Michael A. Carron

Identification of Helicobacter pylori biofilms in human gastric mucosa.

The purpose of this study was to use endoscopically directed biopsies and scanning electron microscopy (SEM) to document the existence of Helicobacter pylori biofilms in human gastric mucosa. Patients underwent flexible esophagogastroduodenoscopies with three gastric mucosal biopsies. Rapid urease testing was performed to determine the presence or absence of H pylori. Urease-positive and urease-negative control specimens were imaged with SEM to obtain detailed images of gastric mucosa for the identification of biofilm colonies. Samples were obtained from patients who underwent esophagogastroduodenoscopies. Eleven were found to be H pylori positive and nine were H pylori negative. These were imaged at 50O × and 1000 × with electron microscopy. Dense, mature biofilms were present and attached to the cell surface of H pylori-positive specimens and were absent in urease-negative controls. Photomicrographs were obtained. Biofilms are complex microbiological ecosystems where sessile bacteria surround themselves in a protective matrix. This lifestyle affords protection, allows for growth in hostile environments, and alters host physiology. Many have hypothesized that H pylori infections resulting in gastric ulcers may be a manifestation of biofilms. Our investigation is the first to photographically document the existence of H pylori biofilms on human gastric mucosa. This elucidation of the ecology and pathophysiology of the mucosa of the organism is important to our understanding of a potential mechanism of this organism’s resistance to current therapy and how to better eradicate it in the future.

Presence and density of Helicobacter pylori biofilms in human gastric mucosa in patients with peptic ulcer disease

Our purpose was to use endoscopically directed biopsies and scanning electron microscopy to quantify Helicobacter pylori biofilm density on the surface of human gastric mucosa in urease-positive and -negative patients. Participating patients underwent flexible esophagogastroduodenoscopies coupled with gastric mucosal biopsies. Rapid urease testing was performed on all specimens to determine the presence of H. pylori, followed by scanning electron microscopy to identify the existence of biofilms. Samples were then analyzed using Carnoy Image Analysis Software to determine percent biofilm coverage of the total surface area. These data were compared to control specimens that were urease negative. Of the patients who tested urease positive for H. pylori, the average percent of total surface area covered by biofilms was 97.3%. Those testing negative had an average surface area coverage of only 1.64%. These differences were determined to be statistically significant at the 0.0001 level. This study demonstrates that compared with controls, urease-positive specimens have significant biofilm formation, whereas urease-negative specimens have little to none. This was reflected in the significantly increased biofilm surface density in urease positive specimens compared with urease-negative controls.

Sinonasal Mucosal Melanoma: A 13-Year Experience at a Single Institution

OBJECTIVE Report the experience of the Karmanos Cancer Institute with sinonasal mucosal melanoma (SNMM) in patients diagnosed between 1995 and 2007. RESULTS Eighteen patients, ages 31 to 85 (mean, 67), whose most common presenting symptoms included epistaxis and facial pressure. Most common anatomic locations were the maxillary sinus and nasal cavity. Seventy-two percent presented with tumors extending to the skull base, frontal sinus, orbit, or cranium. Tumor size ranged from 0.3 cm to 5.3 cm. Most common surgical procedure was medial maxillectomy (12 patients). Eight patients received chemotherapy, ten received radiotherapy and six received both. One third of patients received interferon-alpha. Median recurrence-free survival (RFS) was 14.4 months, with a 1-year RFS rate of 55%. Median overall survival (OS) was 19.3 months with a 1-year OS rate of 60% and a 2-year OS rate of 42%. The 5-year OS rate was 34%. CONCLUSION SNMM remains a disease that has eluded breakthroughs in treatment. Patients are typically treated with wide local resection; however unique to our institution was the frequent use of interferon and chemoradiation. Further research in adjuvant therapies will be necessary to improve outcomes.

Tongue base schwannoma: report, review, and unique surgical approach

Base of tongue schwannomas are exceedingly rare and therefore often are not immediately included in the differential diagnosis and treatment of oropharyngeal tumors. After a thorough review of the English literature, we found only 6 previously reported cases of tongue base schwannomas. We are contributing a report of a 37-year-old woman with progressive dysphagia, dysarthria, and large tongue base schwannoma. Diagnosis was confirmed by imaging studies and biopsy followed by surgical excision designed to preserve nerve function. A number of surgical approaches have been described for tongue base schwannomas. Each has its own degree of postoperative morbidity. The use of a unilateral transcervical incision with blunt dissection was simple and quickly accomplished with protection of nearby nerves. Histologic identification of Antoni A and B areas along with strong and diffuse staining with S-100 stain pathologically completed the diagnosis of schwannoma.

Craniocervical necrotizing fasciitis with and without thoracic extension: management strategies and outcome

OBJECTIVE First objective was to review cases of craniocervical necrotizing fasciitis (CCNF) at Wayne State University/Detroit Medical Center (Detroit, MI) for the last 18 years. Second was to analyze patients with and without thoracic extension for contributing factors. METHODS Retrospective review of 660 patients with necrotizing fasciitis treated at WSU/DMC from January 1989 to January 2007 was conducted. Data regarding source/extent of infection, presenting signs/symptoms, computed tomography, microbiology, antibiotics, comorbidities, number/type of operations, hyperbaric oxygen (HBO) therapy, hospital duration, complications, and overall outcome were compared/analyzed between patients with and without thoracic extension. RESULTS Twenty patients with CCNF for the past 18 years met the inclusion criteria. Ten patients had thoracic extension, and 10 patients did not have. Individuals in the thoracic extension group were likely to be older, had increased comorbidity, required more surgical debridement, experienced increased postoperative complications, and had lower overall survival. Three patients with thoracic extension underwent HBO therapy and 66% survived. CONCLUSION This is the largest single institutional review of CCNF comparing patients with and without thoracic extension. Patients with thoracic extension have a poorer outcome as follows: 60% (6/10) survival vs 100% (10/10) for those without thoracic extension (P < .05). The CCNF patients without thoracic extension treated at our institution all survived after prompt medical and surgical intervention. Overall survival of CCNF patients without thoracic extension may be attributed to rigorous wound care, broad spectrum intravenous antibiotics, aggressive surgical debridement, and vigilant care in surgical intensive care unit. The HBO therapy should be included if the patient can tolerate it.

Single-Incision Transaxillary Robotic Thyroidectomy Challenges and Limitations in a North American Population

Objective We reviewed our initial experience with robotic thy-roidectomy to identify challenges and limitations of this new surgical approach when applied to a North American population. Study Design Case series. Setting Academic institution. Subjects/Methods Retrospective review of 18 consecutive robotic thyroid lobectomies performed from February 2010 to April 2012 involving 16 female patients. Two patients underwent robot-assisted completion thyroidectomy a few months following the initial thyroid surgery, one for cancer and the other for goiter. Results Median age was 47.5 years (range, 18-62 years), and median body mass index was 28.7 (range, 19.4-44.5). Median thyroid nodule size was 2.9 cm (range, 1.1-4.7 cm). All but 1 case (6%) was performed successfully via single axillary incision. There was no conversion to an open approach. Median operative time was 170 minutes (range, 95-220 minutes), and median blood loss was 12.5 mL (range, 5-75 mL). Complications occurred in 4 cases (22%) to include temporary vocal cord pareses (n = 3) and a postoperative hematoma that required exploration. Median hospital stay was 2 days (range, 1-3 days). Conclusion Single-incision transaxillary robotic thyroidectomy can be technically challenging in North American patients with a larger body frame due to difficulty in optimal placement of all 4 robotic instruments via a single axillary incision. All 3 cases of temporary vocal cord paresis occurred early in our experience and may have been due to our relative inexperience with this new approach and associated instrumentation. Other limitations include less than optimal visualization of the recurrent laryngeal nerve in the contralateral lobe as well as poor access to the substernal region. Level of Evidence: 4

Baseline laryngeal effects among individuals with dust mite allergy

Objective To examine baseline effects of perennial allergy on laryngeal appearance, laryngeal function, and perceived vocal handicap among individuals without current allergy or voice symptoms. Data Sources This pilot study included 47 adults: 21 with positive and 26 with negative skin test responses for the dust mite, Dermatophagoides pteronyssinus. Methods Subjects were tested for sensitivity to dust mite antigen by prick testing. Laryngeal appearance and function were studied with laryngovideostroboscopy, acoustic and speech aerodynamic analysis, and voice sampling. These parameters were blindly analyzed by three trained examiners. Subjects also completed the Voice Handicap Index (VHI) as a measure of vocal handicap. Results Subjects allergic to dust mites perceived significantly greater vocal handicap on the VHI than did nonallergic subjects. No significant differences were noted between groups in laryngeal appearance or function. Conclusion These pilot data suggest that, at baseline, allergic individuals perceive greater vocal handicap than their nonallergic counterparts (P = 0.04), even in the absence of current allergy symptoms or observable physical or functional abnormalities. These preliminary observations can serve as an impetus for further research into this important area, including the potential interrelationship between acid reflux disease and allergic laryngeal inflammation.

Burns in the head and neck: A national representative analysis of emergency department visits

Head and neck burns (HNBs) engender serious sequelae including airway edema, speech/swallowing dysfunction, sensory deficits, and scarring/disfigurement, often requiring significant reconstructive surgery. We used a nationally representative resource to estimate the number of visits to emergency departments (EDs), analyze burn types and demographic patterns, and identify specific consumer products involved.

Assault by battery: battery-related injury in the head and neck

To estimate nationwide incidence of emergency department (ED) visits for battery‐related injury (BRI) occurring in the head and neck, and analyze demographic and anatomic‐specific trends.

Hockey-related facial injuries: a population-based analysis.

Recognition of the potentially severe sequelae arising from inadequate facial protection has facilitated sustained efforts to increase the use of protective visors in recent decades. Our objective was to characterize nationwide trends among patients presenting to emergency departments (ED) for facial injuries sustained while playing ice hockey.