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Pain Management in the Head and Neck Patient

Key Points Patients should be routinely and regularly screened for the presence of pain so that appropriate management strategies can be implemented. Optimizing control of postoperative pain can reduce postoperative morbidity and cost. Multimodal analgesia in association with protocols for enhanced recovery after surgery may achieve increased pain control, reduced morbidity, decreased length of stay, improved function, and increased patient satisfaction. Perioperative regional anesthetic techniques may…

Otolaryngology in the Elderly

Key Points The population is aging as people are living longer. The geriatric population comprises a significant proportion of otolaryngologic practice. Presentation of diseases in older adults may be different than in the younger population, and the spectrum of disease may be different. Diagnosis, prognosis, and goals of therapy need to be discussed with patients and their families. Sensory disorders that affect hearing, speech, taste, smell,…

Oral Manifestations of Systemic Diseases

Key Points Multiple studies have observed some forms of association between periodontal disease and atherosclerotic vascular disease, based upon periodontal pathogens and certain serologic proteins found in the gingival sulcus that cause systemic inflammation. Yet no demonstrable, sustained causal relationship between the two disease processes has been proven. Antibiotic prophylaxis before certain dental procedures is recommended for patients with cardiac valvular abnormalities who are at risk…

Laryngeal and Tracheal Manifestations of Systemic Disease

Key Points The spectrum of laryngeal and tracheal symptoms of systemic disorders can vary from mild to severe and may include hoarseness, cough, stridor, and airway compromise. Many systemic disorders that affect the larynx may mimic laryngeal carcinoma. A systemic process should be suspected in a hoarse patient with no obvious lesion. Many systemic disorders require a multidisciplinary approach to achieve optimal results, and treatment may…

Head and Neck Manifestations in the Immunocompromised Host

Key Points Most immune deficiencies are acquired and affect the adaptive immune system, resulting in dysfunction of T cells and B cells. Patients with immunodeficiency are at risk for fungal, bacterial, and viral infections, and they have higher rates of certain malignancies, often with a more aggressive clinical course than that seen in immunocompetent individuals. Highly active antiretroviral therapy (HAART) has had a profound impact on…

Deep Neck and Odontogenic Infections

Key Points Methicillin-resistant Staphylococcus aureus (MRSA) is currently the most common isolate in community-acquired deep neck infections in children under 2 years. Up to 10% of MRSA isolates are clindamycin resistant. Conservative management without drainage is more likely to succeed with abscess pockets <2.5 cm in diameter that involve a single neck space. Deep neck infection (DNI) remains a frequent, potentially life-threatening condition in both children and…

Overview of Diagnostic Imaging of the Head and Neck

Key Points The choice of imaging modality varies and depends on the location and nature of the disease process. Computed tomography (CT) is fast and widely available and can be used as the first and often the only imaging modality in the majority of disease processes that affect the neck. CT excels in demonstrating bone detail. Intravenous (IV) contrast administration for CT scans improves the quantity…

Tracheotomy

Key Points Although described in numerous historic texts, tracheotomy did not become a routine surgical procedure until the late 19th to early 20th century. Indications for tracheotomy include relief of airway obstruction, access for head and neck surgery, pulmonary toilet, and need for prolonged mechanical ventilation. Tracheotomy decreases the risk of laryngeal trauma from translaryngeal intubation and promotes an earlier return to oral feeding and communication.…

Surgical Management of the Difficult Adult Airway

Key Points The difficult airway involves a difficult mask ventilation and/or a difficult tracheal intubation. Identification of a difficult airway, whenever possible, is vital prior to manipulation. An essential member of the difficult airway response team is an otolaryngologist with training and expertise in endoscopic techniques such as rigid/flexible laryngoscopy, bronchoscopy, and the ability to provide open surgical access of the airway. Techniques commonly used in…

General Considerations of Anesthesia and Management of the Difficult Airway

Key Points Knowledge of basic anesthetic techniques and of the advantages and disadvantages of various anesthetic agents used for sedation and general anesthesia in the operating room during airway management should be incorporated into the practice of otolaryngology–head and neck (OLHN) surgeons. Preoperative patient evaluation by the anesthesiologist can help to identify patients with a potentially difficult airway for intubation. For a patient who is not…

History, Physical Examination, and the Preoperative Evaluation

Key Points A careful history and detailed physical examination are the cornerstone of excellent patient care. The operating microscope and rigid and flexible endoscopes are useful adjuncts to the basic head and neck examination. Establishing rapport with the patient prior to their utilization, especially in vulnerable patients, is critical to patient comfort, safety, and maximizing the information that can be obtained from the study. Preoperative laboratory…

Evidence-Based Performance Measurement

Key Points All physicians have a moral and ethical obligation to act professionally as agents for the health of their patients by engaging in quality improvement. Physician performance measurement can be used for research, medical error reduction, patient safety, certification, credentialing, or licensing and disciplining. The purpose for which a measure is intended will determine how it is created. Health services research that demonstrates quality gaps…

Interpreting Medical Data

Key Points Learning how to interpret medical data will make you a better clinician, researcher, and teacher. Interpreting data begins by assessing the investigation that produced it; low-quality data with a high risk of bias are of limited value, regardless of how appealing the results may seem. The presence or absence of a control or comparison group has a profound influence on data interpretation. An uncontrolled…

Outcomes Research

Key Points Outcomes research, or clinical epidemiology, is the study of treatment effectiveness or the success of treatment in the nonrandomized, real-world setting. It allows researchers to gain knowledge from observational data. Bias and confounding can affect researchers’ interpretation of study data. Accurate assessments of baseline disease status, treatment given, and outcomes of treatment is critical to sound outcomes research. Many types of studies are available…

Evolution of synthetic graft materials and dural sealants for cerebrospinal fluid leak repair

Introduction Numerous methods have been developed over the years to assist in providing optimal outcomes and minimize postoperative cerebrospinal fluid leak (CSF) rates after skull base surgery. Especially inherent to the endoscopic approach is incision or resection of dura, which can vary from being only limited to the sella to involving more extensive dural surfaces (e.g., cribriform plate, planum sphenoidale, clivus). Although dependent on surgeon preference…

Powered instrumentation and bipolar technology in endoscopic endonasal skull base surgery

Introduction Technologic developments in a variety of instruments and tools have been integral in the development and advancement of endoscopic endonasal skull base surgery. From scopes and camera heads to imaging modalities and surgical navigation down to the very instruments necessary to safely and effectively perform these surgeries, it is fair to say that endonasal skull base surgery exists because of these technologic advancements. Although the…

Advances in endoscopic visualization and surgical navigation

Introduction Endoscopic visualization: Historical context Today, endoscopic endonasal surgery is an important component of skull base surgery. This development has only been possible because of constant evolution of visualization capabilities together with deeper knowledge of anatomy and refinement of surgical tools and techniques. High-fidelity visualization of the internal nasal structures has been a longstanding goal to enable diagnosis and treatment of rhinological and skull base pathologies.…

Role of cerebrospinal fluid diversion in cerebrospinal fluid leak repairs and skull base surgery

Introduction Whether, when, and how to divert cerebrospinal fluid (CSF) after skull base surgery remains a highly controversial topic, and high-quality clinical evidence to guide decisions is lacking. Both otolaryngologists and neurosurgeons encounter such scenarios in daily practice and have varying algorithms for management. The literature has demonstrated that there may be numerous practice patterns with which to successfully prevent and treat skull base CSF leaks.…

Postoperative management after reconstruction following skull base tumor surgery

Introduction Endoscopic skull base surgery has transformed the management of skull base tumors. Although these innovations have expanded the scope of the endoscopic endonasal approach beyond the sella and across the floor of the cranial fossa and substantially lowered the morbidity associated with these procedures, cerebrospinal fluid (CSF) leaks remain a common complication. A myriad of materials have been used by skull base surgeons for reconstruction…

Free flap reconstruction of skull base defects

Introduction Over the past 50 years, advances in technology, endoscopic techniques, and team approaches have revolutionized the abilities of surgeons to successfully treat sinonasal and skull base malignancies as well as repair skull base and orbital defects. Advancements in reconstruction using pedicled flaps have allowed surgeons to resect lesions more successfully while minimizing postoperative morbidities. In many instances, however, these pedicled flaps are not always available…