Faculty Bibliography

Objective To determine whether transcranial motor-evoked potential (TCMEP) monitoring of the facial nerve (FN) during cerebellopontine angle (CPA) tumor resection can predict both immediate and long-term postoperative FN function. Design Retrospective review. Setting Tertiary referral center. Main Outcome Measures DeltaTCMEP (final-initial) and immediate and long-term facial nerve function using House Brackmann (HB) rating scale. Results Intraoperative TCMEP data and immediate and follow-up FN outcome are reported for 52 patients undergoing CPA tumor resection. Patients with unsatisfactory facial outcome (HB >2) at follow-up had an average deltaTCMEP of 57 V, whereas those with HB I or II had a mean deltaTCMEP of 0.04 V (t = -2.6, p < 0.05.) Intraoperative deltaTCMEP did not differ significantly between groups with satisfactory (HB I, II) and unsatisfactory (HB > 2) facial function in the immediate postoperative period. Conclusion Intraoperative TCMEP of the facial nerve can be a valuable adjunct to conventional facial nerve electromyography during resection of tumors at the CPA. Intraoperative deltaTCMEP >57 V may be worrisome for long-term recovery of satisfactory facial nerve function.

BACKGROUND: The treatment for upper aerodigestive tract malignancy with external beam radiation therapy and chemotherapy can result in a "cure," yet result in pharyngoesophageal (PE) stenosis. To improve communication, compare therapeutic results, and assist in treatment planning, we developed a new classification system to describe PE stenoses. Additionally, we analyzed our 6-year experience. METHODS: The new classification system was defined and used to assess patient management. RESULTS: Thirty-one patients underwent treatment for PE stenoses using: 4 rendezvous dilations, 3 regional, and 24 free tissue transfers. Overall success was based on airway status, speech, and swallowing outcomes. CONCLUSION: Classification of posttreatment stenoses has been applied to this patient group. It is effective in defining the problem and considerations related to treatment planning and surgical access when augmentation pharyngoplasty is required. Patients with an intact larynx have many issues that make recovery of function less consistent, despite segment restoration.

OBJECTIVES: To examine the utility of nasopharyngeal culture in the management of children with chronic adenoiditis to determine if it results in a change in antibiotic therapy. METHODS: Retrospective chart review of pediatric patients managed for chronic adenoiditis, being defined as cough, postnasal drip, and congestion for over three months with endoscopic evidence of nasopharyngeal purulence with normal anterior rhinoscopy and middle meati. Standard treatment was defined as amoxicillin clavulanate or amoxicillin clavulanate ES-600 in non-penicillin allergic patients, and cefuroxime or clarithromycin for penicillin allergic patients. Nasopharyngeal culture results and antibiotic prescriptions were reviewed to look for a change from the standard. RESULTS: Of 207 patients diagnosed with chronic adenoiditis, 198 had nasopharyngeal cultures (119 male, 79 female, mean age 3.7 years). The most common organisms isolated were Streptococcus pneumoniae sensitive to penicillin in 40 cultures (20.2%), S. pneumoniae intermediate or resistant to penicillin in 26 (13.1%), Moraxella catarrhalis in 27 (13.6%), Haemophilus influenzae in 57 (28.8%), and Staphylococcus aureus intermediate or resistant to penicillin in 26 (13.1%). 13.3% of S. aureus isolated was methicillin resistant. 103 (52.0%) children required different antibiotics from the standard, and 26 (13.1%) had no antibiotics prescribed based on a negative culture. Of the 87 children suspected to have upper airway reflux, 25 (28.7%) had negative cultures. Of the 135 patients with follow-up, 50 (37.0%) reported resolution and 50 (37.0%) reported improvement of their symptoms. CONCLUSION: Nasopharyngeal culture has significant utility in the choice of antibiotics for children with chronic adenoiditis.

Laryngeal tuberculosis is uncommon and most often associated with a primary lung infection in immunocompromised adults. We describe an atypical case in a pediatric patient with a relatively rapid onset and no history of travel or exposure to high-risk settings. Despite the unusual presentation and relative lack of familiarity with procedural guidelines in managing this uncommon and capricious disease by otolaryngologists in developed countries, reporting is mandated at multiple governmental health department levels. Consequently, this contagious entity must be considered in the interest of avoiding untoward outcomes for not only the patient, but the public as well.

OBJECTIVE: Solid silicone augmentation mentoplasty is a common procedure with consistent aesthetic results in properly selected patients. While many plastic surgeons employ the external approach, the intraoral method affords excellent aesthetic outcomes while avoiding an external scar. This is the largest series in the literature describing the midline intraoral incision approach with minimal disruption of soft tissues. STUDY DESIGN: Case series. SETTING: Academic medical center. SUBJECTS AND METHODS: One hundred twenty-five patients underwent chin augmentation with solid silicone implants between 2004 and 2010. Among these implants, 105 were placed transorally. Eighty-five patients were followed for at least 1 year. Demographic information, indications, patient satisfaction questionnaire results, and complications were recorded. RESULTS: All implants yielded satisfactory results with no displacement, infection, tissue reaction, lower lip incompetence, mental nerve injury, or intraoral implant contamination. Two cases of superficial mucosal irritation at the suture site were observed and resolved without consequence. Symmetry, projection, and overall balance of facial components were excellent. Although all patients were satisfied with the functional and aesthetic results, 20% stated they would like further augmentation. Patients were extremely satisfied with the lack of an external scar. CONCLUSIONS: Based on our series, the intraoral technique with a midline incision avoiding disruption of the mentalis muscle is recommended for its ease, simplicity, patient satisfaction, low complication rate, and circumvention of an external scar. The external approach should be considered in cases that require a very large implant.

Congenital cytomegalovirus infection is the most frequent nongenetic cause of pediatric hearing loss in the United States, affecting approximately 8,000 children each year. Due in part to variable cytomegalic involvement of the auditory cortex, cochlear implantation outcomes have varied widely. Functional magnetic resonance imaging (fMRI) has the potential to assist in determining candidacy for cochlear implantation through the detection of intact auditory pathways including the cortex. We report a case of a 21-month-old girl with cytomegalovirus-related deafness and diffuse white matter involvement in which fMRI was a determining factor for cochlear implantation and side selection.

PURPOSE: Although microdissection testicular sperm extraction has become first line therapy for sperm retrieval in men with nonobstructive azoospermia, there are challenges to the procedure, including difficulty differentiating between seminiferous tubules with normal and abnormal spermatogenesis. Multiphoton microscopy illuminates tissue with a near infrared laser to elicit autofluorescence, which enables real-time imaging of unprocessed tissue without labels. We hypothesized that we could accurately characterize seminiferous tubular histology in humans using multiphoton microscopy. MATERIALS AND METHODS: Seven men with normal or abnormal spermatogenesis underwent testicular biopsies, which were imaged by multiphoton microscopy. We assessed these images in blinded fashion. The diagnosis rendered with multiphoton microscopy was then correlated with that of hematoxylin and eosin stained tissue. We evaluated the ability of multiphoton microscopy to differentiate normal from abnormal seminiferous tubules by examining autofluorescence characteristics and diameters, as imaged by multiphoton microscopy. Assessment was repeated with stained slides and results were compared. RESULTS: The overall concordance rate between multiphoton microscopy and stained slides was 86%. The seminiferous tubules of patients with nonobstructive azoospermia were smaller than those of controls when measured by multiphoton microscopy and staining (p <0.05). The proportion of normal tubules and the diameters obtained with multiphoton microscopy were not different from those obtained with hematoxylin and eosin (p >0.05). CONCLUSION: Multiphoton microscopy can be used to differentiate normal from abnormal spermatogenesis. Its characterization of seminiferous tubular architecture is similar to that provided by hematoxylin and eosin staining. Further investigation of the clinical applications of multiphoton microscopy may improve surgical sperm retrieval outcomes for patients with nonobstructive azoospermia.

Sinonasal mucosal melanomas (SNMM) of the head and neck regions are rare and aggressive malignancies. Although they can affect patients of any ethnicity, they are more numerous in Chinese patients. The diagnosis and treatment of these tumors can be challenging. Recent studies have reported that Sox10 is a sensitive melanocytic marker for cutaneous melanoma (Nonaka et al. in Am J Surg Pathol 32:1291-1298, 2008). In addition, a CD117 (c-kit) gene mutation has been identified in cutaneous melanomas, indicating that there may be potential therapeutic benefits of tyrosine kinase inhibitors, such as Imatinib. The purpose of this study was to detect and test the immunohistochemical expression of Sox10 and c-kit in mucosal melanomas (MM) arising in the nasal cavities of Chinese patients. Twenty eight patients with mucosal melanomas of the nasal cavity were treated in two major hospitals in China. All cases had been locally diagnosed as primary SNMM. We confirmed all diagnoses with positive immunohistochemical stains for S100 and HMB-45. Additionally, automated immunohistochemistry was performed using a goat polyclonal Sox10 antibody and a monoclonal c-kit antibody counterstained using a standard avidin-biotin complex method. Immunohistochemical positive expression of Sox10 was defined by nuclear stain; and positivity for c-kit resulted in a distinct membranous staining. The extent of nuclear positivity for Sox10 and membranous stain for c-kit was graded by 4 board certified pathologists as follows: 1+, 1-25 % of positive tumor cells; 2+, 25-50 %; 3+, 50-75 %; and 4+, >/=75 %. Sox10 nuclear expression was found in all cases (100 %), with 4+ staining in 26 out of 28 cases (92.8 %) and 3+ staining in two cases with (7.1 %). The overall positivity for S100 staining was 23 out of 28 (82.1 %), with 1+ staining in 10 cases, 2+ staining in 6 cases, 3+ staining in 7 cases, and no staining in 5 cases. The sensitivity and intensity of Sox10 immunohistochemistry were both higher than with S100 immunohistochemistry. Immunopositivity of membranous stain for c-kit (CD117) was seen in 24 out of 28 cases (85.7 %), including 6 tumors that were 4+, eight that were 3+, six that were 2+, and four that showed 1+ staining. Our results demonstrate that Sox10 is a sensitive marker for SNMM and it may possess diagnostic value in addition to that of S100 protein. The expression of c-kit in the majority of MMs suggests that it may be useful in the assessment of these tumors for potential treatment with tyrosine kinase inhibitors.