Speech Intelligibility in Patients with Facial Paralysis.

Background: Patients with facial paralysis often report frustration with communication; however, there are limited data regarding intelligibility deficiencies. Objective: To compare speech intelligibility in patients with severe and non-severe facial paralysis, and in patients with or without synkinesis. Methods: Video and audio data were reviewed retrospectively. Groups were stratified as follows: Group A - severe paralysis (Sunnybrook 0-20) without synkinesis; Group B - non-severe (Sunnybrook >20) paralysis without synkinesis; and Group C - non-severe paralysis with synkinesis. Intelligibility was assessed by lay-people and a speech and language pathologist (SLP) using the Frenchay Dysarthria Assessment Version 2 (FDA-2). A receiver operating characteristic (ROC) curve was used to determine a Sunnybrook cutoff for intelligibility. Results: Eighty cases were reviewed with mean age 55.6, 53.8% female. 25.0% were in Group A, 30.0% Group B, and 45.0% in Group C. Lay-people rated 15.0% and the SLP rated 28.7% as having intelligibility deficiency. An ROC curve demonstrated that patients with Sunnybrook ≤18.5 were more likely to have intelligibility abnormality. Conclusion: Patients with Sunnybrook ≤18.5 are more likely to demonstrate intelligibility deficiency. Clinicians with a more trained ear are more likely to identify intelligibility abnormality compared with lay-people. Those with synkinesis are more intelligible compared with those without it.

Chemodenervation Algorithm: Functional and Aesthetic Considerations for Facial Harmony in Patients with Post-Facial Paralysis Synkinesis.

Management of post-facial paralysis synkinesis has evolved for the past decade with diversification of neuromuscular retraining, chemodenervation, and advanced surgical reanimation techniques. Chemodenervation with botulinum toxin-A is a commonly used treatment modality for synkinesis patients. Treatment has shifted from solely weakening the unaffected contralateral facial musculature for rote symmetry to selective reduction of undesired or overactive synkinetic muscles, allowing for a more organized motion of the recovered musculature. Facial neuromuscular retraining should be considered a crucial component of treating patients with synkinesis along with soft tissue mobilization, but specifics of these are beyond the scope of this article. Our goal was to create a descriptive platform for our method of chemodenervation treatment in the evolving field of post-facial paralysis synkinesis. A multi-institutional and multidisciplinary comparison of techniques was performed with photograph and video creation, review, and discussion over an electronic platform with all authors. Anatomic specifics of each region of the face and individual muscles were considered. A muscle by muscle algorithm for synkinesis therapy was created to include chemodenervation with botulinum toxin that should be considered for patients suffering from post-facial paralysis synkinesis.

Botulinum Toxin in Facial Reanimation: Map of the Facial Musculature and Dosage.

Recovery from flaccid facial paralysis can lead to the development of postfacial paralysis synkinesis. Chemodenervation, or treatment with botulinum toxin (BT), is a common treatment for individuals with synkinesis. Patients should be assessed in a multidisciplinary setting to create a specific, individualized, and targeted chemodenervation regimen. This article highlights relevant facial musculature, anatomy, suggested injection patterns, and BT dosages for treating synkinesis patients. These patients require postinjection follow-up, and they should be evaluated by a specially trained facial physical therapist for facial retraining.

Effect of the COVID-19 Pandemic on Otolaryngology Trainee Surgical Case Numbers: A Multi-institutional Review.

OBJECTIVE: To determine the effect of the initiation of COVID-19-related restrictions on the volume of surgical cases performed by otolaryngology trainees. STUDY DESIGN: Multi-institutional retrospective analysis of resident surgical case logs. SETTING: Accredited residency training programs in otolaryngology head and neck surgery. METHODS: Resident surgical case logs were combined from 6 residency training programs from different regions of the United States. Case volumes were compared between the calendar year before March 1, 2020, and the year afterward. Subgroup analyses were performed for the type of hospital (university, pediatric, veteran, county) and the key index cases by subspecialty. RESULTS: All 6 participating residency programs had a decrease in resident operative case volume. Surgical volume decreased from a mean of 6014 to 4161 (P < .05). There were decreases observed in key index cases in every subspecialty (P < .01), without statistical differences seen among subspecialties. There were decreases observed in every hospital type (university, pediatric, veteran, county) without statistical differences among types. Postgraduate year 5 residents were the most affected by volume reductions (51.6%), and postgraduate year 3 residents were the least affected (1.4%). CONCLUSION: In the year following initiation of COVID-19-related restrictions, there was a significant decrease in trainee surgical case volumes within residencies for otolaryngology-head and neck surgery. There were no statistical differences in the volume decreases seen at different institutions, among hospital types, or within various subspecialties.

Anatomic Considerations of Perinasal Musculature for Improved Dental Show During Smile in Facial Synkinesis.

Introduction: There is an anatomic explanation for upper lip and midfacial tethering resulting in lack of motion in facial synkinesis. Objective: To measure the effect of perinasal chemodenervation on dental show in the synkinetic population and clarify the anatomic relationship of perinasal musculature. Methods: Literature search was performed on anatomy of the perinasal modiolus, and anatomic evaluation was performed through human anatomic specimen dissection. Photographic outcomes were observed in synkinetic patients receiving chemodenervation to smile antagonists with and without perinasal muscle injections and assessed through naive observer survey. Retrospective outcomes for all patients receiving perinasal chemodenervation was collected utilizing Facial Clinimetric Evaluation Scale, Sunnybrook Facial Grading System (FGS), Facial Disability Index (FDI), and the Synkinesis Assessment Questionnaire. Results: Anatomic dissections demonstrated muscular confluence spanning the nasal sidewall and upper lip tethering the soft tissue to bone. Thirty-four of 53 chemodenervation patients received perinasal Botox experiencing improvement in synkinetic symptoms of the upper lip, nose, and improved dental show as noted on paired t-test for FGS (p = 0.00096), and FDI social p = 0.015) also supported by naive observer surveys (p = 0.03). Conclusions: Human anatomic specimen dissections support a perinasal confluence of musculature with bony attachments that can be successfully treated with chemodenervation in facial synkinesis patients.

Management of Acute Facial Nerve and Parotid Injuries.

Acute soft tissue trauma to the head and neck is a common reason for emergency department presentation and should be appropriately evaluated by a facial plastic surgeon. The evaluation of a patient who has suffered facial trauma should always include a comprehensive facial nerve exam and carry a low threshold of suspicion for parotid duct injury when involving the cheek. Injuries to the facial nerve and parotid duct can result in significant long-term functional, cosmetic, and emotional morbidity, particularly when diagnosis is delayed. In the repair of facial nerve transection, neurorrhaphy technique is primarily based on the ability to obtain tension-free anastomosis and outcomes are in large part related to timing of repair. Parotid duct injuries are generally repaired based on the site of ductal injury. In this article, we present a guide to the relevant anatomy of the facial nerve branches and the parotid duct, the important factors guiding treatment decisions alongside their related risks and benefits, as well as the management of complications of facial nerve neurorrhaphy and parotid duct injuries and repair.

The Tripod Concept of the Upper Nasal Third.

IMPORTANCE: The tripod theory of the upper nasal third parallels the concept of the well-known nasal tip tripod. We are evaluating the idea that one can simply alter the upper nasal angles reliably without the complex physics associated with the nasal tip to achieve a pleasing cosmetic result. OBJECTIVE: To describe a concept related to the well-known tripod theory with extrapolation to the upper nasal third as it pertains to cosmetic rhinoplasty. DESIGN, SETTING, AND PARTICIPANTS: This is a prospective study in which lateral photographs of 3 women who had not undergone surgery (age range, 20-50 years) were selected for digital manipulation of the nasal radix with subsequent alteration of the nasofrontal and nasofacial angles via imaging software. The altered images were analyzed by 20 blinded individuals between July 2009 and June 2017 to assess how changes in the height of the nasal dorsum and radix alone affect nasal appearance and the perception of ideal nasal angles. The study took place at a tertiary center, and the patients chosen for evaluation had nasal architecture that only required subtle changes rather than structure that demonstrated glaringly obvious overprojection or underprojection and rotation or a large dorsal bony hump. Analysis began June 2018. MAIN OUTCOMES AND MEASURES: Overall trend in recognition of objective and subjective alterations in projection and rotation for the rhinoplasty- and non-rhinoplasty-trained evaluators. RESULTS: Ten medically trained and 10 lay individuals (13 women [65%]; mean [SD] age, 38 [8.6] years) analyzed digitally manipulated photographs of 3 women (age range, 20-50 years) who had not undergone surgery. Lay individuals were more likely to choose an ideal nasal profile based on surrounding facial architecture (28 of 30 [93%]), while individuals with rhinoplasty training tended to separate the ideal nose from the surrounding face (18 of 30 [60%]) (P < .001). Projection was consistently and accurately recognized as being altered by both rhinoplasty-trained and lay individuals (95% CI, -0.18 to 0.38; P = .60 and 95% CI, -0.26 to 0.33; P > .99 for most and least projected), whereas subjective changes in rotation were significantly more elusive to the lay individual (95% CI, -0.04 to 0.52; P = .12 and 95% CI, 0.11 to 0.65; P = .01 for most and least rotated). CONCLUSIONS AND RELEVANCE: Predictable and consistent aesthetic results are the primary aim in rhinoplasty. Alterations in the upper nasal tripod are more reliable with extrapolated healing than with the tripod of the nasal tip. Ultimately, simple alteration of the upper nasal third can result in an improved nasal profile without specific alteration of tip architecture. LEVEL OF EVIDENCE: NA.

Facial Nerve Translocation for Low Tension Neurorrhaphy to Masseteric Nerve.

INTRODUCTION: The techniques of facial reanimation are continually evolving in search of the ideal method for rehabilitating the paralyzed face. In the past, alternative cranial nerve motor nuclei have been used to power facial musculature. The trigeminal nerve is gaining popularity as a promising nerve to drive facial motion, particularly in the lower face. OBJECTIVES: This article describes a low-tension technique of using the transposed facial nerve to the trigeminal nerve (masseteric branch) for facial reanimation. METHODS: Six patients over 2.5 years were treated with facial nerve translocation with division at the geniculate and direct neurorrhaphy to the motor branch of the masseter. Patients were evaluated by physical examination, measurement of oral commissure excursion using MEEI FACE-gram software, video assessment, Sunnybrook Facial Grading System, Facial Disability Index, and Facial Clinimetric Evaluation Scale (FaCE). RESULTS: Patients demonstrated early motion within 4 months postoperatively and were placed into facial physical therapy. All demonstrated improvements in oral competence, strong oral commissure excursion with good symmetry, speech improvements, and variable results in facial tone. Synkinesis to the smile antagonists in the lower face was noted and treated with chemodenervation in three of six. No upper division synkinesis was noted. CONCLUSION: The motor branch of the trigeminal nerve is an effective option for facial reanimation via facial nerve translocation and end-to-end neurorrhaphy. Variable results in facial tone were noted with excellent oral commissure excursion. This procedure is safe in the reoperated mastoid.

The hospital otolaryngologist: The louisiana state university experience.

OBJECTIVES/HYPOTHESIS: To describe the implementation and impact of a hospital otolaryngologist in an academic medical center setting. Our hypothesis was that the hospital otolaryngologist would increase productivity of the Louisiana State University (LSU) faculty otolaryngologists and provide more timely access to inpatient otolaryngology services. STUDY DESIGN: Retrospective clinical and administrative database review. METHODS: A comparative database review was performed with data from the year predating the initiation of the hospitalist program (2013) to the first full year after initiation of the program (2014). A clinical database review including diagnoses and procedures was also performed. RESULTS: Overall outpatient clinic relative value units for the aggregated LSU faculty increased 16% (despite the fact that the direct outpatient contribution of the hospital otolaryngologist was negligible). Overall capture of inpatient consult codes increased 128%. The hospital otolaryngologist was responsible for 84.5% of inpatient consult codes. There was a 100% increase in outpatient consult codes for the LSU faculty, of which <1% was attributed to the otolaryngology hospitalist. No significant impact was seen on length of stay over the study interval. Clinical database review of the first 2 years of the program showed 3,707 total encounters with postoperative encounters the most common. Four hundred fifty-four inpatient procedures were logged. The most common surgical procedure was tracheostomy. CONCLUSIONS: The otolaryngology hospitalist program is a viable clinical and economic model. LEVEL OF EVIDENCE: NA Laryngoscope, 1851-1857, 2018.

Health Care Disparities Knowledge, Attitudes, and Behaviors in Resident Physicians.

PURPOSE: Health care disparities are an important but sometimes underrepresented topic in graduate medical education. In this study we measured the impact of educational and behavioral interventions on resident knowledge about and attitudes toward health care disparities. METHODS: Faculty from 6 residency programs designed and presented an hour-long educational intervention to emphasize the importance of and increase resident knowledge about health care disparities. Selected residents then helped design a month-long behavioral intervention to engage their peers in conversations about disparities with patients. Surveys were administered pre- and post-educational intervention as well as post-behavioral intervention in order to measure the impact each intervention had on resident knowledge and attitudes. RESULTS: Paired-samples t-tests showed that residents were more knowledgeable about health care disparities issues following didactic teaching (P<0.001) and felt such issues were more important (P<0.001). Furthermore, presence of these feelings significantly predicted the frequency of engaging in the behavioral intervention (r=0.44, P<0.01). CONCLUSIONS: Two brief, simple interventions produced significant changes in resident knowledge, attitudes and behaviors regarding health care disparities. The educational intervention was most effective at increasing knowledge of disparities in general and encouraging participation in the behavioral intervention, while the behavioral intervention was useful in increasing knowledge of specific patients' barriers to care.

The brow and forehead in periocular rejuvenation.

Recognition of the brow as an integral contributor to periocular appearance improves and prolongs results from facial rejuvenation surgery. The approach to the brow and forehead in periocular rejuvenation must be chosen on an individual basis. The approaches discussed require in-depth knowledge of complex forehead and temporal anatomy to navigate the planes and important neurovascular structures safely. This article discusses anatomy, preoperative evaluation and considerations, surgical techniques, and complications in rejuvenation of forehead and brow.

Accelerating functional recovery after rat facial nerve injury: Effects of gonadal steroids and electrical stimulation.

OBJECTIVE: We investigated the combined effects of electrical stimulation and testosterone propionate on overall recovery time in rats with extracranial crush injuries to the facial nerve. STUDY DESIGN: Male rats underwent castration 3 to 5 days prior to right facial nerve crush injury and electrode implantation. Rats were randomly assigned to two groups: crush injury + testosterone or crush injury with electrical stimulation + testosterone. Recovery was assessed by daily subjective examination documenting vibrissae orientation/movement, semi-eye blink, and full eye blink. RESULTS: Milestones of early recovery were noted to be significantly earlier in the groups with electrical stimulation, with/without testosterone. The addition of testosterone to electrical stimulation showed significant earlier return of late recovery parameters and complete overall recovery. CONCLUSION: Electrical stimulation may decrease cell death or promote sprouting to accelerate early recovery. Testosterone may affect the actual rate of axonal regeneration and produce acceleration in functional recovery. By targeting different stages of neural regeneration, the synergy of electrical stimulation and testosterone appears to have promise as a neurotherapeutic strategy for facial nerve injury.

Electrical stimulation facilitates rat facial nerve recovery from a crush injury.

OBJECTIVE: To study the effect of electrical stimulation on accelerating facial nerve functional recovery from a crush injury in the rat model. STUDY DESIGN: Experimental. METHOD: The main trunk of the right facial nerve was crushed just distal to the stylomastoid foramen, causing right-sided facial paralysis in 17 Sprague-Dawley rats. An electrode apparatus was implanted in all rats. Nine rats underwent electrical stimulation and eight were sham stimulated until complete facial nerve recovery. Facial nerve function was assessed daily by grading eyeblink reflex, vibrissae orientation, and vibrissae movement. RESULTS: An electrical stimulation model of the rat facial nerve following axotomy was established. The semi-eyeblink returned significantly earlier (3.71 + 0.97 vs 9.57 + 1.86 days post axotomy) in stimulated rats (P = 0.008). Stimulated rats also recovered all functions earlier, and showed less variability in recovery time. CONCLUSION: Electrical stimulation initiates and accelerates facial nerve recovery in the rat model as it significantly reduces recovery time for the semi-eyeblink reflex, a marker of early recovery. It also hastens recovery of other functions.