John P. Leonetti

Increased recurrence and metastasis in patients whose primary head and neck squamous cell carcinomas secreted granulocyte-macrophage colony-stimulating factor and contained CD34+ natural suppressor cells

Human head and neck squamous cell carcinomas (HNSCC) that produce high levels of granulocyte‐macrophage colony‐stimulating factor (GM‐CSF) have been shown to contain CD34+ natural suppressor cells that inhibit the activity of intratumoral T‐cells. The present study evaluated whether GM‐CSF production and the presence of CD34+ cells within primary HNSCC would translate into increased recurrence, metastasis or cancer‐related death during the 2 years following surgical excision. Freshly excised primary HNSCC of 20 patients that subsequently developed disease, and of 17 patients that remained with no evidence of disease were analyzed for production of GM‐CSF and for CD34+ cell content. The cancers of patients that subsequently developed recurrences or metastatic disease produced almost 4‐fold the levels of GM‐CSF and had approximately 2.5‐fold the number of CD34+ cells as did cancers of patients that remained disease‐free. In a second method of analysis, the prognostic significance of high vs. low GM‐CSF and CD34+ cell values was evaluated. These analyses showed that patients whose cancers produced high GM‐CSF levels or had a high CD34+ cell content had a disproportionately high incidence of recurrence or metastatic disease (94% and 100%, respectively), while the majority of patients whose primary cancers produced low levels of GM‐CSF or had a low CD34+ cell content remained disease‐free (16% and 19%, respectively). Our results indicate that the presence of CD34+ cells in GM‐CSF‐producing HNSCC is associated with a poorer prognosis for the cancer patients and suggest the utility of these parameters as prognostic indicators of outcome. Mechanistically, our results suggest that the presence of immune suppressive CD34+ cells in GM‐CSF‐producing HNSCC leads to increased tumor recurrence or metastasis.Int. J. Cancer 74:69–74.

Vascular considerations and complications in cranial base surgery.

The technical evolution of cranial base surgery has resulted in approaches that allow more radical surgical extirpation of complex cranial base lesions. Our service has extensively applied these cranial base approaches for lesions of the cranial base. A subgroup of 100 patients who had cranial base tumors involving potential manipulation or sacrifice of carotid arteries underwent 20-minute balloon test occlusions coordinated with vascular assessments consisting of a combination of the following: 1) four-vessel cerebral angiogram with compression studies; 2) occlusion transcranial Doppler ultrasonography; 3) occlusion single-photon emission computed tomography perfusion studies; and 4) xenon-133 cerebral blood flow studies. Transient neurological deficits associated with balloon test occlusion occurred in 7 of 100 patients (7%). Subsequently, 18 patients underwent permanent carotid occlusion by endovascular detachable balloons. Delayed ischemic complications (> 72 h) occurred in 4 of 18 (22%) patients. Additionally, a number of vascular complications not predicted by the balloon occlusion tests and vascular assessments were experienced. Repeat vascular assessments defined the causes and guided treatment of ischemic patients. Ischemic complications were caused by hemodynamic insufficiency, embolization, vasospasm, radiation vasculopathy, and venous anomaly. Our experience leads us to believe that no vascular assessment exists today that can predict the occurrence of vascular complications accurately. The current enthusiasm for cranial base surgery must be tempered with the sober reality that management of cerebrovascular anatomy and physiology remain significant limitations. Consideration of potential cerebrovascular complications is paramount to successful outcome and implementation of cranial base surgery.

Perioperative Complications With the Bone-Anchored Hearing Aid

OBJECTIVE: To discuss perioperative complications associated with the bone-anchored hearing aid (BAHA) and their management. STUDY DESIGN AND SETTING: A retrospective review of 58 patients who underwent implantation of BAHA for unilateral conductive, mixed, or sensorineural hearing losses was performed at a tertiary referral center. RESULTS: Between September 2003 and June 2005, 58 patients underwent implantation of a BAHA. There were 30 female and 28 male patients, with a mean age of 48 years (range 8–80 years). Complications occurred in 19% (11/58) of patients. Most adverse events were seen early in the series. The most common complication, partial or complete loss of the skin graft, occurred in 10% (6/58) of patients. These were managed successfully with local wound care. Five percent (3/58) of patients had skin growth over the abutment. Two of these cases were managed with office debridement, whereas 1 patient required revision under general anesthesia. There was implant extrusion in 3% (2/58) of patients, and both of these patients later underwent successful reimplantation. All patients had their implant activated 3 months after surgery. There were no perioperative or postoperative deaths. CONCLUSION: Complications related to BAHA implantation are relatively minor and usually involve partial or complete loss of the skin graft. Most complications were successfully managed in the office.

Facial Nerve Grading System 2.0

Objective: To present an updated version of the original Facial Nerve Grading Scale (FNGS), commonly referred to as the House-Brackmann scale. Study Design: Controlled trial of grading systems using a series of 21 videos of individuals with varying degrees of facial paralysis. Results: The intraobserver and interobserver agreement was high among the original and revised scales. Nominal improvement is seen in percentage of exact agreement of grade and reduction of instances of examiners differing by more then one grade when using FNGS 2.0. FNGS 2.0 also offers improved agreement in differentiating between grades 3 and 4. Conclusion: FNGS 2.0 incorporates regional scoring of facial movement, providing additional information while maintaining agreement comparable to the original scale. Ambiguities regarding use of the grading scale are addressed.

Improved Preservation of Facial Nerve Function in the Infratemporal Approach to the Skull Base

Although the infratemporal approach described by Fisch provides excellent exposure of the jugular foramen, intrapetrous carotid artery, and lateral skull base, the anterior displacement of the seventh cranial nerve often results In temporary facial paralysis. The use of a modified technique for facial nerve mobilization resulted In significant improvement of both early and final facial function. Since that earlier report, continuous intraoperative electrical facial nerve monitoring has been used during the infratemporal approach in 20 additional cases. Immediate postoperative facial function was normal in 93% of the monitored coses and In 70% of the cases in the unmonitored group. More Importantly, no patients in the monitored group developed grade V or VI weakness after surgery, whereas 48% of the unmonitored patients had grade V or VI weakness during the early postoperative period. This article will describe how intraoperative facial nerve monitoring is used during infratemporal surgery and will compare early facial function in 31 unmonitored patients with early facial function in 20 monitored procedures.

Clinical Course of Pediatric Congenital Inner Ear Malformations

Objective To determine any factors that could improve the early detection and management of congenital inner ear malformations.

Neurovascular considerations in surgery of glomus tumors with intracranial extensions

Paragangliomas of the skull base, by virtue of their location, locally infiltrative behavior, and vascular nature, are difficult tumors to resect. Surgical removal is especially complicated when intracranial extensions are encountered. Our experience with a one-stage resection of intracranial extensions of glomus tumors in 20 patients is presented. These 20 patients had a total of 29 paragangliomas: 23 glomus jugulare or tympanicum tumors, 5 carotid body tumors, and 1 pterygopalatine lesion. Ten patients had intradural extension; the other 10 had intracranial extradural tumors. The primary complicating treatment factor was the loss of surgical planes in 6 patients with prior surgery and or radiotherapy. The presence of multiple paragangliomas (20%) and catecholamine secretion by the tumors (15%) complicated surgical treatment as well. Surgical morbidity was primarily related to deficits of lower cranial nerves (50%).

Surgical Treatment of Pediatric Cholesteatomas

Objective: Management of pediatric cholesteatomas remains controversial. We reviewed our 16‐year experience in the surgical treatment of cholesteatomas in children and describe a treatment paradigm.

Recurrent Laryngeal Nerve Paralysis Associated with Thoracic Aortic Aneurysm

The association of vocal cord dysfunction with thoracic aortic aneurysm (TAA) has been noted in the cardiovascular and otolaryngologic literature.1–6 A retrospective review of 168 cases of TAA was performed in order to: (1) define the natural history of associated recurrent laryngeal nerve paralysis (RLNP) and (2) propose mechanisms for the development of RLNP in operated and nonoperated aneurysms. Of 168 aneurysms, 5% manifested hoarseness secondary to RLNP. All had type I aneurysms. Only one patient regained vocal cord function after surgical treatment of the aneurysm. RLNP developed as a sequela of TAA repair in 12% of the patients managed surgically. RLNP associated with TAA type III repair had a higher incidence of recovery than paralysis that occurred after TAA type I repair (40% vs. 0% recovery). Sixty-six percent of all patients with permanently paralyzed larynges in this series attained glottic competence sufficient to avoid Teflon injection, and 27% of all RLNP associated with TAA in this series required Teflon injection for aspiration, severe dysphonia, or both. Seventeen percent of the patients with vocal cord paralysis associated with TAA recovered within 12 months. Aneurysm classification and pertinent anatomic relationships are discussed with reference to various mechanisms of recurrent laryngeal nerve paralysis.

Morphine/ondansetron PCA for postoperative pain, nausea, and vomiting after skull base surgery.

Objective Patients who underwent skull base procedures have been noted to experience appreciable pain. This study examines pain after surgery and the effectiveness of patient controlled analgesia (PCA) with combination morphine ondansetron for analgesia and control of emesis. Study Design and Setting A total of 120 skull base surgery patients were randomized to receive placebo, morphine, or morphine ondansetron. Demographic and intraoperative variables were recorded along with pain, nausea, vomiting, and rescue analgesics. Total PCA use, hospital stay, satisfaction, and cost were also compared. Results Demographically the groups were similar. Pain was elevated with placebo PCA, and this group averaged twice as many analgesic rescues. Total usage time was lower with placebo PCA. Morphine ondansetron PCA had the lowest pain score with highest satisfaction. Nausea and vomiting was similar but female patients had more vomiting regardless of PCA group. Conclusions and Significance The use of morphine PCA reduced pain and did not appreciably increase nausea or vomiting. The addition of ondansetron produced no real benefit and its PCA use cannot be justified. EBM rating: A-1b