Timothy D. Doerr

Nutritional and Zinc Status of Head and Neck Cancer Patients: An Interpretive Review

In this review, we provide evidence based on our studies, for zinc deficiency and cell mediated immune disorders, and the effects of protein and zinc status on clinical morbidities in patients with head and neck cancer. We investigated subjects with newly diagnosed squamous cell carcinoma of the oral cavity, oropharynx, larynx, and hypopharynx. Patients with metastatic disease and with severe co-morbidity were excluded. Nutritional assessment included dietary history, body composition, and prognostic nutritional index (PNI) determination. Zinc status was determined by zinc assay in plasma, lymphocytes, and granulocytes. Pretreatment zinc status and nutritional status were correlated with clinical outcomes in 47 patients. Assessment of immune functions included production of TH1 and TH2 cytokines, T cell subpopulations and cutaneous delayed hypersensitivity reaction to common antigens. At baseline approximately 50% of our subjects were zinc-deficient based on cellular zinc criteria and had decreased production of TH1 cytokines but not TH2 cytokines, decreased NK cell lytic activity and decreased proportion of CD4+ CD45RA+ cells in the peripheral blood. The tumor size and overall stage of the disease correlated with baseline zinc status but not with PNI, alcohol intake, or smoking. Zinc deficiency was associated with increased unplanned hospitalizations. The disease-free interval was highest for the group which had both zinc sufficient and nutrition sufficient status. Zinc deficiency and cell mediated immune dysfunctions were frequently present in patients with head and neck cancer when seen initially. Zinc deficiency resulted in an imbalance of TH1 and TH2 functions. Zinc deficiency was associated with increased tumor size, overall stage of the cancer and increased unplanned hospitalizations. These observations have broad implications in the management of patients with head and neck cancer.

Effects of zinc and nutritional status on clinical outcomes in head and neck cancer

The head and neck cancer patient often presents with both protein malnutrition and trace element deficiencies. Zinc has been found to be deficient in many head and neck cancer patients. In this study, pretreatment zinc status and nutritional status (measured by the Prognostic Nutritional Index [PNI]) were correlated with clinical outcomes in 47 patients. The patients were followed-up for a median of 52 mo from the time of enrollment. Our results showed that the tumor size and overall stage correlated significantly to zinc status whereas no such correlation was seen with PNI, alcohol intake, or smoking in our subjects. The results also showed that impaired zinc status was associated with an increased number of treatment morbidities, unplanned hospitalizations, and treatment delays (P < 0.05). Nutritional status was not associated with any studied outcome variable. The disease-free interval was highest for the group which had both zinc-sufficient and nutrition-sufficient status. Although our data do not prove conclusively, they do suggest that impaired zinc status at presentation may contribute to treatment morbidity, and that for an optimal mean disease-free interval, a sufficient zinc and nutritional status is required.

Early tracheotomy in elderly patients results in less ventilator-associated pneumonia.

Objectives: To determine if the timing of tracheotomy in elderly patients results in less ventilator associated-pneumonia, mortality, and morbidity. Study Design: Historical cohort study. Subjects and Methods: This study included 158 ICU patients aged >65 who underwent tracheotomy from March 2003 to June 2007. Patient demographics, outcomes, and ventilation data were collected and analyzed. Results: The early tracheotomy group (continuous intubation time <7 days) included 43 patients, and 115 patients were included in the late group. There were no statistically significant differences in the demographics of the two groups. A statistically significant difference in the rate of ventilator-associated pneumonia was noted in the early versus late tracheotomy group (−0.29% VAP, 95% CI: −0.46, −0.12). There were more intubations per patient noted in the early tracheotomy group versus the late tracheotomy group (0.70 intubations, 95% CI: 0.41, 0.99). The early tracheotomy group has a lower total ICU admission time (−9.5 days, 95% CI: −21.81, −2.25) and total hospital admission time (−10 days, 95% CI: −33.69, −2.249). There was no difference in mortality, although there was a trend of lower mortality in the early tracheotomy group (−11.3% mortality, 95% CI: −0.27, −0.05). Conclusion: Early tracheotomy in elderly patients is associated with less ventilator-associated pneumonia, more frequent intubations, less total admission time, and a trend toward lower mortality.

Treatment of idiopathic sudden sensorineural hearing loss

Abstract Conclusion. The therapeutic role of corticosteroids and/or corticosteroids with antiviral agents for sudden sensorineural hearing loss (SSNHL) has yet to be fully elucidated; however, in cases where deafness is profound and of recent onset, a therapeutic trial is indicated. Objectives. To investigate treatment regimens and their efficacies, as well as evaluating the potential prognostic correlates and allowing comparison between local and national standards of care for SSNHL. Patients and methods. A retrospective evidence-based case series of 143 patients seen at the University of Rochester, Department of Otolaryngology between 1999 and 2002 was investigated. Treatment modalities included (1) observation, (2) steroids, and (3) steroids with antivirals. Results. The study demonstrates that steroid treatment, alone or in combination with antivirals, results in a significant improvement rate compared with observation. Results indicate that the more expediently a patient with SSNHL is seen by an otolaryngologist, the better their prognosis.

Lipoplasty of the face and neck.

Purpose of reviewFacial aesthetic surgery has gained wider acceptance and demand for it is increasing. Patients seeking a more youthful facial look often request lipoplasty. This article reviews the recent advances in lipoplasty and related fat contouring for the face and neck. Recent findingsLipoplasty of the face and neck continues to be popular. There have been improvements in instrumentation, with laser and powered lipoplasty improving the efficiency of fat removal. Lipoplasty indications for neck lipodystrophy have been extended to patients previously only offered neck lifting. Additionally, limited procedures for patients with isolated anterior neck deformities, including direct lipectomy and skin excision, are gaining in popularity. Considerable attention in the lay and professional literature has been paid to mesotherapy for dissolving unwanted fat. Evidence supporting its efficacy is elusive. Finally, there remains enthusiasm for injection fat transfer for facial volume restoration as a component of rejuvenation. SummaryThe treatment of lipodystrophy of the face and neck involves the removal of undesirable fat and the transfer of fat to other areas to produce improved aesthetic results. With the current emphasis on restoring volume, lipoplasty and fat transfer will continue to be important in facial plastic surgery.

The effects of flunarizine and pentoxifylline on vestibular blood flow in the guinea pig

Abstract Several authors have proposed that complications arising from vestibular disorders are the result of compromised circulation. The purpose of the current study was to assess the ability of flunarizine and pentoxifylline to increase peripheral vestibular blood flow (VBF), since flunarizine is a selective calcium-channel entry blocker that inhibits calcium-related contraction of smooth muscle, while pentoxifylline is a xanthine derivative that promotes microcirculation by affecting red blood cell malleability. Both of these treatment strategies have received considerable attention in clinics and laboratory, but their effects on blood flow are unclear. Changes in VBF were evaluated from the posterior semicircular canal ampulla in guinea pigs using a laser Doppler flowmeter. One group of animals was infused with pentoxifylline at concentrations of 10–40 mg/ml, while a second group was treated with 0.3–1.5 mg/kg flunarizine. VBF, blood pressure (BP) and heart rate (HR) were monitored continuously. Findings showed that pentoxifylline induced a concentration-dependent increase in VBF. In contrast, no increase in VBF occurred in response to flunarizine infusions. These studies suggest that the effectiveness of pentoxifylline in the clinical treatment of vestibular disorders may be the result of improved blood flow.

Hashimoto's thyroiditis within ectopic thyroid gland mimicking the presentation of thyroglossal duct cyst

A 9-year-old girl was referred for evaluation of an anterior neck mass that had been present for 6 weeks without significant change in size. On examination, a soft 3.5 × 2.5 cm infrahyoid midline mass was noted. The mass elevated with swallowing and was nontender to palpation. At initial presentation, an evaluation included a serum thyroid-stimulating hormone (TSH) that was noted to be normal (3.52 μ/mL; normal, 0.30 to 5.00 μ/mL). At the time of consultation, the TSH had increased to 11.25 μ/mL with a normal T4 level (8.2μg/dL, normal 4.5 to 12μg/dL). An ultrasound of the thyroid was interpreted as showing normal thyroid tissue in a pretracheal position. A presumptive diagnosis of thyroglossal duct cyst (TGDC) was made, and surgery was planned. At surgery, a limited midline neck exploration did not identify a normal thyroid gland. Frozen section biopsy specimens of the paramidline mass revealed chronic lymphocytic thyroiditis. Secondary to concerns that the mass might represent the patient’s principal functioning thyroid, the aberrant tissue was not removed. Postoperatively, antimicrosomal (72 u/mL; normal, < 0.30u/mL) and antithyroglobulin antibodies (40u/mL; normal < 1.0u/mL) were noted to be elevated. The findings were considered consistent with the diagnosis of Hashimoto’s thyroiditis. A thyroid scan with iodine-123 showed 3 rightsided foci of thyroid tissue with absence of left lobe activity. The largest of the foci, previously felt to be the TGDC, was noted to approximate the midline at the level of the superior thyroid bed. The remaining foci were located superior and lateral (see Fig 1). Postoperatively, the patient had persistently elevated TSH levels requiring the initiation of thyroxine supplementation.

Timing of edentulation and extraction in the management of oral cavity and oropharyngeal malignancies

Pretreatment dental evaluation is an essential element in the management of the head and neck cancer patient. Frequently, the dental condition requires edentulation or multiple extractions prior to radiotherapy. These extractions may be carried out at the time of oncologic resection. Such practice is routine for some surgeons but resisted by others who fear increased postoperative wound complications. To date, no study evaluating the safety and efficacy of extractions at the time of surgical resection has been reported. This paper retrospectively examines the postoperative course of head and neck cancer patients with varying strategies of dental management.

Hyaluronan and its receptors in mucoepidermoid carcinoma

Hyaluronan (HA) is a prominent extracellular matrix component undergoing continuous production and degradation. Increased HA levels have been described in a variety of tumors. The objective of this study was to examine the staining patterns of HA and two of its associated receptors (CD44 and HARE) in relation to the metastatic potential of mucoepidermoid carcinoma (MC). Immunohistochemical staining of preserved surgical specimens was used.

Evidence-Based Facial Fracture Management.

With demands for an evidence-based approach to patient care, the management of facial fractures will come under increasing scrutiny because there is an overall deficiency in higher level clinical evidence. This article reviews the management of facial fractures, focusing on an evidence-based approach. It focuses on select areas of facial trauma in which there is controversy and presents randomized studies and meta-analysis to help define best practice. The article notes the many areas where the evidenced-based literature is weak and looks at the future of evidence-based facial trauma care.