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The objective of our study was to assess the relationship between postoperative opioid prescribing patterns and opioid consumption among patients who underwent septoplasty or rhinoplasty. A chart review of patients who underwent either septoplasty or rhinoplasty by 3 surgeons between July 2016 and June 2017 was performed, and pertinent clinical data were collected including the amount of narcotic pain medications prescribed. A telephone interview was then conducted to assess opioid usage and pain control regimen postoperatively. The number of opioid tablets prescribed and the number consumed were converted to total morphine milligram equivalent (MME) for uniform comparison. A total of 75 patients met the inclusion criteria, and 64 completed the telephone survey. Among these 64 patients, the mean (standard deviation [SD]) prescribed MME was 289.7 (101.3), and the mean (SD) consumed MME was 100.6 (109). Similarly, the mean (SD) number of opioid tablets prescribed was 42.4 (9.7), and the mean number of tablets consumed was 14.7 (16.3). Gender, procedure performed (septoplasty or rhinoplasty), use of Doyle splints, and surgeon were not associated with the amount of opioids prescribed or used. Subjective pain control was the only factor associated with an increase in opioid use ( P = .0288). There was an overabundance of opioid pain medications prescribed compared to the amount consumed for pain control after septoplasty or rhinoplasty. Abuse of prescription opioids represents an important component of the nation's opioid crisis. Surgeons must be cognizant of the problem and adjust prescribing practices accordingly.

Competing Interests: Conflict of Interest No conflicts of interest.

Objectives/hypothesis: To assess the confidence and abilities of medical students to diagnose specific types of otologic pathology, and to determine how different training experiences in medical school impact these outcomes., Study Design: Survey analysis., Methods: Sixty third- and fourth-year medical students completed a computerized online survey. Participants answered questions about their otoscopic training experience and confidence, and provided diagnoses for 72 digital images taken with a high-definition video otoscope that showed common otologic pathologies of the tympanic membrane and middle ear space., Results: Most participants (65%) had received less exposure to otoscopic training in medical school than they expected. Confidence in diagnostic ability was low. For diagnostic ability, the mean percent correct across pathologies was 54% ± 7.7%. Medical school year (P = .006), intended specialty (P = .022), and total number of otolaryngology rotations (P = .048) were predictive of diagnostic accuracy on univariable logistic regression analyses, but medical school year (P = .039) was the only significant independent predictor in multivariable analysis. Intended specialty (P = .047) and total number of otolaryngology rotations (P = .035) were predictive of prequiz diagnostic confidence on univariable logistic regression analyses., Conclusions: Medical students were not satisfied with their exposure to otoscopic training. Intended specialty, total number of otolaryngology rotations, and year in medical school predicted diagnostic accuracy. Intended specialty and total number of otolaryngology rotations predicted diagnostic confidence. Additional studies are needed to investigate how training experiences can be improved to optimize otoscopy training during medical school., Level of Evidence: NA Laryngoscope, 129:1891-1897, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To assess factors associated with repair of facial dog bites in the emergency department (ED) versus the operating room (OR) and to compare rates of surgical site infection and reoperation for each venue., Study Design: Case series with chart review., Setting: Single institution., Subjects and Methods: All patients younger than 18 years of age who underwent surgical repair by a consulting surgical service within 24 hours of presentation for facial dog bites between 2010 and 2013 were included. Demographics, site of injury, associated evidence of complex injury, surgical site infections within 30 days, and reoperation within 2 years were compared between patients undergoing surgical repair in the ED versus the OR., Results: One hundred sixty-five patients were evaluated; 75 patients underwent repair in the ED, and 90 patients were treated in the OR. Patients treated in the ED underwent surgery more promptly than patients treated in the OR (median time from arrival to procedure start 3.3 vs 6.8 hours, P < .001). Patients treated in the OR were more likely to have longer lacerations (3.0 cm vs 7.8 cm, P < .001), lacerations of the eyelid (17% vs 42%, P = .001), involvement of multiple regions of the face (11% vs 22%, P = .039), and multiple indicators of severe injury (3% vs 12%, P = .024). There were no differences in surgical site infections (1% vs 1%, P = .721) or reoperation rates (5% vs 13%, P = .071)., Conclusions: Surgical management of pediatric facial dog bites may be successfully performed in both the ED and OR settings. Severity of the injury should dictate the choice for management.

Introduction: Dog bite injuries to the face are a serious, yet modifiable public health concern. This study explores the relationship between dog breed and the risk of biting and injury. The objective of this study is to determine the relative risk and severity of dog bite injuries to the face by breed., Methods: Retrospective chart review of facial dog bite injuries presenting to the University of Virginia Health System and Nationwide Children's Hospital. Additionally, descriptive data was collected from 240 patients over the last 15 years. Bite risk by breed was assessed by a literature search from 1970 to current. A composite measure was used to determine the severity of injury, and characterize each patient into an ordinal scale of bite severity. An average of each breed bite rate within each study was calculated and combined to create an empiric bite risk by breed. Dog breeds were also further characterized morphologically., Results: Bite risk by breed from the literature review and bite severity by breed from our case series were combined to create a total bite risk plot. Injuries from Pitbull's and mixed breed dogs were both more frequent and more severe. This data is well-suited for a bubble plot showing bite risk on the x-axis, bite severity on the y-axis, and size of the bubble by number of cases. This creates a "risk to own" graphic for potential dog owners., Conclusions: Breeds vary in both rates of biting and severity. The highest risk breeds had both a high rate of biting and caused significant tissue injury. Physical characteristics can also help determine risk for unknown or mixed dog breeds. Potential dog owners can utilize this data when assessing which breed to own., (Copyright © 2018. Published by Elsevier B.V.)

Objective: To evaluate diagnostic concordance of a synchronous telemedicine otolaryngology clinic with use of currently available technology., Study Design: Prospective., Methods: Patients in a rural otolaryngology clinic were enrolled in a pilot telemedicine clinic. To assess system fidelity, an on-site and remote (consulting) otolaryngologist conducted simultaneous patient evaluations using streaming telecommunication technology for all aspects of the clinical encounter, including high-definition examination and endoscopic images. Both physicians and patients were blinded and diagnoses recorded. Post-encounter physician surveys and an original patient-centered TeleENT Satisfaction Questionnaire (TESQ) were used to assess overall satisfaction., Results: Twenty-one patients were enrolled consecutively. Visual technology was found acceptable in all cases, and audio technology was acceptable in 20 of 21 encounters. Patient satisfaction was 96%, and patients felt comfortable using a telemedicine system in the future. Encounters were not significantly longer than traditional encounters. Physician diagnostic agreement was found in 95% of cases, and the consulting physician indicated that all encounters provided sufficient history, examination, and high-quality images to generate an accurate diagnosis, order additional workup, and/or make an appropriate referral., Conclusion: A synchronous otolaryngology telemedicine clinic is comparable to a standard clinic in terms of diagnostic concordance and patient satisfaction when using streaming technology and high-definition images. Using telemedical technology may be a viable way to increase otolaryngology access in remote or underserved areas. With system validity now established, future studies will assess the feasibility of using trained on-site physician extenders (nurse practitioners or physician assistants) to conduct in-person patient encounters with remote otolaryngologist support., Level of Evidence: 2c. Laryngoscope, 128:1068-1074, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Importance: Traditional facial trauma laboratories are used for teaching basic concepts of fracture reduction and hardware manipulation. Facial trauma simulation laboratories allow training physicians the opportunity to develop unique treatment plans as they would in real patient encounters., Objective: To assess the value of a novel facial trauma simulation course requiring residents to practice advanced decision making., Design, Setting, and Participants: Data were prospectively collected July 23 and August 23 and 24, 2016, in a survey study during a resident physician trauma simulation course. Fresh frozen cadaver heads were fractured using an impactor that applied a measurable amount of force. Each head was scanned with high-resolution computed tomography. Residents were paired and tasked with evaluating their specimen's imaging findings and developing a treatment plan., Main Outcomes and Measures: Before the course, residents were asked their postgraduate year level, number of facial fractures treated as a resident surgeon, and their comfort level based on the Otolaryngology Milestone for Facial Trauma (OMFT; ratings range from 0-5, with 5 indicating equivalent to fellow-level experience). After the course, residents were asked to assess the course's value relative to a theoretical number of actual operative cases, and a posttraining OMFT assessment was obtained., Results: Thirty resident physicians completed the course at 2 institutions. Residents represented an equivalent distribution of postgraduate year levels. The residents stated that the course was worth a mean (SD) of 6.4 (2.8) operative cases of facial trauma in terms of surgical learning. The mean change in self-reported OMFT rating after the course was 0.87 (95% CI, 0.67-1.07; P < .001, paired t test). On the basis of this change in self-perceived OMFT rating, the course was deemed to be worth 1.5 years of residency training in the management of facial fractures., Conclusion and Relevance: Conducting a facial trauma simulation course increases resident experience with advanced surgical decision making., Level of Evidence: NA.

Objective: To determine the clinical impact of an initiative to use ultrasound (US) as the primary diagnostic modality for children with superficial face and neck infections versus use of computed tomography (CT)., Methods: Children with a diagnosis of lymphadenitis, face or neck abscess, or face and neck cellulitis were retrospectively evaluated by the otolaryngology service. Patients were separated into two groups based on implementation of a departmental initiative to use US as the primary diagnostic modality. The pre-implementation cohort consisted of patients treated prior to the initiative (2006-2009) and the current protocol cohort consisted of patients treated after the initiative was started (2010-2013). Demographics, use of US or CT, necessity of surgical intervention, and failure of medical management were compared., Results: Three hundred seventy three children were evaluated; 114 patients were included in the pre-implementation cohort and 259 patients were included in the current protocol cohort for comparison. Patients presenting during the current protocol period were more likely to undergo US (pre-implementation vs. current protocol, p-value) (12% vs. 49%, p < 0.0001) and less likely to undergo CT (66% vs. 41%, p < 0.0001) for their initial evaluation. There were no differences in the percentage of children who underwent prompt surgical drainage, prompt discharge without surgery, or trial inpatient observation. There were also no differences in the rate of treatment failure for patients undergoing prompt surgery or prompt discharge on antibiotics. For those patients who underwent repeat evaluation following trial medical management, US was used more frequently in the current protocol period (4% vs. 20%, p = 0.002) with no difference in CT use, selected treatment strategy, or treatment failure rates., Conclusion: Increased use of US on initial evaluation of children with superficial face and neck infections resulted in decreased CT utilization, without negatively impacting outcome. Decreasing pediatric radiation exposure and potential long-term effects is of primary importance., (Copyright © 2017. Published by Elsevier B.V.)

Background: Current surgical standard of care in sporadic medullary thyroid carcinoma (sMTC) consists of a minimum of total thyroidectomy with central neck dissection. Some have suggested thyroid lobectomy with isthmusectomy and central neck dissection for patients with sMTC, given their lower frequency of bilateral disease, although this topic has not been thoroughly studied. This study assessed the prevalence of multifocality in sMTC via a large international multi-institutional retrospective review to quantify this prevalence, including the impact of geography, to assess more accurately the risks associated with alternative surgical approaches., Methods: A retrospective chart review of sMTC patients from 11 institutions over 29 years (1983-2011) was undertaken. Data regarding focality, extent of disease, RET germline analysis plus family and clinical history for multiple endocrine neoplasia type 2 (MEN2), and demographic data were collected and analyzed., Results: Patients from four continents and seven countries were included in the sample. Data for 313 patients with documented sMTC were collected. Of these, 81.2% were confirmed with negative RET germline testing, while the remaining 18.8% demonstrated a negative family history and no manifestations of MEN2 syndromes other than MTC. Bilateral disease was identified in 17/306 (5.6%) patients, while multifocal disease was noted in 50/312 (16.0%) sMTC patients. When only accounting for germline negative patients, these rates were not significantly different (5.6% and 17%, respectively). Among them, when disease was unifocal in the ipsilateral lobe and isthmus, bilateral disease was present in 6/212 (2.8%) cases. When disease was multifocal in the ipsilateral lobe or isthmus, then bilateral disease was present in 8/37 (21.6%) cases (p < 0.001). No geographic differences in focality were identified., Conclusions: The 5.6% prevalence of bilateral foci in sMTC suggests that total thyroidectomy should remain the standard of care for initial surgery, as less complete thyroid surgery may fail to address fully the primary site of disease. Whether ipsilateral tumor focality should be an independent factor determining the need for completion thyroidectomy when sMTC is diagnosed after hemithyroidectomy remains to be determined.