Joseph Shvidler

Acute rise in methicillin-resistant Staphylococcus aureus infections in a coastal community

Objective Describe the incidence of head and neck community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections over a 5-year period at a coastal tertiary medical center. Study Design Retrospective chart review. Subjects and Methods All patients presenting to the otolaryngology service with cultures taken from head and neck infections between 1999 and 2004 were eligible for inclusion. Statistical analysis was used to determine significance of the changing incidence of isolated organisms over the study period. Results CA-MRSA infections rose from 21% to 64% over the 5-year period. The increasing trend in CA-MRSA infections reached statistical significance from 2003 to 2004. All CA-MRSA isolates were resistant to cefazolin and penicillin, but most were sensitive to clindamycin. Conclusions Our data demonstrates a striking increase in the incidence of CA-MRSA. We have tailored our treatment of cutaneous head and neck infections to include empiric treatment for CA-MRSA using clindamycin. Awareness and monitoring of this trend will be important for all practitioners involved in the care of these patients.

Fusaric acid: a novel agent and mechanism to treat HNSCC.

OBJECTIVE: A new class of carboxylic acids has tumoricidal activity for head and neck squamous cell cancer (HNSCC). Fusaric acid (FA) can chelate divalent cations, especially zinc, and inactivate zinc finger proteins involved in DNA repair and protein synthesis. METHODS: 2 squamous carcinoma lines were utilized for in vitro and in vivo portions of this study. Cell counting and flow cytometry were used to analyze cells in culture in treatment and control groups over 96 hours. HNSCC subcutaneous implants were created in treatment and control groups of BALB-c nude mice (N = 30). RESULTS: In vitro studies demonstrated significant changes in cell numbers and cell cycle. In vivo studies of daily intralesional therapy for 1 month also showed reduced onset of growth and overall growth compared to controls. CONCLUSION: FA appears to have a tumoristatic/tumoricidal effect on HNSCC. Further nude mice studies are needed to optimize dosing and administration regimens for FA in anticipation of clinical trials.

Refining indications for the use of mitomycin C using a randomized controlled trial with an animal model.

Objectives To evaluate the effect of mitomycin on the repair of acquired subglottic stenosis and to define the optimal concentration of mitomycin that would minimize restenosis after repair. Study Design And Setting A randomized prospective model was used in which 20 ferrets (Mustela putorius furo) underwent simulated intubation injury that was then treated with CO2 laser lysis. Results Comparison of cross-sectional airway areas, after stenosis repair, showed no significant differences between control and mitomycin treatment groups. Comparison of histologic scores for both inflammation and mucosalization yielded no difference between control and treatment animals. Conclusions Mitomycin C appeared to have no benefit when placed after repair of an acquired stenosis. Significance This study closely models the injury experienced by children with acquired subglottic stenosis. These data provide clear evidence that mitomycin is limited in its effect on established wounds and help further define its role as an adjuvant for surgery in the aerodigestive tract.

Hairy polyp in the oropharynx of a 5-week-old infant with sudden-onset respiratory distress.

A5-week-old boy presented with sudden onset respiratory distress. The child was born at term by spontaneous vaginal delivery. He had no prior episodes of respiratory or feeding difficulties. On further questioning, the child’s mother noted that the patient seemed to spit up frequently but that he also had been gaining weight appropriately. At the time of initial intubation, no masses or lesions were noted. Direct laryngoscopy and bronchoscopy were performed without any identifiable lesion except for a fullness found in the membranous tracheal wall. Esophagoscopy was attempted but could not be completed because of a mass that was obstructing the esophagus. The mass appeared to be pedicled from the oropharynx. The patient was kept intubated, and a CT scan was performed. This examination revealed a mass originating in the oropharynx and extending into the esophageal inlet. The patient was returned to the operating room, where the mass was found to originate from the superior portion of palatopharyngeus. It was excised in total. The patient recovered uneventfully and had no further episodes of respiratory difficulty or dysphagia. Final pathology revealed a hairy polyp.

R049: Airway Injury Model for the Application of RNAi Therapy

airway during the pharyngeal stage of swallowing. But the relationships between mobility of the epiglottis and the hyoepiglottic ligament are not fully understood. METHODS: It is a retrospective comparative study. Hematoxylin-Eosin stain and Elastica Van Gieson stain were performed on paraffin-embedded sections from 20 normal postmortem larynx without laryngeal diseases. The hyoepiglottic ligament was compared between an elderly group (n 11, 81 to 91 yrs old) and nonelderly group (n 9, 31 to 48 yrs old) using an image analysis system (Image J 1.34S). RESULTS: Although it has been believed that the hyoepiglottic ligament anatomically attaches to the anterior surface of the epiglottic cartilage to the hyoid bone, this study showed it extended to the two parts (both lingual muscles and hyoid bone from the epiglottis). The team named the two parts of the ligament as pars lingualis and pars hyoideus. In the elder group, distributions of the muscle fibers, collagen fibers, and elastic fibers were significantly decreased than those in the nonelderly group. CONCLUSION: This study showed that there are age-related differences between elder adults and young adults in the hyoepiglottic ligament. SIGNIFICANCE: This study focused on the hyoepiglottic ligament in order to elucidate age-related changes and its functional characteristics in airway protection during swallowing. Results suggest that active regulation in positioning the epiglottis can be decreased in elders.

Useful CT techniques in head and neck imaging

The goal of this article is to demonstrate various previously described methods that use CT in head and neck imaging to the otolaryngologist. Patient maneuvers and postprocessing CT techniques can both be used to help the otolaryngologist achieve better CT images. Maneuvers to improve head and neck imaging include “puff cheek” technique to visualize the buccal mucosa lesions, phonation to demonstrate cord paralysis, and valsalva for improved visualization of the pyriform sinuses and laryngoceles. These imaging techniques can be performed on older helical CT scanners as well as on the new Multidetector CT (MDCT). We will review several tips for otolaryngologists to use when imaging head and neck patients. Although patient maneuvers can be performed on any type of CT scanner, detailed reconstruction techniques are more effective with MDCT.

R139: Refining Indications for the Use of Mitomycin in the Airway:

PROBLEM: While the drug mitomycin has shown great promise as an adjuvant to surgical airway repair, specific indications for its use have yet to be defined. The objective of this study is to evaluate mitomycin’s efficacy when used in the repair of acutely established airway stenoses. METHODS: A randomized-prospective model in which 20 ferrets underwent simulated intubation airway injury by having a segment of endotracheal tube placed tightly at the level of the subglottis for two weeks. After an additional two weeks, the animals were anesthetized and resulting stenoses were measured and ablated with a CO2 laser. Animals immediately received a topical dose of saline or mitomycin at 0.2 mg/ml, 1 mg/ml, or 10 mg/ml. Subjects were examined twice at 14-day intervals. Histologic sections were evaluated. RESULTS: Mild to moderate stenosis was obtained. Subglottic diameters between each animal at the time of tube placement to time of laser treatment showed a significant difference, p .004. Animals treated with mitomycin showed no gross or histologic differences when compared to control animals. No differences were found between any of the three treatment doses of mitomycin. CONCLUSION: The ferret tracheal injury model used in this study is reliable for producing a mild to moderate tracheal stenosis. Mitomycin, when applied during a repair that is undertaken soon after a stenosis has become established, does not appear to protect the airway from re-stenosis. SIGNIFICANCE: Numerous animal studies have shown a protective effect when mitomycin is placed at the time of initial airway insult. This study more closely models realistic conditions and argues that mitomycin may not be successful when used in acute injury repair.This evidence highlights the need to place mitomycin before the inflammatory process begins as well as the need for development of further therapeutic strategies. SUPPORT: Funded by TAMC Department of Clinical Investigation.

Metastatic Spitz Nevus of the Auricle

Abstract Objectives: The Spitz Nevus was first described in 1948 as a juvenile melanoma. Since that time, our understanding of this benign lesion has evolved, but its definitive diagnosis often remains a challenge. We present the case of Spitz Nevus of the auricle with apparent local metastasis and review the literature concerning diagnosis and treatment options. Methods: The patient is a 21-year-old male who presented to our clinic with a 4-month history of a slowly growing, nodular, pigmented lesion of the helix of the left auricle. The patient underwent excisional biopsy that histologically confirmed Spitz Nevus. The patient returned 1 year later with recurrence at the biopsy site and a new separate lesion 2 cm distal on the lobule. Results: The patient underwent re-excision of the primary lesion and excision of the secondary lesion with immediate closure. Histologic review confirmed Spitz Nevi without evidence of direct extension at the dermal-epidermal junction. The patient healed well and has had no sign of further recurrence 6 months following surgery. Conclusion: Spitz Nevi are spindle cell and epithelioid cell tumors that very closely resemble malignant melanomas. They may possess a broad spectrum of characteristics that include recurrence or persistence, metastasis to lymph nodes, and malignant transformation of benign disease. Differentiation from melanoma is difficult but critical. This case represents an unusual presentation of this lesion, with an uncommon local skin metastasis.

Laryngeal ventricle mass in a newborn with stridor

Abstract Objectives: Newborn stridor can be an alarming symptom to the child’s parents and health care team. While a few etiologies explain the majority of cases, unusual causes must be kept within the differential diagnosis. Methods: We report and discuss an unusual case of a 6-day-old newborn male with presumed meconium aspiration who underwent deep suctioning of the trachea at birth. The child subsequently developed inspiratory stridor soon after birth. Nasopharyngoscopy revealed a pale polypoid mass arising from the left laryngeal ventricle. Results: With a presumptive diagnosis of vocal cord granuloma, the patient was initially treated with steroids. There was no change in the mass size after several days of steroid treatment. The child underwent direct laryngoscopy and the mass was excised using cupped biopsy forceps. Pathological examination of the mass revealed herniated ventricular tissue into the larynx with central necrosis. Conclusion: From our review of the literature, this is the first reported case of ventricular mucosal herniation causing stridor in a newborn. The differential diagnosis of newborn stridor and treatment courses are discussed.