An institutional experience in applying quality improvement measures to pituitary surgery: clinical and resource implications

OBJECTIVE

The aim of this study was to report the authors' experience developing a Lean Six Sigma clinical care pathway (CCP) for endoscopic endonasal transsphenoidal operations.

METHODS

Using Lean Six Sigma quality improvement principles-including the define, measure, analyze, improve, and control framework-the authors developed a CCP for endoscopic endonasal transsphenoidal operations, incorporating preoperative, intraoperative, and inpatient and outpatient postoperative phases of care. Efficacy and quality metrics were defined as postoperative length of stay (LOS), presentation to the emergency department (ED) or readmission within 30 days of discharge, and hospital charges. The study included all adult patients who underwent elective endoscopic endonasal resection for pituitary adenoma, Rathke's cleft cyst, craniopharyngioma, pituicytoma, or arachnoid cyst during the sampling period (April 1, 2018, to December 31, 2022).

RESULTS

Two hundred twenty-eight patients met criteria and were included; 94 were treated before and 134 were treated after implementation of the CCP. Differences between groups in age, gender, race, BMI, American Society of Anesthesiologists classification, geographic distribution, preoperative serum sodium, tumor size, adenoma functional status, and prior surgery were not significant. The mean postoperative LOS significantly decreased from 4.5 to 1.7 days following CCP implementation (p < 0.0001); LOS variability also decreased, with the standard deviation declining from 3.1 to 1.5 days. The proportion of patients discharged on postoperative day (POD) 1 significantly increased from 0% to 61.9% (p < 0.0001). Fewer than one-quarter of the patients (23.4%) were discharged by POD 2 prior to the CCP, while 88.8% of were discharged by POD 2 after CCP implementation (p < 0.0001). Rates of 30-day ED presentations or readmissions were not significantly different (2.1% vs 6.0%, p = 0.20, and 7.5% vs 6.7%, p > 0.99, respectively). Mean per-patient hospital costs declined from $38,326 to $26,289 (p < 0.0001), with an associated change in cost variability from a standard deviation of $16,716 to $12,498.

CONCLUSIONS

CCP implementation significantly improved LOS and costs of endoscopic endonasal resection, without adversely impacting postoperative ED presentations or readmissions.

Prolactinoma extension as a contributing factor in dopamine agonist-induced CSF rhinorrhea: a systematic review of the literature

BACKGROUND

Dopamine agonist-induced cerebrospinal fluid (CSF) rhinorrhea is an uncommon treatment-related complication arising in 6.1% of prolactinoma patients treated with dopamine agonists. Locally invasive prolactinomas may create CSF fistulae through formation of dural and osseous skull base defects. Tumor shrinkage secondary to dopamine agonist therapy unmasks skull base defects, thus inducing CSF rhinorrhea. In these cases, repair of the leak may be achieved through collaborative surgical intervention by rhinologists and neurosurgeons. Multiple variables have been investigated as potential contributors to the risk of CSF rhinorrhea development in medically treated prolactinoma patients, with little consensus.

OBJECTIVE

The primary aim of our study was the characterization of risk factors for CSF rhinorrhea development following dopamine agonist treatment.

METHODS

A systematic review of the literature was conducted to identify cases of CSF rhinorrhea following dopamine agonist treatment of prolactinoma. The clinical history, radiographic findings and treatment outcomes are discussed.

RESULTS

Fifty-four patients with dopamine agonist-induced CSF rhinorrhea were identified across 23 articles published from 1979 to 2019. Description of diagnostic imaging [computed tomography (CT)/magnetic resonance imaging (MRI)] was not provided for 18/54 subjects. For the 36 cases that described prolactinoma appearance on CT or MRI, invasion of the cavernous sinuses was reported in 13 (36.1%) and invasion of the sphenoid sinus was reported in 18 (50%).

CONCLUSION

Based on our systematic review, we propose that CT findings of osseous erosion of the sella or the anterior skull base may predict dopamine agonist-induced CSF rhinorrhea. We recommend obtaining a thin-slice CT of the sinuses in cases with MRI evidence of sphenoid involvement.

Orbital resection by intranasal technique (ORBIT): A new classification system for reporting endoscopically resectable primary benign orbital tumors

BACKGROUND

The Cavernous Hemangioma Exclusively Endonasal Resection (CHEER) staging system has become the gold standard for outcomes reporting in endoscopic orbital surgery for orbital cavernous hemangiomas (OCHs). A recent systematic review demonstrated similar outcomes between OCHs and other primary benign orbital tumors (PBOTs). Therefore, we hypothesized that a simplified and more comprehensive classification system could be developed to predict surgical outcomes of other PBOTs.

METHODS

Patient and tumor characteristics as well as surgical outcomes from 11 international centers were recorded. All tumors were retrospectively assigned an Orbital Resection by Intranasal Technique (ORBIT) class and stratified based on surgical approach as either exclusively endoscopic or combined (endoscopic and open). Outcomes based on approach were compared using chi-squared or Fisher's exact tests. The Cochrane-Armitage test for trend was used to analyze outcomes by class.

RESULTS

Findings from 110 PBOTs from 110 patients (age 49.0 ± 15.0 years, 51.9% female) were included in the analysis. Higher ORBIT class was associated with a lower likelihood of gross total resection (GTR). GTR was more likely to be achieved when an exclusively endoscopic approach was utilized (p < 0.05). Tumors resected using a combined approach tended to be larger, to present with diplopia, and to have an immediate postoperative cranial nerve palsy (p < 0.05).

CONCLUSION

Endoscopic treatment of PBOTs is an effective approach, with favorable short-term and long-term postoperative outcomes as well as low rate of adverse events. The ORBIT classification system is an anatomic-based framework that effectively facilitates high-quality outcomes reporting for all PBOTs.

Decision-Making in Clival Mass Lesions: Risk Factors for Malignant Disease and an Illustrative Case Example

Introduction  Clival tumors are rare and heterogeneous. Although some benign prototypical sellar lesions may present as clival tumors, the likelihood of malignant disease is higher. Here we define a novel algorithm for the workup and management of clival masses through an illustrative case of colorectal adenocarcinoma metastasis to the clivus. Methods  In this case report, the best practice guidelines for managing clival masses are described through a literature review and refined by senior author consensus. We conducted a focused systematic review to characterize the present case in the context of clival metastasis from gastrointestinal malignancy. Results  An 83-year-old woman presented with 4 weeks of headaches and blurry vision. Examination revealed partial right abducens and left oculomotor palsies. Magnetic resonance imaging (MRI) identified a large, weakly enhancing sellar and clival mass with sphenoid sinus extension. An aggressive subtotal endoscopic endonasal resection was performed with removal of all sphenoid, clival, and sellar disease without cavernous sinus wall resection. Pathology confirmed colorectal adenocarcinoma; computed tomography (CT) imaging identified an ascending colon mass with metastases to the liver and mesenteric nodes. Palliative oncologic therapies were recommended, but she elected hospice, and died 3 months after initial presentation. Gastrointestinal clival metastases are exceedingly rare among sellar and clival pathologies, with eight prior cases reported, most of which presented with diplopia from abducens nerve involvement. Conclusion  Clival masses are uncommon skull base lesions that are associated with more aggressive diseases. We present a consolidated framework for decision-making in these challenging patients, alongside an unusual case example that illustrates the importance of increased suspicion for malignant clinical entities in this setting.

Chronic cerebrospinal fluid rhinorrhea as an initial presentation of chordoma: illustrative case

BACKGROUND

Skull base chordomas are typically extradural and present with cranial nerve deficits, headache, and visual disturbances. Clival chordoma involving the dura and presenting as a spontaneous cerebrospinal fluid (CSF) leak is extremely rare and can be mistaken for other skull base lesions. Here the authors present a case of chordoma with an unusual presentation.

OBSERVATIONS

A 43-year-old female who presented with clear nasal drainage was diagnosed with CSF rhinorrhea secondary to a clival defect previously thought to be ecchordosis physaliphora. The patient subsequently developed bacterial meningitis and underwent endoscopic, endonasal, transclival gross-total resection of the lesion with repair of the dural defect. Pathology revealed brachyury-positive chordoma. She received adjuvant proton beam radiotherapy and has remained stable for 2 years.

LESSONS

Spontaneous CSF rhinorrhea can occur as a rare primary presentation of clival chordoma, requiring careful radiological interpretation and a high index of suspicion for diagnosis. Chordoma cannot be reliably differentiated from benign notochordal lesions based on imaging alone; thus, intraoperative exploration and immunohistochemistry play key roles. Clival lesions presenting with CSF rhinorrhea should undergo prompt resection to facilitate diagnosis and prevent complications. Future studies on connections between chordoma and benign notochordal lesions may help to establish management guidelines.

Nasal Septal Perforation Secondary to Graft-Versus-Host Disease

Nasal septal perforation is a full-thickness defect of the nasal septum. There are many described etiologies of nasal septal perforation, including trauma, infectious, neoplastic, iatrogenic, and autoimmune. Graft-versus-host disease (GVHD) is a common and potentially life-threatening complication that can occur after an allogenic transplant. GVHD can result in the development of autoantibodies that lead to granulomatous inflammation with necrotizing vasculitis, causing perforation of the nasal septum. In this report, we describe a patient with nasal septal perforation secondary to GVHD and hope to provide novel insights into the association of GVHD and nasal septal perforation.

Clinicopathological features and prognostic outcomes of molecularly defined entities in the new edition of the WHO classification of sinonasal carcinoma

Introduction

We investigated the clinicopathological features and prognoses of the new molecularly defined entities in latest edition of the World Health Organization (WHO) classification of sinonasal carcinoma (SNC).

Methods

Integrated data were combined into an individual patient data (IPD) meta-analysis.

Results

We included 61 studies with 278 SNCs including 25 IDH2-mutant, 41 NUT carcinoma, 187 SWI/SNF loss, and 25 triple negative SNCs (without IDH2 mutation, NUTM1 rearrangement, and SWI/SNF inactivation) for analyses. Compared to other molecular groups, NUT carcinoma was associated with a younger age at presentation and an inferior disease-specific survival. Among SNCs with SWI/SNF inactivation, SMARCB1-deficient tumors presented later in life and were associated with a higher rate of radiotherapy administration. SMARCA4-deficiency was mostly found in teratocarcinosarcoma while SMARCB1-deficient tumors were associated with undifferentiated carcinoma and non-keratinizing squamous cell carcinoma.

Conclusion

Our study facilitates our current understanding of this developing molecular-defined spectrum of tumors and their prognoses.

High-Grade Biphenotypic Sinonasal Sarcoma: A Case Report

Introduction  Biphenotypic sinonasal sarcoma (BSNS) is a recently found entity that first described by Lewis et al. It was then added to the 4th edition of the World Health Organization (WHO) of head and neck tumors in 2012. BSNS has been described as a rare low-grade sarcoma arising in the upper sinonasal tract. It is believed that in the past, BSNS was, likely, previously diagnosed as other low-grade or benign malignancies. Fibrosarcoma, leiomyosarcoma, and peripheral nerve sheath tumors, all fall within the differential diagnosis of BSNS. However, BSNS is unlike other mesenchymal sinonasal tumors, as it displays both neural and myogenic differentiation. BSNS has thus far been recognized in only a hand full of case reports, all of which have reported similar morphologic features of a low-grade soft tissue tumor with neural involvement arising from the nasal cavity or ethmoid air cells in middle aged individuals. In fact, being low-grade sarcoma became such a hallmark characteristic of this tumor that it even received the name low-grade sinonasal sarcoma with neural and myogenic features or LGSSNMF.

Case Presentation  We present, however, for the first time, a high-grade differentiation of BSNS in an otherwise healthy 72-year-old female. The patient was referred from an outside ENT (ear, nose, and throat) after pathology from a presumed polypectomy returned positive for a BSNS. Initial imaging revealed erosion through the bilateral lamina papyracea, anterior cranial fossa floor, and posterior table of the frontal sinus. She then underwent a combined endoscopic and bicoronal open approach for resection of the skull base lesion that was found to encompass the entirety of the sinonasal cavities bilaterally. Postoperatively, the patient underwent significant complications including infection of the pericranial flap, pneumocephalus, and eventually death.

Discussion  As BSNS is a fairly new entity, currently there has only been four case series conducted, each identifying features of a low-grade sarcoma with both myogenic and neural differentiation. Histologically, BSNS has monophasic spindle cells with uniform, elongated nuclei with scant cytoplasm between benign proliferations of surface-type respiratory epithelium, with a low mitotic rate. Our case, however, revealed pleomorphic hyperchromatic cells with high mitotic activity and necrosis with invasion of bone, staging it as high grade. Immunohistochemistry also differed from the previously reported standards. This case describes a new category for BSNS which may change the differential diagnosis, management, and surgical recommendations that are currently utilized for this skull base neoplasm.

From a Slave to a Surgeon: David Kearney McDonogh, the First Black Otolaryngologist

David McDonogh, born into chattel slavery in Louisiana in the early 1800s, accomplished the unfathomable by becoming the first Black otolaryngologist in the United States of America. With tireless determination and profound intellect, Dr McDonogh surmounted immeasurable adversity along his improbable journey to freedom and success as an eye, ear, nose, and throat doctor in New York. His doctorate in medicine was posthumously awarded to his great-great-granddaughter in 2018 by the Columbia University Vagelos College of Physicians and Surgeons. In this History of Otolaryngology piece, we share his extraordinary story.

Sinonasal immunoglobin G4-related disease: case report and review

Immunoglobin G4-related disease (IgG4-RD) is a chronic fibro-inflammatory condition that presents as a single or multiple tumefactive lesions affecting virtually any organ system. Here we report a case of recurrent sinonasal IgG4-RD and review the literature of this evolving entity.

Primary Repair of Posteriorly Located Anterior Skull Base Dural Defects Using Nonpenetrating Titanium Clips in Cranial Trauma

Objective Primary repair of posteriorly located anterior skull base (ASB) dural defects following cranial trauma is made difficult by narrow operative corridors and adherent dura mater. Inadequate closure may result in continued cerebrospinal fluid (CSF) leak and infectious sequelae. Here, we report surgical outcomes following the use of nonpenetrating titanium microclips as an adjunctive repair technique in traumatic anterior skull base dural defects extending from the olfactory groove to the tuberculum sellae.

Methods All trauma patients who underwent a bifrontal craniotomy from January 2013 to October 2019 were retrospectively reviewed. Patients with ASB defects located at posterior to the olfactory groove were analyzed. Patients with isolated frontal sinus fractures were excluded. All patients presented with CSF leak or radiographic signs of dural compromise. Patients were divided according to posterior extent of injury. Patient characteristics, imaging, surgical technique, and outcomes are reported.

Results A total of 19 patients who underwent a bifrontal craniotomy for repair of posteriorly located ASB dural defects using nonpenetrating titanium microclips were included. Defects were divided by location: olfactory groove (10/19), planum sphenoidale (6/19), and tuberculum sellae (3/19). No patients demonstrated a postoperative CSF leak. No complications related to the microclip technique was observed. Clip artifact did not compromise postoperative imaging interpretation.

Conclusion Primary repair of posteriorly located ASB dural defects is challenging due to narrow working angles and thin dura mater. Use of nonpenetrating titanium microclips for primary repair of posteriorly located dural defects is a reasonable adjunctive repair technique and was associated with no postoperative CSF leaks in this cohort.

Endoscopic trans-pterygoid resection of a low-grade cribriform cystadenocarcinoma of the infratemporal fossa

This article presents a case of low-grade cribriform cystadenocarcinomas (LGCCC), a rare salivary gland tumor manifesting in the infratemporal fossa (ITF). The lesion in this case is unique in its location, histopathology, and management in that the tumor resection was performed using an exclusively endoscopic, endonasal approach. This case highlights the expanding application of endoscopic skull base techniques to address an indolent, slow-growing malignancy of the ITF.

The Endoscopic Endonasal Approach to the Hypoglossal Canal: The Role of the Eustachian Tube as a Landmark for Dissection

IMPORTANCE

Improvements in endoscopic technology and reconstructive techniques have made the endoscopic endonasal approach (EEA) a viable option to approach ventromedial lesions in the region of the hypoglossal canal. Prior to contemplating this surgical corridor, a thorough understanding of anatomic relationships and landmarks is essential to safely approach this region of the posterior skull base through an EEA.

OBJECTIVE

To describe the surgical technique and anatomic landmarks in the EEA to the hypoglossal canal through referencing nasopharyngeal and posterior skull base anatomy.

DESIGN, SETTING, AND PARTICIPANTS

Study of latex-injected cadaveric heads at the North Carolina Eye Bank Multidisciplinary Surgical Skills Laboratory at the University of North Carolina.

INTERVENTIONS

An EEA to the hypoglossal canal was carried out bilaterally in 5 embalmed, latex-injected cadaver heads.

MAIN OUTCOMES AND MEASURES

Cadaveric measurements of anatomic landmarks and relationships in the approach were obtained using a 10-cm surgical ruler and were reported as mean distances. Additionally, high-quality endoscopic images demonstrating the operative technique and anatomic relationships were obtained.

RESULTS

The distance between the lacerum segment of the internal carotid arteries, the superolateral boundary, was 23.6 mm (SD, 11.8 mm). The distance between the anterolateral edge of the occipital condyles, the inferolateral boundary, was 19 mm (SD, 0.80 mm). The supracondylar groove was identified in the same anteroposterior plane as the nasopharyngeal orifice of the eustachian tube, and the anterior-most edge of the occipital condyle was 14 mm (SD, 0.82 mm) from the posterosuperior edge of the salpingopharyngeal fold. Additionally, the transtubercular corridor was on the same plane as the superior edge of the torus tubarius in the anteroposterior axis. The distance to the hypoglossal canal from midline was 10 mm, which was found after completing drilling in the transcondylar and transtubercular corridors. Last, the hypoglossal nerve rootlets were identified entering the canal 6 mm inferiorly and 8 mm laterally from the vertebrobasilar junction.

CONCLUSIONS AND RELEVANCE

The eustachian tube and other elements of nasopharyngeal anatomy are fixed landmarks that provide important points of reference when approaching the hypoglossal canal through an EEA. A thorough understanding of these anatomic relationships is vital in safely navigating this direct, surgical corridor to the posterior fossa.

A computational study of functional endoscopic sinus surgery and maxillary sinus drug delivery

BACKGROUND

Topical medication is increasingly used following functional endoscopic sinus surgery (FESS). Information on particle sizes that maximise maxillary sinus (MS) delivery is conflicting, and the effect of antrostomy size on delivery is unclear. The purpose of this study was to estimate antrostomy and particle size effects on topical MS drug delivery.

METHODOLOGY

Sinonasal reconstructions were created from a pre- and a post-FESS CT scan in each of four chronic rhinosinusitis patients. Additional models were created from each post-FESS reconstruction representing four alternative antrostomy sizes. Airflow and particle deposition were simulated in each reconstruction using computational fluid dynamics for nebulised and sprayed delivery.

RESULTS

MS ventilation and drug delivery increased following FESS, the largest virtual antrostomy led to greatest delivery, and MS delivery was sensitive to particle size. Particles within a 5-18 μm and 5-20 μm size range led to peak MS deposition for nebulised and sprayed particles, respectively. Post-FESS increases in drug delivery varied across individuals and within individuals by the type of antrostomy created.

CONCLUSION

Our findings suggest that FESS, particularly with larger antrostomies, improves topical drug delivery, and that certain particle sizes improve this delivery. Further research is needed to contextualise these findings with other post-surgical effects.

Characterization of postoperative changes in nasal airflow using a cadaveric computational fluid dynamics model: supporting the internal nasal valve

IMPORTANCE

Collapse or compromise of the internal nasal valve (INV) results in symptomatic nasal obstruction; thus, various surgical maneuvers are designed to support the INV.

OBJECTIVE

To determine the effect on nasal airflow after various surgical techniques focused at the level of the INV and lateral nasal sidewall.

DESIGN AND SETTING

A fresh cadaver head was obtained and underwent suture and cartilage graft techniques directed at the level of the INV using an external approach. Preoperative and postoperative digital nasal models were created from the high-resolution, fine-cut, computed tomographic imaging after each intervention. Isolating the interventions to the level of the INV, we used computational fluid dynamic techniques to calculate nasal resistance, nasal airflow, and nasal airflow partitioning for each intervention.

INTERVENTION

Suture and cartilage graft techniques.

MAIN OUTCOMES AND MEASURES

Nasal airflow, nasal resistance, and partitioning of airflow.

RESULTS

Using the soft-tissue elevation model as baseline, computational fluid dynamic analysis predicted that most of the suture and cartilage graft techniques directed toward the nasal valve improved nasal airflow and partitioning while reducing nasal resistance. Specifically, medial and modified flare suture techniques alone improved nasal airflow by 16.9% and 15.1%, respectively. The combination of spreader grafts and modified flare suture improved nasal airflow by 13.2%, whereas spreader grafts alone only improved airflow by 5.9%. The largest improvements in bilateral nasal resistance were achieved using the medial and modified flare sutures, outperforming the combination of spreader grafts and modified flare suture.

CONCLUSIONS AND RELEVANCE

Techniques directed at supporting the INV have tremendous value in the treatment of nasal obstruction. The use of flare sutures alone can address dynamic valve collapse or upper lateral cartilage incompetence without gross disruption of the nasal architecture. Using computational fluid dynamic techniques, this study suggests that flare sutures alone may improve flow and reduce resistance when placed medially, surpassing spreader grafts alone or in combination with flare sutures. The longevity of these maneuvers can only be assessed in the clinical setting. Studies in additional specimens and clinical correlation in human subjects deserve further attention and investigation.

LEVEL OF EVIDENCE

NA.

A computational study of functional endoscopic sinus surgery and maxillary sinus drug delivery

BACKGROUND

Topical medication is increasingly used following functional endoscopic sinus surgery (FESS). Information on particle sizes that maximise maxillary sinus (MS) delivery is conflicting, and the effect of antrostomy size on delivery is unclear. The purpose of this study was to estimate antrostomy and particle size effects on topical MS drug delivery.

METHODOLOGY

Sinonasal reconstructions were created from a pre- and a post-FESS CT scan in each of four chronic rhinosinusitis patients. Additional models were created from each post-FESS reconstruction representing four alternative antrostomy sizes. Airflow and particle deposition were simulated in each reconstruction using computational fluid dynamics for nebulised and sprayed delivery.

RESULTS

MS ventilation and drug delivery increased following FESS, the largest virtual antrostomy led to greatest delivery, and MS delivery was sensitive to particle size. Particles within a 5-18 μm and 5-20 μm size range led to peak MS deposition for nebulised and sprayed particles, respectively. Post-FESS increases in drug delivery varied across individuals and within individuals by the type of antrostomy created.

CONCLUSION

Our findings suggest that FESS, particularly with larger antrostomies, improves topical drug delivery, and that certain particle sizes improve this delivery. Further research is needed to contextualise these findings with other post-surgical effects.

Endoscopic endonasal approaches to infratemporal fossa tumors: a classification system and case series

OBJECTIVES/HYPOTHESIS

To propose a clinically applicable anatomic classification system describing three progressive endoscopic endonasal approaches (EEAs) to the infratemporal fossa (ITF) and their potential sequelae. Overall feasibility and outcomes of these approaches are presented through a consecutive case series.

STUDY DESIGN

Description of classification system for EEAs to the ITF and case series.

METHODS

A classification system of EEAs to ITF tumors was created based on the senior author's clinical experience and cadaveric dissection. A retrospective chart review of 21 child and adult patients with primary ITF tumors treated by these approaches from 2008 to 2012 at a tertiary-care academic medical center was conducted.

RESULTS

Three progressive EEAs to ITF tumors were defined: 1) a transpterygopalatine fossa approach, 2) a transmedial pterygoid plate approach, and 3) a translateral pterygoid plate approach. Twenty-one patients treated with these approaches were identified consecutively, with a mean age of 44.2 years (range, 11-79 years). Tumors primarily involving the pterygopalatine fossa and not the ITF were excluded. Pathology included three advanced juvenile nasopharyngeal angiofibromas, three adenoid cystic carcinomas, two recurrent inverted papillomas, two trigeminal schwannomas, and 11 other diverse skull base pathologies. No intraoperative or postoperative complications occurred, with a mean follow-up of 21.5 months (range, 1-55 months). Expected potential sequelae such as V2/palatal numbness, Eustachian tube dysfunction, and trismus occurred in 10/21 patients.

CONCLUSIONS

EEAs to ITF tumors are technically feasible with low risk of complications for well-selected patients. The proposed classification system is useful for anticipating potential sequelae for each approach.

Image-guided robotic skull base surgery

Objectives To describe the potential uses of computed tomography image guidance in concert with the surgical robot for skull base surgery. Design An anatomical study was conducted. Setting Tertiary academic center. Participants Cadaveric skull. Main Outcome Measures The primary outcome measure was to measure the accuracy of robotic arm positioning to anatomical landmarks on a skull using image guidance and the surgical robot synchronously. Instruments with different angles of rotations were used. Estimated systematic error was calculated and compared with achieved errors. Clinical applications of metachronous image guidance and robotic system were discussed. Results The skull model approximated < 1 mm accuracy using standard image guidance instruments and the 0-degree robotic arm positioning. Increased angles of instruments from 20 to 60 degrees on the robotic system revealed more significant increases in error than estimated. Conclusions Image guidance may be useful for transoral robotic approaches. Precise movements are improved by limiting the angle of deviation. Future studies will help optimize the combined technologies before validating the study in clinical settings.

Expression of protease-activated receptors in allergic fungal rhinosinusitis

BACKGROUND

The etiology of the intense inflammatory response showed by patients with allergic fungal rhinosinusitis (AFRS) remains a mystery. Potential sources of this inflammation may include fungal proteases. Protease-activated receptors (PARs) are components of the innate immune response that are modulated by proteolytic activity and are involved in potentiating T helper 2 (Th2) responses. The objective of the study was to determine whether there is differential expression of PARs in patients with AFRS compared to controls.

METHODS

The study was designed as a comparison of gene expression profiles in patients with AFRS vs diseased and nondiseased controls. Twenty-five patients were enrolled. Patients with AFRS (n = 15) were compared to nondiseased controls (n = 5) undergoing minimally invasive pituitary surgery (MIPS) and patients with chronic rhinosinusitis with nasal polyps (CRSwNP, n = 5) undergoing functional endoscopic sinus surgery (FESS). Ethmoid mucosa RNA was hybridized to 4 × 44 K microarray chips. Four gene probes (PAR1, PAR2, PAR3, and PAR4) were used to assess for differential expression. A linear-mixed model was used to account for some patients having multiple samples. Significance level was determined at p < 0.05.

RESULTS

Of the 4 probes, only PAR3 showed statistically significant differential expression between AFRS and nondiseased control samples (p = 0.03) as well as a 2.21-fold change. No additional statistical difference in PAR expression among the comparison groups was noted.

CONCLUSION

PARs have been shown to enhance production of inflammatory cytokines and potentiate Th2 responses. In this initial report, patients with AFRS have a significantly increased expression of PAR3 compared to nondiseased controls.

Markers of disease severity and socioeconomic factors in allergic fungal rhinosinusitis

BACKGROUND

Allergic fungal rhinosinusitis (AFRS) is a refractory subtype of chronic rhinosinusitis. There is a paucity of data investigating the association of epidemiologic markers of disease severity. The primary objective of this study is to evaluate components of disease severity with socioeconomic status and health care access.

METHODS

A retrospective analysis was performed on patients diagnosed with AFRS by Bent and Kuhn criteria from 2000 to 2013. Severity of disease was measured by orbitocranial involvement, bone erosion, Lund-Mackay score, serum immunoglobulin E (IgE), and mold hypersensitivity. The North Carolina State Data Center provided county-specific socioeconomic and demographic data. Fisher's exact test, Wilcoxon rank sum test, Pearson correlations, and multivariable linear regression models were used to explore associations between variables.

RESULTS

Of 93 patients, 58% were African American and 39% Caucasian with a male:female ratio of 1.4:1 and average age at presentation of 29 years. Race, age, insurance status, and gender were not associated with severity of disease. Bone erosion was correlated with residence in counties with lower income per capita (p = 0.01). Patients with orbitocranial involvement resided in more rural counties (p = 0.01) with less primary care providers per capita (p = 0.02). Residence in counties with older or poorer quality housing was associated with a higher prevalence of bone erosion (p = 0.02).

CONCLUSION

Within our cohort of patients residing in North Carolina, markers of disease severity (bone erosion and orbitocranial involvement) in AFRS were associated with lower income, rural counties, poor housing quality, and less health care access.

Quantification of airflow into the maxillary sinuses before and after functional endoscopic sinus surgery

BACKGROUND

The effects of increases in maxillary sinus (MS) airflow following functional endoscopic sinus surgery (FESS) are unknown. The goal of this study was to quantify the effects of FESS on airflow into the MS in a cohort of patients with chronic rhinosinusitis, and compare MS flow rate with patient-reported outcome measures.

METHODS

A pilot study was conducted in which preoperative and postoperative computed tomography scans of 4 patients undergoing bilateral or unilateral FESS were used to create 3-dimensional (3D) reconstructions of the nasal airway and paranasal sinuses using Mimics™ (Materialise, Inc.). The size of the maxillary antrostomies post-FESS ranged from 107 to 160 mm(2). Computational meshes were generated from the 3D reconstructions, and steady-state, laminar, inspiratory airflow was simulated in each mesh using the computational fluid dynamics (CFD) software Fluent™ (ANSYS, Inc.) under physiologic, pressure-driven conditions. Airflow into the MS was estimated from the simulations and was compared preoperatively and postoperatively. In addition, patients completed preoperative and postoperative Rhinosinusitis Outcome Measure-31 (RSOM-31) questionnaires and scores were compared with MS airflow rates.

RESULTS

CFD simulations predicted that average airflow rate into post-FESS MS increased by 18.5 mL/second, and that average flow velocity into the MS more than quadrupled. Simulation results also showed that MS flow rate trended with total RSOM-31 and all domain scores.

CONCLUSION

CFD simulations showed that the healed maxillary antrostomy after FESS can greatly enhance airflow into the MS. Our pilot study suggests that to some extent, increasing airflow into the MS may potentially improve chronic rhinosinusitis patients' quality of life pre-FESS and post-FESS.

Single-blind randomized controlled trial of surfactant vs hypertonic saline irrigation following endoscopic endonasal surgery

BACKGROUND

Recent discussion has revolved around formulations of irrigation in the postoperative functional endoscopic sinus surgery patient, specifically the efficacy of emulsion based nasal irrigations.

METHODS

Forty adult candidates for endoscopic endonasal surgery with chronic rhinosinusitis (CRS) were prospectively randomized. The 22-item Sino-Nasal Outcome Test (SNOT-22) and 31-item Rhinosinusitis Outcome Measure (RSOM-31) quality of life assessments, as well as a phenyl ethyl alcohol (PEA) smell threshold test were obtained preoperatively and over 3 postoperative visits in a 4-month period. Repeated measures analyses and Fisher's exact tests were used to assess statistical differences.

RESULTS

Of the 40 patients enrolled, 33, 32, and 26 patients were seen at postoperative visits 1, 2, and 3, respectively. The surfactant (S) and hypertonic saline (HS) irrigation groups both showed significant decreases in scores for both the SNOT-22 and RSOM-31 over time (both p < 0.0001), but no difference was seen between the 2 groups (p = 0.09, p = 0.5). PEA thresholds showed overall improvement in both groups 3 to 4 months after surgery: 62% (8/13) of HS patients and 50% (6/12) of S patients, but did not differ between the groups (p = 0.3). The S group reported significantly more side effects (52% vs 6%, p = 0.002) and had more patients stop the solution (20% vs 0%) and fewer S patients finished the study compared to the HS group.

CONCLUSION

There were no significant differences in overall subjective symptoms related to sinonasal disease between S and HS irrigation, but tolerability appeared to be an issue. More patients reported side effects with S irrigation, and 20% receiving S irrigation stopped the solution, compared to none receiving HS irrigation.

Allergic fungal sinusitis in children

Allergic fungal sinusitis (AFS) is a subtype of eosinophilic chronic rhinosinusitis (CRS) characterized by type I hypersensitivity, nasal polyposis, characteristic computed tomography scan findings, eosinophilic mucus, and the presence of fungus on surgical specimens without evidence of tissue invasion. This refractory subtype of CRS is of the great interest in the pediatric population, given the relatively early age of onset and the difficulty in managing AFS through commercially available medical regimens. Almost universally, a diagnosis of AFS requires operative intervention. Postoperative adjuvant medical therapy is a mainstay in the treatment paradigm of pediatric AFS.

Nasoseptal flap closure of traumatic cerebrospinal fluid leaks

The vascularized nasoseptal flap has become a principal reconstructive technique for the closure of endonasal skull base surgery defects. Despite its potential utility, there has been no report describing the use of the modern nasoseptal flap to repair traumatic cerebrospinal fluid (CSF) leaks and documenting the outcomes of this application. Specific concerns in skull base trauma include septal trauma with disruption of the flap pedicle, multiple leak sites, and issues surrounding persistent leaks after traumatic craniotomy. We performed a retrospective case series review of 14 patients who underwent nasoseptal flap closure of traumatic CSF leaks in a tertiary academic hospital. Main outcome measures include analysis of clinical outcome data. Defect etiology was motor vehicle collision in eight patients (57%), prior sinus surgery in four (29%), and assault in two (14%). At the time of nasoseptal flap repair, four patients had failed prior avascular grafts and two had previously undergone craniotomies for repair. Follow-up data were available for all patients (mean, 10 months). The overall success rate was 100% (no leaks), with 100% defect coverage. The nasoseptal flap is a versatile and reliable local reconstructive technique for ventral base traumatic defects, with a 100% CSF leak repair rate in this series.

Nasoseptal Flap Reconstruction of Secondary Palatal Defects

Objective: 1) Describe a novel operative technique using a posteriorly pedicled nasoseptal flap (NSF) for reconstruction of secondary palatal defects. 2) Report initial outcomes of patients with secondary palatal defects who underwent NSF palatal reconstruction.

Method: Case series of 5 patients who underwent NSF for repair of secondary palatal defects at a tertiary referral center from October 2008 to October 2010. A NSF pedicled on the posterior nasoseptal artery was used for coverage of palatal defects. Clinical outcomes and images will be presented.

Results: Two patients had secondary palatal defects from prior tumor resection, 1 patient had a traumatic injury, 1 patient had granulomatous disease, and 1 patient had a palatal defect after Le Fort I advancement. Area of defects ranged from 0.5 to 7cm2. Initial outcomes reveal that all defects less than 1cm in width (n = 3) closed successfully and defects larger than 2cm in width (n = 2) did not completely close. There were no intraoperative complications. All patients had complete intranasal healing by 6 weeks postoperatively. There were no postoperative bleeding, infectious, or wound complications, as well as no cerebrospinal fluid leaks.

Conclusion: Secondary palatal defects are challenging and reconstruction with vascularized tissue is desirable. A posteriorly pedicled nasoseptal flap offers a novel option to repair palatal defects. The success rate for small defects is promising with minimal donor site morbidity.

Oral resveratrol therapy inhibits cancer-induced skeletal muscle and cardiac atrophy in vivo

The mechanism by which cancer mediates muscle atrophy has been delineated in the past 3 decades and includes a prominent role of tumor-derived cytokines, such as IL-6, TNFα, and IL-1. These cytokines interact with their cognate receptors on muscle to activate the downstream transcription factor NF-κB and induce sarcomere proteolysis. Experimentally, inhibiting NF-κB signaling largely prevents cancer-induced muscle wasting, indicating its prominent role in muscle atrophy. Resveratrol, a natural phytoalexin found in the skin of grapes, has recently been shown to inhibit NF-κB in cancer cells, which led us to hypothesize that it might have a protective role in cancer cachexia. Therefore, we investigated whether daily oral resveratrol could protect against skeletal muscle loss and cardiac atrophy in an established mouse model. We demonstrate resveratrol inhibits skeletal muscle and cardiac atrophy induced by C26 adenocarcinoma tumors through its inhibition of NF-κB (p65) activity in skeletal muscle and heart. These studies demonstrate for the first time the utility of oral resveratrol therapy to provide clinical benefit in cancer-induced atrophy through the inhibition of NF-κB in muscle. These findings may have application in the treatment of diseases with parallel pathophysiologies such as muscular dystrophy and heart failure.

Transpalatal greater palatine canal injection: Radioanatomic analysis of where to bend the needle for pediatric sinus surgery

BACKGROUND

The greater palatine canal (GPC) local injection is used to limit posterior bleeding during sinus surgery in adults. Given the potential for causing iatrogenic damage to the intraorbital contents, this procedure is not commonly used in the pediatric population. No studies have described the anatomic development of the GPC during facial growth. By using age-stratified radioanatomic analysis, the dimensions of the GPC and the clinical implications are described for pediatric patients. An age-stratified radioanatomic study was performed.

METHODS

High-resolution computed tomography measurements included the thickness of the mucosal plane overlying the GPC, the length of the GPC, and the distance between the base of the pterygopalatine fossa (PPF) and the orbital floor. Mean distance and standard deviation were calculated for each age cohort and compared using the one-way ANOVA test.

RESULTS

The GPC length correlated directly with patient age. It varied from 9.14 ± 0.11 mm in the youngest age group (<2 years) to 19.36 ± 2.76 mm in adults (18-64 years). The height of the orbit relative to the hard palate approximated the adult dimensions described in the literature by 12-13 years (49.58 ± 1.72 mm).

CONCLUSION

These radioanatomic results suggest that the GPC injection described for adult patients may be safely administered to selected pediatric patients. For patients >12 years old, we recommend bending the needle 45° and inserting it 25 mm. For patients 6-12 years old, the needle should be inserted 20 mm to enter into the PPF. In patients <6 years old, the needle may safely be placed 12 mm into the GPC. Each of these descriptions is based on the minimal distance required to effectively access the PPF but with maximal safety in regard to the orbit. Further clinical correlation of these findings is necessary through future investigation.

Nasoseptal flap takedown and reuse in revision endoscopic skull base reconstruction

OBJECTIVES/HYPOTHESIS

To provide a description of the techniques and limitations of nasoseptal flap takedown and reuse during second-stage and revision endoscopic skull base surgery and review the institutional experience with the use of this reconstructive technique.

STUDY DESIGN

: Case series.

METHODS

A retrospective analysis of cerebrospinal fluid (CSF) leak outcomes was performed for a consecutive series of patients who underwent the nasoseptal flap takedown technique during endoscopic skull base surgery at two tertiary care skull base centers.

RESULTS

Twenty-eight consecutive cases with nasoseptal flap takedown procedures for endoscopic skull base reconstruction were collected and evaluated for flap viability and CSF leak outcomes. This cohort was composed of 14 revision surgeries and 14 planned second-stage procedures. There were no cases of flap loss. Twenty cases involved the presence of intraoperative CSF leaks. Twelve of these 20 cases were second-stage surgeries, and eight were revision or recurrent-tumor procedures. Nineteen of 20 had successful skull base reconstruction without a postoperative CSF leak. One patient required revision endoscopic CSF leak repair and bolstering of the defect with a fat graft 3 days after the initial surgery. Endoscopic skull base reconstructive techniques and limitations of flap takedowns are discussed.

CONCLUSIONS

Expansion of the limits of endoscopic skull base surgery must be accompanied by the development of new reconstructive options. This report illustrates the ability to take down and reuse the nasoseptal flap in staged and revision cases with a high success rate and minimal additional nasal morbidity.

A prospective study of the clinical impact of a multidisciplinary head and neck tumor board

OBJECTIVE

There have been no studies undertaken on the effect of the multidisciplinary head and neck tumor board on treatment planning. The objective of this study was to determine the efficacy of the multidisciplinary tumor board in altering diagnosis, stage, and treatment plan in patients with head and neck tumors.

STUDY DESIGN

Case series with planned data collection.

SETTING

Comprehensive cancer center and tertiary academic hospital.

SUBJECTS AND METHODS

A prospective study of the discussions concerning 120 consecutive patients presented at a multidisciplinary head and neck tumor board was performed. As each patient was presented, a record was made of the "pre-conference" diagnosis, stage, and treatment plan. After case discussion, the "post-conference" diagnosis, stage, and treatment plan were recorded. Results are compared between malignant and benign tumor cohorts.

RESULTS

The study population comprised 120 patients with new presentations of head and neck tumors: 84 malignancies and 36 benign tumors. Approximately 27 percent of patients had some change in tumor diagnosis, stage, or treatment plan. Change in treatment was significantly more common in cases of malignancy, occurring in 24 percent of patients versus six percent of benign tumors (P = 0.0199). Changes in treatment were also noted to be largely escalations in management (P = 0.0084), adding multi-modality care.

CONCLUSION

A multidisciplinary tumor board affects diagnostic and treatment decisions in a significant number of patients with newly diagnosed head and neck tumors. The multidisciplinary approach to patient care may be particularly effective in managing malignant tumors, in which treatment plans are most frequently altered.

Effect of a novel DNA vaccine on angiogenesis and tumor growth in vivo

OBJECTIVE

To develop a DNA cancer vaccine that targets the vascular endothelial growth factor receptor.

DESIGN

Mice were vaccinated intramuscularly with listeriolysin O-fetal liver kinase 1 (LLO-Flk1) or controls. Mice were also challenged subcutaneously with the tumor cell line TC-1. Tumor sizes were measured after vaccination. At the conclusion of the experiments, the tumors were harvested for immunohistochemical analysis and determination of hemoglobin content.

SETTING

Research laboratory.

SUBJECTS

Six- to 8-week-old C57BL/6 mice.

INTERVENTION

Fifty micrograms of each vector was administered 3 times at weekly intervals.

MAIN OUTCOME MEASURES

Tumor size, mean vessel density of tumors, hemoglobin content of tumor.

RESULTS

Mice treated with the LLO-Flk1 vaccine experienced slower tumor growth relative to the other treatment groups. Complete tumor regression was observed in several cases. Immunohistochemical staining of tumors revealed fewer blood vessels in the mice vaccinated with the LLO-Flk1 vaccine relative to the other treatment groups. Finally, colorimetric assessment for hemoglobin suggested decreased vasculature in the tumor bed of these mice relative to the control groups.

CONCLUSION

The novel DNA cancer vaccine LLO-Flk1 can slow tumor growth in vivo.

Anatomical considerations for endoscopic endonasal skull base surgery in pediatric patients

OBJECTIVES/HYPOTHESIS

Pediatric skull base surgery is limited by several boney sinonasal landmarks that must be overcome prior to tumor dissection. When approaching a sellar or parasellar tumor, the piriform aperture, sphenoid sinus pneumatization, and intercarotid distances are areas of potential limitation. Quantitative pediatric anatomical measurements relevant to skull base approaches are lacking. Our goal was to use radio-anatomic analysis of computed tomography scans to determine anatomical limitations for trans-sphenoidal approaches in pediatric skull base surgery.

STUDY DESIGN

A radio-anatomic cross-sectional survey.

METHODS

Measurements included the diameter of the piriform aperture, posterior extent of sphenoid sinus pneumatization, and intercarotid distances on fine-cut, age-stratified maxillofacial scans. Fifty pediatric (<18 years of age) and 10 adult patients were equally subdivided into seven age groups and compared to determine age-related differences in sphenoid sinus pneumatization, skull base thicknesses, and intercarotid distances.

RESULTS

Piriform aperture width was significantly greater in adults than in patients under age 7 years (P <or= .002). Three fourths of the planum and sellar face and one half of the sellar floor were pneumatized by ages 6 to 7 years. Superior clival pneumatization was not evident until 12 years of age. Clival intercarotid distances were not different among groups. Drilling distances for trans-planar, trans-sellar, and trans-clival approaches are described.

CONCLUSIONS

Several potential anatomic limits must be considered in pediatric skull base surgery, and these vary according to age. Piriform aperture is likely a limit only in the youngest patients (under 2 years). Sphenoid pneumatization to the planum and sella start at 3 years and complete by age 10 years. Clival intercarotid distances do not change significantly and are not prohibitively narrow in any age group.

When, how and why to treat the neck in patients with esthesioneuroblastoma: a review

Esthesioneuroblastoma is an uncommon tumor that presents in the sinonasal cavity and anterior skull base. Cervical metastases are not frequently found on initial presentation but eventually occur in 20-25% of these patients. This presents the treating physician with the difficult decision as to how and when to treat the neck in this disease. The aims of this study were to provide a comprehensive review of the incidence of N+ disease at presentation, make recommendations about the optimal treatment strategy of patients with N+ disease, explain the role of elective neck treatment in patients with N0 disease, and comment on treatment of patients with late cervical metastases that require salvage therapy, using the literature review of the incidence and treatment of neck disease in patients with esthesioneuroblastoma. This review revealed an approximately 5-8% incidence of cervical nodal metastasis at the time of presentation. Combined modality therapy with surgery and radiotherapy is recommended to treat the N+ neck at the time of diagnosis and later. Chemotherapy may have a role combined with radiation treatment, but there are little data to support this. There is limited evidence to substantiate the use of elective neck dissection or elective radiotherapy in the clinically and radiologically N0 neck. Patients who have late cervical metastases have a clear survival advantage (59 vs. 14%) when treated with combined surgery and radiotherapy relative to single modality methods alone. The results indicate that the management of the neck in esthesioneuroblastoma continues to be a significant challenge in the treatment algorithm of these complex patients.

Induction of antitumor immunity in vivo following delivery of a novel HPV-16 DNA vaccine encoding an E6/E7 fusion antigen

Human papillomavirus type 16 (HPV-16) infection is associated with a majority of cervical cancers and a significant proportion of head and neck cancers. Here, we describe a novel-engineered DNA vaccine that encodes a HPV-16 consensus E6/E7 fusion gene (pConE6E7) with the goal of increasing its antitumor cellular immunity. Compared to an early stage HPV-16 E7 DNA vaccine (pE7), this construct was up to five times more potent in driving E7-specific cellular immune responses. Prophylactic administration of this vaccine resulted in 100% protection against HPV E6 and E7-expressing tumors. Therapeutic studies indicated that vaccination with pConE6E7 prevented or delayed the growth of tumors. Moreover, immunization with pConE6E7 could also partially overcome immune tolerance in E6/E7 transgenic mice. Such DNA immunogens are interesting candidates for further study to investigate mechanisms of tumor immune rejection in vivo.

Treatment-seeking women at menopause: a comparison between two university menopause clinics

OBJECTIVE

We wished to determine the expectations of women about the benefits of hormone replacement therapy (HRT) and how these expectations may be influenced by cultural factors and previous experience of disease by the patient or in their families.

DESIGN

The attitudes of patients seeking HRT in Belfast, United Kingdom (n = 218) and Portland, USA (n = 100) were compared at their first clinic attendance using a questionnaire. Physical and mental health issues, previous use of HRT and continuance on treatment were compared.

RESULTS

Belfast women were less healthy than their Portland counterparts, with a higher prevalence of cardiovascular disease and psychiatric disorders (p < 0.05). Belfast patients showed a significantly lower continuance with treatment (p < 0.01). Collectively, the patients ranked relief of menopausal symptoms as their main expectation from HRT followed by osteoporosis protection, psychiatric relief and cardioprotection. The Belfast group had higher expectations for the relief of psychological/psychiatric problems (p < 0.01). All women with a family history of cardiac disease or fractures were more concerned for the protective effects of HRT than those women with no relevant family history (p < 0.05). There were cultural difference in expectations from HRT with Belfast women expecting more psychological/psychiatric relief and therefore trying a greater number of preparations.

CONCLUSIONS

These findings suggest that menopausal women in both countries are well informed about the potential protective benefits of HRT, and now expect an improvement in the quality of their lives well beyond the relief of menopausal symptoms.

A practical guide to prescribing hormone replacement therapy

Over the past 20 years there has been increasing interest in the menopause and hormone replacement therapy (HRT). More recently, postmenopausal HRT has been seen as a specific treatment for symptoms in the short term and preventative therapy in the long term. Women must be counselled regarding the risks and benefits of HRT according to the best available evidence. The patient should also be actively involved in the decision regarding HRT therapy, which should then improve patient compliance. Generally, an appropriate regimen of HRT can be formulated for the majority of patients. Progestogen should be added to therapy in women with an intact uterus in a cyclical or continuous regimen. The management of common estrogenic and progestogenic adverse effects is important in improving compliance. At present, new drugs are being developed for the management of the menopause (selective estrogen receptor modulators and phytoestrogens). Obviously, further research will be necessary to determine whether these drugs have advantages over regular HRT. By offering postmenopausal women HRT an attempt is made to optimise their physical and psychological well-being. However, HRT is not without adverse effects, the most worrying of which is the possible increase in breast cancer risk with long term use. However, with patient education efforts, treatment regimens acceptable to both patient and practitioner can be initiated; in this regard, the aim of the practitioner should be to help the menopausal woman make the decision which is the most appropriate for her.

Differential effects of subcutaneous estrogen and progesterone on low-density lipoprotein size and susceptibility to oxidation in postmenopausal rhesus monkeys

OBJECTIVE

To study the differential effects of subcutaneous E2 alone or in combination with P on the susceptibility of low-density lipoprotein (LDL) cholesterol to oxidation in naturally postmenopausal diet-controlled rhesus monkeys.

DESIGN

Prospective, longitudinal controlled study.

SETTING

Oregon Health Sciences University, Portland, Oregon, and Oregon Regional Primate Research Center, Beaverton, Oregon.

PATIENT(S)

Five naturally postmenopausal rhesus monkeys.

INTERVENTION(S)

Estradiol was administered subcutaneously for the first 4 weeks, followed by E2 plus P for 4 weeks, followed by a third 4-week washout period.

MAIN OUTCOME MEASURE(S)

Changes in plasma lipoprotein levels and oxidation of LDL and serum concentrations of E2 and P.

RESULT(S)

Levels of LDL cholesterol fell after 4 weeks of treatment with E2, compared with baseline. The lag time to half maximal light absorbancy after 4 weeks of E2 treatment was significantly increased compared with baseline. The maximal absorbance values and the slope of the propagation phase after 4 weeks of treatment with E2 were decreased compared with baseline. After 4 weeks of combined E2 and P treatment, all values were comparable to baseline.

CONCLUSION(S)

These results suggest that subcutaneous E2 therapy appears to enhance LDL resistance to oxidation and that this effect is attenuated by the addition of the P.

An intrauterine insemination-ready cryopreservation method compared with sperm recovery after conventional freezing and post-thaw processing

OBJECTIVE

To test a sucrose-glycerol cryoprotectant for IUI-ready sperm preparation.

DESIGN

Semen aliquots from normozoospermic donors either were subjected to conventional semen freezing (TES and Tris yolk buffer in 7.4% final glycerol) with post-thaw processing or were preprocessed and frozen in HEPES-buffered human tubal fluid with 1% human serum albumin, 4% sucrose, and 6% glycerol. All aliquots were cooled to 4 degrees C, exposed to liquid nitrogen vapors, and stored in liquid nitrogen. Aliquots from each were processed by centrifugation resuspension or by centrifugation in Percoll (Pharmacia, Alameda, CA) before sperm parameters were analyzed.

SETTING

University-based andrology laboratory.

MAIN OUTCOME MEASURE(S)

Recovery of motile sperm.

RESULT(S)

Percoll processing produced preparations with higher percentages of motile cells; however, cryopreserved sperm had a lower recovery of motile sperm compared with Percoll-processed fresh semen or centrifugation/resuspension-processed fresh or frozen samples. The percentages of sperm with normal morphologies were significantly increased in the IUI-ready samples compared with samples frozen conventionally. The IUI-ready Percoll-processed sample produced the best results, with a final mean motility of 36% and an overall yield of motile sperm of 17.4%.

CONCLUSION(S)

The sucrose-glycerol-based cryoprotectant produced an IUI-ready preparation with motile sperm recovery comparable to that of conventional semen cryopreservation but with improved percent morphology.

Reactive oxygen species generation in human sperm: luminol and lucigenin chemiluminescence probes

The objective of this study was to compare measurements of reactive oxygen species (ROS) generation from human spermatozoa in vitro using the luminol and lucigenin chemiluminescent probes. Luminol reacts with a variety of reactive oxygen species (H2O2, O2-, OH) and allows both intra- and extracellular ROS to be measured. Lucigenin, however, yields a chemiluminescence that is more specific for superoxide anions released extracellularly. Therefore, measurements made with both probes on the same samples should allow the intra- and extracellular components of ROS generation to be identified. Sperm samples from 47 men were divided into two equal aliquots, then processed by centrifugation and swim-up. Following further division into aliquots and the addition of the two chemiluminescent probes, Phorbol 12-myristate 13-acetate was added to trigger ROS release. Forty three percent of the sperm samples generated detectable levels of ROS. In the centrifuged preparations luminol produced a significantly higher peak luminescence than lucigenin. However, the sperm prepared by swim-up showed no significant differences in peak luminescence between luminol and lucigenin. The higher level of ROS generation produced by centrifugation may be due to membrane disruption or possibly the use of unfractionated cell suspensions. Extracellular ROS generation is more clinically important because surrounding healthy spermatozoa may be damaged. Therefore the lucigenin probe may be a more useful diagnostic tool than luminol for identifying sperm at risk of peroxidative damage after swim up preparation. The patients identified in this way may benefit from the addition of ROS scavengers to the culture medium in order to protect healthy sperm from collateral damage.

The effects of pentoxifylline on the generation of reactive oxygen species and lipid peroxidation in human spermatozoa

The aims of this study were to compare the in vitro effects of 3.6 mM and 7.2 mM pentoxifylline on the ability of spermatozoa to generate reactive oxygen species (ROS) and on lipid peroxidation (LPO). Semen samples were obtained from 10 asthenozoospermic men who had been previously identified as producing ROS after addition of Phorbol 12-myristate 13-acetate (PMA) during the screening of patients attending with male factor infertility. Spermatozoa were prepared by a swim-up technique from unprocessed semen and divided into 3 aliquots. To the control aliquot [A] an equal volume of BWW medium was added. To aliquots B and C an equal volume of BWW medium containing pentoxifylline was added to obtain final concentrations of 3.6 and 7.2 mM, respectively. ROS production was measured from peak luminescence (mV 10(-7) sperm) using a lucigenin chemiluminescent probe. LPO was also measured in the medium surrounding the spermatozoa after 30 min exposure to pentoxifylline using the thiobarbituric acid (TBA) assay for malondialdehyde (MDA). The reduction in ROS production was significantly greater in the samples exposed to 7.2 mM pentoxifylline as compared with the control and 3.6 mM pentoxifylline samples. There was no significant difference in peak luminescence between control and 3.6 mM pentoxifylline specimens. Both concentrations of pentoxifylline caused comparable reductions in MDA concentration in the medium (P < 0.05) surrounding the spermatozoa compared with control after 30 min exposure. Extracellular ROS generation may damage surrounding healthy spermatozoa. These findings suggest that higher concentrations of pentoxifylline are protective against ROS release in susceptible spermatozoa and may also reduce collateral LPO.

Total antioxidant capacity of seminal plasma is different in fertile and infertile men

OBJECTIVE

To determine if the total antioxidant capacity of seminal plasma is different in fertile and infertile men.

DESIGN

An enhanced chemiluminescence assay applied to seminal plasma from groups of fertile and infertile men.

SETTING

The Assisted Conception Unit, Royal Maternity Hospital, Belfast.

SUBJECTS

Men of proven fertility whose partners had an ongoing pregnancy resulting from IVF and male partners of couples attending our subfertility clinic.

RESULTS

Total antioxidant capacity was significantly higher in seminal plasma from fertile men than from that of infertile men with normozoospermic samples that exhibited reactive oxygen species or asthenozoospermic samples with or without reactive oxygen species activity.

CONCLUSIONS

Seminal plasma from infertile men has lower antioxidant levels than that of fertile men, particularly of patients whose semen have poor sperm motility. The presence of reactive oxygen species activity in sperm of infertile groups also is associated with lower levels of chain-breaking antioxidants in seminal plasma.