Composite Sterno-Omohyoid Functional Muscle Transfer for Dual-Vector Smile Reanimation: A Case Series.

Background: Facial reanimation flaps often add bulk and produce single-vector smiles, and multivector flaps frequently require challenging intramuscular dissection. Objective: To evaluate the effectiveness of sterno-omohyoid flap (SOHF) transfer for dual-vector smile reanimation by measuring upper dental show and oral commissure movement. Methods: SOHF transfers from 2017 to 2020 were retrospectively evaluated using eFACE and Emotrics software. Results: Four patients with flaccid and one with nonflaccid facial paralysis were identified (four females and one male, median age: 39 years (range: 38-65); two acoustic neuromas, two congenital, one temporal bone fracture). Median follow-up was 20 months (range: 14-26). All flaps received masseteric nerves and two had additional cross-face grafts. Four developed contraction [median time to contraction: 5.5 months (range: 3-10)]. Mean oral commissure excursion and dental exposure improvements were 7.6 ± 4.0 mm (p = 0.03) and 2.9 ± 1.8 mm (p = 0.05), respectively. Dynamic, smile, and midface-smile eFACE improvements were 20.3 ± 6.8 (p = 0.007), 25.5 ± 14.5 (p = 0.03), and 50.5 ± 12.0 mm (p = 0.004) points, respectively. Mean SOHF mass was 14 ± 1.7 g. Conclusion: The SOHF is a small flap that provides dual-vector smile reanimation in flaccid and nonflaccid facial paralysis.

Complications Following Orbital Floor Repair: Impact of Intraoperative Computed Tomography Scan and Implant Material.

Importance: Orbital floor fracture repair is complex and postoperative complications are common. A variety of applicable surgical techniques and technologies are available to surgeons, so data about which of these may decrease postoperative complication rates can help better guide clinical decision making. Objectives: To characterize the patient demographics and surgical techniques utilized in orbital floor fracture repairs at San Antonio Military Medical Center and their relationship with rates of postoperative complications. Design, Setting, and Participants: Retrospective chart review of patients who underwent orbital floor fracture repairs from March 2014 to March 2019 with a mean follow-up time of 1.86 months at a tertiary care academic military hospital and level 1 trauma center. Main Outcomes and Measures: Demographic data, indication for surgical repair, fracture severity, orbital floor approach, implant material, and use of intraoperative computed tomography (CT) scan were recorded. Chi-square analysis was performed to determine the relationship between these factors and postoperative diplopia, hypoglobus, enophthalmos, and infection. Results: A total of 124 procedures were performed during the study period: 71.8% of patients were male and 74% were civilian. Mean age was 39 years (range 19-81). Thirty-one patients were lost to follow-up. The most common approach was transconjunctival (83%), which was most frequently used exclusively (68.5%), but was also combined with cantholysis, transcaruncular, or transantral approach. Postoperative diplopia at follow-up was common (53.8%), resolved after an average of 36.3 days, and was significantly associated with surgical indication of entrapment or revision (p = 0.01) and nonutilization of intraoperative CT (p = 0.04). From 2014 to 2016, intraoperative CT was utilized in 21% of cases and revision rate was 10.5%. From 2017 to 2019, 50% of cases utilized intraoperative CT and revision rate was 2% (p = 0.15). Three cases were revisions performed for abnormal plate position noted on postoperative CT scan. Conclusions and Relevance: A statistically significant association was found between postoperative diplopia, surgical indication of entrapment or revision, and nonutilization of intraoperative CT. Revision rates decreased when use of intraoperative CT increased. Three revision cases may have been prevented by use of an intraoperative CT scan. Patients with entrapment should be counseled regarding the increased risk of postoperative diplopia.

Sterno-omohyoid Free Flap for Dual-Vector Dynamic Facial Reanimation.

BACKGROUND: Dynamic rehabilitation of longstanding facial palsy with damaged, atrophied, or absent facial muscles requires replacement of neural and muscular components. The ideal reconstruction would include a fast-twitch muscle that is small, a reliable donor vessel and nerve, and the potential to provide a natural, synchronous, dentate smile with minimal donor site morbidity. Many flaps have been successfully used historically, but none has produced ideal rehabilitation. OBJECTIVE: To evaluate the novel sterno-omohyoid, dual-vector flap in rehabilitation of chronic facial paralysis. RESULTS: We performed sterno-omohyoid free tissue transfer for smile reanimation in a 39-year-old male with a history of longstanding right facial palsy following resection of a skull base tumor several years previously. We transferred both muscles with the superior thyroid artery, middle thyroid vein, and ansa cervicalis. The patient developed a dynamic smile by 6 months postoperatively, and he had improved objective facial symmetry. CONCLUSION: Herein, we demonstrate the first use of the sterno-omohyoid flap for successful facial reanimation. Overall, it is a novel flap in facial reanimation with many advantages over traditional flaps, including the potential to produce a more synchronous, dynamic smile while adding minimal bulk to the face. Future series will better elucidate the potential of the sterno-omohyoid flap.

Masseteric-to-Facial Nerve Transfer and Selective Neurectomy for Rehabilitation of the Synkinetic Smile.

IMPORTANCE: Synkinesis is the involuntary movement of 1 area of the face accompanying volitional movement of another; it is commonly encountered in patients affected by facial palsy. Current treatments for synkinesis include biofeedback for muscular retraining and chemodenervation via the injection of botulinum toxin. Chemodenervation is effective in reducing unwanted muscle movement, but it requires a commitment to long-term maintenance injections and may lose effectiveness over time. A permanent solution for synkinesis remains elusive. OBJECTIVE: To evaluate masseteric-to-facial nerve transfer with selective neurectomy in rehabilitation of the synkinetic smile. DESIGN, SETTING, AND PARTICIPANTS: In this case series, 7 patients at a tertiary care teaching hospital underwent masseteric-to-facial nerve transfer with selective neurectomy for synkinesis between September 14, 2015, and April 19, 2018. The medical records of these patients were retrospectively reviewed and demographic characteristics, facial palsy causes, other interventions used, and changes in eFACE scores were identified. INTERVENTION: Masseteric-to-facial nerve transfer. MAIN OUTCOMES AND MEASURES: Changes in eFACE scores (calculated via numeric scoring of many sections of the face, including flaccidity, normal tone, and hypertonicity; higher scores indicate better function and lower scores indicate poorer function) and House-Brackmann Facial Nerve Grading System scores (range, 1-6; a score of 1 indicates normal facial function on the affected side, and a score of 6 indicates absence of any facial function [complete flaccid palsy] on the affected side). RESULTS: Among the 7 patients in the study (6 women and 1 man; median age, 49 years [range, 41-63 years]), there were no postoperative complications; patients were followed up for a mean of 12.8 months after surgery (range, 11.0-24.5 months). Patients experienced a significant improvement in mean (SD) eFACE scores in multiple domains, including smile (preoperative, 65.00 [8.64]; postoperative, 76.43 [7.79]; P = .01), dynamic function (preoperative, 62.57 [15.37]; and postoperative, 75.71 [8.48]; P = .03), synkinesis (preoperative, 52.70 [4.96]; and postoperative, 82.00 [6.93]; P < .001), midface and smile function (preoperative, 60.71 [13.52]; and postoperative, 78.86 [14.70]; P = .02), and lower face and neck function (preoperative, 51.14 [16.39]; and postoperative, 66.43 [20.82]; P = .046). Preoperative House-Brackmann Facial Nerve Grading System scores ranged from 3 to 4, and postoperative scores ranged from 2 to 3; this change was not significant. CONCLUSION AND RELEVANCE: This study describes the application of masseteric-to-facial nerve transfer with selective neurectomy for smile rehabilitation in patients with synkinesis, with statistically significant improvement in smile symmetry and lower facial synkinesis as measured with the eFACE tool. This technique may allow for long-term improvement of synkinesis and smile. This study is only preliminary, and a larger cohort will permit more accurate assessment of this therapeutic modality. LEVEL OF EVIDENCE: 4.

Postoperative Nasal Septal Abscess Following Use of 2-Octylcyanoacrylate and Polydioxanone Plate in Open Septorhinoplasty: A Case Series.

BACKGROUND: The employment of 2-octylcyanoacrylate adhesive (Dermabond) to assist graft placement in open septorhinoplasty has been increasingly used to stabilize cartilage grafts. Literature regarding this application has been mixed, with some showing the possibility of increased rates of inflammation, if not infection. We present an original comparative case series involving postoperative septal abscess formation adjacent to caudal strut grafting where both Dermabond and an absorbable polydioxanone (PDS) plate were used. OBJECTIVE: To report an original comparative case series of patients who developed a postoperative septal abscess following open septorhinoplasty in the context of Dermabond application to affix cartilage to a PDS plate to facilitate caudal septal strut grafting. DESIGN: Retrospective comparative series with relevant clinical photographs, culture studies, and surgical figures. SETTING: Tertiary medical treatment facility. RESULTS: Two patients underwent primary open septorhinoplasty with placement of an autologous caudal septal extension graft, which was stabilized using a PDS plate and secured into position using both Dermabond and PDS suture. Postoperatively, both patients presented a nasal septal abscess at an average of 8 weeks that required serial drainage and subsequent removal of the PDS plate in 1 of the patients. Cultures demonstrated mixed flora as well as Proteus mirabilis, previously unreported in the nasal septal abscess literature. In comparison to 8 patients who underwent reconstruction with PDS plate alone (without Dermabond application), this represents a relative risk of 15 ( P value = .053) for a septal abscess complication when Dermabond is employed . CONCLUSIONS: We present an original case series on our limited, though impactful experience with PDS plate reconstruction using Dermabond to facilitate caudal septal graft placement in open septorhinoplasty. In conjunction with previously reported case series, which demonstrated elevated risk of prolonged inflammation and infection, we would recommend avoidance of subcutaneous Dermabond as an adjunct, particularly in combination with PDS plate utilization.

Utility of a Systematic Approach to Teaching Photographic Nasal Analysis to Otolaryngology Residents.

IMPORTANCE: Photographic nasal analysis constitutes a critical step along the path toward accurate diagnosis and precise surgical planning in rhinoplasty. The learned process by which one assesses photographs, analyzes relevant anatomical landmarks, and generates a global view of the nasal aesthetic is less widely described. OBJECTIVES: To discern the common pitfalls in performing photographic nasal analysis and to quantify the utility of a systematic approach model in teaching photographic nasal analysis to otolaryngology residents. DESIGN, SETTING, AND PARTICIPANTS: This prospective observational study included 20 participants from a university-based otolaryngology residency program. The control and intervention groups underwent baseline graded assessment of 3 patients. The intervention group received instruction on a systematic approach model for nasal analysis, and both groups underwent postintervention testing at 10 weeks. Data were collected from October 1, 2015, through June 1, 2016. INTERVENTION: A 10-minute, 11-slide presentation provided instruction on a systematic approach to nasal analysis to the intervention group. MAIN OUTCOMES AND MEASURES: Graded photographic nasal analysis using a binary 18-point system. RESULTS: The 20 otolaryngology residents (15 men and 5 women; age range, 24-34 years) were adept at mentioning dorsal deviation and dorsal profile with focused descriptions of tip angle and contour. Areas commonly omitted by residents included verification of the Frankfort plane, position of the lower lateral crura, radix position, and ratio of the ala to tip lobule. The intervention group demonstrated immediate improvement after instruction on the teaching model, with the mean (SD) postintervention test score doubling compared with their baseline performance (7.5 [2.7] vs 10.3 [2.5]; P < .001). At 10 weeks after the intervention, the mean comparative improvement in overall graded nasal analysis was 17% (95% CI, 10%-23%; P < .001). CONCLUSIONS AND RELEVANCE: Otolaryngology residents demonstrated proficiency at incorporating nasal deviation, tip angle, and dorsal profile contour into their nasal analysis. They often omitted verification of the Frankfort plane, position of lower lateral crura, radix depth, and ala-to-tip lobule ratio. Findings with this novel 10-minute teaching model should be validated at other teaching institutions, and the instruction model should be further enhanced to teach more sophisticated analysis to residents as they proceed through training. LEVEL OF EVIDENCE: NA.

The Saddle Deformity: Camouflage and Reconstruction.

This article presents a comprehensive review of past and present modalities in the surgical management of saddle nose deformities. Various surgical techniques, including allograft materials, are systematically reviewed. The senior author's surgical experience and current management approach are highlighted.

Traumatic Hearing Loss in the Context of Blast-Related Tympanic Membrane Perforation.

OBJECTIVE: Identify associated clinical factors and characterize the various forms of hearing loss in the context of blast-related traumatic tympanic membrane (TM) perforation sustained in the combat setting. METHODS: A prospective study of 41 patients who sustained a TM perforation secondary to blast injury between 2010 and 2012 while serving in combat. Clinical examinations and audiograms were obtained for all patients by a single-institution Otolaryngology service with comparative data generated from review of pre and post-trauma hearing screens. Follow-up clinical and audiogram data were obtained on all available subjects. RESULTS: 59 TM perforations were documented with audiograms. A conductive hearing loss of 14.8, 22.4, 20.3, and 18.9 dB and sensorineural hearing loss (SNHL) of 18.0, 13.5, 19.9, and 22.0 dB at 500, 1,000, 3,000, and 4,000 Hz, respectively, were observed. 49% of all hearing loss was SNHL. Clinical factors did not correlate statically to hearing loss (p > 0.05). On average, patients demonstrated a 51% improvement in SNHL at time of follow-up. CONCLUSION: In the subacute setting, patients with traumatic TM perforations secondary to combat blast injury demonstrate both a conductive hearing loss and SNHL, with 49% of all loss being sensorineural. An average SNHL improvement of 51% was seen at follow-up.

The effect of tonsillectomy alone in adult obstructive sleep apnea.

OBJECTIVE: The purpose of this study was to determine the effect of tonsillectomy as a single procedure in the treatment of adult obstructive sleep apnea (OSA). STUDY DESIGN: Prospective multi-institutional study evaluating adults with tonsillar hypertrophy scheduled to undergo tonsillectomy as an isolated surgery. SETTING: Tertiary care medical centers within the US Department of Defense. SUBJECTS AND METHODS: Adult subjects with tonsillar hypertrophy who were already scheduled for tonsillectomy were enrolled from October 2010 to July 2013. Subjects underwent physical examination, Epworth Sleepiness Scale, Berlin Questionnaire, and polysomnogram before surgery and after. Collected data included demographics, questionnaire scores, apnea-hypopnea index (AHI), and lowest saturation of oxygen. RESULTS: A total of 202 consecutive subjects undergoing tonsillectomy were enrolled. The final analysis included 19 subjects testing positive for OSA. The mean age was 27.9 years; mean body mass index, 29.6; median tonsil size, 3; and most frequent Friedman stage, 1. The AHI before surgery ranged from 5.4 to 56.4 events per hour. The mean AHI decreased from 18.0 to 3.2 events per hour after surgery, a reduction of 82%. The responder rate--with subjects achieving at least a 50% reduction of AHI to a value <15--was 94.7%. Following tonsillectomy, there were statistically significant reductions in median lowest saturation of oxygen level and Epworth Sleepiness Scale and Berlin scores. CONCLUSIONS: Adult tonsillectomy alone has beneficial effect in OSA management, particularly in young overweight men with large tonsils, moderate OSA, and low Friedman stage.

RNA interference of transforming growth factor-ß 2 in human respiratory fibroblasts.

OBJECTIVE: Transforming growth factor-ß2 (TGF-ß2) is a principal cytokine of interest in the pathogenesis of scar formation and is a potential target for future molecular-based adjunctive therapies. The authors hypothesize that interfering RNA (RNAi) can be used to modulate TGF-ß2 production in cultured human respiratory fibroblasts. STUDY DESIGN: Basic science. Setting. Laboratory. SUBJECTS AND METHODS: RNAi constructs targeted to the TGF-ß2 transcript were complexed with microsomal lipids and applied to human fibroblasts in cell culture. Transfection efficiency and cell viability were measured by fluorescence microscopy. Messenger RNA (mRNA) for TGF-ß2 was measured 48 hours posttransfection using real-time quantitative PCR. The quantity of TGF-ß2 protein produced with increasing concentrations of RNAi was measured using enzyme-linked immunosorbent assay. The function of RNAi-treated fibroblasts was tested using a wound-healing assay. RESULTS: Transfection efficiency of more than 80% was achieved with minimal induced cell death. Treated cells showed selective knockdown of 80% of TGF-ß2 mRNA, which was confirmed with negative controls. As the concentration of RNAi was increased, an incremental decrease in TGF-ß2 protein was measured. CONCLUSION: RNAi technology is an effective means of localized and transient gene silencing in cultured human fibroblasts. Transfection can be achieved using microsome complexed RNAi with minimal induced cell death. This preliminary result shows promise for future in vitro studies.

Diagnostic efficacy of surgeon-performed ultrasound-guided fine needle aspiration: a randomized controlled trial.

OBJECTIVE: To evaluate the clinical efficacy of surgeon-performed, office-based head and neck ultrasound in facilitating diagnostic fine needle aspiration (FNA) of lesions in the head and neck. STUDY DESIGN: A randomized controlled trial of ultrasound-guided FNA versus traditional palpation-guided technique for palpable masses in the head and neck. SETTING: An office-based study performed in a military academic medical center. SUBJECTS AND METHODS: Eighty-one adults older than 18 years of age with a palpable head and neck mass (less than 3 cm in largest diameter) were randomized to ultrasound-guided or traditional palpation-guided FNA of a head and neck mass. Measured variables and outcomes for the study included tissue adequacy rates, tissue type, and operator variability. RESULTS: Following three passes using either palpation or ultrasound guidance, a comparative tissue adequacy rate of 84 percent for ultrasound guidance versus 58 percent for standard palpation was established (P < 0.014). With regard to tissue type, a statistically significant comparative diagnostic advantage for ultrasound guidance was observed in thyroid tissue while remaining statistically insignificant for lymphatic and salivary tissues. No statistical significance was found when comparing the ability of otolaryngology residents versus attending otolaryngologists to obtain ultrasound-guided diagnostic samples. CONCLUSION: Office-based surgeon-performed ultrasound-guided FNA of palpable lesions in the head and neck yields a statistically significant higher diagnostic rate compared to standard palpation technique. Our institutional experience supports the utility of surgeon-performed ultrasound as a core competency in clinical practice.

Adult presentation of a fourth branchial pouch sinus.

A fourth branchial pouch sinus is a rare clinical entity. The handful of previously reported cases have all involved children. We report a rare case of an intrathyroidal fourth branchial pouch sinus in an adult. A 36-year-old man presented with a recurrent left-sided deep neck abscess. A diagnostic evaluation by barium pharyngoesophagography in conjunction with computed tomography revealed the presence of a sinus tract that extended inferiorly from the left piriform sinus to the left thyroid lobe. The synchronous use of both of these imaging modalities with shared contrast enabled us both to establish the diagnosis and formulate a successful surgical approach. The patient underwent elective neck exploration with resection of the left thyroid lobe and superior sinus tract. Postoperative pathology confirmed the presence of an epithelium-lined sinus within the left lobe of the thyroid consistent with a branchial pouch derivative. Follow-up barium pharyngoesophagography demonstrated successful closure of the sinus tract. This unique case represents a delayed clinical presentation, and it broadens the differential diagnosis of recurrent deep neck abscess and thyroid cyst in the adult.

Aggresomes protect cells by enhancing the degradation of toxic polyglutamine-containing protein.

Expression of misfolded protein in cultured cells frequently leads to the formation of juxtanuclear inclusions that have been termed 'aggresomes'. Aggresome formation is an active cellular response that involves trafficking of the offending protein along microtubules, reorganization of intermediate filaments and recruitment of components of the ubiquitin proteasome system. Whether aggresomes are benevolent or noxious is unknown, but they are of particular interest because of the appearance of similar inclusions in protein deposition diseases. Here we present evidence that aggresomes serve a cytoprotective function and are associated with accelerated turnover of mutant proteins. We show that mutant androgen receptor (AR), the protein responsible for X-linked spinobulbar muscular atrophy, forms insoluble aggregates and is toxic to cultured cells. Mutant AR was also found to form aggresomes in a process distinct from aggregation. Molecular and pharmacological interventions were used to disrupt aggresome formation, revealing their cytoprotective function. Aggresome-forming proteins were found to have an accelerated rate of turnover, and this turnover was slowed by inhibition of aggresome formation. Finally, we show that aggresome-forming proteins become membrane-bound and associate with lysosomal structures. Together, these findings suggest that aggresomes are cytoprotective, serving as cytoplasmic recruitment centers to facilitate degradation of toxic proteins.