Virtual reality can reduce anxiety during office-based great saphenous vein radiofrequency ablation.

OBJECTIVE: Office-based treatment of venous pathology is common and frequently involves the use of anxiolytic medication to reduce anxiety. Virtual reality (VR) has been shown to effectively reduce pain and anxiety in a variety of settings. The objective of the present study was to determine whether VR could be smoothly integrated into office-based vascular procedures and to ascertain whether VR could reduce procedural pain or anxiety. METHODS: A total of 40 patients undergoing an office-based endovenous radiofrequency ablation were included in the present study. Of the 40 patients, 20 were randomized to the VR group and 20 to the control group. The patients in the VR group were equipped with a Samsung GearVR headset and headphones (Samsung, Suwon, South Korea) running AppliedVR software (AppliedVR Inc, Los Angeles, Calif), which ran throughout the duration of the procedure. All 40 patients underwent unilateral great saphenous vein radiofrequency ablation. After the procedure, the patients were surveyed regarding their preprocedure anxiety and their pain and anxiety during the procedure using the Wong-Baker scale. RESULTS: All procedures were successfully completed, and all patients were generally satisfied with their treatment. The average procedure time was not significantly different. No statistically significant differences were present in preprocedure anxiety or procedural pain between the two groups. The anxiety level during the procedure, however, was 4.09 of 10 in the control group vs 2.95 of 10 in the VR group, statistically significant difference using a paired t test. Furthermore, the anxiety level for the control group had increased during the procedure but that of the VR group had decreased. Finally, 85% of the patients in the VR group would recommend using VR to someone undergoing a similar procedure. CONCLUSIONS: VR can be safely and efficiently integrated into office-based vascular procedures. VR was generally well liked and recommended by those who used it. Most importantly, our findings suggest that VR can decrease procedural anxiety. Further research should examine whether this might obviate the need for anxiolytic medication.

Mid-infrared laser orbital septal tightening: ex vivo dosimetry study and pilot clinical study.

IMPORTANCE: Blepharoplasty is one of the most commonly performed facial aesthetic surgeries. While myriad techniques exist to improve the appearance of the lower eyelids, there is no clear consensus on the optimal management of the orbital septum. OBJECTIVES: To evaluate the safety and feasibility of the use of the holmium:yttrium aluminum garnet (Ho:YAG) laser for orbital septal tightening, and to determine whether modest use of this laser would provide some degree of clinical efficacy. DESIGN, SETTING, AND PARTICIPANTS: Direct laser irradiation of ex vivo bovine tissue was used to determine appropriate laser dosimetry using infrared thermal imaging and optical coherence tomography before conducting a pilot clinical study in 5 patients. Laser irradiation of the lower eyelid orbital septum was performed through a transconjunctival approach. Standardized preoperative and postoperative photographs were taken for each patient and evaluated by 6 unbiased aesthetic surgeons. EXPOSURE: Use of the Ho:YAG laser for orbital septal tightening. MAIN OUTCOME AND MEASURE: To determine appropriate laser dosimetry, infrared thermal imaging and optical coherence tomography were used to monitor temperature and tissue shape changes of ex vivo bovine tissue that was subjected to direct laser irradiation. For the clinical study, preoperative and postoperative photographs were evaluated by 6 surgeons on a 10-point Likert scale. RESULTS: Optical coherence tomography demonstrated that laser irradiation of bovine tissue to a temperature range of 60°C to 80°C resulted in an increase in thickness of up to 2-fold. There were no complications or adverse cosmetic outcomes in the patient study. Patient satisfaction with the results of surgery averaged 7 on a 10-point Likert scale. For 3 patients, 3 (50%) of the evaluators believed there was a mild improvement in appearance of the lower eyelids after surgery. The remaining patients were thought to have no significant changes. CONCLUSIONS AND RELEVANCE: Transconjunctival Ho:YAG laser blepharoplasty is a safe procedure that may ameliorate mild pseudoherniation of lower eyelid orbital fat and is a first step toward the development of percutaneous techniques.

Threshold of visual perception of facial asymmetry in a facial paralysis model.

OBJECTIVE: To determine the degree of facial asymmetry required to trigger conscious perception in the observer in a simulated model of facial paralysis. METHODS: A model of unilateral facial paralysis was created using the face of a participant without facial paralysis. Digital morphing software was used to create progressive asymmetry of the brow, oral commissure, and combined brow and oral commissure based on the typical sequelae seen in facial paralysis. Volunteers naive to the goals of the study repeatedly were shown a series of photographs of faces without facial paralysis, with the manipulated image interspersed within the series. RESULTS: At least 3 mm of facial asymmetry of the oral commissure, brow, or both was required before participants detected the asymmetry. With longer display intervals, participants tended to detect a smaller degree of asymmetry. CONCLUSIONS: To our knowledge, this is the first study directed at determining the amount of facial asymmetry required to trigger conscious perception of patients' facial paralysis in the naive observer. The pilot data and the discussion herein provide insight into the processes of visual perception of facial asymmetry and may be useful to surgeons for patient counseling and in setting surgical goals.

Adult nasal dermoid sinus cyst.

Midline congenital nasal lesions are rarely encountered in adults. We present the case of a 31-year-old man with a nasal dermoid sinus cyst who presented with a nasal dorsal abscess. We review the embryology of nasal dermoid sinus cysts, and we discuss their presentation, evaluation, and management in adults.

Combined endoscopic and transoral resection of a primary nasopharyngeal paraganglioma.

We present what to the best of our knowledge is only the fourth case of a primary nasopharyngeal paraganglioma to be reported in the literature, and we describe a novel surgical approach to its removal. The patient was a 53-year-old woman who presented with a nasopharyngeal mass. A subtotal resection and biopsy of the mass identified it as a paraganglioma. The remainder of the tumor was completely excised via a combined transnasal endoscopic and transoral approach that allowed us to spare the palate. The total operating time was less than 90 minutes. Blood loss was estimated at 300 ml, and there were no intraoperative or postoperative complications. At follow-up 12 months later, endoscopic examination and imaging found no residual or recurrent tumor.

Local flaps I: bilobed, rhombic, and cervicofacial.

This article is the first in a series focusing on the reconstruction of defects of the head and neck created by the resection of a skin cancer. This series begins with a detailed description of specific types of local flaps, and is followed by articles emphasizing the options for reconstruction by anatomic site. The surgical technique for three workhorse flaps of the face are described: the bilobed flap, rhombic flap, and cervicofacial flaps.

Surgical treatment of dysthyroid orbitopathy.

OBJECTIVES: Orbital decompression for dysthyroid orbitopathy may be performed by open or transnasal endoscopic approaches; however, criteria for the selection of the appropriate surgical technique have not been well-defined. Our goal was to compare the surgical outcomes of orbital decompression techniques employed by the otolaryngology and ophthalmology services at a single institution, so as to clarify the indications and develop a rationale for optimal management. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care academic medical center. SUBJECTS AND METHODS: Orbital decompressions on 112 orbits of 69 patients from 2001 to 2008 at a tertiary care academic medical center. RESULTS: The majority (83%) of orbital decompressions were performed primarily for proptosis, whereas the remainder was indicated for dysthyroid optic neuropathy. Maximum reduction of proptosis was achieved with an endoscopic medial and inferior orbital wall decompression combined with a lateral orbitotomy with fat removal. The average reduction in proptosis was 7.4 mm+/-2.3 mm (primary surgery for proptosis). The endoscopic approach alone provided the least average proptosis reduction but was highly successful in the treatment of dysthyroid optic neuropathy. CONCLUSIONS: A three-wall decompression using a combined endoscopic and external approach provides the greatest amount of decompression. The endoscopic approach as a single modality is best suited for patients with mild proptosis and for patients with dysthyroid optic neuropathy. Cooperation between otolaryngology and ophthalmology achieves the best care for patients with thyroid eye disease who require surgical treatment.

Selective endoscopic decompression of the orbital apex for dysthyroid optic neuropathy.

OBJECTIVES/HYPOTHESIS: To introduce the concept of selective endoscopic decompression of the orbital apex for dysthyroid optic neuropathy and present surgical outcomes. STUDY DESIGN: Prospective case series. METHODS: Consecutive patients undergoing urgent endoscopic orbital apex decompression for dysthyroid optic neuropathy were studied prospectively. Surgical indications consisted of retrobulbar optic neuropathy with radiologic evidence of apical crowding in the setting of Graves' disease. Pre- and postoperative parameters assessed included exophthalmometry, visual acuity, presence or absence of exposure keratitis, diplopia, an afferent papillary defect, and Ishihara color plate testing. RESULTS: In all patients, visual acuity was improved or was stabilized by selective orbital apex decompression. Preoperative afferent papillary defects were reversed in all but one patient. Patients with decreased color vision by Ishihara color plate testing had postoperative improvement in their scores. No patients developed postoperative diplopia. An average of 3.1 mm of ocular recession was achieved. CONCLUSIONS: Selective decompression of the orbital apex spares the anteromedial and inferior orbital walls that are typically removed in a standard endoscopic orbital decompression. This focused approach successfully addresses compressive optic neuropathy, while minimizing the risk of postoperative diplopia or delayed sinus outflow obstruction. In patients with progressing dysthyroid optic neuropathy without diplopia this modified procedure should be considered. Laryngoscope, 2009.

Nasopharyngeal carcinoma: the role of the Epstein-Barr virus.

Nasopharyngeal carcinoma (NPC) arises from the epithelium of the nasopharynx and is a rare tumor in most parts of the world, including the United States. Neck swelling, nasal obstruction, and epistaxis are the most common presenting symptoms. The etiology of NPC is multifactorial and includes genetic susceptibility, exposure to carcinogens, and prior infection with the Epstein-Barr virus (EBV). We report a case of a 16-year-old African-American male who presented with hemoptysis and a 3-month history of a neck mass. Diagnostic evaluation identified a nasopharyngeal mass that upon biopsy was shown to be an undifferentiated nasopharyngeal carcinoma with immunohistochemical stains markedly positive for EBV. Recent studies have further elucidated the role of EBV in the pathogenesis of NPC and have demonstrated the utility of EBV studies in staging, prognosis, and post-therapeutic monitoring.

Laryngeal cancer: diagnosis and preoperative work-up.

Laryngeal carcinoma is the eleventh-most common form of cancer among men worldwide and is the second-most common malignancy of the head and neck. The primary functions of the larynx involve phonation, respiration, and deglutition but it also contributes to taste and smell by allowing the movement of air over the special sense organs. Thus, loss of laryngeal function affects speech and swallowing and some of the senses that allow us to enjoy the world. Moreover, total laryngectomy bypasses the critical humidification function of the upper aerodigestive tract that renders pulmonary toiletry problematic for these patients. With relatively little change in mortality since the 1970s, recent research has focused not only on improving survival but on laryngeal preservation modalities.

Treatment considerations in facial paralysis.

Facial nerve paralysis and its sequelae are devastating to patients. For the reconstructive surgeon, the management of the patient with facial paralysis is challenging. There is a lack of consensus regarding the initial management. Then, there is the dizzying array of treatment options for each patient, including nonoperative observation, nerve transfers, static slings, dynamic muscle transfers, and chemodenervation. The appropriate timing of any intervention is often not clear. In this article, we will briefly outline some important considerations for the facial plastic surgeon in the management of facial paralysis. This includes the relevant anatomy and the initial evaluation. An overview of treatment options, with suggestions for the appropriate use of each option, is then provided.

The artificial tympanic membrane (1840-1910): from brilliant innovation to quack device.

OBJECTIVE: To present the rich and checkered history of the artificial eardrum, a widely used device in the 19th century, and to illustrate the behavior of otologists in response to the introduction of a promising new technology. DATA SOURCES: Over 40 published books and articles spanning the years 1821 to 1909 in English, German, and French. DEVICE DESCRIPTIONS: A wide variety of devices were used to improve hearing and, purportedly, to reduce aural discharge. The most popular devices were made of gutta percha attached to a silver wire stem (Toynbee) and cotton balls with extraction cords (Yearsley). Other membranes included India rubber, lint, tin or silver foil, and even the vitelline membrane of an egg. Adhesion to the drum remnant was with saliva, water, petroleum jelly (Vaseline), or glycerin. Some were applied by the physician, whereas others were inserted daily by the patient, much as contact lenses are today. CONCLUSIONS: In several cases, the method of positioning an object over the drum remnant was actually invented by clever patients and then later adopted by practitioners. Once introduced, great optimism was generated about the "miraculous" value of this deafness cure. Petty jealousy among early inventors led to very public (and unprofessional) quarrels over the primacy of invention and bickering about whose device was superior. Over the subsequent decades, as more experience demonstrated the device's limited value, enthusiasm waned until otologists largely abandoned these devices around the turn of the last century. In the first two decades of the 20th century, artificial eardrums reached their peak of fame among the public when they were enthusiastically (and dishonestly) marketed by numerous quacks through newspaper advertisements as a universal cure for all forms of deafness. Only with the coming of the Food and Drug Administration did advertisements for US dollars 5 mail-order, medicated eardrums disappear from popular newspapers and magazines.