W. Matthew White

Allergic contact dermatitis: Correlation of in vivo confocal imaging to routine histology

BACKGROUND Allergic contact dermatitis (ACD) is a common and often challenging clinical problem. In vivo near-infrared confocal reflectance microscopy (CM) is a new vital microscopy technique. OBJECTIVE CM was used to evaluate acute ACD. METHODS Patch testing by means of Finn Chambers technique was performed in 5 subjects to induce an acute allergic skin reaction. Noninvasive CM images from normal and eczematous skin were sequentially recorded before and after removal of the Finn Chambers. RESULTS The epidermis and papillary dermis were clearly seen in high resolution. Retention of nuclei in stratum corneum, epidermal edema with microvesicle formation, and transepidermal migration of inflammatory cells were observed in vivo. Isolated dendritic cells were present in the ACD sites of 2 subjects, with morphology, size, and location consistent with Langerhans cells. Dermal vasodilation was observed as well. CONCLUSION CM is a useful tool to study ACD and may be able to track Langerhans cell activation.

Noninvasive Imaging of Human Oral Mucosa in Vivo by Confocal Reflectance Microscopy

Objectives/Hypothesis: To study the microscopic anatomy of normal oral tissues in vivo using confocal reflectance microscopy (CRM). This novel and noninvasive imaging modality can define and characterize healthy oral mucosa and thus this work serves as the foundation for studying oral diseases in vivo.

Confocal reflectance imaging of folliculitis in vivo: correlation with routine histology.

Near‐infrared confocal reflectance microscopy (CM) is a high‐resolution non‐invasive imaging technique with promising future in dermatology. A pustular lesion from a 35‐year‐old male with a known history of folliculitis was non‐invasively viewed with CM and later biopsied. Optical sections were correlated with routine histology, This optical technique allows us to view non‐invasively transverse skin sections to a conirolled depth in real time. In the CM images, tissue can be visualized with cellular and subeellular detail as shown by imaging infiltrating neutrophils (PMNs) within the subcorneal pustule of a superficial folliculitis in vivo.

Selective transcutaneous delivery of energy to porcine soft tissues using intense ultrasound (IUS)

Various energy delivery systems have been utilized to treat superficial rhytids in the aging face. The Intense Ultrasound System (IUS) is a novel modality capable of transcutaneously delivering controlled thermal energy at various depths while sparing the overlying tissues. The purpose of this feasibility study was to evaluate the response of porcine tissues to various IUS energy source conditions. Further evaluation was performed of the built‐in imaging capabilities of the device.

Confocal imaging of sebaceous gland hyperplasia in vivo to assess efficacy and mechanism of pulsed dye laser treatment

This case demonstrates, for the first time, the use of in vivo confocal imaging to assess the efficacy of laser treatment of a skin lesion with a vascular component.

Near-infrared confocal laser scanning microscopy of bladder tissue in vivo

OBJECTIVES To assess the potential of a near-infrared confocal laser scanning microscope (CLSM) for imaging bladder tissue in vivo. METHODS Confocal images of the exposed bladder of male Sprague-Dawley rats were obtained with a CLSM. To minimize tissue motion, the bladder was placed in light contact under an objective lens housing, and the top surface was lightly flattened with a coverslip. Images were obtained from the outer and inner layers of the bladder wall with a lateral resolution of 0.5 to 1 microm and an axial resolution (section thickness) of 3 to 5 microm. The confocal images were later correlated with routine histologic studies. RESULTS The CLSM allows imaging of the urothelium, the superficial and deep portions of the lamina propria, the muscularis propria, and the serosa of the bladder wall in vivo. Urothelial cells, collagen bundles and fibers, muscle, and circulating blood cells in capillaries and larger blood vessels are easily visualized. The confocal images correlated well with the histologic studies. CONCLUSIONS Confocal microscopy allows real-time, high-resolution, high-contrast imaging of cellular and structural morphologic features to a maximal depth of 300 microm within the bladder wall in vivo. Artifacts caused by tissue motion can be minimized with a bladder-objective lens contact housing.

Recurrent Laryngeal Nerve Monitoring During Thyroidectomy and Related Cervical Procedures in the Pediatric Population

OBJECTIVES To gather data on, and assess the applicability of, intraoperative recurrent laryngeal nerve (RLN) monitoring during thyroidectomy and related cervical procedures in children and adolescents. Recurrent laryngeal nerve trauma is one of the most serious complications of surgery in the anterior neck compartment. Numerous studies have demonstrated the utility of intraoperative monitoring of the RLN in adult thyroid surgery to prevent such injury. Although the risk of RLN injury is reportedly higher in the pediatric population, little data exist regarding the use of intraoperative RLN monitoring in children and adolescents. DESIGN Retrospective case series review. SETTING A pediatric otolaryngology practice in a tertiary care hospital. PATIENTS Five patients undergoing surgical excision of thyroid neoplasms or branchial pouch anomalies. INTERVENTIONS During surgical excision, intraoperative RLN monitoring was performed with use of the Xomed NIM II monitor and Xomed RLN monitoring endotracheal tube, which allow for both passive and stimulation-evoked electromyographic monitoring of the thyroarytenoid muscle. MAIN OUTCOME MEASURES True vocal fold mobility as assessed by postoperative flexible laryngoscopy. RESULTS Intraoperative RLN monitoring was performed successfully for up to 4 hours. Such monitoring facilitated the identification of the RLN and was predictive of the subsequent presence or absence of postoperative RLN paresis. CONCLUSIONS Intraoperative RLN monitoring can be a useful tool during cervical procedures that place the RLN at risk in children and adolescents. As has been demonstrated in adults, it is a safe and reliable technique that can be predictive of and may lessen the risk of RLN morbidity in this younger patient population.

Optical integrating balloon device for photodynamic therapy

It is difficult to deliver light uniformly and efficiently over the complex shapes presented by various organs for photodynamic therapy (PDT). A balloon delivery device for photodynamic therapy was designed and tested for treatment of various anatomic tissues. The device uses the principle of optical integration by multiple internal diffuse reflections to achieve uniform output illumination.

Reformatted Computed Tomography to Assess the Internal Nasal Valve and Association With Physical Examination

OBJECTIVES To assess the cross-sectional area and angle of the internal nasal valve more accurately by reformatting computed tomography (CT) scans of the nasal airway according to a more appropriate orientation than scans traditionally sectioned in the coronal plane and then to compare the results with clinical data on the nasal valve obtained from physical examination. METHODS We performed a retrospective review of the medical records of 24 rhinoplasty patients treated at a private practice facial plastic surgery office affiliated with a tertiary care university hospital. The patients had fine-cut (0.75-mm section) CT scans ordered for nasal airway obstruction or nasal valve compromise at the same institution. These patients were evaluated from January 1, 2000, through December 31, 2010. The previously acquired CT scans were reformatted to obtain sections through the internal nasal valve at a more appropriate orientation. The internal nasal valve cross-sectional area and valve angle were measured through a standardized section (1 cut immediately anterior to the head of the inferior turbinate) from the reformatted scans. The cross-sectional area was also measured through the same point on the traditionally oriented CT scan, and the values were compared. The results from each patients scan were compared with data from the patients medical record and analyzed against the patients preoperative modified Cottle examination findings. RESULTS The CT scans oriented in the reformatted plane through the internal nasal valve provided a narrower valve angle than the traditionally oriented CT scans and more closely approximated the hypothesized true value of the internal nasal valve of 10° to 15° (P < .001). In a comparison of the same-side internal nasal valve angle and cross-sectional nasal valve area between the 2 different CT scan orientations, a statistically significant difference in the internal nasal valve angles between the 2 scan orientations was discovered, but this finding did not reach significance when distinguishing the nasal valve cross-sectional area. Finally, no correlation was found with regard to the preoperative modified Cottle maneuver scores for the internal nasal valve angle and cross-sectional valve area values in either scan orientation. CONCLUSIONS Precise preoperative evaluation of the internal nasal valve is critical to the workup for reconstruction or repair of problems that involve this area. Although tools such as acoustic rhinometry exist to evaluate the cross-sectional area of the nasal valve, many rhinoplasty surgeons do not have access to this expensive equipment. A CT scan with reformatting in the proper plane of the internal nasal valve can provide the surgeon with improved anatomical information to assess that region. With this in mind, however, the surgeon should always perform a thorough preoperative physical examination and treat the patient and his or her symptoms, not the imaging studies, when considering a candidate for a surgical intervention.

Use of the thoracodorsal nerve for facial nerve grafting in the setting of pedicled latissimus dorsi reconstruction

Facial paralysis after tumor excision is devastating for a patient, both cosmetically and functionally. Immediate repair of the nerve defect is warranted to ensure rapid, optimal recovery of facial nerve function. In facial reanimation, multiple factors should be considered including: type of injury, location of injury, and duration of paralysis anticipated. Among the many clinical modalities available for facial nerve rehabilitation, cable nerve interposition grafting has been most successfully used to rehabilitate the patient after radical parotidectomy. In the past few decades much work has been dedicated to the study of nerve regeneration as well as to the refinement of microneural repair techniques. Still, many controversies regarding extratemporal facial nerve grafting exist. Some areas of debate include optimal source for cable nerve grafts, technical aspects of neurorrhaphy, and effects of radiation on functional outcome. This case illustrates an alternative nerve source for interposition grafting in facial reanimation. A 48year-old male presented with a recurrent basalsquamous cell carcinoma of the temporal bone. He had previously undergone numerous scalp resections, a left partial parotidectomy, bilateral radical neck dissections, and full course radiation therapy. He presented with diminished facial nerve function at the time of his recurrence: extensive weakness in the upper and lower branches with only mild movement of the buccal braches (House-Brackmann scale V/VI). Imaging revealed recurrence of disease at the mastoid tip extending into the stylomastoid foramen with facial