Robert Deeb

Three-dimensional volumetric measurements and analysis of the maxillary sinus.

Background Multiple chronic rhinosinusitis (CRS) staging systems have been developed in an attempt to correlate symptoms with radiological imaging results. Currently, no perfect system exists. We sought to analyze the maxillary sinus (MS) using three-dimensional volumetric measurements and advanced high-resolution CT imaging. Methods We reviewed MS CT scans from 50 control subjects and 50 subjects with documented CRS involving at least one MS. The following measurements were recorded: (1) volume of MS free air, (2) MS mucosal thickening, and (3) MS lateral wall bony thickness. Average Hounsfield unit (HU) values for mucosal thickening among CRS subjects were also recorded. Values are expressed as mean ± SD and median. Values from the CRS patients were compared with healthy controls using Students t-tests. Results Among controls (n = 50), volumes (mL) of right and left MS were 24.1 ± 9.7 and 24.7 ± 9.0, respectively. Among CRS patients (n = 50), the portion of mucosal disease to total sinus volume was 51.8% (right) and 50.7% (left). Mean bony thickness (mm) in controls was 0.98 ± 0.2 (right) and 1.0 ± 0.3 (left). CRS patients had significantly greater bony thickness 1.9 ± 0.8 (right) and 2.0 ± 0.9 (left; p = 0.0001). HU for diseased MS were 30.1 ± 18.7 (right) and 35.7 ± 22.1 (left). Conclusion Three-dimensional volumetric analysis combined with HU calculations and bony thickness measurements represents a new and unique way to evaluate CT scans in patients with CRS. Additional studies correlating symptoms with imaging findings as well as analysis of all paranasal sinuses is the next step toward a novel staging system.

Snoring and carotid artery intima‐media thickness

A growing body of evidence indicates that primary snoring (PS) may be the initial presentation of sleep‐disordered breathing and can adversely affect an individuals health. Individuals with the sole diagnosis of PS were evaluated to determine if a relationship exists between snoring and thickening of the intima media of the carotid arteries.

Metastatic renal cell carcinoma to the parotid gland in the setting of chronic lymphocytic leukemia.

Renal cell carcinoma (RCC) is infamous for its unpredictable behavior and metastatic potential. We report a case of a patient with a complex history of multifocal renal cell carcinoma and chronic lymphocytic leukemia (CLL), who subsequently developed a parotid mass. Total parotidectomy revealed this mass to be an additional site of metastasis which had developed 19 years after his initial diagnosis of RCC.

Metastatic renal cell carcinoma to the parotid gland presenting 19 years after nephrectomy: case report and review of literature.

OBJECTIVE To present a case of metastatic renal cell carcinoma to the parotid gland occurring 19 years after nephrectomy with review of literature. STUDY DESIGN Case report and literature review. METHODS Literature review of cases of metastatic renal cell carcinoma to the parotid gland and discussion of a recent representative case within our tertiary care health system. RESULTS We present a case of an 82 year old male who presented with a 18 month history of progressive right parotid enlargement. His past medical history is notable for renal cell carcinoma status post partial nephrectomy in 1990, followed by completion nephrectomy 15 years later. He also has a history of chronic lymphocytic leukemia, which has not been treated. He complained of some pain symptoms, but no signs of facial paralysis. Fine needle aspiration was non-diagnostic. The patient underwent a total parotidectomy with facial nerve preservation, and final pathology was consistent with metastatic renal cell carcinoma, clear cell type. Based on our literature review we believe this to be the longest disease free interval of renal cell carcinoma preceding a metastatic lesion to the parotid gland.

Molecular characterization of late stomal recurrence following total laryngectomy

The goal was to determine recurrent or second primary status for late stomal malignancies, 16 and 17 years post-total laryngectomy in two laryngeal squamous cell carcinoma (LSCC) patients, based on DNA methylation signatures and HPV typing. Adopting a literature review based definition of late stomal recurrences as new primaries at the site of the stoma or neopharynx occurring >5 years after total laryngectomy, we employed a multi-gene candidate approach to examine promoter methylation in 24 tumor suppressor genes and PCR-based assays for HPV status offered additional insights into whether the late stomal tumors post-total laryngectomy were related or not. The primary tumor for Patient 1 was negative for HPV but had aberrant hypermethylation of APC, MLH1 and BRCA1. The stomal biopsy 17-years later showed presence of HPV-16 without any methylated genes. In Patient 2, HPV-11 and promoter methylation of APC identified in the primary tumor was also observed in the stomal malignancy 16 years post-total laryngectomy. Additional information provided by molecular typing for HPV and methylation markers underscored Patient 1s and 2s late stomal presentation as most likely a second primary and recurrence, respectively. DNA methylation markers are particularly advantageous because DNA methylation is an early event in tumorigenesis, and the epigenetic modification, 5-methylcytosine, is a stable marker. Molecular marks to discern genetic heterogeneity or relatedness of stomal malignancies several years post-total laryngectomy can provide clues to their status as either second primaries or likely recurrences. Our results support the hypothesis that a subset of stomal recurrences after total laryngectomy represents second primary tumors.

Bleeding risk associated with resection of the middle turbinate during functional endoscopic sinus surgery.

Background The decision to resect the middle turbinate (MT) during functional endoscopic sinus surgery is controversial. Although there have been a variety of studies that examined the functional outcome related to this maneuver, very few studies evaluated the potential for complications, in particular, epistaxis. Objective We sought to determine ifresection of the MT during functional endoscopic sinus surgery leads to an increased risk for postoperative bleeding. Methods Patients who underwent functional endoscopic sinus surgery for chronic sinusitis or nasal polyposis between 2004 and 2014 at a single institution were analyzed for bleeding and other complications after resection of the MT. Results Between 2004 and 2014,1185 sinus surgeries were performed by 18 surgeons. A propensity matched set of 228 patients who underwent turbinate resection, and 228 controls were selected based on predicted probabilities from a logistic regression that predicted turbinate resection and that was adjusted for age, sex, and procedure. There were 89 patients with bilateral turbinates removed and 139 with unilateral turbinates removed. There was no significant difference in major bleeding or other complication rates between the two groups. Patients who underwent resection of at least one MT were 3.95 times more likely to have minor bleeding compared with those who did not; this risk increased with the number of turbinates resected (trend p = 0.008). Patients on anticoagulation medications were at a significant risk of bleeding if their MT was removed (p = 0.007), whereas patients on aspirin or antiplatelet therapy were not at a significant risk. Conclusion There was no increased risk of major bleeding or other complication associated with resection of the MT. However, there was a significantly increased minor bleeding rate associated with MT resection, particularly ifthe patient was on anticoagulants.

Snoring and carotid artery disease: A new risk factor emerges: Snoring and Carotid Artery Disease

Previous studies have identified a relationship between snoring, carotid intima media thickening, and the presence of atherosclerosis. This study examines the correlation between snoring and carotid artery disease through use of duplex ultrasound identifying greater than 50% internal carotid artery stenosis.

Complex multiple flap reconstruction in a rare recurrent metastatic osteosarcoma of the mandible

Metastasis of osteosarcoma from the femur to the mandible is extremely rare. Massive defects from radical excision of facial tumors involving the mandible and oral cavity are a significant reconstructive challenge. This unique case illustrates initial reconstructive surgery using multicomponent scapular free flap used in conjunction with a fibula free flap, long-term outcomes and management of additional reconstructive needs. We present the case of an 18-year-old male with metastatic osteosarcoma of the mandible. Radical composite salvage surgery was performed, consisting of near total mandibulectomy, total oral glossectomy, excision of bilateral buccal mucosa and excision of the entire lower lip, submental and upper central neck skin. The complex initial reconstruction is described as well as long-term follow-up with additional reconstructive challenges. The patient tolerated the surgery well and had an excellent recovery despite losing the skin paddle on the fibula and needing a pectoralis major myocutaneous pedicled flap to reconstruct his submental area. He made a great recovery both functionally and socially. He also had multiple scar excisions, and a supraclavicular flap for detethering of his left neck scar. He developed a recurrence nearly 3 years after the original surgery in the left upper cheek soft tissue at the boundary of the reconstruction and native tissue. This was widely excised and a delayed anterolateral thigh reconstruction was performed. Massive facial defects involving the lip subunit, mandible, oral tongue, and neck skin are extremely challenging from cosmetic and functional outcomes. This case report illustrates initial reconstructive management and long-term reconstructive challenges. Correspondence to: Dr. Tamer Ghanem, Department of Otolaryngology – Head & Neck Surgery, Henry Ford Health System, Detroit, MI, USA, Tel: +1-313-9165741; E-mail: tghanem1@hfhs.org Received: April 08, 2016; Accepted: May 07, 2016; Published: May 11, 2016 Introduction Osteosarcoma is the most common malignant bone tumor and is characterized by osteoid production by malignant cells [1,2]. In the United States, the incidence of osteosarcoma is 400 cases per year (4.8 per million population < 20 years) [3]. Osteosarcoma is very rare in young children, however the incidence increases in adolescents, coinciding with adolescent growth spurt between the ages of 13 and 16 [4]. In this age group, osteosarcomas are more commonly found in boys and in non-Caucasians [4]. The location of the primary lesion in children is most frequently found in the metaphyses of long bones, particularly the distal portion of the femur, proximal tibia and proximal humerus [5]. While lung metastasis is a common event in the course of the disease, metastasis of osteosarcoma to the mandible is extremely rare [6]. This report will describe a case of recurrent metastatic osteosarcoma and 4 year follow-up post-surgery with particular attention to the reconstructive challenges encountered in this time period.

In response to snoring and carotid artery intima-media thickness

We would like to thank Sereflican et al. for their letter in response to our article “Snoring and Carotid Artery Intima-Media Thickening.” We are pleased that this area of sleep medicine is attracting the much needed attention that it deserves. In devising our study, we were hopeful that both clinicians and scientists would be interested in further investigating the relationship between primary snoring and other potentially serious medical conditions. These investigations could address a variety of issues surrounding the topic including disease manifestations of primary snoring, potential etiologies of these relationships, and possible synergistic effects of snoring and other disease conditions. Sereflican et al. have made the observation that the relationship between snoring and intima-media thickness could be the result of the autonomic nervous system. Although our study did not actually investigate this possibility, we do find this to be a very interesting theory, and their claim is supported by a variety of studies that they reference. One of the theories we put forth in our article is that vibratory mechanisms, given the proximity of the carotid artery to the source of the snoring, may have a contributing role. Like many things in medicine, the mechanism is likely very complicated and multifactorial. Our study did not specifically study possible etiologies but was intended to point out that a relationship exists. We believe that much more study is needed in this area. We are hopeful that studies can be designed that will strengthen the evidence for a causal relationship and identify possible mechanisms.