Diagnosis, treatment and prognosis of otomastoiditis induced by Fusobacterium necrophorum: A retrospective multicentre cohort study.

OBJECTIVES: Otomastoiditis caused by the anaerobic Fusobacterium necrophorum (F. necrophorum) often induces severe complications, such as meningitis and sinus thrombosis. Early diagnosis is difficult, partly because little is known about specific early signs. Comprehensive research about clinically chosen antimicrobial therapy has not been done yet and prognostic information about otomastoiditis caused by F. necrophorum is scarce. More knowledge about this subject is required. METHODS: In this retrospective cohort study, we included all cases of otomastoiditis caused by F. necrophorum treated in two university medical centres in the Netherlands during the past 10 years. Data was gathered from patient records and analysed using independent sample T-tests and Chi2-tests. RESULTS: This study reveals that otomastoiditis caused by F. necrophorum potentially induces neurological sequelae. Thereby, 80% of all included patients (n = 16) needed readmission within six months due to recurrence or complications of otomastoiditis caused by F. necrophorum. Mean (range) of age, CRP and temperature were 4.5 years (0.9-29.3), 243 mg/L (113-423) and 40 °C (37-41). All patients were hospitalized and treated with antibiotics, mostly metronidazole (n = 13/16) and a ß -lactam (n = 15/16). Additional treatment contained low molecular weight heparin (83%, n = 10/12), dexamethasone (78%, n = 7/9) and/or surgery (80%, n = 12/16, whereof 9/12 mastoidectomy). CONCLUSIONS: Patients and/or their parents need to be informed about this potential unfortunate prognosis when otomastoiditis caused by F. necrophorum is diagnosed. To improve early diagnosis, otomastoiditis caused by F. necrophorum should be suspected and therefore immediately cultured when a) young children present with otomastoiditis, with b) high CRP values, and/or c) vomiting and decreased consciousness.

Posterior drooling in children with cerebral palsy and other neurodevelopmental disorders.

AIM: To evaluate the effect of botulinum neurotoxin A (BoNT-A) injections, submandibular gland excision (SMGE), and bilateral submandibular duct ligation (2DL) for the control of posterior drooling in children with neurological impairment. METHOD: In a retrospective cohort, children with neurological impairment (e.g. cerebral palsy) treated between 2000 and 2016 were identified. Mean age at time of surgery was 9 years (range 1-21y). The primary outcome was posterior drooling severity by a visual analogue scale (VAS; 0-10) at baseline, 8-weeks, and 32-weeks follow-up. The secondary outcome was lower respiratory tract infections during the follow-up period. RESULTS: Ninety-two patients (out of 475; 47 males, 45 females) were identified. They were undergoing three different treatments: BoNT-A (n=63), SMGE (n=16), and 2DL (n=13). A significant reduction in VAS over time was observed in the total group of 92 patients. After SMGE, VAS decreased significantly from 6.82 (SD 3.40) at baseline to 2.29 (SD 1.93) at 8 weeks, and 2.17 (SD 2.58) at 32 weeks (F[2.34]=11.618, p<0.001). There was no significant decrease after both BoNT-A and 2-DL. INTERPRETATION: Posterior drooling is an unfamiliar, potentially life-threatening condition that is treatable with medication, BoNT-A injections, or surgery. Although all treatments reduced signs and symptoms of posterior drooling, there is a greater effect after SMGE compared to BoNT-A and 2-DL. What this paper adds Submandibular gland excision has better results for posterior drooling than botulinum toxin A or submandibular duct ligation.

Repeated onabotulinum neurotoxin A injections for drooling in children with neurodisability.

AIM: To evaluate the effect of repeated onabotulinum neurotoxin A injections for the treatment of drooling in children with neurodisabilities. METHOD: This was a retrospective cohort study, in which the first, second, and third onabotulinum neurotoxin A injection were compared within children treated between 2000 and 2020. Primary outcomes included drooling quotient, visual analogue scale (VAS), and treatment success defined as ≥50% reduction in drooling quotient and/or VAS 8 weeks after treatment. Each outcome was obtained at baseline and 8 weeks posttreatment. RESULTS: Seventy-seven children were included (mean age at first injection: 8y 3mo, SD 3y 7mo, range 3-17y; 44 males, 33 females; 51.9% with cerebral palsy, 45.5% wheelchair-bound). The objective (drooling quotient) and subjective (VAS) effect after the second injection was lower compared to the first injection. The third injection showed less objective and significantly less subjective effect compared to the first injection. An overall success rate of 74.0%, 41.6%, and 45.8% were found for the first, second, and third injection respectively. INTERPRETATION: Although onabotulinum neurotoxin A remained effective throughout the entire treatment course, there is less effect of subsequent onabotulinum neurotoxin A injections compared to the first. Although there might be a loss of effect after repeated injections, there is continued improvement for most children. What this paper adds Repeated injections show a diminished treatment effect after the second injection. A continued improvement is seen in most patients.

Surgery versus botulinum neurotoxin A to reduce drooling and improve daily life for children with neurodevelopmental disabilities: a randomized controlled trial.

AIM: To compare the effect of bilateral submandibular duct ligation and botulinum neurotoxin A (BoNT-A) on drooling severity and its impact on daily life and care in children and adolescents with moderate-to-severe drooling. METHOD: This was a randomized, interventional, controlled trial in which 53 children and adolescents (31 males, 22 females, mean age 11y, range 8-22y, SD 2y 10mo) with cerebral palsy (58.5%) or other non-progressive developmental disorders (41.5%) were randomized to BoNT-A (n=26) or bilateral submandibular duct ligation (n=27). A parent questionnaire on the severity of drooling in specific positions and daily activities and the impact of drooling on daily life and care was filled out at baseline and 8 and 32 weeks posttreatment. RESULTS: Both BoNT-A and bilateral submandibular duct ligation had a positive effect on daily care, damage to electronic equipment and/or furniture, social interactions, and self-esteem. However, bilateral submandibular duct ligation had a significant greater and longer-lasting short- (8wks) and medium-term (32wks) effect on daily care, reducing damage to electronic devices, and improving social interactions and satisfaction with life in general. INTERPRETATION: This randomized controlled trial confirms reduced drooling by both BoNT-A and bilateral submandibular duct ligation, but provides new evidence on improved well-being through a reduction in drooling. Even though there is a greater risk of complications and morbidity after bilateral submandibular duct ligation, compared to BoNT-A there was a significantly greater and longer-lasting positive effect on most outcomes. What this paper adds Bilateral botulinum neurotoxin A (BoNT-A) and submandibular duct ligation had a positive effect on the well-being of individuals with moderate-to-severe drooling. Bilateral submandibular duct ligation had a greater effect on the impact of drooling during daily care than BoNT-A. Bilateral submandibular duct ligation reduced damage to electronic devices and improved social interactions and satisfaction with life.

Cost-effectiveness of botulinum neurotoxin A versus surgery for drooling: a randomized clinical trial.

AIM: This study compared the cost-effectiveness of botulinum neurotoxin A (BoNT-A) injections with two-duct ligation of the submandibular glands as treatment for severe drooling after one treatment cycle. METHOD: The study was part of a larger, partly single-blinded, randomized clinical trial (trialregister.nl identifier NTR3537). Data were collected between 2012 and 2017. Evaluation was at 32 weeks after one treatment cycle. Fifty-seven patients with cerebral palsy or other neurological, non-progressive disorders and severe drooling classified as having a drooling frequency ≥3 or a drooling severity ≥2, in whom conservative treatment was deemed ineffective, were randomized to treatment by BoNT-A or two-duct ligation. An incremental cost-effectiveness ratio (ICER) was calculated using the success rates as the measure of benefit. Treatment success was defined as a decrease ≥50% from baseline to 32 weeks in the subjective visual analogue scale for the severity of drooling or the objective drooling quotient. RESULTS: Fifty-three patients were analysed (22 females, 31 males; mean age 11y, range 8-22y). Average costs for one treatment cycle, which included one BoNT-A injection, were €1929 (standard error 62) for BoNT-A and €3155 (standard error 99) for two-duct ligation. Treatment success was in favour of two-duct ligation (63% vs 27%; number needed to treat 3). The ICER was €34 per 1% gain in treatment success in favour of two-duct ligation versus BoNT-A. INTERPRETATION: The additional cost of two-duct ligation is to some extent offset by a larger treatment success rate compared with BoNT-A. WHAT THIS PAPER ADDS: Botulinum neurotoxin A (BoNT-A) is less expensive per percentage of success than two-duct ligation. The additional cost of two-duct ligation over BoNT-A is offset by greater treatment success.

Submandibular duct ligation after botulinum neurotoxin A treatment of drooling in children with cerebral palsy.

AIM: To assess: (1) the effect on drooling of bilateral submandibular duct ligation as surgical therapy after the administration of submandibular botulinum neurotoxin A (BoNT-A) for excessive drooling and (2) the predictive value of treatment success with BoNT-A on treatment success after bilateral submandibular duct ligation. METHOD: This was a within-participant retrospective observational study in which 29 children with severe drooling (15 males, 14 females) received BoNT-A treatment at a mean age of 9 years 6 months (SD 2y 5mo), followed by bilateral submandibular duct ligation at a mean age of 10 years 11 months (SD 2y 4mo). Fifteen children were diagnosed with cerebral palsy (CP), with 12 children classified in Gross Motor Function Classification System levels IV and V. The 14 children without CP had non-progressive developmental disorders. The primary drooling severity outcomes were the Visual Analogue Scale (VAS; subjective assessment) and drooling quotient (objective assessment). Measurements were taken before each intervention and again at 8 and 32 weeks. RESULTS: The VAS was significantly lower after bilateral submandibular duct ligation at follow-up compared to BoNT-A treatment (mean difference -33, p≤0.001; 95% confidence interval [CI]=-43.3 to -22.9). The mean drooling quotient did not significantly differ between BoNT-A treatment and bilateral submandibular duct ligation at follow-up (3.3, p=0.457; 95% CI=-4.35 to 9.62) or between 8 and 32 weeks (4.7, p=0.188; 95% CI=-2.31 to 11.65). INTERPRETATION: BoNT-A treatment and bilateral submandibular duct ligation are both effective treatment modalities for drooling. At 32-week follow-up, subjective drooling severity after bilateral submandibular duct ligation was significantly lower compared to previous BoNT-A injections in participants. However, treatment success with BoNT-A is no precursor to achieving success with bilateral submandibular duct ligation. WHAT THIS PAPER ADDS: Bilateral submandibular duct ligation is an effective therapy for drooling after treatment with botulinum neurotoxin A (BoNT-A). Treatment success with BoNT-A is not a predictor of successful therapy with bilateral submandibular duct ligation.

Determinants of disability after proximal interphalangeal joint sprain or dislocation.

BACKGROUND: Sprain or dislocation of the proximal interphalangeal joint may be a useful example of the counterintuitive aspects of recovery as the prognosis is excellent, but protectiveness in response to discomfort often hinders the stretching exercises that are a key component of the recovery process. OBJECTIVE: The aim of this study was to investigate the relationship between disability and pain self-efficacy in this context. METHODS: A total of 82 patients (54 men and 28 women) were enrolled in this prospective study. Finger motion was measured, and the patients completed measures of upper limb-specific disability (the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire), symptoms of depression (Patient Health Questionnaire-9), effective coping strategies in response to pain (the Pain Self-Efficacy Questionnaire), and a pain scale at enrollment. RESULTS: Patients were enrolled a mean of 48 days after injury. The final multivariable model accounting for greater disability included lower self-efficacy, greater symptoms of depression, and gender (women have more disability). Lower self-efficacy was also the strongest predictor of pain intensity and finger stiffness. CONCLUSIONS: Effective coping strategies such as self-efficacy facilitate recovery (less disability, pain, and stiffness) after proximal interphalangeal joint sprain/dislocation. LEVEL OF EVIDENCE: Prognostic level I.

The National Hospital Discharge Survey and Nationwide Inpatient Sample: the databases used affect results in THA research.

BACKGROUND: The National Hospital Discharge Survey (NHDS) and the Nationwide Inpatient Sample (NIS) collect sample data and publish annual estimates of inpatient care in the United States, and both are commonly used in orthopaedic research. However, there are important differences between the databases, and because of these differences, asking these two databases the same question may result in different answers. The degree to which this is true for arthroplasty-related research has, to our knowledge, not been characterized. QUESTION/PURPOSES: We tested the following null hypotheses: (1) there are no differences between the NHDS and NIS in patient characteristics, comorbidities, and adverse events in patients with hip osteoarthritis treated with THA, and (2) there are no differences between databases in factors associated with inpatient mortality, adverse events, and length of hospital stay after THA. METHODS: The NHDS and NIS databases use different methods of data collection and weighting to provide data representative of all nonfederal hospital discharges in the United States. In 2006 the NHDS database contained 203,149 patients with hip arthritis treated with hip arthroplasty, and the NIS database included 193,879 patients. Multivariable analyses for factors associated with inpatient mortality, adverse events, and days of care were constructed for each database. RESULTS: We found that 26 of 42 of the factors in demographics, comorbidities, and adverse events after THA in the NIS and NHDS databases differed more than 10%. Age and days of care were associated with inpatient mortality with the NHDS and the NIS although the effect rates differ more than 10%. The NIS identified seven other factors not identified by the NHDS: wound complications, congestive heart failure, new mental disorder, chronic pulmonary disease, dementia, geographic region Northeast, acute postoperative anemia, and sex, that were associated with inpatient mortality even after controlling for potentially confounding variables. For inpatient adverse events, atrial fibrillation, osteoporosis, and female sex were associated with the NHDS and the NIS although the effect rates differ more than 10%. There were different directions for sources of payment, dementia, congestive heart failure, and geographic region. For longer length of stay, common factors differing more than 10% in effect rate included chronic pulmonary disease, atrial fibrillation, complication not elsewhere classified, congestive heart failure, transfusion, discharge nonroutine compared with routine, acute postoperative anemia, hypertension, wound adverse events, and diabetes mellitus, whereas discrepant factors included geographic region, payment method, dementia, sex, and iatrogenic hypotension. CONCLUSIONS: Studies that use large databases intended to be representative of the entire United States population can produce different results, likely related to differences in the databases, such as the number of comorbidities and procedures that can be entered in the database. In other words, analyses of large databases can have limited reliability and should be interpreted with caution. LEVEL OF EVIDENCE: Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Opioid use after fracture surgery correlates with pain intensity and satisfaction with pain relief.

BACKGROUND: In 2012, Medicare began to tie reimbursements to inpatient complications, unplanned readmissions, and patient satisfaction, including satisfaction with pain management. QUESTIONS/PURPOSES: We aimed to identify factors that correlate with (1) pain intensity during a 24-hour period after surgery; (2) less than complete satisfaction with pain control; (3) less than complete satisfaction with staff attention to pain relief while in the hospital; and we also wished (4) to compare inpatient and discharge satisfaction scores. METHODS: Ninety-seven inpatients completed measures of pain intensity (numeric rating scale), satisfaction with pain relief, self-efficacy when in pain, and symptoms of depression days after operative fracture repair. The amount of opioid used in oral morphine equivalents taken during the prior 24 hours was calculated. Through initial bivariate and then multivariate analysis, we identified factors that were associated with pain intensity, less than complete satisfaction with pain control, and less than complete satisfaction with staff attention to pain relief. RESULTS: Patients who took more opioids reported greater pain intensity (r = 0.38). No factors representative of greater nociception (fracture type, number of fractures, days from injury to surgery, days from surgery to enrollment, or type of surgery) correlated with greater pain intensity. The best multivariable model for greater pain intensity included: depression or anxiety disorder (p = 0.019), smoking (0.047), and greater opioid intake (p = 0.001). Multivariable analysis for less than ideal satisfaction with pain control included the Pain Self-Efficacy Questionnaire (PSEQ) (odds ratio [OR], 0.95; 95% CI, 0.92-0.99) alone; for less than ideal satisfaction with staff attention to pain control, the PSEQ (OR, 0.96; 95% CI, 0.92-0.99) and opioid medication use before admission (OR, 3.6; 95% CI, 1.1-12) were included. CONCLUSIONS: After operative fracture treatment, patients who take more opioids report greater pain intensity and less satisfaction with pain relief. Greater self-efficacy was the best determinant of satisfaction with pain relief. Evidence-based interventions to increase self-efficacy merit additional study for the management of postoperative pain during recovery from a fracture. LEVEL OF EVIDENCE: Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

The influence of patients' participation in research on their satisfaction.

PURPOSE: To determine if there was a difference between patients participating in research and those who did not regarding their satisfaction with the medical encounter and their physician. METHODS: We prospectively randomized 128 patients to either complete 20 minutes of questionnaires (participate in research) or not. After the visit, all patients rated their satisfaction with their visit and satisfaction with the doctor on an 11-point ordinal satisfaction scales, with 0 being not at all satisfied and 10 being completely satisfied. Average satisfaction scores were analyzed in relation to demographics, questionnaires, and involvement in research. RESULTS: There were no significant differences between patients that did and did not participate in research for satisfaction with the medical encounter or satisfaction with the treating physician. Satisfaction was not associated with marital status, work status, or diagnosis. There was a significant correlation between greater satisfaction and both less education and lower self-efficacy. There was no significant correlation between patient satisfaction and magnitude of disability, pain intensity, or health anxiety. CONCLUSIONS: This study demonstrated that patients' participation in research can coexist with patient satisfaction. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic I.

Relationships between pain misconceptions, disability, patients' goals and interpretation of information from hand therapists.

INTRODUCTION: Patient interpretation of advice from hand therapists may be related to nonadaptive pain thoughts (automatic, overprotective, unduly pessimistic statements triggered by nociception and exacerbated by psychological distress). PURPOSE OF THE STUDY: This study aimed to determine whether there were correlations between participants' hand therapy goals, interpretation of advice from hand therapists, nonadaptive pain thoughts, and upper extremity-specific disability. METHODS: One hundred and five participants completed questionnaires assessing nonadaptive pain thoughts, upper extremity-specific disability, lessons from hand therapists, and hand therapy goals. RESULTS: Nonadaptive pain thoughts correlated with disability and were bi-directionally related to participant goals and interpretation of advice from hand therapists. DISCUSSION: Patients' nonadapative pain thoughts and the words/concepts used by hand therapists are both important in recovery from upper extremity illness. CONCLUSIONS: Hand therapists should be mindful that nonadaptive pain thoughts are an important determinant of disability and that such thoughts can affect and be affected by their recommendations. LEVEL OF EVIDENCE: n/a.

Characteristics and Clinical Management Strategy of Petrous Apex Cholesterol Granulomas.

Purpose: To evaluate the clinical characteristics of petrous apex cholesterol granulomas (PACG) and assess outcomes after different treatment strategies. Method: A consecutive case series of 34 patients with a PACG. Main outcomes were PACG growth, symptoms, and the outcomes of different treatment strategies: wait-and-scan (WS) and surgical drainage. Results: Thirty-four patients were analyzed; mean follow-up time was 7.1 years. Twenty-one patients (61.7%) showed symptoms, mostly more than one. Most symptoms reported were cranial nerve palsy (58.8%) and headache (35.3%). Twenty-one patients (61.8%) received solely wait-and-scan (WS), and thirteen patients (38.2%) underwent surgery, five of whom (38.5%) after an initial WS period. In the solely WS group, one (4.8%) developed new symptoms, and two (9.5%) reported symptom progression despite a stable granuloma size. Two (9.5%) showed granuloma growth on follow-up scans without symptom progression. Surgery consisted of drainage. Eleven (84.6%) of these thirteen patients reported partial recovery; one (7.7%) reported no recovery; and one (7.7%) reported full recovery of reported symptoms related to PACG. Among the patients with cranial nerve involvement, 7.7% showed full recovery after surgery; 84.6% showed partial recovery; and 7.7% did not recover. Adverse events occurred in five out of 13 patients who underwent surgery, all with full recovery. Conclusions: This study confirms that PACG are slow-growing lesions with a low risk of adverse events. Solely using wait-and-scan strategy is a safe option for patients without symptoms, with acceptable symptoms without symptom progression, and with asymptomatic growth. Surgical treatment can be considered in patients with symptom progression or symptomatic growth.

An Adolescent With a Retropharyngeal Swelling: To Drain or Not to Drain?: Keeping a Broad Vision During the COVID-19 Pandemic.

CASE PRESENTATION: An 18-year-old patient with a history of COVID-19 (1 month previously) was admitted with malaise and complaints of a stiff neck, a left-sided cervical mass, headache, and difficulty in swallowing and breathing, which had been present for 4 days. Two days after the onset of the first symptoms, a painless skin rash on the legs, arms, palms of both hands, and soles of both feet developed. Despite 2 days of treatment with antibiotics (amoxicillin/clavulanic acid, 500/125 mg three times daily orally), symptoms progressed. On presentation, the patient was alert and oriented, there were no neurologic disorders, and all symptoms related to the recent COVID-19 infection had subsided. His medical history was negative for sexually transmitted diseases, and the patient had received all vaccines except for meningococcus and COVID-19.

Sensorineural Hearing Impairment Recovery after Transmastoidal Surgery for a Petrous Apex Cholesterol Granuloma: A Case Report.

Cholesterol granulomas are the most common primary lesions of the petrous apex. Although their benign character, impingement of critical neurovascular structures can cause significant symptomatology such as hearing impairment. We present unique results after treatment of a cholesterol granuloma located in the petrous apex causing sensorineural hearing impairment. A transmastoidal approach was performed using an intraoperative computed tomography-guided navigation system. The video, which is included for reference, illustrates clear drainage of the cyst and drain positioning. The hearing improved completely in the lower frequencies at 500 and 1000 Hz and with a 19 dB improvement in overall bone conduction in the affected ear.

Clinical characteristics and an evaluation of predictors for a favourable outcome of Mycobacterium abscessus otomastoiditis: a systematic review and meta-analysis of individual participant data.

BACKGROUND: Otomastoiditis caused by Mycobacterium abscessus is rare, but its incidence has increased over the past decades and its optimal treatment remains unknown. This study aims to summarise the clinical and therapeutic features and find characteristics of patients with M. abscessus otomastoiditis associated with favourable treatment outcomes. METHODS: We searched MEDLINE, Embase and Web of Science to identify studies including patients with M. abscessus otomastoiditis. A 1-stage individual patient data (IPD) meta-analysis was conducted. A 2-level mixed-effects linear regression model was provided for antimycobacterial treatment duration. RESULTS: Twenty-three studies reported a total of 85 patients. Children possess a unique clinical profile including a history of ear infections, tympanostomy tube placement and antibiotic treatment. Antimycobacterial treatment was administered for 26 (interquartile range [IQR]: 15-35) weeks. Macrolides were prescribed in 98.8% of the cases. Surgery was performed in 80.5% of the cases, of which, 47.1% required revision surgery. Otalgia was a significant predictor (ß = 9.3; P = .049) of antimycobacterial treatment duration. CONCLUSIONS: Mastoid surgery (regularly requiring revision) and a multidrug regimen for a minimum of 6 months, including a minimum of 3 active agents, are most often needed to attain cure. The presence of otalgia significantly extends the treatment duration of M. abscessus otomastoiditis.

The medium to long-term effects of two-duct ligation for excessive drooling in neurodisabilities, a cross-sectional study.

OBJECTIVES: This study aims to evaluate the medium to long-term (1-12 years) effectiveness of two-duct ligation (2-DL) in patients with nonprogressive neurodisabilities. METHODS: Main outcomes included a Visual Analogue Scale (VAS), Drooling Severity (DS) and Drooling Frequency (DF), collected at baseline, 32 weeks postintervention and 1-12 years postintervention. Secondary outcomes were adverse events (AEs), and satisfaction. RESULTS: Forty-two patients were analyzed (mean age 17 years, mean baseline VAS 82). VAS decreased significantly from baseline to long-term (n = 30. Mean difference -36.5, CI -47.0 to -26.0, p ≤ 0.001; -26.1, CI -36.2 to -15.9, p ≤ 0.001). However, long-term VAS significantly increased compared to VAS at 32 weeks (+10.4, CI 1.0-19.8, p = 0.031). Out of 42 patients, 64% would recommend 2-DL to peers. CONCLUSION: There is a significant subjective 2-DL effect on drooling severity in the medium to long-term as reported by patients and caregivers, but there is also a certain degree of recurrence in this time span, and 33% of the patients required subsequent treatment. However, the majority of patients and/or caregivers would recommend 2-DL to peers.

Bilateral Vocal Cord Paralysis Due to an Immune-related Adverse Event of Nivolumab: A Case Report.

Nivolumab is an anti-programmed death-1 inhibitor used in the treatment of cancer. Nivolumab has recently been approved as an adjuvant treatment for patients with stage IIIB, IIIC, and completely resected stage IV melanoma in the Netherlands. Despite the promising results of nivolumab, there is a wide variation in toxic side effects. A nivolumab-induced bilateral vocal cord paralysis (BVCP) was not reported. In this case, we present a nivolumab-induced BVCP. A 75-year-old man received nivolumab as adjuvant therapy for stage III melanoma. After the first cycle of nivolumab, this patient developed immune-related hepatitis and colitis. During admission, the patient became respiratory insufficient as a result of a BVCP. This case report describes immune-related hepatitis, colitis, and BVCP after the first cycle of nivolumab in the treatment of stage IIIb melanoma. Follow-up has not yet shown improvement in the mobility of the vocal cords.

An evaluation of predictors for success of two-duct ligation for drooling in neurodisabilities.

BACKGROUND: Drooling is dependent on various clinical variables. However, while drooling proves refractory to two-duct ligation in 40% of patients, predictors for treatment success are sparse and to date there is little evidence why some respond well while others are non-responders. We aim to find predictors for treatment success and study the effectiveness of two-duct ligation for drooling in neurodisabilities. METHODS: Fifty-four patients with moderate to severe drooling who had undergone two-duct ligation were screened for inclusion. Four patients were excluded due to missing or unreliable primary outcomes. The average age at the time of surgery was 12 years. Predictors were evaluated for treatment success which was defined as ≥ 50% visual analog scale for severity of drooling and/or drooling quotient reduction from baseline. Treatment effect was measured after 8 and 32 weeks compared to baseline. RESULTS: Age (more mature), adequate posture (no anteflexion), and normal speech are predictors for treatment success. Compared to baseline, drooling quotient was significantly lower at 8 (difference 18.6%, 95% confidence interval 12.3-24.9%) and 32 weeks (difference 10.1%, 95% confidence interval 3.9-16.4%). Compared to baseline, visual analog scale was significantly lower at 8 (difference 45.0, 95% confidence interval 37.0-52.9) and 32 weeks (difference 32.9, 95% confidence interval 25.0-40.7). CONCLUSIONS: Age, adequate posture, and a normal speech are predictors for treatment success, are easily determined pre-operatively, and help the clinician providing patient-specific probability of treatment success. There is a significant subjective and objective decrease of drooling after two-duct ligation.