Marianne Abouyared

The role of indeterminate fine-needle biopsy in the diagnosis of parotid malignancy

To examine the significance of indeterminate fine needle aspiration biopsy in the diagnosis of parotid gland malignancy.

Surgical techniques for zenker's diverticulum: A comparative analysis

Objective To compare the different modalities for treatment of Zenker’s diverticulum and the associated clinical outcomes. Study Design Case series with chart review. Setting Tertiary care hospital. Subjects and Methods Between 1995 and 2011, 164 patients underwent surgery for Zenker’s diverticulum (stapler, n = 69; laser, n = 68; open, n = 27). Patient sociodemographics, medical comorbidities, pre- and postoperative subjective dysphagia and regurgitation score, complications, length of stay, time to oral intake, and recurrence were reviewed for each surgical modality. Results No statistically significant difference in diverticulum prevalence was associated with age, gender, or treatment group. Mean length of hospital stay was not significantly different between the 3 groups (P = .14). A significant difference in time to oral intake was observed in the laser group compared with the other 2 groups (P = .012). No significant difference in recurrence (P = .21) or complication (P = .12) rates was identified between the 3 groups. Although all 3 groups demonstrated a significant decrease between preoperative and postoperative dysphagia and regurgitation scores, the degree of improvement was not significant when the 3 groups were compared. Conclusion There is no single “best” approach to Zenker’s diverticulum. The open, laser, and stapler methods are equally effective and have similar complication rates.

Oxytocin decreases sweet taste sensitivity in mice

Oxytocin (OXT) suppresses food intake and lack of OXT leads to overconsumption of sucrose. Taste bud cells were recently discovered to express OXT-receptor. In the present study we tested whether administering OXT to wild-type mice affects their licking behavior for tastants in a paradigm designed to be sensitive to taste perception. We injected C57BL/6J mice intraperitoneally (i.p.) with 10mg/kg OXT and assayed their brief-access lick responses, motivated by water deprivation, to NaCl (300mM), citric acid (20mM), quinine (0.3mM), saccharin (10mM), and a mix of MSG and IMP (100mM and 0.5mM respectively). OXT had no effect on licking for NaCl, citric acid, or quinine. A possible effect of OXT on saccharin and MSG+IMP was difficult to interpret due to unexpectedly low lick rates to water (the vehicle for all taste solutions), likely caused by the use of a high OXT dose that suppressed licking and other behaviors. A subsequent experiment focused on another preferred tastant, sucrose, and employed a much lower OXT dose (0.1mg/kg). This modification, based on our measurements of plasma OXT following i.p. injection, permitted us to elevate plasma [OXT] sufficiently to preferentially activate taste bud cells. OXT at this low dose significantly reduced licking responses to 0.3M sucrose, and overall shifted the sucrose concentration - behavioral response curves rightward (mean EC50saline=0.362M vs. EC50OXT=0.466M). Males did not differ from females under any condition in this study. We propose that circulating oxytocin is another factor that modulates taste-based behavior.

Utricular Dysfunction in Refractory Benign Paroxysmal Positional Vertigo.

Objective To determine the prevalence of otolith dysfunction in patients with refractory benign paroxysmal positional vertigo (BPPV). Study Design Unmatched case control. Setting Tertiary care institution. Subjects and Methods Patients included were diagnosed with BPPV, failed initial in-office canalith repositioning maneuvers (CRMs), and completed vestibular testing and vestibular rehabilitation (n = 40). Refractory BPPV (n = 19) was defined in patients whose symptoms did not resolve despite vestibular rehabilitation. These patients were compared with a control group of those with nonrefractory BPPV (n = 21) for results of a caloric test, cervical vestibular evoked myogenic potential (cVEMP), and subjective visual vertical (SVV). Results Forty-six of 251 patients failed initial treatment with in-office CRM. Forty patients met inclusion criteria. There was no significant difference between the cases (refractory BPPV) (n = 19) and controls (nonrefractory BPPV) (n = 21) in terms of age, duration of symptoms, laterality of BPPV, and BPPV symptoms. There was no difference in the prevalence of caloric weakness and cVEMP abnormalities (P > .05), with odds ratios (ORs [95% confidence interval (CI)]) of having abnormal results among cases vs controls of 1.1818 (0.3329-4.1954) and 4.3846 (0.7627-25.2048), for caloric and cVEMP, respectively. Abnormal eccentric SVV was more prevalent in refractory BPPV cases (58%) than in controls (14%) (P < .0072). The OR (95% CI) of having abnormal SVV was 8.25 (1.7967-37.8822) higher among patients with refractory BPPV than those with nonrefractory BPPV. Conclusion Patients with refractory BPPV are more likely to have abnormal eccentric SVV and thus underlying utricular dysfunction. This finding is important to take into account when designing rehabilitation strategies for patients with BPPV who fail CRM.

Transoral laser microsurgery in previously irradiated patients with laryngeal cancer

PURPOSE Early laryngeal cancer is successfully managed with transoral laser microsurgery. Previously radiated patients may experience more post-operative complications. We investigate disease-free survival and secondarily prolonged pain and chondronecrosis. MATERIALS AND METHODS Retrospective review of 52 patients undergoing transoral laser microsurgery after previous radiation. RESULTS Mean disease-free survival was 36.7 months. Overall disease-free survival was 57.6% at 3-year and 48.4% at 5-year follow-up, with no significant difference between surgery within as opposed to after 60 months of radiation or within as opposed to after 12 months of radiation. Thirteen patients, all with surgery within 60 months of radiation, experienced prolonged pain. Twelve experienced chondronecrosis, all within 12 months of surgery. CONCLUSION Transoral laser microsurgery for early laryngeal cancer is an adequate therapeutic option in patients with history of radiation with comparable disease-free survival to other reports. Patients undergoing transoral laser microsurgery within 60 months of radiation treatment are more likely to experience prolonged pain.

Abnormal Microvasculature in Laryngectomy Mucosal Margins may be Associated with Increased Risk of Fistula

Pharyngocutaneous fistula after laryngectomy is common and significantly increases the morbidity of the procedure. Intraoperative, objective variables that can reliably predict fistula formation would be useful to surgeons deciding how to reconstruct the laryngectomy defect. Retrospective chart review of 50 radiated patients and 10 non-radiated patients who underwent total laryngectomy at a single tertiary care institution. Patients with pharyngocutaneous fistula were selected to ensure a representative sample were available for comparison. All patients had pathology slides available for re-review by a single, blinded pathologist. Margins of both radiated (n = 50) and non-radiated (n = 10) larynges were examined for 7 histologic features, and odds ratios were calculated to assess whether these features were associated with fistula. When evaluating all 60 patients, both telangiectatic capillaries and hyalinized arterioles were associated with fistula (OR 3.72 and 9.21, respectively). Collinearity between the variables was evaluated; findings indicated a high likelihood of having hyalinized arterioles if telangiectatic capillaries were also present (OR 31.67 [3.13, 320.06]). Microvascular changes in radiated tissue have previously been described in other anatomic subsites, but the larynx and pharynx have not been specifically evaluated. Laryngectomy mucosal margins appear to display similar changes, and evidence of this damage may be associated with fistula formation. These features could potentially guide the surgeon to alter the reconstructive technique.

The effect of n-acetyl-cysteine on recovery of the facial nerve after crush injury: N-Acetyl-Cysteine and Facial Nerve Recovery

Facial nerve dysfunction can vary in severity and recovery is dependent on the character of the injury. N‐acetyl‐cysteine prevents oxidative stress and cellular damage, and its use in the setting of nerve dysfunction from crush injury has not yet been established. In this study, rats with facial nerve crush injury will be treated with n‐acetyl‐cysteine or control and functional recovery and electrophysiologic outcome will be compared.

Open airway reconstruction in adults: Outcomes and prognostic factors

PURPOSE The purpose was to assess the success of open tracheal resection and re-anastomosis for non-malignant tracheal stenosis in adults. Successful operations were defined as T-tube or tracheostomy-free status by 6months post-operatively. MATERIALS AND METHODS Retrospective chart review was performed and data were recorded in a de-identified manner. The primary outcome was T-tube or tracheostomy-free status by 6months following tracheal resection. Clinical and demographic characteristics were evaluated as potential prognostic variables. RESULTS Thirty-two patients met inclusion criteria, with a median age of 46. Seven patients underwent tracheal resection with primary closure, without stenting. Successful tracheal resection was defined as tracheostomy or T-tube free by 6months post-operation, and this was possible in 21 patients (66%). Eighty-two percent of patients with cricoid cartilage-sparing tracheal resection had a successful outcome, versus 30% of patients who underwent cricoid cartilage resection (HR 5.02, 95% CI 1.46-17.3; p=0.011). Patients with a history of tracheostomy-dependence were four times more likely to remain tube-dependent at 6months (HR 4.15, 95% CI 1.56-10.86; p=0.004). CONCLUSIONS Tracheal stenosis remains a very difficult problem to treat. In our series, we confirm that patients with cricoid involvement or with a history of tracheostomy were more likely to be tube dependent at 6-months post-operation.

The Role of Fine-Needle Aspiration in Parotid Pleomorphic Adenoma

Objective: Fine-needle aspiration (FNA) biopsy is often used as a well-accepted and both sensitive and specific diagnostic adjunct in the workup of parotid masses. In the case of pleomorphic adenoma, the most common benign tumor of the parotid gland, we examine cytopathologic reports to assess the performance of FNA for this particular histologic diagnosis. Method: A total of 317 patients who underwent parotidectomy over the past 5 years and met eligibility criteria of 1) primary parotid tumor, 2) age greater than 18 years, and 3) availability of pathology (FNA, intraoperative frozen section, final pathology) were reviewed. Clinical history and demographics, physical exam findings, and intraoperative findings were noted. Results: Pleomorphic adenoma was noted on final pathology in 136 patients (42.9%). Interestingly 24 (17.6%) of these patients had initially undergone FNA and been given a incorrect diagnosis, despite the FNA being “diagnostic.” One patient received false positive diagnosis of malignancy by FNA. Of the 24 patients with incorrect diagnosis on FNA, 15 (62.5%) received the correct diagnosis of pleomorphic adenoma with intraoperative frozen section, though one patient received a false positive for malignancy and underwent surgical upstage unnecessarily. For pleomorphic adenoma, it appears that diagnostic sensitivity increases from 82% for FNA to 92% with frozen section. Conclusion: While FNA is commonly used as preoperative diagnostic adjunct for parotid masses, one must exercise caution, even in the context of a diagnostic sample, as nearly 18% of pleomorphic adenomas were not identified. Fortunately, misdiagnosis was benign 95% of time, and subsequently had no surgical implications.