Soundings
President’s Message
Cognetti, MD, FACS PAO-HNS President
Welcome to Fall Soundings! Fall seems especially beautiful in Pennsylvania this year. The vivid autumn colors have been in full affect, with the extra glow from the red October of Phillies playoff baseball. Similarly, the Pennsylvania Academy of Otolaryngology – Head and Neck Surgery (PAO-HNS) enjoyed extra glow this summer. In June, we returned to an in-person annual meeting in Hershey and in September, welcomed our colleagues from across the country to Philadelphia for the American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) 2022 Annual Meeting and OTO Experience.The excitement of being back together was palpable for attendees at both events.
It is always sweet to be in Hershey, but this year it was extra sweet. The PAOHNS 2022 Annual Scientific Meeting was the first time the membership of PAO-HNS was together in-person since 2019. Program Co-Chairs, Drs. Andrew McCall and Nicholas Purdy, led an outstanding program that attracted prepandemic attendance levels. Dr. Kelly
Malloy, Associate Chief Clinical Officer of Surgical and Rehabilitation Services at University of Michigan Hospital, delivered keynote talks for the general session and the Women in Otolaryngology event. Dr. Malloy is a Philadelphia native and attended medical school and residency in Pennsylvania. It was exciting to welcome Dr. Malloy back to her home state and have her share her expertise in surgical simulation and her recommendations for sponsorship throughout our field. This year we introduced committee meetings to foster collaboration across our membership and to open opportunities for those who would like to be more involved in our society. These committees are helping to organize sessions for next year’s meeting. We also introduced a hands-on Otolaryngology experience for children which included numerous stations that were both fun and educational.
This event was wellreceived and reinforced the strong family atmosphere of our meeting.
Congratulations to the resident team from Geisinger Medical Center on the Conchal Bowl award for winning the Jeopardy session. Congratulations to Lauren Gardiner from University of Pittsburgh Medical Center and Joann Butkus from Thomas Jefferson University Hospital for winning first and second place in the Oral Presentations. Congratulations to Thomas Haupt from Howard University and Emily Milarchi from Pennsylvania State University for winning first and second place in the Poster Presentations. The Academy also recognizes this year’s well-deserving awardees. The Community Service Citation Award was awarded to the Honorable Marty Flynn and the
Distinguished Service Award was given to Paula Marcinkevich, AuD, CCC-A. I was deeply honored to be bestowed the The Helen Krause, MD Distinguished Service Award.
Speaking of honors, the PAO-HNS was awarded the Board of Governors Model Society Award at the AAO-HNSF 2022 Annual Meeting and OTO Experience in Philadelphia in September. During the meeting, PAO-HNS participated in a panel discussing the benefits of state societies and the ways in which the AAO-HNS could further support them. Dr. Jessyka Lighthall joined me as a panelist along with Jefferson resident Dr. Jena Patel and Penn State medical student Dana Goldenberg, both of whom illustrated the personal impact that PAO-HNS has had on them. Many of our members attended the AAO-HNSF 2022 Annual Meeting and OTO Experience which enjoyed robust attendance this year. As typical for September, the weather was beautiful. The meeting not only highlighted the beauty of our state but also showcased the extensive groundbreaking research being conducted at the Otolaryngology – Head and Neck Surgery programs within it.
As for advocacy, the PAO-HNS partnered with the AAO-HNSF on a letter of support of cytomegalovirus (CMV) education and screening of newborns in Pennsylvania. On June 27th, Governor Wolf signed Senate Bill 709 establishing the CMV Education and Newborn Screening Act into law. This is great news for the hearing health of our state’s children.
In closing, it was an exciting year for the PAO-HNS! The return to in-person meetings reminded us of the biggest benefit of our Academy…each other. I look
PUBLISHEDforward to this coming year and I am thrilled that the PAO-HNS is well positioned to continue its tradition of fostering collaboration and career development across the state. Please save the dates of June 16-17 2023 for the PAO-HNS 2023 Annual Scientific Meeting to be held at the beautiful Lancaster Marriott at Penn Square in Lancaster.
Thank you
David Cognetti, MD, FACS
PAO-HNS President
President David M. Cognetti, MD, FACS
Otolaryngology-Head & Neck Surgery
Thomas Jefferson University 925 Chestnut St Fl 6 Philadelphia PA 19107-4204
President-Elect Jessyka G. Lighthall, MD Penn State Hershey Otolaryngology-Head & Neck Surgery 500 University Dr., Ste. 400 UPC, H091 Hershey, PA 17033-2360
Secretary-Treasurer Colin T Huntley MD Otolaryngology-Head & Neck Surgery
Thomas Jefferson University 925 Chestnut St Fl 6 Philadelphia, PA 19107-4204
Administrative Office 400 Winding Creek Blvd. Mechanicsburg, PA 17050-1885 833-770-1544 855-918-3611 (fax) Visit our website at www.otopa.org
Soundings accepts classified advertisements; however, there is no guarantee that they will be published. All submissions are subject to review. The advertisement should be of interest/ pertain to otolaryngologists, their practice, and health care in Pennsylvania. Submissions that are self-promotional or commercial in nature will not be accepted. Publication of advertising does not imply endorsement of the products advertised or the statements contained in such advertising by Soundings or the PAO-HNS. The opinions expressed in this newsletter do not necessarily reflect the opinion of PAO-HNS.
Combatting Unnecessary Opioid Prescription: Alternative Strategies for Pain Management in Surgical Treatment of Facial Fractures
Madison Oxford, BA1
Jacqueline Tucker, BS1
Jessyka G. Lighthall, MD, FACS2
1 Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA.
2 Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA.
Conflicts of interest: The authors have no relevant conflicts of interest or financial disclosures
Funding: None
Corresponding Author: Jessyka G. Lighthall, MD, FACS
Chief, Division of Facial Plastic and Reconstructive Surgery Director, Facial Nerve Disorders Clinic Medical Director, Esteem Penn State Health Cosmetic Associates Associate Professor, Department of Otolaryngology-Head and Neck Surgery 500 University Drive, H091 Hershey, PA 17033-0850
Telephone: 717-531-8945 Fax: 717-531-6160 E-mail: jlighthall@pennstatehealth.psu.edu
Introduction
Despite growing awareness of the risks of dependence, abuse, and overdose associated with opioid use and the recent policy efforts to reduce unnecessary opioid prescriptions, opiates remain commonly used for pain management following facial fracture repair. One step to decrease addictive opioid use without sacrificing appropriate pain control in facial fracture patients is to use multimodal analgesic therapies to reduce or avoid opioids for post-operative pain control. Multimodal therapies focus on achieving analgesia through combinations of
non-addictive medications with different mechanisms of action. This could include pharmaceutical pain control as well as non-pharmaceutical techniques such as counseling, and distraction techniques such as hypnosis and virtual reality.
Alternatives to Opioid Use –Pharmacologic Options
Acetaminophen
Acetaminophen is an analgesic and antipyretic medication that blocks cyclooxygenase (COX) enzyme activity, inhibiting the synthesis of prostaglandins, and it is commonly used for mild to moderate pain management. Previous literature has demonstrated efficacy of acetaminophen at both reducing postoperative pain and decreasing opioid use in facial fracture patients.1 Often, for continuous, around-the-clock pain management after surgery, acetaminophen is used in combination with non-steroidal anti-inflammatory drugs (NSAIDs). These two medications are often alternated every 3-4 hours.
NSAIDs and COX-2 inhibitors
NSAIDs and COX-2 inhibitors also work by inhibiting COX pathway activity, which reduces prostaglandin synthesis and associated inflammation, pain, and fever. In addition to NSAIDs being used as scheduled dosing post-operatively, medications such as ketorolac or tramadol can be given as a one-time dose at the end of surgery. Prior studies assessing pain after mandibular fracture have shown that these medications provide improved pain control and decrease the need for opioids post-operatively.2 Physicians are sometimes hesitant to use NSAIDs due to concerns of postoperative bleeding, but a meta-analysis of randomized control trials found no increased risk of postoperative bleeding associated with use of this family of medications.3 NSAIDs have been shown to delayed bone healing in animal
studies4,5; however, there is no consensus on how these medications contribute to the risk of delayed union or nonunion in humans. One recent study found that there was no increase in nonunion or delayed union rates when NSAIDs were used for < 3 weeks.6 Similarly, a 2021 meta-analysis concluded that patients who received these medications for less than 2 weeks did not have an increased risk for nonunion compared to a control group, but that those who received NSAIDs for greater than 4 weeks did show an increased risk for nonunion. 7 While more work is needed to determine the impact of these medications on bone healing in humans, these studies indicate that short-term use of NSAIDs may not have a detrimental impact on bone healing and thus could be useful for pain management in fracture patients.
Local Anesthetics
Lidocaine, the most commonly used local anesthetic, is usually injected minutes before surgical incision, and works by inhibiting voltage-gated sodium channels. Morgan et al. found that use of lidocaine during surgery has utility in reducing postoperative opioid usage in facial fracture management.1 In addition to lidocaine, other local anesthetics include but are not limited to mepivacaine, bupivacaine, and ropivacaine, with the latter two being longer acting local anesthetics. These local anesthetics have similar efficacy to lidocaine.
Liposomal Bupivacaine
Liposomal bupivacaine is a long-acting form of local anesthetic which can be used as an adjunct for optimal post-operative pain control. Studies have demonstrated that the use of liposomal bupivacaine in oral and maxillofacial surgery, orthopedic surgery, and trauma has the potential limit post-operative pain and associated opioid use.10-13 This success in other fields supports
Combatting Unnecessary Opioid Prescription: Alternative Strategies for Pain Management in Surgical Treatment of Facial Fractures
Melatonin
investigation into its utility specifically for facial fracture pain management.
Regional Anesthesia/Nerve Blocks
Regional anesthesia such as nerve blocks work by inhibiting nerve signal transmission. Regional anesthesia has been used much more often in plastics and orthopedic literature compared to in otolaryngology literature. However, it has been shown that mandibular nerve blocks result in significantly less pain after otolaryngologic procedures such as mandibular osteotomies and mandibular fractures.8,9 The utilization of mandibular nerve blocks has not only resulted in reduced pain but has also led to less opioid use. These results demonstrate that nerve blocks are a promising methodology to reduce post-operative pain in facial fractures.
Gabapentinoids
Gabapentinoids are gamma-aminobutyric acid (GABA) analogues that are commonly used to treat neuropathic pain. Two recent studies, a systematic review and a randomized control study, both investigated the use of a newer generation gabapentinoid, pregabalin, in cervicofacial surgery, and both concluded that pre-operative administration of pregabalin can alleviate pain and reduce the need for rescue analgesia and opioid consumption, post-operatively.14,15 While future studies are necessary to determine the ideal preoperative dosage of gabapentinoids to optimize pain management and reduce post-operative opioid requirements, these studies have shown a potential for their use in facial fracture pain management.
Melatonin is a sleep aid that acts on melatonin receptors in the suprachiasmatic nucleus. While it is not typically considered to have analgesic effects, one study found its pre-operative use for zygomatic fractures to be better than a placebo in reducing the required opioid dosage.16
Alternatives to Opioid Use –
Nonpharmacologic Therapies
In addition to the pharmacologic treatments discussed above, several non-pharmacologic strategies have been demonstrated to reduce post-operative pain and potentially decrease opioid usage. Some of these therapies are pre-operative (regional anesthesia/ nerve blocks, counseling) while others are post-operative (hilotherapy, acupuncture, virtual reality, hypnosis, music therapy) interventions. Here we present evidence of how these therapies may be used in conjunction with traditional analgesic modalities to decrease pain and associated opioid use in post-operative patient populations.
Pre-operative counseling
Setting expectations before surgery is an extremely important part of the preoperative visit. Physicians must consent the patient and explain the surgery to them, but this is also an optimal time to talk about expectations for pain after surgery. Prior literature in other surgical subspecialties has demonstrated that explanations of pain management pre-operatively can reduce opioid use and decrease recovery time. Craniomaxillofacial trauma literature is limited, and, therefore, future studies are necessary to determine if pre-operative pain counseling similarly reduces postoperative opioid use and dependency.
Hilotherapy
Hilotherapy is a newer technique in which 15°C water is continuously circulated through a polyurethane mask applied directly to a surgical site, and thus far this treatment has been primarily utilized in craniofacial surgeries. Several studies have demonstrated the benefits of hilotherapy compared to traditional cryotherapy, which involves ice packs or cold compresses. These benefits include decreased postoperative pain and increased ease of use leading to increased patient compliance.17 While none of these studies suggest that hilotherapy could replace pharmacologic analgesia, they do support its utility as part of a multimodal regimen to reduce pain with few or no side effects.
Acupuncture
At least two systematic reviews have found that acupuncture performed on postoperative trauma patients decreased both post-operative pain and opioid use.18,19 The use of this modality to reduce opioid use also decreases risk for side-effects related to opioid use. There are not many reports of acupuncture use in craniofacial trauma, but its utility in other specialties is promising.
Virtual Reality (VR)
Virtual reality has most commonly been reported for use in phantom limb pain with amputee patients. Additional studies have shown utility in using VR for distraction for children undergoing dental procedures.20 These studies reported reduced pain s cores compared to patients utilizing standard analgesics, which supports further investigation into the potential role of VR in a post-operative pain-management regimen.
Combatting Unnecessary Opioid Prescription: Alternative Strategies for Pain Management in Surgical Treatment of Facial Fractures
Multimodal Therapy
Hypnosis
A 2020 systematic review concluded that mind-body therapies, like hypnosis, moderately reduce pain as well as the required opioid dose in patients who were prescribed opioids for chronic, acute, post-operative, or cancer pain.21 While this conclusion supports the utility of hypnosis in pain management, further studies are needed to determine the relevance of this modality for postoperative patients in general, as well as for facial fracture patients.
Music therapy
Multiple studies have been performed on patients who have undergone orthopedic and facial fracture surgeries and have shown that listening to music pre- and post-operatively, especially when it is chosen by the patient, can reduce postoperative anxiety, pain, and quantity of analgesics.22 Music therapy is a safe, inexpensive modality, and thus it would be a relatively simple addition to a painmanagement regimen for post-operative, craniofacial patients.
The American Pain Society (APS) published guidelines recommending physicians utilize multimodal therapy in their practice.23 Multimodal pain management is a concept that aims to find combinations of analgesic medications that synergistically maximize pain control while also minimizing complications. Multimodal therapy can include, but is not limited to, acetaminophen, local anesthetics and regional nerve blocks, non-steroidal anti-inflammatory drugs, gabapentinoids, muscle relaxants, and neuropathic agents. We highly recommend the use of multimodal pain management in patients with facial fractures. Combining multiple analgesic therapies discussed here can lead to optimal pain management. While multimodal therapy is recommended, continued work is needed to determine the ideal combination of treatment components which will likely vary depending on the patient and surgical procedure. Figure 1 outlines proposed combinations of therapy that may be used for pain management.
Opioids continue to be the most-common analgesic prescribed to patients following facial trauma repair, which puts these patients at high risk of opioid-related side effects including misuse and dependence. As described above, many studies have demonstrated promising results of opioid-sparing or opioid-reducing pain management regimens that utilize alternative pharmacologic and nonpharmacologic modalities. Nevertheless, much future work is needed to establish well-supported and universal guidelines for the use of non-narcotic analgesics for post-surgical pain management. It is imperative that researchers within the medical field continue to search for optimal pain management strategies that balance the comfort of the patient and the risks of the treatments.
Combatting Unnecessary Opioid Prescription: Alternative Strategies for Pain Management in Surgical Treatment of Facial Fractures
References
1. Morgan AC, Davis GL, Mehta IH, Stark P, Paap MK, Gosman AA. Analysis of Narcotic Use in Isolated Facial Fractures: Potential Targets for a Narcotic Reduction Protocol. J Craniofac Surg. 2021;32(3). Doi:10.1097/ SCS.0000000000007185
2. Jain AD, Ravisankar V, Siva Bharani K, Sudheesh K, Tewathia N. A Comparative Assessment of Postoperative Analgesic Efficacy of Lornoxicam versus Tramadol after Open Reduction and Internal Fixation of Mandibular Fractures. Craniomaxillofacial Trauma & Reconstruction. 2017;10(3). Doi:10.1055/s-0037-1600901
3. Gobble RM, Hoang HLT, Kachniarz B, Orgill DP. Ketorolac Does Not Increase Perioperative Bleeding. Plastic and Reconstructive Surgery. 2014;133(3):741-755. Doi:10.1097/01. prs.0000438459.60474.b5
4. Pountos I, Georgouli T, Calori GM, Giannoudis P v. Do Nonsteroidal Anti-Inflammatory Drugs Affect Bone Healing? A Critical Analysis. The Scientific World Journal. 2012;2012:1-14. Doi:10.1100/2012/606404
5. Al-Waeli H, Reboucas AP, Mansour A, Morris M, Tamimi F, Nicolau B. Nonsteroidal anti-inflammatory drugs and bone healing in animal models—a systematic review and meta-analysis. Systematic Reviews. 2021;10(1):201. Doi:10.1186/ s13643-021-01690-w
6. Kim H, Kim DH, Kim DM, et al. Do Nonsteroidal Anti-Inflammatory or COX2 Inhibitor Drugs Increase the Nonunion or Delayed Union Rates After Fracture Surgery? Journal of Bone and Joint Surgery. 2021;103(15):1402-1410. Doi:10.2106/ JBJS.20.01663
7. Al Farii H, Farahdel L, Frazer A, Salimi A, Bernstein M. The effect of NSAIDs on postfracture bone healing: a meta-analysis of randomized controlled trials. OTA International: The Open Access Journal of Orthopaedic Trauma. 2021;4(2):e092. Doi:10.1097/OI9.0000000000000092
8. Bertuit M, Rapido F, Ly H, et al. Bilateral mandibular block improves pain relief
and morphine consumption in mandibular osteotomies: A prospective, randomized, double-blind, placebo-controlled clinical trial. Regional Anesthesia and Pain Medicine. 2021;46(4). Doi:10.1136/rapm-2020102417
9. Singh B, Bhardwaj V. Continuous mandibular nerve block for pain relief: A report of two cases. Canadian Journal of Anesthesia. 2002;49(9). Doi:10.1007/BF03016881
10. Neal TW, Hammad Y, Schlieve T. Liposomal bupivacaine: a literature review of applications in oral and maxillofacial surgery. Journal of Oral and Maxillofacial Anesthesia. 2022;1:3-3. Doi:10.21037/ joma-21-22
11. Wallen TE, Singer KE, Makley AT, et al. Intercostal liposomal bupivacaine injection for rib fractures: A prospective randomized controlled trial. Journal of Trauma and Acute Care Surgery. 2022;92(2):266-276. Doi:10.1097/TA.0000000000003462
12. Ott M. Efficacy of Liposomal Bupivacaine in Orthopedic Procedures in an Academic Trauma Hospital. Annals of Musculoskeletal Medicine. 2017;1(2):027-031. Doi:10.17352/amm.000006
13. Davidovitch R, Goch A, Driesman A, Konda S, Pean C, Egol K. The Use of Liposomal Bupivacaine Administered With Standard Bupivacaine in Ankle Fractures Requiring Open Reduction Internal Fixation: A Single-Blinded Randomized Controlled Trial. Journal of Orthopaedic Trauma. 2017;31(8):434-439. Doi:10.1097/ BOT.0000000000000862
14. Liébana-Hermoso S, Manzano-Moreno FJ, Vallecillo-Capilla MF, Olmedo-Gaya MV. Oral pregabalin for acute pain relief after cervicofacial surgery: a systematic review. Clinical Oral Investigations. 2018;22(1). Doi:10.1007/s00784-017-2272-2
15. Ahiskalioglu A, Ince I, Aksoy M, Yalcin E, Ahiskalioglu EO, Kilinc A. Effects of a single-dose of pre-emptive pregabalin on postoperative pain and opioid consumption after double-jaw surgery: A randomized controlled trial. Journal of Oral and Maxillofacial Surgery. 2016;74(1). Doi:10.1016/j.joms.2015.09.008
16. de Carvalho Nogueira EF, de Oliveira Vasconcelos R, Teixeira Correia SS, Souza Catunda I, Amorim JA, do Egito Cavalcanti Vasconcelos B. Is There a Benefit to the Use of Melatonin in Preoperative Zygomatic Fractures? Journal of Oral and Maxillofacial Surgery. 2019;77(10). Doi:10.1016/j.joms.2019.05.016
17. Bates AS, Knepil GJ. Systematic review and meta-analysis of the efficacy of hilotherapy following oral and maxillofacial surgery. International Journal of Oral and Maxillofacial Surgery. 2016;45(1):110-117. Doi:10.1016/j.ijom.2015.08.983
18. Sun Y, Gan TJ, Dubose JW, Habib AS. Acupuncture and related techniques for postoperative pain: A systematic review of randomized controlled trials. British Journal of Anaesthesia. 2008;101(2). Doi:10.1093/bja/aen146
19. Wu MS, Chen KH, Chen IF, et al. The efficacy of acupuncture in post-operative pain management: A systematic review and meta-analysis. PloS ONE. 2016;11(3). Doi:10.1371/journal.pone.0150367
20. Kumari S, Bahuguna R, Garg N, Yeluri R. Immersive and Non-Immersive Virtual Reality Distraction on Pain Perception to Intraoral Injections. Journal of Clinical Pediatric Dentistry. 2021;45(6):389-394. Doi:10.17796/1053-4625-45.6.5
21. Garland EL, Brintz CE, Hanley AW, et al. Mind-Body Therapies for OpioidTreated Pain: A Systematic Review and Meta-analysis. JAMA Internal Medicine. 2020;180(1). Doi:10.1001/ jamainternmed.2019.4917
22. Lin CL, Hwang SL, Jiang P, Hsiung NH. Effect of Music Therapy on Pain After Orthopedic Surgery—A Systematic Review and Meta-Analysis. Pain Practice. 2020;20(4). doi:10.1111/papr.12864
23. Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. The Journal of Pain. 2016;17(2):131-157. doi:10.1016/j. jpain.2015.12.008
The American Academy of Otolaryngology Head and Neck Surgery had its annual meeting in Philadelphia from September 10th to the 14th. Over 400 continuing education sessions were available. Opportunities to connect with leaders in the specialty and see the latest advancements in the specialty were available. By all accounts all who attended were very satisfied with the experience. Dr. Kathleen Yaremchuk was installed as President. She is the current chair of the department of Otolaryngology/Head and Neck Surgery at Henry Ford Health System in Detroit. Dr. Douglas Backous a neuro otologist from Puget Sound, Oregon is President elect.
The Board of Governors held their General Assembly where presentations on best practices for Advocacy promotion were done. Our own State Society (PAO/HNS) was awarded the BOG Model Society Award and Dr. G. Lee Bryant the Practitioner Excellence Award. Dr. Cognetti and Dr. Lighthall spearheaded the State Society Panel discussing what ideas have worked well in the past for the society and activities that may be considered in the future to promote growth, involvement, and collaboration with the BOG and AAO/HNSF.
Topics of concern that the Academy are currently working on include an update on the Surprise billing law and OTC hearing aids.
An interim final rule on surprise billing was recently released. The final rule states that a qualifying payment amount described as a calculation of a median in network rate, is only one of multiple inputs to be considered by the arbitrators in the independent dispute resolution process which out of network providers and insurers are required to use to adjudicate payment rates. Other factors such as the provider’s level of training and patient acuity should be considered by arbitrators as well. The agencies recognize the significance of down coding claims and the negative effect it can have on providers. The final rule defines down coding and includes requirements that mandate payers to disclose that a
Save the Date!
service was down coded, why it was down coded, and allow rebuttal of such down coding in the independent dispute resolution process.
The US Food and Drug administration issued a final rule to create a category of over the counter hearing aids for people aged 18 or older with perceived mild to moderate hearing loss. The Academy worked with the FDA and other components of the hearing healthcare community to develop a final regulation that expands access and keeps patient safety maximized. Several of the academy’s recommendations were included such as lowering the maximum sound output, revising the insertion depth limit to 10 millimeters or greater from the tympanic membrane, simplifying the wording on the product labeling, and delineating red flag conditions that prompt a consultation with a doctor preferably an ear nose and throat doctor.
Finally, as the new Chair of the Board of Governors, I encourage any interested Otolaryngologist in our state to get more involved with the Board of Governors by participating in any of its 3 committees (Legislative, Socioeconomic and Grassroots, or GOSE-Governance and Society Engagement). Please consider getting more involved!!
Device Failure During Injection Medialization Laryngoplasty
Nicole Molin MD, Mursalin M. Anis, MD PhD, Ahmed M.S. Soliman, MDInjection medialization laryngoplasty is a commonly performed procedure for the management of glottic insufficiency. Since first described by Brunings in 1911, both the technique and materials used have evolved greatly.2 Complications of this procedure are uncommon but include migration of the injection material, bleeding/ hematoma at the injection site, patient intolerance, suboptimal voice outcome, vasovagal response, and rarely airway compromise.2-4 Among the rarer complications is device failure for which literature is scarce.
On a recent survey of active members of The American Bronchoesophagological Association (ABEA) by our group, nearly all 24 respondents experienced needle failures during injection laryngoplasty, and 1/6th of them experienced needle failures more than 10 times.5 The most common reason for needle failure was clogging (59%), followed by twisting (22%), and needle tip fracture (19%). Most device failures occurred when the procedure was being done on an awake patient. Fifty four percent of respondents reported needle failure while using a percutaneous approach. CAHA was the injection material being used during nearly half of needle failures. Twenty percent of survey respondents reported aborting a procedure due to needle failure.
Familiarity with managing these complications is essential. The most common reason for needle failure was clogging and twisting which can be managed by replacing the needle. Nearly a fifth of respondents, however, experienced needle tip fracture, a complication that has the potential for significant patient morbidity from the presence of a sharp foreign body in the aerodigestive tract and requires immediate intervention. All airway foreign bodies require urgent retrieval which has been traditionally performed using rigid bronchoscopy under general anesthesia.6
When the foreign body is not visible upon flexible laryngoscopy, radiography of the neck and chest is necessary to help locate it. Suspected foreign bodies in the airway will require prompt retrieval whereas those in the digestive tract have several management options based on the size of the needle. 7
While device failure during injection laryngoplasty is rarely reported in the literature, it was experienced by almost all respondents in our survey, most of whom were fellowship trained laryngologists and perform these procedures regularly. Awareness of this complication is important to allow otolaryngologists to appropriately provide informed consent to patients and proceed cautiously.
References
1. Brunings W. Uber eine neue Behandlungs-method der Rekurrenslahmung. Vern Ver Dtsch Laryngol. 1911;18:525–30.
2. Bock JM, Lee JH, Robinson RA, Hoffman HT. Migration of Cymetra after vocal fold injection for laryngeal paralysis. Laryngoscope. 2007;117(12):2251–4.
3. Carroll TL, Rosen CA. Long‐term results of calcium hydroxylapatite for vocal fold augmentation. Laryngoscope. 2011;121(2):313–9.
4. DeFatta RA, Chowdhury FR, Sataloff RT. Complications of injection laryngoplasty using calcium hydroxylapatite. J Voice. 2012;26(5):614–8.
5. Molin N, Anis M, Soliman, AMS. Device failure during injection medialization laryngoplasty. J. Voice. In Press.
6. Aydoğan LB, Tuncer U, Soylu L, Kiroğlu M, Ozsahinoglu C. Rigid bronchoscopy for the suspicion of foreign body in the airway. Int J Pediatr Otorhinolaryngol. 2006;70(5):823–8.
7. Ambe P, Weber SA, Schauer M, Knoefel WT. Swallowed foreign bodies in adults. Dtsch Arztebl Int. 2012;109(50):869.
An understanding of appropriate management is critical particularly for needle fractures that result in an aerodigestive tract foreign body which require prompt attention.
Photos from Advocacy Leadership Breakfast
Photos from the 2022 Annual Meeting
WELCOME NEW MEMBERS!
D. Gregory Farwell, MD
Thomas Chung, MD Erik Interval, MD, FACS
Congratulations to the 2022 Top Physicians Under 40!
This year’s Pennsylvania Medical Society Top Physicians Under 40 recipients were nominated by colleagues and selected by a committee of Pennsylvania Medical Society member physicians.
