Use of transabdominal ultrasound-guided transjugular portal vein puncture on radiation dose in transjugular intrahepatic portosystemic shunt formation

PURPOSE

Transjugular intrahepatic portosystemic shunt (TIPS) creation is used to treat portal hypertension complications. Often the most challenging and time-consuming step in the procedure is the portal vein (PV) puncture. TIPS procedures are associated with prolonged fluoroscopy time and high patient radiation exposures. We measured the impact of transabdominal ultrasound guidance for PV puncture on duration of fluoroscopy time and dose.

METHODS

We retrospectively analyzed the radiation dose for all TIPS performed over a four-year period with transabdominal ultrasound guidance for PV puncture (n=212, with 210 performed successfully and data available for 206); fluoroscopy time, dose area product (DAP) and skin dose were recorded.

RESULTS

Mean fluoroscopy time was 12 min 9 s (SD, ±14 min 38 s), mean DAP was 40.3±73.1 Gy·cm2, and mean skin dose was 404.3±464.8 mGy.

CONCLUSION

Our results demonstrate that ultrasound-guided PV puncture results in low fluoroscopy times and radiation doses, which are markedly lower than the only published dose reference levels.

Endovascular Management of Arterial Injuries Related to Venous Access: A Retrospective Review of 10‑Year Single-Center Experience

Purpose: Retrospective review of the pattern and management techniques of arterial injuries related to central venous access with long-term outcomes. Materials and Methods: Between January 2007 and November 2017, a total of 20 patients (13 females) were included with the mean age of 63 (28–89 years) and mean body mass index of 25.75 (13.3–36.5). Venous access procedures included central venous catheter (CVC) placement, dialysis line insertion, or endovascular venous procedures. The study excluded patients who had arterial injuries related to arterial access, such as postarterial line placement, postangiography, or percutaneous coronary interventions. Results: Iatrogenic arterial injuries occurred after attempted venous access procedures involving the common femoral vein (n = 18) and subclavian vein (n = 2). Injuries were related to CVC placement (n = 5), temporary dialysis catheter (n = 14), and inferior vena cava filter insertion (n = 1). Nine patients had transarterial venous catheter insertion complicated by active bleeding from pseudoaneurysm and arteriovenous fistula. Other injuries included isolated fistula (n = 3), isolated pseudoaneurysm (n = 4), isolated branch injury (n = 2), and intra-arterial insertion (n = 2). Endovascular management included stent–graft placement (n = 14), embolization of bleeding vessel (n = 2), and thrombin injection for pseudoaneurysm (n = 2). Conservative management with manual compression achieved hemostasis in two patients. Technical success was achieved in 100%. One patient required repeat angiography and embolization of bleeding branch vessel following stent–graft placement to control bleeding fistula and pseudoaneurysm. Clinical success was achieved in all patients. Procedure-related complications included puncture site hematoma (n = 1) and partially occlusive thrombus/spasm of deep femoral artery after stent–graft placement. Six patients (33%) died within 20 days after the procedure (3–20 days) due to other comorbidities. Three additional patients (16%) died during the same hospital admission at the time of the procedure (38–114 days). There were no reported complaints related to possible stent–graft stenosis or occlusion at mean follow-up time of 5 years (50 days–8.64 years) in all seven patients who survived after stent–graft placement procedure. Conclusion: Despite technically successful endovascular management of arterial injuries related to venous access in critically ill patients, the mortality rate remains high due to other comorbidities. Allowing for the small sample size, stent–graft placement for arterial injuries in this cohort of patients appears to be an effective option with high long-term patency rate.

The clinical significance of antinucleolar antibodies

BACKGROUND

The importance of antinucleolar antibodies seen by indirect immunofluorescence on HEp-2 cells, although associated with systemic sclerosis (SSc), in unselected patients is unknown.

AIMS

To determine the true clinical significance of antinucleolar antibodies in an unselected patient population.

METHODS

Antinucleolar antibody (ANoA) positive samples were identified in the immunology laboratory during routine autoimmune screening tests; case notes were reviewed using a standard proforma.

RESULTS

104 patients with ANoA were identified and ANoA+ samples were subclassified into homogeneous, clumpy and speckled antinucleolar types. SSc was evident in only two (1.8%) patients. Other connective tissue diseases were identified in 33 patients (32%); 22 patients (21%) had evidence of various malignancies. Both disordered liver function and anaemia were seen in 22 patients and were the commonest laboratory abnormalities.

CONCLUSIONS

Neither the presence nor subtype of ANoA is specific for systemic sclerosis. Laboratory comments appended to results should reflect this fact.

Prevalence study to elucidate the transmission pathways of Helicobacter pylori at oral and gastroduodenal sites of a South Indian population

INTRODUCTION

Since the discovery of Helicobacter pylori (H. pylori), much progress has been made worldwide in the field of its epidemiology. In spite of these advancements, many aspects of epidemiology still remain unclear, particularly among populations with low socio-economic status. The present study was designed to elucidate the different routes of transmission of H. pylori in the Hyderabad (South India) population and to investigate the impact of certain factors, such as age, gender, and lifestyle.

METHODS

Samples used for the study included saliva and biopsy samples of 400 symptomatic subjects from Hyderabad, India. The patients were retrospectively grouped, based on histopathology of the biopsy and 16S rRNA amplification of both saliva and biopsy as H. pylori positive and negative.

RESULTS

This study showed that the prevalence of H. pylori in both saliva and biopsy samples increased with age. In addition, the H. pylori infection was found more commonly in the saliva and biopsy samples among males (64 percent and 60 percent, respectively) than females (53.3 percent and 64 percent, respectively). Similarly, 71.6 percent and 73.5 percent of those who consumed municipal water acquired H. pylori (which were respectively found in their saliva and biopsy samples) compared to a lesser proportion (12.6 percent and 12.6 percent, respectively) of those who consumed boiled or filtered water. The study also found that subjects who preferred home-cooked food (57.1 percent and 57.7 percent) showed a lower prevalence of H. pylori in saliva and biopsy samples, respectively, compared to those (80 percent and 88 percent) who frequently ate out.

CONCLUSION

The results of the present study suggest that besides the oral-oral route, the transmission of H. pylori also takes place through the consumption of food prepared under unhygienic conditions. Consumption of municipal tap water also has a high impact in the transmission of H. pylori.

An unusual case of breast ulceration

We present an unusual case of breast ulceration secondary to heroin injection in a pregnant woman.

Rapid diagnosis of Helicobacter pylori infection in dyspeptic patients using salivary secretion: a non-invasive approach

INTRODUCTION

Current guidelines that recommend Helicobacter pylori eradication treatment without endoscopy in selected patients underscore the importance of non-invasive testing. The accuracy of saliva as a non-invasive specimen was compared with that of invasive tests in pretreatment diagnosis of H. pylori infection.

METHODS

One hundred patients undergoing gastroscopy were grouped into 80 symptomatic and 20 asymptomatic subjects and were investigated for the presence of H. pylori in saliva and stomach. Samples tested comprised saliva and gastric biopsies collected from each patient. Exclusion criteria were history of peptic ulcer, bleeding ulcer, cancer or recent use of antibiotics, proton pump inhibitors and non-steroidal anti-inflammatory drugs. Two sets of primers homologous to 534 bp fragment of H. pylori DNA, which have been shown previously to be highly specific and sensitive, were used for the polymerase chain reaction (PCR) amplification.

RESULTS

72 (90 percent) of the symptomatic group and 10 asymptomatic subjects were infected with H. pylori in the stomach as determined by histology and direct PCR amplification of biopsy DNA obtained from each subject. H. pylori DNA was identified in the saliva of 70 (87.5 percent) symptomatic subjects and 12 (60 percent) asymptomatic control subjects.

CONCLUSION

High rates of detection using saliva as a specimen indicate that saliva of the infected person could serve as a reliable non-invasive alternative to detect the presence of H. pylori infection in comparison to the currently available standard diagnostic tests.

Total arterial revascularisation as a primary strategy for coronary artery bypass grafting

BACKGROUND

Bilateral internal thoracic arteries confer improved survival benefit after coronary artery bypass grafting (CABG). Despite increasing evidence, the use of arterial conduits has not been accepted as a primary practice in most of the centres in the UK for various reasons. A series of patients has been analysed to assess the feasibility of total arterial revascularisation as a primary strategy in patients requiring first time CABG.

METHODS

Altogether 245 patients undergoing first time CABG by one surgeon, from June 1999 to October 2000, were studied. Group 1 consisted of 165 patients undergoing total arterial revascularisation (using bilateral internal thoracic and radial arteries) and group 2 consisted of 80 patients undergoing conventional CABG (using one internal thoracic artery and supplemental veins). Thirty day mortality and early morbidity with particular reference to resternotomy for bleeding, cerebrovascular accidents, renal failure, and sternal dehiscence were the main outcome measures.

RESULTS

Patients in group 1 were younger (mean (SD) 60 (10) v 65 (9) years; p<0.001), had lower Parsonnet scores (mean (SD) 5 (5) v 11 (7); p<0.001), and better left ventricular function. Both groups received a similar number of grafts. The percentage of patients undergoing total arterial revascularisation rose from 44% in the first three months to over 75% in the three latter three month periods. Overall 30 day mortality was 1.3%, one patient (0.6%) in group 1 and two patients (2.5%) in group 2. There was a similar incidence of postoperative complications and length of median postoperative stay in both groups.

CONCLUSION

Total arterial revascularisation can be adopted as a primary strategy in most patients undergoing CABG with no increase in mortality or morbidity.

pH-dependent modulation of alkaline phosphatase activity in Serratia marcescens

Serratia marcescens is an opportunistic pathogen responsible for causing nosocomial infections, corneal ulcer, necrotizing fasciitis, cellulites, and brain abscess. Alkaline phosphatase (APase) is believed to play an important role in the survival of several intracellular pathogens and their adaptation. We have studied the effect of low phosphate concentration and acid pH on the APase activities of S. marcescens. In a low phosphate medium, some strains of S. marcescens synthesize two different types of APases, a constitutive (CAPase) and an inducible (IAPase). Both the CAPase and IAPase isoenzymes completely lost their enzyme activities at pH 2.3, within 10 min of incubation at 0 degrees C. Acid-treated IAPase isoenzymes I, II, III, and IV solutions when adjusted to pH 7.8 showed recovery of 70%, 52%, 72%, and 60% of the lost activities, respectively. When the pH of the CAPase reaction mixture was raised to pH 7.8, the enzyme activity regained only 5% of its initial activity. Variations in protein concentration also affected the pH-dependent reversible changes of the IAPase activity. The higher the protein concentration, the faster the inactivation of enzyme activity observed at acidic pH at 0 degrees C. Conversely, the lower the protein concentration, the higher the rate of reactivation of enzyme activity observed for IAPase at alkaline pH. Protein interaction studies revealed a lack of similarity between CAPase and IAPase, suggesting separate genetic origin of these potentially virulent genes of S. marcescens.

The bicoronal flap approach in craniofacial trauma

The utilization of the bicoronal scalp flap in craniofacial trauma has proved indispensable in the management of severe craniofacial injuries. It provides vast exposure of such critical structures as the cranium, frontal sinus, orbit and upper midface, compared with that for previous techniques of facial fracture reduction. Although the flap has great utility, severe complications, such as facial nerve injury, diplopia, telecanthus, and scalp necrosis, can occur. This article reviews the surgical anatomy, technique, and indications for the safe utilization of the bicoronal scalp flap approach in the management of craniofacial trauma.

Trauma to the temporal bone: diagnosis and management of complications

The temporal bone contains important sensory and neural structures that may be damaged in patients who experience craniofacial trauma. The most serious complications of temporal bone trauma include facial nerve paralysis, cerebrospinal fluid leak, and hearing loss. Injury to the temporal bone often presents with subtle signs and symptoms, such as otorrhea, facial palsy, and hemotympanum. A high index of suspicion and a thorough knowledge of how to diagnose injury to the temporal bone are paramount in treating patients who present to the emergency room with craniofacial trauma. This article provides an overview of temporal bone trauma, outlines a methodical approach to the patient with temporal bone trauma, details four cases, and describes the treatment of complications.

Bone-screw mandible fixation: an intraoperative alternative to arch bars

OBJECTIVES

Bone-screw mandible fixation (BSMF) is evaluated as an alternative to intraoperative arch-bar maxillomandibular fixation before plating of mandibular fractures. BSMF is achieved by wire ligation of opposing bone-screws placed in the maxilla and mandible.

METHODS

A retrospective evaluation of 23 patients with 40 mandibular fractures who underwent mandibular fracture repairs. BSMF was used instead of arch bars to ensure proper dental occlusion. All fractures were then plated, after which BSMF was removed before termination of anesthesia.

RESULTS

Normal occlusion was observed in 21 patients (91.3%), Class II malocclusion was noted in 1 patient (4. 3%), and 1 patient was edentulous. No complications related to the use of BSMF were observed.

CONCLUSION

BSMF can serve as a viable alternative to arch-bar maxillomandibular fixation for obtaining temporary intraoperative occlusion. BSMF produces acceptable malocclusion rates and offers the advantages of decreased intraoperative time, lower risk for percutaneous and mucosal wire punctures, and ease of use.

Evidence on the presence of two distinct alkaline phosphatases in Serratia marcescens

Certain strains of Serratia marcescens synthesized two different types of alkaline phosphatase (APase), constitutive (CAPase) and inducible (IAPase) APases, in low phosphate medium. Synthesis of the IAPase was repressed in the presence of high phosphate. Purification and separation of these electrophoretically distinct APases was achieved by using fractional (NH(4))(2)SO(4) precipitation, adsorption on a DEAE-cellulose column and elution of enzymes by a linear sodium chloride gradient. Starch gel electrophoresis of certain fractions revealed the separation of not only IAPase from CAPase but its separation into four distinct isozymes. CAPase gave maximum enzyme activity around pH 9.5, whereas for IAPase a broad range of enzyme activity was found between pH 8.5 and 10.5. Reversible inactivation at low pH occurred for IAPase but very little with CAPase. CAPase was more thermolabile than IAPase at 95 degrees C. The two APases were found to be distinct in their kinetic as well as immunological properties, suggesting two distinct enzyme species.

Common head and neck manifestations of AIDS

Head and neck manifestations of acquired immunodeficiency syndrome (AIDS) can involve the skin, ear, upper aerodigestive tract, and neck. Several head and neck manifestations of AIDS may be the only initial sign of this disease process and therefore primary-care physicians and otolaryngologists must be able to recognize and understand the management of these lesions. Cystic enlargement of the parotid gland and Kaposi's sarcoma are increasingly being encountered in the head and neck exam of HIV-infected patients. An example of each of these disease processes is presented with full discussion about the various treatment methods.

Breaking the bad news of cancer: the patient's perspective

OBJECTIVE

Head and neck cancers present a special challenge to the patient and the physician because they affect the quintessential aspects of living such as breathing, eating, and speaking. Numerous articles have described how the physician should perform the difficult task of conveying bad news, but only a small number of articles specifically assess the patients' perceptions when being told of a serious diagnosis. The purpose of this survey was to evaluate the thoughts and concerns of patients receiving diagnoses of head and neck cancer.

STUDY DESIGN

Questionnaire survey.

METHODS

A 41-item questionnaire was sent to head and neck cancer patients who have been treated for and remain free of disease for at least 2 years.

RESULTS

All of the respondents felt that their diagnosis was adequately explained to them and that no further explanations were necessary. Eighty-one percent of the respondents did not wish to have anyone else present at the time of diagnosis. Additionally, 75% of the respondents did not want the physician to touch their hands or hug them when given the bad news. Only 63% of the respondents had further discussions with family, friends, or other physicians after being told of their diagnosis.

CONCLUSION

When patients are told of the diagnosis of head and neck cancer, they want their physician to be truthful, caring, and compassionate. The patients want their diagnosis in simple and direct terms without the incorporation of complex medical terminology. The results of this survey can provide insightful information to physicians when they are undertaking the difficult task of conveying bad news to their patients.

Acute intracranial complications of temporal bone trauma

Temporal bone trauma can be disastrous for the individual and his or her family. With the increase in violent crime throughout our society, the number of intracranial complications associated with temporal bone injury has increased significantly. Although multiple reports concerning the diagnosis and management of temporal bone trauma have been published, few studies on its intracranial complications have been addressed. In this study, we assessed the cases of 43 patients treated for temporal bone fractures between January 1992 and December 1994. The number of temporal bone fractures increased from 6 in 1992 to 21 in 1994. Twenty-one patients (49%) presented with decreased mental status. Significant alcohol and drug use was documented in 28% and 58% of patients, respectively. The most common radiologic finding was skull and intracranial injury. Thirty-six patients (84%) had at least one abnormal intracranial finding; of these patients, 14 (39%) had more than one abnormal finding on computed tomography. Cerebral midline shift, subarachnoid hemorrhage, subdural hemorrhage, and cerebral edema were the most common radiologic findings. Nineteen patients (44%) required an open neurosurgical procedure, and almost all patients with more than one abnormal radiologic finding underwent neurosurgery (86%). Seven patients required further institutional care after discharge. Four patients died (9% mortality); all the deaths were neurologically related. Mean hospital charges increased from $30,900 in 1992 to $63,000 in 1994.

When is facial pain trigeminal neuralgia?

The pain of trigeminal neuralgia can be excruciating and debilitating. Fortunately, effective medical and surgical therapies for the disorder exist. Successful treatment hinges on thorough history taking and accurate diagnosis. Diagnostic evaluation of patients with orofacial pain should include complete head and neck, dental, and neurologic examinations combined with radiologic imaging of the head and appropriate laboratory tests.

Microscopic examination of routine tonsillectomy specimens: is it necessary?

Controversy continues to exist regarding the routine histologic examining of tonsillectomy specimens. Proponents suggest that among other reasons, missing an important diagnosis such as occult malignancy or granulomatous disease and possible medicolegal consequences argue in favor of routine histologic examination. Others state that we should consider the very low yield of significant histologic findings in routine tonsillectomy specimens and its added cost. We performed a retrospective evaluation of all cases of patients who underwent tonsillectomy with or without adenoidectomy between January 1992 and July 1996. Two hundred eighty-eight charts were evaluable. Group 1 consisted of all tonsillectomy specimens that were subjected to gross examination only. Group 2 consisted of all tonsillectomy specimens that were subjected to gross examination as well as microscopic examination. In group 1, no abnormal gross findings were noted. Group 2 consisted of specimens from an older population with a mean age of 21.6 years. There were 43 patients older than 20 years old in group 2, and in all cases except four the preoperative clinical impression correlated with the microscopic findings. Occult malignancy was found in only one of these four patients. No cases of granulomatous disease were discovered. Overall, no patients except one had any change in postoperative treatment on the basis of the results of microscopic examination. We believe that routine microscopic examination of tonsillectomy specimens results in unnecessary cost and consumption of resources and time. Microscopic examination should be done in only selected cases such as in patients with grossly asymmetric tonsils or in patients with a history of malignancy.

Head and neck manifestations of AIDS in adults

Head and neck manifestations of acquired immunodeficiency syndrome (AIDS) are among the most common complications of this disease. Some of these manifestations are the initial signs of human immunodeficiency virus (HIV) infection, and others are associated with full-blown AIDS. Otologic manifestations include otitis externa, otitis media, Kaposi's sarcoma and sensorineural hearing loss. Nasal and oral manifestations of AIDS are more common than otologic manifestations and range from infections, caused by both opportunistic and nonopportunistic organisms, to malignancies. We address common manifestations and current treatment recommendations.

Development of distant metastasis after treatment of advanced-stage head and neck cancer

BACKGROUND

The recognition of risk factors for the development of distant metastasis is necessary for identifying high-risk patients who may benefit from systemic therapy. Previous investigations studying possible risk factors have been heterogeneous, with patients having varied forms of therapy. This study is designed to evaluate the clinical and histologic risk factors for the development of distant metastasis (DM) in patients with only advanced-stage head and neck squamous cell carcinoma after surgery and radiotherapy.

METHODS

Retrospective analysis of a cohort of potentials with-surgically treated stage III and IV squamous cell carcinoma of the hypopharynx, tongue, and supraglottic larynx between 1988-1992. The cohort consisted of 130 patients of which 30 patients developed DM as the initial site of failure. All patients underwent surgical resection of the primary. Neck dissection was performed in 26 of 30 (87%0 patients who developed distant metastasis. Almost all patients received radiation therapy. Patients who initially developed DM (DM group) were compared with patients who did not initially develop DM (no DM group) with respect to certain clinical and histo-pathological factors.

RESULTS

The majority of patients in the DM group had advanced T stage and clinically palpable cervical lymph nodes (73% and 93% respectively). In the no DM group, most patients had advanced T stage (85%) but 42% of the patients had stage NO necks (p < .05). Eighty-eight percent of patients in the DM group and 60% of patients in the no DM group had histological evidence of extracapsular spread of tumor from cervical lymph nodes (p < .05). Three or more positive lymph nodes were found in 69% of patients who developed DM and in only 35% of patients in the no DM group (p < .05). Age, gender, primary site, history of radiation therapy, perineural invasion and tumor grade were not associated with a higher risk for DM (p > .05).

CONCLUSION

Patients wit clinically palpable neck disease (N1-3), histological evidence of metastatic nodal disease, extracapsular spread, and three or more positive lymph nodes are at greater risk of developing failure at distant sites. This subset of patients should have an extensive evaluation for distant metastatic disease and should be considered for systemic therapy.

Self-inflicted traumatic macroglossia

Macroglossia is a potentially life-threatening problem. The multiple aetiologies responsible for this condition include cysts, tumours, amyloidosis, angioedema, and infections. Although injuries to the oral cavity are common, self-inflicted traumatic macroglossia is not common. We report a case of a comatose patient with limb contractures and severe trismus who developed entrapment of the tongue with progressive macroglossia and near auto-amputation of the tongue. The importance of early recognition and treatment of tongue entrapment in comatose patients is emphasised since this is a potentially reversible condition.

Skin graft reconstruction of the composite resection defect

BACKGROUND

Reconstruction of the composite resection defect should provide for adequate speech and swallowing functions. Poorly designed reconstructive efforts can result in significant oral dysfunction. The composite resection defect can be reconstructed by a variety of methods. The split-thickness skin-graft method provides excellent speech and swallowing functions with minimal morbidity.

METHODS

Forty-three patients who underwent composite resections and were reconstructed by split-thickness skin graft (STSG) were analyzed. The patients' charts were reviewed for oncologic outcome, speech and swallowing functions, and length of hospital stay.

RESULTS

Speech and swallowing functions were excellent. At last follow-up, more than 90% of the patients tolerated either a soft or regular diet. The length of hospital stay was only 13 and 18 days for patients who underwent marginal and lateral segmental mandibulectomy, respectively. There were few complications. Radiation therapy had no adverse effects on the grafts.

CONCLUSION

The STSG method is our preferred method for reconstruction of marginal or lateral segmental mandibulectomy defects that do not require tissue bulk.

Post-tonsillectomy hemorrhage: an assessment of risk factors

Hemorrhage is the most frequent complication of tonsillectomy and is responsible for the majority of post-tonsillectomy fatalities. The incidence of this hemorrhage has been reported to be as high as 20% [6]. Despite continued efforts to reduce this problem, it remains a persistent risk. The charts of 1138 patients who underwent tonsillectomy with or without adenoidectomy from 7-1-89 to 6-30-93 were reviewed. Post-tonsillectomy hemorrhage occurred in 36 patients (3%). Preoperative, intraoperative and postoperative risk factors were assessed. Postoperative bleeding occurred more often in older patients (69% over age 11 years). Seventy-five per cent of these patients were operated on for chronic tonsillitis as compared to 11% operated on for upper airway obstruction. The majority of these patients presented after postoperative day 1 (83%). Four patients required blood transfusions. Postoperative hemorrhage occurred in 14% of patients with elevated postoperative mean arterial pressures. Intraoperative blood loss that exceeded 50 cm3 was also a significant risk factor for post-tonsillectomy hemorrhage. It is concluded that older age, a history of chronic tonsillitis, excessive intraoperative blood loss and elevated postoperative mean arterial pressure are significant risk factors for post-tonsillectomy hemorrhage. An awareness of these risk factors can help identify patients with potential to bleed postoperatively.

Electrodissection tracheotomy

The acquired immune deficiency syndrome (AIDS) epidemic and other potentially fatal blood-borne infectious diseases have produced a heightened awareness for preventing accidental inoculation of surgeons and operating theatre staff. It is incumbent upon the head and neck surgeon to use safe and effective surgical technique in these patients to prevent such an event. We are seeing an increasing number of patients with AIDS and hepatitis undergoing tracheotomy. We present a sharps-free technique for tracheotomy which is safe for the hospital staff and the patient.

Parathyroid cyst: current diagnostic and management principles

BACKGROUND

Parathyroid (PTH) cyst is a rare lesion. Only about 200 cases have been reported to date. The diagnosis of a PTH cyst is difficult, particularly in its differentiation from thyroid cyst. It has clinical significance because PTH cysts can mimic a thyroid mass and can be associated with hyperparathyroidism.

METHODS

This presentation illustrates an additional case of a PTH cyst. The importance of fine-needle aspiration (FNA) in the diagnosis of PTH cyst and its management are discussed.

RESULTS

Fine-needle aspiration of clear fluid containing an elevated PTH hormone level proved to be diagnostic in the patient. Recurrence of the cyst after FNA required surgical resection. The current concepts of etiology and treatment are summarized.

CONCLUSIONS

PTH cyst should be in the differential diagnosis in any patient initially seen with an anterior cystic neck mass. Radiologic imaging and FNA can accurately diagnose PTH cysts. Surgical excision may be needed for recurrent cysts after aspiration.

Management of carcinoma of the supraglottic larynx: evolution, current concepts, and future trends

The treatment of cancer of the supraglottic larynx has undergone an evolution. Better understanding of the anatomy and biology of cancer in this anatomic site has enabled surgeons to devise effective oncologic strategies while making every effort to preserve the function of the larynx. Certain recent concepts and changing trends have emerged in the treatment of cancer of the supraglottic larynx, including the treatment of the neck, significance of extracapsular spread of tumor in cervical lymph nodes, and conservation laser surgery. In 1985, Snyderman et al. reported the prognostic significance of extracapsular spread in patients with cancer of the supraglottic larynx. In 1990, Lutz et al. reported the results of our experience with the treatment of 202 patients. The review verified the significant risk of bilateral neck disease in these patients, even with adjuvant radiation therapy. Accordingly, since 1990 all patients having cancer of the supraglottic larynx have been treated in the Department of Otolaryngology at the University of Pittsburgh with bilateral neck dissections. The use of adjuvant radiation therapy has been based on the presence of extracapsular spread. This study documents the oncologic effectiveness of this treatment and confirms the efficacy of bilateral neck dissections in an attempt to control neck disease and the prognostic significance of extracapsular spread. We review the evolution of the treatment of cancer of the supraglottic larynx, present our results, and consider innovative surgical approaches.

Acute epistaxis. How to spot the source and stop the flow

The goals of epistaxis treatment are control of hemorrhage, prevention of cardiovascular and airway compromise, and determination of the cause and the source of bleeding. Distinguishing anterior from posterior epistaxis is important because therapeutic approaches differ. Epistaxis can usually be managed nonsurgically, but a surgical procedure is sometimes necessary. Cauterization, nasal packing, and use of an intranasal tampon or balloon catheter are effective nonsurgical interventions, but they may cause sinusitis, middle ear effusion, patient discomfort, and hypoxia. Surgical interventions include arterial ligation, endoscopic cauterization, and angiographic embolization. These highly effective methods incur the risks of general anesthesia and require technical expertise. A thorough and methodical approach to epistaxis is necessary, with otolaryngologic consultation when appropriate.

Oral cancer: how to recognize the danger signs

Oral cancer remains a challenge to clinicians. Early treatment results in excellent cure rates and minimal functional disability. However, patients with advanced-stage disease often require extensive surgical procedures and adjuvant therapy. Despite radical treatment, survival rates are low and morbidity is high. Detection of oral cancer at an early stage, when it is most amenable to treatment, is an important goal. Only with continued education of the public and of healthcare providers, including primary care physicians and dentists, can this goal be achieved.

Extracapsular spread in the clinically negative neck (N0): implications and outcome

Cervical metastasis is the most important prognostic factor in head and neck cancer patients. The prognostic significance of extracapsular spread of tumor in metastatic lymph nodes has also been documented. The presence of extracapsular spread further reduces the survival by 50% in those patients with cervical metastatic disease. Most patients with clinically negative necks (stage N0) have a good prognosis. However, some of these patients will have neck disease and distant metastasis and will eventually die. Because the presence of extracapsular spread is a predictor of poor outcome, we hypothesized that extracapsular spread may be a factor in the subset of patients with clinically negative necks who have poor outcomes. One hundred nine patients with clinically negative necks who had undergone neck dissection were identified. Occult metastasis was observed in 34% of patients. In this group, extracapsular spread was present in 18 (49%) patients. Overall, 103 patients were evaluable, of whom 70 (68%) remain free of disease 2 or more years after treatment. A subgroup of 68 patients had histologically negative nodes, of whom 56 (82%) are free of disease. Of patients with extracapsular spread, only 5 (31%) of 16 are free of disease. This is in contrast to patients with metastasis confined to the lymph node, of whom 9 (47%) of 19 are free of disease. Statistical analysis of these data shows that for this sample size this difference is significant. The addition of radiation therapy did not improve outcome in these patients. Extracapsular spread predicts a worse outcome in patients with subclinical cervical metastasis. Alternative modes of adjuvant therapy are suggested because of the poor results of postoperative radiation therapy in patients with extracapsular spread.

Extracapsular Spread in the Clinically Negative Neck (N0): Implications and Outcome

Cervical metastasis is the most important prognostic factor in head and neck cancer patients. The prognostic significance of extracapsular spread of tumor in metastatic lymph nodes has also been documented. The presence of extracapsular spread further reduces the survival by 50% in those patients with cervical metastatic disease. Most patients with clinically negative necks (stage N0) have a good prognosis. However, some of these patients will have neck disease and distant metastasis and will eventually die. Because the presence of extracapsular spread is a predictor of poor outcome, we hypothesized that extracapsular spread may be a factor in the subset of patients with clinically negative necks who have poor outcomes. One hundred nine patients with clinically negative necks who had undergone neck dissection were identified. Occult metastasis was observed in 34% of patients. In this group, extracapsular spread was present in 18 (49%) patients. Overall, 103 patients were evaluable, of whom 70 (68%) remain free of disease 2 or more years after treatment. A subgroup of 68 patients had histologically negative nodes, of whom 56 (82%) are free of disease. Of patients with extracapsular spread, only 5 (31%) of 16 are free of disease. This is in contrast to patients with metastasis confined to the lymph node, of whom 9 (47%) of 19 are free of disease. Statistical analysis of these data shows that for this sample size this difference is significant. The addition of radiation therapy did not improve outcome in these patients. Extracapsular spread predicts a worse outcome in patients with subclinical cervical metastasis. Alternative modes of adjuvant therapy are suggested because of the poor results of postoperative radiation therapy in patients with extracapsular spread.

Optic nerve elongation: does it exist?

The length of the optic nerves is a reflection of normal postnatal cranio-orbital development. Unilateral elongation of an optic nerve has been observed in two patients with orbital and skull base neoplasms. In the first case as compared to the patient's opposite, normal optic nerve, an elongated length of the involved optic nerve of 45 mm was present. The involved optic nerve in the second patient was 10 mm longer than the normal opposite optic nerve. The visual and extraocular function was preserved in the second patient. The first patient had only light perception in the affected eye. In this paper, the embryology, anatomy, and physiology of the optic nerve and its mechanisms of stretch and repair are discussed.

The neck mass. A challenging differential diagnosis

In patients with neck masses, accurate history taking and physical examination often narrow the differential diagnosis tremendously. Diagnostic tests may be helpful but should be done only if management is affected as a result. Fine-needle aspiration, when necessary, is often valuable to obtain a tissue diagnosis, but its accuracy may depend on the experience of the cytopathologist. Antibiotic therapy is sufficient for some inflammatory masses; excision is generally needed for congenital lesions and malignant neoplasms.