PubMed Health⌕ Search

Biomedical subjects

Daniel G Deschler

Publications and source records attributed to Daniel G Deschler.

At least 19 recordsLinked to original sources
PubMed2006

Proton beam radiation therapy for skull base adenoid cystic carcinoma.

OBJECTIVE: To determine the treatment outcome and prognostic factors in patients with adenoid cystic carcinoma of the skull base treated with proton beam radiation therapy. DESIGN: Retrospective analysis. SETTING: Massachusetts General Hospital, Massachusetts Eye and Ear Infirmary, and Harvard Medical School, Boston. PATIENTS: From 1991 to 2002, 23 patients with newly diagnosed adenoid cystic carcinoma with skull base extension were treated with combined proton and photon radiotherapy. There was tumor involvement of the sphenoid sinus in 61% of patients (14), nasopharynx in 61% (14), clivus in 48% (11), and cavernous sinus in 74% (17). The extent of surgery was biopsy alone in 48% (11), partial resection in 39% (9), and gross total resection with positive margins in 13% (3). The median total dose to the primary site was 75.9 cobalt-gray equivalent. The median follow-up of all surviving patients was 64 months. MAIN OUTCOME MEASURES: Locoregional control and disease-free survival and overall survival rates. RESULTS: Tumors recurred locally in 2 patients at 33 and 68 months, respectively. No patients developed neck recurrence. Eight patients had distant metastasis as the first site of recurrence. The local control rate at 5 years was 93%. The rate of freedom from distant metastasis at 5 years was 62%. The disease-free and overall survival rates at 5 years were 56% and 77%, respectively. In multivariate analysis, significant adverse factors predictive for overall survival were change in vision at presentation (P = .02) and involvement of sphenoid sinus and clivus (P = .01). CONCLUSIONS: High-dose conformal proton beam radiation therapy results in a very encouraging local control rate in patients with adenoid cystic carcinoma of the skull base. Changes in vision at presentation and tumor involvement of the sphenoid sinus and clivus are important prognostic factors.

Adult↗
PubMed2006

Histologic correlation of in vivo optical coherence tomography images of the human retina.

PURPOSE: To correlate in vivo human retina optical coherence tomography (OCT)3 images with histology. DESIGN: Case series. METHODS: Linear OCT3 scans through the macula and optic nerve were obtained in three eyes of three patients who then underwent exenteration surgery for orbital cancers. OCT3 images were then correlated with histology. RESULTS: On histology, two eyes were normal, and one eye had dry macular degeneration. The plexiform layers on histology correlated with the green/yellow areas on the OCT3 scans, and the nuclear layers correlated with the black areas on the OCT3 scans. CONCLUSIONS: The authors are unaware of previous reports correlating histology to in vivo human retina OCT3 images. Our findings using human eyes are not different from previous animal studies, in that the plexiform layers are optically highly backscattering and the nuclear layers are not.

Aged↗
PubMed2006

Common ENT disorders.

OBJECTIVE: To provide a succinct and updated discussion on common ear, nose, and throat (ENT) disorders encountered by primary care physicians. METHODS: Review of recent and pertinent literature. RESULTS: Recent data was identified via a PubMed search as well as commonly utilized texts in otolaryngology. DISCUSSION: While it is impossible to discuss all of the ENT disorders encountered by primary care physicians, it is helpful to have a succinct resource to highlight the common disorders and their presenting signs, symptoms and initial treatments. CONCLUSION: Recognizing specific signs and symptoms can help primary care physicians diagnose common ENT disorders. This review discusses these presentations and provides the initial management steps, as well as when to refer patients for further evaluation.

Clinical Competence↗
PubMed2005

Phase I trial and pharmacokinetics of escalating doses of paclitaxel and concurrent hyperfractionated radiotherapy with or without amifostine in patients with advanced head and neck carcinoma.

BACKGROUND: Amifostine was developed to protect normal tissues from radiation exposure. The current study was undertaken to determine whether amifostine would allow the delivery of greater numbers of weekly paclitaxel treatments with concomitant, hyperfractionated radiotherapy in patients with advanced head and neck carcinoma. METHODS: Patients received radiation therapy twice daily using 1.6-gray (Gy) fractions up to a total of 70.4 Gy over an elapsed time of 6.5 weeks. All patients received paclitaxel 60 mg/m(2) once weekly starting on Day 1. The number of doses of paclitaxel was escalated from three to a maximum of six in groups of three patients. For the patients who received amifostine, a dose of 400 mg/m(2) was given intravenously over 15 minutes on Days 1-5, 8, 29-33, and 36. Patients underwent surgery for persistent tumor after radiotherapy. The plasma pharmacokinetics of paclitaxel were characterized during treatment with the first weekly dose to determine the effect of concurrently administered amifostine. RESULTS: Thirty-six patients were evaluable for this study. In the absence of amifostine, a maximum of four doses of paclitaxel were tolerated in combination with the radiotherapy. With amifostine, up to five doses of paclitaxel could be given. Generally, the treatment resulted in Grade 2 and 3 stomatitis. Overall, 69% of patients had a complete remission, and 29% had a partial remission. Both progression-free survival and overall survival were 66% at 30 months. Amifostine had no effect on the pharmacokinetics of paclitaxel. CONCLUSIONS: The administration of amifostine allowed the authors to give an additional dose of paclitaxel to patients who were undergoing hyperfractionated radiotherapy for head and neck carcinoma. This treatment regimen resulted in a high frequency of complete remissions and an excellent progression-free survival pattern without compromising the plasma kinetics of paclitaxel.

Amifostine↗
PubMed2005

Clopidogrel use for reducing the rate of thrombosis in a rat model of microarterial anastomosis.

OBJECTIVES: The national success rate for microvascular free tissue transfer is around 94%. However, in cases of failure, which is most often due to thrombosis in the vascular pedicle, the morbidity can be significant. Microvascular surgeons have used various pharmacologic agents to reduce thrombosis rates; however, none have been ideal. We examined the effects of clopidogrel bisulfate (Plavix), a member of the relatively new class of antiplatelet agents, on the rate of arterial thrombosis in a rat model. DESIGN: Prospective randomized, blinded. SETTING: Tertiary care academic medical center. SUBJECTS: Male Sprague-Dawley rats weighing between 350 and 400 g. INTERVENTION: Clopidogrel or placebo via gavage. After waiting 2 hours for absorption and activation, the "tuck" model of microvascular anastomosis was performed on both femoral arteries. Arteries were transected after 3 hours and patency was assessed. MAIN OUTCOME MEASURES: Bleeding time was obtained by determining the time to clot after removal of 2 mm from the tail tip. Vessel patency was assessed after 3 hours in the clopidogrel-treated and control groups. RESULTS: Of 33 arteries, 19 (58%) in the control group developed complete thrombosis by the end of the period compared with only 6 (19%) of 32 arteries in the group that received clopidogrel. Chi(2) analysis revealed this to be significant (P = .001). The mean (SD) bleeding time in the control group was 158 (44) seconds compared with 233 (48) seconds in the clopidogrel group. CONCLUSIONS: Clopidogrel significantly reduced the rate of arterial thrombosis in a rat model of microvascular repair. The average bleeding time in the clopidogrel group was prolonged, suggesting that absorption and activation occurred. These preliminary data suggest a potential role for clopidogrel in select high-risk patients undergoing microvascular free tissue transfer.

Anastomosis, Surgical↗
PubMed2005

Early use of a mechanical stretching device to improve mandibular mobility after composite resection: a pilot study.

OBJECTIVE: To evaluate the use of a mechanical stretching device, the Therabite, for the early postoperative management of trismus in select patients. DESIGN: Prospective series of consecutive head and neck cancer patients. SETTING: Academic, tertiary referral center. PARTICIPANTS: Seven patients with oropharyngeal carcinoma who underwent resection and radial forearm flap reconstruction. Five had midline mandibulotomy procedures for exposure. Six had radiation therapy (2 pre, 4 post). INTERVENTIONS: Patients were given a Therabite mechanical jaw mobilization device, were instructed in its proper use, and began using it within 6 weeks postoperatively. MAIN OUTCOME MEASURES: Maximal interincisor opening (MIO) was measured at the beginning of use and at the most recent postoperative visit. A 5-question self-assessment telephone survey was administered on study completion. RESULTS: The average MIO was 30 mm (range, 21-38 mm) at the beginning of the study and 40 mm (range, 30-57 mm) at the last visit. Average gain in MIO was 10 mm (range, 1-21 mm). Four of 5 assessable patients had minimal or no limitation on overall quality of life relative to jaw opening. No complications were associated with use of the device. Two patients could not be located for follow-up. CONCLUSIONS: The Therabite mechanical stretching device is effective and safe for the management of trismus in a select group of head and neck cancer patients after extensive ablation and complex reconstruction. Specifically, there were no adverse effects in the 5 patients who had undergone midline mandibulotomy.

Adult↗
PubMed2005

Success of multiple, sequential, free tissue transfers to the head and neck.

INTRODUCTION: Free tissue transfer has become the primary reconstructive modality for significant ablative defects in the head and neck. The overall success rate is high, approaching 95% in most centers. The success rate of multiple sequential free flaps has been thought to be lower, based on the absence of optimal vessel availability and the presence of significant scar tissue in the previously operated patient. We evaluated a series of patients who underwent multiple free flaps at different time points to determine the overall success rate and to identify pitfalls encountered in this population. METHODS: Retrospective review, tertiary care medical center. RESULTS: From 1995 to 2002, 377 free flaps were performed by our reconstructive service. Of this group, 36 underwent multiple free flaps at different time points. Thirty-two had two flaps, and four had three flaps. Reasons for performing sequential free flap procedures were as follows: recurrent disease/new primary (18), need for further augmentation (10), failed previous flap (6), delayed mandibular reconstruction after plate fracture (2), mandibular osteoradionecrosis (3), and delayed pharyngoesophageal stenosis (1). The overall failure rate on the second and third flap was 2 of 32 and 0 of 4, respectively, with an overall success rate of 94%. CONCLUSION: Multiple, sequential, free tissue transfer for reconstruction of head and neck defects is a safe and reliable procedure with success rates equal to that in patients undergoing initial free flap reconstruction. Careful preoperative planning can result in optimal outcomes even in this difficult patient population.

Adult↗
PubMed2005

Effects of aspirin and low-dose heparin in head and neck reconstruction using microvascular free flaps.

OBJECTIVE: The success of microvascular free-tissue transfer to the head and neck has been greatly increased secondary to increased experience, yet postoperative anticoagulation continues to be routinely used to prevent pedicle thrombosis. However, there is currently no consensus as to what the ideal regimen, if any, is recommended for postoperative anticoagulation. This study reviews the outcome and incidence of perioperative complications in patients undergoing free flaps for head and neck reconstruction, using a simple postoperative anticoagulation regimen of aspirin and subcutaneous heparin (SQH). DESIGN: Retrospective chart review. METHODS: With institutional review board approval, the charts of 261 patients undergoing free flap reconstruction from January 2000 to January 2004 were retrospectively reviewed. Patients who received a standard postoperative anticoagulation regimen of SQH (5000 U SC bid) and aspirin (325 mg PO qd) were included in the study (216 patients). Charts were reviewed for postoperative complications, specifically for free flap failure, vascular compromise (arterial insufficiency/venous congestion), and hematoma. RESULTS: There were six flap failures (2.8%), resulting in an overall free flap survival rate of 97.2%. There were six patients with venous congestion of the flap that required neck exploration (2.8%), and 12 patients with postoperative hematoma (5.6%), requiring surgical intervention. CONCLUSION: The free flap survival rate in patients undergoing head and neck reconstruction using this simple anticoagulation regimen of aspirin and SQH appears to be equivalent to the free flap survival rate in patients using other anticoagulation agents. In addition, aspirin and SQH do not increase the incidence of postoperative hematoma when compared with the other anticoagulation agents. Therefore, aspirin and SQH appear to be reliable postoperative anticoagulation agents for patients undergoing head and neck reconstruction using free flaps.

Adolescent↗
PubMed2004

Operative prevention and management of voice-limiting pharyngoesophageal spasm.

Voice-limiting pharyngoesophageal spasm presents a challenge to the surgeon who is trying to optimize functional voice outcomes in the laryngectomy patient. Modified closure techniques, adjunctive myotomy, and pharyngeal plexus neurectomy have the ability to improve or prevent pharyngoesophageal spasm. Attempts to maximize vocal outcome should be considered at the original time of laryngectomy and tracheoesophageal voice restoration because salvage treatment can be challenging.

Botulinum Toxins, Type A↗
PubMed2004

Tracheoesophageal speech following laryngopharyngectomy and pharyngeal reconstruction.

Voice restoration following total laryngectomy and pharyngeal reconstruction is an achievable yet challenging reconstructive task. Because numerous methods exist for pharyngeal reconstruction in conjunction with total laryngectomy, a thorough knowledge of the tissues used for reconstruction is necessary. This knowledge allows for realistic expectations for patient success. Also, specific modifications in voice restoration may be necessary with individual reconstruction methods. This article reviews the methods for reconstruction and the available literature on voice restoration in reconstructed patients.

Gastric Mucosa↗
PubMed2004

Sinonasal malignancies.

Sinonasal malignancies are highly heterogeneous lesions that are challenging to diagnose, treat, and follow clinically. Outcomes remain relatively poor and are associated with late diagnosis, difficult surgical anatomy, and a lack of effective adjuvant modalities of treatment. New multimodal treatment protocols addressed to specific tumor entities are being assessed with promising results. Because of the relative rarity of these lesions, however, progress is slow. The best therapeutic outcomes are achieved in the setting of early diagnosis combined with a meticulous, comprehensive, multidisciplinary approach to the management of these complex tumors.

Humans↗
PubMed2004

Pedicled temporoparietal fascial flap reconstruction of select intraoral defects.

OBJECTIVES/HYPOTHESIS: Multiple modalities exist for reconstruction of oral cavity defects following resection. Although microvascular free tissue transfer is often the first choice for complex intraoral defect reconstruction, not all patients are suitable candidates for "free flaps." The authors present their experience with the pedicled temporoparietal fascial flap (TPFF) for reconstruction of selected intraoral defects. STUDY DESIGN: Retrospective chart review. METHODS: Charts of patients who underwent a TPFF for reconstruction of intraoral defects at a tertiary academic institution between 2001 to 2003 were reviewed. Information regarding tumor, surgical procedure, complications, and results was gathered. The anatomy and surgical technique of using the TPFF for intraoral reconstruction were reviewed. RESULTS: Three patients underwent reconstruction of an intraoral defect with a TPFF. All defects were on the lateral buccal space with significant anterior or posterior extension. All patients had specific contraindications for free flaps, including compromised donor site or recipient site vascularity and medical comorbidity. The procedures were uncomplicated. There was no incidence of flap failure, and all flaps accepted a split-thickness skin graft. The average hospital stay was 7 days. An oral diet was begun on the fifth postoperative day. The cosmetic result at the donor site was excellent. Follow-up has ranged from 7 to 30 months. Mild contracture of the flap developed in two patients, limiting mandibular motion. CONCLUSION: The TPFF is a thin, vascular, durable flap that is a viable option for reconstruction of selected intraoral defects in patients who are not suitable candidates for other methods.

Aged↗
PubMed2004

Mandibular reconstruction in 2004: an analysis of different techniques.

PURPOSE OF REVIEW: The field of mandibular reconstruction has evolved dramatically over the past fifty years. Numerous advances in microsurgical technique, plating technology and instrumentation, and an understanding of donor site angiosomes have made consistent and reliable mandibular reconstruction possible. Refinements in technique continue to improve the functional and aesthetic outcomes of oromandibular reconstruction. This review discusses the current state-of-the-art techniques for mandibular reconstruction and highlights the latest innovations in technique. RECENT FINDINGS: The most common indication for oromandibular reconstruction remains ablative surgery for advanced neoplastic processes of the oral cavity and oropharynx. Reconstruction of these complex three-dimensional composite bony and soft-tissue defects is paramount for rehabilitation of form and function. Vascularized osseous free tissue transfer is the state-of-the-art for mandibular reconstruction. The long-term excellent functional and aesthetic outcomes of this technique have recently been reported. The most commonly used free flaps for mandibular reconstruction are the fibula, iliac crest, and scapula. Each of these typically accepts endosseous implants improving functional outcomes. The use of mandibular reconstruction plates and coverage with a soft-tissue flap remains a reconstructive option for selected patients. The latest refinements in technique include temporary intraoperative external fixation, the use of periosteal free flaps, distraction osteogenesis, and development of biodegradable biopolymer scaffolds for mandibular defects. SUMMARY: Oromandibular reconstruction, although a challenge for the head and neck reconstructive surgeon, is now reliable and highly successful with excellent long-term functional and aesthetic outcomes.

Bone Transplantation↗
PubMed2004

Follow-up quality of life assessment in patients after head and neck surgery as evaluated by lay caregivers.

OBJECTIVE/HYPOTHESIS: As rehabilitation after head and neck surgery is increasingly dependent upon caregivers with no formal training (lay caregivers), the lay caregiver's assessment of the patient's quality of life (QOL) status may be critical to successful rehabilitative efforts. This study evaluates lay caregiver QOL assessment at six and 12 months post-operatively and compares the findings to pre-operative assessments. MATERIALS AND METHODS: Twenty-five patients undergoing head and neck surgery and their primary lay caregivers completed the Medical Outcomes Survey Short Form 36 (SF-36) pre-operatively and were followed. Six and 12-month post-operative forms were completed and compared for available patient/lay caregiver pairs. Pair assessment was considered congruent if the lay caregiver's assessment of each domain of the SF-36 fell within the 90th % confidence interval of the patient's score. High congruence was defined as congruence between the pairs for six or more of the eight domains. Results were also related to previously published preoperative data. RESULTS: Fourteen and six patient/lay caregiver pairs completed the six and 12-month follow-up forms, respectively. Overall congruence was 55% and 45% at six and 12 months, respectively, down from 70% found pre-operatively. Forty-two percent and 17% of the patient/lay caregiver pairs were highly congruent at six and 12 months, respectively. Both values were below the 60% high congruence value noted pre-operatively. The trend toward lay caregivers underrating general health was maintained, while overrating of bodily pain leveled at six months and returned at 12 months. Same generation pairs demonstrated a steady decrease in high congruence levels at six and 12 months. Recurrent disease status no longer predicted high congruence at six or 12 months. CONCLUSION: Trends predicting high congruence in patient/lay caregiver QOL assessment identified preoperatively were not maintained in the post-operative evaluations, except the underrating of patients' general health status. Lay caregiver ability to accurately assess patient QOL status did not improve and, in fact, appeared to worsen. Further study into lay caregiver assessment of patients' quality of life status following head and neck surgery is warranted. Efforts should be directed toward the use of standardized assessment tools and anticipation of subject dropout with greater subject recruitment.

Aged↗