The Impact of Surgical and Nonsurgical Interventions on Overall Oral, Palpebral Fissure, and Brow Height Symmetry in a Patient with Facial Synkinesis.

Background: The treatment of facial nerve synkinesis remains complex and variable. Objective: To compare oral, palpebral fissure, and brow symmetry among surgical and nonsurgical interventions in patients with facial synkinesis. Methods: Patients with facial nerve synkinesis at a single tertiary care center between 2008 and 2022 were analyzed before and after interventions using Emotrics software. Symmetry was compared among treatment combination groups (chemodenervation and rehabilitation [CR] vs. chemodenervation and surgery [CS] vs. chemodenervation, surgery, and rehabilitation [CSR]) and among surgical intervention groups (selective neurectomy [SN] vs. selective neurectomy with facelift [SnFa] vs. no surgery). Results: Of the 29 patients meeting inclusion criteria, 72.4% were female and the median age was 60.6 years (interquartile range 49.9-67.6). The median follow-up was 32.6 months; patients who received surgery had a greater follow-up time (57.4 months vs. 26.5 months, p = 0.045). The use of a trimodal approach (CSR) was associated with improved symmetry versus CR for smile angle (p = 0.021). Among surgical interventions, the greatest improvement in palpebral fissure symmetry was in patients who received SN versus no surgery (p = 0.039); the greatest improvement in smile angle was in patients who received SnFa versus no surgery (p = 0.008). Conclusion: We recommend a comprehensive approach to the management of facial synkinesis consisting of chemodenervation, rehabilitation, and surgery tailored to each patient's needs.

Rate of Fat Graft Volume Loss After Parotidectomy.

BACKGROUND: Reconstruction after parotidectomy can include fat grafting, which allows for symmetry, but grafts have demonstrated volume loss over time. OBJECTIVES: To provide quantitative evidence for the rate of volume loss of fat grafts. METHODS: Patients who received parotidectomy with fat graft reconstruction at a single institution from August 2016 to October 2020 were identified. Relationships between clinical factors and the logarithmic rate of fat graft volume loss were analyzed. RESULTS: Twelve patients received parotidectomy, fat graft reconstruction, and underwent a postoperative magnetic resonance imaging (MRI) scan. Rate of fat graft volume loss was a mean of 1.8% per month (standard deviation [SD]: 2.1% per month). Total parotid fat graft volume loss was a mean of 57.4% (SD: 67.5%). The mean follow-up time was 35.5 months (range: 9-89.8 months). Correlations between body mass index (BMI), history of smoking, and history of alcohol consumption and logarithmic rates of fat graft volume loss were increased but not significantly. CONCLUSIONS: Fat grafts have the potential of 60% volume loss at approximately 1 year. If there is clinical suspicion that patients will require adjuvant radiation or have clinical factors such as a smoking or alcohol-use history, volume requirements may be even greater to maintain adequate parotid volume for aesthetic purposes.

Impact of great auricular nerve sacrifice on sensory disturbance after parotidectomy.

PURPOSE: To investigate the association between great auricular nerve (GAN) sacrifice during parotidectomy and postoperative sensory disturbance. MATERIALS AND METHODS: Patients who underwent parotidectomy between November 2016 and May 2020 at a single academic institution were included in this retrospective chart review. Operative notes were reviewed to determine incidence of GAN sacrifice. Prevalence of patient-reported sensory complaints in the GAN distribution and time to spontaneous resolution of symptoms were assessed. RESULTS: Of 305 parotidectomy patients, 111 (36.4%) endorsed complaints of postoperative sensory disturbances in the GAN distribution typically characterized by numbness or shooting pains. GAN sacrifice was present in 9 (8.1%) of 111 patients who experienced sensory disturbances compared to 9 (4.6%) who reported no sensory disturbances (p > 0.05). Twenty-five patients (32.5%) experienced spontaneous resolution of symptoms at their most recent follow-up at a mean of 6.2 months after onset of symptoms. Of those that experienced a sensory disturbance, GAN preservation was not significantly associated with likelihood of spontaneous recovery (p > 0.05). CONCLUSIONS: We report the largest series to date of post-operative sensory disturbance in parotidectomy patients as it relates to intraoperative GAN sacrifice. Although the relationship between GAN sacrifice and the incidence of postoperative sensory disturbance and its subsequent resolution were not significant, we continue to advocate for GAN preservation to reduce incidence of postoperative sensory disturbances.

A randomized control trial employing infraorbital nerve stimulation as a neural distractor during nasopharyngeal swab.

INTRODUCTION: With the global COVID-19 pandemic, nasopharyngeal swabbing has become commonplace and can occasionally cause discomfort, tearing, and anxiety. OBJECTIVE: To evaluate whether using a neural distraction device during nasopharyngeal swabbing can mitigate patient discomfort. METHODS: Participants were randomized into nasal swab with vibration first (treatment-control or Tc) or nasal swab without vibration first (control-treatment or Ct). Then the swab was repeated with the opposite technique. The vibration device was used to stimulate the infraorbital nerve at the midpupillary line, while a nasopharyngeal swab was performed according to CDC protocol. After each swab, participants filled out a survey to assess pain, discomfort, and tearing. This procedure was replicated on the contralateral nostril for a total of 4 swabs and 4 surveys. RESULTS: Thirty-four subjects were included in the analysis. In the Ct group, there was a median 1.0-point decrease in pain with the use of vibration (95% CI [-1.8, -0.3], P = 0.0117), 2.5-point decrease (95% CI [-3.0, -0.8], P = 00039) in discomfort, and a 1.0-point decrease (95% CI [-2.6, -0.2] P = 0.0303) in tearing when the vibratory device was used. In the Tc group, there was a median 2.0-point decrease in pain with vibration (95% CI [ -2.7, -1.1], P < 0.0001), 2.3-point decrease in discomfort (95% CI [-3.1, -1.5], P < 0.0001), and a 1.5-point decrease in tearing (95% CI [-2.5, -0.5], P = 0.0037) when vibration was used. CONCLUSION: Vibratory stimulation of the infraorbital nerve is safe and effectively reduced pain, discomfort, and tearing during nasopharyngeal swab. Vibration is a reasonable option to minimize patient discomfort during COVID-19 or other microbiological testing.

First Bite Syndrome After Parotidectomy: A Case Series and Review of Literature.

INTRODUCTION: First bite syndrome (FBS) is a rare but potentially debilitating complication observed after surgery involving the upper cervical region. Patients classically complain of severe facial pain in the ipsilateral parotid region with the first few bites of a meal. OBJECTIVE: The aim of this study is to shed light on the incidence and potential risk factors of FBS, including a series of cases depicting FBS observed after parotidectomy. METHODS: Retrospective review of 419 patients who underwent parotidectomy at a single tertiary care facility between December 2016 and June 2020. RESULTS: With a mean follow-up time of 16.5 months, 8 (2%) patients were documented to have symptoms of FBS after parotid gland surgery. Six of these patients underwent partial parotidectomy by dissection of the deep lobe of the parotid (DLP). CONCLUSION: Patients undergoing dissection of the DLP are particularly at risk for the development of FBS. All patients should be appropriately counseled during informed consent discussions, especially in high-risk cases.

Assessment of narcotic use in management of post-op pain after functional endoscopic sinus surgery.

OBJECTIVES: Pain and analgesic requirements after functional endoscopic sinus surgery (FESS) vary widely. This study aims to quantify pain after routine FESS and determine the most commonly used pain management regimen. METHODS: Retrospective chart review of 100 patients who underwent FESS from Oct 2017 to May 2019. Patients prospectively completed a daily pain diary and reported pain levels that were categorized into no pain (0), mild (1-3), moderate (4-7), or severe (8-10). Patients were categorized into narcotics, non-narcotics, combination, or none based on type of analgesic used. RESULTS: Sixty-nine patients were included. Majority of patients reported either mild (39%) or no pain (28%) during the first 5 PODs. Mean POD1 pain score was 3.98, which decreased with each subsequent POD. On POD1, 37% used opioids (n = 37), 32% used non-opioids (n = 32), 22% used a combination (n = 22), and 9% used no pain meds (n = 9). Mean number of narcotic pills used within the first 5 PODs was 2 pills on any given day. Age was inversely associated with reported POD1 pain scores (P = .003) and use of preoperative steroids in patients with sinonasal polyposis was associated with lower POD1 pain scores (P = .03). CONCLUSIONS: Even on POD1, majority of patients experienced either mild or no pain, and this decreases with each POD. Narcotics are grossly overprescribed and underutilized by patients postoperatively after FESS. We advocate for more judicious prescribing habits of narcotics by Otolaryngologists after FESS, and emphasize relying on non-narcotic alternatives like Acetaminophen or NSAIDS to diminish narcotic use and abuse in the postoperative period. LEVEL OF EVIDENCE: 4.

Naso- or Orbitocutaneous Fistulas after Free Flap Reconstruction of Orbital Exenteration Defects: Retrospective Study, Systematic Review, and Meta-Analysis.

Objective Naso- or orbitocutaneous fistula (NOF) is a challenging complication of orbital exenteration, and it often requires surgical repair. We sought to identify the incidence and risk factors for NOF after orbital exenteration. Study Design Retrospective chart review, systematic review, meta-analysis. Setting Tertiary care center. Participants Patients undergoing free flap reconstruction following orbital exenteration. Records were reviewed for clinicopathologic data, operative details, and outcomes. Main Outcome Measures Univariate analysis was used to assess risk factors for incidence of postoperative NOF. PubMed and Cochrane databases were searched for published reports on NOF after orbital exenteration. Rates of fistula and odds ratios for predictive factors were compared in a meta-analysis. Results Total 7 of 77 patients (9.1%) developed NOF; fistula formation was associated with ethmoid sinus involvement ( p < 0.05) and minor wound break down ( p < 0.05). On meta-analysis, pooled rates of fistula formation were 5.8% for free flap patients and 12.5% for patients receiving no reconstruction. Conclusion Immediate postoperative wound complications and medial orbital wall resection increased the risk for NOF. On review and meta-analysis, reconstruction of orbital exenteration defects decreased the risk for fistula formation, but published series did not demonstrate a significant decrease in risk with free flaps compared with other methods of reconstruction.

Tumor Metabolism in the Microenvironment of Nodal Metastasis in Oral Squamous Cell Carcinoma.

Objective In many cancers, including head and neck squamous cell carcinoma (HNSCC), different regions within a tumor have different metabolic phenotypes. Transfer of metabolites between compartments promotes tumor growth and aggressive behavior. Metabolic compartmentalization in HNSCC nodal metastases has not been studied, nor has its impact on extracapsular extension or clinical outcomes been determined. Study Design Retrospective analysis based on immunohistochemistry staining. Setting Tertiary care center. Subjects and Methods Primary tumors and nodal metastases from 34 surgically treated oral cavity HNSCC patients with extracapsular extension (ECE) were stained for monocarboyxlate transporter (MCT) 4, MCT1, translocase of outer mitochondrial membrane 20, and Ki-67. Strength of staining was assessed using a computer-assisted pathology algorithm. Immunohistochemistry (IHC) scores along with clinical factors were used to predict disease-free survival (DFS). Results Patterns of IHC staining showed metabolic compartmentalization both at the primary tumor sites and in nodal metastases. MCT4 staining in the perinodal stroma was significantly higher in specimens with ECE greater than 1 mm (macro-ECE, P = .01). Patients with high perinodal MCT4 staining were compared with those with low perinodal MCT4 staining. On multivariate analysis, only high perinodal MCT4 staining had a significant impact on DFS ( P = .02); patients with high perinodal MCT4 had worse survival. DFS was not significantly worsened by advancing T stage, N stage, ECE extent, or perineural invasion. Conclusion Oral HNSCC displays compartmentalized tumor metabolism at both primary and metastases. Greater cancer-associated stromal conversion around ECE, denoted by high stromal MCT4, may be a biomarker for aggressive disease and worsened DFS.

Metformin effects on head and neck squamous carcinoma microenvironment: Window of opportunity trial.

OBJECTIVE: The tumor microenvironment frequently displays abnormal cellular metabolism, which contributes to aggressive behavior. Metformin inhibits mitochondrial oxidative phosphorylation, altering metabolism. Though the mechanism is unclear, epidemiologic studies show an association between metformin use and improved outcomes in head and neck squamous cell carcinoma (HNSCC). We sought to determine if metformin alters metabolism and apoptosis in HNSCC tumors. STUDY DESIGN: Window of opportunity trial of metformin between diagnostic biopsy and resection. Participants were patients with newly diagnosed HNSCC. Fifty patients were enrolled, and 39 completed a full-treatment course. Metformin was titrated to standard diabetic dose (2,000 mg/day) for a course of 9 or more days prior to surgery. METHODS: Immunohistochemistry (IHC) for the metabolic markers caveolin-1 (CAV1), B-galactosidase (GALB), and monocarboxylate transporter 4 (MCT4), as well as the Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) apoptosis assay and Ki-67 IHC, were performed in pre- and postmetformin specimens. Exploratory mass spectroscopy imaging (MSI) to assess lactate levels also was performed in three subjects. RESULTS: Metformin was well tolerated. The average treatment course was 13.6 days. Posttreatment specimens showed a significant increase in stromal CAV1 (P < 0.001) and GALB (P < 0.005), as well as tumor cell apoptosis by TUNEL assay (P < 0.001). There was no significant change in stromal MCT4 expression or proliferation measured by Ki67. Lactate levels in carcinoma cells were increased 2.4-fold postmetformin (P < 0.05), as measured by MSI. CONCLUSION: Metformin increases markers of reduced catabolism and increases senescence in stromal cells as well as carcinoma cell apoptosis. This study demonstrates that metformin modulates metabolism in the HNSCC microenvironment. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1808-1815, 2017.

Postoperative cerebrospinal fluid leak after microvascular reconstruction of craniofacial defects with orbital exenteration.

OBJECTIVES: To assess risk factors for cerebrospinal fluid (CSF) leak and complications after microvascular reconstruction of cranio-orbitofacial resection with orbital exenteration (CFOE). STUDY DESIGN: Retrospective case series. METHODS: Seventy consecutive patients at a tertiary hospital underwent 76 procedures with microvascular reconstruction of CFOE defects. Patients were stratified by extent of skull base exposure and presence or absence of dural resection. Patients with exposure of the orbital apex and roof alone were classified as minimal skull base exposure (MS) (n = 32). Those with skull base exposure beyond the orbital apex and roof were classified as significant skull base exposure (SS) (n = 38) and were subdivided into those with dural exposure (SSe) (n = 15) and those with dural resection (SSr) (n = 23). The main outcome measure was incidence of postoperative CSF leak according to univariate and multivariate analysis of risk factors, including previous radiation, surgery, and location of defect. RESULTS: Intraoperative leaks occurred in five and four patients in the MS and SSe groups, respectively, with no postoperative leaks. In the SSr group, five patients developed a postoperative CSF leak and three required operative management. Multivariate analysis revealed middle fossa exposure to be the only significant predictor of CSF leak (P = 0.03). The overall complication rate was 31.6%. Major complications were greater in the SS group compared to the MS group (P = 0.05). CONCLUSION: In this series, middle fossa resection increased the risk of postoperative CSF leak after microvascular reconstruction of CFOE defects, and complication rates were greater with more complex defects. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:835-841, 2017.

Sinonasal malignancy: What to do with an unexpected pathology result?

BACKGROUND: Endoscopic sinus surgery has become the mainstay in surgical treatment of sinusitis and nasal polyps. While rare, diagnostic discrepancies or pathological contamination during routine specimen analysis has been described. Thus, an accurate diagnosis and indication for surgery are mandatory before proceeding with surgical intervention. METHODS: We present the case of a 40-year-old female patient who underwent endoscopic sinus surgery (ESS) for chronic sinusitis without nasal polyposis and fragments of squamous cell carcinoma (SCC) were found in the pathology specimen. RESULTS: We propose an algorithm to help guide physicians presented with a tissue diagnosis that does not match the clinical scenario. Moreover, we discuss strategies to help prevent medical errors and the importance of DNA genetic analysis in this situation. CONCLUSION: When an unexpected diagnosis occurs, the pathology slides should be reviewed for a second opinion. If the unexpected diagnosis is confirmed, the tissue should undergo STR genetic analysis to ensure against tissue contamination.

Thyroid Cancer Metabolism: A Review.

Metabolic dysregulation within the tumor microenvironment (TME) is critical to the process of tumorigenesis in various cancer types. Thyrocyte metabolism in papillary and anaplastic thyroid cancer, however, remains poorly characterized, and studies analyzing the role of multicompartment metabolism in thyrocyte oncogenesis are sparse. We present a review of the current knowledge on cellular metabolism in non-cancerous and cancerous thyroid tissues, focusing on the monocarboxylate transporters MCT1 and MCT4, and on a transporter of the outer mitochondrial membrane TOMM20. Understanding the metabolic phenotype of tumor cells and associated stromal cells in thyroid cancer can have profound implications on the use of biomarker staining in detecting subclinical cancer, imaging as it relates to expression of various transport proteins, and therapeutic interventions that manipulate this dysregulated tumor metabolism to halt tumorigenesis and eradicate the cancer. Future studies are required to confirm the prognostic significance of these biomarkers and their correlation with existing staging schemas such as the AGES, AMES, ATA and MACIS scoring systems.

An Unusual Presentation of Adenoid Cystic Carcinoma.

Adenoid cystic carcinoma (ACC) is a relatively rare tumor of epithelial cell origin, most commonly arising from major salivary glands. It is uncommonly found outside the major or minor salivary glands and is especially rare when located in the nasal cavity. Diagnosis and treatment of ACC pose numerous challenges, partly due to its biological behavior of slow growth, high tendency of local recurrence, and perineural invasion. We present the case of a 67-year-old male with complaints of facial pain and swelling, with a CT scan showing a soft tissue mass extending from the right nasal cavity with osseous destruction. Biopsy revealed ACC with perineural invasion. ACC of the nasal cavity continues to pose diagnostic and therapeutic challenges to physicians. Because this rare pathology presents in a vague manner, early diagnosis requires a high index of suspicion for this disease and close follow-up care. Since ACC of the nasal cavity is seldom reported in the literature, it is our hope that reporting these rare instances as case reports will heighten physician awareness of this rare disease, allowing for early diagnosis and treatment.

Colorectal Adenocarcinoma Metastasis to the Tongue.

This case presentation examines a rare clinical entity: colorectal adenocarcinoma (CRC) metastasis to the tongue. CRC is among the least common tumors to metastasize to the oral cavity. Objectives for this case report are to (1) maintain a high index of suspicion for oral cavity tumors representing metastatic disease, (2) consider appropriate surgical and adjunctive interventions, and (3) recognize the significance of identifying the primary tumor via immunohistochemical staining. We present a case of a 57-year-old male with a history of stage IV rectal adenocarcinoma metastatic to the lung who presented to our clinic with a painful mass of the right lateral tongue that he noticed one month before. MRI of the neck revealed a mass involving the anterior two-thirds of the right tongue with irregular margins and an ipsilateral enlarged right jugulodigastric lymph node. The patient underwent right partial glossectomy with primary reconstruction and right modified radical neck dissection. Pathology confirmed poorly differentiated adenocarcinoma consistent with a colorectal primary with lymphovascular and perineural invasion. The tumor was staged as T2N1, and the patient was referred for chemoradiation. In this report, we discuss the presentation, diagnosis, and treatment of this uncommon disease, with a thorough review of the world literature.