Optimal Management of Proliferative Verrucous Leukoplakia: A Systematic Review of the Literature.

OBJECTIVE: Proliferative verrucous leukoplakia (PVL) is a rare and recalcitrant form of leukoplakia. The purpose of this review is to further characterize the risk factors, clinical course, and optimal treatment for this highly aggressive, premalignant lesion. DATA SOURCES: Twenty-six articles on PVL with a total of 329 PVL cases. REVIEW METHODS: A systematic review of the literature using Ovid, PubMed, Cochrane Database, and gray literature was conducted of all PVL cases reported between 1985 and 2014. Inclusion criteria required reporting of patient follow-up and recurrence rates. Data were analyzed using descriptive statistics. Student t test and Fisher exact test were used to identify factors associated with malignant transformation. RESULTS: The mean patient age was 63.9 years. Most patients were female (66.9%) and nontobacco users (65.22%). Mean follow-up was 7.4 years, with an average of 9.0 biopsies per patient during this period. Proliferative verrucous leukoplakia exhibited histopathologic features along a progressive spectrum, evolving from leukoplakia to verrucous hyperplasia and ultimately invasive carcinoma. Surgery was the most common treatment implemented, but recurrence rates among 222 patients reached 71.2%. Subgroup analysis of 277 patients identified a 63.9% malignant transformation rate, and 39.6% of patients died of their disease. Age, sex, and tobacco use were not identified as risk factors associated with progression to cancer. CONCLUSIONS: Proliferative verrucous leukoplakia is a rare form of leukoplakia with a high rate of malignant transformation. It necessitates high clinical suspicion, to include a lifetime of close follow-up and repeat biopsies by a health care provider well versed in oral carcinoma.

Surfactant improves irrigant penetration into unoperated sinuses.

BACKGROUND: Saline irrigations are proving to be a valuable intervention in the treatment of chronic sinusitis. The use of surfactants is a well established additive to topical treatments known to reduce surface tension and may prove to be a simple, nonoperative intervention to improve intrasinus douching penetration. METHODS: Six 30-mL, flat-bottomed medicine cups with circular holes cut through the bottom center and varying in diameter from 1 to 6 mm were created with punch biopsies. Water, saline, saline/dye, and saline/dye/surfactant were compared for maximum holding pressure via these modeled ostia. Holding pressures also were determined for cups with septal mucosa fused to the bottom with holes ranging from 1 to 6 mm. In addition, analysis was carried out with blood and blood/surfactant. Finally, five thawed, fresh-frozen cadaver heads were evaluated before any sinus surgery with water/dye and water/dye/surfactant for intrasinus penetration. RESULTS: Surfactant significantly improved the ability of all solutions to penetrate ostia in both the plastic cup and fused septal mucosa model. All nonsurfactant-containing solutions were not statistically different from one another, nor did surfactant change the ostial penetration of blood. Surfactant significantly improved the ability of sinus irrigant to penetrate unoperated sinus cavities (3.12 vs 3.5, p = .021). CONCLUSIONS: The addition of surfactant to saline irrigation improves ostial penetration in undissected and undiseased cadavers. This has practical implications for unoperated patients seeking care for sinus-related symptoms in that we have now described a method for improving topical treatment of target sinus mucosa prior to surgical intervention.

Unexpected consequences of transnasal balloon dilation of the maxillary ostium.

BACKGROUND: Nasal irrigations and topical sprays have been demonstrated to have benefit in chronic sinusitis. Increasingly, it is evident that delivery system, patient anatomy, and inflammatory process have significant impacts on irrigant distribution. METHODS: Intrasinus endoscopy was performed during sinus irrigation of 5 thawed fresh frozen cadavers (10 sides) before and after transnasal dilation of the maxillary, frontal, and sphenoid ostia with a 5-mm balloon. RESULTS: Guidewire insertion created false passages through maxillary fontanelle on all of 10 attempts; 1 of 10 frontal insertions entered the ostia in a submucosal plane, while all 10 sphenoid attempts were successful without complication (p < 0.0001). Average minimum ostial dimension increased from 1.73 mm to 3.6 mm (p < 0.0001) after dilation. Obtaining an ostial size of 5 mm was associated with significantly improved irrigation penetration relative to a minimum dimension of 4 mm or less (p = 0.019). After balloon dilation of the true ostia, irrigation of the sphenoid increased, irrigations into the frontal sinuses were unchanged, and irrigation into the maxillary sinuses decreased. CONCLUSION: Guidewire insertion in this study was noted to frequently create a false passage during maxillary sinus ostial dilation. After balloon dilation, irrigant penetration was increased into the sphenoid sinus for heavy and mist irrigators whereas the maxillary sinus had diminished irrigant penetration for heavy and NetiPot irrigators.

Irrigation penetration of nasal delivery systems: a cadaver study.

BACKGROUND: To determine the sinus penetration potential of several commercially available irrigation systems in maximally operated sinus cavities; cadaveric study in a tertiary care center. METHODS: Seven fresh cadaver heads with brains removed were maximally dissected to include a Draf III frontal sinusotomy, wide maxillary antrostomy, and complete sphenoethmoidectomy. Drill-holes (4 mm) were created to allow visualization of the irrigations from within the respective sinus cavity. Seven commercially available irrigation systems were then tested according to manufacturer recommendation, and the data recorded using an ordinal scale for comparison. RESULTS: Among the 3 atomized particle delivery systems tested, the squeeze atomizer took 1.15 attempts, the pump atomizer took 1.85 attempts, and the mechanized atomizer required 30 seconds of continuous application for intrasinus delivery of aerosol (p = 0.009). Penetration with 4 heavy irrigators showed significant variability depending on the sinus cavity being tested. The NeilMed irrigator showed more consistent penetration than any other tested device (p < 0.01). The other systems tested had varying degrees of efficacy, dependent on sinus cavity irrigated. CONCLUSION: Delivery of irrigant to maximally operated sinus cavities is variable and highly dependent on the method of nasal delivery. Use of these systems should be tailored appropriately for the desired effect.