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Objectives: Venous thromboembolic events (VTEs) are a leading cause of postoperative morbidity, prolonged hospital stay, and increased cost. Recommendations for mechano- and chemoprophylaxis are currently based on the 2005 Caprini score, a screening tool developed to identify patients at risk for VTE. The Caprini risk assessment model (RAM) was designed for surgical impatients and has been tested in a number of surgical fields, including otolaryngology. However, the vast majority of otolaryngology cases are performed as ambulatory surgery. Simpler RAMs include the COBRA scoring system and Pannucci-NSQIP. Here, we evaluate risk stratification of otolaryngology surgical patients and correlate the findings of these three RAMs., Study Design: Retrospective chart review., Methods: A retrospective chart review of 869 patients undergoing surgery by Weill Cornell faculty otolaryngologists between June and December 2022 was performed. Patient demographics, VTE risk factors, admission status, surgical subservice, and postoperative events were collected, and RAM scores were calculated for each patient. Wilcoxon and Kruskal-Wallis rank-sum tests were utilized to assess differences in VTE risk scores based on type of procedure and admission status, and Spearman's correlation was utilized to assess agreement between the three different scoring systems. Multivariate linear regressions were utilized to assess variables that impacted the Caprini, COBRA, and NSQIP RAMs., Results: In total, two patients developed postoperative venous thromboembolism. Furthermore, there is a strong positive correlation between Caprini and COBRA RAMs (even when broken down by admission status, although it weakens in the inpatient population). There is a moderate positive correlation between Caprini and Pannucci-NSQIP in the full cohort, but that correlation is lost in the inpatient population., Conclusions: Otolaryngology surgical patients are at low risk of postoperative VTE. Caprini, Pannucci-NSQIP, and COBRA RAMs correlate well in determining ambulatory patients at risk for postoperative VTE and shorter, simpler RAMS such as COBRA and Pannucci-NSQIP can be used instead of Caprini RAM., Level of Evidence: 3 Laryngoscope, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To understand post-pandemic interest in plastic surgery procedures via Joinpoint analysis of Google Trends search data., Methods: Google Trends was used to quantify search volumes from January 2019-December 2022 for select cosmetic face and body procedures in the United States. A keyword analytic tool (Keywords Everywhere) extracted absolute search volumes (average monthly searches). Joinpoint analysis assessed search trends over time reported as monthly percentage change (MPC)., Results: All procedures queried, including a non-cosmetic control (cataract surgery), demonstrated expected declines at the start of the COVID-19 pandemic. Blepharoplasty, face lift, neck lift, and Botox demonstrated statistically significant increase in search volumes that remained elevated relative to pre-pandemic levels. Rhinoplasty, fillers, and abdominoplasty interest increased initially followed by return to pre-pandemic levels by the end of 2022. The remainder of search terms did not show a clear temporal associated with COVID-19 lockdowns., Conclusion: The "Zoom Boom" appears to be a real phenomenon reflected by sustained increase in public interest in relation to facial plastic procedures., Level of Evidence: NA Laryngoscope, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

In addition to its sweet taste, glucose has potent and rapid postoral actions (appetition) that enhance its reward value. This has been demonstrated by the experience-induced preference for glucose over initially preferred nonnutritive sweetener solutions in 24-h choice tests. However, some sweetener solutions (e.g., 0.8% sucralose) have inhibitory postoral actions that may exaggerate glucose appetition whereas others (e.g., 0.1% sucralose + 0.1% saccharin, S+S) do not. Experiment 1 revealed that food-restricted (FR) male C57BL/6J mice displayed similar rapid glucose appetition effects (stimulation of glucose licking within minutes) and conditioned flavor preferences following 1-h experience with flavored 0.8% sucralose or 0.1% S+S and 8% glucose solutions. Thus, the inhibitory effects of 0.8% sucralose observed in 24-h tests were not apparent in 1-h tests. Experiment 2 evaluated the effects of food deprivation state and sweetener concentration on glucose appetition in female mice. Unlike FR mice tested with 0.1% S+S and 8% glucose, ad libitum (AL) fed mice displayed no stimulation of 8% glucose licking in the 1-h tests. A second ad libitum group (AL) tested with 0.2% S+S and 16% glucose solutions displayed stimulation of 16% glucose licking by the third 1-h test. Both AL groups, like the FR group, developed a preference for the glucose-paired flavor over the S+S paired flavor. Thus, food restriction promotes increased glucose licking but is not required for a conditioned preference. The FR male mice (Exp. 1) and FR female mice (Exp. 2) showed similar appetition responses (licking stimulation and flavor preference) to 8% glucose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Importance: Facial trauma makes up a significant number of emergency room visits, with morbidity costs in excess of 1 billion dollars each year. Few studies have evaluated the economic outcomes of management and inpatient burden of facial trauma, most focusing solely on the mandible and isolated midface fractures., Objective: The authors aim to evaluate characteristics associated with increased cost and length of hospitalization of zygoma fracture management., Design: Cross-sectional study., Setting: Level 1-trauma academic medical center., Participants: Patients with zygoma fractures who presented to our institution from 2008 to 2021., Main Outcomes and Measures: Demographics, injury mechanisms, associated injuries, treatment information, and associated costs were collected. Univariate and multivariate analyses were performed to identify the patient and fracture characteristics associated with increased cost and length of hospitalization., Results: Our 14-year experience identified 689 patients with zygoma fractures who presented from 2008 to 2021. Seventy percent were male, and 40% occurred in Caucasian patients. The mean cost, adjusted for inflation, was $21,799.34, and the mean length of hospitalization was 5.5 days. Four or more fractures, associated cranial or intracranial injuries, and length of stay were associated with significantly higher cost, and 4 or more fractures, associated cranial or intracranial injuries, and female gender were associated with significantly longer length of hospitalization., Conclusions and Relevance: This study represents one of the largest comprehensive databases of zygoma fractures and one of the first to provide a descriptive cost and inpatient burden analysis. To improve outcomes and reduce hospital cost and inpatient burden, protocols should be implemented to address the factors that the authors identified as contributing to increased cost and length of hospitalization., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Rats can condition cephalic-phase insulin responses (CPIRs) to specific sounds or times of the day that predict food availability. The present study asked whether mice can condition a CPIR to the flavor of sapid solutions that produce postoral glucose stimulation. To this end, we subjected C57BL/6 mice to one of six experimental protocols. We varied both the duration of the five training sessions (i.e., 23 h or 1 h) and the nature of the training solution. In Experiment 1, consumption of a 0.61% saccharin solution was paired with IG co-infusion of a 16% glucose solution. In Experiments 2-6, the mice consumed a training solution containing a mixture of 0.61% saccharin + 16% glucose, 32% sucrose, 32% maltodextrin, flavored 32% maltodextrin, or 16% maltodextrin. We subsequently asked whether consumption of any of these fluids conditioned a CPIR to a test solution that produced a similar flavor, but which did not elicit a CPIR in naïve mice. The mice did condition a CPIR, but only to the solutions containing 32% maltodextrin. We attribute this conditioning to postoral actions of the concentrated maltodextrin solutions.

Objective: To discuss patient demographics and management and better understand the economic impact associated with the treatment of facial fractures at a major metropolitan level 1 trauma center., Study Design: Retrospective chart review., Methods: We identified 5088 facial fractures in 2479 patients who presented from 2008 to 2022. Patient demographics, mechanism of injury, associated injuries, treatment information, and hospital charges were collected and analyzed to determine factors associated with surgical management and increased cost burden., Results: Our 14-year experience identified 1628 males and 851 females with a mean age of 45.7 years. Orbital fractures were most common (41.2%), followed by maxilla fractures (20.8%). The most common mechanism was fall (43.0%). Surgical management was recommended for 41% of patients. The odds of surgical management was significantly lower in female patients, patients age 65 and older, and patients who presented after the onset of the COVID-19 pandemic. The odds of surgical management was significantly higher for patients who had a mandible fracture or greater than 1 fracture. The average cost of management was highest for naso-orbito-ethmoidal fractures ($37,997.74 ± 52,850.88), followed by LeFort and frontal fractures ($29.814.41 ± 42,155.73 and $27,613.44 ± 39.178.53, respectively). The highest contributor to the total average cost of management was intensive care unit-related costs for every fracture type, except for mandible fractures for which the highest contributor was operating room (OR)-related costs., Conclusions: This study represents one of the largest comprehensive databases of facial fractures and one of the first to provide a descriptive cost analysis of facial trauma management., Level of Evidence: 4 Laryngoscope, 134:3120-3126, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Secondary cleft rhinoplasty remains a challenging operation that requires an understanding of the aberrant anatomy in cleft lip nasal deformity as well as the ability to adapt various techniques suited to the needs of each patient. In this article, we review some of the classically described approaches in cleft rhinoplasty and different strategies to address the nasal subunits. Presurgical adjuncts, surgical interventions before facial skeletal maturity, and patient reported outcome measures are also discussed., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: To determine if an endoscopic otologic and rhinologic examination performed by a patient and interpreted remotely by an otolaryngologist is non-inferior to in-person examination, and to assess the feasibility of this system for telemedical visits., Materials and Methods: Twenty healthy subjects performed a self-examination of their ears and nose using a commercially available endoscope under remote guidance by an otolaryngology provider over Zoom. This same provider and another otolaryngologist also performed separate, in-person examinations of each subject and rated their findings. Finally, both providers blindly reviewed a video recording of each virtual exam four weeks later and rated their findings. Subjects were surveyed about their experience. Interrater reliability was calculated using Cohen's kappa coefficients and the ability to detect different anatomic structures and features by in-person vs. virtual examination was compared using Wilcoxon tests and Chi-squared proportion tests., Results: The subjects' average age was 30 (SD 11.5) years. Interrater reliability was excellent; kappa coefficients were 0.72 and 0.81 (p < 0.001) for virtual and in-person exams, respectively. Of the 3 anatomic structures within the ear exam, none showed a difference in detectability between virtual and in-person exams. Of the 12 structures in the nasal exam, 3 were better visualized in-person and 9 showed no difference. Subject satisfaction was excellent; the average likelihood of recommending this virtual technology to peers (1-10) was 8.65 (SD 1.4)., Conclusions: Patient self-examination of the ears and nose using a portable endoscope may be an effective strategy for obtaining valuable data during telemedical otolaryngology visits., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Few studies have critically evaluated the quality of data obtained during telemedical evaluations of patients with nasal complaints. Objective: To compare the quality of data provided by remote endoscopic and external nasal examination with those by in-person evaluations for rhinoplasty and functional nasal surgery, measured by detectability of anatomic features, and to assess associated patient experience measured by reported ease, discomfort, and likelihood of peer recommendation. Materials and Methods: Twenty healthy subjects performed a nasal self-examination using an endoscope and webcam under remote videoconferencing service (VCS) guidance. They subsequently underwent in-person examination and were surveyed about their experience. Inter-rater reliability was calculated using kappa coefficients. Detectability of anatomic features by in-person versus virtual examination was compared using Wilcoxon and chi-square tests. Results: Median subject age was 27.5 years (range 23-77). Kappa coefficients were 0.78 for in-person and 0.66 for virtual evaluations. Only the internal nasal valve and inferior turbinate were better visualized in person. There were no differences between detectability of external features on in-person versus virtual examinations. Subjects' average likelihood of recommending this technology (1-10) was 8.65 (SD 1.4). Conclusions: Intranasal examination by physician-guided remote endoscopy and webcam-based facial analysis demonstrate nasal anatomy comparable with in-person evaluation and anterior rhinoscopy.

Competing Interests: None declared.

Isomaltulose, a slowly digested isocaloric analog of sucrose, and allulose, a noncaloric fructose analog, are promoted as "healthful" sugar alternatives in human food products. Here we investigated the appetite and preference conditioning actions of these sugar analogs in inbred mouse strains. In brief-access lick tests (Experiment 1), C57BL/6 (B6) mice showed similar concentration dependent increases in licking for allulose and fructose, but less pronounced concentration-dependent increases in licking for isomaltulose than sucrose. In Experiment 2, B6 mice were given one-bottle training with a CS+ flavor (e.g., grape) mixed with 8% isomaltulose or allulose and a CS- flavor (e.g., cherry) mixed in water followed by two-bottle CS flavor tests. The isomaltulose mice showed only a weak CS+ flavor preference but a strong preference for the sugar over water. The allulose mice strongly preferred the CS- flavor and water over the sugar. The allulose avoidance may be due to gut discomfort as reported in humans consuming high amounts of the sugar. Experiment 3 found that the preference for 8% sucrose over 8% isomaltulose could be reversed or blocked by adding different concentrations of a noncaloric sweetener mixture (sucralose + saccharin, SS) to the isomaltulose. Experiment 4 revealed that the preference of B6 or FVB/N mice for isomaltulose+0.01%SS or sucrose over 0.1%SS increased after separate experience with the sugars and SS. This indicates that isomaltulose, like sucrose, has postoral appetition effects that enhances the appetite for the sugar. In Experiments 5 and 6, the appetition actions of the two sugars were directly compared by giving mice isomaltulose+0.05%SS vs. sucrose choice tests before and after separate experience with the two sugars. In general, the initial preference the mice displayed for isomaltulose+0.05%SS was reduced or reversed after separate experience with the two sugars although some strain and sex differences were obtained. This indicates that isomaltulose has weaker postoral appetition effects than sucrose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Among zygomaticomaxillary complex (ZMC) fractures presenting to a tertiary urban academic center, the authors hypothesized the presence of both clinical and radiographic predictors of operative management. The investigators conducted a retrospective cohort study of 1,914 patients with facial fractures managed at an academic medical center in New York City between 2008 and 2017. The predictor variables were based on both clinical data and features of pertinent imaging studies, and the outcome variable was an operative intervention. Descriptive and bivariate statistics were computed and the p -value was set at 0.05. In total, 196 patients sustained ZMC fractures (5.0%) and 121 (61.7%) ZMC fractures were treated surgically. All patients who presented with globe injury, blindness, retrobulbar injury, restricted gaze, or enophthalmos and a concurrent ZMC fracture were managed surgically. The most common surgical approach was the gingivobuccal corridor (31.9% of all approaches), and there were no significant immediate postoperative complications. Younger patients (38.9 ± 18 years vs. 56.1 ± 23.5 years, p  < 0.0001) and patients with greater than or equal to 4 mm of orbital floor displacement were more likely to receive surgical treatment than observation (82 vs. 56%, p  = 0.045), as were patients with comminuted orbital floor fractures (52 vs. 26%, p  = 0.011). In this cohort, patients more likely to undergo surgical reduction were young patients with ophthalmologic symptoms on presentation and at least 4 mm displacement of the orbital floor. Low kinetic energy ZMC fractures may warrant surgical management as often as high-energy ZMC fractures. While orbital floor comminution has been shown to be a predictor for operative reduction, in this study we also demonstrated a difference in the rate of reduction based on the severity of orbital floor displacement. This may have significant implications in both the triage and selection of patients most suitable for operative repair., Competing Interests: None declared., (Thieme. All rights reserved.)

Nasal reconstruction has important functional and cosmetic considerations, as proper repair of nasal defects is necessary to maintain function of the nasal airway and to recreate the normal appearance of this central facial structure. Cheek advancement flaps provide matched, mobile, and highly vascularized tissue for the reconstruction of nasal defects, allowing for the concealment of incisions within natural creases in a one-stage approach. However, cheek advancement flaps are often underutilized for nasal reconstruction because of their difficulty in restoring nasal contour. We describe reconstruction of 19 nasal dorsal and sidewall defects 0.8 to 3 cm in size. We incorporated a periosteal anchoring suture to maintain/restore nasal contour and additionally removed a half standing cone inferior to the defect to prevent encroachment of the nasal ala or alar crease. All patients were evaluated at least 3 months postoperatively. In all patients, we were able to restore concavity of the nasofacial sulcus, preserve the biconvex nasal tips, prevent alar flaring and retraction, and conserve the alar groove. All patients had excellent functional and cosmetic outcomes. We believe this modified cheek advancement flap provides functionally and aesthetically superior results and can be considered as a first-line approach for repair of nasal dorsal and sidewall defects in subselected patients., Competing Interests: None declared., (Thieme. All rights reserved.)

Opioid and dopamine (DA) D1 receptor antagonists differentially reduce nutritive and non-nutritive sweetener intakes in inbred mouse strains. Sucrose intake was more effectively reduced by naltrexone in C57BL/6 (B6) mice relative to 129P3 (129) mice, but more effectively reduced by SCH23390 in 129 mice relative to B6 mice. Opioid and DA D1 antagonists differentially reduced saccharin intakes in B6 mice relative to other strains. Given these differential patterns in sweetener intake in B6 and 129 mice, the present study examined whether systemic naltrexone (0.01-5 mg/kg) and SCH23390 (50-1600 nmol/kg) reduced intakes of 10 % sucrose or 0.2 % saccharin solutions over a 120 min time course in first-generation hybrid mice (B6:129) of B6 and 129 parents and reduced low-nutritive sweetener intakes in 129 mice. Naltrexone (5 mg/kg) significantly reduced 10 % sucrose intake in B6:129 hybrid mice more like that of 129 than B6 mice. In contrast, SCH23390 (400-1600 nmol/kg) reduced 10 % sucrose intake in B6:129 hybrid mice more effectively than that observed in B6 or 129 parental strains. Because 129 mice consumed relatively low amounts of 0.2 % saccharin, they were tested with a more attractive low-nutritive solution containing 0.2 % saccharin and 2 % sucrose. Naltrexone failed to reduce saccharin intake in B6:129 hybrid mice but suppressed saccharin+sucrose intake in 129 mice more like that observed in B6 mice. SCH23390 similarly inhibited saccharin or saccharin+sucrose intakes in hybrid B6:129, 129, and B6 mice with B6 mice more resistant to the lowest SCH23390 dose. Thus, whereas sucrose intake in B6:129 hybrid mice exhibited similar sensitivity to opioid and to a lesser degree DA D1 antagonism to their 129, but not B6 parents, opioid and DA D1 mediation of low- and non-nutritive sweet intake produced unique profiles among B6:129 hybrid and B6 and 129 strains which does not support a simple heritability explanation., (Copyright © 2023 Elsevier Inc. All rights reserved.)

There is much evidence that gustation mediates the preference for dietary fat in rodents. Several studies indicate that mice have fat taste receptors that activate downstream signaling elements, including TRPM5 and CALHM1 ion channels and P2×2/P2×3 purinergic gustatory nerve receptors. Experiment 1 further documented the involvement of TRPM5 in fat appetite by giving Trpm5 knockout (KO) mice, which show global taste deficits, 24-h two-bottle choice tests with ascending concentrations of soybean oil (0.1 - 10% Intralipid) vs. water. Unlike wildtype (WT) mice, naive Trpm5 KO mice were indifferent to 0.5 - 2.5% fat. They preferred 5-10% fat but consumed much less than WT mice. The same KO mice preferred all fat concentrations in a second test series, which is attributed to a postoral fat conditioned attraction to the non-taste flavor qualities of the Intralipid, although they consumed less fat than the WT mice. The fat preference deficits of the Trpm5 KO mice were as great or greater than those observed in Calhm1 KO mice, another KO line with global taste deficits. Experiment 2 examined experience-enhanced fat preferences in Trpm5 KO and Calhm1 KO mice by giving them one-bottle training with 1%, 2.5%, and 5% fat prior to two-bottle fat vs. water tests. The KO mice displayed increased two-bottle preferences for all concentrations, although they still consumed less 1% and 2.5% fat than WT mice. Thus, the postoral actions of fat induce robust preferences for fat in taste-deficient mice, but do not stimulate the high fat intakes observed in WT mice with normal fat taste signaling., (Copyright © 2022. Published by Elsevier Inc.)

Purpose: To identify areas of critical otolaryngology contributions to inpatient care resistant to disruption by the COVID-19 pandemic., Methods: Medical records of 614 otolaryngology consults seen between January and June of 2019 and 602 seen between January and June of 2020 were reviewed. Extracted data included patient demographics, SARS-CoV-2 status, medical comorbidities, consult location, consult category, reason for consult, procedures performed, and overall outcome. Prevalence of data items was compared using t tests and Chi-squared tests., Results: The number of monthly consults to the otolaryngology service remained approximately stable after the onset of the COVID-19 pandemic. However, there was a substantial increase in ICU consults and a decrease in ER and floor consults. The proportion of otology, rhinology, and head and neck consults decreased while that of airway consults-most of which were tracheostomy-related-greatly increased. While the top ten reasons for consult remained essentially the same, they dramatically increased as a percentage of consults during COVID-19 (55-92%), whereas there was a dramatic decrease in the proportion of less frequent consults., Conclusion: The changes in otolaryngology consultation patterns seen after the onset of the pandemic are multifactorial, but may be attributed to novel pathologies, attitudes, and policies. Nonetheless, these patterns reveal that a set of core otolaryngologic issues, including acute airway issues, head and neck lesions, severe sinusitis and epistaxis, are essential and need to be addressed in the inpatient setting, whereas the significant drop in other consults suggests that they may be appropriately managed on an outpatient basis., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Inbred mouse strains differ in their postoral appetite stimulating response (appetition) to fructose as demonstrated in intragastric (IG) sugar conditioning and oral sugar vs. nonnutritive conditioning experiments. For example, FVB and SWR strains show experience-induced preferences for 8% fructose over a 0.1% sucralose + 0.1% saccharin (S + S) solution, whereas C57BL/6 (B6) and BALB/c strains do not. All strains, however, learn to prefer 8% glucose to S + S after experience, which is attributed to the potent appetition actions of this sugar. The present study extended this analysis to DBA/2 (DBA) and 129P3 (129) inbred mice. In Experiment 1A, ad libitum fed DBA and 129 mice preferred S + S to fructose before and after separate experience with the two sweeteners, indicating an indifference to the postoral nutrient effects of the sugar. When food restricted (Experiment 1B), 129 mice continued to prefer S + S to fructose while DBA mice showed equal preference for the sweeteners after experience, indicating some sensitivity to fructose appetition. In Experiment 1C, both strains acquired significant preferences for glucose over S + S after experience, confirming their sensitivity to postoral glucose appetition. Experiment 2 revealed that C57BL/6 × 129P3 (B6:129) hybrid mice responded like inbred B6 mice and 129 mice in acquiring a preference for glucose but not fructose over S + S. This is of interest because sweet "taste-blind" P2 × 2 / P2 × 3 double-knockout (DKO) mice on a B6:129 genetic background prefer fructose to water in 24 h tests, which is indicative of fructose appetition. Whether differences in the genetic makeup of DKO and B6:129 hybrid mice or other factors explain the fructose appetition of the DKO mice remains to be determined., (Copyright © 2021 Elsevier Inc. All rights reserved.)

This study aimed to define better the clinical presentation, fracture patterns, and features predictive of associated injuries and need for surgery in pediatric facial trauma patients in an urban setting. Charts of patients 18 years or younger with International Classification of Disease 9th and 10th revision (ICD-9/ICD-10) codes specific for facial fractures (excluding isolated nasal fractures) at NY-Presbyterian/Weill Cornell Medical Center between 2008 and 2017 were retrospectively reviewed. Of 204 patients, most were referred to the emergency department by a physician's office or self-presented. Children (age 0-6 years) were most likely to have been injured by falls, while more patients 7 to 12 years and 13 to 18 years were injured during sporting activities ( p  < 0.0001). Roughly half (50.5%) of the patients had a single fracture, and the likelihood of surgery increased with greater numbers of fractures. Older patients with either orbital or mandibular fractures were more likely to undergo surgery than younger ones ( p  = 0.0048 and p  = 0.0053, respectively). Cranial bone fractures, CSF leaks, and intracranial injuries were more common in younger patients ( p  < 0.0001) than older patients and were more likely after high energy injuries; however, 16.2% of patients sustaining low energy injuries also sustained cranial bone, CSF leak, or intracranial injury. In an urban environment, significant pediatric facial fractures and associated injuries may occur after nonclassic low kinetic energy traumatic events. The age of the patient impacts both the injuries sustained and the treatment rendered. It is essential to maintain a high index of suspicion for associated injuries in all pediatric facial trauma patients., Competing Interests: None declared., (Thieme. All rights reserved.)

Competing Interests: None declared.

Competing Interests: None declared.

Omnivores, including rodents and humans, compose their diets from a wide variety of potential foods. Beyond the guidance of a few basic orosensory biases such as attraction to sweet and avoidance of bitter, they have limited innate dietary knowledge and must learn to prefer foods based on their flavors and postoral effects. This review focuses on postoral nutrient sensing and signaling as an essential part of the reward system that shapes preferences for the associated flavors of foods. We discuss the extensive array of sensors in the gastrointestinal system and the vagal pathways conveying information about ingested nutrients to the brain. Earlier studies of vagal contributions were limited by nonselective methods that could not easily distinguish the contributions of subsets of vagal afferents. Recent advances in technique have generated substantial new details on sugar- and fat-responsive signaling pathways. We explain methods for conditioning flavor preferences and their use in evaluating gut-brain communication. The SGLT1 intestinal sugar sensor is important in sugar conditioning; the critical sensors for fat are less certain, though GPR40 and 120 fatty acid sensors have been implicated. Ongoing work points to particular vagal pathways to brain reward areas. An implication for obesity treatment is that bariatric surgery may alter vagal function., (© 2021. The Author(s).)

Purpose: Telemedicine use in otolaryngology waxed and waned during the COVID-19 pandemic outbreak in the U.S. Assessing the patterns of telemedicine use and its perceived limitations during the COVID-19 outbreak in 2020 allows identification and correction of impediments to consistent telemedicine use by otolaryngologists., Materials and Methods: Full-time faculty of 2 academic otolaryngology departments in New York City were surveyed regarding their telemedicine use from March through August 2020 during the "first wave" of the COVID-19 pandemic. Based on these findings, a method of "augmented outpatient otolaryngology teleconsultation" designed to enhance the quality of the physical examination was developed and employed from August to December 2020. Patients receiving this augmented teleconsult were anonymously surveyed about their telemedical experience., Results: Telemedicine use by faculty was minimal prior to the pandemic, but as total outpatient volume decreased 65-84% across subspecialties, it was used by all otolaryngologists during COVID-19. Physicians were less confident in making a telemedical diagnosis at all phases of the study in all subspecialties. Patients who had an augmented otolaryngology teleconsultation were satisfied with it, believed it facilitated earlier care, limited the time and cost of travel to the physician's office and felt their physician was able to perform a sufficient physical examination., Conclusions: During the COVID-19 crisis, physicians utilized teleotolaryngology to provide care but were less satisfied with their ability to make an accurate diagnosis. Inexpensive direct-to-consumer digital otoscopes can improve the quality of the physical examination provided and can address both patient and physician needs., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective/hypothesis: To report characteristics and management of facial fractures in a major metropolitan center within the United States., Study Design: Retrospective chart review., Methods: Retrospective review at a level 1 trauma academic medical center of 3,946 facial fractures in 1,914 patients who presented from 2008 to 2017. Demographics, injury mechanism, associated injuries, and treatment information were collected. Logistic regression analyses were performed to determine factors associated with management., Results: There were 1,280 males and 630 females with a median age of 42 years. Orbital fractures were the most common (41.4%) followed by maxilla fractures (21.9%). The most common mechanism was fall (43.6%). Surgical management was recommended for 38% of patients. The odds of surgical management were less for females (OR 0.59, 95% CI 0.48-0.73). Patients over 70 years were significantly less likely to undergo surgery compared to other age groups (OR 0.15-0.36, P < .001). The odds of surgical management were 1.69 times greater for patients with more than three fractures than for a single fracture (95% CI 1.18-2.42) and 2.23 times greater for traffic injuries compared to injuries from activities of daily living (95% CI 1.42-3.5)., Conclusions: This represents one of the largest comprehensive databases of facial fractures. Our patients were most frequently injured during activities of daily living, most commonly from falls. The majority of patients were managed conservatively. Gender, age, fracture number, and mechanism of injury were independently associated with the decision to treat surgically. Our data are in stark contrast to that from other populations in which assault or motor vehicle accidents predominate., Level of Evidence: 4 Laryngoscope, 131:E2176-E2180, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: The main objective of this study was to quantify daily pain and opioid use in patients after hemithyroidectomy and cervical lymph node biopsy (CLNB). The secondary objective was to identify factors associated with decreased pain and opioid use., Study Design: Prospective cohort study from June 2017 to February 2019. Patients were given paper surveys to record daily postoperative opioid use and maximal pain on a visual analog scale., Setting: Single institution (NewYork-Presbyterian/Weill Cornell Medical Center)., Methods: All adult patients undergoing hemithyroidectomy and CLNB by a single surgeon were consecutively selected for participation. Patients recorded daily pain and opioid analgesic use over a 2-week postoperative period., Results: Of 33 patients enrolled, 29 (87.9%) returned a survey. Thirteen underwent CLNB, and 16 underwent hemithyroidectomy. Pain resolved after both procedures by the end of the 2-week period. CLNB patients used a median (interquartile range) of 15.0 (0-41.2) morphine milligram equivalents (MME), and 95% used 70 or fewer MME. Hemithyroidectomy patients used a median of 8.2 (4.5-13.9) MME, and 95% used 30 or fewer MME. Use of nonopioid analgesics was associated with a statistically significant decrease in pain (56.1 vs 171 visual analog scale, 95% confidence interval [CI] of Δ = [12.0 to 217.8]) and opioid use (12.2 vs 48.8 MME, 95% CI of Δ = [5.0 to 68.1 MME]) in CLNB but not in hemithyroidectomy., Conclusion: Patients have low pain and opioid requirements after hemithyroidectomy and CLNB. Head and neck surgeons should evaluate their opioid-prescribing patterns for opportunities to safely decrease postoperative prescriptions., Competing Interests: Disclosures: Competing interests: None. Sponsorships: None. Funding source: None., (© The Authors 2021.)

Abstract: Frontal sinus fractures account for 5% to 15% of all facial fractures, and have traditionally been associated with high kinetic energy blunt injury. Surgical management is largely focused on minimizing potentially serious sequelae including frontal sinus dysfunction, CSF leak, and significant cosmetic deformity. An institutional database of 1944 patients presenting with maxillofacial fractures over a 10-year period was queried. Demographics, mechanism of injury, yearly trends, surgical approaches, and follow-up data were examined. A total of 160 (8.3%) patients presented with at least 1 fracture of the frontal sinus anterior table, posterior table, or frontal sinus outflow tract during the study period. The average annual number of cases was 15.9 ± 5.7 per year with a peak of 21.5 ± 4.0 cases during the 2014 to 2015 period and a decline to 8.5 ± 1.5 cases/year from 2016 to 2017. Among those patients with falls, 61.5% (n = 40) were a result of tripping or fainting at a height of <6 ft. 55.6% of fracture types were isolated to the anterior table, but fracture location was not significantly associated with operative intervention. Cases of operative fracture type had a higher rate of both displacement and comminution compared to nonoperative fractures (P < 0.00001). Of all patients presenting with frontal sinus fractures, 75% of cases were managed nonoperatively. However, many patients presented with falls and other seemingly low energy injuries which are not traditionally associated with frontal sinus trauma. These results highlight the need for continued follow-up even in otherwise low-risk urban populations in order to avoid long term sinus dysfunction., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 by Mutaz B. Habal, MD.)

This article determines if patient, defect, and repair factors can be used to predict the use of additional treatments to achieve optimal aesthetic results after repair of facial Mohs defects. An electronic chart review of patients undergoing Mohs excision and reconstruction of facial neoplasms from November 2005 to April 2017 was performed, reviewing patient demographics and history, tumor size, defect size and location, method and service of reconstruction, time between resection and repair, complications, and subsequent treatments. A total of 1,500 cases with basal cell and squamous cell carcinoma were analyzed. The average defect size was 3.09 ± 8.06 cm 2 ; 81.9% of defects were less than 4 cm 2 in size. Advancement flaps were used to repair 44.3% of defects. Complications and undesired sequelae (CUS) were noted in 15.9% of cases; scar hypertrophy or keloid (10.8%) was most common. Postoperative ancillary procedures were performed in less than one-quarter (23.4%) of patients to enhance the postrepair appearance; the most common procedures were intralesional corticosteroid injections and pulse dye laser treatments. CUS were more likely in females (19.6%), defects on the lips (28.7%) and on the nose (27.3%) ( p  < 0.001 for each). Females (22.7% vs. 12.7%), lip repairs (40.2% vs. 18.3%), transposition flaps (39.2% vs. 14.8%), and repairs performed by a dermatologist (17.9% vs. 11.2%) ( p  < 0.001 for each) were more likely to be treated with postoperative corticosteroid injections. Females (14.5% vs. 7.4%), patients under the age of 60 years (13.9% vs. 8.8%), and patients whose repair was performed by a dermatologist (11.9% vs. 2.9%) ( p  < 0.001 for each) were more likely to receive postoperative pulsed dye laser treatments. CUS and ancillary procedures after repair of facial Mohs defects are uncommon. Awareness of individual risk factors and defect characteristics allows the surgeon to choose the most appropriate repair technique while anticipating the potential need for ancillary procedures., Competing Interests: None declared., (Thieme. All rights reserved.)

Platelet preparations are autologous blood concentrates with supraphysiologic concentrations of platelets with or without leukocytes used in various clinical applications including regenerative medicine, wound healing, and facial rejuvenation. Their use harnesses the important role of platelets and their secretory products in immunoregulation, wound healing, angiogenesis, and tissue remodeling. The use of platelet preparations has been long documented in orthopaedic surgery, maxillofacial surgery, and other fields, but over the years research has increased in their application to facial plastic surgical techniques. Here we review the various formulations of platelet rich concentrates, their applications to facial skin rejuvenation, wound healing, scar reduction, and tissue fill as documented in the literature since 2018., Competing Interests: None declared., (Thieme. All rights reserved.)

Objectives: Adverse events are common occurrences in hospitals that detract from quality of care. There are few data on errors in otolaryngology (ENT) and even fewer data comparing ENT to other services., Methods: We retrospectively reviewed adverse event data collected across a regional hospital network from July 2014 to August 2017. We examined categories of adverse events that occurred most commonly in ENT and compared the number of adverse events reported in ENT to those reported across all other departments. Descriptive analysis and the paired t test were used to analyze the data., Results: Two hundred ninety-one adverse events were reported in ENT departments during the period studied compared to 58,219 events reported across all other specialties. In ENT, the most commonly reported adverse events occurred in the perioperative setting, followed by issues regarding equipment and medical devices and, lastly, airway management. Across all other departments, the most common categories included medication and fluid errors, falls, and safety and security events. ENT departments had significantly higher proportions of perioperative and airway management errors and significantly lower proportions of events related to diagnosis and treatment (P = .004), falls (P < .001), lab results and specimens (P = .001), medication and fluids (P < .001), and safety and security (P < .001)., Conclusion: Perioperative and airway management errors occur with a statistically higher frequency in ENT compared to other in-patient and out-patient departments across hospitals. It is important to analyze adverse event reporting in surgical specialties to ensure the development of appropriate quality initiatives., Level of Evidence: 4 Laryngoscope, 131:509-512, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: The COVID-19 health crisis abruptly disrupted the practice of otolaryngology. This article aims to define the changes needed to operate an academic otolaryngology practice safely and efficiently from within the epicenter of the pandemic. We define the areas of normal patient workflow that have been affected by COVID-19, and we offer mitigation strategies with attention paid to the specific needs of subspecialties., Data Sources: The article includes data specific to the office practice metrics of the Weill Cornell Medicine Department of Otolaryngology-Head and Neck Surgery, as well as publically available data from New York Presbyterian Hospital system and the New York Times ., Review Methods: Expert opinion., Conclusions: Through careful planning and execution, it is possible to reestablish safe otolaryngologic patient care during the COVID-19 pandemic. It will require a significant change from prior practice models for successful implementation. Additionally, telemedicine can be positively integrated into the treatment of otolaryngology diseases for new and established patients., Implications for Practice: The information conveyed in this review can be used as a guide by large and small otolaryngology groups to identify aspects of the patient visit that are "at risk" due to COVID-19, and it suggests sensible responses that can be made without a significant disruption to normal practice. The methods used to identify vulnerabilities with the patient visit process can be applied to future unforeseen crises, such as a resurgence of COVID-19 or a novel pandemic.

Objective: To quantify pain and opioid use after otorhinolaryngologic surgery. To determine the effect of patient and surgical factors on primary outcomes., Study Design: Prospective cohort., Setting: Tertiary academic hospital., Subjects and Methods: Patients undergoing elective otorhinolaryngologic surgery were prospectively enrolled. Patients completed demographic surveys and psychometric questionnaires assessing attitudes toward pain and baseline anxiety and depression before surgery. After surgery, patients documented peak pain levels (0-100 mm, visual analog scale) and daily prescription and nonprescription analgesic requirements over a 2-week period. Average daily and cumulative pain and opioid use were calculated and compared among patient cohorts stratified by procedure and preoperative factors., Results: A total of 134 patients were enrolled. Total tonsillectomy was associated with significantly higher pain scores and opioid consumption, as compared to all other procedures. There was moderate correlation between average cumulative pain and opioid use. Older patients required significantly fewer doses of opioids. There was no effect of sex, marital status, or education level on postoperative pain or opioid use. Psychometric instrument scores and chronic pain or analgesic use were not associated with significant differences in pain or opioid requirements. Most patients were prescribed substantially more opioids than they actually required., Conclusion: Postoperative pain following elective otorhinolaryngologic surgery decreases dramatically within the first week and requires only few days of opioid analgesia, with the exception of tonsillectomy. Almost all patients required fewer than 15 doses of opioids.

Aplasia cutis congenita is a rare but heterogeneous group of conditions characterized by the absence of one or more areas of skin sometimes extending to deeper tissues. The disorder as a solitary neck lesion has yet to be reported in the literature. Our patient presented with a pseudo-cobra neck deformity secondary to aplasia cutis congenita. Guidance on optimal management for non-scalp and more "benign" presentations of this disorder is lacking., (Copyright © 2020 Elsevier B.V. All rights reserved.)

The postoral actions of nutrients in rodents can stimulate intake and condition flavor preferences through an appetition process. Appetition is revealed in rodents by their increased intake of and preference for a flavored solution paired with intragastric (IG) nutrient infusions. Here we determined if IG 16% maltodextrin (MD) infusions can stimulate intake and preference in the absence of a distinctive flavor cue. Rats implanted with IG catheters were given chow and water 2 h/day followed, 2 h later, by 20-h oral access to water paired with IG MD infusions. Other rats were given bitter sucrose octaacetate solution (SOA) paired with IG MD infusions 20 h/day. Over 8 test days, the SOA rats increased their total 20-h fluid intake (oral + IG) from 26 to 119 g/20 h and Water rats increased their intake from 31 to 96 g/20 h. When infused IG with water instead of MD in a 4-day extinction test, the SOA and Water groups reduced their fluid intakes to 45-48 g/20 h. When oral fluids were again paired with IG MD infusions, the SOA and Water groups increased their intakes to 115 and 109 g/20 h, respectively. In two-bottle tests, the SOA rats drank more SOA paired with IG MD than water paired with IG water. Water rats given the choice of a water bottle paired with IG MD and water bottle paired with IG water did not consistently prefer the H2O/ID MD bottle. Instead they displayed side or sipper tube preferences although neither cue was consistently paired with IG MD during one-bottle training., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Competing Interests: None declared.

Knockout (KO) mice missing the sweet taste receptor subunit T1R3 or the signaling protein TRPM5 have greatly attenuated sweetener preferences. Yet both types of KO mice develop preferences for glucose but not fructose in 24-h tests, which has been attributed to the postoral reinforcing actions of glucose. Here we probed for residual sugar taste sensitivity in KO mice. Unlike wildtype (WT) mice, food-restricted T1R3 KO and TRPM5 KO mice displayed little attraction for 8% glucose and 8% fructose in 1-min, two-bottle choice tests. However, in 1-h tests about half of the T1R3 KO mice displayed a significant preference for glucose over fructose (78-84%), while WT mice showed either no or weak preferences (41-56%) for glucose. Following one-bottle training sessions, WT mice display greater glucose preferences although still weaker than those observed in T1R3 KO mice. In contrast, TRPM5 KO mice were indifferent to sugars in 1-h tests but developed a strong preference for glucose over fructose in 24-h tests. T1R3 taste cells contain the sodium glucose cotransporter 1 (SGLT1) and the ATP-gated K+ (K ATP ) metabolic sensor, which may mediate the unlearned glucose preference displayed by T1R3 KO mice. Unlike WT mice, many T1R3 KO mice strongly preferred glucose to a non-metabolizable glucose analog (α-methyl-D-glucopyranoside, MDG) in initial 1-h choice tests. Glucose and MDG are both ligands for SGLT1 which indicates that SGLT1 sensing does not mediate the glucose preference of T1R3 KO mice. Instead, K ATP sensing and/or other oral sensors are implicated. The MDG findings also argue against postoral sensing as the primary source of the initial glucose preference displayed by T1R3 KO mice. Why only half of the T1R3 KO mice showed this preference in 1-h tests remains to be determined. All T1R3 KO mice preferred glucose to fructose in 24-h tests, which appears to be due to both oral and postoral glucose sensing., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Judicious management of analgesics following rhinologic surgery is important for curtailing over-prescription of opioids. Limited data exists defining expected pain levels and appropriate opioid requirements after rhinologic surgery., Methods: A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. PubMed, Embase, Ovid MEDLINE, Cochrane Library databases were queried, and relevant articles were identified., Results: A total of 405 articles were identified, of which 13 met final inclusion criteria. Significant heterogeneity existed regarding type and quantity of opioid medication prescribed. Eight studies utilized a subjective patient-reported pain score as an outcome measure and reported mild to moderate postoperative pain that diminished over the first 3-6 days. Eight studies reported over-prescription of opioid medications with inappropriate storage of excess pills at home. Several factors were associated with an increased opioid requirement, including concurrent septoplasty, younger age, and current smoking status., Conclusion: Rhinologic surgery is well tolerated with mild to moderate, short-lived postoperative pain. A limited amount and duration of opioid medications is required for routine management. Patients are frequently prescribed more opioids than is necessary for expected pain level, resulting in the potential for opioid misuse, abuse, and diversion. Current evidence is limited by a predominance of level 4 studies. Larger, higher quality studies with standardized reporting of pain score and opioid prescription quantity are needed., Competing Interests: Declaration of competing interest None. There are no commercial or financial grant/assistance/disclosures declarations associated with this publication. The views expressed in this manuscript are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US government. Accepted for podium presentation at the American Rhinologic Society Annual Meeting in September 2019 in New Orleans, LA., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

When offered glucose and fructose solutions, rodents consume more glucose solution because it produces stronger postoral reinforcement. Intake of these sugars also conditions a higher avidity for glucose relative to fructose. We asked which chemosensory cue mediates the learned avidity for glucose. We subjected mice to 18 days of sugar training, offering them 0.3, 0.6, and 1 M glucose and fructose solutions. Before and after training, we measured avidity for 0.3 and 0.6 M glucose and fructose in brief-access lick tests. First, we replicated prior work in C57BL/6 mice. Before training, the mice licked at a slightly higher rate for 0.6 M fructose; after training, they licked at a higher rate for 0.6 M glucose. Second, we assessed the necessity of the glucose-specific ATP-sensitive K + (K ATP ) taste pathway for the learned avidity for glucose, using mice with a nonfunctional K ATP channel [regulatory sulfonylurea receptor (SUR1) knockout (KO) mice]. Before training, SUR1 KO and wild-type mice licked at similar rates for 0.6 M glucose and fructose; after training, both strains licked at a higher rate for 0.6 M glucose, indicating that the K ATP pathway is not necessary for the learned discrimination. Third, we investigated the necessity of olfaction by comparing sham-treated and anosmic mice. The mice were made anosmic by olfactory bulbectomy or ZnSO 4 treatment. Before training, sham-treated and anosmic mice licked at similar rates for 0.6 M glucose and fructose; after training, sham-treated mice licked at a higher rate for 0.6 M glucose, whereas anosmic mice licked at similar rates for both sugars. This demonstrates that olfaction contributes significantly to the learned avidity for glucose.

Background: Cosmetic concerns following Mohs Micrographic surgery (MMS) are significant and may require adjunctive treatments for unsatisfactory appearance., Objective: To determine factors associated with adjunctive cosmetic intervention for facial defects following MMS., Methods and Materials: A retrospective review of 699 patients undergoing repair of facial defects after MMS from 2008-2018 was performed. Tumor types, defect sizes, patient demographics, repair methods, complications, and post-operative cosmetic interventions were examined., Results: 666 Mohs cases and resultant defects were analyzed. The most common method of repair following MMS was primary closure (52.3%), and the most common post-operative intervention was steroid injection (18.3%). The lip subunit was more than twice as likely as other locations to be treated with steroid injections (P&lt;.001). The lip subunit also had the highest frequency of scar revision (13%; P&lt;0.001). Patients who had primary closure were less likely to require scar revision (P=0.003) or dermabrasion (P=0.042), and there was no significant association between skin graft repair and cosmetic intervention., Conclusions: Both defect subunit and closure type were independently associated with adjunctive cosmetic intervention following MMS. Defect size was not significantly associated with an adjunctive intervention in our study. Understanding the factors affecting the need for adjunctive cosmetic interventions may improve patient counseling prior to Mohs repair. J Drugs Dermatol. 2020;19(3): doi:10.36849/JDD.2020.4701.

The postoral actions of sugar and fat can rapidly stimulate the intake of and preference for flavors associated with these nutrients via a process known as appetition. Prior findings revealed that postoral glucose appetition is not attenuated following capsaicin-induced visceral deafferentation. The present experiment determined if capsaicin treatment altered fat appetition in C57BL/6 mice. Following capsaicin (Cap) or control (Con) treatment, mice were fitted with chronic intragastric (IG) catheters. They were then given 1-h sessions with a flavored saccharin solution (CS-) paired with IG water infusion or a different flavor (CS+) paired with IG 6.4% fat infusion. IG fat stimulated CS+ intakes in both Cap and Con mice, and the groups displayed similar preferences for CS+ over CS- in two-choice tests. These results confirm prior reports of normal fat conditioning in rats exposed to capsaicin or vagal deafferentation surgery. In contrast, other recent findings indicate that total or selective vagotomy alters the preference of mice for dilute vs. concentrated fat sources., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives/hypothesis: To assess and define the level of pain after rhinoplasty and septoplasty and to better define the strength and quantity of postoperative opioids needed., Study Design: Prospective outcomes research., Methods: Two groups of patients were enrolled. One group underwent septoplasty with/without turbinate reduction and the other group underwent functional and/or cosmetic rhinoplasty (with/without septoplasty). Patients completed a 15-day log (daily, beginning on the day of surgery) to record the analgesics used and the daily maximal level of pain using a visual analog scale. Level of pain, number of days of moderate or severe pain, total number of opioid pills used, and total morphine milligram equivalents (MMEs) of opioid used were assessed., Results: Pain after septoplasty and rhinoplasty was generally mild. Average pain was moderate through postoperative day (POD) 2 after rhinoplasty and only on POD 0 after septoplasty. There was no statistically significant difference between the two groups in terms of number of opioid tablets consumed or total MMEs used. Patients undergoing rhinoplasty consumed more acetaminophen than septoplasty-only patients (7471 ± 1009 vs. 2781 ± 585, P = .0112). Ninety percent of patients would have received adequate analgesia with as few as 11 opioid tablets. All patients had excess opioid at the end of the study period., Conclusions: Both septoplasty and rhinoplasty are associated with mostly mild pain, and postoperative opioid requirements are quite low. Surgeons can reliably reduce opioid prescription after septoplasty and rhinoplasty to as few as 11 tablets. Reducing opioid prescribing will not adversely affect the patient but will reduce the availability of opioids for misuse or diversion., Level of Evidence: 2c Laryngoscope, 129:2020-2025, 2019., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)