Peraza, Lazaro R.

Abstract To review key concepts in facial nerve anatomy, physiology, injury mechanisms, and recovery patterns, and to summarize current approaches to classification, evaluation, and management of facial nerve dysfunction following skull base surgery. Narrative review of anatomical, clinical, and evaluative frameworks relevant to facial nerve dysfunction. Academic and clinical contexts involving the assessment and management of facial nerve injury, with emphasis on skull base surgery. Not applicable; this is a literature-based review. Descriptions of facial nerve anatomy and microanatomy; established classification systems for facial nerve injury; mechanisms of injury; patterns of recovery; common clinical presentations of post-surgical facial paralysis; and current grading scales and evaluation protocols. The review synthesizes foundational anatomical principles with contemporary understanding of facial nerve injury and recovery. It outlines the full spectrum of clinical outcomes observed after facial nerve injury, including typical post-surgical paralysis patterns and their natural course. Commonly used facial paralysis grading scales are compared, and standardized evaluation strategies are highlighted to promote consistent assessment across providers. Taken together, the findings provide a comprehensive framework for understanding and evaluating facial nerve dysfunction following skull base surgery. Understanding and treating facial nerve dysfunction requires nuanced knowledge of anatomy, injury mechanisms, recovery trajectories, and standardized evaluation methods. Consolidating these elements offers valuable guidance for skull base surgeons, facial plastic surgeons, and other clinicians caring for patients with facial paralysis, and supports more consistent and informed clinical decision-making.

Abstract Objective To describe the presenting symptoms, treatment regimens, and outcomes associated with oropharyngeal adenoid cystic carcinoma. Data Sources Ovid MEDLINE(R), Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, and Scopus via Elsevier. Review Methods This review followed the Preferred Reporting Items for Systematic Reviews and Meta‐analyses. A medical librarian conducted the literature search using controlled vocabulary and keywords, with investigator input. Eligible articles were clinical trials and observational studies reporting on clinical features, treatment, or outcomes for oropharyngeal adenoid cystic carcinoma. Results Our search identified 233 unique citations, with 44 articles included covering 195 patients. The female‐to‐male ratio was 1.7:1, and the base of the tongue was the most common subsite (73%). Presenting symptoms were mainly pain/discomfort (n = 31), followed by a palpable mass (n = 19) and dysphagia (n = 12). At diagnosis, 22.3% (29 patients) had positive lymph nodes. Treatment was primarily surgical (n = 102), with definitive radiation therapy used in 58 cases. Disease progression was noted in 86 patients, 36% (n = 31) of whom developed distant metastases—primarily to the lungs (n = 26). Long‐term outcomes (n = 76) showed 3‐ and 5‐year overall survival rates of 71.5% to 100% and 47.6% to 79.0%, and disease‐free survival rates of 54.7% to 70.0% and 21.9% to 44.0%, respectively. Conclusion Among patients with available data, oropharyngeal adenoid cystic carcinoma appeared more common in women and has a predilection for the base of the tongue. However, this finding should be interpreted with caution, given the high proportion of missing data. These tumors appear to carry a higher risk for nodal metastases and may lead to poor outcomes.

Background: Facial nerve injury can result in a spectrum of clinical presentations from complete facial paralysis (CFP) to facial synkinesis. Willingness to pay (WTP) and quality-adjusted life years are established metrics used to assess the societal value of treatments. Objective: To quantify the perceived value of surgery for CFP and synkinesis amongst casual observers, as measured by WTP and quality of life indices. Methods: Casual observers were shown standardized videos of faces with complete paralysis, synkinesis, and nonparalyzed controls (eight videos each). Observers were asked to imagine having each condition and to rate their quality of life and WTP for surgical repair. Results: A total of 557 observers were included (mean age 36.5 years, 59% female). Both complete paralysis and synkinesis were associated with reduced quality-adjusted life year indices (0.9 [95% confidence interval [CI] 0.87–0.93]) for synkinesis; 0.86 (95% CI: 0.83–0.89) for complete paralysis, p = 0.0011). The mean WTP was $22,791 for complete flaccid paralysis and $15,718 for synkinesis repair and increased with income. WTP per quality-adjusted-life year gained was $6,844 for complete paralysis and $6,604 for synkinesis ( p > 0.05). Conclusion: Observers perceived surgical repair of CFP and synkinesis as highly valuable and within common cost-effectiveness thresholds.

Background: There is a spectrum of facial paralysis patient presentations from complete flaccid facial paralysis (CFFP) to facial aberrant reinnervation syndrome (FARS). Objective: To objectively compare how laypersons direct attention to faces with different facial paralysis subtypes using eye-tracking technology. Methods: Lay observers freely gazed at standardized videos of 24 individuals’ faces as follows: 8 with CFFP, 8 with FARS, and 8 nonparalyzed Controls performing common facial expressions. Eye-tracking measured observers’ gaze and extracted data as time in milliseconds looking at facial subsites. Mixed effects regression was used for comparative analyses. Results: A total of 85 observers completed the study. For faces at rest, measurable differences in gaze patterns were noted for CFFP faces (more attention spent on nonparalyzed hemiface), whereas FARS and Control faces showed similar symmetric gaze patterns. With dynamic movement (smiling and brow-elevation), gaze patterns for both CFFP and FARS faces became altered and asymmetrical compared with Control faces. Conclusions: Faces with CFFP and FARS are viewed differently by casual observers, which has implications for patient care and future research. While CFFP showed gaze alterations (compared with Control) in both rest and facial expression states, FARS caused gaze alterations only with facial movement.

Background Orbital decompression is an essential tool for reducing proptosis in thyroid eye disease (TED), yet the impact of surgical approach and preoperative factors on outcomes remains uncertain. Objective To compare proptosis reduction following different orbital decompression techniques, identify additional risk factors that may play a role in surgical orbital decompression outcomes, and develop clinical decision-making recommendations based on these results. Methods A retrospective analysis was performed on TED patients who underwent endoscopic medial wall, orbital floor, and/or open lateral wall decompression. We evaluated the influence of preoperative comorbidities, anatomic and laboratory values, and surgical approach on postdecompression Hertel exophthalmometry outcomes. Results Analysis encompassed 130 orbits from 80 patients, 83% female, 48 with preoperative diplopia, and mean age of 54.4 years. Preoperative Hertel measurement was predictive of extent of proptosis reduction ( P < .0001), indicating that higher initial Hertel measurement predicts greater absolute reduction following surgical intervention. Surgical technique correlated with outcome on univariate analysis ( P = .04), but not multivariate ( P = .13) analyses. When categorized into preoperative Hertel ranges, combined endoscopic medial and open lateral wall decompression resulted in mean proptosis reduction of 3.13 mm for range 20.01 to 24 mm and 3.85 mm for range 24.01 to 28 mm. Three-wall decompression resulted in mean proptosis reduction of 2.49 mm for and 3.84 mm for these ranges, respectively. Variables such as smoking, body mass index, orbital wall height, and TRAb level, did not affect outcomes. Nine patients had new onset diplopia. Conclusions Preoperative Hertel exophthalmometry is the strongest predictor of proptosis reduction following orbital decompression in TED. Surgical technique appears to be less impactful on outcome than expected. Surgical decision making should be individualized based on patient goals; these findings can be used to achieve proptosis reduction and limit the risk of new onset diplopia.

AbstractObjectiveTo compare reflux symptoms, Zenker's diverticulum recurrence, and clinical outcomes in patients with and without a history of hiatal hernia who underwent Zenker's diverticulotomy (ZD).Study DesignSingle institution retrospective review.SettingTertiary care academic hospital.MethodsA retrospective review of patients with and without a history of hiatal hernia who underwent ZD via an open stapler, rigid endoscopic CO2 laser, stapler, or harmonic scalpel technique from January 2006 to December 2020 was performed. Data were abstracted for patient demographics, reflux symptoms, and rates of adverse events and symptomatic recurrence.ResultsA total of 426 patients were included in the study, 97 (22.8%) of which had a history of hiatal hernia. Eleven patients (11.3%) with a history of hiatal hernia had undergone Nissen fundoplication prior to ZD. Patients with a history of hiatal hernia showed less symptomatic improvement postoperatively. Significant differences were noted in the change in the Eating Assessment Tool (EAT‐10) (P < .01) and Reflux Symptom Index (RSI) (P = .03) where patients without a history of hiatal hernia improved more than hiatal hernia patients. Despite these differences in symptom relief, rates of postoperative complications and rates of recurrence did not significantly differ between groups. The median time to recurrence was similar for both groups.ConclusionPatients without a history of hiatal hernia had significantly larger improvements in EAT‐10 and RSI scores compared to patients with a history of hiatal hernia. However, these differences in scores may not represent clinically meaningful differences. There were no significant differences in postoperative adverse events or in recurrence of the Zenker's diverticulum between groups.

ObjectiveThe use of composite chondromucosal nasal septal flaps (ccNSF) has been demonstrated to be effective in cadaveric studies for the anterior skull base and the orbit. However, their application in the clinical setting remains unexplored. Our study aims to introduce a new method for treating palatal defects using ccNSF. Additionally, we studied the average NSF area and compared it to the average palate area.MethodsWe collected 108 CT scans from the medical records of patients without head and neck pathologies from a tertiary medical institution. We quantified the quadrangular (septal) cartilage and palate areas. Furthermore, we included a clinical case in which we used the ccNSF for the palatal defect reconstruction. This was to compare the mean area between the palate and the septal cartilage.ResultsThe ccNSF covered the palatal defect without any significant complications for the first 9 months of follow‐up. A total of 102 CT scans met the inclusion criteria and were measured. We found that the mean quadrangular cartilage had a length of 2.50 (±0.52) cm, a width of 2.28 (±0.51) cm, and an area of 5.43 (±1.68) cm2. The mean palate length was 2.73 (±0.44) cm, with a width of 3.13 (±0.34) cm, and area of 7.87 (±1.43) cm2.ConclusionsThe ccNSF proved successful in palatal defect reconstruction, resulting in positive outcomes and no major complications until the 9‐month follow‐up. The ccNSF is a useful flap that avoids the use of free flap transfer and its associated morbidities.Level of Evidence4 Laryngoscope, 134:4882–4887, 2024