Common clonal origin of synchronous primary head and neck squamous cell carcinomas: analysis by tumor karyotypes and fluorescence in situ hybridization.

Two synchronously arising primary squamous cell carcinomas (SCC) originating from separate sites in the anterior floor of mouth (FOM) and the pyriform sinus (PS) were evaluated by karyotype and fluorescence in situ hybridization (FISH) to determine whether they were of common or independent ancestry. The primary tumors were designated Henry Ford Hospital (HFH)-SCC-8a (FOM) and HFH-SCC-9a (PS), and the respective recurrent tumors after chemotherapy and radiation were designated -8b and -9b. HFH-SCC-8a and -8b were cultured and had closely related hypotetraploid karyotypes of monoclonal origin. Karyotypes could not be obtained from the second primary tumor HFH-SCC-9a or its recurrence -9b. However, we used karyotypes from HFH-SCC-8a and -8b as a guide to select FISH probes for the histological evaluation of genetic markers in tumor sections. Fluorescence in situ hybridization on metaphase chromosomes from the cell cultures was useful in modifying the tumor karyotypes. Fluorescence in situ hybridization identified a chromosome Y rearrangement that was not obvious from the HFH-SCC-8a and -8b karyotypes, and this Y rearrangement served as a unique clonal marker. Using two probes for the Y chromosome we showed that all four tumors shared the same Y rearrangement with loss of Yq (DYZ1) and retention of Ycen (DYZ3). Furthermore, FISH showed that all four tumors had the same aneuploidy patterns for chromosomes X, Y, 7, 9, 15, 16, and 17. From karyotypic and FISH analysis disomy for X and 9 centromere regions and the rearranged Y were all predicted and observed in the tumor tissue sections. Tetrasomy and trisomy for 7, 15, 16, and 17 were predicted from the karyotypes and this also was observed using FISH in all four tumors. These FISH aneuploidy patterns and the presence of a clonal Y marker in all four tumor samples indicate that the synchronous primaries and their recurrences were of monoclonal origin.

Microdissection or microspot CO2 laser for limited vocal fold benign lesions: a prospective randomized trial.

UNLABELLED: CO2 lasers have become an important technological advance and an integral tool for the laryngeal surgeon since the 1960s. Surgeons have used lasers for a variety of benign and malignant lesions in the larynx with good success. With better understanding of the microarchitecture of the vocal folds and the recognition of heat distribution into surrounding tissues that occurs with the use of standard CO2 lasers, questions and concerns have been raised regarding the use of the CO2 laser for benign lesions of the vocal folds. With the advent of the microspot CO2 laser with a spot size of less than 250 microm, the potential heat distribution to the deeper layers of the lamina propria has been reduced. The microspot CO2 laser has been suggested to be an appropriate tool for the excision of superficial benign lesions of the vocal fold and may be considered as an appropriate treatment alternative to microdissection. Only a limited number of studies have compared the efficacy of microdissection versus microspot CO2 laser surgery in the larynx, and no prospective, randomized trials have been performed. OBJECTIVE: This study was designed to compare microspot CO2 laser excision and microdissection for superficial benign lesions confined to the free margin of the vocal fold. STUDY DESIGN: A randomized, prospective trial comparing microspot CO2 laser excision and microdissection in the removal of nodules, polyps, and mucous retention cysts of the vocal fold. METHODS: Acoustic and aerodynamic measures and videostroboscopic and perceptual audio recordings evaluated by a panel of blinded viewers and listeners were studied preoperatively and 2 to 3 weeks and 5 to 12 weeks postoperatively. Surgical and recovery times were compared between the two groups. RESULTS: Thirty-seven patients met selection criteria and were enrolled, 21 in the microdissection group and 16 in the laser excision group. Significant improvements in videostroboscopic parameters were found over time in both groups. Significant improvements were noted for perceptual analysis over time for the laser excision group with nonsignificant improvements over time for the microdissection group. There was no difference in any measure between laser excision and microdissection at the two postoperative visits. There was no difference in surgical or recovery time between laser excision and microdissection. Acoustic and aerodynamic parameters were noncontributory in evaluating outcomes of treatment, since most values were normal before surgery. CONCLUSION: No differences in clinical outcomes are identified when comparing microdissection with laser excision of nodules, polyps, and mucous retention cysts of the vocal folds.

Intraoperative infectious disease exposure to otolaryngology operating room personnel.

Health care workers are at risk of exposure to serious infectious diseases. Since the seroconversion rate is approximately 0.4% for human immunodeficiency virus and may be greater than 20% for hepatitis exposure, these risks are substantial. To assess body fluid exposure to otolaryngology operating room personnel, elective operations were prospectively analyzed over 2 months. Statistical evaluation was made between types of cases and length of procedures. Thirty-eight contaminations occurred in 228 operations with 26 torn gloves, 1 soaked grown, 6 skin scratches, 4 skin punctures, and 1 ocular exposure. Exposure was more likely in cases longer than 3 hours. Independent of procedure length, head and neck operations carried the greatest risk, followed by otologic procedures, as compared to general, endoscopic, pediatric, and elective trauma cases. The impact of potential operative exposure and universal precautions is emphasized.

Changing etiology of vocal fold immobility.

HYPOTHESIS: Vocal fold immobility is a sign of underlying disease. When the etiology remains unclear, evaluation may become time consuming and costly, and directed work-up imperative. This study examined the hypothesis that the etiologies of vocal fold immobility are changing, with extralaryngeal malignancies and nonthyroidectomy surgical trauma having become more common causes. METHODS: A retrospective review of consecutive patients with vocal fold immobility who had an adequate workup to determine the etiology. RESULTS: Three hundred ninety-seven cases with a determined etiology were identified, yielding 280 unilateral and 117 bilateral immobilities. The largest single category in unilateral immobility was nonlaryngeal malignancy--69 patients (24.7%)--80% of which were pulmonary or mediastinal, followed by 67 patients (23.9%) with immobility secondary to surgical trauma. Thyroidectomy accounted for only 8.2%. The leading cause of bilateral immobility was surgical trauma-30 patients (25.7%)--21 (18%) of whom had thyroidectomy. Acute and chronic intubation injuries accounted for 21 unilateral (7.5%) and 18 bilateral (15.4%) cases. CONCLUSIONS: These data indicate a changing etiology of vocal fold immobility, with growing percentages of extralaryngeal malignancies and surgery-related injuries. These findings have implications for the timing and method of management based on anticipated outcome.

Factors associated with recurrence and voice quality following radiation therapy for T1 and T2 glottic carcinomas.

Evaluation of 63 patients undergoing primary radiation therapy for treatment of T1 and T2 glottic carcinomas was undertaken to evaluate the success of primary treatment and to identify factors which might influence recurrence or voice quality. Twelve patients (19%) recurred following radiation therapy, with ultimate salvage in 11, for a 3-year survival rate of 98%. Voice preservation was achieved in 83%. Continued smoking after radiation therapy was associated with significantly greater risk of recurrence. Stage of tumor and anterior commissure involvement were not associated with increased recurrences. Sixty-seven percent of patients who did not recur had good voice quality after treatment. Vocal fold stripping or excisional biopsy rather than limited biopsy for initial diagnosis, complications of treatment, and continued smoking after treatment were all significantly associated with an increased risk of poorer voice quality after treatment while bilateral vocal fold tumors were associated with risks that approached significance. Voice analysis of five patients revealed that objective changes in voice can be detected after radiation therapy in those with associated risk factors but may be normal in those without these risk factors.

Gastroesophageal reflux and obstructive sleep apnea.

OBJECTIVE: To determine the extent to which gastroesophageal reflux (GER)-initiated laryngeal chemoreflexes contribute to obstructive sleep apnea (OSA). METHODS: Prospective, nonrandomized clinical trial of an antireflux treatment protocol as a means of reducing the severity of OSA. Population consisted of 10 males aged 20 to 64 years with confirmed OSA (by overnight polysomnography) and GER (by ambulatory pH probe monitoring). Patients were treated with omeprazole and standard antireflux protocol for 30 days and pre- and posttreatment polysomnography variables were compared. RESULTS: Mean apnea index declined 31% (45-31, P = .04); mean respiratory disturbance index declined 25% (62-46, P = .06). Three patients (30%) are "treatment responders" as defined by traditional OSA treatment definitions. CONCLUSIONS: These results suggest a potential relationship between OSA and GER, the treatment of which may be an effective adjunctive in those with both disorders. Treatment of GER may significantly impact OSA in select individuals.

Squamous cell carcinoma of the head and neck in patients 40 years of age and younger.

Squamous cell carcinoma of the head and neck is largely a disease of the middle-aged and elderly. When it occurs in younger patients, the prognosis for long-term survival appears to be worse than in the older age group. The records of 41 patients aged 40 years and younger who presented with squamous cell carcinoma of the head and neck were reviewed. Twenty-eight of these patients (68%) developed recurrence; of these, 21 (51%) died with disease, and two are alive with disease. These results indicate a trend toward poorer survival than previous rates reported nationally for all patients with carcinoma of the head and neck over a similar time period. Lesions of the oral tongue, nasopharynx, and paranasal sinuses seem to have a particularly poor prognosis.

Facial nerve morbidity following parotid surgery for benign disease: the Cleveland Clinic Foundation experience.

Standard surgical management for benign tumors of the parotid gland requires either superficial, subtotal, or total parotidectomy with preservation of the facial nerve. Although this approach is effective in minimizing recurrence, the resultant facial nerve morbidity is seldom addressed. Two hundred fifty-six consecutive patients who underwent parotid surgery for benign neoplasia at this institution in the past 15 years are reviewed, with attention to postoperative facial nerve function. Immediate dysfunction was frequently encountered (46.1%), but permanent dysfunction was uncommon (3.9%). The incidence of long-term dysfunction may be higher in revision cases and when an extended (total or subtotal) parotidectomy is performed.

The development of the Rhinosinusitis Disability Index.

Assessment of patient perception of disability and outcomes from treatment has become an integral part of medical care. General quality-of-life measurement tools have led to the development of disease-specific quality instruments. Conventional methods for evaluating nasal-sinus disease are inadequate to assess the impact of these disorders on everyday life. Therefore, using methods that are well established and validated for creating instruments, the Rhinosinusitis Disability. Index was created to evaluate the self-perceived impact of disease-specific head and neck disorders. The development of the preliminary and final versions (30 items) of the Rhinosinusitis Disability Index is described. Content-related validity using Cronbach's alpha measurement and construct-related validity were accomplished. A comparison of the responses between patients with and without documented nasal or sinus disease was used to verify that the Rhinosinusitis Disability Index is a valid measuring instrument for patients with sinus disease, and test-retest validity reveals reliability over time.

Symptom-directed selective endoscopy: long-term efficacy.

BACKGROUND: Synchronous primary neoplasms have been encountered in some patients with mucosal squamous cell carcinoma of the head and neck. Routine panendoscopy along with various radiological tests have been advocated to identify these potential tumors. In 1993, we originally described symptom-directed, selective endoscopy as an efficient and cost-effective means to evaluate patients to identify synchronous primary neoplasms. OBJECTIVE: To review the ultimate success rate of symptom-directed, selective endoscopy in that initial cohort of patients and the success of the program longitudinally in clinical practice over the intervening 6 years. PATIENTS AND METHODS: The status of the original 100 patients who participated in the selective endoscopy study were reviewed at least 6 months after the original procedure. A statistically significant random sample of 101 subsequent patients who had at least 6 months' follow-up or until their death were reviewed. RESULTS: No additional primary, mucosal head and neck, esophageal, or pulmonary cancers were identified in the surviving original cohort of patients suggesting that the selective endoscopy identified all synchronous tumors. Sixteen metachronous primary cancers were identified between 12 and 70 months after the initial evaluation. Eight synchronous primary cancers were identified in the new cohort using symptom-directed evaluation, direct laryngopharyngoscopy, and chest x-ray films. No additional tumors were detected within 6 months. CONCLUSION: Symptom-directed, selective endoscopy seems to be an effective alternative to routine panendoscopy in identifying synchronous primary cancers.

Outcomes of botulinum toxin treatment for patients with spasmodic dysphonia.

BACKGROUND: Spasmodic dysphonia (SD) is a focal dystonia of the larynx. Although individuals with SD have variable degrees of difficulty in everyday communication and speaking, many report significant impairments. The impact of SD on the quality of life of people with the disorder has not been well measured. OBJECTIVES: To assess the impact of SD using a voice-specific, validated outcomes instrument, the Voice Handicap Index (VHI), and to evaluate the effect of botulinum toxin treatment on quality of life. METHODS: The VHI measures 3 subscales (physical, functional, and emotional) of impact of a voice disorder as well as a total impact score. The VHI was completed by 30 consecutive patients with SD before receiving botulinum toxin injection and 2 to 4 weeks after injection. Pretreatment scores on the VHI were compared with posttreatment scores. RESULTS: Pretreatment scores on the VHI showed significant impairment in all 3 subscales (physical, 25.5; functional, 21.4; and emotional, 20.4) and the total score (67.6). Statistically significant improvements occurred in all 3 subscale scores and the total score (P =.001) for the 22 patients who completed the posttreatment survey. CONCLUSIONS: Spasmodic dysphonia has a significant impact on patients' perception of quality of life as measured by the VHI. Significant improvements in all 3 subscale scores and the total score on the VHI occur after treatment with botulinum toxin.

Near-total laryngectomy with epiglottic reconstruction. Long-term results.

A previous report reviewed the technique and indications for near-total laryngectomy with epiglottic reconstruction in the management of squamous cell carcinoma of the glottis. This approach permits removal of most of both vocal folds, with immediate reconstruction using the epiglottis without the need for stenting or multistage procedures. Forty-eight patients underwent the procedure and were followed up for at least 2 years or until death. Seventeen underwent the surgery for recurrence after failure of radiation therapy for cure. Complications included one wound infection and one laryngocutaneous fistula. All patients underwent decannulation, with little or no compromise of swallowing. All but 1 now have functional voices. Of 8 patients with recurrence, 6 have been salvaged. Two patients died of disease. The value of near-total laryngectomy with epiglottic reconstruction for management of glottic cancer is reviewed.

Model for optimal space and staff efficiency in an otolaryngology clinic.

Maximizing efficiency of staff and resources is one method of reducing costs without affecting quality. Using a methodology similar to that used to maximize efficiency of airline-gate use, we developed a model with which to evaluate nursing support staff and clinical examining-room resources in a general otolaryngology clinic. For 144 patients over 7 consecutive clinic days, with four otolaryngologists and various combinations of support staff and examining rooms, we measured space and staff resource use, including total clinic time, number of patients seen, patient waiting time, physician and nurse productivity, and examining-room use. A simulation model was used as the medium of analysis to define parameters of the patient encounter. We identified optimal efficiency when there were three examining rooms and one and one-half nursing staff per physician or five examining rooms and three nursing staff for two simultaneously practicing physicians. Compared with a model of two rooms and one nursing staff member, our ideal model increased the percentage of the physicians' time spent in direct contact with patients from 84% to 92%. Visit length decreased from 81 minutes to 57 minutes, the average time from check-in to examination decreased from 47 to 16 minutes, and it became possible for three additional patients to be seen each day. Additional rooms and support staff, in comparison with the optimally efficient distribution, did not significantly affect these parameters. Maximizing efficiency with the use of this methodology can decrease waiting times for patients, resulting in greater patient satisfaction, improved physician productivity, total number of patients seen, and increased total contact time between physicians and patients.

Natural ostiotomy vs. inferior antrostomy in the management of sinusitis: an animal model.

An animal model was used to compare the surgical treatment of chronic sinusitis by opening the natural ostium vs. inferior antrostomy. Fifteen rabbits had surgical occlusion of the natural maxillary sinus ostia to induce sinusitis. At a second operation, the sinuses were entered and in each animal the natural ostia was reopened on one side and an inferior antrostomy was performed on the opposite sinus. Eight weeks after these operations the sinuses were evaluated. No differences were found in antrostomy patency rates, gross evidence of acute or chronic inflammation, or light or electron microscopic findings between sinuses with natural ostiotomy and those with lower antrostomy. The gross appearances and light and electron microscopic findings are discussed.

Management guidelines for improvement of otolaryngology referrals from primary care physicians.

OBJECTIVE AND DESIGN: A prospective evaluation of the effectiveness of otolaryngology evaluation, treatment, and referral guidelines developed collaboratively by otolaryngologists and primary care physicians on referrals and access to otolaryngology. Comparisons of appropriate to unnecessary referrals, the percentage of patients referred with disorders addressed to those without disorders addressed in the guidelines, access to otolaryngology, and questionnaire evaluations of primary care physician and patient satisfaction were measured before and after guideline implementation. RESULTS: A significant decrease in appropriate to unnecessary referrals was seen, from 55% before to 12% after guidelines. The percentage of patients seen within 1 month of scheduling improved from 39% to 59%. Guideline-addressed disorders decreased from 63% to 40%. The need for patients to see another physician for the referred symptom while waiting to see an otolaryngologist decreased from 31% to 3%. Patient satisfaction with wait times improved. Eighty-six percent of the primary care physicians used the guidelines, and 85% wanted to expand the guidelines to other specialty areas. CONCLUSIONS: Management and referral guidelines are effective in improving patient access and the ratio of appropriate to unnecessary referrals. Such guidelines are well accepted and used by primary care practitioners in this setting.

The medical management of rhinosinusitis.

The management of rhinosinusitis depends on a number of variables related to the duration and severity of symptoms in the individual patient. Furthermore acute rhinosinusitis is managed differently than chronic rhinosinusitis. Because a variety of conservative and pharmacologic interventions are available, the physician can find it difficult to develop a cohesive and logical approach to treatment. An understanding of the pathophysiology, microbiology, and natural history of rhinosinusitis is necessary to formulate the best treatment plan for the individual patient.

Mucosal regeneration of the maxillary sinus after surgery.

The postsurgical effects of the removal of the maxillary sinus mucosa were studied in an animal model. Ten rabbits underwent Caldwell-Luc procedures with the removal of all the maxillary sinus mucosa from one sinus, while the other sinus in each animal was used as a control. After allowing time for postsurgical healing, animals were examined for mucociliary transport and sections for histologic examination were obtained. Respiratory ciliated epithelium was present in seven of the postsurgical sinuses. Marked increases in acute and chronic inflammation, granulation, fibrosis, and ulcerations were noted.

Nasal patency, aerobic capacity, and athletic performance.

The patency of the nasal airway may directly affect pulmonary ventilation, with obstruction and increased nasal resistance resulting in increased pulmonary resistance, hypoxia, and hypercapnea. Nine aerobic athletes were evaluated to assess the role of the nasal airway on aerobic capacity and athletic performance. A step-ladder graded maximal aerobic capacity test was performed under three test conditions: obstructed, decongested with oxymetazoline hydrochloride, and saline control. No differences in maximum VO2, work load, oxygen saturation, maximal blood pressure, heart rate, or respiratory rate were noted between test conditions. Pre-exercise nasal resistance was lower in the decongested compared to control conditions, but no differences were found after exercise. Athletic performance was not influenced by nasal patency in this model.

Diagnosis and treatment of uncomplicated acute bacterial rhinosinusitis: summary of the Agency for Health Care Policy and Research evidence-based report.

PURPOSE: The goal was to critically examine evidence regarding the performance of diagnostic tests and the efficacy of antibiotic and other treatments for uncomplicated acute bacterial rhinosinusitis (ABR). METHODS: Scientific literature was reviewed, and meta-analysis methods were used to assess diagnostic test and antibiotic efficacy. A decision analysis and cost-effective analysis were performed. RESULTS: Although more sensitive than clinical examination for diagnosis of ABR, sinus radiograms are not cost-effective as an initial management strategy. Antibiotics reduce the incidence of clinical failures by one half compared to no treatment and, when coupled with clinical criteria-based diagnosis, present the most cost-effective treatment strategy. However, without antibiotics, symptoms in two thirds of patients improve by 14 days with no serious complications. The risk of treatment failure does not differ significantly between amoxicillin or folate inhibitors and newer, more expensive antibiotics. CONCLUSIONS: The current literature shows that treatment of uncomplicated ABR with amoxicillin or folate inhibitors and based on clinical criteria is the most cost-effective strategy.

Asymmetric sensorineural hearing loss in a community-based population.

Asymmetric sensorineural hearing loss (ASNHL) is fairly common, but it can be an indication of retrocochlear pathology. The incidence of acoustic neuroma (AN) has been estimated at 1/100,000; however, the incidence of AN in patients with ASNHL is unknown. The limitation of health care resources challenges otolaryngologists to develop reasonable cost-containment guidelines for the evaluation of patients with ASNHL for the presence of retrocochlear pathology. A 5-year (1990 to 1994) retrospective study of all patients with ASNHL who were evaluated in a community-based general otolaryngology practice was performed. Demographic, historic, and audiologic data and results from ABRs and radiologic studies were summarized. ASNHL was present in 325 patients. Auditory brain stem response tests were performed in 179 patients (55%), and 92% (164 of 179) were normal. Patients with abnormal or inconclusive auditory brain stem responses and patients with severe SNHL were evaluated with radiologic studies (46 patients). Among the 193 patients who had diagnostic studies, 4 were found to have ANs, for a prevalence of 2.1%. The charge of diagnosis per AN was more than $41,000. In summary, a small percentage of patients with ASNHL have retrocochlear pathology, and the charge of diagnosis per AN can be excessive. A cost-containment approach for the evaluation and management of patients with ASNHL is proposed.