Node counts in neck dissection: are they useful in outcomes research?

OBJECTIVES: We studied the unilateral nodal yields for procedures reported as standard or modified radical neck dissection (RND) to determine their applicability in outcomes research. METHODS: We analyzed the unilateral nodal yields for all procedures reported as RND for carcinoma of the oral cavity, pharynx, and larynx at our institution from 1985 to 1997 (n = 64, no prior treatment). These included both standard and modified techniques, encompassing levels I through V of the neck. Each side of a bilateral RND was treated as a separate case. This sample was compared with a similar population from the National Cancer Institute's Surveillance, Epidemiology, and End-Results (SEER) registry. Nodal yield was obtained for RND alone and for unspecified neck dissection with primary excision for the same diseases and time period (n = 1499). RESULTS: The mean nodal yield from 64 RND was 30 vs 27 in the SEER data. The standard deviation was 14.7 compared with 17.2 in the SEER data. Values ranged from 7 to 66 nodes whereas the SEER range was from 1 to 97 nodes. Although the SEER data contain nodal yields from regional or selective neck dissection, we corroborate our findings of large variance in nodal yield from our RND sample. CONCLUSIONS: Large variance in nodal yields from RND may have undefined effects on quality of life, cure rate, and survival. Until correlation of nodal yields with outcomes is examined, we cannot know how to relate RND to outcomes.

Xanthoma of the temporal bone: a unique case of this rare condition.

Xanthoma of the temporal bone is extremely rare; we describe only the fourteenth reported case. Our case is further remarkable because it is the first report of such an occurrence in a patient with familial type III hyperlipoproteinemia. Moreover, while otalgia, infection, hearing loss, and tinnitus were the most common initial symptoms in the previous 13 cases, our patient reported only diplopia, vertigo, and unstable gait. The patient underwent a simple mastoidectomy and debulking, and his diplopia, vertigo, and unstable gait resolved.

Intraosseous ganglion of the temporomandibular joint presenting with otorrhea.

A ganglion cyst of the temporomandibular joint is a rare entity that commonly presents as a minimally tender, preauricular mass. This benign cystic lesion, which is lined by synovium and can be found in association with other joints, occasionally erodes adjacent bone to form an intraosseous ganglion. We discuss an unusual case of an intraosseous temporomandibular ganglion cyst that presented with bloody otorrhea. Examination revealed an external auditory canal mass with radiographic evidence of temporal bone erosion. The cyst was excised using a combined approach to the glenoid fossa and mastoid. The management principals of this case and a pertinent review of the literature are included.

Endoscopic repair of cerebrospinal fluid rhinorrhea.

Endoscopic repair of cerebrospinal fluid rhinorrhea is a promising alternative to traditional repair techniques. This article reports our experience with 21 cases (10 spontaneous, 8 iatrogenic, and 3 traumatic). Various diagnostic radiographic modalities were used, including computer-aided techniques. Most repairs were accomplished with a free fascial graft positioned in the epidural space. Postoperative lumbar drainage was used in 15 cases. Initial repair was successful in 18 cases (85.7%). In all 3 failures, the surgeon had difficulty with proper graft placement. Additionally, 2 of these cases were confounded by early inadvertent removal of the lumbar drain. All patients in whom the procedure failed underwent a second successful endoscopic repair. There were no major complications. In our experience endoscopic repair of cerebrospinal fluid rhinorrhea is a safe and effective approach that can be improved with computer-aided localization devices. Proper graft placement is critical, and lumbar drainage is an important adjunct in selected cases.

Olfactory neuron-specific expression of NeuroD in mouse and human nasal mucosa.

Human olfactory neuroepithelium (OE) is situated within the olfactory cleft of the nasal cavity and has the characteristic property of continually regenerating neurons during the lifetime of the individual. This regenerative ability of OE provides a unique model for neuronal differentiation, but little is known about the structure and biology of human olfactory mucosa. Thus, to better understand neurogenesis in human OE, we studied the expression of olfactory marker protein (OMP), TrkB and NeuroD in human nasal biopsies and autopsy specimens and compared these data with those obtained from normal and regenerating mouse OE. We show that NeuroD and TrkB are coordinately expressed in human OE. Thus, by using these markers we have been able to extend the known boundaries of the human OE to include the inferior middle turbinate. In normal mouse OE, TrkB and OMP expression overlap in cells closest to the superficial layer, but TrkB is expressed more strongly in the lower region of this layer. In contrast, NeuroD expression is more basally restricted in a region just above the globose basal cells. These characteristic expression patterns of OMP, TrkB and NeuroD were also observed in the regenerating mouse OE induced by axotomy. These results support a role of NeuroD and brain-derived neurotrophic actor (BDNF), the preferred ligand for TrkB, in the maintenance of the olfactory neuroepithelium in humans and mice.

Efficacy of laser-assisted uvulopalatoplasty in obstructive sleep apnea.

Laser-assisted uvulopalatoplasty (LAUP) enlarges the oropharyngeal airway by reshaping the uvula, soft palate, and tonsillar pillars. In contrast to a uvulopalatopharyngoplasty performed in the operating room, LAUP is staged over several office visits, is less costly, is bloodless, and is not associated with velopharyngeal insufficiency or stenosis. Previous studies have documented the efficacy of LAUP in the treatment of snoring. We explore the efficacy of LAUP in the treatment of obstructive sleep apnea. Forty-eight patients comprised the study group. Each patient snored, exhibited >50% palatal collapse on Müller's maneuver, and had nocturnal polysomnography showing a respiratory disturbance index (RDI) >10. Each patient underwent LAUP until he or she reported that snoring had ceased. Of the 29 patients who underwent post-LAUP nocturnal polysomnography, 7 had RDIs <10, oxygen saturation >86%, and no cardiac arrhythmias. LAUP reduced RDI to <10 in patients with pre-LAUP apnea indexes <3 (P = 0.05) or pre-LAUP RDIs <30 (P = 0.01). The following variables did not correlate with the success of LAUP in treating obstructive sleep apnea: age, sex, pre-LAUP weight, pre-LAUP body mass index, perioperative weight change, perioperative body mass index change, pre-LAUP snoring, and post-LAUP snoring. We conclude that LAUP is an effective means of treating patients with RDIs <30.

The RET/PTC3 oncogene: metastatic solid-type papillary carcinomas in murine thyroids.

Our research goal is to better understand the mechanisms controlling the initiation and progression of thyroid diseases. One such disease, papillary thyroid carcinoma (PTC), is the leading endocrine malignancy in the United States. Recently, a family of related fusion proteins, RET/PTC1-5, has been implicated in the early stages of PTC. Although all five members of this family have the c-RET proto-oncogene kinase domain in their COOH terminus, little is known about how these genes alter follicular cell biology. Consequently, to answer questions related to the mechanism of the RET/PTC fusion protein action, we have devised a molecular genetic strategy to study PTC using a mouse model of thyroid disease. A new member of this fusion oncogene family, RET/PTC3, which has been implicated in more cases of solid tumor carcinoma (79%) than PTC1 or PTC2 and predominates (80%) in radiation-induced thyroid cancer of children, was investigated in our study. We have generated transgenic mice expressing human RET/PTC3 exclusively in the thyroid. These mice develop thyroid hyperplasia, solid tumor variants of papillary carcinoma and metastatic cancer. This new transgenic line will be useful in deciphering the molecular and biological mechanisms that cause PTC and histological variations in humans.

Revision endoscopic sinus surgery: the Thomas Jefferson University experience.

Since its introduction, functional endoscopic sinus surgery (FESS) has demonstrated success rates of 76% to 98%. A small group of the patients in whom initial FESS and optimal medical therapy fail require revision endoscopic sinus surgery (RESS). This group has recently been studied by several authors, and we have evaluated a group of 90 RESS patients selected from 753 consecutive primary FESS patients. Patients were followed for a mean of 22.8 months. Extent of disease, history of polyps, allergy, previous traditional endonasal sinus surgery, male gender, chronic steroid use, and the presence of a deviated septum all appeared to adversely affect RESS outcome. The surgeon's knowledge of the sinus anatomy is critical, especially in revision sinus cases in which landmarks are distorted or absent. In our review, RESS was associated with a 1% major complication rate and was successful in 67% of patients. Computer-assisted endoscopic sinus surgery integrates preoperative imaging with realtime endoscopic visualization, augments the surgeon's knowledge of anatomy, and helps to minimize patient risk.

Patient selection in the treatment of glabellar wrinkles with botulinum toxin type A injection.

OBJECTIVES: To determine the dose-response characteristics and side-effects profile of Clostridium botulinum type A exotoxin (Botox) used to treat glabellar wrinkles and develop guidelines for patient selection based on the nature and severity of the treated wrinkles. DESIGN: Prospective, nonrandomized pilot and electromyogram (EMG)-guided studies. SETTING: Two ambulatory care clinics at university hospitals. PARTICIPANTS: For the pilot study, volunteer samples of 23 patients with glabellar wrinkles; for the EMG-guided study, volunteer samples of 57 patients with glabellar wrinkles. INTERVENTIONS: For the pilot study, 23 patients were serially injected with up to 10.0 mouse units (MU) of Botox into each corrugator muscle; for the EMG-guided study, 57 patients were injected under EMG guidance with an initial dose of 10.0 MU of Botox into each corrugator muscle. Eleven patients with persistent corrugator activity were reinjected with 10.0 MU of Botox. MAIN OUTCOME MEASURES: For the pilot study, slide photographs were obtained before and 2 weeks after injection; for the EMG-guided study, slide photographs were obtained before and at 2 weeks and at 2 months after injection. Patients were asked to evaluate results numerically. RESULTS: For the pilot study, injection of up to 10.0 MU of Botox into each corrugator muscle produced a satisfactory improvement in 12 patients; for the EMG-guided study, 43 patients were satisfied with improvement after full abolition of corrugator or accessory lateral brow muscle activity. Women were more likely to achieve satisfactory results than were men (80% [40/50] vs 43% [3/7]; P < or = .03). Improvement was not age related. No significant side effects or complications were observed. CONCLUSIONS: Glabellar wrinkles may be satisfactorily treated with Botox injection into the corrugator supercilii muscles. Improvement is temporary, dose dependent, and may not be seen in some patients even with successful denervation of the treated muscles. Clinicians may begin treatment with a dose of 10.0 MU of Botox into each corrugator muscle, and may select candidates for injection by determining the type of wrinkle to be treated and its spreadability (glabellar spread test).

Expression of the RET/PTC fusion gene as a marker for papillary carcinoma in Hashimoto's thyroiditis.

Hashimoto's thyroiditis is an inflammatory disease of the thyroid gland with autoimmune etiology. Patients afflicted with Hashimoto's have a higher risk of thyroid malignancies such as papillary thyroid carcinoma. In the present study, we investigated the frequency of papillary thyroid carcinoma specific genes in patients diagnosed with Hashimoto's disease. The newly identified oncogenes RET/PTC1 and RET/PTC3 provide useful and specific markers of the early stages of papillary carcinoma as they are highly specific for malignant cells. Using a sensitive and specific reverse transcriptase-polymerase chain reaction (RT-PCR) assay, we found messenger RNA (mRNA) expression for the RET/PTC1 and RET/PTC3 oncogenes in 95% of the Hashimoto's patients studied. All Hashimoto's patients presenting without histopathologic evidence of papillary thyroid cancer showed molecular genetic evidence of cancer. These data suggest that multiple, independent occult tumors exist in these patients at high frequency.

Keloid excision and recurrence prophylaxis via intradermal interferon-gamma injections: a pilot study.

Keloids are an abnormal response to wound healing distinguished by an overproduction of collagen. Thickened bundles of collagen in the reticular dermis oriented haphazardly in relation to the overlying epithelium are found in keloids, in contrast to thinner collagen fibers in a more orderly arrangement that are found in normal scars. Previous clinical trials of intralesional interferon-gamma (IFN-G) injections by Larrabee et al. and Granstein et al. showed a decrease in lesion size. These findings led to a conclusion that IFN-G would be a useful adjunct to surgical excision of keloids to aid in preventing recurrence. We performed a double-blind, placebo-controlled trial in patients with two or more keloids treated with excision and subsequent local injections of IFN-G or placebo.

Induction of differentiation of human olfactory neuroblastoma cells into odorant-responsive cells.

Olfactory neuroblastoma is a rare malignancy of the olfactory mucosa that may be derived from the olfactory epithelium. To characterize this tumor, we cultured olfactory neuroblastoma cells in the presence or absence of growth factors (transforming growth factor alpha and basic fibroblast growth factor) known to affect olfactory tissue and assessed their responsiveness to known odorants by measuring changes in intracellular calcium. Untreated cells did not respond to odorants. Basic fibroblast growth factor treatment had cytotoxic effects, and treated cells did not respond to odorants. Transforming growth factor alpha treatment resulted in the induction of odor responsiveness in these cells. Cells responded to odorants at 100 nM to 100 microM concentrations and responded with both increases and decreases in intracellular calcium. Increases in intracellular calcium were mediated by a calcium influx and were reversibly blocked by compounds known to inhibit second messenger pathways in olfactory receptor neurons. The calcium responses of the olfactory neuroblastoma cells were thus specific to the odorants and similar to those found in olfactory receptor neurons. The results support the notion that olfactory neuroblastoma cells may be of olfactory origin and thus they can be used as a model cell line to study human olfaction.

Expression of the human Achaete-scute 1 gene in olfactory neuroblastoma (esthesioneuroblastoma).

Olfactory neuroblastoma (ONB) is a rare neuronal malignancy of the olfactory mucosal. Markers used in the diagnosis of ONB do not distinguish ONB from other neuronal tumors or tumors with neuroendocrine features thus making the diagnosis of ONB difficult. Using a modified RT-PCR technique, we show that the human homologue of the Drosophila achaete-scute gene HASH1 is expressed in 6 primary and one metastatic ONB specimens, whereas Olfactory Marker Protein (OMP) is not. Previous studies have shown that HASH1 is expressed in immature olfactory neurons and is required for their development. OMP, whose function is unknown, is expressed exclusively in mature olfactory neurons. Together, these data suggest that ONB is derived from immature olfactory neurons of neuroectodermal origin. Analysis of RNA expression in primary tumor specimens and in an established cell line make this an ideal system to study olfactory growth and differentiation. Furthermore, these studies represent the first molecular genetic analysis of this rare and unusual neuronal tumor.

Laryngeal pacing as a treatment for vocal fold paralysis.

We summarize etiologies of vocal fold paralysis and current treatments. The recent literature involving electrical stimulation of the larynx is reviewed. Four canines were involved in a study to test a new laryngeal pacemaker system. This system was used to stimulate both the lateral cricoarytenoid and thyroarytenoid muscles. The data are taken from two of these canines. One of the goals was to stimulate the paralyzed side of the larynx based on the activity of the normal (nonparalyzed) side of the larynx. The best stimulation parameters for full addition of the paralyzed vocal cord were 3-7 V, pulse duration of 0.5 ms at a frequency of 84-100 Hz. Principles for electrode design and electrophysiologic parameters pertaining to laryngeal pacing are discussed. We believe that unilateral vocal fold paralysis may someday be treated by stimulating the paralyzed lateral cricoarytenoid and thyroarytenoid muscles to move in synchrony with the normal, unparalyzed, lateral cricoarytenoid and thyroarytenoid muscles.

Endoscopic management of a giant cholesterol cyst of the petrous apex.

Giant cholesterol cyst (GCC) of the petrous apex is a rare clinical entity. This benign cystic lesion can cause neurologic deficits and vascular compromise by persistent growth and progressive bone destruction. Magnetic resonance imaging studies of GCC show the lesions to be hyperintense on T(1)-weighted sequences with progressively lower signal intensities on the first and second echoes of T(2)-weighted sequences. These findings are relatively specific for GCC, permitting a narrow differential diagnosis. The goal of surgery is to provide adequate drainage with the creation of a permanent fistula. The classic approaches to these lesions are the posterior fossa craniotomy and the middle fossa extradural craniotomy. The translabyrinthine approach provides wide exposure at the expense of cochlear and vestibular function. The transsphenoidal approach provides adequate drainage with hearing preservation and no craniotomy. The endoscopic, endonasal transsphenoidal approach to a 2.5 cm GCC of the petrous apex accomplished complete drainage with the creation of a fistula. Advances in endoscopic technique and instrumentation facilitated the addition of the approach to the surgeon's armamentarium. In selected cases, this approach provides adequate surgical exposure with minimal morbidity.