Two-Year Outcomes After Pediatric In-Office Tympanostomy Using Lidocaine/Epinephrine Iontophoresis and an Automated Tube Delivery System.

OBJECTIVE: Evaluate 2-year outcomes after lidocaine/epinephrine iontophoresis and tympanostomy using an automated tube delivery system for pediatric tube placement in-office. STUDY DESIGN: Prospective, single-arm. SETTING: Eighteen otolaryngology practices. METHODS: Children age 6 months to 12 years indicated for tympanostomy were enrolled between October 2017 and February 2019. Local anesthesia of the tympanic membrane was achieved via lidocaine/epinephrine iontophoresis and tympanostomy was completed using an automated tube delivery system (the Tula® System). An additional Lead-In cohort of patients underwent tube placement in the operating room (OR) under general anesthesia using only the tube delivery system. Patients were followed for 2 years or until tube extrusion, whichever occurred first. Otoscopy and tympanometry were performed at 3 weeks, and 6, 12, 18, and 24 months. Tube retention, patency, and safety were evaluated. RESULTS: Tubes were placed in-office for 269 patients (449 ears) and in the OR for 68 patients (131 ears) (mean age, 4.5 years). The median and mean times to tube extrusion for the combined OR and In-Office cohorts were 15.82 (95% confidence interval [CI]: 15.41-19.05) and 16.79 (95% CI: 16.16-17.42) months, respectively. Sequelae included ongoing perforation for 1.9% of ears (11/580) and medial tube displacement for 0.2% (1/580) observed at 18 months. Over a mean follow-up of 14.3 months, 30.3% (176/580) of ears had otorrhea and 14.3% (83/580) had occluded tubes. CONCLUSION: In-office pediatric tympanostomy using lidocaine/epinephrine iontophoresis and automated tube delivery results in tube retention within the ranges described for similar grommet-type tubes and complication rates consistent with traditional tube placement in the OR.

In-Office Tympanostomy Tube Placement in Children Using Iontophoresis and Automated Tube Delivery.

OBJECTIVES/HYPOTHESIS: Evaluate technical success, tolerability, and safety of lidocaine iontophoresis and tympanostomy tube placement for children in an office setting. STUDY DESIGN: Prospective individual cohort study. METHODS: This prospective multicenter study evaluated in-office tube placement in children ages 6 months through 12 years of age. Anesthesia was achieved via lidocaine/epinephrine iontophoresis. Tube placement was conducted using an integrated and automated myringotomy and tube delivery system. Anxiolytics, sedation, and papoose board were not used. Technical success and safety were evaluated. Patients 5 to 12 years old self-reported tube placement pain using the Faces Pain Scale-Revised (FPS-R) instrument, which ranges from 0 (no pain) to 10 (very much pain). RESULTS: Children were enrolled into three cohorts with 68, 47, and 222 children in the Operating Room (OR) Lead-In, Office Lead-In, and Pivotal cohorts, respectively. In the Pivotal cohort, there were 120 and 102 children in the <5 and 5- to 12-year-old age groups, respectively, with a mean age of 2.3 and 7.6 years, respectively. Bilateral tube placement was indicated for 94.2% of children <5 and 88.2% of children 5 to 12 years old. Tubes were successfully placed in all indicated ears in 85.8% (103/120) of children <5 and 89.2% (91/102) of children 5 to 12 years old. Mean FPS-R score was 3.30 (standard deviation [SD] = 3.39) for tube placement and 1.69 (SD = 2.43) at 5 minutes postprocedure. There were no serious adverse events. Nonserious adverse events occurred at rates similar to standard tympanostomy procedures. CONCLUSIONS: In-office tube placement in selected patients can be successfully achieved without requiring sedatives, anxiolytics, or papoose restraints via lidocaine iontophoresis local anesthesia and an automated myringotomy and tube delivery system. LEVEL OF EVIDENCE: 2b Laryngoscope, 130:S1-S9, 2020.

Surgical treatment of facial paralysis.

The management of facial paralysis is one of the most complex areas of reconstructive surgery. Given the wide variety of functional and cosmetic deficits in the facial paralysis patient, the reconstructive surgeon requires a thorough understanding of the surgical techniques available to treat this condition. This review article will focus on surgical management of facial paralysis and the treatment options available for acute facial paralysis (<3 weeks duration), intermediate duration facial paralysis (3 weeks to 2 yr) and chronic facial paralysis (>2 yr). For acute facial paralysis, the main surgical therapies are facial nerve decompression and facial nerve repair. For facial paralysis of intermediate duration, nerve transfer procedures are appropriate. For chronic facial paralysis, treatment typically requires regional or free muscle transfer. Static techniques of facial reanimation can be used for acute, intermediate, or chronic facial paralysis as these techniques are often important adjuncts to the overall management strategy.

Management of synkinesis.

Facial synkinesis is one of the most distressing consequences of facial paralysis. Synkinesis refers to the abnormal involuntary facial movement that occurs with voluntary movement of a different facial muscle group. The pathophysiologic basis of facial synkinesis is likely multifactorial although the predominant mechanism appears to be aberrant regeneration of facial nerve fibers to the facial muscle groups after facial nerve injury. Patients experience hypertonic contractures and synkinetic movements such as eye closure with volitional movement of the mouth or midfacial movement during volitional or reflexive eye closure. Synkinesis can cause functional limitation with activities such as eating, drinking, smiling, and may even lead to social isolation. Evaluation of synkinesis is primarily subjective with facial grading scales such as the Sunnybrook scale. Objective measures of synkinesis using computerized video analysis show promise although no objective techniques are currently widely used. The most common therapeutic modalities for the treatment of facial synkinesis include (1) botulinum toxin type A (BTX-A) injections for selective chemodenervation of affected muscle groups and (2) facial neuromuscular retraining. Biofeedback using mirrors or electromyography has been used both for the treatment and prevention of facial synkinesis. Other treatment options include surgical therapies, such as selective neurolysis or myectomy, although these have been rendered nearly obsolete with the advent of BTX-A.

Intraoperative diagnosis of facial nerve schwannoma at parotidectomy.

OBJECTIVE: Our objective was to provide a diagnostic algorithm for facial nerve schwannomas presenting as a parotid mass. STUDY DESIGN: The study is a case report and literature review. METHODS: A clinical case of a patient with an asymptomatic parotid mass diagnosed as a facial nerve schwannoma intraoperatively is presented. The patient's presentation and the diagnostic algorithm and surgical rationale are discussed. A review of the literature on facial nerve schwannomas is presented. CONCLUSIONS: Intraparotid facial nerve schwannomas are an extremely rare entity and are rarely diagnosed preoperatively. Most of these benign lesions can be managed conservatively with the goal of preserving facial nerve function. Intraoperatively, fine-needle aspiration and/or conservative biopsy in a nonstimulating portion of the lesion can be used to make the diagnosis.

Botulinum toxin and quality of life in patients with facial paralysis.

OBJECTIVES: To examine the effect botulinum toxin, a potent neurotoxin that causes temporary paralysis of hyperkinetic musculature, has on the quality of life (QOL) in the patient with facial paralysis. We surveyed patients with facial paralysis, using the previously validated Facial Clinimetric Evaluation QOL instrument, before and then again after therapeutic administration of botulinum toxin for the management of their facial hyperkinesis, and performed pair-wise comparisons to determine the effect on patient QOL. DESIGN: Prospective clinical study at an outpatient facial nerve center. RESULTS: The overall Facial Clinimetric Evaluation score improved from a mean (SD) of 51.7 (20.9) in the pretreatment group to 63.7 (17.8) in the posttreatment group (P < .05). Statistically significant improvements were noted in all subdomain scores, including Facial Movement, Facial Comfort, Oral Function, Eye Comfort, Lacrimal Control, and Social Function (P < .05 for all comparisons). CONCLUSIONS: Botulinum toxin has a well-established objective benefit in the control of facial hyperkinesis in patients with facial nerve disorders. This study establishes the associated QOL benefit and reaffirms its important role in the multimodality management of patients with facial nerve disorders.

Novel 3-D video for quantification of facial movement.

OBJECTIVES: To evaluate a novel 3-D geometry video acquisition system (3-D VAS) for quantifying facial movement. METHODS: Ten normal subjects and four patients with facial paralysis underwent recording of facial movement during three facial expressions. Facial feature points of interest were digitally marked on selected images. The maximum 3-D displacement of the brow and oral commissure and palpebral fissure width were determined. RESULTS: Test-retest reliability using the 3-D VAS in normal subjects was high (Spearman correlation coefficients 0.661-0.830, P < 0.05). The predicted ratio of left to right facial measurements was 1.00 in normal subjects, and measured mean ratios were 1.05 (brow excursion), 1.01 (palpebral fissure width), and 1.03 (oral commissure excursion), respectively, matching the prediction. The 3-D VAS reliably quantified facial movement on both sides in patients with facial paralysis. CONCLUSIONS: The novel 3-D VAS can accurately and reliably quantify facial movement in healthy subjects. It is promising as a clinical tool to quantify facial movement in patients with facial paralysis.

Pediatric deaths due to otolaryngologic causes: a population-based study in Massachusetts, 1990-2002.

OBJECTIVE: To identify the most common otolaryngologic causes of mortality in the 0 to 19 age group in the state of Massachusetts and to estimate the pediatric otolaryngologic mortality rate based on population data. STUDY DESIGN: Population-based retrospective cohort study. METHODS: The Massachusetts State Registry of Vital Records and Statistics electronic database was searched for all otolaryngology related causes of death from 1990 to 2002 for children aged 0 to 19. The individual death certificates were then reviewed, and a database of otolaryngology related pediatric deaths was created. RESULTS: A total of 59 otolaryngology related deaths were identified in the pediatric population from 1990 to 2002. Eighty-one percent of deaths occurred because of airway compromise caused by infection, anatomic obstruction, or congenital anomaly. The remaining 19% of deaths occurred because of aspiration, nonairway infections, and malignant neoplasms. Ninety-five percent of deaths in the children under age 10 were caused by airway compromise. Six of seven deaths (86%) in the age 15 to 19 group occurred because of malignant neoplasms. The overall mortality rate caused by otolaryngologic causes was estimated to be 0.28 per 100,000 population. CONCLUSIONS: The overall mortality rate for otolaryngology related deaths is low in the pediatric population. The vast majority of deaths are caused by airway compromise, primarily because of laryngotracheobronchitis or other upper airway obstruction. In older children (ages 15-19), malignant head and neck neoplasms are the leading cause of otolaryngology related deaths.

Mandibular reconstruction in 2004: an analysis of different techniques.

PURPOSE OF REVIEW: The field of mandibular reconstruction has evolved dramatically over the past fifty years. Numerous advances in microsurgical technique, plating technology and instrumentation, and an understanding of donor site angiosomes have made consistent and reliable mandibular reconstruction possible. Refinements in technique continue to improve the functional and aesthetic outcomes of oromandibular reconstruction. This review discusses the current state-of-the-art techniques for mandibular reconstruction and highlights the latest innovations in technique. RECENT FINDINGS: The most common indication for oromandibular reconstruction remains ablative surgery for advanced neoplastic processes of the oral cavity and oropharynx. Reconstruction of these complex three-dimensional composite bony and soft-tissue defects is paramount for rehabilitation of form and function. Vascularized osseous free tissue transfer is the state-of-the-art for mandibular reconstruction. The long-term excellent functional and aesthetic outcomes of this technique have recently been reported. The most commonly used free flaps for mandibular reconstruction are the fibula, iliac crest, and scapula. Each of these typically accepts endosseous implants improving functional outcomes. The use of mandibular reconstruction plates and coverage with a soft-tissue flap remains a reconstructive option for selected patients. The latest refinements in technique include temporary intraoperative external fixation, the use of periosteal free flaps, distraction osteogenesis, and development of biodegradable biopolymer scaffolds for mandibular defects. SUMMARY: Oromandibular reconstruction, although a challenge for the head and neck reconstructive surgeon, is now reliable and highly successful with excellent long-term functional and aesthetic outcomes.

Cervical bronchogenic cysts: a consideration in the differential diagnosis of pediatric cervical cystic masses.

OBJECTIVE: To discuss the clinical and histopathologic features of cervical bronchogenic cysts. METHODS: Retrospective case series. RESULTS: A 22-year pathology database search identified 24 patients 18 years of age and younger with bronchial/bronchogenic cysts, four of which presented in the cervical region. CONCLUSION: Cervical bronchogenic cysts are rare in the pediatric population but deserve inclusion in the differential diagnosis of cystic neck masses. Such cysts result from abnormal tracheobronchial tree development with characteristic pathology including respiratory-type epithelium, mural cartilage, smooth muscle, and seromucinous glands. Definitive treatment requires surgical excision.

Diagnostic utility of laser-Doppler vibrometry in conductive hearing loss with normal tympanic membrane.

HYPOTHESIS: It was hypothesized that laser-Doppler vibrometry measurements of umbo velocity in aerated middle ears with conductive loss can differentiate ossicular interruptions, stapes fixations, and mallear fixations. More generally, we hypothesize that laser-Doppler vibrometry measurements of umbo velocity can give information about how differences in the impedance that the ossicles work against affect middle-ear function. BACKGROUND: Laser-Doppler vibrometry is a well-established research tool for exploring middle-ear function. The authors wished to investigate its potential as a clinical tool for differential diagnosis of the cause of conductive hearing loss. METHODS: Laser-Doppler vibrometry was used to investigate the relationship between the sound-induced velocity of the tympanic membrane at the umbo and the cause of conductive hearing loss when the tympanic membrane was normal and the middle ear was aerated. The results of measurements in 17 adult ears before exploratory tympanotomy were compared with the surgically determined cause of the hearing loss. The authors also measured the motion of the umbo in 10 patients who had undergone successful small-fenestra stapedectomy procedures. In all the studied ears, pure-tone audiograms were measured at the time of laser-Doppler vibrometry testing. RESULTS: There were clear statistical differences between the umbo velocity in normal ears and in ears with different ossicular pathologic conditions. There was also a clear separation of the results between ears with ossicular interruptions and ossicular fixation. The pattern of laser-Doppler vibrometry measurements in poststapedectomy ears approximated the pattern in ears with ossicular interruptions. CONCLUSION: Comparison of laser-Doppler vibrometry results and audiometry may be a sensitive and selective indicator of ossicular pathologic conditions as well as a useful tool for investigating middle ear function.

Middle-ear mechanics of Type III tympanoplasty (stapes columella): I. Experimental studies.

OBJECTIVE: To investigate the mechanics of Type III tympanoplasty by developing a cadaveric temporal bone model. BACKGROUND: Type III stapes columella tympanoplasty involves the placement of a tympanic membrane graft, usually made of temporalis fascia, directly onto the stapes head. The procedure is usually done in conjunction with a canal wall down mastoidectomy. Postoperative hearing results vary widely, with air-bone gaps of 10 to 60 dB. The structural features responsible for the wide range in hearing results have not been systematically investigated. METHODS: Canal wall down Type III procedures were performed in eight cadaveric temporal bones. Acoustic stimuli were presented in the ear canal, and round window velocity VRW (used as an index of hearing) was measured, while systematically varying stapes mobility, mechanical properties of tympanic membrane graft, and tightness of connection between tympanic membrane graft and stapes. The effect of interposing a thin cartilage disc between the tympanic membrane graft and stapes head was also assessed. RESULTS: When the middle ear was aerated and the stapes was mobile, VRW was 15 to 30 dB lower than in an intact, normal ear. Stapes fixation led to a significant reduction in VRW; reduction was greatest at low frequencies. There was little effect of varying the tightness of connection between the tympanic membrane graft and stapes head. Sound energy was transmitted from the graft to the stapes as long as the graft was in physical contact with the stapes head. Different tympanic membrane graft materials with a range of mechanical properties (stiffness and mass) resulted in little variation in VRW. Interposing a thin cartilage disc between the tympanic membrane graft and stapes improved VRW in the lower frequencies by 5 to 10 dB. The authors hypothesize that the disc acted to increase the effective vibrating area of the graft. CONCLUSIONS: The feasibility of using a cadaveric temporal bone model to study the mechanics of Type III tympanoplasty was demonstrated. A mobile stapes and aerated middle ear were essential for a successful Type III tympanoplasty. There was little effect of varying the mechanical properties of the tympanic membrane graft or changing the tightness of connection between the graft and stapes head. Improved results were achieved by interposing a thin cartilage disc between the graft and stapes head to increase the effective vibrating area of the graft.

Middle ear mechanics of Type III tympanoplasty (stapes columella): II. Clinical studies.

OBJECTIVES: To determine the structural features that are responsible for the large variation in postoperative hearing results after Type III stapes columella tympanoplasty, to compare the clinical results after Type III tympanoplasty with predictions based on experimental investigations using a temporal bone model, and to investigate the effectiveness of a modification in surgical technique for Type III reconstruction. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. INCLUSION CRITERIA: The ear was healed with an intact tympanic membrane graft; the status of the stapes was known, whether mobile or fixed; and the postoperative status of aeration of the middle ear was known, whether aerated or not. MAIN OUTCOME MEASURE: Air-bone gap at frequencies 250, 500, 1,000, 2,000 and 4,000 Hz. RESULTS: In ears with temporalis fascia graft onto stapes head: mobile stapes and aerated middle ear (n = 34), mean air-bone gaps at audiometric frequencies were 15 to 30 dB, consistent with predictions of the experimental model; mobile stapes and nonaerated middle ear (n = 16), large air-bone gaps of 35 to 55 dB; fixed stapes and aerated middle ear (n = 4), large air-bone gaps of 30 to 50 dB; fixed stapes and nonaerated middle ear (n = 2), large air-bone gaps of 30 to 70 dB. In ears with a fascia-cartilage graft onto stapes head, where a thin disc of meatal cartilage, 0.3 to 0.5 mm thick and 4 to 6 mm in diameter was interposed between the fascia graft and the stapes head: mobile stapes and aerated middle ear (n = 9), mean air-bone gaps at audiometric frequencies were 10 to 25 dB, about 5 dB better at 250, 500, and 2,000 Hz than in ears with only a fascia graft ( <0.05), improvement consistent with that observed experimentally when a thin cartilage disc was used in the temporal bone model, hypothesis that the cartilage increased the effective vibrating area of the graft; mobile stapes and nonaerated middle ear (n = 2), air-bone gaps were 40 to 50 dB. CONCLUSIONS: Large air-bone gaps of 30 to 70 dB occurred as a result of stapes fixation, nonaeration of the middle ear, or both. When the stapes was mobile and the middle ear was aerated, a fascia graft resulted in air-bone gaps of 15 to 30 dB. Interposing a thin disc of cartilage between the fascia graft and stapes head to improve the effective vibrating graft area gave better hearing, with air-bone gaps of 10 to 25 dB. The clinical Type III results were consistent with predictions based on experimental investigations of mechanics of the Type III procedure in a temporal bone model.

Malleus fixation: clinical and histopathologic findings.

The goals of this study were to review important clinical and histopathologic features of malleus fixation. Ten clinical cases and 10 histopathologic cases of malleus fixation were identified. For the clinical cases, preoperative clinical data, surgical findings, and preoperative and postoperative audiometric findings were reviewed. Ninety percent of the clinical cases achieved significant reduction of the air-bone gap after operation. Two thirds of these cases had an air-bone gap of 10 dB or less, and the remainder had air-bone gaps between 20 and 28 dB after operation. For the temporal bone cases, clinical data, histopathologic findings, and other otologic diagnoses were reviewed. Malleus fixation can be idiopathic or a result of trauma, chronic otitis media, or developmental anomalies. It is a cause of hearing loss that is likely to be more common than the number of diagnoses would indicate. Certain audiometric findings may lead one to suspect the diagnosis. The surgical approach used depends on the individual anatomy, and surgery is usually highly effective in improving hearing.