Jan C. Groblewski

Predictors of Residual Invasive Disease after Core Needle Biopsy Diagnosis of Ductal Carcinoma In Situ

Abstract:  Core needle biopsy (CNB) is used to sample both mammographically and ultrasound detected breast lesions. A diagnosis of ductal carcinoma in situ (DCIS) by CNB does not ensure the absence of invasive cancer upon surgical excision and as a result an upstaged patient may need to undergo additional surgery for axillary nodal evaluation. This study evaluates the accuracy of CNB in excluding invasive disease and the preoperative features that predict upstaging of DCIS to invasive breast cancer.

Management of subglottic cysts with Mitomycin-C—A case series and literature review

OBJECTIVES To describe the management and outcomes of seven infants with subglottic cysts. To assess the role of Mitomycin-C in the management of subglottic cysts. To discuss the relationship of subglottic cysts with gastro-esophageal reflux. To extensively review the literature on subglottic cysts. DESIGN Retrospective case series and literature review. METHODS Case series of seven children with subglottic cysts at a tertiary care hospital. Charts were reviewed to determine birth history, gender, intubation history, comorbidities, age at presentation, presenting symptoms, interventions and follow-up. RESULTS Between 2001 and 2009, seven patients aged 4-13 months were diagnosed with and treated for subglottic cysts. All children had a history of intubation and had evidence of gastro-esophageal reflux. All children were treated with endoscopic marsupialization (CO(2)-laser, cupped forceps) or bronchoscopic rupture; with or without concomitant topical Mitomycin-C therapy. Infants were followed clinically and with interval endoscopy with a minimum follow-up of 6 weeks. No patients receiving topical post-marsupialization Mitomycin-C (0/4) had cyst recurrence. Those patients who did not receive Mitomycin-C therapy recurred more frequently (66% - 2/3). Cysts ruptured with the bronchoscope tip recurred (66% - 2/3) more often than cysts undergoing endoscopic marsupialization (0/6). The one bronchoscopic rupture case that did not recur was the one in which Mitomycin-C was used concomitantly. Patient follow-up was at 2, 4 and 6 weeks post-procedure. CONCLUSION Endoscopic marsupialization is the treatment of choice for subglottic cysts. Gastro-esophageal reflux has a strong association with subglottic cysts. The post-marsupialization application of Mitomycin-C may have a role in reducing the recurrence rate and scarring after surgical treatment of subglottic cysts.

Dexmedetomidine and proprofol in complex microlaryngeal surgery in infants

We describe the case of an infant undergoing endoscopic repair of a laryngeal cleft where the combination of dexmedetomidine and propofol infusions was used as the anesthetic technique. With this regimen, endotracheal intubation was unnecessary during the perioperative period, the procedure lasted approximately 3h, and the child recovered uneventfully. Historically, the techniques used for microlaryngeal surgery involve the use of intermittent endotracheal intubation and insufflation of halogenated anesthetics to the oropharynx. Given the potential benefits of a technique that obviates the need for endotracheal intubation during microlaryngeal surgery and prevents insufflation of halogenated anesthetics in an open environment, the combination of propofol and dexmedetomidine should be considered as a viable and desirable anesthetic option for infants undergoing complex microlaryngeal surgery.

In reference to Wire grill brush bristle as an unusual foreign body: Report of two pediatric cases

We read with interest and concern the article titled ‘‘Wire Grill Brush Bristle as an Unusual Foreign Body: Report of Two Pediatric Cases.’’ In the article, Arganbright et al. described two pediatric patients who accidentally ingested wire bristles from grill cleaning brushes. Although this has historically been a very rarely reported foreign body, we have had a recent series of patients in our institution to further suggest a possible emerging consumer hazard. Over a 30-month period, our institution has treated eight patients for accidental grill-brush bristle ingestion. Six of these patients were recently reviewed by our radiology colleagues. In our series, patients ranged in age from 11 to 67 years. The most common complaints at the time of presentation were throat pain, odynophagia, and foreign body sensation that developed after the ingestion of grilled meat. Four of the eight patients required operative laryngoscopy with retrieval of the wire bristles. One patient underwent a tonsillectomy to remove a lodged wire bristle but continued to have a foreign body sensation postoperatively. The wire bristle was visualized in the tonsillar fossa and was removed in the office setting. All patients tolerated these procedures without complication. Three patients reported abdominal pain shortly after ingesting grilled meat. Two of these patients were found to have perforated jejunums, whereas in a third patient the wire perforated through the stomach and into the liver, causing a large hepatic abscess. The first two underwent uneventful laparoscopic surgical management, whereas the third underwent a laparotomy with partial hepatectomy. All three patients were discharged within 1 week of presentation. Reports of wire grill-brush bristle ingestion and/or aspiration have been sparse. In light of the article by Arganbright et al. and based on the recent experience in our institution, we believe that accidental grill-brush bristle ingestion and aspiration are more common than previously thought. Furthermore, these patients almost always need surgical intervention, and the potential related complications can be catastrophic. Given the widespread use of wire grill-brushes, it is imperative for the public to be made aware of this hazard.

Papillary Thyroid Cancer in a Child with Progressive Transformation of Germinal Centers.

Objectives. To describe the presentation and management of a child with Progressive Transformation of Germinal Centers (PTGC), an uncommon condition characterized by significant persistent lymphadenopathy, who developed papillary thyroid carcinoma and to explore and review potential links between PTGC and neoplastic processes in the head and neck. Methods. Case presentation and literature review are used. Results. A 10-year-old female presented with a right parotid mass and cervical lymphadenopathy. Multiple biopsies revealed PTGC without malignancy. Two years later, she developed fatigue and weight gain, and a thyroid nodule was found. Fine needle aspiration was strongly suggestive of papillary thyroid carcinoma. The patient underwent total thyroidectomy and central neck dissection without surgical management of the longstanding right lateral neck lymphadenopathy. Final pathology confirmed papillary thyroid carcinoma. She was treated with radioactive iodine therapy postoperatively and remains free of disease at three years of follow-up. Conclusions. PTGC is considered a benign condition but has previously been associated with Nodular Lymphocyte Predominant Hodgkin Lymphoma (NLPHL). This is the first reported case of papillary thyroid cancer in a child with preexisting cervical PTGC and no defined risk factors for thyroid malignancy. No link has been established with thyroid carcinoma, but patients with PTGC may have a defect in immune surveillance that predisposes them to malignancy.

Microdebrider-Assisted Supraglottoplasty for Laryngomalacia

Objective To describe our series in the surgical treatment of laryngomalacia using a microdebrider. Methods A retrospective review of patients undergoing supraglottoplasty for laryngomalacia at a tertiary childrens hospital between October 2004 and February 2008 was performed. Patients with complex co-morbidities and those undergoing alternative methods for supraglottoplasty were excluded. Patient charts and operative reports were reviewed to assess demographic characteristics, co-morbidities, procedural times, hospitalizations, intra-operative and post-operative complications, and post-operative outcome. Main outcome measures included complications, pain, resolution of stridor, presence of aspiration, and need for revision surgery. Results 27 patients underwent microdebrider-assisted supraglottoplasty. Mean age at diagnosis was 109 days; mean age at time of the procedure was 187 days. 18 Eighteen patients (67%) had gastro-esophageal reflux at the time the laryngomalacia was diagnosed. Average operative time was 35.7 minutes (std. dev. 12.9, range 11–65 minutes). No intra-operative complications or device problems were noted. Only 2 patients remained intubated at the conclusion of the procedure; no patient required tracheotomy or revision supraglottoplasty. One patient had post-operative aspiration, which later resolved. One patient was readmitted for stridor one month following her procedure. There was no pain from the procedure, as all patients immediately resumed a diet. All patients had eventual resolution of stridor. Conclusions This is the largest series of patients that underwent microdebrider-assisted supraglottoplasty for laryngomalacia. This procedure is safe, without pain, and effective in patients with laryngomalacia. Microdebrider- assisted supraglottoplasty is the method of choice for supraglottoplasty in our institution.

P157: Nasal Cavity Dimensions in the Normal Pediatric Population

followed by the parapharyngeal (27.8%) and submandibular (16.6%) space. Six (16.6%) children had infections in more than one fascial space. The most common known associated preceding illness was viral upper respiratory infection (53%). Neck swelling, fever, and dysphagia were the most frequent symptoms. The most common pathogens were Streptococcus pyogens(3/10) and Staphylococcus aureus(2/10). The mean duration of hospitalization was 7.7 days (range, 2-15). Leukocytosis (WBC 15000/mm3) was found in 13 (36%) patients. All patients received parenteral antibiotics after admission. Thirteen (36%) children recovered from the infection with conservative treatment and 23 (64%) children received surgical drainage. No complication and tracheotomy occurred. CONCLUSIONS: Deep neck space infections in children are rapidly progressive and usually present with neck swelling and fever. Peritonsillar space and Streptococcus pyogens infections were the most common anatomic site and pathogen in deep neck infection of children.

08:20: A Canine Model for Recurrent Respiratory Papillomatosis

broblasts in the scaffold were observed, with active protein synthesis and release. Viscoelastic shear properties of the scaffold were similar to those of the human vocal fold lamina propria. CONCLUSION: These findings supported the biocompatibility of the HUV scaffold and its potential in vocal fold tissue engineering applications. SIGNIFICANCE: Acellular biological scaffolds can promote a natural remodeling response for the reconstruction and regeneration of the vocal fold ECM, ideal for the phonosurgical replacement of lamina propria deficiencies and scars. Having the appropriate biomechanical properties conducive to phonation is a distinct advantage. SUPPORT: This work was supported by NIH Grant no. R01 DC006101.

P001: Obstructing Venous Malformation of the Tongue

OBJECTIVES: 1. Understand the natural progression of lingual venous malformations and the therapeutic dilemma they present. 2. Learn a novel approach to surgical salvage for lesions unresponsive to less-invasive therapies. METHODS: Case report and literature review. RESULTS: A 56-year-old female presented with progressive dyspnea, dysphagia, and insomnia secondary to increasing enlargement of an anterior tongue mass. Physical exam revealed a tongue mass extruding well beyond the confines of the oral cavity. After undergoing tracheostomy for airway control, conservative management with sclerotherapy was initiated. After two failed treatment cycles over the course of two months, the patient became profoundly debilitated by the disfiguring progression of her disease. Surgical intervention included strangulation with suture ligatures along the normal tongue border to secure control of vessels, followed by partial glossectomy and traditional anterior to posterior rotation for primary closure. The procedure was well tolerated, with an excellent functional and cosmetic result. She was decannulated 2 1/2 weeks after surgery and remains free of recurrence at 12-month follow-up. CONCLUSIONS: Although advances in sclerotherapy have increased the success of conservative management for lingual venous malformations, surgical resection remains an effective tool in the management of refractory cases. In this case, a safe and novel approach using intraoperative strangulation with suture ligatures prior to extirpation was successful.