What Tests are Used to Assess the Physical Qualities of Male, Adolescent Rugby League Players? A Systematic Review of Testing Protocols and Reported Data Across Adolescent Age Groups

BACKGROUND

Understanding the physical qualities of male, adolescent rugby league players across age groups is essential for practitioners to manage long-term player development. However, there are many testing options available to assess these qualities, and differences in tests and testing protocols can profoundly influence the data obtained.

OBJECTIVES

The aims of this systematic review were to: (1) identify the most frequently used tests to assess key physical qualities in male, adolescent rugby league players (12-19 years of age); (2) examine the testing protocols adopted in studies using these tests; and (3) synthesise the available data from studies using the most frequently used tests according to age group.

METHODS

A systematic search of five databases was conducted. For inclusion, studies were required to: (1) be original research that contained original data published in a peer-reviewed journal; (2) report data specifically for male, adolescent rugby league players; (3) report the age for the recruited participants to be between 12 and 19 years; (4) report data for any anthropometric quality and one other physical quality and identify the test(s) used to assess these qualities; and (5) be published in English with full-text availability. Weighted means and standard deviations were calculated for each physical quality for each age group arranged in 1-year intervals (i.e., 12, 13, 14, 15, 16, 17 and 18 years) across studies.

RESULTS

37 studies were included in this systematic review. The most frequently used tests to assess anthropometric qualities were body mass, standing height, and sum of four skinfold sites. The most frequently used tests to assess other physical qualities were the 10-m sprint (linear speed), 505 Agility Test (change-of-direction speed), Multistage Fitness Test (aerobic capacity), bench press and back squat one-repetition maximum tests (muscular strength), and medicine ball throw (muscular power). Weighted means calculated across studies generally demonstrated improvements in player qualities across subsequent age groups, except for skinfold thickness and aerobic capacity. However, weighted means could not be calculated for the countermovement jump.

CONCLUSION

Our review identifies the most frequently used tests, but highlights variability in the testing protocols adopted. If these tests are used in future practice, we provide recommended protocols in accordance with industry standards for most tests. Finally, we provide age-specific references for frequently used tests that were implemented with consistent protocols. Clinical Trial Registration This study was conducted in accordance with the Preferred Reporting Items of Systematic Review and Meta-analysis guidelines and was registered with PROSPERO (ID: CRD42021267795).

Greater symptom burden results in reduced exercise tolerance in adolescents following concussion

OBJECTIVES

To explore the relationship between symptoms and exercise tolerance in adolescents following concussion.

METHODS

A retrospective analysis of 417 adolescents who attended a concussion service between January 2015 and April 2021 was performed, with 149 meeting eligibility criteria for inclusion. Post-Concussion Symptom Scale (PCSS) and graded exercise tolerance time (min) were assessed at initial and follow-up visits. Spearman's correlation was used to examine the relationship between PCSS scores and exercise time.

RESULTS

Adolescents (n = 149, 13.9 ± 1.7 years, 66.4% male) presented at 28.6 ± 19.7 days post-injury. Statistically significant correlations were identified between initial (r = -0.36, p < .001) and follow-up (r = -0.41, p < .001) PCSS scores and exercise time among all participants. Initial PCSS and initial exercise time were inversely correlated for males (r = -0.24, p = .018) and females (r = -0.22, p = .127). Follow-up PCSS and follow-up exercise time were inversely correlated for males (r = -0.30, p = .003) and females (r = -0.35, p = .014).

CONCLUSION

There is a statistically significant relationship between higher PCSS and poorer exercise time and both factors should be considered together to provide the most accurate assessment, particularly in females.

Head and Neck Injury Patterns among American Football Players

IMPORTANCE

American football is a popular high-impact sport, leading to 2.7 million injuries in the United States annually. Recent evidence in football-related neurological damage has spurred national interest in player-safety. Football players injure their head and neck in up to 26% of total injuries. Variation in injury patterns between age groups and correlated hospitalizations for football-related head and neck injury has yet to be characterized.

OBJECTIVE

Our aim is to evaluate injury patterns among American-football related head and neck trauma.

METHODS

A retrospective cohort study of patients with football-related head and neck injury in the National Electronic Injury Surveillance System (NEISS).

RESULTS

Nearly 100 000 ED visits for football-related head and neck injuries occur annually. Males comprised 95% of patients, with a median age of 13. The head comprised 70% of injuries followed by the face (13%). The most common diagnoses were concussions (39%), internal organ injury (26%), and lacerations (11%). Pediatric patients were more likely to sustain concussions while adults experienced more lacerations (P < .05%). Fractures and nerve damage were rare injuries but caused a disproportionate share of hospitalizations.

CONCLUSION

Pediatric males are most likely to present for emergency care from football-related injury to the head and neck. Evaluating physicians can anticipate concussions, internal organ injury, and lacerations among presenting patients. Concussions, facial fractures, and nerve damage are injuries most likely to lead to hospitalization.

Surgical Adjuncts to Rhinoplasty: An Algorithmic Approach

BACKGROUND

Nasal aesthetics can be significantly affected by the interdependence of the surrounding bone and soft tissues of the face. These include the maxilla, septum, frontal bone, mandible, and the soft tissues and cartilage surrounding the nose. Therefore, it is pertinent to analyze and address these critical relationships of the nose in order to achieve a successful rhinoplasty. This work seeks to describe the battery of adjunct procedures available to supplement a rhinoplasty. Furthermore, each preoperative finding or indication for the adjunct is described in an algorithmic fashion.

METHODS

A literature search using PubMed, Google Scholar, and a university library database was performed to locate papers describing adjunctive procedures to rhinoplasty. Indications and preoperative analysis were extracted from each paper. If the indication or finding was unclear, supplementary literature describing rhinoplasty and adjunctive analysis were sought in order to supplement our findings.

RESULTS

Sixteen papers in total described adjunctive procedures for rhinoplasty. Each work highlighted a procedure or set of procedures on a surrounding facial feature including the forehead, brow, cheeks, lips, and chin, and neck. In total, 13 adjunct procedures for rhinoplasty are described with their respective indications. Additional literature and techniques were researched to clarify indicated procedures.

CONCLUSION

The ability to correctly understand the critical relationships of the nose can help the surgeon correctly recognize the indication for a rhinoplasty adjunct procedure, leading to better aesthetic balance and surgical outcomes.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Novel Changes in Resident Education during a Pandemic: Strategies and Approaches to Maximize Residency Education and Safety

Introduction  The COVID-19 pandemic has led to a reduction in surgical and clinical volume, which has altered the traditional training experience of the otolaryngology resident. Objective  To describe the strategies we utilized to maximize resident education as well as ensure patient and staff safety during the pandemic. Methods  We developed a system that emphasized three key elements. First and foremost, patient care remained the core priority. Next, clinical duties were restructured to avoid unnecessary exposure of residents. The third component was ensuring continuation of resident education and maximizing learning experiences. Results  To implement these key elements, our residency divided up our five hospitals into three functional groups based on geographical location and clinical volume. Each team works for three days at their assigned location before being replaced by the next three-person team at our two busiest sites. Resident teams are kept completely separate from each other, so that they do not interact with those working at other sites. Conclusions  Despite the daily challenges encountered as we navigate through the COVID-19 pandemic, our otolaryngology residency program has been able to establish a suitable balance between maintenance of resident safety and well-being without compromise to patient care.

Craniofacial injuries related to motorized scooter use: A rising epidemic

OBJECTIVES

Over the last decade, there has been increased interest in utilizing motorized scooters for transportation. The limited regulation of this modernized vehicle raises numerous safety concerns. This analysis examines a national database to describe the yearly incidence of craniofacial injuries and patterns of injury related to motorized scooter use.

METHODS

The Consumer Product Safety Commission's National Electronic Injury Surveillance system was queried for craniofacial injuries associated with motorized scooter use. Patient demographics, injury type, anatomic location, injury pattern, and helmet status were extracted for analysis.

RESULTS

From 2008 to 2017, there were 990 recorded events for craniofacial injuries secondary to motorized scooters extrapolating to an estimated 32,001 emergency department (ED) visits. The annual incidence was noted to triple over that 10-year period. The majority of patients were male (62.1%) and the common age groups at presentation were young children 6-12 years old (33.3%), adolescents 13-18 years old (16.1%) and young adults 19-40 years old (18.0%). The most common injury pattern was a closed head injury (36.1%) followed by lacerations (20.5%). Facial fractures were only present in 5.2% of cases. In cases in which helmet use was recorded, 66% of the patients were not helmeted.

CONCLUSION

The incidence of motorized scooter related craniofacial trauma is rising, resulting in thousands of ED visits annually. Many patients are experiencing morbid traumatic injuries and may not be wearing appropriate protective equipment. This study highlights the importance of public awareness and policy to improve safety and primarily prevent craniofacial trauma.

Perioperative Desmopressin for Patients Undergoing Otolaryngologic Procedures: A Systematic Review

Objective

Desmopressin (DDAVP) is a hemostatic agent used to manage bleeding in patients with hemostatic disorders, and there is a lack of published data to guide its use during otolaryngology procedures. The objective of this study was to conduct an evidence-based systematic review of the reported uses, efficacy, and adverse effects of DDAVP in the otolaryngology surgical setting.

Data Sources

PubMed, MEDLINE, and EmBase were searched for articles on the use of DDAVP in otolaryngology.

Review Methods

The Methodological Index for Non-Randomized Studies criteria and Cochrane bias tool were used to assess study quality. Patient demographics, DDAVP dosing and route, and outcomes such as bleeding and adverse events were collected. A summary of evidence table was created specifying levels of evidence, benefits, and harm.

Results

Nineteen studies encompassing 440 patients were included. Sixteen studies discussed DDAVP for prophylaxis, and 3 discussed postoperative use. DDAVP effectively prevented bleeding in high-risk patients and successfully facilitated a dry surgical field when necessary. DDAVP had a 100% success rate when used symptomatically. Five studies described adverse effects, including hyponatremia (12.3%), nausea (2.0%), emesis (0.9%), and seizure (0.2%). The aggregate level of evidence for its use was Level B for adenotonsillectomy, septoplasty, and turbinate procedures and Level C for rhinoplasty.

Conclusion

Current literature supports the use of DDAVP in otolaryngology surgical procedures as both a perioperative prophylactic agent and a postoperative symptomatic intervention for bleeding. Both modalities are effective with minimal adverse events. Further well-designed randomized trials are necessary to conclusively formulate guidelines for DDAVP use in otolaryngology.

Search Engine Optimization: An Analysis of Rhinoplasty Web sites

The Internet is the primary source of information for facial plastic surgery patients. Most patients only analyze information in the first 10 Web sites retrieved. The aim of this study was to determine factors critical for improving Web site traffic and search engine optimization. A Google search of “rhinoplasty” was performed in Michigan. The first 20 distinct Web sites originating from private sources were included. Private was defined as personal Web sites for private practice physicians. The Web sites were evaluated using SEOquake and WooRANK, publicly available programs that analyze Web sites. Factors examined included the presence of social media, the number of distinct pages on the Web site, the traffic to the Web site, use of keywords, such as rhinoplasty in the heading and meta description, average visit duration, traffic coming from search, bounce rate, and the number of advertisements. Readability and Web site quality were also analyzed using the DISCERN and Health on the Net Foundation code principles. The first 10 Web sites were compared with the latter 10 Web sites using Student's t-tests. The first 10 Web sites received a significantly lower portion of traffic from search engines than the second 10 Web sites. The first 10 Web sites also had significantly fewer tags of the keyword “nose” in the meta description of the Web site. The first 10 Web sites were significantly more reliable according to the DISCERN instrument, scoring an average of 2.42 compared with 2.05 for the second 10 Web sites (p = 0.029). Search engine optimization is critical for facial plastic surgeons as it improves online presence. This may potentially result in increased traffic and an increase in patient visits. However, Web sites that rely too heavily on search engines for traffic are less likely to be in the top 10 search results. Web site curators should maintain a wide focus for obtaining Web site traffic, possibly including advertising and publishing information in third party sources such as “RealSelf.”

Oropharyngeal lymphoma: A US population based analysis

OBJECTIVES

To describe the epidemiology and analyze factors determinant of survival in patients with oropharyngeal lymphoma, using the Surveillance Epidemiology and End Results (SEER) database.

METHODS

2504 patients with oropharyngeal lymphoma were identified using the most recent SEER database entry from 1976 to 2016. Demographic information, Ann Arbor stage, tumor histopathology and location were collected. Multivariate analysis was used to analyze patient and tumor characteristics associated with survival.

RESULTS

The mean age of the patients studied was 60.5years, 58.4% of the subjects were male and 81% were white. Diffuse large B cell lymphoma (DLBCL) was the most common histologic subtype involving 56.9% of cases. The most common subsite of origin was the tonsil, with 71% of lymphomas originating from there. The association of survival with stage, age, tumor location, presence of B symptoms, tumor pathology, gender and race was analyzed using multivariate regression. Decreased survival was significantly associated with patient age p<0.0001, Ann Arbor staging p=0.005, the presence of B symptoms p=0.003 and tumor histopathology (T cell tumors) p=0.01. Patients with tumors originating from the soft palate were significantly more likely to die asa result of their disease p=0.03.

CONCLUSION

Oropharyngeal lymphoma most commonly originates from the tonsil. DLBCL is the most common subtype and has a good prognosis. The presence of B symptoms, tumors originating from the soft palate and patients with T cell tumors have the worst prognosis. This information can potentially be of great utility to the head and neck surgeon discussing prognosis with patients suffering from oropharyngeal lymphoma.

Analysis of Factors Associated With Rhytidectomy Malpractice Litigation Cases

Importance

This study investigates the financial burden of medical malpractice litigation associated with rhytidectomies, as well as factors that contribute to litigation and poor defendant outcomes, which can help guide physician practices.

Objective

To comprehensively evaluate rhytidectomy malpractice litigation.

Data Sources and Study Selection

Jury verdict and settlement reports related to rhytidectomy malpractice litigations were obtained using the Westlaw Next database. Use of medical malpractice in conjunction with several terms for rhytidectomy, to account for the various procedure names associated with the procedure, yielded 155 court cases. Duplicate and nonrelevant cases were removed, and 89 cases were included in the analysis and reviewed for outcomes, defendant specialty, payments, and other allegations raised in proceedings. Data were collected from November 21, 2015, to December 25, 2015. Data analysis took place from December 25, 2015, to January 20, 2016.

Results

A total of 89 cases met our inclusion criteria. Most plaintiffs were female (81 of 88 with known sex [92%]), and patient age ranged from 40 to 76 years (median age, 56 years). Fifty-three (60%) were resolved in the defendant's favor, while the remaining 36 cases (40%) were resolved with either a settlement or a plaintiff verdict payment. The mean payment was $1.4 million. A greater proportion of cases involving plastic surgeon defendants were resolved with payment compared with cases involving defendants with ear, nose, and throat specialty (15 [36%] vs 4 [24%]). The most common allegations raised in litigation were intraoperative negligence (61 [69%]), poor cosmesis or disfigurement (57 [64%]), inadequate informed consent (30 [34%]), additional procedures required (14 [16%]), postoperative negligence (12 [14%]), and facial nerve injury (10 [11%]). Six cases (7%) involved alleged negligence surrounding a "lifestyle-lift" procedure, which tightens or oversews the superficial muscular aponeurosis system layer.

Conclusions and Relevance

In this study, although most cases of rhytidectomy malpractice litigation were resolved in the defendant's favor, cases resulting in payments created substantial financial burden for the defendants. Common factors cited by plaintiffs for pursuing litigation included dissatisfaction with cosmetic outcomes and perceived deficits in informed consent. These factors reinforce the importance of a comprehensive, preoperative informed consent process in which the specific potential risks and outcomes are presented by the surgeon to the patient to limit or avoid postsurgical allegations. Intraoperative negligence and facial nerve injury were significantly more likely to result in poor defendant outcomes.

Level of Evidence

NA.

Do Patients Access Appropriate Information Online?

Health care providers should be aware of information available on the Internet to ensure proper patient care. The current analysis assesses the reliability, quality, and readability of internet information describing rhytidectomy. Previously validated survey instruments to assess the reliability, quality, and readability of online websites describing rhytidectomy were used. An internet search using Google with the search term “facelift” was conducted. The first 50 search results were reviewed, and 36 were deemed appropriate to be included in this analysis. Websites were divided based on type of authorship into professional organization, academic, physician based, and unidentified. The validated DISCERN instrument was used to determine reliability, quality, and overall rating of each site. The Flesch Reading Ease Score (FRES) and Flesch–Kincaid Grade Level (FKGL) were used to measure readability. A 1 to 3 point scale was used to rate websites, with a higher number indicating a website that possessed either greater reliability or greater quality. Mean scores for reliability ranged from 1.7 (±0.99) in the academic group to 2.0 (±0.12) in the unidentified group. Mean scores for quality ranged from 1.5 (±0.13) in the unidentified group to 1.7 (±0.38) in the physician-based group. The highest overall rating was 1.4 (±0.22 and ± 0.31, respectively) in the unidentified and physician-based groups. The lowest overall rating was 1 (±0.58) in the academic group. FRESs ranged from 21.6 to 74.6. FKGLs ranged from 6.9 to 13.9. Information available online regarding rhytidectomy may be significantly deficient in reliability, quality, and readability. These deficiencies are present in articles with all types of author affiliations. This underscores the clinicians' duty to provide patients with high-quality information at an adequate level of comprehension.

Pediatric rhinoplasty: A discussion of perioperative considerations and systematic review

OBJECTIVES

Pediatric rhinoplasty has traditionally raised numerous concerns, including its impact on growth as well as the psychological sequelae of undergoing a potentially appearance-altering procedure. Our objective was to critically evaluate available individual patient data relevant to pediatric rhinoplasty, and further discuss perioperative considerations.

METHODS

A systematic review was conducted using PubMed/MEDLINE databases. Data extracted and analyzed from included studies included patient demographics, surgical indications, operative approaches, outcomes, complications, revision rates, and other clinical considerations.

RESULTS

Seven studies encompassing 253 patients were included, with age ranging from 7 months to 19 years. Two-thirds of patients were male. 41.7% reported antecedent trauma, and common overall surgical indications included "functional aesthetic" (24.5%) followed by cleft lip nasal deformity (15.8%). The majority (79.1%) underwent open approaches, and 71.1% of patients underwent concomitant septal intervention. The most frequently used grafting materials were septal cartilage (52.8%) and conchal cartilage (16.5%). Surgical outcomes were heterogeneous among these studies. Complication rates were only specified in 5 of the 7 studies and totaled 57 patients (39.6%). Aesthetic dissatisfaction (11.8%) and postoperative nasal obstruction (5.6%) were the most commonly reported complications. Revisions were performed in 13.5%.

CONCLUSION

Rhinoplasty is safe in the pediatric population, although revisions rates appear greater than those reported in adults. This study of 253 represents the largest pooled sample size to date; nonetheless, non-standardized outcome measures, minimal long-term followup data, and lack of discussion regarding psychological sequelae all contribute to the need for further high-quality studies evaluating this topic.

Forgetful but not forgotten: Bathroom-related craniofacial trauma among the elderly

OBJECTIVES/HYPOTHESIS

As our population ages, injuries attributable to falls continue to increase, impacting healthcare delivery. Evaluation of craniofacial trauma with focus on elderly patients remains an underappreciated concern. Our objectives were to evaluate injury trends associated with elderly bathroom falls, as this information may be useful for counseling and preventive purposes.

STUDY DESIGN

Database review.

METHODS

The National Electronic Injury Surveillance System was evaluated for craniofacial trauma among patients 60 years and older presenting to the emergency department (ED) (2010-2014). Injury descriptions were reviewed for mechanism of injury, patient demographics, and other injury characteristics.

RESULTS

In total, 7.2% of the estimated 3.4 million ED visits for elderly craniofacial trauma were bathroom related. Females comprised the majority (60.9%) of patients, and a plurality of patients were in their 80s. A greater proportion of facial injuries resulted from syncope (16.6% vs. 10.9% compared to head injuries). Toilets facilitated a greater proportion of facial insults and were more likely to require admission; the most common mechanism was "falling off." Showers contributed a majority of head injuries and had a lower median age than toilet injuries. Fractures comprised 12.6% of facial injuries; of craniofacial fractures, common sites included the nose (54%), mandible (6%), and orbit (6%). Admitted patients were significantly older than those who were released.

CONCLUSIONS

Bathroom falls result in a significant proportion of elderly traumatic injury. The trends we present offer the opportunity for targeted preventative measures to decrease the occurrence of these events. Additionally, this information may adjunct a detailed history and physical to ensure appropriate patient management.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:820-827, 2017.

Stability of midface fracture repair using absorbable plate and screw system pilot holes drilled and pin placement at angles other than 90°

IMPORTANCE

Conventional plating systems use titanium plates for fixation of fractures, with benefits of strength and biocompatibility. However, titanium plates require that screws be placed at a 90° angle to the pilot holes. In the midface, this becomes extremely difficult. Today, a variety of craniomaxillofacial osteosynthesis systems are available, including resorbable plating systems. Specifically, the KLS Martin Sonic Weld system ultrasonically fuses the plate and the head of the pin when placed and will fill the pilot hole grooves completely even at less than 90° angles, which provides a tremendous advantage in midface fracture repair.

OBJECTIVE

To determine if the KLS Martin Sonic Weld system provides plate-screw construct stability in human heads even when placed at acute angles at the midface buttresses. DESIGN, SETTING, AND SPECIMENS: Twenty cadaveric head specimens with the mandible removed were prepared by creating osteotomies in the midface buttresses bilaterally. Specimens were defleshed and placed in a 2-part testing rig to hold and position the head for testing in a standard material testing system. Testing was performed at the Wayne State University Bioengineering test laboratories, Detroit, Michigan, using an Instron device and high-speed camera. Specimens were plated on one side of the midface using the KLS Martin Sonic Weld system with pilot holes and pins placed at 90° angles. On the contralateral side, the buttresses were plated with the KLS Martin Sonic Weld system at 60°, 45°, and 30° angles. Data were collected using the TDAS data acquisition system and were compared with matched pairs within each specimen.

MAIN OUTCOMES AND MEASURES

Ultrasonically vibrated pins placed into absorbable mini-plates at less than 90° angles with the KLS Martin Sonic Weld system were compared with the same amount of stress as the system placed at a 90° angle before demonstrating plate-screw construct failure. RESULTS Fifty-seven paired tests were collected, with 114 total tests. Twenty failures were due to bone breakage, and 94 fixations failed as a result of the plate-screw construct breaking. Fractures fixated with the ultrasonic absorbable plating system placed with screws at all tested angles failed at similar loads to our control plates with pins placed at 90° angles. These results lend the surgeon to successfully reduce fractures in the midface fragments in difficult-to-reach areas and possibly cut down on operative time while improving the chance of achieving a long-lasting adequate reduction.

CONCLUSIONS AND RELEVANCE

Although there is a measured difference in the laboratory, no clinical difference is observed because the maximum force is not usually encountered. Overall, the clinical scenario indicates absorbable plates to be a viable option in less accessible areas.

LEVEL OF EVIDENCE

NA.

Craniofacial Surgery and Adverse Outcomes

Objective:

This study aimed to evaluate factors contributing to medical negligence relevant to craniofacial surgery.

Methods:

Retrospective analysis of verdict and settlement reports on the Westlaw legal database for outcome, awards, physician defendants, and other specific factors raised in malpractice litigation.

Results:

Of 42 verdicts and settlement reports included, 52.4% were resolved with either an out-of-court settlement or plaintiff verdict, with aggregate payments totaling $50.1M (in 2013 dollars). Median settlements and jury-awarded damages were $988 000 and $555 000, respectively. Payments in pediatric cases ($1.2M) were significantly higher. Plastic surgeons, oral surgeons, and otolaryngologists were the most commonly named defendants. The most common alleged factors included intraoperative negligence (69.0%), permanent deficits (54.8%), requiring additional surgery (52.4%), missed/delayed diagnosis of a complication (42.9%), disfigurement/scarring (28.6%), postoperative negligence (28.6%), and inadequate informed consent (20.6% of surgical cases). Failure to diagnose a fracture (19.0%) and cleft-reparative procedures (14.3%) were the most frequently litigated entities.

Conclusion:

Medical negligence related to craniofacial surgery involves plaintiffs in a wide age range as well as physician defendants in numerous specialties, and proceedings resolved with settlement and plaintiff verdict involve substantial payments. Cases with death, allegedly permanent injuries, and pediatric plaintiffs had significantly higher payments.

Hockey-related facial injuries: a population-based analysis

OBJECTIVES/HYPOTHESIS

Recognition of the potentially severe sequelae arising from inadequate facial protection has facilitated sustained efforts to increase the use of protective visors in recent decades. Our objective was to characterize nationwide trends among patients presenting to emergency departments (ED) for facial injuries sustained while playing ice hockey.

METHODS

The National Electronic Injury Surveillance System was searched for hockey-related facial injuries, with analysis for incidence; age and gender; and specific injury diagnoses, mechanisms, and facial locations.

RESULTS

There were an estimated 93,444 ED visits for hockey-related facial injuries from 2003 to 2012. The number of annual ED visits declined by 43.8% from 2003 to 2012. A total of 90.6% of patients were male; and the peak age of injury was 17 years. Lacerations were the most common form of facial injury (81.5% of patients) across all age groups. Contusions/abrasions and fractures followed in frequency, with fractures increasing with advancing age.

CONCLUSIONS

The overall incidence of ED visits due to facial injuries from ice hockey has significantly decreased over the last decade, concurrent with increased societal use of facial protective equipment. Nonetheless, facial hockey injuries facilitate a significant number of ED visits among both adults and children; thus, the knowledge of demographic-specific trends described in this analysis is relevant for physicians involved in the management of facial trauma. These findings reinforce the need to educate individuals who play hockey about the importance of appropriate facial protection.

Assault by battery: battery-related injury in the head and neck

OBJECTIVES/HYPOTHESIS

To estimate nationwide incidence of emergency department (ED) visits for battery-related injury (BRI) occurring in the head and neck, and analyze demographic and anatomic-specific trends.

METHODS

The National Electronic Injury Surveillance System (NEISS) was searched for BRI in the head and neck, with analysis for incidence, anatomic site, age and gender, and specific diagnoses.

RESULTS

There were an estimated 18,803 head and neck BRI ED visits from 2003 to 2012. A total of 65.8% of patients were male. A total of 92.8% of patients were treated/examined and then released, and 4.7% of patients were admitted. A plurality (34.2%) of patients had BRI related to nose injures, and this represented the youngest cohort (median: 3 years old). The vast majority of ear and nose diagnoses were "foreign bodies"; two-thirds of mouth injuries were related to burns, whereas lacerations predominated in the face and head. Nearly half of ED visits involved patients between 2 and 5 years of age. A total of 45.2% of cases involving patients ≥ 65 years of age were related to hearing aid batteries as foreign bodies.

CONCLUSION

BRI in the head and neck results in a significant amount of ED visits. Mechanisms of injury vary by age and anatomic location, but a considerable male predilection exists. Whereas pediatric patients are primarily affected, particularly patients between 2 to 5 years of age, injuries do occur among adults. Importantly, the prevalence of dislodged hearing-aid batteries in the elderly necessitates comprehensive patient education to increase awareness and counseling regarding this complication. Awareness of demographic and anatomic-specific trends reported in this analysis may be an invaluable adjunct for history-taking and clinical examination.

Measured gain in projection with the extended columellar strut-tip graft in endonasal rhinoplasty

IMPORTANCE

The extended columellar strut-tip graft was designed to improve nasal tip projection and tip definition in patients undergoing rhinoplasty.

OBJECTIVE

To determine whether the extended columellar tip graft leads to a true and measurable increase in nasal tip projection or simply gives the illusion of an increase in projection.

DESIGN

Retrospective case review. The mean time of follow-up photographs was 32 months after surgery (range, 8 months to 10 years).

PARTICIPANTS

The study population comprised 15 patients who underwent primary or revision rhinoplasty during the last 10 years.

INTERVENTION

Primary or revision rhinoplasty.

MAIN OUTCOME MEASURE

The outcome measure was the long-term gain in nasal tip projection. Preoperative and postoperative images were cropped and sized equally for accurate comparison. All measurements were made from the alar-facial crease to the tip defining point.

RESULTS

In all 15 patients, an increase in tip projection was obtained. The mean increase in projection was 19% compared with the preoperative projection. After applying a paired t test for analysis, there was a statistically significant increase in nasal projection (P < .05).

CONCLUSIONS AND RELEVANCE

The extended columellar strut-tip graft effectively corrected poor nasal tip projection. The effect is maintained years later. The extended columellar strut-tip graft is an excellent choice in endonasal rhinoplasty to improve poor tip projection and definition.

LEVEL OF EVIDENCE

4.

Single-incision transaxillary robotic thyroidectomy: challenges and limitations in a North American population

OBJECTIVE

We reviewed our initial experience with robotic thy-roidectomy to identify challenges and limitations of this new surgical approach when applied to a North American population.

STUDY DESIGN

Case series.

SETTING

Academic institution.

SUBJECTS/METHODS

Retrospective review of 18 consecutive robotic thyroid lobectomies performed from February 2010 to April 2012 involving 16 female patients. Two patients underwent robot-assisted completion thyroidectomy a few months following the initial thyroid surgery, one for cancer and the other for goiter.

RESULTS

Median age was 47.5 years (range, 18-62 years), and median body mass index was 28.7 (range, 19.4-44.5). Median thyroid nodule size was 2.9 cm (range, 1.1-4.7 cm). All but 1 case (6%) was performed successfully via single axillary incision. There was no conversion to an open approach. Median operative time was 170 minutes (range, 95-220 minutes), and median blood loss was 12.5 mL (range, 5-75 mL). Complications occurred in 4 cases (22%) to include temporary vocal cord pareses (n = 3) and a postoperative hematoma that required exploration. Median hospital stay was 2 days (range, 1-3 days).

CONCLUSION

Single-incision transaxillary robotic thyroidectomy can be technically challenging in North American patients with a larger body frame due to difficulty in optimal placement of all 4 robotic instruments via a single axillary incision. All 3 cases of temporary vocal cord paresis occurred early in our experience and may have been due to our relative inexperience with this new approach and associated instrumentation. Other limitations include less than optimal visualization of the recurrent laryngeal nerve in the contralateral lobe as well as poor access to the substernal region.

LEVEL OF EVIDENCE

4.

Angiosarcoma of the scalp with complete response to a biweekly gemcitabine and docetaxel (GEMDOC) chemotherapy regimen

Angiosarcoma is a rare, aggressive soft-tissue sarcoma with a high rate of recurrence and distant metastasis. Only a few cases of angiosarcoma involving the scalp have been reported in the literature. We describe a case involving a 75-year-old woman who presented to the emergency department at the Detroit Medical Center with multiple painful scalp lesions. She had had similar lesions intermittently for several years that apparently had responded to treatment with antifungal creams, but those occurring in the 6 months before her presentation had not responded to that therapy. The final diagnosis was a metastatic angiosarcoma. The patient achieved complete remission following treatment with a combination chemotherapy regimen consisting of gemcitabine (1,500 mg/m²) and docetaxel (50 mg/m²) administered biweekly. The patient was free of disease at the 15-month follow-up. This regimen is well tolerated and should be considered, especially in elderly patients and patients with comorbid conditions who may not tolerate other chemotherapeutic regimens.

Biomechanical analysis of anchoring points in rhytidectomy

OBJECTIVE

To quantify tissue tearing force at various anchoring points on the face.

METHODS

This is a prospective anatomic study using 4 fresh cadavers of persons aged 60 to 70 years at the time of death, for a total of 8 sides. Standardized 1-cm distances were measured at the various anchor points, and a single 0 Prolene suture loop was tied at each standardized anchoring point. Steady force was applied perpendicular to the plane of the face with a digital hanging scale. The scale was pulled until the suture ruptured the tissue at the anchoring point. The values at which the tissue ruptured were recorded, averaged, and compared.

RESULTS

The average tissue force was 7.01 kg for the root of the zygoma vs 3.44 kg for the temporalis fascia (P < .05). The average tissue force was 5.50 kg for infralobular tissue vs 4.09 kg for tissue of the superficial musculoaponeurotic system located 1 cm anterior to the infralobular tissue (P < .05). The force for the fascia of the sternocleidomastoid was 3.89 kg vs 5.57 kg for the mastoid fascia (P < .05). There was a statistically significant difference between vertical bites of the temporalis fascia at 1.90 kg vs horizontal bites of the temporalis at 5.01 kg (P < .05).

CONCLUSION

The tissue tearing force varies by location on the face as well as suture orientation.

Treatment of dorsal deviation

The deviated nasal dorsum is a complex problem with a variety of proposed solutions. Straightening the deviated nose should be focused on maximizing cosmetic outcome while preserving or improving nasal function. Deviations can occur in one or a combination of the nasal thirds. A simple approach to treatment is to develop a strategy for each third of the nose. Tailoring maneuvers to alleviate problems in each specific third helps the surgeon deal with deviations in an effective and straightforward manner.

Craniocervical necrotizing fasciitis with and without thoracic extension: management strategies and outcome

OBJECTIVE

First objective was to review cases of craniocervical necrotizing fasciitis (CCNF) at Wayne State University/Detroit Medical Center (Detroit, MI) for the last 18 years. Second was to analyze patients with and without thoracic extension for contributing factors.

METHODS

Retrospective review of 660 patients with necrotizing fasciitis treated at WSU/DMC from January 1989 to January 2007 was conducted. Data regarding source/extent of infection, presenting signs/symptoms, computed tomography, microbiology, antibiotics, comorbidities, number/type of operations, hyperbaric oxygen (HBO) therapy, hospital duration, complications, and overall outcome were compared/analyzed between patients with and without thoracic extension.

RESULTS

Twenty patients with CCNF for the past 18 years met the inclusion criteria. Ten patients had thoracic extension, and 10 patients did not have. Individuals in the thoracic extension group were likely to be older, had increased comorbidity, required more surgical debridement, experienced increased postoperative complications, and had lower overall survival. Three patients with thoracic extension underwent HBO therapy and 66% survived.

CONCLUSION

This is the largest single institutional review of CCNF comparing patients with and without thoracic extension. Patients with thoracic extension have a poorer outcome as follows: 60% (6/10) survival vs 100% (10/10) for those without thoracic extension (P < .05). The CCNF patients without thoracic extension treated at our institution all survived after prompt medical and surgical intervention. Overall survival of CCNF patients without thoracic extension may be attributed to rigorous wound care, broad spectrum intravenous antibiotics, aggressive surgical debridement, and vigilant care in surgical intensive care unit. The HBO therapy should be included if the patient can tolerate it.

S149 – Sinonasal Mucosal Melanoma: A 12-Year Experience

Objectives

1) Describe the Sinonasal Mucosal Melanoma patients (SNMM) our institution has treated. 2) Assess outcomes of surgical and adjuvant therapies for this disease.

Methods

Records of 18 patients diagnosed between 1995 and 2007 were reviewed, with a focus on patient characteristics, treatment outcomes, and modalities.

Results

Patients’ ages ranged from 31 to 85. Most common anatomic locations were maxillary sinus in 12 patients and lateral nasal walls in 6. 5 patients had cribriform plate involvement, and 3 had orbital involvement. Tumor thickness averaged 3.1 cm. 15 of the 18 patients had definitive surgical resection of their primary. Most common surgical procedure was medial maxillectomy. 6 patients were operated on despite disease in prognostically poor locations such as skull base, orbit, cribiform plate, and nasopharynx. Margins ranged from 0.5 to 4 cm. 10 patients received chemo- or immunotherapy, 11 received radiotherapy, and 6 received both. Recurrence rate was 10/18 (55%), while distant metastatic rate was 6/18 (33%), the lung being the most common metastatic location (4 patients). Average follow-up was 38.6 months, with disease-free intervals ranging from 8 to 39 months in patients with recurrences. After 2000, patients only received limited surgical resections, and were treated at stages I-II.

Conclusions

Despite the poor prognosis of SNMM, over the past 13 years at our institution the trend has been towards patients being diagnosed and treated at an earlier stage and having less extensive surgical resections. Advances in imaging, negative margins, radiation, and the use of immunotherapy may have influenced patient outcomes and recurrence rates.

Baseline laryngeal effects among individuals with dust mite allergy

Objective

To examine baseline effects of perennial allergy on laryngeal appearance, laryngeal function, and perceived vocal handicap among individuals without current allergy or voice symptoms.

Data Sources

This pilot study included 47 adults: 21 with positive and 26 with negative skin test responses for the dust mite, Dermatophagoides pteronyssinus.

Methods

Subjects were tested for sensitivity to dust mite antigen by prick testing. Laryngeal appearance and function were studied with laryngovideostroboscopy, acoustic and speech aerodynamic analysis, and voice sampling. These parameters were blindly analyzed by three trained examiners. Subjects also completed the Voice Handicap Index (VHI) as a measure of vocal handicap.

Results

Subjects allergic to dust mites perceived significantly greater vocal handicap on the VHI than did nonallergic subjects. No significant differences were noted between groups in laryngeal appearance or function.

Conclusion

These pilot data suggest that, at baseline, allergic individuals perceive greater vocal handicap than their nonallergic counterparts ( P = 0.04), even in the absence of current allergy symptoms or observable physical or functional abnormalities. These preliminary observations can serve as an impetus for further research into this important area, including the potential interrelationship between acid reflux disease and allergic laryngeal inflammation.

Presence and density of Helicobacter pylori biofilms in human gastric mucosa in patients with peptic ulcer disease

Our purpose was to use endoscopically directed biopsies and scanning electron microscopy to quantify Helicobacter pylori biofilm density on the surface of human gastric mucosa in urease-positive and -negative patients. Participating patients underwent flexible esophago-gastro-duodenoscopies coupled with gastric mucosal biopsies. Rapid urease testing was performed on all specimens to determine the presence of H. pylori, followed by scanning electron microscopy to identify the existence of biofilms. Samples were then analyzed using Carnoy Image Analysis Software to determine percent biofilm coverage of the total surface area. These data were compared to control specimens that were urease negative. Of the patients who tested urease positive for H. pylori, the average percent of total surface area covered by biofilms was 97.3%. Those testing negative had an average surface area coverage of only 1.64%. These differences were determined to be statistically significant at the 0.0001 level. This study demonstrates that compared with controls, urease-positive specimens have significant biofilm formation, whereas urease-negative specimens have little to none. This was reflected in the significantly increased biofilm surface density in urease positive specimens compared with urease-negative controls.

Identification of Helicobacter pylori biofilms in human gastric mucosa

The purpose of this study was to use endoscopically directed biopsies and scanning electron microscopy (SEM) to document the existence of Helicobacter pylori biofilms in human gastric mucosa. Patients underwent flexible esophagogastroduodenoscopies with three gastric mucosal biopsies. Rapid urease testing was performed to determine the presence or absence of H pylori. Urease-positive and urease-negative control specimens were imaged with SEM to obtain detailed images of gastric mucosa for the identification of biofilm colonies. Samples were obtained from patients who underwent esophagogastroduodenoscopies. Eleven were found to be H pylori positive and nine were H pylori negative. These were imaged at 500x and 1000x with electron microscopy. Dense, mature biofilms were present and attached to the cell surface of H pylori-positive specimens and were absent in urease-negative controls. Photomicrographs were obtained. Biofilms are complex microbiological ecosystems where sessile bacteria surround themselves in a protective matrix. This lifestyle affords protection, allows for growth in hostile environments, and alters host physiology. Many have hypothesized that H pylori infections resulting in gastric ulcers may be a manifestation of biofilms. Our investigation is the first to photographically document the existence of H pylori biofilms on human gastric mucosa. This elucidation of the ecology and pathophysiology of the mucosa of the organism is important to our understanding of a potential mechanism of this organism's resistance to current therapy and how to better eradicate it in the future.

Airway Obstruction by Granulation Tissue within a Fenestrated Tracheotomy Tube: Case Report

Complications of tracheotomy tube placement can be categorized as intraoperative, early postoperative, and late postoperative. Among the late complications is the development of granulation tissue. We describe one of the few reported cases of granulation tissue that formed within a fenestrated tracheotomy tube. In this case, the granulation tissue grew through the fenestrations, obliterated the tracheal lumen, and tethered the tube to the trachea itself. As a result, the patient required emergency treatment to restore airway patency.

Airway obstruction by granulation tissue within a fenestrated tracheotomy tube: case report

Complications of tracheotomy tube placement can be categorized as intraoperative, early postoperative, and late postoperative. Among the late complications is the development of granulation tissue. We describe one of the few reported cases of granulation tissue that formed within a fenestrated tracheotomy tube. In this case, the granulation tissue grew through the fenestrations, obliterated the tracheal lumen, and tethered the tube to the trachea itself. As a result, the patient required emergency treatment to restore airway patency.

Embryonic origin of the caudal mesenteric artery in the mouse

It is commonly held that the caudal mesenteric artery (CaMA, or inferior mesenteric artery in humans) arises in the same manner as the celiac and cranial mesenteric artery (CrMA, or superior mesenteric artery in humans), i.e., from the remodeling of the vitelline system of arteries that surrounds and supports the yolk sac. Conflicting evidence about the precise manner in which the CaMA arises was presented in studies of the luxate syndrome (Carter: J. Genet. 1954;52:1-35) and sirenomelia (Schreiner and Hoornbeek: J. Morphol. 1973;141:345-358) in the mouse. These studies suggested that the CaMA arises from the remodeling of the medial umbilical arterial roots. Later studies of blood vessel development in the hindlimb of the Dominant hemimelic mouse (Gest: Anat. Rec. 1984;208:296; Anat. Rec. 1987;218:49A; Gest and Roden: Anat. Rec. 1988;220:37-38A) also supported the results of the previous studies. The present investigation tests the hypothesis that the CaMA arises as a result of the regression and remodeling of the medial umbilical arterial roots. Vascular corrosion casts of 9.5-13.5-day-old mouse embryos were observed by scanning electron microscopy (SEM). The results of the present investigation agree with the aforementioned studies. The medial umbilical roots initially conduct the blood to the placenta. On days 10-12 the medial umbilical roots regress and remodel into the CaMA, while the lateral umbilical roots take over the blood supply to the placenta. On the basis of our results, we conclude that the CaMA arises from the medial umbilical roots and not from the remodeling of the vitelline system of arteries, as previously assumed.