Revision Nasal Reconstruction After Previous Forehead Flap

Reconstructing the nose poses considerable challenges, even for the most skilled surgeons. Significant nasal reconstructions often require later revisions to address persistent issues in both form and function, and it is crucial to discuss this possibility with the patient before embarking on the reconstructive process. Minor revisions can often be managed by making direct incisions between nasal subunits, coupled with soft tissue sculpting or the use of structural grafts for augmentation. When minor adjustments prove insufficient, the initial reconstruction may need to be entirely revised with a second forehead flap.

Hypoglossal Nerve Transfer for Facial Nerve Paralysis: A Systematic Review and Meta-Analysis

Background: Hypoglossal-facial nerve (12-7) anastomosis can restore symmetry and voluntary movement on the face in patients with facial nerve paralysis. Traditional 12-7 transfer includes direct end-to-end nerve anastomosis, sacrificing the entire hypoglossal nerve. Contemporary, end-to-side anastomosis, or split anastomosis techniques limit tongue morbidity by preserving some hypoglossal nerve. Direct outcome comparisons between these techniques are limited. Objective: To compare reported outcomes of facial movement, tongue, speech, and swallow outcomes among the different types of hypoglossal-facial nerve anastomosis schemes. Evidence Review: For this systematic review and meta-analysis, a comprehensive strategy was designed to search PubMed, Scopus, and the Cochrane Database from inception to January 2021, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis, reporting guideline yielding 383 results. Any participant who underwent 12-7 transfer using any of the three techniques, with or without an interposition graft, and had documented preoperative and postoperative evaluation of facial nerve function with a validated instrument such as House-Brackmann (HB), was considered for inclusion. Secondary outcomes of synkinesis, tongue atrophy, and speech or swallowing dysfunction were also compared. Forty-nine studies met inclusion criteria, representing data from 961 total patients who underwent 12-7 transfer. Results: The proportion of good HB outcomes (HB I-III) did not differ by anastomosis type: End-to-side and end-to-end anastomosis (73% vs. 59%, p = 0.07), split and end-to-end anastomosis (62% vs. 59%, p = 0.88), and end-to-side anastomosis and split anastomosis (73% vs. 62%, p = 0.46). There was no difference in reported synkinesis rates between the anastomosis types. However, end-to-side anastomosis (z = 6.55, p < 0.01) and split anastomosis (z = 3.58, p < 0.01) developed less tongue atrophy than end-to-end anastomosis. End-to-side anastomosis had less speech/swallowing dysfunction than end-to-end anastomosis (z = 3.21, p < 0.01). Conclusion: End-to-side and split anastomoses result in similar HB facial nerve outcomes as the traditional end-to-end 12-7 anastomosis. End-to-side anastomosis has decreased complications of tongue atrophy and speech/swallow dysfunction compared to end-to-end anastomosis. In addition, split anastomosis has decreased rates of tongue atrophy compared to end-to-end anastomosis.

A quantitative analysis of Twitter ("X") trends in the discussion of rhinoplasty

Introduction

Rhinoplasty is one of the most common cosmetic surgical procedures performed globally. Twitter, also known as "X," is used by both patients and physicians and has been studied as a useful tool for analyzing trends in healthcare. The public social media discourse of rhinoplasty has not been previously reported in the field of otolaryngology. The goal of this study was to characterize the most common user type, sentiment, and temporal trends in the discussion of rhinoplasty on Twitter to guide facial plastic surgeons in their clinical and social media practices.

Methods

A total of 1,427,015 tweets published from 2015 to 2020 containing the keywords "rhinoplasty" or "nose job" were extracted using Twitter Academic API. Tweets were standardized and filtered for spam and duplication. Natural language processing (NLP) algorithms and data visualization techniques were applied to characterize tweets.

Results

Significantly more "nose job" tweets (80.8%) were published compared with "rhinoplasty" (19.2%). Annual tweet frequency increased over the 5 years, with "rhinoplasty" tweets peaking in January and "nose job" tweets peaking in the summer and winter months. Most "rhinoplasty" tweets were linked to a surgeon or medical practice source, while most "nose job" tweets were from isolated laypersons. While discussion was positive in sentiment overall (M = +0.08), "nose job" tweets had lower average sentiment scores (P < .001) and over twice the proportion of negative tweets. The top 20 most prolific accounts contributed to 14,758 (10.6%) of total "rhinoplasty" tweets. Exactly 90% (18/20) of those accounts linked to non-academic surgeons compared with 10% (2/20) linked to academic surgeons.

Conclusions

Rhinoplasty-related posts on Twitter were cumulatively positive in sentiment and tweet volume is steadily increasing over time, especially during popular holiday months. The search term "nose job" yields significantly more results than "rhinoplasty," and is the preferred term of non-healthcare users. We found a large digital contribution from surgeons and medical practices, particularly in the non-academic and private practice sector, utilizing Twitter for promotional purposes.

Postoperative Radiotherapy and Facial Nerve Outcomes Following Nerve Repair: A Systematic Review

OBJECTIVE

To compare outcomes of facial nerve repair or grafting following facial nerve-sacrificing procedures among patients treated with and without postoperative radiotherapy (RT).

DATA SOURCES

PubMed, OVID, Conference Papers Index, Cochrane Library, ClinicalTrials.gov.

REVIEW METHODS

Databases were searched using terms including "facial nerve," "graft," "repair," and "radiotherapy." Abstracts mentioning facial nerve repair and evaluation of facial nerve function were included for full-text review. Studies that utilized the House-Brackmann or similar validated scale for evaluation of postoperative facial nerve function were selected for review. All identified studies were included in a pooled t test analysis.

RESULTS

Twelve studies with 142 patients were included in the systematic review. All 12 studies individually demonstrated no significant difference in facial nerve outcomes between patients who received postoperative radiation and patients who did not. A pooled t test of data from all studies also demonstrated no significant difference in postoperative facial nerve function between the postoperative RT and non-RT groups (t stat = 0.92, p = .36).

CONCLUSION

This analysis, including 12 studies, demonstrated that among patients undergoing facial nerve grafting or repair, there was no significant difference in postoperative facial nerve function between postoperative RT and non-RT patients. Due to the small sample size and variability in study methods, further studies directly comparing outcomes between patients with and without postoperative RT would be beneficial.

Influence of Subclinical Anxiety and Depression on Quality of Life and Perception of Facial Paralysis

Introduction: Patients with facial paralysis have increased psychosocial distress, which affects overall quality of life (QOL). Objective: To evaluate the relationship between QOL and paralysis severity among patients with subclinical anxiety and/or depression. Methods: Patients with facial paralysis were screened for anxiety and depression using the Generalized Anxiety Disorder-2 and Patient Health Questionnaire-2 surveys. QOL scores (Facial Clinimetric Evaluation) and paralysis severity scores (House-Brackmann [HB] and Sunnybrook [SB]) were collected. Patients with a mental health diagnosis or treatment were excluded. Univariate and multivariate analyses and Pearson's correlations were performed after stratifying by anxiety and/or depression screenings. Results: Positive anxiety and depression screening rates were 25.78% and 22.66%, respectively. Patients screening positive had significantly worse QOL scores despite no difference in paralysis severity. QOL scores did not correlate with SB scores among patients who screened positive for depression. Conclusion: Patients screening positive for anxiety and/or depression demonstrated worse QOL, which did not correlate with paralysis severity suggesting that health care professionals should remain alert to mental health symptoms when QOL impairment is out of proportion with the severity of paralysis.

Masseteric-to-facial nerve transfer for treatment of pediatric facial paralysis: An initial report

OBJECTIVES

The indications and outcomes of masseteric-to-facial nerve transfer in pediatric patients with short-term facial paralysis is incompletely understood as compared to its use in adult patients. This report aims to retrospectively quantify outcomes with both clinician-based measurements and objective facial analysis software.

METHODS

Retrospective case series at a single institution. The Sunnybrook Facial Grading System was used for clinician-based measurements and Emotrics software for objective measurements.

RESULTS

Four pediatric patients underwent masseteric-to-facial nerve transfers from 2016 to 2018. The mean patient age at the time of surgery was 4.5 years (range = 2-7) and the mean time from paralysis onset to surgical intervention was 12.9 months (range = 10.0-16.2). The mean follow-up was 18.3 months (range = 14.5-23.6). With regards to the Sunnybrook resting nasolabial fold symmetry, 3 of the 4 patients improved from 2 (absent nasolabial fold) to 1 (less pronounced nasolabial fold). Per the Emotrics analysis, the pre- and post-operative mean absolute differences for commissure excursion between the normal functioning and paralyzed sides were 11.8 mm and 6.7 mm, respectively (p = 0.04).

CONCLUSION

The masseteric-to-facial nerve transfer technique leads to an objective improvement in dynamic smile function in select pediatric patients.

Patient and Observer Graded Rhinoplasty Scar Outcomes: A Randomized Controlled Trial of Fast Absorbing Versus Permanent Columellar Suture Closure

Background: When performing an open rhinoplasty, surgeons commonly use nonabsorbable skin sutures to close the columellar incision. These are believed to minimize scarring. However, removal can be associated with patient discomfort and outcomes may not be superior to using absorbable sutures. Objective: To compare difference in scar appearance for columellar closure after rhinoplasty with absorbable and nonabsorbable sutures. Methods: We performed a prospective randomized control trial with 61 patients. Forty-one patients completed follow-up and were included in final analysis: 23 whose columellar incision was closed with absorbable sutures and 18 with nonabsorbable sutures. A blinded surgeon performed Stony Brook Evaluation Scale (SBES) and a patient performed Patient Scar Assessment Questionnaire (PSAQ) was completed for each suture type. Results: Our results did not reject the null hypothesis that there is no difference in SBES or PSAQ scores between absorbable and nonabsorbable suture types. Conclusions: No difference was detected in scar outcomes between absorbable and nonabsorbable sutures for closure of the columellar incision created during an open rhinoplasty as rated by both patients and blinded clinicians.

Treating Nasal Valve Collapse in Facial Paralysis: What I Do Differently

Patients with facial paralysis require a systematic zonal assessment. One frequently overlooked region is the effect of facial paralysis on nasal airflow. Patients with flaccid paralysis experience increased weight of the cheek and loss of muscle tone in the ala and sidewall; this significantly contributes to nasal valve narrowing and collapse. These specific findings are often not adequately corrected with traditional functional rhinoplasty-grafting techniques. Flaccid paralysis typically results in inferomedial displacement of the alar base, which must be restored with suspension techniques to fully treat the nasal obstruction. Multiple surgical options exist and are discussed in this article.

Prelaminated paramedian forehead flap for subtotal nasal reconstruction using three-dimensional printing

Nasal reconstruction following a total or subtotal resection presents a challenging clinical scenario. Ample external skin coverage is readily available using the paramedian forehead flap (PMFF), but restoring adequate internal lining of sufficient size and pliability is a major limitation. Intranasal mucosal flaps or free tissue transfer is often employed for this purpose, each with their own sets of limitations. Prelamination of the PMFF with a skin graft prior to transfer is a method to create a composite flap with both internal and external lining. Another challenge in subtotal nasal reconstruction centres around restoring adequate dimensions to the nose without an existing template to work from. Three-dimensional (3D) printing has become an increasingly popular tool in reconstructive surgery as it captures precise patient-specific dimensions to guide reconstruction. Herein, we describe a case of subtotal nasal reconstruction using a prelaminated PMFF using a patient-specific 3D printed model as a template for reconstruction.

Hair Transplantation in Frontal Fibrosing Alopecia and Lichen Planopilaris: A Systematic Review

OBJECTIVE

Evolving hair transplantation (HT) techniques have offered new possibilities for hair restoration. However, the role of HT in patients with frontal fibrosing alopecia (FFA) and lichen planopilaris (LPP) remains unclear. This study aims to evaluate the outcomes and temporal relationship of HT in this population.

METHODS

A literature search of three databases was conducted. We reviewed 1) literature reporting outcomes of patients with LPP or FFA who received HT, and 2) studies reporting the development of LPP or FFA resulting from HT.

RESULTS

Thirteen articles included 42 patients that provided data for evaluation. Fifteen patients had previously been diagnosed with FFA or LPP, and the remaining 27 patients developed disease after undergoing HT. Seven patients with FFA and eight patients with LPP received HT, with a mean sustained disease remission of 2.69 years prior to HT. In total, two of seven (29%) patients with FFA and five of eight (75%) patients with LPP experienced positive HT results over a follow-up period of 8-72 months. Interestingly, 27 patients without evidence of previous disease developed FFA or LPP following HT after a median duration of 16 months.

CONCLUSIONS

HT for LPP and FFA is feasible but results may be less favorable compared to HT for other causes. Outcomes may be more favorable for LPP than FFA but this was not statistically significant and evidence is very limited. FFA and LPP can also develop following HT in patients without previous evidence of disease.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:59-66, 2021.

Comparison of Objective Outcomes in Dynamic Lower Facial Reanimation With Temporalis Tendon and Gracilis Free Muscle Transfer

Importance

Facial paralysis affects patients' physical, social, and psychological function. Dynamic smile reanimation can mitigate these effects, but there are limited data to guide the surgeon in selecting the best reanimation procedure for each patient.

Objective

To compare quantitative changes in oral commissure symmetry and smile excursion following temporalis tendon transfer (T3) and gracilis free muscle transfer.

Design, Setting, and Participants

Retrospective case series of 28 adults with unilateral facial paralysis seeking dynamic lower facial reanimation at a tertiary academic medical center between July 1, 2010, and July 30, 2014. Data were analyzed from May 1, 2016, to June 30, 2016.

Interventions

Minimally invasive T3 (n = 14) compared with gracilis free muscle transfer (n = 14).

Main Outcomes and Measures

Measured symmetry of the oral commissure between the healthy and paralyzed sides in the horizontal, vertical, and angular dimension and excursion of the paralyzed commissure following reanimation compared with the healthy commissure.

Results

Of the 28 patients, 19 (68%) were women; mean (SD) age was 51.7 (17) years. Commissure symmetry during smile improved significantly for the T3 patients in the vertical and angular dimensions, and the gracilis free muscle transfer patients had significant improvement in the vertical and horizontal dimensions. Commissure excursion significantly improved in both groups following surgery, with a larger improvement seen in the gracilis free muscle transfer group (11.3 mm; 95% CI, 7.0 to 15.5 mm) compared with the T3 group (4.8 mm; 95% CI, 0.2 to 9.3 mm), with a mean difference of 6.5 mm (95% CI, 0.7 to 12.4 mm; Cohen d, 0.86). Postoperative smile excursion of the paralyzed side was within 1.0 mm of the healthy side in the gracilis free muscle transfer group (95% CI, -2.1 to 4.0 mm).

Conclusions and Relevance

Temporalis tendon transfer and gracilis free muscle transfer both improve oral commissure symmetry and excursion in facial paralysis. The improvement in smile excursion appears to be larger in patients treated with gracilis free muscle transfer and, on average, the excursion approximates the contralateral healthy side.

Masseteric Nerve Transfer for Facial Nerve Paralysis: A Systematic Review and Meta-analysis

Importance

A review of the role of masseteric nerve transfer is needed to guide its use in facial reanimation.

Objective

To systematically review the available literature, and, when applicable, analyze the combined outcomes of masseteric nerve transfer to better define its role in reanimation and to guide further research.

Data Sources

Two independent researchers conducted the review using PubMed-NCBI and Scopus literature databases for studies on masseteric nerve transfer for facial nerve paralysis.

Study Selection

Studies that examined masseter nerve transfer with additional cranial nerve transposition/coaptation or muscle flap were excluded.

Data Extraction and Synthesis

Literature review and data extraction followed established PRISMA guidelines. Two researchers extracted data independently.

Main Outcomes and Measures

The main planned outcomes for the study were quantitative results of facial nerve movement after nerve transfer including oral commissure movement and time to nerve recovery.

Results

A total of 13 articles met inclusion criteria with a total of 183 patients undergoing masseteric nerve transfer. From those studies, there were a total of 183 patients who underwent masseteric nerve transfer. There were 85 men and 98 women with a mean (SD) age of 43 (12.2) years and mean (SD) follow up examination after surgery of 22 (7.6) months. Mean (SD) duration of nerve paralysis was 14 (6) months. Most common cause of paralysis was cerebellopontine angle tumors (81%). Six studies coapted the masseteric nerve to the main facial nerve trunk, whereas 7 used distal branches (buccal or zygomatic). Four studies used interposition nerve grafts with great auricular nerve. Two measures, improvement in oral commissure excursion and length from reanimation to facial movement, were measured consistently across the studies. Pooled analysis showed time from surgery to first facial movement, described in 10 studies, to be 4.95 months (95% CI, 3.66 to 6.24). Distal branch coaptation improved time to recovery vs main branch coaptation, 3.76 vs 5.76 months (95% CI, -0.33 to 4.32), but mean difference was not significant. The use of interposition graft significantly delayed time of nerve recovery, 6.24 vs 4.06 months (95% CI, 0.20 to 4.16). When controlled for main trunk coaptation only, interposition nerve graft delayed recovery but difference was no longer statistically significant, 6.24 vs 4.75 months (95% CI, -0.94 to 3.92). Reported complications were minor and rare occurring in only 6.5% (12 of 183) of patients.

Conclusions and Relevance

The masseteric nerve was found to be a good option for nerve transfer in this patient population, and showed favorable results in both time to nerve recovery and improvement in oral commissure excursion.

Level of Evidence

NA.

Conscious Perception of Facial Asymmetry in a Unilateral Cleft Lip Model

OBJECTIVE

Lip asymmetry after a unilateral cleft lip repair can be perceived as an unsatisfactory result. The objective of this study is to determine the degree of upper lip asymmetry and/or nasal alar hooding required for recognition of asymmetry in a simulated model of unilateral cleft lip.

DESIGN

A model of unilateral cleft lip was created using digital morphing software to simulate asymmetries in vermilion height and nasal hooding in photographs of children. Volunteers were shown photographs for different time intervals and with varying degrees of asymmetry. Ability to detect facial asymmetry was recorded and analyzed.

SETTING

This study was conducted by surveying layperson volunteers in public community settings.

PARTICIPANTS

108 layperson volunteers were randomly surveyed.

MAIN OUTCOME MEASURES

The primary outcome measure was a reported lip or nose asymmetry by the volunteers. Proportions and corresponding 95% confidence intervals were obtained to estimate the probability of reporting an asymmetry at 3- and 10-second intervals.

RESULTS

After 3- and 10-second exposure, labial asymmetry was perceived by ≥50% of subjects at 2 mm (62%, P = .001) and 1 mm (89%, P < .0001), respectively. Nasal asymmetry was detected by <50% of subjects at 3 seconds, but ≥50% perceived a 3-mm alteration at 10 seconds (64%, P < .0001). Photographs with combined nasal and labial modification did not lower the threshold for asymmetry perception compared to either deformity alone.

CONCLUSIONS

This study is the first to determine a predictable millimeter threshold for perceived asymmetry in cleft lip deformity using a digital model.

Differential expression of adhesion molecules by sinonasal fibroblasts among control and chronic rhinosinusitis patients

BACKGROUND

Chronic rhinosinusitis (CRS) is characterized by inflammatory cell migration into sinus tissue with resultant inflammation fueled by a milieu of cytokines. Fibroblasts may contribute to inflammation through expression of leukocyte adhesion molecules such as vascular cell adhesion molecule (VCAM) and intercellular adhesion molecule (ICAM). VCAM attracts eosinophils and mast cells contributing to Th2 skewing, and ICAM attracts neutrophils and to a lesser degree, eosinophils, and contributes to mixed Th1/Th2 skewing. The purpose of this study was to compare sinus fibroblast adhesion molecule expression ex vivo among CRS subtypes and in vitro after cytokine stimulation.

METHODS

Sinus biopsy specimens were taken from control patients (n = 13), CRS without nasal polyposis (CRSsNP, n = 6), and CRS with nasal polyposis (CRSwNP, n = 15). ex vivo levels of VCAM and ICAM were measured by flow cytometry from single cell suspensions of tissue biopsy specimens. Changes in VCAM and ICAM expression to cytokine exposure were assessed using in vitro cultured sinonasal fibroblasts treated with tumor necrosis factor (TNF)-α, interleukin (IL)-4, or interferon (IFN)-γ.

RESULTS

ex vivo VCAM expression was lowest in controls, higher in CRSsNP, and highest in CRSwNP. in vitro stimulation with TNF-α and IL-4, but not IFN-γ, increased VCAM among CRSsNP, while expression in CRSwNP remained elevated with all treatments except IFN-γ. ex vivo ICAM expression was elevated in both CRS subtypes. in vitro stimulation with TNF-α and IFN-γ, but not IL-4, increased ICAM expression in all patients with the largest effects among the CRSsNP subgroup.

CONCLUSION

Sinonasal fibroblast expression of adhesion molecules in sinusitis varies by disease state and is selectively influenced by exposure to inflammatory cytokines.

The impact of adenoid size on rate of revision sphincter pharyngoplasty

OBJECTIVES/HYPOTHESIS

Determine the impact of adenoid size and prior adenoidectomy on outcomes of sphincter pharyngoplasty.

STUDY DESIGN

Retrospective review.

METHODS

Retrospective review of patients 18 years of age or younger, who underwent sphincter pharyngoplasty for velopharyngeal insufficiency (VPI) from 2007 to 2012. Nasal endoscopy and nasometry testing were administered pre- and postoperatively. Preoperative adenoid size was scored by two blinded otolaryngologists. Primary outcome measures were sphincter pharyngoplasty revision rate, achievement of normal resonance, and degree of improvement in nasometry scores.

RESULTS

Eighty-six patients were included in this study. The overall rate of revision sphincter pharyngoplasty was 28%. Patients with mild adenoid hypertrophy underwent less revision surgery (14%) than patients with moderate to severe adenoid hypertrophy (38%, P = .046). Subgroup analysis was performed based on prior repair of cleft or submucous cleft palate and history of 22q11 microdeletion. Smaller adenoids were associated with lower surgical revision rates in patients who did not have a history of cleft palate or 22q11 microdeletion (P = .014 and .018, respectively). Adenoid size did not impact revision rates in patients with repaired cleft palates or those with 22q11 microdeletions.

CONCLUSIONS

Smaller or absent adenoids are associated with lower rates of revision surgery after sphincter pharyngoplasty in children with VPI. Patients with VPI and bulky adenoids, who do not have a history of cleft palate or 22q11 microdeletion, should be considered for adenoidectomy prior to sphincter pharyngoplasty.

Swallowing Outcomes in Mandibular Osteoradionecrosis Treated with Free Tissue Transfer

Objectives:

Evaluate swallowing outcomes after free tissue transfer (FTT) reconstruction for mandibular osteoradionecrosis (ORN), using aspiration and postoperative tube feed (TF) dependence as surrogates for swallowing ability.

Methods:

Study Design: Case series with chart review. All patients undergoing osteocutaneous FTT reconstruction in an academic tertiary-care hospital for mandibular ORN from 2004-2012 were reviewed. Preoperative patient characteristics, postoperative aspiration, and postoperative TF dependence were noted for each patient. Analysis of patient factors associated with aspiration or TF dependence was performed using Pearson correlation and Fisher’s exact test (when appropriate).

Results:

Sixteen patients met inclusion criteria with an average age of 63.4 years (range 36-81 years) and median follow up of 20 months (range 3-72 months). TF dependence pre- and post-operatively was total dependence in 25% vs. 31%, partial in 25% vs. 31%, and none in 50% vs. 38%, with strong correlation between pre and post-operative TF dependence (r = 0.524, P = 0.04). Aspiration at postoperative follow-up correlated with long-term TF dependence (r=0.701, P < 0.01). Less aspiration was seen after scapular FTT compared to fibular, but this did not reach statistical significance (22% vs. 57% respectively, P = 0.62). Females had lower aspiration rates than males (r = 0.595, P = 0.02), and all females in this study were treated with scapular FTT. Tracheostomy decannulation was achieved in 94% (15/16) of patients.

Conclusions:

TF dependence following osteocutaneous FTT for ORN correlates with pre-operative TF dependence and post-operative aspiration. Aspiration is less likely in females and patients receiving scapular FTT.

Cytokine correlation between sinus tissue and nasal secretions among chronic rhinosinusitis and controls

OBJECTIVES/HYPOTHESIS

Compare cytokine levels in sinus tissue to sinus secretions from controls and chronic rhinosinusitis patients.

STUDY DESIGN

In vitro.

METHODS

Polyurethane foam sponges were placed into middle meati of patients with chronic rhinosinusitis without nasal polyps (CRSsNP), with polyps (CRSwNP), and controls. Sinus biopsies were then taken from the same location. Protein levels of tumor necrosis factor-alpha (TNF-α), interferon-γ (IFN-γ), and interleukins (IL) 2, 4, 6, 8, 10, and 17A were measured via cytometric bead assay for each sample. Protein values from sinus tissue and secretions were compared with Pearson's correlation between samples as well as one-way ANOVA with posthoc t test between groups.

RESULTS

Samples from 43 patients in total were examined. Mucus was measured from 10 controls, 11 CRSsNP and 10 CRSwNP, and sinus tissue was measured from 10 controls, 15 CRSsNP and 10 CRSwNP. IL-8 and IFN-γ levels were outside of the detectable range of the assay. Levels of secreted IL-2, 4, 6, 10, and 17A correlated with tissue levels (P < 0.05 for all, r > 0.49) while TNF-α did not (P = 0.71). CRSsNP had elevated mucus levels of IL-2, 4, 6, 10, and 17A compared to controls. CRSwNP had elevated mucus levels of IL-4, 6, 10, 17A, and TNF-α compared to controls.

CONCLUSIONS

Cytokine levels in sinus secretions correlate with levels in sinus tissue and are elevated in CRS versus control based on Th1/Th2 skewing.

Prognostic Impact of Age in Differentiated Thyroid Cancer

Objective: 1) Determine the impact of age on disease-specific survival in differentiated thyroid cancer. 2) Compare the impact of age on survival between follicular and papillary thyroid cancer subtypes.

Method: The SEER Database was searched for patients with differentiated thyroid cancer between 1988-2003. Patient age, gender, tumor type, size, extension, and metastases were collected. Kaplan-Meier analyses were used to estimate disease specific survival based on age ranges. A multivariate analysis was performed to determine hazard ratios of death for various age cutoffs.

Results: A total of 42,209 patients were identified. Patients 45 years and older had significantly worse survival than younger patients ( P < .001). A significant decrease in disease specific survival was first seen in patients aged 35 years and older, and survival continued to steadily decrease with each additional decade of age ( P < .001). Patients aged 35 years and older were 14 times more likely to die from differentiated thyroid cancer than patients younger than 35. Age played a stronger prognotic role in death among patients with papillary carcinoma compared to follicular carcinoma.

Conclusion: Increasing age is associated with poorer survival in differentiated thyroid cancer. This relationship represents a continuum with an initial decrease in survival starting at age 35 that continues to decline with advancing age.

Endoscopic brow approach for frontal osteoma in a pediatric patient

Osteomas are benign bony growths that have been reported following trauma. Previous management of forehead osteomas has centered around direct excision, but there has been a recent interest in endoscopic resection to improve cosmesis. Endoscopic resection has previously been described in adults, but not in children. We describe a case of a 15-year-old who developed a forehead osteoma following trauma that was resected entirely endoscopically, leaving no visible scar with resolution of edema and good cosmetic result as early as post-operative day 9. Our case lends evidence to support the safe and effective use of this technique in adolescents.

Antimicrobials and chronic rhinosinusitis with or without polyposis in adults: an evidenced-based review with recommendations

BACKGROUND

Chronic rhinosinusitis (CRS) is characterized by inflammation of the mucosa of the nose and paranasal sinuses. The role of bacterial or fungal infection in CRS is unclear, yet antimicrobials are commonly prescribed for this condition. Published guidelines offer little direction regarding antibiotic strategies for CRS. The purpose of this article is to provide an evidence-based approach to the use of antibacterial and antifungal antibiotics in the management of CRS.

METHODS

A systematic review of the literature was performed following recommendations of the Clinical Practice Guideline Manual, Conference on Guideline Standardization (COGS), and the Appraisal of Guidelines and Research Evaluation (AGREE). Inclusion criteria were: age ≥18 years old, chronic rhinosinusitis with or without polyps, antibiotic treatment as the experimental group, and clearly defined primary clinical endpoint. Studies involving patients with cystic fibrosis or acute invasive fungal sinusitis were excluded.

RESULTS

The review identified and evaluated the literature on 8 classes of antimicrobials for CRS: oral antibacterial antibiotics ≤3 weeks, oral antibacterial antibiotics >3 weeks, macrolide antibiotics, intravenous antibacterial antibiotics, topical antibacterial antibiotics, oral antifungals, intravenous antifungals, and topical antifungals.

CONCLUSION

Based on the available evidence, oral antibacterial antibiotics and prolonged macrolide antibiotics are considered therapeutic options in the treatment of CRS while the use of topical antibacterial antibiotics, intravenous antibacterial antibiotics and oral, topical, or intravenous antifungals would be recommended against. These evidence-based recommendations should not necessarily be applied to all patients with CRS and are not intended to supersede clinical judgment based on individual patient circumstances.

Reevaluating the Prognostic Significance of Age in Differentiated Thyroid Cancer

Objective

To determine the impact of age on disease-specific survival in differentiated thyroid cancer.

Study Design

Retrospective analysis of a large population database.

Setting

Surveillance, Epidemiology, and End Results (SEER) database/multiple settings.

Subjects and Methods

The SEER database was examined to identify patients diagnosed with either papillary or follicular carcinoma of the thyroid between the years 1988 and 2003. Information obtained included patient age, sex, tumor type, size, extension, and nodal or distant metastases. Kaplan-Meier survival analyses were used to estimate disease-specific survival based on patient age range, and the log-rank test was used to assess for statistical differences between survival curves. A multivariate analysis was performed including the variables listed above to determine disease-specific hazard ratios of death for various age cutoffs.

Results

A total of 42,209 patients were identified. Patients 45 years and older had significantly worse survival than younger patients ( P < .0001). A significant decrease in disease-specific survival was first seen in patients aged 35 years and older, and survival continued to steadily decrease with each additional decade of age ( P < .001). Patients aged 35 years and older were 14 times more likely to die from differentiated thyroid cancer than patients younger than 35 years.

Conclusion

Increasing age is associated with poorer survival in differentiated thyroid cancer. This relationship represents a continuum with an initial decrease in survival starting at age 35 years that continues to decline with further advancing age.

Influence of Anxiety and Depression on the Predictive Value of the Reflux Symptom Index

Objectives:

Although the Reflux Symptom Index (RSI) is a validated laryngopharyngeal reflux (LPR) outcomes tool, its predictive value for LPR is controversial. Because psychiatric problems may lead to exaggerated patient-perceived symptoms and RSI values, the aim of this study was to determine whether the positive predictive value of the RSI for pH probe–documented LPR is influenced by anxiety and depression.

Methods:

We reviewed the charts of all patients who underwent pH probe testing for LPR between January 2006 and July 2008 at our institution. The RSI, Reflux Finding Score (RFS), medical history, and pH probe findings were recorded. Patients with anxiety or depression were included in the psychiatric disorder (+PSY) group, and those without anxiety or depression comprised the non–psychiatric disorder (–PSY) group. Predictive values of the RSI for pH probe–documented LPR were determined for each group.

Results:

We included 51 patients: 30 patients (59%) in the –PSY group and 21 patients (41%) in the +PSY group. The mean RSI of the +PSY group was higher than that of the –PSY group (p < 0.05), but the +PSY patients actually had a lower incidence of abnormal probe studies (p < 0.02). The positive predictive value of an elevated RSI for an abnormal pH probe study was poor in the +PSY patients (p = 0.495), but strong in the –PSY group (p = 0.004).

Conclusions:

The presence of anxiety and depression impairs the predictive value of the RSI for LPR. This finding potentially explains some of the controversy over the diagnostic utility of the RSI.

Diverse gene expression and DNA methylation profiles correlate with differential adaptation of breast cancer cells to the antiestrogens tamoxifen and fulvestrant

The development of targeted therapies for antiestrogen-resistant breast cancer requires a detailed understanding of its molecular characteristics. To further elucidate the molecular events underlying acquired resistance to the antiestrogens tamoxifen and fulvestrant, we established drug-resistant sublines from a single colony of hormone-dependent breast cancer MCF7 cells. These model systems allowed us to examine the cellular and molecular changes induced by antiestrogens in the context of a uniform clonal background. Global changes in both basal and estrogen-induced gene expression profiles were determined in hormone-sensitive and hormonal-resistant sublines using Affymetrix Human Genome U133 Plus 2.0 Arrays. Changes in DNA methylation were assessed by differential methylation hybridization, a high-throughput promoter CpG island microarray analysis. By comparative studies, we found distinct gene expression and promoter DNA methylation profiles associated with acquired resistance to fulvestrant versus tamoxifen. Fulvestrant resistance was characterized by pronounced up-regulation of multiple growth-stimulatory pathways, resulting in estrogen receptor alpha (ERalpha)-independent, autocrine-regulated proliferation. Conversely, acquired resistance to tamoxifen correlated with maintenance of the ERalpha-positive phenotype, although receptor-mediated gene regulation was altered. Activation of growth-promoting genes, due to promoter hypomethylation, was more frequently observed in antiestrogen-resistant cells compared with gene inactivation by promoter hypermethylation, revealing an unexpected insight into the molecular changes associated with endocrine resistance. In summary, this study provides an in-depth understanding of the molecular changes specific to acquired resistance to clinically important antiestrogens. Such knowledge of resistance-associated mechanisms could allow for identification of therapy targets and strategies for resensitization to these well-established antihormonal agents.