Linda N. Lee

Evaluating the diagnosis of chronic rhinosinusitis based on clinical guidelines and endoscopy

Objective: To validate the diagnosis of chronic rhinosinusitis (CRS) according to recent clinical practice guidelines and determine the added utility of nasal endoscopy. Study Design: Prospective diagnostic cohort study. Setting: Academic medical center. Subjects and Methods: A consecutive series of adult patients presenting for evaluation of CRS were prospectively studied with the use of the rhinosinusitis symptom inventory (RSI), nasal endoscopy, and sinus computed tomography (CT). Symptom scores were tabulated from the RSI. Nasal endoscopy was performed to evaluate for purulence or polyps. Sinus CT scans were scored with the Lund system, with the reviewers blinded to the RSI scores and endoscopic findings. The clinical diagnosis of CRS was determined on the basis of the published adult sinusitis guideline criteria and compared with the diagnostic gold standard, CT. Results: A total of 202 patients were studied. The prevalence of CRS was 39.6 percent, as defined by CT (Lund score ≥ 4). For symptom criteria alone, the sensitivity, specificity, positive predictive value, and negative predictive value were 88.7, 12.3, 39.9, and 62.5 percent, respectively, for CRS (P = 0.82). The addition of endoscopic findings to symptom criteria significantly improved the specificity, predictive value, and negative predictive value to 84.1, 66.0, and 70.3 percent (P < 0.0001). The odds ratio of a true diagnosis of CRS improved from 1.1 to 4.6 (95% confidence interval, 2.3-9.2). Sensitivity analysis adjusting symptom severity did not significantly alter diagnostic accuracy. Conclusion: In patients meeting current guideline symptom criteria for CRS, the addition of nasal endoscopy improves diagnostic accuracy and should be emphasized as an early diagnostic tool. Diagnostic endoscopy may help reduce the use of CT, reducing costs and radiation exposure.

Regional and specialty variations in the treatment of chronic rhinosinusitis.

To identify regional and specialty differences in the medical treatment of chronic rhinosinusitis (CRS).

Two-step highly selective neurectomy for refractory periocular synkinesis.

INTRODUCTION Botulinum toxin type A (BTA) has become a gold standard of treatment for facial synkinesis, and now is an integral part of the treatment paradigm for patients with this sequela. In our center, we routinely treat 30 patients per week with botulinum toxin. Addressing synkinesis via a multidisciplinary approach, we begin with physical therapy and later add chemodenervation to the regimen. Injections of BTA (onabotulinumtoxinA, Botox Cosmetic, Allergan Inc, Irvine, CA) are repeated every 3 to 6 months, if they offer symptom relief. Repeated BTA treatments can lead to decreased effectiveness through the well-described phenomenon of antibody development. Once BTA has lost its effectiveness, despite increased doses, we advance to type B botulinum toxin (BTB) (rimabotulinumtoxinB, Myobloc, Solstice Neurosciences LLC, Louisville, KY). We currently treat 390 patients with BTA injections; only 10 are receiving BTB. The same loss of effectiveness that occurs with BTA can occur with BTB; historically, these patients have continued their physical therapy but experience worsening of synkinesis symptoms in the absence of chemodenervation. To address this problem in the periocular area, we have refined the decades-old technique of selective neurectomy. Traditionally, the procedure did not identify specific nerve branches responsible for the synkinesis symptoms, resulting in either unsatisfactory relief, worsening of facial weakness, or a combination of both. Therefore, we resolved to avoid these problems through precise titration of the neurectomy. To this end, the procedure was divided into two steps: 1) Facial nerve dissection is done under general anesthesia; 2) The patient is awakened and recovered, and then the neurectomy is performed, achieving the exact degree of orbicularis oculi weakening required to decrease ocular synkinesis while avoiding lagophthalmos.

A comparison of facial nerve grading systems.

Purpose This study aimed to compare a computerized tool to standard objective clinical scales for global and zone-specific assessment of facial nerve function. Methods This was a retrospective review of 77 patients with facial paralysis who underwent facial videography. Videos were independently scored by 3 facial nerve specialists using the House-Brackmann Scales (HBI and HBII). Digital scoring was performed with Facogram software. Scores were recorded and compared using intraclass and Pearson (r) correlations. Results Interobserver correlation was high with HBII, with overall scores in excellent agreement (intraclass correlation range, 0.78–0.95; P ⩽ 0.0001). There were strong correlations between Facogram and HBII (r ≥ 0.67, P ⩽ 0.0001) and strong intraobserver correlations between HBI and HBII (r ≥ 0.71, P ⩽ 0.0001). The HBII required more clinician time [mean (SD), 72 (21) seconds per case], compared with Facogram, which did not require any clinician time. Conclusions An automated, zone-specific facial analysis tool can eliminate clinician subjectivity and allow standardized assessment of facial paralysis.

Traumatic Facial Nerve Injury

Facial nerve trauma can be a devastating injury resulting in functional deficits and psychological distress. Deciding on the optimal course of treatment for patients with traumatic facial nerve injuries can be challenging, as there are many critical factors to be considered for each patient. Choosing from the great array of therapeutic options available can become overwhelming to both patients and physicians, and in this article, the authors present a systematic approach to help organize the physicians thought process.

Intraoperative Laser-Assisted Indocyanine Green Imaging for Objective Measurement of the Vascular Delay Technique in Locoregional Head and Neck Flaps

IMPORTANCE Reconstruction of oncologic or traumatic head and neck defects often requires complex planning of locoregional, pedicled, or interpolated flaps. In cases with a higher risk of flap failure, vascular delay with staged reconstruction can help improve tissue perfusion and increase chances of flap survival. An objective tool is needed to help guide reconstructive surgeons with the intraoperative decision to pursue vascular delay. OBJECTIVES To describe a pilot study using a novel application of a technique that quantifies and validates the benefit of the vascular delay procedure in locoregional flaps and to demonstrate a practical and broadly applicable technology that can be easily incorporated into intraoperative decision making and improve outcomes for high-risk flaps. DESIGN, SETTING, AND PARTICIPANTS A pilot study using intraoperative laser-assisted indocyanine green imaging measurements and fluorescence videos to objectively measure the benefit of vascular delay procedures in patients with head and neck defects and wound healing risk factors requiring locoregional flap reconstruction at an academic tertiary care center. MAIN OUTCOMES AND MEASURES Intraoperative laser-assisted indocyanine green imaging with video documentation and quantitative measurements was used to evaluate flap perfusion before a vascular delay procedure. Measurements were repeated after a 3-week vascular delay procedure. RESULTS Two patients were identified based on comorbid conditions that resulted in a higher risk of flap failure, as well as the need for a locoregional flap for reconstruction. At the initial elevation of the flap, quantitative results from flap imaging demonstrated low perfusion numbers and minimal fluorescence, suggesting poor tissue perfusion and increased likelihood of postoperative flap compromise or failure. Following a vascular delay of 3 weeks, repeat measurements were substantially improved. No wound healing issues were observed. CONCLUSIONS AND RELEVANCE This is the first study to date to quantitatively demonstrate the benefit of the vascular delay technique in patients with potential vascular compromise in locoregional head and neck flap reconstruction. Data obtained suggest that this technology can be used to guide intraoperative decision making in complicated reconstructions and help optimize patient outcomes. LEVEL OF EVIDENCE NA.

Treatment of the periocular complex in paralytic lagophthalmos.

Objectives: Paralytic lagophthalmos can lead to devastating exposure keratitis. The main surgical intervention consists of upper eyelid loading. However, adjunctive lower eyelid and brow procedures are also available as necessary. We sought to analyze the use of periocular procedures in paralytic lagophthalmos at Johns Hopkins. Methods: The method was a retrospective review of patients treated at a single tertiary care center from 2006 to 2012. Results: One hundred one patients met inclusion criteria, and 20 patients were excluded for not meeting the minimum follow-up. Upper eyelid loading was required on 95/101 patients (95%). Adjunctive procedures were necessary in 73% (73/101) of patients. Lower eyelid procedures were used in 47% (47/101) and brow lifts in 47% (47/101). Older patients (>50 years) were more likely to require lower eyelid procedures (P = .04) and more likely to require revision (P = .003). Medial canthopexy and direct brow lift were associated with the need for revision (P = .006, P = .03). Conclusion: Paralytic lagophthalmos management is not one-size-fits-all. Upper eyelid loading is the mainstay of treatment; however, adjunctive procedures to the lower eyelid and brow are indicated in the majority of patients. Our retrospective review has allowed us to continue to refine our strategy for managing these patients.

Contemporary trends in procedural volume for adult facial trauma, 1996-2006.

Objectives. To determine how rates of operative facial fractures may have changed between 1996 and 2006 and to determine the potential impact of such change on otolaryngology residency surgical key indicator cases. Study Design. Historical cohort study. Setting. Academic medical center. Subjects and Methods. The National Hospital Discharge Survey (NHDS) and National Survey of Ambulatory Surgery (NSAS) 1996 and 2006 cases were reviewed, extracting all cases of adult nasal, malar/zygomatic, maxillary, and mandibular fracture reductions in inpatient and outpatient settings, respectively. Procedure rates for each facial fracture were tabulated and compared between 1996 and 2006. Results. Overall in 1996, there were an estimated 113,041 ± 3740 operative facial fracture repairs performed. Among the 3 key indicator fracture repairs most relevant to otolaryngologists, there were 15,810 ± 2143 open nasal fracture reductions, 9360 ± 1742 open zygomaticomaxillary (ZMC) fracture reductions, and 20,214 ± 2585 open mandibular fracture repairs. Overall in 2006, there were 120,463 ± 7554 total facial fracture procedures, with 11,613 ± 2846 open nasal fracture reductions, 10,216 ± 2881 open ZMC fracture reductions, and 17,965 ± 3171 open mandibular repairs. Comparing cohorts, there was no significant change in number of open nasal, ZMC, or mandibular fracture repairs (P = .24, P = .58, P = .80, respectively). Conclusion. Facial fracture procedure rates have remained largely stable over the past 10 years. These data have implications for otolaryngology training programs and could help guide resident education in facial trauma.

A Novel Technique for Sculpting Costal Cartilage in Microtia Repair and Rhinoplasty

IMPORTANCE Transforming a block of costal cartilage into a complex 3-dimensional framework that reflects the contours of a normal ear or nasal bridge requires the creation of many subtle curves, concavities, and convexities. Thus, specialized instruments for microtia repair and rhinoplasty, with specifically curved sharp blades, are used for delicate carving without the need for excessive force, which can damage the framework. Several challenges are associated with these specialized instruments. OBJECTIVE To describe a novel alternate technique using disposable skin punch biopsy instruments for sculpting cartilage, which have the potential to decrease cost, ensure consistently sharp blades, and provide a variety of sizes to allow precise, controlled contour changes. DESIGN Surgical technique adapting a commercially available skin punch tool for costocondral sculpting. SETTING Academic tertiary care medical center. PARTICIPANTS Patients undergoing microtia repair and rhinoplasty requiring sculpting of costocondral cartilage. MAIN OUTCOMES AND MEASURES Feasibility and reliability of cartilage contouring. RESULTS This novel technique has been used in microtia repair and rhinoplasty with excellent results. CONCLUSIONS AND RELEVANCE This alternate technique of costocondral sculpting should be included as an additional tool in the reconstructive surgeons armamentarium. LEVEL OF EVIDENCE NA.

Surgical site infections after gracilis free flap reconstruction for facial paralysis.

Compared with other free tissue transfer procedures, the gracilis free muscle transfer (GFMT) for facial reanimation is unique in that the recipient site is typically uninvolved by malignancy or infection. In this study, the authors examined the incidence, bacteriology, and outcomes of surgical site infection (SSI) after gracilis free muscle transfer for facial reanimation. From 2003 to 2011, 105 patients underwent 107 GFMT operations, with 6 SSIs. All cases of infection occurred in patients receiving clindamycin, levofloxacin, and/or cefazolin perioperatively. None of the patients who received ampicillin-sulbactam developed an SSI. Surgical site cultures grew oral flora, including α-hemolytic streptococci, Haemophilus parainfluenzae, Fusobacterium and Neisseria species, and coagulase-negative staphylococci. Notably, there were no methicillin-resistant Staphylococcus aureus (MRSA) infections. These data may have implications for the optimal perioperative antibiotic choice in facial reanimation cases. Further study is needed to determine the ideal antibiotic regimen for this category of free flap surgeries.