R. James Koch

Histologic analysis of the thermal effect on epidermal and dermal structures following treatment with the superpulsed CO2 laser and the Erbium:YAG laser: An in vivo study†

To compare the in vivo histologic effects of the carbon dioxide (CO2) and erbium:yttrium aluminum garnet (Er:YAG) lasers. To ascertain the effects of combining CO2 and Er:YAG laser modalities during a single treatment session.

Delayed radionecrosis of the larynx

Radiation has been used to treat carcinoma of the larynx for more than 70 years. Radionecrosis is a well-known complication of this modality when treating head and neck neoplasms. It has been described in the temporal bone, midface, mandible, and larynx. Laryngeal radionecrosis is manifested clinically by dysphagia, odynophagia, respiratory obstruction, hoarseness, and recurrent aspiration. The vast majority of patients who develop laryngeal radionecrosis present with these symptoms within 1 year of treatment; however, delayed presentations have been reported up to 25 years after radiotherapy. We present, in a retrospective case analysis, an unusual case of laryngeal radionecrosis in a patient who presented more than 50 years after treatment with radiotherapy for carcinoma of the larynx. The cases of delayed laryngeal necrosis in the literature are presented. This represents the longest interval between treatment and presentation in the literature. The details of the presentation, clinical course, and diagnostic imaging are discussed. The pathogenesis, clinical features, and treatment options for this rare complication are reviewed. Early stage (Chandler I and II) laryngeal radionecrosis may be treated conservatively and often observed. Late stage (Chandler III and IV) cases are medical emergencies, occasionally resulting in significant morbidity or mortality. Aggressive diagnostic and treatment measures must be implemented in these cases to improve outcome. This case represents the longest interval between initial treatment and presentation of osteoradionecrosis in the literature. A structured diagnostic and therapeutic approach is essential in managing this difficult problem.

Metastatic renal cell carcinoma to the nose

A 74-year-old man was evaluated for a large fungating, friable mass protruding from his left nasal vestibule causing intermittent epistaxis and nasal obstruction (Fig 1). In 1993 he had been diagnosed with renal cell adenocarcinoma, which had been treated with a radical left nephrectomy. In 1997 mediastinal and right lung masses developed and were seen on chest roentgenograms. Biopsy specimens demonstrated these to be metastatic renal cell carcinoma (RCC). One year later, the nasal mass developed. Biopsy specimens of this friable nasal mass revealed metastatic RCC. Palliative resection of this lesion was performed for management of his epistaxis and partial left nasal obstruction. RCC is the most common malignant renal tumor and typically affects men between the ages of 30 and 60 years.1 RCC has a higher incidence in men than in women and can metastasize to any location in the body. The most common metastatic sites are the lungs (75%), regional lymph nodes (65%), and bones and liver (40%); the incidence in the head and neck is approximately 15%.2 After lung and breast carcinoma, RCC is the third most common infraclavicular tumor to metastasize to the head and neck.2 Metastasis to the nose is extremely rare, and to our knowledge there have been only 25 reported cases in the literature.1-4 When the paranasal sinuses are included, RCC is the most common primary malignancy to cause metastases to this location.2 Swelling, nasal obstruction, and pain can all be nonspecific symptoms, but epistaxis is the chief symptom in more than 70% of cases.2 Histopathology reveals poorly defined cells with abundant clear cytoplasm and indistinct cytoplasmic borders (Fig 2). Epistaxis is caused by the richly surrounding vascular stroma. With electron microscopy, it has been elucidated that the epithelium of the proximal renal tubular cell is the origin of RCC.3 The highly unpredictable ability of RCC to metastasize anywhere has experts theorizing on the routes of spread. The most favored theory at this point is emboli from RCC spreading to the head and neck via Batson’s paraspinal venous plexus. This is a rich venous anastomosis with the prevertebral, vertebral, and epidural systems. A tumor embolus could travel from the kidney to the inferior vena cava in anterograde fashion. An increase in intraabdominal and intrathoracic pressure could push the embolus in retrograde fashion through the anastomotic venous system into the head and neck.3 It also has been postulated that an embolus could travel via a hematogenous or lymphatic route. The 5-year survival rate after a nephrectomy is approximately 60% to 75%.3 In those patients who have a solitary metastasis, the treatment is radical excision and nephrectomy, with an approximate 5-year survival of 35%.2 The prognosis of patients with multiple metastases is poor, and the 5-year survival is 0% to 7%.3 Most patients with RCC die of complications of their tumor or as a direct result of distant metastases.3

In vivo model of histologic changes after treatment with the superpulsed CO2 laser, Erbium:YAG laser, and blended lasers: A 4- to 6-month prospective histologic and clinical study†

To compare the in vivo histologic effects of the pulsed carbon dioxide (CO2) and erbium:ytrium aluminum garnet (Er:YAG) lasers and to assess the effects of combining CO2 and Er:YAG laser modalities during a single treatment session. We previously reported 10 patients treated with four laser regimens: CO2 alone, CO2/Er:YAG, Er:YAG alone, Er:YAG/CO2 with time points at 1 hour and 7 days between laser treatment and histologic analysis. This study found that the optimal treatment consisted of limited CO2 laser passes followed by Er:YAG. This treatment produced less collagen injury, less thermal necrosis, and more robust epithelial and dermal fibrous tissue regeneration in the acute phase of healing. The present study examines the histologic changes resulting from the host healing response to laser treatment on long‐term follow‐up of 4–6 months.

Effects of Mitomycin-C on Normal Dermal Fibroblasts†

Objectives: To evaluate the effects of mitomycin‐C on the growth and autocrine growth factor production of human dermal fibroblasts from the face.

Qualitative and quantitative immunoglobulin production by specific bacteria in chronic tonsillar disease

Tonsillar tissue lymphocyte (TTL) function as measured by immunoglobulin production was assessed in vitro in 60 tonsils, 51 diseased and 9 normal controls. The diseased specimens were from children (aged 3 to 10 years) clinically classified as having recurrent tonsillitis (RT), idiopathic tonsillar hyperplasia (ITH), or recurrent tonsillitis with hyperplasia (RT/H). TTLs were challenged with intact, heat‐inactivated bacteria found in the core of diseased tonsils—Streptococcus pyogenes (SP) and Haemophilus influenzae type B (HIB) as well as the dominant bacterium (DB) grown from that particular tonsillar core. The phytomitogen, leukoagglutinin (LA), was used as a nonspecific activator. Qualitative immunoglobulin production was assessed for the immunoglobulin G (IgG), immunoglobulin M (IgM), and immunoglobulin A (IgA) classes. Immunoglobulin‐specific production was quantified at the basal level, and at 2, 4, and 6 days following stimulation.

GROWTH OF KELOID-PRODUCING FIBROBLASTS IN COMMERCIALLY AVAILABLE SERUM-FREE MEDIA

The purpose of this study was to update our in vitro serum-free keloid fibroblast (KF) model by use of commercially available media. Prior evaluations of fibroblast characteristics in vitro, especially that of growth factor measurement, have been confounded by the presence of serum-containing media. KFs were obtained from patients undergoing facial keloid removal. The 4 commercially available serum-free media evaluated were AIM-V (Gibco, Grand Island, NY), Fibroblast Growth Medium (FGM; Clonetics, San Diego, CA), HB GRO (Irvine Scientific, Santa Ana, CA), and UltraCULTURE (BioWhittaker Inc, Walkersville, MD). The main outcome measures were sustained KF growth and viability as compared with serum-based models. The KFs in UltraCULTURE had a higher viability but did not grow as well as in FGM. The KFs in HB GRO and AIM-V demonstrated significantly decreased viability. Because of FGMs satisfactory proliferative support and viability comparable with serum-based medium, it is recommended for the in vitro propagation of keloid-producing fibroblasts.

Direct bonded orthodontic brackets for maxillomandibular fixation

Objectives/Hypothesis: Mandibular fracture treatment often includes arch bar maxillomandibular fixation (MMF), either alone or in combination with open reduction/internal fixation (ORIF) techniques. The glove perforation rate associated with arch bar placement, the incidence of blood‐borne pathogen positivity in facial fracture patients, and the injurious effects of arch bars on dental enamel and gingiva have prompted the development of safer alternatives to arch bar MMF. This study evaluates the efficacy, ease of use, and safety profile of one such alternative: orthodontic direct bonded bracket fixation (MMF/DBB). Study Design: Prospective study of consecutive mandible fracture patients treated with MMF/DBB. Methods: Thirty‐two patients with mandibular fractures were evaluated from January 1994 to July 1997. Fourteen were appropriate for treatment with MMF/DBB (12 men and two woman; mean age, 24.6 ± 7.2 y; range, 16–42 y). Fracture sites included symphysis, angle, condylar neck, coronoid, and body. Nine patients underwent MMF/DBB alone; five underwent MMF/DBB with subsequent ORIF. Results: No infection, malocclusion, malunion/nonunion, or enamel/ gingiva injury occurred. Mean follow‐up was 6 months (range, 1–12 mo). Oral hygiene with MMF/DBB was superior to historical controls using arch bars. Conclusions: MMF/DBB can serve as the single treatment method with satisfactory results in patients with favorable, less complicated mandible fractures, although with increased experience, we have treated several more complex cases with MMF/DBB alone. In cases necessitating ORIF, MMF/DBB can be performed preoperatively to align fracture segments and reestablish occlusion. This facilitates placement of osteosynthesis plates and reduces ORIF operative time. MMF/DBB is an economical, safe technique that minimizes blood‐borne‐pathogen risk to the operative team, eliminates periodontal injury, facilitates postoperative dental hygiene, and is painless to apply and remove.

Advantages and disadvantages of computer imaging in cosmetic surgery.

background. Despite the growing popularity of computer imaging systems, it is not clear whether the medical and legal advantages of using such a system outweigh the disadvantages. objective. The purpose of this report is to evaluate these aspects, and provide some protective guidelines in the use of computer imaging in cosmetic surgery. methods. The positive and negative aspects of computer imaging from a medical and legal perspective are reviewed. Also, specific issues are examined by a legal panel. results. The greatest advantages are potential problem patient exclusion, and enhanced physician‐patient communication. Disadvantages include cost, user learning curve, and potential liability. conclusion. Careful use of computer imaging should actually reduce ones liability when all aspects are considered. Recommendations for such use and specific legal issues are discussed.

Growth factor profile of irradiated human dermal fibroblasts using a serum-free method.

Radiation therapy for cancer permanently damages tissue in the line of treatment. This study sought to establish a serum-free protocol to evaluate the growth of irradiated fibroblasts and to analyze the levels of basic fibroblast growth factor (bFGF) and transforming growth factor-beta (TGF-beta) compared with normal fibroblasts. One irradiated cell line of human dermal fibroblasts was established from an intraoperative specimen obtained from a patient who had undergone radiation therapy for head and neck cancer. Irradiated and normal fibroblasts were then plated in UltraCULTURE (serum and growth factor free), modified Webbers medium (bFGF 50 ng/ml, insulin-like growth factor 100 ng/ml), and Dulbeccos Modified Eagle Medium with 10% fetal bovine serum (serum with undefined basal growth factors). Irradiated cells were also seeded in UltraCULTURE with 50 and 100 ng/ml of bFGF. Cell counts were performed at 0, 1, 3, 5, and 7 days, and cell supernatants were assayed for bFGF and TGF-beta. Irradiated and normal fibroblasts exhibited stronger growth in modified Webbers medium than in Dulbeccos Modified Eagle Medium with 10% fetal bovine serum. Growth of irradiated fibroblasts under bFGF modulation was similar to their growth in Webbers medium. Furthermore, irradiated fibroblasts remained viable in a serum-free and growth factor-free environment for at least 7 days; however, their growth and autocrine growth factor production was less than that of normal cells. This confirms the results of previous studies suggesting that cells from irradiated tissue undergo cellular changes. This study provides an effective model for the first-line evaluation of agents to improve wound healing, and it helps to establish standard levels of bFGF and TGF-beta production for irradiated fibroblasts.