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The neurosurgical management of lateral skull base trauma

Introduction The lateral skull base is comprised predominantly of the dense, pyramid-shaped petrous temporal bone. Fractures of the petrous temporal bone comprise approximately 20% of all skull fractures. Given the density of the petrous temporal bone, fractures are caused by high-impact trauma and are nearly uniformly associated with traumatic brain injury (TBI). In addition, 8%–29% of temporal bone fractures are bilateral, resulting in significant morbidity. ,…

Labyrinthine concussion: diagnosis and management

Since the 20th century, the term “labyrinthine concussion” or “inner ear concussion” has been used to describe sensorineural hearing loss following head trauma in the absence of temporal bone fracture and is generally defined as head trauma resulting in sensorineural hearing loss without evidence of fracture involving the labyrinth. Although poorly reported in the medical literature, it does not seem to be a rare complication of…

Medical and surgical management of temporal bone fractures

Introduction Temporal bone fractures (TBFs) present complex diagnostic and management challenges. Due to the large amount of force required to fracture the temporal bone, several other injuries may also be present. The severity and number injuries may result in incomplete or evaluation of the temporal bone, which may delay diagnosis and proper follow-up care. The management of TBF overall focuses on restoring functional deficits and reducing…

Conductive hearing loss after head injury: diagnosis and management

Introduction Head injury is a major source of disability and mortality worldwide. The CDC reports that in 2017 there were 224,000 head injury-related hospitalizations in the United States. Unintentional falls accounted for nearly 50% of these hospitalizations, motor vehicle crashes 25%, and strikes by an object, intentional self-harm, and assault accounted for the remaining 25% (CDC, Traumatic Brain Injury). Head injury may result in a variety…

Acute and chronic management of otologic blast injury

Introduction In 2005, the Department of Veterans Affairs awarded more than $1 billion for otologic-related disabilities—the majority of which were due to impulse noise exposures and blast injuries. The ear is the body's most sensitive pressure transducer, and as a result, otologic complaints are common after blasts. Fortunately, blast trauma is a rare occurrence in the United States. As a result, much of the civilian literature…

Physiology of acoustic blast injury

Introduction Damage to the ear is the most common organ injury after exposure to blast overpressure (BOP). A blast injury occurs due to a rapid overpressurization force to the body. The middle and inner ear are particularly sensitive to sudden pressure changes and are therefore very susceptible to blast injuries. Blast injury to the ear may be caused by the detonation of high-order explosives (e.g., dynamite,…

Surgical management of auricular trauma

Auricular anatomy Mastery of auricular anatomy is a prerequisite for achieving successful reconstruction. The majority of the auricle is composed of an intricate cartilaginous framework with an overlying taut skin envelope, creating distinct topographical landmarks ( Fig. 3.1 ). The lobule lacks underlying cartilage and is made up of thin skin overlying fibrofatty tissue. Between the cartilage and skin along the posterior surface of the auricle exists…

Imaging of the temporal bone following otologic and lateral skull base trauma

Introduction Extent and severity of injury in the setting of otologic and lateral skull base trauma are readily detected noninvasively by imaging. Due to its speed and excellent spatial resolution, multidetector CT (MDCT) remains the primary modality of choice in the acute traumatic setting to delineate temporal bone trauma. Detection of subtle fractures and involvement of the otic capsule, carotid canal, and facial nerve canal can…

Epidemiology of traumatic brain injury and lateral skull base injury in the United States

Overview Traumatic brain injury (TBI) is a major public health issue globally and in the United States. The Centers for Disease Control (CDC) defines TBI as an insult (blow or bump to the head) or penetrating head injury affecting the normal function of the brain. TBI can vary in severity, and in the United States, the majority are mild and clinically often described as a “concussion.”…

A systems approach to perioperative pain management

Introduction As a result of the ongoing public health crisis of opioid addiction in the United States, increased focus and scrutiny have been placed on physicians' pain management practices. Moreover, postoperative opioid prescribing practices after routine surgical procedures are often not standardized and can vary widely. While the current epidemic of opioid addiction is multifactorial and cannot solely be ascribed to surgeons' prescribing practices, the impact…

International perioperative pain management approaches

Introduction Opioids were initially used for acute and cancer-related pain in the early 20th century. In a seminal campaign in 1996, the American Pain Society (APS) introduced “pain as the fifth vital sign” to address the issue of inadequate treatment of pain. Since then, opioid-class drugs were approved by the United States Food and Drug Administration (FDA) for pain management. Opioid therapy has hence been readily…

Addiction management in the outpatient setting

Introduction Since the 1990s, the increasing incidence of opioid use disorder (OUD) and overdose deaths involving opioids have reached epidemic proportions. Rising use has been associated with both medical and nonmedical opioid use. While opioids are an effective form of analgesia for acute and postoperative pain, the overprescribing of opioids, in part, has contributed to the escalation of opioid overdoses in the United States. In 1996,…

Nonopioid pain management in otolaryngology—head and neck surgery: the pharmacist’s perspective

Introduction With the setting of the opioid epidemic, a focus has been placed on understanding the prescribing patterns of physicians for postoperative surgery pain. A 2018 survey of 1770 members of the American Rhinologic Society was conducted regarding the prescribing patterns for pain management after endoscopic sinus surgery (ESS). The overall survey response rate was low at 9.49% ( N = 168). At least one kind…

Pain management in head and neck cancer

List of abbreviations AAO/HNSF American Academy of Otolaryngology-Head and Neck Surgery Foundation APCD advanced pneumatic compression devices CI confidence interval CNS central nervous system COX cyclooxygenase ERAS enhanced recovery after surgery FDA Food and Drug Administration GFR glomerular filtration rate HNC head and neck cancers IM intramuscular IV intravenous MME morphine milligram equivalents NCCN National Comprehensive Cancer Network NSAIDs nonsteroidal antiinflammatory drugs OM oral mucositis OUD…

Approach to pain management in otology and neurotology

Overview Otology and neurotology encompass a broad spectrum of procedures, from minor surgical procedures performed under local anesthesia in an outpatient setting (e.g., bone-anchored hearing aid placement), to complex intracranial surgeries involving critical neurovascular structures that require ICU admission (e.g., vestibular schwannoma excision). The patient population also encompasses the entire span of life, from infants to the elderly. The heterogeneity in procedural scope and patient demographics…

Perioperative pain management in pediatric otolaryngology—head and neck surgery

Introduction The two most common pediatric surgeries in the United States, tympanostomy tube insertion and tonsillectomy, are both performed by otolaryngologists. For this reason, a contemporary understanding of pediatric perioperative pain control is critical for otolaryngologists. The majority of these procedures are performed on an outpatient basis, with selected patients requiring one night of monitored observation after tonsillectomy. Anticipated postoperative pain and perioperative risks differ greatly…

Perioperative pain management in facial plastic and reconstructive surgery

Introduction Pain management is a major concern for many patients who contemplate undergoing facial plastic and reconstructive surgeries. Numerous over-the-counter and prescription pain medications have been used to address this important and universal patient issue. The treatment of acute postoperative pain commonly includes the administration of nonopioid analgesics, opioids, and injectable anesthetics. Over time, the large variety of available medications have led to differences in prescribing…

Perioperative pain management in rhinology and anterior skull base surgery

Introduction The nasal cavity exists to warm, humidify, and sample air for olfaction as we inspire. The role of the paranasal sinuses is not as clear, though it is hypothesized that they exist, at least in part, to lighten the skull and provide a source of protection for the intracranial and orbital contents as a sort of “crash zone” in the case of head trauma. While…

Pain management in the care of otolaryngology patients: an anesthesiologist and pain physician’s perspective

Acknowledgment We would like to express our appreciation to Dr. Roger Goucke for the invaluable input, suggestion, and language editing of the manuscript. Introduction Pain has recently been redefined as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” Pain is not only an undesirable experience, but also is associated with many consequences, including lower patient satisfaction,…

Anterior Antrostomy: The Caldwell-Luc Operation

Introduction The Caldwell-Luc procedure was named after two surgeons, Caldwell and Luc. They both described a similar procedure, with Caldwell advocating an inferior meatal antrostomy and Luc advocating enlargement of the natural ostium in the middle meatus. Caldwell practiced in New York and published a report on anterior antrostomy in the New York Medical Journal in 1896. Luc was French, practiced in Paris, and independently reported…