Dermoid cyst of the floor of the mouth.
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Adult↗
Biomedical subjects
M K Wax
Publications and source records attributed to M K Wax.
Transient-evoked otoacoustic emissions in children after cisplatin chemotherapy.
Little is known about cisplatin ototoxicity in pediatric patients. Measurement of otoacoustic emissions is a rapid, reproducible, objective method of evaluating hearing. We examined whether transient-evoked otoacoustic emissions in pediatric patients exposed to cisplatin in the past correlated with audiographic findings. Twelve patients were entered into the study (mean age at treatment 7.8 years, mean cumulative dose 442.5 mg/mm2, mean 7.1 doses). Hearing at 3000 Hz was preserved in 82.6% of patients. In the higher frequencies significant sensorineural hearing loss was noted: 43.5% at 4 kHz; 81.0% at 6 kHz; and 90.5% at 8 kHz. Transient-evoked otoacoustic emissions were measurable in 11 of 12 patients. Middle ear disease accounted for abnormal otoacoustic emission seen in three patients (1 with effusion, 2 with significant negative middle ear pressure). When the middle ear was normal, a statistically significant correlation was seen between the transient-evoked otoacoustic emissions reproducibility and pure-tone threshold (correlation coefficient = -0.69, p = 0.008). Increased hearing loss was also associated with young age at first dose of cisplatin (p = 0.044), high number of chemotherapy cycles (p = 0.042), and high cumulative dose (p = 0.042).
Adolescent↗
Imaging quiz case 2. Malignant peripheral nerve sheath tumor (PNST) of the greater auricular nerve.
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Aged↗
Positron emission tomography in the evaluation of the negative neck in patients with oral cavity cancer.
OBJECTIVE: Proper management of the clinically negative neck (N0) in patients with squamous cell carcinoma (SCC) of the oral cavity (OC) is controversial. Detecting cervical metastasis in these patients is important, because cervical lymph node metastasis is associated with an unfavourable prognosis. Conventional radiographic studies, such as computerized tomography (CT) and magnetic resonance imaging (MRI), may augment physical examination. However, there are still limitations of these modalities in detecting the presence of metastatic cervical disease. Positron emission tomography (PET) is a functional imaging modality that has recently been used in patients to detect head and neck neoplasms. We report using PET in the evaluation of the N0 neck in 11 consecutive patients with SCC of the OC who underwent neck dissection. METHOD: The results of PET scans were correlated with the pathologic findings of 19 neck dissections. RESULTS: Four patients (36%) undergoing 7 neck dissections (37%) had pathologic evidence of disease. Positron emission tomography scans were positive in all of these patients and in all pathologically confirmed cervical metastasis. Seven patients (64%) undergoing 12 neck dissections (63%) had no pathologic evidence of cervical metastasis. Positron emission tomography scans were negative for malignancy in all of these seven patients. In the patient with SCC of the OC with a clinically N0 neck, we found PET to have an overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 100%. Computerized tomography demonstrated 40%, 88%, 67%, 70%, 69%, respectively. In all statistical categories except specificity (p = .1), PET demonstrated statistical significance (p < .05) over CT. CONCLUSION: Positron emission tomography appears to be a promising diagnostic aid that may be applied when evaluating the N0 neck for patients with SCC of the OC.
Adult↗
Internal jugular vein thrombosis after functional and selective neck dissection.
OBJECTIVE: To determine the incidence of internal jugular vein thrombosis after functional or selective neck dissection. DESIGN: Patients underwent serial Doppler ultrasonographic examinations of their internal jugular veins, on postoperative days 1 and 7, following functional neck dissection. Long-term follow-up was conducted at a minimum of 3 months. SETTING: Department of Otolaryngology, West Virginia University, Morgantown. PATIENTS: Sixty-five patients (51 men and 14 women) underwent 100 functional neck dissections between 1993 and 1995. Thirty-five patients had N0, 10 had N1, and 20 had N2 node involvement, respectively. Thirty-five patients underwent bilateral neck dissection, 17 underwent left neck dissection, and 13 underwent right neck dissection. MAIN OUTCOME MEASURES: Thrombosis of the internal jugular veins was determined using duplex Doppler scanning. Correlation with the length of the procedure, intraoperative blood loss, preoperative radiation therapy, stage of neck disease, presence of extracapsular spread, wound infection, and pedicled musculocutaneous flap closure was determined. RESULTS: Of the 100 internal jugular veins studied, 20 (24.7%) of 81 and 19 (26.4%) of 72 were found to have evidence of thrombosis on postoperative days 1 and 7, respectively. On long-term follow-up, the incidence of internal jugular vein thrombosis was significantly lower (5.8%; P < .001). None of the variables examined correlated significantly with the presence of thrombosis. Of the 20 veins that were thrombosed initially, on follow-up 13 had normal flow and 2 had persistent thrombosis. Five patients were unavailable for follow-up. No thrombosis developed as a late finding. CONCLUSIONS: Our results indicate that even though the incidence of internal jugular vein thrombosis is relatively high immediately following neck dissection, a significant number of these veins will undergo recanalization and have excellent long-term patency.
Adult↗
Value of preoperative prothrombin time/partial thromboplastin time as a predictor of postoperative hemorrhage in pediatric patients undergoing tonsillectomy.
OBJECTIVE: Hemorrhage after tonsillectomy is a potentially lethal complication. Preoperative assessment consisting of prothrombin time (PT) and activated partial thromboplastin time (PTT) has been used to identify patients at risk for hemorrhage after tonsillectomy and adenoidectomy. We sought to assess the value of PT/PTT screening as a predictor of posttonsillectomy hemorrhage. DESIGN: A retrospective chart review was carried out with a minimum of 1 month follow-up. SETTING: Tertiary academic referral center. PATIENTS: Between January 1992 and June 1995, 382 patients undergoing tonsillectomy were examined; 339 patients with a minimum of 1 month follow-up were reviewed for this study. MAIN OUTCOME MEASURE: Normal and prolonged PT/PTT values were examined. Bleeding in the intraoperative, immediate postoperative, and delayed phases of healing was examined. RESULTS: Two-hundred and twenty-two patients had normal PT/PTT, 39 had prolonged PT/PTT, and 78 had no preoperative studies performed. Bleeding occurred in 2.7%, 2.6%, and 3.3%, respectively, of patients. Eight patients had positive family histories of bleeding tendencies. One patient (12.5%) with a normal PT/PTT experienced a delayed posttonsillectomy bleed. Of 39 patients with abnormal coagulation studies, 30 were borderline elevations with no repeat studies done; one patient experienced postoperative hemorrhage. Nine abnormal results were repeated; three returned to normal, three remained prolonged but underwent tonsillectomy with no intervention, and three received hematology consultations. One patient had lupus anticoagulant, one had Hageman Factor deficiency, and one was cleared for surgery with no diagnosis. All patients underwent tonsillectomy with no episodes of postoperative bleeding. CONCLUSIONS: Preoperative PT/PTT provides no additional information than does a bleeding history for the general pediatric population undergoing tonsillectomy. This should only be done in selective cases where warranted by history.
Child↗
The use of lidocaine in microvascular reconstruction.
Vasospasm is known to have an adverse effect on the survival of free tissue transfers. Prolonged vasoconstriction decreases blood flow to the flap and promotes thrombosis at the anastomotic site. Because of its wide availability and rapid effect, topically applied lidocaine is used by many surgeons to prevent and correct vasospasm. Mucosal absorption of lidocaine is known to be rapid. Absorption by the surgical bed during microvascular reconstruction has not previously been determined. We had three specific aims: (1) to determine whether systemic absorption occurs, (2) if so, to determine the degree of absorption, and (3) to determine whether the type of reconstruction affects the degree of absorption. Twelve consecutive patients were entered into the study, four in a myocutaneous reconstructive group and eight in a fasciocutaneous group. Baseline serum lidocaine levels were drawn. After the initial application of lidocaine, levels were drawn every 30 minutes. Final levels were drawn 120 minutes after the last application. The total amount of lidocaine used ranged from 720 mg to 2600 mg. Application ranged from 7.5 mg/minute to 34.7 mg/minute (2 to 9 times the estimated toxic dose of 4 mg/minute for a patient weighing 70 kg). Results ranged from undetectable (<0.5 microg/ml) to minimal therapeutic levels (1.6 microg/ml). Toxic levels (>6.0 microg/ml) were not encountered. Significant (p < 0.05) differences were found between the fasciocutaneous group, which generally had no detectable serum levels, and the myocutaneous group, which had detectable subtherapeutic to minimally therapeutic levels. Doses considered toxic by intravenous or mucous membrane application may safely be applied topically. Greater absorption was found in the myocutaneous group, which is believed to be a result of the richer absorption surface provided by the muscular tissue.
Absorption↗
Contemporary management of cerebrospinal fluid rhinorrhea.
Management of patients with cerebrospinal fluid rhinorrhea (CSF) remains controversial. Most studies recommend either an endoscopic or an external extracranial approach, depending on the surgeon's preference. Eighteen patients with CSF rhinorrhea have been managed at our institution since 1990. The causes of the CSF rhinorrhea consisted of functional endoscopic sinus surgery (7), lateral rhinotomy with excision of a benign nasal tumor (3), spontaneous rhinorrhea (7), and secondary repair after intranasal ethmoidectomy (1). In 11 patients the CSF leak was recognized at the time of surgery; in 10 of these patients it was repaired during the primary surgery, whereas one patient underwent secondary repair after failure of conservative management of his CSF fistula. Seven patients underwent exploration for spontaneous CSF rhinorrhea. Four patients had computer tomography scans that showed the leak, and two patients had cisternography to localize the leak. One patient underwent magnetic resonance cisternography. Both of these leaks were identified with cisternography and were then confirmed intraoperatively. Repair methods included a pedicled septal mucosal flap (4), a free mucosal graft from the septum (7), and a middle turbinate (5). Two patients had obliteration of the sinus with muscle/fascia and fibrin glue. Eight patients were repaired endoscopically. The remainder underwent repair through external approaches. Seventeen patients (at a minimum 1 year follow-up) remain free from leakage. One patient required a second repair 8 months after surgery. Iatrogenic trauma remains the most common cause of CSF rhinorrhea. Management at the initial setting is the least morbid approach and is successful in 95% of cases. Whether an endoscopic or external approach is used depends on surgical expertise and experience.
Adult↗
Internal jugular vein patency in patients undergoing microvascular reconstruction.
The objective of this study was to determine the incidence of internal jugular vein thrombosis in patients undergoing free flap reconstruction and simultaneous neck dissection. Patients underwent Doppler ultrasound examination of their internal jugular veins on postoperative days 1 and 7 after functional neck dissection and free flap transfer. Long-term follow up was obtained at a minimum of 3 months. The incidence of internal jugular vein thrombosis in patients undergoing free flap reconstruction with simultaneous neck dissection is similar to that of patients undergoing just neck dissection. A significant number of these veins recanalize and have excellent long term patency. There does not seem to be a correlation between venous thrombosis and free flap survival.
Adult↗
Safety of esophagoscopy in the irradiated esophagus.
Carcinoma of the esophagus is a disease with a poor prognosis. Surgery is considered the treatment of choice. Patients who are surgically unresectable may receive radiotherapy, plus or minus chemotherapy. While this offers reasonable palliation, a significant number of patients develop benign or malignant strictures. Frequent esophagoscopy with dilation is required if they are to swallow. Patients with strictures or malignancy of the esophagus are more prone to complications if they undergo an esophagoscopy. We examined the morbidity of esophagoscopy in a group of patients who had received radiotherapy for carcinoma of the esophagus. Over a 10-year period, 21 patients receiving irradiation for carcinoma of the esophagus were examined. All patients underwent esophagoscopy for staging and diagnosis. The tumor locations were upper (6), middle (6), and lower (9) esophagus. The T-stages were 1 (7), 2 (6), 3 (6), and 4 (2). Five patients had dilation of a malignant stricture at the time of diagnosis. Fever developed and resolved within 24 hours in 2 patients. Following completion of irradiation, a total of 83 esophagoscopies were performed (range 1 to 11 per patient). Six patients with no tumor or stricture underwent 8 esophagoscopies (3 rigid, 5 flexible). There was 1 episode of minimal bleeding and 1 fever that resolved within 24 hours. Ten patients with malignant strictures underwent 62 esophagoscopies (5 rigid, 57 flexible). There were 17 (27%) episodes of fever (all resolved within 24 hours) and 14 (22%) episodes of bleeding. Five patients with benign strictures underwent 13 esophagoscopies (2 rigid, 11 flexible). One patient had a perforation that resolved with conservative treatment, and 1 patient developed an epidural abscess 2 months following dilation. This patient is the only one that required surgical intervention and had prolonged hospitalization. Esophagoscopy of the irradiated esophagus can be performed relatively safely and excellent palliation obtained. Morbidity consisting of minimal bleeding, and fever lasting less than 24 hours, is frequent but self-limited.
Adult↗
Pathologic quiz case 1. Primary systemic amyloidosis in a patient with multiple myeloma.
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Aged↗
Positron-emission tomography in parathyroid hyperplasia.
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Humans↗
Epidermal growth factor regulates topoisomerase II activity and drug sensitivity in human KB cells.
Because of its unique DNA-cleaving and strand-passing activities, topoisomerase II is involved in many aspects of DNA metabolism, including replication, transcription, recombination, and repair. The cytotoxic potential of topoisomerase II-targeted drugs, such as etoposide, is related to their ability to stabilize covalently linked enzyme-DNA complexes, which are intermediates in the enzyme's catalytic cycle. Epidermal growth factor receptor is expressed on the cell surface of the majority of squamous cell carcinomas, and epidermal growth factor binding is known to stimulate a number of cellular transduction pathways, including tyrosine kinase, protein kinase C, and phospholipase C. Because topoisomerase II is a proliferation-dependent protein and has been shown to be a high-affinity substrate for many of these cellular transduction pathways, the effects of epidermal growth factor on cellular regulation and sensitivity to etoposide were studied with the human oral cavity squamous cell line, KB. Topoisomerase II catalytic activity was rapidly and transiently inhibited after the addition of epidermal growth factor to the cellular growth media. Western blot on nuclear extracts did not demonstrate alterations in topoisomerase II polypeptide levels to account for changes in catalytic activity. Epidermal growth factor treatment also led to the formation of stabilized, covalently linked enzyme-DNA complexes. Furthermore, epidermal growth factor-induced, topoisomerase II-mediated DNA strand breaks were additive to those induced by etoposide. This study indicates that epidermal growth factor specifically regulates the catalytic and DNA-cleaving activities of topoisomerase II in KB cells. This may direct clinical strategies for circumventing the intrinsic cellular resistance to chemotherapy commonly observed in squamous cell carcinomas of the head and neck.
Antineoplastic Agents, Phytogenic↗
Carotid body tumor resection with the surgical ultrasonic dissector aspirator.
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Carotid Body Tumor↗
Vibrio fluvialis wound infection associated with medicinal leech therapy.
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Aged↗
Pulmonary atelectasis after reconstruction with a latissimus dorsi myocutaneous flap.
Atelectasis is the most common postoperative complication encountered in head and neck surgery. Risk factors include preexisting pulmonary disease, type of surgery performed, and the length of anesthetic. It is controversial whether reconstruction of defects with regional myogenous flaps predisposes to atelectasis. The latissimus dorsi myocutaneous flap requires the patient to be placed on his side for a period of time. Whether it is the position or the surgery that contributes to the development of atelectasis has not been examined. Eighteen patients underwent latissimus dorsi myocutaneous flap reconstruction following major ablative procedures for head and neck cancer. The cutaneous area transferred ranged from 70 to 225 cm2 (mean, 128 cm2). The flap size ranged from 7 x 10 to 15 x 15 cm. The majority of flaps were 10 x 15 cm or greater. These patients were compared to 18 patients who did not undergo pedicled myocutaneous chest flap reconstruction. Patients were matched for age, sex, length of operation, site of primary, and stage of disease. Postoperative atelectasis was radiographically detected in 89% of flap patients vs. 79% of controls. Major atelectasis was encountered in 16% of patients undergoing flap surgery vs. 11% of patients in the control group. Patients with large cutaneous paddles on the flaps (> 120 cm2) had significantly more atelectasis than patients with smaller cutaneous paddles (P<.05, chi-squared). The incidence of radiographic postoperative atelectasis in patients having a latissimus dorsi myocutaneous flap is high. The size of the skin paddle harvested as well as the position change may contribute to this.
Female↗
Lateral-arm free flap for reconstruction in the head and neck.
OBJECTIVE: To describe the role of the lateral-arm free flap in reconstruction of head and neck defects following ablative oncologic surgery and to discuss the anatomy of this flap as well as indications for its use. DESIGN: A prospective study of all patients undergoing a lateral-arm free flap was performed. Up to 3 years of follow-up was obtained. SETTING: Tertiary referral centre. METHOD: A total of 12 lateral-arm free flaps were utilized to reconstruct defects ranging in size from 4 x 7 to 10 x 7 cm. Maximum width of the flap was 7 cm. A mean area of 55 cm2 was harvested. MAIN OUTCOME MEASURES: Flap survival, morbidity, speech intelligibility, and oral function and intake were assessed. RESULTS: The vascular pedicle was reliable with vessel diameters of 1.5 mm, and length of 6 to 7 cm. All flaps survived, and minimal donor site morbidity was encountered. Nine patients maintained good speech with adequate intelligibility while 10 patients maintained adequate oral intake. CONCLUSIONS: Functional results can be obtained with the lateral-arm free flap. A consistent pedicle of good length and size was found. It is our flap of choice in older, thinner individuals when the width of the donor site is less than 7 cm, which allows for primary closure.
Aged↗
Laryngeal tuberculosis. A cause of stridor in children.
The number of tuberculosis (TB) cases reported in the United States has been on the decline for the last three decades. This trend has been dramatically reversed in the past few years, largely owing to the human immunodeficiency virus epidemic. Laryngeal TB, while well recognized in the adult population, is a rare disease in children. Only six cases have been described in the world literature since 1960. We describe three children with laryngeal TB who presented with stridor. One child required an emergency tracheotomy for control of the airway. The pathogenesis of laryngeal TB in children is postulated to differ from that in adults. In children primary infection of the larynx occurs, while in adults, laryngeal infection is secondary to pulmonary disease. All patients had triple anti-TB chemotherapy for 1 year. Laryngeal TB, although rare, may be seen more frequently in the near future and the diagnosis should always be considered.
Child↗