bluuebunny/crossref_metadata_2025 huggingface dataset:
Molecular Differences in Mucoepidermoid Carcinoma and Adenoid Cystic Carcinoma of the Major Salivary Glands
Authors: Gibbons Mark D. , Manne Upender , Carroll William R. , Peters Glenn E. , Weiss Heidi L. , Grizzle William E.
Published: November 2003

Objective/Hypothesis Mucoepidermoid carcinoma (MEC) and adenoid cystic carcinoma (ACC), the most common malignancies of the major salivary glands, are clinically and pathologically different. To determine whether MEC and ACC have different molecular characteristics, we examined the expression of erbB‐2, erbB‐3, epidermal growth factor receptor (EGFR), and transforming growth factor‐α (TGF‐α), important molecular features in other malignancies.

Study Design/Methods Archival tissue sections of 22 MEC and 6 ACC tumors of the major salivary glands were evaluated immunohistochemically for expression of erbB‐2, erbB‐3, EGRF, and TGF‐α. A differential immunostaining score, reflecting the difference in immunostaining between carcinoma and uninvolved salivary gland tissue, was calculated for cytoplasmic and membranous staining.

Results Positive immunostaining for all biomarkers was observed in the cytoplasm and membrane of both tumors. However, expression was higher in MEC than in ACC tumors and was statistically significant for cytoplasmic EGFR (P = .009), TGF‐α (P = .041), and membranous EGFR (P = .004). A significantly higher percentage of MEC cells also demonstrated positive immunostaining for cytoplasmic erbB‐3 (P = .022), EGFR (P = .005), membranous erbB‐3 (P = .022), and EGFR (P = .013). The differential immunostaining score was significantly higher for MEC compared with uninvolved alveolar tissue and the membranes of uninvolved ductal tissue. There were no statistically positive differential immunostaining scores for ACC.

Conclusions There is a clear difference in the molecular phenotypes of MEC and ACC. The lack of statistically significant expression in ACC, when compared with similar uninvolved salivary gland tissue, suggests minimal involvement for these molecular structures in the pathogenesis of ACC. Conversely, erbB‐2, erbB‐3, EGFR, and TGF‐α may have a role in the development and progression of MEC. These results have therapeutic implications for MEC of the major salivary glands.
Prognostic Factors in Major Salivary Gland Cancer
Authors: Hocwald Eitan , Korkmaz Hakan , Yoo George H. , Adsay Volkan , Shibuya Terry Y. , Abrams Judith , Jacobs John R.
Published: November 2003

Objective To identify features of major salivary gland cancers that are prognostic for disease‐free survival.

Study Design A retrospective study of 78 patients with major salivary gland cancer (64 parotid and 14 submandibular gland) who underwent surgery for definitive treatment from 1976 to 1996. A select group of patients also received adjuvant radiation (56%) and/or chemotherapy (13%).

Method Clinical and pathological risk factors were obtained from patients' charts and pathology reports. Age, gender, tumor site, T‐stage, facial paralysis, histologic neck involvement, perineural invasion, and cancer grade were analyzed with respect to disease‐free survival. The role of adjuvant treatment in terms of clinical outcome was also investigated.

Results In our series, the 5‐year disease‐free survival was 65%. Examining clinical and histologic features one at a time, we found poorer prognosis was associated with submandibular tumors compared with parotid (P = .02), higher T‐stage (P = .001), positive cervical nodes (P <.001), perineural invasion (P = .002), and high‐grade or adenoid cystic tumors (P = .002). A multivariable analysis indicated that positive lymph nodes (P = .07) and perineural invasion (P = .03) were important histologic predictors of shorter disease‐free survival. Receipt of both adjuvant radiation and cisplatin‐based chemotherapy (P = .05) was an independent predictor of longer disease‐free survival.

Conclusion Our study indicated that the presence of positive lymph nodes and perineural invasion is important independent predictors of disease‐free survival. Our limited data also suggest that adjuvant chemotherapy and radiation therapy may improve disease‐free survival.
Dendritic Cells Pulsed With Apoptotic Squamous Cell Carcinoma Have Anti‐Tumor Effects When Combined With Interleukin‐2
Authors: Son Young‐Ik , Mailliard Robbie B. , Watkins Simon C. , Lotze Michael T.
Published: November 2003

Objectives Dendritic cells, the most potent of the antigen‐presenting cells, have been widely studied as a promising tool for antitumor immunotherapies. However, little has been determined about the efficacy of dendritic cell–based therapy for the treatment of squamous cell carcinoma (SCC) because there are no known SCC‐specific antigens. Recent reports indicate that dendritic cells can acquire antigens in the form of apoptotic cells and induce cytotoxic T‐lymphocyte responses. The aim of this study was to test the feasibility of adoptive dendritic cell immunotherapy against SCC by using apoptotic tumor cells as a source of tumor antigens.

Study Design A poorly immunogenic SCC line KLN 205 was used to make subcutaneous tumors on the flank of DBA2/J syngeneic mice. Bone marrow–derived dendritic cells were pulsed with ultraviolet B–irradiated (apoptotic) KLN 205 cells in vitro and transferred to the opposite flank subcutaneously. Some of the animals received simultaneous intraperitoneal injections of low‐dose interleukin‐2.

Results When combined with interleukin‐2, adoptive transfers of dendritic cells that were pulsed with apoptotic SCC significantly suppressed the tumor growth (P <.001) without notable side effects. Splenic T cells of treated mice produced greater amounts of interferon‐γ when restimulated with the relevant tumor (P <.001) as compared with control groups, indicative of an effective T‐cell–mediated systemic immune response.

Conclusion Adoptive transfer of dendritic cells pulsed with apoptotic tumor cells as a source of tumor antigens, can elicit effective antitumor responses in the poorly immunogenic SCC model when combined with interleukin‐2.
Role of Clonazepam in the Treatment of Idiopathic Downbeat Nystagmus
Authors: Young Yi‐Ho , Huang Tsung‐Wei
Published: November 2003

Objective/Hypothesis Downbeat nystagmus is defined as spontaneous nystagmus present with fixation in the primary position or lateral gaze. Those who have downbeat nystagmus but negative magnetic resonance imaging results are termed as idiopathic. Patients with idiopathic downbeat nystagmus, although unconcerned with their etiology, have visual symptoms such as oscillopsia, diplopia, or blurred vision. The purpose of this study is to evaluate the efficacy of clonazepam in treating idiopathic downbeat nystagmus.

Methods Patients with downbeat nystagmus were rechecked by electronystagmography (ENG); then 0.5 mg clonazepam was administered orally. One hour later, follow‐up ENG was performed again to evaluate the evolution of the downbeat nystagmus. If the test was effective, then 1.0 mg clonazepam twice daily was administered to the patients.

Results Seven cases had downbeat nystagmus, including idiopathic in five, cerebellar degeneration in one, and cerebellopontine angle tumor in one. The efficacy rate for the clonazepam test was 100% in five cases of idiopathic downbeat nystagmus, whereas it was ineffective in the case of cerebellar degeneration. After long‐term therapy with clonazepam, all patients with idiopathic downbeat nystagmus experienced elimination of oscillopsia, relief of diplopia, and improvement of visual acuity. Although temporary relief of downbeat nystagmus was observed 1 hour after the clonazepam test, downbeat nystagmus was not eliminated permanently.

Conclusion We recommend long‐term therapy by clonazepam with a dosage of 1.0 mg twice daily in cases of idiopathic downbeat nystagmus. Reducing the downbeat nystagmus as well as eliminating the oscillopsia can be anticipated.
Preoperative Differences Between Male and Female Patients With Sleep Apnea
Authors: Walker Regina Paloyan , Durazo‐Arvizu Ramon , Wachter Bryan , Gopalsami Chellam
Published: November 2003

Objectives/Hypothesis To evaluate the differences between female and male patients with obstructive sleep apnea syndrome (OSAS) in the preoperative period.

Study Design Nonrandomized cross‐sectional study.

Methods An analysis of 686 patients (111 women and 575 men) with OSAS was completed. Multivariate modeling techniques were employed to correlate gender with the preoperative respiratory disturbance index (RDI), apnea index (AI), hypopnea index (HI), body mass index (BMI), age, and initial symptoms.

Results At presentation, the male patients were significantly younger and had a lower BMI and a higher RDI and AI than the female patients. For the entire OSAS population studied, the RDI increased as the BMI increased (correlation coefficient [r] = 0.35, P = <.001). For the female patients there was a weaker correlation (r = 0.21, P = .034), and in male patients there was a stronger correlation (r = 0.40, P <.001). For the entire population there was a negative correlation between age and RDI (r = −0.15, P <.001). In female patients there was a nonsignificant correlation (r = −0.09, P = .35), and in male patients the correlation was significant (r = −0.16, P <.001). There was no difference in the reporting of the number of symptoms based on gender (P = .355). Female patients noted headaches on awakening more commonly than male patients (P = .001), and male patients noted snoring (P = .014) and stopping breathing during sleep (P = .001) more often than female patients.

Conclusions The analysis demonstrated that within a surgical population sample, gender differences exist. The findings of this series were as follows: 1) Apnea severity in women was less weight‐dependent than in men; (2) in men there was a significant negative correlation between age and apnea severity; and (3) female and male patients reported the same number of signs or symptoms on presentation, although certain signs and symptoms were more commonly reported based on gender. Current clinical evaluation practices must take into account this gender disparity.
Use of Helium–Oxygen Mixtures to Relieve Upper Airway Obstruction in a Pediatric Population
Authors: Grosz Anna H. , Jacobs Ian N. , Cho Catherine , Schears Gregory J.
Published: November 2003

Objectives Helium as a component of inspired gas decreases turbulent flow and airway resistance. Helium–oxygen mixtures have been used since the 1930s in the management of patients with upper airway obstruction. The objective of this study was to evaluate the efficacy of helium–oxygen mixtures in relieving upper airway obstruction in a pediatric population.

Study Design Retrospective chart review of 42 pediatric patients who received helium–oxygen mixtures for upper airway obstruction within a 3‐year period.

Methods The study protocol included 42 pediatric patients, aged 1 week to 14 years, who were admitted to the Children's Hospital of Philadelphia from June 1997 to December 2000 and who received a total of 44 treatments of helium–oxygen therapy for upper airway obstruction. Response to treatment was determined by reduction in work of breathing noted on the chart.

Results Thirty‐two of 44 helium–oxygen treatments resulted in a positive response (73%). There were no significant differences in demographic characteristics between responders and nonresponders, except all of the premature infants were responders and 6 of the 9 patients with syndromes were nonresponders.

Conclusions Helium–oxygen therapy is a useful adjunct therapy for upper airway obstruction. Controlled clinical trials are necessary to better define the appropriate settings for use of helium–oxygen.
Predicting Fall Risks in an Elderly Population: Computer Dynamic Posturography Versus Electronystagmography Test Results
Authors: Girardi Marian , Konrad Horst R. , Amin Manali , Hughes Larry F.
Published: November 2003

Objectives/Hypothesis Falls are the leading cause of morbidity and mortality for persons aged 65 years and older, with more than 2 million people falling and sustaining serious injury annually. This study compared computer dynamic posturography (CDP) and electronystagmography (ENG) results as predictors of falls.

Study Design Retrospective.

Methods Thirty‐three patients over the age of 65 years who presented to a balance disorders and falls prevention clinic were used for this study (22 women and 11 men, with an average age of 78.0 y and a mean fall rate of 3.5 times). All had experienced at least one fall in the year before visiting the clinic and were tested with both CDP and ENG. The CDP results were divided into subcategories (sensory organization testing and limits of stability); ENG results were divided into four categories (ocular motor, rotational chair, positional, and caloric studies).

Results Test findings were classified as normal or abnormal based on age‐matched normative data. Of the patients in the study, 27.3% were normal for one type of testing and abnormal for the other. Twenty‐six patients (78.8%) had abnormal results on CDP, and 20 individuals (60.6%) showed ENG abnormalities (42.4% for ocular motor, 28.6% for positional, 13.6% for caloric, and 11.2% for rotational chair studies). The limits of stability category was significant in predicting multiple falls.

Conclusion For this population, CDP was determined to be a more sensitive test for identifying patients who have fallen, with limits of stability testing the most significant part of the CDP battery; for ENG studies, the best falls indicator was the ocular motor battery.
Water‐Jet Dissection in Parotid Surgery: An Experimental Study in Dogs
Authors: Magritz Ralph , Jurk Viktor , Reusche Erich , Siegert Ralf
Published: November 2003

Objective The objective of the present study was to investigate the application of the water‐jet dissection method in parotid surgery by way of animal experiments, paying particular attention to the clinical and histological reactions of the facial nerve.

Study Design An animal experimental study.

Methods Total bilateral parotidectomies with retention of the facial nerve were performed on 19 beagle dogs by means of the Hydro‐Jet device (Andreas Pein Medizintechnik Company, Schwerin, Germany) using different jet diameters and operating pressures. All operations were performed with continuous intraoperative facial monitoring (Neurosign 100, Inomed Company, Teningen, Germany). The dogs were monitored postoperatively over an average period of 20.3 days (range, 14–35 d). Local findings and facial nerve status were documented daily. In a second phase, the dissected nerves were resected and the animals were killed. Samples of water‐jet–dissected parotid tissue, as well as all dissected nerve branches, underwent histological examination and were compared with clinical and electrophysiological findings.

Results It was possible to perform operations easily on all parotid glands by means of the Hydro‐Jet using the small, 120‐μm jet at operating pressures of 40 to 60 bar and to dissect the facial nerve quickly and safely with retention of its functional capability (n = 34). The dissection of nerves using larger‐diameter jets (150 and 200 μm [n = 64]) resulted in a total of two reversible and seven irreversible partial pareses.

Conclusions The study has shown that it is possible to perform tissue‐selective operations on the parotid gland by means of the Hydro‐Jet using the 120‐μm jet at operating pressures of 40 to 60 bar, ensuring safe, atraumatic dissection of the facial nerve with retention of its functional capability. The advantages of the new Hydro‐Jet method offer a valuable alternative compared with the normal dissection methods adopted in parotid surgery. Thus the results of the present investigation currently are being checked within the framework of a clinical study at our clinic.
Microinvasive Nd:YAG Laser Therapy of Early Glottic Carcinoma and Its Effect on Soluble Interleukin‐2 Receptor, Interleukin‐2, and Natural Killer Cells
Authors: Lai Jin‐Ping , Tao Zheng‐De , Xiao Jian‐Yun , Chen Xiang‐Hui , Zhao Su‐Ping , Tian Yong‐Quan , Betz Christian S.
Published: November 2003

Objective To investigate the effectiveness of microinvasive Nd:YAG laser therapy in human glottic Tis and T1 carcinomas, as well as its effect on the cellular immune function of the tumor‐bearing hosts.

Study Design We treated 34 patients with microinvasive Nd:YAG laser therapy and evaluated its effect on the cellular immune function of the host.

Methods Thirty‐four patients with glottic Tis or T1 squamous cell carcinoma were treated with fiberoptic laryngoscopic Nd:YAG laser surgery. Both before and after therapy, serum levels of soluble interleukin‐2 receptor (SIL‐2R) and interleukin‐2 (IL‐2), as well as natural killer (NK) cell activity, were determined by means of double‐antibody sandwich technique, tritiated thymidine‐deoxyribonucleoside incorporation, and iodine 125‐uridine‐deoxyribonucleoside release technique, respectively.

Results All 34 patients tolerated the procedure well. A 3‐ to 7‐year follow‐up in a subgroup of 27 patients resulted in an estimated cure rate of 85.2% (23 of 27 patients). In all 27 patients with a regular follow‐up, a subjective improvement of phonation was noted after therapy to various degrees. In 74% (20 of 27 patients), voice and speech subjectively recovered to almost normal levels. The post‐therapy serum levels of SIL‐2R were significantly declined (P <.001), whereas those of IL‐2 and the NK activity were significantly elevated (P <.001) as compared with those detected before therapy.

Conclusions Therapy with fiberoptic laryngoscopic Nd:YAG laser surgery is simple, safe, effective and only minimally invasive for patients with glottic Tis or T1 carcinoma. At the same time, it has an immunoenhancing effect on its host.
Long‐Term Results of Inferior Turbinate Reduction With Argon Plasma Coagulation
Authors: Bergler Wolfgang F. , Sadick Haneen , Hammerschmitt Nicolas , Oulmi Jasmina , Hörmann Karl
Published: November 2003

Objectives Surgical reduction of the inferior turbinates is a commonly used therapy in patients with hyperplastic inferior turbinates when medical management remains ineffective. Current surgical methods have disadvantages (e.g., necessity of nasal packing, extended postoperative swelling, and high costs). Theoretical considerations render argon plasma coagulation (APC) a promising new therapeutic approach.

Study Design In a prospective study, 121 patients with chronic nasal obstruction were treated for inferior turbinate reduction with APC. Hyperplasia of the nasal turbinates was diagnosed rhinoscopically and endoscopically and confirmed rhinomanometrically. The mean follow‐up period was 12 months, ranging from 10 to 16 months. The treatment results were evaluated by a questionnaire, rhinomanometric findings, and electron microscopic studies of the nasal mucosa. In 50 patients a ciliary function test was performed preoperatively and postoperatively.

Methods Argon plasma coagulation, a high‐frequency electrosurgery, has been used for volume reduction of the inferior turbinate in local anesthesia.

Results Seventy‐six percent of the patients reported an improvement of the postoperative swelling within the first week. After 6 weeks, macroscopically the turbinates were re‐epithelialized by normal mucosa in 63% of the patients. Electron microscopic studies after 3 months verified normal cilia. After 12 months, 83% of the patients stated that they had a better nasal airflow than preoperatively. Crust formation was minimal. No bleeding or impaired ciliary function occurred. Ninety‐five percent of the patients were willing to undergo the same operation again.

Conclusion The long‐term results have proved APC to be an effective and easy‐to‐perform alternative for inferior turbinate reduction with comparable results to other established surgical methods.
Upper Airway Edema Resulting From Use of Ecballium elaterium
Authors: Kloutsos Georgios , Balatsouras Dimitrios G. , Kaberos Antonis C. , Kandiloros Dimitrios , Ferekidis Eleftherios , Economou Constantinos
Published: November 2003

Objectives To present a rare occurrence in ear, nose and throat practice of upper airway allergic edema from use of juice extracted from the fruit of Ecballium elaterium.

Introduction Ecballium elaterium is a plant indigenous to the Mediterranean region that bears the common name squirting cucumber. Many people in this region for the treatment of sinusitis use the juice of its fruit. However, allergy‐prone patients after using it may sometimes present with edema at various sites of the upper respiratory tract. Otolaryngologists are frequently asked to diagnose and treat such an emergency situation.

Study Design Retrospective review of the records of 42 patients with this condition during the last 4 years.

Methods Patient records were retrospectively reviewed for age, sex, presenting symptoms, physical examination, and medical treatment. Seasonal distribution and data from the history of the patients were also considered. Skin prick and prick‐to‐prick testing to various allergens was performed in 12 patients.

Results Most of the patients presented with localized swelling of the uvula and the nasal mucosa, whereas in the remainder of the patients various sites of swelling of the upper respiratory tract were observed. Skin tests elicited positive reactions to pollen weeds and to various fruits of the Cucurbitaceae family. Treatment of the patients with corticosteroids and antihistamines resulted in an uneventful recovery, and we did not need to resort to therapeutic modalities, such as intubation or tracheotomy.

Conclusions We think a further study of the pharmaceutical properties of the plant's fruit juice is needed, especially regarding its curative properties of rhinitis and sinusitis. However, adverse reactions in some patients with a positive history of allergy should always be considered.
Laryngeal Pseudosulcus as a Predictor of Laryngopharyngeal Reflux
Authors: Hickson Charlene , Simpson C. Blake , Falcon Rhonda
Published: November 2003

Objectives/Hypothesis Laryngeal pseudosulcus is an accurate prognostic indicator of laryngopharyngeal reflux (LPR) disease.

Study Design Prospective study of 20 consecutive patients with laryngeal pseudosulcus. Pseudosulcus is infraglottic laryngeal edema that is thought to be secondary to LPR. All patients were evaluated with dual‐channel pH probe 24‐hour monitoring to evaluate for the presence of laryngopharyngeal reflux.

Methods Twenty patients identified with laryngeal pseudosulcus on routine physical examination were included in the study. Each patient underwent a 24‐hour dual‐channel pH probe. The data were analyzed and compared with previously published normative data. The data included the total number of reflux episodes and the percentage of time the pH dropped below 4 at the proximal probe.

Results Eighteen of the 20 patients with laryngeal pseudosulcus were found to have LPR. The mean number of reflux episodes at the proximal probe was 29.4 (range, 3–82). The mean percentage of time the pH dropped below 4 was 1.15%. In the upright position the mean value was 1.59% and in the supine position it was 0.19%. This gives pseudosulcus a positive predictive value for LPR of 90%.

Conclusion This study shows laryngeal pseudosulcus to be an accurate predictor of laryngopharyngeal reflux disease.
Simultaneous Modified Evans Blue Dye Procedure and Video Nasal Endoscopic Evaluation of the Swallow
Authors: Donzelli Joseph , Brady Susan , Wesling Michele , Craney Mary
Published: November 2003

Objective To investigate the results of the modified Evans blue dye test (MEBD) aspiration detection rate to the video nasal endoscopic examination of the swallow (VEES) during simultaneous studies with direct viewing of the subglottis through the tracheostomy site opening by means of endoscopy.

Study Design Prospective, consecutive.

Methods Fifteen consecutive simultaneous MEBD and VEES studies were completed on patients with tracheostomies at an acute care rehabilitation hospital over a 4‐month period. All patients were referred to the swallowing center for a video nasal endoscopic examination who had known or suspected dysphagia.

Results Aspiration was present in 53% (8) of the studies as documented by the VEES. The MEBD showed an overall 50% false‐negative error rate for the detection of aspiration as compared with the VEES. The MEBD identified aspiration in 67% of patients who aspirated more than trace amounts but failed to identify aspiration of trace amounts (0%).

Conclusion The results of the current investigation suggest that the MEBD, at best, should be viewed only as a screening tool for the presence of gross amounts of aspiration in patients with a tracheostomy.
A Treatment for Vocal Cord Dysfunction in Female Athletes: An Outcome Study
Authors: Sullivan Marsha D. , Heywood Barbara M. , Beukelman David R.
Published: November 2003

Objectives This article reports the outcome of a speech pathology treatment program for vocal cord dysfunction (VCD) in 20 adolescent female athletes.

Study Design A retrospective, nonrandomized group design was used to collect the outcome data.

Methods Twenty consecutive referrals of female athletes diagnosed as having symptoms of VCD during exercise were assessed, treated, and followed for at least 6 months after treatment.

Results Ninety‐five percent of the participants reported the ability to control symptoms of VCD during exercise up to 6 months after treatment. Asthma medications were no longer used by 80% of the athletes. All of the females continued to participate in athletics.

Conclusion Speech pathology intervention focusing on respiratory control of VCD in adolescent female athletes is an effective treatment resulting in the athletes' ability to control the symptoms of VCD in exercise for at least 6 months after treatment.
Virtual Endoscopic Evaluation of Labyrinthine Fistulae Resulting From Cholesteatoma
Authors: Briggs Russell D. , Vrabec Jeffrey T. , Cavey Matthew L. , Johnson Raleigh F.
Published: November 2003

Objectives/Hypothesis Fistulae of the otic capsule occur in approximately 10% of cholesteatoma cases. Preoperative imaging of this complication is valuable in limiting intraoperative morbidity. Three‐dimensional virtual endoscopic imaging provides a new method for analysis of conventional computed tomography (CT) imaging data. The purpose of the study was to examine the feasibility and efficacy of this technique in detecting labyrinthine fistulae caused by cholesteatoma.

Study Design Retrospective case study.

Methods Fifteen patients with surgically confirmed lateral semicircular canal fistula and preoperative CT scan were included. Scans meeting inclusion criteria were imported into a software program for production of virtual endoscopic images. Dehiscent and normal lateral semicircular canals were navigated while varying threshold values for surrounding bone. Changes in threshold values produce the effect of thickening or thinning the bone enveloping the semicircular canal. Threshold parameters that produced easy circumnavigation (“open”) and intact inner surface of the lateral canal (“closed”) were recorded.

Results The fistula group demonstrated a significantly lower “closed” threshold level and, consequently, a greater range of navigation between “open” and “closed” thresholds. Intrasubject absolute differences in threshold values between normal and abnormal ears appeared to be the most accurate method for detecting a fistula. The suggested imaging parameters displayed an overall sensitivity for fistula detection of 67% with a specificity of 93%.

Conclusions The three‐dimensional virtual endoscopic algorithm shows promise as a method for confirmation of otic capsule dehiscences. Sensitivity for detection is suboptimal but can be improved by alterations in image acquisition parameters.
Percutaneous Endoscopic Gastrostomy: Strategies for Prevention and Management of Complications
Authors: Lin Ho‐Sheng , Ibrahim Hani Z. , Kheng Jennifer W. , Fee Willard E. , Terris David J.
Published: November 2003

Objective The placement of percutaneous endoscopic gastrostomy (PEG) tubes is within the realm of the head and neck surgeon because most are proficient in the use of rigid and flexible esophagoscopes. The ability to provide comprehensive care for the patient with head and neck cancer provides further incentive for the head and neck surgeon to adopt this technique. Although it is a technically simple procedure, the surgeon must be aware of the range of complications that can occur with PEG. We review our experience with PEG focusing on the complications as well as strategies for the prevention and management of these complications.

Methods A retrospective review of the records of patients who underwent PEG at Stanford University by the Head and Neck Surgery Service between July 1992 and December 1998 was conducted. A total of 103 patients were identified, of which 84 (82%) were patients with head and neck cancers. Complications associated with PEG were identified. All PEGs were performed using the pull technique.

Results There was no mortality associated with the procedure. Minor complications occurred in 11 cases (10.7%). These included cellulitis (4), ileus (3), tube extrusion (1), clogged lumen (1), and peristomal leakage (2). The only major complication was a single case of PEG site metastasis.

Conclusion The review of our experience with PEG tube placement revealed a low complication rate. Safe PEG placement was achieved by transillumination of the abdominal wall and confirmation by ballottement. In addition, appropriate patient selection, use of perioperative antibiotics, as well as meticulous post‐procedure care contributed to the low rate of complications. For the patients with head and neck cancer, a barrier should be placed between the tumor and the instrumentation at the time of tube placement.
Chromosomal Aneuploidy Precedes Morphological Changes and Supports Multifocality in Head and Neck Lesions
Authors: Ai Hong , Barrera Jose E. , Meyers Arlen D. , Shroyer Kenneth R. , Varella‐Garcia Marileila
Published: November 2003

Objective To identify chromosome changes associated with the transformation of dysplastic lesions and to verify evidence for multifocality in synchronous premalignant lesions associated with head and neck squamous cell carcinoma (HNSCC).

Study Design Chromosomal aneuploidy was evaluated in sections of formalin‐fixed, paraffin‐embedded tissues from 16 patients with HNSCC, including sites with normal squamous mucosa, dysplasia (low‐ and high‐grade), and invasive tumor.

Methods A panel of 6 centromeric probes (chromosomes 1, 3, 7, 8, 9, and 17) was analyzed in dual‐color fluorescence in situ hybridization assays, using matched hematoxylin–eosin‐stained sections for histologic correlation.

Results Imbalances for most of the targets tested were found in 20 of 24 invasive carcinoma sites, mainly represented by gain in copy number per cell. However, cell populations with chromosome losses and gains in multimodal patterns were concomitantly observed in a number of tumors, indicating a high degree of chromosome instability. The detection of chromosomal aneuploidy precedes the malignant transformation as indicated by findings of monosomy and trisomy in normal squamous mucosa, and in low‐grade and high‐grade dysplasia sites. Loss of chromosomes 3 and 17 prevailed in low‐grade dysplasias, and gain of chromosomes 7 and 8 were prevalent in high‐grade dysplasias. Synchronous low‐grade and high‐grade dysplastic lesions displayed discordant molecular signatures, suggesting a multifocal origin.

Conclusions The interphase fluorescence in‐situ hybridization (FISH) assay with centromeric may detect early changes in the progression of dyplastic epithelia to invasive carcinoma and supports the field cancerization theory of multifocality.
Laryngospasm: An Atypical Manifestation of Severe Gastroesophageal Reflux Disease (GERD)
Authors: Maceri Dennis R. , Zim Shane
Published: November 2003

Objectives To present a potentially life‐threatening manifestation of gastroesophageal reflux disease (GERD), laryngospasm. This review covers the diagnosis and management of eight patients treated by the authors.

Study Design A retrospective analysis of 8 consecutive patients who were referred for the evaluation of unexplained laryngospasm. The medical therapy and lifestyle modifications of treatment are discussed.

Methods The patient records were reviewed and tabulated for age, onset of symptoms, and history of GERD; the presence of an associated upper respiratory infection with persistent cough; and the development of syncope in the presence of laryngospasm.

Results All 8 patients had initial control of laryngospasm. Three had complete control without relapse, 3 had initial control with rare relapse of mild laryngospasm, and 2 patients had initial control with frequent relapses. Six of the 8 had syncopal episodes as a consequence of the laryngospasm. All patients were initially treated with a proton pump inhibitor. Five of the 8 required the addition of an esophageal prokinetic agent to control the reflux and subsequent laryngospasm. Two patients are off all medications at the time of this writing and 4 of the 8 have had rare relapses after initial control of symptoms. Once control of the laryngospasm had been achieved, there were no subsequent episodes of syncope.

Conclusions Based on the data collected in these 8 individuals, patients with reflux disease (known or unknown) can develop severe laryngospasm and possible syncope. The key factor seems to be the association of a recent or concurrent upper respiratory infection that results in a protracted cough that is more severe when supine and at times violent. The cough increases the amount of the refluxate, which is the noxious insult to the larynx.
Candidate's Thesis: Direct Evidence of Bacterial Biofilms in Otitis Media
Authors: Post J. Christopher
Published: November 2003

Objectives/Hypothesis Bacteriologic studies of otitis media with effusion (OME) using highly sensitive techniques of molecular biology such as the polymerase chain reaction have demonstrated that traditional culturing methods are inadequate to detect many viable bacteria present in OME. The presence of pathogens attached to the middle‐ear mucosa as a bacterial biofilm, rather than as free‐floating organisms in a middle‐ear effusion, has previously been suggested to explain these observations. The suggestion has been speculative, however, because no visual evidence of such biofilms on middle‐ear mucosa has heretofore been collected. The hypotheses motivating the current study were: 1) biofilms of nontypable Hemophilus influenzae will form on the middle‐ear mucosa of chinchillas in an experimental model of OME, 2) these biofilms will exhibit changes in density or structure over time, and 3) biofilms are also present on tympanostomy tubes in children with refractory post‐tympanostomy otorrhea. The objective of this study was to collect visual evidence of the formation of bacterial biofilms in these situations.

Study Design Laboratory study of bacteriology in an animal model and on medical devices removed from pediatric patients.

Methods Experimental otitis media was induced in chinchillas by transbullar injection of nontypable H. influenzae. Animals were killed in a time series and the surface of the middle‐ear mucosa was examined by scanning electron microscopy (SEM) for the presence of bacterial biofilms. Adult and fetal chinchilla uninfected controls were similarly examined for comparison. In addition, tympanostomy tubes that had been placed in children's ears to treat OME and removed after onset of refractory otorrhea or other problems were examined by SEM and by confocal scanning laser microscopy for bacterial biofilms, and compared with unused control tubes.

Results Bacterial biofilms were visually detected by SEM on the middle‐ear mucosa of multiple chinchillas in which H. influenzae otitis media had been induced. Qualitative evaluation indicated that the density and thickness of the biofilm might increase until at least 96 hours after injection. The appearance of the middle‐ear mucosa of experimental animals contrasted with that of uninjected control animals. Robust bacterial biofilms were also visually detected on tympanostomy tubes removed from children's ears for clinical reasons, in contrast with unused control tubes.

Conclusions Bacterial biofilms form on the middle‐ear mucosa of chinchillas in experimentally induced H. influenzae otitis media and can form on tympanostomy tubes placed in children's ears. Such biofilms can be directly observed by microscopy. These results reinforce the hypothesis that the bacterial aggregates called biofilms, resistant to treatment by antibiotics and to detection by standard culture techniques, may play a major etiologic role in OME and in one of its frequent complications, post‐tympanostomy otorrhea.
Intratympanic Steroid Injections for Intractable Ménière's Disease
Authors: Barrs David M. , Keyser Jeffrey S. , Stallworth Christian , McElveen John T.
Published: November 2003

Objective To examine whether intratympanic injection of dexamethasone is effective in controlling vertigo in patients with Ménière's disease who have persistent vertigo despite standard medical treatment, including a low‐salt/no‐caffeine diet and diuretics.

Study Design A prospective study.

Methods From August 1999 to November 2000, 21 patients with intractable Ménière's disease underwent intratympanic injections of 4 mg/mL dexamethasone over a period of 4 weeks as an office procedure. American Academy of Otolaryngology–Head and Neck Surgery guidelines for the definition and reporting of results in Ménière's disease were used. 1

Results Complete relief of vertigo was maintained in 11 of the 21 patients (52%) at 3 months and in 9 of 21 patients (43%) at 6 months. Repeat injections in 5 patients who had initial control of vertigo, but later failed, yielded control in 3 (60%) patients. The complication rate was low: one patient had a 35‐decibel pure tone average decrease in hearing during treatment and one patient had a persistent tympanic membrane perforation.

Conclusions Intratympanic injections of dexamethasone are a reasonable initial surgical treatment for persistent vertigo in Ménière's disease. The principal benefits are avoidance of systemic administration of steroids, lower cost than endolymphatic sac surgery, and ease of administration as an office procedure. The disadvantages are the need for repeated office visits for injections and the decreasing effectiveness over time.
Asymmetry of the Ethmoid Roof: Analysis Using Coronal Computed Tomography
Authors: Lebowitz Richard A. , Terk Alyssa , Jacobs Joseph B. , Holliday Roy A.
Published: November 2003

Objectives/Hypothesis To determine the incidence and degree of asymmetry in the height and contour of the ethmoid roof.

Study Design Retrospective review of direct coronal paranasal sinus computed tomography (CT) scans.

Methods Retrospective review of 200 consecutive direct coronal sinus CT scans done at New York University Medical Center from July 25, 2000 to October 11, 2000. The height and contour of the fovea ethmoidalis were examined for symmetry between the right and left sides. When an asymmetry in the height of the fovea ethmoidalis existed, this difference was quantified.

Results In 19 scans (9.5%), there was an asymmetry between the height of the fovea ethmoidalis on the right and left sides. Of these 19, 12 (63.2%) were lower on the right side, whereas 7 (36.8%) were lower on the left. Ninety‐six patients (48.0%) demonstrated a contour asymmetry with “flattening” of the ethmoid roof on one side, 46 on the right and 50 on the left. One patient demonstrated both height and contour asymmetry. The fovea ethmoidalis on the remaining 86 scans (43.0%) was symmetric.

Conclusions In a patient population with sinus and nasal symptoms, the height and contour of the right and left fovea ethmoidalis were symmetric in less than 50% of individuals. The asymmetry was most often the result of a difference in contour with flattening of the fovea on one side. This underscores the importance of careful preoperative and intraoperative review of paranasal sinus CT scans in patients undergoing endoscopic sinus surgery.
Evaluation of the Utility and Cost‐Effectiveness of Obtaining Histopathologic Diagnosis on All Routine Tonsillectomy Specimens
Authors: Younis Ramzi T. , Hesse Sabine V. , Anand Vinod K.
Published: November 2003

Objectives To evaluate the use and necessity of obtaining histopathology on patients undergoing tonsillectomy, and to provide indications and guidelines for requesting histopathology on tonsillectomy patients.

Study Design At the University of Mississippi Medical Center, we have been routinely obtaining histopathologic diagnoses on every patient undergoing tonsillectomy or tonsillectomy and adenoidectomy. Specimens are separated into left and right tonsils and adenoids. This study was designed at our tertiary care academic center to evaluate the necessity for obtaining histopathologic diagnosis on each of these patients.

Methods A retrospective review of histopathologic reports on all patients in both pediatric and adult age groups undergoing tonsillectomy or tonsillectomy and adenoidectomy between January 1994 and December 1999 was performed.

Results A total of 2438 reports were reviewed. There were 2099 in the pediatric age group and 339 were adults. None of the children had an unusual histopathology finding other than lymphoid hyperplasia. Of the 339 adults, 34 had squamous cell carcinoma and 6 had lymphoma; however, these findings were suspected preoperatively by history and clinical manifestations.

Conclusions The general practice guidelines mandate obtaining histopathologic diagnoses on most of the tissues received. Based on our review, histopathology of tonsillectomy and/or adenoidectomy may not be necessary, especially in children. In this era of cutting excess costs of health care dollars, waving histopathology in these cases may have major implications without compromising delivery of quality care.
Bipolar Scissors versus Cold Dissection Tonsillectomy: A Prospective, Randomized, Multi‐Unit Study
Authors: Raut V. , Bhat N. , Kinsella J. , Toner J. G. , Sinnathuray A. R. , Stevenson M.
Published: November 2003

Objective To evaluate bipolar scissors tonsillectomy by comparing it with traditional cold dissection tonsillectomy.

Study Design A prospective, randomized, multi‐unit study.

Settings Belfast City Hospital, Royal Victoria Hospital Belfast, and Ulster Hospital Dundonald.

Patients Two hundred consecutive patients undergoing tonsillectomy for recurrent or chronic tonsillitis between March 2000 and September 2000.

Outcome Measures (1) Intraoperative bleeding, (2) operative time, (3) postoperative pain, and (4) complication rates, including primary and secondary hemorrhage.

Results Seventeen patients were excluded from the study for various reasons. The mean age of the study population was 22 years (range, 10–54 y). Seventy‐two percent of patients were female. Twenty‐seven percent of patients were children aged 16 years or under. Median intraoperative blood loss was 5 mL for bipolar scissors tonsillectomy and 115 mL for cold dissection tonsillectomy (P <.001). The mean operative time was 13 minutes for bipolar scissors tonsillectomy compared with 20 minutes for the cold dissection method (P <.001). There was no statistically significant difference in the pain scores between the two methods (independent samples t = 1.35;P >.05). The overall primary hemorrhage rate was 2.1%, whereas the overall secondary hemorrhage rate was 16.9%. The hospital readmission rate was 10.3%. The primary and secondary hemorrhage rates were unaffected by the surgical method.

Conclusions Bipolar scissors tonsillectomy is a safe technique with a similar morbidity to the cold dissection method. Its use is associated with a significant decrease in both surgical time and blood loss compared with the cold dissection method.
The Value of Enhanced Magnetic Resonance Imaging in the Evaluation of Endocochlear Disease
Authors: Hegarty Joseph L. , Patel Sandy , Fischbein Nancy , Jackler Robert K. , Lalwani Anil K.
Published: November 2003

Background Gadolinium‐enhanced magnetic resonance imaging (GdMRI) is routinely used in the evaluation and management of suspected retrocochlear pathology such as vestibular schwannoma. However, its value in the evaluation and diagnosis of cochlear pathology associated with sensorineural hearing loss (SNHL) has been less clear.

Study Design Retrospective review of case histories and imaging studies of patients with SNHL and cochlear enhancement on GdMRI diagnosed between 1998 and 2000.

Results Five patients with SNHL who required gadolinium administration to establish the diagnosis of endocochlear disease were identified. Diagnosed lesions included an intralabyrinthine schwannoma, intracochlear hemorrhage, radiation‐induced ischemic change, autoimmune labyrinthitis, and meningogenic labyrinthitis. In these illustrative cases, the GdMRI demonstrated intrinsic high signal or contrast enhancement within the cochlea and labyrinth in the absence of a retrocochlear mass. In one patient with meningogenic labyrinthitis, cochlear enhancement on MRI led to prompt cochlear implantation before the potential development of cochlear ossification.

Conclusion Our experience suggests that GdMRI plays a crucial role in the diagnosis of cochlear pathology associated with sensorineural hearing loss and may directly impact patient management.
MeroGel Hyaluronic Acid Sinonasal Implants: Osteogenic Implications
Authors: Jacob Abraham , Faddis Brian T. , Chole Richard A.
Published: November 2003

Objectives/Hypothesis The study sought to evaluate the effects of MeroGel (Medtronic Xomed Surgical Products, Jacksonville, FL) hyaluronic acid sinonasal implants by using a mouse model. We expected that this material would dissolve, elicit minimal inflammation, and leave intact mucosa. However, pilot data showed that MeroGel may be osteogenic. The present work focuses on the description and quantification of these bony changes.

Study Design Animal experiment.

Methods The effects of MeroGel were evaluated using sinonasal and calvarial implants in C57BL/6 mice. The calvarial experiments employed both light microscopy (bone histomorphometry) and fluorochrome labeling (mineral apposition). Each implant study was subdivided into normal control animals, sham‐operated control animals, a foreign body control, and MeroGel implants. MeroGel was also placed within subcutaneous pockets remote from bone. All mice were killed 1 month after surgery. Both percentage of bone area within the sinonasal cavity and total calvarial bone area were quantified and compared. Fluorochrome images and the subcutaneous implants were examined qualitatively.

Results MeroGel placement engendered new bone formation within the nasal lumen of mice. Compared with normal control animals, sham‐operated control animals, and a foreign body control, this increase was statistically significant. The calvaria from MeroGel‐implanted mice were thickened as compared with normal animals, sham‐operated control animals, and a foreign body control. Tetracycline labeling demonstrated mineral apposition along the dorsal and ventral surfaces of the calvaria and within enlarged marrow spaces. MeroGel placed subcutaneously did not engender bone formation.

Conclusions MeroGel, a unique esterified form of hyaluronic acid, induced bone formation within the sinonasal cavity and on the calvaria of mice implanted with it. Our experiments suggest that, when placed adjacent to traumatized, remodeling bone, MeroGel may have osteogenic potential.