bluuebunny/crossref_metadata_2025 huggingface dataset:
Quantitative evaluation of the upper airway during nasopharyngoscopy with the müller maneuver
Authors: Ritter Christen T. , Trudo Frank J. , Goldberg Andrew N. , Welch Kevin C. , Maislin Greg , Schwab Richard J.
Published: November 2003

Objective: To quantitatively examine changes in the upper airway caliber of normal subjects at graded negative inspiratory pressures generated during nasopharyngoscopy with a Müller maneuver. Study Design: Eighteen normal subjects prospectively underwent nasopharyngoscopy with Müller maneuvers. Subjects performed graded and maximal effort Müller maneuvers while sitting upright, and maximal‐effort Müller maneuvers in the supine position. Two regions of the upper airway—the retropalatal and retroglossal—were examined. Methods: Images from the endoscopic examination were objectively analyzed by adjusting manually traced airway contours using full‐width, half‐maximum edge detection algorithm software. The adjusted tracings' area and dimensions through the airway centroid were measured. Results: Müller maneuvers performed at ‐40 cm H2O resulted in a 64% ± 17% (P = .0001) reduction in upper airway area that consisted of a 51% ± 20% (P = .0001) reduction in the lateral dimension and a 21% ± 24% (P = .0026) reduction in antero‐posterior dimension. Müller maneuvers in the retroglossal region did not significantly reduce airway area (P = .575), but demonstrated an altered airway conformation that consisted of lateral narrowing and an increase in antero‐posterior dimension. Changes in body position did not result in significant differences in either airway caliber or airway dimension. Conclusions: Airway caliber during forced inspiration is mediated primarily through changes in the lateral pharyngeal walls. This study has also shown that antero‐posterior and lateral airway structures are largely independent in their response to Müller maneuvers. Similarly, the retropalatal and retroglossal regions of the upper airway respond differently to forced negative intraluminal pressure. Key Words: Nasopharyngoscopy, Müller maneuver, normal subjects, upper airway, obstructive sleep apnea.
Establishment and characterization of human laryngeal squamous cell carcinoma cell lines
Authors: Ku Ja‐Lok , Kim Woo‐Ho , Lee Jae‐Ho , Park Hyun‐Sook , Kim Kwang Hyun , Sung Myung‐Whun , Park Jae‐Gahb
Published: November 2003

Objectives: Six human laryngeal squamous cell carcinoma cell lines (SNU‐46, ‐585, ‐899, ‐1066, ‐1076, ‐1214) established from Korean patients are reported. Study Design: In vitro culture of six squamous cell carcinoma cell lines derived from primary tumors of the larynx. Description of the cell line phenotypes and determination of molecular characteristics. Methods: Six laryngeal squamous cell carcinoma cell lines were cultured. The cell phenotypes, including the histopathology of the primary tumors and in vitro growth characteristics, were determined. Molecular characterization was also performed, including DNA fingerprinting analysis and abnormalities of p15, p16, p53, and TGF‐βRII genes by polymerase chain reaction‐based single strand conformation polymorphism and sequencing analysis. Results: All cell lines grew as adherent cells; five lines grew as monolayers and one other line grew as stratifying colonies. All lines showed 1) high viability (75%–92%) with various doubling times (36–96 h); 2) absence of Mycoplasma and other bacteria; and 3) genetic heterogeneity by DNA profile analysis. p53 Mutations were found in three lines and p16 mutations were observed in five cell lines. TGF‐βRII mutations were found in two lines: one line had frameshift mutation and another line had a missense mutation at the kinase domain. Conclusions: These newly established and characterized laryngeal squamous cell carcinoma cell lines will be useful for investigating the biologic characteristics of laryngeal cancer. Key Words: Laryngeal squamous cell carcinoma, cell lines, p53, p16, TGF‐βRII.
Idiopathic bilateral vocal fold weakness
Authors: Dray Todd G. , Robinson Lawrence R. , Hillel Allen D.
Published: November 2003

Objective: To describe an unrecognized clinical entity, idiopathic bilateral vocal fold weakness, and propose recommendations regarding the diagnosis and management of these cases. Study Design: Retrospective, nonrandomized case study. Methods: All cases of bilateral vocal fold weakness evaluated at the University of Washington Voice Disorders Clinic between 1991 to 1998 were reviewed. Results: Four patients with bilateral laryngeal weakness were determined to have idiopathic bilateral vocal fold paresis following exhaustive workups, including videostroboscopy, bilateral laryngeal electromyography (EMG), neurological consultation, and other pertinent studies. Conclusions: Performing bilateral laryngeal EMG is an essential aspect of the workup of any laryngeal weakness case, particularly if the etiology is unknown on presentation. Idiopathic bilateral vocal fold weakness is an underrecognized but real clinical diagnosis that will become more familiar with the increasing utilization of laryngeal EMG in clinical situations.
Cosmetic Enhancement Associated With Surgery for Obstructive Sleep Apnea
Authors: Terris David J.
Published: November 2003

Objective: To document the capacity of surgery for obstructive sleep apnea (OSA) to incorporate techniques that incidentally improve the cosmetic features of the patients. Study Design: Retrospective analysis of surgical outcomes at an academic practice. Methods: Moderate to severe OSA usually requires multilevel pharyngeal surgery, including tongue base surgery. The surgical procedures, including hyoid myotomy and mandibular osteotomy with tongue advancement, afford the opportunity to address cosmetic deficits, such as microgenia and excessive submental skin and fat. Outcomes achieved using these procedures over a 4‐year period were analyzed. Results: Of 428 consecutive patients presenting for evaluation of sleep‐related breathing disorders, 212 were deemed surgical candidates. Ninety‐seven of these had office‐based procedures for snoring, upper airway resistance syndrome, or mild OSA. The remaining 115 had formal surgical procedures done, and 68 of these had multilevel pharyngeal surgery. Of these, 12 had defined cosmetic deficiencies that were addressed at the time of the sleep apnea surgery. There were 7 men and 5 women, with a mean age of 48.2 years. The group was moderately obese (mean BMI = 31.8) and had moderate to severe OSA (mean RDI = 37.0, mean LSAT = 78%). Cosmetic deficits identified included turkey gobbler deformity (n = 8), microgenia (n = 6), excessive submental fat (n = 2), and nasal deformity (n = 1); several patients had more than one addressable problem. All patients achieved an improved postoperative appearance. Representative photographs are presented. Conclusions: A surgical approach to the management of sleep apnea affords an opportunity to also address cosmetic deficiencies, including excessive submental skin and fat, microgenia, and nasal deformities.
Treatment of the Clinically Negative Neck in Oral Squamous Cell Carcinoma
Authors: Persky Mark S. , Lagmay Victor M.
Published: November 2003

Objective: To define the most effect treatment plan of patients with oral cavity squamous cell carcinoma with clinically negative (N0) neck staging. Study Design: Retrospective review of 54 patients with N0 neck staging who underwent resection of an oral cavity primary tumor with or without elective neck dissection between January 1982 and December 1992 and with a minimum follow‐up of 3 years. Methods: The records of 54 patients with previously untreated oral cavity squamous cell carcinoma and N0 neck staging were retrospectively reviewed to determine the impact of elective neck dissection on patient outcomes including regional recurrence and overall survival. Results: All patients underwent surgical resection of their oral cavity tumors, with 33 patients undergoing “watchful waiting” observation for the development of neck disease while 21 patients had elective neck dissections. The most controversial group of patients were those with intermediate‐sized (T2 and T3) primary tumors. Eighteen of these patients underwent elective neck dissection, with two patients developing recurrent neck disease and an ultimate prognosis of 72%. Twelve patients had observation of their necks, with five of these patients subsequently requiring neck dissection. An additional seven patients did not undergo neck dissection, and this group had four survivors free of disease. The prognosis was 42% in patients not having elective neck dissections. Conclusions: Tl tumors do well with neck treatment other than careful observation. The data suggest that patients with T2 and T3 oral squamous cell carcinoma should undergo surgical resection of their primary tumor site and elective neck dissection. Patients with T4 oral cavity lesions should routinely undergo neck dissection.
Patient Use of Traditional and Complementary Therapies in Treating Rhinosinusitis Before Consulting an Otolaryngologist
Authors: Krouse John H. , Krouse Helene J.
Published: November 2003

Objectives: It has been estimated that 50 million Americans are bothered with symptoms of allergic disease and sinusitis. Patients treat these symptoms with a variety of traditional and complementary therapies. This study examined the use of these therapies by patients before consulting an otolaryngologist.

Study Design: This investigation involved a prospective clinical survey.

Methods: The sample consisted of 120 adult patients seen in a community‐based otolaryngology practice, who presented with complaints of sinusitis and rhinitis. Patients completed a set of questionnaires at their initial office visit to assess the various traditional and complementary therapies they had used. In addition, they completed a questionnaire evaluating the various symptoms with which they presented to the physician. All data were analyzed with descriptive statistics.

Results: The results demonstrated that patients had been symptomatic for a mean length of 3.5 years before seeking therapy from the otolaryngologist. In addition, 87% of patients had previously seen a primary care provider, and 42% of patients had previously consulted an otolaryngologist. While traditional therapies including medications were commonly used, many patients also attempted a variety of complementary treatments, including dietary management, herbal therapy, exercise, and chiropractic. Patients who had previously seen an otolaryngologist were commonly treated with surgery.

Conclusions: These findings demonstrate that patients employ both traditional and complementary therapies before seeking the care of an otolaryngologist. In addition, findings suggest that, despite aggressive medical and surgical therapy, many patients continue to remain symptomatic.
Tongue Base Reduction With Hyoepiglottoplasty: A Treatment for Severe Obstructive Sleep Apnea
Authors: Chabolle Frédéric , Wagner Isabelle , Blumen Marc B. , Séquert Catherine , Fleury Bernard , De Dieuleveult Thibault
Published: November 2003

Objective:To describe a surgical procedure for the treatment of severe obstructive sleep apnea syndrome (OSAS), the procedure's indications, and its results.

Study Design:A retrospective study of 10 male patients with OSAS treated by tongue base reduction with hyoepiglottoplasty (TBRHE) at the Foch Hospital (Suresnes, France) between 1994 and 1997. Patients had a mean body mass index (BMI) of 32 kg/m2, a mean respiratory disturbance index (RDI) of 70 events/h, and a mean minimal oxygen saturation of 78%. They had refused positive airway pressure therapy or wished to discontinue it.

Methods:Subtotal tongue base reduction preceded by lingual neurovascular bundle identification and derouting, epiglottal verticalization, mouth floor horizontalization, and hyoid bone repositioning was performed, associated in some cases to uvulopalatopharyngoplasty (UPPP). Indications were based on a site‐related obstruction, on the absence of craniofacial deficiencies, and on the presence of hyolingual abnormalities determined by cephalometry and magnetic resonance imaging.

Results:TBRHE associated to UPPP in most cases had an 80% success rate, based on a postoperative RDI below 20 events/h and a reduction of the preoperative RDI of more than 50%. Snoring and excessive daytime sleepiness decreased or disappeared, respectively, in 100% and 90% of the cases. No neurovascular complications occurred.

Conclusion:TBRHE is a safe procedure for the neurovascular bundle. Associated to a pharyngotomy, it is an effective treatment for severe OSAS attributable to tongue base obstruction. These results require confirmation in a larger series of patients.
Comparative Study of Vocal Function After Near‐Total Laryngectomy
Authors: Hanamitsu Masakazu , Kataoka Hideyuki , Takeuchi Eiji , Kitajima Kazutomo
Published: November 2003

Objectives: To assess vocal function after near‐total laryngectomy (NTL) and to compare that with after vertical hemilaryngectomy (VHL), both of which use the laryngeal mucosa as the vibratory tissue.

Study Design: We retrospectively evaluated 29 patients, 11 of whom underwent NTL and 18 of whom underwent VHL. However, 2 patients failed to speak and 1 patient's voice sample was lost following NTL, so we analyzed the voices of 8 patients who underwent NTL and 18 patients who underwent VHL.

Methods: Vocal function was examined by acoustic and aerodynamic analysis. Acoustic analysis involved the evaluation of pitch, intensity, pitch perturbation quotient, amplitude perturbation quotient, and normalized noise energy. In aerodynamic analysis, we studied the mean airflow rate, vocal efficiency index (alternating current/direct current [AC/DC]), and maximum phonation time.

Results: Vocal function except pitch after either NTL or VHL had much variability, but the results following each procedure did not differ significantly.

Conclusions: There are no significant differences between vocal function following NTL and VHL. Fiberscopic examination of the mucosa of the arytenoid was observed to vibrate in patients who underwent NTL, so that the phonatory mechanism after NTL resembled that after VHL.
Optimal Stimulus Duration for Intraoperative Facial Nerve Monitoring
Authors: Selesnick Samuel H.
Published: November 2003

Objectives/Hypothesis: The charge delivered to the facial nerve during intraoperative facial nerve monitoring (IOFNM) is the product of the stimulation amplitude and the duration for which the pulse of charge is applied. In the literature, no standard for pulse duration exists, precluding meaningful comparison of IOFNM between studies. The optimal stimulus pulse duration can be derived from facial nerve strength duration curve analysis and calculation of chronaxy. Chronaxy is directly related to the time constant, τ, of the neuronal membrane, and is a function of neuronal membrane resistance and capacitance.

Study Design: A prospective trial of facial nerve stimulation in both an animal and a human model.

Methods: Five rabbits and 17 humans underwent intraoperative stimulation of healthy facial nerves. Pulse durations using pulses of 10, 20, 50, and 100 microseconds were employed, and the corresponding threshold stimulation amplitudes were recorded. From these data sets, strength duration curves were plotted and chronaxy values calculated.

Results: Average chronaxy values of 18 microseconds in the rabbit and 32 microseconds in the human were found. Given IOFNM system accuracy limitations, the optimal pulse duration for facial nerve stimulation is 50 microseconds.

Conclusion: Most commercially available intraoperative monitoring systems employ a pulse duration default setting of 100 microseconds. Doubling of the 50‐microsecond optimal pulse duration may result in a loss of sensitivity of predictive facial nerve data. Both the stimulation amplitude and the selected pulse duration should be reported by investigators so that meaningful comparison of the IOFNM data in the literature can be made.
Transcochlear Repair of Persistent Cerebrospinal Fluid Leaks
Authors: Grant Iain L. , Welling D. Bradley , Oehler Mary C. , Baujan Melissa A.
Published: November 2003

Objective: The purpose of this study is to demonstrate the utility of a modified transcochlear obliteration of the petrous apex in repair of persistent cerebrospinal fluid (CSF) leaks. A review of temporal bone computed tomography (CT) scans and histological preparations for potential air cells leading to such leaks is also presented.

Study Design: Retrospective case review in an academic tertiary referral center.

Methods: Patients for inclusion in this study had previously undergone either a suboccipital or translabyrinthine removal of an intracranial tumor with subsequent transmastoid and middle ear obliteration of air cell tracts to stop a CSF leak. Ninety CT scans and 178 temporal bones were reviewed and assessed for peritubal and petrous apex pneumatization.

Results: Four patients had initial obliteration of the orifice of the eustachian tube and middle ear that failed to prevent leakage of CSF. The leak was ultimately controlled by a transcochlear petrous apicectomy. From The Ohio State University temporal bone collection, 178 specimens were available for examination. Peritubal pneumatization was found in 42% of the bones examined. The CT scans showed unilateral petrous apex pneumatization in 30% of the specimens and bilateral pneumatization in 11%.

Conclusions: Continuity of air cell tracts from the petrous apex surrounding the internal auditory canal to the medial eustachian tube can provide a path for CSF rhinorrhea that is difficult to stop by conventional means. A modified transcochlear approach successfully terminated persistent leaks in four such patients.
Hemangiopericytoma of the Head and Neck
Authors: Carew John F. , Singh Bhuvanesh , Kraus Dennis H.
Published: November 2003

Objective/Hypothesis: Hemangiopericytomas are uncommon neoplasms of vascular origin that may arise in the head and neck. Their rare occurrence and variable malignant potential have limited attempts to characterize their clinical behavior. This study reviews the experience in treating hemangiopericytomas of the head and neck at a single institution.

Study Design: Retrospective.

Methods: The records of 12 patients with hemangiopericytomas of the head and neck presenting between 1979 and 1995 were reviewed. Site of origin included the neck (4), oral cavity (3), parotid (2), orbit (1), maxillary sinus (1) and mandible (1). Five patients had lesions characterized as high or intermediate grade histologically, and six had lesions characterized as low grade.

Results: Nine patients were treated with curative intent; three presented either with pulmonary metastasis (2) or unresectable primaries (1) and were treated with radiation therapy and/or palliative Adriamycin‐based chemotherapy. Patients treated with curative intent underwent a variety of surgical resections dictated by tumor location and size. Four patients received postoperative radiation therapy to a median dose of 60 Gy, for positive surgical margins (2), high‐grade histology (1) or a recurrent lesion (1). Five‐year overall survival in patients treated surgically was 87.5%. A single mortality occurred in a patient with a recurrent high‐grade lesion who failed at local, regional, and distant sites. Median follow‐up of survivors was 73 months.

Conclusion: The clinical behavior of hemangiopericytomas appears to be related to their histological grade. Aggressive local therapy including surgery and radiation therapy appears to be effective in providing tumor control.
Outcome of Frontal Sinus Obliteration
Authors: Mendians Andrew E. , Marks Steven C.
Published: November 2003

Objectives: To evaluate the indications, technique, and results after long‐term follow‐up of osteoplastic frontal sinusectomy with fat obliteration.

Study Design: A retrospective review of a series of consecutive patients using objective and subjective outcome assessment.

Methods: A retrospective chart review was conducted of all patients undergoing osteoplastic flap procedure with obliteration between July 1, 1991, and July 1, 1997. Each patient also completed a symptom questionnaire rating the degree of symptoms both before and after surgery using a 10‐point scale. The results were tabulated and analyzed for statistical significance.

Results: Twenty osteoplastic flap procedures to obliterate the frontal sinus were reviewed. The average patient age was 41 years, with the average duration of follow‐up being 40.2 months. No surgical failures were noted; one patient underwent a negative reexploration. One surgical and one medical complication are reported. Statistically significant improvement was noted in overall symptoms, headache, congestion, drainage, and frequency of infections when the preoperative to the postoperative symptom scores were compared (P < .001).

Conclusions: Based on these results, the use of the osteoplastic flap in the obliteration of the frontal sinus continues to be an option in the era of endoscopic treatment of frontal sinus disease, particularly in endoscopic failures and chronic frontal sinus pain.
A Comparative Model: Reaction Time Performance in Sleep‐Disordered Breathing Versus Alcohol‐Impaired Controls
Authors: Powell Nelson B. , Riley Robert W. , Schechtman Kenneth B. , Blumen Marc B. , Dinges David F. , Guilleminault Christian
Published: November 2003

Objectives/Hypothesis: Patients with sleep‐disordered breathing have reaction time deficits that may lead to catastrophic accidents and loss of life. Although safety guidelines do not exist for unsafe levels of sleepiness, they have been established for unsafe levels of alcohol consumption. Since reaction time performance is altered in both, we prospectively used seven measures of reaction time performance as a comparative model in alcohol‐challenged normal subjects with corresponding measures in subjects with sleep‐disordered breathing.

Study Design: Institutional Review Board‐approved, nonrandomized prospective controlled study.

Methods: Eighty healthy volunteers (29.1 ± 7.5 y of age, 56.3% female subjects) performed four reaction time trials using a psychomotor test at baseline and at three subsequent rising alcohol‐influenced time points. The same test without alcohol was given to 113 subjects (47.2 ± 10.8 y of age, 19.3% female subjects) with mild to moderate sleep‐disordered breathing.

Results: Mean blood alcohol concentrations (BACs) in the alcoholinfluenced subjects at baseline and three trials were 0, 0.057, 0.080, and 0.083 g/dL. The sleep‐disordered subjects had mean respiratory disturbance indices of 29.2 events per hour of sleep. On all seven reaction time measures, their performance was worse than that of the alcohol subjects when BACs were 0.057 g/dL. For three of the measures, the sleep‐disordered subjects performed as poorly as or worse than the alcohol subjects when alcohol levels were 0.080 g/dL. These results could not be explained by sex or age differences.

Conclusion: The data demonstrate that sleep‐disordered subjects in this study (with a mean age of 47 y) with mild to moderate sleep‐disordered breathing had worse test reaction time performance parameters than healthy, nonsleepy subjects (with a mean age of 29 y) whose BAC is illegally high for driving a commercial motor vehicle in California. This comparative model points out the potential risks of daytime sleepiness in those with sleep‐disordered breathing relative to a culturally accepted standard of impairment.
Lamina Propria of the Mucosa of Benign Lesions of the Vocal Folds
Authors: Dikkers Frederik G. , Nikkels Peter G.J.
Published: November 2003

Objective/Hypothesis: To demonstrate a correlation between the duration and specific pattern of trauma of benign lesions of the vocal folds and their histopathologic appearance. Benign lesions of the vocal folds have various macroscopic appearances. Investigations demonstrate characteristic histopathologic features for three clinically well‐defined lesions: 1) vocal fold polyps, 2) Reinke edema, and 3) vocal fold nodules. It is expected that additional histological stainings can contribute to additional insight into the pathophysiology of these lesions.

Study Design: Retrospective.

Methods: Histological stainings were used to study the constitution of the lamina propria of the mucosa: Verhoeff‐van Gieson, Masson trichrome, alcian blue and alcian blue after pretreatment with hyaluronidase.

Results: Estimation of the age of a lesion was not possible. Specific observations: 1) accumulation of hyaluronic acid around vessels occurred uniquely in polyps and 2) transverse orientation of elastic fibers was more often seen in vocal fold nodules. Combinations of histopathologic findings were specific to the lesion.

Conclusions: The additional stainings support our previous observations, but had no additional discriminating value in making a histopathologic diagnosis.
Noninvasive Imaging of Human Oral Mucosa in Vivo by Confocal Reflectance Microscopy
Authors: White W. Matthew , Rajadhyaksha Milind , González Salvador , Fabian Richard L. , Anderson R. Rox
Published: November 2003

Objectives/Hypothesis: To study the microscopic anatomy of normal oral tissues in vivo using confocal reflectance microscopy (CRM). This novel and noninvasive imaging modality can define and characterize healthy oral mucosa and thus this work serves as the foundation for studying oral diseases in vivo.

Study Design: This was a pilot observational cohort study comparing noninvasive CRM images with histology.

Materials and Methods: Lip and tongue mucosa were imaged by CRM in six healthy human subjects. In CRM living tissue is illuminated by a laser source and backscattered (or reflected) light is collected by a detector. Image contrast is determined by natural differences in refractive indices of organelles and other subcellular structures within the tissues. Gray‐scale images were displayed in real‐time on a video monitor and represented horizontal (en face) optical sections through the tissue. Motion of the oral tissue relative to the objective lens was minimized with a tissue stabilizer. After imaging, biopsies were taken from the same site of lip mucosa to correlate noninvasive confocal images with conventional histology.

Results: Confocal images correlated well with conventional histology, both qualitatively (visual analysis) and quantitatively (stereology). Imaging was possible up to depths of 490 and 250 μm in the lip and tongue, respectively. Cells and organelles including nuclei, circulating blood cells, and extracellular matrix were clearly observed.

Conclusion: CRM provides details of normal human oral mucosa at the cellular level without the artifacts of histological processing, and thus has the potential for further development and use in clinical practice as a diagnostic tool for the early detection of oral cancer and precancer.
Activity Influences on Neuronal Connectivity Within the Auditory Pathway
Authors: Niparko John K.
Published: November 2003

Hypothesis: Sensorineural hearing loss may be associated with altered patterns of neuronal connections within the central auditory pathway.

Study Design: The cat auditory system was used to address the relative importance of impulse traffic within the auditory nerve in maintaining central nervous system connections.

Methods: Acute, unilateral deafness was induced by tetrodotoxin intoxication of cochlear hair cells. Analysis focused on the structural patterns of contact between auditory nerve endings called end bulbs of Held and their target neurons. Specifically, end bulb morphology and target cell size within the cochlear nucleus were examined. Highly specialized synaptic contacts at this junction provide a powerful site for study.

Results: The principal finding was that abolished activity in the auditory nerve caused nerve endings to assume a different shape, typified by more branching and smaller terminal swellings. The new shape is one typically associated with only a subpopulation of fibers in normal‐hearing cats‐those exhibiting a high‐threshold, low‐spontaneous activity profile. This result implies that abolished activity alters patterns of nerve fiber contact with second‐order neurons. Tetrodotoxin produced differential effects on subpopulations of target neurons within the brain‐stem and is interpretable on the basis of “weighing” synaptic inputs. Second‐order neurons that receive large axosomatic inputs from their parent fiber were significantly smaller than neurons that receive small, axodendritic terminals. Thus, attenuated auditory activity may produce differential effects across the auditory pathway, thereby disrupting the normal balance of inputs into synaptic stations.

Conclusions: Impulse traffic is a critical factor in the interaction between the ear and central auditory stations and appears necessary for the maintenance of key synapses. As hearing disorders with impaired comprehension may be modeled by studies of auditory deafferentation, these observations extend the possibility that changes in central neuronal connections underlie reduced capabilities for processing restored auditory input.
Methods of Teaching Stapedectomy
Authors: Levenson Mark J.
Published: November 2003

Objectives: Establish a better method of teaching residents stapes surgery, with the goal of improving surgical outcome.

Study Design: A stapes surgery teaching module was developed with specific criteria to evaluate resident performance. A prospective study of stapes surgery performed by teaching module trained residents was compared with a retrospective review of stapes surgery performed by non‐teaching module trained residents.

Methods: Four residents naive to stapes surgery were assigned to a stapes surgery teaching module. Stapedectomy of 20 temporal bones per resident, with six 3‐hour laboratory sessions, was performed. Laser (C02 and argon) as well as mechanical techniques were used. Specific scoring criteria were applied to measure performance. Results of actual stapes surgery of teaching module trained residents were compared with those of a comparable group of non‐teaching module trained residents.

Results: Laser techniques in the laboratory resulted in statistically significantly better scores by defined criteria than mechanical techniques. Results of actual stapes surgery performed by teaching module trained residents demonstrated a trend toward better surgical results, although this was not statistically significant.

Conclusions: Graded operative experience and standard temporal bone surgery courses may not adequately prepare residents for stapes surgery. A teaching module with criteria to evaluate performance better prepares residents for this delicate procedure. Lasers provide a significant advantage in the laboratory model and should be used by residents at surgery. Residents not wishing to perform stapes surgery because of career pathway should be encouraged to turn over their cases to fellow residents.
Determination of the Levels of Expression of Sarcolectin and Calcyclin and of the Percentages of Apoptotic But Not Proliferating Cells to Enable Distinction Between Recurrent and Nonrecurrent Cholesteatomas
Authors: Choufani Georges , Mahillon Virginie , Decaestecker Christine , Lequeux Thomas , Danguy André , Salmon Isabelle , Gabius Hans‐Joachim , Hassid Sergio , Kiss Robert
Published: November 2003

Objectives: To investigate in a series of cholesteatomas 1. whether subgroups of cholesteatomas with specific proliferative/apoptotic features exhibit distinct differentiation markers and 2. whether these different subgroups identified at the biological level relate to specific groups of clinically identified cholesteatomas.

Study Design: Analysis of 55 cholesteatomas resected by the same surgeon, by means of canal wall up and canal wall down surgical procedures.

Methods: Two differentiation markers were used: biotinylated sarcolectin (to identify sarcolectin‐binding sites) and a monoclonal antibody directed against calcyclin (which is the S100A6 protein). The growth pattern in cholesteatomas was characterized at three distinct levels: 1. the cell proliferation level determined by means of the MIB‐1 antibody, which enables the Ki‐67 cell‐cycle‐related antigen to be identified on archival material; 2. the apoptosis level determined by means of the in situ labeling of nuclear DNA fragmentation (TUNEL staining); and 3. the p53 tumor suppressor gene‐related product determined by means of p53 immunohistochemistry.

Results: The cholesteatomas that exhibited the highest proportion of apoptotic cells were those which exhibited the highest level of sarcolectin‐binding sites (i.e., sialic acids). In contrast, the cholesteatomas exhibiting the lowest level of both proliferation and apoptosis showed the highest level of calcyclin. Recurrent cholesteatomas can be identified from nonrecurrent ones on the basis of three features, namely, the level of apoptotic cells, the way in which the apoptotic cells are distributed (i.e., homogeneously vs. heterogeneously), and the percentage of calcyclin‐positive cells.

Conclusions: The present data emphasize the existence of distinct subgroups of cholesteatomas identifiable at both cell kinetic and differentiation levels. Some of the biological variables used here to identify distinct biological subgroups of cholesteatomas in turn enabled some biological variables to be identified, so making it possible to classify the cholesteatomas in terms of recurrence versus nonrecurrence.
Evolving Experience With Direct Puncture Therapeutic Embolization for Adjunctive and Palliative Management of Head and Neck Hypervascular Neoplasms
Authors: Chaloupka John C. , Mangla Sundeep , Huddle Daniel C. , Roth Toni C. , Mitra Sanchayeeta , Ross Douglas A. , Sasaki Clarence T.
Published: November 2003

Objectives: The use of percutaneous, direct puncture therapeutic embolization (DPTE) of hypervascular head and neck neoplasms is a relatively new modality that may be used to supplement or supplant conventional endovascular transarterial embolization. Although the preliminary clinical experience reported by a single group has been favorable, extensive case series experience is lacking. This prompted us to review our recent clinical experience with these techniques to determine safety, efficacy, and emerging role in the overall neurointerventional therapeutic armamentarium.

Study Design: A retrospective analysis of the previous 34 consecutive cases of hypervascular tumors undergoing DPTE referred to our service for therapeutic devascularization was performed.

Methods: Complete case record review was undertaken. Twenty‐six of 34 cases involved DPTE of head and neck neoplasms. Conventional diagnostic angiography was performed for therapeutic planning and to assist in precise localization. When performed, standard microcatheter transarterial embolization techniques were used either before or after attempted DPTE. Cyanoacrylate embolic mixtures (n‐butyl cyanoacrylate [NBCA], lipiodol, powdered tungsten) were used in 21 of 24 cases, and absolute ethanol in 3 of 24. Direct puncture angiography of the targeted tumor neovasculature was always performed before DPTE.

Results: Twenty‐four of 26 cases had technically successful DPTE. Combined transarterial embolization with DPTE was used in 16 of 24 cases, although for the last 12 cases, 9 were treated predominantly or exclusively by DPTE. There were no major or minor clinical complications, and there was one asymptomatic technical complication. Total or near‐total devascularization was achieved in all cases. All preoperative cases had excellent hemostasis within the resected tumor bed.

Conclusions: Our results lend further support to the safety and efficacy of DPTE in the management of hypervascular neoplasms of the head and neck. With our increasing experience, this technique is evolving into a primary therapeutic modality for optimal tumor devascularization.
Complications in Skull Base Surgery for Malignancy
Authors: Donald Paul J.
Published: November 2003

Objectives: To review a consecutive series of skull base surgeries, establish the rate of complications, and outline their prevention and management.

Study Design: A retrospective review of 107 consecutive intracranial/extracranial operations performed for malignancy that transgresses the skull base.

Methods: The hospital charts of 107 operations performed on 98 patients at the University of California at Davis Medical Center. The type of operation, cause of death, and complications were noted.

Results: The complication rate was 50.5%. Forty‐eight patients had no complications. There were six perioperative deaths. The most common surgical complications were cerebrospinal fluid leak (11.2%), meningitis (4.8%), and wound breakdown (15%). The most common medical complications were pneumonia (6.5%), cardiac disturbance (4.7%), and electrolyte imbalance (3.7%). The only prior treatment that was accompanied by a significant increase in complications was previous surgery.

Conclusions: Complications occurred in approximately half of the patients who had cranial base surgery for the intracranial spread of head and neck cancer. The perioperative death rate is less than 4%. The major complications were at an acceptable rate.
High‐Dose‐Rate Brachytherapy for Primary Carcinomas of the Oral Cavity and Oropharynx
Authors: Rudoltz Marc S. , Perkins Ryan S. , Luthmann Robert W. , Fracke Todd D. , Green Tina M. , Moye Linda , Wludyka Peter , Choi Young‐Ku , Ackerman Scot N.
Published: November 2003

Objective: Local control for patients treated with primary radiation therapy for tumors of the oral cavity is improved using low‐dose‐rate brachytherapy. Oropharyngeal carcinomas have also been treated with brachytherapy. The few reports in the literature regarding high‐dose‐rate brachytherapy (HDRBT) for head and neck cancer involve small numbers of patients and often contain a mix of palliative and curative cases. The purpose of this study is to evaluate the feasibility of HDRBT in the largest reported cohort of primary head and neck cancer patients treated with primary radiation therapy.

Study Design: This is a prospective nonrandomized study.

Methods: Fifty‐five patients with primary untreated squamous cell carcinomas of the oral cavity and oropharynx were analyzed. There were 16 patients with T1, 26 with T2, 8 with T3, and 5 with T4 tumors. All patients received external‐beam radiotherapy (EBRT) followed by HDRBT. Thirty‐eight patients received hyperfractionated (twice daily) EBRT followed by HDRBT two or three times daily. Patients with cervical adenopathy also received hyperthermia and an electron boost to the site(s) of positive nodes. Median follow‐up was 2.7 years. Toxicity and local control were analyzed. Data were analyzed by the Kaplan‐Meier life‐table method with statistical significance determined by the χ2 and log‐rank tests.

Results: High‐dose‐rate brachytherapy was extremely well tolerated. Only 9 patients (16%) developed a complication. Four patients developed osteoradionecrosis, and five developed soft tissue necrosis, all of which healed with conservative medical management. No complication required surgical intervention or hospitalization. Actuarial 2‐year local control for the entire cohort was 79%. Local control was 87% for patients with T1 (15/16) and T2 (22/26) tumors versus 47% for T3 (5/8) and T4 (2/5) tumors (P < .01).

Conclusions: High‐dose‐rate brachytherapy is feasible as a boost for patients with primary squamous cell carcinomas of the oral cavity and oropharynx. Patients with T1 and T2 tumors fared exceptionally well; those with advanced tumors may require more aggressive treatment, such as higher radiation doses, surgical resection, or systemic chemotherapy. The use of HDRBT both shortens the overall treatment time and limits the volume of tissue exposed to high doses of radiation therapy. In the future, as more patients treated with HDRBT are evaluable, we hope to identify potential factors that predict for local control so that we may select patients optimally for this treatment.
Stereotactic Radiosurgery for Glomus Jugulare Tumors
Authors: Jordan Jennifer A. , Roland Peter S. , McManus Chris , Weiner Richard L. , Giller Cole A.
Published: November 2003

Objectives/Hypothesis: Surgery is considered to be the mainstay of treatment for glomus jugulare tumors. A subset of patients are poor surgical candidates based on age, medical problems, tumor size, or prior treatment failure. The purpose of this study was to review our results with stereotactic radiosurgery (gamma knife treatment) in this group of patients, with particular attention to adverse reactions and symptom relief.

Study Design: Retrospective review and phone survey.

Methods: Charts were reviewed for size and location of tumor, history of previous treatment, symptoms before and after treatment, amount of radiation received, acute and late complications, and functional level before and after treatment. Pretreatment and posttreatment magnetic resonance imaging scans were also reviewed. Identified patients were then contacted for a phone interview.

Results: Eight patients were identified. Phone interviews were conducted with four patients. Four patients had failed previous treatment. Follow‐up ranged from 7 to 104 months. One patient experienced an acute complication: intractable vertigo requiring hospitalization. No patient experienced delayed cranial neuropathies. No patient reported worsening of any of the following symptoms: pulsatile tinnitus, hearing loss, facial weakness, hoarseness, or difficulty swallowing. Three patients reported improvement in their pulsatile tinnitus. Two patients reported improvement in hearing loss, and one patient each reported improvement in vertigo and difficulty swallowing.

Conclusions: Preliminary results suggest that stereotactic radiosurgery is useful to control symptoms and may be delivered safely in patients with primary or recurrent glomus jugulare tumors who are poor surgical candidates.
Histological Pattern of Mandibular Invasion by Oral Squamous Cell Carcinoma
Authors: Wong Richard J. , Keel Suzanne B. , Glynn Robert J. , Varvares Mark A.
Published: November 2003

Objective:Mandibular invasion by oral squamous cell carcinoma may progress by either an infiltrative or an erosive histological pattern. The infiltrative pattern is marked by nests and cords of tumor cells along an irregular tumor front, and the erosive pattern exhibits a broad, pushing tumor front. The objectives of this study were 1) to define the characteristics associated with each histological pattern of mandibular invasion, 2) to assess the relationship between pattern of invasion and clinical outcome as measured by death with disease and disease presence at last follow‐up, and 3) to determine whether the cell cycle markers cyclin D1 and Ki‐67 are associated with the histological pattern of invasion or are predictive of outcome.

Study Design:Retrospective study of 68 patients with mandibular invasion by oral cavity squamous cell carcinoma treated by mandibulectomy.

Methods:The clinical records, pathology reports, and original H&E‐stained slides were reviewed for each patient. Immunohistochemical staining of cyclin D1 and Ki‐67 was performed on slides cut from the paraffin blocks of these patients' specimens.

Results:The parameters found to be significantly associated with the infiltrative pattern of mandibular invasion included higher tumor grade, medullary space invasion, positive bone or soft tissue margins, history of previously failed treatment, and postoperative tumor recurrence. The infiltrative pattern had a positive bone margin rate of 47.6% and a primary site recurrence rate of 52.6%. In contrast, the erosive pattern had a positive bone margin rate of 4.9% and a primary site recurrence rate of 16.7%. The infiltrative pattern of invasion gave a fourfold increased risk of death with disease and disease presence at last follow‐up in univariate and multivariate analyses when compared with the erosive pattern of invasion. The 3‐year disease‐free survival was 30% for the infiltrative pattern and 73% for the erosive pattern. The median disease‐free survival was 1.5 years for the infiltrative pattern and 5.5 years for the erosive pattern. There was no correlation between cyclin D1 or Ki‐67 staining and invasion pattern or clinical outcome.

Conclusions:The infiltrative pattern of mandibular invasion by oral squamous cell carcinoma is correlated with a significantly worse prognosis when compared with the erosive pattern of invasion. The infiltrative pattern clearly exhibits a more aggressive behavior with an increased likelihood of positive margins, recurrence, death with disease, and shorter disease‐free survival. We recommend that pathologists routinely comment on the histological pattern of invasion when reviewing oral squamous cell carcinoma with mandibular invasion.
Controversies in the Management of Thyroid Nodule
Authors: Shaha Ashok R.
Published: November 2003

Few subjects in surgery have generated as much controversy as the management of thyroid nodule. The controversial issues include classification and histology, diagnostic evaluation including needle biopsy, indications for surgery, management of incidentalomas of the thyroid, the role of frozen section, extent of thyroidectomy, management of neck nodes, the role of suppressive therapy, the use of radioactive iodine, and appropriate follow‐up. The two major issues in relation to the controversies are diagnostic workup and extent of thyroidectomy. Whenever the issue related to extent of thyroidectomy is discussed, there are two strong groups believing in total thyroidectomy or less than total thyroidectomy. This has generated considerable debate and panel discussions, and this article reviews this on‐going debate.
Saline Irrigation in the Prevention of Otorrhea After Tympanostomy Tube Placement
Authors: Gross Rick D. , Burgess Lawrence P. , Holtel Michael R. , Hall Daniel J. , Ramsey Mitchell , Tsai Paulus D. , Birkmire‐Peters Deborah
Published: November 2003

Objectives: Comparison of intraoperative saline irrigation to otic drops in the prevention of postoperative otorrhea in children with middle ear effusion undergoing bilateral myringotomy with ventilation tubes.

Study Design: This study was designed as a blinded, controlled, prospectively randomized trial.

Methods: Study children were randomly assigned to receive either otic drops for 3 days postoperatively or saline irrigation of the middle ear space at the time of myringotomy. Only children with effusion present at the time of surgery were included. All children were evaluated for drainage 7 to 14 days postoperatively, and the degree of drainage was graded from 0 to 4.

Results: Of the 84 patients entered into the study, 62 patients were eligible for data analysis (16 failed follow‐up, 6 records were lost). Of the patients who completed the study, not all had bilateral effusions, resulting in 111 ears for inclusion in the study. Fifty‐two ears underwent irrigation, and 10 were noted to have otorrhea (19.2%). Fifty‐nine ears received otic drops, resulting in 21 ears with otorrhea (35.6%). Evaluating the degree of otorrhea with a five‐point Leichert scale, the average score per ear was 0.42 for the saline irrigation group and 1.07 for the control group. The rate and degree of drainage were both statistically reduced in the saline irrigation group (P < .05).

Conclusions: Using middle ear irrigation at the time of tympanostomy may be more effective than antibiotic drops in preventing postoperative otorrhea.