Background Debate exists surrounding the morphological evolution of the submandibular gland (SMG) with aging, and due to the inconclusive influence of patient demographics, there remains hesitancy to incorporate targeted interventions of the SMG into clinical practice. Objectives To determine whether SMG ptosis, hypertrophy, or both is the primary etiology behind increased submandibular volume as one ages. Methods MRI segmentation was used to calculate the total and inframandibular (IM) volume and height of the SMG. Adult subjects with prior MRIs of the head and neck were used for analysis. Those with pathology or artifact compromising the SMG were excluded. Subjects were divided into four age-defined cohorts, for clinical applicability. Results The study included 129 patients (Females n=65; Male n=64) with a mean age of 52.3 (range 20-85). No significant change in total SMG volume was observed between the reference group and all cohorts. IM-SMG volume of the reference cohort was 5.77 cm 3. All 3 cohorts had a greater IM-SMG volume compared to the reference group. The 45-54 cohort had a mean volume of 6.7 cm 3 (p=.4), the 55-64 cohort, 7.5 cm 3 (p=.01), and the 55-64 cohort, 7.2 cm 3 (p=.01). Male sex and overweight or obese BMI were associated with significantly larger total and IM-SMG volumes. Conclusions The novel finding of a significantly larger IM-SMG volume with no change in total volume provides evidence for SMG ptosis rather than hypertrophy as a significant contributor to age-related submandibular fullness. Given no significant difference in total volume or height with aging emphasizes glandular descent.

Figure. Differences between average RBCs, SECs and white blood cells (WBCs) cellular content for urine specimens by collection method. Geometric means with 95% CIs are presented. Statistically significant comparisons by Fisher's exact test are bolded. hpf, high power field.

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Guillain-Barre syndrome (GBS) is an acute autoimmune demyelinating polyradiculoneuropathy that presents with rapidly progressive ascending muscle weakness. GBS typically follows a respiratory or gastrointestinal infection. Early detection and treatment can improve recovery rate [1]. We present a case of GBS induced by varicella zoster virus (VZV) reactivation in a patient receiving treatment for multiple myeloma. CASE PRESENTATION:A 68-year-old male with a history of multiple myeloma, abdominal aortic aneurysm with repair and hypertension initially presented to the emergency department (ED) with fever and altered mental status. In the ED, his blood pressure was initially 210/134 and remained elevated despite intravenous (IV) administration of labetalol. The patient was started on empiric therapy with IV vancomycin, acyclovir, ceftriaxone, and ampicillin for possible meningitis. It was found that the patient had previously received an autologous stem cell transplantation, as well as treatment with bortezomib, lenalidomide, and low-dose dexamethasone, with only partial response. The patient was started on an escalated regimen with daratumumab one week prior to admission. The patient was transferred to the intensive care unit (ICU) and placed on an IV esmolol drip for hypertensive emergency. The next day, the patient developed bilateral lower extremity areflexia and motor weakness. IV immunoglobulin (IVIg) was initiated for presumed GBS. Cerebrospinal fluid (CSF) results were significant for positive VZV-PCR and elevated protein. Magnetic resonance imaging (MRI) of the brain showed a linear enhancement in the cauda equina that was consistent with GBS. The patient continued to receive acyclovir and IVIg with clinical improvement.DISCUSSION: GBS induced by reactivation of latent VZV is rare. Prompt initiation of empiric treatment is imperative to prevent further complications and decrease time to recovery. Patients may also present with labile blood pressures or arrhythmias due to dysautonomia and should be monitored closely for cardiovascular and respiratory stability. Daratumumab is an IgG1 subtype human monoclonal antibody directed against CD38, a cell surface glycoprotein that is highly expressed in myeloma cells. Previous studies have noted infection complications of daratumumab [2-5], including reactivation of a viral infection. Further studies investigating the role of prophylaxis and screening in individuals who begin immunomodulatory therapies should be considered. CONCLUSIONS:In an immunocompromised patient presenting with bilateral lower extremity areflexia and motor weakness, GBS should be considered with prompt initiation of appropriate therapy. This case report highlights the importance of a thorough history, prompt treatment, and close follow-up to avoid adverse outcomes.

Background Recently we have seen an expanding practice of targeting the deeper, subplatysmal structures in the neck. In particular, interventions targeting the “bulky” anterior digastric (AD) muscle have been described with excellent results. However, much remains to be understood about the deep anatomy of the neck and the age-associated changes of the AD. Objectives To examine the relationship between AD volume and age. Methods This retrospective study calculated the AD volume utilizing MRI segmentation in subjects between the ages of 20-92 with prior MRIs. Those with compromised imaging due to pathology or artifact were excluded. Subjects were divided into four age-defined cohorts for clinical applicability. Results This study included 129 patients (male n=64) with a mean age of 52.3. The AD volume of the reference group was 3.2 cm3. A linear decrease in muscle volume was observed with age compared to the reference group: age 45-54 cohort, 2.95 cm3 (p=.3), 55-64 cohort, 2.7 cm3 (p=.05) and >65 cohort, 2.45 cm3 (p<0.001). Male sex (p=.0001) and laterality (p=.003) were associated with significantly larger volumes. Overweight and obese BMI classification was not associated with a significantly different volume than normal or underweight subjects (p=.067). Conclusions Our findings suggest an age-associated reduction in AD volume. Gender and laterality significantly affected volume, while BMI did not. While our results do not support the theory of muscular hypertrophy with aging, they reveal that the perceived bulkiness may be due to changes in the surrounding anatomy affecting the morphology of the AD and subsequent blunting of the cervicomental angle.