Treatment of Relapsing HPV Diseases by Restored Function of Natural Killer Cells.

Human papillomavirus (HPV) infections underlie a wide spectrum of both benign and malignant epithelial diseases. In this report, we describe the case of a young man who had encephalitis caused by herpes simplex virus during adolescence and currently presented with multiple recurrent skin and mucosal lesions caused by HPV. The patient was found to have a pathogenic germline mutation in the X-linked interleukin-2 receptor subunit gamma gene (IL2RG), which was somatically reverted in T cells but not in natural killer (NK) cells. Allogeneic hematopoietic-cell transplantation led to restoration of NK cytotoxicity, with normalization of the skin microbiome and persistent remission of all HPV-related diseases. NK cytotoxicity appears to play a role in containing HPV colonization and the ensuing HPV-related hyperplastic or dysplastic lesions. (Funded by the National Institutes of Health and the Herbert Irving Comprehensive Cancer Center Flow Cytometry Shared Resources.).

Differences in Survival between Black and White Patients with Head and Neck Squamous Cell Carcinoma: Comparison of Data from the DOD Central Cancer Registry and SEER.

BACKGROUND: Barriers to health care access may contribute to the poorer survival of Black patients with head and neck squamous cell carcinoma (HNSCC) than their White counterparts in the U.S. general population. The Department of Defense's (DOD) Military Health System (MHS) provides universal health care access to all beneficiaries with various racial backgrounds. METHODS: We compared overall survival of patients with HNSCC by race in the MHS and the general population, respectively, to assess whether there were differences in racial disparity between the two populations. The MHS patients were identified from the DOD's Central Cancer Registry (CCR) and the patients from the U.S. general population were identified from the NCI's Surveillance, Epidemiology and End Results (SEER) program. For each cohort, a retrospective study was conducted comparing survival by race. RESULTS: Black and White patients in the CCR cohort had similar survival in multivariable Cox regression models with a HR of 1.04 and 95% confidence interval (95% CI) of 0.81 to 1.33 after adjustment for the potential confounders. In contrast, Black patients in the SEER cohort exhibited significantly worse survival than White patients with an adjusted HR of 1.47 (95% CI = 1.43-1.51). These results remained similar in the subgroup analyses for oropharyngeal and non-oropharyngeal sites, respectively. CONCLUSIONS: There was no racial difference in survival among patients with HNSCC in the MHS system, while Black patients had significantly poorer survival than White patients in the general population. IMPACT: Equal access to health care could reduce racial disparity in overall survival among patients with HNSCC.

Anterior Cervical Pain Syndromes: Defining the Patient Population and Approach to Treatments.

Objective This study aimed to evaluate patients with anterior cervical pain syndromes (ACPSs) by describing patient characteristics, therapeutic interventions, and response to treatments. Study Design This is a retrospective observational study. Methods Patients treated for diagnoses associated with ACPSs over a seven-year period in one laryngology practice at a tertiary care center were identified and evaluated via a review of clinical and surgical records. Patients identified to have undergone any treatment for ACPSs via medication, trigger-point injections of local anesthetics mixed with steroids, and/or surgical resection of the greater cornu of the hyoid bone and superior cornu of the thyroid cartilage were included. Participants subsequently underwent a medical record review and telephone interview to determine response to treatments. Results Twenty-seven patients met the inclusion criteria, including 12 patients (44.4%) with superior laryngeal neuralgia (SLN), seven patients (25.9%) with superior thyroid cornu syndrome (STCS), and eight patients (29.6%) with hyoid bone syndrome (HBS)/clicking larynx syndrome. The most common symptoms were neck/throat pain (27, 100%), globus sensation (20, 74.1%), and dysphagia (20, 74.1%). A total of 24 patients (93.3%) underwent point injections of bupivacaine and dexamethasone. Of these, 12 patients (52.2%) demonstrated a complete response that was permanent in six patients (26.1%). Seven patients (25.9%) underwent surgical intervention, with at least partial improvement noted in six patients (85.7%). Conclusion ACPSs constitute a number of complex diagnoses that remain poorly characterized in the literature. The use of point injections of local anesthetics with steroids appears efficacious with surgical options available for those with an incomplete response or return of symptoms.

A new lateral neck mass in a 63-year-old man with multinodular goiter.

Described is a rare presentation of ectopic thyroid tissue as a lateral neck mass. This case raises the awareness that a lateral neck mass (including ectopic thyroid mass) needs appropriate investigations to rule out malignancy.

Left Paraglossal Approach for Airway Management of Patient With Large Neck Mass in an Austere Environment: A Case Report.

We present the case of a 25-year-old man with a significant neck mass and describe the technique used for managing his airway given limited equipment in an austere environment. Physical examination and imaging revealed significant proximal airway involvement. Without access to a fiberoptic bronchoscope, we sought a technique that might avoid contact with the mass from both the laryngoscope and endotracheal tube. In this case report, we describe our approach to left paraglossal laryngoscopy and intubation under general anesthesia-a method not well described in the literature and proved to be imperative for our airway management.

Calcifying Fibrous Tumor of the Neck.

A 19 year old otherwise healthy male presented with a history of acute onset left neck pain with subsequent swelling and development of a left neck mass that progressively enlarged over a two month period. Imaging studies revealed a solid heterogeneous mass with prominent calcifications displacing normal structures. The lesion was resected via transcervical approach and a diagnosis of calcifying fibrous tumor (CFT) was rendered. The clinical, radiographic, histologic and immunophenotypic features of CFT are discussed. CFT is a rare benign soft tissue tumor with distinctive histologic findings. They present as well-circumscribed but unencapsulated, paucicellular lesions consisting of hyalinized fibrous tissue with chronic lymphoplasmacytic inflammation and variable amounts of both psammomatous and dystrophic calcifications distributed throughout. They are found in numerous locations throughout the body, most often in the gastrointestinal tract or subcutaneous soft tissue, but are relatively uncommon in the neck. This article describes a case of CFT which presented as an enlarging neck mass in a young male.

Superior laryngeal nerve injury: effects, clinical findings, prognosis, and management options.

PURPOSE OF REVIEW: The superior laryngeal nerve (SLN) provides motor innervation to the cricothyroid muscle. However, the functions of this muscle and the anatomic variations of the nerve that supplies it are not fully understood. SLN paresis and paralysis (SLNp) is difficult to diagnose because of a lack of consistent laryngeal findings, and its effects on the voice likely go beyond simple pitch elevation control. RECENT FINDINGS: Although SLNp has traditionally been thought to lead to voice pitch limitation, recent research findings reveal multiple roles for this nerve in voice and speech. Cricothyroid muscles are the primary controls of fundamental frequency of voice. SLNp can lead to significant contraction of pitch range, vocal fold vibratory phase asymmetry, and acoustic aperiodicity, thus leading to an overall poor vocal quality. In addition, cricothyroid muscles may also play a role in pitch lowering and shifting from voiced to unvoiced sounds during speech. SUMMARY: Subtle signs, symptoms, and diagnostic findings associated with SLNp make this disorder difficult to characterize clinically. Lack of treatment methodologies to restore the dynamic action of the cricothyroid muscles poses difficulties in treating patients with this condition. A more thorough understanding of the effects of SLNp will improve diagnosis and treatment.

Phonatory effects of type I thyroplasty implant shape and depth of medialization in unilateral vocal fold paralysis.

OBJECTIVES/HYPOTHESIS: Medialization thyroplasty (MT) is commonly used to treat glottic insufficiency. In this study, we investigated the phonatory effects of MT implant medialization depth and medial surface shape. METHODS: Recurrent laryngeal nerve (RLN) and vagal paralysis were simulated in an in vivo canine. A type 1 MT was performed using a silicone elastomer implant with variable medialization depths and medial surface shapes: rectangular, V-shaped, divergent, and convergent. The effects on phonation onset flow/pressure relationships and acoustics were measured. RESULTS: Increasing depth of medialization led to improvements in fundamental frequency (F0) range and normalization of the slope of pressure/flow relationship toward baseline activation conditions. The effects of implant medial shape also depended on depth of medialization. Outcome measures were similar among the implants at smaller medialization depths. With large medialization depths and vagal paralysis conditions, the divergent implant maintained pressure/flow relationship closer to baseline. The vagal paralysis conditions also demonstrated decreased fundamental frequency range and worse flow/pressure relationship compared to RLN paralysis. CONCLUSIONS: The depth and medial shape of a medialization laryngoplasty (ML) implant significantly affect both the F0 range and aerodynamic power required for phonation. These effects become more notable with increasing depth of medialization. The study also illustrates that ML is less effective in vagal paralysis compared to RLN paralysis. LEVEL OF EVIDENCE: N/A.

Incidence of laryngospasm and bronchospasm in pediatric adenotonsillectomy.

OBJECTIVES/HYPOTHESIS: To evaluate and describe airway complications in pediatric adenotonsillectomy. STUDY DESIGN: Retrospective case-control study. METHODS: A chart review of patients that underwent adenotonsillectomy between 2006 and 2010 was performed. Perioperative complications, patient characteristics, and surgeon and anesthesia technique were recorded. RESULTS: A total of 682 charts were reviewed. Eleven cases (1.6%) of laryngospasm were identified: one was preoperative, seven occurred in the operating room postextubation, and three occurred in the recovery area. Four patients were given succinylcholine, one was reintubated, and the other cases were managed conservatively. Mean age of patients with laryngospasm was 5.87 years (standard deviation [SD], 4.01; 1.9-15.8 years). There were 12 cases (1.8%) of bronchospasm; all were treated with nebulized albuterol. Mean age of patients with bronchospasm was 5.81 years (SD, 4.17; 1.8-14.1 years). Overall, 22 patients required antiemetics (3.3%), 19 required albuterol (2.9%), and five required racemic epinephrine (0.8%). Compared to the children without airway complications, there was no difference in age, weight, American Society of Anesthesiologists status, length of surgery, need for admission, and anesthesia technique in those that had laryngospasm. Patients with bronchospasm, compared to the patients without complications, had faster surgeries (P < .05), were more likely to have underlying asthma (P < .05), and were more likely to be admitted (P < .05). There were no unexpected admissions or other morbidities. CONCLUSIONS: The rates of laryngospasm (1.6%) and bronchospasm (1.8%) are significantly lower than reported in the literature, reflecting refinements in modern anesthesia/surgical technique. Knowledge of at-risk patients can facilitate planning to potentially reduce the incidence of perioperative airway complications during adenotonsillectomy.

Effects of thrombolytic agents on tympanostomy tubes occluded by blood clots.

OBJECTIVE: To investigate the efficacy of various topical applications in opening a clotted tympanostomy tube (TT) using an in vitro model. DESIGN: In vitro clinical trial. INTERVENTIONS: Fresh human blood was allowed to clot in the lumen of TTs. Seven agents were tested: 0.9% saline (control), 1-mg/mL alteplase, 100-U/mL unfractionated heparin, 3% hydrogen peroxide (H(2)O(2)), 3% acetic acid, 5% acetic acid, and a mixture of 3% H(2)O(2) and 3% acetic acid. Each agent was added twice a day for 14 days to TTs that were incubated and humidified to simulate ear canal conditions. The tubes were analyzed with binocular microscopy to determine the status of the obstruction. RESULTS: A total of 16 trials per agent, including a saline control, were performed. The saline control, alteplase, and heparin failed to open any TTs in any of the trials. Compared with the control, H(2)O(2) also was not effective (P = .23). Acetic acid was increasingly effective, with a 3% concentration completely clearing 5 of 16 tubes and a 5% concentration completely clearing 11 of 16 tubes (P = .006). The addition of 3% H(2)O(2) to 3% acetic acid did not significantly increase clearance (P = .21). CONCLUSIONS: Thrombolytic agents and H(2)O(2) were not effective in resolving TTs that were clotted with blood in an in vitro environment simulating the ear canal. Increasing concentrations of acetic acid are increasingly effective in this capacity.