Impact of early eyelid weight placement on the development of synkinesis and recovery in patients with idiopathic facial paralysis.

PURPOSE: Determine the impact of upper eyelid weight placement at 3 months post onset of idiopathic facial paralysis (IFP) on the recovery of facial function in patients with lagophthalmos. METHODS: This is a retrospective review of patients with incomplete recovery of IFP-defined as a Sunnybrook Facial Grading Scale (FGS) score of less than 100, 3 months after onset. Only patients with FGS and Facial Clinimetric Evaluation (FaCE) scores recorded at 3 and 12 months were included. Patients were categorized into 3 groups: Group A, lagophthalmos with eyelid weight placement; Group B, lagophthalmos without eyelid weight placement; Group C, complete eye closure (CEC) without eyelid weight placement. The eye comfort domain and composite score of the FaCE questionnaire were analyzed. Voluntary eye closure, synkinesis with eye closure, overall synkinesis and the composite score of the FGS were also analyzed. Paired two-tailed t-test was used to evaluate the data comparing the 3 and 12 month FaCE and FGS scores within and between the 3 groups. RESULTS: The change in composite FGS score significantly increased from month 3 to month 12 in Group A as compared to Group B (37 vs 4.25, P = 0.01). While Group A had significantly lower eye comfort (-12.5, P = 0.01), voluntary eye closure (-1.75, P = 0.05) and overall FGS scores (-28.75, P = 0.04) at 3 months compared to those in Group C, there were no differences between these two groups at 12 month follow-up. CONCLUSIONS: For patients with lagophthalmos at 3 months, early eyelid weight placement may lead to improved facial function at 12 months.

Special Populations in Implantable Auditory Devices: Pediatric.

"Hearing loss in the pediatric population can have significant social and developmental implications. Early auditory rehabilitation by at least 6 months of age is imperative. Although traditional hearing aids are often a first-line treatment option, there is a wide array of implantable auditory devices available. This article describes the indications for such devices as they pertain to the pediatric population, including osseointegrated bone-conduction devices, middle ear implants, cochlear implants, and auditory brainstem implants."

Outpatient thyroid surgery: Safety of an optimized protocol in more than 1,000 patients.

OBJECTIVES: Outpatient thyroid surgery is becoming increasingly common. The aim of this study was to clarify the principles for safe outpatient thyroid surgery and review our outcomes with the use of a protocol for outpatient thyroidectomy in a large patient cohort. STUDY DESIGN: A systematic analysis of a prospectively maintained database of outcomes of thyroidectomy in a tertiary endocrine surgery practice. SETTING: Academic medical center. SUBJECTS AND METHODS: A protocol for outpatient thyroidectomy was conceived and refined over 3 years. A prospective analysis of all thyroidectomies accomplished by a single surgeon who used this protocol from May 2006 to November 2013 was then undertaken. Patient demographics, operative and pathologic data, admission status, complications, and readmission rates were recorded. RESULTS: A total of 1,311 thyroidectomy procedures were performed during the study period, of which 1,026 (78.3 %) were conducted on an outpatient basis. The readmission rate for outpatients was 0.9%, with only 1 readmission in the last 200 procedures. Inpatients (which included patients in the 23-hour "observation" category) were readmitted more often than outpatients (3.5% vs 0.9%, P < .01). Outpatient management increased steadily throughout the study period (from 59.7% to 92.3%, P < .01), despite a larger mean nodule size and a greater rate of malignancy over time. There were no changes in the complication rate across the study timeframe except for the incidence of temporary hypocalcemia, which decreased over time (P < .01). CONCLUSION: Outpatient thyroid surgery is safe in appropriately selected patients using an optimized and systematic protocol.

Six-Year Experience With Endoscopic Thyroidectomy: Outcomes and Safety Profile.

BACKGROUND: Though minimally invasive video-assisted thyroidectomy (MIVAT) offers many advantages over traditional thyroid surgery, its adoption in North America has been limited. This study analyzes the largest series of MIVAT in North America to explore its safety. METHODS: A prospectively maintained database of all patients undergoing thyroid surgery by a single surgeon from 2003 to 2011 at an academic tertiary care medical center was evaluated. Demographic information, surgical and pathologic data, and postoperative outcomes were analyzed. RESULTS: Beginning in 2005, a total of 260 MIVATs were performed during the study period. Outpatient surgery was accomplished in 234 MIVATs (90%). MIVAT patients were predominantly young (46.8±14.8 years vs 52.4±14.6 years for conventional thyroidectomy) and female (88.5% vs 75.5% for conventional thyroidectomy). There were no cases of permanent hypoparathyroidism or permanent recurrent laryngeal nerve dysfunction. Observed complications included transient recurrent laryngeal nerve dysfunction (n=10; 3.8%), cellulitis (n=1; 0.4%), and temporary hypocalcemia (n=6; 2.3%). The overall complication rate for MIVAT (6.5%) was lower than the overall complication rate in conventional thyroidectomy (18.5%, P<.0001). CONCLUSION: MIVAT can be performed safely with a low complication profile in a high-volume practice. The safety of MIVAT represented by this experience supports broader adoption across surgical practices.

Endoscopic thyroidectomy is safe in patients with a high body mass index.

BACKGROUND: Obesity is associated with a number of medical comorbidities and is considered a risk factor for surgical complications. However, the impact of obesity on the safety of minimally invasive video-assisted thyroidectomy (MIVAT) has not been well defined. We sought to determine the relationship between obesity and the risk of complications in patients undergoing MIVAT. METHOD: A prospectively maintained database of all thyroid surgeries performed from January 2006 through June 2012 was searched and all cases of MIVAT were identified. Patients were stratified into three body mass index (BMI) groups according to the National Institutes of Health classification for obesity: normal (BMI ≤ 24.9 kg/m(2)), overweight (BMI 25-29.9 kg/m(2)) and obese (BMI ≥ 30 kg/m(2)). The total number of complications was compared among the three groups, and MIVAT patients were also compared to a cohort of patients undergoing conventional thyroid surgery. RESULTS: There were 233 MIVATs performed on 223 patients. The mean overall BMI for the study population was 25.4 kg/m(2). There were 123 procedures (52.8%) in the normal group, 76 procedures (32.6%) in the overweight group, and 34 procedures (14.6%) in the obese group. Complications included 1 case of cellulitis (0.4%), 6 cases of temporary hypocalcemia (2.6%), and 6 cases of transient vocal fold paresis (2.6%). No patients suffered permanent hypocalcemia or a permanent recurrent laryngeal nerve injury. There were 9 complications in the normal group (7.3%), 4 complications in the overweight group (5.3%), and no complications in the obese group. Due to the low number of complications in this series, the overweight and obese groups were combined into a high BMI group for further analysis. Statistical analysis using simple logistic regression models revealed that there was no significant difference in the number of complications in patients with a high BMI compared with patients with a normal BMI (odds ratio [OR] 0.48 [confidence interval (CI) 0.14-1.63], p=0.2). The MIVAT group had fewer overall complications than the conventional thyroidectomy group. CONCLUSIONS: Overweight and obese patients undergoing MIVAT in this series were not at an increased risk for surgical complications. The MIVAT procedure may be considered safe in patients with a high BMI, who may derive particular benefit from a minimally invasive approach.

The prevalence of intragenic deletions in patients with idiopathic hypogonadotropic hypogonadism and Kallmann syndrome.

Idiopathic hypogonadotropic hypogonadism (IHH) and Kallmann syndrome (KS) are clinically and genetically heterogeneous disorders caused by a deficiency of gonadotrophin-releasing hormone (GnRH). Mutations in three genes--KAL1, GNRHR and FGFR1--account for 15-20% of all causes of IHH/KS. Nearly all mutations are point mutations identified by traditional PCR-based DNA sequencing. The relatively new method of multiplex ligation-dependent probe amplification (MLPA) has been successful for detecting intragenic deletions in other genetic diseases. We hypothesized that MLPA would detect intragenic deletions in approximately 15-20% of our cohort of IHH/KS patients. Fifty-four IHH/KS patients were studied for KAL1 deletions and 100 were studied for an autosomal panel of FGFR1, GNRH1, GNRHR, GPR54 and NELF gene deletions. Of all male and female subjects screened, 4/54 (7.4%) had KAL1 deletions. If only anosmic males were considered, 4/33 (12.1%) had KAL1 deletions. No deletions were identified in any of the autosomal genes in 100 IHH/KS patients. We believe this to be the first study to use MLPA to identify intragenic deletions in IHH/KS patients. Our results indicate approximately 12% of KS males have KAL1 deletions, but intragenic deletions of the FGFR1, GNRH1, GNRHR, GPR54 and NELF genes are uncommon in IHH/KS.