Safety and surgical outcomes of transoral endoscopic thyroidectomy vestibular approach for papillary thyroid cancer: A two-centre study.

OBJECTIVE: The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been increasingly used to treat patients with papillary thyroid cancer (PTC) with improved cosmetic outcomes. This study aimed to explore the safety and efficacy of TOETVA in patients with PTC. MATERIALS AND METHODS: This retrospective study included TOETVA patients from Yantai Yuhuangding and Xiamen Zhongshan Hospitals. Among the 297 patients studied, 84 had benign nodules (28.3%), 208 had PTC (70.0%), and five had follicular thyroid cancer (1.7%). RESULTS: The incidence of transient and permanent recurrent laryngeal nerve injury was 1.3%, while that of transient hypoparathyroidism was 1.0%. Mental nerve paraesthesia was observed in 241 cases (81.1%), while permanent mental nerve paraesthesia was noted in seven cases (2.4%). Abnormal motor function of the lower lip and chin was observed in 12 cases (4.0%). Ten of the 208 patients with PTC (4.8%) underwent total thyroidectomy (TT) and bilateral central neck dissection (CND). A mean 6.6 ± 4.1 and 10.9 ± 4.0 lymph nodes were removed in the unilateral and bilateral surgeries, respectively, with a metastasis rate of 49.0%; a mean 2.7 ± 2.3 and 3.2 ± 2.6 lymph nodes were metastatic, respectively. The parathyroid gland was inadvertently removed in 6.6% and auto-transplanted in 10.6% of patients with unilateral PTC. The non-stimulated thyroglobulin level in the TT and bilateral CND patients was below 1 ng/mL at the 6-month follow-up. CONCLUSION: TOETVA is safe in well-selected patients with unilateral PTC. However, its safety remains unclear in patients treated with TT and bilateral CND.

Diagnostic Challenges and Treatment Options for Cutaneous T Cell Pseudolymphoma: A Case Study with Rituximab Treatment.

BACKGROUND Pseudolymphoma is a rare disorder that can mimic lymphoma both clinically and histologically. It usually affects middle-aged females. Since pseudolymphoma is a rare disorder not only is diagnosing the condition difficult, but there is also a lack of standardized treatment guidelines. In the literature, anti-CD20 monoclonal antibody rituximab is described as an effective treatment option. CASE REPORT 46-year-old female fell ill suddenly with swelling and enlargement of her chin. Multiple skin biopsies were done, which were re-evaluated multiple times as well. Each ended with a new diagnosis for the patient. Finally, in the last revision of biopsy material, pseudolymphoma was confirmed. The patient received multiple courses of corticosteroid treatments - locally and systemically - without long lasting effect. After diagnosis of pseudolymphoma, the patient was started on intravenous rituximab and this treatment was effective. CONCLUSIONS Cutaneous pseudolymphoma is a diagnostic challenge. Rituximab is a treatment option for refractory pseudolymphoma. Since there are no treatment guidelines for pseudolymphoma, more clinical studies are needed to establish best treatment options for these patients. Therefore, each reported clinical case is important.

Effects of ventral intermediate nucleus deep brain stimulation across multiple effectors in essential tremor.

OBJECTIVE: Essential tremor (ET) prominently affects the upper-limbs during voluntary movements, but can also affect the lower-limbs, head, and chin. Although deep brain stimulation (DBS) of the ventral intermediate nucleus (VIM) of thalamus improves both clinical ratings and quantitative measures of tremor, no study has quantified effects of DBS on tremor across multiple body parts. Our objective was to quantify therapeutic effects of DBS across multiple body parts in ET. METHODS: We performed quantitative assessment of tremor in ET patients who had DBS for at least one year. We assessed tremor on and off VIM-stimulation using triaxial accelerometers on the upper-limbs, lower-limbs, head and chin during seated and standing tasks. RESULTS: VIM-DBS significantly reduced tremor, but there was no statistical difference in degree of tremor reduction across the measured effectors. Compared to healthy controls, ET patients treated with DBS showed significantly greater tremor power (4-8 Hz) across all effectors during seated and standing tasks. CONCLUSIONS: VIM-DBS reduced tremor in ET patients. There was no significant difference in the degree of tremor reduction across the measured effectors. SIGNIFICANCE: This study provides new quantitative evidence that VIM-DBS is effective at reducing tremor across multiple parts of the body.

Effect of chin tuck against resistance exercise on patients with dysphagia following stroke: A randomized pilot study.

BACKGROUND: Recently, chin tuck against resistance exercise (CTAR) has been reported as a remedial treatment for pharyngeal dysphagia. However, the clinical evidence of the effect is still lacking. OBJECTIVE: This study investigated the effect of CTAR on the swallowing function in patients with dysphagia following subacute stroke. METHODS: The patients were randomly assigned to an experimental (n = 11) or a control group (n = 11). The experimental group performed CTAR using the CTAR device. The control group received only conventional dysphagia treatment. Both groups received training on five days a week, for four weeks. The swallowing function was measured using functional dysphagia scale (FDS) and penetration-aspiration scale (PAS), based on a videofluoroscopic swallowing study (VFSS). RESULTS: The experimental group showed more improvements in the oral cavity, laryngeal elevation/epiglottic closure, residue in valleculae, and residue in pyriform sinuses of FDS and PAS compared to the control group (p < 0.05, all). CONCLUSIONS: This study demonstrated that CTAR is effective in improving the pharyngeal swallowing function in patients with dysphagia after stroke. Therefore, we recommend CTAR as a new remedial training alternative to HLE.

Complicated untreated apical periodontitis causing paraesthesia: A case report.

The purpose of this article was to report a case of untreated apical periodontitis resulting in severe late complications. A patient with an asymptomatic crowned root canal-treated mandibular molar revealing a radiographic substandard endodontic treatment and a slight periapical radiolucency was made aware of the treatment options and opted for no treatment. The lesion slightly increased in size after 6 years, but the tooth remained asymptomatic and endodontic retreatment was again refused. After 4 more years, the patient presented with an abscess and severe pain, complicated by paraesthesia of the left chin and lip. Radiographic examination revealed that the lesion had increased considerably to involve the mandibular canal. The treatment protocol included long-term intracanal medication with calcium hydroxide and follow-ups revealed complete resolution of the periapical radiolucency and the paraesthesia had completely subsided.

Simulation study comparing the helmet-chin PET with a cylindrical PET of the same number of detectors.

There is a growing interest in developing brain PET scanners with high sensitivity and high spatial resolution for early diagnosis of neurodegenerative diseases and studies of brain functions. Sensitivity of the PET scanner can be improved by increasing the solid angle. However, conventional PET scanners are designed based on a cylindrical geometry, which may not be the most efficient design for brain imaging in terms of the balance between sensitivity and cost. We proposed a dedicated brain PET scanner based on a hemispheric shape detector and a chin detector (referred to as the helmet-chin PET), which is designed to maximize the solid angle by increasing the number of lines-of-response in the hemisphere. The parallax error, which PET scanners with a large solid angle tend to have, can be suppressed by the use of depth-of-interaction detectors. In this study, we carry out a realistic evaluation of the helmet-chin PET using Monte Carlo simulation based on the 4-layer GSO detector which consists of a 16 × 16 × 4 array of crystals with dimensions of 2.8 × 2.8 × 7.5 mm3. The purpose of this simulation is to show the gain in imaging performance of the helmet-chin PET compared with the cylindrical PET using the same number of detectors in each configuration. The sensitivity of the helmet-chin PET evaluated with a cylindrical phantom has a significant increase, especially at the top of the (field-of-view) FOV. The peak-NECR of the helmet-chin PET is 1.4 times higher compared to the cylindrical PET. The helmet-chin PET provides relatively low noise images throughout the FOV compared to the cylindrical PET which exhibits enhanced noise at the peripheral regions. The results show the helmet-chin PET can significantly improve the sensitivity and reduce the noise in the reconstructed images.

Not by the Red on My Chinny Chin Chin: A Case of Mandibular Osteomyelitis in a 5-Year-Old Girl.

BACKGROUND: Osteomyelitis is not an uncommon emergency department diagnosis in pediatric patients, and most cases are in the lower extremities. Children can present with acute, subacute, or chronic erythema, pain, swelling, or decreased use of the extremity; some patients will also have fever or elevated serum inflammatory markers, or both. CASE REPORT: We present the case of a healthy 5-year-old girl who presented to the emergency department with 3 weeks of painless chin swelling and 2 days of erythema and pain. While laboratory testing was normal, magnetic resonance imaging demonstrated osteomyelitis of the mandible, later confirmed by biopsy. After 4 weeks of intravenous antibiotics and an additional 2 weeks of oral antibiotics, the patient recovered completely without any residual findings. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case demonstrates that osteomyelitis can develop in previously healthy, fully vaccinated children with competent immune systems. Systemic findings (ie, fever and elevated serum inflammatory markers) may be absent, and osteomyelitis should always be considered in the differential diagnosis for a child presenting with subacute to chronic cutaneous findings without other clear explanation.

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Taking it on the chin: recognizing and accounting for lower face asymmetry in chin augmentation and genioplasty.

During the course of thousands of preoperative facial analyses, it has become apparent that the chin, in most individuals, appears weaker on the left than on the right. This previously unreported disparity spans age, sex, and ethnicity. To document this finding, frontal and lateral photographs of 20 random patients from the senior author's practice were subjected to a battery of soft-tissue measurements. Analysis of four celebrities further demonstrated the ubiquity of relative left chin weakness. Precedent for asymmetry in human anatomy is abundant (e.g., handedness). Asymmetry, moreover, often is conserved throughout the population (e.g., sidedness of visceral orientation). Left-sided chin weakness appears to be another example of well-preserved anatomical asymmetry. The presence of this asymmetry should be considered in planning chin augmentation and genioplasty.

Quantitative EMG criteria for diagnosing idiopathic REM sleep behavior disorder.

PURPOSE: The purpose of this study is to determine the diagnostic cutoff for the proportion of rapid eye movement (REM) sleep with tonic and phasic activities of the submentalis muscle activity that can be used to diagnose REM sleep behavior disorder (RBD). METHODS: Seventeen patients clinically diagnosed as idiopathic RBD and 15 age- and gender-matched controls were studied. Surface electromyography was recorded from the submentalis muscle, and two sleep technologists manually identified epochs with tonic and phasic activities during REM sleep. Receiver operating characteristic (ROC) curves were constructed to find the optimal cutoff values for diagnosing RBD using the proportion of REM sleep with tonic and phasic activities of the submentalis muscle. Cohen's kappa coefficient was calculated to evaluate interrater reliability. RESULTS: The cutoff value with the optimal sensitivity and specificity was 6.5% for the proportion of REM sleep with tonic activity (sensitivity, 94.1%; specificity, 93.3%; area under the ROC curve, 0.976) and 9.5% for the proportion of REM sleep with phasic activity (sensitivity, 94.1%; specificity, 93.3%; area under the ROC curve, 0.992). The cutoff value required to achieve a specificity of 100% was 8.9% for tonic activity and 11.1% for phasic activity. Cohen's kappa coefficient between two scorers was 0.96 (95% confidence interval, 0.95-0.97) and 0.95 (95% confidence interval, 0.94-0.95) for tonic and phasic activities, respectively (both p < 0.001). CONCLUSIONS: Identifying periods of tonic and phasic activities of the submentalis muscle during REM sleep is useful to discriminate patients with idiopathic RBD from controls.

Sleep bruxism and oromandibular myoclonus in rapid eye movement sleep behavior disorder: a preliminary report.

OBJECTIVE: We aimed to compare rhythmic masticatory muscle activity typical of sleep bruxism and oromandibular myoclonus (OMM) during rapid eye movement (REM) sleep in patients with idiopathic REM sleep behavior disorder (iRBD) and in Parkinson disease (PD) patients with RBD (PD-RBD). METHODS: Sleep polygraphic data were collected from 9 age-matched controls and 28 patients (mean±standard error of the mean, 66.0±1.7 y) with a clinical and sleep laboratory diagnosis of RBD. Patients were divided into two groups: 13 patients with iRBD and 15 patients with PD-RBD. Rhythmic masticatory muscle activity, a marker of sleep bruxism, and OMM were scored blind to subject's diagnosis from jaw electromyographic recordings during sleep. RESULTS: The rhythmic masticatory muscle activity index was significantly higher during REM sleep in iRBD subjects compared to controls (P<.01) and was significantly higher during non-REM (NREM) sleep in both subject groups compared to controls (P < or = .03). A positive sleep laboratory diagnosis of sleep bruxism was made in 25% of all patients. In iRBD, patients had more OMM during REM sleep than controls (2.4 times higher; P=.01). CONCLUSION: In the presence of a high frequency of rhythmic masticatory muscle activity during REM sleep, RBD may be suspected and further neurologic assessment is recommended.

Evaluation of neuromuscular activity in patients with obstructive sleep apnea using chin surface electromyography of polysomnography.

BACKGROUND: It is believed that defects in upper airway neuromuscular control play a role in sleep apnea pathogenesis. Currently, there is no simple and non-invasive method for evaluating neuromuscular activity for the purpose of screening in patients with obstructive sleep apnea. This study was designed to assess the validity of chin surface electromyography of routine polysomnography in evaluating the neuromuscular activity of obstructive sleep apnea subjects and probe the neuromuscular contribution in the pathogenesis of the condition. METHODS: The chin surface electromyography of routine polysomnography during normal breathing and obstructive apnea were quantified in 36 male patients with obstructive sleep apnea. The change of chin surface electromyography from normal breathing to obstructive apnea was expressed as the percent compensated electromyography value, where the percent compensated electromyography value = (normal breath surface electromyography - apnea surface electromyography)/normal breath surface electromyography, and the percent compensated electromyography values among subjects were compared. The relationship between sleep apnea related parameters and the percent compensated electromyography value was examined. RESULTS: The percent compensated electromyography value of the subjects varied from 1% to 90% and had a significant positive correlation with apnea hypopnea index (R(2) = 0.382, P < 0.001). CONCLUSIONS: Recording and analyzing chin surface electromyography by routine polysomnography is a valid way of screening the neuromuscular activity in patients with obstructive sleep apnea. The neuromuscular contribution is different among subjects with obstructive sleep apnea.

Do erupted third molars weaken the mandibular angle after trauma to the chin region? A 3D finite element study.

It has been suggested that third molars increase mandibular fragility because they do not contribute to its strength. For ethical reasons, a human study design that would permit the elucidation of this interference is not possible. This study evaluated the impact of the presence of erupted third molars on the mandibular angle of resistance when submitted to trauma. A three-dimensional (3D) mandibular model was obtained through finite element methodology using computed tomography (CT) with the geometry and mechanical properties to reproduce a normal mandibular structure. Human mandibles with no, one or two erupted third molars were evaluated. Whenever the third molar was present there was a greater concentration of tensions around the cervical part of its alveolus. Approximated Von Mises equivalent stress of the third molar region was 107.035 MPa in the mandible with teeth and 64.6948 MPa in the mandible without teeth. In the condylar region it was 151.65 MPa when the third molar was present and 184.496 MPa when it was absent. The digital models created proved that the mandibular angle becomes more fragile in the presence of third molars. When they are absent the energy concentrates on the lateral e posterior aspect of the condylar neck.

Chin fasciculations in Madras motor neuron disease: a new clinical feature.

The characteristic features of Madras motor neuron disease (MMND) are onset in the young in the first two decades, sporadic occurrence, facial and bulbar paralysis, sensorineural hearing impairment, asymmetrical weakness of limbs and pyramidal signs with a slow progression. The majority of the cases reported are from South India. MMND variant has the additional features of optic atrophy and cerebellar signs. We are reporting a 48 year old female of MMND who had persistent fasciculations of chin, with electromyographic features of fasciculations and fibrillations in mentalis muscle. Chin fasciculations, a rare clinical feature, is now described for the first time in Madras motor neuron disease adding a new feature to the clinical constellation of symptoms.

Numb chin syndrome in acute myeloid leukemia.

Numb chin syndrome (NCS) is a rare cranial neuropathy characterized by facial numbness in the distribution of the mental branch of the inferior alveolar nerve. Although commonly associated with local trauma, NCS can indicate an underlying neoplastic condition. Although NCS is most commonly associated with nonmalignant disease states, it may be the presenting symptom of a systemic malignancy, and its prompt recognition is essential for proper management. NCS is associated with a variety of neoplastic conditions but is most commonly seen with lymphoproliferative conditions, breast cancer and prostate cancer. When confronted with a possible diagnosis of NCS, clinical evaluation should include evaluation for occult malignancy or relapse of any known previous cancer. In this study, a case of a patient with NCS in the context of a new diagnosis of acute myeloid leukemia with differentiation with a t(8;21) translocation is presented and the literature regarding the multiple etiologies and significance of NCS reviewed.