Socioeconomic Factors Affect Outcomes in Well-Differentiated Thyroid Cancer.

OBJECTIVES: The effects of socioeconomic status (SES) on the incidence of well-differentiated thyroid cancer (WDTC) are well researched. However, the association between SES and outcomes is not delineated. Our objective was to determine if SES affected outcomes of WDTC. STUDY DESIGNS: Retrospective database review. SETTING: Tertiary care medical center. SUBJECTS AND METHODS: The Henry Ford Virtual Data Warehouse Tumor Registry was used to identify cases of WDTC. Socioeconomic data were obtained through the 2010 US Census: median household income, percentage below poverty line, median household size, percentage rent versus own property, and general demographics. Survival was the primary outcome. Disease-specific survival was also calculated. Cox proportional hazards were calculated and a multivariate analysis performed. RESULTS: There were 1317 patients with WDTC. In multivariable analysis, median household income (hazard ratio [HR]: 0.85, 95% confidence interval [95% CI]: 0.79-0.91), household size (HR: 1.49, 95% CI: 1.09-2.14), younger age (HR: 1.97, 95% CI: 1.74-2.23), and female sex (HR: 0.50, 95% CI: 0.37-0.69) were significantly associated with survival. Controlling for stage revealed percentage below poverty line (stage I, HR: 0.51, 95% CI: 1.34-1.78; stage IV, HR: 1.28, 95% CI: 1.04-1.57) and median household income (HR: 0.84, 95% CI: 0.71-0.99) to be significant factors in survival. Median household income was a statistically significant variable for disease-related death (HR: 0.82, 95% CI: 0.69-0.96) CONCLUSIONS: Along with effects on incidence, lower SES correlates with worse survival in WDTC. This suggests that a patient's economic background, with younger age and female sex, influences one's outcomes with regard to both overall and disease-specific death.

Pilot study of a novel population of head and neck cancer patients in the CRN.

Head and neck cancers are challenging to study because of their relatively low incidence. A large, novel population of patients with head and neck cancers that has not been previously studied and distinct from the referral populations has been identified. The National Cancer Institute-funded Health Maintenance Organization Cancer Research Network is a consortium of 15 nonprofit research centers based in large, vertically integrated health care delivery organizations across the United States. They represent a geographically, racially, and socioeconomically diverse population. These community-based organizations provide care to approximately 10 million individuals and 57,692 patients with head and neck cancer. This pilot study and preliminary analysis seeks to demonstrate the potential this network holds as a resource for clinical cancer research and to identify it as a unique resource that allows for more detailed queries than are currently available to researchers.

Sinonasal epithelial cell expression of Toll-like receptor 9 is elevated in cystic fibrosis-associated chronic rhinosinusitis.

BACKGROUND: Cystic fibrosis (CF) patients frequently suffer from chronic rhinosinusitis (CRS). The extent to which alterations in sinonasal innate immunity contribute to this disease process is unknown. Activation of sinonasal epithelial cell (SNEC) Toll-like receptors (TLRs), an important component of the innate immune system, may be associated with the hyperinflammatory state observed in sinonasal mucosa of CF patients with CRS. This study compares expression of Toll-like receptor 9 (TLR9), in SNRCs collected from CF subjects with CRS to that of normal control subjects. METHODS: This was a prospective study measuring TLR9 on SNECs collected via endoscopic-guided middle meatal brushings from 8 adult controls and 14 adult subjects with CF-associated CRS. RESULTS: TLR9 expression was significantly elevated in CF subjects at 91% ± 6% when compared with 76% ± 10% in normal controls (p = 0.001). CONCLUSION: The significantly greater expression of sinonasal epithelial TLR9 in CF likely reflects increased antimicrobial innate immune activity in chronically colonized and frequently infected CF individuals. However, this finding contrasts with previously reported decreased epithelial TLR9 expression in eosinophilic CRS with nasal polyposis and may indicate differential modulation of innate immunity in Th1-predominent CF versus Th2-dominated CRS with nasal polyps, despite both being diseases of sinonasal mucosal inflammation.

The association between allergic rhinitis and sleep-disordered breathing in children: a systematic review.

BACKGROUND: The objective of this work was to systematically review existing literature on the association between allergic rhinitis (AR) and sleep-disordered breathing (SDB) in children. METHODS: We performed a literature search encompassing the last 25 years in PubMed, EMBASE, and Cochrane CENTRAL. Inclusion criteria included English-language papers containing original human data, number of subjects ≥7, and age <18 years old. Data was systematically collected on study design, patient demographics, clinical characteristics/outcomes, and level-of-evidence. Two investigators independently reviewed all articles. RESULTS: The initial search yielded 433 abstracts, of which 18 articles were included. Twelve (67%) of the 18 articles showed a statistically significant association between AR and SDB. All articles were either case-series or case-control studies. Based on the Newcastle-Ottawa scale, the quality of the articles was determined to be fair to good. For characterizing AR, 7 (39%) studies included skin-prick testing and/or in vitro testing. For determining presence of SDB, 7 (39%) of the studies used polysomnographic data, of which 1 study incorporated data from a home polysomnogram. Habitual snoring was the most common form of SDB studied, in 10 (56%) of the articles. Obstructive sleep apnea was studied in 6 (33%) articles. CONCLUSION: Although the majority of the studies included in this review showed a significant association between AR and SDB, all of the studies were evidence level 3b and 4, for an overall grade of B- evidence (Oxford Evidence-Based Medicine Center). Further higher-quality studies should be performed in the future to better evaluate the relationship between AR and SDB in children.

Role of innate immunity in the pathogenesis of allergic rhinitis.

PURPOSE OF REVIEW: The immunologic causes of allergic rhinitis underscore the important roles of both adaptive and innate immune systems. In recent years, appreciation of the role of nasal innate immunity has grown and evidence suggests that the pathogenesis of allergic rhinitis is partially mediated by the innate immune system. This review focuses on our current knowledge and recent discoveries in nasal innate immunity as they pertain to the cause and management of allergic rhinitis. RECENT FINDINGS: Previously thought to be nonspecific, innate immunity also possesses specific mechanisms as demonstrated by toll-like receptors. The interplay between the external environment and nasal mucosa contributes to innate-immune-mediated development of allergic rhinitis. Certain innate immune cells such as plasmacytoid dendritic cells and natural killer T cells may be important in the induction of Th2 cytokine production characterized in allergic airway disease. SUMMARY: The increasing knowledge of nasal innate immunity gained from recent research not only expands our understanding of the causes of allergic rhinitis, it also leads to new therapeutic approaches. Although current management of allergic rhinitis includes one or a combination of pharmacotherapy, immunotherapy, and/or surgery, novel treatments such as toll-like receptor agonists used as targets or adjuvants for immunotherapy are being tested and may hold promising roles in future allergic rhinitis treatment.

Neck dissection through a facelift incision.

OBJECTIVES/HYPOTHESIS: To determine the feasibility and safety of neck dissection through a facelift incision. STUDY DESIGN: Prospective case series. METHODS: Cadavers and live subjects underwent neck dissection using a facelift incision with and without endoscopic assistance. In the live facelift neck dissection (FLND), the preoperative surgical indications, staging, adjuvant therapy, intraoperative technical procedure, pathology reports on lymph nodes, and short-term outcomes were reviewed. RESULTS: FLND was successfully performed in four cadavers and four live subjects, including selective (less than five neck levels removed) and comprehensive (levels I-V removed) neck dissections. All levels were accessible through this approach, with additional retraction required for levels I and IV. Endoscopic assistance was required in one neck dissection for adequate visualization. Short-term complications and number of excised lymph nodes were comparable to those from traditional neck dissection approaches. CONCLUSIONS: Open neck dissection through a facelift incision is feasible and offers an alternate approach to traditional incisions. This can be performed without requiring robotic assistance and with endoscopic assistance only in certain cases. Endoscopic assistance can offer enhanced visualization of the surgical field and complement open direct approaches in neck dissection. Although FLND offers improved cosmetic outcomes when compared to those of traditional neck incisions, further study is required to determine its efficacy and indications.

Pharmacotherapy for allergic rhinitis.

Allergic rhinitis affects millions of Americans and the numbers continue to increase. Fortunately, there exists a wide array of pharmacotherapeutic options with relatively safe side effect profiles for the management of the varying subtypes. Additionally, there are newer agents on the horizon. The efficacies of intranasal corticosteroids, antihistamines, combination topical therapy, leukotriene inhibitors, mast cell stabilizers, anticholinergics, mucolytics, decongestants, and anti-IgE are reviewed.

The frontal intersinus septum takedown procedure: revisiting a technique for surgically refractory unilateral frontal sinus disease.

OBJECTIVES/HYPOTHESIS: Unilateral frontal sinus obstruction presents a surgical challenge when outflow tract osteoneogenesis or dense scarring is present. Frontal sinus obliteration is often employed as a last resort, but this procedure has potential long-term complications. In some cases, endoscopic modified Lothrop or unilateral drillout procedures may be effective options; however, restenosis rates are often high. Here we report our experience using frontal intersinus septum takedown (FISST) to address unilateral obstruction while preserving the opposite frontal outflow tract. STUDY DESIGN: A retrospective review was performed of 12 patients with unilateral frontal sinus opacification due to irreversible frontal recess obstruction who underwent FISST. Surgical outcomes were assessed based on symptoms and computed tomography (CT) resolution of frontal sinus disease. RESULTS: All 12 patients undergoing FISST had significant improvement in their symptoms. Ten postoperative CT scans were available for review, all showing continued patency of the interfrontal connection, and nine out of 10 with resolution of radiographic frontal sinus disease. Eleven of the procedures were performed via trephination, and one was achieved endoscopically. CONCLUSIONS: In patients with one obstructed frontal sinus and a functional contralateral sinus, removal of the intersinus septum allows for adequate sinus drainage and significant clinical improvement. The success of FISST may be surprising given knowledge of mucociliary clearance patterns, but may be effective because of the naturally dependent position of the frontal sinus ostium.

Allergic rhinitis is associated with decreased expression of Toll-like receptor 9 by sinonasal epithelial cells.

BACKGROUND: Toll-like receptors (TLRs) are important in sinonasal mucosal innate immunity. Previous studies demonstrate that sinonasal epithelial cell (SNEC) TLR9 expression is reduced in T-helper 2 (Th2) cytokine-predominant chronic rhinosinusitis with polyps, and with the in vitro application of Th2 cytokines. To further investigate in vivo modulation of TLR9 by the local cytokine environment, this study examines TLR9 expression in freshly isolated SNECs from subjects with and without active allergic rhinitis (AR). METHODS: SNECs were gathered via endoscopic-guided middle meatal brushings from 9 AR subjects who were skin-prick test (SPT)-positive to environmental allergens in season at the time of study, and 8 controls. Flow cytometry was utilized to compare SNEC TLR9 expression in the 2 groups. RESULTS: TLR9 expression by SNEC in the AR group was significantly reduced compared to normals (35% ± 26% vs 76% ± 10%, p = 0.002). CONCLUSION: Similar to observations in eosinophilic chronic rhinosinusitis, this study shows that active AR is associated with decreased SNEC TLR9 expression. These findings are consistent with the concept that Th2 cytokines suppress expression of TLR9 and other innate immune genes. Multiple endogenous and microbial factors likely modulate sinonasal innate immunity to maintain homeostasis and prevent infection in AR.

Restoring the 3D vestibulo-ocular reflex via electrical stimulation: the Johns Hopkins multichannel vestibular prosthesis project.

Bilateral loss of vestibular sensation causes difficulty maintaining stable vision, posture and gait. An implantable prosthesis that partly restores normal activity on branches of the vestibular nerve should improve quality of life for individuals disabled by this disorder. We have developed a head-mounted multichannel vestibular prosthesis that restores sufficient semicircular canal function to partially recreate a normal 3-dimensional angular vestibulo-ocular reflex in animals. Here we describe several parallel lines of investigation directed toward refinement of this approach toward eventual clinical application.

Allergic rhinitis patients with recurrent acute sinusitis have increased sinonasal epithelial cell TLR9 expression.

OBJECTIVE: Pilot study examining toll-like receptor 9 (TLR9) expression by sinonasal epithelial cells in allergic rhinitis (AR) subjects with and without a history of recurrent acute rhinosinusitis (RARS). STUDY DESIGN: Cohort study. SETTING: Outpatient clinic. SUBJECTS AND METHODS: Adult subjects were eligible for study if skin tested positive for inhalant allergens, and positive allergens were in season at time of study. Subjects were considered to have AR+RARS if they had four symptomatic episodes with major/minor factors in 12 months and CT evidence of sinusitis. Eight AR-only subjects and 13 AR+RARS subjects underwent endoscopic-guided cell brushing from the middle meatus. Flow cytometry for TLR9 expression was performed on collected fresh sinonasal epithelial cells. RESULTS: The AR+RARS group was found to have a significant increase in TLR9 expression in the sinonasal epithelium (66% +/- 30%) compared with that of AR-only patients (32% +/- 21%; P = 0.011). CONCLUSION: The significant difference in expression of TLR9 in allergic sinusitis patients compared with allergy-only patients in this study may indicate a difference in the role of innate immunity in these groups. The results suggest that expression of innate immune markers such as TLR9 may be upregulated in response to repeated microbial insults in AR+RARS. Further research is necessary to determine whether an initial impairment of innate immune gene expression may predispose some AR patients to subsequent development of RARS.

Effects of semicircular canal electrode implantation on hearing in chinchillas.

CONCLUSION: Implantation of vestibular prosthesis electrodes in chinchilla semicircular canal ampullae can be accomplished without significant loss of cochlear function; however, the risk of hearing loss with the current surgical technique is high. OBJECTIVES: To determine if it is possible to implant vestibular prosthesis electrodes into the labyrinth without damaging hearing, and to quantify the extent of hearing loss due to implantation. MATERIALS AND METHODS: The left semicircular canals of six chinchillas were implanted with three bipolar pairs of electrodes using a transmastoid approach. Right ears, which served as controls, were subjected to the same mastoid approach without fenestration and implantation. Auditory brainstem response hearing thresholds to free-field clicks and tone pips at 2, 4, 6, and 8 kHz were measured bilaterally 3-9 weeks after implantation. Hearing thresholds were compared between sides and against data from six normal chinchillas. RESULTS: Four implanted ears suffered severe hearing loss, with thresholds ranging from 5 to 11 SD above the mean threshold of sham surgery control ears across all tested stimuli. Two implanted ears had preserved hearing, with thresholds remaining within 1 SD of the mean threshold of sham surgery control ears across nearly all stimulus frequencies.

The effects of cochlear implantation on vestibular function.

OBJECTIVE: Determine the risk posed by cochlear implantation (CI) to the labyrinth. STUDY DESIGN: Prospective cohort study. SETTING: Academic tertiary referral center. PATIENTS: Thirty-six ears belonging to 35 adult CI candidates (mean age, 46 yr; range, 23-69 yr). INTERVENTION: Cochlear implantation. MAIN OUTCOME MEASURES: Vestibular function was assessed using the quantitative 3-dimensional head impulse test (qHIT), clinical head impulse test (cHIT), post-head shake nystagmus, caloric electronystagmography, vestibular-evoked myogenic potentials, dynamic visual acuity, and Dizziness Handicap Inventory. RESULTS: All 36 ears were tested using qHIT before CI, and 28 ears were tested 4 to 8 weeks after CI. qHIT showed that 1 of 28 ears had reduced function. cHIT was 44% sensitive and 94% specific for identification of severe-to-profound vestibular hypofunction confirmed by qHIT. Post-head shake nystagmus was unchanged in 11 of 11 subjects. New hyporeflexia was found in 1 of 16 electronystagmography-tested ears. Vestibular-evoked myogenic potential showed either a disappearance of response or an increase in threshold by greater than 10 dB in 5 of 16 ears. Passive dynamic visual acuity showed no change in 16 of 16 ears. Dizziness Handicap Inventory scores worsened in 3 of 28 and improved in 4 of 28 subjects. CONCLUSION: Although small, the observed rate of labyrinthine injury was comparable to that for other risks of CI. Thus, it is important to educate CI candidates regarding possible risk to balance function, particularly when CI of an "only balancing ear" is contemplated. cHIT is useful for detecting severe high-frequency vestibular hypofunction and should be part of the pre-CI physical examination.

Overview of facial paralysis: current concepts.

Facial paralysis represents the end result of a wide array of disorders and heterogeneous etiologies, including congenital, traumatic, infectious, neoplastic, and metabolic causes. Thus, facial palsy has a diverse range of presentations, from transient unilateral paresis to devastating permanent bilateral paralysis. Although not life-threatening, facial paralysis remains relatively common and can have truly severe effects on one's quality of life, with important ramifications in terms of psychological impact and physiologic burden. Prognosis and outcomes for patients with facial paralysis are highly dependent on the etiologic nature of the weakness as well as the treatment offered to the patient. Facial plastic surgeons are often asked to manage the sequelae of long-standing facial paralysis. It is important, however, for any practitioner who assists this population to have a sophisticated understanding of the common etiologies and initial management of facial paralysis. This article reviews the more common causes of facial paralysis and discusses relevant early treatment strategies.