Voice Improvement After Essential Tremor Treatment via Focused Ultrasound and Deep Brain Stimulation.

OBJECTIVES: The primary objective of this study was to determine whether two neurosurgical procedures, deep brain stimulation (DBS) and focused ultrasound (FUS), to treat essential tremor (ET) of the upper limb also reduce vocal tremor (VT) in patients with comorbid dysphonia. METHODS: Twelve patients with ET and concomitant VT scheduled for neurosurgical intervention (FUS or DBS) or returning for follow-up after DBS implantation were assessed. FUS patients were assessed pre- and post-intervention and DBS patients were assessed with the electrodes turned on and off post-implantation. Three voice recordings of a sustained /a/ were obtained for each participant condition. Percent fundamental frequency variability (FFV) was calculated for each recorded sustained vowel. Additionally, blinded expert perceptual VT rating (VTR) was performed to assess subjective changes in tremors. RESULTS: Of the 12 patients, seven underwent unilateral FUS, and five underwent bilateral DBS. Mean FFV without neurosurgical intervention was 18.3%, SD = 7.8 and with neurosurgical intervention was 6.3%, SD = 3.0 (t (70) =8.7, p < 0.001). Mean FFV decreased in the FUS cohort from 22.0%, SD = 7.1 pre-ablation to 6.7%, SD = 2.4 post-ablation (t (40) = 7.7, p < 0.001). Mean FFV also decreased in the DBS cohort from 15.7%, SD = 7.0 to 6.0%, SD = 3.3 when stimulation was turned on (t (28)=5.7 p < 0.001). In the FUS group, mean VTR decreased from 4.0 to 1.4 post-ablation (Z = 7.8, p < 0.001). In the DBS group, mean VTR decreased from 3.3 to 2.1 with stimulation (Z = 4.1, p < 0.001). CONCLUSION: Neurosurgical interventions for ET (bilateral DBS and unilateral FUS) demonstrate acoustic and perceptual benefits for VT. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:367-373, 2024.

Addressing intraarticular pathology at the time of anteverting periacetabular osteotomy for acetabular retroversion is associated with better short-term patient-reported outcomes.

Periacetabular osteotomy (PAO) is effective in the management of developmental dysplasia of the hip and femoroacetabular impingement secondary to acetabular retroversion. During anteverting PAO for acetabular retroversion, the need for both labral treatment and femoral head-neck junction osteochondroplasty remains equivocal. Accordingly, this study evaluated patient-reported outcome measures (PROM) and reoperation rates after anteverting PAO with or without intraarticular intervention. Cases of anteverting PAO performed at a single institution between November 2009 and January 2016 were retrospectively reviewed. Patients were divided into three groups: no intervention and intraarticular intervention with arthrotomy or arthroscopy. Subsequently, patients were reclassified by the intraarticular procedure performed at surgery into major (labral repair, femoral head-neck osteochondroplasty) and minor (labral debridement, femoral/acetabular chondroplasty) groups. The cohort was 75% female, median age was 19.5 years and mean body mass index was 25.0 kg/m2. Preoperative to postoperative improvement was compared to minimal clinically important differences (MCID) for eight PROM. Patients receiving major interventions exceeded MCID in a greater proportion of PROM compared to minor and no intervention groups (P < 0.007); major or minor interventions did not increase the risk of reoperation over no intervention (P ≥ 0.39). Based on the current data, surgeons performing anteverting PAO for acetabular retroversion should perform arthroscopic or open labral repair and assess for impingement after the correction and perform a head-neck junction osteochondroplasty if indicated.

Tönnis Grade 1 dysplastic hips have improved patient-reported outcome scores when intraarticular pathology is treated during periacetabular osteotomy.

It is unclear whether treatment of intraarticular pathology should be performed during periacetabular osteotomy (PAO) to improve outcomes. Therefore, we asked: (i) What are the clinical results of PAO in patients with and without intraarticular intervention? (ii) Is there a difference in reoperations with and without intraarticular intervention? and (iii) Is there a difference in clinical results and reoperations depending on preoperative Tönnis Grade if intraarticular intervention is performed? Prospective evaluation of 161 PAO in 146 patients was performed. The cohort was 84.5% female, mean age was 26.7 ± 7.9 years and mean follow-up was 2.4 years; 112 hips had Grade 0 changes and 49 hips had Grade 1 changes. Patients were classified into three groups based on treatments during PAO: major (labral repair, femoral head-neck osteochondroplasty), minor (labral debridement, femoral/acetabular chondroplasty) or no intervention. A subset of eight patient-reported outcome measures (PROMs) was analyzed to determine whether the minimal clinically important difference (MCID) was achieved. Major, minor and no intervention groups exceeded the MCID in 5, 8 and 8, of 8 PROMs (P ≥ 0.20), respectively; intraarticular interventions did not influence reoperation-free survival (P ≥ 0.35). By Tönnis Grade, PROMs exceeding MCID decreased in Grade 1 versus 0 receiving no intervention (P < 0.001) but did not decrease for either intervention (P ≥ 0.14); intraarticular interventions did not influence reoperation-free survival (P ≥ 0.38). Overall, intraarticular intervention was associated with excellent PROMs and reoperation-free survival. Although Grade 1 patients had fewer PROM which achieved MCID, intraarticular interventions attenuated this decrease, suggesting a therapeutic advantage of intraarticular procedures for more advanced pathology.

The Use of Virtual Reality to Reduce Preoperative Anxiety in First-Time Sternotomy Patients: A Randomized Controlled Pilot Trial.

OBJECTIVE: To report the first randomized controlled trial to investigate if immersive virtual reality (VR) treatment can reduce patient perceptions of anxiety compared with a tablet-based control treatment in adults undergoing a first-time sternotomy. METHODS: Twenty first-time sternotomy patients were prospectively randomized (blinded to investigator) to a control or VR intervention. The VR intervention was a game module "Bear Blast" (AppliedVR) displayed using a Samsung Gear Oculus VR headset. The control intervention was a tablet-based game with comparable audio, visual, and tactile components. The State-Trait Anxiety Inventory was administered before and after the assigned intervention. Self-reported anxiety measures between the control and VR groups were evaluated using an unpaired t test. Changes in self-reported anxiety measures pre- and post-intervention were evaluated with a paired t test for both the control and VR groups. The study took place from May 1, 2017, through January 1, 2019 (Institutional Review Board 16-009784). RESULTS: Both control and VR groups were 90.0% male, with a mean ± SD age of 63.4 ± 9.11 and 69.5 ± 6.9 years, respectively. VR users experienced significant reductions in feeling tense and strained, and significant improvements in feeling calm when compared with tablet controls (P<0.05). They also experienced significant reductions in feeling strained, upset, and tense when compared with their own self-reported anxiety measure pre- and post-intervention (P<0.05). Critically, control patients had no change in these categories. CONCLUSION: Immersive VR is an effective, nonpharmacologic approach to reducing preoperative anxiety in adults undergoing cardiac surgery and shows the validity and utility of this technology in adult patients.

Review of treatment modalities and outcomes of patients with basal cell adenocarcinoma.

PURPOSE: This study summarizes the treatment modalities of basal cell adenocarcinoma (BCAC) of the parotid gland and subsequent outcome at a single institution to better define the treatment of this rare tumor. MATERIAL AND METHODS: A retrospective review of patients treated for BCAC of the parotid gland from 1/01/1996 to 08/1/2018 was performed. Patients were identified using our institution's Cancer Registry. RESULTS: A total of thirteen patients (46% female, median age of 56) treated for BCAC of the parotid gland were identified. Eight patients (57%) were staged as T1, four were staged as T2 (29%), and two were stage T4a (14%) due to tumor involvement of the facial nerve. None of the patients had nodal involvement or distant metastases. Three patients (21%) underwent radiation therapy ranging from 60-70Gy for positive margin or facial nerve involvement by tumor. Five patients (36%) underwent a neck dissection (ND) ranging from just a level IIb dissection up to levels IIa, IIb, and III with none of the nodes being positive for disease. The remainder of patients did not undergo a neck dissection. Follow-up was 8.1 ± 6.2 (mean ± SD) years with no local or regional recurrence at time of last follow-up in any patient cohort. CONCLUSIONS: Our review suggests that elective neck dissections are not necessary following resection of T1/T2N0M0 basal cell adenocarcinoma for the prevention of local or regional recurrence. No longer performing neck dissections for T1/T2N0M0 BCAC would reduce the morbidity associated with the treatment of this rare parotid tumor.

Sinonasal mucosal vasculature in yellow nail syndrome and chronic rhinosinusitis with or without polyps.

BACKGROUND: Lymphatic dysfunction is hypothesized to be an underlying factor in the pathophysiology of yellow nail syndrome (YNS) (yellow nails, lymphedema, pleural effusions, and frequently chronic rhinosinusitis [CRS]). It is unclear why some YNS patients develop CRS. We quantified lymphatic and total vasculature of sinonasal mucosa in YNS patients and compared it to controls from CRS patients with (CRSwNP) or without polyps (CRSsNP). METHODS: Immunohistochemistry was performed on archival sinonasal mucosal samples from 5 patients with YNS and 14 controls with antibodies against podoplanin and CD31, markers of lymphatics. Morphometric assessment was performed on digital images using ImageJ software. RESULTS: In YNS, the number of lymphatics/mm2 ranged from 7 to 18/mm2 (controls: 6 to 43/mm2 , p = 0.343), with a mean perimeter between 92 and 201 µm (controls: 42 to 280 µm, p = 0.482). Total vasculature density was higher than lymphatics, ranging between 189 and 1159 vessels/mm2 , average 669 (controls: 139 to 1467/mm2 , average 503, p = 0.257) with smaller average perimeter, 40 to 117 µm, mean 64.8 µm (controls: 42 to 92 µm, mean 65.3 µm, p = 0.965). Lymphatics constituted only a small fragment of the total vasculature, ranging from 1.15% to 4.76%, average 2.34% (controls: 0.81% to 10.58%, average 4.88%, p = 0.156). CRSwNP patients had significantly higher lymphatic density (p = 0.011) and ratio of lymphatics to total vasculature (p = 0.045) than patients with YNS or CRSsNP. CONCLUSION: This is the first histological analysis of sinus mucosa in patients with YNS. Vascular type, density, size, and distribution in the sinonasal mucosa of YNS patients are not statistically significantly different from those of the CRSsNP group. Lymphatic density and ratio to total vasculature is higher in CRSwNP patients.