-
[show abstract]
[hide abstract]
ABSTRACT: Endoscopic endonasal transpterygoid approaches (EETA) use the pneumatization of the sinonasal corridor to control lesions of the middle and posterior skull base. These surgical areas are complex and the required surgical corridors are difficult to predict.
Define anatomical landmarks for the preoperative planning of EETAs.
Anatomical study.
We reviewed images from high-resolution maxillofacial CT scans with (0.6-mm axial slice acquisition). Cephalometric measurements were obtained using Kodak Carestream Image Software (Rochester, NY).
Average distance from midline to the vidian canal was 12.78 mm (range 9.4-15.8 mm). Average horizontal distance from the vidian canal to the foramen rotundum was 5.6 mm (range 2.8-11.5 mm). Average vertical distance from the vidian canal to the foramen rotundum was 6.22 mm (range 4.3-9.3 mm). These landmarks are consequential during the preoperative planning of the surgical corridor. To facilitate communication, we classified EETAs as: A) Partial removal of the pterygoid plates (transposition of temporo-parietal fascia); B) removal of anteromedial aspect of the pterygoid process (lesions involving the lateral recess of the sphenoid sinus); C) involves dissecting the vidian nerve to control the petrous ICA and removing the pterygoid plates base to reach the petrous apex, Meckel's cave, or cavernous sinus; D) variable removal of the pterygoid plates to access the infratemporal fossa; and E) removal of pterygoid process and medial third of the Eustachian tube to expose the nasopharynx.
Our novel classification and landmarks system helps to understand the anatomy of this complex area and to accurately plan the EETA.
The Laryngoscope 04/2013; 123(4):811-5. · 1.75 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: Oncologic resection of the nasopharynx is challenging due to its complex and deep-seated nature. We aimed to illustrate the anatomic landmarks of endoscopic nasopharyngectomy and design a surgical training model that could facilitate learning of this technique. METHODS: An endoscopic endonasal dissection of the nasopharynx was completed in fresh cadaveric specimens under conditions similar to those of our operating suite. Digital data from a high-resolution CT scan were imported to an image guidance system to be used during the dissections. RESULTS: We expanded the sinonasal corridor, harvested a contralateral nasoseptal flap, and exposed the pterygopalatine and infratemporal fossae. A detailed anatomic dissection of the nasopharynx was correlated to multiplanar images provided by the image guidance system, highlighting appropriate bony, neural, and vascular landmarks. CONCLUSIONS: Understanding the anatomy-based endoscopic modular approaches facilitates planning and safe execution of an oncologic nasopharyngectomy. Clinical experience remains mandatory because anatomic models fall short of clinical scenarios. © 2012 Wiley Periodicals, Inc. © 2012 Wiley Periodicals, Inc. Head Neck, 2012.
Head & Neck 06/2012; · 2.40 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Perineural invasion (PNI) in cutaneous squamous cell carcinoma of the head and neck (CSCCHN) is associated with decreased survival. Large-nerve PNI presents with clinical signs and symptoms and/or magnetic resonance imaging evidence of cranial nerve involvement. We sought to determine which variables predict a worse outcome and to analyze patterns of failure.
Case series with planned data collection.
Tertiary care center.
Patients with large-nerve PNI from CSCCHN between 1996 and 2006 were identified from a prospectively collected database. Clinical and demographic variables were recorded. Local control rates and survival analysis were performed using Kaplan-Meier curves.
Thirty-six patients were identified (28 men and 8 women). The mean age was 61 years. Twenty-nine were treated with curative intent, and 7 received palliation. The mean follow-up was 35 months. Involvement of V3, disease zone, and the type of therapy were significantly associated with overall survival (P < .05). The 5-year disease-free survival for patients by therapy was 50% for subcranial surgeries, 53.6% for skull base surgery, and 0% for radiation and palliative therapies (P < .001). None of the patients treated with a skull base resection had a central recurrence, while all patients who received palliation had a central failure.
Disease extent, type of therapy, and involvement of V3 are all significant predictors of survival in PNI from CSCCHN. We confirmed that the natural history of the disease is central progression and that this can be halted, if detected early enough, by a properly planned skull base resection.
Otolaryngology Head and Neck Surgery 01/2012; 146(5):746-51. · 1.72 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Perineural invasion (PNI) in cutaneous squamous cell carcinoma of the head and neck (SCCHN) is associated with decreased survival. Patients with large nerve or clinical PNI present with clinical signs and symptoms or MRI evidence of cranial nerve involvement. These patients often succumb to disease that spreads into the brainstem. In our experience, when the disease extends up to the Gasserian or Geniculate ganglion, surgical resection with negative margins provides the best chance for cure. Herein we review our experience to validate our clinical observations.
We identified patients with large nerve PNI from cutaneous SCCHN between January 1996 and 2006 from a prospectively collected database. Patients who underwent surgical resection as their primary mode of therapy were included. Clinical and demographic variables were recorded. Survival analysis was performed with Kaplan-Meier curves, and the log-rank test was used for significance testing between groups.
Twenty-one patients were identified. The mean age was 60 (range, 38-86) years, with 15 men and 6 women. Nineteen patients had a formal skull base resection, whereas 2 patients had a subcranial resection. We had 3 complications in our series: extradural hemorrhage (n = 1), cerebrospinal fluid leak (n = 1), and wound infection (n = 1). None of the patients who underwent a formal skull base resection to include the lateral cavernous sinus (ie, Gasserian ganglion) suffered ocular palsies or permanent morbidity when the orbit was preserved (n = 11). We had no surgical deaths. The average length of stay was 9 days (SD 6.3 days). The 5-year disease specific survival rate for the entire group was 64.3%. V3 involvement resulted in lower, although not significant, 5-year disease-free survival rates- 0% for those patients with involvement (n = 4) versus 66.8% for no involvement of V3 (n = 17).
Appropriately planned surgical resection of PNI in cutaneous SCCHN up to the ganglion as dictated by the disease extent may improve survival without significant added morbidity. © 2011 Wiley Periodicals, Inc. Head Neck 2011.
Head & Neck 12/2011; 34(11):1622-7. · 2.40 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Local recurrence after primary radiation of nasopharyngeal carcinoma (NPC) remains an important cause of morbidity and mortality. Salvage treatment using reirradiation or surgery has been shown to improve survival over nontreatment. Surgery is traditionally performed using an open approach. Advances in endoscopic approaches for resection of paranasal sinus tumors have been extended to NPC. This article reviews the treatment options, in particular the role of endoscopic nasopharyngectomy in the management of recurrent NPC. The endoscopic anatomy, surgical principles, and published results on endoscopic nasopharyngectomy are presented. Short-term outcomes for early-stage recurrences are promising but long-term follow-up is needed.
Otolaryngologic Clinics of North America 10/2011; 44(5):1141-54. · 1.65 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This article discusses the epidemiology, diagnosis, and management of traumatic cerebrospinal fluid (CSF) leaks. An overview of traumatic CSF leaks is presented, and both conservative and operative therapies are reviewed. Management decisions are discussed based on the current literature. Controversial clinical topics are addressed, including the use of prophylactic antibiotics and the timing of surgical repair.
Otolaryngologic Clinics of North America 08/2011; 44(4):857-73, vii. · 1.65 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The operative management of infratemporal skull base lesions is challenging. Expanded endonasal approaches to this area can decrease surgical morbidity. Access lateral to the natural nasal corridor can be achieved via a middle meatal antrostomy, medial maxillectomy complemented by a septotomy, or anteromedial maxillotomy (i.e., Denker's approach). We sought to compare the access to the infratemporal fossa offered by these endoscopic endonasal approaches.
Software-enabled CT scan measurements.
Axial CT scans obtained with submillimeter cuts through the skull base were examined. All calculations were performed on axial images obtained at the level of the sphenoid floor using Kodak Carestream Image Software (Rochester, NY) measuring tools.
Fifty sides were examined. A medial maxillectomy increased the exposure on average by 18.5 degrees (SD = 4.28), when compared to maxillary antrostomy. When we augmented the access with an ipsilateral Denker's approach, an additional 33.5 degrees (SD = 4.81) of exposure were obtained (P < .0001). The addition of a 1-cm anteromedial maxillotomy accessed the entire posterior maxillary wall in 54% of cases. Equivalent access was obtained via a contralateral approach with a septotomy at 1.56 cm from the columella. To access the entire posterior maxillary wall the average anterior maxillotomy should be 1.1 cm (SD = 0.42). In contrast, to access the entire posterior maxillary wall using a contralateral approach the average septotomy position should be 1.52 cm (SD = 0.39) from the columella.
This radioanatomic study provides objective support for the use of an ipsilateral Denker's approach to augment an endoscopic endonasal approach to the infratemporal fossa.
The Laryngoscope 06/2011; 121(8):1601-5. · 1.75 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: In the past 2 decades, endoscopic sinus surgery has been widely used as a safe and effective treatment for disorders of the paranasal sinuses that are refractory to medical therapy. Advances in surgical technique, including powered instrumentation and stereotactic image-guided surgery, have improved the efficiency and safety of this procedure. These techniques have been further expanded to manage skull base pathologies. This expansion has been facilitated by a better understanding of the endonasal skull base anatomy. Despite these advances, complications are still encountered. Vascular injuries are particularly troublesome. Interior ethmoid artery injuries during sinus surgery that led to orbital hematoma were discussed extensively in a recent issue of this journal. Therefore, this article focuses mainly on inadvertent carotid artery injuries during routine sinus surgery and vascular injuries during endoscopic skull base surgery.
Otolaryngologic Clinics of North America 08/2010; 43(4):817-25. · 1.65 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Technological advances and technical innovations have spearheaded an expansion in the indications for endoscopic sinonasal surgery, which now extend to the resection of sinonasal and skull base malignancies. This review examines recent advances that have contributed to make this technique feasible and reviews the basis of adopting an endonasal approach.
Oncologic goals developed for traditional skull base surgery can be safely applied to endoscopic skull base surgery. This has been made possible with the advent of better understanding of skull base anatomy from the endonasal perspective, as well as the development of better instrumentation, better hemostatic materials and more reliable reconstructive techniques. Recent publications have reported similar short-term outcomes for endoscopic skull base resection as compared with traditional approaches with lower complication rates.
Transnasal endoscopic surgery is an important part of the surgical armamentarium for the treatment of sinonasal and skull base malignancies. New technologies will further expand the limits of what can be achieved endoscopically. Collaborative multiinstitutional studies with long-term follow-up are crucial in defining the role of endoscopic resection in the treatment of skull base malignancies.
Current opinion in otolaryngology & head and neck surgery 04/2010; 18(2):107-13.
-
[show abstract]
[hide abstract]
ABSTRACT: To characterize the endoscopic anatomy of the sphenoid sinus and the adjacent clivus and cavernous sinus, and to review patient outcomes for neoplasms in this region.
Cadaver dissection and chart review.
Cadaver laboratory and tertiary care center.
Fresh-frozen cadaver heads were dissected to study the endoscopic anatomy of the sphenoclival region. Retrospective chart review of patients undergoing endoscopic resection of sphenoclival neoplasms between 2000 and 2008 was performed.
Transnasal endoscopic access to the sphenoid sinus was obtained in 10 cadaver heads. A clival window with mean dimensions of 1.4 cm x 1.7 cm was created. Through the clival window, identification and dissection of the basilar and vertebral arteries, mamillary bodies, third ventricle, cranial nerves III through VI, and cervical rootlets were possible. Nineteen patients with mean age of 56.2 years were treated. The most common pathologies were inverted papilloma (5), chordoma (4), squamous cell carcinoma (2), and adenoid cystic carcinoma (2). None of the patients required adjunct craniotomies. Nine patients received adjuvant therapies. Thirteen (68.4%) patients had no evidence of disease, five (26.3%) patients were alive with disease, and one (5.3%) patient died of disease at mean follow-up of 32.6 months.
The sphenoclival region poses a significant surgical challenge given its central location at the skull base and proximity to critical structures. This study demonstrates that transnasal endoscopic access to the sphenoclival region is technically feasible and allows successful surgical extirpation of tumors with a low complication rate and acceptable patient outcomes.
Otolaryngology Head and Neck Surgery 03/2010; 142(3):315-21. · 1.72 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Perineural invasion (PNI) in cutaneous squamous cell carcinoma of the head and neck (CSCCHN) carries poor prognosis. Tumor markers associated with neurotropism in CSCCHN have not been identified. Our objective was to study the expression of alphaB-crystallin in CSCCHN with neurotropism.
Cross-sectional review of pathologic specimens.
Tertiary care center.
Tissue from patients with CSCCHN with clinical PNI who underwent surgery between 1998 and 2005 was immunostained for alphaB-crystallin. In addition, non-PNI CSCCHN and normal nerve sections were also stained. Staining intensity was calculated by the histologic, or H, score (product of the intensity and proportion of tumor cells stained). The H-score ranged from 0.0 to 3.0, with 0 indicating negative staining in all cells and 3.0 indicating strong staining in 100 percent of cells.
Tissue was available in 15 clinical PNI CSCCHN patients. The analysis was also carried out in 14 non-PNI patients matched by stage and four normal greater auricular nerve (GAN) sections. The mean H-score was 0.56 for CSCCHN with PNI, 1.06 for non-PNI CSCCHN, and 3.0 for normal nerves. The difference in H-score between PNI and non-PNI CSCCHN was statistically significant (P = 0.04).
CSCCHN with clinical PNI has decreased staining for alphaB-crystallin. This finding further demonstrates the differences between clinical PNI and non-PNI CSCCHN tumors. Additional studies are required to identify cell surface markers expressed by CSCCHN that confer neurotropism capabilities.
Otolaryngology Head and Neck Surgery 03/2010; 142(3 Suppl 1):S15-9. · 1.72 Impact Factor
-
C. Arturo Solares MD,
FRCPA Ian Brown MBBS,
Glen M. Boyle PhD,
Peter G. Parsons PhD,
Benedict Panizza MBBS, MBA, FRACS, C. Arturo Solares,
Ian Brown,
Glen M. Boyle,
Peter G. Parsons,
Benedict Panizza
[show abstract]
[hide abstract]
ABSTRACT: Background.Perineural invasion (PNI) in cutaneous squamous cell carcinoma of the head and neck (CSCCHN) is associated with decreased survival, particularly in patients with clinical signs of cranial nerve involvement. There is evidence to indicate that neural cell adhesion molecule (N-CAM) confers capability of PNI. We analyzed our own patient population to determine if N-CAM predicted clinical PNI in CSCCHN.Methods.Tissue from patients with CSCCHN and clinical PNI, who underwent surgery between 1998 and 2005, was immunostained for N-CAM. In addition, non-PNI CSCCHN and normal nerve sections were also stained. A section of neuroendocrine tumor was included in each slide as a positive control. In addition, most of the sections also had an “inbuilt control” in the CD56 positive natural killer T cells that formed part of the inflammatory reaction to the tumors.Results.Tissue was available from 14 patients with CSCCHN and clinical PNI. The analysis was carried out in 14 patients without PNI and 4 normal nerves. N-CAM was not expressed in any of our PNI CSCCHN specimens or non-PNI controls. It was strongly expressed in the neuroendocrine tumors and positive in-built controls, as well as in normal nerve tissue.Conclusion.N-CAM expression did not predict neurotropism in our patient population. Additional studies are required to identify the cell surface markers expressed by CSCCHN which confer neurotropism capabilities. © 2009 Wiley Periodicals, Inc. Head Neck, 2009
Head & Neck 05/2009; 31(6):802 - 806. · 2.40 Impact Factor
-
C Arturo Solares,
Benjamin Wood,
Cristina P Rodriguez,
Robert R Lorenz,
Joseph Scharpf,
Jerrold Saxton,
Lisa A Rybicki,
Marshall Strome,
Ramon Esclamado,
Pierre Lavertu,
David J Adelstein
[show abstract]
[hide abstract]
ABSTRACT: To determine whether vocal cord fixation precludes nonsurgical management of T3/T4 laryngeal carcinoma.
A retrospective chart review.
Between 1989 and 2005 patient records with T3/T4 squamous cell carcinoma of the larynx with vocal cord fixation at presentation were reviewed. All were treated with a concomitant cisplatin-based chemoradiotherapy protocol and were part of the institutional head and neck cancer chemoradiotherapy registry. Only patients with adequate pre- and post-treatment fiberoptic evaluations were included. Charts were reviewed for demographics and tumor characteristics; return of vocal cord function; local, regional, or distant recurrence after treatment; and need for salvage surgery. The Kaplan-Meier method was used to estimate outcomes, and the log-rank test was used to compare those patients whose vocal cords remained fixed to those with recovery of function.
Twenty-three patients met the inclusion criteria, 19 males and 4 females. The median age was 59 years (range, 39-73). Fourteen patients had T3 and nine had T4 tumors. Twelve patients recovered full range of mobility, three had partial recovery, and eight did not recover motion. The median follow-up was 68 months (range, 34-191). Comparing patients with post-treatment partial or fully mobile cords to those with persistent fixation revealed the following: A projected five-year overall survival of 100% versus 25%, (P < .001), freedom from recurrence of 86.7 versus 25% (P < .001), local control without surgery of 86.7% versus 30% (P = .003), and survival with functional larynx of 86.7% versus 25% (P = .008), respectively.
Nonsurgical therapy in patients with pretreatment vocal cord fixation is feasible. However, persistence of vocal cord fixation after definitive chemoradiotherapy is a poor prognostic sign and early surgical intervention should be considered. Laryngoscope, 2009.
The Laryngoscope 05/2009; 119(6):1130-4. · 1.75 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Perineural invasion (PNI) in cutaneous squamous cell carcinoma of the head and neck (CSCCHN) is associated with decreased survival, particularly in patients with clinical signs of cranial nerve involvement. There is evidence to indicate that neural cell adhesion molecule (N-CAM) confers capability of PNI. We analyzed our own patient population to determine if N-CAM predicted clinical PNI in CSCCHN.
Tissue from patients with CSCCHN and clinical PNI, who underwent surgery between 1998 and 2005, was immunostained for N-CAM. In addition, non-PNI CSCCHN and normal nerve sections were also stained. A section of neuroendocrine tumor was included in each slide as a positive control. In addition, most of the sections also had an "inbuilt control" in the CD56 positive natural killer T cells that formed part of the inflammatory reaction to the tumors.
Tissue was available from 14 patients with CSCCHN and clinical PNI. The analysis was carried out in 14 patients without PNI and 4 normal nerves. N-CAM was not expressed in any of our PNI CSCCHN specimens or non-PNI controls. It was strongly expressed in the neuroendocrine tumors and positive in-built controls, as well as in normal nerve tissue.
N-CAM expression did not predict neurotropism in our patient population. Additional studies are required to identify the cell surface markers expressed by CSCCHN which confer neurotropism capabilities.
Head & Neck 04/2009; 31(6):802-6. · 2.40 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Treatments for vestibular schwannomas include surgical removal and radiotherapy. Observation is a reasonable alternative, given the slow growth of these tumors. The goal of this study was to determine the 5-year no-growth rate in patients managed initially by observation in attempts to define indications for treatment.
Retrospective chart analysis of prospectively collected patient database.
Patients with unilateral vestibular schwannomas who presented in the last 10 years were reviewed. Those managed initially by observation were reviewed. At least 2 consecutive imaging studies were required. The following information was recorded from the charts: age, sex, tumor size at presentation and subsequent follow-up sessions, treatment in the event of growth, and time interval between presentation and last imaging available. The institutional ethics committee approved the study.
One hundred ten patients were included. There were 65 male patients and 45 female patients. The mean age was 62.4 years (range, 32-91 yr). The mean follow-up was 31.4 months (range, 6-156 mo). Twenty-three patients demonstrated evidence of growth, with an overall 5-year no-growth rate of 70.6%. Despite growth, the 5-year no-intervention rate was 81.3%. Interestingly, 11 patients (10%) demonstrated tumor regression. Patients with intracanalicular tumors had a 5-year no-growth rate of 89.8% compared with 73.9% and 45.2% for Grade I and Grade II or larger tumors, respectively. The difference between intracanalicular and Grade II or larger tumors was statistically significant (p = 0.0196).
Our data suggest that treatment can be delayed in a large proportion of vestibular schwannoma patients and that this is particularly true in patients with small tumors. Despite growth, only a small percentage of patients require intervention. Thus, we recommend a period of observation to determine the need for treatment in patients without indications for urgent intervention.
Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 09/2008; 29(6):829-34. · 1.44 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To describe a quantitative analysis of the lateral lamella of the cribriform plate (LLCP) height in computed tomographic (CT) images. The LLCP is the thinnest anatomic structure in the skull base.
Software-enabled CT scan measurements.
Academic center.
The CT scans from 50 patients were analyzed. The median height of the LLCP in 100 sides was 2.4 mm. The LLCP height was 0 to 3.9 mm in 83 sides, 4.0 to 7.0 mm in 15 sides, and greater than 7.0 mm in 2 sides. When analyzing differences among sides, the LLCP height was greater on the right side in 28 patients and greater on the left side in 22. The differences between sides was 0 to 1.9 mm in 39 patients, 2.0 to 3.9 mm in 9 patients, and greater than 4.0 mm in 2 patients.
Computer-aided CT scan analysis allows for a quantitative analysis of the paranasal sinus skull base anatomy. Knowledge of these dimensions is invaluable during surgical planning and navigation. Asymmetry of the relative ethmoid roof position is common. Thus, the rhinologic surgeon must exercise caution to prevent unintentional skull base injury and cerebrospinal fluid leak.
Archives of Otolaryngology - Head and Neck Surgery 04/2008; 134(3):285-9. · 1.63 Impact Factor
-
Archives of Otolaryngology - Head and Neck Surgery 10/2007; 133(9):936-8. · 1.63 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Transoral CO2 laser surgery for selected supraglottic tumors results in improved postoperative function and decreased morbidity, with comparable survival to open surgery. Recently, robot-assisted techniques have been reported for the management of supraglottic lesions. There are no reports in the English literature of robotic technology coupled with CO2 laser technology. Our objective was to report the use of such technology.
Experimental resection of the supraglottis in a cadaver and a dog model using a commercially available surgical robot coupled with CO2 laser technology. Initial human experience with such technology is reported.
With use of a hollow core fiber that allows the transmission of CO2 laser energy linked to the daVinci Surgical Robot, a supraglottic laryngectomy was performed in an edentulous female cadaver. The FK Laryngo-Pharyngoscope was used for exposure. In a second experiment, a supraglottic partial laryngectomy was performed in an 80 pound dog. On the basis of our experimental experience, a CO2 laser robotic-assisted supraglottic laryngectomy was attempted in three patients.
Removal of the supraglottic larynx in both a cadaver and canine experimental models was believed to be satisfactory using this technology. Bleeding was easily controlled in the live canine model. A 74-year-old woman with a large supraglottic mass for which she had been offered a total laryngectomy was resected successfully with this technology. The FK Laryngo-Pharyngoscope provided excellent exposure. The patient was able to swallow without difficulty on postoperative day 5. Follow-up endoscopic examination at 1 month showed no evidence of residual laryngeal tumor. Robot-assisted procedures were attempted in two additional patients, but adequate exposure could not be achieved, and more traditional techniques were performed.
The use of the daVinci Surgical robot coupled with CO2 laser technology is feasible, as demonstrated by our experimental and clinical data. Although further development of the robotic technology is required at present, the use of robotics coupled with CO2 laser technology may have important implications in the management of supraglottic laryngeal cancer in the future.
The Laryngoscope 06/2007; 117(5):817-20. · 1.75 Impact Factor
-
Moo-Jin Baek,
Hyun-Min Park,
Justin M Johnson,
Cengiz Z Altuntas,
Daniel Jane-Wit,
Ritika Jaini, C Arturo Solares,
Dawn M Thomas,
Edward J Ball,
Nahid G Robertson,
Cynthia C Morton,
Gordon B Hughes,
Vincent K Tuohy
[show abstract]
[hide abstract]
ABSTRACT: Autoimmune sensorineural hearing loss (ASNHL) is the most common cause of sudden hearing loss in adults. Although autoimmune etiopathogenic events have long been suspected in ASNHL, inner ear-specific Ags capable of targeting T cell autoreactivity have not been identified in ASNHL. In this study, we show by ELISPOT analysis that compared with normal hearing age- and sex-matched control subjects, ASNHL patients have significantly higher frequencies of circulating T cells producing either IFN-gamma (p = 0.0001) or IL-5 (p = 0.03) in response to recombinant human cochlin, the most abundant inner ear protein. In some patients, cochlin responsiveness involved both CD4+ and CD8+ T cells whereas other patients showed cochlin responsiveness confined to CD8+ T cells. ASNHL patients also showed significantly elevated cochlin-specific serum Ab titers compared with both normal hearing age- and sex-matched control subjects and patients with noise- and/or age-related hearing loss (p < 0.05 at all dilutions tested through 1/2048). Our study is the first to show T cell responsiveness to an inner ear-specific protein in ASNHL patients, and implicates cochlin as a prominent target Ag for mediating autoimmune inner ear inflammation and hearing loss.
The Journal of Immunology 09/2006; 177(6):4203-10. · 5.79 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The "starplasty" technique of pediatric tracheostomy was introduced in 1990 as an alternative pediatric tracheostomy technique associated with several advantages. The only apparent drawback of this technique is the higher incidence of persistent tracheocutaneous fistula following decannulation. Several methods have been proposed for closure of persistent tracheocutaneous fistula in children, including fistulectomy with primary closure and fistulectomy with healing by secondary intent. Some authors advocate placement of a drain at the time of primary closure. We present our experience with closure of persistent tracheocutaneous fistula following starplasty in children over the past 15 years.
Ninety-six starplasty procedures were performed on 96 children from 1990 to present, all by the senior author or under the guidance of the senior author. Twenty-eight of these children have been decannulated. Three fistulas closed spontaneously following decannulation. Of the remaining 25 children, 13 have undergone surgical closure of the tracheocutaneous fistula by the senior author. All tracheocutaneous fistula closures were performed as a fistulectomy with primary closure in three layers. Drains were not used in any of the patients.
There were three minor complications in the postoperative period (wound infection and airway granuloma) and no major complications. None of the patients have experienced any degree of airway stenosis and there was no need for a repeat tracheotomy in any of the tracheocutaneous fistula closure patients. The cosmetic results were deemed to be good.
"Starplasty" is a safe, reliable pediatric tracheostomy technique that has been shown to decrease the incidence of perioperative morbidity and mortality. The only drawback appears to be a high incidence of postoperative tracheocutaneous fistula. Our method of persistent tracheocutaneous fistula closure following starplasty is safe and effective, with no major complications and no incidence of postoperative airway narrowing.
International Journal of Pediatric Otorhinolaryngology 02/2006; 70(1):99-105. · 1.17 Impact Factor
