Novel evaluation method for facial nerve palsy using 3D facial recognition system in iPhone.

OBJECTIVE: While subjective methods like the Yanagihara system and the House-Brackmann system are standard in evaluating facial paralysis, they are limited by intra- and inter-observer variability. Meanwhile, quantitative objective methods such as electroneurography and electromyography are time-consuming. Our aim was to introduce a swift, objective, and quantitative method for evaluating facial movements. METHODS: We developed an application software (app) that utilizes the facial recognition functionality of the iPhone (Apple Inc., Cupertino, USA) for facial movement evaluation. This app leverages the phone's front camera, infrared radiation, and infrared camera to provide detailed three-dimensional facial topology. It quantitatively compares left and right facial movements by region and displays the movement ratio of the affected side to the opposite side. Evaluations using the app were conducted on both normal and facial palsy subjects and were compared with conventional methods. RESULTS: Our app provided an intuitive user experience, completing evaluations in under a minute, and thus proving practical for regular use. Its evaluation scores correlated highly with the Yanagihara system, the House-Brackmann system, and electromyography. Furthermore, the app outperformed conventional methods in assessing detailed facial movements. CONCLUSION: Our novel iPhone app offers a valuable tool for the comprehensive and efficient evaluation of facial palsy.

Safety and efficacy of high tracheostomy with inferior retraction of the thyroid isthmus.

OBJECTIVE: In typical surgical tracheostomy, the thyroid isthmus is divided or retracted superiorly and preserved. However, at our institution, the thyroid isthmus is retracted inferiorly and preserved. Thereafter, a tracheal incision is made above the thyroid isthmus. This method, hereinafter defined as high tracheostomy, has the advantage of facilitating immediate access to the trachea in a superficial position; moreover, it can be quickly replaced with cricothyrotomy in emergency situations. However, tracheotomies placed too high can potentially damage the cricoid cartilage, thereby causing subglottic granulation and tracheal stenosis. We aimed to validate the safety and efficacy of high tracheostomy with inferior retraction of the thyroid isthmus. METHODS: This was a retrospective cohort analysis. We analyzed the operative method and other relevant characteristics of 90 patients who underwent surgical tracheostomy between April 2016 and June 2022. For those who underwent high tracheostomies, we analyzed the duration of surgery, amount of intraoperative bleeding, occurrence of complications, problems with stoma closure, and perioperative mortality. RESULTS: High tracheostomy was performed in 73 patients. Subglottic granulation occurred in one patient, and the granulation tissue spontaneously shrank. Subcutaneous emphysema occurred in two patients. No patient developed wound infection or tracheoinnominate artery fistula. Moreover, no patient experienced false route tracheotomy tube insertion because the thyroid glands were located under the stoma. CONCLUSION: The frequency of complications was comparable to that reported in other studies on tracheostomy. Additionally, no patient developed tracheal stenosis secondary to tracheostomy above the thyroid isthmus. Therefore, high tracheostomy with inferior retraction and preservation of the thyroid isthmus is safe and advantageous.

Hemostasis for a Post-tonsillectomy Hemorrhage in a Patient With Coronavirus Disease.

During the coronavirus disease 2019 (COVID-19) pandemic, otolaryngologists should be careful when performing upper airway surgery because of the risk of aerosol generation. This paper describes the case of a 23-year-old male who was diagnosed with COVID-19 four days after undergoing tonsillectomy. COVID-19 was complicated by pulmonary thromboembolism, and anticoagulation was administered, which caused postoperative hemorrhage. The patient had to undergo another surgery for the control of hemorrhage, during the infective period of COVID-19. COVID-19 is sometimes associated with venous embolism, and for postoperative patients, treatment should be carefully considered because of the risk of bleeding. The administration of heparin as an anticoagulant would be preferable because heparin allows for dosage adjustment by measuring activated partial thromboplastin time and also allows the rapid cessation of the anticoagulant effect when the administration is discontinued together with antagonization by protamine administration, even if bleeding occurs. When performing surgery for patients with COVID-19, special care is necessary in order not to spread the infection. Even if the preoperative polymerase chain reaction (PCR) test is negative, the patient may be in the incubation period of COVID-19; therefore, caution should be exercised when performing upper respiratory tract surgery such as tonsillectomy.

Validation of indications for enucleation for benign parotid gland tumors.

BACKGROUND: Enucleation has been reported as a minimally invasive surgery for Warthin's tumor (WT). However, the definite indications for enucleation have not been clarified. METHODS: Enucleation was indicated by the following findings: findings of WT, cystic fluid, or benign leukocytes by fine-needle aspiration cytology; a well-margined and homogeneous pattern on imaging; and a tumor location in the tail or preauricular area of the parotid gland. We reviewed 552 cases treated with parotid gland surgery in our hospital. RESULTS: A total of 108 tumors were treated with enucleation and included no malignant solid tumors or pleomorphic adenoma. Enucleation demonstrated low invasiveness and complication rates. Revision surgery for WT reappearance after enucleation was rare and showed minimal scarring, with a lower risk of facial weakness. CONCLUSIONS: The indication criteria for enucleation were validated. Such enucleation is useful, as it is associated with minimal invasiveness, low complication rates, and safety in revision surgery.

Arthroscopic labral repair combined with less invasive open-shelf acetabuloplasty for patients with developmental dysplasia of the hip.

Hip arthroscopy has become widely used for intra-articular lesions, such as labral tears and femoral acetabular impingement. However, its use in patients with developmental dysplasia of the hip (DDH) has been controversial and has historically demonstrated mixed results, as acetabular dysplasia may cause instability due to insufficient bony coverage of the femoral head, thus causing excessive stress on the repaired labrum and cartilage. We devised a combined hip arthroscopic labral repair and a less invasive open-shelf procedure using a small skin incision as an anterolateral portal in hip arthroscopy. This novel procedure may improve the stability of the repaired labrum with a bony covering in a minimally invasive manner. Moreover, the shelf procedure can be performed under direct vision in a comparatively safe and precise manner. In total, 13 hips with DDH underwent the procedure for labral tears. All patients were females, with a mean age of 30 years. The mean follow-up period was 33 months. The mean Harris hip score improved from 74.2 to 93.6, and Oxford Hip score improved from 32.4 to 19.3. According to the Tönnis classification, the grade of arthritis preoperatively was grade 0 for nine hips and grade I for four hips. No radiographic progression of osteoarthritis was observed. It is possible that this novel procedure could be an effective treatment for labral tears with DDH and may prevent the early onset of secondary osteoarthritis. In this technical tip, we describe hip arthroscopic labral repair combined with a less invasive open-shelf acetabuloplasty in further detail.

Classification of Voice Disorders Using a One-Dimensional Convolutional Neural Network.

OBJECTIVES: Auditory-perceptual voice analysis is a standard method for quantifying pathological voice quality, but perceptual ratings are based on subjective evaluations and therefore may vary among examiners. Although many acoustic metrics have been studied for potential use in the objective evaluation of pathological voices, the interpretation of acoustic metrics in individual cases is difficult and the technique is not widely used by clinicians. The aim of this study was to establish standardized methods to discriminate grade, roughness, breathiness, asthenia, strain (GRBAS) scale scores of pathological voices directly using one-dimensional convolutional neural network (1D-CNN) models. METHODS: We constructed an original dataset utilizing 1,377 voice samples of sustained phonation of the vowel /a/. Each voice sample was rated by three experts according to the GRBAS scale and the median values were used as the correct answer label. We designed an end-to-end 1D-CNN model with a raw voice waveform input having a frame width of 9,600 samples. The models were trained with our original dataset for each GRBAS category individually and the model performance was tested by the five-fold cross validation method. RESULTS: The accuracy, F1 score, and quadratic weighted Cohen's kappa for the testing dataset were determined. The metrics for the G scale showed the most balanced model performance, with high accuracy (0.771) and substantial agreement (kappa = 0.710). The model for the R scale had relatively high accuracy (0.765) and F1 score (0.743) with moderate agreement (kappa = 0.536). The accuracy (0.883) and the F1 score (0.865) for the S scale were the highest among the five categories, whereas the Cohen's kappa was the lowest (0.190). CONCLUSIONS: The end-to-end 1D-CNN models can evaluate overall pathological voice quality with a reliability comparable to human evaluations. The efficiency with which the machine learning models can be trained and evaluated is closely related to the dataset quality.

Prevalence of iliopsoas bursitis in patients with end-stage hip osteoarthritis.

OBJECTIVES: Iliopsoas bursitis (IB) is a relatively rare condition that is associated with hip diseases. It can cause neurological symptoms and swelling of the lower extremities by compressing the femoral nerve and vessels. The aim of this study is to examine the prevalence of IB in patients with end-stage hip osteoarthritis. METHODS: A total of 544 patients underwent total hip arthroplasty between May 2010 and May 2019. All patients were examined using computed tomography (CT) to perform preoperative planning. We reviewed the CT images and examined the prevalence and size of IB. These lesions were divided into three types based on their shape (round type, oval type, and heart-shaped type). RESULTS: Of the 544 patients, IB was found in 37 patients. We observed the round type in 4 patients, the oval type in 31 patients, and the heart-shaped type in 2 patients. Two patients showed severe swelling in the legs and had a blood circulatory disorder of the legs. Both cases were heart-shaped bursitis. CONCLUSION: Symptomatic IB was observed in two cases, both of which had a heart shape surrounding the iliopsoas tendon and femoral neurovascular bundle. Although symptomatic IB is a rare condition, special attention is required for heart-shaped IB.

Impact of Changing Surgical Strategies on Clinical Outcomes in Patients with Parotid Carcinoma: A 53-Year Single-Institution Experience.

Background and Objectives: We investigated the clinical outcomes of patients who underwent surgery for parotid carcinoma in a single institution during a 53-year period. This study aimed to estimate the impact of changing the surgical approach to parotid carcinoma on clinical outcomes including the incidence rate of the facial nerve palsy. Materials and Methods: Sixty-seven patients with parotid carcinoma who underwent surgery between 1966 and 2018 were retrospectively reviewed. Group A consisted of 29 patients who underwent surgery from 1966 to 2002, and Group B consisted of 38 patients from 2002 to 2018. Treatment outcomes were estimated. Additionally, candidate prognostic factors of Group B, the current surgical approach group, were evaluated. Results: Partial parotidectomy and total parotidectomy were performed in 35 and 32 patients, respectively. Partial parotidectomy was performed in 4 patients in Group A and 31 patients in Group B, with a predominant increase in Group B. The facial nerve was preserved in 43 patients, among whom 8 in Group A (8/17; 47.1%) and 7 in Group B (7/26; 26.9%) had temporary postoperative facial nerve palsy. Postoperative radiotherapy was performed on 35 patients. The 5-year OS, DSS, and DFS rates for Group A were 77.1%, 79.9%, and 71.5%, respectively. The 5-year OS, DSS, and DFS rates for Group B were 77.1%, 77.1%, and 72.4%, respectively. Clinical T4 stage, clinical N+ stage, stage IV disease, and tumor invasion of the facial nerve were independent prognostic factors in Group B. Conclusions: The incidence of facial nerve palsy in the current surgical approach group decreased compared with that in the previous surgical approach group. The current surgical management and treatment policies for parotid carcinoma have led to improved outcomes.

Chronic postsurgical pain after total knee arthroplasty: A prospective cohort study in Japanese population.

OBJECTIVES: To elucidate the prevalence and risk factors of chronic postsurgical pain (CPSP) after primary total knee arthroplasty (TKA) in Japanese population. METHODS: Consecutive patients undergoing primary TKA in a Japanese tertiary hospital (211 knees) were assessed. CPSP after TKA was defined as moderate to severe pain (VAS >30 mm), either at rest or during walking, one year after surgery. Clinical and radiographic data were compared between CPSP and non-CPSP groups and multivariate logistic regression was used to identify predictors of CPSP. RESULTS: The prevalence of CPSP was 8.8%. CPSP group showed significantly higher preoperative WOMAC subscales (pain, function and stiffness), higher rate of postoperative coronal malalignment (femorotibial angle >178° or <170°) and larger varus angle of tibial component compared with non-CPSP group. Logistic regression analysis revealed that preoperative higher WOMAC pain and postoperative coronal malalignment were independent risk factors of CPSP. In a subgroup analysis of patients with well-aligned TKA, preoperative pain VAS at rest was the only risk factor of CPSP. CONCLUSION: Preoperative severe pain and postoperative coronal malalignment were independent risk factors of CPSP after TKA. Preoperative pain management in patients with severe pain and good coronal alignment after TKA possibly minimize the development of CPSP.

Objective Assessment of Pathological Voice Using Artificial Intelligence Based on the GRBAS Scale.

OBJECTIVES: The validity and reliability of the psychological assessment of auditory perceptions, as typified by the grade, roughness, breathiness, asthenia, and strain (GRBAS) scale, have been widely recognized. However, due to their subjective nature, inter- and intra-examiner reliability are unavoidable. In this study, we aimed to add objectivity to the GRBAS scale using artificial intelligence and to compare the accuracy of two methods-one based on Google's TensorFlow and another based on Apple's Core ML. METHODS: The GRBAS scale of 1,377 vowel samples was evaluated and used as training data to create a machine learning model. We used TensorFlow and Apple's Create ML to create two machine learning models and examined the difference in their accuracies for classifying the severity of pathological Voice data based on the GRBAS scale. RESULTS: Absolute comparisons are difficult to make because of the difference in methods; however, both training models could objectively evaluate GRBAS scales and were statistically correlated in G and B. CONCLUSION: While TensorFlow requires creation of a training model from scratch, Create ML is a relatively easy way to create a training model for voice by adding training data for GRBAS scales to an existing training model for sounds. Although the data handling and learning methods are different, both models performed well. Findings from this study could be used for medical screening purposes, and there is the potential to change the clinical approach to voice diagnostics in the future.

A New Device for Fine-Needle Aspiration Cytology Consisting of a Vibrating Linear Resonant Actuator.

OBJECTIVE: To evaluate the efficacy of a new device for fine-needle aspiration cytology (FNAC) consisting of a vibrating linear resonant actuator (LRA). STUDY DESIGN: Prospective clinical study. METHODS: The LRA frequency was optimized by visualization of the needle motion using a high-speed camera. The FNAC device consists of a vibrating motor fixed to the stopper of a 5-ml syringe and piston. Upon insertion of the syringe needle into a thyroid nodule (with the stopper attached to the syringe piston), sufficient negative pressure with 1-ml suction was maintained. Subsequently, samples were obtained using vibration generated by an LRA or an eccentric rotating mass (ERM). Surgically resected thyroid specimens from 10 patients were evaluated. The number of follicular groups required for adequate diagnosis and the number of larger follicular groups were counted. Next, 254 thyroid nodules from 187 patients were also evaluated by FNAC. The inadequacy rate was determined, and final cytology was classified according to thyroid Bethesda categories. RESULTS: The optimized LRA frequency was 155 Hz. Both the LRA and ERM devices resulted in sufficient amounts of diagnostic material and achieved low inadequacy rates. The number of large follicular groups obtained was significantly greater with the LRA device compared with the ERM device. CONCLUSIONS: The vibrating device using an LRA for thyroid FNAC resulted in sufficient amounts of thyroid follicular groups and achieved low inadequacy rates. In addition, the LRA device allowed for collection of larger follicular groups sufficient to diagnose appropriate thyroid Bethesda categories. LEVEL OF EVIDENCE: 2 Laryngoscope, 131:E1393-E1399, 2021.

Accuracy of acetabular cup placement using an angle-adjusting alignment guide with laser pointer in total hip arthroplasty.

PURPOSE: To evaluate cup-positioning accuracy in total hip arthroplasty (THA) using a novel angle-adjusting alignment guide with laser pointer and determine whether level of surgical experience affects accuracy of cup placement or not. METHODS: We included 117 hips in 104 patients who underwent THA using the novel guide. We retrospectively reviewed 44 hips in 40 patients who underwent THA before the novel guide was introduced. We compared differences in cup angles between the novel guide group and the conventional guide group as well as the discrepancies in targeted angles between the experienced surgeon group and the inexperienced surgeon group. RESULTS: There were 114/117 hips (97.4%) within the Lewinnek safe zone in the novel guide group and 32/44 hips (72.7%) within the safe zone in the conventional guide group. There were significantly fewer outliers in the novel guide group (p < 0.001). In the experienced surgeon group, the mean absolute errors in inclination and anteversion were 2.0 ± 1.7° and 2.1 ± 2.3°, respectively; which were not significantly different from those in the inexperienced surgeon group (2.3 ± 2.1° and 2.8 ± 2.3°, respectively). CONCLUSION: The novel angle-adjusting alignment guide with laser pointer is a simple tool that provides better accuracy of cup position than that obtained using conventional guides. Accurate cup placement is possible using the novel guide, regardless of surgeons' experience.

Successful treatment of eosinophilic chronic rhinosinusitis and eosinophilic otitis media using the anti-IL-5 receptor monoclonal antibody benralizumab: A case report.

Eosinophilic chronic rhinosinusitis (ECRS) is characterized by the presence of nasal polyps, dominant ethmoid shadows in computed tomography (CT) scans, and elevated levels of eosinophil infiltration into the nasal polyps and peripheral blood. ECRS is often accompanied by severe asthma. The recent development of monoclonal antibody-based biologics, including benralizumab, has offered new therapeutic approaches for the treatment of asthma and allergic diseases. Asthma and ECRS are closely related; hence, benralizumab could provide clinical benefit in ECRS patients with severe asthma. Herein, we report a case of a 47-year-old female patient with severe asthma that presented with nasal obstruction and hearing impairment. Nasal endoscopic and otoscopic examinations indicated the presence of bilateral nasal polyps in the middle nasal meatus, as well as a bilateral effusion in the tympanic cavity. Sinus and temporal CT images showed dominant ethmoid sinus and tympanic cavity shadows. Biopsy of nasal polyps revealed high numbers of eosinophils, which led to the diagnosis of ECRS; eosinophilic otitis media (EOM) with hypereosinophilia was also suspected. Treatment with benralizumab reduced the number of peripheral blood eosinophils and improved asthma symptoms. Prolonged benralizumab administration also resulted in a remarkable size reduction in bilateral middle nasal polyps and aeration of the tympanic cavity. In conclusion, benralizumab treatment improved the symptoms of severe asthma, ECRS, and EOM. Eosinophil depletion could be an important mechanism by which benralizumab improves ECRS and EOM. The use of benralizumab for the treatment of ECRS and EOM patients with severe asthma merits further investigation in large-cohort studies.

Real-Time Acoustic Voice Analysis Using a Handheld Device Running Android Operating System.

OBJECTIVES: We developed a highly accessible acoustic voice analysis system (VArt) using a handheld device running Android operating system. To provide stable and reliable analysis using readily obtainable equipment under unfavorable conditions, we modified the fundamental frequency (F0) extraction algorithm and designed an intuitive user interface representing a new hoarseness index (real-time Ra: Rart), which is a derivative of harmonics-to-noise ratio developed by Kojima and Shoji (Ra2). Since Rart continues to display analysis results in real time, unlike conventional acoustic analysis, it can be used for evaluation such as during phonosurgery and speech therapy. We evaluated the agreement between the earlier version of acoustic voice analysis software (VA) running on a Windows personal computer and VArt running on a handheld device. METHODS: F0, Ra2, and Rart were measured in voice samples of sustained vowel phonation /a/ from 10 healthy volunteers and 22 patients with voice disorders using VA running on a Windows personal computer and VArt running on two types of handheld devices in a sound-treated room or in a medical examination room. Intraclass correlation coefficients were calculated for both systems under both conditions. RESULTS: All of the comparisons were highly correlated. CONCLUSIONS: Measurements obtained using our newly developed VArt were highly consistent with those using VA, indicating high reliability. Moreover, the new system increases the clinical feasibility of acoustic voice analysis.

Adrenal insufficiency following nivolumab therapy in patients with recurrent or metastatic head and neck cancer.

Nivolumab, an anti-programmed cell death-1 monoclonal antibody, is currently used to treat many types of advanced cancers including recurrent and metastatic head and neck cancer. However, there are increasing reports concerning immune-related adverse events related to nivolumab therapy. Here, we report three patients who presented with adrenal insufficiency following nivolumab therapy. Two were diagnosed as having isolated adrenocorticotropic hormone (ACTH) deficiency and one was diagnosed as having primary adrenal insufficiency. All three patients complained of progressive fatigue and appetite loss, so we measured their blood cortisol and ACTH levels and diagnosed them as having adrenal deficiency. Treatment with nivolumab was discontinued for all three patients, and replacement therapy using hydrocortisone was successful after a few days in all cases. Two patients subsequently resumed nivolumab therapy because their general condition had improved. Complaints of fatigue and appetite loss during cancer treatment are common and tend to be regarded as unimportant. Although adrenal insufficiency due to nivolumab is relatively rare, complaints of these symptoms could lead to the detection of adrenal insufficiency at an early stage. The present report highlights the importance of the early recognition of adrenal insufficiency.

An Innovative Voice Analyzer "VA" Smart Phone Program for Quantitative Analysis of Voice Quality.

OBJECTIVE: The 'VA' Windows program that we developed in 2011 for analyzing voice quality quantitatively uses zerocross picking to find individual basic pitch periods. It has a simple and user-friendly user interface and high accuracy. This program determines the fundamental frequency, jitter, shimmer, PPQ, APQ, and signal-to-noise ratio (Ra). It needs only a general-purpose Windows PC, USB audio interface and a microphone. The aim of this study is to improve the version of the VA Windows program in English and to develop a VA smart phone program to allow wider use of objective acoustic analysis. STUDY DESIGN: Cross-sectional study. METHODS: Sustained vowel /a/ sounds from 40 subjects without evident vocal problems, and 40 subjects with slight hoarseness, were examined. We compared the analyzed data with data from other software (MDVP and Praat). For a comparison between VA for Windows and VA for a smart phone, sustained vowel /a/ sounds from six subjects without hoarseness were recorded with each system simultaneously. RESULTS: The normal voice and slightly hoarse voice data analyzed with VA showed a high correlation with most parameters from both MDVP and Praat. There was a strong correlation between the Windows and smart phone versions of VA in terms of the fundamental frequency and Ra. CONCLUSIONS: The results showed that the VA software was not inferior to the other acoustic analysis software tested. The simple and easy to use smart phone version may facilitate our goal of creating an objective, widely available method to evaluate hoarseness.

Discrimination of "hot potato voice" caused by upper airway obstruction utilizing a support vector machine.

OBJECTIVES/HYPOTHESIS: "Hot potato voice" (HPV) is a thick, muffled voice caused by pharyngeal or laryngeal diseases characterized by severe upper airway obstruction, including acute epiglottitis and peritonsillitis. To develop a method for determining upper-airway emergency based on this important vocal feature, we investigated the acoustic characteristics of HPV using a physical, articulatory speech synthesis model. The results of the simulation were then applied to design a computerized recognition framework using a mel-frequency cepstral coefficient domain support vector machine (SVM). STUDY DESIGN: Quasi-experimental research design. METHODS: Changes in the voice spectral envelope caused by upper airway obstructions were analyzed using a hybrid time-frequency model of articulatory speech synthesis. We evaluated variations in the formant structure and thresholds of critical vocal tract area functions that triggered HPV. The SVMs were trained using a dataset of 2,200 synthetic voice samples generated by an articulatory synthesizer. Voice classification experiments on test datasets of real patient voices were then performed. RESULTS: On phonation of the Japanese vowel /e/, the frequency of the second formant fell and coalesced with that of the first formant as the area function of the oropharynx decreased. Changes in higher-order formants varied according to constriction location. The highest accuracy afforded by the SVM classifier trained with synthetic data was 88.3%. CONCLUSIONS: HPV caused by upper airway obstruction has a highly characteristic spectral envelope. Based on this distinctive voice feature, our SVM classifier, who was trained using synthetic data, was able to diagnose upper-airway obstructions with a high degree of accuracy. LEVEL OF EVIDENCE: 2c Laryngoscope, 129:1301-1307, 2019.