Sandeep P. Dave

Surgical outcomes and safety of transnasal endoscopic resection for anterior skull tumors.

Objective To report the surgical outcomes and safety of transnasal endoscopic resection (TER) for anterior skull base (ASB) tumors. Study Design and Setting A retrospective chart review to identify patients undergoing TER for ASB tumors at a tertiary care medical center between September 1997 and June 2006. Results Nineteen patients underwent TER for ASB tumors without open craniotomy. There were 17 malignant and two benign lesions. Olfactory neuroblastoma was the most common pathology, occurring in 53 percent of patients. One patient recurred locally, resulting in an overall local control rate of 94.7 percent for all neoplasms and 94.1 percent for malignant disease. It should be noted that the tumor control rate may be premature given the small sample size and limited follow-up. Overall, there were 16 complications, but only two of these, an orbital hematoma and a frontal lobe abscess, were considered major complications directly attributable to surgery. Conclusions TER for ASB tumors appears to be safe in properly selected patients. In light of the small sample size and limited follow-up, the major complication rate directly attributable to surgery was 11 percent, and the overall local control rate was 95 percent. A larger multi-institutional series with longer follow-up is warranted.

The benign lymphoepithelial cyst and a classification system for lymphocytic parotid gland enlargement in the pediatric HIV population

Objectives/Hypothesis: The objectives of this study are to present a series of parotid gland benign lymphoepithelial cysts (BLEC) in HIV‐positive children and to propose a three‐tiered classification system for HIV‐associated lymphocytic parotid gland enlargement.

Mucoepidermoid carcinoma of the external auditory canal (EAC)

We present the third case of mucoepidermoid carcinoma of the external auditory canal (EAC) in the English literature, and discuss the management of this lesion. The patient underwent a wide local resection, superficial parotidectomy, and selective neck dissection. Although intraoperative frozen section margins were negative, permanent histopathologica examination demonstrated tumor in the medial margin, and the tumor was upgraded to a high-grade mucoepidermoid carcinoma. The patient returned to the operating room for a wider local resection, and EAC reconstruction with a temporoparietal pedicled flap and split thickness skin graft. All margins were negative on final histopathologic examination. Radiotherapy was deferred in the event of a recurrence. The patient is currently disease-free 29 months after the final excision. Most authors advocate an aggressive surgical approach, which includes a form of a temporal bone resection, for the treatment of EAC carcinoma. Although this may be warranted in cases of squamous cell carcinoma, mucoepidermoid carcinoma of the EAC may be amenable to a conservative step-by-step approach for local control with less postoperative morbidity. Given the difficulty in detecting mucoepidermoid carcinoma in surgical margins by frozen section analysis, patients should be informed of the possibility of further surgery (re-resection) when a conservative approach is used.

Management of advanced laryngeal and hypopharyngeal plexiform neurofibroma in adults.

Laryngeal neurofibromas are rare. The plexiform subtype is less common and often presents during childhood in association with neurofibromatosis type I. Because it is unencapsulated and more aggressive, plexiform neurofibroma presents a management dilemma. Imaging, particularly magnetic resonance imaging, can aid in diagnosing neurofibroma, differentiating the nonplexiform and plexiform subtypes, and planning the subsequent operative approach. The importance of conservative surgery to relieve symptoms, but preserve laryngopharyngeal function, and close follow-up are stressed. We report 2 adult cases of plexiform neurofibroma involving the larynx and hypopharynx and discuss the controversies in management.

Microdebriders Used in Functional Endoscopic Sinus Surgery: Secondary Analysis and Validation of a New Tissue Model†

Objectives/Hypothesis: To validate a previously reported in vitro tissue model for microdebrider comparison and determine which microdebrider, tissue type, blade type, and suction strength is most efficient. Specifically, the goal of the secondary analysis is to expand on the results of the preliminary analy‐sis by increasing the sample size, and introduce an aspiration efficiency score (AES) to facilitate microdebrider comparison.

Facial Cutaneous Mucormycosis in a Full-term Infant

Mucormycosis is a rare and potentially fatal fungal infection that most commonly affects the immunocompromised population. Although originally described by Paltauf in 1885 (D. G. Finn as cited by Vessely et al(1)((p573)) and A. M. Marchevsky as cited by Oh and Notrica(2)((p1607))), it was not until 1955 that Harris (as cited by Vessely et al(1)((p573))) reported the first case of a mucormycosis survivor. In recent years, the number of immunosuppressed patients has increased partly owing to the widespread implementation of organ transplantation and the increasing prevalence of human immunodeficiency virus infection. Consequently, the incidence of mucormycosis has also increased, especially in pediatric patients. In the setting of immunocompromise, a high index of suspicion is required to accurately diagnose and treat this potentially lethal infection in a timely fashion. To our knowledge, we report the first case of facial cutaneous mucormycosis in an infant, who also represents the first reported neonate or infant to survive a cutaneous mucormycosis infection of the head and neck.

Undifferentiated pleomorphic sarcoma of the parotid gland: a rare pediatric case.

Undifferentiated pleomorphic sarcoma, or malignant fibrous histiocytoma (MFH) of the head and neck is an uncommon malignancy that is exceedingly rare in the pediatric population. Although MFH was once considered the most common soft tissue sarcoma in adults, recently authors have questioned its existence as a distinct pathologic entity.

Tissue model and preliminary analysis of microdebriders used in functional endoscopic sinus surgery.

OBJECTIVE: To develop a standardized in vitro tissue model for microdebrider comparison, and determine which microdebrider, tissue type, blade type, and suction strength is most efficient. STUDY DESIGN AND SETTING: A prospective randomized comparison of the Diego Powered Dissector and XPS 3000 Powered ENT System was conducted using a soft-tissue and a firm-tissue model. In addition to evaluating tissue aspiration with straight and angled blades, clogging rates and clearance times were measured. Both standard wall suction and liposuction were used. Basic statistical analysis and a one-way analysis of variance using confidence intervals were performed to compare outcomes. RESULTS: The aspiration of soft tissue was statistically superior to and demonstrated less clogging compared to the aspiration of firm tissue. For the “head-to-head” comparison, the XPS 3000 was statistically superior for aspirating soft tissue. When liposuction was excluded, the devices were essentially equivalent. Several notable trends that were not statistically significant were also observed. The aspiration efficiency of straight blades appeared to be superior compared to angled blades. The XPS 3000 and liposuction independently seemed to aspirate more tissue than the Diego Powered Dissector and regular suction, but at the expense of increased clogging. Finally, the Diego Powered Dissector showed a trend toward aspirating more firm tissue. CONCLUSION: Our tissue model represents a reliable and reproducible means of microdebrider comparison. A secondary analysis with a larger sample size is warranted to further validate the tissue model, to improve the power of the statistically significant results, and to better delineate the trends that were observed in the current study.

Imaging Correlation of DFNB1 vs Non-DFNB1 Hearing Loss

Objective To evaluate temporal bone computerized tomography (CT) findings in children with DFNB1 hearing loss (HL) and non-DFNB1 deaf children, using absolute measurements and visual inspection. Methods A retrospective case-control series (1998 to 2005) was performed at an academic tertiary center. Children with non-syndromic HL were diagnosed as DFNB1 or non-DFNB1 after screening for GJB2 allele variants and the large GJB6 deletion. After matching for degree of HL, temporal bone CT images were compared in a cohort of 8 DFNB1 children (16 ears) to 9 non-DFNB1 children (18 ears). Visual criteria and absolute measurements were compared against normative values established by Purcell (2003). Absolute measurements between groups were compared using the student t-test. Non-parametric statistical tests were used when appropriate. Significance level was 0.05. Results Visual inspection failed to identify 2 patients with abnormalities found using absolute measurements. There was a statistically significant difference in the prevalence of abnormal temporal bone CT findings between DFNB1 (1 of 16 ears) and non-DFNB1 (10 of 18 ears) (p<0.0031, Fisher exact test). Of the absolute measurements, only the mean vestibule width in the non-DFNB1 group (4.195 ± 0.5 mm) was significantly greater than in the DFNB1 group (3.65 ± 0.2 mm) (p < 0.001). Conclusions Visual inspection of temporal bone CT images alone may not adequately identify anomalies and should be used in conjunction with absolute CT measurements. Abnormal temporal bone CT findings are significantly less likely in children with DFNB1 when compared to non-DFNB1 children, despite matching for a similar degree of HL.

Tissue Model and Preliminary Analysis of Microdebriders Used in Endoscopic Sinus Surgery

Objectives: In 1999, Ferguson reported the first and only quantitative analysis of microdebriders used in ESS. The purpose of our study was to establish a standardized in vitro model and compare the newer “next-generation” microdebriders to determine which device and combination of tissue type, blade, and suction strength was most efficient for this model. Methods: The Gyrus-Diego-Powered-Dissector and Xomed-XPS-3000-Powered-ENT-System were compared using a soft tissue model consisting of raw oysters (nasal polyps) and a firm-tissue model consisting of scallops mixed with eggshells (nasal/sinus tissue). In addition, the effect of blade type (straight/60) and suction strength (wall-suction/liposuction) on aspiration efficiency was evaluated. Aspiration efficiency was quantified by 3 outcomes (tissue aspiration, clog-frequency, and clearance time). Results: For the “head-to-head” comparison, Xomed was statistically superior for soft tissue/oyster aspiration when using the straight blade regardless of suction strength and when using the angled blade with liposuction. Although not statistically significant, several trends were observed in our analysis. First, Gyrus appeared to be superior to Xomed for firm-tissue/scallop aspiration, clog-frequency, and clearance time. In addition, straight blades appeared to be superior to angled blades for overall tissue aspiration, clog frequency, and clearance time. Finally, liposuction appeared to be superior for both soft tissue/oyster and firm tissue/scallop aspiration, but wall-suction demonstrated less clogging and clearance time. Conclusion: The tissue model presented appears to be both reliable and reproducible. Only 2 statistically significant results were observed, however, several trends toward significance were noted. A second study with a larger sample size and more advanced statistical analysis is needed to better delineate these trends.