level 3..............................................................................80-84 Summary : This paper introduces a new modality, CT imaging, to evaluate patients with orbital floor fractures to help determine the need for surgical intervention. This novel measurement was defined as the difference between the cranial-caudal dimension (CCD), measured just posterior to the globe, of the fractured orbit minus the CCD of the normal side. Using a threshold CCD value of 0.8 cm, the accuracy of CCD predicting development of diplopia and/or enophthalmos needing surgical intervention was 94%. E. Temporal bone trauma Song SW, Jun BC, Kim H. Clinical features and radiological evaluation of otic capsule sparing temporal bone fractures. J Laryngol Otol . 2017; 131(3):209-214. EBM level 4...........................................................................................................................85-90 Summary : This case series reviewed otoscopic findings and symptoms, facial paralysis, and hearing loss in otic capsule–sparing temporal bone fractures. The authors concluded that initial conservative treatment for facial paralysis or conductive hearing loss may be an appropriate option for some patients. Summary : This study is a retrospective chart review of 80 patients at one institution. It explored patients with House-Brackmann I and II function and divided them into groups based on age, onset of paralysis, and timing of repair. There was no significant difference in recovery based on age and onset; however, early intervention was found to be superior. F. Neurological considerations in head and neck trauma Grant AL, Ranger A, Young GB, Yazdani A. Incidence of major and minor brain injuries in facial fractures. J Craniofac Surg . 2012; 23(5):1324-1328. EBM level 2...........................................................................................................................94-98 Summary : In this article, 100 consecutive patients with maxillofacial fractures were assessed prospectively for brain injury. There were significant associations between mechanism of injury and type of facial fractures with brain injury. Specifically, patients involved in a motor vehicle accident with either LeFort or combined fractures were most likely to suffer brain injury. Xie S, Wu X, Zhang Y, et al. The timing of surgical treatment of traumatic facial paralysis: a systematic review. Acta Otolaryngol . 2016; 136(12):1197-1200. EBM level 4.........................................................................................................................99-102 Summary : This meta-analysis assesses the ideal timing for surgical intervention of traumatic facial paralysis. The authors identified that surgical decompression performed within 2 weeks yields the best clinical prognosis, and that surgical exploration performed within 2 months results in acceptable outcomes. Xu P, Jin A, Dai B, et al. Surgical timing for facial paralysis after temporal bone trauma. Am J Otolaryngol . 2017; 38(3):269-271. EBM level 4..............................................91-93

II.

Critical Care and Perioperative Care A. OSA considerations and airway management 1. Best practices for airway management

Aziz MF, Brambrink AM, Healy DW, et al. Success of intubation rescue techniques after failed direct laryngoscopy in adults: a retrospective comparative analysis from the Multicenter Perioperative Outcomes Group. Anesthesiology . 2016; 125(4):656- 666. EBM level 4..............................................................................................103-113 Summary : This is a recent large, multi-centered observational study describing success of rescue techniques after direct laryngoscopy has failed. It found that video laryngoscopy was superior to other rescue techniques. Darby JM, Halenda G, Chou C, et al. Emergency surgical airways following activation of a difficult airway management team in hospitalized critically ill patients: a case series. J Intensive Care Med . 2016 Nov 28. pii: 0885066616680594. [Epub ahead of print]. EBM level 4.............................................................................114-123 Summary : This article from University of Pittsburgh focuses on the surgical outcomes in difficult airway patients in a critical care setting. Specifically, it reviews the incidence of surgical airway management in difficult airway scenarios in addition to the morbidity and mortality associated with these interventions. Gu Y, Robert J, Kovacs G, et al. A deliberately restricted laryngeal view with the GlideScope ® video laryngoscope is associated with faster and easier tracheal intubation when compared with a full glottic view: a randomized clinical trial. Can J Anaesth . 2016; 63(8): 928-937. EBM level 1..................................................124-133 Accompanying Letter : Robert J, Gu Y, Law JA. In reply: deliberately restricted laryngeal view with GlideScope ® video laryngoscope: ramifications for airway research and teaching. Can J Anaesth . 2016; 63(9):1103. EBM level 1................134 Summary : This nice study demonstrated that the best view with the GlideScope may make intubation more difficult; the recommendation is to withdraw the blade and sacrifice the view for better alignment of tube insertion. 2. Best practices for perioperative management of OSA patients undergoing general anesthesia Asha’ari ZA, Rahman JA, Mohamed AH, et al. Association between severity of obstructive sleep apnea and number and sites of upper airway operations with surgery complications. JAMA Otolaryngol Head Neck Surg . 2017; 143(3):239-246. EBM level 4.................................................................................................................135-142 Summary : This study is a retrospective cohort study of 95 patients who underwent upper airway surgery for obstructive sleep apnea. The overall 30-day complication rate was increased with age and higher body mass index. Complication rates were not associated with apnea-hypopnea index severity, type of procedure, or whether the surgery was a single or combination surgery.

Chung F, Liao P, Yegneswaran B, et al. Postoperative changes in sleep-disordered breathing and sleep architecture in patients with obstructive sleep apnea. Anesthesiology . 2014; 120(2):287-298. EBM level 2......................................143-154 Summary : This article examined a cohort of 58 patients (20 without obstructive sleep apnea [OSA], 38 with OSA) in the perioperative setting and then compared polysomnography (PSG) metrics in the pre- and postoperative setting. Overall PSG outcomes were worse in both groups in the postoperative setting. Fouladpour N, Jesudoss R, Bolden N, et al. Perioperative complications in obstructive sleep apnea patients undergoing surgery: a review of the legal literature. Anesth Analg . 2016; 122(1):145-151. EBM level 4.........................................155-161 Summary : This is an interesting article looking at adverse perioperative outcomes in obstructive sleep apnea patients as measured by malpractice suits. The study addresses a concern many providers in the U.S. likely have when making decisions about perioperative obstructive sleep apnea care and one of the driving factors behind current practices that tend to lean towards observation in the hospital setting. Nagappa M, Liao P, Wong J, et al. Validation of the STOP-Bang questionnaire as a screening tool for obstructive sleep apnea among different populations: a systematic review and meta-analysis. PLOS One . 2015; 10(12):e0143697. EBM level 1.................................................................................................................162-182 Summary : The STOP-Bang questionnaire is a validated screening tool for obstructive sleep apnea (OSA). This systematic review and meta-analysis assessed the effectiveness of STOP-Bang for screening patients suspected of having OSA and assessed its accuracy in determining the severity of OSA in the different populations. It found a high performance of the STOP-Bang questionnaire in the sleep clinic and surgical population for screening of OSA, and found that the higher the STOP-Bang score, the greater the probability of moderate-to-severe OSA. B. Management of head and neck hemorrhage Hsueh WD, Hwang PH, Abuzeid WM. Perioperative management of antithrombotic therapy in common otolaryngologic surgical procedures: state of the art review. Otolaryngol Head Neck Surg . 2015; 153(4):493-503. EBM level 5......................183-193 Summary : This study analyzed peer-reviewed literature pertaining to thromboembolic risk among patients undergoing common otolaryngologic procedures. The authors advocate for consideration of three factors when determining perioperative management of antithrombotic therapy: patient risk of thromboembolism, bleeding risk of the surgical procedure, and timing of therapy interruption. Jackson RS, Myhill JA, Padhya TA, et al. The effects of preoperative embolization on carotid body paraganglioma surgery: a systematic review and meta-analysis. Otolaryngol Head Neck Surg . 2015; 153(6):943-950. EBM level 5..........................................194-201 Summary : This study is a literature review evaluating patient outcomes after carotid body tumor resection. Patients undergoing preoperative embolization prior to resection had significantly less blood loss and decreased operative times as compared to patients without preoperative embolization.

Sylvester MJ, Chung SY, Guinand LA, et al. Arterial ligation versus embolization in epistaxis management: counterintuitive national trends. Laryngoscope . 2017; 127(5):1017-1020. EBM level 3..............................................................................202-205 Summary : This study used the National Inpatient Sample database to compare frequency of ligation versus embolization used in the treatment of patients admitted with a primary diagnosis of epistaxis. Ligation management was associated with decreased cost of care and shorter length of stay. C. Caustic ingestion Aronow SP, Aronow HD, Blanchard T, et al. Hair relaxers: a benign caustic ingestion? J Pediatr Gastroenterol Nutr . 2003; 36(1):120-125. EBM level 4...........................206-211 Summary : A retrospective cohort of 96 patients who ingested a high pH substance and underwent endoscopy showed that despite the high pH of these products, no clinically significant esophageal or gastric mucosal injuries and no long-term sequelae were identified. Kochhar R, Ashat M, Reddy YR, et al. Relook endoscopy predicts the development of esophageal and antropyloric stenosis better than immediate endoscopy in patients with caustic ingestion. Endoscopy . 2017; 49(7):643-650. EBM level 4.......................212-219 Summary : This article is a retrospective cohort study of 62 patients with caustic ingestion comparing endoscopic findings on day 1 vs. day 5 after injury. Adverse outcomes, specifically stricture, were then examined in relation to these endoscopic findings and the ability to predict an outcome based on endoscopy at different time points. Summary : This article presents a review of current literature for updates in the treatment of caustic ingestion. Findings suggest that it may be safe to advance the endoscope beyond the first circumferential burn to allow for a more complete assessment of extent of injury, a 3-day course of high-dose methylprednisolone might reduce the occurrence of esophageal stricture formation, balloon dilatation has been shown to be as effective as other bougienage techniques with lower risk of perforations, esophageal dilatation can be safely performed as early as 5 to 15 days after initial ingestion and may decrease risk for long-term stricture formation, and the use of adjunctive treatment, such as topical mitomycin C and esophageal stents, shows promise in reducing the reoccurrence of stricture formation after dilatation. Shub MD. Therapy of caustic ingestion: new treatment considerations. Curr Opin Pediatr . 2015; 27(5):609-613. EBM level 4...........................................................220-224

D. Management of burns to the head and neck Clayton NA, Ward EC, Maitz PK. Intensive swallowing and orofacial contracture rehabilitation after severe burn: a pilot study and literature review. Burns . 2017; 43(1):e7-e17. EBM level 4......................................................................................225-235 Summary : This article reviews two patients who underwent a new protocol to reduce dysphagia and orofacial contracture after head and neck burns. They underwent intensive treatment therapy including scar stretching, splinting, and pharyngeal swallow tasks. Outcomes showed improvement after therapy. Hogg G, Goswamy J, Khwaja S, Khwaja N. Laryngeal trauma following an inhalation injury: a review and case report. J Voice . 2017; 31(3):388.e27-388.e31. EBM level 5.......................................................................................................................236-240 Summary : This article discusses a care report of inhalation injury and does a thorough review of literature on management of inhalational injuries. The management discussed includes initial clinical evaluation, initial surgical management, and long-term airway management of scarring and/or stenosis which occurs after injury. Umstattd LA, Chang CW. Pediatric oral electrical burns: incidence of emergency department visits in the United States, 1997-2012. Otolaryngol Head Neck Surg . 2016; 155(1):94-98. EBM level 4......................................................................................241-245 Summary : This article is a retrospective look at presentation and causes of pediatric electrical burns over a 15-year period in the United States. From 1997 to 2012, there were an average of approximately 65.1 electrical burn emergency department visits per year. Nearly half of these patients were <3 years of age, and more than three-fourths were <5 years of age. Only 19.2% were admitted to the hospital. Most injuries involved electrical outlets or receptacles (10.8%), extension cords (18.5%), and electrical wires (21.5%). E. Perioperative pain control (narcotic and nonnarcotic therapies) Boselli E, Bouvet L, Augris-Mathieu C, et al. Infraorbital and infratrochlear nerve blocks combined with general anaesthesia for outpatient rhinoseptoplasty: a prospective randomised, double-blind, placebo-controlled study. Anaesth Crit Care Pain Med . 2016; 35(1):31-36. EBM level 2........................................................................................246-251 Summary : This article presents a prospective, double-blind, randomized controlled trial in which 40 adult patients undergoing outpatient rhinoseptoplasty under general anesthesia were assigned to receive bilateral infraorbital and infratrochlear nerve blocks with either 10 mL of 0.25% levobupivacaine (Group LB) or isotonic saline (control group). The primary endpoint was total perioperative morphine consumption (intraoperative and in the post-anaesthesia care unit). The secondary endpoints were pain scores, time spent in the post-anaesthesia care unit and the outpatient ward, block-related complications, and patient satisfaction. The total dose of perioperative morphine was lower in Group LB than in the control group. The mean times spent in the post-anaesthesia care unit and in the outpatient ward were lower in Group LB than in the control group. There were no differences between groups for other endpoints.

Chan DK, Parikh SR. Perioperative ketorolac increases post-tonsillectomy hemorrhage in adults but not children. Laryngoscope . 2014; 124(8):1789-1793. EBM level 3.......................................................................................................................252-256 Summary : This article presents a systematic review of adult and pediatric literature. The review showed that adults are at five times increased risk for post-tonsillectomy hemorrhage with ketorolac use. In contrast, children under 18 years are not at statistically significantly increased risk. Both retrospective and prospective studies yielded consistent findings. There is no association of relative risk with pre- or postoperative administration of ketorolac. The study concluded that ketorolac can be used safely in children, but is associated with a five-fold increased bleeding risk in adults. Tsao GJ, Messner AH, Seybold J, et al. Intraoperative acupuncture for posttonsillectomy pain: a randomized, double-blind, placebo-controlled trial. Laryngoscope . 2015; 125(8):1972-1978. EBM level 3..............................................................................257-263 acupuncture or sham acupuncture. There were no significant differences in the amount of opioid medications administered or total postanesthesia care unit time between the two cohorts. Home surveys of patients but not of parents revealed significant improvements in pain control in the acupuncture treatment group postoperatively, and oral intake improved significantly earlier in the acupuncture treatment group. No adverse effects of acupuncture were reported. This study demonstrates that intraoperative acupuncture is feasible, well tolerated, and results in improved pain and earlier return of diet postoperatively. Summary : This study is a prospective, double-blind, randomized placebo-controlled trial of 59 tonsillectomy patients ages 3 to 12 years who were randomized to receive

2017-18 SECTION 3 ADDITIONAL REFERENCES

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Reprinted by permission of J Craniofac Surg. 2014; 25(1):166-171.

T ECHNICAL S TRATEGY

Management of Subcondylar Mandible Fractures in the Adult Patient

Berit Hackenberg,* † Cameron Lee, BS, ‡ and E. J. Caterson, MD, PhD,*§

mildly displaced fractures and for the patient with multiple injuries who cannot tolerate closed reduction. Key Words: Subcondylar mandible fracture, open reduction, maxillomandibular fixation, endoscopic, treatment algorithm ( J Craniofac Surg 2014;25: 166 – 171) I n the polytrauma patient, facial fractures are commonly seen, with 12% to 56% of cases involving the mandible. 1,2 The ascending or vertical component of the mandible is especially vulnerable, and approximately 30% of all mandible fractures are confined to that area. 3 Despite this frequency of occurrence, management of these patients is controversial and treatment is variable. 4 – 7 Anatomically, the subcondylar region is the distal aspect of the condylar process. It is superiorly bound by the sigmoid notch line and anteriorly bound by an oblique line joining the sigmoid notch and the masseteric tuberosity 8 (Fig. 1). This region is clini- cally significant because of the presence of the facial nerve and the temporomandibular joint (TMJ), both of which may be func- tionally impaired by the fracture itself or the operative treatment. Different degrees of dislocation, displacement, comminution, and fracture lines depend on the magnitude of force, the point of appli- cation, its transmission, and the patient's occlusal position at the moment of impact. The resulting clinical spectrum challenges the surgeon to use a range of techniques with different risk profiles to achieve outcomes that are both functionally and esthetically pleas- ing. This article aimed to evaluate 3 current management strategies in the adult patient: closed reduction with maxillomandibular fixa- tion (MMF), open reduction with internal fixation (ORIF), and endoscopic-assisted reduction with internal fixation (ERIF). We present our rationale for surgical decision making and attempt to develop an algorithmic approach to subcondylar fractures. This ar- ticle can represent a cohesive methodology to guide complex surgi- cal decision making with the goal of aiding craniofacial surgeons in the selection of approaches for this complex fracture pattern. Many studies published in the previous 2 decades have fo- cused on comparing surgical outcomes between closed reduction and open reduction. 4,5,9 – 16 In 1998, Jacobovicz et al reported the first endoscopic open repair of a complex mandibular injury, and techniques of both endoscopic-assisted and pure endoscopic repairs have been reported in the literature more recently. 17 – 22 Although not as prevalent as the standard open and closed approaches, the endo- scopic approach revives this classic debate by adding yet another vi- able treatment option to the management of subcondylar mandible fractures. The present study highlights our experience treating sub- condylar fractures in light of current surgical techniques and tech- nology. Three management modalities and their indications are discussed: MMF, ORIF, and ERIF. Each treatment option is pres- ented, highlighting its specific strengths and weaknesses along with clinical examples. Finally, we provide a treatment algorithm based on this experience that derives a structural basis for our decision making with regard to clinical and radiographic findings. In

Abstract: The treatment of subcondylar mandible fractures is a topic of debate and can be variable even though these fractures are commonly seen. Historically, the treatment algorithm was between open reduction and closed treatment. Now, recent technical ad- vances regarding the use of the endoscope in the field of craniofa- cial surgery provide additional treatment options. This article aimed to evaluate 3 current management strategies: closed reduction with maxillomandibular fixation, open reduction with internal fixation, and endoscopic-assisted reduction with internal fixation. We present our rationale for surgical decision making and attempt to develop an algorithmic approach to subcondylar fractures. Ankylosis of the temporomandibular joint is a feared compli- cation in these fractures that can lead to the decision to apply maxillomandibular fixation for potentially too short of a period. It is the condylar head fractures within the joint's capsule that con- tain the hemarthrosis that are often responsible for ankylosis. Sub- condylar fractures are, by definition, below the attachment of the joint capsule and in general are devoid of ankylosis. Therefore, maxillomandibular fixation is recommended to be applied for a period of 4 to 6 weeks in most cases. Open reduction with internal fixation can increase the risk for facial nerve damage during the op- erative approach. However, open reduction is often necessary in fracture patterns with a high degree of displacement. In these cases, facial nerve monitoring can successfully mitigate risks to allow safe exposure for open reduction with internal fixation of subcondylar fractures. Endoscopic-assisted reduction with internal fixation com- bines the benefits of both techniques while minimizing their associ- ated risks. Nevertheless, reduction can be difficult especially when there is significant medial displacement of the proximal fracture fragment. In our experience, the endoscopic option is optimal for

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From the *Center for Surgery and Public Health, Brigham and Women ’ s Hos- pital, Boston, Massachusetts; † University of Heidelberg Medical School, Heidelberg, Germany; ‡ Harvard School of Dental Medicine, Boston, Massachusetts; and §Division of Plastic Surgery, Brigham and Women ’ s Hospital, Boston, Massachusetts. Received May 14, 2013. Accepted for publication October 28, 2013. Address correspondence and reprint requests to Dr E. J. Caterson, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115; E-mail: ecaterson@partners.org

The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000498

The Journal of Craniofacial Surgery • Volume 25, Number 1, January 2014

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