Gender-Specific Differences in Preoperative Concerns in Patients Undergoing Endoscopic Sinus Surgery for Chronic Rhinosinusitis

OBJECTIVES

Among patients with chronic rhinosinusitis (CRS), gender differences in epidemiology as well as quality of life have been reported. However, whether gender differences in endoscopic sinus surgery (ESS) preoperative concerns exist is unclear.

METHODS

CRS patients undergoing ESS at 3 tertiary care centers in Los Angeles completed the validated Western Surgical Concern Inventory - ESS assessing ESS preoperative concerns.

RESULTS

Of the 75 patients included, female patients expressed greater concern than male patients in regard to nasal packing, undergoing anesthesia, impact of surgery on daily activities, and pain and discomfort following surgery.

CONCLUSION

This study suggests there are gender differences in ESS preoperative concerns and otolaryngologists should be aware of these possible concerns during preoperative discussions.

Cost-effectiveness Analysis of Submandibular Gland Preservation With Sialendoscopy for the Management of Sialolithiasis

OBJECTIVE

To compare the cost-effectiveness of sialendoscopy with gland excision for the management of submandibular gland sialolithiasis.

STUDY DESIGN

Cost-effectiveness analysis.

SETTING

Outpatient surgery centers.

METHODS

A Markov decision model compared the cost-effectiveness of sialendoscopy versus gland excision for managing submandibular gland sialolithiasis. Surgical outcome probabilities were found in the primary literature. The quality of life of patients was represented by health utilities, and costs were estimated from a third-party payer's perspective. The effectiveness of each intervention was measured in quality-adjusted life-years (QALYs). The incremental costs and effectiveness of each intervention were compared, and a willingness-to-pay ratio of $150,000 per QALY was considered cost-effective. One-way, multivariate, and probabilistic sensitivity analyses were performed to challenge model conclusions.

RESULTS

Over 10 years, sialendoscopy yielded 9.00 QALYs at an average cost of $8306, while gland excision produced 8.94 QALYs at an average cost of $6103. The ICER for sialendoscopy was $36,717 per QALY gained, making sialendoscopy cost-effective by our best estimates. The model was sensitive to the probability of success and the cost of sialendoscopy. Sialendoscopy must meet a probability-of-success threshold of 0.61 (61%) and cost ≤$11,996 to remain cost-effective. A Monte Carlo simulation revealed sialendoscopy to be cost-effective 60% of the time.

CONCLUSION

Sialendoscopy appears to be a cost-effective management strategy for sialolithiasis of the submandibular gland when certain thresholds are maintained. Further studies elucidating the clinical factors that determine successful sialendoscopy may be aided by these thresholds as well as future comparisons of novel technology.

Fatigue Resistance of Canine Vocal Fold Muscle

The objective of the experiment was to provide data from dogs, the best nonprimate model for the contractile properties of laryngeal muscles, on the fatigue characteristics of vocal fold muscle. Isometric muscle force was recorded from a transducer attached to the section of the thyroid cartilage on which the muscle inserted. Twitch contractions were recorded during supramaximal indirect electrical stimulation by DC pulses for at least 30 minutes. At 5 pulses per second (p/s), potentiation was observed in all records, peaking at an average of 7.5 minutes after stimulation onset. At 10 p/s, the peak of the potentiated average trace was earlier. One third of these records did not show potentiation. Where moderate or large potentiation was observed, the peak twitch tension declined and reached an asymptote above the initial tension, while when potentiation was small or absent, the final force was smaller than initially. Canine vocal fold muscle was observed to be fatigue-resistant, but in phonation other factors may produce fatigue.

Management of a type II nasoethmoid orbital fracture and near-penetration of the intracranial cavity with transnasal canthopexy

Nasoethmoid orbital fractures are perhaps the most complicated aspect of craniomaxillofacial trauma. Involvement of the medial canthal tendon markedly increases the complexity of the repair. We report a case of type II nasoethmoid orbital fracture in a 32-year-old man that was managed without formal medial canthal tendon repair; instead, we used open reduction and internal fixation of the central fragment and the nasoethmoid complex. However, during the immediate postoperative period, we noted anterior and inferior displacement of the medial canthus. We took the patient back to the operating room to address the detachment. Revision surgery was successful, and at the 6-month follow-up, his medial canthi were completely symmetrical in all dimensions. We describe our intraoperative technique and measures to prevent complications that can help the surgeon intraoperatively. We also discuss an important point that has not been adequately addressed in the literature to date—that is, the fact that the use of the frontoethmoid suture line and the anterior ethmoid artery as a guide to the skull base can be inaccurate. Problems associated with this inaccuracy can be avoided by carefully reviewing preoperative computed tomography, which can help keep the surgeon from entering the intracranial cavity while fixing the medial canthal tendon during transnasal canthal repair.

The turbinates in nasal and sinus surgery: A consensus statement

A panel to discuss various issues concerning surgery of the middle and inferior turbinates in patients with nasal and sinus disease was convened by the American Rhino-logical Society during the Combined Otolaryngological Spring Meetings in May 2001. The panel was chaired by the lead author (D.H.R.) and made up of the other authors listed above. What follows are some of the highlights of the presentations and the panelists’ conclusions and consensus recommendations.

Endoscopic Intranasal Dacryocystorhinostomy—A Cadaver Study

Several transnasal, transnasal-transseptal, and external approaches for dacryocystorhinostomy have been described. The first two and especially the first have the disadvantage of limited visualization. The third leaves an external scar, disrupts the horizontal canilicular system, and requires manipulation of the medial canthal tendon. The method described, using nasal endoscopes, affords excellent visualization and precise control, while avoiding an external scar, the canilicular system, and the medial canthal tendon.

Bacterial Biofilms and Increased Bacterial Counts Are Associated with Airway Stenosis

Objectives:

The majority of airway stenoses are acquired secondary to the use of prolonged endotracheal intubation (ETT). Pressure exerted on the tracheal mucosa by the presence of ETT leads to irritation, ulceration, and granulation tissue formation and eventual fibrosis. An excess of granulation tissue promotes excess wound contracture. Antibiotics have been shown to decrease local inflammation and granulation tissue formation in the trachea. However, antibiotic therapy is not 100% effective in preventing or treating granulation tissue formation. Development of bacterial biofilms may explain this finding. This study was done to evaluate the difference between stenotic segment and normal trachea in terms of 1) presence of bacterial biofilms; 2) quantitative analysis of bacterial count; 3) inflammatory markers within tracheal tissue.

Methods:

Institutional review board approved case-control study, where cases were patients with airway stenosis and controls were patients without airway stenosis. We performed scanning electron microscopy (SEM) for biofilm, quantitative polymerase chain reaction (qPCR) for quantitative analysis of bacterial count, and immunohistochemistry (IHC) for inflammatory markers.

Results:

SEM showed presence of biofilm in cases compared to controls. The number of 16S rRNA gene copies using qPCR, a surrogate for the number of bacterial cells, was significantly higher in cases (mean=198) compared to controls (mean=30 ) ( P < 0.05). Pediatric cases showed a significantly higher bacterial count than adult cases. IHC showed stronger staining for SMAD3 and transforming growth factor β (TGF-β).

Conclusions:

Biofilms are present in airway stenotic segments, and there exists a difference in tracheal microbiomes and inflammatory markers between patients with airway stenosis and normal controls.

Presentation and Management of Neck Abscess: Have Things Changed over a 20-Year Period?

Objectives:

Our recent clinical experience with deep neck space infection indicated difference in the presentation, etiology, and bacteriology compared to previously published report from our institution. Hence we decided to evaluate 1) change in the presentation, physical examination, bacteriology, and empiric antibiotic therapy for patients with deep neck space abscess compared to previously published report and, 2) incidence of methicillin-resistant Staphylococcus aureus (MRSA) related infection in our patient population.

Methods:

Institutional Review Board approved retrospective analysis of patients who underwent incision and drainage of neck abscess in the operating room between 2008-2012 at LAC+USC Medical Center. Comparison was made with previously published historical data. Data analysis was done using SAS 9.1.

Results:

44 patients were included in the present study compared to 50 in previously published study. Compared to previously published report from our institution, there has been a statistically significant difference in 1) most common presenting symptom: dysphagia (64%) vs pain (76%); 2) location of neck abscess: parapharyngeal (54%) vs anterior triangle (28%); 3) etiology: upper respiratory tract infection (URI) (41%) vs intravenous drug abuse (IVDA) (28%); 4) higher prevalence of anaerobic bacteria (86%) vs 50%; 5) MRSA was present in only 1 (2%) patient; 6) Clindamycin was empiric antibiotic in 34 (77%) of the patients, with the need for change after culture report in 5 (11%) patients. Chi-square p-value was <0.05 for all comparisons.

Conclusions:

URI and odontogenic infections are now the major cause of neck abscesses compared to IVDA in previous report. Clindamycin is an appropriate empiric antibiotic. MRSA incidence is low.

US-guided fine-needle aspiration of major salivary gland masses and adjacent lymph nodes: accuracy and impact on clinical decision making

PURPOSE

To determine whether ultrasonography (US)-guided fine-needle aspiration (FNA) is an effective technique for diagnosing masses in the salivary gland and adjacent lymph nodes.

MATERIALS AND METHODS

The institutional review board waived the requirement to obtain informed consent and approved this HIPAA-compliant retrospective study. Radiology records of 50 patients (28 female patients aged 25-85 years [median age, 58 years], 22 male patients aged 11-82 years [median age, 62 years]) who underwent 52 consecutive US-guided FNA procedures from 2004 to 2009 were reviewed. In 46 cases, lesions were sampled for biopsy under real-time US guidance by means of three passes with a 25-gauge needle. In six cases, two subsequent passes were performed with a 22-gauge needle after the first pass showed minimal or no aspirate. Findings from cytopathologic analysis, clinical follow-up, and surgery were evaluated and compared.

RESULTS

A diagnostically adequate biopsy specimen was obtained in 48 of the 52 cases (92%). Among the 20 patients who underwent surgical intervention after diagnostic US-guided FNA findings, results of surgical-pathologic analysis helped confirm the cytologic diagnosis in 19 (95%). Twenty of the 50 patients (40%) were spared surgical intervention on the basis of findings from US-guided FNA. US-guided FNA did not result in any intra- or postprocedural complications.

CONCLUSION

The diagnostic accuracy of US-guided FNA is similar to that of core needle biopsy, and there were no complications in this study. Information yielded with FNA cytology plays an integral role in clinical decision making in the management of masses in the major salivary glands and adjacent structures.

Biofilm and persistent inflammation in endoscopic sinus surgery

Bacterial biofilms have been observed in many patients with chronic rhinosinusitis, but their importance is still being investigated. This study examines the association between biofilms and other clinical findings in chronic rhinosinusitis patients. Twenty-four patients with chronic rhinosinusitis who failed medical management underwent endoscopic sinus surgery (ESS). Tissue was collected from the ethmoid sinus and analyzed for the presence of biofilm by hematoxylin and eosin staining, fluorescent in situ hybridization, and confocal scanning laser microscopy. Biofilms were classified as extensive (> 50% of mucosal surface in sample) or present (< 50% of surface). The surgeon remained blinded to the biofilm status of patients until postoperative follow-up was complete. The presence of bacterial biofilm was strongly associated with persistent mucosal inflammation after ESS (53% of biofilm-positive patients vs 0% of biofilm-negative patients, P = 0.009). The amount of biofilm was not important as there was no significant difference between the extensive and present biofilm classifications with respect to inflammation. The presence of biofilm was not associated with prior ESS, allergies, eosinophils, polyps, or presence of fungal elements.

Traumatic pseudoaneurysm of the occipital artery: case report and review of the literature

Only 3 cases of traumatic pseudoaneurysm of the occipital artery have been reported since 1644. We report a fourth case, which occurred in an 85-year-old woman who experienced a blunt trauma during a fall. The pseudoaneurysm resolved without surgical intervention. We also review the literature on traumatic pseudoaneurysms, as well as true aneurysms, of the external carotid system, with emphasis on current diagnostic and therapeutic options.

The significance of EphB4 and EphrinB2 expression and survival in head and neck squamous cell carcinoma

OBJECTIVES

To examine the expression of EphB4 and EphrinB2 in tumor tissue and surrounding normal tissue in patients with head and neck squamous cell carcinoma (HNSCC) and to evaluate its association with overall patient survival.

DESIGN

Retrospective study.

SETTING

University of Southern California-University Hospital, the Los Angeles County and University of Southern California Medical Center, and the Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles.

PATIENTS

Fifty patients, 8 with early-stage (stages I and II) and 42 with advanced-stage (stages III and IV) HNSCC, were enrolled into this study. Staging was based on the system of the American Joint Committee on Cancer.

MAIN OUTCOME MEASURES

EphB4 and EphrinB2 expression was evaluated by Western blot analysis. Overall survival in patients was then compared with EphB4 and EphrinB2 expression.

RESULTS

EphB4 and EphrinB2 expression was detected in all normal and tumor samples in patients with HNSCC, with the magnitude of EphB4 overexpression greater than that of EphrinB2 expression compared with normal tissue. There was a statistically significant decrease in overall survival among patients with elevated EphB4 and EphrinB2 expression (P < .001).

CONCLUSIONS

EphB4 and EphrinB2 overexpression is associated with poor overall survival in patients with HNSCC. Our results are the first to demonstrate an association between decreased survival and elevated expression of the receptor tyrosine kinase EphB4 and its ligand EphrinB2, suggesting that EphB4 and EphrinB2 may be used as biomarkers to predict prognosis and as targets in future HNSCC therapies.

Associations between bovine, human, and raw milk, and beef isolates of non-O157 Shiga toxigenic Escherichia coli within a restricted geographic area of the United States

A survey for Shiga toxigenic Escherichia coli in raw milk and beef was conducted within a defined geographic region of the United States. Prevalence rates based on detection of Shiga toxin gene (stx) were 36% for retail beef, 23% for beef carcasses, and 21% for raw milk samples, which were significantly higher than were Shiga toxigenic E. coli isolation rates of 7.5, 5.8, and 3.2%, respectively. Seasonal prevalence differences were significant for stx positivity among ground beef and milk samples. Distribution of stx subtypes among isolates varied according to sample type, with stx1 predominating in milk, stx2 on carcasses, and the combination of both stx1 and stx2 in beef. Ancillary virulence markers eae and ehx were evident in 23 and 15% of isolates, respectively. Pulsed-field gel electrophoresis demonstrated associations between food isolates and sympatric bovine fecal, and human clinical isolates. These data demonstrate that non-O157 Shiga toxigenic E. coli is present in the food chain in the Pacific Northwest, and its risk to health warrants critical assessment.

Use of AlloDerm Implant to Improve Cosmesis after Parotidectomy

We evaluated the effectiveness and practicality of using AlloDerm, an acellular human dermal matrix graft, as an interpositional barrier in an attempt to improve the appearance of the surgical defect created by parotidectomy. We performed AlloDerm reconstruction in a series of 10 patients, and we found that normal contour was satisfactorily restored in all 10. We conclude that the use of an AlloDerm implant is a low-risk, practical option for repairing the surgical defect in postparotidectomy patients.

Use of AlloDerm implant to improve cosmesis after parotidectomy

We evaluated the effectiveness and practicality of using AlloDerm, an acellular human dermal matrix graft, as an interpositional barrier in an attempt to improve the appearance of the surgical defect created by parotidectomy. We performed AlloDerm reconstruction in a series of 10 patients, and we found that normal contour was satisfactorily restored in all 10. We conclude that the use of an AlloDerm implant is a low-risk, practical option for repairing the surgical defect in postparotidectomy patients.

Management of a type II nasoethmoid orbital fracture and near-penetration of the intracranial cavity with transnasal canthopexy

Nasoethmoid orbital fractures are perhaps the most complicated aspect of craniomaxillofacial trauma. Involvement of the medial canthal tendon markedly increases the complexity of the repair. We report a case of type II nasoethmoid orbital fracture in a 32-year-old man that was managed without formal medial canthal tendon repair; instead, we used open reduction and internal fixation of the central fragment and the nasoethmoid complex. However, during the immediate postoperative period, we noted anterior and inferior displacement of the medial canthus. We took the patient back to the operating room to address the detachment. Revision surgery was successful, and at the 6-month follow-up, his medial canthi were completely symmetrical in all dimensions. We describe our intraoperative technique and measures to prevent complications that can help the surgeon intraoperatively. We also discuss an important point that has not been adequately addressed in the literature to date--that is, the fact that the use of the frontoethmoid suture line and the anterior ethmoid artery as a guide to the skull base can be inaccurate. Problems associated with this inaccuracy can be avoided by carefully reviewing preoperative computed tomography, which can help keep the surgeon from entering the intracranial cavity while fixing the medial canthal tendon during transnasal canthal repair.

Circles of prominence: a new theory on facial aesthetics

OBJECTIVE

To elucidate key elements of facial aesthetics through a new hypothesis called the circles of prominence.

DESIGN

In this subjective survey, 32 persons in the medical field rated frontal-view photographs of 20 subjects in 5 categories on a 0-to-100 scale, 0 representing the most unaesthetic rating, 100, the most aesthetically pleasing. The study was conducted in an academic setting, and the subject photographs were of 9 women (aged 27-65 years) from a clinical setting and 11 women whose pictures appeared in entertainment magazines. Each subject's eyes, nose, mouth, and chin were subjectively rated for their aesthetic quality. A general rating was also given for the subject's face as a whole. The subject's faces were then analyzed and measured based on the circles of prominence theory. A total of 52 measurements were chosen for the analysis. All raters' numbers for each anatomic unit and the face in general for each subject were averaged. The theoretical measurements were also averaged for each unit. The percentage of the ideal for the face in general was calculated based on weighted averages of the measurements from the individual units of each subject. The Wilcoxon signed-rank test was used to determine whether a significant difference existed between the raters' averages and the averages measured based on the facial analysis. Spearman rank coefficient correlation was used to determine if a significant correlation existed between those means.

RESULTS

We set statistical significance at P<or=.05 and found that the mean ratings of 11 of the 20 raters for the face in general were not significantly different from the measured means based on the the circles of prominence theory. There was a significant correlation between the raters' means and the measured percentages of the ideal for all units and the face in general based on the Spearman rank test.

CONCLUSIONS

Although the statistical analysis showed that many of the raters' subjective averages were significantly different from the averages calculated on the circles of prominence theory, the trends for those averages showed that the theory has meaningful validity in assessing facial aesthetics. The measured average ratings based on the theoretical calculations were higher than the subjectively rated averages. This was especially true for the photographs of clinical subjects and might be the cumulative result of multiple measured deviations from what is most aesthetically pleasing, thus creating an impact greater than the sum of its parts on the observer's subjective interpretation. The possible synergistic effects of multiple deviations for each anatomic unit or the face in general might have resulted in the much poorer subjective ratings than what the equally weighted, linearly determined measurements could analyze.

The association between elevated EphB4 expression, smoking status, and advanced-stage disease in patients with head and neck squamous cell carcinoma

OBJECTIVE

To examine the expression of EphB4 in tumor tissue, surrounding normal tissue, and metastatic lymph node in patients with head and neck squamous cell carcinoma (HNSCC) and to evaluate its association with disease stage and smoking.

DESIGN

A retrospective study.

SETTING

University of Southern California-University Hospital, University of Southern California and Los Angeles County Medical Center, and Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles.

PATIENTS

Forty-eight patients with different stages of HNSCC (I-IV) were enrolled into this study. Staging was based on the staging system of the American Joint Committee on Cancer.

MAIN OUTCOME MEASURES

EphB4 expression in tumor tissue, surrounding normal tissue, and metastatic lymph node was evaluated by immunohistochemical analysis, Western blot, and real-time polymerase chain reaction. EphB4 expression was then compared between patients based on disease stage and smoking status.

RESULTS

EphB4 expression was detected in all tumor specimens and metastatic lymph nodes of patients with HNSCC, but expression levels were higher in the metastatic lymph nodes. There was a statistically significantly higher mean EphB4 protein expression and EphB4 gene amplification in patients with advanced disease (stage III or IV) vs patients with initial disease (stage I or II) and in smokers vs nonsmokers.

CONCLUSIONS

Overexpression of EphB4 is associated with advanced stages of HNSCC as well as with patients who smoke. These data are the first to demonstrate the association of EphB4 with advanced stages of disease and smoking in HNSCC and hence provide a strong rationale for targeting EphB4 for HNSCC therapies.

Fibrin Glue in Thyroid and Parathyroid Surgery: Is Under-Flap Suction Still Necessary?

The introduction of fibrin sealants has brought into question the necessity of routinely placing suction drains. We conducted a retrospective study to determine whether fibrin sealants are comparable to traditional drains in terms of length of hospital stay and hematoma prevention. We evaluated 124 patients who had undergone thyroidectomy and 47 patients who had undergone parathyroidectomy. Of these, 22 thyroid surgery patients and 10 parathyroid surgery patients had their incisions closed without a drain after the application of fibrin glue. We found that the use of fibrin glue resulted in a statistically significant decrease in the length of hospital stay following both types of surgery (p = 0.033 and p = 0.022, respectively). Two hematomas in the drain group required immediate surgical evacuation; in both of these patients, the suction was clotted and ineffective. One minor hematoma occurred in the fibrin glue group, and it was opened at the bedside 24 hours after surgery. We conclude that fibrin sealants offer a comparative advantage over under-flap suction in both thyroid and parathyroid surgery. Also, fibrin glue is less expensive, and its use obviates the discomfort felt by patients when a drain is removed.

Platelet-Rich Plasma in Endoscopic Sinus Surgery

The author designed a study to assess the healing properties of platelet-rich plasma (PRP) after endoscopic sinus surgery in 30 patients with bilateral and symmetrical chronic rhino sinusitis that was refractory to medical management. At the conclusion of each operation, PRP was introduced into the middle meatus of a randomly chosen side, while the other side was treated normally and served as a control. Patients were followed until both sides healed. After 13 operations, follow-up evaluations demonstrated no benefit to the use of PRP, and the study was terminated early. In general, both sides healed quickly and uneventfully as expected. There appears to be no advantage to the use of PRP in endoscopic sinus surgery.

Fibrin glue in thyroid and parathyroid surgery: is under-flap suction still necessary?

The introduction of fibrin sealants has brought into question the necessity of routinely placing suction drains. We conducted a retrospective study to determine whether fibrin sealants are comparable to traditional drains in terms of length of hospital stay and hematoma prevention. We evaluated 124 patients who had undergone thyroidectomy and 47 patients who had undergone parathyroidectomy. Of these, 22 thyroid surgery patients and 10 parathyroid surgery patients had their incisions closed without a drain after the application of fibrin glue. We found that the use of fibrin glue resulted in a statistically significant decrease in the length of hospital stay following both types of surgery (p = 0.033 and p = 0.022, respectively). Two hematomas in the drain group required immediate surgical evacuation; in both of these patients, the suction was clotted and ineffective. One minor hematoma occurred in the fibrin glue group, and it was opened at the bedside 24 hours after surgery. We conclude that fibrin sealants offer a comparative advantage over under-flap suction in both thyroid and parathyroid surgery. Also, fibrin glue is less expensive, and its use obviates the discomfort felt by patients when a drain is removed.

Platelet-rich plasma in endoscopic sinus surgery

The author designed a study to assess the healing properties of platelet-rich plasma (PRP) after endoscopic sinus surgery in 30 patients with bilateral and symmetrical chronic rhinosinusitis that was refractory to medical management. At the conclusion of each operation, PRP was introduced into the middle meatus of a randomly chosen side, while the other side was treated normally and served as a control. Patients were followed until both sides healed. After 13 operations, follow-up evaluations demonstrated no benefit to the use of PRP, and the study was terminated early. In general, both sides healed quickly and uneventfully as expected. There appears to be no advantage to the use of PRP in endoscopic sinus surgery.

Management of frontal sinus fractures

PURPOSE OF REVIEW

This review summarizes the contemporary management of frontal sinus fractures.

RECENT FINDINGS

Recent additions to the armamentarium of the facial trauma surgeon include bioresorbable plates and screws, and attempts to use endoscopic techniques when feasible.

SUMMARY

The basic principles of frontal sinus fracture management remain the same. New approaches and new instruments help make repair easier, safer, and more cosmetically acceptable.

Langerhans’ Cell Histiocytosis: Current Trends and the Role of the Head and Neck Surgeon

Langerhans’ cell histiocytosis (LCH)—once called histiocytosis X— is a complex reticuloendothelial disease that often involves the head and neck. We discuss the current nomenclature of this disease and review its pathologic and clinical characteristics, with particular emphasis on the role of the head and neck surgeon. LCH can be challenging to diagnose, and the otolaryngologist must be familiar with its varied presentations. Because LCH usually responds well to medical therapy and extensive resection can easily cause more morbidity than the disease itself, a minimalist approach to treatment usually provides the best outcome. We also discuss the case of a 9-month-old girl with LCH who presented with aggressive head and neck disease.

Langerhans' cell histiocytosis: current trends and the role of the head and neck surgeon

Langerhans' cell histiocytosis (LCH)--once called histiocytosis X--is a complex reticuloendothelial disease that often involves the head and neck. We discuss the current nomenclature of this disease and review its pathologic and clinical characteristics, with particular emphasis on the role of the head and neck surgeon. LCH can be challenging to diagnose, and the otolaryngologist must be familiar with its varied presentations. Because LCH usually responds well to medical therapy and extensive resection can easily cause more morbidity than the disease itself, a minimalist approach to treatment usually provides the best outcome. We also discuss the case of a 9-month-old girl with LCH who presented with aggressive head and neck disease.

Squamous Cell Carcinoma Arising in a Second Branchial Cleft Cyst

The existence of primary branchiogenic carcinoma is controversial. In 1950, Martin et al. established four criteria for the diagnosis of primary branchiogenic carcinoma. In 1989, Khafif et al. proposed new criteria, which are currently most recognized in the literature. A pathologic description of the surgical specimen is analyzed and compared with a critical review of the literature. A case is presented in which imaging established the diagnosis of a benign second branchial cleft cyst 2 years prior to the diagnosis of a branchiogenic carcinoma in the same cyst. This cyst was resected and was found to have squamous cell carcinoma arising from the benign epithelium. This case satisfies the histologic criteria established by Martin and Khafif for a primary branchiogenic carcinoma arising in a previously benign second branchial cleft cyst.

Longitudinal study of fecal shedding of Escherichia coli O157:H7 in feedlot cattle: predominance and persistence of specific clonal types despite massive cattle population turnover

Identification of the sources and methods of transmission of Escherichia coli O157:H7 in feedlot cattle may facilitate the development of on-farm control measures for this important food-borne pathogen. The prevalence of E. coli O157:H7 in fecal samples of commercial feedlot cattle in 20 feedlot pens between April and September 2000 was determined throughout the finishing feeding period prior to slaughter. Using immunomagnetic separation, E. coli O157:H7 was isolated from 636 of 4,790 (13%) fecal samples in this study, with highest prevalence earliest in the feeding period. No differences were observed in the fecal or water trough sediment prevalence values of E. coli O157:H7 in 10 pens supplied with chlorinated drinking water supplies compared with nonchlorinated water pens. Pulsed-field gel electrophoresis of XbaI-digested bacterial DNA of the 230 isolates obtained from eight of the pens revealed 56 unique restriction endonuclease digestion patterns (REDPs), although nearly 60% of the isolates belonged to a group of four closely related genetic subtypes that were present in each of the pens and throughout the sampling period. The other REDPs were typically transiently detected, often in single pens and on single sample dates, and in many cases were also closely related to the four predominant REDPs. The persistence and predominance of a few REDPs observed over the entire feeding period on this livestock operation highlight the importance of the farm environment, and not necessarily the incoming cattle, as a potential source or reservoir of E. coli O157:H7 on farms.

Correlation between geographic distance and genetic similarity in an international collection of bovine faecal Escherichia coli O157:H7 isolates

Evidence from epidemiological and molecular studies of bovine Escherichia coli O157:H7 suggests that strains are frequently transmitted across wide geographic distances. To test this hypothesis, we compared the geographic and genetic distance of a set of international bovine Escherichia coli O157:H7 isolates using the Mantel correlation. For a measure of genetic relatedness, pulsed-field gel electrophoresis of six different restriction enzyme digests was used to generate an average Dice similarity coefficient for each isolate pair. Geographic distance was calculated using latitude and longitude data for isolate source locations. The Mantel correlation between genetic similarity and the logarithm of geographic distance in kilometers was -0.21 (P<0.001). The low magnitude of the Mantel correlation indicates that transmission over long distances is common. The occurrence of isolates from different continents on the same cluster of the dendrogram also supports the idea that Escherichia coli O157:H7 strains can be transferred with considerable frequency over global distances.

Cerebrospinal fluid rhinorrhea: diagnosis and treatment

The diagnosis of cerebrospinal fluid rhinorrhea is usually straightforward. It need not be. The location of the leak is usually clear. It need not be. With modern rigid endoscopes, the repair is usually technically straightforward. It need not be. When a cerebrospinal fluid leak is suggested and the fluid is collectable, testing for beta 2 transferrin will usually settle the issue. The site of the leak is usually obvious. If it is not, but the leak is active, an isoview computed tomography scan will reveal it. Once the leak is established and located, the experienced endoscopic sinus surgeon can generally repair it using the instruments and materials currently available.

Middle turbinate resection: impact on outcomes in endoscopic sinus surgery

There is considerable controversy concerning the advisability and efficacy of middle turbinate resection in endoscopic sinus surgery. Some have reported that it causes an increase in the incidence of frontal sinusitis, while others have found no such association. Surprisingly, in a 35-year review of turbinate surgery literature, Clement and White did not find a single prospective study of turbinate surgery. In this article, we briefly report our prospective study of middle turbinate resection during endoscopic sinus surgery. Our findings lead us to believe that middle turbinate resection has no deleterious effects on the results of endoscopic sinus surgery.

Fibrin Glue Prevents Complications of Septal Surgery: Findings in a Series of 100 Patients

Septal surgery is a common type of otolaryngology–head and neck surgery, and it is often performed in combination with other procedures. Complications of septal surgery include bleeding, hematoma, infection, abscess formation, and perforation. The most common methods of preventing these complications are the use of nasal packing, septal splints, and quilting sutures as a means of approximating the septal flaps. In this article, we describe our study of an alternate method: fibrin glue. We used fibrin glue as the sole method of approximating flaps on 100 consecutive septal surgery patients. Our results indicate that the use of fibrin glue is effective, rapid, comfortable, and inexpensive.

Fibrin glue prevents complications of septal surgery: findings in a series of 100 patients

Septal surgery is a common type of otolaryngology--head and neck surgery, and it is often performed in combination with other procedures. Complications of septal surgery include bleeding, hematoma, infection, abscess formation, and perforation. The most common methods of preventing these complications are the use of nasal packing, septal splints, and quilting sutures as a means of approximating the septal flaps. In this article, we describe our study of an alternate method: fibrin glue. We used fibrin glue as the sole method of approximating flaps on 100 consecutive septal surgery patients. Our results indicate that the use of fibrin glue is effective, rapid, comfortable, and inexpensive.

Transnasal endoscopic closure of cerebrospinal fluid leaks

OBJECTIVES/HYPOTHESIS

To demonstrate an effective method for transnasal endoscopic closure of anterior skull base fistulas that does not involve lumbar drains or fat packing.

STUDY DESIGN

Retrospective.

METHODS

We reviewed the charts of 36 patients who had 37 anterior skull base defects that were repaired endoscopically between 1993 and 2001.

RESULTS

Thirty-three defects were successfully closed on the first attempt. Three were successfully closed on the second attempt. One large defect was repaired by neurosurgery after a failed endoscopic attempt. Our results are similar to those of other published series.

CONCLUSION

Our method is effective and does not require adjuvant procedures or prolonged hospital stays.

Use of AlloDerm implant to prevent frey syndrome after parotidectomy

OBJECTIVE

To evaluate the effectiveness of AlloDerm, an acellular human dermal matrix graft, as an interpositional physical barrier to prevent the development of Frey syndrome after parotidectomy.

METHODS

The 30 patients included in the study were divided into 3 groups of 10. In group 1 (study group), patients underwent superficial parotidectomy with placement of an AlloDerm graft (LifeCell Corp, Branchburg, NJ). In group 2 (control) patients had superficial parotidectomy without placement of an interpositional barrier. In group 3 (control), patients underwent deep-plane rhytidectomy without disruption of the parotid fascia. All were evaluated after 1 year and questioned about gustatory sweating. Subjective assessment of Frey syndrome was documented when patients experienced gustatory sweating, even if they were not perturbed by the symptom. The Minor starch-iodine test was performed in each patient for objective assessment.

RESULTS

The incidence of subjective Frey syndrome was observed in 1 patient in group 1 and 5 patients in group 2. The incidence of objective Frey syndrome was noted in 2 patients in group 1 and 8 patients in group 2. Both subjective and objective differences in incidence of Frey syndrome were statistically significant. None of the group 3 patients had subjective or objective Frey syndrome. Two patients in group 1 and 3 patients in group 2 developed a transient seroma or sialocele that resolved with conservative management.

CONCLUSION

The use of AlloDerm graft as an interpositional barrier improves parotidectomy outcome by reducing the incidence of Frey syndrome.

Partial laryngectomy with imbrication laryngoplasty for glottic carcinoma

BACKGROUND

Treatment options for unilateral glottic carcinoma include radiation therapy, partial laryngectomy, and endoscopic cordectomy. We used partial laryngectomy with imbrication laryngoplasty (PLIL) for definitive treatment with curative intent in a select group of patients.

STUDY DESIGN

Retrospective multicenter review of 24 patients treated with PLIL. Data collection included demographics, tumor characteristics, time to decannulation, time to oral food intake, local control, survival, voice result as judged by the physician, voice result as judged by the patient, and patient satisfaction.

SETTING

Five academic medical centers.

METHODS

PLIL includes a composite resection of the entire vocal fold, with its ligament, muscle, adjacent paraglottic tissues, and the adjacent block of thyroid cartilage. A neocord is reconstructed by imbricating the remaining thyroid cartilage strips and covering them with a false vocal fold flap.

RESULTS

A total of 24 patients (T1, n = 13; T2, n = 10; and T3, n = 1) underwent PLIL. Median time to decannulation was 4 days, and median time to oral food intake was 5 days. Clear margins were achieved in 23 patients (96%). Follow-up ranged from 1 to 11 years (median duration of follow-up, 5.5 years). In the patients who had clear margins at the initial surgery, the rate of overall disease control was 100%. Voice quality was judged by the physician as good or excellent in 100% of the patients who underwent PLIL, and as better than typical hemilaryngectomy in 23 patients (96%). Twenty-three patients (96%) were satisfied with their voice quality.

CONCLUSIONS

PLIL provides us with a single modality curative approach to unilateral glottic carcinoma. It also provides rapid recovery of oral and/or nasal airway and swallowing, excellent voice quality, and a disease-control rate similar to or better than other treatment modalities.

Use of AlloDerm for coverage of radial forearm free flap donor site

OBJECTIVES

To evaluate and discuss the role of acellular human dermal matrix (AlloDerm, LifeCell Corp., Branchburg, NJ) graft for coverage of radial forearm free flap donor site.

STUDY DESIGN

Prospective, nonrandomized study.

METHODS

Fifty-two consecutive patients underwent harvest of 52 radial forearm fasciocutaneous free flaps. All 52 donor sites were covered by AlloDerm graft. Split-thickness skin graft was not used to reinforce the acellular dermal graft in the series. Clinical phases of healing, duration of healing, and donor site complications were studied.

RESULTS

No donor site complications except seroma formation in five patients was noted. This was treated by conservative measures. Full range of hand motion was allowed in 3 days. Complete healing occurred within 8 to 12 weeks. Scar contracture after complete healing was minimum in all patients. Range of motion of the hand and fingers during flexion, extension, supination, and pronation was identical on the operated and nonoperated sides.

CONCLUSION

AlloDerm graft is a viable alternative to split-thickness skin graft for coverage of the radial forearm free flap donor site.

Escherichia coli O157:H7 infection of calves: infectious dose and direct contact transmission

Cattle are considered to be a reservoir host of Escherichia coli O157:H7 and contaminated foods of bovine origin are important vehicles of human infection. In this study, the susceptibility of calves to experimental E. coli O157:H7 infection following low oral exposures was determined. Two of 17 calves exposed to very low (< 300 c.f.u.) doses, and 3 of 4 calves exposed to low (< 10,000 c.f.u.) doses, subsequently excreted the challenge strains in their faeces. All calves (n = 12) sharing isolation rooms with calves that excreted the challenge strain in their faeces similarly began faecal excretion of the same strains within 21 days or less. The identity between the challenge strains and the strains excreted in calf faeces was confirmed by restriction digestion electrophoretic patterns using pulsed field gel electrophoresis. Calves shed E. coli O157:H7 in their faeces after very low dose exposures at concentrations ranging from < 30 to > 10(7) c.f.u./g, and for durations similar to the values previously reported for calves challenged by larger doses. The susceptibility of calves to infection following very low exposures or direct contact with infected calves has important implications for programmes for pre-harvest control of this agent.

Endonasal approaches for sinonasal and nasopharyngeal tumors

This article reviews the published literature on endonasal approaches for sinonasal and nasopharyngeal tumors and synthesizes this information with the author's personal experience into a rational approach to patients with the following disorders: inverted papilloma, adenocarcinoma, hemangioendothelioma, olfactory neuroblastoma, carcinosarcoma, squamous cell carcinoma, melanoma, juvenile angiofibroma, chordoma, and chondrosarcoma.

Livestock drinking water microbiology and the factors influencing the quality of drinking water offered to cattle

The microbial quality of livestock drinking water was evaluated in 473 cattle water troughs located at 99 different cattle operations. The mean log10-transformed coliform and Escherichia coli concentrations per milliliter of trough water were 1.76 +/- 1.25 (SD) and 0.98 +/- 1.06 (SD), respectively. The degree of E. coli contamination was positively associated with the proximity of the water trough to the feedbunk, protection of the trough from direct sunlight, lower concentrations of protozoa in the water, and warmer weather. Salmonella sp. were isolated from 2/235 (0.8%) troughs and shigatoxigenic-E. coli O157 was recovered from 6/473 (1.3%) troughs. Four experimental microcosms simulating cattle water troughs were used to further evaluate the effects of protozoal populations on the survival of E. coli O157 in cattle water troughs. Escherichia coli O157 of bovine fecal origin proliferated in all microcosms. Reduction of protozoal populations by treatment with cycloheximide was associated with increased persistence of E. coli O157 concentrations in the microcosms. Water troughs are a major source of exposure of cattle to enteric bacteria, including a number of foodborne pathogens, and this degree of bacterial contamination appeared to be associated with potentially controllable factors.