Oral isotretinoin and photoaging: A review.

INTRODUCTION: Over the past 20 years, evidence has emerged indicating oral isotretinoin could be considered a potential treatment for photoaged skin. In this review, we provide a succinct overview of the available evidence and provide commentary on the current and future directions for utilizing oral isotretinoin as a potential treatment for photoaging. METHODS: We prepared a review protocol and searched the PubMed and Cochrane databases for relevant literature published between January 1982 and April 2020. Using a defined keyword search, a total of 23 papers were initially identified by the main author. Two authors independently reviewed each of the 23 articles, and 6 articles were deemed relevant to this study. RESULTS: Of the six studies included in this review, three were randomized clinical trials, one was a nonrandomized clinical trial and two were prospective cohort studies. All studies were conducted between 2000 and 2015. Across all 6 studies, 251 patients were recruited, with a mean of 42 patients per study. Four studies were in favor of isotretinoin to improve photoaged skin, 1 study showed no benefit, and 1 study showed no benefit when compared to topical tretinoin treatment. Of the studies available, many were hampered by methodological challenges. CONCLUSION: Oral isotretinoin may be useful for treating photoaging but there is currently insufficient evidence to support its use. In comparison with other established anti-photoaging treatments, it is not clear whether the potential benefits of oral isotretinoin outweigh the potential risks.

Rhytidectomy: A Realself Social Media Analysis.

Importance: Social media has become a mainstream method of allowing patients to report and rate their satisfaction with cosmetic procedures and providers. To date, very few studies have published patient-reported satisfaction with the rhytidectomy procedure. Objective: We sought to perform a social media analysis of the rhytidectomy procedure. Design, Setting, and Participants: Data were extracted from 1876 consecutive rhytidectomy online reviews completed by individuals on "facelift" from the RealSelf website, from April 2017 to June 2019. Patients who did not undergo the procedure were excluded. Main Outcomes and Measures: Reasons for pursuing surgery, choosing a surgeon, and liking the surgical outcome were identified. Surgical and demographic variables, cost, and overall "Worth It" scores were recorded. Data were analyzed using SPSS Version 25. Valid frequencies and percentages are presented excluding missing data. Results: Of the data that could be extracted from 1876 RealSelf reviews, the majority of reviewers were female (88.3%), aged between 60 and 69 years (40.1%). Predominant reasons reviewers chose their surgeons related to favorable surgeon personality/demeanor (20.0%) and establishing a positive rapport with the surgeon during the consultation who was able to answer the patients' questions. In total, 85.0% (1045) of reviewers felt surgery was "Worth It," whereas 0.7% (8) were undecided and 14.4% (177) felt it was not worth it. The aggregate "Worth It Rating" of rhytidectomy, using RealSelf's methodology (i.e., not including unsure responses) was 96.9. The main reasons those who liked their surgical outcome related to reviewers looking younger and "fresher" (31.1%), natural or "not fake" (18.4%), and developing positive emotional responses including feeling more confident and happier (18.2%). Of those who did not feel the surgery was "Worth It," postoperative scarring, short-lasting results, and ineffective and/or poor results were common reasons why reviewers did not like their outcome. Conclusions and Relevance: The overall satisfaction with rhytidectomy surgery was high within this cohort, which is in keeping with satisfaction rates reported in the literature. Many patients chose their surgeon based on favorable personality traits and emotional connections rather than other factors.

A Novel Laryngoscope With an Adjustable Distal Tip.

OBJECTIVES: Various laryngoscopes are currently available for supraglottic, glottic, and cervical esophageal exposure, yet none allow for adjustable articulation of the laryngoscope distal tip. We sought to create a new laryngoscope to improve anatomic field of view exposure. STUDY DESIGN: Novel laryngoscope device validation study. MATERIALS AND METHODS: Three-dimensional printed plastic and titanium prototype designs were created using Solidworks. Validation testing was performed in a cadaveric model. Optimal exposure of the cadaveric larynx and supraglottis was determined by ensuring the endoscope tip was exactly 2.5 cm from the level of the vocal cords. The prototype exposure (22-cm adjustable tip laryngoscope) was compared to the Weerda (18-cm distending laryngoscope) and Dedo (18-cm operating laryngoscope) laryngoscope exposures. Anteroposterior (AP) and lateral (L) exposure measurements were obtained from analysis of endoscopic images. Objective millimeter quantification was performed by pixel calibration to the known width of the vocal cord. RESULTS: The prototype provided 77.3-mm AP and 40.6-mm L exposure of the cadaveric larynx and supraglottis. These measurements were then compared to the exposure provided by the Weerda (49.9-mm AP, 40.4-mm L) and Dedo (15.7-mm AP, 18.6-mm L) laryngoscopes. The investigators found the prototype had similar handling characteristics to the Weerda laryngoscope and laryngeal instrumentation was enhanced due to a wider field of view. CONCLUSION: This novel laryngoscope with an adjustable distal tip provides improved exposure of the supraglottis and glottis in a cadaveric study and has the potential to be used for both supraglottic/glottic and proximal esophageal procedures. LEVEL OF EVIDENCE: 5 Laryngoscope, 2020.

Clinician adherence to the clinical practice guideline: Acute otitis externa.

OBJECTIVES/HYPOTHESIS: Over 10 years have passed since the Clinical Practice Guideline: Acute Otitis Externa (CPG-AOE) was first published, and it has been several years since its update. We sought to assess clinicians' adherence as well as referral patterns. STUDY DESIGN: Survey. METHODS: A 23-question survey was distributed to regional primary care clinicians evaluating demographic data, perception of the clinical practice guideline (CPG), adherence, and details of specialist referral. Statistical analysis was performed to compare adherence and referral patterns using the Fisher exact test or the χ2 test. RESULTS: One hundred seventeen clinicians completed the survey. Fifteen respondents (12.8%) had reviewed the CPG. The recommendations with the least reported adherence were pain management (39.1%) and accounting for prior radiotherapy as a modifying factor (43.0%). The recommendations of prescribing ototopical therapy and avoiding systemic antimicrobials in uncomplicated acute otitis externa had adherence of 94.0% and 83.8%, respectively. When analyzed by provider type (e.g., resident, nurse practitioner/physician assistant), there were no significant differences in adherence. No significant differences in adherence were observed based on previous review of the CPG. When reporting frequency of specialist referral, the majority of respondents selected rarely (53.9%). The most favored reason for referral was symptoms >4 weeks (86.3%). CONCLUSIONS: Of the providers who responded, very few had reviewed the CPG-AOE. Despite the added emphasis on pain management in the CPG update, this recommendation had the lowest adherence. Rates of adherence were similar across provider types and did not differ significantly if the CPG was reviewed. Efforts at improved provider education should be considered to increase adherence to the CPG. LEVEL OF EVIDENCE: NA Laryngoscope, 130:1565-1571, 2020.

The Role of Postoperative Imaging after Orbital Floor Fracture Repair.

Obtaining postoperative images of maxillofacial fractures does not affect the clinical management of asymptomatic patients; however, few studies have evaluated the role of postoperative imaging in the context of orbital floor fractures. In this study, we evaluate current practice techniques and the role of postoperative imaging in the management of orbital floor fractures in isolation and with concomitant facial fractures. Retrospective review of patients who underwent open reduction and internal fixation of orbital floor fractures between 2005 and 2015 at a single medical institution. Operative and perioperative records were reviewed to characterize postoperative imaging as routine or as indicated by concerning clinical symptoms, and to correlate clinical outcomes to postoperative imaging patterns across all identified orbital floor fractures. A total of 139 patients underwent open reduction and internal fixation of orbital floor fractures. Of these, 75 (54%) had zygomaticomaxillary (ZMC) involvement. The remaining 64 (46%) were isolated orbital floor fractures. Overall, 54 (39%) patients underwent postoperative imaging. Of these, 38 (70%) had postoperative imaging in the absence of concerning clinical symptoms. There was no observed difference in complication rates in those who underwent postoperative imaging, and those who did not. Patients with orbital + ZMC fractures underwent a significantly higher number of postoperative imaging studies ( p < 0.001); however, there was no observed difference in complications between isolated orbital and orbital + ZMC fractures. Routine postoperative imaging is not warranted in the absence of persistent clinical symptoms following open reduction and internal fixation of orbital floor fractures.

Otolaryngologist adherence to the AAO-HNSF Allergic Rhinitis Clinical Practice Guideline.

BACKGROUND: In February 2015, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNSF) published the Allergic Rhinitis Clinical Practice Guideline (AR-CPG). The objective of this study was to assess otolaryngologists' perception of the accuracy and adherence to the AR-CPG. METHODS: A survey was distributed to fellows of the American Academy of Otolaryngic Allergy and members of the American Academy of Otolaryngology-Head and Neck Surgery Foundation. A total of 601 otolaryngologists responded. The survey evaluated otolaryngologists' demographic data, perception of the accuracy of the guideline, and adherence to the guideline action statements. RESULTS: The majority of respondents were actively practicing (544 [90.5%]), for a duration of 11-30 years (308 [51.2%]), in a private practice setting (387 [64.4%]). The cohort was largely fellowship trained (348 [57.9%]) and had reviewed the guideline (428 [71.2%]). Most respondents perceived the guideline as being correct "a great deal" (295 [69.7%]) and deviated from the guideline "only a little" (302 [71.6%]). High rates of adherence to the strong guideline recommendations were observed. Respondents "always/most of the time" recommended intranasal steroids (581 [97.6%]), and oral antihistamines (439 [74%]) as primary therapy. Otolaryngologists in practice for longer were more likely to deviate from the guideline recommendations by obtaining sinonasal imaging (p = 0.007) and recommending oral leukotriene receptor antagonists as primary therapy (p = 0.0001). CONCLUSION: Overall perception of the correctness of and adherence to the AR-CPG was high in this cohort. Targeted education resources should be provided to otolaryngologists in practice for longer in efforts to reduce harmful or unnecessary variations in care.

Long-term outcome of a patient with paradoxical hypertrichosis after laser epilation.

One underreported, rare side effect of laser hair removal is paradoxical hypertrichosis. It is largely unknown what the long-term outcomes are of patients who develop this complication. We report a 21-year-old, Fitzpatrick II, male patient, who had patchy areas of dark hair affecting various body areas. An Alexandrite 755 nm laser was used to address the desired areas at energies between 20 and 22 J/cm2 at 10-12-week intervals over a course of seven treatments. After three treatments, the patient noted a significant increase in the density and length of hairs involving the back, shoulders, neck, and upper arms. The patient was followed on a biannual basis, without further epilatory intervention. After 10 years, the areas of paradoxical hair growth were sparser compared to immediate post-treatment but remained denser compared to pre-treatment. This case illustrates improvement in the condition over time without intervention. Further studies are needed to determine the etiopathogenesis of this phenomenon.

Correlation between sinus and lung cultures in lung transplant patients with cystic fibrosis.

BACKGROUND: Lung transplantation has revolutionized the treatment of end-stage pulmonary disease due to cystic fibrosis. However, infection of the transplanted lungs can lead to serious complications, including graft failure and death. Although many of these patients have concurrent sinusitis, it is unclear whether bacteria from the sinuses can infect the allograft. METHODS: This is a single-institution retrospective study of all patients who underwent lung transplantation for cystic fibrosis from 2005 to 2015 at Duke University Hospital. Pre- and posttransplant nasal and pulmonary cultures obtained via nasal endoscopy and bronchoalveolar lavage (BAL), respectively, were analyzed. RESULTS: A total of 141 patients underwent 144 lung transplants. Sinus cultures were available for 76 patients (12 pretransplant, 42 posttransplant, 22 both pre- and posttransplant). Pretransplant BAL cultures were available for 139 patients, and posttransplant BAL cultures were available for all patients. Pseudomonas aeruginosa (PsA) and methicillin-resistant Staphylococcus aureus (MRSA) were the most common organisms cultured. There was a significant correlation between pretransplant sinus and posttransplant BAL cultures for PsA (p = 0.003), MRSA (p = 0.013), and Burkholderia cepacia (p = 0.001). CONCLUSION: There was a high correlation between pretransplant sinus cultures and posttransplant BAL cultures for PsA, MRSA, and Burkholderia sp. This suggests that the paranasal sinuses may act as a reservoir for allograft colonization in patients with cystic fibrosis. Further studies are needed to determine whether treatment of sinusitis affects allograft colonization and transplant outcomes.

Hearing and Mortality Outcomes following Temporal Bone Fractures.

The aim of this article is to determine hearing and mortality outcomes following temporal bone fractures. Retrospective chart review was performed of 152 patients diagnosed with a temporal bone fracture presenting to the emergency room at a tertiary care referral center over a 10-year period. Utilizing Patients' previously obtained temporal bone computed tomographic scans and audiograms, fractures were classified based on several classification schemes. Correlations between fracture patterns, mortality, and hearing outcomes were analyzed using χ2 tests. Ossicular chain disruption was seen in 11.8% of patients, and otic capsule violation was seen in 5.9%; 22.7% of patients presented for audiologic follow-up. Seventeen patients with conductive hearing loss had air-bone gaps of 26 ± 7.5 dB (500 Hz), 27 ± 6.8 dB (1,000 Hz), 18 ± 6.2 dB (2,000 Hz), and 32 ± 7.7 dB (4,000 Hz). Two cases of profound sensorineural hearing loss were associated with otic capsule violation. No fracture classification scheme was predictive of hearing loss, although longitudinal fractures were statistically associated with ossicular chain disruption ( p < 0.01). Temporal bone fractures in patients older than 60 years carried a relative risk of death of 3.15 compared with those younger than 60 years. The average magnitude of conductive hearing loss resulting from temporal bone fracture ranged from 18 to 32 dB in this cohort. Classification of fracture type was not predictive of hearing loss, despite the statistical association between ossicular chain disruption and longitudinal fractures. This finding may be due to the low follow-up rates of this patient population. Physicians should make a concerted effort to ensure that audiological monitoring is executed to prevent and manage long-term hearing impairment.

Radiodensity of the Ostiomeatal Complex in Recurrent Acute Rhinosinusitis.

Objective Recurrent acute rhinosinusitis (RARS) can be an elusive diagnosis due to the lack of clinical and radiographic findings in between acute episodes. This study aims to identify objective computed tomography (CT) characteristics in RARS. Study Design Case series with chart review. Setting Tertiary academic medical center. Subjects and Methods Patients meeting diagnostic criteria for RARS were identified retrospectively from the senior author's practice. Patients were diagnosed with RARS if they experienced 3 or more episodes of acute sinusitis within the past year with complete resolution of symptoms in between episodes. At least 1 episode was confirmed via CT or endoscopy. CT scans showing prior surgery were excluded. The scans for these patients were compared with those from a normal control group. Bone radiodensity of the entire ostiomeatal complex (OMC), including the ethmoid bulla, middle turbinate, and uncinate, was measured in Hounsfield units. Maximum radiodensity was noted for each side. Results A total of 16 patients meeting inclusion criteria for RARS were compared with 16 healthy patients. The mean Lund-MacKay score was 1.6 in the RARS group and 1.3 in the control group. The maximum radiodensity of the OMC was significantly higher in the RARS group (556) compared with that of the control group (327) ( P < .0001). Conclusion Patients with RARS had significantly greater radiodensity of the OMC compared with those in the control group despite minimal differences in mucosal disease. Radiodensity measurement of the OMC using Hounsfield units may help to identify patients with this elusive diagnosis.

Free dermal fat graft reconstruction of the head and neck: An alternate reconstructive option.

OBJECTIVES: Ablative procedures of the head and neck often result in significant facial and cervical irregularities and cosmetic asymmetry. The deformity resulting from ablative procedures of the head and neck is a significant source of cosmetic morbidity and postoperative dissatisfaction. Reconstruction of post-ablative defects in the head and neck can employ a broad range of techniques, ranging from primary closure to free tissue transfer. The free dermal fat graft (FDFG) is one such option and has been used to repair volume defects of varying sizes after common head and neck procedures such as parotidectomy. However, its use is largely undocumented in the literature. We seek to further illustrate the FDFG as an alternate method of reconstruction of head and neck defects. STUDY DESIGN: Non-randomized retrospective analysis. METHODS: The medical records of all patients who underwent primary autologous abdominal FDFG reconstruction of head and neck defects by a single surgeon at Vanderbilt University Medical Center from January 1997 to August 2010 were reviewed. All patients were called in order to assess their post-operative cosmetic satisfaction. RESULTS: Sixty-two patients were analyzed. Only three patients were found to have post-operative complications directly related to the FDFG. No complications were found at the donor site. Based on a telephone survey, the majority of patients were satisfied post-operatively with their cosmetic outcomes in the primary site and donor site. CONCLUSIONS: From our experience the FDFG is a cosmetically and functionally advantageous option for reconstruction of ablative procedures of the head and neck.

Sinusitis in patients on tumor necrosis factor alpha inhibitors.

BACKGROUND: Tumor necrosis factor alpha (TNF-α) inhibitors have revolutionized treatment of many inflammatory diseases. Sinusitis after initiation of TNF-α inhibitors has been observed, but has not been well described in the literature. We aim to characterize the clinical features of sinusitis in patients on anti-TNF-α therapy. METHODS: This is a retrospective chart review of 28 patients on a TNF-α inhibitor diagnosed with sinusitis by otolaryngologists at Duke University. Patient demographics, sinusitis characteristics, and treatment course were studied by chart review. RESULTS: The prevalence of sinusitis diagnosed and treated by an otolaryngologist was less than 1%. Of the 28 patients studied, 12 (42.9%) had a history of preexisting sinusitis and 16 (57.1%) had new-onset sinusitis. 71.4% were diagnosed with chronic rhinosinusitis without polyps (CRSsNP), with disease mainly involving the maxillary and ethmoid sinuses. No patients had major extrasinus complications or required hospital admission or intravenous (IV) antibiotics. 35.7% (n = 10), including 44% (7/16) of new-onset patients required a surgical intervention after initiating anti-TNF therapy. 14.3% (n = 4) of the cohort had improvement in sinonasal symptoms after stopping, changing, or holding doses of the TNF-α inhibitor. CONCLUSION: Anti-TNF-α therapy can be associated with new-onset sinusitis, mainly CRSsNP. Overall, the percentage of patients on a TNF-α inhibitor seeking consultation from an otolaryngologist is low. While some patients with new-onset sinusitis will require surgery, modification of anti-TNF-α therapy should be considered as an option in the medical management of these patients.

Radiographic characterization of the retroantral ethmoid cell.

BACKGROUND: The retroantral ethmoid cell (RAEC) is defined as a posterior ethmoid cell that pneumatizes inferolaterally behind the posterior wall of the maxillary sinus. The RAEC can present a challenge to otolaryngologists during endoscopic ethmoidectomy due to its concealed location. It is also encountered during the endoscopic transpterygoid approach to the skull base, which requires dissection behind the posterior wall of the maxillary sinus. Because the RAEC is not described in the literature, this study aims to better characterize this anatomic variant. METHODS: This is a retrospective review of 58 consecutive patients who underwent revision functional endoscopic sinus surgery (FESS) within a 2-year period at a tertiary referral center. Sinus computed tomography (CT) scans for this cohort (116 sides total) were reviewed independently by 3 authors to determine the incidence of the RAEC and the degree of surgical dissection during prior surgery. RESULTS: Of the 116 sides included in the study, RAEC was identified in 19 (16%). Furthermore, 14 of 19 (74%) cells were diseased with evidence mucosal thickening or neo-osteogenesis. Of the 12 sides with RAEC that had evidence of previous posterior ethmoidectomy, 4 (33%) cells were not opened, 6 (50%) were partially opened, and only 2 (17%) were completely opened. CONCLUSION: This study demonstrates the relatively high prevalence of the RAEC in our patient population. The majority of RAECs showed both evidence of disease and that they were not completely opened during previous surgery. Recognition of this anatomic entity may allow for more thorough ethmoidectomy.

Stroke after adenotonsillectomy in patients with undiagnosed moyamoya syndrome.

IMPORTANCE: Moyamoya syndrome is a rare, occlusive cerebrovascular arteriopathy with significant risk for stroke. Populations that frequently undergo otolaryngologic procedures, including patients with Down syndrome and sickle cell disease, are particularly at risk for moyamoya. The initial presentation of moyamoya syndrome as stroke in the perioperative period of an otolaryngologic procedure has not been reported. OBSERVATIONS: A retrospective medical record review assessed the relationship of otolaryngologic operations and the onset of moyamoya symptoms. Moyamoya syndrome was present in 137 patients. Of these, 19 patients underwent otolaryngologic procedures; 3 children had strokes 2 to 4 days after adenotonsillectomy, including 2 children with Down syndrome. Intraoperative carotid artery injury was considered but was proven not to be the cause of stroke. Bilateral moyamoya disease was diagnosed in all 3 patients via vascular imaging studies; all subsequently underwent revascularization procedures. CONCLUSIONS AND RELEVANCE: Clinicians should be aware of an elevated prevalence of moyamoya syndrome in Down syndrome and sickle cell disease populations and should consider moyamoya syndrome in the differential diagnosis of postoperative stroke. Stroke risk is magnified in the perioperative setting related to perioperative dehydration and hypotension. Awareness and screening for cerebral vasculopathy in high-risk populations could prompt measures to decrease the occurrence of postoperative strokes after adenotonsillectomies.

Mandibular reconstruction using computer-aided design and computer-aided manufacturing: an analysis of surgical results.

PURPOSE: The purpose of this study was to analyze the accuracy of virtual surgical planning in mandibular reconstruction. MATERIALS AND METHODS: This is a retrospective study involving 8 consecutive patients reconstructed with nonvascularized iliac crest bone grafts and free fibula osteomyocutaneous flaps. DICOM data from a maxillofacial skeleton computed tomography (CT) scan were sent to a medical modeling company and used to map the mandibular resection, anatomically place the mandibular reconstruction plate, and create surgical guides. After surgery a postoperative CT compared the virtual plan to the surgical result. Linear measurements [2 transverse and 1 anterior-posterior (A-P)] were performed to determine if the virtual surgical result was achieved. The transverse measurements were made from the condylar head to condylar head and from the gonial angle to gonial angle. The A-P analysis was made by measuring a perpendicular line drawn from the anterior inferior mandibular border to the center point on the condylar head to condylar head measurement. RESULTS: The average surgical error in the A-P dimension for the iliac crest bone grafts and free fibula flap was 0.2 mm (range 0.0 mm to 0.7 mm) and 0.9 mm (range 0.2 mm to 1.9 mm), respectively. In the transverse dimension the average surgical error was 1.6 mm (range 0.7 mm to 2.4 mm) and 2.7 mm (range 1.9 mm to 4.5 mm) from condyle to condyle, and 1.7 mm (range 0.7 mm to 2.7 mm) and 2.5 mm (range 0.4 to 4.8 mm) from gonial angle to gonial angle. CONCLUSION: The use of CAD-CAM (Medical Modeling, Golden, Colorado) technology for the fabrication of surgical resection guides and mandibular reconstruction plates resulted in an accurate surgical result.

Adherence and Risk Behaviour in Patients with HIV Infection Receiving Antiretroviral Therapy in Bangkok.

It could be postulated that due to lifestyle factors, patients with poor antiretroviral therapy (ART) adherence may also have risky sexual behaviour potentially leading to HIV transmission. There are limited data regarding unprotected sex risk and ART adherence in resource limited settings and our study set out to investigate these in an HIV clinic in Bangkok. Patients completed an anonymous questionnaire regarding their relationship details, ART adherence, sexual behaviour, alcohol and drug use and HIV transmission beliefs. Laboratory findings and medical history were also collected. Unprotected sex risk (USR) was defined as inconsistent condom use with a partner of negative or unknown HIV status. Five hundred and twelve patients completed the questionnaire. Fifty seven per cent of patients reported having taken ARV >95% of the time in the last month and 58% had been sexually active in the previous 30 days. Only 27 patients (5%) were classified as having USR in our cohort. Multivariate analysis showed USR was associated with female gender (OR 2.9, 95% CI 1.2-7.0, p0.02) but not with adherence, age, type or number of partners, recreational drug or alcohol use nor beliefs about HIV transmission whilst taking ART. Levels of USR in this resource limited setting were reassuringly low and not associated with poor ART adherence; as all USR patients had undetectable viral loads onward HIV transmission risk is likely to be low but not negligible. Nonetheless condom negotiation techniques, particularly in women, may be useful in this group.