Salvage or Solution: Alloplastic Reconstruction in Hemifacial Microsomia.

INTRODUCTION: Skeletal reconstruction in severe grades of hemifacial microsomia (HFM) continues to be challenging. Traditional techniques of autografts and osseous distraction for reconstruction of the glenoid fossa, condyle, and ramus can fall short of expectations and can create new problems. This intercontinental study analyzes the role of alloplastic skeletal rehabilitation in severe HFM. METHODS: Ten consecutive patients with Pruzansky grade III HFM were reconstructed between October 2014 and July 2017 at 2 craniofacial centers following the same protocol. Data were gathered retrospectively from the medical records, including photographs and virtual planning records. Pre and postoperative photos were taken to compare occlusal status, interincisal opening, sagittal mandibular projection, and posterior facial height. Alloplastic reconstruction was accomplished using a custom designed titanium implant. RESULTS: Ten consecutive skeletally mature patients with HFM with failed traditional reconstructions were successfully treated with virtually planned alloplastic reconstructions (11 joints) and simultaneous orthognathic surgery. The glenoid fossa, condyle, and ramus on the affected sides were reconstructed with custom designed titanium implants. All patients achieved occlusal stabilization, normalization of posterior facial height and sagittal mandibular projection, and maintenance or improved inter-incisal opening. There were no major complications or repeated surgeries. Follow-up ranges from 6 to 50 months. CONCLUSION: Alloplastic reconstruction allows for precise vertical reconstruction of the ramus and condyle and sagittal repositioning of the mandibular body. The glenoid fossa component is firmly anchored to the skull base assuring a stable centric relation on the reconstructed side. Consistent and acceptable results can be achieved in skeletally mature patients.

Disability in patients with head and neck cancer.

BACKGROUND: Patients with head and neck cancer often experience debilitating speech, eating, and respiratory problems as well as the psychological effects of loss of function and change in body image. These patients often become unemployed as a result of their disease process, which adds financial burden to their already stressful lives. Yet the specific factors associated with unemployment have not been systematically studied. METHODS: This multisite study used survey and chart data to determine the predictors of work-related disability. RESULTS: Of the 384 patients who were working prior to their diagnosis of head and neck cancer, 52% (n = 201) were disabled by their cancer treatment. Multivariate analysis demonstrated significant links between disability and chemotherapy (odds ratio [OR], 3.4; P <.001), neck dissection status (OR, 2.3; P =.01), pain scores (OR, 1.2; P =.01), and time since diagnosis (OR, 0.9; P =.04). CONCLUSIONS: More than half of the patients in this study were disabled by their head and neck cancer or treatment. Patients with head and neck cancer who have undergone chemotherapy or neck dissection or have high pain scores are at increased risk for disability from their cancer or their treatment. Efforts to prevent (if possible), better assess, and treat pain and other adverse effects of head and neck cancer treatments may also have the potential to reduce patient disability.

Pathologic evaluation of routine pediatric tonsillectomy specimens: analysis of cost-effectiveness.

OBJECTIVE: Evaluate the utility and explore the cost-effectiveness of mandatory gross or pathologic analysis of routine tonsillectomy specimens in children. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: Retrospective case series of results of pathologic analysis of tonsillectomy specimens from all pediatric patients who underwent tonsillectomy between 1996 and 2008 (n = 5235). The results of pathologic evaluation of routine and nonroutine specimens were evaluated, and an economic analysis of alternative methods of specimen handling was performed. RESULTS: Zero cases of unsuspected pathology were identified on planned gross specimen evaluation (n = 4186), resulting in an estimated prevalence of 0 to 0.00088 (95% confidence interval [CI]). Positive pathologic findings on microscopic analysis (n = 1066) were only identified in posttransplant patients (10/63; 95% CI, 0.079-0.27) and cases of surgeon suspicion (8/78; 0.045-0.19). No cases were identified among the 17 undergoing microscopic pathologic analysis on the basis of pathologist suspicion on gross evaluation (95% CI, 0-0.20). From an economic standpoint, microscopic evaluation of routine pediatric tonsillectomy specimens appears to be superior to gross evaluation but with an estimated cost of $766,500 per case of unsuspected lymphoma identified. CONCLUSIONS: This study identifies a very low prevalence of unsuspected pathology on gross pathologic analysis of routine tonsillectomy specimens in children. Exploration of the cost implications suggests that such a practice is not a cost-effective use of limited health care resources. Microscopic examination is appropriate for posttransplantation patients and in cases of surgeon suspicion.

Cricotracheal resection with hilar release for pediatric airway stenosis.

OBJECTIVE: To determine the effectiveness of cricotracheal resection and hilar release for high-grade, long-segment airway stenosis. DESIGN: We identified 16 patients who underwent cricotracheal resection and hilar release, performed from January 1, 2004, through December 31, 2008, and conducted a retrospective review, emphasizing preoperative findings, operative technique, postoperative course, and results. Complete data sets were available for all patients. SETTING: Tertiary care children's hospital. PATIENTS: The study population comprised 16 patients younger than 18 years who underwent cricotracheal resection and hilar release performed by a thoracic airway team. All patients had high-grade, long-segment subglottic stenosis or severe, long-segment tracheomalacia. INTERVENTION: Cricotracheal resection with hilar release. MAIN OUTCOME MEASURES: Decannulation rate and dehiscence rate. RESULTS: Of the 16 patients, 15 were successfully decannulated. The one patient who was not decannulated remained ventilator dependent and has regained speech. There were no incidents of anastomotic dehiscence. CONCLUSION: Cricotracheal resection with hilar release is a novel and effective way to approach the problem of severe airway stenosis.

Anti-oxidant treatment enhances anti-tumor cytotoxicity of (-)-gossypol.

We showed that tumor cells with wild-type p53 and high levels of Bcl-x(L) are cisplatin resistant but are induced to undergo apoptosis by (-)-gossypol, making this a promising agent for overcoming cisplatin resistance. However, some cells in a population with this phenotype are not killed and continue to survive. Conversely, tumor cells with low Bcl-x(L) expression and either wild type or mutant p53 are relatively cisplatin sensitive and do not exhibit such high levels of apoptosis. However, these do undergo progressive loss of viability after (-)-gossypol that may not be tumor specific. We sought to elucidate the basis for these observations using cDNA microarray analysis of (-)-gossypol treated cisplatin sensitive and resistant cells. Genes in the reactive oxygen species (ROS) pathway were highly upregulated in response to (-)-gossypol. The upregulation was of much greater magnitude in cisplatin sensitive than resistant cells. Staining with an oxidation reporter dye confirmed differential induction of ROS in tumor cells with low Bcl-x(L). As (-)-gossypol is known to undergo oxidative metabolism in vivo, ROS generation may be responsible for both off-target cytotoxicity and inactivation of the drug. In agreement with this hypothesis, oxidation of (-)-gossypol by pre-treatment with hydrogen peroxide eliminated its activity. Combined treatment with the antioxidant N-acetyl-cysteine (NAC) to block ROS increased (-)-gossypol-induced cytotoxicity to tumor but not normal cells. Furthermore, NAC increased the induction of apoptosis as measured by the sub-G(1) population, in both cisplatin sensitive and resistant cells. We postulate that concurrent treatment with antioxidant to block ROS prevents oxidative inactivation of (-)-gossypol and limits off-target toxicity allowing more potent (-)-gossypol-induced anti-tumor activity.