Treatment Patterns and Outcomes in Botulinum Therapy for Patients With Facial Synkinesis.

IMPORTANCE: In the last decade, there has been a significant increase in the number of practitioners administering botulinum toxin for facial synkinesis. However, there are few resources available to guide treatment patterns, and little is known about how these patterns are associated with functional outcomes and quality of life. OBJECTIVE: To evaluate botulinum treatment patterns, including the dosing and frequency of muscle targeting, for treatment of facial synkinesis and to quantify patient outcomes. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study of 99 patients treated for facial synkinesis was conducted from January 2016 through December 2018 at the Vanderbilt Bill Wilkerson Center in Nashville, Tennessee, a tertiary referral center. INTERVENTION: Onabotulinum toxin A treatment of facial synkinesis. MAIN OUTCOMES AND MEASURES: Patient-reported outcomes on the Synkinesis Assessment Questionnaire and botulinum treatment patterns, including the dosages and frequency of injection for each facial muscle, were compared at the initiation of treatment and at the end of recorded treatment. RESULTS: In total, 99 patients (80 female patients [81%]) underwent botulinum injections for treatment of facial synkinesis. The median (interquartile range) age was 54.0 (43.5-61.5) years, and the median (interquartile range) follow-up was 27.1 (8.9-59.7) months. Most patients underwent injections after receiving a diagnosis of Bell palsy (41 patients, 41%) or after resection of vestibular schwannoma (36 patients [36%]). The patients received a total of 441 treatment injections, and 369 pretreatment and posttreatment Synkinesis Assessment Questionnaire scores were analyzed. The mean botulinum dose was 2 to 3 U for each facial muscle and 9 to 10 U for the platysma muscle. The dose increased over time for the majority of all muscles, with steady state achieved after a median of 3 treatments (interquartile range, 2-3). Linear regression analysis for cluster data of the mean total questionnaire score difference was -14.2 (95% CI, -17.0 to -11.5; P < .001). There was a significant association of postinjection questionnaire score with younger patients, female sex, total dose, and synkinesis severity. Oculo-oral synkinesis may respond more to treatment compared with oro-ocular synkinesis. CONCLUSION AND RELEVANCE: Patients with facial synkinesis responded significantly to botulinum treatment. Treatment began with 6 core facial muscles that were injected during most treatment sessions, and dosages increased after the first injection until steady state was achieved. Those with a greater degree of morbidity, younger patients, and females showed significant improvement, and the larger the dose administered, the greater the response. Oculo-oral synkinesis may be more responsive than oro-ocular synkinesis. LEVEL OF EVIDENCE: 3.

Review of a single surgeon's stapedotomy cases performed with a nickel titanium prosthesis over a 14-year period.

CONCLUSION: Stapes surgery with a nickel titanium prosthesis is a safe and well-tolerated procedure that leads to a significant improvement in hearing outcomes. OBJECTIVE: To identify the efficacy and safety of stapedotomy procedures performed with a nickel titanium prosthesis for patients with otosclerosis. METHODS: A review of 431 unique stapedotomies performed over 14 years by a single surgeon at an academic tertiary care center yielded 312 cases with nickel titanium prosthesis that met inclusion criteria of otosclerosis diagnosis, initial surgery in operative ear, and presence of pre-operative and post-operative audiograms. Pure-tone averages (PTA) at baseline and 8 weeks after surgery were calculated over four frequencies; 0.5, 1, 2, and 4 kHz. Average air-bone gaps (ABG) were calculated from pre-operative and post-operative audiograms. RESULTS: Average pre-operative baseline PTA was 56.7 dB in the affected ear. Post-operative PTA was 30.1 dB, a 26.6 dB improvement. Initial average ABG was 29.7 dB, while post-operative ABG averaged 5.4 dB, a 24.2 dB improvement. Surgical success (closure of ABG within 10 dB) was achieved in 263 (84%) patients. Rate of surgical success was not correlated with age, gender, race, or affected ear. Complications included recurrent conductive hearing loss (14), progressive SNHL (4), and post-operative BPPV (3).

Innovations in nasal valve surgery.

PURPOSE OF REVIEW: This article reviews current practices in nasal valve repair and highlights recent innovations in the medical literature. RECENT FINDINGS: A surgeon's choice regarding a proper nasal valve repair technique depends heavily on the patient's site of obstruction. While classical maneuvers to improve the internal and external nasal valves have been employed for several decades, increasing understanding of lateral wall insufficiency and its role in nasal valve compromise has led to improvement of proposed methods for correcting the nasal valve. Radiofrequency-induced thermotherapy, the upper lateral strut graft, stairstep graft, and nasal valve lift techniques are described in detail. These four techniques offer innovative means of dealing with the challenge of nasal valve collapse resulting in nasal obstruction. SUMMARY: This review article provides an overview of the current practice in the field of nasal valve repair and summarizes recent technical advances in the field.

Aesthetic modification to the rintala flap: a case series.

BACKGROUND: Defects of the nasal dorsum have historically been repaired based on size and with respect to subunit principle. This case series provides a previously undescribed option for correcting defects of the nasal dorsum 1.5-2.5 cm in size. The foremost advantages of this technique are preservation of nasal subunit integrity and the integration of subtle nasal tip rotation. METHODS: We present a case series involving five consecutive patients aged 49-74 after Mohs excision for malignancies of the nasal dorsum. Defects were corrected using the aesthetic modification to the Rintala flap over a 10-year period by two primary surgeons. CONCLUSIONS: The aesthetic modification to the Rintala flap should be considered as a reconstruction option for patients with defects of the nasal dorsum between 1.5 and 2.5 cm in size, especially for those patients desiring rotation of the nasal tip. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Mechanisms and efficacy of vismodegib in the treatment of basal cell carcinoma.

Historically patients with advanced basal cell carcinoma have been subjected to large surgical resections for the treatment of their disease. However, with the development of vismodegib, a first in class molecule that acts to inhibit the hedgehog pathway, patients with advanced and metastatic basal cell carcinoma may have renewed hope in limiting the morbidity involved with surgery. Preliminary data shows a relatively good safety profile and promising results, although further research remains to be conducted. Current progress on utilization of vismodegib for the treatment of advanced basal cell carcinoma is reviewed in this article. Only literature with objective clinical evidence was included in this review.

Device fixation in cochlear implantation: is bone anchoring necessary?

OBJECTIVES/HYPOTHESIS: To compare complication rates between patients whose cochlear implants were secured by a bony tie-down technique versus those secured by a periosteal tie-down technique. STUDY DESIGN: A retrospective review of 302 consecutive patients undergoing cochlear implantation (327 implants), including both adults and children, at a single institution by a single surgeon. METHODS: Cochlear implantation was performed in the standard fashion with bony securement of the device in the first subset of patients. The surgical technique was then modified to exclude the bony tie-down step in favor of a periosteally placed suture tie-down in the next subset of patients. The patient's medical records were then reviewed to determine complications, which were then compared between groups using chi(2) testing. RESULTS: The overall complication rate for the periosteally secured cochlear implant subset was 9.5%, with no significant difference noted when compared to the 12.2% overall complication rate seen with the bone-secured implants. Minor complication rates were 9.5% versus 8.1%, respectively, with major complications occurring in 0% versus 4.1% of periosteally secured versus bone-secured devices. There were no statistical differences between groups for major, minor, or any specific complications. There were no cases of device migration. CONCLUSIONS: Cochlear implant devices may be secured in place with periosteally anchored sutures in lieu of bone-anchored sutures without any significant increases in perioperative complications.

Obstructive sleep apnea: a growing problem.

Obstructive sleep apnea is an underrecognized and underdiagnosed medical condition, with a myriad of negative consequences on patients' health and society as a whole. Symptoms include daytime sleepiness, loud snoring, and restless sleep. While the "gold standard" of diagnosis is by polysomnography, a detailed history and focused physical examination may help uncover previously undiagnosed cases. Undetected obstructive sleep apnea can lead to hypertension, heart disease, depression, and even death. Several modalities exist for treating obstructive sleep apnea, including continuous positive airway pressure, oral appliances, and several surgical procedures. However, conservative approaches, such as weight loss and alcohol and tobacco cessation, are also strongly encouraged in the patient with obstructive sleep apnea. With increased awareness, both the medical community and society as a whole can begin to address this disease and help relieve the negative sequelae that result from it.