Robert W. Dolan

Diagnosis and treatment of intracranial complications of paranasal sinus infections.

Complications and local extension of paranasal sinus infections most often involve the orbit and periorbita. Because of the widespread use of antibiotics since World War II, intracranial extension of maxillofacial sinusitis is rarely seen today. Nevertheless, the clinician must be aware of the potential for these complications, because late recognition of this condition and delays in treatment can increase morbidity and mortality rates. A comprehensive, current review of sinogenic intracranial complications is presented, with illustrative cases of brain abscess, subdural empyema, meningitis, cavernous sinus thrombosis, epidural abscess, and osteomyelitis. The mechanisms and potential for intracranial spread of infection from the frontal, sphenoid, and ethmoid sinuses are discussed in detail. The management of each type of complication is outlined, including the use of computed tomography and magnetic resonance imaging, and the role of surgical drainage.

Inactivation of p53 and amplification of cyclin D1 correlate with clinical outcome in head and neck cancer.

The authors have investigated whether genetic abnormalities in two genes, loss of heterozygosity (LOH) of p53 and amplification of the cyclin D1 gene, correlate with clinical outcome in 56 matched pairs of blood and tumor from patients with squamous cell carcinoma of the head and neck (SCCHN). Frequency of p53 LOH was 47.4%, of cyclin D1 amplification 33.9%, and of both abnormalities together 23.7%. p53 LOH was associated with T4 (P = 0.003) and stage IV (P = 0.015) tumors. Cyclin D1 amplification was associated with recurrences and/or metachronous tumors (P = 0.007). The total number of p53 and cyclin D1 abnormalities (scored as zero, one, and two) show a pattern that seems to be additive; the increase in the number of these abnormalities is associated with a proportional increase in the frequency of T4, stage IV, presence of recurrences and/or metachronous tumors, and possibly a proportional decrease in the disease‐free interval in the sample. The association of the markers with recurrences and/or metachronous tumors persists if the tumor stage effect is mathematically removed. The combined analysis of the p53 and cyclin D1 abnormalities seems to be more informative than either of them individually and may have predictive value in SCCHN.

Symptoms in early head and neck cancer: An inadequate indicator ☆ ☆☆ ★ ★★

Screening programs show promise in increasing the rate of early detection of head and neck cancers in high-risk populations. Prout et al (Otolaryngol Head Neck Surg 1997;116:201–8) examined the usefulness of a large-scale screening program for head and neck cancer in an inner city population by primary care physicians. Symptom assessment was based on the American Cancer Societys “Seven Warning Signs for Cancer,” (Cancer manual. 8th ed. Boston: American Cancer Society, Massachusetts Division; 1990. p. 40–64) 4 of which are relevant to the head and neck. However, these signs may be insufficient for detection of early head and neck cancer. We analyzed these and other typical symptoms to determine their role in early detection. Coincident medical problems, tobacco abuse, and alcohol abuse were also analyzed. Our findings indicate that no symptom or symptom complex is strongly correlated with early head and neck cancer for any subsite except the glottis. Symptom duration is an unreliable indicator of the duration of disease. However, patients under medical supervision are more likely to have their cancers detected early, supporting the value of surveillance by the primary care physician. The absence of definite early warning signs for most head and neck cancers suggests the need to develop essential screening criteria. Defining the population that is at high risk for head and neck cancer and subjecting it to an aggressive screening protocol is essential.

Transnasal Esophagoscopy: A High-Yield Diagnostic Tool†

Objectives: Transnasal esophagoscopy (TNE) reveals a wide range of esophageal findings. TNE technique, indications, outcomes, advantages, limitations, and impact on patient care are described.

Metachronous cancer: Prognostic factors including prior irradiation ☆ ☆☆ ★

In this article we evaluate two factors that may be responsible for the reported increased mortality rate in metachronous cancers: prior radiation therapy and stage at presentation. A select group of 358 patients was split into three groups: no prior cancer (group 1), prior cancer treated with radiation therapy (group 2), and prior cancer treated with surgery alone (group 3). We compared survival among the three groups according to stage (T1 or T2 vs. T3 or T4) using the Lifetest procedure. Survival in patients with advanced (T3 or T4) cancers was uniformly poor, and survival in patients with low-staged (T1 or T2) cancers was disproportionately poor only for patients in group 2. Metachronous cancers are not necessarily more lethal, except when the cancer arises within prior irradiated tissue. Initial treatment decisions for patients with primary cancers must always provide for the contingency of a metachronous cancer, and the judicious use of radiation therapy is essential.

Effects of vasoactive topical agents on the survival of dorsal skin flaps in rats.

OBJECTIVE To evaluate 3 vasoactive topical agents regarding their ability to improve the survival of random skin flaps in rats. METHOD Thirty-five adult Sprague-Dawley rats had a single 9 × 2 cm random skin flap raised with topical application of a white petroleum ointment (control group), prostaglandin E2, minoxidil, or nitroglycerin to the flap. The effect of the agents on the viability of the flaps was evaluated. RESULTS The control group had an average survival area of 60.8% ± 7.9%. The nitroglycerin and minoxidil groups were not significantly different, with an average area of survival of 60.1% ± 8.1% and 63.3% ± 4.7%, respectively. The prostaglandin E2 group had average area of survival of 74.2% ± 10.5% (P = 0.002). CONCLUSION Prostaglandin E2 demonstrated a significant increase in flap survival. Nitroglycerin ointment and minoxidil had no beneficial effects when compared with control.

Minimally Invasive Nasal Valve Repair An Evaluation Using the NOSE Scale

OBJECTIVE To determine the efficacy of a new surgical procedure to correct symptoms of nasal obstruction secondary to internal nasal valve narrowing. DESIGN Consecutive case series. SETTING Tertiary care multispecialty clinic. PATIENTS Patients with symptoms of nasal obstruction for at least 1 year, a closed but otherwise anatomically normal nasal valve, and resolution of symptoms with lateralization of the upper lateral cartilage. INTERVENTION Surgical correction of nasal valve stenosis by fibrocartilaginous resection and imbrication at the caudal upper lateral cartilage. MAIN OUTCOME MEASURE Validated Nasal Obstruction Symptom Evaluation (NOSE) scale score. RESULTS Highly significant improvement was seen in nasal obstruction symptoms after the procedure. A significant correlation between the reported improvement and the preoperative NOSE scale scores was demonstrated (P < .01). There was poor correlation of symptomatic improvement with acoustic rhinometry measurements. CONCLUSIONS The described surgical repair is highly successful in relieving symptoms of nasal obstruction due to nasal valve stenosis in this selected group of patients. Patients with more severe symptoms of obstruction derive the greatest benefit.

Microvascular access in the multiply operated neck : Thoracodorsal transposition

Vascular access in the multiply operated neck may be problematic for complex reconstructions that require free tissue transfer. Previously, when recipient vessels in the neck were unavailable, free tissue transfer was not considered possible. A variety of solutions such as the Corlett arteriovenous loop, vein grafts, and cephalic vein transposition have been used to provide angioaccess, but may have limitations in the radically ablated neck. We report a novel method for obtaining recipient vessels for free flap transfer which avoids extensive reoperation in the neck.

Acute lingual tonsillitis

A 45-year-old woman presented to the emergency department (ED) with a 3-day history of fever, progressive sore throat, dysphagia, and difficulty speaking. She was diagnosed with acute lingual tonsillitis. The ED physician must consider this rarely discussed disorder when presented with the previously mentioned signs and symptoms. This will allow for prompt diagnosis and treatment of acute lingual tonsillitis and may help to avoid potential airway compromise.

P189: In-Office Correction of Nasal Valve Collapse in 45 Patients

magnetic resonance image (MRI) guidance using an optical tracking system (MRI-guided therapy: MRT) in performing endoscopic sinus surgery (ESS). METHODS: To evaluate the efficacy of MRT for ESS, the following issues were investigated in this report: (1) additional time required for inclusion of the navigation system, (2) artifacts due to the surgical devices and the accurate detection of anatomical landmarks and target lesions, and (3) the prognosis of patients who underwent surgery in the MRT suite. RESULTS: Preparation of the MRT system required an additional 54 min. in cases involving general anesthesia, and an additional 17 min. in cases involving local anesthesia, in comparison with corresponding control groups undergoing ESS in a traditional operating room. Nonmetal probes were developed that were visualized in a real-time mode and assistive devices for an optical tracking system, which were equipped to avoid obstruction caused by surgical instruments as well as by the hands of surgeons. Using these unique devices, anatomic landmarks were visualized using the present MRT system. The prognosis of patients was favorable, and in particular, no patients with sinus mucocele showed a recurrence of their lesions. CONCLUSIONS: It was concluded that the MRT system used here for performing ESS was beneficial, especially in terms of the intranasal marsupialization of sinus mucoceles and for the verification of orbital contents.