Levator Labii Superioris Alaeque Nasi Targeted Botulinum Toxin Injection for Treatment of Perinasal Facial Discomfort and Snarling.

Botulinum toxin has been increasingly studied and used for varying conditions, most notably, cosmetics. However, it has been shown that botulinum toxin demonstrates a high efficacy in treating spasticity disorders throughout the body, including the face. Facial spasms vary in pathophysiology, region, and severity. Some can be so severe that they can cause discomfort and emotional distress due to the involuntary facial expressions caused by the spasms. Most spasticity conditions are often treated with adjuvant therapy of oral muscle relaxants and analgesics depending on severity. However, these treatments impose risks of varying adverse effects from sedation, hypotension, and if chronic use, more severe effects such as central nervous system complications or QT prolongation. In addition, if spasms are localized, the muscle relaxant's mechanism is not targeted, leading to unnecessary systemic use. That being said, a more targeted and manageable treatment such as botulinum toxin presents itself as a potential option for patient's physical condition and everyday life quality. Our case presents a 62-year-old male, with a chronic history of localized, idiopathic spasms and discomfort within the Levator Labii Superioris Aqulae Nasi region. The patient had no history of previous neurological disorders, and imaging was unremarkable. The patient had been treated over the past 13 years with varying oral therapeutics including Cymbalta, Ibuprofen, and cyclobenzaprine with limited improvement, but presented to the clinic seeking a different treatment plan, as the adverse effects from the muscle relaxants were impeding his everyday activities. The patient was also experiencing significant pain and emotional stress due to the spasms. The risk and benefits of treatment options were discussed and the patient decided to move forward with botulinum injections. After the first injection, the patient reported his pain had significantly improved and was relieved to be off of chronic pain medications. Our case demonstrates, what increasing literature further also supports: botulinum toxin is becoming a potential effective treatment for a breadth of spasticity disorders with a more targeted mechanism, and more manageable treatment plan, while simultaneously improving the patient's quality of life.

Comparison of cervical neck strain in common otolaryngology surgeries.

BACKGROUND: Cervical neck strain and surgical ergonomics is an increasingly important topic being addressed in this time and age. With new technologies, visualizations, and approaches to surgeries, there are now different strains and duration of strains to the cervical neck. Recently the effect of chronic cell phone use has been described as "text neck." In a similar fashion we understand that certain otolaryngology surgeries can also impart chronic strain to the cervical neck. We aim to quantitatively describe strain for different types of surgeries by looking at posture, duration of surgery, and anatomic ergonomics of specific surgeries. METHODS: Lateral photo documentation of posture during 6 common otolaryngology procedures, used to estimate cervical neck angle and calculate force and impulse to cervical neck. RESULTS: Six common otolaryngology procedures show various cervical neck angles ranging from around 0° to 60° of neck flexion, with subsequent forces ranging from 16 lb to 60 lb of force. When accounting for surgical time, bigger differences arose with impulses ranging from 270,000 N∗s to 3,300,000 N∗s. Noticeably, thyroidectomy and cleft palate showed much higher impulses than the other four types of surgeries. CONCLUSION: Both cervical neck flexion and duration of surgery play important roles in total neck theoretical strain. Variance exists between neck strains of common otolaryngology surgeries. There is a necessity for continued study and improvement in surgical ergonomics.

Butterfly Graft Technique for Addressing the Internal Nasal Valve.

Nasal airway obstruction is a common presenting complaint to otolaryngology clinics, with the internal valve a commonly implicated anatomic area of obstruction. The nasal butterfly graft is a robust technique to address this subsite with good reported functional and aesthetic outcomes in both primary and secondary rhinoplasty. We describe our approach to patient evaluation, surgical candidate selection, operative technique, and outcomes assessment for this technique.

Effect of Operative Timing and Bone Grafting on Postoperative Cephalometric Indices in Nonsyndromic Sagittal Synostosis.

ABSTRACT: Surgical repair of sagittal suture craniosynostosis is highly variable, and optimal timing/use of bone grafts remains a subset of parameters that continue to be studied. We sought to compare cephalometric outcomes of early surgical intervention without bone grafting compared to later intervention with bone grafting. Patients undergoing primary surgical repair of nonsyndromic sagittal suture craniosynostosis between 2015 and 2019 were followed with preoperative measurements of cephalic index along with postoperative measurements at 6 months to 1 year, respectively. Nineteen patients undergoing cranial vault reconstruction were studied in 2 groups, namely those younger than 6 months who did not have bone grafting performed during primary repair (31.6%) and patients 6 months and older who underwent cranial vault reconstruction with bone grafting during primary repair (68.4%). Mean 6-month to 1-year postoperative cranial index was significantly increased in both groups (P < 0.001). The average cephalic index change for both groups (younger than 6 months without bone grafting, CI value change 9; 6 months and older with bone grafting; CI value change 6) was not significantly different with regards to 95% confidence interval (P = 0.30). Patients older than 6 months of age undergoing cranial vault reconstruction with bone grafting have similar cephalometric outcomes as their younger counterparts undergoing cranial vault remodeling without bone grafting. Bone grafting in the appropriate cohort may improve functional and esthetic outcomes without compromising primary surgical goals of improving cranial vault cephalometric indices.

Analysis of Frontal Sinus Fracture Management and Resource Utilization.

Frontal sinus fractures require a large amount of force and often occur in the context of a major trauma. Many patients with these fractures are assessed in an emergent setting where stabilization takes precedence. Delayed diagnosis and treatment of a sinus fracture can result in life-threatening conditions, such as a cerebrospinal fluid (CSF) leak. A number of different treatment algorithms have been proposed, highlighting the complexity of frontal sinus fracture management. The goal of this study is to determine how patients with frontal sinus fractures were treated at Texas Tech University Health Sciences Center and what complications arose as a result of the fracture and subsequent management strategy. Over 9 years, there were 69 reported cases. A total of 63 of these occurred in males (91.3%) versus 6 (8.7%) in females. The majority occurred after a motor vehicle collision (MVC) or a motorcycle collision (MCC). A total of 51 cases were unilateral fractures and 18 were bilateral fractures. Five patients (7.2%) had CSF leakage and 64 (92.8%) did not have CSF leakage. One patient with CSF leakage (20.0%) was managed operatively. Of the 64 patients without CSF leakage, 4 (6.3%) were managed operatively. All operative patients were managed by cranialization. Complications included vision changes, facial pressure, anosmia, facial paresthesia, pneumocephalus, and mucus retention cysts. Vision changes were the most common complication. There did not appear to be any significant difference in complications between the CSF leakage groups, indicating that non-operative management remains a viable option in the management of frontal sinus fractures.

Ramsay Hunt Syndrome Associated With Etanercept Treatment for Rheumatoid Arthritis: A Case Report and a Review of Literature.

A 38-year-old woman with rheumatoid arthritis treated with etanercept presented with complaints of ear pain. Over four days, the pain progressed to a vesicular rash and then facial nerve paralysis. The patient was diagnosed with Ramsay Hunt syndrome (RHS), a reactivation of the varicella zoster virus that specifically affects the seventh cranial nerve (CN VII). Etanercept is an anti-tumor necrosis factor (anti-TNF) agent that has known immunosuppressive effects. RHS occurs more commonly in immunocompromised states, such as the one induced by etanercept. To the best of our knowledge, this is one of the first reported cases of RHS with etanercept treatment.

Secondary Contouring for the Butterfly Graft: Improving Form and Preserving Function.

OBJECTIVE: The butterfly graft (BFG) secondary contouring procedure addresses external nasal irregularities following the primary BFG surgery. We explore demographic factors associated with the desire for secondary contouring and assess patient-reported outcomes following the procedure. METHODS: A retrospective analysis of 374 patients undergoing BFG between April 2020 and April 2023 identified 10 individuals electing for secondary contouring. Demographics, Nasal Obstruction Symptoms Evaluation (NOSE) scores, Rhinosinusitis Disability Index (RSDI), and decision regret scale (DRS) were collected and reported. RESULTS: Secondary contouring rate was 2.7% of total cases. The majority of patients desiring BFG secondary contouring were white females (90%). NOSE scores significantly improved post-primary surgery (mean change: 51.7, SD: 14.01, p-value: <0.05). Although overall NOSE scores remained improved after secondary contouring (mean change: 47.2, SD: 18.84, p-value: <0.05) compared with their preoperative NOSE scores, one patient (10%) reported worse score after secondary contouring. Four patients (40%) reported worsening after secondary contouring compared with after initial BFG surgery. DRS indicated minimal regret from patients. CONCLUSION: BFG secondary contouring is a valuable option for patients with external nasal complaints, providing improvements in nasal appearance and durable improvement in breathing outcomes. We emphasize the importance of patient counseling and appropriate patient selection. Our results suggest that patients should expect a slight worsening of NOSE scores following secondary contouring, but that significant worsening is a low risk. LEVEL OF EVIDENCE: Level 4: Case series Laryngoscope, 2024.

Microvascular Gracilis Free Flap: Single and Double Innervation.

Facial paralysis (FP) is a devastating condition that can lead to significant aesthetic, social, and emotional morbidities for patients. For some patients with FP, free gracilis muscle transfer (FGMT) is the best option for smile restoration. Masseteric-driven FGMT produces a reliable voluntary smile. Cross-face nerve graft-driven FGMT can produce a spontaneous smile, but this technique has higher failure rates. Early studies suggest dual-innervation FGMT can produce a spontaneous smile while maintaining the reliability of masseteric-driven procedures. Great care should be taken during FGMT surgery to minimize facial bulk and place medial inset sutures that create a natural-appearing smile.

Mid-Term Effects of Selective Denervation Surgery on Facial Symmetry in Patients with Nonflaccid Facial Paralysis: Intermediate Follow-Up of Rest and Smile Symmetry.

Introduction: Although selective denervation (SD) improves clinician-graded, objective, and patient-reported smile symmetry, changes in resting symmetry have not been comprehensively studied. Objective: To assess mid-term changes in resting facial symmetry after SD, and to evaluate changes in perceived emotions in faces at rest and with smiling. Methods: Nonflaccid facial paralysis (NFFP) patients undergoing SD were studied from September 2021 to October 2022. Patient-reported, clinician-graded, and objective metrics of resting and smile symmetry were quantified. Results: Fourteen patients (median age 59.5 years; median paralysis duration 76.5 months; median follow-up 249.5 days (138-400); average of 5.7 branches sacrificed) underwent SD. Resting oral commissure (OC) symmetry (p = 0.028) and upper lip symmetry (p = 0.030) improved after surgery. In smiling faces, OC excursion (p = 0.004), smile angle (p = 0.016), and dental show (p = 0.012) improved. There were significant increases in perceived happiness at rest (p = 0.006) and with smile (p = 0.002). Clinician grading revealed improved nasolabial fold depth at rest (p = 0.087) after surgery, and patients reported improved facial function and happiness with the decision to undergo surgery. Conclusion: Intermediate follow-up suggests SD can improve objective resting and smile symmetry in patients with NFFP. After surgery, patients' faces convey more happiness in repose and with smile.

Investigation of effects of terpene skin penetration enhancers on stability and biological activity of lysozyme.

The transport of proteins through skin can be facilitated potentially by using terpenes as chemical enhancers. However, we do not know about the effects of these enhancers on the stability and biological activity of proteins which is crucial for the development of safe and efficient formulations. Therefore, this project investigated the effects of terpene-based skin penetration enhancers which are reported as nontoxic to the skin (e.g., limonene, p-cymene, geraniol, farnesol, eugenol, menthol, terpineol, carveol, carvone, fenchone, and verbenone), on the conformational stability and biological activity of a model protein lysozyme. Terpene (5% v/v) was added to lysozyme solution and kept for 24 h (the time normally a transdermal patch remains) for investigating conformational stability profiles and biological activity. Fourier transform infrared spectrophotometer was used to analyze different secondary structures, e.g., α-helix, ß-sheet, ß-turn, and random coil. Conformational changes were also monitored by differential scanning calorimeter by determining midpoint transition temperature (Tm) and calorimetric enthalpy (ΔH). Biological activity of lysozyme was determined by measuring decrease in A (450) when it was added to a suspension of Micrococcus lysodeikticus. The results of this study indicate that terpenes 9, 10, and 11 (carvone, L-fenchone, and L-verbenone) decreased conformational stability and biological activity of lysozyme significantly (p < 0.05) less than other terpenes used in this study. It is concluded that smaller terpenes containing ketones with low lipophilicity (log K (ow) ∼2.00) would be optimal for preserving conformational stability and biological activity of lysozyme in a transdermal formulation containing terpene as permeation enhancer.

A Rare Infratemporal Fossa Abscess of the Lateral Pterygoid.

The infratemporal fossa (ITF) contains many critical neurovascular structures and the muscles of mastication. Infections of the ITF are rare and carry significant pathologic implications due to nearby structures. Abscesses of the ITF often occur due to odontogenic spread and present with trismus and facial pain. We present the case of a 26-year-old male with an uncommon ITF abscess of the lateral pterygoid following maxillary wisdom tooth extraction. The abscess resolved following bedside and operative intraoral drainage in addition to intravenous antibiotic therapy. We highlight the rarity of lateral pterygoid abscesses and the importance of distinguishing ITF abscesses from other similarly presenting conditions such as temporomandibular joint dysfunction.

Virtual otolaryngology interest group meetings and didactic sessions in the COVID-19 pandemic.

The COVID-19 pandemic has placed tremendous strain on medical education and prevented multiple in-person activities like specialty interest group meetings. Specialty interest groups are important resources for students interested in competitive fields like otolaryngology where they may find mentoring, research opportunities, and teaching sessions. To allow continued meetings despite COVID-19, the Texas Tech University Health Sciences Center otolaryngology interest group transitioned to virtual meetings and added student-led didactic sessions. Most students who participated found the virtual didactic sessions helpful and appreciated the opportunity to practice presenting cases. Students were able to network with residents and faculty members, resulting in 60% of participants finding involvement in research projects. Virtual meetings allowed the participation of students from multiple institutions. Participants agreed that the networking, teaching, and research opportunities presented by the virtual sessions made them better applicants for otolaryngology residency. This study provides a framework for transitioning specialty interest group meetings to a virtual platform while adding student-led didactic sessions.

Extranodal natural killer/T-cell lymphoma nasal type.

Extranodal natural killer/T-cell lymphoma nasal type (ENKL) is a rare neoplasm uncommon in the US. Diagnosis is complicated by low incidence and rapid tissue necrosis preventing timely histologic confirmation. We report the case of a 55-year-old woman with ENKL who faced a challenging diagnostic workup due to widespread nasal tissue necrosis and nonspecific sinus-related complaints. While ENKL is significantly more common in Asia and South America, clinicians worldwide should maintain a high level of suspicion for patients presenting with nonspecific nasopharyngeal complaints who have signs of tissue necrosis. Early recognition and treatment with combined radiotherapy and chemotherapy can improve survival.

Biomolecular endotype factors involved in COVID-19 airway infectivity: A systematic review.

OBJECTIVES: To review the current knowledge of biomolecular factors surrounding otorhinolaryngeal illnesses and analyze their presence in COVID-19 virulence. Emphasis was placed on cytokines and vitamin D for determining susceptibility of illness. METHODS: A primary literature search of PubMed and Google Scholar for articles published between January 1, 2002 to May 31, 2020, was performed without language restrictions from May 8, 2020 to May 31, 2020. A focused second search was conducted from October 31, 2020 to November 2, 2020 for articles published between January 1, 2002 to October 31, 2020. Eligible articles were selected after evaluation of titles, abstracts, and references. A total of 45 were included in this review. RESULTS: Differing endotype classification schemes are used to determine cytokines present in chronic rhinosinusitis, asthma, and allergies. While immunologic responses and biomarkers are primary methods of differentiation, recent literature has also implicated geographic distribution of chronic rhinosinusitis patients in accounting for cytokine variations. The cytokines of interest (IL-4, IL-13, and INF-γ) present in the endotypes of these conditions may point towards protective mechanisms against COVID-19 through downregulation of the ACE2 receptor. These cytokines and Vitamin D highlight new areas of study for factors affecting SARS-CoV-2 virulence. CONCLUSIONS: Further research is needed to understand the effects of Vitamin D and the various cytokines prevalent among endotypes of nasal/pharyngeal illnesses on COVID-19 pathogenesis. Findings may point towards epidemiologic trends of SARS-CoV-2 transmission and have future therapeutic indications.

Unique presentation of Aggregatibacter aphrophilus in a superficial left temporal abscess.

Aggregatibacter aphrophilus, previously Haemophilus aphrophilus, is an uncommon organism that historically has been associated with HACEK infective endocarditis and brain abscesses. This organism is most often isolated as part of normal oral flora, and patients with A. aphrophilus infection usually have an underlying periodontal infection or immunocompromised state allowing for infection. This case report outlines a unique presentation of left superficial temporal abscess due to A. aphrophilus infection in an immunocompetent individual.