Richard A. Zoumalan

Etiology of Stridor in Infants

Objectives: We undertook to identify data that facilitate determination of an accurate diagnosis of the cause of stridor in infants and to develop a framework to conceptualize the problem. Methods: We reviewed medical records of patients less than 1 year of age with the presenting symptom of stridor who were initially evaluated in the outpatient setting of a tertiary childrens hospital. Infants with obvious congenital syndromes, cerebral palsy, or hypotonia were excluded. All infants underwent history-taking, physical examination, and when symptoms were mild, office flexible laryngoscopy. With moderate or severe stridor, a more complete endoscopic evaluation was undertaken in the operating room. Results: Of 202 patients, 119 (59%) were boys and 83 (41%) were girls. Their ages ranged from 3 days to 11 months; 175 (87%) were 6 months of age or younger. Congenital anomalies were diagnosed as the cause of stridor in 170 (84%). Congenital laryngeal anomalies caused stridor in 157 (78%); congenital tracheal abnormalities were the cause in 13 (6%). The most common congenital laryngeal anomaly was laryngomalacia (94%). Forty-two (21%) of the 202 patients had at least 1 other anomaly that contributed to airway compromise. Half of all patients had laryngopharyngeal reflux, the most common associated condition. Of patients referred with a presumptive diagnosis by non-otolaryngologists, 28 of 94 (30%) were referred with erroneous presumptive diagnoses for which they were being treated, the most common of which was tracheomalacia. Conclusions: A standard, rational approach to the evaluation of stridor in infants facilitates management. A framework for evaluation is presented.

Monitoring Tracheal Tube Cuff Pressures in the Intensive Care Unit: A Comparison of Digital Palpation and Manometry

Objectives: Tracheal tube cuff overinflation is a recognized risk factor for tracheal injury and stenosis. International studies report a 55% to 62% incidence of cuff overinflation among intensive care unit (ICU) patients. However, there are no data on tracheotomy tubes, and no recent data from ICUs in the United States. It is unknown whether routine cuff pressure measurement is beneficial. We sought to determine the incidence of cuff overinflation in the contemporary American ICU. Methods: We performed an Institutional Review Board-approved, prospective, observational study of endotracheal and tracheotomy tubes at 2 tertiary-care academic hospitals that monitor cuff pressure differently. At hospital A, cuff pressures are assessed by palpation; at hospital B, cuff pressures are measured via manometry. We audited cuff pressures in an unannounced fashion at these hospitals, using a handheld aneroid manometer. Cuffs were considered overinflated above 25 cm H2O. Results: We enrolled 115 patients: 63 at hospital A and 52 at hospital B. Overall, 44 patients (38%) were found to have overinflated cuffs. The incidence of overinflation was identical at the 2 hospitals (38%; p = .99). Of the endotracheal tubes, 43% were overinflated, as were 32% of the tracheotomy tubes (p = .24). Conclusions: Despite increasing awareness among intensivists and respiratory therapists, the incidence of tracheal tube overinflation remains high, with both endotracheal and tracheotomy tubes. Our finding that the use of manometry to assess cuff pressures did not reduce the incidence of overinflation suggests that a more vigilant management protocol may be necessary.

Flat panel cone beam computed tomography of the sinuses

Objective: This study aims to compare the image quality and potential diagnostic accuracy of paranasal sinus CT scans generated by flat panel cone beam CT at three specific data acquisition times. Study Design: Prospective, single blinded analysis. Subjects and Methods: Eleven patients without previous radiologic evaluation were selected based on history and findings suspicious for chronic sinusitis. Each patient was scanned at three different acquisition times: 10, 20, and 40 seconds. A panel of neuroradiologists and otolaryngologists, blinded to the scan acquisition time, individually reviewed images and rated overall image quality and visualization of specific anatomic sites. Image noise values were also calculated. Techniques were compared with a Wilcoxon matched-pairs signed ranks test. Results: Compared to the 10-second acquisition time, the 40- and 20-second acquisition time techniques had significantly better image quality (P < 0.05) and image noise (P < 0.05). No difference in image quality and image noise existed between the 20- and 40-second techniques. No difference in visualization of specific anatomic structures existed between any of the time techniques. Conclusion: The quality of flat panel CT imaging of the sinuses directly relates to scan time and thus radiation dose.

A Novel Mouse Model of Cutaneous Radiation Injury

Background: Radiation therapy is a cornerstone of oncologic treatment. Skin tolerance is often the limiting factor in radiotherapy. To study these issues and create modalities for intervention, the authors developed a novel murine model of cutaneous radiation injury. Methods: The dorsal skin was isolated using a low-pressure clamp and irradiated. Mice were followed for 8 weeks with serial photography and laser Doppler analysis. Sequential skin biopsy specimens were taken and examined histologically. Tensiometry was performed and Youngs modulus calculated. Results: High-dose radiation isolated to dorsal skin causes progressive changes in skin perfusion, resulting in dermal thickening, fibrosis, persistent alopecia, and sometimes ulceration. There is increased dermal Smad3 expression, and decreased elasticity and bursting strength. Conclusions: This model of cutaneous radiation injury delivers reproducible localized effects, mimicking the injury pattern seen in human subjects. This technique can be used to study radiation-induced injury to evaluate preventative and therapeutic strategies for these clinical issues.

Methicillin-Resistant Staphylococcus aureus–Positive Surgical Site Infections in Face-lift Surgery

OBJECTIVES To determine the incidence of methicillin-resistant Staphylococcus aureus (MRSA)-positive surgical site infections after face-lift surgery and to discuss the screening, prevention, and treatment of such infections. METHODS The patient charts of 780 patients who underwent a deep-plane rhytidectomy between 2001 and 2007 were reviewed for postoperative wound infections. Culture results and sensitivities were recorded. To our knowledge, this is the first study that documents MRSA-positive surgical site infections after face-lift surgery. RESULTS Five of 780 patients (0.6%) who underwent face-lift surgery by the senior surgeon had postoperative surgical site infections. Four of the 5 patients had cultures that were positive for MRSA. Two of these patients (0.3%) required hospitalization and had collections that had to be opened or drained and developed wound breakdown. Both patients eventually responded to wound care along with intravenous and then oral antibiotic therapy. The other 2 MRSA-infected patients responded to oral antibiotic therapy and local wound care alone. The 2 complicated infections occurred on postoperative days 5 and 8. These 2 patients were the only ones among the 5 patients with positive cultures who had known recent contact with another physician or a hospital. All infections occurred in the year 2006, with 3 patients experiencing infection in the last 4 months of the year. Herein, we describe the incidence and sequelae of MRSA infections and colonization. The 2 major different subsets of MRSA are community-acquired MRSA and health care-associated MRSA. Surgical site infections that are positive for MRSA blur this division, which affects many aspects of the course of disease and treatment. We also discuss strategies for screening, preventing, and treating MRSA surgical site infections. CONCLUSIONS Methicillin-resistant S aureus-positive surgical site infection is an increasingly problematic issue in all surgical fields. In the future, MRSA-positive infections will be more prevalent and will require well-developed screening, prevention, and treatment strategies.

Inhibition of Smad3 Expression in Radiation-Induced Fibrosis Using a Novel Method for Topical Transcutaneous Gene Therapy

OBJECTIVE To attempt to mitigate the effects of irradiation on murine skin after high-dose radiation using a novel transcutaneous topical delivery system to locally inhibit gene expression with small interfering RNA (siRNA) against Smad3. DESIGN Laboratory investigation. SETTING University laboratory. SUBJECTS Twenty-five wild-type C57 mice. INTERVENTION In an isolated skin irradiation model, the dorsal skin of C57 wild-type mice was irradiated (45 Gy). Just before irradiation, Smad3 and nonsense siRNA were applied to 2 separate dorsal skin areas and then reapplied weekly. Skin was harvested after 1 and 4 weeks. Smad3 expression were assessed by immunohistochemistry, and collagen deposition and architecture was examined using picrosirius red collagen staining. MAIN OUTCOME MEASURES Epidermal thickness was measured semiquantitatively at 4 weeks. Radiation-induced fibrosis was measured quantitatively via tensiometry. The Young modulus, a measure of cutaneous rigidity inversely related to elasticity, was determined, with normal irradiated skin serving as a control specimen. RESULTS Murine skin treated with topical Smad3 siRNA demonstrated effective Smad3 inhibition at 1 week and persistent suppression at 4 weeks. Collagen deposition and epidermal thickness were significantly decreased in skin treated with Smad3 siRNA compared with control irradiated skin. Tensiometry demonstrated decreased tension in Smad3 siRNA-treated skin, with a Young modulus of 9.29 MPa (nonirradiated normal skin, 7.78 MPa) compared with nonsense (control) siRNA-treated skin (14.68 MPa). CONCLUSIONS Smad3 expression can be effectively silenced in vivo using a novel topical delivery system. Moreover, cutaneous Smad3 inhibition mitigates radiation-induced changes in tissue elasticity, restoring a near-normal phenotype.

Hematoma Rates in Drainless Deep-Plane Face-lift Surgery With and Without the Use of Fibrin Glue

OBJECTIVE To determine the rate of hematoma formation in drainless deep-plane rhytidectomy and compare it with the rate using the same technique with the use of fibrin glue. METHODS This is a retrospective review of 605 patients (78 male and 527 female) who, over a 6-year period, underwent deep-plane face-lift surgery (n = 544) or lateral superficial musculoaponeurotic system (SMAS)ectomy (n = 61) by the senior author (S.S.R.) without the use of surgical drains. One hundred forty-six consecutive patients underwent rhytidectomy without fibrin tissue glue, and the following 459 consecutive patients were sprayed with fibrin glue under the flap prior to flap closure. Pressure dressings were used on all patients for 24 hours. RESULTS None of the patients in either group had major or expanding hematomas requiring operative intervention. In the group of patients treated without fibrin glue (n = 146), there were 5 minor, nonexpanding hematomas, all managed by needle aspiration. This is a minor hematoma rate of 3.4%. In the fibrin glue group (n = 459), there were 2 hematomas, for a rate of 0.4%. Using a Fisher exact test, we found a statistically significant decrease in the hematoma rate from 3.4% to 0.4% (P = .01). Male patients had a higher hematoma rate than female patients, and only men had significantly fewer hematomas when fibrin glue was applied (P = .01). All 7 hematomas were recognized in the first 24 hours after surgery. Of the 7 patients with hematomas, 2 (29%) had emesis in the recovery room despite medication. CONCLUSIONS The use of fibrin glue demonstrates a significant decrease in the rate of hematoma formation. Fibrin glue may benefit male more than female patients. If meticulous hemostasis and pressure dressings are used, drains are not necessary. The prevention and prompt treatment of postoperative nausea may also help prevent hematoma formation.

Subjective and Objective Improvement in Breathing After Rhinoplasty

OBJECTIVE To determine whether rhinoplasty improves subjective and objective nasal patency. DESIGN Retrospective study including subjective breathing scores and acoustic rhinometry before and 6 to 9 months after septorhinoplasty among a cohort of 31 patients. We used a paired t test to analyze the difference between preoperative and postoperative values. SETTING Academic medical center. PATIENTS Patients undergoing septorhinoplasty with potassium titanyl phosphate laser turbinate reduction at a single institution. RESULTS The mean subjective breathing scores improved significantly, with an overall improvement of 38%. The overall mean volume increased and the overall resistance decreased, but the changes were significant only on the right side. The minimal cross-sectional area (MCA) did not change, but the distance of the MCA of the nasal cavity moved anteriorly by 0.23 cm on the left side. The patients were stratified into subsets based on other procedures undergone, including spreader grafts and alar batten grafts, and on the absence of osteotomies. These groups had similar results. In patients with severe obstruction, all measured values improved more than any other subgroup, including the MCA, which improved significantly by an average of 55%. Patients with normal preoperative MCA values did not experience any significant changes except for an anterior shift in MCA. CONCLUSIONS Septorhinoplasty increases nasal volume, decreases nasal resistance, and advances the MCA anteriorly. These changes coexist with subjective improvements in nasal patency, which suggests that this new anatomic configuration creates a positive outcome on nasal airflow. Spreader grafts do not increase the MCA significantly. Patients with preoperative severe obstruction have the best overall improvement, whether measured subjectively or objectively.

Regulators and mediators of radiation-induced fibrosis: Gene expression profiles and a rationale for Smad3 inhibition

OBJECTIVE: Radiotherapy, an essential modality in cancer treatment, frequently induces fibrotic processes in the skin, including accumulation of extracellular matrix. Transforming growth factor-β is essential in regulating extracellular matrix gene expression and is dependent on Smad3, an intracellular mediator/transcription factor. Our study characterized the genetic expression involved in extracellular matrix accumulation during radiationinduced fibrosis. We performed Smad3 gene silencing in an attempt to abrogate the effects of radiation. STUDY DESIGN: Laboratory research. SETTING: University laboratory. SUBJECTS AND METHODS: C57 murine dermal fibroblasts were irradiated with 20 Gy RNA isolated (0, 6, 12, 24, 48, 72 hours postirradiation) and mRNA analyzed (reverse transcriptase polymerase chain reaction) for known regulators (Smad3, interleu-kin-13 [IL-13]), tumor necrosis factor-α [TNF-α]) and mediators of fibrosis (collagen 1A1 [Col1A1]), TGF-β, matrix metalloprotease-1 and −2 (MMP-1, MMP-2), and tissue inhibitor of metallo-protease-1 (TIMP-1). Smad3 gene expression was silenced using siRNA in an effort to restore an unirradiated gene profile. RESULTS: Following irradiation, there was a steady increase in mRNA expression of Smad3, IL-13, TGF-β, Col1A1, MMP-2, TIMP-1, with peak at 12 to 24 hours and subsequent decline by 72 hours. TNF-α expression remained elevated throughout. MMP-1 showed minimal expression initially, which decreased to negligible by 72 hours. Inhibition of Smad3 significantly decreased expression of Col1A1, TGF-β, MMP-2, and TIMP-1. IL-13 and TNF-α expression was not affected by Smad3 silencing. CONCLUSION: We have characterized the early-phase mRNA expression profiles of the major mediators of radiation-induced fibrosis. Smad3 siRNA effectively abrogated the elevation of Col1A1, TGF-β, TIMP-1, and MMP-2. IL-13 and TNF-α were unaffected by Smad3 silencing and appear to be minor regulators in fibrosis. These findings suggest a therapeutic rationale for Smad3 silencing in vivo.

Orbicularis Suspension Flap and Its Effect on Lower Eyelid Position: A Digital Image Analysis

OBJECTIVE To evaluate changes in lower eyelid position using digital image analysis in patients who have undergone an orbicularis suspension flap combined with blepharoplasty. METHODS A total of 68 patients (136 eyes) underwent a lower eyelid orbicularis oculi suspension flap combined with blepharoplasty. Digital image analysis was used to standardize each patients preoperative and postoperative photographs for accurate objective comparison. The photographs were analyzed for lower eyelid position. RESULTS The mean (SD) preoperative standardized distance from the center of the pupil to the lower eyelid margin (MRD2) in all procedures was 5.53 (0.74) mm. The mean (SD) postoperative standardized MRD2 was 5.22 (1.0) mm. There was a statistically significant difference in MRD2 position such that the postoperative MRD2 position decreased or the lower eyelid position was elevated by an average of 0.31 mm in comparison to the preoperative position (P < .001). CONCLUSIONS A well-performed suspension flap can elevate the lower eyelid position to a more natural and anatomically appropriate position. By resuspending the ptotic orbicularis muscle, the suspension flap also reinforces the underlying attenuated orbital septum. Such cases may not achieve the optimum level of rejuvenation if isolated lower eyelid blepharoplasty is performed.