Samuel L. Oyer

Antimicrobials and chronic rhinosinusitis with or without polyposis in adults: An evidenced-based review with recommendations

Chronic rhinosinusitis (CRS) is characterized by inflammation of the mucosa of the nose and paranasal sinuses. The role of bacterial or fungal infection in CRS is unclear, yet antimicrobials are commonly prescribed for this condition. Published guidelines offer little direction regarding antibiotic strategies for CRS. The purpose of this article is to provide an evidence‐based approach to the use of antibacterial and antifungal antibiotics in the management of CRS.

Cytokine correlation between sinus tissue and nasal secretions among chronic rhinosinusitis and controls.

Compare cytokine levels in sinus tissue to sinus secretions from controls and chronic rhinosinusitis patients.

Olfactory outcomes in chronic rhinosinusitis with nasal polyposis after medical treatments: a systematic review and meta‐analysis

Olfactory dysfunction is common among patients with chronic rhinosinusitis and has a negative impact upon quality of life. Olfactory dysfunction can be both subjective and objective and appears to be more predominant in patients with concomitant nasal polyposis. The efficacy of medical interventions on olfaction among patients with CRS with nasal polyposis (CRSwNP) is not well known. Our aim was to perform a systematic review with meta‐analysis of the efficacy of medical therapies on objective and subjective hyposmia among patients with CRSwNP.

Differential expression of adhesion molecules by sinonasal fibroblasts among control and chronic rhinosinusitis patients.

Background Chronic rhinosinusitis (CRS) is characterized by inflammatory cell migration into sinus tissue with resultant inflammation fueled by a milieu of cytokines. Fibroblasts may contribute to inflammation through expression of leukocyte adhesion molecules such as vascular cell adhesion molecule (VCAM) and intercellular adhesion molecule (ICAM). VCAM attracts eosinophils and mast cells contributing to Th2 skewing, and ICAM attracts neutrophils and to a lesser degree, eosinophils, and contributes to mixed Th1/Th2 skewing. The purpose of this study was to compare sinus fibroblast adhesion molecule expression ex vivo among CRS subtypes and in vitro after cytokine stimulation. Methods Sinus biopsy specimens were taken from control patients (n = 13), CRS without nasal polyposis (CRSsNP, n = 6), and CRS with nasal polyposis (CRSwNP, n = 15). Ex vivo levels of VCAM and ICAM were measured by flow cytometry from single cell suspensions of tissue biopsy specimens. Changes in VCAM and ICAM expression to cytokine exposure were assessed using in vitro cultured sinonasal fibroblasts treated with tumor necrosis factor (TNF)-α, interleukin (IL)-4, or interferon (IFN)-γ. Results Ex vivo VCAM expression was lowest in controls, higher in CRSsNP, and highest in CRSwNP. In vitro stimulation with TNF-α and IL-4, but not IFN-γ, increased VCAM among CRSsNP, while expression in CRSwNP remained elevated with all treatments except IFN-γ. Ex vivo ICAM expression was elevated in both CRS subtypes. In vitro stimulation with TNF-α and IFN-γ, but not IL-4, increased ICAM expression in all patients with the largest effects among the CRSsNP subgroup. Conclusion Sinonasal fibroblast expression of adhesion molecules in sinusitis varies by disease state and is selectively influenced by exposure to inflammatory cytokines.

Conscious Perception of Facial Asymmetry in a Unilateral Cleft Lip Model

Objective: Lip asymmetry after a unilateral cleft lip repair can be perceived as an unsatisfactory result. The objective of this study is to determine the degree of upper lip asymmetry and/or nasal alar hooding required for recognition of asymmetry in a simulated model of unilateral cleft lip. Design: A model of unilateral cleft lip was created using digital morphing software to simulate asymmetries in vermilion height and nasal hooding in photographs of children. Volunteers were shown photographs for different time intervals and with varying degrees of asymmetry. Ability to detect facial asymmetry was recorded and analyzed. Setting: This study was conducted by surveying layperson volunteers in public community settings. Participants: 108 layperson volunteers were randomly surveyed. Main Outcome Measures: The primary outcome measure was a reported lip or nose asymmetry by the volunteers. Proportions and corresponding 95% confidence intervals were obtained to estimate the probability of reporting an asymmetry at 3- and 10-second intervals. Results: After 3- and 10-second exposure, labial asymmetry was perceived by ≥50% of subjects at 2 mm (62%, P = .001) and 1 mm (89%, P < .0001), respectively. Nasal asymmetry was detected by <50% of subjects at 3 seconds, but ≥50% perceived a 3-mm alteration at 10 seconds (64%, P < .0001). Photographs with combined nasal and labial modification did not lower the threshold for asymmetry perception compared to either deformity alone. Conclusions: This study is the first to determine a predictable millimeter threshold for perceived asymmetry in cleft lip deformity using a digital model.

Masseteric Nerve Transfer for Facial Nerve Paralysis: A Systematic Review and Meta-analysis

Importance A review of the role of masseteric nerve transfer is needed to guide its use in facial reanimation. Objective To systematically review the available literature, and, when applicable, analyze the combined outcomes of masseteric nerve transfer to better define its role in reanimation and to guide further research. Data Sources Two independent researchers conducted the review using PubMed-NCBI and Scopus literature databases for studies on masseteric nerve transfer for facial nerve paralysis. Study Selection Studies that examined masseter nerve transfer with additional cranial nerve transposition/coaptation or muscle flap were excluded. Data Extraction and Synthesis Literature review and data extraction followed established PRISMA guidelines. Two researchers extracted data independently. Main Outcomes and Measures The main planned outcomes for the study were quantitative results of facial nerve movement after nerve transfer including oral commissure movement and time to nerve recovery. Results A total of 13 articles met inclusion criteria with a total of 183 patients undergoing masseteric nerve transfer. From those studies, there were a total of 183 patients who underwent masseteric nerve transfer. There were 85 men and 98 women with a mean (SD) age of 43 (12.2) years and mean (SD) follow up examination after surgery of 22 (7.6) months. Mean (SD) duration of nerve paralysis was 14 (6) months. Most common cause of paralysis was cerebellopontine angle tumors (81%). Six studies coapted the masseteric nerve to the main facial nerve trunk, whereas 7 used distal branches (buccal or zygomatic). Four studies used interposition nerve grafts with great auricular nerve. Two measures, improvement in oral commissure excursion and length from reanimation to facial movement, were measured consistently across the studies. Pooled analysis showed time from surgery to first facial movement, described in 10 studies, to be 4.95 months (95% CI, 3.66 to 6.24). Distal branch coaptation improved time to recovery vs main branch coaptation, 3.76 vs 5.76 months (95% CI, −0.33 to 4.32), but mean difference was not significant. The use of interposition graft significantly delayed time of nerve recovery, 6.24 vs 4.06 months (95% CI, 0.20 to 4.16). When controlled for main trunk coaptation only, interposition nerve graft delayed recovery but difference was no longer statistically significant, 6.24 vs 4.75 months (95% CI, −0.94 to 3.92). Reported complications were minor and rare occurring in only 6.5% (12 of 183) of patients. Conclusions and Relevance The masseteric nerve was found to be a good option for nerve transfer in this patient population, and showed favorable results in both time to nerve recovery and improvement in oral commissure excursion. Level of Evidence NA

The impact of adenoid size on rate of revision sphincter pharyngoplasty

Determine the impact of adenoid size and prior adenoidectomy on outcomes of sphincter pharyngoplasty.

Comparison of Objective Outcomes in Dynamic Lower Facial Reanimation With Temporalis Tendon and Gracilis Free Muscle Transfer

Importance Facial paralysis affects patients’ physical, social, and psychological function. Dynamic smile reanimation can mitigate these effects, but there are limited data to guide the surgeon in selecting the best reanimation procedure for each patient. Objective To compare quantitative changes in oral commissure symmetry and smile excursion following temporalis tendon transfer (T3) and gracilis free muscle transfer. Design, Setting, and Participants Retrospective case series of 28 adults with unilateral facial paralysis seeking dynamic lower facial reanimation at a tertiary academic medical center between July 1, 2010, and July 30, 2014. Data were analyzed from May 1, 2016, to June 30, 2016. Interventions Minimally invasive T3 (n = 14) compared with gracilis free muscle transfer (n = 14). Main Outcomes and Measures Measured symmetry of the oral commissure between the healthy and paralyzed sides in the horizontal, vertical, and angular dimension and excursion of the paralyzed commissure following reanimation compared with the healthy commissure. Results Of the 28 patients, 19 (68%) were women; mean (SD) age was 51.7 (17) years. Commissure symmetry during smile improved significantly for the T3 patients in the vertical and angular dimensions, and the gracilis free muscle transfer patients had significant improvement in the vertical and horizontal dimensions. Commissure excursion significantly improved in both groups following surgery, with a larger improvement seen in the gracilis free muscle transfer group (11.3 mm; 95% CI, 7.0 to 15.5 mm) compared with the T3 group (4.8 mm; 95% CI, 0.2 to 9.3 mm), with a mean difference of 6.5 mm (95% CI, 0.7 to 12.4 mm; Cohen d, 0.86). Postoperative smile excursion of the paralyzed side was within 1.0 mm of the healthy side in the gracilis free muscle transfer group (95% CI, −2.1 to 4.0 mm). Conclusions and Relevance Temporalis tendon transfer and gracilis free muscle transfer both improve oral commissure symmetry and excursion in facial paralysis. The improvement in smile excursion appears to be larger in patients treated with gracilis free muscle transfer and, on average, the excursion approximates the contralateral healthy side.

Swallowing Outcomes in Mandibular Osteoradionecrosis Treated with Free Tissue Transfer

Objectives: Evaluate swallowing outcomes after free tissue transfer (FTT) reconstruction for mandibular osteoradionecrosis (ORN), using aspiration and postoperative tube feed (TF) dependence as surrogates for swallowing ability. Methods: Study Design: Case series with chart review. All patients undergoing osteocutaneous FTT reconstruction in an academic tertiary-care hospital for mandibular ORN from 2004-2012 were reviewed. Preoperative patient characteristics, postoperative aspiration, and postoperative TF dependence were noted for each patient. Analysis of patient factors associated with aspiration or TF dependence was performed using Pearson correlation and Fisher’s exact test (when appropriate). Results: Sixteen patients met inclusion criteria with an average age of 63.4 years (range 36-81 years) and median follow up of 20 months (range 3-72 months). TF dependence pre- and post-operatively was total dependence in 25% vs. 31%, partial in 25% vs. 31%, and none in 50% vs. 38%, with strong correlation between pre and post-operative TF dependence (r = 0.524, P = 0.04). Aspiration at postoperative follow-up correlated with long-term TF dependence (r=0.701, P < 0.01). Less aspiration was seen after scapular FTT compared to fibular, but this did not reach statistical significance (22% vs. 57% respectively, P = 0.62). Females had lower aspiration rates than males (r = 0.595, P = 0.02), and all females in this study were treated with scapular FTT. Tracheostomy decannulation was achieved in 94% (15/16) of patients. Conclusions: TF dependence following osteocutaneous FTT for ORN correlates with pre-operative TF dependence and post-operative aspiration. Aspiration is less likely in females and patients receiving scapular FTT.

Endoscopic brow approach for frontal osteoma in a pediatric patient

Osteomas are benign bony growths that have been reported following trauma. Previous management of forehead osteomas has centered around direct excision, but there has been a recent interest in endoscopic resection to improve cosmesis. Endoscopic resection has previously been described in adults, but not in children. We describe a case of a 15-year-old who developed a forehead osteoma following trauma that was resected entirely endoscopically, leaving no visible scar with resolution of edema and good cosmetic result as early as post-operative day 9. Our case lends evidence to support the safe and effective use of this technique in adolescents.