Techniques in Otolaryngology: Ultrasound-Guided Transcervical Fine-Needle Aspiration of Laryngeal Masses.

Traditionally, laryngeal masses are diagnosed with direct laryngoscopy with biopsy under general anesthesia. The use of transcervical ultrasound-guided fine-needle aspiration for the diagnosis of base of tongue lesions, thyroid nodules, and cervical lymph node metastases has been well documented, and its use in the diagnosis of laryngeal masses has increased in recent years. We report a technique for office-based transcervical ultrasound-guided fine-needle aspiration for laryngeal masses without cervical metastasis (N0), with outcomes from 6 patients. Benefits of this approach included limited side effects, rapid in-office diagnosis, avoidance of aerosolizing procedures during the COVID-19 pandemic, and avoidance of tracheostomy.

Neurotization Preferences in Smile Reanimation: A Discrete Choice Experiment.

BACKGROUND: Common donor nerve options in smile reanimation include ipsilateral trigeminal motor or contralateral facial nerve branches. Neurotization preference may be influenced by multiple factors, whose relative importance remains poorly understood. In this article, decision-making in smile reanimation is assessed using a stated preference model. METHODS: Qualitative interviews with facial palsy patients identified five relevant attributes for study: smile type ("smile when biting" versus "smile spontaneously" as proxies for trigeminal versus cross-facial neurotization), number of operations, success rates, complication rates, and side effects. Community volunteers (n = 250) completed a discrete-choice experiment relevant to free muscle transfer for smile reanimation. Preoperative and postoperative states were demonstrated through video vignettes, together with explanation of surgical risks, consequences, and benefits. Attribute importance was modeled using hierarchical Bayes estimation. RESULTS: Two hundred forty-one responses met quality controls. Attribute importance ranked as follows: chance of success, 37.3 percent; smile type, 21.4 percent; side effects, 13.9 percent; complication rates, 13.8; and number of operations, 13.6 percent. All attributes significantly correlated with decision making (p < 0.0001). An aggregate response model revealed most participants (67.6 percent; standard error, 3.0 percent) preferred smile reanimation by cross-facial (assuming a success rate of 80 percent) as opposed to ipsilateral trigeminal motor branch neurotization. When the success rate for cross-facial neurotization was reduced below 67 percent, trigeminal neurotization was preferred. CONCLUSIONS: Despite a higher risk of failure, most respondents preferred a cross-facial as opposed to trigeminal neurotization strategy for smile reanimation. These findings highlight the complexity of decision-making and need for individualized risk tolerance assessment in the field of facial reanimation.

Development of a Deep Learning Algorithm for Periapical Disease Detection in Dental Radiographs.

Periapical radiolucencies, which can be detected on panoramic radiographs, are one of the most common radiographic findings in dentistry and have a differential diagnosis including infections, granuloma, cysts and tumors. In this study, we seek to investigate the ability with which 24 oral and maxillofacial (OMF) surgeons assess the presence of periapical lucencies on panoramic radiographs, and we compare these findings to the performance of a predictive deep learning algorithm that we have developed using a curated data set of 2902 de-identified panoramic radiographs. The mean diagnostic positive predictive value (PPV) of OMF surgeons based on their assessment of panoramic radiographic images was 0.69(± 0.13), indicating that dentists on average falsely diagnose 31% of cases as radiolucencies. However, the mean diagnostic true positive rate (TPR) was 0.51(± 0.14), indicating that on average 49% of all radiolucencies were missed. We demonstrate that the deep learning algorithm achieves a better performance than 14 of 24 OMF surgeons within the cohort, exhibiting an average precision of 0.60(± 0.04), and an F1 score of 0.58(± 0.04) corresponding to a PPV of 0.67(± 0.05) and TPR of 0.51(± 0.05). The algorithm, trained on limited data and evaluated on clinically validated ground truth, has potential to assist OMF surgeons in detecting periapical lucencies on panoramic radiographs.

The spectrum of facial palsy: The MEEI facial palsy photo and video standard set.

OBJECTIVES: Facial palsy causes variable facial disfigurement ranging from subtle asymmetry to crippling deformity. There is no existing standard database to serve as a resource for facial palsy education and research. We present a standardized set of facial photographs and videos representing the entire spectrum of flaccid and nonflaccid (aberrantly regenerated or synkinetic) facial palsy. To demonstrate the utility of the dataset, we describe the relationship between level of facial function and perceived emotion expression as determined by an automated emotion detection, machine learning-based algorithm. METHODS: Photographs and videos of patients with both flaccid and nonflaccid facial palsy were prospectively gathered. The degree of facial palsy was quantified using eFACE, House-Brackmann, and Sunnybrook scales. Perceived emotion during a standard video of facial movements was determined using an automated, machine learning algorithm. RESULTS: Sixty participants were enrolled and categorized by eFACE score across the range of facial function. Patients with complete flaccid facial palsy (eFACE <60) had a significant loss of perceived joy compared to the nonflaccid and normal groups. Additionally, patients with only moderate flaccid and nonflaccid facial palsy had a significant increase in perceived negative emotion (contempt) when compared to the normal group. CONCLUSION: We provide this open-source database to assist in comparing current and future scales of facial function as well as facilitate comprehensive investigation of the entire spectrum of facial palsy. The automated machine learning-based algorithm detected negative emotions at moderate levels of facial palsy and suggested a threshold severity of flaccid facial palsy beyond which joy was not perceived. LEVEL OF EVIDENCE: NA Laryngoscope, 130:32-37, 2020.

Health utility of rhinectomy, surgical nasal reconstruction, and prosthetic rehabilitation.

OBJECTIVES: Advanced nasal malignancies may require rhinectomy, which can have profound psychosocial impacts. Rhinectomy defects can be rehabilitated through surgery or prosthetics. We seek to understand the health utility of the rhinectomy defect, surgical, and prosthetic reconstruction, which have not been previously studied. STUDY DESIGN: Prospective clinical study METHODS: Adult naïve observers (n = 273) ranked the utility of five randomized health states (monocular blindness, binocular blindness, post-rhinectomy nasal defect, postsurgical reconstruction, and post-prosthetic rehabilitation). Health utilities were measured using visual analogue scale (VAS), standard gamble (SG), and time trade-off (TTO). One-way analysis of variance (ANOVA) with post hoc Scheffe's test and the independent samples T-test for a priori comparisons were performed. Multiple linear regression was performed using participant demographics as independent predictors of utility scores. RESULTS: Health utilities (VAS, SG, TTO) were reported as follows (mean ± SD): monocular blindness (0.71 ± 0.21, 0.84 ± 0.20, 0.85 ± 0.19), binocular blindness (0.48 ± 0.25, 0.68 ± 0.28, 0.63 ± 0.28), post-rhinectomy nasal defect (0.59 ± 0.24, 0.74 ± 0.24, 0.74 ± 0.24), postsurgical reconstruction (0.88 ± 0.16, 0.90 ± 0.18, 0.89 ± 0.13), and post-prosthetic rehabilitation (0.67 ± 0.22, 0.80 ± 0.23, 0.82 ± 0.20). Both surgical reconstruction (P < .001) and prosthetic rehabilitation (P < .001) significantly improved health utility. SG and TTO utility scores were inversely associated with observer age (P < .001) and participants who identified themselves as non-Caucasians (P < .05) in post-rhinectomy nasal defect, post-nasal surgical reconstruction, and post-nasal prosthetic rehabilitation health states, while higher levels of education were directly associated with SG scores (P < .05), respectively. CONCLUSION: This is the first study to demonstrate the significant negative impact of the rhinectomy nasal defect on health utility. Rehabilitation by surgical or prosthetic techniques significantly increases health utility as rated by naïve observers. Laryngoscope, 130:1674-1679, 2020.

Spontaneity Assessment in Dually Innervated Gracilis Smile Reanimation Surgery.

IMPORTANCE: Surgeons have sought to optimize outcomes of smile reanimation surgery by combining inputs from nerve-to-masseter and cross-face nerve grafts. An objective assessment tool could help surgeons evaluate outcomes to determine the optimal neural sources for smile reanimation. OBJECTIVE: To evaluate the use of a novel video time-stamping method and standard outcome measurement tools to assess outcomes of facial reanimation surgery using various innervation strategies. DESIGN, SETTING, AND PARTICIPANTS: Cohort study assessing the outcomes of dually innervated gracilis free muscle transfers vs single-source innervated gracilis transfer performed at a tertiary care facial nerve center between 2007 and 2017 using a novel, video time-stamping spontaneity assessment method. The statistical analyses were performed in 2018. INTERVENTIONS: Dually innervated gracilis free muscle transfers or single-source innervated gracilis transfer. MAIN OUTCOMES AND MEASURES: Spontaneous smiling was assessed by clinicians and quantified using blinded time-stamped video recordings of smiling elicited while viewing humorous video clips. RESULTS: This retrospective cohort study included 25 patients (12 men and 13 women; median [range] age, 38.4 [29.3-46.0] years) treated with dually innervated gracilis free functional muscle graft for unilateral facial palsy between 2007 and 2017. Smile spontaneity assessment was performed in 17 patients and was compared with assessment performed in 24 patients treated with single-source innervated gracilis transfer (ie, nerve-to-masseter-driven or cross-face nerve graft-driven gracilis [n = 13]) (demographic data not available for NTM and CFNG cohorts). The use of time-stamped video assessment revealed that spontaneous synchronous oral commissure movement in a median percentage of smiles was 33% in patients with dually innervated gracilis (interquartile range [IQR], 0%-71%), 20% of smiles in patients with nerve-to-masseter-driven gracilis (IQR, 0%-50%), and 75% of smiles in patients with cross-face nerve graft-driven gracilis (IQR, 0%-100%). Clinicians graded smile spontaneity in dually innervated cases as absent in 40% (n = 6 of 15), trace in 33% (n = 5 of 15) and present in 27% (n = 4 of 15). No association was demonstrated between clinician-reported spontaneity and objectively measured synchronicity. CONCLUSIONS AND RELEVANCE: Dually innervated gracilis free muscle transfers may improve smile spontaneity compared with masseteric nerve-driven transfers but not to the level of cross-face nerve graft-driven gracilis transfers. Quantifying spontaneity is notoriously difficult, and most authors rely on clinical assessment. Our results suggest that clinicians may rate presence of spontaneity higher than objective measures, highlighting the importance of standardized assessment techniques. LEVEL OF EVIDENCE: 4.

Patient experience in nerve-to-masseter-driven smile reanimation.

INTRODUCTION: The nerve-to-masseter is one of the most frequently used neural sources in smile reanimation surgery. Very little information has been reported on patient experience with regard to reanimated smile usage and sequelae following transfer. The aim of this study was to quantify patient perception of nerve-to-masseter use in smile reanimation surgery. METHODS: An online questionnaire was developed based on the clinical expertise of our team, patient interviews, and existing questionnaires of facial palsy-related quality of life and temporomandibular joint dysfunction. All patients treated with nerve-to-masseter-driven smile reanimation surgery, both nerve transfers and muscle transplantations, between 2007 and 2016 with a valid email address were invited to participate. RESULTS: Of 171 operated patients, 122 with a valid email address were invited to participate. Seventy-one patients responded (63.4% female, mean age 51.1 years) after a median follow-up of 3.8 years. A voluntary smile while biting down at least "most of the time" was reported by 83.1% of patients; 46.5% reported ability to smile on the affected side without bite. A "normal" or "almost normal" spontaneous smile was reported in 23.9% of patients. A total of 18.3% of patients self-reported masseter muscle atrophy, and 1.4-14.1% reported temporomandibular joint dysfunction. Forty-one patients (57.7%) reported prandial movement of the face at least "most of the time," with 9 patients (12.7%) considering this bothersome. CONCLUSION: Patients report good voluntary smiling ability following nerve-to-masseter-driven smile reanimation surgery, with low rates of sequelae.

The epidemiology of autologous tissue grafting in primary and revision rhinoplasty.

OBJECTIVES/HYPOTHESIS: To determine the percentage of primary versus revision rhinoplasty cases that require an extranasal source of grafting, as well as age and gender-specific trends. STUDY DESIGN: Cross-sectional analysis of multistate ambulatory surgery and hospital databases. METHODS: Ambulatory rhinoplasty procedures were extracted from the State Ambulatory Surgery Databases for New York, Kentucky, North Carolina, Michigan, and Florida for 2014 to 2015. Cases were examined for simultaneous use of extranasal grafts. RESULTS: A total of 8,510 rhinoplasties were extracted (65.3% female, mean age = 35.6 years), and 11.9% were revision cases (95% confidence interval [CI]: 11.2-12.6). An extranasal, autologous source of grafting was required in 12.7% of cases (5.3% auricular, 95% CI: 4%-6.6%; 1.8% costal, 95% CI: 1%-2.6%). Revision cases were more likely to require a secondary source of grafting (24.4%, 95% CI: 21.8%-27.1% vs. 11.1%, 95% CI: 10.3%-11.8%). In revision cases, the most common graft was auricular cartilage (14.4%, 95% CI: 12.2%-16.6%) followed by costal (7.1%, 95% CI: 5.52%-8.69%). Only 1.1% of primary cases required costal cartilage (95% CI: 0.88%-1.36%) compared to 7.1% of revision cases (95% CI: 5.52%-8.69%). Of the primary cases, 4.1% required auricular cartilage grafting (95% CI: 3.67%-4.57%) compared to 14.4% of revision cases (95% CI: 12.2%-16.6%). Patients who required a graft were older. Significantly more males required autologous grafting than females (P = .047). CONCLUSIONS: Cartilaginous or bony grafting is a critical surgical technique in both primary and secondary rhinoplasties. This is the first study to examine percentages of site-specific autologous grafting from auricular and costal donor sites for primary and revision cases. Gender and age-specific trends associated with specific grafting sites are also identified. These data are important to help guide preoperative counseling and informed consent for all rhinoplasty surgeries. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1549-1553, 2019.

Postoperative revisits and readmissions after facelift surgery.

OBJECTIVES/HYPOTHESIS: To determine 30-day rates and reasons for revisit and readmission after rhytidectomy surgery. STUDY DESIGN: Cross-sectional analysis. METHODS: Cross-sectional analysis was performed of multistate ambulatory surgery and hospital databases. Ambulatory rhytidectomy cases were extracted from State Ambulatory Surgery Databases for New York, Florida, Iowa, and California for 2010 and 2011. Cases were linked to State Emergency Department and Inpatient Databases for visits occurring 1 to 30 days postoperatively. RESULTS: A total of 6,089 rhytidectomy cases were extracted (87.9% female). The mean age was 61.1 years, and the most common age group was 61 to 70 years (40.2%), followed by 51 to 60 years (33.2%), and 71 to 80 years (12.0%). Overall, 3.6% of patients had a revisit after surgery (42.7% to an ambulatory surgery center, 42.2% to an emergency department, and 15.1% to inpatient admission). The most common primary diagnoses at the time of the revisit were hematoma (17.0%), fever/nausea/diarrhea (4.1%), and urinary tract infection (4.1%). CONCLUSIONS: Rhytidectomy is performed to treat facial aging, and can provide surgical outcomes which may not be achievable with nonsurgical alternatives. The 30-day revisit and readmission rate for this procedure in a large multistate cohort has not previously been reported. The revisit rate is low after rhytidectomy, and the most common reason for revisit is hematoma. These data provide important insight to optimize perioperative management and decrease postoperative revisits. This study does not capture return visits to the physician's office; however, postoperative issues that require presentation to outside facilities are important to distinguish from those managed in the practitioner's office, because they may incur additional, unplanned cost to both the patient and the healthcare system. LEVEL OF EVIDENCE: NA Laryngoscope, 128:2714-2717, 2018.

Association of Hair Loss With Health Utility Measurements Before and After Hair Transplant Surgery in Men and Women.

IMPORTANCE: Androgenetic alopecia is a highly prevalent condition across both sexes and can be surgically corrected through hair transplant. Health utility scores, which represent quantitative estimates of individual preferences for a given state of health, are a measure of health-related quality of life. The health utility scores for sex-specific alopecia and the posttransplant state have not previously been quantified. OBJECTIVE: To obtain health utility measurements for the objective assessment of sex-specific alopecia and hair transplant surgery and to analyze layperson perception of alopecia compared with other chronic health conditions. DESIGN, SETTING, AND PARTICIPANTS: A prospective clinical study was conducted from August 1 to December 31, 2017, at the Harvard Decision Science Laboratory. Adult casual observers (n = 308) completed an internet-based health utility questionnaire. Health states were presented using still patient images and a description of 5 health states, including monocular blindness, binocular blindness, male alopecia, female alopecia, and male posttransplant state. MAIN OUTCOMES AND MEASURES: Health utility measures of sex-specific alopecia, posttransplant state, and monocular and binocular blindness were measured by visual analog scale (VAS), standard gamble (SG), and time trade-off (TTO) in quality-adjusted life-years (QALYs). Groups were analyzed with 1-way analysis of variance and post hoc Tukey pairwise comparison. RESULTS: The 308 participants included 157 (51.0%) women with a mean (SD) age of 30.8 (13.5) years. Mean (SD) health utility measures included 0.85 (0.18) QALYs for the VAS, 0.93 (0.17) QALYs for the SG, and 0.93 (0.17) QALYs for the TTO in male alopecia; 0.83 (0.19) QALYs for the VAS, 0.92 (0.17) QALYs for the SG, and 0.91 (0.18) QALYs for the TTO in female alopecia; and 0.93 (0.11) QALYs for the VAS, 0.95 (0.15) QALYs for the SG, and 0.95 (0.16) QALYs for the TTO in a man in the posttransplant state. The mean (SD) health utility of monocular blindness was 0.76 (0.17) QALYs for the VAS, 0.87 (0.21) QALYs for the SG, and 0.86 (0.20) QALYs for the TTO. The health utility score for the posttransplant state was significantly improved compared with the health utility score for alopecia in both sexes (female VAS: +0.10 [95% CI, 0.06-0.14; P < .001]; male VAS, +0.08 [95% CI, 0.04-0.12; P < .001]). Hair loss in women and men demonstrated significantly lower QALYs on the VAS compared with the posttransplant state (female: -0.10 [95% CI, -0.14 to -0.06; P < .001]; male: -0.08 [95% CI, -0.12 to -0.04; P < .001]). CONCLUSIONS AND RELEVANCE: Alopecia has a meaningful negative influence on health utility measures in both sexes. Hair transplant surgery significantly increases health utility measures compared with untreated alopecia in both sexes as rated among layperson observers. LEVEL OF EVIDENCE: NA.

Plasma Electrolytic Oxidation of Titanium Implant Surfaces: Microgroove-Structures Improve Cellular Adhesion and Viability.

BACKGROUND/AIM: Plasma electrolytic oxidation (PEO) is an established electrochemical treatment technique that can be used for surface modifications of metal implants. In this study we to treated titanium implants with PEO, to examine the resulting microstructure and to characterize adhesion and viability of cells on the treated surfaces. Our aim was to identify an optimal surface-modification for titanium implants in order to improve soft-tissue integration. MATERIALS AND METHODS: Three surface-variants were generated on titanium alloy Ti6Al4V by PEO-treatment. The elemental composition and the microstructures of the surfaces were characterized using energy dispersive X-ray spectroscopy, scanning electron microscopy and profilometry. In vitro cytocompatibility of the surfaces was assessed by seeding L929 fibroblasts onto them and measuring the adhesion, viability and cytotoxicity of cells by means of live/dead staining, XTT assay and LDH assay. RESULTS: Electron microscopy and profilometry revealed that the PEO-surface variants differed largely in microstructure/topography, porosity and roughness from the untreated control material as well as from one another. Roughness was generally increased after PEO-treatment. In vitro, PEO-treatment led to improved cellular adhesion and viability of cells accompanied by decreased cytotoxicity. CONCLUSION: PEO-treatment provides a promising strategy to improve the integration of titanium implants with surrounding tissues.

Is the cause of sensorineural hearing loss in patients with facial schwannomas multifactorial?

OBJECTIVES: Facial nerve schwannomas (FNSs) and vestibular nerve schwannomas (VNSs) may occupy similar locations in the internal auditory canal (IAC). Risk factors for hearing loss in patients with FNS are unknown. Similar to VNSs, we hypothesize that the size and location of FNSs do not correlate with hearing loss. STUDY DESIGN: Retrospective cohort study and otopathology case review. METHODS: A single institution retrospective review of all patients diagnosed with FNS was performed. Demographic data, tumor size and location, severity and type of hearing loss, and facial nerve function were analyzed. Otopathologic review of a case of FNS was also performed. RESULTS: Thirty-three patients with FNS were identified. Mean age was 44 years, and 61% (n = 21) were female. Nine patients had tumors involving the IAC facial nerve, whereas 24 had distal tumors without IAC involvement. Eleven patients (33%) had hearing loss, and 55% of patients with sensorineural hearing loss (SNHL) had tympanic segment tumors without IAC involvement. The presence of SNHL was not associated with IAC tumor location (P = 0.21). Maximal dimensions of FNSs were 3 mm to 42 mm, without correlation between size and SNHL severity (r = -0.017, P = 0.926). Otopathologic review of an untreated 5-mm IAC FNS demonstrated disproportionate spiral ganglion and hair cell loss within the ipsilateral cochlea compared to the contralateral ear. CONCLUSION: Tympanic segment FNS without IAC involvement may result in SNHL. Tumor size is not associated with the presence or severity of SNHL. Otopathologic review suggests degenerative cochlear changes in FNS. Mechanisms for SNHL in schwannomas are likely multifactorial and may be unrelated to cochlear nerve compression. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1676-1682, 2017.

Computer-assisted assessment of ocular synkinesis: a comparison of methods.

OBJECTIVES/HYPOTHESIS: To define an objective, easy to perform, rapid method for the assessment of ocular synkinesis by employing both the Facial Assessment by Computer Evaluation software and a modification of the Glasgow Facial Palsy Scale. STUDY DESIGN: Retrospective study. METHODS: Fifty normal subjects and 50 patients with known ocular synkinesis were studied. Measurements of ocular synkinesis were made using the semiautomated Facial Assessment by Computer Evaluation software, and a modification of the automated Glasgow Facial Palsy program. RESULTS: The mean resting vertical palpebral fissure width of a normal eye was 10.17 mm (standard deviation [SD], 1.63 mm), and the degree of eye closure during smile was on average 21.56% (SD, 13.38%). Synkinetic eyes had a statistically significantly smaller resting palpebral fissure width on average (8.99 mm; SD, 1.61 mm; P < .001, t test), and a statistically significantly greater degree of narrowing during smiling (32.65%; SD, 13.68%; P < .001, t test). Using a modified synkinesis-determining application of the Glasgow Facial Palsy Scale did not consistently correlate with the Facial Assessment by Computer Evaluation program or clinical observations of eye closure during smiling (R = 0.251, Pearson correlation) and puckering (R = 0.253, Pearson correlation). CONCLUSIONS: The Facial Assessment by Computer Evaluation program yields rapid, consistent, palpebral fissure width measurements, and when combined with a subjective self-assessment questionnaire yields a comprehensive measure of ocular synkinesis. Our modified application of the Glasgow Facial Palsy Scale did not appear to be a reliable method for quantitative ocular synkinesis assessment.