Eric Wirtz

Diagnostic efficacy of surgeon-performed ultrasound-guided fine needle aspiration: A randomized controlled trial

Objective: To evaluate the clinical efficacy of surgeon-performed, office-based head and neck ultrasound in facilitating diagnostic fine needle aspiration (FNA) of lesions in the head and neck. Study Design: A randomized controlled trial of ultrasound-guided FNA versus traditional palpation-guided technique for palpable masses in the head and neck. Setting: An office-based study performed in a military academic medical center. Subjects and Methods: Eighty-one adults older than 18 years of age with a palpable head and neck mass (less than 3 cm in largest diameter) were randomized to ultrasound-guided or traditional palpation-guided FNA of a head and neck mass. Measured variables and outcomes for the study included tissue adequacy rates, tissue type, and operator variability. Results: Following three passes using either palpation or ultrasound guidance, a comparative tissue adequacy rate of 84 percent for ultrasound guidance versus 58 percent for standard palpation was established (P < 0.014). With regard to tissue type, a statistically significant comparative diagnostic advantage for ultrasound guidance was observed in thyroid tissue while remaining statistically insignificant for lymphatic and salivary tissues. No statistical significance was found when comparing the ability of otolaryngology residents versus attending otolaryngologists to obtain ultrasound-guided diagnostic samples. Conclusion: Office-based surgeon-performed ultrasound-guided FNA of palpable lesions in the head and neck yields a statistically significant higher diagnostic rate compared to standard palpation technique. Our institutional experience supports the utility of surgeon-performed ultrasound as a core competency in clinical practice.

Efficacy of telavancin in the treatment of methicillin-resistant Staphylococcus aureus osteomyelitis: studies with a rabbit model

OBJECTIVES Staphylococcus aureus is the most common pathogen isolated in osteomyelitis. This study evaluated the efficacies of telavancin (an investigational, rapidly bactericidal lipoglycopeptide with a multifunctional mechanism of action against Gram-positive bacteria), vancomycin and linezolid in a rabbit methicillin-resistant S. aureus (MRSA) osteomyelitis model. METHODS Localized osteomyelitis was induced in New Zealand White rabbits by percutaneous injection of 10(6) cfu of MRSA clinical isolate 168-1 into the intramedullary cavity. Two weeks post-infection, rabbits with radiographically confirmed, localized proximal tibial osteomyelitis were randomized into four groups (n = 15 per group): untreated controls; vancomycin 30 mg/kg subcutaneously every 12 h; linezolid 60 mg/kg orally every 8 h; and telavancin 30 mg/kg subcutaneously every 12 h. After 4 weeks of antibiotic treatment, animals were left untreated for 2 weeks. Rabbits were then euthanized and the tibias harvested. Bone matrix and marrow from each tibia were cultured and bacterial counts determined. RESULTS For MRSA isolate 168-1, the MIC was 0.25 mg/L for telavancin, 0.5 mg/L for vancomycin and 0.5 mg/L for linezolid. Tibial cultures were positive for MRSA in 9 of 15 (60%) untreated controls, and 3 of 15 (20%) telavancin-treated, 3 of 15 (20%) vancomycin-treated and 4 of 14 (29%) linezolid-treated rabbits. CONCLUSIONS Telavancin has comparable efficacy to vancomycin and linezolid in a rabbit model of MRSA osteomyelitis.

Otolaryngology and medical malpractice: A review of the past decade, 2001–2011

To better understand the causes and outcomes of lawsuits involving otolaryngologists in the past decade by analyzing malpractice litigation trends to prevent future litigation and improve physician education.

Response of Head and Neck Squamous Cell Carcinoma Cells Carrying PIK3CA Mutations to Selected Targeted Therapies

IMPORTANCE The PIK3CA mutation is one of the most common mutations in head and neck squamous cell carcinoma (HNSCC). Through this research we attempt to elicit the role of oncogene dependence and effects of targeted therapy on this PIK3CA mutation. OBJECTIVES (1) To determine the role of oncogene dependence on PIK3CA-one of the more common and targetable oncogenes in HNSCC, and (2) to evaluate the consequence of this oncogene on the effectiveness of newly developed targeted therapies. DESIGN, SETTING, AND PARTICIPANTS This was a cell culture-based, in vitro study performed at an academic research laboratory assessing the viability of PIK3CA-mutated head and neck cell lines when treated with targeted therapy. EXPOSURES PIK3CA-mutated head and neck cell lines were treated with 17-AAG, GDC-0941, trametinib, and BEZ-235. MAIN OUTCOMES AND MEASURES Assessment of cell viability of HNSCC cell lines characterized for PIK3CA mutations or SCC25 cells engineered to express the PIK3CA hotspot mutations E545K or H1047R. RESULTS Surprisingly, in engineered cell lines, the hotspot E545K and H1047R mutations conferred increased, rather than reduced, IC50 assay measurements when treated with the respective HSP90, PI3K, and MEK inhibitors, 17-AAG, GDC-0941, and trametinib, compared with the SCC25 control cell lines. When treated with BEZ-235, H1047R-expressing cell lines showed increased sensitivity to inhibition compared with control, whereas those expressing E545K showed slightly increased sensitivity of unclear significance. CONCLUSIONS AND RELEVANCE (1) The PIK3CA mutations within our engineered cell model did not lead to enhanced oncogene-dependent cell death when treated with direct inhibition of the PI3K enzyme yet did show increased sensitivity compared with control with dual PI3K/mTOR inhibition. (2) Oncogene addiction to PIK3CA hotspot mutations, if it occurs, is likely to evolve in vivo in the context of additional molecular changes that remain to be identified. Additional study is required to develop new model systems and approaches to determine the role of targeted therapy in the treatment of PI3K-overactive HNSCC tumors.

Role of the otolaryngologist in the treatment of struma ovarii

Struma ovarii, a rare germ cell tumor of the ovary composed of >50% thyroid tissue, is traditionally managed by gynecologic surgeons. Although struma ovarii is typically cured by simple excision, otolaryngology‐head and neck surgeons may play a critical role in caring for these patients. In this article, we present two cases of struma ovarii and discuss the role of the otolaryngologist. Laryngoscope, 2010

Pathology Quiz Case 1

A 44-YEAR-OLD MAN PRESENTED WITH A 6-month history of a slow-growing, tender mass anterior to his left ear. His medical history was remarkable for hypertension and hyperlipidemia. He also had a 7 pack-year smoking history. He denied any previous infections, trauma, otalgia, fevers, chills, night sweats, unexpected weight loss, or other constitutional symptoms. The findings of the physical examination were normal with the exception of a 0.5-cm, firm, mobile, tender, superficial mass anterior to the left tragus. Facial movement was symmetrical bilaterally. There was no evidence of adenopathy. An ultrasonogram showed a 1 1-cm oval mass within the substance of the left parotid gland. After completion of a 2-week course of amoxicillin-clavulanate, without improvement, fine-needle aspiration (FNA) was performed, the results of which were nondiagnostic. Computed tomography of the neck with contrast revealed a 1-cm hyperdense nodule within the left parotid substance and fatty replacement of the left parotid gland (Figure 1). A superficial parotidectomy, which was performed through a facelift incision, demonstrated a wellcircumscribed, soft, pink-tan nodule, measuring 1.3 cm in greatest dimension. Hematoxylin-eosin (H&E)stained sections exhibited a nodular circumscribed lesion composed of variably sized cystic spaces with associated sclerotic collagenous tissue with normalappearing salivary gland tissue along the periphery (Figure 2). A high-power H&E-stained section revealed cells with classic apocrine metaplasia demonstrating decapitation secretion (Figure 3). Brightly staining eosinophilic zymogen granules of variable sizes were evident at the center of this H&E-stained section (Figure 4). What is your diagnosis?

RNA Interference of Transforming Growth Factor–β2 in Human Respiratory Fibroblasts

Objective. Transforming growth factor–β2 (TGF-β2) is a principal cytokine of interest in the pathogenesis of scar formation and is a potential target for future molecular-based adjunctive therapies. The authors hypothesize that interfering RNA (RNAi) can be used to modulate TGF-β2 production in cultured human respiratory fibroblasts. Study Design. Basic science. Setting. Laboratory. Subjects and Methods. RNAi constructs targeted to the TGF-β2 transcript were complexed with microsomal lipids and applied to human fibroblasts in cell culture. Transfection efficiency and cell viability were measured by fluorescence microscopy. Messenger RNA (mRNA) for TGF-β2 was measured 48 hours posttransfection using real-time quantitative PCR. The quantity of TGF-β2 protein produced with increasing concentrations of RNAi was measured using enzyme-linked immunosorbent assay. The function of RNAi-treated fibroblasts was tested using a wound-healing assay. Results. Transfection efficiency of more than 80% was achieved with minimal induced cell death. Treated cells showed selective knockdown of 80% of TGF-β2 mRNA, which was confirmed with negative controls. As the concentration of RNAi was increased, an incremental decrease in TGF-β2 protein was measured. Conclusion. RNAi technology is an effective means of localized and transient gene silencing in cultured human fibroblasts. Transfection can be achieved using microsome complexed RNAi with minimal induced cell death. This preliminary result shows promise for future in vitro studies.

An unusual cause of tachycardia, hypotension, and intraabdominal free fluid: ovarian hyperstimulation syndrome☆

We report a case of ovarian hyperstimulation syndrome (OHSS) in a 37-year-old female who had recently underwent assisted reproductive technology involving oocyte retrieval. Her emergency department (ED) presentation, clinical course, and a discussion of ovarian hyperstimulation syndrome are also presented. Ovarian hyperstimulation syndrome is a critical diagnosis in emergency medicine, and emergency physicians must consider it in the differential for any female nontrauma patient presenting with hypotension, tachycardia, and abdominal pain.