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Background Delayed nonspecific posterior neck pain after pharyngeal instrumentation can be associated with a syndrome of rapidly progressive neurologic embarrassment. We present this cohort to help define the syndrome and aid in early detection. Methods We conducted a retrospective case series of 6 patients presenting from 2003 to 2012 with a history of laryngeal or hypopharyngeal squamous cell carcinoma (SCC) who underwent radiotherapy (RT) or chemoradiotherapy (CRT) followed by salvage laryngectomy. Results Posterior neck and upper back pain developed a mean of 27.5 days after instrumentation of the pharynx (reconstruction after laryngectomy or pharyngeal dilation). Myelopathy developed an average of 21.5 days after the onset of posterior neck pain. Five patients required urgent decompression. Three patients developed quadriplegia. The disease-specific mortality was 50%. Conclusion There is a syndrome of late neurological effects after RT, salvage surgery, and pharyngeal instrumentation that is associated with high morbidity and mortality. © 2015 Wiley Periodicals, Inc. Head Neck, 2015

Background: Postblepharoplasty lower eyelid retraction (PBLER) has been linked to anterior lamellar shortage, unaddressed eyelid laxity, and middle lamellar scarring. The authors believe there are other, less-appreciated physical findings (orbicularis weakness, negative-vector eyelid, and inferior eyelid/orbit volume deficit) that also influence the development and potentially the management of this complex type of eyelid malposition. Objectives: To better understand PBLER, potentially prevent its development, and improve treatment options, the authors determined the incidence of various physical findings present on initial examination of patients referred for PBLER revision. Methods: The medical charts of patients referred for PBLER revision over a 21-month period were reviewed. The presence of anterior lamellar shortage, lower eyelid laxity, and a middle lamellar (internal eyelid) scar was documented. Orbicularis weakness, negative-vector eyelid topography, and volume deficiency of the lower eyelid/inferior orbit also were noted. The incidence of each finding was calculated. Results: Forty-six patients (35 women, 11 men) were included. All patients had undergone primary transcutaneous surgery, which led to the eyelid retraction. Orbicularis weakness, anterior lamellar shortage, inferior eyelid/orbital volume deficit, negative-vector eyelid topography, and eyelid laxity were common. A middle lamellar scar of significance was found in only 17% of eyelids. Conclusions: The data suggest that the aforementioned underappreciated findings are common in patients with PBLER. Evaluating these factors when planning primary blepharoplasty may reduce the incidence of PBLER. Awareness of these findings when planning revisional procedures may improve surgical outcomes. Level of Evidence: 4 ![Graphic][1] [1]: /embed/inline-graphic-1.gif

There are more surgical and medical options for treating patients with facial nerve injury than ever before. However, little high-quality outcomes research has been performed comparing these different interventions. Fortunately, there are a number of well-validated outcomes measures available to evaluate patients with facial nerve injury. This manuscript categorizes and summarizes these tools.

Chronic facial paralysis is a challenging clinical entity. One of the primary goals is re-establishment of a dynamic smile, which is so important to everyday social interaction. When the facial muscles are denervated for longer than approximately 2 years, they atrophy and fibrose making nerve transfer procedures ineffective. In these cases, regional or free muscle transfer is necessary to achieve dynamic facial movement. Over the past decade, orthodromic temporalis tendon transfer has become a favored facial reanimative procedure. The surgical technique, and important pre- and postoperative factors, are discussed.

Facial nerve injuries are debilitating events for patients. In many cases recovery is spontaneous and complete; in others prompt medical and/or surgical intervention will be necessary to improve the patient’s outcome. Objective measurements are valuable tools that can help identify candidates for intervention. Electroneuronography and electromyography are the most commonly used objective measures of facial function. Basic examination techniques and recording parameters are discussed. A literature review indicated that, depending on the criteria used, Electroneuronography was 50-91% accurate (Positive Predictive Value or PPV) in identifying individuals requiring intervention and 80-100% accurate in predicting those who recover spontaneously (Negative Predictive Value or NPV). Electromyography can be used to assess both volitional movements (PPV 75-91% and NPV 62-89%) and for spontaneous activity (PPV 80-100% and NPV 92-96%). Attention is paid to how grading criteria and the timing of the examinations impacts the accuracy of both Electroneuronography and Electromyography. Specific protocols are suggested for patients with facial nerve injury.

Full-thickness nasal deformities are a reconstructive challenge. Restoration of a reliable internal lining is critical for a successful reconstruction. Septal hinge flaps are the workhorse for internal lining defects. However, these and other intranasal mucosal flaps are sometimes unavailable due to prior harvest or previous oncologic resection. We present the two-stage interpolated subcutaneous fat pedicle melolabial flap for lining large defects when traditional intranasal flaps are unavailable. This approach is particularly useful when one forehead flap has already been expended, preserving the patient's remaining forehead tissue for external cover.

The multidisciplinary approach to treatment of amyotrophic lateral sclerosis (ALS) has improved the overall care of patients suffering from this disease ( 1 , 2 ). This approach typically has included neurologists, physiatrists, occupational therapists, respiratory therapists and speech therapists. Dysphonia, dysarthria, and dysphagia are three of the most common bulbar manifestations of ALS, and are often the presenting symptoms in bulbar-onset patients. Despite this, otolaryngologists are often not included in ALS management until a tracheostomy is considered. The otolaryngologist can play an important role in early diagnosis and subsequent management of bulbar manifestations of ALS, and would be a valuable member of the multidisciplinary team.

Delayed nonspecific posterior neck pain after pharyngeal instrumentation can be associated with a syndrome of rapidly progressive neurologic embarrassment. We present this cohort to help define the syndrome and aid in early detection.We conducted a retrospective case series of 6 patients presenting from 2003 to 2012 with a history of laryngeal or hypopharyngeal squamous cell carcinoma (SCC) who underwent radiotherapy (RT) or chemoradiotherapy (CRT) followed by salvage laryngectomy.Posterior neck and upper back pain developed a mean of 27.5 days after instrumentation of the pharynx (reconstruction after laryngectomy or pharyngeal dilation). Myelopathy developed an average of 21.5 days after the onset of posterior neck pain. Five patients required urgent decompression. Three patients developed quadriplegia. The disease-specific mortality was 50%.There is a syndrome of late neurological effects after RT, salvage surgery, and pharyngeal instrumentation that is associated with high morbidity and mortality. © 2016 Wiley Periodicals, Inc. Head Neck 38:1187-1193, 2016.

Chronic facial paralysis is a devastating condition with severe functional and emotional consequences. The current surgical armamentarium permits the predictable reestablishment of a protective blink as well as good resting symmetry. Yet the ultimate goal of symmetric, spontaneous emotional expression remains elusive despite significant progress in the areas of peripheral nerve grafting and free tissue transfer. This commentary explores the possibility of an implantable electrical prosthesis for facial reanimation. It reviews animal studies supporting this concept as well as recent human data suggesting that such an implant could rescue denervated facial musculature, thus overcoming a major hurdle for existing reanimation techniques.

Facial paralysis denervates the orbicularis oculi muscle with important functional and cosmetic deficits. When an intact neural circuit between the brainstem and orbicularis oculi cannot be reestablished, nerve transfer techniques are often utilized. The hypoglossal nerve has been the favored donor nerve for the past 40 years. The past 5 years has witnessed an increased interest in using the masseteric nerve due to its lower incidence of donor deficit and excellent static and dynamic results. We describe the surgical technique for end-to-end masseteric to facial nerve transfer and summarize the published results.

The globe retropulsion and eyelid depression (GRED) technique is described. This involves simultaneous unimanual lower lid depression and globe retropulsion (over the closed upper lid) with two fingers of one hand. The maneuver reliably promotes direct entry to the clearly delineated post-septal fat compartment, obviates the need for an assistant to create this exposure, and does not obscure the globe or lower lid from view.

Endoscopic browlifting techniques have been progressively refined through experience and improvements in equipment. In general, the temporal dissection and temporal fixation have been standardized; however, different options for forehead dissection are available. Subperiosteal dissection with release (elevation, incision, and spread) of the periosteum, or subgaleal dissection and release of brow depressor musculature to the supraorbital rim are both effective techniques used in endoscopic browlifts. Methods of bony fixation remain a controversial topic since there are numerous methods. Some of these methods include absorbable and nonabsorbable screws, bone tunnels with sutures, fixation to soft tissue using absorbable attachment devices such as Endotine or Ultratine (MicroAire, Charlottesville, VA), and fibrin glue. In many, particularly younger patients, we advocate deep temporal fixation only (DTFO) without bone fixation.

The title of this chapter is descriptive in that it reviews a posterior eyelid (conjunctival) approach to cosmetic rejuvenation of the lower eyelid. The designation of the procedure as transconjunctival is important in that it differentiates surgery from the more traditional transcutaneous (through the skin) approach. Transconjunctival blepharoplasty has become the most common approach to cosmetic lower lid surgery over the last decade.1 Since I have been in practice, I have only rarely performed transcutaneous lower blepharoplasty, and not at all in the last 7 years. This is because, in my critical evaluation of this surgery and in my hands, the posterior eyelid approach yields excellent results, with high patient satisfaction and fewer complications.

The role of maternal experience (i.e., pregnancy and pup exposure) on rats' performance in a foraging task was assessed. Primiparous (P) and nulliparous (N) animals were either exposed to pups for 21 days (+) or received no pup exposure (−). Following habituation trials, all animals were tested in spatial and cued versions of the dry land maze (DLM) for three days (three trials per day). In the spatial DLM, the presence of pups decreased latencies in both N and P groups in Trial 5 and P+ rats exhibited shorter latencies to baited food wells than P− animals on Trial 6. In the subsequent probe trial, P+ animals spent significantly more time in proximity to the previously baited well than P− rats. Pups enhanced performance of both P+ and N+ groups in trial 6 of the cued test. Thus, in the spatial task, the individual components of the maternal experience (e.g., pregnancy, parturition, lactation, and pup exposure) converge to produce behavioral modifications in the DLM spatial and probe tasks that enable the female to care for her offspring, in this case, by enhancing foraging behavior. Further, in one trial of each version of the task, pup exposure enhanced performance in N animals suggesting that, in isolation, pup exposure may be a more important influence on ancillary maternal behavior than the pregnancy itself.

Objective: Document the use of transmastoid labyrinthectomy to treat disabling vertigo secondary to a lesion in the internal auditory canal. Patient: A 69-year-old man with nonserviceable left hearing experienced disabling attacks of vertigo refractory to medical measures. Magnetic resonance imaging revealed a small left intracanalicular lesion with an irregular configuration and modest enhancement, suggesting either an unusual acoustic neuroma or a cavernoma. Tumor size remained stable on serial imaging, and the patient declined microsurgical resection, stereotactic radiation, or intratympanic gentamicin therapy. Intervention: Transmastoid labyrinthectomy followed by a customized vestibular rehabilitation program. Main Outcome Measure: Comparison of patient symptoms preoperatively and at 5 and 8 months after surgery. Results: Complete relief of vertigo was achieved, but the patient has moderate imbalance postoperatively. Conclusion: Transmastoid labyrinthectomy alone may be a viable treatment option in patients with an internal auditory canal neoplasm causing disabling attacks of vertigo.

IMPORTANCE Identifying a procedure to address lower eyelid retraction (LER) in the presence of an orbicularis deficit is a useful tool for aesthetic and reconstructive eyelid surgery. OBJECTIVE To describe and evaluate a surgical technique consisting of a closed canthal suspension and true lower eyelid retractor recession to address LER in the setting of orbicularis weakness. DESIGN, SETTING, AND PARTICIPANTS A retrospective medical record review of patients who underwent the minimally invasive, orbicularis-sparing, lower eyelid recession from January 1, 2010, to October 1, 2012, by one of us (G.G.M.) in an ophthalmic plastic surgical practice. We included 29 patients with reduced orbicularis strength and LER resulting from eyelid paresis related to facial nerve disease, surgical trauma (after blepharoplasty), involutional change, or idiopathic causes. INTERVENTIONS Surgical intervention consisting of closed canthal suspension and lower eyelid retractor recession. MAIN OUTCOMES AND MEASURES Surgical results, complications, and patient satisfaction. RESULTS The 29 patients included 18 women and 11 men. The mean patient age was 52 (range, 6-72) years; mean follow-up, 11 (range, 6-21) months; and mean preoperative orbicularis strength, 2.7 (on a scale of 0-4, where 0 indicates no function and 4, normal function). The causes of orbicularis weakness included eyelid paresis related to facial nerve disease (11 patients), surgical trauma (13 patients), involutional change (4 patients), and an isolated idiopathic finding (1 patient). In 12 patients, the eyelid retraction was unilateral; in 17, bilateral. A small tarsorrhaphy was added to the surgery in 6 patients with facial nerve disease. The mean eyelid elevation after surgery was 1.80 mm, with only minor complications. Patient and surgeon satisfaction were high. CONCLUSIONS AND RELEVANCE Recent publications have demonstrated the utility of closed canthal suspension and true lower eyelid retractor recession as separate procedures. In the setting of LER with reduced orbicularis strength and/or tone, the techniques can be combined to recess the lower eyelid without disturbing the already compromised lower orbicularis muscle (minimally invasive, orbicularis-sparing, lower eyelid recession). The combination technique is safe and effective and yields excellent results. LEVEL OF EVIDENCE 4.

Pediatric airway foreign body is a relatively rare but potentially life-threatening event. A significant proportion of foreign body aspirations are unwitnessed, and there are often few early symptoms after the initial coughing/gagging episode. Hence, practitioners must have a high index of suspicion for this diagnosis in any child that presents after such an event. Initially undiagnosed airway foreign body can present later with new or atypical wheezing, cough, stridor, or pneumonia. Once diagnosed, safe removal of a pediatric airway foreign body requires effective communication and coordination between the surgeon, OR staff, and anesthesiologist. This module includes a simulation case, pre- and posttests, an instructional PowerPoint presentation, and case and performance evaluations. The amount of time required to complete the case will vary with the experience of the participant. Junior residents averaged 90 minutes and senior residents 75 minutes in the authors' experience. Fellows and attending physicians may need just 45–60 minutes. This training experience has been successfully employed to train junior and senior otolaryngology residents in the cognitive, procedural, and interpersonal skills required to manage a pediatric airway foreign body. A study confirming face and construct validity for the case has been published and is included in the reference materials. This study included 7 junior and 5 senior otolaryngology trainees, and was administered by two otolaryngology faculty. In July 2012, the simulation was additionally administered by a group of 5 pediatric otolaryngology faculty to a new group of 16 otolaryngology residents during a weekend Otolaryngology Simulation course. The pediatric airway foreign body simulation is now performed with all junior otolaryngology residents at the University of Michigan at the beginning of their first pediatric otolaryngology rotation. This improves patient safety, teaches critical fundamentals of pediatric bronchoscopy, and allows trainees to make better use of operating room time with live patients.

The concept of the ideal female eyebrow has changed over time. Modern studies examining youthful brow aesthetics are reviewed. An analysis of ideal female brow characteristics as depicted in the Western print media between 1945 and 2011 was performed. This analysis provided objective evidence that the ideal youthful brow peak has migrated laterally over time to lie at the lateral canthus. There has been a nonstatistically significant trend toward lower and flatter brows. These findings are discussed in relation to current concepts of female brow aging, with repercussions regarding endoscopic brow lift and aesthetic forehead surgery.

Objective To characterize revision surgery following V-Y subcutaneous tissue pedicle advancement flap repair of large upper lip skin defects. Methods Retrospective review of upper lip skin defects at least 3.0 cm 2 in area that were reconstructed with a V-Y subcutaneous tissue pedicle advancement flap at an academic tertiary care center. Depth and area of the defect, as well as involvement of the vermilion and nasal ala, were recorded as independent variables. Revision techniques were analyzed to identify patterns. Results Thirty patients were identified as having upper lip skin defects with a mean (range) area of 7.0 (3.0-14.0) cm 2 (median, 6.25 cm 2 ). The defect involved the nasal ala in 4 cases and the vermilion in 3 cases. At least 1 revision surgery was performed in 14 patients (47%). Alar or vermilion involvement was a significant factor in revision by χ 2 analysis (P = .03). Larger defect size did not predict a need for revision, even among cases where the defect did not involve the ala or vermilion (P = .68). Conclusions Reconstruction of large upper lip skin defects with a V-Y subcutaneous tissue pedicle advancement flap is associated with a 47% revision rate, and when the defect involves the ala or vermilion, the revision rate is increased. Defect size alone cannot be used to predict the need for revision surgery. Revision techniques are demonstrated.

Objectives: We evaluated the validity and efficacy of a pediatric airway foreign body simulation for otolaryngology resident training. Methods: We created a course using a high-fidelity toddler mannequin designed to instruct and evaluate otolaryngology residents in pediatric airway foreign body management. Seven junior and 5 senior residents participated. Their performance was evaluated by 2 observers using an Objective Structured Assessment of Technical Skills (OSATS) instrument. Results: By the third trial, all junior and senior residents scored a proficiency level of “independent without errors” or “independent and efficient,” and the performance of the junior residents was not different from that of the senior residents. After completing the course, the junior residents self-rated their abilities as commensurate with those of a senior resident, and senior residents rated themselves capable of performing foreign body extraction without supervision. All participants felt that the course and simulator had good overall realism and a realistic feel, demonstrating face validity. Perhaps most importantly, the residents' highest ratings were for “facilitated management of complications” and “facilitated working with the operating room team” — areas difficult to teach during live surgical procedures. Conclusions: This pediatric airway foreign body course using a high-fidelity simulator has face and construct validity, and results in statistically improved performance and self-evaluation of all participants.

Campomelic dysplasia is a rare and historically lethal skeletal dysplasia with a variable but recognizable phenotype; it affects the long bones and is associated with a variety of head and neck anomalies. Mutations in or around the SOX9 gene have been identified as the molecular origin in most patients. We briefly present 2 children who meet the diagnostic criteria for campomelic dysplasia to illustrate the various clinical manifestations. Many patients with campomelic dysplasia have airway obstruction at multiple levels. We describe our approach to managing the airway in these patients, and review recent advances in understanding how SOX9 mutations lead to the spectrum of abnormalities seen in the head and neck.

Maternal behavior is multidimensional, encompassing many facets beyond the direct care of the young. Formerly unfamiliar activities are required of the mother. These include behaviors such as retrieving, grouping, crouching-over, and licking young, and protecting them against predators, together with enhancements in other behaviors, such as nest building, foraging, and aggression (inter/intra-species, predatory, etc.). When caring for young, the mother must strike a seemingly lose-lose bargain: leave the relative safety of the nest and her helpless offspring to forage for food and resources where predators await both mother and her vulnerable young, or remain entrenched and safe, thereby ensuring a slow and inexorable fate. Two predictions thus arise from this maternal cost-benefit ratio: first, there may be enhancements in behaviors on which the female relies, for example, predation and spatial ability, used for acquiring food and resources and for navigating her environment. Second, there may be reductions in the fear and anxiety inherent to the decision to leave the nest and to forage in an unforgiving environment where encounters with predators or reluctant/resistant prey await. There is overwhelming support for both hypotheses, with improvements in learning and memory accompanied by a diminution in stress responses and anxiety. The current review will examine the background for the phenomenon that is the maternal brain, and recent relevant data. In sum, the data indicate a remarkable set of changes that take place in the maternal (and, to a lesser extent, the paternal), brain, arguably, for the natural, simple but singular experience of reproduction.

To compare objective outcomes and complications following temporalis tendon transfer in patients with and without a history of radiation to the parotid bed.Retrospective medical chart review comparing dynamic movement of the oral commissure and resting symmetry achieved in 7 irradiated patients (group R) and 7 nonirradiated patients (group N) after temporalis tendon transfer for unilateral facial paralysis.There were no significant differences between the 2 groups of patients in terms of age, additional facial reanimative procedures, baseline lip position, or follow-up time. Postoperatively, good resting symmetry was achieved in both groups. The mean commissure excursion was significantly inferior in the irradiated group of patients (-1.5 mm in group R vs 2.1 mm in group N; P.05). Two patients in the irradiated group experienced surgical site infections requiring hospital admission and eventual debridement of their tendon transfers.Temporalis tendon transfer seems to produce less dynamic movement in patients who have received radiation to the parotid bed, and these patients may also be at higher risk of postoperative infection. Temporalis tendon transfer can achieve good resting symmetry in both irradiated and nonirradiated patients.