Mitochondrial DNA quantity increases with histopathologic grade in premalignant and malignant head and neck lesions

PURPOSE

Mitochondria are highly susceptible to oxidative damage. Although mitochondrial function decreases with oxidative damage, overall mitochondrial DNA (mtDNA) content increases to compensate for general mitochondrial dysfunction. We performed quantitative polymerase chain reaction for genes specific to mitochondrial and nuclear genomes to investigate relative mitochondrial abundance in a spectrum of dysplastic head and neck lesions.

EXPERIMENTAL DESIGN

DNA from mild, moderate, and severe dysplasias, as well as invasive tumors and normal mucosal cells, was extracted. Using quantitative polymerase chain reaction, mitochondrial to nuclear DNA ratios were determined by quantification of cytochrome c oxidase subunit 1 (CoxI) and beta-actin genes.

RESULTS

Mean CoxI/beta-actin DNA ratios for mild, moderate, and severe premalignant lesions were 0.0529, 0.0607, and 0.1021, respectively. The mean ratio for the normal mucosal cells contained in saliva was 0.0537, whereas the mean ratio for tumors was 0.1667. As a whole, our experimental model demonstrated significance (P = 0.0358). Comparisons between individual categories showed borderline significance when compared with the normal group, with P values of 0.0673, 0.0747, and 0.0824 for moderate and severe dysplasia and invasive tumor, respectively.

CONCLUSIONS

Head and neck squamous cell carcinomas arise through premalignant intermediates and may be merely morphologic manifestations of accumulated genetic alterations. In keeping with this molecular tumor progression model, our study shows that mtDNA increases according to histopathologic grade, a phenomenon that may be a feedback mechanism that compensates for a generalized decline in respiratory chain function. Therefore, high mtDNA content may be another marker of genetic alteration, a measure of relative DNA injury, and a surrogate measure of histopathologic grade.

Elevated body mass index and risk of postoperative CSF leak following transsphenoidal surgery

OBJECT

Postoperative CSF leakage can be a serious complication after a transsphenoidal surgical approach. An elevated body mass index (BMI) is a significant risk factor for spontaneous CSF leaks. However, there is no evidence correlating BMI with postoperative CSF leak after transsphenoidal surgery. The authors hypothesized that patients with elevated BMI would have a higher incidence of CSF leakage complications following transsphenoidal surgery.

METHODS

The authors conducted a retrospective review of 121 patients who, between August 2005 and March 2010, underwent endoscopic endonasal transsphenoidal surgeries for resection of primarily sellar masses. Patients requiring extended transsphenoidal approaches were excluded. A multivariate statistical analysis was performed to investigate the association of BMI and other risk factors with postoperative CSF leakage.

RESULTS

In 92 patients, 96 endonasal endoscopic transsphenoidal surgeries were performed that met inclusion criteria. Thirteen postoperative leaks occurred and required subsequent treatment, including lumbar drainage and/or reoperation. The average BMI of patients with a postoperative CSF leak was significantly greater than that in patients with no postoperative CSF leak (39.2 vs 32.9 kg/m(2), p = 0.006). Multivariate analyses indicate that for every 5-kg/m(2) increase in BMI, patients undergoing a transsphenoidal approach for a primarily sellar mass have 1.61 times the odds (95% CI 1.10-2.29, p = 0.016, by multivariate logistic regression) of having a postoperative CSF leak.

CONCLUSIONS

Elevated BMI is an independent predictor of postoperative CSF leak after an endonasal endoscopic transsphenoidal approach. The authors recommend that patients with BMI greater than 30 kg/m(2) have meticulous sellar reconstruction at surgery and close monitoring postoperatively.

Micropatterned methacrylate polymers direct spiral ganglion neurite and Schwann cell growth

Significant advances in the functional outcomes achieved with cochlear implantation will likely require tissue-engineering approaches to improve the neural prosthesis interface. One strategy is to direct spiral ganglion neuron (SGN) axon growth in a highly organized fashion to approximate or contact stimulating electrodes. Here we assessed the ability of micropatterns induced by photopolymerization in methacrylate (MA) polymer systems to direct cultured neonatal rat SGN neurite growth and alignment of SG Schwann cells (SGSCs). SGN survival and neurite length were comparable among various polymer compositions. Remarkably, there was no significant difference in SGN survival or neurite length between laminin and non-laminin coated MA polymer substrates, suggesting high biocompatibility with SG tissue. Micropatterning with photopolymerization generated microchannels with a ridge periodicity of 50 μm and channel depths of 0.6-1.0 μm. SGN neurites grew within the grooves of the microchannels. These topographies strongly induced alignment of dissociated SGN neurites and SGSCs to parallel the pattern. By contrast, fibroblasts failed to align with the micropattern suggesting cell specific responses to topographical cues. SGN neurites extending from explants turned to parallel the pattern as they encountered the microchannels. The extent of turning was significantly correlated with angle at which the neurite initially encountered the pattern. These results indicate that SGN neurites respond to microtopographical features and that these features can be used to direct neurite growth in a highly organized fashion.

Endoscopic Approach for Pituitary Surgery Improves Rhinologic Outcomes

Objectives:

We hypothesized that the endoscopic approach to pituitary surgery improves rhinology-specific quality of life and has satisfactory tumor outcomes compared with the open approach.

Methods:

Cases of pituitary surgery from the Department of Neurosurgery database included an inception cohort of all patients who had endoscopic procedures and consecutive patients who had open procedures between January 1998 and February 2008. The Sino-Nasal Outcome Test-22 was mailed.

Results:

Since January 1998, 71 endoscopic and 122 open pituitary surgeries had been performed. The mean follow-up was longer for open procedures (49.3 months) than for endoscopic procedures (18.8 months). Recurrence was more common after open surgery (28.4%) than after endoscopic surgery (18.2%; p = 0.219). The most common diagnosis was macroadenoma (77.1% of endoscopic procedures and 93.4% of open procedures). The mean hospital stay was shorter for endoscopic procedures (4.1 days) than for open procedures (6.0 days; p < 0.001). Of patients who presented with visual deterioration, 53.8% with endoscopic surgery and 46.7% with open surgery had improvement. Among patients with normal preoperative hormonal function, 27.5% of patients in the endoscopy group and 29.4% of patients in the open group required medication for more than 2 months after surgery. Complications occurred in 33.3% of endoscopic procedures and 43.4% of open procedures. Cerebrospinal fluid leaks were more common in the endoscopy group (p = 0.035), and diabetes insipidus lasting more than 30 days was more common in the open group (p = 0.017). The mean Sino-Nasal Outcome Test-22 score was lower for patients in the endoscopy group (20.4) than for those in the open group (23.2; p = 0.41). Patients in the endoscopy group had a significantly lower rhinology-specific mean score (6.5) than did patients in the open group (9.2; p = 0.03).

Conclusions:

The endoscopic approach to pituitary surgery offers tumor outcomes comparable to those of open surgery, with no greater incidence of complications and an improved rhinology-specific quality of life.

The Use of Frozen Section in the Early Diagnosis of Acute Invasive Fungal Sinusitis

Objectives

Acute invasive fungal sinusitis (AIFS) remains a significant cause of morbidity and mortality in the immunocompromised patient population. Early diagnosis is key to improving patient outcomes. Frozen section biopsies have been shown to decrease time to diagnosis when compared with permanent pathology. However, its accuracy has not been adequately described in the literature, specifically in regard to AIFS. The aim of this study is to evaluate the statistical diagnostic accuracy of frozen sections and to review the etiology, clinical presentation, and current diagnostic protocols in management of AIFS.

Study Design

Case series with chart review.

Setting

Tertiary referral center.

Subjects and Methods

Retrospective review included 67 pathologic records in Co-Path, with search criteria including invasive fungal, clinical history, frozen section, and final diagnosis between the dates of 2006 and 2015.

Results

Sixty-seven cases were reviewed per the search criteria in Co-Path. Of these, 31 met further criteria of having had frozen section analysis. Variables such as sensitivity, specificity, positive predictive value, and negative predictive value were assessed. All 21 positive frozen sections correlated with positive permanent pathology, giving a positive predictive value of 100%. Frozen section biopsies were 87.5% sensitive and 100% specific.

Conclusion

Early diagnosis of AIFS has been shown to decrease morbidity and mortality. Frozen section biopsies remain key in obtaining an early diagnosis among patients with a high clinical suspicion for invasive fungal sinusitis. Frozen section biopsies positive for invasive fungal pathology were universally consistent with definitive diagnosis.

The Burden of Asthma and Allergic Rhinitis: Epidemiology and Health Care Costs

Allergic rhinitis affects up to 78% of people with asthma, and asthma occurs in 38% of people with allergic rhinitis. Asthma has a prevalence of 8.7% among adults and 6.2% among children and accounts for $50 billion in medical costs and $32 billion in indirect and mortality costs in the United States, respectively. Allergic rhinitis occurs in 5% to 15% of people in the United States. Allergic rhinitis also accounts for a significant health care cost burden, predominantly in terms of indirect costs related to reduced quality of life and presenteeism.

Malpractice in Treatment of Sinonasal Disease by Otolaryngologists

Objective

Sinonasal disease is a common condition treated by otolaryngologists. Malpractice in this area is the most common litigation faced by otolaryngologists. This study analyzes malpractice in the treatment of sinonasal disease.

Study Design

Case series, review of legal records.

Setting

Legal databases.

Subjects and Methods

Using 2 different computerized legal databases, the phrase medical malpractice was searched with terms related to sinonasal disease involving court cases in the past 10 years (2004-2013), yielding 26 cases. The cases were analyzed for pertinent data regarding plaintiffs, presenting complaint, practice setting, type of malpractice, resulting injury, result of verdict, and amount of reward or settlement.

Results

Chronic sinusitis (42%) was the most common presenting symptom. Many cases included multiple types of alleged malpractice, with the most common being negligent technique (38%) and lack of informed consent (27%). The most common alleged injuries included cerebrospinal fluid leak, meningitis, nasal obstruction, and orbital trauma. Defendants prevailed in 13 of 18 cases in which outcomes were known, with mean award of $225,000 and mean settlement of $212,500. The cases won by plaintiffs were all in a private practice setting.

Conclusion

Otolaryngologists should be aware of the causes of malpractice litigation as it relates to treatment of sinonasal disease. Lack of informed consent continues to be a common allegation, and surgeons should ensure complete informed consent is obtained and well documented. A unified and complete database of medical malpractice cases is needed to allow for further analysis of specialty-related claims.

Quality-of-life outcomes following multiple revision endoscopic sinus surgery

BACKGROUND

Although overall success rates of endoscopic sinus surgery (ESS) range from 76.0% to 97.5%, ongoing or recurrent symptoms may require revision surgery. Previous studies have shown that revision status is not a predictor of outcomes following ESS, but no distinction has been made between patients undergoing a single or multiple revision procedure. The purpose of this study was to compare quality-of-life (QOL) outcomes and associated risk factors of patients undergoing primary ESS, first-revision ESS, and multiple-revision ESS (second, third, fourth, and fifth or more).

METHODS

Demographic and risk factor data were collected from a multi-institutional prospective cohort of 552 patients undergoing primary (n = 221) and revision (n = 331) ESS for chronic rhinosinusitis. Mean preoperative Lund-Mackay computed tomography (CT) scan scores, pre-/postoperative Lund-Kennedy endoscopy scores, Rhinosinusitis Disability Index (RSDI), and Chronic Sinusitis Survey (CSS) outcomes were analyzed using chi-square testing and 1-way analysis of variance (ANOVA).

RESULTS

Mean preoperative RSDI and CSS measurements were similar between primary ESS and all revision groups. Significantly more primary ESS patients met rigorous criteria for a minimally important difference in QOL improvement than revision ESS patients (73.8% vs 61.6%; p = 0.003). There was no significant difference in mean QOL improvement between revision groups (all p ≥ 0.174) even when comparing patients with and without nasal polyposis (all p ≥ 0.312).

CONCLUSION

Generally, patients undergoing primary, first-revision, and multiple-revision ESS showed postoperative improvement in QOL scores. More primary ESS patients had significant QOL improvement compared to revision ESS patients. There were no significant differences in mean QOL improvement between any of the individual revision groups. © 2012 ARS-AAOA, LLC.

Arrested Pneumatization of the Sphenoid: A Normal Variant Easily Mistaken for a Pathologic Entitity

Objectives:

(1) Describe the radiologic findings of arrested pneumatization of the sphenoid sinus. (2) Recognize this benign developmental variant to prevent unnecessary surgical intervention.

Methods:

A case series. Between November 2012 to January 2014, 8 subjects presented with radiologic findings consistent with arrested pneumatization of the sphenoid bone, a benign developmental variant. In each case, review of imaging by a neuroradiologist confirmed this diagnosis using strict criteria. This series includes all cases encountered during routine clinical practice during this time period. Charts were reviewed for demographic, clinical, and radiologic data.

Results:

In all 8 cases, arrested pneumatization of the sphenoid sinus was an incidental finding. All subjects underwent computed tomography (CT) imaging as workup for a variety of otolaryngology-related symptoms, including headache, hearing loss, facial trauma, and sinusitis. Two patients were referred after the finding of a sphenoid lesion was mistaken for a pathologic entity. Based on CT imaging, 7 subjects were recognized as having this benign developmental variant and were managed conservatively. One patient, whose imaging revealed what appeared to be an infiltrative, midline tumor of the sphenoid sinus, underwent surgical biopsy with benign results. Upon subsequent review of CT imaging at our institution, the lesion did appear to have features consistent with arrested pneumatization.

Conclusions:

Considering the frequency of identification of arrested pneumatization of the sphenoid, there is a paucity of information about this diagnosis within the otolaryngology literature. Familiarity with this entity may prevent additional costly workup or unnecessary surgical intervention.

Medical Malpractice in Sinonasal Disease: An Analysis of Litigation over the Last Ten Years

Objectives:

(1) Review past literature on medical malpractice in rhinology and sinonasal disease in the Unites States of America. (2) Analyze otolaryngology malpractice litigation related to sinonasal disease in the last 10 years. (3) Discuss ways to prevent future malpractice litigation in this area of otolaryngology.

Methods:

The study is a case series with review of court records pertaining to litigation of otolaryngologic treatment of sinonasal disease using the Westlaw and Lexis Nexis legal databases. The phrase medical malpractice was searched with terms related to sinonasal disease involving court cases in the last 10 years, yielding 26 cases. The cases were analyzed for pertinent data regarding plaintiffs, presenting complaint, practice setting, type of malpractice, resulting injury, result of verdict, and amount of reward or settlement.

Results:

Chronic sinusitis was the most common presenting symptom. Many cases included multiple types of alleged malpractice with the most common being negligent technique and lack of informed consent. The most common alleged injuries included cerebrospinal fluid leak, meningitis, nasal obstruction, and orbital trauma. Defendants prevailed in 13 of the 18 cases in which outcomes were known, with mean award of $225,000 and mean settlement of $212,500. The cases won by plaintiffs were all in a private practice setting.

Conclusions:

Otolaryngologists should be aware of the causes of malpractice litigation as it relates to treatment of sinonasal disease and ensure informed consent is obtained and well-documented. A unified and complete database of medical malpractice cases is needed to allow for further analysis of specialty-related claims.

Death-associated protein kinase promoter hypermethylation in normal human lymphocytes

A high frequency of death-associated protein kinase (DAPK) promoter hypermethylation has been noted in B-cell malignancies, head and neck cancers, and other solid tumors, and it has been used as a tumor marker in molecular detection strategies. Low levels of DAPK promoter hypermethylation, ranging from 0.003 to 1.181%, were detected in peripheral blood cells from 75 of 143 (52%) normal subjects by quantitative methylation-specific PCR (Q-MSP). In 10 of 10 selected patients, MSP amplification of a portion of the DAPK promoter followed by PCR product sequencing confirmed dense hypermethylation of the CpG island in their peripheral blood cells. Q-MSP analysis of fluorescence-activated cell-sorted peripheral blood cells from three of these patients demonstrated that a significantly greater proportion of B cells (1.074-6.026%) were DAPK hypermethylated than were T cells, monocytes, or neutrophils, which were <0.06% hypermethylated. Further analysis after sorting of one subject's B cells into IgM+, IgM-, IgG+, and IgG- subpopulations demonstrated that DAPK hypermethylation was predominantly present in the IgM- compared with IgM+ B cells (3.338% versus 0.436%). DAPK promoter hypermethylation was found in IgM- B cells in normal individuals. The same hypermethylation identified in B-cell malignancies may reflect a clonal outgrowth of B cells arising from this compartment and may indicate a susceptibility to neoplastic transformation in a subset of B cells. Normal circulating lymphocytes with DAPK promoter hypermethylation may act as confounding factors in tumor detection based on DAPK hypermethylation.

Epistaxis in COVID positive ICU patients, implications, and future interventions

PURPOSE

Epistaxis in critically ill patients may prevent the use of non-invasive ventilation and impair nasal oxygen delivery. Since the onset of COVID-19, high-flow nasal oxygen has dramatically increased. There is a paucity of literature on characteristics of epistaxis in critically ill, COVID-19 positive patients. We aimed to establish the incidence of epistaxis and identify risk factors.

MATERIALS AND METHODS

This was a retrospective observational study conducted at a large academic medical center. Chart review was performed on patients with an intensive care admission and COVID-19 diagnosis between January 2020 and May 2022. Data included epistaxis events, supplemental oxygen delivery and duration, anticoagulation, and antiplatelet therapies.

RESULTS

932 patients met study criteria. Epistaxis incidence was 7.4 %. Of those with epistaxis, 78 % were administered supplemental oxygen. For each additional day on nasal oxygen, patients were at a 7.1 % higher risk for epistaxis (p < .001). Most antiplatelet agents and therapeutic anticoagulation were not found to increase risk.

CONCLUSIONS

Nasal oxygen was a major risk factor for epistaxis in this population. Nasal hygiene is a standard regimen recommended by otolaryngologists for epistaxis. Protocolizing the inclusion of nasal hygiene measures may be an easy, inexpensive way to prevent epistaxis in this already unstable patient population.