Merry Sebelik

Effects of adeno-tonsillectomy on polysomnography patterns in Down syndrome children with obstructive sleep apnea: a comparative study with children without Down syndrome.

OBJECTIVE To determine if adeno-tonsillectomy (T&A) in children with Down syndrome (DS) improves breathing, measured by apnea hypopnea index (AHI), rapid eye movement AHI (REM-AHI) and the lowest oxygen desaturation (SaO2), and sleep disruption, measured by arousal index (ArI) and time spent in stages 1-4 and rapid eye movement (REM) sleep and compare these results with a group of non-DS children with obstructive sleep apnea (OSA). STUDY DESIGN Retrospective chart review at pediatric sleep center. PATIENTS Eleven DS and nine non-DS children underwent pre- and post-T&A polysomnography between 1997 and 2005. OUTCOME MEASURES Pre- and post-T&A polysomnography parameters were compared using paired t-test and independent samples test. RESULTS Mean age in DS group was 101 months and non-DS group was 80 months (64% males in DS and 88% in non-DS group). The average BMI was 29.8 and 27.6 for DS and non-DS group. The total AHI showed significant improvement after T&A but this was not as marked as the non-DS group. REM-AHI and lowest SaO2 did not show significant change in the DS children. The non-DS group showed significant improvement in all respiratory parameters. Both groups showed mild improvement in sleep parameters. With the modest overall improvement, 27% of the DS children required no further treatment. However, 73% required CPAP, BiPAP or oxygen for persistent OSA. CONCLUSION This study supports the fact that T&A in DS children improves some parameters of OSA, however not as markedly as in non-DS children.

Factors predictive of poor functional outcome after chemoradiation for advanced laryngeal cancer.

OBJECTIVE: The study goal was to determine whether pretreatment parameters can be used to predict poor outcomes related to laryngeal function among survivors after organ preservation therapy for advanced laryngeal cancer. DESIGN: A retrospective analysis of patients treated in an ongoing chemoradiation trial. SETTING: Academic tertiary care referral medical center. PATIENTS AND METHODS: Among the 65 patients receiving concomitant intra-arterial cisplatin and radiation therapy for stage III and IV laryngeal cancer between 1993 and 1999, we identified 45 who were available for follow-up and were disease free 6 months after the completion of therapy. A nominal logistic regression analysis was performed to study the effect of age, gender, T and N classification, vocal cord fixation, massive cartilage destruction, and neck dissection on the likelihood of requiring a tracheostomy tube for breathing and/or a gastrostomy tube for feeding at 6 months after the completion of therapy. MAIN OUTCOME MEASURE: Persistent use of gastrostomy tube feedings and/or tracheostomy at 6 months after the completion of therapy. RESULTS: Sixteen patients (36%) required a feeding tube and/or a tracheostomy (tracheostomy 13, gastrostomy 13, both 10). Regression analysis of all pretreatment factors indicated vocal cord fixation as being the strongest predictor of a poor functional outcome (defined as the persistent need for a feeding tube and/or tracheostomy at 6 months after therapy). Among the 27 patients in this subset, 15 (56%) had a poor functional outcome. In contrast, only 1 (6%) of 18 patients without vocal cord fixation had poor laryngeal function. Although the history of pulmonary disease was not a significant parameter by itself, when combined with vocal cord fixation, 6 of 8 patients had a poor functional outcome. CONCLUSION: Pretreatment parameters may be used to predict a poor functional outcome after chemoradiation. Because of the high likelihood of poor function, laryngeal cancer patients seeking organ preservation therapy with chemoradiation should be cautioned if they present with a fixed vocal cord.

In Vivo Ultrasonic Detection of Polyurea Crosslinked Silica Aerogel Implants

Background Polyurea crosslinked silica aerogels are highly porous, lightweight, and mechanically strong materials with great potential for in vivo applications. Recent in vivo and in vitro studies have demonstrated the biocompatibility of this type of aerogel. The highly porous nature of aerogels allows for exceptional thermal, electric, and acoustic insulating capabilities that can be taken advantage of for non-invasive external imaging techniques. Sound-based detection of implants is a low cost, non-invasive, portable, and rapid technique that is routinely used and readily available in major clinics and hospitals. Methodology In this study the first in vivo ultrasound response of polyurea crosslinked silica aerogel implants was investigated by means of a GE Medical Systems LogiQe diagnostic ultrasound machine with a linear array probe. Aerogel samples were inserted subcutaneously and sub-muscularly in a) fresh animal model and b) cadaveric human model for analysis. For comparison, samples of polydimethylsiloxane (PDMS) were also imaged under similar conditions as the aerogel samples. Conclusion/significance Polyurea crosslinked silica aerogel (X-Si aerogel) implants were easily identified when inserted in either of the regions in both fresh animal model and cadaveric model. The implant dimensions inferred from the images matched the actual size of the implants and no apparent damage was sustained by the X-Si aerogel implants as a result of the ultrasonic imaging process. The aerogel implants demonstrated hyperechoic behavior and significant posterior shadowing. Results obtained were compared with images acquired from the PDMS implants inserted at the same location.

Sialolipoma of the parotid gland: Case report with literature review comparing major and minor salivary gland sialolipomas

Sialolipoma is a rare tumor found within both major and minor salivary glands. Here we discuss sialolipoma of the parotid gland and briefly review the English literature. Including our case, a total of 35 sialolipomas have been reported, 18 within major salivary glands and 17 within minor salivary glands. Major gland sialolipomas most often are presented in the parotid gland (77%) and those from minor glands were most often seen in the palate (41%). All lesions were well circumscribed and contained mature adipose tissue intimately admixed with benign salivary gland components. Ductal dilatation was found in 100% of minor salivary gland sialolipomas but in only 28% of major salivary gland tumors. Nerve entrapment has also rarely been noted in major salivary glands (14%) whereas myxoid degeneration has been identified in rare minor salivary glands tumors (13%). Treatment is surgical excision and is curative with no reports of recurrence.

Juvenile nasopharyngeal angiofibroma: current treatment modalities and future considerations

Juvenile angiofibroma (JNA) is a relatively uncommon, highly vascular and benign tumor that presents most commonly in adolescent males. Symptoms may persist from months to years and often times, these tumors are asymptomatic until they increase and encroach on critical structures. Because of technological advances both in surgery and radiology, management of JNA patients has been refined. With the advent of more sophisticated capabilities such as CT, MRI, intensity-modulated radiation therapy (IMRT), stereotactic guidance systems as well as advanced embolization techniques, these tumors can be diagnosed and managed more effectively.Patients with juvenile angiofibroma (JNA) are typically silent for years and often present with epistaxis, nasal obstruction, facial numbness, rhinorrhea, ear popping, sinusitis, cheek swelling, visual changes and headaches. In addition to these symptoms, up to one-third of patients with this condition may present with proptosis or other orbital involvement, which are late symptoms and findings.Most physicians agree that surgery is the primary treatment modality for the early-stage disease process. However, controversy arises regarding the best treatment when a patient presents with more locally advanced disease involving widespread cranial-based extension or intracranial involvement which may necessitate a combination of treatment modalities including surgery and postoperative radiation.With the advancement of endoscopic surgery, there have been a number of cases reporting the value of its use. The purpose of this review, however, will address not only endoscopic alternatives, but will discuss other treatment options as reported in the literature. Robotic surgery of the skull base for JNA is something to expect for the future.Finally, with the advent of IMRT and an image-guided robotic radiotherapy delivery system, some researchers speculate that this will result in less objections for radiation in general and certainly less reservations for the use radiotherapy in certain circumstances, i.e. patient refusal of surgery or extensive non-resectable or recurrent JNA tumors.

Ultrasound-Guided Fine-Needle Aspiration of the Tongue Base A Cadaver Feasibility Study

Objective The authors hypothesize that floor-of-mouth and tongue base anatomy can be visualized with ultrasound and that ultrasound can be used to accurately guide needle placement and dye injection into the tongue base, serving as a surrogate for fine-needle aspiration. Study Design Observation of experimental intervention. Setting Medical school cadaver anatomy laboratory. Subjects and Methods Ultrasound imaging was performed on human cadaveric specimens to visualize the anatomy of the floor of mouth and base of tongue in a midline transcervical approach. Methylene blue dye was injected under ultrasound guidance into the base of tongue. Specimens were dissected, and results were counted and analyzed. Results Twenty-five of 32 (78%) cadaver specimens were found to have correct placement of dye within the posterior genioglossus and intrinsic tongue musculature. Seven cadavers did not have correct placement of dye. Of these, 3 had dye staining the walls of the oropharynx and epiglottis. Two specimens had dye injected erroneously into the geniohyoid muscles. One patient was found to have had a partial glossectomy. Difference in neck circumference was not significant between those with correct (mean, 37.9 cm) and incorrect (mean, 37.4 cm) dye placement (P = .75). Conclusion Anatomy of the floor of mouth and tongue base can be readily depicted with ultrasonography. After reasonable success of injecting dye into cadaver tongue bases, the authors conclude that there appears to be a future clinical role for ultrasound-guided fine-needle aspiration of the tongue base for tongue base lesions.

Sphenopalatine Artery Ligation A Cadaver Anatomic Study

Objective. To clarify endoscopic anatomy of the sphenopalatine artery (SPA) in relation to intranasal endoscopic landmarks using a human cadaver model and to simplify the surgical approach to SPA ligation. Study Design. Prospective anatomic study from November to December 2009. Setting. University of Tennessee Health Science Center Gross Anatomy Lab. Subjects. Fifty human cadaveric sagittally sectioned heads. Methods. The cadaveric nasal cavities were examined using a 0° endoscope, and the SPA and foramen were identified. The number of nasal cavities in which a transnasal approach successfully revealed the SPA foramen was compared with those that required maxillary antrostomy. The distance from the posterior edge of the maxillary natural ostium to the anterior edge of the SPA foramen was measured. Results. Successful ligation of the SPA via a lateral nasal wall incision was achieved in 45 of 50 specimens (90%). The mean distance from the posterior edge of the maxillary natural ostium to the anterior edge of the SPA foramen was 23.79 mm (95% confidence interval, 22.03-25.55). Conclusion. The method of performing SPA ligation via lateral nasal wall incision alone was successful in 90% of human cadaveric heads. Maxillary antrostomy revealed the SPA in the remainder. No specimen required uncinectomy. The mean distance from the maxillary natural ostium to SPA foramen was more than 2 cm. The routine use of maxillary antrostomy and uncinectomy is not needed to locate the SPA in most nasal cavities and moreover produces unnecessary mucosal trauma in the often medically fragile or coagulopathic patient.

Duty hour restrictions and surgical complications for head and neck key indicator procedures

Graduate medical education has traditionally required long work hours, allowing trainees little time for adequate rest. Based on concerns over performance deterioration with sleep deprivation and its effect on patient outcomes, duty hour restrictions have been mandated. We sought to characterize complications from otolaryngology key indicator procedures performed before and after duty hour reform.

Histopathological and Postoperative Behavioral Comparison of Rodent Oral Tongue Resection Fiber-Enabled CO2 Laser versus Electrocautery

Objective To compare operative time and hemostasis of fiber-enabled CO2 laser (FECL) energy to that of the electrocautery (EC) technique for oral tongue resection, to compare return to oral intake and preoperative weight after FECL and EC resection, and to compare histologic changes in adjacent tissue after FECL and EC resection. Study Design Prospective animal study. Setting Research laboratory. Subjects and Methods The CO2 laser fiber and the Bovie cautery were each used to resect the anterior tongue in 15 adult rats. Fixative perfusion and killing were performed on postoperative day 0 (n = 10), 3 (n = 10), or 7 (n = 10). Body weight, food intake, and water intake were recorded daily for 3- and 7-day survival rats. After preparation for histologic analysis, the tongue tissue was graded with a mucosal wound-healing scale (MWHS). Results A higher incidence of intraoperative bleeding and shorter operative times were noted in the EC group. No statistically significant difference in postoperative food or water intake between the EC and FECL groups was noted. The FECL group returned to baseline weight by postoperative day 6. MWHS scores were lower in the EC group by postoperative day 3 and lower in the FECL group by postoperative day 7. Conclusions Both EC and FECL are effective for resection of the tongue in rats. EC has the advantage of shorter operative time and lower MWHS scores by postoperative day 3; FECL has the advantages of less intraoperative bleeding, faster return to baseline body weight, and lower MWHS score by postoperative day 7.

Effects of Sensory or Motor Nerve Deafferentation on Oromotor Function in Mice

Objective. To investigate the effect of sensory or motor nerve damage to the tongue using a mouse model. Study Design. Animal study. Setting. Research laboratory. Subjects and Methods. Adult male and female mice from inbred strains B6 (n = 19) and D2 (n = 25). Following lick training, bilateral lingual–chorda tympani nerve cuts (LX) (n = 6 B6, n = 7 D2), unilateral hypoglossal nerve cuts (HX) (n = 7 B6, n = 9 D2), or sham surgery (n = 6 B6, n = 9 D2) was performed. Mice were lick tested postsurgically with both water and sucrose (4 days total). Following testing, post mortem dissections and microscopic analysis of tongue papillae were performed. Results. In both strains, HX and LX mice demonstrated a significant reduction in volume per lick (VPL) in the surgical groups relative to shams. Neither motor nor sensory nerve transection affected local lick rate. In most LX mice in both strains, taste papillae were reduced compared with HX or sham mice. Conclusion. Mice of either strain with either a sensory or a motor nerve injury have a significant loss of VPL during ingestion of either a neutral (water) or preferred (sucrose) stimulus. This reduction in VPL reflects a deficit in licking. Lick rate was not affected by deafferentation. A reduction in fungiform papillae following LX but not HX mice was noted.