Adherence to Clinical Practice Guidelines for Treatment of Bell's Palsy.

BACKGROUND: Bell's palsy is the most common cause of acute facial nerve paresis and paralysis with devastating disability yet high rate of spontaneous recovery. Patients who do not fully recover have functional disability that may require reconstructive surgery. The Clinical Practice Guideline: Bell's Palsy recommends treatment with high-dose steroids as it shows a higher likelihood of complete recovery. However, guideline adherence rates are inconsistent and unstudied. OBJECTIVE: To identify the frequency at which hospital-based clinicians at the University of Wisconsin-Madison follow recommended clinical guidelines and prescribe high-dose steroid medication. METHODS: Charts were reviewed from a single hospital (University Hospital) to evaluate Bell's palsy guideline adherence. All hospital-based encounters from 2008 through 2018 with primary diagnosis of Bell's palsy (ICD-9 351.0 and ICD-10 G51.0) were identified. Encounters were excluded if they had a diagnosis of Bell's palsy within 1 year prior (n=250) and did not have a medication list available (n=353). We examined patient demographics, common comorbidities, and any radiology and lab orders. RESULTS: We identified 565 patients with a primary diagnosis of Bell's palsy with available medication lists; 77.70% received the recommended treatment. The patients' median age was 47 (interquartile range 34-59), 52.16% were male, and 82.46% were treated by emergency medicine clinicians. Other treating clinicians were hospital-based primary care, otolaryngology and plastic surgery, and others. Multivariate analysis showed that treating clinician specialty was the only significant positive predictor. CONCLUSIONS: A significant portion of clinicians followed treatment guidelines for Bell's palsy. Further and larger research is needed to better identify points of intervention to improve guideline adherence.

Association between duration of peripheral facial palsy, severity, and age of the patient, and psychological distress.

BACKGROUND: Peripheral facial palsy (PFP) (paralysis) can be a devastating condition that has been shown to have associations with increased depression and worse quality of life. The aim of the present study is to better understand the complex association of psychological distress with the duration, severity, and age of patients with PFP. We hypothesize that a shorter duration of PFP is associated with higher levels of psychological distress. METHODS: Fifty-nine patients with PFP that existed longer than 3 months were included in this study. The Hospital Anxiety and Depression Scale (HADS) was used to assess the presence and severity of anxiety and depressions. Spearman's correlation analysis was used to determine correlation between psychological distress, duration, severity of the PFP, and age. RESULTS: Fifty-nine patients were included in this study, of whom 22 were male and 37 were female. The mean age was 55.6 ±â€¯14.6 years and mean duration of PFP from onset ranged from 3 months to 35 years (with a mean duration of 5.39 ±â€¯6.06 years). Twenty-eight patients had left-sided PFP, 30 patients had right-sided PFP, and one patient had bilateral PFP. The majority were caused by Bell's palsy (50.8%). In the group with a duration less than 5 years, there were five (12.8%) patients having a score between 11 and 15 (on HADS) compared to two (10%) patients in the group with a duration of 5 years or more(p = 0.04). CONCLUSION: There seems to be an association between moderate depression and duration of the PFP. Further studies need to substantiate our findings.

Sexual and Gender Minority Curriculum Within Otolaryngology Residency Programs.

Purpose: Otolaryngologists are uniquely situated to provide sexual and gender minority (SGM) care, including gender-affirmation (voice/communication, facial surgery) and HIV/AIDS-related conditions. Yet, no research has characterized otolaryngology residency program directors' attitudes toward SGM-related curricula, nor opportunities for supporting training in SGM-related care. Methods: An anonymous cross-sectional e-mail survey was disseminated to 116 otolaryngology residency program directors in July-September 2019. Information collected included current/future curriculum in and attitudes toward SGM care, and program demographics. Data were categorical and analysis utilized chi-square test. Results: The 65 complete responses (56% rate) were nationally representative. Overall, 17% of programs include no SGM-related education. Subjective importance of SGM training ranged from not important at all (3%) to absolutely essential (11%), with mode of average importance (47%); this varied significantly by program geographic setting and population, and program size. The mean percentage of curriculum dedicated to SGM care was 1.0% for didactics and 0.7% for clinical. Curricula include HIV/AIDS-related conditions (58%), facial gender-affirming procedures (50%), culturally informed care (42%), changes with gender-affirming hormones (voice/communication: 48%, facial: 22%), and cancer in SGM patients (42%). Frequently reported barriers were insufficient experienced faculty (52%) and time (42%). Program directors deemed visiting expert lectures (66%), small-group discussion (39%), and online modules (27%) the best ways to incorporate SGM education. Conclusions: More than 80% of otolaryngology residency curricula in a representative national survey include SGM-related education, which represents a limited portion of total curriculum. These results highlight the opportunity for expert lectures and discussion-based and online tool development to facilitate standardized SGM education in otolaryngology residencies.

A closer look at the paralyzed face; a narrative review of the neurobiological basis for functional and aesthetic appreciation between patients with a left and a right peripheral facial palsy.

BACKGROUND: The facial nerve or n. facialis (NVII) is the seventh cranial nerve and it is responsible for the innervation of the mimic muscles, the gustatory organ, and the secretomotor function to the salivary, lacrimal, nasal and palatine glands. Clinical presentation of Facial Palsy (FP) is characterized by unilateral facial asymmetry and may present with a change in taste, decreased saliva production, and dysarthria. A facial palsy has a notable effect on the facial appreciation by both the patient and the environment and also affects quality of life and emotional processing. There appear to be differences in the appreciation of people with a left and right facial palsy. PURPOSE OF THIS REVIEW: The purpose of the review is to give an overview of the anatomy of the facial nerve, neuro-anatomy of face processing, and hemispheric specialization and lateralization. Further,an overview is given of the clinical studies that translated the neuro-anatomical and neurobiological basis of these concepts into clinical studies. What this review adds: This review emphasizes the neurobiological evidence of differences in face processing between the left and right cerebral hemisphere, wherein it seems that the right hemisphere is superior in emotional processing. Several theories are proposed; 1) a familiarity hypothesis and 2) a left-right hemispheric specialization hypothesis. In clinical studies, promising evidence might indicate that, in patients with FP, there is indeed a difference in how left and right FP are perceived. This might give differences in decreased quality of life and finally in occurrence of depression. Further research must aim to substantiate these findings and determine the need for altering the standard therapeutic advice given to patients.

The Role of Voice Therapy and Phonosurgery in Transgender Vocal Feminization.

OBJECTIVE: Nonsurgical and surgical options are available for transgender vocal feminization. This systematic review explores the efficacy of feminizing voice therapy and phonosurgery. METHODS: A systematic review was performed using PubMed, Cinahl Plus, Ovid SP, Web of Science, Science Direct, and Google Scholar with terms related to transgender phonosurgery and voice therapy. Included studies were outcomes-based vocal feminization interventions for transgender women. Data were collected on pre- and postintervention fundamental frequency (F0), externally measured vocal femininity, patient satisfaction, and complications. RESULTS: Two hundred twelve studies were identified and 20 met inclusion criteria. Postintervention patient satisfaction was approximately 80% to 85% for voice therapy, endoscopic shortening, and cricothyroid approximation. Complications were reported for each phonosurgery technique, most commonly decreased mean phonation time and loudness. Of the 20 studies, 17 were used for meta-analysis of F0 change. F0 increased by 31 Hz with voice therapy alone, 26 Hz with laser reduction glottoplasty, 39 Hz with cricothyroid approximation, and 72 Hz with endoscopic shortening. CONCLUSION: The literature supports both voice therapy and phonosurgery, depending on a patient's magnitude of desired pitch change and tolerance for cost and potential complications. Most will likely benefit from voice therapy, as it is highly satisfactory, raises vocal pitch, and is noninvasive. However, endoscopic shortening is also highly satisfactory and provides the greatest absolute increase in vocal pitch. If surgery is chosen, postoperative voice therapy may additionally increase F0, stabilize the voice, and create a more female timbre. However, further studies will be necessary to provide definitive clinical recommendations.

Chondrolaryngoplasty-Thyroid Cartilage Reduction.

Chondrolaryngoplasty, also known as tracheal shave, is a surgical procedure performed for a prominent Adam's apple, usually in transfeminine patients with gender dysphoria to this marker of male sex. Although laryngeal anatomy is complex, knowledge of landmarks and techniques discussed in this article results in a safe procedure with rare complications and improvement in quality of life.

Educational Exposure to Transgender Patient Care in Otolaryngology Training.

OBJECTIVE: Gender dysphoria is estimated to occur in over 1 million people in the United States. With decreasing stigma regarding the transgender population, it is likely more patients will seek medical and surgical gender transition as parts of their treatment. However, otolaryngologists may lack training in gender-confirming surgery. This study aims to determine the current state of transgender-related education in the United States otolaryngology training programs and to evaluate trainee perceptions regarding the importance of such training. METHODS: A cross-sectional survey was performed among the United States otolaryngology training programs. A representative sample of 22 training programs divided within 4 US Census regions completed a cross-sectional 9-question survey between March and May 2017. Respondents were queried regarding demographics, transgender curricular exposure (didactic and/or clinical), and perceived importance of training in transgender patient care. RESULTS: A total of 285 trainees responded (69.3% response rate). Thirty percent of respondents reported education on or direct exposure to transgender care during residency. Among those with experiences in gender-confirming surgery, more than half were exposed to facial (masculinization or feminization) or pitch alteration surgery. Overall, the majority of respondents believed training in gender-confirming surgery is somewhat important and 63.2% supported incorporation of transgender patient care in existing subspecialty fellowship training. CONCLUSION: Less than one-third of otolaryngology trainees are exposed to transgender patient care. The majority of trainees endorsed the importance of residency and subspecialty fellowship training in gender-confirming surgery. To better serve the transgender population, formal didactics on gender-confirming surgery should be offered.

The Otolaryngologist's Role in Providing Gender-Affirming Care: An Opportunity for Improved Education and Training.

Currently, there are limited resources and training available for otolaryngologists and otolaryngology practice personnel to provide gender-affirming care for transgender or gender nonconforming patients. This unique patient population may present to our offices for gender-specific care or with complaints of the ear, nose, and throat unrelated to gender identity. Our current practice has unintentional but direct consequences on our patients care, as transgender patients often report negative experiences in the healthcare setting related to their gender identity. The absence of resources and training is also seen in other specialties. Physicians who create an environment where patients of all gender identities feel welcome can better meet their patients' health care needs. In addition, otolaryngologists can play a role in easing the gender dysphoria experienced by transgender patients. We suggest educational content should be created for and made available to otolaryngologists and office staff to provide gender-affirming care.

Big data in facial plastic and reconstructive surgery: from large databases to registries.

PURPOSE OF REVIEW: There are many limitations to performing clinical research with high levels of evidence in facial plastic and reconstructive surgery (FPRS), such as randomization into surgical groups and sample size recruitment. Therefore, additional avenues for exploring research should be explored using big data, from databases to registries. Other organizations have developed these tools in the evolving landscape of outcomes measurement and value in healthcare, which may serve as models for our specialty. RECENT FINDINGS: Over the last 5 years, FPRS literature of large-scale outcomes research, utilizing several administrative databases, has steadily grown. Our objectives are to describe key administrative databases, strengths and weaknesses of each, and identify recent FPRS publications utilizing big data. A registry with FPRS defined outcomes has the most potential. SUMMARY: Although FPRS research has trended to a more evidence-based approach in the modern healthcare era, gaps persist. Several large administrative databases or registries can address voids in outcomes research within FPRS.

Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty.

Objective Rhinoplasty, a surgical procedure that alters the shape or appearance of the nose while preserving or enhancing the nasal airway, ranks among the most commonly performed cosmetic procedures in the United States, with >200,000 procedures reported in 2014. While it is difficult to calculate the exact economic burden incurred by rhinoplasty patients following surgery with or without complications, the average rhinoplasty procedure typically exceeds $4000. The costs incurred due to complications, infections, or revision surgery may include the cost of long-term antibiotics, hospitalization, or lost revenue from hours/days of missed work. The resultant psychological impact of rhinoplasty can also be significant. Furthermore, the health care burden from psychological pressures of nasal deformities/aesthetic shortcomings, surgical infections, surgical pain, side effects from antibiotics, and nasal packing materials must also be considered for these patients. Prior to this guideline, limited literature existed on standard care considerations for pre- and postsurgical management and for standard surgical practice to ensure optimal outcomes for patients undergoing rhinoplasty. The impetus for this guideline is to utilize current evidence-based medicine practices and data to build unanimity regarding the peri- and postoperative strategies to maximize patient safety and to optimize surgical results for patients. Purpose The primary purpose of this guideline is to provide evidence-based recommendations for clinicians who either perform rhinoplasty or are involved in the care of a rhinoplasty candidate, as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The target audience is any clinician or individual, in any setting, involved in the management of these patients. The target patient population is all patients aged ≥15 years. The guideline is intended to focus on knowledge gaps, practice variations, and clinical concerns associated with this surgical procedure; it is not intended to be a comprehensive reference for improving nasal form and function after rhinoplasty. Recommendations in this guideline concerning education and counseling to the patient are also intended to include the caregiver if the patient is <18 years of age. Action Statements The Guideline Development Group made the following recommendations: (1) Clinicians should ask all patients seeking rhinoplasty about their motivations for surgery and their expectations for outcomes, should provide feedback on whether those expectations are a realistic goal of surgery, and should document this discussion in the medical record. (2) Clinicians should assess rhinoplasty candidates for comorbid conditions that could modify or contraindicate surgery, including obstructive sleep apnea, body dysmorphic disorder, bleeding disorders, or chronic use of topical vasoconstrictive intranasal drugs. (3) The surgeon, or the surgeon's designee, should evaluate the rhinoplasty candidate for nasal airway obstruction during the preoperative assessment. (4) The surgeon, or the surgeon's designee, should educate rhinoplasty candidates regarding what to expect after surgery, how surgery might affect the ability to breathe through the nose, potential complications of surgery, and the possible need for future nasal surgery. (5) The clinician, or the clinician's designee, should counsel rhinoplasty candidates with documented obstructive sleep apnea about the impact of surgery on nasal airway obstruction and how obstructive sleep apnea might affect perioperative management. (6) The surgeon, or the surgeon's designee, should educate rhinoplasty patients before surgery about strategies to manage discomfort after surgery. (7) Clinicians should document patients' satisfaction with their nasal appearance and with their nasal function at a minimum of 12 months after rhinoplasty. The Guideline Development Group made recommendations against certain actions: (1) When a surgeon, or the surgeon's designee, chooses to administer perioperative antibiotics for rhinoplasty, he or she should not routinely prescribe antibiotic therapy for a duration >24 hours after surgery. (2) Surgeons should not routinely place packing in the nasal cavity of rhinoplasty patients (with or without septoplasty) at the conclusion of surgery. The panel group made the following statement an option: (1) The surgeon, or the surgeon's designee, may administer perioperative systemic steroids to the rhinoplasty patient.

Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty Executive Summary.

Objective Rhinoplasty, a surgical procedure that alters the shape or appearance of the nose while preserving or enhancing the nasal airway, ranks among the most commonly performed cosmetic procedures in the United States, with >200,000 procedures reported in 2014. While it is difficult to calculate the exact economic burden incurred by rhinoplasty patients following surgery with or without complications, the average rhinoplasty procedure typically exceeds $4000. The costs incurred due to complications, infections, or revision surgery may include the cost of long-term antibiotics, hospitalization, or lost revenue from hours/days of missed work. The resultant psychological impact of rhinoplasty can also be significant. Furthermore, the health care burden from psychological pressures of nasal deformities/aesthetic shortcomings, surgical infections, surgical pain, side effects from antibiotics, and nasal packing materials must also be considered for these patients. Prior to this guideline, limited literature existed on standard care considerations for pre- and postsurgical management and for standard surgical practice to ensure optimal outcomes for patients undergoing rhinoplasty. The impetus for this guideline is to utilize current evidence-based medicine practices and data to build unanimity regarding the peri- and postoperative strategies to maximize patient safety and to optimize surgical results for patients. Purpose The primary purpose of this guideline executive summary is to provide evidence-based recommendations for clinicians who either perform rhinoplasty or are involved in the care of a rhinoplasty candidate, as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The target audience is any clinician or individual, in any setting, involved in the management of these patients. The target patient population is all patients aged ≥15 years. The guideline is intended to focus on knowledge gaps, practice variations, and clinical concerns associated with this surgical procedure; it is not intended to be a comprehensive reference for improving nasal form and function after rhinoplasty. Recommendations in this guideline concerning education and counseling to the patient are intended to include the caregiver if the patient is <18 years of age. Action Statements The Guideline Development Group made the following recommendations: (1) Clinicians should ask all patients seeking rhinoplasty about their motivations for surgery and their expectations for outcomes, should provide feedback on whether those expectations are a realistic goal of surgery, and should document this discussion in the medical record. (2) Clinicians should assess rhinoplasty candidates for comorbid conditions that could modify or contraindicate surgery, including obstructive sleep apnea, body dysmorphic disorder, bleeding disorders, or chronic use of topical vasoconstrictive intranasal drugs. (3) The surgeon, or the surgeon's designee, should evaluate the rhinoplasty candidate for nasal airway obstruction during the preoperative assessment. (4) The surgeon, or the surgeon's designee, should educate rhinoplasty candidates regarding what to expect after surgery, how surgery might affect the ability to breathe through the nose, potential complications of surgery, and the possible need for future nasal surgery. (5) The clinician, or the clinician's designee, should counsel rhinoplasty candidates with documented obstructive sleep apnea about the impact of surgery on nasal airway obstruction and how obstructive sleep apnea might affect perioperative management. (6) The surgeon, or the surgeon's designee, should educate rhinoplasty patients before surgery about strategies to manage discomfort after surgery. (7) Clinicians should document patient satisfaction with their nasal appearance and with their nasal function at a minimum of 12 months after rhinoplasty. The guideline development group made recommendations against certain actions: (1) When a surgeon, or the surgeon's designee, chooses to administer perioperative antibiotics for rhinoplasty, he or she should not routinely prescribe antibiotic therapy for a duration >24 hours after surgery. (2) Surgeons should not routinely place packing in the nasal cavity of rhinoplasty patients (with or without septoplasty) at the conclusion of surgery. The panel group made the following statement an option: (1) The surgeon, or the surgeon's designee, may administer perioperative systemic steroids to the rhinoplasty patient.

Patterns of Facial Fractures and Protective Device Use in Motor Vehicle Collisions From 2007 to 2012.

IMPORTANCE: Facial fractures after motor vehicle collisions are a significant source of facial trauma in patients seen at trauma centers. With recent changes in use of seat belts and advances in airbag technology, new patterns in the incidence of facial fractures after motor vehicle collisions have yet to be quantified. OBJECTIVES: To evaluate the incidence of facial fractures and assess the influence of protective device use in motor vehicle collisions in patients treated at trauma centers in the United States. DESIGN, SETTING, AND PARTICIPANTS: Using a data set from the National Trauma Data Bank, we retrospectively assessed facial fractures in motor vehicle collisions occurring from 2007 through 2012, reported by level I, II, III, and IV trauma centers. Data analysis was performed from March 13 to September 22, 2015. MAIN OUTCOMES AND MEASURES: We characterized the data set by subsite of facial injury using International Classification of Diseases, Ninth Revision codes including mandible, midface, and nasal fractures. We assessed the influence of variables such as age, sex, race/ethnicity, crash occupant (driver or passenger), use of protective device, and presence or suspicion of alcohol use. RESULTS: A total of 518 106 patients required assessment at a trauma center after a motor vehicle collision, with 56 422 (10.9%) experiencing at least 1 facial fracture. Nasal fracture was the most common facial fracture (5.6%), followed by midface (3.8%), other (3.2%), orbital (2.6%), mandible (2.2%), and panfacial fractures (0.8%). Of the subset sustaining at least 1 facial fracture, 5.8% had airbag protection only, 26.9% used a seat belt only, and 9.3% used both protective devices, while 57.6% used no protective device. Compared with no protective device, the use of an airbag alone significantly reduced the likelihood of facial fracture after a motor vehicle collision (odds ratio, 0.82; 95% CI, 0.79-0.86); use of a seat belt alone had a greater effect (odds ratio, 0.57; 95% CI, 0.56-0.58) and use of both devices provided the greatest odds reduction (odds ratio, 0.47; 95% CI, 0.45-0.48). Younger age, male sex, and alcohol use significantly increased the likelihood of facial fracture. CONCLUSIONS AND RELEVANCE: For patients who presented to US trauma centers after motor vehicle collisions between 2007 and 2012, airbags, seat belts, and the combination of the 2 devices incrementally reduced the likelihood of facial fractures. LEVEL OF EVIDENCE: 3.

Perioperative Arnica montana for Reduction of Ecchymosis in Rhinoplasty Surgery.

BACKGROUND: Studies of homeopathic therapies to decrease postrhinoplasty ecchymosis have previously used subjective measurements, limiting their clinical significance. Recently, Arnica montana was shown to decrease postoperative ecchymosis after rhytidectomy, using an objective measuring tool. We believe that oral A. montana, given perioperatively, can be objectively shown to reduce extent and intensity of postoperative ecchymosis in rhinoplasty surgery. METHODS: Subjects scheduled for rhinoplasty surgery with nasal bone osteotomies by a single surgeon were prospectively randomized to receive either oral perioperative A. montana (Alpine Pharmaceuticals, San Rafael, Calif) or placebo in a double-blinded fashion. Ecchymosis was measured in digital "three-quarter"-view photographs at 3 postoperative time points. Each bruise was outlined with Adobe Photoshop (Adobe Systems Incorporated, San Jose, Calif), and the extent was scaled to a standardized reference card. Cyan, magenta, yellow, black, and luminosity were analyzed in the bruised and control areas to calculate change in intensity. P value of <0.1 was set as a meaningful difference with statistical significance. RESULTS: Compared with 13 subjects receiving placebo, 9 taking A. montana had 16.2%, 32.9%, and 20.4% less extent on postoperative days 2/3, 7, and 9/10, a statistically significant difference on day 7 (P = 0.097). Color change initially showed 13.1% increase in intensity with A. montana but 10.9% and 36.3% decreases on days 7 and 9/10, a statistically significant difference on day 9/10 (P = 0.074). One subject experienced mild itching and rash with the study drug that resolved during the study period. CONCLUSIONS: Arnica montana seems to accelerate postoperative healing, with quicker resolution of the extent and the intensity of ecchymosis after osteotomies in rhinoplasty surgery, which may dramatically affect patient satisfaction.

Nasal tip volume analysis after butterfly graft.

OBJECTIVE: The aim of the study was to evaluate postoperative changes of the nasal tip in patients who underwent internal nasal valve reconstruction with the auricular cartilage butterfly graft. It is believed that this graft may alter the nasal tip appearance, potentially limiting the technique's broad use despite its proven efficacy. METHODS OR DESIGN: A retrospective chart and photograph review, between 2005 and 2009, identified 157 patients who underwent butterfly grafting without other tip modifications at a single institution by 1 surgeon. Changes in supratip projection were measured in the lateral view, and changes in tip width were measured in the frontal view from preoperative to 3-month postoperative photographs. RESULTS: For 21 subjects (12 female and 9 male), the change in tip width ranged from -10.2% to +15.7% (absolute mean 6.4%), and the change in supratip projection ranged from -23.4% to +15.0% (absolute mean 8.5%). Nine subjects with increased projection showed a mean increase of 7.0%, and a mean decrease of 9.7% was found in the 12 subjects with decreased supratip projection. CONCLUSIONS: The butterfly graft for internal nasal valve dysfunction results in cosmetic alteration to nasal tip width with a mean change of 6.4%. The change in supratip projection showed greater variability possibly related to purposeful cosmetic changes. Depending on the patient's level of nasal dysfunction, the 6.4% mean change in nasal tip width may be more or less personally significant.

Midface injectable fillers: have they replaced midface surgery?

This article examines the increasing role of injectable fillers to treat midface aging and our approach to decision making regarding the use of fillers versus surgery. We discuss the volume changes of the aging midface and advocate taking an anatomic approach to correct these changes. We discuss our approach to patient selection and injection technique. Finally, we review potential complications from injectable fillers and discuss the management of complications.