Lord of the (Magnetic) Rings: Rigid Bronchoscopy for Aspirated Magnetic Foreign Bodies in Tertiary Bronchi.

OBJECTIVES: To describe operative techniques using rigid bronchoscopy and ferromagnetic bronchoscopic equipment to retrieve magnetic foreign bodies in distal tertiary bronchi beyond the reach of traditional optical instrumentation. METHODS: A 13-year-old presented to the Emergency Department following aspiration of three backing magnets from a magnetic nose ring. Chest radiographs demonstrated a 4 mm × 3 mm foreign body in the right lower lobe 0.5 cm from diaphragm on expiratory film. She was taken to the operating room for removal of an airway foreign body. RESULTS: The foreign body was visualized with direct laryngoscopy followed by rigid bronchoscopy in the distal right lower tertiary bronchus. Attempts to pass optical instruments were limited both by distance of the object and size of instrumentation compared to the diameter of the tertiary bronchus. A salivary wire basket and ureteral stone retrieval basket were then passed with endoscopic visualization into the tertiary bronchus but were unable to engage the foreign body. An attempt was made to pass a 2 French Fogarty embolectomy catheter distally, but the catheter was too large to bypass the foreign body. Finally, ferromagnetic pulmonary rat tooth biopsy forceps were advanced into the tertiary bronchus and successfully attracted the magnetic foreign body for safe removal through our rigid bronchoscope. CONCLUSION: We present a novel method of utilizing ferromagnetic flexible bronchoscopic instruments to safely remove magnetic foreign bodies in the tertiary bronchi beyond the reach of traditional bronchoscopic instruments. Laryngoscope, 2024.

Geriatric Voice: Distinctive Clinical Profiles of Working Seniors in a Tertiary Laryngology Clinic.

OBJECTIVES: Voice disorders have been reported in up to 47% of the geriatric population. Few studies have assessed dysphonia in the elderly, with none examining vocal function in working seniors. This study aims to profile the clinical characteristics of individuals aged 65 years and older, comparing working and non-working seniors. STUDY DESIGN: Retrospective cohort study. METHODS: Medical charts were reviewed for patients aged 65 years and older referred to the McGill University Health Centre Laryngology Clinic (January 2018-March 2020). Variables studied included sociodemographics, comorbidities, voice complaints, lifestyle factors, diagnoses, voice acoustics [maximum phonation time (MPT), S/Z ratio, F0], GRBAS scale, Voice Handicap Index-10 (VHI-10), Reflux Symptom Index (RSI), and treatment modalities. RESULTS: A total of 267 patients were included, with a mean [standard deviation (SD)] age of 74.2 (6.6) years and 61% of female patients. Occupation information was available in 148 cases, of which 31.1% were still working and 12.8% were professional voice users. The predominant voice complaint was dysphonia/hoarseness (48.8%) and the most prevalent diagnosis was presbyphonia (31.8%). The mean (SD) VHI-10 and RSI scores were 19.8 (9.0) and 18.7 (9.4) points, respectively. Voice therapy was prescribed for 155 patients (58.7%): 124 attended at least one session with significant post-treatment improvements in the GRBAS and VHI-10 scores (P < 0.01). In the univariate analysis, working seniors had a significantly more prevalent singing habit (P = 0.04) and laryngopharyngeal reflux diagnosis (P = 0.01), displaying a significantly longer MPT (P < 0.001) and lower G-B-S scores (P < 0.05). After adjusting mean differences, only MPT and the G-S scores were significantly different between both groups. CONCLUSIONS: The predominant diagnosis in elders with voice complaints was presbyphonia. Voice therapy proved effective in improving the VHI-10 and GRBAS scores for geriatric patients. Almost one-third of seniors remained in the workforce, demonstrating superior vocal profiles, specifically in the MPT and the grade and strain of perceptual voice quality.

Facial Asymmetry Index: Validation and Applications in Various Smile Restoration Techniques.

Consistent and objective evaluation of the paralyzed face is imperative for documenting preoperative findings and assessing postoperative outcomes of reanimation techniques. Static and dynamic facial asymmetry are the key features of the paralyzed face. To date, there is no consensus among surgeons on how best to document facial asymmetry. The authors propose a Facial Asymmetry Index (FAI) as an objective measure of facial asymmetry and validate its use and reliability across numerous reanimation techniques. Frontal photographs of patients with unilateral facial nerve paralysis were analyzed. The length from the medial canthus to the ipsilateral oral commissure was compared between affected and nonaffected sides. The FAI is the difference between the two values, with a higher value reflecting poorer facial symmetry. Validation and reliability testing was then performed. There was a consistent decrease in the FAI with procedural intervention (FAI pre = 10.1, FAI post = 3.17; p < 0.0001). Furthermore, there was excellent inter- and intrarater reliability among independent judges. The FAI is a powerful and accessible tool to quantify operative outcomes for many lower facial nerve reanimation techniques.

Combined endonasal and eyelid approach for management of extensive frontal sinus inverting papilloma.

OBJECTIVES: Sinonasal inverting papilloma (IP) is a benign but locally aggressive mucosal neoplasm with a high recurrence rate. Extension into the frontal sinus presents surgical challenges for endonasal resection. This study presents an orbitofrontal approach for managing extensive IP. STUDY DESIGN: Case series. METHODS: Four patients seen between 2012 and 2016 with biopsy-proven IP with lateral frontal sinus extension underwent a combined endonasal and transpalpebral approach for tumor resection. Patient demographic data, preoperative characteristics, imaging, and follow-up data were compiled through retrospective chart review. Patients were selected for this approach when the tumor extended to the posterior frontal sinus wall, lateral frontal sinus recess, and orbit. Tumors were first approached endonasally until the frontal recess was reached. A Draf IIB or Draf III procedure was then performed to gain better exposure. Orbitofrontal exposure was achieved through an upper eyelid incision. Miniorbitofrontal craniotomy window was designed based on tumor location. Resection of the frontal and orbital extension was enhanced by endoscopic-assisted dissection through the orbitofrontal window. RESULTS: The transpalpebral approach provided access to all walls of the ipsilateral frontal sinus, the intersinus septum, and the medial aspect of the contralateral sinus. Complete tumor resection was achieved in all patients. There were no orbital complications, no visible eyelid asymmetry or scarring, and all patients had preserved forehead sensation. There were no recurrences on follow-up. CONCLUSION: Combining a transpalpebral orbitofrontal craniotomy with the endonasal approach allows complete resection of invasive IP with extension into the frontal sinus. This is achieved with great cosmetic results. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:3-9, 2018.

Vestibular vertigo is associated with abnormal sleep duration.

BACKGROUND/OBJECTIVE: Several small studies in animals and humans have suggested a relationship between vestibular function and sleep. In this study, we evaluate the association between vestibular vertigo and sleep duration in a large, representative sample of US adults. METHODS: We used data from the National Health Interview Survey, which administered a Balance Supplement in 2008 in a sample of 20,950 adult respondents. We evaluated the cross-sectional association between vestibular vertigo (based on a well-validated definition) and sleep duration (defined as short <6 hours, normal 6-8 hours, and long >8 hours). We performed multiple and multinomial logistic regression analyses to estimate the odds ratio and relative risk ratio (RRR) of impaired sleep duration compared to normal sleep duration associated with vestibular vertigo. Analyses were adjusted for demographic, lifestyle and health behavior characteristics as well as relevant comorbid conditions. RESULTS: Thirty percent of individuals with vestibular vertigo reported abnormal sleep duration (15.5% short duration and 14.8% long duration). In adjusted analyses, individuals with vestibular vertigo had a 1.75 (95% CI 1.45-2.11) RRR of having short sleep duration compared to individuals without vestibular vertigo, and a 1.55 (95% CI 1.26-1.91) RRR of having long sleep duration compared to individuals without vestibular vertigo. CONCLUSION: This study presents epidemiologic evidence to support the association between vestibular function and sleep duration. Individuals with vestibular vertigo had a higher RRR for abnormally short or long sleep duration. Further work is needed to evaluate the causal direction(s) of this association.

Upper lateral cartilage composite flap for closure of complicated septal perforations.

OBJECTIVES/HYPOTHESIS: To present a novel technique for the repair of large complicated nasal septal perforations using an upper lateral cartilage composite flap. STUDY DESIGN: This is a case series of five patients with large septal perforations seen at an academic tertiary care center, who have failed previous treatment measures and were selected to undergo this novel reconstruction for closure of their defects. METHODS: Patients were followed clinically to determine the success of the repair. Pre- and postoperative photographic documentation is presented, as well as a description of the surgical technique. RESULTS: All patients were found to have large septal perforations exceeding 2 × 3 cm in size. The reconstructed septal perforations remained closed for the duration of follow-up. There were no long-term complications related to this technique. CONCLUSIONS: The composite upper lateral cartilage flap is an effective and reliable means of repairing large and complicated septal defects with respiratory mucosa recruited from the nasal cavity. It may be considered in revision cases prior to entertaining regional extranasal flaps or the use of septal buttons. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1767-1771, 2017.

Transposition of the Intratemporal Facial to Hypoglossal Nerve for Reanimation of the Paralyzed Face: The VII to XII TranspositionTechnique.

IMPORTANCE: The hypoglossal nerve has long been an axonal source for reinnervation of the paralyzed face. In this study, we report our experience with transposition of the intratemporal facial nerve to the hypoglossal nerve for facial reanimation. OBJECTIVES: To determine the feasibility and outcomes of the transposition of the infratemeporal facial nerve for end-to-side coaptation to the hypoglossal nerve for facial reanimation. DESIGN, SETTINGS, AND PARTICIPANTS: A case series of 20 patients with facial paralysis who underwent mobilization and transposition of the intratemporal segment of the facial nerve for an end-to-side coaptation to the hypoglossal nerve (the VII to XII technique). Participants were treated between January 2007 and December 2014 at a tertiary care center. MAIN OUTCOMES AND MEASURES: Outcome measures include paralysis duration, facial tone, facial symmetry at rest, and with smile, oral commissure excursion, post-reanimation volitional smile, and synkinesis. METHODS: Demographic data, the effects of this technique on facial tone, symmetry, oral commissure excursion and smile recovery were evaluated. Preoperative and postoperative photography and videography were reviewed. Facial symmetry was assessed with a facial asymmetry index. Smile outcomes were evaluated with a visual smile recovery scale, and lip excursion was assessed with the MEEI-SMILE system. RESULTS: All 20 patients had adequate length of facial nerve mobilized for direct end-to-side coaptation to the hypoglossal nerve. The median duration of facial paralysis prior to treatment was 11.4 months. Median follow-up time was 29 months. Three patients were excluded from functional analysis due to lack of follow-up. Facial symmetry at rest and during animation improved in 16 of 17 patients. The median (range) time for return of facial muscle tone was 7.3 (2.0-12.0) months. A significant reduction in facial asymmetry index occurred at rest and with movement. The MEEI FACE-gram software detected a significant increase in horizontal, vertical, overall lip excursion and smile angle. No patient developed significant tongue atrophy, impaired tongue mobility, or speech or swallow dysfunction. CONCLUSIONS AND RELEVENCE: Mobilization of the intratemporal segment of the facial nerve provides adequate length for direct end-to-end coaptation to the hypoglossal nerve and is effective in restoring facial tone and symmetry after facial paralysis. The resulting smile is symmetric or nearly symmetric in the majority of patients with varying degree of dental show. The additional length provided by utilizing the intratemporal segment of the facial nerve reduces the deficits associated with complete hypoglossal division/splitting, and avoids the need for interposition grafts and multiple coaptation sites. LEVEL OF EVIDENCE: 4.

Early Nerve Grafting for Facial Paralysis After Cerebellopontine Angle Tumor Resection With Preserved Facial Nerve Continuity.

IMPORTANCE: Preserving facial nerve function is a primary goal and a key decision factor in the comprehensive management of vestibular schwannoma and other cerebellopontine angle (CPA) tumors. OBJECTIVE: To evaluate the use of the pattern of facial paralysis recovery in the early postoperative months as a sole predictor in selecting patients for facial nerve grafting after CPA tumor resection when cranial nerve VII is uninterrupted. DESIGN, SETTING, AND PARTICIPANTS: Sixty-two patients with facial paralysis and uninterrupted cranial nerve VII who developed facial paralysis after CPA tumor resection at The Johns Hopkins Hospital were followed up prospectively to assess for spontaneous recovery and to determine candidacy for facial reanimation surgery. The study dates and dates of analysis were January 1, 2009, to March 31, 2015. INTERVENTIONS: After a minimum of 6 months of clinical follow-up and no signs of clinical recovery, patients underwent facial nerve exploration and a masseteric or hypoglossal nerve transfer. Intraoperative direct nerve stimulation was performed to assess for the presence of subclinical reinnervation. Patients were followed up for a minimum of 18 months after surgery to evaluate outcomes. MAIN OUTCOMES AND MEASURES: Facial function and recovery were studied objectively with a Smile Recovery Scale, Facial Asymmetry Index, and House-Brackmann (HB) grading system. Other outcome measures included the duration of paralysis, time to recovery, and evidence of synkinesis. RESULTS: Sixty-two patients (33 men, 29 women; mean age 51.8 years) with uninterrupted facial nerves after CPA tumor resection developed HB grade IV, V, or VI facial paralysis. Ten patients underwent nerve grafting by 12 months, 9 patients received grafting after 12 months, and 8 patients had no intervention. Thirty-five patients spontaneously recovered. In all patients who underwent nerve grafting, there were no detectable facial muscle movements or electromyographic response to direct facial nerve stimulation suggestive of occult reinnervation. Overall, early facial reanimation surgery resulted in a shorter total duration of paralysis. Masseteric nerve grafting resulted in earlier recovery compared with hypoglossal nerve grafting (5.6 vs 10.8 months, P = .005). Patients who showed no signs of recovery by 6 months after CPA surgery but declined facial reanimation surgery demonstrated at best HB grade V recovery after 18 months of observation. CONCLUSIONS AND RELEVANCE: The recovery pattern in the early postoperative period among patients who develop facial paralysis after CPA tumor resection is a useful clinical tool in selecting patients for facial reanimation surgery. Patients can be counseled for facial reanimation surgery as early as 6 months after surgery because satisfactory facial functional recovery is unlikely to occur when there is no clinical evidence of spontaneous nerve regeneration in the first 6 months. LEVEL OF EVIDENCE: 3.