The effect of second hand smoke in patients with squamous cell carcinoma of the head and neck.

BACKGROUND: Active tobacco smoking is a well-known risk factor for head and neck malignancy, and strong evidence has associated tobacco as the main carcinogenic factor in squamous cell cancers of this region. Evidence supporting a carcinogenic effect of second-hand smoke (SHS) on head and neck organs in non-smokers was also demonstrated with results consistent with those for active smokers. There is little data on the effects of SHS in patients previously treated for squamous cell carcinomas of the head and neck. OBJECTIVE: The purpose of this study was to prospectively evaluate the role of SHS on recurrence and survival in treated head and neck cancer patients. METHODS: We conducted a prospective cohort study to examine the association between self-reported SHS exposure and the risk of recurrence and mortality in patients treated for squamous cell cancers of the head and neck in a longitudinal fashion. Patients filled out an exhaustive smoking questionnaire on presentation and abbreviated questionnaires at each follow-up visit, which occurred every 6 months. Primary outcome measures were recurrence, development of a second primary malignancy, and recurrence-free survival. Chi square analysis was used to assess the association between SHS and the primary outcomes. A multivariate binary logistic regression analysis was applied to determine the independent predictors of recurrence. Cox proportional hazards and Kaplan Meier modeling were employed to assess the possible relationships between SHS exposure and time to develop the primary outcomes. RESULTS: Untreated new patients with a histologically confirmed diagnosis of first primary SCC of the UADT (defined as cancer of the oral cavity, the oropharynx, the hypopharynx, and the larynx) were recruited. Patients seen at The University of Texas Medical Branch (UTMB) Head and Neck oncology clinic from 1988 to 1996 were considered as cases in this study. One hundred and thirty-five patients were enrolled in the study. The median follow-up time for the sample was 54 months (3.92 years). Complete records were achieved for 92% of patients, thus 124 patients were included in the final analysis. SHS significantly correlated with recurrence and recurrence-free survival. The rate of recurrence was 46% in the group exposed to SHS and 22% in the non-exposed group. Based on multivariate binary logistic regression analysis, SHS exposure was detected as a significant independent predictor for recurrence (HR = 3.00 [95% CI 1.18-7.63]). Kaplan-Meier analysis demonstrated that patients who were not exposed to SHS had a statistically significant longer recurrence-free survival (log-rank P = 0.029). The mean survival for non SHS-exposed patients was 76 [63-89] months versus 54 [45-63] months for those exposed to SHS. CONCLUSIONS: SHS exposure is an independent predictor of recurrence and survival after head and neck cancer treatment. These results support the importance and efforts of reducing smoking at home in in the work-place.

US antibiotic stewardship and penicillin allergy.

PURPOSE OF REVIEW: The purpose of this review is to improve otolaryngologists' antibiotic stewardship by detailing current approaches to penicillin allergy. RECENT FINDINGS: Although up to 15% of hospitalized patients in the United States have a penicillin allergy recorded on their charts, fewer than 10% of these have a true penicillin allergy. SUMMARY: Using a combination of a detailed allergy history, skin testing and graded-dose administration, many patients whose charts say 'penicillin-allergic' can safely be treated with penicillin and cross-reacting antibiotics. This permits use of narrower-spectrum antibiotics and saves money.

Asthma treatments: new and emerging therapies.

BACKGROUND: As part of this primer, this article is intended to introduce new and emerging therapies for treating asthma. METHODS: A PubMed search was performed for the years 2013 through 2015 for asthma review, asthma treatment, asthma therapy, and asthma new. Subset searches were additionally performed as suggested by information contained in the first round of searches. RESULTS: There is continuing work toward the identification of additional cellular and molecular mechanisms of asthma. Many of these suggest additional targets for therapy. New pharmaceuticals, biologics, and procedures are reviewed in greater depth. CONCLUSION: This is a summary of new and emerging asthma therapies.

Allergy in the geriatric population.

PURPOSE OF REVIEW: Allergies and asthma have long been considered diseases of children and young adults. They are, however, prevalent among older patients also. This article summarizes findings on the diagnosis and treatment of allergies and asthma in the older population. RECENT FINDINGS: Allergies and asthma occur with fair frequency in older patients. Remembering to look and test for these problems enables better treatment and symptom control for these patients. Immunotherapy works well in this population. SUMMARY: Regardless of the patient's age, the differential diagnosis for sinonasal and dyspnea complaints should include allergies and asthma. Diagnosis is straightforward, and appropriate treatment improves quality of life.

The role of fractional exhaled nitric oxide in asthma management.

Measuring fractional exhaled nitric oxide (FeNO) is a relatively new option for assessing allergic inflammation in the lungs. Clinical management of asthma is challenging, and measuring exhaled nitric oxide can provide another type of data to assist in meeting this challenge. FeNO is easy to perform, and the equipment is not forbiddingly expensive. FeNO provides a complement to traditional measures of asthma control and can help guide diagnostic and treatment choices. This article explains what it is, how the measurements are performed, what the norms are, and its use and limitations in the management of asthma.

Immunology of allergy.

Knowledge of the immune system is advancing rapidly. This review provides an update on the allergy players-the cells and major mediators-and the form and function of each; discusses how these cells and mediators weave together in the elegant but destructive dance of allergy; and details how specific immunotherapy can cure allergy.

IgE-mediated food allergy.

PURPOSE: The increasing incidence of IgE-mediated food allergy has led to further study of this atopic disease. RECENT FINDINGS: Food allergy represents a failure to attain oral tolerance marked by a pronounced Th2 versus T-regulatory cell response. The gold standard for the diagnosis of food allergy is a double-blind, placebo-controlled food challenge. Evidence supports breastfeeding to prevent certain atopic diseases but there is no support for delayed food introduction or maternal diet restrictions during pregnancy or lactation. There is no cure for food allergies. The mainstay of therapy is avoidance and management of severe reactions with self-injectable epinephrine. Other promising therapies include oral immunotherapy and sublingual immunotherapy. SUMMARY: The mechanism of IgE-mediated food allergy is better understood but further research is needed to prevent and treat food allergies.

Tonsillectomy for the treatment of tonsillitis-induced immunoglobulin A nephropathy.

Tubular occlusion from red blood cell casts secondary to immunoglobulin A nephropathy (IgAN) is a rare, serious complication of tonsillitis that can cause acute renal failure, also referred to as acute kidney injury. IgAN is the most common primary glomerulonephritis with up to 20% of cases resulting in renal failure worldwide. Tonsillectomy is an effective treatment option for patients suffering from IgAN secondary to recurrent acute tonsillitis. Tonsillectomy alone or in combination with additional medical modalities improves renal function and can have a positive effect on long-term renal survival.

Columellar schwannoma.

Schwannomas of the nose or paranasal sinuses are very rare. In fact, only 19 cases of schwannoma of the nasal septum have been reported in the otolaryngology literature. In all of those cases, only the cartilaginous or bony septum was involved. To the best of our knowledge, no case of soft-tissue involvement of the columella has been documented until now. We report a case of a columellar schwannoma in a 57-year-old white man. The mass was easily palpated on physical examination, and it was removed surgically. We summarize this case and discuss the incidence, general characteristics, radiographic findings, pathology, and treatment of schwannomas.

Depressed anterior table fracture: a minimally invasive method of reduction.

One-third of frontal sinus fractures are isolated to the anterior table. Traditional approaches to the reduction of an isolated anterior table fracture include the coronal incision, the bilateral brow incision, an endoscopic brow lift with an incision either directly over the fracture or in the brow, and delayed repair with a camouflaging implant. We describe a case involving a 14-year-old boy with a depressed anterior table fracture that we successfully treated using a minimally invasive technique requiring only one 2-cm incision.

Otolaryngology residency training: resurgence of the specialty.

Five decades ago, otolaryngology dealt primarily with infectious diseases of the head and neck. The quality of otolaryngology residency training programs was inconsistent and mostly determined by the institution and local faculty. The specialty flourished by developing new expertise in all facets of head and neck medicine and surgery through the leadership of outstanding clinicians and scientists in private practice and universities. Otolaryngology programs subsequently grew from weak divisions within a department of surgery with few faculty members to departments of otolaryngology with full-time, mostly fellowship-trained faculty. Teaching shifted from resident-to-resident to faculty teaching. Organized medicine encouraged systematic quality improvement and periodic review of programs for accreditation. Residencies were also bolstered through Medicare, Medicaid, and Veterans Administration hospitals, which provided funds for growth but limited flexibility of the faculty schedules. The American Academy of Otolaryngology/Head and Neck Surgery shouldered an enormous load of teaching and maintaining unity of the specialty from its birth to the present.

Clavipectoral osteomyocutaneous free flap in oromandibular reconstruction.

INTRODUCTION: Mandibular reconstruction continues to challenge most head and neck reconstructive surgeons despite the tremendous advances in surgical and fixation techniques. We recently described the clavipectoral osteocutaneous flap for mandibular reconstruction. This flap encompasses the clavicle and the clavicular head of the pectoralis major with overlying skin. OBJECTIVES: The purpose of this article is to report our prospective clinical experience with the use of clavipectoral osteocutaneous flap in the reconstruction of oromandibular defects. STUDY DESIGN: Prospective case series. METHODS: Five patients with significant mandibular defects underwent reconstruction using the newly described clavipectoral flap. All patients had shoulder range of motion testing preoperatively and at 3 and 6 months postoperatively. Panorex and bone scans were obtained on the seventh postoperative day. RESULTS: All five flaps survived. The transferred clavicles demonstrated good vascularity on the postoperative bone scans. The shoulder morbidity was minimal, with all patients resuming their preoperative level of activity. CONCLUSIONS: The clavipectoral flap has bone and soft tissue components that are especially suited for composite mandibular defects, but it should be used as a second-line flap owing to the short pedicle and the regular need for vein grafts.

Snoring and its management.

There are numerous strategies, devices and procedures available to treat snoring. The surgical procedures have an overall success rate of 60-70%, but this probably decreases over time, especially if there is weight gain. There are no long-term rigorously-designed studies comparing the various procedures for decreasing snoring.

The effects of intradermal and topical mitomycin C on wound healing.

OBJECTIVE: To determine the effect of intradermal and topical mitomycin C (MMC) on skin wound healing. STUDY DESIGN/SETTING: A prospective, controlled study in a rat wound model performed in an academic medical center. RESULTS: Intradermal and topical MMC application decreased wound integrity when compared with saline-treated animals at 1 week, 2 weeks, 1 month, and 6 months. Skin necrosis occurred in animals that received intradermal MMC. Hemotoxylin and eosin and immunohistochemical staining showed no consistent difference between treatment arms. Fibrosis and collagen deposition were reduced in MMC-treated wounds on trichrome staining. CONCLUSIONS: MMC-treated wounds showed decreased wound strength compared with controls. Intradermal MMC can cause skin necrosis. Histologic findings did not always correspond with clinical data. SIGNIFICANCE: The data suggest cautious use of MMC in clinical situations when wound breaking strength is critical.

Effect on hospital-wide sedation practices after implementation of the 2001 JCAHO procedural sedation and analgesia guidelines.

OBJECTIVE: To describe the effect of implementing the Joint Commission on Accreditation of Healthcare Organization's guidelines for procedural sedation and analgesia (PSA) on the frequency of adverse events occurring during sedation. DESIGN: Prospective, descriptive study. SETTING: Urban, tertiary care children's hospital. PARTICIPANTS: Patients requiring PSA. INTERVENTIONS: A PSA committee and a standardized protocol for PSA were developed during a 6-month period. Institutional oversight was initiated to monitor practitioner compliance with the program. Data were abstracted from the sedation record. MAIN OUTCOME MEASURES: The change in incidence of adverse events during PSA during the study. The strength of the association was determined by computing the Pearson product moment correlation. RESULTS: A total of 14 386 patients received PSA between July 1, 2001, and June 30, 2004. During the study, 7.6% of patients had an adverse event, with the most common being hypoxemia (39.7% of all adverse events). A trend toward a decrease in the incidence of adverse events was found during the study (Pearson product moment correlation, -0.68; P<.001). CONCLUSIONS: Implementation of the 2001 Joint Commission on Accreditation of Healthcare Organizations guidelines for the provision of PSA appeared to lead to a decrease in the incidence of adverse events during the study. Implementation of uniform standards of monitoring and care for the provision of PSA may lead to safer conditions for pediatric patients undergoing PSA.

Relationship between rhinosinusitis symptoms and mucociliary clearance time.

OBJECTIVE: To determine the correlation between rhinosinusitis symptoms as assessed by the Sino-Nasal Outcomes Test-20 (SNOT-20) and mucociliary clearance as assessed by the saccharin method. STUDY DESIGN AND SETTING: This was a cross-sectional study of 50 adult volunteers. Subjects completed the SNOT-20, and mucociliary clearance was determined with the saccharine method. Correlation coefficients (Spearman's Rho) were calculated for the global SNOT-20 score. RESULTS: The SNOT-20 scores varied from 20 to 54 (mean 30.28) with a possible range of 20 to 100. Clearance times varied from 418 to 2865 seconds (mean 999). There was no significant correlation between global SNOT-20 score and clearance time (r = 0.196). CONCLUSIONS: There is no significant correlation between rhinosinusitis symptoms as assessed by SNOT-20 scores and mucociliary clearance. SIGNIFICANCE: Mucociliary clearance is important for the health of the sinonasal cavities, but clearance time does not appear to be associated with symptom severity in the population studied. EBM RATING: A-1b.

The association of tongue scalloping with obstructive sleep apnea and related sleep pathology.

OBJECTIVE: The association between OSAS and patient history and physical exam findings is previously established; however, to our knowledge there are no studies that evaluate the role of tongue scalloping as a reliable clinical indicator for OSA, snoring, or the presence of other sleep pathology as evidenced by polysomnography. This study evaluates the hypothesis that such an association exists. SUBJECTS AND METHODS: Sixty-one otolaryngology clinic patients were evaluated by history and physical exam for the presence and degree of tongue scalloping, snoring, and other previously established clinical indicators for sleep-disordered breathing and obstructive apnea. Twenty-five of the 61 study patients were additionally evaluated by overnight polysomnography to provide conclusive diagnosis of sleep pathology. The degree of tongue scalloping was graded from 0 to 3 and its significance as a screening, diagnostic, and predictive factor for sleep pathology was then statistically determined. RESULTS: Twenty-seven patients (44%) had known or newly documented OSA and 47 (77%) had a history of snoring. Twenty-seven patients (44%) had some degree of tongue scalloping (1-3) and 74% of these patients were male. The presence of any degree of tongue scalloping (grade 1-3) in patients with known or newly documented OSA showed sensitivity, specificity, PPV, and NPV of 52%, 68%, 70%, and 50% respectively. The presence of tongue scalloping in patients with either known snoring history or newly documented snoring showed sensitivity, specificity, PPV, and NPV of 47%, 64%, 81%, and 26% respectively. Presence of tongue scalloping was 71% specific for abnormal sleep efficiency (<85%), 70% specific for abnormal AHI (>5), and 86% specific for nocturnal desaturation >4% below baseline. Presence of tongue scalloping also showed PPV of 67% for abnormal AHI, 89% for apnea or hypopnea, and 89% for nocturnal desaturation. Presence and severity of tongue scalloping showed positive correlation with increasing Mallampati and modified Mallampati airway classification. CONCLUSIONS: In high-risk patients we found tongue scalloping to be predictive of sleep pathology. Tongue scalloping was also associated with pathologic polysomnography data and abnormal Mallampati grades. We feel the finding of tongue scalloping is a useful clinical indicator of sleep pathology and that its presence should prompt the physician to inquire about snoring history.

Reconstruction of the auricle.

The intricate and delicate anatomy of the external ear (auricle) makes reconstruction a daunting task for beginning as well as experienced surgeons. The complex framework of the auricle is composed of graceful curves, peaks, and valleys of a thin pliable uniform thickness of cartilage. This article discusses techniques for reconstruction of the auricle.