Behrad B. Aynehchi

Systematic review of laryngeal reinnervation techniques.

OBJECTIVE: To systematically review outcomes of reinnervation techniques for the management of unilateral vocal fold paralysis (UVFP). DATA SOURCES: Medline and Cochrane databases for English-language studies published between 1966 and 2009 on the surgical management of UVFP. REVIEW METHODS: Studies were excluded if they reported on bilateral vocal fold paralysis, used nonhuman subjects, or did not assess clinical outcomes. Outcomes of interest were visual analysis, acoustic analysis, perceptual analysis, and electromyography. RESULTS: Of 686 initial studies, 14 studies encompassing 329 patients were eligible for analysis. All studies had a case-series design. Of reported patients, 60.2 percent were men, with mean age of 51 years (range, 12-79 years). The most common reinnervation technique was ansa cervicalis-to-recurrent laryngeal nerve (RLN), which was most commonly performed after thyroidectomy (43.5%). Other techniques with reportable outcomes included primary RLN anastomosis, ansa-to-RLN combined with cricothyroid muscle-nerve-muscle pedicle, ansa-to-thyroarytenoid neural implantation, ansa-to-thyroarytenoid neuromuscular pedicle, and hypoglossal-to-RLN. Median postsurgical follow-up was 12 months, and mean time to first signs of reinnervation was 4.5 months (SD 2.9 months). Visual analysis of glottic gap showed the greatest mean improvement with ansa-to-RLN, from 2.25 (SD 0.886) to 0.75 (SD 0.886) mm (P < 0.01). Acoustic analysis showed greatest improvement with neural implantation, with a change in mean phonation time from seven (SD 1.22) to 16 (SD 5.52) seconds (P < 0.01). Perceptual analysis and electromyography demonstrated improvement in all studies. CONCLUSION: Reinnervation is effective in the management of UVFP, although the specific method may be dictated by anatomical limitations. Prospective studies utilizing uniform and consistent outcome parameters are necessary.

Vertical Incision Intraoral Silicone Chin Augmentation

Objective. Solid silicone augmentation mentoplasty is a common procedure with consistent aesthetic results in properly selected patients. While many plastic surgeons employ the external approach, the intraoral method affords excellent aesthetic outcomes while avoiding an external scar. This is the largest series in the literature describing the midline intraoral incision approach with minimal disruption of soft tissues. Study Design. Case series. Setting. Academic medical center. Subjects and Methods. One hundred twenty-five patients underwent chin augmentation with solid silicone implants between 2004 and 2010. Among these implants, 105 were placed transorally. Eighty-five patients were followed for at least 1 year. Demographic information, indications, patient satisfaction questionnaire results, and complications were recorded. Results. All implants yielded satisfactory results with no displacement, infection, tissue reaction, lower lip incompetence, mental nerve injury, or intraoral implant contamination. Two cases of superficial mucosal irritation at the suture site were observed and resolved without consequence. Symmetry, projection, and overall balance of facial components were excellent. Although all patients were satisfied with the functional and aesthetic results, 20% stated they would like further augmentation. Patients were extremely satisfied with the lack of an external scar. Conclusions. Based on our series, the intraoral technique with a midline incision avoiding disruption of the mentalis muscle is recommended for its ease, simplicity, patient satisfaction, low complication rate, and circumvention of an external scar. The external approach should be considered in cases that require a very large implant.

Validation of the Modified Brief Fatigue Inventory in Head and Neck Cancer Patients

Objective The aim of this study is to validate the Modified Brief Fatigue Inventory (MBFI). This is the first instrument designed to measure intensity and frequency of fatigue specifically in head and neck cancer patients, potentially allowing objective measurement in addressing this common symptom in a concise yet thorough fashion. Study Design Survey validation. Setting Academic tertiary medical center. Subjects and Methods The 9-item MBFI was administered to 52 consecutive cancer patients and 57 consecutive controls. Demographics, comorbidities, cancer site, and cancer stage were recorded. Psychometric properties and predictors of the MBFI were analyzed. Results The MBFI 1-week test-retest reliability was excellent (r = 0.800, P < .001). Internal consistency was also excellent (Cronbach’s α = 0.938). Construct validity of the MBFI compared with the previously validated Multidimensional Fatigue Symptom Inventory–Short Form was excellent (r = 0.814, P < .001). Discriminant validity of cancer patients vs controls was significant (P = .027). Predictors of increased MBFI score included American Society of Anesthesiologists (comorbidity) score (bivariate analysis, r = 0.287, P = .039), cancer stage (analysis of variance, P = .007), and adjuvant radiotherapy (t test, P = .016). Cancer stage and comorbidity were further correlated with a multiple regression linear model. No significant relationship was found with age, sex, marital status, education, ethnicity, feeding tube, tracheostomy, or laryngectomy. Conclusion The MBFI is a reliable and valid tool for measuring fatigue levels in head and neck cancer patients. In the context of initial assessment or posttreatment trending, this brief survey can be rapidly administered, providing valuable objective data on a very common and potentially debilitating symptom.

The utility of nasopharyngeal culture in the management of chronic adenoiditis

OBJECTIVES To examine the utility of nasopharyngeal culture in the management of children with chronic adenoiditis to determine if it results in a change in antibiotic therapy. METHODS Retrospective chart review of pediatric patients managed for chronic adenoiditis, being defined as cough, postnasal drip, and congestion for over three months with endoscopic evidence of nasopharyngeal purulence with normal anterior rhinoscopy and middle meati. Standard treatment was defined as amoxicillin clavulanate or amoxicillin clavulanate ES-600 in non-penicillin allergic patients, and cefuroxime or clarithromycin for penicillin allergic patients. Nasopharyngeal culture results and antibiotic prescriptions were reviewed to look for a change from the standard. RESULTS Of 207 patients diagnosed with chronic adenoiditis, 198 had nasopharyngeal cultures (119 male, 79 female, mean age 3.7 years). The most common organisms isolated were Streptococcus pneumoniae sensitive to penicillin in 40 cultures (20.2%), S. pneumoniae intermediate or resistant to penicillin in 26 (13.1%), Moraxella catarrhalis in 27 (13.6%), Haemophilus influenzae in 57 (28.8%), and Staphylococcus aureus intermediate or resistant to penicillin in 26 (13.1%). 13.3% of S. aureus isolated was methicillin resistant. 103 (52.0%) children required different antibiotics from the standard, and 26 (13.1%) had no antibiotics prescribed based on a negative culture. Of the 87 children suspected to have upper airway reflux, 25 (28.7%) had negative cultures. Of the 135 patients with follow-up, 50 (37.0%) reported resolution and 50 (37.0%) reported improvement of their symptoms. CONCLUSION Nasopharyngeal culture has significant utility in the choice of antibiotics for children with chronic adenoiditis.

Atypical presentation of laryngeal tuberculosis in a pediatric patient

Laryngeal tuberculosis is uncommon and most often associated with a primary lung infection in immunocompromised adults. We describe an atypical case in a pediatric patient with a relatively rapid onset and no history of travel or exposure to high-risk settings. Despite the unusual presentation and relative lack of familiarity with procedural guidelines in managing this uncommon and capricious disease by otolaryngologists in developed countries, reporting is mandated at multiple governmental health department levels. Consequently, this contagious entity must be considered in the interest of avoiding untoward outcomes for not only the patient, but the public as well.

The Subalar Graft and Its Role in Nasal Tip Medialization and Improved Nostril Symmetry

Objectives Relationships between nasal axis deviation and lower midfacial asymmetry or hypoplasia have been established in prior studies. We describe our experience with the subalar grafting technique in addressing nasal tip deviation associated with facial asymmetry. Indications in using this graft in isolation or in conjunction with other tip modification techniques are also investigated. Study Design Retrospective case series. Setting Academic medical center. Subjects and Methods Thirty-seven consecutive patients from a single surgeon (R.W.W.) treated using subalar grafting are evaluated for correction. Various measurements from preoperative and postoperative photographs are analyzed to determine the effectiveness of this intervention. Results Statistically significant correlations between improvement in nasal axis and alar-facial angle on base view (AFAB) (P < .001) and between alar-facial angle on frontal view (AFAF) (P = .017) were observed. In addition, a significant correlation between AFAB improvement and AFAF normalization was observed (P < .001). The improved nostril symmetry was significantly correlated with base view correction and was not the result of general improvements in nasal deviation. Conclusion While measuring the independent effects of subalar grafting is limited due to contaminant procedures, it can be recognized as a foundation rhinoplasty technique that, in conjunction with septoplasty, provides medialization of the tip in patients with facial asymmetry. Furthermore, aesthetic correction of nostril horizontal dystopia and/or nostril “show” is achieved with the proper application of this technique. This correction represents a unique intervention in rhinoplasty and should be considered a second indication for its use.

Lateral nasal artery pedicled island flap for repair of nasal alar defects.

T he lower third of the nose is a prominent structure vulnerable to cutaneous malignancies. From a reconstructive standpoint, patients with moderate-sized defects that do not involve the alar rim or supra-alar crease represent a reasonably rare but singularly unique situation. Single stage flaps will typically cross the supra-alar crease and multi-staged flaps are often considered too aggressive for the lesion in question, unless full subunit excision and reconstruction is performed. It is for this specific anatomic indication that the lateral nasal island flap was designed. The small flap is ideal for moderate alar lesions (1-1.5 cm), supplying acceptable texture and color matches based on a well-vascularized pedicle in a single-stage procedure. It also allows for cartilage grafting underneath the flap and avoids violation of the supra-alar crease.

Modified Brief Fatigue Inventory in Head and Neck Cancer

Objective: The aim of this study is to validate the Modified Brief Fatigue Inventory (MBFI). This is the first instrument designed to measure intensity and frequency of fatigue specifically in head and neck cancer patients, potentially allowing objective measurement in addressing this common symptom in a concise yet thorough fashion. Method: The 9-item MBFI was administered to 52 consecutive cancer patients and 57 consecutive controls from the outpatient otolaryngology clinic of an academic tertiary medical center. Subject demographics, co-morbidities, cancer site, and cancer stage were recorded. Psychometric properties and predictors of the MBFI were analyzed. Results: MBFI 1-week test-retest reliability was excellent (r = 0.800, P < .001). Internal consistency was also excellent (Cronbach’s α = .938). Construct validity of the MBFI compared to the previously validated Multidimensional Fatigue Symptom Inventory Short Form was excellent (r = 0.814, P < .001). Discriminant validity of cancer versus controls was significant (P = .027). Predictors of increased MBFI score included 1) American Society of Anesthesiologists (comorbidity) score (bivariate analysis r = 0.287, P = .039), 2) cancer stage (analysis of variance P = .007), and 3) adjuvant radiotherapy (t test P = .016). No significant relationship was found with age, gender, marital status, education, ethnicity, feeding tube, tracheostomy, or laryngectomy. Conclusion: The MBFI is a reliable and valid tool for measuring fatigue levels in head and neck cancer patients. In the context of initial assessment or posttreatment trending, this brief survey can be rapidly administered, providing valuable objective data on a very common and potentially debilitating symptom.

Intraoral Approach to Chin Augmentation

Objective: Silicone augmentation mentoplasty is a common procedure with consistent results in properly selected patients. While many plastic surgeons employ external approachs, the intraoral method affords acceptable aesthetic outcomes while avoiding an external scar. To date, a series of this magnitude involving the intraoral route has yet to be reported. Method: A total of 125 patients underwent chin augmentation with silicone implants between 2004 and 2010. Among these implants, 105 were placed transorally. 85 patients were followed for at least one year. Demographic information, indications, patient satisfaction questionnaire results, and complications were recorded. Results: All implants yielded satisfactory results with no displacement, infection, tissue reaction, lower lip incompetence, or mental nerve injury. In addition, no intraoral contamination of implants occured. Two cases of superficial mucosal irritation at suture sites were observed and resolved without consequence. Symmetry, projection, and overall balance of facial components were excellent as well. Although all patients were satisfied with the functional and aesthetic results, 20% stated they would like further augmentation. Patients were extremely satisfied with the lack of an external scar. Conclusion: Silicone augmentation mentoplasty is a relatively simple, reliable, and aesthetically pleasing procedure associated with minimal morbidity. Based on our series, with the avoidance of excessively large implants, the intraoral technique is recommended for its lack of complications and circumvention of an external scar.

Systematic Review of Steroid Prophylaxis for Thyroidectomy

Objective: Determine whether systematic review with meta-analysis supports the use of corticosteroids to reduce postoperative nausea, vomiting, pain, and voice dysfunction after thyroidectomy. Method: A systematic review of currently available randomized controlled trials in EMBASE and PUBMED databases comparing intravenous perioperative corticosteroids with placebo to prevent postoperative nausea, vomiting, pain, or voice dysfunction was performed by 2 independent reviewers. The quality of studies was evaluated and results synthesized using standard random-effects meta-analysis methods. Results: Eight randomized controlled trials were eligible for review. Dexamethasone reduced the absolute incidence of postoperative nausea at 24h by 18% (95% CI, 2-8-27%), P < .001, and postoperative vomiting at 24h by 27% (95% CI, 13-40%), P < .001 in 4 trials with 304 patients. Dexamethasone increased the absolute incidence of complete response (no episodes of nausea or vomiting) to steroids by 30% (95% CI, 7-52%), P = .11 in 3 trials with 246 patients. Dexamethasone reduced the absolute VAS score for pain (0-10 scale) at 24h by 1.32 95% CI (0.49-2.15), P = .002 in 3 trials with 232 patients. There was insufficient data to perform meta-analysis for voice dysfunction. Conclusion: These results argue strongly for routine use of dexamethasone during thyroidectomy because the intervention is safe and only about 2.5 patients need treatment to prevent one episode of postoperative nausea or vomiting.