Nasal Analysis of Classic Animated Movie Villains versus Hero Counterparts.

Opposing facial features between animated villains and heroes have historically been used to demonstrate contrasting morality between characters, and this could have an impact on how humans view someone as good or evil in everyday life. Studies have been done investigating classic dermatologic features of villainous characters. This principle can be applied to nasal features as well. A search for "top animated characters" was performed. Characters were chosen from American Film Institute's "The Top Tens," Rolling Stone's "25 Best Pixar Movie Characters," and Screenrant's "The 30 Best Animated Movie Characters of All Time." Twenty villains and twenty hero counterparts from respective films were chosen. Classic nasal features were analyzed. Twenty villains (14 male, 6 female) and 20 heroes (12 male, 8 female) were analyzed. Sixteen villains (80%) had greater than normal nasal frontal angle versus 18 heroes (90%). Thirteen villains (65%) had an acute nasolabial angle versus two heroes (10%). Two villains (10%) had excess columellar show versus seven heroes (35%). Seven villains (35%) and one hero (5%) had a dorsal hump. Twelve villains (60%) had an overprojected chin versus three heroes (15%). Villains in pre-2000s films more frequently had a dorsal hump, overprojected chin, ptotic tip, pollybeak deformity, and bulbous tip. Heroes in pre-2000s films more frequently had an overrotated tip. Villains and heroes commonly have a greater than normal nasofrontal angle. Villains more commonly have an acute nasolabial angle, underrotated tip, overprojected chin, dorsal hump, and pollybeak deformity. Heroes more commonly have a large nasolabial angle and overrotated tip. Further research in conjunction with psychologists is required to obtain concrete data on how this affects whether an individual in real life is seen as good or evil, and the impact this has on interactions in society, including in the medical field.

Orbital Paraganglioma: A Systematic Review.

Purpose The purpose of this study was to perform a systematic review of the literature on orbital paragangliomas, evaluating clinical presentation, diagnosis, management patterns, and prognosis. Methods The systematic review was conducted based on the principles described in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. PubMed, Cochrane databases, Embase, and Web of Science were searched for articles related to orbital paragangliomas. Inclusion criteria included English language articles with original reports on human subjects. Data on clinical presentation, diagnosis, treatment, and prognosis were collected. Results Twenty-seven articles met inclusion criteria (28 total patients). The mean patient age was 37.1 years (range, 3-75 years); 13 (46.4%) patients were male. The most common presenting symptoms were proptosis (89.2%), visual acuity changes (67.9%), and extraocular muscle restriction (64.2%). Lesions were most commonly intraconal (92.9%). Single modality therapy was employed in 19 patients (67.9%), including excision in 12 patients (42.9%) and exenteration in 5 patients (17.9%). Ten patients (35.7%) developed recurrence, and there was a 92.9% survival rate (mean follow-up, 29 months). Conclusion Orbital paragangliomas are rare tumors with an excellent prognosis. These lesions commonly present with proptosis, and are primarily managed surgically with simple excision, although exenteration and adjuvant radiation may be necessary for invasive tumors. This series is the largest and most comprehensive systematic review of orbital paragangliomas conducted to date.

Adverse Events in Facial Implant Surgery and Associated Malpractice Litigation.

IMPORTANCE: Facial implants represent an important strategy for providing instant and long-lasting volume enhancement to address both aging and posttraumatic defects. OBJECTIVE: To better understand risks of facial implants by examining national resources encompassing adverse events and considerations facilitating associated litigation. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study reviewed complications following facial implants. The procedures reviewed were performed on patients at locations throughout the United States from January 2006 to December 2016. Data collection was completed in March 2017. The Manufacturer and User Facility Device Experience database, which contains medical device reports submitted to the US Food and Drug Administration (FDA), was searched for complications that occurred from January 2006 to December 2016 involving facial implants made by Implantech, MEDPOR, Stryker, KLS Martin, and Synthes. Furthermore, the Thomson Reuters Westlaw legal database was searched for relevant litigation. MAIN OUTCOMES AND MEASURES: The complications of facial implants were analyzed in relation to the location of implant and severity of complication. Litigation was analyzed to determine which factors determine outcome. RESULTS: Thirty-nine instances of adverse events reported to the FDA were identified. Sixteen (41%) involved malar implants, followed by 12 chin implants (31%). The most common complications included infection (18 [46%]), implant migration (9 [23%]), swelling (7 [18%]), and extrusion (4 [10%]). Thirty-two patients (83%) had to have their implants removed. Infection occurred at a mean (SD) of 83.3 (68.8) days following the surgery. One-third of complications involved either migration or extrusion. The mean (range) time to migration or extrusion was 381.1 (10-2400) days. In 12 malpractice cases identified in publicly available court proceedings, alleged inadequate informed consent and requiring additional surgical intervention (ie, removal) were the most commonly cited factors. CONCLUSIONS AND RELEVANCE: Infection and implant migration or extrusion are the most common complications of facial implants. Most of these complications necessitate removal. These considerations need to be discussed with patients preoperatively as part of the informed consent process, as allegedly inadequate informed consent was cited in a significant proportion of resultant litigation, and there were overlapping considerations among adverse events reported to the FDA and factors brought up in relevant litigation. Cases resolved with settlements and jury-awarded damages encompassed considerable award totals. LEVEL OF EVIDENCE: NA.

A Cross-sectional Analysis of Adverse Events and Litigation for Injectable Fillers.

IMPORTANCE: Injectable fillers are increasing in popularity as a noninvasive option to address concerns related to facial aging and volume loss. To our knowledge, there have been no large-scale analyses of adverse events and associated litigation related to filler injections. OBJECTIVES: To determine risks of injectable fillers and analyze factors raised in litigation related to injectable fillers. DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional review, the US Food and Drug Administration's (FDA) manufacturer and user facility device experience (MAUDE) database was evaluated for complications from the use of the following fillers: Juvederm, Restylane, Belotero, Sculptra, Radiesse, Artefill, Bellafill, and Juvederm Voluma from 2014 to 2016. The Westlaw Next database was used to identify jury verdicts. MAIN OUTCOMES AND MEASURES: Complications were organized by type of filler used, location of injection, and severity. Intra-arterial injections without sequelae and those resulting in blindness or necrosis were considered severe complications. Factors raised during the litigation process were also analyzed. RESULTS: Of 1748 adverse events analyzed, most cases stemmed from cheek (751 [43.0%]) or lip (524 [30.0%]) injection. Commonly reported adverse events reported included swelling (755 [43.2%]) and infection (725 [41.5%]). Among FDA-reported complications, blindness was significantly associated with dorsal nasal injections (P < .001). Vascular compromise with and without sequela of dermal necrosis and blindness were significantly associated with Radiesse injections P < .001. Of the 9 malpractice cases identified, two-thirds involved allegations of inadequate informed consent, and the median award in cases resolved with payment was $262 000. CONCLUSIONS AND RELEVANCE: Although specific complication profiles vary by material and injection site, common adverse events associated with injectable fillers include swelling and infection. More serious events include vascular compromise, resulting in necrosis and blindness; these events are also raised in cases involving litigation. This analysis illustrates the importance of outlining these risks in a comprehensive preoperative informed consent process. LEVEL OF EVIDENCE: NA.

Oropharyngeal lymphoma: A US population based analysis.

OBJECTIVES: To describe the epidemiology and analyze factors determinant of survival in patients with oropharyngeal lymphoma, using the Surveillance Epidemiology and End Results (SEER) database. METHODS: 2504 patients with oropharyngeal lymphoma were identified using the most recent SEER database entry from 1976 to 2016. Demographic information, Ann Arbor stage, tumor histopathology and location were collected. Multivariate analysis was used to analyze patient and tumor characteristics associated with survival. RESULTS: The mean age of the patients studied was 60.5years, 58.4% of the subjects were male and 81% were white. Diffuse large B cell lymphoma (DLBCL) was the most common histologic subtype involving 56.9% of cases. The most common subsite of origin was the tonsil, with 71% of lymphomas originating from there. The association of survival with stage, age, tumor location, presence of B symptoms, tumor pathology, gender and race was analyzed using multivariate regression. Decreased survival was significantly associated with patient age p<0.0001, Ann Arbor staging p=0.005, the presence of B symptoms p=0.003 and tumor histopathology (T cell tumors) p=0.01. Patients with tumors originating from the soft palate were significantly more likely to die asa result of their disease p=0.03. CONCLUSION: Oropharyngeal lymphoma most commonly originates from the tonsil. DLBCL is the most common subtype and has a good prognosis. The presence of B symptoms, tumors originating from the soft palate and patients with T cell tumors have the worst prognosis. This information can potentially be of great utility to the head and neck surgeon discussing prognosis with patients suffering from oropharyngeal lymphoma.

Locoregional recurrence following maxillectomy: implications for microvascular reconstruction.

OBJECTIVE: Reconstruction of maxillectomy defects offers potential quality-of-life improvement, although cavity coverage may impact surveillance of recurrent malignancy. We describe the pattern of postmaxillectomy locoregional recurrence. STUDY DESIGN: Retrospective review. METHODS: Patients from 2001 to 2011 at the University of California, San Francisco and the Cleveland Clinic. RESULTS: Among 75 patients with malignancy resulting in partial or total maxillectomy, 57 were treated with obturators and 18 underwent reconstructive surgery. Disease recurrence occurred primarily locally (19 of 22 cases of recurrence, 25% of the cohort) at a mean of 17 months postoperatively. Recurrence was associated with T4 disease, positive margins, and surveillance imaging. Four (5.3%) patients required flap mobilization/obturator removal to obtain biopsy. Salvage surgery was attempted in 13 of the 19 cases with recurrent disease (68%) and was successful in six (46%) patients. Of these, five patients initially had Brown type 1 or type 2 defects. The free flap had to be revised in one (1.3%) patient to achieve successful salvage. CONCLUSION: Maxillectomy provides good long-term locoregional oncologic control, with cure being correlated to disease stage at presentation and negative margins after initial surgery. Patients with recurrent disease whose initial resection resulted in a Brown class 3 defect or greater were rarely successfully salvaged. Surveillance is best performed with a combination of physical exam and imaging. Obturator removal/flap mobilization rarely impedes the diagnosis of recurrent disease, and either modality should be offered to appropriate patients in the primary setting if significant quality-of-life improvement is likely. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2534-2538, 2017.

Tumor Differentiation as a Prognostic Factor for Major Salivary Gland Malignancies.

Objective The effect of tumor differentiation on prognosis of major salivary gland malignancies is controversial. The aim of this study was to determine the effect of tumor differentiation on prognosis by stage in patients with major salivary gland malignancies and to analyze which patient factors are associated with tumor differentiation. Study Design and Setting Cross-sectional analysis of Surveillance, Epidemiology, and End Results (SEER) database. Subjects and Methods In total, 9810 patients who had a major salivary gland malignancy from 2004 to 2012 were identified using the SEER database. Patients with no staging information or no information on histologic differentiation were excluded. A total of 5366 patients were included in the study. For analysis, patients were categorized by American Joint Committee on Cancer (AJCC) stage and subdivided by tumor differentiation. Multivariate analysis was used to analyze the impact of tumor differentiation on survival, tumor location (parotid, submandibular, sublingual), and sex within each AJCC stage of disease. Results Data analysis demonstrated a significant difference in histologic differentiation by stage, with P < .0001. Within stages II, III, and IV, tumor differentiation was significantly associated with a decrease in survival. There was no significant difference in tumor differentiation between the parotid and submandibular gland. Conclusion For patients with stage II, III, and IV disease, tumor differentiation was an independent predictor of survival. This information can be useful when discussing prognosis and can potentially influence management of disease.

Thyroglossal Duct Cyst Carcinoma: A Systematic Review of Clinical Features and Outcomes.

Objective Although thyroglossal duct cysts (TGDCs) are relatively common, malignancies within these lesions are infrequent. As a result, there are no large-scale series describing clinical characteristics. Our objectives were to perform a systematic review of the literature evaluating patient demographics, pathology, management, and prognosis of these patients. Data Sources PubMed, Embase, Cochrane reviews, and Google Scholar were searched for relevant articles. Articles meeting inclusion criteria were reviewed for data detailing epidemiology, treatment, and outcomes. Review Methods Inclusion criteria included English-language articles with original reports on human subjects. Two investigators independently reviewed all articles for the data collected, including epidemiology, treatment, and outcomes. Results Ninety-eight articles comprising 164 patients were included in the final analysis. The mean age at presentation was 39.5 years (9-83 years); 68.3% of patients were female. In total, 73.3% of cases were found on final pathologic analysis. The most common pathology was papillary cancer (92.1%). Of the patients, 98.9% underwent a Sistrunk procedure and 61.0% underwent total thyroidectomy. There was a 4.3% recurrence rate with a mean time to recurrence of 42.1 months from initial treatment. One patient died of TGDC carcinoma, while all other patients were disease free at the time of last follow-up (mean follow-up was 46.1 months). Conclusion TGDC carcinoma is typically diagnosed on final pathology. While management encompasses a Sistrunk procedure, further consideration should be given to thyroidectomy among patients ≥45 years of age and individuals with aggressive disease. TGDC carcinoma harbors an exceedingly low rate of mortality.

A critical analysis of melanoma malpractice litigation: Should we biopsy everything?

OBJECTIVES/HYPOTHESIS: The aim of this study was to evaluate factors raised in malpractice litigation related to the diagnosis and management of melanoma and to further assess issues impacting outcome. STUDY DESIGN: Retrospective chart review. METHODS: The Westlaw legal database was searched for malpractice litigation resolved over the last 20 years relating to melanoma. Cases were evaluated for allegations, defendant specialty, outcome, and other issues raised. RESULTS: Of the 80 cases evaluated, 49% were resolved in the defendants' favor. In greater than 80% of cases, there was alleged misdiagnosis. In 35% of cases, the patient had expired secondary to melanoma at the time of litigation. There was no statistical difference in payments upon comparison of cases with and without mortality. A greater proportion of cases with dermatologists and pathologists as defendants involved alleged misdiagnosis. The most common locations for melanoma were the extremities and the head-and-neck region, at 32.5% and 22.5%, respectively. Location did not significantly impact the outcome of cases. CONCLUSION: Malpractice litigation relating to melanoma involves numerous physicians, including dermatologists, pathologists, and otolaryngologists. Alleged misdiagnosis of a pigmented lesion was the most common cause of litigation and involved physicians from numerous specialties. Patients who were misdiagnosed had a significantly higher likelihood of having active disease at the time of litigation. Ultimately improved methods of detecting concerning pigmented lesions need to be developed. Factors such as death and poor cosmetic outcome did not significantly impact litigation outcome. LEVEL OF EVIDENCE: NA Laryngoscope, 127:134-139, 2017.

Predictive factors and outcomes of cochlear implantation in patients with connexin 26 mutation: a comparative study.

PURPOSE: To compare hearing outcomes in patients with connexin 26 (Cx 26) mutations undergoing cochlear implantation to age matched controls and to examine whether age at implantation, gender and type of mutation were correlated with hearing outcome. MATERIALS AND METHODS: Retrospective chart review of 21 patients with Cx 26 mutations that underwent cochlear implantation compared to 18 age-matched controls. Patients' characteristics, type of mutation and pre- and postoperative short and long-term hearing thresholds, word and sentence scores were analyzed. RESULTS: There was no statistically significant difference between the Cx 26 and control group in the mean short term and mean long term post-operative pure tone averages (PTA), speech reception thresholds (SRT), word and sentence scores. Gender, age at implantation and type of connexin 26 mutation did not predict hearing outcomes. CONCLUSIONS: In patients with connexin 26 mutation, cochlear implantation provides an effective mean of auditory habilitation. Mutational status, age and gender do not seem to predict hearing outcomes.

Predictive factors for patient outcomes following open bedside tracheotomy.

OBJECTIVES/HYPOTHESIS: Open bedside tracheotomy (OBT) in the intensive care unit (ICU) has been advocated as a safe and more cost-effective alternative to tracheotomy performed in the operating room. The objective of this study is to determine predictive factors for postoperative outcomes, including decannulation and in-hospital mortality following OBT. STUDY DESIGN: Retrospective chart review. METHODS: The charts of 330 consecutive adult patients who underwent OBT at a tertiary care medical center between January, 2005, and April, 2011, were reviewed. Perioperative variables including demographics, comorbidities, serological markers, and time to tracheotomy were collected and analyzed in relation to the endpoints of in-hospital mortality and decannulation rate. RESULTS: A total of 218 patients were included in the final analysis. The decannulation rate was 26.1% and inpatient mortality was 24.2%. On multivariate analysis, the inpatient mortality rate was significantly increased and the decannulation rate was significantly decreased among patients with concomitant cardiac or respiratory disease, or a coincident diagnosis of malignancy. ICU length of stay was increased by 4.5 days for each unit increase in cardiac comorbidity count. CONCLUSIONS: Admitting diagnosis and serological markers did not predict the rates of decannulation or in-hospital mortality. However, the presence of cardiac disease and/or oncologic comorbidities played a significant role in predicting hospital mortality or eventual decannulation. Several comorbidity combinations resulted in a greater than 60% likelihood of inpatient mortality. In this population, the overall benefit of an OBT may be debatable. Despite very high overall acuity levels, there were no serious procedural complications, indicating that bedside tracheotomy is safe in ill patients.