Ossifying fibroma of the maxilla and sinonasal tract: Case series.

BACKGROUND: Head and neck ossifying fibroma (OF) is a rare, benign, locally aggressive, fibro-osseous tumor. The mandible is the most common site of involvement, followed by the maxilla, and, less frequently, the sinonasal cavities, orbit, skull base, and calvarium. In this study, we aimed to expand our understanding of this entity by presenting a case series of OF that involved the maxilla and sinonasal tract. METHODS: A multicenter retrospective review was performed on all the patients with a diagnosis of OF from 2004 to 2013. Data were collected with respect to age, sex, clinical presentation, treatment, and outcome. RESULTS: A total of 13 patients were identified. The mean age was 37 years, with a female predominance (69%). The maxillary sinus was most frequently involved site (46%). Eighty-five percent underwent open surgical resection. After a mean follow-up time of 47.3 months, three patients (23%) developed recurrent disease; all of whom were treated with an open approach. CONCLUSION: OF of the maxilla and sinonasal tract is an uncommon clinicopathologic entity. Although a timely diagnosis may obviate the need for external approaches, open surgical resection is often still necessary for management of extensive lesions. Close follow-up and additional surgery may also be required to treat recurrent disease.

Complication Rates in Delayed Reconstruction of the Head and Neck After Mohs Micrographic Surgery.

IMPORTANCE: Same-day Mohs reconstructive surgery is not always possible owing to patient factors, scheduling, and complexity of defect, but there is hesitancy in delaying closure of such defects. OBJECTIVE: To describe the frequency of and predictors of complications in patients undergoing delayed facial reconstruction after Mohs micrographic surgery (MMS). DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective, multi-institutional cohort study from February 1, 1989, to December 31, 2012. Data were pooled from 2 institutions: University of Washington Medical Center and Virginia Mason Medical Center. All patients who underwent MMS for facial carcinomas with delayed (non-same-day) reconstruction were included. We excluded those with incomplete medical records and no follow-up. The analysis was performed from June 2014 to March 2016. MAIN OUTCOMES AND MEASURES: Our main outcome measure was postoperative complication, classified as immediate (≤24 hours after surgery) or delayed (>24 hours after surgery). RESULTS: A total of 415 cases in 342 patients were identified. Reconstruction occurred from 1 to 11 days after excision, with 95.4% of repairs occurring within 2 days of MMS. The overall complication rate was 8.2%. The total delayed complication rate was 7.7% (32 of 415 cases). The overall infection rate was 2.4%. In terms of patient characteristics, reconstruction delayed more than 2 days, bone or cartilage exposure, and large defects were associated with complications. In terms of defect location and reconstruction type, complications were associated with composite defects (those that included >1 facial subunit) and use of interpolated flaps with cartilage grafting. We used these variables in a multivariable logistic regression model and found that composite location, use of interpolated flap with cartilage grafting, and reconstruction delayed more than 2 days were associated with postoperative complications. Among the variables in the model, composite location of defects, interpolated flap with cartilage grafting, and delayed reconstruction greater than 2 days were found to have a statistically significant association with a complication (OR, 3.48 [95% CI, 1.16-10.56]; OR, 4.93 [95% CI, 1.44-16.95]; OR, 4.26 [95% CI, 1.24-14.60], respectively). CONCLUSIONS AND RELEVANCE: To our knowledge, this is the largest study to report complication rates in delayed reconstruction of MMS defects in the head and neck, noting a rate that is similar to what has been reported in the literature. We noted a statistically significant increased risk of complications when reconstruction is performed for composite defects, if an interpolated flap with cartilage is performed, and if reconstruction is performed after more than 2 days. LEVEL OF EVIDENCE: 3.

The significance of response shift in sinus surgery outcomes.

BACKGROUND: Functional endoscopic sinus surgery (FESS) aims to improve quality-of-life (QOL). Perception of QOL can change according to one's current medical or emotional state. This is known as response shift. It can be measured by the "then-test," which asks patients to report pretreatment symptoms after receiving treatment. Patients often do not understand their disease burden until their symptoms are improved. This study aims to assess the significance of response shift in FESS outcomes. METHODS: This was a prospective cohort study that included chronic rhinosinusitis patients from 2010 to 2012 who completed a preoperative 20-item Sino-Nasal Outcome Test (SNOT-20). Two SNOT-20 forms were mailed approximately 6 months after surgery. Patients completed 1 SNOT-20 according to their preoperative symptoms in light of their current state of health ("then-test") and the other based on postoperative symptoms. The preoperative and postoperative SNOT-20 difference represented the treatment effect and the preoperative SNOT-20 and then-test difference represented the response shift. RESULTS: Thirty-two completed responses were obtained. Using a 0 to 5 scale, mean treatment effect was -0.96 (p < 0.01), which signifies a QOL improvement. Mean response shift was +0.42 (p = 0.01). This positive value signifies that patients felt they were worse off preoperatively, likely due to a positive change in health status. The actual treatment effect is the sum of the measured treatment effect and response shift, which was -1.38. CONCLUSION: Response shift exists and can be quantified. The actual treatment effect was more profound when response shift was included. Therefore, future studies should account for this often unmeasured, potential change in QOL.

Comparison of two nasal cell collection methods in determining cyclic adenosine monophosphate levels and its association with olfaction: A feasibility study.

Cyclic adenosine monophosphate (cAMP) is a second messenger that may be associated with olfactory function. No known studies have compared existing collection methods for determining nasal cAMP levels. This is a prospective study comparing the comfort and reliability of the nasal curette and cytobrush. A secondary outcome collected for feasibility testing was characterizing the association between cAMP and olfactory function. We enrolled 19 normal olfaction and 10 olfactory dysfunction subjects. Olfaction was measured by the University of Pennsylvania Smell Identification Test. Two samples were obtained from each nasal cavity at the initial visit and at 1 week follow-up. Comfort was measured by a visual analog scale (VAS). cAMP levels were determined by an enzyme immunoassay. For the curette and cytobrush, mean VAS scores were 0.3 and 0.7 cm (p = 0.48). Intraclass correlation coefficients were 0.81 (curette) and 0.65 (cytobrush) for the initial visit and 0.64 and 0.54 between the initial and follow-up visit. Using the curette, mean cAMP was 537 and 480 fmol/(mg/mL) for the normal and dysfunction cohorts (p = 0.18). Using the cytobrush, cAMP was 505 and 477, respectively (p = 0.65). The curette and cytobrush are both comfortable and reliable collection methods for determining nasal cAMP levels.

Nasal saline irrigation has no effect on normal olfaction: a prospective randomized trial.

BACKGROUND: Nasal saline irrigation is a safe treatment for chronic rhinosinusitis; however, its effect on olfaction is unclear. Cyclic adenosine monophosphate (cAMP) is a key second messenger in the mechanism of olfaction and has been shown to be associated with smell function. In animal studies, olfactory cilia may be harvested by simple saline preparations. This study aimed to characterize the effect of nasal saline irrigation on smell function. METHODS: Volunteers with normal olfaction were randomized into a control or irrigation cohort. In the initial appointment, subjects completed a University of Pennsylvania Smell Identification Test (UPSIT) and nasal samples were obtained by 2 methods: the nasal curette and cytobrush. The irrigation cohort performed daily nasal saline irrigations. Both cohorts then returned in 1 week. The UPSIT and nasal cell collection were repeated, and each subject completed a subjective olfactory transition scale. Nasal samples were processed for cAMP levels using a commercial assay. RESULTS: Thirty-two subjects were enrolled and randomized into each cohort. Control and postirrigation mean UPSIT scores were 36.8 and 36.7 (p = 0.48). No subjects reported a subjective smell loss. Ten pairs of nasal samples were assayed. Using the curette, control and postirrigation cAMP levels were 509 and 490 fmol/(mg/mL), respectively (p = 0.94). Using the cytobrush, respective cAMP levels were 424 and 449 fmol/(mg/mL), respectively (p = 0.94). CONCLUSION: Nasal saline irrigation has no subjective or objective effect on olfaction. It also does not appear to affect cAMP levels, a potential marker of smell function.

Computer-guided orbital reconstruction to improve outcomes.

OBJECTIVES: (1) To describe repair of complex orbital fractures using computer planning with preoperative virtual reconstruction, mirror image overlay, endoscopy, and surgical navigation. (2) To test the hypothesis that this technique improves outcomes in complex orbital fractures. METHODS: A series of 113 consecutive severe orbital fracture cases was analyzed, 56 of which were performed with mirror image overlay guidance, and 57 of which were repaired without. Data were collected on patient characteristics, fracture severity, diplopia and globe position outcomes, complications, and need for revision surgery. RESULTS: The mirror image overlay group showed decreased postoperative diplopia in all fracture types (P = .003); the effectiveness was maximal for fractures that involved 3 or 4 walls or the posterior one-third of the orbital floor (P < .001). The need for revision surgery was greatly reduced in this cohort (4% vs 20%; P = .03). CONCLUSIONS: The efficacy of mirror image overlay navigation and orbital endoscopy was studied in one of the largest series of complex orbital fractures in the literature. Based on statistically significant improved outcomes in postoperative diplopia and orbital volume, as well as the decreased need for revision surgery, we accept the hypothesis that mirror image overlay guidance improves outcomes in complex orbital reconstruction and recommend its use for complex orbital fracture repair.

Evaluation of real-time infrared intraoperative cholangiography in a porcine model.

BACKGROUND: Intraoperative cholangiograms (IOCs) may increase cost, surgical time, and radiation exposure of staff and patients. The authors introduce the application of passive infrared imaging to intraoperative cholangiography as a feasible alternative to traditional fluoroscopic IOCs. METHODS: A porcine model was used in which the gallbladder, cystic duct, common bile duct (CBD), and duodenum were exposed and an 18-gauge angiocatheter was inserted into the cystic duct. Infrared emission was detected using a digital infrared camera positioned 30 to 60 cm above the abdomen. Infrared images were taken in real time (approximately 1/s) during infusion of room-temperature saline. A thermoplastic polymer stone then was inserted into the CBD. Once the artificial stone was placed, room-temperature saline was again injected. A standard single-shot renograffin IOC was obtained to confirm the obstruction. The experiment was concluded by creation of a lateral 2-mm CBD injury immediately proximal to the duodenum followed by infusion of room-temperature saline. RESULTS: Six pigs were used in this study. Baseline infrared imaging was able to capture a visible temperature decrease, outlining the lumen of the CBD. With injection of room-temperature saline, a decrease in temperature was visualized as a dark area representing flow from the CBD to the duodenum. After placement of the synthetic stone, real-time infrared images displayed slowing of the injected bolus by the obstruction. The obstruction was correlated with fluoroscopic IOCs. Finally, after partial transection of the CBD, the infrared camera visualized saline flowing from the site of injury out into the peritoneal cavity. CONCLUSIONS: The CBD anatomy, obstruction, and injury can be clearly visualized with an infrared camera. Intraoperative infrared imaging is an emerging method already being used in several surgical fields. Ultimately, the integration of infrared and laparoscopic technology will be necessary to make infrared technology important in laparoscopic cholecystectomy.

Salvage partial nephrectomy for hereditary renal cancer: feasibility and outcomes.

PURPOSE: Patients with von Hippel-Lindau disease may require repeat partial nephrectomies to avoid the need for renal replacement therapy. We evaluated outcomes in patients who underwent third or fourth partial nephrectomies on the same kidney, which we call salvage partial nephrectomy. MATERIALS AND METHODS: We retrospectively reviewed the charts of patients who underwent surgery at the National Cancer Institute from 1999 to 2006. We identified 11 of 13 patients in whom salvage partial nephrectomy was performed. Surgical outcomes were assessed by renal preservation as well as intraoperative and postoperative complications. Functional outcomes were assessed by comparing serum creatinine, 24-hour urine creatinine clearance, and nuclear renal scan before and after salvage partial nephrectomy. RESULTS: All patients were alive and had no radiographic evidence of metastatic disease at a median followup of 25 months (range 3 to 83). Major perioperative complications occurred in 6 of 13 patients (46%) and loss of a renal unit occurred in 3 (23%). None of the patients in whom renal units were preserved required dialysis, although there was an upward trend in serum creatinine and a downward trend in creatinine clearance at postoperative followup (p = 0.07 and 0.08, respectively). CONCLUSIONS: Although salvage partial nephrectomy is technically demanding and it has a high complication rate, it allows many patients to avoid dialysis. We believe that this experience can be used as a reference for surgeons and patients when considering the risks and benefits of salvage partial nephrectomy.