Gender-Specific Differences in Preoperative Concerns in Patients Undergoing Endoscopic Sinus Surgery for Chronic Rhinosinusitis.

OBJECTIVES: Among patients with chronic rhinosinusitis (CRS), gender differences in epidemiology as well as quality of life have been reported. However, whether gender differences in endoscopic sinus surgery (ESS) preoperative concerns exist is unclear. METHODS: CRS patients undergoing ESS at 3 tertiary care centers in Los Angeles completed the validated Western Surgical Concern Inventory - ESS assessing ESS preoperative concerns. RESULTS: Of the 75 patients included, female patients expressed greater concern than male patients in regard to nasal packing, undergoing anesthesia, impact of surgery on daily activities, and pain and discomfort following surgery. CONCLUSION: This study suggests there are gender differences in ESS preoperative concerns and otolaryngologists should be aware of these possible concerns during preoperative discussions.

Cost-effectiveness Analysis of Submandibular Gland Preservation With Sialendoscopy for the Management of Sialolithiasis.

OBJECTIVE: To compare the cost-effectiveness of sialendoscopy with gland excision for the management of submandibular gland sialolithiasis. STUDY DESIGN: Cost-effectiveness analysis. SETTING: Outpatient surgery centers. METHODS: A Markov decision model compared the cost-effectiveness of sialendoscopy versus gland excision for managing submandibular gland sialolithiasis. Surgical outcome probabilities were found in the primary literature. The quality of life of patients was represented by health utilities, and costs were estimated from a third-party payer's perspective. The effectiveness of each intervention was measured in quality-adjusted life-years (QALYs). The incremental costs and effectiveness of each intervention were compared, and a willingness-to-pay ratio of $150,000 per QALY was considered cost-effective. One-way, multivariate, and probabilistic sensitivity analyses were performed to challenge model conclusions. RESULTS: Over 10 years, sialendoscopy yielded 9.00 QALYs at an average cost of $8306, while gland excision produced 8.94 QALYs at an average cost of $6103. The ICER for sialendoscopy was $36,717 per QALY gained, making sialendoscopy cost-effective by our best estimates. The model was sensitive to the probability of success and the cost of sialendoscopy. Sialendoscopy must meet a probability-of-success threshold of 0.61 (61%) and cost ≤$11,996 to remain cost-effective. A Monte Carlo simulation revealed sialendoscopy to be cost-effective 60% of the time. CONCLUSION: Sialendoscopy appears to be a cost-effective management strategy for sialolithiasis of the submandibular gland when certain thresholds are maintained. Further studies elucidating the clinical factors that determine successful sialendoscopy may be aided by these thresholds as well as future comparisons of novel technology.

US-guided fine-needle aspiration of major salivary gland masses and adjacent lymph nodes: accuracy and impact on clinical decision making.

PURPOSE: To determine whether ultrasonography (US)-guided fine-needle aspiration (FNA) is an effective technique for diagnosing masses in the salivary gland and adjacent lymph nodes. MATERIALS AND METHODS: The institutional review board waived the requirement to obtain informed consent and approved this HIPAA-compliant retrospective study. Radiology records of 50 patients (28 female patients aged 25-85 years [median age, 58 years], 22 male patients aged 11-82 years [median age, 62 years]) who underwent 52 consecutive US-guided FNA procedures from 2004 to 2009 were reviewed. In 46 cases, lesions were sampled for biopsy under real-time US guidance by means of three passes with a 25-gauge needle. In six cases, two subsequent passes were performed with a 22-gauge needle after the first pass showed minimal or no aspirate. Findings from cytopathologic analysis, clinical follow-up, and surgery were evaluated and compared. RESULTS: A diagnostically adequate biopsy specimen was obtained in 48 of the 52 cases (92%). Among the 20 patients who underwent surgical intervention after diagnostic US-guided FNA findings, results of surgical-pathologic analysis helped confirm the cytologic diagnosis in 19 (95%). Twenty of the 50 patients (40%) were spared surgical intervention on the basis of findings from US-guided FNA. US-guided FNA did not result in any intra- or postprocedural complications. CONCLUSION: The diagnostic accuracy of US-guided FNA is similar to that of core needle biopsy, and there were no complications in this study. Information yielded with FNA cytology plays an integral role in clinical decision making in the management of masses in the major salivary glands and adjacent structures.

Biofilm and persistent inflammation in endoscopic sinus surgery.

Bacterial biofilms have been observed in many patients with chronic rhinosinusitis, but their importance is still being investigated. This study examines the association between biofilms and other clinical findings in chronic rhinosinusitis patients. Twenty-four patients with chronic rhinosinusitis who failed medical management underwent endoscopic sinus surgery (ESS). Tissue was collected from the ethmoid sinus and analyzed for the presence of biofilm by hematoxylin and eosin staining, fluorescent in situ hybridization, and confocal scanning laser microscopy. Biofilms were classified as extensive (> 50% of mucosal surface in sample) or present (< 50% of surface). The surgeon remained blinded to the biofilm status of patients until postoperative follow-up was complete. The presence of bacterial biofilm was strongly associated with persistent mucosal inflammation after ESS (53% of biofilm-positive patients vs 0% of biofilm-negative patients, P = 0.009). The amount of biofilm was not important as there was no significant difference between the extensive and present biofilm classifications with respect to inflammation. The presence of biofilm was not associated with prior ESS, allergies, eosinophils, polyps, or presence of fungal elements.

Biofilm detection with hematoxylin-eosin staining.

OBJECTIVE: To demonstrate that hematoxylin-eosin staining can be used to detect the presence of bacterial biofilm in patients with chronic rhinosinusitis (CRS). DESIGN: A prospective study. SETTING: The University of Southern California University Hospital and the Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Keck School of Medicine, Los Angeles. PATIENTS: A total of 34 patients: 24 undergoing endoscopic sinus surgery for CRS and 10 undergoing septoplasty with or without turbinate reduction with no history of sinusitis, were enrolled in the study. MAIN OUTCOME MEASURES: Contiguous sections from patient samples were examined by both hematoxylin-eosin staining and fluorescence in situ hybridization (FISH) with the bacterial-specific probe EUB338 for evidence of bacterial biofilm. RESULTS: Biofilm was detected by hematoxylin-eosin staining in 15 of 24 patients with CRS and 1 of 10 control patients. In all cases, hematoxylin-eosin staining was found to be an accurate predictor of the presence or absence of biofilm using FISH as a control standard. CONCLUSION: Hematoxylin-eosin staining of surgical specimens is a reliable and available method for the detection of bacterial biofilm in chronic infectious disease.

Traumatic pseudoaneurysm of the occipital artery: case report and review of the literature.

Only 3 cases of traumatic pseudoaneurysm of the occipital artery have been reported since 1644. We report a fourth case, which occurred in an 85-year-old woman who experienced a blunt trauma during a fall. The pseudoaneurysm resolved without surgical intervention. We also review the literature on traumatic pseudoaneurysms, as well as true aneurysms, of the external carotid system, with emphasis on current diagnostic and therapeutic options.

The significance of EphB4 and EphrinB2 expression and survival in head and neck squamous cell carcinoma.

OBJECTIVES: To examine the expression of EphB4 and EphrinB2 in tumor tissue and surrounding normal tissue in patients with head and neck squamous cell carcinoma (HNSCC) and to evaluate its association with overall patient survival. DESIGN: Retrospective study. SETTING: University of Southern California-University Hospital, the Los Angeles County and University of Southern California Medical Center, and the Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles. PATIENTS: Fifty patients, 8 with early-stage (stages I and II) and 42 with advanced-stage (stages III and IV) HNSCC, were enrolled into this study. Staging was based on the system of the American Joint Committee on Cancer. MAIN OUTCOME MEASURES: EphB4 and EphrinB2 expression was evaluated by Western blot analysis. Overall survival in patients was then compared with EphB4 and EphrinB2 expression. RESULTS: EphB4 and EphrinB2 expression was detected in all normal and tumor samples in patients with HNSCC, with the magnitude of EphB4 overexpression greater than that of EphrinB2 expression compared with normal tissue. There was a statistically significant decrease in overall survival among patients with elevated EphB4 and EphrinB2 expression (P < .001). CONCLUSIONS: EphB4 and EphrinB2 overexpression is associated with poor overall survival in patients with HNSCC. Our results are the first to demonstrate an association between decreased survival and elevated expression of the receptor tyrosine kinase EphB4 and its ligand EphrinB2, suggesting that EphB4 and EphrinB2 may be used as biomarkers to predict prognosis and as targets in future HNSCC therapies.

Use of AlloDerm implant to improve cosmesis after parotidectomy.

We evaluated the effectiveness and practicality of using AlloDerm, an acellular human dermal matrix graft, as an interpositional barrier in an attempt to improve the appearance of the surgical defect created by parotidectomy. We performed AlloDerm reconstruction in a series of 10 patients, and we found that normal contour was satisfactorily restored in all 10. We conclude that the use of an AlloDerm implant is a low-risk, practical option for repairing the surgical defect in postparotidectomy patients.

Management of a type II nasoethmoid orbital fracture and near-penetration of the intracranial cavity with transnasal canthopexy.

Nasoethmoid orbital fractures are perhaps the most complicated aspect of craniomaxillofacial trauma. Involvement of the medial canthal tendon markedly increases the complexity of the repair. We report a case of type II nasoethmoid orbital fracture in a 32-year-old man that was managed without formal medial canthal tendon repair; instead, we used open reduction and internal fixation of the central fragment and the nasoethmoid complex. However, during the immediate postoperative period, we noted anterior and inferior displacement of the medial canthus. We took the patient back to the operating room to address the detachment. Revision surgery was successful, and at the 6-month follow-up, his medial canthi were completely symmetrical in all dimensions. We describe our intraoperative technique and measures to prevent complications that can help the surgeon intraoperatively. We also discuss an important point that has not been adequately addressed in the literature to date--that is, the fact that the use of the frontoethmoid suture line and the anterior ethmoid artery as a guide to the skull base can be inaccurate. Problems associated with this inaccuracy can be avoided by carefully reviewing preoperative computed tomography, which can help keep the surgeon from entering the intracranial cavity while fixing the medial canthal tendon during transnasal canthal repair.

The association between elevated EphB4 expression, smoking status, and advanced-stage disease in patients with head and neck squamous cell carcinoma.

OBJECTIVE: To examine the expression of EphB4 in tumor tissue, surrounding normal tissue, and metastatic lymph node in patients with head and neck squamous cell carcinoma (HNSCC) and to evaluate its association with disease stage and smoking. DESIGN: A retrospective study. SETTING: University of Southern California-University Hospital, University of Southern California and Los Angeles County Medical Center, and Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles. PATIENTS: Forty-eight patients with different stages of HNSCC (I-IV) were enrolled into this study. Staging was based on the staging system of the American Joint Committee on Cancer. MAIN OUTCOME MEASURES: EphB4 expression in tumor tissue, surrounding normal tissue, and metastatic lymph node was evaluated by immunohistochemical analysis, Western blot, and real-time polymerase chain reaction. EphB4 expression was then compared between patients based on disease stage and smoking status. RESULTS: EphB4 expression was detected in all tumor specimens and metastatic lymph nodes of patients with HNSCC, but expression levels were higher in the metastatic lymph nodes. There was a statistically significantly higher mean EphB4 protein expression and EphB4 gene amplification in patients with advanced disease (stage III or IV) vs patients with initial disease (stage I or II) and in smokers vs nonsmokers. CONCLUSIONS: Overexpression of EphB4 is associated with advanced stages of HNSCC as well as with patients who smoke. These data are the first to demonstrate the association of EphB4 with advanced stages of disease and smoking in HNSCC and hence provide a strong rationale for targeting EphB4 for HNSCC therapies.

Platelet-rich plasma in endoscopic sinus surgery.

The author designed a study to assess the healing properties of platelet-rich plasma (PRP) after endoscopic sinus surgery in 30 patients with bilateral and symmetrical chronic rhinosinusitis that was refractory to medical management. At the conclusion of each operation, PRP was introduced into the middle meatus of a randomly chosen side, while the other side was treated normally and served as a control. Patients were followed until both sides healed. After 13 operations, follow-up evaluations demonstrated no benefit to the use of PRP, and the study was terminated early. In general, both sides healed quickly and uneventfully as expected. There appears to be no advantage to the use of PRP in endoscopic sinus surgery.

Fibrin glue in thyroid and parathyroid surgery: is under-flap suction still necessary?

The introduction of fibrin sealants has brought into question the necessity of routinely placing suction drains. We conducted a retrospective study to determine whether fibrin sealants are comparable to traditional drains in terms of length of hospital stay and hematoma prevention. We evaluated 124 patients who had undergone thyroidectomy and 47 patients who had undergone parathyroidectomy. Of these, 22 thyroid surgery patients and 10 parathyroid surgery patients had their incisions closed without a drain after the application of fibrin glue. We found that the use of fibrin glue resulted in a statistically significant decrease in the length of hospital stay following both types of surgery (p = 0.033 and p = 0.022, respectively). Two hematomas in the drain group required immediate surgical evacuation; in both of these patients, the suction was clotted and ineffective. One minor hematoma occurred in the fibrin glue group, and it was opened at the bedside 24 hours after surgery. We conclude that fibrin sealants offer a comparative advantage over under-flap suction in both thyroid and parathyroid surgery. Also, fibrin glue is less expensive, and its use obviates the discomfort felt by patients when a drain is removed.

Circles of prominence: a new theory on facial aesthetics.

OBJECTIVE: To elucidate key elements of facial aesthetics through a new hypothesis called the circles of prominence. DESIGN: In this subjective survey, 32 persons in the medical field rated frontal-view photographs of 20 subjects in 5 categories on a 0-to-100 scale, 0 representing the most unaesthetic rating, 100, the most aesthetically pleasing. The study was conducted in an academic setting, and the subject photographs were of 9 women (aged 27-65 years) from a clinical setting and 11 women whose pictures appeared in entertainment magazines. Each subject's eyes, nose, mouth, and chin were subjectively rated for their aesthetic quality. A general rating was also given for the subject's face as a whole. The subject's faces were then analyzed and measured based on the circles of prominence theory. A total of 52 measurements were chosen for the analysis. All raters' numbers for each anatomic unit and the face in general for each subject were averaged. The theoretical measurements were also averaged for each unit. The percentage of the ideal for the face in general was calculated based on weighted averages of the measurements from the individual units of each subject. The Wilcoxon signed-rank test was used to determine whether a significant difference existed between the raters' averages and the averages measured based on the facial analysis. Spearman rank coefficient correlation was used to determine if a significant correlation existed between those means. RESULTS: We set statistical significance at P

Langerhans' cell histiocytosis: current trends and the role of the head and neck surgeon.

Langerhans' cell histiocytosis (LCH)--once called histiocytosis X--is a complex reticuloendothelial disease that often involves the head and neck. We discuss the current nomenclature of this disease and review its pathologic and clinical characteristics, with particular emphasis on the role of the head and neck surgeon. LCH can be challenging to diagnose, and the otolaryngologist must be familiar with its varied presentations. Because LCH usually responds well to medical therapy and extensive resection can easily cause more morbidity than the disease itself, a minimalist approach to treatment usually provides the best outcome. We also discuss the case of a 9-month-old girl with LCH who presented with aggressive head and neck disease.

Squamous cell carcinoma arising in a second branchial cleft cyst.

The existence of primary branchiogenic carcinoma is controversial. In 1950, Martin et al. established four criteria for the diagnosis of primary branchiogenic carcinoma. In 1989, Khafif et al. proposed new criteria, which are currently most recognized in the literature. A pathologic description of the surgical specimen is analyzed and compared with a critical review of the literature. A case is presented in which imaging established the diagnosis of a benign second branchial cleft cyst 2 years prior to the diagnosis of a branchiogenic carcinoma in the same cyst. This cyst was resected and was found to have squamous cell carcinoma arising from the benign epithelium. This case satisfies the histologic criteria established by Martin and Khafif for a primary branchiogenic carcinoma arising in a previously benign second branchial cleft cyst.