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OBJECTIVE: To evaluate the efficacy of omega-3 fatty acid (O3FA) supplementation in the treatment of COVID-related olfactory dysfunction (OD). METHODS: Patients with laboratory-confirmed or clinically-suspected COVID-19 infection and new-onset OD from August 2020 to November 2021 were prospectively recruited. Patients with quantitative OD, defined as a brief smell identification test (BSIT) score of 9 or less, were eligible for study inclusion. The experimental group received 2 g of O3FA supplementation, while the control group received an identical placebo to be taken daily for 6 weeks. The primary outcome was a change in BSIT score between the initial and 6-week follow-up tests. RESULTS: One hundred and seventeen patients were included in the analysis, including 57 patients in the O3FA group and 60 in the placebo group. O3FA group patients demonstrated a mean BSIT improvement of 1.12 ± 1.99 compared to 0.68 ± 1.86 in the placebo group (p = 0.221). Seventy-seven patients, 42 within the O3FA group and 35 in the placebo group, completed a follow-up BSIT survey at an average of 717.8 days from study onset. At long-term follow-up, there was an average BSIT score improvement of 1.72 within the O3FA group compared to 1.76 within the placebo group (p = 0.948). CONCLUSION: Among patients with persistent COVID-related OD, our study showed no clear evidence of relative short-term or long-term olfactory recovery among patients receiving high doses of O3FA supplementation.
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COVID-19 , Ácidos Grasos Omega-3 , Trastornos del Olfato , Humanos , Ácidos Grasos Omega-3/uso terapéutico , Olfato , COVID-19/complicaciones , Trastornos del Olfato/tratamiento farmacológico , Suplementos DietéticosRESUMEN
BACKGROUND: Preoperative corticosteroids have been shown to improve surgical visibility and intraoperative blood loss for chronic rhinosinusitis with nasal polyposis (CRSwNP) patients undergoing endoscopic sinus surgery (ESS). However, there is no consensus on the optimal dosing regimen. METHODS: A randomized, controlled trial was conducted to compare low, medium, and high dose corticosteroids prior to ESS. Patients with CRSwNP refractory to medical management were randomized to low (N = 8), medium (N = 10), or high (N = 5) dosing regimens of corticosteroids prior to ESS. Baseline disease severity was measured with the 22-item Sino-nasal Outcome Test and Lund-Mackay scores. Modified Lund-Kennedy endoscopic scores (MLKES) were measured at baseline and after corticosteroid treatment. Intraoperative parameters were measured including Boezaart surgical visibility score, intraoperative blood loss, and operative time. RESULTS: Medium dose corticosteroids demonstrated a superior surgical visibility score to low dose and comparable results to high dose, but these results were not significant (p = 0.33). No significant difference was observed between groups for total blood loss (p = 0.15), operative time (p = 0.87), or change in MLKES (p = 0.27). CONCLUSIONS: Current recommendations include the use of preoperative corticosteroids in patients with CRSwNP undergoing ESS, but there is no consensus on dose or duration. We did not find a statistically significant difference in surgical field visibility, intraoperative blood loss, or operative time between different dosing regimens. Further studies are needed to evaluate the efficacy of a low-dose preoperative regimen with the goal of reducing cumulative patient exposure to systemic corticosteroids.
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Pólipos Nasales , Rinitis , Sinusitis , Corticoesteroides/uso terapéutico , Pérdida de Sangre Quirúrgica/prevención & control , Enfermedad Crónica , Endoscopía/métodos , Humanos , Pólipos Nasales/complicaciones , Pólipos Nasales/tratamiento farmacológico , Pólipos Nasales/cirugía , Rinitis/complicaciones , Rinitis/tratamiento farmacológico , Rinitis/cirugía , Sinusitis/complicaciones , Sinusitis/tratamiento farmacológico , Sinusitis/cirugía , Resultado del TratamientoRESUMEN
OBJECTIVE: To characterize the clinical features associated with sinonasal complaints after maxillectomy with free flap reconstruction as well as propose a screening and treatment algorithm. METHODS: Retrospective review of patients who underwent maxillectomy and free flap reconstruction at a tertiary care center. RESULTS: Fifty-eight patients were included, 25 (43.1%) of them had documented sinonasal complaints postoperatively. Eleven patients subsequently underwent revision surgery for sinonasal complaints. Among the 25 patients with sinonasal complaints, 22 patients (88.0%) had nasal crusting, 17 (68.0%) had nasal obstruction, 12 (48.0%) had rhinorrhea, 9 (36.0%) had facial pain or pressure, and 7 (28.0%) had foul odor. Twenty-two patients (88.0%) had multiple sinonasal complaints. There was a higher incidence of both sinonasal complaints and surgical intervention in patients who underwent adjuvant radiation, but this was not statistically significant (47.7% vs 28.6%, P = .235; 29.4% vs 7.1%, P = .265). CONCLUSIONS: Sinonasal complaints are common following free flap reconstruction for a maxillectomy defect and should be screened for at postoperative visits, with early referral to a rhinologist for consideration of endoscopic sinus surgery. Nonsurgical treatment strategies include large-volume nasal saline irrigations, xylitol irrigations for persistent inflammatory symptoms, and culture-directed antibiotic irrigations for persistent infectious symptoms. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:67-72, 2022.
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Colgajos Tisulares Libres/efectos adversos , Reconstrucción Mandibular/efectos adversos , Maxilar/cirugía , Senos Paranasales , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Femenino , Colgajos Tisulares Libres/cirugía , Humanos , Incidencia , Masculino , Reconstrucción Mandibular/métodos , Persona de Mediana Edad , Enfermedades Nasales/epidemiología , Enfermedades Nasales/etiología , Estudios Retrospectivos , Sinusitis/epidemiología , Sinusitis/etiología , Adulto JovenRESUMEN
OBJECTIVES/HYPOTHESIS: Suboptimal ergonomics during endoscopic sinus surgery can lead to considerable physical discomfort and fatigue for the surgeon. The purpose of this pilot study is to objectively evaluate the ergonomic positions of trainee and attending surgeons while performing functional endoscopic sinus surgery (FESS). STUDY DESIGN: Pilot prospective trial. METHODS: Six surgeons (two attendings and four trainees) performed FESS while wearing 11 inertial measurement units (IMUs) affixed to either side of each major joint. Screen placement was standardized to be 1 m directly in front of the surgeon and on the patient's left, 0-15° declined from the surgeons' eyes. Bed height was standardized such that the workspace was 0 to 10 cm below the elbows. IMU data were analyzed to calculate joint angles. Ideal joint angles (i.e., <10° for neck and trunk) were determined by the validated Rapid Entire Body Assessment tool. Subjects subsequently completed a modified National Aeronautics and Space Administration Task Load Index to assess cognitive and physical burden and pain. Student's t-test was employed to detect differences between groups. RESULTS: Trainees adopted positions involving significantly greater neck flexion (9.90° vs. -6.48°, P = .03) and reported significantly higher frustration levels (3.04 vs. 1.33, P = .02) while operating than attendings. For both cohorts, increased operative time was significantly correlated with greater back flexion (r = 0.90, P = .02; r = 0.55, P = .04, respectively). CONCLUSIONS: Our data suggest that trainees operate with higher risk neck postures than do attendings. These data indicate high-risk operative postures may be borne of inexperience and present an opportunity for postural interventions at an early stage of training. LEVEL OF EVIDENCE: NA Laryngoscope, 132:1153-1159, 2022.
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Enfermedades Profesionales , Cirujanos , Ergonomía , Humanos , Enfermedades Profesionales/diagnóstico , Enfermedades Profesionales/etiología , Enfermedades Profesionales/prevención & control , Proyectos Piloto , Estudios ProspectivosRESUMEN
Carotid artery blowout syndrome (CBS) is a deadly complication usually linked to head and neck cancer therapy. We present a different etiology of endoscopic CBS, a complication of endovascular coiling of an intracranial aneurysm, treated with sternocleidomastoid (SCM) muscle graft packing. Case Presentation: An otherwise healthy 55-year-old female presented to the emergency room with right-sided painless vision loss of 23 days. Computed tomography angiography demonstrated a right ophthalmic ICA aneurysm eroding into the right sphenoid sinus with optic nerve compression. Attempted endovascular repair of the aneurysm was complicated by ICA rupture into the sphenoid. An endovascular balloon was inflated proximal to the aneurysm to reduce hemorrhage as ENT performed an endoscopic sphenoidotomy. A hematoma was seen overlying the aneurysm in the superior lateral sphenoid sinus. Layers of SCM muscle were morselized and packed serially. Post-repair angiography showed no further extravasation. Aggressive antiplatelet therapy was initiated. Packing was removed after 14 days. Twenty days postoperatively, the patient had profuse left-sided epistaxis requiring a left sphenopalatine artery ligation. The patient's vision recovered. Discussion: Whereas CBS is often managed by endovascular coil embolism, in our case CBS was caused by this very treatment itself. This case shows the use of SCM muscle graft as an effective repair modality of ICA rupture due to endovascular coiling. Laryngoscope, 131:E764-E766, 2021.
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Traumatismos de las Arterias Carótidas/cirugía , Arteria Carótida Interna/cirugía , Endoscopía/métodos , Procedimientos Endovasculares/efectos adversos , Músculos/trasplante , Complicaciones Posoperatorias/cirugía , Aneurisma Roto/cirugía , Traumatismos de las Arterias Carótidas/etiología , Femenino , Humanos , Aneurisma Intracraneal/cirugía , Ilustración Médica , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Rotura Espontánea/cirugía , Seno Esfenoidal/cirugía , SíndromeRESUMEN
OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic disrupted the standard management paradigms for care of patients with sinus and skull base presentations due to concern for patient and health care provider safety, given the high aerosol-generating potential of endonasal procedures. DATA SOURCES: We reviewed the relevant literature complied from available sources, including PubMed, Google Scholar, and otolaryngology journals providing electronic manuscripts ahead of indexing or publication. REVIEW METHODS: Incorporating available evidence and the projected infection control and resource limitations at our institution, we collectively authored a dynamic set of protocols guiding (1) case stratification, (2) preoperative assessment, (3) operative setup, and (4) postoperative care of patients with sinus or skull base presentations. Due to the rapidly evolving nature of COVID-19 publications, lack of rigorous data, and urgent necessity of standardized protocols, strict inclusion and exclusion criteria were not employed. CONCLUSIONS: As scarce hospital resources are diverted to COVID-19 care and staff are redeployed to forward-facing roles, endonasal procedures have largely ceased, leaving patients with ongoing sinonasal and skull base complaints untreated. Skull base teams now weigh the urgency of surgery in this population with the regional availability of resources. IMPLICATIONS FOR PRACTICE: The COVID-19 pandemic will have an enduring and unpredictable impact on hospital operations and surgical skull base practices and will require a dynamic set of management protocols responsive to new evidence and changing resources. In the current resource-limited environment, clinicians may utilize these protocols to assist with stratifying patients by acuity, performing preoperative assessment, and guiding peri- and postoperative care.
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Infecciones por Coronavirus/epidemiología , Transmisión de Enfermedad Infecciosa/prevención & control , Endoscopía/métodos , Control de Infecciones/métodos , Procedimientos Quírurgicos Nasales/métodos , Procedimientos Neuroquirúrgicos/métodos , Neumonía Viral/epidemiología , Base del Cráneo/cirugía , Betacoronavirus , COVID-19 , Humanos , Pandemias , SARS-CoV-2RESUMEN
OBJECTIVE: To evaluate postoperative opiate use and patients' opinions regarding pain management after endoscopic sinus surgery (ESS). STUDY DESIGN: Case series with planned data collection. SETTING: Tertiary referral medical center. SUBJECTS AND METHODS: We prospectively evaluated postoperative opiate utilization in adults undergoing ESS over a 2-year period at an academic medical facility. Exclusion criteria included use of nasal packing, intracranial or orbital procedures, tumor surgery, and any use of endoscopic drills. All patients underwent bilateral maxillary antrostomy, total ethmoidectomy, sphenoidotomy, and frontal sinusotomy with or without septoplasty. Patients were discharged with 30 oxycodone-acetaminophen (5-325 mg) and a survey assessing pain and narcotic/nonnarcotic use on postoperative days 0 to 7. RESULTS: A total of 64 patients completed surveys. Mean ± SD narcotic use over the 7-day postoperative period was 7.7 ± 7.6 pills. Patients with high narcotic use (>6 pills total) had no differences in demographic or surgical factors from those with low use (≤6 pills) but did report a higher level of postoperative day 1 pain (4.8 ± 1.1 vs 2.0 ± 1.4, P < .001). Narcotic use declined during this period, with <30% of patients requiring narcotics by postoperative day 3. CONCLUSION: Our results support reduced opiate prescription and encouragement of nonnarcotic use after ESS without compromising effective pain management.
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Analgésicos Opioides/uso terapéutico , Endoscopía/métodos , Senos Etmoidales/cirugía , Seno Frontal/cirugía , Manejo del Dolor/métodos , Dolor Postoperatorio/tratamiento farmacológico , Medicamentos bajo Prescripción/provisión & distribución , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/diagnóstico , Estudios ProspectivosRESUMEN
Objectives The aim of this study was to analyze the effect of the multimodality treatment on survival in sinonasal minor salivary gland tumors. Methods Adult clinical American Joint Committee on Cancer (AJCC) tumor (T) 1-4a staged cases of sinonasal minor salivary gland tumors were isolated from the National Cancer Database (2004-2014). Multivariate regressions were performed to analyze the effect of multimodality treatment. A subset analysis was also performed in patients with positive margins following surgical management. Results We identified 556 cases, of which 293 (52.7%) patients were treated with surgery and radiotherapy (RT), 160 (28.8%) were treated with surgery alone, and 52 (9.4%) were treated with surgery and chemoradiotherapy (CRT). No patients were treated with chemotherapy alone. With surgery and CRT as a reference, the only treatment modality associated with decreased survival was RT alone (hazard ratio [HR]: 3.213 [95% confidence interval (CI): 1.578-6.543]; p = 0.001). Within a subset analysis of patients with positive margins, surgery was associated with decreased survival (HR: 2.021 [95% CI: 1.401-3.925]; p = 0.038), but not triple modality therapy (HR: 1.700 [95% CI: 0.798-3.662]) when compared with surgery with RT. Conclusion The most common treatment was surgery and RT, consistent with National Comprehensive Cancer Network (NCCN) guidelines which recommends chemotherapy (CT) only in the most concerning cases. However, we found no difference in survival among most treatment modalities when compared with triple modality therapy, with the exception of RT alone. Although margins were prognostic within these cancers, we found no evidence that adjuvant CRT provides any survival benefit over surgery and RT, though surgery alone was associated with decreased survival.
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OBJECTIVES: To identify factors associated with positive margins following surgical management of sinonasal squamous cell carcinoma (SNSCC), especially with regard to endoscopic treatment. METHODS: In a retrospective analysis of adult patients with clinically staged tumor (T)1 to T4a SNSCC within the National Cancer Database (NCDB) from 2004 to 2014, factors were associated with positive margins using multivariable binary logistic regression. Cases from 2010 to 2014 had surgical approach (open vs. endoscopic) available and were analyzed in a subgroup to assess the association of surgical approach with margin status. The association of margin status with overall survival (OS) and additional therapy administration was also assessed. RESULTS: We identified 2,968 cases, of which 807 (27.2%) had positive margins. On multivariable analysis, factors associated with positive margins included higher T stage (T4a vs. T1: odds ratio [OR] 2.768 [95% CI 2.143-3.577]), less differentiated tumors (poorly differentiated vs. well differentiated: OR 1.403 [95% CI 1.060-1.856]), and tumors in the ethmoid sinus (vs. nasal cavity; OR 1.889 [95% CI 1.305-2.734]). Cases treated at higher volume facilities (HVFs) were associated with a lower likelihood of positive margins (OR 0.716 [95% CI 0.582-0.881]). Positive margins were associated with decreased OS (hazard ratio 1.672 [95% CI 1.464-1.908]) and an increased rate of additional therapy (OR 1.966 [95% confidence interval 1.597-2.421]). An endoscopic approach was not associated with an increased likelihood of obtaining positive margins (vs. open; OR 1.151 [0.903-1.651]). CONCLUSION: Positive margins were less likely when performed at HVFs and more likely in the ethmoid sinus than other subsites. Importantly, there was no association between positive margins and surgical approach. Endoscopic surgery may offer a safe, less invasive alternative to open surgery for select patients. LEVEL OF EVIDENCE: NA Laryngoscope, 130:E388-E396, 2020.
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Carcinoma de Células Escamosas/mortalidad , Endoscopía/mortalidad , Neoplasias de los Senos Paranasales/mortalidad , Adulto , Anciano , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/cirugía , Endoscopía/métodos , Senos Etmoidales/patología , Senos Etmoidales/cirugía , Femenino , Humanos , Modelos Logísticos , Masculino , Márgenes de Escisión , Persona de Mediana Edad , Cavidad Nasal/patología , Cavidad Nasal/cirugía , Estadificación de Neoplasias , Oportunidad Relativa , Neoplasias de los Senos Paranasales/patología , Neoplasias de los Senos Paranasales/cirugía , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVES: To undertake a large-scale review of otogenic intracranial sepsis in an area of highly prevalent HIV and tuberculosis (TB) to re-examine and inform early diagnosis and treatment efforts. METHODS: Seventy-seven consecutive cases of otogenic intracranial sepsis in KwaZulu-Natal, South Africa were reviewed for demographics, presentation, imaging, HIV status, culture results, and outcomes. RESULTS: The most common intracranial complications were intracranial abscess (46.8%), hydrocephalus (31.2%), subdural empyema (28.6%), and epidural empyema (26.0%). Ear discharge (87.0%), postauricular abscess (29.9%), and hearing loss (29.9%) were notable presenting symptoms. Overall mortality was 15.6%. Of the 45.5% of patients with HIV testing, 54.2% were HIV+, Mortality among HIV+ patients was 15.8% but only 6.3% in HIV- patients (pâ=â0.61, ORâ=â2.8). Eight patients (10.4%) had culture or histological evidence of TB infection. CONCLUSIONS: Otogenic intracranial complications continue to present late and are associated with significant mortality and morbidity, despite advances in diagnostic and treatment modalities. This study represents one of the largest case-series in the literature, and the first to specifically evaluate the effects of HIV and TB infection.Patient presentation and severity of illness varied; however, a majority of patients presented with ear discharge and no focal neurological signs. An effect size for higher mortality among HIV+ patients compared with HIV- patients was noted but was not significant. Tuberculosis infection was prevalent compared with previous studies.This study reinforces the need for enhanced screening and early treatment of ear disease to minimize associated mortality and morbidity, particularly in immunocompromised patients.
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Absceso Encefálico , Enfermedades del Oído/etiología , Infecciones por VIH/complicaciones , Sepsis/etiología , Tuberculosis/complicaciones , Adulto , Absceso Encefálico/diagnóstico , Absceso Encefálico/etiología , Enfermedades del Oído/diagnóstico , Femenino , Humanos , Masculino , Estudios Retrospectivos , Sepsis/diagnóstico , Sudáfrica , Adulto JovenRESUMEN
OBJECTIVES: To analyze head and neck mucosal melanoma (MM) treatment patterns, and their association with survival, relative to National Comprehensive Cancer Network (NCCN) guidelines. MATERIAL & METHODS: Adult head and neck MM patients with clinically-staged T3/4aN0 disease were identified in a retrospective analysis of the National Cancer Database (2010-2014) and stratified into sinonasal cavity (SN) and oral cavity, oropharynx, larynx, or hypopharynx (non-SN) cohorts. RESULTS: We identified 353 SN and 79 non-SN MM cases. The majority of patients were treated with surgery (SN: 92.4%; non-SN 84.8%), within NCCN guidelines. Treatment within the non-SN MM NCCN recommendation of elective neck dissection (END) was approximately 26.6%. END is not recommended for SN MM and was not performed in 91.5% of cases. Radiotherapy (RT) is recommended in both SN and non-SN MM and was utilized in 63.5% of SN patients and 46.8% of non-SN patients. END was not independently associated with OS compared to surgery alone (SN HR: 1.350 [95% CI: 0.733-2.485]; non-SN HR: 3.460 [95% CI: 0.912-13.125]). RT was independently associated with improved OS in SN MM cases (HR: 0.679 [95% CI: 0.479-0.963]), but not in non-SN MM cases (HR: 0.824 [95% CI: 0.331-2.051]). CONCLUSION: The majority of patients with head and neck MM are not treated within NCCN guidelines. The use of recommended END in non-SN patients is low. Similarly, adjuvant RT utilization is low. Our analysis shows that while greater use of RT may increase survival rates in this disease, the utility of END is unclear.
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Neoplasias de Cabeza y Cuello/diagnóstico , Neoplasias de Cabeza y Cuello/terapia , Melanoma/diagnóstico , Melanoma/terapia , Membrana Mucosa/patología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Terapia Combinada , Bases de Datos Factuales , Manejo de la Enfermedad , Femenino , Neoplasias de Cabeza y Cuello/epidemiología , Humanos , Estimación de Kaplan-Meier , Ganglios Linfáticos/patología , Masculino , Melanoma/epidemiología , Persona de Mediana Edad , Estadificación de Neoplasias , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina , Pronóstico , Modelos de Riesgos Proporcionales , Resultado del Tratamiento , Adulto JovenRESUMEN
The presence of bile is not an uncommon finding in acidic oesophageal and extra-oesophageal refluxate, possibly affecting the hypopharyngeal mucosa and leading to neoplastic events. We recently demonstrated that acidic bile (pH ≤ 4.0) can induce NF-κB activation and oncogenic mRNA phenotype in normal hypopharyngeal cells and generate premalignant changes in treated hypopharyngeal mucosa. We hypothesize that curcumin, a dietary inhibitor of NF-κB, may effectively inhibit the acidic bile-induced cancer-related mRNA phenotype, in treated human hypopharyngeal primary cells (HHPC), supporting its potential preventive use in vivo. Luciferase assay, immunofluorescence, Western blot, qPCR and PCR microarray analysis were used to explore the effect of curcumin in HHPC exposed to bile (400 µmol/L) at acidic and neutral pH. Curcumin successfully inhibited the acidic bile-induced NF-κB signalling pathway (25% of analysed genes), and overexpression of NF-κB transcriptional factors, c-REL, RELA(p65), anti-apoptotic bcl-2, oncogenic TNF-α, EGFR, STAT3, WNT5A, ΔNp63 and cancer-related IL-6. Curcumin effectively reduced bile-induced bcl-2 overexpression at both acidic and neutral pH. Our novel findings suggest that, similar to pharmacologic NF-κB inhibitor, BAY 11-7082, curcumin can suppress acidic bile-induced oncogenic mRNA phenotype in hypopharyngeal cells, encouraging its future in vivo pre-clinical and clinical explorations in prevention of bile reflux-related pre-neoplastic events mediated by NF-κB.
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Anticarcinógenos/farmacología , Ácidos y Sales Biliares/antagonistas & inhibidores , Curcumina/farmacología , Células Epiteliales/efectos de los fármacos , FN-kappa B/genética , ARN Mensajero/genética , Bilis/química , Ácidos y Sales Biliares/farmacología , Células Epiteliales/citología , Células Epiteliales/metabolismo , Receptores ErbB/genética , Receptores ErbB/metabolismo , Regulación de la Expresión Génica , Humanos , Concentración de Iones de Hidrógeno , Hipofaringe/citología , Hipofaringe/efectos de los fármacos , Hipofaringe/metabolismo , Interleucina-6/genética , Interleucina-6/metabolismo , FN-kappa B/antagonistas & inhibidores , FN-kappa B/metabolismo , Fenotipo , Cultivo Primario de Células , Proteínas Proto-Oncogénicas c-bcl-2/genética , Proteínas Proto-Oncogénicas c-bcl-2/metabolismo , Proteínas Proto-Oncogénicas c-rel/genética , Proteínas Proto-Oncogénicas c-rel/metabolismo , ARN Mensajero/antagonistas & inhibidores , ARN Mensajero/metabolismo , Factor de Transcripción STAT3/genética , Factor de Transcripción STAT3/metabolismo , Transducción de Señal , Factor de Transcripción ReIA/genética , Factor de Transcripción ReIA/metabolismo , Factor de Necrosis Tumoral alfa/genética , Factor de Necrosis Tumoral alfa/metabolismo , Proteína Wnt-5a/genética , Proteína Wnt-5a/metabolismoRESUMEN
BACKGROUND: The management of sialorrhea can be difficult for both the patient and the clinician. Current management includes behavioral modification, anticholinergics, botulinum injections, and a variety of surgical options, which all have demonstrated some efficacy. As minimally invasive procedures flourish, we explore the feasibility of highly selective transoral submandibular neurectomy (TOSN) for the management of sialorrhea. METHODS: Ten human cadaver dissections of the floor of mouth were performed bilaterally, for a total of 20 separate cases. An intraoral technique for highly selective, submandibular ganglion neurectomy is demonstrated. RESULTS: A transoral submandibular ganglion neurectomy was performed in 10 cadavers (20 neurectomies) easily and reliably, without injury to the submandibular duct or the main trunk of the lingual nerve. CONCLUSION: Transoral submandibular neurectomy is an attractive addition to the armamentarium of surgical options for the treatment of medically intractable sialorrhea. Further study in selected patients would need to be performed to demonstrate clinical feasibility.
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Ganglios Parasimpáticos/cirugía , Nervio Lingual/cirugía , Cirugía Endoscópica por Orificios Naturales/métodos , Parasimpatectomía/métodos , Sialorrea/cirugía , Glándula Submandibular/inervación , Cadáver , Estudios de Factibilidad , Humanos , BocaRESUMEN
BACKGROUND: Paraneoplastic syndromes are systemic or organ-related functional tumor-associated changes that arise distant to the tumor. METHODS AND RESULTS: We present a rare case of a 63-year-old man with dermatomyositis as a paraneoplastic syndrome developing more than a year before clinical manifestations of tonsillar squamous cell carcinoma (SCC). He subsequently developed stage T1N2bM0 IVA tonsillar SCC. He was treated on a research protocol with 3 weeks of neoadjuvant rapamycin therapy before right transoral lateral pharyngectomy and modified radical neck dissection with preservation of CN XI. His symptoms of dermatomyositis subsequently improved and he was weaned off immunosuppressive therapy. CONCLUSION: To our knowledge, this is the first report of dermatomyositis as a paraneoplastic syndrome of tonsillar SCC in North America. We suggest that clinicians should monitor for signs of persistent or recurrent dermatomyositis symptoms as this may herald development or a return of the underlying malignancy.
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Carcinoma de Células Escamosas/complicaciones , Dermatomiositis/etiología , Síndromes Paraneoplásicos/diagnóstico , Síndromes Paraneoplásicos/etiología , Neoplasias Tonsilares/complicaciones , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/terapia , Dermatomiositis/diagnóstico , Dermatomiositis/terapia , Humanos , Masculino , Persona de Mediana Edad , Factores de Tiempo , Neoplasias Tonsilares/patología , Neoplasias Tonsilares/terapiaRESUMEN
BACKGROUND: To evaluate the use of hyperosmolar therapy in the management of elevated intracranial pressure (ICP) and transtentorial herniation (TTH) in patients with renal failure and supratentorial lesions. METHODS: Patients with renal failure undergoing renal replacement therapy treated with 23.4% saline (30-60 mL) and/or mannitol for high ICP or clinical evidence of TTH were analyzed in a retrospective cohort. RESULTS: The primary outcome measure was reversal of TTH or ICP crisis. Secondary outcome measures were modified Rankin scale on hospital discharge, survival to hospital discharge, and adverse effects. Of 254 subjects over 7 years, 6 patients with end-stage renal disease had 11 events. All patients received a 23.4% saline bolus, along with mannitol (91%), hypertonic saline (HS) maintenance fluids (82%), and surgical interventions (n = 2). Reversal occurred in 6/11 events (55%); 2 of 6 patients survived to discharge. ICP recording of 6 TTH events showed a reduction from ICP of 41 ± 3.8 mmHg (mean ± SEM) with TTH to 20.8 ± 3.9 mmHg (p = 0.05) 1 h after the 23.4% saline bolus. Serum sodium increased from 141.4 to 151.1 mmol/L 24 h after 23.4% saline bolus (p = 0.001). No patients were undergoing hemodialysis at the time of the event. There were no cases of pulmonary edema, clinical volume overload, or arrhythmia after HS. CONCLUSIONS: Treatment with hyperosmolar therapy, primarily 23.4% saline solution, was associated with clinical reversal of TTH and reduction in ICP and had few adverse effects in this cohort. Hyperosmolar therapy may be safe and effective in patients with renal failure and these initial findings should be validated in a prospective study.