Sensation loss after superficial parotidectomy: A prospective controlled multicenter trial.

BACKGROUND: The purpose of this study was to evaluate the occurrence of hypoesthesia after superficial parotidectomy depending on preservation of posterior branch of the great auricular nerve (GAN). METHODS: This prospective, controlled, double blind, multicenter trial included 130 patients. The posterior branch was preserved in 93 patients (GAN group), and ligated in 33 patients (non-GAN group). In 4 patients, GAN status was unknown. Included patients underwent sensory testing (TouchTest) and subjective evaluation at 6, 12, and 24 months after surgery. RESULTS: Better improvement of sensation was present in the GAN group. After 12 months, 59% of the patients in the GAN-group showed positive test results in the lobule, versus 24% of the non-GAN group (p = .013). Additionally, after 24 months, 71% of the patients in the GAN-group showed a positive test in the antitragus, versus 31% in the non-GAN group (p = .045). Hypoesthesia equally limited quality of life in both groups (all p > .05). CONCLUSION: Preservation of the posterior branch of the GAN led to significantly better improvement of sensation in the lobule and antitragus, and should be recommended during parotidectomy. © 2017 Wiley Periodicals, Inc. Head Neck 39: 520-526, 2017.

Frey's syndrome after superficial parotidectomy: role of the sternocleidomastoid muscle flap: a prospective nonrandomized controlled trial.

BACKGROUND: The prevalence of Frey's syndrome (FS) after superficial parotidectomy in correlation to the sternocleidomastoid muscle flap (SCMMF) interposition is analyzed. METHODS: A prospective nonrandomized controlled multicenter trial included 130 patients. During superficial parotidectomy, SCMMF was dissected, if excised specimens' volume exceeded 25 mL (SCMMF group). Follow-up examinations took place after 6, 12, and 24 months and included a Minor's test. RESULTS: SCMMF was dissected in 30 (23.1%) patients. A total of 104, 80, and 68 patients completed the 1st, 2nd, and the 3rd follow-up, respectively. FS was detectable with nonvarying prevalence (46.3%, 45.6%, and 43.4%, respectively) during follow-up. The prevalence was higher in the SCMMF group (59.9%) than in the non-SCMMF group (41.8%; P = .92). The sweating area increased during follow-up (P = .12). Overall, 89.5% of patients characterized FS as not disturbing after 2 years. CONCLUSIONS: FS occurred with a steady and high prevalence after superficial parotidectomy. In particular, SCMMF did not lower the risk of FS.

3D-Ultrasonography for evaluation of facial muscles in patients with chronic facial palsy or defective healing: a pilot study.

BACKGROUND: While standardized methods are established to examine the pathway from motorcortex to the peripheral nerve in patients with facial palsy, a reliable method to evaluate the facial muscles in patients with long-term palsy for therapy planning is lacking. METHODS: A 3D ultrasonographic (US) acquisition system driven by a motorized linear mover combined with conventional US probe was used to acquire 3D data sets of several facial muscles on both sides of the face in a healthy subject and seven patients with different types of unilateral degenerative facial nerve lesions. RESULTS: The US results were correlated to the duration of palsy and the electromyography results. Consistent 3D US based volumetry through bilateral comparison was feasible for parts of the frontalis muscle, orbicularis oculi muscle, depressor anguli oris muscle, depressor labii inferioris muscle, and mentalis muscle. With the exception of the frontal muscle, the facial muscles volumes were much smaller on the palsy side (minimum: 3% for the depressor labii inferior muscle) than on the healthy side in patients with severe facial nerve lesion. In contrast, the frontal muscles did not show a side difference. In the two patients with defective healing after spontaneous regeneration a decrease in muscle volume was not seen. Synkinesis and hyperkinesis was even more correlated to muscle hypertrophy on the palsy compared with the healthy side. CONCLUSION: 3D ultrasonography seems to be a promising tool for regional and quantitative evaluation of facial muscles in patients with facial palsy receiving a facial reconstructive surgery or conservative treatment.

Quantitative ultrasonography of facial muscles in patients with chronic facial palsy.

INTRODUCTION: In this study we introduce quantitative facial muscle ultrasound as a diagnostic tool for patients with chronic unilateral facial palsy. METHODS: Muscle area, thickness, and echo intensity of 6 facial muscles (frontalis, orbicularis oculi, orbicularis oris, depressor anguli oris, depressor labii inferioris, and mentalis) and of 2 chewing muscles (temporalis and masseter, as controls) were measured in 20 patients with chronic facial palsy. RESULTS: Aside from 1, all facial muscles were significantly smaller on the paralyzed side. With exception of frontalis and orbicularis oculi muscles, all other facial muscles showed significantly higher echo intensity on the affected side. Muscle size and echo intensity of the chewing muscles showed no side-to-side asymmetry. CONCLUSIONS: Quantitative ultrasound of facial muscles helps to better characterize their status in patients with chronic facial palsy in the phase of denervation and during regeneration.

Reduced cholinergic and glutamatergic synaptic input to regenerated motoneurons after facial nerve repair in rats: potential implications for recovery of motor function.

Deafferentation of motoneurons after facial nerve injury is a well-documented phenomenon but whether synaptic inputs to facial motoneurons are completely restored after reinnervation is unknown. Here, we tested the hypothesis that deficits in motor performance after transection/suture of the facial nerve (facial-facial anastomosis, FFA) in adult rats are associated with incomplete recovery of synaptic inputs. At 2 months after FFA, we found, in congruence with previous results, that the amplitude of whisking had recovered to only 31 % of control (sham operation). In the same FFA-treated rats, estimates of number of chemically defined synaptic terminals in the facial nucleus by immunohistochemistry and stereology showed a significant loss, compared with sham controls, of glutamatergic terminals (-26 %) and cholinergic perisomatic boutons (-31 %), but not inhibitory (GABA/glycinergic) terminals (-14 %). Synaptic deficits were accompanied by persistent microgliosis in the facial nucleus but soma area, dendritic arbor volume, and total number of motoneurons were normal. Correlation analyses revealed significant co-variations of whisking amplitude with number of glutamatergic and cholinergic synapses. Compared with 2 months, analyses of animals at 4 months after FFA showed no attenuation of the functional deficit and structural aberrations with one exception, increase of inhibitory terminal numbers beyond control level (+11 %) leading to further reduction of the excitatory/inhibitory terminal ratio. We suggest that deficits in motoneuron innervation in the regenerated facial nucleus-reduced glutamatergic and cholinergic input and reduced excitatory/inhibitory terminal ratio-could attenuate the motor output and, thus, negatively impact the functional performance after facial nerve regeneration.

Pediatric adenoidectomy: a population-based regional study on epidemiology and outcome.

OBJECTIVES: To evaluate population-based data on incidence of pediatric adenoidectomy and rate of revision surgery. METHODS: A retrospective study of all adenoidectomies in children was performed in the year 2009 in all otolaryngology departments in one federal state, Thuringia, in Germany. Patients' characteristics, preoperative diagnostics and postoperative complications were analyzed. The association between baseline characteristics and the risk of re-adenoidectomy was examined using Kaplan-Meier method with univariate log-rank test, and with a multivariate Cox regression model. Population data were used to calculate age-related annual rates of adenoidectomies. RESULTS: 1939 adenoidectomies were performed in 2009 in Thuringia. 89% were primary cases and 11% of the children already had an adenoidectomy prior to 2009. Immediate re-surgery because of primary hemorrhage was necessary in 0.8% of the cases. Re-adenoidectomy because of recurrent symptoms was needed in 9% of patients after a median interval of 16 months. The univariate analysis showed that the factors age ≤3 years and primary surgery were significantly associated to a higher risk of surgery because of recurrent symptoms The multivariate analysis showed that primary surgery was independently associated with the risk of re-surgery (hazard ratio 1.66; 95% confidence interval 1.01-2.74). The annual adenoidectomy rate was 678/100,000 underage habitants. The incidence was highest between 2 and 4 years of age. CONCLUSIONS: This population based analysis is showing that adenoidectomy is performed country-wide with good results and low risk on important scale in daily routine by otorhinolaryngologists. The risk of re-adenoidectomy seems to be higher than hitherto reported by hospital-based studies.

Postoperative pain assessment after pediatric otolaryngologic surgery.

OBJECTIVES: To describe postoperative pain within the first 24 hours after pediatric otolaryngologic surgery and to identify factors influencing postoperative pain. METHODS: One-hundred and thirty four children were included in a prospective cohort single center study. Outcome and process parameters were analyzed using the questionnaires of the German-wide project Quality Improvement in Postoperative Pain Management in Infants (QUIPSI). RESULTS: Maximal pain within the first 24 hours after typical otolaryngologic surgery reached average numeric rating scale values of 4.00 ± 3.49. About one fifth demanded more pain medications. Inpatient surgery, longer surgery, and major surgery were associated with more maximal pain. Analysis of analgesic use on the ward indicated insufficient utilization of these drugs, especially when piritramide was used (beta = 3.597, P = 0.039). When ibuprofen was used on the ward, this was significantly associated with the desire for more pain medication (odds ratio [OR]: 0.274, confidence interval [CI]: 0.103-0.725, P = 0.009). Children with American Society of Anesthesiologists status 2 were more fatigued after surgery than status 1 children (OR: 0.296, CI: 0.100-0.874, P = 0.028). Nausea was more common when ibuprofen was used on the ward for pain treatment (OR: 0.195, CI: 0.049-0.777, P = 0.020). CONCLUSIONS: QUIPSI is an easy tool to evaluate the quality of postoperative pain management following pediatric otolaryngologic surgery in children older than 3 years, especially in children older than 9 years. The maximal pain values within the first 24 hours are significant, so that pain therapy is required. It seems that both nonopioids and opioids are underdosed.

Prognostication of recovery time after acute peripheral facial palsy: a prospective cohort study.

OBJECTIVE: Owing to a lack of prospective studies, our aim was to evaluate diagnostic factors, in particular, motor and non-motor function tests, for prognostication of recovery time in patients with acute facial palsy (AFP). DESIGN: Prospective cohort study. SETTING: University hospital. PARTICIPANTS: 259 patients with AFP. MEASUREMENTS: Clinical data, facial grading, electrophysiological motor function tests and other non-motor function tests were assessed for their contribution to recovery time. RESULTS: The predominant origin of AFP was idiopathic (59%) and traumatic (21%). At baseline, the House-Brackmann scale (HB) was >III in 46% of patients. Follow-up time was 5.6±9.8 months with a complete recovery rate of 49%. The median recovery time was 3.5 months (95% CI 2.2 to 4.7 months). The following variables were associated with faster recovery: Interval between onset of AFP and treatment <6 days versus ≥6 days (median recovery time in months 2.1 vs 6.5; p<0.0001); HB ≤III vs >III (2.2 vs 4.6; p=0.001); no versus presence of pathological spontaneous activity in first electromyography (EMG; 2.8 vs probability of recovery <50%; p<0.0001); no versus voluntary activity in EMG (probability of recovery <50% vs 3.1; p<0.0001); normal versus pathological ipsilateral electroneurography (1.9 vs 6.5; p=0.008), normal versus pathological stapedius reflexes (1.6 vs 3.3; p=0.003). CONCLUSIONS: Start of treatment and grading, but most importantly EMG evaluated for pathological spontaneous activity and the stapedius reflex test are powerful prognosticators for estimating the recovery time from AFP. These results need confirmation in larger datasets.

Short-term outcome and patient satisfaction after sialendoscopy.

Sialendoscopy is an established, minimally invasive technique to diagnose and treat obstructive disorders of major salivary glands. Knowledge about patient satisfaction and quality of life is limited. All patients who underwent sialendoscopy were prospectively followed and evaluated. To determine the quality of life after sialendoscopy, an established questionnaire was evaluated (Short-Form-36 Health Survey-SF-36). To determine patient satisfaction, a self-made questionnaire was applied and evaluated. Furthermore, postoperative follow-up examination and the amount of patients who could be saved from sialadenectomy were determined. Main reasons for sialendoscopy were recurrent or permanent swelling of the affected salivary gland. 46 patients were included, 52 sialendoscopies were performed. Immediately after sialendoscopy operative ablation of the respective gland was averted in 98.1 % of the patients. After the follow-up period of 225.4 ± 79.0 days operative ablation of the respective gland was avoided in 89.9 % of the patients. Overall, 85.2 % reported an improvement of symptoms during follow-up, however, values for role-physical functioning (p = 0.025) and bodily pain (p = 0.011) still showed a significant difference when compared to a matched reference group of healthy individuals. Significant negative influence factors towards the outcome were younger age, long-term duration of symptoms and selected SF-36 items (vitality, social functioning, and mental health). Operative ablation of major salivary glands can be avoided by means of sialendoscopy in high percentages during short-term. There seems to be a high patient satisfaction in these selected cases. The duration of preoperative symptoms appears to be an important factor predisposing towards poor satisfaction.

Quantitative ultrasonography of facial muscles.

INTRODUCTION: There is no standardized method for examination of facial muscles with ultrasound. The purpose of this study was to identify those facial muscles accessible for reliable identification and to provide reference data. METHODS: In healthy subjects all facial muscles were screened for visibility, separation from adjacent muscles, and reliability of landmarks. Bilateral scans of reliable muscles were performed in 40 adult volunteers. RESULTS: Six facial muscles were clearly demarcated with ultrasound. These were: frontalis, orbicularis oculi, orbicularis oris, depressor anguli oris, depressor labii inferioris, and mentalis muscles. Cross-sectional area and muscle thickness showed gender differences and were independently related to age for some muscles. A significant left-right side difference was only seen for the orbicularis oculi muscle in women. CONCLUSIONS: These data demonstrate the usefulness of ultrasonography to assess facial muscles and provide reference values that can be applied in the clinical setting.

Prognostic impact of pretherapeutic laboratory values in head and neck cancer patients.

PURPOSE: The high comorbidity in patients with head and neck cancer (HNC) is mainly caused by the high incidence of tobacco and alcohol abuse and has direct impact on overall survival. We investigated whether HNC and its comorbidity also influence routine laboratory values and whether these values have influence on overall survival. METHODS: A retrospective cohort of 261 patients with primary squamous cell carcinoma of the oral cavity, pharynx, or larynx diagnosed between 2001 and 2006 with a complete set of pretherapeutic laboratory values was identified. The influence of standard oncological parameters, comorbidity, and each laboratory value on overall survival (OS) was investigated in univariate and multivariate analyses. RESULTS: Two-thirds of patients were active smokers and about one half reported high alcohol consumption. 40 % of patients had severe comorbidity according to Charlson comorbidity index. The most frequent laboratory pathologies were elevated C-reactive protein (CRP) values (66 %), impaired liver enzymes (30-50 %), decreased urea levels (33 %), leukocytosis (20 %), and anemia (10 %). In multivariate analysis for OS, a comorbidity index ≥5 (Hazard ratio [HR], 2.008; 95 % confidence interval [CI], 1.117-3.610; p = 0.020), high CRP level (HR, 2.469; CI, 1.414-4.310; p = 0.001), and abnormal low red-cell count (HR, 2.525; CI, 1.250-5.102; p = 0.010) were independent prognostic variables. CONCLUSIONS: Comorbidity reflected by pathologic laboratory values is a major issue in HNC patients. Several pretherapeutic laboratory values have prognostic relevance for overall survival in HNC patients.

Postoperative pain assessment after functional endoscopic sinus surgery (FESS) for chronic pansinusitis.

Postoperative pain after functional endoscopic sinus surgery (FESS) and its optimal management has not been described in detail. The objective was to evaluate pain, its influencing factors and its management on the first postoperative day following FESS. In a prospective case study, 101 FESS patients were examined after removal of the nasal packing within the Quality Improvement in Postoperative Pain Management (QUIPS) project allowing a standardized assessment of patients' characteristics, pain parameters, outcome and process parameters. The influence of these parameters on the patients' postoperative pain was estimated by univariate and multivariate statistic analysis. Pain during the first postoperative day after FESS was moderate. Younger patients reported significantly more pain than did older patients. Specific counseling about the possibilities of postoperative pain management reduced pain intensity highly significantly in univariate and multivariate analysis. Patients demanding for pain relief in the recovery room and on the ward predominantly received acetaminophen as non-opioid and piritramide as opioid. This pain management was obviously insufficient as these patients still reported significantly more from pain on the first postoperative day than patients not demanding for pain relief. We conclude that QUIPS could help to optimize the quality of postoperative pain management following FESS.

Laryngeal electromyography: a proposal for guidelines of the European Laryngological Society.

Although recognized as a valuable diagnostic tool for more than 60 years, many laryngologists do not routinely use laryngeal electromyography (LEMG). This may be due to a persisting lack of agreement on methodology, interpretation, validity, and clinical application of LEMG. To achieve consensus in these fields, a laryngeal electromyography working group of European neurolaryngologic experts was formed in order to (1) evaluate guidelines for LEMG performance and (2) identify issues requiring further clarification. To obtain an overview of existing knowledge and research, English-language literature about LEMG was identified using Medline. Additionally, cited works not detected in the initial search were screened. Evidence-based recommendations for the performance and interpretation of LEMG and also for electrostimulation for functional evaluation were considered, as well as published reports based on expert opinion and single-institution retrospective case series. To assess the data obtained by this literature evaluation, the working group met five times and performed LEMG together on more than 20 patients. Subsequently, the results were presented and discussed at the 8th Congress of the European Laryngological Society in Vienna, Austria, September 1-4, 2010, and consensus was achieved in the following areas: (1) minimum requirements for the technical equipment required to perform and record LEMG; (2) best practical implementation of LEMG; (3) criteria for interpreting LEMG. Based on this consensus, prospective trials are planned to improve the quality of evidence guiding the proceedings of practitioners.