Prevalence of hypersensitivity to specific fungal allergens as determined by intradermal dilutional testing.

OBJECTIVE: To determine fungal allergen reactivity prevalence by intradermal dilutional testing in patients with and without chronic rhinitis or rhinosinusitis symptoms. STUDY DESIGN: Prospective comparison of fungal allergen reactivity prevalence in symptomatic and asymptomatic patients. SETTING: University medical center. METHODS: Group I (chronic rhinitis and/or rhinosinusitis symptoms) and Group II (asymptomatic) patients underwent intradermal dilutional testing with usual and fungal allergens. RESULTS: Fungal reactivity occurred in 65% (13/20) of Group I, and 13% (4/30) of Group II (P < 0.0002 by chi(2) testing). Group I was more reactive to non-fungal allergens (85% vs. 33%, p < 0.0004), and to all allergens considered together (95% vs. 40%, p < 0.0001). CONCLUSIONS: Patients with chronic rhinitis and rhinosinusitis symptoms were more reactive to fungal and nonfungal allergens. Fungal allergens were as likely as nonfungal to elicit reactivity. SIGNIFICANCE: These findings suggest a role for fungal hypersensitivity in chronic rhinitis and chronic rhinosinusitis.

The impact of a skilled nursing facility on the cost of surgical treatment of major head and neck tumors.

BACKGROUND: The finite resources available for health care and the proliferation of managed care in the United States have forced the head and neck surgeon to critically evaluate the cost of tumor treatment. OBJECTIVE: To determine whether the cost of treating patients with head and neck tumors would be reduced if the patients were to spend a portion of what would otherwise be acute care hospital days in a hospital-based skilled nursing facility (HB/SNF). DESIGN: Retrospective cost-benefit analysis. SETTING: Tertiary referral center. PATIENTS: Twenty-four consecutive hospital admissions for definitive surgical treatment of head and neck tumors were retrospectively reviewed. The postoperative day on which the patient theoretically could have been transferred to the HB/SNF was determined. The charges and cost of each patient's actual hospital stay were compared with the theoretical counterparts had the patient been transferred to the HB/SNF on the determined day. MAIN OUTCOME MEASURE: Cost savings. RESULTS: The total hospital stay for the 24 patients was 524 days. One hundred eighty-two of those days could have been spent in the HB/SNF. The total charge and cost savings with the use of an HB/SNF were $201,045 and $84,238, respectively (15% of the total charge and cost). This represents an average charge and cost savings of $8377 and $3510, respectively, per patient. The difference was statistically significant (P<.005). CONCLUSION: An HB/SNF could reduce the cost of head and neck tumor treatment without compromising patient care.

Nocturnal nasal congestion and nasal resistance.

OBJECTIVES: To compare total nasal resistance (TNR) in upright and supine positions in patients who did and did not complain of nocturnal (supine) nasal congestion symptoms without daytime (upright) congestion, and to determine what other conditions were associated with nocturnal nasal congestion (NNC) symptoms. STUDY DESIGN: A prospective study comparing objectively measured nasal airflow in different positions (upright and reclining) with subjective patient symptoms. METHODS: Subjects completed a questionnaire about nasal symptoms. Anterior rhinomanometry was performed with patients upright, reclined 45 degrees, and supine. TNR in subject subsets was compared using the Student t test. RESULTS: TNR did not differ between upright patients with (n = 27) and without (n = 20) NNC. Supine TNR (P < .04) and increase in TNR (P < .02) between upright and supine was greater in patients with NNC. Smokers (n = 15, 10 with NNC, 5 without) had greater TNR increases when supine versus nonsmokers (P < .02). Patients with rhinitis symptoms (n = 29, 18 with NNC, 11 without) had greater TNR increases when supine than patients without rhinitis (P < .01). Patients who both smoked and had rhinitis (n = 11, 7 with NNC, 4 without) had a greater supine TNR than patients who smoked or had rhinitis alone (P < .02). CONCLUSIONS: Some patients without daytime nasal congestion experience NNC. They have a significantly greater TNR increase when supine versus patients without NNC. Smokers and patients with rhinitis, with or without NNC, have a significantly greater TNR increase when supine versus nonsmokers or patients without rhinitis. Smoking cessation and treatment of rhinitis may improve the patients' NNC.

Role of screening chest computed tomography in patients with advanced head and neck cancer.

OBJECTIVE: The presence of pulmonary metastases significantly alters the treatment of patients with head and neck cancers. Currently, a chest radiograph (CXR) is used as a screening examination, although a chest CT (CCT) can detect smaller lesions. The aim of this study was to evaluate the benefit of CCT as a screening tool in patients with newly diagnosed advanced head and neck cancers. METHOD: New patients with stage III and IV head and neck squamous cell carcinomas were enrolled in this prospective study from August 1994 to December 1995. Twenty-five patients underwent CXR ($71) and CCT ($597) within 2 weeks of diagnosis of the index cancer. RESULTS: In 20 patients neither the CXR nor the CCT showed any evidence of pulmonary malignancy. Two patients had normal CXRs but possible metastases on CCT. Both the pulmonary lesions resolved on follow-up evaluation. Two patients had suspicious lesions on CXR, 1 of whom had a normal CCT. The second patient underwent CT-guided biopsy which was negative for malignancy. Both the CXR and CCT of the final patient, who had a bronchogenic carcinoma, were suspicious. CONCLUSION: In 2 patients CCT detected suspicious lesions missed on CXR, although neither revealed malignancy. Three patients with suspicious CXRs would have had CCTs anyway. Thus 22 of 25 CCTs done at the additional cost of $13,314 did not add to the sensitivity of the screening for pulmonary metastasis or second lung primary.

An integrated theory of the no-reflow phenomenon and the beneficial effect of vascular washout on no-reflow.

OBJECTIVES: No-reflow is failure of perfusion in free tissue transfer despite adequate arterial inflow. The objectives of this study were to construct a theory of interactive mechanisms of the no-reflow phenomenon and to determine whether preischemic vascular washout could increase flap ischemia tolerance. STUDY DESIGN: The evidence for the role of various mechanisms in the development of no-reflow is reviewed, and an integrated network proposed. A rat-groin free flap model is used to test preischemic vascular washout with normal saline, heparinized normal saline, lactated Ringer's solution, Tis-U-Sol, and Viaspan. METHODS: The mean ischemia tolerance of this flap without any therapeutic intervention was first determined, using 22 animals. An additional 50 animals were used to compare with the control group the ischemia tolerance of flaps washed out with the above fluids before their ischemic period. RESULTS: The critical ischemia time 50 (time after which half of the flaps are expected to survive and half, die) of the untreated flap is 23.4 hours in this model (P<.05). Flaps washed out with normal saline or lactated Ringer's solution have significantly worse ischemia tolerance (P<.0001). Flaps washed out with Tis-U-Sol or Viaspan behave similarly to the control group (P>.57). Flaps receiving preischemic washout with heparinized normal saline (4,000 units/L) had a significantly better outcome than the control group (P<.027). CONCLUSIONS: Preischemic washout with normal saline, lactated Ringer's solution, or heparinized Tis-U-Sol is detrimental for flap survival after ischemia, Tis-U-Sol- and Viaspan-treated flaps do have ischemia tolerance similar to the control group, and flaps washed out with heparinized normal saline have a survival advantage in this model.

Epistaxis.

Epistaxis is a common clinical problem. The widespread availability of endoscopic equipment is shifting management philosophy toward targeting the bleeding point. This shift may have a significant impact on decreasing length of stay and blood transfusion rates. Advances in interventional radiology have also reduced the risk of embolization. Patient education, especially teaching first-aid measures to patients at high risk for nosebleeds, also encourages more effective use of health care resources.

Smoking increases facial skin flap complications.

This study was undertaken to determine whether smokers have a higher risk of complications after reconstruction of facial skin defects. Ninety-one patients with facial skin defects reconstructed with local flaps were reviewed retrospectively. Thirty-eight (42%) were active smokers, 12 (13%) had not smoked for at least 1 year prior to surgery, and the rest were nonsmokers. Complications occurred in 23 patients (25%; 37% in smokers, 17% in ex-smokers, and 17% in nonsmokers; p < .03). All full-thickness skin losses and all cellulitis occurred in active smokers. We conclude that active smokers are at a higher risk for complications in facial skin flap surgery. That ex-smokers had a complication rate similar to that of nonsmokers suggests that part of smoking's adverse effect on skin flaps may be an acute phenomenon, and that smoking cessation for shorter (<1 year) periods of time before surgery may have a beneficial effect.

Combined Epstein-Barr virus and human papillomavirus infection in nasopharyngeal carcinoma.

Epstein-Barr virus (EBV) has been shown to be a likely etiologic agent in nasopharyngeal carcinogenesis. Human papillomaviruses (HPVs) have previously been identified in numerous upper aerodigestive tract carcinomas. This pilot study was undertaken to investigate the prevalence of combined EBV and HPV infection in 17 patients with nasopharyngeal carcinoma (NPCA) using polymerase chain reaction (PCR). The primary goal was to determine if the presence of HPV could be correlated with molecular, histologic, or clinical parameters. There were seven patients with undifferentiated NPCA (World Health Organization [WHO] type III) and 10 patients with squamous cell carcinoma (WHO type I). All 17 patients had stage IV disease at presentation. EBV was identified in 15 patients (88.2%), and HPV subtypes were identified in samples from nine patients (52.9%). All HPV-positive cases were also EBV positive. Western blot analysis of six samples showed a high level of expression of c-myc and cdc2 kinase and a low level of p53 protein in NPCAs that contained both HPV and EBV (n = 3). Increased expression of c-myc and cdc2 kinase was seen in the cases that contained EBV only, but to a lesser extent (n = 2). These findings indicate an effect of the virus on cellular proliferation and differentiation. Similarly, an elevated level of Rb protein was found only in the HPV-containing NPCAs. Moderate differentiation (keratinization) occurred in four of eight HPV-negative and none of the nine HPV-positive NPCAs. (All HPV-positive cases were poorly differentiated or undifferentiated.) This difference is statistically significant for this sample size (P < 0.03). There was a trend for the group that was HPV positive to have WHO III histology and for the HPV-negative group to have WHO I. The presence of HPV could not be correlated with any clinical parameters in this small group of patients with advanced disease; however, these data suggest that coexistence of EBV and HPV infection may be a factor in the pathogenesis of NPCA and may have an effect on regulation of cellular proliferation and differentiation.

Teaching paradigm for decision making in facial skin defect reconstructions.

OBJECTIVE: To present a decision paradigm for facial defect reconstruction, and test the ability of this paradigm to improve resident performance. DESIGN: A decision paradigm for reconstruction of facial skin defects is proposed and explained, with patient examples. The paradigm's usefulness is then tested with residents. SETTING: Otolaryngology residency training program at a tertiary hospital. STUDY PARTICIPANTS: Otolaryngology residents. INTERVENTIONS: Twelve residents took a pretest wherein they were presented with drawings of skin defects and asked to choose the "best" (most aesthetically pleasing) type of reconstruction from a closed set. This paradigm was presented to these residents, and their posttest consisted of choosing again with the same defects and closed set of choices. MAIN OUTCOME MEASURES: Cosmetic outcomes of reconstructive decisions on the pretest and posttest were rated on a scale of 0 to 5 (with 0 indicating poor; 5, excellent). RESULTS: There was a significant improvement in reconstructive choices between the pretest and posttest (P<.001, Student t test). CONCLUSION: This paradigm can be easily modified to accommodate different surgical approaches preferred by individual surgeons and is thus useful in almost any reconstructive teaching situation.

Predictors of residency performance: a follow-up study.

In a 1990 study we investigated resident applicant characteristics associated with successful matching into otolaryngology. Of the 175 applicants studied, 87 matched, for a 49.7% success rate. Successful matching was much more likely for applicants with a history of excellent academic achievement in medical school. Of the 88 applicants who did not match during the year that was originally studied, 30 matched to otolaryngology in subsequent years. Of the 58 who never matched in otolaryngology, there is no evidence of board certification for 30. Of the other 28, 12 are board certified in anesthesia; 3 in radiology; 2 each in family medicine, internal medicine, general surgery, psychiatry, and physical medicine, and rehabilitation; and 1 each in pathology, emergency medicine, and dermatology. Of the total of 117 who matched in otolaryngology, 109 began residency training, and 107 finished otolaryngology training. Program directors answered questionnaires about 100 of 107 of these residents, detailing aspects of residency performance. The only correlation found between a highly satisfactory residency performance and characteristics that could be evaluated at the time of interviewing for residency positions was with excellent academic performance in medical school.

Communication after laryngectomy. An assessment of patient satisfaction.

OBJECTIVES: To determine the satisfaction of patients with their current method of alaryngeal communication. To focus primarily on the patients' perception of their own speech. DESIGN: A retrospective review of patients who underwent total laryngectomy for malignancy identified 4 groups of patients. A survey using a mailed questionnaire was used to compare groups. SETTING: Tertiary care university hospital, University of Texas Medical Branch at Galveston. PATIENTS: Forty-seven patients underwent total laryngectomy for cancer and survived. Thirty-one of the 47 patients responded to the survey. Patients were divided into 4 groups by their current method of communication: (1) tablet writers; (2) esophageal speech; (3) electrolarynx; and (4) tracheoesophageal speech. MAIN OUTCOME MEASURES: Satisfaction with communication, satisfaction with speech quality, ability to communicate over telephone, limitation of interaction with others, and satisfaction with quality of life. RESULTS: Patients in group 4 were significantly more satisfied with their speech (P < .001), perceived their speech to be of better quality (P < .001), had improved ability to communicate over the telephone (P < .001), and had less limitation of their interactions with others (P < .004). Patients in group 4 also rated their overall quality of life higher (P = .23). CONCLUSION: Although many studies in the past have demonstrated the objective superiority of tracheoesophageal speech compared with other methods of alaryngeal communication, most studies have focused on the intelligibility of speech judged by listeners. This study demonstrates that patients who use tracheoesophageal speech rate their own speech significantly higher than patients who use other methods and most likely have an overall superior quality of life.

Extended use of topical nasal decongestants.

Use of sympathomimetic topical nasal decongestants to treat nasal obstruction is usually restricted to 3 to 5 days to avoid potential rebound swelling (rhinitis medicamentosa). In this study, 10 healthy volunteers used oxymetazoline (long-acting topical nasal decongestant) nightly for 4 weeks. Subjects who used antihistamines, oral or topical decongestants, or systemic steroids or who had active sinusitis were excluded from the study. Weekly history, physical examination, and anterior rhinomanometry revealed no adverse effects. Eight (80%) subjects developed nightly nasal obstruction a few hours before the evening dose; the obstruction resolved within 48 hours if no more decongestant was used. All subjects remained responsive to oxymetazoline 4 weeks and 8 weeks after the study began. This finding suggests that long-acting decongestants may be safely used for longer than the recommended 3 to 5 days without adverse effects if used once nightly.

Biomechanics of the helical rim advancement flap.

OBJECTIVES: To determine how helical rim closure with advancement flaps affects ear length and cupping, to compare the tension of closure with wedge excision and helical rim advancement and the effects of 3 tension-decreasing surgical techniques, and to review clinical experience with this flap. DESIGN: The laboratory study was performed on 6 fresh cadaver ears, by means of sequential excision of tissue, and closure tension was measured with a strain gauge. Results obtained in 10 patients were reviewed. SETTING: University referral hospital. PATIENTS: Ten patients with helical rim defects treated with helical rim advancement flaps. INTERVENTION: In cadaver ears, a helical rim defect of 5 mm was enlarged sequentially to 10 mm, 15 mm, and finally 20 mm. In the patients, defects of the helical rim caused by trauma or tumor were closed by this helical rim advancement flap method. MAIN OUTCOME MEASURES: For the laboratory study, the outcome measures were tension of closure of the defect, ear length, and ear cupping. For the review of cases, outcome was determination of perioperative complications and the patient's and surgeon's judgment of cosmetic appearance. RESULTS: Closure of a helical rim defect with advancement flaps caused minor shortening and moderate cupping of the ear. The tension of closure was decreased by extending the inferior incision into the earlobe, creating a Burow triangle, and shaving cartilage from the scapha. Both the Burow triangle and the scaphal shave caused mild increases in ear cupping. CONCLUSION: Helical rim advancement flaps provide satisfactory closure of helical rim defects up to at least 20 mm (longer in some ears) with excellent preservation of normal anatomic landmarks and a near-normal appearance of the reconstructed ear.

Allergic fungal sinusitis.

Allergic fungal sinusitis is a non-invasive disease, first described in the early 1980s. We review our experience with 25 patients treated at the University of Texas Medical Branch, Galveston. All patients were treated surgically, using endoscopic techniques in 17, and combined endoscopic and external procedures in eight. Histological evidence of tissue invasion was absent in all 25 patients, in spite of extensive destruction of the skull base in four. Dematiaceous fungi were the most common cultural isolate. Fifteen patients were available for more than 6 months post-operative follow-up. None of the eight patients who developed recurrent disease had been treated with post-operative systemic steroids. Four of the seven patients who remained disease-free had received steroids. Clinical trials to test the efficacy of systemic steroids in the prevention of disease recurrence are clearly warranted.

Effect of hyperbaric oxygenation on existing oral mucosal carcinoma.

Hyperbaric oxygen therapy (HBO) is used to treat some complications of head and neck carcinoma treatment. Several patients treated with HBO have had rapid growth of a clinically cured squamous cell carcinoma. Prior studies have produced conflicting evidence about the effect of HBO on tumor growth. This study was undertaken to determine the effects of HBO on established squamous cell carcinoma. Forty Golden Syrian hamster cheek-pouch carcinomas were induced with the established chemical carcinogen 9,10-dimethyl-1,2-benzanthracene. Twenty hamsters underwent 30 HBO dives for 60 minutes each to 2.81 atm, while 20 served as controls. At necropsy, animals receiving HBO therapy had significantly smaller tumors (P < .05) and showed a trend toward fewer cervical metastases (P < .06). HBO therapy with coexistent carcinoma inhibited the established tumor's growth.