Biomedical subjects
F E Lucente
Publications and source records attributed to F E Lucente.
Resident work hours and working environment in otolaryngology. Analysis of daily activity and resident perception.
OBJECTIVE: --To analyze the working environment and work hours of a cohort of otolaryngology--head and neck surgery residents. DESIGN: --Environmental analysis questionnaire and a log of daily activities. SETTING: --Residents were on a clinical rotation system. PARTICIPANTS: --Fifty-nine residents from six programs, including three public and three private institutions, from geographically diverse regions of the country were involved in the study. Residents were equally distributed from their second year through their fifth year of postgraduate work. All eligible residents participated in and completed the study. INTERVENTION: --The environmental analysis survey was designed to elicit resident perception of different aspects of their working environment. The daily activity log required the resident to report on activities for each half-hour period for 7 consecutive days. RESULTS: --Residents were on call an average of 52.8 hours (2.2 days) and worked 79.4 hours per week. Seventy-five percent believed that the level of faculty supervision and the degree of resident responsibility was about right. Two major inefficiencies were the time involved in completion of paperwork and the lack of nonmedical support services. Thirty-one percent of the residents responded that fatigue resulted in substandard patient care 10% of the time. Forty-seven percent responded that their educational experience was substandard 25% of the time secondary to fatigue. Two thirds responded that the demands of residency training had a negative impact on their family and personal life. CONCLUSIONS: --Seventy percent of the otolaryngology--head and neck surgery residents surveyed at six institutions believe that an 80-hour workweek, including being on call every third night with no more than 24 hours of continuous work without sleep, approximates a reasonable, maximum work schedule. Residents working the longest hours expressed concern about rendering substandard care and developing negative attitudes toward patients. Noneducational inefficiencies were identified and solutions were proposed. Demands of residency training, even within guidelines established as reasonable, can have detrimental effects on residents' educational activities and personal life.
Otolaryngologic aspects of acquired immunodeficiency syndrome.
Currently, most patients with AIDS present with a manifestation involving the head, neck, or respiratory tract. The otolaryngologist may be the first physician to evaluate the patient with HIV infection and, therefore, must be aware of the various manifestations. The otolaryngologist may also be involved in diagnosing and managing the disease through modalities such as biopsy, endoscopy, tracheotomy, and other surgical procedures. In all phases of care, it is important to retain a medically appropriate and psychologically supportive environment. Although universal precautions should be followed in all phases of care, there is no need to avoid the supportive gestures such as handshaking and shoulder patting. These contacts can be most comforting to patients. Physicians should also be aware of all sources of information and medical assistance within the community that might be of further assistance to patients. The AIDS epidemic presents an enormous challenge to all health care providers. Good interdisciplinary communication among the various specialists involved in the AIDS epidemic will promote increased standards of patient care. Such communication will also provide information and support for physicians who are uncomfortable with the challenges of this epidemic.
Electromyography of masticatory muscles in craniomandibular disorders.
Patients presenting to the otolaryngologist with complaints such as otalgia, dizziness, tinnitus, or fullness in the ear may be experiencing the effects of craniomandibular disorders. These disorders can involve dysfunction in the delicate interrelationship of the skull, mandible, cervical vertebrae, and neuromuscular apparatus and can present as myofacial pain. Electromyographic recordings using surface electrodes were made bilaterally on the masseter, anterior temporalis, and digastric muscles in 641 craniomandibular patients, before and after transcutaneous electrical neural stimulation, at their initial presentation and following the insertion of mandibular orthopedic appliances. In the presenting patient, muscle-resting levels significantly decreased from hyperactive levels with transcutaneous electrical neural stimulation therapy. The creation of a new occlusal position with an orthotic appliance was found to correlate with a significant reduction in otolaryngologic symptoms as well as an increase in maximum muscle activity in function and coordination of muscle groups during mandibular movement. Thus, clinical electromyographic studies are an important aid in the treatment of craniomandibular disorders.
Benign nasopharyngeal masses and human immunodeficiency virus infection.
Manifestations of the acquired immunodeficiency syndrome are common in the head and neck and are becoming well known to the otolaryngologist. We present a series of seven patients who complained of nasal obstruction and hearing loss and were found, on examination, to have large obstructing nasopharyngeal masses and otitis media with effusion. Biopsy revealed benign lymphoid proliferation. Because of a suspicion of human immunodeficiency virus infection by history, antibody titers were obtained and were found to be positive in all cases. With the known increased rate of aggressive extranodal B-cell lymphomas in human immunodeficiency virus-infected patients, its existence in the nasopharynx should be ruled out histologically in symptomatic patients. Nasal obstruction and hearing loss secondary to nasopharyngeal lymphoid proliferation in high-risk patients can be an early sign of human immunodeficiency virus infection. Patients presenting with this clinical entity should be advised to have serologic testing and further treatment and counseling if necessary.
Calibrated approach to endoscopic sinus surgery.
Endoscopic sinus surgery, in which the surgeon views the nose and paranasal sinuses through a telescope, can potentially lead to loss of perspective of the patient's entire head. Preoperative computed tomographs are also taken at angles different from those encountered in the surgical setting. As a result, the appropriate angle and depth of instrument insertion can fail to be appreciated. In order to study those angles and depths in a setting that more closely resembles the clinical situation in the operating room, we have performed 15 cadaver dissections and measured 14 dimensions relevant to the endoscopic approach. We recommend that cadaver dissection be an important part of continued training in sinus surgery. We also recommend that a reference probe be place along the floor of the nose and that endoscopic instruments be calibrated at 1-cm intervals so that the depth of insertion can be monitored by an observer or instructor.
Patient care issues in the acquired immunodeficiency syndrome.
The AIDS epidemic challenges practitioners to examine all aspects of the patient-physician relationship, including forms of interpersonal communication, the scope of physician responsibility, and the influence of the patient care experience on the physician's own psychological well-being. The burden of dealing with these challenges is exacerbated by the almost universally fatal outcome of this disease. Fortunately, there are many sources of information and assistance available to clinicians and their patients.
Sinus and nasal manifestations of the acquired immunodeficiency syndrome.
The AIDS epidemic has made previously uncommon infectious diseases and tumors commonplace in HIV-infected individuals. In this article we discuss specific cases of various infections and tumors of the sinonasal tract. Several of these diseases may be the presenting signs of HIV-seropositivity and AIDS. As a result, the clinician first to see such patients must be aware of the diagnosis of these diseases and tumors so that proper testing and treatment may ensue.
Carbon dioxide laser excision of earlobe keloids. A prospective study and critical analysis of existing data.
When steroid injections have failed, the most common approach for the treatment of earlobe keloids is surgical excision. The carbon dioxide laser has recently been used with varying reported success in the treatment of keloids and hypertrophic scars. Proponents of this technique claim that the intrinsic properties of laser surgery, which slows fibroblast proliferation, may be responsible for delaying or preventing the recurrence of keloids. We report results on the effectiveness of carbon dioxide laser excision of earlobe keloids. Eighteen patients were followed up from 8 months to 2 years, or up to a recurrence. Four patients within this group with bilateral keloids provided a self-controlled sample. One ear was randomly chosen for laser excision and the other for scalpel excision. There were recurrences in both groups. There were also 17 recurrences in a group of 23 keloids excised by laser, 9 occurring between 6 and 12 months postoperatively. We failed to demonstrate a lower recurrence rate of earlobe keloids using the carbon dioxide laser and discuss some of the factors responsible for this outcome.
Computed tomography in patients with laryngeal carcinoma: a clinical perspective.
Among the various diagnostic modalities that have been recommended for preoperative assessment of the patient with laryngeal carcinoma is computed tomography. While good overall correlation between CT findings and operative findings has been noted, a significant number of false positives and false negatives have been found, particularly with regard to cartilage invasion and lymphadenopathy. We compared the findings of direct laryngoscopy, palpation of the neck, and CT with pathologic specimens in 29 patients who underwent surgery for carcinoma of the larynx. We found that CT scanning underestimated the extent of neoplastic involvement in over half the cases. With respect to cartilage invasion we determined a significant number of false-negative findings. Computed tomographic scanning was equivalent to palpation in predicting cervical metastasis. Our findings indicate that the role of CT scanning may be more limited than previously acknowledged, particularly in patients for whom nonconservation surgery is planned.
Use of ceftazidime for malignant external otitis.
During the past 2 years we have used ceftazidime (Fortaz), a third-generation cephalosporin, in the treatment of eight patients with progressive necrotizing "malignant" external otitis. Ceftazidime is very active against Pseudomonas species and provides penetration into the CSF. Our results suggest that this medication has several advantages over the previously recommended combinations of aminoglycosides and semisynthetic penicillins, including improved cure rate, lower toxicity, and simpler administration schedules. We review our experience with ceftazidime in the treatment of eight patients.
Rhinitis and nasal obstruction.
Inflammation of the nasal mucosa is a common cause of nasal obstruction. The multitude of causes are discussed, and treatment protocols are detailed.
Osteoma of the tongue.
Osteomas are benign bony neoplasms commonly found in long bones and in the skull and facial bones. Osseous growths within soft tissue structures of the head and neck are rare. Review of the English literature reveals only 31 cases of osteomas within the soft tissues of the tongue and 2 in the buccal mucosa. We report on a patient with a bony hard asymptomatic mass at the base of the tongue, which was found to be an osteoma by biopsy. Complete removal was declined by the patient. There was no progression during a six-month period of follow-up.
AIDS and the otolaryngologist.
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Submucosal hypopharyngeal lipoma.
We present the case of a 58-year-old man with a history of dysphagia, who was found to have a submucosal lipoma of the hypopharynx. The lesion was removed endoscopically, with resolution of the patient's symptoms. Lipomas are benign fatty neoplasms commonly found in the soft tissues of the neck. Although they are rarely seen in the tissues of the upper aerodigestive tract, they must be considered in the differential diagnosis of hypopharyngeal masses that may cause dysphagia.
Total Patient Care Conference.
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In vitro effectiveness of 13 agents in otomycosis and review of the literature.
Many agents have been recommended for treating otomycosis, but no preparation has been widely accepted. To compare the effectiveness of many recommended preparations, we performed an in vitro study using 15 species of fungi and yeast cultured from patients presenting with otomycosis during the past year. By measuring zones of inhibition, we assessed the effectiveness of aqueous Merthiolate, Burow's solution (2%), VoSol HC, VoSol plain, Cortisporin suspension, clotrimazole 1%, Mycostatin, amphotericin B, ethanol 95%, miconazole, tolnaftate 1%, natamycin, and flucytosine. Most otic preparations showed little or no growth inhibition. However, Merthiolate was very effective against all organisms tested, clotrimazole was very effective against most yeast and fungi tested, and nystatin had the widest spectrum of activity among the antifungals. Tolnaftate was ineffective. Vigorous cleaning of the external auditory canal remains the mainstay in treating otymycosis, but proper laboratory identification and suitable topical therapy are also important in dealing with this capricious infection.
The Caldwell-Luc procedure: institutional review of 670 cases: 1975-1985.
The Caldwell-Luc procedure, which has long been fundamental in the treatment of perisinus disease, has undergone increasing scrutiny when used for inflammatory antritis. Individual morbidity rates of less than 10% to greater than 40% have been reported. To assess the data from our own institution, a retrospective study of 670 Caldwell-Luc procedures was undertaken. Patients ranged in age from 10 to 82, with a mean age of 42.9 years. There were 271 males and 325 females. Parameters studied included symptoms, physical findings, operative techniques, surgical findings, length of hospitalization, and postoperative complications. Immediate postoperative complications included facial swelling in 89% of patients, cheek discomfort in 33%, significant hemorrhage in 2.9%, and temperature elevation in 12.1%. Long-term follow-up ranged from 2 years to 10 years. Overall complication rates in 464 patients included facial asymmetry (3), facial numbness or paresthesia (42), oroantral fistulas (5), gingivolabial wound dehiscences (7), dacryocystitis (12), devitalized tooth (2), recurrent sinusitis (56), and recurrent polyposis (25). A revision antrostomy was required in 37 patients, a revision Caldwell-Luc in 22 patients, an intranasal sphenoethmoidectomy in 17, and root canal therapy in 2 patients. The most frequent complication was recurrent nasal obstruction, occurring in 28% of patients. Overall complication rates tended to increase with a longer follow-up period.