Utility of Smartphone Telemedical Consultations for Peritonsillar Abscess Diagnosis and Triage.

Importance: Telemedicine is rapidly gaining traction as a way to reduce costs and connect patients with medical experts outside their local communities. Peritonsillar abscess (PTA) is a logical pathologic condition to evaluate for effectiveness of remote diagnosis given its prevalence and the paucity of on-site otolaryngologists at many institutions. Objective: To explore the potential of otolaryngology telemedical consultation in triaging and diagnosing patients with suspected PTA. Design, Setting, and Participants: A comparative effectiveness research study was conducted from January 1 to June 30, 2018, at 3 tertiary care hospitals among 31 consecutive patients aged 18 to 85 years for whom the otolaryngology department was consulted to assess for PTA. Statistical analysis was conducted from July 1 to September 30, 2018. Interventions: Telemedical evaluation of suspected PTA by 5 attending otolaryngologists blinded to patients' history aside from the chief report of odynophagia. Otolaryngologists rated each patient video on whether they believed the patient had a PTA and whether the case warranted prompt evaluation by an otolaryngologist. Predictions were compared with the criterion standard of drainage or negative needle aspiration. Otolaryngologists additionally assessed video quality. Main Outcomes and Measures: Rates of accurate diagnosis and triage of PTA based on otolaryngologists' review of oropharyngeal examinations recorded using standard smartphone cameras, as well as percentage of videos of oropharyngeal examinations using standard smartphone cameras deemed of sufficiently high quality for clinical decision-making. Results: A total of 31 patients (16 women [51.6%]; mean age, 31.9 years [range, 18-62 years]) were recruited, and 16 patients (51.6%) had a PTA. Comparing otolaryngologists' predictions with PTA status by the criterion standard, the prediction was consistent with that of the criterion standard 81% of the time averaged across otolaryngologists (mean diagnostic accuracy, 0.81). Similarly, the mean diagnostic accuracy was 0.83 when comparing the otolaryngologist's suggestion for a prompt in-person evaluation with actual PTA status by the criterion standard. Comparing patients who were deemed to require prompt otolaryngology evaluation and those with PTA by the criterion standard, mean sensitivity was 90%. Videos were rated as of sufficiently high quality to make a diagnosis in 154 of 155 videos (99.4%). Conclusions and Relevance: This study suggests that telemedical consultation is a viable, cost-conscious, efficient, and safe approach to PTA management. Despite having some difficulty diagnosing PTAs based on "history concerning for PTA" and oropharyngeal video alone, otolaryngologists are able to determine, with high sensitivity, which patients require prompt otolaryngology evaluation. The recording of consistently high-quality video using a standard smartphone camera is achievable without formal training.

Analysis of Cervical Angle in the Submental Muscular Medialization and Suspension Procedure.

IMPORTANCE: The submental muscular medialization and suspension (SMMS) procedure is an option for addressing an obtuse cervical angle in select patients vs the use of traditional rhytidectomy techniques. OBJECTIVE: To compare the change in position of the cervical point between groups undergoing SMMS vs the traditional rhytidectomy technique. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review was performed of 141 patients undergoing rhytidectomy in an accredited private surgery center between January 1, 2013, and December 31, 2014, comparing cervical point depth between patients undergoing SMMS vs those undergoing traditional rhytidectomy with platysma plication. Statistical analysis was performed from November 11, 2017, to January 5, 2018. INTERVENTIONS: Patients underwent either SMMS or traditional rhytidectomy with platysma plication. MAIN OUTCOMES AND MEASURES: The primary end point was change in the cervical point distance between preoperative and postoperative standardized profile photos. RESULTS: A total of 141 patients were included in the analysis. A cohort of 46 patients (43 women and 3 men; mean age, 63.5 years [range, 49.0-79.0 years]) underwent neck contouring with the SMMS technique and a cohort of 95 patients (90 women and 5 men; mean age, 61.0 years [range, 48.0-73.0 years]) underwent traditional rhytidectomy with platysmaplasty. The cervical point distance of the SMMS cohort had a mean (SD) postoperative increase of 2.0 (1.05) cm (95% CI, 1.73-2.28; P < .001) compared with 0.78 (0.82) cm in the traditional rhytidectomy cohort (95% CI, 0.54-1.02; P < .001). CONCLUSIONS AND RELEVANCE: The results of this study suggest that submental muscular medialization and suspension appears to be an effective option to address the obtuse neck in select patients. LEVEL OF EVIDENCE: 3.

Hemifacial spasm secondary to middle ear cholesteatoma.

Hemifacial spasm is a peripheral myoclonus of the VIIth cranial nerve that is characterized by paroxysmal contraction of the muscles of facial expression. It exists in both primary and secondary forms. In rare cases, hemifacial spasm is caused by middle ear pathology. We describe the case of a 90-year-old man with recurrent cholesteatoma and tympanic segment fallopian canal dehiscence manifesting as right-sided hemifacial spasm. His history was significant for a right-sided tympanomastoidectomy for cholesteatoma 6 years earlier. Computed tomographic angiography performed to look for vascular compression of the facial nerve demonstrated a right middle ear opacification. Middle ear exploration revealed a completely dehiscent tympanic segment with cholesteatoma abutting the facial nerve. The overlying keratin debris and matrix were carefully dissected off, and facial nerve function was preserved. The final diagnosis was hemifacial spasm. During 14 months of postoperative follow-up, the patient experienced no further facial spasm.

Manipulation of the Periorbital Musculature.

The resting and expressive states of the periorbital region contribute to perceived age, emotion, gender, race, and countenance. A thorough understanding of the periorbital musculature is essential for comprehensive facial rejuvenation. Surgical and nonsurgical manipulation of these muscles can lead to alterations in brow elevation, resting brow position, and dynamic periorbital rhytids. Both surgical and nonsurgical techniques can produce desired effects, and they are often used concomitantly to obtain optimal results.

Use of the outreach distal access catheter as an intracranial platform facilitates coil embolization of select intracranial aneurysms: technical note.

OBJECTIVE: The Outreach distal access catheter (DAC; Concentric Medical, Mountain View, California, USA) has been designed to assist the Merci device (Concentric Medical) with clot retrieval in the setting of acute stroke. Its application for coil embolization of intracranial aneurysms was investigated. METHODS: Between December 2008 and January 2010, 150 aneurysms were treated with endovascular methods. In 18 cases of small aneurysms and/or increased parent vessel tortuosity, the DAC was used for additional support. Merits and complications related to the use of this catheter are reviewed. RESULTS: The mean aneurysm size was 7.1 mm (range 3.5-25). In each case, the DAC was used as an intracranial platform catheter in close proximity to the target aneurysm. This catheter (outer diameter 3.9 or 4.3 French) increased the stability and reduced the redundancy of the microcatheter. As a result, handling and control of the microcatheter were improved. In three cases, the coiling procedure could not be completed because of difficulties not related to the DAC. Aneurysms in the remaining patients were treated successfully with complete (n=12) or near complete (n=3) angiographic occlusion. CONCLUSION: For smaller or distal intracranial aneurysms with difficult access, use of the DAC as an additional platform in close proximity to the target aneurysm subjectively enhanced microcatheter control and safety.