Vagococcus: An under-recognized and emerging cause of antibiotic-resistant infection.

Vagococcus, a bacterium generally isolated from fish and domestic animals, is a rarely reported human pathogen whose clinical characteristics and antimicrobial susceptibility remain uncertain. In this case report we describe a 19-year-old active-duty military sailor who suffered a blast injury to the left foot from a firework explosion. The injury was complicated by a polymicrobial wound infection that included Vagococcus fluvialis. Vagococcus spp. infections in humans are often associated with skin and soft tissue infection, including those resulting from trauma or blast injuries. This case serves to highlight this pathogen's role in causing invasive infections and as well as the importance of recognizing its clinical characteristics and antibiotic resistance profiles.

Refractory Osteomyelitis in a Military Service Member Resolved With Adjunctive Hyperbaric Oxygen Therapy.

Refractory osteomyelitis is typically defined as a chronic infection that persists or recurs despite definitive surgical management and antibiotic therapy. Cases often involve complex wounds or fractures and can be challenging to treat, resulting in multiple courses of broad-spectrum antibiotic therapy and numerous surgeries over periods of months to years. Adjuncts to improve resolution of these complicated infections are sorely needed. Here, we describe the case of a 47-year-old active duty military member who sustained an open right ankle fracture during a skydiving accident that was subsequently complicated by refractory osteomyelitis. The patient failed more than three courses of combined medical and surgical management over a 9-month period before undergoing adjunctive hyperbaric oxygen therapy (HBOT), ultimately resulting in resolution of the infection. Adjunctive HBOT for treatment of conditions such as refractory osteomyelitis may be an underutilized resource in part because of a general paucity of high-quality data in the literature supporting its use, as well as a relative lack of availability of this resource. Nonetheless, the overall accumulating body of evidence indicates that the use of adjunctive HBOT in select patients with refractory osteomyelitis is safe and effective and further research may be warranted given its relevance and potential impact to military populations.

Doxycycline Prophylaxis for Skin and Soft Tissue Infections in Naval Special Warfare Trainees, United States1.

In 2015, several severe cases of skin and soft tissue infection (SSTI) among US Naval Special Warfare trainees prompted the introduction of doxycycline prophylaxis during the highest-risk portion of training, Hell Week. We performed a retrospective analysis of the effect of this intervention on SSTI incidence and resulting hospital admissions during 2013-2020. In total, 3,371 trainees underwent Hell Week training during the study period; 284 SSTIs were diagnosed overall, 29 of which led to hospitalization. After doxycycline prophylaxis was introduced, admission rates for SSTI decreased from 1.37 to 0.64 admissions/100 trainees (p = 0.036). Overall SSTI rates remained stable at 7.42 to 8.86 SSTIs/100 trainees (p = 0.185). Hospitalization rates per diagnosed SSTI decreased from 18.4% to 7.2% (p = 0.009). Average length of hospitalization decreased from 9.01 days to 4.33 days (p = 0.034). Doxycycline prophylaxis was associated with decreased frequency and severity of hospitalization for SSTIs among this population.

Utility of susceptibility weighted imaging (SWI) and pseudo-continuous arterial spin labeling (pCASL) in diagnosis of falcine venous thrombosis in a child with transient ischemic attack.

Pediatric stroke and transient ischemic attack (TIA) are uncommon but true emergencies with a wide differential diagnosis. Diagnostic imaging plays a critical role in differentiating the diverse range of etiologies. In this case, we report a 3-year-old female with no medical history who developed acute neurological deficits and demonstrate how adjunct advanced imaging including susceptibility weighted imaging (SWI) and pseudo-continuous arterial spin labeling (pCASL) can play a significant diagnostic role in the emergent setting. Imaging was performed with a Philips Ingenia 3.0T MRI. MRI brain, MR angiography (MRA), and phase contrast angiography MR Venography (PCA-MRV) were obtained. pCASL and SWI sequences were performed using SENSE (sensitivity encoding) parallel imaging techniques. MRI/MRA brain showed no restricted diffusion, abnormal T1/T2/FLAIR signal, arterial occlusion, or irregular angioarchitecture. SWI revealed increased susceptibility along the posterior falx cerebri and right posterior parietal and occipital lobes, and pCASL showed decreased blood flow within these same regions. No falcine sinus was visualized on PCA-MRV, but SWI and pCASL findings led to diagnosis of falcine sinus thrombosis and initiation of appropriate treatment. Repeat MRI one month later showed interval resolution of the abnormal SWI findings and a now patent persistent falcine sinus visualized on PCA-MRV imaging. Routine use of SWI imaging on all brain MRIs and addition of pCASL imaging when there is concern for ischemia or infarction in the emergent setting can limit the risk of missed occult diagnoses like a thrombosed falcine sinus.

Incidence and Impact of Swimming-Induced Pulmonary Edema on Navy SEAL Candidates.

BACKGROUND: Respiratory complications such as swimming-induced pulmonary edema (SIPE) are a common feature of United States Navy Special Warfare (NSW) training. RESEARCH QUESTION: This study was designed to evaluate the incidence and clinical features of SIPE seen in this population. STUDY DESIGN AND METHODS: A prospective, observational review of all NSW candidates over a 15-month period was designed. Baseline height, weight, and ECG data were obtained. Candidates with respiratory issues were evaluated with a two-view chest radiograph and ECG while symptomatic and were closely followed up. The chest radiograph and clinical data were then independently reviewed. RESULTS: A total of 2,117 NSW candidates participated in training during the study period, with 106 cases of SIPE identified (5.0%). Ten additional cases of SIPE were repeat episodes in candidates already diagnosed. Forty-four cases of pneumonia were identified (no repeat cases). The majority had cough (90.4%), frothy-pink sputum (35.6%), and hemoptysis (23.7%). Overall, 80.1% of candidates had an oxygen saturation ≥ 90%. Physical examination findings were variable: crackles (50%), wheezing (36%), and rhonchi (19%). Several had more than one feature; 23% presented with a normal examination. Radiologic findings in patients with SIPE most commonly revealed an interstitial pattern with perifissural thickening, larger average azygos vein diameter, larger average heart size, and normal lung height. ECG findings were not significantly different from baseline. Height and weight were not significantly different between the groups. Lower water temperatures were suggestive of increased SIPE incidence, but this was not a statistically significant trend. INTERPRETATION: The burden of SIPE in NSW training was greater than anticipated. Clinical symptoms and physical examination assisted by imaging were able to differentiate SIPE from pneumonia. ECG was not a useful diagnostic or screening tool, and height and weight did not affect risk of SIPE. TRIAL REGISTRY: Institutional Review Board registration at Naval Medical Center, San Diego, California; Registration No.: NMCSD.2017.0020.

Faculty Wellness: Educator Burnout among Otolaryngology Graduate Medical Educators.

Objectives Burnout is a well-described psychological construct with 3 aspects: exhaustion, depersonalization, and lack of personal accomplishment. The objective of this study was to assess whether faculty members of an otolaryngology residency program exhibit measurable signs and symptoms of burnout with respect to their roles as medical educators. Study Design Cross-sectional survey. Setting Otolaryngology-head and neck surgery residency program. Subjects and Methods Faculty members from an otolaryngology residency program, all of whom are involved in resident education, completed the Maslach Burnout Inventory-Educators Survey (MBI-ES). The surveys were completed anonymously and scored with the MBI-ES scoring key. Results Twenty-three faculty members completed the MBI-ES, and 16 (69.6%) showed symptoms of burnout, as evidenced by unfavorable scores on at least 1 of the 3 indices (emotional exhaustion, depersonalization, or low personal accomplishment). The faculty consistently reported moderate to high personal accomplishment and low depersonalization. There were variable responses in the emotional exhaustion subset, which is typically the first manifestation of the development of burnout. Conclusion To our knowledge, this is the first application of the MBI-ES to investigate burnout among otolaryngology faculty members as related to their role as medical educators. Discovering symptoms of burnout at an early stage affords a unique and valuable opportunity to intervene. Future investigation is underway into potential causes and solutions.

Neck recurrence and mortality in esthesioneuroblastoma: Implications for management of the N0 neck.

OBJECTIVES/HYPOTHESIS: To review the literature on neck recurrence in esthesioneuroblastoma. STUDY DESIGN: PubMed database. METHODS: A PubMed database search was performed using keywords "esthesioneuroblastoma," "olfactory neuroblastoma," and "esthesioneuroblastoma neck metastasis." Articles written in English with greater than 10 subjects that had data regarding the association of neck recurrence and mortality and/or the association of neck recurrence with Kadish stage were included for analysis. RESULTS: Thirteen studies met inclusion criteria with information regarding the association of neck recurrence and mortality, and 15 studies had data associating neck recurrence and Kadish stage. The neck recurrence rate was 14.1% in studies analyzing mortality. Among those patients who developed regional metastases, mortality was 60%. Of patients without regional recurrence, the mortality rate from disease was 26% (P < 0.0001) and overall mortality was 32% (P < 0.0001). The rate of neck recurrence within each Kadish stage was 0%, 11%, 21%, and 18% for Kadish stages A, B, C, and D, respectively. The trend toward an increased incidence of neck recurrence from stage A to stage D is statistically significant, with P value 0.003. CONCLUSION: The rate of neck recurrence in esthesioneuroblastoma is close to 15%. There is a strong association of recurrence with Kadish stage B and C. Mortality from disease in patients with recurrence in cervical lymph nodes is significant when compared to those who never develop neck disease. Prospective studies are needed to evaluate a potential role for elective neck dissection versus elective neck radiation for patients with esthesioneuroblastoma. LEVEL OF EVIDENCE: N/A. Laryngoscope, 126:1373-1379, 2016.

Short hospital stay following neck dissection.

OBJECTIVES: To review the clinical characteristics of patients who had a short hospital stay (<24 hours) following neck dissection, and to assess the incidence and type of complications in this patient group. DESIGN: Case series. SETTING: University-based academic medical center. PATIENTS: All patients who underwent neck dissection at our institution from July 2004 through June 2008 and were discharged within 24 hours postoperatively (short stay) were included. MAIN OUTCOME MEASURES: Patient demographics, cancer site and type, and details of the procedures performed were quantified. In addition, medical records were reviewed for complications requiring readmission within 30 days postoperatively. RESULTS: Review of a prospectively maintained surgical database identified 122 consecutive neck dissections performed at our institution from July 1, 2004, to June 30, 2008. Of these 122 procedures, 71 involved a subsequent postoperative stay of less than 24 hours. These 71 procedures were performed in 69 patients; they had a mean age of 59 years and a sex distribution that was 33% female and 67% male. Neck dissection alone was performed in 22 of the 71 short-stay cases (31%). The most commonly performed concurrent procedures included limited oral cavity or oropharyngeal resections (21 patients) and parotidectomy (13 patients). Modified radical neck dissection was performed in 22 of the 71 cases (31%); the remaining procedures were selective neck dissections. Cranial nerve XI, the internal jugular vein, and the sternocleidomastoid muscle were all preserved in 57 cases (80%). Of the 71 short-stay cases, only 2 (3%) required readmission for a surgical complication within 30 days of their procedure. CONCLUSIONS: In carefully selected patients, discharge within 24 hours following neck dissection seems to be safe and appropriate. Given the potential for substantial cost savings, short stay should be studied further in this patient population.

Prevalence, morphology, and prognosis of human papillomavirus in tonsillar cancer.

OBJECTIVES: We sought to identify the prevalence of human papillomavirus (HPV) in tonsillar squamous cell carcinoma, and to examine the relationship of HPV to prognosis and tumor morphology. METHODS: We performed in situ hybridization for HPV and retrospective clinical outcome analysis. RESULTS: Of the 48 patients with tonsillar carcinoma, in situ hybridization identified 35% as HPV-positive tumors. Age-matched controls had no evidence of HPV. There was no significant difference between HPV-positive and HPV-negative patients regarding age (p = 0.34), tobacco consumption (p = 0.59), alcohol consumption (p = 0.91), or treatment method (p = 0.39). Forty-four patients were eligible for outcome analysis. The overall rate of recurrence in this population was 25%, and the disease-specific survival rate was 84%. There was no significant difference between the two groups either in the incidence of recurrence (p = 0.14) or in the disease-specific survival rate (p = 0.19). HPV-associated tumors developed from the tonsillar crypts significantly more frequently than did HPV-negative tumors (p = 0.01). CONCLUSIONS: As previously described, HPV is significantly associated with squamous cell carcinoma of the tonsil; however, HPV status in our series did not correlate with clinical outcome. Morphologically, we found that HPV-positive tumors had their origin in the tonsillar crypts, whereas HPV-negative tumors arose from the surface epithelium.

Percutaneous transtracheal jet ventilation in head and neck surgery.

OBJECTIVE: To assess the safety and efficacy of percutaneous transtracheal jet ventilation (PTJV) in the management of the difficult airway. DESIGN: Retrospective case series. SETTING: Academic, tertiary care medical center. PATIENTS: Forty-three consecutive PTJV procedures performed on 33 patients with anticipated airway difficulty undergoing direct laryngoscopy for diagnosis and/or treatment of head and neck cancer (91%) or benign lesions. MAIN OUTCOME MEASURES: Duration of PTJV, oxygen saturation values by pulse oximetry, and incidence of tracheotomy and complications. RESULTS: The mean duration of PTJV was 43 minutes, and mean minimum oxygen saturation was 97%. Biopsy was performed in 27 (62%) of the cases, and a laser excision in 12 (28%). Seven tracheotomies were planned preoperatively, and 2 were performed intraoperatively. Two additional patients required tracheotomies in the immediate postoperative period. Two (5%) complications occurred: 1 pneumothorax that resolved with chest tube insertion and 1 kinked catheter resulting in soft tissue emphysema that resolved spontaneously. CONCLUSIONS: Percutaneous transtracheal jet ventilation is a safe and effective method of ventilation in patients with anticipated airway difficulty. It is particularly useful in patients who are not in immediate airway distress preoperatively but who may be difficult or impossible to intubate after induction of general anesthesia. Percutaneous transtracheal jet ventilation may help to avoid tracheotomy in this setting and should be routinely available as an option for airway management in patients with head and neck cancer.

Mohs micrographic surgery vs traditional surgical excision: a cost comparison analysis.

OBJECTIVE: To compare the cost and margin adequacy of Mohs micrographic surgery (Mohs) and traditional surgical excision (TSE) for the treatment of facial and auricular nonmelanoma skin cancer (NMSC). DESIGN: Prospective cost analysis with each patient serving as his or her own control. SETTING: Study was performed from 1999 to 2001 at the University of Connecticut dermatology clinic, a tertiary care referral center. PATIENTS: A total of 98 consecutive patients with a primary diagnosis of NMSC on the face and ears. MAIN OUTCOME MEASURES: The average cost of Mohs and TSE per patient for the treatment and repair of NMSC; adequacy of TSE margins after the initial procedure(because this outcome affects overall cost). RESULTS: Mohs was cost comparable to TSE when the subsequent procedure for inadequate TSE margins after permanent section was Mohs (937 vs 1029 US dollars; P =.16) or a subsequent TSE (937 vs 944 US dollars; P =.53). When facility-based frozen sections were requested for TSE, Mohs was significantly less costly (956 vs 1399 US dollars; P<.001). The cost difference between Mohs and TSE was sensitive to the type of repair chosen. CONCLUSIONS: If the end point is clear margins, Mohs is cost comparable to TSE performed by otolaryngologic surgeons. Some caution is needed when evaluating the cost of facial and auricular NMSC treatment because the choice of repair can significantly affect the cost conclusions.

Cancer of the parotid gland: role of 7th nerve preservation.

Most neoplasms arising in the parotid gland are benign. Patients with cancer of the parotid gland usually present with normal facial nerve function. In these patients, findings at the time of surgery will guide the management of the facial nerve, with most surgeons preserving the nerve unless it is adherent to, or imbedded in, a malignant tumor. In cases where the margins of resection are close to the facial nerve, adjuvant radiotherapy administered postoperatively has significantly improved local control of disease. The minority of patients with parotid cancer who present with facial nerve palsy has a poor prognosis despite extensive surgical resection including the facial nerve.

Expression of vascular endothelial growth factor receptors on tumor cells in head and neck squamous cell carcinoma.

BACKGROUND: Angiogenesis is essential for the growth of solid tumors, including head and neck squamous cell carcinoma (HNSCC). Angiogenesis is regulated by angiogenic factors such as vascular endothelial growth factor (VEGF) and VEGF receptors (VEGFRs) 1, 2, and 3 known to be located on vascular endothelial cells (VECs). We hypothesize that VEGFRs are also expressed on HNSCC tumor cells in vitro and in vivo and likely control tumor function in vivo. DESIGN: Immunohistochemical analysis for VEGFR-1 (n = 13), VEGFR-2 (n = 21), and VEGFR-3 (n = 16) was performed on human HNSCC tumor samples. Specimens were analyzed for receptor expression and staining intensity. A cultured oral SCC cell line (SCC-25) and a pharyngeal SCC cell line (FADU) were also studied for receptor expression. RESULTS: The HNSCC tumor cells expressed VEGFR-1, VEGFR-2, and VEGFR-3 in all specimens evaluated. Staining for all 3 receptors was also found on tumor-associated macrophages and fibroblasts, except that VEGFR-2 was not present on fibroblasts. Staining intensity for VEGFR-1 and VEGFR-2 was significantly higher in tumor cells and macrophages than in VECs stained for the same receptor. Both cultured HNSCC cell lines demonstrated expression of all 3 receptors. CONCLUSIONS: This represents the first report of all 3 VEGFRs being expressed by HNSCC cells. These findings indicate that VEGF may be an autocrine regulator of tumor cell activity in addition to its known angiogenic effects on VECs. The presence of VEGFRs on tumor-associated macrophages and fibroblasts contributes to the complexity of the VEGF/VEGFR system in human cancer.

Association of fibrin and interleukin 8 in human oral squamous cell carcinoma.

OBJECTIVE: We have recently demonstrated that fibrin induces a specific, dose- and time-dependent upregulation of the angiogenic factor interleukin 8 (IL-8) from human oral squamous cell carcinoma (OSCC) cells in vitro. In this study we begin to test the hypothesis that fibrin induces IL-8 expression from tumor cells in vivo by studying their in vivo association in OSCC. STUDY DESIGN: The presence of fibrin(ogen) was initially evaluated in 20 archival human OSCCs by means of immunohistochemistry with a polyclonal antibody. The presence of fibrin and IL-8 was then studied in 19 sections from 8 different patients' head and neck tumors (including 6 OSCCs) by means of immunohistochemistry with a monoclonal antibody against fibrin. These 8 tumors had been treated with inhibitors of new fibrin formation and degradation immediately after surgical removal. RESULTS: Fibrin staining was found in 100% of the tumor sections tested. IL-8 staining was found in the cytoplasm of tumor cells in 100% of the studied tumors, including areas adjacent to fibrin. CONCLUSIONS: These data demonstrate an in vivo association between fibrin and IL-8 in OSCC. These studies support our hypothesis that fibrin induces expression of protumorigenic factors such as IL-8 from tumor cells in vivo.

Results of selective neck dissection in management of the node-positive neck.

BACKGROUND: Although increasingly accepted in treatment of the N0 neck, use of selective neck dissection in patients with node-positive squamous cell carcinoma of the head and neck remains controversial. OBJECTIVE: To determine the oncologic efficacy of selective node dissection in patients with node-positive squamous carcinoma of the head and neck. SETTING: Three tertiary care academic/Veterans Affairs medical centers. METHODS: Ten-year retrospective medical chart review of 106 previously untreated clinically and pathologically node-positive patients undergoing 129 selective neck dissections and followed for a minimum of 2 years or until patient death. RESULTS: Regional metastasis was clinically staged as N1 in 58 patients (54.7%), N2a in 5 (4.7%), N2b in 28 (26.4%), N2c in 14 (13.2%), and N3 in 1 (0.9%). Extracapsular extension of tumor was present in 36 patients (34.0%), and postoperative radiation therapy was administered to 76 patients (71.7%). Overall, 9 patients experienced disease recurrence in the neck. Six of these recurrences were in the side of the neck that had undergone selective neck dissection, for a regional control rate of 94.3%. CONCLUSIONS: These results support the use of selective neck dissection in carefully selected patients with clinically node-positive squamous cell carcinoma of the head and neck region. Regional control rates comparable to those achieved with comprehensive operations can be achieved in appropriately selected patients.

Using Lasers in Head and Neck Oncologic Surgery.

Few technologic advances in medicine have captured the imagination of the general public, and physicians, to the extent that the laser has. The laser clearly evokes images of space-age technology, and is frequently regarded as a panacea by patients. The reality is, of course, that the laser has no inherent special ability to cure diseases, and is simply another tool available to contemporary surgeons. We will review the current application of lasers in head and neck oncologic surgery. The basic mechanism of lasers will be discussed, with emphasis on the carbon dioxide (C02) laser. This discussion will include analysis of photodynamic therapy for cancer of the upper aerodigestive tract, which is rapidly evolving as a means of incorporating lasers in the treatment of head and neck cancer.