bluuebunny/crossref_metadata_2025 huggingface dataset:
Laryngeal Cancer Cost Analysis: Association of Case‐Mix and Treatment Characteristics With Medical Charges
Authors: Arnold David J. , Funk Gerry F. , Karnell Lucy Hynds , Chen Achih H. , Hoffman Henry T. , Ricks Joan M. , Zimmerman M. Bridget , Corbae Dean P. , Zhen Weining , McCulloch Timothy M. , Graham Scott M.
Published: November 2003

Objectives: To examine the relationship of various pretreatment case‐mix characteristics and treatment modalities with medical charges incurred during diagnosis, treatment, and 2‐year follow‐up for patients with laryngeal cancer.

Design: Retrospective chart review and billing record analysis.

Methods: The charts and billing records of patients diagnosed with laryngeal cancer at the University of Iowa Hospitals and Clinics (UIHC) between January 1, 1991 and December 31, 1994 were reviewed. The independent variables included various pretreatment patient‐mix and tumor characteristics (age, AJCC TNM clinical stage, smoking history, ASA class, and comorbidity as defined by Kaplan‐Feinstein grade) as well as type of treatment. The dependent variables included total physician, office, and university hospital‐based charges incurred during the pretreatment evaluation and 0‐ to 3‐, 3‐ to 12‐, and 12‐ to 24‐month billing periods after the initiation of cancer‐directed therapy. Total 1‐year and 2‐year charges were also evaluated. Univariate and multivariate analyses were used to investigate the relationships between dependent and independent variables and to develop models predictive of management charges during the individual and total billing periods.

Results: Pretreatment charges showed no significant associations (P < .05) with any of the independent variables. Multiple regression analyses indicated that comorbidity, stage, and initial treatment modality were significant variables in one or more of the models predicting charges incurred during the 0‐ to 3‐month, 3‐ to 12‐month, total 1‐year, and total 2‐year billing periods. The models yielded R2 values for the total 1‐ and 2‐year billing periods of 0.5246 and 0.5055, respectively.

Conclusions: This work supports continued study of measures that may result in earlier detection of laryngeal cancer as a potential means of reducing management charges. These results also indicate that a more accurate method of stratifying the disease severity of laryngeal cancer patients for reimbursement purposes would include measurements of the severity of the index disease as well as comorbid diseases.
Polymerase Chain Reaction Detection of Mycobacterium tuberculosis From Fine‐Needle Aspirate for the Diagnosis of Cervical Tuberculous Lymphadenitis
Authors: Baek Chung‐Hwan , Kim Sun‐Il , Ko Young‐Hyeh , Chu Kwang‐Chol
Published: November 2003

Background: Despite its well‐established usefulness in the diagnosis of cervical tuberculous lymphadenitis, fine‐needle aspiration cytology (FNAC) has several limitations in its clinical applications, especially when the presence of acid‐fast bacilli is not proven. Furthermore, fine‐needle aspirate is sometimes inadequate for diagnosis, and the sensitivity and specificity of this technique for cervical tuberculous lymphadenitis has not been firmly established.

Objective: The authors performed Mycobacterium tuberculosis polymerase chain reaction (PCR) for mycobacterial DNA sequences from the remainder of fine‐needle aspirate after cytological examination and evaluated its diagnostic efficacy in clinical situations.

Methods: Conventional diagnostic procedures including FNAC and M tuberculosis PCR were performed simultaneously in 29 cases that had been suspected to be cervical tuberculous lymphadenitis on patients' first visit. The results of FNAC and M tuberculosis PCR were compared with the clinical outcomes after several months of follow‐up and pathological results from open biopsy of some cases.

Results: Among the 17 cases of cervical tuberculous lymphadenitis diagnosed in clinical situations, M tuberculosis DNA was found by PCR in 13 cases (76.4%). Negative findings on PCR were achieved in 12 cases, which revealed non‐granulomatous lymphadenopathy.

Conclusion: From these results, we conclude that M tuberculosis PCR using the remainder of aspirate for cytological examination is a very useful tool for the diagnosis of cervical tuberculous lymphadenitis, and its clinical application with FNAC could reduce the necessity for open biopsy.
Absence of Nuclear p16 From Epstein‐Barr Virus‐Associated Undifferentiated Nasopharyngeal Carcinomas
Authors: Shibosawa Eriko , Tsutsumi Kouichiro , Koizuka Izumi , Hoshikawa Masahiro , Takakuwa Toshifumi
Published: November 2003

Objective: Epstein‐Barr virus (EBV) is detected in the majority of undifferentiated nasopharyngeal carcinomas (UNPCs, World Health Organization type III). However, the exact mechanism involved in the carcinogenesis of EBV‐associated UNPCs remains to be elucidated. An important unresolved question is: how is the normal cell cycle deregulated during EBV‐associated UNPC development? The p16CDKN2 gene encodes a nuclear protein, p16, which inhibits the D‐type cyclin/cyclin‐dependent kinase complexes that phosphorylate the retinoblastoma gene product (pRb), thus blocking G1 cell cycle progression. The objective of this study was to determine whether p16 absence is involved in the development of EBV‐associated UNPCs.

Methods: We performed immunohistochemistry to detect p16 and pRb and in situ hybridization to detect EBV‐encoded small RNA (EBER) in UNPCs from 28 patients.

Results: No p16 was detected in 23 of 28 UNPCs (82.1%), whereas pRb was expressed in all those examined and EBER was detected in 22 of 28 (78.6%). The absence of p16 was associated with the presence of EBER in UNPCs (P < .0001): none of the 22 EBER+ UNPCs expressed p16, whereas 5 of 6 EBER− UNPCs did.

Conclusion: Our data suggest that loss of p16‐related cell cycle regulation plays an important role in the development of EBV‐associated UNPCs.
Microdissection or Microspot CO2Laser for Limited Vocal Fold Benign Lesions: A Prospective Randomized Trial
Authors: Benninger Michael S.
Published: November 2003

CO2lasers have become an important technological advance and an integral tool for the laryngeal surgeon since the 1960s. Surgeons have used lasers for a variety of benign and malignant lesions in the larynx with good success. With better understanding of the microarchitecture of the vocal folds and the recognition of heat distribution into surrounding tissues that occurs with the use of standard CO2lasers, questions and concerns have been raised regarding the use of the CO2laser for benign lesions of the vocal folds. With the advent of the microspot CO2laser with a spot size of less than 250 μm, the potential heat distribution to the deeper layers of the lamina propria has been reduced. The microspot CO2laser has been suggested to be an appropriate tool for the excision of superficial benign lesions of the vocal fold and may be considered as an appropriate treatment alternative to microdissection. Only a limited number of studies have compared the efficacy of microdissection versus microspot CO2laser surgery in the larynx, and no prospective, randomized trials have been performed.

ObjectiveThis study was designed to compare microspot CO2laser excision and microdissection for superficial benign lesions confined to the free margin of the vocal fold.

Study Design:

A randomized, prospective trial comparing microspot CO2laser excision and microdissection in the removal of nodules, polyps, and mucous retention cysts of the vocal fold.

MethodsAcoustic and aerodynamic measures and videostroboscopic and perceptual audio recordings evaluated by a panel of blinded viewers and listeners were studied preoperatively and 2 to 3 weeks and 5 to 12 weeks postoperatively. Surgical and recovery times were compared between the two groups.

ResultsThirty‐seven patients met selection criteria and were enrolled, 21 in the microdissection group and 16 in the laser excision group. Significant improvements in videostroboscopic parameters were found over time in both groups. Significant improvements were noted for perceptual analysis over time for the laser excision group with nonsignificant improvements over time for the microdissection group. There was no difference in any measure between laser excision and microdissection at the two postoperative visits. There was no difference in surgical or recovery time between laser excision and microdissection. Acoustic and aerodynamic parameters were noncontributory in evaluating outcomes of treatment, since most values were normal before surgery.

ConclusionNo differences in clinical outcomes are identified when comparing microdissection with laser excision of nodules, polyps, and mucous retention cysts of the vocal folds.
Length of Stay After Free Flap Reconstruction of the Head and Neck
Authors: Ryan Matthew W. , Hochman Marcelo
Published: November 2003

Objectives: To analyze the incidence and timing of postoperative complications after free tissue transfer (FTT) and relate that to length of stay (LOS.)

Study Design: We reviewed one surgeon's experience with 97 patients undergoing 100 head and neck reconstructions via FTT for a variety of traumatic and ablative defects.

Methods: Charts were reviewed for demographic data, type of defect and flap, complications, LOS, length of intensive care unit (ICU) stay, date of decannulation, and first oral intake, any readmission to the hospital, and preoperative radiation status.

Results: Using strict guidelines, 31% of patients had some form of complication, including a 9% flap failure rate. Average postoperative LOS for all patients was 11 days. Average LOS for uncomplicated cases was 9 and for complicated cases was 16 days. For cases with flap‐related complications the average LOS rose to 20 days. All reconstructive failures (defined as patients requiring subsequent surgical procedures after a flap‐related complication, regardless of outcome) occurred within the first 7 postoperative days. Three patients were readmitted for various reasons: a partial flap dehiscence (postoperative day [POD] 9), meningitis (POD 24), and orocutaneous fistula (POD 22), for a 3.2% readmission rate. Fourteen percent of patients were on a regimen of oral intake, and 13% had decannulation by the time of discharge. Resumption of oral intake and tracheostomy decannulation were accomplished on an outpatient basis in the remainder of patients.

Conclusions: There were no preventable complications associated with early hospital discharge, nor was there evidence of adverse patient outcome. We conclude that early hospital discharge is feasible after FTT reconstruction and is consistent with quality care.
Radiation Dose to Otologic Structures During Head and Neck Cancer Radiation Therapy
Authors: Ondrey Frank G. , Greig J. Robert , Herscher Laurie
Published: November 2003

Background: Otologic structures are often contained within head and neck cancer radiation treatment ports. The dosimetry to otologic structures has not been routinely analyzed and radiation treatment planning does not currently attempt to specifically avoid the inner ear structures when dosimetry is calculated. Recent studies demonstrate that up to 30% of patients experience sensorineural hearing loss on multimodality therapy with cisplatin and radiation.

Methods: In the current case series, radiation dosimetry to otologic structures was calculated from computed tomogram treatment plans on patients. Fifteen nasopharyngeal, oral cavity, oropharyngeal, and hypopharyngeal cancer patients were analyzed.

Results: Between 8% and 102% of the total dose is delivered to the petrous bone/cochlea, with 4 of 15 patients getting more than 50% of the dose to at least one cochlea. The mastoid air cells received between 3% and 75% of the total dose, with higher doses being delivered to patients with bulky high neck metastases or nasopharyngeal tumors. The eustachian tubes received between 2% and 102% of the total dose, with 10 of 15 patients receiving more than 50% of the dose to this anatomic site.

Conclusion: We conclude that the cochlea and eustachian tubes receive significant radiation during treatment, particularly in nasopharyngeal cancer patients. Careful design of radiation treatment ports may allow for the reduction of radiation to hearing structures.
Consequences to Hearing During the Conservative Management of Vestibular Schwannomas
Authors: Walsh Rory M. , Bath Andrew P. , Bance Manohar L. , Keller Anne , Rutka John A.
Published: November 2003

Objective:To estimate the risk of loss of serviceable hearing during the conservative management of vestibular schwannomas.

Study Design:Retrospective case review.

Methods:Twenty‐five patients with a radiological diagnosis of unilateral vestibular schwannoma were managed conservatively for a mean duration of 43.8 months (range, 12–194 mo). The pure‐tone average (PTA) (0.5, 1, 2, and 3 kHz) and speech discrimination scores (SDS) were measured at regular intervals throughout the entire duration of follow‐up. Serviceable hearing was defined using two criteria: 70% SDS/30 dB PTA (the 70/30 rule) and 50% SDS/50 dB PTA (the 50/50 rule). The size and growth rate of tumors were determined according to the American Academy of Otolaryngology—Head and Neck Surgery guidelines (1995). Intervention was recommended if there was evidence of continuous or rapid radiological tumor growth, and/or increasing symptoms or signs suggestive of tumor growth.

Results:The risk of loss of serviceable hearing for the total group was 43% using the 70/30 rule and 42% using the 50/50 rule. Tumor growth was considered significant (> 1 mm) in 8 tumors (32%) and nonsignificant in 17 (68%). The risk of loss of serviceable hearing for the tumor‐growth group was 67% using the 70/30 rule and 80% using the 50/50 rule. In contrast, the risk of loss of serviceable hearing for the no tumor–growth group was 25% using the 70/30 rule and 14% using the 50/50 rule. No audiological factors predictive of tumor growth were identified.

Conclusions:There is a significant risk of loss of serviceable hearing during the conservative management of vestibular schwannomas. This risk appears to be greater in tumors that demonstrate significant growth.
Pressure Transfer Between Intracranial and Cochlear Fluids in Patients With Meniere's Disease
Authors: Konrádsson Konrád S. , Nielsen Lars Holme , Carlborg Björn I. R. , Borgkvist Britt
Published: November 2003

Objectives: To elucidate the pressure transfer between intracranial and labyrinthine fluids in patients with well‐defined unilateral Meniere's disease.

Study Design: Eleven patients previously exposed to hypobaric pressure agreed to be investigated further with the tympanic membrane displacement (TMD) technique. TMD was used to indirectly analyze perilymph pressure changes as the result of changes in body position.

Methods: Repeated measurements for both the diseased and the healthy ears were made with the patients supine and then in a sitting position. The TMD parameters for the maximum inward displacement, the Vi, and the mean volume displacement, the Vm, were calculated and compared.

Results: The paired comparison showed statistically significant larger Vi values for both ears in the supine position. A similar tendency was observed for the Vm value. This difference of the Vi was significantly larger for the diseased ear compared with the currently healthy ear. The results were compared to the audiometric and electrocochleographic results previously obtained on the same patients when they were subjected to hypobaric pressure. Patients who experienced the largest differences in hearing level thresholds in the lower frequencies also showed the greatest differences in TMD values as the result of postural changes.

Conclusions: Despite the limited number, the statistically supported results suggest a relation between the efficiency of the routes of pressure transfer and the observed effect of hypobaric exposure. The results also indicate that for the patients tested, the routes of communication are more effective in the diseased ear than in the healthy ear—a condition that may relate to the pathogeneses of Meniere's disease.
Temporal Bone Histopathology in Connexin 26–Related Hearing Loss
Authors: Jun Andrew I. , McGuirt Wyman T. , Hinojosa Raul , Green Glenn E. , Fischel‐Ghodsian Nathan , Smith Richard J. H.
Published: November 2003

Objective: Mutations in GJB2, a gene that encodes a gap junction protein, Connexin 26 (Cx26), are responsible for approximately one third of sporadic severe‐to‐profound or profound congenital deafness and half of severe‐to‐profound or profound autosomal recessive nonsyndromic hearing loss (ARNSHL). Mouse mutants homozygous for knockouts of this gene are nonviable, precluding histopathologic studies of the associated inner ear pathology in this animal model. Therefore, we studied archival temporal bone sections to identify temporal bone donors with Cx26‐related deafness.

Study Design: Temporal bone donors with a history of congenital severe‐to‐profound or profound deafness were identified in the registry of the Temporal Bone Library at the University of Iowa. Histological findings were interpreted in a blinded fashion. DNA extracted from two celloidin‐embedded mid‐modiolar sections from each temporal bone was screened for the 35delG Cx26 mutation. The entire coding region of Cx26 was screened for other deafness‐causing mutations if the 35delG mutation was detected.

Results: Of five temporal bone donors with congenital severe‐to‐profound deafness, one donor was found to have Cx26‐related deafness. This individual was a Cx26 compound heterozygote, carrying the 35delG mutation and a noncomplementary Cx26 missense mutation on the opposing allele. Microscopic evaluation of this temporal bone showed no neural degeneration, a good population of spiral ganglion cells, near‐total degeneration of hair cells in the organ of Corti, a detached and rolled‐up tectorial membrane, agenesis of the stria vascularis, and a large cyst in the scala media in the region of the stria vascularis.

Conclusion: This study is the first to report the temporal bone histopathology associated with Cx26‐related deafness. Preservation of neurons in the spiral ganglion suggests that long‐term successful habilitation with cochlear implants may be possible in persons with severe‐to‐profound or profound Cx26‐related deafness.
Role of Vascular Reflex in Nasal Mucosal Swelling in Nasal Allergy
Authors: Numata Tsutomu , Konno Akiyoshi , Terada Nobuhisa , Hanazawa Toyoyuki , Nagata Hiroshi , Tanikawa Hirokazu
Published: November 2003

Objective: In patients with nasal allergy, antigen challenge on the unilateral nasal mucosa results in nasal secretion not only in the ipsilateral but also in the contralateral nasal cavities that can be inhibited almost completely by premedication with atropine sulfate. The present study was performed to elucidate if centrally mediated vascular reflex induced by antigen challenge plays a role in nasal mucosal swelling in subjects with nasal allergy.

Methods: Variations of mucosal swelling and mucosal blood flow in the ipsilateral and the contralateral nasal cavities after unilateral antigen challenge were evaluated by acoustic rhinometry and laser Doppler flowmetry in 20 patients with perennial nasal allergy.

Results: Unilateral antigen challenge caused ipsilateral and contralateral nasal mucosal swelling in 17 and 13 patients, respectively. Incidence of contralateral nasal mucosal swelling after unilateral antigen challenge was significantly higher compared with that after control disc challenge (P < .001). In 10 patients in whom unilateral antigen challenge caused bilateral nasal mucosal swelling, significant swelling of the nasal mucosa lasted for more than 30 minutes in the ipsilateral nasal cavity after antigen challenge compared with only 15 minutes in the contralateral nasal cavity. Peak values of contralateral mucosal swelling were 45.3% of those of ipsilateral nasal mucosa.

Conclusions: Centrally mediated vascular reflex is partially involved in the onset of nasal mucosal swelling observed after antigen challenge in subjects with nasal allergy. However, nasal mucosal swelling that persists and proceeds even 20 minutes after antigen challenge is caused by the direct effects of chemical mediators on the nasal vasculature.
Arterial Supply of the Nasal Tip in Asians
Authors: Jung Dong Hak , Kim Hee Jin , Koh Ki Seok , Oh Chang Seok , Kim Kyung‐Su , Yoon Joo‐Heon , Chung In‐Hyuk
Published: November 2003

Objectives:The blood supply to the nasal tip and columella was examined to determine whether it could be damaged as a result of transcolumellar incision during an external rhinoplasty approach in Asians.

Methods:The blood vessels that supply the nasal tip were examined by dissecting 51 cadavers, and their corresponding 102 nasal sections were injected with red latex before dissection. The size and distribution of the vessels were measured with the unaided eye and the primary supply vessels were determined. The subdermal layer in which the vessels lie and the course of the vessels were also investigated.

Results:The main blood supply source of the nasal tip proved to be the lateral nasal artery in 78% (80/102) of the cases examined, while the remaining cases (22%) received their blood supply via the dorsal nasal artery. Columellar branches were narrow in diameter and varied in size and appearance, and were therefore appeared insufficient as a main blood supply. These arteries passed through the musculoaponeurotic layer, but they were also in close proximity to the main surgical plane in the dome of the lower lateral cartilage.

Conclusions:The authors speculate that the nasal tip blood supply in Asians is primarily derived from the lateral nasal or dorsal nasal arteries, with a variable contribution from the columella arteries. Therefore, it is important to correctly determine the surgical plane below the musculoaponeurotic layer in order to prevent skin flap necrosis or nasal tip deformity that may occur from damage to the main vessel during an external rhinoplasty approach.
Influence of Tobacco and Alcohol on the Stage of Laryngeal Cancer at Diagnosis
Authors: Trigg Dean J. , Lait Marci , Wenig Barry L.
Published: November 2003

Objective This study sought to examine the influence of cigarette smoking and alcohol consumption on the stage of laryngeal cancer at diagnosis.

Study Design A retrospective review of 499 laryngeal cancer patients diagnosed between 1978 and 1997 was conducted.

Methods Parameters that included smoking history, history of alcohol consumption, and the tumor stage and location at diagnosis were analyzed using the proportional odds model, correlation coefficient, and Student t test.

Results Three hundred sixteen patients met the inclusion criteria, and 180 (56%) had advanced‐stage disease at the time of presentation. The statistical model demonstrated a small but significant relationship between tobacco and alcohol on the stage of laryngeal cancer at diagnosis. Patients diagnosed with an advanced‐stage tumor (stage III or IV) smoked a significantly greater amount and were more likely to be heavy drinkers than those diagnosed with a localized laryngeal cancer.

Conclusions Our results demonstrate that for every incremental increase in pack years of smoking, there is a small but measurable increase in the odds that a patient's laryngeal cancer will be stage III or IV at diagnosis. Likewise, being a “heavy” drinker as opposed to a “social” drinker raises the likelihood of an advanced tumor. Given the preventable nature of these risk factors, the moderation of alcohol consumption and cessation of smoking is prudent advice that should be conveyed to all patients.
The Nose As Bacterial Reservoir: Important Differences Between the Vestibule and Cavity
Authors: Glück Ulrich , Gebbers Jan‐Olaf
Published: November 2003

The difference between the spectra of potential bacterial pathogens (PBPs) in the nasal vestibule and cavity has not been taken into account in clinical studies.

Purpose Since one can anticipate different flora in different kinds of mucosae, the authors compared bacterial species in the vestibule with those of the cavity.

Subjects and Method A total of 534 healthy male clerical workers in a downtown Lucerne office building were examined with fractionated swabs.

Results PBPs, notably Staphylococcus aureus, were found in 412 subjects and surprisingly, differences in flora of the two sites were noted in 130 of them: PBPs were observed in the vestibule and not in the cavity in 85 of the subjects, and in 45 of them, the reverse was true.

Conclusion The practical implications of these findings are considerable regarding infection control in patients at increased infection risk.
Modified Particle Repositioning Procedure
Authors: Tirelli Giancarlo , D'Orlando Elena , Zarcone Oscar , Giacomarra Vittorio , Russolo Mario
Published: November 2003

Objectives To evaluate the efficacy of modifications to traditional particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo.

Study Design Prospective trial of 118 patients with cupolocanalithiasis of the posterior canal treated with three different canal‐repositioning techniques.

Methods Results were compared with the maneuvers employed and the statistical importance of rotating patients by 360° along their longitudinal axis and head shaking on reaching each single position were evaluated.

Results Treatment of patients with our maneuver, which, in comparison with traditional repositioning maneuvers, was modified by breaking the procedure up into seven positions and rotating patients by 360° along their longitudinal axis, gives a higher, but not statistically significant, number of treatment successes (84.5%) than the traditional Parnes maneuver (60%) (P = .154); treatment of a third group of patients with our modified particle repositioning maneuver with the addition of head‐shaking on reaching each single position gives a higher (95.6%), statistically significant number of treatment successes than traditional Parnes maneuver (P = .00011).

Conclusions The success rates achieved from modified particle repositioning maneuvers are statistically significant. Onset or persistence of dizziness, which patients frequently complain of after liberatory maneuvers, affects only 5.6% of the patients treated. This low incidence is statistically correlated to head‐shaking.
Clinimetrics of Meniere's Disease
Authors: Gates George A.
Published: November 2003

Two clinically useful measures to quantify the morbidity of Meniere's disease are the daily vertigo diary card and the Meniere's Disease Patient‐Oriented Severity Index (MD POSI). The development and application of these outcomes instruments for patients with vertigo are discussed.
Pediatric Outcomes Research: Development of an Outcomes Instrument for Tonsil and Adenoid Disease
Authors: Stewart Michael G.
Published: November 2003

We describe the design and validation process of a disease‐specific health status instrument for use in children with tonsil and adenoid disease. This instrument is reliable and valid and should be useful in future outcomes research on tonsil and adenoid disease. Some of the unique issues and challenges regarding outcomes research in pediatric patients are also discussed.
Community‐Based Outcomes Research: The Project Solo Experience
Authors: Isenberg Steven F.
Published: November 2003

One of the critical issues in outcomes research is physician participation. The lack of such participation is one of several factors that have made widespread adoption of outcomes measurement slow to materialize. This article focuses on the 6‐year experience of Project Solo, a multi‐site community‐based outcomes research effort.
Pain, Quality of Life, and Spinal Accessory Nerve Status After Neck Dissection
Authors: Terrell Jeffrey E. , Welsh Deborah E. , Bradford Carol R. , Chepeha Douglas B. , Esclamado Ramon M. , Hogikyan Norman D. , Wolf Gregory T.
Published: November 2003

Objective To assess quality of life (QOL) in patients with head and neck cancer who underwent neck dissection and to compare QOL scores for patients in whom the spinal accessory nerve (CN XI) was resected or preserved.

Setting and Design and Outcomes Measures Three hundred ninety‐seven patients who had undergone treatment for head and neck cancer completed the University of Michigan Head and Neck Quality of Life (HNQOL) instrument, the Medical Outcomes Study SF‐12 General Health Survey, and questions on “pain despite pain medications” and headaches.

Results Of the 397 patients, 222 had no neck dissection, 46 had neck dissections resecting CN XI, and 129 had dissection sparing CN XI. Of the latter group, 68 patients had dissections sparing level V and 61 dissections included level V. Age, sex, primary site distribution, and T stage were not different between the groups. Patients who had neck dissections sparing CN XI had better scores on the HNQOL pain domain (P = .002), had less shoulder or neck pain (P = .003), and took pain medications less frequently (P = .0004) compared with patients who had neck dissections sacrificing CN XI. When CN XI was preserved, patients who had no level V dissection had better pain domain scores (P = .03) and eating domain scores (P = .007) on the HNQOL, had less shoulder or neck pain (P = .006), and had less physical problems (P = .03) than patients who had level V dissected. On multivariate analysis, pain‐related QOL scores after neck dissection were significantly better (P < .01) if patients had dissections with preservation of CN XI and if level V was not dissected.

Conclusion Neck dissections sparing CN XI are associated with better pain scores on the HNQOL, less shoulder and neck pain, and less need for medications. When CN XI is spared, not dissecting level V of the neck is associated with better HNQOL pain scores, less shoulder or neck pain, and fewer physical problems.
Effect of High Laryngeal Mask Airway Intracuff Pressure on the Laryngopharyngeal Mucosa of Dogs
Authors: Martins Regina Helena Garcia , Braz José Reinaldo Cerqueira , Defaveri Júlio , Gregório Elisa Aparecida , Abud Tânia Mara Vilela
Published: November 2003

Objectives To evaluate the effect of increased of laryngeal mask airway (LMA) intracuff pressures on the laryngopharyngeal mucosa.

Study Design Animal model.

Methods Sixteen mixed‐breed dogs were randomly allocated to two groups, G1 (intracuff volume, 30 mL; n = 8) and G2 (intracuff volume, 54 mL; n = 8), to produce, respectively, high or very high intracuff pressures. Anesthesia was induced and maintained with pentobarbital. Intracuff pressures were measured immediately after insertion and inflation of a No. 4 laryngeal mask airway (LMA) and 30, 60, 90, and 120 minutes thereafter. The dogs were euthanized, and biopsy specimens from eight predetermined areas of the laryngopharynx in contact with LMA cuff were collected for light microscopic (LM) and scanning electron microscopic (SEM) examination.

Results Initial LMA cuff inflation in G1 and G2 resulted in intracuff pressures of 119 mm Hg ± 4 mm Hg and 235 mm Hg ± 13 mm Hg, respectively. Over a 2‐hour period, the intracuff pressure decreased significantly in G1 (P < .001) and G2 (P < .01), and there was a significant difference between the groups over time (P < .001). The LM study of laryngopharyngeal mucosa in both groups showed mild congestion in the subepithelial layer. There were no differences between the groups (P > .10) or among the areas sampled (P > .10). In some areas of G2, the SEM study showed epithelial desquamation that was more intense than that in G1.

Conclusions The increase in LMA intracuff pressure caused only mild alterations in the laryngopharyngeal mucosa of the dog.
Unaided Speech in Long‐Term Tube‐Free Tracheostomy
Authors: Eliachar Isaac
Published: November 2003

Objectives/Hypothesis Objectives of the current study were as follows: 1) to determine whether a self‐sustaining, tube‐free tracheostomy with unaided speech capability can be achieved, 2) to propose new surgical techniques to enhance voluntary constriction of a tube‐free tracheostoma to improve cough and speech production, and 3) to explain the mechanism involved in unaided speech after long‐term tracheostomy. The hypotheses were that long‐term, tube‐free tracheostomy could minimize the unwanted effects of conventional tube‐dependent tracheotomy; that surgical shunting of the trachea to the skin surface can be established through a short, skin‐lined, self‐supporting, nostril‐like opening; and that patients could generate speech and cough without the need to occlude the stoma or use stents and/or one‐way valves if such a long‐term tube‐free tracheostoma were established.

Study Design A prospective study of tube‐free tracheostomy intended to establish unaided cough and speech.

Methods Thirty‐five patients who underwent long‐term flap tracheostomies between 1992 and 1999 with the prospective intent of establishing a self‐sustaining stoma without the need for tubes or stents were reviewed. The patients were trained to intentionally constrict the stoma for production of unaided speech and cough. The pertinent techniques developed for successful achievement of these characteristics are presented and reviewed. A new surgical technique using a local tendinous muscular sling was designed to further improve the efficacy of stomal constriction.

Results A tube‐free stoma was successfully established in all 35 patients. Eighteen patients achieved effective intentional constriction of the stoma and thereby were capable of unaided speech production. Four patients required an additional new surgical sling procedure to optimize unaided cough and speech production. Thirteen patients achieved only limited unaided speech production, but were satisfied to do nothing further.

Conclusions New surgical techniques and postoperative management to create a modified tube‐free tracheostomy with self‐constricting capabilities can enable production of effective cough and near‐normal generation of unaided speech. In this manner, the airway can be secured with little or no voice compromise.
A Novel Approach to Laryngeal Suspension After Partial Laryngectomy
Authors: Giacchi Renato J. , Abraham Kuriakose M. , Kaufman David , DeLacure Mark D.
Published: November 2003

Objectives Supraglottic laryngectomy is a well‐established surgical therapy for selected carcinomas of the larynx and hypopharynx. Most compromised by this procedure and its variations is the laryngeal mechanism that protects the lower respiratory tract from aspiration. Laryngeal suspension serves to compensate for the loss of the resected laryngeal elevator muscles by pulling the larynx upward and forward beneath the tongue base. In this study we describe a method of laryngeal suspension in supraglottic laryngectomy using a cartilage‐anchored suture carrier device.

Study Design Report of this novel approach to laryngeal suspension using seven suture anchors in two patients undergoing supraglottic laryngectomy.

Methods Seven Mitek Micro anchors (Mitek, Westwood, MA) were used to perform laryngeal suspension in two patients undergoing supraglottic laryngectomy. Our technique is compared with traditional methods. Operative data as well as postoperative functional results are reviewed.

Results Laryngeal suspension using suture anchors was successful, with failure of only one anchor. Oral alimentation was quickly re‐established in both patients. There were no perioperative or postoperative complications.

Conclusions We describe a novel approach to laryngeal suspension that overcomes some of the technical challenges inherent in traditional suturing techniques. This novel approach is technically easier and more efficient than traditional methods and accomplishes distribution of stress forces on the thyroid cartilage remnant.
Pneumococcal Antibiotic Resistance and Rates of Meningitis in Children
Authors: Ryan Matthew W. , Antonelli Patrick J.
Published: November 2003

Objectives/Hypothesis Recent studies have shown alarmingly high rates of antibiotic resistance in Streptococcus pneumoniae isolates from patients with otitis media. A recent study has implicated resistant S pneumoniae for rising rates of acute mastoiditis. The purpose of this study was to determine whether S pneumoniae antibiotic resistance has similarly affected the rate of pediatric community‐acquired meningitis, the most common intracranial complication of otitis media.

Study Design Retrospective chart review.

Methods All cases of pediatric community‐acquired meningitis treated at an academic tertiary care hospital during a 10‐year period were reviewed, and meningitis rates were calculated as a proportion of yearly admissions.

Results The overall rate of meningitis decreased linearly during the study period (P = .001). This was largely because of a drop in the rate of Haemophilus influenzae meningitis (P = .001), corresponding with the introduction of H influenzae type B vaccine. Annual rates of S pneumoniae meningitis did not change. Only one case of S pneumoniae meningitis was due to a highly penicillin‐resistant strain and isolates from four cases had intermediate sensitivity. Twenty‐four of 83 cases were associated with antecedent acute otitis media and 63% of these had been treated with antibiotics before admission. Otitis media, as a cause of meningitis, did not increase during the study period.

Conclusion
S pneumoniae is responsible for a greater proportion of cases of pediatric community‐acquired meningitis. However, this is because of a decline in the rate of H influenzae cases, not the rise in S pneumoniae antibiotic resistance.
Controlling Advanced Neck Disease: Efficacy of Neck Dissection and Radiotherapy
Authors: Richards Bryan L. , Spiro Jeffrey D.
Published: November 2003

Objective Neck dissection remains the standard method of treating cervical metastasis from head and neck squamous cell carcinoma. In light of recent trends to modify the classic radical neck dissection (RND) for early neck disease, we reviewed our experience with radical and modified RND (MRND) plus radiotherapy as treatment for N2/N3 neck disease in head and neck squamous cell carcinoma.

Methods We retrospectively reviewed our clinical records from July 1989 to June 1996 to identify 43 neck dissections in 39 patients who were found to have pathologically N2 or N3 neck disease treated primarily by neck dissection and postoperative radiotherapy. All patients had head and neck squamous cell carcinoma with a minimum follow‐up of 24 months.

Results Nine percent (4/43) of the dissected necks were pathologically N2a, 72% (31/43) were N2b, 7% (3/43) were N2c, and 12% (5/43) were N3. Of these, 28% (12/43) underwent a RND and 72% (31/43) underwent a MRND. The most common modification of RND was preservation of the spinal accessory nerve. All patients underwent postoperative radiotherapy with a mean dose of 55 Gy. Only 4 of 43 dissected necks had isolated treatment failure, for a regional control rate of 91%.

Conclusions The combination of RND or MRND and radiotherapy is highly effective in controlling neck disease in the absence of persistent or recurrent local disease. Also, in our e‐perience, MRND appears to be as effective as RND in controlling even advanced neck disease, which supports preservation of the spinal accessory nerve whenever oncologically feasible.
Transoral CO2 Laser for Surgical Management of Glottic Carcinoma in Situ
Authors: Damm Michael , Sittel Christian , Streppel Michael , Eckel Hans E.
Published: November 2003

Objectives/Hypothesis In carcinoma in situ (CIS) tumors malignant cells have not penetrated the basement membrane and therefore have no metastatic potential. Treatment strategies of CIS are topics of ongoing discussion. The aim of this study was to evaluate long‐term results of CO2 laser therapy in laryngeal CIS.

Methods From 1986 to 1995, 29 patients with glottic CIS with a minimum follow‐up of 2 years were treated initially with transoral CO2 laser surgery and were included is this series.

Results A complete removal of the tumor was possible with superficial laser cordectomy in 21 patients and with subligamental laser cordectomy in 8 cases. There was no tumor‐related death in this series. Repeated laser resections were performed in four patients for local recurrences. No patient required total laryngectomy or radiotherapy during a follow‐up ranging from 25 to 143 months.

Conclusions Local control rates presented in this study are superior to those previously reported with conventional surgery and similar to those after radiotherapy. The ultimate rate of larynx preservation was seven times higher than reported after radiotherapy. Our results add further support to the observation that laser surgery is the best treatment option for CIS of the larynx. Based on the material of this study, recommended treatment for CIS is CO2 laser resection in combination with a meticulous follow‐up for early recognition of local recurrence.
Endoscopic Stapled Diverticulotomy: Treatment of Choice for Zenker's Diverticulum
Authors: Philippsen Luke P. , Weisberger Edward C. , Whiteman Thomas S. , Schmidt Jonathan L.
Published: November 2003

Objective To evaluate the efficacy and safety of endoscopic stapled diverticulotomy in the treatment of patients with Zenker's diverticulum.

Study Design Cohort study.

Methods Fourteen elderly patients (11 men and 3 women) with Zenker's diverticulum were evaluated in a community hospital setting from July 1996 to November 1999. Before surgery patients had significant dysphagia, regurgitation, cough, or aspiration pneumonia. The common septum between the diverticulum and cervical esophagus was visualized with a Weerda diverticuloscope. While using videoendoscopic monitoring, the septum was divided and the edges simultaneously sealed with a linear endoscopic stapler. Average operative time was 31 minutes.

Results The operation was successfully performed in 11 of 14 patients. In the three unsuccessful cases, one patient's pouch was too small to staple and the other two patients had a septum that was difficult to visualize with the diverticuloscope. There was no significant postoperative morbidity or mortality. Patients started a liquid diet on the first postoperative day and resumed a soft diet a week later. They were usually discharged on the first postoperative day. Most patients reported significant improvement with resolution of dysphagia and regurgitation.

Conclusions Compared with the traditional open technique, the endoscopic stapled diverticulotomy technique is safe, quick, and effective and requires a shorter length of stay in the hospital. Therefore it has become our treatment of choice for elderly, high‐risk patients with a large (>2 cm) hypopharyngeal (Zenker's) diverticulum.
Preservation of Olfaction in Anterior Skull Base Surgery
Authors: Dale Browne J. , Mims James W.
Published: November 2003

Objectives/Hypothesis In selected unilateral tumors and defects of the anterior skull base, the preservation of contralateral olfaction is achievable through a localized subcranial approach without compromising surgical objectives of resection or repair.

Study Design Description of a functional adaptation of anterior skull base surgical techniques through a retrospective patient series.

Methods Nine patients underwent anterior skull base surgery for unilateral cribriform plate disease including four malignant and two benign tumors, two encephaloceles, and one iatrogenic cribriform injury with cerebrospinal rhinorrhea. All nine patients consented to a localized subcranial approach to the anterior skull base to preserve the contralateral olfactory nerves. In four patients with benign disease a portion of the ipsilateral nerves was additionally conserved. Postoperative olfaction was assessed objectively with a commercially available smell test. Indications, technique, results, and complications are reported and discussed.

Results All patients had eradication of disease with preservation of functional olfaction

Conclusions Conservation of olfaction is possible in selected cases of anterior skull base surgery when the lesion is unilaterally confined.
Odontogenic Keratocysts: A Clinicopathological Study in Hong Kong Chinese
Authors: Lam K. Y. , L. Chan Alexander C.
Published: November 2003

Objective To analyze the clinicopathological features of odontogenic keratocysts in Chinese patients.

Study Design Retrospective analysis.

Methods The clinical records and pathological features of odontogenic keratocysts from 69 ethnic Hong Kong Chinese patients (40 male and 29 female patients) were reviewed.

Results The male‐to‐female ratio was 1.4:1; patient age ranged from 6 to 69 years with a modal peak in the third decade (mean age, 28 y; median age, 23 y). The preoperative diagnosis was correct in 78% of the cases and the most common misdiagnosis was dentigerous cyst. Sixty‐two percent of the cysts were found in the mandible, and 38% in the maxilla. Multiple cysts occurred in 9% (including three cases of basal cell nevus syndrome). Histologically, 82.6%, 5.8%, and 11.6% of the cysts were parakeratinized, orthokeratinized, and mixed types, respectively. Patients with multiple cysts all showed parakeratinization. The majority (80%) of the cysts were lined by epithelia with a thickness of five to eight cells. Surface corrugation, subepithelial split, suprabasal split, satellite microcysts, epithelial islands, significant inflammation, hyaline bodies, and dystrophic calcification were present in 100%, 81%, 25%, 38%, 42%, 46%, 7%, and 10% of cysts, respectively. The overall recurrence rate was 24%, with a median time for first recurrence of 19 months (range, 1 mo–22 y). Cysts showing orthokeratinization or mixed types of keratinization recurred less often than parakeratinized cysts. Recurrence had the same type of keratinization as the initial cyst.

Conclusions Pathological examination of keratocysts is important, because keratocysts have different clinicopathological features and carry a risk for clinical misdiagnosis.
Microvascular Angiogenesis and Apoptosis in the Survival of Free Fat Grafts
Authors: Nishimura Toshiro , Hashimoto Harumi , Nakanishi Isao , Furukawa Mitsuru
Published: November 2003

Objectives/Hypothesis Autologous fat is an ideal material for augmentation in plastic surgery because of its minimal tissue reaction and easy availability, but its long‐term graft survival is somewhat unpredictable. This study was conducted to determine how fat grafts get their vascular supply from the recipient bed and why they keep reducing in volume and weight.

Study Design Experimental study using animal models.

Methods The expression of vascular endothelial growth factor (VEGF) in grafted fat tissue was examined by using immunohistochemical staining, and apoptotic cell death in the grafted fat was studied by using terminal deoxynucleotidyl transferase (TdT)–mediated deoxy‐uridine triphosphate (dUTP)‐biotin nick end‐labeling method. Twenty‐five Wistar rats were used as models of free fat grafts. Fat tissue taken from inguinal fat pads was grafted to the back skin with an 18‐gauge needle injection.

Results The weight of the injected fat was significantly reduced on the 180th day compared with the original weight (32% ± 10%). VEGF+ cells were observed in fibrous connective tissue of the grafts on days 7 and 30 but not after day 90. Apoptotic cells were also observed on days 7 and 30.

Conclusions Angiogenic factors including VEGF started to revascularize the graft around day 7, and the extent of the vasculature was not reduced after the revascularization. In addition to necrosis in the graft's early stages, apoptosis induced by many factors in the graft's environment is also, at least in part, a cause of long‐term volume reduction of the fat graft. Thus clinical application of angiogenic factors such as VEGF to fat grafts and control of apoptosis may contribute to improvements in fat‐grafting techniques.