Brian L. Matthews

Multiple simultaneous tumors in patients with head and neck cancer. A prospective, sequential panendoscopic study

A prospective panendoscopic study (bronchoscopy, laryngoscopy, esophagoscopy) was carried out in 81 consecutively seen, untreated patients newly diagnosed as having a mucosal neoplasm in the upper aerodigestive tract, to determine how many had a synchronous second primary lesion of the aerodigestive tract. Fourteen patients (17%) proved to have multiple primary lesions (14 second‐primary and two third‐primary lesions). Three lesions were hypopharyngeal, six esophageal, three pulmonary, two laryngeal, and two oropharyngeal. Two of the additional lesions were found during routine head and neck examination, nine lesions would have been found with a single routine symptom‐ or roentgenogram‐directed endoscopic examination; five, because of their location or small size, would not have been found without panendoscopy, even after chest roentgenography, indirect laryngoscopy, and barium esophagography had been done. The most productive endoscopic examinations for detecting second primary lesions were esophagoscopy and laryngoscopy, the former detecting six lesions, the latter five lesions. The yield of chest roentgenograms was low (1/79). No complications resulted from this prospective panendoscopic protocol study. These findings should reinforce the belief that head and neck cancer is a panmucosal disease of the aerodigestive tract, that silent second synchronous primary lesions are not uncommon, and that every effort should be made to find all primary sites before treatment of the index tumor is begun.

Reflux in infants with laryngomalacia: results of 24-hour double-probe pH monitoring.

Laryngomalacia is the most common cause of stridor in children. Previous studies using barium esophagrams or single-probe esophageal pH testing have indicated that 68% to 80% of infants with laryngomalacia have reflux. A recent study in a large series of pediatric patients has shown that these 2 testing modalities are relatively insensitive in detecting reflux when compared with 24-hour double-probe pH testing. This study was undertaken to determine the incidence and frequency of reflux in children with laryngomalacia by use of 24-hour double-probe pH monitoring. Twenty-four children with endoscopically diagnosed laryngomalacia underwent 24-hour double-probe pH testing. The distal probe was placed in the lower esophagus, and the proximal probe was placed just above the cricopharyngeus immediately posterior to the larynx. All 24 (100%) children had pharyngeal acid exposure as judged by the proximal pH probe. These children had a mean of 15.21 episodes of reflux to the level of the pharynx during the 24-hour study period. In contrast, only 16 (66%) children had abnormal acid exposure as measured by the distal esophageal probe. These results indicate that essentially all children with laryngomalacia have reflux of gastric acid to the pharyngeal level. Multiple authors have documented the detrimental effects of acid and the accompanying pepsin in the larynx and tracheobronchial tree. Persistent laryngeal edema is an almost universal finding in patients with reflux to the pharyngeal level and is a common finding in children with laryngomalacia. In some patients with laryngomalacia, reflux may be the primary cause of their airway compromise, whereas in others it may be a significant cofactor exacerbating a preexisting neurologic or anatomic abnormality.

Endoscopic Sinus Surgery: Outcome in 155 Cases

For this retrospective study of endoscopic sinus surgery, charts of 22 patients from a medical center and 133 patients from a private practice (N = 155) were reviewed. Preoperative complaints, clinical findings, computed tomographic evidence of extent of sinus disease, surgical outcome, possible predictors of success, and complications were considered. Indications for endoscopic surgery were persistence of symptoms despite aggressive medical therapy and radiologic evidence of a significant sinus abnormality. Median followup was 12 months. Hemorrhage occurred postoperatively in two patients (1.5%); 17 patients required additional endoscopic surgery. Overall, 140 (91%) patients believed that the surgery was beneficial. Patients with facial pain pre-operatively showed the greatest improvement. All patients having simultaneous septoplasty (N = 64) had successful outcome. The total number of opacified sinuses was not a predictor of outcome, but opacification of the sphenoid sinus correlated with a poorer outcome. The patients seen at the medical center had poorer results, but had a larger number of opacified sinuses, were more likely to have had previous sinus surgery, and were more likely to have underlying medical conditions contributing to their sinus disease.

Chronic sinusitis : characterization of cellular influx and inflammatory mediators in sinus lavage fluid

Chronic sinusitis is a recurrent disorder commonly found in atopic individuals, yet few studies have explored the role of inflammatory mediators in sinusitis. Sinus lavage fluid from ten patients with chronic sinusitis obtained during endoscopic surgery was analyzed for total cell counts and then assayed for histamine, immunoreactive leukotriene C4/D4/E4 (LTC4/D4/E4), and prostaglandin D2 (PGD2). All ten patients had been unresponsive to medical treatment, including oral corticosteroids in most cases. High concentrations of histamine, LTC4/D4/E4 and PGD2 were found in sinus fluid and were comparable to levels seen in nasal secretions of allergic rhinitis patients following allergen challenge. In the sinus fluid, inflammatory cells were predominantly neutrophils with only low percentages of mast cells, basophils or eosinophils. On the basis of the histamine and PGD2 concentrations in sinus fluid, we conclude that mast cell/basophil activation does occur in chronic sinusitis and may contribute to the persistent inflammation present in sinusitis.

Vestibular Contribution to Spatial Orientation

To determine if animals are capable of utilizing vestibular sensory input for spatial orientation, a six-arm radial maze with a rotating central turntable was constructed. Sprague-Dawley rats were trained on this apparatus by rotating them without visual, auditory, or olfactory cues. Animals were required to locate a reward (located in a constant position relative to the starting position) following random rotations varying from 0 to pm360d`, growing progressively larger in 60d` increments. Normal rats (N= 10) showed a steady improvement in performance over the training and testing period. Bilateral labyrinthectomy (N=5) produced a profound decrement in that performance (p>0.001). When visual cues were added, labyrinthectomized animals improved their performance, but remained significantly below that of normal animals without visual cues (p>0.001). Normal animals allowed to use visual cues showed no improvement over their performance without visual cues. The results indicate that rats can utilize vestibul...

Rotational stimulation disrupts spatial learning in fornix-lesioned rats

Normal and fornix-lesioned rats were trained to find water in a version of a spatial discrimination task involving the use of a cross maze modified for interspersing rotational stimulation before the start of each trial. The central (cross) portion of the maze rested on a turntable and consisted of a covered start box opening into the intersection of the cross, allowing choice among three covered alleys, each of which led through a black curtain onto a stationary goal arm. The animal could be started in one of three positions (0 degree, 90 degrees, 270 degrees) in relation to the rewarded goal arm. Room cues were not available until after the animal made the choice in the covered tunnel area. A 20-day testing period in which one to ten full revolutions were interspersed before the start of each trial revealed marked differences between normal and fornix-lesioned animals. The overall performance of normal animals improved from 40% correct choices to 85% correct during the testing period. Fornix-lesioned rats showed no significant improvement during the same period. Performance on probe trials in which room cues were made available to the animals during interspersed rotations improved rapidly and was not significantly different between the two groups. The results suggest that adaptation to vestibular system stimulation was required to solve the covered tunnel task in normal rats and that such processes were disrupted in fornix-lesioned rats.

Once‐A‐Day therapy for sinusitis: A comparison study of cefixime and amoxicillin

The efficacy and safety of a once‐a‐day antibiotic in the treatment of sinusitis was studied. Two randomly assigned groups were treated with either once‐a‐day cefixime, a third generation cephalosporin, or amoxicillin three times a day.

Basaloid-squamous carcinoma of the palate.

Basaloid-squamous carcinoma is a rare, nonsquamous cell tumor presenting in the head and neck that has recently been described. The clinical and histopathologic features of basaloid-squamous carcinoma derived from the 12 reported cases in the literature, including our case resembling an arteriovenous malformation, are described. The important interaction of the operating surgeon with the surgical pathologist in guiding the extent of the resection is emphasized.

Incidence of pulmonary edema after tracheotomy for obstructive sleep apnea.

OBJECTIVE: The phenomenon of postobstructive pulmonary edema (POPE) has been associated with the relief of upper airway obstruction, which itself is fundamental to the pathophysiology of obstructive sleep apnea (OSA). A review of patients with OSA undergoing tracheotomy was performed to characterize this process. STUDY DESIGN: Retrospective chart review of study patients with OSA undergoing tracheotomy and of control patients without OSA undergoing tracheotomy for unrelated problems. Chest radiographs were reviewed in a double-blind fashion to score posttracheotomy changes in pulmonary status. SETTING: Academic tertiary referral center. RESULTS: Thirty (67%) of 45 OSA patients treated by tracheotomy had evidence of POPE, whereas only 5 (20%) of 25 control group patients had increased pulmonary edema. The remaining 15 (33%) of 45 OSA patients and 20 (80%) of 25 control patients had either no change or an improved pulmonary status. Those with OSA that developed POPE were mostly graded as having mild pulmonary edema (22/30, 73%). Far fewer were graded as having moderate pulmonary edema (6/30, 20%), and fewer still with severe pulmonary edema (2/30, 7%). Two (7%) of 45 patients with severe POPE died of complications related to cor pulmonale in the postoperative period. CONCLUSION: Results support maintaining a high index of suspicion for the development of postobstructive pulmonary edema in patients treated for OSA. Treatment options, such as positive pressure ventilation and diuresis, and an increased awareness of this condition may help reduce the morbidity and mortality associated with treatment of this disease.

Pulmonary edema after tracheotomy for obstructive sleep apnea

within each group, and a t test was used to compare both groups. A P value of 0.05 was considered significant. Results: The 2 populations did not differ in age, sex ratio, snorers/sleep apneics ratio, or severity of sleep apnea when present. RF significantly improved snoring, with a mean score of 1.6 after a mean of 2.6 treatments compared with a score of 8.1 before surgery. Efficacy of LAUP was not significantly different. Mean discomfort and mean pain for the first 7 days were, respectively, 3 and 4 times worse for LAUP than for RF. Doses of level I and level II analgesics absorbed were significantly higher for LAUP than for RF. Doses of anti-inflammatory drugs used were the same. Abnormal diet duration was significantly higher for LAUP than for RF. Conclusion: RF, in our study, was as efficacious for a short-term period as LAUP but was better tolerated. These results must be confirmed in a larger population.