Ryan Winters

Persistent oro-nasal fistula after primary cleft palate repair: Minimizing the rate via a standardized protocol §,§§

OBJECTIVES Multiple methods are described for cleft palate repair. Similarly, a wide range of postoperative oro-nasal fistula rates are described, depending on technique and series examined. We describe long-term outcomes and fistula rates for primary cleft palate repair for a single surgeon using a standardized protocol. Furlow palatoplasty was used for clefts limited to the soft palate, and two-flap palatoplasty was used for clefts involving both the hard and soft palate. METHODS Retrospective review of prospectively gathered data. RESULTS Eighty-two patients underwent cleft palate repair within the study period. Average age at time of repair was 1.69 years (range 0.47-12.1 years), 19 patients had cleft palate as a part of a known genetic syndrome, and male:female ratio was 1.05:1. Overall fistula rate requiring repair was 5.5%, and fistula development was not significantly associated with type of cleft repair or use of AlloDerm in the repair. CONCLUSIONS A very low rate of oro-nasal fistula and good postoperative outcomes were achieved utilizing this protocol for cleft palate repair. It is effective both in isolated cleft palate, as well as in more complicated syndromic patients. It is possible that significant associations between repair technique and fistula rate exist that were not elucidated in this study as a result of the small number of oro-nasal fistulas.

A faith- and community-based approach to identifying the individual at risk for head and neck cancer in an inner city.

To perform a subset analysis of faith‐ and community‐based screening events to further identify at‐risk populations for head and neck cancer in hopes of further focusing screening efforts.

Preoperative Parathyroid Needle Localization: A Minimally Invasive Novel Technique in Reoperative Settings

Background. Reoperative parathyroid surgery for primary hyperparathyroidism can be challenging. Numerous preoperative localization techniques have been employed to facilitate a more focused surgical exploration. This paper describes a novel, minimally invasive, and highly successful method of parathyroid localization. Methods. Patients with recurrent or persistent primary hyperparathyroidism underwent parathyroidectomy following CT scan or ultrasound-guided wire localization of the parathyroid. Accurate placement was confirmed by fine-needle aspiration with immunocytochemistry or PTH washout. The guide wire was left in situ to guide surgical excision of the gland. Curative resection was established by monitoring intact serum PTH levels after excision of the adenoma. Results. All ten patients underwent successful redo-targeted parathyroidectomy. Nine of the ten patients were discharged on the day of surgery. One patient was observed overnight due to transient postoperative hypocalcemia, which resolved with calcium supplementation. Conclusion. Placement of a localization wire via preoperative high-resolution ultrasound or CT can expedite reoperative parathyroid surgery. It allows identification of parathyroid adenoma via a minimally invasive approach, especially in cases where a sestamibi scan is inconclusive.

When is immediate surgical intervention required for isolated orbital blowout fractures

BACKGROUND Optimal timing for repair of the isolated orbital blowout fracture, wherein the orbital floor is fractured but the remaining orbital and facial bones are not, has been a matter of debate for decades. Recommendations over this time have ranged from immediate repair within 14 days for all fractures to observation of all fractures for 6 months before considering surgery. It is only within the past 10 years that attempts have been made to formulate guidelines for this injury, with definitive consensus yet to be reached.

Screening for Human Papillomavirus in Basaloid Squamous Carcinoma: Utility of p16INK4a, CISH, and PCR

This study compares p16 INK4a immunohistochemistry (IHC), HPV chromogenic in situ hybridization (ISH), and HPV polymerase chain reaction (PCR) genotyping for detection of HPV infection in basaloid squamous carcinoma (BSCC). A retrospective histopathological analysis of 40 BSCC from a single institution was carried out. p16 IHC, HPV DNA extraction and ISH, and HPV PCR genotyping were performed, and there was excellent agreement between all 3 methods of HPV detection. Analysis of variance yielded no significant differences between the results of the 3 tests ( P = .354) and Pearson product—moment correlation coefficients calculated for each pair of tests demonstrated direct correlation (r = .61 for PCR and IHC, r = .61 for PCR and ISH, and r = 1.00 for ISH and IHC). This supports the use of p16INK4a IHC as an initial screening tool for HPV infection in BSCC, while definitive evidence of HPV DNA can be sought subsequently with PCR or CISH.

A novel technique for superior-based pharyngeal flaps: 10-year results with formal speech outcomes assessment

PURPOSE Describe a novel technique for superior-based pharyngeal flaps allowing restoration of bulk to the soft palate and intraoperative fine-tuning of lateral port size, while avoiding midline palate-splitting. Validated speech assessment tools are employed for quantitative analysis. METHODS Retrospective review of all patients who underwent superior-based pharyngeal flap in a 10-year period by a single surgeon. Pittsburgh Weighted Values for Speech Symptoms Associated with VPI and the Goldman-Fristoe Test of Articulation were used for formal speech assessment. RESULTS 78 patients met inclusion criteria with clinical data up to 10years postoperatively. 31 patients had congenital velopharyngeal insufficiency (VPI), and the remainder acquired VPI after cleft palate repair or adenoidectomy. 37 patients had a recognized syndrome. All patients noted subjective improvement in nasality, and evaluation with the validated speech assessment tools demonstrated statistically significant improvement in speech. Only one flap takedown was required in a patient with severe midface hypoplasia who developed sleep apnea several years postoperatively. CONCLUSIONS This technique is successful in congenital and acquired VPI, and in patients with complex craniofacial syndromes. Customization of lateral ports based on preoperative nasopharyngoscopy, and avoidance of a midline palate splitting incision, make this an attractive option for superior-based flap surgery.

Intractable epistaxis and systemic lupus: High-dose intravenous pulse steroids ☆

IMPORTANCE Epistaxis is most commonly an easily treated ENT entity with a relatively simple algorithm. Occasionally, however, it is encountered as a devastating disease process that can humble the otolaryngologist. In the setting of comorbidities that exacerbate bleeding, in this case vasculitis due to systemic lupus erythematosus (SLE), epistaxis can be life-threatening and refractory to conservative management. OBSERVATIONS This case report describes the hospital course of a patient with severe SLE and intractable epistaxis. We discuss classic management options for epistaxis and offer a novel treatment option for patients with SLE-related vasculitides-goal-directed medical therapy with high-dose intravenous pulse steroid therapy. CONCLUSIONS AND RELEVANCE To our knowledge, this report not only is the first description of targeted treatment options for intractable epistaxis in patients with SLE, but also serves to augment the traditional algorithm with the addition of a goal-directed medical therapy-control of epistaxis through high-dose intravenous pulse steroid therapy. We demonstrated that 6 mg of intravenous dexamethasone given every 6 hours can be highly effective in controlling epistaxis in patients with uncontrolled SLE. The presumed mechanism is through control of associated vasculitides.

Multiple branchial cleft anomalies in conjunction with a congenital dermal fistula of the lower extremity: First report of the Guarisco-Winters syndrome

Branchial cleft anomalies are congenital remnants of the embryologic branchial clefts persisting past the embryo stage. Most occur singly and sporadically, though syndromic associations are described. Multiple branchial cleft anomalies coincident in the same patient are exceptionally rare, and rarer still are peripheral dermal sinus tracts on the extremities, with one prior documented case. We report the first case of multiple branchial cleft anomalies with a peripheral dermal sinus of the ipsilateral lower extremity. Numerous concurrent congenital anomalies exist in the patient, representing the first description of the Guarisco-Winters syndrome. The patient is intellectually and developmentally age-appropriate in all other regards.

A Comparison of p16INK4A Immunohistochemistry, Chromogenic in situ Hybridization, and Polymerase Chain Reaction Genotyping for Screening for Human Papillomavirus in Basaloid Squamous Carcinoma

Human papillomaviruses (HPV) can promote tumorigenesis at various anatomical sites in the body. Screening for dysplastic changes caused by HPV has decreased the morbidity and mortality due to invasive cervical cancer. Over the last two decades, HPV detection has included molecular methods as an adjunct to traditional Papanicolaou test for cervical cancer screening. HPV-positive HNSCC, specifically high risk HPV-16, have been recognized as a distinct molecular, behavioral and clinical subtype than HPV-negative tumors and therefore the importance of HPV detection in the head and neck region is becoming clear. On the molecular level, oncogenic HPV has two viral genes that synergistically cause deregulation of the cell cycle and malignant transformation. Specifically, viral proteins E6 and E7 act to degrade p53 and retinoblastoma gene family proteins (Rb), respectively. Inhibition of these tumor suppressor genes provokes a cascade of events that causes two points of interest: cell proliferation that escapes normal DNA check points and p16INK4A over-expression. Physiologically, p16INK4A is a cyclin-dependent kinase inhibitor that acts to offset the downstream actions of E6. With increase E6 activity, there is increase p16INK4A expression. Through another mechanism, with the degradation of Rb by E7, the transcription factor E2F is released and this also promotes p16INK4A synthesis. The purpose of this study was to evaluate correlation of HPV detection when using polymerase chain reaction (PCR), chromogenic in situ hybridization (CISH) or p16 immunohistochemistry (IHC), to determine p16INK4A could be used as a surrogate marker for HPV detection. Figure 1: Focal p16 IHC pattern (A) vs. diffuse p16 IHC pattern (B). Both at 40x magnification.