Arjun S. Joshi

Human palatine tonsil: a new potential tissue source of multipotent mesenchymal progenitor cells

IntroductionMesenchymal progenitor cells (MPCs) are multipotent progenitor cells in adult tissues, for example, bone marrow (BM). Current challenges of clinical application of BM-derived MPCs include donor site morbidity and pain as well as low cell yields associated with an age-related decrease in cell number and differentiation potential, underscoring the need to identify alternative sources of MPCs. Recently, MPC sources have diversified; examples include adipose, placenta, umbilicus, trabecular bone, cartilage, and synovial tissue. In the present work, we report the presence of MPCs in human tonsillar tissue.MethodsWe performed comparative and quantitative analyses of BM-MPCs with a subpopulation of adherent cells isolated from this lymphoid tissue, termed tonsil-derived MPCs (T-MPCs). The expression of surface markers was assessed by fluorescent-activated cell sorting analysis. Differentiation potential of T-MPCs was analyzed histochemically and by reverse transcription-polymerase chain reaction for the expression of lineage-related marker genes. The immunosuppressive properties of MPCs were determined in vitro in mixed lymphocyte reactions.ResultsSurface epitope analysis revealed that T-MPCs were negative for CD14, CD31, CD34, and CD45 expression and positive for CD29, CD44, CD90, and CD105 expression, a characteristic phenotype of BM-MPCs. Similar to BM-MPCs, T-MPCs could be induced to undergo adipogenic differentiation and, to a lesser extent, osteogenic and chondrogenic differentiation. T-MPCs did not express class II major histocompatibility (MHC) antigens, and in a similar but less pronounced manner compared with BM-MPCs, T-MPCs were immunosuppressive, inhibiting the proliferation of T cells stimulated by allogeneic T cells or by non-specific mitogenic stimuli via an indoleamine 2,3-dioxygenase-dependent mechanism.ConclusionHuman palatine T-MPCs represent a new source of progenitor cells, potentially applicable for cell-based therapies.

Da Vinci Robot–Assisted Endocrine Surgery: Novel Applications in Otolaryngology

Endoscopic procedures and minimally invasive surgeries have been touted for their improved postoperative outcomes while preserving comparable efficacy to open procedures. These results provided impetus for the creation of the da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, CA). This revolutionary robotic technology consists of a master console linked to a video cart mounted with robotic arms. The surgeon sits at the computer console, in front of a three-dimensional (3D) display gathered by a binocular endoscope (Fig 1). Three-dimensional movements of the surgeon’s hands in the console are translated to the robotic instruments to perform identical 3D movements. While transferring these intended operations, the computer filters out regular oscillations, such as resting tremors. The robotic tower supports the use of three to four robotic arms, which are attached to the video telescope and surgical instruments. These features separate the da Vinci system from other endoscopic instrumentation. While the emergence of robotic technology has been embraced avidly by several specialties including cardiothoracic and urological surgeries, otolaryngology has not widely implemented its use in the surgical management of head and neck diseases. In the porcine model, the da Vinci Surgical System has demonstrated to be effective in four different types of neck surgery, including a neck dissection and thymectomy. Surgical robotic use in human patients by otolaryngologists in the United States is limited to excision of a vallecular cyst. This report reviews our experience with two cases of robot-assisted endocrine surgery and, to our knowledge, represents its first reported application in otolaryngology literature.

Gene Expression Analysis in Sinonasal Polyposis before and after Oral Corticosteroids: A Preliminary Investigation

OBJECTIVE: To characterize gene expression in sinonasal polyps and to gain insight into change in expression after oral corticosteroid treatment. STUDY DESIGN AND METHODS: Nasal polyps were obtained before and after oral corticosteroid treatment and gene expression was analyzed with a focused gene array technique. RESULTS: Pretreated sinonasal polyps demonstrated high gene expression for chemokine and leukotriene receptor genes (CCR2, CCR5, CX3CL1, and LTB4R) in all patients. After treatment, the global effects of corticosteroids were evident on gene expression. CONCLUSIONS: Gene array techniques hold promise as a research method in sinonasal polyposis. The potential benefits, as well as the potential challenges, in using these research methods will be discussed.

Adult Intralesional Cidofovir Therapy for Laryngeal Papilloma: A 10-Year Perspective

OBJECTIVE To assess the long-term efficacy of intralesional cidofovir therapy in a previously reported cohort of adult subjects with laryngeal papilloma. DESIGN Retrospective review. SETTING Tertiary care medical center. PATIENTS We previously reported on the favorable clinical response to intralesional cidofovir therapy in 13 adult subjects. The subjects were enrolled in an open-trial prospective study (1997-2001) and completed the injection-only treatment protocol, and all subjects achieved a disease remission after a mean of 6 injections. In the present study, we review the clinical course of these subjects during an extended observational period (2001-2006). INTERVENTION Patients with documented relapse of disease underwent additional intralesional cidofovir injections. MAIN OUTCOME MEASURES Additional interventions, disease severity, and adverse outcomes are reported. RESULTS Following the original cidofovir protocol, 6 patients (46%) received no further interventions. The remaining 7 patients (54%) required further treatment for disease relapse, with a mean duration of remission before relapse of 1.05 years. Of the 7 patients who experienced disease relapse, 2 continued to have stable disease with regular injections, 2 were lost to follow-up during relapse treatment, and 3 achieved disease remission again. For this latter cohort, the mean number of injections per year necessary to achieve a second remission was 3.82. This compares with a mean of 1.77 injections per year that these patients received on an as-needed basis prior to the original study. CONCLUSION Intralesional cidofovir injections have been shown to be an effective therapy for adult laryngeal papilloma and should be considered in those patients who experience disease relapse.

Volumetric facelift: evaluation of rhytidectomy with alloplastic augmentation.

Objectives Facial aging occurs as a result of soft tissue atrophy and resorption of the bony skeleton, which results in a loss of soft tissue volume and laxity of the overlying skin. Volumetric augmentation is a key component of facial rejuvenation surgery, and should be considered of equal importance to soft tissue lifting. Augmentation can be accomplished with synthetic fillers, autologous grafts, soft tissue repositioning techniques, and/or alloplastic implants. Only alloplastic implants, however, provide truly long-term volumetric correction. To date, there have been no large series dealing with the complications and results of implantation performed concurrently with rhytidectomy, which we have termed “volumetric rhytidectomy.” We present our experience with 100 patients treated with a combination of malar and chin implants and rhytidectomy, compared to 200 patients who underwent rhytidectomy alone. Methods The authors performed a retrospective review of patients treated with a combination of silicone malar and chin augmentation with rhytidectomy versus patients treated with rhytidectomy alone. Both groups of patients underwent close postoperative evaluation at 3 days, 1 week, 2 weeks, and 1 month. All patients were surveyed at 6 months to assess aesthetic satisfaction. Complication rates were noted and tabulated. Statistical analysis was performed to evaluate for any differences in the two groups. Results Between 2002 and 2006, 100 patients underwent malar and chin implantation along with rhytidectomy; 200 patients underwent rhytidectomy alone. In the first group, there were a total of 6 cases in which implant removal was necessary, and 2 cases in which revision was required. There were no statistically significant differences (p < 0.05) observed between the two groups with respect to major or minor hematoma, seroma, infection, sensory nerve injury, facial nerve injury, hypertrophic scarring, dehiscence, skin sloughing, or revision. Conclusions Volumetric rhytidectomy reliably augments the malar and mental areas, allows for subtle skeletal contouring, and results in successful rejuvenation. Rhytidectomy is relatively safe to perform concurrently with silicone augmentation, and does not result in an increased complication rate as compared to rhytidectomy alone.

Does suture material and technique really matter? Lessons learned from 800 consecutive blepharoplasties.

Objectives: The purpose of this study was to evaluate established suture materials and techniques for blepharoplasty closure and evaluate for any differences in rates of complications between these groups.

Sonopalpation A Novel Application of Ultrasound for Detection of Submandibular Calculi

OBJECTIVE To study the sensitivity and specificity of physical examination, ultrasound (US) alone, and sonopalpation (concurrent US and transoral palpation) for identification of submandibular gland (SMG) calculi. STUDY DESIGN Case series with prospective data collection. SETTING Tertiary-level academic center. SUBJECT AND METHODS Patients with suspected SMG swelling were examined by physical examination, US alone, and sonopalpation. The presence or absence and location of sialolithiasis was noted in each group. Sialendoscopy, open sialolithotomy, or sialadenectomy was performed as the gold standard for definitive diagnosis. Sensitivity and specificity for each technique was then determined. RESULTS Sixty-nine patients were identified with SMG swelling. Physical examination, US, and sonopalpation positively identified sialoliths in 49, 54, and 57 patients, respectively. Fifty-nine patients eventually demonstrated calculi. Sensitivity of physical examination, US alone, and sonopalpation for SMG calculi was 83%, 91%, and 96.6%, respectively. Specificity for physical examination was 60%, 80% for US alone, and 90% for sonopalpation. Of 59 patients with stones, 17 patients underwent purely endoscopic procedures, 36 patients underwent combined or purely transoral approaches, and 6 underwent sialadenectomy. Of the 3 modalities, only sonopalpation was able to both identify and localize pathology and guide treatment management. CONCLUSION US is effective in the diagnosis and management of SMG stones during sialendoscopy or sialolithotomy. Sonopalpation has increased sensitivity and specificity over US alone or physical examination not only for the detection of SMG calculi but also for localization of pathology in the ductal system.Objective To study the sensitivity and specificity of physical examination, ultrasound (US) alone, and sonopalpation (concurrent US and transoral palpation) for identification of submandibular gland (SMG) calculi. Study Design Case series with prospective data collection. Setting Tertiary-level academic center. Subject and Methods Patients with suspected SMG swelling were examined by physical examination, US alone, and sonopalpation. The presence or absence and location of sialolithiasis was noted in each group. Sialendoscopy, open sialolithotomy, or sialadenectomy was performed as the gold standard for definitive diagnosis. Sensitivity and specificity for each technique was then determined. Results Sixty-nine patients were identified with SMG swelling. Physical examination, US, and sonopalpation positively identified sialoliths in 49, 54, and 57 patients, respectively. Fifty-nine patients eventually demonstrated calculi. Sensitivity of physical examination, US alone, and sonopalpation for SMG calculi was 83%, 91%, and 96.6%, respectively. Specificity for physical examination was 60%, 80% for US alone, and 90% for sonopalpation. Of 59 patients with stones, 17 patients underwent purely endoscopic procedures, 36 patients underwent combined or purely transoral approaches, and 6 underwent sialadenectomy. Of the 3 modalities, only sonopalpation was able to both identify and localize pathology and guide treatment management. Conclusion US is effective in the diagnosis and management of SMG stones during sialendoscopy or sialolithotomy. Sonopalpation has increased sensitivity and specificity over US alone or physical examination not only for the detection of SMG calculi but also for localization of pathology in the ductal system.

Miller fisher syndrome presents as an acute voice change to hypernasal speech.

The authors describe a 38‐year‐old man who presented with hypernasality, perioral and acroparesthesia, dyspnea, and dysphagia. Further evaluation revealed a diagnosis of Miller‐Fisher syndrome (MFS). MFS is a variant of Guillain‐Barré syndrome previously described in neurology and critical care journals; however, there is a paucity of work concerning this disease in the otolaryngology literature. An acute change in voice usually occurs secondary to inflammatory processes as seen after intubation and infection, but can occur as part of a more complex disease entity such as Guillain‐Barré or Miller‐Fisher syndrome. As such, clinicians should consider this in their evaluation of rhinolalia aperta. Laryngoscope, 2010

Management of the nasolacrimal system during transnasal endoscopic medial maxillectomy

Background During transnasal endoscopic medial maxillectomy (TEMM) for sinonasal tumors, the nasolacrimal duct (NLD) is resected as it forms part of the medial wall of the maxillary sinus. This disrupts the nasolacrimal drainage system. To ensure that epiphora does not develop after such resection, an endoscopic dacryocystorhinostomy (DCR) is traditionally performed. This is based primarily on prior experience with open medial maxilloethmoidectomy. It is unclear whether a concurrent DCR during endoscopic medial maxillectomy is necessary, however. This study was designed to compare patients undergoing TEMM with or without concurrent DCR for postoperative patency of the NLD. Methods This is a prospective cohort study comparing12 patients undergoing TEMM, 5 with concurrent DCR and 7 without, to assess for patency of the NLD system. In the group that underwent a concurrent DCR, a Jones silastic stent was inserted for 2–3 months. Patients were followed for a minimum of 1 year for assessment of epiphora. The patency of the NLD was judged by clinical and qualitative evidence for epiphora. Results None of the patients in either group developed epiphora. All were completely symptom free for epiphora during the follow-up period. Conclusion It appears that after TEMM, patients do not develop epiphora, whether or not a concurrent DCR is performed. Hence, a concurrent DCR does not seem necessary during TEMM.

Semiquantitative and Quantitative Analyses of Dynamic Contrast-Enhanced Magnetic Resonance Imaging of Thyroid Nodules.

Objective This study was aimed to determine the utility of quantitative dynamic contrast-enhanced magnetic resonance imaging (MRI) in differentiating benign and malignant lesions in patients with known thyroid gland lesions scheduled for resection. Methods Patients scheduled for resection of a thyroid mass were prospectively enrolled. Dynamic contrast-enhanced MRI scans of the neck were performed before surgery. After resection, patients were divided into benign and malignant groups. Quantitative and semiquantitative MRI kinetic measurements of benign and malignant lesions were compared and analyzed. Results Twelve benign and 9 malignant lesions were identified in 19 patients. Mean Ktrans, Ve, and Kep for benign lesions were 1.69 ± 1.59 min−1, 0.44 ± 0.21 min−1, and 4.51 ± 2.96 min−1, respectively; for the malignant lesions, 0.96 ± 0.57 min−1, 0.45 ± 0.19 min−1, and 3.57 ± 3.53 min−1, respectively (P = 0.1886, 0.8036, and 0.3028, respectively). Tpeak, ERmax, slopemax, and iAUGC60 for benign lesions were 7.00 ± 8.09 seconds, 293.27 ± 141.25 seconds, 76.45 ± 65.80 seconds, and 63.46 ± 46.84, respectively; for malignant lesions, 8.11 ± 8.55 seconds, 227.6 ± 113.37 seconds, 81.17 ± 109.71 seconds, and 43.69 ± 26.19, respectively (P = 0.7525, 0.4941, 0.4474, and 0.3028, respectively). Conclusions Dynamic contrast-enhanced MRI pattern of kinetics was not significantly different for benign and malignant lesions of the thyroid using quantitative or semiquantitative methods.