The profunda artery perforator flap for head and neck reconstruction.

INTRODUCTION: The profunda artery perforator (PAP) fasciocutaneous flap is underutilized in head and neck reconstruction, with advantages including ease of harvest and minimal donor site morbidity. METHODS: Cadaveric dissection of cutaneous perforators to origin at profunda femoris system to characterize vascular anatomy. RESULTS: 22 PAP flaps were studied. Each contained 1-6 cutaneous perforators originating from the profunda system, designated into A, B, or C vascular pedicle systems. Muscular perforators did not consistently extend to skin in systems A and C, but all dissections demonstrated myocutaneous perforator in system B. Average distance from groin crease to cutaneous perforators of A, B, and C respectively was 8 cm (range 3-15 cm), 11.4 cm (range 5-17 cm), and 17.5 cm (range 12.5-22 cm). Average pedicle length was 11.07 cm (range 7-16 cm), 11.78 cm (range 9-16 cm), and 11.23 cm (range 9-15 cm). Average vena comitans diameter at origin was 3.14 mm (range 1.27-4.46 mm). Average arterial diameter at origin was 2.07 mm (range 1.27-3.82 mm). Range of maximal primary closure was 6-11 cm. CONCLUSION: PAP free flap demonstrates reliable vascular anatomy in cadavers, with adequate pedicle length and vessel diameter. All specimens contained adequate myocutaneous perforator to support free tissue transfer.

Nasal Septal Perforation Reconstruction with Polydioxanone Plate: A Systematic Review.

Nasal septal perforation is an uncommon pathology that is difficult to surgically repair and may significantly impact patients' quality of life. Existing treatments have high complication and failure rates. The use of polydioxanone (PDS) plates to repair septal perforations is an innovative approach that has demonstrated superior outcomes to the conventional techniques. This study aimed to review the literature on PDS plates for nasal septal perforation reconstruction. PubMed, OVID Medline, and OVID Embase databases were searched for relevant articles in June 2021. Search terms included nasal septal perforation, polydioxanone, septal perforation, septal repair, nasal septum, and PDS plate. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were adhered to for this systematic review. Database searches yielded 80 articles. Seven articles were included representing 74 patients. All studies reported the use of PDS plates in addition to other materials. They all reported closure rates of at least 80%. The majority of studies reported no postoperative complications. Nasal septal perforation reconstruction with PDS plates is a promising approach that has demonstrated positive outcomes. Further larger studies are required to evaluate the long-term efficacy of using PDS plates on patients with septal perforations.

Operating Room Noise and Team Communication during Facial Plastic and Reconstructive Surgery: A Multicenter Study.

Operating room (OR) noise contributes to team miscommunication. In facial plastic and reconstructive surgery (FPRS), many cases are completed under sedation. This creates a unique environment wherein patients are aware of OR noise. The objectives of this study were to quantify noise and evaluate team members' perspectives on communication inside of FPRS ORs. This study was completed across three surgical institutions. Objective noise measurements were recorded with SoundMeter X. A communication questionnaire was delivered to OR team members following each case. Four hundred and twenty-three noise measurements were recorded during facelift/neck, eye/brow, rhinoplasty, and fat transfer/lip surgeries. The mean and maximum noise levels were 66.1 dB (dB) and 87.6 dB, respectively. Measurements during cases with general anesthetic (221/423, 52.2%) had higher noise measurements (70.3 dB) compared with those with sedation (202/423, 47.8%) (69.7 dB) (p = 0.04). The OR was louder with suction on (72.3 dB) versus off (69.3 dB) (p <0.00). Suction (34.5%) and music (22.4%) were the largest noise contributors according to questionnaire replies. Intraoperative noise, awake patients, and suctions/music may negatively impact FPRS OR communication. Innovation to improve FPRS intraoperative communication should be considered for effective patient care.

Patient Satisfaction following Structural versus Preservation Rhinoplasty: A Systematic Review.

Recently, dorsal preservation rhinoplasty has been gained acceptance among facial plastic surgeons. Despite this, there is limited literature on patient satisfaction following preservation rhinoplasty. This systematic review aims to evaluate all studies quantifying patient satisfaction and to compare results between structural and dorsal preservation rhinoplasty. OVID Medline, EMBASE, and PubMed databases were searched. All studies from the years 2010 to 2020 evaluating satisfaction in patients receiving either structural or dorsal preservation rhinoplasty were included. Data regarding study demographics as well as patient satisfaction results were extracted from included studies. Descriptive results and analysis were calculated. A total of 2,172 articles were initially identified, of which 29 articles were included in the final analysis. Of the 29 articles, 25 were focused on structural rhinoplasty and 4 were focused on preservation rhinoplasty. Of the 25 structural rhinoplasty articles, 17 used the Rhinoplasty Outcome Evaluation (ROE) questionnaire to evaluate patient satisfaction and 5 used the FACE-Q scale. Among the 25 structural rhinoplasty studies, 14 (56%) reported statistically significant improvements in patient satisfaction evaluation scores after rhinoplasty. Among the four preservation rhinoplasty studies, one (25%) study reported significant improvements in satisfaction scores after rhinoplasty. Despite this, most studies included a statement that satisfaction improved in patients following rhinoplasty. Literature in this review supports both structural and preservation rhinoplasty, resulting in high satisfactory results for patients following surgery. More research must be conducted to further quantify satisfaction following preservation rhinoplasty and prospectively compare satisfaction between the two rhinoplasty techniques.

Osseocartilaginous Rib Graft L-Strut for Nasal Framework Reconstruction.

BACKGROUND: In the setting of major nasal framework reconstruction, it is critical to create a stable, warp-resistant L-strut to resist the contractile forces of healing to achieve a durable outcome. OBJECTIVES: The authors sought to demonstrate the effectiveness of the osseocartilaginous rib graft for nasal framework reconstruction. METHODS: Retrospective analysis was performed of all patients who underwent osseocartilaginous rib graft for L-strut reconstruction from 2007 to 2017 at a tertiary care hospital. Only patients with severe framework-only defects (Type IV, Daniel Classification) or total/subtotal nasal defects (Type V, Daniel Classification) were included. Primary outcome measures were: (1) maintenance of projection; (2) graft warping; and (3) graft resorption. RESULTS: Twenty-six patients aged an average of 54.6 years underwent nasal framework reconstruction with an osseocartilaginous rib graft L-strut. Eighteen patients had framework-only deformities (Daniel Type IV) and 8 had total or subtotal nasal deformities (Daniel Type V). Twelve patients underwent reconstruction for autoimmune mediated deformity, 10 for malignancy, 3 for traumatic injury, and 1 for an iatrogenic deformity. Average follow-up was 21 months. There was no observed warping of the L-strut construct, and all but 2 patients demonstrated total maintenance of projection. Resorption of the caudal cartilage graft was identified as the etiology of partial loss of projection in 2 patients. CONCLUSIONS: The osseocartilaginous rib graft L-strut provides a stable, warp-resistant construct for patients lacking major dorsal and caudal support, which may be applied to reconstruction of defects due to malignancy, autoimmune, traumatic, or iatrogenic etiologies.

Perspectives of Facial Plastic Surgeons on Opioid Dependence in Rhinoplasty Patients.

Understanding the perspectives and opinions of facial plastic surgeons on opioid dependence is critical in a national epidemic of opioid overuse. Findings may encourage surgeon education so that facial plastic surgeons may be able to judiciously prescribe opioids, improving patient outcomes and reducing healthcare opioid-related spending. The objective of this study is to understand facial plastic surgeons' perspectives on opioid dependence in rhinoplasty patients. A key secondary objective was to quantify facial plastic surgeons' opioid prescribing patterns. This was a prospective survey study. A nine-question survey was sent to all members of the American Academy of Facial Plastic and Reconstructive Surgery in July of 2018, and analysis of the data was completed in August of 2018. The primary study outcome measurement was surgeon perspectives on opioid dependence. This was measured by an online survey. A total of 164 facial plastic surgeons responded to the survey (response rate: 6.6%). The majority were experienced surgeons in practice for more than 10 years (61.96%) who perform less than five rhinoplasties per week (84.15%). Of the facial plastic surgeons, 89.51% prescribe some variation of opioids following rhinoplasty. Most surgeons believe that opioid dependence is not a problem in rhinoplasty patients (86.96%), but that it is a problem among surgical patients in general (61.11%). The majority (52.45%) of surgeons prescribe between 11 and 25 tablets of opioids following rhinoplasty, with 25.17% of surgeons prescribing > 25 tablets of opioids. Facial plastic surgeons do not believe opioid dependence to be a problem among rhinoplasty patients. Resultantly, many facial plastic surgeons can prescribe more than 25 tables of opioids following rhinoplasty. The findings suggest that facial plastic surgeons may require further education and complete more research regarding opioid dependence among the rhinoplasty population. Additionally, the findings are important for health policy in that they encourage the creation of rhinoplasty specific opioid prescription guidelines.

Dual-Energy CT Characteristics of Parathyroid Adenomas on 25-and 55-Second 4D-CT Acquisitions: Preliminary Experience.

OBJECTIVE: The objective of this study was to compare the dual-energy computed tomography (CT) characteristics of parathyroid adenomas (PAs), thyroid tissue, and lymph nodes (LNs) and assess whether the spectral information can improve distinction of these tissues. METHODS: Dual-energy CT scans from 20 patients with pathologically proven PAs were retrospectively evaluated, identifying 19 eligible PAs and region of interest analysis used for spectral characterization. RESULTS: There was a significant difference in multiple spectral parameters between PAs, LNs, and the thyroid gland (P < 0.05-0.0001). The greatest difference in spectral characteristics of PAs compared with that of LNs was on the 25-second acquisition, whereas the 55-second acquisition was better for distinguishing PAs from the thyroid gland. CONCLUSIONS: Four-dimensional CT acquired in dual-energy CT mode has the potential to further enhance diagnostic accuracy for PA identification on individual phases of the perfusion study.

Quantifying the Ototoxicity of Mitomycin: Before versus after Myringotomy.

OBJECTIVES: Recent research has focused on mitomycin C (MMC) application as a means to circumvent complications that arise when using ventilation tubes during myringotomy. This study has two aims: (1) to synergize the current literature to create a standardized clinical approach for using MMC, and (2) to determine at which point during the myringotomy the application of MMC proves the safest (i.e., before or after incision). METHODS: We measured the auditory brainstem response (ABR) and distortion product otoacoustic emissions (DPOAE) in 9 female chinchillas to determine whether applying MMC before or after incision was also the safest. The tests were then repeated on days 3, 10 and 17. RESULTS: The change in the ABR thresholds from baseline was greater in the experimental than in the control group; however, after stratification, the 'after' group experienced a statistically significant change (19.38 ± 8.26) on day 17, whereas the 'before' group did not (2.00 ± 3.26; p = 0.003). No such changes were seen with DPOAE testing. CONCLUSIONS: Mitomycin is less ototoxic to the middle ear when applied before myringotomy is done. We recommend future studies to apply the clinical approach we have designed to standardize its use in selected cases.

Modalities of Post-Rhinoplasty Edema and Ecchymosis Measurement: A Systematic Review.

Background: Post-rhinoplasty edema and ecchymosis can influence patient satisfaction with surgery as well as result in poor quality of life. Methods to quantify such edema and ecchymosis have been described in the literature. Despite this, there is currently no collective understanding of which methods are the most effective. Hence, this systematic review aims to describe and analyze the literature on post-rhinoplasty edema and ecchymosis measurement techniques. Methods: Standard bibliographic databases (OVID Medline, EMBASE, and PubMed) were searched from their inception to December 2019 for the terms: "rhinoplasty", "postoperative", "edema", and "ecchymosis". Descriptive analysis was completed. Results: The search revealed 1116 articles of which 33 met inclusion criteria and were included for qualitative synthesis. A total of 1801 patients from all studies were included. Of the 33 included studies, there were 57 unique ecchymosis/edema measurements. The majority of studies measured edema/ecchymosis on post-operative day 1, 2, 3 and 7. Ninety-three percent of measurements described were taken subjectively from a human rater. Other techniques described included magnetic resonance imaging, ultrasound, 3-dimensional imaging, and digital analysis. Less than half of the subjective ecchymosis/edema gradings were completed by a blinded rater. Conclusion: There are a wide variety of post-rhinoplasty edema and ecchymosis techniques being used by rhinoplasty surgeons. The majority of post-rhinoplasty edema and ecchymosis measurements are completed by unblinded subjective raters. It is important that facial plastic surgeons select an accurate measurement tool so they may be able to initiate precise patient-specific management of edema and ecchymosis.

Historique: L'œdème et les ecchymoses après une rhinoplastie peuvent nuire à la satisfaction du patient envers l'opération et entraîner une mauvaise qualité de vie. Les publications contiennent des méthodes pour les quantifier. Pourtant, il n'y a actuellement aucune compréhension collective de la méthode la plus efficace. La présente analyse systématique vise à décrire et à analyser les publications sur les techniques de mesure de l'œdème et des ecchymoses après une rhinoplastie. Méthodologie: Les chercheurs ont fouillé les bases de données bibliographiques standards (OVID Medline, EMBASE et PubMed) à compter de leur création jusqu'à décembre 2019 au moyen des termes rhinoplasty, postoperative, edema et ecchymosis. Ils ont procédé à l'analyse descriptive. Résultats: La recherche a permis d'extraire 1 116 articles, dont 33 respectaient les critères d'inclusion et ont servi à la synthèse qualitative. Au total, 1 801 patients de toutes les études ont été retenus. Les 33 articles étudiés contenaient 57 mesures différentes des ecchymoses et de l'œdème. Dans la majorité des études, la mesure de l'œdème et des ecchymoses avait lieu le premier, le deuxième, le troisième et le septième jour après l'opération. Par ailleurs, 93% des mesures décrites avaient été prises de manière subjective par un évaluateur humain. Parmi les autres techniques décrites, soulignons l'imagerie par résonance magnétique, l'échographie, l'imagerie tridimensionnelle et l'analyse numérique. Moins de la moitié des évaluations subjectives des ecchymoses et de l'œdème avait été effectuée par un évaluateur en insu. Conclusion: Les chirurgiens spécialisés en rhinoplastie recourent à une vaste gamme de techniques pour mesurer l'œdème et les ecchymoses après une rhinoplastie. La majeure partie de ces mesures est effectuée par des évaluateurs subjectifs sans insu. Il est important que les chirurgiens faciaux choisissent un outil de mesure précis pour pouvoir entreprendre une prise en charge de l'œdème et des ecchymoses adaptée au patient.

Postoperative Ecchymosis and Edema After Creation of Subperiosteal Tunnels in Rhinoplasty: A Randomized Clinical Trial.

IMPORTANCE: Periorbital ecchymosis and edema are commonly associated with rhinoplasty and are the principal limiting factors for return to daily activities after rhinoplasty. Several methods have been evaluated to minimize these sequelae including creation of subperiosteal tunnels, which involves elevating the vascular periosteal layer, preserving it from trauma when creating osteotomies. OBJECTIVE: To assess the efficacy of the creation of subperiosteal tunnels prior to lateral osteotomies during rhinoplasty for reducing postoperative ecchymosis and edema. DESIGN, SETTING, AND PARTICIPANTS: A randomized, blinded, matched-paired, prospective, clinical trial took place between April 1 and August 30, 2015, in a private practice in a stand-alone clinic and surgical center. All patients who were undergoing aesthetic rhinoplasty requiring bilateral lateral osteotomies were offered inclusion in the trial. All 34 enrolled patients completed the follow-up requirements. INTERVENTION: Creation of subperiosteal tunnels prior to lateral osteotomies on 1 randomly selected side. MAIN OUTCOMES AND MEASURES: Three blinded evaluators independently graded the degree of ecchymosis and edema on a visual analog scale of 0 to 10 on each side of the nose on postoperative days 2 and 7. Each patient had 1 side that was randomly selected to undergo creation of subperiosteal tunnels. A difference in mean score between sides of the nose was calculated for each patient using a paired t test. RESULTS: Of the 34 patients (28 females and 6 males; mean [SD] age, 27.3 [9.2]), the mean (SD) difference in ecchymosis scores between sides on day 2 was -0.05 (1.94) (95% CI, -0.43 to 0.33) and on day 7 was -0.22 (1.23) (95% CI, -0.47 to 0.02), favoring the side without tunnels. The mean (SD) difference in edema scores on day 2 was -0.21 (1.66) (95% CI, 0.53-0.12) and on day 7 was -0.29 (1.11) (95% CI, -0.51 to -0.07). There were no clinically significant differences between sides in terms of postoperative ecchymosis and edema. CONCLUSIONS AND RELEVANCE: Ecchymosis and edema can have significant postoperative practical, emotional, and financial effects on patients. Creation of subperiosteal tunnels prior to lateral osteotomies showed no clinically significant differences in edema and ecchymosis after the procedure. LEVEL OF EVIDENCE: 1. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN42741475.

Combination of polyetherketoneketone scaffold and human mesenchymal stem cells from temporomandibular joint synovial fluid enhances bone regeneration.

Therapies using human mesenchymal stem cells (MSCs) combined with three-dimensional (3D) printed scaffolds are a promising strategy for bone grafting. But the harvest of MSCs still remains invasive for patients. Human synovial fluid MSCs (hSF-MSCs), which can be obtained by a minimally invasive needle-aspiration procedure, have been used for cartilage repair. However, little is known of hSF-MSCs in bone regeneration. Polyetherketoneketone (PEKK) is an attractive bone scaffold due to its mechanical properties comparable to bone. In this study, 3D-printed PEKK scaffolds were fabricated using laser sintering technique. hSF-MSCs were characterized and cultured on PEKK to evaluate their cell attachment, proliferation, and osteogenic potential. Rabbit calvarial critical-sized bone defects were created to test the bone regenerative effect of PEKK with hSF-MSCs. In vitro results showed that hSF-MSCs attached, proliferated, and were osteogenic on PEKK. In vivo results indicated that PEKK seeded with hSF-MSCs regenerated twice the amount of newly formed bone when compared to PEKK seeded with osteogenically-induced hSF-MSCs or PEKK scaffolds alone. These results suggested that there was no need to induce hSF-MSCs into osteoblasts prior to their transplantations in vivo. In conclusion, the combined use of PEKK and hSF-MSCs was effective in regenerating critical-sized bone defects.

Three-dimensionally printed polyetherketoneketone scaffolds with mesenchymal stem cells for the reconstruction of critical-sized mandibular defects.

OBJECTIVE: Additive manufacturing offers a tailored approach to tissue engineering by providing anatomically precise scaffolds onto which stem cells and growth factors can be supplied. Polyetherketoneketone (PEKK), an ideal candidate biomaterial, is limited by a poor implant-bone interface but can be functionalized with adipose-derived stem cells (ADSC) to promote integration. This in vivo study examined the interaction of a three-dimensional printed PEKK/ADSC implant within the critical-sized mandibular defect in a rabbit model. STUDY DESIGN/METHODS: Trapezoidal porous scaffolds with dimensions of 1.5 × 1.0 × 0.5 cm were printed using selective laser sintering. ADSCs were seeded on the scaffolds that were then implanted in marginal defects created in New Zealand rabbits. Rabbits were euthanized at 10- and 20-week intervals. Microcomputed tomography was used to characterize bone ingrowth and was correlated with histological analysis. Stress testing was performed on the scaffolds before and after implantation. RESULTS: All scaffolds were well integrated into adjacent bone. Bone-to-tissue volume increased from 30.34% ( ± 12.46) to 61.27% ( ± 8.24), and trabecular thickness increased from 0.178 mm ( ± 0.069) to 0.331 mm ( ± 0.0306) in the 10- and 20-week groups, respectively, compared to no bone regrowth on the control side (P < 0.05). Histology confirmed integration at the bone-implant interface. Biomechanical testing revealed a compressive resistance 15 times that of bone alone (P < 0.05) CONCLUSION: 3D-printed PEKK scaffolds combined with ADSCs present a promising solution to improve the bone-implant interface and increase the resistance to forces of mastication after mandibular reconstruction. LEVEL OF EVIDENCE: NA. Laryngoscope, 127:E392-E398, 2017.

Three-Dimensional Printed Scaffolds with Multipotent Mesenchymal Stromal Cells for Rabbit Mandibular Reconstruction and Engineering.

Multipotent mesenchymal stromal cells (MSC) derived from both the bone marrow and adipose tissue possess the ability to differentiate into multiple cell lineages, regulate the immune function by secreting numerous bioactive paracrine factors, and hold great potential in cell therapy and tissue engineering. When combined with three-dimensional (3D) scaffolds, MSC can be used for bone defect reconstruction and engineering. This protocol describes the isolation of bone marrow mesenchymal stromal cells (BMMSC) and adipose-tissue derived stem cells (ADSC) from rabbits for subsequent seeding on tissue-engineered 3D-printed scaffolds and transplantation into a rabbit-model with the goal of repairing large osseous mandibular defects (one quarter of the lower jaw is removed surgically). Steps to demonstrate the three cell differentiation lineage potentials of BMMSC and ADSC into osteocytes, adipocytes, and chondrocytes are described. A modified cell seeding method using syringes on scaffold is detailed. Creating a large mandibular bone defect, the rapid prototyping method to print a customized 3D-scaffold, the scaffold implantation procedure in rabbits, and microcomputed tomography (micro-CT) analysis are also described.

The use of a modified abbé island flap to reconstruct primary lip defects of over 80.

BACKGROUND: Lip reconstruction for defects greater than 80 % present a challenge in maintaining acceptable oral function and good aesthetic results. Abbé flaps offer an excellent reconstructive option but are limited to defects under 65 %. METHODS: We describe a two-stage "modified Abbé island flap" technique whereby a full-thickness myocutaneous flap is combined with a modified Karapandzic flap, allowing for reconstruction of total and near total lip defects. RESULTS: Six patients underwent successful two-stage lower and upper lip reconstruction with this technique. Oral competence and satisfactory aesthetic outcomes were achieved in all six cases. There were no complications. Although microstomia was noted to a certain extent, we argue this impact to be less than the morbidity of a free flap that lacks sphincteric function. CONCLUSION: The "Modified Abbé Island Flap" can be used to reconstruct near-total lip defects using locally innervated, well-vascularized tissues that recreate the oral sphincter and restore oral competence. The combination of the conventional Abbé flap with a modified Karapandzic flap provides reliable results and significantly reduces operating time.

Improving PEEK bioactivity for craniofacial reconstruction using a 3D printed scaffold embedded with mesenchymal stem cells.

OBJECTIVE: Polyetheretherketone (PEEK) is a bioinert thermoplastic that has been investigated for its potential use in craniofacial reconstruction; however, its use in clinical practice is limited by a poor integration with adjacent bone upon implantation. To improve the bone-implant interface, two strategies have been employed: to modify its surface or to impregnate PEEK with bioactive materials. This study attempts to combine and improve upon the two approaches by modifying the internal structure into a trabecular network and to impregnate PEEK with mesenchymal stem cells. Furthermore, we compare the newly designed PEEK scaffolds' interactions with both bone-derived (BMSC) and adipose (ADSC) stem cells. DESIGN: Customized PEEK scaffolds were designed to incorporate a trabecular microstructure using a computer-aided design program and then printed via selective laser sintering (SLS), a 3D-printing process with exceptional accuracy. The scaffold structure was evaluated using microCT. Scanning electron microscopy (SEM) was used to evaluate scaffold morphology with and without mesenchymal stem cells (MSCs). Adipose and bone marrow mesenchymal cells were isolated from rats and cultured on scaffolds. Cell proliferation and differentiation were assessed using alamarBlue and alkaline phosphatase assays, respectively. Cell morphology after one week of co-culturing cells with PEEK scaffolds was evaluated using SEM. RESULTS: SLS 3D printing fabricated scaffolds with a porosity of 36.38% ± 6.66 and density of 1.309 g/cm(2). Cell morphology resembled viable fibroblasts attaching to the surface and micropores of the scaffold. PEEK scaffolds maintained the viability of both ADSCs and BMSCs; however, ADSCs demonstrated higher osteodifferentiation than BMSCs (p < 0.05). CONCLUSIONS: This study demonstrates for the first time that SLS 3D printing can be used to fabricate customized porous PEEK scaffolds that maintain the viability of adipose and bone marrow-derived MSCs and induce the osteodifferentiation of the adipose-derived MSCs. The combination of 3D printed PEEK scaffolds with MSCs could overcome some of the limitations using PEEK biopolymers for load-bearing bone regeneration in craniofacial reconstruction.

3-phase dual-energy CT scan as a feasible salvage imaging modality for the identification of non-localizing parathyroid adenomas: a prospective study.

OBJECTIVES: Accurate pre-operative imaging of parathyroid adenomas (PAs) is essential for successful minimally invasive surgery; however, rates of non-localizing PAs can be as high as 18 %. Multiphasic dual-energy CT (DECT) has the potential to increase accuracy of PA detection by enabling creation of paired material maps and spectral tissue characterization. This study prospectively evaluated the utility of 3-phase DECT for PA identification in patients with failed localizatio n via standard imaging. METHODS: Patients with primary hyperparathyroidism and non-localizing PAs underwent a 3 phase post-contrast DECT scan acquired at 25, 55, and 85 s. The scans were prospectively evaluated by two head and neck radiologists. Pre-operative localization was compared to intraoperative localization and final histopathology. A post-hoc DECT spectral density characterization was performed on pathologically-proven PAs. RESULTS: Out of 29 patients with primary hyperparathyroidism and non-localized PAs, DECT identified candidates in 26. Of the 23 patients who underwent parathyroidectomy, DECT provided precise anatomic localization in 20 patients (PPV = 87.0%), one with multi-gland disease. The virtual unenhanced images were not found to be useful for diagnosis but successful diagnosis was made without an unenhanced phase regardless. Spectral analysis demonstrated a distinct spectral Hounsfield attenuation curve for PAs compared to lymph nodes on arterial phase images. CONCLUSION: 3-phase DECT without an unenhanced phase is a feasible salvage imaging modality for previously non-localizing parathyroid adenomas. Optimal interpretation is achieved based on a combination of perfusion characteristics and other morphologic features. Advanced spectral DECT analysis has the potential for further increasing accuracy of PA identification in the future.

Evaluating the timing of injection laryngoplasty for vocal fold paralysis in an attempt to avoid future type 1 thyroplasty.

OBJECTIVES: To determine whether immediate (less than 3 months from time of nerve injury), early (from 3 to 6 months from time of nerve injury) or late (more than 6 months from time of nerve injury) vocal fold injection influences the long-term outcomes for patients with permanent unilateral vocal fold paralysis. METHODS: A total of 250 patients with documented unilateral vocal fold paralysis were identified in this retrospective chart review. 66 patients met the inclusion criteria, having undergone awake trancervical injection with gelfoam™, collagen, perlane™ or a combination. Patients with documented recovery of vocal fold mobility, or patients with less than one year of follow-up after the onset of paralysis were excluded. Patients were stratified into immediate (<3 months), early (3-6 months) and late (>6 months) groups denoting the time from suspected injury to injection. The need for open surgery as determined by a persistently immobile vocal fold with insufficient glottic closure following injection was the primary outcome. RESULTS: 1 out of 21 (4.8%) in the immediate group, 2 out of 17 (11.8%) in the early group and 20 out of 28 (71.4%) in the late group required type 1 thyroplasty procedures to restore glottic competence. There was significance when comparing late injection to both early and immediate injection (p < 0.001). No statistically significant differences were seen when comparing the number of injections needed to restore glottic competence. CONCLUSIONS: This 10-year longitudinal assessment revealed that early medialization of a permanent paralyzed, abducted vocal fold with a temporary material appears to diminish the likelihood of requiring permanent laryngeal framework surgery.

Assessment of the ototoxicity of docusate sodium (colace) in a guinea pig animal model.

OBJECTIVE: Docusate sodium (Colace) is an off-label ceruminolytic agent used to soften ear wax and relieve ear canal obstruction. At present, its effect on hearing in the presence of tympanic membrane (TM) perforation is not clear. The present study aimed to assess the safety of ototopic docusate sodium on hearing in the presence of TM perforation. STUDY DESIGN: A prospective, randomized, controlled trial in a guinea pig animal model. MATERIALS AND METHODS: Ten guinea pigs underwent bilateral myringotomy. In each animal, one ear received docusate sodium, serving as the experimental ear, and the other received normal saline as the control. Auditory brain response (ABR) was performed at baseline and then 1, 7, and 14 days following the application. RESULTS: At day 14 following application, there was no significant change in ABR thresholds at 8, 12, 16, 20, or 25 kHz. CONCLUSION: In guinea pigs with perforated TMs, docusate sodium does not seem to cause ototoxicity. Future clinical studies are required.

Vitamin D deficiency as a potentially modifiable risk factor for thyroid cancer.

BACKGROUND: Vitamin D, classically involved in calcium homeostasis, has garnered recent interest for its potential role in cancer prevention and therapy. Although few risk factors have been established in the development of well-differentiated thyroid carcinoma, some would argue that no clear modifiable risk factor exists. Our study is one of the first to explore the relationship between vitamin D deficiency and thyroid cancer. METHODS: This retrospective cohort study was done at a university-affiliated thyroid cancer centre. In 2010, 212 patients undergoing thyroidectomy had their preoperative 25-hydroxyvitamin D(3) levels recorded in addition to the final pathologies of their resected thyroid nodule. The patients were stratified based on vitamin D status; vitamin D deficiency (VDD), reflecting levels under the established threshold of 37.5 nmol/L; and vitamin D sufficiency (VDS), reflecting levels above it. The primary outcome of malignancy rate was used to compare the proportion of malignant nodules in the VDD versus the VDS groups. RESULTS: The malignancy rate rises when comparing the VDS and VDD groups, from 37.5 (33 of 88) to 75% (9 of 12), respectively, corresponding to a relative risk of 2.0 (p  =  .03, 95% CI 1.07-2.66). CONCLUSION: This is the first study to demonstrate the inverse relationship between VDD and well-differentiated thyroid carcinoma. Larger prospective studies are needed to replicate these results. Should this happen, VDD may be the first modifiable risk factor for thyroid cancer.