Selective neurectomy for nonflaccid facial palsy.

PURPOSE OF REVIEW: To review the evolving role of selective neurectomy in the management of patients with synkinesis including the history of selective neurectomy, operative techniques, and clinical outcomes. RECENT FINDINGS: Modified selective neurectomy alone or in conjunction with other procedures achieves more durable outcomes based on objective measures such as time to recurrence of symptoms and units of botulinum toxin required postoperatively. This is also reflected on patient reported quality of life outcome measures. Regarding operative technique, lower rates of oral incompetence are reported with division of an average of 6.7 nerve branches as opposed to more branches. SUMMARY: Chemodenervation has long been the mainstay of treatment in facial synkinesis, but in recent years, the paradigm has begun to shift in favor of incorporating interventions with more durable outcomes such as modified selective neurectomy. Modified selective neurectomy is often performed with other simultaneous surgeries such as nerve transfer, rhytidectomy, lid surgery and static facial reanimation primarily to address periocular synkinesis and synkinetic smile. The outcomes have been favorable with improvement in quality-of-life measures and a decrease in botulinum toxin requirements.

Bidirectional needs assessment of otolaryngology-head and neck surgery short-term surgical trips to Ethiopia and Kenya.

Objectives: To create an otolaryngology-specific needs assessment tool for short-term global surgical trips and to describe our findings from its implementation. Methods: Surveys 1 and 2 were developed based on a literature review and disseminated to Low-Middle Income (LMIC) hosting institutions in Kenya and Ethiopia and to High-Income surgical trip participants (HIC), respectively. Respondents were otolaryngologists identified online, through professional organizations, and by word-of-mouth, who had participated in a surgical trip of <4 weeks. Results: HIC and LMIC respondents shared similar goals of expanding host surgical skills through education and training while building sustainable partnerships. Discrepancies were identified between LMIC desired surgical skills and supply needs and HIC current practices. Microvascular reconstruction (17.6%), advanced otologic surgery (17.6%), and FESS (14.7%) were most desired skills and high-demand equipment needs were FESS sets (89%), endoscopes (78%), and surgical drills (56%). Frequently taught techniques included advanced otologic surgery (36.6%), congenital anomaly surgery (14.6%), and FESS (14.6%) with the largest gap between LMIC-need and HIC-offerings being in microvascular reconstruction (17.6% vs. 0%). We also highlight the discrepancy in expectations of responsibility for trip logistics, research, and patient follow-up. Conclusion: We created and implemented the first otolaryngology-specific needs assessment tool in the literature. With its implementation in Ethiopia and Kenya, we were able to identify unmet needs as well as attitudes and perceptions of LMIC and HIC participants. This tool may be adapted and utilized to assess specific needs, resources, and goals of both host and visiting teams to facilitate successful global partnerships. Level of Evidence: Level VI.

Prevalence of Surgical, Anesthetic, and Device-related Complications Among Infants Implanted Before 9 and 12 Months of Age Versus Older Children: Evidence for the Continued Expansion of Pediatric Cochlear Implant Candidacy Criteria.

OBJECTIVE: To compare the prevalence of surgical, anesthetic, and device-related complications among infants and older children receiving cochlear implantation (CI). STUDY DESIGN: Retrospective chart review. SETTING: Tertiary academic referral center. PATIENTS: Pediatric patients who underwent CI from November 1990 to January 2020. INTERVENTION: CI. MAIN OUTCOME MEASURES: Surgical, anesthetic, and device-related complication rates were compared by age group (<12 versus 12-23 versus 24+ months with subset analysis of <9 versus 9-11 months). RESULTS: A total of 406 primary pediatric CI surgeries encompassing 482 ears were analyzed, including 45 ears in 23 patients implanted less than 9 months and 89 ears in 49 patients less than 12 months. No anesthetic complications occurred. Postoperative surgical and device-related complication rates were not significantly different among the less than 12, 12 to 23, and 24+ month groups (16% versus 16% versus 12%; p = 0.23) or between the less than 9 and 9 to 11 month groups (22% versus 9%; p = 0.09). Thirty-day readmission was significantly higher for patients less than 12 months compared with patients 24+ months (6% versus <1%; p = 0.011), but was not significantly higher compared with patients 12 to 23 months (6% versus 3%; p = 0.65). Reoperation rates did not differ significantly among the less than 12, 12 to 23, and 24+ month groups (10% versus 7% versus 6%; p = 0.31). CONCLUSIONS: The prevalence of surgical, anesthetic, and device related complications was not significantly different among infants implanted less than 9 or less than 12 months of age when compared with older children. These data provide evidence for the continued expansion of pediatric cochlear implant candidacy criteria to include appropriately selected infants less than 9 months of age.

Language and Audiological Outcomes Among Infants Implanted Before 9 and 12 Months of Age Versus Older Children: A Continuum of Benefit Associated With Cochlear Implantation at Successively Younger Ages.

OBJECTIVE: To compare language and audiological outcomes among infants (<9 and <12 mo) and older children receiving cochlear implantation (CI). STUDY DESIGN: Retrospective chart review. SETTING: Tertiary academic referral center. PATIENTS: Pediatric patients receiving CI between October 1995 and October 2019. INTERVENTION: Cochlear implantation. MAIN OUTCOME MEASURES: Most recent language and audiological assessment scores were evaluated by age group. RESULTS: A total of 118 children were studied, including 19 who were implanted <9 months of age, 19 implanted 9 to <12 months of age, and 80 implanted 12 to <36 months of age. The mean duration of follow-up was 7.4 ±â€Š5.0 years. Most recent REEL-3 receptive (88 ±â€Š12 vs. 73 ±â€Š15; p = 0.020) and expressive (95 ±â€Š13 vs. 79 ±â€Š12; p = 0.013) communication scores were significantly higher in the <9 months group compared to the 9 to <12 months group. PLS and OWLS auditory comprehension and oral expression scores were significantly higher in the <12 months group compared to the 12 to <36 months group. The difference in NU-CHIPS scores between <12 and 12 to <36 months was statistically significant (89% ±â€Š6 vs. 83% ±â€Š12; p = 0.009). LNT scores differed significantly between <9 and 9 to <12 months (94% ±â€Š4 vs. 86% ±â€Š10; p = 0.028). CONCLUSIONS: The recent FDA expansion of pediatric CI eligibility criteria to include infants as young as 9 months of age should not serve as a strict clinical cutoff. Rather, CI can be pursued in appropriately selected younger infants to optimize language and audiological outcomes.

Disease-Specific Quality of Life in Vestibular Schwannoma: A National Cross-sectional Study Comparing Microsurgery, Radiosurgery, and Observation.

OBJECTIVE: To examine the impact of treatment on disease-specific health-related quality of life (HRQOL) among patients with sporadic vestibular schwannoma (VS). STUDY DESIGN: National cross-sectional study. SETTING: Tertiary referral center and the Acoustic Neuroma Association. SUBJECTS AND METHODS: Adult patients with VS who completed the Penn Acoustic Neuroma Quality of Life (PANQOL) survey. Patients were classified by treatment at the most recent survey as microsurgery, radiosurgery, observation, or recently diagnosed (RD). PANQOL scores were compared among VS treatment groups and with nontumor controls using analysis of covariance. RESULTS: A total of 1362 respondents with VS were analyzed. Total PANQOL scores differed significantly by treatment (P = .024) with adjusted means of 60, 63, 65, and 62 for the microsurgery, radiosurgery, observation, and RD groups, respectively. Subdomain scores for facial function, balance, hearing loss, and pain differed significantly (P < .05) by treatment. Comparisons that surpassed thresholds for clinical significance included microsurgery compared to radiosurgery and observation for facial function, microsurgery compared to observation and RD for hearing loss, and microsurgery compared to radiosurgery and observation for pain. Subdomain scores for anxiety, facial function, balance, hearing loss, energy, and pain and total PANQOL scores for nontumor controls were significantly higher (ie, more favorable) compared to the VS groups (P < .05). General health scores did not differ significantly between the nontumor controls and the VS groups (P = .19). CONCLUSION: Differences in HRQOL among treatment modalities are small and variably exceed the minimal clinically important difference. The impact of a VS diagnosis on HRQOL supersedes that of the treatment type.

Population-based analysis on the effect of nodal and distant metastases in sinonasal adenocarcinoma.

BACKGROUND: Minimal information has been reported on the effect of distant and nodal metastases at the time of diagnosis on survival in patients with sinonasal adenocarcinoma (SNAC). METHODS: The Surveillance, Epidemiology, and End Results database was utilized to compare overall survival (OS) and disease-specific survival (DSS). RESULTS: Of the 325 patients with SNAC identified, 5-year and 10-year OS for all included patients was 64% and 58%, respectively. On multivariate analysis, the presence of distant metastases (P < .0001), maxillary and frontal sinus primary tumors (P = .0042, P = .0006), and increasing age (P = .007) were risk factors for worsened DSS. The presence of regional spread to multiple cervical nodal basins (OS RR 3.26, P = .002; DSS RR 2.51, P = .013) and a single nodal basin (DSS RR 2.19, P = .046) was associated with worsened survival compared to no regional spread. CONCLUSION: Survival in SNAC was significantly worsened with increasing age, tumor site of origin, and distant metastatic disease.

For Whom the Bell's Toll: Recurrent Facial Nerve Paralysis, A Retrospective Study and Systematic Review of the Literature.

PURPOSE: To examine the etiology, clinical course, and management of recurrent peripheral facial nerve paralysis. METHODS: Retrospective review at a single tertiary academic center and systematic review of the literature. Clinical presentation, laboratory and imaging findings, treatment and outcome for all cases of recurrent ipsilateral, recurrent contralateral, and bilateral simultaneous cases of facial paralysis are reviewed. RESULTS: Between 2000 and 2017, 53 patients [41.5% men, 29 median age of onset (range 2.5 wk-75 yr)] were evaluated for recurrent facial nerve paralysis at the authors' institution. Twenty-two (41.5%) cases presented with ipsilateral recurrences only, while the remaining 31 patients (58.5%) had at least 1 episode of contralateral recurrent paralysis. No cases of bilateral simultaneous facial nerve paralysis were observed. The median number of paretic events for all patients was 3 (range 2-20). The median nadir House-Brackmann score was 4, with a median recovery to House-Brackmann grade 1.5 over a mean recovery time of 61.8 days (range 1-420 d). Diagnostic evaluation confirmed Melkersson-Rosenthal syndrome in four (7.5%) cases, neurosarcoidosis in two (3.7%), traumatic neuroma in one (1.9%), Ramsay Hunt syndrome in one (1.9%), granulomatosis with polyangiitis in one (1.9%), and neoplastic causes in three (5.7%) cases [facial nerve schwannoma (n = 2; 3.7%), metastatic squamous cell carcinoma to the deep lobe of the parotid gland (n = 1; 1.9%)]; ultimately, 77.4% (41) of cases were deemed idiopathic. Facial nerve decompression via a middle cranial fossa approach was performed in three (5.7%) cases without subsequent episodes of paralysis. CONCLUSION: Recurrent facial nerve paralysis is uncommon and few studies have evaluated this unique population. Recurrent ipsilateral and contralateral episodes are most commonly attributed to idiopathic facial nerve paralysis (i.e., Bell's palsy); however, a subset harbor neoplastic causes or local manifestations of underlying systemic disease. A comprehensive diagnostic evaluation is warranted in patients presenting with recurrent facial nerve paralysis and therapeutic considerations including facial nerve decompression can be considered in select cases.

Salvage Radiosurgery After Subtotal Resection for Catecholamine-secreting Jugular Paragangliomas: Report of Two Cases and Review of the Literature.

OBJECTIVES: Catecholamine-secreting jugular paragangliomas (JPs) represent a rare subset of head and neck paragangliomas that may present with hypertension, arrhythmia, or syncopal episodes. Subtotal resection to protect critical neurovascular structures may result in persistent catecholamine excess from residual tumor. Herein, we report our experience with stereotactic radiosurgery (SRS) for salvage treatment of catecholamine-secreting JP following subtotal microsurgical resection. PATIENTS: Adult patients treated with SRS after subtotal microsurgical resection of catecholamine-secreting JP. INTERVENTIONS: SRS. MAIN OUTCOME MEASURES: Post-treatment catecholamine and metanephrine levels, clinical outcomes, and tumor control. RESULTS: Of 85 patients with JPs treated with primary or salvage radiosurgery between 1990 and 2017, 2 (2%) harbored nonmalignant secreting tumors. Patient 1 developed catecholamine excess with elevated norepinephrine (NE) at 475 mcg/24 hours (normal < 80 mcg/24 h). Following subtotal resection, she developed catecholamine excess with radiographic evidence of tumor growth and therefore underwent SRS. Three years post-SRS and beyond, catecholamine levels remained normalized (NE 62 mcg/24 h at 10 yr) and tumor volume remained stable on serial MRI studies over the 17-year follow-up period.Patient 2 developed symptomatic arrhythmia and was found to have a JP. Urine norepinephrine (NE) was elevated at 213 mcg/24 hours. She underwent nerve-sparing subtotal resection and upfront SRS was used to treat residual tumor. Twenty months following SRS, the area of residual JP had not enlarged in size and catecholamine levels remained normal (NE 46 mcg/24 h). CONCLUSIONS: Radiosurgery can be used in salvage treatment of catecholamine-secreting JP, providing durable tumor control and resolution of catecholamine excess. For patients with large catecholamine-secreting JP and normal lower cranial nerve function, aggressive nerve-sparing subtotal resection with adjuvant radiosurgery may offer a low-morbidity alternative to gross total resection. Further study of this subset of patients is warranted to substantiate these promising, yet preliminary findings.

APOBEC3B lysine residues are dispensable for DNA cytosine deamination, HIV-1 restriction, and nuclear localization.

The APOBEC3 DNA cytosine deaminase family comprises a fundamental arm of the innate immune response and is best known for retrovirus restriction. Several APOBEC3 enzymes restrict HIV-1 and related retroviruses by deaminating viral cDNA cytosines to uracils compromising viral genomes. Human APOBEC3B (A3B) shows strong virus restriction activities in a variety of experimental systems, and is subjected to tight post-translational regulation evidenced by cell-specific HIV-1 restriction activity and active nuclear import. Here we ask whether lysines and/or lysine post-translational modifications are required for these A3B activities. A lysine-free derivative of human A3B was constructed and shown to be indistinguishable from the wild-type enzyme in DNA cytosine deamination, HIV-1 restriction, and nuclear localization activities. However, lysine loss did render the protein resistant to degradation by SIV Vif. Taken together, we conclude that lysine side chains and modifications thereof are unlikely to be central to A3B function or regulation in human cells.