David J. Arnold

Sentinel node biopsy in oral cavity cancer: Correlation with pet scan and immunohistochemistry

Lymphoscintigraphy and sentinel node biopsy (LS/SNB) is a minimally invasive technique that samples first‐echelon lymph nodes to predict the need for more extensive neck dissection.

MUC4 and ERBB2 expression in major and minor salivary gland mucoepidermoid carcinoma

Peptide sequence homology between the gene product of human MUC4 and rat sialomucin complex (SMC) has recently been reported. Each contains a mucin subunit with antiadhesive activity linked to the plasma membrane by means of a transmembrane subunit with two epidermal growth factor (EGF)–like domains that act as ligand for ErbB2. This study investigates MUC4 and ErbB2 receptor expression in major and minor salivary gland mucoepidermoid carcinoma and correlates patterns of expression with clinical outcomes.

Laryngeal Cancer Cost Analysis: Association of Case‐Mix and Treatment Characteristics With Medical Charges

Objectives: To examine the relationship of various pretreatment case‐mix characteristics and treatment modalities with medical charges incurred during diagnosis, treatment, and 2‐year follow‐up for patients with laryngeal cancer.

MANAGEMENT OF THE NECK IN MERKEL CELL CARCINOMA OF THE HEAD AND NECK: UNIVERSITY OF MIAMI EXPERIENCE

We reviewed management of the cervical lymph nodes in patients with Merkel cell carcinoma (MCC) of the head and neck.

Professional Burnout Among Microvascular and Reconstructive Free-Flap Head and Neck Surgeons in the United States

OBJECTIVES To determine the prevalence of professional burnout among microvascular free-flap (MVFF) head and neck surgeons and to identify modifiable risk factors with the intent to reduce MVFF surgeon burnout. DESIGN A cross-sectional, observational study. SETTING A questionnaire mailed to MVFF surgeons in the United States. PARTICIPANTS A total of 60 MVFF surgeons. MAIN OUTCOMES MEASURES Professional burnout was quantified using the Maslach Burnout Inventory- Human Services Study questionnaire, which defines burnout as the triad of high emotional exhaustion (EE), high depersonalization (DP), and low personal accomplishment. Additional data included demographic information and subjective assessment of professional stressors, satisfaction, self-efficacy, and support systems using Likert score scales. Potential risk factors for burnout were determined via significant association (P < .05) by Fisher exact tests and analyses of variance. RESULTS Of the 141 mailed surveys, 72 were returned, for a response rate of 51%, and 60 of the respondents were practicing MVFF surgeons. Two percent of the responding MVFF surgeons experienced high burnout (n = 1); 73%, moderate burnout (n = 44); and 25%, low burnout (n = 15). Compared with other otolaryngology academic faculty and department chairs, MVFF surgeons had similar or lower levels of burnout. On average, MVFF surgeons had low to moderate EE and DP scores. High EE was associated with excess workload, inadequate administration time, work invading family life, inability to care for personal health, poor perception of control over professional life, and frequency of irritable behavior toward loved ones (P < .001). On average, MVFF surgeons experienced high personal accomplishment. CONCLUSIONS Most MVFF surgeons experience moderate professional burnout secondary to moderate EE and DP. This may be a problem of proper balance between professional obligations and personal life goals. Most MVFF surgeons, nonetheless, experience a high level of personal accomplishment in their profession.

Pediatric microvascular reconstruction: a report from the Microvascular Committee.

BACKGROUND: Free tissue transfer is an integral part of modern head and neck surgery in the adult population. Its use in the pediatric population has not been well described. Recently, there has been an increase in the application of these techniques in the pediatric population. The morbidity of free tissue transfer in small pediatric patients and its effect on growth has not been well described. OBJECTIVE: To evaluate the utility of microvascular reconstruction techniques in the pediatric population. STUDY DESIGN: A consensus study was performed by the microvascular committee of the American Academy of Otolaryngology-Head and Neck Surgery. Thirty active microvascular surgeons reviewed their databases to find patients less than 21 years of age who underwent free tissue transfer. RESULTS: 49 free tissue transfers performed between 1999 and 2005. The mean age was 12.1 years (age range, 3–21). The types of flaps transferred were radial forearm (10), fibula (21), rectus abdominus (7), scapula (1), latissimus dorsi (3), groin (1), gracillus (4), and jejunum (2). Morbidity at the donor site was relatively minimal. Five patients developed wound breakdown. One of these required return to the operating room. Morbidity at the reconstructed site was also rare. Patients were followed for an average of 49 months (range, 1–131 months), and no problems were noted with growth at the donor or recipient sites. CONCLUSIONS: Free flaps in the pediatric population have morbidity and survival similar to those in the adult population. SIGNIFICANCE: While indications differ from those in the adult population, these techniques are viable and valuable and should be considered in the pediatric reconstructive paradigm.

Five-chlorodeoxycytidine, a tumor-selective enzyme-driven radiosensitizer, effectively controls five advanced human tumors in nude mice.

PURPOSE The studys goals were as follows: (1) to extend our past findings with rodent tumors to human tumors in nude mice, (2) to determine if the drug protocol could be simplified so that only CldC and one modulator, tetrahydrouridine (H4U), would be sufficient to obtain efficacy, (3) to determine the levels of deoxycytidine kinase and dCMP deaminase in human tumors, compared to adjacent normal tissue, and (4) to determine the effect of CldC on normal tissue radiation damage to the cervical spinal cord of nude mice. METHODS AND MATERIALS The five human tumors used were as follows: prostate tumors, PC-3 and H-1579; glioblastoma, SF-295; breast tumor, GI-101; and lung tumor, H-165. The duration of treatment was 3-5 weeks, with drugs administered on Days 1-4 and radiation on Days 3-5 of each week. The biomodulators of CldC were N-(Phosphonacetyl)-L-aspartate (PALA), an inhibitor of aspartyl transcarbamoylase, 5-fluorodeoxycytidine (FdC), resulting in tumor-directed inhibition of thymidylate synthetase, and H4U, an inhibitor of cytidine deaminase. The total dose of focused irradiation of the tumors was usually 45 Gy in 12 fractions. RESULTS Marked radiosensitization was obtained with CldC and the three modulators. The average days in tumor regrowth delay for X-ray compared to drugs plus X-ray, respectively, were: PC-3 prostate, 42-97; H-1579 prostate, 29-115; glioblastoma, 5-51; breast, 50-80; lung, 32-123. Comparative studies with PC-3 and H-1579 using CldC coadministered with H4U, showed that both PALA and FdC are dispensable, and the protocol can be simplified with equal and possibly heightened efficacy. For example, PC-3 with X-ray and (1) no drugs, (2) CldC plus the three modulators, (3) a high dose of CldC, and (4) escalating doses of CldC resulted in 0/10, 3/9, 5/10, and 6/9 cures, respectively. The tumor regrowth delay data followed a similar pattern. After treating mice only 11/2 weeks with CldC + H4U, 92% of the PC-3 tumor cells were found to possess CldU in their DNA. The great majority of head-and-neck tumors from patient material had markedly higher levels of dC kinase and dCMP deaminase than found in adjacent normal tissue. Physiologic and histologic studies showed that CldC + H4U combined with X-ray, focused on the cervical spinal cord, did not result in damage to that tissue. CONCLUSIONS 5-CldC coadministered with only H4U is an effective radiosensitizer of human tumors. Ninety-two percent of PC-3 tumor cells have been shown to take up ClUra derived from CldC in their DNA after only 11/2 weeks and 2 weeks of bolus i.p. injections. Enzymatic alterations that make tumors successful have been exploited for a therapeutic advantage. The great electronegativity, coupled with the relatively small Van der Waal radius of the Cl atom, may result in CldCs possessing the dual advantageous properties of FdC on one hand and BrdU and IdU on the other hand. These advantages include autoenhancing the incorporation of CldUTP into DNA by not only overrunning but also inhibiting the formation of competing TTP pools in tumors. A clinical trial is about to begin, with head-and-neck tumors as a first target of CldC radiosensitization.

Permeability of tympanotomy tubes to ototopical preparations.

Myringotomy with tube placement is the most frequently performed otolaryngologic procedure in the United States, and purulent otorrhea after this procedure is not uncommon. Believing that ototopical preparations have proved useful in treating this malady, our group was compelled to examine whether and in what quantities these preparations are able to penetrate tympanotomy tubes. To this end, models were constructed and in vitro testing carried out with several popular formulations.

Inflammatory neuroma of the facial nerve associated with chronic otomastoiditis

| t is well known tha t o to log ic infec t ion can compro mise facial nerve funct ion . 1-7 This cause of seventh nerve c o m p r o m i s e has b e c o m e ra re in the pos tan t ib iot ic era. T a k a h a s h i et al. 2 found 50 cases of facial pa lsy caused by ot i t is m e d i a tha t m a d e up 3.1% of all cases o f facial para lys is dur ing a 10-year pe r iod . Djer ic , 3,4 and Schuknech t a s tud ied t e m p o r a l bone spec imens f rom pa t i en t s wi th acute and chronic ea r d isease . His to log ic ev idence of nerve invo lvement was ev ident in subjects bo th wi th and wi thou t clinical d e c r e a s e in ne rve funct ion. W h e n facial pares i s occurs wi th o to log ic infect ion, it is thought to be pa thophys io log ica l ly due to e i the r d i rec t in f lammatory effects on the nerve or compres s ion a t rophy. T h e occu r r ence of facial para lys is is not d e p e n d e n t on the ex ten t of bone des t ruc t ion involving the facial canal . A l t h o u g h it is a c c e p t e d tha t chronic ea r infec t ion and c h o l e s t e a t o m a can c o m p r o m i s e facial nerve funct ion, to our knowledge no case has b e e n p r e s e n t e d prev ious ly of facial para lys is a s soc ia t ed with chron ic oti t is m e d i a and n o n n e o p l a s t i c facial nerve n e u r o m a .

Diagnostic pitfalls of infarcted Warthin tumor in frozen section evaluation

Warthin tumor (WT) is the second most common benign salivary gland neoplasm and has characteristic cytologic and histologic findings. Fine-needle aspiration is a common and useful preoperative diagnostic technique, which sometimes leads to ischemic injury resulting in the infarction of these lesions. Infarcted WT may demonstrate variable gross and histologic alterations that may render the diagnosis challenging, particularly during intraoperative frozen section evaluation. In this study, we collected 11 resection specimens from 9 patients with infarcted WT. Seven patients were men and 2 were women, ranging from 49 to 85 years (mean, 69). All the patients had fine-needle aspiration before the resection. Macroscopically, the tumors were tan-white and contained soft, yellow, exudative material. The histologic findings were variable and included necrosis, ghosts of papillae, squamous metaplasia, cholesterol clefts, foamy macrophages, multinucleated giant cell reaction, necrotizing granulomas, and fibrosis. Each case predominantly demonstrated 1 or 2 of these histomorphologic features. In the permanent sections, additional sampling revealed foci of residual viable WT in 8 cases. Three cases were completely infarcted; however, they all had ghost-like papillae in which the architecture of WT was evident. Infarcted WT may present a diagnostic challenge during intraoperative frozen section evaluation. Associated morphologic alterations may preclude a definitive diagnosis of WT and may mimic malignancy. Awareness of the gross and microscopic features associated with infarcted WT is important, particularly for accurate frozen section evaluation of these salivary gland tumors.