Objective Photoanalysis of Feminizing Frontal Cranioplasty Outcomes.

Study Design: Retrospective analysis at a tertiary care center. Objective: This study describes a method of analyzing postoperative results using lateral view clinical photographs to create normalized projection ratios of the glabella and radix. Methods: We reviewed preoperative and postoperative photographs of 15 patients. All photographs were in the lateral view Frankfort horizontal plane. We calculated the distances between the (a) tragus and cornea, (b) cornea and radix, (c) cornea and glabella, and the (θ) nasofrontal angle. Results: Fifteen sets of patient photographs were analyzed and found that there was a favorable 14% reduction at the radix and an even greater reduction (78.9%) at the glabella. The nasofrontal angle was improved to a more feminine range from 131.84° preoperatively to 145.86° postoperatively. Conclusions: Normalized projection ratios of the glabella and radix, along with the nasofrontal angle, can be used to objectively measure outcomes of frontal feminizing cranioplasty.

Music Perception in Bone-Anchored Hearing Implant Users.

OBJECTIVE: Music is a highly complex acoustic stimulus in both spectral and temporal contents. Accurate representation and delivery of high-fidelity information are essential for music perception. However, it is unclear how well bone-anchored hearing implants (BAHIs) transmit music. The study objective is to establish music perception performance baselines for BAHI users and normal hearing (NH) listeners and compare outcomes between the cohorts. METHODS: A case-controlled, cross-sectional study was conducted among 18 BAHI users and 11 NH controls. Music perception was assessed via performance on seven major musical element tasks: pitch discrimination, melodic contour identification, rhythmic clocking, basic tempo discrimination, timbre identification, polyphonic pitch detection, and harmonic chord discrimination. RESULTS: BAHI users performed comparably well on all music perception tasks with their device compared with the unilateral condition with their better-hearing ear. BAHI performance was not statistically significantly different from NH listeners' performance. BAHI users performed just as well, if not better than NH listeners when using their control contralateral ear; there was no significant difference between the two groups except for the rhythmic timing (BAHI non-implanted ear 69% [95% CI: 62%-75%], NH 56% [95% CI: 49%-63%], p = 0.02), and basic tempo tasks (BAHI non-implanted ear 80% [95% CI: 65%-95%]; NH 75% [95% CI: 68%-82%, p = 0.03]). CONCLUSIONS: This study represents the first comprehensive study of basic music perception performance in BAHI users. Our results demonstrate that BAHI users perform as well with their implanted ear as with their contralateral better-hearing ear and NH controls in the major elements of music perception. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:1381-1387, 2024.

Posterior Canal Fibrosis: A Case Series.

OBJECTIVE: To establish a case series where loss of magnetic resonance fluid signal intensity in the posterior semicircular canal (SCC) corresponded with a functional deficit on clinical and video head impulse testing, and most likely a result of canal fibrosis or obstruction. PATIENTS: Three patients with an magnetic resonance imaging (MRI) showing loss of T2-weighted signal intensity in their posterior SCC corresponding to a vestibular weakness in that canal. INTERVENTIONS: All patients underwent a comprehensive neuro-otologic examination. Vestibulo-ocular reflex was evaluated using clinical head impulse testing (cHIT) and quantified with video head impulse testing. MRI for all patients was obtained using clinical protocols for gadolinium-enhanced MRI of the internal auditory canal on 1.5 or 3 T scanners, which all included high-resolution, heavily T2-weighted imaging of the membranous labyrinth. MAIN OUTCOME MEASURE: Correlation of MRI findings with vestibular weakness in the corresponding posterior SCC. RESULTS: Subject 1 showed abnormal vHIT in the left lateral and left posterior SCCs. MRI showed loss of T2 signal intensity of the entire left posterior SCC as well as in the posterior limb of the superior SCC. Subject 2 showed isolated loss of function (cHIT) and low gain with catch-up saccade (vHIT) of the left posterior SCC. MRI showed loss of T2 signal intensity of the superior portion of the left posterior SCC, as well as in the posterior limb of the superior SCC. Subject 3 showed catch-up saccades of the left posterior SCC on cHIT and vHIT and loss of T2 signal intensity of the entire left posterior SCC and partial loss of bilateral lateral SCC on MRI. CONCLUSIONS: In this case series, loss of posterior SCC function correlated with vestibular function testing and high-resolution, T2-weighted MRI findings, perhaps related to fibrosis of the posterior SCC.

Diagnosis, Prognosticators, and Management of Acute Invasive Fungal Rhinosinusitis: Multidisciplinary Consensus Statement and Evidence-Based Review with Recommendations.

BACKGROUND: Acute invasive fungal sinusitis (AIFS) is an aggressive disease that requires prompt diagnosis and multidisciplinary treatment given its rapid progression. However, there is currently no consensus on diagnosis, prognosis, and management strategies for AIFS, with multiple modalities routinely employed. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on AIFS, summarize the existing evidence, and provide recommendations on the management of AIFS. METHODS: The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through January 2022. Studies evaluating management for orbital, non-sinonasal head and neck, and intracranial manifestations of AIFS were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on management principles for AIFS were generated. RESULTS: A review and evaluation of published literature was performed on 12 topics surrounding AIFS (signs and symptoms, laboratory and microbiology diagnostics, endoscopy, imaging, pathology, surgery, medical therapy, management of extrasinus extension, reversing immunosuppression, and outcomes and survival). The aggregate quality of evidence was varied across reviewed domains. CONCLUSION: Based on the currently available evidence, judicious utilization of a combination of history and physical examination, laboratory and histopathologic techniques, and endoscopy provide the cornerstone for accurate diagnosis of AIFS. In addition, AIFS is optimally managed by a multidisciplinary team via a combination of surgery (including resection whenever possible), antifungal therapy, and correcting sources of immunosuppression. Higher quality (i.e., prospective) studies are needed to better define the roles of each modality and determine diagnosis and treatment algorithms.

RNA Sequencing and Gene Ontology Analysis in Acute Invasive Fungal Sinusitis.

BACKGROUND: Acute invasive fungal sinusitis (AIFS) is an aggressive and dangerous disease of the paranasal sinuses with high morbidity and mortality. The immune response at the level of the nasal mucosa, the site of entry, has not been previously evaluated. OBJECTIVE: To evaluate differential gene expression in the sinonasal mucosa of AIFS patients as compared to control patients using RNA sequencing. METHODS: Sinonasal tissue samples were prospectively obtained from consenting patients undergoing surgery between November, 2020 and November, 2021. RNA extraction and sequencing were performed and differential expression was analyzed to detect transcriptional differences between patient groups. RESULTS: Tissue samples were collected from 4 patients with active AIFS diagnoses, 2 patients with recovered AIFS, 1 patient with a diagnosis of non-invasive fungal ball, and 4 healthy controls. 255 genes were differentially expressed in AIFS patients as compared to control patients. Specific Gene Ontology (GO) biological processes that were identified as differentially expressed in AIFS patients as compared to controls included the following: 1. GO:0007155 (cell adhesion), 2. GO:0030199 (collagen fibril organization) and 3. GO:0001525 (angiogenesis). CONCLUSION: Transcriptional differences were noted between AIFS and control patients in sinonasal tissue samples. Future work is necessary to determine causes of the differential gene expressions between AIFS and control patients, specifically those who are immunosuppressed, or with preexisting non-invasive forms of fungal sinusitis, to guide treatment and prevention strategies.

Objective Outcomes of Trichophytic Brow Lift and Hairline Advancement in Facial Feminization Surgery.

Importance: The upper facial third is an important area to address in facial feminization surgery (FFS). Objective: This study seeks to quantify the changes in eyebrow, hairline, and forehead heights associated with brow lift and hairline advancement surgery in the transgender patient population. Design, Setting, and Participants: A cohort study performed at an academic medical center. Main Outcomes and Measures: Pre- and postoperative frontal view photographs underwent computer-aided photograph analysis. Brow position, hairline position, and forehead height were measured. Patient self-identified race, ethnicity, as well as other demographic factors were also collected. Results: Forty-six patients underwent FFS with brow lift and hairline advancement with photographs permitting measurement. Eyebrow analysis was performed in 33 patients. Hairline and forehead analyses were accomplished in 30 patients. The mean brow elevation was 4.6 mm across all locations. The forehead reduction achieved was 9.8-11.3 mm. Conclusion and Relevance: Trichophytic brow lifting with hairline advancement outcomes was able to be reliably quantified from standardized clinical photographs. On average, 4-5 mm of brow lift, 6-7 mm of hairline lowering, and 10-11 mm of forehead reduction were achieved, contributing to a more feminine appearance of the upper facial third.

Economic analyses of supported employment programmes for people with mental health conditions: A systematic review.

BACKGROUND: Employment is intrinsic to recovery from mental health conditions, helping people live independently. Systematic reviews indicate supported employment (SE) focused on competitive employment, including individual placement and support (IPS), is effective in helping people with mental health conditions into work. Evidence is limited on cost-effectiveness. We comprehensively reviewed evidence on the economic case for SE/IPS programmes. METHODS: We searched PubMed/MEDLINE, EMBASE, PsycINFO, CINAHL, IBSS, Business Source Complete, and EconLit for economic and return on investment analyses of SE/IPS programmes for mental health conditions. Traditional vocational rehabilitation, sheltered work, and return to work initiatives after sickness absence of less than 1 year were excluded. Studies were independently screened by two reviewers. We assessed quality using the Consolidate Health Economic Evaluation Reporting Standards checklist. The protocol was preregistered with PROSPERO-CRD42020184359. RESULTS: From 40,015 references, 28 studies examined the economic case for IPS, four IPS augmented by another intervention, and 24 other forms of SE. Studies were very heterogenous, quality was variable. Of 41 studies with quality scores over 50%, 10 reported cost per quality-adjusted life year gained, (8 favourable to SE/IPS), 14 net monetary benefits (12 positive), 5 return on investment (4 positive), and 20 cost per employment outcome (14 favorable, 5 inconclusive, 1 negative). Totally, 24 of these 41 studies had monetary benefits that more than outweighed the additional costs of SE/IPS programmes. CONCLUSIONS: There is a strong economic case for the implementation of SE/IPS programmes. The economic case is conservative as evidence on long-term impacts of programmes is limited.

Effect of microporous polysaccharide hemospheres on anterolateral thigh free flap donor site complications.

Background: Postoperative seroma is the most common donor site complication following anterolateral thigh (ALT) free flap harvest for head and neck reconstruction. The utility of novel microporous polysaccharide hemospheres (MPH) has not been studied as a hemostatic agent in this setting. Methods: Prospective, single-blind, randomized controlled trial of patients undergoing fasciocutaneous ALT harvest for head and neck reconstruction at a tertiary academic medical center between April 2018 and February 2020. The intervention (MPH) group received 3 g of topical MPH to the ALT donor site prior to closure whereas the control group did not receive application of MPH. Outcomes included total drain output (ml), drain output during postoperative days (POD) 1-3 alone, drain duration (days), and incidence of donor site hematoma, seroma, or infection. Results: Twenty-nine patients were randomized to the MPH group and 26 to the control group. For MPH and control groups, mean total drain output was 284.7 ± 153.0 ml versus 317.9 ± 177.6 ml (p = .527), mean POD 1-3 drain output alone was 169.3 ± 88.8 ml versus 157.9 ± 78.7 ml (p = .749), and drain duration was 5.9 ± 1.5 days versus 6.5 ± 1.6 days (p = .144), respectively. There was no significant difference in seroma (p = .733), hematoma (p = .492), or infection (p = 1.000). Drain output was not significantly influenced by gender, age, body weight, or smoking habits. Conclusion: MPH administration to ALT free flap donor sites did not significantly improve drain output, hematoma formation, or seroma formation.Level of Evidence 2.

Outcomes of an Early Childhood Hearing Screening Program in a Low-Income Setting.

IMPORTANCE: Early identification of childhood hearing loss through newborn hearing screening mitigates permanent speech, language, and developmental delays, but many children are lost to follow-up or develop postnatal hearing loss. Early childhood hearing screening programs may help identify these children, but evidence on their outcomes is limited. OBJECTIVE: To assess outcomes from a low-income, preschool-based hearing screening program and risk factors for hearing loss in this population. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of 6820 children aged 2 to 6 years from urban, low-income public preschools who received hearing screening from July 1, 2015, to June 30, 2019, was performed using San Francisco Department of Public Health records. A multivariate logistic regression analyzed risk factors for hearing loss. Data analysis was conducted from January 14, 2020, to April 20, 2021. EXPOSURES: Annual single-visit, 2-tiered screening was implemented with conditioned play pure-tone audiometry (CPA) and distortion product otoacoustic emissions (OAEs). MAIN OUTCOMES AND MEASURES: Rates of successful screening, referred screening, loss to follow-up, and hearing loss. RESULTS: Of 6820 children (age, 2-6 years) screened, 3425 (50.2%) were boys, 15% were White/non-Hispanic, and 48% had English as the primary home language. A total of 403 (5.9%) children were referred for full medical or audiologic evaluation after 2-tiered CPA/OAE screening. Only 24 children were unable to complete both CPA and OAE testing for a screening completion rate of 99.6%. After medical evaluation, 114 of 403 children (28.3%) passed hearing rescreening and 55 (13.6%) were lost to follow-up. The prevalence of conductive hearing loss was 2.9% (n = 195), and the prevalence of sensorineural hearing loss was 0.2% (n = 13). Primary language, race and ethnicity, and sex were not associated with rates of referral or hearing loss. CONCLUSIONS AND RELEVANCE: The findings of this cohort study suggest that preschool-based screening programs can be a useful method to identify early childhood hearing loss and that teacher concerns are associated with final diagnostic hearing status.

Facilitating drug delivery in the central nervous system by opening the blood-cerebrospinal fluid barrier with a single low energy shockwave pulse.

BACKGROUND: The blood-cerebrospinal fluid (CSF) barrier (BCSFB) is critically important to the pathophysiology of the central nervous system (CNS). However, this barrier prevents the safe transmission of beneficial drugs from the blood to the CSF and thus the spinal cord and brain, limiting their effectiveness in treating a variety of CNS diseases. METHODS: This study demonstrates a method on SD rats for reversible and site-specific opening of the BCSFB via a noninvasive, low-energy focused shockwave (FSW) pulse (energy flux density 0.03 mJ/mm2) with SonoVue microbubbles (2 × 106 MBs/kg), posing a low risk of injury. RESULTS: By opening the BCSFB, the concentrations of certain CNS-impermeable indicators (70 kDa Evans blue and 500 kDa FITC-dextran) and drugs (penicillin G, doxorubicin, and bevacizumab) could be significantly elevated in the CSF around both the brain and the spinal cord. Moreover, glioblastoma model rats treated by doxorubicin with this FSW-induced BCSFB (FSW-BCSFB) opening technique also survived significantly longer than untreated controls. CONCLUSION: This is the first study to demonstrate and validate a method for noninvasively and selectively opening the BCSFB to enhance drug delivery into CSF circulation. Potential applications may include treatments for neurodegenerative diseases, CNS infections, brain tumors, and leptomeningeal carcinomatosis.

Seroprevalence, Genotyping, and Monitoring of Hepatitis C Viral Loads in Patients on Antivirals in Burkina Faso.

INTRODUCTION: Hepatitis C virus (HCV) infection remains a major public health problem worldwide. In Burkina Faso, nearly 720,000 people are living with HCV, and each year about 900 people die from complications of cirrhosis or hepatocellular carcinoma. This study was planned to determine the HCV seroprevalence, characterize circulating genotypes, and monitor HCV viral loads in patients under treatment with antivirals. METHODS: A total of 4,124 individuals and 167 patients in the pre-therapy program were recruited. The "SD Bioline HCV" kit was used for rapid screening of anti-HCV antibodies. Viral load and genotyping were performed in 167 HCV patients on antivirals using the "Iontek HCV Quant" and "Iontek genotyping" kits. RESULTS: Prevalence of HCV was 1.65% (68/4,124), and the median viral load of participants was 5.37 log10/mL (1.32-7.67 log10/mL). Genotype 2 was predominant with a frequency of 86.23% (144/167) and appeared to be more active with higher viral load compared to 13.77% (23/167) for genotype 1 (p < 0.001). After 24 weeks of pan-genotypic direct-acting antivirals, such as sofosbuvir/daclatasvir and sofosbuvir/velpatasvir, the viral loads of all patients became undetectable. CONCLUSION: The responses to antivirals by the circulating genotypes indicate that the results are very satisfactory. Therefore, the prevalence of HCV in the population can be reduced through identification of cases and treatment.

Utility of Microporous Polysaccharide Hemosphere on Anterolateral Thigh Free Flap Donor Site Complications.

Background: Anterolateral thigh (ALT) microvascular free tissue transfer is an integral part of head and neck reconstructive surgery, but it can be complicated by postoperative donor site fluid collections. Objective: To measure the rate of hematoma and seroma formation in the ALT donor site in those treated with microporous polysaccharide hemosphere (MPH) and those without. Methods: This was a retrospective cohort study examining patients undergoing ALT free tissue transfer for head and neck reconstruction at a single academic center between 2014 and 2017. Primary outcomes were interventional hematomas and seromas and drain duration. Results: In total, 118 patients underwent ALT free flap reconstruction for head and neck defects. Of these, 57 patients received MPH at the donor site and 61 did not. Eleven patients had a clinically significant seroma in the non-MPH group compared with three in the MPH group (p = 0.045). Drain duration for the MPH group compared with that for the non-MPH group was 6.9 versus 8.2 days (p = 0.020), and drains were removed when output was <60 mL over 24 h. Conclusion: This study supports the use of MPH in ALT free flap donor sites for reduction of clinically significant postoperative seromas. Further investigation with larger prospective randomized clinical trials is warranted.

Aesthesiometer-Based Testing for Laryngopharyngeal Hyposensitivity.

OBJECTIVES/HYPOTHESIS: To develop a method for threshold estimation of the laryngeal adductor reflex (LAR) response using Cheung-Bearelly monofilaments. STUDY DESIGN: Cross-sectional. METHODS: Twenty-two healthy adults (12 men, 10 women) were tested for LAR response outcome using 30 mm 5-0 and 4-0 nylon monofilaments. Tactile stimuli were delivered to the aryepiglottic (AE) fold and medial pyriform sinus (MPS). Dichotomous classifier features and performance (area under the curve (AUC)), the LAR response outcome agreement and disagreement matrix, and test-retest reliability were examined. From those data, a test protocol that would minimize patient burden to estimate the LAR triggering threshold was formulated. RESULTS: Classifier performance of 5-0 monofilament stimulation of the AE fold (sensitivity = 0.63, specificity = 0.63, PPV = 0.74, NPV = 0.25) and MPS (sensitivity = 0.45, specificity = 0.77, PPV = 0.74, NPV = 0.23,) was slightly below that of 4-0 monofilament stimulation of the AE fold (sensitivity = 0.82, specificity = 0.50, PPV = 0.82, NPV = 0.50) and MPS (sensitivity = 0.84, specificity = 0.64, PPV = 0.90, NPV = 0.56), based on AUC. LAR response outcome agreement for 5-0 and 4-0 stimulations was high (93%) for 5-0 positive response, but low (29%) for 5-0 negative response. Aesthesiometer test-retest reliability for LAR response outcome was excellent (Cronbach's alpha = 0.97). CONCLUSIONS: Threshold estimation of the LAR response may be operationalized by adopting a decision tree protocol. For negative LAR response to initial 5-0 monofilament stimulation and positive response to subsequent 4-0 monofilament stimulation, the higher threshold is confirmed. Positive LAR response to 5-0 or 4-0 monofilament stimulation is expected in over 90% of asymptomatic adults. Negative LAR response to 4-0 monofilament stimulation identifies patients at risk for laryngopharyngeal hyposensitivity. LEVEL OF EVIDENCE: 3b Laryngoscope, 132:163-168, 2022.

Presentation and management of post-operative cerebrospinal fluid leaks after sphenoclival expanded endonasal surgery: A single institution experience.

While surgical approaches and techniques of expanded endonasal approach (EEA) surgery have been well described, little data exist regarding management of post-operative cerebrospinal fluid (CSF) leaks. In this study, we examined a surgeon's continuous 12-year experience with failed closure of sphenoclival skull base defects. We conducted a retrospective case series of patients identified with post-operative CSF leaks after EEA of the sphenoclival axis, managed by a single otolaryngologist at a minimally invasive skull base center. Ten out of 326 patients required therapeutic intervention for central skull base defect closure failure. Median time to presentation of CSF leak was 25 days (range 6-542 days). Symptoms included rhinorrhea (n = 7), meningitis (n = 6), and pneumocephalus (n = 1). The majority of patients (7 of 10) were first managed by lumbar drain placement - one of which had resolution of his/her CSF leak. Overall, 9 of 10 patients required endoscopic repair. The majority of the post-operative CSF leaks (9/13, 69.2%) were repaired using a vascularized mucosal flap. There were 3 patients who required a second revision surgery. All CSF leaks were repaired without completely deconstructing the initial repair. Failure sites most frequently occurred outside of the sella (80%), likely reflecting their direct relationship to the intracranial cisterns. Initial operative repair provided definitive treatment in most cases (70%). Correct placement of a vascularized local pedicle-based flap is essential for successful repair. Knowledge of alternative flaps is particularly important when the nasoseptal flap is no longer available.

Facial Reanimation and Reconstruction of the Radical Parotidectomy.

Radical parotidectomy may result from treating advanced parotid malignancies invading the facial nerve. Survival is often enhanced with multimodality treatment protocols, including postoperative radiation therapy. In addition to the reconstructive challenge of restoring facial nerve function, patients may be left with a significant cervicofacial concavity and inadequate skin coverage. This should be addressed with stable vascularized tissue that is resistant to radiation-induced atrophy. This article describes a comprehensive strategy, includes the use of the anterolateral thigh free flap, the temporalis regional muscle transfer, motor nerve to vastus lateralis grafts, nerve to masseter transfer, and fascia lata grafts for static suspension.

A Single High-Intensity Shock Wave Pulse With Microbubbles Opens the Blood-Brain Barrier in Rats.

Focused extracorporeal shockwave (FSW), one kind of focused high-intensity pulsed ultrasound, has been shown to induce blood-brain barrier (BBB) opening in targeted brain areas in rat animal models with minimal detrimental effects below threshold intensity levels or iterations. In the current study, we found that the thresholds could be further reduced by the addition of microbubbles (ultrasound contrast agents or UCA; SonoVue). FSW with 2 × 106 MBs/kg of UCA (20% of clinical dosage) at an intensity level of 0.1 (peak positive pressure 5.4 MPa; peak negative pressure -4.2 MPa; energy flux density 0.03 mJ/mm2) resulting in a 100% BBB opening rate without detectable hemorrhage or apoptosis in the brain. Significantly reduced free radical production was found compared with 0.5 MHz focused ultrasound at a peak negative pressure of 0.44 MPa (1% duty cycle and 4 × 107 MBs/kg of UCA). FSW devices offer advantages of commercial availability and high safety, and thus may facilitate future research and applications of focal BBB opening for oncological and pharmacological purposes.