Faculty Bibliography

Deep plane facelift surgery is not new, having originally been described over 30 years ago, however the technique has seen a recent surge in popularity. While proponents emphasize its ability to deliver very natural results, critics often cite the possibility of additional risk of the procedure due to its technically challenging dissection in proximity to branches of the facial nerve and other critical structures. These risks are perhaps greatest when operating in what have historically been described as the "danger zones," particularly when releasing the zygomatic retaining ligaments, when performing the medial deep plane dissection in the midface, and when extending the platysma flap over the angle of the mandible into the neck. The senior author (DBR) has performed deep plane facelift surgery for over 20 years, training many novice surgeons to perform this procedure safely and incrementally. Herein, we illustrate surgical techniques to optimize safety when performing deep plane dissections. A novel vertical midline platysmaplasty combined with extended release of the low cervical platysma provide rejuvenation of the neck that extends to the clavicles.

BACKGROUND:Patient electronic messaging has increased clinician workload contributing to burnout. Large language models can respond to these patient queries, but no studies exist on large language model responses in thyroid disease. METHODS:This cross-sectional study randomly selected 33 of 52 patient questions found on Reddit/askdocs. Questions were found through a "thyroid + cancer" or "thyroid + disease" search and had verified-physician responses. Additional responses were generated using ChatGPT-3.5 and GPT-4. Questions and responses were anonymized and graded for accuracy, quality, and empathy using a 4-point Likert scale by blinded providers, including 4 surgeons, 1 endocrinologist, and 2 physician assistants (n = 7). Results were analyzed using a single-factor analysis of variance. RESULTS:For accuracy, the results averaged 2.71/4 (standard deviation 1.04), 3.49/4 (0.391), and 3.66/4 (0.286) for physicians, GPT-3.5, and GPT-4, respectively (P < .01), where 4 = completely true information, 3 = greater than 50% true information, and 2 = less than 50% true information. For quality, the results were 2.37/4 (standard deviation 0.661), 2.98/4 (0.352), and 3.81/4 (0.36) for physicians, GPT-3.5, and GPT-4, respectively (P < .01), where 4 = provided information beyond what was asked, 3 = completely answers the question, and 2 = partially answers the question. For empathy, the mean scores were 2.37/4 (standard deviation 0.661), 2.80/4 (0.582), and 3.14/4 (0.578) for physicians, GPT-3.5, and GPT-4, respectively (P < .01), where 4 = anticipates and infers patient feelings from the expressed question, 3 = mirrors the patient's feelings, and 2 = contains no dismissive comments. Responses by GPT were ranked first 95% of the time. CONCLUSIONS:Large language model responses to patient queries about thyroid disease have the potential to be more accurate, complete, empathetic, and consistent than physician responses.

BACKGROUND:Racial and ethnic disparities in thyroid cancer care may be mitigated by improving enrollment of more diverse patient populations in clinical trials. We studied trial eligibility criteria and enrollment to assess barriers to equitable representation. METHODS:ClinicalTrials.gov was searched for studies on thyroid cancer treatment conducted between 1993 and 2023. The inclusion and exclusion criteria of each study were examined. For published studies, reported demographic information was collected. Observed enrollment by race was compared with the expected distribution as determined using data from the US Census and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) databases. Over- and under-representation was defined as the ratio of observed to expected (O/E) enrollment by the race and ethnicity group. RESULTS:Of 309 thyroid cancer-related trials, 23 (7.4%) used language as an exclusion criterion. Most were interventional (n = 239, 77.3%), university-initiated (194, 62.8%), and drug/device-focused (195, 63.1%). Of studies that excluded by language, 20 (87.0%) were university-initiated. Eighty-eight trials were subsequently published, with 16 (18.2%) reporting race and/or ethnicity distributions. When comparing O/E ratios, White American participants were over-represented (O/E ratio: 1.2, P < .0001). Under-represented groups included Asian/Native Hawaiian (O/E ratio: 0.6, P = .0085), Black (0.6, P = .014), Native American (0.2, P = .072), and Hispanic patients (0.2, P < .0001). CONCLUSION/CONCLUSIONS:Over the last 3 decades, 1 in 13 thyroid cancer-related clinical trials excluded patients based on language. In the fraction of published studies to report on racial and ethnic demographics, Asian/Native Hawaiian, Black, and Hispanic patients were under-represented. Improved reporting of demographics in published studies and elimination of exclusion criteria such as language that hinder enrollment of minority patients could improve equitable representation of patients in thyroid cancer clinical trials.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Hydrocephalus after Gamma Knife® stereotactic radiosurgery (SRS) for vestibular schwannomas is a rare but manageable occurrence. Most series report post-SRS communicating hydrocephalus in about 1% of patients, thought to be related to a release of proteinaceous substances into the cerebrospinal fluid. While larger tumor size and older patient age have been associated with post-SRS hydrocephalus, the influence of baseline ventricular anatomy on hydrocephalus risk remains poorly defined. METHODS:A single-institution retrospective cohort study examining patients who developed symptomatic communicating hydrocephalus after undergoing Gamma Knife® SRS for unilateral vestibular schwannomas from 2011 to 2021 was performed. Patients with prior hydrocephalus and cerebrospinal fluid diversion or prior surgical resection were excluded. Baseline tumor volume, third ventricle width, and Evans Index (EI)-maximum width of the frontal horns of the lateral ventricles/maximum internal diameter of the skull-were measured on axial postcontrast T1-weighted magnetic resonance imaging. RESULTS:A total of 378 patients met the inclusion criteria; 14 patients (3.7%) developed symptomatic communicating hydrocephalus and 10 patients (2.6%) underwent shunt placement and 4 patients (1.1%) were observed with milder symptoms. The median age of patients who developed hydrocephalus was 69 years (IQR, 67-72) and for patients younger than age 65 years, the risk was 1%. For tumor volumes <1 cm3, the risk of requiring shunting was 1.2%. The odds of developing symptomatic hydrocephalus were 5.0 and 7.7 times higher in association with a baseline EI > 0.28 (P = .024) and tumor volume >3 cm3 (P = .007), respectively, in multivariate analysis. Fourth ventricle distortion on pre-SRS imaging was significantly associated with hydrocephalus incidence (P < .001). CONCLUSION/CONCLUSIONS:Patients with vestibular schwannoma with higher baseline EI, larger tumor volumes, and fourth ventricle deformation are at increased odds of developing post-SRS hydrocephalus. These patients should be counseled regarding risk of hydrocephalus and carefully monitored after SRS.

OBJECTIVE:This study aims to evaluate the clinical outcomes of patients receiving in-office vocal fold steroid injections (VFSI), highlighting relatively new measures around vocal pitch. METHODS:Patients with a diagnosis of vocal fold scar who received in-office VFSI from 2013 to 2024 were evaluated. Pre- and post-steroid Voice Handicap Index (VHI-10) scores, stroboscopic vibratory parameters, acoustic measures of cepstral peak prominence (CPP), and fundamental frequency coefficient of variation (F0CoV) during sustained phonation were analyzed using Wilcoxon signed-rank tests and McNemar's tests. RESULTS:Twenty-two patients had follow-up data 1-3 months after steroid injection. The median decrease in VHI-10 after one injection was 4 points (p = 0.02). We found no difference in CPP and F0CoV measures at follow-up. Forty-five percent of patients improved in mucosal wave and amplitude of at least one vocal fold. Earlier presentation from vocal injury was associated with improvement in mucosal wave and amplitude of the left vocal fold (p = 0.03). We found no difference in sex, tobacco smoking history, singing status, secondary diagnosis, and baseline VHI-10 score between patients who improved in vibratory parameters and those who did not. CONCLUSION/CONCLUSIONS:This single-center study is one of the largest exploring patient outcomes following in-office VFSI. Though patients reported modest improvement in voice use after VFSI, this may not be as impactful as previously believed. Improvement in videostroboscopy is expected in about half of the patients, with recency from vocal injury a likely predictor of success. These partially negative results provide insight into counseling patients regarding benefits from in-office VFSI. LEVEL OF EVIDENCE/METHODS:4 Laryngoscope, 2024.

INTRODUCTION/BACKGROUND:Glucocorticoids (GCs) are commonly prescribed for laryngeal indications due to their potent anti-inflammatory properties. However, GCs effect on vocal fold (VF) epithelial morphology and barrier function following injury is overlooked and may be key to efficacy. In this study, the effects of GCs on epithelial morphology and barrier function were quantified in injured VFs. We seek to increase our understanding of biochemical processes underlying GC mechanisms to refine therapeutic strategies. METHODS:Microflap injury was induced in 65 rabbits. Seven days after injury, animals received bilateral 20 μL intracordal injections of saline, dexamethasone, methylprednisolone, or triamcinolone (n = 15 per condition). Five rabbits in each condition were euthanized 1, 7, or 60 days following treatment. An additional five animals served as non-injured/untreated controls. To quantify transepithelial electrical resistance (TEER), 1 mm epithelial biopsies were placed in an Ussing chamber. The contralateral VF was processed for transmission electron microscopy and epithelial depth analysis. RESULTS:At 60 days, GC treatment maintained TEER levels similar to non-injured/untreated controls. However, triamcinolone reduced TEER compared with saline-treated conditions. Acutely, epithelial hyperplasia typically persisted in all injured VFs. At 60 days, only dexamethasone and triamcinolone increased epithelial depth in injured VFs; all GCs increased epithelial depth compared with non-injured/untreated controls. CONCLUSION/CONCLUSIONS:Acutely, GCs did not alter TEER. Additionally, GCs did not alter epithelial depth compared with saline treatment, indicating alignment with natural healing responses. At 60 days, GCs exhibited varying degrees of TEER restoration and epithelial hyperplasia, possibly due to distinct pharmacodynamic profiles. LEVEL OF EVIDENCE/METHODS:NA Laryngoscope, 2024.

PURPOSE/OBJECTIVE:Fear of recurrence (FoR) is a prevalent and difficult experience among cancer patients. Most research has focused on FoR among breast cancer patients, with less attention paid to characterizing levels and correlates of FoR among oral and oropharyngeal cancer survivors. The purpose was to characterize FoR with a measure assessing both global fears and the nature of specific worries as well as evaluate the role of sociodemographic and clinical factors, survivorship care transition practices, lifestyle factors, and depressive symptoms in FoR. METHODS:Three hundred eighty-nine oral and oropharyngeal survivors recruited from two cancer registries completed a survey assessing demographics, cancer treatment, symptoms, alcohol and tobacco use, survivorship care practices, depression, and FoR. RESULTS:Forty percent reported elevated global FoR, with similar percentages for death (46%) and health worries (40.3%). Younger, female survivors and survivors experiencing more physical and depressive symptoms reported more global fears and specific fears about the impact of recurrence on roles, health, and identity, and fears about death. Depression accounted for a large percent of the variance. Lower income was associated with more role and identity/sexuality worries, and financial hardship was associated with more role worries. CONCLUSIONS:FoR is a relatively common experience for oral and oropharyngeal cancer survivors. Many of its correlates are modifiable factors that could be addressed with multifocal, tailored survivorship care interventions. IMPLICATIONS FOR CANCER SURVIVORS/CONCLUSIONS:Assessing and addressing depressive symptoms, financial concerns, expected physical symptoms in the first several years of survivorship may impact FoR among oral and oropharyngeal cancer survivors.

OBJECTIVES/OBJECTIVE:To examine the effects of short-term and long-term engagement with structured choral singing on vocal function and quality of life outcomes in older adults. METHODS:Two groups of older adult singers over 55 years, one with fewer than 4 semesters and one with 4 or more semesters singing in a chorale, were assessed at 3 time points: baseline, after 1 semester of singing, and either after 1 semester of rest or after 1 semester of rest and 1 semester more of singing. Acoustic and aerodynamic measures, voice-related quality of life ratings, and measures of singing accuracy were obtained. Percent change between time points were calculated to determine three outcomes: improvement, lack of change, or worsening of measures across time. RESULTS:Long-term average spectrum (LTAS), difference in first and second harmonics and estimated subglottic pressure were significantly more likely to improve after a semester of singing with less experience singers, and LTAS continued to improve after a semester of rest. Flow was significantly more likely to improve with more singing experience after a semester of singing. Aerodynamic variables consistently changed in more experienced singers and improvement was maintained over the three visits. No significant changes occurred over time for singing accuracy for any singer type. Self-perception of singing voice continued to improve with more singing experience. CONCLUSIONS:This study demonstrated that for older adults in good health, regular singing provided a mechanism for maintaining speaking voice over time.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:An increasing number of older adults are seeking behavioral voice therapy to manage their voice problems. Poor adherence to voice therapy is a known problem across all treatment-seeking populations. Given age-related physical and cognitive impairments and multiple chronic conditions, older adults are more susceptible to low adherence to behavioral therapies. The purpose of this study was to test the feasibility of an at-home, vocal training intervention for older adults without a known voice disorder living in a senior living community, as well as compare the effects of two modes of mobile health (mHealth) technology-assisted vocal training targeting vocal function and adherence in older adults. STUDY DESIGN/METHODS:Cohort Study (Prospective Observational Study). METHODS:Twenty-three individuals were recruited from a single residential retirement community and randomly allocated into two experimental groups. Both groups were asked to practice the Vocal Function Exercises with increasing frequency over an 8-week period. Tablets with instructions for performing the exercises were provided to all participants. The feedback group's tablets also contained an application providing real-time feedback on pitch, loudness, and duration. Acoustic and aerodynamic measures of vocal function and cognitive measures were obtained before and after the intervention. Self-reported measures of practice frequency, perceived vocal progress and changes, and motivation were obtained weekly. RESULTS:The feedback control group adhered to the requested practice sessions more in the latter half of the intervention (weeks 5 and 8). Vocal function measures remained stable. Overall, a pattern reflecting self-reported vocal progress and a general improvement in working memory and global cognitive functioning was observed in the feedback group. CONCLUSIONS:This study demonstrated that an 8-week mHealth intervention is viable to facilitate vocal practice in older adults. Although vocal ability did not improve with training, results indicated that vocal performance remained stable and age-related vocal changes did not progress. Future research on implementation of mHealth applications in conjunction with behavioral voice therapy is warranted to assess adherence and improvements in vocal function in individuals with age-related voice problems.