Faculty Bibliography

OBJECTIVES: Radiation induced cranial nerve palsy (RICNP) involving the lower cranial nerves (CNs) is a serious complication of head and neck radiotherapy (RT). Recommendations for delineating the lower CNs on RT planning studies do not exist. The aim of the current study is to develop a standardized methodology for contouring CNs IX-XII, which would help in establishing RT limiting doses for organs at risk (OAR). METHODS: Using anatomic texts, radiologic data, and guidance from experts in head and neck anatomy, we developed step-by-step instructions for delineating CNs IX-XII on computed tomography (CT) imaging. These structures were then contoured on five consecutive patients who underwent definitive RT for locally-advanced head and neck cancer (LAHNC). RT doses delivered to the lower CNs were calculated. RESULTS: We successfully developed a contouring atlas for CNs IX-XII. The median total dose to the planning target volume (PTV) was 70Gy (range: 66-70Gy). The median CN (IX-XI) and (XII) volumes were 10c.c (range: 8-12c.c) and 8c.c (range: 7-10c.c), respectively. The median V50, V60, V66, and V70 of the CN (IX-XI) and (XII) volumes were (85, 77, 71, 65) and (88, 80, 74, 64) respectively. The median maximal dose to the CN (IX-XI) and (XII) were 72Gy (range: 66-77) and 71Gy (range: 64-78), respectively. CONCLUSIONS: We have generated simple instructions for delineating the lower CNs on RT planning imaging. Further analyses to explore the relationship between lower CN dosing and the risk of RICNP are recommended in order to establish limiting doses for these OARs.

Skeletal infections secondary to Candida albicans are uncommon and described primarily in adults. Nearly all 22 pediatric cases of C. albicans osteomyelitis described to date have occurred in neonates with specific risk factors or in children with a severe immunodeficiency. We report an unusual presentation of C. albicans osteomyelitis and arthritis in a 1-year-old boy without an immunodeficiency, which led to a delayed diagnosis. He most likely developed C. albicans arthritis and osteomyelitis during the neonatal period with a subsequent indolent and subacute presentation. Our literature search found no prior or recent reviews of C. albicans osteomyelitis in pediatric patients. On the basis of this patient and the case reports previously published, we discuss an approach to the evaluation and management of pediatric patients with Candida osteomyelitis.

OBJECTIVES/OBJECTIVE:Emergency physicians (EPs) frequently evaluate patients at risk for diseases that cause optic disc swelling, and they may encounter conditions that make traditional fundoscopy difficult or impossible. The objective was to assess whether EP-performed point-of-care (POC) ultrasound (US) could accurately assess swelling of the optic disc. METHODS:This was a blinded, prospective study using a convenience sample of patients presenting to a neuroophthalmology clinic who were thought to be at risk for conditions associated with optic disc edema. Two EPs performed POC US examinations. Patients then underwent standard clinical assessment by a specialist. RESULTS:Fourteen patients were assessed with disc swelling noted on dilated fundoscopic exam in 11 of 28 (39%) eyes. A maximum disc height greater than 0.6 mm as measured by US predicted the presence of optic disc edema noted on fundoscopic exam, with a sensitivity of 82% (95% confidence interval [CI] = 48% to 98%) and a specificity of 76% (95% CI = 50% to 93%). A threshold value of 1.0 mm for disc height yielded a sensitivity of 73% (95% CI = 39% to 94%) and a specificity of 100% (95% CI = 81% to 100%). Measurements of disc height as determined by optical coherence tomography (OCT) exhibited good correlation when compared to US measurements (r = 0.836, p < 0.0001, 95% CI = 0.65 to 0.93). CONCLUSIONS:These data suggest that EP-performed POC US can detect clinically apparent optic disc swelling. Because sonography can be performed readily at the bedside, even in cases where fundoscopy is difficult or impossible, this technique may prove to be a valuable tool for the assessment of optic disc swelling in the emergency department (ED).

PURPOSE: The need to improve chemotherapeutic efficacy against head and neck squamous cell carcinomas (HNSCC) is well recognized. In this study, we investigated the potential of targeting the established tumor vasculature in combination with chemotherapy in head and neck cancer. METHODS: Experimental studies were carried out in multiple human HNSCC xenograft models to examine the activity of the vascular disrupting agent (VDA) 5,6-dimethylxanthenone-4-acetic acid (DMXAA) in combination with chemotherapy. Multimodality imaging (magnetic resonance imaging, bioluminescence) in conjunction with drug delivery assessment (fluorescence microscopy), histopathology and microarray analysis was performed to characterize tumor response to therapy. Long-term treatment outcome was assessed using clinically-relevant end points of efficacy. RESULTS: Pretreatment of tumors with VDA prior to administration of chemotherapy increased intratumoral drug delivery and treatment efficacy. Enhancement of therapeutic efficacy was dependent on the dose and duration of VDA treatment but was independent of the chemotherapeutic agent evaluated. Combination treatment resulted in increased tumor cell kill and improvement in progression-free survival and overall survival in both ectopic and orthotopic HNSCC models. CONCLUSION: Our results show that preconditioning of the tumor microenvironment with an antivascular agent primes the tumor vasculature and results in enhancement of chemotherapeutic delivery and efficacy in vivo. Further investigation into the activity of antivascular agents in combination with chemotherapy against HNSCC is warranted.

OBJECTIVES:: The purpose of this study was to determine how the bandwidth of the hearing aid (HA) fitting affects bimodal speech recognition of listeners with a cochlear implant (CI) in one ear and severe-to-profound hearing loss in the unimplanted ear (but with residual hearing sufficient for wideband amplification using National Acoustic Laboratories Revised, Profound [NAL-RP] prescriptive guidelines; unaided thresholds no poorer than 95 dB HL through 2000 Hz). DESIGN:: Recognition of sentence material in quiet and in noise was measured with the CI alone and with CI plus HA as the amplification provided by the HA in the high and mid-frequency regions was systematically reduced from the wideband condition (NAL-RP prescription). Modified bandwidths included upper frequency cutoffs of 2000, 1000, or 500 Hz. RESULTS:: On average, significant bimodal benefit was obtained when the HA provided amplification at all frequencies with aidable residual hearing. Limiting the HA bandwidth to only low-frequency amplification (below 1000 Hz) did not yield significant improvements in performance over listening with the CI alone. CONCLUSIONS:: These data suggest the importance of providing amplification across as wide a frequency region as permitted by audiometric thresholds in the HA used by bimodal users.

Animal communication sounds contain spectrotemporal fluctuations that provide powerful cues for detection and discrimination. Human perception of speech is influenced both by spectral and temporal acoustic features but is most critically dependent on envelope information. To investigate the neural coding principles underlying the perception of communication sounds, we explored the effect of disrupting the spectral or temporal content of five different gerbil call types on neural responses in the awake gerbil's primary auditory cortex (AI). The vocalizations were impoverished spectrally by reduction to 4 or 16 channels of band-passed noise. For this acoustic manipulation, an average firing rate of the neuron did not carry sufficient information to distinguish between call types. In contrast, the discharge patterns of individual AI neurons reliably categorized vocalizations composed of only four spectral bands with the appropriate natural token. The pooled responses of small populations of AI cells classified spectrally disrupted and natural calls with an accuracy that paralleled human performance on an analogous speech task. To assess whether discharge pattern was robust to temporal perturbations of an individual call, vocalizations were disrupted by time-reversing segments of variable duration. For this acoustic manipulation, cortical neurons were relatively insensitive to short reversal lengths. Consistent with human perception of speech, these results indicate that the stable representation of communication sounds in AI is more dependent on sensitivity to slow temporal envelopes than on spectral detail.

IMPORTANCE: Neck dissection is the standard staging procedure to ascertain the pathologic status of cervical lymph nodes in patients with oral cavity squamous cell carcinoma (OSCC), but it results in multiple morbidities. OBJECTIVE: To examine outcomes of patients with OSCC who underwent sentinel node biopsy (SNB) as the sole neck staging procedure. DESIGN: Retrospective review of patients who underwent SNB during the period 2005 through 2011. SETTING: National Cancer Institute-designated comprehensive cancer center. PARTICIPANTS: Thirty-eight patients with clinically T1 or T2N0 OSCC. INTERVENTIONS: Preoperative lymphoscintigraphy with intraoperative gamma probe localization was used. Sentinel lymph nodes were serially sectioned, formalin fixed, and examined at 3 levels. All patients with positive SNB results underwent neck dissection, and the patients with negative SNB results were observed clinically. MAIN OUTCOMES AND MEASURES: Sensitivity and predictive value of SNB, recurrence rates, and disease-specific survival rates. RESULTS: There were 18 T1 and 20 T2 tumors. Five patients had positive SNB results, of whom 3 had additional positive nodes on subsequent neck dissection. Two of 33 patients with negative SNB results developed a regional recurrence. The sensitivity and negative predictive value for staging the neck with SNB alone were 71% (5 of 7) and 94% (31 of 33), respectively. Mean follow-up was 31 months. The mean disease-free survival duration for patients with positive and negative SNB results was 30 and 65 months, respectively (P = .08). The disease-specific survival rate for patients with positive and negative SNB results was 80% and 91%, respectively. There was no significant difference in disease-specific survival between patients with true-negative and false-negative SNB results (34 vs 44 months; P = .38). CONCLUSIONS AND RELEVANCE: The majority of patients with positive results on SNB had additional positive nodes on neck dissection. A low rate of isolated neck recurrence was found in patients with negative results on SNB. Individuals with negative results on SNB exhibited better overall and disease-specific survival than those with positive results.

OBJECTIVES/HYPOTHESIS: Malpractice litigation has increased in recent decades, contributing to higher health-care costs. Characterization of complications leading to litigation is of special interest to practitioners of facial plastic surgery procedures because of the higher proportion of elective cases relative to other subspecialties. In this analysis, we comprehensively examine malpractice litigation in facial plastic surgery procedures and characterize factors important in determining legal responsibility, as this information may be of great interest and use to practitioners in several specialties. STUDY DESIGN: Retrospective analysis. METHODS: The Westlaw legal database was examined for court records pertaining to facial plastic surgery procedures. The term "medical malpractice" was searched in combination with numerous procedures obtained from the American Academy of Facial Plastic and Reconstructive Surgery website. RESULTS: Of the 88 cases included, 62.5% were decided in the physician's favor, 9.1% were resolved with an out-of-court settlement, and 28.4% ended in a jury awarding damages for malpractice. The mean settlement was $577,437 and mean jury award was $352,341. The most litigated procedures were blepharoplasties and rhinoplasties. Alleged lack of informed consent was noted in 38.6% of cases; other common complaints were excessive scarring/disfigurement, functional considerations, and postoperative pain. CONCLUSIONS: This analysis characterized factors in determining legal responsibility in facial plastic surgery cases. Several factors were identified as potential targets for minimizing liability. Informed consent was the most reported entity in these malpractice suits. This finding emphasizes the importance of open communication between physicians and their patients regarding expectations as well as documentation of specific risks, benefits, and alternatives. Laryngoscope, 2012.

OBJECTIVE:To assess the long-term occurrence of hydroceles and varicocele recurrence in patients receiving lymphatic sparing laparoscopic varicocelectomy (LSLV) compared to those receiving plain laparoscopic varicocelectomy (PLV), and also to assess the growth of testicular volume postoperatively. METHODS:We employed a standard three-trocar configuration. The spermatic vessels were identified in the retroperitoneum above the internal inguinal ring. Lymphatics were dissected free from the spermatic artery and veins based on laparoscopic appearance. The spermatic artery and veins were divided between plastic locking clips. We performed a retrospective chart review of all pediatric patients who underwent laparoscopic varicocelectomy between June 2003 and January 2009. RESULTS:Of a total of 97 patients, 67 underwent LSLV with mean follow-up of 45.8 ± 20.7 months and 30 underwent PLV with mean follow-up of 40.8 ± 25.3 months (p = 15). There was a 4.5% hydrocele rate in the LSLV group compared to 43.3% in the PLV group. Of the patients who underwent a PLV and subsequently developed a hydrocele, 31% (n = 4) required a hydrocelectomy, vs none of those who developed a hydrocele after LSLV. Varicocele rate was 6% in the LSLV group vs 3.3% in the PLV group. However, when the artery was not preserved, the probability of recurrence in the LSLV group was 1.3%. Time to hydrocele formation was 16 months in the LSLV group vs 37 months in the PLV group. There was catch-up testicular growth in both groups. CONCLUSIONS:There appears to be increased risk of need for a hydrocelectomy after a PLV as compared to LSLV. Performing a lymphatic sparing, non-artery preserving, laparoscopic varicocelectomy has success and complication rates comparable with those of subinguinal microsurgical varicocelectomy. There appears to be excellent catch-up testicular growth with either laparoscopic varicocelectomy technique.