Luv Javia

CD4+CD25+ suppressor lymphocytes in the circulation of patients immunized against melanoma antigens.

Murine studies have suggested that a population of CD4+ T cells expressing the alpha chain of the interleukin (IL)-2 receptor (CD25+) are phenotypically anergic in response to T cell receptor stimulation and can suppress the function of CD4+ and CD8+ T cells. Recent studies of peripheral lymphocytes from healthy human volunteers have identified a similar population, although little is known about the presence and activity of these cells in patients with cancer and their possible impact on anticancer immunization strategies. Thus, the authors have undertaken these studies in patients with metastatic melanoma undergoing immunizations with known melanoma antigens. CD4+CD25+, CD4+CD25−, and a 1:1 ratio of these isolated T cells were stimulated with soluble anti-CD3 antibody in the presence of irradiated T cell-depleted PBMCs, and proliferation was assessed by measuring [3H]thymidine incorporation. In 13 patients, isolated CD4+CD25+ T cells proliferated 68% (± 5.8%) less than separately cultured CD4+CD25− T cells. Moreover, CD4+CD25+ T cells suppressed the proliferation of an equal number of cocultured CD4+CD25+ T cells in 11 of 13 patients by an average of 60% (± 4.9%). Suppression was not seen at day three of culture and became apparent at days five through nine. The degree of suppression was proportional to the numbers of CD4+CD25+ T cells. Addition of high-dose IL-2 reversed the hypoproliferative phenotype of the CD4+CD25+ T cells and abrogated their suppressive function. These studies demonstrate that anergic and functionally suppressive CD4+CD25+ T cells exist in patients with melanoma undergoing tumor antigen immunization and thus may play a role in modifying the magnitude of the T cell response to immunization.

A Systematic Review of Simulators in Otolaryngology

Objective To conduct a systematic review of published articles that describe simulators that could be used in otolaryngology for education, skill acquisition, and/or skill improvement. Data Sources Ovid and Embase databases searched July 14, 2011. Review Methods Three hundred fifty-three abstracts were independently reviewed by both authors, then 154 eligible articles were reviewed by both authors, and 95 articles were categorized by organ system (eg, otologic); type of simulator (eg, physical, virtual); whether the simulator was a prototype, could be purchased, or was constructed; validation; and level of learning assessment. Discrepancies were resolved by re-review and discussion. Results In addition to 11 overview articles, 28 articles described 16 otology simulators, most of which are virtual and prototypes. Ninteen articles described 10 sinus/rhinology simulators; most are virtual surgery simulators and prototypes. Eight articles described 8 oral cavity simulators, and 8 articles described neck simulators. Seventeen articles described 13 bronchoscopy simulators; several are full-body high-technology manikins adapted from other purposes. Five articles described eclectic simulators, including some for learning nontechnical and teamwork skills. Half of the simulators have been validated. Learning levels were often not assessed or assessment was limited to the learners’ perceptions. Conclusion A wide variety of simulators are available or under development. Lack of unified validation concepts and limited descriptions restricted our ability to assess model characteristics, availability, and validation. Simulators are emerging as powerful tools to facilitate learning; this review may provide a platform for discussion and refinement of the information reported and analyzed in evaluating simulators.

Evolving treatments in the management of laryngotracheal hemangiomas: Will propranolol supplant steroids and surgery?

There has been a dramatic evolution in the treatment of laryngotracheal hemangiomas during the past decade and recent accounts and case reports of propranolol treatment have been encouraging. The purpose of the study is to determine the clinical course and outcomes of treating laryngotracheal hemangiomas at The Childrens Hospital of Philadelphia in the last 8 years with the various modalities. We review with contemporary surgical techniques, including propranolol, and determine the results, limitations and complications. The study was a retrospective review of all patients referred to the Otolaryngology service at The Childrens Hospital of Philadelphia with symptomatic laryngotracheal hemangiomas between January 2002 and December 2010. The study consisted of 30 infants, ranging in age from 1 to 18 months at time of diagnosis. Surgical interventions included open surgical excision, laser surgery, microdebrider excision and/or propranolol therapy. The main outcome measures include improvement in symptoms, decannulation, number of required treatments and airway size. All but two patients underwent an initial trial of steroids. Thirteen patients underwent open surgical excision, 9 requiring cartilage grafts and 12 were done in a single stage. Twelve surgical patients remained asymptomatic. One patient with diffuse mediastinal disease experiencing postoperative airway symptoms despite a normal appearing airway improved on propranolol. Two patients underwent at least 2 laser ablations, 4 responded to systemic steroids alone, and 1 had microdebrider resection. In the last 14 months, 12 patients have had propranolol therapy at a dose of 2mg/kg divided every 8h. Eight patients improved clinically within 1 week of initiating treatment. Four patients failed to respond to propranolol therapy; 1 patient subsequently underwent open excision and the other continued with a tracheostomy for 18 months and finally was decannulated. A third patient had a partial response, but remains relatively asymptomatic. A fourth patient has had no response at all. There were no major complications from propranolol; minor complications included diarrhea and decreased appetite. This study gives an overview of the evolution of hemangioma treatment at our institution over the last 8 years. Surgical excision remains an effective treatment for subglottic hemangiomas. Carefully administered, propranolol may demonstrate efficacy as a first-line agent in most cases avoiding surgery, tracheostomy, prolonged steroids, or as treatment of diffuse and unresectable disease. However, some lesions may be resistant to propranolol and require surgery or long-term steroids.

Laryngotracheal reconstruction with resorbable microplate buttressing

In patients undergoing laryngotracheal reconstruction (LTR), malacic segments of trachea can pose challenges to successful reconstruction. Malacic segments may inadequately support cartilage grafts used in augmentation surgery, sometimes requiring cricotracheal or tracheal resections. We describe a novel technique of LTR with resorbable microplate buttressing of malacic lateral tracheal segments.

Methicillin-resistant Staphylococcus aureus (MRSA) pediatric tympanostomy tube otorrhea.

OBJECTIVES To describe our experience and clinical outcomes with the management of pediatric tympanostomy tube otorrhea secondary to methicillin-resistant Staphylococcus aureus (MRSA). METHODS Retrospective review of pediatric patients (age <18) diagnosed with culture-positive MRSA tympanostomy tube otorrhea. RESULTS MRSA positive ear cultures in the presence of tympanostomy tubes were identified in 41 patients (6.3%). The average age was 2.9 years old. In all cases, culture results indicated sensitivity to trimethoprim/sulfamethoxazole and gentamicin; resistance to fluoroquinolones and clindamycin occurred in 87.8% and 61.0% of cases, respectively. Fluoroquinolone and sulfacetamide ototopical medications were found to be associated with successful otorrhea resolution (p=0.005 and 0.009, respectively). Adjunctive therapy with oral antibiotics, bactrim and clindamycin (p=0.172 and 0.877, respectively), did not improve resolution rates with medical treatment. Tympanostomy tube removal was more successful than medical therapy alone (p<0.0001). CONCLUSION Appropriately treated recurrent or recalcitrant tympanostomy tube-related otorrhea should raise the suspicion for MRSA-related tympanostomy tube otorrhea. Fluoroquinolone ototopical medication should be considered for initial therapy. Sulfacetamide ototopical medication can be considered for failures. The adjunctive use of oral antibiotics, bactrim and clindamycin, and aminoglycoside ototopical medications did not improve clinical outcomes for medical therapy alone. We believe that some consideration be given to removal of the tympanostomy tube with or without replacement, after an initial treatment period with fluoroquinolone and/or sulfacetamide otopical medications. Our findings seem to suggest an improved rate with tympanostomy tube removal over medical therapy alone (p<0.0001). No standard management guidelines currently exist.

Rings, slings, and other tracheal disorders in the neonate

Tracheal and bronchial pathologies in the neonate can be rapidly fatal if prenatal or quick postnatal diagnosis and intervention is not performed. Close multidisciplinary collaboration between multiple medical and surgical specialties is vital to the effective diagnosis and treatment of these pathologies. The fetal and neonatal airway may be affected or compromised by more prevalent pathologies such as tracheomalacia and tracheo-esophageal fistula with esophageal atresia. However, it is imperative that we also consider other potential sources that may perhaps be less familiar such as congenital cardiovascular abnormalities, tracheal stenosis, complete tracheal rings, tracheal sleeve, and foregut duplication cysts. Modern imaging studies and surgical techniques are allowing us to better serve these children.

An improved, practical stent for choanal atresia and pyriform aperture stenosis repair

Intranasal stenting is often used to maintain patency following repair of choanal atresia and pyriform aperture stenosis. Although there is a trend toward less frequent use of stents as endoscopic techniques have improved, more than 96 percent of surgeons surveyed still use them at least some of the time. Our institution employs stenting in most neonates, particularly if they are too small for endoscopic repair, and in older infants and children on a case-by-case basis. Historically, stents are commonly variants of hollow tubes; trimmed, polyvinylchloride endotracheal tubes (ETTs) are by far the most common. Hollow tube stents allow immediate relief of nasal obstruction but require diligent care to prevent occlusion. Commonly, the anterior end of an ETT stent is left protruding slightly from the nose, providing easy access for suctioning. However, such exposed tubes are unsightly and vulnerable to accidental dislodgement. More importantly, because of the natural downward curvature of the anterior nasal airway, these straight tubes can exert pressure on the superior alar rim, creating a risk for necrosis and notching. To reduce these risks, some surgeons trim the ETTs flush with the alar margin, and/or employ translabial sutures to attempt to tether the stent tips downward. Unfortunately, local complications remain common. Stents are prone to migrate, and often the open end becomes obscured under the alar rim. The result is frequent calls from caregivers and nurses unable to suction the stents or, worse, excoriation of skin of the nasal tip due to excessive nasal manipulations. In an effort to better match the infant’s anatomy and reduce these complications, in 2004, the senior author began employing a readily available alternative, the Ring-AdairElwyn endotracheal tube (RAE tube). The RAE tube has a region of preformed curvature molded into its shape, that we believed would better match the natural downward curvature of the nasal vestibule without special suturing tech-

Physical Models and Virtual Reality Simulators in Otolaryngology

The increasing role of simulation in the medical education of future otolaryngologists has followed suit with other surgical disciplines. Simulators make it possible for the resident to explore and learn in a safe and less stressful environment. The various subspecialties in otolaryngology use physical simulators and virtual-reality simulators. Although physical simulators allow the operator to make direct contact with its components, virtual-reality simulators allow the operator to interact with an environment that is computer generated. This article gives an overview of the various types of physical simulators and virtual-reality simulators used in otolaryngology that have been reported in the literature.

Total Airway Reconstruction in the Neonate: Combined Mandibular Distraction and Slide Tracheoplasty for Multiple Level Airway Obstruction.

Background:Long-segment congenital tracheal stenosis (CTS) is characterized by segmental tracheal stenosis, complete tracheal rings, and absent posterior pars membranosa for >50% of tracheal length. Slide tracheoplasty on cardiopulmonary bypass (CPB) has traditionally been the procedure of choice for airway reconstruction. Pierre Robin sequence (PRS) is characterized by the triad of micrognathia, glossoptosis, and airway obstruction. The authors and others, have demonstrated the efficacy of mandibular distraction osteogenesis (MDO) to avoid tracheostomy in severe cases of PRS. Methods:The authors present a unique case of the multidisciplinary management of long-segment CTS and concomitant PRS via total airway reconstruction off CPB, involving our otolaryngology, cardiothoracic, and plastic surgery teams. Results:This 36-week baby girl, prenatally diagnosed with PRS and polyhydramnios concerning for airway obstruction, was delivered via planned ex utero intrapartum treatment (EXIT). Tracheostomy was aborted because of long-segment CTS. A 2.5-French endotracheal tube (ETT) was temporarily sutured in before transfer to our facility for definitive airway management.Bilateral MDO was performed without complication at 2 weeks old (distraction to 20mm by postoperative day 25). At 6 weeks old, delayed slide tracheoplasty avoiding cardiopulmonary bypass was followed by an uneventful recovery. Most recent follow-up demonstrates airway patency without signs of obstruction. Conclusions:This patients case is the first reporting combined MDO and slide tracheoplasty to relieve multilevel neonatal airway obstruction. Unique and challenging, it demonstrates the importance of multidisciplinary management of complex neonatal airway obstruction.

Infectious complications and ventilation tubes in pediatric cochlear implant recipients

At many centers, ventilating tubes (VTs) are placed routinely in otitis‐prone pediatric cochlear implant recipients. However, this practice is controversial, as many otologists believe VTs represent a possible route for contamination of the device. Toward better understanding of the safety of VTs, we reviewed our centers infectious complications and their relationship to the presence of tubes.