Chatbots as Patient Education Resources for Aesthetic Facial Plastic Surgery: Evaluation of ChatGPT and Google Bard Responses.

Background: ChatGPT and Google Bard™ are popular artificial intelligence chatbots with utility for patients, including those undergoing aesthetic facial plastic surgery. Objective: To compare the accuracy and readability of chatbot-generated responses to patient education questions regarding aesthetic facial plastic surgery using a response accuracy scale and readability testing. Method: ChatGPT and Google Bard™ were asked 28 identical questions using four prompts: none, patient friendly, eighth-grade level, and references. Accuracy was assessed using Global Quality Scale (range: 1-5). Flesch-Kincaid grade level was calculated, and chatbot-provided references were analyzed for veracity. Results: Although 59.8% of responses were good quality (Global Quality Scale ≥4), ChatGPT generated more accurate responses than Google Bard™ on patient-friendly prompting (p < 0.001). Google Bard™ responses were of a significantly lower grade level than ChatGPT for all prompts (p < 0.05). Despite eighth-grade prompting, response grade level for both chatbots was high: ChatGPT (10.5 ± 1.8) and Google Bard™ (9.6 ± 1.3). Prompting for references yielded 108/108 of chatbot-generated references. Forty-one (38.0%) citations were legitimate. Twenty (18.5%) provided accurately reported information from the reference. Conclusion: Although ChatGPT produced more accurate responses and at a higher education level than Google Bard™, both chatbots provided responses above recommended grade levels for patients and failed to provide accurate references.

The Effectiveness of Facial Neuromuscular Retraining on Patients with Facial Nerve Dysfunction: A Mental Health and Quality of Life Analysis.

Background: Facial muscle dysfunction can have drastic psychosocial effects. Objectives: To evaluate the impacts of customized neuromuscular retraining on mental health, quality of life (QoL), facial muscle function, and synkinesis. Methods: Thirty patients with facial nerve dysfunction completed a course of neuromuscular retraining. Patients' mental health, QoL, facial muscle function, and synkinesis were evaluated using Patient Health Questionnaire (PHQ-9), Facial Clinimetric Evaluation (FaCE) scale, electronic, clinician-graded facial function scale (eFACE), and Synkinesis Assessment Questionnaire (SAQ) at the initial and final visits. Scores were compared before and after treatment. Results: Patients (n = 30) included had a mean age of 59.4 ± 13.4 years (range 32.3-82.8) and were mostly female (22/30, 73.3%). The most common etiology was Iatrogenic facial nerve paralysis (11/20, 36.7%). Most patients had postfacial paralysis synkinesis (15/30, 50%), while 10 had complete flaccid paralysis. The median house-Brackmann score was 2 (range 1-6). The mean duration of facial palsy was 39.5 ± 106.9 (range 1-576 months). The duration of follow-up after the initial treatment session was 5.5 months, including 10 sessions. After neuromuscular retraining median PHQ-9 scores improved from 5 (range 0-25) to 3 (range 0-20) (p = 0.002). Mean FaCE PROM scores increased from 47.7 ± 11.5 to 56.5 ± 8.8 (p = 0.001). The mean eFACE score increased from 55.8 ± 15.1 to 71.7 ± 13.6 (p < 0.001). Median SAQ score was lower at the final visit (34.6 ± 13.4) compared to the initial visit (47.7 ± 17.8; p < 0.001). Conclusion: Customized neuromuscular retraining may improve patient-reported mental health, QoL, and facial muscle function and reduce synkinesis in facial nerve dysfunction.

Quantifying Aerosol Generation in Maxillofacial Trauma Repair Techniques.

Study Design: Cadaveric simulation study. Objective: The novel coronavirus (COVID-19), which can be transmitted via aerosolized viral particles, has directed focus on protection of healthcare workers during procedures involving the upper aerodigestive tract, including maxillofacial trauma repair. This study evaluates particle generation at different distances from open reduction and internal fixation (ORIF) of maxillofacial injuries in the intraoperative setting to reduce the risk of contracting airborne diseases such as COVID-19. Methods: Two cadaveric specimens in a simulated operating room underwent ORIF of midface and mandible fractures via intraoral incisions as well as maxillomandibular fixation (MMF) using hybrid arch bars. ORIF was performed with both self-drilling screws and with the use of a power drill for creating guide holes. Real-time aerosol concentration was measured throughout each procedure using 3 particle counters placed 0.45, 1.68, and 3.81 m (1.5, 5.5, and 12.5 feet, respectively) from the operative site. Results: There was a significant decrease in particle concentration in all procedures at 1.68 m compared to 0.45 m, but only 2 of the 5 procedures showed further significant decrease in particle concentration when going from 1.68 to 3.81 m from the operative site. There was significantly less particle concentration generated at all distances when using self-drilling techniques compared to power drilling for ORIF. Conclusions: Consideration of using self-drilling screwing techniques as well as maintaining physical distancing protocols may decrease risk of transmission of airborne diseases such as COVID-19 while in the intraoperative setting.

Mechanical stimulation of a bioactive, functionalized PVDF-TrFE scaffold provides electrical signaling for nerve repair applications.

Traumatic nerve injuries have limited success in achieving full functional recovery, with current clinical solutions often including implementation of nerve grafts or the use of nerve conduits to guide damaged axons across injury gaps. In search of alternative, and complimentary solutions, piezoelectric biomaterials demonstrate immense potential for tissue engineering applications. Piezoelectric poly(vinylidene fluoride-triflouroethylene) (PVFD-TrFE) scaffolds can be harnessed to non-invasively stimulate and direct function of key peripheral nervous system (PNS) cells in regeneration strategies. In this study, electrospun PVDF-TrFE was characterized, fabricated into a 3D scaffold, and finally rendered bioactive with the incorporation of a cell-secreted, decellularized extracellular matrix (dECM). PVDF-TrFE scaffolds were characterized extensively for piezoelectric capacity, mechanical properties, and cell-material interactions with fibroblasts and Schwann cells. Through functionalization of PVDF-TrFE scaffolds with a native, cell-assembled dECM, the ability to promote cell adhesion and enhanced viability was also demonstrated. Additionally, incorporation of bioactive functionalization improved the assembly of key regenerative ECM proteins and regenerative growth factors. PVDF-TrFE scaffolds were then fabricated into a conduit design that retained key physical, chemical, and piezoelectric properties necessary for PNS repair. This work shows great promise for multi-cue, electrospun biomaterials for regeneration of the PNS in traumatic injury.

Sternocleidomastoid Tendon as a Consistent Landmark for Identifying the Spinal Accessory Nerve: A Case Series.

Objective: We propose a standardized approach of using the tendon of the sternocleidomastoid (SCM) muscle to locate the spinal accessory nerve (SAN) in neck dissection. Study Design: Cross-sectional anatomic study. Setting: Tertiary academic medical center. Methods: Adult patients aged ≥18 years undergoing primary neck dissection for head and neck cancer were included. Anatomic measurements included the length of the SCM tendon, the distance from the mastoid tip to the entrance of the SAN into the SCM, the distance from the SAN to the distal edge of the SCM tendon, and the perpendicular distance from the anterior edge of the SCM to the SAN. Five cadaveric specimens also underwent bilateral modified radical neck dissections with the same anatomic measurements taken. Results: Twenty-two living subjects and 5 cadavers were included. No statistical correlation was noted between patient demographics and any measurement. The mean (SD) length of the SCM tendon was 63.7 mm (11.8) in living subjects and 61.5 mm (10.4) in cadaveric specimens. The average distance from the mastoid tip to the entrance of SAN into the SCM was 51.6 mm (12.2) in living subjects and 51.6 mm (7.1) in cadaveric subjects. The distance of the SAN insertion into the SCM muscle from the anterior edge was 8.9 mm (3.4) in living subjects and 16.2 mm (7.2) in cadaver specimens. Laterality was compared in the cadaveric specimens; there was no statistically significant difference in any of the measurements between sides. Conclusion: This study demonstrates the SCM tendon to be a reliable and safe surgical landmark to identify and preserve the SAN during neck dissection.

Patient perspectives on recall period and response options in patient-reported outcome measures for chronic rhinosinusitis symptomatology: A pilot study.

OBJECTIVE: Patient-reported outcome measures (PROMs) for assessment of chronic rhinosinusitis (CRS) employ a variety of recall periods and response scales for reporting CRS symptom burden. CRS patient perspective is unknown with respect to recall periods and response scales in PROMs. DESIGN: Cross-sectional study. SETTING: Tertiary rhinology clinic. PARTICIPANTS: Sixty three adults with CRS. MAIN OUTCOME MEASURES: Participants were asked to choose which CRS symptom recall period-1 day, 2 weeks, 1 month or greater than 1 month-was most reflective of their current disease state and best to base treatment recommendations (including surgery) upon. Participants were also asked to report which of six response scales (one visual analogue scale [VAS] and five Likert scales ranging from four to eight items) were easiest to use and understand, and most preferred. RESULTS: A majority of participants felt the current state of their CRS symptoms was best reflected by a recall period of 2 weeks to 1 month; however, patients preferred that recommendations about treatments, including endoscopic sinus surgery, be determined by symptoms experienced over at least a one-month period. Participants generally found the VAS and seven-item Likert scale to be the easiest to use and understand, and their most preferred scales. No patient characteristics associated with preferences for recall periods or response scales. CONCLUSION: Future PROMs for CRS symptoms should consider assessment of symptoms over a one-month time frame and use either a VAS or seven-item Likert response scale to optimally balance reflection of current disease state, need for intervention and patient preference.

Olfactory Dysfunction is not a Determinant Of Patient-Reported Chronic Rhinosinusitis Disease Control.

OBJECTIVES/HYPOTHESIS: As a cardinal symptom of chronic rhinosinusitis (CRS), hyposmia has been recommended to be assessed as a component of CRS disease control. Herein we determine the significance of hyposmia in CRS in the context of nasal obstruction and drainage symptoms. STUDY DESIGN: Prospective, cross-sectional METHODS: Cross-sectional study of 308 CRS patients (102 CRSwNP, 206 CRSsNP) without prior endoscopic sinus surgery. The burden of nasal obstruction and hyposmia were assessed using the corresponding item scores on the 22-item Sinonasal Outcome Test (SNOT-22). Burden of nasal discharge was assessed using the mean of "thick nasal discharge" and "thick post-nasal discharge" SNOT-22 item scores. Patients were all asked to rate their CRS symptom control as "not at all," "a little," "somewhat," "very," or "completely." RESULTS: In CRSwNP, only 4.9% had a hyposmia score > 1 with nasal obstruction and drainage scores less than or equal to 1. In CRSsNP, only 1.9% had a hyposmia score > 1 with nasal obstruction and drainage scores less than or equal to 1. On univariate association, CRS symptom control was significantly associated with nasal obstruction, hyposmia, and drainage in both CRSwNP and CRSsNP (P < .05 in all cases). Using multivariable regression to account for all nasal symptoms, only nasal obstruction and nasal discharge scores (but not hyposmia) were significantly associated with CRS symptom control. CONCLUSIONS: Hyposmia rarely occurs without nasal obstruction or nasal drainage, and may therefore be redundant to assess for CRS disease control. Moreover, hyposmia was not associated with patient-reported CRS symptom control when accounting for the burden of nasal obstruction and drainage. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2116-E2120, 2021.

Unbiased Measure of General Quality of Life in Chronic Rhinosinusitis Reveals Disease Modifiers.

INTRODUCTION: Chronic rhinosinusitis (CRS) is associated with a significant decrease in general health-related quality of life (QOL). The EuroQol 5-dimensional questionnaire measures general health-related quality of life through a health utility value (EQ-5D HUV)-based on five domains reflecting mobility, self-care, activities of daily life, pain/discomfort, and anxiety/depression-and an unbiased visual analog scale (EQ-5D VAS). We sought to identify characteristics of CRS patients with a high EQ-5D HUV but low EQ-5D VAS score. MATERIALS AND METHODS: Retrospective cross-sectional study of 300 CRS patients with EQ-5D HUV equal to 1.0 (reflecting perfect health). All patients completed a 22-item Sinonasal Outcome Test (SNOT-22)-from which nasal, sleep, ear/facial discomfort, and emotional subdomain scores were calculated, as well as the EQ-5D. Low EQ-5D VAS was defined as a score less than 80. RESULTS: On multivariate analysis, low EQ-5D VAS was associated with only the SNOT-22 sleep subdomain score (odds ratio [OR] = 1.07, 95%CI: 1.02-1.12, P = .003). Comorbid asthma was also associated with lower EQ-5D VAS (OR = 2.16, 95%CI: 1.02-4.59, P = .045). In contrast, polyps were negatively associated with having a lower EQ-5D VAS (OR = 0.34, 95%CI: 0.17-0.69, P = .003). CONCLUSION: There are patients with perfect general health-related QOL according to a health utility value-based methodology (like the EQ-5D HUV) who report low general health-related QOL on an unbiased measure like the EQ-5D VAS. In CRS patients with perfect EQ-5D HUV, poor sleep and asthma were associated with low QOL on the EQ-5D VAS, while polyps were negatively associated with low QOL. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:1206-1211, 2021.

Characterising the potential for recall bias in anchor-based MCID calculation of patient-reported outcome measures for chronic rhinosinusitis.

OBJECTIVE: Anchor-based methods to calculate the minimal clinically important difference (MCID) of a patient-reported outcome measure (PROM) may suffer from recall bias. This has never been investigated for otolaryngic PROMs. We sought to identify evidence of recall bias in calculation of MCIDs of PROMs for patients with chronic rhinosinusitis (CRS). DESIGN: Retrospective analysis of data from two previous studies calculating the MCID of the 22-item Sinonasal Outcome Test (SNOT-22) and 5-dimensonal EuroQol questionnaire (EQ-5D) in CRS patients. SETTING: Tertiary rhinology clinic. PARTICIPANTS: Adults with CRS. MAIN OUTCOME MEASURES: SNOT-22 score, and EQ-5D visual analog scale scores (EQ-5D VAS) and health utility values (EQ-5D HUV) before and after medical treatment for CRS. After treatment, participants were asked to rate the change in sinonasal symptoms and general health (the anchor question) as "Much worse," "A little worse," "About the same," "A little better" or "Much better." Participants' responses to the anchor question were checked for association with post-treatment and pre-treatment scores using ordinal regression. RESULTS: On univariate association, post-treatment SNOT-22 and EQ-5D scores were associated with respective participants' anchor question responses (P < .001 in all cases). Only pre-treatment SNOT-22 score was associated with anchor question responses (P = .017) on univariate association, in contrast to pre-treatment EQ-5D scores. Pre-treatment EQ-5D scores only associated with anchor question responses when controlling for post-treatment scores. CONCLUSION: The anchor-based MCIDs of the SNOT-22, which reflects disease-specific QOL, and the EQ-5D, which reflects general health-related QOL, appear to be largely free of recall bias.

Comparison of Modern Rigid Fixation Plating Outcomes for Segmental Mandibular Microvascular Reconstruction.

OBJECTIVES/HYPOTHESIS: New advances in osseous microvascular mandibular rigid fixation are being employed at many institutions. These include standardized prebent/preformed reconstruction plates as well as computer-aided design/computer-aided manufacturing (CAD/CAM) custom plates that are patient specific. Our goal was to assess and compare the outcomes of both of these new technologies when utilized for mandibular microvascular reconstruction. STUDY DESIGN: Retrospective chart review. METHODS: Subjects were categorized into two groups according to their mandibular rigid fixation technique: group 1 = prebent/preformed plates and group 2 = CAD/CAM custom plates. Primary outcome measures were 1) perioperative complications (defined as deep tissue infection, wound dehiscence resulting in bone exposure, and/or plate exposure) and 2) reoperation rates for mandibular hardware failure/explantation. Statistical analysis consisted of χ2 , Fisher exact test, and multivariable regression models. RESULTS: A total of 142 subjects underwent microvascular mandibular reconstruction in a 6-year period. Eighty-nine subjects utilized prebent/preformed plates, and 53 employed CAD/CAM custom plates. Perioperative complications occurred in 32 of 89 (35.9%) subjects with prebent/preformed plates and 11 of 53 (20.7%) subjects using CAD/CAM custom plates. Reoperation requiring hardware explantation occurred in 18 of 89 (20.2%) subjects and three of 53 (5.6%) using CAD/CAM custom plates. Statistical comparison of perioperative complications between the two groups approached significance (P = .0556), and the rate of reoperation was significant favoring CAD/CAM implants (P = .0180). CONCLUSIONS: In our experience, CAD/CAM custom plates utilized for rigid fixation during microvascular mandibular reconstruction demonstrated fewer complications and statistically lower reoperation rates when compared with prebent/preformed plates. LEVEL OF EVIDENCE: 2c Laryngoscope, 129:1081-1086, 2019.

Novel approach using transoral robotic surgery for resection of cervical spine chordoma.

Chordomas are rare, infiltrative neoplasms of notochordal origin that present along the spinal canal; en bloc surgical resection is paramount to successful treatment. Limited visualization and complex anatomy are major challenges to resection of upper cervical spine chordomas and often require invasive surgery. A 27-year-old male presented with an incidentally discovered chordoma of the midline second cervical vertebra of the spine. To obtain en bloc resection of the lesion while both overcoming limitations due to access and without introducing morbidity from traditional anterior approaches, we elected using transoral robotic surgery for resection. Due to complete resection, the patient remains disease-free and was spared adjuvant radiation. Laryngoscope, 129:1395-1399, 2019.

Atypical Form of Cervicofacial Actinomycosis Involving the Skull Base and Temporal Bone.

BACKGROUND:: Cervicofacial actinomycosis is an uncommon indolent infection caused by Actinomyces spp that typically affects individuals with innate or adaptive immunodeficiencies. Soft tissues of the face and neck are most commonly involved. Actinomyces osteomyelitis is uncommon; involvement of the skull base and temporal bone is exceedingly rare. The authors present a unique case of refractory cervicofacial actinomycosis with development of skull base and temporal bone osteomyelitis in an otherwise healthy individual. METHODS:: Case report with literature review. RESULTS:: A 69-year-old man presented with a soft tissue infection, culture positive for Actinomyces, over the right maxilla. Previous unsuccessful treatment included local debridement and 6 weeks of intravenous ceftriaxone. He was subsequently treated with conservative debridement and a prolonged course of intravenous followed by oral antibiotic. However, he eventually required multiple procedures, including maxillectomy, pterygopalatine fossa debridement, and a radical mastoidectomy to clear his disease. Postoperatively he was gradually transitioned off intravenous antibiotics. CONCLUSIONS:: Cervicofacial actinomycosis involves soft tissue surrounding the facial skeleton and oral cavity and is typically associated with a history of mucosal trauma, surgery, or immunodeficiency. The patient was appropriately treated but experienced disease progression and escalation of therapy. Although actinomycosis is typically not an aggressive bacterial infection, this case illustrates the need for prompt recognition of persistent disease and earlier surgical intervention in cases of recalcitrant cervicofacial actinomycosis. Chronic actinomycosis has the potential for significant morbidity.

Spontaneous retropharyngeal and mediastinal thoracic duct cyst in an infant with respiratory distress.

Thoracic duct cysts (TDC) within the retropharyngeal space and mediastinum are exceedingly rare lesions, with the majority related to trauma or neoplasm. We describe a case of an otherwise healthy 8-month-old boy who presented with severe respiratory distress, which was found to be caused by a large, spontaneous TDC occupying most the retropharyngeal and mediastinal space. To our knowledge, this is the youngest patient to date presenting with TDC. Ultimately, his TDC was completely resolved with sclerotherapy, however the patient's age and size presented unique challenges to his medical management, which we describe below.

Assessing the clinical applicability of prior head imaging in patients with chronic rhinosinusitis.

BACKGROUND: Patients often have received some modality of head imaging prior to being evaluated for chronic sinonasal complaints, and the clinical significance of these scans on current sinonasal symptomatology is unknown. METHODS: We performed a retrospective, cohort study of 578 patients with chronic sinonasal indications for maxillofacial computed tomography scans (CTs) in 2016. Patients were included if previous head cross-sectional imaging had been performed. Lund-McKay (LM) scores were calculated on the prior CT scan for each patient and compared to LM scores of the most recent scan. Scans with LM scores ≤3 were deemed normal, scores >3 were deemed positive, and Δ >3 was deemed a significant change. RESULTS: Of 578 patients, 153 (26.5%) patients had previous imaging. Overall, a strong correlation was noted between scans (r = 0.791, p < 0.001). Significant correlations remained with the subset of positive prior scans (r = 0.743, p < 0.001). The 3 most common prior imaging modalities were maxillofacial CT, head CT, and brain magnetic resonance imaging (MRI). Correlations between these modalities and subsequent maxillofacial CTs range from strong to moderately strong. Women were significantly more likely to have negative prior imaging (p = 0.048). Patients with negative prior imaging (80/153) were significantly more likely to remain unchanged (71/80) compared to patients with positive prior scans (56/73) (p = 0.023). CONCLUSION: Prior head imaging highly correlates to future maxillofacial CT in patients with chronic sinonasal complaints, and patients with prior negative scans are likely to remain negative on future imaging. If prior head scans exist, practitioners may want to avoid ordering additional scans in the absence of changing symptoms.