HSC Section 3 - Trauma, Critical Care and Sleep Medicine

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Trauma, Critical Care and Sleep Medicine

Home Study Course

Hsc Home Study Course

Section 3 February 2020

© 2020 American Academy of Otolaryngology–Head and Neck Surgery Foundation The global leader in optimizing quality ear, nose, and throat patient care.

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

SECTION 3

Trauma, Critical Care, and Sleep Medicine

February 2020

SECTION FACULTY: Robert H. Chun, MD* Phillip LoSavio, MD* Jeffrey J. Stanley, MD* Cristina Cabrera-Muffly, MD

Marc J. Gibber, MD Jessica Kepchar, MD Loring I. Perry, MD

American Academy of Otolaryngology - Head and Neck Surgery Foundation

Section 3 suggested exam deadline: March 10, 2020 Expiration Date: August 6, 2020; 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, critical care, and sleep 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, critical care, and sleep 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. Outcomes Objectives The participant who has successfully completed this section should be able to: 1. Compare and contrast the different methods of managing pediatric mandible fractures. 2. Describe the current management of laryngeal-tracheal trauma. 3. Apply current principles for treating penetrating facial and neck trauma. 4. Interpret CT findings in orbital fractures that will predict the need for surgical intervention and influence operative management. 5. Distinguish and compare the recommended approaches for the medical and surgical treatment of acute facial paralysis. 6. Summarize current contemporary paradigms in managing the “difficult airway.” 7. Apply evidence-based medicine protocols in the perioperative care of tracheostomy patients. 8. Explain effective strategies to manage major head and neck hemorrhage. 9. Discuss the management principles of caustic ingestion. 10. Synthesize current concepts in perioperative care of otolaryngology patients including narcotic pain control and DVT management. 11. Summarize the current evidence for hypoglossal nerve stimulation including indications, technique, and outcomes.

12. Explain the VOTE scoring system for evaluation of OSA. 13. Select appropriate palate procedures for the treatment of OSA. 14. Summarize the various types of oral appliance therapy devices. 15. Interpret the clinical practice guidelines and indications for home sleep testing .

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, critical care, and sleep 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

2020 Section 3 TRAUMA, CRITICAL CARE, AND SLEEP MEDICINE FACULTY

* Co-Chairs: Robert H. Chun, MD, Associate Professor and Pediatric Otolaryngology Fellowship Director, Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI. Disclosure: No relationships to disclose. Phillip LoSavio, MD, Assistant Dean for Graduate Medical Education, Residency Program Director – Otolaryngology; Associate Professor and Section Head of Sleep 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. Faculty: Cristina Cabrera-Muffly, MD, Associate Professor of Otolaryngology, Otolaryngology Residency Program Director, University of Colorado School of Medicine, Aurora, CO. Disclosure: No relationships to disclose. Marc J. Gibber, MD, Director of General Otolaryngology, Department of Otolaryngology/Head and Neck Surgery, Montefiore/Albert Einstein College of Medicine; Director, Research and Development, Montefiore/Einstein Center for Simulation, Bronx, NY. Disclosure: Intellectual Property Rights; Sigma Surgical. Jessica Kepchar, MD, Assistant Professor, Uniformed Services University Chief, Department of Otolaryngology, San Antonio Military Medical Center, San Antonio, TX. Disclosure: No relationships to disclose. Loring I. Perry, MD, Chief, Otolaryngology/Head and Neck Surgery, Captain James A. Lovell Federal Health Care Center, North Chicago, IL. Disclosure: No relationships to disclose.

Planner(s): Linda Lee, AAO−HNSF Education Program Manager Stephanie Wilson, Stephanie Wilson Consulting, LLC; Production Manager Jeffrey J. Stanley, MD, AAO-HNSF General Otolaryngology & Sleep Education Committee Chair Stacey L. Ishman, MD, MPH, AAO-HNSF General Otolaryngology & Sleep Education Committee Past Chair

No relationships to disclose No relationships to disclose

No relationships to disclose

Consulting Fee: Genus Lifesciences; Consulting Fee: Inspire Medical; Leadership: American Board of Otolaryngology Head and Neck Surgery; Research Funding: National Institute of Health; Research Funding: American Society of Pediatric Otolaryngology; Research Funding: Inspire Medical

Jeffrey Simons, MD, AAO-HNSF Education Steering Committee Chair Richard V. Smith, MD, AAO-HNSF Education

No relationships to disclose

Expert Witness: various legal

Steering Committee, Past Chair

firms

This 2019-20 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 6, 2020: Deadline for all 2019-20 exams to be received; course closes August 7, 2020.

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

Level 2

Level 3

Level 4

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 2020 Section 3

TRAUMA, CRITICAL CARE, AND SLEEP MEDICINE

I.

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

B. Management of laryngeal and tracheal injuries C. Management of penetrating head and neck injuries D. Orbital trauma E. Temporal bone trauma Critical Care and Perioperative Care A. Complex airway management 1. Managing the “difficult airway” 2. Tracheostomy protocols B. Management of head and neck hemorrhage C. Caustic ingestion D. Management of burns to the head and neck E. Perioperative care of the otolaryngology patient

II.

1. Pain control (narcotic and nonnarcotic therapies) 2. DVT management

III.

Sleep A. Hypoglossal nerve stimulation B. Drug-induced sleep endoscopy

C. Palatal surgery for OSA D. Oral appliance therapy E. Home sleep testing

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

2020 SECTION 3: TRAUMA, CRITICAL CARE, AND SLEEP MEDICINE

ADDITIONAL REFERENCE MATERIAL...................................................................................i - iv

I. TRAUMA A. Contemporary management of mandible, midface, and frontal fractures

Kao R, Rabbani CC, Patel JM, et al. Management of mandible fracture in 150 children across 7 years in a US tertiary care hospital. JAMA Facial Plast Surg . 2019 Jun 6. doi: 10.1001/jamafacial.2019.0312. [Epub ahead of print]. EBM level 4........................................................................................................1-5 Summary : This is a retrospective cohort study of 150 patients with 310 total mandible fractures; 109 patients (72.7%) had 2 or more mandible fractures. The mean (SD) patient age was 12.8 (4.6) years. There were 78 condylar or subcondylar fractures (60 patients), 75 ramus or angle fractures (69 patients), 69 body fractures (62 patients), 78 symphyseal or parasymphyseal fractures (76 patients), and 10 coronoid fractures (10 patients). Thirty-eight (25%) of patients were treated with observation and a soft diet. Children 12 years and older were more likely to receive open reduction internal fixation (ORIF) ( p   = 0.02). Of the 112 patients treated with surgery, 63 (56.2%) were treated with maxillomandibular fixation (MMF), 24 (21.4%) received ORIF, and 20 (17.9%) received both MMF and ORIF. Thirteen patients experienced complications, for a total complication rate of 8.7%. Conservative management, using MMF and a soft diet, was favored for most operative pediatric mandible fractures. ORIF with titanium plating was less commonly used. Outcomes were favorable despite a lack of consistent follow up. Summary : This is an evidence-based review to understand the epidemiology, preoperative evaluation, perioperative management, and surgical outcomes of mandible fractures. The objective of this series is to present a review of the literature so that the practicing physician can remain up-to-date on key evidence-based guidelines to enhance management and improve outcomes. B. Management of laryngeal and tracheal injuries Panagiotopoulos N, Patrini D, Barnard M, et al. Conservative versus surgical management of iatrogenic tracheal rupture. Med Prin Pract . 2017; 26(3):218-220. EBM level 2.............................................15-17 Summary : This article reviews management strategies for iatrogenic tracheal rupture. This type of tracheal injury, which is usually the result of orotracheal intubation, requires prompt diagnosis and management, as it is a potentially life-threatening condition. Pickrell BB, Hollier LH Jr. Evidence-based medicine: mandible fractures. Plast Reconstr Surg . 2017; 140(1):192e-200e. EBM level 3............................................................................................................6-14

Parida PK, Kalaiarasi R, Alexander A. Management of laryngotracheal trauma: a five-year single institution experience. Iran J Otorhinolaryngol . 2018; 30(100):283-290. EBM level 4..................18-25

Summary : This review of 253 patients with neck injury highlights the presenting symptoms and physical findings of patients with acute laryngotracheal injury. This report emphasizes the importance of CT imaging in the management of this patient population.

C. Management of penetrating head and neck injuries Nowicki JL, Stew B, Ooi E. Penetrating neck injuries: a guide to evaluation and management. Ann R Coll Surg Engl . 2018; 100(1):6-11. EBM level 4..............................................................................26-31 Summary : This article is a comprehensive review that helps guide clinical management of patients with penetrating trauma to the neck. It presents an evidence-based, algorithmic, practical guide for clinicians to use when assessing and managing penetrating neck injury. D. Orbital trauma Frohwitter G, Wimmer S, Goetz C, et al. Evaluation of a computed-tomography-based assessment scheme in treatment decision-making for isolated orbital floor fractures. J Craniomaxillofac Surg . 2018; 46(9):1550-1554. EBM level 4.................................................................................................32-36 Summary : This is a retrospective study of 106 patients with unilateral isolated orbital floor fractures. Correlations between preoperative ophthalmological examinations and specific CT parameters were performed, looking at CT scans of orbital floor fractures with the aim of facilitating treatment decision- making using four CT-based variables. Findings showed that critical size defects of the orbital floor of ≥ 2 cm are likely to cause clinically significant posterior displacement of the globe, resulting in enophthalmos, and the authors proposed parameters of a readily accessible and easy-to-evaluate scheme to help identify patients in need of surgical intervention. Sharma AN, Tiourin E, Banyard DA, et al. Clinical utility of postoperative computed tomography imaging in orbital floor fracture management. Ann Plast Surg . 2019; 83(1):43-47. EBM level 4...................................................................................................................................................37-41 Summary : A retrospective chart review was conducted for all patients who underwent orbital floor fracture repair at University of California, Irvine, from 2008 to 2017. Demographics, injury characteristics, and presurgical and postsurgical management were retrospectively extracted for 217 cases. Patients who experienced a change of care following postoperative CT (N = 6) were compared with the entire patient cohort. In this patient cohort, postoperative CT imaging and its associated costs did not significantly benefit management of orbital floor fracture repair. Careful clinical physical examination should be emphasized over postoperative CT imaging to reliably determine the necessity for reoperation in orbital floor fracture management. E. Temporal bone trauma O TM. Medical management of acute facial paralysis. Otolaryngol Clin North Am . 2018; 51(6):1051- 1075. EBM level Review....................................................................................................................42-46 Summary : This article provides an expansive differential diagnosis of the causes and medical treatment of acute facial paralysis. The author briefly discusses trauma, but succinctly addresses the clinical practice guideline gap analysis of making the proper diagnosis of Bell’s palsy versus other causes of facial paralysis. The article includes an algorithm for medical therapy. The review article includes CT as an objective endpoint in management.

Sun DQ, Andresen NS, Gantz BJ. Surgical management of acute facial palsy. Otolaryngol Clin North Am . 2018; 51(6):1077-1092. EBM level Review...............................................................................67-82

Summary : This article discusses common causes of facial nerve palsy, including Bell’s palsy and temporal bone fracture, discusses rationale and surgical approaches for Bell’s palsy and trauma, and is a complete review of electrophysiologic testing. The review article includes CT as an objective endpoint in management.

II. CRITICAL CARE AND PERIOPERATIVE CARE A. Complex airway management 1. Managing the “difficult” airway

Detsky ME, Jivraj N, Adhikari NK, et al. Will this patient be difficult to intubate? The Rational Clinical Examination systematic review. JAMA . 2019; 321(5):493-503. EBM level 1.............83-93

Summary : This meta-analysis evaluates risk factors and physical findings as a means of predicting a difficult intubation. While no clinical finding reliably excludes a difficult intubation, an abnormal upper lip bite test raises the probability from 10% to greater than 60%.

Pandian V, Zhen G, Stanley S, et al. Management of difficulty airway among patients with oropharyngeal angioedema. Laryngoscope . 2019; 129(6):1360-1367. EBM level 3..............94-101

Summary : This article reviews the experience of the Difficult Airway Response Team (DART) at a single institution in responding to angioedema cases. The article reviews outcomes of patients in the pre-DART group versus the post-DART cohort. 2. Tracheostomy protocols Masood MM, Farquhar DR, Biancaniello C, Hackman TG. Association of standardized tracheostomy care protocol implementation and reinforcement with the prevention of life- threatening respiratory events. JAMA Otolaryngol Head Neck Surg . 2018; 144(6):527-532. EBM level 3........................................................................................................................................102-107 Summary : This study compares a cohort of patients that received a standardized tracheostomy perioperative care protocol. It compares outcomes, including life-threatening events, in patients before and after the protocol was implemented at the institution. It demonstrated a reduction in life- threatening rapid-response calls for mucus plugging. Summary : This article investigated the effect of an institutional quality-improvement protocol to reduce the incidence of tracheostomy pressure ulcers. The incidence decreased from 10.9% to 1.3%. B. Management of head and neck hemorrhage Cogbill TH, Cothren CC, Ahearn MK, et al. Management of maxillofacial injuries with severe oronasal hemorrhage: a multicenter perspective. J Trauma . 2008; 65(5):994-999. EBM level 4..............118-123 Summary : This is a retrospective review in which seven trauma registries from nine trauma centers were queried over a 7-year period for injuries with an abbreviated injury scale face ≥ 3 and transfusion of ≥ 3 units of blood within 24 hours. An algorithm was devised for management of patients with severe oronasal hemorrhage after maxillofacial trauma. O'Toole TR, Jacobs N, Hondorp B, et al. Prevention of tracheostomy-related hospital-acquired pressure ulcers. Otolaryngol Head Neck Surg . 2017; 156(4):642-651. EBM level 3............108-117

Manzoor NF, Rezaee RP, Ray A, et al. Contemporary management of carotid blowout syndrome utilizing endovascular techniques. Laryngoscope . 2017; 127(2):383-390. EBM level 4.............124-131

Summary : This is a retrospective review to illustrate complex interdisciplinary decision making and the utility of modern endovascular techniques in the management of patients with carotid blowout syndrome (CBS). Between 2004 and 2014, 33 patients had 38 hemorrhagic events related to head and neck cancer that were managed with endovascular means. Of these, 23 were localized to the external carotid artery (ECA) branches and five were localized to the ECA main trunk; nine were related to the common carotid artery (CCA) or internal carotid artery (ICA), and one event was related to the innominate artery. Seven events related to the CCA/ICA or innominate artery were managed with endovascular sacrifice, whereas three cases were managed with a flow-preserving approach (covered stent). Only one patient developed permanent hemiparesis. In two of the three cases in which the flow- preserving approach was used, the covered stent eventually became exposed via the overlying soft tissue defect, and definitive management using carotid revascularization or resection was employed to prevent further hemorrhage. In cases of soft tissue necrosis, vascularized tissues were used to cover the great vessels as applicable. C. Caustic ingestion Bird JH, Kumar S, Paul C, Ramsden JD. Controversies in the management of caustic ingestion injury: an evidence-based review. Clin Otolaryngol . 2017; 42(3):701-708. EBM level 3......................132-139

Summary : This article discusses evidence-based guidance in the acute management of caustic ingestion injury. The article addresses the limited role of CT imaging in the acute setting.

D. Management of burns to the head and neck Wong S, Melin A, Reilly D. Head and neck reconstruction. Clin Plast Surg . 2017; 44(4):845-856. EBM level 5.....................................................................................................................................140-151 Summary : This article discusses the acute treatment of head and neck burns, including management based upon burn depth, and timing and extent of reconstruction based upon the involved anatomic site in the head and neck.

E. Perioperative care of the otolaryngology patient 1. Pain control (narcotic and nonnarcotic therapies)

Cramer JD, Wisler B, Gouveia CJ. Opioid stewardship in otolaryngology: state of the art review. Otolaryngol Head Neck Surg . 2018; 158(5):817-827. EBM level 4.......................................152-162

Summary : This systematic review evaluates the risk of opioid abuse after otolaryngology surgeries and discusses strategies to avoid misuse. Among opioid-naïve patients who underwent otolaryngology procedures, the rate of postoperative chronic opioid use was 6%. The article summarizes recommendations for how to counsel patients about opioid use and screen for abuse, and gives examples of pain management strategies to use for various surgical procedures.

2. DVT management Moubayed SP, Eskander A, Mourad MW, Most SP. Systematic review and meta-analysis of venous thromboembolism in otolaryngology-head and neck surgery. Head Neck . 2017; 39(6):1249-1258. EBM level 2...............................................................................................................................163-172 Summary : This systematic review evaluated the data about venous thromboembolism (VTE) in otolaryngology. Twenty-three studies representing 618,264 patients met inclusion criteria. Incidence of VTE was 0.4%, while bleeding complication incidence was 0.9%. The use of chemoprophylaxis was not associated with a decreased risk of VTE. Head and neck cancer cases had a higher incidence of VTE (0.9%) when compared to non-cancer cases (0.1%). Chemoprophylaxis may not be necessary in otolaryngology surgical cases. A. Hypoglossal nerve stimulation Soose RJ, Gillespie MB. Upper airway stimulation: a novel approach to managing obstructive sleep apnea. Laryngoscope . 2016; 126 Suppl 7:S5-S8. EBM level 5....................................................173-176 Summary : This article presents a succinct overview of upper airway stimulation therapy as an option for patients with moderate to severe OSA who are unable to adhere to CPAP therapy. It reviews the genioglossal contribution to upper airway collapse. A description of early scientific and feasibility studies is included, and the authors outline the results of the multicenter prospective Stimulation Therapy for Apnea Reduction (STAR) trial.

III. SLEEP

Heiser C, Thaler E, Boon M, et al. Updates of operative techniques for upper airway stimulation. Laryngoscope . 2016; 126 Suppl 7:S12-S16. EBM level 5............................................................177-181

Summary : This article provides an overview of neuroanatomy related to the hypoglossal nerve and a detailed description of surgical technique and perioperative care.

Woodson BT, Strohl KP, Soose RJ, et al. Upper airway stimulation for obstructive sleep apnea: 5-year outcomes. Otolaryngol Head Neck Surg . 2018; 159(1):194-202. EBM level 2...........................182-190

Summary : This article provides 5-year results from a prospective cohort study of patients treated for obstructive sleep apnea (OSA) with upper airway stimulation. It describes a response rate (defined as AHI < 20 events per hours and > 50% reduction of AHI after surgery) of 63% at 5 years with a 6% rate of serious device-related events in a cohort of 71 patients who completed the entire protocol. These statistically significant improvements in PSG measures were accompanied by statistically significant improvements in patient quality-of-life measures. B. Drug-induced sleep endoscopy Hohenhorst W, Ravesloot MJL, Kezirian EJ, de Vries N. Drug-induced sleep endoscopy in adults with sleep-disordered breathing: technique and the VOTE Classification system. Operative Techniques Otol . 2012; 23:11-18. EBM level 5..........................................................................................................191-198 Summary : This paper provides an overview of drug-induced sleep endoscopy (DISE) techniques and a description of the VOTE classification, which describes common terminology for the description of upper airway collapse to allow for an individualized approach to treatment options. The review focuses on achieving the appropriate level of sedation and the importance of avoiding oversedation. The authors also discuss the need to develop a common language to report DISE findings and therefore focus a significant portion of the paper on discussing the VOTE classification as this universal qualitative assessment.

C. Palatal surgery for OSA Yaremchuk K. Palatal procedures for obstructive sleep apnea. Otolaryngol Clin North Am . 2016; 49(6):1383-1397. EBM level Review.............................................................................................199-213 Summary : This article reviews in detail palatal procedures used to treat obstructive sleep apnea. Descriptions and drawings depicting uvulopalatopharyngoplasty, uvulopalatal flap, laser-assisted uvulopalatopharyngoplasty, cautery-assisted palatal stiffening, lateral pharyngoplasty, expansion sphincter pharyngoplasty, Z-palatoplasty, radiofrequency volumetric tissue reduction, and pillar implants are presented. D. Oral appliance therapy Serra-Torres S, Bellot-Arcis C, Montiel-Company JM, et al. Effectiveness of mandibular advancement appliances in treating obstructive sleep apnea syndrome: a systematic review. Laryngoscope . 2016; 126(2):507-514. EBM level 2.........................................................................................................214-221 Summary : This article summarizes the use of different mandibular advancement devices as an alternative to positive airway pressure therapy. The authors reviewed 22 primarily prospective studies, revealing a significant reduction in AHI in the 16/18 papers that reviewed AHI, and a significant reduction in Epworth Sleepiness Scale in the 11 studies evaluating ESS. No significant adverse effects were noted in any of the reviewed articles. E. Home sleep testing Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med . 2017; 13(3):479-504. EBM level 3.............................................................................222-247 Summary : This systematic review and clinical practice guideline establishes recommendations for diagnosis of obstructive sleep apnea in adults. Protocols for ordering in-facility sleep testing versus home sleep testing are described. Specifically, in-facility testing is recommended for patients with significant cardiorespiratory disease, neuromuscular conditions causing respiratory muscle weakness, awake hypoventilation, chronic opioid use, history of stroke, or severe insomnia. Rosen IM, Kirsch DB, Chervin RD, et al. Clinical use of a home sleep apnea test: an American Academy of Sleep Medicine position statement. J Clin Sleep Med . 2017; 13(10):1205-1207. EBM level 5...............................................................................................................................................248-250 Summary : This article is a consensus statement from the American Academy of Sleep Medicine about guidelines for the clinical use of home sleep apnea testing. The Academy recommends that only a physician diagnose sleep apnea, and only a physician who is board-certified in sleep medicine interpret home sleep testing data.

2019-20 SECTION 3 ADDITIONAL REFERENCES

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.

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.

Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology . 2013; 118(2):251-270.

Aronow SP, Aronow HD, Blanchard T, et al. Hair relaxers: a benign caustic ingestion? J Pediatr Gastroenterol Nutr . 2003; 36(1):120-125.

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. 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. 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. Capasso R, Rosa T, Tsou DY, et al. Variable findings for drug-induced sleep endoscopy in obstructive sleep apnea with propofol versus dexmedetomidine. Otolaryngol Head Neck Surg . 2016; 154(4):765- 770.

Chan DK, Parikh SR. Perioperative ketorolac increases post-tonsillectomy hemorrhage in adults but not children. Laryngoscope . 2014; 124(8):1789-1793.

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.

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.

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.

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 . 2018; 33(9):517-526.

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.

i

Frank E, Carlson B, Hu A, et al. Assessment and treatment of pain during in-office otolaryngology procedures: a systematic review. Otolaryngol Head Neck Surg . 2019; 161(2):218-226.

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.

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.

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. 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.

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Reprinted by permission of JAMA Facial Plast Surg. 2019 Jun 6. doi: 10.1001/jamafacial.2019.0312. [Epub ahead of print].

Research

JAMA Facial Plastic Surgery | Original Investigation

Management of Mandible Fracture in 150 Children Across 7 Years in a US Tertiary Care Hospital

Richard Kao, MD; Cyrus C. Rabbani, MD; Janaki M. Patel, BS; Samantha M. Parkhurst, BS; Avinash V. Mantravadi, MD; Jonathan Y. Ting, MD, MBA; Michael W. Sim, MD; Karl Koehler, PhD; Taha Z. Shipchandler, MD

IMPORTANCE Pediatric mandible fractures are the most common pediatric facial fracture requiring hospitalization, but data are lacking on management methods, outcomes, and complications.

OBJECTIVE To analyze management methods, outcomes, and complications of pediatric mandible fractures at an urban academic tertiary care center.

DESIGN, SETTING, AND PARTICIPANTS Single-institution cohort study conducted at 2 urban level 1 pediatric trauma centers including all patients aged 0 to 17 years diagnosed with mandible fractures between January 1, 2010, and December 31, 2016. Fractures were treated by multispecialty surgical teams. Data were analyzed between January 1, 2018, and March 1, 2018.

MAIN OUTCOMES AND MEASURES Fracture distributions, mechanisms, treatment methods, complications, and follow-up.

RESULTS Of 150 patients with 310 total mandible fractures, the mean (SD) age was 12.8 (4.6) years; 108 (72.0%) were male; 107 (71.3%) were white; and 109 (72.7%) had 2 or more mandible fractures. There were 78 condylar or subcondylar fractures (60 patients), 75 ramus or angle fractures (69 patients), 69 body fractures (62 patients), 78 symphyseal or parasymphyseal fractures (76 patients), and 10 coronoid fractures (10 patients). The most common mechanisms of injury were assault and battery, motor vehicle collisions, falls or play, and sports-related mechanisms. Thirty-eight (25%) patients were treated with observation and a soft diet. Children 12 years and older were more likely to receive open reduction internal fixation (ORIF) ( P = .02). Of 112 patients treated with surgery, 63 (56.2%) were treated with maxillomandibular fixation (MMF), 24 (21.4%) received ORIF, and 20 (17.9%) received both MMF and ORIF. Nonabsorbable plating was used in all but 1 of the ORIF procedures. Five of 44 (11.4%) patients receiving ORIF or ORIF and MMF had follow-up beyond 6 months, and 8 of the 44 (18.2%) had documented plating hardware removal; hardware was in place for a mean (SD) 180 (167) days. Sixty of the 150 patients (40.0%) had some form of follow-up, a mean (SD) 90 (113) days total after initial presentation. Thirteen patients experienced complications, for a total complication rate of 8.7%. CONCLUSIONS AND RELEVANCE Conservative management, using MMF and a soft diet, was favored for most operative pediatric mandible fractures. Open reduction internal fixation with titanium plating was less commonly used. Outcomes were favorable despite a lack of consistent follow-up.

Author Affiliations: Department of Otolaryngology–Head and Neck Surgery, Indiana University School of Medicine, Indianapolis (Kao, Rabbani, Parkhurst, Mantravadi, Ting, Sim, Koehler, Shipchandler); Medical Student, Indiana University School of Medicine, Indianapolis (Patel). Corresponding Author: Taha Z. Shipchandler, MD, Department of Otolaryngology–Head and Neck Surgery, Indiana University School of Medicine, 1130 WMichigan St, Ste 400, Indianapolis, IN 46202 ( tshipcha@iupui.edu ).

LEVEL OF EVIDENCE 4 .

JAMA Facial Plast Surg . doi: 10.1001/jamafacial.2019.0312 Published online June 6, 2019.

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Research Original Investigation

Management of Mandible Fracture in Children

P ediatric facial fractures can cause lasting, irreversible impairment in function and cosmesis. 1 Comprising 15% of all facial fractures in the United States, facial frac- tures occur less frequently inpediatric patients than in adults. 2 Part of the reason for this disparity is that the pediatric skel- eton is more resilient to traumatic forces, owing to its higher elasticity, higher cancellous to cortical bone proportion, and thicker overlying soft tissue and fat. 3 Pediatric mandible fractures (PMF) are the most com- mon pediatric facial fracture requiring hospitalization. 4 The risk of PMF increases with age, in part owing to facial growth. First, the face to cranium ratio increases with age, from 1:8 at birth to 1:2 to 1:2.5 in adulthood. 5 The mandibular growth in height at the alveolus as well as posterior and superior growth at the condyle ultimately results in translation of the man- dible anteriorly and inferiorly. 3 This makes the mandible a larger and more accessible structure for trauma with age. To our knowledge, this study represents the largest single institution cohort study in theUnited States for pediatricman- dible fractures in the literature. The goal of this study was to retrospectively analyzemanagementmethods, outcomes, and complications of pediatric mandible fractures at our institu- tion. We hypothesize that owing to favorable biology, the pe- diatric trauma populationhas greater osteogenic potential than the adult trauma population. We believe that conservative management, using observation with a soft diet or maxillo- mandibular fixation (MMF), vs open reduction internal fixa- tion (ORIF) with plating, is favored in most pediatric man- dible fractures. ComparedwithORIF,MMF confers adecreased risk of long-term facial deformity and is a less extensive sur- gerywithdecreased soft tissue trauma; however, it is acknowl- edged that extended periods of MMF increase the risk of tem- poromandibular joint ankylosis. Methods This study followed the Strengthening the Reporting of Ob- servational Studies in Epidemiology ( STROBE ) reporting guideline. We performed a single-institution, retrospective cohort study at 2 level 1 trauma centers. Inclusion criteriawere (1) International ClassificationofDiseases,NinthRevision ( ICD-9 ) codes 802.xx, or ICD-10 code S02.6XX; (2) aged 0 to 17 years at time of presentation, and (3) occurring between January 1, 2010, andDecember 31, 2016, anddata analysiswas conducted from January 1, 2018, to March 1, 2018. At our institution, multiple surgical specialty teams treat pediatric mandible fractures, including otolaryngologists, plastic surgeons, and oral and maxillofacial surgeons. This study was approved by the Indiana University School ofMedicine institutional review board. Expedited review was obtained, allowing informed consent to be waived because no interventionwas performed and no patient contact occurred while obtaining, reviewing, or analyzing the data. Data extracted from the electronic medical record in- cluded basic demographic characteristics,mechanism(s) of in- jury, operations, complications, and follow-up. All imaging studieswere reviewed. All fractureswere categorizedaccording

to Association of Osteosynthesis, Craniomaxillofacial Man- dible Fracture Classifications. 6 Statistical analysis was per- formed using SPSS 22.0 for Windows (IBM Corp) using uni- variate andmultivariate analyses. Two-tailed P < .05 indicated statistical significance. Results A total of 150 patients with documented pediatric mandible fractures were evaluated at our institution. Themean (SD) age was 12.8 (4.6) years, and 99 (66%) of the patients were teen- agers. One hundred eight (72.0%) patients weremale; and 107 (71.3%)werewhite,which is representativeof our patient popu- lation. Insurance was most commonly provided by Medicaid (74 patients [49.3%]) and managed care programs (59 pa- tients [39.3%]). One hundred twenty-seven of the patients (84.7%) presented directly to our emergency department vs by transfer from another institution ( Table 1 ). Therewere 310 totalmandible fractures ( Table 2 ), with 109 (72.7%) patients having 2 or more fractures. The distribution of fracture locationwas evenly split among the 4major groups of condylar or subcondylar, ramus or angle, body, and sym- physeal or parasymphyseal, with each comprising between 22% to 25% of all fractures. Coronoid fractures were encoun- tered in 10 (6.7%) of the 150 patients. Themost common frac- ture combinations were condylar or subcondylar only (3 with bilateral fractures), condylar or subcondylar plus symphy- seal or parasymphyseal (10with bilateral condylar or subcon- dylar fractures), and angle or ramus plus body. The most common mechanisms of injury among the 150 patients were assault and battery (33 [22.0%]), motor vehicle collisions (31 [20.7%]), falls or play (22 [14.7%]), and sport- related (22 [14.7%]) ( Figure 1 ). Multivariate analysis showed that condylar or subcondylar fractures were statisticallymore likely to be caused by falls and play vs othermechanisms (falls vs assault: difference of means, 0.89 [95%CI, 0.15-1.30]; falls vs motor vehicle collision: difference of means, 0.56 [95%CI, 0.15-0.97]; falls vs sport, difference of means, 0.85 [95% CI, 0.41-1.30]; P < .001 for all), angle or ramus fracturesmore likely caused by assault (assault vs falls: difference in means, 0.37 [95% CI, 0.01-0.84]; P = .03; assault vs motor vehicle colli- sion: difference in means, 0.44 [95% CI, 0.01-0.84]; P = .04), Key Points Question What are the treatment methods and associated complication rates in pediatric mandible fractures managed at a tertiary care center? Findings In this cohort study with 150 patients, one-fourth of pediatric mandible fractures were treated without surgery. Most operative pediatric mandible fractures were treated with maxillomandibular fixation alone and a soft diet. Meaning This study suggests that conservative management of pediatric mandible fractures using maxillomandibular fixation or observation with a soft diet predominates over open reduction internal fixation with plating.

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