Nadim B. Bikhazi

Refinement in the Rehabilitation of the Paralyzed Face using Botulinum Toxin

A number of surgical procedures exist to improve facial symmetry for patients with facial paralysis. Whereas static symmetry is often improved, dynamic asymmetry frequently persists because of the imbalance of complex coordinated movements of facial expression. The paralyzed face is often distorted by the excessive pull of the normal contralateral face during emotional expression. This study reports an expanded clinical indication for botulinum toxin in patients with unilateral facial paralysis. Ten patients with facial paralysis and markedly asymmetric smiles were treated with botulinum toxin A injections into the contralateral zygomaticus major, levators labii superioris and angulii oris, or risorius muscles. Eight of the 10 patients noted improvement in the symmetry of their smiles and underwent repeat injections. The onset and duration of effect averaged 5.9 days and 3 months, respectively. Botulinum toxin therapy provides a safe and efficacious modality for refining the appearance of the paralyzed face during mimetic activity.

Superior Orbital Fissure Syndrome Caused by Indolent Aspergillus Sphenoid Sinusitis

Aspergillus fumigatus is the most common fungal pathogen of the paranasal sinuses. Its clinical significance ranges from noninvasive colonization to fulminant invasion of the sinuses and surrounding structures. Immunocompromised individuals are at highest risk for invasive infection. While the maxillary sinus is most commonly affected, isolated sphenoid sinusitis is infrequent. 1 Complications of sphenoid involvement result from extension into contiguous structures such as the orbit, cavernous sinus, or brain. Prompt diagnosis and treatment are paramount to reducing morbidity and mortality. Superior orbital fissure syndrome includes ophthalmoplegia, ptosis, forehead hypesthesia, and retro-orbital pain. Any process that invades the superior orbital fissure may lead to this constellation of findings. We report a case of indolent Aspergillus sphenoid sinusitis presenting as a superior orbital fissure syndrome over a 6-week period. The unusual clinical and radiologic features of this report that led to a delay in diagnosis and treatment are detailed.

Nasal reconstruction using a combination of alloplastic materials and autogenous tissues: A surgical alternative

Re‐creation of a functional and aesthetically acceptable nose after partial nasal defect requires accurate reproduction of nasal lining, support, and coverage. Most authors recommend an approach to reconstruction with cantilevered bone grafting and paramedian forehead flap placement. The authors propose an alternative approach for selected patients with total or near‐total nasal defects combining both alloplastic and autogenous tissues. This method uses vitallium or titanium mesh for the dorsal framework formation, tissue‐expanded paramedian forehead flap for soft tissue coverage, and composite chondrocutaneous auricular grafts for tip reconstruction. Nine individuals underwent nasal reconstruction using this method. The indications, details, and potential advantages of this technique are described with accompanying photographic results. A flexible approach using a combination of alloplastic materials and autogenous tissues provides additional reconstructive options for individuals with total or near‐total nasal defects.

First Place—Resident Clinical Science Award 1997: Germline screening of the NF-2 gene in families with unilateral vestibular schwannoma

Vestibular schwannoma may present clinically in two forms: sporadic unilateral or hereditary bilateral. Familial transmission of vestibular schwannoma is known to occur only in neurofibromatosis type II (NF-2). We have previously described the clinical characteristics of unilateral vestibular schwannoma presenting in families, in the absence of ther criteria necessary for the diagnosis of NF-2. Polymerase chain reaction–single strand chain polymorphism was used to screen for germline NF-2 gene mutations in six families with unilateral vestibular schwannoma. Direct sequencing of DNA from blood was done in affected subjects from three families. No germline mutations were identified. Because NF-2 gene mutations are detected in only 33% of patients with NF-2, hereditary transmission of mutations cannot be entirely excluded. However, in the absence of germline mutations in the NF-2 gene, familial occurrence of unilateral vestibular schwannoma more likely represents either a chance somatic NF-2 gene mutation or originates from a separate genetic loci. (Otolaryngol Head Neck Surg 1998;119:1–6.)

Familial Occurrence of Unilateral Vestibular Schwannoma

Vestibular schwannoma (VS) may present clinically in one of two forms: sporadic unilateral or hereditary bilateral. Almost all cases of familial transmission have been associated with the diagnosis of neurofibromatosis type II (NF‐2). In this report, we describe nine families (18 individuals) presenting with unilateral VS without evidence of NF‐2. In four of the nine families, the affected individuals were of parent‐offspring relationship, in three families they were cousin‐cousin, and in the remaining two families, they were sibling‐sibling and aunt‐nephew. No other members of the families were diagnosed with NF‐2. There was no evidence for gender predilection or genomic imprinting among affected individuals. This study suggests that familial occurrence of unilateral VS may be genetically inherited as it occurs more commonly than would be estimated by chance alone. Future genetic studies will elucidate whether occurrence of unilateral VS in these families represents a variable expression of NF‐2, chance occurrence of unilateral VS in families, or a new genetic disorder.

Germline screening of the NF-2 gene in families with unilateral vestibular schwannoma

Abstract Vestibular schwannoma may present clinically in two forms: sporadic unilateral or hereditary bilateral. Familial transmission of vestibular schwannoma is known to occur only in neurofibromatosis type II (NF-2). We have previously described the clinical characteristics of unilateral vestibular schwannoma presenting in families, in the absence of ther criteria necessary for the diagnosis of NF-2. Polymerase chain reaction-single strand chain polymorphism was used to screen for germline NF-2 gene mutations in six families with unilateral vestibular schwannoma. Direct sequencing of DNA from blood was done in affected subjects from three families. No germline mutations were identified. Because NF-2 gene mutations are detected in only 33% of patients with NF-2, hereditary transmission of mutations cannot be entirely excluded. However, in the absence of germline mutations in the NF-2 gene, familial occurrence of unilateral vestibular schwannoma more likely represents either a chance somatic NF-2 gene mutation or originates from a separate genetic loci.

The use of coblation technology for traditional tonsillectomy

condition in the differential diagnosis of a patient with choanal atresia. Methods: Approximately 100 cases of children born with 9p(-) have been reported, and a third child in this population has been identified to have choanal atresia. A comparison of CHARGE association and 9p(-) presentation and morphologic features are discussed to illustrate the fundamental differences in the 2 conditions. Results: Neonates with 9p(-) often are classified as having CHARGE association secondary to the similar presentations and dysmorphic features. The identification of a third child with bilateral choanal atresia suggests that it is not uncommon in this population. This diagnosis may be missed if not in the differential diagnosis and karyotypic studies are not completed. Conclusion: CHARGE association is by far the most common diagnosis in a child born with choanal atresia. However, an understanding of 9p(-) syndrome and its association with choanal atresia is necessary. The differential diagnosis should be broadened to reduce the potential for misdiagnosis.

Outpatient tonsillar biopsy safely determines HIV viral load

Methods: The patient sample for this study consisted of 50 consecutive patients who presented to a private otolaryngology practice who were diagnosed with chronic rhinosinusitis using standard AAO-HNS criteria. All patients were examined with nasal endoscopy in the office at one of their first two visits and were included in the sample if they met the appropriate criteria. These patients all completed the Rhinosinusitis Disability Index (RSDI) and a symptom questionnaire at their initial visit. They all had coronal CT scans of their sinuses, which were blindly staged using the Lund-Mackay system. Allergy testing was done in all patients using serial endpoint titration (SET) as the method for testing. Endpoints were assessed on each of 18 antigens and were used for data analysis. Results: The results of the study demonstrated a mean CT stage among patients with chronic rhinosinusitis of 4.0, with a range of 0 to 18. As had been previously noted, there was no significant correlation between CT stage and quality of life as assessed by the 3 subscales of the RSDI. Of these 50 patients, all had at least one significant endpoint of 2 or higher on SET testing, demonstrating some degree of allergy among all patients presenting with symptoms of chronic sinusitis. There was no significant correlation, however, between CT stage and allergy as assessed by any of the 18 antigens or the overall SET mean. A small but significant correlation was noted between SET scores and quality of life as assessed by the RSDI. Conclusion: These findings demonstrate no association between CT stage and quality of life, confirming findings of previous researchers. In addition, there was no correlation between CT stage and severity of allergic disease. There was, however, an association between SET results and quality of life. Patients with more severe allergic disease were more impaired in their specific quality of life than those with milder disease. These findings support prior research demonstrating the association between quality-of-life impairment and allergic rhinitis. The presence of allergic disease appears to be a better indicator of impaired quality of life among patients with chronic rhinosinusitis than are CT findings. These findings support the need for careful evaluation of allergic disease among patients with chronic rhinosinusitis.