Comparison of Running Cutaneous Suture Spacing During Linear Wound Closures

Comment: This paper compares spacing of sutures and found no difference between those placed 2 mm and 5 mm apart. The closures examined were from surgical fusiform wounds. Of course, this is not analogous to the traumatic wounds encountered on call, but is food for thought, especially considering the time involved in placement of very fine sutures with no obvious cosmetic benefit (at least at three months).—Jennifer A. Villwock, MD

What are the outcomes and wound cosmesis achieved with running cutaneous sutures spaced 2 mm vs. 5 mm apart?

Bottom Line: No statistically significant difference in wound cosmesis or total complications were noted between running cuticular sutures spaced 2 mm vs. 5 mm apart. Both suturing techniques resulted in similar cosmetic outcomes and complication rates. Surgeons may want to consider whether the extra time involved in placing very closely spaced cuticular sutures is worthwhile.

Background: Surgeons have varying opinions on the ideal cutaneous suture spacing for optimal cosmetic outcomes. To date, no studies concerning the effect of suture spacing on cosmetic outcomes exist in the literature.

Study design: Randomized clinical trial.

Setting: University of California, Davis dermatology clinic.

Synopsis: The trial was conducted from November 28, 2017, to June 15, 2018. Fifty-six patients 18 years or older with surgical fusiform wounds (from Mohs procedure or surgical excision) on the head or neck with assumed closure lengths of at least 3 cm were screened. Resarchers excluded six patients, enrolled 50 patients, and followed up with 48 patients. Fifty surgical fusiform wounds were randomized to running cuticular closure with 2-mm spacing on half and 5-mm spacing on half. At three months, patients and two masked observers evaluated each scar using the patient and observer scar assessment scale (POSAS). A total of 50 patients (mean [SD] age, 71.1 [11.4] years; 43 [86%] male; 50 [100%] white) were enrolled in the study. The mean (SD) sum of the POSAS observer component scores was 10.7 (4.3) for the 2-mm interval side and 10.8 (3.5) for the 5-mm side at three months. No statistically significant difference was found in the mean (SD) sum of the patient component for the POSAS score between the 2-mm interval side (10.2 [4.7]) and the 5-mm interval side (11.5 [6.4]) at three months. No statistically significant difference was observed in mean (SD) scar width between the 2-mm side (0.9 [0.6] mm) and the 5-mm side (0.8 [0.4] mm).

Citation: Sklar LR, Pourang A, Armstrong AW, et al. Comparison of running cutaneous suture spacing during linear wound closures and the effect on wound cosmesis of the face and neck: a randomized clinical trial [published January 16, 2019 online ahead of print]. JAMA Dermatol. doi: 10.1001/jamadermatol.2018.5057.

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UAS Successful Treatment for OSA When Compared with TORS

How do transoral robotic surgery (TORS) and upper airway stimulation (UAS) compare for treating tongue base obstruction contributing to obstructive sleep apnea (OSA)?

Bottom line: UAS is successful in treating OSA, showing improved outcomes, length of stay, and readmission compared to TORS.

Background: TORS tongue base reduction utilizes robotic instrumentation to perform a lingual tonsillectomy combined with midline glossectomy and supraglottoplasty. With UAS, the hypoglossal nerve is selectively stimulated to induce muscle tone in the upper airway, relieving obstruction and reducing apnea and hypopnea burden; there is also evidence that it improves obstruction at the velum through coupling of the palatoglossus muscle.

Study design: Retrospective review of 100 patients (24 TORS, 76 UAS) from the senior authors’ surgical database who were treated between January 2011 and July 2017.

Setting: Thomas Jefferson University, Philadelphia.

Synopsis: Thirty-seven TORS and 94 UAS were performed. In the TORS cohort, 16 underwent prior OSA surgery; the mean preoperative AHI and O2 desaturation nadir were 35.70 and 80.50, respectively. In the UAS cohort, 14 patients underwent prior OSA surgery; the mean preoperative AHI and O2 desaturation nadir were 36.64 and 80.27, respectively. The mean postoperative AHI and O2 desaturation nadir in the TORS cohort were 20.05 and 84.10, respectively. The surgical success rate, patients who reached an AHI less than 15, and patients who reached and AHI less than 5 were 54.17%, 50.00%, and 20.83%, respectively. The mean postoperative AHI and O2 desaturation nadir of the UAS cohort were 7.20 and 88.77, respectively. Surgical success rate, patients who reached an AHI less than 15, and patients who reached an AHI less than 5 were 86.84, 89.47, and 59.21, respectively. TORS cohort patients had a mean length of hospital stay of 1.33 days; four patients had a 30-day unplanned readmission for dehydration and pain control. All UAS cohort patients underwent ambulatory surgery, and no patients were readmitted to the hospital. There were no major complications in either group. Limitations included a less-direct comparison between UAS and TORS due to the multilevel nature of UAS.

Citation: Huntley C, Topf MC, Christopher V, et al. Comparing upper airway stimulation to transoral robotic base of tongue resection for treatment of obstructive sleep apnea. Laryngoscope. 2019;129:1010–1013.

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Tranexamic Acid Could Decrease Operative Time, Intraoperative Blood Loss in ESS

How effective is systemic tranexamic acid compared to a control in blood loss, operative time, and surgical field and incidence of postoperative emesis and thromboembolism in endoscopic sinus surgery (ESS)?

Bottom line: The systemic administration of tranexamic acid could decrease operative time and intraoperative blood loss, increasing the satisfaction of surgeons. It did not provoke intraoperative hemodynamic instability, postoperative emetic events, or coagulation profile abnormality.

Background: Because the nose and paranasal sinuses are highly vascularized, surgery there may cause significant bleeding, making identification of important anatomic landmarks and structures difficult, increasing intraoperative complication risks and prolonging operating time. Tranexamic acid can decrease intraoperative bleeding. Although it is usually well tolerated, nausea and vomiting are known common side effects, and hypotension has been observed during rapid intravenous administration.

Study design: Literature review of seven studies comprising 562 participants, comparing perioperative tranexamic acid administration (treatment group) with a placebo (control group).

Setting: PubMed, SCOPUS, Embase, the Web of Science, Google Scholar, and the Cochrane database; search results are from their inception to July 2018.

Synopsis: Outcomes of interest were intraoperative morbidities, including surgical time, operative bleeding, and hypotension; postoperative morbidities such as nausea and vomiting; and coagulation profiles. Operative time, intraoperative blood loss, and the surgical field score were statistically lower in the treatment group than in the control group. Surgeon satisfaction was statistically higher in the treatment group than in the control group. There was no significant difference between the groups in intraoperative blood pressure. The incidence of postoperative nausea and vomiting and thrombotic accident showed no significant differences between the groups. Platelet count, prothrombin time, and partial thromboplastin time showed no significant differences between the groups. In sensitivity analyses that evaluated the differences in the pooled estimates by repeating the meta-analyses with a different study omitted each time, all results were consistent with the outcomes previously found. Limitations included a lack of consideration of external factors such as polyps versus no polyps, revision versus primary, and usage of other hemostatic agents because the analysis was performed based on the statistical measurements of the figures.

Citation: Kim DH, Kim S, Kang H, Jin HJ, Hwang SH. Efficacy of tranexamic acid on operative bleeding in endoscopic sinus surgery: a meta-analysis and systematic review. Laryngoscope. 2019;129:800–807.

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Nimodipine May Improve Vocal Fold or Facial Motion After Injury

Is nimodipine effective for neuroprotection following cranial nerve injury?

Bottom line: Nimodipine significantly increased the odds of vocal fold motion and facial recovery after injury.

Background: Nimodipine is a calcium channel blocker that has been used to treat hypertension and vasospasm. Various otolaryngology studies suggest that nimodipine exerts a neuroprotective effect on injured neurons, but the exact mechanism remains unknown and no large, multi-institutional clinical trials exist to investigate its efficacy for treatment of various cranial nerve injuries.

Study design: Literature review of nine studies ranging in date from January 1, 1987, to October 11, 2017.

Setting: PubMed, Embase, CINAHL, Web of Science, Cochrane Central Register of Controlled Trials, Clinical, WHO International Clinical Trials Registry Platform, and EU Clinical Trials Register databases.

Synopsis: Overall, nimodipine-treated patients had significantly higher odds of recovering vocal fold or facial motion compared with controls. Nimodipine efficacy on vocal fold motion recovery following recurrent laryngeal nerve (RLN) injury was assessed in three studies; nimodipine treatment was associated with a statistically significant increase in odds of vocal fold motion recovery at three to six months after RLN injury. Nimodipine efficacy on facial motion recovery following facial nerve injury was assessed in three studies; nimodipine treatment was associated with a statistically significant moderate increase in odds of facial motion recovery at six to 12 months after vestibular schwannoma surgery. The effect of nimodipine on symptoms relating to the cochleovestibular nerve was investigated in three trials, which showed general improvement of patient-reported symptoms of subjective tinnitus and vertigo; study methodology and outcome measures were too heterogeneous to be combined for meta-analysis, however. Of the nine studies, five reported on adverse events associated with nimodipine treatment, with the most common being drowsiness and dizziness, likely secondary to hypotension. Limitations included heterogeneity of some of the studies related to the cochleovestibular nerve.

Citation: Lin RJ, Klein-Fedyshin M, Rosen CA. Nimodipine improves vocal fold and facial motion recovery after injury: a systematic review and meta-analysis.
Laryngoscope. 2019;129:943–951.

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