Roundtable. Blueprint for conversion of patients on metformin and sulfonylurea to Glucovance.
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Counseling↗
Biomedical subjects
C M Stiernberg
Publications and source records attributed to C M Stiernberg.
Animal bites to the head and neck.
There is controversy regarding the timing of repair and the use of prophylactic antibiotics in patients with animal bites to the head and neck. In this paper we review our experience with such wounds, and address surgical management and the use of prophylactic antibiotic therapy. A retrospective review of the medical records of 29 patients with animal bites to the head and neck was conducted. All patients were seen and treated at a large teaching hospital in Houston, Texas over an 18-month period. Seventy-six percent of our patients were 12 years old or younger. Most came to the emergency room soon after sustaining their injuries, and their wounds were repaired primarily with favorable results. There were no cases of wound infection. Ninety percent were treated with prophylactic antibiotics. The wounds of the 10% of patients who did receive antibiotics were similar to those of the other patients and healed well without infection. Wounds resulting from animal bites to the head and neck can be repaired primarily when treated shortly after injury. Further prospective, randomized studies are recommended to evaluate the effectiveness and necessity of prophylactic antibiotic therapy in this patient population.
Adolescent↗
Sinusitis in the intensive care unit patient.
A retrospective study was undertaken to determine the incidence of sinusitis as a source of fever in the intensive care unit (ICU) patient, evaluate the effectiveness of radiologic studies in diagnosing sinusitis, and develop guidelines that may help predict the result of antral lavage. Sixteen of 52 (30.7%) lavages in patients studied with plain films and 27 of 67 (40.3%) lavages in patients studied with computed tomography of the sinuses revealed purulence in the maxillary sinuses. Conversely, 23 of 30 (76.7%) of the cases with purulence in the middle meatus had purulence in the maxillary sinus (chi-squared = 27.1). If no purulence was seen, the results of the antral lavage were negative in 68 of 89 cases (76.4%). When physical examination was used in conjunction with computed tomography, 92.3% of lavages confirmed purulence in the maxillary sinus (chi-squared = 16.6). In conclusion, the most important factor in predicting a positive result with antral lavage is the presence of purulence in the middle meatus on physical examination in conjunction with the presence of sinus disease on computed tomography of the sinuses.
Adult↗
Contemporary management of deep neck space infections.
Deep neck infections continue to be seen despite the wide use of antibiotics. These infections follow along fascial planes to create deep neck space abscesses. The clinical presentation often points to the space involved. Understanding the regional anatomy gives the surgeon the ability to treat these grave infections. The records of 24 patients with a diagnosis of deep neck space abscess admitted to Hermann Hospital between 1988 and 1993 were reviewed. Fifty percent of the patients had received antibiotics for an infection of the ear, nose, or throat before the development of a neck space abscess. Ten patients had parapharyngeal abscesses, seven had retropharyngeal abscesses, six had submandibular space abscesses, and one had parotid space abscess. Thirty-five organisms were isolated in 18 cases (1.9 isolates per patient). The most common organism cultured was Streptococcus (13 of 18), followed by Staphylococcus (6 of 18), Bacteroides (5 of 18), Micrococcus (2 of 18), and Neisseria (2 of 18). One case each of Candida, Enterobacter, Enterococcus, Peptostreptococcus, Proteus, Proprionobacter, and Pseudomonas was cultured. Six patients had no growth on culture but did have organisms found on Gram's stain. The operative techniques and antibiotics used are discussed. The main complications of jugular vein thrombosis, carotid artery rupture, and mediastinitis are described, as well as an unusual case of meningitis from a large retropharyngeal-parapharyngeal abscess.
Adolescent↗
Endoscopic approach to traumatic visual loss.
OBJECTIVE: To review our experience with the use of endoscopic optic nerve decompression in traumatic blindness. METHOD: We did a retrospective analysis of patients with traumatic blindness that underwent endoscopic decompression of the optic canal to determine postoperative visual acuity and correlate it to preoperative visual loss and intraoperative findings. The setting was a Level I university trauma center. We identified 8 patients treated with both surgery and steroids over a 10-month period beginning in 1993 (Seven males, one female). RESULTS: Four of six patients with total blindness (no light perception) had improvements in visual acuity. In three patients, visual acuity returned to preinjury levels. One patients with total blindness was operated on 6 weeks after injury and had a visual acuity of 20/800 at 1-year follow-up. Two patients with hand motion preoperatively had improvement in visual acuity. In one patient, vision returned to normal (20/20), and in the other it improved to 20/200). Five patients were operated on after megadose steroid treatment for at least 48 hours failed; four of five noted dramatic improvements in visual acuity. CONCLUSION: The endoscopic approach may be used to successfully decompress the optic nerve in traumatic blindness.
Adolescent↗
Pediatric gunshot wounds to the head and neck.
Gunshot wounds to the head and neck in the pediatric population have become alarmingly common. They often result in death of the victim, devastate families, and inflict a considerable financial burden to hospitals and society. We present a retrospective study of cases treated at a level I trauma center in Houston, Texas, from July 1990 to July 1993. We identified 115 cases of gunshot wounds in children, 32 of which were exclusively confined to the head and neck region. There were 26 male and 6 female patients. Ages ranged from 3 to 17 years. The cranial cavity was involved in 13 cases, leading to 9 deaths and 1 institutionalization. The shootings took place at home in 11 cases, and they involved play in 12 cases. The shooter was known to 14 of the victims, and the wounds were self-inflicted in 7 cases. The most common type of weapon was the .22 caliber pistol, which caused four of the deaths. Two of our cases involved BB air rifles, one of which mandated a craniotomy for the evacuation of an epidural hematoma. Our findings indicate that gunshot wounds to head and neck in children are in most instances preventable and result in high fatality rates because of common intracranial involvement, even when low-energy missiles are used.
Adolescent↗
Inhibition of cholesteatoma migration in vitro with all-trans retinoic acid.
Retinoids have recently become of interest to clinicians because of their ability to inhibit migration and proliferation of premalignant squamous cells while enhancing growth and proliferation of normal cells. An in vitro investigation was undertaken to determine whether retinoic acid exhibits similar inhibitory effects on cholesteatoma cells. Cholesteatoma specimens were obtained intraoperatively from 10 patients undergoing mastoidectomy or revision mastoidectomy for chronic ear disease. Cholesteatoma explant growth and en mass migration were observed daily, and topographic maps were constructed at various time intervals to quantity rate and direction of explant migration in the presence or absence of all-trans retinoic acid. Before all-trans retinoic acid administration, explants migrated very rapidly (1 to 2 mm/day). A maximum threefold inhibition of migratory rate occurred, with explants exposed to 0.1 micromol/L retinoic acid when compared with controls. A sixfold maximum inhibition was observed at higher retinoic acid concentrations (5 micromol/L). On removal of all-trans retinoic acid, twofold and fourfold increases in migratory rates were observed. The direction of explant migration varied significantly for long periods of time and appeared not to be affected by retinoic acid. This investigation suggests that all-trans retinoic acid has an inhibitory effect on cholesteatoma cell migration. Retinoids may have a role in controlling cholesteatoma disease in the future.
Cell Adhesion↗
Massive epistaxis due to pseudoaneurysm. Treated with detachable balloons.
A case of massive epistaxis refractory to nasal packing and bilateral surgical ligation of the internal maxillary and ethmoidal arteries is presented. Angiography revealed a pseudoaneurysm of the cervical portion of the internal carotid artery, and intravascular detachable balloons were used for epistaxis control. The appropriate use of intravascular diagnostic and therapeutic techniques is described.
Adult↗
Gunshot wounds to the head and neck.
Gunshot wounds to the head and neck contribute to substantial medical, economic, and social problems in the United States today. The treatment of these patients requires the contemporary head and neck surgeon to be precisely informed in anatomy, wound ballistics, resuscitation, and surgical decision making. Ninety recent cases at the University of Texas Health Science Center affiliated hospitals in Houston were reviewed and are reported. Data show substantial trends in patient demographics and corroborate other reports in the trauma literature. Controversies in patient management continue, but current evidence favors a protocol of selective surgical exploration.
Adolescent↗
The relationship between the nasal cycle and mucociliary clearance.
Nasal airway resistances were measured bilaterally on subjects at 30-minute intervals over 6 hours using anterior rhinomanometry. The first 10 subjects found to exhibit alternating congestion and decongestion of the nasal mucosa (i.e., the nasal cycle) were included in the study. Using the saccharin method, nasal mucociliary clearance was determined for each subject in both the congested and decongested phases of the cycle. The results were statistically significant at the P less than .09 level, highly suggestive of a difference in nasal mucociliary clearance between the two phases of the cycle, with the congested phase having the more rapid clearance. However, when compared to the mucociliary clearance times in disease states, the difference in transport times between the two phases is probably not clinically significant.
Adult↗
Otolaryngology-head and neck surgery.
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Head↗
Surgical anatomy of the lateral nasal wall.
Both the success and safety of intranasal functional endoscopic sinus surgery depend on the surgeon's knowledge of nasal and sinus anatomy, especially the lateral nasal wall. The purpose of this study was to determine measurements and angles between lateral nasal wall landmarks. Linear and angular measurements were made to determine the mean and range distances between selected structures. The results provide a guide for the surgeon.
Humans↗
Spontaneous cervical and mediastinal emphysema.
Subcutaneous cervical emphysema often appears as a result of surgery or trauma. However, when it occurs spontaneously, the patient may present with clinically impressive and dramatic features. The etiology is related to the rupture of terminal alveoli and dissection of air along the pulmonary vasculature. Exercise may contribute to the process by increases in intrathoracic pressure. Six cases of spontaneous cervical emphysema, all related to SCUBA diving training at a Naval facility, were recently seen at our institution. Proper management entails having a high index of suspicion for diagnosis, and then being able to identify potentially life-threatening complications.
Adult↗
Vitamins A and E do protect against oral carcinoma.
Tumorigenesis requires accelerated polyamine biosynthesis, and elevated levels of ornithine decarboxylase, the rate-limiting enzyme in this reaction chain. The primary goal of this study was to determine whether induction of oral cavity carcinoma by dimethylbenzanthracene was accompanied by increased ornithine decarboxylase. It has previously been demonstrated in an oral carcinogenesis model that cotreatment with vitamins A or E delayed tumor development. The second goal of this study was to determine whether this chemoprotective effect was associated with a decrease in ornithine decarboxylase activity. We found that dimethylbenzanthracene did stimulate ornithine decarboxylase. Vitamins A and E alone also stimulate ornithine decarboxylase, and this effect is additive with dimethylbenzanthracene. Use of both vitamins together prevents the additive effect of either, alone, and vitamin A inhibits the late-phase ornithine decarboxylase response to dimethylbenzanthracene in all animals. We conclude that pretreatment with vitamins A, or A and E together protects against the carcinogenic action of dimethylbenzanthracene, and that the mechanism of this protection is early truncation of the ornithine decarboxylase response to dimethylbenzanthracene.
9,10-Dimethyl-1,2-benzanthracene↗
Interobserver variability in the interpretation of fine-needle aspiration biopsy of head and neck masses.
Fine-needle aspiration biopsy is gaining acceptance as a clinically useful tool. We set out to evaluate the accuracy of fine-needle aspiration biopsy at our institution by measuring the interobserver variability in cytopathologic interpretation, and by measuring the agreement between cytopathologic and histologic diagnosis. In a prospective study, 253 aspirations were performed on head and neck masses by the otolaryngology service. Specimens were interpreted independently by two cytopathologists (V.J.S. and P.Z.), and interpretations were compared with the surgical histopathologic diagnosis when available. The interobserver variability between cytopathologists was 8% with a specificity of 96% and a sensitivity of 97%. We conclude that fine-needle aspiration biopsy is a safe and useful tool in the diagnosis of head and neck masses. In the diagnosis of epithelial cysts and squamous epithelial malignancies, fine-needle aspiration biopsy is as accurate as open biopsy.
Biopsy, Needle↗
Teaching indirect mirror laryngoscopy.
Indirect mirror laryngoscopy is difficult to learn. An anatomic model of the oropharynx and larynx is described here. This model is used to familiarize medical students with the component skills of mirror laryngoscopy. The students progress to competency at mirror laryngoscopy on patients more quickly after initial use of this model.
Laryngoscopy↗
The effect of hyperbaric oxygen therapy of oral mucosal carcinoma.
Hyperbaric oxygen is sometimes used in the course of treatment in head and neck cancer patient. This study was undertaken to investigate the effect of hyperbaric oxygen on oral cavity carcinogenesis in an animal model. Dimethylbenzanthracene was applied three times weekly to induce oral squamous cell cancers. The group that received simultaneous hyperbaric oxygen had fewer tumors, but the tumors were larger than the dimethylbenzanthracene-only group. We concluded that hyperbaric oxygen has a tumor-suppressive effect during the induction phase of oral carcinoma and appears to have a stimulatory effect during the proliferative phase of carcinoma in this animal model.
9,10-Dimethyl-1,2-benzanthracene↗
Surgical care of submental gunshot wounds.
The care of patients with self-inflicted facial gunshot wounds is complex and challenging. The magnitude and self-inflicted nature of the injuries naturally give rise to questions about potential for successful rehabilitation. The surgical care and rehabilitation of ten such patients are described. The initial grotesque disfiguration belies the reasonable chances for functional restoration. Patients in this series who completed reconstruction swallow well enough to maintain body weight, speak understandably, breathe without tracheostomy, and have an appearance sufficiently normal that they can interact socially without embarrassment. Guidelines are proposed for multidisciplinary medical care leading to satisfactory functional, aesthetic, social, and psychiatric rehabilitation.
Adult↗