Jeffrey H. Spiegel

Bald scalp in men with androgenetic alopecia retains hair follicle stem cells but lacks CD200-rich and CD34-positive hair follicle progenitor cells

Androgenetic alopecia (AGA), also known as common baldness, is characterized by a marked decrease in hair follicle size, which could be related to the loss of hair follicle stem or progenitor cells. To test this hypothesis, we analyzed bald and non-bald scalp from AGA individuals for the presence of hair follicle stem and progenitor cells. Cells expressing cytokeratin15 (KRT15), CD200, CD34, and integrin, α6 (ITGA6) were quantitated via flow cytometry. High levels of KRT15 expression correlated with stem cell properties of small cell size and quiescence. These KRT15(hi) stem cells were maintained in bald scalp samples. However, CD200(hi)ITGA6(hi) and CD34(hi) cell populations--which both possessed a progenitor phenotype, in that they localized closely to the stem cell-rich bulge area but were larger and more proliferative than the KRT15(hi) stem cells--were markedly diminished. In functional assays, analogous CD200(hi)Itga6(hi) cells from murine hair follicles were multipotent and generated new hair follicles in skin reconstitution assays. These findings support the notion that a defect in conversion of hair follicle stem cells to progenitor cells plays a role in the pathogenesis of AGA.

Microvascular Flap Reconstruction by Otolaryngologists: Prevalence, Postoperative Care, and Monitoring Techniques

Background/Objectives: Microvascular “free flap” transplants have become the preferred method of reconstruction for a great variety of complicated head and neck defects. As recently as 10 years ago, having a microvascular surgeon within a department of otolaryngology was the exception rather than the rule, whereas it is our impression that today most academic programs have one or more microvascularly trained head and neck surgeons. Among microvascular surgeons, postoperative care and management regimens vary greatly. Through informal conversations, we discerned that some surgeons take a very aggressive approach to monitoring, perhaps including prolonged stays in an intensive care setting with implanted Doppler devices to monitor flap blood flow and intravenous administration of dextran or other pharmaceutical projects. Others report that patients are quickly discharged from the hospital after just aspirin and subcutaneous heparin for a few days. Some physicians perform “flap checks” hourly, whereas others have residents check only once daily.

Hearing loss in Wegener's granulomatosis.

Objective: To describe the frequency, type, and clinical course of hearing loss in Wegeners granulomatosis and assess hearing loss as an indicator of disease activity. Study Design, Setting, and Patients: Retrospective cohort review of all patients with Wegeners granulomatosis seen in 1 year at an academic medical center. Main Outcome Measures: Hearing loss documented by pure-tone audiogram. Results: Thirty-six patients were included in the analysis: 20 men and 16 women, with a mean age of 55.5 years (range, 22–87 yr); 30 (83%) were antineutrophil cytoplasmic autoantibodies–positive, and the mean disease duration was 47 months (range, 2–196 mo). Twenty patients (56%) had documented hearing loss: there were 17 (47%) cases of sensorineural hearing loss and 12 (33%) cases of conductive hearing loss. Seven of 12 cases of conductive hearing loss improved with immunosuppressive treatment of Wegeners granulomatosis, 2 worsened, and 3 remained stable. Of 17 cases of sensorineural hearing loss, 3 improved, 4 worsened, and 10 remained stable. Seven patients had hearing loss requiring amplification. Five of 35 (14%) patients had established hearing loss months to years before diagnosis of Wegeners granulomatosis. Hearing loss occurred both on initial presentation and with disease relapse. The rates of conductive hearing loss (38%) and sensorineural hearing loss (31%) were also high in the subset of patients 65 years of age or younger and without history of noise exposure. Conclusions: Both sensorineural hearing loss and conductive hearing loss are common in Wegeners granulomatosis, may result in significant morbidity, and may precede the diagnosis of Wegeners granulomatosis by years. Both types of hearing loss in patients with Wegeners granulomatosis may be used as an indicator of disease. These data suggest that it may be appropriate to obtain screening audiograms in all patients with newly diagnosed or relapsing Wegeners granulomatosis.

Metastasis to the submandibular gland in head and neck carcinomas

The purpose of this retrospective chart review was to determine whether and how the submandibular gland is involved in metastases of squamous cell carcinoma of the head and neck.

Facial determinants of female gender and feminizing forehead cranioplasty

Information determined by viewing a face includes familiarity, emotion, attractiveness, and gender. However, the specific facial characteristics that enable one to identify gender are largely unknown. Research suggests that femininity is a critical component of beauty; however, the most important identifiers of a womans face are unknown. The objectives of this article were: 1) determine the area of the face most significant in identifying female gender, 2) determine if individuals with gender‐confirming surgery of the face are identified as male or female, 3) review the efficacy and safety of a series of feminizing forehead cranioplasties.

CT measurement of the frontal sinus – Gender differences and implications for frontal cranioplasty

OBJECTIVE To describe frontal sinus anatomy and explore gender variations that may have significance for cranioplasty and sinus surgery. METHODS 150 subjects who underwent maxillofacial computed tomography (CT) between 1/1/2008 and 6/11/2008 were enrolled. Frontal sinus dimensions and forehead measurements were taken at midline and at 10, 20, and 30 mm to the left and right of midline using sagittal, coronal, and axial images. The data was analyzed for significant differences between measurements made at the selected points in the frontal sinus, for left to right variations, and for gender variations. RESULTS Mean anterior table thickness ranged from 2.6 to 4.1 mm and was thinnest at 10 mm left and right of midline (2.9 and 2.6 mm). Mean anteroposterior depth of the frontal sinus ranged from 8.0 to 9.3 mm and did not vary significantly at any distance from midline. Frontal sinus height was greatest at midline (mean=24.5 mm) and progressively lessened at lateral distances. Mean total width at the level of the supraorbital ridge was 52.2 mm. For all measurements, no significant left to right variation was noted. Comparing the sexes, males were found to have greater dimensions in most frontal sinus measurements, though these differences were only found to be significant at or close to midline. The male forehead was marked by more acute nasofrontal angle (119.9° versus 133.5°) and a steeper posterior forehead inclination (-7.2° versus -3.5°). The glabella was wider in males (44.4 versus 33.9 mm) and more frequently protruded beyond the ideal forehead slope line (51% versus 30%). CONCLUSIONS Using CT imaging, forehead and frontal sinus dimensions have been described. Generally, males had larger overall frontal sinus dimensions, and this was most pronounced in the medial area of the supraorbital ridge known as the glabella.

Tympanic membrane perforation repair with acellular porcine submucosa.

Objectives: To evaluate the efficacy of acellular porcine small intestine submucosa in the repair of chronic tympanic membrane perforations. Although tympanoplasty with autologous temporalis fascia and cartilage is common practice in the repair of chronic tympanic membrane perforations, these materials are associated with increased operative time and have variable availability and quality in individual patients. Recently, new materials for tympanoplasty have been explored, including acellular human dermis. Small intestine submucosa (Surgisis) is an inexpensive and readily available alternative to autologous and cadaveric grafts. In this study, we examined the use of small intestine submucosa in the repair of chronic tympanic membrane perforations in a chinchilla model. Study Design: Prospective pilot study using 10 adult chinchillas. Methods: Chronic tympanic membrane perforations were created in 10 adult chinchillas for a total of 20 perforations. Each animal underwent observation in one ear and repair with either autologous cartilage or small intestine submucosa in the opposite ear with Type I tympanoplasty. Results: A total of 20 chronic membrane perforations were created, with zero healing spontaneously after 8 weeks. In tympanoplasties performed in five chinchillas with small intestine submucosa, five of five (100%) remained healed 6 weeks postoperatively, whereas three of five (60%) remained healed with cartilage repair. Histologic analysis was performed in both successful cartilage and small intestine submucosa repairs. Conclusion: These results suggest that small intestine submucosa is a viable alternative to autologous and cadaveric grafts in tympanoplasty. A larger randomized study in humans is indicated to evaluate this material in clinical practice.

Antibiotic prophylaxis in the management of complex midface and frontal sinus trauma.

Although mandible trauma has been studied extensively, there is no standard for use of pre‐ and postoperative antibiotics in other facial trauma. We sought to determine whether antibiotic strategies have an effect on infection rates.

Management of intracranial complications of sinus surgery

Endoscopic sinus surgery has an impressive and continually im-proving safety record. Increasing surgical experience and improved techniques and equipment make this procedure fundamentally safe. Anatomic variations, extensive disease, and the tight confines that the sinuses occupy between the skull base and orbits, however, do allow the possibility of untoward events. Many of these complications are minor, but the potential for significant morbidity, including blindness, diplopia, cerebrospinal fluid fistula with or without meningitis, intracranial brain injury, and hemorrhage from internal carotid artery injury, is real. This article discusses the avoidance and management of these complications.

Sjögren's disease

In summary, Sjögrens syndrome is a chronic autoimmune disorder characterized by lymphocytic infiltration of the exocrine glands, particularly the salivary and lacrimal glands. The sicca complex of xerophthalmia and xerostomia are the hallmark features of Sjögrens symptomatology. In addition to these hallmark symptoms of oral and ocular dryness, one third of patients with Sjögrens syndrome present with extraglandular manifestations. Many osf these extraglandular manifestations, as well as the sicca symptoms, have otolaryngologic relevance. Because patients with Sjögrens syndrome may present with vague or nonspecific head and neck complaints, ranging from oral dryness to hoarseness to hearing loss, an otolaryngologists high index of suspicion for this disorder may prevent delay in diagnosis, allow appropriate diagnostic evaluation, and optimize therapeutic intervention.