Publications by authors named "Michael J Brenner"

134 Publications

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations Executive Summary.

Otolaryngol Head Neck Surg 2021 Apr;164(4):687-703

American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA.

Objective: Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families.

Purpose: The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients.

Action Statements: The guideline development group made for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.
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http://dx.doi.org/10.1177/0194599821996303DOI Listing
April 2021

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations.

Otolaryngol Head Neck Surg 2021 Apr;164(2_suppl):S1-S42

American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA.

Objective: Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families.

Purpose: The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients.

Action Statements: The guideline development group made for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.
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http://dx.doi.org/10.1177/0194599821996297DOI Listing
April 2021

Shared Decision-making and Stakeholder Engagement in COVID-19 Tracheostomy.

JAMA Otolaryngol Head Neck Surg 2021 Mar 25. Epub 2021 Mar 25.

Department of Otolaryngology-Head & Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan.

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http://dx.doi.org/10.1001/jamaoto.2021.0181DOI Listing
March 2021

Standard versus Accelerated Speaking Valve Placement after Percutaneous Tracheostomy: A Randomized-Controlled Feasibility Study.

Ann Am Thorac Soc 2021 Mar 24. Epub 2021 Mar 24.

Johns Hopkins University, 1466, Baltimore, Maryland, United States;

Rationale: Feasibility of a large, multi-center, randomized controlled trial (RCT) comparing the risks and benefits of early use speaking valve following tracheostomy is not clear.

Objective: To investigate the feasibility of accelerated (≤ 24 hours) versus standard (≥ 48 hours) one-way speaking valve ("speaking valve") placement after percutaneous tracheostomy.

Method: Twenty awake patients (Glasgow Coma Scale score >9) were randomized to accelerated or standard timing of speaking valve placement. Outcomes included patient identification and recruitment, adherence to protocol-defined time windows for valve placement, experimental separation in time to first speaking valve placement between groups, effectiveness of speech and swallowing (sentence intelligibility test [SIT] score, patient-reported quality of life [QOL]), and clinical outcomes (safety events, speaking valve tolerance, decannulation, length of stay, mortality).

Results: Of 161 patients undergoing percutaneous tracheostomy, 20 of 36 meeting eligibility criteria were randomized. The median time to speaking valve placement was 22 (IQR: 21, 23) hours in the accelerated arm versus 45.5 (IQR: 43, 50) hours for the standard arm. No aspiration, hypoxemia, or other safety events occurred in either arm as a result of the speaking valve. SIT scores were not different between arms but correlated with QOL. After 3 sessions, patients in the accelerated arm tolerated longer speaking valve trials than the standard arm [Median (IQR): 65 (45 - 720) vs. 15 (3-20) minutes]. Seven patients in the accelerated arm were decannulated before hospital discharge versus one patient in the standard arm.

Conclusions: Speaking valve placement within 24 hours of percutaneous tracheostomy is feasible. A multicenter, randomized, control trial should be conducted to evaluate the safety of this strategy and compare important clinical outcomes, including time to speech and swallow recovery following tracheostomy. Clinical trial registered with ClinicalTrials.gov (NCT03008174).
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http://dx.doi.org/10.1513/AnnalsATS.202010-1282OCDOI Listing
March 2021

Improving the Safety and Science of COVID-19 Tracheostomy: Challenges and Opportunities.

Laryngoscope 2021 Mar 16. Epub 2021 Mar 16.

Division of Head and Neck Surgery, Hôpital de la Tour, Meyrin, Geneva University, Geneva, Switzerland.

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http://dx.doi.org/10.1002/lary.29512DOI Listing
March 2021

Early Percutaneous Tracheostomy in the Coronavirus Disease 2019 Era: Shining New Light on Old Questions.

Crit Care Med 2021 Mar 3. Epub 2021 Mar 3.

Global Tracheostomy Collaborative, Raleigh, NC Department of Otolaryngology-Head & Neck Surgery, University of Michigan Medical School, Ann Arbor, MI UK National Tracheostomy Safety Project, NHS England, London, United Kingdom Department of Anaesthesia & Intensive Care Medicine, Manchester University NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy Department of Anesthesiology and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy.

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http://dx.doi.org/10.1097/CCM.0000000000004884DOI Listing
March 2021

Rebuttal from Drs Brenner, Feller-Kopman, and De Cardenas.

Chest 2021 Feb 27. Epub 2021 Feb 27.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan Medical School, Ann Arbor, MI. Electronic address:

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http://dx.doi.org/10.1016/j.chest.2021.01.076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7997601PMC
February 2021

POINT: Tracheostomy in Patients With COVID-19: Should We Do It Before 14 Days? Yes.

Chest 2021 Feb 27. Epub 2021 Feb 27.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan Medical School, Ann Arbor, MI. Electronic address:

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http://dx.doi.org/10.1016/j.chest.2021.01.074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7910662PMC
February 2021

Commentary on "Opioid Prescribing Patterns Among Facial Plastic and Reconstructive Surgeons in the Medicare Population" by Barbarite et al.: Shorter Duration Opioid Prescribing After Surgery-Moving Needles or Goalposts?

Facial Plast Surg Aesthet Med 2021 Mar 2. Epub 2021 Mar 2.

Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA.

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http://dx.doi.org/10.1089/fpsam.2020.0627DOI Listing
March 2021

Laryngeal and Tracheal Pressure Injuries in Patients With COVID-19.

JAMA Otolaryngol Head Neck Surg 2021 Feb 25. Epub 2021 Feb 25.

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland.

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http://dx.doi.org/10.1001/jamaoto.2021.0001DOI Listing
February 2021

Lip and Perioral Trauma: Principles of Aesthetic and Functional Reconstruction.

Facial Plast Surg 2021 Feb 22. Epub 2021 Feb 22.

Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan.

Successful management of lip and perioral trauma requires a nuanced understanding of anatomy and surgical techniques. Surgical correction is particularly challenging in instances of tissue loss, due to a narrow tolerance for aesthetic deformity and highly specialized functions of the perioral region, including facial expression, communication, and oral competence. Restoring continuity of the orbicularis oris musculature is critical for dynamic sphincter function of the upper and lower lips. Lip and perioral tissue symmetry are also critical for aesthetic balance, and failure to restore a natural appearance can adversely affect personal identity, with attendant psychological trauma. This discussion of lip and perioral trauma management encompasses lip and perioral anatomy, evaluation of injuries, reconstructive techniques, and prevention and management of complications. Perioral injuries are classified by size, depth, and extent of injury, and the corresponding reconstructive approaches are a function of complexity. These approaches proceed sequentially up rungs of the reconstructive ladder including primary repair, local flaps, grafting, regional flaps, as well as microvascular free tissue transfers. Procedures may be single stage or require multiple stages or subsequent refinement. Regardless of the defect size or location, the guiding principle of repair in the perioral region is restoring natural function and aesthetic appearance. This still-evolving area of facial plastic and reconstructive surgery lends itself to artistry and technical precision, offering opportunities for further innovation to improve the outcomes of patients with lip and perioral trauma.
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http://dx.doi.org/10.1055/s-0041-1725110DOI Listing
February 2021

Metastatic signet ring cell gastric carcinoma bypassing Virchow's node: An unexpected etiology of a painful neck mass.

Clin Case Rep 2021 Feb 4;9(2):650-653. Epub 2020 Dec 4.

Division of Facial Plastic and Reconstructive Surgery Department of Otolaryngology-Head and Neck Surgery University of Michigan Medical School Ann Arbor MI USA.

Metastatic lymph nodes of the head and neck are often associated with locoregional spread of mucosal squamous carcinoma, but in rare instances visceral malignancies may bypass Virchow's node. The possibility of distant metastasis should be considered.
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http://dx.doi.org/10.1002/ccr3.3594DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869360PMC
February 2021

COVID-19 survivorship: How otolaryngologist-head and neck surgeons can restore quality of life after critical illness.

Am J Otolaryngol 2021 Jan 9;42(3):102917. Epub 2021 Jan 9.

Department of Otolaryngology-Head & Neck Surgery, University of Michigan Medical Center, Ann Arbor, MI, United States; Global Tracheostomy Collaborative, Raleigh, NC, United States. Electronic address:

Mortality from COVID-19 has obscured a subtler crisis - the swelling ranks of COVID-19 survivors. After critical illness, patients often suffer post-intensive care syndrome (PICS), which encompasses physical, cognitive, and/or mental health impairments that are often long-lasting barriers to resuming a meaningful life. Some deficits after COVID-19 critical illness will require otolaryngologic expertise for years after hospital discharge. There are roles for all subspecialties in preventing, diagnosing, or treating sequelae of COVID-19. Otolaryngologist leadership in multidisciplinary efforts ensures coordinated care. Timely tracheostomy, when indicated, may shorten the course of intensive care unit stay and thereby potentially reduce the impairments associated with PICS. Otolaryngologists can provide expertise in olfactory disorders; thrombotic sequelae of hearing loss and vertigo; and laryngotracheal injuries that impair speech, voice, swallowing, communication, and breathing. In the aftermath of severe COVID-19, otolaryngologists are poised to lead efforts in early identification and intervention for impairments affecting patients' quality of life.
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http://dx.doi.org/10.1016/j.amjoto.2021.102917DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7833311PMC
January 2021

New Age Mentoring and Disruptive Innovation-Navigating the Uncharted With Vision, Purpose, and Equity.

JAMA Otolaryngol Head Neck Surg 2021 Apr;147(4):389-394

Department of Head and Neck Surgery & Communication Sciences, Duke University, Durham, North Carolina.

For individuals aspiring to a career in otolaryngology-head and neck surgery, mentorship can shape destiny. Mentorship helps assure safe passage into the specialty, and it influences the arc of professional development across the career continuum. Even before the novel coronavirus disease 2019 (COVID-19) pandemic, technology and social networking were transforming mentorship in otolaryngology. Now, in an increasingly virtual world, where in-person interactions are the exception, mentorship plays an even more pivotal role. Mentors serve as trusted guides, helping learners navigate accelerating trends toward early specialization, competency-based assessments, and key milestones. However, several structural barriers render the playing field unlevel. For medical students, cancellation of visiting clerkships, in-person rotations, and other face-to-face interactions may limit access to mentors. The pandemic and virtual landscape particularly threaten the already-leaky pipeline for underrepresented medical students. These challenges may persist into residency and later career stages, where structural inequities continue to subtly influence opportunities and pairings of mentors and mentees. Hence, overreliance on serendipitous encounters can exacerbate disparities, even amid societal mandates for equity. The decision to take deliberate steps toward mentoring outreach and engagement has profound implications for what otolaryngology will look like in years to come. This article introduces the concept of new age mentoring, shining a light on how to modernize practices. The key shifts are from passive to active engagement; from amorphous to structured relationships; and from hierarchical dynamics to bidirectional mentoring. Success is predicated on intentional outreach and purposefulness in championing diversity, equity, and inclusion in the progressively technology-driven landscape.
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http://dx.doi.org/10.1001/jamaoto.2020.5448DOI Listing
April 2021

Percutaneous Tracheostomy.

N Engl J Med 2021 02 3;384(8):779. Epub 2021 Feb 3.

University of Michigan Medical School, Ann Arbor, MI

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http://dx.doi.org/10.1056/NEJMc2035339DOI Listing
February 2021

Keeping an Open Mind: tracheostomy for patients with COVID-19.

Anesth Analg 2021 Jan 8;Publish Ahead of Print. Epub 2021 Jan 8.

Michael J. Brenner, MD, FACS Associate Professor and Co-Director of Branch Science, Medical School President, Global Tracheostomy Collaborative, Raleigh NC Chair, Centralized Otolaryngology Research Efforts, American Academy of Otolaryngology - Head & Neck Surgery, Alexandria, VA Department of Otolaryngology - Head & Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, United States

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http://dx.doi.org/10.1213/ANE.0000000000005419DOI Listing
January 2021

Assessing Candidacy for Tracheostomy in Ventilated Patients With Coronavirus Disease 2019: Aligning Patient-Centered Care, Stakeholder Engagement, and Health-Care Worker Safety.

Chest 2021 01;159(1):454-455

Anaesthesia & Intensive Care Medicine, Manchester University NHS Foundation Trust; Faculty of Biology, Medicine and Health, the University of Manchester, Manchester, UK.

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http://dx.doi.org/10.1016/j.chest.2020.07.100DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7831711PMC
January 2021

The Future of Telemedicine: Revolutionizing Health Care or Flash in the Pan?

Otolaryngol Head Neck Surg 2021 Jan 5:194599820983330. Epub 2021 Jan 5.

Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA.

The meteoric rise of telemedicine early in the COVID-19 pandemic might easily be mistaken for an ephemeral trend-one reaching its zenith in a moment of crisis. To the contrary, momentum has been mounting for telehealth over decades. The recent increase in telecare reveals its potential to deliver efficient, patient-centered, high-quality care in an increasingly technology-dependent landscape. Prior to COVID-19, surgeons lagged behind medical counterparts in embracing telemedicine; however, the pragmatic imperatives for remote care of patients and changes to Medicare removed key barriers to adoption. Otolaryngology-head and neck surgery has innovated across subspecialties, leading in COVID-19 scholarship and year-over-year publications on telemedicine. Yet, improved access to subspecialists is tempered by a digital divide that threatens to exacerbate disparities. Otolaryngology is poised to lead the transformation of procedural specialties while ensuring equitable care.
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http://dx.doi.org/10.1177/0194599820983330DOI Listing
January 2021

Intraoperative Sentinel Events in the Era of Surgical Safety Checklists: Results of a National Survey.

OTO Open 2020 Oct-Dec;4(4):2473974X20975731. Epub 2020 Dec 9.

University of Michigan Medical School, Ann Arbor, Michigan, USA.

Objective: Despite the implementation of advanced health care safety systems including checklists, preventable perioperative sentinel events continue to occur and cause patient harm, disability, and death. We report on findings relating to otolaryngology practices with surgical safety checklists, the scope of intraoperative sentinel events, and institutional and personal response to these events.

Study Design: Survey study.

Setting: Anonymous online survey of otolaryngologists.

Methods: Members of the American Academy of Otolaryngology-Head and Neck Surgery were asked about intraoperative sentinel events, surgical safety checklist practices, fire safety, and the response to patient safety events.

Results: In total, 543 otolaryngologists responded to the survey (response rate 4.9% = 543/11,188). The use of surgical safety checklists was reported by 511 (98.6%) respondents. At least 1 patient safety event in the past 10 years was reported by 131 (25.2%) respondents; medication errors were the most commonly reported (66 [12.7%] respondents). Wrong site/patient/procedure events were reported by 38 (7.3%) respondents, retained surgical items by 33 (6.4%), and operating room fire by 18 (3.5%). Although 414 (79.9%) respondents felt that time-outs before the case have been the single most impactful checklist component to prevent serious patient safety events, several respondents also voiced frustrations with the administrative burden.

Conclusion: Surgical safety checklists are widely used in otolaryngology and are generally acknowledged as the most effective intervention to reduce patient safety events; nonetheless, intraoperative sentinel events do continue to occur. Understanding the scope, causes, and response to these events may help to prioritize resources to guide quality improvement initiatives in surgical safety practices.
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http://dx.doi.org/10.1177/2473974X20975731DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7731722PMC
December 2020

Capping or Suctioning for Tracheostomy Decannulation.

N Engl J Med 2020 12;383(25):2480

University of Michigan Medical School, Ann Arbor, MI

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http://dx.doi.org/10.1056/NEJMc2031385DOI Listing
December 2020

ENT-MS-12 questionnaire: A novel tool to investigate otolaryngology symptoms in patients with relapsing-remitting multiple sclerosis. Results from a pilot study.

Mult Scler Relat Disord 2021 Jan 2;47:102660. Epub 2020 Dec 2.

Wayne State University, Multiple Sclerosis Center, Detroit, USA.

Background: Multiple sclerosis (MS) is associated with otolaryngology-related manifestations including vestibular or auditory symptoms; facial motor or sensory disorders; voice or swallowing impairment; and snoring/sleep apnea. Because these symptoms are nonspecific, their significance in MS is seldom recognized by patients with MS and their physicians; yet, presence of these symptoms may be a harbinger of impending relapse or disease progression. We developed and investigated a survey instrument, the ENT-MS-12, to standardize reporting of otolaryngology symptoms in patients with MS, correlating its scoring with disability and lesions.

Methods: The ENT-MS-12 was administered to 40 patients with relapsing-remitting MS in different phases of their disease. We collected data using the Expanded Disability Status Scale (EDSS) and analyzed patient brain MRIs to evaluate the state (active or non-active) of brain lesions based on gadolinium enhancement. Odds ratios for diverse otolaryngology symptoms across the EDSS scores and brain lesions were calculated.

Results: Higher EDSS scores were associated with auditory and vestibular symptoms (Odd Ratio (OR): 3.06; p: 0.0003); voice and swallowing symptoms (OR: 6.8; p=0.007); and snoring/sleep apnea (OR: 5.1; p=0.03). Presence of active brain lesions was also associated with auditory and vestibular symptoms (OR: 6.7); voice and swallowing symptoms (OR: 5.7); and snoring/sleep apnea (OR: 5).

Conclusions: The ENT-MS-12 survey instrument standardizes reporting of otolaryngology symptoms in patients with MS and documents association between symptoms and phase of disease in this series. Because ear, nose and throat (ENT)- related symptoms (i.e., sensory symptoms, such as numbness) are under-reported in MS, further investigation is warranted, as such data may improve clinical management of MS.
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http://dx.doi.org/10.1016/j.msard.2020.102660DOI Listing
January 2021

Adverse events in facial plastic surgery: Data-driven insights into systems, standards, and self-assessment.

Am J Otolaryngol 2021 Jan - Feb;42(1):102792. Epub 2020 Oct 24.

Mercy Facial Plastic Surgery, Mercy Health Care, 1965 S. Fremont Avenue, Suite #120, Springfield, MO 65804, United States. Electronic address:

Purpose: Complications in facial plastic surgery can lead to pain, suffering, and permanent harm. Yet, the etiology and outcomes of adverse events are understudied. This study aims to determine the etiology and outcomes of adverse events reported in aesthetic facial plastic surgery and identify quality improvement opportunities.

Material And Methods: A cross-sectional survey analysis was conducted using an anonymous 22-item questionnaire distributed to members of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Participants were queried on demographics, practice type, and adverse events related to aesthetic facial surgeries.

Results: Two hundred fifty-three individuals participated; nearly half of respondents (49.0%) held membership in both AAO-HNS and AAFPRS. Of these, 40.8% of respondents reported at least one adverse event within the past 12 months of practice. A total of 194 adverse events were reported, most commonly related to facelift (n = 59/194, 30.4%), rhinoplasty (n = 55/194, 28.4%), and injection procedures (n = 38/194, 19.6%), with hematoma or seroma being the most commonly described. Most adverse events were self-limited, but approximately 68% resulted in further procedures. Surgeon error or poor judgement (n = 42) and patient non-adherence (n = 18) were the most commonly ascribed reasons for adverse events; 37.1% of participants reported a change in clinical practice after the incident.

Conclusions: Adverse events were not infrequent in facial plastic surgery. Understanding these adverse events can provide impetus for tracking outcomes, standardization, and engagement with lifelong learning, self-assessment, and evaluation of practice performance.
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http://dx.doi.org/10.1016/j.amjoto.2020.102792DOI Listing
October 2020

Tracheostomy During the COVID-19 Pandemic: Comparison of International Perioperative Care Protocols and Practices in 26 Countries.

Otolaryngol Head Neck Surg 2020 Nov 3:194599820961985. Epub 2020 Nov 3.

Department of Otolaryngology-Head & Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA.

Objective: The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic.

Data Sources: Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols.

Review Methods: The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management.

Conclusions: Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results.

Implications For Practice: Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.
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http://dx.doi.org/10.1177/0194599820961985DOI Listing
November 2020

Airway obstruction from tracheostomy balloon cuff herniation during oral cancer removal. Emergency successfully managed and lessons learnt from device malfunction.

Oral Oncol 2021 Feb 31;113:105048. Epub 2020 Oct 31.

Otolaryngology- Head and Neck Surgery Department, Santa Croce Hospital AORMN, Fano, Italy.

Objective: Tracheostomy tube cuff balloon herniation is a rare event and can determine airway obstruction. Sometimes the obstruction is not very evident but, if it is not correctly solved, can determine a severe hypoxia with patient's death.

Material And Methods: We present a 49-year-old male patient, with cT4aN0M0 squamous cell carcinoma of the oral cavity, who was admitted to the hospital for definitive surgical resection. Due to mass an endo-oral intubation was not possible, so a surgical tracheotomy was performed. General anaesthesia was induced with Propofol (2 mg/kg) and Fentanil (1 mcg/kg) without gas. Surgery commenced via a trans-oral and trans-cervical approach, but it was halted after approximately 2 min as oximetry demonstrated a progressive fall from 98% to 78%. After confirmation of correct function of anaesthetic devices, the endotracheal cannula was tested; although surgeon deflated the tube cuff, repositioned the tube, and re-inflated the cuff, oxygen saturation did not change. So, the cannula was changed and patient's saturation increased up to normal value.

Results: The balloon cuff of the cannula showed a herniation, responsible of insufficient ventilation.

Conclusions: Cuff herniation should be considered in case of unexpected airway obstruction, and a systematic, rapid approach to investigation and management should ensure timely identification and correction.
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http://dx.doi.org/10.1016/j.oraloncology.2020.105048DOI Listing
February 2021

Comment on Tracheotomy in Ventilated Patients with COVID-19: Is it Time to Rethink Timing?

Ann Surg 2020 Jul 14. Epub 2020 Jul 14.

Department of Otolaryngology - Head & Neck Surgery, University of Michigan Medical School, Ann Arbor, MI Interventional Pulmonology, Johns Hopkins University, Baltimore, MD Department of Surgery, University of Michigan Medical School, Ann Arbor, MI Department of Surgery, Department of Anesthesiology / Critical Care Medicine, Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD.

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http://dx.doi.org/10.1097/SLA.0000000000004220DOI Listing
July 2020

Oral Intubation Attempts in Patients With a Laryngectomy: A Significant Safety Threat.

Otolaryngol Head Neck Surg 2020 Oct 13:194599820960728. Epub 2020 Oct 13.

American Board of Otolaryngology-Head and Neck Surgery, Houston, Texas, USA.

It is impossible to secure the airway of a patient with "neck-only" breathing transorally or transnasally. Surgical removal of the larynx (laryngectomy) or tracheal rerouting (tracheoesophageal diversion or laryngotracheal separation) creates anatomic discontinuity. Misguided attempts at oral intubation of neck breathers may cause hypoxic brain injury or death. We present national data from the American Academy of Otolaryngology-Head and Neck Surgery, the American Head and Neck Society, and the United Kingdom's National Reporting and Learning Service. Over half of US otolaryngologist respondents reported instances of attempted oral intubations among patients with laryngectomy, with a mortality rate of 26%. UK audits similarly revealed numerous resuscitation efforts where misunderstanding of neck breather status led to harm or death. Such data underscore the critical importance of staff education, patient engagement, effective signage, and systems-based best practices to reliably clarify neck breather status and provide necessary resources for safe patient airway management.
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http://dx.doi.org/10.1177/0194599820960728DOI Listing
October 2020

Prioritizing Diversity in Otolaryngology-Head and Neck Surgery: Starting a Conversation.

Otolaryngol Head Neck Surg 2021 02 13;164(2):229-233. Epub 2020 Oct 13.

America Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia, USA.

Academic centers embody the ideals of otolaryngology and are the specialty's port of entry. Building a diverse otolaryngology workforce-one that mirrors society-is critical. Otolaryngology continues to have an underrepresentation of racial and ethnic minorities. The specialty must therefore redouble efforts, becoming more purposeful in mentoring, recruiting, and retaining underrepresented minorities. Many programs have never had residents who are Black, Indigenous, or people of color. Improving narrow, leaky, or absent pipelines is a moral imperative, both to mitigate health care disparities and to help build a more just health care system. Diversity supports the tripartite mission of patient care, education, and research. This commentary explores diversity in otolaryngology with attention to the salient role of academic medical centers. Leadership matters deeply in such efforts, from culture to finances. Improving outreach, taking a holistic approach to resident selection, and improving mentorship and sponsorship complement advances in racial disparities to foster diversity.
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http://dx.doi.org/10.1177/0194599820960722DOI Listing
February 2021

Multidisciplinary Safety Recommendations After Tracheostomy During COVID-19 Pandemic: State of the Art Review.

Otolaryngol Head Neck Surg 2020 Sep 22:194599820961990. Epub 2020 Sep 22.

Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA; Global Tracheostomy Collaborative, Raleigh, North Carolina, USA.

Objective: In the chronic phase of the COVID-19 pandemic, questions have arisen regarding the care of patients with a tracheostomy and downstream management. This review addresses gaps in the literature regarding posttracheostomy care, emphasizing safety of multidisciplinary teams, coordinating complex care needs, and identifying and managing late complications of prolonged intubation and tracheostomy.

Data Sources: PubMed, Cochrane Library, Scopus, Google Scholar, institutional guidance documents.

Review Methods: Literature through June 2020 on the care of patients with a tracheostomy was reviewed, including consensus statements, clinical practice guidelines, institutional guidance, and scientific literature on COVID-19 and SARS-CoV-2 virology and immunology. Where data were lacking, expert opinions were aggregated and adjudicated to arrive at consensus recommendations.

Conclusions: Best practices in caring for patients after a tracheostomy during the COVID-19 pandemic are multifaceted, encompassing precautions during aerosol-generating procedures; minimizing exposure risks to health care workers, caregivers, and patients; ensuring safe, timely tracheostomy care; and identifying and managing laryngotracheal injury, such as vocal fold injury, posterior glottic stenosis, and subglottic stenosis that may affect speech, swallowing, and airway protection. We present recommended approaches to tracheostomy care, outlining modifications to conventional algorithms, raising vigilance for heightened risks of bleeding or other complications, and offering recommendations for personal protective equipment, equipment, care protocols, and personnel.

Implications For Practice: Treatment of patients with a tracheostomy in the COVID-19 pandemic requires foresight and may rival procedural considerations in tracheostomy in their complexity. By considering patient-specific factors, mitigating transmission risks, optimizing the clinical environment, and detecting late manifestations of severe COVID-19, clinicians can ensure due vigilance and quality care.
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http://dx.doi.org/10.1177/0194599820961990DOI Listing
September 2020