Modification of Chin Projection and Aesthetics With OnabotulinumtoxinA Injection.

IMPORTANCE: Because of the soft-tissue envelope and the dimensional complexity of the muscular contraction of the mentalis muscle, the projection and shape of the chin is not determined by only the bony projection. In a subset of patients with a seemingly underprojected chin, a hyperactive, high-riding mentalis muscle contributes to a blunted chin contour. OBJECTIVE: To evaluate the use of onabotulinumtoxinA (botulinum toxin A) for improving chin aesthetics in patients with an underprojected bony chin and a high-riding hyperactive mentalis muscle. DESIGN, SETTING, AND PARTICIPANTS: This case series and photographic analysis included 11 patients presenting with an underprojected bony chin and a high-riding hyperactive mentalis muscle at a private facial plastic surgery practice from August 25, 2006, to November 10, 2012. Data were analyzed from November 13, 2012, to April 9, 2013. INTERVENTIONS: Injection with 12 to 15 U of onabotulinumtoxinA into the mentalis muscle. MAIN OUTCOMES AND MEASURES: Photographic analysis of the vertical and horizontal positions of the pogonion relative to fixed facial points before and after injection. A patient satisfaction scale was also used to assess improvement in overall chin aesthetic. RESULTS: Eleven patients (3 men and 8 women; mean [SD] age, 46.3 [16.4] years) participated in the study, including 2 who had undergone prior chin implantation. The vertical position of the pogonion was more inferior after injection in 10 of 11 patients (mean [SD] vertical position, 1.36 [0.18] preinjection and 1.44 [0.18] postinjection; P = .005). Although the horizontal position of the pogonion changed in all patients, this change was not statistically significant (mean [SD] horizontal position, 0.11 [0.13] preinjection and 0.14 [0.13] postinjection; P = .32). All patients experienced improvement in their overall chin aesthetic and a subjective decrease in chin tension. Chin contour was improved, with soft-tissue volume overall displaced more inferiorly with a rounded rather than blunted appearance. No adverse effects were reported after injection. CONCLUSIONS AND RELEVANCE: OnabotulinumtoxinA is effective at improving chin aesthetics by altering the position of the pogonion. In this first photographic analysis to date of the influence of onabotulinumtoxinA treatment, patients demonstrated a measurable change in the position of the pogonion, in addition to improvements to the chin contour on profile. This nonsurgical mentoplasty may be used as an independent procedure or as an adjunct to optimize traditional chin augmentation in carefully selected patients. LEVEL OF EVIDENCE: 4.

Endoscopic cerebrospinal fluid leak closure in an infected field.

BACKGROUND: Sinonasal cerebrospinal fluid (CSF) leaks during an active infection present the unique challenge of preventing spread of infection without compromising the integrity of the closure. We describe the technique and clinical course of patients undergoing endoscopic CSF leak repair in an actively infected field. OBJECTIVE: To evaluate the safety and efficacy of endoscopic CSF leak repair in an actively infected field. METHODS: Retrospective chart review of patients with sinonasal CSF leaks that were endoscopically repaired during an acute infection. RESULTS: Nine patients were identified. Etiologies of CSF leak were iatrogenic after endoscopic sinus surgery (n = 5, 55.6%) or revision craniopharyngioma resection (n = 1, 11.1%), spontaneous (n = 1, 11.1%), anterior skull base meningocele with CSF leak (n = 1, 11.1%), and posttraumatic (n = 1, 11.1%). The locations of the leaks were ethmoid in five patients, frontoethmoid in three patients, and sphenoid in three patients. Seven patients had acute sinusitis (77.8%) and two patients had meningitis (22.2%) at the time of closure. Two patients (22.2%) had failure of previous CSF leak closure. All leaks were repaired in a multilayered fashion with multiple graft types, including septal or conchal cartilage, temporalis fascia, fascia lata, fat, Medpor, and tissue sealant. Three patients additionally had mucosal flaps or grafts. The patients were treated with an average of 11.1 days (range, 6-14 days) of antibiotics. The average hospital stay was 4.1 days (range, 2-7 days), and the mean follow-up time was 8.7 months (range, 2.9-19.3 months). No patients experienced recurrence of CSF leak or postoperative complication or infection. CONCLUSION: Endoscopic closure of skull base defects was successfully performed in nine patients during acute infections without complications, recurrent infection, or need for revision CSF leak closure. Endoscopic CSF leak repair appears to be safe and effective in patients with active infection with sinusitis or meningitis.

Familial congenital bilateral vocal fold paralysis: a novel gene translocation.

OBJECTIVES: True vocal fold (TVF) paralysis is a common cause of neonatal stridor and airway obstruction, though bilateral TVF paralysis is seen less frequently. Rare cases of familial congenital TVF paralysis have been described with implied genetic origin, but few genetic abnormalities have been discovered to date. The purpose of this study is to describe a novel chromosomal translocation responsible for congenital bilateral TVF immobility. METHODS: The charts of three patients were retrospectively reviewed: a 35 year-old woman and her two children. The mother had bilateral TVF paralysis at birth requiring tracheotomy. Her oldest child had a similar presentation at birth and also required tracheotomy, while the younger child had laryngomalacia without TVF paralysis. Standard karyotype analysis was done using samples from all three patients and the parents of the mother, to assess whether a chromosomal abnormality was responsible. RESULTS: Karyotype analysis revealed the same balanced translocation between chromosomes 5 and 14, t(5;14) (p15.3, q11.2) in the mother and her two daughters. No other genetic abnormalities were identified. Neither maternal grandparent had the translocation, which appeared to be a spontaneous mutation in the mother with autosomal dominant inheritance and variable penetrance. CONCLUSIONS: A novel chromosomal translocation was identified that appears to be responsible for familial congenital bilateral TVF paralysis. While there are other reports of genetic abnormalities responsible for this condition, we believe this is the first describing this particular translocation.

Estimation of skin removal in aging Asian blepharoplasty.

OBJECTIVES/HYPOTHESIS: To describe a novel method for estimating the amount of skin to resect in upper blepharoplasty in the aging Asian eyelid and to report our experience with this technique. STUDY DESIGN: Retrospective review of patients in a single private practice. METHODS: Resection of skin in upper blepharoplasty in an Asian eyelid can often be less forgiving than in other ethnicities due to the unique anatomy of the supratarsal fold. Excising a maximal amount of excess skin will result in an unfavorable appearance of the upper eyelid in an Asian patient. We applied a technique of pinching the skin while the patient is awake until the patient is satisfied with the appearance. The skin is then measured and the precise amount resected during blepharoplasty. The supratarsal crease is always recreated even in patients who have a preexisting crease. We conducted a retrospective review of 99 consecutive patients who underwent upper blepharoplasty using this technique. All patients were Asian and aged 40 years or older. RESULTS: The study group included 99 patients with a mean age of 55.7 years (range, 42-78 years). The mean follow-up time was 24 months (range, 12-30 months). The amount of desired skin overhang superior to the supratarsal crease varied considerably among patients. Complications included asymmetry in nine patients (9.1%), scarring in three patients (3.0%), and unfavorable cosmetic result in two patients (2.0%). No patients experienced infection, bleeding, or visual changes. CONCLUSIONS: In upper blepharoplasty in the aging Asian eyelid, it is necessary to resect less skin than in the Caucasian patient to achieve the desired appearance of the upper eyelid complex. Using a patient-assisted approach to estimate the amount of skin to remove, a favorable cosmetic result with a low incidence of complications was achieved in a consecutive series of patients.

Indications, technique, safety, and accuracy of office-based nasal endoscopy with biopsy for sinonasal neoplasm.

BACKGROUND: Office-based nasal endoscopy with biopsy may provide histopathological diagnosis in patients with sinonasal neoplasms while avoiding operative biopsy. The objective of this study was to describe the technique, safety, and accuracy of office-based nasal endoscopy with biopsy for a primary indication of sinonasal neoplasm. METHODS: A retrospective review of the indications, complications, and results of office-based nasal endoscopy with biopsy for primary indication of neoplasm was performed. When available, comparison was made between the histopathological findings at biopsy vs surgery. RESULTS: A total of 61 patients underwent 69 office-based endoscopic sinonasal biopsies during the 3-year study period. The results of the biopsies in this cohort included inflammatory changes in 36 procedures (52%), benign neoplasm in 14 procedures (20%), malignant lesion in 12 procedures (17%), nondiagnostic tissue in 5 specimens (7%), and granulomatous/vasculitic lesion in 2 procedures (3%). Comparison of office biopsy vs surgery in 28 procedures (25 patients) revealed agreement in 23 procedures (82%), 2 false-negative results for malignancy, 1 false-negative result for hemangioma, and 1 false-negative result and 1 false-positive result each for inverted papilloma. Accuracy analysis for a diagnosis of neoplasm yielded a sensitivity of 71%, specificity of 93%, false-positive rate of 9%, and false-negative rate of 24%. No major complications were experienced. CONCLUSION: Office-based nasal endoscopy with biopsy represents a safe and important diagnostic tool in the evaluation of sinonasal neoplasms. The procedure is generally safe and provides diagnostic information that may alter treatment decisions. Limitations of the procedure do exist, notably issues related to accuracy.

Mentorship in otolaryngology residency: the resident perspective.

OBJECTIVES/HYPOTHESIS: To assess the current state of mentorship in otolaryngology residency. STUDY DESIGN: Internet-based anonymous survey of chief residents in otolaryngology residency. METHODS: Nonidentifying demographic information, career plans, and general questions about residency experience were queried. Participants were asked to rate their mentorship experience in general and specifically with regard to research, personal quality of life, and career preparation. Responses were scored using a five-point ordinal Likert scale, with higher scores representing more favorable responses. RESULTS: The survey was completed by 47 (17.2%) respondents. Eighteen respondents (38%) were assigned an official faculty mentor, and 23 respondents (49%) were assigned a research mentor during their residency. Thirty-nine respondents (83%) reported receiving meaningful mentorship from faculty who were not officially assigned mentors. Overall, 18 respondents (38%) were neutral or not satisfied with the mentorship they received during residency. Statistically significant higher scores were noted for mentorship in career preparation (median, 4) versus mentorship in research (median, 4; P < .001) and resident quality of life (median, 3; P < .001). Lower scores were noted for availability of mentorship in preparation for a career in private practice versus academic medicine (median, 4 vs. 5; P < .001). Residents who were officially assigned mentors reported statistically significant higher scores with regard to satisfaction with the overall mentorship experience (median, 4 vs. 3; P = .05) and different aspects of mentorship in career preparation and research training. CONCLUSIONS: The current study reveals variability in the mentorship experience in otolaryngology residency. Potential deficiencies may exist, including absence of formal mentorship in some residency programs. Increased attention to mentorship, especially with regard to research, career preparation, and quality of life may improve the overall residency experience.

Indications, techniques, and complications of major salivary gland extirpation.

This article reviews major salivary gland anatomy and the differential diagnosis of salivary gland disease. The surgical technique for parotid and submandibular gland excision is described in detail. Possible complications and their management are also discussed, followed by a brief literature review of new surgical techniques.

Synechia formation after endoscopic sinus surgery and middle turbinate medialization with and without FloSeal.

BACKGROUND: The aim of this study was to determine the incidence, outcomes, and risk factors for synechia formation after endoscopic sinus surgery (ESS) and middle turbinate medialization with and without FloSeal. METHODS: A retrospective review was performed of patients who underwent primary ESS with middle turbinate medialization, with or without the placement of FloSeal. Medialization was performed with the placement of an absorbable conchopexy suture and silastic splint. Operative variables and outcomes were analyzed to identify risk factors for synechia formation. RESULTS: One hundred thirty-five patients underwent medialization alone and 37 patients underwent medialization with placement of FloSeal. Overall, synechia formation was noted in 16 patients (9.3%). A statistically significant higher incidence of synechia formation was noted in patients who underwent middle turbinate medialization with the placement of FloSeal versus medialization alone (18.9% versus 6.7%). The incidences of intraoperative complications (6.2% versus 4.7%) and postoperative complications (6.2% versus 7%) were similar between patients with and without synechia, respectively. Patients experiencing synechia, however, underwent a statistically significant higher rate of revision procedures (25% versus 5.1%). CONCLUSION: Despite adequate prevention with middle turbinate medialization, synechia formation after ESS may result in higher rates of revision procedures. The placement of FloSeal in conjunction with middle turbinate medialization may result in a higher incidence of synechia formation.

Recurrent laryngeal cancer presenting as delayed hypoparathyroidism.

BACKGROUND: Endocrine dysfunction following therapy for head and neck cancer has been previously described. Permanent hypoparathyroidism may result from the tumor, surgery, or radiation therapy. However, the incidence and significance of delayed hypoparathyroidism following treatment for laryngeal cancer remains unclear. METHODS AND RESULTS: We report a patient who had stable serum calcium measurements on serial testing following concurrent chemoradiation and salvage laryngectomy for locally advanced laryngeal cancer. The patient subsequently presented 32 months following salvage laryngectomy with new onset, symptomatic hypocalcemia secondary to hypoparathyroidism. Subsequent evaluation revealed local recurrence. CONCLUSION: To our knowledge, this case represents the first report of delayed hypoparathyroidism as the presenting manifestation of recurrence following treatment for laryngeal cancer. Possible pathophysiologic mechanisms are discussed.

Quality of life and complications following image-guided endoscopic sinus surgery.

OBJECTIVES: To compare the quality of life (QOL) outcome and incidence of complications following image-guided versus non-image-guided endoscopic sinus surgery (ESS). STUDY DESIGN: The operative, office, and hospital charts of patients who underwent primary ESS for chronic sinusitis by a single surgeon with (2002-2005) or without (1997-2002) image guidance were reviewed for patient demographics, incidence of complications, and revision procedures. A telephone survey was used to administer the QOL survey to both cohorts. RESULTS: In comparing patients who underwent image-guided (60) versus non-image-guided surgery (179), respectively, there was no statistically significant difference in the incidence of major intraoperative complications (6.6% vs 5.6%), major postoperative complications (5% vs 3.9%), revision procedures (6.6% vs 7.3%), and postoperative SNOT-20 symptom scores (23.6 vs 23.4). A higher incidence of intraoperative cerebrospinal fluid leak was noted in the non-image-guided group (0% vs 2.2%). CONCLUSIONS: Our study does not demonstrate an improvement in the incidence of complications, need for revision procedures, or quality-of-life outcome for patients undergoing primary ESS for chronic sinusitis. The use of image guidance may result in a lower incidence of skull base trauma and cerebrospinal fluid leak. EBM RATING: B-2b.

Coexpression analysis of human genes across many microarray data sets.

We present a large-scale analysis of mRNA coexpression based on 60 large human data sets containing a total of 3924 microarrays. We sought pairs of genes that were reliably coexpressed (based on the correlation of their expression profiles) in multiple data sets, establishing a high-confidence network of 8805 genes connected by 220,649 "coexpression links" that are observed in at least three data sets. Confirmed positive correlations between genes were much more common than confirmed negative correlations. We show that confirmation of coexpression in multiple data sets is correlated with functional relatedness, and show how cluster analysis of the network can reveal functionally coherent groups of genes. Our findings demonstrate how the large body of accumulated microarray data can be exploited to increase the reliability of inferences about gene function.